Intense Psychological Distress Research Articles

State-of-the-Art Review: Evaluation and Management of Delusional Infestation.

Delusional infestation is a condition encountered frequently by healthcare professionals across a variety of specialties in which patients have a fixed, false belief that they are infested with living creatures, such as bugs, parasites, worms, or mites, or nonliving objects, such as fibers. Delusional infestation can be debilitating for patients, who not only present with intense psychological distress and physical discomfort but are also at risk of developing numerous dermatological and psychiatric complications. This condition poses unique diagnostic challenges, as these symptoms can occur secondary to many metabolic or infectious causes, as well as unique treatment challenges, with patients frequently refusing psychiatric care and consequently seeking evaluation by other healthcare professionals. In this review, we aim to use existing literature to provide clinicians in infectious diseases or other specialties with sufficient clinical context and treatment guidance for the appropriate management of delusional infestation.

A mixed-method study to develop and evaluate a structured therapeutic communication module on psychological distress and perceived needs among caregivers of critically ill patients in Critical Care Units

Aims and objectivesTo develop and evaluate the effectiveness of a structured therapeutic communication module on psychological distress and perceived needs among caregivers of critically ill patients. BackgroundCaregivers of critically ill patients experience intense psychological distress, and their needs often go unexpressed or unidentified. Structured therapeutic communication enables nurses to explore and fulfill these needs. MethodA mixed-method study was conducted among 30 caregivers of critically ill patients. During phase one, a qualitative interview was conducted, and a structured therapeutic communication module was developed based on Hildegard Peplau's Interpersonal Relations Theory. In the second phase, one group pre-test and post-test design was adopted. The Hospital Anxiety and Depression Scale (HADS) and a Semi-structured interview schedule were used to assess psychological distress and perceived needs, respectively. ResultsHalf of (50 %) the caregivers reported a high level of anxiety before intervention, with a mean of 11.30 (SD: 4.0), and 66.7 % of them had a high level of depression, with a mean of 12.03 (SD: 0.08). There was a statistically significant difference in anxiety (CI: 0.451–2.016) and depression (CI: 0.261–1.538) before and after the intervention. The qualitative analysis revealed unmet needs perceived by caregivers. ConclusionUsing a structured therapeutic communication module helps nurses to alleviate the psychological distress experienced by caregivers of CCU patients. Relevance to clinical practiceNurses need to be sensitive to the unexpressed needs of caregivers of critically ill patients. The structured therapeutic communication modules can be integrated into routine nursing care practice to ensure family-centered care.

Consumer values, perspectives and experiences of psychological health when living with dialysis at home: An in-depth interview study.

People treated with home dialysis report social and emotional isolation, fear of catastrophic events and concern about being a burden. There is a paucity of research exploring psychological well-being among consumers dialysing at home. We aimed to explore the psychological health issues related to home dialysis, and how these issues may impact on sustaining home-based treatment. We conducted a qualitative interview study with 36 consumers. We included patients with experience of home dialysis and caregivers. Thirteen participants had experienced peritoneal dialysis, seven home haemodialysis, seven had experienced both and nine caregivers. Data were analysed inductively to generate themes and a conceptual framework. We identified four themes and subthemes: overwhelming isolation and disconnection (devastating isolation of home dialysis; abandoned from support; escalating anxiety; compounding impact of feeling like a burden); importance of support systems (impact on relationships; need for emotional support; reassurance through shared experiences; valuing trustworthy and committed clinicians); burden of distress (individualised feelings of low mood; grappling with stigma surrounding diagnosis; contemplating treatment withdrawal and suicide); seeking mental health support (normalising mental health support as a distinct entity in dialysis care; overcoming barriers to seeking mental health support; additional tools for mental health support and connection). Consumers may experience intense psychological distress during home-based dialysis care. Increasing clinician and health services literacy about the management of psychological impacts of home-based dialysis may improve consumer safety, quality of life and sustainability of home treatment.

Translation, adaptation, and initial evaluation of a guided self-help intervention to reduce psychological distress among nurses during COVID-19 in China.

This study aimed to reduce the unprecedented and intense psychological distress that nurses were forced to experience during the COVID-19 pandemic. A Chinese version of the World Health Organization's Self-Help Plus (SH+) intervention guide was adapted and tested among nurses. The objective of this study was to translate and adapt the SH+ guideline into the Chinese version and to test its feasibility in reducing psychological distress among nurses during COVID-19. A staged approach comprising translation, adaptations, initial evaluation by pilot implementation, and a qualitative process evaluation was conducted in two hospitals in Xi'an, China. The translation of the Chinese version was authorized by the World Health Organization. We adapted SH+ for use among clinical nurses working during the pandemic in China through a qualitative process evaluation, which was guided by the descriptive phenomenological study design. The outcomes of the pilot included psychological distress, psychological flexibility, depressive and anxiety symptoms, post-traumatic stress disorder (PTSD) symptoms, and subjective psychological wellbeing, which were assessed using the Kessler 6 symptom checklist, the Comprehensive Assessment of ACT Process (CompACT), the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder scale (GAD-7), the PTSD Checklist-Civilian Version (PCL-C), and the Index of Wellbeing (IWB), respectively. The SH+ materials, including audio-recorded sessions and an accompanying illustrated manual, were translated into Chinese and adapted in line with feedback from the nurses. An uncontrolled pilot study (n = 28) for 5 weeks showed a statistically significant reduction of psychological distress (mean difference in Kessler 6 score, -2.74; 95% CI [-3.71, -1.78]; p < 0.001). We also found improvements in psychological flexibility (mean difference in CompACT score, 6.89; 95% CI [-12.35, -4.47]; p < 0.001), subjective psychological wellbeing (mean difference in IWB score, 0.86; 95% CI [0.07, 1.65]; p < 0.05), and depressive symptoms (mean difference in PHQ-9 score, -1.52; 95% CI [-2.78, -0.26]; p < 0.05). The process evaluation showed that nurses found the SH+ program very useful but difficult to adhere to. We found that the translated Chinese version of SH+ was applicable and feasible in the Chinese cultural context. There was a potential effect of adapted SH + in reducing nurses' psychological distress during COVID-19 and suggested the value of exploring strategies to increase adherence to the program.

A qualitative study of nursing practitioners' experiences with COVID-19 patients dying alone in Greece.

In Greece, there is still limited research on death in isolation due to COVID-19. This deserves attention because of the recent financial crisis, which profoundly impacted public health, and the high relevance of the Hippocratic tradition to the moral values of clinical practice. A prospective qualitative study using in-depth interviews with 15 frontline nursing practitioners working in a COVID-19 ward or intensive care unit (ICU) was conducted from July 2021 to December 2021. The inability of family members to say a final goodbye before, during, or after death by performing proper mourning rituals is extremely inhuman and profoundly impacts the mental health status of patients, family members, and nursing practitioners. Patients and their family members strongly desire to see each other. Epidemiology, liability, and proper nursing performance emerged as reasons for the enforced strict visitation restrictions. Participants emphasized that visitations should be allowed on an individual basis and highlighted the need for the effective use of remote communication technology, which, however, does not substitute for in-person contact. Importantly, physicians allowed "clandestine" visits on an individual basis. Nursing practitioners had a strong empathic attitude toward both patients and their families, and a strong willingness to provide holistic care and pay respect to dead bodies. However, they also experienced moral distress. Witnessing heartbreaking scenes with patients and/or their families causes nursing practitioners to experience intense psychological distress, which affects their family life rather than nursing performance. Ultimately, there was a shift from a patient-centered care model to a population-centered care model. Furthermore, we identified a range of policy- and culture-related factors that exaggerate the negative consequences of dying alone of COVID-19. These results reinforce the existing literature on several fronts. However, we identified some nuances related to political decisions and, most importantly, convictions that are deeply rooted in Greek culture. These findings are of great importance in planning tailored interventions to mitigate the problem of interest and have implications for other similar national contexts.

Sociocultural Moderators of Emotion Regulation in Family Members of the Critically Ill.

Coping with a loved one's critical illness as a surrogate decision-maker (SDM) elicits intense psychological distress. Emotion regulation (ER) may mitigate psychological distress. However, ER tendencies and their effects on psychological distress vary by racial and gender identity, which can inform the tailoring of ER-focused interventions. For this study, we examined between-group differences and the moderating effects of race and gender on ER (reappraisal and suppression) and psychological distress. We recruited 274 SDMs from a Midwestern academic medical center. Men reported a greater tendency to use suppression than women, and SDMs identifying as non-White reported a greater tendency to use reappraisal and suppression. Reappraisal resulted in greater psychological distress for non-White men and less psychological distress for White women. Incorporating tailored ER skill building into supportive interventions may improve the short- and long-term psychological well-being of SDMs, which may improve their ability to make value-concordant decisions and fulfill other informal caregiving responsibilities.

Sleep disturbance in adult dermatologic patients: A cross-sectional study on prevalence, burden, and associated factors

Sleep disturbance remains insufficiently characterized in many dermatoses. To investigate the prevalence, burden, and factors associated with sleep disturbance in dermatologic patients. We recruited 800 patients and recorded pruritus characteristics and sociodemographic and clinical parameters. Validated questionnaires were used to assess sleep disturbance, psychological distress, health-related quality of life, and work productivity. Two thirds of patients met criteria of poor sleep, which was associated with psychological distress, diminished health-related quality of life, and lost work productivity. Patients with average and maximum pruritus on the visual analog scale exceeding 5 and 6.5 points, respectively, were at high risk of suffering pruritus-related sleep disturbance. Overall pruritus intensity and its nocturnal exacerbation contributed independently to sleep disturbance. Psychological distress was of even higher impact on sleep than pruritus and almost a third of the relationship between pruritus intensity and sleep was mediated by psychological distress. Sleep disturbance is prevalent in dermatologic patients and constitutes a considerable burden. Dermatologic patients with intense pruritus and psychological distress should be examined for sleep disorders. Adequate antipruritic therapy and complementary psychotherapy in affected patients may help them regain restorative sleep.

Emotional impact of clinical practice in Burns Unit among nursing students: a qualitative study.

Background and aim of the work.In Burns Units, the long professional relationship with patients suffering from intense physical pain and psychological distress, which cannot be completely resolved or minimized, exposes nurses to very intense emotions and stressful experiences. Learning to care for patients with such medical conditions can arouse many emotions also in nursing students, that can be both positive and negative.The goal of this study was to describe the emotional impact experienced by nursing students in a Italian Burns Unit.Methods.A qualitative research was implemented among 16 undergraduate nursing students, before and after clinical practice in a Burns Unit, through a semi-structured interview.Results.Strong and conflicting emotions from nursing students were reported in the preliminary stage of the internship. Their enthusiasm and curiosity for a new opportunity countered their fear and anxiety of not feeling able to deal with the clinical situation. The internship experience ranged from emotions of joy at the healing of patients to impotence and frustration at not being able to alleviate intense and lasting suffering. All students reported that the internship was experienced as an important opportunity for personal and professional growth.Conclusions.In light ofthe results, we highlight that nurse trainers should support studentsto take full advantage of this training, helping them to express their emotions and, in the same time, to learn to manage them profitably. (www.actabiomedica.it)

Psychotherapy in Dark Times: The Role of Moral Injury

Psychotherapy in Dark Times: The Role of Moral Injury

The health of healthcare professionals coping with the Covid-19 pandemic.

This work aims to systematize a set of scientific evidence presented in international papers that identify the main problems affecting health professionals directly involved in coping with the COVID-19 pandemic and point out actions and strategies for the protection and healthcare of these professionals. The risk of infection is the main issue and has led to absence from work, illness, death, and intense psychological distress, expressed in generalized anxiety and sleep disorders, fear of becoming ill and infecting colleagues and relatives. In the Brazilian reality, this work revives the analysis of the chronic problems affecting health workers, resulting from the underfinancing of the Brazilian Unified Health System (SUS), the sector's spending freeze, the deterioration of services and workforce's insecurity, and points out the acute challenges of work management and staff training, given the expanded hospital bed infrastructure and reorganization of the work process in primary care to face the pandemic, emphasizing the necessary measures for the protection and promotion of the physical and mental health of health professionals and workers.

Psychological distress associated with COVID-19 quarantine: Latent profile analysis, outcome prediction and mediation analysis

BackgroundMental health of the population during COVID-19 quarantine could be at risk. Previous studies in short quarantines, found mood-related and anxiety symptomatology. Here we aimed to characterize the subtypes of psychological distress associated with quarantine, assess its prevalence, explore risk/protective factors, and possible mechanisms. MethodsOnline cross-sectional data (n = 4408) was collected during the Argentine quarantine, between 1st-17th April 2020 along a small replication study (n = 644). Psychological distress clusters were determined using latent profile analysis on a wide-range of symptoms using the complete Brief-Symptom Inventory-53. Multinomial and Elastic-net regression were performed to identify risk/protective factors among trait-measures (Personality and Resilience) and state-measures (COVID-19 related fear and coping-skills). ResultsThree latent-classes defined by symptom severity level were identified. The majority of individuals were classified in the mild (40.9%) and severe classes (41.0%). Participants reported elevated symptoms of Phobic-Anxiety (41.3%), Anxiety (31.8%), Depression (27.5%), General-Distress (27.1%), Obsession-Compulsion (25.1%) and Hostility (13.7%). Logistic-regressions analyses mainly revealed that women, young individuals, having a previous psychiatric diagnosis or trauma, having high levels of trait-neuroticism and COVID-related fear, were those at greater risk of psychological distress. In contrast, adults, being married, exercising, having upper-class income, having high levels of trait-resilience and coping-skills, were the most protected. Mediation analysis, showed that state-measures mediated the association between trait-measures and class-membership. ConclusionsQuarantine was associated intense psychological distress. Attention should be given to COVID-19-related fear and coping-skills as they act as potential mediators in emotional suffering during quarantine.

A single ovarian stimulation, as performed in assisted reproductive technologies, can modulate the anxiety-like behavior and neuronal activation in stress-related brain areas in rats

Infertility affects about 8 to 12% of couples of childbearing age around the world, and is recognized as a global public health issue by the WHO. From a psychosocial perspective, infertile individuals experience intense psychological distress, related to emotional disorders, which have repercussions on marital and social relationships. The symptoms persist even after seeking specialized treatment, such as assisted reproductive technologies (ART). While the stress impact of ART outcome has been comprehensively studied, the role of supraphysiological concentrations of gonadal hormones on stress response, remains to be elucidated. This study aimed to evaluate the effect of a single ovarian stimulation on the stress response in rats. To mimic the context of ART in rodents, female rats were submitted to the superovulation (150 UI/kg of PMSG and 75 UI/kg of hCG) and then to psychogenic stress (restraint stress for 30 min/day, repeated for three days). Anxiety-like behavior was evaluated in the elevated plus-maze, and neuronal activation in the stress-related brain areas assessed by Fos protein immunoreactivity. Corticosterone, estradiol, progesterone and corpora lutea were quantified. Data were analyzed using Generalized Linear Model (GzLM). Our findings indicate anxiolytic-like and protective effects of supraphysiological concentrations of gonadal hormones induced by a single ovarian stimulation on stress response. An activation of hypothalamus-pituitary-adrenal response inhibitory pathways, with participation of the prefrontal cortex, basomedial amygdala, lateral septum, medial preoptic area, dorsomedial and paraventricular hypothalamus, was detected.

Pseudoangiomatous stromal hyperplasia of the breast presenting as gigantomastia: case report

Pseudoangiomatous stromal hyperplasia (PASH) of the breast is a benign condition generally seen as an incidental finding of biopsies for other causes. In some rare cases, it can evolve with expressive growth of breast tissue, leading to large breasts. The present study presents a case report of a patient who started with breast hypertrophy during lactation, evolving with gigantomastia, and arrived at the office 3 years after gestation with breasts of 6.2 and 4.3 kg and growth of accessory breast and axillary lymph nodes. The patient was emaciated, with bodily pain and psychological distress. Computed tomography was performed with the finding of diffuse retroglandular nodules and axillary and mediastinal lymph node enlargement, without being able to rule out the lymphoproliferative process. Then, core biopsies were made in several places on the breast whose pathological examination revealed PASH samples. Bilateral mastectomy was performed as a surgical treatment, with resection of the left accessory breast and left axillary lymph node, and breast reconstruction, with placement of silicone prostheses and graft of the areola-papillary complex, together with a plastic surgeon. She evolved in the postoperative period with good healing of the surgical wound, weight gain, necrosis of the areola-papillary complex and with severe psychiatric disorder, which was treated appropriately by psychiatrists, with remission of symptoms. This case report presents a rare evolution of PASH with gigantomastia, bringing intense physical and psychological distress to the patient, whose treatment chosen was total surgical resection of the breast tissue and aesthetic reconstruction.

Autoestima en las mujeres víctimas de violencia por la pareja íntima

Antecedentes: La violencia contra la mujer por su pareja íntima (VPI) puede provocar un malestar psicológico intenso y afectar su autoestima. Método: estudio con enfoque cuantitativo de tipo comparativo entre mujeres víctimas de violencia por sus parejas y las no víctimas. El grupo de mujeres maltratadas (n = 170), grupo mujeres víctimas, buscaron ayuda en un centro de asistencia psicológica a mujeres maltratadas; y las no maltratadas (n = 170), grupo no víctimas, fueron contactadas mediante la red de apoyo del Patronato de Ayuda a Casos de Mujeres Maltratadas (PACAM). Se identificó el tipo de violencia con un formulario estructurado y autoadministrado y se evaluó la autoestima con el Inventario de Autoestima de Rosenberg. Resultados: Los resultados mostraron diferencias estadísticamente significativas en la autoestima (p&lt;0.001*) entre ambos grupos. La edad media de las mujeres víctimas fue de 38.55 años (DE = 9.72, rango = 20 – 67). En el grupo de las no víctimas, la edad media fue de 37.25 años (DE = 11.43, rango = 18 – 65). Los resultados evidencian que la baja autoestima se asocia de manera estadísticamente significativa con la violencia de pareja.

Lessons from the Field Beyond the Numbers: Narratives of Professionals on Women who Experienced Severe Maternal Morbidity.

Several factors might affect the health and the quality of life of women who had a severe maternal morbidity (SMM) or a maternal near-miss (MNM) episode. The objective of the present study was to explore the perspectives of the professionals on the repercussions of SMM or of MNM after interviewing women who survived such episodes. Selected cases that captured the attention of professionals were reported. The professionals built individually 10 narratives, which were analyzed with the technique of content analysis. According to the perspectives of the professionals, women surviving a severe maternal condition and their families experienced clinical and psychosocial consequences. Some cases portrayed the intense psychological distress in mourning for the loss of the fetus or of their reproductive capacity and changes in family dynamics generating emotional overload, depression, and gender violence. The analysis of narratives may offer an idea on the complexity of the perception of care by professionals and on the need for an interdisciplinary follow-up of women surviving an SMM or an MNM episode.

Non-Suicidal Self-Injury in Adolescence: Longitudinal Associations with Psychological Distress and Rumination.

Non-suicidal self-injury (NSSI) constitutes a significant mental health concern that is highly prevalent in adolescence. Theoretical accounts and empirical research suggest that, in the short-term, NSSI may provide instant relief from intense psychological distress and ruminative thoughts. However, much less is known about these associations over time throughout adolescence. Therefore, we designed a three-year longitudinal study and examined the bidirectional prospective associations between psychological distress, rumination, and NSSI. We assessed 528 secondary school students (at Time 1: Mean age = 15.0years, SD = 1.85, range 11 to 19years, 50.6% female, 98.7% of Belgian nationality) using self-report questionnaires at three annual measurement points. Cross-lagged structural equation modelling was performed to examine the directionality of associations. Results indicated positive bidirectional associations between (1) distress and NSSI; and positive unidirectional associations between (2) distress and rumination, and (3) NSSI and rumination. The current study embeds NSSI in a broader network of cognitive and emotional antecedents and consequents, and is the first to consider the long-term influence these components exert on each other. As NSSI may play a significant part in increasing distress and rumination, the behaviour potentially sustains a longer-term maladaptive cycle between emotion, cognition, and NSSI. Clinical implications of these findings are discussed.

Comparison of Coping, Psychological Distress, and Level of Functioning in Patients With Gastric and Colorectal Cancer Before Adjuvant Chemotherapy

ContextPatients with gastrointestinal cancers are at high risk for functional problems that are generally accompanied by a decline in their overall status and intense psychological distress. ObjectivesThis study compares the level of functioning in individuals with gastric cancer (GC) and colorectal cancer (CRC) and analyzes whether improved functioning can be explained by patients' psychological status and coping strategies. MethodsThis is a prospective, transversal, multicenter study in patients with nonmetastatic GC and CRC before initiating adjuvant chemotherapy. Participants answered questionnaires evaluating quality of life, including functioning (European Organization for Research and Treatment of Cancer Quality of Life questionnaire), coping strategies (Mini–Mental Adjustment to Cancer), and psychological distress (Brief Symptom Inventory–18). ResultsBetween December 2015 and July 2017, 266 patients with CRC and 69 patients with GC were consecutively recruited. A pathological level of functioning was more prevalent in people with GC than in those with CRC (20% vs. 5%). Individuals with GC presented worse functioning and more psychological distress and displayed more hopelessness, anxious preoccupation, and cognitive avoidance as coping strategies than those with CRC. Psychological distress and fighting spirit accounted for 40% of the functional status in GC patients, whereas psychological distress and hopelessness represented 58% of CRC patients' functional status. ConclusionOur findings suggest that level of functioning affects many subjects with GC and reveals the importance of developing interventions targeted at enhancing adaptive coping strategies before initiating adjuvant cancer treatment.

Hope Tree: An Interactive Art Installation to Facilitate the Expression of Hope in a Hospice Setting.

Individuals confronting a terminal illness can experience intense psychological distress. Previous research has shown that hope can enhance one's ability to acknowledge, accept, and fight a terminal illness. Patients can continue to have hope or be hopeful, even in the face of a terminal illness. Can participation in a creative writing practice improve the expression of hope in a hospice setting? In this program evaluation, each expressed hope placed on the "Hope Tree" was independently coded by all research team members utilizing inductive content analysis. Overall themes were derived using a constant comparative approach and arranged into overarching themes based on consensus. Eight major themes emerged from the data: "Peace," "Dreams," "Total well-being," "Acknowledgment of loss," "Relationships," "Hospice care," "Spirituality," and "Dichotomies." The Hope Tree is a creative art project that can be used within a hospice environment to promote hope among family members and the health-care professionals who care for patients.

Physical, functional, and psychosocial recovery from burn injury are related and their relationship changes over time: A Burn Model System study

ObjectiveWhile burn injuries can have dramatic effect on patients’ physical health, they can also lead to intense psychological distress, loss of important social and role functioning, and alterations in outward appearance. We aimed to identify potential leading indicators of recovery in the post-discharge period following acute burn injury and hospitalization. MethodUsing data derived from the Burn Model System National Database, we identified five outcomes of interest measured at four time points (Pre-burn/Discharge, 6 months, 12 months, and 24 months post-discharge), including mental health, physical functioning, community integration, life satisfaction, and satisfaction with appearance. We applied cross-lagged panel analysis to the sample of 1052 injured patients admitted to burn intensive care units. ResultsOverall, there was little mean change in the five measures after the 6-month assessment. A time-varying panel model was superior to a time-invariant model, showing that the process of recovery itself may change over the course of two years post-burn. Physical functioning is an important predictor throughout this period, while satisfaction with appearance is quite predictive of other factors at discharge, but somewhat less predictive later. Overall mental health functioning is less predictive at discharge but at later intervals was a meaningful leading predictor of the other outcomes. ConclusionsRecovery from burn injury is complex and the most important facets of recovery change over time. Future research should focus on developing treatments to help patients adjust to post-burn appearance in the early post-discharge period, and mental health interventions may be effective as patients progress in recovery.

Demoralization and embitterment.

Individuals may experience a wide range of psychological reactions in response to negative life events. Even if events that threaten life have been always played a central role in research, recent studies have outlined that experiences, considered exceptional but part of the human existence (e.g., divorce, unemployment, or chronic illness) may also lead individuals to experience enduring emotional states of suffering. Demoralization has been substantially described as an important condition occurring in response to stressful events, while a recent interest is growing on embitterment as a common reaction. By analyzing the most relevant studies (MEDLINE, EMBASE, PsycLit, and Cochrane Library), this article discusses the main features of embitterment and demoralization, summarizing the similarities as well as the differences detectable between the 2 constructs. Some authors have described these phenomena as spectrum or gradients that start with normal human responses until getting to pathological conditions, characterized by prolonged intense psychological distress in relation to stressful events. Both have shown distinct psychopathological features than other stress-related mental disorders and have been recognized as predictors of negative outcomes, such as impairment in work and social functioning, reduction of quality of life, risk for mental and physical disorders, and suicidality. Demoralization and embitterment are multidimensional phenomena, connected to each other by bridge dimensions and in the meanwhile characterized by distinct features. Accurately exploring these clinical conditions is an ongoing challenge to clinicians and researchers, who are called for improving their recognition and proper therapeutic interventions that can ameliorate patients quality of life. (PsycINFO Database Record