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Abstract Introduction The mother and child attachment could have an important and long-lasting impact. An insecure attachment could lead to emotional development difficulties. It has been suggested that maternal care in infants is associated with personality. However, more studies in adults are needed. Objective To determine if attachment styles in subjects with affective or anxiety disorders are associated with the expression of personality traits, and if this effect can be modulated by the presence of the short allele of the 5-HTTLPR polymorphism. Method Our sample included 87 patients with mood or anxiety disorders. The NEO-PI-R questionnaire and the Adult Attachment questionnaire by Melero were used. Results Insecure attachment styles were associated with a higher expression of neuroticism, and a lower expression of extraversion, conscientiousness, and agreeableness, especially in individuals with the most insecure attachment. An interaction was identified between the attachment style and the 5-HTTLPR genotype on the expression of agreeableness. Higher neuroticism, and lower extraversion and conscientiousness tended to be present in carriers of the S allele. Discussion and conclusion There was a significant association between the attachment styles and the expression of neuroticism, extraversion, agreeableness, and conscientiousness-responsibility according to the Big Five Model. The short allele may be associated with the modulation of certain aspects of personality. Prevention strategies should be established to promote adequate attachments between infants and caregivers to avoid a possible risk factor for future maladaptive personality traits.
Resumen Introducción El apego entre la madre y el hijo puede tener un impacto importante. Un apego inseguro podría afectar el desarrollo emocional. Se ha sugerido que los cuidados de la madre en la infancia temprana se asocian a la personalidad. Sin embargo, se requieren más estudios en adultos. Objetivo Determinar si los estilos de apego en personas con trastornos del afecto o ansiedad se asocian a la expresión de rasgos de personalidad y si esta expresión es modulada por la presencia del alelo corto del polimorfismo 5-HTTLPR. Método Se incluyeron 87 pacientes. Se emplearon los cuestionarios NEO-PI-R y el de Apego en el Adulto de Melero. Resultados Los estilos de apego inseguro se asociaron con una expresión mayor de neuroticismo y menor de extroversión, conciencia y amabilidad, especialmente en los individuos con el estilo de apego más inseguro. Se identificó una interacción entre el estilo de apego y el genotipo del 5-HTTLPR en la expresión de amabilidad. En los portadores del alelo corto hubo una tendencia hacia mayores valores de neuroticismo y menores niveles de extroversión y conciencia. Discusión y conclusión Los estilos de apego se asocian con la expresión de neuroticismo, extroversión, amabilidad y conciencia/responsabilidad. El alelo corto del 5-HTTLPR podría asociarse con la modulación de algunos aspectos de la personalidad. Los resultados sugieren la importancia de promover un apego adecuado entre los niños y sus cuidadores primarios para evitar posibles riesgos que se asocien con rasgos desadaptativos de la personalidad.
ABSTRACT
Antecedentes La fibromialgia (FM) se caracteriza por dolor crónico generalizado, fatiga, alteraciones del sueño, depresión, ansiedad y disautonomía (hiperactividad simpática). Objetivo Comparar la variabilidad de la frecuencia cardiaca (VFC) en mujeres: 20 pacientes con FM vs. 20 controles, mediante Holter de 24 hrs. Método La medición consistió en segmentos de cinco minutos. El dominio de la frecuencia se determinó por logaritmo natural de la razón LF/HF (Low/High Frecuencies). Se utilizó ANOVA simple para dos grupos de variables dimensionales. Resultados El rango de edad fue de 30 a 60 años. Nueve mujeres presentaron comorbilidad psiquiátrica: depresión (77.7%) y ansiedad (22.3%). Hubo diferencias (F=24.45, p<0.0001) en LF/HF entre los grupos en la fase nocturna del registro (22 hrs a 2 am), mostrándose mayor activación simpática en las pacientes. En el índice SDNN (desviación estándar de intervalos entre latidos) existieron diferencias significativas en 9 de 12 periodos del registro. En el índice pNN50 (porcentaje de intervalos que difieren en más de 50 milisegundos), el grupo control mostró valores más altos de 6 a 12 hrs. La variación nocturna se observó de 22 hrs. (F=22.37, p=0.0001) hasta las 6 am (F=30.27, p=0.0001). El indicador rMSSD (raíz cuadrada de la media de las diferencias de la frecuencia cardiaca) mostró valores más altos para el grupo control desde las 22 hrs. (F=67.71, p=0.0001) hasta las 6am (F=80.35, p=0.0001). Discusión y conclusión Los resultados reflejan la disminución del influjo parasimpático en las pacientes con FM. Esto confirma la participación del sistema nervioso parasimpático en la fisiopatología de la FM.
Background Fibromyalgia (FM) is characterized by chronic widespread pain, fatigue, sleep disturbances, depression, anxiety and dysautonomia (sympathetic hyperactivity). Objective To compare the heart rate variability (HRV) in women: 20 patients with FM vs. 20 controls by Holter 24 hrs. Method The measurement consisted of segments of five minutes. The frequency domain is determined by the natural logarithm of the LF/HF (Low/ High Frecuencies) reason. Simple ANOVA was used for two groups of dimensional variables. Results The age range was 30-60 years. Nine presented psychiatric comorbidity: depression (77.7%) and anxiety (22.3%). There were differences (F = 24.45, p <0.0001) in LF/HF between groups in the nocturnal phase of registration (22 pm to 2 am) showing increased sympathetic activation in patients. In the SDNN index (standard deviation of intervals between heartbeats) there were significant differences on December 9 periods of record. In pNN50 index (percentage of intervals which differ by more than 50 milliseconds), the control group showed higher values of 6 to 12 hrs. Nocturnal variation was observed in 22 hrs (F = 22.37, p = 0.0001) until 6am (F = 30.27, p = 0.0001). The rMSSD indicator (square root of the mean of the differences in heart rate) showed higher values for the control group from 22 hrs (F = 67.71, p = 0.0001) until 6am (F = 80.35, p = 0.0001). Discussion and conclusion The results reflect the decreased parasympathetic influence in patients with FM. This confirms the participation of parasympathetic nervous system in the pathophysiology of FM.
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According to studies conducted in different countries, it is estimated that approximately 30% to 50% of people with mental health problems are not recognized by the general practitioner. Given this situation, it has been proposed that the practitioner at the primary care services must play a decisive role in the early detection of cases by establishing a definitive diagnostic and a timely treatment. Several organizations have pointed out that one of the first actions that need to be implemented to fulfill the aims in the care of people with mental disorders is to prepare the first-contact doctors and to have a brief, low cost, self-applied, valid and reliable scale. The studies mention that using screening tests at the primary care level is crucial for the success of the programs. The detection and recognition of psychiatric symptomatology rates vary depending on the type of scale applied. The tools that have been widely used are the Goldberg's General Health Questionnaire (GHQ), Zung Self-Rating Depression Scale, Beck Depression Inventory, the Depression Symptom Checklist (DS 20), the Hopkins Symptom Checklist (SCL), the Hamilton Depression Scale, the Center for Epidemiologic Studies Depression Scale (CES-D), the Montgomery-Asberg Depression Rating Scale, the Geriatric Depression Scale (GDS), the self-administered computerized assessment (PROQSY), the criteria of the 3rd revised edition of the Diagnostical and Statistical Manual of Mental Disorders (DSM-III-R), the Structured Clinical Interview for DSM-IV (SCID), and the criteria of the Symptom Driven Diagnostic System for Primary Care (SDDS-PC), among others. The preliminary results confirm the existence of a high percentage of possible psychiatric cases (46.9%), but only 4% of cases are referral. The low capability of the general practitioner at the primary care level in detecting these pathologies has been confirmed as well. These scales have been applied in different scenarios and to different types of population. Although the dominating criteria for choosing the tool are sensitivity and specificity, some authors mention that strategies for adequately handling cases, such as the confirmation of the diagnosis and follow-up of the patients, are required once the treatment has started. In this paper, we present the psychometric characteristics of the Kessler (K-10) scale in detecting depression and anxiety disorders in the primary care. Material and methods The study is a methodological process that aims to validate the Kessler Psychological Distress scale (K-10). It was conducted in two health care centers of primary care level in Mexico City. The subjects were 280 individuals who requested attention at the mentioned centers and to whom the K-10 test was applied after giving their informed consent. Later on, the computerized version of the International Neuropsychiatric Interview (MINI), which uses the diagnostic criteria of the DSM-IV, was applied to the subjects in order to confirm the diagnostics for depression and anxiety. The MINI is a version adapted to Latin American Spanish by the National Institute of Psychiatry Ramon de la Fuente Muñiz. The diagnostic accuracy was processed following the MINI diagnoses for depression and anxiety closely, and the scores on the scale K-10 as a predictor. The sensitivity and specificity were calculated for all possible cut points in order to establish the optimal cut off point. The efficiency and maximum likelihood ratios were also calculated. The area under the ROC curve as well as the probability quotients, positive and negative (LR+ and LR-), were also calculated. The K-10 is a brief screening tool that can be easily applied by the primary care personnel which measures the psychological distress of a person during the four weeks prior to the application. It consists of ten questions with Likert-like answers that range from 1 to 5 and are categorized in a five level ordinal scale: Always, Very Often, Sometimes, Rarely, Never; where «Never¼ has an assigned value of 1, and «Always¼ has assigned value of 5. It has a minimum score of 10 and a maximum of 50. The ranges of the instrument are four levels: low (10-15), moderate (16-21), high (22-29) and very high (30-50). The instrument showed an internal consistency of 0.90 and it has been used in various population studies promoted by the World Health Organization as well as government organizations in Australia, Spain, Colombia and Peru. Results Out of 280 individuals to whom the tool was applied, 78.9% (221) were female and 21.1% (59) male. These values represent the proportion of patients attending the primary care services (95% confidence interval=±5.4%). The mean age of women was 39 years, and the mean age of men was 41. The 70.6% of the women manifested more psychological distress than men (52.5%)[χ2(1)=6.05,p=0.014. No other socio-demographic variable showed significant differences. The instrument is highly precise, it can detect up to 87% of depression cases, and 82.4% of anxiety cases. The scale was compared with the MINI and it presented a prevalence of 26.8% and 10.6%, respectively. Of the total of depression cases, 26.4% also presented anxiety; these represent a co-morbidity of 5.4%. The construct validity presented one factor alone that explains the 53.4% of the total variance, this is why the scale is considered as one-dimensional. In other words, the scale only measures the construct of the psychological distress. The internal consistency was α=0.901. Once the sensitivity and specificity for all cut off points had been determined using the MINI as a golden rule, it was observed that the cut off point for maximum sensitivity and specificity corresponded to 21 for the diagnosis of depression, and 22 for anxiety. Conclusions The K-10 is a good instrument for the detection of depression and anxiety cases at the primary care level which meets the criteria of validity and reliability. However, given that only one diagnosis was considered for all the range of anxiety disorders, the scale must be chosen carefully for all the other disorders that are not included in this paper. The use of the instrument is recommended for the general practitioners at the primary care level, mainly for diagnosing depression. Various studies in which other screening instruments have been used for the detection of depressive disorder at primary care point out that any screening method are useful in making the diagnosis. By using these instruments, the depression diagnosis at primary care level increases from 10% to 47%. The latter supports the fact that the selection of a good instrument turns out to be effective in detection, treatment and clinical outcomes of the entity. Since this recommendation is only one of the activities required in primary care level for good handling of detected cases, it is noteworthy to mention that a comprehensive care model that encompasses both the detection as well as the pharmacological and psychosocial treatments is required.
De acuerdo con estudios realizados en diferentes países se estima que aproximadamente hay entre 30% a 50% de personas que presentan algún problema de salud mental que no es reconocido por el médico general. En virtud de esta situación se ha propuesto como estrategia a la atención primaria como base del sistema de salud, lo que permitiría la detección temprana de pacientes con algún trastorno psiquiátrico. Diferentes organismos señalan que una de las primeras acciones para cumplir con los objetivos en la atención de personas con algún trastorno mental, consiste en contar con una escala breve, autoaplicable, válida y confiable y de bajo costo. En este trabajo se presentan las características psicométricas de la escala Kessler (K-10) para detectar trastornos depresivos y ansiosos. La K-10 es un instrumento de tamizaje breve y de fácil aplicación por el personal del primer nivel de atención y ha sido utilizada en diferentes estudios a nivel poblacional. En Australia, en 1997, se aplicó la K-10 en una encuesta de salud, por medio del Consejo Nacional de Encuestas de Salud Mental. Material y métodos Se trata de un estudio de proceso metodológico, cuyo objetivo fue la validación de la escala de malestar psicológico K-10 de Kessler. El estudio se llevó a cabo en dos Centros de Salud del primer nivel de atención en la Ciudad de México. Los participantes fueron 280 personas que acudieron a la consulta externa de dichos centros. Se utilizaron los criterios del DSM-IV para la confirmación del diagnóstico de depresión y de ansiedad, por medio de la Mini International Neuropsychiatric Interview (MINI), en su versión computarizada, adaptada al español latinoamericano en el Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. La validez diagnóstica se procesó utilizando los diagnósticos de la MINI para depresión y ansiedad como regla de oro y las puntuaciones obtenidas en la escala K-10 como predictor. Se calculó la sensibilidad y especificidad para todos los posibles puntos de corte con el fin de establecer el óptimo. Se calculó adicionalmente la eficiencia y las razones de máxima verosimilitud, así como el área bajo la curva ROC y los cocientes de probabilidad, positivo y negativo (LR+ y LR-). Resultados Del total de personas a quiénes se les aplicó la escala, el 78.9% (221) fueron mujeres y 21.1% (59) hombres. Estos valores representan la proporción en que los pacientes acuden a los servicios de primer nivel (IC 95%=±5.4%). El 70.6% de las mujeres presentaron mayor malestar psicológico en comparación con los hombres que representaron el 52.5% [χ²(1)=6.05,p=0.014]. En ninguna otra variable socio-demográfica se presentaron diferencias significativas. El instrumento tiene una alta precisión, ya que puede detectar hasta el 87% de los casos de depresión y un 82.4% de los casos de ansiedad. La escala se comparó con el MINI en español y presentó una prevalencia de 26.8% y 26.4%, respectivamente. Conclusiones El instrumento cumple con los criterios de validez y confiabilidad, por lo que se recomienda su uso por los médicos generales en el primer nivel de atención. Dado que esta recomendación sólo es una de las actividades que se requieren en la atención primaria para un buen manejo de los casos que se detecten, es necesario señalar que se requiere de un modelo de atención integral que incorpore tanto la detección como el tratamiento farmacológico y psicosocial.
ABSTRACT
Mental health problems, specifically mental disorders, develop from a complex system and not from a single cause. Obsessive-compulsive disorder (OCD) affects more than 2% of the population and generally the course of the illness is insidious and chronic. When functioning adequately, family constitutes a very important resource to face health problems and to help to improve the patient's life quality. This is the reason why it is important to underline the relevance of a stable, good functioning of the family system aimed at attaining an optimal development of all its members. Such development may be hindered by the family's incapability to modify functioning patterns at crucial moments when they are trapped in a series of inadaptable interactions which prevent to give specific solutions to the problems that are appearing, and when reporting, within a context of expressed emotion, an emotional over-involvement and high levels of hostility and criticism towards the member with OCD. Family accommodation is a phenomenon typical of families where the identified patient exerts a control based on aggressiveness when his/her wishes are not rewarded within the group. There are very few researches on the functioning of families of patients diagnosed with obsessive-compulsive disorder. Generally, these researches are related with the partially negative effects that the interactions have on the behavior of patients and their relatives by preventing or hindering the development of the subject's system. The accordance between the patient's emotional regulation or emotional intelligence and their relatives has not been studied. On the other hand, the knowledge of the beliefs that relatives hold regarding the illness may be related with the functioning of the group as a family, whereas beliefs will provide consistency to family life because they provide continuity between past, present and future. They are also a way to address new and ambiguous situations such as mental illness. This is the reason why getting to know these family systems may allow elaborating more specific and effective intervention programs for groups and families. Objective To determine the family types through a member identified with obsessive-compulsive disorder; to compare the emotional intelligence profile between patients and relatives according to the perceived type of family; to compare the relatives' beliefs toward the illness according to the perceived type of family. Material and methods A sample of patients and their families with obsessive-compulsive disorder was obtained from those who were sent by the doctor in charge of their treatment to participate in a model of group therapy for OCD, consisting of cognitive behavioral theory, practices and psychoeducation. During the first session patients and their relatives answered the following instruments: Family Adjustment and Cohesion scales (FACES-II) by Olson, Profile of Emotional Intelligence (PIEMO) by Cortés et al., Beck Inventory of Anxiety. Relatives answered too the Beliefs and Attributions Questionnaire by Salorio et al. In addition, data on family structure was complied. The sample was constituted by 48 patients and 61 relatives. All instruments were self-applied. Once that the type was obtained according to the Olson's circumflex model, the emotional profile, the anxious and the depressive symptoms were compared through factorial 2x3 ANOVA. Beliefs and attributions were compared through simple ANOVA. Results Three types of families were determined as follows: high cohesion with chaotic standards for expressing emotions and ideas; high cohesion with a rigid expression of ideas and emotions; low cohesion with a little expression of ideas and emotions. Different profiles of emotional intelligence were found not only for patients but also for relatives, in each family type. Families with high cohesion and high adjustment appear as most emotionally intelligent, less anxious and depressed, and with beliefs more attuned to reality. This type of family function was the less frequent. For beliefs and illness attributions, it was observed that comprehension of the disorder increases in proportion to a higher family adaptation, while the tendency of family members to experience feelings of guilt either towards themselves or towards the patient is decreased. As a result, the perception of experiencing the patient's illness as a nuisance disappears. With regard to the results of the Beck scales, family members perceived a high cohesion and low adaptation had higher scores for depression and anxiety. In patients who show high levels of depression and anxiety perceive family functioning as a rigid structure, with little prospect of change and interaction that prevents growth (high cohesion, low adaptation), and in those perceived isolation, without significant emotional ties with other family members and with the rigidity that prevents problem situations. Conclusions The results obtained are congruent with Olson's statements in regard to family functioning in the specific case of obsessive- compulsive disorder; these findings permit to understand the family dynamics which may typify the symptoms in the identified patients, and also to explain the adjustment situation described in literature. Family intervention is justified, stressing the handling of emotions as an important element to be considered in order to obtain higher therapeutic benefits for the patient. This study found differences in adjustment between patients and their families, do not perceive the need for flexibility in the operation of the system to find solutions that do not perpetuate and sustain interactions that reinforce symptoms. As for depression and anxiety, similar levels in either condition may be observed, thus confirming the close relationship between both. It was found that in patients and relatives, higher levels of family adaptation correspond to lower levels of depressive and anxious symptoms. One of the first approaches to the dynamics of these systems must be headed towards the family systems of beliefs, as the ideas that family members hold regarding the importance of their participation in the whole process of the illness has an impact in its course. Many families have rigid systems that make them more vulnerable to the fluctuations that this illness presents since for their members it is important and decisive to have control over the ailment. Families with flexible systems of beliefs are more prone to experience losses with a feeling of acceptance and therefore it is easier for them to let their members to implement changes in their functioning, thus compensating and overcoming their limitations. In this sense it is important to attain a therapeutic collaboration relationship that may create within the family a sense of realistic control and may help also to put into action the system's capabilities to promote improvement. This idea allows for openness in the system that may lead it to consider that there are more efficient operational measures that those applied to date.
Los problemas de salud mental y específicamente los trastornos mentales se desarrollan a partir de un complejo sistema biopsicosocial y difícilmente se puede identificar una causa única. El trastorno obsesivo compulsivo (TOC) afecta a más de 2% de la población y en general el curso de la enfermedad es insidioso y crónico. La familia es un importante recurso para enfrentar los problemas de salud y facilitar el mejoramiento de la calidad de vida del paciente, cuando su funcionamiento es adecuado. Existen pocas investigaciones realizadas sobre el funcionamiento de las familias de pacientes diagnosticados con trastorno obsesivo-compulsivo. Generalmente estas investigaciones están relacionadas con los efectos potencialmente negativos que dichas interacciones tienen en las conductas de pacientes y familiares que impiden u obstaculizan el desarrollo del sistema y de los individuos. La concordancia de la regulación emocional o inteligencia emocional de los pacientes y sus familiares no ha sido estudiada. Por otra parte el conocimiento de las creencias sobre la enfermedad por parte de los familiares puede estar relacionado con el funcionamiento del grupo como familia. Es por ello que el conocimiento de estos sistemas familiares podrá permitir estructurar programas de intervención grupal o familiar más específicos y eficaces. Objetivo Determinar la tipología de las familias con un miembro identificado con trastorno obsesivo compulsivo, comparando tres aspectos: 1) El perfil de inteligencia emocional entre pacientes y familiares según el tipo de familia percibido. 2) La ansiedad y depresión entre pacientes y familiares según el tipo de familia percibido y 3) Las creencias de los familiares hacia la enfermedad según el tipo de familia percibido. Material y métodos Se obtuvo una muestra de pacientes y sus familiares con trastorno obsesivo compulsivo (TOC) los que fueron enviados por su médico tratante a participar en el modelo terapéutico grupal para TOC, que consiste en Teoría y Técnicas cognitivo conductuales y psicoeducativas. Durante la primera sesión los pacientes y sus familiares acompañantes contestaron los siguientes instrumentos: Escala de cohesión y adaptación familiar (FACES-II) de Olson et al., Perfil de Inteligencia Emocional (PIEMO 2000) de Cortés et al., Inventario de Ansiedad de Beck, Inventario de depresión de Beck. Los familiares contestaron además el Cuestionario de Creencias y Atribuciones sobre la enfermedad de Salorio et al. Además se recabaron datos sobre la estructura familiar. La muestra se conformó por 48 pacientes y 61 familiares. Todos los instrumentos fueron autoaplicados. Una vez obtenida la tipología según el modelo circumplejo de Olson se compararon el perfil emocional y los síntomas ansiosos y depresivos por medio de ANOVA factorial 2x3. Las creencias y atribuciones se compararon por medio de ANOVA simple. Resultados Se determinaron tres tipos de familia: 1. Las de alta cohesión con lineamientos caóticos para la expresión de emociones e ideas. 2. Las de alta cohesión con rigidez en la expresión de ideas y emociones y 3. Las de baja cohesión con escasa expresión de ideas y emociones. Se encontraron perfiles de inteligencia emocional diferentes tanto para pacientes como para familiares en cada uno de los tipos de familia. Las familias con alta cohesión y adaptación se manifiestan como las más inteligentes emocionalmente, menos ansiosas y deprimidas y con creencias más apegadas a la realidad. Sin embargo, este grupo fue el menos frecuente. Conclusiones Los resultados obtenidos son coherentes con los planteamientos de Olson en relación al funcionamiento de las familias. En el caso específico del trastorno obsesivo-compulsivo estos hallazgos permiten entender la dinámica familiar que pudiera caracterizar el mantenimiento de la sintomatología en los pacientes identificados. La intervención familiar es un elemento importante a considerar para obtener mayores beneficios terapéuticos para el paciente.
ABSTRACT
Introduction Recent studies have shown an increase in psychiatric symptomatology in medical students and physicians during their professional practice. Some studies show that these professionals have a higher prevalence of psychiatric symptoms than the general population. This phenomenon is a consequence of the particular conditions of this professional activity, and, in the case of students, of high academic demands that lead to stressful situations that interfere with their academic performance and the development of clinical skills, which may have repercussions on their relationship with their patients. The predominant symptoms are anxiety, depression and stress, as well as substance use; there has also been an increase in the number of students with suicide attempts. Most of these problems occur during the first two years of the degree course as well as the internship year. Depression is masked by anger, by virtue of the fact that it is an internalized form of anger. It has also been documented that there is a significant link between certain personality traits and the presence or absence of mental symptoms, regardless of the situations to which people are exposed. The feature with the highest association with the presence of symptomatology is neuroticism, while the personality traits that are most conducive to the achievement of academic success and better adaptation and, therefore, a lower number of symptoms are empathy and kindness. The purpose of this study was to establish a diagnosis of the mental health and personality traits of medical students in the high performance groups and compare them with those of the groups of students that performed poorly during the first two years of the degree course. This transversal, exploratory study involved the participation of 370 students from the UNAM Medical School: 220 belonged to the high performance groups, called educational quality nuclei (NUCE), while 1 50 were repeat students. The variables considered were: age, sex, type of group (NUCE or repeat), academic year (first or second year of the degree), place of origin and type of high school from which they had graduated (public or private). Two instruments were used to measure personality traits and psychiatric symptomatology: the Big Five Personality Traits and the Symptom Check List-90. The results of the study show that in both groups (repeat students and NUCE) over 85% were from the Federal District. Repeat students were mainly women (85.3%) and students from public schools (93.6%). As for the high performance group (NUCE), 83.1 % were from private schools and just 1 6.9% from public schools. Repeat students showed personality traits that included neuroticism and very little openness compared with the high performance groups, which displayed traits of greater openness and less neuroticism, with p<0.01. In general, students from NUCE groups showed traits of greater extraversion, empathy and diligence compared with repeaters. Psychiatric symptomatology was more severe among the repeat group than the NUCE group (p<0.05). The psychiatric symptomatology displayed by both groups included: obsession-compulsion, depression and anxiety. In the comparisons, the two groups showed significant differences in total symptomatology. There were also differences in the following symptomatology, by order of importance: phobia, interpersonal sensitivity, somatization, anxiety, obsessive-compulsive disorder and psychoticism (p<0.05). Differences were found between academic years, with second-year students showing greater symptomatology; women displayed the greatest symptomatology. No differences were found for the interaction between sex and academic year. The analysis of structural models was used to determine the relationship between the variables being studied, with significant correlation coefficients with p<.05 being found between personality and sex, personality and type of high school, as well as type of group and suicidal ideation, academic year and psychiatric symptomatology, personality and suicidal ideation and personality and psychiatric symptomatology. The results of the study coincided with those in the literature, although there were some differences between the two groups of students. Repeat students displayed greater levels of psychiatric symptomatology compared with students in the high performance groups. This suggests that students who perform less well in their degree courses also report higher mean responses in psychiatric symptomatology, mainly on scales of somatization, anxiety, phobia and interpersonal sensitivity. As for type of personality, students in the high performance group reported higher average scores on the scales of extraversion, empathy and openness, with the exception of the neuroticism scale. This suggests that personality features may be predictors of better academic performance as well as greater intellectual skill. This finding is reinforced by the repeater group's results, since they report higher scores in the personality trait of neuroticism. The diligence scale was the same for both groups. The study corroborated the fact that second-year students display the greatest symptomatology, with women reporting higher averages in psychiatric symptomatology scores (mean = 7.3). Sex is associated with greater empathy and solidarity, with women achieving higher scores in both personality traits. Although the neuroticism trait is also associated with the female sex and suicidal ideation, scores for this trait were higher for men. This trait can be considered a predictor for both suicidal ideation and the presence of a higher number of psychiatric symptoms. Lastly, the symptomatology in which these students obtained the highest scores is related to the obsessive-compulsive disorder, a situation which we consider may be due to the type of screening test used. It is a fact that studying medicine involves continuously stressful conditions. For these students, however, seeking help to cope with the presence of psychiatric symptomatology is extremely complicated since they regard it as a form of weakness. This raises the need to develop large-scale programs to orient students in order to enable them to identify symptoms at an early stage, which in turn will permit timely treatment.
En estudios recientes se ha demostrado un incremento en la sintomatología psiquiátrica que presentan los estudiantes de medicina, así como los médicos durante su ejercicio profesional. En algunos estudios se señala que estos profesionistas tienen una prevalencia de síntomas psiquiátricos por arriba de los de la población general. Este fenómeno es una consecuencia de las condiciones propias de la actividad profesional y, en el caso de los alumnos, por situaciones que demandan una mayor exigencia académica, que conlleva a su vez situaciones estresantes que interfieren en su desempeño académico, así como en el desarrollo de habilidades clínicas que pueden repercutir en su relación con los pacientes. Los síntomas que predominan son la ansiedad, la depresión y el estrés, así como el consumo de sustancias; también se ha incrementado el número de estudiantes con intentos de suicidio. Se observa que la mayoría de estos problemas tipo se presentan en los dos primeros años de la carrera, así como en el año de internado. La depresión se encuentra enmascarada por enojo, en virtud de que ésta representa un enojo internalizado. Asimismo se ha documentado que existe una relación importante entre la presencia de ciertos rasgos de personalidad y la presencia o ausencia de síntomas mentales, independientemente de las situaciones a las que se expongan las personas. El rasgo que presenta una mayor asociación con la presencia de sintomatología es el neuroticismo, así como también los rasgos de personalidad que influyen con un mejor cumplimiento de logros académicos y una mejor adaptación. El objetivo de este trabajo fue establecer un diagnóstico de la salud mental y los rasgos de personalidad de los estudiantes de medicina que se encuentran en los grupos de alto rendimiento y compararlo con los grupos de alumnos que presentan bajo rendimiento académico durante los dos primeros años de la carrera. En este estudio exploratorio, de tipo transversal, participaron 370 estudiantes de la Facultad de Medicina de la UNAM: 220 correspondían a los grupos de alto rendimiento, llamados núcleos de calidad educativa (NUCE), y 150 eran alumnos repetidores. De entre los resultados que arrojó el estudio, se encontró que para ambos grupos (repetidores y NUCE) más de 85% provenía del Distrito Federal. En el grupo de repetidores predominaron las mujeres (85.3%) y los alumnos procedentes de escuelas públicas (93.6%). En relación con el grupo de alto rendimiento (NUCE), 83.1% procedía de escuelas privadas y sólo 16.9% de escuelas públicas. Los alumnos repetidores mostraron rasgos de personalidad de neuroticismo y de poca apertura en comparación con los grupos de alto rendimiento, quienes mostraron rasgos de mayor apertura y menor neuroticismo, con una p<0.01. En general, los alumnos de los grupos NUCE mostraron rasgos de mayor extroversión, mayor empatía y diligencia en comparación con los repetidores. La sintomatología psiquiátrica mostró mayor gravedad en el grupo repetidor con respecto al grupo NUCE (p<0.05). La sintomatología psiquiátrica que presentaron ambos grupos fue: obsesión-compulsión, depresión y ansiedad. Entre las comparaciones resultaron diferencias significativas en ambos grupos en el total de sintomatologías. También hubo diferencias en las siguientes sintomatologías por orden de importancia: fobia, sensibilidad interpersonal, somatización, ansiedad, trastorno obsesivo-compulsivo y psicoticismo (p<0.05). Los resultados del estudio presentan coincidencias con lo publicado por la bibliografía; sin embargo, hay diferencias entre ambos grupos de estudiantes. En los alumnos repetidores se observó mayor sintomatología psiquiátrica en comparación con los alumnos de los grupos de alto rendimiento. Por lo anterior, se concluye que los alumnos que presentan menores niveles de logro en la carrera también presentan medias de respuestas mayores en sintomatología psiquiátrica, principalmente en las escalas de somatización, ansiedad, fobia y sensibilidad interpersonal.
ABSTRACT
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Summary During the decade of 1880, Paul Briquet made a well detailed description of a syndrome named after him, characterized by a series of unexplainable medical symptoms that appeared in a hideous way, with clinical curse and without the paroxysmal seizures mentioned by Charcot in his description of hysteria. Nevertheless, all the patients that showed these symptoms were diagnosed as hysteric. Nowadays, the clinical scenery is substituting the term of hysteria in favour of its components and giving it different names such as dissociative disorder, conversive disorder, and disorder caused by somatic symptoms of somatoform. Other terms such as "functional somatic syndrome" or "medically unexplainable symptoms" have been added to the list. In spite of these denominations no explanation has been given to the etiology of hysteria. Each medical specialty has to contend with some functional somatic syndrome: gastroenterology presents irritable colon; cardiology, precordial pain; neurology, tensional cephalalgia; stomatology presents tempomandibular dysfunction, and ginecology, chronic pelvic pain. Lumbar pain is present in orthopedia, chronic fatigue in cases of infectiousness, and finally, in rheumatology, there is fibromyalgia. In spite of their differences, these symptoms have some likenesses: they are associated to depression and anxiety, and have a high comorbidity with personality disorders; patients show major emotional distress, they share stories of either psychological, physical or sexual abuse during childhool, and suffer from some type of chronic pain. Although having visited several specialists in their search for explanations and treatment, results have been poor and patients have been labelled, in a pejorative way, as hysteric or hypochondriac. When diagnosed with any of these syndromes, patients' stress is reduced while having to face the invisible, uncontrollable and unpredictable fact implied by suffering from the symptoms that are typical. In particular, fibromyalgia assembles all the characteristics mentioned above. Turk and Cathébras proposed that establishment and exacerbation of the main symptoms of fibromyalgia (pain and fatigue) still constitute and model of respondent conditioning and that repeated exposure to certain stimulus generalizes learning. Also, they affirm that the same symptoms create later a cycle that perpetuates fibromyalgia. Once that symptom have been installed and strengthened, patients avoid all kind of activities, they get involved in legal procedures to obtain leave or else, they look for labour prerogatives. Besides, patients with fibromyalgia show the classic behaviour described for hysteria: "belle indifference", secondary advantages, dramatizing, blaming for their sufferings events which are out of their daily routine, and scarce tolerance. The purpose of this study is to present quantitatively, in patients diagnosed with fibromyalgia, the following agents: symptoms severity, prevalent personality, comorbidity with personality disorders, and degree of severity of depression and anxiety. Qualitatively, we wish to demonstrate the presence of the cycle that sustains the given symptoms. Participants: Ten patients with fibromyalgia participated in our study, 9 women and 1 man, diagnosed according to the criteria of the American College of Rheumatology, aged 37.9 ± 8.8 and with a medium time of evolution of 3 (2-23) years. Quantitative variables: Physical status and syndrome's severity were assessed using the Fibromyalgia Impact Questionnaire (FIQ); for personality, disorders were evaluated with the Revised Personality Diagnose Questionnaire (PDQ-R); depression, with Beck's Inventory, and anxiety with Spielberger's Trait State Inventory. Qualitative theoretical focus: Life experiences narrated by patients in their daily record of events, emotions and thoughts associated with pain, are presented. Procedure: All patients were evaluated individually at the beginning of a cognitive behavioural intervention. Qualitative data was obtained from daily records kept during at least three weeks or a maximum of 12. Texts were transcribed and the words most mentioned were identified, as well as those scarcely reported, thus propitiating descriptive categories. Results: The American College of Rheumatology established as one of the diagnose criteria for fibromyalgia, the presence of al least 11 of a total of 18 hypersensitive sites. Patients presented in average 16.3 ± 2.5 painful sites. Incapability was measured by patients in 2.3 ± 2.2 in a scale of 0 to 3 points; they reported to have felt well 1.1 ± 1.2 days per week; they didn't work 1.0 ± 1.1 days per week. The following measures are reported in scale from 1 to 10 points. Laboural interference was calculated in 7.3 ± 2.3; intensity of pain was 8.1 ± 1.4, day long fatigue, 8.4 ± 1.9, morning fatigue was 8.5 ± 2.3. Rigidity was 7.5 ± 3.0; anxiety perceived, 7.5 ± 2.6 (FIQ), and anxiety state along 12 weeks was 38.5 ± 10.3. Anxiety trait during the same period was 50.9 ± 9.7; perceived depression, 6.9 ± 3.4 (FIQ), and cognitive depression 14.7 ± .5. In the scale of personality it was found that six patients reached punctuations higher than T60 in neuroticism, and two other punctuated below T40 in extroversion. Regarding personality disorders it was found an average for 1.8 ± 1.1 disorders per patient; those more frequent were the following: histrionic (4), borderline (3), passive aggressive (2) and schizoid (2). Qualitative data support the existence of the typical symptoms described for hysteria. Conclusions: According to the results obtained from the quantitative analysis of this group of patients with fibromyalgia, we can conclude that they suffer from a disorder that generates major incapability accompanied of pain and fatigue. Nevertheless, their personality characteristics show that they have high levels of neuroticism with presence of personality disorders and at the same time important levels of depression and anxiety, predominating in the former, anxiety as a trait. Manifestations described by patients in their daily record of events, emotions and thoughts associated with pain and fatigue, confirm the presence of the classic symptoms that typified the construct of hysteria. These patients are vulnerable to their surroundings, have a story of childhood sufferings, and assumed an adult role from a very early age. Symptoms appear to be the only mechanism which at a given moment in life allowed them to get rid of the responsibilities that burdened them from childhood. Unfortunately, this symptom was associated to their environment, according to the laws of learning. It is concluded that fibromyalgia, as nosologic entity accomplishes the characteristics of hysteria, although as etiology it is established by learning.
ABSTRACT
Los trastornos del sueño son problemas frecuentes que se observan en las grandes poblaciones, provocados principalmente por situaciones de tensión. Desafortunadamente en nuestra población a estos problemas no se les da la debida importancia y suelen no ser identificados. El presente estudio fue llevado a cabo para analizar los trastornos del sueño en una población no seleccionada de un hospital general de la ciudad de México, utilizando un cuestionario desarrollado para este fin. El estudio analizó 597 sujetos, de ambos sexos, mayores de 18 años. Las características y hábitos del sueño fueron constantes en la mayor parte de los pacientes. No obstante, la frecuencia encontrada de trastornos del sueño fue mayor que la reportada en otros estudios similares. En nuestro población, estos trastornos no fueron identificados como un posible problema primario, ni por los pacientes ni por médicos, pero fueron considerados como un síntoma que acompañaba otras enfermedades. También fueron relacionados con cambios del humor o del carácter, y en algunos casos, estos cambios fueron de larga duración. Los resultados obtenidos demuestran que el instrumento utilizado fue de gran utilidad para conocer las características del sueño en los pacientes de un medio hospitalario. Se necesitan más estudios en otros grupos de sujetos para precisar los trastornos más importantes del sueño y sus factores desencadenantes en nuestra población