Elena Tomba

University of Bologna, Bolonia, Emilia-Romagna, Italy

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Publications (40)167.72 Total impact

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    ABSTRACT: A large body of research, documenting the impact of a family's functioning on health outcomes, highlights the importance of introducing the evaluation of patients' family dynamics into clinical judgment. The Family Assessment Device (FAD) is a self-report questionnaire designed to assess specific dimensions of family functioning. This qualitative systematic review, which follows PRISMA guidelines, aimed to identify the FAD's clinimetric properties and to report the incremental utility of its inclusion in clinical settings. A thorough literature search was performed, using both computerized and manual searches, yielding a total of 148 studies that were included in this review. The FAD has been extensively used in a variety of research contexts. In the majority of studies it was able to discriminate between clinical populations and controls and among groups of patients with different illnesses. The FAD also showed good test–retest and concurrent reliability, and modest sensitivity to change after treatment. FAD-dysfunctional family functioning was related to several patient clinical outcomes, including lower recovery rates and adherence to treatment, longer recovery time, poorer quality of life, and increased risk of relapse and drop-out. The present review demonstrates that the FAD is a suitable instrument for the evaluation of family functioning both in clinical and research settings.Una amplia bibliografía de investigación que documenta el efecto que tiene el funcionamiento de una familia en los resultados de salud, destaca la importancia de introducir la evaluación de la dinámica familiar de los pacientes en el juicio clínico. La escala de evaluación familiar (Family Assessment Device, FAD) es un cuestionario de autoevaluación diseñado para evaluar aspectos específicos del funcionamiento familiar. Esta revisión sistemática cualitativa, que sigue las pautas PRISMA, tuvo como fin identificar las propiedades clinimétricas de la escala de evaluación familiar e informar la utilidad incremental de su inclusión en entornos clínicos. Se realizó una búsqueda minuciosa de bibliografía, tanto computarizada como manual, de la cual se obtuvieron 148 estudios que se incluyeron en esta revisión. La escala de evaluación familiar se ha utilizado ampliamente en diversos contextos científicos. En la mayoría de los estudios pudo distinguir entre las poblaciones clínicas y los controles y entre grupos de pacientes con diferentes enfermedades. La escala de evaluación familiar también demostró una buena confiabilidad concurrente y de prueba-reprueba, y una modesta sensibilidad a los cambios después del tratamiento. El funcionamiento familiar disfuncional de la escala de evaluación familiar estuvo relacionado con varios resultados clínicos de los pacientes, por ejemplo, ritmos más lentos de recuperación y cumplimiento del tratamiento, mayor tiempo de recuperación, peor calidad de vida y mayor riesgo de recaída y abandono. La presente revisión demuestra que la escala de evaluación familiar es un instrumento adecuado para la evaluación del funcionamiento familiar tanto en entornos clínicos como científicos.有大量记载家庭功能对健康影响的研究强调了将患者家庭动态评估引入临床判断的重要性。家庭评估机制(FAD) 是一种自我报告的问卷,用来评估家庭功能的特定层面。本项定量系统审查根据PRISMA准则,致力于确定FAD的临床衡量尺度属性及报告将其纳入临床背景的增量实用性。通过使用计算机和手工搜索,我们进行了一次彻底的文献搜索,在本次回顾中共包括148项研究。FAD被广泛应用与多种研究背景下。在大多数研究中,它可以区分开临床人群和控制组,在患者群中区分开不同的病症。FAD还具有很好的同期可信度,对治疗后变化的适度敏感性。FAD功能紊乱的家庭功能与若干患者临床结果有关,包括更低的康复率,对治疗的依赖,更长的康复时间,更低的生活质量及增加复发和中途退出治疗的风险。本项审查表明FAD在临床和研究背景中都是合适的家庭功能评估工具。
    Family Process 08/2014; · 1.73 Impact Factor
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    ABSTRACT: Background: Demoralization has been described as a psychological state characterized by helplessness, hopelessness, a sense of failure and the inability to cope. Methods: We conducted a systematic review with qualitative data analysis following PRISMA criteria with the following aims: to review validated assessment instruments of the demoralization syndrome, report main findings regarding demoralization as measured by validated instruments that emerge in the literature, compare and report evidence for the clinical utility of the identified instruments. Utilizing the key word ‘demoralization’ in PubMed and PsycINFO databases, an electronic search was performed, supplemented by Web of Science and manual searches. Study selection criteria included the assessment of medical patients and use of instruments validated to assess demoralization. Seventy-four studies were selected. Results: Four instruments emerged in the literature. Main findings concern prevalence rates of demoralization, evidence of discriminant validity from major depression, factors associated with demoralization and evidence of clinical utility. The instruments vary in their definition, the populations they aim to assess, prevalence rates they estimate and their ability to discriminate between different conditions. Nonetheless, demoralization appears to be a distinctive psychological state characterized by helplessness, hopelessness, giving up and subjective incompetence. It is not limited to life-threatening diseases such as cancer, but may occur in any type of clinical situation. It is associated with stress and adverse health outcomes. Conclusions: Studies addressing the incremental value of demoralization in psychiatry and psychology are needed. However, demoralization appears to entail specific clinical features and may be a distinct condition from major depression.
    Psychological medicine. 07/2014;
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    ABSTRACT: Positive functioning is widely neglected in research on eating disorders (EDs). The aim of this exploratory study was to assess psychological well-being (PWB) in out-patients with ED and in controls. The authors assessed PWB in 245 out-patients with EDs [105 with bulimia nervosa (BN), 57 with anorexia nervosa (AN), and 83 with binge eating disorder (BED) who met DSM-IV-TR] and 60 controls. They tested whether PWB was associated with eating attitude test (EAT) scores and if such associations differed among ED groups while taking into account confounding variables. Significant differences between groups in all PWB scales were found. While individuals with BN reported significantly lower scores in all PWB dimensions than healthy controls, patients with BED scored significantly lower than controls in PWB autonomy, environmental mastery, and self-acceptance scales. Patients with AN showed similar scores to controls in all PWB dimensions, except for positive relationships and self-acceptance. In all ED groups, most PWB dimensions resulted significantly and negatively associated with EAT scales, except for AN where oral control was found to positively correlate with a high sense of purpose in life. All results were maintained even after adjusting for possible confounding variables. Patients with EDs reported an impairment in PWB. The paucity of PWB was not necessarily dependent on the presence of high levels of psychological distress and on the severity of the disorder. Such assessments may therefore yield a more comprehensive evaluation in this clinical population. © 2013 Wiley Periodicals, Inc. (Int J Eat Disord 2013;).
    International Journal of Eating Disorders 10/2013; · 3.03 Impact Factor
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    ABSTRACT: Background: Placebo-controlled trials showed that both benzodiazepines (BDZ) and antidepressant drugs (AD) are effective in treating anxiety disorders. However, in the last years a progressive shift in the prescribing pattern from BDZ to newer AD has taken place. The aim of this systematic review and meta-analysis is to analyze whether controlled comparisons support such a shift. Methods: CINHAL, the Cochrane Library, MEDLINE, PubMed and Web of Science were searched from inception up to December 2012. A total of 22 studies met the criteria for inclusion. They were mostly concerned with tricyclic antidepressants (TCA; 18/22) and involved different anxiety disorders. In order to reduce clinical heterogeneity, only the 10 investigations that dealt with the comparison between TCA and BDZ in panic disorder were submitted to meta-analysis, whereas the remaining papers were individually summarized and critically examined. Results: According to the systematic review, no consistent evidence emerged supporting the advantage of using TCA over BDZ in treating generalized anxiety disorder (GAD), complex phobias and mixed anxiety-depressive disorders. Indeed, BDZ showed fewer treatment withdrawals and adverse events than AD. In panic disorder with and without agoraphobia our meta-analysis found BDZ treatments more effective in reducing the number of panic attacks than TCA (risk ratio, RR = 1.13; 95% CI = 1.01-1.27). Furthermore, BDZ medications were significantly better tolerated than TCA drugs, causing less discontinuation (RR = 0.40; 95% CI = 0.20-0.57) and side effects (RR = 0.41; 95% CI = 0.34-0.50). As to newer AD, BDZ trials resulted in comparable or greater improvements and fewer adverse events in patients suffering from GAD or panic disorder. Conclusions: The change in the prescribing pattern favoring newer AD over BDZ in the treatment of anxiety disorders has occurred without supporting evidence. Indeed, the role and usefulness of BDZ need to be reappraised. © 2013 S. Karger AG, Basel.
    Psychotherapy and Psychosomatics 09/2013; 82(6):355-362. · 9.38 Impact Factor
  • Article: Reply.
    Per Bech, Elena Tomba
    Psychotherapy and Psychosomatics 06/2013; 82(4):259. · 9.38 Impact Factor
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    ABSTRACT: Background: The prevalence, characteristics and implications of excessive arousal-activation in children and adolescents treated with antidepressants for specific illnesses have not been systematically examined. Methods: We compared reports of antidepressant trials (n = 6,767 subjects) in juvenile depressive (n = 17) and anxiety disorders (n = 25) for consensus-based indications of psychopathological mood elevation or behavioral activation. Results: Rates of excessive arousal-activation during treatment with antidepressants were at least as high in juvenile anxiety (13.8%) as depressive (9.79%) disorders, and much lower with placebos (5.22 vs. 1.10%, respectively; both p < 0.0001). The antidepressant/placebo risk ratio for such reactions in paired comparisons was 3.50 (12.9/3.69%), and the meta-analytically pooled rate ratio was 1.7 (95% confidence interval: 1.2-2.2; both p ≤ 0.001). Overall rates for 'mania or hypomania', specifically, were 8.19% with and 0.17% without antidepressant treatment, with large drug/placebo risk ratios among depressive (10.4/0.45%) and anxiety (1.98/0.00%) disorder patients. Conclusions: Risks of excessive mood elevation during antidepressant treatment, including mania-hypomania, were much greater than with placebo, and similar in juvenile anxiety and depressive disorders. Excessive arousal-activation in children or adolescents treated with antidepressants for anxiety as well as depressive disorders calls for particular caution and monitoring for potential risk of future bipolar disorder.
    Psychotherapy and Psychosomatics 03/2013; 82(3):132-141. · 9.38 Impact Factor
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    ABSTRACT: Background and Objectives: There is increasing interest in the issue of demoralization, particularly in the setting of medical disease. The aim of this investigation was to use both DSM-IV comorbidity and the Diagnostic Criteria for Psychosomatic Research (DCPR) in order to characterize demoralization in the medically ill. Methods: 1700 patients were recruited from 8 medical centers in the Italian Health System and 1560 agreed to participate. They all underwent a cross-sectional assessment with DSM-IV and DCPR structured interviews. 373 patients (23.9%) received a diagnosis of demoralization. Data were submitted to cluster analysis. Results: Four clusters were identified: demoralization and comorbid depression; demoralization and comorbid somatoform/adjustment disorders; demoralization and comorbid anxiety; demoralization without any comorbid DSM disorder. The first cluster included 27.6% of the total sample and was characterized by the presence of DSM-IV mood disorders (mainly major depressive disorder). The second cluster had 18.2% of the cases and contained both DSM-IV somatoform (particularly, undifferentiated somatoform disorder and hypochondriasis) and adjustment disorders. In the third cluster (24.7%), DSM-IV anxiety disorders in comorbidity with demoralization were predominant (particularly, generalized anxiety disorder, agoraphobia, panic disorder and obsessive-compulsive disorder). The fourth cluster had 29.5% of the patients and was characterized by the absence of any DSM-IV comorbid disorder. Conclusions: The findings indicate the need of expanding clinical assessment in the medically ill to include the various manifestations of demoralization as encompassed by the DCPR. Subtyping demoralization may yield improved targets for psychosomatic research and treatment trials.
    European Journal of Psychiatry 03/2013; 27(1):7-17. · 0.46 Impact Factor
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    ABSTRACT: According to the biopsychosocial model, psychosocial and biological factors interact in a number of ways influencing onset and course of medical disease. In a longitudinal perspective, such factors may elicit different effects on health depending on their accumulation mechanisms and timing of exposure over the life course. These aspects have become particularly relevant in the field of chronic diseases such as chronic dermatological conditions, where complete healing is unlikely to occur. Two key concepts may aid understanding of chronic medical conditions in a more comprehensive manner. In the first place, the concept of allostatic load may represent the link between the cumulative effect of various challenging situations and the disease onset through the progressive 'wear and tear' induced by chronic exposure to fluctuating allostatic responses. In addition, the allostatic overload model emphasizes the fact that the cumulative interaction of stressors, psychological symptoms and impaired psychological well-being may constitute a danger to health. In the second place, the concept of cumulative life course impairment, which takes into account the multiple dimensions of chronic disease, underlines the fact that illness is only one of many recordable parameters which ultimately determine, through their mutual interaction, the 'life trajectory of individuals'. In a broader sense, both concepts of allostatic load and cumulative life course impairment allow more light to be shed on a new perspective on illness - the life course perspective - and on its interactions with psychological, social and environmental factors. This perspective may ultimately result not only in a substantial improvement of clinical care, but also in a different and long-lasting approach to interventions in chronic illness, with wide economic, political and social consequences whose entity has yet to be appreciated.
    Current problems in dermatology 01/2013; 44:17-32.
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    ABSTRACT: The standard randomized controlled trial design is still based on the acute disease model. This is in sharp contrast with the fact that the patient is likely to have experienced other treatments before, that may actually modify clinical course and responsiveness . The current standard of therapeutic trial in psychiatry is represented by the large, multi-center, controlled randomized trial with broad inclusion criteria, and little attention to other factors such as the clinical history of patients and comorbidity. The heterogeneous features of these patients would then affect the outcome of the trial. Conflicting results among randomized controlled trials can represent a spectrum of outcomes, based on different patient groups, more than bias or random variability. If a treatment is tested by a series of small trials with inclusion criteria for specific characteristics (including treatment history, subgroups and comorbidity), we may have a better knowledge of its indications and contraindications. Further, there is increasing need of expanding the content of customary clinical information, by including evaluation of variables such as stress, lifestyle, well-being, illness behavior and psychological symptoms. These joint strategies would actually constitute a paradigm shift in psychopharmacology and psychotherapy research.
    Progress in Neuro-Psychopharmacology and Biological Psychiatry 10/2012; · 3.55 Impact Factor
  • Elena Tomba, Per Bech
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    ABSTRACT: Background: Clinimetrics was introduced three decades ago to specify the domain of clinical markers in clinical medicine (indexes or rating scales). In this perspective, clinical validity is the platform for selecting the various indexes or rating scales (macro-analysis). Psychometric validation of these indexes or rating scales is the measuring aspect (micro-analysis). Methods: Clinical judgment analysis by experienced psychiatrists is included in the macro-analysis and the item response theory models are especially preferred in the micro-analysis when using the total score as a sufficient statistic. Results: Clinical assessment tools covering severity of illness scales, prognostic measures, issues of co-morbidity, longitudinal assessments, recovery, stressors, lifestyle, psychological well-being, and illness behavior have been identified. Conclusion: The constructive dialogue in clinimetrics between clinical judgment and psychometric validation procedures is outlined for generating developments of clinical practice in psychiatry.
    Psychotherapy and Psychosomatics 09/2012; 81(6):333-43. · 9.38 Impact Factor
  • Elena Tomba, Emanuela Offidani
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    ABSTRACT: No abstract available.
    Psychotherapy and Psychosomatics 09/2012; 81(6):378-379. · 9.38 Impact Factor
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    ABSTRACT: While there is an increasing recognition of the role of subthreshold symptomatology in bipolar disorder, little attention has been dedicated to its only formally acknowledged subtype, cyclothymic disorder. The aim of this investigation was to provide a controlled evaluation of DSM-IV cyclothymic disorder by using a broad assessment strategy geared to subclinical signs. Sixty-two patients who met the DSM-IV criteria for cyclothymic disorder and did not present comorbidity with other mood disorders, alcohol and drug abuse, and borderline personality disorder and 62 control subjects matched for sociodemographic variables were administered the Structured Interview for Diagnostic Criteria for Psychosomatic Research (DCPR), the Clinical Interview for Depression (CID) and the Mania Scale (MAS). In DSM-IV terms, there was an overlap with anxiety disorders in more than half of the cases. About 3 patients out of 4 were found to present with at least one DCPR syndrome (particularly demoralization and irritable mood). Cyclothymic patients displayed significantly higher levels of depressive and anxiety disturbances on the CID, with particular reference to reactivity to social environment. They also had significantly higher scores on the MAS. The study was cross-sectional and the sample, because of the exclusion criteria, may not be representative of the clinical populations in psychiatric settings. In our patients with cyclothymia, without comorbidity with major mood disorders, DSM-IV anxiety disorders, psychosomatic clinical syndromes (irritable mood, demoralization) and subclinical symptoms such as reactivity to social environment resulted to be more frequent than in controls. The use of a broad assessment strategy aimed at subclinical symptomatology may help identifying clinical phenomena that cut across the current definition of subthreshold forms of bipolar disorder.
    Journal of affective disorders 04/2012; 139(3):244-9. · 3.76 Impact Factor
  • Elena Tomba, Giovanni A Fava
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    ABSTRACT: The selection of treatment in depression should be filtered by clinical judgment, taking into consideration a number of clinical variables, such as characteristics and severity of depressive episode, co-occurring symptomatology and problems (not necessarily syndromes), medical comorbidities, and patient’s history with particular reference to treatment of previous episodes, if they occurred. Such information should be placed within what is actually available in the specific treatment setting and should be integrated with the patient’s preferences. In clinical practice, on the one end, clinical decisions may be affected by irrational factors (eg, exposure to massive doses of pharmaceutical propaganda or familiarity with a specific psychotherapy or medication). On the other end, psychiatrists often use sophisticated forms of clinical judgment that are suitable for clinical challenges but are not addressed by current research strategies. There is increasing awareness of the need of differentiating depression according to specific subtypes, yet clear-cut indications for these subdivisions are still missing. The role of biomarkers, despite many promising research strategies, is still far from offering reliable clinical guidance. In the meanwhile, there are important indications that come from clinical research. Treatment of depression may be conceptualized as integrated treatment of the various components of symptomatology, lifestyle, and social adjustment. An integrated treatment model, discussed in detail elsewhere, is realistic and practical, and not just idealistic. It may be frustrating to those who like oversimplified biological models; however, approaches that integrate clinimetrics, patient priorities, lifestyle issues, and clinical judgment are more in keeping with the complexity of clinical situations and the challenge of depression treatment.
    The Psychiatric clinics of North America 03/2012; 35(1):87-98. · 1.87 Impact Factor
  • G A Fava, E Tomba, N Sonino
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    ABSTRACT: 'Clinimetrics' is the term introduced by Alvan R. Feinstein in the early 1980s to indicate a domain concerned with indexes, rating scales and other expressions that are used to describe or measure symptoms, physical signs and other clinical phenomena. Clinimetrics has a set of rules that govern the structure of indexes, the choice of component variables, the evaluation of consistency, validity and responsiveness. This review illustrates how clinimetrics may help expanding the narrow range of information that is currently used in clinical science. It will focus on characteristics and types of clinimetric indexes and their current use. The clinimetric perspective provides an intellectual home for clinical judgment, whose implementation is likely to improve outcomes both in clinical research and practice.
    International Journal of Clinical Practice 01/2012; 66(1):11-5. · 2.43 Impact Factor
  • Elena Tomba
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    ABSTRACT: No abstract available.
    Psychotherapy and Psychosomatics 01/2012; 81(2):69-72. · 9.38 Impact Factor
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    Elena Tomba
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    ABSTRACT: Habits relevant to health include physical activities, diet, smoking, drinking and drug consumption. Despite the fact that benefits of modifying lifestyle are increasingly demonstrated in clinical and general populations, assessment of lifestyle and therapeutic lifestyle changes is neglected in practice. In this review, associations between unhealthy lifestyle and health outcomes are presented. Particular emphasis will be placed on description and discussion of the standardized assessment instruments and behavioral methods that could be used in clinical practice to measure lifestyles.
    Advances in psychosomatic medicine 01/2012; 32:72-96.
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    ABSTRACT: No abstract available.
    Psychotherapy and Psychosomatics 11/2011; 81(1):1-4. · 9.38 Impact Factor
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    ABSTRACT: The aim of this review was to examine the clinical process in psychiatry, with special reference to clinimetrics, a domain concerned with the measurement of clinical phenomena that do not find room in customary taxonomy. A MEDLINE search from inception to August 2010 was performed for English-language articles using the keywords clinical judgment, clinimetric, staging, comorbidity, sequential treatment, and subclinical symptoms in relation to psychiatric illness. It was supplemented by a manual search of the literature. Choice of assessment strategies was based on their established or potential incremental increase in clinical information compared to use of diagnostic criteria. Contributions were evaluated according to the principles of clinimetrics. Several innovative assessment strategies were identified: the use of diagnostic transfer stations with repeated assessments instead of diagnostic endpoints, subtyping versus integration of different diagnostic categories, staging methods, and broadening of clinical information through macroanalysis and microanalysis. The most representative examples were selected. Current assessment strategies in psychiatric research do not reflect the sophisticated thinking that underlies clinical decisions in practice. The clinimetric perspective provides an intellectual home for the reproduction and standardization of these clinical intuitions.
    The Journal of Clinical Psychiatry 08/2011; 73(2):177-84. · 5.81 Impact Factor
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    ABSTRACT: There is a lack of controlled studies of psychological treatment of cyclothymic disorder. The aim of this investigation was to examine the benefits of the sequential combination of cognitive behavioral therapy (CBT) and well-being therapy (WBT) compared to clinical management (CM) in DSM-IV cyclothymic disorder. Sixty-two patients with DSM-IV cyclothymic disorder were randomly assigned to CBT/WBT (n = 31) or CM (n = 31). Both CBT/WBT and CM consisted of ten 45-min sessions every other week. An independent blind evaluator assessed the patients before treatment, after therapy, and at 1- and 2-year follow-ups. The outcomes included total score of the change version of the Clinical Interview for Depression, and the Mania Scale. All analyses were performed on an intent-to-treat basis. Significant differences were found in all outcome measures, with greater improvements after treatment in the CBT/WBT group compared to the CM group. Therapeutic gains were maintained at 1- and 2-year follow-ups. A sequential combination of CBT and WBT, which addresses both polarities of mood swings and comorbid anxiety, was found to yield significant and persistent benefits in cyclothymic disorder.
    Psychotherapy and Psychosomatics 03/2011; 80(3):136-43. · 9.38 Impact Factor
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    ABSTRACT: Our objective was to investigate psychological correlates in a population with primary aldosteronism (PA) using methods found to be sensitive and reliable in psychosomatic research. Twenty-three PA patients (12 male, 11 female; mean age 50 ± 9 yr) were compared with 23 patients with essential hypertension (EH) (15 male, eight female; mean age 47 ± 8 yr) and 23 matched normotensive subjects. A modified version of the Structural Clinical Interview for DSM-IV, a shortened version of the structured interview for the Diagnostic Criteria for Psychosomatic Research, and two self-rating questionnaires, the Psychosocial Index and the Symptom Questionnaire, were administered. Twelve of 23 patients with PA (52.2%) suffered from an anxiety disorder compared with four of 23 with EH (17.4%) and one control (4.3%) (P < 0.001). Generalized anxiety disorder was more frequent in PA than in EH patients and controls (P < 0.05). As assessed by Diagnostic Criteria for Psychosomatic Research, irritable mood was more frequent in PA and EH compared with controls (P < 0.05) but did not differentiate PA from EH. According to Psychosocial Index results, patients with PA had higher levels of stress (P < 0.01) and psychological distress (P < 0.01) and lower level of well-being (P < 0.05) than controls. Compared with EH patients, PA patients had higher scores in stress subscale (P < 0.05). The Symptom Questionnaire showed higher levels of anxiety (P < 0.01), depression (P < 0.01) and somatization (P < 0.01) and lower physical well-being (P < 0.05) in PA than controls. A role of mineralocorticoid regulatory mechanisms in clinical situations concerned with anxiety and stress is suggested.
    The Journal of Clinical Endocrinology and Metabolism 03/2011; 96(6):E878-83. · 6.31 Impact Factor

Publication Stats

401 Citations
167.72 Total Impact Points


  • 2003–2014
    • University of Bologna
      • • Department of Psychology PSI
      • • Department of Experimental, Diagnostic and Specialty Medicine DIMES
      Bolonia, Emilia-Romagna, Italy
  • 2013
    • University of Copenhagen
      København, Capital Region, Denmark
  • 2007
    • University of Padova
      • Department of Statistical Sciences
      Padova, Veneto, Italy