Evidence-based clinical care

Not all deep sadness is depression

Sadness is a healthy emotion in the face of loss, disappointment and change, and it can be very intense without being an illness. Mood disorders differ from one another in important ways:

• Sadness and grief: they have a reason, come in waves and coexist with moments of relief; self-worth stays intact.
• Major depression: low mood or loss of pleasure nearly every day for at least two weeks, with changes in sleep, appetite, energy and concentration, guilt, hopelessness and impairment in daily life.
• Dysthymia: milder, but lasting two years or more; the person comes to believe “that’s just how I am”.
• Bipolar depression: depressive episodes that alternate with phases of euphoria or irritability.
• Adjustment disorder: disproportionate distress after a stressful event, which improves as the person adapts.
• PMDD: intense sadness and irritability that appear only in the premenstrual phase.

Why tell them apart: each condition has a different treatment. Treating bipolarity as depression, or turning normal sadness into an illness, can make things worse.

Depression

Persistent sadness, tiredness, loss of interest and pleasure, changes in sleep and appetite, a sense of emptiness and of having no future. In depression and dysthymia, treatment helps to understand what keeps this cycle going and to recover, step by step, activity, meaning and connection.

Bipolar disorder

Alternation between phases of elevated or irritable mood, with high energy, little sleep and impulsivity, and depressive phases. Psychotherapy, in dialogue with the psychiatrist, helps recognise early warning signs, regulate routines and sleep, and build stability.

Bipolar disorder in women: a difficult diagnosis

In women, bipolar disorder is often recognised later. This happens because:

• depressive episodes tend to predominate, and women seek help in the depressive phase and are treated as if they had “only” depression;
• type II (with milder hypomanias that go unnoticed or even seem like good periods), rapid cycling and mixed episodes, with agitation and sadness at the same time, are more common;
• irritability and instability are mistaken for PMS, PMDD, anxiety or borderline personality disorder;
• times of hormonal change, such as the postpartum period and perimenopause, carry a higher risk of episodes.

What we do: a detailed life history, mood tracking (the energy calendar), attention to the menstrual cycle and reproductive stages, and joint work with the psychiatrist. Antidepressants without a mood stabiliser can worsen bipolar disorder: that is why the correct diagnosis matters so much.

Energy calendar

For people who experience highs and lows of mood and energy, a simple daily log (mood, energy, hours of sleep, menstrual cycle, medication, alcohol and important events) turns vague impressions into visible patterns.

• spotting early signs of a shift: sleeping less, speeding up, withdrawing;
• identifying triggers and cycles: seasonal, menstrual, work-related;
• planning the week around available energy: demanding tasks on high-energy days and protection for low days;
• bringing concrete data to the psychologist and psychiatrist.

Basis: mood tracking and regular daily rhythms are part of approaches such as interpersonal and social rhythm therapy (IPSRT), developed for bipolar disorder.

Emotional regulation

Very intense emotions that change quickly or feel out of control often affect relationships and decisions. We work on skills to recognise, tolerate and respond to emotions more effectively.

Emotional dysregulation and anger outbursts

Anger itself is a healthy emotion: it signals injustice and helps us set limits. The problem is when it explodes, too fast and too hard. An anger outburst usually follows the same path:

• a trigger (a criticism, a delay, a “no”);
• an automatic interpretation: “they’re disrespecting me”, “it’s unfair”;
• the body fires up: heat, racing heart, clenched jaw;
• a point of no return, where the person “loses it”: shouting, insulting, breaking things;
• quick relief, followed by guilt, shame and damaged relationships.

When to seek treatment: when outbursts are frequent or disproportionate, when you regret what you said or did, when the people close to you become afraid or start walking on eggshells, or when there is damage at work and in relationships. With DBT and CBT, people learn to recognise the body’s signals before the point of no return, use skills to bring the intensity down (such as STOP and TIP) and express what they feel without destroying.

Self-harming behaviour: it is not only borderline

Hurting one’s own body is rarely “attention-seeking”. Most of the time it is a way, which works in the short term and does harm in the long term, to relieve unbearable emotional pain, escape a state of emptiness or dissociation, punish oneself or express suffering for which there are no words. Because its function is to regulate emotions, self-harm appears in many conditions beyond borderline personality disorder:

• depression and severe anxiety;
• PTSD and complex PTSD, especially after childhood trauma;
• eating disorders;
• autism and intellectual disability, sometimes linked to sensory overload or difficulty communicating feelings;
• body-focused repetitive behaviours, such as pulling out hair (trichotillomania) or picking the skin (dermatillomania);
• use of alcohol and other substances;
• adolescents with no diagnosis at all, at times of great distress.

Treatment: DBT is the approach with the most evidence: understanding the function of the behaviour and building, step by step, other ways of getting through emotions. If you are hurting yourself, you do not have to face it alone: contact us. If you are at immediate risk, contact an emergency service.

The feeling of emptiness

It is neither sadness nor boredom: it is the sense of a hole inside, of feeling nothing, of not knowing who you are or what you want. People often try to fill this emptiness with food, shopping, alcohol, intense relationships or screens. Chronic emptiness appears above all:

• in borderline personality disorder, where it is one of the diagnostic criteria;
• in depression, as a loss of meaning and pleasure;
• in narcissistic personality disorder, when the admiration of others is missing;
• in complex trauma and dissociation, as disconnection from oneself;
• in addictions and eating disorders, as something the behaviour tries to silence.

Personal restructuring: treatment does not try to “fill” the emptiness from the outside. We work on emotional awareness, personal values (what really matters to you), identity and more authentic relationships, so that life gradually regains a content of its own.

Premenstrual dysphoric disorder (PMDD)

It is not “just PMS”. In the days before menstruation, irritability, sadness, anxiety, sudden mood swings and a sense of losing control appear, and they improve once the period starts. PMDD is recognised in the diagnostic manuals (DSM-5-TR and ICD-11) and is linked to greater brain sensitivity to the normal hormonal changes of the cycle.

What recent research says: PMDD is much more frequent and intense in people with ADHD, autism or other forms of neurodivergence, and also in those living with anxiety, depression or a history of trauma. That is why we assess it carefully in these cases, with a cycle diary, emotional regulation strategies and joint work with a gynaecologist and psychiatrist.

Burnout

Physical and emotional exhaustion, detachment or cynicism towards work and the sense of not being able to cope any more: it is the result of work stress that has built up without enough recovery. ICD-11 recognises burnout as a work-related phenomenon. We work on limits, energy recovery, perfectionism and returning to work, or changing course, sustainably.

Anxiety

Constant worry, panic attacks, phobias and avoidance can make life smaller and smaller. With evidence-based approaches, people learn to handle uncertainty and move back towards what matters.

Social phobia (social anxiety)

Intense fear of being judged, evaluated or embarrassed in front of others: speaking in public, eating in front of someone, walking into a full room, talking on the phone, starting a conversation. Blushing, trembling and a blank mind follow, and afterwards hours spent replaying what was said. To avoid suffering, the person avoids, and life gets smaller. CBT is the first-line treatment: gradual exposure, less self-focused attention and dropping “safety behaviours”.

Panic disorder

Sudden attacks of intense fear, with a pounding heart, shortness of breath, dizziness, tingling and the feeling of dying, fainting or going mad. After the first attack comes the fear of having another, and the person starts avoiding places and situations, such as public transport, crowds or going out alone. CBT teaches people to understand what happens in the body, stop fearing the sensations and gradually return to the places they have avoided.

Panic attack, panic disorder and agoraphobia: what is the difference?

They are three different things that often appear together:

• Panic attack: a sudden wave of intense fear that peaks within minutes, with a pounding heart, shortness of breath, dizziness and fear of dying or going mad. A single attack can happen to anyone and in many conditions: it is not a diagnosis in itself.
• Panic disorder: attacks that recur unexpectedly, followed by at least a month of fear of further attacks or changes in behaviour to avoid them.
• Agoraphobia: fear and avoidance of situations from which it would be hard to escape or get help: public transport, open or enclosed spaces, queues and crowds, leaving home alone. It can occur with or without panic disorder.

Why tell them apart: the treatment changes. In agoraphobia the focus is gradual exposure to avoided situations; in panic disorder, learning not to fear the body’s own sensations.

OCD (obsessive-compulsive disorder)

Intrusive thoughts, images or fears that cause great distress (obsessions) and repeated behaviours or rituals to relieve it, such as cleaning, checking, ordering or counting (compulsions). The relief is short-lived and the cycle grows stronger. Exposure and response prevention, within CBT, is the psychological treatment with the most evidence for OCD.

The different types of OCD

OCD is not just an obsession with cleanliness. It can take many forms, and recognising your own type already brings relief: you understand that you are not “going mad” but caught in a cycle that can be treated.

• Contamination and cleaning: fear of germs, dirt or illness, with repeated washing and cleaning.
• Sexual orientation: obsessive, distressing doubts about whether one is homosexual (or heterosexual), which reflect fear rather than desire; the person keeps “testing” themselves and seeking certainty.
• Control over objects: checking doors, gas and appliances; keeping order, symmetry and the “right” position of things; counting or repeating until it “feels right”.
• Control over people: fear that something bad will happen to loved ones, needing to know where the other person is, obsessive doubts about one’s partner or relationship, fear of harming someone.

Procrastination

Putting off what matters, even knowing the consequences, is rarely laziness: it is usually a way of escaping uncomfortable emotions, such as fear of failure, boredom or overload. We work on what lies behind the putting off and on practical strategies for starting and finishing tasks.

Sleep disorders

Poor sleep is today one of humanity’s biggest health problems. The difficulty takes many forms:

• going to bed and being unable to slow your mind down;
• anxiety and difficulty falling asleep;
• waking up several times during the night;
• waking up in the early hours and being unable to get back to sleep;
• very vivid dreams or nightmares;
• sleeping the “right” number of hours and still waking up tired.

The consequences: poorer memory and concentration, irritability, raw emotions, more anxiety and depression, more hunger and sugar cravings, pain, weaker immunity and a higher risk of accidents and of cardiovascular and metabolic disease.

Why sleep hygiene is not enough: switching off screens and keeping regular hours helps, but rarely solves the problem on its own. Sleep has to be addressed from every angle: CBT for insomnia (the first-line treatment), biological rhythm and light exposure, anxiety and rumination, emotional regulation, nightmares and trauma, diet and physical activity, and medical assessment of other causes, such as sleep apnoea.

Alcoholism (alcohol use disorder)

It often starts as a way to relax, sleep or bear difficult emotions, and little by little the person needs to drink more, loses control over when to stop and carries on despite harm to health, work and relationships. It often goes hand in hand with anxiety, depression and trauma. Treatment combines motivational interviewing, CBT and relapse prevention, together with the doctor (stopping may require medical supervision), and includes support for the family.

Alcohol as emotional anaesthesia

Alcohol is often sought not for pleasure but as anaesthesia: to avoid feeling anxiety, sadness, anger or loneliness, to tolerate the discomfort of being with oneself. It works for a few minutes and costs a lot afterwards: more anxiety the next day, worse sleep, impulsivity and guilt.

The link with emotional regulation: people who find it harder to recognise, tolerate and regulate emotions are at greater risk of using alcohol as a strategy. That is why treatment is not just “stop drinking”: it is learning other ways of getting through discomfort, such as DBT distress-tolerance and emotion-regulation skills.

PTSD (post-traumatic stress disorder)

It can arise after an event in which the person felt their own life, or someone else’s, was in danger: an accident, a robbery, a disaster, a traumatic birth, the sudden death of someone close or having come close to death. The memory returns as if it were happening again (flashbacks and nightmares), the person avoids anything that recalls the event and lives on high alert. Trauma-focused treatments have strong evidence of effectiveness.

Complex PTSD (C-PTSD)

It arises from repeated or prolonged trauma from which escape was difficult or impossible: bullying, abuse, neglect or violence at home or in a relationship. Beyond the symptoms of PTSD, it affects how a person regulates emotions, sees themselves (shame, guilt, feeling worthless) and trusts others. Care begins with safety and stabilisation and moves, at each person’s pace, towards processing.

What is the difference? In PTSD the core is the memory of an event. In complex PTSD, recognised by ICD-11, repeated trauma also affects identity, emotions and relationships. That is why treatment is usually longer and organised in phases.

Autism and neurodivergence

Autism, ADHD, giftedness, dyslexia and other forms of neurological functioning are different ways of perceiving, feeling and processing the world, not defects to be corrected. Assessment helps to understand this profile, with its strengths and difficulties, and ongoing support helps the person live in line with how they function.

ADHD

Inattention, impulsivity, restlessness and difficulty with organisation and time management, present since childhood and often continuing into adulthood. Assessment confirms the diagnosis and maps each person’s profile; ongoing support builds practical strategies for study, work and relationships, in dialogue with the psychiatrist when medication is involved.

ADHD and mental disorganisation

It is like having many tabs open at once: ideas arrive all together, everything seems urgent, a thousand things get started and few get finished, the thread is lost halfway through a task. It is not a lack of willpower or intelligence: it is a difficulty with executive functions, which organise, prioritise and sustain action. We work on getting organisation out of the head and onto the outside (lists, visual boards, alarms), breaking tasks into small steps, deciding priorities and dealing with frustration and self-criticism.

It is not ADHD: it is digital mental fatigue

Not every concentration problem is ADHD. Phones, notifications, social media and emails hijack attention dozens of times a day and gradually drain mental energy. By the end of the day there is no energy left to focus on what really matters and comes first.

How we tell them apart: in ADHD the difficulties have been present since childhood and appear in several settings; with digital fatigue they arise from excessive device use and improve when habits change. Assessment clarifies which it is, and we work on routines that protect attention and restore energy.

It was not ADHD: so what is it?

Sometimes assessment does not confirm ADHD, and the question remains: so why can’t I concentrate? Inattention is a symptom, not a diagnosis, and it can have many causes:

• anxiety and constant worry;
• depression;
• trauma and a permanent state of alert;
• insufficient sleep or sleep disorders;
• digital mental fatigue;
• learning disorders, such as dyslexia and dyscalculia;
• giftedness and boredom;
• burnout;
• medical causes, such as thyroid problems, anaemia or medication side effects.

The next step: a complete clinical and neuropsychological assessment does not stop at “it’s not ADHD”: it investigates what it is, so that the treatment is the right one.

Masking (social camouflaging)

It is the effort, often automatic, to hide one’s way of being in order to seem “normal”: imitating expressions, rehearsing conversations, holding back movements and sensory discomfort. It is most studied in autism, especially in women and girls, and is also common in ADHD; it appears in social anxiety too and in people who learned through trauma that showing themselves is dangerous. It works for a while, but at a high price: exhaustion, anxiety, depression, loss of identity and late diagnoses.

Energy and motivation in neurodivergence

Many neurodivergent people live with their battery almost flat: concentrating, filtering stimuli and adapting to the environment use up much more energy. In ADHD, motivation often depends on interest, novelty or urgency rather than on how important the task is. We work on energy management, realistic routines and recovery breaks to prevent exhaustion and burnout.

Dyslexia

A specific learning disorder affecting reading and writing: reading slowly, swapping or reversing letters, struggling hard to understand a text, despite normal intelligence and adequate teaching. It is not laziness or lack of effort. Neuropsychological assessment identifies the profile, and intervention and accommodations at school, university and work make a big difference.

Dyscalculia

A specific learning disorder in mathematics: persistent difficulty understanding what numbers mean, doing sums, memorising times tables, telling the time and handling money, despite normal intelligence and adequate teaching. It is not lack of effort or “not being a maths person”, and it often causes a lot of anxiety and shame at school. Neuropsychological assessment identifies the profile; intervention uses concrete, visual tools, and school accommodations make a difference.

Technology as support in neurodivergence

Reminders, visual timers, digital planners, text-to-speech, organisation apps and artificial intelligence tools can act as external support for executive functions. We help people choose and use these tools in a personalised way, so that technology works for them and does not become yet another distraction.

Group therapy for autistic adults (level 1 support) and adults with ADHD

A group designed for neurodivergent functioning, with clear rules, predictability and respect for sensory needs. Being among people who function in a similar way brings relief and belonging: there is no need to explain everything or to mask.

• sharing practical strategies for organisation, energy and routine;
• practising social and communication skills in a safe environment;
• working on self-esteem wounded by years of being misunderstood;
• building a positive neurodivergent identity, with strengths and limits.

Binge eating disorder

Episodes of eating a large amount of food in a short time, with a sense of losing control, followed by guilt and shame. Bingeing is often a way of coping with difficult emotions: treatment works on this function, on regular meals and on the relationship with the body.

Bulimia nervosa

Cycles of bingeing followed by behaviours to “compensate”, such as vomiting, laxatives, fasting or excessive exercise, often kept secret. Treatment breaks this cycle and works on the emotions and self-evaluation linked to weight and body shape, in dialogue with the doctor and nutritionist.

Anorexia and other eating disorders

In anorexia, food restriction and an intense fear of gaining weight take up more and more space. This and other dysfunctional eating behaviours involve much more than food: treatment considers emotions, thoughts and behaviour, in dialogue with other professionals when needed.

Chew and Spit (CHSP)

Chewing food, usually very high in calories, and spitting it out before swallowing, to taste it without “absorbing” the calories. It is a little-known behaviour, lived with great shame and secrecy, so it is rarely mentioned spontaneously. It occurs mainly alongside food restriction, anorexia and bulimia, and deserves to be assessed and treated with the same care.

Disordered eating

Even after treatment for an eating disorder, traces often remain: counting calories in your head, rigid rules about what you “can” and “cannot” eat, fear of certain foods, guilt after eating, body-checking in the mirror, compensating with exercise. Disordered eating also appears in people who have never been diagnosed. It is not fussiness or a detail: addressing these traces is what prevents relapse and restores a calm relationship with food.

Regulating emotions through food

Eating to calm down, comfort yourself, reward yourself or avoid feeling. It often happens without the person noticing:

• at the end of the day, when accumulated tension lets go;
• when faced with boredom or loneliness;
• after an argument or criticism;
• when very tired or short on sleep;
• after days of restriction, when the body demands payback;
• grazing on autopilot in front of screens.

How we work: noting what you felt before eating, telling physical hunger from emotional hunger, broadening regulation strategies and reducing the restriction and guilt that feed the cycle.

Tirzepatide and the rebound of binge eating

Medicines such as tirzepatide (Mounjaro) greatly reduce appetite and help weight loss. But when they are stopped, appetite returns. In the SURMOUNT-4 trial, people who switched from tirzepatide to placebo regained on average 14% of their weight in about a year, while those who continued treatment kept losing weight (Aronne et al., JAMA, 2024). If the emotional function of food has never been addressed, bingeing can come back strongly.

How to prevent the rebound: psychotherapy should accompany treatment from the start, not only at the end: identifying the emotional triggers of hunger, building regular eating without excessive restriction, developing other ways of regulating emotions and planning with the doctor how to reduce or stop the medicine. Never stop medication without medical advice.

Body image disorders

When the image we see in the mirror does not match the real body, or when one detail of our appearance occupies the mind for hours, as in body image distortion and body dysmorphic disorder. We work on how the person sees, compares and evaluates themselves, so that appearance stops running their life.

Pathological jealousy

Jealousy becomes a problem when it is disproportionate, does not depend on facts and starts running the relationship: checking the phone and social media, interrogating, controlling schedules and friendships, imagining betrayal from small details. It hurts both the person who feels it and the person who is its target. Behind it there may be insecurity and fear of abandonment, attachment patterns, trauma, alcohol use or obsessive functioning. We work on tolerating uncertainty, emotional regulation and trust, individually or as a couple; where the conviction of betrayal is unshakeable, together with the psychiatrist.

Romantic relationships and triangulation

Triangulation happens when a third party takes the place of a conversation the couple cannot have: a lover, an ex, a friendship, a child, the family of origin or even the phone. Instead of speaking directly to the partner, the tension is diverted: provoking jealousy, seeking allies, venting to someone else, using the children as messengers. It eases anxiety for a while, but stops the problem from being solved. In therapy, individual or couples, we identify the triangles and give the conversation back to those it belongs to.

Abusive relationships

Control, humiliation, possessive jealousy, isolation from friends and family, threats, cycles of explosion and reconciliation. Over time, the person starts to doubt themselves and their own perception.

You do not need to wait until you have the strength to leave before starting therapy. Treatment begins long before that strength grows: we structure the areas of your life, work on self-esteem and personal healing and build a solid support network, so that when the decision is made you are safe and supported.

If you are in immediate danger, get help: in Italy 112 or 1522; in Brazil 190 or 180; elsewhere, your local emergency number.

LGBTQIA+ and disclosure

A safe, affirming space where sexual orientation and gender identity are not treated as problems. Suffering often comes from outside: prejudice, fear of rejection, having to hide.

Preparing for disclosure: we help plan the conversation with family and friends: whom to tell first, when and how, rehearsing the words, anticipating reactions, strengthening the support network, protecting your own safety and handling difficult responses. The timing is always the person’s own.

Sexual dysfunctions

Little or no desire, difficulty with arousal, erectile dysfunction, premature ejaculation, difficulty reaching orgasm, pain during sex (as in vaginismus). They are far more common than people admit, and almost always come with shame and silence.

How we work: first, a medical assessment to rule out physical causes and medication effects (some antidepressants, for example). Then sex therapy works on performance anxiety, beliefs, the couple’s communication and gradual exercises such as sensate focus, individually or as a couple.

Psychology of assisted reproduction

The path of assisted reproduction is made of waiting, injections, tests and great expectations with every cycle. It is common to feel intense anxiety while waiting for results, grief for each unsuccessful attempt or pregnancy loss, pressure on the couple and a sex life that starts to run to a schedule.

Psychological support helps to: get through each cycle with less suffering, protect the couple’s relationship, make difficult decisions (such as gamete donation or when to stop treatment) and process losses. European human reproduction guidelines (ESHRE) recommend that psychosocial care be part of treatment.

Family therapy: the dynamics that make people ill

Many symptoms that appear in a son or daughter, whether a child, teenager or adult, arise and are maintained within family dynamics. Some patterns we often see:

• Parents who are not humanised. When parents are seen as perfect or as villains, rather than as people with limits, histories and mistakes, the child stays trapped between idealisation and guilt. Humanising parents is what makes it possible to set limits, forgive where appropriate and move on.
• Expectations and guilt. Expectations never spoken but always demanded, and guilt used to keep children close or obedient, produce children who live so as not to disappoint.
• Ambivalent parents and chronic anxiety. Affection and criticism, closeness and rejection, rules that change with the adult’s mood: the child learns to live on alert, trying to predict what is coming. This state of constant vigilance often becomes chronic anxiety in adulthood.
• Parents who do everything for their children. Out of love, they remove every discomfort from the path. The child does not develop tolerance for discomfort, feels incapable at the first obstacle, and insecure self-esteem and anxiety disorders find fertile ground.
• The perfect idea that paralyses. Parents who struggle to be authentic and realistic build a grandiose image of their child, who absorbs it as their own. Later they freeze: nothing they do will ever match that idea. To achieve is to translate an idea into reality, and, as the Italian saying goes, traduttore, traditore: to translate is to betray. So as not to betray the idea, and not to feel the discomfort of an outcome that will never be 100% perfect, the person postpones, never starts or gives up. Therapy helps people tolerate imperfection and trade the idea for real life.

When family instability makes a child ill

Stomach aches before school, headaches, bedwetting again, insomnia, tantrums, new fears: in children, distress often speaks through the body and behaviour. And every symptom has a function. Sometimes, when the child falls ill, the parents stop fighting and come together to look after them: without anyone noticing, the symptom “works” and so it persists.

Treatment is with the parents: working on the couple’s conflict, communication and the stability of routines relieves the child of the job of holding the family together. Always after a paediatric assessment to rule out medical causes.

Parent training for oppositional defiant disorder (ODD)

Children who argue, defy rules, get irritated easily and seem to do the opposite on purpose. Parent training is the first-line treatment:

• specific attention and praise for positive behaviour;
• clear, short instructions, one at a time;
• predictable, proportionate consequences instead of shouting and threats;
• routines and a daily “special time” with the child;
• parents regulating their own anger before stepping in.

Why it works: the child defies, the adult shouts, the child defies more. When parents change how they respond, the cycle breaks.

Parent training for parents of neurodivergent children

Parents of children with ADHD or autism often lovingly apply strategies that work for other children, and get frustrated when they do not work with their own. Parent training starts from the child’s profile:

• understanding how the child functions: what is a difficulty and what is a “tantrum”;
• visual routines, advance notice of changes and prepared transitions;
• short, concrete instructions and immediate reinforcement of what goes well;
• recognising sensory overload and telling a meltdown from a tantrum;
• co-regulation: the calm adult lends their calm to the child;
• also caring for the parents’ tiredness and guilt.

Scientific basis: parent training is recommended as first-line treatment for ADHD in preschool children and also improves behaviour and family climate in autism.

Personality disorders

Persistent patterns of thinking, feeling and relating can cause suffering and repeated conflict. With structured treatments and a solid therapeutic relationship, it is possible to build more flexible ways of living.

Borderline personality disorder and differential diagnoses

In borderline personality disorder, emotions rise fast, very high, and take a long time to come down. There is instability in self-image and relationships, intense fear of abandonment, impulsivity, a sense of emptiness and sometimes self-harm. DBT was created for borderline personality disorder and is the treatment with the most evidence.

What it can be confused with:

• Bipolar disorder: changes are episodes lasting days or weeks, with altered sleep and energy, even without a trigger; in borderline, mood shifts within hours, almost always in reaction to events in relationships.
• Cyclothymia (cyclothymic disorder): milder, persistent swings between higher- and lower-energy phases for at least two years, linked more to a biological rhythm than to relationships.
• Dependent personality disorder: there is also fear of being left, but the response is submission and difficulty deciding alone, not intense anger, impulsivity or swinging between idealising and devaluing the other person.
• Complex PTSD and ADHD can mimic borderline or coexist with it.

Why it matters: the wrong diagnosis leads to the wrong treatment. That is why assessment is careful and carried out over time.

Narcissistic personality disorder

Behind the need for admiration, the sense of being special and the difficulty recognising what others feel, there is often fragile self-esteem, highly sensitive to criticism and failure. People rarely seek help for narcissism itself: they come because of depression, crises at work or in relationships. With a firm and respectful therapeutic relationship, it is possible to build steadier self-esteem and more genuine relationships.

Avoidant personality disorder: what it looks like in practice

The person longs for connection but has an enormous fear of being criticised, rejected or ridiculed. In everyday life it looks like this:

• only approaching someone when sure of being accepted;
• not speaking in meetings despite having good ideas, and turning down promotions that require more contact;
• rehearsing conversations in their head and replaying them afterwards, looking for mistakes;
• feeling inferior, awkward or inadequate around others;
• ending up with a smaller life than they want, more out of fear than choice.

Treatment: CBT and Schema Therapy help people gradually face avoided situations, reduce self-criticism and build, within a safe therapeutic relationship, the experience of being accepted as they are.

Psychotherapy for chronic pain

Pain that lasts more than three months, as in fibromyalgia, migraine or back pain, affects sleep, mood, work and relationships; and these factors in turn increase the pain. Psychotherapy, especially CBT and ACT, does not say “the pain is all in your head”: it helps reduce suffering, fear of movement and the weight of pain in life, together with the medical team.

Palliative care

Psychological support for patients with serious illnesses or no prospect of cure, and for their families. The focus is quality of life and dignity: facing fear, emotional pain and difficult decisions, talking about what matters, saying goodbye and living anticipatory grief, always together with the healthcare team.

Grief

The pain of losing someone important is a natural response, not an illness. Sometimes, however, longing and suffering remain very intense for a long time and stop life from moving on: this is what ICD-11 calls prolonged grief disorder. We accompany grief to give space to the pain, find ways of keeping the bond with the person who has gone and rebuild routine. Children and adolescents grieve too, often in silence: we help families talk about the loss in an age-appropriate way.

Grieving the loss of a job

Work is not just income: it structures the day and gives identity (“I am…”), belonging, recognition and purpose. That is why a dismissal, closing a business or even retirement can be experienced as grief, with sadness, anger, shame and the feeling of no longer having any value. This grief deserves support: processing the loss, caring for self-esteem and rebuilding routine, identity and new paths.

Retirement and new habits in later life

Retirement removes, all at once, routine, professional role, colleagues and sometimes the feeling of being useful. Without preparation, free time can turn into isolation, inactivity, anxiety and depression.

How to prevent it: planning the transition before it happens; building a new routine with schedules and goals; keeping the body moving and the brain learning; cultivating friendships and taking part in the community, for example through volunteering; renegotiating time together with your partner; and finding new projects that give meaning to the days.

Cognitive disorders

Changes in memory, language, perception, attention and movement can appear after a stroke, traumatic brain injury, tumours, neurodegenerative diseases (such as Alzheimer’s and Parkinson’s) or other neurological conditions. Neuropsychological assessment identifies what has changed, and rehabilitation helps recover or compensate for functions and preserve independence.

Neuropsychological assessment: Alzheimer’s and dementia

Forgetting appointments, repeating the same questions, getting lost in familiar places or struggling with money and medication are signs that deserve investigation. Assessment uses standardised tests of memory, attention, language, perception and executive functions, comparing results with people of the same age and education.

What it is for: distinguishing normal ageing from mild cognitive impairment; identifying conditions that mimic dementia, such as depression; differentiating types of dementia (Alzheimer’s, vascular, frontotemporal, Lewy body), together with the neurologist and brain imaging; and creating a baseline to track progress and guide the family.

Geriatric neuropsychology

Forgetfulness, slowness or changes in behaviour in later life deserve attention. Neuropsychological assessment distinguishes normal ageing from mild cognitive impairment and dementia, and guides cognitive stimulation, rehabilitation and family support.

Cognitive stimulation in ageing

The brain remains able to learn and adapt throughout life. Cognitive stimulation, with exercises for memory, attention, language and reasoning, combined with physical activity, good sleep, social life and learning new things, helps preserve functions and independence and build what is known as cognitive reserve. It is suitable for people who want to age while caring for their mind, for those beginning to notice small lapses and in mild cognitive impairment, with personalised programmes based on neuropsychological assessment.

Menopause and cognitive symptoms

During perimenopause and menopause, many women feel “foggy”: forgetfulness, difficulty finding words, concentrating and multitasking. Falling oestrogen, hot flushes, broken sleep and mood changes all contribute. In most cases these changes are mild and tend to improve after the transition, but they are frightening and weigh on work and self-esteem. We assess the cognitive profile, reassure with concrete data and work on sleep, anxiety and memory strategies, together with the gynaecologist.

Technology in cognitive rehabilitation

Computerised cognitive stimulation programmes, memory and planner apps, external memory aids, alternative communication tools for aphasia and virtual-reality environments complement neuropsychological rehabilitation, with exercises adjusted to each person’s level and progress monitoring.