- Email: [email protected]
P.2.d.028 Emotion dysregulation and bipolar I disorder
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P.2.d. Mood disorders and treatment − Bipolar disorders (clinical)
The frequency of the depressive episodes exerted the strongest influence on the probability that the depressive episode under scrutiny was bipolar: if the mean frequency grew by 1 episode/ year, the chances for underlying bipolar disorder rose 825.8 times. The other indices impacting the chance for actual bipolar disorder were onset of the disease before the age of 25; presence of evening brightening; severe impairment of concentration. However, high severity of somatic anxiety was in favour of unipolar depression. The model displayed high positive predictive value (PPV) − 90.7%, and negative predictive value (NPV) − 87.1%. Sensitivity and specificity were also high − 90.7% and 87.1%, respectively, with AUC of 94.4%. Conclusions: Depressed patients presenting with a history of frequent depressive episodes, onset of the first episode before the age of 25, mood brightening in the evening, more severe impairment of the concentration and less somatic anxiety are more likely to suffer from bipolar disorder. References [1] Marinova P., Hranov LG, 2014. A model to predict bipolarity from the first depressive episode Eur Neuropsychopharm, (Suppl.), S429. [2] Sheehan DV, Lecrubier Y, Sheehan KH, et al., 1998. The MiniInternational Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J. Clin. Psychiatry 59 (Suppl 20), 22−33. [3] Bowden CL, Singh V, Thompson P, et al., 2007. Development of the bipolar inventory of symptoms scale. Acta Psychiatr Scand 116: 189– 194.
P.2.d.027 Post-traumatic growth in caregivers of bipolar affective disorder patients and related factors N. Eradamlar1 ° , A.H. K¨uc¸ u¨ kt¨ufek¸ci1 , O.D. Balaban1 , K. Senya¸sar1 1 Bakirk¨oy Ruh ve Sinir Hastaliklari Hastanesi, Psychiatry, Istanbul, Turkey Aim: The aim of the present study is to investigate the presence of Posttraumatic Growth and the factors, which are defined as sociodemographic characteristics of patient and caregivers, clinical features of illness, depression and anxiety levels, burden, personality traits, coping ways, social support and religiosity of caregivers, predicted to be related to posttraumatic growth in the caregivers of the bipolar affective disorder patients. Method: 75 patients diagnosed as bipolar affective disorder according to the Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-1) and 75 relatives who give primary care to the patients were consecutively enrolled in the study. A clinical and socio-demographic data form was administered to the patients. Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Posttraumatic Growth Inventory (PTGI), Ways of Coping Inventory (WCI), Multidimensional Scale of Perceived Social Support (MSPSS), Basic Personality Traits Inventory (BPTI), Religiosity Scale (RS) were administered to the caregivers who were evaluated with SCID-1. Results: Moderate posttraumatic growth was determined in caregivers. There was no relationship between the posttraumatic growth and the socio-demographic like as gender, age, marital status, educational level, employment of patients and the clinical features like as duration of illness, number of episodes, the history of hospitalization and suicide. Posttraumatic growth levels of caregivers of the patients with aggressive behavior were found to be higher. It was found that female caregivers have higher posttraumatic growth levels rather than male caregivers. There
was no relationship between the posttraumatic growth and the socio-demographic features of caregivers like as age, marital status, educational level, employment, income level and duration of caregiving. Posttraumatic growth levels of caregivers who took care of another person were found to be lower. Posttraumatic growth levels of caregivers who have a psychiatric disorder were found to be lower. There was a negative correlation between the posttraumatic growth and the depression levels of caregivers. There was a negative correlation between the posttraumatic growth and the caregiver burden. There was a significant positive correlation between the posttraumatic growth and some personality traits like as agreeableness and the openness to new experiences. The positive correlation between the posttraumatic growth and problem-solving coping was found to be close to being statistically significant. Posttraumatic growth levels of the caregivers with higher social support were found to be higher. It was found that the intrinsic religiosity has positive effect on the posttraumatic growth. Conclusion: The result of the current study indicates that moderate posttraumatic growth develops in caregivers of bipolar affective disorder patients. Female gender, mental health status of caregiver, history of aggressive behavior, caregiving another person, some personality traits like agreeableness and the openness to new experiences, depression level, caregiver burden, social support and intrinsic religiosity are considered to be related factors with posttraumatic growth.
P.2.d.028 Emotion dysregulation and bipolar I disorder L. Yasmine1 ° , S. Ben Alaya1 , A. Hajri1 , U. Ouali1 , F. Nacef1 1 Razi hospital, Avicenne, Manouba, Tunisian Republic Objective: Individuals with bipolar disorder(BD) experience a wide range of emotional disturbances including mood symptoms, emotional lability and reactivity, irritability, anxiety and anger, suggesting the existence of inappropriate or inadequate emotion regulation during acute illness and inter-episode phase. Furthermore, individuals with BD experience this emotional dysregulation in their everyday lives,even during euthymia. The aim of our study was therefore to evaluate emotion dysregulation in clinically stabilized BD I patients, and to study the link between emotion dysregulation and clinical characteristics of BD I. Method: A cross sectional study was conducted at Razi Hospital between January and March 2015 that included patients diagnosed with BD I as defined by DSMIV-R. The consent process involved a detailed description of the study by a psychiatrist supplemented by written information summarizing the protocol and project for the subjects. We included patients with a stable outpatient status for at least 3 months (Hamilton Depression Scale (HAMD)10 and Young Mania Rating Scale(YMRS). All patients were evaluated with the Difficulties in Emotion Regulation Scale (DERS) which is a brief 36 items self-report questionnaire designed to assess multiple aspects of emotion dysregulation. The measure yields a total score as well as scores on subscales:Nonacceptance of Emotional Responses, Difficulties Engaging in Goal-Directed Behavior, Impulse Control Difficulties, Lack of Emotional Awareness, Limited Access to Emotion Regulation and Lack of Emotional Clarity. We selected key clinical variables identified in previous research as important characteristics of BD and indicators of course of illness including number of episodes, onset characteristics, manic versus depressive polarity at onset, psychotic features at onset),
P.2.d. Mood disorders and treatment − Bipolar disorders (clinical) rapid cycling, suicide attempts, substance misuse (abuse and/or dependence). SPSS 20 package was used for statistical analysis. Results: The sample consisted of 30 bipolar patients aged 21 to 77 years, of whom 30% were female and 70% were male. 40% were married and 60% were single. Average age of onset of the disease was 26.2 years. 46.7% of patients had a family history of psychiatric disorder. 83.7% of the sample presented with manic episodes with psychotic features. Emotion dysregulation was positively correlated to suicide attempts(p = 0.028),number of depressive episodes (p = 0.001), and total duration of the disease(p = 0.025). We found a positive correlation between impulse control difficulties and suicide attempts. There was no correlation between emotion dysregulation and age of onset, number of manic episodes, and social and occupational status. Conclusion: Our study supports precedent research suggesting an association between clinical features of bipolar disorder and emotion dysregulation. The results of our work show that emotion dysregulation seems to increase with the duration of the disease, and that emotion dysregulation has an impact on the severity of this mood disorder. For clinical researchers,the current study highlights the interest of using a self-report scale inlarge cohorts to investigate specific emotional subgroups according to the level of emotional reactivity. It may also allow us to investigate and better understand links between emotional disturbances and comorbidities or evolutionary patterns of the disease in specific sub-groups classified. References [1] Gross, J.J., & Munoz, R.F., 1995. Emotion regulation and mental health. Clinical Psychology. Science and Practice, 2, 151–164. [2] Bech, P., Rafaelsen, O.J., Kramp, P., Bolwig, T.G., 1978. The mania rating scale. Scale construction and inter-observer agreement. Neuropharmacology 17, 430–431. [3] Aldao A, Nolen-Hoeksema S, Schweizer S., 2010. Emotion-regulation strategies across psychopathology.a meta-analytic review. Clin Psychol Rev30, 217−37. [4] Butler, E.A., Gross, J.J., 2009. Emotion and emotion regulation. Integrating individual and social levels of analysis. EmotionReview, 1(1), 86−87. [5] Gratz KL, Roemer L., 2004. Multidimensional assessment of emotion regulation and dysregulation development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav Assess26, 41−54.
P.2.d.030 Clock genes associate with white matter integrity in depressed bipolar patients: a tract-based spatial statistics study I. Bollettini1 ° , E.M.T. Melloni1 , V. Aggio1 , S. Poletti1 , B. Vai1 , S. Dallaspezia1 , F. Benedetti1 1 Scientific Institute and University Vita-Salute San Raffaele, Clinical Neurosciences, Milan, Italy Background and Purpose of the study: Bipolar disorder (BD) is a progressive and disabling psychiatric condition associated with neurostructural changes and disruption of circadian rhythms. CLOCK and Period3 (PER3) genes are involved in the control system of circadian rhythms. A single nucleotide polymorphism in the 3’ flanking region of CLOCK (3111 T/C; rs1801260) is known to influence occurrence of insomnia, response to treatment of sleep complaints, and lifetime recurrence rate of illness episodes in patients affected by BD. A variable-number tandem-repeat polymorphism of PER3 (PER34/5) was found to influence age at onset in bipolar patients, and to influence cognitive performances in response to sleep loss in healthy subjects [1]. A growing body
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of literature suggests that bipolar symptomatology is associated with dysfunctions in white matter (WM) integrity [2]. Based on these data, we hypothesized that these two polymorphisms of the biological clock could be associated with WM microstructure integrity in bipolar patients. Methods: We studied the relationship between CLOCK and PER3 polymorphisms with WM integrity in a sample of 98 depressed bipolar patients. First we compared the DTI measures of patients carrying the mutant C allele and of T homozygotes for CLOCK gene. Then we analyzed differences in WM microstructure between the two homozygote groups for PER34 and PER35 alleles. We used whole brain tract-based spatial statistics in the WM skeleton with threshold-free cluster enhancement on the DTI measures: axial, radial, and mean diffusivity, and fractional anisotropy. We accounted for the effect of nuisance covariates which could influence WM integrity. Results: In regard to CLOCK gene, we found that, compared to T homozygotes, C carriers showed a widespread increase of mean diffusivity in several WM tracts, including superior and inferior longitudinal fasciculus, corpus callosum, uncinate fasciculus, medullary lamina of thalamus, and corona radiata. Additionally, PER34 homozygotes showed reduced fractional anisotropy and increased radial diffusivity compared to PER35 homozygotes in several WM tracts, including thalamic radiations, inferior longitudinal and fronto-occipital fasciculus, and internal capsule. Conclusions: Mean diffusivity measures the magnitude of water molecules diffusion and reflects the presence of boundaries to the free diffusion of water in each voxel, and correlate with membrane density and myelin integrity. Increased mean diffusivity indicates myelin degeneration. Radial diffusivity represents the water diffusivity perpendicular to the axonal fibres, reflecting the integrity of myelin sheaths, while fractional anisotropy is a scalar value which indicates the magnitude fraction of the diffusion tensor that is anisotropic, thus reflecting the structure of axonal cell membranes, myelin sheaths, and bundle coherence within the WM tracts. Therefore, our results highlight greater damages to myelin in rs1801260 C carriers, and in PER34 homozygotes. These findings suggest that CLOCK and PER3 genes could enhance the negative influence of BD on WM microstructure, with specific detriments resulting from effects on specific WM tracts contributing to the functional integrity of the brain and involving critical networks for bipolar symptomatology. References [1] Dallaspezia, S., Benedetti, F., 2011. Chronobiological therapy for mood disorders. Expert Rev Neurother 11, 961–970. [2] Benedetti, F., Bollettini, I., 2014. Recent findings on the role of white matter pathology in bipolar disorder. Harv Rev Psychiatry 22, 338–341.
P.2.d.031 Integrated mania management: an observational study at the rehabilitative mood disorder unit of San Raffaele hospital in Milan S. Brioschi1 ° , D. Delmonte2 , F. Cassulo3 , F. Fossati3 , B. Barbini3 , L. Franchini3 , C. Colombo4 1 Ospedale San Raffaele, Neuroscienze Cliniche, Milano, Italy; 2 Ospedale San raffaele, Clinical neurosciences, Milan, Italy; 3 Ospedale San Raffaele, Clinical Neurosciences, Milano, Italy; 4 University Vita Salute San Raffaele, Clinical Neurosciences, Milano, Italy Purpose of the study: Psychological treatment has become a wellestablished adjunct to pharmacotherapy for patients affected by
P.2.d. Mood disorders and treatment − Bipolar disorders (clinical)
The frequency of the depressive episodes exerted the strongest influence on the probability that the depressive episode under scrutiny was bipolar: if the mean frequency grew by 1 episode/ year, the chances for underlying bipolar disorder rose 825.8 times. The other indices impacting the chance for actual bipolar disorder were onset of the disease before the age of 25; presence of evening brightening; severe impairment of concentration. However, high severity of somatic anxiety was in favour of unipolar depression. The model displayed high positive predictive value (PPV) − 90.7%, and negative predictive value (NPV) − 87.1%. Sensitivity and specificity were also high − 90.7% and 87.1%, respectively, with AUC of 94.4%. Conclusions: Depressed patients presenting with a history of frequent depressive episodes, onset of the first episode before the age of 25, mood brightening in the evening, more severe impairment of the concentration and less somatic anxiety are more likely to suffer from bipolar disorder. References [1] Marinova P., Hranov LG, 2014. A model to predict bipolarity from the first depressive episode Eur Neuropsychopharm, (Suppl.), S429. [2] Sheehan DV, Lecrubier Y, Sheehan KH, et al., 1998. The MiniInternational Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J. Clin. Psychiatry 59 (Suppl 20), 22−33. [3] Bowden CL, Singh V, Thompson P, et al., 2007. Development of the bipolar inventory of symptoms scale. Acta Psychiatr Scand 116: 189– 194.
P.2.d.027 Post-traumatic growth in caregivers of bipolar affective disorder patients and related factors N. Eradamlar1 ° , A.H. K¨uc¸ u¨ kt¨ufek¸ci1 , O.D. Balaban1 , K. Senya¸sar1 1 Bakirk¨oy Ruh ve Sinir Hastaliklari Hastanesi, Psychiatry, Istanbul, Turkey Aim: The aim of the present study is to investigate the presence of Posttraumatic Growth and the factors, which are defined as sociodemographic characteristics of patient and caregivers, clinical features of illness, depression and anxiety levels, burden, personality traits, coping ways, social support and religiosity of caregivers, predicted to be related to posttraumatic growth in the caregivers of the bipolar affective disorder patients. Method: 75 patients diagnosed as bipolar affective disorder according to the Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-1) and 75 relatives who give primary care to the patients were consecutively enrolled in the study. A clinical and socio-demographic data form was administered to the patients. Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Posttraumatic Growth Inventory (PTGI), Ways of Coping Inventory (WCI), Multidimensional Scale of Perceived Social Support (MSPSS), Basic Personality Traits Inventory (BPTI), Religiosity Scale (RS) were administered to the caregivers who were evaluated with SCID-1. Results: Moderate posttraumatic growth was determined in caregivers. There was no relationship between the posttraumatic growth and the socio-demographic like as gender, age, marital status, educational level, employment of patients and the clinical features like as duration of illness, number of episodes, the history of hospitalization and suicide. Posttraumatic growth levels of caregivers of the patients with aggressive behavior were found to be higher. It was found that female caregivers have higher posttraumatic growth levels rather than male caregivers. There
was no relationship between the posttraumatic growth and the socio-demographic features of caregivers like as age, marital status, educational level, employment, income level and duration of caregiving. Posttraumatic growth levels of caregivers who took care of another person were found to be lower. Posttraumatic growth levels of caregivers who have a psychiatric disorder were found to be lower. There was a negative correlation between the posttraumatic growth and the depression levels of caregivers. There was a negative correlation between the posttraumatic growth and the caregiver burden. There was a significant positive correlation between the posttraumatic growth and some personality traits like as agreeableness and the openness to new experiences. The positive correlation between the posttraumatic growth and problem-solving coping was found to be close to being statistically significant. Posttraumatic growth levels of the caregivers with higher social support were found to be higher. It was found that the intrinsic religiosity has positive effect on the posttraumatic growth. Conclusion: The result of the current study indicates that moderate posttraumatic growth develops in caregivers of bipolar affective disorder patients. Female gender, mental health status of caregiver, history of aggressive behavior, caregiving another person, some personality traits like agreeableness and the openness to new experiences, depression level, caregiver burden, social support and intrinsic religiosity are considered to be related factors with posttraumatic growth.
P.2.d.028 Emotion dysregulation and bipolar I disorder L. Yasmine1 ° , S. Ben Alaya1 , A. Hajri1 , U. Ouali1 , F. Nacef1 1 Razi hospital, Avicenne, Manouba, Tunisian Republic Objective: Individuals with bipolar disorder(BD) experience a wide range of emotional disturbances including mood symptoms, emotional lability and reactivity, irritability, anxiety and anger, suggesting the existence of inappropriate or inadequate emotion regulation during acute illness and inter-episode phase. Furthermore, individuals with BD experience this emotional dysregulation in their everyday lives,even during euthymia. The aim of our study was therefore to evaluate emotion dysregulation in clinically stabilized BD I patients, and to study the link between emotion dysregulation and clinical characteristics of BD I. Method: A cross sectional study was conducted at Razi Hospital between January and March 2015 that included patients diagnosed with BD I as defined by DSMIV-R. The consent process involved a detailed description of the study by a psychiatrist supplemented by written information summarizing the protocol and project for the subjects. We included patients with a stable outpatient status for at least 3 months (Hamilton Depression Scale (HAMD)10 and Young Mania Rating Scale(YMRS). All patients were evaluated with the Difficulties in Emotion Regulation Scale (DERS) which is a brief 36 items self-report questionnaire designed to assess multiple aspects of emotion dysregulation. The measure yields a total score as well as scores on subscales:Nonacceptance of Emotional Responses, Difficulties Engaging in Goal-Directed Behavior, Impulse Control Difficulties, Lack of Emotional Awareness, Limited Access to Emotion Regulation and Lack of Emotional Clarity. We selected key clinical variables identified in previous research as important characteristics of BD and indicators of course of illness including number of episodes, onset characteristics, manic versus depressive polarity at onset, psychotic features at onset),
P.2.d. Mood disorders and treatment − Bipolar disorders (clinical) rapid cycling, suicide attempts, substance misuse (abuse and/or dependence). SPSS 20 package was used for statistical analysis. Results: The sample consisted of 30 bipolar patients aged 21 to 77 years, of whom 30% were female and 70% were male. 40% were married and 60% were single. Average age of onset of the disease was 26.2 years. 46.7% of patients had a family history of psychiatric disorder. 83.7% of the sample presented with manic episodes with psychotic features. Emotion dysregulation was positively correlated to suicide attempts(p = 0.028),number of depressive episodes (p = 0.001), and total duration of the disease(p = 0.025). We found a positive correlation between impulse control difficulties and suicide attempts. There was no correlation between emotion dysregulation and age of onset, number of manic episodes, and social and occupational status. Conclusion: Our study supports precedent research suggesting an association between clinical features of bipolar disorder and emotion dysregulation. The results of our work show that emotion dysregulation seems to increase with the duration of the disease, and that emotion dysregulation has an impact on the severity of this mood disorder. For clinical researchers,the current study highlights the interest of using a self-report scale inlarge cohorts to investigate specific emotional subgroups according to the level of emotional reactivity. It may also allow us to investigate and better understand links between emotional disturbances and comorbidities or evolutionary patterns of the disease in specific sub-groups classified. References [1] Gross, J.J., & Munoz, R.F., 1995. Emotion regulation and mental health. Clinical Psychology. Science and Practice, 2, 151–164. [2] Bech, P., Rafaelsen, O.J., Kramp, P., Bolwig, T.G., 1978. The mania rating scale. Scale construction and inter-observer agreement. Neuropharmacology 17, 430–431. [3] Aldao A, Nolen-Hoeksema S, Schweizer S., 2010. Emotion-regulation strategies across psychopathology.a meta-analytic review. Clin Psychol Rev30, 217−37. [4] Butler, E.A., Gross, J.J., 2009. Emotion and emotion regulation. Integrating individual and social levels of analysis. EmotionReview, 1(1), 86−87. [5] Gratz KL, Roemer L., 2004. Multidimensional assessment of emotion regulation and dysregulation development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. J Psychopathol Behav Assess26, 41−54.
P.2.d.030 Clock genes associate with white matter integrity in depressed bipolar patients: a tract-based spatial statistics study I. Bollettini1 ° , E.M.T. Melloni1 , V. Aggio1 , S. Poletti1 , B. Vai1 , S. Dallaspezia1 , F. Benedetti1 1 Scientific Institute and University Vita-Salute San Raffaele, Clinical Neurosciences, Milan, Italy Background and Purpose of the study: Bipolar disorder (BD) is a progressive and disabling psychiatric condition associated with neurostructural changes and disruption of circadian rhythms. CLOCK and Period3 (PER3) genes are involved in the control system of circadian rhythms. A single nucleotide polymorphism in the 3’ flanking region of CLOCK (3111 T/C; rs1801260) is known to influence occurrence of insomnia, response to treatment of sleep complaints, and lifetime recurrence rate of illness episodes in patients affected by BD. A variable-number tandem-repeat polymorphism of PER3 (PER34/5) was found to influence age at onset in bipolar patients, and to influence cognitive performances in response to sleep loss in healthy subjects [1]. A growing body
S427
of literature suggests that bipolar symptomatology is associated with dysfunctions in white matter (WM) integrity [2]. Based on these data, we hypothesized that these two polymorphisms of the biological clock could be associated with WM microstructure integrity in bipolar patients. Methods: We studied the relationship between CLOCK and PER3 polymorphisms with WM integrity in a sample of 98 depressed bipolar patients. First we compared the DTI measures of patients carrying the mutant C allele and of T homozygotes for CLOCK gene. Then we analyzed differences in WM microstructure between the two homozygote groups for PER34 and PER35 alleles. We used whole brain tract-based spatial statistics in the WM skeleton with threshold-free cluster enhancement on the DTI measures: axial, radial, and mean diffusivity, and fractional anisotropy. We accounted for the effect of nuisance covariates which could influence WM integrity. Results: In regard to CLOCK gene, we found that, compared to T homozygotes, C carriers showed a widespread increase of mean diffusivity in several WM tracts, including superior and inferior longitudinal fasciculus, corpus callosum, uncinate fasciculus, medullary lamina of thalamus, and corona radiata. Additionally, PER34 homozygotes showed reduced fractional anisotropy and increased radial diffusivity compared to PER35 homozygotes in several WM tracts, including thalamic radiations, inferior longitudinal and fronto-occipital fasciculus, and internal capsule. Conclusions: Mean diffusivity measures the magnitude of water molecules diffusion and reflects the presence of boundaries to the free diffusion of water in each voxel, and correlate with membrane density and myelin integrity. Increased mean diffusivity indicates myelin degeneration. Radial diffusivity represents the water diffusivity perpendicular to the axonal fibres, reflecting the integrity of myelin sheaths, while fractional anisotropy is a scalar value which indicates the magnitude fraction of the diffusion tensor that is anisotropic, thus reflecting the structure of axonal cell membranes, myelin sheaths, and bundle coherence within the WM tracts. Therefore, our results highlight greater damages to myelin in rs1801260 C carriers, and in PER34 homozygotes. These findings suggest that CLOCK and PER3 genes could enhance the negative influence of BD on WM microstructure, with specific detriments resulting from effects on specific WM tracts contributing to the functional integrity of the brain and involving critical networks for bipolar symptomatology. References [1] Dallaspezia, S., Benedetti, F., 2011. Chronobiological therapy for mood disorders. Expert Rev Neurother 11, 961–970. [2] Benedetti, F., Bollettini, I., 2014. Recent findings on the role of white matter pathology in bipolar disorder. Harv Rev Psychiatry 22, 338–341.
P.2.d.031 Integrated mania management: an observational study at the rehabilitative mood disorder unit of San Raffaele hospital in Milan S. Brioschi1 ° , D. Delmonte2 , F. Cassulo3 , F. Fossati3 , B. Barbini3 , L. Franchini3 , C. Colombo4 1 Ospedale San Raffaele, Neuroscienze Cliniche, Milano, Italy; 2 Ospedale San raffaele, Clinical neurosciences, Milan, Italy; 3 Ospedale San Raffaele, Clinical Neurosciences, Milano, Italy; 4 University Vita Salute San Raffaele, Clinical Neurosciences, Milano, Italy Purpose of the study: Psychological treatment has become a wellestablished adjunct to pharmacotherapy for patients affected by