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Anhedonia is present in Parkinson's Disease (PD) as well as in addictive behaviors. Pathological Gambling (PG) and other Impulse Control Disorders (ICDs) have emerged as iatrogenic complications associated with dopamine replacement therapy. We studied 154 PD patients, divided into three groups: 11 with PG, 23 with other ICDs (compulsive buying, hypersexuality, binge eating), 120 without ICDs. All patients underwent a thorough clinical, neuropsychological and psychiatric evaluation. The PG-group, compared to the ICDs-group and PD-controls, reported a significantly higher incidence of anhedonia (45% vs. 9% vs. 14% respectively), higher Snaith–Hamilton Pleasure Scale (SHAPS) scores (2.0±1.3 vs. 1.0±1.1 vs. 1.0±1.2), higher levels of impulsivity traits as measured by the Barratt Impulsiveness Scale (70.0±10.6 vs. 64.8±11 vs. 60.9±9.3) and more severe frontal dysfunctions (Frontal Assessment Battery, FAB: 12.4±4.9 vs. 15.5±1.6 vs. 14.4±3). A model for PG (incorporating anhedonia, impulsivity levels and frontal impairment) is discussed in the context of the pathophysiology of addictive behaviors. The impairment of hedonic capacity, possibly resulting from an underlying neuropsychological dysfunction, might facilitate loss of control over reward-related behavior, thus favoring the shift towards predominantly habit-based compulsive behaviors.

The DSM-5 has modified the diagnostic criteria for gambling disorder, compared to the fourth edition of the manual; new diagnostic instruments are therefore needed. This study evaluated the psychometric characteristics of the Gambling Disorder Screening Questionnaire (GDSQ), a self-report questionnaire based on the DSM-IV and DSM-5 criteria for Gambling Disorder, measuring its validity, internal consistency, and submitting the questionnaire to a principal components analysis.71 patients from a gambling disorder outpatient clinic and 70 controls were evaluated with the GDSQ, the South Oaks Gambling Screen (SOGS), and a psychiatric interview.The test showed a good sensibility, specificity, internal consistency, concurrent validity with the SOGS. The exclusion of the “illegal acts” item, and the lowering of the cut-off score to four positive items, as suggested by the DSM-5 criteria, improved the test sensibility and internal consistency.The GDSQ can be considered a useful screening test for Gambling Disorder. Furthermore, this study confirms the improved diagnostic accuracy of the criteria listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, compared to the previous edition.

Chronic cocaine and heroin users display a variety of central nervous system (CNS) dysfunctions including impaired attention, learning, memory, reaction time, cognitive flexibility, impulse control and selective processing. These findings suggest that these drugs may alter normal brain functions and possibly cause neurotoxicity. Neurotrophins are a class of proteins that serve as survival factors for CNS neurons. In particular, nerve growth factor (NGF) plays an important role in the survival and function of cholinergic neurons while brain-derived neurotrophic factor (BDNF) is involved in synaptic plasticity and in the maintenance of midbrain dopaminergic and cholinergic neurons. In the present study, we measured by enzyme-linked immunosorbent assay (ELISA) the NGF and BDNF levels in serum of three groups of subjects: heroin-dependent patients, cocaine-dependent patients and healthy volunteers. Our goal was to identify possible change in serum neurotrophins in heroin and cocaine users. BDNF was decreased in heroin users whereas NGF was decreased in both heroin and cocaine users. These findings indicate that NGF and BDNF may play a role in the neurotoxicity and addiction induced by these drugs. In view of the neurotrophin hypothesis of schizophrenia the data also suggest that reduced level of neurotrophins may increase the risk of developing psychosis in drug users.

Although the pathophysiology of gambling is unknown, an involvement of midbrain dopaminergic pathway has been hypothesized. In this study, the association between brain-derived neurotrophic factor (BDNF) and pathological gambling was investigated. We measured BDNF serum levels in (1) video players (n = 10); (2) card players (n = 9); (3) mixed players (n = 21; both video and card players) and (4) age-matched controls (n = 18). Mixed players had increased BDNF serum levels as compared to controls and higher South Oaks Gambling Screen score as compared to card or video players. Thus, the data demonstrate that patients affected by severe pathological gambling show enhanced BDNF serum levels.

Bipolar disorders and addictions constitute reciprocal risk factors and are best considered under a unitary perspective. The concepts of allostasis and allostatic load may contribute to the understanding of the complex relationships between bipolar disorder and addictive behaviors. Allostasis entails the safeguarding of reward function stability by recruitment of changes in the reward and stress system neurocircuitry and it may help to elucidate neurobiological underpinnings of vulnerability to addiction in bipolar patients. Conceptualizing bipolar disorder as an illness involving the cumulative build-up of allostatic states, we hypothesize a progressive dysregulation of reward circuits clinically expressed as negative affective states (i.e. anhedonia). Such negative affective states may render bipolar disorder patients more vulnerable to drug addiction, fostering a very rapid transition from occasional drug use to addiction, through mechanisms of negative reinforcement. The resulting addictive behavior-related allostatic loads, in turn, may contribute to illness progression. This framework could have a heuristic value to enhance research on pathophysiology and treatment of bipolar disorder and addiction comorbidity.

Previous studies have shown that food ingestion is not capable of inhibiting the GHRH-induced GH release in anorexia nervosa, at variance with what is observed in normal subjects. Moreover, a cholinergic alteration has been hypothesized in this disorder. In a group of 24 anorectic patients in a stabilized phase of the illness, we tested, before and after a standard meal, the GH response to GHRH alone and after pre-treatment with pyridostigmine, an inhibitor of acetylcholinesterase, and, on a different day, with oxiracetam, which stimulates the central cholinergic neurones. The GH response to GHRH was significantly increased by both drugs in a fasting state. The postprandial response was not significantly modified by pyridostigmine nor by oxiracetam. Neither of these compounds was able to enhance the postprandial GH ‘paradoxical’ response to GHRH in anorectic patients. The lack of effect of both drugs postprandially also suggests a suppression of somatostatinergic activity.

IntroductionPathological gambling (PG) is currently included among Addictive Disorders (DSM-5). However, its phenomenology resembles features of Obsessive Compulsive Disorder. Several models of addiction conceptualize a progression from impulsivity to compulsivity transitioning from initial positive reinforcement motivations to later negative reinforcement and less pleasurable and automaticity mechanisms.Clinical presentationA 34-year-old male, since diagnosed with PG in 2013 and prescribed a group rehabilitation therapy, presented in 2015 complaining of intrusive thoughts and depression symptoms. During the psychiatric examination emerged: low mental concentration; dysphoria; hyporexia; irritability; insomnia; persistent ideas and excessive preoccupations to be betrayed by his girlfriend; and behaviours of hyper control on her life. He has been evaluated using MMPI-2 (obsessivity Tscore 70, depression Tscore 67) and BIS-11 (high score of non-planning impulsiveness).TreatmentIt appeared there was a shift from ego-syntonic novelty driven/impulsive behaviours focused primarily on gambling to ego-dystonic habit driven/compulsive behaviours focused on her girlfriend. He started an individual psychodynamic psychotherapy centred on dysfunctional beliefs and behavioural strategies for treating the compulsive features. As thought content was the most relevant aspect, he was prescribed olanzapine, not a SSRI (normally indicated for OCD), up to 10 mg/die. After a month obsessions and compulsions reduced, and he seemed to reach a good level of personal functioning, despite a rigid anankastic personality trait.ConclusionsAs the management of compulsive behaviours is complex, physician should better assess and recognize psychological personality aspect, collecting patients’ complete history, also testing them psychometrically, and paying more attention to an eventual treatment (both psychological and pharmacological).Disclosure of interestThe authors have not supplied their declaration of competing interest.

The alpha-2-adrenoceptor agonist clonidine is able to stimulate GHRH secretion directly or via beta-endorphin and, therefore, induces a GH release in normal subjects. This effect has been shown to be blunted in alcoholism during early abstinence, due to central alterations of adrenergic mechanisms. To evaluate pituitary responsiveness to direct stimulation with GHRH, we have studied the GH and PRL response to GHRH in 10 alcoholics during early abstinence. Our data indicate that the pituitary response to GHRH is intact in abstinent alcoholics, except in obese patients, who displayed a blunted GH response. GHRH did not increase PRL. The dissociation between clonidine and GHRH in GH stimulation could reveal a different neuroendocrine mechanism, in comparison with other psychiatric disorders (anorexia nervosa), in which such a dissociation is accompanied by a PRL response to GHRH.

Background and Aims Internet Gambling has become one of the most popular and lucrative internet business. The recent improvements in technology have changed betting habits with online poker, casinos, sport betting, bingo and lotteries. Liberalization of the Italian online gambling market gradually started in 2006, but only in 2010 foreign gambling operators have been able to launch online real money games. Our aim is to study the impulsivity and personality traits of an Italian sample of Pathological Gamblers (PG), showing the peculiarities of Online Gambling (OG). Methods 69 patients affected by PG, who accessed to our clinical center, were asked to fill the following questionnaires: - Temperament and Character Inventory-Revised (TCI-R) - Europ-ASI (Addiction Severity Index) - Barratt Impulsiveness Scale (BIS-11) Results we found significant statistical correlations between OG and: younger age (p Conclusions internet gamblers’ young age could explain the correlations between OG and higher scores in NS1, HA2 and ST3, and consequently risky behaviours and less spiritual believes/acceptance. Higher scores in Persistence indicate perseverance in spite of fatigue or frustration. Cloninger's research found that Persistence, like the other temperament traits, is highly heritable.

Trazodone is a non-tricyclic antidepressant drug with specific antagonistic activities at 5-HT(2) and alpha-1 adrenoceptors. We test the efficacy of trazodone (T) compared with clonidine (C) in rapid opiate detoxification (ROD) from methadone after reduction to a daily maintenance dose

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.

Aims There is substantial evidence indicating that pharmacological treatments targeting glutamatergic transmission are of potential utility in the treatment of drug addiction. The aim of this study was to evaluate the long-term outcome of glutamatergic treatments in patients with pathological gambling. Methods Fifteen patients fulfilling criteria for pathological gambling and receiving drugs with effects on glutamatergic transmission (amantadine, N-acetylcysteine, gabapentin, pregabalin and topiramate) were enrolled. Gambling craving (Gambling Symptom Assessment Scale, G-SAS, and visual analogue scale, VAS) and relapse (Gambling Timeline Follow Back, G-TLFB) rating scales were administered before and after treatment (1, 3, 6 months follow-up). Results Gambling craving and behavior were significantly reduced (p Discussion Our results are discussed in the context of the glutamatergic hypothesis of addiction. Our data seem to confirm the utility of targeting the glutamatergic system for the treatment of PG, in particular by acting on craving and increasing treatment retention. In particular, glutamatergic medications may offer some advantages in preventing relapse.

Introduction Frequent and increasing relations among psychiatric and substance dependence disorders, have made, to date, more complex the treatment of this dependence, especially when the patient is facing the difficult task of maintaining abstinence, which requires a work of self-awareness, motivation to change and active modification of dysfunctional lifestyles. Objectives Our study has the aim to detect patients’ changes in personality between the beginning of the rehabilitative therapy and its end, trying to get information on aspects of addiction on which the treatment affects the most. Methods Our sample was formed by 153 patients, recruited at the Department of Psychiatry of Gemelli General Hospital, who were subjected to an integrated approach of treatment, both pharmacological and rehabilitative group-therapy, according to Minnesota rehabilitation model, that considers addiction as a bio-psycho-social problem. Patients, after a first psychiatric evaluation, were asked to fill out two psychometric tests, the SymptomCheckList-90 R and the Structural Clinical Interview for DSM-IV, in two times, at the first meeting and at the last one, after 20 meetings of group therapy. Results At the end of the group therapy 39 patients dropped-out, 114 patients had a significant improvement in depressive symptoms (DEP item), greater responsibility perseverance and attention in their activities and habitual contexts (GSI, DIS, W/S items), as well as better management of compulsion and impulsivity (OC item) and a lower sense of inferiority, inadequacy and discomfort in interpersonal relationships (PAR, ANX, IS, SOC. A., PSY. A. items).

Introduction Different questionnaires were formulated in order to assess the severity of gambling. The most used questionnaire is the South Oaks Gambling Screen (SOGS), based on DSM-III criteria for gambling, even though it has poor specificity, because overestimates the prevalence of the disorder when used in general population. Objectives Try to overcome SOGS limits using a questionnaire based on DSM-IV criteria for gambling. Aims Validate the questionnaire based on DSM-IV criteria, using as gold standard the clinical interview developed through the SOGS. Methods The sample used is formed by 71 subjects, 58 men (81.7%) and 13 women (18.3%), recruited from the Psychiatric Department of Gemelli General Hospital in Rome, who were asked to fill out both questionnaires. Results The sensitivity of our questionnaire was 93% (compared to 100% in the SOGS); the specificity was 100% (97.1% in the SOGS). False negatives were 7%, while they were absent in the SOGS ; false positives were absent in the DSM-IV questionnaire, while they were 2.9% in the SOGS. We also determined the prevalence of each item of DSM-IV questionnaire in all gamblers identified (66 subjects): the most relevant item was “chasing one's losses”(item6), instead the least one was “committing illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling”(item8). Conclusions Our data confirm the greater specificity of the questionnaire of DSM-IV criteria for gambling compared to the SOGS. We suggest its use for the identification of gamblers in a sample formed by general population.

Introduction Pathological gambling (PG) disorder occurs when a person gambles repetitively despite severe negative effects on important aspects of life. PG tends to be a heterogonous disorder in which patients differ with respect to type and intensity of gambling behavior, psychiatric comorbidity, family history, age at onset and gender. Gamblers may accordingly be classified into three subtypes: the “impulsive”, “obsessive-compulsive” and “addicted” subtypes. Aims to characterize a sample of Italian PG pathological gamblers and assess the prevalence of the various gambling subtypes in this population. Methods 52 outpatients (44 men, 9 women), diagnosed with PG according to DSM IV-TR and SOGS criteria, were administered the Dannon Ainhold Gambling Scale (DAGS), which assesses the presence of the disorder and is useful for patient subtyping. Results 37 gamblers enrolled in our study played one specific kind of game, while 15 played multiple games. 30 patients played slot machines, 18 sport betting, 11 casino and card games, 14 bingo and scratch cards. According to DAGS, 5 (9,6%) patients belonged to the “addicted” subtype, 4 (7,7%) to the “obsessive-compulsive” subtype and 9 (17,3%) to the “impulsive” subtype. 15 (28,8%) gamblers were classified as “addicted-impulsive” subtype, 10 (19,2%) as “addicted-obsessive-impulsive” subtype, while 9 (17,3%) did not belong to any specific subtype though they displayed a tendency for one of the subtypes. Conclusion DAGS allows to identify three major subtypes of gamblers and also considers possible combinations between the different subtypes. An evaluation of these aspects could be useful in treatment options based on patient subtype.

Introduction Pathological gambling refers to the uncontrollable impulse to gamble, irrespective of the interference the behaviour has on the individual's life. It often results in disrupted relationships, financial problems, criminal behaviour and yet the individual is unable to refrain. Aims Our aim is to evaluate the relationship among impulsivity traits, personality assessment and psychiatric comorbidity in a sample of pathological gamblers. Methods 78 pathological gamblers were evaluated with the following instruments: MINI to evaluate psychiatric comorbidity; TCI to evaluate personality traits, and BIS-11 to evaluate impulsivity. Pathological gambling was assessed with DSM-IV-TR criteria. Results In our sample we found an average score of BIS-11 (66,9) slightly higher than the score of the general population (63,8). The scores of TCI, compared with the mean scores of the general population, differ significantly with regard to NS, RD, C, ST. As to MINI, it reveals a significant prevalence of Major Depressive Episode, Dysthymia, GAD, and risk of suicide. We identified two groups at high and low impulsivity and we conducted an analysis in relation to personality traits measured by TCI and incidence of psychiatric comorbidity measured by the MINI. The group with high impulsivity was associated with significantly higher scores of NS and HA, and lower RD and SD. Also in this group there was a higher incidence of Major Depressive Episode and GAD. Conclusions The analysis allows to identify the impulsive trait as a discriminating factor of two different types of players in relation to personality characteristics and psychiatric comorbidity.

IntroductionPsychiatrists play an important role as members of the bariatric surgery team. A preoperative psychiatric evaluation is considered as part of a mandatory workup before approving surgery.AimsThis evaluation focuses on the identification of any pre-existing psychiatric disorders among candidates for TOGa[1], a new experimental technique of bariatric surgery, and their correlations with post surgical weight loss.Method45 obese patients underwent a psychiatric interview and several psycho diagnostic questionnaires (SCL-90; HAM-D; HAM-A; EDI; TAS).A follow-up was set each 3 months.ResultsWe found that 34.1% of surgery candidates had a current diagnosis of depression; the majority showed anxiety symptoms. We also documented dissatisfaction about body shape, desire of slimness, fear of maturity, perfectionism, bulimia and binge eating disorder. Other frequent psychiatric symptoms were somatization, sensitivity, obsession and compulsion. After 3 months from surgery we found that the best weight loss was associated to low score in HAM-A, high score in hanger-hostility item (SCL-90) and low score in sensitiveness item (SCL-90).ConclusionThe diagnosis of a psychiatric pathology during the pre-surgical evaluation can be considered a predictive negative factor for the outcome of the surgery. The predictive positive factors are firstly the nonexistence of psychiatric symptoms, secondly the high score in sensitiveness-insight item (SCL-90) and the high score in the ability to express feelings. [1] (TransOral Gastroplasty)

Erratum to “Correlates of symptoms of depression and anxiety in chronic hemodialysis patients” [General Hospital Psychiatry 32 (2010) 125–131] Maurizio Bossola, M.D.⁎, Claudia Ciciarelli, M.D., Enrico Di Stasio, M.D., Gian Luigi Conte, M.D., Carlo Vulpio, M.D., Giovanna Luciani, M.D., Luigi Tazza, M.D. Servizio Emodialisi, Istituto di Clinica Chirurgica, Universita Cattolica del Sacro Cuore, 8-00168 Rome, Italy Istituto di Psichiatria, Universita Cattolica del Sacro Cuore, 8-00168 Rome, Italy Istituto di Chimica Clinica, Universita Cattolica del Sacro Cuore, 8-00168 Rome, Italy

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.