Group family psychotherapy during relapse. Case report of a novel intervention for severe and enduring anorexia nervosa / Psicoterapia familiar grupal durante la recaída. Caso clínico de una intervención novedosa para la anorexia nerviosa grave y duradera

Abstract Background Anorexia nervosa is a complex and highly variable disorder. Preventing patients from becoming resistant to treatments is fundamental since an important percentage develops a severe and enduring disorder; and because relapse is highly associated with psychiatric comorbidity, poor prognosis, and serious medical consequences due to malnutrition. Contemporary treatments for anorexia nervosa support the benefits of involving the family in treatment, and although the gold standard of family psychotherapy offers an excellent option for anorexia nervosa, that intervention is aimed at early stages, and therapeutic options for later stages of the disorder are reduced and not clearly established. Objective Expose the therapeutic effect of the protocol for severe and enduring cases of anorexia nervosa at relapse, used at the Clinic of Eating Behavior of the National Institute of Psychiatry, Ramón de la Fuente Muñiz, whose theoretical foundation is systemic therapy. Method To develop this case report, we carried out an in-depth review of the clinical records, and of the clinic attendance records of the case presented here. CARE clinical case report guidelines format were used. Results The case shows how a young woman, diagnosed with anorexia nervosa with clinical signs of severe and enduring anorexia nervosa (SE-AN), was able to achieve symptomatic remission after her parents, but not her, were administered the protocol for SE-AN. Discussion and conclusion Here we present an emblematic case showing the importance of getting the parents involved in the treatment of anorexia nervosa.

Resumen Antecedentes La anorexia nervosa es un trastorno complejo y muy variable. Evitar que los pacientes se vuelvan resistentes a los tratamientos es fundamental, pues un porcentaje importante desarrolla un trastorno grave y duradero; adicionalmente, la recaída está muy asociada con una alta comorbilidad psiquiátrica, un mal pronóstico y graves consecuencias médicas debido a la desnutrición. El tratamiento actual de la anorexia nervosa respalda los beneficios de involucrar a la familia en el tratamiento, y, aunque el estándar de oro en psicoterapia familiar ofrece una excelente opción para la anorexia nervosa, dicha intervención está orientada a etapas tempranas y las opciones para las etapas tardías del trastorno son reducidas, además de no estar claramente establecidas. Objetivo Exponer el efecto terapéutico del protocolo para casos graves y duraderos de anorexia nervosa en recaída, de la Clínica de Trastornos de la Conducta Alimentaria (CTA) del Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, cuya base teórica es la terapia sistémica. Método Para integrar este caso, realizamos una revisión a fondo del expediente clínico y de los registros asistenciales del caso que aquí presentamos. Se utilizó el formato de reporte de caso de las guías CARE. Resultados El caso muestra cómo una joven, con signos clínicos de anorexia nervosa grave y duradera (AN-GD), pudo lograr remisión sintomatológica después de que sus padres, pero no ella, recibieran tratamiento con el protocolo para AN-GD. Discusión y conclusión Aquí presentamos un caso emblemático que muestra la importancia de involucrar a los padres en el tratamiento de la anorexia nervosa.

Anorexia nervosa: experiencias familiares sobre el inicio del padecimiento, el tratamiento, la recaída y la remisión / Anorexia nervosa: family experiences about the start of suffering, treatment, relapse and remission

Introduction Anorexia nervosa is a suffering entity from eating disorders and family has a relevant role in this disorders; a severe family dysfunction is a risk factor and an important maintainer factor. On the other hand, the family's participation in treatment increases the possibility of success. The aim of this paper is to contribute with the analysis of the form on which the subjects, who suffer from anorexia nervosa and their parents, coexist with their suffering, and share their story. Materials and methods It is a qualitative research study that pretends to know about the family's experiences. The informants where selected according to a theoretical non probabilistic sample. Depth interviews were used and the material was analyzed through a narrative analysis by thematic axis according to Kolher Riessman model. Results The presented family is formed by three members, mother, father and daughter, with anorexia nervosa. Presenting excessively restrictive behaviors oscillating between control and impulsivity. The mother turns her into her confident and the father is too strict and demanding. Concerning the treatment, it lasted approximately three years on impasse, the patient did not show any evolution. Discussion The four evolution moments of the suffering had several points of view according to each of the informants, in literature, the mother and daughter's symbiotic relationship and the peripheral relationship established with the father are mentioned, change was achieved in the family alliances and the change in the nature of their bonds was facilitated. Conclusions These findings are an initial step to know the experiences of each of the family members during the treatment and the expectations they have towards the remission of the suffering.

Antecedentes La anorexia nervosa es un padecimiento de la conducta alimentaria en el que se ha observado que la familia desempeña un papel relevante, ya que una grave disfunción familiar puede ser un factor de riesgo y mantener la sintomatología. La participación de la familia en el tratamiento incrementa la posibilidad de éxito. La presente investigación pretende contribuir con un análisis de la forma en la que los propios sujetos que padecen anorexia nervosa y sus padres, conviven con el padecimiento y narran su historia. Material y métodos Se llevó a cabo un estudio cualitativo y un análisis de narrativa por ejes temáticos de acuerdo al modelo de Kolher Riessman. Los informantes se eligieron de acuerdo a un muestreo teórico no probabilístico y se realizaron entrevistas a profundidad focalizadas. Se eligió a una familia para este reporte. Resultados La familia analizada estuvo conformada por tres miembros: la madre, el padre y la hija con anorexia nervosa, presentándose conductas excesivamente rígidas que oscilan entre el control y la impulsividad. La paciente funciona como confidente de la madre, en tanto que el padre se muestra rígido y exigente. El tratamiento duró tres años aproximadamente en impasse ya que la paciente no mostró ninguna evolución. Discusión En los cuatro momentos de la evolución del padecimiento se observó que cada uno de los participantes tenía diferentes puntos de vista. En la bibliografía se menciona la relación simbiótica de la hija con la madre y la relación periférica establecida con el padre, en la información obtenida en este caso se confirma esa estructura. Conclusiones Estos hallazgos son un primer paso para conocer las experiencias de cada uno de los integrantes de la familia durante el inicio de la enfermedad, el tratamiento, la recaída y las expectativas que se tienen en cuanto a la remisión del padecimiento.

Effect of acupuncture treatment on depression: Correlation between psychological outcomes and salivary cortisol levels / Efecto del tratamiento de acunpuntura sobre depresión: un estudio de correlación sobre variables psicológicas y niveles de cortisol salivar

Introduction There are growing scientific data that show the potential therapeutic benefit of treating depression with acupuncture. The most studied mechanisms of action of antidepressants, such as the monoamine oxidase inhibitors, tricyclic antidepressants or serotonine reuptake inhibitors, are their ability to enhance the synaptic availability or the binding of these monoamines to their respective receptors and their effect on adaptations within signal transduction pathways downstream from monoamine receptors. Life stressors or psycho-social events play a significant role in precipitating a first or second episode of major depression. Physiologically, stress activates the Hypothalamic-Pituitary-Adrenal (HPA) axis. Activation of the axis begins with the release of a corticotrophin-releasing factor (CRF), which stimulates the remainder of the cascade, successively prompting the release of adrenocorticotrophic hormone (ACTH) and cortisol. Multiple reports have related HPA axis hyperactivity, including CNS (i.e., corticotrophin-releasing factor), pituitary (i.e., adrenocorticotrophic hormone), and adrenal (i.e., cortisol) to major depression, and suicide behaviour. One of the resources of TCM for the treatment of depression is acupuncture, and it has been suggested as an alternative to antidepressants for its action on the brain monoaminergic systems. Up to now, there are a few examples of randomized and controlled clinical trials of the effect of acupuncture and electroacupuncture on major depression and we have obtained similar results when using acupuncture and electroacupuncture or conventional antidepressant drugs. Since the 1970's many reports have been done to explain the mechanism of action of acupuncture. Some studies performed in humans and animals studies had found an increment in the levels of 3-endorphin, ACTH and cortisol following low frequency electroacupuncture. The release of ACTH and cortisol suggests that electroacupuncture is acting on the HPA axis and through this mechanism could have a modulatory effect on the stress system and depression. The influence of acupuncture on different neurotransmitter systems like 3-endorphin itself or monoamines, like noradrenaline and serotonine, can also mediate effects of acupuncture on mood and behavior. The aim of this study was to establish the effect of a low frequency electroacupuncture point formula on the clinical improvement of depressed patients and its relation with changes on salivary cortisol. Material and methods Subjects: 42 patients, recruitment and Study Population, at a Universitary Primary Care clinic and randomly divided into control (sham acupuncture) or case group (real acupuncture). Intervention: Low frequency electroacupuncture point formula Main Outcome Measures: Clinical score in the Carroll Scale for Depression and psychiatric Symptoms Check List (SCL-90). Salivary cortisol Results The formula used in this study showed a major effect on the reduction of the depressive symptomatology of patients studied compared to the control group. Conclusions To our knowledge, this is the very first report on acupuncture treatment that evaluates depression symptoms and its evolution using the Carroll rating scale. Effect over depressive symptomatology was higher in the real acupuncture group than in the sham acupuncture group. Taking all data together, the formula used in this study showed a major effect on the reduction of the depressive symptomatology and Cortisol levels of patients studied compared to the sham control group.

Antecedentes La medicina moderna describe la depresión como una enfermedad mental, que se caracteriza por al menos dos semanas continuas de presentar alguno de estos síntomas: labilidad emocional, pérdida del interés en actividades que resultaban placenteras, sentimientos de culpa y aburrimiento, nivel de energía notablemente disminuido, cambio en el patrón de sueño y en el apetito, pérdida de la concentración, agitación psicomotora, pensamientos relacionados con la muerte, sentimiento de desesperanza, irritabilidad y decremento de la libido, afectando las diversas áreas de funcionamiento: sociales, laborales e interpersonales. Investigaciones recientes han encontrado que los trastorno afectivos muestran un beneficio terapéutico en el tratamiento con acupuntura. Se sabe que el estrés de los eventos de la vida pone a las personas en alto riesgo de presentar un cuadro depresivo. Psicológicamente el estrés activa el eje hipotalámico- adrenal-pituitario (HPA); esta activación del eje comienza con la relación del factor liberador de corticotropina, el cual estimula el resto de la cascada, promoviendo sucesivamente la producción de hormona adrenocorticotrópica. Eje hipotálamo-hipófisis-adrenal. La activación de este eje comienza con la liberación del Factor liberador de corticotropina (FLC), que estimula una cascada que sucesivamente incrementa la liberación de la hormona adrenocorticotrópica (ACTH) y el cortisol. Múltiples reportes han relacionado la hiperactividad de este eje con la depresión mayor y la conducta de suicidio. Se ha sugerido que el hipercortisolismo puede ser un factor relevante en la patogénesis de la depresión. Otros hallazgos que refuerzan la hipótesis anterior son el incremento de cortisol y los pulsos secretores de ACTH, así como los niveles elevados de CRF en el fluido corticoespinal, y un incremento de neuronas secretoras de CRF en la región límbica del cerebro con una disminución del número de receptores de CRH en la corteza frontal, y alteraciones en la prueba de supresión con dexametasona en pacientes deprimidos. Dentro de la perspectiva de la acupuntura, la depresión es tratada con el método de nutrir al corazón y calmar la mente, regulando la energía y la sangre. Por lo anterior, se sugiere la acupuntura como una alternativa para la sintomatología de la depresión, ya que por su acción en el sistema monoaminérgico en el cerebro actúa como antidepresivo. Algunos estudios han reportado el efecto de la acupuntura y la electroacupuntura en la depresión mayor, mostrando resultados similares al uso de las drogas antidepresivas. También la acupuntura y la electroacupuntura han demostrado en algunos estudios, tanto en humanos como en animales, el incremento de los niveles de p-endorfinas, ACTH y cortisol. La relación del ACTH y el cortisol sugiere que la electroacupuntura activa el eje HPA y a través de este mecanismo se puede modular el efecto en el sistema de la depresión y el estrés, así como la influencia de la acupuntura en los diferentes neurotransmi-sores del sistema, como las p-endorfinas, monoaminas, noradrenalina y serotonina. Objetivo Establecer el efecto de la baja frecuencia de electroacupuntura en los puntos clínicos adecuados para manejar la depresión en relación con el cortisol en la saliva. Material y métodos Cuarenta y dos pacientes de la población general, divididos en grupo control y grupo experimental, siguiendo un diseño doble ciego, haciendo una intervención de baja frecuencia de electroacupuntura, en puntos adecuados y en puntos placebo, midiendo el cortisol en saliva y utilizando la escala de Carroll para medir sintomatología depresiva y la escala de síntomas psiquiátricos (SCL - 90). Resultados La fórmula utilizada en el estudio mostró un mayor efecto en la reducción de la sintomatología depresiva en los pacientes del grupo experimental que en los pacientes pertenecientes al grupo control. Estos resultados fueron observados hasta la sexta semana de tratamiento. La fórmula utilizada en este estudio mostró una disminución en los niveles de cortisol en los pacientes del grupo control. Conclusiones Desde nuestro punto de vista, éste es el primer reporte del tratamiento acupuntural que evalúa la sintomatología depresiva usando la escala de Carrol. El efecto sobre la sintomatología depresiva fué mayor en el grupo de acupuntura real que en el de acupuntura ficticia. Consideramos este efecto una respuesta parcial porque no hubo al menos una reducción de 50% de la sintomatología depresiva, la que se pudiera convertir en una respuesta completa si los pacientes fueran tratados por mayor tiempo o con otros esquemas acupunturales de tratamiento. Tomando en conjunto todos los datos, la formula usada en este estudio mostró un mayor efecto en la reducción de la sintomatología depresiva y en los niveles de cortisol en el grupo de los pacientes estudiados comparado con el grupo de los pacientes control.

Datos sobre la validez y confiabilidad de la Symptom Check List 90 (SCL 90) en una muestra de sujetos mexicanos

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Abstract: A genetic epidemiology paradigm employed in the identification of genes associated with a disease depends on the comparison of the frequency of common genetic variants between groups of individuals who possess a relevant trait versus those who do not show the trait (i.e., cases vs. controls genetic association study). The adequate classification of groups of contrast is therefore of seminal importance for the identification of relevant genes. For psychiatric disorders, the careful clinical evaluation of particular symptoms is the basis for the classification of the "affected or disease group". However, in many psychiatric genetics studies the constitution of the "control" or "normal" group has been based only on the absence of an overt expression of symptoms, where no particular emphasis is given to the symptom evaluation to exclude the phenotype. The use of psychometric instruments can help to assess some behavioral traits of clinical relevance. In turn, these assessments could help in the diagnosis, prognosis and treatment of disorders. Moreover, quantitative assessments let determine if these traits belong to the normal range of variation in a population or could be a deviation of the trend. The Symptom Checklist 90 (SCL90) is a 90-item self-report inventory that assesses the level of distress recently experienced by the subject. It is comprised of nine dimensions: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism and a General Severity Index (GSI). Although the SCL 90 is a well-accepted and widely used instrument in research and clinical practice in many countries, we found a scarcity of relevant studies for Latin America and a lack of normative data for Mexican populations. The aim of the present report was to evaluate the reliability and construct validity of the SCL 90. Method Subjects A Spanish translation of the original SCL90 English version was administered to a group of 228 subjects, comprised by relatives of patients, members of a family parents association, medical and paramedical staff, and college students. The SCL90 was included within a battery of clinical and psychometric assessments of individuals participating at ongoing research protocols on the genetics of personality and creativity. An additional group of 30 ambulatory psychiatric patients from the Instituto Nacional de Psiquiatría Ramón de la Fuente (INPRF) was also analyzed. The instrument was applied by experienced qualified personal. Statistical analyses Statistical analyses were performed using SYSTAT 8.0. Reliability was evaluated by assessing the response consistency obtained from those items with similar questions. The Cronbach's alpha coefficient was used as the measure of the internal consistency for all nine subscales for this purpose. Construct validity was assessed using two complementary criteria: a) evaluating pre-conceptual hypotheses and b) analysing psychometric data. In the first case, and based on previous reports showing that the level of distress is a function of social-demographic, gender and clinical status, it was hypothesized that the mean scores should be higher in women, younger people and individuals affected with a psychiatric condition. ANOVA and F statistics were computed using the mean scores and standard deviations for the nine dimensions and GSI. In addition, the extent of correlation between individual items and its own subscale dimension should be higher than the other subscales, and the level of correlation between each item and the GSI should be positive. In this case, a Spearman rank correlation matrix was constructed for the SCL90 items and the nine subscales, as well as the GSI. Results Internal consistency All but two of the nine SCL90 dimensions showed good internal consistency values (Cronmbach's alphas >0.7-0.85); with only hostility and paranoid ideation subscales reaching an acceptable value (>0.6-<0.7). The overall Cronbach's alpha score obtained for the GSI was 0.96. Construct validity Fifty-six of the SCL90 items showed a Spearman rank correlation coefficient value (r > 0.5), 23 items showed a moderate value (r >0.25 and <0.5), and only one item showed a weak correlation with its own scale (r =0.2). Only in one case (item 80) the highest correlation value did not correspond with its particular dimension. Mean scores for all of the nine dimensions of the SCL90, as well as the GSI, were higher in women compared to men, and in subjects < 25 years old. The ANOVA showed statistically significant differences (p< 0.01) for somatization, depression, obsessive-compulsive, interpersonal sensitivity, anxiety, hostility dimensions as well as for the GSI. Likewise, an ANCOVA, using age as a covariable, showed an age effect for the last five dimensions (p < 0.005), and in lesser degree for paranoid ideation (p =0.014). Likewise, both men and women patients populations showed higher scores for each dimension compared to general population. Comparison between Mexican and Argentine populations Independent sample t test showed meaningful differences for three scales (obsessive compulsive, interpersonal sensitivity, anxiety, as well as for the GSI) in men and women. Somatization was statistically different only for women from Argentina. Percentiles calculated for each one of all dimensions and the GSI showed a general tendency to be higher for the Mexican population compared with data from Argentina. Discussion The SCL90 is a self-report inventory where the subject reflects his/her perception about the degree of distress that he/she is experiencing. It is used by clinicians and researchers to gather information about the mental health of subjects. In the mental health field, the SCL90 has been employed world-wide to monitor the quality of the medical-psychological interventions, as well as a screening tool to identify psychopathology symptoms. We examined certain psychometric properties of the Spanish version of the SCL90, as there is a lack of normative data for Mexico. The internal consistency reliability for the scale as a whole and for individuals subscales was in general terms adequate for the group of individuals examined. Validity was assured throughout the confirmation of expected differences of groups of comparison and by the good correlation agreement among specific items and their particular dimensions. Compared to the only Latin American study, the mean scores for Mexican population were higher than in Argentina and even higher compared with the USA normative sample. Among others putative factors, translation issues (e.g. use of double negative sentences) and /or cross-cultural differences (e.g. demographic characteristics, socioeconomic differences) should be taken into account to explain these differences; therefore caution should be applied when comparing data of different populations. Among the limitations of this study we must include the analysis of a non-population sample of modest size. Nonetheless, we can conclude that the SCL90 inventory shows good psychometric attributes that may be useful for research and/or clinical purposes. Percentiles rank data can be used as a starting reference for others researchers interested in evaluating in a fast and simple way the psychological distress status of a particular individual, underlying the necessity of developing on a short-term basis normative data for the Mexican population.