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Elisa Torselli,1 Marcella Ottonello,2 Emilio Franceschina,1 Emanuele Palagi,1 Giorgio Bertolotti,3 Elena Fiabane2,4 1Miller Institute for Behavioral and Cognitive Therapy, Genoa, Italy; 2Department of Physical and Rehabilitation Medicine, ICS Maugeri Spa SB, Institute of Genoa Nervi, Genoa, Italy; 3Psychology Unit, ICS Maugeri SPA SB, IRCCS, Tradate, Italy; 4Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy Purpose: The aims of this pilot study were to examine cognitive factors (brooding and craving) together with positive/negative metacognitive beliefs about alcohol during a residential program for alcohol addiction and to explore relationships with psychological variables at discharge, with the scope of identifying predictive factors of psychological outcome and patients at greatest risk of relapse. Methods: Thirty patients underwent a brief semistructured interview on admission to a 28-day rehabilitation program for alcohol addiction, and completed at admission and discharge the following five self-report questionnaires: 1) brooding (Brooding subscale of Ruminative Response Scale [B-RRS]), 2) craving (Penn Alcohol Craving Scale [PACS]), 3) positive beliefs about alcohol use (Positive Alcohol Metacognitions Scale [PAMS]), 4) negative beliefs about alcohol use (Negative Alcohol Metacognitions Scale [NAMS]), and 5) the psychophysical state of health (Cognitive Behavioral Assessment – Outcome Evaluation [CBA-OE]). Results: Significant changes were found between admission and discharge in CBA-OE, B-RRS, and PACS. Brooding at admission was a significant predictor of post-treatment psychological variables of “anxiety”, “depression”, and “psychological distress”, whereas craving at admission was a good predictor of “perception of positive change” at discharge. Conclusion: Our results confirm the importance of brooding in mood regulation and its role in the development and maintenance of problem drinking. In addition, craving was negatively associated with the perception of positive change in the post-treatment outcomes and was a predictor of this psychological variable, which includes features related to the individual’s resilience and strength. The changes in metacognitive beliefs regarding alcohol use were not statistically significant, but we found a reduction in positive metacognitions and an increase in negative alcohol-related beliefs; future studies are needed to further explore this issue. Keywords: alcohol addiction, cognitive factors, metacognition, rehabilitation, craving, brooding

Silvana Rocchi,1 Claudio Ghidelli,2 Roberto Burro,3 Michele Vitacca,4 Simonetta Scalvini,5 Anna Maria Della Vedova,6 Gianmarco Roselli,7 Jean-Pierre Ramponi,8 Giorgio Bertolotti9 1Psychology Service, ICS Maugeri Spa SB, Institute of Lumezzane, 2Psychological Counselling Service, Università Cattolica del Sacro Cuore, Brescia, 3Department of Human Sciences, University of Verona, Verona, 4Respiratory Rehabilitation Division, 5Cardiac Rehabilitation Division, ICS Maugeri Spa SB, Institute of Lumezzane, 6Department of Clinical and Experimental Sciences, University of Brescia, 7Department of Mental Health, Spedali Civili, 8ICS Maugeri Spa SB, Institute of Lumezzane, Brescia, 9Psychology Unit, ICS Maugeri Spa SB, Institute of Tradate, Varese, Italy Background: Resilience focuses on strength under stress, in the context of adversity. Walsh’s theoretical model identifies relational processes that allow families to tackle and overcome critical situations, dividing them into three domains of family function. The aim of this study was to assess resilience in families of patients with a chronic disease by adapting and validating the Italian version of the Walsh Family Resilience Questionnaire (Walsh-IT). Patients and methods: An Italian adult sample of 421 participants (patients and relatives) was collected with the aim to assess the reliability and validity of the Walsh-IT. Concurrent validity was carried out by comparing this instrument with the Family Adaptability and Cohesion Evaluation Scale III (FACES III) administered at the same time as the Walsh-IT. Results: Reliability showed high correlation between repeated measurements. The alpha coefficient was 0.946. Both parallel analysis and minimum average partial criteria suggested that the best number of domains is equal to 3, explaining 50.4% of the total variance. Based on the results obtained from the Rasch analysis, items 10, 11, 16, 22, and 23 have been removed resulting in a short-form questionnaire (Walsh-IT-R) of 26 items with three domains: shared beliefs and support (SBS, α=0.928); family organization and interaction (FOI, α=0.863); and utilization of social resources (USR, α=0.567). The total score of the Walsh-IT-R was strongly correlated with the total score of FACES III Real Family Scale (r=0.68; p

Antonia Pierobon,1 Elisa Sini Bottelli,1 Laura Ranzini,1 Claudio Bruschi,2 Roberto Maestri,3 Giorgio Bertolotti,4 Marinella Sommaruga,5 Valeria Torlaschi,1 Simona Callegari,1 Anna Giardini1 1Psychology Unit, 2Department of Pulmonary Rehabilitation, 3Department of Biomedical Engineering, Istituti Clinici Scientifici Maugeri, IRCCS, Montescano, 4Psychology Unit, Istituti Clinici Scientifici Maugeri, IRCCS, Tratate, 5Clinical Psychology and Social Support Unit, Istituti Clinici Scientifici Maugeri, IRCCS, Camaldoli, Italy Abstract: In addition to clinical comorbidities, psychological and neuropsychological problems are frequent in COPD and may affect pulmonary rehabilitation delivery and outcome. The aims of the study were to describe a COPD population in a rehabilitative setting as regards the patients depressive symptoms, anxiety, mild cognitive impairment (MCI) and self-reported adherence and to analyze their relationships; to compare the COPD sample MCI scores with normative data; and to investigate which factors might predict adherence to prescribed physical exercise. This was a multicenter observational cross-sectional study. Of the 117 eligible stable COPD inpatients, 84 were enrolled according to Global initiative for chronic Obstructive Lung Disease (GOLD) criteria (mainly in Stage III–IV). The assessment included Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), anxiety, depression and self-reported pharmacological and nonpharmacological adherence. From the MMSE, 3.6% of patients were found to be impaired, whereas from the MoCA 9.5% had a likely MCI. Patients referred had mild-severe depression (46.7%), anxiety (40.5%), good pharmacological adherence (80.3%) and difficulties in following prescribed diet (24.1%) and exercise (51.8%); they struggled with disease acceptance (30.9%) and disease limitations acceptance (28.6%). Most of them received good family (89%) or social (53%) support. Nonpharmacological adherence, depression, anxiety and MCI showed significant relations with 6-minute walking test, body mass index (BMI) and GOLD. Depression was related to autonomous long-term oxygen therapy modifications, disease perception, family support and MCI. In the multivariate logistic regression analysis, higher BMI, higher depression and lower anxiety predicted lower adherence to exercise prescriptions (P=0.0004, odds ratio =0.796, 95% CI =0.701, 0.903; P=0.009, odds ratio =0.356, 95% CI =0.165, 0.770; and P=0.05, odds ratio =2.361, 95% CI =0.995, 5.627 respectively). In COPD patients, focusing on pharmacological and nonpharmacological adherence enhance the possibility of tailored pulmonary rehabilitation programs. Keywords: depression, anxiety, mild cognitive impairment, adherence, COPD, pulmonary rehabilitation

Davide Massidda,1 Ines Giorgi,2 Giulio Vidotto,3 Salvatore Tringali,4 Marcello Imbriani,4,5 Paola Baiardi,6 Giorgio Bertolotti7 1Giunti O.S. Organizzazioni Speciali, Firenze, Italy; 2Psychology Unit, ICS Maugeri, IRCCS, Pavia, Italy; 3Department of General Psychology, University of Padova, Padova, Italy; 4ICS Maugeri, IRCCS, UOOML, Pavia, Italy; 5Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy; 6Scientific Direction, ICS Maugeri, IRCCS, Pavia, Italy; 7Psychology Unit, ICS Maugeri, IRCCS, Tradate, Italy Introduction and objectives: A multidimensional self-report questionnaire to evaluate job-related stress factors is presented. The questionnaire, called Maugeri Stress Index – reduced form (MASI-R), aims to assess the impact of job strain on a team or on a single worker by considering four domains: wellness, resilience, perception of social support, and reactions to stressful situations. Material and methods: The reliability of a first longer version (47 items) of the questionnaire was evaluated by an internal consistency analysis and a confirmatory factor analysis. An item reduction procedure was implemented to obtain a short form of the instrument, and the psychometric properties of the resulting instrument were evaluated using the Rasch measurement model. Results: A total of 14 items from the initial pool were deleted because they were not productive for measurement. The analysis of internal consistency led to the exclusion of eight items, while the analysis performed using structural equation models led to the exclusion of another six items. According to the Rasch model, item properties and the reliability of the instruments appear good, especially for the scales for wellness and resilience. In contrast, the scales for perception of social support and negative coping styles show a lower internal consistency. Conclusions: The Maugeri Stress Index – reduced form provides a reliable and valid measure, useful for early identification of stress levels in workers or in a team along the eustress–vadistress continuum. Keywords: occupational stress, stress, psychometrics, questionnaire, validation

Michele Vitacca,1 Mara Paneroni,1 Paola Baiardi,2 Vito De Carolis,3 Elisabetta Zampogna,4 Stefano Belli,5 Mauro Carone,3 Antonio Spanevello,4,6 Bruno Balbi,5 Giorgio Bertolotti7 1Respiratory Rehabilitation Division, Salvatore Maugeri Foundation, IRCCS, Institute of Lumezzane, Brescia, 2Scientific Direction, Salvatore Maugeri Foundation, IRCCS, Institute of Pavia, Pavia, 3Respiratory Division, Salvatore Maugeri Foundation, IRCCS, Institute of Cassano delle Murge, Bari, 4Respiratory Division, Salvatore Maugeri Foundation, IRCCS, Institute of Tradate, Varese, 5Respiratory Division, Salvatore Maugeri Foundation, IRCCS, Institute of Veruno, Novara, 6Respiratory Diseases Unit, University of Insubria, Varese, 7Psychology Unit, Salvatore Maugeri Foundation, IRCCS, Institute of Tradate, Varese, Italy Background: As Barthel Index (BI) quantifies motor impairment but not breathlessness, the use of only this index could underestimate disability in chronic respiratory disease (CRD). To our knowledge, no study evaluates both motor and respiratory disability in CRD during activities of daily living (ADLs) simultaneously and with a unique tool. The objective of this study was to propose for patients with CRD an additional tool for dyspnea assessment during ADLs based on BI items named Barthel Index dyspnea.Methods: Comprehensibility, reliability, internal consistency, validity, responsiveness, and ability to differentiate between disease groups were assessed on 219 subjects through an observational study performed in an in-hospital rehabilitation setting.Results: Good comprehensibility, high reliability (interrater intraclass correlation coefficient was 0.93 [95% confidence interval 0.892–0.964] and test–retest intraclass correlation coefficient was 0.99 [95% confidence interval 0.983–0.994]), good internal consistency (Cronbach’s alpha 0.89), strong concurrent validity with 6 minute walking distance (Pearson r=–0.538, P

Mauro Carone,1 Michele Vitacca,2 Mara Paneroni,2 Paola Baiardi,3 Antonio Spanevello,4,5 Giorgio Bertolotti6 1Respiratory Division, ICS MAUGERI SPA SB, Institute of Cassano Murge (BA) IRCCS, Italy; 2Respiratory Rehabilitation Division, ICS MAUGERI SPA SB, Institute of Lumezzane (BS) IRCCS, Italy; 3Scientific Direction, ICS MAUGERI SPA SB, Institute of Pavia, IRCCS, Italy; 4Respiratory Rehabilitation Division, ICS MAUGERI SPA SB, Institute of Tradate (VA) IRCCS, Italy; 5Respiratory Diseases Unit, University of Insubria, Varese; 6Psychology Unit, ICS MAUGERI SPA SB, Institute of Tradate (VA) IRCCS, Italy We read the remarkable letter by Chuang.1 We thank him for his valid suggestions on our paper. Interestingly, he focused on the two dimensions of the Barthel index-dyspnea (BI-d), which was exactly our goal. As rehabilitators, our goal is to provide patients with physical therapy depending on their health status and to improve their respiratory function. We need to verify and demonstrate the efficacy and the outcomes of respiratory rehabilitation, supported by physical therapy. For these reasons, we need an assessment device that measures respiratory improvement during daily motor activities that should be monitored.The modified Barthel index2 is a well-consolidated and widely used instrument to assess the performance of a person in a predetermined and fixed set of activities of daily living (ADLs). By proposing BI-d,3 we aimed to develop a scale to measure how dyspnea precludes or reduces the same ADLs, with the ultimate goal of globally assessing the effectiveness of rehabilitation. Hence, an assessment method that measures the impact of dyspnea on activities monitored by a rehabilitation program is of utmost importance for rehabilitators. Large part of Chuang’s letter is based on the Chronic Respiratory Questionnaire-dyspnea (CRQ-d). The CRQ-d is a health-related quality of life (health status) questionnaire, with a dyspnea “domain”.4 However, for our purposes, the CRQ-d is too individualized as each subject selects five activity items – “the most important” – out of 26 listed activities. Therefore, each subject may choose different items from other subjects in the same study group. Due to this significant methodology, CRQ was standardized recently into a version that contains a total of only five items with a dyspnea domain, all of which have to be responded.5 View the original paper by Vitacca et alView the original letter by Chuang

Ines Giorgi,1 Marcella Ottonello,2,3 Giovanni Vittadini,4 Giorgio Bertolotti5 1Psychology Unit, Salvatore Maugeri Foundation, Clinica del Lavoro e della Riabilitazione, IRCCS, Pavia, 2Department of Physical & Rehabilitation Medicine, Salvatore Maugeri Foundation, Clinica del Lavoro e della Riabilitazione, IRCCS, Genoa, 3Department of Medicine, PhD Program in Advanced Sciences and Technologies in Rehabilitation Medicine and Sport, Università di Tor Vergata, Rome, 4Alcohol Rehabilitation Unit, Salvatore Maugeri Foundation, Clinica del Lavoro e della Riabilitazione, IRCCS, Pavia, 5Psychology Unit, Salvatore Maugeri Foundation, Clinica del Lavoro e della Riabilitazione, IRCCS, Tradate, Italy Background: Alcohol-dependent patients usually experience negative affects under the influence of alcohol, and these affective symptoms have been shown to decrease as a result of alcohol-withdrawal treatment. A recent cognitive–affective model suggests an interaction between drug motivation and affective symptoms. The aim of this multicenter study was to evaluate the psychological changes in subjects undergoing a residential rehabilitation program specifically designed for alcohol addiction, and to identify at discharge patients with greater affective symptoms and therefore more at risk of relapse.Materials and methods: The sample included 560 subjects (mean age 46.91±10.2 years) who completed 28-day rehabilitation programs for alcohol addiction, following a tailored routine characterized by short duration and high intensity of medical and psychotherapeutic treatment. The psychological clinical profiles of anxiety, depression, psychological distress, psychological well-being, and self-perception of a positive change were assessed using the Cognitive Behavioral Assessment – Outcome Evaluation questionnaire at the beginning and at the end of the program. The changes in the psychological variables of the questionnaire were identified and considered as outcome evaluation of the residential intervention. Moreover, differences in the psychological functioning between patients with different characteristics were investigated.Results: The score measured by the Cognitive Behavioral Assessment – Outcome Evaluation showed significant improvements in all the psychological characteristics assessed, and the profile at discharge was within the normal scores. Some significant differences were found in relation to specific characteristics of the sample, such as age, sex, level of education, type of intervention, and polysubstance use.Conclusion: This study shows the changes in psychological profile in subjects undergoing residential rehabilitation from alcohol and how this profile may permit identification of subjects requiring more psychosocial support after discharge. Keywords: alcohol dependence, alcohol withdrawal, outcome measure, residential rehabilitation, psychological support

Giorgio Bertolotti,1 Paolo Michielin,2 Giulio Vidotto,2 Ezio Sanavio,2 Gioia Bottesi,2 Ornella Bettinardi,3 Anna Maria Zotti4 1Psychology Unit, Salvatore Maugeri Foundation, IRCCS, Scientific Institute, Tradate, VA, 2Department of General Psychology, Padua University, Padova, 3Department of Mental Health and Addictive Behavior, AUSL Piacenza, Piacenza, 4Salvatore Maugeri Foundation, IRCCS, Scientific Institute, Veruno, NO, Italy Background: Cognitive behavioral assessment for outcome evaluation was developed to evaluate psychological treatment interventions, especially for counseling and psychotherapy. It is made up of 80 items and five scales: anxiety, well-being, perception of positive change, depression, and psychological distress. The aim of the study was to present the metric qualities and to show validity and reliability of the five constructs of the questionnaire both in nonclinical and clinical subjects. Methods: Four steps were completed to assess reliability and factor structure: criterion-related and concurrent validity, responsiveness, and convergent–divergent validity. A nonclinical group of 269 subjects was enrolled, as was a clinical group comprising 168 adults undergoing psychotherapy and psychological counseling provided by the Italian public health service. Results: Cronbach’s alphas were between 0.80 and 0.91 for the clinical sample and between 0.74 and 0.91 in the nonclinical one. We observed an excellent structural validity for the five interrelated dimensions. The clinical group showed higher scores in the anxiety, depression, and psychological distress scales, as well as lower scores in well-being and perception of positive change scales than those observed in the nonclinical group. Responsiveness was large for the anxiety, well-being, and depression scales; the psychological distress and perception of positive change scales showed a moderate effect. Conclusion: The questionnaire showed excellent psychometric properties, thus demonstrating that the questionnaire is a good evaluative instrument, with which to assess pre- and post-treatment outcomes. Keywords: outcome evaluation, well-being, treatment effects, patient perception, anxiety, depression, questionnaire