ABSTRACT
Abstract The Mexican Council of Psychiatry is celebrating this year its 45th anniversary. It is one of the first specialized medical councils in the country, and to date has certified 2 532 psychiatric specialists. This article recounts how the Council was founded, the contributions that more than 40 Mexican psychiatrists have made to its consolidation over the years, and the outlook of its work for the future.
Resumen El Consejo Mexicano de Psiquiatría celebra este año su aniversario 45. Se trata de uno de los primeros consejos médicos de especialidad en el país, y a la fecha ha emitido constancia de certificación a 2 532 especialistas en psiquiatría. En este artículo se relata su historia fundacional, la contribución de más de 40 psiquiatras mexicanos a su consolidación a lo largo de los años y la perspectiva de sus trabajos hacia el futuro.
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
Parkinson's disease is a progressive and degenerative disease due to the loss of the substantia nigra dopaminergic neurons in the mesencephalon. Its manifestations are: tremor at rest, rigidity and slowing of movements, and alterations in posture and gait. The early onset of dementia or the presence of hallucinations, not related to the dopaminergic treatment, are associated with the presence of dementia with Lewy bodies (DLB) or Alzheimer's disease. The scales used to assess the stage and severity of Parkinson's disease are: the scale of Stages of Hoehn and Yahr, and the Unified Parkinson's Disease Rating Scale. Although there is not a drug that stops the progression of Parkinson's disease, the current treatment for this illness consist in: a) dopamine replacement through the use of its precursor, levodopa, b) administering substances, like ropinirole, pramipexole, and bromocriptine, that increase dopamine activity to stimulate their receptors, and c) inhibiting the enzymes that destroy dopamine as the catechol- O-methyltrans-ferase with entacapone, and monoamine oxidase type B (MAO B) with selegiline and rasagiline. Surgical treatment of Parkinson's disease consists of ablative procedures and deep brain stimulation. This review describes their indications, administration and side effects.
La enfermedad de Parkinson es una enfermedad degenerativa y progresiva debida a la pérdida de las neuronas dopaminérgicas de la sustancia nigra del mesencéfalo. Sus manifestaciones son: temblor en reposo, rigidez y enlentecimiento de los movimientos, alteraciones en la postura y en la marcha. La aparición temprana de problemas en la memoria o alucinaciones, no debidas al tratamiento, indica la presencia de demencia con cuerpos de Lewy. Las escalas utilizadas para evaluar el estado y la gravedad de la enfermedad de Parkinson son: la Escala de los Estadios de Hoehn y Yahr y la Escala Unificada de Calificación de la Enfermedad de Parkinson (UPDRS). Aunque todavía no existe un medicamento que detenga la evolución de la enfermedad de Parkinson, el tratamiento actual consiste en mejorar los síntomas mediante: a) la reposición de la dopamina por medio del uso de su precursor (levodopa, L-Dopa), b) la administración de sustancias que aumentan la actividad dopaminérgica al estimular a sus receptores (ropinirol, pramipexol, bromocriptina) y c) la inhibición de las enzimas que destruyen la dopamina como la catecol- O- metiltransferasa (COMT) con la entacapona, y a la monoamino oxidasa tipo B (MAO B) con la selegilina y la rasagilina. Existe además el tratamiento quirúrgico de la enfermedad de Parkinson que consiste en procedimientos ablativos y la estimulación cerebral profunda. En esta revisión se describen los elementos básicos de la enfermedad, su cuadro clínico y sus complicaciones. En una segunda parte se aborda el tratamiento médico con sus indicaciones, administración y efectos secundarios, y para terminar se describirá el tratamiento quirúrgico.
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
Depression is a frequent mental disorder in the general population. Approximately 3.7% of the population will suffer a major depressive episode throughout life. Pharmacological treatment with selective serotonin receptor inhibitors (SSRIs) is useful to treat this condition and other mental disorders. Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline, which constitute this group, are characterized by having an easy way of administration and a very extensive security profile. Objectives The objectives in this revision were: 1. To establish current indications of selective serotonin receptor inhibitors, using as basis those authorized by the Food and Drug Administration (FDA) of the United States of America. 2. To describe the mechanisms that explain antidepressant action. Initially, the SSRIs inhibit the reuptake of serotonin at the synaptic cleft; later there is a downregulation of the 5HT1A receptors; and finally antidepressants raise the levels of brain derived neurotrophic factor (BDNF). 3. To present its way of administration and dosage. 4. To describe frequent collateral effects and those specifically associated to this group of antidepressants and the recommended treatment. Results SSRIs antidepressants are the first choice treatment in depression, in the anxiety disorder, the obsessive-compulsive disorder, the post-traumatic stress disorder, bulimia nervosa and the premenstrual dysphoric disorder. At present, SSRIs displace benzodiacepines in the treatment of generalized anxiety disorder, just as they displaced tricyclic antidepressants in the past. Depressed patients show less activity than normal of the serotonin neurotransmitter (serotonergic hypothesis of depression) and the reuptake blockade at the site of the serotonergic presinaptic receptors 5HT1A, 5HT2C and 5HT3C increases neurotransmission in this system. Desensitization of autoreceptors 5HT1A and the downregulation of the 5HT2 receptors coupled to the G protein, a late effect of the SSRIs, result in the improvement of the depressive symptoms. The mechanism that explains the relatively late antidepressant effect seems to be different to the acute and fast serotonergic effect responsible of improvement in the premenstrual dysphoric disorder. Moreover, these antidepressants, in the same way than mood stabilizers and electroconvulsive therapy, increase serum levels of the brain-derived neuronal growth factor, as well as other neurotrophic factors. Although the SSRIs dosages are variable, it is possible to start antidepressant treatment with therapeutic doses in the majority of cases; at the same time, if necessary, it is possible to augment them gradually up to the largest dose, with a wide security margin. Their most frequent collateral effects occur in the gastrointestinal system, in the sexual response and on bone density. Nevertheless, there are collateral effects specifically related to the use of these antidepressant medications: 1. The serotonergic syndrome, characterized by changes in the mental status, autonomic hyperactivity and neuromuscular anomalies. 2. The syndrome of inappropriate secretion of antidiuretic hormone, which occurs in 25% of the elder depressed patients treated, and which is characterized by a high serum osmolarity, low urinary osmolarity and hyponatremia. Its manifestations are malaise, myalgias, drowsiness and headache, but it may produce also confusion, convulsions and coma. 3. Gastrointestinal bleeding mainly and cutaneous bleeding: Use of SSRIs raises 2 to 4 times the risk of bleeding. When the patient takes aspirin it is raised up to 7 times, and with the concomitant use of anti-inflammatory drugs, by nearly 16 times. Other risk factors are age, the antecedent of bleeding and the potency of SSRIs to inhibit the serotonin reuptake. 4. The discontinuation syndrome, lesser with fluoxetine, and greater with paroxetine and sertraline. It appears by the second day and it lasts two weeks. Its manifestations are nausea, headache, paresthesias, nasal congestion and general malaise. They are due to the decrease in serotonin levels at the synaptic cleft. 6. Effects on the newborn when the SSRIs are used during pregnancy consist in specific congenital malformations. Sertraline has been associated to omphalocele, ventricular septum heart defects and anencephaly. Fluoxetine is associated to craniosynostosis and paroxetine to heart defects, gastroschisis, neural tube defects, omphalocele and anencephaly also. Its use also increases the range of spontaneous abortions up to 1.45 times, premature delivery and low birth weight, problems in the early newborn period (respiratory problems and hypotony), hypoglycemia, cyanosis, restlessness, convulsions and low Apgar. Its use during the third trimester can cause persistent lung hypertension. Although it is a rare condition, it is associated to a mortality range of 10% to 20%. 8) Little is known about the effects caused by the use of SSRIs during breastfeeding. In the case of sertraline and paroxetine, these antidepressant drugs are not detected in the child's serum; on the other hand, serum levels of citalopram were 1.9 nmol/L, fluoxetine 47 nmol/L, and venlafaxine 91 nmol/L. In the available studies, neither behavioral effects nor effects in the development of the newborn were observed. 9) Suicide risk or suicidality. Although the antidepressant treatment lowers both, ideation and the frequency of suicides in the patients treated, the FDA has established a series of general recommendations for the management of patients who start the treatment with antidepressants. To start with the lowest dose, to make an appointment weekly during six consecutive weeks, to recommend and facilitate contact via telephone, to prohibit the use of alcohol and drugs, to ask on each date about suicidal thoughts or behaviors or about self-mutilation, to document the information in the file and to use supportive psychotherapy or cognitive, behavioral or interpersonal therapies.
La depresión es un trastorno mental que afecta a 3.7 % de la población. Los antidepresivos inhibidores selectivos de la recaptura de serotonina (ISRS) resultan útiles en el tratamiento de éste y otros trastornos mentales. El citalopram, escitalopram, fluoxetina, fluvoxamina, paroxetina y sertralina constituyen este grupo de fácil administración y con un amplio perfil de seguridad. Objetivos 1) Establecer las indicaciones actuales de los antidepresivos ISRS. 2) Describir los mecanismos que explican su acción antidepresiva. 3) Describir los efectos secundarios frecuentes y aquéllos específicamente relacionados con este grupo antidepresivo. Resultados Los antidepresivos ISRS son el tratamiento de elección para la depresión, los trastornos de angustia, de ansiedad generalizada, obsesivo-compulsivo, de estrés postraumático, disfórico premenstrual y la bulimia nervosa. Los pacientes deprimidos muestran una actividad menor a la normal del neurotransmisor serotonina. La inhibición de la recaptura de la serotonina sobre los receptores serotoninérgicos presinápticos 5HT1A, 5HT2C y 5HT3C aumenta la neurotransmisión en este sistema. La desensibilización de los autorreceptores 5HT1A y la regulación hacia abajo (downregulation) de los receptores 5HT2 acoplados a la proteína G, efecto tardío de los ISRS, dan por resultado la mejoría de los síntomas depresivos. El mecanismo que explica el efecto antidepresivo relativamente tardío parece ser distinto al efecto serotoninérgico agudo y rápido responsable de la mejoría en el caso del trastorno disfórico premenstrual. Estos antidepresivos, como los estabilizadores del ánimo y la terapia electroconvulsiva, incrementan los niveles séricos del factor de crecimiento neuronal cerebral, así como de otros factores neurotróficos. Aunque las dosis de los ISRS son variables, en la mayoría de los casos es posible iniciar el tratamiento antidepresivo con dosis terapéuticas e incrementarlas paulatinamente hasta las dosis máximas con seguridad. Sus efectos secundarios más frecuentes son gastrointestinales, en la respuesta sexual y sobre la densidad ósea. Los efectos secundarios específicamente relacionados con el uso de estos antidepresivos son: 1. El síndrome serotoninérgico, caracterizado por cambios en el estado mental, hiperactividad autonómica y anomalías neuromusculares. 2. El síndrome de secreción inapropiada de hormona antidiurética, que se caracteriza por osmolaridad sérica alta, urinaria baja e hiponatremia, así como por mialgias, letargo, cefalea e incluso confusión, convulsiones y coma. 3. El sangrado, principalmente de tubo digestivo y cutáneo. El uso de los ISRS aumenta el riesgo de sangrar entre dos y cuatro veces. Cuando el paciente usa aspirina, el riesgo aumenta hasta siete veces y con el uso concomitante de antiinflamatorios, cerca de 16 veces. La edad, el antecedente de sangrado y la capacidad de inhibir la recaptura constituyen también factores de riesgo. 4. El síndrome de descontinuación, menor con la fluoxetina, mayor con la paroxetina y sertralina, aparece a partir del segundo día y su duración es de dos semanas. Manifestaciones como náusea, cefalea, parestesias, congestión nasal y malestar general se deben a la disminución de los niveles de serotonina en la sinapsis. 5. Los efectos sobre el producto cuando los ISRS se utilizan durante la gestación consisten en malformaciones congénitas específicas. La sertralina se ha asociado a onfalocele, defectos del septum cardíaco y anencefalia. A su vez, la fluoxetina se ha asociado a craneosinostosis y defectos cardíacos. Y la paroxetina a defectos cardíacos, gastrosquisis, defectos del tubo neural y también a onfalocele y anencefalia. Su uso también aumenta la tasa de abortos espontáneos hasta 1.45 veces, parto prematuro y bajo peso al nacer, problemas en el neonato inmediato (problemas respiratorios e hipotonía), hipoglucemia, cianosis, inquietud, convulsiones y Apgar bajo. Su uso durante el tercer trimestre puede ocasionar hipertensión pulmonar persistente que, aunque es rara, se asocia a una mortalidad de 10- 20 %. 6) De los efectos por el uso de ISRS durante la lactancia se conoce poco. En el caso de la sertralina y la paroxetina no se detectan estos antidepresivos en el suero del niño; en cambio, los niveles séricos de citalopram fueron de 1.9 nmol/L, de fluoxetina 47 nmol/L y de venlafaxina de 91 nmol/ L. En los estudios disponibles no se observaron efectos conductuales o en el desarrollo del recién nacido. 7) Suicidalidad o riego suicida. Aunque el tratamiento antidepresivo disminuye tanto la ideación y la frecuencia de suicidios en los pacientes tratados, la FDA ha establecido una serie de recomendaciones para el manejo de pacientes que inician el tratamiento con antidepresivos ISRS: Iniciar con la dosis más baja, citar semanalmente a los pacientes durante 6 semanas consecutivas, recomendar y facilitar el contacto telefónico, prohibir el uso de alcohol y drogas, interrogar en cada ocasión sobre pensamientos y comportamientos suicidas o autolesivos, documentar en el expediente la información y usar psicoterapia de apoyo, cognitivo-conductual o interpersonal en el tratamiento.
ABSTRACT
Las funciones neurocognitivas básicas como el control ejecutivo cognoscitivo representan un endofenotipo prometedor que puede mejorar el entendimiento del desarrollo y la expresión del TLP. Evaluamos la asociación entre el funcionamiento en una Batería de Funciones Ejecutivas y el TLP. Se estudió a 10 mujeres diagnosticadas con TLP a quienes por separado se les administró esta batería y fueron comparadas con un grupo control no clínico que constó de 10 sujetos. El desempeño en los participantes con TLP fue menor en la batería de Función Ejecutiva (U=18, p=0,015) y fueron más impulsivo que el grupo de control (U=21, p=0,28); por otra parte no hubo diferencias entre ambos grupos sobre la inteligencia (U=28, p=0,096). Los pacientes con TLP demostraron impedimentos significativos en la prueba de toma de decisiones y planeación lo que puede sugerir la disfunción del lóbulo frontal.
Basic neurocognitive functions such as executive cognitive control represent promising endophenotypes that may improve understanding of the development and expression of TLP. We evaluated the association between performance on a Battery of Executive Functions and the TLP psychopathology. 10 TLP-diagnosed women were evaluated with this battery and their results were compared with those of a non clinical control group, consisting of 10 subjects. It was found that TLP participants performed more poorly than controls in the Executive Function Battery (U=18, p=0,015) and were more impulsive than the control group (U=21, p=0,28); on the other hand, there were no differences between both groups in intelligence (U=28, p=0,096) It was concluded that patients with TLPexhibited significant impairments in test of decision-making and planning, suggesting frontal lobe dysfunction.
Subject(s)
Female , Frontal Lobe/abnormalities , Borderline Personality Disorder/diagnosis , Borderline Personality Disorder/psychology , Cognitive Science , Neurobehavioral ManifestationsABSTRACT
Abstract: Panic disorder is present in 2.9% of females and 1.3% of males in the Mexican urban population; about two thirds of these patients have an associated depressive disorder. Genetics and psy-chosocial factors are intertwined in the etiology of this disorder. There are several studies related to the role of defense mechanisms in the pathogenesis of psychiatric disorders. Few studies of anxiety disorders have been conducted in Mexico, and there is little evidence about the importance of the defense mechanisms that are present in these disorders. In the DSM-IV-TR, defense mechanisms or coping styles are defined as "automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. Individuals are often unaware of the processes as they operate". The purpose of the present research was to identify the differential use of the defense mechanisms in normal controls and in patients with panic disorder alone or complicated mainly with mood disorders, and the patients who responded or did not respond to psychopharmacological treatment. Method. The sample of this study comprised 48 consecutive outpatients with panic disorder from the Instituto Nacional de Psiquiatría, Ramón de la Fuente Muñiz. All of them were evaluated three times: first by a third grade psychiatry resident, in second place by a specialist in psychiatry and finally by one of the authors. After the patients agreed to participate, they completed a demographic questionnaire, the Hopkins Symptom Check List (SCL-90), and the Defense Style Questionnaire (DSQ, Spanish Version). To evaluate the intensity of anxiety and depression, the Anxiety Hamilton Scale and the Hamilton Scale for Depression were used in their first appointment. Patients were treated as usual with a tricyclic antidepressant, a benzodiazepine, or both, during an eight week period. Then they were evaluated again with the same instruments and scales. The Defense Style Questionnaire (DSQ) is a self-report instrument of common defense styles, which are empirically validated clusters of perceived defense mechanisms. Subjects rate their degree of agreement with 88 statements designed to tap defense or coping mechanisms on a ninepoint scale. The DSQ is a widely used measure of empirically derived groupings of defense mechanisms ranking an adaptive hierarchy. A review of published studies, indicates strong evidence that adaptiveness of defense style correlates with mental health, and that some diagnoses are correlated with specific defense patterns (borderline personality disorder correlates with greater use of both, maladaptive and image-distorting defenses, and less use of adaptive defenses). For other diagnoses, the pattern of defenses is less clear. The validity and the reliability of the DSQ Spanish Version were established before its application, in a sample of 261 psychiatric patients and controls. Two factors were obtained in the factor analysis. The first was denominated Mature Style. This category included: suppression, working orientation, sublimation, anticipation, affiliation, reactive formation, altruism, and humor. The Immature Style was the second factor; it included projection, acting out, repression, somatization, autistic fantasy, affective isolation and social withdrawal, inhibition, help rejection, splitting, undoing, consume, idealization, denial, projective identification, passive-aggression, and omnipotence. Higher mean scores indicated greater use of the individual defense mechanism and style. The mean scores for individual DSQ defense mechanisms and styles were calculated by adding and averaging the scores. The reliability calculated was .89 (Cronbach alpha) for the items cor-responding to the 25 defense mechanisms. Axis I was ascertained reliably with face-to-face interview and a list of the DSM-III-R criteria. This group had 32 patients with panic disorder and 16 patients with panic disorder associated to mood comorbidity or alcohol dependence, in persistent remission for at least one year; 32 subjects were included in the normal control group. Results. The comparison of patients with panic disorder, pa-tients with panic disorder associated to mood disorders and controls, showed that both groups of patients used more projection, regression, inhibition, acting out, fantasy, splitting, help rejection, undoing, and reactive formation (p<.01), than the control group. The patients with panic disorder alone, used more somatization and denial (p<.01) than controls, but not more than the group of patients with panic and mood disorders. They also used less humor and sublimation as defenses than the control group (p=.03). The defense mechanisms of the patients who responded to pharmacological treatment were similar to the defenses of patients who did not improve or deserted. The only defense used more by the patients who responded to treatment was undoing. Conclusions. Overall, the results of this study on panic disorder draw us to the conclusion that patients with this disorder make more use of immature and neurotic defenses than nonpatients. It is clear that maladaptive defenses, measured with this version of the DSQ, are related to mental illness and greater symptomatology, and adapative defenses are related to a better health. There was a clear difference in the use of defense mechanisms between the groups with illnesses and the control group. The clinical value of these observations depends on the relationship of the defenses with the symptoms. In this survey it is not possible to propose that defense mechanisms are the cause of the panic disorder, the reaction to the disease, or just a manifestation of the illness. The theory which establishes that the predominant use of certain defenses predisposes an individual to the development of specific illnesses, is attractive, but there is no evidence to support this hypothesis at present. In order to determine whether specific defenses or defense styles create vulnerability for the development of specific illnesses, the ideal study would be a prospective and longitudinal one; it would measure defenses in childhood, in adolescence, and at several points in adulthood, and would note whether there were significant correlations between preexisting defenses and specific illnesses. Such a study has yet to be under-taken. It is intriguing to speculate if an assessment of defenses could guide to treatment choices. Therapists do tend to consider diagnosis, ego strength, symptoms, behavior, and defenses when planning treatment, but a systematic assessment of defenses is not used as a basis for planning specific interventions. Although several studies have examined the relationship among defenses, alliance, therapist interventions, and outcome, more studies looking at a wider range of specific diagnoses are necessary.
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ABSTRACT
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Abstract: Temperament and character are terms utilized to delinéate the participation of biologic and psychosocial factors in the development of normal and disordered personality. At times, biological factors, and in others rearing, education, psychological and social events at an early age are the main determinants. The American Psychiatric Association describes Borderline Personality Disorder (BPD) as characterized by a pattern of interpersonal, selfimage and affective instability, as well as notable impulsivity. In this disorder, temperament as an inherited factor plays an important role, as demonstrated by familial studies in which the disorder is more frequently present in the families of probands than non-probands. Other disorders where impulsivity is an outstanding feature, such as antisocial personality disorder and substance abuse, are also frequent in first degree relatives of patients with BPD. Psychological factors, such as sexual abuse during childhood, are particularly high in this disorder. This is believed to generate features such as emotional instability, distrust, and dissociative states. From this point of view, it is possible that BPD is a form of "adaptation" not only psychological and behavioral, but also biological. Changes in the volume of the amygdala and hippocampus have been described in the brain of women abused during childhood, and those with BPD. BPD is frequently present in clinical practice, either or not associated to other psychiatric disorders; it can be found anywhere from 11 to 40.4% according to the setting studied. This incidence is even higher in patients with multiple suicide attempts. The term "borderline" was established when this pathological condition was conceptualized to origínate between neurosis and psychosis. However, current understanding of personality is better explained with a psychobiological model based on various dimensions. There is one related to schizophrenia (cognitive-perceptual organization dimension) and others related to mood disorders (mood regulation dimension), impulse control (impulsivity-aggression dimension), and anxiety disorders (anxiety-inhibition dimension). Patients with BPD show persistent disturbance on the four dimensions. The combination of these disturbances, along with specific defense mechanisms and coping strategies, originate the characteristic behaviors of individuals with BPD. Regarding the first dimension (cognitive-perceptual organization), BPD patients manifest paranoid ideation and dissociative symptoms usually under severe stress. It is possible that frontal lobe functioning is compromised due to a reactive dopamine and norepinephrine surge in the prefrontal lobe. The disturbance in the second dimension (mood regulation) is manifested in BPD by rapid mood shifts due to excessive sensitivity to separation, frustration and criticism. Although present in all cluster B personality disorders, mood instability in BPD is responsible for stormy relationships, self-image and self-esteem fluctuations, constant rage and bad temper, physical fights, and feelings of emptiness. This mood instability seems to be related to a serotonin effect on the dopaminergic and noradrenergic systems. Disturbances in the third dimension (impulsivity-aggression) originate a lack of control in the use of alcohol and/or drugs, as well as binge eating, reckless driving, shopping sprees, suicide gesture/attempts, self mutilation, and uncontrollable/inappropriate anger. Most studies note the inverse relationship between serotonin levels, and impulsivity, aggression, and selfharm behavior. Finally, abnormalities in the fourth dimension (anxiety-inhibition) manifest as themselves frantic attempts to prevent real or imaginary abandonment. No neurobiological substrate has been proposed in this dimension. The growing evidence of neurobiological basis favors the utilization of pharmacological agents in the treatment of BPD. This paper reviews available publications on controlled clinical trials, hoping to provide a guide in the prescription of psychopharma-cological agents to the patient with BPD. These patients can benefit from pharmacological treatment for impulsivity, psychotic states, affective instability and depression. After establishing a diagnosis, and ruling out associated conditions -such as major psychiatric disorders, substance use disorders, and/or general medical conditions-, a treatment plan including medications can be implemented. Studies on selective serotonin reuptake inhibitors (SSRI's) show the efficacy of fluoxetine in diminishing irritability and aggression and, to a lesser degree, depressed mood. A study adding fluoxetine to behavioral dialectic therapy did not seem to improve the outcome. Fluvoxamine, an antidepressant from the same class, improved emotional lability. Antipsychotics have shown to be useful. Olanzapine is the most studied of the atypical antipsychotics. Case reports using quetiapine and clozapine have also been published. Haloperidol improved depression, anxiety and anger. Anticonvulsants such as carbamazepine, valprote and, more recently topiramate, were reported to improve depressed mood, aggression and self-mutilation. TCA's and MAOI's seemed to help in symptoms such as anxiety, anger, suicidal ideation and rejection sensitivity. In turn, benzo-diacepines were associated with decreased impulse control, in-creased aggression and risk for overdose. Based on this literature review, the following considerations can be made: Patients with BPD, where aggressive behavior, self-multilation, or chronic disphoria are the outstanding features, should be started on an antipsychotic and as second option an anticonvulsant. In resistant cases, clozapine or lithium should be considered. In patients where depressed mood, anxiety, or impulsivity predominate, it is recommended to start an SSRI; as a second option, and only in cases where the patient is reliable, consider a tricyclic antidepressant (TCA), and as a last option, a monoaminoxidaseinhibitor (MAOI). In the more unstable cases, a combination of two or more medications may be needed. Fortunately, there is one study evaluating the combination of fluoxetine and olanzapine. In the pratice, drug combinations are frequent, and they seem to be matter of craft rather than science, as the clinician commonly uses his/ her experience rather than the limited published evidence. Treatment with medication should be started at a low dose, slowly increased for at least four weeks, as most controlled studies available do not show improvement earlier. Therefore, it is not recommended to change or add medications before waiting for a reasonable period, in spite of a patient's demand expecting a faster relief to his/her suffering.