Psychiatric emergencies (part III): psychiatric symptoms resulting from organic diseases.

An exhaustive review on the organic illnesses presenting with psychiatric manifestations, properly defined pseudopsychiatric emergencies, is presented. A systematic classification of the numerous organic causes of psychiatric disorders, based on authors' experience and literature revision, is carefully analysed, and their suitable diagnostic management in emergency setting is proposed. Moreover, the role of bedside ultrasonography in Emergency Department is emphasized. The underlying pathogenetic mechanisms are separately discussed. A particular significance is given to "neuropsychological studies", displaying the complex connection between the central nervous system and the endocrine system. The role of immune system in influencing the central nervous system, explaining the model of "sickness behaviour" in inflammatory disease, is also described, according to recent reports of "psychoneuroimmunology". Moreover, the immune-mediated mechanism explaining how neoplasm can influence brain function in the "paraneoplastic syndromes" is shown. In order to facilitate the teaching method, organic illnesses presenting with acute psychic manifestations or mimicking specific psychiatric disorders are subdivided into three groups: (1) Endocrine and metabolic disorders and deficiency states; (2) Internal diseases; (3) Neurologic disorders.

Psychiatric emergencies (part I): psychiatric disorders causing organic symptoms.

Psychiatric emergencies are conditions that mostly destabilize the already frenetic activity of the Emergency Department. Sometimes the emergency is clearly referable to primitive psychiatric illness. Other times, psychiatric and organic symptoms can independently coexist (comorbidity), or develop together in different conditions of substance abuse, including alcohol and prescription drugs. Differentiating between substance induced and pre-existing psychiatric disorder (dual diagnosis) may be difficult, other than controversial issue. Finally, an organic disease can hide behind a psychiatric disorder (pseudopsychiatric emergency). In this review (part I), psychiatric disorders that occur with organic symptoms are discussed. They include: (1) anxiety, conversion and psychosomatic disorders, and (2) simulated diseases. The physiologic mechanisms of the stress reaction, divided into a dual neuro-hormonal response, are reviewed in this section: (1) activation of the sympathetic nervous system and adrenal medulla with catecholamine production (rapid response), and (2) activation of the hypothalamic-pituitary-adrenal axis with cortisol production (slow response). The concept of the fight-or-flight response, its adaptive significance and the potential evolution in paralyzing response, well showing by Yerkes-Dodson curve, is explained. Abnormal short- and long-term reactions to stress evolving toward well codified cluster of trauma and stressor-related disorders, including acute stress disorder, adjustment disorder and post-traumatic stress disorder, are examined. A brief review of major psychiatric disorder and related behaviour abnormalities, vegetative symptoms and cognitive impairment, according to DMS IV-TR classification, are described. Finally, the reactive psychic symptoms and behavioral responses to acute or chronic organic disease, so called "somatopsychic disorders", commonly occurring in elderly and pediatric patients, are presented. The specific conditions of post-operative and intensive care unit patients, and cancer and HIV positive population are emphasized.

[Psychic disorders in emergency room: a qualitative analysis of psychological intervention]. / Disturbi psichici in pronto soccorso: una analisi qualitativa dell'intervento psicologico.

OBJECTIVES: Our study aims to analyze typologies of psychological intervention that respond to spontaneous request of Emergency Room's users and care providers, and their distribution in relation to observed psychic disorders. MATERIALS AND METHODS: 364 Subjects (134 males and 230 females), mean age 41.55 (± 22.38) reaching Emergency room were involved in this study. Data from an observation form were related to patients' triage code, their provisional diagnosis, the request of psychiatric advice and emergency outcome. Non-parametric variables were analyzed by Chi Square method, while parametric ones by ANOVA method. RESULTS: Patients were the more frequent users of psychological intervention, while relatives used it in lesser proportion. Anxiety Disorder was the most frequent psychiatric diagnosis associated to psychological consulting. The patient's triage code was not significantly related to frequency of consulting. The type of intervention that was most often choosen has been supportive. As to outcome, the majority of patients who consulted psychologists was discharged, while a low percentage was admitted, particularly in psychiatric wards. CONCLUSIONS: Psychological consulting appears related to a wider and more varied range of urgent situations than psychiatric consulting. Therefore, psychological intervention seems to be useful both to relieve hic et nunc psychological discomfort, and to help and direct sicker patients to formulate a long-term treatment plan.

Organizational models of emergency psychiatric intervention: state of the art.

Authors outline the differences between medical and psychiatric definition of emergency and analyze different organizational models of psychiatric intervention in Emergency Room. The historical evolution changed these models, and the relation with services for acute and subacute patients in hospital and community services. The Italian reform model is compared with the slow deinstitutionalization of psychiatry in other countries. Critical points in Italian emergency organization after the Psychiatric Reform are pointed out: low number of beds for acute patients, difficulties and delays in transfer from Emergency Room to GHPW (General Hospital Psychiatric Ward), waiting lists for voluntary treatments. To overcome some of these problems, the Authors propose that even in hospitals without psychiatric ward, a small unit of short psychiatric observation be implemented, for voluntary treatments, before transfer to other institutions.

Serum magnesium profile in heroin addicts: according to psychiatric comorbidity.

Psychiatric comorbidity in heroin addiction can modify both the biological pattern and clinical course of this disorder. Because of the role of magnesium in neurotransmission and its specific patterns in some psychiatric conditions, such as depression and schizophrenia, we studied a sample of heroin dependent subjects, with and without psychiatric comorbidity. A sample of 162 drug addicts (123 men and 39 women, mean age 32.3 +/- 6.7) was diagnosed for the presence of psychiatric comorbidity with DSM IV criteria. They were subsequently divided in 4 subgroups: No comorbidity, Anxiety Disorders, Mood Disorders, Personality Disorders. Differences in serum magnesium level between the groups were analysed with the Anova method, with age as covariate. Results show that serum Mg++ levels are significantly higher in patients with heroin dependence and personality disorders compared to patients with depression comorbidity and without comorbidity. Psychiatric codiagnosis significantly modifies Mg++ levels in this drug dependent sample. Gender modifies Mg levels in no comorbid subjects so that females show significantly lower Mg++ levels compared to males. The presence of psychiatric comorbidity abates this difference.

Dental anxiety in adolescent people.

AIM: Anxiety in adolescence is a complex phenomenon, but could affect oral hygiene and compliance to dental therapies in young people. METHODS: Owing to the importance of anxiety in coping with odontostomatologic therapy, 2 groups of adolescent subjects (age range 16-20 years) have been compared: a group of patients under treatment at the Policlinico Gemelli (45 subjects, 27 females and 18 males) and a control group of students (39 subjects, 20 females and 19 males). Different aspects of anxiety have been analysed by the STAI Y-I test (state anxiety), STAI Y-2 test (trait anxiety) and the Dental Anxiety Scale, on the basis of the hypothesis that the group of patients should show higher anxiety levels as to state anxiety and dental anxiety. Data were evaluated by the analysis of variance method and Student's t test as regards mean differences. RESULTS: The group of patients showed significantly higher state anxiety than controls, and significant differences as to trait anxiety were also found. In both groups girls were significantly more anxious than boys. Our results confirm the hypothesis that high anxiety levels are related to odontostomatologic treatments. Patients from Policlinico Gemelli showed a significantly better knowledge of dental hygiene than control group. CONCLUSIONS: A better knowledge of dental hygiene is not sufficient to reduce anxiety. Preventive measures that could reduce anxiety and ensure a better compliance in adolescent patients are thus discussed.

Psychiatric emergencies and services availability: a comparison of two hospitals in Rome.

The development of Psychiatric Emergency Services (PES) as an autonomous organization has allowed the registration of urgent request in different urban areas and their correlation with real clinical needs. Our aim was to investigate different patterns of psychiatric emergencies, considering that A) qualitative differences in diagnostic distribution could emerge in relation to the availability of local hospital services; B) gender differences could condition the type of demand. In particular, the availability of services appears to have a modulating effect on the demand: it's possible to deduce that socio-economic factors can influence demand and change over time the epidemiological features of patients availing of PES.

[Making real]. / Concretizzazioni.

OBJECT: This paper has the aim to explore psychopathological traits of anorexia nervosa leading to somatization, in critical periods of this disorder, in the clinical framework of analytically oriented psychotherapy performed in hospital setting. DESIGN: Psychodynamic observations in high risk cases, with at least three years of follow-up, are compared with different crisis situations, of psychosomatic or psychic nature. Common and specific psychopathologic features are outlined. BACKGROUND: General Hospital background, liaison problems, and integrative needs between medical and psychotherapeutic caregivers are not only aspects of real situation, but also a group matrix of change for anorexic patients. PATIENTS: Twelve high risk subjects with restricting anorexia were studied, out of a sample of 36 women with eating disorders, admitted to hospital between 1989 and 1991. They were treated by integrated psychotherapeutic and medical methods, in a supportive, unprescriptive therapy plan. RESULTS: Psychosomatic crisis points out that the process that makes real death risks and fantasies is both intrapsychic and interpersonal one. Absence of a cohesive inner organization leads patients to try to establish fusion with other and to search for cohesion in hospital field turning away from adaptive integration in real life. Psychotherapy, in this setting, is a first movement of integrating identity as separate from family and field. From doctor's point of view, to be only concretely oriented involves the risk of losing patient's thought dimension, and, from psychotherapist's point of view, to pay attention only to mind or interactions involves the risk of losing real subject's and field's coordinates. Converging attention and investment by both caregivers seem to rapidly reverse somatization process and to help a first step of integration by the anorexic patients.

Opioid dysregulation in anorexia nervosa: naloxone effects on preprandial and postprandial growth hormone response to growth hormone-releasing hormone.

Previously, we have shown that in the opposite extremes of nutritional status, obesity and anorexia nervosa (AN), growth hormone (GH) response to growth hormone-releasing hormone (GH-RH) is not inhibited by the ingestion of a normal 800-cal meal consumed at lunch time (1 PM), which is at variance with results in normal subjects. However, in obese patients the postprandial increase in GH response to GH-RH is inhibited by an infusion of naloxone (NAL). In this study we have tested anorectic patients, performing the following tests at 1 PM: GH-RH test (50 micrograms IV) or, in a different day session, NAL (1.6 mg/h, starting 30 minutes before GH-RH) + GH-RH test (50 micrograms IV). The tests were performed in the following three different experimental conditions: (1) short-term fasting studies (lasting from breakfast), (2) long-term fasting studies (from midnight of the day before) and (3) postprandial studies (after a standard meal consumed 1 hour before the test). In AN, the GH response to GH-RH was not influenced by NAL infusion at 1 PM, in both short- and long-term fasting studies (short-term fasting: peak values after GH-RH alone, 26.5 +/- 6.5 ng/mL, during NAL, 28.0 +/- 3.3 ng/mL; long-term fasting: peak values after GH-RH alone, 32.2 +/- 6.8 ng/mL, during NAL, 30.6 +/- 4.0 ng/mL). A partial NAL-inhibitory effect was instead observed in postprandial studies, as evidenced by the calculation of areas under the curve ([AUCs] 1,662.1 +/- 90.0 after GH-RH alone v 1,090.5 +/- 245.4 ng/mL/h during NAL).(ABSTRACT TRUNCATED AT 250 WORDS)

Transanal electrostimulation for fecal incontinence: clinical, psychologic, and manometric prospective study.

A prospective study was carried out to analyze the clinical, psychologic, and manometric short-term results of transanal electrostimulation (TES) in the treatment of fecal incontinence. Fifteen patients underwent TES. An initial clinical and manometric assessment was carried out before and 1 month after the procedure. A psychologic evaluation was also performed by means of interviews and appropriate tests. Early improvement of symptoms was noted in 10 patients. The nonresponders were women with gross daily incontinence to solid stool. At anal manometry, resting tone and rectal sensation remained unchanged, whereas a significant increase of voluntary contraction was observed following TES (from 48 +/- 26 to 59 +/- 39 mm Hg, P = 0.03). Psychologically, TES led to a significant decrease of both latent and paranoid anxiety related to symptoms (P = 0.02). At a clinical reassessment 6 months later, one of the nonresponders became continent after a further course of TES. In conclusion, TES is well accepted by the patients, is followed by positive emotional response, and, by improving striated sphincter function, seems to be effective in the treatment of partial fecal incontinence.