1. Comparison of R-PAS Stress and Distress Scores of Obese Patients with Different Genetic Makeup A Pilot Study
Good morning! I’m very happy to be here and to present you this pilot study.
Like the other research of this session, we tried to think out of the picture, inspiring by what rDoc suggest
Emanuela Brusadelli (1,2,3), Franco Del Corno (3), Tullio Giraldi (4), Alessandra Tomasich (2), Alessia Romanazzi (2), Giuseppe Toffoli (5), Masa Jovic (4), Erika Cecchin (5), Francesca Ales (6), & Luciano Giromini (6)

2. “The RDoC framework assumes that data from genetics and clinical neuroscience will yield biosignatures that will augment clinical symptoms and signs for clinical management”
“NIMH hopes that the scientific and clinical communities will recognize the importance of joining in constructive dialogue on efforts aiming to accelerate the pace of new clinical discoveries and improve clinical outcomes”
Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders.
Am J Psychiatry 167:7, July 2010
rDoC encourage the collaboration between specialists to improve the knowledge that we have of patients.
For this reason we decided to start a collaboration with a genetic working group to take advantage of our different points of view on individuals.

3. 1) Department of Psychology, University of Milano-Bicocca
2) Clinical Psychology Unit, ASST Rhodense Hospital,
3) Association for Research in Clinical Psychology (ARP)
4) Department of Life Sciences, Faculty of Medicine and Psychology, University of Trieste,
5) Experimental and Clinical Pharmacology Unit CRO-National Cancer Institute, Aviano, Pordenone.
For this reason, this research involved 3 different italian beautiful cities:
Milano, where i come from, with prof. Franco del corno, alessandra tomasich and other collegues of the clinical psychology unit of a public hospital.
Trieste, where there is the genetic working group, thanks to prof tullio giraldi and collegues
And, in the end, Torino, with luciano giromini and collegues
6) Department of Psychology, University of Turin

4. Serotonin (5-HT), a key central nervous system neurotransmitter, is involved in regulating a broad range of psychological traits, behaviors, and physical functions including mood, sleep, appetite, and sexual activity.
The serotonin transporter protein (5-HTT), facilitating the reuptake of the serotonin from the synapse, appears to be part of the pathway leading to psychiatric disorders and has been a target of widely used pharmacological treatments.
We decided to focus our attention on serotonin, which as you well know is involved in regulating a broad range of psychological traits, behaviors, and physical aspects.
All of this functions seem to be mediate by the role of the serotonin transporter protein (5-HTT).
Indeed, the gene associated with the transporter (SLC6A4) has been the focus of extensive research.
More specifically, we choosed 5httlpr
Noreen Goldman, Dana A. Glei, Yu-Hsuan Lin, Maxine Weinstein (2010).
The Serotonin Transporter Polymorphism (5-HTTLPR): Allelic Variation and Links with Depressive Symptoms
Depress Anxiety, March ; 27(3): 260–269. doi: /da NIH Public Access

5. 5HTTLPR
a polymorphism in the promoter region of the gene encoding the serotonin transporter protein (Heils et al., 1996) ..
was identified by Heils et al. (1996)
The allele of 5httlpr can be in two variants : SHORT and LONG
And since it is functionally bi-allelic, we can have 3 versions of 5httlpr, which implicate different transcriptional activities L S

6. 3 possible 5-HTTLPR versions with different transcriptional activity each
“Researchers speculated that the differential transcriptional activity caused by this polymorphism would influence complex traits and diseases, including affective disorders [Heils et al. ,1996; Collier et al., 1996]”.
Goldman et al. (2010)
low SS
medium SL
high LL
Ss sl e ll
It seems that the low transcriptional activity related to the S allele influence the develop of some disorders, so we can think about it as a sort of vlnerability to the develop of psychiatric disorder

7. 3 possible 5-HTTLPR versions with different transcriptional activity each
“Researchers speculated that the differential transcriptional activity caused by this polymorphism would influence complex traits and diseases, including affective disorders [Heils et al. ,1996; Collier et al., 1996]”.
Goldman et al. (2010)
low SS
medium SL
high LL
For this reason, many research suggests to put togheter SS and SL, because both contain the S allele

8. ASSOCIAtions between the presence of Short allele and psychiatric disorders
studies
Depression and anxiety
Lesch L. et al., 1996; Ohara et. Al., 1998; Bellivier F. et al., 2002; Munafò et al., 2009; Risch et al., 2010; Karg et al., 2011
Obsessive-compulsive disorder
Hu et al., 2006
SAD (seasonal affective disorder)
Rosenthal NE. et al., 1998
Schizofrenia
Shcherbatykh TV. et al., 2000
Nevrosis
Sen S. et al., 2004
alcohol dependence
Gorwood P. et al., 2000
Suicide attempts
Courtet P. et al., 2004; Li et al., 2004
in literature there are many studies that indicate a relation between the presence of S allele and psychiatric disorders. Even if it continue to be a debate in literature about it. here, we have reported only some of them,

9. “The gene itself exists as several alleles, the short “S” allele and the long “L” allele. The S
variant is associated with less, and the L variant with more, of the uptake protein. The effect of stressful life events on depressive symptoms
in young adults was found to be significantly stronger among SS or SL subjects than among LL subjects.”
Moreover, recent studies showed that it seems to be an association not only with disorders but, more in general, with the way of react/tolerate stress, and this in an element that worsen the psychiatric picture.
As this article of Wurtman suggests, the SS/SL variants, compared to the L variant, have been associated with higher risk of stress, distress, and depression.

10. Aim
Explore the relationship between 5HTTLPR S allele and RPAS stress distress variables
low SS
medium SL
high LL
Based on this background, the aim of this study was to ..
With the hypothesis that SS/SL individuals should produce higher scores than L individuals on R-PAS variables located in the Stress and Distress domains of Page 1 and Page 2.

11. Method
We administered the Rorschach test (CS; Exner, 2003) to a group of obese patients in the clinical psychology unit of the ASST-Rhodense Hospital (MILANO).
We also took a sample of saliva in a specific container and shipped them to the Experimental and Clinical Pharmacology Unit of the CRO-National Cancer Institute settled in Aviano, Pordenone (TRIESTE). They sent back the genetic variants of patients, i.e., SS/SL vs LL
We recruited a group of obese patients in the clinical psychology unit. They asked for an help to follow dietary indications provided by the dietician of the hospital.
we adminstered them a psychodiagnostic battery which include the rorschach test and we also took a saliva sample for the genetic evaluation, and shipped them to trieste.

12. Measures
Rorschachs were administered using CS, and later re-scored using R-PAS
Page 1 and Page 2 R-PAS variables located in the Stress and Distress domain were analyzed;
Additionally, because dependence and orality, as well as body concerns likely play a key role in obesity and binge eating, we also inspected ODL% and An.
Regarding the genetic make-up, each patient was cathegorized in genetic terms as SS/SL vs. LL
Rorschachs were administered using CS, and later re-scored using R-PAS focusing on stress and distress variables
We also inspected odl and an for the role played by dependence and orality
For each patients we received the genetic category SS/ SL or LL

13. Participants
The initial sample was comprised of 33 patients affected by obesity. The percentage of SS or SL vs. LL subjects was:
We discovered that there were only 8 LL subjects, whereas 76% was SS or SL. This distribution was expected, given that all were patients who referred to the hospital and many of them met the criteria for a diagnosis of DSM 5 binge eating disorders . As such, it is highly likely that they were subject to a certain degree of stress and distress.
To make u better understand u think that the LL distribution in outpatients is of 32%-57%

14. Participants
Of these 33 patients, a subgroup was selected. Specifically, the following were excluded:
1 subject was excluded as he was the only man
4 were excluded because did not meet binge eating criteria
3 were excluded as we did not have the verbatim transcript
The final sample consisted of 25 individuals:
8 (32.0%) were LL; 17 (68.0%) were SS or SL;
All were women, with binge eating;
Ages ranged 21 to 72 (M = 54.5; SD = 11.9)
In order to make more homogeneus the sample, we excluded ..
.. Verbatim transcript, so it was impossible to re-scored that protocols
So, in the end, we selected 25 subjects
The sample ranged in age from 21 to 72 so, as u can see, the standard deviation of age was very high,

15. Participants
The ages of the LL vs. SS/SL groups were not significantly different, t(23) = .51, p = .62
Group N M SD LL 8
52.8
14.9
SS or SL 17
55.4
10.7
Total 25
54.5
11.9
However

16. Data analysis
Because of the small sample size, we focused on effect size.
Additionally, because the records were collected using CS, we also inspected distribution of R and tested both raw and complexity-adjusted scores.
Regarding data analysis
..distribution of R because it correlates with several, interpretatively important variables

17. Results
As u can see, four of the protocols were shorter than optimal, with 14 responses only, while other records were very long, with 40 or more responses.
I’m going to show u only complexity adjusted scores because they should remove the effects of R from the interpretative scores, and also because raw scores revealed a similar patterns.

18. Results Compl.Adj. SS d=.46 d=.43 d=.47 d=.63 Page 1 variables
These are the results. in this table we highlighted the best differences
As u can see, the most notable differences are observed for little-m, MOR, percentage of critical content, and anatomy. Except for little-m, these differences are in the expected direction, indicating that SS or SL subjects showed higher stress and distress than LL subjects.
Also, it should be noted that no notable differences were found for SC-Comp, PPD, sum shading, color-shading blend, achromatic color, and vista.
In terms of comparisons against the normative reference values, the highest scores were observed for anatomy and, to a lesser extent, critical content, achromatic color, MOR, and diffuse shading.
Critcont is typically interpreted as an index of severity of psychophatology
d=.46
d=.43
d=.47
d=.63
Page 1 variables
Page 2 variables
Other variables

19. May little-m < in SS/SL patients represent a freezed thought?
Discussion
To sum up, in this pilot study SS/SL subjects scored higher than LL subjects on An, CritCont%, and MOR. However, on the contrary of the expected direction, they scored lower on m.
Subjects with S allele
We tried to give a clinical interpretation to this data because we know these patients, given that they partecipate to a group therapy program in the clinical psychology unit
So in our clinical experience SS/SL patients attribute to themselves everything happen to them, with a strong sense of inadequacy that they feel as unchangeable and ontological. They think to be born defective.
This experience, well highlited with MOR responses, seem to block their thought. So we thought that maybe low little-m may represents this freezed thought that they have.
May little-m < in SS/SL patients represent a freezed thought?

20. Conclusions (simply new questions!)
At this time, it is difficult to draw any conclusions on whether this study does vs. does not support the utility of R-PAS Stress & Distress variables.
Content-related variables (i.e., MOR, CritCont%, and An) seem to be the most promising ones, with this respect.
This pilot study has raised New Questions for which we have not found answers yet but we hope to find them soon

21. Future directions Reducing all the limits of this study!
Extend the sample size, using R-Optimized administration, and reducing the age range
Replicate our results on a sample of outpatients
Hoping that excluding the problem of R (short or long records) there will produce more encouraging results.
- to have a higher number of LL subject and to verify the pattern we found in a non-clinical condition.
Investigate the hystory of patients

22. emanuela.brusadelli@gmail.com Ph.D
Thank you!
Ph.D