BEHAVIORAL DISORDERS. Transnographic clinical framework for Psychodynamic Play Focused Semi-Residential Territorial Care.
Grassi Antonio¹, Berivi Sandra², Camerlingo Carlo³, Casamassima Stefania³, Russello Carla³, Benedetta Romano⁴, Sinatti Cristiana⁵, Alvisi Francesca⁶, Allocca Amalia⁷.

Keywords: behavioral disorders, Play-Focused Psychodynamic Therapy, diagnosis, semi-residential interventions and treatments.

BEHAVIORAL DISORDERS

Transnosographic clinical framework

For Psychodynamic Play Focused Semi-Residential Territorial Care⁶

Grassi Antonio¹, Berivi Sandra², Camerlingo Carlo³, Casamassima Stefania³, Russello Carla³, Benedetta Romano⁴, Sinatti Cristiana⁵, Alvisi Francesca⁶, Allocca Amalia⁷.

¹Psychiatrist, Medical Director of the San Raffaele Monte Mario Institute, President – Italian Laboratory of Research in Analytical Psychology (LIRPA);

²Psychologist, Teaching Analyst – Vice President Italian Laboratory of Research in Analytical Psychology (LIRPA);

³Psychologist – Italian Laboratory of Research in Analytical Psychology (LIRPA);

⁴Psychiatrist, Medical Doctor, Outpatient Clinic and Day Center “La Mongolfiera” Service for Adult Disabled People District XIV ASL Roma 1

⁵Psychiatrist,Medical Doctor, Outpatient Clinic Contact Person for Adult Disabled People District XIV ASL Roma 1

⁶Neuropsychiatrist, Medical Doctor, Director of UOSD – Residential and Housing Support District XIV ASL Roma1

⁷ Medical Doctor specialized in Hygiene and Preventive Medicine – Public Health Orientation, Rheumatology and Psychotherapy. Health Director IRCCS San Raffaele

Abstract: Behavioral disorders occur trans-nosographically across psychiatric, medical, and neurological conditions. The authors propose a diagnosis-intervention model according to which patients with behavioral disorders can be categorized as Mild, Moderate, or Severe. This would allow each patient to access the most suitable care and treatment service during both pre-acute and post-acute phases. The proposed diagnostic framework includes the involvement of a territorial network of prevention, care, and rehabilitation interventions and services, as well as the synergistic collaboration between hospitals and the Territorial Services of the National Health Service (SSN) and authorized and/or accredited private entities. The common denominator of all behavioral disorders is anxiety and depression, and the authors propose play as an operational tool within Psychodynamic Therapy, grounding this approach on neuroscientific and neurocognitive bases.

Keywords: behavioral disorders, Play-Focused Psychodynamic Therapy, diagnosis, semi-residential interventions and treatments.

Introduction

Given that the Lazio Region, with Determination no. G08249 of 24 June 2022, approved the regional document “Care Pathway for people with psychiatric pathology and/or behavioral disorders for access and management in the Emergency Room and hospitalization“, it is evident that the Region intended to address the pressing need for responses to such issues. This is especially relevant regarding States of Psychomotor Agitation, which concern not only known or primary acute psychiatric conditions but also neurodevelopmental disorders, neurocognitive disorders, personality disorders, addictions, and eating disorders. Given this complexity, we deem it essential to deepen the clinical analysis and reflection on Behavioral Disorders.

From a dimensional perspective, these disorders manifest most prominently as States of Psychomotor Agitation—particularly affecting emergency departments. More broadly, Behavioral Disorders cut across psychiatric, medical, and neurological conditions and, to prevent their progression to extreme agitation states, require attention during pre-acute and post-acute phases. This necessitates a Territorial Network of interventions, involving cooperation among hospitals, local SSN (National Health Service) services, and accredited private entities, integrating Prevention, Treatment, and Rehabilitation services.

This proposal constitutes a comprehensive semi-residential territorial intervention project in collaboration with hospitals for acute states and outpatient services for mild or remissive states, where public-private collaboration holds significant social relevance. Henceforth we propose:

• Play Focused and Cognitive Behavioral Psychodynamic Therapy which helps to identify behaviors as reactions to underlying unconscious conflicts of an emotional nature.
• Financial Support provides budgeting aided by a professional, in Compulsive Shopping or Pathological Gambling.
• Pharmacological therapy: In some cases, antidepressants may be used to reduce anxiety and improve impulse control.

1. Focused Psychodynamic Therapy: Play as a Transnosographic Treatment and Cure

In this paper, we would like to propose that all the syndromes mentioned share, as a common denominator, anxiety and underlying depression. It therefore becomes essential to first address cognitive disorders and behavioral disorders, then anxiety, and finally depression, as the final step.

To gradually approach the anxious-depressive cores that underlie the various identified diagnoses, we consider it fundamental to use a form of psychotherapy that employs play as an operational tool.

Play, as a function of the mind connected to the activation of the right hemisphere, allows us to speak of a psychodynamic therapy that is Play Focused.

The neuro-scientific foundations supporting the choice of a Play Focused psychotherapy certainly began with the pioneering work of Winnicott. He attributed to playful relationality the individual’s capacity to create culture—a concept now confirmed by recent findings. These identify the polyvagal autonomic nervous system (ANS) as the primary channel through which individuals receive the most significant information from both the external and internal environment. This information can then be used for the development of consciousness and, consequently, for cultural activity. Such activity first emerges in the transitional area in symbolic form through images, and is later translated into the logical thought of the left hemisphere. This symbolic activity, in fact, is the domain of the right hemisphere, as demonstrated by current research by Wilma Bucci (2022).

In her theory of the multiple code, Bucci (1985) distinguishesd between a sub-symbolic level and a symbolic level, the latter further divided into two dimensions: that of images without words and that of images with words. Bucci then proposed a translation of images with words into the formal logical language of the left hemisphere through a process she defines as the referential activity.

To these foundational concepts, we must add another important contribution from the neurocognitive sciences: the research conducted on split-brain subjects.

Neurocognitive research on split-brain subjects has shown that while the left hemisphere is responsible for logical functions such as problem analysis, problem solving, and decision making, the right hemisphere handles visuospatial synthesis and emotional activity. The right hemisphere, therefore, governs symbolic and analogical language, while the left hemisphere processes formal, logical language, which is typical of rational thought.

These studies and findings on visuospatial synthesis and emotional functions support Bucci’s hypotheses regarding her conclusions about images that possess their own emotional life. These images are divided into “without words” or “with words,” and their processing, according to Bucci, is assigned to the right hemisphere. The author indeed draws on Winnicott’s insightful ideas and applies them to her theory of psychodynamic treatment for various behavioral disorders. This involves focusing more closely on play and its development, which also results in containing disinhibited behaviors that are instead expressions of the erotic or aggressive drive-based universe. Play has the capacity to channel instinctual energy along a path bounded by the framework of the play itself. This allows the instinctual energy to be transformed, shedding its primitive drive-based nature and fostering the development of the playful dimension—that is, the sentimental and emotional sphere.

From this perspective, the first heteroceptive and interoceptive information is processed by the autonomic nervous system (ANS), particularly by the polyvagal system. This implies that such information forms the basis of true knowledge, or truth, revealing that ethical competencies tied to the concept of truth no longer pertain solely to the cerebral cortex, but rather to the peripheral structures of the autonomic nervous system.

This information corresponds to sub-symbolic content, as defined by Bucci. At the level of the brainstem, through the nuclei of the vagus nerve, sub-symbolic content is transmitted to the right hemisphere, where it is transformed into images—first without words, then with words. It is the referential activity that subsequently allows the transfer of these images to the left hemisphere, where they are converted into concepts, which are the domain of the left hemisphere.

Psychotherapeutic intervention through play thus takes on the role of restoring and recovering this pathway. The result is an evident benefit, not only in terms of the patient’s cognitive functions, but even more so in their ability to regain control over their behaviors. This is achieved through the activation of the Controller function, which, as can be easily inferred, is not merely cortical. Rather, it is linked to the activation of the entire pathway that extends from the vagal system to the cortex.

2. The features of Play.

There are main characteristics that define play and serve specific functions. These are the same for both traditional play and video games. An activity is defined as play or a video game when:

• it is fun and non-productive: one plays because it is enjoyable;
• it is limited in time;
• it is based on intrinsic motivation: play does not require external reinforcements;
• participation is voluntary and without obligations, which implies a certain willingness to play and an open attitude;
• it can be abandoned at any time, making the challenge and competitive environment feel safe;
• it has rules, which help develop strategic thinking and free creativity;
• it is characterized by internal control and active engagement: each player has the power to decide their actions and carries them out directly;
• it has a goal that focuses the player’s attention and gives a sense of purpose;
• it includes an open feedback system (scores, levels, rankings, etc.), which increases motivation by providing the perception that the goal is attainable.

Play, therefore, represents a true evolutionary lever in life, contributing to the development and strengthening of motor, cognitive, and interpersonal skills, as well as to emotional well-being. For this reason, it is recognized as a human right by the United Nations (Article 31 of the United Nations Convention on the Rights of the Child, 20 November 1989). Although it may seem like a trivial act, play prepares and supports individuals in life. It helps them understand the rules of the world, teaches them to distinguish between reality and fantasy and enables them to build new and diverse forms of interpersonal communication and develop and consolidate new knowledge.

Play is the language through which individuals express their feelings freely, express themselves, and give meaning to what surrounds them. It is an activity in which a person experiences a special kind of freedom—one in which they are fully in control of themselves, striving for self-realization and meaning-making, or discovering the meaning of things. It is a fun experience that promotes creativity and stimulates individuals in a positive way.

One of the fundamental roles of play is the construction of personal and social identity through learning the rules of interacting with others. Furthermore, in play, the primary human emotions are creatively experienced. The playful dimension accompanies a person throughout their entire life.

The idea of play as an expression of the person’s inner psychic life and their relationship with others is an ancient concept. However, the first images that are most likely evoked by this term in the psychoanalytic imagination are those of little Ernst, Freud’s grandson. He was described by the Viennese psychoanalyst while playing with his spool, which would disappear and reappear, accompanied by his “ho-o-o” as he threw the toy far away, and his “da” when it returned—thus illustrating one of the most famous clinical vignettes of child psychoanalysis (Freud 1920). Or we may recall Winnicott’s squiggle game, in which, through a sort of drawing ping-pong, the child not only outlined their internal world but also revealed the need, in child treatment, for the analyst to participate actively in the relationship by drawing with the child (Winnicott 1951).

Roger Caillois (1958) divided play into four main categories:

• Agon, or play as competition, contest, respect for rules—as in chess, soccer, running, or sports competitions in general;
• Mimicry, that is, play as simulation, pursuit of illusion—as in playing with dolls, dressing up, theater, or disguise;
• The search for thrill, risk, falling into the void—as in dance, amusement rides, roller coasters, or extreme sports;
• Alea, or play dominated by chance, luck, gambling, and the challenge of fate. Victory depends on fortune, which is repeatedly tested.

From our perspective, play can also be autistic (Tustin, 1972): when it reduces living people to the state of dead things, and it can be animistic when it brings life to inanimate objects, thus becoming transitional (Winnicott 1951). Play enacts the anthropo-analytic a priori of continuity.

The relational nature of the self in transitional play opens the child’s personality to transitional phenomena and objects. These imply a tacit recognition of their being a real not-me, that is, the Other.

Play is populated by archetypes (Kalf 1966), in their meaning as “a priori categories of experience and knowledge” (Jung 1936-1954).

Play Therapy is an effective therapeutic approach that uses play precisely as a tool to address and manage behavioral disorders.

As previously noted, Winnicott (1951) saw play as an essential dimension of being human, since it fulfills a necessary and indispensable function in representing not only mental content, but particularly information coming from the neurovegetative nervous system directed toward the conscious system, typically associated with the activation of the left hemisphere.

It forms the basis of the individual’s capacity for symbolization, essential for cultural development in every life stage—from birth to death.

Play is also based on one of the two fundamental relational modes through which the individual connects with the object, that is, the external world:

a) Orgasmic relationality

b) Playful relationality

Orgasmic relationality is based on drive apparatus, in which the object, experienced as separate from the self, is used solely for the satisfaction of an erotic or aggressive drive. Winnicott defined it as orgasmic because he saw in it a beginning, a build-up, and an end determined by an orgasmic peak of pleasure.

Modern research into the subcortical reward system and the dopaminergic nuclei from which it is formed (nucleus accumbens, ventral tegmental area, amygdala) has shown that these subcortical brain nuclei are activated by erotic and aggressive drives.

Playful relationality is based on the prefrontal and orbitotemporal cortical apparatus. It is a relational mode also defined by the author as a relationality of the self, in which no drives are at play, but rather affective identity processes that connect subject and object through identity-forming processes developed within the transitional area, giving rise to transitional phenomena. This is a form of relationality responsible for structuring and developing a sense of personal identity, within a transitional area that unites the “me” and the “not-me” in a shared space—the transitional space.

We would now like to briefly provide an overview of the main clinical effects of play:

1. Emotion management: helps patients express and understand their emotions in a safe, non-judgmental environment. This is especially useful for dealing with anxiety, depression, and aggression.
2. Development of social skills: through play, patients learn to interact with others, improving communication, cooperation, and conflict resolution.
3. Promotion of creativity and strategic thinking: play stimulates creativity and helps develop cognitive abilities such as problem-solving and critical thinking.
4. Stress reduction and improved well-being: play provides an opportunity to relax and reduce stress, contributing to overall emotional well-being.
5. Support for specific disorders: play therapy is particularly effective in treating disorders such as attention deficit, learning difficulties, and deficits in social development.

Game Therapy, also known as Play Therapy, is a broad field of therapeutic and educational intervention based on play. This psychotherapeutic approach is primarily used with children to help them face their difficulties, improve pathological conditions, and promote optimal development.

There is also Videogame Therapy, a particularly versatile type of treatment used within psychotherapy paths. It is based on the use of video games as therapeutic, educational, and rehabilitative tools and proves effective not only for children but also for adolescents and adults.

The video game can be seen as a modern form of play, containing all the characteristics of classic play, but potentially even more interactive and social. It is a channel of expression, promotes creativity and imagination, provides gratification, and can serve therapeutic purposes. A good video game, when used appropriately, can inspire participation and motivation and can generate positive emotions. Video gaming is a voluntary activity, not undertaken out of duty or obligation. It requires a certain level of commitment, and people play because investing one’s energy—even intensely—into something enjoyable is satisfying.

In this mental state of concentration and optimistic engagement, positive thoughts emerge and social connections improve. This becomes an ideal setting for the expression of a wide range of emotions—from omnipotence and euphoria to helplessness and frustration, from fear and anxiety to pride and joy. A strong emotional response occurs because all neurological circuits related to happiness are activated, including those involved in attention, gratification, and motivation.

Today, there is a rapidly growing niche in the healthcare sector focused on repurposing interactive digital games to improve health in various conditions: so-called “serious games”. These are games specifically developed and marketed to reduce symptoms of various disorders and to promote functional behaviors. Video games stimulate multitasking thinking, free expression, creativity, and focused attention—along with all the benefits of traditional play. Compared to the latter, video games allow for broader interaction with the imaginary dimension, visually materialized through digital support.

Videogame Therapy also offers the opportunity to practice new coping strategies and problem analysis/problem-solving skills initially developed in the therapeutic relationship, within the protected and fictional environment of the video game—skills that can later be transferred to real life. This therapy can be carried out with an individual patient or in small groups of two or three people, with the guidance of a properly trained play therapist.

The therapeutic process begins with a preliminary session in which primary emotions are identified. Based on this, specific video games can be selected and a treatment plan defined. A typical session consists of about 30 minutes of video game play, followed by a psychotherapeutic discussion where the content and emotions that emerged during the game experience are processed. There are also other types of protocols that allow patients to play at home. As further evidence of our proposal, we refer to several studies from recent years. As an example, we consider video games and videogame-based interventions for the treatment of Feeding and Eating Disorders (DSM-5-TR, 2023).

In 2008, particularly concerning the treatment of ADHD, anxiety, and autism spectrum disorders, a systematic review was conducted on online video games. The conclusion was that online games can be therapeutic for mental health issues and may focus on two broad types of games: social games, which are accessible and suitable for all ages, and online virtual worlds, which offer the opportunity to interact with therapists and other patients.

In a 2013 study involving nine female patients with bulimia nervosa, the aim was to assess whether Videogame Therapy could be effective, particularly in improving emotional and impulse self-control. The results showed an improvement in emotional regulation and impulsivity even after the treatment. This was significant because psychological treatments had previously been considered effective in managing many symptoms, but not in addressing emotional self-regulation and impulsivity—factors that are typically resistant to change. The patients were treated with a video game called Playmancer, specifically designed to treat mental disorders, in addition to psychotherapy (Fagundo et al. 2013).

A 2017 systematic review focused on the use of video games as therapeutic interventions within treatment programs for childhood obesity, autism spectrum disorders, and developmental disabilities. The study evaluated the benefits of therapeutic video games and digital assistive technology, and a protocol was also developed for a videogame therapy program for obesity. Involvement in Videogame Therapy for obese children resulted in calorie consumption and weight loss, with an average of 381 kcal burned per hour. This led to the targeted development of specific software for this condition. One such development is an advanced and realistic virtual reality system created by a team of cognitive neuroscientists and video game developers for individuals on the autism spectrum. With the use of “custom avatars” and facial tracking technology, players can practice non-threatening social interactions. In doing so, they build confidence and social skills that can later be applied in real-world situations (AA,VV 2017).

Our proposal is framed as a comprehensive hospital-community intervention project for acute cases, in which public-private collaboration takes on a precise social relevance for the benefit of the community.

 3. Which Behavioral Disorders Can Be Treated from a Transnosographic Perspective?

We would now like to summarize which disorders can be fully included under Behavioral Disorders, within a transnosographic framework, according to the following outline.

BEHAVIORAL DISORDERS

Our basic assumption is that all behavioral disorders originate from an underlying depressive state, which can only be accessed by working through the experience of anxiety. This process allows for the identification and resolution of deep, unconscious motivations using psychodynamic tools (such as Sand Play Therapy-Dixit). At the same time, behavioral self-assertiveness is reconstructed using cognitive-behavioral tools, by exploring and resolving maladaptive components through methods such as Schema Therapy.

Drug addiction and non-substance addiction	Personality disorders	ADHD	Eating disorders	OCD	MCI	Rare neurocognitive and developmental disorders	Psychotic onsets	Anxiety disorders	Depressive Disorder	Intellectual Disabiltity
Cognitive disorders (Appendix A)	Cognitive disorders (Appendix B)	Cognitive disorders (Appendix C)	Cognitive disorders (Appendix D)	Cognitive disorders (Appendix E)	Cognitive disorders (Appendix F)	Cognitive disorders (Appendix O)	Cognitive disorders (Appendix U)	Cognitive disorders (Appendix Q)	Cognitive disorders (Appendix S)	Cognitive disorders (Appendix U)
Behavioral disorders (Appendix G)	Behavioral disorders (Appendix H)	Behavioral disorders (Appendix I)	Behavioral disorders (Appendix L)	Behavioral disorders (Appendix M)	Behavioral disorders (Appendix N)	Behavioral disorders (Appendix P)	Behavioral disorders (Appendix V)	Behavioral disorders (Appendix R)	Behavioral disorders (Appendix T)	Behavioral disorders (Appendix V)

 4. Play as a psychotherapy for behavioral disorders

If we were to summarize the connection that we see between psychotherapy and play, it is that psychotherapy is like a game, especially psychodynamic psychotherapy.

We can state—hopefully in a broadly agreeable way—that cognitive-behavioral therapy is inherently adaptive in nature. It tends to improve the personality’s adjustment in a more realistic way than previous maladaptive psychopathological functioning, using coaching-style interventions along with behavioral directives, prescriptions, and requests. Although the effectiveness of cognitive-behavioral therapy is fairly well established, its medium- and long-term results are much less convincing, as patients often tend to revert to earlier behavior patterns. Thus, the changes appear less profound and more superficial. In our view, this is because the deep unconscious roots of these behaviors have not been removed.

Psychodynamic psychotherapy, on the other hand, is deeply motivational in nature. It allows the patient—without behavioral prescriptions, directives, or demands—to express their unconscious drives and dimensions within an unstructured, non-conditioned therapeutic space. This includes both pathological and healthy aspects of behavior. Healthy behaviors are understood as arising from the unconscious perceptual-cognitive subsystem, as outlined by Robert Langs (1973,1974) in terms of clinical methodology, and by Carl Gustav Jung (1936-1954) from a theoretical-symbolic perspective.

In this approach, anxiety is not avoided. Instead, in psychodynamic therapy, anxiety must be experienced and regulated, as it is an open gateway to the unconscious contents that generate it. These are the only elements that, once processed in connection with consciousness, can be dissolved—since they are the knots at the core of maladaptive behavioral patterns. These knots can be untied in favor of healthy configurations and behavioral patterns, offered by the deep cognitive unconscious through its symbolic language. These are expressed directly by this unconscious subsystem through symbols such as associations, dreams, slips of the tongue, Freudian slips, and both physiological and pathological bodily language.

Whereas behavioral techniques may lead to quick but temporary improvement, psychodynamic psychotherapy, by dissolving the unconscious ego motivations in favor of the healthy motivations of the deep unconscious, offers not just improvement, but “healing”.

 5. An Italian research on videogame therapy

The fundamental assumption of our research (Grassi 2022) is that the Senex and Puer archetype manifests in every individual, regardless of biological age. Essentially, Jung (1936-1954) said that within each of us coexist a wise old man and a young explorer. From early childhood through to old age, there exist both an old and a young part of the self, each with their own positive and negative traits. This is indeed a paradox, because a child is both young and old at the same time and, just as they are constantly dying and growing, they also carry a configuration that evolves throughout the life cycle—being at once past experience and openness to the new. At the same time, every elder is also a child, meaning they possess an attitude of future-oriented planning in cognitive, relational, and behavioral terms. The reduction in neurocognitive inhibition strength, in psychoanalytic terms, translates into a weakening of the Senex archetype and, in effect, an increasing exercise of instinctual satisfactions (the Puer), accompanied by a progressive atrophy of cortical structures, including the executive functions of problem analysis, problem solving, and decision making.

In our project, two main operational perspectives were followed. The first aimed to provide the older generations – Boomers – with the theoretical and practical tools needed to function more effectively in the digital world (Digital Skills), enhancing their ability to understand their surroundings (the exploratory activity of the Puer). On the other side, we focused on the ethical and rehabilitative use of play, assigning the play activity an ethical meaning (the judgment and behavioral ethics of the Senex). In this sense, those over 50 were recruited as custodians of an ethical framework, while those under 30 were brought in as bearers of increasingly innovative digital literacy.

Recent discoveries in neurocognitive sciences, especially research on split-brain patients by Michael Gazzaniga (2005, 2009), and the concept of the referential activity of the mind from Wilma Bucci’s Multiple Code Theory (2021), to which we have already referred, have historically shown that play represents a functional dimension of the mind and brain. Specifically, the right hemisphere, with its functional specialization in emotional activation and visuospatial synthesis, represents the psycho-biological lab of what is known as emotional intelligence—and of play itself. This research yielded statistically significant results and is the subject of a full issue of Lirpa International Journal^[1] .

In conclusion, the use of play and video games in the treatment of behavioral disorders represents a promising and innovative approach, which uses the playful dimension to foster personal growth and psychological well-being. This methodology is based on several core principles, including the creation of a safe and motivating environment (Bowlby, 1989), the stimulation of cognitive and social skills, and the integration of targeted therapeutic techniques.

In summary, the key aspects are mainly:

1. Positive interaction: play provides a relational and stimulating context that encourages emotional expression and the improvement of social skills;
2. Personalization: play therapy allows interventions to be tailored to the specific needs of the patient, maximizing treatment effectiveness;
3. Technological support: Serious Games and digital games are concrete tools that, through gamification mechanisms, engage the patient and increase participation levels;
4. Stress reduction: the playful dimension helps reduce anxiety linked to pulsional orgasmic relationality, (Winnicott 1951) and improves emotional regulation linked to playful relationality, (Winnicott 1951).

In essence, play is not only a method of treatment, but a gateway to autonomy, creativity, and self-discovery, offering opportunities for learning and development that go beyond conventional therapy. In the future, it will be essential to deepen research and develop new tools to ensure even more effective implementation of this methodology.

 6. The Hospital-Territory Care Network in the SSN.

Let us now summarize the symptom-related corollary that can be found in Behavioral Disorders:

• Irresistible impulse;
• Repetitive behaviors;
• Impairment of daily activities.

In order to clearly define the diagnostic boundaries of various behavioral disorders—and to establish, from our point of view, an efficient and effective care network—we aimed to design a model in which the different treatment missions for disturbed behaviors both respect specialized competencies and effectively pursue the specific goals assigned to each node of the care network.

To this end, we developed a table of signs and symptoms, structured around four dimensions:

1. Meaning of the symptom/sign
2. Severity level of the symptom/sign
3. Duration of the symptom/sign
4. Severity level of the stress-inducing trigger event, the cause of the symptom/sign

The items in point 1) are ordered by severity, from 1 to 18 “vertically,” so to speak.

Each corresponds to a categorical variable, meaning a variable whose set of possible values consists of a finite number of logically orderable categories (2 or more), for example: “never / sometimes / often / habitually” or “never / once / more than once.”

In this sense, for each variable, the category that appears in the case being observed can be indicated.

For example, if observing a patient named Mario, one might say whether he is often angry, whether he habitually curses, or whether he has ever hurt someone else—or himself.

In this way, the list can also be expanded “horizontally,” forming a sort of “tree structure.”

The following table was developed by a group of independent judges^[2], composed as follows:

A coordinating Psychologist Analyst with a Communicative Orientation, a Psychologist, Specialist in Psychotherapy, and two Physicians, Residents in Psychiatry and Psychotherapy.

In defining the items, the members of the independent judging panel took into account general scales related to the construct of “Aggressiveness”, particularly the following:

1. Buss-Durkee Hostility Inventory – BDHI (Buss & Durkee, 1957)
2. Cohen-Mansfield Agitation Inventory – CMAI (Cohen-Mansfield & Billing, 1986)
3. Modified Overt Aggression Scale – MOAS (Kay et al., 1988)
4. Neuropsychiatric Inventory – NPI (Cummings et al., 1994)
5. State-Trait Anger Expression Inventory – STAXI (Spielberger, 1988)

They also referenced the Table of “Types of Aggression” by Lo Presti and Ricci (Bullying and Relational Distress in Schools, Formella, Lo Presti & Ricci, 2008, LAS Edizioni).

Below, we present the 18 dimensional levels from the signs/symptoms table that we developed, summarizing the aforementioned points 1), 2), and 3):

Table 1 “Types of Aggressionà” by Formella, Lo Presti e Ricci 2008

LEVEL OF EXPRESSION/LEVEL OF SEVERITY	No.	BEHAVIOR	DURATION LEVEL
			Never	Once	Some time	Often
Behavioral EMOTIONAL	1	Show irritation, annoyance, impatience, intolerance
	2	Showing a consistently angry or irritable mood without loss of control
	3	Having short, sudden displays of anger with yelling and swearing not directed at anyone
Behavioral PASSIVE-AGGRESSIVE	4	Intentionally adopting passive-aggressive behaviors: “pouting”; making scathing jokes instead of direct criticism; not cooperating, etc.
Behavioral VERBAL	5	To speak ill of others: to insinuate, to despise, to gossip, to denigrate, to slander, etc.
	6	To mortify with humiliating words: to blame, to discriminate, to harass, to persecute, to socially isolate, etc.
	7	Adopting uninhibited attitudes: undressing, using indecent language, making advances sexual verbal and physical etc.
	8	To raise one’s voice at someone during an argument
	9	Swearing, insulting or verbally attacking someone using direct offensive language
	10	Threatening someone with physical violence against them or their property
Behavioral OTHER-DIRECTED HARMING ACTIONS	11	Performing acts of physical aggression towards things: throwing or breaking objects; slamming doors, etc.
	12	Engaging in intimidating physical behavior without directly touching or hitting someone: making threatening postures, banging your fists on the table, pointing your finger at someone’s face, making threatening gestures, grabbing someone’s clothing, etc.
	13	Carrying out hidden aggressive other-directed acts: stealing or destroying other people’s things; sabotage, retaliation or indirect revenge, etc.
	14	Spitting, pushing, grabbing someone without causing injury
Behavioral SELF-HARMING ACTIONS	15	Performing minor self-harm acts without causing serious injury (e.g. scratching, pinching, etc.) or causing minor physical damage (e.g. cutting, wounding, incising, burning skin, legs, arms, etc.)
Behavioral OTHER-DIRECTED HARMING ACTIONS	16	Scratching, kicking, biting, hitting someone causing minor physical harm
	17	Hitting animals or people possibly with the use of objects or weapons causing serious physical injuries or even death
Behavioral SELF-HARMING ACTIONS	18	Inflicting serious injuries on oneself (e.g. deep cuts, lesions or fractures) or engaging in conduct intended to cause death or risk one’s life (e.g. intentional overdose , jumping from a high place, simulated hanging, poisoning)

Furthermore, acknowledging that the development of Behavioral Disorders has often been clinically observed as causally linked to the emergence of stress-inducing factors, we have also developed a table of stressors, as outlined below.

Table 2 stressful factors

Frequency	rarely	sometimes	frequently	constantly	TOT
1. Grieving the loss of a loved one: the death of a spouse, child, or close family member.					5=Serious
2. Divorce or separation: The emotional, legal and social process can be devastating.					5=Serious
3. Major illnesses or accidents: serious health problems for yourself or a family member.					5=Serious
4. Job loss: economic and psychological impacts.					4= Severe
5. Significant life changes: moving, major career changes, or retirement.					4= Severe
6. Financial problems: persistent insolvency or financial difficulties.					3= Moderate
7. Interpersonal conflicts: Serious problems with friends, family, or colleagues.					4= Severe
8. Legal Problems: Being involved in lawsuits, criminal proceedings, or other legal problems.					3= Moderate
9. Having a child: While it is a happy event, it can cause great stress due to the changes in life.					4= Severe
10. Daily stress: for example, balancing work and private life.					1= Minimum 0 2= Mild

In order to complete the nosographic definition, we have included another conceptual model that has, for decades, formed the basis of training for both family and professional caregivers: the PLST – Progressively Lowered Stress Threshold (Richards & Beck 2004). This model recognizes that the cause of these symptoms is a reduced stress threshold in patients with Neurocognitive Disorders. Conflicting interactions between the person and the environment may therefore trigger the onset of BPSD (Behavioral and Psychological Symptoms of Dementia), as the individual, with the progression of the illness, is no longer able to provide adequate cognitive and functional responses.

Six main categories of stressors have thus been identified, which can contribute to the onset of behavioral disorders:

1. Fatigue
2. Changes in daily routine
3. Demands that exceed the patient’s abilities
4. Multiple overlapping stimuli
5. Physical stimuli, such as pain or invasive care procedures
6. Emotional stimuli, such as grief or anger

From an intervention perspective, the PLST model recommends that both families and the entire healthcare team limit these key stressors, and in general, adopt an individualized care approach aimed at reducing any type of stress-inducing factor.

 7. Conclusions

Based on the use of these scales, we have defined that a care network for Behavioral Disorders can be efficient and effective if these disorders are classified as severe, moderate, or mild, according to the comparative scores of the aforementioned scales, and patients can be categorized as having mild, moderate, or severe Behavioral Disorders.

Following this, patients evaluated as severe would require early hospital admission, with the primary goal of transforming the disorder from severe to moderate. Moderate disorders could be assigned to residential or semi-residential accredited private facilities, which would have the mission to reduce the disorder from moderate to mild. Finally, disorders classified as mild would be managed by outpatient facilities of the National Health Service (SSN) or accredited private providers.

The diagnostic decision for each case, to ensure consensual agreement, would be entrusted to a team composed of a psychiatrist and a psychotherapist from each of the three areas (Severe – hospital, Moderate – residential/semi-residential territorial, and Mild – outpatient territorial).

The team could meet as often as necessary not only to establish an initial diagnosis for entry into the care pathway but also to provide a working-through diagnosis and a final diagnosis at discharge or exit from the pathway.

In conclusion, we affirm that the proposed diagnosis/intervention model would have the advantage of ensuring a two-way transition between Hospital and Territory and vice versa. This could increase, in terms of efficiency, effectiveness, and safety, the possibility of implementing a personalized pathway that is increasingly appropriate, with measurable outcomes, aiming for a greater presence of evidence-based methodologies (EBM) in a field so widespread yet still relatively unexplored.

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1. https://www.lirpa-internationaljournal.it/pub-nr-01-del-2018-5/ ↑

2. Dr. Guido Caramanico, Dr. Carlo Camerlingo, Dr. Cesare Maria Civitelli, and Dr. Saverio Pelle collaborated with the panel of judges. ↑