Parte III: las locuras histéricas / Part III: the hysterical follies

Caso Clínico Paciente María R.A., 28 años, Escolaridad básica en programa diferencial, dueña de casa, Casada, 9 años de matrimonio. Su pareja tiene 62 años. Actualmente vive con esposo e hijo de 2 años, en Maipú. Durante 2016, María consultó en distintos servicios de urgencia, recibiendo distintos diagnósticos: Conversión, Síndrome conversivo. Se ingresa en Urgencia con diagnóstico: Síndrome Psicótico lúcido. Paciente en cama, sin movimientos espontáneos, con rigidez, mirada fija, deshidratada, no acepta alimentarse, negativista, no establece contacto visual, no responde preguntas simples, sin embargo, en forma espontánea puede permanecer hablando, dando cuenta de contenidos delirantes. El día de su ingreso a sector se inició terapia Electro convulsiva, y completó 5 sesiones. Tras la primera sesión paciente evoluciona favorablemente, se levanta de la cama, solicita agua, es capaz de comer. Síntomas psicóticos ceden tras la tercera sesión, señalando además no recordar nada de lo ocurrido. En entrevista de evolución paciente vigil, orientada TE, actitud parcialmente cooperadora. En cuanto a las psicosis histéricas en sí, es una psicosis aguda, de rápida curación cuando se las trata adecuadamente y Bleuler habla de los llamados estados crepusculares histéricos. La duda diagnóstica es entre un trastorno disociativo tipo psicosis histérica o bien un trastorno psicótico agudo, refiriéndose a trastornos de presunto origen disociativo con sintomatología que podríamos denominar pseudopsicótica. La CIE-10 clasifica las psicosis agudas no afectivas, como Trastornos psicóticos agudos y transitorios (TPAT), (Acute and Transient Psychotic Disorders (ATPD) en inglés), comparten las características comunes de inicio agudo dentro de dos semanas, y la presencia de síntomas psicóticos típicos. La descripción de TPAT fue influenciada por los conceptos de psicosis cicloide, bouffée délirante y psicosis reactiva. No es sorprendente, por lo tanto, que los ATPD de la CIE-10 (al menos diagnósticamente) sean un heterogéneo grupo de trastornos. Tanto los sistemas CIE como DSM se basan en síntomas, y descuentan los aspectos "no empíricos" del diagnóstico, que pueden constituir el «fenómeno" esencia de un trastorno psicótico. Actualmente, no existe una categoría de diagnóstico para definir individuos que están experimentando tal psicopatología y tienen un riesgo significativamente mayor de desarrollar esquizofrenia u otro desorden psicótico. Trastorno histriónico de la personalidad (HPD), como argumento aquí, no es una patología mental real; más bien, "histriónico" se refiere a un rasgo o grupo de rasgos de personalidad que podría conducir a algún otro trastorno mental.

Clinical case. Patient María R.A., 28 years old, Basic schooling in differential program, housewife, Married, 9 years of marriage. His partner is 62 years old. Currently lives with husband and 2 year old son in Maipú. During 2016, Maria consulted in different emergency services, receiving different diagnoses: Conversion and conversion syndrome. Urgency is entered with diagnosis: Syndrome Psychotic lucid. Patient in bed, without spontaneous movements, with rigidity, stare, dehydrated, does not accept to feed, negativist, does not establish visual contact, does not answer simple questions, however, spontaneously can remain talking, giving account of delusional contents. On the day of his admission to the sector, Electro Convulsive therapy was started, and he completed 5 sessions. After the first patient session he progresses favorably, gets up from bed, requests water, is able to eat. Psychotic symptoms give way after the third session, noting also not remember anything of what happened. In an evolution interview, vigil patient , oriented TE, partially cooperative attitude. As for hysterical psychoses per se, it is an acute, rapidly healing psychosis when properly treated and Bleuler speaks of so-called hysterical crepuscular states. The diagnostic doubt is between a dissociative disorder type hysterical psychosis or an acute psychotic disorder. referring to disorders of presumed dissociative origin with symptomatology that we could call pseudopsychotic. The ICD-10 classifies acute non-affective psychoses, as Acute and Transient Psychotic Disorders (ATPD), share the common characteristics of acute onset within two weeks, and the presence of typical psychotic symptoms. The description of ATPD was influenced by the concepts of cycloid psychosis, bouffée délirante and reactive psychosis. It is not surprising, therefore, that the ATPD of the ICD-10 (at least diagnostically) is a heterogeneous group of disorders. Both CIE and DSM systems are based on symptoms and discount the "non-empirical" aspects of diagnosis, which may constitute the "phenomenon" essence of a psychotic disorder. Currently, there is no diagnostic category to define individuals who are experiencing such psychopathology and have a significantly increased risk of developing schizophrenia or other psychotic disorder. Histrionic Personality Disorder (HPD), as an argument here, is not a real mental pathology; rather, "histrionic" refers to a trait or group of personality traits that could lead to some other mental disorder.

One year readmission rates of acute and transient psychotic disorders & diagnosis of patients admitted at the National Center for Mental Health from Jan-Dec 2012

OBJECTIVES:The aim of this study was to determine the readmission rates of Acute and Transient Psychotic Disorders (ATPD) who were admitted for the first time in the National Center of Mental Health from January to December 2012.METHODOLOGY: This study used the retrospective cohort method. Patients included in the study were admitted for the first time with a diagnosis of Acute and Transient Psychotic Disorders (ATPD) during the period of January to December 2012. The source of data involved the chart review during the first admission and the subsequent admission. Patients who were readmitted beyond one year from time of admission were excluded.RESULTS:Results showed that 25 out of 204 (12.26%) patients diagnosed with an ATPD were readmitted within one year. The most common diagnosis of ATPD upon admission were: Acute Schizophrenia-Like Psychotic Disorder (n=95), Other Schizophrenia (n=90) and Acute Polymorphic Psychotic Disorder (n=19). ATPD's with the highest 1 year readmission rates were Acute Polymorphic Psychotic Disorder (3/19),Other Schizophrenia (13/90) and Acute Schizophrenia-Like Psychotic Disorder(9/95).Those that were readmitted had a different discharge diagnosis in their second admission.The three most common diagnosis upon readmission were Undifferentiated Schizophrenia (36%), Bipolar Affective Disorder, current episode manic, with psychotic symptoms (24%) and Other Schizophrenia (12%). Acute Schizophrenia-Like Psychotic Disorder were mostly readmitted as Bipolar Affective Disorder in 44% of patients; Acute Polymorphic Psychotic Disorder (APPD) were readmitted as another ATPD (66.6%); and Other Schizophrenia was diagnosed as Undifferentiated Schizophrenia (54%).CONCLUSION:Only a small percentage of patients with ATPD were readmitted one year from admission and those who were readmitted revealed that they may have actually been suffering from or developed another more chronic psychotic disorder.

Psicosis cicloides: a propósito de dos probables casos / Cycloid psychosis: regarding two probable cases

Cases of acute psychosis which during longitudinal follow-up did not meet criteria for schizophrenic psychosis or affective psychosis are common in clinical practice; however, those cases can be classified into diagnostic categories that are not sufficiently representative of their nosological individuality. This intermediate group of psychosis: characterized by acute onset, usually brief course, polymorphic symptomatology and recovery without defect, has been conceived in different psychiatric schools through different concepts: in this sense, the construct of Cycloid Psychoses, original from German psychiatry, has demonstrated validity and is embedded in a heuristically profitable diagnostic system (the Wernicke-Kleist-Leonhard classification). Apropos of two representative cases, we review here the relevant literature and highlight the need to consider this diagnostic possibility - not fully considered in the present diagnostic systems yet- in order to avoid prolonged antipsychotic treatments based on unnecessarily ominous nosological hypothesis.

Los casos de psicosis aguda que durante el seguimiento longitudinal no reúnen criterios de esquizofrenia ni de psicosis afectivas son frecuentes en la práctica clínica habitual; sin embargo, pueden ser catalogados dentro de categorías diagnósticas que no representan de modo suficiente su individualidad nosológica. Este grupo intermedio de psicosis: caracterizado por su inicio agudo, curso usualmente breve, sintomatología polimórfica y recuperación sin defecto, ha sido concebido en diferentes escuelas psiquiátricas mediante diferentes conceptos: en tal sentido, el constructo de Psicosis Cicloides, proveniente de la psiquiatría alemana, ha demostrado validez y se halla engarzado en un sistema diagnóstico heurísticamente valioso (el de Wernicke-Kleist-Leonhard). A propósito de dos casos representativos, revisamos la literatura pertinente y resaltamos la necesidad de considerar esta posibilidad diagnóstica, a fin de evitar prolongados y potencialmente perjudiciales tratamientos antipsicóticos, prescritos bajo hipótesis incorrectas y gravosas.