PROBLEMATICHE ATTUALI E FUTURE DEL TSO (PRESENT AND FUTURE ISSUES OF THE MANDATORY MEDICAL TREATMENT )

Milia P., Nieddu G.F., Satta I.N., Fumagalli L., Nivoli G.C. Published in Ciliberti R., Pedrucci T. (eds) (2011) I diritti dei soggetti deboli. Nuovi scenari e nuove tutele (The rights of the weak. New scenarios and new protections). Pensa MultiMedia Editore s.r.l.: Lecce. Introduction The law n. 180 of May 13, 1978 (later incorporated into the law n. 833 of December 23, 1978 called for "Establishment of the National Health Service"), sanctioned the end of the special legislation (dating from 1904 ) which confined patients sick of mind in asylums and denied them the rights recognized to all other patients. Psychiatry was then fully included into the National Health Service conquering dignity as medical field with specific therapeutic tasks. It was definitively established the concept of health as a primary right of the individual. Consequently, the criteria of dangerousness and public scandal at the base of psychiatric treatments without consent disappeared. However, despite the closure of the Psychiatric Hospitals and the effort to move assistance at a regional area level, there has been a substantial lack of specific regulation at national level. That often led psychiatrists to confuse their own therapeutic role with the practical management measures of Mandatory Treatments. In fact, it has been frequently observed the occurrence of disputes concerning roles and responsibilities of the professional figures involved in executing the medical measure. These ongoing disputes have ended up producing a number of voluntary initiatives and heterogeneous solutions often very diverse between different territories. Through specific protocols, it has been tried to delimit areas and roles of the different professionals involved (doctors, nurses, policemen, etc. ). The fundamental principle, on which the legal and medical-legal debate hinges with regard to the Mandatory Medical Treatment, is certainly the health protection respecting will and dignity of the individual. However, the peculiarity of the measure may conceal a series of possible errors (such as evaluative and procedural errors) of which every doctor, in particular every psychiatrist, may be responsible. Furthermore, it is not to underestimate the psychiatrist's difficulties linked to the choice of correct strategies in front of patients or difficult situations in which they must predict and prevent resounding conducts. The aim of this paper is to identify and expound possible evaluative and procedural errors linked to the Mandatory Medical Treatment, also referring to any provision of law. Conclusions The intent of the law n. 180 was to distinguish the concept of mental illness from the concept of dangerousness. While leaving open the road to treatment without consent, the law provides broad and generic criteria for this type of intervention (e.g., "mental changes such as to require urgent therapeutic treatments") leading, in fact, to different interpretations and significant operational differences in diverse territories. Consequently, the long-time lack of specific, clear and consistent operational guide lines has created many dissimilarities between specialists. It has also led to a progressive isolation of the psychiatrist in managing the Mandatory Treatment which instead should be collegial and transparent by nature. This has resulted in a more operational difficulties and a significant increase in direct professional liability. It is our opinion, independently from possible future changes to the law, that a correct clinical practice based on scientific evidence with continuous medical education, prudence, comparison and dissemination of knowledge may be the first and most important way to practicing the profession not defensively but respectful of the patient and at the same time rewarding for the operator.

VITTIMA CHE SIMULA E DISSIMULA (VICTIM THAT SIMULATES AND CONCEALS)

Lorettu L., Nivoli A.M.A., Nivoli L.F., Fumagalli L., Satta I.N. Published in Nivoli G.C. et al. (2010) Vittimologia e psichiatria (Victimology and Psychiatry). CSE, Edi-ermes: Milano. Introduction There are different types of victims such as victims of abuse, murders, violence, theft, loan sharking, natural disasters and so on. In this chapter we want to thoroughly analyze that category of individuals who are victims of sexual violence, especially subjects who are underage. Only in the last 40 years scientific attention has been directed to sexual abuse in childhood as an important and frequent risk factor for mental discomforts. It's rather difficult to find objective figures that provide a quantitative and qualitative examination of childhood sexual abuse intended in a broader understanding including behaviors such as exhibition of genitals or making sexual references. A study in the USA of 1145 men and 1481 women has revealed that approximately 16% of men and 7% of women suffered childhood sexual abuse. Given the social dimension of the problem, the demand for good quality of life and greater awareness of child sexual abuse will make the clinician more and more attentive to the evaluation of this phenomenon and his psychological, psychosocial and victimological consequences. Given that childhood sexual abuse has an important psychological impact, a qualitative estimation of abuse on the child cannot ignore the real problem of truthfulness or falsity of what the victim says. As indication, we will refer to two categories of victim: the victim who reports, with a good degree of awareness, of being victim of sexual abuse that actually not occurred; and the victim that denies, also with a good degree of awareness, having been subject to sexual abuse that actually occurred. In a study, out of 576 complaints to the social service of a U.S. city, 47% was found not sufficiently documented, 8% of which were indisputably false. Because of these specific problems related to child sexual abuse, we will present several typologies of charges and the psychodynamics of simulation and dissimulation related to them. Conclusions The pattern of psychopathology that underlies the different charges is indicative but not exhaustive of the variety of clinical cases; also, the psychological and psychopathological dynamics described can only be a simplification of the clinical reality. Thus, during the collection of data for diagnostic, therapeutic and forensic purposes, it may be useful to consider five dimensions to improve the clinical understanding of sexual abuse both in its psychopathological and psychosocial aspects: the proliferation of accusations; the impoverishment of the prosecution; the magnification of the prosecution; the halo of confirmation; the validation over the body.

RUOLO DELLA VITTIMA NELLEVENTO CRIMINALE (ROLE OF THE VICTIM IN THE CRIME)
Nivoli A.M.A., Nivoli L.F., Fumagalli L., Satta I.N. Published in Nivoli G.C. et al. (2010) Vittimologia e psichiatria (Victimology and Psychiatry). CSE, Edi-ermes: Milano. Introduction The role of the victim in the criminal event has been studied by several authors who have highlighted the importance of this role in the realization of the crime. Seelig (1956 ), in line with many criminologists of his time, argues that the victim becomes a specific cause of the criminal event when a particular aspect of the victim leads to the fact. Von Hentig ( 1948), in turn, denounced the role of the victim as somehow causing the crime in which is involved; he has also developed the classification of victims in two main groups: the latent victim (that due to some vulnerability factors can be victim more easily than other individuals) and the criminals-victims (which can play unconditionally the victim or the criminal role, depending on the context). Fattah (1971), in his work "The victime coupable est-elle ?", examined a series of murders consequent to robbery. He highlighted the factors contributing to the choice of the victim by the attacker and pointed out that the role of the victim in the criminal dynamics is equally decisive as the perpetrator role is. In fact, it is not the chance that determines the probability of becoming a victim. It follows that in the genesis of the crime there is a relationship and a very important interaction between the criminal and his victim. The importance of this interaction is related to the fact that the two protagonists develop several mental processes of attraction, repulsion, rebellion, liabilities, provocation that may lead to the criminal event. Many of these positions have been subject to fierce criticism because of misinterpretation of these criminologists who have in some way penalized the victim. Finally, recognizing the responsibility of the victim has often led to its criminalization and, consequently, to a lack of interventions and protection towards the victim (for example, the case of prostitutes victims of aggression). From clinical experience, we present a descriptive typology of victims. In describing this typology of victims we want to emphasize how the victim participates in the criminal event; in fact, the only aim is to highlight the dynamics related to crime in order to prevent the state of victimization. Conclusions Clinical practice has shown that some individuals are victims of some type of criminals rather than others, and some individuals are more frequently victims than others. Therefore, for each individual there is a certain risk of being a victim of a particular crime. However, this probability is not equal for all individuals and does not remain constant for the same individual, rather is subject to numerous fluctuations in time and space. The victim participates in the offense with different levels of participation influenced by several elements (Victimogenics Elements) whose knowledge, rather than leading to the criminalization of the victim, may lead to therapeutic and preventive interventions. The Victimogenics Elements, in the past often stigmatized as elements of responsibility, are now being interpreted in their preventive value. Moreover, the concept of vulnerability, intended in its clinical value as a risk factor, allows to program strategies for primary prevention with psycho-educational and informative interventions on the general population.

PSICOTERAPIE PER LE VITTIME (PSYCHOTHERAPIES FOR THE VICTIMS)

Nivoli L.F., Nivoli A.M.A., Fumagalli L., Satta I.N. Published in Nivoli G.C. et al. (2010) Vittimologia e psichiatria (Victimology and Psychiatry). CSE, Edi-ermes: Milano. Introduction By reason of the great variety of patterns that characterizes the types of victims, it is necessary to select specific psychotherapies to best treat these patients. The victim may present prevalent or even exclusive symptoms ascribable to specific diagnostic categories such as Post Traumatic Stress Disorder, Acute Stress Disorder, Adjustment Disorder, Major Depression, Panic Attacks, Phobias and so on. The victim may also present anticonservative behaviors such as self-injury and suicide attempts, thus requiring general psychiatric interventions. Furthermore, due to serious trauma such as intense and prolonged sexual and physical abuse or physical and psychological torture during kidnappings, the victim may present a complex psychopathology with symptoms of dissociation, avoidance, hyper-arousal, feelings of guilt, secondary victimization and so on. In addition to general psychiatric interventions these patients require specific interventions in the field of victimology. Finally, the victim may require not only psychotherapeutic interventions but also pharmacological and psychosocial interventions in case, for example, of severe traumatic injury, dementia, severe brain damage, addictions or substance abuse. The aim of the present paper is to identify and expound the main psychotherapies for victims, bearing in mind the current trend to integrate the various psychotherapies and adapt them to each individual case. Conclusions In writing this chapter we tried to broadly and comprehensively expound the various psychotherapeutic approaches adopted in the field of victimology. While considering the real need to avoid stereotypical actions on the victims because of the different clinical picture, of the type of trauma and especially of the resulting psychological consequences, we have focused with careful attention to the latest techniques and experience in matter of taking care and treatment of victims. It is widely accepted that the a good therapist will use various psychotherapies depending on the individual case, thus adapting them to the psychopathological and personological characteristics of the victims and associating them to a psychopharmacological treatment and social rehabilitation if useful or necessary.

TAPPE DEL TRATTAMENTO PSICOTERAPICO (STAGES OF THE PSYCHOTHERAPEUTIC TREATMENT)

Nivoli L.F., Nivoli A.M.A., Fumagalli L., Satta I.N. Published in Nivoli G.C. et al. (2010) Vittimologia e psichiatria (Victimology and Psychiatry). CSE, Edi-ermes: Milano. Introduction In regard of psychotherapeutic interventions we should consider at least three basic steps. The first step concerns the evaluation of post-traumatic symptoms. It consists of the clinical interview with the victim and the administration of assessment tools such as questionnaires or scales. This step's aim is to examine the symptoms consequent the traumatic event and the presence of any pre-traumatic factors, precipitating factors, maintenance factors and expectations of the victim. This phase also includes psychoeducation to posttraumatic reactions. The second step requires a specific treatment focused on the symptoms. Treatments focused on affective symptoms, emotions and thought process with cognitive biases are particularly privileged. Furthermore, specific therapeutic interventions should be tailored for each type of victim and towards particular symptoms such as hyperactivity, avoidance or attachment to secondary gains. Depending on the symptoms presented by the victim, the therapist will choose the treatment that best meets the needs of the patient. Finally, the third step include the conclusion of the therapeutic process. This process requires an assessment of the patient's symptoms to evaluate its improvement. It also requires concrete preventive measures. In regard of psychotherapeutic treatment it is important to note that many symptoms (e.g., dissociation, denial, isolation) are mechanisms that the victims use to protect themselves from feelings of discomfort and distress, and must therefore be treated with extreme caution and sensitivity. Furthermore, depending on the specific clinical case, psychotherapy should be integrated with pharmacological treatment. Finally, it is important to point out that at the present state of knowledge we are still in need of accurate and reliable assessments of the validity of the therapeutic interventions. Therefore, in the present chapter we will consider the more prevalent interventions in the victimological centers. Conclusions In this paper we examined the stages of psychotherapeutic treatment in the field of victimology. We particularly highlighted the need to qualify and quantify the symptoms after the traumatic event in terms of victimology. We also pointed out the necessity to give appropriate psychotherapeutic treatments targeted on specific post-traumatic symptoms and using the tools provided by multiple disciplines, especially cognitive-behavioral techniques. Finally, we identified the need to conclude the therapeutic process with an assessment of the patient's symptoms alongside the use of specific preventive measures.

Poster edito a stampa in sede congressuale durante il corso organizzato da Lundbeck dal titolo "Psichiatria e Pratica clinica" in data 09.09.2011
DEPRESSIONE UNIPOLARE RESISTENTE AL TRATTAMENTO VS DEPRESSIONE BIPOLARE: CASE REPORT
Fumagalli L. Dipartimento di Scienze Materno-Infantili, Clinica Psichiatrica, Universit degli Studi di Sassari clinpsic@uniss.it

PREMESSA
Viene riportato il caso clinico di un paziente con Depressione Unipolare resistente al trattamento che ha risposto con successo ad un adeguamento del trattamento farmacologico a seguito del sospetto diagnostico di una mancata diagnosi di Depressione bipolare.

Sintesi anamnestica
V.G., 42 anni, maschio caucasico, celibe, senza figli. Lutto paterno in giovane et. Debutto della patologia psichiatrica a 21 anni: DOC associato a Ritardo Mentale Lieve. Depressione Unipolare che si cronicizza nel tempo. Emergono inoltre alcuni episodi di umore irritabile ed aggressivit verbale associati ad ansia marcata.

Comorbidit di rilievo
Asse I: Disturbo Ossessivo Compulsivo le cui ossessioni si presentano sotto forma di canzoni e cantilene continue e le compulsioni tramite comportamenti ripetitivi riguardanti la sfera sessuale. Asse II: Ritardo Mentale di tipo Lieve in associazione con tratti Istrionici di Personalit. Asse III: Obesit importante con BMI di 40.

Indagini diagnostiche
Vengono eseguite le seguenti indagini diagnostiche: Accurata raccolta anamnestica Richiesta di informazioni ai familiari Valutazione sintomatologica secondo DSM-IV-TR

Indagini strumentali
Al paziente vengono somministrate le seguenti scale: la scala Hamilton-D con un punteggio totale di 24; la scala Beck Depression Inv. con un totale di 24; la scala Hamilton-A con un punteggio totale 24.

Trattamenti farmacologici e non farmacologici

Trattamenti farmacologici impostati in passato: SSRI (sertralina fino a 200 mg/die, fluvoxamina fino a 250 mg/die, paroxetina fino a 60 mg, citlopram fino a 40 mg/die); SNRI (venlafaxina fino a 300 mg/die, Duloxetina fino a 120 mg/die); Antidepressivi Triciclici (Clomipramina Cloridrato fino a 200 mg/die); Antipsicotici (Aloperidolo fino a 15 gtt/die, Amisulpiride fino a 400 mg) . Trattamento farmacologico attuale (da 3 mesi): Escitalopram 10 mg/die, Aripiprazolo 10 mg/die, Lorazepam 3 mg/die.

Risultati A Comparazione dei punteggi ottenuti alla scala Hamilton-D al

t0 (momento dellintroduzione dellattuale terapia farmacologica) ed al t1 (stato attuale).
30

dei punteggi ottenuti alla scala Hamilton-A, somministrata alla 1a, 4a, 8a e 12a settimana dallinizio del precedente trattamento farmacologico e di quello attuale.
30 25 20 15

Risultati B Comparazione

t0 t1

25 20 15 10 5 0
HAMD Totale Subscala Ansiet Subscala Maier Subscala rallentamento

10 5 0 1a sett. 4a sett. 8a sett. 12a sett.

Th attuale Th precedente

Risultati C Comparazione

dei punteggi ottenuti alla scala BDI, somministrata alla 1a, 4a, 8a e 12a settimana dallinizio del precedente trattamento farmacologico e di quello attuale.
30 25 20 15 10 5 0 1a sett. 4a sett. 8a sett. 12a sett.
Th attuale Th precedente

Risultati D In tabella viene riportata la variazione della sintomatologia

clinica col passaggio dalla terapia precedente a quella attuale. Sintomatologia Terapia Terapia precedente attuale +++ + Umore depresso +++ + Ansia + Anedonia +++ + Sintomi vegetativi ++ + Sintomi somatici ++ Disturbi del sonno ++ + Disturbi cognitivi + Disturbi della motricit

CONCLUSIONI
Una mancata risposta al trattamento farmacologico in una Depressione Unipolare deve far porre al clinico il sospetto di una misdiagnosi, per la possibile presenza di una Depressione Bipolare sottostante non correttamente diagnosticata. Fare una diagnosi accurata perci essenziale per un trattamento appropriato

Translation of the poster published during the course "Psichiatria e pratica clinica" (Psychiatry and Clinical Practice) organized by Lundbeck on 09.09.2011 in Napoli (Naples).
TREATMENT-RESISTANT UNIPOLAR DEPRESSION VS BIPOLAR DEPRESSION: CASE REPORT
Fumagalli L. Department of Maternal-Infantile Sciences, Psychiatric Clinic, University of Sassari clinpsic@uniss.it

INTRODUCTION
We report the clinical case of a patient with treatment-resistant unipolar depression. The patient successfully responded to the adjustment of the treatment as a result of a suspected diagnosis of an underlying Bipolar Depression.

Anamnesis
V.G, 42 years old unmarried caucasian male, no children. Grieving the loss of the father at a young age. Debut of psychiatric disorder at age 21: OCD associated with Mild Mental Retardation. Unipolar Depression becomes chronic over time. Some episodes of irritable mood and verbal aggression associated with marked anxiety.

Significant comorbidities
Axis I: Obsessive Compulsive Disorder whose obsessions come in the form of continuous songs and chants and compulsions come as repetitive behaviors related to sexuality. Axis II: Mild Mental Retardation in association with Histrionic Personality traits. Axis III: Morbid Obesity (BMI of 40).

Diagnostic investigations
Performed the following diagnostic tests: Detailed anamnesis Information gathered from the family Assessment according to DSM-IV-TR

Instrumental investigations
The following scales are administered to the patient: Hamilton-Depression scale with a total score of 24; Beck Depression Inventory with a total score of 24; Hamilton-Anxiety scale with a total score of 24.

Pharmacological and non-pharmacological treatment

Past pharmacological treatments: SSRI (sertraline up to 200 mg/day, fluvoxamine up to 250 mg/day, paroxetine up to 60 mg/day, citlopram up to 40 mg/day); SNRI (venlafaxine up to 300 mg/day, duloxetine up to 120 mg/day); Tricyclic Antidepressant (clomipramine up to 200 mg/day); Antipsychotics (haloperidol up to 15 gtt/day, amisulpride up to 400 mg/day). Current pharmacological treatment (from 3 months): Escitalopram 10 mg/day, Aripiprazole 10 mg/day, Lorazepam 3 mg/day.

Results A Comparison
30

of the scores obtained with the HamiltonDepression scale, administered at t0 (time of introduction of the pharmacological therapy) and at t1 (current state).
t0 t1
25 20 15 10 5 0
HAMD Total Subscale Anxiety Subscale Maier Subscale Slowdown

of the scores obtained with the HamiltonAnxiety Scale, administered at the 1st, 4th, 8th and 12th week of the previous and current pharmacological treatment.
30 25 20 15 10 5 0 1st week 4th week 8th week 12th week
Current Therapy Previous Therapy

Results B Comparison

of the scores obtained with the Beck Depression Inv. scale, administered at the 1st, 4th, 8th and 12th week of the previous and current pharmacological treatment.
30 25 20 15 10 5 0 1st week 4t h week 8t h week 12t h week

Results C Comparison

Results D The table

shows the change of the clinical symptoms switching from the previous to the current therapy. Symptomatology Previous Current therapy therapy +++ + Depressed mood +++ + Anxiety + Anhedonia +++ + Vegetative symptoms ++ + Somatic symptoms ++ Sleep disorders ++ + Cognitive impairment + Disturbi della motricit

CONCLUSIONS
A lack of response to pharmacological treatment in a Unipolar Depression should raise the clinical suspicion of a misdiagnosis, with the possible presence of an underlying Bipolar Depression not properly diagnosed. Making an accurate diagnosis is therefore essential for appropriate treatment.