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Epilepsy and mental illness share similar problems in terms of stigma, as a result of centuries of superstition, ignorance and misbeliefs. Stigma leads not only to discrimination and civil and human rights violations but also to poor access to healthcare and non-adherence or decreased adherence to treatment, ultimately increasing morbidity and mortality. Despite continuous efforts in fighting stigma in these conditions, there is very limited knowledge on the phenomenon of double stigma, meaning the impact of having two stigmatised conditions at the same time.
To discuss double stigma in mental health with special reference to epilepsy.
Articles were identified through searches in PubMed up to 31 October 2019 using the search terms ‘epilepsy’, ‘psychiatric disorders’, ‘stigma’ and additional material was identified from the authors’ own files and from chosen bibliographies.
Double stigma is gaining attention for other stigmatised medical conditions, such as HIV, however, the literature on epilepsy is almost non-existent and this is quite astonishing given that one in three people with epilepsy have a lifetime diagnosis of a psychiatric condition. Felt (perceived) stigma and psychiatric disorders, particularly depression, create a vicious circle in epilepsy maintaining both, as depression correlates with stigma and vice versa as well as epilepsy and depression serving as bidirectional risk factors. This phenomenon has no geographical and economic boundaries as similar data have been reported for low-income and high-income countries.
Governments and policymakers as well as health services, patients’ organisations, families and the general public need to be aware of the phenomenon of double stigma in order to develop campaigns and interventions tailored for these patients.
Dissociative symptoms in mood and anxiety disorders are still under-diagnosed and undertreated. Growing evidence suggest that dissociative symptoms are highly present in mood disorders. We hereby describe the case of a 35-year-old Caucasian young lady affected by bipolar disorder (BD), panic disorder (PD) and dissociative symptoms, referred to our clinic for depressive episode accompained by reoccurrence of PD and severe affective and autopsychic depersonalization (scoring at DES 45 and at CDS 80). with paroxetine 40 mg and lamotrigine 50 mg, daily, depressive and panic symptoms progressively improved until remission while depersonalization symptoms remained unchanged causing significant distress. Therefore, ziprasidone 40 mg was introduced with significant improvement in dissociative symptoms at six months (more than 50% at DES and CDS scale). To our knowledge there is no report on the use of ziprasidone augmentation to lamotrigine in treating dissociative symptoms in BD. It's interesting to note that ziprasidone has a relatively high affinity for 5-HT2C serotonin receptors, is a potent 5-HT2C inverse agonist and has a high affinity to 5-HT1A receptors where displays a partial agonist pharmacological profile (4). This is important because partial agonism at the 5-HT1A receptor has been postulated as a potential therapeutic mechanism in the alleviation of depression and anxiety symptoms (5). It is, thus, possible to speculate that the serotoninergic potentiation correlated to ziprasidone introduction, resulted in an improvement of dissociative symptoms, due to the blockade of postsynaptic 5-HT1A receptors (5). Obviously, further research in this area is warranted to replicate our clinical observation.
Prevalence and clinical correlates of dissociative symptoms in general, and depersonalization (DP) in particular, in patients with mood disorders have received limited attention in the literature1. Thus, the aim ofour study is to evaluate the association between depersonalization symptoms and mood dimensions in a sample of unipolar (UD) and bipolar (BD) patients.
185 patients (95 BD and 90 UD) in eutimic phase (evaluate with YMRS and HDRS) are assessed with: SCID-P for axis I diagnosis, HDRS, YMRS, MOOD-SR-lifetime version2 and SCI-DER.
through a regression analysis we underline in UD patients that the presence of depersonalization symptoms is significantly associated with the following mood dimensions: psychomotor retardation (p = 0.031; B = 2,197), mixed irritability (p = 0.035; B = 2,137) and social extroversion (p = 0.028; B = -2,229). We found no significat association in the group of BD patients.
In UD patiens, the presence of depersonalization symptoms must carefully consider. Further research are needed to identify specific clinical endophenotypes3.
Impulsivity is a core feature of bipolar disorder (BD). The best definition of impulsivity is the predisposition to have rapid and unplanned reactions to internal and external stimuli without regard to the negative consequences of these actions to the impulsive individual or others. Thus, the aim of our study is to investigate the relationship between impulsivity, panic disorder (PD) comorbidity and panic spectrum symptoms in patients with BD.
247 eutimic patients were assessed with SCID-P, MOOD-SR, PAS-SR. Impulsivity dimension was defined on the basis BIS Scale score (version 11).
A backward stepwise logistic regression in bipolar patients with PAS explained score statistically much higher for impulsivity (pas +6.09 vs pas - 3.88 p < 001) and the difference is statistically significant stratifing for BD. A stepwise linear regression, corrected by age and gender, displayed significantly statistical correlation with impulsivity score and PAS-SR by cut-off 35 (OR = 1.210).
In our sample BD eutimic patients explained score statistically much higher for impulsivity. This data confirm the presence of the trait impulsivity in BD eutimic patients. BD patients with a comorbid anxiety disorder seem to display significant higher levels of impulsivity when compared to patients without an anxiety disorder. Impulsivity was linked with atypical panic like symptoms more with PD diagnosis. Results suggest the presence of specific bipolar disorder endophenotipe. Further neurobiologies studies are needed to elucidate the implications and reasons of this association.
To quantify knowledge among the general Spanish population of attention deficit hyperactivity disorder (ADHD).
Material and method:
We developed a telephone-administered questionnaire to ask about ADHD (acronym and full name) on a spontaneous and suggested basis. Questions were asked relating to myths, symptoms, treatment, implications and healthcare professionals involved in the disease.The study sample was 770 adults (sample precision at national level 3.5) with no personal, familial or professional relationship to ADHD.
Only 4% of the subjects spontaneously answered the question about what ADHD means, while 85.3% identified the disease after we suggested what “ADHD” meant. Only 50% admitted that the disease represents a probably genetic brain disorder. A total of 39.6% believed that there was no treatment or healthcare intervention for ADHD. the intervention most often cited as being adequate was psychological treatment (48%), followed by multimodal therapy (44%). Only 12% mentioned medication. Thus, psychological intervention was regarded as the most effective option, followed by psychoeducational measures. Most of the subjects identified the psychologist as the professional indicated to treat ADHD, followed by the pediatrician, psychiatrist and neuropediatrician. Reasonable knowledge was observed in reference to affirmations / myths in ADHD (78.3–95.3%).
There are areas for improvement among the general population regarding knowledge of ADHD, its implications and treatment.
There is a strong association between depersonalization (DP) and panic disorder (PD), as documented by Roth (1960) and later by Cassano (1989)1. In the PD is shown a prevalence of 7.8% to 82.6% from the DP. The aim of our study was to evaluate the association between depersonalization symptoms and PD in a sample of patients with anxiety disorders and mood.
A sample of 310 patiens was assessed with: SCID-P for axis I diagnosis and SCI-DER (structured clinical interview for depersonalization and derealization symptoms, lifetime version)2.
Through a linear regression analysis we underline that, the presence of depersonalization symptoms, irrespective of age, gender and mood disorder, is significantly associated with the PD diagnosis (total score SCI-DER Tot p = 0.001; derealization p = 0.001; somatopsychic depersonalization p = 0.001; autopsychic depersonalization p = 0.003; affective depersonalization p = 0.047).
The presence of depersonalization symptoms must carefully assess in clinical setting and suggest the presence of panic disorder.
The aim of our study is to evaluate, in a sample of bipolar (BD) eutimic patients, the association between depersonalization symptoms, facial emotions expression recognition and affective temperament.
95 bipolar eutimic patients (YMRS< 6 and HDRS< 8), are assessed with: SCID-P, TEMPS, SCI-DER1 e POFA (test of recognitionof facial emotions expression by Ekman e Friesen).
Throught a regression analysis we underline that, independently to panic disorder, the ipertimic temperament is associated with: major recognition of happiness (p < 0.001; β = -4,483) and minor recognition of anger (p = 0.005; β = 3,202) in BD patients with high scores in autopsychic depersonalization domain; major recognition of sadness (p = 0.001; β = -3,944) and minor recognition of anger (p = 0.005; β = 3,181) in BD patients with high scores in affective depersonalization domain. Moreover, the cyclotimic temperament is associated with: major recognition of surprise (p = 0.004; β = -3,233) and happiness (p = 0.044; β = -2,124) in BD patients with high scores in Derealization (DER-TOT); major recognition of surprise (p = 0.001; β = -3,792) and happiness (p = 0.018; β = -2,532) in BD patients with high scores in somatopsychic depersonalization domain.
The presence of depersonalization and derealization symptoms is associated with a selective deficit in the recognition of several emotions. in bipolar patients this selective deficit is dependent of type of affective temperament. Further research is warranted to replicate our clinical observation.
Depersonalization (DP) and derealization (DR) may be detected both in healthy and pathological conditions, but the prevalence and clinical correlates of dissociative symptoms in bipolar disorder have received limited attention in literature (1). The aim of this study is to discuss new treatment possibilities of derealization and depersonalization in bipolar disorder.
We describe three different case reports of bipolar disorder patients with depersonalization and derealization. Case 1: M.P., 26 years old, lamotrigine (100 mg) augmentation with ziprasidone (40 mg); Case 2: C.A., 32 years old, lamotrigine (100 mg) augmentation with quetiapine ER (150 mg); Case 3: M.M., 38 years old, lamotrigine (100 mg) augmentation with aripiprazole (5 mg).
The addition of aripiprazole, quetiapine and ziprasidone in RP lamotrigine lead to a resolution of dissociative symptoms, most likely due to stimulation of serotonin. It is possible that partial agonism at the 5-HT1A receptor has been postulated as a potential therapeutic mechanism in the alleviation of depression, anxiety, negative symptoms, and extrapyramidal side effects  and the blockade of postsynaptic 5-HT1Areceptors may impart complementary anxiolytic properties, facilitate cortical and hippocampal glutamatergic [3,4]. Further research is warranted to replicate our clinical observations and, in general terms, controlled studies are needed to confirm the efficacy of this treatment.
Bipolar disorder is a common, severe, long-term condition, characterized by manic/hypomanic, depressed, or mixed states
(1) Lithium is the traditional treatment option, and valproate and carbamazepine have been introduced to better treat and stabilize manic/depressive cyclicity. Recently antipsychotics turned into a broader therapeutic option for bipolar disorder, as both alternative and adjunct to traditional mood stabilizers.
(2) Asenapine is an atypical antipsychotic indicated for the treatment of schizophrenia and of the manic or mixed episodes in bipolar I disorder (1,3). “Mrs. O.M.”, is a caucasian woman aged 55 suffering from bipolar disorder type I since she was 22 years old, with mood cycles characterized by long manic episodes with soft mixed and cognitive features. Readmitted for a manic exacerbation, the increasing of clozapine up to 250 mg/day was accompanied by hyperphagia, weight gain, cognitive impairment, sedation, fatigue, anergy, resistant chronic constipation. To that point clozapine was abruptly replaced with asenapine 20 mg/day with rapid clinical improvement within two days without major side effects. After 6 months the patient is still showing a good affective stability, without side effects. Our case report underlines the possibility of rapid switch from clozapine to asenapine in bipolar I disorder therapy resistant manic patients, presenting extrapyramidal, cognitive and metabolic side effects with atypical and typical neuroleptics.
Misidentification phenomena and Capgras Syndrome (CS) occur in different psychiatric (psychotic or major affective illnesses) and neurological (traumatic brain injury, epilepsy, neurosyphilis, etc.) disorders [1,2]. The aim of this report is to redefine dissociative spectrum dimensions inside CS and misidentification syndromes in patients with Bipolar Disorder (BD).
Five inpatients were assessed with the SCID-P, SCID-DER, DSS, HRSD, YMRS, a neurological and general medicine review, a first-level brain imaging examination (CT and/or MRI). We conducted a systematic literature review (PubMed, Embase, PsychInfo) using the key terms “Capgras Syndrome” and “Misidentificaition”.
All patients were diagnosed with type-I BD and had concomitant CS that presented with misidentification phenomena in the context of psychotic mixed state. They reported high scores for autopsychic and affective depersonalization symptoms as well as high SCI-DER (mean = 24.4) and DSS (mean = 13) total scores.
Discussion and conclusion
To our knowledge in literature, there are not studies that evaluated dissociative spectrum symptoms in CS in BD. This condition of identity and self fragmentation could be the key to shedding light on the interconnection between affective and non-affective psychotic disorders from schizophrenia to BD, and may underscore the possible validity of the concept of the unitary psychosis proposed by Griesinger [3–5]. Further research is warranted to replicate our clinical and qualitative observations and, in general, quantitative studies in large samples followed up over time are needed. Methodological limitations are considered.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
The social and economic impact of mood disorders and suicide is extremely high. In depression, suicide is included among the cognitive disturbances, together with guilt, paranoid and obsessive-compulsive symptoms, depersonalization/derealization and agitation [1,2]. The aim of this report is to study a sample of depressed patients with bipolar disorder or major depressive disorder, to evaluate the level of impulsivity and dissociation in a context of a suicidal plan.
Twenty inpatients with suicidal plan were assessed with: the SCID-P for Axis I diagnosis, SCI-DER, DSS, HRSD, HAS, YMRS, GSR. We conducted a systematic literature review (PubMed, Embase, PsychInfo) using the key terms “depression”, “suicide”, “suicidal plan”, “depersonalization”, “derealization” AND “dissociation”.
An independent sample T-Test analysis suggested that the patient with high sucidal plan present significant highter score at SCI-DER TOT (P = 0.015), DSS TOT (P = 0.037), BIS-11 motor perseveration factor (P = 0.023) and inversely significant HAS TOT (P = .029).
Discussion and conclusion
It's suggestive that when are lost the boundaries of the self, the clarity of suicidal's purpose reduces the levels of anxiety and suicide appears the only way to achieve the liberation of the suffering of depression. Methodological limitations, clinical implications and suggestions for future research directions are considered.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
In this paper, the dynamics of electrons emitted by a spherical object when the total charge of the system is constant is studied in detail. In particular, the condition for which the total electron charge presents damped oscillations is deduced rigorously by considering a perturbation with respect to the steady-state solution. The results obtained can be of utility in simulating the expansion of a spherical plasma by separating the ion and electron time scales.
When patients feel spiritually supported by staff, we find increased use of hospice and reduced use of aggressive treatments at end of life, yet substantial barriers to staff spiritual care provision still exist. We aimed to study these barriers in a new cultural context and analyzed a new subgroup with “unrealized potential” for improved spiritual care provision: those who are positively inclined toward spiritual care yet do not themselves provide it.
We distributed the Religion and Spirituality in Cancer Care Study via the Middle East Cancer Consortium to physicians and nurses caring for advanced cancer patients. Survey items included how often spiritual care should be provided, how often respondents themselves provide it, and perceived barriers to spiritual care provision.
We had 770 respondents (40% physicians, 60% nurses) from 14 Middle Eastern countries. The results showed that 82% of respondents think staff should provide spiritual care at least occasionally, but 44% provide spiritual care less often than they think they should. In multivariable analysis of respondents who valued spiritual care yet did not themselves provide it to their most recent patients, predictors included low personal sense of being spiritual (p < 0.001) and not having received training (p = 0.02; only 22% received training). How “developed” a country is negatively predicted spiritual care provision (p < 0.001). Self-perceived barriers were quite similar across cultures.
Significance of results
Despite relatively high levels of spiritual care provision, we see a gap between desirability and actual provision. Seeing oneself as not spiritual or only slightly spiritual is a key factor demonstrably associated with not providing spiritual care. Efforts to increase spiritual care provision should target those in favor of spiritual care provision, promoting training that helps participants consider their own spirituality and the role that it plays in their personal and professional lives.
Epilepsy is one of the most serious neurological conditions and has an impact not only on the affected individual but also on the family and, indirectly, on the community. A global approach to the individual must take into account cognitive problems, psychiatric comorbidities and all psychosocial complications that often accompany epilepsy. We discuss psychosocial issues in epilepsy with special focus on the relationship between stigma and psychiatric comorbidities. Social barriers to optimal care and health outcomes for people with epilepsy result in huge disparities, and the public health system needs to invest in awareness programmes to increase public knowledge and reduce stigma in order to minimise such disparities.
In the framework of the Sardinia Radio Telescope (SRT) Early Science Program, we obtained single-dish high-resolution imaging of the Supernova Remnants IC443 and W44 at 7 GHz. By coupling them with SRT 1.5 GHz maps, we provided spatially-resolved spectral measurements that are highlighting a spread in spectral slope distribution. The observed features range from flat or slightly inverted spectra corresponding to bright radio limbs and filaments, to relatively steep spectra in fainter radio regions. Different theoretical possibilities explaining the above challenging findings are discussed. In particular, we exclude that the observed region-dependent wide spread in spectral slope distribution could be related to absorption processes. Our high-frequency results can be directly related to distinct electron populations in the SNRs including secondary hadronic electrons and resulting from different shocks conditions and/or undergoing different cooling processes. Integrated fluxes associated with the whole SNRs obtained by SRT in comparison with previous results in the literature support the evidence for a slight spectral steepening above 1 GHz for both sources, which could be related to primary electrons or more likely secondary hadronic electrons cut-offs.
We present single-dish imaging of the well-known Supernova Remnants (SNRs) IC443 and W44 at 1.5 GHz and 7 GHz with the recently commissioned 64-m diameter Sardinia Radio Telescope (SRT). Our images were obtained through on-the-fly mapping techniques, providing antenna beam oversampling, automatic baseline subtraction and radio-frequency interference removal. It results in high-quality maps of the SNRs at 7 GHz, which are usually lacking and not easily achievable through interferometry at this frequency due to the very large SNR structures. SRT continuum maps of our targets are consistent with VLA maps carried out at lower frequencies (at 324 MHz and 1.4 GHz), providing a view of the complex filamentary morphology. New estimates of the total flux density are given within 3% and 5% error at 1.5 GHz and 7 GHz respectively, in addition to flux measurements in different regions of the SNRs.
In the framework of the Astronomical Validation and Early Science activities of the Sardinia Radio Telescope (SRT, www.srt.inaf.it), we performed 22 GHz imaging observations of SNR W44 and IC443. Thanks to the single-dish imaging performances of SRT and innovative ad hoc imaging techniques, we obtained maps that provide a detailed view of the structure of the remnants. We are planning to exploit the high-frequency radio data of SNRs to better characterize the spatially-resolved spectra and search for possible spectral steepening or breaks in selected SNR regions, assessing the high-energy tail of the region-dependent electron distribution.
Major depressive disorder (MDD) is moderately heritable, however genome-wide association studies (GWAS) for MDD, as well as for related continuous outcomes, have not shown consistent results. Attempts to elucidate the genetic basis of MDD may be hindered by heterogeneity in diagnosis. The Center for Epidemiological Studies Depression (CES-D) scale provides a widely used tool for measuring depressive symptoms clustered in four different domains which can be combined together into a total score but also can be analysed as separate symptom domains.
We performed a meta-analysis of GWAS of the CES-D symptom clusters. We recruited 12 cohorts with the 20- or 10-item CES-D scale (32 528 persons).
One single nucleotide polymorphism (SNP), rs713224, located near the brain-expressed melatonin receptor (MTNR1A) gene, was associated with the somatic complaints domain of depression symptoms, with borderline genome-wide significance (pdiscovery = 3.82 × 10−8). The SNP was analysed in an additional five cohorts comprising the replication sample (6813 persons). However, the association was not consistent among the replication sample (pdiscovery+replication = 1.10 × 10−6) with evidence of heterogeneity.
Despite the effort to harmonize the phenotypes across cohorts and participants, our study is still underpowered to detect consistent association for depression, even by means of symptom classification. On the contrary, the SNP-based heritability and co-heritability estimation results suggest that a very minor part of the variation could be captured by GWAS, explaining the reason of sparse findings.
Illegal killing/taking of birds is a growing concern across the Mediterranean. However, there are few quantitative data on the species and countries involved. We assessed numbers of individual birds of each species killed/taken illegally in each Mediterranean country per year, using a diverse range of data sources and incorporating expert knowledge. We estimated that 11–36 million individuals per year may be killed/taken illegally in the region, many of them on migration. In each of Cyprus, Egypt, Italy, Lebanon and Syria, more than two million birds may be killed/taken on average each year. For species such as Blackcap Sylvia atricapilla, Common Quail Coturnix coturnix, Eurasian Chaffinch Fringilla coelebs, House Sparrow Passer domesticus and Song Thrush Turdus philomelos, more than one million individuals of each species are estimated to be killed/taken illegally on average every year. Several species of global conservation concern are also reported to be killed/taken illegally in substantial numbers: Eurasian Curlew Numenius arquata, Ferruginous Duck Aythya nyroca and Rock Partridge Alectoris graeca. Birds in the Mediterranean are illegally killed/taken primarily for food, sport and for use as cage-birds or decoys. At the 20 worst locations with the highest reported numbers, 7.9 million individuals may be illegally killed/taken per year, representing 34% of the mean estimated annual regional total number of birds illegally killed/taken for all species combined. Our study highlighted the paucity of data on illegal killing/taking of birds. Monitoring schemes which use systematic sampling protocols are needed to generate increasingly robust data on trends in illegal killing/taking over time and help stakeholders prioritise conservation actions to address this international conservation problem. Large numbers of birds are also hunted legally in the region, but specific totals are generally unavailable. Such data, in combination with improved estimates for illegal killing/taking, are needed for robustly assessing the sustainability of exploitation of birds.