ABSTRACT
A pesar de la farmacoterapia, tratamiento esencial del trastorno bipolar I, un porcentaje importante de pacientes experimenta nuevos episodios afectivos. La terapia cognitivo conductual (TCC), la psicoterapia interpersonal y ritmo social y la terapia familiar focalizada, lo mismo que la psicoeducación, enfoques psicosociales útiles en el tratamiento del trastorno bipolar, comparten el énfasis en el empoderamiento del paciente para convertirlo en participante activo de su tratamiento. La adición de la TCC al tratamiento tiene como objetivos aliviar los síntomas depresivos, restablecer el funcionamiento psicosocial y prevenir la aparición de nuevos episodios afectivos. Aunque la investigación es limitada, en este trabajo se describen las bases teóricas y los estudios empíricos que avalan el uso de la TCC como una intervención psicosocial indispensable. Objetivos El presente trabajo tuvo como objetivo demostrar la utilidad de la TCC como tratamiento coadyuvante en la depresión del trastorno bipolar I para los síntomas residuales, la adherencia y el cumplimiento del tratamiento, la conciencia y la comprensión del trastorno bipolar, la identificación temprana de los síntomas de los episodios afectivos y el desarrollo de habilidades de afrontamiento. Método Se revisaron los ensayos clínicos controlados acerca de la utilidad de la TCC como tratamiento del paciente con depresión del trastorno bipolar I. Resultados La TCC aumenta la adherencia al tratamiento farmacológico, disminuye la frecuencia de recaídas en el primer año, los síntomas depresivos residuales, las hospitalizaciones y la duración de los episodios y mejora la adherencia terapéutica y el funcionamiento psicosocial; su utilidad es similar a la terapia familiar focalizada y la psicoterapia interpersonal y ritmo social. Los efectos terapéuticos disminuyen a lo largo del tiempo y sus resultados son menores en pacientes con mayor número de episodios afectivos (>12) y mayor comorbilidad. Conclusiones La TCC es una intervención que mejora la evolución del trastorno bipolar tipo I.
Although pharmacotherapy is the essential treatment for bipolar I disorder depression, a significant percentage of patients continue experiencing emotional episodes. Cognitive behavioral therapy (CBT), interpersonal psychotherapy and social rhythm and focused family therapy, as well as psychoeducation, share the emphasis on the empowerment of the patient so she/he becomes an active participant in treatment, becomes aware of the nature of the disorder who suffers, and learns to recognize early symptoms of depressive episodes in order to prevent its recurrence. The addition of the CBT aims to alleviate depressive symptoms, restore the psychosocial functioning and prevent the appearance of new affective episodes. Objectives This paper aimed to demonstrate the importance and usefulness of the CBT as an adjuvant of the pharmacological management of depression in bipolar disorder type I in those areas which cannot be resolved by pharmacological treatment (residual symptoms, adherence and compliance with treatment, awareness and understanding of bipolar disorder, identification of prodromal symptoms and developing coping skills). Method Controlled clinical trials about the usefulness of CBT as an adjunctive treatment of patient with depression due to bipolar disorder type I are reviewed. Results CBT increases adherence to drug therapy, decreases the frequency of relapses, diminishes residual symptoms, the need for hospitaliza-tion, and the duration time of depressive episodes; it also improves psychosocial functioning. However, these effects diminish over time and its results are lower in patients with more affective episodes and greater comorbidity. Conclusions There is evidence of the utility of the CBT as a useful tool to improve the evolution of the condition in depressed patients due to bipolar I disorder and of the need to extend the time of this and other psychosocial interventions, since this disorder is a condition that lasts a lifetime and causes significant impact on psychosocial functioning of the person.
ABSTRACT
Otto Kernberg states three types of personality organizations, also named psychological functional levels. They reflect the patient's predominant psychological characteristics: identity integration grade, defense mechanisms, and reality test. In mental disorders, the predominant defensive influences significantly in the severity and evolution of the suffering. Objectives The objective of the actual study was to determine the usage of defense mechanisms by patients with some mental disorder, grouping them according to personality organization levels or psychological functioning and the DSM-IV-TR Axis II diagnostic. Sample The sample included two groups: a) 1 02 hospitalized patients in the Instituto Nacional de Psiquiatría, 20 males and 82 females. b) A control group formed by 125 individuals, 48 males and 77 females; in all cases, they lived in Distrito Federal or Estado de México. Method The sample of this study was evaluated with the Defensive Questionnaire (DSQ-40) and the Personality Diagnostic Questionnaire (PDQ-4 + ); both instruments were applied as soon as patients were admitted to the hospital. The concepts of borderline psychological functioning and borderline personality disorder make reference to: The levels of personality organization or borderline psychological functioning characterized by an identity integration failure named identity diffusion, habitually reality judgment conserving and low level defenses supported on the splitting. b) The patients that were diagnosed with borderline personality disorder in agreement with the DSM-IV-TR. According to the personality organization, the psychotic disorders were grouped in the psychotic functioning level; the rest of the patients that suffered some anxiety or mood disorders were included in the borderline functioning level when they had also a diagnosis of borderline, narcissistic, antisocial, paranoid, schizoid, schizotypal, avoidant, dependent or histrionic personality disorder; in the neurotic functioning level those patients without personality disorder. The members of the control group were included in different academic level, labor and social scopes during the same period. Results The patients with a low level of personality organization (psychotic or borderline personality organization) used predominantly the immature or primitive defense mechanisms; patients with a high level of personality organization (neurotic level of psychological functioning) and members of the control group used predominantly mature or advanced defense mechanisms. Derived from the factorial analysis, three levels of defensive were determined: mature/advanced, neurotic and immature/primitive. In the mature/advanced defensive, the members of the control group were those that scored higher, followed by the psychotic patients and borderline. The scores of the neurotic defensive were higher in the borderline and psychotic groups than the control group. In the immature/primitive defensive, the borderline patients had higher scores than the psychotic and control group. The patients that were diagnosed through the PDQ-4+ with borderline personality disorder in agreement with the DSM-IV-TR had lower scores in the mature/advance defensive and higher than the control group in neurotic and immature/primitive defensive . The characteristics of personality of clusters A and B correlated positively with the following defensive s: immature/ primitive and neurotic and negatively with the mature/advanced defensive . The relation between the defensive s and the characteristics of personality of cluster C was negative in the defensive mature/advanced and positive in the neurotic and immature/ primitive. Conclusions: Through these findings a hierarchy between the levels of psychological functioning can be established, so that the lower the level of psychological functioning (borderline or psychotic), the higher is the use of immature mechanisms of defense and vice versa. The level of high psychological functioning (neurotic) used mature mechanisms of defense mainly; the borderline and psychotic levels of psychological functioning had major use of immature defenses, such as projection and autistic fantasy.
Los mecanismos de defensa son los elementos fundamentales de la organización de la personalidad, junto con la constancia objetal y el juicio de realidad. En los trastornos mentales, el estilo defensivo predominante influye significativamente en la gravedad y evolución del padecimiento. Objetivos El objetivo de este estudio fue determinar la relación existente entre los mecanismos de defensa, los trastornos de la personalidad y los niveles de funcionamiento psicológico (organización de la personalidad tipo neurótica, límite o psicótica) propuestos por Kernberg. Muestra La muestra del estudio estuvo constituida por dos grupos: a) Un grupo de 102 pacientes psiquiátricos hospitalizados, 20 del sexo masculino y 82 del femenino, provenientes del Instituto Nacional de Psiquiatría Ramón de la Fuente. b) Un grupo control, constituido por 1 25 sujetos, 48 hombres y 77 mujeres, en su mayoría residentes del Distrito Federal o del Estado de México. Método La población de este estudio fue evaluada con el Cuestionario de Estilos Defensivos (DSQ-40) y el Cuestionario Diagnóstico de la Personalidad (PDQ-4 + ) para determinar el uso de los mecanismos de defensa y detectar los trastornos de la personalidad, respectivamente. A los pacientes se les aplicaron ambos instrumentos al momento de su ingreso y se les agrupó en alguno de los tres niveles de funcionamiento psicológico de Kernberg. Los conceptos nivel de funcionamiento psicológico límite y trastorno límite de la personalidad hacen referencia a: a) La organización de la personalidad o nivel de funcionamiento límite caracterizada por la difusión de identidad, habitualmente conservación de la prueba de realidad y mecanismos de defensa basados en la escisión. b) El trastorno límite de la personalidad descrito por la Asociación Psiquiátrica Americana en el DSM-IV-TR. De acuerdo con la organización de la personalidad, los pacientes esquizofrénicos y con otras psicosis quedaron en el nivel de funcionamiento psicótico. Los pacientes que sufrían algún trastorno de ansiedad o del estado de ánimo se incluyeron en el nivel de funcionamiento límite o borderline cuando también tenían diagnóstico de trastornos de personalidad límite, narcisista, antisocial, paranoide, esquizoide, esquizotípico, evitativo, dependiente e histriónico; en el nivel de funcionamiento neurótico se incluyeron los pacientes con los trastornos mencionados, que no tenían trastorno de personalidad o bien cuyo diagnóstico fue de trastorno obsesivo-compulsivo de la personalidad. Los sujetos que sirvieron como controles fueron captados en distintos ámbitos escolares, laborales y sociales durante el mismo periodo. Resultados Los pacientes pertenecientes a los niveles de funcionamiento psicológico menores (psicótico o límite) usaron más los mecanismos de defensa inmaduros en comparación con los pertenecientes al nivel de funcionamiento psicológico de mayor nivel (neurótico) y que los sujetos controles. Se determinaron tres estilos defensivos: maduro/ avanzado, neurótico e inmaduro/primitivo. En el estilo maduro/ avanzado los sujetos del grupo control fueron los que puntuaron más alto, seguidos de los pacientes con nivel de funcionamiento psicológico psicótico y límite. Las puntuaciones del estilo defensivo neurótico fueron mayores en los grupos límite y psicótico que en el grupo control. En el estilo defensivo inmaduro/primitivo, los pacientes límites tuvieron puntuaciones mayores que los grupos psicótico y control. El grupo control puntuó más alto que el límite en sublimación, humor, anticipación y supresión, y que el psicótico en humor y supresión. El grupo de funcionamiento límite tuvo puntuaciones mayores que el grupo control en anulación, aislamiento, racionalización, proyección, agresión pasiva, exoactuación, fantasía autista, escisión y somatización. En cambio, puntuaron más alto que el grupo psicótico en supresión, agresión pasiva y somatización. El grupo psicótico tuvo puntuaciones mayores que el grupo límite en sublimación, anticipación y formación reactiva, y que el grupo control en anulación, desplazamiento, proyección y fantasía autista. Los pacientes diagnosticados a través del PDQ-4+ con trastorno límite de personalidad de acuerdo con el DSM-IV-TR tuvieron puntuaciones menores en el estilo defensivo maduro/avanzado que el grupo control pero mayores en los estilos defensivos neurótico e inmaduro/ primitivo. En el análisis individual de cada mecanismo de defensa se encontró que el grupo control tuvo mayores puntuaciones en sublimación, humor, anticipación, supresión y disociación que el grupo de pacientes con trastorno límite de la personalidad. Éstos puntuaron más alto en desplazamiento, racionalización, aislamiento, proyección, escisión, exoactuación, agresión pasiva, devaluación, fantasía autista, negación y somatización. Cuando se determinó el uso de las defensas de acuerdo con el diagnóstico de trastornos de la personalidad pertenecientes a los clusters A y B, se observó un mayor uso de los mecanismos de defensa basados en la escisión; de éstos, la fantasía autista fue la que tuvo mayor valor predictivo. Por el contrario, los trastornos de la personalidad del cluster C estuvieron asociados a los mecanismos de defensa de la esfera de la represión. Conclusiones Los resultados dan sustento empírico a la organización de la personalidad propuesta por Kernberg sobre los tres niveles de funcionamiento psicológico y a la vez demuestran la relación entre los trastornos de la personalidad y los mecanismos de defensa. El mecanismo de defensa denominado fantasía autista resultó ser un factor explicativo y predictivo de las características de la personalidad de los clusters A y B y del trastorno límite de la personalidad, en específico.
ABSTRACT
resumen está disponible en el texto completo
Abstract: Introduction. Schizophrenia is a chronic psychotic disorder whose prevalence in adults is from 0.5 to 1.5%, and its annual incidence ranks from 0.5 to 5 by each 10,000 inhabitants. Antipsychotic medications have shown to be effective in the treatment of acute psychosis and the prevention of relapse for persons suffering form schizophrenia. However, most of them have not shown to be able to correct fully the alterations in social and labor adjustment. Several studies -refering to the most important advances of the last years regarding this pathology, emphasize the necessity to know which are the psycho-social factors that participate in schizophrenia in order to prevent psychotic relapses and re-hospitalization. Approaches tending to find out the influence of the familiar surroundings have been limited by methodological matters. Although it is certain that attachment has been studied to understand the influence of the raising, in the evolutionary process of the personality and of some mental disorders, little is known about the early parental relations of the schizophrenic. Objectives. 1. To compare the description of the raising made by the schizophrenic patients in remission, with that made by healthy subjects with similar sociodemographic characteristics; 2. To compare the pattern of raising described by the hospitalized schizophrenic patient while presenting acute manifestations of psychosis, with that described once that such manifestations have been controlled; 3. To determine the relation and participation of the dimensions of the raising in regard to schizophrenia and its evolution. Methodology. An explanatory nonexperimental transeccional correlacional causal study was made. The sample was formed by the 23 schizophrenic patients hospitalized in the Instituto Nacional de Psiquiatría during the second semester of 2003, and by a control group formed by 50 healthy subjects with similar socio-demographic characteristics. The schizophrenic patients were evaluated through a clinical history and the application of The Positive and Negative Syndrome Scale (PANSS) and The Parental Bonding Instrument (PBI)(formed by two dimensions: 1. warmth; 2. distance and emotional coldness). These instruments were applied within the first five later days to their hospitalization and within the five previous days to their discharge by improvement. The control group was evaluated only on one occasion. A brief interview was made to collect some sociodemographic data and The Parental Bonding Instrument (PBI) was applied. Results. In order to determine the existing differences in the perception of the paternal and maternal raising between the group of schizophrenic patients in remission and the control group, a t test for independent samples was made. As established in the first hypothesis, significant differences in both groups were found, but only in the dimension paternal of distance and emotional coldness (p = .03) and maternal distance and emotional coldness (p = .000). With the purpose of determining the differences in the perception of the raising by the schizophrenic patients while suffering from acute psychosis and once they were in remission, the punctuation of the paternal and maternal PBI of admission and discharge were compared. In the maternal raising it was observed, in spite that both dimensions scored higher at the discharge, that distance and emotional coldness did not show significant changes. Warmth scored significantly higher at discharge (p = .003). In the case of perception of the parental raising, warmth (p = .001) as will as distance and emotional coldness (p = .02) scored significantly higher at the time of discharge. When analyzing with more detail the items of PBI that showed a significant change with the improvement of acute psychosis, it was observed that in the paternal warmth those were items 5 (p = .008), 7 (p = .021), 11 (p = .015), 12 (p = .049) and 17 (p = .047). As to distance and emotional coldness the items that changed were 16 (p = .002), 18 (p = .004) and 23 (p = .012). In the case of maternal warmth, the items that showed a significant change with the improvement of acute psychosis were 3 (p = .03) and 13 (p = .004). In distance and emotional coldness, only number 14 (p = .015) changed. Of the items of paternal being up that showed a significant change at the time of discharge, it was observed that item 5 had direct relation with the positive symptoms of discharge (p = .03); 7 with the positive symptoms of discharge (p = .01), the general psychopathology of discharge (p = .029) and the total qualification of the PANSS of discharge (p = .012); 11 with the positive symptoms of discharge (p = .04), the general psychopathology of discharge (p = .045) and the total qualification of the PANSS of discharge (p = .037); 12 with the positive symptoms of discharge (p = .003), the general psychopathology of discharge (p = .006) and the total qualification of the PANSS of discharge (p = .009); 18 with the general psychopathology of discharge (p = .041). With respect to the maternal raising it was observed that only number 13 correlated with the positive symptoms of admission (p = .014). In order to determine the relation between these dimensions with the variables and evolution of schizophrenia, a correlation of Pearson was made. In the paternal raising, Warmth (admission) correlated positively with the positive symptoms (admission) (p = .032). Warmth (discharge) was negatively correlated with the positive symptoms (admission) (p = .032) and the number of hospitalizations (p = .034). The paternal Distance and Emotional Coldness (admission) correlated negatively with the age of beginning of the schizophrenia (p = .04), and positively with time of evolution of the disease (p = .048). Distance and emotional coldness (discharge) did not have correlation. With respect to the maternal raising, warmth (admission) was positively correlated with the punctuation of general psychopathology (admission) (p = .032) and the years of study of the patient (p = .026). Distance and Emotional Coldness (admission) did not correlate significantly, nevertheless at the time of discharge did it positively with years of study (p = .03). In order to deter mine if the dimensions of the raising could predict the symptoms of the schizophrenic patient at the time of discharge, a multiple regression analysis was made. It was found that the positive symptoms could be predicted in 41.5% (R2 = .415) through the punctuation of the paternal Distance and Emotional Coldness (admission) (P = .510) and paternal Warmth (discharge) (P = -.622). Negative symptoms were not influenced neither by the paternal raising, nor by the maternal one. The punctuation of the scale of general psychopathology of the PANSS could be predicted in 26.3% (R2 = .263) through maternal warmth (P = -1.01) (discharge) and maternal distance and emotional coldness (P = .805) (discharge). The total qualification of the PANSS at the time of discharge could be predicted in 29.8% (R2 = .298) by maternal warmth (P = .516) (admission) and paternal Warmth (P = -.620) (discharge). The age in with the patient got sick could be predicted though the punctuation of the paternal distance and emotional coldness (P = -.625) (admission) and maternal warmth (P = .5) (discharge) in 44.8% (R2 = .448). The time of evolution could be predicted in 18.2% (R2 = .182) through paternal Distance and Emotional Coldness (P = .427) (admission). The number of hospitalizations was predicted in 37.5% (R2 = .375) by paternal Distance and Emotional Coldness (P = .543) (admission), maternal Warmth (P = -.916) (discharge) and maternal distance and emotional coldness (P = .811) (discharge). The number of days that was committed the patient at the moment of the evaluation could be predicted in 19.6% (R2 = .196) by paternal distance and emotional coldness (P = .484) (admission). Other variables, as the years of study were predicted in 18.6% (R2 = .186) by maternal warmth (P = .474) (admission). Conclusions. The schizophrenic patient in remission had a different perception of their parents than the control group. Schizophrenic patients perceived both parents colder and distant than the control group. In the particular case of first, it was observed that when improving the psychosis, also improved the perception of the raising. This one was related to the psychotic symptoms and other variables of the schizophrenia. These findings indicate the importance of the raising in the evolution of the schizophrenic patient.