Psychiatria Danubina PSYCHIATRIC

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DANUBIAN ASSOCIATION psychiatria

psychiatria danubina PSYCHIATRIC

FACULTAS MEDICA UNIVERSITATIS

danubina STUDIORUM 2018 supplement 7 volume 30 ZAGRABIENSIS UDC 616.89 ISSN 0353 - 5053 www.hdbp.org/psychiatria_danubina

International Twined Congress Psychiatry beyond DSM-5 Vol. 30/Suppl. 7 pp 393-652 (2018 )

November 15-17, 2018 Iseo, Italy ISSN 0353 - 5053 Excerpta Medica (EMBASE), Psychological Abstracts/ PsycINFO, Chemical Abstracts, MEDLINE/PubMed, EBSCO, Cambridge Scientific Abstracts/Social Services Abstracts, Science Citation Index Expanded (SciSearch), Social Sciences Citation Index , Social SciSearch, Journal Citation Reports/ Social Sciences Edition, Journal Citation Reports/ Science Edition, SCOPUS, HRCAK, MEDICINSKA NAKLADA ZAGREB, CROATIA BioMedWorld.com, Research Alert, Google Scholar, Current Contents 9 770353 505002 - Social and Behavioral Sciences,, Web of Science (WoS), CiteFactor. PRO MENTE d.o.o. ZAGREB, CROATIA PSYCHIAT DANUB, 30(suppl. 7): S393-652 November 2018

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PSYCHIATRIA DANUBINA An Official Journal of Danubian Psychiatric Association Vol. 30, Suppl. 7 November, 2018 Acknowledgement to genuine initiative for founding Psychiatria Danubina Nenad Bohaþek Gustav Hofmann

Honorary Editors - Ehrenredakteure

Norman Sartorius, Association for the Improvement of Mental Health Programs 14 Chemin Colladon, CH-1209 Geneve, Switzerland

Editors in Chief - Hauptredakteure

Miro Jakovljeviü, Department of Psychiatry Werner Schöny University Hospital Centre Zagreb OÖ Landes - Nervenklinik Wagner Jauregg Kišpatiüeva 12, 10000 Zagreb, Croatia Wagner-Jauregg-Weg 15, 4020 Linz, Austria

International Editorial Board – Internationale Redaktion

Agius M. (Cambridge) Jukiü V. (Zagreb) Peþenak J. (Bratislava) Bitter I. (Budapest) Kapfhammer H.P. (Graz) Raboch J. (Prague) Bomba J. (Krakow) Kores Plesniþar B. (Ljubljana) Rakus A. (Bratislava) Dantendorfer K. (Vienna) Krasnov V. (Moscow) Sass H. (Aachen) Deckert J. (Würzburg) Lehofer M. (Graz) Tsygankov B. (Moscow) Hoschl C. (Prague) Libiger J. (Prague) Vlokh I. (Lvov) Jarema M. (Warsaw) Loga S. (Sarajevo) Voracek M. (Vienna) Jašoviü-Gašiü M. (Belgrade) Marksteiner J. (Graz)

International Advisory Board – Internationaler Fachbeirat

Bhugra D. (London) Gianacopoulos P. (Geneva) Kurimay T. (Budapest) Chiu H. (Hong Kong) Goldberg D. (London) Lazarescu M. (Timisoara) Dimsdale J. (San Diego) Herrman H. (Melbourne) de Leon J. (Lexington) Ferrero F. (Geneva) Hranov L. (Sofia) Oancea C. (Bucharest) Fleischacker W. (Innsbruck) Kasper S. (Vienna) Rossler W. (Zurich) Friedrich M.H. (Vienna) Koichev G. (Sofia) Svrakic D. (St. Louis) Gabriel E. (Vienna) Kua E.H. (Singapore) Veltischev D. (Moscow)

Editor Assistants – Assistenten an der Redakteur

Ivona Šimunoviü Filipþiü (Zagreb) Martina Rojniü Kuzman (Zagreb) Ena Iveziü (Zagreb)

Guest Editor: Giuseppe Tavormina (Iseo)

Computer service: UNIGRAF P. Heruca 6, Zagreb Printed by - Herstellung: MEDICINSKA NAKLADA Cankarova 13, Zagreb PSYCHIATRIA DANUBINA

Psychiatria Danubina is cited/ abstrac- ted in Excerpta Medica (EMBASE), Psychological Abstracts/ PsycINFO, CONTENTS Chemical Abstracts, MEDLINE/ PubMed, EBSCO, Cambridge Scientific International Twined Congress - Psychiatry beyond DSM-5 Abstracts/Social Services Abstracts, Science Citation Index Expanded (SciSearch), Social Sciences Citation Iseo, Italy, November 15-17, 2018 Index, Social SciSearch, Journal Cita- tion Reports/ Social Sciences Edition, Editorials...... 396 Journal Citation Reports/ Science Tavormina G: HOW UNDERSTANDING THE TEMPERAMENTS Edition, SCOPUS, BioMedWorld.com, Research Alert, Google Scholar, CAN HELP CLINICIANS TO MAKE A CORRECT DIAGNOSIS HRýAK, Current Contents - Social OF BIPOLAR MOOD DISORDERS: 10 CASE REPORTS ...... 398 and Behavioral Sciences, Web of Science (WoS). Zdanowicz N, Reynaert C, Jacques D, Lepiece B, Godenir F, Psychiatria Danubina (ISSN 0353-5053) Pivont V & Dubois T: DEPRESSION AND PHYSICAL HEALTH, is published quarterly by Medicinska naklada, Cankarova 13, 10000 Zagreb, THE THERAPEUTIC ALLIANCE AND ANTIDEPRESSANTS ...... 401 Croatia; Pro Mente d.o.o., 10000 Zagreb, Franza F, Solomita B, Pellegrino F & Aldi G: Croatia. The cost of a yearly subscription to RELATIONSHIP BETWEEN COGNITIVE REMEDIATION the journal is € 50.00 for institutions, AND EVALUATION TOOLS IN CLINICAL ROUTINE...... 405 € 40.00 for individual subscribers and € 30.00 for students - the prices are Patigny P, Zdanowicz N & Lepiece B: HOW SHOULD PSYCHIATRISTS without postage. (Payments in other currencies will be accepted on the basis AND GENERAL PHYSICIAN COMMUNICATE TO INCREASE of the official currency exchange rates). PATIENTS’ PERCEPTION OF CONTINUITY OF CARE AFTER Advertising enquiries, correspondence and copy requests should be addressed to THEIR HOSPITALIZATION FOR ALCOHOL WITHDRAWAL?...... 409 Prof. Miro Jakovljeviü, Psychiatric Therasse A, Persano HL, Ventura AD & Tecco JM: University Clinic, KBC Zagreb, Kišpatiüeva 12, HR-10000 Zagreb, Croatia INCIDENCE AND PREVENTION OF DEEP VEIN (tel: +385 1 23-88-394; THROMBOSIS IN RESTRAINED PSYCHIATRIC PATIENTS ...... 412 tel/fax: +385 1 23-88-329). E-mail: [email protected] Lantin C, Franco M, Dekeuleneer F-X, Chamart D & Tecco JM: All advertising material is expected to conform to ethical and medical NEUROLEPTIC MALIGNANT SYNDROME IN A PATIENT standards. No responsibility is assumed TREATED WITH CLOTIAPINE ...... 415 by the publisher for any injury and/or damage to persons or property as a Jacques D, Maricq A, Dubois T, Lepiece B, Zdanowicz N & Zelgrange E: matter of products liability, negligence PARTIAL DENIAL OF PREGNANCY AT 32 WEEKS IN A DIABETIC or otherwise, or from any use or operation of any methods, products, instruc- AND SUICIDAL PATIENT: A CASE REPORT. tions or ideas contained in the material What Are the Treatment Recommendations? ...... 418 herein. Because of the rapid advances in the medical sciences, the Publisher Naviaux A-F: TRIAGE OF CHILDREN WITH MENTAL HEALTH recommends that independent verification of diagnosis and drug dosages DIFFICULTIES PRESENTING IN A&E IN A GENERAL HOSPITAL ...... 422 should be made. Discussion, views and Tavormina D: STRESSFUL CHILDHOOD EVENTS: A RETROSPECTIVE recommendations as to medical procedures, choice of drugs and drug dosages JOURNEY INTO THE LIFE OF ADULTS WITH DEPRESSION; are the responsibility of the authors. A REPORT OF 5 CASES. The importance of maternal love...... 426 ©2018 MEDICINSKA NAKLADA Zagreb, Cankarova 13, Croatia; Amorosi M: ECOSUSTAINIBILITY AND MENTAL HEALTH: FACULTAS MEDICA UNIVERSITATIS STUDIORUM FEMALE ASPECTS ...... 431 ZAGRABIENSIS, Zagreb, Croatia; Del Buono G: THE PRECISION PSYCHIATRY. PRO MENTE d.o.o., Zagreb on the behalf of the Danube Psychiatric An Individualized Approach to the Diseases...... 436 Association. de Ruffi T & Zdanowicz N: EFFECTS OF FINANCIAL Tel/fax: +385 1 37-79-444; Website: www.medicinskanaklada.hr PRECARIOUSNESS ON MENTAL HEALTH...... 439 E-mail: [email protected] Franco M, Lantin C, Dekeuleneer F-X, Bongaerts X & Tecco JM: All rights reserved. It is a condition of publication that manuscripts submited to A TRANSIENT PERSONALITY DISORDER INDUCED this journal have not been published and BY FOOTBALL MATCHES...... 443 will not be simultaneously submitted or published elsewhere. By submitting a Dubois T, Reynaert C, Jacques D, Lepiece B, Patigny P & Zdanowicz N: manuscript, the authors agree that the IMMUNITY AND PSYCHIATRIC DISORDERS: VARIABILITIES copyright for their article is transferred to the Publisher if and when the article is OF IMMUNITY BIOMARKERS ARE THEY SPECIFIC? ...... 447 accepted for publication. No part of this publication may be reproduced, stored in Juli G, Juli R & Juli L: SLEEP DISORDERS: retrieval system, or transmitted, in any ARE THEY A GENETIC QUESTION? ...... 452 form or by any means, electronic, mechanical, photocopying, recording or other- Spurio MG: REWRITING NEURAL PATHWAYS TO STOP wise, without the prior written permission of the Publisher. DEPRESSIVE DISTRESS IN A SUSPENDED SPACE AWAY ...... 457 Printed in Croatia. Weatherby TJM & Agius M: ETHICAL AND ORGANISATIONAL Publication of the journal is supported by the Croatian Ministry of Science, CONSIDERATIONS IN SCREENING FOR DEMENTIA...... 463 Education and Sport. McKeever A & Agius M: DEMENTIA RISK ASSESSMENT AND RISK IMPACT FACTOR: 1.34 REDUCTION USING CARDIOVASCULAR RISK FACTORS...... 469 PSYCHIATRIA DANUBINA 2018 Ɣ supplement 7 Ɣ volume 30

Demont C, Zdanowicz N, Reynaert C, Jacques D & Dubois T: CORRELATIONS BETWEEN EVENT-RELATED POTENTIALS AND NK CELLS, B AND T LYMPHOCYTES ...... 475 Tavormina MGM, Tavormina R, Franza F, Vacca A & Di Napoli W: MENTAL ILLNESS AND PREJUDICES IN PSYCHIATRIC PROFESSIONALS. Data from the social stigma questionnaire for psychiatric professionals: a multicentre study ...... 479 Cervone A, Esposito G & Cimmino G: TAILORING TREATMENT FOR MAJOR DEPRESSIVE EPISODE: LESSONS LEARNED FROM THE INPATIENT UNIT...... 485 Menculini G, Verdolini N, Lanzi R, Pomili G, Moretti P & Tortorella A: INVOLUNTARY HOSPITALIZATION AND VIOLENT BEHAVIORS: MEDICAL ACT OR SOCIAL CONTROL? A 3-year retrospective analysis ...... 488 Deschietere G: MOBILITY IN PSYCHIATRY, AN ALTERNATIVE TO FORCED HOSPITALIZATION?...... 495 Lepièce B, Dubois T, Jacques D & Zdanowicz N: “PLEASE ADMIRE ME!” WHEN HEALTHCARE PROVIDERS' POSITIVE STEREOTYPES OF ASYLUM SEEKER PATIENTS CONTRIBUTE TO BETTER CONTINUITY OF CARE...... 498 Bow A: IS ELECTROCONVULSIVE THERAPY ANY MORE EFFECTIVE THAN SIMULATED ELECTROCONVULSIVE THERAPY IN TREATMENT-RESISTANT DEPRESSION? ...... 502 Johnson HP & Agius M: A POST-TRAUMATIC STRESS DISORDER REVIEW: THE PREVALENCE OF UNDERREPORTING AND THE ROLE OF STIGMA IN THE MILITARY ...... 508 Colucci A: THE ROLE OF THE SOCIAL NETWORKS, BETWEEN A UTILITY AND A NEW ADDICTION...... 511 Tavormina R & Tavormina MGM: OVERCOMING DEPRESSION WITH DANCE MOVEMENT THERAPY: A CASE REPORT ...... 515 Juli MR: THE SUFFERING BODY: MANIPULATION AND DISCOMFORT IN EATING DISORDERS...... 521 d’Errico I: HOW ARTWORKS CAN GATHER UNSPOKEN YET DEEPLY FELT EXPERIENCES. USING NARRATIVE LAB IN DAILY PSYCHIATRIC CENTER...... 527 Jassogne C & Zdanowicz N: MANAGEMENT OF ADULT PATIENTS WITH ANOREXIA NERVOSA: A LITERATURE REVIEW ...... 533 Khatcherian E & Zdanowicz N: WHY DO CYBERBULLIED ADOLESCENTS STAY IN CONTACT WITH THEIR HARASSER? A Literature Review and Reflection on Cyberbullied Adolescents’ Coping Strategies ...... 537 Agius M: NEUROSCIENCE AND VISUAL ART; MOVING THROUGH EMPATHY TO THE INEFFABLE...... 541 Wang S & Oldfield A: THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY ...... 546 Agius M: WHAT IS BEAUTY? SHOULD DOCTORS POINT OUT BEAUTY TO THEIR PATIENTS DURING THERAPY? ...... 555 Cooper Y & Agius M: DOES SCHIZOAFFECTIVE DISORDER EXPLAIN THE MENTAL ILLNESSES OF ROBERT SCHUMANN AND VINCENT VAN GOGH? ...... 559

S394 PSYCHIATRIA DANUBINA 2018 Ɣ supplement 7 Ɣ volume 30

McGill IK & Agius M: TERTIARY SYPHILIS (GENERAL PARALYSIS OF THE INSANE) AND BIPOLAR DISORDER; THE ROLE OF THESE TWO DISORDERS IN THE LIFE OF FAMOUS COMPOSERS ...... 563 Bedetti C, D’Alessandro P, Piccirilli M, Marchiafava M, Baglioni A, Giuglietti M, Frondizi D, Menna M & Elisei S: MOZART'S MUSIC AND MULTIDRUG-RESISTANT EPILEPSY: A POTENTIAL EEG INDEX OF THERAPEUTIC EFFECTIVENESS...... 567 Stranieri G: GENIUS AND MADNESS BETWEEN NORMALITY AND PATHOLOGY ...... 572 Nardini M & d’Errico I: THE PERSISTING SADNESS, AN INCLINATION TO BECOME EMOTIONAL: THE CASE OF INSPECTOR RICCIARDI GIFTED WITH THE CAPACITY TO FEEL PAIN...... 574 Urliü I: DEPRESSION AS A "COMORBIDITY" OF A DISORDER NOT RECOGNIZED IN ADOLESCENCE...... 577 Moretti P, Bachetti MC, Sciarma T & Tortorella A: DYSPHORIA AS A PSYCHIATRIC SYNDROME: A PRELIMINARY STUDY FOR A NEW TRANSNOSOGRAPHIC DIMENSIONAL APPROACH ...... 581 Wang S & Agius M: THE NEUROSCIENCE OF MUSIC; A REVIEW AND SUMMARY...... 588 Wang S & Agius M: THE USE OF MUSIC THERAPY IN THE TREATMENT OF MENTAL ILLNESS AND THE ENHANCEMENT OF SOCIETAL WELLBEING...... 595 Spurio MG: AESTHETIC EXPERIENCE: WHEN EMOTIONS BECOME A CARE ...... 601 Perito M: DIGNITY THERAPY: PREVENTION OF SUICIDAL RISK IN THE PENITENTIARY AREA ...... 603 Joshi A: SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS: AN OVERVIEW ...... 605 Ferreira Bruco ME, Gamlin C, Bradbury J, Bill S, Armour C & Agius M: SELF HARM AND SUICIDALITY: AN AUDIT OF FOLLOW-UP IN PRIMARY CARE...... 610 Zaman R, Carrick FR & Hankir A: INNOVATIVE APPROACHES TO IMPROVING THE IMAGE OF PSYCHIATRISTS AND PSYCHIATRY AMONGST MEDICAL STUDENTS AND DOCTORS IN THE UK...... 616 Treviranus GRS: RESCUE OF THE APPROPRIATIVE “THOUGHT-ACTION-MOOD” SPACE: ANATOMY AND MAST CELLS GENERATE “MIXABLE” DIMENSIONS IN LANGUAGE AND STATISTICS ...... 620 Acharya T & Agius M: POOR COMPLIANCE AS A SIGN OF DEPRESSION. Why might an elderly man stop his medication?...... 630 Ngaage M & Agius M: THE PSYCHOLOGY OF SCARS: A MINI-REVIEW ...... 633 Chadha A: THE IMPORTANCE OF ANXIETY IN UNDERSTANDING HOW DECISION MAKING IS AFFECTED IN AUTISM SPECTRUM DISORDER ...... 639 Marchiafava M, Piccirilli M, Bedetti C, Baglioni A, Menna M & Elisei S: EFFECTIVENESS OF SEROTONERGIC DRUGS IN THE MANAGEMENT OF PROBLEM BEHAVIORS IN PATIENTS WITH NEURODEVELOPMENTAL DISORDERS...... 644 Tavormina G: CAN WRITING POEMS AND TAKING PHOTOS HELP THE PSYCHIATRIST TO IMPROVE HIS HUMANITY AND THE MENTAL HEALTH OF HIS PATIENTS? ...... 648

S395 EDITORIALS

It is my pleasure to indroduce you, as president of Psychiatric Studies Centre and chair of the congress, to the fifth edition of this international congress held in Iseo, a very attractive town on the lake of Iseo, in Italy. This time, as four years ago, the scientific management of the meeting has been done not only by Psychiatric Studies Centre but together with the Université Catholique de Louvain (Belgium), the Centre Hospitalier Universitaire et Psychiatrique de Mons Borinage (Brussels, Belgium), and the Bedfordshire Centre for Mental Health Research in association with the University of Cambridge (BCMHR-UC, UK). As in past congress edition in Iseo, we have obtained the co-sponsorship of the World Psychiatric Association (Evidence Based Psychiatry WPA Section) and of the Italian Health Office. This twined congress follows the others, which have been held in Brussels and in Cambridge every two years since 2010, with the plan of continuing to hold them every two years also in future. The programme includes 56 papers (regular presentations, short presentations and posters), in less then 3 days, so as to intensely stimulate all the delegates on several topics of psychiatry, ranging from research to clinical practice , in order to illustrate the broad spectrum of science within the field of psychiatry. Many thanks to all speakers and authors; but a particular thanks goes to the Centre Hospitalier Universitaire et Psychiatrique de Mons Borinage of Brussels for its support in printing these scientific papers. Giuseppe Tavormina, MD President of “Psychiatric Studies Centre” (Cen.Stu.Psi.) Provaglio d’Iseo (BS), Italy

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Exchange ideas and progress together An international congress is an opportunity to exchange ideas and progress together. It's an opportunity to interact with other members of the scientific community, to meet colleagues, to meet people who are known by their writings and other delegates from the same country and from other countries, to share ideas, to create professional links. It is an opportunity to transmit what we do and also to learn what is done elsewhere, to acquire knowledge sharing points of view from research and practices, It is a way to take collective positions, to confront the orientations during the debates, to discover new perspectives, to measure the stakes, to apprehend the tendencies and orientations of the public health policies and management resources for health professionals, to act as a member of a community, to make proposals supported by a community. These are issues to promote innovation, exercise leadership and influence public health policies. Thank you to all who have made this event possible in the past years until today. Thanks to all the participants, authors and speakers, thanks to Psychiatrica Danubina. Thanks to Mark Agius and Nicolas Zdanowicz for their incredible contribution over the years. Special thanks for the one who took the leadership to make us grow and progress together this year: Dr. Giuseppe Tavormina. Juan Martin Tecco, MD, MBA Centre Hospitalier Universitaire et Psychiatrique de Mons-Borinage (CHUP-MB) Mons, Belgium

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For several years, biological model is running out of innovative molecules. We managed to limit undesirable effects but the efficacy of our molecules reaches its limit. It is the case for antidepressants as well as for neuroleptic drugs. However, this brake on biological research didn’t shake the dynamism of our congress. Even if there are less communications about psychopharmacology, the other branches of psychiatry show an updated dynamism: social psychiatry, art therapy, care organization policy, psychotherapy, consequences of stress and recovery after stress, personality troubles… Concerning psychopharmacology, the researches performed aim to use interactions between different fields such as immune system and psychobiology, therapeutic collaboration and antidepressants, physical and mental health, care and ethics. Our congress has still a bright future. Prof. Nicolas Zdanowicz, MD, PhD Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital Yvoir, Belgium

S396 Do we treat Risk Factors or Illness - Modern changes in the Paradigm of Medicine In recent years, we have experienced a change in the way doctors function in Medicine. This change has important consequences for the Doctor-Patient Relationship, because it affects, we shall argue, the intention that a doctor has when he/she treats patients. This change is presently most notable in Primary Care. It affects both why a doctor sees patients and also why patients choose to see doctors. Up till recently, and also still, in many parts of Europe and the rest of the world, it was clear why a patient went to see a doctor; the patient went to see the doctor when the patient felt that they were ill, or when they had a health related problem. The patient’s aim was to get help to return to health. The doctor’s aim was to identify what was wrong and then to prescribe treatment in order to help the patient to recover. This led to the most important description of the Consultation and of the Doctor Patient Relationship. This was said by Sir James Spence in 1960: “The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it.” Sir James Spence 1960 It was clear what illnesses were; Hypertention was seen as a disease, which might be silent, but which might lead to stroke or myocardial infarction. It included complications such as Hypertensive retinopathy or heart failure. Diabetes was a disease of glucose metabolism with severe effects including coma, arterial disease and retinopathy, Hypercholesterolaemia was a disorder which, especially in the familial kind, could lead to coronary artery disease. Advice and medication was given by the doctor to treat these problems. Today, there has been a major move towards preventive medicine, which includes screening, but the same conditions mentioned above become now seen as risk factors for future disease. This new view does, indeed, enable lifestyle changes to be discussed in such a way as to enable more ‘joint decision making’ between doctor and patient. However there is a subtle risk that this new view, in which we invite apparently healthy persons in to surgery to see us for screening procedures, rather than simply waiting for persons to come in with problems, there is a change in what we intend to do, so that the aim of our interaction with the patient changes from that of dealing with problems to instead trying to influence their way of life, to, in our view, optimise it. This becomes particularly so when we use risk factor scores to predict morbidity, or even mortality in cardiovascular risk screening, or to predict the onset of dementia, which our colleagues are presently studying and have reported on in this supplement (Mckeever & Agius 2018). This is not to say that such use of scoring systems is in itself problematic, but they need to be used properly. We must treat the person, not simply the risk factor, and again, when we need to treat the ‘risk factor’ or illness, it must be done appropriately, with treatments, including pharmacological ones, aimed at treating actual disorders, rather than unthinkingly following fixed protocols even when inappropriate. Not all risk factors are modifiable, and some may be only partially modifiable. The risk score should alert us to finding treatable disorders and then treating appropriately. The full assessment of the person before offering treatment is endorsed by NICE guidance (NICE 2016). One further reflection on the Doctor Patient relationship is that, before giving patients advice, people need to be assessed properly. This is never more so when assessing mental health conditions, including conditions which may have led to patients attempting to take their own life. The aftercare of a suicide attempt is another issue discussed in this supplement (Gamlin 2018). It is not sufficient to simply make sure that a ‘Mental State Examination’ is recorded in the notes. The issue is how comprehensive that mental health examination is. Many, but not all, patients who attempt suicide have a depressed mood, but the examination needs to be comprehensive enough to assess the type of depression; many patients might suffer Bipolar Disorder (Agius 2015), and this could contribute to increased risk of suicide in particular phases of the illness, such as mixed affective states (Annear 2016). Here too, a constellation of risk factors need to be assessed and recorded in order to ensure that a proper diagnosis has been made and risk is adequately assessed before treatment can be offered. Hence the patient’s notes should demonstrate in each patient with depression that such details as presence of recurrent depressive episodes, atypical depression, episodes of hypomania, presence of affective mixed states, family history and past history, which may alert to the presence of bipolarity, have been asked about and assessed. It is only by appropriate assessment followed by appropriate treatment that we can help our patients deal with their problems. This should remain the central Paradigm of Medicine. References 1. Agius M & Verdolini N: The Cambridge-Perugia Inventory for assessment of Bipolar Disorder. Psychiatr Danub 2015; 27(Suppl 1):S185-7 2. Agius M: The medical consultation and the human person. Psychiatr Danub 2014; 26(Suppl 1):S15-8 3. Annear D & Agius M: Should Assessment for Bipolar Disorder and mixed affective state be a standard part of assessment for suicide risk? Psychiatr Danub 2016; 28(Suppl 1):S18-20 4. Ferreira Bruco ME, Gamlin C, Bradbury J, Bill S, Armour C & Agius M: Self harm and suicidality: an audit of follow-up in primary care. Psychiatr Danub 2018; 30(Suppl 1):S610-5 5. McKeever A & Agius M: Dementia risk assessment and risk reduction using cardiovascular risk factors. Psychiatr Danub 2018; 30(Suppl 7):S469-74 6. NICE: Cardiovascular disease: risk assessment and reduction, including lipid modification. 2016. https://www.nice.org.uk/guidance/cg181 7. Spence J: The purpose and practice of medicine: Selections from the writings of sir james spence: With A memoir. Oxford University Press, 1960 Mark Agius, MD Clare College Cambridge, Department of Psychiatry, University of Cambridge Cambridge, UK

S397 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 398-400 Conference paper © Medicinska naklada - Zagreb, Croatia

HOW UNDERSTANDING THE TEMPERAMENTS CAN HELP CLINICIANS TO MAKE A CORRECT DIAGNOSIS OF BIPOLAR MOOD DISORDERS: 10 CASE REPORTS Giuseppe Tavormina "Psychiatric Studies Center" (Cen.Stu.Psi.), Provaglio d'Iseo (BS), Italy

SUMMARY The temperament is a key factor when assessing a patient within the bipolar spectrum. The temperaments are conditions in their own right within the bipolar spectrum, since they are ‘soft’ forms of bipolar condition within the spectrum: they can develop over time into a more clear bipolar condition, and hence are important in early diagnosis. Bipolar disorders are very often diagnosed late (approximately 25 year late, on average, from the beginning of the illness), in part because the temperaments of the patients have not been identified early.

Key words: bipolar spectrum – temperaments - early diagnosis – mixed states – mixity - mixed state rating scale

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BACKGROUND and incapable of fun, tending to worry, with frequent pessimistic cognitions, introverted, passive and le- Disorders of the bipolar spectrum (including sub- thargic, tending habitually to sleep long hours or threshold forms) are very common: more common suffering from intermittent insomnia, constantly than is usually believed, especially when we include preoccupied with inadequacy, failure, or negative the sub-threshold forms. These conditions are often events, tending to be sceptical, self-critical, over- underestimated epidemiologically, under-diagnosed, critical. and ineffectively treated or untreated (Agius 2007, The patient with the “Hyperthymic Temperament” Tavormina 2007). Inadequate diagnosis and conse- shows instead the following aspects: he is cheerful, quent inadequate treatment of these illnesses can lead tending to overoptimism and exuberance, demonstra- to various public health issues, with serious con- ting mental overactivity, tending to be overtalkative, sequences, including abuse of substances, employ- extrovert, people seeking, overconfident, a habitually ment difficulties, suicidal risk and problematic or short sleeper, having a high energy level, tending to be criminal behaviour (Akiskal-Rihmer 2009, Tavormina full of plans and improvident activities, tending to be 2010). overinvolved, uninhibited, stimulus seeking, or pro- Evaluating the characteristic of temperament of the miscuous. patient at the beginning of his history of mood disorder Finally, the patient with the “Cyclothymic-irritable is essential in making a correct diagnosis and pro- Temperament” shows the following aspects: he pre- viding the correct therapy. Rihmer and Akiskal (2009) sents a biphasic dysregulation of mood characterised have commented: “The sub-threshold types of tem- by slight endoreactive shifts from one phase to the perament have an important role in the evolution of other, each phase lasting for a few days at a time, with clinical episodes of mood disorder in that they indicate infrequent euthymia; mental overactivity, insomnia or the direction of the polarity and the formation of bad quality of sleep, and somatization. symptoms of acute mood episodes… They also signi- The “Softly- unstable Temperament” is a “soft ficantly affect the course and development of these cyclothymic temperament”, characterised by: vague pathologies, thus influencing the suicidal risk and and fluctuating uneasiness, mood instability of low other forms of self-destructive behaviours such as grade, anxiety traits, and trait-state overlap. substance abuse and eating disorders”. All the temperaments may develop over time into a Every patient with BSD has already presented in more clear bipolar picture. their personal history of illness subclinical evidence of Whereas the other three temperaments had been one of the temperaments: depressive temperament, described by Akiskal (1989), the softly unstable tem- hyperthymic temperament and cyclothymic-irritable perament has been first described by our group, based temperament; inside the cyclothymic temperament we on our clinical observations. can find the so called “softly-unstable temperament” (a When this temperament develops to threshold forms “soft cyclothymic temperament) (Tavormina 2012). of bipolar disorder, it presents a better prognosis than The patient with the “Depressive Temperament” cyclothymic temperament development (Tavormina shows the following aspects: he is gloomy, humourless 2009).

S398 Giuseppe Tavormina: HOW UNDERSTANDING THE TEMPERAMENTS CAN HELP CLINICIANS TO MAKE A CORRECT DIAGNOSIS OF BIPOLAR MOOD DISORDERS: 10 CASE REPORTS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 398-400

Table 1. Patients ages: diagnosis, years without correct diagnosis Beginning age Years lost GT-MSRS, Patients Sex Age Diagnosis Temperament of symptoms without diagnosis initial 1 F 31 28 3 Agitated depression Cyclothymic 6 (L) 2 F 44 14 30 Bipolar II Hyperthymic 11 (M) 3 F 50 20 30 Agitated depression Hyperthymic 11 (M) 4 M 32 28 4 Dysphoric depression Cyclothymic 8 (M) 5 M 40 30 10 Agitated depression Hyperthymic 9 (M) 6 F 47 20 27 Cyclothymia Cyclothymic 10 (M) 7 F 47 15 32 Cyclothymia Hyperthymic 10 (M) 8 F 76 40 36 Agitated depression Cyclothymic 8 (M) 9 M 52 25 27 Agitated depression-GAD Softly-unstable 8 (M) 10 M 45 15 30 Cyclothymia Cyclothymic 8 (M)

OBJECTIVE AND METHOD scale “GT-MSRS”, administered to the patients on the day of the “first visit”, helped and speeded this up. Ten consecutive new out-patients with the diag- Table 1 also shows for how many years the patients nosis of mood disorders, visited in my office in the had not received a correct diagnosis (data carefully first two months of the year 2018, have been included assessed from their history of illness) before the visit in this observational study, with the aim to show how in my office (all the patients told they were taking the correct evaluation of the temperament of the some inappropriate drugs, because they were feeling patients with mood disorders enables the psychiatrist ill). The prescription of a correct treatment with a to make an early diagnosis of bipolar disorder and at mood regulator allowed the patients to quickly reach a the same time, consequent to this, to prescribe ap- good level of quality of mood (figure 1 shows the propriate treatment (mood-stabilisers, with eventual average level of the improvement of the quality of antidepressant) to these patients. mood obtained by GAS). As the table 1 shows, the patients include males (4 patients) and females (6 patients), with a range of age GAS scores between 40 and 52 years old (except: only one patient 120 aged 76 years, and two patients under 40 years old). 96 The history of the illness of the patients, crucial to 100 identify the correct development of the symptoms of 80 the mood disorders (Tavormina 2007), shows how 60 early (sometimes very early) the mood disorder has 36 begun in the life of the patients, much before the day 40 of the “first visit” in my office. 20 The “G.T. Mixed States Rating Scales” was admi- 0 nistered on the day of the “first visit” of the patient, on at first visit, avarage points after 4 months, avarage points easier making a diagnosis of mixed states (and Figure 1. Level of quality of mood focusing on the symptoms of “mixity”; Tavormina et al. 2017); the level of uneasiness of the patients has been assessed by administering the GAS scale on the Clinical evaluations day of their “first visit”, and also after four months to It is crucial for the clinician to carefully assess the evaluate the level of the improvement of the quality of patient by taking a careful history of the illness and mood (Figure 1); the “Tavormina bipolar disorders also the family history, identifying the temperaments scheme” (Tavormina 2007, Tavormina 2012) has been so as to make a correct diagnosis of mood disorders: followed for the diagnostic modalities. my motto is “a correct treatment follows to a correct diagnosis”. RESULTS Very often the patients with bipolar disorders received a correct diagnosis after several years: my present Interesting results have been obtained with this and also past papers (McCombs et al. 2007, McCraw et observational study: the diagnostic approach of iden- al. 2014) have confirmed that bipolar patients receive a tifying the temperaments of the patients alongside their correct diagnosis 25 year late, on average, from the be- history of illness enabled an early diagnosis of ginning of the ilness. The clinicians meet great diffi- bipolarity and the prescription of a correct treatment culties in making a correct diagnosis of mood dis- with a mood regulator; the utilization of the rating orders which they are assessing, above all when mixed

S399 Giuseppe Tavormina: HOW UNDERSTANDING THE TEMPERAMENTS CAN HELP CLINICIANS TO MAKE A CORRECT DIAGNOSIS OF BIPOLAR MOOD DISORDERS: 10 CASE REPORTS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 398-400 states are present: this is because the patients mainly 6. Tavormina G & Agius M: A study of the incidence of focus their own symptoms on depressive uneasiness bipolar spectrum disorders in a private psychiatric (inducing the clinicians to frequently prescribe antide- practice. Psychiatr Danub 2007; 19:370-74 pressants drugs alone or together with benzodiazepines), 7. Rihmer Z, Akiskal HS, et al.: Current research on affective temperaments. Current Opinion in Psychiatry 2010; inducing them to prescribe these inadequate treatments 23:12-18 and not take note of the real problem of increasing 8. McCombs JS, Ahn J, et al.: The impact of unrecognized dysphoria caused by these treatments. bipolar disorders among patients treated for depression The “mixity” of depressive phases (that are the with antidepressants in the fee-for-services California most insidious symptoms of overlapped depression- Medicaid (Medi-Cal) program: a 6-year retrospective restlessness-irritability) can cause increased risk of analysis. J Affect Disord 2007; 97:171-9 suicidality (Akiskal 2007). 9. McCraw S, Parker G, et al.: The duration of undiagnosed bipolar disorder: effect on outcomes and treatment response. J Affect Disord 2014; 168:422-9 CONCLUSIONS 10. Tavormina G: The bipolar spectrum diagnosis: the role of the temperaments. Psychiatr Danub 2009; 21:160-161 The bipolar disorders are pathologies which are of- 11. Tavormina G: The temperaments and their role in early ten underestimated or, worse, not diagnosed or mis- diagnosis of bipolar spectrum disorders. Psychiatr Danub treated (Agius 2007, Tavormina 2007). The subthre- 2010; 22(suppl 1):15-17 shold presence of the temperaments in the history of 12. Agius M, Zaman R, et al.: Mixed affective states: a study the patients with BSD allows us to consider this to be a within a community mental health team with treatment crucial method for early diagnosis of bipolar spectrum recommendations. European Psychiatry 2011; mood disorders. It is very important to focus on the 26(suppl 1):P01-145 temperaments during the clinical interview, in order to 13. Tavormina G: Are somatisations symptoms important evidence for an early diagnosis of bipolar spectrum mood be effective in the early diagnosis of mood instability. disorders? Psychiatr Danub 2011; 23(suppl 1):13-14 14. Tavormina G & Agius M: An approach to the diagnosis and treatment of patients with bipolar spectrum mood Acknowledgements: None. disorders, identifying temperaments. Psychiatr Danub 2012; 24(suppl 1):25-27 Conflict of interest: None to declare. 15. Tavormina G: An early diagnosis of bipolar spectrum disorders needs of valuing the somatisation symptoms of patients. J Int Clin Psychopharmacol 2012; 28:e59-e60 References 16. Tavormina G: A long term clinical diagnostic-therapeutic evaluation of 30 case reports of bipolar spectrum mixed 1. Akiskal HS: The prevalent clinical spectrum of bipolar states. Psychiatr Danub 2013; 25(suppl 2):190-3 disorders: beyond DSM-IV. J Clin Psychopharmacol 17. Tavormina G: An introduction to the bipolar spectrum. 1996; 16 (suppl 1):4-14 The management of bipolar spectrum disorders, summer 2. Akiskal HS, Pinto O: The evolving bipolar spectrum: Proto- 2013, CEPIP, 3-6 types I, II, III, IV. Psychiatr Clin North Am 1999; 22:517- 18. Tavormina G: Treating the bipolar spectrum mixed states: 534 a new rating scale to diagnose them. Psychiatr Danub 3. Akiskal HS: Targeting suicide prevention to modifiable 2014; 26(suppl 1):6-9 risk factors: has bipolar II been overlooked? - Acta 19. Tavormina G: Clinical utilisation of the “G.T. MSRS”, the Psychiatr Scand 2007; 116:395-402 rating scale for mixed states: 35 cases report. Psychiatria 4. Agius M, Tavormina G, Murphy CL, Win A, Zaman R: Danubina 2015; 27(suppl 1):155-59 Need to improve diagnosis and treatment for bipolar 20. Tavormina G: An approach to treat bipolar disorders disorder. Br J Psych 2007; 190:189-191 mixed states. Psychiatr Danub 2016; 28(suppl 1):9-12 5. Tavormina G & Agius M: The high prevalence of the 21. Tavormina G et al.: Clinical utilisation and usefullness of bipolar spectrum in private practice. J Bipolar Dis Rev & the rating scale of mixed states, (GT- MSRS)”: a multi- Comm 2007; 6:19 center study. Psychiatr Danub 2017; 29(supp 3):365-67

Correspondence: Giuseppe Tavormina, MD President of "Psychiatric Studies Center" (Cen.Stu.Psi.) Piazza Portici, 11 - 25050 Provaglio d'Iseo (BS), Italy E-mail: dr.tavormina.g @libero.it

S400 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 401-404 Conference paper © Medicinska naklada - Zagreb, Croatia

DEPRESSION AND PHYSICAL HEALTH, THE THERAPEUTIC ALLIANCE AND ANTIDEPRESSANTS Nicolas Zdanowicz1, Christine Reynaert1, Denis Jacques1, Brice Lepiece1, Fabrice Godenir2, Valerie Pivont3 & Thomas Dubois1 1Université Catholique de Louvain, CHU Namur Godinne, Psychosomatics Unit, Yvoir, Belgium 2CHU Namur, Hopital St Vincent, Dinan, Belgium 3CHU Namur, Clinique St Elisabeth, Namur, Belgium

SUMMARY Background: In a two-year study we compared the efficacy of noradrenergic (duloxetine D) and serotonergic (escitalopram E) antidepressants with and without the addition of 100 mg acetylsalicylic acid (ASA) in subjects suffering from a major depressive episode (MDE). The results showed that the D + ASA (DASA) group improved more rapidly than the E + placebo (EP) subgroup. In particular, Hamilton Depression Scale (HDS) scores improved as early as two months, Clinical Global Impression (CGI) scores improved at five months, and remission rates were better. In the course of this study, we also investigated the role of the therapeutic relationship (alliance) on both the progress of the MDE, and patients’ mental and physical health. Subjects and methods: 40 people suffering from an MDE were randomly assigned to treatment groups. At the beginning of the study sociodemographic data were collected, and the Helping Alliance Questionnaire (HAQ) was completed. During the study, patients were regularly assessed using the HDS, CGI and the Short Form Health Survey (SF-12). Results: Subgroup comparisons revealed that HAQ scores are not correlated with HAD scores, but a correlation was found with remission rates (r=0.316*). Similarly, at all times, HAQ scores were correlated with physical health (p<0.05), which is in turn correlated with HDS and CGI scores. Conclusion: Physical health is linked to the level of depression. While the alliance with the patient is not directly correlated with the intensity of depression, is it correlated with their physical condition and its improvement. For patients, improving their physical health appears to be more important than improving their mental health. These observations must be confirmed.

Key words: depression – alliance – therapeutic relationship – antidepressant drugs – physical health

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INTRODUCTION The 2012 study also sought to investigate the influence of the therapeutic relationship on depression, and, The efficacy of antidepressant medication remains a more generally, on the health of the patient as many major research challenge. Although new generations of previous studies have highlighted: antidepressants have revolutionized treatment compared The determinant role of the alliance in treatment to older tricyclics, ultimately, they do not seem to have and, in particular, in patients suffering from a major improved response or remission rates (Zdanowicz et al. depressive episode (MDE) (De Bolle et al. 2010, 2008). The long-term efficacy of antidepressants and the Martin et al. 2000). comparative effectiveness of noradrenergic (SNRI) and And, on the other hand: serotonergic (SSRI) treatments remain poorly-explored. The reciprocal influence of depression on health and Similarly, in the context of the psychoimmunology vice versa. Physical comorbidities associated with de- hypothesis, the administration of an adjunctive anti- pression are well-established (Coulehan et al. 1990), inflammatory drug, such as acetylsalicylic acid (ASA), and studies demonstrating the impact of physical to increase the effectiveness of an antidepressant has health on depression have found an effect, notably in shown inconsistent results. the elderly (Berkman et al. 1986). Therefore, in 2012 we launched a study to compare, over a two-year period the effectiveness of an SSRI SUBJECTS AND METHODS (escitalopram: E) with an SNRI (duloxetine: D), each with concomitant administration of either 100 mg ASA Subjects or a placebo. The initial results were published in 2017 This randomized, open-label study began on 1 June (Zdanowicz et al. 2017). These showed that for the 2012 with the first 40 inpatients that met the inclusion SNRI + ASA group, Hamilton Depression Scale (HDS) criteria. Patients were followed up for two years. Inclu- scores improved at two months (t=-3.114, p=0.01), sion criteria were as follows: Clinical Global Impression (CGI) scores had improved the patient must meet DSM-IV-R criteria for a MDE; at five months (t=-2.119, p=0.05), and remission rate it must be the patient’s first or second MDE; 2 improved (Ȥ =6.296, p= 0.012) compared to the SSRI + no symptoms of depression during the preceding two placebo (EP) subgroup. years;

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no history of other psychiatric disorders on Axis I of red test, and means were compared using Student’s t- the DSM-IV-R; test. Significance levels were set at p>0.95 and p<0.05. no history of gastritis, or gastric or oesophageal ulcers; Data are presented as the mean ± standard deviation. aged between 18 and 63 years; at the beginning of the study the patient must be free RESULTS of any other medical condition. Patient demographics Patients taking depressogenic drugs (e.g. beta blockers, morphine derivatives) were excluded, and no The study group comprised seven men and 33 wo- formal psychotherapy took place for the duration of men, with a mean age of 40.33±14.37 years. Monthly the study. income was 1800±723 € and household size was 2.7±1.5 Volunteer screening was conducted, and written con- people. Comparisons of the ASA and placebo groups sent was validated by the local ethics committee (under only found a significant difference in age (ASA group, B03920072846). Patients were then randomly allocated 46.4 years; placebo group, 34.25 years; t=2.98, p=0.05). to one of the four experimental groups. In total, 40 pa- No correlation was found between age and HDS scores, tients completed the study. The antidepressant + placebo except at month one (p=0.026, r=-0.352). No significant group (n=20) comprised a duloxetine + placebo (DP) difference was observed between the duloxetine and esci- subgroup (n=11), and an escitalopram + placebo (EP) talopram groups, and the two groups were statistically subgroup (n=9). The antidepressant + ASA group similar in terms of income (t=0.086, p=0.932). (n=20) comprised a duloxetine + ASA (DASA) subgroup (n=8), and an escitalopram + ASA (EASA) Depression, remission subgroup (n=12). and therapeutic relationship The mean HDS score was 23.83±3.2. No correlation Methods was found between HAQ and HDS scores and reci- No further medication was administered to patients divism. The only significant correlation was found bet- in remission (defined as the disappearance of all of ween the level of remission and therapists’ HAQ scores diagnostic criteria for a MDE) at six months, but follow- (p=0.01, r=0.404**) – but not patients’ HAQ scores. up continued until the end of the study. For patients who left, the last score obtained was recorded for the re- Health and the therapeutic relationship maining assessments (the Last Observation Carried The physical and mental health of patients is clearly Forward method). poorer than healthy controls (physical health (PH) At time 0, the following assessments were carried out: 36.74/51.14, t=6.353, p<0.000; mental health (MH) The Mini International Neuropsychiatric Interview, 35.10/51.51, t=5.846, p<0.000). The composition of the to exclude any past or present psychiatric pathology. ‘healthy’ patient group is described in earlier work Sociodemographic data: age; gender; number of (Zdanowicz et al. 2011). Even if, at the end of the study, people in the household; and socioeconomic status, patients described themselves as being better, both in evaluated by approximate net monthly income (€; terms of their physical (36.74 ĺ 39.09, t=-2.032, <1000, 1000–2000, 2000–3000, 3000–4000, >4000). p=0.049) and mental health (35.10 ĺ 40.81, t=-2.476, The relationship between the patient and his/her thera- p=0.018) differences with the control group at 24 pist, and the relationship between the therapist and months remain significant (PH 39.09/52.39, t=4.659, the patient, based on the revised Helping Alliance p<0.000; MH 40.81/52.70, t=3.965, p<0.000). Questionnaire (HAQ) (Luborsky et al. 1996). Table 1. Correlation between SF12 and HAQ Patients were assessed with the 17-item Hamilton HAQ patient HAQ therapist depression scale (HDS) at 0, 0.5, 1, 1.5, 2, 3, 6, 12, 18, and 24 months. The clinical global impression (CGI) PH0 -0.035 0.309* scale was completed by the therapist following each visit. PH6 -0.281 0.442** The level of physical health (physical functioning, daily PH12 0.197 0.489** life functioning, physical pain, and general health), and PH18 0.189 0.476** mental functioning (vitality, social functioning, daily PH24 0.220 0.530** mental life functioning, and mental health) was assessed MH0 -0.154 0.319* using the Short Form Healthy Survey (SF12) (Ware et MH6 0.237 0.066 al. 1996) and recorded at 0, 6, 12, 18, and 24 months. A parametric statistical analysis was carried out using MH12 0.225 0.127 SPSS 25, taking Type 1 and 2 errors into account. No MH18 0.222 0.109 post hoc tests were carried out. A Pearson correlation MH24 0.215 0.111 analysis was carried out to identify potential covariates. * Correlation is significant at the 0.05 level (bilateral); Qualitative variables were compared with the Chi-squa- ** Correlation is significant at the 0.01 level (bilateral)

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Table 2. Correlations between SF12, HDS and CGI HDS0 HDS6 HDS12 HDS18 HDS24 CGI0 CGI6 CGI12 CGI18 CGI24 PH0 -0.442* -0.357* -0.338 -0.341 -0.337 -0.144 -0.297 -0.350* -0.350* -0.351* PH6 -0.255 -0.478** -0.472** -0.482** -0.488** 0.032 -0.482** -0.476** -0.476** -0.468** PH12 -0.397* -0.502** -0.501** -0.507** -0.501** 0.017 -0.463** -0.524** -0.524** -0.510** PH18 -0.421* -0.499** -0.508** -0.508** -0.500** 0.001 -0.467** -0.524** -0.524** -0.509** PH24 -0.380* -0.519** -0.522** -0.527** -0.519** 0.014 -0.479** -0.534** -0.534** -0.536** MH0 0.150 0.053 0.043 0.047 0.046 0.138 -0.103 -0.037 -0.037 -0.057 MH6 -0.170 -0.388* -0.364* -0.360* -0.359* 0.223 -0.479** -0.472** -0.472** -0.495** MH12 -0.133 -0.385* -0.422* -0.419* -0.407* 0.280 -0.507** -0.530** -0.530** -0.549** MH18 -0.174 -0.416* -0.446** -0.443** -0.433* 0.297 -0.534** -0.554** -0.554** -0.566** MH24 -0.171 -0.425* -0.451** -0.450** -0.440* 0.302 -0.537** -0.570** -0.570** -0.583** * Correlation is significant at the 0.05 level (bilateral); ** Correlation is significant at the 0.01 level (bilateral); *** Correlation is significant at the 0.001 level (bilateral)

Table 1 shows that the alliance, as perceived by the It appears that psychiatrists believe that they are therapist, is an important factor in improving the pa- acting on the patient’s depression and that the HDS tient’s physical condition. scores are proof. On the other hand, it appears that patients are more preoccupied by their physical health, Health and depression and any improvement in the intensity of their depression is secondary to this physical improvement. Finally, thera- Table 2 shows that there is a significant correlation pists believe that they can achieve complete remission, between patients’ physical and mental health, on the one while for the patients, even after two years, there is still hand and, on the other hand, the intensity of depression no return to normal. and clinician’s assessment of its severity. However, How can we interpret these differences? In the what is surprising in this table is the virtual absence of a elderly, it is commonly understood that depression can correlation at time 0 - the link between ‘health’ and occur as a result of chronic pain due to progressive, age- ‘depression’ dimensions only appears in the sixth month. related loss of autonomy. Therefore, we tend to think of We see two possible interpretations. First, it should be depression in the elderly as an evolution that begins noted that the SF12 is completed by the patient, while with deteriorating physical health, which transitions into the psychiatrist completes the HDS and the CGI. The depression. Conversely, in adults we understand that a first possibility is that it is a univocal mechanism that is depressive state can subsequently be expressed by dependent on the therapist: he/she has to have seen the somatic complaints. But perhaps we are wrong. It may patient several times before his/her evaluation becomes be that even adults feel physically impaired before they consistent with his/her patient’s perceptions. The second say that they are depressed. possibility is that a dynamic process operates between the therapist and the patient, who come to an ‘agreement’ on the evaluation of the situation. CONCLUSION Physical health is linked to the level of depression. DISCUSSION While the relationship with the patient is not found to be directly correlated with the intensity of depression, it is The first point to note is the study’s small sample correlated with physical health and its improvement. For size, which greatly limits the generalizability of our patients, it appears that improving their physical health conclusions. Despite this, several points deserve further is more important than improving their mental health. discussion. First, unlike earlier work, we did not find a These observations must be confirmed. direct link between the alliance and the intensity of depression. The only direct link was found with the remission rate. On the other hand, the relationship Acknowledgements: None. described by the clinician is clearly linked to the patient’s perception of their health and its improvement. Conflict of interest: None to declare. What is very surprising, however, is that an effect is seen regarding patients’ physical, rather than their Contribution of individual authors: mental health. Physical health is clearly associated with All authors made a substantial contribution to the the intensity of depression and, if both improve, it does design of the study, and/or data acquisition, and/or not return to the ad integrum level when compared to the data analysis and its interpretation. the control group.

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References 5. Martin DJ, Garske JP, Katherine Davis M: Relation of the therapeutic alliance with outcome and other variables: A 1. Berkman LF, Berkman CS, Freeman DH, Leo L, Ostfeld meta-analytic review. J Cons Clini Psychol 2000; 68:438-450 AM, Cornoni J et al: Depressive symptoms in relation to 6. Ware JE, Keller SD: A 12-item short form healthy survey: physical health and functioning in the elderly. Am J construction of scales and preliminary tests of reliability Epidemiol 1986; 124:372-388 and validity. Medical Care 1996; 34:220-233 2. Coulehan JL, Schulberg HC, Block MR, Janosky JE, 7. Zdanowicz N, Jacques D, Reynaert Ch: Comparisons Arena VC: Medical comorbidity of major depressive between psychotropics drugs: must the risk of side effects disorder in a primary medical practice. Arch Intern Med dictate our practices? Acta Clin Belg 2008; 4:235-241 1990; 150:2363-7 8. Zdanowicz N, Lepiece B, Tordeurs D, Jacques D, Rey- 3. De Bolle M, Johnson JG, De Fruyt F: Patient and clini- naert Ch: Predictibility of levels of physical and mental cian perceptions of therapeutic alliance as predictors of health: a 2 years longitudinal study. Psychiatr Danub improvement in depression. Psychother Psychosom 2010; 2011; 23:8-12 79:378-385 9. Zdanowicz N, Reynaert C, Jacques D, Lepiece B. Dubois T: 4. Luborsky L, Barber JP, Siqueland L, Johnoson S, Naja- Selective serotoninergic (SSRI) versus noradrenergic reup- vatis LM, Frank et al: The revised helping alliance ques- take inhibitors with and without acteylslicylic acid in major tionnaire. J Psychother Pract Research 1996; 5:260-271 depressive disorder. Pycha Danub 2017; 27:270-273

Correspondence: Prof. Nicolas Zdanowicz, MD, PhD Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital 5530 Yvoir, Belgium E-mail: [email protected]

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RELATIONSHIP BETWEEN COGNITIVE REMEDIATION AND EVALUATION TOOLS IN CLINICAL ROUTINE Francesco Franza1, Barbara Solomita2, Ferdinando Pellegrino3 & Gino Aldi4 1"Villa dei Pini" Psychiatric Rehabilitation Centre, Avellino, Italy 2Neamente Neuroscience Association, Avellino, Italy 3Mental Health Department, ASL Salerno, Nocera Inf (SA), Italy 4Zetema Association, Caserta, Italy

SUMMARY Many clinicians do not have adequate knowledge and interest in assessing cognitive deficits in psychiatric patients. However, these deficits are crucial and key symptoms, which can lead to impairment of quality of life, worsening of symptoms of disorders and difficulties in social, family and work relationships. Another limitation to the assessment of cognitive deficits is the poor maneu- verability and practicality of the main cognitive assessment tools. Because there are no appropriate pharmacological approaches, new techniques have been developed to improve cognitive abilities in these patients. The most important techniques concern cognitive remediation (CR). In this article we summarize the main techniques of cognitive remediation.

Key words: cognitive deficits - cognitive remediation - CRT

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INTRODUCTION that may be crucial for understanding the social impairments in some psychiatric disorders (Pinkham Cognitive deficits are a central and enduring fea- 2014). In this context four domains of cognition were ture of some psychiatric disorders such as schizo- considered: (1) emotion processing, (2) social percep- phrenia, bipolar disorder (BD) and major depressive tion, (3) theory of mind/mental state attribution (ToM), disorder (MDD). They have a significant impact on the and (4) attributional style/bias. Social cognition is an social functioning, on the response to rehabilitation important aspect in schizophrenia and other psychiatric programs and on psychotic symptomatology. These disorders, in general, as in major depressive disorder deficits also interfere with the overall functioning of (MDD). Indeed, several studies have highlighted defi- the individual, such as work activity, quality of life cits in executive function in approximately 20% to and psychosocial functioning. As confirmed by nu- 40% of patients with MDD, and this impairment is merous scientific studies, patients with schizophrenia disproportionately represented in patients who have or major depressive disorder have worse cognitive not returned to full psychosocial functioning (Cul- responses than healthy comparators in neuropsycho- pepper 2017). The definitive objective of treatment in logical trials, particularly, in the speed of information MDD is a functional recovery, and implement of reco- processing, in selective attention, in working memory very needs regular clinician assessment, patient self- and in the executive function (Kaser 2017, Albert report, and performance testing. Below, the main 2018). Patients with schizophrenia, for example, have cognitive assessment tools will be listed and analyzed. profound and disabling cognitive deficits that represent However, cognitive impairment in patients with de- an independent and separate symptom domain, with pression is often overlooked because cognitive deficits respect to negative symptoms, depression, neurocog- and symptoms of depression often overlap. It must be nition, and social cognition (Franza et al. 2017). emphasized that cognitive deficits are also present in Cognitive deficits are qualitatively similar in schizo- other psychiatric disorders, for examples, in Mixes phrenia and bipolar and unipolar depression. However, States (Tavormina 2017), in some personality dis- the severity of impairment differs among these disorders, in anxiety districts, in the OCD. orders, with the most severe deficits seen in patients The foremost problem of the clinician is the diffi- with schizophrenia, followed by BD, and the least culty to evaluate these domains despite the importance severe deficits noted in individuals with MDD (Russo they have in the management of the disease. The limits 2015). of the evaluation are numerous. First of all, there is the An important aspect of cognition in psychiatric lack of knowledge of these symptoms; then there is disorder is the social cognition. Usually, it’s defined as little information on cognitive evaluation mainly due “the cognitive processes that allow people to perceive, to the reduced information of specific cognitive interpret, and respond to the intentions, dispositions, assessment tools. Thus, the difficulty in administering and behaviors of others”. And this definition under- the main rapid, and repeatable cognitive assessment lines a link between social cognition and behaviour tools.

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A “BRIEF OVERVIEW” OF COGNITIVE psychomotor speed, and executive function; Perceived ASSESSMENT TOOLS Deficits Questionnaire 5-Item Version (PDQ) that assesses self-perceived cognitive difficulties; EpiTrack® An increasing interest in the study of cognition in (Lutz 2005) a tool designed to assess and track changes several psychiatric disorders has risen sharply in the last in cognitive function in people with epilepsy. Finally, decade although cognitive problems have been des- the THINC-Integrated Tool (THINC-it) (McIntyre 2017) cribed in these disorders since the beginning of the 20th that is used in screening and assessment of cognitive century (Bralet 2008). Assessment of cognitive symp- Dysfunction; this tool is equipped with a simple toms in the research context has a long history. Several application for tablets, free to be scribbled. validated instruments are available with good to excellent psychometric properties. However, in clinical prac- COGNITIVE REMEDIATION (CT) tice most psychiatrists not only they are not very capable, but they do not consider their evaluation important These brief considerations highlight the importance in assessment of disorders. So, cognitive symptoms are of the assessment, management and treatment of cogni- neither fully understood nor commonly assessed in tive deficits. As pharmacological therapies have not clinical practice. The use of instruments to assess cogni- been found to be effective in this symptomatic group of tion in major depressive disorder (MDD) and bipolar psychiatric patients, several cognitive remediation disorder (BPD) was lower, 38% and 37% respectively. techniques (“cognitive remediation”) have been develo- Among the reported instruments used, only a few were ped. Therefore, there is a crucial need of new treatment actually appropriate for the use in the diseases (12% in strategies for patients with schizophrenia to achieve schizophrenia, 3% in MDD and 0% in BPD) (Belgaied clinically relevant enhancement in these functional do- 2014). These findings reveal some lacunas in routine mains (Palumbo 2017). Over the years there has been a clinical evaluation of cognitive function. proliferation of new cognitive treatment approaches and several meta-analyses indicate that cognitive treatment The correct identification and evaluation of objecti- has the most benefit when included in a comprehensive ve cognitive dysfunction is increasingly important for program of psychiatric rehabilitation. Cognitive reme- clinicians because it can help to formulate a correct diation (CR) is, indeed, a behavioural intervention ai- therapeutic management of the diseases. McIntyre (2017) ming to improve cognitive processes in neuropsychiatric believes that an effective psychometric tool for assessing disorders. Cognitive remediation therapy (CRT) is a cognition should comprehensively assess the domains of psychological therapy, which improves cognitive and attention and concentration, learning and memory, social functioning in several disorder such as schizo- processing speed and executive function and should phrenia, mood disorders and depression disorder. CR is include self-rated and objective measures. Despite the a behavioural approach to treatment with basic beliefs prevalence and significant impact on patients' lives, that involve the following three components: cognitive during the different episodes of the disorders, cognitive functions representing separable domains (e.g., atten- symptoms are neither fully understood (Franza 2016). tion, memory, etc.); rehabilitation of impaired cogni- The tool must be sensitive (i.e., cognitive impair- tive; improving skills that may result in reduced illness ment), produce consistent results across time for healthy symptom burden or functional impairment (Dickstein controls, be valid and easy to administer in the clinical 2015, Vinogradov 2012). routine, quick and repeatable. Moreover, today, the The Cognitive Remediation Therapy (CRT) is speci- availability and knowledge of computers make prefer- fically designed for rehabilitating attention, memory and able the computerized tools (Hargreaves 2018). The cost functions executive bodies, i.e., areas that are parti- of testing and restricted cooperation of psychiatric pa- cularly deficient in schizophrenia. The Cognitive Reme- tients are both promoters for developing brief efficient diation Experts Workshop in 2012 defined it as “an batteries. Evaluating the cognitive benefits of treatments intervention targeting cognitive deficit using scientific requires reliable, valid, and efficient assessment proce- principles of learning with the ultimate goal of impro- dures. Various tools have been developed for the assess- ving functional outcomes”. As defined at the Cognitive ment of cognitive deficits in psychiatric patients (see Remediation Experts Workshop (Florence, Italy, April table 1). The most widely used scales (including 2010), cognitive remediation therapy for schizophrenia MCCB, EUFEST, CATIE, BACS, WAIS-IV), however, is “a behavioral training-based intervention that aims to for complexity and time used for compiling are difficult improve cognitive processes (attention, memory, execu- to use in daily clinical practice. Thus, the use of instru- tive function, social cognition or metacognition) with the ments for cognitive assessment in schizophrenic and goal of durability and generalization.” The CRT con- other psychiatric patients is very low (Franza 2016). sists of a structured cognitive training program of three Recently, several cognitive assessment tools have been modules generated for the development of functions as proposed. Among the assessment tests, assessment bat- cognitive flexibility, working memory and planning, teries and procedures, the main ones are the following: with the aim of encouraging the person to acquire stra- Mini-Mental State Examination (MMSE); Brief Assess- tegies to solve problems, with the support of a therapist ment Cognition Schizophrenia (BACS); Digit Symbol who leads the subject towards an appropriate response Substitution Test (DSST) designed to assess attention, to the demands of the environment.

S406 Francesco Franza, Barbara Solomita, Ferdinando Pellegrino & Gino Aldi: RELATIONSHIP BETWEEN COGNITIVE REMEDIATION AND EVALUATION TOOLS IN CLINICAL ROUTINE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 405-408

Table 1. Cognitive assessment tools Administra- Autor/s tion time BACS Brief Assessment of Cognition in Schizophrenia 35 min Keefe et al. 2004 CATIE Clinical Antipsychotic Trials of Intervention Effectiveness Keefe et al. 2006 MCCB MATRICS Consensus Cognitive Battery 60-80 min Nuechterlein 2008, Kern 2008 WAIS-IV Wechsler Adult Intelligence Scale - Fourth Edition 90 min Wechsler 2008 EUFEST European First Episode Schizophrenia Trial Fleischhacker 2005 MMSE Mini-Mental State Examination 10-15 min Folstein & McHugh 1975 DSST Digit Symbol Substitution Test 10 min Wechsler 1981 PDQ Perceived Deficits Questionnaire 5-Item Version 5-10 min Sullivan et al. 1990 EpiTrack® 20 min Lutz 2005 THINC THINC-Integrated Tool (THINC-it) 15 min McIntyre et al. 2017

Table 2. Cognitive remediation therapy programmes CIRCuiTS A new generation computerised CR programme developed to en- Wykes et al. 2018 Computerised Interactive hance strategic and metacognitive processing, with an integrated Reeder et al. 2017 Remediation of Cognition - focus on the transfer of cognitive skills to daily living a Training for Schizophrenia SoCIAL A new social cognition (SC) remediation intervention, designed Palumbo et al. 2017 The Social Cognition for patients with schizophrenia or schizoaffective disorder, spe- Individualized Activities cifically aimed to improve SC). The training includes a module Lab (SoCIAL) for emotion recognition (ER) and one for theory of mind (ToM) SSANIT Include a computerized neurocognitive individualized training Bucci et al. 2013 Social Skills And Neuro- (NIT) and a social skills individualized training (SSIT, in im- cognitive Individualized proving daily functioning and quality of life, and reported that Training (SSANIT) although both NIT and SSIT have a favorable impact on domains of functional outcome, only NIT improves cognitive functioning COGPACK A cognitive remediation program. It offers exercises with a Scheu et al. 2013 variety of difficulty levels to target visual-motor functioning, comprehension, attention, memory, language use, and skills training. It also allows clinicians and users to determine the initial difficulty level

In a recent article Listunova and colleagues (2018) CONCLUSIONS have summarized the neurocognitive deficits during acute and remitted states of depression and their In this brief communication we have tried to high- relationship with cognitive remediation therapy (CRT), light the critical aspects of cognitive evaluation and its physical exercise, yoga, mindfulness-based therapy, and management. The assessment, management and treat- modern neuromodulation approaches, like neurostimu- ment of cognitive deficits are a challenge for clinicians. lation and neurofeedback training. Authors concluded In fact, the function of cognitive domains is a funda- that CRT is an efficacy tool as non-pharmacological mental element in the management of many psychiatric treatment in these patients. Particularly, the authors em- disorders, for example, schizophrenic spectrum disorders, phasized acceptability and ease of administration of this mood disorders, personality disorders. In recent years tool. Moreover, Lindenmayer and colleagues (2018) em- there has been an increase in knowledge on the effec- phasize the importance of cognitive remediation (CRT) tiveness of cognitive assessment techniques and cogni- with computerized social cognition. ”CRT with compu- tive remediation. Simple, quick and more repeatable terized social cognition training produced greater cognitive assessment tools, and especially accepted by benefits in neurocognition, including visual learning, patients, begin to be used in clinical practice. Some cog- memory, executive functions, and social cognition nitive evaluation tools should be more widely used. relative to cognitive training alone”. “These findings” Particularly useful, repeatable and simple to use are the they conclude “favouring the combined training may be Brief Assessment Cognition Schizophrenia (BACS); Digit contributed to both the greater overall amount of Symbol Substitution Test (DSST); Perceived Deficits cognitive practice, as well as the specific cognitive Questionnaire 5-Item Version (PDQ); EpiTrack® (Lutz functions engaged by the social cognition training”. 2005) and the THINC-Integrated Tool (THINC-it). These The most widespread cognitive remediation therapy instruments are accepted by the patient and can be used to programmes are in table 2. evaluate their effectiveness of cognitive remediation tech-

S407 Francesco Franza, Barbara Solomita, Ferdinando Pellegrino & Gino Aldi: RELATIONSHIP BETWEEN COGNITIVE REMEDIATION AND EVALUATION TOOLS IN CLINICAL ROUTINE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 405-408 niques over time, behavioural interventions aiming to im- 11. Hargreaves A, Daly-Ryan N, Dillon R, Donohoe G: Inde- prove cognitive processes in neuropsychiatric disorders. pendent Computerized Cognitive Remediation for Psycho- The cognitive remediation therapy (CRT) should be sis: An Investigation of Patient Experiences. J Nerv Ment Dis 2018; 206:606-613 used in clinical pathology and become a priority thera- 12. Kaser M, Zaman R, Sahakian BJ: Cognition as a treatment peutic strategy for the management of cognitive deficits target in depression. Psychol Med 2017; 47:987-989 of patients affected by several psychiatric diseases. 13. Keefe RS, Goldberg TE, Harvey PD, Gold JM, Poe MP, Coughenour L: The Brief Assessment of Cognition in Schizo- Acknowledgements: None. phrenia: reliability, sensitivity, and comparison with a standard neurocognitive battery. Schizophr Res 2004; 68:283-9 Conflict of interest: None to declare. 14. Keefe RS, Bilder RM, Harvey PD, Davis SM, Palmer BW et al.: Baseline neurocognitive deficits in the CATIE schizo- Contribution of individual authors: phrenia trial. Neuropsychopharmacology 2006; 31:2033-46 Francesco Franza, Barbara Solomita, Ferdinando 15. Lindenmayer JP, Khan A, McGurk SR, Kulsa MKC, Ljuri I, Pellegrino & Gino Aldi conceived and designed the Ozog V, et al.: Does social cognition training augment study; all authors approved the final version of the response to computer-assisted cognitive remediation for manuscript. schizophrenia? Schizophr Res 2018; 14 16. Listunova L, Roth C, Bartolovic M, Kienzle J, Bach C, Weisbrod M, Roesch-Ely D: Cognitive Impairment Along References the Course of Depression: Non-Pharmacological Treatment 1. Albert KM, Potter GG, McQuoid DR, Taylor WD: Cogni- Options. Psychopathology 2018; 5:1-11 tive performance in antidepressant-free recurrent major 17. McIntyre R, Best MW, Bowie CR, Carmona NE, Cha DS, depressive disorder. Depress Anxiety 2018; 35:694-699 Lee Y, et al.: The THINC-Integrated Tool (THINC-it) Scree- 2. Belgaied W, Samp J, Vimont A, Rémuzat C, Aballéa S, El ning Assessment for Cognitive Dysfunction: Validation in Hammi E, Kooli A, Toumi M, Akhras K: Routine clinical Patients With Major Depressive Disorder. J Clin Psychiatry assessment of cognitive functioning in schizophrenia, major 2017; 78:873-881 depressive disorder, and bipolar disorder. Eur Neuro- 18. McIntyre: Cognitive Impairment in Patients With De- psychopharmacol 2014; 24:133-41 pression: Awareness, Assessment, and Management. 3. Bralet MC, Navarre M, Eskenazi AM, Lucas-Ross M, https://www.cmeinstitute.com/Psychlopedia/Pages/depressi Falissard B: Interest of a new instrument to assess cogni- on/29cip/sec2/section.aspx tion in schizophrenia: The Brief Assessment of Cognition in 19. Palumbo D, Mucci A, Piegari G, D'Alise V, Mazza A, Schizophrenia (BACS). Encephale 2008; 34:557-62 Galderisi S: SoCIAL - training cognition in schizophrenia: 4. Bucci P, Piegari G, Mucci A, Merlotti E, Chieffi M, De Riso a pilot study. Neuropsychiatr Dis Treat 2017; 13:1947-1956 F, De Angelis M, Di Munzio W, Galderisi S: Neurocognitive 20. Pinkham AE: Social Cognition in Schizophrenia. J Clin individualized training versus social skills individualized Psychiatry 2014; 75(Suppl 2):14-9 training: a randomized trial in patients with schizophrenia. 21. Reeder C, Huddy V, Cella M, Taylor R, Greenwood K, Lan- Schizophr Res 2013; 150:69-75 dau S, Wykes T: A new generation computerised metacogni- 5. Cognitive Remediation Experts Workshop: Cognitive Re- tive cognitive remediation programme for schizophrenia mediation Experts Workshop Meeting. Florence: Schizo- (CIRCuiTS): a randomised controlled trial. Psychol Med phrenia International Research Society, 2012 2017; 4:1-11 6. Culpepper L: Strategies for Managing Patients With De- 22. Russo M, Mahon K, Burdick KE: Measuring cognitive pression Who Are Experiencing Cognitive Impairment. J function in MDD: emerging assessment tools. Depress Clin Psychiatry 2017; 78:e1432 Anxiety 2015; 32:262-9 7. Dickstein DP, Cushman GK, Kim KL, Weissman AB, 23. Scheu F, Aghotor J, Pfueller U, Moritz S, Bohn F, Weisbrod Wegbreit E: Cognitive remediation: potential novel brain- M, Roesch-Ely D: Predictors of performance improvements based treatment for bipolar disorder in children and within a cognitive remediation program for schizophrenia. adolescents. CNS Spectr 2015; 20:382-90 Psychiatry Res 2013; 209:375-80 8. Franza F, Solomita B, Aldi G, Del Buono G: Assessing the 24. Tavormina G, Franza F, Stranieri G, Juli L, Juli MR: critical issues of atypical antipsychotics in schizophrenic Clinical Utilisation and Usefullness of the Rating Scale of inpatients. Psychiatr Danub 2017; 29(Suppl 3):405-408 Mixed States, ("Gt-Msrs"): a Multicenter Study. Psychiatr 9. Franza F, Carpentieri G, De Guglielmo S, Fasano V, Fio- Danub 2017; 29(Suppl 3):365-367 rentino N, Perito M, Solomita B, Del Buono G: Neuro- 25. Vinogradov S, Fisher M, de Villers-Sidani E: Cognitive cognitive management of the primary negative symptoms of training for impaired neural systems in neuropsychiatric schizophrenia: a role of atypical antipsychotics. Psychiatr illness. Neuropsychopharmacology 2012; 37:43-76 Danub 2016; 28(Suppl 1):145-148 26. Wykes T, Joyce E, Velikonja T, Watson A, Aarons G et al.: 10. Franza F: Risk and efficacy in cognitive functions in The CIRCuiTS study (Implementation of cognitive reme- Bipolar Disorder II with atypical antipsychotic augmen- diation in early intervention services): protocol for a tation. Psychiatr Danub 2016; 28(Suppl 1):13-17 randomised controlled trial. Trials 2018; 19:183

Correspondence: Francesco Franza, MD, PhD Rehabilitation Center “Neamente” Via Nazionale, 88 – 83013 Mercogliano (AV), Italy E-mail: [email protected]; www.neamente.com

S408 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 409-411 Conference paper © Medicinska naklada - Zagreb, Croatia

HOW SHOULD PSYCHIATRISTS AND GENERAL PHYSICIAN COMMUNICATE TO INCREASE PATIENTS’ PERCEPTION OF CONTINUITY OF CARE AFTER THEIR HOSPITALIZATION FOR ALCOHOL WITHDRAWAL? Pierre Patigny, Nicolas Zdanowicz & Brice Lepiece Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital, Yvoir, Belgium

SUMMARY Background: There are medico-psycho-social indications to apprehend the alcohol use disorder (AUD) as a chronic problem for which a continuous care is necessary. The perception of continuity of care is also associated with positive outcomes on the patient’s health. Communication between caregivers is essential to maintain a good continual care. In order to put patients back into the center of care, we asked them the question: “why should the psychiatric department (PD) and general physicians (GP) should communicate about AUD patients”? Subjects and methods: After a week of hospitalization for alcoholic withdrawal, we used a qualitative approach with 4 open questions to explore AUD patients’ point of view (N=17) about the best way of communication between psychiatrists and GP to improve care continuity. The data collection was carried out in the psychiatric department of the University Hospital of Mont- Godinne, Belgium. Results: AUD patients consider that the GP is the first line actor that will be consulted after hospitalization and have a privileged relationship with him. These arguments justify him being informed. Concerning these patients, communication is useful to have a continuous treatment and project care, for purposes of symptoms’ evolution follow-up and so as to help the GP to understand them better to follow the evolution of symptoms and to help the GP to understand them better. Conclusion: From AUD patients’ point of view, communication between psychiatric department and the GP is useful for a perspective of continuity of care at discharge from the hospital. This communication seems to be at the service of the GP and his patient rather than for the psychiatrist himself. Mainly because of the GP’s role as a privileged first-line care, but also thanks to the specific relationship relating him to his patient.

Key words: alcohol use disorder – continuity of care – communication – general physician * * * * * INTRODUCTION Haggerty et al. (2003) refer to three types of continuity of care: Informational Continuity, Manage- Alcohol abuse is a major health issue in our modern ment Continuity, Relational Continuity. In all of society. According to a World Health Organization them, communication and collaboration between report, «it is a causal factor in more than 200 diseases caregivers is essential. The reference scale used to and injury conditions” (World Health Organization assess the patient's perception of continuity of care 2014). In 2012, 5.9% of all global deaths could be ex- (e.i. the Alberta Continuity of care scale: ACCS- plained by alcohol (World Health Organization 2014). MH) also refers several times to the communication AUD's population is more vulnerable because it shows between the psychiatric service and the GP (Digel greater mortality risks compared to the general population Vandyk 2016). Other authors report deficits in (Roerecke & Rehm 2013). In Belgium, 10% of the communication and information transfer between population is affected by AUD (Gisle & Demarest 2014). hospital-based and primary care physicians, which In response to this major public health issue, poli- may have implications for the patient’s safety and the ticians and scientists provide the below recommenda- patient’s continuity of care (Kripalani et al. 2007). tions: The patient's PCC is resulting into positive effects on The theoretical framework to which we refer in this the patient's health (Bekkering et al. 2016). For article gives an important place to the concept of example, PCC is associated with adherence to treat- “continuity of care” (COC) that was proposed by ment, a decreased emergency room visits and Bachrach (1993) and developed by Haggerty et al. hospitalization (Joyce et al. 2010). Lack of continuity (2003). Several authors have studied the link bet- of care is referenced as a major factor for patient ween continuity of care experience and patient dissatisfaction and disengagement (Puntis et al. 2015). health outcomes. Perception of continuity of care In the area of mental health, continuity of care is (PCC) is "the way in which care is experienced by significantly related to the number of hospitalizations, a patient as consistent and time-bound; this aspect the severity of the patient's symptoms, the social of care is the result of good information transfer, functioning and the service satisfaction (Puntis et al. good interpersonal relationships and coordinated 2015). About AUD, PCC is associated with lower care" (Reid et al. 2002). alcohol consumption (Adair 2005).

S409 Pierre Patigny, Nicolas Zdanowicz & Brice Lepiece: HOW SHOULD PSYCHIATRISTS AND GENERAL PHYSICIAN COMMUNICATE TO INCREASE PATIENTS’ PERCEPTION OF CONTINUITY OF CARE AFTER THEIR HOSPITALIZATION FOR ALCOHOL WITHDRAWAL? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 409-411

Concerning Belgian policy, there was in 2010 a participate or not. All 17 patients agreed to participate reform of the law relating to hospitals (the so-called and were asked to answer 4 open questions: 1) “Why “reform 107”) which encourages the outpatient care should the psychiatric department communicate with and the creation of care networks for mental health your general physician?” 2) About what they should problems. This reform targets both patients suffering communicate? 3) When should they communicate? 4) from acute psychiatric problems and chronic ones, How should they communicate? such as AUD. It helps to meet the needs of these patients and it is also an alternative to hospital care. Participants At scientific level, the current trend is to propose Seventeen Caucasian participants hospitalized in our continuous care for AUD (Bekkering et al. 2016) department during 12 days between April 2018 and May simply because there is a bio-psycho-social indica- 2018 were questioned. All of them were admitted after 3 tion to apprehend this disorder as a chronic problem pre admission consultations. The participants must meet (McLellan et al. 2000). In order to give continuous DSM-V criteria for an AUD and have no history of care to the patient, the collaboration between the other psychiatric disorders on Axis I of the DSM-V different care providers is essential. (APA 2013). To put it in a nutshell, patients suffering from AUD The sample mean age was 43-58 years (std: 12.12). often require a complex combination of professio- The youngest subject was 21, and the oldest 62. The nals who are having diversified trainings in the bio- gender ratio was 6 females for 11 males. 70,6 % of the psycho-social fields (Digel Vandyk et al. 2013) so as participants (12/17) had already been hospitalized for to provide tailored care (e.g., hospitalizations, alcohol withdrawal and 76.5% of them (13/17) consume outpatient psychiatric care, primary and emergency tobacco. care) (Digel Vandyk et al. 2013). Collaboration between such services is a major challenge (Digel Vandyk et al. 2013) where communication is a pro- RESULTS minent component (Way et al. 2000). However, even Taking into account that we asked an open ques- if the importance of communication has been repor- tion, for purposes of the current research, we grouped ted, there is a theoretical lack concerning the modali- together patient patient’s answers by themes in order ties of this communication (Bekkering et al. 2016). to interpret the results more effectively. Please note that Patients can give several arguments for the same Aim and research questions questions: In this perceptive of continuous care, there is a need “After hospitalization, why should the psychiatric de- to better understand the communication between the partment communicate with your general physician?” different providers of care at all the stages of their treat- Patients’ point of view : The GP has a role of "infor- ment (admission, detoxification and care in the hospital, mation centralization" and “follow up” about patient outpatient care) (Bekkering et al. 2016). To do so, we health (8/17), the GP is the first line actor that will asked the following question: “How should the psychia- be consulted (4/17), the patient considers having a trist and the general physician communicate in order to privileged relationship with his GP that justifies the increase the patients’ perception of continuity of care fact for him to be informed (4/17), aiming at helping after their hospitalization for alcohol withdrawal?” the GP to better understand the patient (4/17), giving the possibility to the GP to being able to manage Since the current trend in mental health is working drug treatment (4/17). with patients suffering from chronic diseases to manage their care (Karazivan et al. 2015), we included patients- “What they should communicate?” as-partners in this reflection and we asked the opinion Patients’ point of view: Evolution of the patient's con- of the patients hospitalized for an alcohol withdrawal. dition, symptomatology and diagnosis (7/17), objectives, care pathway and care project (5/17), content of SUBJECTS AND METHODS psychological interviews and psychological assumptions (5/17), information about the treatment and the We used a qualitative approach to explore the AUD medical examinations (4/17), situations at risk of patient’s point of view. The data collection was carried relapse and corresponding action plan to avoid them out in the psychiatric department of the University (2/17), direct answers to the specific questions of the Hospital of Mont-Godinne, Belgium. The duration of GP in order to optimize its efficiency (2/17). hospitalization in this department is 12 days. After a “When should they communicate?” week of hospitalization, at the occasion of a consul- Patients’ point of view: Quickly after the end of the tation with their referring psychologist, patients were hospitalization (10/17), at the end of the hospita- informed about the goals of this study (i.e. to better lization (6/17), before the hospitalization or at the understand the collaboration between the psychiatric beginning of the hospitalization (5/17), in case of department and the general physician) and were free to problem or in case of risk of relapse (4/17).

S410 Pierre Patigny, Nicolas Zdanowicz & Brice Lepiece: HOW SHOULD PSYCHIATRISTS AND GENERAL PHYSICIAN COMMUNICATE TO INCREASE PATIENTS’ PERCEPTION OF CONTINUITY OF CARE AFTER THEIR HOSPITALIZATION FOR ALCOHOL WITHDRAWAL? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 409-411

“How should they communicate?” 2. Adair CE, McDougall GM, Mitton CR, Joyce AS, Wild TC, Patients’ point of view: By post (8/17), by e-mail Gordon A et al.: Continuity of care and health outcomes (8/17), through the patient (3/17), by phone 2/17, not among persons with severe mental illness. Psychia Serv by use on the phone because the GP is not easily 2005; 56:1061-1069 3. Bachrach LL: Continuity of care and approaches to case reachable by phone (5/17). management for long-term mentally ill patients. Psychia Serv 1993; 44:465-468 DISCUSSION 4. Bekkering GE, Zeeuws D, Lenaerts E, Pas L, Verstuyf G, Matthys F et al.: Development and Validation of Quality This study is only a first step to explore the AUD Indicators on Continuing Care for Patients With AUD: A patient’s point of view about communication between the Delphi Study. Alcoh and Alcohol 2016: 51:555-561 psychiatric department and the GP after hospitalization. 5. Digel Vandyk A, Graham ID, VanDenKerkhof EG, Ross- According to our observations, patients seem to White A & Harrison MB: Towards a conceptual consensus understand the importance of communication between of continuity in mental healthcare: focused literature the psychiatric department and the GP. Our results con- search and theory analysis. Internat J Evide Bas Health 2013; 11:94-109 firm that the GP have a role of "information centra- 6. Digel Vandyk A: Using the Alberta Continuity of Services lization" and “follow up” about patients’ health. They Observer-Rated Scale to Measure Continuity of Care in a seem to be the first-line caregivers preferred by the AUD Psychiatric Population. J of nurs measur 2016; 4:131 patients in case of relapse. Furthermore, patients keep a 7. Gisle L & Demarest S: Gezondheidsenquête 2013, Rapport privileged relationship with their GP and the psychiatric 2: Gezondheidsgedrag en leefstijl. WIV-ISP, Brussel, 2014 department can help such GP to better understand them 8. Joyce AS, Adair CE, Wild TC, McDougall GM, Gordon A, and to be more effective for continuity of care. The Costigan N et al.: Continuity of care: validation of a self- patient is aware of restrictions of availability of his GP report measure to assess client perceptions of mental health and therefore considers that collaboration by post is the service delivery. Commu Ment Heal J 2010; 46:192-208 most appropriate, while wishing to be involved in the 9. Kripalani S, LeFevre F, Phillips CO, Williams MV, exchange of information between the psychiatric depart- Basaviah P & Baker DW: Deficits in communication and information transfer between hospital-based and primary ment and the GP. In the patients’ mind, this commu- care physicians: implications for patient safety and nication should be at the service of the GP leading to continuity of care. JAMA 2007; 297:831-841 more continuity after hospitalization due to the fact that 10. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair the transmission of information goes systematically from CE & McKendry R: Continuity of care: a multidisci- the psychiatric department to the GP. plinary review. BMJ 2003; 327:1219-1221 11. Karazivan P, Dumez V, Flora L, Pomey MP, Del Grande CONCLUSION C, Ghadiri DP et al.: The patient-as-partner approach in health care: a conceptual framework for a necessary This paper confirms the importance of communi- transition. Acad Med 2015; 90:437-441 cation between the psychiatric department and the GP 12. McLellan AT, Lewis DC, O'brien CP & Kleber HD: Drug because he has a central role in the perception of dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA, continuity of care for AUD patients. 2000; 284:1689-1695. 13. Puntis S, Rugkåsa J, Forrest A, Mitchell A & Burns T: Associations between continuity of care and patient out- Acknowledgements: None. comes in mental health care: a systematic review. Psychia Serv 2015; 66:354-363 Conflict of interest: None to declare. 14. Reid R, McKendry R & Haggerty J: Dissiper la confusion: concepts et mesures de la continuité des soins. Fondation Contribution of individual authors: canadienne de la recherche sur les services de santé, 2002 All authors made a substantial contribution to the 15. Roerecke M & Rehm J: Alcohol use disorders and morta- design of the study, and/or data acquisition, and/or lity: a systematic review and meta-analysis. Addict 2013; the data analysis and its interpretation. 108:1562-1578 16. Way D, Jones L & Busing N: Implementation strategies: collaboration in primary care family doctors & nurse References practitioners delivering shared care. Toronto: Ontario Coll Fam Physi 2000; vol. 8 1. American Psychiatric Association: Diagnostic and statis- 17. World Health Organization & World Health Organiza- tical manual of mental disorders (DSM-5®). American tion. Management of Substance Abuse Unit: Global status Psychiatric Pub 2013 report on alcohol and health. WHO 2014

Correspondence: Pierre Patigny, MD Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital 5530 Yvoir, Belgium E-mail: [email protected]

S411 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 412-414 Conference paper © Medicinska naklada - Zagreb, Croatia

INCIDENCE AND PREVENTION OF DEEP VEIN THROMBOSIS IN RESTRAINED PSYCHIATRIC PATIENTS Alexis Therasse1, Humberto L. Persano2, Adrian D. Ventura2 & Juan Martin Tecco3 1Vascular Surgery Unit, Centre Hospitalier Universitaire et Psychiatrique de Mons-Borinage (CHUP-MB), Mons, Belgium 2Eating Disorders Unit, Hospital Borda, Cuidad Autonoma de Buenos Aires, Argentina 3Department of Psychiatry, Centre Hospitalier Universitaire et Psychiatrique de Mons-Borinage (CHUP-MB), Mons, Belgium

SUMMARY Background: Although physical restraint is still used in psychiatric inpatient settings, it sometimes causes serious side effects, including deep vein thrombosis (DVT) and resulting pulmonary embolism. The aim of this study was to review the literature investigating the incidence of the DVT in restrained psychiatric patients, to identify the risk factors of this condition and the effectiveness of routine prophylaxis. Subjects and methods: Studies investigating associations between deep vein thrombosis and restrained psychiatric patients were searched in the Pubmed database. More than 700 articles were sorted independently by two of the authors using predefined criteria. Only research articles, reviews and meta-analyses were selected for this review. Results: 5 articles published between 2010 and 2016 were selected. Although antipsychotics and restrain are known to be thrombogenenic, in all retrospective studies, with anticoagulant prophylaxis for those restrained for more than 12 or 24 h, incidence of DVT in restrained psychiatric patients was almost not existent. Controversially, in a comparative study by Ishida, although deep sedation and physical comorbidities were associated with the occurrence of DVT, not using of anticoagulants was not associated with any increased incidence of DVT. DVT may be overlooked because psychiatric patients are often unaware of leg symptoms because of their psychiatric disease and induced sedation. Furthermore most DVT, in particular distal DVT are asymptomatic. When screened and assessed with more appropriate methods such as plasma D Dimer and ultrasound scanning the incidence of DVT reaches 11.6%. Conclusion: The incidence of DVT in restrained psychiatric patients was not low in spite of prophylaxis. These findings emphasize the importance of regular screening of and thorough assessments of DVT, especially in restrained psychiatric patients.

Key words: deep vein thrombosis – physically restrained – psychiatric patient

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INTRODUCTION boembolic risk factors include history of venous thromboembolism (VTE), major familial thrombophilia, can- The practice of physical restrain puts patients at risk. cer, chemotherapy, heart failure or respiratory failure, Not only it is associated with physical injury but it may hormonal therapy, oral contraception, accidents cerebro- also be perceived as punitive and aversive (Petti et al. vascular disorders with neurological deficit, postpartum, 2001), with potential traumatic sequels (Mohr et al. age, obesity, prolonged bed rest, severe renal insuffi- 2003). ciency. HAS recommends that special attention be paid The French National Authority for Health (HAS) is to patients at highest risk somatically or psychologi- an independent public scientific authority with an ove- cally, including: extremely agitated patients; patients rall mission of contributing to the regulation of the intoxicated by alcohol or psychostimulant substances; healthcare system by improving health quality and effi- patients with a history of heart or respiratory disease, ciency. According to HAS recommendations edited en morbid obesity, neurological and/or metabolic disor- 2017 (HAS 2017), the prevention of thromboembolic ders; elderly patients; pregnant or postpartum women diseases should be considered for each patient put under and patients who have been abused in the past. mechanical restraint depending on the benefit-risk ba- The aim of this review is to seek what is known lance, including the prescription of anticoagulant therapy. about the incidence of deep vein thrombosis in Deep vein thrombosis (DVT) is a partial or complete restrained psychiatric patients and whether preventive obstruction of a leg vein by a thrombus. The most measures can be suggested. critical complication of DVT is pulmonary thromboembolism. The thrombogenic role of second generation anti- SUBJECTS AND METHODS psychotic drugs has been repeatedly reported (Hagg & Spigst 2002, Liperoti et al. 2005, Liperoti & Gambassi Medline, Cochrane Library and Psycinfo databases 2010). Antipsychotics facilitate platelet aggregation and were searched for the terms: "thrombosis", "thrombo- increase anticardiolipin antibodies. In addition, drug- embolic risk", "thrombophilia", “thromboembolism” induced sedation promotes venous stasis. Other throm- combined with each of the following terms: "restrai-

S412 Alexis Therasse, Humberto L. Persano, Adrian D. Ventura & Juan Martin Tecco: INCIDENCE AND PREVENTION OF DEEP VEIN THROMBOSIS IN RESTRAINED PSYCHIATRIC PATIENTS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 412-414 ned", "psychiatric patients", "schizophrenia", up to De- The incidence of DVT in catatonic patients was cember 2017. More than 700 articles were sorted found to be much higher than in restrained patients. independently by two of the authors using those pre- Using the same protocol with plasma D-dimer level defined criteria. Only research articles, reviews and measured and Doppler ultrasound scanning performed meta-analyses were sorted out for this review. Excluded at levels of 0.50 ug/dL or higher the presence of DVT at were theoretical articles, editorials and opinion articles. their lower limbs was as high as 25.3% (20/79). None of Eligibility assessment of titles and abstracts was the DVTs was symptomatic. Proximal DVT was performed independently by two of the authors and detected in 2 patients. The incidence of DVT was not disagreements between reviewers were resolved by associated with not using UFH, but because of the consensus with a third author. Pertinent data was further retrospective observations design, this may be attribu- extracted by two of the authors. table to uncontrolled factors. Patients with more risk of DVT are more likely to be prescribed UFH than others. RESULTS (Ishida et al. 2016). In a retrospective study carried out in Germany in 2012 and 2013, 12734 patients were hospitalized. The 5 articles with retrospective designs met the inclu- number of restraining episodes was 1035 and involved sion criteria. Extracted data was sorted according to our 469 patients. 75 episodes lasted more than 24h and in research questions. that cases patients were give,Exoparin 40 mg subcuta- 679 inpatients suffering from psychosis were follo- neously as a DVT profilaxis. None of the prolonged wed in a descriptive and retrospective study carried out restrain episodes nor the shorter ones were associated in Belgium between 2002 and 2009. 68.8% were male with sings or symptoms of DVT and 31.2% females. Out of 170 secluded patients, 138 Although antipsychotics and restrain are known to underwent 296 physical restrain episodes. 65 (38.2%) be thrombogenenic, in all retrospective studies, with out of 170 secluded patients benefited from anticoagu- anticoagulant profilaxis for those restrained for more lants as a preventive measure. DVT prevention with than 12 or 24 h, incidence of DVT in restrained psychia- anticoagulants was more frequent when patients were tric patients was almost not existent. Interestingly the restrained and in seclusion lasting more than one day. incidence is higher in other categories of patients that Because no thromboembolic event was observed might appear similar such as unrestrained catatonic throughout the study the authors suggested that the patients, or intensive care restrained inpatients preventive measures were effective. This statement Controversially, in a comparative study by Ishida, must be taken with caution since it relies on a although deep sedation and physical comorbidities were retrospective analysis of electronic records (De Hert et associated with the occurrence of DVT, not using of al. 2010). anticoagulants was not associated with any increased In Sakuragaoka Memorial Hospital in Tokyo, Japan incidence of DVT. When evaluated relying only on routine prophylaxis for DVT has been employed for clinical and symptoms, the incidence of DVT is likely to physically restrained patients since 2008. All restrained be underestimated. DVT may be overlooked because patients wear graduated compression stockings. Unless psychiatric patients are often unaware of leg symptoms contraindicated, patients restrained for more than 12 because of their psychiatric disease and induced hours, receive subcutaneous UFH 5000 IU b.i.d. Plasma sedation. Furthermore most DVT, in particular distal D-dimer level is measured when restraint was removed. DVT are asymptomatic. Most DVTs originate in calves, At levels of 0.50 ug/dL or higher Doppler ultrasound and 80% og distal DVTs are known to resolve spon- scanning is performed to look for the presence of DVT taneously (Mohr et al. 2003). However the remaining at their lower limbs.181 patient were included in a study 20% cvan extent to proximal veins, such as popliteal conducted between December 2008 and September vein or higher. Once DVT reach the popliteal vein pul- 2010. DVT was detected in 21 (11.6%) in despite of monary embolism occurs in 50%of the patients. When prophylaxis. None of the DVTs that were found with a screened and assessed with more appropriate methods dopler ultrasound scanning in this study was sympto- such as plasma D Dimer and ultrasound scanning the matic. Incidence of DVT was associated with longer incidence of DVT reaches 11.6%. duration of restraint, excessive sedation, recent hospitalization for physical comorbidities and paradoxically DISCUSSION low antipsychotic dosage (Ishida et al. 2014a). UFH was not used from December 2010 to Sep- Although antipsychotics and restrain are known to tember 2012 to compare the incidence of DVT with and be thrombogenenic, in all retrospective studies, with without the use of UFH in restrained psychiatric anticoagulant profilaxis for those restrained for more patients. 93 heparin (+) patients were matched to 117 than 12 or 24 h, incidence of DVT in restrained psychia- heparin (-) patients. Surprisingly, the use of UFH was tric patients was almost not existent. Interestingly the not associated with any reduction in the incidence of incidence is higher in other categories of patients that DVT. Deep sedation and psychical comorbidities were might appear similar such as unrestrained catatonic associated with DVT (Ishida et al. 2014b). patients, or intensive care restrained inpatients

S413 Alexis Therasse, Humberto L. Persano, Adrian D. Ventura & Juan Martin Tecco: INCIDENCE AND PREVENTION OF DEEP VEIN THROMBOSIS IN RESTRAINED PSYCHIATRIC PATIENTS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 412-414

Controversially, in a comparative study by Ishida, although deep sedation and physical comorbidities were Acknowledgements: associated with the occurrence of DVT, not using of The authors thank Andrew Taylor for his technical anticoagulants was not associated with any increased assistance in writing this manuscript in English. incidence of DVT. When evaluated relying only on clinical and symptoms, the incidence of DVT is likely to Conflict of interest: None to declare. be underestimated. DVT may be overlooked because psychiatric patients are often unaware of leg symptoms because of their psychiatric disease and induced References sedation. Furthermore most DVT, in particular distal DVT are asymptomatic. Most DVTs originate in calves, 1. De Hert M, Einfinger G, Scherpenberg E, Wampers M, and 80% og distal DVTs are known to resolve sponta- Peuskens J: The prevention of deep venous thrombosis in neously (Mohr et al. 2003). However the remaining physically restrained patients with schizophrenia. Int J Clin Pract 2010; 64:1109-15 20% can extent to proximal veins, such as popliteal vein 2. Hägg S, Spigset O: Antipsychotic-induced venous thrombo- or higher. Once DVT reach the popliteal vein pulmo- embolism: a review of the evidence. CNS Drugs. 2002; nary embolism occurs in 50%of the patients. When 16:765-76. Review screened and assessed with more appropriate methods 3. HAS, The French National Authority for Health: Con- such as plasma D Dimer and ultrasound scanning the tention mécanique en psychiatrie générale, Synthèse de la incidence of DVT reaches 11.6%. recommendation de bonne pratique, Février 2017. https://www.has-sante.fr/portail/jcms/c_2055362/ fr/isolement-et-contention-en-psychiatrie-generale CONCLUSION 4. Hilger H, von Beckerath O, Kröger K: Prophylaxis of venous thromboembolism in physically restrained Although often asymptomatic, in view of the high psychiatric patients. Int J Psychiatry Clin Pract 2016; incidence of DVT in psychiatric restrained patients, it 20:187-90. doi: 10.3109/13651501.2016.1174274. Epub seems appropriate to put preventive and scanning 2016 Apr 25 measures in place. 5. Ishida T, Sakurai H, Watanabe K, Iwashita S, Mimura M, Excessive sedation, physical comorbidities, longer Uchida H: Incidence of deep vein thrombosis in catatonic restrains are aggravation that must be taken into consi- patients: A chart review. Psychiatry Res 2016; 241:61-5 deration. The prophylactic effectiveness of anticoagu- 6. Ishida T, Sakurai H, Watanabe K, Iwashita S, Uchida H, lants is still a subject of controversy. Ishisa’s detection Mimura M: Prophylactic use of heparin for deep vein protocol looking for plasma levels of D dimers, follo- thrombosis in restrained psychiatric patients: a chart wed by ultrasound scanning for those with plasma levels review. Gen Hosp Psychiatry 2014; 36:690-3 7. Ishida T, Katagiri T, Uchida H, Takeuchi H, Sakurai H, >0.5 µg/dl appear to be a promising suggestion worth Watanabe K, Mimura M: Incidence of deep vein throm- deepen. Given the paucity of data on this clinical bosis in restrained psychiatric patients. Psychosomatics relevant issue, further research is needed to devise more 2014; 55:69-75 efficient scanning protocols for the prevention and 8. Liperoti R, Gambassi G: Antipsychotics and the risk of detections of DVT. venous thromboembolism. BMJ 2010 21; 341:4216 9. Liperoti R, Pedone C, Lapane KL, Mor V, Bernabei R, Gambassi G: Venous thromboembolism among elderly patients treated with atypical and conventional anti- Contribution of individual authors: psychotic agents. Arch Intern Med. 2005; 165:2677-82 All four authors participated to the literature search 10. Mohr WK, Petti TA, Mohr BD: Adverse effects associated and medical writing. Dr Tecco came up with the with physical restraint. Can J Psychiatry 2003; 48:30-7 idea of this manuscript. Dr Therasse wrote the first 11. Petti TA, Mohr WK, Somers JW, Sims L: Perceptions of draft. The final draft was written by or under Dr seclusion and restraint by patients and staff in an Tecco’s close supervision. Finally, the manuscript intermediate-term care facility. J Child Adolesc Psychiatr was approved by all co-authors Nurs 2001; 14:115-27

Correspondence: Juan Martin Tecco, MD, MBA Centre Hospitalier Universitaire et Psychiatrique de Mons-Borinage (CHUP-MB) 24 Chemin du Chêne aux Haies, 7000 Mons, Belgium E-mail: [email protected]

S414 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 415-417 Conference paper © Medicinska naklada - Zagreb, Croatia

NEUROLEPTIC MALIGNANT SYNDROME IN A PATIENT TREATED WITH CLOTIAPINE Clémentine Lantin, Miriam Franco, François-Xavier Dekeuleneer, Didier Chamart & Juan Martin Tecco Mental Health Unit, Centre Hospitalier Universitaire et Psychiatrique de Mons-Borinage (CHUP-MB), Mons, Belgium

SUMMARY Background: Neuroleptic malignant syndrome (NMS), which is linked to the use of antipsychotic medication, is a potentially lethal neurological emergency. The interest of our study is that NMS induced by the use of clotiapine has never previously been described. Subjects and methods: We present the case of a 61-year old man whose sleep disorders were treated with clotiapine 40 mg/day. After 7 days of taking 40 mg clotiapine, the patient presented with a deterioration of his general health which had gradually taken hold, with altered consciousness accompanied by generalised muscle rigidity and hypersalivation. Laboratory blood tests revealed elevated levels of Creatine Phosphokinase (CPK) at 812 U/l. The patient was diagnosed with NMS and treated accordingly. Results: The mechanism that underlies the appearance of NMS remains largely unknown. Clotiapine is a second-generation antipsychotic, first released onto the market in the 1970s, and is available in a few countries, including Belgium. NMS is treated as a medical emergency due to the possibility of morbidity and death. The first step in the treatment of NMS consists in withholding the agent suspected of provoking the symptoms. Conclusions: NMS is difficult to diagnose due to a great variability in clinical presentations and the absence of specific tests and laboratory results. The use of clotiapine in treating sleep disorders can provoke NMS as a life-threatening side-effect. To our knowledge, this is the first time a case of clotiapine-induced NMS has been published.

Key words: neuroleptic malignant syndrome – clotiapine - sleep disorder

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INTRODUCTION In this case study, we present the case of NMS in a 61-year old man whose sleep disorders were treated Neuroleptic malignant syndrome (NMS), which is with clotiapine. This patient was hospitalised in the linked to the use of antipsychotic medication, is a poten- mood disorder department of Centre Hospitalier Univer- tially lethal neurological emergency. The syndrome was sitaire et Psychiatrique de Mons-Borinage (CHUP- first described by Delay et al. in 1960 (Delay et al. MB) and was transferred to the neurology department 1960). While there is no laboratory verification test, of CHUP-MB (Mons, Belgium) in June 2017. The NMS has a distinctive clinical presentation that includes interest of this report lies in the fact that we have not impaired consciousness, muscle rigidity, hyperthermia found any case of clotiapine-induced NMS described and symptoms of autonomic nervous system dysfunc- in the literature. tion, such as tachycardia, high blood pressure or an elevated respiratory rate. Furthermore, anomalies in SUBJECTS AND METHODS blood test results are also present; they are characterised mainly by an increase in Creatine Phosphokinase A 61-year old patient was hospitalised in the (CPK), leucocytosis, an increase in lactic acid dehy- department specialising in mood disorder at CHUP- drogenase, an alteration of liver enzymes and of serum MB (Mons, Belgium) for generalised anxiety disorder, electrolyte levels (Levenson 1985). NMS has an inci- benzodiazepine dependency and a major depressive dence of 0.02 to 3% and is difficult to diagnose, with episode. His medication on admission consisted in mortality rates estimated at 5.6% (Levenson 1985, Modi quetiapine 200 mg/day, prothipendyl 80 mg/day, lor- et al. 2016, Velamoor 1998). Speedier recognition and metazepam 16 mg/day, mirtazapine 30 mg/day, perin- diagnosis have probably enabled mortality over the last dopril 10 mg/day and acetylsalicylic acid 80 mg/day. decades. However, morbidity remains an important Weaning off anxiolytics had been initiated. As the factor in a patient’s recovery, due to the risk of rhabdo- patient was reporting sleep disorder due to excessive myolysis, deep vein thrombosis and organ failure. NMS night time awakenings, medication based on 40 mg is most often associated with the use of first-generation clotiapine at bedtime was offered to replace the 80 mg antipsychotics (El-Gaaly et al. 2009, Kantrowitz & prothipendyl. Citrome 2008, Pasa et al. 2008, Pope et al. 1986, Strawn After 7 days of daily intake of clotiapine 40 mg, et al. 2007, Stubner et al. 2004), but it can also arise the patient presented with a deterioration of his general with second-generation medication and anti-emetic condition which took hold progressively, with altered agents (Breeden et al. 2017). consciousness accompanied by generalised muscle

S415 Clémentine Lantin, Miriam Franco, François-Xavier Dekeuleneer, Didier Chamart & Juan Martin Tecco: NEUROLEPTIC MALIGNANT SYNDROME IN A PATIENT TREATED WITH CLOTIAPINE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 415-417 stiffness and hypersalivation. The patient was trans- impairment of the autonomous nervous system (Vela- ferred to the emergency department of CHUP-MB moor 1994). Hyperthermia may be a symptom that is (Mons, Belgium). less present in NMS associated with second-generation On admission to the emergency department, the cli- antipsychotics (Picard et al. 2008, Sakar & Gupta 2017). nical examination showed generalised muscle stiffness, There is great variability in way NMS can present, extremely slowed limb movements, fine tremors in the making diagnosis sometimes difficult. Blood test result extermities, bilateral weakening of osteotendinous anomalies are frequent, with elevated CPK, typically reflexes, profuse sweating and sialorrhea. Observations above 1000 U/l, or four time higher than laboratory were as follows: peripheral body temperature of 36.9°C; norms (Gurrera et al. 2011, Levenson 1985). The ele- blood pressure of 140/90 mmHg; pulse rate of 108 vation in CPK is a factor in the severity and prognosis beat/min; capillary blood glucose level of 145 mg/dl and of NMS (Levenson 1985). Other anomalies in blood test oxygen saturation of 92%. Blood test results showed results are frequent, but non-specific, such as leucocy- elevated levels of CPK at 812 U/l, four times the tosis, a moderate elevation of lactates, alkaline phospha- laboratory norms; other observations were unremark- tases and liver transaminases, electrolyte anomalies, able. In the light of this, the patient was diagnosed with signs of kidney insufficiency that could be the result NMS. rhabdomyolysis (Levenson 1985). Thus, clinical presen- The patient was then hospitalised in the neurology tation and laboratory results can lead to a diagnosis of department for monitoring. Antipsychotic medication NMS, but other pathologies need to be excluded, such was discontinued. The patient was given a bolus of 1 as meningitis, non-convulsive status epilepticus, malign litre of saline solution in 1 hour, followed by a main- hyperthermia and serotonin syndrome (Strawn 2007). tenance perfusion of a mixed solution of 2.5 l/24 hours The treatment of NMS is considered as a medical for the first 24 hours. The treatment consisted in intra- emergency due to possible morbidity and mortality. The venous injections of dantrolene 80 mg/day for 8 days, as first step in the treatment of NMS consists in discon- well as scopolamine 0.25 mg/day for 3 days. The pa- tinuing the agent suspected of provoking the symptoms. tient’s clinical condition gradually improved. On the 7th When clinical manifestations are severe, care in an day after the NMS diagnosis, the patient presented with intensive care unit may be necessary. In order to avoid a pain in the right leg. A Doppler ultrasound revealed a complications, supportive care must be put in place. deep vein thrombosis, requiring the introduction of en- This consists in hydration to prevent kidney lesions due exoparin 120 mg/day for 10 days, followed by aceno- to elevated CPK levels, as well as reducing body coumarol. From then on, the patient’s evolution was temperature using cooling techniques. If blood pressure favourable. is too high, antihypertensive dugs may be administered. Dantrolene, a skeletal muscle relaxant, is a medicine RESULTS that can be used in the treatment of NMS. Dantrolene is administered in a dose of 1 to 2.5 mg per kilogramme of The mechanism underlying the development of body weight (Strawn et al. 2007). The literature is NMS remains largely unknown and poorly understood. currently divided as to the effectiveness of dantrolene The blocking of dopamine receptors may be the cause (Reulbach et al. 2007, Rosenberg & Green 1989). (Mann et al. 2000). First-generation antipsychotics seem Whilst the literature may be contradictory, dantrolene is to present a higher risk of NMS than second-generation used in the absence of other treatment options. Other antipsychotics (El-Gaaly et al. 2009, Kantrowitz & treatment options include bromocriptine, a dopamine Citrome 2008, Pasa et al. 2008, Pope et al. 1986, Strawn agonist, and amantadine, which have a dopaminergic et al. 2007, Stubner et al. 2004). Furthermore, NMS has activity (Strawn et al. 2007). Once NMS is suspected in also been described in patients taking medication that a patient, antipsychotic medicines are to be avoided to interacted with dopamine receptors, such as the prevent a relapse. However, for some patients, treatment antiemetic agent metoclopramide (Breeden et al. 2017). with antipsychotics remains necessary. The recommen- Clotiapine is a second-generation antipsychotic that dation then is to wait at least two weeks before has been on the market since the 1970s, and is recommencing taking an antipsychotic drug. available in a few countries, including Belgium. This molecule belongs to the dibenzothiazepine family of CONCLUSION antipsychotics, and has a chemical structure close to that of clozapine. NMS is difficult to diagnose due to a great varia- There is no consensus in the literature about the bility in the clinical presentations and in the absence of potential risk factors for the development of NMS. The specific laboratory tests and results. Patients suffering symptoms generally appear within one week, almost all from NMS generally present wit muscle stiffness, an cases manifest within 30 days of initiation of anti- impairment of the autonomous nervous system, elevated psychotic treatment (Caroff & Mann 1988). The majo- body temperature and altered consciousness. When rity of patients initially present with altered mental state, NMS is suspected, antipsychotics must be suspended then muscle stiffness, followed by hyperthermia and and the patient needs to be monitored. Treatment for

S416 Clémentine Lantin, Miriam Franco, François-Xavier Dekeuleneer, Didier Chamart & Juan Martin Tecco: NEUROLEPTIC MALIGNANT SYNDROME IN A PATIENT TREATED WITH CLOTIAPINE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 415-417

NMS consists in supportive care and dandrolene may 5. Gurrera RJ, Caroff SN, Cohen A, Carroll BT, DeRoos F, be administered. Psychiatric patients often need anti- Francis A et al.: An international consensus study of psychotic drugs as part of their medical treatment, and neuroleptic malignant syndrome diagnostic criteria using it is possible to reintroduce antipsychotics in a patient the Delphi method. J Clin Psychiatry 2011; 72:1222 suffering NMS. The use of clotiapine in sleep dis- 6. Kantrowitz JT, Citrome L: Olanzapine: review of safety 2008. Expert Opin Drug Saf 2008; 7:761-769 orders can provoke NMS, a side-effect that is poten- 7. Levenson JL: Neuroleptic malignant syndrome. Am J tially life-threatening. To our knowledge, this is the Psychiatry 1985; 142:1137 first time that a case of NMS induced by clotiapine has 8. Mann SC, Caroff SN, Fricchione G, Campbell EC: Cen- been published. tral dopamine hypoactivity and the pathogenesis of the neuroleptic malignant syndrome. Psychiatr Ann 2000; 30:363-374 Acknowledgements: None. 9. Modi S, Dharaiya D, Schultz L, Varelas P: Neuroleptic malignant syndrome: complications, outcomes, and Conflict of interest: None to declare. mortality. Neurocrit Care 2016; 24:97-103 10. Pasa S, Sayhan MD, Boyraz T, Urakci Z, Altintas A: A Contribution of individual authors: case of neuroleptic malignant syndrome accompanied to an atypical anti-psychotic agent: risperidone. Neurotoxi- The authors certify that the work described has not cology 2008; 29:750-751 been published before and that it is not under 11. Picard LS, Lindsay S, Strawn JR, Kaneria RM, Patel NC, consideration for publication anywhere else. All the Keck PE Jr: Atypical neuroleptic malignant syndrome: authors contributed to the article, they participated diagnostic controversies and considerations. Pharmaco- to the literature search and medical writing. All are therapy 2008; 28:530 answerable for published reports of the research. Dr. Tecco came up with the idea of the manuscript, 12. Pope HG, Cole JO, Choras PT, Fulwiler CE: Apparent Dr. Lantin wrote the first draft. The final draft was neuroleptic malignant syndrome with clozapine and written under Dr. Tecco close supervision. This lithium. J Nerv Ment Dis 1986; 174:493-495 publication has been approved by all co-authors, as 13. Reulbach U, Dutsch C, Biermann T, Sperling W, Thuerauf well as by responsible authorities where there work N, Kornhuber J et al.: Managing an effective treatment for has been carried out. neuroleptic malignant syndrome. Crit Care 2007; 11:R4 14. Rosenberg M, Green M: Neuroleptic malignant syndrome: review of response to therapy. Arch Intern Med 1989; References 149:1927-1931 15. Sarkar S, Gupta N: Drug information update. Atypical 1. Breeden R, Ford H, Chrisman C, Mascioli C: Neuroleptic antipsychotics and neuroleptic malignant syndrome: malignant syndrome secondary to metoclopramide use in nuances and pragmatics of the association. BJ Psych Bull an elderly gastroenterologic surgery patient. Gastroente- 2017; 41:211 rol Nurs 2017; 40:93-100 16. Strawn JR, Keck PE Jr, Caroff SN: Neuroleptic malignant 2. Caroff SN, Mann SC: Neuroleptic malignant syndrome. syndrome. Am J Psychiatry 2007; 164:870 Psychopharmacol Bull 1988; 24:25-29 17. Stubner S, Rustenbeck E, Grohmann R, Wagner G, Engel 3. Delay J, Pichot P, Lemperiere T, Elissalde B, Peigne F: A R, Neundörfer G et al.: Severe and uncommon involuntary non-phenothiazine and non-reserpine major neuroleptic, movement disorders due to psychotropic drugs. haloperidol, in the treatment of psychoses. Ann Med Pharmacopsychiatry 2004; 37:S54-S64 Psychol 1960; 118:145–52 18. Velamoor VR, Norman RM, Caroff SN, Mann SC, Sullivan 4. El-Gaaly S, John PS, Dunsmore S, Bolton JM: Atypical KA, Antelo RE: Progression of symptoms in neuroleptic neuroleptic malignant syndrome with quetiapine a case malignant syndrome. J Nerv Ment Dis 1994; 182:168-173 report and review of the literature. J Clin Psycho- 19. Velamoor VR: Neuroleptic malignant syndrome. Recogni- pharmacol 2009; 29:497-499 tion, prevention and management. Drug Saf 1998; 19:73

Correspondence: Juan Martin Tecco, MD, MBA Centre Hospitalier Universitaire et Psychiatrique de Mons-Borinage (CHUP-MB) 24 Chemin du Chêne aux Haies, 7000 Mons, Belgium E-mail: [email protected]

S417 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 418-421 Conference paper © Medicinska naklada - Zagreb, Croatia

PARTIAL DENIAL OF PREGNANCY AT 32 WEEKS IN A DIABETIC AND SUICIDAL PATIENT: A CASE REPORT. What Are the Treatment Recommendations? Denis Jacques, Aurélie Maricq, Thomas Dubois, Brice Lepiece, Nicolas Zdanowicz & Etienne Delgrange Université Catholique de Louvain, Psychosomatics Unit, CHU UcL Namur Godinne Hospital, Yvoir, Belgium

SUMMARY Background: Denial of pregnancy is an issue that is often discovered a posteriori with sometimes dramatic complications. Denial of pregnancy is considered partial when the woman becomes aware of the pregnancy after the fifth month before delivery. The populations studied were heterogeneous, which made it impossible to establish a standard algorithm of the treatment and support of a discovery of partial denial of pregnancy. Subjects and methods: Based on a literature review and a discussion of partial denial of pregnancy case and the consequential treatment with a five-year follow-up, the global management recommendations need consideration in the case of partial denial of pregnancy. Results: The reported case confirmed the significance of the trauma caused by the discovery of pregnancy in a patient in denial, but also showed that this trauma can extend to caregivers concerned by the treatment. Conclusion: Continuous training of all caregivers for denial of pregnancy is essential even if the issue may be considered infrequent. Contraception, prevention of sexually transmitted diseases and the importance of gynecological follow-up must be systematically addressed in a medical consultation. A standard algorithm for the treatment of partial denial is difficult to establish, but the rapid mobilization of a multidisciplinary team or hospitalization is recommended for the announcement of the diagnosis as well as personalized support during ultrasounds. The establishment of a relationship of trust remains the major issue.

Key words: pregnancy – denial – partial – diabetes - avoidant personality- psychotherapy

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INTRODUCTION living standard (Dubé et al. 2003). Other authors have suggested that for partial denial, there is no correlation The issue of denial of pregnancy remains a com- with age or socio-economic status (Rott 2016). Some plex subject that generates a particular emotional con- authors have also underlined the frequent presence in text for both patients, their families and their caregivers. these patients of immaturity, dependency, repression of Denial of pregnancy complicated by infanticide has emotions, passivity or avoidance in the face of conflicts, given rise to several legal and psychiatric debates due poor communication with family and the social environ- to the different legislations from one country to ano- ment (Vellut et al. 2012), and a lack of sexual education ther (Dayan et al. 2013). The definition of denial of and understanding of the female anatomy (Gorre-Feragu pregnancy is "in a woman, a lack of subjective awa- 2002). Overall, these women do not have a notable reness of being pregnant, beyond the third trimester" psychiatric history (Jacob Alby et al. 2014). In the lite- (Beier et al. 2006). Denial is complete if it lasts until rature, the concepts of prevention and screening are the birth and partial if the woman becomes aware of regularly mentioned as indispensable (Pansarasa 2004). the pregnancy from the fifth month. It is estimated that When considering a treatment algorithm for partial this concerns 0.5-3/1000 births (Chaulet et al. 2013, denial of pregnancy, the population heterogeneity Wessel et al. 2007). From a theoretical point of view, (Seguin et al. 2013, Friedman et al. 2004) makes it many authors tend to classify denial of pregnancy as a impossible to reach a common and systematic consen- particular entity (Zaguri 2013, Oliveira 2013). This sus. Nevertheless, based on a case report and a literature type of denial cannot be simply assimilated to anosog- review, the purpose of our observations and reflections nosia phenomena, psychotic denial, or reaction denial is to try to draw general recommendations in the context with dissociative components. Although it remains in of the discovery of a denial of partial pregnancy. the spectrum of these different processes, our team has already considered the link between denial of pregnancy SUBJECTS AND METHODS and denial of fertility (Struye et al. 2013); the latter is probably linked to a lack of knowledge and education Based on a literature review and a discussion of about sexual life in the family system. A typology of partial denial of pregnancy case and the consequential these women who have experienced complete denial of treatment with a five-year follow-up, the global ma- pregnancy is young, single women living with their nagement recommendations need consideration in the parents, with a low socioeconomic and primiparous case of partial denial of pregnancy.

S418 Denis Jacques, Aurélie Maricq, Thomas Dubois, Brice Lepiece, Nicolas Zdanowicz & Etienne Delgrange: PARTIAL DENIAL OF PREGNANCY AT 32 WEEKS IN A DIABETIC AND SUICIDAL PATIENT: A CASE REPORT. What Are the Treatment Recommendations? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 418-421

Information concerning the patient studied was In mid-December 2012, in an endocrinology consul- collected from 11 psychiatric interviews prior to the tation, although the diabetic management had improved, discovery of the denial of pregnancy from December a weight gain of 8 kg as well as a secondary amenorrhea 2010 to December 2011, five endocrinology consulta- triggered a blood test to exclude pregnancy. The patient tions since December 2010 where the diagnosis of refuted that she could be pregnant. The beta HCG do- pregnancy was made in December 2011, monitoring in sage came back positive and confirmed the pregnancy. psychiatric hospitalization in December 2011, and 30 The patient had no prior gynecological follow-up. psychiatric interviews from January 2012 to June 2017. The patient's attending physician ensured that she saw Consultations and hospitalization took place at the an emergency gynecologist, who assessed the preg- Catholic University of Louvain, UCL Namur UHC, nancy at 32 weeks. The patient was seen again four days Psychosomatic Dpt, avenue Dr G. Therasse n°1, 5530 later in a psychiatric consultation where she expressed Yvoir, Belgium. that she did not want this child as well as suicidal The literature review was conducted using the data- ideation. Further hospitalization for psychiatric care was bases, PsycArticles, PsycInfo, and Pubmed with the follo- organized the same day. Having no maternity and wing keywords: partial-denial-pregnancy and treatment. neonatal services at the hospitalization site for psychia- A total of 154 articles were found in the search and tric care, contact was made with the Maternal Intensive 21 were selected for their clinical relevance. Care (MIC) service; however, an immediate transfer was impossible since the patient had suicidal thoughts RESULTS and continued follow-up with her attending psychiatrist and the psychiatric team with whom a relationship of The patient was 23 years old when she begin trust was well established. While remaining hospitalized psychiatric follow-up in December 2010. in psychiatry care, consultations with the MIC were She was single, pursuing vocational studied, and organized in order to assess the 32-week pregnancy in a lived with her parents. She had type I diabetes diagno- diabetic patient, which had not been followed-up, and sed in childhood and Hashimoto's thyroiditis. gradually established a link with the gynecology team She was treated with insulin and thyroid hormones. that would accompany her during childbirth. In parti- She was also overweight. She regularly followed-up by cular, a nurse from the psychiatric department accom- an endocrinology consultation. In 2008, she presented a panied the patient during the first ultrasound exams, coma on ketoacidosis that required hospitalization in where confrontation with the reality of pregnancy was intensive care. the most difficult. The patient was referred to a psychiatric consultation Psychiatric interviews during hospitalization made it for impulsive behavior and poor management of diabetes. possible to appease the suicidal ideation. Support of the In the first 10 psychiatric interviews from December patient, as voluntary interruption of pregnancy is illegal 2010 to November 2011, the Mini International Neuro- beyond 12 weeks in Belgium, tended toward a process psychiatric Interview diagnosis and DSM IV criteria of legal abandonment of her child with a proposal of showed moderate major depressive disorder, impulse adoption. The patient, although seemingly determined control disorder. Psychodynamically, the patient presen- about this solution, remained open to the fact that she ted typical traits of avoidant personalities. Psychiatric could always change her mind and the social service follow-up shifted from psychoeducation to impulsivity also explained the help that could be put in place if she management and better adherence to diabetes moni- decided to keep her child. toring. The patient reported family tension dominated A family interview was also organized. The patient by an apparent lack of communication that seemed to spoke very little and the interview remained focused on reinforce the avoidant features of her behavior. Mo- practical and medical questions about the risks asso- ments of impulsiveness seemed to be closely related to ciated with this unmet pregnancy in terms of potential frustrations related to lack of communication or family complications. affective disorders. After three weeks of hospitalization in psychiatry In March 2011, in this context, the patient expe- care, the patient agreed to be hospitalized for a week at rienced drug abuse (excessive intake of benzodiaze- the MIC for further assessment and then returned for pines), which required emergency room monitoring and one week in the psychiatric ward. The patient gave birth hospitalization in the psychiatric unit. The patient at the end of January 2012 to a boy in good health and worked on the issue of impulsivity and better expression no significant complications were reported. The patient of her emotions, and then continued outpatient psychia- decided to keep her child and with the help of the social tric follow-up. At that moment, the family refused to service, set up home support. undergo family follow-up. Psychiatric follow-up continued with a monthly The therapeutic alliance with her attending psychia- interview, alone or with her son, at the beginning. In trist consolidated well with the follow-up. Contact with December 2012, the patient no longer presented any social services allowed her to begin living in apartment suicidal ideas or behaviors and the mother-son rela- in order to become autonomous. tionship was established harmoniously. The report was

S419 Denis Jacques, Aurélie Maricq, Thomas Dubois, Brice Lepiece, Nicolas Zdanowicz & Etienne Delgrange: PARTIAL DENIAL OF PREGNANCY AT 32 WEEKS IN A DIABETIC AND SUICIDAL PATIENT: A CASE REPORT. What Are the Treatment Recommendations? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 418-421 similar in December 2013 with more time between each 2014). In the reported case, the decision-making follow-up. In December 2014, the situation remained priorities process was very difficult when the patient, stable. In December 2015, her son integrated into the confronted with the reality of her pregnancy, deve- nursery school very well. In December 2016, the patient loped intense suicidal thoughts, but accepted and asked resumed and passed vocational training and the mother- for care in a hospital where trusted caregivers work. son relationship was still harmonious, based on the Intensive gynecological monitoring, with all the risk consultations and the social management team. The management of a 32-week pregnancy not followed-up correct integration of the child in school continued. in a diabetic patient, required a transfer to a maternity During psychiatric interviews, compliance with oral unit with an associated neonatal unit. In this case, the contraception was well consolidated. The patient conti- priority given to the relationship of trust established nued her endocrinology follow-up. with caregivers helped to sustain suicidal thoughts to The time between psychiatric follow-up became give the patient time to consider the various options more spaced out, but the patient regularly updated the available to her and to create a progressive link with team. The family refused to carry out other family the maternity team. The limiting factor remains the interviews. pregnancy progress, which does not allow in all cases to have enough time to establish psychotherapeutic and DISCUSSION psychosocial treatment. Another pivotal moment in the treatment was the In our case report presents a frequent typology of referent nurse’s accompaniment of the patient to the women who present denial of pregnancy (Dubé et al. ultrasounds. These ultrasounds were confrontational 2003): young, single, living with parents, and with a low for the patient who, with the real-time support of the level of education and knowledge about sexuality. The psychiatric nurse, was able to gradually look at the avoidant personality context in this case report also goes images and develop an awareness of the presence of hand in hand with poor communication with the entou- her child. rage and passivity/avoidance in the face of conflict The importance of the social worker has already (Gorre-Ferragu 2002, Friedman et al. 2007); confirmed been noted (Berns 1982), and in this case it has proved by the observation of the family interview and the to be indispensable for the mobilization of support or subsequent refusal to carry out family follow-up the administrative procedures concerning the final (Desaunay et al. 2016). decision of the patient. Meetings with social services A decisive factor in this case report, but which is also participated in working the patient’s ambivalence. very different from what is observed in general, is the Lastly, the continuation of multidisciplinary medico- presence of moderate psychiatric disorders associated psycho-social postpartum follow-up is an important with type 1 diabetes with the implementation of stabilizing factor. Addressing the issue of prevention psychiatric follow-up prior to the discovery of denial in terms of contraception or risky sexual behavior of pregnancy. This dimension of an existing psycho- should also be systematic. therapeutic trust relationship was a decisive factor that treatment was possible. In the case of neonaticide CONCLUSION phenomena (murder of the newborn within 24 hours of birth), one hypothesis retained is that the brutal trauma Coordinated multidisciplinary work allowed a of confrontation with the reality of childbirth leads to a patient, in partial denial of pregnancy discovered at 32 dissociative state of derealization or depersonalization weeks who want to leave her child for adoption, to (Viaux et al. 2010) in a patient who has no gyneco- agree finally to keep her child with the development of logical or psychiatric medical follow-up to support her. a harmonious relationship mother-son in a follow-up at Nevertheless, it seems important to emphasize that five years. although the conditions for prior follow-up appeared This case discussion concerning a partial denial of optimal, the emotional reactions of the caregivers pregnancy led us to consider that initial prevention lies directly involved in the follow-up were intense, rein the context of continuing education for caregivers in gardless of years of experience. Being overweight general (general practitioners, medical specialists, nur- probably contributed to the difficulty of perception of sing teams, and social workers), awareness of denial of pregnancy; nevertheless, the retrospective experience pregnancy, although uncommon, is important because of having met this patient in consultation several times it is destabilizing when the caregiver is confronted. In without perceiving the pregnancy remained disturbing general, and systematically, including in psychiatric for the caregivers as well. Therefore, in our opinion, follow-up, the importance of addressing the issue of decision-making algorithms concerning the denial of regular gynecological follow-up, possible contracep- pregnancy were not implemented in caregivers and the tion, and measures to protect sexually transmitted confrontation with the reality of a denied pregnancy diseases are important factors of prevention already was also a difficulty for caregivers (Janati Idrissi et al. well accepted in the literature.

S420 Denis Jacques, Aurélie Maricq, Thomas Dubois, Brice Lepiece, Nicolas Zdanowicz & Etienne Delgrange: PARTIAL DENIAL OF PREGNANCY AT 32 WEEKS IN A DIABETIC AND SUICIDAL PATIENT: A CASE REPORT. What Are the Treatment Recommendations? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 418-421

In case of discovery of a partial denial of pregnancy, 6. Dubé S, Léveillée S, Marleau JD: Cinq cas de néonaticide we would recommend the rapid mobilization of a multi- au Québec. Santé Ment Qué 2003; 28:183-194 disciplinary team (attending physician, gynecologist, 7. Friedman SH, Heneghan A, Rosenthal M: Characteristics psychiatrist, psychologist, nurses, and social worker) of whomen who deny or conceal pregnancy. Psychoso- and, in view of the trauma that can constitute the an- matics 2007; 48:117-122 nouncement of the diagnosis, consideration of making 8. Friedman SH, Resnick PJ: Neonaticide: Phenomenology and considerations for prevention. Int J Law Psychiatry this announcement in the presence of the patient’s trus- 2009; 32:43-47 ted persons and if necessary announcing it during hospi- 9. Gorre-Ferragu: Le déni de grossesse: une revue de la talization to allow monitoring and mobilization of more littérature. Rennes, Université de Rennes 1, 2002 comprehensive support. 10. Jacob Alby V, Quaderi A, Vedie C: Is denial of pregnancy We would also recommend a sustained and perso- related to a mental pathology? Ann Med Psychol 2014; nalized accompaniment when the patient had routine 172:382-386 ultrasounds. 11. Janati Idrissi M, Dany L, Libert M: Social representations The remaining limiting and unpredictable parame- of denial of pregnancy for professionnals and future ters are the possibility of establishing a professional and professionnals in the vicinity of Lille. Neuropsy Enf Ado trusting therapeutic relationship and the pregnancy pro- 2014; 62:195-202 gress at the time of the discovery of a partial denial. 12. Milstein KK, Milstein PS: Psychophysiologic aspects of denial in pregnancy: Case report. The Journal of Clin Psych 1983; 44:189-190 13. Oliveira CP: Is denial of pregnancy a valid term for None. Acknowledgements: clinical practice? Topique: Psychanalyse 2013; 123:189-207 Conflict of interest: None to declare. 14. Pansarasa CL: Adolescent pregnancy denial, dissociative symptoms and neonaticide: Expanding understanding, Contribution of individual authors: furthering treatment and prevention. ProQuest Informa- All authors made a substantial contribution to the tion & Learning, 2004. AAI3133416 design of the study, and/or data acquisition, and/or 15. Rott P: Denial of pregnancy. Dtsch Med Wochenschr the data analysis and its interpretation 2016; 141:1854-1857 16. Seguin S, Golse B, Apter G: Denial and negation of pregnancy: A review of the literature. Psych de l’enf 2013; References 56:267-292 17. Struye A, Zdanowicz N, Ibrahim C, Reynaert C: Can 1. Berns J: Denial of pregnancy in single women. Health and denial of pregnancy be a denial of fertility? A case Social Work 1982; 7:314-319 discussion. Psychiatr Danub 2013; 25:113-117 2. Beier KM, Wille R, Wessel J: Denial of pregnancy as a 18. Vellut N, Cook JM, Tursz A: Analysis of the relation- reproductive dysfunction: A proposal for international ship between neonaticide and denial of pregnancy classification systems. J Psychosom Res 2006; 61:723-730 using data from judicial files. Child Abuse and Neglect 3. Chaulet S, Juan-Chocard AS, Vasseur S, Hamel JF, Du- 2012; 36:7-8 verger P: The denial of pregnancy; Study of 75 cases of 19. Viaux JL, Combaluzier S: Néonaticide, un non-désir late discovery of pregnancy. Ann Med Psychol 2013; mélancolique: étude clinique de 12 cas. L’évol psychiatry 171:705-709 2010; 75:3-17 4. Dayan J & Bernard A: Denial of pregnancy, infanticide 20. Wessel J, Gauruder-Burmeester A, Gerlinger C: Denial of and justice. Ann Med Psychol 2013; 171:494-498 pregnancy-characteristics of women at risk. Acta Obstet 5. Desaunay P, Guenole F, Andro G, Baleyte JM: Denial of Gynecol Scand 2007; 86:542-546 pregnancy and anonymous childbirth at adolescence: 21. Zagury D: Is pregnancy denial a denial? Cliniques médi- Which links? Neuropsyc Enf et Ado 2016; 64:455-463 térranéeennes 2013; 87:33-41

Correspondence: Denis Jacques, MD, MSc Université Catholique de Louvain, Psychosomatics Unit, CHU UcL Namur Godinne Hospital 5530 Yvoir, Belgium E-mail: [email protected]

S421 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 422-425 Conference paper © Medicinska naklada - Zagreb, Croatia

TRIAGE OF CHILDREN WITH MENTAL HEALTH DIFFICULTIES PRESENTING IN A&E IN A GENERAL HOSPITAL Anne-Frédérique Naviaux Summerhill Community Mental Health Service, Summerhill, Wexford, Ireland

SUMMARY In Wexford and Waterford, an “out of hours” child psychiatric service has been developed, in order to provide help when the regular Child Psychiatry services (CAMHS) are not accessible. Providing a service for under 18 years old patients with mental health issues presenting in the Emergency Department (ED) of a General hospital, it functions with extremely limited resources (a consultant psychiatrist and a doctor in psychiatric training), and therefore needs an efficient triage procedure. The purpose of this article is to review the literature about existing triage tools, and especially the 2016 Irish Children’s Triage System (ICTS) and to discuss how to optimise triaging our specific patients in this new ‘out of hours’ CAMHS cover for Waterford /Wexford area. Conclusion: A post triage tool and some clinical changes could improve the service. Key words: triage – tool - child psychiatry – emergency - ICTS * * * * * INTRODUCTION Health Services (CAMHS). CAMHS is organised in a 4-tiered model. An increasing young population in Ireland A ‘Vision for Change' (AVFC) (HSE 2006) is a stra- In Ireland, the total population aged less than 18 tegy document which sets out the direction for Mental years increased by 10.9% between 2006 and 2011 (HSE Health Services in Ireland, including CAMHS. It des- RCSI 2015). The increase in 2011 was largely in the cribes a framework for building and fostering positive 0-4 years and the 5-12 years age groups. Currently, one mental health across the entire community and for in four of the population is under 18 years of age (Barry providing accessible, community-based, specialist ser- 2017). vices for people with mental illness. This policy, was developed by an expert group, which combined the An increasing need for expertise of different professional disciplines, health Youth Mental Health Services service managers, researchers, representatives of voluntary organisations, and service user groups. For the past decades, we have observed an increa- To cut it short, it describes and recommends an ideal sing demand for Child and Adolescent mental Health way to staff, organize, deliver and develop CAMHS… Services (Wallis et al. 2017, Aras et al. 2014). For example, AVFC (HSE 2006, 2015) recommends As outlined in the 2014 Health Service Executive the following CAMHS services per 300 000 total popu- (HSE) Fifth Annual report of Child and Adolescent lation: Mental Health Services (CAMHS) 2012-2013: the pre- A total of 7 multidisciplinary community mental valence of mental illness in young people is increasing health teams (MHTs) which includes: 2 teams per over time. An examination of the prevalence rates of 100 000 population (1/50 000) + 1 additional team mental illness, suicidal ideation and intent, and para- to provide a hospital liaison service per 300 000 suicide in the population of Irish adolescents aged 12-15 population + 1 day hospital service per 300 000 years in a defined geographic area found that 15.6% of population. the total population met the criteria for a current mental Each CAMHS team should comprise: 1 consultant illness (including 2.5% with an affective disorder, 3.7% psychiatrist (clinical lead), 1 doctor in training, 2 with an anxiety disorder and 3.7% with ADHD). psychiatric nurses, 2 clinical psychologists, 2 social The World Health Organization (Dolan & Fein workers, 1 occupational therapist, 1 speech and lan- 2011, Aras et al. 2014) predicts that childhood neuro- guage therapist, 1 childcare worker and 2 admi- psychiatric diseases will be one of the causes of mor- nistrative staff. tality and disability among the five most common diseases of adolescence in 2020. While AVFC recommends 1 CAMHS team/50 000 total population, it is more appropriate to relate this to The CAMHS Model and ‘Vision for Change’ the number of the population aged under 18 years. According to the National Clinical Programme for Chapter 13 of the National Model of Care for Paediatrics and Neonatology, it is now agreed that there Paediatric Healthcare services (HSE RCSI 2015) in should be one team per 12 500 aged under 18 years. In Ireland, is dedicated to the Child and Adolescent Mental 2015, there were 63 CAMHS teams.

S422 Anne-Frédérique Naviaux: TRIAGE OF CHILDREN WITH MENTAL HEALTH DIFFICULTIES PRESENTING IN A&E IN A GENERAL HOSPITAL Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 422-425

THE PROBLEM: consultant’s presence was not necessary (usually con- AN UNDER-RESOURCED CAMHS PROVISION sultant in WGH and doctor in psychiatric training in UHW). Between February 2018 and August 2018, a These recommendations are great on paper (though total of 675 interventions were provided by the ‘out of there are controversies) but the reality is very different hours’ CAMHS consultant between both hospitals. The due to the lack of available resources. high number of interventions provided by this ‘out of For example, currently, only 2 out of 5 posts of hours’ CAMHS cover certainly highlighted the need for CAMHS consultants are filled for the geographic area an adjusted triage procedure or tool in order to optimize of both Wexford and Waterford Counties. Without its operation, especially in A&E, which is the common clinical lead, these CAMHS struggle to provide a full entry point for most of these young people. service as expected and waiting lists get longer. Triage (Aras et al. 2014) originates from military The number of patients waiting for their first ap- medicine and means to categorize the injured indivi- pointment in CAMHS (Aras et al. 2014) is gradually duals into 3 groups on the basis of a pre-examination: increasing because of a high number of patients, long the ones who require urgent intervention, ones who can follow-up times, and insufficient number of physicians. wait and ones who will not benefit from treatment. This Long waiting times decrease the rate of attendance at means that in the triage system, patients are directed to the first appointment and lead to waste of time for the appropriate treatments according to their clinical re- team, delayed solution of problems, and inability to quirements, the possibility of benefiting from the treat- evaluate cases of top priority in time. ment, and the urgency level. This is particularly frustrating, knowing that a range of efficacious psychosocial and pharmacological treat- THE CHALLENGE ments exists for many mental illnesses in children and adolescents, and knowing that long-term consequences Triage in an A&E is used to focus limited staff and of untreated childhood mental illness are costly, in both material resources on what is medically urgent (Stocker human and fiscal terms (HSE 2016). 2006). Therefore, we needed to explore how we could But if these young patients cannot access (soon triage our young patients with mental health issues enough) CAMHS, they present to A&E in hospital, presenting to A&E. We wanted a triage tool that was where they expect to be psychiatrically assessed, in- both easy to use with a paediatric population but also vestigated, treated and linked appropriately with inpa- specific to our young people mental health issues. We tient or outpatient services (Wallis et al. 2017, Goldstein also had to keep in mind that the staff using the triage & Findling 2006). And we don’t want the same problem tool would be an A&E staff and or a Paediatric A&E to be recreated. During opening hours, these patients staff, and not child psychiatrists. used to be seen from a psychiatric point of view by CAMHS in hospital, and out of hours, the psychiatric THE METHOD cover was provided by the adult psychiatric team on call Reviewing the literature, we compared various triage as there was no proper CAMHS on call. tools that had been developed by different Countries, either for paediatric patients or for patients with mental THE IDEA: health issues. AN OUT OF HOURS CAMHS COVER Between June and August 2018, we conducted a lite- FOR WATERFORD/WEXFORD rature search based on electronic bibliographic databases as well as other sources of information (grey literature). Two extra factors contributed to the creation of the We also had to question our own specificities, needs ‘out of hours’ CAMHS cover in Waterford/Wexford. and requirements and establish a few definitions prior to On one side, from the 01.09.2016 onwards, the adult establish a triage tool. psychiatrists in UHW decided to stop providing an out of hours ‘cover’ for patients under 18 years. On the other side, from January 2017 onwards, the psychiatric care IMPORTANT DEFINITIONS provided during opening hours by the CAMHS teams for AND CONSIDERATIONS children in WGH was ceased. Indeed, CAMHS being Child under resourced could not manage to deal appropriately with the always growing amount of young patients pre- Under the Mental Health Act, 2001, a child is defi- senting directly to hospital, and stopped to provide that ned as “a person under the age of 18 years other than a type of intervention. It is in this context that an ‘out of person who is or has been married”. hour’ child psychiatry cover was initiated; it has been active since 01.09.2016, and has continually been adjus- How do they come to A&E? ting as circumstances have always been changing (espe- They can self-refer, or come with some non-profes- cially depending on how operational the regular CAMHS sional referrers/escorts (parents, friends or non-parental were). It has been operated by one consultant psychia- carers) or be referred by professionals such as GP, trist and a doctor in psychiatric training on call when the Ambulance, Police, School, CAMHS, social work, etc.

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What is difficult with these young patients in A&E? primarily an adult triage tool. For example, in MTS Young patients who need mental health care can be there is no child age-specific parameters available for disturbing to the routine and flow of the Emergency De- abnormal pulse or respirations for children. It is adapted partment, and require more resources (including moni- for phone triage. toring from the hospital security) than many medical or trauma patients. A&E is often a high-stimulation environ- Canada ment where privacy that is an issue, leading to distraction The “Paediatric Canadian Triage and Acuity Scale” and disruption of care for these patients and their families (PaedsCTAS) is also a 5 model levels. It was created in as well as the other A&E patients (Dolan & Fein 2011). 1999 and revised in 2005 (presenting complaint list) and Among children who frequently used mental health 2008 (first and second modifiers). Its purpose is to services in A&E, approximately 50% of them were seen standardize triage rules. again within 2 months of their initial visit, which sug- The attribution of a patient to a triage category does gests that patterns of recidivism are high for psychiatric not depend on flow-charts, but is based on “description” patients (Wallis et al. 2017). Repeat patients are more of clinical presentation or illnesses (for example, the likely to threaten to harm others, to be under the care of critical first look is accomplished by a rapid visual in- a child welfare agency and to have an increased risk spection of the patient using the principles of the Paedia- involvement with juvenile justice. tric Assessment Triangle: general appearance, work of breathing and circulation. Most PaedsCTAS level 1 and 2 Assessing Children and Adults, patients will be identified and immediate care provided. what is different? Further clarification of the presenting complaint and The nature of parental responsibility, the child protec- modifiers can await stabilisation of the child). tion framework, the issues of competency to give consent The PaedCTAS was the only child specific triage or to withhold treatment, the rights to confidentiality, con- system identified. It was considered less user-friendly sideration and understanding of the family and support than MTS but included an age specific physiologic social environment in which the young person may be parameter assessment. discharged and of course, the child’s development. Australia MAIN TRIAGING SYSTEMS The Australasian College for Emergency Medicine (ACEM) has adapted the “National Triage Scale” that Triage is a clinical process to assess and identify the was created in 1993, and developed the “Australasian needs of a person and the appropriate response required. Triage Scale” (ATS). The ATS has been used since The most important element of triage is the identifi- 2000, both for adults and children, in all the emer- cation of risk. United States, Canada, United Kingdom gency departments in Australia, New Zealand and New and Australia (Stocker 2006, Maule 2014) were the first Guinea. It is also a 5 levels model. The attribution of a to develop triage for the Emergency Medical System. patient to a triage category happens after assessment of They worked on triage tools which are described below. the patient’s breathing, respiratory tract, circulation, They all have in common the fact that they use clinical consciousness and pain. Each of these parameters is criteria to limit the maximum waiting time for patients rated between 1 and 5, and subsequently, some further in A&E. Basically the assignment of triage acuity level criteria (neuro-vascular, psychiatric and ophthalmo- addresses 2 issues (Warren et al. 2008): “What is this logical) are also considered. The parameter with the patient’s priority (urgency) to be seen?” and “How long lowest level determines the global category level for is it safe to wait?” the patient. These 5 parameters are assessed indepen- United States dently from the patient’s main diagnosis. There is no homogeneity. There are models with 3, 4 IRELAND: THE IRISH CHILDREN’S and 5 levels of triage (and poor concordance between them). There is a preference for 5 levels triage systems. TRIAGE SYSTEM (ICTS) Neither MTS nor PaedsCTAS on their own were United Kingdom considered to fully address the need of the Irish paediatric The “Manchester Triage Group” (MTS) has deve- patient population or the users of the system, thus the loped a five levels model. A first model was developed merits of both systems were identified and merged into in 1996, and some further versions were made available one child-specific triage tool, namely the ICTS. in 2006 and 2014 (EMP). It was agreed to use a similar format to that of the It uses a series of flow charts for various “presenta- MTS as the flow charts used in the MTS were thought tions” with key “discriminators” to determine the triage to be user friendly and easy to follow. It was also category. It takes account of the severity of the pro- considered appropriate to build on a system that was blem but also of the pain level. This system can be already familiar to the staff rather than introduce a used (adapted) both for adults and children, but remain completely new system that would require substantial

S424 Anne-Frédérique Naviaux: TRIAGE OF CHILDREN WITH MENTAL HEALTH DIFFICULTIES PRESENTING IN A&E IN A GENERAL HOSPITAL Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 422-425 re-education. Furthermore, ICTS adapted the use of References numbering categories and ideal time targets from MTS rather than the target times recommended in the Canadian 1. Aras S, Varol Tas F & Baycara B; Triage of Patients in or Australasian triage tools. Finally the physiologic the Child and Adolescent Psychiatry Outpatient Clinic. parameters assessment of PaedsCTAS, was modified and Archives of Neuropsychiatry 2014; 51:248-252 incorporated in the new tool. Hereafter, ICTS was 2. Barry A: Children’s lives ‘at risk’ over lack of nationwide developed using flowcharts representing the 22 most out-of-hours mental health services. JRNL.IE/3181003, common paediatric presenting complaints to Irish EDs (+ 14.01.2017, Ireland 2 extra flowcharts: unwell child and unwell infant). 3. Bullard M, Musgrave E, Warren D, Unger B, Skeldon T, On 16.06.2016, the EMP formally launched the Grierson R et al: Revision des lignes directrices de l’echelle canadienne de triage et de gravite (ETG) 2016, ICTS at the Royal College of Surgeons in Ireland CJEM-JCMU 2017; 19(S2) (RCSI) (HSE 2016, EMSP 2013). 4. College of Psychiatrists of Ireland (review date 2020): Post Triage Mental Health Triage Tool, National Clinical DISCUSSION Programme for Emergency Medicine l, version 1, December 2017 The ICTs proved itself efficient through our 675 5. Dolan M, Fein J: Pediatric and Adolescent Mental Health interventions. But some barriers to adequate paediatric Emergencies in the Emergency Medical Services System. mental health services provision in ED, have been Pediatrics 2011: 127:5 identified. There are limitations of the A&E setting 6. Gerson R & Havens J: The Child and Adolescent that influence timely and comprehensive evaluation, Psychiatric Emergency: A public Health Challenge. but also a need for education and training of ED staff Psychiatric Times 2015; 32:11 regarding identification and management of paediatric 7. Goldstein A & Findling R: Assessment and Evaluation of psychiatric illness. The lack of access to and effective- Child and Adolescent Psychiatric Emergencies. ness of inpatient and outpatient CAMHS for follow-up Psychiatric Times 2006; 23:9 is also problematic. 8. HSE RCSI: A National model of Care for Paediatric Healthcare Services in Ireland. Chapter 13: CAMHS. In first instance, we need to address the lack of Health Service Executive, Ireland, 2015 information about paediatric psychiatric illness within 9. HSE: A vision for change, 2006, Health Service Executive the ED but also in the general population. Developing a (HSE) Ireland, 2006 practical though detailed post-triage mental health tool 10. HSE: Irish Children’s Triage System (ICTS) # Children’s for young patients, like it has recently been developed Triage, June 2016, Health Executive Service (HSE), for an adult population (review in 2020) (College of Ireland, 2016 Psychiatrist of Ireland 2017) could also help to an 11. Lofchy J, Boyles P & Delwo J: La psychiatrie d’urgence: appropriate and efficient provision of care. Availing from formation et pratique clinique, 2015, La revue canadienne a dedicated and specially organised place within the A&E de psychiatrie, vol 60, no.6 en ligne department to meet young patients presenting either with 12. Maule Y: Echelles de tri Tour d’horizon, CHU Brugmann a psychiatric emergency or in crisis, and their family, is 04.12.2014, (online) certainly crucial. Making this environment safe for both 13. National Emergency Medicine Programme (EMSP): A patients and staff is also essential. Providing observation guide to assist matching of staff clinical level and mode of or short hospitalisation beds in this system could help transport with the care needs of patients with mental for the assessment /monitoring of some patients and also health problems in the Emergency Department, 2013 help to diffuse crises and avoid inappropriate referrals to 14. Stocker S: Triage dans les situations d’urgence pédia- an already saturated CAMHS system. In order to make trique en Suisse. Paediatrica 2006; 17 this psychiatric emergency/crisis intervention centre 15. Wallis M, Azam M & Akhtar F: Paediatric Admissions due to perceived mental health and behavioural issues: audit functional, we believe that not only psychiatrists should 2017, Wexford General Hospital Audit 2017 report be present 24/7, but that psychiatric nurses and social 16. Warren D, Jarvis A, LeBlanc L, Gravel J & CTAS workers should also be present 24/7. National Working Group: Revisions to the Canadian Triage and Acuity Scale Paediatric Guideline. PaedCTAS 2008; 10:224-32 Acknowledgements: None.

Conflict of interest: None to declare.

Correspondence: Anne-Frédérique Naviaux, MD Consultant Psychiatrist and Child Psychiatrist - Healh Service Executive (HSE) Summerhill Community Mental Health Service Summerhill, Wexford, W35 KC58, Ireland E-mail: [email protected]

S425 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 426-430 Conference paper © Medicinska naklada - Zagreb, Croatia

STRESSFUL CHILDHOOD EVENTS: A RETROSPECTIVE JOURNEY INTO THE LIFE OF ADULTS WITH DEPRESSION; A REPORT OF 5 CASES. The importance of maternal love Dominique Tavormina Bergamo, Italy

SUMMARY The importance of maternal care for a harmonious development of the child has been at the center of the interest of child psychology since the second half of the twentieth century. Great scholars such as Lorenz, Harlow, Spitz and Bowlby have asserted that love for mum does not have its roots in satisfying the need for food, but in the need for protection and if there is a lack of care the consequences are extremely negatives. Nowadays, epigenetics is finding the biological basis of the effects of maternal care, if they are present and affectionate, and even if they are lacking or absent. A report of 5 cases helps to understand the importance of maternal love. Key words: maternal care – childhood – negative events – depression * * * * * INTRODUCTION mental stress can have such a profound impact on the physiology of an individual that his biological modifica- Today, more and more researchers agree that mater- tions can be inherited for generations to follow. There nal care leaves its mark in the DNA of children; how an seems to be a striking analogy between modern neuro- individual is depends on his/her genes but also on his/ science and the more traditional horizons of evolutio- her first experiences of life, both in the mother's womb nary psychology regarding studies of maternal love, as and during childhood, and therefore from the environ- if the biological foundations of what was theorized in ment and the social context in which he/she grows and the past by some great researchers were finally found. lives. The most recent studies in the field of epigenetics In fact, the scientific study of the importance of show that there are important interconnections between maternal care and physical contact on the nervous, environmental influences and genetic characteristics. affective and behavioral development of mammals dates Researchers at the Salk Institute for Biological Studies back to the mid-twentieth century. Some studies in in California (study published in Science in 2018) have particular represent milestones in the history of medical recently shown how maternal care in the early days of and psychoanalytic research. life can modify the DNA sequence in mouse pup neurons, translating into persistent changes in their beha- LITERATURE vior: the mice that during the first days of life receive more attention and pampering from the mother, have the René Spitz, an Austrian physician and psychoanalyst DNA of some neurons different from that of the rodents (1887-1974), working in the United States, performed that have received less as if, explain the researchers, the numerous researches on the mother-child relationship experience of the very first moments of life was since the 1940s. He is one of the first scholars to apply recorded in the genome. the methods of field research to early childhood studies; A spokesman for the research team explains that the from his research he draws the conclusion that the discovery could help psychiatric medicine in the pre- relationship between the mother and the child is vention field (experts believe it could be used to combat fundamentally an environment-individual relationship anxiety, depression and schizophrenia): "We are taught and that the mother constitutes an essential growth that our DNA is something stable and immutable that stimulus for the child. "We rarely realize the great makes us what we are, but in reality it is much more importance of the mother in the child's learning and dynamic. It turns out that there are genes in cells that are awareness processes. Even more rarely we realize the able to copy themselves and move, which means that primordial importance that in this process have the DNA changes." feelings of the mother, that is what we call "affective The last mystery of heredity, (2011) the book of the attitude". The mother's tenderness allows her to offer writer and biologist Richard C. Francis, still unpub- the child a rich range of life experiences; his affective lished in Italy, is one of the first popular works on the attitude determines the quality of the experiences new frontiers offered by epigenetics and the way in themselves. [...] In the first months the child's which the environment can leave indelible traces on experiences are exclusively emotional." (R. Spitz, The DNA, referring in particular to the fact that environ- first year of the child's life, 1965).

S426 Dominique Tavormina: STRESSFUL CHILDHOOD EVENTS: A RETROSPECTIVE JOURNEY INTO THE LIFE OF ADULTS WITH DEPRESSION; A REPORT OF 5 CASES. The importance of maternal love Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 426-430

Between 1945 and 1946 Spitz compares two groups introduced into the cage, the little macaque runs towards of institutionalized children. The first consists of 220 the cloth puppet and crouches there as a source of secu- elements, children of women held in a women's prison, rity. Harlow demonstrates the preference of the little ones but with the opportunity to dedicate themselves perso- for the "soft" mother who does not provide milk, noting nally to their children in a nursery attached to the struc- how a warm contact is more important for the little ones ture. The second one, however, includes several hundred than the need for food itself. It is not the fulfillment of abandoned infants and hosted in a foundling hospital. primary needs to create that indissoluble bond that is Spitz notes that in both cases the children are established between mother and child in every species, adequately nourished and treated hygienically, but in the but the need for physical closeness, warmth, the possi- second group, despite the presence of professional bility of feeling protected. In fact, very soon the soft pup- workers specially trained for assistance to infants, the pet is no longer enough: the young macaques begin to suf- children present a disturbing clinical picture starting fer the lack of the mother in the flesh and become sad and from the fulfillment of the 1st year of life, because the apathetic. The puppet is not able to embrace them, hold nurses do not have the opportunity to cuddle or caress them gently, kiss them, let them go and take them back, the children, having to look after too many of them. in short, to perform all those actions that convey love. Many will not have a regular growth: they will manifest After some weeks of this experience, some of the evident delays in cognitive and motor development - animals are again placed with the real mothers, but this with symptoms such as lack of response to external fact will not be enough to repair the serious damage stimuli, facial expression (apathy and indifference), done: in fact, once grown, monkeys will exhibit social, muscle spasms, crying crisis - as well as a marked sexual and maternal pathological behavior; they will lowering of immune defenses. 37% of them will come show excessive fear of any change, they will not play to die within the second year of life. Spitz concludes with their companions, they will not be receptive to the that they are treated in an aseptic and impersonal way, courtship and, if they become mothers in turn, they will as an object, when instead what is needed is an attack their young. Deprivation of maternal care, in environment that is primarily emotional and relational, particular the lack of affectionate contact, determines not merely material. dramatic and pervasive effects: love not received and The child does not need only material care but also, not experienced cannot be given. (Harlow 1958) and above all, to establish a strong emotional bond with John Bowlby, a British physician and psychoanalyst, the mother (or the person who cares for the child (1907-1990), carried out his rich research activity in regularly). The smiles, the caresses, the physical contact London. All of his experience in the field gives him the with her body stimulate in the child a positive reaction conviction that the origin of psychopathologies is to be absolutely necessary for their proper development. The found in the real experiences of interpersonal life and already formed self of the mother enables the creation they direct his interest, from the beginning, to the study of and formation of the child's self, through a continuous the nature of that link, powerful and enduring, that is interaction consisting of sensations and emotions established precociously between the growing individual transmitted through symbols, that is the words and and those who take care of it, leading him over time to gestures with which the mother communicates her formulate a true and proper theory of attachment, affection to the child. If instead this link is absent, or expressed in a complete and systematic way in the trilogy fails for any reason, the child feels abandoned, lost, Attachment and loss (1969; 1973; 1980). Today this unable to find the reference point that is vital. Here the theory constitutes "the most complete and articulated emotional stress caused by the lack of a real maternal theoretical model to refer to in order to understand and figure affects the maturation giving rise to a series of explain the psychodynamic mechanisms that underpin serious physical and psychological disorders. evolutionary processes" (Tani 2011). In 1958 the American psychologist Harry Harlow Supported by Harlow's studies of the comforting carried out an experiment that became extremely famous. nature of mother attachment, Bowlby goes so far as to More than 60 little macaques are separated from the refute what he calls "the love of object relations", ac- mother a few hours after birth and raised with artificial cording to which the child attaches to the mother be- milk. It is interesting how the pups are immediately cause she satisfies some of his/her physiological needs attracted to diapers found in the cage and when these such as those of food and warmth (Bowlby 1969). cloths are removed to be washed, the macaques protest Based on observations of the mother-child bond in and show signs of great affliction. Faced with this, the non-human primates, as well as those derived from his scholar decides to build two "surrogate mothers" and to clinical practice, Bowlby comes to theorize that the place them in the cages 24 hours a day: one of iron with a child has a "biological predisposition" to develop an bottle that dispenses milk attached to the chest and one attachment bond towards the person who takes care of with the same structure but covered with cloth and him/her. This predisposition is genetically determined without bottles. Harlow observes that the monkeys tend and phylogenetically transmitted as it is functional to to embrace the "soft mother", warm and welcoming, and the survival of the individual and of the species. Bowlby spend only the time necessary for feeding with the other explores ethology influenced by K. Lorenz's findings on figure. Moreover, if a strange object that inspires fear is the phenomenon of imprinting and Harlow's studies.

S427 Dominique Tavormina: STRESSFUL CHILDHOOD EVENTS: A RETROSPECTIVE JOURNEY INTO THE LIFE OF ADULTS WITH DEPRESSION; A REPORT OF 5 CASES. The importance of maternal love Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 426-430

In Lorenz's studies it can be seen that in small From the last interview granted in 1990, just before ducklings an attachment bond develops even without dying: "It all started in the 1930s, between 1936 and the intermediation of food. In short, it can be inferred 1940. I worked as a child psychiatrist in London while that the attachment system is not connected to nourish- completing my psychoanalysis training. One of the ment, as theorists of social learning and psychoanalytic concepts I was interested in very early on was the school argued, but it is a primary need that can be importance of early parent-child relationships and the studied within an evolutionary circle. According to extent to which adverse experiences within the family Lorenz's theory, the ducklings, deprived of the natural could have a negative effect on the child's physical and maternal figure, follow a human being or any other mental health. At that time many psychoanalytic collea- object, towards which they develop a strong bond that gues were unwilling to attach importance to adverse goes beyond the simple request for nutrition, given that life events as an important factor in the development of this type of animal feeds independently (Lorenz 1935). the child. [...] In the 1930s, in London, there was a Returning to Bowlby, the style of attachment that the strong attitude that one should never have believed the child develops depends on the "quality" of the maternal stories of patients regarding sexual abuse or any other care received and not on the "quantity" of food, and the adverse experience caused by the parents, and that one style of the first attachment relationships has a consider- should not trust the validity of the patient's account. able influence on the early organization of the perso- Instead, I thought adverse events were of great impor- nality and above all the concept that child will have of tance, and as a young psychoanalyst and young himself/herself and of others. Anxiety and depression psychiatrist of childhood, I tried to show that early manifested in adulthood, could derive from periods in childhood real life events played a prominent role in which the person has experienced childhood anguish determining mental health. And that's how the study and detachment from the reference figure. began which I have since then dedicated to. [...] The Three basic types of attachment are identified: secure reason why I focused on separation and loss was, in attachment, insecure-ambivalent attachment, insecure- part, because it could be the object of research; I had avoiding attachment, and later, by a group of scholars of also observed, at the Child Guidance Clinic, a number the University of Berkeley, disorganized attachment. of cases where the personality of the child, who later Secure attachment occurs when the caring figure is became delinquent and unmanageable, seemed to me sensitive to the child's signals, available and ready to to have been precociously preceded by very destructive give protection when the child requests it; consequently, relationships between the child and the mother. Once the child acquires and maintains security in the explo- considered early antecedent events, their presence ration of the world, the conviction of being lovable, the could be demonstrated in a statistically significant way capacity to endure prolonged detachment, no fear of to study if an important connection was likely. There abandonment, trust in one's own abilities and those of were many internal clinical evidences suggesting that others. An insecure attachment occurs when the child is early adversity had led to results that included chil- not sure that the mother is available to respond to a dren with poor emotional relationships or disinte- request for help, indeed most likely will be refused. In restedness in them, who did not seem to be influenced particular, the attachment figure is available on some by praise or punishment, or who went their own way. occasions but not on others (ambivalent), unpredictable They sailed the school, ran away, they made petty in its behavior, alternating in feelings, unexpected in theft, and so on. They were emotionally blocked. It all reactions. These children develop the anxiety of aban- started like this; I was starting from a condition that I donment, insecurity in the exploration of the world and believe represents, in reality, the early stages of a the sense of guilt, the inability to bear prolonged detach- psychopathic personality.” ments, the mistrust in their abilities. It is also possible to (Interview held in London, 11 January 1990, by prof. check that the mother constantly rejects her son every Leonardo Tondo and published the same year in the time he approaches her for comfort or protection, journal Clinical Neuropsychiatry.) avoiding any physical contact. In this child the pre- In more recent times, since the 70/80s of the twen- dominant emotions are sadness, pain and emotional tieth century, numerous studies have verified that adults coldness, detachment and a tendency for avoidance. exposed in childhood to stressful events are more likely As we can see, the oral gratification received by the to present mental illness (in particular, a causal link child is no longer in the foreground, but rather the between loss and the presence of depressive pathology quality of the care, that is the availability and the ability was sustained) (Brown & Harris 1989). The experiences to respond to the mother. His work as a child of detachment and/or abandonment experienced in psychiatrist at the Child Guidance Clinic in London childhood determine an intrapsychic vulnerability pre- contributes to the development of his thought, but also disposing to the depressive illness, a condition characte- his ten-year experience as director of the "Department rized by passivity, low self-esteem, psychic and emotio- for Children and Parents" of the Tavistock Clinic in nal dependence, self-evaluation and psycho-behavioral London and the appointment of a World Health Organi- rigidity (Infrasca 2002). Many of these studies have zation consultant with the task of preparing a report on used a method of investigation organized with a the mental health of abandoned children. retrospective criterion, that is recording the number and

S428 Dominique Tavormina: STRESSFUL CHILDHOOD EVENTS: A RETROSPECTIVE JOURNEY INTO THE LIFE OF ADULTS WITH DEPRESSION; A REPORT OF 5 CASES. The importance of maternal love Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 426-430

"weight" of negative events occurring in patients treated 2 for depression during their childhood (Campbell 1983, A thirty year old woman, married with two children, Bernstein 1986, Barnett 1988, Kessler 1993, Brown born in a family who owned a restaurant. She remem- 1994, Berger 1998). bers to have never experienced the warmth of the home, The possibility of having reliable parameters capable to have never experienced the pleasure of lunches or of assessing the consistency of childhood factors linked dinners (both daily and Sunday) or parties in her home, to the risk of depression in adults is an essential condi- which was always half empty. She recalls her loneliness tion for organizing appropriate prevention interventions. and the search for her parents' closeness (even through the daily afternoon study at the restaurant). She speaks THE REPORT with pain of their disinterest and inattention (in particular showing anger towards her mother, anger born Even in the clinical pedagogical practice, my per- during adolescence). She could never tell anyone in her sonal workplace, within the unavoidable anamnestic family about having a voluntary abortion when she was moment of knowing the other, it is possible to detect the 16. She lives in regret of what she has not had, does not life experiences of the subjects via a journey through the enjoy the present, always complains and is uncom- personal memory. promising, never happy. Five subjects of differing age, sex, origin, training, It is known that the lack of parents' presence in the qualification (but with an identical and comfortable home does not allow the child to continuously enjoy the economic condition) have in common a negative child- main sources of affection, sometimes feeding him the pro- hood experience of loneliness and sadness due to a found desire to live in another family unit. If the paternal rejection/detachment from the mother figure and a un- attitudes are added to the maternal ones, this introduces affectionate family atmosphere, unprotected and some- additional problematic elements in the child's personality. times conflictual, poor in communication, frustrating and unsatisfactory, resulting in adolescence with inner 3 discomfort, difficulty in emotional relationships, lack of A thirty five year old young woman, married with autonomy and self-esteem, pessimism. The relationship two children, emotionally detached from her husband with the mother is still problematic and painful, despite and children, very critical and dissatisfied. She tells about adulthood; on the part of the female subjects the resent- her mother, a very strict school manager, totally absor- ment and the anger due to the lack of love received and bed in her work, from her own problems and personal the poor care are strongly present. Most of the vital fulfillment, emotionally distant from her, never sweet energies of the aforementioned subjects are spent in and affectionate, even at home. wanting to find at all costs a reason for the lack of During her stories she melts and cries tears of pain. maternal affection; there is no acceptance or resignation She tells of not being able to accept her mother's lack of or understanding. affection and that this in turn prevents her from loving In addition to the path of clinical pedagogical help, her husband, being unable to live as a couple and from they are being treated for problems in disorders of mood being caring in her family; she sees the children as her and anxiety. property, prevents the spouse from educating them. Subject opposed to authority, maternal authoritaria- 1 nism assumes the meaning of rejection towards the child, A twenty-five year old male, graduated, an only causing in it a counter-hostility. Moreover, the authori- child, says he has no happy memory of his childhood. tarian attitude tends to organize in the mother-child rela- Lived in a condition of material well-being, he re- tionship an emotional-affective "wall", a condition that members the absence of the mother from home as a inserts elements of conflict in the child's personality. bar owner, a cold family atmosphere, an absent communication with both parents and a strong sense of 4 detachment and subjection in their comparisons. He A young 20-year-old male, a university student, still remembers with sorrow her own loneliness and remembers violent quarrels above all for years between the lack of physical contact and sweetness of her his parents, and the memory of this still frightens him. mother, the absence of play with her, the severity of The subsequent separation between the two did not the rules. The absence of playful and communicative bring him particular benefit: he lives with his mother, a relationality with the mother tends to establish feelings woman in a detached and uncomprehending career. He of frustration and psycho-affective isolation in the shows a negative view of life, sadness, anhedonia, small precocious child (Mahler et al. 1978). Moreover, relational closure, psychological fragility. The constant subjection and fear produce conflicts in the cognitive conflict in the couple in this case has taken on meanings and affective sphere and stimulate strong closure, that have prompted in the child negative experiences of unease and tendency to silence. considerable importance, such as a permanent condition Today he lives in an inner condition of dissatisfac- of insecurity, fear and emotional alarm and a continuous tion, hypercritical attitude, devaluation of self, work frustration of child expectations related to the need to be disengagement. at the centre of parents’ emotional interests.

S429 Dominique Tavormina: STRESSFUL CHILDHOOD EVENTS: A RETROSPECTIVE JOURNEY INTO THE LIFE OF ADULTS WITH DEPRESSION; A REPORT OF 5 CASES. The importance of maternal love Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 426-430

5 A fifty year old woman, unmarried, with unsuccess- Acknowledgements: None. ful love affairs, the last of four children, parents advanced in age, not very communicative and strict; she Conflict of interest: None to declare. remembers the constant avoidance of the mother towards her and her own search for affection never satisfied. A very cold father. She has no pleasant episodes of References her childhood to remember. She lives a situation of estrangement and disinterest in life and the surrounding 1. Bowlby J: Attaccamento e perdita. Vol. 1 - L'Attaccamento reality, feelings of guilt for not living up to maternal alla madre. Bollati Boringhieri, Torino 1972. Vol. II - La expectations, low self-esteem, sense of despair. The separazione dalla madre. 1975. Vol. III – La perdita della madre, 1983 perception of herself as an unaccepted person, even 2. Barnett P, Gotlib I: Psycosocial functioning and depres- rejected by her parents, has assumed a configuration that sion. Distinguishing among antecedents, concomitants and has torn the construction of basic trust; this negative consequences. Psichological bulletin 1988; 153 perception has assumed a meaning of overall inadequacy 3. Berger AK et al.: Preclinical symptoms of major depres- and introduced a profound psychological discomfort. sion in very old age. A prospective longitudinal study. American Journal of Psychiatry 1998; 155 CONCLUSIONS 4. Bernstein VJ, Marcus J: Mother – Infant interaction in multiproblem families. Finding those at risk. Journal of To conclude, the continuity and permanence of American Academic Child Psychiatry 1986; 25 stressful childhood experiences endanger the so-called 5. Brown GW, Harris TO: Life events and illness. London, "basic trust" (Erikson 1950), a necessary prerequisite to Guilford Press, 1989 face life with serenity, and makes negative the image 6. Brown GW: Life events and endogenous depression. A that the child has of himself, as not worthy of love and puzzle remained. Archives General of Psychiatry 1994; 51 guilty. Feeling of being "unpleasant" for the mother 7. Campbell LA et al.: Social factors and affective disorders. figure, determines in children an experience of nega- An investigation of Brown and Harris’ model. British tivity, consequent to the perception of not being able to Journal of Psychiatry 1983; 143 satisfy the maternal expectations (Bowlby 1983). In the 8. Erikson E: Infanzia e società. Armando editore, Roma, mother-child relationship, the reiteration of these expe- 1950 riences tends to organize a stable trace in the intra- 9. Harlow H: From learning to love. Albion Publishing Company, 1971 psychic structure of the child, originating a series of 10. Infrasca R: Dall’infanzia alla depressione. Edizioni depressive veins in its personological structure. The Scientifiche Magi, Roma, 2002 affective and emotional distance introduced by the 11. Kessler RC, Magee WJ: Childhood adversities and adult conviction of "not pleasing to the mother" creates a depression. Basic patterns of association in a US national situation in which, unable to understand such rejection survey. Psichological Medicine 1993; 23 (not attributing it to the parent's problems), the subject 12. Lorenz K: L'anello di Re Salomone. Milano, Adelphi, 1989 tends to invest his person with devaluing meanings. 13. Mahler et al.: La nascita psicologica del bambino. Thanks to the numerous recent research in the biolo- Boringhieri, Torino, 1978 gical field, the teaching that perinatal psychology experts 14. Spitz R: Il primo anno di vita del bambino. Firenze, Giunti nowadays recommend to new parents to bring home is Barbera, 1965 very simple: do not be afraid to cuddle children, remem- 15. Tani F: I legami di attaccamento fra normalità e pato- ber the importance of physical demonstrations of affec- logia. Firenze, 2011 tion and provide for the most affective care of the child.

Correspondence: Dominique Tavormina, MD, Clinical Pedagogist Via Chiesa san Grisogono, 20, 24068 Seriate, Bergamo, Italy E-mail: [email protected]

S430 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 431-435 Conference paper © Medicinska naklada - Zagreb, Croatia

ECOSUSTAINIBILITY AND MENTAL HEALTH: FEMALE ASPECTS Marilisa Amorosi Mental Health-AUSL, Pescara, Italy

SUMMARY The relationship with the environment is one of determinants of the health status of the human population. Many aspects of today's society negatively affect the environment and, consequently, human health. In particular there seems to be a prevalence of diseases, linked to environmental pollution, which affects the female gender, almost to assume a role of gender pathogenicity. But the female gender is also the promoter of changes; in fact, women are more sensitive to environmental health and adopt more appropriate behavior to prevent environmental damage. It is precisely in the balance between these two aspects that we can see a factor promoting behaviors to combat the effects of environmental pollution on the mental health of Man. Key words: environmental pollution - mental illness of gender - prevention of damage to health from pollution * * * * * INTRODUCTION In general, the prevention of diseases of environmental origin requires a complex effort of action both The relationship with the environment is one of the on behaviors and lifestyles, and on the norms and fundamental determinants of the health status of the institutional measures that allow to guarantee the safety human population. From the polluted city to the pristine of the population exposed to environmental risks. forest, the relationship between the individual and dif- Attention must be paid to environmental health is- ferent environmental factors can result in different sues with reference to all those conditions in which the stages of well-being or illness. Understanding which determinants of illness and disability are chemical, elements to take into consideration, from an epidemio- physical, economic and structural conditions, organiza- logical point of view, to assess the impact of various tional and preventive deficiencies, behaviors and envi- factors on the state of health is a very complex task. ronments at risk. It is only through the intersection of environmental, So we can briefly list the environmental problems territorial and urban, epidemiological, mortality data as that affect health in general and on the mental one in well as other health, demographic, cultural and social particular: indicators that a series of possible scenarios can be traced for a given population. Useful to regulate and Waste and Health foresee, when necessary, health policy actions that im- The problem of waste, Incinerators and health, prove the health of the population and limit the damages Mortality, malformations, tumors. deriving from specific environmental components. Electromagnetic fields Many enemies of health can easily be prevented by Electromagnetic fields made by Electrical, industrial promoting healthy lifestyles, through the implemen- and domestic instruments, mobile telephony, TV ecc: tation of a policy and an effective strategy that can also tumors, schizophrenia, increase in aggression. act on socio-environmental conditions to considerably Some scientific studies have suggested that exposure reduce the burden of diseases and disabilities that weigh to electromagnetic fields generated by these devices on society (Chief Medical Officer 1999). may have harmful effects on health (cancer, impaired But it is not enough to urge people to adopt healthy fertility, loss of memory and negative changes in chil- lifestyles because the environment can have an indirect dren's behavior and development, increase of schizo- or direct impact on health; in fact it promote the phrenia and aggression). circulation of pathogens and other biological factors, such as pollens and other allergens, which affect, when Pesticides present, the susceptible population. Pesticides, although they are still widely used in However, it can also act through non-biological fac- intensive farming, are for the most part substances that tors, such as the presence of chemical and physical are very toxic and harmful to human health and the contaminants: in this case, it is more difficult to deter- whole eco-system (environment), causing damage to mine a cause-effect relationship and epidemiological spontaneous vegetations or to insects useful. The dan- studies try to describe and quantify the exposure dama- gers of pesticides are also due to some of their chemical ges, both acute and chronic, to different substances. characteristics: they are persistent molecules, so once Finally, the environment can be the source of accidents they are spread into the environment they bind to the and disability when, at work or on the road, adequate soil, spread in the water where they can contaminate and safety and protection measures are not observed. bind to the tissues of fish and other animals (defined

S431 Marilisa Amorosi: ECOSUSTAINIBILITY AND MENTAL HEALTH: FEMALE ASPECTS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 431-435 mechanism of bio-accumulation), which entering the aspects and should try to organize cities also on the food chain, end up in our tables, thus constituting an basis of criteria that take into account the green per additional source of exposure, in addition to plant pro- capita or accessibility to green spaces or live healthier ducts that are treated directly. environments. There is a close relationship between direct or indi- City dwellers often face crime, pollution, social rect exposure to these substances, and some serious isolation and other environmental stress factors that are diseases: obesity, diabetes, Parkinson's disease, chronic higher than those of people living in rural areas. For diseases (allergies especially in workers), disorders of years, studies have constantly linked the risk of deve- the reproductive system, autism and tumors. Particularly loping schizophrenia with urban environments, but only sensitive to the damage of pesticides, in addition to now researchers begin to understand why this asso- children, are women, precisely because of their physical ciation exists. structure, so much so that we can speak of "gender The first time the researchers hypothesized that difference" especially with regard to some types of urban life could increase the risk of schizophrenia was pesticides that are classified as "endocrine disruptors" or in the thirties of the last century. " endocrine disrupters ", endocrine active substances Convergent evidence indicates that growing in the able to interact or interfere with the normal hormonal city doubles the risk of developing psychosis later in action, causing pathologies of the female reproductive life. These studies have also begun to suggest that urban system, including endometriosis. environments may increase the risk of incurring other Environmental pollution mental health problems, such as depression and anxiety. According to the European Environment Agency in Environmental contamination is now a national emer- Italy, 84,400 premature deaths are recorded each year gency that compromises not only reproductive health but due to air pollution, which increases the risk of tumors, also the overall health of the population and of future compromises the development of the fetus and increases generations. If we do not intervene promptly on the the possibility that the child is born with mental causes of diseases such as cancer, hormonal diseases, retardation. The scientific evidence amply demonstrates spontaneous abortion, infertility, autism, diabetes, obe- that the toxic substances present in the air, in food, in sity, psychosis etc. - improving air quality, of water and the water generate an increased risk not only of cancer food and reducing exposure to poisons such as heavy or cardiovascular pathologies, but also of numerous metals, dioxins, PCBs, ultrafine particulates, is likely to other pediatric and non-pediatric diseases, among which condemn all public health policy to the ineffectiveness. are dramatically increasing diabetes, infertility, endo- While on the one hand the attention of the popu- crinopathies, neurological, cognitive and behavioral dis- lation and of the local communities grows - starting orders and premature aging of the woman as the from those impacted - on the environmental determi- increase in finer dust increases the atrophy of the white nants of health, the government policies go in a com- matter of the brain, accelerated aging of two years for pletely different direction and reclamation and environ- women between 71 and 89 years. mental protection are lagging behind in the list of priorities of government - denounces Laura Greco, WHAT TO DO? President of the A South Association (www.fbi.gov). The Land of Fires has shown that environmental con- Living in the green is good not only for physical tamination causes serious diseases, infertility and cancer health but also for mental health. A UNEP dossier, the diseases that increasingly affect children. In Campania, UN agency for the environment, and the WHO, the the region with the youngest population in Italy, the World Health Organization, have dealt with the relation- health cuts are enormous. Not only primary prevention ship between environment and mental health. The is essential, but also the possibility of treatment. And document, entitled "Healthy environment, healthy Campania is only the tip of the iceberg of the environ- people", was presented to the United Nations Assembly mental emergency spread throughout the country. on the Environment in Nairobi (Rapporto UNEP- Agenzia ONU per l’ambiente-OMS 2003). ENVIRONMENTAL SUSTAINABILITY IS The report emphasizes that the presence of more A WOMAN - THE FUTURE IS A WOMAN green spaces in the city, in addition to increasing physical activity outside the home, and therefore reducing the The adult female population is on average more incidence of obesity, also reduces stress levels and is informed, aware and attentive to the environmental and beneficial for mental health. Several researches in the social sustainability of the male counterpart, already past have analyzed the correlation between environment orientating consumption and lifestyles of Italian fa- and depression, a condition that in the world affects, milies. according to the WHO, 350 million people. Women, especially in the age group between 18 and Is it possible to promote better mental health by 34, with a higher educational qualification and employ- intervening directly on urban furniture? Who has admi- ment as a student, clerk or teacher, are shown to be nistrative responsibilities should not underestimate these more informed on average.

S432 Marilisa Amorosi: ECOSUSTAINIBILITY AND MENTAL HEALTH: FEMALE ASPECTS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 431-435

Table 1. Frequency of disorders in Italy, lifetime differences between males and females Prevalence at 12 months% (IC 95%) Prevalence of lifetime% (IC 95%) Males Females Total Males Females Total Every mental disorder 3.9 (2.6-5.3) 10.4 (82-3.0) 7.3 (6.0-8.6) 11.6 (9.7-14.0) 24.4 (21.0-28.0) 18.3 (16.0-20.0) Every affective disorder 2.0 (1.3-2.6) 4.8 (3.9-5.8) 3.5 (2.9-4.0) 7.2 (6.0-8.4) 14.9 (13.0-17.0) 11.2 (9.8. 13.0) Every anxiety disorder 22 (1.0-3.4) 7.8 (6.1-9.6) 5.1 (4.0-6.3) 5.5 (4.0.7.1) 16.2 (13.0-19.0) 11.1 (9.3- 13.0) Every alcohol disorder 0.2 (0.0-0.5) 0.1 (0.0-0.2) 0.1 (0.0-0.3) 2.0 (1.1-3.0) 0.1 (0.0-0.3) 1.0 (0.6-1.5) Major depression 1.7 (1.1-2.2) 4.2 (3.4-5.0) 3.0 (2.6.3.4) 6.5 (5.5-7.5) 13.4 (11.0-15.0) 10.1 (9.0- 1.0) Dystimia 0.7 (3.3-1.1) 1.3 (0.8-1.9) 1.0 (0.7-1.4) 2.3 (1.6-3.0) 4.4 (3.2-5.5) 3.4 (2.7-1.1) Generalized anxiety 0.1 (0.0-0.2) 0.9 (0.4-1.4) 0.5 (0.3-0.8) 0.8 (0.4-1.2) 3.0 (2.0-4.0) 1.9 (1.3-2.5) Social phobia 0.6 (0.2-1.1) 1.4 (0.7-2.1) 1.0 (0.6.-1.3) 1.6 (0.8-2.3) 2.6 (1.6-3.6) 2.1 (1.4-2.8) Specific phobia 0.5 (0.2-0.9) 4.6 (2.9-6.4) 2.7 (1.7-3.6) 25 (1.4-3.6) 8.8 (6.2-11.0) 5.7 (4.3-7.0) PTSD 0.7 (0.0-1.7) 0.9 (0.2-1.5) 0.8 (0.2-1.4) 1.1 (0.1-2.1) 3.3 (1.7-4.9) 2.3 (1.2-3.3) Agoraphobia 0.1 (0.0-0.2) 0.7 (0.3-1.1) 0.4 (0.1-0.6) 0.6 (0.1-1.1) 1.7 (0.9-2.5) 1.2 (0.6-1.7) Panic disorder 0.3 (0.1-0.5) 0.9 (0.5-1.3) 0.6 (0.4-0.8) 0.9 (0.5-1.-3) 22 (1.6-2.8) 1.6 (1.2-1.9) Alcohol abuser 0.2 (0.0-0.5) 0.0 0.1 (0.0-0.2) 1.6 (0.7-2.4) 0.1 (0.0-0.1) 0.8 (0.4-1.2) Alcohol addiction 0.0 0.1 (0.0-0.2) 0.0 (0.0-0.1) 0.4 (0.1-0.8) 0.1 (0.0-0.3) 0.3 (0.1-0.5) PTSD: post-traumatic stress disorder

The increase in sales of loose products is to be Results of the study (www.iss.it): Italian women attributed to women (thus reducing the environmental are much more at risk than men of suffering from impact of packaging, making cities more liveable). psychological or psychiatric discomfort during their Ultimately, if sustainability is becoming a style of life, in particular women are more vulnerable to mood sight increasingly felt and practiced in our country, this disorders (Lifetime prevalence of Major Depression: is also thanks to the daily, generous and often obscure 14.9% among women, 7.2% among men), anxiety commitment of women. On issues such as the fight disorders (Lifetime prevalence: 16.2% among women, against environmental pollution, climate change and the 5.5% among men), phobias (Lifetime prevalence: waste of natural resources, we women have a sensitivity 8.6% among women, 2.5% among men), panic attacks and depth of view that derive from the protection of life (Lifetime prevalence: 2.2% among women, 0.9% and that today are becoming a common heritage of among men). Italian society (www.iss.it). More recent data released by WHO show that about A correct environmental education must lead to res- 25% of the work days lost by the female population in pect for natural cycles, must be based on scientific the world is attributable to depressed mood. knowledge of the effects of environmental deterioration, on the assessment of the different aspects of the eco- ENVIRONMENTAL POLLUTION logical problem that require integration of approaches: AND WOMEN'S HEALTH from biological, to economic, industrial, legal and ethical. The development of an ecological awareness at "Guardians of the Earth-Women's Health is the a personal and community level must be accompanied Future of the Planet" (www.greenstyle.it). by appropriate policy interventions to ensure the It is important to bear in mind that primary preven- conditions for sustainable development by controlling tion, ie the elimination of the causes of diseases, is a the management of the environment. problem of a political nature and of health planning. Environmental causes have a huge impact on wo- WOMAN AND MENTAL HEALTH: men's health and the scientific literature on this subject SOME DATA is vast and consolidated:

In 2005 in Italy the results obtained from the first Possible damages during pregnancy epidemiological study on the prevalence of mental (even at low levels) disorders were presented in a representative sample of An American survey recently revealed that even the general adult population: this survey is part of a minimal levels of exposure to pollution imply neuro- wider European project called ESEMed (European logical damage to the fetus as well as a greater inci- study on the Epidemiology of mental disorders) at the dence of respiratory diseases due to premature birth: initiative of the World Health Organization and Harvard pre-term birth can be induced by intrauterine inflamma- University; in Italy the study was promoted and tion due to to the pollutants present in the air and that coordinated by the Istituto Superiore di Sanità (ISS) the future mothers have breathed, accumulated in the (www.iss.it) (Table 1). placenta and transmitted to the newborn.

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Premature aging of the woman otherwise, the distance from the sea combined with the A 2015 study in Los Angeles found that air pollution poverty of green spaces increases the levels of anxiety accelerates the physiological aging process of our brain; and stress in women. the survey was conducted on a sample of over 1400 healthy women, aged between 71 and 89 years, without WOMAN AND SPORT ongoing dementia processes, residing in areas with high levels of pollution. Choosing to practice physical activity not inside a gym but in an open place (when the weather allows it) Results turns out to be a strategic action for women in many With increasing exposure to the finer powders (which ways because: penetrate more easily into the respiratory tract) there is a Activate your metabolism more by allowing you to diffuse atrophy of the white matter of the brain, made up burn more fat; of fibers that deeply connect very distant areas: to be Allows better oxygenation and strengthening of reduced in these women is particular the white matter of muscles; the temporal lobe, of the frontal lobe and of the corpus Boosts immune defenses; callosum, thus accelerating aging for a good two years. Reduces free radicals by slowing down aging; Stimulates the production of endorphins helping to WOMEN'S CONTRIBUTION TO reduce anxiety and stress; ENVIRONMENTAL PROTECTION Improves mood; FOR BETTER MENTAL HEALTH By means of adequate sun exposure, it is possible to store and absorb vitamin D for the benefit of the The Ristorative effect and the attention of women: skeleton; natural environments produce a regenerating effect on The tendency towards socialization increases; our psychophysical state under stress conditions. How Does not require an economic investment in terms of does all this happen? subscriptions, membership cards, etc... Often women feel tired not so much or not only physically but especially under the psychological profile WOMAN AND BEAUTY: ("I should just pull the plug!"): Mental fatigue derives from a condition of attention focused on a particular ORGANIC COSMETICS task that requires a considerable expenditure of energy Carefully and consistently taking care of both their (a child? work? a parent with health problems?), a con- appearance and the natural environment through the dition that - if protracted over time - leads to a decline in choice of organic cosmetics has positive effects on cognitive performance; the environment helps us be- mood and on the overall level of well-being experienced cause through ecological initiatives such as: by women: this is demonstrated by neuro-cosmetic -Practicing the cd. zero-cost tourism (a responsible studies, that sector of biology skin that studies the journey in natural areas that preserves the environ- relationship between skin and the nervous system; a ment and improves the well-being of local popula- simple gesture such as applying a biological cream on tions); the face causes the brain to send nerve impulses which: Stroll along the promenade or on the park road for at make the most beautiful skin appear; least 30 minutes; they counteract skin aging and brain decay. Exit by bike and not in the car when possible - there Shiseido, a famous Japanese company and world lea- is a positive impact on women in terms of anxiety der in the production of cosmetics and beauty products, reduction, anti-age effects, stress reduction but abo- has announced some data according to which the use of ve all the recovery of the indispensable attentional organic creams and make-up has positive effects, as capacities in planning our days (Costa 2015). well as on the environment, on the cognitive functions of women over 65 (hence on memory, attention, reaso- THE WOMAN AND THE SEA ning) since it increases the oxygenation of the left British and German researchers have verified that prefrontal cortex, implicated: the noise of the sea waves and the noise of the petrol in the planning of complex cognitive behaviors engines are perceived as very similar by the brain by the (planning, decision making); women living in the apartment; they did listen to a in the expression of personality; group of volunteers this noise (similar to both the waves in the manifestation of positive and negative emo- and the engine) presenting at the same time to some of tions; them (Group 1) the image of a street with buildings, and The woman who chooses to adopt virtuous beha- others that of a pristine beach (Group 2) Magnetic viors of environmental protection acquires more aware- Resonance has shown how - with the same perceived ness both of the positive consequences of her actions sound - the brain of Group 1 gave signals of stress while and of personal responsibility in determining positive in the Group 2 volunteers new connections were created effects on other people; in this way the levels of: - Self- with a growing sense of harmony and well-being; efficacy perceived, the subjective perception of the

S434 Marilisa Amorosi: ECOSUSTAINIBILITY AND MENTAL HEALTH: FEMALE ASPECTS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 431-435 qualities possessed with respect to a task to be carried responsibility for intervening in the environment is not out - Self-esteem - Creativity and imagination; that are always easy, this effect indicates a situation in which all mediators of a greater psychological well-being of individuals do not offer help to the victim in the pre- the person (Bandura 2000). sence of other people, creating an inversely proportional relationship between the number of witnesses and the WOMAN AND SECURITY possibility of rescue, the greater the number of spectators, the less likely it is that someone will act. How safe do you feel in your living environment (the The environment that protects: the role of women house, the condominium, the neighborhood)? And why? and the Neighborhood Watch (Terraciano 2009): in the The need for security is an anthropological need, United States, at the end of the Sixties, the phenomenon primary, that the State has for years considered able to of neighborhood surveillance originated, at the time satisfy by repressing the illicit and neutralizing those with preventive initiatives of a community nature based who delinque, taking for granted the resulting sense of on the collaboration between police and citizens; in the well-being of citizens. eighties the United Kingdom also adopted this initiative But is it really like that? in which the role of women emerged both as promoters and as beneficiaries of: An increase in the sense of In August 2017, the Minister of the Interior presented community and an improvement in the quality of life. the latest data on crime in Italy (www.interno.gov.it) In Italy, in 2013, the ACDV Neighborhood Control from which it emerges that crimes are decreasing, in Association was established, consisting of a territorial particular this applies to murder and theft; despite these network of volunteers and specialists -women and men- reassuring data, our perception of criminality remains who provide support both to municipalities and to among the highest in Europe, so the level of criminality private citizens wishing to develop participatory secu- and perceived safety of the environment do not coincide rity programs in their neighborhood. (as one decreases, it does not correspond to an increase It is true that more repression of crime no longer in the other). implies perceived security; otherwise, by strengthening The environment is scary (Gennaro 2010) for a neighborhood networks and community relations (in the constant increase in the difference of the people who neighborhood, in the condominium, with local shop- often become passive spectators, and this in reference to keepers) and by reserving an active role for women, we 2 theories. obtain an increase in psychological well-being for them The theory of the broken window (Gennaro 2010) as well as for all citizens. The criminologists J. Wilson and G. Kelling already detected in 1982 how it is necessary to deal not only with crime itself but also with all those deviant and Acknowledgements: None. transgressive actions that we often experience in our places of life; the idea is born from the image of a Conflict of interest: None to declare. broken window: if someone breaks a window of a building and is not adjusted, who sees it spreads the idea References that that building is abandoned or "no man's land", are so attracted others thugs who break other windows or 1. Bandura A: Autoefficacia,teoria e applicazioni. Erickson real criminals who will carry out illicit activities such as ed., 2000 drug dealing or prostitution, in a spiral of urban decay 2. Chief Medical Officer: Ten golden rules to stay Healthy, and violence. England, 1999 3. Costa M: Psicologia ambientale e architettonica, Franco The theory of the viewer effect Angeli ed., 2015 The episode of Kitty Genovese, when the environ- 4. Gennaro G: Manuale di Sociologia della devianza. Fanco ment turns to the other side: Catherine "Kitty" Genovese Angeli ed. Milano, 2010 was a 29-year-old girl who lived on the outskirts of New 5. Rapporto UNEP-Agenzia ONU per l’ambiente-OMS: York where she was killed in 1964, attacked in the Assemblea Nazioni Unite sull’ambiente ONU, 2003 street by a man who stabbed her for half an hour: the 6. Terraciano U: Le politiche della sicurezza in Italia. Ex- killer, seeing several people behind the windows wat- perta ed., Forlì, 2009 ching the scene, sometimes interrupted himself fearing 7. www.fbi.gov the arrival of the police, but then resumed his aggression 8. www.greenstyle.it because none of the many witnesses intervened or called 9. www.interno.gov.it for help. Why do you think? The spectator effect: taking 10. www.iss.it

Correspondence: Marilisa Amorosi, MD Via Tassoni 5, 65122 Pescara, Italy E-mail: [email protected]

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THE PRECISION PSYCHIATRY. An Individualized Approach to the Diseases Gianfranco Del Buono Mental Health Department Hospital “S. Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy

SUMMARY The Precision Psychiatry is a new emergent topic in Psychiatry, and is “an approach for treatment and prevention that takes into account each person’s variability in genes, environment, and lifestyle”. It promises to be even more transformative than in other fields of medicine, because the psychiatry has not yet benefited from the advanced diagnostic and therapeutic technologies that now form an integral part of other clinical specialties. It may be an epistemological change in the field of psychiatry. This paper briefly highlights the story, the features, and the future of the Precision Psychiatry. Indeed, this approach is becoming a reality with the availability of massive data (derived from physiological recordings, brain imaging, ‘omics’ biomarkers, environmental exposures, self-reported experience). Key words: precision psychiatry – omics - big data - biomarkers * * * * * In 2015, the President B. Obama launched the exactness in measurement will be achieved such that, ‘Precision Medicine Initiative’ (Terry 2015). Precision eventually, it will be personalized. It can be concep- medicine is “an emerging approach for treatment and tualized as a highly sophisticated and intricate classi- prevention that takes into account each person’s fication system. The precision medicine has been variability in genes, environment, and lifestyle” currently empowered by new available and powerful (National Research Council Committee 2011). This technologies! initiative aims to bring medicine into a new era by In psychiatry, we possess a poor knowledge about changing our concepts of how medicine is traditionally the pathophysiology of mental disorders, because symp- applied in all clinical areas (Collins & Varmus 2015). toms overlap considerably among different diagnoses, Already in the 19th Century, the physiologist Claude while vary greatly among patients with the same diag- Bernard stated that: “A physician is not a physician … to nosis. The Precision Psychiatry might contribute to the living beings in general, not even physician to the evolving knowledge of the biological pathways invol- human race, but rather, physician to a human ved in the major mental illnesses. A few examples are: individual, and still more physician to an individual in C-reactive protein as a predictor of differential response certain morbid conditions peculiar to himself and to escitalopram or nortriptyline (Uher et al. 2014), and forming what is called his idiosyncrasy” (Bernard association of brain magnetic resonance imaging and 1827). childhood trauma with poor response to antidepressants The intellectual father of precision medicine is A. (Korgaonkar et al. 2015, Miller et al. 2015). Garrod (Perlman & Govindaraju 2016), who published, A such kind of research approach is the Research in 1902, a paper entitled “The Incidence of Alkapto- Domain Criteria (RDoC, by the National Institute of nuria: A Study in Chemical Individuality” (Garrod Mental Health) (Insel 2014), which has generated a 1902). In this paper, he wrote about the importance of neurobiologically valid framework for classifying men- individual ‘chemical differences’ in disease context: tal illness and generating novel interventions related to “…these [alkaptonuria, albinism and cystinuria] are neurobiological underpinnings. merely extreme examples of variations of chemical The precision is becoming reality with the develop- behavior which are probably everywhere present in ment of powerful biological tools and methods: assess- minor degrees” and “ …no two individuals of a species ment of behaviours and life experiences, physiological are absolutely identical in bodily structure neither are techniques, brain imaging, ‘omics’ biomarkers. Nowa- their chemical processes carried out on exactly the days brain imaging techniques with sufficient spatial same lines”. and temporal resolution can quantify neural connections Precision Medicine is different from Personalized in vivo (Tretter & Gebicke-Haerter 2012). Medicine, because medicine has always had a perso- In the English-language, neologism “omics” infor- nalized approach, but not completely precise, or at least, mally refers to a field of study in biology ending in - not precise enough. The original term, personalized omics, such as genomics, proteomics or metabolomics. medicine, was changed to precision medicine in order to Omics aims at the collective characterization and quan- emphasize that its technologies and treatments are not tification of pools of biological molecules that translate developed for each individual patient, but a high level of into the structure, function, and dynamics of an orga-

S436 Gianfranco Del Buono: THE PRECISION PSYCHIATRY. An Individualized Approach to the Diseases Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 436-438 nism. Genomics, epigenomics, transcriptomics, proteo- Is it the right time to reformulate our understanding mics, metabolomics, metagenomics and lipidomics are of mental illness as disorders of brain functioning? Will capable of independently providing valuable informa- the Precision Psychiatry be an epistemological change tion about the neurobiology of psychiatric conditions. in the field of Psychiatry? When combined with a multi-omics approach - called But, we must remember the words of M. Maj, presi- panomics - and analyzed using systems’ biology com- dent of WPA (2008-2011), who hoped in a balanced putations, they might show the underlying biological view of technical and non-technical aspects of psychia- pathways involved in psychiatric disorders. All these tric care. Indeed, he claimed: “without a communicative methods involve accumulations of massive datasets that interaction no person will allow any professional to require new analytic approaches for interpretation. genuinely access his/her personal world (thus rendering These new approaches need an interdisciplinary work spurious and clinically insignificant any superficial de- among mathematicians, physicists, biologists and clini- gree of diagnostic reliability which may be achieved)”, cians in order to achieve an appropriately integrative and “that the person’s narratives of psychopathological understanding of mental illness as disorders of the brain. experiences and their origins should be actively For the next years, the precision psychiatry para- encouraged and worked on, and that relationship and digm will lead to the discovery of biomarkers able to context variables have a major impact on the outcome guide treatment choice and predict treatment response to of all mental health interventions”. And he added: “I commonly used drugs such as antidepressants and would like to see a psychiatric practice in which […] antipsychotics. both technical and non-technical elements of care are With an interdisciplinary approach, we can ‘biomar- valued”, […] “the limitations of our current knowledge kers’ – “a defined characteristic that is measured as an concerning both these elements are acknowledged” indicator of normal biological processes, pathogenic (Maj 2014). processes, or responses to an exposure or intervention, including therapeutic interventions” (Biomarkers Defi- nitions Working Group, 2001) – as indicators of patho- Acknowledgements: None. physiology, risk for pathophysiology, or treatment outcome that can be measured by gene and/or brain assays Conflict of interest: None to declare. or their combination with environmental factors. No single biomarker will define any psychiatric disorder as defined by traditional diagnostic boundaries References (Fernandes et al. 2009. Carvalho et al. 2016a, Carvalho et al. 2016b): it will be essential to delineate the 1. Andersson G, Titov N: Advantages and limitations of multivariate and combinatorial profiles of biomarkers Internet-based interventions for common mental disorders. that account for the heterogeneity of mental illnesses as World Psychiatry 2014; 13:4–11 they clinically manifest. 2. Bernard C: Introduction to Experimental Medicine. This massive information (“Big Data”), currently Chicago: McMillan and Co., Ltd., 1827 available, now allows the analysis of patient’s different 3. Biomarkers Definitions Working Group: Biomarkers and characteristics. “Big Data” is provided by the acquisi- surrogate endpoints: preferred definitions and conceptual tion of biological data on scale and by incorporating framework. Clin Pharmacol Ther 2001; 69:89–95 data from electronic devices such as smartphones 4. Carvalho AF, Kohler CA, Brunoni AR, Miskowiak KW, Herrmann N, Lanctot KL, Hyphantis TN, Quevedo J, (Anderson & Titov 2014). Fernandes BS, Berk M: Bias in peripheral depression The major challenge that precision psychiatry faces biomarkers. Psychother Psychosom 2016a; 85:81–90 is that psychiatry does not yet use measurement to track 5. Carvalho AF, Kohler CA, Fernandes BS, Quevedo J, the equivalent of vitals and images of the organs. These Miskowiak KW, Brunoni AR, Machado-Vieira R, Maes M, measurements will eventually lead to a personalized Vieta E, Berk M: Bias in emerging biomarkers for bipolar treatment. In precision psychiatry, a given patient would disorder. Psychol Med 2016b; 46:2287–97 receive an existent treatment according to the patient’s 6. Collins FS, Varmus H: A new initiative on precision disease class, and not a medication that would be medicine. N Engl J Med 2015; 372:793–5 specifically created for that individual following consi- 7. Fernandes BS, Gama CS, Kauer-Sant’Anna M, Lobato deration of their unique features. MI, Belmonte-de-Abreu P, Kapczinski F: Serum brain- derived neurotrophic factor in bipolar and unipolar Systems’ biology and computational psychiatry tools depression: a potential adjunctive tool for differential would produce a set of biomarkers (a biosignature) that, diagnosis. J Psychiatr Res 2009; 43:1200–4 when applied to individuals and populations, will pro- 8. Garrod AE: The incidence of alkaptonuria: a study in duce better diagnosis, endophenotypes (measurable chemical individuality. 1902 [classical article]. Yale J components unseen by the unaided eye along the path- Biol Med. 2002; 75:221–31 way between disease and distal genotype), classifica- 9. Insel TR: The NIMH Research Domain Criteria (RDoC) tions and prognosis, as well as tailored interventions for Project: precision medicine for psychiatry. Am J better outcomes. Psychiatry 2014; 171:395–7

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10. Korgaonkar MS, Rekshan W, Gordon E, Rush AJ, Medicine. Building a Knowledge Network for Biomedical Williams LM, Blasey C, Grieve SM: Magnetic resonance Research and a New Taxonomy of Disease. Washington, imaging measures of brain structure to predict antide- DC: National Academies Press, 2011 pressant treatment outcome in major depressive disorder. 14. Perlman RL, Govindaraju DR. Archibald E: Garrod the EBioMed 2015; 2:37–45 father of precision medicine. Genet Med 2016; 18:1088–9 11. Maj M: Technical and non-technical aspects of 15. Terry SF: Obama’s Precision Medicine Initiative. Genet psychiatric care: the need for a balanced view. World Test Mol Biomarkers 2015; 19:113–14 Psychiatry 2014; 13:3 16. Tretter F, Gebicke-Haerter PJ: Systems biology in psychia- 12. Miller S, McTeague LM, Gyurak A, Patenaude B, Wil- tric research: from complex data sets over wiring dia- liams LM, Grieve SM, Korgaonkar MS, Etkin A. Cogni- grams to computer simulations. Methods. Mol Biol 2012; tion-childhood maltreatment interactions in the prediction 829:567–92 of antidepressant outcomes in major depressive disorder 17. Uher R, Tansey KE, Dew T, Maier W, Mors O, Hauser J, patients: results from the iSPOT-D trial. Depress Anxiety Dernovsek MZ, Henigsberg N, Souery D, Farmer A, et al.: 2015; 32:594–604 An inflammatory biomarker as a differential predictor of 13. National Research Council Committee on a Framework for outcome of depression treatment with escitalopram and Developing a New Taxonomy of Disease: Toward Precision nortriptyline. Am J Psychiatry 2014; 171:1278–86

Correspondence: Gianfranco Del Buono, MD, PhD Mental Health Department Hospital “S. Giovanni di Dio e Ruggi d’Aragona” Via Giovanni Berta, 30 - 84127 Salerno, Italy E-mail: [email protected]

S438 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 439-442 Conference paper © Medicinska naklada - Zagreb, Croatia

EFFECTS OF FINANCIAL PRECARIOUSNESS ON MENTAL HEALTH Thalia de Ruffi & Nicolas Zdanowicz Université Catholique de Louvain, CHU Namur Godinne, Psychosomatics Unit, Yvoir, Belgium

SUMMARY Background: The physical and mental health of a population is based, in particular, on its quality of life and its access to health care. Given these determinants, Greece’s population has greatly suffered due to the sharp cuts in the budget for social benefits and health care (some measurable evidence is the recent increase in the suicide rate). Starting January, the 1st of 2015, unemployment benefits in Belgium have been eliminated for all recipients who do not have a full-time year of work over the last three years. Therefore, we must ask whether there will be similar psycho-medical consequences for Belgium’s population. Subjects and methods: Open study over a year (01/07/14 – 30/06/15) of emergencies admitted to the University Hospital Center of Mont-Godinne including a psychopathological motif. In addition to general socio-demographic data, psychic disorders are measured, as well as different types of crises (familial, professional or couple crisis), familial support and its dynamic (FACES III of Olson) and finally social integration (social isolation scale from the National Social Life, Health, and Aging Project (NSHAP)). These patients are compared with those admitted during the six months preceding the Act modifying the unemployment benefits. Results: Between July the 1st of 2014 and June the 30th of 2015, we saw an increase in the number of admissions to the psychiatric emergency department by 2.5% in six months, despite a decrease in the number of admissions to all-cause emergencies. Our study also shows a degradation of social network quality characterized by a more pronounced social isolation of our patients. At last, an alteration of cohesion in the patient’s origin family was highlighted. Conclusion: Although we cannot establish a direct causal link between this law and the results of this study, these may suggest a weakening of the population mental health due to difficult socio-economic context. As a result, we are faced not only with a public health problem but also with one concerning health care organization.

Key words: mental health – precariousness – exclusion – poverty

* * * * * INTRODUCTION al. 2015, Cornwell & Waite 2009, Hawkley & Cacioppo 2010). Indeed, social isolation can lead to precarious- On January 1, 2015, Belgium passed a law stipula- ness, or aggravate the latter if both are associated, and ting that all citizens who had not collected the equi- finally, precariousness dissolves the social bond regard- valent of one year's full-time work in the previous three less of its degree of quality. An outstanding study called years would no longer receive unemployment benefits. the Harvard Study of Adult Development, shows that Therefore, we asked ourselves what the consequences of the key element of a successful life is not wealth or such exclusion might be for an individual's mental fame, but having quality social relationships. This study health. Indeed, several historical examples illustrate the started in 1938 by Harvard University researchers and it deleterious effects of precariousness on a given popu- still is in progress today. To be precise, there are two lation: in 2010, the financial crisis in Greece led to a types of social isolation: isolation that can be quantified 20% increase in the suicide rate (Stuckler & Basu (by the number of friends, family, social activities etc.) 2014). Earlier in 2007, during the Subprime Mortgage and, isolation that is perceived (the feeling of being crisis in the United States, we saw a significant increase alone). The perception of loneliness seems to be the in the depression rate for the people in neighborhoods most harmful to mental health (Cornwell & Waite that were affected the hardest from house repossessions 2009). Thus, we have seen that financial precariousness, and abandonments (Cagney et al. 2014). During our a fortiori marked by strong economic disparities, as well research, two elements drew our particular attention: the as a perception of lack of social support were risk fac- first is that beyond the intrinsic deleterious character of tors for an individual's health. In Belgium, the restric- poverty and precariousness at the level of an individual's tion of access to unemployment benefits affects many psychological health, it would be above all the econo- individuals who already are in a difficult financial mic and social disparities that would have the most situation. We are interested in what could be the psycho- harmful consequences e.g. the fact of being unemployed medical consequences of this exclusion. We believe, and seeing one's neighbour find work, not having access based on the literature and historical examples cited to certain health care while others do, etc. (Burrows & above, that it is likely to lead to a decline in the quality Laflamme 2010, Laflamme et al. 2009a, Kuo et al. of life and health of the individuals involved and an 2004, Crawford & Prince 1999, Whitley et al. 1999). increase in the rate of attempted suicide and suicide, in The second element is the real killer: social isolation, any case risky behaviors for the patient's life. Taking which seems to be a cause, risk factor, and consequence into account the literature, we have made five hypo- of precariousness (Holt-Lunstad et al. 2015, Hawkley et theses: we expect an increase in the number of patients

S439 Thalia de Ruffi & Nicolas Zdanowicz: EFFECTS OF FINANCIAL PRECARIOUSNESS ON MENTAL HEALTH Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 439 442 admitted to psychiatric emergencies, an increase in the lows: for each item, an average score is calculated number of socially disadvantaged patients, i.e. those and for each individual, the average score is subtrac- who have suffered a loss of employment or litigation for ted from the score obtained. The score for each pa- example, a decrease in the quality of the patients' social tient and for each item is therefore centered on the network, an increase in the rate of depression among mean. The objective social isolation score and the hospitalized patients and finally a less good cohesion isolation perception score are then obtained by sum- and/or adaptability of the patient's original family or ming the mean scores divided by the number of items current couple. to which the subject responded. Thus, a score of 0 means that the patient is exactly in the mean, a score SUBJECTS AND METHODS of less than 0 suggests greater social isolation than the mean and a score of more than 0 means that the Subjects patient enjoys greater social support than the mean; We based ourselves on admissions to the emergency BECK Depression Scale; room of the Mont-Godinne University Hospital inclu- Family Adaptability and Cohesiveness Evaluation ding a psychopathological reason between July 1, 2014 Scale III - FACES III from David Olson. and June 30, 2015. During this period, 425 patients were From a statistical point of view, we used the SPSS 22 registered. 210 came during the first 6 months and 215 program for Windows, using parametric tests. We com- during the following 6 months. Of the 425 question- pared the quantitative values using the Student t-test. naires we sent out, 77 patients responded (18.4%). Of For the qualitative variables, we used Pearson's Chi these, 41 were admitted between 1 July 2014 and 31 Square independence test. The correlations were studied December 2014 and 36 between 1 January 2015 and 30 using the Pearson correlation coefficient, possibly con- June 2015. trolled by a co-variable. If necessary, we performed a linear regression by introducing all variables at once and Methods in decreasing order of correlation coefficient. The tests The questionnaires used make it possible to evaluate take into account errors of the first and second types. No a set of parameters: post-Hoc tests were performed. General socio-demographic questionnaire: age, date of birth, nationality, number of years of work al- RESULTS ready done, current and previous social status, whether the patient had a dispute or not, total unem- Patient demographics ployment time and hospitalisation history; Among the respondents, the mean age is 44.6 years Social isolation scale taken from the "NSHAP" for the "before" group and 41.5 years for the "after" study: taken from the National Social Life, Health, group. Although there is a decrease in the mean age, and Aging Project, this questionnaire is used to this difference is not significant (t=0.967; p=0.337). assess the patient's social isolation (Cornwell & There is an equal distribution of men between the two Waite 2009). This questionnaire makes it possible to groups. Women represent 59% of the total and are five develop two scales of measurement: the first measu- less in the second group. There is no significant diffe- res an individual's objective social isolation, which rence in the gender distribution before and after De- depends on two main factors: the lack of a strong cember 31, 2014 (Ȥ²=0.232; p=0.630). 94.8% of the social network and the lack of participation in social patients who answered our questionnaire are Belgian. activities. Among the various items in the question- Two patients are of French origin, one of Algerian naire, eight were selected: size of the social network, origin and one last patient is of Portuguese origin. extent of the social network, frequency of interac- Between the two groups, we observe a decrease in the tions, proportion of social network composed by number of patients whose cause of admission to the family members, number of friends, participation in emergency room was a suicide attempt. However, this group meetings, socialization with family members, difference is not significant (Ȥ²=0.081; p=0.776). volunteer work. The first four items focus on the limited dimension of the restricted social network, Admissions to psychiatric emergencies and the next four on that of social inactivity. The second scale measures an individual's perception of Between July 1, 2014 and December 31, 2014, 8,282 isolation. It also depends on two factors: a sense of patients were admitted to the general emergency lack of support and a sense of loneliness. Nine items department of the Mont-Godinne University Hospital; were selected: confide in the family, relying on fa- 210 of them were referred to psychiatric emergencies. mily, confide in friends, relying on friends, confide Between January 1, 2015 and June 30, 2015, there were in your spouse, relying on your spouse, sense of lack 7855 admissions, 215 of which were psychiatric. We are of entourage, sense of isolation, feeling abandoned. therefore witnessing a 2.5% increase in the number of The first six items are related to feelings of lack of admissions to psychiatric emergencies in six months, support and the last three items are related to fee- while the total number of admissions has decreased by lings of loneliness. The scores are calculated as fol- 5.2%. This difference is significant (Ȥ²=0.242; p<0.05).

S440 Thalia de Ruffi & Nicolas Zdanowicz: EFFECTS OF FINANCIAL PRECARIOUSNESS ON MENTAL HEALTH Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 439-442

Number of socially disadvantaged patients years of work in their life. We see that those in the "before" group have an average Beck score of 19.26, Current social status refers to whether one works or while those who visited the emergency department after not. Although there was a 28% increase in the number of January 1 have one of 26.36, meaning an increase of patients who were not working and a 19% decrease in the 37%. We are therefore witnessing an increase in the rate number of patients who were working in both periods, of depression among patients presenting this social risk. these differences were not significant (Ȥ²=0.864; These results are significant (t=-2.019; p=0.048). p=0.353). We note a 50% increase in the number of disputes from January the first, 2015, but this result is not significant either (Ȥ²=1.339; p=0.247). In one year, Family cohesion and flexibility according to Olson the number of years already worked has risen from Only the results concerning cohesion in the family 17.42 years to 15.33 years. Although there is a diffe- of origin are significant (t=2.039; p=0.046). This means rence of more than two years to the disadvantage of the that patients who arrived after January 1 had a less second group, that is, these patients had an average of united family of origin than those in the second group. two years less work than those in the first group, these We can make two hypotheses: since there is an increase differences are not significant (t=0.652; p=0.517). in the number of admissions, more patients are being admitted with a lower quality family of origin. Or, as Social network quality the patients in the second group had a more dysfunctional We observe a decrease in the objective social isola- family of origin, they were therefore unable to benefit tion score between the two groups as well as a negative from a stable and structuring emotional base. As a result, mean for patients in the second group. This means that they find themselves more vulnerable and less able to the latter are more objectively and socially isolated than manage the emergence of problems in their current lives. patients in the first group. These differences are signi- In other words, when a difficulty arises (whether social or ficant (t=3.172; p<0.002). We are witnessing a decrease personal), individuals from these broken families are the in the perception of being socially isolated. Patients in first to suffer and will have a harder time coping than the second group would feel less alone than those in the those who have grown up in a loving family. first group. However, these differences are not significant (t=-0.630; p=0.530). Links between the explanatory variables We see that there is a link between an individual's Depression objective social isolation and the intensity of depression We observe a 9.4% increase in Beck's score between (p<0.000). Therefore, we conclude that the more so- the two groups, which suggests that patients in the cially isolated a patient is, the more likely he is to be second group are more depressed than those in the first. depressed. The same conclusion is reached with respect However, these differences are not significant (t=-0.690; to family cohesion: the closer a family is, the less likely p=0.492). We also looked at whether there was a link its members are to be affected by depression (p<0.001). between having work-related difficulties and depres- Finally, there is a correlation between family cohesion sion. For this we have taken back patients presenting a and observed social isolation. In other words, the social risk, i.e. who either do not have a job, or have presence of love in the family of origin would decrease already had a dispute, or have totaled less than 17.42 the risk of subsequent social isolation (p=0.05).

Table 1. Correlations between objective social isolation, Beck and family of origin cohesion scores Correlations Objective Social Isolation BECK Cohesion Family of Origin Objective Social Pearson Correlation 1 -0.451** 0.238 Isolation Sig. (bilateral) 0.000 0.050 BECK Pearson Correlation -0.451** 1 -0.414** Sig. (bilateral) 0.000 0.001 Cohesion Family Pearson Correlation 0.238 -0.414** 1 of origin Sig. (bilateral) 0.050 0.001

Table 2. Coefficients and standard deviation from the linear regression of objective social isolation on the cohesion of the family of origin Coefficients Non-standardized coefficients Standardized coefficients t Sig. B Standard error Beta Constant 35.105 3.990 8.799 0.000 Objective Social Isolation -7.647 2.569 -0.331 -2.976 0.004 Family of Origin Cohesion -0.425 0.141 -0.335 -3.005 0.004

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Table 1 shows that social isolation and family cohesion are important risk factors for depression. Acknowledgements: None. We then wanted to know if these two factors (social isolation + family cohesion of origin) could be corre- Conflict of interest: None to declare. lated with the intensity of patients' depression. We have therefore made a linear regression which shows the Contribution of individual authors: following results visible in table 2: there is indeed a significant link between these two explanatory factors All authors made a substantial contribution to the and the intensity of depression (p<0.000), namely that design of the study, and/or data acquisition, and/or 25% of the variance of the latter can be explained by the the data analysis and its interpretation. two items. Each of these elements alone has a significant participation as predicted by Pearson's correlation coefficients as we can see in table 2. References

1. Burrows S & Laflamme L: Socioeconomic disparities and DISCUSSION attempted suicide: state of knowledge and implications for As we can see, we were able to validate three out of research and prevention. Int J Inj Contr Saf Promot 2010; 17:23-40 five of our hypotheses. Unfortunately, the results for our 2. Cagney K, Browning C, Iveniuk J & English N: The Onset two last hypotheses are not significant. They suggest of Depression During the Great Recession: Foreclosure nonetheless the existence of an increasingly disadvan- and Older Adult Mental Health. Am J Public Health 2014; taged population. We are not able to confirm the validity 104:498-505 of these statements, but they let us think that a precarious 3. Cornwell, E & Waite L: Measuring Social Isolation social status can weaken a patient's mental health. There Among Older Adults Using Multiple Indicators From the are some limitations to this work: first, out of 425 ques- NSHAP Study. J Gerontol B Psychol Sci Soc Sci 2009; tionnaires sent, we received only 78 returns, or only 64B:i38-i46 18.4% of the total. In addition, these questionnaires were 4. Cornwell E & Waite L: Social Disconnectedness, Percei- sometimes partially completed, which further limited the ved Isolation, and Health among Older Adults. J Health number of interpretable responses. As a result, obtaining Soc Behav 2009; 50:31-48 meaningful results was laborious and not all of our 5. Crawford M & Prince M: Increasing rates of suicide in hypotheses could be demonstrated. There are also certain young men in England during the 1980s: the importance biases: for example, we have separated patients who of social context. Soc Sci Med 1999; 49:1419-1423 work from those who do not, but not all those who do not 6. Hawkley L & Cacioppo J: Loneliness Matters: A work are necessarily unemployed (they may still be Theoretical and Empirical Review of Consequences and students or receive a disability pension for example). We Mechanisms. Ann Behav Med 2010; 40: 218-227 have presented the fact that in total we have collected less 7. Hawkley LC, Duvoisin R, Ackva J, Murdoch JC & than 17 years of work as a social risk, yet some patients Luhmann M: Loneliness in older adults in the USA and Germany: Measurement invariance and validation. have not been able to reach numbers simply because they Working Paper Series, NORC at the University of are still young and only beginning to work. Finally, we Chicago, 2015, Paper 2015–002 certainly cannot demonstrate that the results of our work 8. Holt-Lunstad J, Smith T, Baker M, Harris T & Stephenson can be explained by the passing of this legislation. D: Loneliness and Social Isolation as Risk Factors for Mortality. Perspect Psychol Sci 2015; 10:227-237 CONCLUSION 9. Kuo W, Gallo J & Eaton W: Hopelessness, depression, substance disorder, and suicidality. Soc Psychiatry Even though we cannot establish a direct causal Psychiatr Epidemiol 2004; 39 effect with the passing of this legislation, we have seen 10. Laflamme L, Burrows S & Hasselberg M: Socioeconomic that a precarious situation associated with a marked per- differences in injury risks: a review of findings and a ception of social isolation can probably worsen a pa- discussion of potential countermeasures. Copenhagen: tient's mental as well as physical well-being. We can con- WHO Regional Office for Europe, 2009a sider our results as a bundle of "mini-evidences" used to 11. Stuckler D & Basu S: Quand l'austérité tue. Epidémies, highlight certain problems linked to precariousness and dépressions, suicides. Paris: Editions Autrement, 2014 perhaps motivate people to dive deeper into the subject. 12. Whitley E, Gunnell D, Dorling D & Smith G: Ecological It would therefore be interesting to repeat this study at study of social fragmentation, poverty, and suicide. BMJ this time to see if the rate of depression among those 1999; 319:1034-1037 who were unemployed that year has increased or not.

Correspondence: Prof. Nicolas Zdanowicz, MD, PhD Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital 5530 Yvoir, Belgium E-mail: [email protected]

S442 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 443-446 Conference paper © Medicinska naklada - Zagreb, Croatia

A TRANSIENT PERSONALITY DISORDER INDUCED BY FOOTBALL MATCHES Miriam Franco, Clémentine Lantin, François-Xavier Dekeuleneer, Xavier Bongaerts & Juan Martin Tecco Mental Health Unit, Centre Hospitalier Universitaire et Psychiatrique de Mons-Borinage (CHUP-MB), Mons, Belgium

SUMMARY Background: Personality disorders are a class of mental diseases characterized by inflexible and maladaptive patterns of behavior, cognition, and inner experience, involving several areas of functioning, such as affectivity, impulse control, ways of perceiving and thinking and reaction to stress factors. In the literature, personality disorders have always been described as stable patterns of long duration, and their onset can be found during adolescence or early adulthood. These patterns are associated with significant distress or impairment in a patient’s life in which a main element affects every aspect of living, and in which no biological or other pathologies exist to assist in its identification. Therefore, they often lead to comorbidities such as dysfunctional anxiety, drug abuse, major depression and suicide. Subjects and methods: We present a case of a 37-year-old man, who came to the outpatient department needing support to quit smoking. During the follow up, he described some transitory changes in his personality while watching football (soccer) games. These episodes were characterized by inappropriate anger crises, rapid and dramatic shifts in emotional tone, dysphoria and superstitious and magical beliefs with paranoid elements; connecting himself, his family and friends to players in the match and to the unfolding of the game. Every manifestation was induced by the football match, and there were no signs of difficulty in handling impulses and in managing relationships, or any superstitious beliefs, outside of it. Results: The combination of all the symptoms led us to think about a diagnosis of the borderline personality disorder. There was a lack of managing impulsivity, intense uncontrollable emotional reactions, and episodes of psychotic decompensation with unreal and paranoid connections made between the patient’s entourage and the results of the match. Conclusions: With this case, we propose to consider the personality disorder, not just as a stable and inflexible pattern, but also as a transitory dysfunction induced by stress factors, as in this case, a football match, introducing therefore a new entity: transient personality disorder.

Key words: borderline - personality disorders - stress factors - transitory dysfunction

* * * * *

INTRODUCTION the physiological effects of a substance or another medical condition. These disorders are highly comorbid with Personality is defined as the combination of habitual other mental diseases, including major depression, behaviors, cognitions and emotional patterns that evolve alcohol abuse, drug abuse, and suicide. from biological and environmental factors. The DSM-5 includes 10 personality disorders grou- It consists of enduring patterns of thinking, percei- ped into three main clusters, based on descriptive ving and connecting in relationships that are exhibited similarities (American Psychiatric Association 2013): across numerous social and personal contexts. Cluster A characteristics A personality disorder is diagnosed when personality Individuals may appear odd and eccentric, including traits are so inflexible and maladaptive across a wide the Paranoid, the Schizoid and the Schizotypal perso- range of situations that they cause significant distress and nality disorder; impairment of social, occupational, and role functioning. The thinking, the management of emotions and the Cluster B characteristics interpersonal behavior of the individual must deviate Individuals often appear dramatic, emotional, or markedly from the expectations of the individual's culture erratic including the Antisocial, the Borderline, the to qualify as a personality disorder (Skodol et al. 2017). Histrionic and the Narcissistic personality disorder; In the literature, personality disorders have always Cluster C characteristics been described as stable patterns of long duration, and Individuals often appear anxious or fearful including their onset can be found during adolescence or early the Avoidant, the Dependent and the Obsessive-compul- adulthood. These patterns are associated with significant sive personality disorder. distress or impairment in a patient’s life, in which a main element affects every aspect of living and inter- The estimated international prevalence of personality relating, and in which no biological or other pathologies disorders in the community is 11 percent (Oldham et al. exist to assist in its identification. This enduring pattern 2014). Individual personality disorders differ on gender is not better explained as a manifestation or consequence and age. The prevalence of personality disorders in clini- of another mental disorder and it is not attributable to cal populations has been estimated to be over 64%.

S443 Miriam Franco, Clémentine Lantin, François-Xavier Dekeuleneer, Xavier Bongaerts & Juan Martin Tecco: A TRANSIENT PERSONALITY DISORDER INDUCED BY FOOTBALL MATCHES Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 443-446

Between the different personality disorders, Bor- SUBJECTS AND METHODS derline personality disorder (BPD) affects 2% of the adult general population, 10% of psychiatric out- In this article, we present the case of a 37 years old patients and 20% of psychiatric inpatients. The asso- man with no history of psychiatric disorders, who came ciated morbidity is high, mainly related to impulsive to the inpatient department needing support to quit smo- behavior and self-harm danger such as cutting or king. He didn’t have a family history of psychiatric disor- suicide attempts (Lieb et al. 2004, American Psychia- ders. He was Caucasian, he was born and grew up in Bel- tric Association 2013, Bourvis et al. 2017). This gium and he was a university researcher in economics. personality disorder is also related to a high mortality He had smoked ten cigarettes per day for several years. caused by suicide; in fact, among borderline patients, He had quit smoking for a period of two years, two years 10% of subjects die from suicide, a rate 50 times earlier, and then he restarted consumption. During the higher than that in the general population (Lieb et al. follow up the patient started to describe some episodes in 2004, Bourvis et al. 2017). his daily routine. He reported a transitory change in his Borderline personality disorder is a mental disorder personality while he was watching a football match on characterized by a pervasive pattern of difficulties with the TV, when the team he supported was playing. emotion regulation, impulse control, instability in relationships and low self-image (Skodol et al. 2017). RESULTS We can categorize this complex symptomatology in: Affective symptoms, such as affective instability, During the matches, he described himself as having chronic and major depression, chronic anger and fre- violent anger crises, characterized by shouting and quent acts of anger, chronic anxiety and chronic breaking objects, with rapid and dramatic shifts in feelings of loneliness or emptiness. emotional tone and the progressive instauration of a depressive mood. The patient was persuaded that there Cognitive symptoms like quasi-psychotic thought, was a link between his life and the unfolding of the serious identity disturbance, odd thinking and match. He started to believe that there was a connection unusual perceptual experiences or non-delusional between himself, his friends and the football players, the paranoia. team managers and the team coach. In his perception, Impulsive symptoms, such as substance abuse and the connections were stable and real and they played a dependence, dangerous behavior, general impul- role in the unfolding of the match. In this absurd link sivity in reactions and non-suicidal self-injury. between his entourage and the game, he assumed Interpersonal symptoms, such as stormy relation- different kinds of positions between idealization and ships, devaluation/manipulation/sadism, demanding- devaluation of his best friends until he started to ness, abandonment engulfment or annihilation fears, develop distrustfulness towards them. He also started to counter dependency or serious conflict over help/care, believe that there were some base political and countertransference problems and beliefs in “spe- economic conspiracies aiming for the defeat of his team cial” treatment relationships, dependency and maso- in the match. In some cases, he was convinced that he chism (Zanarini et al. 2016). was cursed by some magic influences to the point where he refused to watch the matches to avoid bringing bad Patients with Borderline personality disorder are luck, because he was sure to cause certain defeat to his often considered to be “complicated to work with” by team. Outside these episodes, the patient didn’t show healthcare providers. Every problematic issue may be any interest in any kind of superstition and he declared presented by the patient as a crisis or an emergency, and himself to be an atheist, even though he came from a this kind of interactions can leave the healthcare catholic family. Anytime his team lost, he even presented providers feeling mentally exhausted or overwhelmed some brief phases of dysphoria and excessive irritability, (Sheppard & Duncan 2018). followed by a feeling of emptiness that he tried to While personality disorders are supposed by their manage with alcohol abuse, never reaching the point of definition to be a structural and stable diagnosis, this intoxication, even though in his daily life he was just an definition has been recently challenged suggesting that occasional drinker. All the described manifestations were the personality disorders could be an unstable or totally connected with, and induced by, the football fluctuating entity. A study conducted by Zanarini et al. match. There wasn’t any difficulty in handling feelings or in 2016 involving a cohort of 290 patients showed that impulses, in dealing with relationships, or any supersti- after two years of follow-up, 93% of subjects showed a tious conviction, outside of it. partial remission of the symptoms that led them out of the diagnosis criteria for personality disorder (Bourvis DISCUSSION et al. 2017, Zanarini et al. 2016). The aim of our case report is to propose a different approach to the A lot of studies on the etiology of BPD (Crowell et personality disorders suggesting that they may be, in al. 2009, Koenigsberg et al. 2009, Linehan et al. 1993) some cases, transitory dysfunction. propose that this personality disorder is conceived as an

S444 Miriam Franco, Clémentine Lantin, François-Xavier Dekeuleneer, Xavier Bongaerts & Juan Martin Tecco: A TRANSIENT PERSONALITY DISORDER INDUCED BY FOOTBALL MATCHES Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 443-446 emotion dysregulation disorder, caused by an increased be easily detectable by questionnaires or predefined emotional sensitivity and an inability to regulate scales (Bourvis et al. 2017). In our particular case, the emotional responses. The incapacity to handle and stressful factor cannot be found in the patient’s general regulate the emotional circuit of impulses and responses past or formative years. The only specific scenario able might lead to marked impulsive behavior, characteristic to induce all the symptoms was watching his team for BPD patients (Bourvis et al. 2017) (Figure 1). playing a football match. Among the new proposals for In our case, the patient presents 6 out of 9 of the the DSM-5, the position of personality disorders has borderline disorder criteria (DSM-5), consisting in: affec- been a topic of debate (Robin and Rechtman 2014, tive instability due to a marked reactivity of mood with Bourvis et al. 2017). As we know the division into axis intense episodes of dysphoria, chronic feelings of empti- of the DSM-IV, was erased. Proposals were made to ness, inappropriate and intense anger with difficulty in deeply change the diagnosis framework for personality controlling it with frequent burst of rage, a lack of control disorders, and adopt preferentially a dimensional ap- of his impulses with alcohol abuse, a pattern of unstable proach (Guelfi 2014, Bourvis et al. 2017). and intense interpersonal relationships, characterized by Most patients have a gradual remission of the sympto- alternating between extremes of idealization and matology over time, and this remission can be faci- devaluation, in particular towards his friends and the litated by psychosocial treatments. In our case, the influence he believed they had on the results of the ensemble of the symptoms confirmed the diagnosis of match; and lastly, he presented a transient stress-related borderline personality disorder, but there wasn’t any paranoid ideation: during the matches he felt like he was evolution or gradual remission. There wasn’t any surrounded by magic influences, and that his actions manifestation outside of the context of the football could either bring good luck or curse his team, leading match. The total absence of these symptoms in all the him in the second case to even not to watch the game. other circumstances of his life, even in other stressful As we all know, there is a connection between stress situations, led us to propose a new approach to the exposure and BDP, and, among the clinical signs of the diagnosis of personality disorder in general and to disorder, the acute features, like anger management and formulate the diagnosis of a transient borderline impulsivity control, that are the less stable dimensions personality disorder induced by a football match. The (Roberts et al. 2006, Blonigen et al. 2008, Zanarini et al. limit of our study is related to the fact that we present 2016), are mostly triggered by acute stressful situations only one case report, and to the fact that the personality (Bourvis et al. 2017). A direct and unequivocal connec- disorders have always been studied as constant and tion between past traumatic events and BPD sympto- enduring patterns; as consequence, a possible transient matology has never been formally proven; recent works dysfunction has never been detected as a separate support models that associate individual genetic diagnosis. To better understand the real incidence of the vulnerability with different experiences of early adver- transient personality disorder we need more studies sity in development. The characteristics of these towards this direction to confirm our theory and to have stressful factors are variable and consequently may not statistically significance with solid data.

Figure 1. Putative relationships between risk factors and emergence of symptoms in BPD distinguishing chronic features and acute response to stress (Bourvis et al. 2017)

S445 Miriam Franco, Clémentine Lantin, François-Xavier Dekeuleneer, Xavier Bongaerts & Juan Martin Tecco: A TRANSIENT PERSONALITY DISORDER INDUCED BY FOOTBALL MATCHES Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 443-446

CONCLUSIONS from late adolescence to early adulthood: a longitudinal twin study. J Pers 2008; 76:229–266 With this case report, we propose to consider 3. Bourvis N, Aouidad A, Cabelguen C, Cohen D, and Xavier personality disorder not just as a stable and inflexible J: How Do Stress Exposure and Stress Regulation Relate pattern with repercussions on every aspect of life that to Borderline Personality Disorder? Front Psychol 2017; 8:2054 has its origins in the person’s development and/or 4. Crowell SE, Beauchaine TP, Linehan MM: A biosocial trauma, but also as a transitory dysfunction induced by developmental model of borderline personality: elabo- determined stress factors, in this case football matches, rating and extending Linehan's theory. Psychol Bull 2009; introducing therefore a new entity: the transient 135:495-510 personality disorder. 5. Guelfi JD: Les troubles de la personnalité dans le DSM-5. Ann Méd Psychol Rev Psychiatr 2014; 172:667–670 6. Oldham JM, Skodol AE, Bender DS: The American Acknowledgements: None. Psychiatric Publishing Textbook of Personality Disorders, Second Edition, Washington, 2014 Conflict of interest: None to declare. 7. Koenigsberg HW, Fan J, Ochsner KN, Liu X, Guise KG, Pizzarello S, et al.: Neural correlates of the use of psychological distancing to regulate responses to negative Contribution of individual authors: social cues: a study of patients with borderline personality The authors certify that the work described has not disorder. Biol Psychiatry 2009; 66:854-863 been published before and that it is not under 8. Lieb K, Zanarini MC, Schmahl C, Linehan MM, Bohus M: consideration for publication anywhere else. All the Borderline personality disorder. Lancet 2004; 364:453–461 authors contributed to the article, they participated 9. Linehan MM: Cognitive–Behavioral Treatment of Border- to the literature search and medical writing. All are line Personality Disorder Guilford Press, New York,1993 answerable for published reports of the research. 10. Roberts BW, Walton KE, Viechtbauer W: Patterns of Dr. Tecco came up with the idea of the manuscript, mean-level change in personality traits across the life Dr. Franco wrote the first draft. course: a meta-analysis of longitudinal studies. Psychol The final draft was written under Dr. Tecco close Bull 2006; 132:1–25 supervision. This publication has been approved by 11. Robin M, Rechtman R: Un changement de paradigme au all co-authors, as well as by responsible authorities sein du DSM? Le cas de la personnalité borderline à where there work has been carried out. l’adolescence. Évol Psychiatr 2014; 79:95–108 12. Sheppard K and Duncan C: Borderline personality disorder: Implications and best practice recommendations. References Nurse Pract 2018; 43:14-17 13. Skodol A, Murray BS, Richard H: Overview of personality 1. American Psychiatric Association: Diagnostic and Statis- disorders. Uptodate Dec 01; 2017 tical Manual of Mental Disorders, Fifth Edition (DSM-5), 14. Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice Arlington, 2013 GM: Fluidity of the subsyndromal phenomenology of bor- 2. Blonigen DM, Carlson MD, Hicks BM, Krueger RF, derline personality disorder over 16 years of prospective Iacono WG: Stability and change in personality traits follow-up. Am J Psychiatry 2016; 173:688–694

Correspondence: Juan Martin Tecco, MD, MBA Centre Hospitalier Universitaire et Psychiatrique de Mons-Borinage (CHUP-MB) 24 Chemin du Chêne aux Haies, 7000 Mons, Belgium E-mail: [email protected]

S446 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 447-451 Conference paper © Medicinska naklada - Zagreb, Croatia

IMMUNITY AND PSYCHIATRIC DISORDERS: VARIABILITIES OF IMMUNITY BIOMARKERS ARE THEY SPECIFIC? Thomas Dubois1, Christine Reynaert1, Denis Jacques1, Brice Lepiece2, Pierre Patigny2 & Nicolas Zdanowicz1 1Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital, Yvoir, Belgium 2Université Catholique de Louvain, Psychosomatics Unit, CHU UcL Namur Godinne Hospital, Yvoir, Belgium

SUMMARY Background: In previous studies we showed the interaction between depression and immunity. We observed that psychological stress seems to be important in this association. In this review we try to understand if psychological stress and immunity have similar or specific impact on the other psychiatric disorders. More generally we review literature to understand if specific immune alterations exist between the main psychiatric diagnoses. Method: We studied the literature in search of variabilities between the different psychiatric disorders in terms of immunity especially inflammation. We search on Pubmed, PsycINFO, PsycARTICLES and Sciencedirect articles with the keywords immunity or inflammation and depression, anxious disorders and schizophrenia. Results: Prevalence of inflammation in psychiatric disorders seems to be between 21 to 42%. Psychiatric disorders are correlated with elevated levels of CRP, pro-inflammatory cytokines (IL-6, IL-1ȕ and TNFĮ) and anti-inflammatory factors (TGF ȕ, IL-10, sIL-2, IL-1RA). IL-6 in childhood were associated with subsequent risk of depression or psychotic disorders in early adulthood and in a dose dependent manner. Discussions: We found similar immune processes through the different disorders. Variations in cytokines levels seem paralleling various stages of the illness and treatment. Inflammatory markers are linked with severity and resistance to treatment and with subsequent risk of disorders. Conclusions: Some inflammatory parameters could be considered as risk factor, severity, resistance, trait or state markers of a psychiatric disorder. Other studies are necessary to a better understanding of clinical implications of this heterogeneity.

Key words: inflammation - psychological stress - psychiatric disorder

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INTRODUCTION studies between them. This probably induce interpretation bias. We have as much as possible promoted The role of immunity in psychiatric disorders is re- recent literature (2012 to early 2018) and large cohort ported in several recent and older studies. The debate study or meta-analysis. But for a better understanding concerning whether alterations in immunity or increase and to answer the questions asked, we also looked for in inflammatory markers is a cause or a consequence of other more specific and sometimes with a lower statis- illness is still relevant. In previous studies we studied tical significance studies. Animals studies are also in the interaction between depression and immunity as a our scope. psychosomatic model influenced by several factors (Zdanowicz et al. 2017, Dubois et al. 2017). Particu- RESULTS larly, we observed that psychological stress seems to be important in this association and have a persistent effect Prevalence of inflammation is 32% in psychotic on subsequent symptoms. Psychological stress is also a disorders, 21% in mood disorder, 22% in neurotic frequent risk factor for other psychiatric disorders. In disorder and 42 % in personality disorder (Osimo et al. this review we try to understand if psychological stress 2018). Meta-analysis showed that acute episode of and immunity have similar or specific impact on the depression or mania, first episode psychosis or acute other psychiatric disorders. More generally we review psychotic relapse are associated with elevated levels of literature to understand if specific immune alterations c-reactive protein (CRP) and pro-inflammatory cyto- exist between the main psychiatric diagnoses. kines such as interleukin-6 (IL-6), interleukin-1 ȕ (IL- 1ȕ) and tumor necrosis factor Į (TNFĮ). Besides the METHOD AND LIMITATIONS increase of pro-inflammatory cytokines, it is observed higher levels of some anti-inflammatory cytokines such We search on Pubmed, PsycINFO, PsycARTICLES as interleukin-10 (IL-10) or transforming growth factor and Sciencedirect articles with the keywords immunity ȕ (TGF ȕ) or cytokine receptor such as sIL-2R (soluble or inflammation and depression, anxious disorders, interleukin-2 receptor) and cytokine receptor antagonist bipolar disorder and schizophrenia. Articles comparing such as IL-1RA (interleukin-1 receptor antagonist) the different psychiatric disorders in term of immunity (Modabernia et al. 2013, Goldsmith et al. 2016, exist but are not frequent and so we had to compare Upthegrove et al. 2014, Liu et al. 2012, Kohler et al.

S447 Thomas Dubois, Christine Reynaert, Denis Jacques, Brice Lepiece, Pierre Patigny & Nicolas Zdanowicz: IMMUNITY AND PSYCHIATRIC DISORDERS: VARIABILITIES OF IMMUNITY BIOMARKERS ARE THEY SPECIFIC? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 447-451

2017, Gray et al. 2012, Passos et al. 2015). Several (Pariante 2017). Molecular and genetics studies are a studies showed that pro-inflammatory cytokines such as very large field of research and we will only describe a IL-1, IL-6 or TNFĮ are involved in dysfunction of the few elements. Tryptophan-kynurenine pathway (Chiap- glucocorticoid receptor and HPA axis hyperactivity pelli et al. 2018, Kim et al. 2017) and oxidative stress characterizing most psychiatric disorders (Pariante 2017, seems to be involved in psychiatric disorders. Elevated Belvederi et al. 2016, Borges et al. 2013). Modabbernia levels of oxidized compounds in peripheral blood, red et al. (2013) showed that levels of some cytokines such blood cells, mononuclear cells, urine and cerebrospinal as TNFĮ and IL-6 normalize during the euthymic phase fluid are observed in patients with panic disorder and of a bipolar disorder whereas levels of other such as obsessive–compulsive disorder (das Graças Fedoce et sIL-2R remains abnormal. Goldsmith et al. (Goldsmith al. 2018). Studies about post-traumatic stress disorder et al. 2016) showed that following treatment of acute (PTSD) found that variant in FK506-binding protein 5 mania, there was a significant decrease in IL-1RA (FKBP5) gene may predict vulnerability to PTSD. Some levels. In schizophrenia IL-1ȕ, IL-2, IL-6 and TGFȕ FKBP5 gene polymorphisms were associated with a increase in acute relapse and first episode psychosis and higher vulnerability to PTSD symptoms following child normalize with treatment. In contrast IL-12, IFN Ȗ, abuse or maltreatment (Binder et al. 2008) TNFĮ and sIL-2R remaining elevate in acute exacerbation and following antipsychotic treatment (Capuzzi DISCUSSIONS et al. 2017). Similar phenomenon is observed following treatment of acute depression (decrease IL-6) and in Which immune processes are involved chronically patients with depression compared with in psychiatric disorders? controls (increase IL-6) (Goldsmith et al. 2016). Elevate IL-6 level or other inflammatory markers (such as C- Similar immune processes seem to be involved in reactive protein(CRP)) in major depressive disorder or most of psychiatric disorders. Mood disorders such as in psychosis are connected to a poor response to res- major depressive or bipolar disorder, schizophrenia or pectively antidepressant or antipsychotic treatment com- psychosis and anxiety are correlated with a low grade pared with patients with one of this two disorders but systemic inflammation reflected by an increased con- lower level of inflammation (Khandaker et al. 2018, centration of circulating inflammation markers in peri- Carvalho et al. 2013, Mondelli et al. 2015). In major pheral blood such as cytokines, acute phase proteins and depressive patients, inflammatory markers are associa- anti-inflammatory cytokines whole the role is to dampen ted with symptoms severity (Kohler-Forsberg et al. the immune-inflammatory response. Results showed that patients with psychiatric disorders activate the immune- 2017). A well-documented link exists between suicidal inflammatory response system (IRS) during the acute behavior (DSM-5) and inflammation (Courtet et al. phase or relapse of the disease. Macrophages secrete 2015). A meta-analysis reported that suicidal patients pro-inflammatory cytokines (IL-1ȕ, IL-6, TNFĮ) known had significantly increased in vivo IL-1ȕ and IL-6 blood to stimulate lymphocytes proliferation leading to cell- levels compared to both non-suicidal and healthy con- mediated immunity (acute immune activation) and acti- trol (Black et al. 2015). Gonzalez-blanco et al. (2018) vate hypothalamic-pituitary-adrenal (HPA) axis. A com- showed that IL-2 specifically marks severity of the pensatory anti-inflammatory system (Maes et al. 2018) motivation and pleasure domain of negative symptoms. and immune regulatory systems are activate. Anti-inflam- Goldsmith et al. showed that TNF and IL-6 were Į matory cytokines (IL-10, TGF ȕ) or cytokines receptor elevated in patients with deficit schizophrenia compared (sIL-2R inhibit IL-2 pro-inflammatory activity) or recep- to non-deficit patients and healthy controls. IL-6 and tor antagonist (IL-1RA have an antagonist activity on IL- CRP were elevated in newly-diagnosed antipsychotic 1b receptor) try to dampen inflammatory activity by lo- naïve patients with deficit. Recent longitudinal studies wered mitogen-induced lymphocytes response or macro- showed that higher levels of serum IL-6 in childhood phages activity, activation of regulatory lymphocytes were associated with subsequent risk of depression or and increase negative feedback exerted by cortisol psychotic disorders in early adulthood and in a dose levels. Immune system tends towards humoral immu- dependent manner (Khandaker et al. 2017, Osimo et al. nity and resolution of inflammatory processes. Signs of 2018). Risk for psychiatric disorders such as schizo- inflammatory and anti-inflammatory are observed indi- phrenia or mood disorders is well known after prena- cating that there is no return to the original homeostasis tally infection (Depino 2018). Childhood atopic and and so a chronic mild inflammatory co-existing with a autoimmunity disorders are associated with increased mild immunosuppression. Inflammation tends to norma- risk of psychoses or depression in adulthood (Iseme et lize after recovery or after antidepressant/antipsychotic al. 2014, Al-Diwani et al. 2017). Psychological stress treatment. An important fact is that variations in cyto- during prenatal life or early in life such as childhood kines levels seem paralleling various stages of the ill- maltreatment or abuse induces inflammatory response ness and treatment. Some authors (Capuzzi et al. 2017) (Baumaister et al. 2016). Moreover adults with history proposed in schizophrenia «state-markers» and «trait- of childhood trauma or maltreatment without psychiatric markers». Given similar results in the literature, we disorder showed an increase level of inflammation hypothesized that this model exist for other disorders.

S448 Thomas Dubois, Christine Reynaert, Denis Jacques, Brice Lepiece, Pierre Patigny & Nicolas Zdanowicz: IMMUNITY AND PSYCHIATRIC DISORDERS: VARIABILITIES OF IMMUNITY BIOMARKERS ARE THEY SPECIFIC? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 447-451

Figure 1. Heterogeneity of inflammation levels in the different stages of the illness

What are the clinical implications of concomitant stress. Acute stress activate HPA axis releasing gluco- inflammation with a psychiatric disorder? corticoid and pro-inflammatory cytokines. To explain this persistent inflammation in adulthood after an early- Inflammation could be present in all major psychia- life stress we noted that prenatal or early inflammation tric diagnosis but not all individuals with one of this can affect microglial cells development and activity major psychiatric disorder present inflammatory pro- (activate microglial cells express cytokines) and a cesses. It seems there are clinical differences observed psychological stress later in life lead to an exacerbated in patients with psychiatric disorders with or without inflammatory response (Leboyer et al. 2015). Some inflammation. We observed that inflammatory markers cytokines elevated in psychiatric disorders and in adult are linked with a greater depression or psychosis se- with history of early-life stress or childhood maltreat- verity and resistance to treatment. Concerning schizo- ment are involved in glucocorticoid receptor resistance phrenia several recent studies suggest that inflammatory and so an impaired negative feedback resulting in a markers are associated with deficit and negative symp- HPA axis hyperactivity and an inability for cortisol to toms. Negative symptoms or deficit schizophrenia are stop inflammatory processes. Another element in favor known to be particularly treatment resistant (Garcia-Rizo of this is that some FK506-binding protein 5 (FKBP5 et al. 2012). Based on transnosographic studies about sui- binds to the GR and maintains it in an unresponsive cidal behavior, we suggest there is evidences for impact state) genes polymorphism seems to have an impact on of inflammation in suicide and so severity whatever the the development or not of PTSD after an early stress. diagnosis. Further evidences should be investigated for a better understanding of clinical implications. How does inflammation lead to psychiatric disorders? Where does the inflammation come from? Cytokines cross the brain blood barrier (BBB) and Genetic and environmental interactions seems to be activate microglial cells to express cytokines and important in the appearance and impact of inflammation several metabolism pathways. Microglial cells are in a in psychiatric disorders. Prenatal life and childhood central place in several neurologic diseases probably seem to be a particularly vulnerable period for psychia- due to their role of «housekeeper», maintaining sensi- tric disorders. Inflammation in this key period for the tive immune defense of the brain. Cytokines may acti- brain development have long-term consequences such vate indoleamine 2,3-dioxygenase (IDO) transforming as depression or psychosis in adulthood. Prenatal or tryptophan into kynurenine. This pathway is involved in childhood infectious or auto-immunity are a possible depression by using tryptophan to form kynurenine source of inflammation but also psychological stress instead of serotonine. Microglial cells further metabo- such as childhood maltreatment or abuse. Adult with lize kynurenine in 3-hydroxykynurenine (3-HK), quino- such history and without psychiatric disorder could have linic acid (QA) and kynurenic acid (KA). 3-HK and QA higher inflammatory levels than adult without early-life are oxidative stressor but QA is also an agonist of the

S449 Thomas Dubois, Christine Reynaert, Denis Jacques, Brice Lepiece, Pierre Patigny & Nicolas Zdanowicz: IMMUNITY AND PSYCHIATRIC DISORDERS: VARIABILITIES OF IMMUNITY BIOMARKERS ARE THEY SPECIFIC? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 447-451

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Correspondence: Thomas Dubois, MD Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital 5530 Yvoir, Belgium E-mail: [email protected]

S451 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 452-456 Conference paper © Medicinska naklada - Zagreb, Croatia

SLEEP DISORDERS: ARE THEY A GENETIC QUESTION? Giada Juli1, Rebecca Juli1 & Luigi Juli2 1Catanzaro, Italy 2Mental Health Department, Catanzaro, Italy

SUMMARY Sleep disorders are commonly studied from the psychiatric and neurological point of view, leaving aside other aspects such as genetic component. Despite the limited literature regarding this field, different genetic variants have been proposed to be associated with sleep disorders. In this review, we summerize the experimental research that has brought to light the pivotal genetic influence in the development of these pathologies. Key words: genetics – psychiatry - genetic factors - sleep disorders

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INTRODUCTION Syndrome (FASPS) that is caused by mutations in human clock-related genes (Toh et al. 2001, Xu et al. Complex anatomical structures and sophisticated 2005) and has an autosomal dominant pattern. The neurobiochemical processes are involved in the the analysis of two pedigree populations indicated defects sleep-wake rhythm. Sleep is an active process, capable in phosphorylation of PER2 as the most common alte- of inducing profound changes in vegetative life such as ration and mutations in both PER2 and Casein Kinase 1 heart rate, blood pressure, oxygen saturation, body genes (CK1į) (Sehgal and Mignot 2012). Circadian temperature and so on, but also in life’s relations, such rhythm disorders have been investigated also in other as increasing aggression or decreasing perfomances organisms such as Drosophila and the Syrian hamster after sleep deprivation. Biological, psychological and where mutations in the CK1İ kinase lead to reduction of social factors can alter the physiological pattern of PER phosphorylation that is critical for determining the sleep, producing complex clinical pictures. In all sleep/wake period length (Sehgal and Mignot 2012). In organisms, a substantial portion of life is spent during addition, a genetic variant has been reported in the core sleep and its disruption has immediate negative health clock gene CRYPTOCHROME 2 (CRY2) defined as an consequences (Mukherjee et al. 2015), leading to alanine to threonine replacement at amino acid residue conditions defined “sleep disorders”. 260 (A260T) (Hirano et al. 2016). However, a recent As for other psychiatric diseases such as bipolar study reported an association between CRY1 variation disorders (Juli et al. 2012), eating disorders (Juli et al. and delayed sleep phase disorder (DSPD) (Patke et al. 2014) and addiction disorders (Juli et al. 2015), sleep 2017). disorders have been evaluated through genetic studies in order to identify genetic factors that may influence the NARCOLEPSY vulnerability to these complex disorders. In this review, we report the emerging insights on molecular genetic Narcolepsy is characterized by involuntary “sleep studies that, using the development of detailed human attacks” that can occur while talking, standing, walking, genome map, have already led to the identification of eating and driving (Veatch et al. 2017, Zhang & Fu genetic factors in several sleep disorders. 2018). It is defined by excessive daytime sleepiness (EDS) and cataplexy but also by symptoms of dissociated CIRCADIAN RHYTHM DISORDERS rapid eye movement (REM) sleep (such as sleep paralysis and dream-like “hypnagogic” hallucinations at The circadian rhythm is the “internal body clock” sleep onset) (Sehgal & Mignot 2012). This sleep dis- that regulates the approximately 24-hour cycle of bio- order also occurs in dogs and mutation in the hypocretin logical processes in animals and humans. Circadian (orexin) receptor 2 gene (Hcrtr2) is believed to be the rhythm disorders are disruptions in a person’s circadian cause (Lin et al. 1999). It has been demonstrated that rhythm and include different conditions involving a narcolepsy is influenced by environmental factors and misalignment between actual and desired sleep periods susceptible genes. In fact, close relatives have about 1- (Benjamin 2007). Day-night circadian rhythm is con- 2% probability to develop the disease increasing by 20- trolled by cells that are dependent on cryptochrome 40 fold respect to normal population (Bidaki et al. (CRY) and period (PER) genes activity which control 2012). Human Leukocyte Antigen (HLA) and T cell CRY and PER protein levels (Viaterna et al. 2005, receptor (TCR) variants have been implicated in the Bidaki et al. 2011). The most recognized circadian predisposition of narcolepsy (Sehgal & Mignot 2012). rhythm disorder is the Familial Advanced Sleep Phase In particular, narcolepsy was associated with some HLA

S452 Giada Juli, Rebecca Juli & Luigi Juli: SLEEP DISORDERS: ARE THEY A GENETIC QUESTION? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 452-456 alleles such as DR2/DQW1 (Hayduk et al. 1997), DR5 Fatal Familial Insomnia (FFI) is a neuro-genetic and DRB1*1501/DRB1*1503 (Mignot 1998), disorder with an autosomal dominant pattern of inheri- DQB1*0602 (Tafti et al. 2016, Mignot 2000). In tance. This pathology is characterized by mutation in addition, the role of HLA-alleles in the susceptibility of codon D178N of prion protein (PrP) gene that was the the disease has been documented in monozygotic twins first gene to be linked to human sleep disorder (Medori with cataplexy (Hayduk et al. 1997). The TCR alpha et al. 1992) and it is now believed to be the cause of gene (TCRA), involved in the immune response thereby thalamic nuclei degeneration (Bidaki 2012). It has been interaction with peptide-buond HLA antigens, has been shown that this mutation is the result of change in implicated in the susceptibility of narcolepsy; a poly- aspartate location (Winkelmann 2008); patients with morphism in one of its segment showed significant homozygote methionine in codon 129 show a shorter association in Caucasians and other ethnic groups period of disease compared with those who have hetero- (Hallmayer et al. 2009). Since HLA and TCR genes are zygote valine-methionine in codon 129 (Bidaki 2012). involved in the immune response, it has been Idiopathic Hypersomnia, a poorly defined and he- hypothesized that narcolepsy is caused by autoimmune terogeneous phenotype, has shown a frequency of attack of orexin neurons (Veatch et al. 2017). DQB1*0602 of 40% in its patients although hypocretin Genome-wide association studies also identified levels in cerebrospinal fluid are in normal range. As polymorphisms in carnitine palmitoyltransferase 1B narcolepsy, a polymorphism located between CPT1B (CPT1B), a carnitine shuttle, and Choline Kinase B and CHKB is associated with hypersomnia in Japanese (CHKB) that metabolizes choline, associated with cohorts (Sehgal and Mignot 2012). narcolepsy in Japanese sample (Sehgal & Mignot In addition, Kleine Levin syndrome (KLS), a dis- 2012, Miyagawa et al. 2008). On the other hand, it has order that affects adolescent males and disappears in been demonstrated the implication of purinergic adulthood, has been associated with genetic factors. It receptors in narcolepsy in Caucasians as well as in has been shown that 5 out of 105 KLS patients reported multiple ethnic groups (Kornum et al. 2011). Because an affected family member. Furthermore, Arnulf et al. of its role in immune regulation, a polymorphism in shown an HLA association with KLS but this data has the purinergic receptor gene decreases the receptor’s not been demonstrated in other studies (Arnulf et al. expression in peripheral mononuclear cells associating 2008; Sehgal & Mignot 2012). with narcolepsy susceptibility (Sehgal & Mignot Among REM sleep features, sleep paralysis shows 2012). Genetic studies have been also performed in an high concordance in monozygotic twins and an autosomal recessive canine model of narcolepsy and in autosomal dominant transmission (Mignot, 1997). In gene-targeted mice where the hypothalamic hypocretin Parkinson’s disease it can occur REM sleep behavior (orexin) neuropeptide system was identified as the disorder as an early sign of neurodegenerative disorder; major pathway implicated in this pathology (Taheri a number of single gene defects and HLA-DR/DQ have 2004, Billiard 1994); in these patients hypocretin level been involved in the development of Parkinson’s in the cerebrospinal fluid (CSF) is low (Dauvilliers disease (Sehgal & Mignot 2012). 2003). Furthermore, it has been demonstrated that Non-REM sleep parasomnias such as sleepwalking, Deberman/ Labrador dogs are affected by narcolepsy sleep talking, nocturnal enuresis, bruxism and night showing mutation in hypocretin receptor 2 (Lin et al. terrors have also genetic basis (Hublin et al. 2001, 1999). Sehgal & Mignot 2012). For istance, the rate of sleep walking in a child whose none of the parents are involved INSOMNIA, HYPERSOMNIAS, is 22% and if one or both of the parents are involved, this PARASOMNIAS rate increased to 45% (Behram et al. 2000). In addition, an association between HLA O501 and DQ-B1 with Insomnia is characterized by difficulty in initiating sleep walking have been recently demonstrated (Abe & and maintaining sleep, waking up too early, or sleep that Shimakawa 1966, Hublin at al. 1997, Bidaki et al. 2012). is chronically non-restorative or poor in quality On the other hand, four gene locations including 8q, (American Academy of Sleep Medicine 2005, Bidaki et 12q, 12qh, and 22qu were found in nocturnal enuresis al. 2012). Its prevalence is about 10% to 50% in general (Kaplan and Sadock 1998). population and 35% of people with insomnia have a positive family history. Insomnia runs in families and RESTLESS LEG SYNDROME (RLS) has higher concordance in monozygotic twins (Sehgal and Mignot 2012). It has been demonstrated that Restless Leg Syndrome is characterized by an un- insomnia is often associated with major depressive comfortable desire to move the lower limbs with disorder (Benjamin 2007) which seems to have a periodic leg movements during the sleep. Regarding genetic explanation. In fact, twin studies showed that pathophysiological factors, it has been shown that the association between sleep disorders and depression reduced dopaminergic neuronal activity and iron defi- is 30% in 8-year-old twins and 11% in 10-year-old ciency in the brain are often present in RLS (Salas et al. (Gregory et al. 2009). 2010, Sehgal & Mignot 2012).

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An autosomal dominant pattern has been suggested because of nitric oxide acts as an atypical neuro- for Restless Leg Syndrome (Kimura & Winkelmann transmitter in the central nervous system with roles in 2007) and more than half of the cases have a familiar pain perception, control of sleep-wake regulation and pattern with risk of 3-6 fold more in close relatives modulation of dopaminergic activity (Winkelmann et (Bidaki et al. 2012). However, an high concordance al. 2008, Sehgal & Mignot 2012). (83%) has been reported in monozygotic twins (Sehgal & Mignot 2012). Recent genome-wide association OBSTRUCTIVE SLEEP studies revealed different transcription factors that affect spinal cord regulation of sensory perception and APNEA/HYPOPNEA SYNDROME locomotor pattern generation interacting with brain (OSAHS) iron homeostasis, as a developmental regulatory factors (Sehgal & Mignot 2012). For istance, MEIS1, a Obstructive Sleep Apnea is composed by periods of member of Hox transcriptional regulatory network that intermittent and functional obstruction of the upper specifies motor neuron pool identity and thus the airway collapse during sleep, resulting in decreases in pattern of target-muscle connectivity within the spinal arterial oxygen saturation which impairs ventilation cord, has been considered as the most important RLS and disrupts sleep (White 2005, Bidaki et al. 2012, susceptibility gene. MEIS1 is expressed in dopami- Sehgal & Mignot 2012). Genetic studies have not led nergic neurons of the substantia nigra, spinal cord and to consistently data for this complex phenotype using red nucleus that regulates coordination of limb the apnea hypopnea index. However, an association movement, all regions where it has been demonstrated between Apolipoprotein E allele e4 (APOE e4) and lower iron levels in RLS cases (Sehgal & Mignot sleep apnea has been reported (Gottlieb et al. 2004) 2012). Winkelmann et al. shown that MEIS1 variants although samples differed by age, ethnicity and body near exon 9, a region with high interspecies conserva- mass index. It has been hypnotized that APOE e4 tion, revealed the strongest association with RLS could predispose to sleep apnea thereby lower levels of (Winkelmann et al. 2007). Subsequently, an additional choline acetyltransferase and reduced neuromuscular study found an independent association in a region activation of the upper airway dilator muscles (Sehgal regulating MEIS1 expression (Winkelmann et al. & Mignot 2012). On the other hand, one study in 2011). Japan shown an association between HLA-DR2 and BTBD9 (BTB (POZ) domain containing 9) variants OSAHS (Riha 2006) and an American study on have also revealed association with RLS. Although narcoleptic population with OSAHS demonstrated that little is known for BTBD9 function in mammals, it has the frequency of HLA-DR2 sequence in such patients been shown that in Drosophila proteins containing the was higher than normal subjects (Guilleminault 1992, BTB (POZ) domain have relevant roles in metamor- Bidaki et al. 2012). Furthermore, it has been proposed phosis and limb pattern formation (Sehgal & Mignot that epigenetic modifications may be crucial in 2012). Stefansson et al. shown single nucleotide poly- pediatric obstructive sleep apnea (Perikleous et al. morphism associations in an Icelandic cohort that were 2018). In particular, DNA methylation patterns has strongly bound to the presence of periodic limb move- been implicated in the development of the disorder: ments such as repetitive cramping or jerking of the forkhead Box P3 (FOXP3) DNA methylation levels legs during sleep suggesting that this gene probably were associated with inflammatory biomarkers and confers risk for the motor component of RLS (Stefans- serum lipids, hypermethylation of the core promoter son et al. 2007, Li et al. 2017). Taken together, these region of endothelial Nitric Oxide Synthase (eNOS) data indicated that BTBD9 is a genetic determinant of gene in OSA children were related with decreased limb movements during sleep (Zhang & Fu 2018). eNOS expression. In addition, increased expression of However, two additional loci have been proposed pro-oxidant enzymes genes and decreased expression by genome-wide association studies such as PTPRD of anti-oxidant enzymes genes revealed the distur- (protein tyrosine phosphatase receptor type delta) lo- bances in oxygen homeostasis throughout neonatal cus that emerged through fine mapping of a significa- period predetermined increased hypoxic sensing in tive signal in a linkage region on chromosome 9p adulthood (Perikleous et al. 2018). (Schormair et al. 2008), and a large linkage disequili- brium block containing TOX3, a breast cancer suscep- CONCLUSIONS tibility locus, and untranslated BC034767 all togheter associated with RLS pathogenesis (Winkelmann 2011). Multiple lines of evidences have reported the Finally, linkage analysis in population based RLS genetic influence in developing sleep disorders, cases and controls suggested a role for neuronal nitric although not all studies have succeeded in confirming oxide synthase (NOS1) through finemapping of a them. Certainly, additional studies with more selected region on chromosome 12q (Winkelmann et al. 2008). models are needed to better clarify the role of genetic Despite no mutations were detected in RLS1-linked fa- component in these pathologies and to provide a novel mily members nitric oxide synthase is a good candidate approach in the currently used therapeutic strategies.

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Correspondence: Giada Juli, MD, Biologist PhD Catanzaro, Italy E-mail: [email protected]

S456 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 457-462 Conference paper © Medicinska naklada - Zagreb, Croatia

REWRITING NEURAL PATHWAYS TO STOP DEPRESSIVE DISTRESS IN A SUSPENDED SPACE AWAY FROM EVERYDAY LIFE Maria Grazia Spurio Research Center and Psychological Training "Genius Academy", Rome, Italy

SUMMARY An increasing number of human behavior scholars are redirecting their professional curiosity towards studies carried out with innovative research and intervention methods, far from the obsolete and reductive systems of analysis of the past. As part of these studies, aimed at the individual's bio-psycho-social betterment, the fascinating perspective of using the opportunities offered by a trip as a catalyst for important changes, has an important place. A sort of 'Journey' in the Journey, in which the suspended space-time of a travel can be the frame for innovative and interesting situations of parallel discovery of one's inner world. According to Hippocrates, therapy was not just a question of medicine and diet, in fact the cure he gave to his patients included also a trip to an island in order to temporarily move away from their environment, and therefore from the context that, somehow, had contributed to the emergence of the disease. Furthermore, the journey in itself, produces extraordinary beneficial effects. According with another study, for example, conducted by the Global Commission on Aging and Transamerica Center for Retirement Studies, in partnership with the U.S. Travel Association, women who vacationed every 6 years, or less, had a significantly higher risk of developing a heart attack or a coronary death, compared to women who vacationed at least twice a year. Similarly, another study showed that men who did not take an annual vacation had a 20 percent higher risk of death and 30 percent greater risk of death from heart disease. (www.globalcoalitiononaging.com, 2013) As regards the therapeutic value, the idea of facing a fascinating “Journey” in a Journey, could prepare the individual to enter in a sort of a suspended space, in which, according to many authors, the travel can induce both psychophysical and psychosomatic beneficial changes. For this reason, Body and Mind project, prepared by the Genius Academy Research and Psychological Studies Center, started in 2015, thanks to a protocol of intervention which includes associated psycho-physical inductions, with the aim of demonstrating the increase in the level of well-being (from the 30% to the 60% ). The research, continued in 2016/17 with the objective of raising the level of well-being perceived and measured, has shown a further health improvement. This improvement was evaluated and compared to data expressed by measurement of heart rate, blood pressure, hours of night time sleep, headache, sense of anxiety recorded an increase in well-being of 67% by stimulating the organisms affected by a specific suffering such as depression in the oncological patient. As the results of three years of study have been so encouraging, it was decided to continue the research by making the necessary changes to contextualize the Body and Mind project within a travel situation. The project a "Journey" in the Journey, which for the last five years optimizes the opportunities offered by a trip to promote the psychological growth of individuals through prescriptions, work shops, seminars, drinking and talking, social dreams, has therefore widened the research space, also bonding the objectives of the Body and Mind project. A "Journey" in the Journey in the places of Body and Mind, develops along two main directions: 1) the places of Body and Mind; 2) the Body and Mind project. But the red thread that binds and unites the study and research initiatives we have talked about is always the same: the innovative strategic approach where the individual is at the center of the scene, in contexts where life is live and where it is always the person to have the role of leading actor. Key words: suspended space - places of body and mind - journey as therapy - changement

* * * * * INTRODUCTION tions, conceived since 2013 and realized by the Writer in her professional role of Psychotherapist, Director of Embarking on a journey means putting oneself in the "Genius Academy" Psychological Research Center, comparison with different realities and cultures. and as Tourist Manager of Genius Handling Vip (GHV) For this reason the tourist experience, in all its as- sector, present in Italian and European airports. GHV is pects, is impregnated with interesting but underestima- another project, born in more recent years, with the aim ted psychological dynamics. The novelty of environ- of studying the behavior of people traveling, in transit ments and people could be perceived by the traveler as a (airport tourism), and working in the airport, as well as loss of points of reference, experienced with a feeling of doing training activity dedicated to this last type of uncertainty, as well as with a confused and not well people (Alitalia Training Genius Academy). defined feeling of unconfortable state. The professionals Thinking about the psychology of tourism, means to who devote themselves to the study of human behavior, think mainly about purchase behaviors of touristic aimed at bio-psycho-social improving of the individual, products. It seems to be very interesting to study the will be interested to use the opportunities offered by a behavior of tourists with other objectives, different from journey as a catalyst for important changes. The project sales or advertising. The stimuli and the circumstances a "Journey" in the Journey moves from these assump- offered by a trip, can be important occasions for growth

S457 Maria Grazia Spurio: REWRITING NEURAL PATHWAYS TO STOP DEPRESSIVE DISTRESS IN A SUSPENDED SPACE AWAY FROM EVERYDAY LIFE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 457-462 and well-being, if adequately optimized in situations of developing a heart attack or a coronary death, compared reflection and psychological therapy, as it will be stu- to women who vacationed at least twice a year. died further on. In the meanwhile one detaches from Similarly, another study showed that men who did not ones living environment, in order to enter in what can take an annual vacation had a 20 percent higher risk of be defined as a kind of suspended time-space, with an death and 30 percent greater risk of death from heart experience of new rhythms, habits, sensations, emotions, disease. (www.globalcoalitiononaging.com 2013) as well as new cognitive, emotional-behavioral and The 1992 Framingham Heart Study, which still psychophysiological stimulus: a kind of suspended space stands as the gold standard for long-term health studies far from everyday life. (www.framinghamheartstudy.org), tracked workers over 20 years, found that "men who don't take vacations were THE JOURNEY AS A THERAPY 30% more likely to have heart attack and for women it went up to 50%," according to Brigid Schulte, author of Traveling means changing: place, look, idea, and "Overwhelmed: Work, Love & Play When No One has consequently discovering places, discovering oneself, to the Time" and the director of the Better Life Lab at the heal. According to Hippocrates (Lopez 2004) therapy is New America Foundation (Starre 2018). not just a question of medicine and diet, in fact the cure Experts affirm that benefits of traveling are almost he gave to his patients included also a trip to an island in immediate: after only a day or two of holiday, 89% of order to temporarily move away from their environment, the study participants saw significant stress reduction, and therefore from the context that, somehow, had with undoubted benefits both physically and mentally. contributed to the emergence of the disease. This is the first evidence of the therapeutic value of ANXIETY AND DEPRESSION: traveling, of moving, of going elsewhere, this is what SECONDARY BIOLOGICAL DAMAGE sometimes is called dromotherapy, from the Sanskrit "dremi", wandering, from the Romanian "drom", travel- Anxiety is a spontaneous and fundamental emotion ling, and from the Greek "dromos", race. Another im- necessary to protect against external threats as it has the portant aspect of travelling and vacation is the presence function of activating the available resources of an of new incentives which provoke new reactions, but individual to prepare him/her to face the dangerous also the absence of the usual familiar, working and situation in the best possible way. When the risk persists social pressures. Some studies would seem to point out over time, or when the individual feels oneself inade- that inner paths of self-awareness and changing can be quate to go up against the situation, then the environment favoured and stimulated in particular in circumstances is perceived as an important danger to one's balance and other than the walls of a study. Some researchers, such anxiety becomes a negative emotion. Anxiety is a defect as Marc G. Berman and collaborators at the University that limits the performance, productivity and quality of of Michigan, wanted to test the positive effect of expe- a person's life, causing a loss of thoughts, concentration riences of moving outdoors compared to closed environ- and attention span and, sometimes, it causes energy ments, on cognitive functions, in particular on short-term blocks. If this state remains, generalized anxiety can memory. According to these researches the experiences evolve in situations of different diseases, such as panic of outdoor travel, like a journey, would seem to increase attacks and depressive states. Possible symptoms of these the memory up to 20% (Berman et al. 2008). situations of discomfort are: psychological state of anti- A review of 17 independent studies (Whear et al. cipation, characterized by fear, expectation of unplea- 2014), has highlighted a decrement, even without medi- sant or tragic events for ones self and for loved ones; cation, of the symptoms of dementia in patients who are mental alertness, characterized by hyper-attention that given the opportunity to leave their rooms and move paradoxically transforms into distraction, difficulties in outdoors. Researchers at the University of Exeter Medi- concentration and memory, impatience, irritability, cal, in particular Dr Rebecca Whear (2014), noted that physically blocked, highlighted by tremors, muscle the possibility of getting out and moving in new spaces pain, inability to stand still and relax, eyelid tremors, provided new stimulation to dementia patients, reducing easy exhaustion, vegetative hyperactivity (which affects agitation and depression and promoting states of that part of the nervous system not controllable by will) relaxation and resurfacing of memories at the same that determines tachycardia, dizziness, dry mouth, in- time. Therefore, if the possibility to make trips or walks creased sweating, tingling in the hands and feet, diges- in the clinicized patients has produced excellent results, tive difficulties, sensation of heat and sudden cold, knot we can imagine the positive effect produced by a in the throat, difficulty in swallowing, increased brea- journey on the cognitive and emotional psychological thing, cold and wet hands, diarrhea, feeling of "empty sphere in people not affected by disabling diseases. head" or "floating", knot in the pit of the stomach. These According with another study, conducted by the situations of depressive or anxiety psychological dis- Global Commission on Aging and Transamerica Center tress can be induced either by external events or by for Retirement Studies, in partnership with the U.S. inner states (an example of which is the level of sensory Travel Association (2013), women who vacationed and perceptual sensitiveness of the individual), as well every 6 years, or less, had a significantly higher risk of as a combination of both.

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Stressors, or external situations, that one perceives widely demonstrated that the first response to environ- as negative or dangerous, can be transitory or permanent mental stimuli, emotions, condition not only rational and impact differently, modifying an organism accor- processes, but they also act on neuroendocrine and ding to the amount of time they have been able to act. immune systems, responsible for well-being, as well as However, stressors impact on bodily functions by modi- the onset of diseases (Spurio 2017). fying it, and in turn causing further psychological changes. This results in a dysfunctional self-feeding body A "JOURNEY" IN THE JOURNEY IN and mind cycle (Spurio 2016). In a depressed organism THE PLACES OF BODY AND MIND different areas of the neuroendocrine system are involved, such as the hypothalamoipofisario axis, which A "Journey" in the Journey in the places of Body directly stimulates the adrenal gland, triggering a and mind, develops along two main directions: 1) the secretion of adrenaline and cortisol which consequently places of Body and Mind; 2) the Body and Mind project. causes a lowering of the immune system (Spurio 2016). The persistence of a pathological condition of this The places of Body and Mind type is manifested by a symptomatology of the depressive states already mentioned, anxiety, lowering of The journeys studied with an itinerary and a pro- immune defenses, as well as mental burden, insomnia, gram to induce to work on specific psychological reali- cramps, changes in sensory perceptions, migraines, ties are included in this first line of research. It is tachycardia, apathy. possible to take as an example the journey to the space - Therefore, the permanence of a depressive state, can temporal doors in the Yucatan. An ethnographic reproduce a non-ignorable psychophysical damage, called search has shown that some descendants of the Maya "secondary biological damage", since it involves an people, in order to explain the mysterious disappearance alteration of the balance of the endocrine system, with, of that ancient people, report that the Maya used a sort consequently, an incorrect production of neurotrans- of space-time doors to disappear into nothingness. They mitters and the development of psychosomatic illnesses. abandoned their beautiful cities, as well as the archaeo- Recently it has been shown that the sympathetic and logists who found those sites and passed through the parasympathetic system are directly influenced by a same space- time doors to realize their dream of leaving particular area of the brain called the limbic system that a dimension of reality too hostile and unsuitable for has the function of activating and manifesting emotions. them. As many observers affirm, for example Lacan- Each emotion corresponds to either an affective reacti- dones, that people did not leave definitively, because it vity or a response from the organs of the body mediated is as if it still existed in those places, even in a different by the autonomous nervous system. Therefore, it is dimension (Figure 1).

Figure 1. Spacetime according with Maya philosophy

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Figure 2. One of the places used for individual psychotherapy

Beyond the legend, the idea of facing a fascinating Within these journeys, in fact, the emotions evoked by and mysterious on the spot - “Journey” in the Journey, the experiences lived in the visited places are associated could prepare the individual to enter in that sort of within the places of the mind, such as individual and suspended space time, so favorable, according to many group psychotherapy (Figure 2). authors, to both psychophysical and psychosomatic Seminars held during a cruise are always part of this changes. The suspended space-time of a journey can be first guidelines of research. Five years of research and the frame for innovative and interesting situations of experimentation have allowed us to produce encouraging parallel discovery of one's inner world. results. Results have also been confirmed by documented In this kind of journey the suggestions produced by positive feedback (www.mariagraziaspurio.com) from places where, as the most ancient and secret Mayan the participants of the project. The program of the legends tell, there would exist passages between diffe- seminars has been specifically prepared taking into rent temporal space dimensions, make possible an account the itinerary, the places visited as well, which important psychological work. The passage through the are able to evoke sensations and emotions, and they door of self-awareness (Tulum), the door of courage have been associated to specific psychological programs: (Chichen Itza) and the door of hope (Merida), allows a seminars, individual and group psychotherapy, social synergy between the places visited, mystical, full of dreams, prescriptions, and more. In this way they charm, suggestion and mystery, and specific psycho- provided the energy of change, even after the travel logical situations associated, the places of the mind. experience was completed and travelers returned home.

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Figure 3. Improvement in the general health conditions: comparison between data of first and second version of B&M project

The Body and Mind project This means to combine the achievement of a psychological, physical and emotional well-being that you Body and Mind project, in its three years of res- expect to experience when you undertake any journey. earch, involved a sample of 150 people, with the aim of In fact, one decides to travel for many reasons: to redis- creating the right mind and body synergies to restore cover physical and mental energy, to seek transgression energy and well-being, starting from the assumption that and otherness, to rediscover the meaning of life and a situation of emotional distress can easily be transfor- interiority, to discover new places and new people. In med in a situation of physical discomfort. Treatment fact, it is precisely when we travel that changes occur in protocols have been proposed to people involved, in our mind linked to new situations. The moment you which the administration of body stimulations, such as leave your home and habits, you enter a kind of sus- kata Shiatzu, have been associated with psychothera- pended time. In this area of suspension new rhythms peutic and psychological interventions such as guided and habits are experimented, feelings and emotions are fantasies, regressive techniques and hypnosis. The sub- sought, subjected to cognitive, emotional-behavioral jects involved in the research have therefore received a and psychophysiological stresses. Satisfaction is not the psychological, emotional and physical stimulation at the result of a moment's judgment, but it is a process that same time. The precise bodily stimulations, associated begins when we leave and can continue indefinitely with psychological inductions, have involved and stimu- every time that experience is called into question. lated the organs touched by a certain situation of distress and suffering, such as depression in the onco- Benefits and positive personality changes solicited logical patient. The results were encouraging, as there by the travel experience are not self-evident. was an improvement in the general health conditions, The conditions partly favored by the trip, partly in- measured quantitatively and qualitatively, from 30 up to duced by a specific program, constitute the right com- 67% (Figure 3). bination, a prerequisite for starting the change, and rewriting neural pathways to stop depressive distress in CONCLUSION: Future perspectives a suspended space away from everyday life.

As the results have been so encouraging, with the support of other researches as, for example, the one Acknowledgements: None. conducted by Hunter and colleagues at the University of Sheffield (Hunter et al. 2010), which highlighted the Conflict of interest: None to declare. beneficial effect of natural scenarios, such as marine landscapes, which allows different areas of the brain to work in sync, it has been decided to expand and move References the protocols, successfully tested in the three years of laboratory research. Special spaces within Cruises were 1. Berman G, Jonides J, Kaplan S: The Cognitive Benefits of created for the Body and Mind project. In this case the Interacting With Nature, First Published December 1, Body and Mind project (B&M) adds and aligns its 2008, Volume: 19 issue: 12, page(s): 1207-1212, objectives to those of a “Journey” in the Journey. https://doi.org/10.1111/j.1467-9280.2008.02225.x

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2. Global Commission on Aging and Transamerica Center 7. Spurio MG: Il suono della guarigione, Roma, 2015, ISBN for Retirement Studies, in partnership with the U.S. Travel 9788893068291 Association: Destination Healthy Aging: the physical, 8. Spurio MG: The magic of caressing the mind by touching cognitive and social benefit on travel, white paper on the body. A new frontier of psycho-oncology. Psychiatr www.globalcoalitiononaging.com, 2013; “Journey to Danub 2017; 29(Suppl. 3):383-8 Healthy Aging: Planning for Travel in Retirement”, 9. Spurio MG: The new functional identity: a body that Survey on www.transamericancenter.org, December 2013, thinks, a mind that feels- frontiers and unexplored TCRS 1112-1213 territories of the "body and mind zone". Psychiatr Danub 3. Hunter PR, MacDonald AM, Carter RC: Water Supply 2016; 28(Suppl 1):111-5 and Health, www.plosmedicine.com, Nov 2010, Volume 7, 10. Spurio MG: Words that Heal. Psychiatr Danub 2015; Issue 12, e1000361 27(Suppl 1):21-7. www.mariagraziaspurio.com 4. Lopez F: Il pensiero olistico di Ippocrate. Percorsi di 11. Starre, Vartan: Why vacations matter for your health, ragionamento e testimonianze, Vol. I, Cosenza, Edizioni www.edition.cnn.com CNN. Updated 30th January 2018 Pubblisfera, 2004 12. Whear R, Thompson JC, Bethel A, Stein K, Garside R: 5. Paget J: On a Form of Chronic Inflammation of Bones What Is the Impact of Using Outdoor Spaces Such as (Osteitis Deformans), 1877, Medico-chirurgical transac- Gardens on the Physical and Mental Well-Being of Those tions. 60: 37–64.9. PMC 2150214 Freely accessible. With Dementia? A Systematic Review of Quantitative and PMID 20896492 Qualitative Evidence. Published Online: July 14, 2014, 6. Spurio MG: Milton Erickson e la Pet therapy, Quale Open Access, PlumX Metrics, Psicologia, 2011, ISSN 1972 – 2338 Anno 20 - N. 38 DOI: https://doi.org/10.1016/j.jamda.2014.05.013

Correspondence: Maria Grazia Spurio, MD, PhD, Psychotherapist Research Center and Psychological Training "Genius Academy" Via C.A. Jemolo 83, Rome, Italy E-mail: [email protected]

S462 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 463-468 Conference paper © Medicinska naklada - Zagreb, Croatia

ETHICAL AND ORGANISATIONAL CONSIDERATIONS IN SCREENING FOR DEMENTIA Thomas J. M. Weatherby1 & Mark Agius2,3 1University of Cambridge School of Clinical Medicine, Cambridge, UK 2Department of Psychiatry, University of Cambridge, Cambridge, UK 3Clare College, University of Cambridge, Cambridge, UK

SUMMARY The United Kingdom National Screening Committee (UKNSC) defines screening as “the process of identifying individuals who may be at higher risk of a disease or condition amongst large populations of healthy people”. Building on foundations laid by Wilson and Jungner in the landmark paper in 1968, the UKNSC states that “Once identified, those individuals can consider further tests, and healthcare providers can offer them interventions of benefit. A screening programme needs to offer more benefit than harm, at a reasonable cost to the NHS” (gov.uk 2014). We will consider the ethical issues surrounding some of the UK’s screening programmes and other methods used to assess and communicate patients’ risk of disease. We will discuss the appropriateness of candidate dementia biomarkers in order to inform research into developing such a biomarker or series of biomarkers. Key words: Alzheimer’s disease – dementia – screening - ethics * * * * * INTRODUCTION incidence of disease? We will spare individuals from suffering but also reduce the economic burden asso- Dementia, renamed “Major Cognitive Disorder” in ciated with disease. Does the economic or humani- DSM-V is a syndrome characterised by impairment in tarian gain weigh more heavily in an argument for one or more cognitive domains, that is recognised by screening? If patients can choose to accept or decline the patient, a clinician, objective cognitive assessment screening, how does the healthcare provider treat or by adverse effect on activities of daily living (Hugo patients who declined screening and subsequently 2014). Dementia is associated with an increasingly develop the disease? More importantly, how do we significant socio-economic burden in the UK. The total determine the level of morbidity spared as “a reason- number of people with dementia in the UK is predicted able cost to the NHS”? An effective treatment or to increase to over 1 million by 2025 and over 2 means of risk reduction should be available for partici- million by 2051 with increases driven by demographic pants identified as being at high risk of developing the ageing (Prince 2014). Therefore, the possibility of disease. It would be unacceptable to identify and introducing a screening programme for dementia and inform persons, presently healthy, that they are risk of reduce the incidence of disease is very attractive, to policy makers and the public. Early detection of a developing a serious condition without offering an disease process causing dementia or detection of subtle intervention to reduce the risk. A third ethical consi- cognitive changes may allow intervention before the deration linked with finance; should healthcare profes- onset of frank symptoms to improve patient outcomes sionals receive a financial incentive to screen? In the and to reduce disease burden. UK, GPs have a financial incentive screen all women In 1968, at the request of the WHO, Wilson and of the appropriate age group for cervical cancer, as it is Jungner produced their famous criteria for an ethical paid for as an item of service. All other UK adult screening programme (Wilson 1968). Although some screening programmes are delivered centrally, so this other criteria have been proposed and are increasingly financial incentive does not exist. In the aging po- widely accepted (Andermann 2008), these remain the pulation, dementia presents an increasing challenge to gold standard for considering the ethical issues around primary care, secondary care, care in the community screening programmes (see Table 1). In this article we and to families. Current treatments for Alzheimer’s will consider the ethical issues surrounding some of disease and other causes of dementia rarely provide the UK’s current screening programmes, and then con- adequate symptom relief and do not slow disease sider how these may apply to dementia screening. progression (Buckley 2015). Detection of persons at high risk of future dementia may facilitate early THE AIM OF SCREENING - SAVING intervention with lifestyle modification or pharmaco- MORBIDITY, MORTALITY OR MONEY? logical agents. If such interventions were shown to be effective, a reduction in cognitive decline in this The aim of screening is to reduce incidence of population would serve the individual, their family, disease, but what is the motivation behind reducing communities and healthcare systems.

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Table 1. The Wilson and Jungner Screening Criteria (Wilson & Jungner 1968) The condition sought should be an important halth problem. There should be an accepted treatment for patients with recognised disease. Facilities for Diagnosis and treatment should be available. There should be a recognisable latent or early symptomatic stage. There should be a suitable test or examination. The test should be acceptable to the population. The natural History of the condition, including development from latent to declared disease, should be adequately understood. There should be a declared policy on whom to treat as patients. The cost of Case-Finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole. Case-Finding should be a continuing process and not a ‘’once and for all’’ project.

TESTING AND DELIVERING nature of a cervical smear against the benefits of the INFORMATION TO programme and consider it worthwhile enough to take A “HEALTHY” POPULATION part (Jo’s Cervical Cancer Trust 2017).

Participants invited to screening programmes view Breast Screening themselves as being free from the disease in question. Although it is estimated to prevent 1300 deaths per Usually, screening is carried out in two stages. Scree- year in the UK, breast cancer screening has been ning often involves an initial test which by itself is not controversial in recent years (Public Health England diagnostic, but indicates whether further investigation is 2017). The areas of particular concern are over-diag- warranted. The initial test is offered to the population nosis, radiation exposure and additional anxiety (Marmot determined to be sufficiently at risk of disease. Thus the 2012). The screening programme aims to detect lesions test should be acceptable to the population – safe and which are at an early stage, will go on to cause mor- non-invasive. Patients’ ability to identify as “healthy” bidity and mortality, and could be treated more effec- should be respected. Diagnostic labels should not be tively earlier than they could if they were identified at a administered to asymptomatic persons unless the loss of later stage. However, it is not clear that for the lesions their “healthy identity” is justified by being able to picked up by breast cancer screening this is always the deliver an effective and acceptable intervention. Further- case. In some groups of women at lower risk, such as more, the ethics of screening large populations for a women in the 40-49 age group the benefits are parti- condition such as dementia, with the implication of cularly difficult to demonstrate as outweighing the assessing person’s cognition and thence competence in harms (Health Quality Ontario 2007). Overall, it does decision making, long term or short term, and keeping seem that the benefits outweigh the harms, but it is record of such data, has yet to be considered. important to communicate to patients that some women across the population will be harmed in this screening PRESENT ADULT UK programme (Myers 2015, Elmore 2016). SCREENING PROGRAMMES Bowel Cancer Screening We will examine the various adult screening pro- Bowel cancer screening is conducted by way of grammes at present available in the UK and to draw guaiac faecal occult blood tests followed by a lessons from them, so as to see whether similar scree- colonoscopy if the test was abnormal (Logan 2012). ning programmes could be applied to Dementia. This aims to reduce mortality in colorectal cancer. One- off flexible sigmoidoscopy is being introduced to all Cervical Screening men and women aged 55 following a recent successful Cervical cancer can be detected in an early but latent pilot (Atkin 2017). The ethical issues involved in bowel stage, when it can be treated by large loop excision of cancer screening are to do with health inequalities. Due the transformation zone as an outpatient procedure to difference in uptake of the screening by different much less invasive than that which would be required if socio-economic groups there is a risk that healthcare it were at a later stage. The facilities to do this exist resources spent on this screening programme will widely in the UK, and the natural history of the disease exacerbate inequalities in colorectal cancer outcomes if left untreated are well understood. Acceptability of across different groups (von Wagner 2011). While sig- the test is the only one of the Wilson criteria which nificant efforts have been dedicated to identifying a way could be debated. However, with a participation rate of to better reach these underserved communities, good above 70% most women seem to weigh the invasive solutions are lacking (Wardle 2016). It has however

S464 Thomas J. M. Weatherby & Mark Agius: ETHICAL AND ORGANISATIONAL CONSIDERATIONS IN SCREENING FOR DEMENTIA Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 463-468 been argued that the continued low participation rates LESSONS FROM PRESENT could be the result of genuine informed choices, thus SCREENING PROGRAMMES making the well-intentioned continued attempts to persuade groups who currently choose not to participate In summary, present screening programmes cervical ethically questionable (Essink-Bot 2016). screening, bowel Cancer screening and Cardiovascular risk assessment programmes involve simple non- Abdominal Aortic Aneurysm (AAA) Screening invasive tests carried out in Primary care with patients referred on to secondary care if high risk or serious The Wilson’s criterion which is most notable in the disease is found. However, in Breast Screening and context of abdominal aortic aneurysm (AAA) scree- Abdominal Aaortic Aneurysm Screening procedures, ning is that of an acceptable treatment, with pre- the initial tests are more sophisticated and expert ventative surgery carrying a 3-5% mortality risk and a opinion is required to interpret the screening test. In 32% complication rate (Stather 2013). While many both Breast Screening and Abdominal Aaortic Aneu- AAAs can be managed endovascularly, the screening rysm screening, the, treatment offered to high-risk indi- does not detect only those aneurysms for which an viduals is more invasive, and there is a greater risk of endovascular repair would be appropriate. Is it ethical over diagnosis and over treatment. These programmes to screen for AAA in a man for whom open repair set a precedent for the degree of risk that is likely to be would not performed (Lath 2011)? While open repair accepted as other programmes are introduced. has been performed in people much older than the current screening time point of 65 (Huber 2001), the invasiveness of a potential treatment is so great that APPLICATIONS OF SCREENING considerable counselling would need to be conducted FOR DEMENTIA prior to screening to ensure truly informed consent for many. Thus far, no formal screening programs have been Additionally, over diagnosis is a significant risk. recommended for mental health conditions. The Wilson For every death prevented by the scheme, four people and Jungner criteria state that facilities for diagnosis and are diagnosed with an aneurysm which would never treatment should be available before initiating any have caused a problem in their lifetime (Johansson screening programme. This is a very important hurdle in 2015). This then leaves the patient with the agonising the UK. There is a huge shortfall in mental health staff knowledge that they have this problem, and the diffi- with 10% of posts vacant; this is over 20 000 unstaffed cult decision of whether it is worth the risk of pre- positions (Nuffield Trust 2017, Health Education Eng- ventative surgery. land 2017). It is unlikely, then, that even if a suitable test for a suitable condition were available that it would be possible to mount a screening programme, as at risk Hypertension patients would not be able to be managed. It has long been advocated that patients on UK Dementia is not a single entity, but a syndrome general practitioners’ lists should be screened for associated with several diseases. Alzheimer’s disease, hypertension and that those found to suffer from vascular dementia, and Lewy body dementia are three hypertension should be treated in order to prevent examples, each with a separate pathology. Hence we stroke (Hart 1970, 1975, 1980). This idea eventually have the potential to screen for dementia or for the onset developed into the idea of screening for all cardio- of a particular disease process such as Alzheimer’s vascular risk factors (Hart 1988) and is now a part of disease or Vascular dementia. To screen for dementia in routine UK General Practice, within the routine assess- general, is conceptually different to the above screening ments when a new patient registers. programmes, which look for evidence of the beginning In 2006, the UKNSC did not recommend routine of or a latent stage of a disease process. screening but did recommend the introduction of a Focusing on Alzheimer’s disease, it seems there is a Vascular Risk Management Program as a result of the pathological early latent phase, but there at present is no Diabetes, Heart Disease and Stroke (DHDS) pre- treatment available that modifies disease trajectory. vention project. A Handbook of Vascular Risk Therefore, screening is ethically unjustifiable. However, Assessment, Risk Reduction, and Risk Management in order to conduct the research necessary to produce was published in 2008 and an NHS Health Check has disease modifying drugs it is likely to be necessary to been rolled out (UKNSC 2006). This programme find groups of these individuals who are likely to go on covers screening of adults with early intervention for to develop Alzheimer’s disease but haven’t yet mani- all cardiovascular risk factors including Hypertension, fested any signs. These people would need to be well Diabetes Mellitus, and Hypercholesterolemia, as well informed volunteers, as they would be suffering the as educational interventions regarding obesity and distress of an early diagnosis of a currently incurable smoking. In a subsequent paper, we will later discuss degenerative disease, with no guarantee the research the potential contribution such a programme could have they are participating in will bear fruit quickly enough to reducing the risk of dementia (Mackeever 2018) for them to benefit from it (Vandershaeghe 2018).

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The UKNSC does not recommend screening for about Mild Cognitive Impairment in the Patient’s Notes, dementia. (UKNSC 2015) The UKNSC highlights the while the patient is still well can have major impli- poor sensitivity and specificity available from neuro- cations for the patient, for example when the patient cognitive test batteries that have been used to test for applies for life insurance or employment. Early bio- dementia and MCI. (UKNSC 2015) The difficulties markers of dementia are not definitive, that is they relating to false positives make the use of present tests indicate an increased risk but they will not say when and unethical, despite several papers (Robert 2003, (Solo- whether the person will be disabled. This can be mon 1998, Ijuin 2008) which report good results in disturbing for people because this information is con- terms of rater to rater reliability. The UKNSC also fusing and it is not clear what action one should take states; ‘In order to offer enough information to allow when receiving this information. This is why there anyone invited to screening to make an informed should be proper counselling and professional support choice, we would first need to understand how dementia before and after the test. Another issue is that if the develops and be confident that early treatment will slow person tested now knows that they may develop the progression or even prevent the disease”. However, dementia, how will this impact on their behaviour there is emerging evidence that reduction of towards friends, family and others, including himself? cardiovascular risk through lifestyle modification This might even include ideas of suicide. The person reduces cognitive decline and incidence of dementia in tested may feel that other people will be less likely to later life (Christie 2017, Solomon 2018). trust them because of the test result. Therefore, considering other UK screening programmes as a model, a screening program for dementia CONCLUSION might be a stepwise process, with testing of cognition (using a battery of cognitive tests) at a first stage (Sindi Because of the potential problems mentioned above, 2015), followed if necessary by specific tests, e.g. for the following points are recommended regarding any amyloid beta or cerebral microbleeds. Alternatively, form of genetic testing (Arribas-Ayllon 2011). In our rather than a single test, a panel of biomarkers may offer view these points should be relevant to every person increased sensitivity and specificity, depending on the who might be screened for any form of cognitive im- selected component tests (Tan 2014). Indeed, if we are pairment or dementia, whether the technique is genetic testing for dementia, which has clinical diversity and testing or not; it is recommended that the decision to many causes, a panel of tests would be essential. If we take the test should be voluntary, free of coercion and are testing for an early stage of Alzheimer’s disease, a based on informed consent (Arribas-Ayllon 2011). panel of tests e.g. amyloid-PET, CSF amyloid beta and Each person screened should receive proper coun- MRI might be used to provide optimum sensitivity to selling and professional support (Arribas-Ayllon very early stages of disease (Tan 2014). However, cost 2011). Only persons who have reached the age of ma- and/or invasiveness of the tests listed here make them jority should be offered any form of screening for inappropriate for screening, and hence other tests need future dementia (Arribas-Ayllon 2011). Full confi- to be found. It is clear from the above that other dentiality, including confidentiality regarding all forms biomarkers or methods of predicting patients risk of of note-keeping should be maintained so as to avoid disease are required if dementia screening is to be any form of discrimination as a result of screening considered. (Arribas-Ayllon 2011). This means that the results of a In a separate paper we will suggest that there is screening procedure are confidential and the property potential in screening for risk factors for dementia rather of the individual and under no circumstances shall any than dementia itself (Makeever 2018). professional communicate this information to third parties (Arribas-Ayllon 2011). Any screening for a FURTHER PROBLEMS WITH potential dementing process should be delayed if there is evidence that the results will lead to psychosocial SCREENING FOR DEMENTIA harm (Arribas-Ayllon 2011). Adhering to these rules There are a number of issues which arise if scree- will enable useful advice to be given to individual ning is carried out for conditions which cannot be patients while avoiding harm to the patient as a treated and which have important implications for the consequence of the screening, information storing, and future health of patients. It is not therefore surprising councelling process. that the Wilson criteria do not recommend screening in these circumstances. However, in the context of De- mentia, genetic testing for the apolipoprotein E (APOE) Acknowledgements: None. İ4 allele has been suggested. Such genetic testing not Conflict of interest: None to declare. only reveals the risk to an individual, but it also reveals the risk to other family members. Also, the recording of the results of Genetic Testing and even information

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17. Ijuin M, Homma A, Mimura M, Kitamura S, Kawai Y, Contribution of individual authors: Imai Y, Gondo Y: Validation of the 7-Minute Screen for the detection of early-stage Alzheimer's disease. Dement Thomas J. M. Weatherby - review of lessons from Geriatr Cogn Disord 2008; 25:248-55 current screening and applications of screening for 18. Johansson M, Hansson A, Brodersen J: Estimating dementia; overdiagnosis in screening for abdominal aortic Mark Agius - supervision and significant contributions aneurysm: could a change in smoking habits and lowered to redrafting manuscript. aortic diameter tip the balance of screening towards harm? BMJ 2015; 350:h825 19. Jo’s Cervical Cancer Trust: Cervical Screening in the References Spotlight, 2017. http://www.content.digital.nhs.uk/catalogue/PUB22414 1. Andermann A, Blancquaert I, Beauchamp S, Déry V: 20. Lath NR, Rai K, Alshafie T: Open repair of abdominal Revisiting Wilson and Jungner in the genomic age: a aortic aneurysm in a centenarian. 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33. Tan C, Yu C, Tan L: Biomarkers for Preclinical Alzhei- screening programme: results from the first 2.6 million mer's Disease. J Alzheimers Dis 2014; 42:1051-69 invitations in England. Int J Epidemiol 2011; 40:712-8 34. UKNSC 2006. https://legacyscreening.phe.org.uk/ 38. Wardle J, von Wagner C, Kralj-Hans I, Halloran SP, Smith hypertension-adult SG, McGregor LM, Vart G, Howe R, Snowball J, Handley 35. UKNSC 2015. https://legacyscreening.phe.org.uk/dementia G, Logan RF, Rainbow S, Smith S, Thomas MC, Counsell N, 36. Vanderschaeghe G, Schaeverbeke J, Bruffaerts R, Van- Morris S, Duffy SW, Hackshaw A, Moss S, Atkin W, Raine denberghe R, Dierickx K: From information to follow-up: R: Effects of evidence-based strategies to reduce the Ethical recommendations to facilitate the disclosure of socioeconomic gradient of uptake in the English NHS Bowel amyloid PET scan results in a research setting. Alzhei- Cancer Screening Programme (ASCEND): four cluster- mers Dement (N Y) 2018; 4:243-251 randomised controlled trials. Lancet 2016; 387:751-9 37. von Wagner C, Baio G, Raine R, Snowball J, Morris S, 39. Wilson JMG & Jungner G: Principles and practice of Atkin W, Obichere A, Handley G, Logan RF, Rainbow S, screening for disease. Geneva: WHO, 1968. Available Smith S, Halloran S, Wardle J: Inequalities in partici- from: http://www.who.int/bulletin/ volumes/86/4/07- pation in an organized national colorectal cancer 050112BP.pdf

Correspondence: Thomas J. M. Weatherby, BA (Cantab) University of Cambridge School of Clinical Medicine Cambridge, UK E-mail: [email protected]

S468 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 469-474 Conference paper © Medicinska naklada - Zagreb, Croatia

DEMENTIA RISK ASSESSMENT AND RISK REDUCTION USING CARDIOVASCULAR RISK FACTORS Anna McKeever1 & Mark Agius2,3 1University of Cambridge School of Clinical Medicine, Cambridge, UK 2Department of Psychiatry, University of Cambridge, Cambridge, UK 3Clare College, University of Cambridge, Cambridge, UK

SUMMARY Given the poor efficacy of disease modifying treatments and evidence that Alzheimer’s Disease (AD) pathophysiology begins in middle-age, efforts to reduce the substantial disease burden have shifted towards preventative intervention in midlife. Up to a third of all AD(the commonest cause of dementia) is attributable to modifiable cardiovascular risk factors. A tool for predicting risk of future dementia using only cardiovascular risk factors has been validated and the effect of lifestyle modification on future cognitive decline is under investigation. In the UK, the QRISK3 risk calculator is used to quantify 10-year risk of cardiovascular disease. Lifestyle changes and lipid modifying therapy are recommended to patients based on their risk score. We will compare the emerging evidence for dementia risk assessment and risk reduction using cardiovascular risk factors with the evidence used to support the implementation of QRISK3 for cardiovascular disease risk assessment and intervention. This will guide future research to determine whether cardiovascular risk assessment can also be used to inform patients of risk of future dementia and advise on risk reduction strategies, in a primary care setting. Key words: Alzheimer’s disease – dementia – screening - primary prevention * * * * * INTRODUCTION Several studies have found that multi-domain lifestyle interventions including diet and exercise, have bene- In 2014 there were 835,000 people in the UK living ficial effects on cognition in later life (Rosenberg 2018). with dementia and in our aging population, the pre- Using QRISK3 and the UK National Vascular Risk valence and socio-economic burden of dementia are in- Management Programme (UKNSC 2012) as a model for creasing (Alzheimer’s Society 2014). Treatments targe- risk stratification, disclosure of information and evi- ting symptomatic stages of diseases that cause dementia dence based intervention, we will consider whether cur- (e.g. Alzheimer’s disease) provide limited symptom rent evidence can support implementation of a program- relief and do not slow disease progression (Buckley me for dementia risk assessment and reduction using 2015). As AD pathology begins decades before the cardiovascular risk factors. onset of dementia, there is potential to prevent or delay symptom onset through intervention in mid-life (Barnes ASSESSING RISK OF 2011, Ritchie 2010). Detection of subtle cognitive chan- FUTURE DEMENTIA ges or early stages of a disease process causing dementia may facilitate intervention before the onset of frank Screening is defined by The United Kingdom Natio- symptoms. It is hoped that early intervention will im- nal Screening Committee (UKNSC) as “the process of prove patient outcomes and reduce disease burden. identifying individuals who may be at higher risk of a However, neurocognitive tests do not provide sufficient disease or condition amongst large populations of healthy sensitivity or specificity for early dementia to qualify people”. At present, The UKNSC does not recommend for use as a screening tool, and detection of disease bio- screening for dementia (UKNSC 2015). They highlight markers such as amyloid-beta plaques may be too inva- the poor sensitivity and specificity of neurocognitive sive or expensive for screening purposes. In the absence test batteries used to diagnose dementia and Mild Cog- of a practical test to quantify risk of future dementia nitive Impairment (UKNSC 2015). High false positivity using signs of early disease, emerging research may rates make the use of such tests unethical. Dementia is a support an alternative means of assessing risk. A reli- syndrome associated with several diseases including able quantification of patients’ risk of future dementia Alzheimer’s disease, Vascular dementia, and Lewy may be achieved using cardiovascular risk factors such body dementia, each with a separate pathology. Hence, as age, gender, education and physical activity. Follo- it may be possible to screen for dementia or for the wing the principles for disease screening set out by onset of a particular disease process. The UKNSC sta- Wilson and Jungner (1968), patient’s risk of future de- tes; ‘In order to offer enough information to allow any- mentia should not be disclosed without offering a one invited to screening to make an informed choice, we proven means of risk reduction. Risk assessment should would first need to understand how dementia develops”. always be accompanied by recommendation of an evi- Alzheimer’s disease (AD) is the most common cause of dence-based intervention that reduces patients’ risk. dementia, contributing to 60-80% of cases. AD patho-

S469 Anna McKeever & Mark Agius: DEMENTIA RISK ASSESSMENT AND RISK REDUCTION USING CARDIOVASCULAR RISK FACTORS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 469-474 logy is known to begin decades before the onset of de- rheumatoid arthritis, atrial fibrillation, stage 3, 4 or 5 mentia (Ritchie 2015). Therefore, it is theoretically chronic kidney disease, systolic blood pressure varia- possible to detect pathological changes that precede the bility, migraine, corticosteroid use, systemic lupus, onset of cognitive decline (Jack 2010). The potential to atypical antipsychotic use, severe mental illness, and detect early AD using specific disease biomarkers (e.g. erectile dysfunction. Patient data is collected in primary amyloid-PET and hippocampus volume) is under inves- care and risk scores are shared with patients, according tigation (Ritchie 2012), but the cost and/or invasiveness to NICE recommendations to clinical practitioners of candidate tests may make them inappropriate for use (NICE 2016). Patients identified as being at high risk of in screening. future cardiovascular disease are offered evidence-based interventions to reduce their risk of cardiovascular AN ALTERNATIVE DEMENTIA events. Patients are firstly advised on lifestyle modifica- RISK ASSESSMENT USING tion and where appropriate, engage in a discussion on lipid modification therapy (NICE 2016). CARDIOVASCULAR RISK FACTORS Considering the QRISK3 protocol as a precedent for implementation of risk stratification, disclosure of infor- In the absence of a reliable test for all cause de- mation and evidence based intervention in a UK popu- mentia or a practical means of detecting early AD lation, we will consider whether current evidence can pathology, there may be a proxy method to assess risk support a similar programme for dementia. The Wilson of future dementia using known dementia risk factors. and Jungner criteria for screening programmes were Although a precise mechanism for AD has not been published in 1968 and continue to influence the require- determined, several inherited and environmental fac- ments for disease screening (Wilson 1968). Although tors are known to affect the probability and time of the proposed dementia risk assessment is not a scree- symptom onset. Accounting for non-independence of ning programme (because it would measure the burden risk factors, up to a third of AD cases worldwide may of risk factors rather than attempting to detect signs of a be attributable to modifiable risk factors including disease process), the Wilson and Jungner criteria pro- diabetes, hypertension, obesity, smoking, and cognitive vide a useful framework to assess its validity. Guided by and physical inactivity (Norton 2014). The CAIDE these criteria, it is critical that a dementia risk assess- (Cardiovascular Risk Factors, Aging, and Incidence of ment offers 1.) a suitable test that is acceptable to the Dementia) Dementia Risk Score was developed to public and 2) an effective intervention for those identi- predict later life dementia using cardiovascular risk fied as high-risk to reduce their risk of developing factors (Sindi 2015). CAIDE provides a predictive risk disease. We will take each of these criteria in turn and score without the need for genetic testing or invasive use QRISK3 as a benchmark to assess the potential for testing. The multifactorial risk assessment includes dementia risk assessment in the UK. age, hypertension, hypercholesterolemia, physical inactivity, obesity and educational level. Inclusion of Apolipoprotein E İ4 status, the most significant of all Development and validation of the CAIDE known genetic risk factors for AD, did not increase Dementia Risk Score in comparison to QRISK3 predicative value (Sindi 2015). This simple test is The CAIDE risk score was developed in a longi- therefore available at minimal cost and minimal risk to tudinal study of 1409 participants, where 4% developed the patient, and avoids the ethical complexity associa- dementia over 20 years of follow-up (Kivipelto 2006). ted with genetic testing. Future dementia was significantly predicted by age (47 years), education (<10 years), hypertension, hyperchole- ASSESSING CARDIOVASCULAR sterolaemia, and obesity. Risk score values were assig- RISK IN THE UK ned to candidate risk factors using ȕ coefficients from logistic regression. An individuals’ dementia risk score Following the UK National Screening Committee’ s was calculated as the sum of these weighted risk scores, recommendation for a National Vascular Risk Manage- and ranged from 0-15. The CAIDE risk score provided a ment Programme in 2006, there is a system in use reliable prediction of future dementia, (area under within the UK National Health Service for assessing 10- receiver operating characteristic curve 0·77; 95% CI year risk of cardiovascular disease (UKNSC 2012). This 0·71–0·83). Participants were then assigned a dementia involves a risk calculation tool, QRISK3 (Hippisley- risk category: 1.0% for those with a score of 0–5, 1.9% Cox 2017) which has been validated in 7.9 million for a score of 6–7, 4.2% for a score of 8–9, 7.4% for a adults aged between 25 and 84. QRISK3 includes the score of 10–11, and 16.4% for a score of 12–15. Ap- following cardiovascular risk factors: age, ethnicity, plying a cut-off of scores 9 points, the risk score provi- deprivation, systolic blood pressure, body-mass index, ded a sensitivity of 0·77, specificity of 0·63, and nega- total-to-HDL cholesterol ratio, smoking, coronary heart tive predictive value of 0·98 (Kivipelto 2006). disease in a first-degree relative younger than 60, pre- Like QRISK, the CAIDE score has been subsequen- sence of type 1 or type 2 diabetes, treated hypertension, tly validated in a retrospective cohort study (Exalto

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2014). The study aimed to validate the CAIDE Demen- the most recent validation of QRISK3 (Hippisley-Cox, tia Risk Score in a different population and determine 2017). It is difficult to determine specific criteria for whether addition of other risk factors (central obesity, implementation of a risk score – current practice can depressed mood, diabetes mellitus, head trauma, lung be used as a guide but the current iteration of QRISK function, or smoking) would improve prediction value. has been subjected to re-validation and improvement The study included 12,247 participants in the validation since induction into clinical practice. Indeed, QRISK cohort, (mean age 46.4±4.4 years). Of these 12,247 (Hippisley-Cox 2007) was introduced to replace the participants, 9480 participants aged 40–55 years were less reliable Framingham score (Anderson 1991), which included in analysis to determine whether the prediction was validated in population with limited ethnic diver- accuracy was improved by adding other risk factors to sity and a high prevalence of cardiovascular disease the model. Among the included participants, 2767 par- (Hippisley-Cox 2007). Here, we will compare the ticipants (25%) were diagnosed with dementia. Harrell’s CAIDE Dementia Risk Score to the most recent vali- C statistics, (a similar measure of discrimination to the dation of QRISK3, as current practice and standards area under receiver operating characteristic curve) should form a sound basis for future recommendations. shows that the CAIDE risk score was well replicated The most striking difference between development and with a C statistic of 0.75, (similar to the original validation of the risk prediction tools is the size of the CAIDE C statistic of 0.78). It achieved a good predic- derivation and validation cohorts. The original QRISK tion within different race groups and prediction was tool (QRISK) was derived in a cohort of 1.28million not improved by addition of other risk factors (central patients and the validation cohort comprised 0.61 mil- obesity, depressed mood, diabetes mellitus, head lion (Hippisley-Cox 2007). QRISK3 and CAIDE both trauma, lung function, or smoking). The risk score was achieve good prediction accuracy, but clinical applica- demonstrated to allow stratification of participants into tion of the CAIDE Dementia Risk Score requires groups with low and high risk of dementia in the next validation using a large database such as UK primary 40 years (Exalto 2014). care records. Future validation of CAIDE should also Table 1 provides a summary of the development consider the effect of comorbidities on risk of future and validation of CAIDE (Exalto 2014) compared to dementia and include younger and older participants.

Table 1. Derivation and validation of QRISK3 and CAIDE Dementia Risk Score (Hippisley-Cox 2017, Exalto 2014) QRISK3 CAIDE Study Design Retrospective cohort study Retrospective cohort study Derivation n 7,889,803 9,480 Age 25-84 years 40–55 years Outcome Clinical record of CVS disease using ICD-10 codes Clinical record of Dementia diagnoses using for: TIA and related syndromes, angina pectoris, acute ICD-9 codes for: possible dementia (excluded MI, subsequent MI, complications after MI, other in analyses to investigate prediction improve- acute ischaemic heart disease, chronic ischaemic heart ment from addition of risk factors) and specia- disease, cerebral infarction, stroke not specified as list confirmed dementia haemorrhage or infarction Statistical Cox’s proportional hazards - Regression coefficients Logistic regression - ȕ coefficients were used Methods for each risk factor in women and men were used to to assign scores for each risk factor. Indivi- weight risk factors in the final risk equation. Non- duals’ risk score was obtained by summing the linear risk relationships were accounted for using scores for the appropriate level of each of the fractional polynomials. Rubin’s rules for multiple risk factors. imputations of missing data were applied. Validation n 2,671,298 12,247 Statistical Harrell’s C statistic and Kaplan-Meier estimates eva- Harrell’s C statistic and Kaplan-Meier esti- Methods luated at 10 years. Analyses were stratified by: age, mates of observed 40-year population-level ethnic origin, comorbidity and treatment subgroups. dementia risk. Analyses were stratified by race. Results The QRISK3 algorithm explained 59.5% of the varia- The risk score allowed stratification of partici- tion in time to diagnosis of cardiovascular disease. For pants into those with 40-year low and high de- women, C statistic was 0.88, for men C statistic was mentia risk. The CAIDE risk score C statistic 0.86. was 0.75, similar to the original CAIDE C statistic of 0.78. Abbreviations – CVS: Cardiovascular, ICD: International Classification of Diseases, MI: myocardial infarction, TIA: Transient ischaemic attack

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Intervention to reduce risk of future dementia rapy and diabetes treatment) found no strong evidence due to cardiovascular risk factors for the effectiveness of such interventions on preventing or delaying age-related cognitive decline, MCI Echoing Wilson and Junger’s stipulation that “there and clinical Alzheimer’s-type dementia (Kane 2017). should be an accepted treatment for patients with Although they found no consistent benefit from phy- recognised disease” (Wilson 1968), the UKNSC states sical activity interventions in preventing cognitive that we should “be confident that early treatment will decline, the authors concluded that the proportion of slow the progression or even prevent the disease” results reporting a benefit was unlikely to be due to (UKNSC 2015). As AD pathology begins decades be- chance and warranted investigation of a potentially fore the onset of dementia, there is potential to prevent significant relationship (Kane 2017). These findings or delay symptom onset through intervention in mid- provide an incentive for further research to determine life (Barnes 2011, Ritchie 2010). A 10-25% reduction whether interventions before the onset of dementia can in 7 modifiable AD risk factors (diabetes, midlife improve patient outcomes and reduce disease burden. hypertension, midlife obesity, smoking, depression, To support implementation of the proposed scheme low cognitive activity and low physical activity) could (CAIDE risk assessment in an appropriate patient potentially prevent as many as 3 million AD cases group), studies should demonstrate reduced incidence worldwide (Barnes 2011). Studies have found that of dementia following reduction of cardiovascular risk multi-domain lifestyle intervention (e.g. diet and (by lifestyle or pharmacological measures) in patients exercise) has beneficial effects on cognition in later shown to have high CAIDE Dementia Risk Scores in life, regardless of Apolipoprotein E İ4 status (Solomon mid-life. 2018). A recent a double-blind randomised controlled In addition to lifestyle advice, patients identified as trial of 2654 individuals aged 60-77 years, used CAIDE having high risk of cardiovascular disease using Dementia Risk Scores as an indicator of dementia QRISK3 may be offered lipid-modifying therapy risk and investigated the effect of multi-domain (NICE 2016). Clinicians are urged to promote cardio- lifestyle intervention in those with CAIDE scores 6 vascular risk reduction through lifestyle modi- (Rosenberg 2018). The intervention included diet fications in the first instance and advise patients that advice, exercise, cognitive training, and monitoring statin therapy is designed to supplement not replace of vascular and metabolic risk factors. Cognition at such changes. Clinicians engage in a discussion with baseline and 2-year follow-up was assessed using the patient on the risk and benefits associated with neuropsychological test battery Z-scores. The inter- statins and come to a decision that is acceptable for the vention had a significantly beneficial impact on individual patient. In a systematic review including cognition; scores were 25% higher in the intervention two randomised controlled trials and 26,340 par- group than those of the control group. Although at a ticipants, statins were found to have no effect on superficial level this may provide theoretical support occurrence of Alzheimer's disease or dementia com- for using CAIDE scores and lifestyle intervention as a pared to placebo (McGuinness et al. 2016). However, means of reducing the incidence of dementia, the age range in the cohort was 40 to 82 years and 11,610 application of this evidence to dementia is limited. participants were more than 70 years old. Targeted Better cognitive performance after 2-year follow-up pharmacological intervention in a middle-aged high- does not reflect the incidence of dementia in the co- risk cohort may have a beneficial effect on incidence hort. Although cognition is an important factor influ- of dementia. encing the development of dementia (through the me- Wilson and Jungner highlighted the potential for chanism of “cognitive reserve”), the outcomes are not recommending intervention to falsely positive par- interchangeable. ticipants i.e. those who are not truly at high-risk of In a large intervention study that did use incidence developing the disease (Wilson & Jungner 1968). There of dementia as the outcome measure, dementia inci- are benefits and risks associated with any intervention. dence was not affected by a reduction in exposure to However, lifestyle modification (a low risk interven- cardiovascular risk factors in an unselected cohort tion) and existing treatments to lower cardiovascular aged 70-78 (van Charante 2016). Better patient out- risk factors are known to provide greater benefit than comes may be achieved through earlier, targeted inter- harm for patients with high QRISK3 scores (NICE vention in cohorts identified as high-risk. Therefore, 2016). As there is overlap between the components of there is a need to identify middle-aged individuals at QRISK3 and CAIDE, patients with high QRISK3 high risk of developing dementia and demonstrate de- scores are likely to have high CAIDE Dementia Risk mentia risk reduction using cardiovascular factors in Scores. There should be strong evidence to show that this high-risk population. A meta-analysis of 263 stu- interventions recommended following risk assessment dies with various interventions including cognitive achieve a significant risk reduction, but at all events, training, physical activity, diet, dietary supplements, adjusting the same cardiovascular risk factors should hormone therapy and pharmacological intervention reduce patients’ risk of stroke and myocardial in- (including antihypertensive therapy, lipid-lowering the- farction.

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RECOMMENDATIONS decisions to change their lifestyle to reduce their risk of FOR CLINICAL PRACTICE dementia. Until a sensitive and specific test for early dementia or AD becomes available, we look forward to Wilson and Jungner emphasised that “Facilities for further evaluation of whether such an assessment will diagnosis and treatment should be available”. If vali- reduce the onset of dementia in our patients. dated in the UK, the infrastructure to support such a programme is almost already in place. Cardiovascular risk factors are routinely assessed in primary care and Acknowledgements: None. lifestyle modification programmes such as smoking cessation services and cardiac rehabilitation are avail- Conflict of interest: None to declare. able. We would be able to offer information and intervention to high-risk patients with the only additional Contribution of individual authors: cost being the increased access to those identified as Anna McKeever - application of cardiovascular risk high risk. NICE guidelines for completing the QRISK3 assessment to screening for dementia. assessment indicate appropriate patient populations and Mark Agius – supervision. how to navigate disclosure of results (NICE 2016). Clinicians are guided on how to engage in a joint decision making process with patients. Similar guidance should be available should a dementia risk assessment References be introduced. Secondly, investigation is needed to 1. Alzheimer’s Society: Dementia 2014: Opportunity for determine whether informing patients of their risk of change, 2014. Available at: dementia can be ethically justified. Certainly, given that https://www.alzheimers.org.uk/sites/default/files/migrate/d the patients would not be suffering from Dementia when ownloads/dementia_2014_opportunity_for_change.pdf assessed, there must be consideration given to keeping 2. Anderson KM, Odell PM, Wilson PW, Kannel WB: Dementia Risk scores private, and to proper confiden- Cardiovascular disease risk profiles. American Heart tiality in record keeping (Arribas-Ayllon 2011). If the Journal 1991; 121:293–298 evidence continues to show that reduction of cardiovas- 3. Arribas-Ayllon M: The ethics of disclosing genetic cular risk in individuals at high risk of dementia has a diagnosis for Alzheimer's disease: do we need a new beneficial effect on long-term cognitive function, it paradigm? Br Med Bull 2011; 100:7-21 would be a strong indication for inclusion of individuals 4. Barnes DE. & Yaffe K: The projected effect of risk factor reduction on Alzheimer’s disease prevalence. 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At present, an appropriate population is prediction of dementia four decades later. Alzheimer’s & informed of their risk of cardiovascular disease using Dementia 2014; 10:562–570 QRISK3 (Hippisley-Cox 2007). Patients then have the 8. Hippisley-Cox J, Coupland C, Vinogradova Y, Robson J, choice of starting an evidence-based therapy to reduce May M, Brindle P: Derivation and validation of QRISK, a their cardiovascular risk, modify their lifestyle, or do new cardiovascular disease risk score for the United nothing. If future research supports lifestyle modifica- Kingdom: prospective open cohort study. BMJ 2007; tion as an effective means of reducing risk of dementia, 335:136 we could offer the same in the context of future 9. Hippisley-Cox J, Coupland C & Brindle P: Development dementia – assessing patients’ risk of dementia using and validation of QRISK3 risk prediction algorithms to the CAIDE Dementia Risk Score and offering cardio- estimate future risk of cardiovascular disease: prospective vascular rehabilitation to reduce risk. However, further cohort study. BMJ 2017; 357:j2099 10. Kane RL, Butler M Fink HA, Brasure M, Davila H, Desai evaluation needs to be made as to the degree to which P, Jutkowitz E, McCreedy E, Nelson VA, J Riley McCarten, targeting cardiovascular risk factors actually reduces the Calvert C, Ratner E, Hemmy LS, Barclay T: Interventions to risk of dementia. If we can reliably inform patients of Prevent Age-Related Cognitive Decline, Mild Cognitive their risk of dementia due to modifiable risk factors that Impairment, and Clinical Alzheimer’s-Type Dementia. are already routinely tested, and educate them on Comparative Effectiveness Reviews, No. 188 Minnesota lifestyle changes that will reduce risk of cognitive Evidence-based Practice Center Rockville (MD): Agency decline, it would empower patients to make informed for Healthcare Research and Quality (US), 1917

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11. Kivipelto M, Ngandu T, Laatikainen T, Winblad B, Soininen H, Stigsdotter-Neely A, Strandberg T, Tuomi- Soininen H, Tuomilehto J: Risk score for the prediction of lehto J, Solomon A, Kivipelto M: Multidomain lifestyle dementia risk in 20 years among middle aged people: a intervention benefits a large elderly population at risk for longitudinal, population-based study. The Lancet Neuro- cognitive decline and dementia regardless of baseline logy 2006; 5:735-41 characteristics: The FINGER trial. Alzheimer’s & 12. McGuinness B, Craig D, Bullock R, Passmore P: Statins Dementia 2018; 14:263–270 for the prevention ofdementia. Cochrane Database of 19. Sindi S, Calov E, Fokkens J, Ngandu T, Soininen H, Systematic Reviews 2016; CD003160 Tuomilehto J, Kivipelto M: The CAIDE Dementia Risk 13. NICE: Cardiovascular disease: risk assessment and Score App: The development of an evidence-based mobile reduction, including lipid modification, 2016. application to predict the risk of dementia. Alzheimers https://www.nice.org.uk/guidance/cg181 Dement (Amst) 2015; 1:328-33 14. Norton S, Matthews FE, Barnes D, YaffeK &Brayne C: 20. Solomon A, Turunen H, Ngandu T, Peltonen M, Levälahti Potential for primary prevention of Alzheimer’s disease: E, Helisalmi S, Antikainen R, Bäckman L, Hänninen T, an analysis of population-based data. The Lancet Jula A, Laatikainen T, Lehtisalo J, Lindström J, Paajanen Neurology 2014; 13:788-794 T, Pajala S, Stigsdotter-Neely A, Strandberg T, 15. Ritchie CW & Ritchie K: The PREVENT study: a prospec- Tuomilehto J, Soininen H, Kivipelto M: Effect of the tive cohort study to identify mid-life biomarkers of late- Apolipoprotein E Genotype on Cognitive Change During onset Alzheimer’s disease. BMJ open 2012; 2:p.e001893 a Multidomain Lifestyle Intervention A Subgroup Analysis 16. Ritchie KI, Carrière CW, Ritchie C, Berr S, Artero M-L, of a Randomized Clinical Trial JAMA Neurol 2018; Ancelin: Designing prevention programmes to reduce 75:462-470 incidence of dementia: prospective cohort study of 21. UKNSC: The Handbook for Vascular Risk Assessment, modifiable risk factors. BMJ 2010; 341:c3885 Risk Reduction and Risk Management. A report prepared 17. Ritchie K, Craig W, Ritchie, Kristine Yaffe, Ingmar Skoog, for the UK National Screening Committee. University of Nikolaos Scarmeas: Is late-onset Alzheimer’s disease Leicester, 2012. https://legacyscreening.phe.org.uk/ really a disease of midlife? Alzheimer’s & Dementia: policydb_download.php?doc=259 Translational Research & Clinical Interventions 2015; 22. UKNSC: 2015. https://legacyscreening.phe.org.uk/dementia 1:122–130 23. Wilson JMG & Jungner G: Principles and practice of 18. Rosenberg A, Ngandu T, Rusanen M, Antikainen R, Bäck- screening for disease. Geneva: WHO, 1968. Available man L, Havulinna S, Hänninen T, Laatikainen T, Lehtisalo from: http://www.who.int/bulletin/ volumes/86/4/07- J, Levälahti E, Lindström J, Paajanen T, Peltonen M, 050112BP.pdf

Correspondence: Anna McKeever, BA (Cantab) University of Cambridge School of Clinical Medicine Cambridge, UK E-mail: [email protected]

S474 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 475-478 Conference paper © Medicinska naklada - Zagreb, Croatia

CORRELATIONS BETWEEN EVENT-RELATED POTENTIALS AND NK CELLS, B AND T LYMPHOCYTES Camille Demont, Nicolas Zdanowicz, Christine Reynaert, Jacques Denis & Thomas Dubois Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital, Yvoir, Belgium

SUMMARY Background: The links between psychiatry and immune dysfunctions are well known. By contrast, there are few studies that evaluate the link between neuroelectrophysiology and immune system disturbances. Subjects and methods: We retrospectively included 31 patients hospitalized between 2011 and 2012. They completed a socio- demographic questionnaire and were assessed using DSM IV TR on Axis 1. Event-related potentials were performed. Lymphocyte subtypes were quantified using flow cytometry. Results: In terms of P300 latency, there are correlations with the absolute value of leukocytes: for P3a component, we find a correlation in frontal derivation Fz (r=0.405*), in central derivation Cz (r=0.438*), in parietal derivation Pz (r=0.403*) and for P3b component, there is a correlation in Fz (r=0.414*), in Cz (r=0.402*) and in Pz (r=0.425*). In terms of P300 amplitude, for P3b component, there are correlations with CD3 lymphocytes percentage in all derivations (Fz (r=-0.621**); Cz (r=-0.567**); Pz (r=- 0.499**)) and with CD19 lymphocytes percentage in all derivations (Fz (r=0.469*); Cz (r=0.466*); Pz (r=0.430*)). For P3a, it is correlated with CD3 percentage (in Fz (r=-0.539**); Cz (r=-0.406*)) and with CD19 percentage (Fz (r=0.364*); Pz (r=0.357*)). With respect to the relationship between mismatch negativity (MMN) amplitude and natural killer (NK) cells percentage, there are correlations in left temporal derivation T3 (r=-0.426*), in Cz (r=-0.401*) and in right temporal derivation T4 (r=-0.427*). A correlation is found between the contingent negative variation (CNV) amplitude and the lymphocytes percentage in Fz (r=-0.471**). Conclusions: There is a link between lymphocyte-related immunity and electrophysiological disturbances in psychiatric patients. Further studies would be needed to evaluate this relationship more specifically, particularly prospectively and by pathology. Key words: immunity - event-related potentials - lymphocytes

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INTRODUCTION it constitutes a preattentive auditory memory, an automatic alerting system (Langosh et al. 2008). It occurs Event-related potentiels and psychiatry between 100 and 250 ms (Faugere et al. 2013). Event-related potentials (ERP) are electroencephalo- It is a non-invasive way of exploring N-methyl-D- graphic tracings obtained following various types of sti- aspartate glutamatergic perturbations. It is modera- mulations (auditory, visual, etc.). They allow the proces- tely disturbed in bipolar disorder and more severely ses underlying cognition and attention to be explored. in schizophrenia (Hermens et al. 2018) and in Alz- The interpretation of these plots is based on two para- heimer's dementia. In schizophrenia, we find a de- digms: one electrophysiological and the other neuro- crease in amplitude and a latency delay (Faugere et cognitive. These ERP are useful in the exploration of al. 2013). psychiatric disorders. The P300 wave corresponds to a positive hyper- They reveal an interest in three preferential domains: polarization wave occurring in an auditory modality the field of description, understanding of cognitive around 300 ms. It is obtained in a stimulation para- disorders and especially attention disorders; digm similar to that used for the MMN, this time with active detection from the subject who must, for that of the therapeutic relationship; example, perform a motor reaction to each target that of the prescription of medicines (Timsit- sound. There are two components: the P3a which Berthier & Gerono 1997, Timsit-Berthier 2003). intervenes in the orientation reactions of the atten- In this review, different types of waves are studied, tion to a stimulus. This wave is of frontal origin and including: dependent on dopamine and the P3b which corres- The mismatch negativity (MMN), a negative depo- ponds to the update of the working memory with res- larization wave obtained during a preattentive auto- pect to this new stimulus. The latter is of temporo- matic discrimination task. To make it appear, rare parietal origin and is dependent on norepinephrine stimuli are randomly issued, among frequent and (Faugere et al. 2013, Somani & Shukla 2014). repetitive stimuli, without active detection of the The P300 wave is modified in almost all cerebral subject (Faugere et al. 2013, Sur & Sinha 2009). pathologies (Sur & Sinha 2009). In schizophrenia, This wave is correlated with an extraction function the amplitude is reduced and it corresponds to the of relevant information from irrelevant information distractibility phenomenons observed in clinical flow (Hermens et al. 2018). In its auditory modality, practice (Micoulaud Franchi et al. 2012).

S475 Camille Demont, Nicolas Zdanowicz, Christine Reynaert, Denis Jacques & Thomas Dubois: CORRELATIONS BETWEEN EVENT-RELATED POTENTIALS AND NK CELLS, B AND T LYMPHOCYTES Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 475-478

The contingent negative variation (CNV) is a depo- decrease in the enzyme tetrahydrobiopterin (BH4) larization wave obtained in the following paradigm: activity by cytokines. The latter is normally involved a warning stimulus is followed by an imperative in the dopamine synthesis. This mechanism would stimulus to which the patient must quickly respond be responsible for amotivational syndrome and anhe- with a motor response. It involves processes of lear- donia related to inflammation (Capuron et al. 2011). ning, by association, processes of sustained attention In schizophrenia, an excess of TH2 activity directs and motor preparation. It allows, in clinical practice, the degradation of tryptophan towards the formation the reactivity of serotonergic and catecholaminergic of kynuretic acid, antagonist of the glutamate re- receptors to be examined according to its amplitude ceptor, which eventually causes a hypoglutamatergy (Timsit-Berthier & Gerono 1997) and to guide the at the brain level (Najjar et al. 2013). treatment.

Inflammation and Psychiatry Neuroelectrophysiology and inflammation Associations between inflammation and psychiatric These links can be observed in the literature as those disorders are common. For example, the study by existing between interleukin 2 (IL-2) and P300. The in- Zdanowciz et al. (2017) showed the existence of a link jection of IL-2, an inflammatory mediator secreted in between severity of depression, adaptive immunity and particular by CD4, is one of the only substances causing external events (relationships, family dynamics, life a direct alteration of P300 with phencyclidine; interes- events) and how these external events are managed tingly, it has hallucinogenic properties like the latter (coping mechanisms and intrinsic determinants such as (Smith & Maes 1995). Another article (Davidson et al. gender) and influence this depression-immunity pairing. 1999) highlights the link between neuroelectrophysio- Many hypotheses have emerged about the mecha- logy and inflammation and shows that "individual diffe- nisms underlying this link between mental illness and rences in prefrontal activation asymmetry predict natu- immune system disruption. Thus, the article by Pity- ral killer cell activity at rest and in response to chal- choukis & Padadopoulou (2010) summarizes how in- lenge". In his study, Davidson uses an electroencephalo- flammation and stress can influence each other and also graphic measurement for this purpose and explains that reminds us of the importance of gender as a moderating people with a negative basic affective tone have notably factor. a greater depletion of natural killer (NK) cells activity On one hand, chronic stress influences the reactivity when they are under stress. of the immune system, both in the sense of immuno- To the best of our knowledge, there has been no activation - as an example, we observe a migration to study that has investigated the link between immunity the nervous central system of myeloid cells in the rat factors like CD3, CD19, NK cells and ERP. subjected to a repeated social distress (Ménard et al. 2017) - and also in the sense of an increase in the SUBJECTS AND METHODS secretion of interferon (IFN) by T cells, in depression. This latter process is underpinned by a modification of We explored the correlations between immunity the glucorticoid receptor present on these cells, corisol and: can no longer ensuring its anti-inflammatory function P300 latency; (Eyre et al. 2014, Dantzer et al. 2008, Ménard et al. P300 amplitude; 2017). This influence of stress also leads to immuno- MMN alteration; supression, as it has been demonstrated in depression, CNV amplitude. via a decrease in the cytotoxic activity of natural killer cells, among others (Pitychoukis & Padadopoulou 2010). After retrospectively including 31 patients who were On the other hand, inflammation causes stress. A hospitalized during the 2011-2012 year, we used socio- first argument for this effect is the finding that deregu- demographic data such as age, sex and ethnicity. All pa- lation of T lymphocytes may be an important precursor tients were hospitalized for adjustment disorder, major of depressive disorder (Eyre et al. 2014). A second argu- depressive disorder (unipolar or bipolar), pain disorder, ment is that excessive brain inflammation creates an im- psychotic disorder, generalized anxiety, panic disorder, balance among the two CD4 population subtypes (helper substance use disorder (including alcohol, sedative or or auxilliary T lymphocytes), namely TH1 and TH2: opioide medication and cannabis), and were evaluated In depression, the increase in TH1 activity induces according to the DSM 4 TR on axis 1. All patients the production of indoleamine 2,3-dioxygenase admitted to the department underwent an event-related (IDO), an enzyme that degrades serotonin and in- potential. creases the production of quinolinic acid from tryp- In routine practice, we performed ERP for all our tophan in the brain. Quinolinic acid causes an excess inpatients and blood analysis including white cells typo- of glutamate release, neurotoxic, which is noted for logy. Analysis by flow cytometry measured the various its role in depression (Najjar et al. 2013, Dantzer et lymphocyte populations identified by the antigenic al. 2008). Another mechanism in depression is a properties of the membrane markers. They included:

S476 Camille Demont, Nicolas Zdanowicz, Christine Reynaert, Denis Jacques & Thomas Dubois: CORRELATIONS BETWEEN EVENT-RELATED POTENTIALS AND NK CELLS, B AND T LYMPHOCYTES Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 475-478

CD3, present on all T cells. There are two subpo- r=-0.406*). The P3b amplitude is correlated with the pulations: helper/suppressor and cytotoxic T cells; absolute value of leukocytes in Pz (r=-0.389*) and with CD4, found on helper or auxiliary T cells. These the CD3 percentage in all derivations (Fz: r=-0.621**; lymphocytes activate the immune response through Cz: r=-0.567**; Pz: r=-0.499**). It is correlated with the the release of cytokines and in liaison with other CD16 & 56 percentage in frontal derivation (Fz: immune cells. There are two CD4 subtypes: TH1, r=0.383*) and with the CD19 percentage in all deriva- responsible for macrophage activation and TH2, tions (Fz: r=0.469*; Cz: r=0.466*; Pz: r=0.430*). which induces B cells to produce antibodies; Correlation with the MMN CD8 which are cytotoxic markers. These cells are capable of targeted cells destruction once they have Regarding the amplitude: it is correlated with the been activated; lymphocytes percentage, in right temporal derivation T4: r=-0.430* and with the CD 16 & 56 percentage, in The CD4/CD8 ratio evaluates the health of the im- left temporal derivation T3: r=-0.426*; in Cz: r=-0.0401*; mune system, for example in the progress of AIDS; in right temporal derivation T4: r=-0.427*. CD16 and 56 which are surface markers of NK cells. For latency, we find only one result with the NK cells are part of the innated immune system and absolute value of leukocytes (Cz: r=0.367*). they are capable of destroying their target in the absence of major histocompatibility complex (MHC). Correlation with the CNV amplitude: NK cells are non-T cells (CD3); The CNV amplitude is correlated with the lympho- CD19 which are B cell surface proteins. These cells cyte percentage (Fz: r=-0.471**). produce immunoglobulin. As the overall lym- So there seems to be a correlation between lympho- phocyte analysis of patients is normal, and for ease cyte immunity and ERP in our patients. of presentation, we only present relative results (Zdanowicz et al. 2017). Note: *P<0.05; **P<0.01; ***P<0.001. All statistical tests were performed using SPSS 23.0 parametric methods; types 1 and 2 errors were taken DISCUSSION into account. No post-hoc tests were performed. Corre- There are many biases in our study, whether from lations were performed using Pearson's correlation test. the point of view of the limited number of subjects or Selected significance levels were p>0.95 and p<0.05. the retrospective nature of our study. Nevertheless, we can note different points: RESULTS First, these results seem consistent with previous studies examining the impact of IL-2 on the P300 We present our initial findings, the others will be the amplitude since IL-2 is produced in particular by CD4 T subject of other publications. cells. In addition, as stated in the introduction, it is Sociodemographic parameters known that CD4 lymphocytes may intervene in certain mechanisms underlying mental pathology. Age Secondly, as event-related potential is a measure of The sample of patients is aged between 29 and 69 cognitive and attentional processes, it could be argued years, with a mean of 49 years (SD: 12). that there is a link between cognitive function and lym- Gender phocyte immunity in patients. Preattentive automatic discrimination functions (MMN) appear to be linked to the There were 19 Women and 12 men. NK cells rate. Orientation attention functions (P3a) and Ethnicity work memory update (P3b) seem to be related to the CD3 All patients were Caucasians. and CD19 rate, with a different type of correlation if it is the CD3 or CD19 population. Finally, this study asks the Correlation with the P300 latency following questions: is there a transnosographic link bet- The P300 latency is correlated with the absolute ween cognitive function and immune factors? Can this value of leukocytes: for P3a component: in frontal "cognitive function and immunity" pairing be found in derivation Fz (r=0.405*), in central derivation Cz the general population or is the link only present in per- (r=0.438*), in parietal derivation Pz (r=0.403*). For P3b sons with a disturbed mode of information processing? component: in Fz (r=0.414*) in Cz (r=0.402*) in Pz (r=0.425*). CONCLUSION

Correlation with the P300 amplitude This study shows only a correlation between lym- For the P3a component: it is correlated with the phocyte-related immunity and event-related potentials, CD16 & CD56 percentage in Fz (r=0.367*) and with the providing information on attentional and cognitive func- CD19 percentage (Fz: r=0.364*; Pz: r=0.357*). It is tions. Further studies are needed to clarify the nature of correlated with the CD3 percentage (Fz: r=-0.539**; Cz: this link.

S477 Camille Demont, Nicolas Zdanowicz, Christine Reynaert, Denis Jacques & Thomas Dubois: CORRELATIONS BETWEEN EVENT-RELATED POTENTIALS AND NK CELLS, B AND T LYMPHOCYTES Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 475-478

5. Faugere M, Cermolacce M, Balzani C, Micoulaud Acknowledgements: Franchi JA & Vion Dury J: Potentiels évoqués cognitifs en psychiatrie. Dans Annales Médico-psychologiques, Financial support: revue psychiatrique; 171:342-349. Elsevier Masson 2013 This research received no specific grant from any 6. Hermens DF, Chitty KM & Kaur M: Mismatch negativity funding agency, commercial or not-for-profit sectors in bipolar disorder: A neurophysiological biomarker of intermediate effect? Schizophr Res 2018; 191:132-139 None to declare. Conflict of interest: 7. Langosh J, Rand S, Ghosh B, Sharma S, Tench C, Stratton et al.: A clinical electrophysiological study of emotional Contribution of individual authors: lability in patients with systemic lupus erythematosus. J Camille Demont is the first author, he conduct the Neuropsychiatry Clin Neurosci 2008; 20:201-209 study and write the manuscript. 8. Ménard C, Pfau ML, Hodes GE & Russo SJ: Immune and Nicolas Zdanowicz made substantial contributions to neuroendocrine mechanisms of stress vulnerability and conception and design, and/or acquisition of data, resilience. Neuropsychopharmacology 2017; 42:62 and/or analysis and interpretation of data. 9. Micoulaud Franchi JA, Vion Dury J & Cermolacce M: Camille Demont, Christine Reynaert, Denis Jacques Endophénotypes neurophysiologiques et trouble schizo- & Thomas Dubois participated in the proofreading of phrénique: naissance et évolution d’un concept clinique. the article. Encéphale 2012; 38:103-109 10. Najjar S, Pearlman DM, Alper K, Najjar A & Devinsky O: Neuroinflammation and psychiatric illness. J Neuroinfl References 2013; 10:816 11. Pitychoukis PM & Padadopoulou-Daifoti Z: Of depression and immunity: does sex matter? Int J Neuro- 1. Capuron L, Schroecksnadel S, Féart C, Aubert A, Higue- ret D, Barberger-Gateau P et al.: Chronic low-grade psychopharmacology 2010; 13:675-689 inflammation in elderly persons is associated with 12. Smith RS & Maes M: The macrophage-T-lymphocyte altered tryptophan and tyrosine metabolism: role in theory of schizophrenia: additional evidence. Med Hypo- neuropsychiatric symptoms. Biol Psychiatr 2011; theses 1995; 45:135-141 70:175-182 13. Somani S & Shukla J: The P300 wave of Event-Related 2. Dantzer R, O’Connor JC, Freund GG, Johnson RW & Potential. RRJMHS Dec 2014; 3:33-42 Kelley KW: From inflammation to sickness and depres- 14. Sur S & Sinha VK: Event-related potential: An overview. sion: when the immune system subjugates the brain. Nat Ind Psychiatry J 2009; 18:70 Rev Neurosci 2008; 9:46 15. Timsit-Berthier M & Gerono A: Manuel d’interprétation 3. Davidson RJ, Coe CC, Dolski I & Donzella B: Individual des potentiels évoqués endogènes (P300 et CNV). differences in prefrontal activation asymmetry predict na- Mardaga Editions Bruxelles tural killer cell activity at rest and in response to chal- 16. Timsit-Berthier M: Intérêt de l’exploration neurophysiologi- lenge. Brain Beha Immu 1999; 13:93-108 que en psychiatrie clinique. Neurophysiol Clin 2003; 33:67-77 4. Eyre HA, Stuart MJ & Baune BT: A phase-specific neuro- 17. Zdanowciz N, Reynaert C, Jacques D & Dubois T: De- immune model of clinical depression. Prog Neuro- pression and immunity: a psychosomatic unit. Psychiatr psychopharmacol Biol Psychiatry 2014; 54:265-274 Danub 2017; 29:274-278

Correspondence: Camille Demont, MD, MSc Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital 5530 Yvoir, Belgium E-mail: [email protected]

S478 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 479-484 Conference paper © Medicinska naklada - Zagreb, Croatia

MENTAL ILLNESS AND PREJUDICES IN PSYCHIATRIC PROFESSIONALS Data from the social stigma questionnaire for psychiatric professionals: a multicentre study Maurilio Giuseppe Maria Tavormina1, Romina Tavormina2, Francesco Franza3, Antonella Vacca4 & Wilma Di Napoli5 1Mental Health Deptartment, Naples, Italy 2Centre of Psychology and Psychotherapy, Naples, Italy 3 Neuropsychiatric Center “Villa dei Pini”, Avellino, Italy 4Psychologist consultant for Psychiatic Rehabiltative Communities, Brindisi, Italy 5Mental Health Deptartment, Trento, Italy

SUMMARY The prejudices about mental illness and the related social stigma are still present in the population. People suffer from both the disease and the marginalization behaviors implemented by the "so-called healthy" towards them and their relatives. Even psychiatric professionals can get sick and suffer for the same reason. The authors of this multicentric study have focused their attention on the presence or absence of groups of psychiatric pathologies among the "insiders". The most frequent pathologies encountered were the mood and anxiety disorders, in a percentage similar to that of the general population. To continue the research on the stigma begun in a previous study, the authors asked themselves if there could be prejudices and/or stigma among psychiatric professionals towards sick colleagues, how they relate in the workplace and how they react to the behavior of colleagues. The stigma questionnaire has been used on psychiatric professionals, and 130 Italian colleagues were tested in the provinces of Avellino, Brindisi and Trento. The data were compared with those of the research on the stigma "Thinking of Psychiatric Disorders as" Normal "Illness" (Tavormina et al. 2016) and it emerged that among the attending professionals there are no statistically significant behaviors of marginalization, exclusion or stigma against sick colleagues, even if there is a certain discomfort in working together. Above all, it emerged that 80% of the interviewees, who have had work experience with sick colleagues, have replied that the latter can treat those who are also sick of their own disease, thus showing esteem and confidence in their work, in analogy with the Jungian thesis of the "wounded Healer" in the myth of the centaur Chiron.

Key words: mental illness, prejudices, social stigma, questionnaire, psychiatric professionals

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INTRODUCTION THEORETICAL BACKGROUND

In many people, mental disorders are viewed with Can a psychiatric professional who has suffered suspicion and have a different consideration in relation from psychiatric diseases treat his/her patients well and to other diseases. The history of the old madhouse, the in particular those who have had the same illness? social danger of the mental sick and the therapeutic The psychoanalyst psychiatrist C. Jung, in the greek difficulty of the psychiatric patient's care are still myth of the centaur Chiron (Smith 1997) the "Wounded present. Bad information and misinformation contribute Healer", suggests that those who have experienced the to highlighting prejudices and social stigma for mental pain of a disease is more sensitive to understanding and illnesses. The "stigma" is a sign that distinguishes a treating sufferers. Barr Ellison, an English psycho- person in a negative way: it becomes an additional analyst, in 2006 showed that 73.9% of 253 respondent difficulty for him/her that deeply affects the social life psychotherapists and counselors who work in mental of patients and their families (Casacchia 2005). It has health, have had personally psychological problems manifested itself in Western countries, for example in (65%) affecting themselves or their families (10%), and Germany (Angermey 1997) or in the UK (Crisp 2000), that has had directed their career choice in psychiatry and in the Eastern countries, for example in Hong Kong (Barr 2006). (Chou 1996) and Singapore (Lai 2001). The authors of this work agree with the thesis of the The purpose of our research is to evaluate if there "Wounded Healer", wished to continue the research on are mental illnesses and prejudices even in mental the social stigma to see if psychiatric disorders were health professionals towards the sick colleague and any present in the mental health professionals, if they could relationship difficulties in the work in common. How have caused therapeutic difficulties in patient care and if much the mental illness of the psychiatric professional they were present prejudices or stigmatizing behaviors, can negatively influence the patient's care and in what continuing the ethical project against the social stigma professional consideration the sick operator is kept by of the Torre del Greco Mental Health Unit of the ASL his/her colleagues. Naples 3 South Mental Health Department.

S479 Maurilio Giuseppe Maria Tavormina, Romina Tavormina, Francesco Franza, Antonella Vacca & Wilma Di Napoli: MENTAL ILLNESS AND PREJUDICES IN PSYCHIATRIC PROFESSIONALS. Data from the social stigma questionnaire for psychiatric professionals: a multicentre study Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 479-484

Is mental illness an emotional and professional bur- OBJECTIVE AND METHODS den on the psychiatric professional who has experienced his/her suffering? How much are psychiatric illnesses The mental illness and the stigma, with the pre- present in them? Do they compromise the relationship judices related to it, are a real difficulty for the patients, with the patient? Does the mental health professional find they suffer for a twofold reason, the first caused directly it difficult to take care of or remove patients by entrusting by their pathology and the second connected to the them to another colleague? Does he retain the trust and social stigma and to the preconceptions present in the esteem of his/her colleagues in his/her professional opera- population. Looking for psychiatric pathologies and the tions? Does he admit he/she has suffered from psychiatric possible presence of prejudices on it even among illness or are he/she ashamed? Does the mental illness of psychiatric professionals has been the specific purpose the psychiatric professional compromise his/her relation- of this research. ship with colleagues? These are the most important questions that have guided the authors of this research.

Table 1. The research data. Questionaire for the psychiatric professional – part A N° 130 respondents professionals - Data Summary (Avellino, Trento, Brindisi) Age: Qualification: a) till to 30 years 32 a) Psychiatrist 19 b) from 31 to 40 years 34 b) Psycologist 32 c) from 41 to 50 years 31 c) Nurse 39 d) from 51 to 60 years 26 d) Social Worker 8 e) over 60 years 7 e) Technician in rehabilitation service 32 Sex: Country: M 42 Italy 130 professionals F 88 Province: Place of work: a) Avellino 40 a) public 78 b) Trento 43 b) private 52 c) Brindisi 47 Questions Please, give only one answer, choosing the closest 7. Were you or are you being treated for your problem? 1. Did you choose to work in Psychiatry? YES 11 YES 105 NO 3 NO 25 8. What sort of therapy? 2. Why did you choose to work in this sector? (Please, allowed also more then one answer a) Because of Personal Interest 97 a) Medication 5 b) Because of Scientific Interest 11 b) Psychotherapy 6 c) Because it was easy to get an opportunity ab =1 NA =2 to work in this sector 14 9. Has your problem caused / Does your ac=1 NA=7 problem now cause difficulties in the exercise 3. Why are you still working in Psychiatry? of your profession? a) By Choice 105 YES 4 b) Out of necessity 21 NO 10 NA=4 10. Do you feel that a patient with a problem 4. Have you experienced Psychological or psychiatric problems? similar to yours could reactivate YES 14 your problems? NO 115 YES 3 NA=1 NO 11 Ɣ if NO, go to the answer number 13! 11. Would you have difficulty treating a patient with 5. If Yes, what sort of problem? a problem similar to yours? a) Mood or Affective Disorders 6 a) NO 12 b) Anxiety Disorders 6 b) A little 1 c) Psychotic Disorders 0 c) Quite a lot 1 d) Personality Disorders 0 d) A great deal 0 e) Substance abuse 0 12. What would you do if you have to treat comorbidity: ab = 1, abd = 1 a patient with a problem similar to yours? 6. In which period of your life did the problems begin? a) I must look after him 12 a) Infancy 0 b) I will delegate the care of the patient 1 b) Adolescence 3 c) I will minimise the illness 1 c) Adult Life 11

S480 Maurilio Giuseppe Maria Tavormina, Romina Tavormina, Francesco Franza, Antonella Vacca & Wilma Di Napoli: MENTAL ILLNESS AND PREJUDICES IN PSYCHIATRIC PROFESSIONALS. Data from the social stigma questionnaire for psychiatric professionals: a multicentre study Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 479-484

Table 2. The research data. Questionaire for the psychiatric professional – part B N° 130 respondents professionals - Data Summary (Avellino, Trento, Brindisi) Questions Please, indicate a single answer; 19. Do you have psichiatric problems? the one which is most reprasentative or frequent YES 7 NO 116 13. Have you ever worked with a colleague who is NA 7 affected by a mental illness? ( Ɣ only continue if the answer is affermative! YES 60 NO 70 20. How do your colleagues behave towards you? Ɣ if NO, go to the answer number 19! a) well 7 b) badly 0 14. If Yes, what was the diagnosis? 21. Are you afraid to tell your colleagues about a) Mood Disorders 17 your illness? b) Anxiety Disorders 2 YES 1 c) Psychotic Disorders 11 d) Personality Disorders 7 NO 6 e) Substance abuse 0 22. Do your colleagues comment on your absences comorbidity: from work? ab = 7, ac = 3, ad=1, bc=1, bd=3, de=2, abc=2, abcde=2 YES 1 Total = 21 NO 6 15. How do you relate to him? 23. Do your colleagues band together against you? a) I avoid him/her 8 YES 1 b) I am forced to work together 9 NO 6 c) I tell him/her to get treatment 16 d) I look after him/her 24 24. Do you believe that you should be protected from 16. How do you feel about how you relate to your their behaviour? mentally ill colleague? YES 1 a) Good 46 NO 6 b) Necessary 7 25. Have you ever wished to change your workplace? c) Defensive 7 YES 3 17. How does your mentally ill colleague relate to you? NO 4 a) He/she is aggressive 9 b) He/she is diffident 8 26. Has it ever been ‘’suggested’’ to you that you c) He/she is absent frequently from work 15 should change your workplace? d) He/she shows gratitude 25 YES 4 NO 3 18. Do you believe that someone who cannot look after himself can look after others? 27. Do you want to continue working in psychiatry? YES 48 YES 5 NO 13 NO 2 NA 18

The questionnaire on social stigma has been used for professional qualification. Then follow 27 specific ques- psychiatric professionals (psychiatrists, psychologists, tions divided into two sections (part A and B): in the nurses, social workers, technicians for the rehabilitation first part (A), they are focused on the mental health service), elaborated and validated by the authors of ethi- professional, on his motivation to work in psychiatry, if cal, multicentric, statistical and observational research he has had psychiatric problems, what kind, if he/she is on social stigma (Tavormina et al. 2015). It is a self- under treatment and with what kind of therapy; in the administered questionnaire for adults, fully informed second part (B) the questions are focused on the rela- about the purpose of the study and free to not answer to tionship between the professionals and the sick collea- the questions also. It was formulated in Italian and gues. They are asked if they have had the opportunity to translated into English, French and Croatian. The ques- work with sick colleagues, what kind of diagnosis with tionnaire for psychiatric professionals, together with the same groups of disease, their behavior towards the that one for patients, was evaluated on a sample, before sufferer, if they welcome him/her, treat him/her or the administration, to confirm its simplicity and functio- contrariwise they are forced to work together and try to nality and was approved by the ethics committee of the avoid him/her or worse, they marginalize him/her. They Mental Health Department of the ASL Naples 3 South. are asked how their sick colleague reacts and if him/her It is anonymous and protects the rights of privacy, it self is the same person interviewed to have psychic is standardized and with closed demand. Composed of a problems. A significant question for prejudices about general part in which the age is requested, indicated not mental illness is if he/she can cure those who are ill. in a specific way, but for age groups, to avoid identi- This is to see if the confidence of the sick colleague's fying the interviewee. The place where he/she works, if therapeutic value in taking care of his/her patients is he/she works in public or private service, sex and reduced or impaired.

S481 Maurilio Giuseppe Maria Tavormina, Romina Tavormina, Francesco Franza, Antonella Vacca & Wilma Di Napoli: MENTAL ILLNESS AND PREJUDICES IN PSYCHIATRIC PROFESSIONALS. Data from the social stigma questionnaire for psychiatric professionals: a multicentre study Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 479-484

In the questionnaire the mental pathologies have self (16/60) and only 9 people out of 60 say that they are been divided into large groups of belonging, without a forced to work together or avoid him/her (8/60) and specific and precise research of the psychic disorder, for believes that just behavior towards the suffering collea- operational simplicity and because the questionnaire, so gue is right and necessary (46/60). The sick colleague structured, is addressed to all the professionals working shows gratitude (25/60). in psychiatry and not only to the doctors (Table 1, 2). To the question n°18 in which it is asked if "can someone who cannot look after himself can look after DATA EVALUATION others can cure those who are sick?", the prevailing opinion among the interviewed professionals has been In outlining the prevalent figure of a Mental Health affirmative, 48 people out of 60 (80%). At the congress Professional that emerged from the greater number of of Avellino, despite the 19 positive answers out of 3, 18 answers given to the questionnaire, we can say that a people did not answer and it has been the highest female professional prevails (67.9%), with an average number of non-responses. The question has been ap- age between 31/40 years (26.1%), with the qualification plied to the professionals (60 out of 130) who had work of a nurse (30%) and working in a public service (60%). experience with colleagues suffering from mental patho- She choses to work in psychiatry (80.7%) for personal logy. This data is in tune and is better than that emerged interest (74.6%), continues to work by choice (80.7%) in the patients interviewed in the multicenter interna- and has had no psychological or psychiatric problems tional study on the stigma: "Thinking of Psychiatric (88.4%). Only 14 professionals out of 130, equal to Disorders as Normal Illness" (Tavormina et al. 2016), 10.7%, which only 1 in Brindisi, claimed to have had which expressed confidence in the sick professional, psychological or psychiatric problems and 1 person did because he/she had suffered from their own pathological not answer to the question. 33% of the professionals experiences: "they can understand me better because they interviewed work in Trento in the public service. too are ill" (237 answers out of 476, equal to 49.78%). The diseases reported by mental health professio- Instead it is in contrast with that recorded among pro- nals, which have admitted to have had psychic professionals, in the same multicentric study of 2016, in blems, has been 6 cases of Mood disorders (42.8%), which the prevailing opinion was negative, 90 people which 3 at the EDA Italia congress in Avellino, 6 out of 155 (58.6%) answered No and only 65 Yes. anxiety disorder (42.8%), which 4 in Trento, 1 case of The data recorded in this research shows an increase comorbid mood and anxiety disorders (7.1%) and 1 in confidence among the interviewed professionals, person with mood disorders, anxiety and psychotic compared to the similar one in 2016, on the therapeutic disorder (7.1%). The diseases occurred in adulthood value of the colleague who has had psychiatric problems (78.5%) and were treated in 6 cases only with psycho- and it is an overcoming of the wall of prejudices against therapy, 5 with drugs, 1 with drugs and psychotherapy those who are ill, not thinking more than the sick and 2 people did not answer to the question. professional can not cure his/her patients well, in a good Only 4 people out of 14 (28.5%) have had difficulty and significant percentage of 80% of the interviewees. in professional practice due to their psychiatric con- Another relevant indication is that out of 130 psychia- ditions. Only 3 psychiatric professionals (21.4%) think tric professionals who answered question n° 4 of the that a patient with a mental illness similar to her can questionnaire: "Have you experienced psychological or cause her to suffer, 12 people out of 14 (85.7%) have no psychiatric problems?", only 14 people (10.7%) ans- difficulty to treat him/her, 1 mental health professional wered Yes and 115 (88,4%) No. It should be noted that has bit difficulty, 1 minimizes the disease and 1 (7.1%) to the question n°19, " Have You psychic problems?", has enough and delegates patient care. which is a direct and control question of n°4, only 7 To 60 professionals out of 130 (46.1%), which only people answered YES, equal to 5.38%, 5 people in 11 in Brindisi, it happened to work with colleagues suf- Avellino, 1 in Trento and 1 in Brindisi, and 7 people did fering from mental pathology. The most frequent psychic not answer, for a total of 14 people. The diversity of disorders highlighted were mood disorders 17 out of 60 results in 7 professionals who did not respond to the (28.3%), followed by psychotic disorders 11 out of 60 question, highlights more how difficult it is for the (18.3%), which 4 in Trento, personality disorders 7 out interviewee to express psychic problems at the moment of 60 (11.6%), anxiety disorders 2 out of 60 (3.3%), 1 in because of the inconvenience related to them. Diffe- Brindisi and 1 in Trento. Among the 22 comorbidities rently 7 professionals who answered YES, there is no (36.6%) reported the most frequent has been that of difficulty in revealing their illness to their colleagues. mood disorders and anxiety disorders 7 out of 22 Therefore, in consideration of the foregoing, the pos- (31.8%), followed by psychotic and mood disorders sible inconvenience to admit their own psychic diffi- (13.6%), 3 cases out of 22, anxiety and substance abuse culties would be present in 50% of the suffering (9%) and at last anxiety with personality disorder, and professionals (7 out of 14). psychotic with mood disorders (1/22). The prevalent suffering professional believes that The prevalent professional takes care of the sick other colleagues behave well with her, 7 affirmative an- colleague (24/60), advises him/her to take care of him/her swers out of 7, is not afraid to reveal to them her illness

S482 Maurilio Giuseppe Maria Tavormina, Romina Tavormina, Francesco Franza, Antonella Vacca & Wilma Di Napoli: MENTAL ILLNESS AND PREJUDICES IN PSYCHIATRIC PROFESSIONALS. Data from the social stigma questionnaire for psychiatric professionals: a multicentre study Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 479-484

(85.7%), do not point out her absence from work (85, been overcome, recognizing the professionalism and 7%) and do not feel marginalized (85.7%). The 85.7% therapeutic value of the ill psychiatric professional, in believe that it should not be protected by the behavior of perfect harmony with the concept of therapeutic colleagues, did not want to change the work environ- efficacy of the "wounded healer". There is only a ment (57.1%), even if they suggested to do so (57.1%) discomfort in working cooperation between colleagues and 71.4% want to continue working in psychiatry. and a relative difficulty in revealing their mental illness to others. CONCLUSIONS

Analysis of the data shows that psychiatric diseases Acknowledgements: None. are not so present among professionals. Only 10.7% answered affirmatively that they had psychological or Conflict of interest: None to declare. psychiatric problems, or least few professionals admitted to having them, also considering the fact that 46.6% Contribution of individual authors: of the professionals interviewed said they work with Maurilio Giuseppe Maria Tavormina projected and colleagues sick with psychiatric diseases. Probably designed the study, discussed results and super- some of the interviewees did not feel to declare his/her vised manuscript; illness. Romina Tavormina wrote the first draft of the manu- The most frequent pathologies were those of mood script; and anxiety disorders, with a prevalence of 48.2%, on Francesco Franza conducted and collected the 14 professionals who admitted their diseases, while their questionnaires for Avellino’s data; incidence fell to 28.3% for mood disorders and in the Wilma Di Napoli conducted and collected the ques- last place anxiety disorders (3.3%), in the evaluations tionnaires for Trento’s data; made by professionals who have worked with sick Antonella Vacca conducted and collected the questionnaires for Brindisi’s data. colleagues. In second place are psychotic disorders and personality disorders. The most frequent comorbidity has been that of mood and anxiety disorders. References Therefore, we can point out that the most frequent pathologies are mood and anxiety disorders, both 1. Angermeyer MC, Matschinger H: Social distance individually and in comorbidity, in the provinces of towards the mental ill: results of representative surveys Avellino, Brindisi and Trento. This data is in tune with in the Federal Republic of Germany. Psychol 1997; the most frequent psychiatric disorders in the general 27:131-41 population, as it can be seen from “Anxiety disorders 2. Baranzini F: Discriminazione e accoglienza della persona con disturbo psichico nella popolazione. Noos 2005; 3- are the most common disorders in all but 1 country 4:245-268 (higher prevalence of mood disorders in Ukraine), with 3. Barr A: Wounded Healer Counsellor Psychotherapist prevalence in the range 2.4% to 18.2% (IQR, 5.8%- Research. COSCA Research Dialogue, from The Green 8.8%). Mood disorders are next most common in all but Rooms, 2006 2 countries (equal or higher prevalence of substance 4. Casacchia M: Lo stigma di chi soffre di un disturbo disorders in Nigeria and Beijing), with prevalence in the mentale e dei familiari. Noos 2005; 3-4:197-218 range 0.8% to 9.6% (IQR, 3.6%-6.8%)” (Demyttenaere 5. Chou KL, Mak KY, Chung PK et al.: Attitudes towards et al. 2004). mental patients in Hog Kong. Int J Soc Psychiatry 1996; The evaluation of the data shows that the prejudices 42:213-9 on the mental health of psychiatric professionals have 6. Corringan PW, Penn D: Lesson from social psychology on discrediting psychiatric stigma. Am Psychol 1999; been debunked and that their mental health is weak due 54:765-76 to burn-out, or simply because by treating the mentally 7. Crisp AH, Gelder MG, Rix S, et al.: Stigmatisation of ill one can get sick of the same illness, almost like if it people with mental illnesses. Br J Psychiatry 2000; 177:4-7 were contagious. The frequency of the emerged patho- 8. Demyttenaere K, Bruffaerts R, Posada-Villa J et al: logies are in line with those of the general population. Prevalence, Severity, and Unmet Need for Treatment of From a statistical point of view there are no signi- Mental Disorders in the World Health Organization ficant behaviors of marginalization, exclusion or mani- World Mental Health Surveys. JAMA 2004; 291:2581–90 fest stigma towards the sick colleague, even if 4 out of 7 9. Hankir A et al: The Wounded Healer: an effective anti- (57.1%) were recommended to change their jobs, take stigma intervention targeded at the medical profession. Psychiatr Danub 2014; 26(suppl 1):89-95 care of him/her self and 15% of Mental Health Pro- 10. Lai YM, Hong CP, Chee CY: Stigma of mental illness. fessionals express difficulties to be forced to work with Singapore Med J 2001; 42:111-4 him/her. 11. Robert C, Smith: The Wounded Jung: Effects of Jung's In the end, above all, the preconception that "can not Relationships on His Life and Work. Psychosocial Issues, cure the patient who is ill with his/her own illness" has Paperback 1997; 177

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12. Sato M: Renaming schizophrenia: a Japanese perspective. 15. Tavormina MGM et al: Malattia mentale e pregiudizi: World Psychiatry 2006; 5:53-55 studio multicentricico sullo stigma sociale”. Acts of 2th 13. Tavormina MGM, et al: A questionnaire to assess social National Congress EDA Italia onlus. Telos Magazine, stigma. Psychiatr Danub 2015; 27(suppl 1): S328-31 2017 suppl Oct. pp 61 14. Tavormina MGM et al: Thinking of Psychiatric Disorders 16. Vender S: Stigma interiorizzato e vergogna. Noos 2005; as “Normal” Illness. Psychiatr Danub 2016; 28(suppl 1): 3-4:233-243 125-131

Correspondence: Maurilio Giuseppe Maria Tavormina, MD, PhD DSM ASL NA 3 SUD, “Centro Diurno” of Mental Health 57 via Marconi 66, 80059 Torre del Greco (NA), Italy E-mail: [email protected]

S484 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 485-487 Conference paper © Medicinska naklada - Zagreb, Croatia

TAILORING TREATMENT FOR MAJOR DEPRESSIVE EPISODE: LESSONS LEARNED FROM THE INPATIENT UNIT Alba Cervone, Giulia Esposito & Giuseppe Cimmino Psychiatric Inpatient Unit, Department of Mental Health, Naples, Italy

SUMMARY Major depressive disorder (MDD) represents one of the main diagnosis of admission to the inpatient psychiatric unit, because of the frequent comorbid suicidal behavior. It is a clinically heterogeneous diagnostic category comprising a various array of symptoms presentation. This clinical heterogeneity can represent a challenge for treatment, and patients are often discharged with substantial residual symptomatology that still impacts functioning1. Characterizing subtypes of major depressive disorder ad admission could possibly help tailoring treatment and improving outcomes. The aim of the study was to detected clinical signs at admission for tailoring treatment (that includes pharmacotherapy, cognitive behavioral therapy, individual psychoeducation) in order to prevent suicide, improve quality of life and reduce re-hospitalization. Tailored treatment was routinely implemented in a sample of patient with a major depressive episode consecutively admitted to an inpatient psychiatric unit from 1st april 2018 to 31st august 2018. Results showed that, at 5 months follow up, it was associated to symptoms reduction, improved quality of life and reduction of hospitalization. The limited sample size, the absence of a control group and the naturalistic structure of the study, limit the generalizability of those results. However, those preliminary findings could provide a blueprint for a larger study and a longer follow up.

Key words: major depressive episode - Inpatient unit – suicide - treatment

* * * * *

INTRODUCTION bipolar depression, then it is possible to identify the specifiers (Wagner 2017). The characterization of subtypes Major depressive disorder (MDD) represents one of of depression is important in order to further delineate the main diagnosis of admission to the inpatient psychia- biological causes of depressive syndromes (Musil et al. tric unit, because of the frequent comorbid suicidal be- 2018). For instance, early Improvement of depressive havior. Moreover, MDD is a costly disease characte- symptoms within two weeks of antidepressant treatment rized by loss of productivity, and frequent use of mental is a highly sensitive but less specific predictor of later health care resources. treatment outcome. DSM-5 specifiers include: MDD with MDD is a clinically heterogeneous diagnostic cate- anxious distress, with mixed features, with melancholic gory comprising a various array of symptoms presenta- features, with atypical features, with mood-congruent tion. This clinical heterogeneity can represent a chal- psychotic features, with mood-incongruent psychotic lenge for treatment. Biological markers that could guide features, with catatonia, with peripartum onset, with sea- a clinical decision in this field are still far from being sonal pattern; comorbidity with substance abuse and/or standardized and implemented in the routinary work. personality disorder; cognitive symptoms; response to The high difference of the clinical presentation of antidepressant treatments. MDD, and the fact that psychiatrists have to rely purely Important long-terms goals of current recovery- on the clinical presentation for making decision about oriented treatment plans for depression in Italy and treatment, and the restrained duration of admission, a elsewhere include the enhancement of adherence to significant proportion of patients are often discharged medication and psychotherapy (rilevazione dati italiani from the inpatient unit with a substantial residual in www.edaitaliaonlus.org). The combination of antide- symptomatology that still impacts functioning (Musil et pressant/mood stabilizers medication with other thera- al. 2018). For example, cognitive impairments represent peutic interventions is an important for the achievement frequent residual symptoms that worsened prognosis of these long-terms goals. and influenced negatively the quality of life. Characteri- The aim of this study was to identify clinical fea- zing subtypes of major depressive disorder at admission tures at treatment initiation which are associated with could help tailoring treatment and improving outcomes. early improvement at the discharge(mean time of Relapse, for patient with residual symptoms of MDD, admission:25(+/5 days)) and non-improvement, as well includes the risk of harming themselves or others, as to identify variables predicting non-remission in impoverishment in personal relationships, discontinua- patients showing an early improvement (Wagner 2017). tion of work, all leading to loss self-esteem and overall The secondary aim of the study is to evaluate the use of reduced quality of life (Large 2018). a tailored treatment (TT) of inpatients with Major First, in order to prescribe a correct pharmacological Depressive Episode (MDE) and then to discuss the treatment it is important to distinguish unipolar from potential role of TT in improving MDE outcomes.

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MATERIALS AND METHODS features, with catatonia, with peripartum onset, with seasonal pattern, the comorbidity with substance abuse A chart review was performed for patients conse- and/or personality disorder) (DSM-5 2016). In our opi- cutively admitted to the inpatient psychiatric unit with a nion, it is important to investigate personality traits diagnosis of major depressive episode, unipolar and (novelty seeking, impulsivity, harm avoidance) in order bipolar, from April 1st 2018 to august 31st 2018. Demo- to improve this therapeutic model and to prevent the graphic and clinical variables were collected at admis- suicide. Wagner et al. (2017), demonstrate that patients sion and at discharge from the hospital. Assessment with more severe depression and suicidality were more included evaluation of severity of depressive symptoms likely to become non-improver, and also non-remitter (By means of the Montgomery-Asberg Depression after 8 weeks of treatment in case of early improve- Scale (MADRS), the Hamilton Depression Rating Scale ment. Moreover, early improver with melancholic, (HAM-D), anxiety by means of The Hamilton Anxiety anxious or atypical depression as well as with comorbid Rating Scale (HAM-A), measures of quality of life by social phobia or avoidant personality disorder had an the administration of Qol, and evaluation of global increased risk for non-remission at study end. The assessment of functioning (GAF). combined marker of early non-improvement and the Improvement of the overall clinical symptomatology occurrence of melancholic features increased the spe- was measured by a reduction/increase of 20%, at dis- cificity of treatment prediction from 30% to 90% charge of the baseline scores of MADRS and HAM, and (Wagner 2017). Our data confirm that DSM-5 speci- increase of QoL and GAF total score at discharge. fiers, personality traits and suicide risk factors are Remission was defined has having reached a score of 8 useful for clinical treatment or less at MADRS. At admission, based on clinical features, the assig- CONCLUSIONS ned psychiatrist was able to formulate a treatment that could include a different combination of the following: Tailored treatment was routinary used in a small clinical interviews with psychiatrist and psychologist, sample of patient with MDE attending a psychiatric hos- psychoeducational activities lead by trained specialist, pital and it was associated to symptoms reduction, ove- cognitive behavioral psychotherapy (integrating strate- rall better quality of life and reduction of hospita- gies that target emotion regulation skills improves the lization. Considering that early detection and interven- efficacy of CBT for MDE). tion should be accessible to all people with a first major Patients were followed up by the clinical team of the depressive episode, irrespective of the person's age or outpatient services for 5 months after discharge for the duration of untreated disease, using a tailored treat- monitoring of re-hospitalizations. ment (antidepressant and/or mood stabilizer, social intervention, psychoeducation for patients and care- RESULTS givers, psychotherapy) could potentially improve the prognosis of MDE and maximizing clinical remission. During the assessment period, eight patients presen- For this reason, tailored treatments could play an ted to the Inpatient Psychiatric Unit with a diagnosis of important role to improve recovery with a radical shift MDE. Those patients were all men; mean age was 33.5 in treatment paradigms: from suicide prevention to care. years (±11.5). All patients received a tailored treatment Further investigations examining the long-term effi- (TT) during hospitalization. cacy, clinical features, risk factors are also needed. They showed an overall improvement in terms of The limited sample size, the absence of a control reduced depressive and anxiety symptoms and improved group and the naturalistic structure of the study, limit global functioning and quality of life. the generalizability of those results. However, those During the observation period, none of them needed preliminary findings could provide a blueprint for a to be re-admitted to the inpatient unit. larger study and a longer follow up.

DISCUSSION Acknowledgements: None. Our results show that tailored treatment could represent a mean to achieve symptoms remission ad reducing Conflict of interest: None to declare. the risk of hospitalization in people affected by MDE. In order of prescribing a tailored therapy, the clinical Contribution of individual authors: interview is important to distinguish unipolar depression Alba Cervone conceived and designed the study, for bipolar depression and to identify the specifiers (with wrote the Manuscript; anxious distress, with mixed features, with melancholic Alba Cervone, Giulia Esposito & Giuseppe Cimmino features, with atypical features, with mood-congruent visited patients and carried out clinical work. psychotic features, with mood-incongruent psychotic

S486 Alba Cervone, Giulia Esposito & Giuseppe Cimmino: TAILORING TREATMENT FOR MAJOR DEPRESSIVE EPISODE: LESSONS LEARNED FROM THE INPATIENT UNIT Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 485-487

References 5. Musil R, Seemüller F, Meyer S, Spellmann I, Adli M, Bauer M, Kronmüller K, Brieger P, Laux G, Bender W, 1. Albert U, De Cori D, Maina G: The clinical hetereogenity Heuser I, Fisher R, Gaebel W, Schennach R, Möller HJ, of major depressive disorder: implication and treatment. Riedel M: Subtypes of depression and their overlap in a Nòos 2016; 2:69-84 naturalistic inpatient sample of major depressive dis- 2. Berking M, Ebert D, Cuijpers P, Hofmann SG: Emotion order. Int J Methods Psychiatr Res 2018; 27 regulation skills training enhances the efficacy of in- 6. National Institute for Health & Clinical Excellence patient cognitive behavioral therapy for major depres- NICE, 2010 sive disorder: a randomized controlled trial. Psychother 7. rilevazione dati italiani in www.edaitaliaonlus.org Psychosom 2013; 82:234-45 8. Wagner S, Tadiü A, Roll SC, Engel A, Dreimüller N, 3. DSM-5, Diagnostical and Statistical Manual of Mental Engelmann J, Lieb K: A combined marker of early non- Disorder, APA, 2016 improvement and the occurrence of melancholic fea- 4. Large M, Myles N, Myles H, Corderoy A, Weiser M, David- tures improve the treatment prediction in patients with son M, Ryan CJ: Suicide risk assessment among psychia- Major Depressive Disorders. J Affect Disord 2017; tric inpatients: a systematic review and meta-analysis of 221:184-191 high-risk categories. Psychol Med 2018; 48:1119-1127

Correspondence: Alba Cervone, MD Psychiatric Inpatient Unit, Department of Mental Health Via Tino di Camaino, 2/a, Napoli, Italy E-mail: [email protected]

S487 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 488-494 Conference paper © Medicinska naklada - Zagreb, Croatia

INVOLUNTARY HOSPITALIZATION AND VIOLENT BEHAVIORS: MEDICAL ACT OR SOCIAL CONTROL? A 3-year retrospective analysis Giulia Menculini1, Norma Verdolini1,2,3,4, Roberta Lanzi1, Giorgio Pomili1, Patrizia Moretti1 & Alfonso Tortorella1 1Division of Psychiatry, Department of Medicine, University of Perugia, Perugia, Italy 2Bipolar Disorder Unit, Institute of Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain 3FIDMAG Germanes Hospitalàries Research Foundation, Barcelona, Catalonia, Spain 4CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Barcelona, Catalonia, Spain

SUMMARY Background: The present retrospective study is aimed at assessing the clinical and psychopathological correlates of violent behaviors in a sample of acute involuntary committed inpatients. Subjects and methods: Involuntary inpatients were retrospectively assessed for the presence of violent behaviors. Patients with and without overt hetero-aggressive behaviors were compared according to socio-demographic, clinical and psychopathological features. A stepwise backward logistic regression was performed in order to assess the variables most associated with the perpetration of violent acts. The sample of violent patients was then divided in two subgroups on the basis of the presence/absence of a serious mental illness (SMI). Bivariate analyses were performed between SMI and non-SMI violent patients. Results: In the present sample of 160 inpatients, 88 (55%) perpetrated violent acts. Subjects who performed violence presented a higher rate of mood stabilizers prescription (p=0.038). The PANSS-excited component was positively associated with violent behaviors (p=0.027, Odds Ratio (OR)=1.14, Confidence Interval (CI) 1.01-1.28), whilst the PANSS-depressed/anxiety factor displayed a negative association (p=0.015, OR=0.78, CI 0.64-0.95). Violent inpatients diagnosed with SMI presented higher rehospitalization rate (p=0.009), longer length of stay (p=0.005), more frequent long-acting injectable antipsychotics prescription (p<0.001) and a higher positive symptoms severity as measured by the PANSS-positive factor (p=0.049). Conclusions: The clinical population of acute psychiatric inpatients performing violent behavior represents a specific and heterogeneous subgroup of patients for which prevention and treatment strategies should be addressed.

Key words: violent behavior – aggression - psychiatric inpatients - involuntary commitment

* * * * * INTRODUCTION tions needed to manage these episodes, representing a major challenge (San et al. 2016). A better characteri- Violent behaviors, defined as overt destructive beha- zation of the population of violent patients and the viors perpetrated with the intention to cause harm (Láta- identification of predictive factors could help addressing lová 2009) can be often observed in acute patients atten- therapeutic choices, in order to prevent violent acts ding a psychiatric ward, with particularly high prevalence (Amore et al. 2008). Despite this, literature defining and among involuntarily committed patients (Dack et al. differentiating violent inpatients is still not univocal and 2013, Pinna et al. 2016, San et al. 2016). Violent acts can mainly considers forensic populations, without specific broadly include verbal aggression, aggression against ob- focus on involuntary hospitalized patients (Volavka 2014, jects, self-aggression and physical aggression against Ogloff et al. 2015). Furthermore, different definitions of others (Calegaro et al. 2014). The issue of violence per- violent and aggressive behavior, also including self-harm, formed by people with mental disorders has been widely are considered, with scarce comparability of the provided investigated, due to its relevance from a public health results and a not always reliable assessment of symptoms perspective and to the common perception of the dange- (Amore et al. 2008, Dack et al. 2013, Volavka et al. 2014, rousness of mental disorders (Iozzino et al. 2015, Ose et Ose et al. 2017). As a consequence, a specific characte- al. 2017). The clinical population of violent inpatients is rization of involuntary inpatients who perpetrate violent rather heterogeneous, frequently including patients affec- behaviors is lacking. The aims of the present retrospec- ted by a wide range of mental disorders, namely schizo- tive study are: (i) to estimate the prevalence of violent phrenia and other psychotic disorders, bipolar disorder, behaviors in a sample of involuntary hospitalized inpa- personality disorders and substance use disorders tients; (ii) to assess clinical and psychopathological (Volavka et al. 2014, San et al. 2016, Van Dorn et al. characteristics more related to violent behaviors towards 2012). Furthermore, episodes of acute agitation with vio- others and potential predictive factors of such behaviors; lent behaviors can require psychiatric involuntary admis- (iii) to investigate the difference between subgroups of sion also in absence of a major psychiatric disorder, violent patients according to the presence/absence of a affecting the course of hospitalization and the interven- severe mental illness.

S488 Giulia Menculini, Norma Verdolini, Roberta Lanzi, Giorgio Pomili, Patrizia Moretti & Alfonso Tortorella: INVOLUNTARY HOSPITALIZATION AND VIOLENT BEHAVIORS: MEDICAL ACT OR SOCIAL CONTROL? A 3-year retrospective analysis Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 488-494

SUBJECTS AND METHODS different comparative analyses were then performed. First, involuntarily hospitalized patients who presented Subjects violent behaviors were compared to the patients with The present retrospective study was conducted in the negative history of violent behaviors by means of biva- Psychiatric Inpatient Unit of University/General Hos- riate analyses (chi-square test for cathegorical variables, pital Santa Maria della Misericordia, Perugia, Umbria, t-test or Mann Whitney U for continuous variables; Italy, between January 1st 2015 and December 31st 2017. p<0.05). A stepwise backward logistic regression model The selected sample included inpatients aged 18, ad- was then used in order to clarify the association between mitted to the Unit using involuntary treatment proce- violent behavior and three significant variables (mood dures. In order to better address the aim of the study, stabilizers at discharge, PANSS excited component, only patients hospitalized as a result of psychomotor PANSS anxiety/depression component). Odds ratios agitation or behavioral disturbances, particularly due to (OR) with 95% confidence intervals (CI) were assessed substance/alcohol abuse, were recruited for the present for observed associations. All tolerance values in the analysis, in consideration of the most frequent co- regression analyses were >0.2 and all variance inflation occurrence of the above-mentioned conditions and vio- factors were <2, expressing that the assumption of lence in psychiatric inpatients (Ogloff et al. 2015, Huber multicollinearity was not violated. Secondly, subjects et al. 2016, Mi et al. 2016, San et al. 2016). Subjects who performed violent behaviors were divided in two presenting with mental disturbances due to a medical subgroups according to the presence/absence of a se- illness were excluded. All selected patients signed their rious mental illness (SMI), namely psychotic, bipolar or informed consent prior to inclusion in the study. anxiety disorders according to previous literature definitions (Miquel et al. 2013). Socio-demographic, clinical Methods and psychopathological characteristics of the two subgroups were then compared in order to better characte- A retrospective analysis of clinical charts routinely rize the population of violent patients in the present used in the Unit was performed. Socio-demographic and hospitalized sample. All analyses were performed using clinical data were collected. Violent behaviors at the the Statistical Package for Social Sciences (SPSS), 21.0 moment of admission or during the previous 30 days version for Windows Inc. were assessed according to clinical details recorded in the medical charts, collected directly from patients and, RESULTS whenever possible, from other informants. Violent behaviors were defined as overt injurious behaviors direct Comparison between involuntarily towards another person/object with intention to inflict hospitalized patients with and without harm (Látalová 2009, Verdolini et al. 2017, Verdolini et history of violent behaviors al. 2018). All diagnoses were made according to the The population of the present study consisted of 160 Diagnostic and Statistical Manual of Mental Disorders, th th patients. Among these, 88 (55%) presented violent be- 4 Text-Revision and 5 Edition (American Psychiatric haviors at the moment of admission or during the pre- Association 2000, American Psychiatric Association vious 30 days. No differences in socio-demographic 2013). Psychopathological characteristics of selected characteristics were found between the two subgroups. patients were assessed by means of the Positive and As for clinical characteristics, violent patients were mo- Negative Syndrome Scale (PANSS) (Kay et al. 1987) re frequently prescribed mood stabilizers at the moment and the 24-item Brief Psychiatric Reporting Scale of discharge (64.8% versus (vs) 47.2%, p=0.038). When (BPRS) (Lukoff et al. 1986). Previously defined five- psychopathological characteristics were considered, factor models of the PANSS and BPRS were considered subjects displaying violent behavior presented higher (Davis & Chen 2001, van Beek et al. 2015), which were PANSS-excited factor score (mean 13.56± standard broadly validated and previously used for assessing popu- deviation 4.81 vs 10.94±3.95, p=0.012) and lower lations of offenders affected by psychiatric illnesses PANSS-anxiety/depression score (6.08±2.20 vs (Ruggeri et al. 2005, Levine & Rabinowitz 2007, Kope- 7.53±3.21, p=0.027) (see Table 1). lowicz et al. 2008, Huber et al. 2016, van Beek et al. After performing a stepwise backward multivariate 2015). Symptom severity was evaluated using the Clini- 2 cal Global Impression (CGI) (Guy 1976). All data were modeling procedure (Ȥ (3)=14.972, p=0.002) using entered in an electronic datasheet. Assessment was violent behavior as the dependent variable, the model performed by conveniently trained residents in psychiatry explained between 18.1% (COX and Snell R Square) with the supervision of an expert senior psychiatrist. and 24.1% (Nagelkerke R Square) of the variance. Statistical significance persisted for the PANSS- excitement factor (p=0.027), positively associated Statistical analyses with violent behavior (OR=1.14, CI 1.01-1.28) and Descriptive analysis and examination of the distri- for the PANSS-anxiety/depression factor (p=0.015), butional properties of sociodemographic, clinical and which displayed a negative association (OR=0.78, CI psychopathological variables were first carried out. Two 0.64-0.95).

S489 Giulia Menculini, Norma Verdolini, Roberta Lanzi, Giorgio Pomili, Patrizia Moretti & Alfonso Tortorella: INVOLUNTARY HOSPITALIZATION AND VIOLENT BEHAVIORS: MEDICAL ACT OR SOCIAL CONTROL? A 3-year retrospective analysis Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 488-494

Table 1. Comparison between involuntarily hospitalized patients with (Hos-VB) and without (Hos-NVB) history of violent behaviors Hos-VB (n=88, 55%) Hos-NVB (n=72, 45%) 2 p n, % n, % Ȥ Socio-demographic characteristics Female gender 33 (37.5) 32 (44.4) 0.530 0.467 Foreign nationality 22 (25) 12 (16.7) 1.183 0.277 Marital status: single 47 (53.4) 38 (52.8) 0.000 1.000 Clinical features History of rehospitalizations 41 (46.6) 25 (34.7) 1.838 0.175 Committed from a Mental Health Service 39 (44.3) 29 (40.3) 0.125 0.724 Diagnostic features Impulse control disorders 5 (5.7) 4 (5.6) 0.000 1.000 Medical comorbidity 14 (15.9) 11 (15.3) 0.000 1.000 Mood disorders 11 (12.5) 11 (15.3) 0.077 0.782 Personality disorders 15 (17) 14 (19.4) 0.034 0.853 Psychiatric comorbidity 33 (37.5) 19 (26.4) 1.751 0.186 Schizophrenia spectrum disorders 54 (61.4) 46 (63.9) 0.027 0.870 Substance-related disorders 23 (26.1) 13 (18.1) 1.056 0.304 Treatment features at admission Antidepressants 7 (8) 7 (9.9) 0.014 0.906 Benzodiazepines 30 (34.1) 25 (35.2) 0.000 1.000 Long acting injectable antipsychotics 21 (24.1) 11 (15.5) 1.313 0.252 Mood stabilizers 22 (25.3) 13 (18.3) 0.736 0.391 Oral antipsychotics 38 (44.2) 28 (40) 0.132 0.716 Treatment features at discharge Antidepressants 0 (0) 3 (4.2) 1.815 0.178 Benzodiazepines 71 (80.7) 55 (76.4) 0.217 0.641 Long acting injectable antipsychotics 29 (33) 21 (29.2) 0.118 0.732 Mood stabilizers 57 (64.8) 34 (47.2) 4.283 0.038 Oral antipsychotics 73 (83) 57 (79.2) 0.166 0.684 Commitment at discharge Community Residential Facility 19 (21.6) 11 (15.3) 0.663 0.415 Outpatient Mental Health Service 52 (59.1) 33 (45.8) 2.288 0.130 Mean (SD) Mean (SD) t p Age 40.72 (12.31) 41.49 (13.89) 0.372 0.711 Length of stay 15.62 (16.87) 13.12 (16.67) -0.937 0.350 Psychopathological features CGI total score 5 (1.15) 5.02 (0.69) 0.119 0.906 BPRS-activation 14.2 (4.62) 13.22 (5.11) -0.935 0.352 BPRS-affective 7.22 (3.24) 7.22 (4.08) 1.126 0.239 BPRS-psychosis 11.59 (4.59) 10.95 (4.32) -0.663 0.509 BPRS-resistance 13.89 (4.31) 13.51 (4.95) -0.382 0.704 BPRS-retardation/negative symptoms 9.04 (3.29) 8.12 (3) -1.360 0.177 BPRS total score 60.09 (14.57) 56.85 (13.29) -1.072 0.287 PANSS-depressed/anxiety 6.08 (2.20) 7.53 (3.21) 2.263 0.027 PANSS-disorganized 10.15 (3.96) 9.56 (3.69) -0.675 0.502 PANSS-excited 13.56 (4.81) 10.94 (3.95) -2.567 0.012 PANSS-positive 16 (6.54) 15.58 (6.33) -2.800 0.780 PANSS-negative 12.72 (5.30) 14.31 (6.30) 1.184 0.240 PANSS total score 79.05 (19.68) 79.54 (16.82) 0.113 0.910 Notes: BPRS=Brief Psychiatric Rating Scale; CGI=Clinical Global Impressions; PANSS=Positive and Negative Syndrome Scale; SD=standard deviation; BPRS-activation: blunted affect, elevated mood, excitement, grandiosity, motor hyperactivity, motor retardation; BPRS-affect: anxiety, depression, guilt feelings, suicidality; BPRS-psychosis: hallucinations, somatic concerns, suspiciousness, unusual thought content; BPRS-resistance: bizarre behavior, emotional withdrawal, self-neglect, tension, uncooperativeness; BPRS-retardation/negative symptoms: conceptual disorganization, disorientation, distractability, mannerism and posturing; PANSS-depressed/anxiety: anxiety, depression, guilt feelings; PANSS-disorganized: conceptual disorganization, difficulty in abstract thinking, mannerism and posturing, poor attention; PANSS-excited: excitement, hostility, poor impulse control, uncooperativeness; PANSS-positive: delusions, grandiosity, hallucinatory behavior, suspiciousness/persecution, unusual thought content; PANSS-negative: active social avoidance, blunted affect, emotional withdrawal, lack of spontaneity and ﬂow of conversation, motor retardation, passive/apathetic social withdrawal.

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Table 2. Comparison between violent patients with (VB-SMI) and without (VB-NSMI) serious mental illness VB-SMI VB-NSMI (n=62, 70.5%) (n=26, 29.5%) Ȥ2 p n, % n, % Socio-demographic characteristics Female gender 25 (40.3) 8 (30.8) 0.364 0.546 Foreign nationality 16 (25.8) 6 (23.1) 0.000 1.000 Marital status: single 36 (58.1) 11 (42.3) 1.249 0.264 Clinical features History of rehospitalizations 35 (56.5) 6 (23.1) 6.913 0.009 Committed from a Mental Health Service 40 (60.4) 9 (34.6) 5.480 0.019 Treatment features at admission Antidepressants 5 (8.2) 2 (7.7) 0.000 1.000 Benzodiazepines 25 (41) 5 (19.2) 2.916 0.088 Long acting injectable antipsychotics 18 (29.5) 2 (7.7) 3.746 0.053 Mood stabilizers 17 (27.9) 6 (23.1) 0.039 0.843 Oral antipsychotics 31 (51.7) 8 (30.8) 2.409 0.121 Treatment features at discharge Antidepressants 0 (0) 0 (0) - - Benzodiazepines 25 (41) 36 (59) 2.916 0.088 Long acting injectable antipsychotics 28 (45.2) 1 (3.8) 12.344 <0.001 Mood stabilizers 42 (67.7) 15 (57.7) 0.430 0.512 Oral antipsychotics 53 (85.5) 20 (76.9) 0.441 0.507 Commitment at discharge Community Residential Facility 10 (16.1) 8 (30.8) 1.597 0.206 Outpatient Mental Health Service 39 (62.9) 14 (53.8) 0.306 0.580 Mean (SD) Mean (SD) t p Age 36.96 (13.85) 42.29 (11.35) 1.880 0.064 Median Median Mann-Whitney U p Length of stay 12 10 502 0.005 Mean (SD) Mean (SD) t p Psychopathological features BPRS-activation 14.58 (4.19) 12.37 (6.32) 1.233 0.224 BPRS-psychosis 12.05 (4.26) 9.37 (5.73) 1.521 0.136 BPRS-resistance 13.79 (3.88) 14.37 (6.28) -0.254 0.806 BPRS total score 60.42 (11.98) 58.29 (28.85) 0.214 0.837 PANSS-excited 13.23 (4.16) 14.87 (6.98) -0.640 0.540 PANSS-positive 17.03 (6.03) 12 (7.31) 2.017 0.049 PANSS-negative 12.81 (4.97) 12.37 (6.80) 0.203 0.840 PANSS total score 79.45 (17.58) 77.62 (27.44) 0.229 0.820 Median Median Mann-Whitney U p CGI total score 5 5 186.5 0.824 BPRS-affective 6 7 106.5 0.401 BPRS-retardation/negative symptoms 9 8 105 0.170 PANSS-depressed/anxiety 6 7 71 0.061 PANSS-disorganized 9 9 105 0.505 Notes: BPRS=Brief Psychiatric Rating Scale; CGI=Clinical Global Impressions; PANSS=Positive and Negative Syndrome Scale; SD=standard deviation.

Comparison between violent patients p=0.019) and presented a longer length of stay (median with and without serious mental illnesses (SMI) 12 vs 10, p=0.005). Treatment features also differed significantly between the two groups, with long acting In the sample of subjects who displayed violent be- injectable (LAI) antipsychotics more frequently prescri- haviors, 72 (70.5%) suffered from SMI. The two sub- bed to SMI patients (45.2% vs 3.8%, p<0.001). No groups did not display any differences in terms of socio- significant differences in psychopathological features demographic characteristics. Patients in the SMI sub- were detected between the two subgroups, except for a group presented more rehospitalizations (56.5% vs significantly higher PANSS-positive factor in SMI sub- 23.1%, p=0.009), were more frequently committed from jects (17.03±6.03 vs 12±7.31, p=0.049) (see Table 2). an outpatient Mental Health Service (64.5% vs 34.6%,

S491 Giulia Menculini, Norma Verdolini, Roberta Lanzi, Giorgio Pomili, Patrizia Moretti & Alfonso Tortorella: INVOLUNTARY HOSPITALIZATION AND VIOLENT BEHAVIORS: MEDICAL ACT OR SOCIAL CONTROL? A 3-year retrospective analysis Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 488-494

DISCUSSION behaviors (Látalová 2009). Furthermore, the item “poor impulse control” additionally contributes to this factor In the present sample of acute inpatients more than a and confirms the dimension of impulsivity to be signi- half displayed violent behaviors at admission or during ficantly associated with violence in psychiatric patients, the 30 days prior to hospitalization. This finding is con- also in consideration of its link with antisocial traits and sistent with part of the literature, reporting rates of maladaptive behaviors such as substance misuse (Vo- hospitalized patients perpetrating violence up to 50%, lavka 2014, Huber et al. 2016). The negative association with a higher risk among involuntarily committed sub- between PANSS-depressed/anxiety factor and the occur- jects (Choe et al. 2008, Colasanti et al. 2008, Ose et al. rence of violent behaviors was not previously reported 2017). No differences in socio-demographic characte- in literature, but could be partly consistent with the fact ristics were detected in the present study. This could be that anxiety and depressive disorders were linked to a partly consistent with the fact that socio-demographic lower risk of violent behaviors than other diagnoses in characteristics seem to represent a less reliable predictor previous research (Pinna et al. 2016, Ose et al. 2017) in hospital settings than in the general community and with the lower scores at anxiety/ depression measu- (Woods & Ashley 2007). Surprisingly, no patient-rela- red by scales other than the PANSS (Calegaro et al. ted clinical characteristics except from treatment see- 2014). The present study compared violent patients med to differ among the two subgroups of patients. As according to the presence/absence of serious mental for diagnostic features, schizophrenia seemed to be most illness (SMI) in an Italian sample of involuntary inpa- frequently related to violent behaviors in previous re- tients. The higher rehospitalization rate, the more fre- search (Biancosino et al. 2009, Sands et al. 2012, Vo- quent commitment from outpatient Mental Health lavka 2014, Caqueo-Urízar et al. 2016), thus univocal Services and the longer length of stay in SMI subjects, results are lacking and other disorders, namely bipolar along with the more frequent treatment with long-acting disorders, substance use and personality disorders, also injectable antipsychotics, may be considered as indexes appeared to play a fundamental role in the risk of of illness severity and are thus consistent with the displaying overt aggressive acts (Colasanti et al. 2008, composition of this subgroup (Di Lorenzo et al. 2016). Ballester et al. 2012, Volavka 2014, Pinna et al. 2016). As for psychopathological characteristics, the higher It should also be considered that a direct comparison score of the PANSS-positive factor in the SMI subgroup with data from other studies may be misleading, due to could be at least in part supported by the fact that acute different settings, methods employed to collect data, psychotic symptoms represented risk factors for the different definitions of violence episodes, study designs development of violent behaviors in previous studies and cultural background of the analyzed samples. and were linked to aggression also in populations of Furthermore, the recently approved law ordering the patients affected by severe disorders other than schizo- closure of forensic hospitals in Italy may have changed phrenia, i.e. mood disorders (Swanson et al. 2006, Sands the population of patients admitted to psychiatric wards et al. 2012, Verdolini et al. 2017). The present study and subsequently the findings of the present study could presents limitations. First, the retrospective nature did be replicated by future research (Barbui & Saraceno not provide a standardized evaluation of violent beha- 2014). The more frequent prescription of mood stabili- viors, which relied on an operational clinical criterion. zers in inpatients who perpetrated violent acts is Second, the small sample size may limit the statistical consistent with part of the literature (Biancosino et al. power of the analyses. Moreover, additional socio-demo- 2009), suggesting that the occurrence of aggressive graphic and clinical characteristics possibly related with behaviors could define a distinct clinical subgroup for overt aggression, such as socio-economic status, having which targeted treatment strategies should be evaluated being subjected to violence during childhood and his- (Verdolini et al. 2017). When analyzing psychopatho- tory of previous recurrent violent acts were not eva- logical features, specific dimensions, but not the overall luated in the present study, along with setting-related symptom severity, appeared to be related to violent characteristics connected to the perpetration of violent behavior. This could be in contrast with part of the behaviors (Biancosino et al. 2009, Pinna et al. 2016). previous literature, but the heterogeneity of the analyzed Finally, restrictive inclusion criteria considering only samples, frequently not including only compulsory patients hospitalized due to specific reasons might have inpatients, and the inclusion of self-aggressive subjects increased the risk of selection bias. As a consequence, in the samples might have contributed to this findings the results of the present research should be replicated (Colasanti et al. 2008, Calegaro et al. 2014, Pinna et al. in future prospective studies on larger samples. 2016). The association with PANSS-excited component could be explained by the items contributing to this CONCLUSIONS factor, which has actually been used as an outcome measure for evaluating treatment strategies in violent The present study confirms that the occurrence of inpatients (Huber et al. 2016, Mi et al. 2016). First, the violent behaviors among acute psychiatric inpatients PANSS-excited dimension includes the item “hostility”, may be related to specific symptomatological cons- which contains specific information about aggressive tellations, defining a specific subgroup of patients for

S492 Giulia Menculini, Norma Verdolini, Roberta Lanzi, Giorgio Pomili, Patrizia Moretti & Alfonso Tortorella: INVOLUNTARY HOSPITALIZATION AND VIOLENT BEHAVIORS: MEDICAL ACT OR SOCIAL CONTROL? A 3-year retrospective analysis Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 488-494 which tailored treatment strategies should be addressed. Prevalence and risk factors. A multicentric study from The population of inpatients perpetrating violent acts is three Latin-America countries. Schizophr Res 2016; heterogeneous and should be better stratified in order to 178(1-3):23-28 understand different pathways leading to offending and 9. Choe JY, Teplin LA, Abram KM: Perpetration of violence, to develop prevention strategies. violent victimization, and severe mental illness: balancing public health concerns. Psychiatr Serv 2008; 59:153-64 10. Colasanti A, Natoli A, Moliterno D, Rossattini M, De Gas- pari IF, Mauri MC: Psychiatric diagnosis and aggression Acknowledgements: before acute hospitalisation. Eur Psychiatry 2008; 23:441-8 The authors thank the support of the Instituto de 11. Dack C, Ross J, Papadopoulos C, Stewart D, Bowers L: A Salud Carlos III that supported this work through a Review and Meta-analysis of the patient factors associated “Río Hortega” contract (CM17/00258) to NV). with psychiatric in-patient aggression. Acta Psychiatr Scand 2013; 127:255-68 Conflict of interest: None to declare. 12. Davis JM & Chen N: The effects of olanzapine on the 5 dimensions of schizophrenia derived by factor analysis: Contribution of individual authors: combined results of the North American and international Giulia Menculini, Norma Verdolini & Patrizia Moretti trials. J Clin Psychiatry 2001; 62:757-71 conceived and designed the study; 13. Di Lorenzo R, Sagona M, Landi G, Martire L, Piemonte Giulia Menculini & Norma Verdolini conceived the C, Del Giovane C: The revolving door phenomenon in an electronic datasheet for data collection, and per- Italian acute psychiatric ward. J Nerv Ment Dis 2016; formed statistical analyses; 204:686–92 Giulia Menculini, Roberta Lanzi & Giorgio Pomili col- 14. Guy W: ECDEU Assessment Manual for Psychopharma- lected clinical data; cology. US Department of Heath, Education, and Welfare Public Health Service Alcohol, Drug Abuse, and Mental Roberta Lanzi & Giorgio Pomili wrote substantial part Health Administration, Rockville, 1976 of the introduction; 15. 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results from a national census. Nord J Psychiatry 2017; 30. Van Dorn R, Volavka J, Johnson N: Mental disorder and 71:551-60 violence: is there a relationship beyond substance use? 26. San L, Marksteiner J, Zwanzger P, Figuero MA, Romero Soc Psychiatry Psychiatr Epidemiol 2012; 47:487-503 FT, Kyropoulos G et al.: State of Acute Agitation at 31. Verdolini N, Perugi G, Samalin L, Murru A, Angst J, Azorin Psychiatric Emergencies in Europe: The STAGE Study. JM et al.: BRIDGE-II-Mix Study Group: Aggressiveness in Clin Pract Epidemiol Ment Health 2016; 12: 75-86. depression: a neglected symptom possibly associated with 27. Sands N, Elsom S, Gerdtz M, Khaw D: Mental health- bipolarity and mixed features. Acta Psychiatr Scand 2017; related risk factors for violence: using the evidence to 136:362-72 guide mental health triage decision making. J Psychiatr 32. Verdolini N, Pacchiarotti I, Köhler CA, Reinares M, Ment Health Nurs 2012; 19:690–701 Samalin L, Colom F et al.: Violent criminal behavior in 28. Swanson JW, Swartz MS, Van Dorn RA, Elbogen EB, the context of bipolar disorder: Systematic review and Wagner HR, Rosenheck RA et al: A national study of meta-analysis. J Affect Disord 2018; 239:161-70 violent behavior in persons with schizophrenia. Arch Gen 33. Volavka J: Comorbid personality disorders and violent be- Psychiatry 2006; 63:490–99 havior in psychotic patients. Psychiatr Q 2014; 85:65-78 29. Van Beek J, Vuijk PJ, Harte JM, Smit BL, Nijman H, 34. Woods P & Ashley C: Violence and aggression: A litera- Scherder EJ: The factor structure of the Brief Psychiatric ture review. J Psychiatr Ment Health Nurs 2007; 14:652-60 Rating Scale (expanded version) in a sample of forensic 35. Woods P & Ashley C: Violence and aggression: A lite- psychiatric patients. Int J Offender Ther Comp Criminol rature review. J Psychiatr Ment Health Nurs 2007; 2015; 59:743-56 14:652-60

Correspondence: Prof. Alfonso Tortorella, MD Division of Psychiatry, Department of Medicine, University of Perugia Piazzale Lucio Severi, 1, 06132, S. Andrea delle Fratte, Perugia (PG), Italy E-mail: [email protected]

S494 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 495-497 Conference paper © Medicinska naklada - Zagreb, Croatia

MOBILITY IN PSYCHIATRY, AN ALTERNATIVE TO FORCED HOSPITALIZATION? Gérald Deschietere Psychiatric Emergency Unit, Department of Adult Psychiatry, Clinique universitaire Saint Luc, Université catholique de Louvain, Brussels, Belgium

SUMMARY Background: The number of forced hospitalizations has increased across Europe. One way to reduce these is to set up mobile crisis teams. A reform of psychiatry in Belgium allowed the creation of these mobile teams. These offer an alternative to forced hospitalization. Subjects and methods: 196 situations were referred to the mobile crisis team located east of Brussels in 2017. We examined the orientation of these requests according to the applicants and the reasons for them. Results: It appears that the health sector has the best indications for using the mobile crisis team. Conclusion: Access to psychiatric care is of major importance in Western societies. The creation of mobile teams increases this accessibility and should reduce the need for forced hospitalizations. These observations must be confirmed.

Key words: mobile team – forced hospitalizations – accessibility – organization of care

* * * * *

INTRODUCTION re is therefore a significant reactivity (Johnson 2008). In both cases, the team checks the intervention indications: Everywhere in Europe, and sometimes despite re- Is the patient in the area served by the mobile team? cent legislation that is supposed to temper their use, There is a crisis in this patient? There is no other way to deprivation measures for care are increasing (Salize et give access to patient care (Figure 1)? al. 2004). In Belgium, various studies have been conducted to explain this trend and this significant SUBJECTS AND METHODS development (Benoît 2011). Thus, for the judicial district of Brussels, the number of psychiatric eva- The retrospective analysis of the situations suppor- luations requested by the judicial world to obtain ted in 2017 was conducted on the following items: spe- observation (term enshrined in Belgian law) has cifications of the intervention seeker, reasons for refusal increased by more than 150% in 10 years (Deschietere of support at different stages and outcomes of the 2011). Access to care is an important issue in this intervention of the mobile team for situations taken care issue. Since 2011 a reform of psychiatry exists in Bel- of. The patients were all over 16 years old. gium. She has set up mobile crisis teams. These teams must improve access to care, especially for non- claimant patients. It is an alternative before eventually RESULTS proceeding to forced hospitalization. Thus, the role of a rapidly moving mobile team was In 2017, 198 situations supported by the mobile well defined by a working group of caregivers, mana- team closed. gers and political representatives. We can read the con- After the first call, 63 situations were not eligible for clusions of the working group on mobile crisis teams. the intervention of the mobile crisis team. The main This defines the target audience of these teams: adults in reasons for refusal of care were as follows: patients crisis with a psychic problem and no other possible outside the intervention zone of the mobile team (16 intervention modality (http://www.psy107.be/index.php/ situations), chronic situations (14), abandonment of the fr/organe-de-concertation/equipes-mobiles). request (14), requesting patient (9), possible alternative The situations taken over in 2017 by the mobile cri- (6), forced hospitalization of the patient during demand sis team located in east of Brussels (400,000 inhabi- analysis (2), unknown (2). tants) were analyzed retrospectively in this perspective. In these 63 directly reoriented situations, 35 came The mobile team intervenes in situations after two from families and relatives, 13 came from the health analyzes: a first analysis is done at the time of a first sector, 11 came from the non-health professional sector, phone call. The team verifies that the situation described 2 applicants could not be identified, 2 were from a by the applicant corresponds to the expected interven- patient directly. tion. If this is the case, a second analysis is done after After this first telephone analysis, 135 situations led consultation with the applicant. This consultation often to a consultation at the request of a third party, carried takes place within 24/48 hours after the phone call. The- out most of the time within 24/48h.

S495 Gérald Deschietere: MOBILITY IN PSYCHIATRY, AN ALTERNATIVE TO FORCED HOSPITALIZATION? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 495-497

Figure 1. Summary of the steps of the inclusion according to the providers

Table 1. Summary of orientation according to the providers Step 1. Reorientation 2. Reorientation 3. Situations supported Total per provider Provider after phone call after consultation by the crisis mobile team Families 35 28 13 76 Health sector 13 6 64 83 Non Health sector 11 2 15 28 Patient 2 3 0 5 Unknow 2 0 4 6 Total 63 39 96 198

At the end of these consultations, 39 situations were Of the 198 situations encountered, here are the appli- referred to another care device. The reasons for this cants: 76 requests came from families and relatives, 83 reorientation are as follows: In 16 situations, patients from the health sector; 28 of the non-health sector; 5 of were applicants; in 10 situations, the applicant was no a patient himself; 6 of a misidentified applicant (Table 1, longer; in 3 situations the patient had been hospitalized Figure 2). (once in a forced setting); in 9 situations the situation was chronic; in one situation, the patient had changed his place of residence and was outside the intervention zone. In these 39 situations, the applicants were distributed as follows: 28 situations from families and relatives; 6 situations came from the health sector, 3 situations from a patient himself and 2 situations were sent by the non- health professional sector. This leaves 96 situations supported by the mobile team in 2017, with intervention in the patient's home. Let's re-analyze the sender of these situations: 64 situations came from the health sector; 15 situations came from the non-health professional sector; 13 situations came from a request from families and relatives; 4 of a misidentified applicant. Figure 2. Orientation according to the applicant The outcome of the management by the mobile team is as follows: 15 forced hospitalizations, 39 relayed to DISCUSSION the outpatient psychiatric service, 11 hospitalizations granted, 20 situations did not break out in any other It is not abnormal to see that the care rate is better care; 11 relays to general medicine. when the demand comes from the health sector, as they She took care of 96 patients. 15 of them (15.6%) re- could probably better verify the absence of alternative quired the intervention of forced hospitalization in the care. It is also not abnormal to note that 15.6% of the course of the intervention. In the 102 situations analy- interventions by the mobile team end with a forced zed without support, 3 situations required observation. hospitalization given the difficulty of these situations

S496 Gérald Deschietere: MOBILITY IN PSYCHIATRY, AN ALTERNATIVE TO FORCED HOSPITALIZATION? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 495-497 and that 27% of the situations of the situations taken reasons for not taking charge of psychiatric situations by care of ends with a hospitalization. This means that in a mobile crisis team. The interest of naturalistics studies more than 70% of situations, despite the fact that the in the psychiatric field is confronted with the com- demand comes mainly from the health sector, hospita- plexity of carrying out such studies. More than ever, the lization has been avoided. Of course, there should be a question of the accessibility of psychiatric care is a prio- prospective study of other determinants of forced hospi- rity issue for public health. talization. From these results, we can not know what would have happened to the 81 situations if there was no mo- Acknowledgements: None. bile crisis team. Would these patients have been hospitalized forcibly? Would they have access to care in Conflict of interest: None to declare. other ways? Impossible to say according to our study. But it is certain that in 81 out of 96 situations (84% of cases) these patients could have had another outcome References than forced hospitalization. And that's partly because the 1. Benoit G, Burton L, Caels T, Caspar P, Constant H, Daled family was able to find help other than forced hospi- PF, et al: La protection de la personne des malades mentalization. As shown in other studies (Quenum 2017, taux: éthique, médecine et justice. La Charte, Brussels, 2011 Zeltner 2018), the mobile team is heavily used by 2. Deschietere G: Oral communication. Congress of Ence- families in contact with a psychologically suffering phale, January 2011 person. The importance of family demands is an 3. Keown P et al: Association between provision of mental important point in our study, since 38.3% of total illness beds and rate of involuntary admissions in the NHS requests come from families. in England 1988-2008: ecological study. BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d3736 (Published 05 July The limit of this study is also the small sample size 2011)BMJ, 2011 despite the duration of the data collected over one year. 4. Johnson S, Needle J, Bindman JP and Thornicroft G: Consideration should be given to collecting this data Crisis Resolution and Home Treatment in Mental Health over several years in order to increase the relevance of Cambridge University Press, 2008 the results produced. 5. Quenum Y, Fakra E: Community treatment outreach teams It is important to note that some studies undermine in Saint-Etienne, France. Annales Médico-psychologiques this hypothesis that the establishment of mobile psychia- 2017; 176:70-73 tric teams decreases the number of forced hospitaliza- 6. Salize HJ & Dressing H: Epidemiology of involuntary tions (Keown 2011). placement of mentally ill people across the European Union. BJP 2004; 184:163-168 7. Zeltner L, Fousson J, Stefant P, Luttenbacher C, Boudon CONCLUSION J, Pastour N: Suicidal crisis, trauma, crisis intervention, what adjustments could be proposed? Inf Psyc 2018; The study presented here allows to see the data con- 94:247-252 cerning the applicants for intervention of a mobile crisis 8. Website: http://www.psy107.be/index.php/fr/organe-de- team in an urban context. It also helps to understand the concertation/equipes-mobiles

Correspondence: Gérald Deschietere, MD Psychiatric Emergency Unit, Department of Adult Psychiatry, Clinique universitaire Saint Luc, Université catholique de Louvain Avenue Hippocrate 10, B1200 Brussels, Belgium E-mail: [email protected]

S497 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 498-501 Conference paper © Medicinska naklada - Zagreb, Croatia

“PLEASE ADMIRE ME!” WHEN HEALTHCARE PROVIDERS' POSITIVE STEREOTYPES OF ASYLUM SEEKER PATIENTS CONTRIBUTE TO BETTER CONTINUITY OF CARE Brice Lepièce1,2, Thomas Dubois2, Denis Jacques2 & Nicolas Zdanowicz2 1Université Catholique de Louvain, Institute of Health and Society, Mont-Godinne University Hospital, Yvoir, Belgium 2Université Catholique de Louvain, Psychosomatics Unit, CHU UcL Namur Godinne Hospital, Yvoir, Belgium

SUMMARY Background: Among asylum seekers (AS), mental health conditions are highly prevalent. However this population group has poor access to adequate services and frequently incurs discontinuity of mental healthcare. Many factors explain discontinuity of mental healthcare for asylum seekers. The aim of this study is to evaluate if facilitation of care for AS decreases healthcare provider stereotypes of this population and improves their continuity of care. Subjects and methods: General practitioners (GPs) and mental health professionals (MHPs) were invited to participate in a vignette study, presenting an AS patient manifesting post-traumatic stress symptoms. We randomly manipulated the context of the clinical vignette to create two experimental conditions: facilitated care versus non-facilitated care. In each condition, we measured participants’ stereotypes and continuity of care. Results: There was a significant effect of participant’s type of stereotypes on continuity of care (F=2.87, p=0.035). However, we found no effect of condition (facilitated vs. non facilitated care) on stereotypes (F=0.11, p=0.95), nor on continuity of care (F=0.35, p=0.55). Furthermore, there was a significant effect of profession (GPs vs MHPs) on continuity of care (F=11.43, p=0.001). Participants’ number of consultations per week (F=10.33, p=0.002) and their gender (F=3.69, p=0.030) both have a significant effect on continuity of care. Conclusion: Among healthcare providers, we found that “admiration” stereotypes were associated more with continuity of care. Paradoxically, continuity of mental healthcare was better among GPs compared to MHPs. Thus, improvement of continuity of mental healthcare for AS among MHPs should be investigated in further studies.

Key words: general practitioners - mental health professionals - asylum seekers - care facilitation - stereotype content - continuity of mental healthcare * * * * *

INTRODUCTION different levels: the political (e.g. host policies), the organizational (e.g. fragmentation of services), the pa- Since the last few years, Europe has been hosting tient (e.g. linguistic proficiency, help-seeking beha- several thousands of people who have left their country viours), and also from the healthcare provider (e.g. because of human rights violation or military conflicts. stereotype, avoidance) (O’Donnell et al. 2016). Most of these migrants were exposed to stressful expe- We know that stereotypes exist among mental health riences during migration, and past traumas are likely to providers, and that they are likely to impair quality of be exacerbated by post-migration environment (prolon- care, contributing to healthcare disparities (Chapman et ged detention, insecure status, loss of community and al. 2013, Lepièce et al. 2014). Stereotypes are consi- family ties). This situation makes migrants vulnerable to dered as a psychological mechanism that economizes on mental health conditions (Turrini et al. 2017). Accor- time and effort spent on information processing by ding to the United Nations High Commissioner for simplifying social reality (Fiske et al. 1991). Therefore, Refugees (UNHCR) and the World Health Organization stereotypes are more likely to be elicited under certain (WHO) most asylum seekers (AS) and refugees with contextual variables, for instance: when providers are in mental health issues will never receive appropriate a situation of overload, uncertainty, unfamiliarity, social services (Silove et al. 2017). Thus, one of the main and cultural distance with “outgroup” patients (Balsa et challenges for such vulnerable group is to provide them al. 2003, Burgess 2010). Providing care to asylum see- accessible, tailored and continuous mental healthcare. kers could well be perceived as a highly demanding Continuity of care (COC) is considered both by pa- task, leading providers to stereotypes, particularly when tients and professionals as an essential feature of high they are not sufficiently supported to treat this popu- quality of care (Biringer et al. 2017). In an influential lation group. review, Bachrach defined COC as a: “process involving The stereotype content model (SCM) hypothesizes the orderly, uninterrupted movement of patients among that stereotypes possess two dimensions: “warmth” and the diverse elements of the service delivery system” “competence” that predict distinct intergroup behaviors (Bachrach 1981). (Fiske et al. 2002). Several barriers prevent asylum seekers from COC Social groups are perceived as “warm” if they do not within mental health services. These barriers stem from compete with the ingroup for the same resources, and

S498 Brice Lepièce, Thomas Dubois, Denis Jacques & Nicolas Zdanowicz: “PLEASE ADMIRE ME!” WHEN HEALTHCARE PROVIDERS' POSITIVE STEREOTYPES OF ASYLUM SEEKER PATIENTS CONTRIBUTE TO BETTER CONTINUITY OF CARE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 498-501 they are considered “competent” if they are high in p=0.035) as shown in figure 1. However, we found no status. Combinations of perceived warmth and compe- effect of condition (facilitated vs. non facilitated care) tence result in four types of stereotype: “contemptuous” on stereotypes (F=0.11, p=0.95) nor on continuity of (low warmth, low competence); “paternalistic” (high care (F=0.35, p=0.55). Furthermore, there was a signi- warmth, low competence); “ambivalent” (low warmth, ficant effect of profession (GPs vs MHPs) on continuity high competence), and “admiration” (high warmth, high of care (F=11.43, p=0.001). Participants’ number of competence) (Cuddy et al. 2008). consultations per week (F=10.33, p=0.002) and gender The aim of this paper is to evaluate if facilitation of (F=3.69, p=0.030) have both a significant effect on care for asylum seekers decreases healthcare provider continuity of care. stereotype manifestation, and if the four types of stereotypes impact differently continuity of care. Table 1. Population characteristics Participants N % Mean SD SUBJECTS AND METHODS characteristics (N=88) Condition (asylum seeker General practitioners (GPs) and mental health pro- patient vignette) fessionals (MHPs) were invited by email to participate facilitated care 42 47.7 in a study about their practices when treating migrant non-fecilitated care 46 52.3 patients. GPs were included in the study, as they are often dealing with asylum seekers’ mental health issues. Profession general practi 52 59.1 Qualtrics® software was used to design a web survey tioners (GPs) in which participants were randomly assigned to one of mental health pro 36 40.9 two experimental conditions. All participants dealt with fessionnals (MHPs) the same clinical vignette of a 20 year-old Iraqi asylum psychologists 22 25.0 seeker, presenting post-traumatic stress disorder symp- psychiatrists 14 15.9 toms. However, in one of the two conditions, the Gender vignette contained information on the participant’s men 27 30.7 eligibility to receive support from the asylum facility women 61 69.3 centre to treat the patient, such as help for: admini- Age 88 35.5 11.1 strative task, payment, transport, interpreter (facilitated care vignette). In the other condition, the vignette did Consultations per week 88 57.7 36.0 not contained information about additional support to Practice type treat the patient (non-facilitated care vignette). solo 10 11.4 Participants self-reported socio-demographic data, group-medical center 52 59.1 clinical activities, and other relevant variables (Table 1). hospital 26 29.5 For each participant, we assessed the two dimensions of Status the stereotype: warmth (6 items) and competence (6 employee 65 73.9 items). We measured continuity of care based on Bach- independent 23 26.1 rach’s multidimensional model, circumscribing to 4 re- Activity localization levant dimensions: globality (collaboration with servi- rural 13 14.8 ces, comprehensiveness, coordination of care, 3 items), semi-urban 20 22.7 longitudinality (long term follow-up, 3 items), flexi- urban 55 62.5 bility (adjustment to patient’s needs, 3 items) and, com- Ethnicity (non-caucasian) 4 4.5 munication (information exchange with other health Proportion of migrants 88 17.5 25.7 professionals, 2 items). Our dependant variable, conti- among patients nuity of care, consists of the sum of these 4 dimensions. Working time (<50%) 88 6.8 Statistical analyses were performed with IBM SPSS 25®. Our study has been approved by the Ethics Com- DISCUSSION mittee of Saint-Luc Brussel University Hospital (UCL), and conforms to the provisions of the Declaration of The aim of this research was to evaluate if facili- Helsinki in 1995 (as revised in Edinburgh in 2000). tation of care for asylum seekers (AS) could decrease providers’ manifestation of stereotypes and if provi- RESULTS ders’ stereotypes were influencing continuity of healthcare. We found that “admiration” stereotypes (percep- Population characteristics are described below in tion of AS as both high in warmth and competence) table 1. were associated with more continuity of care. The Our general model and covariables are presented in three others types of stereotypes (i.e. “contemptuous”, table 2. There was a significant effect of participant’s “paternalistic”, and “ambivalent”) were associated with type of stereotype on continuity of care (F=2.87, less continuity of care. However, in opposition to our

S499 Brice Lepièce, Thomas Dubois, Denis Jacques & Nicolas Zdanowicz: “PLEASE ADMIRE ME!” WHEN HEALTHCARE PROVIDERS' POSITIVE STEREOTYPES OF ASYLUM SEEKER PATIENTS CONTRIBUTE TO BETTER CONTINUITY OF CARE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 498-501

Table 2. General model and covariables Sum of mean Mean Partial Continuity of care df F p square square Ș2 Corrected model 27.942* 17 1.6 3.47 0.000 0.476 Constant 109.4 1 109.4 231.22 0.000 0.781 Condition (facilitated vs non facilitated care) 0.2 1 0.20 0.35 0.558 0.005 Type of stereotype 4.1 3 1.4 2.87 0.035 0.117 Profession 5.4 1 5.4 11.43 0.001 0.150 Gender 1.7 1 1.7 3.69 0.030 0.054 Consultations per week 4.9 1 4.9 10.33 0.002 0.137 Age 0.0 1 0.0 0.03 0.852 0.001 Practice type 1.2 2 0.6 1.22 0.302 0.036 Status 0.7 1 0.7 1.56 0.216 0.023 Activity localization 0.9 2 0.5 0.99 0.378 0.029 Proportion of migrants among patients 1.1 1 1.1 2.27 0.136 0.034 Interaction: Condition x Type of stereotype 0.2 3 0.1 0.11 0.953 0.005 Error 30.8 65 0.5 Total 2626.6 83 Total corrected 58.7 82 *Adjusted R2=0.340

Figure 1. Effect of participant's type of stereotype on continuity of care hypothesis, the facilitated care condition (providers get of continuity, which includes the globality dimension support to treat the patient) did not have a significant (i.e. collaboration with services, comprehensiveness, effect either on stereotype, or on the continuity of care. and coordination of care), which is typically the role of As stereotypes are more likely to be triggered in over- GPs within the healthcare system. Another explanation load context, facilitation of care particularly when could be that on the field, most asylum seekers’ mental treating potential demanding situations (i.e. migrants’ health situations are treated in primary care. This pheno- care) should remain a priority in healthcare organi- menon is reinforced by a lack of availability of specia- sations, thus to avoid stereotype manifestation and their lised mental health care services. A better articulation negative consequences on quality of care (Penner et al. between primary care and specialized mental health 2014). services should be sustained to avoid over-solicitation Our measure of continuity of care consisted in: within general practice and offer most adapted care to globality, longitudinality, flexibility and, communica- asylum seekers presenting mental health conditions. tion (Bachrach 1981). Surprisingly, we observed that We found that women providers were offering more GPs offered more continuity of care in comparison with continuity of care than their male colleagues; this could MHPs even if the presented vignette was a mental confirm gender different practices when treating vulner- health issue (PTSD). This could be due to our measure able population groups (Howe 2007).

S500 Brice Lepièce, Thomas Dubois, Denis Jacques & Nicolas Zdanowicz: “PLEASE ADMIRE ME!” WHEN HEALTHCARE PROVIDERS' POSITIVE STEREOTYPES OF ASYLUM SEEKER PATIENTS CONTRIBUTE TO BETTER CONTINUITY OF CARE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 498-501

Regarding limits of the study, our results should be 2. Balsa I, Seiler N, McGuire G & Bloche G: Clinical uncer- taken with caution due to our limited sample, and repre- tainty and healthcare disparities. Am J Law Med 2003; sentativeness bias (i.e. gender and profession compo- 29:203 sition, practice type and localization). Finally, most 3. Biringer E, Hartveit M, Sundfør B, Ruud T & Borg M: participants in our study could have been participants Continuity of care as experienced by mental health service users - a qualitative study. BMC Health Serv Res 2017; with an interest in migrants’ health. Further research 17:763 should focus on organisational improvement of con- 4. Burgess J: Are providers more likely to contribute to tinuity of mental healthcare for asylum seekers among healthcare disparities under high levels of cognitive load? MHPs, and enlighten contextual variables that make How features of the healthcare setting may lead to biases healthcare providers developing positive stereotypes in medical decision making. Med Decis Making 2010; about their patients thus to improve continuity and 30:246-257 quality of care. 5. Chapman N, Kaatz A & Carnes M: Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013; 28:1504- CONCLUSION 1510 6. Cuddy A, Fiske S & Glick P: Warmth and competence as This study stresses the importance of stereotypes on universal dimensions of social perception: The stereotype establishment of continuity of care, which is a funda- content model and the BIAS map. Adv Exp Soc Psychol mental dimension of healthcare quality, particularly for 2008; 40:61-149 vulnerable groups such as asylum seekers. A part of 7. Fiske S & Taylor S: Social cognition. McGraw-Hill, New healthcare providers were showing positive stereotypes York, 1991 (“admiration”) with regard to asylum seekers, which 8. Fiske S, Cuddy A, Glick P & Xu J: A Model of (Often generated a better continuity of care. Paradoxically, Mixed) Stereotype Content: Competence and Warmth continuity of mental healthcare was better among GPs. Respectively Follow From Perceived Status and Therefore, improvement of continuity of mental health- Competition. J Pers Soc Psychol 2002; 82:878–902 care for asylum seekers among MHPs and a better 9. Howe A: Why family medicine benefits from more women understanding of how positive stereotypes are elicited doctors. Br J Gen Pract 2007; 57:91-92 should be investigated in further studies. 10. Lepièce B, Zdanowicz N, Jacques D, Reynaert C & Tordeurs D: Review of disparities in the mental health care of ethnic minority patients. Psychiatr Danub 2014; 26:43 Acknowledgements: None. 11. O’Donnell C, Burns N, Mair F, Dowrick C, Clissmann C, van den Muijsenbergh M & de Brun T: Reducing the Conflict of interest: None to declare. health care burden for marginalised migrants: the potential role for primary care in Europe. Health Policy Contribution of individual authors: 2016; 120:495-508 12. Penner L, Blair I, Albrecht T & Dovidio J: Reducing All authors make substantial contributions to concep- racial health care disparities: A social psychological tion and design and or acquisition of data and.or analysis. Policy Insights Behav Brain Sci 2014; 1:204- analysis or interpretation of data. 212. 13. Silove D, Ventevogel P & Rees S: The contemporary refugee crisis: an overview of mental health challenges. References World Psychiatry 2017; 16:130-139 14. Turrini G, Purgato M, Ballette F, Nosè M, Ostuzzi G & 1. Bachrach L: Continuity of care for chronic mental Barbui C: Common mental disorders in asylum seekers patients: a conceptual analysis. Am J Psychiatry 1981; and refugees: umbrella review of prevalence and 138:1449-56 intervention studies. Int J Ment Health Syst 2017; 11

Correspondence: Brice Lepièce, MD CHU UCL Namur, Psychosomatic Unit avenue Dr G. Therasse n°1, 5530 Yvoir, Belgium E-mail: [email protected]

S501 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 502-507 Conference paper © Medicinska naklada - Zagreb, Croatia

IS ELECTROCONVULSIVE THERAPY ANY MORE EFFECTIVE THAN SIMULATED ELECTROCONVULSIVE THERAPY IN TREATMENT-RESISTANT DEPRESSION? Alexander Bow University of Cambridge, Emmanuel College, Cambridge, UK

SUMMARY Background: Electroconvulsive therapy (ECT) fell out of favour towards the end of the 20th century with the advent of effective and well-tolerated antidepressants. It is now experiencing somewhat of a ‘renaissance’ in England, with an 11 percent increase in the number of ECT treatments carried out in 2015-16 compared with 2012-13, which represents approximately 2,000 additional treatments. Aims: This paper seeks to examine clinical trials comparing the efficacy of real ECT with simulated ECT in treatment-resistant depression (TRD) to determine whether the resurgence of ECT in recent years is justified. Methods: A PubMed search was performed to identify clinical trials comparing real ECT with simulated ECT. 6 trials met the inclusion criteria. These were then analysed, and their methodology assessed. Results: 5 out of the 6 trials found real ECT to have a greater antidepressant effect than simulated ECT. The trial that showed no significant difference used a unilateral electrode placement. Analysis revealed significant weaknesses in the trials. Conclusions: There is clear evidence that real ECT has a greater antidepressant effect than simulated ECT when a bilateral electrode placement is used, despite the weaknesses identified in the trials. Continued use of ECT to treat TRD in England and other countries should be encouraged. Further research is needed to better understand its mechanism of action and refine the techniques used.

Key words: electroconvulsive therapy – simulated – depression - ECT

* * * * *

INTRODUCTION patient, which makes a bespoke drug regime necessary. A good trial design must balance the needs of the Electroconvulsive therapy (ECT) is a controversial patient with the need for comparable groups of patients treatment in psychiatry and is sometimes viewed unfa- with regards to medication. Ideally all the patients vourably by both members of the medical profession would be on identical drugs or none at all throughout and the public. The Royal College of Psychiatrists states the whole study. In the trials discussed, a common on its website: “It has been suggested that ECT works theme is difficulty in interpreting the data due to diffe- not because of the fit, but because of all the other things rences in the drugs prescribed between patients. – like the extra attention, support and the anaesthetic – Second, ECT is often considered a last resort, which that happen to someone who has it.” This commonly places a limit on the sample size that can be achieved in held view has been a barrier to its use in treatment- a single trial. The National Institute for Health and Care resistant depression (TRD). Excellence (NICE) guidelines (2009) advise “Consider To determine if the electrical stimulus applied to a ECT for acute treatment of severe depression that is patient during ECT has an antidepressant effect, clinical life-threatening and when a rapid response is required, trials comparing simulated ECT with real ECT have or when other treatments have failed.” In practice, this been carried out. In simulated ECT, the patient receives means that trial participants can only be recruited from a the same medical treatment as a patient undergoing real very limited pool of patients. This means that the ECT, but the electrical stimulus is not applied. In all the differences observed between real ECT and simulated clinical trials identified in this paper, the medical ECT groups may be due to low statistical power. treatment included the use of a muscle relaxant and Finally, the severity of TRD means that ethical general anaesthesia. This is termed ‘modified ECT’ and considerations preclude further trials of this sort from is preferable for safety reasons. being approved, as ECT is now believed to be an The main use of ECT in the West is in the treatment effective treatment. This is especially important due to of TRD. TRD is defined as depression with an unsatis- the risks of general anaesthesia itself, which is now factory response to two adequate trials of two different required for safety reasons. classes of antidepressant. Inherent difficulties exist in conducting a clinical trial for this indication and in METHODS interpreting results. First, variation in the drugs between patients makes them less comparable. The drugs used A PubMed search was carried out to identify clinical vary between patients because of differences in the side trials (using the clinical trials filter) which compared the effects experienced and how effective they are for that efficacy of real ECT and simulated ECT using the key

S502 Alexander Bow: IS ELECTROCONVULSIVE THERAPY ANY MORE EFFECTIVE THAN SIMULATED ELECTROCONVULSIVE THERAPY IN TREATMENT-RESISTANT DEPRESSION? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 502-507 words ‘electroconvulsive therapy’ AND ‘simulated’ follow-ups. The medications prescribed after the AND ‘depression’. After removing a duplication, 17 treatment period were similar between the groups, so it results were returned. The inclusion criteria were: is hard to attribute the loss of effect to differential Original clinical trial (2); treatment. The authors concluded that the antidepressant Comparing efficacy between real and simulated effect of real ECT is short-lived. ECT as the main aim (8); West and colleagues (1981) conducted another trial which showed real bilateral ECT to be significantly Indication of TRD (1). superior to simulated ECT, although it was limited in its Numbers in brackets indicate papers that did not sample size (just 11 patients per group). A crossover meet each of the stated inclusion criteria. phase, where 10 of the 11 in the simulated group then After applying the inclusion criteria, 6 trials were had real ECT, showed these patients improved too. identified for further analysis. The Leicestershire trial (Brandon et al. 1984) had the advantage of a large sample size (n=95 intended to treat RESULTS and n=77 completers included in the analysis). At the 2- week and 4-week assessments (where the results were Six clinical trials met the inclusion criteria. Table 1 comparable due to cessation of antidepressant therapy), outlines the methods and findings of the six trials. Four there was a significant advantage in the real ECT group of these trials compared bilateral ECT with simulated compared to the simulated ECT group. At the 12- and ECT and one compared unilateral ECT with simulated 28-week assessments, there was no significant diffe- ECT. The final trial (Brandon et al. 1985) had two rence between the groups. The disappearance of this experimental groups, comparing right unilateral ECT, difference could be attributed to the unrestricted use of bilateral ECT and simulated ECT. drugs in the follow-up period. In addition, those in the Five out of the six trials found real ECT to have a simulated group were more likely to be prescribed a greater antidepressant effect than simulated ECT. The course of real ECT in the follow-up period (20 out of 34 trial in which no significant difference was seen used versus 17 out of 43; p=0.04) and additional courses had unilateral electrode placement rather than bilateral a greater number of treatments for those in the electrode placement (Lambourn & Gill 1978). simulated group compared to the real group (6.77 versus In the Freeman trial (Freeman et al. 1978), the 5.24 treatments). simulated ECT group received two simulated treatments Gregory and colleagues (1985) carried out another in week 1, followed by real treatments twice-weekly trial, but this time comparing bilateral ECT, unilateral from week 2. The real ECT group received real treat- ECT and simulated ECT. Whilst five patients received ments twice-weekly from the start. As such, the simu- additional drugs unique to them during the treatment lated group were ‘delayed’ by 1 week and two real period, the drugs used are clearly stated (the research treatments. After two treatments, the real ECT group team decided that it was unethical to stop these). Their were significantly less depressed than the simulated results are statistically significant during the treatment group by all measures other than the Beck self-rating period, finding bilateral ECT and unilateral ECT to be depression scale. After this time, the simulated ECT more effective than simulated ECT, and bilateral ECT group caught up with the real ECT group such that there having the fastest speed of response. was no significant difference in depression scores after the final treatment. The mean number of treatments for DISCUSSION the simulated group was 7.15 (including the two simulated treatments) and 6.0 for the real ECT group, Whilst most of the trials provide support for real suggesting that factors other than the electrical stimulus ECT, differences exist in the use of medications during had a part to play in the recovery of the patients. the trials and the treatment prescribed after the ECT Lambourn and Gill found no benefit of real ECT course. Differences in the anaesthetic and other medica- over simulated ECT in terms of improvement in symp- tions used as part of the procedure make the studies less toms, as measured by the Hamilton rating scale for comparable. In four of the trials, antidepressant drugs depression. Unilateral electrode placement is used, were either stopped or standardised during the treatment rather than bilateral electrode placement. At the time of period. In the Freeman trial, however, patients were the study (1978), it may not have been fully understood allowed to continue taking their antidepressant drugs that the efficacy of unilateral ECT is strongly dose- throughout the study, which is a weakness in their related, which could explain the absence of a significant methodology. In the Gregory trial, five out of sixty-nine difference. patients received additional drugs in the treatment In the Northwick Park trial (Johnstone et al. 1980), a period, but this was due to ethical considerations, rather statistically significant advantage was found in the than poor trial design. Hamilton scores over the 4-week treatment period, but In the Freeman trial, had the simulated treatments not the Leeds and nurses’ rating scales. Additionally, been of equivalent effect to the real treatments, it would the advantage was not maintained at the 1- and 6-month be reasonable to assume that the simulated group would

S503 S504 Alexander Bow: IS ELECTROCONVULSIVE THERAPYANYMORE ELECTROCONVULSIVE Alexander Bow: IS

Table 1. A Comparison of Studies Investigating Simulated ECT and Real ECT Blinding and Study Intervention and patient treatment Metrics Results summary Conclusion stated Randomisation 2018; Vol. 30, Suppl. 7, pp 502-507 Danubina, Psychiatria DEPRESSION? TREATMENT-RESISTANT IN Freeman Not blinded: ECT N=20 for real and simulated groups. The real HRSD, visual After two treatments, greater “The results show that ECT is et al. 1978 doctor, anaesthetist group received bilateral ECT twice weekly from analogue scale, improvement in real group by all clearly superior to simulated and ECT nurse. week one. The simulated group received Wakefield and Beck measures except the Beck score ECT.” Other clinicians simulated ECT twice in week one followed by self-rating depression (no significant difference). and assessors were twice weekly real bilateral ECT from week two. scales. Subsequent ‘catch-up’ so there blinded. Random Identical anaesthesia used. Patients were allowed are no significant differences allocation. to continue pharmacotherapy. after the final treatment. Mean total number of treatments was 6.0 for real and 7.15 for simulated. Lambourn & Assessor was N=16 for real and simulated groups. The real HRSD, global assess- No significant difference “… the effectiveness of Gill 1978 blinded, as was the group received brief pulse unilateral ECT three ment of improvement between the two groups in terms unilateral brief pulse ECT… referring doctor. A times a week for two weeks. The simulated by the referring of improvement in Hamilton is due in large part to the

constrained random group received the same treatment except no doctor one day after score. 5 patients failed to attendant procedures SIMULATEDEFFECTIVE EL THAN procedure based on electrical stimulus was applied. Psychotropic the six treatments, improve at all from the treatment associated with the age and sex. drugs were discontinued during the treatment days in hospital and (4 of which were from the administration of an period except for benzodiazepines. treatment received in simulated group). Six patients anaesthetic and the mystique the one-month did not complete the one-month associated with an unusual follow-up. follow-up. form of treatment.” Johnstone Not blinded: N=70 overall (Assume N=35 for each group). 62 HRSD, Leeds rating Significant results established for “… our findings suggest that et al. 1980 anaesthetist and completers. Real ECT group received 8 real scale and nurses’ the HRSD, but not the Leeds or the antidepressant effects of ECT doctor. All bilateral ECT treatments over 4 weeks. Control rating scale. Present nurses’ rating scales. No repeated electrically induced other parties group received 8 simulated procedures. State Examination. difference at the one month and convulsions are of relatively blinded. Random Antidepressants stopped for treatment period. 6-month follow-up between the short duration.” allocation. groups. THERAPY ECTROCONVULSIVE Alexander Bow: IS ELECTROCONVULSIVE THERAPYANYMORE ELECTROCONVULSIVE Alexander Bow: IS

Table 1. Continued Blinding and Study Intervention and patient treatment Metrics Results summary Conclusion stated Randomisation

West et al. 1981 Patients and N=11 for real and simulated groups. Bilateral Visual analogue scale, Significant improvement by all “In this study, electric 2018; Vol. 30, Suppl. 7, pp 502-507 Danubina, Psychiatria DEPRESSION? TREATMENT-RESISTANT IN assessors were ECT used twice weekly for three weeks. nurses’ rating scale measures for the real group, but convulsion therapy was blinded. Random Simulated group received simulated procedures. and Beck Depression not the simulated group. 10 shown to be an excellent allocation. All received 50 mg Amitriptyline at night. No Inventory. patients entered the crossover treatment of severe other medications were prescribed. phase (all from the simulated depressive illness. The group) and there was a question of further treatment significant improvement in all after the initial study was not measures. investigated.” Brandon Extensive efforts to N=53 for real ECT and N=42 for simulated A comprehensive N=77 for analysis. The real ECT “We believe that our data et al. 1984 ensure blinding were ECT. Real group given bilateral ECT twice rating package inclu- group showed greater indicate that carried out. Random weekly. Maximum of eight treatments over 4 ding the HRSD at the improvement at the 2-week and electroconvulsive therapy is allocation. weeks. Control group received simulated initial interview. Then 4-week assessments. This an effective and rapidly procedures. Only anxiolytics were prescribed assessment at 2 difference was not maintained at acting treatment for severe during the trial. After the trial, antidepressants weeks, 4 weeks, 12 12 and 28 weeks. 11 out of 43 depressive illness and that its

were prescribed freely. weeks (one month real ECT patients did not need use should be favoured in SIMULATEDEFFECTIVE EL THAN after last treatment) all eight treatments, compared to patients at risk of suicide and 26 weeks (6 just 2 out of 34 simulated ECT because of the rapidity of months after last patients. response.” treatment). Gregory Assessors and N=23 for each group. Patients were randomly A comprehensive Bilateral and unilateral ECT “… the passage of electricity et al. 1985 clinicians allocated to receive either bilateral ECT, right rating package were both significantly better is an important part of the responsible for the unilateral ECT or simulated ECT twice weekly (including the HRSD than simulated ECT, using either ECT procedure. Both patients were for three weeks. Small doses of benzodiazepines and MADRS) MADRS, HRSD or PIRS scores, bilateral and unilateral ECT blinded. Random given during the study and 5 patients received initially. MADRS or percentage change scores. are highly effective, but allocation. additional drugs during the study. after every two Differences were not maintained unilateral requires more treatments and a final after treatment. Speed of onset treatments, and the speed of THERAPY ECTROCONVULSIVE assessment to include was slower for unilateral ECT response is probably slower.” the MADRS, PSE, compared to bilateral ECT. PIRS and HRSD. S505 Alexander Bow: IS ELECTROCONVULSIVE THERAPY ANY MORE EFFECTIVE THAN SIMULATED ELECTROCONVULSIVE THERAPY IN TREATMENT-RESISTANT DEPRESSION? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 502-507 require the same total number of treatments as the real type would be very difficult owing to contemporary ECT group to achieve the same improvement in ethical considerations, making further analysis of symptoms. However, the simulated ECT group required existing trials necessary. The data itself consistently 7.15 treatments, whilst the real ECT group required only shows an advantage of bilateral ECT over simulated 6.0. This indicates that the electrical stimulus provided ECT. On balance, it can be reasonably concluded that an antidepressant effect, but also that improvement was real ECT is superior to simulated ECT in terms of not solely due to the electrical stimulus (in which case a alleviating TRD, despite the weaknesses identified. full 2 additional treatments would be required). Thus, the electrical stimulus does have an antidepressant In the Northwick Park trial (Johnstone et al. 1980), a effect and the improvement in depressive symptoms is statistically significant advantage of real ECT over not solely due to the placebo effect or increased medical simulated ECT was found with the Hamilton rating attention. scale, but not the nurses’ rating scale or the Leeds rating It is therefore prudent to encourage further research scale. This discrepancy was largely neglected in the into the mechanism of action of ECT and refining the results and discussion, which makes drawing a techniques used (such as the electrode placement and confident conclusion from this trial difficult. the properties of the electrical stimulus). Its continued In the trial by Gregory and colleagues, the data ana- and increasing clinical use in England and elsewhere is lysis is not entirely clear with regards to withdrawals. In justified and it remains a valuable treatment in the figure, the ‘number on whom complete data avail- combating TRD. able’ is given as a higher number than the number of participants minus the withdrawals, so some of the withdrawals had been included in the analysis. This Acknowledgements: ambiguity reduces the credibility of the paper. In I would like to thank Dr Mark Agius for his help in re- contrast, the Leicestershire trial (Brandon et al. 1984), viewing the original text. I would also like to thank which found real ECT to be significantly better than Patrick Warren for his help in reviewing a later copy of simulated ECT, had the advantages of a large sample the text. size and complete cessation of antidepressant drugs during the treatment period. Conflict of interest: None to declare. The two main rating scales used to measure the severity of depression are the Hamilton Rating Scale for Depression (HRSD; Hamilton 1960) and the Mont- References gomery Åsberg Depression Rating Scale (MADRS; Montgomery & Åsberg 1979). Whilst the HRSD is the 1. Bagby RM, Ryder AG, Schuller DR & Marshall MB: The most commonly used measure of depression, it has clear Hamilton Depression Rating Scale: Has the Gold weaknesses. Critics of Hamilton’s scale argue that Standard Become a Lead Weight? American Journal of Psychiatry 2004; 161:2163-2177 heterogeneity exists within the rating descriptors (i.e. 2. Barnes R: Information about ECT (Electro-convulsive the- the items do not measure a single symptom), the rapy). Royal College of Psychiatrists, 2015. Retrieved from reliability of the scale is poor, it is insensitive to change https://www.rcpsych.ac.uk/healthinformation/treatmentsan (thus reducing the apparent efficacy of treatments used dwellbeing/ect.aspx in clinical trials), and it provides no justification for the 3. Brandon S, Cowley P, McDonald C, Neville P, Palmer R & differential weighting of items (some items score a Wellstood-Eason S: Electroconvulsive therapy: results in de- maximum of 4, whereas others score a maximum of 2) pressive illness from the Leicestershire trial. British Medi- (Bagby et al. 2004). Whilst this is not the focus of this cal Journal (Clinical Research Edition) 1984; 288:22-25 discussion, it is important to realise that many of the 4. Davis N & Duncan P: Electroconvulsive therapy on the rise th trials discussed above rely on this scale which has again in England. The Guardian, 17 April 2017. Retrieved significant shortcomings. from https://www.theguardian.com/society/2017/apr/17/ electroconvulsive-therapy-on-rise-england-ect-nhs 5. Freeman CPL, Basson JV & Crighton A: Double-Blind CONCLUSION Controlled Trial of Electroconvulsive Therapy (E.C.T.) and Simulated E.C.T. in Depressive Illness. The Lancet When evaluating each of these trials in turn, it is 1978; 311:738-740 apparent that weaknesses exist in all of them. However, 6. Gregory S, Shawcross CR & Gill D: The Nottingham ECT in many cases these weaknesses arise because of the Study. British Journal of Psychiatry 1985; 146:520-524 difficult nature of conducting a well-designed trial for 7. Johnstone EC, Lawler P, Stevens M, Deakin JFW, Frith this indication, as described in the introduction. Five out CD, Mcpherson K & Crow TJ: The Northwick Park of the six trials demonstrated an advantage of real ECT Electroconvulsive Therapy Trial. The Lancet 1980; 316:1317-1320 over simulated ECT. The trial by Lambourn and Gill 8. Lambourn J & Gill D: A Controlled Comparison of used only unilateral ECT, which may not have been Simulated and Real ECT. British Journal of Psychiatry administered effectively due to a low charge being used. 1978; 133:514-519 Unfortunately, undertaking further clinical trials of this

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9. NICE: Depression in adults: recognition and manage- 10. West ED: Electric convulsion therapy in depression: a ment. Clinical guideline, 2009. CG90. 1.10.4 Electrocon- double-blind controlled trial. British Medical Journal vulsive therapy (ECT). Retrieved from (Clinical Research Edition) 1981; 282:355-357 https://www.nice.org.uk/guidance/cg90/chapter/1- Guidance#step-4-complex-and-severe-depression

Correspondence: Alexander Bow, BA (Cantab) University of Cambridge, Emmanuel College Cambridge, CB2 3AP, UK E-mail: [email protected]

S507 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 508-510 Conference paper © Medicinska naklada - Zagreb, Croatia

A POST-TRAUMATIC STRESS DISORDER REVIEW: THE PREVALENCE OF UNDERREPORTING AND THE ROLE OF STIGMA IN THE MILITARY Hayley P. Johnson1 & Mark Agius2 1Clinical School, University of Cambridge, Selwyn College Cambridge, Cambridge, UK 2Clare College Cambridge, Department of Psychiatry, University of Cambridge, Cambridge, UK

SUMMARY Exposure to traumatic events has been a part of human existence since the beginning of time; however modern lifestyles and developments mean that the majority of the population are spared the affliction of extreme trauma. The military, however, are one subgroup of individuals who are actively and repeatedly exposed to terrifying events on a regular basis, putting them at risk of developing "Post-Traumatic Stress Disorder" (PTSD). Despite this, the prevalence of PTSD reports in the UK military remains lower than its international allies, suggesting this value may be an underestimation of the true prevalence. Wider investigation of the potential causes of this has highlighted the stigmatization of mental illness in the military as the key barrier to the help-seeking behaviours. However, the effect of national de-stigmatization programs on PTSD help seeking is unclear. This review aims to determine the prevalence of PTSD within the UK military in the context of other international powers and examine how stigmatization of mental illness in military may contribute to this. The international value of de-stigmatization programs will be debated and future directions for research suggested.

Key words: PTSD – stigma - military

* * * * * INTRODUCTION mental health difficulties within the military society (Hoge 2004). Because of this, many of the studies Post-traumatic stress disorder (PTSD) may develop tasked with estimating the prevalence of PTSD within after ‘a stressful event or situation of an exceptionally the UK military are likely to generate underestimations threatening or catastrophic nature, which is likely to of the true value (Baines 2017, Yehuda 2014). Given cause pervasive distress in almost anyone’ (ICD-10 the fact that the key barrier to help-seeking behaviours definition). If left untreated, PTSD can become chronic in those with PTSD has been identified as stigma; and complex, leading to more sinister behavioural international discrepancies in mental illness-related issues, including attempted suicide and harm to others stigma and differences in de-stigmatization programs (Bachynski 2012, Jakupcak 2009, Pietrzak 2009). It has should be considered as a potential cause for this. been demonstrated that appropriate and timely follow- up programs coupled with evidence-based individua- THE ROLE OF STIGMA: A WORTHWHILE lized therapies could effectively lead to a cure (Sunil J CANDIDATE FOR REDUCED Wimsalawansa n.d.), stressing the need to understand HELP-SEEKING BEHAVIOURS? and remove any perceived barriers to accepting care. The key barrier to help-seeking behaviours in those with Stigma is defined as a ‘negative and erroneous atti- PTSD has been identified as perceived stigmatization of tude about a person, a prejudice, or negative stereotype the disorder (Murphy 2015). (Corrigan 1999). Concern about the effects of mental Self-administered questionnaires have generated illness-related stigma has been the focus and precipi- prevalence estimates for UK veterans who served in tator of much of the reasoning behind the reduced help Iraq and Afghanistan which range from 3.4% to 6% seeking behaviours of combat-exposed UK military (Browne 2007, Hotopf 2006, Mulligan 2010). However, personnel. Not only have military subjects reported larger scale studies in the US indicate that PTSD may be barriers to receiving mental health care (Greene-Shor- a highly prevalent disorder among U.S. service men and tridge 2007), but records indicate that soldiers with women returning from current military deployments, mental health problems are more likely to be prema- with prevalence estimates as high as 14–16% (Milliken turely discharged from the UK Armed Forces (Iversen 2007, Tanielian 2008), suggesting the UK estimates are 2005, Jones 2010). These deterrents make it unsur- on the lower end of the international spectrum. How- prising that a negative relationship between stigma and ever, developing accurate estimates for the prevalence help seeking for mental health difficulties within the of PTSD within the UK military is challenging not only armed forces has been identified (Coleman 2017). due to poor follow up of veterans treated in the NHS In light of this, international discrepancies in mental (Committee 2017), but also due to the stigma and illness-related stigma and differences in de-stigma- potential career compromise associated with disclosing tization programs may be what contribute to the reported

S508 Hayley P. Johnson & Mark Agius: A POST-TRAUMATIC STRESS DISORDER REVIEW: THE PREVALENCE OF UNDERREPORTING AND THE ROLE OF STIGMA IN THE MILITARY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 508-510 international discrepancies in PTSD prevalence. How- CONCLUSION ever, a closer examination of these de-stigmatization programs reveals that not only do they fail to account The relationship between stigma and care seeking in for the inter-military differences in PTSD-prevalence, the military is complex. Several trials have been con- but they also fail to produce a significant outcome with ducted to improve the numbers of people seeking treat- regard to reported incidences of PTSD post-trial. A ment by aiming to reduce stigma; however the efficacy large randomised controlled trial of post-deployment of these interventions remains unclear. Inconsistencies mental health screening in Regular Service personnel and contradictions within the research stress the need to was recently conducted in the U.S., in which individuals examine more closely the dimensions involved in help were trained within each unit to identify risk factors in seeking attitudes; in particular this paper has identified a individuals exposed to traumatic situations (trauma risk need to address and control for the existence of public management; “TRiM”). However, this study did not and self-stigma in future research in order to determine yield an effect on levels of reported PTSD within the utility of international de-stigmatization programs. subjects. Researches in the UK have also launched two recent initiatives aimed at de-stigmatising PTSD; the most successful being ‘Combat Stress’, which provides Acknowledgements: None. 24-hour help line and community outreach free of charge and has been proven highly effective (Murphy Conflict of interest: None to declare. 2017, Kaur 2016, Murphy 2016). However, this British Army initiative has been criticized as it lacks a single Contribution of individual authors: program to educate its soldiers on those services avail- This review was searched and drafted by Hayley P. able to them (Bale 2014). John Bale, the CEO and co- Johnson and supervised by Mark Agius founder of “Soldier on”, argues that to reach the modern veteran all forms of media must be utilized, particularly social media. References In addition to the lack of effect of various de-stigmatization programs, the data exploring the relationship 1. Bachynski KE, Canham-Chervak M, Black SA, Dada EO, between stigma and help seeking in the UK military is Millikan AM & Jones BH: Mental health risk factors for also not unanimous. Sharp et al. (2015) found that suicides in the US Army. Injury Prevention 2012; 18:405-412 subjects who endorsed high-anticipated stigma still 2. Baines LS, Mitchell L, Long K, Abbot C, Clarke N, Tyler D, Khan F: Post-deployment screening for mental dis- utilized mental health services and were interested in orders and help-seeking in the UK military. Lancet 2017; seeking help. In addition, other studies show that 390:553–554 military personnel who reported a disproportionate 3. Bale J: PTSD and Stigma in the Australian Army. 2014; amount of mental illness-related stigma were more Retrieved from http://www.army.gov.au/~/media/Army/ likely to seek care than those who did not (Weeks Ourfuture/Publications/Papers/ARP3/Bale_PTSDandStig 2017). Gould et al. (2010) explored the potential role ma_B5_web_9Oct.pdf of cultural differences in stigma between Armed 4. Browne T, Hull L, Horn O, Jones M, Murphy D, Fear NT, Forces; however found that the pattern of reported Hotopf M: Explanations for the increase in mental health stigma and barriers to care was similar across the problems in UK reserve forces who have served in Iraq. Armed Forces of all US, UK, Australian, New Zealand British Journal of Psychiatry 2007; 190:484-9 and Canadian militaries. 5. Coleman SJ, Stevelink SAM, Hatch SL, Denny JA & Greenberg N: Stigma-related barriers and facilitators to Perhaps the most important methodological limi- help seeking for mental health issues in the armed forces: tation of the above studies is that they have not ade- a systematic review and thematic synthesis of qualitative quately differentiated between two very important sub- literature. Psychological Medicine 2017; 47:1880-1892 types of stigma: anticipated “self-stigma” and perceived 6. Committee D: Mental Health and the Armed Forces. Part “public-stigma”. Anticipated self-stigma refers to inter- One: The Scale of mental health issues, 2017 nalization of negative stereotypes about people who seek 7. Corrigan PW & Penn DL: Lessons from social psychology help, whereas perceived public stigma refers to dis- on discrediting psychiatric stigma. American Psychologist crimination and devaluation by others (Pattyn 2014). 1999; 54:765-76 Indeed, it has been shown that these two stigma dimen- 8. Gould M, Adler A, Zamorski M, Castro C, Hanily N, Steele sions require different mitigation strategies; for example, N, Greenberg N: Do stigma and other perceived barriers to a study by Pattyn et al. (2014) showed that test subjects mental health care differ across Armed Forces? Journal of the Royal Society of Medicine 2010; 103:148-56 with higher levels of anticipated self-stigma allocated 9. Greene-Shortridge TM, Britt TW & Castro C: A.The less importance to formal care provided by health-care Stigma of Mental Health Problems in the Military. professionals, whereas those who perceived higher Military Medicine 2007; 172:157–161 levels of public stigma rated informal help seeking as 10. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI less important. It may be that the presence of these & Koffman RL: Combat Duty in Iraq and Afghanistan, dichotomous forms of stigma confound the studies Mental Health Problems, and Barriers to Care. New discussed and underpin the inconsistency in research. England Journal of Medicine 2004; 351:13-22

S509 Hayley P. Johnson & Mark Agius: A POST-TRAUMATIC STRESS DISORDER REVIEW: THE PREVALENCE OF UNDERREPORTING AND THE ROLE OF STIGMA IN THE MILITARY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 508-510

11. Hotopf M, Hull L, Fear NT, Browne T, Horn O, Iversen A, UK veterans with military-related PTSD: an observational Wessely S: The health of UK military personnel who study. BMJ Open 2016; 011667 deployed to the 2003 Iraq war: a cohort study. Lancet 20. Murphy D, Parry B, Busuttil W: Exploring the Efficacy of 2006; 367:1709-10 an Anger Management Programme for Veterans with 12. Iversen A, Nikolaou V, Greenberg N, Unwin C, Hull L, Post-Traumatic Stress Disorder. Journal of Psychiatry Hotopf M, Wessely S: What happens to British veterans and Cognitive Behaviour 2017 v:JPCB-117 when they leave the armed forces? European Journal of 21. Pattyn E, Verhaeghe M, Sercu C & Bracke P: Public Public Health 2005; 15:175-84 Stigma and Self-Stigma: Differential Association With 13. Jakupcak M, Cook J, Imel Z, Fontana A, Rosenheck R & Attitudes Toward Formal and Informal Help Seeking. McFall M: Posttraumatic stress disorder as a risk factor Psychiatric Services 2014; 65:232-8 for suicidal ideation in Iraq and Afghanistan war 22. Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, veterans. Journal of Traumatic Stress 2009; 22:303-6 Southwick SM: Perceived stigma and barriers to mental 14. Jones N, Fear NT, Jones M, Wessely S & Greenberg N: health care utilization among OEF-OIF veterans. Long-Term Military Work Outcomes in Soldiers Who Psychiatric Services 2009; 60:1118-22 Become Mental Health Casualties When Deployed on 23. Tanielian T, Jaycox LH, Adamson DM, Burnam MA, Burns Operations. Psychiatry: Interpersonal and Biological RM, Caldarone LB, Yochelson MR: Invisible Wounds of War: Processes 2010; 73:352-64 Psychological and Cognitive Injuries, Their Consequences, 15. Kaur M, Murphy D & Smith KV: An adapted imaginal and Services to Assist Recovery. RAND Corporation 2008; 60 exposure approach to traditional methods used within 24. Sharp ML, Fear NT, Rona RJ, Wessely S, Greenberg N, trauma-focused cognitive behavioural therapy, trialled Jones N & Goodwin L: Stigma as a barrier to seeking with a veteran population. The Cognitive Behaviour health care among military personnel with mental health Therapist 2016; 9:1- 11 problems. Epidemiologic Reviews 2015; 37:144-62 16. Milliken CS, Auchterlonie JL & Hoge CW: Longitudinal 25. Wimsalawansa SJ: Post-Traumatic stress disorder: An Assessment of Mental Health Problems Among Active and underdiagnosed and under-treated entity. Comprehen- Reserve Component Soldiers Returning From the Iraq sive Research Journal of Medicine and Medical Science War. JAMA 2007; 298:2141-8 2013; 1:1-12 17. Mulligan K, Jones N, Woodhead C, Davies M, Wessely S 26. Weeks M, Zamorski MA, Rusu C & Colman I: Mental & Greenberg N: Mental health of UK military personnel Illness–Related Stigma in Canadian Military and Civilian while on deployment in Iraq. British Journal of Psychiatry Populations: A Comparison Using Population Health 2010; 197:405-10 Survey Data. Psychiatric Services 2017; 68:710-716 18. Murphy D & Busuttil W: PTSD, stigma and barriers to 27. Yehuda R, Vermetten E, McFarlane AC & Lehrner: A. help-seeking within the UK Armed Forces. Journal of the PTSD in the military: Special considerations for under- Royal Army Medical Corps 2015; 161:322-6 standing prevalence, pathophysiology and treatment 19. Murphy D, Spencer-Harper L, Carson C, Palmer E, Hill K, following deployment. European Journal of Psychotrau- Sorfleet N, Busuttil W: Long-term responses to treatment in matology 2014; 5:25322

Correspondence: Hayley P. Johnson, BA (Cantab) University of Cambridge, Selwyn College Cambridge, CB3 9DQ, UK E-mail: [email protected]

S510 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 511-514 Conference paper © Medicinska naklada - Zagreb, Croatia

THE ROLE OF THE SOCIAL NETWORKS, BETWEEN A UTILITY AND A NEW ADDICTION Annalisa Colucci Neamente Association, Naples, Italy CTU (Court appointed expert), Court of Nola, Naples, Italy

SUMMARY The reality of social networks in recent years has taken on new and enriching scenarios, to learn more about the problems and complex dynamics of life that surround the generations of preadolescents and adolescents. This work has matured over several years, interacting with schools in the Campania region (southern Italy), meeting and talking with teachers, parents and students, observing the reality that surrounds them. The territory of Naples and its province was the one in which the activity was mainly carried out. It has been found that the new frontiers of youth language find their maximum form of exposure in sharing, exhibition, media "exposure", through the channel of the narration of their daily life "live" (most of the time), often it implies a high probability of incurring dangers and dangers that are difficult to manage, as "children" of an age in which to exhibit is in conformity with the historical moment. The definition given by the experts is "Digital Natives", “Digital Immigrants” are adults, who have a different and less fluid approach compared to the reality of youth. Dangers, pitfalls and others are amplified through the simple sharing of one's own experiences. This work benefited from the help of various professional figures, which made sure that some difficult aspects and contexts could emerge. Some problems of this reality linked to social networks are distinguished in a more specific and authentic way.

Key words: social network - Internet addiction - grooming (priming) – hikikomori – loneliness- social phobia

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INTRODUCTION difficulties in interacting and relating to each other, due to the lack in some contexts of "emotional reactions" to In this work the presentation of an Italian reality, events. Until a few decades ago, the youth contexts through a more accurate and complete vision of the life were linked to interactions with the "familiarity" of their aspects of most of the adolescents of this territory, has context, because they behaved according to examples of been of great impact. The collection of data that emer- parents, siblings, grandparents. Now the experiential ged from a large part of the territory has brought out an experience is observed, cultivated, often elaborated interesting psychophysical and emotional involvement through the social network, which works for images and for many students, teachers and parents, often not aware not emotions through sensory experience, but through of the correct management linked to certain situations. It the visual and the auditory, penalizing the sense of smell has been found that there is a new type of behavior and touch, important in the sphere of the senses, to related to addiction, through the exchange of informa- know emotions and sensations. The topics touched tion in the network, and there is a multifaceted lan- mainly, the compliant problems and finally the interface guage, which is fascinating and at the same time dan- with pupils, parents and teachers led to review and gerous, because the network is a resource for everyone, reiterate very clearly some studies to refer to. but also a source of dangers and pitfalls, traps from which it is difficult to get out of it. METHODOLOGY

SOCIAL NETWORK ... The team made up by "network" specialists (psycho- NEW CHALLENGE, NEW CHANGE ... logist, law enforcement specialists in communication, OR NEW ADDICTION? pol postal), with active participation in some contexts of teachers and parents. Presentation of the difficulties and During these years of "knowledge" of the resources dangers of the network, cognitive exposition of the and problems of social networks in Campania through problematic; cognitive questionnaire (questions related meetings, but also conferences and seminars in schools, to competence, social experience, use if considered it was found that the institutions have visited in the "aware and safe" with examples of peers involved in same way the behavior at risk for both boys and girls for risky activities for themselves and others), assessment adults, especially in communication that is not always of the degree of knowledge and sharing of the network understandable, because it is not "on par" between the by boys (teenagers from 10 to 18 years of age), then different generations. Despite the meeting between the with the vision of some movies, shows the importance adult world and the youth world has always been and effectiveness of "mirror neurons", studied by difficult to manage, the new generations have important Gallese, Rizzolati et al. (1996) and their functionality.

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Table 1. Epidemiological data School Year Students (numbers) School visited (number) Teachers (number) Parents (number) 2014/2015 7502 54 653 667 2015/2016 30975 228 2665 2033 2016/2017 31060 240 2750 2118 2017/2018 31900 280 2798 2958

Mirror neurons are a class of neurons which are involves not only a new language, but also a Challenge selectively activated both when we perform an action in which digital immigrant adults cannot access, which and when we observing it activate areas that allow both implies many difficulties. the observer and the observed subject to perform the Intentional consonance same action. They activate what happens in the subject's In the phenomenological field intersubjectivity is mind. In fact, many children tell of episodes of important; the consonance is the non-alienation from the "emulation", or "popularity syndrome" to be part of a actions, from the emotions or sensations that others feel, role-playing game that seems important to them; various the world of others with ours. Thanks to the mechanisms risk situations have emerged in the network where most of mirroring and simulation, the other is experienced as of the adolescents are involved, precisely because they "other self", this "mirror" character is sometimes syno- often expose a private trait, without understanding the nymous with decoding other people's feelings, through real unknowns they will encounter. The overwhelming social networks some problematic situations do not have difficulty is related to the comparison with adults such decoding. ("digital immigrants"), because less experts of children with technology and less prepared to damage "veiled" Embodied simulation on the net. This amplifies the "dependence" on the Considering the cognitive strategy allows the expe- network, also creating episodes of stress, discomfort rience of the other, Welsh speaks of a Multiple Cogni- from "deprivation from the network". At the end of the tive System. Communication or understanding takes meeting, the return is often of great impact, since there place through the reciprocity of intentions. is an observation that the reality of social media is of This implies the difficulty in the future of having to great impact, however it is a probable weapon (bomb), constantly "conform" to what is continually propitiated of very difficult management. by social media, television sources, etc. Different beha- The work of interaction begins through sharing, viors have led some boys to be victims of cyberbullying, "focus group" or through stories in which children leave and to suffer from problems of stress, anxiety or de- freedom and space to their thoughts, fears, uncertainties pression. Table 2 shows the main risk behaviors . and often also to their safety with respect to the knowledge of the dangers and the belief that they manage to Table 2. Risk behaviors manage everything. An effective and synergistic inter- Specific disorders (obsessive-compulsive); vention for the purposes of work, to understand the real Compromised circadian rhythm; difficulties, but created a communicative space in which Telematic solipsism; to compare. IAD (Internet addiction disorder); Relationship Difficulty; RESULTS H syndrome (isolation to navigate); The Table 1 illustrates not only the growth com- Second life (automatism, deprivation) pared to the demand, but also the request for the training Depression; experience and the great involvement that has led to an Real relationships, greater needs; important success. Bullying, cyberbullying (Menesini, intentional social exclusion); “Internet addiction” Surgical operations in the carpal tunnel; Waking up and as a first thought check who is Insomnia; online or if someone has "posted" or "shared" or com- Irregularity of meals; mented photos, states, this is a form of Addiction a Nomophobia (blood pressure); condition of dependency characterized by patterns of Reduction of melatonin function in the brain. "dysfunctional" behavior with a constant desire for control against his will, with repercussions on the psychophysical level. Addiction has the same effect as Feedback of emerging problems. substance dependence. Change consists in perceiving In ALL the schools there were moments of hardship through the brain, but also the organism. Sharing in bringing out circumstances, episodes in which there emotions through the network and in the network was a suspicion linked to an eventuality of risk for the

S512 Annalisa Colucci: THE ROLE OF THE SOCIAL NETWORKS, BETWEEN A UTILITY AND A NEW ADDICTION Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 511-514 boy. Almost everyone was contacted by Fake (false Knockout game - extreme game, you hit a passer- profiles), probably victims of jokes among peers... other by and you throw it on the ground, even kicks and times by adults with intent about something else. The punches; greatest probabilities of risk emerging are related to Planking, eyeball - amaze, challenge, get noticed; grooming. Balconing - launch from the balconies; Grooming Horsemanning - body separated from the head, decapitation illusion; Priming, charm of the many characters that are present on the net. Because of techniques of multimedia Chocking - suffocation, oxygen blockage to the and psychological manipulation, the victim suffers the brain; charm of a character, throgh online knowledge and can Eyebanning - pour on alcoholic eyes. incur harmful situations for himself or his family. Depressive phenomenon Idealization of the character Several studies have dealt with the depressive The idealization of the character involves six phases: phenomenon with social abuse, Instagram would be 1) election of the victim; the worst. A British survey (Royal Society for Public 2) Creating friendship; Health), through a sample of young people (nr 1479) 3) Creation of the relationship; between 14 and 24 years, has studied how young people 4) Risk assessment; suffer the social phenomenon and how they suffer risks 5) Exclusivity of the relationship; for their mental health. We move from pro-anorexia to 6) Physical relationship/ sexuality. the more complex phenomena of self-harm, up to the "mediaticity" of suicide. THIS CRUSH The phenomena that affect the boys most are the lack of expressiveness; anxiety and depression (forms of It's a social network to get insulted (Instagram). New exclusion throws in panic); disconnection; unrealistic fashion, new social: allows you to post, even ano- representation of the body (second life); famous or nymously, messages with content mainly rich in insults, followed profiles involve the risk of depression; violence and sexual sphere in very vulgar form. The depersonalization. However, the subjects at risk do not problem that emerged is that of cyberbullying that always through the "like" change their malaise, their would "explode" even more. Teenagers who "target" state linked to the disease. other teenagers. Luca Pisano, psychologist and psychotherapist, internal supervisor of the national observatory, HIKIKOMORI recently reported this social, highlighting the dangerous aspects, because it works like a real media pillory; the Hikikomori is a phenomenon known, viral and problem is that to make use of it more are the boys of 12 present in almost all families who have a teenager at years, the age of children on the net decreases more and home. It has the following characteristics: stay in dis- more, without "protection". There have been episodes of parts; insulate; withdrawal; social withdrawal; 90% defamation, parents are unfortunately not informed of male cases: medium high social extraction; unique the relevant danger. children, graduated parents; autostima / revaluation; physical / school foby. Kiki Challeng "In My Feelings" by Drake, the track record of the CONCLUSIONS summer, a record, in which the Canadian rapper tells the attempt to regain the woman he loves. In the video During these years the field experience has had an appear some international celebrities, such as Phylicia enormous response with optimal feedback; in every Rashad or Shiggy, the comedian that with a video on reality, the territory forms and influences the growth of Instagram has made viral in a very short time the children, social networks are a great resource, but also choreography born on the notes of the single of Drake. a large container of deception and also makers of Thus began the "Kiki Challenge", improvised "addictions" that are now on par with "addictions to dance moves on the refrain of the song "Kiki, do you drugs." worrying relationship between social and love me?". But if the comedian was dancing on the depression should reflect on the use "improper", the street, the phenomenon with the hashtag phenomenon does not only affect adolescents, but also #DoTheShiggy became viral and many users were a large share of adults, already suffering from improvised dancers, getting caught while they drifted relational problems, low self-esteem and depressive down from the cars in the race, causing concern for aspects. the danger.

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problems: è un libro o un articolo? Mancano le referenze Acknowledgements: Baratta A. Chat and instant messaging, Apogeo, Monza, 2006 Thanks to the P.D Silvestri D. ssa Fabiola, Manager 6. Bouna-Pyrrou P, Mühle C, Kornhuber J, Lenz B: Internet of the Postal and Communications Police "Campania" gaming disorder, social network disorder and laterality: for the availability and professionalism with which I handedness related to pathological use of social networks. could interface my work, thanks to Mrs. Rosaria Gal- J Neural Transm 2015; 122: 1187-1196 biati for speed and efficiency with which he accepted 7. Cantelmi T, Grifo LG: The virtual mind, Sanpaolo Edi- my requests, a special thanks to the Ass.C. Dr. Fran- tion, Milan, 2002 cesco Giobbe, in which I found great competence, 8. Cantelmi T: Online betrayals, Franco Angeli, Milan, 2006 effectiveness in interventions, love and professio- 9. Carli V1, Durkee T, Wasserman D, Hadlaczky G et al.: nalism for his immense work and for his territory, and The association between pathology and the use of for the synergy with which my professional requests comorbid psychopathology: a systematic review. were accepted, thank you very much; a heartfelt Psychopathology 2013; 46:1-13 thanks to Dr. Francesco Franza for the exchange and help in preparing everything, a thank you to Dr. 10. Ferree M: Women and the web: cybersex activity and Giuseppe Tavormina. implications, sexual and relationship therapy. Sexual and Thanks to my affections ... my beloved Rosalba, of Relationship Therapy 2003; 3: 385-393 great help… 11. Giusti E, Iacono M: Abuses and ill-treatment. Sovera, 2010 12. Giusti E, Militello F: Mirror neurons and psychotherapy. Conflict of interest: None to declare. Sovera, 2011 13. Lewis B: Raising Children in a Digital Age. Lion Hudson plc, Oxford, England, 2014 References 14. Padrini P: Chat place and time of communication and meeting. Effatà Editrice, Cantalupa, Torino, 2006 1. AA. VV: Chat, network relationship scenarios, Meltemi 15. Suler J: Cyberspace as psychological space (online). publisher, Rome, 2007 http://users.rider.edu/~suler/psycyber/decade.html, 1999 2. Aboujaoude E, Koran LM, Gamel N, Large MD, Serpe 16. Wallance P: The psychology of the internet. Raffaello RT: Potential markers for problematic internet use: a Cortina, Milan, 2000 telephone survey of 22.513 adults. CNS Spectr 2006; 17. Welsh V, Goldman A: Mirror neurons and the simulation 11:750-5 theory of mind-reading, Trends Cogn Sci 1998; 2:493-501 3. Abraham FD: Cyborgs, cyberspace, cybersexuality: the 18. Welsh V, Migone P, Eagle MN: The embodied simulation: evolution of everyday creativity in social and spiritual mirror neurons, the neurophysiological basis of inter- perspective (Ruth Richards, ed) APA, Washington DC, 2007 subjectivity and some implications for psychoanalysis. 4. Andreoli V: Digital life, Rizzoli, Milan, 2012 Psychotherapy & Human Sciences 2006; 3; 543-580 5. Arkowitz H, Westra HA, Miller WR, Rollnick S: The 19. Windley PJ: Digital Identities. New Techniques, Milan, motivational interview for the treatment of psychological 2006

Correspondence: Annalisa Colucci, MD Neamente Association via San Pietro 27, - 80035 Nola (NA), Italy E-mail: [email protected]

S514 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 515-520 Conference paper © Medicinska naklada - Zagreb, Croatia

OVERCOMING DEPRESSION WITH DANCE MOVEMENT THERAPY: A CASE REPORT Romina Tavormina1 & Maurilio Giuseppe Maria Tavormina2 1Centre of Psychology and Psychotherapy, Naples, Italy 2Mental Health Department, Naples, Italy

SUMMARY In our society that sets high standards of perfection to be ok and wins, the depressed is commonly considered as an outsider, a marginalized person unable to be in line with standards and rhythms fast and competitive of the time we live. So the social stigma against people who suffer from mood disorders is a very powerful factor that negatively affects the healing of patient. He is often isolated from the others for the fear of being judged “fool, crazy or dangerous” or discriminated and emarginated for his mental health problem. For this reason, a cornerstone of depression rehabilitation is the bringing out of the patient from his isolation, the reintegration of user in the social context with the increase and the improvement in the quality of interpersonal relationships in the family and in the external context. So in this way is possible an increase in the tone of mood and a reduction of the symptoms of depression. The method used in our project is the dance movement therapy. In particular, dancing the “Bachata”and later more spontaneous dance becomes a rehabilitation tool to express emotions through the body and to open to the world, on the territory, overcoming the fear of being judged by others, the prejudice and the social stigma about mental illness. This work presents the results of a case report of a depressed patient treated with dance movement therapy. Key words: depression - dance movement therapy - dance-group - psychosocial rehabilitation

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INTRODUCTION Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a Depression (major depressive disorder or clinical specific plan for committing suicide. depression) is a common but serious mood disorder. It causes feelings of sadness and/or a loss of interest in To receive a diagnosis of depression, these symp- activities once enjoyed. It can lead to a variety of toms must cause the individual clinically significant dis- emotional and physical problems: it causes severe tress or impairment in social, occupational, or other symptoms that affect how you feel, think, and handle important areas of functioning. The symptoms must daily activities, such as sleeping, eating, or working. To also not be a result of substance abuse or another be diagnosed with depression, the symptoms must be medical condition. present for at least two weeks. Depression is one of the most common mental dis- The DSM-5 outlines the following criterion to make orders in the U.S. Current research suggests that depres- a diagnosis of depression. sion is caused by a combination of genetic, biological, The individual must be experiencing five or more environmental, and psychological factors. The World symptoms during the same 2-week period and at least Health Organization in recent years has estimated that one of the symptoms should be either (1) depressed the main source of deficit and disability in 2010 would mood or (2) loss of interest or pleasure. have been depression. Forecasts it gave depression the second place for costs for 2020 (just overcoming heart Depressed mood most of the day, nearly every day. disease). In industrial societies depression and anxiety are Markedly diminished interest or pleasure in all, or al- a public health problem. In the US of 50 million mentally most all, activities most of the day, nearly every day. disturbed, only a quarter is undergoing treatment. Significant weight loss when not dieting or weight As for depression, only 10 out of 100 go to the gain, or decrease or increase in appetite nearly every psychiatrist. The other 90 don’t go beyond the family day. doctor, and as only a small part of them can afford to be A slowing down of thought and a reduction of physi- treated, the majority remains helpless, suffers silently cal movement (observable by others, not merely sub- and remains isolated. One of the strongest reasons for jective feelings of restlessness or being slowed down). isolation is the negative injury and the stigma to those who suffer from mood disorder. Fatigue or loss of energy nearly every day. These data confirm the strong need for treatment of Feelings of worthlessness or excessive or inappro- depression to avoid a further increase in the disease. priate guilt nearly every day. Depression, even the most severe cases, can be Diminished ability to think or concentrate, or indeci- treated. It is among the most treatable of mental siveness, nearly every day. disorders. The earlier that treatment can begin, the more

S515 Romina Tavormina & Maurilio Giuseppe Maria Tavormina: OVERCOMING DEPRESSION WITH DANCE MOVEMENT THERAPY: A CASE REPORT Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 515-520 effective it is. Between 80 percent and 90 percent of language. People in treatment communicate conscious people with depression eventually respond well to treat- and unconscious feelings through dance. Dance thera- ment. Almost all patients gain some relief from their pists help people work on issues through the use of a symptoms (https://www.psychiatry.org/patients-families/ “movement vocabulary” that is centered around physi- depression/what-is-depression). cal expression instead of words. Dance movement thera- Depression is usually treated with medications, pists assess body language, non-verbal behaviors and psychotherapy, or a combination of the two. If these emotional expressions. Treatment interventions are treatments do not reduce symptoms, electroconvulsive tailored to address the needs of certain populations. therapy (ECT) and other brain stimulation therapies There are different studies that shows the utility of may be options to explore. dance movement therapy in treatement of depression, Another effective tool in the treatment of depression one of this is the project of Psychosocial Rehabilitation is psychosocial rehabilitation. Different studies/resear- and DMT “Dance that you go”. The work tool used to ches have shown that people also treated with psycho- achieve the goals of that project with mood-minded social rehabilitation have reached better results than patients is the dance. those who were treated only with medications and "Dance That You Go" is a group of psychosocial psychotherapy. rehabilitation that operates since 2009 in the Day Centre The fundamental aim of rehabilitation in the field of UOSM of Torre del Greco, Mental Health Department mood disorders is to overcome shame and injury to the ASL NA 3 SUD (Tavormina et al. 2015). illness, to enhance the positive aspects of the patient and Its aim is to help psychiatric patients especially with to integrate the latter into society by returning to do the depression to come out of isolation which characterizes common things that everyone does in everyday life. their condition, recovering interpersonal relationships There are different methods and techniques used in through the Caribbean dance. In particular, the "Bachata" this field: one of the most effective is Art-therapy. Art was chosen and used for its structural characteristics and therapy, as the name suggests, involves creating art as a for the simplicity of the steps. It is a dance that pro- therapeutic tool to help facilitate emotional growth, and motes immediately the encounter with the other and it promote both mental and physical healing and recovery. actives non-verbal body communication. It facilitates It is often used in combination with other forms of the expression of emotions through the body. Dancing medical or mental health treatment. Art therapy can be with the other, the patient not only recovers the beneficial for a wide variety of individuals, including relational dimension but also he rediscovers the contact patients dealing with mental health issues, such as with his body and the ability to sense and communicate schizophrenia or anorexia nervosa, as well as those emotions. After several years of rehabilitative activity battling serious medical issues, like cancer or chronic and consequently to the evaluation of the good results illness. It can also help those recovering from trauma achieved in the Day Centre, the activities were brought or addiction, working through grief, or coping with a on the territory. disability. It is very powerful also in the treatment of From this idea was born "Dance and go on": a pro- depression. One of the form of Art-therapy well known ject of Psychosocial Rehabilitation on the road. The pur- in the treatment of depression is Dance Movement pose of this next step is the transition from the protec- Therapy. ted, reassuring and incentive environment of the Day Dance Movement Therapy (DMT) is the therapeutic Centre to the external social context where the patient is use of movement to further the emotional, cognitive, compared with the competitive social life. The patient physical and social integration of the individual, based uses the instrument of dance, as a stimulus and resource on the empirically supported premise that the body, for getting to know and to deal with others in the mind and spirit are interconnected. A study from the outside world to the psychiatric context. The purpose is journal The Arts in Psychotherapy (2007) found out that not to become successful dancers but to engage the dance therapy had a positive effect on participants audience with their artistic expression of emotions, experiencing symptoms of depression. Most people dancing and overcoming the fear of being criticized for understand that dancing can be good for their health: it their pathology. The aim is to help psychiatric patients, improves cardiovascular endurance, muscle tone, ba- especially with depression, to come out of isolation lance, and coordination. Dance can also boost a person’s which characterizes their condition, recovering interper- mood, improve his or her body image, and provide an sonal relationships through the Caribbean dance. opportunity for fun that may lower overall stress and At the beginning of the project has been crucial for anxiety. While these elements are certainly beneficial, the patients to have a structured dance to reduce the dance movement therapy takes therapeutic dance to shame of exposing themselves to the public. Further- another level. more, it was very reassuring for patients to reproduce in People in treatment with a qualified dance therapist the social context a dance well known, as danced for have the right to confidentiality and dance therapists years inside the Day Centre of Mental Health Depart- provide a safe space for people to express themselves. ment. To reproduce the same dance but in a different Movement becomes more than exercise, it becomes a context has created a sense of continuity between the

S516 Romina Tavormina & Maurilio Giuseppe Maria Tavormina: OVERCOMING DEPRESSION WITH DANCE MOVEMENT THERAPY: A CASE REPORT Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 515-520 inside (Mental Health Department) and the outside 0 - No problems; (social external context) where for the first time people 1 - Presence of a problem (intervention performed); see the patient in a new way as a normal dancer and not as mentally ill. 2 - Presence of a problem (intervention project carried out); In a second moment it was used popular dance of Neapolitan tradition. Subsequently patients, when they 3 - Intervention in progress; were more secure of themselves, have learned to dance 4 - Intervention concluded, problem in all or in part more spontaneously in a less structured way, dancing solved; freely with unknown people. The project has been 5 - NV Area not assessable or not applicable. monitored with the administration of the VADO (Morosini et al. 1998), a test of psycho-social rehabilita- The scale of Personal Functioning (FPS) instead pro- tion and with clinical interview to evaluate the patient’s vides a synthetic numerical value expressed on a scale satisfaction and mood tone progression, and the com- between 0 and 100 that indicates the level of personal pliance to pharmacological therapy. and social functioning of the patient. The determination In this paper it will be described a case report of a of the level, with intervals of 10 points for the various psychiatric patient with depression who has attended the bands, depends on the degree of dysfunction in four project from the beginning to today. groups below: 1 - Socially useful activities (including work and PRESENTATION OF CASE REPORT school); 2 - Personal and social relationships (including A.M. is being treated at the Mental Health Depart- relationships with family members); ment of Torre del Greco since 1999, diagnosed with Delusional Psychosis and depression. She is 50 years 3 - Care of the appearance and hygiene; old and she lives alone from two years since her 4 - Disturbing and aggressive behaviors. mother's death. She has a relationship with another The evaluation of dysfunction in the areas is from patient of the Day Centre that often goes to her house mild to very serious: for a few days. She regularly attends the activities of the Day Center, in particular she attends the project “Dance Mild, no apparent difficulty, known only to those who that you go” from the beginning and in these years has know the person well; reached great results. As every patient in the day center Evident but unmarked, difficulty easily identifiable of the mental health department, she was administrated by anyone, but that does not affect the function of the test VADO, a test of psycho-social rehabilitation the person; and clinical interview to evaluate patient’s motivation to Marked, obvious difficulties impair social functioning participate at the activities of the Day Centre and to in that area, but the person can still do something develop an individual therapeutic project with specific even poorly and irregularly; rehabilitation goals. The word VADO stands for Evaluation Activity Serious, difficulty that makes the person incapable of Definition Objectives. The test consists of several performing any role in that area, or she does take a negative role, but without compromising the chances valuation tabs used for the definition of the objectives of of survival; rehabilitation. In our study we used two evaluation forms of VADO: Very serious, such as to determine a danger for the survival, apparent to all. Scale of Personal Functioning – FPS; Form of Rehabilitation Areas – AR. The VADO was administrated at the beginning of the project and then every six months to monitorate the The AR module of VADO consists of 28 items that rehabilitation process. explore areas of personal and social functioning of the patient: Care of appearance and hygiene (item 1-7); OBJECTIVES Socially useful activities (item 8-10); From results to the first VADO and after several talks Personal and social relationships (items 11-16); with the referring doctor of the case report and in colla- Compliance with the rules of coexistence (items boration with the operators that follow A.M. in this 17-21); therapeutic path, they have established the following goals for the patient: Battery Life in instrumental activities (items 22-28). The scoring is done on the basis of the presence or Global objective absence of problems with respect to the capacity or To promote personal growth through a therapeutic ability expressed by the item: route of psycho-social rehabilitation in group;

S517 Romina Tavormina & Maurilio Giuseppe Maria Tavormina: OVERCOMING DEPRESSION WITH DANCE MOVEMENT THERAPY: A CASE REPORT Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 515-520

General objective At the beginning the patient, influenced by mother’s To achieve improvements in the AREA Personal and opinion, did not want to participate for fear of being social relationships and Care of the self; called crazy by the public but later she overcame this fear with courage and so from that moment she always Specific objectives: wanted to perform in public. to stimulate positive socializing behaviors of patient In June 2015, A.M. took part in an essay of Carib- and to discourage isolation; bean dances of the “Cuban Academy" at the theater to learn to share times and spaces with others; “Rome” in Portici (Naples). Through a video it presen- to establish friendships with other patients of the DC; ted the work done by the group over the years both in the Day Centre of the Mental Health Department and in to promote the integration of user in the social context with performances of “Bachata”; external contexts. The patient received compliments and congratulations, so she felt appreciated for her work to express her discomfort by moderating aggressive In September 2015, for the first-time patient, to- tones; gether with the dance group, made some Caribbean les- to have a prompt and effective action to psycho- sons with 2 teachers of the “Cuban Academy 2" in logical well-being with the improvement of mood; Torre del Greco (Naples), in the city where she lives. to focus on the resources of the patient improving In October 2015, in occasion of the “Depression "healthy parts “; Day”, an international congress on mood disorders to increase self-esteem; made in a scientific high school of Torre del Greco, to stimulate the care of oneself and one's body; patient had the opportunity to present a choreography of “Bachata”, dancing in integration with the teachers of to cause the overcoming of inhibitions and social phobias; “Cuban Academy 2". After the exhibition, A.M. danced a bachata in group with students. to fight against stigma. In December 2015, during the International Con- gress against Mental Health Stigma “Nobody is Per- METHODS fect”, A.M. made another choreography of Bachata in collaboration with two teachers of the “Cuban Academy To achieve these goals, the patient was included in 2". Then, in the same congress, for the first time the different activities of the day centre in particular in the patient was one of the speakers of the congress. She project “Dance that you go”. Now we will illustrate the talked about her experience and that of all the dance modality of the participation to the project and the result group of psychosocial rehabilitation. She has explained gained in these years. how she has overcomed depression and the stigma The methodology used for this project is the dance toward her mental health problem dancing. therapy, principles of psychosocial rehabilitation and In May 2016, patient took part in a congress of dance- techniques of psychology with group. therapy organized at the University of Naples “Suor Orsola Benincasa”, in wich she presented a performance Operating Modes of dance-therapy together with all the dance group. At the Weekly meeting to the Day Centre on Tuesday end of the conference she danced toghether with students afternoon from 4:00 p.m to 6:00 p.m to prepare and and other partecipants of the congress. train the dance group for performances outside. In October 2016, during “Depression DAY”, organized in two different locations (“A. Nobel” Scientific In the vicinity of an event there is a second weekly High School in Torre del Greco (Naples) and in “Villa meeting to prepare the choreography. Bruno” in San Giorgio a Cremano (Naples) A.M. had External exhibitions to the Centre. the opportunity to present a choreography in which she Monthly interviews with patients and administration represented how dance can help people to improve of the VADO every six months mood and overcome depression. In November 2016, during the congress “The Art of RESULTS ACHIEVED Changing” A.M. together with the dance group performed in a popular dance with tambourines involving The great results obtained by the patient are due people to dance with them. The aim of this performance mostly to the activities of social integration in the was to demonstrate how art and in particular dance can territory dancing. These are the best results achieved in be a potent instrument to join people, to spread joy and these years: in 2009, the patient together with the dance to prevent and support fight against depression. group took part in a sporting event of the City of Torre In October 2017, during The Week of Dance Move- del Greco (Naples) performing on a stage in the center ment Therapy APID, at the theatre of a church in Portici of the city. The group presented a brief choreography of (Naples) Italy she involved the audience in a DMT Bachata. This was the first performance on the territory. performance with colored foulards.

S518 Romina Tavormina & Maurilio Giuseppe Maria Tavormina: OVERCOMING DEPRESSION WITH DANCE MOVEMENT THERAPY: A CASE REPORT Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 515-520

The great result, deriving from all these experiences by herself because she was doing something shared and of integration on the territory with dance, has been the accepted by society. In this way, A.M. has created a positive effects that they have had on mood of patient. point of similarity and contact with the other "normal" A.M. was very happy because she felt appreciated and despite his pathology that until that moment it made her accepted in spite of her mental health problems. So she feel like an outsider. Also, seeing a depressive person to has overcome the fear of the judgment of the other dance a solar and jovial dance, helps the latter not only connected to the social stigma against psychiatric ill- to raise the tone of mood but to rediscover moments of ness. She has strengthened the self-confidence and self- joviality. In a second moment when the patient felt more esteem. Furthermore, citizens have been involved from secure of herself was possible to dance in a more spon- the performance and appreciated the work done by taneous and less structured way with unknown people. patient and the courage to perform in public. Above all, it’s important for the overcoming of The results achieved from 2009 to 2017 with the stigma, to show to society as a depressive person can rehabilitative activities of the dance-therapy have been emerge from the black tunnel of depression making a verified and confirmed by the administration of the test joyful dance, like everyone else who does not have his VADO, by the clinical evaluation of the patient in mood pathology. medical records. The paradox created in the common imagination by "seeing a depressive person, dancing with joy" helps to Evaluation of the results with test VADO reduce the prejudice that depressed people are asocial, always disruptive in spite of what they are doing. This It emerged, compared with the beginning of the pro- shows that doing jovial things in association to the ject, an increase in scores on the scale FPS from 51 to psycho-pharmacological therapy helps to overcome the 65 mainly due to an improvement in the area Personal symptom better and before reducing the social stigma. and Social Relationships. In this area patient is increased from a level of marked dysfunction to an evident one. Acknowledgements: None. It is described below scores reported on the scale FPS from the beginning of the project to date (Figure 1). Conflict of interest: None to declare.

70 Contribution of individual authors: 60 Romina Tavormina planned and designed the study, 50 wrote the first draft of the manuscript and carried 40 out case report; 30 FPS Maurilio Giuseppe Maria Tavormina supervised manu-

Score scale FPS scale Score 20 script.

0 FPS 51 52 55 57 58 60 62 63 65 SUCCESSI ON SCORES OVER THE YEARS References NOTE: 0 to 70 scale scores FPS test VADO (from 41-50 1. Adorisio A: La danza e il movimento. L'immaginazione marked difficulties in two main areas; from 51-60 marked attiva. Curated by F. De Luca Comandini e R. Mercurio, difficulty in one main area; from 61-70 evident difficulties in Vivarium, Milan, 2002 one main area) 2. Anthony W, Cohen M, Farkas M: Psychiatric Rehabilita- Figure 1. Scale FPS tion. Boston University Center for 1990-08 3. Ba G: Strumenti e tecniche di riabilitazione psichiatrica e Future Goals psicosociale. Milan, Franco Angeli editor, 2002 Given the positive results seen in these years it was 4. Basurto C: Esperienze di danzaterapia nel Servizio Psichia- trico di Diagnosi e Cura. Published in: “Se la cura è una thought to the future: danza: la metodologia espressivo relazionale nella danza- -to go to do other performances in the social context; terapia”, Bellia V. Milan, Franco Angeli editor, 2007 -to participate with dance therapy choreography to 5. Carozza P: Centri diurni e approccio ai processi cronici other events such as “Dance Therapy Week” and the in psichiatria. Il Metodo Spivak e nuovi modelli di terapia. “Depression Day” in the next months. Franco Angeli editor, 2000 6. Carozza P: La riabilitazione psichiatrica nei centri diurni. Aspetti clinici e organizzativi. Franco Angeli editor, 2003 CONCLUSIONS 7. Carozza P: Principi di riabilitazione psichiatrica. Per un sistema di servizi orientato alla guarigione. Franco Angeli In these years Dance Movement Therapy has helped editor, 2006 the patient to face better depression in different ways. 8. Ciompi L, Dauwalder HP, Agué C: Un programma di At first Dancing a socially accepted dance as the ricerca sulla riabilitazione del malato psichiatrico. Psico- “Bachata” has facilitated the patient to feel accepted terapia e scienze umane 1987; 21:47-64

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9. Cerruto E: A Ritmo di Cuore. La danza terapeutica. Xenia 22. Sacco N: L'arte del movimento. Educazione e terapia attra- Edizioni, 1994 verso la danza Musicoterapia e danzaterapia. Curated by 10. Cerruto E: Danzaterapia: una danza nella pelle. La Salute Maria Favorini. Franco Angeli editor. Milan, 2004 Olistica, marzo, 2002 23. Saccorotti C: Il processo creativo nel percorso verso 11. De Vera d'Aragona P: Una Danza per la Psicosi. Riza l'autonomia. Acts of the Conference “Il corpo e la gioia", Psicosomatica, N.48, 1985 Milan, 14-15-16 maggio 2000 12. De Vera d'Aragona P: Curarsi Danzando: il Movimento 24. Saccorotti C: La complessità e l'autonomia del processo te- come Psicoterapia. Riza Scienze, n.13., 1986 rapeutico, Danzamovimentoterapia. Modelli e pratiche nell'- 13. De Vera d'Aragona P: Vinci la Depressione. Riza esperienza italiana. Scientific Editions Magi, Rome, 2004 Psicosomatica, N.143, 1992 25. Saraceno B: La fine dell’intrattenimento. Manuale di 14. Di Berardino C: La conoscenza di sé e la conduzione dei riabilitazione psichiatrica. Milan: Etas Libri, 1995 gruppi riabilitativi. Procedure di riabilitazione 26. Scala A: L'agire riabilitativo. Manuale di riabilitazione psicosociale. Milan: Franco Angeli editor, 2012 psicosociale. Rome. Il Pensiero Scientifico, 1998 15. Garcìa ME, Plevin M: Gli aspetti non verbali della 27. Spivak M: Introduzione alla riabilitazione sociale, teoria, relazione: il contributo della DanzaMovimentoTerapia. tecnologia e modelli d’intervento. Riv Sper Fren 1987; Saturday seminars. Order of Psycologists of Lazio, Rome, 111:52274 4 giugno 2004 28. Tavormina R et al: The advantages of “Dance-group” for 16. Garcìa ME, Plevin M, Macagno P: Movimento Creativo psychotic patients. Psychiatr Danub 2014; 26(Suppl e Danza, metodo Garcia/Plevin. Gremese Editor, Rome, 1):162-166 2006 29. Tavormina R et al: Development of the life skills for 17. Groenlund E, Renck B, Vaboe, NG: How depressed promotion health with the art-therapy. Psychiatr Danub teenage girls can be helped by dance movement therapy. 2014; 26(Suppl 1):167-172 In Presentation on the 2nd International Research 30. Tavormina R et al: Dance and Go On: a project of Colloquium in Dance Therapy, Feb. 10–11, 2006 rehabilitation psychosocial on the road. Psychiatr Danub 18. Koch SB, Morlinghaus K, Fuchs T: The joy dance Specific 2015; 27(Suppl 1):143-147 effects of a single dance intervention on psychiatric 31. Tavormina R et al: Overcoming the social stigma on patients with depression. The Arts in Psychotherapy 2007; Mood disorders with dancing. Psychiatr Danub 2017; 34:340–349 29(Suppl 3):427-431 19. Liberman RP: La riabilitazione psichiatrica. Raffaello 32. Tavormina R: La danzaterapia come strumento di espres- Cortina Editor, 1998 sione e cura nelle patologie dell’umore. Acts of 2th 20. Morosini P, Magliano L, Brambilla L: Test VADO - National Congress EDA Italia onlus. Telos Magazine, Valutazione di Abilità, Definizione di Obiettivi. Editions 2017; Suppl Oct. pp 209 Erickson, 1998 33. World Health Organization: International classification of 21. Puxeddu V: Danzaterapia e Riabilitazione, in AA.VV. “Le functioning, disability and health (ICF). Geneva, World Arti Terapie in Italia”, Ed. Gutenberg Rome, 1995 Health Organization, 2001

Correspondence: Romina Tavormina, MA Centre of Psychology and Psychotherapy 4/F Leone Street - 80055, Portici, Naples, Italy E-mail: [email protected]

S520 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 521-526 Conference paper © Medicinska naklada - Zagreb, Croatia

THE SUFFERING BODY: MANIPULATION AND DISCOMFORT IN EATING DISORDERS Maria Rosaria Juli Family Counseling, Foggia, Italy

SUMMARY What is the meaning of piercing and tattoo in sixteen years old? What are the deep reasons, affective and relational, that explain the explosion of this “fashion” among teenagers? The recent spread of these practices among young people and very young people offered the opportunity to reflect on the value attributed to the body manipulation in teenager growth context. Inked bodies, pierced, and other similar manipulations, express a communicative intention, whose strength is proved by the violence of these practices. The sense of the message, however, risks remaining obscure to adults, who lack the tools to decode it. Self-injury begins as a general expression of a lack of integration between oneself and the alienation of one's own body, resulting in conflicting and split feelings. Many manifest a behavior of disrespect, disapproval, devaluation of the bodily ego, whose self-injurious gesture would represent a particularly dramatic expression. The variability that characterizes the manifestations of self-injury prevents one from applying to a universal definition, valid under any circumstances. Instead it reveals the conceptual flexibility of self-injury that appears itself as a peculiar product in the current historical time. In a society that increasingly accepts various forms of transformative intervention on the physicality of each, where piercing and tattoos, once considered barbaric practices, now these become ordinary practices, a distinction between ornaments and self-injuries becomes necessarily confused (Levenkron 1998). The ego leak is unnecessarily buffered, occluded, braked trough any means (food, alcohol, substances, self-injury, shopping, kleptomania) because the bets are not really the shape of the body but the possibility to escape the dissolution of the Self. Self-injury and eating disorder have many common factors: impulsive, ritualistic, hidden behavior characterized by shame and guilt. These are experiences that use the body to resolve psychological conflicts and feelings of tension, anger, loneliness and emptiness. The two syndromes report a distorted image and a deep disdain of their body, lived as an enemy to fight, punish and anesthetize. The body that gets sick is very often of a teenager. The food and the obsession with the shape of the body have a primary value because they validate the identity structure, precarious, shaky, of personality in progress. The adhesion to the symptom is understandable only from this point of view, this self- destructive research, carried out to the bitter end, would not otherwise be explained if underneath there was not the fear of the disagreement of the ego. The body becomes the refuge, the theater where you can experience the emotions that you cannot tolerate in life. The problem that revolves around the emotional life is just that: we feel that we cannot control our emotions, and unable to support them from within, we try an external control. All teenagers experience pubertal transformations in a problematic way, as accepting them requires the cognitive integration of one's body into a positive image.

Key words: cutters - the body of teenagers - the manipulation of the body in adolescence - cutters end eating disorders - eating disorders * * * * * INTRODUCTION scars, piercings, they vent their anger against the body they care so much, as well as they were children they The body is the place where power is expressed; it is used to pour out their sufferings on the most beloved the attacked, seduced, deciphered, undermined, manipu- doll, cutting her hair or making it into pieces". They are lated by plastic surgeons, acclaimed and deified by teen- symbolic wounds similar to those that self-inflict cut- agers from all over the Western world. Since the seven- ters, young people driven by the irrepressible impulse to ties, more or less aggressive practices of body surgery hurt themselves, who cut themselves, burn themselves, such as tattoos and piercings have spread. Young people hurt themselves not to show the world, a signed world, write on their skin, they consider cosmetic surgery as but to secretly relieve their anguish by recording on the normal, they invest exaggerating the aesthetic change, skin, scar after scar, the map of an opaque pain, which from which they make their happiness depend. If with does not find words to express itself. But while cutting graffiti the male teenager paints his own brand of iden- is the expression of a psychological discomfort that tity on the walls, with the body art there is a message takes on a body size, as happens more and more often in impressed directly on his body, as if it were a living the forms of juvenile discomfort, body art has almost picture, up to resort to more violent practices to perso- always a positive meaning even in its most bloody nalize the body; it is the case of the body branding, forms: the pain inflicted by the scalpel, from the hot branding the skin with a burning iron writing, numbers, iron and the awl is in some way equivalent to the tribal drawings, symbols; the scaring, which produces with rites of passage to adulthood. From tattoos to pearcing deep cuts artistic scars, up to the most extreme forms of to its most innovative and bizarre forms, body art fasci- body art, to the grafts under titanium skin, to the nates many youngsters not so much for its provocative, pearcing that crosses the glans horizontally, to the cut of exhibitionistic impact, but it assumes a new collective the tongue to make it bifurcated. At the age when the language. The body becomes the refuge, the theater aesthetic exaltation is stronger, according to Charmet: where you can experience the emotions that you can not "Adolescents female mistreat their bodies with cuts, tolerate in life. Tattoos and piercings are the most

S521 Maria Rosaria Juli: THE SUFFERING BODY: MANIPULATION AND DISCOMFORT IN EATING DISORDERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 521-526 common form of body modification, that is the desire of life already from the early days. The base is guaranteed for transformation, decoration, embellishment of one's by initial relations with the caregivers; the encounters of body too often dismissed as an "adolescent whim" but life, the group of peers, the first sentimental and sexual which often hides something different from adapting to experiences, the culture in which one grows up contri- a simple fad (Borgia 2005). In some mental illnesses butes to give life to the mental image of the body and to typical of adolescence, such as Eating Disorders, there satisfaction - dissatisfaction with one's own appearance. is an isolation of the soul which corresponds to the Since the Middle Ages the theme of the body has estranging of the body. In this solitude the body is no involved different visions, often contradictory, we talked longer lived as its own, what remains is the difference about a glorified body, repressed, exalted and rejected. It between the idealized body and the objectified body. The is during this period that all manifest forms of enjoyment dimension of being one's own body and encountering of the body disappear, the woman is demonized, con- other bodies in the world is compromised, the only pos- trolled sexuality, manual work debased, homosexuality sible form of knowledge is entrusted to the impoverish- banished. The body is considered the prison and the ment of subjectivity in order to attempt a recovery on an poison of the soul. Over the years, many authors have abstract plane. Young people live in temporal suspension, highlighted connections between behaviors of saints and the future is compromised and the past is demonized, medieval women and the experience of the body in the what remains is a present made eternal for a moment psychopathology of modern mental anorexia. However indefinitely suspended. The psychopathological nucleus the mystics with the negation to the corporeity seek the of Eating Disorders is the excessive evaluation of the Absolute and the corporal practices have been an attempt shape of the body, weight and their control; this means to get rid of the lived body as an obstacle to the aesthetic judging its value mainly or exclusively on the basis of the experience, in the words of today's girls the body be- form and weight and the ability to control them. In 1990 comes the obsession, the prison, the center around which Gordon defined the problem as a "social epidemic", it equality of identity is played; there is no spiritual search seems that this discomfort affects today four million for a desire to dispose of the body, but every physical and people in Italy and tens of millions of young people in the mental energy is concentrated on the body, prison - world fall ill each year. Eating Disorders afflict mainly obsession which sums up every possible meaning on the female sex compared to the male one in a ratio of 10: itself. In Saints, as well as in anorexics, there are physical 1 and in the age group of young people between 12 and hyperactivity, insomnia, emotional instability, bodily 25 years the pathology affects 10% of the population; misrepresentation; and exasperated perfectionism. In any according to the Ministry of Health, out of a hundred case, the history of the body clarifies the history of ideas, adolescent girls, ten suffer from some eating disorders. In mentality, institutions and the economy. The body chan- the last ten years, new expressions of food pathology ges in physical reality, in its fictions in its imaginary. have appeared, even if to a small extent, such as Bigo- Beginning with preadolescence, certainties relating to rexia and Orthorexia other severe and difficult-to-treat one's own body fail and the individual is urged to build childhood disorders. Nutrition and eating disorders have new ones based on both anatomical and physical trans- multifactorial etiopathogenesis and therefore must be formations and social expectations with respect to body considered psychological, evolutionary, biological and identity. The transformation that puberty brings with its socio-cultural factors (Juli 2012), it is no coincidence impetuosity calls into question the image of the body that the disorders have been defined by Russel: "patho- built progressively by the child. On the adolescent forma- plastic", ie they are adaptable and flexible mutations to tion of the body image can also influence aspects of the changes historians. individual personality, in which one of the most important is undoubtedly represented by the degree of self- BRIEF HISTORY OF THE BODY esteem enjoyed and therefore by the self-confidence that derives from it. These personality traits, besides favoring At the beginning of life the newborn must integrate the development of a positive evaluation of one's own his own bodily ego with his own psychic ego. At first, the body, are used as defense mechanisms against eventual body is foreign to him, as evidenced by the reaction he events that threaten the body image. On the contrary, a has at the sight of his own hands, of his own feet, which poor opinion of the self increases the vulnerability of the he agitates with a marvelous astonishment. The newborn subject regarding the consideration that he assigns to his treats the parts of his body as if they were external body. The stage of adolescent development contains objects, only after a long time and with the help of his fears, fantasies, representations filtered by the personal mother, the parts are reunited under the controllers of a relationship with one's own body, also managed with psychic entity that receives all the feelings of pleasure behaviors kept hidden by fear or shame of being punished and pain starting from these separate parts. This process or considered abnormal. The behavioral manifestations of is established through identification with the body, which adolescents who have experienced an emotional break- is therefore not given, but constructed. What we call body down vary enormously, but a high percentage is repre- image is the result of a subjective interpretation of the sented by attacks on one's own body: suicide, attempted appearance, interpretation given by a series of cognitive, suicide, self-harm, drug-taking, perverse behavior. Clini- emotional, thoughts and feelings elements (Montecchi cal observation suggests that women's special attention to 1998). The mental image of the body is built in the course the functioning of their bodies may constitute a plausible

S522 Maria Rosaria Juli: THE SUFFERING BODY: MANIPULATION AND DISCOMFORT IN EATING DISORDERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 521-526 cause of the increased frequency of self-harm and eating who do not notice them, for those who look at them but disorders in the female population, compared to the male do not see them, for those who hear them but do not listen population. The symptoms are then read as an attempt to to them. We might think that cutting oneself is a sort of repossess the body to perceive it as its own, to know it rebellion against the insensitivity that lives in interper- and make it impenetrable (Cross 1993). It is experienced sonal relationships. Rebellion that, however, fail to as a fragmented unmanageable stranger: object, not sub- realize through the rejection of disappointing situations ject. This bodily alienation, created during childhood, is but that becomes a symptom of serious mental illness. By amplified in adolescence, when the young woman, tyran- cutting themselves they try to survive the deep pain they nizing on the functions of the organism, tries to repress feel and to stay anchored to what they have. They emotions, impulses and sensorial stimuli induced by challenge life by trying to do everything on their own sudden physiological and hormonal changes. Through because they have the certainty that no one can under- vomiting, bingeing, abstinence, physical exhaustion, self- stand them and no one can help them and then they help injury, the adolescent may have the impression of exer- by implementing a kind of sick "self-therapy". From the cising a form of control over himself. Initially, the body clinical experience emerged three types of Cutters: some turns from an enemy to an ally, creating a solution that is of them are deeply rabid guys who try to get rid of anger apparently simple and effective: moving psychological by venting it on their skin. They hurt themselves almost discomforts into a physical disorder; but it soon escapes as if to challenge those who hurt them every day, because the control of the adolescent to inflict his personal perse- they do not love them. They scream their anger to the cution. The vomit creates a feeling of satiety, the self- whole world through their scarred body. They propose wounded wound heals, hiding the blood, numbing the those which, symbolically, can be the wounds inflicted on physical pain, causing the need to be damaged again. their inner reality by disappointing, violent and patho- Adolescence represents a critical phase of the life cycle, logical interpersonal relationships in which the boy especially as regards the formation of the self-image and became ill. The causes of this phenomenon we find for the body pattern. The relationship with food in this age about 60% in experiences of harassment and sexual group is of fundamental importance not only for the abuse, in which the personal and intimate boundaries of growth and development of the body, but also as a the child are violated and his psychic identity is symbolic value that contributes to defining personal destroyed. 40% instead develops in so-called "normal" identity and psychosocial autonomy (Juli 2017). families, well integrated into the social fabric where, often, there are no obvious and obvious pathological THE SUFFERING BODY situations of the parents but disappointing interpersonal relationships because they are based on anaffectivity. The In recent years psychiatry has witnessed the develop- child is taken care of on a material level, one thinks above ment of a disturbing clinical phenomenon, mostly juve- all of the satisfaction of his needs but does not consider nile: Cutting, an English term that derives from the verb his needs, his needs to be loved, understood, "seen". to Cut (cut, wound). Young boys, sometimes children, Cutting speaks to us therefore of a lesion of the inner hurt the skin of the arms or other parts of the body as if reality, reality that appears at birth and that needs valid this gesture would help them endure unbearable despair. relations among humans for being able to develop and They mostly use razor blades, in 57 percent of cases, but become a solid psychic identity. One can think of the also scissors, blades of the penknife, knives and other repetition of the unconscious psychic dynamics that the sharp objects. It is not a fashion, as we often hear it said, boy lived in his first years of life. Injured inwardly by the nor a way to attract attention. In fact, in most cases, Cut- violence of cold relationships, today it is he who, by ters, are very careful to hide the cuts with long-sleeved becoming active, inflicts wounds on himself, becomes shirts even when the heat of the summer would lead to violent because he is incapable of rejecting and rebelling, discoveries. We are not facing adolescent whims but a in a healthy way, to the anciency of others. He becomes real mental pathology. According to a survey conducted ill by losing his ability to love, himself and others. The by the Italian Society of Pediatrics (2017), 15% of spread of self-injurious behavior in large segments of the adolescents aged between 14 and 18 in Italy have youth population of the Western world is not directly suffered self-harm to experience relief from emotional related to an increase in depressive or suicidal issues, but distress; a fact that worries, but what are the psycho- rather to the absence of a symbolic reference system, in logical reasons that lead a teenager to "cutting", the which the omnipotence of the body and the uncertainty of gesture of cutting himself voluntarily? According to Fabi its borders tend to grow immeasurably. A wide variety of in Cutting we are faced with something that leaves you clinical studies reveals an increasingly widespread terrified and that has nothing to do with a way to take connection between those who self-harm and those with your life; it is a way to remain anchored to reality, not to eating disorders, in a variable percentage of 35% in the sink into a more serious mental pathology that could lead women's range between 12 and 25 years. Although the them to suicide (Fabi 2010). It is a form of self-harm that dissatisfaction about the body exists specially among begins in late childhood or adolescence and only a low young people, in its extreme condition it is considered an percentage, 15% of them, asks for help by contacting a essential component for the start of pathological beha- psychotherapist. They are boys who express a deep viors. Indeed, the dissatisfaction about the body can be malaise, anguish, other times anger and hatred for those associated with a distorted view of the body image that

S523 Maria Rosaria Juli: THE SUFFERING BODY: MANIPULATION AND DISCOMFORT IN EATING DISORDERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 521-526 can be closely related to eating disorders. Currently we to that of alcohol, food, drugs, kleptomania or multi- do not know exactly what is the role of body dissatis- compulsive shopping. The distinction of superficial self- faction in causing or promoting the onset of Eating injurious behaviors in compulsive and impulsive suggests Disorders and whether it is primary to the disorder or the reason why this kind of disorder can easily develop in secondary to changes in cognitive functions determined personality characterized by poor impulse control, as is by fasting (anorexia) or abusing (bulimia) (Juli 2017). the case of bulimic patients. Compulsive self-harm refers However, several studies, including the one of Bruch H. to repetitive and ritualistic gestures, similar to the obses- (1978), highlight that there is a close correlation between sive-compulsive ones, put in place to quell growing the dissatisfaction about the body and the onset of eating anxiety, to ease the state of tension. Impulsive superficial disorders. Some research conducted by Garner (2002) self-injury includes episodic or occasional gestures and and Stice (2007) shows a link between the low satisfac- usually symptomatic of other psychological disorders, but tion for the body and many factors related to a bad likely to become repetitive if they are automated in the psychic health such as depression, low self-esteem, stress-stimulating response mechanism. It is in this transi- anxiety, substance abuse and alcohol abuse (Juli 2017). tion that the disorder acquires autonomy starting from an The lack of satisfaction regarding the body image is original state of emergency, the self-destructive compul- represented by the personal sorrow for the shape of the sion gives rise to automatisms or behavioral rituals that body in general or for the size of some parts of the body. are chronicized on the basis of an underlying obsessive The psychological discrepancy between the perception mode of thought, then structured with external stimuli. that we have about our own body and the body consi- Episodic superficial self-injury refers to self-destructive dered as ideal can lead to a negative feeling about behavioral manifestations that occur from time to time, ourselves and to behaviors harmful to our health subjects are not considered cutters. There may be several (Thompson 2004). determinants of occasional self-injury which is usually a When we talk about self-harm we refer to a complex symptom of a more complex pathological picture. set of behaviors voluntarily implemented to injure or alter In many cases, behavior is sought as a form of intense parts of the body, without conscious suicidal intent (Stone sensorial self-stimulation that interrupts feelings of 2003). Culturally approved self-harm includes activities diffuse apathy, indifference, and estrangement from the that reflect the traditions and beliefs of the particular surrounding environment, in this way the self-injurious culture and society that perpetuates them, and rituals that practice allows the subjects largely young women to re- indirectly act in the promotion of health, spirituality and establish contact with the just body and get a sense of social order. An important example is the rites of control over it, cutting, scratching and burning. The epi- adolescent initiation: transitional ceremonies that have the sode can therefore remain episodic, but it can also assume purpose of sanctioning the acquisition of social rules and a condition of dependence, which involves developing therefore access to the adult stage. (Bettelheim 1973). one's own identity around self-harm, until one identifies Often it is a matter of bodily modifying activities emplo- with it; in general, this behavior takes on the characte- yed to reach special states of ecstasy and sacredness, in a ristics of chronicity when this is repeated a dozen times. search for asceticism that passes through self-discipline Those who are self-destructive, use their skin as a sheet and self-certification (Beneduce 1999). This group also on which to engrave the message for the world, which includes cultural practices of our time, such as elaborate they are not able to express with words. The skin there- tattoos and piercings in various parts of the body: ears, fore becomes a primitive instrument of communication: tongue, navel, lips, representing examples of physical inflicting wounds and scars, scratching, sinking the nails modification and manipulation now popular and often into the skin, the external subject anger without the use of shared to sanction the belonging to a certain cultural words, but in a direct and effective (Caplan 2000). In context. Groups of self-injuring youths are no longer an general, after the first episode others follow at intervals of exception, they express the need to separate themselves a week or a few months, the first slight injuries are some- from the context of belonging, family and school, in an times premonitory of increasingly serious and frequent attempt to identify themselves, through the manipulative wounds. Many authors agree that the precipitating factor rite, in a micro collective environment. A particular type seems to be an experience, a threat of abandonment or an of deviant self-injurious behavior is spreading more and impasse in interpersonal relationships. Often these are more in our society, often in association with an eating seemingly minimal events followed by an unbearable disorder, where the impulse to binge and vomit are often tension, depression, anger, a sense of emptiness, inex- combined with other kinds of impulsive behaviors (such pressible feelings expressed in a gesture. The common as abuse of substances or drugs) which is often used. This condition that leads to self-injury seems to be deperso- behavior is called "moderate superficial self-harm" and is nalization, the person is passive, does not participate in distinguished by the lower severity of typical manifesta- their actions, foreign to itself and to the surrounding tions. Boys can use several methods at the same time, world. The physical pain induced by the cortico-adrenal such as cutting themselves, scratching, but prefering one and endorphinic hormonal production rapidly interrupts or some, especially those who prefer to cut their skin the condition of obnubilation causing a change in mood. constantly assume the identity of cutter (cutting himself) The injured wound becomes the error for the subject and so often they think to hurt themselves from deve- perceives the body and verifies its being alive, a sort of loping an addiction psychological behavior, very similar physiological shock to awake from its sensory and

S524 Maria Rosaria Juli: THE SUFFERING BODY: MANIPULATION AND DISCOMFORT IN EATING DISORDERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 521-526 emotional anesthesia. Hyperstimulation is often accom- the body and its features as an elective place of com- panied and therefore favored by the consumption of alco- munication of its identity of its values, of its social hol, drugs, medicines, binges, vomiting or food with- status and also of one's own happiness and mental drawal. The self-destructive choice is aimed at inter- health. The emotional instability in the adolescent can vening directly on one's own body, to indirectly modify make his body be considered an enemy; he is often the external context, in this perspective self-destructive considered the scapegoat, forcing him to eat too much, actions are interpreted as a distorted form of self-care. to drink everything, to sleep always or never, to humi- The boys say they do not feel pain while they hurt, even liating weariness, to prolonged rest, as if he were when the wound is deep, rather they feel relief and / or a convalescent for life. Because of the many emotional temporary mood change because self-destructive beha- situations experienced, the body goes into crisis in its vior is not able to solve the real causes of emotional dialogue with the ego, the others and the world no longer tension, so that the next conflict episode is again about allow the exchange of relationships that unfold in daily hurting again. Superficial self-injury often accompanies life, without problems (Le Breton 2003). In some other diseases such as borderline personality disorder, pathologies, such as Eating Disorders, we see the isola- histrionic personality, post-traumatic stress, masochism, tion of the body, its closure towards the world, its oppo- eating disorders. sition to itself. In these cases the body becomes an object, it loses its capacity and can not alternate between the CONCLUSIONS dimension of the object body and the subject body, which in the normal experience intertwine and alternate. In the It seems that the typical characteristic of the adoles- last twenty years, the literature on the issue has confirmed cent to use his body or somatic behaviors to express with numerous studies the frequent association between their difficulties or to relate to others, is responsible for body dissatisfaction and Eating Disorders, to the point a series of disorders focused on the body, whose that the attitude towards one's physical appearance is a physiological needs (sleep, feeding) are used to manifest more indicative predictor in the development of Eating an inconvenience. Even more so in adolescence, than in Disorders than the wrong perception of their own adulthood, one is in the world through and through the measures. However, the causes of eating disorders can body, and that is why the body can become ill to the not be traced back to body dissatisfaction, in fact, other extent that change does not occur or is not adequate. In cognitive and affective components of the body image change one renounces one body and one is preparing to seem to play an important role. Western society tends to attribute another one to it that is profoundly different, so consider the body as something that one possesses, as an much so that because of this transformation one is about image to be contemplated from the outside, as an object to inhabit the different world with one's modified body. to be improved and / or modified (Borgia 2005). There- The contrast between the pre-adolescent way of being of fore adolescents are dissatisfied with their physical the body, to which one does not want to renounce, and appearance and are always looking for a perfect shape. the way of being of the post-adolescent body, gives life Changes in the body and the emergence of sexuality to the adolescent crisis. At no other stage like this it can create critical movements in the social and relational happen to love and/or hate your body, or use it with field. Physical transformations involve a real revolution such dedication, or use it as a territory in which to trace in perception and self-knowledge. In the ten years that the messages to be sent to the world on representations the child takes to know his body and to construct a of self. The body is adorned, rigged, painted, covered mental image, he reaches a trend and a balance from with tattoos, modified in a thousand ways but with the which he draws a sense of identity and continuity. Ado- planned goal of making it pleasant, beautiful and desir- lescent transformation breaks this balance and places the able. From these assumptions the widespread conviction adolescent at a crossroads: nostalgia for the childish of the centrality of the body in adolescence is born: the body and the biological drive for change. The loss of the transformations of the body and the acquisition of child's body causes the adolescent a life of mourning sexual abilities, of mating and reproduction, accom- that must be overcome in order to find new balances. panied and signaled by the disturbances of desire The new bodily sensations are therefore perceived with involve the adolescent's mind in a demanding process a sense of extraneousness and discomfort, and danger. aimed at giving meaning to biological events and their The feelings they experience are to be self-conscious, psychic and emotional equivalents. The narcissistic awkward and disharmonious with themselves and with insecurity of contemporary adolescents is impeding the others. To restore harmony with one's body, one needs to process of mentalization of the sexual and reproductive enter into confidence, taking care of it. Since the body, body. Today's socio-cultural context encourages the besides being the mediator between the ego and the illusion that complex and difficult problems of form and internal world, is also the relational mediator between the substance can be solved through the manipulation of adolescent and the external world (family, social, physiognomies, in particular those of the body and its scholastic); it is in this phase that attempts to adapt the social aspects. Today's adolescents are influenced by a physical aspect to external models, and / or proposed by culture based on mass media messages, functional to the the company. The whole body is therefore subjected to a pursuit of commercial purposes, this glorifies the use of severe attention and to a continuous critical evaluation

S525 Maria Rosaria Juli: THE SUFFERING BODY: MANIPULATION AND DISCOMFORT IN EATING DISORDERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 521-526 that can result in a negative judgment of ugliness, of deformity up to the possibility of structuring real pho- Acknowledgements: None. bias concerning some parts of one's body (dysmorpho- phobia). Those who decide to cut themselves out usu- Conflict of interest: None to declare. ally secretly and try to keep the secret of this behavior (Pomereau 1997). Any indicators of the existence of cutting, burning or branding behaviors can be: References clothes not appropriate for the season, such as wearing only shirts or shirts with long sleeves in 1. Beneduce R et al: La guarigione. Quaderni di Orzinuovi. the middle of summer; La Feltrinelli, 1999 2. Bettelheim B: Ferite simboliche. Una interpretazione blood stains on clothes; psicoanalitica dei riti puberali. Firenze. Sansone Saggi, wounds, bruises or unexplained cuts; 1973 possession of sharp objects (razors, razor blades, 3. Bruch H: Patologie del comportamento alimentare. scissors, knives, needles, pieces of glass); Feltrinelli. Milano, 1978 isolation, such as spending a lot of time in the 4. Borgia L: La manipolazione del corpo in adolescenza. bathroom; Una riflessione bioetica. In Saggi Child Develepment & Disabilities 2005; 31:67-77 irritability; 5. Clapan J: Written on the body: The tattoo in European difficulty in coping with strong emotions; and American History. London, Princeton, Princeton excessive rage or depressed mood; University Press, 2000 lack of social bonds; 6. Cross L: Body and self in femmine development: implications for cating disorders and delicate self – drawings, writings etc. which have as their theme mutilation. Bull Menninger Clin 1993; 57:41-68 the pain, the sadness, the wounding. 7. Fabi M et al: Autolesionismo. L’Asino d’oro edizioni It is important not to react with disgust, to blame, to Bios Psichè, 2016 liquidate these behaviors of cutting, burning and branding 8. Garner DM et al: Levels of cigarettes and Alchol. as childish jokes or to reduce them to the simple request International Journal of Psychology and Psychological for attention is not very useful. They are gestures that Therapy, 2002 contain a deep suffering and that grant to those who im- 9. Gordon RA: Anoressia e Bulimia: anatomia di una plement them a truce, the appearance of a comfort, a form epidemia sociale. Trad. It. Raffaello Cortina Editore, Milano, 1990 of self-help that must first be respected: as it may seem 10. Juli MR: Analysis of multi – instrumental eating absurd, this is the best way that the person has so far disorders: Anorexia and abaulimia in comparation. found to master his problems and keep on living. Prob- Psychiatr Danub 2012; 24(Suppl 1)119-124 ably not proud of it, indeed he feels ashamed and thinks 11. Juli MR: Perception of body Image in Early adoles- that no one can understand what he feels (Fabi 2016). cence. An investigation in secondary schools. Psychiatr If you want to help a friend or a child who cuts or gets Danub 2017; 29(Suppl 3):245-482 hurt in another way, the starting point is not to judge and 12. Montecchi F: Anoressia mentale dell’adolescente. Mo- offer support. Offering support means avoiding ultima- delli teorici, diagnostici e terapeutici. Libreria Cortina, tums, punishments or threats: if it had been easy, the Milano, 1998 person would have already stopped. Offering support 13. Pietropolli Charmet GM: I nuovi adolescenti. Padri e means helping you to recognize emotions and manage madri difronte ad una sfida. Raffaello Cortina Editore, Milano, 2000 them differently than with cuts, encourage them to 14. Stice E: A meta- analyticrevview of eating disorder understand what they need to cut themselves and identify prevention programs: encouraging findings. Annual healthier ways to express their moods. All this is not easy Rewiew of clinical Psycologist, 2007 and referring to an expert is most often the most 15. Stone JA, Sias SM: Self- injurious behavior: A bimodal sensible thing, the goal is to recreate an affective and treatment approach to working whith adolescent females. sensitive internal reality and a certainty of oneself. Health Source: Nursing/Academia 2003; 25:112-125

Correspondence: Maria Rosaria Juli, MD, Clinical Psycologist, Psychotherapist, Specialist in Alimentary Behaviour Disorders, Consultant Family Counseling Service of Foggia via C. Baffi, 1, Foggia, Italy E-mail: [email protected]

S526 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 527-532 Conference paper © Medicinska naklada - Zagreb, Croatia

HOW ARTWORKS CAN GATHER UNSPOKEN YET DEEPLY FELT EXPERIENCES. USING NARRATIVE LAB IN DAILY PSYCHIATRIC CENTER Immacolata d’Errico Bari, Italy

SUMMARY In this paper I’m going to illustrate my experience related to the six month narrative laboratory with the psychiatric patients of the Daily Psychiatric Center located in Rutigliano. This project originated from my own way of conceiving the concept of Psychiatric and Psychosocial Rehabilitation in terms of Therapeìa, that is in my view the regaining "sense and meaning" as the essence of rehabilitation therapy. My goal was to awaken thoughts, words, gestures, emotions in order to reconnect an interrupted dialogue with themselves and start an initial storytelling experience. By telling this new story the relationship between the Self, the Story and the Character is recreated so that freedom and life planning are generated again. In order to “gather unspoken yet deeply felt experiences” I used artworks extracted from the catalogue “tutti uguali, tutti diversi”; catalogue created during the awareness campaign and the fight against social stigma and social exclusion by Art, that the Center of Mental Health 3 – CSM 3 - in Troia (Puglia, Italy) held in 2007 in synergy with the School of Fine Art and with the Monuments and Fine Art Department.

Key words: artworks - psychosocial rehabilitation * * * * * INTRODUCTION In the opening lines from Pirandello’s poem we can observe the concept of otherness to itself and of itself, How can I put up with this stranger within me? the being mine of experience that does not belong to The stranger that I have been to myself? me. The fact that experiencing does not belong to me How can’t I see him? and therefore it does not correspond with how every How can’t I know him? time my life acquires a meaning, leads to life expe- How can I be forever condemned to carry him with me, within me, at the sight of the others and of my own. riences that are not reconfigured in terms of identity, not (extracted from Uno, Nessuno, intelligible, where the Story can no longer narrate the Centomila, by Luigi Pirandello) happening of experiences. And this leads to the emergence of psychopathology. The aim of this paper is to report my experience My goal throughout the lab experience was to awa- related to the six month narrative laboratory with the ken thoughts, words, gestures, emotions in order to psychiatric patients of the Daily Psychiatric Center reconnect an interrupted dialogue with themselves and located in Rutigliano (Bari). The structuring of this lab start an initial storytelling experience. By telling this originated from my own way of understanding the new story the relationship between the Self, the Story concept of Psychiatric and Psychosocial Rehabilitation and the Character is recreated so that freedom and life in terms of “Therapeìa”, that is the Cure. Therapeìa planning are generated again. means regaining “sense” and this is the essence of the The instruments I used to gather unspoken yet deeply therapy. Regaining “sense” and generating new oppor- felt experiences were artworks able to reveal parts of the tunities to find a sense that leads to the creation of new Self, known or unknown. Artworks telling angst, pain, meanings and therefore to a progression of the Story. difficulties, suffering, desires, doubts, fears, hopes, per- Story that is often frozen while waiting for a new plexities, prejudices, refusals, stigma. Artworks to under- narration and for a renewed capacity of change. stand more, to observe from within. Artworks in order Change that happens through actions and passions. to know, to listen, to think, to understand, to get invol- Using this different point of view, the traditional ved and involve, to claim. Artworks to solicit, to pro- concept of psychiatric and psychosocial rehabilitation is pose, to invoke, to promote. overturned, where to re-enable it means to re-give some I extracted the artworks I used from the catalogue forms of support for the quality of life, some lost skills, “tutti uguali, tutti diversi”. This catalogue was created starting from a "damage" that has been operated, in during the awareness campaign and the fight against some way, in the psyche. I believe that this is a social stigma and social exclusion by Art, that the limiting aspect and limited to a specific sector. The Center of Mental Health 3 – CSM 3 - in Troia (Puglia, concept of Re-habilitation doesn’t have the concept of Italy) held in 2007 in synergy with the School of Fine therapy/treatment/cure in itself, whereas the concept of Art and with the Monuments and Fine Art Department. Therapeìa can easily include in itself the rehabilitative Project, an opportunity to firmly take position against aspect in the strict sense. the inhuman culture of social exclusion, which denies

S527 Immacolata d’Errico: HOW ARTWORKS CAN GATHER UNSPOKEN YET DEEPLY FELT EXPERIENCES. USING NARRATIVE LAB IN DAILY PSYCHIATRIC CENTER Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 527-532 rights and opportunities to the people with mental Patient n.1, G., 50-year-old male disorder. The project originates in a poor and difficult Patient n. 1 worked on "SEGREGAZIONE" (that is land, as the southern Sub-Appennino Dauno... It arises from the fusion of two worlds, that of the mental health “segregation”), oil on canvas, by Rosanna Roggia, brin- and that of the art; worlds that are complex and ging the theme of loneliness: a life, emotional and therefore hard, full of contradictions and brilliant interior loneliness; an immense existential emptiness. G. manifestations, sometimes obvious sometimes absolu- has always showed an image of bravado and hardness, tely unpredictable, fascinating and mysterious... so far so completely rejecting a daily reality full of survival but also so close and, above all, as fusion of their and gratification anxieties and suffering from a ” black protagonists: students, teachers, mental health wor- dog” represented by loneliness, abandonment and alie- kers and people with severe mental disorder. nation. Bringing out to oneself and to the others the (Giuseppe Pillo, director of the CSM 3 in Troia, theme of loneliness opened a gap that allowed other project developer). members of the group to enter his inner world and This project included educational-training meetings introduce warmth and the color of life. Below there are on the theme of "madness" and its origins, addressed a series of thoughts on the theme of loneliness that G. to 100 students from the School of Fine Art, through shared with the group. videos, testimonies, role-play, interactive discussions, Why me? Why this feeling of emptiness? Loneliness. interactions with patients and their relatives and A desert in which you will find your way. Loneliness can production of artistic creative activities in colla- be therapeutic, I mean that if we overcome this dis- boration - and side by side - with psychiatric patients comfort alone, we can face it better, perhaps! Medita- themselves. At the end of all the meetings, students ting and feeling our soul over and over. were asked to produce original artistic works that Loneliness is isolation from the World and from the would be used in the awareness campaign and fight Others. Nobody understands me and my dream is to be against social stigma. These 73 artworks, realized after read out. I dream in an empty room, I’m alone in the the meetings of fusion and indispensable collaboration real world, but in my dreams I take shelter. between artist and psychiatric patient, have been Loneliness is a beast. Why me? collected in the catalogue “TUTTI UGUALI TUTTI DIVERSI”. Patient n. 2, M., 26-year-old male I color photocopied all the artworks contained in Patient n. 2 worked on “INSIDE”, digital processing the catalogue and I submitted them to the group of 11 on colored photographic paper, by Gianfranco D'Aver- psychiatric patients belonging to the Day Center sa, telling himself in terms of "mental confusion" and Phoenix (Figure 1). I told them to look at them, to rest, "the earth with its disorder". M. had just entered the day to reflect and choose the ones that “touch the soul center; his behavior was characterized by emotional more”. I asked them to verbalize and write; and to be lability and discontinuity. He followed, often opposed, with themselves but also to share with the Other. I told thoughts, impossible dreams and unavoidable frustra- them to express themselves using different forms of tions. He was very confused and in anguish of non- language: gesture, prose, color, object, poetry and success. Starting from “INSIDE” read as a brain with its more. We worked to put together the fragments of chaotic cells, the patient with the group worked on the stories and complex personalities, fragments of events theme of “having on my mind a network of infinite left in the space of a past life, never collected, never thoughts that I cannot solve”, by analyzing all the facets understood, never felt. through the use of various expressive mediums: the In the impact with the complexity that an artwork metaphor of the ball of wood, the writing and various arouses, it is as if the patients had built a bridge able to theatrical techniques. It was remarkable what a mate meet themselves, to recover those absent-minded and (D.) said to him in a lab session: “It happened to me. incoherent realities in order to find the path of My mind created lies that were true to me and I had to perceiving oneself as "a whole" and to weave a new face those lies and the truth. It was like resolving a dialogue with themselves and their affective-emotional dilemma!” This sentence resulted from the analysis of aspects. the following lines from Patrick Ness: “Your mind will In this paper I am going to report, for each indi- believe comforting lies while also knowing the painful vidual patient, the most highly affecting artwork and truths that make those lies necessary. And your mind the reflections based on them. I would state that the will punish you for believing both”. patients did not know the title of the artwork to avoid (extracted from A Monster Calls, by Patrick Ness) to be influenced. I worked in a transversal way despite the different diagnosis and the personality styles, while Patient n. 3, V., 33-year-old male considering their psychological and psychopathological aspects. During the lab sessions I availed myself of Patient n. 3 worked on "LO STIGMA FRAMMEN- the precious collaboration of a young psychologist, TATO DALL'IRA" (that is “stigma fragmentated by an- Carlotta Rubino. ger”), a glass fusion mosaic by Leonardo Avezzano, re-

S528 Immacolata d’Errico: HOW ARTWORKS CAN GATHER UNSPOKEN YET DEEPLY FELT EXPERIENCES. USING NARRATIVE LAB IN DAILY PSYCHIATRIC CENTER Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 527-532 naming it in "the scream. The angry man who screams". typical psychopathological condition in F. Every V.’s main characteristics were his bonhomia, his condition that doesn’t coincide with his principles mildness and his calmness that were opposed to the generates in him a sense of uncertainty that sometimes behavior that his relatives reported he had had at home turns into doubt (and therefore indecision), sometimes since the beginning of the psychopathology. The mental into self-loathing. During this lab experience F. health workers of the day center had never observed composes the following lines: such behavior: explosion of anger leading to rage! An The battle between good and evil is eternal, extremely compliant and peaceful behavior and the War leads only to hate and destruction, absence of clinical symptoms (without depression, Mars and Venus, the Sun and the Moon, anxiety, delusions and hallucinations) made us Falling asleep and awakening, chaos, perplexed. The only typifying traits were an eternal fake Possessing evil and wanting good, smile and the difficulty with meta-communication and Emptiness is by my side and in the end everything is insight. It can be easily argued that the choice of this accomplished. artwork could represent a communicative channel As an operative we have used both the artwork and between us and his “inner anger”. This artwork the lines in order to work on shades of grey, on the faces represented the hammer that knocked down the wall of that men can show without necessarily being a betrayer, the patient’s incommunicability. During the lab sessions on the others…between light and shadows, on the we worked with drawings, poems (telling myself relationship between the theoretical and practical, bet- through poems) and with theatrical techniques. V. who ween the ideal reality and the experiential reality. wasn’t able to tell about himself, at last he was able to find, using these instruments, a communicative channel Patient n. 5, A., 42-year-old male in order to regain himself, his emotions and his meanings. The use of art, in any form, became Patient n. 5 worked on “ESPRESSIONI NASCO- fundamental medium to convey a new meaning and STE” (that is “hidden expressions”), acrylic and oil on allowed getting to a place the patient’s inner world canvas by Cristina Trentalange, that A. renamed where words were not able to. For example, the poem “Masks, a number of smiley faces, that reveal while on which V. worked and recited is extremely interesting concealing”. A. is an ever smiley, helpful, gentle, and extremely meaningful from the psychopathological willing “boy”. His psychopathology is due to mild cog- analytical point of view of the individual; the poem is nitive impairment that entailed a sense of unsuitableness reported below: and diversity worsened by life and educational expe- I have the feeling I am fighting against stones, riences. A. loves working and successfully worked in a the future opens wide in my eyes bakery for about two years as an intern within a project that came to an end and was not set up again perhaps for but my gut is frozen, economic or political problems. Despite the unemploy- the only possible space is far away, ment condition and the obvious consequent frustration, the only possible time is never, A. has always given and shown off a self-image of sere- when I am with them nothing else exists, nity. In the view of this, we will understand how the my mind is fragile, choice of this artwork has opened a way towards the it can’t stand ups and downs, understanding of inner unease hidden by the patient. In it avoids the human presence, order to develop the topic brought up in the lab exit forces me to catchphrases perience I asked A. to find in literature a poem that could and fake smiles represent better his feelings and he chose the following while a lot of earth inside of me is miserably on fire extract from the letter written by Luigi Pirandello to his st and in every moment my skin is peeling off. sister Lina, on 31 of October 1886, in which the theme (extracted from Mancanza, by Ilaria Palomba) of the meaningless life is remarkably present. “When you run out of ideals, because life seems a huge comedy, without any connection, without any Patient n. 4, F., 31-year-old male whatsoever explanation, when you run out of feelings, Patient n. 4 worked on “MADNESS”, paper on can- because you have come to a point where you don’t value, vas by Paolo Lupoli that F. renamed “crying masks, you don’t care about people and things and therefore you fight between good and evil, black and white, the run out of routine, that you can’t find, and employment, contrasts”. The reinterpretation of this artwork in terms that you reject – when you, in short, live without life, of contraposition is extremely interesting because this think without thought, feel without heart – then you won’t recalls the lack of flexibility, the incapability of F.’s know what to do: you will be a wanderer without no stiff obsessive system of integrating within himself the home, a bird without a nest. This is what I am.” shades, perplexities, and the imperfections that reality Simultaneously with this lab, A. developed depres- necessarily brings about. The presumption of including sion, for sure due to the insight and the acknowledge- the variability of human experience in his orderly ment, as if it was abreaction, of what he had always system, without modifying it or adapting it to reality is a hidden to himself.

S529 Immacolata d’Errico: HOW ARTWORKS CAN GATHER UNSPOKEN YET DEEPLY FELT EXPERIENCES. USING NARRATIVE LAB IN DAILY PSYCHIATRIC CENTER Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 527-532

Figure 1. Artworks

S530 Immacolata d’Errico: HOW ARTWORKS CAN GATHER UNSPOKEN YET DEEPLY FELT EXPERIENCES. USING NARRATIVE LAB IN DAILY PSYCHIATRIC CENTER Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 527-532

Patient n. 6, T., 43-year-old female Patient n. 8, D., 44-year-old male Patient n. 6 worked on “DOLORE ED INDIFFE- Patient n. 8 worked on “GUARDA QUELLO” (that RENZA” (that is “emotional pain and indifference”), is “ look at him”), mixed technique by Palmina Brescia. glass mosaic with electrical wires by Natalia Gentile. D. experienced the dramatic economic and social failure T. chose this artwork because it represented for her of his family. He experienced the transition from wealth “the giant mouth, blood molecules, mask that covers to extreme poverty to the point that keeping warm in the my detestable face”. She is not very good-looking and winter was extremely difficult. His mother, who origi- her body and her face have always been her drama. nally owned a house full of housekeepers, ended up The lack of self-acceptance has always been associated working as a housekeeper in other people’s houses in with episodes of low mood; during these episodes she order to make a living. D. was marginalized from his would interrupt every human relationship. She would social circle, mocked and often humiliated. His family spend days wearing pigiamas as if they were a second was disrupted, his brothers distanced themselves, their skin. It is interesting to point out that T. attended the father died early. D. began to have problems of self- lab regularly. This extraordinary behavior surprised all reference in his everyday life and to feel terrified of of us, allowing deeper connections, reciprocating smi- going out and meeting people; every event was inter- les and improving listening to each other. preted according to the "me concernere" (everything affected me). He became abulic, impossible, neglected Patient n. 7, G., 30-year-old male in appearance, tending more and more to isolation and his angst was badly controlled. The delusions that ini- Patient n. 7 worked on “IDENTITA’ INESPRES- tially were of persecution became more bizarre and resi- SE” (that is “ unexpressed identities”), mixed tech- stant to therapy over time. He attempted suicide. He nique by Carmen Fratta. G. expressed himself as survived without physical outcomes, as it was a non- follows: “The homologation of man, the conven- fatal suicide. Before the lab experience, many years had tionalism of man with reduction of individual passed since the acuteness and suicidal act. The patient consciousness into collective consciousness … In the has changed a lot, questioning the authenticity of hallu- future the Self will turn into a machine. It’s a total cinatory and delusional experiences, distancing himself war; mankind is extinct, the world is empty. Aliens are from them and taking note of improvement, but a among us, artificial intelligences that show self- general lowering of his aspirations and a narrowing of consciousness to the Other”. And he called this vision the field of interests remain. Fear and close attention to “cyber-punk”. G. has always had a conflicting the signals from others remain unaltered. Every modu- relationship with his parents, above all with his father. lation of drug-therapy terrifies him, because he is afraid An unbalanced relationship between a too strong and of his inner psychological destabilization and of tyrannous father and his weak, yet always in contrast, retreating to a previous condition. He always wears dark son. A father who embodies a system of values at glasses and the frequent attendance of the Day Center which G. aims but with which he is in contrast. A represents for him the only social activity, being very father that he can’t get rid of without arguing close to the Center's mates and to the mental workers. I constantly, whose opinion he is afraid of. A father believe that the knowledge of the whole contextual without any respect for the judgement of the son. A background and of the psychiatric illness is essential to father from whom to keep a distance by means of an understand the choice of the artwork "LOOK AT HIM" oppositive behavior and to demarcate oneself in order where there is a head with an open mouth that seems to not to feel crushed. A father always in contrast with say "look at him" and there are two indices pointing G.’s mother, who although is ambiguous and ambi- towards. D. during the lab renamed the artwork in valent, backs up her son and acts as a counterpart. This "universal love. The finger pointing man is falling apart, son who is crushed by the personalities and parental he will disintegrate without the universal love that can tensions, ends up becoming insecure and fragile, and save the world!” Indeed, his world has been shattered and in which the sense of guilt, shame, uncertainty and only the warmth he finds in the Daily Center, gives him inadequacy become stable traits of a way of being. strength, courage and a sense of belonging. With this heavy load G. goes to Germany to work, but this experience lasts a few days. The world seems Patient n. 9, M., 29-year-old female alien; he feels like his moving within predefined and non-logical schemes. He feels surrounded by an Patient n. 9 worked on “INCUBO” (that is “night- unknown and obscure mankind. He escapes and has a mare”), stone mosaic by Vita Contangelo. For M. the delusion, on persecutors and persecuted. G. is an nightmare is represented by the death of the mother intelligent young man with whom we have worked on when she was still a child. Later suffering and connections between his cyber vision and the sense of incomprehension, always lying in wait, took place. She unreality that he experiences when he doesn’t find his had emotional difficulties with her father though she reality. wished for a safe shelter. In this way sadness has endu-

S531 Immacolata d’Errico: HOW ARTWORKS CAN GATHER UNSPOKEN YET DEEPLY FELT EXPERIENCES. USING NARRATIVE LAB IN DAILY PSYCHIATRIC CENTER Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 527-532 red over time by channeling into depressive crises that CLOSING REMARKS adolescence had then enriched with rage and rebellion, always mismanaged and misunderstood, thus turning In the initial part of the paper I stressed the concept of into social maladjustment. M. has now reached a ba- psychiatric rehabilitation as Therapeìa. Therapeìa as re- lance also thanks to a romantic relationship, very impor- gaining “sense”, but also as generating new opportunities tant for her. She also continued her studies graduating to give meaning to one’s own story - perturbed and and that is why she renamed the artwork "the Redemp- perturbing stories that, as we have seen, are difficult, tion through love. From happiness to pain through complex and anguishing – and giving voice and new which I encounter love.” At the end of the lab, M. faces meaning to stories allowing the recovery of possibilities the grieving process by creating and reciting a scene in of being, which are believed lost. This idea guided me in which the mother says: "My dear child, do not worry! proposing this mode of conduction of the lab. A path Mom is fine now and doesn’t want to see you so sad... which, as I have described in detail by analyzing the now you have to face life, a great achievement ". individual cases, has represented only the initial phase, that is the phase of the disease reconstruction through the analysis and the appropriation of life themes, helping the Patient n. 10, M., 47-year-old male patient to give a meaning to his psychic suffering. Deli- Patient n. 10 worked on “LUIGI” (that is “Louis”), berately in the paper I did not mention the patient’s digital photo by Francesca Loprieno that M. renamed diagnosis because I believe it is not significant in the “Self-determination”, spotting him as a farmer satisfied context of the work carried out. I worked with people, with his lush fields. “Homo faber fortunae suae” is his whose main characteristic was the difficulty of intro- motto! LUIGI’s choice of farming the land, reflects the spection and insight, and my only concern was to choose sense of rootedness that he has always lacked, as his life a suitable for access channel to express oneself for has been characterized by dissipation and dysphoria. everyone. I think I succeeded! All the material and "the Extreme irritability and emotional lability have been new sense gained" will be the starting point for a new amplified by the existential emptiness filled by M. with goal. Which goal? We cannot know that a priori because drug abuse. A life led bouncing between high expe- reconnecting an interrupted dialogue with themselves is ctations and disappointment, dying every night and very personal. The project has been interrupted due to rising with every sunrise, in dangerous suburbs and organizational problems but it is about to continue. among bodies torn by abandonment and misery. It took However, I think it is useful to point out that this way of him time to get out of that pit and to defeat the understanding the concept of Psychiatric and Psycho- emptiness promising to himself: I will make it! Trust me social Rehabilitation in terms of “Therapeìa”/Cure must because homo faber fortunae suae. The mental worker become an integral part of every rehabilitation project, of the Center believed him. Undoubtedly the ad inte- regardless of the theoretical reference models. grum recovery of a life entirely torn is extremely difficult, but M. hasn’t given up and is still fighting. Acknowledgements: None.

Patient n. 11, C,. 41-year-old male Conflict of interest: None to declare. Patient n. 11 worked on “MATTO DA LEGARE” (that is “barking mad”), digital processing on colored References photographic paper by Antonio Nasuto. C. simply pointed to a teddy bear wearing a straitjacket saying one 1. Arciero G & Bondolfi G: Selfhood, Identity and only word throughout the whole lab: this! However, he Personality Styles. Wiley-Blackwell, 2009 filled the room with gestures, such as shooing snakes, 2. Arciero G, Bondolfi G, Mazzola V: The foundations of miming talking mouths, ears and eyes always tense and Phenomenological Psychotherapy. Springer, 2018 attentive to silent sounds and invisible people. His 3. Ness P, Dowd S: A Monster Calls. Walker books, 2011 mental disease as a straitjacket slowly wrapped him 4. Palomba I: Mancanza. AUGH Ed. Viterbo, 2017 relentlessly and hopelessly. So C. let himself be carried 5. Pirandello L: Uno, Nessuno e Centomila. Oscar Moderni away with the swallowing waves of his disease. Mondadori, 2016

Correspondence: Immacolata d’Errico, MD psychiatrist and constructivist psychotherapist via Libertà 53, 70123 Bari, Italy E-mail: [email protected]

S532 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 533-536 Conference paper © Medicinska naklada - Zagreb, Croatia

MANAGEMENT OF ADULT PATIENTS WITH ANOREXIA NERVOSA: A LITERATURE REVIEW Carole Jassogne & Nicolas Zdanowicz Université Catholique de Louvain, CHU Namur Godinne, Psychosomatics Unit, Yvoir, Belgium

SUMMARY Background: Anorexia is a frequent pathology; not only does it cause major changes in patients’ quality of life, but also the mortality rate is high. This mortality mainly affects young people. However, care remains controversial. The aim of this literature review is, therefore, to review current guidelines. Subjects and methods: A review of the literature published between 2006 and 2017, from articles contained in the Cochrane, PubMed, Scopus and PsychINFO databases. Keywords were ‘anorexia nervosa’, ‘adults’ and ‘management’. Results: Patient management must be multidisciplinary and prioritise weight gain. For this to happen, outpatient monitoring must include a gradual normalisation of eating habits. This always involves psychotherapy and sometimes prescription medication. However, no specific therapy or psychotropic drug has demonstrated statistical superiority in the management of anorexic patients. Cognitive behavioural therapy remains the most effective therapy in preventing relapse, and family therapies for the treatment of young patients who are still living with their families of origin. Hospitalization is sometimes necessary and must then include gradual and closely monitored refeeding to avoid the potentially fatal refeeding syndrome. Conclusions: The management of anorexic patients is complex but always involves reaching a normal weight. The best prognosis is found in young patients with the least chronic disease.

Key words: anorexia nervosa – adults - treatment

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INTRODUCTION SUBJECTS AND METHODS

Anorexia nervosa (AN) is a common psychiatric A literature review was conducted of studies pub- disorder. It mostly affects young women and its life- lished between 2006 and December 2017. Studies were time prevalence is 5 out of 100 women. It is mainly identified in the PubMed, Scopus, PsychINFO and Co- present in countries that are socio-economically deve- chrane databases and focused on current adult thera- loped. AN has a high mortality rate due to its medical pies. Keywords used were ‘anorexia nervosa’, ‘adults’ (which cause half of all deaths) and psychosocial and ‘management’. Ninety articles were selected. complications. Overall, AN mortality is the highest of all psychiatric disorders - five times higher than in the RESULTS general population for age and sex. In addition, on average, death occurs in subjects who are between 25 Whatever the care regime, and independent of the and 34 years of age. point of view of the author, patient management must Even without taking this mortality rate into be multidisciplinary, and include physicians, psycho- account, AN has a far greater impact on the quality of logists, psychiatrists, dieticians, nurses, occupational life of patients than other psychiatric disorders. This is therapists and social workers (Hay et al. 2014, 2015). mainly due to the high relapse rate. Communication within the team is crucial: what is said The management of AN patients remains very to the patient and their family must be coherent and difficult and controversial. In practice, patients deny non-judgmental. their own needs. And even when they are persuaded of the need for care, it is necessary to be extremely Outpatient care cautious due to the risk of refeeding syndrome (ionic The first objective of therapy is to stabilize the pa- alteration linked to too-rapid refeeding) and under- tient’s physical state, in particular, to correct metabolic nourishment (too slow refeeding, which keeps the abnormalities. This relies, notably, on weight gain. All patient in deficiency, often due to a fear of refeeding weight and BMI goals must be clarified with the syndrome). patient at the outset and the entire team must be infor- Controversy surrounds each stage of an adult AN med. Setting realistic objectives requires a detailed patient’s ‘classic’ care journey, which raises the follo- knowledge of the patient’s situation at the beginning of wing three questions: What strategies should be used treatment. Taking a basic history is essential, together for outpatient consultations? Are there pharmaco- with a physical examination, notably blood sugar and logical treatments that can help these patients? How prealbumin tests. Other complementary examinations can hospitalization be best managed? are required: an electrocardiogram, or even an echo-

S533 Carole Jassogne & Nicolas Zdanowicz: MANAGEMENT OF ADULT PATIENTS WITH ANOREXIA NERVOSA: A LITERATURE REVIEW Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 533-536 cardiogram, an abdominal scan (to exclude mesenteric mized trials have suggested that olanzapine (2.5 to artery syndrome), a bone scan, and a cerebral MRI 10 mg/day) may increase weight gain (Walsh et al. scan (in the case of cognitive disorders). 2017, Attia 2012, McKnight & Park 2010). This effect, Once weight gain and dietary behaviour goals have when demonstrated, is statistically modest (Walsh et al. been clarified, treatment should be adjusted to be as 2017, Lebow et al. 2013, McKnight & Park 2010, Hay unrestrictive as possible, and as consistent as possible et al. 2014). Antipsychotics do not alter misperceptions with the compromises agreed with the patient. It is of the body. Some studies have even shown an increase important to keep in mind that weight gain is very in eating symptoms and anxiety disorders (probably anxiogenic. Most authors agree that to reach the target related to patients being aware of the effect of weight BMI is necessary to combine psychotherapy and the gain and/or increased hunger signals) (Lebow et al. normalization of eating behaviours (Fisher et al. 2010, 2013, McKnight & Park 2010). On the other hand, they Claudino et al. 2006, Forman et al. 2016). With respect appear to limit depressive disorders. However, the exi- to the different psychotherapies that are available, none stence of significant side effects (extrapyramidal syn- has been demonstrated to be clearly better in the drome, QT prolongation, etc.) supports their introduc- management of adult AN patients. Their effectiveness is tion during hospitalisation rather than outpatient care. consistently limited: studies are small and follow-up is Another controversial issue regarding their use is the short-term. Various elements must be taken into account dose to be prescribed and the duration of treatment - notably that care based solely on dietary advice is not (McKnight & Park 2010). enough. Cognitive Behavioural Therapy (CBT) is the Regardless of the type of medication prescribed, re- most interesting treatment for AN related to sexual commended practice is to start with small doses to limit trauma but also in preventing relapse. With respect to side effects (Walsh et al. 2017). Side effects increase as family therapies, they remain the first-line treatment for the patient is thinner. It should also be noted that low adolescents and young adults who still live with their weight decreases the response to these drugs. Finally, families of origin, although some studies question this the ambivalence of patients with respect to a drug that (Swenne et al. 2017, The Society for Adolescent Health could cause them to gain weight must be taken into and Medicine 2015). account.

Pharmacotherapy Hospital management Should psychotropic drugs be prescribed to AN There is consensus on the criteria that indicate hos- patients? If so, which ones? When? For how long? So pitalisation: significant medical instability (incessant far, drug therapy has provided relatively little evidence weight loss, bradycardia below 40 or tachycardia at rest, of its effectiveness. Most studies suggest that drugs hypokalaemia, hypoglycaemia, hypophosphatemia, ar- should not be a first-line treatment (Claudino et al. rhythmia, orthostatic hypotension, <36.1°C, poor cere- 2006, Forman et al. 2016, Walsh et al. 2017). They are bral perfusion, organ damage, severe dehydration, acute only necessary when the patient does not respond to any complications, severe refeeding syndrome); significant other treatment (i.e. does not gain weight) or when psychological instability (mood disorder, alcohol abuse); psychological symptoms persist despite weight gain. or when outpatient care fails. The objectives of hospi- When the decision is taken to prescribe a psycho- talization are the same as those of outpatient therapy, tropic drug, antidepressants can be used to treat depres- namely to correct metabolic disorders and the complica- sive, anxiety and obsessive-compulsive disorders often tions of anorexia through weight gain. These objectives associated with anorexia. However, some studies claim must be clarified at the beginning of hospitalization, that such drugs have not been demonstrated to be together with the requirements of the hospital setting. effective in treating these disorders (Claudino et al. Patients must be monitored during meals and for one 2006, Attia 2012, Marzola et al. 2015), notably with hour afterwards to limit compensatory behaviours. respect to overall improvement, acceptability of treat- Physical activity is restricted at first and then gradually ment, weight gain or dropout rate. Moreover, body reintroduced. image distortion and food perception disorders do not It is vital not to over-medicate nutrition. However, respond to their administration. Nevertheless, some a nasogastric tube is required if the BMI is below 15. authors consider it reasonable to offer an antidepressant Gastrostomy is only very rarely indicated and paren- to treat depressive and anxiety disorders, notably those teral nutrition is only indicated in the absence of an that persist during weight gain (Walsh et al. 2017, Pike alternative. The target weight gain of an inpatient is et al. 2017). They advise against tricyclics (which in- 1 kg/week (between 500 and 1400 g). In practice, crease the risk of heart rhythm disorders) and bupropion therapists do not attempt to go faster than this for fear (which increases the risk of food crises) (Walsh et al. of a triggering a potentially fatal refeeding syndrome, 2017). The prescription of antipsychotics is consistent which usually occurs within the first three (up to 15) with irrational thoughts suggesting possible delusional days of rapid re-feeding. This risk is present whether disorders. These drugs are all the more interesting as the diet is oral, enteral or parenteral. The syndrome mani- one of their side effects is weight gain: some rando- fests in hypophosphatemia, hypokalaemia, vitamin D

S534 Carole Jassogne & Nicolas Zdanowicz: MANAGEMENT OF ADULT PATIENTS WITH ANOREXIA NERVOSA: A LITERATURE REVIEW Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 533-536 deficiency, heart failure, oedema and coma. To avoid CONCLUSIONS this, it is advisable to start with an electrolytic correction. The management of AN patients is extremely com- There is no consensus on the number of calories to plex, there are multiple famine-related complications, be provided initially. One study recommends starting at and treatment almost always involves weight gain. 5–10 kcal/kg/day and increasing to 15–20 kcal/kg/day There is no evidence to support one particular therapy within 48 hours (30–35 kcal/kg/day for severe cases) over any another with respect to individual therapies. (Robinson & Nicholls, 2015). The number of calories Family therapies seem more effective in the short term, should be slightly higher than the patient’s energy ex- but there is not enough evidence in the longer term. The penditure. After the first few days, a balanced diet is best response rates are found in the youngest groups and offered in terms of the full range of nutrients, including with the least chronic disease. Pharmacotherapy has not carbohydrates, protein (1.5 g/day) and fat. Thiamine is been shown to have a dramatic effect in these disorders added (200–300 mg/day to be gradually reduced), to- and great attention must be paid to side effects, gether with ascorbate and folic acid. One study pro- especially in very thin patients. poses starting with 1500–1800 kcal/day (Steinglass et al. 2016). Once patients are stabilized, this is increased by 300 kcal every three days, reaching 45 kcal/kg/day Acknowledgements: None. to be maintained for six months.More recent studies contradict these figures and propose a higher calorie Conflict of interest: None to declare. intake from the outset (The Society for Adolescent Health and Medicine 2015, Garber et al. 2016, Haynos Contribution of individual authors: et al. 2016). All authors made substantial contributions to the Whatever the approach, during the refeeding period, design of the study, and/or data acquisition, and/or the ionogram should be monitored every day or every its analysis and interpretation. other day, then once a week. If, despite these pre- cautions, refeeding syndrome occurs, it is imperative to first restore the ionic balance and to consider a reduc- References tion in food intake. Sometimes, there is no full-blown 1. Andrade R, Gonçalves-Pinho M, Roma-Torres A, Brandao refeeding syndrome – only rehydration oedema. In this I: Treatment of anorexia nervosa: the importance of case, treatment includes bed rest with legs elevated, disease progression in the prognosis. Acta Med Port fluid intake monitoring and a low salt diet. 2017; 30:517-523 The objectives to be achieved before discharge are 2. Attia E: In the clinic: Eating disorders. An of Inter Med the resolution of cognitive problems and stabilisation of 2012; 4:2-16 the physical state but, above all, a discharge weight that 3. Attia E & Walsh BT: Behavioral management for anorexia is as close as possible to normal. In practice, the more nervosa. NEJM 2009; 360:500-506 normal the discharge weight, the lower the risk of 4. Carter FA, Jordan J, Mcintosh VVW, Luty SE, McKenzie relapse (Steinglass et al. 2016). However, the relapse JM, Frampton CMA, Bulik CM: The long-term efficacy of rate is close to 50%. Outpatient follow-up must three psychotherapies for anorexia nervosa: a rando- therefore be offered at discharge from hospital. mized, controlled trial. Int J Eat Disord 2011; 44:647-654 5. Claudino AM, Silva de Lima M, Hay PPJ, Bacaltchuk J, Schmidt UUS, Treasure J: Antidepressants for anorexia DISCUSSION nervosa (review). Cochrane Database Syst Rev 2006; 1 6. Fichter MM, Quadfflieg N: Mortality in eating disorders – The purpose of this study is to review current know- results of a large prospective clinical longitudinal study. ledge about the management of AN disorders. However, Int J Eat Disord 2016; 49:391-401 the results obtained by the various studies reviewed 7. Filosso PL, Garabello D, Lyberis P, Ruffini E, Oliaro A: highlight that no particular therapy is better than any Spontaneous pneumomediastinum: a rare complication of other. The physical risks associated with weight loss in anorexia nervosa. The journal of thoracic and cardio- patients should be limited and the psychological symp- vascular surgery 2010; 139:79-80 toms associated with this disease should be treated to 8. Fisher CA, Hetrick SE, Rushford N: Family therapy for limit mortality. anorexia nervosa (review). Cochrane Database Syst Rev 2010; 4 Specific elements, such as antipsychotic medication 9. Forman SF, Yanger J, Solomon D: Eating disorders: or CBT, are difficult to assess because the studies cur- overview of treatment. Cochrane Database Syst Rev 2016 rently available are based on small patient samples and 10. Frank GK: Aripiprazole, a partial dopamine agonist to have a high drop-out rate. improve adolescent anorexia nervosa – a case series. Int J New studies involving more patients and extending Eat Disord 2016; 49:529-533 over longer periods would be useful. In practice, anti- 11. Frank GK, Shott ME, Hagman JO, Mittal VA: Taste psychotics or antidepressants take several weeks for reward circuitry related brain structures characterize ill their effects to be fully felt, and most studies do not last and recovered anorexia nervosa and bulimia nervosa. Am this long. J Psychiatry 2013; 170:1152-1160

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12. Gaudiani JL, Sabel AL, Mechler PS: Low prealbumin is a 24. Mascolo M, Dee E, Townsend R, Brinton JT, Mehler PS: significant predictor of medical complications in severe Severe gastric dilatation due to superior mesenteric artery anorexia nervosa. Int J Eat Disord 2014; 47:148-156 syndrome in anorexia nervosa. Int J Eat disord 2015; 13. Garber AK, Sawyer SM, Golden NH, Guarda AS, Katzman 48:532-534 DK, Kohn MR, Le Grange D, Madden S, Whitelaw M, 25. McKnight RF, Park RJ: Atypical antipsychotics and ano- Redgrave GW: A systematic review of approaches to rexia nervosa: a review. Eat Disorders Rev 2010; 18:10-21 refeeding in patients with anorexia nervosa. Int J Eat 26. Mehler P, Winkelman AB, Andersen DM, Gaudiani JL: Disord 2016; 49:293-310 Nutritional rehabilitation: practical guidelines for 14. Golden NH, Katzman DK, Sawyer SM, Ornstein RM, refeeding the anorectic patient. Journal of nutrition and Rome ES, Garber AK, Kreipe RE: Position paper of the metabolism 2010; 1-7 society for adolescent health and medicine: medical 27. Mehler P, Yager J, Solomon D: Anorexia nervosa in management of restrictive eating disorders in adolescents adults and adolescents: medical complications and their and young adults. Journal of adolescent health 2015; management. Up To Date Waltham, MA 2016 56:121-125 28. Mehler P, Yager J, Solomon D: Anorexia nervosa in 15. Hay P, Chinn D, Forbes David, Madden S, Newton R, adults and adolescents: the refeeding syndrome. Up TO Sugenor L, Touyz S, Ward W: Royal Australian and New Date Waltham, MA 2017 Zealand college of psychiatrists clinical practice 29. Mehler P, Yager J, Solomon D: Anorexia nervosa in adults: guidelines for the treatment of eating disorders. evaluation for medical complications and criteria for Australian & New Zeland Journal of Psychiatry 2014; hospitalization to manage these complications. Cochrane 48:977-1008 Database 2017 16. Hay P, Claudino AM, Touyz S, Abd Elbaky G: Individual 30. Pike K, Yager J, Solomon D: Anorexia nervosa in adults: psychological therapy in the outpatient treatment of adults cognitive-behavioral therapy (CBT). Cochrane Database with anorexia nervosa (review). Cochrane Database Syst 2017 Rev 2015; 4 31. Roberto CA, Mayer LES, Brickman AM, Barmes A, Mura- 17. Haynos AF, Snipes C, Guarda A, Mayer LE, Attia E: skin J, Yeung LK, Steffener J, Sy M, Hirsch J, Stern Y, Comparison of standardized versus individualized caloric Walsh BT: Brain tissue volume changes following weight prescriptions in the nutritional rehabilitation of inpatients gain in adults with anorexia nervosa. Int J Eat Disrod 2011; with anorexia nervosa. Int J Eat disord 2016; 49:50-58 44:406-411. 18. Kameoka N, Iga JI, Tamaru M, Tominaga T, Kubo H, 32. Robinson PH, Nicholls D: Critical care for anorexia Watanabe SY, Sumitani S, Tomotake M, Ohmori T: Risk nervosa. Springer 2015; 1-173 factors for refeeding hypophosphatemia in Japanese 33. Sachs KV, Harnke B, Mehler PS, Krantz MJ: inpatients with anorexia nervosa. Int J Eat disord 2016; Cardiovascular complications of anorexia nervosa: a 49:402-406 systematic review. Int J Eat Disord 2016; 49:238-248 19. Kass AE, Kolko RP, Willfey DE: Psychological treatments 34. Steinglass J, Yager J, Solomon D: Anorexia nervosa in for eating disorders. Curr Opn Psychiatry 2013; 26:549- adults and adolescents: nutritional rehabilitation (nutri- 555 tional support). Cochrane Database 2016 20. Latzer Y, Stein D: Bio-psycho-social contributions to 35. Swenne I, Parling T and Salonen Ros H: Family-based understanding eating disorders. Springer 2016; 1-216 intervention in adolescent restrictive eating disorders: 21. Lebow J, Sim LA, Erwin PJ, Murad MH: The effect of early treatment response and low weight suppression is atypical antipsychotic medications in individuals with associated with favourable one-year outcome. BMC anorexia nervosa: a systematic review and meta-analysis. Psychiatry 2017; 17:333 Int J Eat Disord 2013; 46:332-339 36. Titova OE, Hjorth OC, Schiöth HB, Brooks SJ: Anorexia 22. Martin J, Padierna A, Lorono A, Munoz P, Quintana JM: nervosa is linked to reduced brain structure in reward and Predictors of quality of life in patients with eating somatosensory regions: a meta-analysis of VBM studies. disorders. European Psychiatry 2017; 45:182-189 BMC psychiatry 2013; 13:110 23. Marzola E, Desedime N, Giovannone C, Amianto F, 37. Walsh BT: The enigmatic persistence of anorexia nervosa. Fassino S, Abbate-Daga G: Atypical antipsychotics as Am J Psychiatry 2013; 170:477-484 augmentation therapy in anorexia nervosa. PloS one 38. Walsh BT, Yanger J, Solomon D: Anorexia nervosa in 2015; 10:e0125569 adults: pharmacotherapy. Cochrane Database 2017

Correspondence: Carole Jassogne, MD Psychosomatics Unit, Mont-Godinne University Hospital 5530 Yvoir, Belgium E-mail: [email protected]

S536 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 537-540 Conference paper © Medicinska naklada - Zagreb, Croatia

WHY DO CYBERBULLIED ADOLESCENTS STAY IN CONTACT WITH THEIR HARASSER? A Literature Review and Reflection on Cyberbullied Adolescents’ Coping Strategies Eugénie Khatcherian & Nicolas Zdanowicz Université Catholique de Louvain, Psychosomatics Unit, Mont-Godinne University Hospital, Yvoir, Belgium

SUMMARY Background: Many young patients who are cyberbullied maintain communication with their harasser, despite the fact that this behaviour perpetuates the harassment. Numerous studies describe coping strategies adopted by cyberbullied adolescents. None describe what motivates adolescents to continue to communicate with their harassers. Methods: We conducted a literature review of cyberbullying, taking into account the challenges of adolescence. We used several search engines (Scopus, PsycINFO, Cairn and PubMed), using the following keywords: cyberbullying, teens, behaviour, coping strategies, social network, Facebook, counterpart. Our search returned 526 results, which were subsequently sorted as a function of their relevance. We also consulted reference books on adolescent psychology. Results: The adolescent, whose identity is being rebuilt, seeks a peer group, but also a relationship with a counterpart. This search is replayed on social networks and can lead adolescents to meet a counterpart harasser. Studies show that adolescents who suffer from cyberbullying are more likely than others to be in search of new friendships, and use social networks to make up for a lack or absence of fulfilling social relationships. They have fewer friends, have more difficulty maintaining social ties, and have fewer communication skills. In addition, cyberbullied adolescents have poorer relationships with their parents and teachers than their peers. Conclusions: Narcissistically fragile adolescents are at greater risk of being unable to stop communicating with their cyberbully. If the adolescent has no other relationships that enable him or her to develop their identity, they will be unable to put an end to this harmful counterpart relationship. It would be interesting to supplement this review with an experimental study, and to consider the development of new, secondary prevention strategies in the adolescent population. Key words: adolescent – cyberbullying – coping strategies – counterpart relationship – social networks

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INTRODUCTION adopted by victims of cyberbullying, with the aim of secondary prevention (Navarro et al. 2016). Among With the democratization of the internet, social net- the coping strategies reported by adolescents we find works are omnipresent in our daily lives and are chan- ongoing communication with the harasser (Slonje et al. ging the way we interact with others and ourselves. 2012, Perren et al. 2012, Machackova et al. 2013). The Adolescents are the most affected by these transfor- aim of this behaviour may be to harass the harasser or mations; this hyper-connected generation is eager for to contact him or her in a more constructive way to ask novelty in any form, and they invest in multiple social them to stop. Approximately 60% of adolescents use networks. According to a study by the Pew Research such strategies and describe a positive impact on their Center in 2015, 92% of American adolescents connect emotional state. Yet such strategies are the least to the internet every day, and 71% use more than one effective in ending cyberbullying (Price & Dagleish social network. 2010, Machackova et al. 2013). New modes of harassment have emerged with the Why do these adolescents maintain contact with use of these modes of communication. They can be their cyberabuser when they could be using other, more grouped under the term ‘cyberbullying’. Tokunaga effective strategies? (2010) defines cyberbullying as “any behaviour performed through electronic or digital media by indivi- METHODS duals or groups that repeatedly communicates hostile or aggressive messages intended to inflict harm or To answer this question, we used several search discomfort on others”. These new types of harassment engines (Scopus, PsycINFO, Cairn and PubMed), using affect approximately one fifth of the adolescent popu- the following keywords: cyberbullying, teens, beha- lation. A study by EU Union Kids Online (Livingstone viour, coping strategies, social network, Facebook, et al. 2011) revealed that approximately 20% of Euro- counterpart. Our search returned 526 results, which pean adolescents have been victims of harassment via were subsequently sorted as a function of their rele- the internet. The increase in this type of aggression has vance. We also consulted reference books on adoles- led many studies to look at the coping strategies cent psychology.

S537 Eugénie Khatcherian & Nicolas Zdanowicz: WHY DO CYBERBULLIED ADOLESCENTS STAY IN CONTACT WITH THEIR HARASSER? A Literature Review and Reflection on Cyberbullied Adolescents’ Coping Strategies Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 537-540

Our study is structured as follows: First we examine Social networks represent an opportunity to join a the construction of the body image and identity during peer group, giving them an identity, and endorsement childhood. Next, we address the questioning of body for their existence through integration into the group image and identity in adolescence, taking into account (Gozlan & Masson 2013). Social networks are spaces the influence of social networks on these processes. In that parents cannot see into, where the adolescent has the third and fourth steps, we look in detail at the the opportunity to identify with a group of individuals importance of counterpart relationships in adolescence who share the same language, norms and preferences. and the influence they can have on the occurrence and The creation of a profile is an opportunity for the perpetuation of cyberbullying. adolescent to see themselves in a mirror, to create a virtual counterpart that will be seen and approved by RESULTS others. Social networks are an environment that is conducive to revisiting the mirror stage (Gozlan 2014). Construction of the body image Through this profile the adolescent is able to appropriate and identity during childhood his or her physical identity, now sexualized, work on The image of the body is built around the age of 6 to their relational identity, and build a self towards which 18 months during the mirror stage described by Lacan he or she can evolve. Social networks allow adolescents (1949). Until this age the body is only perceived as parts to re-appropriate these new identities, enabling them to through different sensory experiences. In the mirror see themselves and be seen by others, confirming their stage the child sees him or herself through a reflective existence. surface, which is not necessarily a mirror in the physical sense, but rather a mirroring element. Winnicott (1971) Counterpart relationships in adolescence describes the maternal face as the first mirror used by the child. During this psychological experience, the The adolescent looks for a narcissistic counterpart child becomes aware of the unity of his or her body and among their peers, ‘someone else who looks like me’. It acquires a unified body image, together with its limits. is a period of deep friendships and passionate loves. The This operation also allows the child to discern what is function of this other self is to confirm the individual external to itself. This first self-image represents the existence of the adolescent. This other, who is similar physical identity, which is supported by the affectionate and at the same time different, allows the adolescent to feelings and words of the child’s parents and relatives. contemplate a mirror image of him or herself and to This physical identity, together with the associated come to terms with their strangeness (Maïdi 2012; affects constitutes primary narcissism (Freud 1914). Carbone 2013). Social networks enable adolescents to meet people who are similar to themselves and satisfy Subsequently, secondary narcissism is constructed through verbal relationships with others. The child the need to search for this counterpart. Sharing intimacy builds a symbolic identity from exchanges with his or is promoted by physical distance and a sense of her entourage and the place that is intended for it within anonymity; social networks heighten the illusion of society (Freud 1921). Symbolic identity constitutes a continuity with the interlocutor (Jung 2014). future form for the child, an ideal towards which he or The function of the counterpart is to support the she will tend. adolescent’s identity. He or she protects the adolescent from the sudden disappearance of their infantile self- Revisiting identity in adolescence esteem. However, the counterpart can also become a and the impact of social networks persecutor (Maïdi 2012) who can be dangerous for the identity. He or she is able to seize the identity and trans- The adolescent is confronted with a body in transform it. The adolescent then becomes an impotent by- formation, which becomes foreign, unknown, and which stander, who can only watch the manipulation of his or he or she must be able to reclaim. The individual must, her new identity. In this type of relationship, the coun- once again, repeat the process of corporal appropriation terpart comes to represent the ‘uncanny’ described by and identity building what was first accomplished at the Freud (1919). The adolescent is confronted with fee- beginning of childhood. lings of loss of control and worrying unknown origin, In adolescence, the emergence of sexuality signals while being in an intimate relationship. In their search the need to distance oneself from parental images for a counterpart, they can meet on social networks (Carbone 2013). The adolescent loses parental narcis- another who can take possession of his or her image, sistic support, which has become a burden, and conse- leaving the individual impotent and faced with the dark quently becomes narcissistically fragile (Carbone 2013). and undesired parts of themselves. A parallel can be He or she is obliged to find new models of identi- drawn with Oscar Wilde’s novel The Picture of Dorian fication beyond the parental environment. Gozlan Gray (1890). Dorian Gray thanks to his portrait (coun- (2014) compares the adolescent to “a Narcissus in terpart of himself), painted by one of his friends, beco- search of a body separated from his parents”. The mes aware of his unusual beauty. He vows to remain adolescent seeks to reconstruct his or her image by young. His wish comes true and only his portrait changes interacting with their peers. over time. However, when the hero is confronted with his

S538 Eugénie Khatcherian & Nicolas Zdanowicz: WHY DO CYBERBULLIED ADOLESCENTS STAY IN CONTACT WITH THEIR HARASSER? A Literature Review and Reflection on Cyberbullied Adolescents’ Coping Strategies Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 537-540 aging portrait, which reflects all of his vices and the by peers becomes equivalent to no longer existing, to darkest parts of himself, he cannot bear it. He destroys being excluded. When the adolescent is confronted with the canvas and kills his friend, the painter. In the same the risk of the disappearance of his or her identity due to way the adolescent is confronted with the loss of his or the complete indifference of their peers, they prefer to her identity, transformed by the counterpart into an deal with a counterpart persecutor who they hope to be unwanted mirror image of themselves. He or she then able to control or, failing that, to destroy in order to tries to regain their identity or destroy this unsightly regain their initial place. reflection. This explains the behaviour of adolescent It would be interesting to supplement this review victims of cyberbullying, who desperately try to con- with an experimental study and to consider the develop- vince their harasser to change their mind or become ment of new, secondary prevention strategies in the aggressive in the hope of destroying the counterpart. adolescent population. However, some adolescents do not use this type of coping strategy. Some end all relations with the aggres- CONCLUSION sor or ignore their messages. They use cognitive and behavioural avoidance coping techniques, involving The goal of secondary prevention is to end the harm- themselves in other activities (Navarro et al. 2016). ful counterpart relationship between cyberbullies and These adolescents do not seem tormented by the search their victims. The management of an adolescent suffe- for a counterpart when confronted with a cyberbully. ring from cyberbullying consists, primarily, of encoura- How do we explain the choice of these types of ging participation in a peer group that includes one or behaviours? more counterparts, who are not harassers. These peers allow the adolescent to revisit the mirror stage and pro- The role played by peers vide positive support during identity construction. In these circumstances, it becomes easier for the young Adolescents suffering from cyberbullying are much person to end the relationship with their bully. It is more likely to be in search of new friendships and use essential for the family and professionals working with social networks to compensate for a lack or absence of adolescents to identify individuals who are at risk, who fulfilling social relationships. They have fewer friends, may be isolated and whose identity is fragile, in order to have more difficulty maintaining social ties and have do everything possible to promote positive social inter- fewer communication skills (Navarro et al. 2016). In actions with peers. addition, cyberbullied adolescents have poorer relation- These findings give us hope for the future deve- ships with their parents and teachers than others lopment of new, secondary prevention strategies for (Bjereld et al. 2017, Garaigordobil & Machimbarrena cyberbullying in the adolescent population. 2017). Most cyberbullied adolescents live in a family environment where communication is lacking and little attention, recognition and affection are given to their Acknowledgements: None. needs (Garaigordobil & Machimbarrena 2017, Elsaesser et al. 2017). Conflict of interest: None to declare. DISCUSSION Contribution of individual authors: All authors made substantial contributions to the de- The environment that surrounds cyberbullied adoles- sign of the study, and/or data acquisition, and/or its cents is unconducive to building a solid narcissistic analysis and interpretation. foundation. They have the narcissistic fragility that is specific to adolescence but is exacerbated by a lack of investment from parental figures. These adolescents, References who lack narcissistic security, are more dependent on a counterpart relationship. Compared to others, they have 1. 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S539 Eugénie Khatcherian & Nicolas Zdanowicz: WHY DO CYBERBULLIED ADOLESCENTS STAY IN CONTACT WITH THEIR HARASSER? A Literature Review and Reflection on Cyberbullied Adolescents’ Coping Strategies Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 537-540

6. Freud S: Psychologie des foules et analyse du moi. Payot, 15. Navarro R, Larrañaga E, Yubero S: Differences between Paris, 1981. (Original work published in 1921) preadolescent victims and non-victims of cyberbullying in 7. Garaigordobil M, Machimbarrena JM: Stress, competence, cyberrelationship motives and coping strategies for and parental educationnal styles in victims and aggressors handling problems with peers. Curr Psychol 2016 of bullying and cyberbullying. Psicothema 2017; 29:335-340 16. Perren S, Corcoran L, Cowie H, Dehue F, Garcia DJ, Mc 8. Gozlan A, Masson C: Le théâtre de Facebook: Réflexion Guckin C et al.: Tackling cyberbullying: Review of empiri- autour des enjeux psychiques pour l’adolescent. cal evidence regarding successful response by students, Adolescence 2013; 31:471-481 parents, and schools. Int J Conf Violence 2012; 6:283-293 9. Gozlan A: Le héros éphémère sur la scène facebookienne. 17. Pew Research center: Teens, social media & technology Topique 2014; 126:51-63 overview 2015 10. Jung J: Formes transitionnelles du double à l’adoles- 18. Price M, Dagleish J: Cyberbullying: Experiences, impacts cence. Perspectives Psy 2014; 53:73-79 and coping strategies as described by Australian young 11. Lacan J: Le stade du miroir comme formateur de la fonc- people. Youth studies Austalia 2010; 29:51-59 tion du Je, telle qu’elle nous est révélée dans l’expérience 19. Slonje R, K. Smith P, Frisén A: The nature of cyber- psychanalytique. Rev Fr Psychanal 1949; XIII:449-454 bullying, and strategies for prevention. Comput Human 12. Livingstone S, Haddon L, Gorzog A, Olafsson K: EU kids Behav 2012; 29:26-32 online final report. EU kids online 2011 20. Tokunaga RS: Following you home from school: A critical 13. Machackova H, Cerna A, Sevcikova A, Dedkova L, review and synthesis of research on cyberbullying victimi- Daneback K: Effectiveness of coping strategies for zation. Comput Human Behav 2010; 26:277-287 victims of cyberbullying. Cyberpsychology (Brno) 2013; 21. Wilde O: Le portrait de Dorian Gray. Le Livre de Poche, 7: article 5 Paris, 1972. (Original work published in 1890) 14. Maïdi H: Clinique du narcissisme. L’adolescent et son 22. Winnicott DW: Jeu et réalité. L’espace potentiel. Galli- image. Armand Colin, Paris, 2012 mard, Paris, 1975. (Original work published in 1971)

Correspondence: Khatcherian Eugénie, MD Université Catholique de Louvain, Faculty of Medicine 1200 Bruxelles, Belgium E-mail: [email protected]

S540 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 541-545 Conference paper © Medicinska naklada - Zagreb, Croatia

NEUROSCIENCE AND VISUAL ART; MOVING THROUGH EMPATHY TO THE INEFFABLE Mark Agius Clare College Cambridge, Department of Psychiatry, University of Cambridge, Cambridge, UK

SUMMARY In this article we wish to discuss recent work on neurobiology and visual arts, with impact on human pleasure, wellbeing and improved mental health. We wish to discuss briefly our model of the Human Person and apply it to Visual Art, and we wish to discuss our view of how empathy has been suggested as an important factor in how visual art can impact the human person, with its links with neuroscience and anthropology, and thus how Visual Art can put Human Beings in touch with their deepest feelings and even with the ineffable.

Key words: art – neuroscience - Thomistic model of the person - empathy - mirror neurons - embodied cognition

* * * * * INTRODUCTION Freedberg’s study belongs to the field of neuro- aesthetics, which explores how the brain processes a Art has been an important part of the everyday lives work of art (Freedberg 2007, 2009). It was reported that of human beings for thousands of years. It is a means of seeing the raised wrist causes an activation of the self-expression and communication. Art is able to muscle. Similarly, viewers of Degas’ ballerinas have transport human beings to the distant past or to remote sometimes reported that they experience the sensation lands. It is able to cause strong emotions and deep of dancing. Thus, the brain mirrors actions depicted on thoughts. Its brilliance can have great impact on the the canvas. watcher. When it is used to express deep meaning and In another study (Di Dio 2007) the reaction of the concepts such as supplicating, thanking (e.g ex-voto brains of observers to classical sculpture was monitored. paintings) and illustrating the presence of a power greater The body proportions of the sculpture were then chan- than that of humanity itself, it can be used to represent ged, and it was observed how the viewer’s response that power. Individual Persons have different and unique changed. This was done using fMRI. The most impor- reactions to art, but its ability to impact us is clear. In this tant result was that the observation of original sculp- article we intend to show that this impact is because of tures, compared to the modified ones, produced acti- the strong effect art can have on the human brain. vation of the right insula as well as of some lateral and Viewing, analyzing, and creating art can stimulate medial cortical areas (lateral occipital gyrus, precuneus the brain in substantial and long-lasting ways. This is and prefrontal areas). When volunteers were required to why the cultural and intellectual benefits of art can ser- give an overt aesthetic judgment, the images judged as ve as a powerful tool that can be used to achieve perso- beautiful selectively activated the right amygdala, nal fulfilment. Both viewing and making art do have compared to those judged as ugly. It was concluded that positive impacts on the brain. the sense of beauty is mediated by two non-mutually exclusive processes: one based on a joint activation of HOW THE BRAIN PROCESSES ART sets of cortical neurons, triggered by parameters intrinsic to the stimuli, and the insula (objective beauty); Freedberg has described a study in which ten the other based on the activation of the amygdala, subjects were asked to examine the wrist detail from driven by the observer’s own emotional experiences Michelangelo’s Expulsion from Paradise, a fresco panel (subjective beauty) (Di Dio 2007). on the ceiling of the Sistine Chapel. In this, the fallen- The context of viewing artwork has been studied by from-grace Adam wards off a sword-wielding angel, his Kirk (2009). The question which he addressed was eyes averted from the blade and his wrist bent back whether a viewer would react in the same way if he saw defensively. The aim of the study was to find out what it the same picture in a famous gallery and in a less was that triggers the viewer’s aesthetic response, that is, important setting. Kirk showed subjects a series of the sense of the observer being with Adam in the images - some, he explained, were fine artwork; others painting, acting to fend off the blows. The study used were created by Photoshop. (Kirk 2009). In fact, none of trans-cranial magnetic stimulation (TMS) to monitor the the images had been generated by Photoshop. It was functioning of the subjects’ brains. What was found was found that different areas of viewers’ brains were that observing the image excited areas in the primary activated when the image was said to be “art.” The motor cortex that controlled the observers’ own wrists study used fMRI. Subjects' aesthetic ratings (that is, (Freedberg 2007, 2009). their perception of beauty) were significantly higher for

S541 Mark Agius: NEUROSCIENCE AND VISUAL ART; MOVING THROUGH EMPATHY TO THE INEFFABLE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 541-545 stimuli viewed in the ‘gallery’ (that is, images known to looking at certain pieces of art. It has been shown that be from a gallery) than ‘computer’ contexts (Kirk brain regions associated with vision, pleasure and 2009). This modulation according to context correlated emotions are consistently triggered by looking at pieces with activity in the medial orbitofrontal cortex and of art. prefrontal cortex, while the context, independent of Looking at art causes a response by the reward aesthetic value, correlated with bilateral activations of mechanism. Thus, viewing the works of famous painters temporal pole and bilateral entorhinal cortex. This like Claude Monet, Vincent Van Gogh and other artists shows that the prefrontal and orbitofrontal cortices more strongly activates the brain’s “reward system” involved in aesthetic judgments are significantly biased compared to the brain activity that happens when by the subjects' prior expectations about the likely looking at photographs of similar subjects. hedonic (pleasure) value of the stimuli according to In a study, four male volunteers and four females their source (Kirk 2009). were asked to view paintings made by famous and unknown artists and photographs with the same subject BENEFIT TO THE BRAIN as of the paintings. Imaging technology revealed that OF LOOKING AT ART when an individual viewed a painting, the ventral striatum (part of the reward system) was more strongly Apart from the emotional and societal aspects of art activated, compared to just looking at the photograph creation and appreciation, does observing visual art give version. Furthermore, not only did art viewing stimulate any benefit to the brain? the ventral striatum, but it also activated the hypo- It appears that looking at art helps persons improve thalamus which is the part of the brain that is associated the processing of information. with appetite regulation and the orbitofrontal cortex, The experience of art is a complex one. It emerges which is responsible for calculating risk, impulse cont- from the interaction of multiple cognitive and affective rol and detection of social rules. processes. Neuropsychological and neuroimaging stu- Zeki et al. (Kawabata 2004, Ishizu 2011) carried out dies reveal the broadly distributed network of brain studies where MRI scans were taken as people looked at regions upon which the experience of art relies. This 30 works of art. Each piece of art was placed by the network is divided into three functional components: (i) research team on a spectrum of conventionally ‘beauti- prefrontal, parietal, and temporal cortical regions which ful’ (John Constable, Jean-Auguste-Dominique Ingres, support evaluative judgment, attentional processing, and Guido Reni) to ‘ugly’ (Hieronymus Bosch, Honore memory retrieval; (ii) the reward circuit, including Damier, Quinten Massys).They found that "when you cortical, subcortical regions, and some of its regulators, look at art – whether it is a landscape, a still life, an which is involved in the generation of pleasurable abstract or a portrait – there is strong activity in that part feelings and emotions, as well as the valuation and of the brain related to pleasure. The blood flow to the anticipation of reward; and (iii) attentional modulation of brain increased for a beautiful painting just as it increa- activity in low-, mid-, and high-level cortical sensory re- ses when you look at somebody you love. It tells us art gions which enhance the perceptual processing of certain induces a feel good sensation direct to the brain." In features, relations, locations, or objects. We have yet to other words, the reward mechanism is stimulated by understand how these regions act together to produce looking at art. There is a surge of the feel-good unique and moving art experiences. Research is still chemical, dopamine, into the orbito-frontal cortex of the ongoing regarding the impact of personal and cultural brain, from the Nucleus Accumbens) resulting in meaning and context on this network (Nadal 2013). feelings of intense pleasure. Dopamine and the orbito- Creative thinking involves both hemispheres of the frontal cortex are both known to be involved in desire brain communicating with each other(Kirk 2009). Art and affection and in invoking pleasurable feelings in the enhances problem-solving skills and attention to details. brain. Both romantic love and illicit drug taking are Data supports the view that art appreciation is inde- similarly associated with dopamine. The interior insula, pendent of the artists' intent or original interpretation which is connected to pleasant emotions, and the and is related to the individual message that viewers putamen, an area that has ties to the experience of (creatively) themselves provide to each piece of art reward, are two parts of the brain which are also (Herrera-Arcos 2017).Recent data suggests that active stimulated by viewing art. perception of the images with sustained cognitive atten- In a series of fMRI brain-mapping experiments, Zeki tion in parietal and central areas caused the generation et al., scanned the brains of volunteers as they looked at of the judgment about their aesthetic appreciation in 28 pictures. They included The Birth of Venus by frontal areas (Maglione 2017). Sandro Botticelli, Bathing at La Grenouillere by Claude Monet and Constable's Salisbury Cathedral. Prof Zeki ART AND THE REWARD MECHANISM found that blood flow increased in the areas of the brain usually associated with romantic love (Kawabata 2004). One important result of looking at art is stimulation Hence, when things considered to be beautiful are of the reward mechanism. Lay persons experience the looked at, there is increased activity in the pleasure increase of positive feelings which are brought about by reward centres of the brain(Kawabata 2004). In the

S542 Mark Agius: NEUROSCIENCE AND VISUAL ART; MOVING THROUGH EMPATHY TO THE INEFFABLE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 541-545 study, paintings by John Constable, Ingres, the French HELPING OUR BODIES th neoclassical painter, and Guido Reni, the 17 century TO RE-BALANCE Italian artist, produced the most powerful ‘pleasure’ response in those taking part in the experiment (Kawa- Art has been shown to enable persons to de-stress. It bata 2004). This reaction was immediate. The increase can also improve physical wellbeing. A study links in blood flow on fMRI was in proportion to how much looking at art with normalising heart rate, blood pres- the painting was liked. This demonstrated that art sure and cortisol levels. A study on workers in West- induces a ‘feel good sensation’ by affecting the reward minster showed that participants' stress levels decreased centers of the brain” (Kawabata 2004). after a lunchtime visit to an art gallery. Participants self- reported their stress levels before entering the gallery IMPROVING OUR and then spent 35 minutes exploring the space in any PERCEPTION SKILLS way they wanted. When they left the gallery, they expressed being less stressed. Furthermore, they also Vessel et al. (2013, 2012, 2010, Yue 2007) studied had lower concentrations of cortisol, which is a patterns in people’s reactions to 109 different works of hormone linked with stress (Clow 2006). art. Personal opinions are highly subjective, and the This is important because of the link between stress brain was able to choose whether it likes or dislikes a and depression via stress and BDNF (Krzak 2017). piece of art extremely rapidly. It is reported that “The most powerfully engaging works of art appeared to trigger brain regions in the frontal cortex that are REWARD AND EMOTION involved in introspective thought, as well as nearby regions usually directed at more outward matters. The- Vartanian and Goel demonstrated on fMRI that both se two areas usually do not activate simultaneously” the areas of the brain involved in processing emotion (Vessel 2013, 2012, 2010). Thus art can involve mul- and those that activate pleasure and reward systems are tiple perception skills at once. engaged when looking at art (Vartanian 2004). They attempted to determine the neuroanatomical correlates In 2013, Vessel reported ‘In a task of rating images of aesthetic preference for paintings using fMRI. Parti- of artworks in an fMRI scanner, regions in the medial cipants were shown a series of artwork pictures and prefrontal cortex ,known to be part of the default mode asked to rate them according to preference (Vartanian network (DMN) were positively activated on the 2004). Activation in right caudate nucleus decreased in highest-rated trials. This is surprising given the DMN's response to decreasing preference, and that activation in original characterization as this set of brain regions bilateral occipital gyri, left cingulate sulcus, and bila- that show greater fMRI activity during rest periods teral fusiform gyri increased in response to increasing than during performance of tasks requiring focus on preference (Vartanian 2004). This showed that parts of external stimuli (Vessel 2013). However, further the brain linked with emotion and those linked with research showed that DMN regions could be positively reward were both involved in the brain’s response to activated also in structured tasks, if those tasks looking at art (Vartanian 2004). involved self-referential thought or self-relevant information’ (Vessel 2013). The experimental design em- Many of these studies used fMRIs to look at neural phasized the personal aspects of aesthetic experience, systems while responding to paintings. and observers based their ratings on how much each It is expected that the brain will recognize faces and artwork "moved" them (Vessel 2013). Each artwork process scenes when a person looks at art. But parts of was rated highly by some observers and poorly by the brain linked to emotions also show activity in the others. Thus the ratings related to the aesthetic expe- process. Hence both perception and emotion is invol- rience itself (Vessel 2013). Thus the DMN activity ved. Lines, patterns, and drawing on canvas are inter- suggested that certain artworks, may be so well- preted by the brain into a face, person, or other object. matched to an individual's unique makeup that they The brain is remarkably adept at discerning familiarity obtain access to the neural substrates concerned with and meaning from patterns, abstract forms, and in- the self-access which other external stimuli normally complete information. Whenever a piece of art is obser- do not get (Vessel 2013). This mediates a sense of ved, the brain acts to interpret the visual information it being "moved," or "touched from within" (Vessel is receiving (Maglione 2017). 2013). This account is consistent with the modern notion that individuals' taste in art is linked with their EMBODIED COGNITION sense of identity, and suggests that DMN activity may serve to signal "self-relevance" (Vessel 2013). Thus, When viewing art, there is a tendency of the obser- not only does it appear that our brain may be ver to attempt to place himself into the artwork. This ‘hardwired’ to appreciate and process art, but it may be placement occurs through a process known as embodied that observing art might enable a person to access deep cognition (Caramazza 2014) in which mirror neurons in experiences of identity, self-relevance and a feeling of the brain turn elements such as action, movement, and being "moved," or "touched from within". energy seen in art into actual emotions which can be

S543 Mark Agius: NEUROSCIENCE AND VISUAL ART; MOVING THROUGH EMPATHY TO THE INEFFABLE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 541-545 felt. Embodied cognition starts with looking at a piece These concepts linking mirror - neurons, empathy, of art (Mahon 2015). The more the piece is analyzed, and also the previously described ‘experiences of to the more there is a tendency for the viewer to place access deep experiences of identity, self-relevance and a himself within the scene and actually feel the quality of feeling of being "moved," or "touched from within"’ the works (Trentini 2015). could come together to explain how art can be used to enable an experience of deep , ineffable experiences. EMPATHY AND ARTISTIC EXPERIENCE CONCLUSION

Recently, Agius and Mckeever had hypothesized Some neuroscientists are concerned that neuroscience (Agius 2017) that empathy was important in the offers a reductionist perspective on the human person perception of the beauty and meaning of visual art and and his/her relationship with art. could lead to deep moving feelings and even to In previous papers (Agius 2017, 2014) we have experiencing the ineffable. Recent papers have born out argued that a model of man based on Augustine and the role of empathy in experiencing art. Thomas Aquinas , in that man is an embodied spirit , Thus, (Brinck 2018) argues as follows; A recent and so every function of man is represented by a bodily version of the view that aesthetic experience is based in function, is more acceptable to modern neuroscience empathy as inner imitation explains aesthetic expe- than Decartes’ dualist model. In the papers which we rience as the automatic simulation of actions, emo- had reviewed previously (Agius 2017), we identified tions, and bodily sensations depicted in an artwork by many levels of function where this was true, from gross motor neurons in the brain (Brinck 2018). Aesthetic observable functioning to molecular levels. This point is experience is enacted and skilful, based on the recog- essential when relating neuroscience to art and any part nition of others' experiences as distinct from one's own of human activity, since the model we use- of Man as an (Brinck 2018). An explanation of the aesthetic expe- embodied spirit- is consonant with both our observa- rience is the reciprocal interaction between viewer and tions of neurobiology and of the necessity of recogni- artwork (Brinck 2018). The viewer achieves the sing the fundamental dignity of the Human being, without reducing Man to biology alone, however we aesthetic experience by participating in making sense recognise that this is simply a model, all be it one which of the work, while movement is a means for creating fits with the natural observations. meaning (Brinck 2018). Aesthetic engagement is coupling to an artwork and provides the context for Therefore, based on our present review, we suggest exploration, and eventually for moving, seeing, and that our review of how we perceive art is entirely conso- feeling with art (Brinck 2018). Aesthetic experience nant with a Thomistic model of the human person, emerges from bodily and emotional engagement with where every one of our thoughts and actions is repre- works of art through complementary perception-action sented in our bodies, in the case of art, in our brain. We and motion-emotion loops (Brinck 2018). Perception- suggest that it is because of the mechanisms that we action involves the embodied visual exploration of an have described above that art can be used, not only to artwork in physical space, and progressively structures describe landscapes and persons, but also abstract and organizes visual experience by way of perceptual concepts, including religious ones. feedback from body movements made in response to the artwork (Brinck 2018). Motion-emotion concerns the movement qualities and shapes of implicit and explicit Acknowledgements: None. bodily responses to an artwork that cue emotion and Conflict of interest: None to declare. thereby modulate over-all affect and attitude (Brinck 2018). The two processes cause the viewer to bodily and emotionally move with and be moved by individual References works of art, and consequently to recognize another psychological orientation than her own (Brinck 2018). 1. Agius M, Mckeever A: Charity, Hospitality, and the Hu- Thus, art can cause feelings of insight or awe and man Person. Psychiatr Danub 2017; 29(Suppl. 3):546-549 disclose aspects of life that are unfamiliar or novel to 2. Agius M: The medical consultation and the human person. the viewer (Brinck 2018). Similar Accounts are given Psychiatr Danub 2014; 26(Suppl. 1):15-8 by Stamatopoulou (2018) and Gernot et al. (2018). It 3. Brinck I: Empathy, engagement, entrainment: the inter- has been suggested that looking at traces of actions action dynamics of aesthetic experience. Cogn Process 2018; 19:201-213 used in creating artwork (e.g. brush marks) is asso- 4. Caramazza A, Anzellotti S, Strnad L, Lingnau A: ciated with a simulation of these actions in the ob- Embodied cognition and mirror neurons: a critical server's sensorimotor-cortex (Hoenen 2017). This was assessment. Annu Rev Neurosci 2014; 37:1-15 demonstrated by recent data and thence it has been 5. Clow A, Fredhoi C: Normalisation of salivary cortisol suggested that individuals scoring high in emotional levels and self-report stress by a brief lunchtime visit to an empathy feature a particularly responsive mirror neu- art gallery by London City workers. Journal of Holistic ron system (Hoenen 2017). Healthcare 2006; 3:29-32

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6. Di Dio C, Macaluso E, Rizzolatti G: The Golden Beauty: 16. Maglione AG, Brizi A, Vecchiato G, Rossi D, Trettel A, Brain Response to Classical and Renaissance Sculptures. Modica E, Babiloni F: A Neuroelectrical Brain Imaging PLoS ONE 2007; 2: e1201 Study on the Perception of Figurative Paintings against 7. Freedberg D & Gallese V: Motion, emotion and empathy Only their Color or Shape Contents. Front Hum Neurosci in esthetic experience TRENDS in Cognitive Sciences 2017; 11:378 2007; 11:197-203 17. Mahon BZ et al.: The burden of embodied cognition. Can 8. Freedberg D: The Power of Images: Studies in the History J Exp Psychol 2015; 69:172-8 and Theory of Response, 1989 18. Nadal M: The experience of art: insights from 9. Gernot G, Pelowski M, Leder H: Empathy, Einfühlung, neuroimaging. Prog Brain Res 2013; 204:135-58 and aesthetic experience: the effect of emotion contagion 19. Stamatopoulou D: Empathy and the aesthetic: Why does on appreciation of representational and abstract art using art still move us? Cogn Process 2018; 19:169-186 fEMG and SCR. Cogn Process 2018; 19:147-165 20. Trentini B: Immersion as an embodied cognition shift: 10. Herrera-Arcos G, Tamez-Duque J, Acosta-De-Anda EY, aesthetic experience and spatial situated cognition. Cogn Kwan-Loo K, de-Alba M, Tamez-Duque U, Contreras-Vidal Process 2015; Suppl 1:413-6 JL, Soto R: Modulation of Neural Activity during Guided 21. Vartanian O, Goel V: Neuroanatomical correlates of Viewing of Visual Art. Front Hum Neurosci 2017; 11:581 aesthetic preference for paintings. NeuroReport 2004; 11. Hoenen M, Lübke KT, Pause BM: Sensitivity of the human 15:893-897 mirror neuron system for abstract traces of actions: An 22. Vessel EA, Starr GG, Rubin N: Art reaches within: EEG-study. Biol Psychol 2017; 124:57-64 aesthetic experience, the self and the default mode 12. IshizuT, Zeki S & Toward A: Brain-Based Theory of network. Front Neurosci 2013; 7:258 Beauty. PLoS One 2011; 6:e21852 23. Vessel EA, Starr GG, Rubin N: The brain on art: intense 13. Kawabata H, Zeki S: Neural Correlates of Beauty. J aesthetic experience activates the default mode network. Neurophysiol 2004; 91:1699–1705 Front Hum Neurosci 2012; 6:66 14. Kirk U, Skov M, Hulme O, Christensen MS, Zeki S: 24. Vessel EA, Rubin N: Beauty and the beholder: highly Modulation of aesthetic value by semantic context: an individual taste for abstract, but not real-world images. J fMRI study. Neuroimage 2009; 44:1125-32 Vis 2010; 10:181-14 15. Krzak AM, Cao JJL, Agius M, Hoschl C: Does neurogenesis 25. Yue X, Vessel EA, Biederman I: The neural basis of scene relate to depression and do antidepressants affect preferences. Neuroreport 2007; 18:525-9 neurogenesis? Psychiatr Danub 2017; 29(Suppl 3):241-246

Correspondence: Mark Agius, MD Clare College Cambridge, Department of Psychiatry University of Cambridge Cambridge, UK E-mail: [email protected]

S545 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 546-554 Conference paper © Medicinska naklada - Zagreb, Croatia

THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY Shentong Wang1 & Amelia Oldfield2 1Clare College Cambridge, School of Clinical Medicine, University of Cambridge, Cambridge, UK 2Cambridge Institute for Music Therapy Research (CIMTR), Anglia Ruskin University Cambridge, Cambridge, UK

SUMMARY Music therapy and attachment is an expanding field and the number of studies addressing the theoretical work is slowly growing. There are both qualitative and quantitative approaches to studying the effect of regular music therapy sessions on parent-child interactions and these cover a range of patient populations including: children at risk of neglect, parents with a trauma history, children coping with bereavement and a large number addressing the disability population, including autism spectrum disorder. These studies suggest that music therapy benefits the parent-child relationship through the improvement communication, especially non-verbal communication, and so increased the feeling of closeness and understanding. Following a review of the available literature, a pilot study is described using transcripts of video recordings of music therapy sessions, and subsequent colour coding and conversion of the data into pie charts provides a potential method of analysis that produces an “interaction profile” of each parent-child dyad. Preliminary results of this method of analysis suggest that music therapy sessions might be able to improve interactions through therapists addressing the power dynamics within a relationship. The new method developed in this pilot study to visualise and study the parent-child relationship in music therapy sessions was effective and could be used and developed by music therapy researchers in the future.

Key words: music therapy - parent-child relations - object attachment * * * * * INTRODUCTION not “perfect” in the eyes of the infant but good enough to strike a balance between allowing her child to expe- Music therapy began to be in large scale demand rience frustrations, and adapting to her child’s needs after the two world wars as a way of supporting the enough for these needs to be addressed (Winnicott 1991). large numbers of returned servicemen (Edwards 2007). The application of this hefty background of material has Its use within families has been to “strengthen parent- been increasingly explored within music therapy. child relationships through increasing developmentally There have been many parallels drawn between conducive interactions, by assisting parents to bond with music therapy and the theoretical background of inter- their children, and by extending the repertory of paren- personal relationships. For example, Levinge describes ting skills in relating to their child through interactive the way that during musical performances, the inner play” (Abad 2007). The literature surrounding attach- self is never quite revealed, much like Winnicott’s ment and music therapy has grown, with the suggestion description of the conflict between the desire to that it promotes positive, meaningful interactions that communicate and the desire to remain private (Levinge create a context for developing healthy relationships 2015). However, Levinge also explains how music has over time (Pasiali 2014). the capacity to give shape and meaning to experiences Attachment theory originated and was developed by and feelings which may be beyond words. Music can Bowlby and Ainsworth. Bowlby described attachment be a method of communication for those who struggle as a “lasting psychological connectedness between hu- with expressing themselves, and therefore can encou- man beings” (Bowlby 1969). Ainsworth developed the rage a more communicative relationship between two study of attachment with her work on the Strange Situa- people. In this way, music therapy can be and has been tion Procedure, producing a method of measuring infants’ used clinically to improve difficult parent-child rela- attachment to their mothers (Ainsworth & Wittig 1969). tionships with potentially different forms of insecure This experimental procedure classified attachment into attachment. three categories: secure, insecure-avoidant and insecure- There have been both qualitative and quantitative ambivalent/resistant, which were based on the degree studies into the effects of music therapy on parent-child and type of distress a child showed upon separation relationships. One of the earliest quantitative studies from their mother (Ainsworth 1970). The work of into parent-child bonding is the Sing & Grow pro- Winnicott and the school of object relations further adds gramme in Australia (Abad 2004). The programme has to the literature on parent-child bonding, notably for his continued to generate evidence for the value of music concept of the “good enough mother”, a mother who is therapy, and will be discussed in later paragraphs.

S546 Shentong Wang & Amelia Oldfield: THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 546-554

Various qualitative studies have also explored not just reduce their reactivity in conflict with their children the parent-child relationship but also the role of the (Colegrove 2018). The adolescents were also helped to parent within music therapy. One study focused on the be more emotionally regulated and positively engaged. perception of parents taking part in music therapy with The parents improved in non-verbal communication, their children and found that many were initially unsure potentially due to an increased understanding of ado- of what they were expected to do (Oldfield 2011). When lescents’ non-verbal communication, and parents were the perceived aims of music therapy were further less likely to interpret signs as being abusive. How- explored, one of the benefits found was that parents felt ever, self-report questionnaires were used to measure they were learning ways of non-verbal communication the outcomes and so could be open to bias. If the to better interpret their child’s music ideas and allow the parents were expecting change post-music therapy, maintenance of an interesting dialogue. they may report a more positive set of answers compa- The current literature available contains a wide range red to before they started the therapy course. The of foci. One paper focuses on “marginalised” parents authors also state that their “Tuning Relationships with and their children and use of music therapy to promote Music” programme focuses on non-verbal communi- “positive parenting” (Nicholson 2008). They used the cation. This potentially limits the degree of benefit Sing & Grow intervention, following a 10-week, weekly gained from the sessions, especially when parents who session structure and used both questionnaire and have past experiences of interpersonal trauma may not observational data to assess the potential effectiveness have good models of how to interact verbally with of early intervention in parent-child relationships. their children. They found significant improvements for clinician The disability demographic has been most tho- observed measures, self-reported irritable parenting roughly researched in terms of music therapy and and parental mental health, use of educational acti- parent-child interactions, with many subject groups vities in the home and child communication and social involving children with autism. One study found that play skills. However, despite the positivity of the re- the Sing & Grow programme improved communica- sults, there was a low attendance rate, with only around tion and social skills of autistic/disabled children, 53% receiving the minimum therapeutic dose of 6 parenting sensitivity, engagement and acceptance of sessions. Variation in group sizes may also have affec- child, child responsiveness to parent, and child interest ted the “dose” of therapy delivered during the sessions. in program activities (Williams 2012). A different There was also no control group to compare results. study found that their programme (Musical Bonds) Given the circumstances, it is difficult to discern whe- improved parental responsiveness and child-initiated ther a set music therapy programme is necessary for a communication, as well as parent-child synchrony perceived benefit, or whether there may simply be (Yang 2016). While the data for parent-child syn- positive effects arising from group activity. chrony showed ceiling and floor effects that may have Another focus of research is the effect of music limited the efficacy of the programme, it is possible therapy on relationships involving emotionally neglec- that in groups where parent-child interactions may be ted children or parents with a trauma history. In a difficult and improvement may not be limited by the study involving parents exhibiting signs of emotional child's social ability, e.g. insecure attachment, the neglect and children without developmental deficits/ Musical Bonds program might be more successful. diagnoses, the effects of 10 weekly music therapy ses- The short and long term benefits of music therapy sions were compared to a control group receiving their on parent-child relationships involving children with usual interventions (Jacobsen 2014). While there were severe Autism Spectrum Disorder (ASD) has been improvements in interaction, mutual attunement and studied using quantitative and thematic analysis non-verbal communication, between groups analysis (Thompson 2013, 2017). 16 weeks of “family centred shows no effect of music therapy on attachment score, music therapy” found no significant effect of treatment with authors explaining this as being due to the com- as measured by the quantitative relationship inventory plexity of attachment. They suggest that because but did find positive changes through qualitative attachment is related to the parent's sense of emotional themes. More than half the parents described being closeness to the child and ability to observe and able to “see the child rather than the autism” after understand the child's needs accurately, music therapy therapy. They also found they were “actively seeking sessions may not have adequately tackled all of these engagement” opportunities with their child and felt factors. While parent child interactions improved, the positive shifts in their emotional responses (Thompson fundamental ability of the parent to understand their 2013). Four years later, the parents’perceptions follo- child was not significantly affected. Instead, parents wed five global themes: more confidence to engage may have gained skills in reading non-verbal cues their child; rare opportunities for mutual enjoyment; without changing their fundamental communication improved child social communication and quality of framework. life; mothers’ new understanding of the child’s interests/ For parents with a trauma history, music therapy strengths; and more opportunities for continuing the was able to improve the responsiveness of parents and child’s interest in music (Thompson 2017). The

S547 Shentong Wang & Amelia Oldfield: THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 546-554 benefits of music therapy might be explained by the therapy (Jacobsen & Killen 2015, Jacobsen SL & formation of rehearsed communication between parent McKinney 2015). However, such a tool could not be and child. Having a pre-existing routine for parents used for this study’s design as we were not in a and children to interact may not only benefit children position to do addition assessments on the relation- with a disability or autism, but also many other parent- ships of the families whose videos we used. To explore child dyads (Pasiali 2012). the possibilities, a pilot study into a potential method Music therapy has also been used to help maintain for analysis was carried out, with the hope that future a healthy relationship between parent and child in studies might further examine the effects of music families where bereavement threatens attachment. One therapy from an attachment perspective. The study study performed thematic analysis on song lyrics follows a qualitative structure initially to determine written by parents diagnosed with cancer and music what themes to compare across the parent-child dyads, therapists for their children (O’Callaghan 2009). They before employing a quantitative approach to explore found recurring lyrical ideas such as love, grief, and the exact differences between each interaction profile. suggestions about to whom the children can turn. Overall, there was an emphasis on the importance of METHODS children maintaining secure attachments with their parents even through the transitional process of Participants bereavement. They promoted child resilience, with the Three parent-child dyads, two of which were twins, songs providing support for children as "they attempt were newly recorded at The Croft Child and Family to endure the cancer trajectory and adjust to whatever Unit participating in a music therapy session. Partici- life unfolds." The study suggests how music therapy pants gave written consent to the use of their recor- may influencethe parent-child interaction even when dings for research purposes. Session length varied the role of a healthy attachment extends beyond physi- between 30-45 minutes. These videos were transcribed cal presence. fully, making note of all non-verbal communication, There are additionally two different approaches to facial expression and tone of voice of participants. studying interpersonal interactions. First, music the- This included the exact words used in speech or an rapy has an effect on cross generation attitudes, which approximation of the words ‘babbled’ by the child, and could have applications in attachments to other family any actions the participants engaged in, with the members. Children gained a more positive view to- expectation that any section of the video could be wards aging, and adults living in a retirement facility enacted from what was written down. An excerpt from experienced improved attitudes towards children after Eddie’s transcript is included in the appendix. This participation in an intergenerational music programme was then used as a guide for producing transcripts of (Belgrave 2011). The second is a study on how pa- two previously recorded sessions of another parent- tients with borderline personality disorder (BPD) differ child dyad spaced three weeks apart after having one to controls during musical improvisations (Foubert 30-40-minute session per week with the music 2017). They suggest that BPD may affect the ability to therapist. The precise details and diagnoses of the par- improve and maintain synchrony over time. Controls’ ticipants are given in Table 1. All names have been synchrony with the music therapistincreasedwith time changed to preserve anonymity. whereas that of BPD patients did not. This effect was only visible in the less predictable section of impro- Analysis visation, which the authors hypothesised brought out insecure attachment systems. However, it is unclear The transcripts were reviewed for recurring themes whether an insecure attachment leads to the formation of non-verbal interaction. The choice to focus on the of new strategies of interaction, including increased structure of the interaction rather than the content of impulsivity; or whether impulsivity leads to formation speech was due to the descriptive nature of the of insecure attachment. The study gives an insight into transcripts and the largely non-verbal nature of each the mechanisms by which different attachment classi- music activity. There were seven themes applicable to fications might present in music therapy sessions. Ralph, Eddie and Randall’s transcripts, with a different set of six for Lucy due to the age and underlying diagnosis discrepancy. Because of Lucy’s older age, A pilot study there was lower emphasis on keeping her engaged with In the literature, there is a recurring theme of im- music therapy, which was difficult for the younger provement of non-verbal communication and also the participants. Instead, the challenge faced by the thera- development of interaction scripts that parents and pist was Lucy’s lack of engagement with mother, and children could use outside of music making in the so it was deemed appropriate to use different themes. literature. Currently, tools such as the Assessment of Each theme was then assigned a colour, with plain Parenting Competencies have been developed for use black text representing all other “un-themed” text. The in the study of parent-child interaction within music themes are listed in Table 2.

S548 Shentong Wang & Amelia Oldfield: THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 546-554

Table 1. Participant information; ASD = autism spectrum disorder Participant Age (years) Gender Parent present Diagnosis Ralph 3 Male Mother ASD and behavioural problems (e.g. temper tantrums), showing signs of learning disability Eddie 4 (twin of Randall) Male Mother ASD Randall 4 (twin of Eddie) Male Mother ASD Lucy 11 Female Mother Asperger syndrome

Table 2. Recurring themes of interaction Single time point interactions Two time point interactions Red = mother and child physical imperatives e.g. Red = Lucy blocking/hostility towards of mother mother moving child’s hands onto instrument Orange = mother tries to engage Lucy e.g. verbally or Orange = distractedness i.e. child, all other actions body orientation Yellow (highlighted) = mother imperative speech Green = mother follows Lucy’s cue Blue = mother and child non-imperative speech Blue = Lucy takes a cue from mother Pink = mother and child positive engagement in therapy Pink = Lucy’s body language warms up towards mother Green = child comfort seeking behaviours/mother Purple = Lucy and mother eye contact/direct physical reassurance engagement with mother Purple = adult (therapist/mother) anxious behaviours

Figure 1. Ralph-mother interactions

Figure 2. Eddie-mother interactions

S549 Shentong Wang & Amelia Oldfield: THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 546-554

Figure 3. Randall-mother interactions

Figure 4. Lucy-mother session 1 Figure 5. Lucy-mother session 2

Table 3. Raw participant data Ralph Eddie Randall Lucy session 1 Lucy session 2 Colour Word count % Word count % Word count % Word count % Word count % Red 223/8285 3 921/4808 19 309/5606 5 121/896 13 199/1060 19 Orange 2481/8285 30 1274/4808 27 1940/5606 35 124/896 14 119/1060 11 Yellow 117/8285 1 474/4808 10 310/5606 6 N/A N/A Green 559/8285 7 151/4808 3 75/5606 1 183/896 20 42/1060 4 Blue 508/8285 6 448/4808 9 225/5606 4 50/896 6 123/1060 12 Pink 4078/8285 49 1492/4808 31 2713/5606 48 153/896 17 158/1060 15 Purple 319/8285 4 48/4808 1 33/5606 1 265/896 30 419/1060 39

S550 Shentong Wang & Amelia Oldfield: THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 546-554

The colour coded transcripts were then converted to measures indicate a shift in session 2 towards a more percentages of each colour compared to the whole mother-led framework. The proportion of positive body transcript. This was done using the word count of each language exhibited by Lucy and the proportion of time total colour sum as a percentage of the total word count mother attempted to engage Lucy in music roughly of the transcript, as given by Microsoft Word. Eddie and stayed the same (17 and 14% vs 15 and 11% respec- Randall’s transcripts were split into two individual tively). However, hostile body language increased in the versions with information related to solely the other second session (13 vs 19%). twin removed. Twin interactions were retained. Pie charts were then used to represent this information using DISCUSSION Microsoft Excel (Figure 1-5). Separate analysis was done for session 1 and 2 for Lucy’s transcript. The results from this method of analysis were able to show clearly distinguishable patterns of parent-child RESULTS interaction such that each child had an interaction profile. Despite the different set of themes used for the The initial colour coding highlighted the different analysis of Lucy’s sessions, there was no difficulty patterns of interactions for each participant. The most applying the same method. obvious contrast occurred in Eddie and Randall’s tran- The higher proportion of comforting seeking requi- script as they were both interacting with the same parent red by Ralph could be suggestive of a lower degree of but produced very different colour configurations. The separation from his mother in terms of identity, but this raw data (Table 3) and the pie charts (Figure 1-5) could be normal behaviour for a 3-year-old compared to confirmed some of the initial impressions. 4-year-olds. Without a baseline proportion for each age Ralph was generally engaged in the music therapy group, it is difficult to comment on just how “normal” session for 49% of the time. He did receive the highest this is. The greater proportion of adult anxious beha- proportion of physical reassurance out of the single viours and increased need for physical reassurance, session participants (7% vs 3 and 1%). There was also could be suggestive of an anxious attachment pattern, a higher proportion of adult anxious behaviours (4% vs and/or an anxious internal working model in Ralph that 1%). was quickly reflected by the music therapist in their 30- Eddie and Randall both required a higher proportion minute session. Given how rapidly the anxious mother- of verbal and physical commands from mother to child relationship was mirrored by the “music mother”- maintain engagement in the music therapy session than child relationship, it seems likely that Ralph’s way of Ralph did. However, Eddie required much more than interacting with objects around him and their subse- Randall (19 and 10% vs 5 and 6% respectively). Eddie quent responses to him are highly fixed and easily also had a lower level of engagement than Randall (31 replicable. vs 48%), although he did have a lower proportion of From Eddie and Randall’s data, it is possible to see distractedness (27 vs 35%). Eddie was more vocal than both the differences and similarities between the twins Randall (9 vs 4%). The comparisons between between when compared to Ralph. The twins required many the twins and Ralph confirm that colour coding more commands from mother to focus their attention on according to common themes can detect different the music therapy tasks but the number for Eddie interaction patterns. The comparisons between Eddie exceeded those for Randall by a large proportion. What and Randall suggest that this is not just a method of is not shown by these charts is the competition for detecting differences in parenting ability. mother and the music therapist’s attention between Speech for all three of the single time point Eddie and Randall. Randall’s distractedness usually participants was limited since their language capacities arose when mother or the therapist had turned their were still developing, most of them using a mixture of attention to Eddie. Having a shared session means that babbling and one or two-word outbursts. Because of the relationship data only applies to that particular this, the content of the speech is less important than the shared context but it is likely that this is a true measure frequency of interactions between mother and child, as of the relationship; at home, the twins are also likely to the likelihood of the child or mother verbally interacting have to share their mother’s attention. with each other is a better measure of their relationship The effects of 3 weeks of regular music therapy at this stage of development. sessions for Lucy were mixed. Lucy appeared to tole- The framework provided by the analysis of Ralph, rate mother’s music ideas more. However, hostile Eddie and Randall suggested that Lucy’s sessions could behaviours from Lucy towards mother grew. This was be analysed in a similar fashion. For Lucy, the charts accompanied by a decrease in the times that mother were able to show a clear improvement in engagement took Lucy’s cues. Part of this may be due to the (increase from 30 to 39%). The data also confirmed structure of the second session, as the music therapist the increased incidence of Lucy taking mother’s cues deliberately instructed mother to lead music play. The (6 vs 12%) and this was also accompanied by a drop in changes may be explained by an increase in resentment, mother taking Lucy’s cues (20 vs 4%). These two and therefore hostile actions, towards mother as she

S551 Shentong Wang & Amelia Oldfield: THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 546-554 may have interpreted mother leading the session as produce a method of analysis for the study of parent- mother being less attentive to her, but the increase in child relationships, and the study of effects are a engagement suggests that after a period, Lucy was able secondary aim. A framework for future studies has been to accept her new role in the musical relationship, thus produced which reflects the parent-child interaction choosing to maintain this form of social interaction pattern and allows easy comparison within groups and rather than reject it. After three weeks of music therapy between groups. sessions, Lucy and mother’s interaction profile seemed There are also some limitations to the method of to shift from a relationship where mother was largely analysis. Firstly, different emotions and themes maybe compliant to Lucy’s needs towards a more reciprocal be expressed in more or less concise methods and so and equal style. While this could reflect a greater analysis of parent-child interaction via word count might confidence in mother’s role as parent and therefore not be the most representative method.For example, a boundary setter, any interpretation on the power balance parent may spend more time engaging a child in play present in the relationship may be speculation without than they would giving commands to regain their atten- interviewing the participants. tion. The word count may form an accurate represen- Future studies could include an interview with the tation of what formed a greater proportion of the session parents after each session to ask how they felt their chil- but this may not be representative of the subjective dren engaged, what might have contributed to the experience of the parent and child, who may ascribe child’s level of participation and how they feel about more prominence to the times that sharp words were their relationship with their child. This would aid in the spoken. This can be addressed by including a post ses- interpretation of data and would be easily achievable sion interview to help with interpretation and weighting since it was usual practice for the music therapist to of various themes. include a feedback section at the end of each session. There is a certain amount of bias generated from the Future studies could also analyse the patterns of flexibility of language used during transcription of the themes within a transcript. The sequence of coloursfor videos. For example, one of the musical activities in each session could be usedto determine the frequency Lucy’s second session involved a “conversation” using of different patterns present. For example, the fre- kazoos. When describing this scene, the language ten- quency of verbal imperatives followed by engagement ded to bemore poetic in order to be more specific about in the session could be compared to the frequency of the tones generated. While this author believes that this physical imperatives followed by engagement. This was justified in the pursuit of accurate representation, could provide an insight into which type of parental such an activity understandably has a higher word count intervention was more effective. It would also aid in than a simple drum beat exercise due to ease of finding patterns of parenting that are perhaps neces- description, which suggests closer defined parameters sary to a good parent-child relationship e.g. perhaps are necessary in future studies for what is included periodic hugs may encourage Ralph to engage more. within music therapy sessions. There is potential for application clinically, although too labour intensive to perform for every music therapy CONCLUSION service user. Using the transcript of a short session to generate a simple chart could allow parents to see how The number of studies specifically relating to music what behaviours are most prominent when they engage therapy’s effect on parent-child interactions is still limi- in a joint activity with their child, and it would be ted and combining these studies meaningfully in a meta- possible to show them how these patterns have changed analysis would be difficult. However, they largely show over time with the measure of active engagement being the benefits of music therapy on the parent-child rela- a marker of how successful various changes have been. tionship, especially in terms of parents gaining under- However, it would still be beneficial to review the standing of their children and how to communicate recordings of sessions with parents, as is currently done with them. The pilot study hopefully provides one in clinical practice. example of how qualitative and quantitative approaches can be combined to produce a tailored parent- Limitations child interaction profile. Preliminary investigations into the effect of music therapy on parent-child inter- There are many limitations to this pilot studydue to actions suggest that it might address potential power the small number of participants, especially in terms of imbalances in the relationship when a difficult child is the two time point participants. There is also a large involved but at this stage of the study, it is difficult to discrepancy in the ages and underlying diagnoses. In draw firm conclusions. However, it does suggest what addition, as there was only one researcher producing parenting techniques would be beneficial to each the transcripts without back-up checks to ensure the individual child. An extension with tighter study para- transcripts were reliable, there could be a degree of meters would hopefully tackle the question of exactly bias arising from the perspective of the transcriber. what are the effects of music therapy sessions in this However, the objective of this pilot study was to context.

S552 Shentong Wang & Amelia Oldfield: THE EFFECT OF MUSIC THERAPY SESSIONS ON THE INTERACTIONS BETWEEN CHILDREN AND THEIR PARENTS AND HOW TO MEASURE IT, WITH REFERENCE TO ATTACHMENT THEORY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 546-554

Appendix Excerpts from Ralph’s transcript: a hello song A = music therapist, R = Ralph Two chairs are positioned beneath the window next to a piano.

R runs in and sits on left chair. A: [Exaggerated speech] Look at you sitting down (R giggles). What a good boy. Let’s show mummy. Look at this boy sitting on his chair. (R stands up, both hands up in the air and a single laugh explodes out of him. Sits back down). Yes. Aren’t you clever? Aren’t you clever? Shall we start? R grins and holds out his hand to mother and she walks in, takes his outstretched hand and sits down next to him on the right chair. A picks up guitar and sits cross-legged on the floor in front of R + mother. She shuffles in closer. R leans to the right, onto mother. Mother: Sit up! [kindly] A puts a finger to her lips to indicate R should be quiet. Gently strums guitar. Mother makes shushing noises. A: [Singing Hello song] Hello from music. Hello, hello. Hello for sitting down R today. Hello for sitting down – (R gestures and holds out left arm to the side) – Ooh! (A reaches out, gestures at R’s top and asks “What’s that?”) Hello (R stands up and takes off jacket) for motorcycle R today (R plonks back down on chair). Hello (mother takes jacket off R, puts on lap, A reaches out and points to R’s top again, takes hand back) [exaggerated speech] that’s motorcycle R! [Singing] Hello, hello today. A: [Slightly exaggerated speech] That’s motorcycle R. Let’s see R’s special way of playing (puts guitar flat on R’s lap, R put’s hands on shoulder of guitar, reaches out and rubs flat of hand and fingers underneath strings while A strums strings gently.) *For full transcripts, please contact the corresponding author.

Foss (Ed.), Determinants of infant behavior (Vol. 4, pp. Acknowledgements: 111-136) 1969. London: Methuen Many thanks to Dr Amelia Oldfield for her guidance 5. Belgrave M: The Effect of a Music Therapy Intergenera- and for providing the video recordings of the music tional Program on Children and Older Adults’ Inter- therapy sessions. generational Interactions, Cross-Age Attitudes, and Older Adults’ Psychosocial Well-Being. Journal of Music Conflict of interest: None to declare. Therapy 2011; 48:486-508 6. Bowlby J: Attachment. Attachment and loss: Vol. 1. Loss Contribution of individual authors: 1969. New York: Basic Books 7. Colegrove VM, Havighurst SS, Kehoe CE & Jacobsen SL: Shentong Wang carried out the literature search, Pilot randomized controlled trial of Tuning Relationships analysis and drafting of this paper; with Music: Intervention for parents with a trauma history Amelia Oldfield provided the recordings and oversaw and their adolescent. Child Abuse and Neglect 2018; the development of this project. 79:259-268 8. Edwards J: Antecedents of contemporary uses for music in healthcare contexts: the 1890s to the 1940s. Music: References Promoting health and creating community in healthcare contexts 2007; 181-202 1. Abad V & Edwards J: Strengthening families: A role for 9. Foubert K, Collins T & De Backer J: Impaired music therapy in contributing to family centred care. maintenance of interpersonal synchronization in musical Australian Journal of Music Therapy 2004; 15:3 improvisations of patients with borderline personality 2. Abad V & Williams KE: Early intervention music therapy: disorder. Frontiers in Psychology 2017; 8:1–17 Reporting on a 3-year project to address needs with at- 10. Jacobsen SL & Killen K: Clinical application of music risk families. Music Therapy Perspectives 2007; 25:52-58 therapy assessment within the field of child protection’. 3. Ainsworth MDS & Bell SM: Attachment, exploration, and Nordic Journal of Music Therapy 2015; 24:148-166 separation: Illustrated by the behavior of one-year-olds in 11. Jacobsen SL & McKinney C: A music therapy tool for a strange situation. Child Development 1970; 41:49-67 assessing parent-child interaction in cases of emotional 4. Ainsworth MDS & Wittig BA: Attachment and exploratory neglect. Journal of Child and Family Studies 2015; behavior of one-year-olds in a strange situation. In B. M. 24:2164-2173

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Correspondence: Shentong Wang, BA (Cantab) Clare College Cambridge, School of Clinical Medicine, University of Cambridge Cambridge, UK E-mail: [email protected]

S554 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 555-558 Conference paper © Medicinska naklada - Zagreb, Croatia

WHAT IS BEAUTY? SHOULD DOCTORS POINT OUT BEAUTY TO THEIR PATIENTS DURING THERAPY? Mark Agius Clare College Cambridge, Department of Psychiatry, University of Cambridge, Cambridge, UK

SUMMARY It has been argued that aesthetics, or the appreciation of beauty, can be used in therapy. We explore this concept from the point of view of new findings in neurobiology which give us an understanding of the mechanisms by which we experience beauty and creativity. We argue from anthropological perspectives that the experience of beauty is common to all cultures, and leads to the experiencing of important abstract concepts which enhance our lives, but which may be described differently in different cultures. We are beginning to understand how these abstract concepts are perceived, but this does not mean that the concepts themselves do not exist. Indeed, a Thomistic view of the human person will predict that there will be a mechanism within the body to express every bodily function. Based on this we argue that doctors should encourage their patients to appreciate beauty itself, as they understand it, because experiencing it can be therapeutic.

Key words: creativity – empathy – aesthetics – beauty - default mode network – anthropology - Thomistic philosophy

* * * * *

INTRODUCTION experience’ (Musalek 2017) can begin. It is in this way that the Doctor-Patient relationship is reinforced, so that When we talk about Psychiatry and the Humanities, the dictum of Michael Balint can be brought about in we have been talk about Aesthetics. Aesthetics, or ap- the consultation; ‘Remember that the first thing that you preciating beauty, is about (as the Viennese Philosopher as a Doctor prescribed to a patient is yourself’ (Balint Martin Poltrum says) ‘seeing things in a different way’ 1957). Indeed, the reality is that all the beautiful things so as to be aware of their beauty. So, Aesthetics is the which both doctor and patient will have experienced seeing of beauty in something /someone else. over several years in the same community will be part Musalek has argued recently that ‘European intellec- of the ‘mutual investment fund’ of experiences which tual history teaches us that beauty is not just an Balint referred to as providing a common language for adornment to life but is also a major source of strength doctor and patient to use over the years they have for our life’ (Musalek 2017). Musalek goes on to argue known each other (Balint 1957). that ‘the positive aesthetic experience also has healing power’ (Musalek 2017). WHAT, THEREFORE, IS BEAUTY? If, as Musalek argues, ‘Social aesthetics that wishes also to be understood as the science of beauty in What we see could be the beauty of Nature. In the interpersonal relationships provides us with knowledge accompanying presentation I have used an image of the that in medical-therapeutic practice becomes a key pillar countryside of Mount Carmel in Israel because this of human-centred approaches to prevention and place is reputed to be very beautiful, but, wherever we treatment, (Musalek 2017)’ then the beauty of inter- look, nature is always beautiful. personal relationships must be of great importance in Beauty is that property we see in other things /persons the doctor-patient relationship, and so also must be the which attracts and gives us a sense of wellbeing. We look common understanding, shared by doctor and patient, of at a landscape, we look at nature, we hear music, we meet the beauty of their families, communities, inter-personal another person, and we recognise the wonder of that relationships, the nature around them, the books they ‘other’, and that wonder engenders wellbeing. read, the art or music they enjoy, and so on. This Beauty extends to our perception of nature, animals, understanding of the beauty of all their surroundings man-made buildings, other human persons. becomes the common language shared between patient And vice-versa, as well as referring to the beauty of and doctor, and it is reinforced every time a patient Nature, we are able to generate beautiful thoughts, casually asks after the doctor’s family, remarks that he beautiful words, beautiful designs, beautiful sounds, and had been at the same cinema as the doctor, and a myriad others can recognise them as beautiful. of other instances which may occur when the patient enters the doctor’s presence, before the business of the BEAUTY AND CREATIVITY consultation begins. This creates a feeling of humanity between doctor and patient, so that the ‘healing power’ Musalek and others have argued (Musalek 2017) for (Musalek 2017) engendered by ‘the positive aesthetic appreciating Beauty, and in this conference, there have

S555 Mark Agius: WHAT IS BEAUTY? SHOULD DOCTORS POINT OUT BEAUTY TO THEIR PATIENTS DURING THERAPY? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 555-558 been papers describing the neurobiology of Appre- HUMAN EXPERIENCE OF BEAUTY ciating Music (Wang 2018) and Visual Arts (Agius 2018). Others, such as Nancy Andreasen, have discus- Brinck (2018) has recently described how mecha- sed the neurobiology of Creativity (Andreasen 2011, nisms related to empathy can enable human persons to 2006, 2012, 2011). Creativity has been linked with men- feel or enter into a work of art. Presumably it is possible tal illness, such as bipolar disorder (Jamison 1996, An- by the same mechanisms to ‘enter into’ and feel obser- dreasen 2008, 1988, 1987, 1975), and this implies that ved beauty of any sort, including the beauty of nature. creativity is related to the functioning of the brain. Literature is full of descriptions of the beauty of nature, Thus Appreciation of Beauty (Aesthetics) and the and of persons who have let themselves be surrounded Creating of Beauty (Creativity) appear to be two sides by this beauty, to the extent of becoming one with it. of the same coin. The poem ‘The Living Flame of Love’, by John of the Often Aesthetics and Creativity combine, as in the Cross, Spain’s most famous romantic poet and also a Collection of Photos and Poems recently published by great Mystic of Christianity gives a description of a Psychiatrist Giuseppe Tavormina (Tavormina 2018). person whose union with beauty (in the shape of a beautiful bridegroom) is of extatic proportions. It is the NEURAL MECHANISMS LINKING most famous description of becoming one with beauty. BEAUTY AND CREATIVITY In the poem is implied a sense of fulfilment and of being fully human which suggests the link between Neural Mechanisms have been described which are empathy and self which we described neurologically linked with appreciating music (Wang 2018) (Rey- earlier in this paper. brouck 2018) and the visual arts (Agius 2018, Vessel ‘O living flame of love 2013, 2012, Kawabata 2004). Only one cortical area, that tenderly wounds my soul located in the medial orbito-frontal cortex (mOFC), was in its deepest center! Since active during the experience of musical and visual now you are not oppressive, beauty (Ishizu 2011). Andreasen has described neural now consummate! if it be your will: Mechanisms related to Creativity (Andreasen 2011). In tear through the veil of this sweet encounter!’ the papers quoted, both appreciation of art (Vessel 2013) and music (Reybrouck 2018) and creativity (An- In another poem, ‘The Dark Night of the Soul’ John dreasen 2011) appear to be linked with the default mode of the Cross describes the journey to his beloved in network of neurons. Interestingly, the default mode terms of beauty, but also raises an important point network appears to be linked with the sense of self as regarding our appreciation of that beauty ... the need to well as appreciating others, including empathy (An- avoid distraction (in his analogy by travelling at night), drews-Hanna 2012), Thus all the functions we have in order to see the beauty. The avoidance of distraction mentioned- appreciating art and music and creativity is extremely reminiscent of mindfulness meditation, so appear to be linked with a person’s sense of self and much utilised in mental health work today, but in fact capability of being empathic with others, while the based on Buddist meditation practices of ‘Living in the medial orbito-frontal cortex (mOFC) is described as a present moment’. region involved in representing stimulus-reward value, ‘Oh, night that guided me, in other words as evaluating beauty, including that of, Oh, night more lovely than the dawn, for example another person’s smile (O’Doherty 2003). Oh, night that joined Beloved with lover, It is known (Kawabata 2004, Reybrouck 2018) that the Lover transformed in the Beloved’. consequence of this evaluating of beauty is then the activation of the dopaminergic reward mechanism. Thus, man expresses the need to stop to admire the beauty, which means turning away from things which distract us. This is what mindfulness is about (Andre A THOMISTIC MODEL 2014). OF THE HUMAN PERSON Over time, science has enabled man to observe better the laws which govern the universe, so man has We have argued elsewhere (Agius 2017, 2014) that been able to see great beauty in the laws and patterns such a neurological model is compatible with the model which govern the universe, and see that they are all of Aquinas and Augustine that human persons can be perfectly balanced. Zeki has been able to write about the described as embodied spirits. This is, in fact the classic neural correlates of Mathematical Beauty (Zeki 2014). philosophical model of man, coming from Greek and Roman philosophy and formulated by the scholastics in that human beings are spirits with bodies so that ANTHROPOLOGICAL everything a human being does, including such actions EXPLANATION OF BEAUTY as empathy, appreciating beauty or creativity must have an expression in our bodies, in this case, the neural It has been difficult for mankind to explain beauty. mechanisms we have described. Recently an old man told one of my students ‘beauty is

S556 Mark Agius: WHAT IS BEAUTY? SHOULD DOCTORS POINT OUT BEAUTY TO THEIR PATIENTS DURING THERAPY? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 555-558 something you cannot touch’. In some cultures, such as ‘When we care for others our own strength increases the Western European one, human beings have called When we help people expand their state of life, this sense of beauty ‘God’, however a person wishes to our lifes also expand describe it, while other cultures, as in some Eastern Actions to benefit others are not separate from Ones, which concentrate on meditation, man just actions to benefit onself. admires the beauty. In the Koran is the saying ‘Allah is beautiful, Allah loves Beauty’. These are examples Our Life and the life of others are ultimately which show that all cultures recognise this wonder of inseparable.’ Beauty in nature and in Others. Since we experience As a result some human beings feel and express beauty in other persons and in the creativity of other religious ideas such as those about the interdependence persons, we see other human beings as having a unique of all human beings, the relationship between God and dignity, to the extent that human beings or persons man, man being made in the likeness of God. Other have been recognised as having rights, enshrined by Human Persons simply admire the beauty around then such organisations as the united Nations, so that all the and the beauty of each other. nations of the world agree on the unique dignity of the Given the model of the human person as being an Human Person (United Nations 1948). embodied spirit, it appears that the fact of parts of the brain being linked with the perception of the abstract PERCEIVING BEAUTY concepts we have mentioned above is not in AND ABSTRACT CONCEPTS contradiction of the existence of these abstract concepts themselves. We have simply described the mechanisms Before the Beauty of Nature, man reacted psycho- by which they have been perceived. logically by personifying nature; by describing nature as if it were persons like himself. Thus he described BEAUTY AND CREATIVITY spirits of earth and sea, woodland and streams. We IN MENTAL ILLNESS. find these in the all early cultures, and it was assumed that these spirits had powers. As civilisations deve- What is interesting, however, is that, when a human loped, some people called these ‘spirits’ ‘gods’, and as person is unwell, that does not mean that the perception time went on, man began to consolidate all these or creation of beauty stops. We have the examples of spirits/persons into one, thus moving from polytheistic Robert Schumann (Domschke 2010), mentally ill but to monotheistic beliefs all the powers of the spirits still creating music, or Vincent van Gogh (Arnold being consolidated into one power. 2004), mentally ill but still painting. Thus, as man contemplate nature’s beauty, man Even when there is gross damage to the brain, as in comes to be aware that this beauty is a quality within the Dementias or Schizophrenia, Creativity can continue all nature, which can be experienced as personal, and over time, though its expression becomes more bizarre therefore something which can be related to. The as the brain damage progresses. An example in Jewish story of Elijah experiencing God in the gentle schizophrenia are Louis Wain ’s Cat pictures, which breeze suggests the benign nature of this quality of grew more and more bizarre, but still creative and beauty (1 Kings 19.12). beautiful as his illness progressed (Latimer 2002). This quality, linking persons together, will be expe- In Dementia, creative art is important in therapy, and rienced as a feeling of giving life and love to each helps patients circumvent the blockages in self other – that is the feeling of empathy we have des- expression/creativity caused by the illness; however cribed. It was of this feeling of empathy that Michael over time the damage to the neural pathways gets in the Balint wrote when he said ‘Remember that the first way more and more of the self expression. thing that you as a Doctor prescribed to a patient is So the perception of beauty persists, even during yourself’ (Balint 1957). The consultation is nothing illness, and may be of help in illness. We have dis- but a relationship between two persons, and the em- cussed that, while the neural mechanisms for percei- pathy engendered can sustain human beings, being ving beauty and creativity are the same for each human experienced as it were, as a life – force flowing bet- person, different cultures will express the perception of ween them. beauty differently, using different languages, mytho- Because human persons see beauty in other per- logies, religions or so forth. Thus in these multicultural sons, and this is linked with the neural mechanisms of times there is a risk that the use of the imagery of any empathy, creativity, and appreciating beauty described one particular culture to give therapy or support to above, it comes as no surprise that these feeling can be patients may be challenged if only one particular experienced as very powerful forces. cultural model is used, and there is concern that some This force of empathy is beautifully expressed by a might see this as imposing our own cultural models on motto which a Senior Registrar in Psychiatry at the others. However, as we have seen, all human beings Maudsley Hospital has on her desk: perceive and experience beauty in the same way.

S557 Mark Agius: WHAT IS BEAUTY? SHOULD DOCTORS POINT OUT BEAUTY TO THEIR PATIENTS DURING THERAPY? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 555-558

Hence we, as Doctors, need not tell our patients what 12. Andreasen NC: Creativity and mental illness: prevalence to call the beauty, but it is extremely legitimate that we rates in writers and their first-degree relatives. Am J should point them towards perceiving and enjoying Psychiatry 1987; 144:1288-92 beauty itself, so that patients can appreciate it and it 13. Andreasen NJ & Powers PS: Creativity and psychosis. An examination of conceptual style. Arch Gen Psychiatry can support their lives. 1975; 32:70-3 14. Arnold WN: The illness of Vincent van Gogh (PDF). Journal of the History of the Neurosciences 2004; 13:22–43 Acknowledgements: 15. Balint M: The Doctor, His Patient and the Illness. Churchill Livingstone, 1957 Editorial Note: This paper was the concluding paper of the conference on ‘Psychiatry and the Arts’ in 16. Brinck I: Empathy, engagement, entrainment: the interac- Verdala Palace, Malta on 13-14 July 2018. It is here tion dynamics of aesthetic experience. Cogn Process 2018; re-presented at the Iseo Conference with some 19:201-213 additions and comments which arose from the 17. Domschke K: Robert Schumann's contribution to the discussion with my students during the following genetics of psychosis. British Journal of Psychiatry 2010; days. It is dedicated to His Grace Charles Scicluna, 196:325 Archbishop of Malta, who tells me that Appreciating 18. Ishizu T, Zeki S, Toward A: Brain-Based Theory of Beauty is the centre of his own Spirituality. Beauty. PLoS One 2011; 6:e21852 19. Jamison KR: Touched With Fire: Manic-depressive Illness Conflict of interest: None to declare. and the Artistic Temperament, 1996 20. John of the Cross: ‘The Living flame of Love’ 21. John of the Cross: ‘The Dark Night of the Soul’ References 22. Kawabata H, Zeki S: Neural Correlates of Beauty. J Neurophysiol 2004; 91:1699-1705 1. Agius M: Neuroscience and Visual Art; Moving through 23. Latimer H: The English Cat Artist - Louis Wain. Papyrus empathy to the Ineffable. Psychiatr Danub 2018; Publishers, 2002 29(Suppl 7):541-5 24. Musalek M: Social aesthetics and mental health – Theory 2. Agius M & McKeever A: Charity, Hospitality, and the Hu- and practice. European Psychiatry 2017; 41(Suppl):S51 man Person. Psychiatr Danub 2017; 29(Suppl 3):546-549 25. O’Doherty J, Winston J, Critchley H, Perrett D, Burt DM, 3. Agius M: The medical consultation and the human person. Dolan RJ: Beauty in a smile: the role of medial Psychiatr Danub 2014; 26(Suppl 1):15-8 orbitofrontal cortex in facial attractiveness. Neuro- 4. Andre C: Mindfulness. 2014 psychologia 2003; 41:147–155 5. Andrews-Hanna JR: The brain's default network and its 26. Reybrouck M, Vuust P, Brattico E: Brain Connectivity adaptive role in internal mentation. The Neuroscientist: A Networks and the Aesthetic Experience of Music. Brain Review Journal Bringing Neurobiology. Neurology and Sci 2018; 8.pii: E107. Psychiatry 2012; 18:251-270 27. Tavormina G: La mia vita e il mare - Raccolta di foto- 6. Andreasen NC: The Creating Brain: The Neuroscience of poesie. Associazione Arnaldo da Brescia, 2018 Genius, 2011 28. United Nations: The Universal Declaration of Human 7. Andreasen NC: The Creative Brain: The Science of Rights, 1948 Genius 2006 29. Vessel EA, Starr GG, Rubin N: Art reaches within: 8. Andreasen NC, Ramchandran K: Creativity in art and aesthetic experience, the self and the default mode science: are there two cultures? Dialogues Clin Neurosci network. Front Neurosci 2013; 7:258 2012; 14:49-54 30. Vessel EA, Starr GG, Rubin N: The brain on art: intense 9. Andreasen NC: A journey into chaos: creativity and the aesthetic experience activates the default mode network. unconscious. Mens Sana Monogr 2011; 9:42-53 Front Hum Neurosci 2012; 6:66 10. Andreasen NC: The relationship between creativity and 31. Wang S, Agius M: The neuroscience of music: a review mood disorders. Dialogues Clin Neurosci 2008; 10:251-5 and summary. Psychiatr Danub Supplement 7 (in Press) 11. Andreasen NC & Glick ID: Bipolar affective disorder and 32. Zeki S, Romaya JP, Dionigi MT, Benincasa, Atiyah MF: creativity: implications and clinical management. Compr The experience of mathematical beauty and its neural Psychiatry 1988; 29:207-17 correlates Front Hum Neurosci 2014; 8:68

Correspondence: Mark Agius, MD Clare College Cambridge, Department of Psychiatry University of Cambridge Cambridge, UK E-mail: [email protected]

S558 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 559-562 Conference paper © Medicinska naklada - Zagreb, Croatia

DOES SCHIZOAFFECTIVE DISORDER EXPLAIN THE MENTAL ILLNESSES OF ROBERT SCHUMANN AND VINCENT VAN GOGH? Yasmeen Cooper1 & Mark Agius1,2 1Clare College Cambridge, University of Cambridge, Cambridge, UK 2Department of Psychiatry, University of Cambridge, Cambridge, UK

SUMMARY The geniuses Robert Schumann and Vincent Van Gogh show striking similarities both in the longitudinal nature of the progression of their illnesses, and the symptoms they experienced. There have been physiological explanations posed for both men, including Meniere’s disease, tertiary syphilis, acute intermittent porphyria, terpenoid and lead poisoning, intracranial masses, temporal lobe epilepsy and dementia caused by vascular hypertension. The evidence for these physiological explanations is assessed. Schizophrenia and Bipolar disorder have also both been postulated to explain the symptoms of the two men, but neither man perfectly fits the diagnostic criteria for either. Schizoaffective disorder is a term used to describe patients who experience symptoms from both the psychosis of Schizophrenia and the mood disorders of Bipolar disorder. This paper aims to explain why Schizoaffective disorder explains the symptomology of these men better than either Schizophrenia or Bipolar disorder does alone. Schizoaffective disorder, however, did not exist as a diagnosis when Van Gogh and Schumann were alive, and so was not considered by their physicians.

Key words: schizophrenia - bipolar disorder - schizoaffective disorder - Robert Schumann - Vincent Van Gogh

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INTRODUCTION progression of illness to Schumann in that, from birth to death, he experienced elated periods and depressed While many people know that Robert Schumann and periods. In his elated periods he worked intensely at Vincent Van Gogh suffered from a psychiatric disorder, preaching early in his life, and later at his art. In his it is difficult to detail the psychopathology of their depressed periods, except for one period in the Saint- illnesses as they died such a long time ago. The symp- Remy asylum in 1889 where Starry Night was created, toms that the two famous men presented with show he did not produce any artwork. similarities. Many different diagnoses can be postulated Van Gogh suffered from fits with both visual and for the two men. These include a disorder that falls within auditory hallucinations and delusions, again similarly to the ‘Schizophrenia Spectrum’ between Schizophrenia and Schumann (Blumer 2002). Self-mutilation, including Bipolar disorders: Schizoaffective disorder. cutting off his ear, was a further psychiatric symptom. Subsequently he committed suicide. MENTAL SYMPTOMS PHYSICAL SYMPTOMS The case is easily made that both Robert Schumann and Vincent Van Gogh suffered from Mental Health AND EXPLANATIONS Symptoms. It has, however, been suggested that in the case of Robert Schumann both subjects, physical illnesses could be explanations Robert Schumann (1810-1856) was a Romantic for the reported symptoms. These could explain some of composer and music critic. He suffered from alternating both the mental and additional physical symptoms. depressed and elated moods from the ages of 18 to 38, Vincent Van Gogh when in 1848 his mental health went into decline. He attempted suicide and was voluntarily admitted to the A different explanation for the visual hallucinations Endenich asylum, where he died. described by Van Gogh’s physician is that they are a manifestation of nystagmus. Another interpretation for In addition to these melancholic depressive episodes, the auditory hallucinations is tinnitus. As such, a po- Schumann suffered from auditory hallucinations. These tential retrospective diagnosis of Meniere’s disease has took the form of the note A, angelic voices and the been proposed (Kaufman Arenberg 1990). voices of demons. He suffered from delusions of being poisoned, and of being threatened with metallic items Van Gogh presented with abdominal pain as (Domschke 2010). described in his letters to his brother Theo. This has led to the suggestion of acute intermittent porphyria, a Vincent Van Gogh disorder of heme metabolism (Arnold 2004). Van Gogh (1853-1889) was a post-impressionist Van Gogh was said to eat his oil colours, which, as painter. He suffered from a similar longitudinal well as containing lead, contained turpentine. He took

S559 Yasmeen Cooper & Mark Agius: DOES SCHIZOAFFECTIVE DISORDER EXPLAIN THE MENTAL ILLNESSES OF ROBERT SCHUMANN AND VINCENT VAN GOGH? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 559-562 camphor for his insomnia, as well as drinking absinthe, paresis 10-25 years after first diagnosis. This involves which contains thujone; camphor’s structural isomer. paranoid persecutory psychosis or simple dementia, These are all terpenoids. The convulsions that ter- which is consistent with Schumann’s later mental state penoids induce are ameliorated by bromide, and in (Walker 1972). There is debate as to whether the Arles bromide treatment helped Van Gogh (Arnold autopsy showed changes that are consistent with this. 2004). This provides evidence for terpenoid intoxi- The prosector described brain atrophy, thickening of the cation. Van Gogh’s art showed a lot of yellow, for meninges, and meninges adhering to the cortex, example the yellow coronas around each star in Starry however it is not clear that this can be interpreted as Night. He could have simply liked yellow, or his significant (Janisch 1986). Furthermore, Schumann was physical state could have influenced his work and painted several times in his final years, and he was said created xanthopsia (yellow halos). A first theory to to have had large pupils. This could have been from loss explain this links the xanthopsia to terpenoid inges- of light reflex in Argyll Robertson pupil (Walker 1972). tion, as excessive consumption of terpenoids may lead The treatment for syphilis at the time was Mercury, to the consumer seeing all objects with a yellow hue. which could also explain some of his symptoms. An investigation showed that a person must drink 182 Schumann’s autopsy mentions a ‘gelatinous’ intra- litres to produce this visual effect, so this is an cranial mass (Janisch 1986) at the base of the brain. unlikely explanation. There is insufficient evidence to interpret what this mass Lead intoxication, as well as alcohol withdrawal and was, but possibilities include a colloid cyst, cranio- porphyrias amongst other things, can precipitate epi- pharyngioma or a chordoid meningioma. Both colloid lepsy. A further theory centres around Van Gogh having cysts (Lawrence 2015) and meningiomas have been had temporal lobe epilepsy that was precipitated by the linked to mental health symptoms, the latter to auditory used of absinthe (Blumer 2002). Temporal lobe epilepsy musical hallucinations (Scott 1979). is the most common cause of partial seizures. This could Another suggested diagnosis has been dementia due explain his hallucinations and the temporal pattern of to vascular hypertensive disease, which consists of his illness in discrete episodes. Evidence against this is small strokes due to hypertension. There is no evidence that potassium bromide controlled Van Gogh’s condi- for this. The quoted symptoms include ‘giddy feelings’, tion, and while potassium bromide is effective against shortness of breath, and cardiac anxiety, which sound grand mal seizures, absinthe intoxication, and acute much more like common anxiety. Despite this, the diag- intermittent porphyria, it is not effective against partial nosis was made popular by Joseph Goebbels, the Nazi seizures. Furthermore, Van Gogh’s episodes lasted head of Propaganda. Goebbels was trying to promote much longer than the typical minutes-to-hours duration Schumann’s reputation over Mendelssohn’s, who was of partial seizures (Arnold 2004). Jewish. There existed however, in Nazi Germany, a law This links to a second theory for Van Gogh’s po- which mandated sterilization for anyone diagnosed with tential xanthopsia, which is that he was overmedicated Schizophrenia or Bipolar disorder, so Goebbels promo- with digitalis. At the time, digitalis was a common ted a non-psychiatric diagnosis to explain Schumann’s treatment for epilepsy. Patients on large and repeated illness. This idea then lingered in medical and musical doses see world with a yellow-green hue, or yellow discourse until as recently as the mid-1980s (Braun- spots with coronas, much like in the starry night schweig 2010). painting. Furthermore, Van Gogh painted 3 portraits of Gachet, his physician, who was depicted in one of these holding in his hand a stem of Digitalis purpurea SCHIZOAFFECTIVE DISORDER (purple foxglove), from which digitalis the drug is Schizoaffective Disorder History extracted (Wolf 2001). Emil Kraepelin, in his 1899 book Psychiatrie, divi- One further piece of evidence is that both a photo- ded the complex spectrum of psychiatric conditions graph of Van Gogh as an adolescent and later self- known as psychoses into two major classes, which were portraits suggest craniofacial asymmetry. This might manic-depressive psychosis and dementia praecox. This suggest that Van Gogh might have suffered an early is referred to as the Kraepelian dichotomy. He did not brain injury at birth, which could have lead to his categorise patients which had symptoms of both, suffering epilepsy. although he acknowledged that ‘there are many overlaps Robert Schumann in this area’. Schumann suffered from auditory symptoms. This Schizoaffective psychosis was introduced as a term could have, in fact, been tinnitus. The diagnosis of by Jacob Kasanin in 1933 to describe episodic psychosis Meniere’s disease can be discounted as Schumann never with affective symptoms. lost his hearing. The tinnitus, or hallucinations, are also In 1959 Kurt Schneider began to look at psychotic compatible with the diagnosis of syphilis (Walker 1972). illnesses sequentially over a longitudinal course. This Syphilis was very common in the time of Schumann. was the key observation needed to elucidate Schizo- Tertiary syphilis can cause the development of general affective disorder. He identified patients with a

S560 Yasmeen Cooper & Mark Agius: DOES SCHIZOAFFECTIVE DISORDER EXPLAIN THE MENTAL ILLNESSES OF ROBERT SCHUMANN AND VINCENT VAN GOGH? Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 559-562 sequential type illness, which was marked with alter- Bipolar disorder was also suggested frequently as nating mood and psychotic episodes. He described Van Gogh suffered from reactive depression followed Schizoaffective disorders as ‘cases in between’ the by euphoric periods. Evidence against pure Bipolar is Kraepelian dichotomy. the speed of onset and offset of the mood changes - Van In 1970 Kendell and Gourlay brought up the schizo- Gogh’s were rapid, while Bipolar patients seem to have affective concept again by describing a trimodal distri- more sustained mood changes. The nature of his cycloid bution of symptoms in a large group of patients: those psychosis has also been used to rule out pure schizo- with schizophrenic type symptoms, those with bipolar phrenia due to the total recovery between episodes, as symptoms, and those with a mixture of both (Kendell well as the amnesic confusion experienced after his 1970). Sir Robin Murray described 3 groups of genes attacks (Blumer 2002). Schizoaffective disorder combi- related to psychosis: one group linked to schizophrenia, ning the symptomology of both disorders could there- another to Bipolar disorder, and a third with both fore fit the account of his symptoms. conditions. With the onset of genome-wide association Robert Schumann studies (GWAS), it became more evident that not even a trimodal distribution is sufficient, and that psychosis is Mental health diagnoses clearly fit due to the ado- not one illness, but many illnesses due to many lescent onset, progression by fits and starts with pe- combinations of genes (Craddock 2005). riods of partial remission, symptoms of delusions, In terms of symptoms, it is beyond the scope of this hallucinations, mood changes, and behavioural disor- paper to describe all symptoms or subtypes. Reference ders. The psychotic symptoms of hallucinations and is made to the international classification of diseases delusions discussed are more likely to be explained by ICD10 (WHO 1994) and DSM-5 (American Psychia- schizophrenia than Bipolar if one were to analyse tric Association 2013). In general, however, Schizo- Schumann’s symptoms using Kraepelin’s dichotomy. Schizophrenia does not, however, fit alone, as the phrenia is a mental disorder characterized by abnormal cycle of mood changes in his earlier years looks more social behaviour and failure to understand reality. like Bipolar disorder, which is primarily a mood Positive symptoms include false beliefs, referred to as disorder. An intermediate diagnosis of schizoaffective delusions; unclear or confused thinking, manifested as disorder thus could fit Schumann well. This does not various types of thought disorder; hallucinations of necessarily exclude concomitant symptoms of physical any modality, but especially including third party audi- diseases. In fact it has been suggested that the final tory hallucinations; and cognitive deficits. Negative illness, from the suicide attempt onwards, must have symptoms include reduced social engagement and begun from a state of delirium, typical of acute emotional expression, and a lack of motivation. Bipo- psychosis but not schizoaffective disorder. This state lar disorder, formerly known as Manic Depression, is a could be explained by neurosyphilis. condition that affects mood, which can swing from one extreme to another. People with Bipolar disorder can have periods of depression, feeling very low and CONCLUSIONS lethargic, or mania, feeling very high and overactive. Each episode of high or low mood can last for several Both subjects could have potentially been diagnosed weeks. At the highest degree of mania, as well as in with Schizoaffective disorder if presenting now, but the deep depression, psychotic symptoms including hallu- concept was not present at the time and so this diagnosis cinations and delusions may occur. Schizoaffective could not be used. Schumann died in 1856, and Van disorder is a mental disorder diagnosed in patients who Gogh in 1890, both before even dementia praecox was have features of both Schizophrenia and Bipolar used as a term (1891), let alone Schizoaffective disorder disorder or depression, but who may or may not meet (1933). If this diagnosis had been available, it may have the diagnostic criteria for either alone. been used, and it may then have turned out that some of the mental and physical diagnoses postulated were not PSYCHIATRIC EXPLANATIONS good fits. Vincent Van Gogh Another psychiatric explanation for Van Gogh’s Acknowledgements: None. symptoms is borderline personality disorder. Van Conflict of interest: None to declare. Gogh’s brother Theo once sent a letter to his younger sister regarding Vincent, saying ‘it seems as if he were Contribution of individual authors: two persons: one marvellously gifted, tender and refined, the other egotistic and hard hearted. They Yasmeen Cooper carried out the literature search and present themselves in turns, so that one hears him talk drafted the text. first in one way, then in the other, and always with Mark Agius commented on and corrected the text and supervised the project. arguments on both sides.’ (Blumer 2002).

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References 8. Kaufman Arenberg I, Flieger Countryman L et al: Van Gogh had Meniere’s Disease and not Epilepsy. JAMA 1. American Psychiatric Association: DSM-5, 2013 1990; 264:491-493 2. Arnold: The Illnesses of Vincent Van Gogh. Journal of the 9. Kendell RE, Gourlay J: The Clinical Distinction between History of the Neurosciences 2004; 13:22-43 the Affective Psychoses and Schizophrenia. British Jour- 3. Blumer D: The Illness of Vincent Van Gogh. Am J Psy- nal of Psychiatry 1970; 117:261-266 chiatry 2002; 159:519-526 10. Lawrence JE, Nadarajah R, Treger TD, Agius M: Neuro- 4. Braunschweig Y: To Listen To Schumann, Bring a Couch. psychiatric Manifestations of Colloid Cysts: a review of The New York Times, 2010 the literature. Psychiatr Danub 2015; 27(Suppl 1): 5. Craddock N, Owen MJ: The beginning of the end for the S315-20 Kraepelinian dichotomy, 2005; 186:364-366 11. Scott M: Musical Hallucinations from Meningioma. JAMA 6. Domschke K: Robert Schumann’s contribution to the 1979; 241: 1683 genetics of psychosis. The British Journal of Psychiatry 12. Walker A: Robert Schumann: The Man and His Music. 2010; 196:325 Barrie & Jenkins, London, 1972 7. Janisch W, Nauhaus G: Autopsy report of the corpse of 13. WHO: ICD-10, 1994 the composer Robert Schumann – publication and inter- 14. Wolf P: Creativity and chronic disease Vincent van Gogh pretation of a rediscovered document. Zentralbl Allg (1853-1890). West J Med 2001; 175:348 Pathol 1986; 132:129-36

Correspondence: Yasmeen Cooper Clare College Cambridge, University of Cambridge Trinity Lane, Cambridge, CB2 1TL, UK E-mail: [email protected]

S562 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 563-566 Conference paper © Medicinska naklada - Zagreb, Croatia

TERTIARY SYPHILIS (GENERAL PARALYSIS OF THE INSANE) AND BIPOLAR DISORDER; THE ROLE OF THESE TWO DISORDERS IN THE LIFE OF FAMOUS COMPOSERS Isabelle K. McGill1 & Mark Agius1,2 1Clare College Cambridge, University of Cambridge, Cambridge, UK 2Department of Psychiatry, University of Cambridge, Cambridge, UK

SUMMARY Syphilis is a complex disease, which can lead to General Paralysis of the Insane if left untreated. Before antibiotics this was the natural progression of the disease, with many people being admitted to mental asylums with the diagnosis of GPI, and going on to die there. Diagnoses however, were difficult, as it was difficult to distinguish between GPI and other mental conditions such as bipolar disorder. We can use the works of the classical composers Beethoven, Schubert, Schumann and Smetana, who all suffered from mental illness, to gain an insight into what it is like to live with these conditions. All these are potential cases of GPI, highlighting how a sexually transmitted disease can end the life of such talented and influential people. With antibiotic resistance becoming a growing concern, it is key that we continue to recognise and treat syphilis in an appropriate manner, so as to limit the future of this disease.

Key words: tertiary syphilis - general paralysis of the insane - bipolar disorder - classical composers

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INTRODUCTION cure. There were many hypotheses as to the cause of GPI from bereavement to excess alcohol and tobacco. Many famous composers were troubled with mental Syphilis was suggested in 1857, but was not accepted illness throughout their careers. There are many hypo- until the discovery of Treponema pallidum (then called theses as to the reason behind this, and two which Spirochaeta pallida) in the brain of deceased patients stand out are tertiary syphilis (General Paralysis of the in the 20th century. At this point, one fifth of male Insane) and Bipolar Disorder. admissions to asylums were with the diagnosis of GPI and the prognosis for all those admitted was death. The SYPHILIS seriousness of this disease affecting those expected to be at the peak of their life is thus clear (Davis 2012). Syphilis is a disease that some believe dates back In the early 20th century, following unsuccessful to 3000 BC, nonetheless, it has been recognised in treatments with heavy metals, a new treatment was Europe from the 13th century (Tampa 2014). This developed in the hope to reduce deaths from syphilis; sexually transmitted disease is caused by the bacteria this method was to infect a patient with malaria in Treponema pallidum. The initial infection is charac- order to induce a fever to kill the Treponema pallidum, terised by open lesions, but these close as the infection and then treat the patient with quinine to cure the enters its second phase – the multiplication of the malaria. Although this was more effective than pre- organism in different tissues causing fever, malaise, vious treatments, the huge decline in syphilis in the and a mucocutaneous rash, and then its tertiary phase – mid 20th century, was due to the development of peni- inflammation due to high numbers of the organism cillin (Wallis 2012). causes tissue destruction, after a latent phase which The availability of penicillin to treat syphilis meant may last 25 years. Inflammation of the parenchyma- that GPI all but disappeared in the UK, however, in tous parts of the brain leads to general paralysis of the 2015, there were 2811 new syphilis diagnoses in insane (Radolf 1996). London, of which 39.5% were in the early latent phase In the 19th century, general paralysis of the insane (Public Health England 2016).Could this be due to became a very prominent issue in the world of antibiotic resistant strains of Treponema pallidum? psychiatry. Patients would be admitted to asylums for A point mutation has introduced macrolide resi- a wide variety of symptoms from grandiose to para- stance in some strains of T. pallidum found in areas of noid delusions, personality changes, insomnia and the United States, Canada, Europe and China, with use mania. Shivering and Argyll Robertson pupil were also of these antibiotics thought to be adding selective pres- observed. Throughout Europe, men in their late 30s sure (Stamm 2009). Use of macrolides, therefore, in and 40s were being admitted to asylums with the the treatment of syphilis must be done with caution suspected diagnosis of GPI, however, at this time the under close clinical monitoring (Stamm 2009). cause of the disease was unknown and there was no Although this resistance should not be overlooked, it is

S563 Isabelle K. McGill & Mark Agius:TERTIARY SYPHILIS (GENERAL PARALYSIS OF THE INSANE) AND BIPOLAR DISORDER; THE ROLE OF THESE TWO DISORDERS IN THE LIFE OF FAMOUS COMPOSERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 563-566 not itself critical in the future of syphilis treatment, as Ludwig von Beethoven (1770-1827) the first line drug remains penicillin (Stamm 2009). It is well known that Beethoven was completely deaf Penicillin is a ȕ-lactam antibiotic which prevents cell for the final 9 years of his life; his post mortem revealed wall synthesis and thus causes cell lysis. It is vestibulocochlear nerve atrophy (Franzen 2008). In bactericidal for growing bacteria; however, many addition to this, he suffered from ascites, hepatic fai- species are developing mechanisms of resistance. lure, chronic alternating constipation and diarrhoea, These include producing ȕ-lactamase enzymes that and uveitis. Tertiary syphilis could explain the atrophy destroy the critical ȕ-lactam ring and the use of of the eighth cranial nerve, due to meningeal irritation, different transpeptidase enzymes, that have a lower which could also be responsible for the uveitis. affinity to the -lactam ring (Stamm 2009). Neither of ȕ Untreated tertiary syphilis may also cause gummas of these, however, are yet to be found in T. pallidum the liver, leading to cirrhosis, and hence the ascites and (Stamm 2009). The thought behind this is that T. liver failure. Syphilis however, does not give a reason- pallidum lacks plasmids, bacteriophage, or transpo- able explanation of the bowel symptoms. sons, preventing horizontal transfer of genes; further- The most likely explanation for the bowel symp- more, development of genes to code for these new toms is irritable bowel syndrome, although Crohn’s proteins would require multiple mutations in the DNA, disease and ulcerative colitis are other possibilities. compared to the single mutation required to confer Whipple’s disease is also a possible cause of Beetho- macrolide resistance (Stamm 2009). This is not to say ven’s symptoms; however, it is extremely rare (Don- that resistance could occur at any point in the future nenberg 2000). (Stamm 2009). With regards to Beethoven’s compositions, the most interesting symptom is inevitably his deafness. BIPOLAR DISORDER Other than syphilis, it has been proposed that this could be due to low-dose chronic exposure to heavy Another condition with potentially similar symp- metals, such as lead in wine. This explanation is toms to tertiary syphilis is bipolar disorder (APA 2013, favoured by some as his hearing loss was slow over WHO 1994). This is characterised by periods of de- years; an autoimmune hearing loss would develop in pression, followed by periods of mania. Interactions months (Stevens 2013). between a collection of genes and environmental and social factors making a person more likely to develop Franz Schubert (1797-1828) the condition (Craddock 2005, nhs.uk 2016). Both the depressive and manic states of bipolar disorder may Schubert received his diagnosis of syphilis aged 25 after experiencing mood changes, depression, head- feature hallucinations and delusions. aches and dizziness. He was treated with mercury Bipolar disorder was not recognised until the 19th inhalation which had many side effects including hair century, when Jean-Pierre Falret described ‘la folie loss (Franzen 2008). The effect of his condition on his circulaire’ – circular insanity. He documented the work is very obvious, in a way that Beethoven’s is not. change in patients from depression to mania, and how This may be because he was diagnosed with syphilis, this condition tended to run in families (Mason 2016). th whereas Beethoven’s infection is a retrospective pos- In the early 20 century, the distinction between tulation; or perhaps it is because he had more neuro- bipolar disorder and schizophrenia was noted by Emil logical (at least documented neurological) symptoms Kraepelin. Although neither term was yet coined, than Beethoven. ‘dementia praecox’ (schizophrenia) showed positive Upon diagnosis, Schubert decided to not complete (e.g. hallucinations) and negative (e.g. anhedonia) his Unfinished Symphony, leaving it as a two-move- symptoms in the setting of a ‘chronic mental disorder ments-symphony, not the traditional four, perhaps a in which a person loses touch with reality (psychosis)’; reminder of mortality? His sense of hopelessness is this contrasts to the distinct periods of mania and also reflected in other compositions including Der Tod depression seen in bipolar disorder (Krans 2018). und das Mädchen (Death and the maiden), really enforcing his fear of approaching death. DISCUSSION Schubert’s life seems to be clouded with depression, but also auditory and visual hallucinations which On admission to an asylum, or when diagnosing also suggests bipolar disorder. It is very difficult to retrospectively, the presence of grandiose delusions know for certain, what exactly ailed him, as a diag- applies to both the manic phase of bipolar disorder and nosis of syphilis was highly stigmatised in the 19th to GPI (Mason 2016). Before the introduction of century and so medical records were destroyed or doc- serological tests, it is understandable that the diagnosis tored to keep the diagnosis from friends and family. of GPI as a result of tertiary syphilis may be delayed This is thought to be an explanation for the rather un- as other possible disorders were excluded. explained typhus of Schubert (Rempelakos 2014).

S564 Isabelle K. McGill & Mark Agius:TERTIARY SYPHILIS (GENERAL PARALYSIS OF THE INSANE) AND BIPOLAR DISORDER; THE ROLE OF THESE TWO DISORDERS IN THE LIFE OF FAMOUS COMPOSERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 563-566

Robert Schumann (1810-1856) Now that we have the appropriate treatment, the key is to establish the presence of syphilis as soon as At age 23 Schumann first displayed signs of a men- possible, to kill the bacteria before it causes irrever- tal disorder, with alternating depressive and manic sible damage. Available now are serum analysis for episodes. Consistent with his history of frequently syphilis with non-specific lipoidal tests (venereal di- changing sexual partners, it is thought that Schumann sease research laboratory tests) and treponemal-specific contracted syphilis aged 20, which quickly progressed tests (fluorescent treponemal antibody absorption) to the tertiary stage. He suffered serious decline in (Wlodarczyk 2017). These tests used to be routine on mental stability and in 1854 he attempted suicide by admission to a mental hospital but were stopped as jumping in the Rhine. Following his rescue, he was incidence decreased. Perhaps, however, they should be admitted to a mental asylum where he died two years brought back and awareness of syphilis increased, as later (Franzen 2008). this disease is returning (Wlodarczyk 2017). Schumann’s exact diagnosis is argued with possibi- We have also now developed tests to look at the lities, other than tertiary syphilis, including bipolar affect that neurosyphilis has on the brain. By looking disorder and schizophrenia. Regardless, his mental con- at the apparent diffusion coefficient (ADC) of water dition is very apparent throughout his compositions. A under MRI, one can look for white matter atrophy; marking of ‘lively but not too fast’ in the third move- unimpeded diffusion indicates white matter disinte- ment of Violin Concerto in D minor led to ‘awkward gration (Czarnowska-Cuba 2017). This imaging may music flow’; the explanation for this marking being that suggest neurosyphilis before a person becomes sympto- Schumann heard music at different speeds to others. matic and so could prove invaluable in the future of Furthermore, a single sounding note in Ghost Varia- syphilis screening. tions for piano, his last published work, could indicate tinnitus (Rempelakos 2014). Whether or not Beethoven had syphilis, we will most likely never find out, although we can be fairly Bedrich Smetana (1824-1884) certain that Schubert, Schumann and Smetana were all infected. Again, a diagnosis of bipolar disorder is also Smetana first developed symptoms of tertiary syphi- hard to determine, as at this time, this condition was lis aged 38, when he experienced auditory hallucina- not recognised, and the limited literature available tions, followed by tinnitus, and by aged 50, he was does not provide sufficient detail. We can, however, completely deaf. This however, did not halt his com- learn a lot about what it can be like living with these posing. In 1876 he composed ‘Aus meinem Leben’, a conditions through the interpretation of their composi- string quartet in e minor (Franzen 2008). tions. This should act as a reminder that syphilis must This composition depicts his journey with his ill- be recognised as a serious disease, which, if diagnosed ness, with, in the last movement, a poignant harmonic in the primary stage, is entirely treatable. high E from the first violin, over a low tremolo chord by the lower three instruments. This reflects the tinnitus from which he suffered throughout his deafness. Acknowledgements: None. Due to severe neurological decline, Smetana was admitted to an asylum following violent behaviour, Conflict of interest: None to declare. memory loss and writing letters to imaginary friends. He died in this asylum (Rempelakos 2014). Contribution of individual authors: In 1987, his body was exhumed, and the tissues tes- Isabelle K. McGill carried out the literature search and ted for syphilis, all with a positive result. This provided drafted the text. a full explanation for all his symptoms and ceased Mark Agius corrected and commented on the text and different hypotheses as to their origin. For instance, it supervised the project. had been suggested that his hearing loss was related to a gunpowder accident that happened when he was 11 and resulted in osteomyelitis. High levels of mercury were References also found in his body, suggesting that they suspected at the time that he had syphilis (Höschl 2012). 1. American Psychiatric Association: DSM-5, 2013 2. Czarnowska-Cuba M, Wlodarczyk A, Szarmach J, Gwoz- dziewicz K, Pienkowska J, Wiglusz M, Jerzy Cuba W & CONCLUSIONS Krysta K: Neurosyphilis - The White Matter Disintegration? Two Case Studies. Psychiatr Danub 2017; 29(supp 3):357-60 Life for these composers became very bleak through 3. Craddock N & Owen MJ: The beginning of the end for the the course of their illness. The diagnosis could never Kraepelinian dichotomy. 2005; 186:364-366 be certain, as appropriate tests had not been developed 4. Davis G: The most deadly disease of asylumdom: general yet; and even if a confident diagnosis was made, the paralysis of the insane and Scottish psychiatry, c.1840- treatment with mercury most probably contributed to 1940. Journal of the Royal College of Physicians of their mental deterioration. Edinburgh 2012;42:266-273

S565 Isabelle K. McGill & Mark Agius:TERTIARY SYPHILIS (GENERAL PARALYSIS OF THE INSANE) AND BIPOLAR DISORDER; THE ROLE OF THESE TWO DISORDERS IN THE LIFE OF FAMOUS COMPOSERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 563-566

5. Donnenberg M, Collins M, Benitez R & Mackowiak P: 12. Radolf JD: Treponema. in: Baron S. (eds.) Medical Micro- The sound that failed. The American Journal of Medicine biology, 1996; 4th edition. Galveston (TX): University of 2000; 108:475-480 Texas Medical Branch at Galveston, 1996. Chapter 36 6. Franzen C: Syphilis in composers and musicians – Mo- 13. Rempelakos L, Poulakou-Rebelakou E, Tsiamis K & zart, Beethoven, Paganini, Schubert, Schumann, Smetana. Rempelakos A: FRII-01 Syphilis’ impact on late works of European Journal of Clinical Microbiology & Infectious classical music composers. The Journal of Urology 2014; Diseases 2008; 27:1151-1157 191:e627 7. Höschl C: Bedrich Smetana – Art and Disease. Psychiatr 14. Stamm L: Global Challenge of Antibiotic-Resistant Trepo- Danub 2012; 24(Supp1):176-178 nema pallidum. Antimicrobial Agents and Chemotherapy 8. Krans B & Cherney K: History of Bipolar Disorder, 2018. 2009; 54:583-589 [online] Healthline. Available at: 15. Stevens M, Jacobsen T & Crofts A: Lead and the deafness https://www.healthline.com/health/bipolar- of Ludwig van Beethoven. The Laryngoscope 2013; disorder/history-bipolar [Accessed 27 Aug. 2018] 123:2854-2858 9. Mason B, Brown E, Croarkin P: Historical Underpinnings 16. Tampa M: Brief History of Syphilis. Journal of Medicine of Bipolar Disorder Diagnostic Criteria. Behavioral Scien- and Life, 2014; 7:4-10 ces 2016; 6:14 17. Wallis J: Looking back: this fascinating and fatal disease. 10. nhs.uk: Bipolar disorder, 2016. [online] Available at: The Psychologist 2012; 25:790-791 https://www.nhs.uk/conditions/bipolar-disorder/ 18. WHO: ICD-10, 1994 [Accessed 22 Aug. 2018] 19. Wlodarczyk A, Szarmch J, Jakuszkowiak-Wojten K, Galuzko- 11. Public Health England: Syphilis epidemiology in London: Wegielnik M & Wiglusz M: Neurosyphilis Presenting with sustained high numbers of cases in men who have sex with Cognitive Deficits – A Report of Two Cases. Psychiatr men, 2016 Danubina 2017; 29(supp 3):341-344

Correspondence: Isabelle K. McGill Clare College Cambridge, University of Cambridge Cambridge, UK E-mail: [email protected]

S566 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 567-571 Conference paper © Medicinska naklada - Zagreb, Croatia

MOZART'S MUSIC AND MULTIDRUG-RESISTANT EPILEPSY: A POTENTIAL EEG INDEX OF THERAPEUTIC EFFECTIVENESS Chiara Bedetti1, Patrizia D’Alessandro1, Massimo Piccirilli1,2, Moreno Marchiafava1, Antonella Baglioni1, Marta Giuglietti1, Domenico Frondizi3, Marina Menna1 & Sandro Elisei1,4 1Istituto Serafico, Assisi, Perugia, Italy 2Department of Experimental Medicine, University of Perugia, Perugia, Italy 3Neurophysiopathology Division, Department of Neuroscience, Santa Maria Hospital, Terni, Italy 4Department of Philosophy, Social and Human Sciences and Education, University of Perugia, Perugia, Italy

SUMMARY Multidrug-resistant epilepsy is a pathological condition that affects approximately one-third of patients with epilepsy, especially those with associated intellectual disabilities. Several non-pharmacological interventions have been proposed to improve quality of life of these patients. In particular, Mozart’s sonata for two pianos in D major, K448, has been shown to decrease interictal electroencephalography (EEG) discharges and recurrence of clinical seizures in these patients. In a previous study we observed that in institutionalized subjects with severe/profound intellectual disability and drug-resistant epilepsy, a systematic music listening protocol reduced the frequency of seizures in about 50% of cases. This study aims to assess electroencephalography as a quantitative (qEEG) predictive biomarker of effectiveness of listening to music on the frequency of epileptic discharges and on background rhythm frequency (BRF).

Key words: Mozart effect – EEG – music - drug-resistant epilepsy

* * * * *

INTRODUCTION development of the arcuate fasciculus and corpus callosum when compared to a control group of children who Music is one of the most complex, fascinating and were not exposed to any kind of musical training (Hyde enigmatic human abilities and has been the object of et al. 2009). It should be kept in mind that these brain numerous investigations from specialists of both huma- changes may be diversely detected in relation to specific nistic and natural sciences. In recent years, neuroscience expertise: as a matter of fact, changes are not present in has made a substantial contribution to the comprehen- an undifferentiated way but correlate with a number of sion of the peculiar characteristics of the musical expe- characteristics linked to personal history and individual rience. Classic neuropsychological studies have sugges- competence (Merret et al. 2013). These differences in ted that music is a highly complex stimulus consisting musical competence may be responsible for significant of a large number of components which are relatively differences in individual brain anatomical and func- autonomous of one another: indeed melody, harmony, tional organization. For example, the sensorimotor re- rhythm, meter, memory, imagination, emotional res- presentation of the hands is different between violinists ponse and so on may be compromised independently of and pianists, and significant anatomical aspects can be each other (Peretz & Coltheart 2003, Piccirilli et al. found between professional musicians and those who 2000). Music processing requires an ongoing process of just plays for fun (Bangert et al. 2006, Wan & Schlaug decomposition and recomposition of these different 2010). In other words, it is now well-documented that components; from an anatomical perspective, it is a musical training can shape brain and improves the widespread function of the nervous system involving a efficiency of the connections between different brain highly complex neuronal network (Sacks 2008). More regions. Musicians possess a different connectome than recently, currently available neuroimaging techniques non-musicians (Schlaug 2015). In this view, with re- have demonstrated that musical training is a powerful gards to nervous system damage it is plausible that the means of reorganization of brain structures (Bodner et reorganization of brain structures can result from musi- al. 2001). Music may be considered an outstanding tool cal training. The various components of music can be for promoting brain plasticity (Wan & Schlaug 2010). used in a differentiated manner in relation to the type of Changes which result involve both grey and white pathology in question, therefore justifying the effec- matter. This structural/functional reorganization affects tiveness of music therapy in different clinical conditions the size, asymmetry and density of grey matter of such as parkinsonism, aphasia, neglect, dementia, lear- specific cerebral regions, along with the size, volume, ning disorders and autism (Altenmuller & Schlaug and composition of white matter fiber bundles. For 2013, D’Alessandro 2016, Särkämö et al. 2016, Schlaug example, with regards to brain development, six year- et al. 2010, Thaut et al. 2015). Actually, as Patel points old children undergoing musical training who were out (2008), music may be considered a “transformative followed for two years were found to have a marked technology” of the mind.

S567 Chiara Bedetti, Patrizia D’Alessandro, Massimo Piccirilli, Moreno Marchiafava, Antonella Baglioni, Marta Giuglietti, Domenico Frondizi, Marina Menna & Sandro Elisei: MOZART'S MUSIC AND MULTIDRUG-RESISTANT EPILEPSY: A POTENTIAL EEG INDEX OF THERAPEUTIC EFFECTIVENESS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 567-571

MUSIC THERAPY AND EPILEPSY MOZART EFFECTS AND MULTIDRUG-RESISTANT EPILEPSY Recently growing interest has been demonstrated by researchers studying the effects of music in epilepsy. In The beneficial effect of Mozart music as an add-on particular a considerable group of studies have been car- treatment in the clinical management of epilepsy is ried out by Lin and coll. (Lin & Yang 2015) investi- particularly valuable in the case of drug-resistant epi- gating the so-called "Mozart effect" (Rauscher et al. lepsy, accounting for 20-30% of all cases of epilepsy, 1993). Their investigations revealed that both seizure where standard pharmacological treatments have not frequencies, recurrence of first unprovoked seizure, and proven to be effective and where prevalence is related to epileptiform discharges are significantly reduced when degree of intellectual disability (Kwan et al. 2010, listening to sonata K.448 of Mozart. With regards to French et al. 2004). Regarding drug-resistant epilepsy, epileptiform discharges, forty-seven (81%) of fifty-eight Lin et al. (2011b) observed a 53.6±62.0% reduction in children between the ages of 1 year to 19 years 8 seizure frequency; 72.7% of subjects (n=11) demonstra- months showed a significant decrease in interictal dis- ted a greater than 50% reduction, including 18.9% who charges (Lin et al. 2010). In eighteen children with epi- were seizure-free. In their sample of 11 outpatients (age lepsy under good pharmacological control a significant range 1.5 to 21 years) Coppola et al. (2015) observed a decrease in epileptiform discharges were found when 51.5% reduction in seizure frequency. In a subsequent compared with EEGs prior to listening to music (Lin et study (2018) significant seizure reduction was observed al. 2011a). In another study of sixty-four epileptic chil- in 9 of 19 patients, two while listening to Mozart’s sonata dren 90.2% demonstrated decreased epileptiform dischar- K448 and seven (including two seizure-free cases) while ges during and immediately following their listening to listening to a set of Mozart’s compositions. In a rando- Mozart K.448 and 82.6% while listening to Mozart K.545 mized study conducted at a residential facility for indi- (Lin et al. 2013); similar results were obtained in other viduals with heterogeneous neurological impairments, investigations (Lin et al. 2012). According to a recent (age range 12-78 years), Bodner et al. (2012) observed a meta-analysis, a reduction in interictal epileptic dischar- 24% reduction in seizure frequency and 24% of subjects ges appears to be significant in 84% of patients (Dastg- were seizure-free. In our previous investigation of 12 heib et al. 2014). Regarding seizure frequency, a rando- institutionalized subjects with severe intellectual disa- mized controlled study carried out over 24 months in bility (age range 5-35 years), we observed a 20.5% re- children with initial unprovoked seizures revealed that duction in seizure frequency; 50% of patients demon- those children who were under musical treatment had a strated a positive response to treatment, including 8% 76.8% reduction in epileptic seizures compared to 37.2% who were seizure-free (D’Alessandro et al. 2017). Since of children in the control group (Lin et al. 2014a). Studies none of the patients in our sample worsened in seizure of Lin et al. have confirmed previous sporadic and frequency, though the beneficial effect was lost following anecdotal observations (Turner 2004, Lahiri & Duncan the end of the intervention, we have decided to continue 2007, Kuester et al. 2010) and overall have stimulated music therapy in all our subjects. At a one year follow- further investigations on this subject. A first report of up, the available data suggest some considerations: the Mozart effect on epileptic patients dates back to subjects who exhibited a very good response to treat- 1998: Hughes et al. found reductions in epileptiform ment continued to maintain efficacy over time; there activities in patients with status epilepticus or with pe- was no reduction in the effectiveness of music the- riodic lateralized epileptiform discharges (PLEDs). More rapy; no adverse side effects were observed; recently Grylls et al. (2008) evidenced a significant re- on the contrary, subjects in our sample who were duction in the frequency of epileptic discharges while nonresponders had not benefited from the continua- listening to Mozart’s music compared to baseline and to tion of music therapy; control music in their study of forty five children who the response obtained after the first month appears had epileptiform activity on EEG (2–18 years; mean 7 sufficient to determine whether such intervention is years 10 months). In conclusion, the available data sug- worth continuing; gest that music may be considered a valuable non-inva- some variables appear to be associated to a favourable sive, non-pharmacologic treatment of epilepsy. In addi- response: in our study, different responses of the sub- tion, further information about the Mozart effect has been jects to music therapy can be inferred from the average discovered from a number of experimental and clinical monthly baseline seizure frequency. Age, gender, de- investigations. Differential response of brain activity to gree of intellectual disability as well as characteristics the different characteristics of musical stimuli is well of epilepsy did not affect the results. The literature documented by both neurophysiological and functional suggests that the largest seizure reduction is observed neuroimaging investigations (Bodner et al. 2012, Ver- among patients with generalized or central epilepti- rusio et al. 2015). Seizure frequencies and spontaneous form discharges; however, all types of epilepsy, both discharges were reduced in Long Evans rats with sponta- idiopathic and symptomatic, with the exception of neous absence seizure during and after music exposure as those with occipital discharges, showed a significant compared to the pre-music stage (Lin et al. 2013b). decrease in epileptiform discharges (Lin et al. 2011b);

S568 Chiara Bedetti, Patrizia D’Alessandro, Massimo Piccirilli, Moreno Marchiafava, Antonella Baglioni, Marta Giuglietti, Domenico Frondizi, Marina Menna & Sandro Elisei: MOZART'S MUSIC AND MULTIDRUG-RESISTANT EPILEPSY: A POTENTIAL EEG INDEX OF THERAPEUTIC EFFECTIVENESS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 567-571

Figure 1. EEG background rhythm frequency before (A), during (B) and after (C) music listening

considering the differences in responses between (Jackson et al. 2015). In particular, in the absence of different subjects, it appears extremely important to effective pharmacological and surgical therapies, non- search for any differential characteristics between pharmacological interventions are currently playing an responders and nonresponders. In this perspective, increasing role. Listening to Mozart’s music may be very interesting preliminary data suggest that some potentially useful as an add-on non-pharmachological qEEG markers are able to identify subjects poten- therapy in the treatment of epilepsy, including multi- tially sensitive to the positive effect of Mozart's drug-resistant epilepsy. At the moment, due to the small music (Lin et al. 2014b). Our preliminary data sug- sample sizes examined and methodological differences gest that subjects who positively respond to treat- utilized, the truthfulness of this statement appears diffi- ment with music listening show a difference in EEG cult to establish and various aspects of this issue need to background rhythm frequency (BRF) between the be further investigated. The effect of music on patients intervention period and the baseline period; in these with epileptic seizures is complex and at present poorly subjects the pattern of brain wave activity shows less understood; it appears that some patients with seizures į frequencies and more ș and Į frequencies, while might benefit from musical exposure, whereas other no changes in EEG activity are detected in our non- patients may experience an exacerbation of their symp- responder subjects (Figure 1). tomology. The dichotomous effect of music on epilepsy Significant differences in the BRF between the base- is an intriguing yet poorly understood phenomenon and line period (A), the intervention period (B) and post- the subject of ongoing research and debate. Music may intervention (C), in a 21 year-old male affected by the act as an anticonvulsant via activation and enhancement inv dup (15) syndrome, one of the most common chro- of cortical areas involved in spatial cognitive processes mosomal abnormalities associated with Drug Resistant that produce greater inhibition, either directly on sur- Epilepsy (DRE). Distinctive clinical findings are repre- rounding motor areas or via inhibitory corticothalamic sented by early central hypotonia, developmental delay, feedback loops (Maguire 2012). Similarly, music may intellectual disability, epilepsy, and autistic behaviour. act as proconvulsant in musicogenic epilepsy where qEEG may be a useful model for predicting therapeutic anticipation of music and memory responses may effectiveness of music in patients with epilepsy. enhance activity in the prefrontal cortex and associated frontostriatal connections (Leaver et al. 2009). However CONCLUDING REMARKS it is noteworthy that Mozart’s music seems to be effective regardless of the different treatment protocols The frequency of epilepsy and drug-resistant epi- used in various studies. Mozart’s music is supposedly lepsy (DRE) remains higher in subjects with intellectual the only piece to demonstrate beneficial effects on epi- disability (ID), a population where a direct relationship lepsy. Mozart composed more than 600 works in his between the severity of ID and the presence of DRE has lifetime: his music is considered purely “cortical;” since been previously documented (Robertson et al. 2015). he did not make corrections on paper it is said that his Living with ID and epilepsy represents many challenges hand was only the “printer,” and that his musical for the individual, caregivers, and family. Medical structure had a “direct line from his brain to that of the science has failed to provide evidence-based data on the listener” (Greenberg 2000). In particular, Mozart com- care of patients with ID and DRE (Devinsky et al. posed with very repetitive melodic lines and his compo- 2015). The presence of DRE in subjects with ID has sitional structure reveals a highly detailed organization. therefore strongly stimulated research on new and In general, when comparing Mozart’s music with the innovative approaches to intervention, the effectiveness music of other composers such as Beethoven, Wagner of which are still the subject of further investigation or Chopin, or other types of music, this hypothesis seems

S569 Chiara Bedetti, Patrizia D’Alessandro, Massimo Piccirilli, Moreno Marchiafava, Antonella Baglioni, Marta Giuglietti, Domenico Frondizi, Marina Menna & Sandro Elisei: MOZART'S MUSIC AND MULTIDRUG-RESISTANT EPILEPSY: A POTENTIAL EEG INDEX OF THERAPEUTIC EFFECTIVENESS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 567-571 to be validated (Hughes 2001). Some authors evidence 3. Bodner L, Muftuler T, Nalcioglu O, Shaw GL: fMRI study the peculiar characteristics of Mozart’s music; Hughes relevant to the Mozart effect: Brain areas involved in spa- et al. (2001) found that the long-term periodicity of the tial–temporal reasoning. Neurological Res 2001; 23:683-90 melodic line in Mozart’s music was significantly more 4. Bodner M, Turner RP, Schwacke J, Bowers C, Norment C: apparent and frequent when compared to the music of Reduction of Seizure Occurrence from Exposure to Auditory Stimulation in Individuals with Neurological Handicaps: A 55 other composers. Lin et al. (2010) compared the Randomized Controlled Trial. PLoS ONE 2012; 7:e45303 piano K.448 with a digitally computerized string version 5. Bradt J, Dileo C, Grocke D: Music interventions for me- of the same musical stimulus: although these two kinds chanically ventilated patients. Cochrane Database Syst of music possessed the same melody, piano K.448 and Rev 2010; 12:CD006902 string K.448 differed in their harmonics. The diffe- 6. Coppola G, Operto FF, Caprio F, Ferraioli G, Pisano S, rences were particularly noteworthy at higher frequen- Viggiano A, Verrotti A: Mozart's music in children with cies because the string K.448 was composed of stronger drug-refractory epileptic encephalopathies: Comparison high frequency harmonics. Interestingly, lower harmo- of two protocols. Epilepsy Behav 2018; 78:100-3 nics found in piano K.448 work better to decrease 7. Coppola G, Toro A, Operto FF, Ferrarioli G, Pisano S, seizure activity compared to higher harmonics found in Viggiano A, Verrotti A: Mozart's music in children with drug refractory epileptic encephalopathies. Epilepsy string K.448. The hypotheses regarding the mechanism Behav 2015; 50:18-22 of action of Mozart’s music are still under investigation; 8. D’Alessandro P: Le armonie della mente: musica, musico- there is no value that can be attributed to the aspecific terapia e neuroscienze. Morlacchi University Press, action of music on attentional processes or on mood Perugia, 2016 (Bradt et al, 2010). A well-known typical effect of a 9. D'Alessandro P, Giuglietti M, Baglioni A, Verdolini N, musical experience is entrainment, the phenomenon by Murgia N, Piccirilli M, Elisei S: Effects of music on sei- which a musical rhythm resonates with cerebral rhythms zure frequency in institutionalized subjects with severe/ (Levitin 2006). Brain activity responds in different ways profound intellectual disability and drug-resistant to the different characteristics of musical stimuli (Xing epilepsy. Psychiatr Danub 2017; 29:399-404 et al. 2016); music can therefore be considered a power- 10. Dastgheib SS, Layegh P, Sadeghi R, Foroughipur M, Shoeibi ful agent of neuroplasticity given its ability to induce A, Gorji A: The effects of Mozart’s music on interictal activity in epileptic patients: systematic review and meta-analysis brain reorganization and favourably modify connections of the literature. Curr Neurol Neurosci Rep 2014; 14:420 between neuronal networks. In conclusion, our data 11. Devinsky O, Asato M, Camfield P, Geller E, Kanner AM, seems to justify further studies on Mozart effect as a po- Keller S, Kerr M, Kossoff EH, Lau H, Kothare S, Singh BK, tential add-on treatment for individuals with drug-resi- Wirrell E: Delivery of epilepsy care to adults with intellectual stant epilepsy, where standard pharmacological treat- and developmental disabilities. Neurology 2015; 85:1512-21 ments have not proven to be effective. 12. French JA, Kanner AM, Bautista J, Abou-Khalil B, Browne T, Harden CL, et al: Efficacy and tolerability of the new antiepileptic drugs II: treatment of refractory Acknowledgements: epilepsy. Neurology 2004; 62:1261–73 13. Greenberg R: Mozart: his life and music. The Great The authors wish to thank Sandra Cicuttin for her Courses, Chantilly VA, 2000 assistance in preparation of this manuscript. 14. Grylls E, Kinsky M, Baggott A, Wabnitz C, McLellan A: Study of the Mozart effect in children with epileptic Conflict of interest: None to declare. electroencephalograms. Seizure 2018; 59:77-81 15. Hughes JR: The Mozart effect. Epilepsy Behav 2001; Contribution of individual authors: 2:396-417 Chiara Bedetti: study conception and preparation, 16. Hughes JR, Daaboul Y, Fino JJ, Shaw GL: The "Mozart acquisition of data, drafting manuscript; effect" on epileptiform activity. Clin Electroencephalogr 1998; 29:109-19 Patrizia d’Alessandro, Antonella Baglioni, Marta Giuglietti, Domenico Frondizi, Marina Menna: study 17. Hyde K, Lerch J, Norton A, Forgeard M, Winner E, Evans preparation, interpretation of data; A, Schlaug G: Musical training shapes structural brain development. J Neurosci 2009; 29:3019-25 Moreno Marchiafava: interpretation of data; 18. Jackson CF, Makin SM, Marson AG, Kerr M: Non- Sandro Elisei, Massimo Piccirilli: revising manuscript. pharmacological interventions for epilepsy in people with intellectual disabilities. Cochrane Database Syst Rev 2015; 9:CD005502 References 19. Kuester G, Rios L, Ortiz A, Miranda M: Effect of music on the recovery of a patient with refractory non-convulsive 1. Altenmuller E, Schlaug G: Neurobiological aspects of status epilepticus. Epilepsy Behav 2010; 18:491–3 neurologic music therapy. Music Medicine 2013; 5:210–6 20. Kwan P, Arzimanoglou A, Berg AT, Brodie MJ, Hauser 2. Bangert M, Peschel T, Schlaug G, Rotte M, Drescher D, WA, Mathern G, Moshé SL, Perucca E, Wiebe S, French Hinrichs H, Heinze HJ, Altenmüller E: Shared networks for J: Definition of drug resistant epilepsy: consensus auditory and motor processing in professional pianista: evi- proposal by the ad hoc task force of the ILAE Commission dence from fMRI conjunction. Neuroimage 2006; 30:917-26 on therapeutic strategies. Epilepsia 2010; 51:1069–77

S570 Chiara Bedetti, Patrizia D’Alessandro, Massimo Piccirilli, Moreno Marchiafava, Antonella Baglioni, Marta Giuglietti, Domenico Frondizi, Marina Menna & Sandro Elisei: MOZART'S MUSIC AND MULTIDRUG-RESISTANT EPILEPSY: A POTENTIAL EEG INDEX OF THERAPEUTIC EFFECTIVENESS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 567-571

21. Lahiri N, Duncan JS: The Mozart effect: encore. Epilepsy 33. Maguire MJ: Music and epilepsy: A critical review. Behav 2007; 11:152–3 Epilepsia 2012; 53:947-61 22. Leaver AM, Van Lare J, Zielinski B, Halpern AR, 34. Merrett DL, Peretz I, Wilson SJ: Moderating variables of Rauschecker JP: Brain activation during anticipation of music training-induced neuroplasticity: a review and sound sequences. J Neurosci 2009; 29:2477–85 discussion. Front Psychol 2013; 4:606 23. Levitin DJ: This is your brain in music. The science of a 35. Patel DA: Music as a transformative technology of the human obsession. Dutton Penguin, New York, 2006 mind. Proceedings of the symposium at Music: Its Evo- 24. Lin LC, Chiang CT, Lee MW, Mok HK, Yang YH, Wu HC, lution, Cognitive Basis, and Spiritual Dimensions, 2008 Tsai CL, Yang RC: Parasympathetic activation is involved 36. Peretz I, Coltheart M: Modularity of music processing. in reducing epileptiform discharges when listening to Nat Neurosci 2003; 6:688-91 Mozart music. Clin Neurophysiol 2013a; 124:1528-35 37. Piccirilli M, Sciarma T, Luzzi S: Modularity of music: 25. Lin LC, Juan CT, Chang HW, Chiang CT, Wei RC, Lee evidence from a case of pure amusia. J Neurol Neurosurg MW, Mok HK, Yang RC: Mozart K.448 attenuates Psychiatry 2000; 69:541-45 spontaneous absence seizure and related high-voltage 38. Rauscher FH, Shaw GL, Ky KN: Music and spatial task rhythmic spike discharges in Long Evans rats. Epilepsy performance. Nature 1993; 365:611 Res 2013b; 104:234-40 39. Robertson J, Hatton C, Emerson E, Baines S: Prevalence 26. Lin LC, Lee MW, Wei RC, Mok HK, Wu HC, Tsai CL et al. of epilepsy among people with intellectual disabilities: A Mozart k.545 mimics Mozart k.448 in reducing systematic review. Seizure 2015; 29:46-62 epileptiform discharges in epileptic children. Evid Based 40. Sacks O: Musicophilia. Knopf Pub, New York, 2008 Complement Alternat Med 2012; 2012:607517 41. Särkämö T, Altenmüller E, Rodríguez-Fornells A, Peretz I: 27. Lin LC, Lee WT, Wu HC, Tsai CL, Wei RC, Jong YJ et al. Music, Brain, and Rehabilitation: Emerging Therapeutic Mozart K.448 and epileptiform discharges: effect of ratio Applications and Potential Neural Mechanisms. Front of lower to higher harmonics. Epilepsy Research 2010; Hum Neurosci 2016; 10:103 89:238–45 42. Schlaug G: Musicians and music making as a model for 28. Lin LC, Lee WT, Wu HC, Tsai CL, Wei RC, Jong YJ, Yang the study of brain plasticity. Progr Brain Res 2015; RC: The long-term effect of listening to Mozart K.448 217:37-50 decreases epileptiform discharges in children with 43. Schlaug G, Altenmuller E, Thaut MH: Music listening and epilepsy. Epilepsy Behav 2011a; 21:420-4 music making in the treatment of neurologic disorders and 29. Lin LC, Lee WT, Wu HC, Tsai CL, Wei RC, Jong YJ, Yang impairments. Music Percept 2010; 4:249-55 RC: Mozart K.448 acts as a potential add-on therapy in 44. Thaut MH, McIntosh GC, Hoemberg V: Neurobiological children with refractory epilepsy. Epilepsy & Behav foundations of neurologic music therapy: rhythmic entrain- 2011b; 20:490-3 ment and the motor system. Front Psychol 2015; 5:1185 30. Lin LC, Lee WT, Wu HC, Tsai CL, Wei RC, Jong YJ, Yang 45. Turner RP: Can a piano sonata help children with RC: Mozart K.448 listening decreased seizure recurrence epilepsy? Neurology Rev 2004; 12:13 and epileptiform discharges in children with first 46. Verrusio W, Ettorre E, Vicenzini E, Vanacore N, Caccia- unprovoked seizures: A Randomized Controlled Study. festa M, Mecarelli O: The Mozart Effect: A quantitative BMC Complement Altern Med 2014a: 14:17 EEG study. Conscious Cogn 2015; 35:150-5 31. Lin LC, Ouyang CS, Chiang CT, Wu HC, Yang RC: Early 47. Wan CY, Schlaug G: Music making as a tool for pro- evaluation of the therapeutic effectiveness in children with moting brain plasticity across the life span. Neuroscientist epilepsy by quantitative EEG: a model of Mozart K.448 2010; 16:566–77 listening - a preliminary study. Epilepsy Res 2014b; 48. Xing Y, Xia Y, Kendrick K, Liu X, Wang M, Wu D, Yang 108:1417-26 H, Jing W, Guo D, Yao D: Mozart, Mozart Rhythm and 32. Lin LC, Yang RC: Mozart’s music in children with Retrograde Mozart Effects: Evidences from Behaviours epilepsy. Translat Pediatr 2015;4: 323-26 and Neurobiology Bases. Sci Rep 2016; 6:18744

Correspondence: Chiara Bedetti, MD Istituto Serafico di Assisi Viale Guglielmo Marconi n.6 06081, Assisi, Perugia, Italy E-mail: [email protected]

S571 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 572-573 Conference paper © Medicinska naklada - Zagreb, Croatia

GENIUS AND MADNESS BETWEEN NORMALITY AND PATHOLOGY Giuseppe Stranieri Mental Health Department, Catanzaro, Italy

SUMMARY It is reasonable to affirm that madness is inborn with the human spirit and that only in lunacy it is possible to be creative, being the intellect a system of rules that make possible to live with the least conflict possible, as masterfully said by Umberto Galimberti. To understand madness we must glean our lunacy and put aside the reason which relates to the non contradiction principle thus being not capable to comprehend madness that does not respond to the rational principles, whereas as Schopenhauer says, is the essence and the strength of the will to live.

Key words: genius – madness – trascendence – normality - pathology

* * * * *

Perhaps in any shape, in any state the world through what Schopenhauer calls principium Inside one’s lair or cradle, individuationis are at the origin of all the sufferings, the The day of birth is dreadful to those who were born. struggles and the worries that life saves us, as one can (from: Night song of a wandering shepherd well understand. in Asia – Giacomo Leopardi) In art man expresses his true essence with its grave- ness, its creativity and its pain, detaching himself from In As if the world ended E. Borgna affirms: psychiatry external reality and from pure phenomena. We can thus as a frontier science must be denied in its raison d’être understand why in critical-artistic contemporary litera- of natural science, it goes beyond the categories in the ture the relationship between art-therapy/ art-pain is one context of the human sciences and the sciences released of the most recalled, used and abused, especially since by the reason. Only by denying itself as a (natural) the artistic avant-garde with Dada and Surrealism pri- science and by re-emerging radically criticizing any marily from the sixties on, the artists sympathized with objectification of the other from oneself, it places itself the Unconscious and then exalted its most morbid beyond any ideology and re-found itself as a human features. Certainly, the artist is not a genius as a lunatic, science. If we intend psychiatry this way and consider he has already in himself some sort of talent, but it is the man as a person and not as an individual, as a body- also surely true that talent, thanks to madness, reaches organism, a man as a body and mind, we will be able to peaks of brilliant authenticity. As Jasper wrote, “just as see beyond the phenomenon the essence of a person in the pearl is born from a flaw of the shell, schizophrenia its transcendence, its creativity and its pain for being in can give birth to incomparable works”. this world. Only in this context we may understand the Tracing a clear line of demarcation between norma- close proximity between art and madness, art and pain, lity and pathology seems therefore impossible. What melancholy and happiness. differentiates the artists and the lunatics from the A great philosopher of the nineteenth century which ordinary mortals is the ability of the first ones to name is Arthur Schopenhauer in his main work The approach “transcendence”, the “demonic” and the world as will and representation writes that the origi- impossible that inhabits every human existence. So, as nating essence of every phenomenon and every indivi- much as contemporary art continues to programmati- dual is the will. It is nevertheless, an irrational and blind cally sympathize with the Unconscious, sometimes esta- will, a pure and uncontrolled will to live. In fact, for blishing with it in the worst cases an almost scholastic Schopenhauer the irrational or blind will dominates our calendar, it is clear that there are wide boundaries of mind and the world is equally divided between wicked- meaning between art and psychological disorders and ness and madness. The will leads all human beings to between art and particular interpretative psychoanalytic fear death or “nothing”, for they transcend every theories; despite the fact that psychoanalysis helped us evaluation of life, over the good and the evil that destiny to scrutinize the abysses of the human soul, the same saves us, or over what awaits after our death. It is ones that art seems unable to totally and autonomously equally irrational the general behaviour of men induced lead to the climax. by will, because man, despite his intellect, is constantly Another contemporary philosopher Umberto Galim- prone to the domain of an irrational and tyrannical will, berti, writes in Psychiatry and phenomenology: in the his rationality is thus not independent nor “free”. These body-organism classic psychiatry has built itself, so, in features that the will assumes when it objectives itself in front of a man what is discovered is not his way of

S572 Giuseppe Stranieri: GENIUS AND MADNESS BETWEEN NORMALITY AND PATHOLOGY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 572-573 being in the world but the damages or the flaws of his functioning or between genius and madness, because organism, the disturbances of his performances and his both represent the extremes of a continuum on which functions. In this way classic psychiatry does not multiple elements act, including the psychic resources understand man, but it “explains” him, that is, it reduces of the individual, the environmental factors, the genetic him to his own reference system which is the substratum and the early relational experiences. naturalistic one, which in order to guarantee objectivity We must favour then, a system based on prevention is forced to resolve all existence into some thing. It is and dialogue, mitigating the tendency to the exclusion therefore reasonable to assume that madness is inborn of diversity and acquiring the awareness that the human with the spirit of the human being and that only in being is characterized by factors of vulnerability and lunacy it is possible to be creative, being the reason a weakness that could however evolve into elements of system of rules in order to manage the coexistence with resource. the least possible conflict. To understand madness we must glean our lunacy and put aside the reason, which relates to the non contradiction principle, thus being not Acknowledgements: None. capable of comprehend madness that does not respond to the rational principles, whereas as Schopenhauer Conflict of interest: None to declare. says, is the essence and the strength of the will to live. Then art, as a form of free and disinterested knowledge on the part of the genius, who oblivious to his References own individuality and a bit crazy himself, addresses to 1. Borgna E: Come se finisse il Mondo. Feltrinelli Editore, ideas (eternal models of the things) by contemplating or 2015 by grasping them while reproducing them as universal 2. Jaspers K: Psicopatologia Generale. Il Pensiero Scienti- aspects of reality, regardless of the practical (instinctual) fico Editore, 2000 needs of the will, and thus finding a way to overcome 3. Kierchegaard S: La Malattia Mentale. Sansoni Editore pain. We can think of the boundary between normality Firenze, 1965 and pathology as a subtle thread on which we try to 4. Galimberti U: Psichiatria e Fenomenologia. Feltrinelli juggle like a tightrope walker. Editore, 2006 To conclude, we can state that there is no rigid line 5. Schopenhauer A: Il mondo come volontà e rappresenta- of separation between pathological traits and normal zione. Mondadori Editore, 1989

Correspondence: Giuseppe Stranieri, MD Mental Health Department Via Milano 28 – 88024 Girifalco, Catanzaro, Italy E-mail: [email protected]

S573 Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 574-576 Conference paper © Medicinska naklada - Zagreb, Croatia

THE PERSISTING SADNESS, AN INCLINATION TO BECOME EMOTIONAL: THE CASE OF INSPECTOR RICCIARDI GIFTED WITH THE CAPACITY TO FEEL PAIN Marcello Nardini & Immacolata d’Errico Bari, Italy

SUMMARY Through the analysis of “Luigi Alfredo Ricciardi” the main character of detective series by Maurizio De Giovanni, the structuring of a normal melancholic constitution, which we term the depression-prone style of personality, is reconstructed.

Key words: detective series – depression

* * * * *

"The laceration caused by Rosa's death in his life, Rosa remembered that when the young gentleman Ricciardi thought, would never be healed. It would have was a child, there was a group of bad guys in the village left an open scar, ready to bleed... A dull and pulsating who bullied him ... laughing as he passed ... Luigi pain, ready to be renewed again and again. He had Alfredo suffered a lot, even if he never spoke about it, finally understood, having made friends with suffering and she realized this from the sad look he had every since he was a child, how terrible it was to endure a time he went back home after having meeting with them. loss like that." Rosa, trying to settle the situation, went to talk to the (extracted from “Anime di vetro”, head of the boys settling the situation with a couple of by Maurizio De Giovanni) slaps. Since then it had not happened that the young Luigi Alfredo Ricciardi, son of the Baron Ricciardi gentleman was mocked, but they called for him less and di Malomonte and Lady Marta, was born in a small less: perhaps the cure had been worse than the disease." village in Cilento. The year of birth is 1900. “And my (extracted from “Il posto di ognuno”, childhood …I was the son of the baron, I didn’t have by Maurizio De Giovanni) many friends. I used to spend my time playing alone, The secret feature of inspector Ricciardi, which he daydreaming about scenarios taken from fairy tales told calls "the Done", is the ability to perceive the last words by Rosa and Mario, the farmer". " And my mother used and all the pain of the victims of violent death. "I see the to read pages of books in the evening.... We did not talk pain. I see the regret, the suffering. I hear the echo of the much and we looked at each other a lot .... But she died love that disappears, the claws that break in the anxiety ... a long time ago. She was insane, perhaps ". " I went of holding back the last part of the life that is going away. to a boarding school, managed by priests. Mass, I hear the scream that accompanies the fall into the abyss." Vespers, spiritual exercises. So many words." (extracted from “Il senso del dolore”, (extracted from “ Il senso del dolore”, by Maurizio De Giovanni) by Maurizio De Giovanni) "Your legacy, mother. Your terrible gift. The con- “…Enigmatic figure, the inspector Luigi Alfredo demnation you inflicted on me, which I carry on me like Ricciardi, the baron of Malomonte. ... the late father ... a cross. ... And he felt all together the scars on his heart died in the prime of life ... the mother, a delicate girl and soul, as if they were fresh wounds: they bleed and with green eyes ... retired to the meanders of the lower they would still bleed." Cilento before dying from a serious illness of nerves. ... (extracted from ” Serenata senza nome”, And Luigi, a taciturn ... in boarding school, managed by by Maurizio De Giovanni) the Jesuits, always setting aside, a little frightening, was We have chosen the main character of Maurizio De therefore ignored by everyone." Giovanni's detective series as a significant and peculiar (extracted from “Serenata senza nome”, figure with a particular way of feeling due to a chronic by Maurizio De Giovanni) eliciting and a constant activation of those basic emo- “But the social distance - in the village of the lower tions which are relevant to both depression and bereave- Cilento - was not a good premise for friendship; ment: sadness and anger. A way of feeling, due to the therefore Luigi Alfredo preferred to spend his time with sedimentation of this tonality over time as a character Rosa, the nanny. ... The child ... surrounded by trait, may predispose to develop a temperate melan- imaginary friends and enemies, fought loneliness with cholic constitution or (according to the language of post- fantasy ... " rationalist constructivism) to a depressive-prone style of (extracted from “Il posto di ognuno”, personality (tDD). From the analysis of the Ricciardi by Maurizio De Giovanni) character there are no traits and signs that can make us

S574 Marcello Nardini & Immacolata d’Errico: THE PERSISTING SADNESS, AN INCLINATION TO BECOME EMOTIONAL: THE CASE OF INSPECTOR RICCIARDI GIFTED WITH THE CAPACITY TO FEEL PAIN Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 574-576 think of a depressive personality disorder (DPD) or a A recurrent triggering of the above-mentioned life chronic depression on an affective basis. The keys point themes, sedimented over time, inclined the young Luigi that allows us to discriminate a tDD from a DPD is the toward a contest of reference that is mainly focused on individual’s capacity to disengage from the situation states of sadness and anger and anxiety, whose constant that generates sadness by grasping this affective states activation anchored him to a body-centred reference not as destructive emotions, but as sources of meanings, system that allowed him to focus on inward signals, on so that the understanding of himself generates new internal polarization, on visceral states. Hence, the struc- possibilities of engagement with himself, with others turing of the personality will be progressively declined and with the world. The person with this type of perso- according to narrative themes necessarily coherent with nality perceives himself through emotional states such the constant activation of these emotions. Thus the ways as sadness and anger that become ontological in the of being-in the multiplicity of experiences will be mostly constitution of his being-in-the-world, but also pos- directed by a visceralness of sadness and anger that, in sesses the capacity, in order to change the negative being then reconfigured according to themes of lone- emotional states through which he perceives his situa- liness, impotence and inadequacy, will progressively tedness, to generate new possibilities of meanings. The develop a personal identity as the tDD (Arciero 2009). crucial discriminant is this: the ability not to fall prey to “He had always been a gloomy and silent man, allowing sadness and anger. And absolutely one of the most himself at most some sharp, sudden irony." important variables that mostly determines the beco- (extracted from “ Anime di vetro”, ming a prey and a slave to one's restlessness, subtracting by Maurizio De Giovanni) from oneself the freedom to be, is the intensity of the Ricciardi is “ontological solitude” and “ontological experience of rejection in the course of development. unacceptability”. Because of his enduring disposition Extraordinary contributions to explaining the genesis of towards sadness he is kept at a distance by colleagues depressive-prone style of personality have been made and subordinates, except Maione and Modo. It is this by psychoanalysis and the attachment theory by brin- “excess of inwardness” that gives that feeling of ging to light that a chronic condition of lack of care – election and “that makes solitude and uniqueness ranging from indifference to detachment, disdain, hosti- coincide: being unique makes one feel one is alone. Also lity and abuse – loss, separation, contempt may affect deriving from this excess of inwardness is a difficulty in the development of one’s personality, to the point of communicating: almost a feeling of shame to present making it more vulnerable to depression. The above one’s being to others, which makes one feel alien, like mentioned experiences seem to indicate that a dysfunc- an exile in the world” (G. Arciero, 2009). Indeed De tional parental style – in Ricciardi’s case, the dynamic Giovanni tells us that Ricciardi "had no friends, wasn’t and affective father died when Luigi was 3 while his seeing anyone". “The mode of feeling situated corres- mother is described as beautiful and sad - elicits emo- ponds to an attitude of mistrust toward the world and tional reactions that, sedimented over time, carry within particularly toward others, perceived as possible them the power to "mean" silently, thus inclining the sources of intolerable emotions” (Arciero 2009). child’s feelings towards a reference context focused more His emotional life is empty, though he loves Enrica at or less on states of sadness, anger and anguish. However, a distance, a shy neighbor a few years younger than him, only in the case of enduring situations! In fact, an early with whom he only exchanges glances through the win- loss is not enough to prepare for melancholy. dow, not knowing that in turn he is observed by the girl. As we can see during the reconstruction of the child- Rosa, his nanny/housekeeper says: "You have to hood and youthful experiences of the young Ricciardi, know that in character he is a little closed, how you say ... the themes of loneliness, sadness and anguish, emo- reserved, shy. In short, he is not the type that comes for- tional and physical distance from the parental figure ward easily. In my opinion, he’s afraid of being rejected" recur: “And my childhood ... I was the baron's son, I did (extracted from “Il giorno dei morti”, not have many friends. I spent my time playing alone ". by Maurizio De Giovanni) The father, who is described as a lively man, died when And Luigi: "This is me, Enrica. A man fated to walk his son was 3 years old, leaving him alone with a in pain, to be deafened, softened, suffocated. What can beautiful and sad mother, with big desperate green eyes, someone like that give you? What kind of life? What who used to read pages and pages of books, but we can kind of love?” (extracted from “ Il giorno dei morti”, by infer, very reserved, sad and with poor physical contact Maurizio De Giovanni); "loving someone means to want with the child. “But she died ... a long time ago. She was his or her own good ... when you are sure you are evil, insane, perhaps ". " I was in a boarding school, managed you must move away" (extracted from “ Anime di by priests. Mass, Vespers, spiritual exercises. So many vetro”, by Maurizio De Giovanni). “If only you knew words". ”…And Luigi, a taciturn ... in boarding school, what hell I had in my heart, and how much I would like managed by the Jesuits, always setting aside, a little to stand by you like any other man" (extracted from “ In frightening, was therefore ignored by everyone”, and fondo al tuo cuore”, by Maurizio De Giovanni). “That further the social distance in the village of the lower man, you know, feels a very strong feeling. But he is Cilento that was not a good premise for friendship. terrified of it, because he sees the effects of that feeling

S575 Marcello Nardini & Immacolata d’Errico: THE PERSISTING SADNESS, AN INCLINATION TO BECOME EMOTIONAL: THE CASE OF INSPECTOR RICCIARDI GIFTED WITH THE CAPACITY TO FEEL PAIN Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 574-576 on everyday life. And he thinks that keeping it then out of his life, and keeping him out of the lives of people who Acknowledgements: None. ... of the people who are dear to him, is the best way to do them good. That's all. And for this reason, perhaps, he Conflict of interest: None to declare. keeps away, in the terrible hope of being forgotten; and in the knowledge that being forgotten would kill him " Contribution of individual authors: (extracted from “In fondo al tuo cuore”, by Maurizio De Giovanni) Marcello Nardini reviewed it and wrote the final version of the paper; As we can see, the initial attitude towards the affec- Immacolata d’Errico wrote the first draft of the paper; tive relationship is to feel fear / avoidance in order to reduce the risk connected to the uncontrol of rejection or loss, but as the relationship stabilizes and the link can no longer be ignored, he will change strategies to reduce References the danger related to involvement. In the final novel of 1. Arciero G & Bondolfi G: Selfhood, Identity and Perso- the detective series, the inspector will recognize Enrica nality Styles. Wiley-Blackwell, 2009 as reliable after confiding her his deep despair and the 2. Arciero G, Bondolfi G, Mazzola V: The foundations of pain of his soul, and then she will welcome him by Phenomenological Psychotherapy. Springer, 2018 promising to him eternal love. 3. De Giovanni M: Anime di vetro. Einaudi, 2017 Finally, let us ask what has allowed inspector 4. De Giovanni M: In fondo al tuo cuore. Einaudi, 2017 Ricciardi not to develop a depressive personality 5. De Giovanni M: Il giorno dei morti. Einaudi, 2017 disorder? Rosa says: "My young gentleman took all the 6. De Giovanni M: Il senso del dolore. Einaudi, 2017 love I had in my heart" ... " I held my young gentleman 7. De Giovanni M: Serenata senza nome. Einaudi, 2016 much more than the baroness herself." 8. De Giovanni M: Il posto di ognuno. Einaudi, 2017 (extracted from “ In fondo al tuo cuore”, by Maurizio De Giovanni)

Correspondence: Marcello Nardini, MD psychiatrist via Prospero Petroni 30, 70121 Bari, Italy E-mail: [email protected]

DEPRESSION AS A "COMORBIDITY" OF A DISORDER NOT RECOGNIZED IN ADOLESCENCE Ivan Urliü Medical School and the Academy of Arts, Univesity of Split, Split, Croatia

SUMMARY Depression is one of the most frequent mood disorders. The spectrum of its meanings is very complex. Symptoms of depression can be felt at every stage of life. Depressed mood states can, as for intensity, show the clinical picture that varies from mood changes to psychotic states. In this presentation, it is described a case of the patient who since early childhood showed the symptoms of ADHD that was showing as a comorbidity feelings of depression, which have significantly hindered the emotional maturation of the person. This etiological clarification has led to effective treatment, including the psychopharmacological and psychotherapeutic approach.

Key words: depression – comorbidity - ADHD * * * * *

INTRODUCTION position, giving these concepts a meaning that is not only universal, but that holds true throughout life Times change and we change with them, says the (Chronis-Tuscano et al. 2013). old Latin wisdom. Today these changes have gotten so There is not always a clear transition between mood much acceleration that it is difficult to explore all the swings and depression, depressive reactions, and de- symptoms of this phenomenon. In the human sciences, in pressive states that turn into a crisis, and even psychotic general, we can say that the more we follow these chan- states. It is the merit of Emil Kraepelin to have intro- ges in order to recognize and understand them more we duced the term 'depression' between psychiatric and are able to predict them. These changes, coming from the psychological concepts, which replaced the previous broad social spheres, have permeated the family and the term 'melancholy' (Reus 1995). Today, 122 years after individual, deeply influencing and changing the traditio- the publication of his capital work, the concept of nal ways. For example, with regard to serious mental depression that characterizes mood and thought is now disorders it is considered that in the population there is part of usual terminology. Despite numerous clinical and about 1% of people with disorders from the schizophrenic neuroscientific research, the question of the complex circle, and people with disorders of emotional regulation and multifactorial etiology of depression can not yet be (bipolar, cyclothymic) 0.5%. However, it has been shown answered. In studying the causes of depression in recent that affective dysregulation is much more frequent, so years it has been widely recognized that not only is that depending on some new research it would represent depression very poorly recognized and rarely treated up to 3.5% of the population. These data are not unexpec- adequately, but that the control of behaviour and attention ted in the situation of increasingly demanding requirements disorders in children can continue later in life. This article that technological advances and scientific knowledge put focuses on such cases, where the symptoms of uniden- before an individual, a family, a group and a society (Ami- tified ADHD in children pass unrecognized during the haesei & Zamfir 2016, Young et al. 2015, Daviss 2008). adolescent period and continue into adulthood. For a human being it is increasingly difficult to res- Because the etiology of ADHD is unclear, it is assu- pond adequately to the ever more complex needs and med that the genetic and neurophysiological basis is expectations of the environment and of him/her/self. very important. Environmental factors are considered One could imagine that such situation "haunts", putting less important (Bond et al. 2012, Gerdes et al. 2007). a continuous pressure on us and that for this reason we ADHD in adults is often recognized due to perma- often feel unhappy. nent anxiety and depressed mood that patients complain In Melanie Klein's conceptualisation such a situation of, and that a number of patients describe this as the would be called paranoid-schizoid (Segal 1986). When reason for the use of illegal psychoactive substances in we experience that we can not accept everything and order to alleviate the symptoms. that we can not always respond adequately, appears the Difficulty in adjusting behaviour and impulse con- depressive position in which we need to feel sorry for trol, with greater distractibility, difficulty in controlling what we lose and what we can not reach (Urliü 2013). emotions, with increased anxiety, depression, easy mood This gives us the opportunity to evaluate the inner and changes, and the low self-esteem of people with ADHD outer reality more appropriately and to adapt to it. The is hard to bear. This is reflected in the difficulties of followers of Melanie Klein this concept have extended establishing and maintaining relationships with others to permanent oscillations between one and the other (Bramham et al. 2009, Rostain & Ramsai 2006).

S577 Ivan Urliü: DEPRESSION AS A "COMORBIDITY" OF A DISORDER NOT RECOGNIZED IN ADOLESCENCE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 577-581

Studies show that ADHD appears in 3-5% of pupils, high distractibility he obtained mediocre school grades. and in 2-4% of adults, and that is 2-3 times more com- He decided to study medicine to help others, but be- mon in males. The research shows that there are no cause of the grades he could not enroll at any university significant differences in different cultures (Gerdes et al. in his country and chose to study abroad. 2007). In ICD-10 the disturbance is encoded as F-90.0. In Croatia, the situation repeates itself, and the new In childhood and adolescence the playfulness, the environment has not diminished his despair because he cheerful character, should be distinguished from ADHD could keep the newly acquired knowledge only with by taking a detailed medical history. It is important to difficulty. In spite of the great efforts in learning he note that in the case of ADHD, the child or adolescent used to obtain a very mediocre grades in the exams. suffers greatly from symptoms of the disorder. So, the This situation helped motivate him to seek help from a psychic functioning doesn't encompass only playfulness psychiatrist in another country and a better understan- or cheerful mood. The suffering of a child or adolescent ding of what was happening to him. He said that he was causes an unfavorable image of him/her/self, resulting often depressed and that his moods and thoughts had in low self-esteem. The environment usually reacts in a been sad since childhood. I will expose his moods, restrictive and aggressive manner. Unawareness and reflections and experiences not only through his story, inadequate approach to this disorder result in the but also through his dreams. absence of treatment or in inadequate treatment of the The first dream disorder, and in a very unfavorable effect on the development of the child or adolescent, exerting unfavor- A student party. He does not like the atmosphere, able impact on education and the formation of his/her does not find close friends, then goes out to the resting personality. place of a large staircase. He passes through an open There are three types of ADHD: door of a school class and sees 15 dead pupils, lying on the benches and the floor ... He passed beyond this combined type (inattention, hyperactivity – impulsivity); scene without feeling strong emotions, rather indifferently. Than he goes down the stairs and meets a type predominantly distracted; solitary figure of an old man dressed in white, who predominantly hyperactive - impulsive type. appears as descended from the paintings of the ancient To demonstrate difficulties that an emotionally im- prophets ... This figure tells him nothing and does not mature person with ADHD experiences and think on the look at him in his face ... He looks like his father... consequences that may affect emotional maturation and Semir continued to go down the stairs and behind a the adaptation process for a lifetime, I will present a glass wall he sees a scene in his house - around the paradigmatic clinical example for this disorder, and the table there were sitting his mother and his younger role it can have in the general framework of depression, brother, commenting on something. He can not hear anxiety and restlessness. what they say, and they do not even take no notice of him... he wakes up very amazed. CLINICAL EXAMPLE: In the first place Semir deals with an encounter with THE CASE OF THE PATIENT SEMIR a person who looks like his father and says that it is not surprising that this person says nothing because his father is a very taciturn and withdrawn person. He still The patient Semir comes in search of help for his says it is strange that the mother and younger brother symptoms, which have accompanied him since child- speak together, because the brother is very withdrawn hood. The psychotherapist's address he found on the too, spending a lot of time in his room, alone, listening Internet. He comes from Northern Europe and studies to the music. With him it is difficult to establish any medicine in English in Croatia. He originates from the dialogue ... his mother is much more accessible. You Middle East. When he was a young child the family had can talk to her, but she does not seem to have much moved to Europe. The education of Semir and the patience to talk to him, especially lately. company of the local peers developed in him a sense of belonging to the European culture, rather than according Then Semir fell into a long silence. He seemed anxious, worried, and remained motionless. the impact of the traditional culture of his parents. He did not suffer from any diseases he could remember. He Comment: I suggest that the initial image of a was a healthy boy. However, he was constantly restless student party in which the patient does not find a place and with difficulty in keeping his attention in com- for himself and does not meet the people with whom he parison to his peers. For this reason he had lower grades would have gladly entertained, perhaps transmits his and was aware of having to learn longer than his com- experience that accompanies him from early childhood, panions. He had been constantly warned to calm down, that he is different from others and that others find it to behave decently and to be attentive in the school. difficult to accept him. Probably, this also applies to the Those warnings and criticisms echoed in the house, difficult acceptance of him not only on the side of where his parents were warning him in the same way, as others, but also others of him who is constantly reste- well as his friends. Because of constant restlessness and less, anxious and absent-minded.

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The following scene is an image of 15 students dead Semir says that he feels very excited when he hears in a class. He passes by that class without any disturbed the interpretation of the content of his dreams. He feelings, as if he were accustomed to the experience of recognizes his experiences, and is surprised because he losing. As if this number "15" represented the 15 years could never imagine that in his dreams, which he often that he used to fight with the symptoms of inability to perceives as absurd appearances, relive his profound maintain the attention and physical expression of experiences, fears and the sensation of not being pro- inability to control physical activity ... In the dream he perly understood. remembered the figure of the father in relation to the After holidays that he spent at home, he came back white figure that he meets at the stairs. The dream quite disappointed. His parents and brother treated him describes his father as a solitary person, who did not very carefully. This made him feel very sad. He did a know how to participate in the difficulties of Samir. detailed neuropsychological examination. The results An image behind the glass follows, a family meeting indicated that he is a very intelligent and very sensitive between the mother and the younger brother. It shows person, and that he shows a high level of anxiety and that in his experience the mother is more oriented depression. As a fundamental diagnosis, the diagnosis towards the younger child. of ADHD was outlined. With tears in his eyes Semir says that he could not He says he felt very loaded at home. Relations bet- imagine that his memory and his experiences were so ween the parents were very tense. The mother was very intertwined in his inner world that even during the night active in her work and at home, while his father was he was experiencing all the difficulties he constantly coming home in silence, was locking himself in his room was facing. The comparison with the images of the and was spending hours reading. The younger brother dream stimulates numerous associations of episodes avoided contact and closed himself in his room. He was from school and family experiences. very patient. He expected that the psychological finding, The dream seems to convey his experiences that no which confirmed that it was an ADHD, will arouse grea- one understands him and that he is rejected because of ter interest in his psychic situation. However, everything his constant restlessnes and distraction, so everyone was remained on the critical comment of his mediocre study always criticizing him. results, with the remark that he should be more diligent. The clinical image indicates a distraught, depressed, He returned sad and the morning of the day of the etiologically most likely young man with symptoms psychotherapy session dreamed of the following dream: most probably associated to ADHD. The psychological The third dream tests and the lithium blood test were also indicated to In his house he sees a big, old and very hairy dog. exclude a possible cyclothymic type disturbance. His family tells him that they bought the dog to eat it. At the next session Semir brings the following dream: He is very surprised because they do not eat dogs or The second dream cats ... he is very anxious and wakes up. Spontaneously he continues to explain that in recent Semir is not seen as a figure in the dream but is like days, as in recent months, he was worried about rela- an eye, like a camera, and he knows that it is he who tionships with friends and students. Some are very sees the scene and experiences the event. overwhelming, irritable, inaccessible. They tell him that He is with a girl at a party. They seem to be sepa- he should not take medication and visit the psychiatrist rated from others, and he also feels he must pay special because everyone will say that he is crazy, that he is lost attention to her so as not to offend her, showing some- his way ... Generally, some of his friends he feels to be thing like negligence... He is always busy with himself, very arrogant and that their company no longer satisfies he can not relax. He does not want others to perceive him. He decided not to take care of them anymore and his difficulties in controlling his behaviour... Next scene: to find new friends. they are with friends in the café-bar. He has a sense of alienation and worry. He is not like other peers ... Comment: In that dream, as well as in reality, he Spontaneously he continues to talk that in the mor- feels anxiety because he can not imagine absorbing, ning he woke up with a sense of dissatisfaction. He 'swallowing', the arrogance of old friends and their should travel home. There he should do the neuro- offensive behaviour. That hurts him. He will leave old psychological testing. He's worried about what his friends because for him they have become 'indigestible' family and friends will say, because he's got very and will turn to new ones, and will keep only those that mediocre study results ... he wants to be a good doctor, inspire joy and sense of satisfaction ... Maybe it is a shift of feelings of bitterness from parents to friends? help people, but he's afraid he will not succeed because he's not a particularly successful student... Semir says that his parents' behaviour is inadequate. As well as teachers in schools and doctors, they did not Comment: Semir is followed by a constant feeling pay enough attention to his symptoms and left him alone that is different from his peers, that he is often with the symptoms of constant agitation and difficulty in misunderstood, and that is not helped enough. These concentration, which is why he always had fairly modest thoughts are accompanying him constantly. He feels grades and he could not enroll in medical studies in his envious of peers who do not have such disorders. country. This make him feel badly, as well.

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Asked to say something about his parents who so far of himself. Semir asked him what he was feeling, but his he failed to express, he says that his father lost one leg father did not give any answer. He felt a deep pain in war, putting his foot on a mine. This happened before within himself and woke up in tears ... arriving in Northern Europe. The father is a man, help- He continues that he talked with his mother about less, distant, too quiet, with whom it is difficult to estab- the possibility that the father suffered from PTSD. For lish close contact. On a recent visit home he was very holidays he was planning to go home. When he talked worried because his mother wanted to get divorced and to her mother she no longer mentioned divorce and "start to live". about father she spoke with more empathy and According to some new data regarding his parents, understanding... Previously he was going home hoping especially that the father has been living with the for recognition in relation to the change in behaviour artificial leg that goes back to above the knee, already related to the results of the treatment, but nothing like for many years, and that he has probably developed the that happened. Now he awaited for a different complex PTSD, with permanent personality change, and atmosphere in their relationship. that trauma in him remain closed, encapsulated, in order to enable him to survive the most vulnerable part of his Comment: I say that the images of this brief episode psyche. He probably does not talk about trauma, not even of dream that he had brought was impressive in the with his wife, and she does not even know how much sense that he could empathetically approach his father, pain he feels inside himself... "Try to imagine, when the identifying himself with his unrecognized pain, closed parents are in intimate relationships, how he could appear in his inner world... Semir remained silent and in tears when only the rest remains of the leg, a stump, remains in he finished that session. place of a leg..." (Boumans et al. 2017). Semir's reaction was a painful grimace and tears. FINAL CONSIDERATIONS We talked about the possibility of talking with the mother because the father does not remain without Depressive feelings, accompanied by feelings of being understood, as Semir was feeling from his early futility and inferiority towards other peers, which in the childhood. patient's eyes were confirmed with constant critical After the diagnosis of ADHD was confirmed Semir warnings, now had to be psychologically, emotionally reacted positively to the introduction of methylpheni- and rationally elaborated and understood in depth. His date therapy. He took the pill with a prolonged effect memories the patient expressed with great bitterness, very early on Sunday morning, fearing unknown effects. and complained of many years of suffering and diffi- After two hours he felt a wave of relaxation and en- culty due to unrecognized disorder. This was reflected couragement towards a more cheerful mood. He could significantly on his life and relationships, with a sit and study, and he could concentrate on the content. constant desire for better understanding and love. He He was very happy and continued with the same wanted to study medicine because he wanted to help activity in the afternoon. The next day, in the classroom, others. In fact, he seemed to have had a preconscious he could sit still and concentrate on the lectures. While desire to help himself, but he received only warnings the days were passing on, he was feeling more and more and criticism. However, he did not give up. Becoming a relieved of unrest, fears and loss of concentration. His student in another country, he sought help (Bramham et friends noticed the changes. An even better result was al. 2009). reached with the median dose of the drug. He reported The ever better understanding of the neurophysio- this with some uneasiness, because he thought that our logy of the brain, the psychodynamics of development, psychotherapy sessions would be interrupted because and the functioning of the personality, whose conse- the result had been achieved. quences can create disturbances especially on the emo- However, from the first dream through the contents tional side, are at the center of psychiatric research. presented persists the experience that the patient is not Work in the field of mental health assumes that psycho- understood and that is not helped, and that he has not logical phenomena must be approached in a complex deserved a constant critical attitude towards his beha- and comprehensive way. viour and his results of mediocre grades. He did not feel This means that we must always remember that able to do more about his studies than he was trying to psychiatry is based on three pillars: biological, psycho- do, but the result was quite modest. Now he was about logical and social (Gerdes et al. 2007, Rostain & to return home with a desire for recognition of change Ramsay 2006). The ever better understanding of the and to get the support and praise for the calm attitude components of mental functioning, which even Freud and good grades that he started to obtain in the Medical as a neurologist assumed that essentially are based on School. neurophysiological processes and relationships with the environment, require a thorough psychological The fourth dream analysis of feelings, experiences and relationships, in Semir claims to have talked with his father in the order to be able to evaluate a person's capacity for dream. He has not seen himself. His father was sitting in intrapersonal, interpersonal and social functioning his chair with a book on his knee, silent, looking in front (Goodman & Thase 2009).

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The popular saying of the Native Americans states therapy for adults with ADHD. J Atten Disord 2009; that no one should ever judge a person if he has not 12:434-41 been in his shoes for at least three weeks. This recog- 5. Chronis-Tuscano A, Clarke TL, O'Brien KA, Raggi VL, nition of the importance of empathy and partial iden- Diaz Y, Mintz AD, Rooney ME, Knight LA, Seymour KE, tification is the basis for access to people suffering Thomas SR, Seeley J, Kosty D, Lewinsohn P: Development and preliminary evaluation of an integrated treatment from mental pain. This is especially true for people targeting parenting and depressive symptoms in mothers overwhelmed by anxiety and depressive feelings, of children with ADHD. J Consult Clin Psychol 2013; which must be addressed and presented. Or, as Marie 81:918-25 Curie said: "Nothing in our lives must be feared, we 6. Daviss WB: A review of co-morbid depression in pediatric just have to understand." ADHD: Etiology, phenomenology, and treatment. J Child The assessment of the importance of some etiolo- Adolesc Psychopharmacol 2008; 18:565-71 gical factors in the appearance and development of de- 7. Gerdes AC, Hoza B, Arnold LE, Hinshaw SP, Wells KC, pressive disorders requires the search for specific Hechtman L, Greenhill LL, Swanson JM, Pelham WE, elements that lead to mental decompensation. The only Wigal T: Child and parent predictors of perceptions of parent – child relationship quality. J Atten Disord 2007; reconstruction of the traumatic experiences is not 11:37-48 enough (Herman 1992) to elaborate the trauma and its 8. Goodman DW & Thase ME: Recognizing ADHD in adults consequences. First of all, it is necessary to elaborate with comorbid mood disorders: Implications for identi- the sense of loss, to raise trust in oneself and to open fication an management. Postgrad Med 2009; 121:20-30 new perspectives (Urliü et al. 2013). 9. Herman JL: Trauma and recovery. New York: Basic Books, Inc. 1992; 183-195 10. Reus VI: Mood disorders. In: H.H.Goldman (ed.), Review of General Psychiatry. Appleton & Lange 254-265, 1995 Acknowledgements: None. 11. Rostain AL & Ramsay JR: A combined treatment approach for adults with ADHD – results of an open study of Conflict of interest: None to declare. 43 patients. J Atten Disord 2006; 10:150-9 12. Segal H: Melanie Klein's technique. In: The Work of Hanna Segal., London: Free Association Books, 1986; 10-14 References 13. Torrente F, Lopez P, Alvarez Prado D, Kichic R, Cetkovich- Bakmas M, Lischinsky A, Manes F: Dysfunctional cogni- 1. Amihaesei IC & Zamfir CL: ADHD – a troubling entity, tions and their emotional, behavioral, and functional cor- sometimes perpetuating during adult life. Rev Med Chir relates in adults with ADHD: is the cognitive-behavioral Soc Med Nat Iasi 2016; 120:10-4 model valid. J Atten Disord 2014; 18:412-24 2. Bond DJ, Hadjipavlou G, Lam RW, McIntyre RC, 14. Urliü I, Berger M, Berman A: Victimhood, vengefulness, Beaulieu S, Schaffer A, Weiss M: The Canadian Network and the culture of forgiveness. New York. Nova Science for Mood and Anxiety Treatments (CANMAT) task force Publishers 2013; 165-167 reccomendations for the management of patients with 15. Young S & Amarasinghe JM: Practitioner review: Non- mood disorders and comorbid ADHD. Ann Clin pharmacological treatments for ADHD: A lifespan Psychiatry 2012; 24:23-37 approach. J Chil Psychol Psychiatry 2010; 51:116-33 3. Boumans J, Baart I, Widdershoven G, Kroon H: Coping 16. Young S, Khondoker M, Emilsson B, Sigurdsson JF, with psychotic-like experiences without receiving help Philipp-Wiegmann F, Baldursson G, Olafsdottir H, from mental health care. A qualitative study. Psychosis Gudjonsson G: Cognitive-behavioural therapy in medica- 2017; 1:1-11 tion-treated adults with ADHD and co-morbid psycho- 4. Bramham J, Young S, Bickerdike A, Spain D, McCartan pathology: a randomized controlled trial using multi-level D, Xenitidis K: Evaluation of group cognitive behavioral analysis. Psychol Med 2015: 45:2793-804

Correspondence: Prof. Ivan Urlic, MD, PhD Medical School and the Academy of Arts, Univesity of Split Split, Croatia E-mail: [email protected]

DYSPHORIA AS A PSYCHIATRIC SYNDROME: A PRELIMINARY STUDY FOR A NEW TRANSNOSOGRAPHIC DIMENSIONAL APPROACH Patrizia Moretti, Massimo C. Bachetti, Tiziana Sciarma & Alfonso Tortorella Division of Psychiatry, Department of Medicine, University of Perugia, Perugia, Italy

SUMMARY Background: We currently define dysphoria as a complex and disorganized emotional state with proteiform phenomenology, characterized by a multitude of symptoms. Among them prevail irritability, discontent, interpersonal resentment and surrender. Dysphoria, in line with the most recent Interpersonal Dysphoria Model, could represent a “psychopathological organizer” of the Borderline Personality Disorder. We would like to extend this theoretical concept to other psychiatric disorders in order to consider dysphoria as a possible psychopathological nucleus, a syndrome on its own. This syndromic vision may open up the possibility of new paths both in the differential diagnosis and in the therapeutic approach to the various disorders. Aims: The goal of this paper is to understand if the dimensional spectrum that composes dysphoria differs from the different psychiatric disorders. Specifically, we would like to assess if the phenomenological expression of dysphoria differs in patients with Borderline Personality Disorder (BPD), Mixed State Bipolar Disorder (BDM) and Major Depressive Disorder (MDD) through an observational comparative study. Subjects and methods: In this study, 30 adult patients, males and females between the ages of 18 and 65, were enrolled from the Psychiatric Service of the Santa Maria della Misericordia Hospital in Perugia (PG), Italy, from January 1st to June 30th, 2018. The aim was to form 3 groups each one composed of 10 individuals affected respectively with Borderline Personality Disorder (BPD), with Bipolar Disorder, Mixed State (BPM) and Major Depression Disorder (MDD). After a preliminary assessment to exclude organic and psychiatric comorbidity, we administered them the Neapen Dysphoria Scale – Italian Version (NDS-I), a specific dimensional test for dysphoria. Starting from the dataset, with the aid of the statistical program SPSS 20, we have obtained graphs showing the comparison between disorders groups selected and NDS-I total score and subscales (irritability, discontent, interpersonal resentment, surrender). Finally, a comparison was made, taking two groups at a time, between the means of single groups for total scores and for single subscales considered into the NDS-I test. We made it using the Mann-Whitney U test, a nonparametric test with 2 independent samples, by setting a significance level Į=0.05. Conclusions: This study, through a transnosographic-dimensional approach, allowed us to explore dysphoria and its expressions in different psychopathological groups, despite analyzing a small sample. Differences between means of values obtained through NDS-I subscales were statistically significant in patients with BPD, BDM and MDD (p<0.05). Among the latter, the group of BPD patients has greater pervasiveness and severity of dysphoria symptoms.

Key words: dysphoria – borderline personality disorder – mixed state bipolar disorder – major depressive disorder – transnosographic approach - neapen dysphoria scale Italian version

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INTRODUCTION irritability, discontent, interpersonal resentment and surrender (Starcevic et al. 2007, Starcevic, Rossi Monti, The word “dysphoria” came into English from the D’Agostino 2013). Dysphoria appears to be an unstable Ancient Greek word įȣıĳȠȡȓĮ (dusphoría), which and unpredictable “entity”. Generally, we consider it as means “excessive pain”. The Greek word itself is a a temperamental tract but its manifestation arises in compound noun: it’s made up of two Greek words įȣı- response to environmental stimuli, especially to adverse (dus-, “bad”) and ĳȑȡȦ (phérǀ, “I bear, carry”). ones, from which it is often modulated. Its usage in heterogeneous clinical areas contributes to the lack of clarity and imprecision that hovers around Dimensions of dysphoria the specific meaning of the term itself. Usually, the term is used to indicate a generic state Alongside these general traits, dysphoria could be of dissatisfaction and affective instability, characterized characterized exquisitely by three specific components: at the same time by anxiety and depression, without any tension, irritability and urge (D’Agostino et al. 2016). specific feature. This wide range of situations in which Tension is a condition of strong emotional pressure this term is applied and its relative conceptual indeter- caused by deflection of the mood, chronic and unde- minacy often implies an implicit and shared meaning, fined unhappiness and extremely extended and persi- with no need of definition. stent discontent, which leads the subject to surrender. We currently define dysphoria as a complex and In addition, there is a persistent state of oppressive, disorganized emotional state with proteiform pheno- often ambivalent, painful expectation of the present menology, characterized by a multitude of symptoms: and the future.

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Irritability refers to a state of constant and annoying We would like to extend this theoretical concept to restlessness, worry and incessant anxiety. Similar to a other psychiatric disorder in order to consider dysphoria sensation of adversity towards the world that leads the as a possible psychopathological nucleus, a syndrome subject to assume a suspicious, hostile and resentful on its own. This hypothesis derives not only from the attitude towards the environment and the people around above speculative considerations, but also from the him. clinical evidences that the symptomatic grouping com- Urge, finally, is characterized by impatience and in- monly defined as dysphoria, represents a clear trans- tolerance, by an irresistible need to act, which often nosographic element, manifesting itself with various leads to the appearance of self-harm behaviour. The facets and degrees of expression. Furthermore, in addi- action, in the dysphoric patient, is always a violent tion to personality disorders, even some major psycho- action; violence not necessarily with a physical mea- pathological disorders such as PTSD have affective and ning, but rather referred to the great intensity of behavioural patterns that we cannot define in any other emotions that invest the subject. The patient tries to get way than dysphoric. If the term manages to describe out from his discomfort state through the action, thus behavioural and affective pictures so complex, our trying to modulate, in some way, the dysphoric state. theory is that it should not be considered a simple symptom affecting the various disorders in which it manifests Dysphoria phenomenology in Borderline itself and is deeply rooted. In support of this hypothesis, Personality Disorder DSM-5 too has recognized for the first-time dysphoria like as a separated nosographic entity defining Gender However, in most of the current literature this psycho- Dysphoria and Premenstrual Dysphoria. pathological phenomenon is described as nonspecific Such syndromic vision may open up the possibility and is inscribed within a multitude of psychiatric dis- of new paths both in the differential diagnosis and in the orders including, for example, Major Depressive Dis- therapeutic approach of the various disorders as well. order (MDD), Mixed States of Bipolar Disorder (BPM), Although, the differential diagnosis among certain Post-Traumatic Stress Disorder (PTSD), Feeding and mood disorders, personality disorders, PTSD etc., often Eating Disorders (FED) and Personality Disorders be- causes problems for clinicians. Consequently, having a longing to cluster B where Borderline Personality psychometric tool capable of providing dimensional ana- Disorder (BPD) occupies a privileged position. lysis of dysphoria could help the clinician to distinguish Inside the BPD, dysphoria appears to be a charac- more easily and earlier these pathological states. terizing and disabling psychopathological element. The BPD patient suffers continuous disturbances of his NDS-I for new approach to dysphoria affective sphere. These disturbances are characterized by behavioural reactions often disproportionate and in- To reach this aim, it is necessary a psychometric adequate compared to the real gravity of the stimulus test which, starting from a dimensional construct, turns event. Dysphoria fits between subjective perception and out to detect if the subject is dysphoric, but "how" the behavioural response. subject is dysphoric. The test better responding to such Dysphoria replaces the normal neuromodulatory features seem to be the Neapen Dysphoria Scale – Ita- mechanisms that leads a healthy subject to separate the lian Version (NDS-I). It has been translated and adap- real distance between the severity of the objective ted in Italian by D'Agostino et al. (2016) and repre- external event and the severity of the representation of sents the Italian version of the homonymous NDS the same in order to provide an adequate response. introduced in Australia by Starcevic et al. (2007). This Thus, we can imagine as if these modulatory mecha- auto-administered test consists of 24 items in Likert nisms fail, or become dysregulated and the inability to scale from 0 to 4. At the end of the test you can get a control one's emotions prevails. These can be so specific Total Score, that provides a rough assessment amplified as to make the subject a slave to them, of their of the degree of dysphoria, and additional scores continuous variability according to environmental sti- divided into 4 subscales that represent the dimensions muli. In severe cases, this subject, who over time has of the dysphoria (irritability, discontent, personal and learned to identify him-self with the emotional reactions interpersonal resentment, renunciation / surrender). elicited by extern event, ends up losing the boundaries The test has not any cut-off and represents a dimen- between the Self and the object. sional, non-nosographic tool. That means hopefully, that it might show the severity of the symptomatology and above all if some domains are more involved than Dysphoria as syndrome others. Unfortunately, it has not been validated yet on According to D’Agostino A., Rossi Monti M. and a large scale. Although the psychometric properties are Starcevic V. who proposed the Interpersonal Dysphoria excellent for the healthy population, they have not Model, dysphoria could represent a “psychopathological been verified yet in the pathological population organizer” of BPD could represent a “psychopatho- (D'Agostino et al. 2016). This is the reason why our logical organizer” of the BPD (D’Agostino et al. 2017). group, in collaboration with other terms, next months,

S583 Patrizia Moretti, Massimo C. Bachetti, Tiziana Sciarma & Alfonso Tortorella: DYSPHORIA AS A PSYCHIATRIC SYNDROME: A PRELIMINARY STUDY FOR A NEW TRANSNOSOGRAPHIC DIMENSIONAL APPROACH Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 582-587 is undertaking validation of this tool, hoping to be we calculated the scores of the four subscales as useful for clinicians and researchers (Starcevic et al. indicated by D'Agostino et al. 2016. 2015, Berle, Starcevic et al. 2012, Berle, Starcevic et The data obtained have been reported in a specific al. 2018). database. Because of the small size of the samples, it has been decided to avoid the division by gender and to AIMS consider males and females indiscriminately within the reference group. Starting from the dataset, with the aid The goal of this paper is to understand whether the of the statistical program SPSS 20, we have obtained dimensional spectrum that composes dysphoria differs graphs showing the comparison between the disorders from the different psychiatric disorders. Specifically, we groups selected and NDS-I total score and subscales would like to assess if the phenomenological expression Subsequently, in order to provide a quantitative of dysphoria differs in patients with Borderline Perso- imprint, we have calculated arithmetic means of each nality Disorder (BPD), Mixed State Bipolar Disorder NDS-I subscales for each group of patients. As a result, (BDM) and Major Depressive Disorder (MDD) through we have calculated the average percentage too. an observational comparative study. Finally, we took the NDS-I subscales and total scores’ means of each group and then we have compared SUBJECTS AND METHODS these values between them, considering two groups at time. We did it using the Mann-Whitney U test, a In this study, males and females’ patients between nonparametric test with 2 independent samples, by set- the ages of 18 and 65, were enrolled from the Psychia- ting a significance level Į=0.05. tric Unit of the Santa Maria della Misericordia Hospital in Perugia, Italy, from January 1st to June 30th, 2018. They were divided into 3 groups each one composed of RESULTS individuals respectively affected by Borderline Perso- Analyzing the graphs obtained we tried to highlight nality Disorder (BPD), Mixed State Bipolar Disorder some differential dimensional aspects between the (BPM) and Major Depression Disorder (MDD). expression of the total score and the various subscales Once eligible patients were identified, we proceeded of the NDS-I in the disorders examined. then carrying out their history and clinical informations, In Figure 1 we can see how the group of BPD pa- through clinical interview and using other clinical tools tients has a higher total score, therefore a higher decla- like Structured Clinical Interview for DSM-5-Clinical red degree of dysphoria, compared to the other two Version (SCID-5-CV) to detect major psychiatric groups that do not tend to have statistically significant disorders, the Structured Clinical Interview for DSM - II differences, in line with our predictions. (SCID-II) and Minnesota Multiphasic Personality Inventory - 2 (MMPI-2), to detect personality disorders. After obtaining the diagnoses related to the groups we were interested in, the patients presenting with organic comorbidities, overlapping among the major psychiatric disorders, personality disorders and with double diagnosis were excluded from the study. At the end, the patients enrolled in the study were 30 divided in groups of 10 patients: the BPD group, the BDM group and the MDD group. The patients agreed to give their informed consent according to the current EU regulations on privacy through an information talk and related information form, with the possibility for patients to withdraw at any Figure 1. Comparison between the groups of patients stage of the study. and the NDS-I Total Score Once the consents were obtained we continued administering the NDS-I test to the patients, prior instruc- In Figure 2 we are going to analyze the dimension of ting them in its correct compilation. After that, we irritability. In this dimension, BPD and BDM groups collected and re-processed the patients tests in a specific appear to have a higher trend of irritability traits than database. depressive states. As the NDS-I test is a dimensional tool does not In Figure 3 we can observe a substantial overlap bet- have a cut-off, therefore, its goal is not to define whe- ween the three disorders groups in regard to the dis- ther or not a subject is dysphoric, but rather to show content. However, the DBM group shows a slight lower which dysphoria domains are more interested than others. score, resulting unexpected as we would have expected In order to do that we have extrapolated the scores of such a result in patients affected by MDD, compared to the individual items expressed on the Likert scale and other groups.

S584 Patrizia Moretti, Massimo C. Bachetti, Tiziana Sciarma & Alfonso Tortorella: DYSPHORIA AS A PSYCHIATRIC SYNDROME: A PRELIMINARY STUDY FOR A NEW TRANSNOSOGRAPHIC DIMENSIONAL APPROACH Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 582-587

Figure 2. Comparison between the groups of patients Figure 4. Comparison between the groups of patients and the NDS-I Irritability Subscale Score and the NDS-I Interpersonal Resentment Subscale Score

30 25 20 15 10 NDS-I SCORE NDS-I 5 0 024681012

PATIENTS BPD BDM MDD Figure 3. Comparison between the groups of patients Figure 5. Comparison between the groups of patients and the NDS-I Discontent Subscale Score and the NDS-I Surrender Subscale Score

In Figure 4, analyzing the interpersonal resentment, favor of BPD patients. No difference was found in the we notice a statistically significant difference between surrender dimension (p>0.05) as shown in Table 2. the expression of this dimension in the BPD group, with In Table 3, comparing BPD and MDD patients, same a higher score than the remaining two groups. differences can be remarked: the highest, as expected, is In Figure 5, we observe a statistically significant the subscale irritability with p<0.001. What did not prevalence of the surrender dimension in MDD patients surprise us is the lack of any statistically significant compared to the other two groups. It is worth noticing difference between the mean subscale discontent score that there is a greater difference in the BDM group of MDD patients compared to BPD ones. rather than the BPD one. Comparing score means of the BDM and MDD In Table 1 we have translated in numerical language groups, we have obtained a significant statistically diffe- what we have already analyzed previously in the graphs. rence for the irritability and discontent subscales In particular, if we pay attention to averages percentages (p<0.001). As illustrated in Table 4, the difference res- it is easily understandable the different dysphoria ults higher for the MDD groups. In the surrender sub- expression in these disorders, even if only qualitatively. scale results show a statistically significant difference The data obtained with Mann-Whitney U test shows (p<0.05) for the same group even with a minor sta- that the disorders group presents a different distribution tistical strength. On the other hand, the difference bet- of the values within the individual subscales. The diffe- ween the total scores means of the two groups shows no rences in the statistical analysis confirm the qualitative significant differences (p>0.05). observation previously made. These results could be indicative for a possible diffe- Comparing the scores between BPD and BDM pa- rential criterion in the expression of dysphoria and tients, before the experiment we expected to obtain a sub- would also demonstrate that this is not just a nonspecific stantial overlap between the degree of irritability and the symptom, but a real syndrome with a variety of expres- total score, with a possible variation in the interpersonal sions of its dimensional domains within different psy- resentment subscale. Whereas, the study shows a great chiatric disorders. difference (p<0.001) between the two groups regarding In particular, what emerges from these data is how total score, irritability and interpersonal resentment in dysphoria permeates the DBP and this could lead us to favor of the BPD group. The difference in the score of the consider the hypothesis of dysphoria as the psycho- subscale discontent is also significant (p<0.05), again in pathological nucleus founding this disorder.

S585 Patrizia Moretti, Massimo C. Bachetti, Tiziana Sciarma & Alfonso Tortorella: DYSPHORIA AS A PSYCHIATRIC SYNDROME: A PRELIMINARY STUDY FOR A NEW TRANSNOSOGRAPHIC DIMENSIONAL APPROACH Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 582-587

Table 1. In this table are resumed means and average percentage of each pathological group for each NDS-I subscales Groups µIRRIT µDISC µINT RES µSURR µTOT SCORE BPD 31.8 (45.6%) 21.4 (35.5%) 16.4 (42.3%) 10.8 (32.4%) 80.4 BDM 25.2 (36.2%) 17.2 (28.5%) 10.5 (27%) 9 (27.1%) 59.9 MDD 12.7 (18.3%) 21.7 (36%) 11.9 (30.7%) 11.5 (40.5%) 56.3 µTOTAL 69.7 (100%) 60.3 (100%) 38.8 (100%) 33.3 (100%)

Table 2. Comparison between means of BPD and BDM subscales scores Total Score Irritability Discontent Interpersonal resent Surrender U di Mann-Whitney 1.000 9.500 11.000 5.500 26.000 Sig. Asint. a 2 code 0.000 0.002 0.003 0.001 0.065 Significatività esatta 0.000 0.001 0.002 0.000 0.075 [2*(Significatività a 1 coda)]

Table 3. Comparison between means of BPD and MDD subscales scores Total Score Irritability Discontent Interpersonal resent Surrender U di Mann-Whitney 0.000 0.000 46.000 20.000 12.000 Sig. Asint. a 2 code 0.000 0.000 0.759 0.022 0.004 Significatività esatta 0.000b 0.000b 0.796b 0.023b 0.003b [2*(Significatività a 1 coda)]

Table 4. Comparison between means of BDM and MDD subscales scores Total Score Irritability Discontent Interpersonal resent Surrender U di Mann-Whitney 38.500 1.500 8.000 37.000 8.000 Sig. Asint. a 2 code 0.383 0.000 0.001 0.323 0.001 Significatività esatta 0.393b 0.000b 0.001b 0.353b 0.001b [2*(Significatività a 1 coda)]

Study limitations CONCLUSION This paper has several limitations. First of all, the small number of samples taken into consideration, thus This study, through a transnosographic-dimensional the impossibility of carrying out a gender differential approach, allowed us to explore dysphoria and its ex- analysis. For this reason, the study does not presume to pressions in different psychopathological groups, des- be exhaustive and complete, rather as a preliminary pite analyzing a small sample. Differences between work to be implemented over time. Consequently, data means of values obtained through NDS-I subscales obtained from it must be considered as a transitory and, were statistically significant in patients with BPD, on the other hand, suggestive to continue the work. BDM and MDD (p<0.05). Among the latter, the group The second limitation concerns the NDS-I test. This of BPD patients has greater pervasiveness and severity test, as already mentioned, has not been validated yet in dysphoria symptoms. Italy and its psychometric properties have been evalua- The possibility of identifying this different dimen- ted exclusively in a sample of healthy subjects. The test sional expression could open new clinical and research was selected to respond to the study's aim to analyze the scenarios. In particular, if the data will be confirmed dysphoria dimensions construct and there was no other by other studies, by expanding the comparison to other test currently validated by the literature with these charac- psychiatric disorders, this study could provide to the teristics. Furthermore, our group is willing to validate this clinician an instrument that allows them to perform test on a national scale and this experience has also early differential diagnoses among the various dis- served us to test the compliance of so-called difficult orders with obvious positive implications on patient’s patients in its administration, with satisfactory results. management. This will be made easier thanks to tools Finally, these data should be read as a research area, like the NDS-I. It is exactly for this reason that our as in a clinic it is often difficult to observe, especially in group considers necessary and indispensable to BPD patients, a phenomenological continuity stable over validate the NDS-I test on a national scale, perhaps as time. In this regard, NDS-I should be administered seve- a multicentric study. Obviously, all this must never be ral times during the hospital stay, but also in the territory to the detriment of the individuality and subjectivity of once the patient has been discharged. After data collec- the patient's symptoms that we are facing, which often tion, through of a longitudinal study, more indicative data results hardly inscribed even within a dimensional could be obtained from a clinical point of view. approach.

S586 Patrizia Moretti, Massimo C. Bachetti, Tiziana Sciarma & Alfonso Tortorella: DYSPHORIA AS A PSYCHIATRIC SYNDROME: A PRELIMINARY STUDY FOR A NEW TRANSNOSOGRAPHIC DIMENSIONAL APPROACH Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 582-587

References Acknowledgements: None. 1. Berle D, Starcevic V, et al.: Confirmatory Factor Analysis Conflict of interest: None to declare. of the Nepean Dysphoria Scale in a Clinical Sample. Psy- chiatr Q 2018. https://doi.org/10.1007/s11126-018-9564-9 Contribution of individual authors: 2. Berle D, Starcevic V: Preliminary validation of the Nepean Dysphoria Scale. Australas Psychiatry 2012; Patrizia Moretti & Massimo Claudio Bachetti concei- 20:322–326 ved and designed the study and wrote the first draft 3. D’Agostino A, Rossi Monti M & Starcevic V: Models of of the manuscript; borderline personality disorder: recent advances and new Patrizia Moretti, Massimo Claudio Bachetti & Alfonso perspectives. Curr Opin Psychiatry 2017; 30:000-000 Tortorella performed statistical analyses; 4. D’Agostino et al.: Development, cross-cultural adaptation Patrizia Moretti, Massimo Claudio Bachetti & Tiziana process and preliminary validation of the Italian version Sciarma visited patients and carried out clinical of the Nepean Dysphoria Scale. Journal of Psychopatho- work; logy 2016; 22:149-156 Massimo Claudio Bachetti & Tiziana Sciarma con- 5. Starcevic V, et al.: Specificity of the Relationships Between ducted testing; Dysphoria and Related Constructs in an Outpatient Sample. Stefano Ferracuti & Martina Curto wrote portions of Psychiatr Q 2015. DOI 10.1007/s11126-015-9344-6 Methods; 6. Starcevic V, Rossi Monti M, D’Agostino A, et al.: Will Patrizia Moretti, Massimo Claudio Bachetti & Alfonso DSM-5 make us feel dysphoric? Conceptualization(s) of Tortorella discussed results; dysphoria in the most recent classification of mental Patrizia Moretti, Massimo Claudio Bachetti, Tiziana disorders. Aust NZ J Psychiatry 2013; 47:954–955 Sciarma & Alfonso Tortorella supervised the writing 7. Starcevic V: Dysphoric about dysphoria: towards a of the manuscript; all authors approved the final greater conceptual clarity of the term. Australas version of the manuscript. Psychiatry 2007; 15:9.13

Correspondence: Patrizia Moretti, MD Division of Psychiatry, Department of Medicine, University of Perugia Piazzale Lucio Severi, 1, 06132, S. Andrea delle Fratte, Perugia (PG), Italy E-mail: [email protected]

THE NEUROSCIENCE OF MUSIC; A REVIEW AND SUMMARY Shentong Wang1 & Mark Agius2 1Clare College Cambridge, School of Clinical Medicine, University of Cambridge, Cambridge, UK 2Clare College Cambridge, Department of Psychiatry University of Cambridge, Cambridge, UK

SUMMARY Present knowledge about the neurobiology of music is discussed and summarised. Music playing, reading and listening are all complex processes requiring co-ordination of various parts of the brain in hierarchically structured sequences. The involvement of the right hemisphere of the brain in musical functions is well established, however in fact both hemispheres are involved. Plasticity is heavily involved in all functions of the brain related to music. The role of mirror neuron systems of the brain appears to be of great importance and parallels exist in the development and functioning of language and music.

Key words: music - language – emotion – mirror neurons - right cerebral hemisphere * * * * * APPRECIATING MUSIC discussed by Jourdain can be found in Table 1, along with updates from recent papers. Music performance is a natural human activity, One constant finding to emerge from the studies of present in all societies, and also one of the most the effects of listening to music is the emphasis on the complex and demanding cognitive challenges that the right hemisphere (Stewart 2006). It is possible that human mind can undertake (Zatorre 2007). The ability hemispheric specialization for musical processing may to create and enjoy music is a universal human trait and develop with age, with a study on a group of young it plays an important role in the daily life of most children showing some differential specialisation for cultures (Molnar-Szakacs 2006). In other words, music melody and rhythm processing, but to a lesser extent is a trait which is very clearly bound up with human ex- than previously reported in adults (Overy 2004). pression, and so, indeed with the very essence of being human. THE PERCEPTION OF MUSIC Music has a unique ability to trigger memories, to awaken emotions and to intensify our social experiences We do not only listen to music for pleasure and the (Molnar-Szakacs 2006). Music has soothed the souls of attention we give to music will vary with circumstance human beings for centuries and it has helped people to from merely hearing music through to listening recover from ailments since ancient times (Mula 2009). carefully (Jourdain 1998). The different aspects and Hence it is no surprise that today, there is a widespread corresponding processes that have been proposed by interest in the relationship between music, affect and Jourdain are again best summarised in a table with mental illness (Mula 2009). updates from recent papers (Table 2). Listening to In this article, we wish to review some of these com- music is a human experience, which becomes an plex relationships, including examples from the neuro- aesthetic experience when individuals immerse them- biology of emotions, perceptions and music language selves in the music, dedicating attention to interpre- (Mula 2009). We do not expect to be fully compre- tation and evaluation (Reybrouck 2018). Recent hensive but instead have based our review on Jourdain’s neuroimaging findings indicate that music listening is work: “Music, the brain, and ecstasy: How music traceable in terms of network connectivity and acti- captures our imagination” (Jourdain 1998). vations of target regions in the brain, in particular between the auditory cortex, the reward brain system COORDINATION OF THE BRAIN and brain regions active during mind wandering AREAS INVOLVED IN PLAYING (Reybrouck 2018). OR LISTENING TO MUSIC Miles’ surprise hypotheses (Miles 2007) can be illustrated by the music of Alexander Scriabin. His music Several areas of the brain are coordinated to play or has been described as a “polyphony and aesthetical listen to music to produce a single but complex activity, experience” because his innovative use of chord struc- and is called a hierarchically structured sequence (Jour- ture and sequence; his creation of a chord based on dain 1998). The precise physical movement required by fourths rather than the conventional thirds are pro- musical performances requires very accurate coordi- posed as points of departure for insight (Triarhou nation of numerous parts of the body bolstered by detai- 2016). The underlying neuronal processes are complex led feedback at all levels (Jourdain1998). The different and yet to be demystified despite the sophistication of areas involved in the neuroscience of music, as our love for music.

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Table 1. Parts of the brain involved in music playing/listening Area Function Right hemisphere Prosody (poetic rhythm and emotional tone of speech) (Mula 2009) Recognition of melody (Jourdain 1998, Overy 2004) Auditory cortex Relations between simultaneous sounds (Jourdain 1998) Left hemisphere Dominant for rhythm (Jourdain 1998) Posterior Sylvian Sensorimotor integration, part of an auditory–motor fissure at the parie- integration circuit that may play an important role in tal-temporal speech and musical ability development (Hickok 2003), boundary (Spt) and may support verbal working memory (Zatorre 2007). The cerebrum Auditory dorsal Forward and inverse models related to music stream listening/performance (Rauschecker 2014). Basal ganglia Redistribution of information, initiation of movement (Jourdain 1998) Frontal cortex Part of an auditory–motor integration circuit that may play an important role in speech and musical ability development (Hickok 2003), and may support verbal working memory (Zatorre 2007). Fusiform gyrus Rhythm reading (Stewart 2005) Motor cortex Types of basic physical movements (Jourdain 1998) Motor neurones Direction of movement(Jourdain 1998) Medial prefrontal Representation of elapsed time between events (shown by cortex significant trial-by-trial relation between decoded times and the timing behaviour of the monkeys) (Merchant 2017) Parietal cortex Coordination of touch, sight and hearing (Jourdain 1998) Superior parietal Melody reading (Stewart 2005) cortex Premotor cortex Coordination of sequences of movements (Jourdain 1998) Dorsal premotor Integration of higher order features of music with cortex appropriately timed and organized actions (Zatorre 2007) Somatosensory Feedback from muscle fibre spindles and fingerprints cortex (Jourdain 1998) Cerebellum Physical balance between ballistic movements too quick for feedback (Jourdain 1998)

Studies have been carried out regarding mecha- MUSIC AND EMOTION nisms by which music is perceived. In one study, formally trained musicians compared with nonmusi- The link between music and emotion seems to be cians showed more efficient neural detection of tones, accepted for all time (Cooke 1959). Plato considered superior auditory sensory-memory traces for acoustic that music played in different modes would arouse features, and revealed enhanced sensitivity to acoustic different emotions (Mula 2009). Harmony can affect the (Nikjeh 2009). These findings suggest that musical emotional significance of a piece of music e.g. major training influences central auditory function and chords are cheerful and minor ones are sad (Mula 2009). modulates the auditory neural system. The tempo or movement in time is another component Along with local features such as pitch, tuning, of this, slower music seeming less joyful than faster consonance/dissonance, harmony, timbre, or beat, glo- rhythms. Mula suggests that this reminds us that motion bal sonic properties could also be viewed as con- is an important part of emotion; “in the dance we are tributing toward creating an aesthetic musical expe- moving – as we are moved emotionally by music” rience (Brattico 2017). These contributing factors to (Mula 2009). beauty are hypothesized to be global, formal/non- Meyer explored in detail the meaning of music, es- conceptual, computational and/or statistical, and based pecially from an emotional point of view (Meyer 1956). on relatively low-level sensory properties (Brattico Music, arouses feelings and associated physiological res- 2017). ponses, and these can now be measured (Mula 2009).

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Table 2. The processes underlying music listening Aspect Underlying process Expectation Episodic memory (Jourdain 1998) Anticipation Semantic memory (Jourdain 1998), pattern recognition and temporal predictions combined to generate anticipation (Salimpoor 2015) Attention Perception of “edge elements” e.g. melodies at the peaks and troughs, and violations of metrical pattern, thus making the perception of complex harmony a listening skill that requires training (Jourdain 1998). General emotion Brain structures that are known to be crucially involved in emotion, such as the amygdala, nucleus accumbens, hypothalamus, hippocampus, insula, cingulate cortex and orbitofrontal cortex (Koelsch 2014) Anger Misattribution of anger in the music of avantgarde jazz saxophonists could be explained by the activity of mirror neurones (Gridley 2006) Preference/ Absolute-Surprise Hypothesis – unexpected events lead to pleasure (Miles 2017) Enjoyment Contrastive-Surprise Hypothesis – juxtaposition of unexpected and expected events leads to rewarding response (Miles 2017) Hybrid-Surprise Hypothesis – both hypotheses play roles in the enjoyment of popular music (Miles 2017) Dopaminergic reward system in the ventral striatum (Gold 2013). Some musical pieces may preferentially activate reward centres in the brain (Miles 2017) Integration of complex cognitive abilities with subcortical reward and motivation systems for musical pleasure (Salimpoor 2015)

For the ordinary listener, however, there may be no Huron approached the emotional impact of music necessary relationship of the emotion to the form and from an ethological perspective (Huron 2015). He raised content of the musical work since “the real stimulus is five questions about music-related affect regarding: why not the progressive unfolding of the musical structure music can only induce certain emotions (e.g. exuberance but the subjective content of the listener's mind” (Meyer or tenderness) but not others (e.g. jealousy and guilt); 1956). why some induced emotions are similar to the displayed Mirror neurones are said to have a role in emotional emotion whereas others aren’t; why listeners often response.Individual mirror neurons were first seen in the report feeling mixed emotions; why only some emo- macaque brain that fire both when an action is executed tional connotations are similar across musical cultures; and when that same action is observed or heard (Overy and finally, why musicians appear to rely on some emo- 2009). The fact that music performance requires precise tion-inducing mechanisms more than others. Huron timing of several hierarchically organized actions has does not provide absolute answers to these questions but suggested that a mirror neuron system in humans might instead suggests that there is a potential role of etho- be important in music production. There may be two logical signals in music-related emotion. One example processing-levels underlying common music emotiona- he gives is the use of vibrato in highly emotional string lity: 1) a widely shared core-affective process that is con- instrument playing. He suggests that vibrato correlates fined to a limbic network and mediated by temporal regu- with the trembling frequency of an emotional voice and larities in music and 2) an experience based process that therefore evokes a similar emotional response. is rooted in a left fronto-parietal network that may involve functioning of the 'mirror-neuron system (Singer 2015). BRAIN PLASTICITYAND MUSIC Further evidence regarding audio-motor mirror neurons was obtained from filming musicians observing There is much evidence that brain plasticity is cau- piano performances (Hou 2017). In this scenario, enhan- sed by learning to play music. Many studies have shown ced mirror neurone activation in musicians may stem grey matter differences between musicians and non- from imagining themselves actually playing the observed musicians in different parts of the brain. Furthermore, piece (Hou 2017). A different study similarly concluded early exposure to music training makes a significant that auditory stimuli can activate the human mirror neu- difference and there are critical periods of development rone system when sounds are linked to actions (Wu (Joudain 1998). From the second half of the 20th century 2017). Long-term training in musicians and short-term onwards, several teams of neuroscientists around the training in novices may be associated with different world have tried to understand the ability that our brain stages of audio-motor integration and these changes were adapts to new experiences and the environment (neuro- not found for participants listening to rhythms, suggesting plasticity). In the last decade, several studies have a degree of specificity related to training (Wu 2017). investigated the changes that some training (such as

S590 Shentong Wang & Mark Agius: THE NEUROSCIENCE OF MUSIC; A REVIEW AND SUMMARY Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 588-594 musical practice) can elicit in the brain. Results from motor mappings are formed that generalise outside the these investigations show that intense musical training musical context (Stewart 2004). One study found that elicits changes in sensory and motor regions, and im- after musical (but not painting) training, children sho- prove the auditory discrimination and the motor syn- wed enhanced reading and pitch discrimination abilities chronisation. in speech (Moreno 2009). A separate study on the effect In one experiment, subjects listened to music from of piano or string lessons in 5- to 7-year olds found which one specific spectral frequency was removed; this correlations between music perceptual skills and both led to rapid and reversible adaptation of neuronal res- non-verbal reasoning and phonemic awareness (Norton ponses in auditory cortex (Pantev 2001). Further experi- 2005). Interestingly, some studies have suggested im- mental evidence demonstrated that long years of prac- portant performance advantages of musical training; tice and training by professional musicians enable them music training in children results in long-term enhance- to reach their capacity and is associated with enlarged ment of visual-spatial, verbal, and mathematical perfor- cortical representations in the somatosensory and audi- mance (Schlaug 2005). tory domains (Pantev 2001). Regarding plasticity of Furthermore, plasticity also occurs when learning to the brain to enhance playing music, plastic changes in read music. While reading music, the eyes embrace an the somatosensory cortex proved to be specific for the area about 25mm in diameter and move every 20th of a fingers frequently used and stimulated and were not de- second in a manner which reflects the structure of the tected in the fingers of the hand that were not involved music (Jourdain 1998). The presence of musical nota- in playing the particular instrument (Pantev 2001). tion produces systematic effects on reaction time, de- Adult musicians’ brains show structural enlarge- monstrating that reading of the written note, like the ments, but it is not known whether these are inborn or a written word, is obligatory for those who are musically consequence of long-term training (Norton 2005). literate (Stewart 2005). The visuo-spatial mapping that Playing a musical instrument demands extensive proce- occurs is present in musically naïve individuals after dural and motor learning that results in plastic reorgani- only a short period of training (Stewart 2003). In sight- zation of the human brain. These plastic changes seem reading in pianists, direct contrasts between music nota- to include the rapid unmasking of existing connections tion and verbal or numerical notation tasks were found and the establishment of new ones. Both functional and in the right occipito-temporal junction (OTJ), superior structural changes take place in the brain of instru- parietal lobule and the intraparietal sulcus (Schon 2002). mentalists as they learn to cope with the demands of The difference in the right OTJ was interpreted by their activity (Pascual-Leone 2001). These structural Schon as being due to differences at the encoding level and functional differences were found in the brains of between notes, words and numbers. adult instrumental musicians compared to those of While plastic changes appear to be crucial for skilful matched non-musician controls, with intensity/duration playing, they potentially pose a risk for the development of instrumental training and practice being important of motor control dysfunctions (Pascual-Leone 2001). predictors of these differences (Schlaug 2005). Extensive musical practice is a two-edged blade that can Voxel-based morphometry (VBM) studies have facilitate or degrade ﬁne motor control. However, in- shown volumetric differences between musicians and sufficient evidence in movement organisation within the non-musicians in several brain regions including the brain limits the understanding of how much music prac- superior temporal gyrus, sensorimotor areas, and supe- tice is optimal (Furuya 2015). The little evidence that is rior parietal cortex (Sato 2015). These differences are available suggests that motor failures in musicians considered to be caused by neuroplasticity during long develop on a continuum, “starting with subtle transient and continuous musical training periods (Sato 2015). degradations, and transform into more permanent, still MEG studies of the auditory cortex have demonstrated fluctuating motor degradations, the dynamic stereo- enlarged cortical representation of tones of the musical types, until a more irreversible condition, musician’s scale compared to pure tones in skilled musicians and dystonia manifests” (Altenmüller 2014). suggested that enlargement was correlated with the age at which musicians began to practice (Pantev 2003). IS MUSIC A PROTOTYPICAL The corpus callosumis 15-percentlarger in adults who LANGUAGE? started playing the piano before the age of 8 than otherwise (Jourdain 1998). There appear to be links with emotion and music in In another experiment, a subset of voxels (in the the the right brain that are analogous to language and bilateral superior parietal cortex) was activated when rhythm in the left brain. Jourdain suggested that spoken musical notation was present, but was irrelevant for task language is a type of rhythm because it is devoted to performance. These activations suggest that music rea- mapping the flow of time (Jourdain 1998). He described ding involves the automatic sensorimotor translation of how there is both meaning (definition) and intonation a spatial code (written music) into a series of motor (feeling) in verbal language. There may be parallels responses (keypresses) (Stewart 2003). Musical notation between music and language based on the left is automatically processed in trained pianists and visuo- hemisphere language area and corresponding right area

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(Jourdain 1998). However, there are differences bet- these areas are tuned to detect and represent complex ween language and music. For example, language tends hierarchical dependencies, regardless of modality and to be externally focused and are more distinct and com- use. It has consequently been speculated that this ponetised; music tends to be internally feeling focused capacity evolved from motor and premotor functions and more turbulent (Jourdain 1998), but the similarities associated with action execution and understanding, outweigh the differences. such as those characterising the mirror-neuron system. Language and music are human universals involving perceptually discrete elements organized in hierarchically MUSIC, LANGUAGE AND EMOTION - structured sequences (Jentschke 2005). Hence the ques- SUGGESTED FUNCTION tion arises as to what kind of survival value could music OF MIRROR NEURONS have conferred to early hominids in comparison to pro- positional speech (Mula 2009). Darwin considered music Recent neuroimaging evidence suggests that music, to have evolved from primate sexual selection calls, and like language, involves a coupling between the percep- argued for a common origin of music and language tion and production of sequential information, and this (Darwin 1871). Music and language have been described structure allows the ability to communicate meaning as communication devices to express emotional meaning and emotion (Molnar-Szakacs 2006). The use of fMRI through high-registered socially accepted patterned sound to demonstrate an active mirror neurone system in (Mula 2009). Corballis remarked that given the rather pianists suggests that music is perceived not only as an diffuse yet pervasive quality of music in human society, auditory signal, but also as intentional sequences of it may well have been a precursor to language, perhaps expressive motor acts behind the signal, which allows even providing “the raw stuff out of which generative for co-representation and sharing of a musical ex- grammar was forged” (Corballis 1991). Some support perience between agent and listener (Overy 2009). The for these views comes from the work of Mithen, who same team expanded upon this model of Shared argued that spoken language and music evolved from a Affective Motion Experience (SAME) and discussed its proto-language, which evolved from primate calls used implications for music therapy and special education by the Neanderthals: “it was emotional but without (Overy 2009). words as we know them” (Mithen 2005). One application of the theory of mirror neurones in If there is an overlap between music and language music production relates to autism. Individuals with centres, shared resources are needed to hold a harmonic autism show impairment in emotional tuning, social key in some form of unification workspace related to interaction and communication, which been attributed to the integration of chords and words (Kunert 2016). In a dysfunction the human mirror neuron system. Inter- one study, event-related potentials were found for the ventions using methods of music making may offer a violation of expectancies in both musical regularities promising approach for facilitating expressive lan- and syntax (Jentschke 2005). There is evidence to sug- guage in otherwise nonverbal children with autism gest that these potentials are generated in the same brain (Wan 2010). regions and it therefore seems plausible that there are shared processing resources for music and language. In addition, Jentschke found heightened musical expectan- EPILOGUE; UNDERSTANDING MUSIC cies in musicians compared to non-musicians, and in (Jourdain 1998) linguistically non-impaired children but not in age- Over the years, a large quantity of research on the matched children with an impairment (Jentschke 2005). neuroscience of music has been generated. It seems In a different study, musicians with dyslexia did not fitting to summarise and end our review with a collec- perform significantly different to typical musicians and tion of Jourdain’s descriptions of music: performed better than non-musicians with dyslexia for Music is interesting when it goes just beyond ex- auditory sequencing and the discrimination of spectral pectations. cues, but typical musicians were better at discriminating amplitude information (Zuk 2017). People almost always prefer music with too little information content rather than too much and people Current research suggests that Broca’s area (inferior tend to prefer increasingly complex music as they frontal gyrus and ventral premotor cortex) are activated grow older. for tasks other than language production (Fadiga 2009). A growing number of studies report the involvement of People primarily use music for mood enhancement these two regions in language comprehension, action but people’s personal preferences regarding genre execution and observation, and music execution and are generally guided by their peer group. listening (Fadiga 2009). Recently, the critical involve- We listen to it for its meaning; purpose and meaning ment of the same areas in representing abstract hierar- are inseparable; meaning requires context. chical structures has also been demonstrated (Fadiga There may be parallels between music and language 2009). Indeed, language, action, and music share a com- based on the left hemisphere language area and mon syntactic-like structure. It has been proposed that corresponding mysterious right area.

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16. Koelsch S: Brain correlates of music-evoked emotions. Acknowledgements: None. Nat Rev Neurosci 2014; 15:170-80 17. Kunert R, Willems RM, Hagoort P: Language influences Conflict of interest: None to declare. music harmony perception: effects of shared syntactic integration resources beyond attention. R Soc Open Sci Contribution of individual authors: 2016; 3:150685 18. Merchant H, Averbeck BB: The Computational and Shentong Wang carried out the main literature search Neural Basis of Rhythmic Timing in Medial Premotor and developed the presentation on which this paper Cortex. J Neurosci 2017; 37:4552-4564 is based. 19. Meyer LB: Emotion and meaning in music. Chicago: Mark Agius supervised the project, added to the lite- University of Chicago Press, 1956 rature search, and helped in developing the final 20. Miles SA, Rosen DS, Grzywacz NM: A Statistical Analysis text. of the Relationship between Harmonic Surprise and Preference in Popular Music. 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36. RauscheckerJP: Is there a tape recorder in your head? 44. Stewart L, Walsh V, Frith U: Reading music modifies How the brain stores and retrieves musical melodies. spatial mapping in pianists. Percept Psychophys 2004; Front Syst Neurosci 2014; 8:149 66:183-95 37. Reybrouck M, Vuust P, Brattico E: Brain Connectivity 45. Stewart L: A neurocognitive approach to music reading. Networks and the Aesthetic Experience of Music. Brain Ann N Y Acad Sci 2005; 1060:377-86 Sci 2018; 8: pii: E107 46. Stewart L, Walsh V: Infant learning: music and the baby 38. Salimpoor VN, Zald DH, Zatorre RJ, Dagher A, McIntosh brain. Curr Biol 2005;15:R882-4 AR: Predictions and the brain: how musical sounds 47. Stewart L, von Kriegstein K, Warren JD, Griffiths TD: become rewarding. Trends Cogn Sci 2015; 19:86-91 Music and the brain: disorders of musical listening. Brain 39. Sato K, Kirino E, Tanaka S: A voxel-based morphometry 2006; 129:2533-53 study of the brain of university students majoring in music 48. Triarhou L: CNeuromusicology or Musiconeurology? and nonmusic disciplines. Behavioural neurology 2015; "Omni-art" in Alexander Scriabin as a Fount of Ideas. 2015. Article ID 274919 Front Psychol 2016; 7:364 40. Schlaug G, Norton A, Overy K, Winner E: Effects of music 49. Wan CY: From music making to speaking: Engaging the training on the child's brain and cognitive development. mirror neuron system in autism. Brain Res Bull 2010; Ann N Y Acad Sci 2005; 1060:219-30 82:161–168 41. Singer N, Jacoby N, Lin T, Raz G, Shpigelman L, Gilam 50. Wu CC, Hamm JP, Lim VK, Kirk IJ: Musical training G, Granot RY, Hendler T: Common modulation of limbic increases functional connectivity, but does not enhance mu network activation underlies musical emotions as they suppression. Neuropsychologia 2017; 104:223-233 unfold.Neuroimage 2016; 141:517-529 51. Zatorre RJ, Chen JL, Penhune VB: When the brain plays 42. Stewart L, Henson R, Kampe K, Walsh V, Turner R, Frith music: auditory-motor interactions in music perception U: Brain changes after learning to read and play music. and production. Nat Rev Neurosci 2007; 8:547-58 Neuroimage 2003; 20:71-83 52. Zuk J, Bishop-Liebler P, Ozernov-Palchik O, Moore E, 43. Stewart L, Henson R, Kampe K, Walsh V, Turner R, Frith Overy K, Welch G, Gaab N: Revisiting the "enigma" of U: Becoming a pianist. An fMRI study of musical literacy musicians with dyslexia: Auditory sequencing and speech acquisition. Ann N Y Acad Sci 2003; 999:204-8 abilities. J Exp Psychol Gen 2017; 146:495-511

Correspondence: Shentong Wang, BA (Cantab) Clare College Cambridge, School of Clinical Medicine, University of Cambridge Cambridge, UK E-mail: [email protected]

THE USE OF MUSIC THERAPY IN THE TREATMENT OF MENTAL ILLNESS AND THE ENHANCEMENT OF SOCIETAL WELLBEING Shentong Wang1 & Mark Agius2 1Clare College Cambridge, School of Clinical Medicine, University of Cambridge, Cambridge, UK 2Clare College Cambridge, Department of Psychiatry University of Cambridge, Cambridge, UK

SUMMARY Music Therapy can be broadly described as the use of Music in a therapeutic context in order to help improve mental health. Music Therapy does not simply imply the playing of music to patients, relaxing though this may be, but in fact it does involve more active involvement of the patient, so as to use the power of music in order to help improve the mental health of patients and in order to treat mental health conditions. We review the evidence for the effect of Music Therapy on Depression, Anxiety, Schizophrenia, Sleep Disorders, and Dementia. Encouraging singing appears to be a good adjunct to treating all of these conditions, and it also seems to help bonding between mothers and children within families. Music appears to be beneficial to both the individual, and also to the improvement of social cohesion. The reasons for this must reside in the nature of music itself as an art form which supports human interactions within society.

Key words: music therapy – depression – anxiety - sleep disorders - dementia * * * * * MUSIC THERAPY- DEFINITION “Music therapy is the skilful use of music and musical elements by an accredited music therapist Music Therapy can be broadly described as the use to promote, maintain, and restore mental, physical, of Music in a therapeutic context in order to help im- emotional, and spiritual health. Music has nonverbal, prove mental health. Brown and Pedder, responding to creative, structural, and emotional qualities. These the question ‘What is therapy?’, argue that therapy is are used in the therapeutic relationship to facilitate essentially a conversation which involves listening to contact, interaction, self-awareness, learning, self- and playing with those in trouble with the aim of expression, communication, and personal develop- helping them understand and resolve their predicament. ment.” – Canadian Association for Music Therapy / (Brown & Pedder 1991) Association de Musicothérapie du Canada Annual A clear definition of what music therapy includes is General Meeting, Vancouver, British Columbia, necessary in order to further assess its effects. May 6, 1994. It is clear that Music Therapy does not simply imply Therefore Music therapy is not simply about liste- the playing of music to patients, relaxing though this may ning to music, but includes also elements of music ma- be, but in fact it does involve more active involvement of king and discussion, in order to access the ‘nonverbal, the patient, so as to use the power of music in order to creative, structural, and emotional qualities’ of music help improve the mental health of patients and in order to so as to achieve self-awareness, learning, self-expres- treat mental health conditions. The aim of this review is sion and personal development by the patient as well to identify how music therapy can be used to help as contact, communication and interaction with other patients and discuss the evidence for these applications. persons. Among other applications, we in particular wish to assess how the involvement of patients in actively singing can help improve the Mental Health of Patients. MUSIC THERAPY – Music therapy is a Post-war phenomenon. A LITERATURE SEARCH It has proved very difficult to define, but here we quote two authoritative definitions: A literature search demonstrates that music therapy “Music therapy is the professional use of music and has been applied to several mental illnesses. Research its elements as an intervention in medical, educa- presently exists which examines the efficacy of music tional, and everyday environments with individuals, therapy in many specific areas, including depression, groups, families, or communities who seek to opti- dementia, schizophrenia and psychosis. There are also mize their quality of life and improve their physical, broader investigations, which examine more general social, communicative, emotional, intellectual, and areas, such as wellbeing or sleep quality. spiritual health and wellbeing. Research, practice, In a systematic review of music therapy practice and education, and clinical training in music therapy are outcomes with acute adult psychiatric in-patients, 98 based on professional standards according to cultural, papers were identified, of which 35 reported research social, and political contexts.” – World Federation findings. No single clearly defined model exists for for Music Therapy; music therapy with adults in acute psychiatric in-patient

S595 Shentong Wang & Mark Agius: THE USE OF MUSIC THERAPY IN THE TREATMENT OF MENTAL ILLNESS AND THE ENHANCEMENT OF SOCIETAL WELLBEING Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 595-600 settings, however all the studies with significant positive adjunct to ‘usual Care’, which must follow the usual effects used active musical participation with a degree treatment guidelines for depression, including appro- of structure and were delivered in four or more sessions. priate treatment with antidepressants. However, the greater frequency of therapy, active struc- Regarding the effect of music therapy in specific tured music making with verbal discussion, consistency groups of patients, the effects on psycho-physiological of contact and boundaries, as well as an emphasis on indices of music intervention, together with the presence building a therapeutic relationship and building patient of nurses has been studied in caregivers to cancer resources all appear to be of particular importance (Carr patients. Both music intervention with nursing presence 2013). and recorded music interventions had beneficial effects Study of the effects of music on the patients' psycho- on anxiety, depression and blood volume pulse logical sphere have confirmed that it reduces psycho- amplitude, however music intervention with nursing pathologic symptoms (such as anxiety and depression), presence was more effective in lessening anxiety and on it improves the patient’s self-rating of symptoms and improving the ease of getting to sleep compared with general wellbeing, it influences quality and disorders of recorded music (Lai 2012). sleep, it reduces pain, and furthermore it improves the Music listening has also been studied in depressed patient’s ‘moral immunity’ and the patients' openness, patients over the age of 65. Music Listening has been readiness, co-operation in treatment process (Sliwka said to reduce symptoms of depression in older (over 65) 2006). adults. Thus, In the music group, there were statistically-significant decreases in depression scores (P<0.001) MUSIC THERAPY IN DEPRESSION and blood pressure (Chan 2009), and depression levels reduced weekly in the music group, indicating a Depression is the medical condition most studied cumulative dose effect, and a statistically significant regarding the effectiveness of music therapy. It has been reduction in depression levels was found over time in suggested that Music therapy is effective in the treat- the music group compared with non-music group. ment of depression because active music-making within Listening to music can help older people to reduce their the therapeutic frame offers the patient opportunities for depression level (Chan 2012). new aesthetic, physical and relational experiences (Maratos 2011). EFFECTS OF SINGING IN DEPRESSION However, simply listening to Music is said to reduce symptoms of depression in adults (17 studies). Music We have been particularly interested in recent stu- listening over a period of time helps to reduce depressive dies regarding the effect of encouraging patients with symptoms in the adult population. Daily intervention depressive symptoms to sing or join choirs, the latter does not seem to be superior over weekly intervention being in particular a community group activity. Recent and it is recommended that the music listening session studies have shown that singing improves symptoms of should be conducted repeatedly over a time span of more depression. than 3weeks to allow an accumulative effect to occur. All In patients, choir participation improved vitality, types of music can be used as listening material, depen- overall mental health and anxiety. In non-patients, choir ding on the preferences of the listener (Chan 2011). participation improved anxiety (p<0.05). Participants Music Therapy has been shown to be effective com- experienced the choirs as both an uplifting musical acti- bined with Standard Care in treating depression. Indi- vity and a supportive community group. vidual music therapy combined with standard care is Group singing interventions may have beneficial effective for depression among working-age people with effects on HRQoL (health related quality of life), anxiety, depression. The results of this study along with the depression and mood. Community group singing ap- previous research indicate that music therapy with its pears to have a significant effect on mental health- specific qualities is a valuable enhancement to establi- related quality of life, anxiety and depression, and it shed treatment practices (Erkkilä 2011). This is based may be a useful intervention to maintain and enhance on a meta-analysis of 9 studies including 411 partici- the mental health of older people (Coulton 2015). pants. The findings of the meta-analysis indicate that In working age patients, studies were heterogeneous music therapy provides short-term beneficial effects for with significant methodological limitations, allowing people with depression. Music therapy added to treat- only a weak recommendation for group singing as an ment as usual (TAU) seems to improve depressive intervention for adults with chronic health problems symptoms compared with TAU alone. Furthermore, (Reagon 2017, 2016). However, when comparing ‘Music music therapy plus TAU was not associated with more therapy’ to ‘recreational singing ’,the level of depressive or fewer adverse events than TAU alone. Music therapy symptoms improved significantly more in those assig- also showed efficacy in decreasing anxiety levels and ned to music therapy (n=60) than in recreational singing improving the functioning of depressed individuals. In (n=53), both in 6th week (mean difference 3.0 scores, interpreting these statements, it is important to clearly 95% CI 1.21 to 4.79, p=0.001) and 12th week (Werner describe the music therapy (Aalbers 2017). It is impor- 2017). In general, singing is shown to improve symp- tant to note that Music Therapy needs to be seen as an toms of depression.

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SINGING AND questionnaires completed by the participants. However POST-NATAL DEPRESSION a deterioration, was observed stated in the therapy group at follow-up six months post-therapy. Overall, among all mothers with symptoms of Post- Hayashi et al. (2002) studied the efficacy of group Natal Depression, there was a non-significant faster musical therapy for inpatients with DSM-IV schizo- improvement in symptoms in the singing group phrenia or schizoaffective psychosis in thirty-four the- (Fancourt 2018). rapy group subjects in a long-stay female ward (Hayashi Among all mothers with symptoms of PND, there 2002). The patients received 15 group musical therapy was a non-significant faster improvement in symptoms sessions over 4 months, while 32 waiting group subjects in the singing group. When isolating mothers with from another ward were used as a control group moderate-severe symptoms of PND, this result became (Hayashi 2002). The assessment included measures of significant, with a faster improvement in symptoms in psychotic symptoms, objective quality of life and the singing group. subjective musical experiences (Hayashi 2002). There Data show associations between singing to babies appeared to be significant advantages in the therapy and fewer symptoms of postnatal depression. Data also group in some measures concerning personal relations show associations with enhanced wellbeing, self-esteem and furthermore there was a subjective sense of partici- and improved mother-infant bond (Fancourt 2018, 2017). pation in a chorus activity (Hayashi 2002). However, However, as mothers experience depressive symptoms, the follow-up evaluation suggested that the improve- their infant directed (ID) singing may lack the sensi- ment in personal relations and musical experiences of tivity and emotional expression that infants need for these chronic psychotic patients might be only short- affect regulation. An intervention that combines inter- lived (Hayashi 2002). action coaching and ID singing may help mothers with Another study by Talwar et al. (2006) was somewhat depressive symptoms to engage in sensitive and less positive. Up to 12 weeks of individual music the- emotionally synchronized interactions with their infants. rapy plus standard care was compared with standard The Sing&Grow programme in Australia is one of the care alone. 81 patients were randomised (Talwar 2006). first studies to take a quantitative approach. It is a Assessments of mental health, global functioning and Community driven music therapy project that provides satisfaction with care were conducted at 3 months services for young children and their families. The (Talwar 2006). Two-thirds of those randomised to music programs focus on strengthening family relationships, therapy attended at least four sessions (median atten- building capacity in parents to support their children's dance, eight sessions) (Talwar 2006). A Multivariate development in the early years of life, and encouraging analysis demonstrated a trend towards improved symp- the use of music within communities (Abad 2004). tom scores among those randomised to music therapy, especially in general symptoms of schizophrenia MUSIC THERAPY IN SCHIZOPHRENIA (Talwar 2006). It was concluded that the effects and AND PSYCHOSIS cost-effectiveness of music therapy for acute psychosis should be further explored (Talwar 2006). It has been reported that music therapy and exercise Silverman (2003) carried out a meta-analysis was have been found to be useful for unspecified negative conducted on 19 studies of music therapy in schizo- symptoms of schizophrenia (Veerman 2017, Helgason phrenia. Results indicated that music has proven to be 2013). This was emphasized by a randomized study by significantly effective in suppressing and combating the Ulrich (2007), which studied Thirty-seven patients with symptoms of psychosis (d=+0.71). There were no psychotic disorders, who were were randomly assigned differing effects between live versus recorded music and to experimental and control groups (Ulrich 2007). Both between structured music therapy groups versus passive groups received medication and treatment indicated for listening, nor were there differing effects between their disorder. Additionally, the experimental group preferred versus therapist-selected music. Furthermore, (n=21) underwent group music therapy (Ulrich 2007). classical music was not as effective as nonclassical Significant effects of music therapy were found in the music in reducing psychotic symptoms. This supports patients' self-evaluation of their psychosocial orientation the therapeutic potential of popular music in treating and in negative symptoms (Ulrich 2007). No differences patients with psychotic symptoms. were found in the quality of life. It was concluded that Various different methodologies of delivering music Musical activity diminished negative symptoms and therapy to patients with schizophrenia have been descri- improved interpersonal contact (Ulrich 2007). bed. Schmuttermayer (1980, 1983) described four types Pfeiffer et al. (1987) studied the effects of a course of music therapy (listening, singing, dancing and playing of music therapy with free improvisation, consisting of instruments) which can be combined to obtain a "gra- 27 sessions over a period of 6 months, in 7 patients with duated group-centred music therapy" in order to treat a diagnosis of schizophrenia or schizoaffective psycho- patients schizophrenia. Each of the therapy types is said sis, with a control group of a similar number. Signifi- to act in a different way on the variables "anxiety" and cant positive changes were found in the self-assessment "activity", and it was recorded to be possible to

S597 Shentong Wang & Mark Agius: THE USE OF MUSIC THERAPY IN THE TREATMENT OF MENTAL ILLNESS AND THE ENHANCEMENT OF SOCIETAL WELLBEING Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 595-600 influence these variables during group-centered treat- The reason music has been thought to be helpful in ment and to lead the group towards modes of communi- patients with dementia is because Music has a number of cation and behaviour that are more appropriate to reality. 'design features' that make it uniquely equipped to engage Regarding the way in which music therapy works in multiple aspects of the self. Each design feature interacts schizophrenia, Insellmann has pointed out the emotional with different aspects of the self to varying degrees, and cognitive aspects of music perception and its promoting overall wellbeing. Thus Baird’s framework of possible influence on self perception and strengthening music therapy may be useful for the diagnosis and of ego. It was suggested that in patients with schizo- treatment of impairments of self in people with dementia, phrenia, the effects of music therapy were related to and may highlight how music, given its ability to engage self-object-differentiation. all aspects of the self simultaneously, can result in an overall enhanced sense of self (Baird 2018). MUSIC IMPROVES SLEEP QUALITY There have been reports that Preferred Music The- rapy, that is, playing music which is the Patient’s own It has been shown that the use of music does im- preference can help Anxiety and Agitation in Dementia. prove sleep quality in several groups of patients. Thus Sung in 2005 reported that Preferred music (Pa- In Older Adults, music resulted in significantly bet- tient’s preference) has positive effects on decreasing agitated behaviours in older people with dementia (NB ter sleep quality in the experimental group, as well as Small numbers) (Sung 2005). His reported numbers significantly better components of sleep quality: better were, however, small. perceived sleep quality, longer sleep duration, greater sleep efficiency, shorter sleep latency, less sleep distur- Hence, the effect of Music therapy on agitation in bance and less daytime dysfunction (P=0.04-0.001). Dementia has been further studied. A metanalysis of 17 Sleep improved weekly, indicating a cumulative dose studies with 620 participants suggest using five sessions effect (Lai 2005). of a music-based therapeutic intervention probably reduces depressive symptoms but had little or no effect on In students, music statistically significantly impro- agitation or aggression. There may also have little or no ved sleep quality; Depressive symptoms decreased sta- effect on emotional well-being or quality of life, overall tistically significantly in the music group (Harmat behavioural problems and cognition. The reporters 2008). further stated that they were uncertain about effects on In abused women in shelters, the results indicated anxiety or social behaviour, and about any long-term that music therapy constituted an effective method for effects (Van der Steen 2017, Cooke 2010). reducing anxiety levels. Results also indicated a significant effect on sleep quality for the experimental group, SINGING AND DEMENTIA but not for the control group (Hernández-Ruiz 2005). In a meta-analysis of Music-assisted relaxation to The effect of singing has been studied in dementia. improve sleep quality, which studied five randomized Patients with both dementia and depression have been controlled trials with 170 participants, Music-assisted encouraged to join choirs, as in the Michaelhouse relaxation was shown to have a moderate effect on the Corale in Cambridge, UK. sleep quality of patients with sleep complaints. Thus Singing and painting interventions may reduce pain Music-assisted relaxation can be used without intensive and improve mood, quality of life, and cognition in investment in training and materials and is therefore patients with mild Alzheimers Disease, with differential cheap, easily available and can be used by nurses to effects of painting for depression and singing for me- promote music-assisted relaxation to improve sleep mory performance. Depression was reduced over time quality (de Niet 2009). in painting group only. Verbal Memory performance remained stable over time in singing group, but de- MUSIC THERAPY AND DEMENTIA creased in painting group (Pongan 2017). Music therapy has also been studied in Dementia. SINGING AND INCREASED It has been suggested that Receptive music therapy DEMENTIA AWARENESS (that is, listening to music) could reduce agitation, behavioural problems, and anxiety in older people with Harris et al. studied the effect of using an intergene- dementia, and it appears to be more effective than rational choir in order to attempt to make a university interactive music therapy. However, providing people community more dementia friendly. They reported that with dementia with at least five sessions of a music- results across all four cohorts showed in the students: based therapeutic intervention probably reduces de- changed attitudes, increased understanding about depressive symptoms but has little or no effect on mentia and the lived experience, reduced dementia agitation or aggression. There may also be little or no stigma, and the development of meaningful social con- effect on emotional well-being or quality of life, overall nections. People with dementia and their family mem- behavioural problems and cognition (Tsoi 2018, Van bers expressed feelings of being part of a community der Steen 2017). (Harris 2018).

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CONCLUSION 10. Coulton S, Clift S, Skingley A, Rodriguez J: Effectiveness and cost-effectiveness of community singing on mental It appears clear that the use of music as a therapeutic health-related quality of life of older people: randomised tool is very useful in a number of different mental health controlled trial. Br J Psychiatry 2015; 207:250-5 conditions and in promoting general mental wellbeing. 11. de l'Etoile SK, Leider CN: Acoustic parameters of infant- directed singing in mothers with depressive symptoms. This is particularly true when music is an adjunct for Infant Behav Dev 2011; 34:248-56 treating depression, anxiety, schizophrenia, and also 12. de Niet G, Tiemens B, Lendemeijer B, Hutschemaekers G: dementia. Music-assisted relaxation to improve sleep quality: meta- Encouraging singing appears to be a good adjunct analysis. J AdvNurs 2009; 65:1356-64 to treating all of these conditions, and it also seems to 13. Edwards: Antecedents of contemporary uses for music in help bonding between mothers and children within fa- healthcare context: the 1890s to the 1940s p181-202, 2007 milies. 14. Erkkilä J, Punkanen M, Fachner J, Ala-Ruona E, Pöntiö I, Music appears to be beneficial to both the indi- Tervaniemi M, Vanhala M, Gold C: Individual music vidual, and also to the improvement of social cohesion. therapy for depression: randomised controlled trial. Br J Psychiatry 2011; 199:132-9 The reasons for this must reside in the nature of music 15. Fancourt D, Perkins R: Effect of singing interventions on itself as an art form which supports human interactions symptoms of postnatal depression: three-arm randomised within society. controlled trial. Br J Psychiatry 2018; 212:119-121 16. Fancourt D, Perkins R: Associations between singing to babies and symptoms of postnatal depression, wellbeing, Acknowledgements: None. self-esteem and mother-infant bond. Public Health 2017; 145:149-152 Conflict of interest: None to declare. 17. Harris PB, Caporella CA: Making a university community more dementia friendly through participation in an Contribution of individual authors: intergenerational choir. Dementia (London) 2018; 1:1471301217752209 Shentong Wang carried out the main literature search 18. Harmat L, Takács J, Bódizs R: Music improves sleep and developed and presented the presentation on quality in students. J Adv Nurs 2008; 62:327-35 which this paper is based. 19. Hayashi N, Tanabe Y, Nakagawa S, Noguchi M, Iwata C, Mark Agius supervised the project andhelped in deve- Koubuchi Y, Watanabe M, Okui M, Takagi K, Sugita K, loping the final text. Horiuchi K, Sasaki A, Koike I: Effects of group musical therapy on inpatients with chronic psychoses: a controlled study. Psychiatry Clin Neurosci 2002; 56:187-93 References 20. Helgason C, Sarris J: Mind-body medicine for schizophrenia and psychotic disorders: a review of the evidence. 1. 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J Clin Routlidge, 1991 Nurs 2012; 21:745-56 5. Carr C, Odell-Miller H, Priebe S: A systematic review of 24. Lai HL, Good M: Music improves sleep quality in older music therapy practice and outcomes with acute adult adults. J Adv Nurs 2005; 49:234-44 psychiatric in-patients. PLoS One 2013; 8:e70252 25. Maratos A, Crawford MJ, Procter S: Music therapy for 6. Chan MF, Wong ZY, Thayala NV: The effectiveness of mu- depression: it seems to work, but how? Br J Psychiatry. sic listening in reducing depressive symptoms in adults: a 2011; 199:92-3 systematic review. Complement Ther Med 2011; 19:332-48 26. Pfeiffer H, Wunderlich S, Bender W, Elz U, Horn B: Music 7. Chan MF, Chan EA, Mok E, Kwan Tse FY: Effect of music improvisation with schizophrenic patients - a controlled on depression levels and physiological responses in study in the assessment of therapeutic effects. Rehabili- community-based older adults Int J Ment Health Nurs tation (Stuttg) 1987; 26:184-92 2009; 18:285-94 27. Pongan E, Tillmann B, Leveque Y, Trombert B, Getenet 8. Chan MF, Wong ZY, Onishi H, Thayala NV: Effects of JC, Auguste N, Dauphinot V, El Haouari H, Navez M, music on depression in older people: a randomised Dorey JM, Krolak-Salmon P, Laurent B, Rouch I; LAC Mé controlled trial. J ClinNurs 2012; 21:776-83 Group: Can Musical or Painting Interventions Improve 9. Cooke ML, Moyle W, Shum DH, Harrison SD, Murfield Chronic Pain, Mood, Quality of Life, and Cognition in JE: A randomized controlled trial exploring the effect of Patients with Mild Alzheimer's Disease? Evidence from a music on agitated behaviours and anxiety in older people Randomized Controlled Trial. J Alzheimers Dis 2017; with dementia. Aging Ment Health 2010; 14:905-16 60:663-677

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28. ReagonC, Gale N, Dow R, Lewis I, van DeursenR: Choir 36. Talwar N, Crawford MJ, Maratos A, Nur U, McDermott singing and health status in people affected by cancer. O, Procter S: Music therapy for in-patients with schizo- Reagon C, Gale N, Dow R, Lewis I, van Deursen R, Eur J phrenia: exploratory randomised controlled trial. Br J Cancer Care (Engl) 2017; 26:5 Psychiatry 2006; 189:405-9 29. Reagon C, Gale N, Enright S, Mann M, van Deursen R: A 37. TsoiKKF, Chan JYC, Ng YM, Lee MMY, Kwok TCY, Wong mixed-method systematic review to investigate the effect of SYS: Receptive Music Therapy Is More Effective than group singing on health related quality of life, Reagon C, Interactive Music Therapy to Relieve Behavioral and Gale N, Enright S, Mann M, van Deursen R, Complement Psychological Symptoms of Dementia: A Systematic Ther Med 2016; 27:1-11 Review and Meta-Analysis. J Am Med Dir Assoc 2018. pii: 30. Schmuttermayer R: Possibilities for inclusion of group music S1525-8610(17)30694-1 therapeutic methods in the treatment of psychotic patients. 38. Ulrich G, Houtmans T, Gold C: The additional thera- Psychiatr Neurol Med Psychol (Leipz) 1983; 35:49-53 peutic effect of group music therapy for schizophrenic 31. Schmuttermayer R: Methodological considerations and patients: a randomized study. Acta Psychiatr Scand 2007; practical experiences with music therapy in psychotics. 116:362-70 Psychiatr Neurol Med Psychol (Leipz) 1980; 32:739-44 39. Van der Steen, van Soest-Poortvliet, van der Wouden, 32. Silverman MJ: The influence of music on the symptoms of Bruinsma, Scholten & Vink: Music-based therapeutic psychosis: a meta-analysis. J Music Ther 2003; 40:27-40 interventions for people with dementia, Cochrane Data- 33. Sliwka A, Jarosz A, Nowobilski R: Music therapy as a part base Syst Rev 2017; 5:CD003477 of complex healing. Pol MerkurLekarski 2006; 21:401-5 40. Veerman SRT, Schulte PFJ, de Haan L: Treatment for 34. Sung HC, Chang AM: Use of preferred music to decrease Negative Symptoms in Schizophrenia: A Comprehensive agitated behaviours in older people with dementia: a Review. Drugs 2017; 77:1423-1459 review of the literature. J Clin Nurs 2005; 14:1133-40 41. Werner J, Wosch T, Gold C: Effectiveness of group music 35. Sung HC, Chang AM, Lee WL: A preferred music listening therapy versus recreational group singing for depressive intervention to reduce anxiety in older adults with dementia symptoms of elderly nursing home residents: pragmatic in nursing homes. J Clin Nurs 2010; 19:1056-64 trial. Aging Ment Health 2017; 21:147-155

Correspondence: Shentong Wang, BA (Cantab) Clare College Cambridge, School of Clinical Medicine, University of Cambridge Cambridge, UK E-mail: [email protected]

AESTHETIC EXPERIENCE: WHEN EMOTIONS BECOME A CARE Maria Grazia Spurio Educational and Psychological Center "Genius Academy", Roma, Italy

SUMMARY Visual arts enable the artist to present to the viewer their internal subconscious thoughts. There is a connection between the artist and the viewer. This is so with famous artists, but also with patients who create artworks. This link between artist and viewer can be used in therapy to explore the artist/patient’s interior self. This understanding between artist and viewer can , in therapy, become an expression of caring.

Key words: creative arts - visual arts - art therapy - psychiatry

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The history of the creative and visual arts is intert- the notable emotional experience that pervades them, wined, from ancient times, with that of health and so that the common man succeeds to enter into a sort mental wellbeing. From the Greek theater, which can be of emotional symbiosis with the emotional world of considered a sort of 'therapeutic support-art', to psycho- the artist. A bridge of connection develops between analysts such as Freud and Jung, who considered the those who create and those who enjoy the creation, work of art an expressive form of the unconscious, and that is mysteriously established, in spite of all derivative of the process of sublimation of basic ins- rationality. Thus arises an aesthetic experience where tincts, to the founder of art therapy in America, Marga- no logical rule exists anymore, and where, only thanks ret Naumburg, who identifies the artistic material with to the strong emotions evoked, it is possible to realize an instrument of interpretation and resolution of inter- one of the highest forms of emotional transmission full nal conflicts. of contents and therapeutic potentials. When we talk Art therefore, can be considered as means of sup- about great artists we think of the school of belonging porting the ego, a healing factor, and an instrument for or the technique used, not necessarily about deepening reconciling emotional conflicts. By artistically ela- the psychological aspect hidden behind the works. borating one's own experience, educating oneself to For example Cèzanne, the Monte Sante-Victoire be- creative transformation, could mean filling the gray came his obsessive thought: he had always happily pain- roads of rationality with the colours of the emotions. ted the landscape of his Provence, but in the last period Art therapy may be used both in the medical- the mountain was painted in an almost obsessive way, psychiatric context and also in rehabilitation, as well so much so that he dedicated over fifty works to it. as in education-prevention contexts. In the medical Magritte, through the elaboration of the thought represen- field, art therapy has proved to be an excellent tool for ted in 'The collective invention', a work from 1935 in the emotional regulation of patients suffering from which a naked woman, half fish, is mute and lies dead chronic diseases, or anticipating major surgery or a on the seashore, seems to have been helped, albeit on an medical procedure, the most common examples being unconscious level, in the mourning of the mother. A those aimed at children and oncology patients. The depressed mother, disappeared in the middle of the night success obtained in the psychiatric field has led to the from her bedroom, distressing images, often revisited in addition of art therapy to the rehabilitation field for the artist's works through continuous references to open subjects with neurological damage. wardrobes and abandoned female nightwear. After hours In the field of prevention, art therapy can facilitate of feverish research she was found dead from suicide by the creation of a space in which to meet oneself in an drowning, with the nightgown on her face. The observer authentic way, express one’s emotions and deal with of these works of art can therefore be encouraged, in a one's most profound and unaware aspects of personality. free and conscious activity of mirroring, to bring out The task of the sensible professional, in this case, is to emotions that, thanks to the support of the professional, accompany the patient, in a prepared and careful way, in can be accepted and re-interpreted in a functional way. the exploration of himself/herself, using this tool so This is the starting point for the realization of the intrinsically linked to his emotional sphere. Thus this union of art and psychiatry, thanks to the great becomes a journey made through individual expressive therapeutic value of the art world. This therapeutic technique, sometimes unconsiously, but also one of value is sublimated in the strong emotions conveyed by careful observation. the aesthetic experience, which allows, thanks to the The same painters can be considered great artists, special and mysterious connection of souls, to penetrate just because they are able to impress in their creations into the extraordinary emotional world of the others.

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3. Gettings F: You are an artist: A pratical approach to art. Acknowledgements: None. Hamlin, New York, 1966 4. Jung GC: The spirit in man, art, and literature. Princeton Conflict of interest: None to declare. University Press, Princeton, Usa, 1966 5. Naumburg M: Dynamically oriented art therapy: its principles and practices. Grune & Stratton, New York, 1966 References 6. Spurio MG: Il suono della guarigione. Roma, 2015, ISBN 9788893068291 1. Denner A, Malavasi L: Arteterapia: Metodologia e Ricerca. 7. Spurio MG: May we feed cancer? Insights Depress Anxiety. Atelier terapeutici di espressione plastica. Edizioni Del 2018; 2:001-006. Cerro, Pisa, 2002 https://doi.org/10.29328/journal.ida.1001005 2. Freud S: Formulation regarding the two principles in men- 8. Warren B: Using the creative arts in therapy. Routledge tal functioning, trad it. Precisazioni sui due principi dell- London, N.Y., trad.it. Arteterapia in educazione e ’accadere psichico. OSF, vol. 6, Boringhieri, Torino, 1911 riabilitazione, Erickson, 1995

Correspondence: Maria Grazia Spurio, MD, PhD, Psychotherapist Educational and Psychological Center "Genius Academy" Via Carlo Arturo Jemolo, 83 00156, Roma, Italy E-mail: [email protected] Web: www.mariagraziaspurio.com - www.unchainyourmind.org

DIGNITY THERAPY: PREVENTION OF SUICIDAL RISK IN THE PENITENTIARY AREA Mariangela Perito Neamente Neuroscience Association, Avellino, Italy

SUMMARY Dignity therapy was administered to ten prisoners in a detention center. The Beck Depression Inventory was administered before and after the intervention. The results obtained from the Beck Depression Inventory have highlighted dimensional changes in all the prisoners. There was a significant improvement in relational abilities and the disappearance of self-harming thoughts.

Key words: dignity therapy – depression - suicide risk - prisoners

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INTRODUCTION to evaluate the effect of the narrative of important life issues and the consequences on depressive symptoms. From clinical practice and daily observation of pri- The selected prisoners were 10 aged between 18 and 60 soners, it emerges that within the prison, the person years (8 M - 2F), with different lives and detention loses autonomy, identity, values, the success of one’s histories. existential project, the desire for self realization. The most frequently observed psychiatric symptoms are RESULTS AND CONCLUSION depression, tendency to isolation, adaptation disorders, blame, and self-injurious gestures (Ferraro 2001). In this experimental study, it has emerged that the prisoners first have accepted and listened to this the- AIM rapy, and then they applied the narratives and this led to a reworking of their personal experience which enabled The aim of the project was the administration of a them to accept themselves better as people. The results protocol of dignity therapy in a detention center, to obtained from the Beck Depression Inventory have assess whether the preservation of dignity and highlighted dimensional changes in all the prisoners. relationships, which is one of the goals of the treatment There was a significant improvement in relational abi- of dignity (Mai et al. 2018), can affect the improvement lities and the disappearance of self-harming thoughts. of the observed depressive symptoms, guilt, self- Three people show deep changes in the range of injurious gesture, suicidal thoughts. Dignity Therapy mood. (DT) is a multi-dimensional, brief and individualized In particular, the following cases are highlighted: psychotherapeutic intervention, that aims to relieve In R.D. 57-year-old drug-addicted who had anxious psychological and existential distress in patients living and depressive symptoms has gone from a moderate with life-threatening behavior or life-limiting diseases depression state to one of mild depression. After the (Chochinov et al. 2005). Originally, it was conceived interview, his relational skills increase, the ability to for terminal or cancer patients, but some research has enjoy things as in the past increases and self- begun to highlight its importance in a population of harming thoughts do not emerge; non-cancer patients (Chochinov et al. 2016). Dignity In C.G., 68-year-old, already diagnosed with depres- Therapy can represent an ethical will, a life review, a sed mood and resulting with a slight depression in personal narrative; it may promote spiritual and the first administration of the Beck test, after the psychological well-being (Boyken et al. 2015), it may interview, depressive symptoms do not appear, mood give meaning and hope and improve life experience of generally improves, relational skills improve; people subject to restraint. In M.E., 33-year-old sentenced to life in prison, re- MATERIAL AND METHODS sulting with a slight depression in the first administration of the Beck test, after the delivery of the document, depressive symptoms, pessimistic thoughts Dignity Therapy was offered to prisoners in the Bel- about the future and self-destructive behavior dis- lizzi Irpino (AV), Italy, a detention center, throughout a appear. guided interview based on standardized thematic questions and other reinforcement sub-themes. Before the Three people show deep changes in the range of Dignity interview, the Beck Depression Inventory was mood. Restoration of dignity was the common element administered to each prisoner in pre and post-test phases of the different interviews.

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2. Chochinov HM, Johnston W, McClement SE, Hack TF et al: Dignity and Distress towards the End of Life across Four None. Acknowledgements: Non-Cancer Populations. PLoS One 2016; 11:e0147607 3. Chochinov HM, Hack T, Harlos M, Hassard T, Kristjon- Conflict of interest: None to declare. son LJ, McClement S: Dignity Therapy: a novel psychotherapeutic intervention for patient near the end of live. J Clin Oncol 2005; 23:5520-5 References 4. Ferraro G: Filosofia in Carcere. Incontri con i minori di Nisida. Filema; 2ed, 2001 1. Boyken L, Emmanuel L, Fitchett G, Handzo G, Wilkie DJ: 5. Mai SS, Goebel S, Jentschke E, van Oorschot B, Renner Care of the human spirit and role of dignity therapy: a KH, Weber M: Feasibility, acceptability and adaption of systematic review of dignity therapy research. BMC dignity therapy: a mixed methods study achieving 360° Palliat Care 2015; 21:14-8 feedback. BMC Palliat Care 2018; 17:73

Correspondence: Mariangela Perito, MA Neamente Neuroscience Association Via Lorenzo Ferrante n.100, 83100 Avellino, Italy E-mail: [email protected]

SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS: AN OVERVIEW Amol Joshi Emmanuel College, University of Cambridge, Cambridge, UK

SUMMARY Selective serotonin re-uptake inhibitors (SSRIs) are front-line pharmacotherapies in the treatment of major depressive disorder (MDD), a disorder characterized by a persistent low mood, anhedonia and feelings of worthlessness. Since their formulation over 40 years ago, there have been several conflicting studies exploring the efficacy of these highly prevalent drugs. The nature of their therapeutic effect has also remained elusive, with several hypothesises pertaining to neurotransmitter and endocrine modulation proposed. While the medications are better tolerated than their predecessors, the tricyclic antidepressant family (TCAs), the side effect profile of SSRIs is not insubstantial and novel cases have highlighted adverse effects enduring past the cessation of drug treatment. Data gathered from clinical practice also highlights that the prevalence of these side effects is often underestimated, leading to patient frustration and non-compliance. This report will seek to outline the rise of SSRI usage in the last half century while exploring possible avenues of pharmacotherapeutic action, with a particular focus on the side effect profile of these drugs.

Key words: selective serotonin re-uptake inhibitor (SSRI) - major depressive disorder (MDD) - psychopharmacology

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INTRODUCTION the concentration of these monoamines in the synaptic cleft (Preskom 1982). The TCAs however, while effi- The role of serotonin (5-HT) itself in the aetiology cacious for depression, had an unpleasant side effect of major depressive disorder (MDD) was initially brought profile as a result of their near-ubiquitous off-target to light in the form of the monoamine hypothesis of activity; symptoms including dry mouth, hypotension depression, which in its simplest form postulated that and urinary retention were frequent complaints among MDD was a consequence of chemical imbalances’ of TCA users (Furukawa 2002). serotonin, noradrenaline (NA) and dopamine (DA) While the monoamine hypothesis has since been levels in limbic areas (Smart 2015). Initial studies lent shown to be overly simplistic (Salomon 1997), the un- weight to this argument, with decreased 5-HIAA levels derlying rational that modulating 5-HT would improve being reported in suicide attempters diagnosed with MDD symptoms has endured. Indeed, this has been MDD compared to healthy controls (Mann 1997). corroborated by animal studies which have kept afloat Further evidence for depression precipitating as a result the argument for the role of serotonin in depression, of aberrant monoamine modulation stemmed from data with SERT deficient mice expressing depressive pheno- collected from the use of reserpine, a potent anti- types (Ansorge 2004). The pharmaceutical giant Eli th hypertensive used extensively in the mid 20 century Lilly eventually shone the spotlight exclusively on sero- (Achor 1955). While animal studies had demonstrated tonin, and in 1986 the first selective serotonin reuptake the efficacy of reserpine in depleting 5-HT and NA antidepressant fluoxetine was approved in the USA as from the mammalian hypothalamus (Holzbauer 1956), a novel treatment for MDD (Wong 2005). Several it was also noted that the use of reserpine had led to decades on, it is clear that the SSRI class of drugs have the unwanted of effect of inducing depression in hu- revolutionised the treatment of depression; indeed, they mans undergoing therapy for hypertension. One such remain a first line pharmacotherapy for MDD to this example, involving a 54-year old woman being treated day (NICE 2009). with reserpine for severe hypertension, recovered fully from her depression upon withdrawal of the offending drug (Freis 1954). PSYCHOPHARMACOLOGY The effect of the monoamine hypothesis was to spur Therapeutic effect the development of compounds that could artificially augment multiple monoamine systems simultaneously. SSRI drugs exert their therapeutic effect by causing The answer to this came in the form of the tricyclic regional blockade of the presynaptic serotonin trans- antidepressant (TCA) class of drugs. Derived from the porter (SERT) located abundantly in dorsal raphe- structure of the antihistamine promethazine (Domino originatingneurons (DRN) and in the hippocampi, 1999), the first drug of the class, imipramine, was amygdala and prefrontal regions (Descarries 1975). shown to cause pharmacological blockade at the pre- These structures play critical roles in mediating the synaptic NA and 5-HT uptake channels, thus increasing response to rewarding and emotionally salient stimuli,

S605 Amol Joshi: SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS: AN OVERVIEW Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 605-609 and as such it is likely that the pathogenesis of depres- A landmark review that analysed the pharma- sion has a neural basis amongst the limbic circuitry and ceutical data collected by the FDA about SSRIs its associated cortical connections (Goldin 2008). between 1983 and 2008 revealed that placebo con- Initially, this blockade facilitates an increase in the ditions led to a significant improvement in moderate extracellular concentration of 5-HT, thereby activating MDD phenotypes for over 80% of the cohort (Kirsch inhibitory auto-receptors which open G-protein-coupled 2014). Further probing revealed a SSRI effect size of potassium channels, causing neuronal hyperpolarisation approximately two points on the Hamilton Scale for and an attenuation of 5-HT neurotransmission (Nutt et Depression, contravening the NICE guidelines that al. 1999). Microdialysis studies have revealed that these require a minimum of a 3-point difference between auto-receptors can be classified into two types; 5-HT1A placebo and active compound for it to be considered somatodendritic receptors which mediate Gi-coupled as therapeutically significant (Moncrieff 2005). In ad- neurotransmission (particularly in forebrain regions dition, systematic reviews of RCTs involving antidepressants were found to show a hyperinflated which receive projections from the DRN) and 5-HT1B receptors, which also mediate Gi-coupled inhibition, judgment of SSRI efficacy and a poor benefit to risk leading to adenylyl cyclase inhibition and a subsequent ratio when assessed alongside the potential side effects dampening in serotonergic transmission (Stahl 1998). 5- incurred by patients (Jakobsen 2017). However, major criticisms of this paper have since surfaced including HT1B stimulation on non-serotonergic neurons in the medial prefrontal cortex (mPFC) also has the effect of the “misleading classification” of any adverse effects reducing theta oscillations in layer V pyramidal neurons detailed in Jakobsen’s method’s section (Hieronymus by suppressing hippocampal and contralateral mPFC 2017). inputs (Kjaerby 2016). These theta oscillations arise in The current stance has attempted to undo some of the ventral hippocampus and are thought to encode the negativity surrounding antidepressant efficacy, anxiolytic signals, and as such SSRI treatment can lead with a 2018 network meta-analysis uncovering that SSRIs were indeed more effective than placebos at to consistent 5-HT1B stimulation by 5-HT located in the synaptic cleft (Adhikari 2010). ameliorating MDD (Cipriani 2018). However, it is imperative to consider that this review analysed mul- Chronic treatment with SSRIs is believed to mediate tiple other classes of antidepressants, some of which PKC-dependent desensitisation of presynaptic 5HT 1A were shown to be significantly more efficacious than receptors, thereby disinhibiting the DRN neuron and thus SSRIs. The overall picture about the extent of SSRI increasing basal 5-HT neurotransmission. This was efficacity therefore, remains unclear. reflected in the fall in Gi/Go proteins in the mammalian It is important to note that the indecisiveness cau- midbrain with repeated fluoxetine administration, along- sed by multiple conflicting pieces of literature on SSRI side reduced 5HT mRNA transcription in the anterior 1A efficacy has a profound effect on the lives of the raphe (Li 1997). However, it is often reported that the general public, of which almost 20% will experience antidepressant effect of SSRIs is only evident after some form of depression in their lifetime in the UK several weeks, a finding which may be explained by the (MIND 2018). Headlines such as “Anti-Depressants: time taken to gradually desensitise the inhibitory 5HT 1A Major study finds they work” (BBC 2018) are able to receptors. This is supported by the evidence that pindolol, shape the ideas and expectations of thousands of a 5HT antagonist, augmens the antidepressant effect 1A patients that may require pharmacotherapy for MDD. when given in conjunction with SSRIs (Blier 2001). Therefore, it is evident that there remains further work Changes in the SERT protein may also be seen with until the public are left with a single answer as to the chronic SSRI treatment, with sustained treatment true nature of the effectiveness of SSRIs. radiolabelled paroxetin eleading to a decrease in 5-HT binding sites on the transporter itself (Pineyro 1994). COMPLICATIONS Effectiveness While SSRIs are incredibly selective for the SERT While the molecular mechanism of SSRIs is slowly transporter, they do also have varying degrees of off being unravelled, there still exists a large gap between target activity, which gives rise to some common side the neurobiological understanding of MDD and the effects shared by all members of the drug family. therapeutic effect of SSRIs. Indeed, it is believed that over 80% of individuals Initial studies conducted have concluded that the beginning SSRI therapy experience at least one side drugs within the class are equipotent in the treatment effect, with over half experiencing multiple adverse of severe MDD yet not “interchangeable”, and as such effects (Hu 2004). These side effects appear to be dose patients can be easily switched onto another SSRI dependent and resolve within a few weeks of (Nurnberg 1999). However, the lack of direct placebo- beginning drug treatment. However, there appears to controlled results published during the time the drugs be new evidence that more persistent and serious side were undergoing regulatory approval has led to several effects may occur, which in turn has implications for authors revisiting the efficacy of these compounds. patient compliance and treatment efficacy.

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Nausea Tardive dyskinesia, a condition which involves the abnormal movement of the orofacial and upper body Nausea is one of the chief complaints with anti- areas, may also be a manifestation of aberrant signalling depressant usage and is often a leading cause for early caused by SSRIs. A common presentation of this is in discontinuation of SSRI pharmacotherapy. They are the form of bruxism, a disorder characterised by re- thought to be as a result of excessive 5-HT receptor 3 peated grinding of the teeth with accompanying mandi- signalling in the solitary nucleus and in vagal terminals bular dystonia. Neuroanatomical mapping experiments embedded along the length of the gastric tract (Tyers in the 1980s highlighted that motor neurons responsible 1992). In addition, there is clear impetus of the role of for the control of the face and jaw had a comparatively the 5-HT receptor in SSRI-induced nausea as ondanse- 3 large density of 5-HT input from the DRN, thus poin- tron, a 5-HT antagonist, was able to alleviate nausea in 3 ting to a drug-induced effect for bruxism (Steinbusch SSRI-treated individuals (Bailey 1995). 1981). The disorder has been shown to be successfully treated by buspirone, a 5-HT1A agonist, however further Dopaminergic effects research is required before commenting on its efficacy Neurophysiological studies have revealed that ex- in clinical practice (Bostwick 1999). cessive synaptic 5-HT can lead to the modulation of dopaminergic signalling downstream of the target- Sexual effects neuron pool. DRN neurons project to the striatum, an area abundant with dopaminergic cells and are thought Decreased libido and sexual pleasure are characteristic features of MDD and often improve upon to mediate 5-HT2 receptor dependent inhibition of DA cell firing (Zangen 2001). Indeed, positron-emission remission of the depressive episode. However, evid- tomography studies in female baboons have demon- ence points to the nature of a pharmacological origin to the distinctive sexual dysfunction seen in those strated that altansterin, a 5-HT2 receptor antagonist, enhanced striatal DA transmission (Dewey 1995). As undergoing SSRI treatments as a consequence of such, it is hypothesised that SSRIs may exacerbate neurotransmitter modulation in CNS areas respon- dopaminergic inhibition as a result of excessive sero- sible for desire, arousal, orgasm and resolution. tonin receptor stimulation. These modulations include the serotonergic inhibition of dopamine release discussed previously, which may This notion is reflected in case reports of SSRI- contribute to the erectile difficulties experienced by treated patients experiencing extrapyramidal symp- over 35% of patients (Montejo-González 1997). toms (EPS) and akathisia, which is of grave concern. Initially believed to be a by-product of long-term high In a similar fashion, the control of prolactin secre- potency neuroleptic use, these debilitating adverse ef- tion is under dynamic reciprocal control by serotonin fects have a poor prognosis, and can severely impair (stimulatory) and dopamine (inhibitory) (Advis 1979). day-to-day functioning. One such case, of a female As SSRIs enhance serotonin signalling and supress being treated for MDD, reports how she began to dopaminergic neurotransmission one may assume the exhibit severe akathisia upon commencing 20 mg/day occurrence of hyperactivity in the prolactin-secreting fluoxetine treatment, with a profound inability to sit hypothalamic regions in SSRI-treated individuals. still. Upon titrating the dose to 5 mg/day, the symp- Indeed, SSRIs have been shown to cause hyperpro- toms lessened, only to remerge weeks later alongside lactinemia, a condition associated with sexual dysfunc- suicidal intent (Hamilton 1992). The mechanism be- tion, with raised plasma concentrations of prolactin hind SSRI-induced akathisia is unclear, as it appears to observed after citalopram administration (Laine 1997). occur without the dystonic features seen in neuro- Furthermore, the aspects of orgasm and ejaculation are leptic-induced akathisia. Animal studies have tenta- believed in part to be mediated by descending spinal tively pointed at the role of the mesolimbic DA system autonomic pathways (Stein 1994). These pathways are in being complicit in the pathophysiology of akathisia. rich in the 5-HT2C receptor, and thus dysfunction of Indeed, lesions of the A10 cell fields, in which the these intrinsic pathways may contribute to the global mesolimbic projections originate, have induced persi- picture of sexual dysfunction observed in SSRI-treated stent hyperactivity and ‘restlessness’ in rodents (Tassin patients. While direct treatment options are limited (e.g. 1978). SSRI treatment may therefore mirror the effect sildenafil for erectile dysfunction), dose titration is often the preferred method for combatting SSRI-induced of fine lesions by causing 5-HT2 receptor-dependent inhibition of these cell fields, giving rise to the sexual dysfunction. akathisia phenotype in patients. Management of this condition primarily involves titrating the dose (or CONCLUSION discontinuing the drug) until symptoms improve, however beta-blockers have also been shown to be efficacious Given the high prevalence of MDD and the increa- in alleviating symptoms, perhaps as a consequence of sing use of SSRIs in conditions such as anxiety, further the complex interplay of monoamine transmitters in the study of these front-line drugs is necessary. Overall, it basal ganglia (Lipinski 1989). can be concluded that SSRIs remain effective drugs in

S607 Amol Joshi: SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS: AN OVERVIEW Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 605-609 the treatment of severe MDD however their efficacy in 16. Dewey SL, Smith GS, Logan J, Alexoff D, Ding YS, King P mild to moderate depression is still unclear. Pertaining & Ashby CR: Serotonergic modulation of striatal dopa- to their extensive side effect profile, some of which mine measured with positron emission tomography (PET) and in vivo microdialysis. Journal of Neuroscience 1995; may remain as persistent, post-exposure effects, life- 15:821-829 style remedies (e.g. exercise, mindfulness) should be 17. Domino EF: History of modern psychopharmacology: a considered as alternative first-line therapies where personal view with an emphasis on antidepressants. possible. The role of the 5-HT1A and 5-HT2C receptors, Psychosom Med 1999; 61:591-598 while currently under investigation, may eventually 18. 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Hieronymus F, Lisinski A, Näslund J & Eriksson E: Multiple possible inaccuracies cast doubt on a recent report suggesting selective serotonin reuptake inhibitors References to be toxic and ineffective. Acta neuropsychiatrica 2018; 30:244-250 6. Achor RW, Hanson NO & Gifford RW: Hypertension 23. Holzbauer M & Vogt M: Depression by reserpine of the treated with Rauwolfia serpentina (whole root) and with noradrenaline concentration in the hypothalamus of the reserpine: controlled study disclosing occasional severe cat. Journal of neurochemistry1956; 1:8-11 depression. Journal of the American Medical Association 24. Hu XH, Bull SA, Hunkeler EM Ming E, Lee JY, Fireman B 1955; 159:841-845 & Markson LE: Incidence and duration of side effects and 7. 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Kirsch I: Antidepressants and the placebo effect. 10. Bailey JE, Potokar J, Coupland N & Nutt DJ: The 5-HT3 Zeitschrift für Psychologie 2014; 222:128 antagonist ondansetron reduces gastrointestinal side 27. Kjaerby C, Athilingam J, Robinson SE, Iafrati J & Sohal effects induced by a specific serotonin re-uptake inh- VS: Serotonin 1B receptors regulate prefrontal function by ibitor in man. Journal of Psychopharmacology 1995; gating callosal and hippocampal inputs. Cell reports 9:137-141 2016; 17:2882-2890 11. BBC: Anti-depressants: Major study finds they work. 28. Laine K, Anttila M, Heinonen E, Helminen A, Huupponen 2018. Retrieved from BBC News: Anti-depressants: Major R, Mäki-Ikola O & Scheinin M: Lack of adverse inter- study finds they work actions between concomitantly administered selegiline and 12. Blier P: Pharmacology of rapid-onset antidepressant treat- citalopram. Clinical neuropharmacology 1997; 20:419-433 ment strategies. The Journal of clinical psychiatry 2001; 29. Li Q, Muma NA, Battaglia G & Van de Kar LD: A 62:12-17 Desensitization of Hypothalamic 5-HT1A receptors by 13. Bostwick JM & Jaffee MS: Buspirone as an antidote to repeated injections of paroxetine: reduction in the levels SSRI-induced bruxism in 4 cases. Journal of Clinical of Gi and Go proteins and neuroendocrine responses, but Psychiatry 1999; 60:857-860 not in the density of 5-HT1A receptors. Journal of 14. Cipriani A, Furukawa TA, Salanti G, Chaimani A, Pharmacology and Experimental Therapeutics 1997; Atkinson LZ, Ogawa Y & Egger M: Comparative efficacy 282:1581-1590 and acceptability of 21 antidepressant drugs for the acute 30. Lipinski JF, Mallya G, Zimmerman P & Pope HG: treatment of adults with major depressive disorder: a Fluoxetine-induced akathisia: clinical and theoretical systematic review and network meta-analysis. The Lancet implications. The Journal of clinical psychiatry 1989; 2018; 391:1357-1366 50:339-42 15. Descarries L, Alain B & Watkins KC: Serotonin nerve 31. 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32. MIND: Depression. 2018. Retrieved from MIND: 40. Salomon RM, Miller HL, Krystal JH, Heninger GR & https://www.mind.org.uk/information-support/types-of- Charney DS: Lack of behavioral effects of monoamine mental-health-problems/depression/#.W7jJExNKjOQ depletion in healthy subjects. Biological Psychiatry 1997; 33. Moncrieff J & Kirsch I: Efficacy of antidepressants in 41:58-64 adults. BMJ 2005; 331:155-157 41. Smart C, Anderson IM & McAllister-Williams RH: Mono- 34. Montejo-González A, Llorca G, Izquierdo JA, Ledesma A, amine hypothesis of depression. Fundamentals of Clinical Bousono M, Calcedo A & Franco M: SSRI-induced sexual Psychopharmacology 2015; 77 dysfunction: fluoxetine, paroxetine, sertraline, and 42. Stahl SM: Mechanism of action of serotonin selective fluvoxamine in a prospective, multicenter, and descriptive reuptake inhibitors: serotonin receptors and pathways clinical study of 344 patients. Journal of sex & marital mediate therapeutic effects and side effects. Journal of therapy 1997; 23:176-94 affective disorders 1998; 51:215-235 35. NICE: Depression in adults: recognition and manage- 43. Stein DJ & Hollander E: Sexual dysfunction associated ment. 2009. Retrieved from NICE guidelines: with the drug treatment of psychiatric disorders. Cns https://www.nice.org.uk/guidance/cg90 Drugs1994; 2:78-86 36. Nurnberg HG, Thompson PM & Hensley PL: Antide- 44. Steinbusch HW: Distribution of serotonin-immuno- pressant medication change in a clinical treatment setting: reactivity in the central nervous system of the rat cell a comparison of the effectiveness of selective serotonin bodies and terminals. Neuroscience 1981; 6:557-618 reuptake inhibitors. The Journal of clinical psychiatry 45. Tassin JP, Stinus L, Simon H, Blanc G, Thierry AM, Le 1999; 60:574-579 Moal M & Glowinski J: Relationship between the locomo- 37. Nutt DJ, Forshall S, Bell C, Rich A, Sandford J, Nash J & tor hyperactivity induced by A10 lesions and the Argyropoulos S: Mechanisms of action of selective sero- destruction of the frontocortical dopaminergic innervation tonin reuptake inhibitors in the treatment of psychiatric in the rat. Brain Research 1978; 141:267-281 disorders. European Neuropsychopharmacology 1999; 46. Tyers MB: Mechanism of the anti-emetic activity of 5-HT3 9:81-86 receptor antagonists. Oncology 1992; 49:263-268 38. Pineyro G, Blier P, Dennis T & de Montigny C: 47. Wong DT, Perry KW & Bymaster FP: The discovery of Desensitization of the neuronal 5-HT carrier following its fluoxetine hydrochloride (Prozac). Nature reviews Drug long-term blockade. Journal of Neuroscience 1994; discovery 2005; 4:764 14:3036-3047 48. Zangen A, Nakash R, Overstreet DH & Yadid G: 39. Preskorn SH & Irwin HA: Toxicity of tricyclic anti- Association between depressive behavior and absence of depressants - kinetics, mechanism, intervention. The serotonin–dopamine interaction in the nucleus accumbens. Journal of clinical psychiatry 1982; 43:151-156 Psychopharmacology 2001; 155:434-439

Correspondence: Amol Joshi, BA (Cantab) Emmanuel College, University of Cambridge Cambridge, CB2 3AP, UK E-mail: [email protected]

SELF HARM AND SUICIDALITY: AN AUDIT OF FOLLOW-UP IN PRIMARY CARE Maria Eduarda Ferreira Bruco1, Chloe Gamlin1, Jack Bradbury1, Simon Bill1, Charlotte Armour2 & Mark Agius3 1School of Clinical Medicine, University of Cambridge, Cambridge UK 2Suffolk Primary Care, Cambridge UK 3Clare College Cambridge, Department of Psychiatry, University of Cambridge, Cambridge UK

SUMMARY Deliberate self harm is the strongest predictor of completed suicide. Primary care is often the entry point for those presenting with self harm and suicidality and so the primary care follow-up of such patients should include risk assessment for repeated self harm and completed suicide. This is of particular importance in patients at high risk for suicide, such as those with Bipolar Affective Disorder. This audit makes recommendations for the average UK GP Teaching Practice based on standards from the NICE guidelines relating to the prevalence, timing and content of follow-up in primary care of those patients who present with self harm or suicidality in the practice population.

Key words: self harm - suicide attempt – depression - Bipolar Affective Disorder - primary care - risk assessment * * * * * BACKGROUND students at the University of Cambridge for the purposes of performing this audit. The entries for patients with Deliberate self harm is the strongest predictor of read-codes indicating self-harm or suicidality between completed suicide (Karasouli 2015). Self harm encom- September 2013 and September 2018 were reviewed in passes 'any act of self-poisoning or self-injury carried October 2018. This timeframe was chosen so that data out by an individual irrespective of motivation' and is could be compared to the standards suggested by the commonly self-reported in the community setting (Allan NICE Guidelines published in June 2013 regarding ma- 2012). Such behaviours are usually associated with naging self-harm in primary care. The authors reviewed depressive symptoms, however self harm can occur with the NICE guidelines for follow-up after acts of self- any psychiatric illness, giving rise to a 10.5% lifetime harm and/or suicidality and together developed an audit risk (Allan 2012). There is a higher risk of repeated self- framework. Each case was assessed against the criteria harm and suicidal behaviour in people with bipolar displayed in table 1. This table also shows the percen- disorder who self harm when compared to those who tage standards that each criterion should satisfy. Each self harm and have other diagnoses (Clements 2015). case was audited independently by at least two of the Since primary care can be considered the ‘entry point’ authors. Data were tallied and any discrepancies were for those presenting with mental illness including self resolved by consensus. Events that were not documen- harm and suicidal ideation, it follows that risk assess- ted were considered not to have taken place. Data were ment for repeated self harm and completed suicide analysed, and key results were depicted graphically. would be a key component of the primary care consultation following an initial presentation of self harm or FOLLOW-UP suicidality (Neves 2014). Of the 66 patients included in our study, two thirds AUDIT AIMS (n=44) were followed up in the GP practice. The time interval between initial presentation and follow-up in This audit is designed to analyse the prevalence, primary care ranged from 0-27 days, with the mean time timing and content of follow-up in primary care for interval being 7 days. The fastest follow up was over the those patients who present with self harm or suicidality telephone, but the shortest face-to-face follow-up occur- in the practice population. In reviewing current practices red after 1 day. Of the 44 patients who were followed up in an average UK GP teaching practice against stan- in primary care, 68.2% were later seen again in the GP dards generated from the NICE Guidelines, we aim to practice (n=30). A higher proportion (81.8%, n=36) were produce recommendations for the safe management of referred to other services after initial follow-up. these patients in the primary care setting. CAPACITY METHODS Capacity assessments are standard assessments ba- Medical records at an average GP Teaching Practice sed on the ‘Capacity Act’ in the UK in order to ascer- in the East of England were accessed by four medical tain that patients are able to make their own decisions.

S610 Maria Eduarda Ferreira Bruco, Chloe Gamlin, Jack Bradbury, Simon Bill, Charlotte Armour & Mark Agius: SELF HARM AND SUICIDALITY: AN AUDIT OF FOLLOW-UP IN PRIMARY CARE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 610-615

Table 1. Audit criteria and corresponding standards for primary care follow up of patients presenting with self harm or suicidality Criteria Standard All patients should be followed up with a GP appointment 100% All initial follow up appointments should occur within 7 days 100% At first appointment all patients should be risk assessed for suicide 100% At first appointment all patients should be risk assessed for self harm 100% At first appointment all patients should receive a mental state examination 100% At first appointment all patients should have their capacity assessed 100% At first appointment all patients should have their safeguarding needs assessed 100% All patients should receive a second follow up appointment at a later date for further assessment 100%

Figure 1. A 100% stacked column chart showing how often each audit criterion was assessed in the teaching practice follow up

Figute 2. Diagnoses recorded for 66 patients who presented with self harm and/or suicidality in a UK GP teaching practice population

S611 Maria Eduarda Ferreira Bruco, Chloe Gamlin, Jack Bradbury, Simon Bill, Charlotte Armour & Mark Agius: SELF HARM AND SUICIDALITY: AN AUDIT OF FOLLOW-UP IN PRIMARY CARE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 610-615

Of the 44 patients who were followed up exclusively in Of these, 13 patients had additional psychiatric diag- primary care, there is evidence that capacity was asses- noses. A further 15 patients received a diagnosis of sed in 11 records. This corresponds to capacity assess- depression without anxiety. 11 of the 15 patients had ments being recorded in only 25% of cases. depression as their only mental health diagnosis, while 4 had co-morbid psychiatric conditions (other than FINDINGS anxiety). A third common diagnosis was emotionally unstable personality disorder, with 10 cases and 8 of Be presented at figure 1. the 10 patients also diagnosed with other psychiatric conditions including – most commonly - depression MENTAL STATE and anxiety. Only two patients had a diagnosis of Bi- polar Affective Disorder and one patient had a tenta- There is evidence of assessment of the patient's tive diagnosis of cyclothymia. mental state in 33 out of 44 records. This corresponds to The full range of diagnosed conditions is displayed 75% of follow-up appointments including some form of in figure 2. Mental State Examination.It is important to note that even in those where a Mental State examination was SCREENING FOR MANIA performed, the mental state was not assessed fully in the majority of patients. Whilst most records show evidence Interestingly, of our sample of 66 patients, screening of the patient's mood, behaviour and appearance, there for bipolar symptoms of mania or hypomania was only is limited evidence for the assessment of thought form carried out for two patients with an existing diagnosis of and content, as well as perception. bipolar affective disorder. One further patient volun- teered feelings of elevated mood and restlessness and SELF HARM AND SUICIDALITY was given a tentative diagnosis of cyclothymia. Mania and/or hypomania symptoms were otherwise not scree- Of the 44 patients who were reviewed in primary care ned for or elicited during follow up of self harm in pri- only, 35 (80%) were documented to have been asked a- mary care. bout continuing suicidal thoughts or intent. Fewer patients were asked about continuing thoughts of or active RECOMMENDATIONS self harm behaviours, with this documented in 30 patients (68%). 5 patients were asked about suicide without also Follow-up in general practice being asked about self harm, while 4 patients were asked about self harm but not suicide. 5 patients were not asked Findings from a Multicentre Study show that the risk about suicide or self harm at all. Of these five, one was of completed suicide is highest during the first year after under the care of the local CAMHS (Community Mental self harm, and especially in the initial period, with the Health) team but four patients who had not been asked risk of completed suicide being 49 times greater in those about suicidality or self harm in primary care were not who have previously attempted self harm than in the referred to secondary services. One of these patients was general population (Hawton 2015). Early follow-up not subsequently followed up in primary care either. after self harm has been shown to decrease the risk of repetition (Bilén 2014), meaning that GPs should attempt to see patients as soon as reasonably practicable SAFEGUARDING after initial presentation. Currently, the NICE guidelines on self harm do not Safeguarding in the UK is the process whereby provide clear recommendations regarding follow-up of patients are assessed as to whether they are vulnerable patients in primary care (NICE 2013). The evidence sug- to risks of violence and exploitation or are a risk to gests that increased contact with practitioners is effective others. Seventeen out of 44 patient records show evi- in preventing suicide, and so we strongly recommend dence of safeguarding assessments, meaning that only that all patients are followed up by their general prac- 38.6% of follow-up appointments were used to assess titioner within 7 days of the initial incident. the risks of violence and exploitation to the patient, and Additionally, we recommend that GPs also invite the patient’s risk to others. patients who have been referred directly to Mental Health Services after first presentation for a DIAGNOSIS consultation, as waiting lists can be long and may discourage patients from engaging with services. 61 of the 66 patients had been diagnosed with at According to the CQC (Care Quality Commission – a least one psychiatric condition, with a total of 94 commission in the UK which assesses the quality of diagnoses recorded for all patients regardless of services) in 2015/2016 only 52% of patients referred follow-up location. The most common diagnosis was for assessment or brief interventions were seen within mixed anxiety and depressive disorder, with 26 cases. 4 weeks and maximum waiting times reached 26

S612 Maria Eduarda Ferreira Bruco, Chloe Gamlin, Jack Bradbury, Simon Bill, Charlotte Armour & Mark Agius: SELF HARM AND SUICIDALITY: AN AUDIT OF FOLLOW-UP IN PRIMARY CARE Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 610-615 weeks (CQC, 2017). It is essential that these patients Risk assessment in General Practice are followed up in the interim and that their risk of Risk assessment is one of the most important tools to suicide and self harm is assessed. ensure patient safety. We recommend that every patient Assessment of Capacity in General Practice should undergo a risk assessment for suicidality and non-suicidal self harm, as both can have a devastating Only patients with capacity can make decisions effect on the patient’s health and safety. Additionally, regarding treatment. This is particularly important in there is an intimate relationship between suicidal and the context of self-harm and suicide where patients non-suicidal self injury (NSSI), with multiple studies may refuse treatment as a result of psychiatric illness showing that a history of NSSI, is the biggest risk factor and it is therefore essential to assess whether their ca- for suicide (Cavanagh 2003). In fact, a 4-year cohort pacity to make choices has been compromised. Whilst study which followed 7968 participants who self har- this is a more pressing issue in emergency settings, it med showed that the risk of suicide was more strongly also applies to primary care, particularly when consi- correlated to the practice of non-suicidal self harm than dering engagement with long-term management. Cur- to the degree of suicidal intention (Cooper 2005). The rently, the practice is only recording patient capacity in recognition that a history of NSSI is a stronger predictor 25% of cases, which we deem to be unacceptable and of successful suicide than intention to die strongly we would therefore like to strongly reinforce the recom- supports our recommendation to always assess both the mendation in the NICE guidelines for self harm, which risk of suicide and the risk of self harm. states that capacity should be assessed in all patients. Furthermore, we noted that when suicidal risk was assessed, patients were only asked about whether or Mental State Examination in General Practice not they had thoughts of hurting themselves, but other factors affecting risk of completed suicide were not The 2013 NICE guidelines recommend that all considered. We encourage general practitioners to ask patients have a full Mental State Examination when about factors that make suicide more likely, including presenting after an incident of self harm. We recognize access to lethal means, living in social isolation or in that a full mental state examination is not feasible in areas of high social fragmentation (Whitley 1999), or primary care due to time constraints, however we substance abuse (Yuodelis-Flores 2015). We also en- strongly encourage doctors to record examination of courage GPs to enquire about protective factors, such thoughts and perception, in addition to behavior, mood as any dependent family members who would be upset and appearance. This enables screening for psychosis should the patient commit suicide or beliefs that and bipolar disorder. Not all the patients who were discourage suicide (Wu 2015). followed up after suicide attempts or self harm at this teaching practice had their mental state assessed, so we Assessment of Safeguarding recommend that practitioners document the components of the MSE described above in all patients According to the NICE guidelines all records should who attend for follow-up. contain evidence of whether any safeguarding con- In addition, it is important to pay particular atten- cerns were raised, yet currently only 38.6% of the tion to screening for mania or hypomania since many consultations showed any evidence of safeguarding patients with depressive disorder do in fact display a assessments. It seems as though the current practice is predisposition to ‘convert’ to bipolar affective disorder to only record this if a concern is raised. We would (Rogers 2013). For instance, patients presenting with encourage doctors to consider safeguarding issues in agitated depression may in fact be presenting with an every consultation, particularly in the context of psy- affective mixed state, associated with a high risk of chiatry where patients are themselves at an increased suicide (Akiskal 2005, Chesin 2013). Since suicide risk of exploitation and abuse, but may also be a risk to prevention should remain a priority when assessing others, both actively and by neglect. mental state, it is crucial that there is a comprehensive assessment of the patient to identify specific risks of Recommendations for the Planning Stage self harm and suicide as well as high-risk conditions of the Consultation such as bipolar affective disorder and mixed affective states (Annear 2016). The recording of a family Not every patient who self harms needs to be refer- history of depression, anxiety, bipolar disorder and red to secondary care, particularly if they have regular suicide or other mental health condition such as follow up with their GP. According to the NICE guide- schizophrenia or indeed admission to mental hospital, lines, referral is a priority if: and the recording of a past history of recurrent levels of distress are rising, high or sustained; depression or manic or hypomanic episodes are the risk of self-harm is increasing or unresponsive to important since these items should indicate the need attempts to help; for further assessment whether the patient has bipolar the person requests further help from specialist disorder (Agius 2015). services;

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levels of distress in parents or carers of children and young people are rising, high or sustained despite Acknowledgements: attempts to help. We thank the patients and staff of our chosen GP Out of all 44 patients who were seen in primary Teaching Practice for enabling us to access their data care, 36 were referred to secondary mental health ser- for the purposes of this audit. vices. Of those remaining under the care of the GP, 4 Conflict of interest: None to declare. were encouraged to schedule a further follow-up appointment, however 4 left without a care plan in place that included follow up. A study conducted References across 5 culturally different countries, showed that increased contact time with practitioners significantly 1. Agius M & Verdolini N: The Cambridge-Perugia reduces the number of deaths by suicide (Fleischmann Inventory for assessment of Bipolar Disorder. Psychiatr 2008). Therefore, we highly recommend that no pa- Danub 2015; 27(Suppl 1):S185-7 tients are left without a plan to see a doctor, whether 2. Akiskal HS, Benazzi F, Perugi G & Rihmer Z: Agitated this be in primary or secondary care, so as to increase "unipolar" depression re-conceptualized as a depressive the contact time each patient has with professionals. mixed state: implications for the antidepressant-suicide controversy. J Affect Disord 2005; 85:245-58 3. Allan CL, Behrman S & Ebmeier KP: Primary care FURTHER RECOMMENDATIONS management of patients who self-harm. Practitioner 2012; 256:19-22 We would like to suggest the use of an electronic 4. Annear D & Agius M: Should assessment for bipolar template when following-up a patient after self harm. disorder and mixed asffective state be a standard part of The domains in table 2, encompass all recommen- assement for suicide risk? Psychiatr Danub 2016; dations made in this audit report, and are aimed at the 28(Suppl 1):18-20 average UK GP Teaching Practice. 5. Bilén K, Pettersson H, Owe-Larsson B, Ekdahl K, Ottosson C, Castrén M & Ponzer S: Can early follow-up after deliberate self-harm reduce repetition? A prospective Table 2. Suggested primary care follow-up template for study of 325 patients. Journal of Affective Disorders 2014; patients presenting with self harm or suicidality 152–154:320–325 Follow up all patients within 7 days of incident 6. Cavanagh JTO, Carson AJ, Sharpe M & Lawrie SM: Psychological autopsy studies of suicide: a systematic Does the patient have capacity? review. Psychological Medicine 2003; MSE 33:S0033291702006943 x Thoughts 7. Chesin M & Stanley B: Risk Assessment and Psychosocial x Perceptions Interventions for Suicidal Patients. J Bipolar Disorder x Behaviour 2013; 15 x Mood 8. Clements C, Jones S, Morriss R, Peters S, Cooper J, While D & Kapur N: Self-harm in bipolar disorder: findings x Appearance from a prospective clinical database. J Affect Disord Does the patient have continuing suicidal thoughts? 2015; 173:113-9 x Enabling factors 9. Cooper J, Kapur N, Webb R, Lawlor M, Guthrie E, x Protective factors Mackway-Jones K & Appleby L: Suicide after deliberate Is the patient experiencing mania or hypomania? self-harm: A 4-year cohort study. American Journal of Psychiatry 2005; 162:297–303 Are any safeguarding concerns raised? 10. CQC Report: The state of care in mental health services x Risks from others 2014 to 2017. Retrieved from x Risks to others https://www.cqc.org.uk/sites/default/files/20170720_stateo fmh_report.pdf 11. Fleischmann A, Bertolote JM, Wasserman D, De Leo D, Bolhari J, Botega NJ & Thanh HTT: Effectiveness of brief Contribution of individual authors: intervention and contact for suicide attempters: A Eduarda Ferreira Bruco is 'first author' and led the randomized controlled trial in five countries. Bulletin of project she drafted the text; the World Health Organization 2008; 86:703–709 Chloe Gamlin, Jack Bradbury, Simon Bill & Jack 12. Hawton K, Bergen H, Cooper J, Turnbull P, Waters K, Bradbury collected the data and contributed to the Ness J & Kapur N: Suicide following self-harm: Findings text; from the Multicentre Study of self-harm in England, 2000- Charlotte Armor contributed the data and supervised 2012. Journal of Affective Disorders 2015; 175:147–151 the data collection; 13. Karasouli E, Owens D, Latchford G & Kelley R: Suicide Mark Agius mentored the project and added text. After Nonfatal Self-Harm: A Population Case-Control Study Examining Hospital Care and Patient Charac- teristics. Crisis 2015; 36:65-70

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14. Neves MG & Leanza F: Mood disorders in adolescents: 17. Whitley E, Gunnell D, Dorling D & Smith GD: Ecolo- diagnosis, treatment, and suicide assessment in the gical study of social fragmentation, poverty, and suicide. primary care setting. Primary Care 2014; 41:587-606 BMJ 1999; 319:1034–1037 15. NICE: Self-Harm. Quality standard [QS34]. 2013. 18. Wu A, Wang JY & Jia CX: Religion and completed Retrieved from https://www.nice.org.uk /guidance/qs34/ suicide: A meta-analysis. PLoS ONE 2015; 10 chapter/Using-the-quality-standard 19. Yuodelis-Flores C & Ries RK: Addiction and suicide: A 16. Rogers J & Aguis M: Conversion from Unipolar to Bipo- review. American Journal on Addictions 2015; 24:98- lar Depression. Cutting Edge Psychiatry in Practice: The 104 Management of Bipolar Spectrum Disorder, 2013; p16-18

Correspondence: Maria Eduarda Ferreira Bruco, BA (Cantab) School of Clinical Medicine, University of Cambridge Cambridge, UK E-mail: [email protected]

INNOVATIVE APPROACHES TO IMPROVING THE IMAGE OF PSYCHIATRISTS AND PSYCHIATRY AMONGST MEDICAL STUDENTS AND DOCTORS IN THE UK Rashid Zaman1,2, Fredrick R. Carrick2,4 & Ahmed Hankir2,3,4 1Department of Psychiatry, University of Cambridge, Cambridge, UK 2Bedfordshire Centre for Mental Health Research in association with the University of Cambridge (BCMHR-CU), Cambridge, UK 3Leeds York Partnership Foundation Trust, Leeds, UK 4Department of Psychiatry, Carrick Institute for Graduate Studies, Cape Canaveral, FL, USA

SUMMARY In this paper we identify some of the critical factors that contribute to the ongoing shortage of psychiatrists in the UK. We discuss initiatives that have been launched to try and encourage more medical students and trainee doctors to choose psychiatry as a career. We describe the innovative anti-stigma Wounded Healer programme that was pioneered in the UK with the aim of improving the image of psychiatry and psychiatrists and that was subsequently scaled up and rolled out to over 65,000 medical students and doctors in 14 countries in five continents worldwide. We conclude, with some suggestions that we believe will help recruitment efforts into psychiatry.

Key words: psychiatry – recruitment – stigma - medical students - trainee doctors

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INTRODUCTION collective perceptions and can play a significant role in the career decisions that medical students and graduates According to the World Health Organization (WHO), make. The results of a survey conducted by researchers at there is a chronic shortage of psychiatrists on a global St. George’s University of London showed that 47% of scale (Hankir et al. 2015). In the UK, only 78% of core the public would feel ‘uncomfortable sitting next to a training year one posts in psychiatry were filled in 2012 psychiatrist at a party.' Furthermore, 60% of the public and psychiatry continues to be quoted as a ‘recruiting, believed that ‘psychiatrists know what you are thinking’ not a selecting, specialty’ (Henfrey 2015). The psychia- and over half of the public did not realize a psychiatrist tric workforce in the UK is heavily reliant on Interna- had a medical degree (http://www.rcpsych.ac.uk/ tional Medical Graduates (IMGs), and only 6% of people mediacentre/pressreleases2013/psychiatristsrole.aspx). who took the Membership of the Royal College of Potential recruits to psychiatry are not unaided when Psychiatrists (MRCPsych) exams were UK graduates. making their career decisions and are influenced by their Mental health problems are on the rise. Indeed, the friends, families and social norms. All of this suggests an Global Burden of Disease Study indicates that by 2020 unfriendly cultural atmosphere in relation to choosing mental health conditions are projected to become a psychiatry as a career (Henfrey 2015), highlighted by evi- leading cause of morbidity worldwide accounting for dence from Canada suggesting that negative comments 15% of all cases of diseases (Vigo et al. 2016). Therefore, from ‘friends and family about choosing psychiatry there is a strong argument for an urgent need to increase were a deterrent' when surveying a cohort of psychiatry recruitment and retention of doctors into psychiatry. trainees (Weisenfeld et al. 2014). However, what about the negative comments made WHAT ARE THE FACTORS THAT by medical students and doctors about psychiatry, might CONTRIBUTE TO THE ‘RECRUITMENT that have any impact on recruitment into the specialty? CRISIS’ IN PSYCHIATRY? According to the former President of the Royal College of Psychiatrists Professor Sir Simon Wessely, it does. In Despite the Royal College of Psychiatrists (RCPsych) an article that Professor Wessely co-authored with maintaining an active recruitment programme for Professor Maureen Baker, former chair of the Royal several years, psychiatry remains unpopular among College of General Practitioners, they report that the medical students; indeed only 4-5% of medical students systematic denigration of psychiatry and general in the UK reported an interest in psychiatry (Halder et practice leads to medical students rejecting these al. 2013). Multiple factors have been postulated to specialties. So, the banter, Wessely and Baker argue is explain why this might be the case. not so friendly after all but instead is exacerbating the Portrayals of psychiatry in literature, media and film shortage of GPs and psychiatrists in the NHS (Baker et are powerful influences in shaping our individual and al. 2016).

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Wessely and Baker cite a fascinating study by Ajaz their Choose Psychiatry campaign. As part of the latest and colleagues entitled, ‘BASH: badmouthing, attitudes wave of the Choose Psychiatry campaign, the College and stigmatization in healthcare as experienced by med- invited members to create and share a video on social ical students. The study aimed to investigate medical media about who inspired them to choose psychiatry students' perceptions of the apparent hierarchy between (hashtag #InspiredtoChoosePsychiatry). An example of specialties, whether they have witnessed disparaging a response to the call was a tweet by AH, a Specialty comments (‘badmouthing' or ‘bashing') against other Trainee in psychiatry with Leeds and York Partnership specialists and whether this had any effect on career NHS Foundation Trust: choice. 960 students from 13 medical schools throu- https://twitter.com/ahmedhankir/status/10496253692 ghout the UK completed an online questionnaire ran- 74449920 , part of which stated king medical specialties according to the level of “What could be more thrilling, challenging and badmouthing and answered questions on their expe- rewarding than healing wounded minds and hearts? rience of specialty bashing. Psychiatry and General Be audacious. Be tenacious. Be the best. Make a Practice attracted the most significant number of nega- difference. Save lives. Choose psychiatry!” tive comments, which were made by academic staff, We believe all this will certainly help to address the doctors, and students. Twenty-seven percent of students current worrying situation concerning recruitment into had changed their career choice as a direct result of psychiatry. However, from the primary author’s (RZ) bashing, and a further 25.5% stated they were more experience (as a consultant psychiatrist and teacher for likely to change their specialty choice. The authors con- Cambridge University medical students for over 10 clude that the bashing of psychiatry represents another years) of having been directly involved in the successful form of stigmatization that needs to be challenged in recruitment into psychiatry of a significant number of medical schools and that it not only has an impact on medical students and junior doctors (including AH), it is recruitment into the specialty but also has the broader felt that work at grassroots level needs to be not only effect of stigmatizing people with mental health dis- supported but also given prominence. orders (Ajaz et al. 2016). Our collective experiences suggest that encourage- Whilst stigma against psychiatry is widespread a- ment of students at the start of medical school, with mongst doctors in other medical and surgical specialties continuous support and encouragement throughout and medical students, we must also recognize the stigma their training, well in to the foundation years helps that exists against psychiatry in our own ranks and, to a greatly. Indeed, a recent British study revealed that certain degree, amongst allied mental health profes- hospitals providing the most formal psychiatry tea- sionals (psychologists, psychiatric nurses mental health ching have the highest proportions of foundation doc- providers/managers). This "self-stigma" amongst certain tors who specialise in psychiatry (Collier et al. 2013). psychiatrists may be a result low self-esteem in our pro- Furthermore, teaching and training of non-psychiatric fession and possibly as a result of specializing in doctors (to dispel negative ideas and myths), provision psychiatry because they could not secure training in of excellent psychiatry attachments led by enthusiastic their preferred specialty. A widespread but, fortunately, psychiatrists (Hankir et al 2015), as well as involving not so common idea that has been perpetuated by some students in research and audit projects which could of the members of the allied profession is that psychia- lead to publications (Linton et al 2017) along with trists are just there to prescribe psychotropic medica- having inspirational psychiatrists as role models, will tions to mentally ill individuals, has not helped either. also go a long way to address the dire future our profession faces. WHAT CAN WE DO TO RESOLVE THE Below are a few selected quotes from past senior RECRUITMENT ‘CRISIS’ IN PSYCHIATRY? Cambridge University medical students in their clinical years who were considering psychiatry as a career. The Royal College of Psychiatrists has beneficial “Almost all psychiatrists I have met have been information on its website for medical students who positive role models. I found that most were interested may be considering a career in psychiatry in their patients as individuals, an attitude I did not find (http://www.rcpsych.ac.uk/specialtytraining/careersinps in many of my other hospital attachments. Many ychiatry/careersinfoforugs.aspx). opportunities have been granted to me by psychiatrists Indeed, students are encouraged to become Student such as Dr. Mark Agius, Dr. Rashid Zaman, Prof. Associates of the college free of charge Christos Pantelis, who were enthusiastic in helping me (http://www.rcpsych.ac.uk/training/studentassociates.aspx). get into audits/research and which resulted in outputs Additional activities of the College include prizes such as oral presentations in international conferences and bursaries for Student Associates and the allocation and publications journals listed on PubMed. This has of funding to help create and maintain medical school allowed me to explore my psychiatry interest and psychiatry societies (‘Psych Socs’) throughout the UK. develop skills that will be useful to any career I end up The College recently founded the Promoting Rec- doing.” ruitment into Psychiatry (PRIP) committee and launched Sophie Butler

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"If I say that I am thinking about being a psychiatrist THE FUTURE EXCELLENCE the usual reaction is "why would you want to do that?" INTERNATIONAL MEDICAL Generally, it seems that there is a perception among SUMMER SCHOOL non-psych doctors that psychiatry is rather depressing and a bit "woolly" - not "real medicine" While I have The Future Excellence International Medical Sum- tried not to be influenced by this negative attitude mer School (FEIMSS) is a 5-day event for medical stu- towards psychiatry, I can imagine that it might serve to dents held yearly in Manchester, UK. FEIMSS is the put some other students off." largest event of its kind in the world; the 2013 cohort Clare Holt was comprised of 244 students from 40 countries "I think my 6-week placement with psychiatry has representing 80 universities. FEIMSS included two dispelled many of the negative notions associated with lectures delivered by Consultant and Early-Career the specialty. I realized that we do not only work with Psychiatrists. The lectures incorporated references to 'crazy people,' but rather we care for the general mental the humanities (literature, poetry, history, film, drama, health of the population - something which has often and art). been neglected." A mixed-methods study on the psychiatry lectures Kenrick K.H. Ng delivered in FEIMSS revealed that 23/25 of the res- THE WOUNDED HEALER: A ‘DOUBLE- pondents (92%) agreed or strongly agreed that 'The PRONGED’ APPROACH TO REDUCING psychiatry talks were interesting' and that 'Attending MENTAL HEALTH STIGMA AND FEIMMS improved my understanding and respect for other cultures.' INCREASING RECRUITMENT Free text comments across the different cultures INTO PSYCHIATRY? were also exceptionally positive: The Canadian Psychiatric Association reported that “I totally enjoyed the lectures they were super inspiring, good job!” conventional education alone would not reduce stigmati- Medical Student, Kosovo zing attitudes [towards mental illness and psychiatry] in “The talk was very helpful for me to understand medical students (Stuart et al. 2014). Under the primary psychiatry and psychiatric conditions.” author’s (RZ) direct supervision, AH pioneered the Medical Student, Japan Wounded Healer, which is an innovative method of peda- “Great psychiatry lectures, inspiring and would gogy that blends the performing arts with psychiatry. The have liked to hear more from both speakers.” main aims of the Wounded Healer are to engage, enthuse, Medical Student, England enthral and to educate to challenge mental health-related “Both were very inspiring and charismatic guys! stigma, debunk myths about mental illness and encourage Overall excellent and made me more inclined towards care seeking (Hankir et al. 2014). The Wounded Healer psychiatry than I was before and proved to me that harnesses the power of story telling and traces AH’s re- psychiatrists are not the boring stereotype!” covery journey from when he was a homeless and impo- Medical student, Czech Republic verished ‘service user’ to receiving the 2013 Royal Colle- ge of Psychiatrists Foundation Doctor of the Year Award, We concluded that notwithstanding the limitations which marks the highest level of achievement in psychia- of our evaluation, which to our knowledge was the first try in the UK (Hankir et al. 2013). Hitherto, the Wounded of its kind on such an ethnically eclectic sample, our Healer has been delivered to over 65,000 people in 14 results suggested that two brief lectures incorporating countries in five continents worldwide. The Wounded the humanities delivered by a Consultant and an Early Healer has also been integrated into the medical school Career Psychiatrist may have positively influenced the curriculum of four UK universities, and it has featured in perceptions of psychiatry and psychiatrists that medical the 2014 and 2017 Royal College of Psychiatrists Natio- students from diverse cultural backgrounds have. We nal Medical Student Conference in Liverpool and Leeds contend that FEIMSS provides a platform to recruit respectively (and will also feature in the 2019 RCPsych medical students into psychiatry from all over the world Medical Student Conference in Cardiff). Audiences re- and enables them to develop cultural competency port that the Wounded Healer is ‘inspirational' and ‘the (Hankir et al. 2015). best lecture they have ever attended.' The written feedback below from a delegate who attended the 2014 CONCLUSION RCPsych National Medical Student Conference in Liverpool illustrates that the Wounded Healer positively In this short paper, we have identified some of the influences students' perceptions of psychiatry: critical factors that contribute to the ongoing recruit- ‘Unbelievable. This guy had charisma in spades. It ment crisis into psychiatry in the UK. We have discus- was so reassuring to know that a doctor with mental sed and described initiatives launched by organizations health issues can overcome them and be so successful. such as the Royal College of Psychiatrists to encou- Quite possibly the poster boy for my future career rage medical students and trainee doctors to choose choice’. psychiatry as a career.

S618 Rashid Zaman, Fredrick R. Carrick & Ahmed Hankir: INNOVATIVE APPROACHES TO IMPROVING THE IMAGE OF PSYCHIATRISTS AND PSYCHIATRY AMONGST MEDICAL STUDENTS AND DOCTORS IN THE UK Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 616-619

Whilst innovative programmes led by the Royal 2. Collier A & Moreton A: Does access to role models in- College of Psychiatrists (UK) to address the recruitment fluence future career choice? Impact of psychiatry tea- crisis into psychiatry are helping, more work needs to be ching on recently graduated doctors in the United King- done at the grassroots level. dom. Acad Psychiatry 2013; 37:408-11 3. Goldacre MJ, Turner G & Lambert TW: Variation by This work aimed at medical students and non- medical school in career choices of UK graduates of 1999 psychiatric doctors should encompass: and 2000. Med Edu 2004; 38:249-58 Education and information about psychiatry targe- 4. Halder N, Hadjidemetriou C, Pearson R, Farooq K, Lydall ting medical students and trainee doctors; GJ, Malik A & Bhugra D: Student career choice in psychia- Busting harmful myths about psychiatry as a spe- try: findings from 18 UK medical schools. Int Rev Psychiatry cialty not just perpetuated by non-psychiatric doc- 2013; 25:438-44. doi:10.3109/09540261.2013.824414 tors, medical students, but also by some members of 5. Hankir A & Zaman R: Global strategies targeting the recruitment crisis in psychiatry: the Doctors Academy the psychiatric profession. Future Excellence International Medical Summer School. A comprehensive approach aimed at the public and Psychiatr Danub 2015; 27(Suppl 1):S130-5 medical profession (including medical students), high- 6. Hankir A & Zaman R: Jung's archetype, 'The Wounded lighting and recognising that psychiatry is an intellectual, Healer,' mental illness in the medical profession and the emotionally challenging, academic, science-based medi- role of the health humanities in psychiatry. BMJ Case Rep cal specialty that draws in arts and humanities, when 2013; 2013. pii:bcr2013009990. doi:10.1136/bcr-2013- 009990 delivered with pride, by enthusiastic, driven, intelligent 7. Hankir A, Khalil S, Wadood Q, Madarbukus D, Yunus and compassionate doctors, will undoubtedly go a long HA, Bibi S, Carrick FR & Zaman R: The Federation of way in improving the image of psychiatry. Student Islamic Societies programme to challenge men- Finally, successful strategies, for recruitment into psy- tal health Stigma in Muslim communities in England: chiatry must recognize that medical students and trainee The FOSIS Birmingham study. Psychiatr Danub 2017; doctors are not a homogeneous group. Indeed, to sell 29(Suppl 3):512-520 psychiatry to medical students and trainee doctors, we 8. Hankir A, Zaman R & Evans-Lacko S: The Wounded must first understand what would attract an individual to Healer: an effective anti-stigma intervention targeted at the medical profession? Psychiatr Danub 2014; psychiatry. This can range from emphasis on the scienti- 26(Suppl 1):89-96 fic basis of psychiatry and the intellectual and emotional ri- 9. Henfrey H: Psychiatry - recruitment crisis or oppor- gour that is required to practice it, to the artistic and huma- tunity for change? Br J Psychiatry 2015; 207:1-2. nistic dimensions of psychiatry that enable us to develop doi:10.1192/bjp.bp.114.157479 a positive rapport and therapeutic alliance with patients. 10. http://www.rcpsych.ac.uk/mediacentre/pressreleases2013/ psychiatristsrole.aspx; Accessed 19th October 2018? 11. http://www.rcpsych.ac.uk/specialtytraining/careersinpsych Acknowledgements: None. iatry/careersinfoforugs.aspx; Accessed 19th October 2018 12. http://www.rcpsych.ac.uk/training/studentassociates.aspx; Conflict of interest: None to declare. Accessed 19th October 2018 13. https://twitter.com/ahmedhankir/status/104962536927444 Contribution of individual authors: 9920; Accessed 19th October 2018 Rashid Zaman conceived the idea for the paper and 14. Linton S, Hankir A, Anderson S, Carrick FR & Zaman R: conducted a review of the literature on recruitment Harnessing the Power of Film to Combat Mental Health into psychiatry and wrote the manuscript; Stigma. A University College London Psychiatry Society Fredrick R. Carrick carried out the literature search Event. Psychiatr Danub 2017; 29(Suppl 3):300-306 and contributed to the manuscript; 15. Stuart H, Chen SP, Christie R, Dobson K, Kirsh B, Knaak S, Koller M, Krupa T, Lauria-Horner B, Luong D, Modgill Ahmed Hankir conducted a review of the literature on recruitment into psychiatry and made a substantial G, Patten SB, Pietrus M, Szeto A & Whitley R: Opening contribution to the manuscript. minds in Canada: targeting change. Can J Psychiatry 2014; 59(10 Suppl 1):S13-8 16. Vigo D, Thornicroft G & Atun R: Estimating the true References global burden of mental illness. Lancet Psychiatry 2016; 3:171-8. doi:10.1016/S2215-0366(15)00505-2 1. Baker M, Wessely S & Openshaw D: Not such friendly 17. Wiesenfeld L, Abbey S, Takahashi SG & Abrahams C: banter? GPs and psychiatrists against the systematic Choosing psychiatry as a career: motivators and denigration of their specialties. Br J Gen Pract 2016; deterrents at a critical decision-making juncture. Can J 66:508–509. doi:10.3399/bjgp16X687169 Psychiatry 2014; 59:450–4

Correspondence: Rashid Zaman, BSc (Hons), MBBChir (Cantab), MRCGP, FRCPsych Department of Psychiatry, University of Cambridge Cambridge, UK E-mail: [email protected]

RESCUE OF THE APPROPRIATIVE “THOUGHT-ACTION-MOOD” SPACE: ANATOMY AND MAST CELLS GENERATE “MIXABLE” DIMENSIONS IN LANGUAGE AND STATISTICS Gottfried R. S. Treviranus Psychiatrische Praxis am Unitobler Campus, Berne, Switzerland

SUMMARY Background: The orthogonal axes of Thought (T), Action (A), and Mood (M) span a phase space which corresponds e.g. to the three medial thalamic areas related to three resonating cortico-subcortico-thalamo-cortical loops. The above three of several loops constitute an “appropriative engine”, since within that space, as hinted to via Fig. 228 by Emil Kraepelin to illustrate bipolar mixed states, circular waves of appropriative functioning - from need via action to e.g. satisfaction - reflect a spectrum of temperamental to anxio-affective signatures of sequential appropriation waves. This neo-classical “dyn4TAM”-model also posits that a prime (thalamic) motivating system of Uncertainty-orientation (R. M. Sorrentino) regulates the temperamental balance between only 4- dimensional (D)-“Thought” (G. Halford) about effort-sparing models and high-D-“Action” (G. Rizzolatti) meaningfully related to movement. In fact the exchange across this “complexity divide” - between “grasping” action-related high-D-modules and “calculating” 4D-modules of brains – even concerns the grounding of symbolic relational “concepts.” It thus expands on the Franco-Kraepelinian “TAM”-System (FKS) which suffered a distortion by Kraepelin and the eliminative eugenicist Wilhelm Weygandt, unfortunately carried on in the “bipolar spectrum” current. Because the above loops are independently segregated they generate true dimensions. Furthermore the phenomena they jointly create become patterns, i.e. independently filled slots. Now these are irremediably destroyed at acquisition by Galtonian statistics which is detrimental to conceiving dimensional topics. Hypothesis: Here we posit that preponderantly “uncertainty-oriented”, calculating academics unless depressed, are attracted by 4D-Thought and repulsed by intuition. They thus avoid bio-psychologically the “comprehension” of patterns. Method & Result: New research initiated by dyn4TAM confirmed, that the homologous rodent sign-tracking depends on mast cells modulating the ACC-loop for “Action.” Conclusion: The “complexity divide” warrants more attention in clinical and pure cognitive sciences and should include a “psychology of statistics”.

Key words: neurolinguistics - bipolar mixed states - cortical-subcortical-thalamo-cortical-circuits - mast cells - psychology of mathematics

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INTRODUCTION aversion in “soldiers”, who like to master routines physically through high-dimensional movements and “It is better to plan the undertaking to wisely study by unquestioned orders – unless depression doesn’t observable phenomena, to posit connections revert this game. Meanwhile the banausas remain the between them, to install a methodological balanced normals, denigrated as being “banally bad“ framework for them, and then to draw some (Arendt 1963) thus disculpating cholerics. Neglected general and falsifiable truths from them.” by mainstream, Richard M. Sorrentino (Sorrentino & Phillipe Pinel (1745-1826) Roney, Sorrentino 2008) through the psychological “Big Data” - driven science in a central sense has spectrum of “Un- versus Certainty-orientation” (i.e. at- also led to a crisis of translation in psychiatry, which tractedness versus repulsion by yet unexplained topics) increases the long-standing denigration by ”intuitive has posited and broadly corroborated what constitutes ideologues” of simple, Galilean abstract-to-concrete- the strongest (also) human motivator. Crucially in and-back again-theorizing in psychopathology. Terrible, depression these extremes of cognitive temperament, choleric, simplifications about human affairs certainly being proportional to mood, abruptly swap into the have, even before the Shoah, legitimated ethico-histo- opposite. While in depression soldiers start to look out rical concerns. The crude divisiveness suffered by for argued solutions, philosophers – especially if fue- psychiatry nevertheless may be more cognitive-tem- led by mixed states – can be predicted to become dan- peramental than legitimate: it could be caused by the gerously fanatic. fact that, what in Plato’s, pro-eugenic (Goering 2014), Here a new convergent interdisciplinary stance is “Republic” (Plato 1994) the philosophical “guardians” taken based on the dyn4TAM-model. Its also neuro- cherish most, i. e. mastering the daily renewed uncer- economical foundations (Treviranus 2017a, 2017b) tainties through hopefully harmonious models (in just here are only summarized before addressing questions 4 dimensions as Graeme Halford’s network has shown; of “graspability” in statistics and taxonomy (by using Halford 2005, 2014, Cocchi 2014), elicits the strongest the example of mixed states).

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AN UPDATE ON 2014), to primordially conceive less effortful ways of THE dyn4TAM-FRAMEWORK appropriation; Action instead, F), is primordially driven by the need to re-resource for auto-sustainment by in- The neurobiological (and linguistic) elaborations of vesting in “opportune appropriative movement”, which the dyn4TAM-framework posit, that A) mixed and other is calculated (and signaled via effort to decisional affective states, including fear or anxiety, are generated Thought) in the anterior cingulate cortex (ACC; Hol- along the three medial of the several cortico-subcortico- royd & Umemoto), who’s CSTC when lesioned results thalamo-cortical circuits (CSTCs), and similarly struc- in abulia (Mega & Cummings 1994). At the same time tured areas (Uddin 2015), of the brain; that B) these and Action must relate (Luppino 1991, Caminiti 2017,) to other CSTC-loops are segregated among each other the high-dimensional “significant steering” of the (in the (Alexander 1986, Draganski 2008) and thus generators arm alone 7) degrees of freedom of articulated motor of orthogonal, i. e. truly dimensional phenomena (modu- chains. Mood instead is driven by the CTCs running lated by dopamine; Afonso-Oramas; Ikemoto 2015, through the vmPFC/mOFC (Roy 2012). Haber 2014, Ferré 2018); that C) these in the case of Furthermore G) at these also learning interfaces, the above three “appropriative” ones can be mapped to between the latter two transitions across this “com- an (also “neuro-economical”) classical Thought- plexity divide”, named Intention and Perception, occur, Action-Mood space harboring repetitive tempera- of which H) the temperamental balance constitutes the mental cycles attracted by mixed corner states, which human prime motivator “Un-/certainty-orientation” of correspond - Figure 1 - to “Fig. 228” (Kraepelin 1913; Richard M. Sorrentino, a cognitive temperament, which Fig. XXIV1904) illustrating phased sinus curves (Figure swaps into the opposite in depression, whereby I) this 2) and D) that these cycles map to the basic sequence of cognitive temperament was posited to be homologous “appropriation” constituting the basic formula for beha- to sign-/goal-tracking behavior of rats. This, J), moti- vioral sciences, complementing perception-action cycles vated my suggestion for the first, successful, beha- (Fuster & Bressler 2012), which alternates between vioral mast cell experiment, that the mast cell stabi- private Thought and public Action. In this E) Thought is lizer chromoglycin would cancel sign-tracking as far conceived to be limited to 4 dimensions albeit with ranks as it would be maintained by “manicogenic” mucosal tha- of complexity up to six (Halford 2005, 2014, Cocchi lamic mast cells at the periventricular thalamic nucleus

Figure 1. Three segregated cortico-thalamo-subcortico-cortical contiguous loops (Mega & Cummings 2001), located medially in the thalamus, relate to the functions of Mood, Action, and Thought provided with the ventromedial, anterior cingulate, and dorsolateral prefrontal cortex. Their interruptions cause instinctual impulsivity, abulia, or thought disorder. They map to the homonymous dimensions of the Thought-Action-Mood defining “mixed states” (Treviranus 2006)

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Figure 2. The dyn4TAM-model names the corners (vectors) of the “mixed” Thought-Action-Mood-cube with natural language terms. The treble phased sinus curves from Fig. XXIV or 228 (Kraepelin 1904, 1913), derivatives among themselves, determine the cycling “appropriation waves” from need to outcome

(Morrow & Fitzpatrick 2017). This prediction was ge- (Csaba 1961, 2015). Interacting with mast cells espe- nerated by hypotheses of an ongoing project (Tre- cially infectious (Steinberg & Himmerich 2013, Khan- viranus 2014, 2015) on a afferent non-canonical daker 2015, Khandaker & Dantzer 2016) somatic pro- “highway” of often subverted mast cells (traveling cesses antedate the emergence of severe mental dis- from e.g. nailfolds or other germ- and toxin-accepting orders (Kraepelin 1881, Ilankovic 2014). Finally, K), barriers via the lymphatics to the walls of vessels and the syllogistic evolutionary utility of the loop dedica- then counter-flow along the outside of cerebral arte- ted to Thought, which developed last (Treviranus ries) as main actors (Silver 2013) of a more “tangible” 2010), consists in balancing the rigid “either-or” of psycho-neuro-endocrino-immunology (PNEI-2.0) follo- approach by a syllogistic graduation from true for all, wing the course of cerebral arteries – against the not for all, some, not even for some in a way inspired “intangible” connectionist a-neurovascular stance of by Sydney Axinn (Axinn 1994). This syllogistic back- RDoC (Insel 2010). Early bipolar disorder e. g. is ground informs subcortically generated language spo- related to white matter damage at the left anterior limb ken in appropriation (as illustrated in Figure 3, a of the internal capsule (Lu 2012) supplied by the Croatian version of Table 1, with context in Treviranus lenticulo-striate artery, which runs where the average 2017a), and this contributes to understand the grasp of putamen shows a groove from “arteriitis”: such could contiguous concepts (Galetzka 2017). cause in bipolar disorder (Hwang 2006). Likewise As to the focus of this paper though, the orthogonal average thalamic deformations in MDD-depression nature of the “appropriative engine” as defined by (Lu 2016) or schizophrenia (Coscia 2009) could be CSTCs with their indirect path providing their oscilla- associated with supplying arteries (Schmahmann 2003) ting nature (Szirmai 2010, Bramson 2018) is essential. allowing e.g. for intrusion of damaging mast cells The recognition of the simple harmonic oscillator, fami- (Theoharides 1990, 2016) intruding from the peri- liar from alternate current circuits (Figure 2), within phery, where they would be variously imprinted as to Kraepelin’s hint in Fig. 228 (Treviranus 2012) has destination and destiny as prefigured by György Csaba been elaborated further (Koutsoukos 2014).

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Figure 3. The triple permutations of increased or decreased instances of Thought, Action, and Mood subcortico- linguistically create 8 corner and 56 transition terms e. g. in Croatian (English version: Table 1 in Treviranus 2017a)

THE UNFORTUNATE SWAP CAUSING despite Weygandt’s stance against the “predominance of DOUBLE-SWITCH TRANSITIONS the affective” (Salvatore 2002; p.259); c) the consequential persistent “swap” between Inhibited Mania The dyn4TAM-cube (Treviranus 2006), by taking an (Interest-TaM) and Agitated Depression (Fear-tAm) “orthogonal grasp” on the “cubed” (Salvatore 2002) assigned erroneously by Kraepelin to the group of classic model, originally clarified unfortunate errors, Depression (Need-tam) and Mania (Pursuit-TAM) res- which led to the collapse into the bi-dimensional “ad- pectively - although being 2 switches (of thought and mixture framework” used by the “bipolar spectrum” mood) away. Eugen Bleuler spoke of “Abnormal movement (Marneros & Goodwin 2005, Marneros 2001). facilitation or inhibition of the centrifugal functions of Wilhelm Weygandt studying at Strasbourg had assi- deciding, acting, including the psychic parts of milated eugenism (Mucchielli 2000) and “mixed states” motility.”(p. 354) . Yet (p.364) he excluded “depression (plausibly) through his later mentor Wilhelm the Wundt’s with flight-of-ideas” and the subsumption of friend Théodule Ribot (Feuerhahn 2016). A companion ”melancholia agitata”, where agitation “is nothing else paper questions the dark sides and scientific merits of this but the expression of fear, and next to that the other key figure of destructive eugenics (Treviranus 2019). centrifugal functions are clearly inhibited.” Kraepelin This path of ideas had been as follows: a) Weygandt, started to introduce the concept in the 4th, and cited from who from the hardly cited French Aliénistes had learned Weygandt’s dissertation in the 5th edition of his “The unique relationship between patterns of symptoms textbook (Kraepelin 1893, 1899). Unfortunately the that seem to be irreconcilable.” (Salvatore 2002) “swaps” were carried on by the neo-kraepelinian move- occurring as the occasional persistent mixed states, ment (Akiskal & Benazzi 2004, Perugi & Akiskal, which “marked the whole course of the episode”, 2005. Fountoulakis 2015; p. 52 ff.). Wilhelm Weygandt practically limited these to the three thought-less states: was accredited with the introduction of mixed states (1) Manic Stupor (“Bliss-taM” in dyn4TAM coding for (Maggini 2000, Salvatore 2002), while his case reports the extremes of thought, action, and mood with upper mention the maturing French conceptualization of and lower case initials and with common terms for the 8 mixed states (Ritti 1883) since Philippe Pinel (Pinel permutations), (2) Unproductive Mania with thought 1801) up to Jules Falret (1824-1902) in a footnote only poverty (Joy-tAM), and (3) Agitated Depression (Fear- up to the year 1854. Yet Jules Falret’s «mixed state» as tAm) – mingled with the worry of Despair-TAm an observation evolved to a concept in 1861 (Falret 1861; (Dysphoric Mania). b) the previous hypostasis of Manic Haustgen & Akiskal 2006, Haustgen 2017): “(…) the Stupor (Bliss-taM) as a starting point was associated hybrid and contradictory expressions of manic erroneously by Kraepelin (1913) with the manic group - melancholies or melancholic manias are the most evident

S623 Gottfried R. S. Treviranus: RESCUE OF THE APPROPRIATIVE “THOUGHT-ACTION-MOOD” SPACE: ANATOMY AND MAST CELLS GENERATE “MIXABLE” DIMENSIONS IN LANGUAGE AND STATISTICS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 620-629 condamnation of the reigning classification.” Weygandt Even when patterns emerge (Costafreda 2011) they iterated, that mixed states of opposite capital symptoms are never crossed with vascular supply. Instead a com- disproved all theories opposing two different principles, mand of brain is rule (Kotkowski 2018). Nevertheless notably the theory of the Viennese pathology chair CSTCs and other micro- (Li 2016) and macro-anatomical Theodor Meynert (1833-92). The latter held, maybe categories are returning (Tréhout 2017, Vandevelde 2017, more realistically than we concede, that mania was Avram 2018). Naturalistic animal modeling runs the risk caused by dilatation and depression by constriction of to adapt to consensus-dimensions (Anderzhanova 2017) arteries (Meynert 1884, 1990). Weygandt PhD-thesis while other potential “tangible” anatomical or inflamma- was praised for repudiating such a “cut and dried” tory dimensions (Lee 2015) are neglected. While mas- scheme, but was considered a “bit too casuistic” by sive-data and high number projects have been clinically others (p.94), while he himself wrote, that it seemed productive, many expectations still have to be met. In “farfetched” or premature to make any theoretical use parallel severe doubts on “significance” both in psycho- of his unsystematic remarks on aetiology. After his logy and imaging presently are pushing for methodo- article (1901) on “Manic-depressive insanity” interes- logical pre-publication. Beyond this the increase of tingly Weygandt, outside his general treatises, never significance by numbers is loaded with promises which returned to this topic. often can be expected to dry out asymptotically.

UN-GRASPED DIMENSIONS: KEEP DIMENSIONAL PATTERN-NEGLECTS IN THE FIELD PATTERNS SAFE WITH CONFIGURAL-FREQUENCY-ANALYSIS Not all dimensional topics in the psychiatric field can be expected to advance through pattern-preserving The inventive idea of CFA (Configural-Frequency- statistics, i.e. mainly configural frequency analysis Analysis, to be disambiguated from Confirmatory Fac- (CFA; see below). In the genetics of relevant muta- tor Analysis) of Gustav Lienert (1920-2001) was a) to tions e.g., as far as we know their primary effects, we count the frequency of “configurations” (patterns, per- encounter many steps along causal pathways where mutations, ordered sets) of categorically measured, these are lacking thus remaining silent (missing herit- mutually rather independent (and thus - what has not ability). Neutralizing interactions of linkage or epis- been explicitly notice till date - dimensionally gene- tasis (Wei 2014) are restricted to sub-samples which rated) attributes (carried by persons or entities) within a would show up as deviant occupancies in CFA. Also n-dimensional contingency table, and then b) to bio-models (Monir 2017, Monir & Zhu, Hall 2015) are compare them with the occupancies expected (following emerging to bridge these spots. a “base model” reflecting state-of-the-art modeling or CFA can quickly suffer from excess of configural just the distribution of marginal sums) in order to addresses with ensuing scarcity of occupancy, but this is discover “types” or “anti-types” where thus addressed mitigated by increasing samples or by orderly “agglu- cells (vectors) would realize more or less occupants (the tinating” categories, dimensionality reduction - also author’s term) from a counted sample than expected to a applied by still pattern-destroying Galtonians (Grell- degree as dictated c) by, often contradicting, models of mann 2016), or again by nesting, causality analysis, or stochastic significance. Only hereby it emerges, as the by using any meaningful category, including such main developer of CFA, Alexander von Eye unders- from indexes or multivariate processing. Nevertheless cores: that “main effects and interactions reflect local the need for better pattern recognition is apparent across relationships among variables. (…) identified for some all fields (Treviranus 2018). In the meantime e. g. a categories of variables, but not for others.” (von Eye common genetic pool of bipolar versus schizophrenic 2013), whereby generalizing models often do not fit the disorders opens on a thus guided search of sequential behavior of important minorities: overall or – through common uphill causes, yet polygenic risk scores (PRS; higher order CFA(von Eye 2002, 2016 ) – in respect to Bogdan 2017) are used, whereby complex data is specific terms of such e.g. log-linear modeling equa- collapsed onto two dimensions: individual predictor tions. Thus the “person-oriented approach” could not be (PRS) and e. g. predicted variance within a broadly statistically realized beforehand, which was particularly psychotic population (Calafato 2018). Recently doubts detrimental to the field of developmental psychology have been voiced on population genetics’ asymptotic Von Eye works in. He thus also contributed prediction claims, lack of combinatorial insight, and monothetic CFA and causality-tracing techniques for longitudinal models (Verna & Ritchie 2018). Few studies struggle research (von Eye 2002, 2018). Today the field flou- with the problem: one boldly uses a 3-way continuous rishes even more, as a handful of researchers mainly data analysis in cutting-edge study on Alzheimer’s and pivoting around Alexander von Eye (von Eye 2010) mast cells (Kayer 2017). Genetics also point to a protein surprises regularly with both ergonomic (e.g. cfa in R) integrating a spike-velocity divide counter-regulated by or fundamental new developments: “The doors for so- phenotype (Schork 2012, Schork 2016, Devor 2017), phisticated data analysis and, more important, for ana- and finally a related network confronted the pattern lysis that exactly tests the hypotheses that researchers problem head-on (Mellerup & Møller 2017a). ask are wide open.” (von Eye 2016) (Figure 4).

S624 Gottfried R. S. Treviranus: RESCUE OF THE APPROPRIATIVE “THOUGHT-ACTION-MOOD” SPACE: ANATOMY AND MAST CELLS GENERATE “MIXABLE” DIMENSIONS IN LANGUAGE AND STATISTICS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 620-629

Figure 4. While by Galtonian statistics attributes (or garments) are plugged off from entities (or persons) whereby individual patterns are erased, Gustav Lienert started to count the frequency for all possible patterns

This hesitancy of researchers does not seem to be results reflect the nature of at times topic-specific due to computational limits related e. g. to scarce disequilibria within the contingency tables. Yet “CFA- occupancies, which e. g. can be mitigated by re- informed” work is limited to a handful studies in aggregating cells, but rather to deeper psycho-social developmental psychology (Matinez-Torteya 2009), causes, not least incredulity, which hinder also other and scattered studies in other fields. Despite these sensible ideas, e. g. related to the related slowness in meager applications CFA excels in common sense developing an epistemology for also longitudinal transparency and robustness where other methods only person-oriented research (Bergman 2014; von Eye), thrive on often unmet tacit assumptions. Variances in particularly missing in psychiatric early recognition future, after investments in simulative and other research, without there being little awareness of the mathematical work, could be decomposed yielding contribution of syndromes’ internal, personally patter- dimensional and thus meaningfully mixable, partly ned information, leading to a state of psychopatho- dimensional, and intractably high- or un-dimensional logical helplessness: “Symptoms considered alone, components. (…) without additional (external; ...) information are simply an insufficient evidential base on which to CONCLUSION make a valid diagnosis.” (Duffy 2018). Patterns thus only appear in the one-against-the-rest-game, e.g. The pervasive „loss-of-patterns-issue“ should be depression doubling the score regarding personality advanced by numerical psychology along the trans- (Post 2018). lations from genes to behavior by using pattern- and While the problems from insufficient occupancies thus “true dimension”- preserving CFA – Configu- of cells fade with size and can often be circumvented rational Frequency Analysis – and integrated with by “agglutination” or “hierarchical CFA”, it can be- dimensional bio-evolutionary hypotheses to prioritize come demanding in various kinds of CFA realizations bio-psycho-socially genuine dimensionalities mani- to establish significance by running tests from the fested in epidemiology by „mixities.“ The burdensome stochastic shadow world, and often amounts to a fair conundrum of bipolar mixity (Verdolini 2010, Muneer amount of skillful guessing reflected in various 2017) to the benefit of many is likely to profit from a discrepancies in how many of types and anti-types more “grasping” approach in bio-modeling and emerge (Table 13 in van Eye 2002). Nevertheless such statistics.

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14. Cocchi L, Halford GS, Zalesky A, Harding IH, Ramm BJ, Acknowledgements: Cutmore T et al.: Complexity in relational processing predicts changes in functional brain network dynamics. This project was encouraged by Jules Angst till date, Cereb Cortex 2014; 24:2283-96 and also by Hagop Akiskal within the European Bipolar 15. Confirmatory Factor Analysis [en.wikipedia.org/wiki/ Forum (Russ Pendleton), and recently by talks given Confirmatory_factor_analysis] at the CenStuPsi of Giuseppe Tavormina 16. Coscia DM, Narr KL, Robinson DG, Hamilton LS, Sevy S, (www.censtupsi.org) and Heidelberg Psychiatric Uni- Burdick KE et al.: Volumetric and shape analysis of the versity clinic (www.biposuisse.ch/hd18) thanks to thalamus in first-episode schizophrenia. Hum Brain Mapp Michael Mike Schmitgen. 2009; 30:1236-45. doi: 10.1002/hbm.20595 17. Costafreda SG, Fu CH, Picchioni M, Toulopoulou T, Conflict of interest: None to declare. 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Uddin LQ: Salience processing and insular cortical social psychology. Psychology Pr, Philadelphia, 1999 function and dysfunction. Nat Rev Neurosci 2015; 16: 55- 79. Sorrentino RM, Szeto ACH, Nezlek JB, Yasunaga S, 61. doi: 10.1038/nrn3857 Kouhara S, Otsubo Y: Uncertainty regulation: The master 96. Vandevelde A, Leroux E, Delcroix N, Dollfus S: Fronto- motive? In R. M. Sorrentino & S. Yamaguchi (eds.). subcortical functional connectivity in patients with Handbook of Motivation and Cognition Across Cultures, schizophrenia and bipolar disorder during a verbal 49-70. Academic Pr, San Diego, CA, 2008 fluency task. World J Biol Psychiat 2017; Aug 8: 1-9. doi: 80. Steinberg H & Himmerich H: Emil Kraepelin's habilita- 10.1080/15622975.2017.1349339 tion and his thesis: a pioneer work for modern systematic 97. Verdolini N, Agius M, Quartesan R, Elisei S: Mixed reviews, psychoimmunological research and categories of States: a "new" nosographic entity. Psychiatr Danub 2014; psychiatric diseases. World J Biol Psychiatry 2013; 26(Suppl 1):103-11 14:248-57. doi: 10.3109/1562 98. Verma SS & Ritchie MD: Another round of “clues” to 81. Sullivan PF: Puzzling over schizophrenia: schizophrenia uncover the mystery of complex traits. Genes 2018; 9:61. as a pathway disease. Nat Med 2012; 18:210–11 doi:10.3390/genes9020061 82. Szirmai I: How does the brain create rhythms? Ideggyogy 99. von Eye A, Eun-Young M: Configural Frequency Analysis Sz 2010; 63:13-23 Analysis for Research on Developmental Processes. Chp. 83. Theoharides TC, Stewart JM, Panagiotidou S, Melamed I: 20. In Cicchetti D (ed.): Developmental Psychopathology, Mast cells, brain inflammation and autism. Eur J Pharma- vol. 1, 866-9213, rd ed. Wiley: New York, 2016. col 2016; 778:96-102. doi: 10.1016/j.ejphar.2015.03.086 ISBN: 978-1-118-12087-3

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100. von Eye A, Mair P, Mun E-Y: Advances in Configural 103. von Eye A: Configural Frequency Analysis. Methods, Frequency Analysis Guilford Pr, New York, London, Models, and Applications. LEA, Mahwah, NJ, 2002 2010 104. Von Eye, A, Mun, E-Y: Configural Frequency Analysis 101. von Eye A, Mun E-Y, Mair P, von Weber S.: Configural for Research on Developmental Processes. Chp. 20. In Frequency Analysis. In Little TD (ed.): The Oxford Cicchetti D (ed.) Developmental Psychopathology. Vol. Handbook of Quantitative Methods in Psychology: Vol. 1 of 4. Theory and Method. 3rd ed., 2016 2: Statistical Analysis. OUP, Oxford, 2013 105. Wei WH, Hemani G, Haley CS: Detecting epistasis in 102. von Eye A, Wiedermann W: Locating event-based cau- human complex traits. Nat Rev Genet 2014; 15: 722-33. sal effects: A configural perspective. Integr Psychol doi: 10.1038/nrg3747 Behav Sci 2018; 52:307-30. 106. Weygandt W: Über das manisch-depressive Irresein. doi: 10.1007/s12124-018-9423-0 Berlin klin Wochenschr 1901; 38: 70-2 & 105-6

Correspondence: Gottfried R. S. Treviranus, MD Psychiatrische Praxis am Unitobler Campus CH 3012 Berne, Switzerland E-mail:

POOR COMPLIANCE AS A SIGN OF DEPRESSION. Why might an elderly man stop his medication? Tanvi Acharya1,2 & Mark Agius3,4 1School of Clinical Medicine University of Cambridge, Cambridge, UK 2Emmanuel College Cambridge, Cambridge, UK 3Clare College Cambridge, Cambridge, UK 4Department of Psychiatry, University of Cambridge, Cambridge, UK

SUMMARY With only half of individuals prescribed medication actually taking it, the reasons behind non-compliance warrant a thorough understanding. This paper reviews the factors behind medication non-adherence with a special interest in the link between depression and non-compliance. Whilst this link has been evidenced, we propose that non-compliance could be a presenting sign of underlying depression. Implications of the role of depression as a cause of non-compliance - in particular, why a patient might suddenly stop taking their medication - are discussed; further, early intervention to circumvent a major depressive episode could be implemented if recognition of sudden non-compliance is used by clinicians as a diagnostic tool to alert them to screen the patient for depression.

Key words: depression - non-compliance - early intervention

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INTRODUCTION FACTORS INFLUENCING NON-COMPLIANCE Non-compliance – namely, the inability to adhere to the recommended medication course – is a critical A difficulty arises when we try to demarcate the barrier for a patient’s recovery. Unfortunately, this reasons underlying non-compliance, due to the indi- practice is pervasive: 50% of the prescription drugs for vidualistic nature of treatment experience by the circumventing bronchial asthma were untouched patient, therefore making it difficult to have a one- (Sabaté 2003); antihypertensive therapy compliance sized approach to addressing these issues. However, averaged 50-70 % (Sabaté 2003); and adherence to studies attribute non-adherence to one’s personal cancer therapy for adolescent teenagers was reported to (Voils 2005) and cultural (Fleck 2005) attitudes and be only 41 % (Tebbi1986). The seriousness of these explanatory models. An example of this is that the per- figures can be summarised in one short sentence: only ception of antidepressants as addictive (Paykel 1998) half of those that are prescribed medication actually take and a cause of stigma (Sirey 2001) decreased the pro- it; and the consequences are potentially very serious. pensity to adhere to medication. Other studies highlight distressing side effects as a cause for non-adherence: CONSEQUENCES OF experiencing greater side effects was significantly NON-COMPLIANCE associated with worse adherence in Ethiopian patients with schizophrenia (Eticha 2015); and weight gain was Existing literature stresses the link between non- cited as a side effect lowering adherence to medicinal adherence, poor insight (Bollini 2004) and side effects treatment in bipolar patients (Baldessarini 2008). Note caused by the medication (Awad 1993), with the that the aforementioned can be classed as intentional limitation being that they are correlational in nature. nonadherence, whilst unintentional nonadherence in- However, the most obvious negative correlate of clude substance use and abuse; for example, cannabis nonadherence would be the increase in symptoms use was a key variable associated with nonadherence (Verdoux 2000). Further, the interruption of anti- in patients with schizophrenia (Miller 2009) and bi- psychotic treatment resulted in an increased risk of polar disorder (Gonzalez-Pinto 2010). A study explo- hospitalisation in patients with schizophrenia (Weiden ring the subjective experience of taking medication 2004), with medication non-adherence not only fuelling elicited the necessity of shared-decision making in the violence, arrests and an increased risk of suicide doctor-patient relationship to allow patients the attempt; but also, poor social functioning and reduced opportunity of informed involvement in their treatment quality of life (Ascher-Svanum 2006) - not to mention decision; indeed, external pressures by clinicians, and the significant economic burden on families and society lack of opportunity by patients to discuss the need for (Leo 2005). For all these reasons, it is important to treatment, was a driving factor of non- compliance assess the reasons behind poor-compliance. (Adams 2006).

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DEPRESSION AND NON-COMPLIANCE Acknowledgements: None. Depression is a complex condition characterised by a negative mood and loss of interest in activities once Conflict of interest: None to declare. enjoyed. It is worthy of exploration due to the striking finding that people who are depressed are less likely to Contribution of individual authors: adhere to medications for their chronic health pro- Tanvi Acharya - Literature Search. blems than patients who are not depressed, putting Mark Agius - Supervisor. them at increased risk of poor health (Jerry 2011). Both contributed to the text. More specifically, depressed patients across a wide array of chronic illnesses such as diabetes and heart disease had 76 percent greater odds of being non- References adherent with their medications compared to patients who were not depressed (DiMatteo 2002). In CVD 1. Adams JR & Drake RE: Shared decision making and patients, a study involving a depression diagnosis as- evidence based practice. Community Mental Health signed by diagnostic interview and objective adhe- Journal 2006; 42:97-105 rence to 81 mg aspirin measured by an electronic 2. Ascher-Svanum H, Faries DE, Zhu B, Ernst FR, Swartz monitor, highlighted that non depressed patients adhe- MS, Swanson JW: Medication adherence and long-term red to their medications 69% of the days when they functional outcomes in the treatment of schizophrenia in usual care. J Clin Psychiatry 2006; 67:453-60 were monitored, but depressed patients adhered to 3. Awad GA: Subjective response to neuroleptics in their medication only 41% of the days they were schizophrenia. Schizophrenia Bulletin 1993; 19:609-618 monitored (Carney 1995). The poignant disparity in 4. Baldessarini RJ, Perry R & Pike J: Factors associated adherence to treatment between depressed and non with treatment nonadherence among US bipolar disorder depressed patients is one that cannot be ignored, for patients. Hum Psychopharmacol 2008; 23:95-105 depression impedes ideal adherence behaviour, and 5. Bollini P, Tibaldi G, Testa C & Munizza C: Understan- thus contributes to increased mortality. Crucially, a ding treatment adherence in affective disorders: A quali- vicious cycle is created as medication nonadherence tative study. Journal of Psychiatric Mental Health Nursing means the symptoms of a disease are less likely to be 2004; 11:668-674 alleviated, resulting in the patient being less likely to 6. Carney RM, Freedland KE, Eisen SA, Rich MW, Jaffe AS: return to normality and partake in activities prior to the Major depression and medication adherence in elderly onset of a disease, thus exacerbating depression. patients with coronary artery disease. Health Psychol 1995; 14:88-90 7. DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW: NON COMPLIANCE – Patient adherence and medial treatment outcomes: A A SIGN OF DEPRESSION? meta-analysis. Med Care 2002; 40:794-811 8. Eticha T, Teklu A, Ali D, Solomon G, Alemayehu A: Literature has established the link between depres- Factors associated with medication adherence among sion and non-compliance; however, why depressed patients with schizophrenia in Mekelle, Northern Ethiopia. patients are non-compliant remains inconclusive. This PLoS One 2015; 10:e0120560 could be due to the fact that the very symptoms that 9. Fleck DE, Keck PEJr, Corey KB & Strakowski SM: depression encompasses, including apathy and anhe- Factors associated with medication adherence in African donia, will militate against actively taking treatment , American and white patients with bipolar disorder. Journal of Clinical Psychiatry 2005; 66:646-652 and, indeed , could be so severe that the patient does 10. Gonzalez-Pinto A, Reed C, Novick D, Bertsch J, Haro JM: not even feel the need for recovery, and hence the need Assessment of medication adherence in a cohort of for persevering with treatment. Thus it follows that if a patients with bipolar disorder. Pharmacopsychiatry 2010; patient suddenly stops taking their medication, then it 43:263-270 is possible that depression could be a possible 11. Grenard JL, Munjas BA, Adams JL, Suttorp M, Maglione contribution to this. M, McGlynn EA, Gellad WF: Depression and Medication Adherence in the Treatment of Chronic Diseases in the United States: A Meta-Analysis. Journal of General CONCLUSION Internal Medicine 2011; 26:1175-1182 Depression is a condition which commonly occurs 12. Leo JR, Jassal K &Bakhai DY: Nonadherence with psychologic treatment among psychiatric patients. in elderly patients who suffer from multiple physical Primary Psychiatry 2005; 12:33-39 conditions and are prescribed several medications. In 13. Miller R, Ream G, McCormack J, Gunduz-Bruce H, Sevy S, order to increase compliance with complex regimes, Robinson D: A prospective study of cannabis use as a risk these patients are often dispensed medication in ‘Dosset factor for non-adherence and treatment dropout in first- Boxes’ or similar appliances. We wish to suggest that, if episode schizophrenia. Schizophr Res 2009; 113:138-144 it is apparent from these appliances that the patient has 14. Paykel ES, Hart D & Priest RG: Changes in public at- stopped taking his medication, then depression should titudes to depression during the Defeat Depression Cam- be considered as a cause of the non-compliance. paign. British Journal of Psychiatry 1998; 173:519-522

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15. Sabaté E (editor): Adherence to long-term therapies: evi- Predictors and impact on outcome. A 2-year follow-up of dence for action. Geneva: World Health Organization, 2003 first-admitted subjects. ActaPsychiatrica Scandinavia 16. Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, 2000; 102:203-210 Friedman SJ & Meyers BS: Stigma as a barrier to 19. Voils CI, Steffens DC, Flint EP & Bosworth HB: Social recovery: Perceived stigma and patient-rated severity of support and locus of control as predictors of adherence to illness as predictors of antidepressant drug adherence. antidepressant medication in an elderly population. Ame- Psychiatric Services 2001; 52:1625-1620 rican Journal of Geriatric Psychiatry 2005; 3:157-165 17. Tebbi CK, Cummings KM, Zevon MA, Smith L, Richards 20. Weiden PJ, Kozma C, Grogg A, Locklear J: Partial M, Mallon J: Compliance of pediatric and adolescent compliance and risk of rehospitalization among California cancer patients. Cancer 1986; 58:1179-84 Medicaid patients with schizophrenia. Psychiatr Serv 18. Verdoux H, Lengronn J, Liraud F, Gonzales B, Assens F, 2004; 55:886-91 Abalan F et al.: Medication adherence in psychosis:

Correspondence: Mark Agius, MD Clare College Cambridge, Department of Psychiatry University of Cambridge Cambridge, UK E-mail: [email protected]

THE PSYCHOLOGY OF SCARS: A MINI-REVIEW Mildred Ngaage1 & Mark Agius2 1Clinical Research Fellow University of Maryland / R Adams Cowley Shock Trauma Center, Maryland ,USA 2Department of Psychiatry, University of Cambridge, Clare College Cambridge, Cambridge, UK

SUMMARY Scars can result from a range of causes: accidents, surgery, and even acne. The resultant change in appearance can negatively affect body image and self-confidence. Scarring is stigmatised in society because of the premium placed on beauty - disfigurement or unsightly features are still used to portray evil in horror films, comic strips, and fairy tales. Patients describe scars as living with the trauma and sufferers can feel devalued by society. Scars are inflexible and cause functional impairment which may prompt a change in career and have financial repercussions. Those with scars undergo a remodelling of their emotional state and are more prone to the development of depression and anxiety; feelings of shame and aggression can follow. This creates strain in social interactions, resulting in stunted communication, reduced intimacy, and avoidant behaviours. There is limited treatment available to address the psychological burden in this subset of patients. Additionally, doctors often lack training in recognition and management of psychosocial issues. Steps must be taken to relieve the physical, emotional, and psychological marks caused by scars.

Key words: scar – adaptation - social psychology - emotional adjustment - body image

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INTRODUCTION acid attacks, which result in great disfigurement and impaired psychosocial functioning, knowledge of the "Is it going to leave a scar?" This panicked ques- psychological consequences of scars has never been tion feels familiar, and is often heard in a doctor’s more relevant (Morgan 2017). Although some in- office; concern for the long term impact can often trump dividuals adapt to the change in appearance and interest in current treatment risks. Scars, and certainly, ability, others react negatively and have decreased any permanent mark on our complexion, remain a fear psychosocial performance (functioning of emotional, amongst many, not for the physical impairment the social, mental well-being). This mini-review will ex- inflexible tissue causes, but rather the aesthetic change plore the extent to which scarring causes psychological that results (Fukunishi 1999). This fear can occur for a injury. range of severities, from blemishes to disfigurement (Fukunishi 1999, Dyer et al. 2013, Hazarika & Archana WHAT IS BODY IMAGE? 2016, Fried & Wechsler 2006). In a world where the “beautiful” are given many Internal factors advantages, it is easy to understand why appearance is weighted so highly. The old adage, “What is beautiful Identity is constructed through social interactions, is good” is still true today, when being perceived as interpersonal relationships, and perception of one's attractive creates a halo effect (Dion et al. 1972). At- self-worth. It has a fine interplay with body image: the tractive people are treated more positively (Langlois et impression one forms of one’s physical self and any al. 1972), judged more favourably (Thombs et al. 2008), feelings that result from this view (Moss & Rosser are more likely to receive help from strangers (Thombs 2012). Identity and body image affect behaviours and et al. 2008), and receive better job performance eva- inform actions, as well as how individuals perceive luations (Hosoda et al. 2003). Indeed, the rise of laparo- each other. scopic surgery may be an indication of the negative Following a critical incident, previously held be- public opinion on scars. "Scarless surgery" is lauded as liefs about one’s self are called into question and a major advance with multiple benefits, particularly reevaluated. One theory by Moss & Rosser 2012, increased self-esteem and positive body image (Rafiq describes the skin as a protective barrier separating & Khan 2016, Iyigun et al. 2017). self from the environment. A scar can be viewed as an Measuring quality of life is an important aspect of intrusion - the barrier is no longer whole and one is left delivering holistic dermatological care (APPG 2013). exposed. The change in appearance threatens sense of Psychological impact on patients results from a com- self and personhood. Patients must grieve for what has bination of distorted self-image, fall in social standing, been lost and often there is a lack of continuity and economic backlash. In addition to the emotional between the two self-images. For example, MacLeod wounds inflicted, scars cause a physical impairment et al. 2016, found that the pre-burn self is idealised and consisting of pain, itch, and immobility, all of which the post-burn self devalued, demonstrating the decline carry their own psychological burden. With the rise of in self-image.

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External factors contribute greatly to our self-image. Acne scarring on the face causes a reduction in self-confidence and social The World Health Organisation (WHO) defines activities due to embarrassment and low self-esteem quality of life as “the individual's’ perception of their (Hazarika & Archana 2016) . Facial scars, regardless of position in life, in the context of the cultural and value size or percentage of body surface affected, have been system in which they live and in relation to their goals, linked to higher levels of post-traumatic stress disorder expectations, standards, and concerns” (WHOQL Group (PTSD) symptoms, in particular, avoidance and emo- 1995). Context is everything - society influences the tional numbing (Fukunishi 1999). worth placed on individuals. The media bombard the public with images of the "perfect body", fuelling society’s current preoccupation with elevated beauty IS IT ONLY VANITY? standards. This pressure can lead to anxiety and nega- Bias in scar origin tively impact quality of life, and its burden is particularly felt by young women. Anxiety and depression There is an expectation of psychological trauma following scarring are more likely in those under 50 with certain forms of scarring, for example, burns, years old (Chahed et al. 2016, Hassan et al. 2009), and where scars can act as a permanent reminder of the female (Thombs et al. 2008). This is not unexpected in incident and trigger negative emotions (Macleod et al. a “modern” society that attaches great importance to 2016). When a scar originates from deliberate attack it outward appearance and equates attractiveness with can be viewed as a mark of the attacker - an intrusion - femininity. However, men are quickly catching up so becomes difficult to accept as part of self (Macleod (Dryer et al. 2016, Dyer et al. 2014). The rise of gym et al. 2016). The other mechanisms of injury are often culture and increasing social pressures may play a role broadly grouped into surgical, disfigurement, and acne in the decreased self-esteem and distorted body image (Clarke 1999). This means there is a risk of neglecting now notable in this group. other types of scarring, such as self-inflicted, for which little information exists. Dyer et al. 2013, compared LOCATION, LOCATION, LOCATION those with self-inflicted scars to those with accidental or traumatic scars. They found that self-inflicted scars Visibility were linked to a greater negative body image, regard- The most important characteristic that causes pa- less of gender, and were more visible than surgical or tients to judge scar aesthetic as poor is high visibility accidental scars. There is an underlying social stigma (Hoeller et al. 2003). Visibility, and not the size of the associated with such scars, which may further exa- scar, is associated with a more negative body image cerbate the psychological burden. (Fukunshi 1999, Dyer et al. 2013). Being easily iden- There has also been a disparity in how others per- tifiable as "different" can be intimidating and isolating. ceive congenital and acquired scars (Rumsey & Back acne and scarring can be hidden by clothing but Harcourt 2004). Although, both groups possess a greater were significantly associated with increased sexual dissatisfaction with appearance and lower self-esteem self-consciousness of appearance in both men and than controls (Versnel et al. 2010); this distress stems women (Hassan et al. 2009). Hand injuries act twofold from contrasting experiences. People with congenital to cause mental distress; they difficult to conceal, and scars often do not have a normal social development - can result in loss of self-sufficiency and cause vocation adults stare at them instead of smile (Bradbury & impairment (Solnit & Priel 1975). Although when the Hewison 1994); whereas those with acquired scars functional impairment becomes too great, cosmesis, encounter a loss of self and change in social status. although still mentally disturbing, can be seen as a luxury healthcare option (Bijlard et al. 2017). This rule Functional impairment remains the same for younger generations; children with visible scarring struggle more socially than those Scars can impede physical functioning; burns create with non-visible scarring (Maskell et al. 2014). an abundance of inflexible scar tissue and keloids distort appearance and compromise functionality. For example, scars located across joints restrict movement, Taking things at face-value thus imposing physical limitations with a reduced Perhaps, the most psychologically significant loca- ability to perform activities of daily living, tion for a scar is the face. It is highly visible and diffi- The reduced functionality can be life-changing, war- cult to hide from view; its features confer "attractive- ranting a change in career and re-training. The pro- ness" and play a role in human bonding. Face perception found impact on employment can be divided into three has a crucial function in communication and patients aspects: reduced work opportunities, prejudice and may suffer a decline in social skills when difficulties interpersonal problems in the workplace, and psycho- occur (Macgregor 1990); for example, when others logical and financial impact of job loss. Although focus on the scar instead of maintaining eye contact. disability and/or disfigurement are protected characte- Faces act as unique identifiers for each individual and ristics under the Equality Act 2010, discrimination

S634 Mildred Ngaage & Mark Agius: THE PSYCHOLOGY OF SCARS: A MINI-REVIEW Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 633-638 may still occur (Scope 2012). Those with scars have Intimacy and love increased unemployment rates (Levine et al. 2005), The common assumption is that scarring is unat- and are less likely to be successful at job interviews tractive to others. Unfortunately, the evidence supports (Brown et al. 2008). An inconsistent ability to access this claim; scars can lead to interpersonal rejection disability benefits adds to the financial burden (APPG with a negative effect on intimacy (Fried & Wechsler 2013). Scarring is associated with emotional sup- 2006). Robust evidence shows decreased frequency of pression and many patients have difficulties in face-to- sexual activity, adopting unnatural positions to hide face interactions with the public. This creates a chal- scars, and difficulty initiating new relationships (Hassan lenge to their role in the workplace where colleagues et al. 2009, Connell et al. 2014). Initial meetings are can find them withdrawn or unfriendly (Connell et al. awkward due to answering questions and recalling 2014). memories (Brown et al. 2008), making the search for love more daunting. FALLING OFF THE SOCIAL LADDER Social stigma FACING THE MIRROR: EMOTIONAL TURMOIL We are programmed to be averse to visible imperfections. Perception of an unusual feature may suggest Disrupted identity a connection to contagious diseases or a lack of hygiene When one thinks of oneself, a mental picture forms and thus initiate avoidance and social stigmatisation of based on reflections, photographs, and comments from the individual (Oaten et al. 2011). Disfigurement or others. Scars cause a permanent identity change, and unsightly features are still used to portray evil in adjustment to the new outward and inner self-image is horror films, religious imagery, and fairy tales. Stigma needed. The mismatch between appearance and iden- is a constant social threat to a person's life experience tity can trigger a psychological shift and invoke fee- whereby society creates a new identity for these poor lings of anxiety and shame (Thombs et al. 2008). souls and foists it upon them. Scarred patients often describe their new appearance as The perception of stigma can change one’s identity living with this trauma. This can trigger a cascade of to that of a devalued individual. Some may argue that feelings: shame, self-rejection, and self-consciousness this stigma is merely an unconscious bias that does not (Macleod et al. 2016). escalate to actions. However, individuals experience Distorted body image is reflected in everyday inter- intrusive questions, stares (Connell et al. 2014), and actions. Those with a history of acne scarring exhibit strangers maintaining a greater distance from them enhanced fixation on acne lesions and judged scarred (Furr 2014). This continuous hostile reaction and the faces more harshly (Lee et al. 2014) whilst also taking unwanted attention make the injured acutely aware of pains to hide scars and avoid reflective surfaces or their difference, and conditions them to anticipate conversely become obsessed with their reflection negative reactions. Those with scars often adopt be- (Brown et al. 2008). It is a patient’s subjective expe- haviours of preemptive avoidance or aggression rience and perceived severity of scarring, rather than (Chahed et al. 2016), thus fulfilling the villain stereo- objective clinical severity, that predicts the level of type. distress (Chouliara & Affleck 2014, Kleve & Robinson 1999). The heightened awareness of scars can also Family and loved ones manifest as various mental disorder symptomatology: anger, anxiety, and frustration; ultimately leading to Reactions from family and friends to scars, both aggression (Chahed et al. 2016). positive and negative, can detrimentally affect patients' emotions. Lack of sympathy forces the patient to minimise their feelings, whereas concern evokes Social disturbance feelings of guilt for causing unnecessary distress in The anticipation of rejection leads to concealment their loved ones (Brown et al. 2008). The loss of and avoidance (Thompson & Kent 2002). The resultant independence from functional disability may mean social disability can be characterised by these coping reliance on a family member or carer. The frustration strategies: avoidance of eye contact, closed body lan- and emotional distress in the patient can lead to guage, and shutting down conversations. There is an tension and in rare cases, abuse of the carer, further association between appearance concern and PTSD isolating the individual. The carers, themselves may be symptoms after burn injury (Shepherd 2015). Depres- juggling care with work and family life, and have to sion (Thombs et al. 2007) and anxiety are also common reduce working hours, leading to a drop in household (Fried & Wechsler 2006). These mood disorders may income (Carers UK 2014). Carers may also experience also translate into increased alcohol abuse, and signi- poor mental health due to this new role (Carers UK ficantly decreased satisfaction with life (Levine et al. 2015) which compounds this unfortunate situation. 2005). People with scars also expressed a strong desire

S635 Mildred Ngaage & Mark Agius: THE PSYCHOLOGY OF SCARS: A MINI-REVIEW Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 633-638 to be alone and avoid activities where they can be Archana 2016, Maskell et al. 2014). Unfortunately, observed; this behavioural change had been described many individuals currently rely on charities, such as on multiple occasions (Macleod et al. 2016, Levine et Restore or Changing faces, to close the research gap al. 2005, Thompson & Kent 2002) and highlights the and deliver these interventions. need for peer and family support, education, and social skills training (Martin et al. 2016). CONCLUSIONS CURRENT MEDICAL PRACTICE Scarring may be skin deep but their psychological impact goes deeper still. The evidence is decisive; the Medical failings presence of scars can result in clear markers of mental Healthcare professionals’ time is limited; they may disturbance in patients with associated symptoms of not have enough resources or adequate training to do depression, anger, anxiety, and post-traumatic stress. A psychosocial assessments or simply do not believe it is scar creates physical, emotional and psychological their responsibility (Changing Faces 2016). With marks. Identity is called into question and individuals current provision for mental health lacking we are far must integrate the scar with their sense of self in order from a solution. Evidence strongly suggests that there to achieve psychological acceptance. This process is still a long way to go to improve integration between causes a change of behaviour and reduced functioning, socially and psychologically, driven by a fear of being physical and mental health (Department of Health singled out. This is supported by the theory that scar England 2014). visibility acts as a mediator of psychological distress; Patients can experience a loss of control when in- thus, hiding the scars relieves maladaptive behaviour jured due to a reduction in physical capabilities and and often leads to a return to normal functioning. limited treatment options (Abdel Hay et al. 2016). Scar Leaving us with hope that these psychological scars revision treatment consists of steroid treatment, laser can be managed and even reversed. therapy, and surgical excision, but is not widely available via the public health system (NHS Choices 2014). Physical symptoms, such as pain, itch, and restricted Acknowledgements: None. movement are part of the eligibility criteria to receive treatment but there is little guidance on psychological Conflict of interest: None to declare. impairment as a qualifying condition. Instead, affected individuals must turn to the private sector. Addi- Contribution of individual authors: tionally, none of these treatments eradicate the scar completely and the improvements offered take months Mildred Ngaage drafted text. or years. They also carry their own risks, for example, Mark Agius advice and supervision. surgical excision leaves a scar. In addition to costs of private healthcare, there is a further economic backlash on those who spend exorbi- References tant amounts on “miracle cures” (Fried & Wechsler 1. Abdel Hay R, Shalaby K, Zaher H, Hafez V, Chi CC, 2006). These patients represent a vulnerable group Dimitri S et al.: Interventions for acne scars. Cochrane who we are failing to protect. Attention-grabbing ad- Database Syst Rev 2016; 4:CD011946 vertisements make unrealistic promises on the benefits 2. All Party Parliamentary Group (APPG) on Skin: The of these over-the-counter solutions, although the evi- Psychological and Social Impact of Skin Diseases on dence remains murky yet spending remains high (Shih People’s Lives, a report by the All Party Parliamentary et al. 2007). Group on Skin. England, 2013 3. Bijlard E, Kouwenberg CA, Timman R, Hovius SE, Busschbach JJ & Mureau MA: Burden of Keloid Disease: Looking to the future A Cross-sectional Health-related Quality of Life Assess- Cognitive behavioural therapy (CBT) has been ment. Acta Derm Venereol 2017; 97:225–229 shown to improve psychological symptoms associated 4. Bradbury ET & Hewison J: Early parental adjustment to with scarring so presents a possible future solution visible congenital disfigurement. Child Care Health Dev 1994; 20:251–66 (Kleve et al. 2002). The therapy aims to facilitate deci- 5. 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acne lesions in patients with acne. Psychol Health Med 28. Kleve L, Rumsey N, Wyn-Williams M & White P: The 2014; 19:680–686 effectiveness of cognitive behavioural interventions pro- 9. Chahed MK, Bellali H, Ben Jemaa S & Bellaj T: vided at Outlook: a disfigurement support unit. J Eval Psychological and Psychosocial Consequences of Zoo- Clin Pract 2002; 8:387-395 notic Cutaneous Leishmaniasis among Women in Tunisia: 29. Langlois JH, Kalakanis L, Rubenstein AJ, Larson A, Preliminary Findings from an Exploratory Study. PLoS Hallam M & Smoot M: Maxims or myths of beauty? A Neglected Trop Dis 2016; 10:10 meta-analytic and theoretical review. Psychol Bull 2000; 10. Changing Faces: Look at Me Campaign - Integrated care 126:390–423 for people with skin conditions. Changing Faces, England, 30. Levine E, Degutis L, Pruzinsky T, Shin J & Persing JA: 2016 Quality of life and facial trauma: Psychological and body 11. Chouliara Z & Affleck A: Psychological Adjustment to image effects. Ann Plast Surg 2005; 54:502–10 Disfiguring Skin Conditions. Derm Practice 2014; 20:16-20 31. Macgregor F: Facial disfigurement: problems and ma- 12. Clarke A: Psychosocial aspects of facial disfigurement: nagement of social interaction and implications for mental problems, management and the role of a lay-led health. Aesthet Plast Surg 1990; 14:249-257 organization. Psych, Health & Med 1999; 4:2 32. Macleod R, Shepherd L & Thompson AR: Posttraumatic 13. Connell KM, Phillips M, Coates R, Doherty-Poirier M & stress symptomatology and appearance distress following Wood FM: Sexuality, body image and relationships burn injury: An interpretative phenomenological analysis. following burns: Analysis of BSHS-B outcome measures. Health Psychol 2016; 35:1197-1204 Burns 2014; 40:1329-37 33. Martin L, Byrnes M, McGarry S, Rea S & Wood F: Social 14. Department of Health: Closing the Gap, Priorities for challenges of visible scarring after severe burn: a quali- Essential Change in Mental Health. Department of tative analysis. Burns 2016; S0305-4179:30263–30267 Health, England, 2014 34. Maskell J, Newcombe P, Martin G & Kimble R: Psycho- 15. Dion K, Berscheid E & Walster E: What is beautiful is logical and psychosocial functioning of children with burn good. J Pers Soc Psychol 1972; 24:285–290 scarring using cosmetic camouflage: a multi-centre pros- 16. Dryer R, Farr M, Hiramatsu I & Quinton S: The Role of pective randomised controlled trial. Burns. 2014; 40:135–149 Sociocultural Influences on Symptoms of Muscle Dys- 35. Morgan B: Plastic surgeons facing 'epidemic of acid morphia and Eating Disorders in Men, and the attacks' in London, expert says. Evening Standard, 2017 Mediating Effects of Perfectionism. Behav Med 2016; 36. Moss TP & Rosser BA: The Moderated Relationship of 42:174-82 Appearance Valence on Appearance Self Consciousness: 17. Dyer A, Hennrich L, Borgmann E, White AJ & Alpers Development and Testing of New Measures of Appearance GW: Body image and noticeable self-inflicted scars. J Schema Components. PLoS ONE 2012; 7: e50605 Nerv Ment Dis 2013; 201:1080–1084 37. National Health Service (NHS) Choices: Scars – Treat- 18. Dyer A, Mayer-Eckhard L, White AJ & Alpers GW: The ment. NHS Choices, 2014 role of scar origin in shaping men’s body image. Am J 38. Oaten M, Stevenson RJ & Case TI: Disease avoidance as Men’s Health, 2014; 9:115–123 a functional basis for stigmatization. Biolog Sci 2011; 19. Fried RG & Wechsler A: Psychological problems in the 366:3433-3452 acne patient. Dermatol Ther 2006; 19:237–40 39. Rafiq MS & Khan MM: Scar Pain, Cosmesis and Patient 20. Fukunishi I: Relationship of cosmetic disfigurement to the Satisfaction in Laparoscopic and Open Cholecystectomy. severity of posttraumatic stress disorder in burn injury or J Coll Physicians Surg Pak 2016; 26: 216-9 digital amputation. 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Correspondence: Mildred Ngaage, MA Cantab. MB BChir. University of Maryland / R Adams Cowley Shock Trauma Center Maryland, USA E-mail: [email protected]

THE IMPORTANCE OF ANXIETY IN UNDERSTANDING HOW DECISION MAKING IS AFFECTED IN AUTISM SPECTRUM DISORDER Ankit Chadha Emmanuel College, University of Cambridge, Cambridge, UK

SUMMARY Autobiographical and clinical accounts of individuals with autism spectrum disorder (ASD) have highlighted that these individuals experience several difficulties during the decision making process. A review of the experimental based studies assessing performance in decision making tasks compared to controls emphasizes key differences including altered risk preferences, decreased sensitivity to social rewards, increased deliberative reasoning and atypical integration of emotional cues. Despite several attempts to devise cognitive theories to explain these differences, none so far can account for all the differences seen. However, one key observation, consistent with clinical accounts, is elevated levels of anxiety in populations with ASD. Whilst this has traditionally been considered a bi-product of the decision making process, I argue that increased anxiety may directly influence decision making in individuals with ASD, through 2 main routes. Firstly, elevated anxiety overwhelms Type 1 (intuitive) fast processes (within the Dual Process Model), leading to a decision making style biased by Type 2 (deliberative) processes. In addition, heightened anxiety decreases cognitive flexibility, leading to a more logic based, deliberative decision making style. This is superimposed on pre-existing cognitive impairments which altogether may account for the differences seen. Therefore, anxiety must be considered as a key variable in cognitive models of decision making in ASD. Specific recommendations for future research exploring the role of anxiety are discussed.

Key words: anxiety – autism spectrum conditions/disorder (ASC/ASD) – decision making

* * * * * INTRODUCTION This included an altered sensitivity to risk as assessed by the Iowa Gabling task, an increased reward pre- Autism spectrum disorder is a heterogeneous set of ference for circumscribed interests in the absence of neurodevelopmental disorders characterized by impaired social rewards, increased deliberation as well as a de- social interactions, restrictive interests and repetitive be- crease in sensitivity to contextual stimuli and cognitive haviors (Landa 2008). Green et al. (2000) reported that flexibility. In particular, Damiano et al. (2012) high- <5% of adults with ASDs are rated by their parents as lights a failure to integrate emotional cues into the being able to buy items, plan their routine or make de- decision making process, basing their decisions using cisions about self-care. To understand the impairments in increased levels of logical reasoning. decision making, the literature has focused on autobiographical and clinical accounts of individuals with ASD, as EVIDENCE FOR ANXIETY IN ASD well as a limited number of experimental studies directly comparing decision making in ASCs and controls. There is converging evidence from a large number Both experimental studies and clinical accounts of of sources that elevated levels of anxiety is a substantial individuals with ASD report that a frequent issue obser- issue in autism spectrum disorder. Autobiographical ac- ved is heightened levels of anxiety. Anxiety can be defi- counts provide excellent qualitative insight, allowing ned as a feeling of uneasiness, usually generalized as an individuals to express the difficulties they face during overreaction to a situation that is only subjectively seen decision making in their own words. For example, Jen as menacing. Here, we assess the contribution that eleva- Birch highlighted how she needs “more time than the ted anxiety may make to the decision making process in average person in order to weigh up my options, come individuals with ASD by evaluating three questions: to a decision, cope with the sudden change of options… what are the differences in decision making between it is the moment of decision-making which is often the individuals with ASD and controls, what is the evidence difficultly for me.” (Birch 2003). Clinical reports rein- for increased anxiety in ASD and finally, how this may force the notion that anxiety is a pertinent issue in ASD, influence decision making to explain the differences as adults with ASD were almost three times more seen in decision making in the experimental studies. anxious than a comparison group and gained significantly higher scores on anxiety subscales of panic and DIFFERENCES IN DECISION MAKING agoraphobia, separation anxiety, obsessive-compulsive disorder and generalized anxiety disorder (Gillott 2007). A review of the experimental studies highlighted Gillott et al. (2001) reported high-functioning children several abnormalities in decision making, relating to 6 with autism to be significantly more anxious than nor- main cognitive processes – as summarized in Table 1. mally developing controls. Seven out of their sample of

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Table 1. Summarizing the results of lab-based experimental studies comparing decision making in ASD and controls Aspect of decision making Effect of ASD Studies Sensitivity to risk No significant difference in overall Johnson et al. 2006, South et al. 2008, Yechiam performance on IGT et al. 2010, Faja et al. 2013, Mussey et al. 2014 More advantageous selections on IGT South et al. 2014, Vella et al. 2017 Increased switching between decks Mussey et al. 2014 on IGT No significant different on BART South et al. 2011 Subjective representation Increased expenditure for rewards Damiano et al. 2012 of reward Decreased rewards for social stimuli Demurie et al. 2011, Damiano et al. 2012, Lin et al. 2012, Faja et al. 2013, Robic et al. 2015, Levin et al. 2015 Increased temporal discounting O’Connell et al. 2013, Chantiluke et al. 2014 No difference in temporal discounting Demurie et al. 2011, Demurie et al. 2013 Deliberative vs intuitive Increased deliberation De Martino et al. 2008, Morsanyi & Holyoak 2010, thinking Brosnan et al. 2013, Brosnan et al. 2014, Brosnan et al. 2016 Flexibility Decreased flexibility in high error rate Minassian et al. 2007 Sensitivity to contextual Reduced sensitivity to contextual Farmer et al. 2017 stimuli stimuli Integration of emotion Failure to integrate emotional cues Damiano et al. 2012, Brewer et al. 2015 General features Increased response latency Winter 2003, Luke et al. 2011, Vella et al. 2017 Increased Anxiety + stress Winter 2003, Luke et al. 2011, Southet al. 2011, Vella et al. 2017

15 children with autism were found to be clinically the Subjective Expected Utility theory (von Neumann anxious as rated by the Spence Children’s Anxiety 1947) assumed that people solely assess the severity Scale. Kim et al. (2000) also found elevated levels of and likelihood of the possible outcomes of choices and separation anxiety as well as generalized anxiety in integrate this information using expectation-based their sample, whereas Muris et al. (1998) found simple calculus to arrive at a decision. phobia to be the most common anxiety disorder in One model which addressed several of the findings populations with ASC. Reinforcing these clinical bain autism is the Dual Process Theory model which has sed accounts, Luke et al. (2011) collected self-report been a dominant model within cognitive psychology data to examine the type of problems that people with for almost 50 years (Evans 2013). De Martino et al. ASD (n=78) experience during decision making. The (2008) hypothesized that individuals with ASD have data suggests that people with ASD often experience an increased tendency towards deliberation, attribu- elevated anxiety, simultaneously with mental “free- table to impairments within intuitive reasoning systems. zing”, mental exhaustion, slowness in reaching a deci- Hence, a slower, effortful, deliberative reasoning style sion, as well as a tendency to collect too much infor- would be dominant in individuals with ASD, who mation, consistent with earlier findings from Winter demonstrate an ‘unusual enhancement in logical con- (2003), who used a questionnaire and the General sistency’, which would also support the empathizing- Decision Making Style inventory (Scott 1995). There- systemizing (E-S) theory of autism (Baron-Cohen fore, despite relatively few attempts to evaluate anxiety 2005). For example, during the framing task, ASD in this population, there is significant interest in the idea subjects are better able to ignore biasing contextual that heightened anxiety is concomitant with autism. information and isolate critical information about the numerical value of the sure and risky options. This HOW MAY ANXIETY result is consistent with other experimental findings INFLUENCE DECISION MAKING showing that ASD subjects have enhanced attention for the task's details but reduced capacity to deal with Whilst there is substantial evidence for elevated le- the global aspect of the task as predicted by weak vels of anxiety in populations with ASD, it is rarely coherence theory (Frith 1994). Whilst some argue that included as a key variable in cognitive models of deci- those with ASD have dominant deliberative reasoning sion making in individuals with autism. Traditionally, due to impaired intuitive mechanisms, another possible the earliest models of decision making suggested explanation however, is that these intuitive mecha- formal models based on social and economic nisms are intact in different contexts but this context behaviour – with a key focus being on rational choice. triggers deliberative reasoning in those with higher In particular, with respect to choices involving risk, levels of autistic traits.

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Figure 1. Diagrammatic representation of cognitive impairments seen in ASD superimposed on the risk-as-feelings model of decision making (Loewenstein 2001)

Whilst the Dual Process model addresses several of reasoning tasks (Leon 1985). Hence, highly anxious the findings regarding decision making in ASD, it participants may require greater information sampling ignores the effects of heightened anxiety, especially in before having the confidence to choose a particular social situations. Therefore, I argue that anxiety has a deck, explaining the slower rate in learning which two-sided effect on the decision process. Firstly, rather decks are advantageous (Yechiam 2010). than having impaired intuitive mechanisms as proposed Subjective representation of reward – It is argued by De Martino et al. (2008), I argue that the affective that social stimuli are more complex to process – this state (which contributes to type 1 processes) may become cognitive overload may exacerbate anxiety in indivi- overwhelmed by high levels of anxiety in ASD. As there duals with ASD, explaining why social stimuli are are limited cognitive resources to accommodate type 1 perceived as less salient to people with the disorder. processes, it is plausible that elevated anxiety may reduce Furthermore, elevated levels of anxiety may explain the influence of other Type 1 processes (other emotions, the steeper temporal discounting seen in ASD heuristics etc.) from influencing the decision making (O’Connell 2013), as individuals strive to regain process, leading to a decision style that is dominated by control of a situation by electing for a smaller imme- Type 2 processes, contributing to a decision making style diate reward over a larger delayed prize. which appears to be more deliberative. Deliberative thinking – The lack of confidence in Secondly, heightened anxiety in itself may play a one’s decision making process may explain the need direct role in the decision making process. There has to acquire more information before making a decision, been research showing that decisions regarding risk resulting in a circumspect reasoning bias (Brosnan (involving probabilities) use global, affect based 2013, 2014), and the appearance of a deliberative way responses: for example, the risk-as-feelings hypothesis of thinking - although this cannot be confirmed since (Loewenstein 2001), shown in figure 1, postulates that anxiety levels were not measured in participants. This decision making results in part from direct (i.e. not tendency of increased elaboration when making choi- cortically mediated) emotional influences, including ces has previously been associated with high anxiety feelings such as worry, fear, or anxiety, which directly (Calvo 2003). However, this would be counterproduc- feed into the decision making process. tive in a complex decision-making task like the IGT Therefore, by considering anxiety as an input vari- in which declarative cues on the optimum gambling able in the decision making process, increased anxiety strategy typically only become available between may explain several of the findings within the studies: trials 50 and 80 in healthy volunteers (Bechara 1997), Risk preference –When people decide to choose a explaining poorer performance seen by individuals particular deck in the IGT (Bechara 1994) they need a with ASD in this task. certain level of confidence to persist with it. Flexibility – When the error rate is high, it is argued Heightened anxiety in ASD may decrease confidence that the constant mismatch between expectation and about the contingencies of a particular deck, leading outcome may overwhelm cognitive resources and in- individuals with autism to switch between decks more crease anxiety further. Hence this may lead to indivi- often. Similarly, Leon & Revelle (1985) demonstrated duals with ASD picking an option they “know” already a relationship between anxiety and the tendency to instead of switching between options, decreasing per- inefficiently select relevant from irrelevant cues in ceived cognitive flexibility (Minassian 2007).

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Integration of emotion – As discussed earlier the ele- CONCLUSION vated anxiety may lead to an overwhelming of Type 1 intuitive cognitive resources which process emotion, In conclusion, anxiety may play a significant role in leading to a failure to integrate other emotions during the decision making process in individuals with ASD. I decision making (Brewer 2015), leading to decisions have argued that rather than failing to integrate emo- being operated by Type 2 (deliberative) processes. tional information into the decision making process, It is important to note that increased anxiety cannot individuals with ASD have elevated levels of anxiety account for all the effects seen in decision making with which may overwhelm Type 1 intuitive processes, and ASD. Vella (Vella 2017) noted that increased anxiety also directly feed into the decision making process to was weakly associated with reduced information sam- produce a more deliberative style of reasoning, which is pling. Furthermore, neurotypical subjects with experi- superimposed on pre-existing cognitive impairments. In mentally induced anxiety, “jumped to conclusions” order to validate this hypothesis, experimental studies when completing the beads task (Lincoln 2010) colla- directly measuring anxiety levels or controlling for the ting less information before making a decision, in sharp effects of increased anxiety in ASD are required. contrast to the circumspect reasoning bias seen in people with ASD (Brosnan2014). However, in both these studies, there may have been significant variation Acknowledgements: in the impact of anxiety on reasoning styles. I would like to thank Dr. Will Skylark for his help in It is critical to understand that the argument I have reviewing the original text. I would also like to thank put forward about increased anxiety is not mutually Dr. Mark Agius for his help in reviewing a later copy of exclusive with existing cognitive theories of autism (see the text. Rajendran & Mitchell 2007 for a review). Instead, the Conflict of interest: None to declare. effects of heightened anxiety maybe superimposed on the cognitive impairments highlighted by theories such as Executive Dysfunction and/or Weak Central Cohe- References rence, which altogether may account for more of the differences in decision making seen. Whatever the exact 1. Baron-Cohen S, Belmonte, M &Knickmeyer R: Sex Diffe- effect of anxiety is, the fact that it is commonly obser- rences in the Brain: Implications for Explaining Autism. ved in ASD during decision making tasks (Luke 2011, Science 2005; 310:819-823 Vella 2017), consistent with autobiographical (Birch 2. Bechara A, Damasio H, Travel D &Damasio A: Deciding 2003) and clinical accounts, it would seem unjust to Advantageously Before Knowing the Advantageous Strategy. exclude it from models of decision making in ASDs. Science 1997; 275:1293-1295 3. Birch J: Congratulations! It's Asperger Syndrome. 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Neuropsychology 2014; 28:222-228 Motivational processes and autonomic responsivity in As- 38. South M, Dana J, White SE & Crowley MJ: Failure is not perger's disorder: evidence from the Iowa Gambling Task. an option: risk-taking is moderated by anxiety and also by Journal of the International Neuropsychological Society cognitive ability in children and adolescents diagnosed with 2006; 12:668-676 an autism spectrum disorder. Journal of Autism and 21. Kim JA, Szatmari P, Bryson SE, Streiner DL & Wilson FJ: Developmental Disorders 2010 The Prevalence of Anxiety and Mood Problems among Chil- 39. South M, Ozonoff S & Mcmahon WM: Repetitive Behavior dren with Autism and Asperger Syndrome. Autism 2000; Profiles in Asperger Syndrome and High-Functioning 4:117-132 Autism. Journal of Autism and Developmental Disorders 22. Landa RJ: Diagnosis of autism spectrum disorders in the 2005; 35:145-158 first 3 years of life. Nature Clinical Practice Neurology 40. Steketee G, Frost RO, Wincze J, Green KAI & Douglass H: 2008; 4:138-147 Group and individual treatment of compulsive hoarding: a 23. Leon MR & Revelle W: Effects of anxiety on analogical pilot study. Behavioural and Cognitive Psychotherapy reasoning: A test of three theoretical models. Journal of 2000; 28:259-268 Personality and Social Psychology 1985; 49:1302-1315 41. Sze KM & Wood JJ: Cognitive behavioral treatment of co- 24. Levin IP, Gaeth GJ, Foley-Nicpon M, Yegorova V, Ceder- morbid anxiety disorders and social difficulties in children berg C & Yan H: Extending decision making competence to with high-functioning autism: a case report. Journal of special populations: a pilot study of persons on the autism Contemporary Psychotherapy 2007; 37:133-143 spectrum, Frontiers in Psychology 2015; 6 42. Vella L, Ring HA, Aitken MR, Watson PC, Presland A & 25. Lin Rangel A & Adolphs R: Impaired Learning of Social Clare IC: Understanding self-reported difficulties in Compared to Monetary Rewards in Autism. Frontiers in decision-making by people with autism spectrum disorders. Neuroscience 2012; 6A Autism 2017; 136236131668798 26. Loewenstein GF, Weber EU, Hsee CK & Welch N: Risk as 43. von Neumann J & Morgenstern O: Theory of Games and feelings. Psychological Bulletin 2001; 127:267-286 Economic Behaviour. Princeton: Princeton University 27. Luke L, Clare IC, Ring H, Redley M & Watson P: Decision- Press, 1947. making difficulties experienced by adults with autism 44. Yechiam E, Arshavsky O, Shamay-Tsoory SG, Yaniv S & spectrum conditions. Autism 2011; 16:612-621 Aharon J: Adapted to explore: reinforcement learning in 28. Luke L: Decision-making in autism spectrum conditions. autistic spectrum conditions. Brain and Cognition 2010; PhD Thesis, University of Cambridge, 2011 72:317-324

Correspondence: Ankit Chadha, BA (Cantab) Emmanuel College, University of Cambridge CB2 3AP, Cambridge, UK E-mail: [email protected]

EFFECTIVENESS OF SEROTONERGIC DRUGS IN THE MANAGEMENT OF PROBLEM BEHAVIORS IN PATIENTS WITH NEURODEVELOPMENTAL DISORDERS Moreno Marchiafava1, Massimo Piccirilli1,2, Chiara Bedetti1, Antonella Baglioni1, Marina Menna1 & Sandro Elisei1,3 1Istituto Serafico, Assisi, Perugia, Italy 2Department of Experimental Medicine, University of Perugia, Perugia, Italy 3Department of Philosophy, Social and Human Sciences and Education, University of Perugia, Perugia, Italy

SUMMARY Neurodevelopmental disorders often result in disabilities associated with auto- and / or hetero-aggressive behaviors, that can be defined as "problem behaviors" (Lacy 2007). Therapeutic interventions are mainly directed towards the use of neuroleptic drugs or benzodiazepines, to ensure a rapid and significant sedation in most of cases. These pharmacological devices exposes the patient to clinical risks and/or long-term management difficulties. The main problem of the chronic use of benzodiazepines is the development of tolerance and dependence; furthermore benzodiazepine withdrawal or their abrupt reduction may lead to rebound effect. Regarding the long-term effects of neuroleptics, it is necessary to focus on extrapyramidal effects, motor restlessness and akathisia, anticholinergic effects, as well as endocrine and metabolic alterations. Several studies have shown that the reduction of serotonergic receptor activity is associated with the appearance of aggressive behavior (Farnam et al. 2017), especially impulsive behaviors (Manchia et al. 2017, Takahashi et al. 2012). The dynamics that subtend these data are still not fully clarified, however there are evidences that the use of selective serotonin reuptake inhibitors (SSRI) is helpful in the treatment of aggressive behavior in mental disabilities (Sterke et al. 2012, Janowsky et al. 2015). In this study we observe the behavioral response to sertraline, for minors, and to vortioxetine, for adults, considering that the literature shows significant evidence of modulation of synaptic neuroplasticity (Waller et al. 2017). To support the observation we used behavioural scales to collect the data, before the administration of the drug, during the course of treatment, at 3 months from the start of the administration. We detected the improve of behavioral disorders with the less use neuroleptic drugs and benzodiazepines.

Key words: SSRI – problem behaviors – self-aggressivity – neurodevelopment

* * * * *

INTRODUCTION term management difficulties. The main problem of the chronic use of benzodiazepines is the development of Autism spectrum disorders, such as neurodevelop- tolerance and dependence. Tolerance is establish in a mental disorders, result in disabilities associated with an relatively short time as a drastic reduction of the thera- auto- and/or hetero-aggressive behavior, repetitive ges- peutic effect of the drug, imposing a gradual titration of tures (perseverations, stereotypies), and rituals, up to the dosage. In addition, benzodiazepine withdrawal manifestations related to the clinical sphere of obses- especially if it is abrupt may lead to rebound effect or sive-compulsive disorder. abstinence syndrome: this consists in the return of the It is pleonastic to emphasize how these circumstan- symptoms for which the patient was treated, sometimes ces require a pharmacological intervention, both for the more marked. Abstinence syndrome appears when health of patients and for those around them. Therefore benzodiazepines are discontinued and is the main sign we are directed mainly towards an intervention based on of physical dependence. Treatment with neuroleptics the use of neuroleptic drugs or benzodiazepines, which usually does not give loss of efficacy over time, but it is guarantee, in the majority of cases, a rapid and signifi- necessary to pay attention to the appearance of extra- cant sedation. Benzodiazepines are drugs that act by pyramidal effects (tremors, stiffness, involuntary move- binding the interface between the Ȗ and Į subunits of the ments), motor restlessness and akathisia, anticholinergic GABA-A receptor, causing an increase in the affinity of effects (xerostomia, constipation, blurred vision, seda- GABA to its binding site, amplifying the inhibitory tion, as well as endocrine and metabolic alterations action of the neurotransmitter and increasing its seda- (hyperprolactinemia with, galactorrhea, gynecomastia tive, hypnotic and anticonvulsant properties. Neurolep- and sexual dysfunction, metabolic syndromes with in- tics, instead, exert their sedative effect by acting as creased risk of type 2 diabetes and weight gain espe- antagonists of the D2, 5HT1A, 5HT1C receptors, as cially after prolonged treatment). Therefore, considering well as the H1 receptor. Often the use of these phar- the necessity of chronic treatments in patients with macological devices, does not guarantee the desired neurodevelopmental disorders, is critical to evaluate effect and puts the patient to clinical risks and/or long- new pharmacological guidelines is evident.

S644 Moreno Marchiafava, Massimo Piccirilli, Chiara Bedetti, Antonella Baglioni, Marina Menna & Sandro Elisei: EFFECTIVENESS OF SEROTONERGIC DRUGS IN THE MANAGEMENT OF PROBLEM BEHAVIORS IN PATIENTS WITH NEURODEVELOPMENTAL DISORDERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 644-647

The scientific literature in recent years focuses on In our structure, we assist many patient with mental the correlation between behavioral disorders and the use disabilities and every days we have to manage auto- of selective serotonin reuptake inhibitors (SSRI), drugs and/or hetero-aggressive behaviors, in addition to that increase the sinaptic availability of serotonin. Sero- clinical issues related to their clinical conditions. tonin (5-HT) has long been considered as a key trans- Few month ago, we started to collect clinical data mitter in the neurocircuitry controlling aggression. Im- about them, first of all by clinical observations, then by paired regulation of each subtype of 5-HT receptor, 5- consulting daily reports that our educators compile HT transporter, synthetic and metabolic enzymes has about them. been linked particularly to impulsive aggression (Taka- We observed, especcialy, patients with neurodeve- hashi et al. 2011). lopment disorders, mental disabilities and "problem be- Multiple evidences shown that the reduction of the haviors" like auto- and/or hetero-aggressivity and/or activity of the serotonin receptors is associated with OCD and the response to the treatment with sertraline, aggressive behaviors, especially impulsive behaviors for minors, and with vortioxetine, for adults. The drugs (Manchia et al. 2017). At present, the dynamics that cor- were administered orally, in the form of tablets. relate these data are still not fully clarified; however To analyze the data, we use these following scales: there are evidences that the use of SSRI is useful in the The Brief Psychiatric Rating Scale (BPRS) that is a treatment of aggressive behavior in mental disabilities rating scale which clinicians or researchers may use (Sterke et al. 2012, Janowsky et al. 2015). Furthermore to measure psychiatric symptoms such as depres- the fact that this category of drugs is effective in the sion, anxiety, hallucinations and unusual behaviour: treatment of obsessive-compulsive disorder (OCD) is each of the 24 items is rated 1-7, in increasing order consolidated as it can reduce, in a short time, behaviors of gravity. The scale is one of the oldest, most like ruminations, rituals and the anxiety associated with widely used scales to measure psychotic symptoms them. Indeed Sertraline, Paroxetine and Clomipramine (Overall and Gorham, 1962). have long been the first choice drugs in OCD therapy. The Neuropsychiatric Inventory–Questionnaire Despite this premise, in clinical practice, the thera- (NPI-Q) that was developed and crossvalidated with pies usually chosen in patients that suffering from disea- the standard NPI to provide a brief assessment of ses associated with these disorders, the pharmacological neuropsychiatric symptomatology in routine clinical orientation is directed almost exclusively to neuroleptics practice settings The NPI-Q is adapted from the NPI and benzodiazepines; such use becomes massive (and a validated informant-based interview that assesses often not resolutive) when it is necessary to manage neuropsychiatric symptoms (Kaufer et al. 2000). acute episodes of psychomotor agitation and aggression. Therefore we decide to evaluate the clinical response The Clinical Global Impression (CGI) rating scales to SSRI, in association or in substituttion of the already are measures of symptom severity, treatment res- established therapy, with the aim of managing agitation ponse and the efficacy of treatments in treatment and aggression, as well as rituals, stereotypies and per- studies of patients with mental disorders. It is a 7- severations. point scale that requires the clinician to rate the severity of the patient's illness at the time of assessment, relative to the clinician's past experience with SUBJECTS AND METHODS patients who have the same diagnosis (Guy 1976). This study will examine the efficacy of the anti- We present preliminary data: we are focused on one depressant drugs Sertraline and Vortioxetine. Sertraline, patient treated with the Sertraline and a second patient like all SSRI, acts by inhibiting serotonin transporter treated with Vortioxetine and we are matching the data (SERT) a transmembrane protein present on the pre- collected before the treatment, with data collected after synaptic neuron, providing to "recycle" the unused 3 months from the start of the treatment in two patients. serotonin: the blockage of the SERT allows a greater availability of serotonin in the intersinaptic space, a CASE 1 condition that promotes, among others, antidepressive and anxiolytic effects. Vortioxetine is a modulator of A 17 years old boy affected by moderate-severe serotonin drug because it inhibits serotonin reuptake intellectual disability, autism spectrum disorder (ASD) (such as SSRI) and acts as a SERT inhibitor, a 5HT1A from a probable perinatal suffering, with subsequent receptors agonist (which could increase antidepressant psycho-motor delay. In addition to the typical motor and anxiolytc efficacy and decrease some side effects stereotypes, since the age of 3 impulsive phenomena especially sexual ones), as an antagonist of 5HT3 have appeared, environmental destructiveness tenden- receptors (which could help to decrease the side effects cies and heterodirect aggressiveness that have consti- of nausea and concurs to the anxiolytic effects since tuted, over time, an increasingly important problem, so these receptors are involved in the release of GABA) much so that it was necessary to enter our institute at and as an antagonist of 5HT7 (the latter is known to be the age of 16. The boy showed severe heterodirect the site of action of others antidepressant drugs). aggressiveness, sleep disturbances, poor collaboration

S645 Moreno Marchiafava, Massimo Piccirilli, Chiara Bedetti, Antonella Baglioni, Marina Menna & Sandro Elisei: EFFECTIVENESS OF SEROTONERGIC DRUGS IN THE MANAGEMENT OF PROBLEM BEHAVIORS IN PATIENTS WITH NEURODEVELOPMENTAL DISORDERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 644-647 with the clinicians and the entire staff. At the time of CASE 2 taking charge his therapy was: haloperidol 9 mg/die, quetiapine 1200 mg/die, levetiracetam 1500 mg/die, A 46 years old man affected by affected by ence- fenobarbital 50 mg/die, clonazepam 3 mg/die. Nume- phalopathy with a probable genetic genesis charac- rous therapeutic modifications have been attempted terized by severe intellectual disability, psychotic beha- such as the addition of clotiapine up to 60 gtt/die, the vioral disorder, poor language, neuromotor disorders reduction of quetiapine to 600 mg/die, the reduction of of the march, bilateral congenital cataract and micro- the haloperidol to 7.5 mg/die and the addition of ris- cornea and flat bilateral foot. The patient has been peridone up to 2 mg/die (suspended after about 1 institutionalized since the first years of life, due to his month for sexual disorders). Then was introduced in psychomotor agitation, auto and hetero-direct aggres- therapy valproic acid, up to 1500 mg/die, without cli- sivity, stereotypies and marked oppositional behaviors. nical benefit. The surveys using rating scales showed In adulthood, after numerous pharmacological chan- the following scores: for BPRS 40/126 with greater ges, his therapy consisted in quetiapine 400 mg/die, involvement of the items related to: blunted affected valproic acid 1000 mg/die, clotiapine 15 gtt/die, with a (5/7), tension (6/7), mannerisms and posturing (5/7), little result on problem behaviors. His behavioral sta- unco-operativeness (6/7), emotion withdrawal (5/7), tus, evaluated through the scales was as follows: BPRS excitement (5/7). We remind that values “5” and “6” 31/126 with greater involvement of the items related concern, respectively: “moderately severe” and “se- to: blunted affected (6/7), tension (6/7), mannerisms vere” wording. The NPI-Q score was 4/12 for the item and posturing (5/7), unco-operativeness (6/7), emotion elation/euphoria with a distress value of 2/3, was 12/12 withdrawal (5/7), excitement (5/7). We remind that for the item agitation/aggression with a distress value values “5” and “6” concern, respectively: “moderately of 3/3, was 9/12 for the item irritability/lability with a severe” and “severe” wording. The NPI-Q score was distress value of 2/3, was 6/12 for the item motor 12/12 for the item agitation/aggression with a distress disturbance with a distress value of 2/3. GCI score was value of 2/3, was 6/12 for the item anxiety with a dis- 7/7 corresponding to the wording “among the most tress value of 2/3, was 8/12 for the item disinhibition extremely ill patients”. Subsequently additional the- with a distress value of 2/3, was 6/12 for the item rapy with sertraline was introduced at the dosage of irritability/lability with a distress value of 2/3, was 25 mg/die. 8/12 for the item motor disturbance with a distress During the course of treatment, there was a slow value of 2/3, was 6/12 for the item nightmare beha- but progressive reduction in the frequency and inten- viors with a distress value of 3/3. GCI score was 6/7 sity of aggressive and heterodirect behaviors. The pa- corresponding to the wording “severely ill”. Subse- tient was more condescending and congruous with the quently additional therapy with vortioxetine at the daily life of the structure. Likewise, there was an dosage of 20 mg/die. In the following 3 months, there improvement in the quality of nocturnal sleep. The was a gradual reduction of psychomotor agitation, with evaluation by scales carried out after three months a greater agreement with the educators. The patient from the beginning of the treatment showed a reduc- often used to oppose to the routine of personal care, tion of the BPRS score to 30/126 with an improvement while over time he seems to have lost the habit of of the items most affected: blunted affected (4/7), undressing or selecting the clothes to wear in a small tension (4/7), mannerisms and posturing (4/7), unco- circle of clothes. At the same time, episodes of hetero- operativeness (4/7), emotion withdrawal (4/7), excite- directed physical aggression are reduced in frequency ment (4/7). We remind that values “4” concern “mode- and intensity. The evaluation by scales carried out after rate” wording. The NPI-Q score was 1/12 for the item three months from the beginning of the treatment sho- elation/euphoria with a distress value of 1/3, was 4/12 wed a reduction of the BPRS score to 25/126 with an for the item agitation/aggression with a distress value improvement of the items most affected: blunted affec- of 2/3, was 4/12 for the item irritability/lability with a ted (4/7), tension (4/7), mannerisms and posturing (3/7), distress value of 2/3, was 4/12 for the item motor unco-operativeness (4/7), emotion withdrawal (3/7), ex- disturbance with a distress value of 2/3. GCI score was citement (3/7). We remind that values “4” and “3” 6/7 corresponding to the wording “severely ill”, with a concern, respectively, “moderate” and “mild” wording. global improved value corresponding to “much im- The NPI-Q score was 2/12 for the item agitation/ proved” and an efficacy index equal to 6, which aggression with a distress value of 1/3, was 1/12 for the means: “decided improvement, partial remission of item anxiety with a distress value of 1/3, was 1/12 for symptoms” and “do not significantly interfere with the item disinhibition with a distress value of 0/3, was patient’s functioning”. This improvement made it pos- 1/12 for the item irritability/lability with a distress value sible to reduce therapy with clotiapine up to 30 gtt/die of 1/3, was 1/12 for the item motor disturbance with a and to suspend clonazepam. If these changes are con- distress value of 1/3, was 1/12 for the item nightmer firmed over time, the neuroleptic therapy could be behaviors with a distress value of 1/3. GCI score was reduced further. unchanged: 6/7 corresponding to the wording “severely

S646 Moreno Marchiafava, Massimo Piccirilli, Chiara Bedetti, Antonella Baglioni, Marina Menna & Sandro Elisei: EFFECTIVENESS OF SEROTONERGIC DRUGS IN THE MANAGEMENT OF PROBLEM BEHAVIORS IN PATIENTS WITH NEURODEVELOPMENTAL DISORDERS Psychiatria Danubina, 2018; Vol. 30, Suppl. 7, pp 644-647 ill”, with a global improved value corresponding to 2. Farnam A, Mehrara A, Dadashzadeh H, Chalabianlou “much improved” and an efficacy index equal to 5, G, Safikhanlou S: Studying the Effect of Sertraline in which means: “decided improvement, partial remission Reducing Aggressive Behavior in Patients with Major of symptoms” in the absence of side effects. Depression. Adv Pharm Bull 2017; 7:275–27 3. Guy W: Clinical Global Impressions. ECDEU Assess- ment Manual for Psychopharmacology - Revised. Rock- CONCLUSIONS ville, MD: U.S. Department of Health, Education, and Welfare; Public Health Service, Alcohol; Drug Abuse, The cases described show us how it is possible to and Mental Health Administration; National Institute of obtain satisfactory results on the control of behavioral Mental Health; Psychopharmacology Research Branch; disorders thanks to the use of drugs with serotonergic Division of Extramural Research Programs, 1976 pp. action. Observation on such a small number of patients 218–222 obviously requires further confirmation data, but this 4. Janowsky DS, Shetty M, Barnhill J, Elamir B & Davis JM: Serotonergic antidepressant effects on aggressive, initial analysis is encouraging. The patients taken into self-injurious and destructive/disruptive behaviours in consideration present complex general clinical condi- intellectually disabled adults: a retrospective, open- tions (in fact the overall score of CGI remains high, label, naturalistic trial. Int J Neuropsychopharmacol despite the treatment), but the single items regarding the 2005; 8:37-48 behavioral aspects show a significant improvement that 5. Kaufer DI, Cummings JL, Ketchel P, Smith V, deserves further study, as well as a longer follow-up in MacMillan A, Shelley T et al: Validation of the NPI-Q, a order to evaluate the durability of the therapeutic effect. brief clinical form of the Neuropsychiatric Inventory. J We present these preliminary data in order to contribute Neuropsychiatry Clin Neurosci 2000; 12:233-9 to the achievement of an adequate and effective ma- 6. Lacy B: Treatment of Aggression in Patients with Mental nagement of “problem behaviors”, so widespread and so Retardation. Am Fam Physician 2007; 75:622-624 difficult to control. 7. Manchia M, Carpiniello B, Valtorta F & Comai S: Serotonin dysfunction, aggressive behavior, and mental illness: exploring the link using a dimensional approach. ACS Chem Neurosci 2017; 8:961-972 Acknowledgements: None. 8. Overall JE, Gorham DR: The brief psychiatric rating scale. Psychological Reports 1962; 10:799-812 Conflict of interest: None to declare. 9. Sterke CS, Ziere G, van Beeck EF, Looman CW, Van Der Cammen TJ: Dose-response relationship between selec- Contribution of individual authors: tive serotonin re-uptake inhibitors and injurious falls a study in nursing home resident with dementia. Br J Clin Moreno Marchiafava: study conception and prepa- Pharmacol 2012; 73:812-20 ration, interpretation of data, drafting manuscript; 10. Takahashi A, Quadros IM, De Almeida RMM, Miczek Chiara Bedetti, Antonella Baglioni & Marina Menna: KA: Brain Serotonin Receptors and Transporters: Ini- study preparation, interpretation, acquisition of data; tiation vs. Termination of Escalated Aggression. Psycho- Sandro Elisei & Massimo Piccirilli: revising manuscript. pharmacology (Berl) 2011; 213:183–212 11. Takahashi A, Quadros IM, De Almeida RM & Miczek KA: Behavioral and Pharmacogenetics of Aggressive References Behavior. Curr Top Behav Neurosci 2012; 12:73-138 12. Waller JA, Nygaard SH, Li Y, du Jardin KG, Tamm JA, 1. Ekhart C, Matic M, Kant A, Puijenbroek E, Schaik R: Abdourahman A, Elfving B et al: Neuroplasticity CYP450 genotype and aggressive behavior on selective pathways and protein-interaction networks are modu- serotonin reuptake inhibitors. Pharmacogenomics 2017; lated by vortioxetine in rodents. BMC Neurosci 2017; 18:613-620 18:56

Correspondence: Moreno Marchiafava, MD Istituto Serafico di Assisi Viale Guglielmo Marconi n.6 06081, Assisi, Perugia, Italy E-mail: [email protected]

CAN WRITING POEMS AND TAKING PHOTOS HELP THE PSYCHIATRIST TO IMPROVE HIS HUMANITY AND THE MENTAL HEALTH OF HIS PATIENTS? Giuseppe Tavormina "Psychiatric Studies Center" (Cen.Stu.Psi.), Provaglio d'Iseo (BS), Italy

SUMMARY The relationship between the art forms of photography and poetry and mental wellbeing is described, both for the psychiatrist and for the patient. These, as well as other art forms, improve the experience of human persons interior life. It is suggested that these art forms, as well as music and dance, can be helpful in the treatment of Depression.

Key words: poetry – photography - Mental Wellbeing * * * * * INTRODUCTION the “beauty and arts” (“Il mondo della bellezza: depressione, arte, vita”). “Beauty will save the world”, Here we describe the experience of a psychiatrist said Dostoevskij: and we made this sentence, last who is both a poet and a photographer. The questions October, the central theme of our conferences. we would like to address are; What is the meaning to a Educating people (and the patients) about the sen- psychiatrist that he/she is also a poet and a photo- sibility of art leads them to pay more attention to intro- grapher? How does this express humanity and what are spectivity, and supports them even when they are less the implications for psychiatry? Can writing poems and well. Then, often, song or dance can also be used for taking photo help the psychiatrist to improve his therapeutic aims as atypical ways of treating depression, humanity and the mental health of his/her patients? augmenting the use of "antidepressants", as well as in psychiatric rehabilitation (D’Errico 2017, Tavormina et BEING HUMAN al. 2017). Apparently these activities (the psychiatrist, the poet and the photographer) seems to be so different each CONCLUSION other; and maybe they are really different, but being a Writing poems is the real psychotherapy for the Human Person, a “man” or “woman” is the real connec- psychiatrist! (Tavormina 2012, Tavormina 2017). tion between them, not vice-versa. When a psychiatrist appreciates the arts, the poems, and has the ability to create poems, this indisputably can support his interior peacefulness, and induce him to improve his intro- Acknowledgements: None. spectiveness. All these notions off course facilitate the Conflict of interest: None to declare. role of the psychiatrist in better understanding the interiority - or interior world/life - of the patients. The ability of a person who can both take photo- References graphs and write poetry, when it is present, enables that person both to capture beautiful photos and to support 1. D’Errico I: Art as a means of accessing ourselves: using the involvement of the viewer (or of the reader-viewer) art in psychotherapy. Psychiatr Danub 2017; 29:3:368-374 within the meaning of the poems. 2. Tavormina R & Tavormina MGM: Overcoming the social stigma on mood disorders with dancing. Psychiatr Danub BEAUTY, PSYCHIATRY AND DEPRESSION 2017; 29:427-431 3. Tavormina G: Parole di musica, musica di parole. Sardini In Italy we organised, over the past year 2017, the Editore, 2012 annual European Depression Day events (23 events all 4. Tavormina G: La mia vita e il mare – raccolta di over the Country) having the annual theme focused on fotopoesie. Da Brescia Editore, 2017

Correspondence: Giuseppe Tavormina, MD President of "Psychiatric Studies Center" (Cen.Stu.Psi.) Piazza Portici, 11 - 25050 Provaglio d'Iseo (BS), Italy E-mail: dr.tavormina.g @libero.it

S648 29th DANUBIAN PSYCHIATRIC SYMPOSIUM

PSYCHIATRY, MEDICINE AND SOCIETY: Homo Deus of the 21st Century and Challenges of Mental Health and Personalised Medicine

1. Comorbidity, resilence and epigenetics in psychiatry from the perspective of predictive, preventive and person centered medicine

2. Transdisciplinary integrative approach in psychiatry, personalised medicine and creative psychopharmacotherapy

3. Psychiatry, spirituality and religion from the perspective of public and global mental health

4. Psychiatry, ethics and politics from the perspective of public and global mental health

Zagreb, Croatia, May 13-15, 2020

All presentations will be published in Psychiatra Danubina as conference papers GUIDELINES FOR AUTHORS General considerations Psychiatria Danubina is a peer-reviewed open access journal of the Psychiatric Danubian Association, aimed to publish original scientific contributions in psychiatry, psychological medicine and related science (neurosciences, biological, psychological, and social sciences as well as philosophy of science and medical ethics, history, organization and economics of mental health services). Its scope includes mental health in general and all psychological aspects of any branch of medicine, surgery, or obstetrics; and any subspecialty of psychiatry and related clinical and basic sciences. The specific aim is to promote psychiatry in Danube region countries as well as to stimulate collaboration and joint projects. Manuscripts are published in English language only. 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Throughout the entire editorial process, Psychiatria Danubina follows the best practice guidelines given by the Committee on publication ethics (COPE) (available at: http://publicationethics.org/files/Code_of_Conduct.pdf) and Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly work in Medical Journals by International Committee of Medical Journal Editors (ICMJE) (available at: http://www.icmje.org/recommendations/) Editors at Psychiatria Danubina are committed to ensure the integrity and promote innovative and evidence-based sources of information in order to maintain the quality and ensure the impact of the papers published in our Journal, according to the principles set by Sarajevo Declaration on Integrity and Visibility of Scholarly Publications communication (http://www.cmj.hr/2016/57/6/28051276.htm). Instructions for authors Manuscripts must be written in standard and grammatical as well as clear and concise scientific English. It is the responsibility of the authors to ensure the quality of the language. The acceptance criteria for all papers are the quality and originality of the research and its significance to our readership. Submission of the manuscript Submission of a manuscript implies: that the work described has not been published before (except in the form of an abstract or as part of a published lecture, review or thesis); that it is not under consideration for publication anywhere else; that its publication has been approved by all co-authors, if any, as well as by responsible authorities – tacitly or explicitly – at the institute where the work has been carried out. This must be stated in the Covering letter. Manuscripts submitted for publication must contain a statement to the effect that all human studies have been approved by a suitably constituted Ethics Committee of the institution within which the work was undertaken and that it conforms to the provisions of the Declaration of Helsinki in 1995 (as revised in Edinburgh 2000). All investigations on human subjects must include a statement that the subject gave informed consent and patient anonymity should be preserved. Any experiments involving animals must be demonstrated to be ethically acceptable. This should be stated in the Subjects sections of the manuscript (see below). Authors are asked to refrain from submitting papers which have overlap in content with previously accepted papers by the same authors. If the differences between the two are substantial enough that the papers should be considered as distinct, authors are advised to forward copies of both to the Editorial Office. The editors reserve the right to reject manuscripts that do not comply with the above-mentioned requirements. The author will be held responsible for false statements or for failure to fulfil these requirements. The manuscript, together with the Covering letter, should be uploaded electronically to the official page of Psychiatria Danubina: http://www.hdbp.org/psychiatria_danubina/about.html. By accessing the online submission at http://journal.sdewes.org/psych-dan you will be guided stepwise through the creation and uploading of the various files. The Editorial Office will acknowledge the receipt of the manuscript and provide it with a manuscript reference number. The reference number of the manuscript should be quoted in all correspondence with the Chief Editor and Editorial Office. Each manuscript will be assigned to at least two peer reviewers. Where revisions are sought prior to publication, authors are advised to incorporate any suggestions which they agree would improve their paper. The response letter (separate Word file) should thoroughly respond to each reviewer's comment (numbered), indicating where in the text it has been dealt with, or why the authors disagree or cannnot incorporate it. After the assessors' further comments have been received, the editors will make the final decision, including priority and time of publication, and the right to modify and, if necessary, shorten the material for publication. Types of papers Types of accepted papers are given below. Word count for the manuscript includes only the plain text (not tables, figures, abstracts or references). Contributions will be considered for the following categories: Original research; Review/Mini-review; Brief report;

S650 Viewpoint; Letter to the Editor: 600-800 words, up to 10 references, 1 figure/table; Case report; Book review; Invitation/Announcement. Preparation of the manuscript Submit the manuscript as an editable Word (preferred) or rich text format (rtf) document. Use Times New Roman in 12 point size and double line spacing. All pages should be numbered. Use a clear system of headings to divide up and clarify the text, with not more than three grades of headings. Figures should be submitted as separate TIF or EPS format files and the desired position of figures and tables should be indicated in the manuscript. Footnotes to the text are not allowed. All measurements must be given in standard SI units. Abbreviations should be used sparingly and only where they ease the reader's task by reducing repetition of long terms. Initially use the word in full, followed by the abbreviation in the parentheses. Thereafter use the abbreviations. Drugs should be referred to by their generic names. When a brand name is used, it shall begin with a capital letter and the manufacturer's address details should be given. Do not use pejorative labels such as 'schizophrenics', instead refer to 'patients with schizophrenia'. Manuscripts should be presented in the following order: 1. Title page The first page should contain: the title of the paper - should be short, informative and contain the major key words; the full names of the authors and position titles at the respective institutions; the addresses of the institutions at which the work was carried out (addresses for authors other than the correspondence author should contain the department, institution, city and country); indicate all affiliations with superscript number after the author's name and in front of the appropriate address; corresponding author - the full postal and email address, plus facsimile and telephone numbers, the department, institution, city and country. The title page should be uploaded separately. The rest of the manuscript should not contain personal information of the authors. 2. Summary and Key words The second page should carry on a Summary in the region of 300 words, followed by a list of 3-5 key words or short phrases drawn, if possible, from the medical subject headings (MeSH) list of Index Medicus (http://www.nlm.nih.gov/mesh/meshhome.html). The Summary should state, whenever applicable, very specifically, the main purposes, procedures, findings, and conclusions of the paper, emphasizing what is new or important. For original papers and review articles, a structured Summary using the headings is preferred: Background (questions addressed; principal aims of a review); Subjects and Methods (design, setting, sample, interventions, chief outcome measures; for reviews sources of data and criteria for their selection); Results (main findings together with their statistical significance, if possible); Conclusions (those related to results, limitations as appropriate, clinical and researh implications; for reviews principal conclusions and clinical and research implications). 3. Text It should be divided by subheadings into the following sections: Introduction (authors should provide an adequate background and end with the aims of the study); Subjects and methods (Subjects with ethical considerations and informed consent, Methods, Statistical Analyses; authors should provide sufficient detail to enable possible reproduction of the study); Results (the results section should simply state the findings of the research arranged in a logical sequence without bias or interpretation); Discussion (the discussion section should contain interpretation of the results and their comparison with previous studies, also include limitations of the study); Conclusions (needs to summerize the content and purpose of the paper). 4. Acknowledgements The source of financial grants and other funding should be acknowledged. The contribution of institutions, colleagues, technical writers or language editors should be noted. Thanks to anonymous reviewers are not needed. If there are no acknowledgements please state so by putting 'None' in the respective section.

S651 5. Conflict of Interest Authors are requested to disclose any commercial or other associations that might pooose a conflict of interest in connection with the submitted articles. If there is no conflict of interest please put 'None to declare' in the respective section. 6. Contributors It is required to declare every author's individual contribution to the manuscript. Every author should be mentioned for his exact work (e.g. design of the study, literature searches and analyses, statistical analyses, interpretation of data). 7. References In the text give the author last name and publication year within parentheses (e.g. Jakovljevic 2008, Sartorius 2009). If there are two authors, both should be named (e.g. Svrakic & Cloninger 2010, Sher & LaBode 2011). If there is an article with more than two authors, only the first author's name plus 'et al.' need to be given (e.g. Sartorius et al. 1996, Stinson et al. 2008). If there is more than one reference by the same author or team of authors in the same year, differentiate between papers by adding a, b, c, etc. to the publication year, both in the text and the list of references. All references cited in the text are to be listed in the References section at the end of the text, in alphabetical and chronological order under the last name of the first author. Where there are more than six authors, list the first six authors and use 'et al.'. All works cited must be listed at the end of the paper, ordered alphabetically by first author's name. Names of journals should be abbreviated in the style used in Index Medicus. References should be listed in the following form: 1. Svrakic DM & Cloninger RC: Epigenetic perspective on behavior development, personality, and personality disorders. Psychiatr Danub 2010; 22:153-66 2. Grant BF, Hasin DS, Blanco C, Stinson FS, Chou SP, Goldstein RB et al.: The epidemiology of social anxiety disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2005; 66:1351-61 3. Reiter RJ & Robinson J: Melatonin. Bantam Books, New York, 1995 4. Doghramji K, Brainard G & Balaicuis JM: Sleep and sleep disorders. In Monti DA & Beitman BD (eds): Integrative Psychiatry, 195-339. Oxford University Press, 2010 8. Tables Tables should be included on separate pages and numbered consecutively with Arabic numerals (e.g. Table 1). Column headings should be brief, with units of measurement in parentheses. All abbreviations and symbols should be defined in the legend. The table and its legend should be understandable without reference to the text. Desired position of tables should be indicated in the text. 9. Figures Illustrations such as graphs, diagrams or photographs should also be numbered consecutively with Arabic numerals (e.g. Figure 1) on separate pages, after the Tables. They should contain a short title followed by a concise description. All abbreviations and symbols should be defined in the legend. The figure and its legend should be understandable without reference to the text. Provide a letter stating copyright authorization if figures have been reproduced from another source. Photographs of persons must be made unidentifiable or the subject's written permission must be obtained. Desired position of figures should be indicated in the text. The cost of reproducing colour illustrations is charged to the authors. Please contact the publishers for an estimate of this cost ([email protected]). Copyright All materials sent for publication will become the property of the Journal until, and if, publication is refused. The material so referred should not be sent elsewhere for publication. Galley proofs Unless indicated otherwise, galley proofs are sent to the corresponding authors as Acrobat PDF files and should be returned with the least possible delay. Authors are advised that they are responsible for proof-reading of the text, references, tables and figures for absolute accuracy. Major alterations made in galley proofs, other than essential correction of errors, are unacceptable at this stage and authors may be charged for excessive alterations. For further information about Psychiatria Danubina, as well as full-text articles published in this Journal, visit the homepage: http://www.hdbp.org/psychiatria_danubina/

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