Anorexia nerviosa: el cuerpo y los mandatos sociales-superyóicos / Anorexia nervosa: The body and commands from the social-superego

En este trabajo analítico y cualitativo presentamos los resultados de una investigación aplicada a cinco chicas con diagnóstico de anorexia nerviosa o trastorno alimentario no especificado. Utilizamos metodología de la sociología clínica en seis sesiones grupales y dos entrevistas individuales, para conocer las instancias psíquicas que se ponen en juego cuando la joven con anorexia nerviosa es capaz de lastimar su cuerpo tan gravemente, y continuar con esa dinámica a veces hasta la muerte. Encontramos que no las mueve un ideal de delgadez estético y que la enfermedad es regulada por el superyó, sostenida por lo que llamamos mandatos sociales superyóicos, que son frases coaguladas -carentes de sentido-, que las instala en un fuera de control, como un regulador implacable, propiciando el dominio de la pulsión de muerte...

Riesgo y letalidad suicida en pacientes con trastorno límite de la personalidad (TLP), en un hospital de psiquiatría / Suicidal risk and lethality in patients with borderline personality disorder (BPD), at a psychiatry hospital

Suicide attempt in patients diagnosed with Borderline Personality Disorder (BPD) is the most frequent cause of hospitalization in this clinical category and suicidal risks are usually the first manifestation of such disorder. Patients frequently relapse, thus generating high personal and family costs, including: treatments, hospitalization, medication, work disability in economically active people and even death. The American Psychiatric Association, through the DSM-IV, defines the Borderline Personality Disorder as <>. More specifically, criterion five of the disorder mentions self-mutilating behavior, threats, and recurrent suicidal behavior. DSM-IV reports that 8-10% of borderline patients commit suicide. In our country, however, there are no specific data about people diagnosed with BPD who actually have commited suicide. Prevalence of BPD among the general population ranks from 1 to 2%, from 11 to 20% of the psychiatric population; representing 20% of hospitalized patients. The gender distribution is 3:1, being more frequent among women than men. The objective of this study is the assessment of suicidal risk and lethality of 15 patients diagnosed with Borderline Personality Disorder. This research was conducted at the doctors' offices of the host institution, where 1.39% of a total of 1151 hospitalized patients in 2007 were diagnosed with BPD. The comorbidity of DSM-IV Axis I and BPD is frequent and can be found together with mood disorders (depression, dysthymia), substance-related disorders, eating disorders (bulimia nervosa), post-traumatic stress disorder, anxiety disorder and/or attention-deficit hyperactivity disorder. A research conducted in the USA with 504 patients diagnosed with BPD showed that 93% (n = 379) of the patients showed comorbidity of DSM-IV Axis I and mood disorders. Similar results were reported by other researchers. This study was designed to be a descriptive and transversal study. We went through the records of all the adult patients who had been hospitalized due to suicide ideation or attempt, diagnosed by psychiatrists as Borderline Personality Disorder, and confirmed by the SCID-II, and medicated by a psychiatrist. Selection criteria: 18 year-old patients or older, hospitalized due to suicide attempt or ideation, and diagnosed with BPD. The research was conducted in compliance with the regulations governing human research ethics set forth in the Declaration of Helsinki (1975). The instruments used were: the medical history of the patients, the ID file for clinical and epidemiological studies, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID -II), the Hopelessness Scale, the Depressive Syndrome Questionnaire, the Suicidal Ideation Scale, the Risk-Rescue Scale and some risk factors such as: sexual abuse, separation from partner, parental divorce, the suicide of a close relative, and alcohol and substance abuse. The results on the lethality of suicide attempts are similar to the results of other studies: women show a higher number of less lethal suicide attempts, and the methods used are also similar (medication intoxication and mutilation). The comorbidity with depressive disorders was of 86.6%, thus our results concur with those of other studies. Regarding risk factors, 86.6% (n = 13) mentioned they have experienced some type of sexual abuse, 46.6% (n = 7) separated from their partner, 40% (n = 6) had divorced parents, and 6.6% (n = 1) had a close relative who had committed suicide. During their last suicide attempt, one of the subjects had consumed alcohol and none of them had taken drugs; however, these behaviors did not appear to potentiate the suicidal risk. According to the scales applied, 46% of the subjects (n = 7) showed severe hopelessness, while 54% (n = 8) ranged between mild or moderate hopelessness; 13% (n = 2) had severe depression according to Calderon's scale. According to the Suicidal Ideation Scale, 93.3% (n=14) had a >10 score, which means patients show risk of attempting suicide again. The Risk-Rescue Scale suggests that most patients (n = 13) exhibited deliberate self-harming behavior (e.g. cutting superficially the skin around the wrist, taking prescription drugs or intoxicating near key people who could rescue them or provide help and rescue), which are not considered true parasuicidal behavior. The literature shows that BPD is the most prevalent of all personality disorders, both in the general and clinical population, the one with the highest number of suicide attempts in the DSM-IV Axis II, and the one with the highest comorbidity with Axis I mood disorders and Axis II personality disorders. The 15 patients in this sample carried out a total of 128 suicide attempts throughout their lives, which coincides with other research results, which describe that a history of multiple suicide attempts is a predictor of future suicidal behavior and increase the suicidal risk. As shown above, there were no cases obtaining high scores in all the scales applied (hopelessness, depression, suicidal ideation, high risk and low rescue), even in the result integration per subject, thus showing very few, high-lethality suicidal cases. It would be a mistake, however, to think that suicide attempts will always be less lethal, since there is always the risk of someone attempting a more lethal suicide that translates into the death of the patient. Suicide attempt assessment in dealing with Borderline Personality Disorder becomes a necessary condition to design better therapeutic strategies, since it allows health professionals to know the degree of lethality and timely treatment. The assessment of suicide attempts enables a more realistic prognosis, which backs up and guides clinical decisions.

Perfil de la relación de factores psicológicos del deseo sexual hipoactivo femenino y masculino / Profile of the relationship between psychological factors and hypoactive sexual desire in men and women

At the Department of Psychology of the Instituto Nacional de Perinatología 'Isidro Espinosa de los Reyes' (INPERIER), a hospital specialized in reproductive problems, we have detected a high proportion of couples with sexual problems. Therefore we decided to develope a line of research on human sexuality. Ever since, several exploratory studies have taken place with the aim of assessing the prevalence and the frequency of sexual dysfunction in both women and men attending the INPERIER. Our studies showed that 52% of women had one or more sexual dysfunctions and 38.8% of men had one or more sexual dysfunctions. Objective The main purpose of the study was to identify (in women and men) the relationship and the combination between hypoactive sexual desire disorder and some intervening variables catalogued as personality factors: gender role, self-esteem and locus of control. We also analysed sexual backgrounds by indentifying: child sexual traumatic experience, sexual information available, sex fears, masturbation and couple problems; in order to propose a profile of the relationship between psychological factors and hypoactive sexual desire in women and men. Material and methods A non-experimental, retrospective, transversal, field study with a correlation-multivariate design was used, which consisted of two independent samples divided into four groups selected through intentional sampling by quotas. This study is part of a larger research study aimed to assess risk factors for feminine and masculine sexual dysfunctions, whose original sample size was 400 participants. Out of this sample only participants with hypoactive sexual desire were selected, so in the end the groups included 58 women and 55 men. However, they were compared with the same number of participants with no sexual dysfunction. The groups were organized as follows: Group 1, women or men with no sexual dysfunction; Group 2, women or men who presented hypoactive sexual desire disorder. The participants included in the study were INPERIER regular patients. Samples were handled individually. In order to have an accurate sample all participants had to cover the selection criteria. Additionally, in order to place participants in the right group we used the Codified Clinical History Form on Female Sexuality (CCHFFS) for women -which also was used to examine their sexual background information- and in the case of men, we used the Male Sexuality Questionnaire. Furthermore the measurement of personality items was done by using the Inventory of Masculinity and Femininity IMAFE, the Coppersmith Self-Esteem Inventory and the Internal-External Locus of Control Scales. Sexuality questionnaires as well as other measurement instruments were applied at the External Clinic area during a single session followed by the transcription of data. In order to analyse the results we applied measures of central tendency to describe the socio-demographic factors (such as: age, civil status and education); for the analysis of personality factors (role of gender, self-esteem and locus of control) and its relationship with hypoactive sexual desire disorder we used the Student's T-test and estimated the Eta coefficient. The analysis of sexual background (child sexual traumatic experience, sexual information, sex fears, masturbation and couple problems) and its relationship with hypoactive sexual desire disorder was calculated by χ² and Cramer's V. Data analysis was performed with the statistical and data management package SPSS version 11. Results The thrown results showed that the descriptive analysis of data from women and men had a normal distribution. Also, results indicate that women with a hypoactive sexual desire disorder present a decrease in masculinity features and in their self-esteem level, and an increase in the submissive features when compared to women with no sexual dysfunction. When we analyzed the results of the sexual background in this group, we found a relationship between hypoactive sexual desire and child sexual traumatic experience, and between sex fears and couple problems, suggesting that these variables significantly intervene in the presence of hypoactive sexual desire disorder during women's adult life. In the discriminant analysis we obtained just one factor out of the six previously isolated variables with 75% of the cases correctly classified, indicating that this proportion of women with hypoactive sexual desire disorder are related to such indicators, the variables discriminated were an approximate explanation for the disorder. The results in the other group showed that in men with hypoactive sexual desire disorder there is a decrease in masculinity and femininity features and in the levels of self-esteem, plus an increase in the submissive features when compared to men with no sexual dysfunction. When we analyzed sexual background information, we found in the group with hypoactive sexual desire disorder that sex fears and couple problems significantly intervene in men's adult life. The discriminant analysis revealed a single factor with the six variables previously isolated, with 68.6% of cases correctly classified, which shows that men with hypoactive sexual desire disorder also have a relationship with the indicators, being the discriminated variables an approximate explanation. Conclusions When we discussed the results, we observed differences in two ways. First, for both women and men there was a decrease in masculinity features, defined as conducts directed to action, with well-defined, self-affirmed and self-reflective targets. Also there was a decrease in self-esteem, defined as the personal value judgment expressed as the individual's attitudes towards himself and the subjective experience transmitted to others; when masculinity features and self-esteem are diminished they may have an impact on sexuality, becoming a risk factor. In the group of men we also observed a decrease in the femininity features, defined as the traits aimed at feelings and abstraction, the expression of affection, the desire to provide protection as well as to experience nature feelings. When these three factors predominate they turn out to be a protective factor for an adequate practice of sexuality; both masculinity and femininity features could appear together or independently. In a second way, both in women and men we observed an increase in the submissive behavior, a risk indicator for the development of sexuality, because of the presence of self-denial, dependency, conformism, shyness and the capacity to endure suffering, features all shown as particular conducts. When it comes to sexual background in women, we found a close relationship with child sexual traumatic experience, sex fears and couple problems. In the case of men, the hypoactive sexual desire disorder was related to sex fears and couple problems. In this respect, in the review made by Basson, she mentions a new body of evidence that confirms what we have found in this study. She indicates that there are psychological factors that inhibit sexuality in women, for example, a history of child sexual traumatic experience may have a major impact in their sexual development, particularly in desire.

En el Departamento de Psicología del Instituto Nacional de Perinatología <> (INPERIER), se detectó un alto porcentaje de parejas con problemas en su vida sexual. Por ello se abrió una línea de investigación en sexualidad humana, mediante la cual se han realizado estudios exploratorios para determinar la prevalencia y frecuencia de las disfunciones sexuales de la población atendida. Los resultados muestran que 52% de las mujeres estudiadas y 38.8% de los hombres estudiados presentaron una o más disfunciones sexuales. Objetivo El objetivo de este estudio es identificar la relación y la combinación, entre el deseo sexual hipoactivo y algunas variables catalogadas como factores de personalidad -el papel del género, la autoestima y el locus de control- y como antecedentes sexuales -experiencia sexual infantil traumática, información sexual, temores a la sexualidad, masturbación y problemas de pareja- con el fin de proponer un perfil de factores relacionados con el deseo sexual hipoactivo, tanto femenino como masculino. Material y método Se realizó un estudio no experimental de campo, retrospectivo y transversal, con un diseño correlacional-multivariado de dos muestras independientes divididas en cuatro grupos, seleccionados mediante un muestreo intencional por cuota. Este trabajo forma parte de una investigación más amplia sobre el estudio de algunos factores de riesgo en las disfunciones sexuales femeninas y masculinas, cuya muestra original constó de 400 participantes. De éstos sólo se tomaron los participantes con deseo sexual hipoactivo que fueron 58 mujeres y 55 hombres. Este grupo se comparó con el mismo número de participantes que no tuvieron ninguna disfunción sexual. Las muestras se clasificaron en dos grupos: como grupo 1 sin disfunciones sexuales y como grupo 2 con deseo sexual hipoactivo. Tanto el grupo de mujeres como el de hombres debieron cubrir todos los criterios de inclusión. Para la clasificación de los grupos y la captura de los antecedentes sexuales se utilizaron la Historia Clínica Codificada de la Sexualidad Femenina (HCCSF) y el Cuestionario de Sexualidad Versión Hombres. La medición de los factores de personalidad estudiados se realizó con el Inventario de Masculinidad y Feminidad IMAFE, el Inventario de Autoestima de Coopersmith, y la Escala de locus de control interno-externo. Primero se capturó la muestra de hombres y posteriormente la de mujeres. Resultados Los resultados obtenidos indican que las mujeres con deseo sexual hipoactivo presentan un decremento en las características de masculinidad y en los niveles de autoestima, y un incremento en las características de sumisión. Los resultados acerca de los antecedentes sexuales, en este grupo, mostraron que el deseo sexual hipoactivo se relaciona estrechamente con la experiencia sexual infantil traumática, los temores a la sexualidad y los problemas conyugales. En el análisis discriminante se obtuvo un solo factor por medio de las seis variables aisladas previamente, con el 75% de los casos correctamente clasificados. Los hombres con deseo sexual hipoactivo mostraron un decremento en las características de masculinidad y de feminidad, al igual que en los grados de autoestima, y un incremento en las características de sumisión. Los resultados que se obtuvieron acerca de los antecedentes sexuales mostraron que el deseo sexual hipoactivo tiene una relación estrecha con los temores a la sexualidad y los problemas conyugales. En el análisis discriminante se obtuvo un solo factor con las seis variables aisladas previamente, con el 68.6% de los casos correctamente clasificados. Conclusiones La investigación arrojó diferencias principalmente en dos sentidos. Por un lado tanto en las mujeres como en los hombres hay un decremento en las características de masculinidad y en la autoestima. Además, en los hombres también se presentó un decremento en los rasgos de feminidad. Este decremento muestra que estos tres factores constituyen indicadores de riesgo para el ejercicio satisfactorio de la sexualidad. Tanto las características de masculinidad como de feminidad pueden presentarse independientes o de manera combinada.

El deseo de maternidad en pacientes sujetas a tratamiento de reproducción asistida: una propuesta de psicoterapia / The desire of maternity in patients under reproductive assisted treatments: a psychotherapy proposal

Objetivo: Este trabajo tiene como finalidad la presentación de una propuesta de lineamientos para una psicoterapia dirigida a pacientes sujetas a tratamientos de reproducción asistida en instituciones de salud pública. Dichos lineamientos surgen a partir de los resultados obtenidos en una investigación realizada a esta población que tuvo como finalidad detectar los factores relevantes que influyen en su deseo de maternidad.Material y métodos: El estudio del que se parte fue realizado a 100 mujeres de 25 a 40 años de edad diagnosticadas de esterilidad primaria y que acudieron al Servicio de Reproducción Humana del Servicio de Ginecología del Centro Médico Nacional "20 de Noviembre" del ISSSTE para su tratamiento. A todas las pacientes se les realizaron de seis a ocho entrevistas a profundidad, semi-dirigidas, con el fin de facilitar las respuestas a indicadores clínicos previamente establecidos. Se escogieron diez casos representativos para su análisis a profundidad de acuerdo a una metodología interpretativa denominada teoría fundamentada en los datos.Resultados: En el estudio realizado se detectaron diversos factores que influyen en la decisión del grupo seleccionado de someterse reiterada e insistentemente a tratamientos de reproducción asistida. Entre ellos se encuentran de manera central el imaginario social genérico, las fallas en la estructura narcisista de la personalidad y el hijo imaginario A partir de este estudio, de las observaciones preliminares y el aporte de otros especialistas, se proponen lineamientos a seguir para llevar a cabo una psicoterapia focalizada en la paciente estéril que presenta una insistencia a someterse a tratamientos de R.A.Conclusiones: Dada la complejidad del fenómeno estudiado, es relevante llevar a cabo no sólo un trabajo individual con la paciente estéril, sino también considerar tanto sus redes de apoyo como el personal médico responsable. Se establecen elementos para trabajar con estas pacientes en la modalidad de psicoterapia breve focalizada, tomando en cuenta los niveles de acción-interacción, el imaginario social sobre el género, las fallas narcisistas de la personalidad y el hijo imaginario, en función de reestructurar estos factores en un proyecto identificatorio adecuado a su realidad psíquica, afectiva y socioeconómica.