Background. – The cross-sectional clinical differentiation of schizophrenia or schizoaffective disorder from mood-incongruent psychotic mania or mixed mania is difficult, since pathognomonic symptoms are lacking in these conditions.

Aims of the study. – To compare a series of clinical variables related to mood and cognition in patient groups with DSM-III-R diagnosis of schizophrenia, schizoaffective disorder, mood-incongruent psychotic mania and mood-incongruent psychotic mixed mania.

Methods. – One hundred and fifty-one consecutive patients were evaluated in the week prior to discharge by using the structured clinical interview for DSM-III-R-patient edition (SCID-P). Severity of psychopathology was assessed by the 18-item version of the brief psychiatric rating scale (BPRS) and negative symptoms by the scale for assessment of negative symptoms (SANS). Level of insight was assessed with the scale to assess unawareness of mental disorders (SUMD).

Results. – There were no differences in rates of specific types of delusions and hallucinations between subjects with schizophrenia, schizoaffective disorder, psychotic mania and psychotic mixed mania. SANS factors scores were significantly higher in patients with schizophrenia than in the bipolar groups. Patients with mixed state scored significantly higher on depression and excitement compared to schizophrenia group and, to a lesser extent, to schizoaffective group. Subjects with schizophrenia showed highest scores on the SUMD indicating that they were much more compromised on the insight dimension than subjects with psychotic mania or mixed mania.

Conclusion. – Negative rather than affective symptomatology may be a useful construct to differentiate between schizophrenia or schizoaffective disorders from mood-incongruent psychotic mania or mixed mania.

Insight is a complex phenomenon that can be interpreted according to a dimensional model. Given the controversial data of insight in obsessive–compulsive disorder (OCD), our study aimed to investigate insight in an Italian sample of patients with OCD by means of the specific item on the Yale–Brown obsessive–compulsive scale (Y-BOCS) and to explore the possible correlations between it and clinical features. One hundred and seventeen out-patients with a DSM-IV diagnosis of OCD and different comorbid psychiatric disorders were included in the study and assessed by means of the Y-BOCS, Hamilton rating scale for depression (HRSD) and the global clinical impression. The results showed that almost 50% of the patients had an excellent level of insight and 15% had a little or no insight. No correlation between levels of insight and clinical features was observed, except for a negative trend with the presence of somatic obsessions. In addition, a trend towards a lower level of insight was observed in those bipolar patients with a positive history of repeated manic or hypomanic episodes. Further studies seem to be necessary in order to establish whether or not OCD patients with poor insight represent a distinct sub-group of patients.

Although the precise etiological nature of autism—the most common development disorder—remains elusive, two main biological factors have been suggested. One is related to a possible neurochemical dysfunction at the level of the serotonergic system; the other underlines the presence of neuroanatomical abnormalities in different areas, in particular, in the cerebellum.

The authors propose a unifying hypothesis linking serotonin (5-hydroxytryptamine, or 5-HT) to the cerebellum on the basis of the observation of a specific 5-HT receptor subtype, 5-HT5A, in this area. The 5-HT5A receptors may be involved in the pathophysiology of autism, and perhaps, in autism-related disorders, since they are mainly expressed in Purkinje's cells. Future studies with specific drugs that interact with 5-HT5A receptors should permit the testing of this hypothesis through the evaluation of the receptors themselves in autopsied brain samples or in vivo by positron emission tomography. Theoretically, such compounds might prove effective in the treatment of autism.

Available data from the literature supporting the hypothesis that partial manifestations of the panic-agoraphobic spectrum may be as clinically relevant as a full-fledged syndrome were reviewed. These partial expressions of disorder may occur singly or in connection with other mental disorders. In particular, we have examined evidences indicating relationships of panic-agoraphobic spectrum with other mental disorders in childhood and adolescence and with psychotic disorders. Their importance in childhood and adolescence is significant because we believe that these symptoms influence adult behavior and are viewed, at a later time, as atypical symptoms. Panic-agoraphobic spectrum syndromes, both in their full-fledged and partial manifestations frequently co-occur with other mental disorders and are likely to be associated with significant impairment either when occurring singly, partially, or comorbidly. Several conditions typical of childhood, such as separation anxiety, school phobia, and other symptoms related to the concept of “behavioral inhibition” seem to be connected with the panic-agoraphobic spectrum and deserve attention in relation to the development of different anxiety and mood disorders in subsequent phases of the life cycle. Identification of panic-agoraphobic spectrum features is also important within the realm of psychoses where they may substantially affect phenomenology, course of illness, and treatment response.

Panic disorder occurs frequently with different forms of cardiovascular disease and hypertension. The 13 panic symptoms described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) often overlap with manifestations of cardiovascular disorders, raising problems in the differential diagnosis. In order to explore in greater detail the phenomenology of panic symptoms in cardiovascular patients, the Structured Clinical Interview for Panic-Agoraphobic Spectrum (SCI-PAS) was administered to 111 patients with hypertension and 29 patients with a recent myocardial infarction.

With regard to the frequency of endorsement of many of the symptoms assessed on the SCI-PAS, more than 40% of the cardiovascular patients who failed to meet the DSM-IV criteria for panic disorder did not significantly differ from the 10% of cardiovascular patients who did fulfill the criteria for panic disorder. A third distinct subgroup comprising 48.6% of the cardiovascular patients reported a significantly smaller number of SCI-PAS symptoms than the other two groups.

These preliminary findings suggest the existence of a relatively large proportion of cardiovascular patients who present with physical and psychological symptoms that are potentially related to panic disorder and that may provoke considerable subjective distress. Further studies are needed to clarify the nature of these symptoms and their potential interference with treatment and symptomatology of cardiovascular disease.

Although the precise etiologic nature of obsessive-compulsive disorder (OCD), one of the most common psychiatric conditions, is unknown, several findings indicate involvement of the serotonin (5-HT) transporter. Apart from the specific effects of selective 5-HT reuptake inhibitors, other studies show decreased functionality of the platelet 5-HT transporter in OCD. In this report, the authors combine data from two independent studies of patients with OCD, showing both an increased activity of protein kinase type C (PKC) and a decreased activity of protein kinase type A (PKA). The authors propose a unifying hypothesis that OCD might be determined by an imbalance between PKC and PKA, with a prevalence of the former and, more generally, of the phosphoinositide over the cyclic adenosine monophosphate (cAMP) pathway. Should this hypothesis prove correct, the path would be open for new therapeutic interventions in the treatment of OCD.

Separation anxiety has long been of interest in psychiatry. The term refers to both a phenomenon of normal psychological development and to the symptoms of a common childhood psychiatric disorder, classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD 10), as separation anxiety disorder. Available epidemiological studies suggest a prevalence rate of this disorder of about 4%. Treatment studies using cognitive behavioral therapy and/or medication are reported in the literature. There is also evidence that symptoms of separation anxiety may occur in adulthood, though this is far less widely known. We consider childhood and adult separation anxiety to be a component of panic spectrum, described in other papers of this issue.

A small and somewhat confusing literature addresses the question of outcome of childhood separation anxiety disorder, with support for a weak association between childhood separation anxiety and adult panic disorder. We believe there is a suggestion of a stronger association of the childhood condition with persistence of a similar syndrome of adult separation anxiety. Symptoms of adult separation anxiety may be a manifestation of panic spectrum, as we suggest. Such symptoms may represent a separate, specific clinical entity, or symptomatic separation anxiety may occur as a manifestation of a range of Axis I disorders, and may respond to treatment of these disorders. In any case, we urge researchers and clinicians to begin to attend to the possibility that adult psychiatric patients may suffer from clinically significant symptoms of adult separation anxiety.

This paper describes a model of psychopathology termed the panic-agoraphobic spectrum. The model has been constructed by identifying different psychopathologic and clinical domains that incorporate and extend the diagnosis of panic disorder as described in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Categorical classifications do not take into account the subthreshold, atypical, and often enduring symptoms that accompany the core manifestations of full-blown mental disorders. These often-neglected spectrums of symptoms, however, may be as distressing and debilitating as the full-blown disorders and can have unrecognized importance in selection of and response to treatment. At the Department of Psychiatry, Neurobiology, Pharmacology, and Biotechnology, Institute of Psychiatry of the University of Pisa, Italy, a spectrum approach to mental disorders (eg, bipolar, obsessive-compulsive, eating, and panic disorders) has been used extensively and has proven effective in clinical practice.

The need for systematic identification and assessment of a broad array of symptoms and behavioral features has led, as a first step, to the conceptualization of the panic-agoraphobic spectrum model. In collaboration with researchers from the University of Pittsburgh, PA, and elsewhere, the University of Pisa scientists have further refined the panic-agoraphobic spectrum model and have developed a structured interview for this spectrum called the Structured Clinical Interview for Panic-Agoraphobic Spectrum. The rationale, clinical usefulness, and heuristic significance of the panic-agoraphobic spectrum model are discussed below.

The current tools used to define and diagnose mental disorders, including the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, have added specificity to the psychiatric nomenclature. However, their stereotypic rigidity in classification has resulted in the failure to identify the full range of potentially debilitating psychiatric symptoms with which patients may present. A spectrum model of psychopathology is more adept at recognizing the subclinical or threshold symptomatology that may occur concomitantly with core psychiatric disorders. The authors discuss the development of a spectrum approach to the diagnosis of mental disorders, which offers the potential to improve treatment selection and therapeutic outcomes.

The neuropsychological performance of 19 unmedicated patients with panic disorder (PD) was compared with 15 age- and education-matched control subjects. The test results indicate a selective pattern of neuropsychological dysfunctions in patients with PD, suggestive of an involvement of the right frontal and temporoparietal brain areas.

What are the symptoms of panic disorder and how is the disorder most effectively treated? One of the most commonly encountered anxiety disorders in the primary care setting, panic disorder is a chronic and debilitating illness. The core symptoms are recurrent panic attacks coupled with anticipatory anxiety and phobic avoidance, which together impair the patient's professional, social, and familial functioning. Patients with panic disorder have medically unexplained symptoms that lead to overutilization of healthcare services. Panic disorder is often comorbid with agoraphobia and major depression, and patients may be at increased risk of cardiovascular disease and, possibly, suicide. Research into the optimal treatment of this disorder has been undertaken in the past 2 decades, and numerous randomized, controlled trials have been published. Selective serotonin reuptake inhibitors have emerged as the most favorable treatment, as they have a beneficial side-effect profile, are relatively safe (even if taken in overdose), and do not produce physical dependency. High-potency benzodiazepines, reversible monoamine oxidase inhibitors, and tricyclic antidepressants, have also shown antipardc efficacy. In addition, cognitive-behavioral therapy has demonstrated efficacy in the acute and long-term treatment of panic disorder. A n integrated treatment approach that combines pharmacotherapy with cognitive-behavioral therapy may provide the best treatment. Long-term efficacy and ease of use are important considerations in treatment selection, as maintenance treatment is recommended for at least 12–24 months, and in some cases, indefinitely.

El insight es un fenómeno complejo que se puede interpretar según un modelo dimensional. Dados los polémicos datos del insight en el trastorno obsesivo-compulsivo (TOC), nuestro estudio tenía el propósito de investigar este fenómeno en una muestra italiana de pacientes con TOC por medio del elemento específico en la Escala de Obsesión-Compulsión de Yale-Brown (Y-BOCS) y explorar las posibles correlaciones entre el insight y los rasgos clínicos. Se incluyó en el estudio a 117 pacientes ambulatorios con un diagnóstico del DSM IV de TOC y diferentes trastornos psiquiátricos comórbidos y se los evaluó por medio de la Y-BOCS, la Escala de Depresión de Hamilton (HRSD) y la Impresión Clínica Global. Los resultados mostraron que casi el 50% de los pacientes tenía un nivel excelente de insight y el 15% tenía poco o ningún insight. No se observó correlación entre los niveles de insight y los rasgos clínicos, excepto una tendencia negativa con la presencia de obsesiones somáticas. Además, se observó una tendencia hacia un nivel inferior de insight en los pacientes bipolares con antecedentes positivos de episodios maníacos o hipomaníacos repetidos. Parecen necesarios estudios adicionales para establecer si los pacientes de TOC con mal insight representan o no un subgrupo distinto de pacientes.

Systematic and detailed psychopathological examination of 400 consecutive primary major depressives failed to confirm common clinical stereotypes which ascribe greater somatisation, hypochondriasis, agitation, psychotic tendencies, and chronicity to old age. Those above 65 were more likely to suffer from single episodes of depression that were often precipitated, whereas subjects whose illness began earlier were more likely to express depression as part of a recurrent unipolar or bipolar disorder, with higher rates of affective temperamental pathology and familial affective illness. The acute clinical picture was relatively uniform in older and younger depressives and, taken together with the other findings, tends to favour a spectrum model of primary mood disorders.