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Repetitive transcranial magnetic stimulation (rTMS) of human motor cortex can produce long-lasting changes in the excitability of excitatory and inhibitory neuronal networks. The effects of rTMS depend critically on stimulus frequency. The aim of our present study was to compare the effects of different rTMS protocols. We compared the aftereffects of 6 different rTMS protocols [paired associative stimulation at interstimulus intervals of 25 (PAS25) and 10 ms (PAS10); theta burst stimulation delivered as continuous (cTBS) or intermittent delivery pattern (iTBS); 1- and 5-Hz rTMS] on the excitability of stimulated and contralateral motor cortex in 10 healthy subjects. A pronounced increase of cortical excitability, evaluated by measuring the amplitude of motor evoked potentials (MEPs), was produced by iTBS (+56%) and PAS25 (+45%). Five-hertz rTMS did not produce a significant increase of MEPs. A pronounced decrease of cortical excitability was produced by PAS10 (−31%), cTBS (−29%), and 1-Hz rTMS (−20%). Short-interval intracortical inhibition was suppressed by PAS10. Cortical silent period duration was increased by 1-Hz stimulation. No significant effect was observed in the contralateral hemisphere. Head-to-head comparison of the different protocols enabled us to identify the most effective paradigms for modulating the excitatory and inhibitory circuits activated by TMS.

Objective To investigate if different interneuronal circuits in human motor cortex mediate inhibition through different subtypes of the gamma-aminobutyric acid A receptor (GABAAR). Methods Two distinct forms of motor cortical inhibition were measured in 10 healthy subjects by established transcranial magnetic stimulation (TMS) protocols: short interval intracortical inhibition (SICI) and short latency afferent inhibition (SAI). Their modification by a single oral dose of three different positive GABAAR modulators (20 mg of diazepam, 2.5 mg of lorazepam and 10 mg of zolpidem) with different affinity profiles at the various α-subunit bearing subtypes of the GABAAR (diazepam: non-selective, lorazepam: unknown, zolpidem: 10-fold higher affinity to α1- than α2- or α3-subunit bearing GABAARs, no affinity to α5-subunits) was tested in a randomized crossover design. In addition, the sedative drug effects were recorded by a visual analogue scale. Results Diazepam and lorazepam increased SICI, whereas zolpidem did not change SICI. In contrast, diazepam had no effect on SAI, whereas lorazepam and zolpidem decreased SAI. The sedative effects were not different between drugs. Conclusions The dissociating patterns of drug modification of SICI versus SAI strongly suggest that different GABAAR subtypes are involved in SICI and SAI. Significance We provide evidence, for the first time, for a dissociation of effects of diazepam and zolpidem on SAI and confirm the previously reported differential effect of zolpidem and of diazepam and lorazepam on SICI. The differential effects of the three benzodiazepines on SAI and SICI suggest that neuronal circuits in human motor cortex that mediate inhibition through different GABAAR subtypes can be segregated by TMS.

In a cross-comparison study, the Cloninger's Temperament and Character Inventory (TCI) personality profile was administered to 28 probable pathological gamblers (PPGs), 32 nonpathological gamblers (non-PGs), and 65 controls. As a screening device, the validated Italian version of the South Oak Gambling Screen was administered to all subjects. Novelty Seeking (NS) values were higher in PPGs in comparison with both non-PGs (p.05) and controls (p.001). PPGs showed lower Self-Directedness (SD) and Cooperativeness (CO) values with respect to both non-PGs (p.05 and p = .001, respectively) and controls (p.001 and p = .001, respectively). The subsamples of PPGs reporting either a current substance misuse condition or a parental involvement in gambling/substance misuse showed higher NS (p = .01) and lower CO (p = .005) values than the remaining PPGs. A duration of problem gambling in excess of 20 years was associated with lower (p = .001) CO values. Specific temperamental (NS) and character (SD; CO) dimensions differentiated PPGs from both non-PGs and controls; assessment of personality profile with the TCI may identify at-risk social gamblers.

Giovanni Camardese,1 Beniamino Leone,1 Riccardo Serrani,1 Coco Walstra,1 Marco Di Nicola,1 Giacomo Della Marca,2 Pietro Bria,1 Luigi Janiri1 1Institute of Psychiatry and Psychology, 2Institute of Neurology, Catholic University of the Sacred Heart, Rome, Italy Objectives: We investigated the clinical benefits of bright light therapy (BLT) as an adjunct treatment to ongoing psychopharmacotherapy, both in unipolar and bipolar difficult-to-treat depressed (DTD) outpatients.Methods: In an open-label study, 31 depressed outpatients (16 unipolar and 15 bipolar) were included to undergo 3weeks of BLT. Twenty-five completed the treatment and 5-week follow-up.Main outcome measures: Clinical outcomes were evaluated by the Hamilton Depression Rating Scale (HDRS). The Snaith–Hamilton Pleasure Scale and the Depression Retardation Rating Scale were used to assess changes in anhedonia and psychomotor retardation, respectively.Results: The adjunctive BLT seemed to influence the course of the depressive episode, and a statistically significant reduction in HDRS scores was reported since the first week of therapy. The treatment was well-tolerated, and no patients presented clinical signs of (hypo)manic switch during the overall treatment period. At the end of the study (after 5weeks from BLT discontinuation), nine patients (36%, eight unipolar and one bipolar) still showed a treatment response. BLT augmentation also led to a significant improvement of psychomotor retardation.Conclusion: BLT combined with the ongoing pharmacological treatment offers a simple approach, and it might be effective in rapidly ameliorating depressive core symptoms of vulnerable DTD outpatients. These preliminary results need to be confirmed in placebo-controlled, randomized, double-blind clinical trial on larger samples. Keywords: light therapy, unipolar depression, bipolar depression, anhedonia, psychomotor dysfunction&nbsp

Inhibition is of fundamental importance to regulate activity in cortical circuits. Inhibition is mediated through a diversity of different interneurones and γ-aminobutyric acid A receptor (GABAAR) subtypes. Here we employed paired-pulse transcranial magnetic stimulation (TMS) to measure short interval intracortical inhibition (SICI), a GABAAR-mediated inhibition in human motor cortex, to address the question of which GABAAR subtype is responsible for this form of inhibition. It has been shown that classical benzodiazepines (diazepam and lorazepam) have a non-selective affinity profile at different α-subunit-bearing subtypes of the GABAAR while zolpidem has a 10-fold greater affinity to the α1-subunit-bearing GABAAR compared with those bearing the α2- or α3-subunit. We found that, in seven healthy subjects, a single oral dose of 20 mg of diazepam or 2.5 mg of lorazepam significantly increased SICI, whereas 10 mg of zolpidem did not change SICI. This dissociation occurred despite equal sedation by all three drugs, an α1-subunit GABAAR-mediated effect. The findings strongly suggest that SICI is not mediated by the α1-subunit-bearing subtype of the GABAAR but by those bearing either the α2- or α3-subunit. This study represents an attempt by means of TMS to identify GABAAR subtype-specific action at the systems level of human cortex, a highly relevant issue because the different α-subunit-bearing subtypes of the GABAAR are differently involved in benzodiazepine-mediated effects such as sedation, amnesia or anxiolysis, in developmental cortical plasticity, and in neurological disorders such as epilepsy.

Objective A few personality traits are characteristic of pathologic gamblers (PGs), but it is not clear if and how their personality profile differs from that of non-pathologic gamblers (non-PGs). Methods Sixty-five non-clinical subjects, differentiated into non-PGs and PGs with the means of the South Oak Gambling Screen (SOGS) and Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition–Text Revision ( DSM-IV-TR ) criteria, were administered with the Temperament and Character Inventory; their values were compared with those of control subjects (CS). Results Novelty seeking (NS) and self-transcendence (ST) values were higher whereas self-directedness and cooperativeness values were lower in PGs with respect to both non-PGs and CS. A positive correlation was noted between SOGS score and NS ( r = 0.40) and ST ( r = 0.50) values, as well as a significant positive dependence between SOGS score and a family history of gambling ( t = 2.816; P = .007). The subsamples of PGs reporting a parental involvement in gambling showed higher NS than the remaining PGs. Conclusions Specific temperamental and character dimensions, especially NS and ST, differentiated PGs from both non-PGs and CS; the identification of a personality profile at risk for problem gambling may represent an important predictor of outcome and constitute a possible target for specific treatment approaches.

Antiphospholipid syndrome is a disorder characterised by recurrent venous or arterial thrombosis and/or foetal losses associated with typical laboratory abnormalities. The initial manifestation of anthiphospholipid syndrome can involve many organ systems either singly or in combination. We describe the case of a 62 year old female showing schizophrenia-like symptoms in which further evaluations allowed us to diagnose the antiphospolipid syndrome.

Study Objectives: To evaluate sleep modifi cations induced by chronic benzodiazepine (BDZ) abuse. Methods: Cohort study, comparison of sleep measures between BDZs abusers and controls. Drug Addiction Unit (Institute of Psychiatry) and Unit of Sleep Disorders (Institute of Neurology) of the Catholic University in Rome. Six outpatients affected by chronic BDZ abuse were enrolled, (4 men, 2 women, mean age 53.3 ± 14.8, range: 34-70 years); 55 healthy controls were also enrolled (23 men, 32 women, mean age 54.2 ± 13.0, range: 27-76 years). All patients underwent clinical evaluation, psychometric measures, ambulatory polysomnography, scoring of sleep macrostructure and microstructure (power spectral fastfrequency EEG arousal, cyclic alternating pattern [CAP]), and heart rate variability. Results: BDZ abusers had relevant modifi cation of sleep macrostructure and a marked reduction of fast-frequency EEG arousal in NREM (patients: 6.6 ± 3.7 events/h, controls 13.7 ± 4.9 events/h, U-test: 294, p = 0.002) and REM (patients: 8.4 ± 2.4 events/h, controls 13.3 ± 5.1 events/h, U-test: 264, p = 0.016), and of CAP rate (patients: 15.0 ± 8.6%, controls: 51.2% ± 12.1%, U-test: 325, p < 0.001). Discussion: BDZ abusers have reduction of arousals associated with increased number of nocturnal awakenings and severe impairment of sleep architecture. The effect of chronic BDZ abuse on sleep may be described as a severe impairment of arousal dynamics; the result is the inability to modulate levels of vigilance.

Objective To examine attachment and affective temperament in patients who have been diagnosed with Bipolar Disorder and to investigate possible differences in both variables among Bipolar I Disorder (BD-I), Bipolar II Disorder (BD-II), and cyclothymic patients. Methods Ninety (45 male and 45 female) outpatients with bipolar or cyclothymic disorder between the ages of 18 and 65 years were recruited consecutively between September 2010 and December 2011 at the Bipolar Disorder Unit of the Psychiatry Day Hospital affiliated with the University General Hospital “A. Gemelli” in Rome, Italy. Patients were assessed using the Structured Clinical Interview for DSM-IV, the Hamilton Depression Rating Scale, the Young Mania Rating Scale, the Temperament Evaluation of Memphis, Pisa, and San Diego—auto-questionnaire version, and the Experiences in Close Relationships (ECR) questionnaire applied by trained interviewers. Results The 3 groups of patients differed only on the ECR Anxiety scores with BD-I patients having the highest anxiety levels, followed by the BD-II patients, and the patients with cyclothymic disorder reporting the lowest level of anxiety. Conclusions This finding suggests that bipolar disorder (type I, type II) and cyclothymic/dysthymic temperament are more strongly associated with insecure attachment style as compared to the general population.

The aims of the study were: (1) to study possible associations between temperament, personality dimensions, and psychopathological variables in a clinical sample of euthymic patients with bipolar disorder (BD) and cyclothymia; and (2) to assess how Cloninger's temperament and personality dimensions were associated with affective temperaments. Participants, consisting of 60 patients with BD (type I or II) and cyclothymia in the euthymic phase, completed Akiskal's Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A), and Cloninger's Temperament and Character Inventory-revised version (TCI-R). The diagnostic groups differed in past hospitalization, for age at onset of the disorder, and on two affective temperaments: the TEMPS-A Hyperthymia, and the TEMPS-A Irritability. There were six significant associations between affective temperaments and Cloninger's personality dimensions, ranging from 0.26 to 0.54. The measures of Akiskal and of Cloninger tap common behavioral features in patients with bipolar disorder and cyclothymia, yet the differences indicate that the two measures are not redundant. BD and cyclothymic patients differed significantly in temperament and personality, differences that may have important implications for treatment.

Epidemiological studies suggest that n-3 polyunsaturated fatty acid (n-3 FA) deficiency is a risk factor for bipolar disorders (BDs). The aim of this study was to determine whether such a deficit does exist in patients with BD and to characterize the overall plasma fatty acid (FA) profile in these patients. Using gas chromatography/mass spectrometry, we measured fasting plasma levels of 15 FAs in 42 patients diagnosed with BD according to DSM-IV criteria and in 57 age- and gender-matched healthy controls. Plasma docosahexaenoic acid (DHA) levels were significantly decreased in bipolar patients (p < 0.001 versus healthy controls). Compared with controls, patients had higher plasma levels of all other FAs, including arachidonic acid (AA, p < 0.001), alpha-linolenic acid (ALA, p < 0.001), and eicosapentaenoic acid (EPA) (p < 0.001). Although in the present study we observed significant DHA deficits in the plasma of bipolar patients our findings do not support the therapeutic use of ALA and/or EPA supplementation. DHA may provide a basis for possible pharmacological intervention in psychiatric disorders at the level of second messengers linked to the phosphatidylinositol cycle. Finally, measurement of FA levels in plasma seems to be more reliable and reproducible than assays of erythrocyte FA content.

Background: Our aim was to study the relationship between hormonal disturbances and psychopathology in Eating Disorders (ED).Methods: Forty-nine women diagnosed as Eating Disorders according to DSM-IV were subjected to control plasma levels of TSH, FT3, FT4, LH, FSH, 17beta-estradiol, prolactin, cortisol, DHEAS, GH and IGF-1. They were also administered by SCL-90R, BAT, DES II questionnaires. We applied multivariate regression models.Results: Our results highlight a statistically significant relation between LH, FSH and prolactin decreased levels, mood and thought disturbances (subscales 3, 5, 7, 8 and 9 of SCL-90r) which are associated to Body Attitude ( BAT total scale) and Dissociative Experiences (DES II total scale). Conclusions: Decreased sexual hormones levels could have a role in ED psychological disturbances, not inquired yet

Our study aims to assess the prevalence of behavioural addictions in an adolescent population, evaluating the effects of gender and age, and to assess the correlations among different behavioural addictions. 2853 high school students were assessed in order to evaluate the prevalence of behavioural addictions such as Pathological Gambling (PG), Compulsive Buying (CB), Exercise Addiction (EA), Internet Addiction (IA), and Work Addiction (WA), in a population of Italian adolescents. The South Oaks Gambling Screen-Revised Adolescent (SOGS-RA), the Compulsive Buying Scale (CBS), the Exercise Addiction Inventory (EAI), the Internet Addiction Test (IAT), and the Work Addiction Risk Test (WART), were compiled anonymously by the students. Overall prevalence was 7.0% for PG, 11.3% for CB, 1.2% for IA, 7.6% for WA, 8.5% for EA. PG and EA were more common among boys, while gender had no effect on the other conditions. CB was more common among younger (

AimHigh-sensitive C-reactive protein (hs-CRP) has been used to assess low-grade immune system activation. In a population-based cohort hs-CRP was associated with functional somatic symptoms (SS), particularly with general and musculoskeletal functional SS clusters.Immune system dysregulation has also been reported in depression that is frequently associated to a high burden of SS.We investigated the correlation between hs-PCR and SS in depressed patients.Methods123 outpatients (M/F = 58/65; mean age 48,6 ± 14,8) during a Major Depressive Episode were recruited at the Institute of Psychiatry of the Catholic University in Rome. Severity of depression was assessed with the HAM-D scale. The somatization factor of the HAM-D (somatic anxiety, gastrointestinal symptoms, general somatic symptoms, hypochondria, weight loss) measured SS burden. A blood sample was collected to determine hs-CRP.ResultsHs-CRP and depression severity were not correlated, while hs-CRP and SS were (r = -0,27; p = 0,001). Patients with higher (> 3) somatizazion factor had significantly lower hs-PCR values compared to patients with lower (≤3) somatization factor (2,47 mg/L ± 4.77 vs. 3.20 mg/L ± 4.44; p = 0,026).ConclusionsIn contrast with the hypothesized cytokine involvement in somatic features of sickness behavior, higher somatic burden correlates with lower immune activation.The role of sickness behavior in experiencing SS and hs-CRP's use as valid indicator of cytokine production remain uncertain. Further studies are necessary, also to explore the relationship between HPA axis dysregulation and immune activation, possibly relevant to the interpretation of our results.

Background and aimHigh, normal or low plasma magnesium (Mg) levels have been observed in depressed patients. The aim of our study was to investigate the relationship of plasma Mg levels with depression severity, specific psychopathological dimensions and treatment outcome.Materials and methods123 outpatients (M/F 60/63; mean age = 48 ± 15) during a Major Depressive Episode (MDE) were recruited. Most of them were affected by “difficult to treat” depression, that includes patients with history of at least two MDE, risk of chronicization and who did not achieve remission in previous treatments.The psychopathological status was assessed using HAM-D, HAM-A, DRRS for psychomotor retardation and SHAPS for anhedonia. HAM-D was repeated at 3 months. A blood sample was collected to determine total plasma Mg levels.ResultsWe observed an association between Mg levels and psychomotor retardation scores (p = 0.045). Moreover, subjects with residual symptoms after treatment (HAM-D at 3 months > 15) have lower starting Mg values compared to treatment-responsive individuals (2.14 ± 0.2 vs. 2.25 ± 0.21, p = 0,039).ConclusionsConflicting data on plasma Mg levels in depression could be due to the isolation of brain Mg compartments from blood Mg compartments. As in a previous study, the association between high Mg levels and psychomotor retardation found in this larger sample strengthens the notion that high Mg levels play a part in the hypoactivity so often observed in depressed patients. Also, low Mg values in patients with poor treatment outcome suggest Mg could have a therapeutic potential in “difficult-to-treat” patients.

In recent years, mobile phone use has become increasingly common among Italian youth, while a growing scientific literature has been identifying the occurrence of a problematic mobile phone use which seems to share some features of other conditions often referred to as behavioural addictions. The study aimed to assess the prevalence of problematic mobile phone use in a population of Italian adolescents and its association with other behavioural addictions. The Mobile Addiction Test (MAT) was administered to 2,790 high school students from Barletta, an Italian town, together with the South Oaks Gambling Screen-Revised for Adolescents (SOGS-RA), the Compulsive Buying Scale (CBS), the Internet Addiction Test (IAT), the Exercise Addiction Inventory (EAI), the Work Addiction Risk Test (WART). MAT scores fitted a Gaussian distribution model. Scores ≥ 17 was found as a cut-off value over which identifying problematic mobile phone users. Overall prevalence of problematic mobile phone use was 6.3%; this condition was associated with other behavioural addictions like compulsive buying. Problematic mobile phone use in adolescence should become a public health issue, and it could be a cause of health problems and social costs.

Slow waves and sleep spindles are the two main oscillations occurring during non-REM sleep. While slow oscillations are primarily generated and modulated by the cortex, sleep spindles are initiated by the thalamic reticular nucleus and regulated by thalamo-reticular and thalamo-cortical circuits. In a recent high-density EEG study, the authors found that 18 medicated schizophrenia patients had reduced sleep spindles, compared with healthy and depressed subjects, during the first non-REM episode. In the present study, the authors investigated whether spindle deficits were present in a larger sample of schizophrenia patients, were consistent across the night, were related to antipsychotic medications, and were suggestive of impairments in specific neuronal circuits.Whole-night high-density EEG recordings were performed in 49 schizophrenia patients, 20 nonschizophrenia patients receiving antipsychotic medication, and 44 healthy subjects. In addition to sleep spindles, several parameters of slow waves were assessed.Schizophrenia patients had whole-night deficits in spindle power (12-16 Hz) and in slow (12-14 Hz) and fast (14-16 Hz) spindle amplitude, duration, number, and integrated activity in the prefrontal, centroparietal, and temporal regions. Integrated spindle activity and spindle number had the largest effect sizes (effect size: ≥ 2.21). In contrast, no slow wave deficits were found in schizophrenia patients.These results indicate that spindle deficits can be reliably established in schizophrenia, are stable across the night, are unlikely to be due to antipsychotic medications, and point to deficits in the thalamic reticular nucleus and thalamo-reticular circuits.

Brain-derived neurotrophic factor (BDNF) gene variants may potentially influence behaviour. In order to test this hypothesis, we investigated the relationship between BDNF Val66Met polymorphism and aggressive behaviour in a population of schizophrenic patients. Our results showed that increased number of BDNF Met alleles was associated with increased aggressive behaviour.

Objective The purpose of the present study was to assess a group of patients with fibromyalgia (FM) and control subjects using the personality questionnaire proposed by Cloninger and to determine possible changes in the Italian version of the Temperament and Character Inventory—Revised patterns of patients with FM after therapy with serotoninergic antidepressants (selective serotonin reuptake inhibitors [SSRIs]). Methods Sixty patients with FM filled out the Temperament and Character Inventory—Revised and Beck Depression Inventory before and after 6-month therapy with SSRIs (escitalopram 10 mg, fluoxetine 20 mg, or paroxetine 20 mg). A total of 80 age-, sex-, and education level-matched healthy subjects were selected as a control group. Results Both in the pretreatment and posttreatment period, patients were found to have higher harm avoidance and lower self-directedness scores than healthy controls. In addition, harm avoidance and self-directedness were state and trait dependent. Conclusions Depressive symptoms in patients with FM can be significantly decreased by treatment with SSRIs. A careful clinical assessment and study of personality profile is needed to identify patients with FM who may benefit from antidepressant pharmacologic therapy and specific psychotherapeutic interventions.

Despite the high prevalence of depressive disorders in cancer patients and elderly people, the topic of depression in elderly cancer patients still remains unexplored. This emerges from a systematic review of the literature conducted to investigate issues of depression, diagnosis, pathogenesis, treatment and their complex neuroimmunobiological interactions. Indeed, it becomes apparent that depression in elderly patients with cancer may have a peculiar phenomenology. In addition, the moderate rate of major depressive disorder and the high rate of minor depressive disorder are accompanied by subthreshold forms of depression that are at risk to be underrecognized and untreated. Immune dysfunction may represent a common pathogenic ground of depression, cancer and aging. This may have important implications for treatment. In the near future, we need to develop validated mood disorder diagnoses and verify antidepressant treatment efficacy for elderly cancer patients with depression in order to improve their clinical outcome and quality of life.

IntroductionMany evidences stress the implication of dopamine systems in the pathophysiology of depression. Currently, few and uncertain results are available on pre-synaptic dopaminergic dysfunction during depression. Our aim was to assess dopamine transporter (DAT) density in Major Depressive Disorder (MDD) with marked psychomotor retardation or anhedonia using 123I-FP-CIT SPET.Methods15 drug-free patients (F/M=8/7, mean age=44.6 SD=12.6 years) with MDD according to DSM-IV-R criteria, were enrolled for: 1. Psychometric assessment (of depression, anxiety, anhedonia and psychomotor impairment using Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Snaith-Hamilton Pleasure Scale and Depression Retardation Rating Scale);2. DAT measurement with 123I-FP-CIT SPET.14 healthy subjects, comparable for gender and age, formed the control group.ResultsPatients had moderate-to-severe depression. They showed a significant decrease in DAT density in whole striatum bilaterally compared to controls. Furthermore, mean 123I-FP-CIT uptake ratios were significantly lower in caudate and putamen bilaterally. Patients were then divided into two subgroups: 7 had a relevant psychomotor retardation without anhedonia; 8 had severe anhedonia without retardation. The psychomotor retardation group showed significantly lower 123I-FP-CIT uptake ratios in left putamen compared to the anhedonic group. An inverse correlation between DAT density in left putamen and retardation scores were observed.ConclusionPresent results confirm a decrease of DAT binding in MDD. Low DAT availability could represent a compensatory mechanism following dopamine reduction. Moreover, DAT reduction seems to be related more to retardation than anhedonic features, in agreement with previous PET imaging findings.

Although poststroke depression is unlikely to represent a single disorder and numerous etiologies for different kinds of poststroke depression will likely emerge as the result of future research, we believe that a number of poststroke depressive disorders are likely to be the result of specific changes in brain pathology and neurophysiology. Nevertheless, there are relatively few hypotheses about the pathophysiology of poststroke depression. This paper, therefore, proposes a new hypothesis for poststroke depression involving increased production of proinflammatory cytokines resulting from brain ischemia in cerebral areas linked to the pathogenesis of mood disorders. This paper reviews the evidence supporting the hypothesis that proinflammatory cytokines are involved in the occurrence of stroke as well as mood disorders linked to the brain damage. The increased production of proinflammatory cytokines such as IL-1beta, TNF-alpha or IL-18 resulting from stroke may lead to an amplification of the inflammatory process, particularly in limbic areas, and widespread activation of indoleamine 2,3-dioxygenase (IDO) and subsequently to depletion of serotonin in paralimbic regions such as the ventral lateral frontal cortex, polar temporal cortex and basal ganglia. The resultant physiological dysfunction may lead to poststroke depression. Future investigations may explore this hypothesis through more extensive studies on the role of proinflammatory cytokines, such as IL-1beta, TNF-alpha or even IL-18, in patients with poststroke depression.

Apolipoprotein E (ApoE) ε4 allele represents a well known vascular risk factor for developing Alzheimer disease (AD) and differences in ApoE genotypes may explain a part of the variability in AD phenotypes. In fact, ApoE ε4 allele possession seems to be associated with a more precocious age of onset, greater episodic memory impairment, and psychotic symptoms. The first question we discuss regards the role of ApoE ε4 on cognitive progression of AD. In fact, while a general agreement exists about the role played by ApoE ε4 on the precocious onset of AD, cognitive decline has been differently associated with ApoE ε4 allele possession in AD patients in a continuum of faster decline, no effect, and slower decline. An attemptable interpretation is that the biological processes leading to the onset of AD are different from those involved in determining its clinical course. The second question regards the possible relationship between the presence of the degenerative pathological hallmarks of the disease in specific cerebral areas and different cognitive or behavioural symptoms. In fact, there is evidence that degenerative pathology in hippocampal formation and frontal cortex reflects the progression of cognitive deficits in brain aging and AD and that hypometabolism in right frontal lobe and greater frontal neuropsychological deficits occur in AD patients with psychosis in comparison to those without. The third question regards, specifically, the relationship between ApoE ε4 variant and behavioural symptoms. In fact, there is evidence supporting the link between being carriers of ApoE ε4 allele and severity of delusions, mostly at the early stage of the illness. In an interpretative challenge, we suggest that the link between being carriers of ApoE ε4 allele and suffering from delusions in AD may be explained by frontal lobe dysfunctions. Finally, we hypothesize that the most precocious onset of AD illness, described in carriers of ApoE ε4 allelic variant, may also be related to the precocious onset of psychotic symptoms, which produces caregiver and patient distress and requires immediate assessment and treatment.

IntroductionThis issue of the Journal of Public Health presents articlesrelating to different fields in public health research, fromthe organization of humanitarian aid action to the preven-tion of infectious diseases, the diffusion of problematicbehaviors, and the management of chronic conditions. Mostof the contributors underline the importance of the diffusionof knowledge and information among the general popula-tion for the primary prevention of diseases, and the role ofcommunication and patient education in the management ofchronic conditions.Human behavior can in fact influence the spread ofinfectious diseases, and it is based on the individuals’knowledge as well as on the information received aboutsuch conditions (Funk et al. 2010). In turn, a correctevaluation of the benefits obtained from immunization, andof the risks and the adverse effects related to the vaccineswould facilitate a wider diffusion of vaccinations (Baejens2010). Some of the papers in this issue are in line with theafore-mentioned hypotheses: Al-lela et al., who developed aquestionnaire on knowledge, attitude and practice aboutimmunization among Iraqi parents, suggest that parentswho have adequate information on this field also have apositive attitude and practices towards immunization;Kamal et al. assessed the knowledge, attitude and practicetowards the pandemic H1N1 influenza virus among El-MiniaUniversity students in Egypt, and maintain that adequateacquaintance with the problem is associated with a betterwillingness to comply with preventive measures; Naing andTan focused on the knowledge of pandemic influenza A andon the willingness to be vaccinated among a sample of 264medical students in Kuala Lumpur, Malaysia, and underlinethenecessitytostrengthenevidence-basedhealtheducationinorder to help people adopting effective preventive behaviorsand vaccination.One of the main factors contributing to the spread ofbacterial resistance is the misuse of antibiotics. Educationalprograms for both health professionals and the generalpopulation are strongly needed: reducing misconceptionsabout the utility of antibiotics in minor ailments andimprovingthegeneralpublicawarenessoftheriskscorrelatedwiththeirimproperusewouldbeakeycomponentonpoliticsaimed to control the diffusion of antibiotic resistance(Grigoryan et al. 2010). Two studies focus respectively onthe topic of the diffusion of antibiotic-resistant bacteria andon the knowledge of MRSA in both medical students and thegeneral population: Sathiamoorthi et al. describe the preva-lence of multidrug-resistant Salmonella enterica typhi andparatyphi among 368 human cases of typhoid and paraty-phoid fever from the Tiruchirappalli district in India, whileDe Giusti et al. report a survey conducted on a sample ofstudents attending an Italian Faculty of Medicine and ontheir cohabitants, focusing on their knowledge on MRSA, its

The need for a specific therapeutic-rehabilitative group for cocaine addicted patients rises up both from the progressive increase of cocaine use in the general population and from peculiar personality traits and associated psychopathology of these clients. Moreover, it is difficult to mantain a compliance to therapy, because there are no specific anticraving or antidothic drugs for cocaine addiction.Therefore our equipe developed a short integrated treatment (ten weeks), of “group concelling” and “psychodinamic group therapy” in association. The group is open and composed by a maximum of eight participants.The novelties of this model are: (1) hospital setting, (2) a short duration and (3) synergy between two different approaches: Minnesota 12 steps model (one sessions weekly, held by a councellor on addiction), and a psychodinamic group therapy (one session weekly).Main success is the retention of patinets in therapy for a long time. In twenty months (March 2005- October 2006), fourty cocaine-addicted patients started this program: only 30% of them dropped out, while 70% of patients completed the treatment. 64% of the latter where completely abstinent, while 36% relapsed during the therapy. All of them are still continuing some therapy at the moment: 46% individual psychotherapy, 25% individual psychotherapy and pharmacological therapy, 14% narcotics anonymous attendance, 11% N.A. groups and pharmacological therapy, 4% is in a T. C.

Objective To demonstrate the complex correlation existing in patients with eating disorders between hormonal alterations and psychopathological symptomatology, that has been little studied until now. Methods 60 women aged between 16 and 35 years and diagnosed with Anorexia Nervosa and Bulimia Nervosa according to the DSM-IV were assessed using the SCL-90-R, EDI, BAT and DES II. A blood sample was taken from each patient in the morning, on the seventh day of the menstrual cycle or on the corresponding day from the women with amenorrhea; the following hormone levels were measured: TSH, FT3, FT4, LH, FSH, 17-beta-estradiol, cortisol, DHEAS. Pearson's Correlation Coefficient has been used to test the correlation between hormonal level and test scores. Results Positive correlations exist between BMI and FT3 and LH, which decrease when BMI decreases. We can observe positively significant correlations between LH and FSH levels and the BAT scale scores.No one significant correlation was found between hormonal levels and dissociative symptoms as measured by DES. With regard to EDI, the following psychopathological features correlate with hormonal assessment: the wish to be thin, body dissatisfaction and perfectionism. Conclusions Our findings suggest a significant correlation between psychopathological features we considered and hormonal readings, especially LH, FSH, TSH, FT3. When these hormonal readings decrease, the patients’ self-ratings and their body dissatisfaction decrease. That attributes a protective meaning to the dietary symptom akin to an effective measure that relieves the person's feelings of inadequacy.

AimRecent studies suggest an association of affective symptoms with striatal dopaminergic activity in Parkinson's Disease (PD). On the other hand, the psychopathological features of other common Movement Disorders (MD), such as Essential Tremor (ET) and Primary Dystonia, are less explored.We investigated striatal dopamine transporter (DAT) availability and affective symptoms in these three different MD.Materials and methods22 pts with ET, 14 pts with focal dystonia and 34 idiopathic PD pts underwent 123I-FP-CIT SPECT. A control group of 15 healthy subjects was also analyzed.Psychiatric assessment included the HAM-D scale for severity of depression, the HAM-A scale for anxiety levels, the Snaith Hamilton Pleasure Scale (SHAPS) for anhedonia.SPECT was carried out 3 hours after 111 MBq 123I-FP-CIT intravenous injection. Specific 123I-FP-CIT binding in the striatum and striatal subregions was calculated based on ROI analysis.ResultsSignificant reduction of 123I-FP-CIT binding ratios was found only in PD. Spearman's analysis showed an inverse correlation between anxiety and DAT availability in the left striatal regions of both ET and dystonic patients. On the contrary, a significant positive correlation was found in PD subjects.ConclusionThis preliminary study provided evidence for an association between pre-synaptic striatal dopaminergic function of the left hemisphere and anxiety in MD, thus confirming the “transnosologic” relevance of dopaminergic dysfunction.Unexpected findings in PD patients are in contrast with previous results. A down-regulation of DAT could be hypothesized in both ET and dystonic patients. This pattern seems to be concordant with preliminary findings in primary anxiety disorders.

ObjectivesTemperament represents one of the basic elements of bipolar spectrum.MethodsA systematic search was undertaken in MEDLINE (from 1977 to 2007) to obtain articles published in English regarding the association of temperament and bipolar disorder. Keywords used were “temperament”, “bipolar disorder”, “assessment”, “bipolar spectrum”, “subthreshold”.ResultsIn opposition to the dichotomic conception which up to the end of XIX century considered mania and depression as two distinct and separate categories, Kraepelin has postulated a psychopathological “continuum” between temperament and affective disorders called “bipolar spectrum”. This concept has been reintroduced in contemporary psychiatry by Akiskal's works. By rebuilding the history of patients affected by bipolar disorder, temperamental traits can be already observed in the pre-morbid period and can also persist during disorder-free intervals.ConclusionsBy interpreting and diagnosing multiple expressions of bipolar spectrum, psychiatrists today are facing one of the most important challenges in everyday clinical practice. The temperamental “dysregulation” is the pathological basis of mood disorders and some temperamental traits in individuals can reflect a predisposition to develop a mood disorder.

IntroductionThe purpose of this study is to contribute to the knowledge of the clinical characteristics of the bipolar spectrum by examining factors associated to course of symptoms in BP patients. We evaluated differences between acutely depressed versus subthreshold mixed patients.Methods90 depressed patients (Group 1, HDRS: 18.2±4.6, YMRS: 1.4±2.9) and 41 patients presenting a mixed subthreshold symptomathology (Group 2, HDRS: 9.1±3.2, YMRS: 9.6±6.4) were included in the study. All patients underwent structured diagnostic interviews for axis I and axis II disorders (SCID-I, SCID-II) and have been submitted to psychometric assessment with Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Young Mania Rating Scale (YMRS), Global Assessment Scale (GAS), Social Adjustment Self-reported Scale (SASS), Quality of Life Scale (QoL), at baseline and repeated follow-up (1, 3, 6, 12 months). Personality dimensions were evaluated by Temperament and Character Inventory (TCI-R).ResultsThe most important result is the slight increase in depressive symptoms in subthreshold mixed patients after 3 months of treatment. These patients were more likely diagnosed as BP-I, were non-SUD patients and/or non-comorbid for axis II personality disorders and had a shorter duration of current episode prior intake. Measures of social and functional adjustment were not different in the two groups, though a slight trend for depressed patients to report a poorer quality of life. No difference in personality traits were observed among the two samples.ConclusionsOur study confirms the importance of considering subthreshold symptoms in the evaluation and treatment of patients with Bipolar Disorder.

ObjectivesThis study aims to evaluate different kinds of temperament and attachment in a sample of alcohol-dependent patients, divided in Cloninger typology 1 and 2, compared to an healthy group.Materials and procedureA group of 40 patients was recruited, in a 3 months period, from Alcohology Unit of “Villa Rosa” in Viterbo. This sample was selected by a clinical diagnosis of Alcohol Dependence and compared to a control group of 40 healthy subjects. Each participant was screened by: SCID-I for Axis I Diagnosis, SCID-II for Axis II Diagnosis, TEMPS-A for Temperament, ECR for Attachment Styles.ResultsStatistical analysis showed significative differences between the two groups (p< 0.05). The mean of the scores (t Student) and the Mann-Whitney U test results higher in the experimental group. Regarding the ECR, we found differences in the “avoidance” between Cloninger's typology 1 and 2. Control group: 92.5% of the subjects showed a “secure” attachment, 7.5% a “dismissing” attachment. Experimental group: 40% of the sample showed a “secure” attachment, 35% a “dismissing” attachment, 17.5% a “preoccupied” attachment and 7.5% a “fearful/avoidant” attachment.DiscussionOur sample showed that the “preoccupied” and the “dismissing” attachment styles were the most prevalent among alcoholists, while the “secure” style was typical of control subjects. Concerning the TEMPS-A we found high prevalence of the hyperthymic and cyclothymic temperaments.

ObjectivesBehavioural addictions (BAs) can be understood as disorders characterized by repetitive occurrence of impulsive and uncontrolled behaviours. Very few studies have investigated their association with mood disorders. The present study was undertaken to determine the prevalence of the main behavioural addictions in a sample of bipolar outpatients in euthymic phase or stabilised by medications and to investigate the role of impulsivity and temperamental and character dimensions.MethodsOne-hundred-fifty-eight Bipolar Disorder (BD) (DSM-IV) outpatients were assessed with tests designed to screen the main behavioural addictions: pathological gambling (SOGS), compulsive shopping (CBS), sexual (SAST), internet (IAD), work (WART) and physical exercise (EAI) addictions. TCI-R and BIS-11 were administered to investigate impulsivity and personality dimensions mainly associated with BAs. The clinical sample has been compared with 200 matched healthy control subjects.ResultsIn bipolar patients, 33% presented at least one BA respect to the 13% of controls. Significantly higher scores at the scales for pathological gambling (p< .001), compulsive buying (p< .05), sexual (p< .001) and work addictions (p< .05) have been found. Self-Directness (p=.007) and Cooperativeness (p=.014) scores were significantly lower while impulsivity level was significantly higher (p=.007) in bipolar patients with BA than those without BA.ConclusionsTo our knowledge, this is the first study investigating the prevalence of behavioural addictions in BD showing a significant association of these disorders. BAs are more frequent in bipolar patients than in healthy controls and are related to higher impulsivity levels and character immaturity.

Introdution:Our study represents a pilot evaluation about how the MOOD-SR recognizes subthreshold manifestations that may be associated with clinical symptomatology in a group of bipolar patients.Methods:At Day Hospital of Psychiatry, Policlinico “A. Gemelli”, Bipolar Disorders Unit, it has been conducted an experimental study on a heterogeneous sample of 24 patients with a diagnosis of Bipolar Disorder type I. Patients have been assessed with the MOOD-SR, a clinical self-reported interview, that is specific for the spectrum of subthreshold pathology, and with the Quality of Life (QoL), that investigates the patient's quality of life.Results:We have found that 16 patients on 24 report a score higher than 60 (68,4%). Among these, 10 female patients on 15 have a total score higer than 61 (68.75%) while 6 male patients on 9 obtain a total score higher than 60 (62,5%). However, these results have only preliminary value, further studies are needed in order to obtain a deeper evaluation.Conclusion:Spectrum manifestations are both indicator of course and response to treatment and predictive for relapse. This finding may represent an important preventive instrument for maniacal relapse in patients with Bipolar Disorder, that is often underdiagnosed or confused for Unipolar Depression. By adequately recognizing the problem we will be able to refine diagnosis and individualize therapy.

Aims:Aims of this study were to investigate alexithymic traits and dissociative experiences in a sample of patients with Alcohol Use Disorders, the significance of this association and the possible correlation with temperamental and character personality traits.Methods:Eighty patients with diagnosis of Alcohol Use Disorder (DSM-IV) were consecutively recruited and assessed with the Toronto Alexithymia Scale-20 (TAS-20), to evaluate the alexithymic traits, the Dissociative Experience Scale II (DES II), to investigate the possible presence of dissociative experiences, and the Temperament and Character Inventory - Revised (TCI-R) in order to define a personality profile.Results:The mean scores obtained by the experimental group in both the TAS-20 and DES II do not differ from those estimated during the validation procedure. Pearson's linear correlation between scores was found statistically significant (p < .05). Significant correlations with some personality dimensions have also been found.Conclusions:According to some authors substances related disorders could be classified as “disturbs of emotional regulation”, an active process in which neurophysiological, motor-behavioural and cognitive-experiential systems are involved. The lack of connection or an inadequate development of these systems would result in the malfunction of the symbolic function and then in the inability for the subject to contain the tensions generated by internal needs and/or by environmental stimulations. Both alexithymia and dissociation may assume the form of defence mechanisms against the unbearable emotions. Finally, some personality factors may be involved both in the rise of dissociative states and in the alexithymic traits.

Since November 2005 our Institute has been developing a group therapy program for pathological gamblers, alternating a counselling/rehabilitation and a group psychotherapy session each week. For a better understanding of psychodynamic aspects of our patients we have started to assess them through Rorschach test according to Klopfer signing and with TAS-20 (Toronto Alexithymia Scale, Taylor et al., 1990). Preliminary results regarding ten patients have shown the following features: a discrepancy between high ambition and real intellectual skills; a psychic life condition dominated by immature resources and impulses; an inappropriate self-control which is performed through emotional distance and experiences of deep anguish. These features can be indicative of a difficulty in expression of emotions, according to alexithymia construct. Most of the patients were found to have significantly higher levels of alexithymia at Tas-20. This outcome is in accordance with previous works on the topic.Our preliminary observations suggest to focus group therapy not only on communication contents, but also on the communication style of the patient. These results also suggest that could be important to help patient to recognize and discriminate emotional conditions to prevent relapses due to out of control or repressed emotions.[1]. Parker J.D., Wood L.M., Bond B.J., Shaughnessy P. (2005) Alexithymia in young adulthood: a risk factor for pathological gambling. Psychother. Psychosom. 74(1): 51-5.