Behavioral or neuropsychiatric symptoms of Alzheimer's disease: from psychopathology to pharmacological management / Sintomas comportamentais ou neuropsiquiátricos da doença de Alzheimer: psicopatologia e abordagem terapêutica

Abstract Neuropsychiatric or behavioral symptoms of dementia encompass a series of disorders, such as anxiety, depression, apathy, psychosis, and agitation, all commonly present in individuals living with dementia. While they are not required for the diagnosis of Alzheimer's disease (AD), they are ubiquitously present in all stages of the disease, contributing to negative clinical outcomes, including cognitive decline, functional disability, and caregiver burden. Neuropsychiatric symptoms have been conceptualized not only as risk factors but as clinical markers of decline along the AD spectrum. The concept of "mild behavioral impairment", the behavioral correlate of mild cognitive impairment, has been proposed within this framework. The first steps in the management of behavioral symptoms in AD involve defining the target and investigating potential causes and/or aggravating factors. Once these factors are addressed, non-pharmacological approaches are preferred as first-line interventions. Following the optimization of anticholinesterase treatments, specific pharmacological approaches (e.g., antidepressants, antipsychotics) can be considered weighing potential side effects.

Resumo Sintomas neuropsiquiátricos ou comportamentais de demência envolvem uma série de condições, como ansiedade, depressão, apatia, psicose e agitação, frequentemente observadas em indivíduos com demência. Embora esses sintomas não sejam necessários para o diagnóstico da doença de Alzheimer, estão presentes em todas as fases ou estágios da doença, contribuindo negativamente para o declínio cognitivo, comprometimento funcional e sobrecarga do cuidador. Os sintomas neuropsiquiátricos têm sido conceituados não apenas como fatores de risco, mas também como marcadores clínicos de progressão da doença de Alzheimer. O construto "comprometimento comportamental leve", correlato comportamental do comprometimento cognitive leve, tem sido proposto nesse contexto. Os primeiros passos na abordagem dos sintomas comportamentais da doença de Alzheimer envolvem definir os alvos-terapêuticos e investigar potenciais causas ou fatores agravantes. Após intervir nesses fatores, abordagens não farmacológicas constituem a primeira linha de intervenção. Depois da otimização do tratamento anticolinesterásico, terapias farmacológicas específicas (por exemplo, antidepressivos, antipsicóticos) podem ser consideradas, levando-se em conta potencias efeitos colaterais.

Coexistencia de distintos síndromes de falsos reconocimientos delirantes en la práctica clínica: serie de casos

Objetivo: El objetivo de este estudio es analizar la coexistencia de varios síndromes de falsos reconocimientos delirantes en una muestra clínica. Métodos: A lo largo de 1 ano, se seleccionó una muestra de 6 pacientes con 2 o más tipos de falsos reconocimientos delirantes durante el mismo episodio. Todos ellos se encontraban hospitalizados en la unidad de hospitalización psiquiátrica en un hospital de España. Resultados: A pesar de los distintos diagnósticos, los pacientes incluidos presentaban diferentes tipos de falsos reconocimientos delirantes, tanto de hiperidentificación como de hipoidentificación. El tratamiento antipsicótico fue escasamente eficaz contra estos síndromes de falsos reconocimientos delirantes. Conclusiones: La coexistencia de varios síndromes de falsos reconocimientos delirantes indica que la etiopatogenia de los distintos tipos es similar. Se trata de un campo con importantes implicaciones tanto clínicas, por la baja respuesta al tratamiento, como las posibles médico-legales.

Objective: The objective of this study is to analyze the coexistence of several delusional misidentification syndromes in a clinical sample. Methods: Over one year, a sample of six patients presenting two or more types of delusional misidentification syndromes was selected. All these patients were admitted to the psychiatric inpatient unit of a Spanish hospital. Results: Despite the different diagnoses, the patients included presented different types of delusional misidentification syndromes, both hyperidentification and hypoidentification. Antipsychotic treatment was not very effective against these delusional misidentification syndromes Conclusions: The coexistence of several delusional misidentification syndromes indicates that the aetiopathogenesis of the different types is similar. It is a field with important clinical implications, due to the poor response to treatment, as well as the possible medico-legal implications.

El problema etiológico de los delirios en la esquizofrenia para la neuropsiquiatría actual / The Etiological Problem of Psychotic Delusions in Current Neuropsychiatry / O problema etiológico dos delírios na esquizofrenia para a neuropsiquiatria atual

Introducción: el delirio constituye uno de los síntomas más complejos y severos de la psicosis. Uno de los problemas más fundamentales que enfrenta la investigación en el campo de la neuropsiquiatría tiene que ver con el desafío de producir teorías explicativas para la producción de este tipo de estado mental, a lo que se denomina problema etiológico de los delirios psicóticos. Desarrollo: se analizan críticamente las principales alternativas dentro de la neuropsiquiatría contemporánea al problema etiológico en el contexto de la esquizofrenia. Conclusión: el análisis indica que las tres teorías fundamentales que conviven en la actualidad poseen problemas para avanzar en el desafío de explicar la etiología de los delirios. Por lo anterior, se propone la idea de que, a la luz del estado del debate reciente, la hibridación teórica podría perfilarse como el mejor candidato metodológico para generar progreso real en la disciplina

Introduction: Delusions constitute one of the most complex and severe symptoms of psychosis. One of the most fundamental problems within current research in neuropsychiatry has to do with the challenge of producing explanatory theories of the aetiology of the phenomenon. I call this the etiological problem of psychotic delusions. Development: The main alternatives to the etiological problem in schizophrenia in current neuropsychiatry are critically assessed. Conclusion: The three current co-existing approaches possess a number of problems to make real progress in the etiological debate. For this reason, I suggest that, in light of the current state of the art, theoretical hybridization could become the best methodologi- cal candidate to make progress within the target debate

Introdução: o delírio é um dos sintomas mais complexos e graves da psicose. Um dos problemas mais fundamentais enfrentados atualmente pelas pesquisas no campo da neuropsiquiatria diz respeito ao desafio de produzir teorias explicativas para a produção desse tipo de estado mental, que chamo de o problema etiológico dos delírios psicóticos. Desenvolvimento: são analisadas criticamente as principais alternativas da neuropsiquiatria contemporânea ao problema etiológico no contexto da esquizofrenia. Conclusão: a análise indica que as três teorias fundamentais que coexistem atualmente têm problemas para avançar no desafio de explicar a etiologia dos delírios. Portanto, propõe-se a ideia de que, à luz do estado atual do debate, a hibridação teórica poderia surgir como o melhor candidato metodológico para gerar um progresso real na disciplina.

Espectro clínico de la Encefalitis Autoinmune no NMDAR en pediatría

En este trabajo se realizó una revisión narrativa de los principales hallazgos en la literatura médica sobre las manifestaciones clínicas de la encefalitis autoinmune pediátrica (EAP) no mediada por anticuerpos anti receptor del ácido N-metil-D-aspartato (NMDAR). Las EAP que se destacaron se asocian con anticuerpos específicos como el complejo de canales de potasio dependiente de voltaje, la decarboxilasa del ácido glutámico, el receptor del ácido alfa-amino-3-hidroxi-5-metil-4-isoxazolpropiónico y el receptor ácido-gamma-aminobutírico. El diagnóstico de esta patología es un desafío en pediatría debido a la complejidad de las manifestaciones psiquiátricas y neurológicas generadas por la afectación de la corteza, el sistema límbico, el tallo cerebral, los ganglios basales y el cerebelo. A su vez, la comprensión de sus síntomas permite identificar la superposición en las presentaciones clínicas entre los diferentes tipos de EAP y el diagnóstico diferencial con otras enfermedades inflamatorias del cerebro, infecciones, enfermedades metabólicas y trastornos psiquiátricos. El conocimiento biomédico y la sospecha clínica de las EAP no NMDAR establece un campo de investigación que crece en neuropsiquiatría y favorece el diagnóstico y tratamiento de las encefalitis subdiagnosticadas.

This work presents a narrative review of the main findings in the medical literature on the clinical manifestations of pediatric autoimmune encephalitis (PAE) not mediated by anti-N-methyl-Daspartate acid receptor (NMDAR) antibodies. Prominent PAEs are associated with specific antibodies, such as the voltage-gated potassium channel complex, glutamic acid decarboxylase, alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor, and alpha-amino -3-hydroxy-5. -methyl-4-isoxazolepropionic acid receptor. -gamma-aminobutyric. Diagnosis of this pathology is a challenge in pediatrics due to the complexity of psychiatric and neurological manifestations generated by involvement of cortex, limbic system, brainstem, basal ganglia and cerebellum. In turn, understanding its symptoms allows identifying the overlap in clinical presentations between the different types of PAE and the differential diagnosis with other inflammatory diseases of the brain, infections, metabolic diseases and psychiatric disorders. Biomedical knowledge and clinical suspicion of non-NMDAR PAE establishes a growing field of research in neuropsychiatry and favors the diagnosis and treatment of underdiagnosed encephalitides.

Pacientes neuropsiquiátricos e os benefícios do tratamento com fitocanabinóides / Neuropsychiatric patients and the benefits of phytocannabinoid treatment / Pacientes neuropsiquiátricos y los beneficios del tratamiento con fitochanabinoides

presente revisão visa sumarizar os estudos que abordam o uso de fitocanabinóides em pacientes com doenças neuropsiquiátricas, abordando os benefícios e possíveis efeitos adversos que podem ser observados. Foi realizada uma revisão integrativa de literatura com descritores MeSH: Cannabis, Medical Marijuana, Neurology, Neuropsychiatry e as bases de dados: PubMed, MEDLINE, CINAHL, SCOPUS, Web of Science e SciELO. Selecionou-se artigos entre 2015 a 2021 utilizando como critérios de inclusão, artigos que abordassem sobre o uso de fitocanabinoides em pacientes com doenças neurológicas e/ou psiquiátricas, disponíveis integralmente nos bancos de dados sem restrição de idioma. Após análise, foram encontrados 15 artigos, que evidenciaram benefícios como: propriedades ansiolíticas, antiepilépticas, antiparkinsonianas, antipsicóticas, de estabilização de humor, além de ser benéfico na regulação do sono, na Síndrome de Tourette, na demência, dores crônicas, amenização de sintomas eméticos dos tratamentos oncológicos e da espasticidade na esclerose múltipla, no TEPT e no autismo. Além disso, os fitocanabinoides parecem ter propriedades anti-inflamatórias e de neuroproteção. Entretanto, efeitos colaterais também foram observados, sendo os principais: piora no desempenho em testes cognitivos, sintomas gastrointestinais, sonolência, agitação, piora de alguns transtornos psiquiátricos, diminuição da concentração, aumento da ansiedade social, bem como boca e olhos secos. Conclui-se portanto que os fitocanabinóides podem apresentar ação terapêutica benéfica no tratamento de condições neuropsiquiátricas, tratamento de doenças neurodegenerativas, propriedades anti-inflamatórias e neuroprotetoras e tratamento de dores crônicas, entretanto devem ser considerados e monitorados os efeitos adversos em cada paciente.

This review aims to summarize the studies that address the use of phytocannabinoids in patients with neuropsychiatric diseases, addressing the benefits and possible adverse effects that can be observed. An integrative literature review was conducted with MeSH descriptors: Cannabis, Medical Marijuana, Neurology, Neuropsychiatry and the databases: PubMed, MEDLINE, CINAHL, SCOPUS, Web of Science and SciELO. Articles were selected between 2015 and 2021 using as inclusion criteria articles that addressed the use of phytocannabinoids in patients with neurological and/or psychiatric diseases, available in full in the databases without language restriction. After analysis, 15 articles were found, which showed benefits such as: anxiolytic, antiepileptic, antiparkinsonian, antipsychotic, mood stabilization properties, besides being beneficial in sleep regulation, Tourette's syndrome, dementia, chronic pain, mitigation of emetic symptoms of cancer treatments and spasticity in multiple sclerosis, PTSD and autism. In addition, phytocannabinoids appear to have anti-inflammatory and neuroprotective properties. However, side effects have also been observed, the main ones being: worsening performance in cognitive tests, gastrointestinal symptoms, drowsiness, agitation, worsening of some psychiatric disorders, decreased concentration, increased social anxiety, as well as dry mouth and eyes. Therefore, it is concluded that phytocannabinoids may present beneficial therapeutic action in the treatment of neuropsychiatric conditions, treatment of neurodegenerative diseases, anti-inflammatory and neuroprotective properties and treatment of chronic pain, however, the adverse effects in each patient should be considered and monitored.

Esta revisión tiene como objetivo resumir los estudios que abordan el uso de fitocanabinoides en pacientes con enfermedades neuropsiquiátricas, abordando los beneficios y posibles efectos adversos que pueden observarse. Se realizó una revisión integral de la literatura con los descriptores de MeSH: Cannabis, Medical Marijuana, Neurology, Neuropsychiatry y las bases de datos: PubMed, MEDLINE, CINAHL, SCOPUS, Web of Science y SciELO. Se seleccionaron artículos entre 2015 y 2021, utilizando como criterios de inclusión artículos que abordaban el uso de fitocanabinoides en pacientes con enfermedades neurológicas y/o psiquiátricas, disponibles enteramente en las bases de datos sin restricción lingüística. Después del análisis se encontraron 15 artículos que mostraron beneficios tales como: propiedades ansiolíticas, antiepilépticas, antiparkinsonianas, antipsicóticas, estabilizadoras del estado de ánimo, además de ser beneficiosos para regular el sueño, en el síndrome de Tourette, en demencia, dolor crónico, alivio de los síntomas eméticos de los tratamientos contra el cáncer y de la espasticidad en esclerosis múltiple, TEPT y autismo. Además, los fitobarabinoides parecen tener propiedades antiinflamatorias y neuroprotectoras. Sin embargo, también se observaron efectos adversos, siendo los principales: empeoramiento del desempeño en las pruebas cognitivas, síntomas gastrointestinales, somnolencia, agitación, empeoramiento de algunos trastornos psiquiátricos, disminución de la concentración, aumento de la ansiedad social, así como sequedad de boca y ojos. Por lo tanto, se concluye que los fitocanabinoides pueden tener una acción terapéutica beneficiosa en el tratamiento de las afecciones neuropsiquiátricas, el tratamiento de las enfermedades neurodegenerativas, las propiedades antiinflamatorias y neuroprotectoras y el tratamiento del dolor crónico, sin embargo, se deben considerar y monitorizar los efectos adversos en cada paciente.

Blood levels of brain-derived neurotrophic factor (BDNF) in systemic lupus erythematous (SLE): a systematic review and meta-analysis

Abstract Objectives BDNF has been implicated in the pathophysiology of systemic lupus erythematosus (SLE), especially its neuropsychiatric symptoms. The purpose of this study was to investigate the profile of blood BDNF levels in patients with SLE. Methods We searched PubMed, EMBASE, and the Cochrane Library for papers that compared BDNF levels in SLE patients and healthy controls (HCs). The Newcastle-Ottawa scale was used to assess the quality of the included publications, and statistical analyses were carried out using R 4.0.4. Results The final analysis included eight studies totaling 323 healthy controls and 658 SLE patients. Meta-analysis did not show statistically significant differences in blood BDNF concentrations in SLE patients compared to HCs (SMD 0.08, 95% CI [− 1.15; 1.32], P value = 0.89). After removing outliers, there was no significant change in the results: SMD -0.3868 (95% CI [− 1.17; 0.39], P value = 0.33. Univariate meta-regression analysis revealed that sample size, number of males, NOS score, and mean age of the SLE participants accounted for the heterogeneity of the studies (R2 were 26.89%, 16.53%, 18.8%, and 49.96%, respectively). Conclusion In conclusion, our meta-analysis found no significant association between blood BDNF levels and SLE. The potential role and relevance of BDNF in SLE need to be further examined in higher quality studies.

Mini International Neuropsychiatry Interview Kid or Child Posttraumatic Stress Disorder Symptom Scale 5I for Posttraumatic Stress Disorder among Adolescent Girls Infected with COVID-19

Background: Posttraumatic stress disorder (PTSD) is a mental disorder that may develop after exposure to exceptionally life threatening or horrifying events. People suffering from PTSD are vulnerable for both physical and mental health. Objectives: To find out sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and to plot receiver operating characteristic curve taking Mini International Neuropsychiatry Interview-Kid (MINIKID) as the gold standard and Child PTSD Symptom Scale 5I (CPSS-5I) as the newer diagnostic tool for diagnosing PTSD. Materials and Methods: The cross?sectional study was carried out for a period of 6 months from January 2021 to June 2021 at R. L. Jalappa Hospital and Research Center, Kolar, Karnataka through telephonic interviews. All the data entered in Microsoft office Excel sheet, analyzed using the SPSSv22 (IBM Corp). Results: Sensitivity of the CPSS?5I was 56% and specificity was 96% compared with MINIKID. 83% and 85%, respectively, was PPV and NPV of the CPSS?5I compared with MINIKID. Area under the curve is 83.9% with P < 0.001 (72.5–95.2) indicating CPSS?5I is 84% sensitive proving to be a very good diagnostic tool for diagnosing PTSD. Furthermore, scores of 9.5 or 10.5 from CPSS?5I can be used as cutoff in diagnosing PTSD using CPSS 51. Conclusion: CPSS-5I is extremely well designed, helpful and functional tool used in diagnosing PTSD. With the current study showing CPSS-5I can be used in post-COVID PTSD diagnosis, it also provides cutoff which can be helpful in mass screening.

Clinical profile of tuberous sclerosis complex patients with and without epilepsy: a need for awareness for early diagnosis / Perfil clínico de pacientes com complexo de esclerose tuberosa com e sem epilepsia: uma necessidade de conscientização para o diagnóstico precoce

Abstract Background Tuberous sclerosis complex (TSC) is a multisystemic disorder. Its clinical features manifest differently in several organs, prompting the need for better knowledge. Objective The goal of the present study is to evaluate the neurological findings of TSC, such as cerebral lesions and epilepsy, and to raise awareness of non-neurological findings that could contribute to an earlier diagnosis and treatment. Methods This was a natural history study of patients with a definitive diagnosis of TSC who were referred to a specialized outpatient clinic and followed-up for 2 years with clinical and radiological exams. Results A total of 130 TSC patients (59 males [45.4%], mean age 20.4 years old [1 to 56 years old]); 107 patients (82.3%) were diagnosed with epilepsy. Seizures predominantly began at < 1 year old (72.8%); focal seizures predominated (86.9%); epileptic spasms occurred in 34.5% of patients, and refractory epilepsy was present in 55.1%. Neuropsychiatric disorders, cortical tubers and cerebellar tubers were significantly more frequent in the epilepsy group. Moreover, rhabdomyomas were significantly more frequent in the epilepsy group (p = 0.044), while lymphangioleiomyomatosis was significantly less frequent in the epilepsy group (p = 0.009). Other non-neurological findings did not differ significantly between the groups with and without epilepsy. Conclusions The present study of TSC patients demonstrated the predominantly neurological involvement and significantly higher proportion of TSC-associated neuropsychiatric disorders in the epilepsy group. Higher proportions of cortical and cerebellar tubers may be a risk factor for epilepsy and neurodevelopmental disorders.

Resumo Antecedentes O Complexo da esclerose tuberosa (CET) é uma doença multissistêmica. As apresentações clínicas em diferentes órgãos são diversas, necessitando um maior conhecimento da doença. Objetivo O objetivo do presente estudo foi avaliar na CET o envolvimento neurológico, como lesões cerebrais e epilepsia, e chamar a atenção para achados não neurológicos que contribuiriam para o diagnóstico e tratamento precoces. Métodos Estudo de história natural do CET em pacientes com critérios diagnósticos definidos encaminhados aleatoriamente para serviço especializado e que foram acompanhados, durante 2 anos, com exames clínicos e radiológicos. Resultados O total de 130 pacientes (59 do sexo masculino [45.4%]), idade média de 20,4 anos [1 a 56 anos]) foram avaliados; 107 pacientes (82.3%) foram diagnosticados com epilepsia. As crises epilépticas se iniciaram especialmente em pacientes < 1 ano de idade (72,8%); predomínio de crise focal (86,9%); ocorrência de espasmos infantis em 34,5% deles e de epilepsia refratária em 55,1%. A frequência de distúrbios neuropsiquiátricos, túberes corticais e túberes cerebelares foi significativamente mais frequente no grupo com epilepsia. Além disso, rabdomioma foi significativamente mais frequente no grupo com epilepsia (p = 0,044), enquanto a linfoangioleiomiomatose foi significativamente menos frequente (p = 0,009). Outros comprometimentos não neurológicos, como os oftalmológicos e os nefrológicos, não diferiram significativamente nos grupos com e sem epilepsia. Conclusões O presente estudo com pacientes com CET com e sem epilepsia pode demonstrar uma maior proporção significativa de transtornos neuropsiquiátricos associados ao CET no grupo com epilepsia. A maior proporção de túberes corticais e cerebelares parecem ser um fator de risco para epilepsia e para o comprometimento do neurodesenvolvimento.

Neuropsychiatric symptoms of dementia and caregivers' burden: a study among Indian caregivers / Sintomas neuropsiquiátricos de demência e sobrecarga dos cuidadores: um estudo entre cuidadores indianos

ABSTRACT Dementia is considered a most serious and disabling condition, affecting both the individual suffering from it and their caregiver. Objective: The study aimed to evaluate the relationship between neuropsychiatric problems of dementia and caregiver burden. Methods: A total of 138 caregivers of people with dementia participated in this cross-sectional study. The caregivers completed the questionnaires containing sociodemographic information as well as neuropsychiatric problems of dementia and caregiver burden. Results: The findings showed that all of the care-recipients were suffering from some kind of neuropsychiatric symptoms, the most common being apathy, anxiety, motor disturbance, and hallucination. Out of 12 symptoms, 11 were significantly associated with caregivers' burden. The most important finding is that the severity of neuropsychiatric symptoms is highly responsible for severe caregivers' burden. Conclusions: The identification of neuropsychiatric symptoms of dementia that influence caregiver burden is very critical for both caregivers' and care-recipients' health perspective. These findings can also be utilized to create care settings for demented people and help determine policies in the future.

RESUMO A demência é considerada a condição mais grave e incapacitante que afeta ao mesmo tempo tanto o indivíduo que a sofre como o seu cuidador. Objetivo: O estudo tem como objetivo avaliar a relação entre problemas neuropsiquiátricos de demência e sobrecarga do cuidador. Métodos: 138 cuidadores de pessoas com demência participaram do estudo transversal. Os cuidadores preencheram os questionários contendo informações sociodemográficas, bem como problemas neuropsiquiátricos de demência e sobrecarga do cuidador. Resultados: Observou-se que todos os atendidos apresentavam algum tipo de sintoma neuropsiquiátrico; os mais comuns foram apatia, ansiedade, distúrbios motores e alucinações. Com exceção de um sintoma, 11 outros sintomas foram significativamente associados à sobrecarga dos cuidadores. O achado mais importante é que a gravidade dos sintomas neuropsiquiátricos é altamente responsável pela sobrecarga dos cuidadores. Conclusões: A identificação de sintomas neuropsiquiátricos de demência que influenciem a sobrecarga do cuidador é muito importante para a perspectiva de saúde dos cuidadores e dos receptores de cuidados. Essas descobertas também podem ser utilizadas para criar ambientes de atendimento para pessoas com demência e ajudar a determinar políticas no futuro.

Brain functional connectivity in takotsubo cardiomyopathy patients. A systematic review of magnetic resonance imaging studies / Conectividad funcional cerebral en pacientes con miocardiopatía de takotsubo: Revisión sistemática de estudios de imagen por resonancia magnética

Abstract Background: Functional neuroimaging studies may aid to our understanding of the pathophysiology of the takotsubo cardiomyopathy. Objective: The aim of the study was to review the available evidence of brain functional connectivity in takotsubo cardiomyopathy patients. Methods: This was a systematic review. We searched MEDLINE, LILACS, Ovid (Cochrane), Scopus, and Science Direct for studies conducting functional magnetic resonance imaging (fMRI) in takotsubo patients. After reviewing title/abstract and full text, we selected relevant studies, extracted methodological characteristics, and their main findings, and assessed their risk of bias with the Newcastle-Ottawa scale. We present a narrative review. Results: We included five case-control studies from 600 registries. The risk of bias was low; comparability was the main issue. Resting-state fMRI findings suggest significant differences for the hippocampus, the Insula, the amygdala, and the para-hippocampal gyrus. Task fMRI findings suggest significant differences for the Insula, the superior occipital gyrus, and the amygdala. Studies were heterogeneous about the laterality and directionality of these differences. Conclusion: Brain connectivity alterations involving elements relevant for autonomic control like the Insula and the Amygdala provide evidence in favor of the role of functional networks in the neurocardiology of stress-related cardiomyopathies. However, it is not possible to determine if this role is causal or consequential.

Resumen Antecedentes: Los estudios de neuroimagen funcional podrían ayudar a clarificar la fisiopatología de la miocardiopatía de takotsubo. Objetivo: Revisar la evidencia disponible sobre conectividad funcional cerebral en pacientes con cardiomiopatía de takotsubo. Métodos: Revisión sistemática. Se buscaron en MEDLINE, LILACS, Ovid (Cochrane), Scopus, y ScienceDirect estudios de imagen por resonancia magnética funcional (IRMf) en pacientes con cardiomiopatía de takotsubo. Tras revisar títulos, resúmenes y textos completos se seleccionaron los estudios relevantes, se extrajeron sus características metodológicas y resultados principales, y se valoró su riesgo de sesgo mediante la escala Newcastle-Ottawa. Se presenta revisión narrativa de los resultados. Resultados: Se incluyeron cinco estudios de casos y controles de entre 600 registros. El riesgo de sesgo fue bajo, la comparabilidad fue la principal limitante. Los estudios de IRMf en estado de reposo sugieren diferencias significativas en el Hipocampo, la Ínsula, la Amígdala y el Giro parahipocampal. Los estudios de IRMf bajo paradigma sugieren diferencias en la Ínsula, el Giro occipital superior y en la Amígdala. Los estudios fueron heterogéneos respecto a la lateralización y direccion de estas diferencias. Conclusión: Alteraciones en la conectividad cerebral de zonas relevantes para el control autonómico como la ínsula y la Amígdala provén evidencia a favor del rol de redes funcionales en la neurocardiología de miocardiopatías relacionadas con el estrés. Sin embargo, aún no es posible determinar si esto obedece a un rol causal o consecuencial.

Implementación de un sistema protocolizado de pesquisa temprana de patología psiquiátrica en un hospital general. Protocolo de Vigilancia Neuropsiquiátrica (VNP): avanzando hacia un modelo de psiquiatría de enlace proactivo / Implementation of a protocol for neuropsychiatric disease surveillance in a general hospital

BACKGROUND: The COVID-19 pandemic increased the incidence of neuropsychiatric diseases. Proactive models of consultation-liaison psychiatry (CLP-p) could play a key role in the prevention and management of these diseases in a general hospital. AIM: To develop a protocol for implementing screening tools for neuropsychiatric symptoms in routine clinical practice. MATERIAL AND METHODS: Elements of the Plan-Do-Study-Act (PDSA) model were used to modify the Neuropsychiatric Surveillance protocol implemented at a clinical hospital during the COVID-19 pandemic by members of the hospital's CLP team. RESULTS: A flowchart for active follow-up of neuropsychiatric symptoms during hospitalization is presented, with sequential management and referral flows, accompanied by suggestions for pre-discharge evaluation to define continuity of care actions. The COSMOS tool is also presented, designed for the detection of risk factors and actions for the prevention of neuropsychiatric diseases in general hospitals. CONCLUSIONS: The neuropsychiatric surveillance protocol facilitates early and timely interventions and establishes criteria for the continuity of post-discharge care. These changes could improve the quality of care in general hospitals and reduce the gap between mental and physical health.

Eje cerebro intestino microbiota. Importancia en la práctica clínica

El eje cerebro-intestino-microbiota es un complejo bidireccional que comunica al sistema nervioso central con el aparato digestivo. Las alteraciones en la composición de la microbiota intestinal se han relacionado con la presencia de enfermedades digestivas y extradigestivas tales como las enfermedades neuropsiquiátricas. La disbiosis predispone a la aparición de alteraciones en la permeabilidad intestinal, lo cual facilita la liberación de neurotransmisores y citoquinas que generan las condiciones propicias para que aparezca un estado conocido como neuroinflamación, que parece ser clave en la fisiopatogenia de las enfermedades neuropsiquiátricas. En virtud de estos datos, la modulación de la microbiota a través de cambios en la dieta, antibióticos y probióticos, podría ser una alternativa útil, no sólo para el tratamiento de enfermedades digestivas sino también de trastornos extra digestivos como las enfermedades neuropsiquiátricas.

The brain-gut-microbiota axis is a bidirectional complex that connects the central nervous system with the digestive system. Alterations in the composition of the intestinal microbiota have been linked to the presence of digestive and extradigestive diseases such as neuropsychiatric diseases. Dysbiosis predisposes to the appearance of alterations in intestinal permeability, which facilitates the release of neurotransmitters and cytokines that generate favorable conditions for the appearance of a state known as neuroinflammation, which seems to be key in the physiopathogenesis of neuropsychiatric diseases. Based on these data, the modulation of the microbiota through changes in diet, antibiotics and probiotics could be a useful alternative, not only for the treatment of digestive diseases but also extra-digestive disorders such as neuropsychiatric diseases.

Treatment adherence in patients with diffuse neuropsychiatrie disorders associated with systemic lupus erythematosus / Adherencia al tratamiento en pacientes con trastornos neuropsiquiátricos difusos asociados a lupus eritematoso sistémico

ABSTRACT Introduction: Systemic lupus erythematosus (SLE) is a chronic disease that affects multiple systems and may include neurological and psychiatric events that could compromise treatment adherence and long-term outcomes in SLE. Objective: To evaluate treatment adherence in patients with diffuse neuropsychiatric disorders associated with SLE. Methods: A cross-sectional descriptive study was conducted. Treatment adherence was eval uated with the Morisky Medication Adherence Scale (MMAS-8) in patients with diffuse neuropsychiatric disorders associated with SLE (cognitive impairment, psychosis, mood disorders, and anxiety). Results: A total of 60 patients with neuropsychiatric disorders associated with SLE were included. Thirteen patients (21.6%) had high adherence, 9 (15%) had medium adherence, and 38 patients (63.3%) had low treatment adherence. Conclusion: This study has identified that almost two-thirds of the participants (63.3%) had low treatment adherence.

RESUMEN Introducción: El lupus eritematoso sistémico (LES) es una enfermedad crónica que afecta a múltiples sistemas, entre ellos el sistema nervioso, con eventos neurológicos y psiquiátricos que podrían influir en la adherencia al tratamiento y los resultados a largo plazo de la enfermedad. Objetivo: Evaluar la adherencia al tratamiento de los pacientes con trastornos neuropsiquiátricos difusos asociados con el LES. Metodología: Se llevó a cabo un estudio descriptivo transversal que evaluó el grado de adhe rencia al tratamiento con el test de Morisky en pacientes con trastornos neuropsiquiátricos difusos asociados con LES (alteración cognitiva, psicosis, trastornos del ánimo y ansiedad). Resultados: Se incluyó a 60 pacientes con trastornos neuropsiquiátricos difusos asociados con LES, de los cuales 13 (21,6%) tuvieron adherencia alta, 9 (15%) adherencia media y 38 (63,3%) presentaron baja adherencia al tratamiento. Conclusión: En este estudio se identificó que más de la mitad de los participantes (63,3%) presentaron baja adherencia al tratamiento.

Quiste aracnoideo (Galassi Tipo II) y síntomas neuropsiquiátricos: a propósito de un caso / Arachnoid Cyst (Galassi Type II) and neuropsychiatry symptoms: about a case

INTRODUCCIÓN: un quiste aracnoideo es originado de la alteración de una de las membranas de la meninges (aracnoides), de predominio en la fosa craneal media; es una patología poco común que cause síntomas y si ocurren, se pueden presentar manifestaciones neuropsiquiatrías. OBJETIVO: exponer los datos clínicos; y la metodología diagnóstica y terapéutica. CASO: presentamos una paciente femenina de 24 años de edad; sin antecedentes personales médicos psiquiátricos y médicos no psiquiátricos conocidos, quien presenta una historia con un mes de evolución de síntomas psicóticos y cambios conductuales. Se le realizo CAT cerebral simple y luego una resonancia magnética cerebral contrastada para definir el tamaño del quiste aracnoideo, por los posibles síntomas neuropsiquiátricos encontrados. Por medio de exámenes de laboratorios, estudios electrofisiológicos (electroencefalograma), neuroimágenes y evaluación clínica. Se decide presentar las características clínicas encontradas de la paciente quien requirió manejo con antipsicóticos, benzodiacepinas y estabilizador del humor con gradual mejoría de sus sintomatologías de ingreso (agitación psicomotora y psicosis).

INTRODUCTION: an arachnoid cyst is caused by the alteration of one of the membranes of the meninges (arachnoid), predominantly in the middle cranial fossa; It is an uncommon pathology that causes symptoms and if they occur, neuropsychiatric manifestations may take place. OBJECTIVE: expose the clinical data; and the diagnostic and therapeutic methodology. CASE: we present a 24-year-old female patient; with no personal history of psychiatric and known non-psychiatric medical records, whom presents a story with a month of evolution of psychotic symptoms and behavioral changes. A simple cerebral CAT was performed and then a cerebral magnetic resonance imaging with contrast to define the size of the arachnoid cyst, due to the possible neuropsychiatric symptoms found. Through laboratory tests, electrophysiological studies (electroencephalogram), neuroimaging and clinical evaluation. It was decided to present the clinical characteristics of the patient who required management with antipsychotics, benzodiazepines and mood stabilizer with gradual improvement of her admission symptoms (psychomotor agitation and psychosis)

Spanish version of the frontotemporal dementia knowledge scale: adaptation and validation / Versión en español de la escala de conocimiento sobre demencia frontotemporal: adaptación y validación

ABSTRACT Background: Frontotemporal dementia (FTD) is a neurodegenerative disease and is one of the most common causes of dementia in people under 65. There is often a significant diagnostic delay, as FTD can be confused with other psychiatric conditions. A lack of knowledge regarding FTD by health professionals is one possible cause for this diagnostic confusion. Objectives: The aim of this study was to adapt and validate the Frontotemporal Dementia Knowledge Scale (FTDKS) in Spanish. Methods: A translation was done, following cross-cultural adaptation guidelines, which consisted of forward translation, blind back translation, and an analysis by a committee of experts. For the present study, 134 professionals from different health areas responded the Spanish version of the FTDKS. The statistical analysis was performed using R version 4.0.0 "Arbor day" and the Psych, sjPlot packages. Results: The Spanish version of the FTDKS had good reliability and internal consistency (Cronbach alpha 0.74.). The sample's mean score was 19.78 (range = 4-32, SD 6.3) out of a maximum of 36 points. Conclusions: The results obtained show that the Spanish version has good psychometric properties. The FTDKS is applicable in our environment and can be a useful tool to evaluate the knowledge of health professionals regarding frontotemporal dementia.

RESUMEN Antecedentes: La demencia frontotemporal (DFT) es una enfermedad neurodegenerativa y es una de las causas más comunes de demencia en personas menores de 65 años. A menudo existe un retraso significativo en el diagnóstico, ya que la FTD puede confundirse con otras afecciones psiquiátricas. La falta de conocimientos sobre la DFT por parte de los profesionales de salud es una posible causa de esta confusión diagnóstica. Objetivos: El presente estudio describe nuestros esfuerzos para adaptar y validar la Escala de Conocimiento de la Demencia Frontotemporal (FTDKS) en español. Métodos: Se realizó una traducción, siguiendo las pautas de adaptación transcultural, que consistió en una traducción directa, una traducción inversa ciega y un análisis por parte de un comité de expertos. Para el presente estudio, 134 profesionales de diferentes áreas de la salud respondieron la versión en español del FTDKS. El análisis estadístico se realizó utilizando la versión 4.0.0 de R "Arbor day" y los paquetes Psych, sjPlot. Resultados: La versión en español del FTDKS tiene una buena fiabilidad y consistencia interna (alfa de Cronbach 0,74.). La puntuación media de la muestra fue de 19,78 (rango = 4-32, SD 6,3) sobre un máximo de 36 puntos. Conclusiones: Los resultados obtenidos muestran que la versión española tiene buenas propiedades psicométricas. El FTDKS es aplicable en nuestro medio y puede ser una herramienta útil para evaluar los conocimientos de los profesionales sanitarios sobre la demencia frontotemporal.

As crianças no hospital colônia infantil de oliveira (mg): uma história institucional (1931-1974) / Los/as niños/as del hospital colonia infantil de oliveira (mg): una historia institucional (1931-1974) / The children at the colony hospital of oliveira (mg): an institutional history (1931-1974)

Resumo: Este estudo objetiva resgatar os registros de práticas institucionais destinadas a crianças e adolescentes internados no antigo Hospital Colônia de Neuropsiquiatria Infantil de Oliveira (HCNPO), em Minas Gerais, no período de 1931 a 1974. Para isso, foi feito um estudo de caso a partir da análise documental de fontes primárias e bibliográficas sobre a instituição e as políticas referentes ao cuidado da loucura. Constata-se que a situação de saúde dos/as internos/as era caracterizada pela negligência e a violência do modelo asilar, com condições precárias de higiene, poucas atividades terapêuticas e deficientes medidas de socialização das crianças. Conclui-se que o HCNPO falhou em cuidar, proteger e estimular o desenvolvimento desses sujeitos, alvos de políticas que justificaram a intervenção social sobre seus corpos, tanto como "menores" quanto como "loucos".

Resumen: Este estudio tiene como objetivo recuperar los registros de prácticas institucionales hacia niños y adolescentes hospitalizados en el antiguo Hospital Colonia de Neuropsiquiatria Infantil de Oliveira (HCNPO), en Minas Gerais, de 1931 a 1974. Para eso, se realizó un estudio de caso a partir del análisis documental de fuentes primarias y bibliográficas sobre la institución y políticas relacionadas con el cuidado de la locura. Resulta que la situación de salud de los/as internos/as se caracterizó por la negligencia y la violencia del modelo de asilo, con malas condiciones de higiene, pocas actividades terapéuticas y medidas de socialización insatisfactorias para los niños. En conclusión, HCNPO no cuidó, protegió y estimuló el desarrollo de estos sujetos, blanco de políticas que justificaban la intervención social en sus cuerpos, tanto como "menores" cuánto como "locos".

Abstract: This study aims to retrieve the records of institutional practices towards children and adolescents hospitalized at the former Hospital Colônia de Neuropsiquiatria Infantil de Oliveira (HCNPO), in Minas Gerais, from 1931 to 1974. For that, a case study was made from the documentary analysis of primary and bibliographic sources on the institution and policies related to the care of madness. As it turns out, the health situation of the inmates was characterized by negligence and the violence of the asylum model, with poor hygiene conditions, few therapeutic activities and unsatisfactory socialization measures for the children. In conclusion, HCNPO failed to care for, protect and stimulate the development of these subjects, targets of policies that justified social intervention on their bodies, both as "minors" and as "mad".

Potenciales mecanismos de neuroinvasión del SARS-CoV-2: una revisión de la literatura actual / Potential neuroinvasion pathways of SARS-CoV-2: a review of the current literature

RESUMEN Desde su inicio, en diciembre del 2019, la pandemia causada por el nuevo coronavirus 2019 (COVID-19), ha infectado a más de 116 millones de personas. A las bien documentadas manifestaciones respiratorias causadas por el SARS-CoV-2, se está añadiendo un creciente número de manifestaciones neurológicas y psiquiátricas entre los pacientes afectados y sobrevivientes. En este artículo se revisan y describen los potenciales mecanismos de invasión del virus al sistema nervioso. Sobre la base de estudios precedentes en coronavirus similares (MERS-CoV y SARS-CoV) y la evidencia actual, se plantea que las posibles rutas de neuroinvasión que emplea el SARS-CoV-2 son la transneuronal (vía axonal retrógrada, a través de los nervios periféricos), la hematógena/linfática (libre a través de la sangre y linfa o en el interior de las células inmunes) y la digestiva (mediante disrupción de la barrera intestinal). Si bien es necesario conducir más investigaciones en varias áreas, dilucidar las rutas de neuroinvasión, así como las capacidades neurotrópicas del virus, son puntos de vital importancia para entender y tratar las múltiples manifestaciones neurológicas y psiquiátricas, así como las potenciales secuelas a largo plazo que los pacientes infectados puedan desarrollar.

SUMMARY Since its beginning, in December 2019, the pandemic caused by the coronavirus disease 2019 (COVID-19) has infected more than 116 millions of people. In addition to the well-documented respiratory manifestations caused by SARS-CoV-2, an increasing number of neurological and psychiatric manifestations are being reported among affected individuals and survivors. In this article we describe the potential invasion mechanisms of SARS-CoV-2 to the nervous system. On the basis of preceding studies on similar coronaviruses (MERS-CoV and SARS-CoV) and current evidence, three possible neuroinvasion routes used by SARS-CoV-2 are suggested: the transneuronal pathway (retrograde axonal pathway through the peripheral nerves), the hematogenous / lymphatic pathway (free through the blood and lymph or inside immune cells), and the digestive pathway (through disruption of the intestinal barrier). Although more research is needed in several areas, the elucidation of neuroinvasion routes and of the neurotropic capacities of the virus, are vital to understand and treat the multiple neurological and psychiatric manifestations as well as the long-term sequelae that the infected patients may potentially develop.

A descriptive study of stress as indicated by perceived stress scale scores among the Neuropsychiatry unit staff of the Makati Medical Center over a one month period in 2015

OBJECTIVE@#The aim of this study was to describe the degree of stress experienced among staff of a high-risk unit in Makati Medical Center - the Neuropsychiatry Unit.@*METHODOLOGY@#The Perceived Stress Scale developed by Cohen in 1983 was the tool used. It is a ten-item, self-administered questionnaire that measures perceived stress levels of respondents. Perceived stress levels may be lower than average, slightly lower than average, average, slightly higher than average or much higher than average. Demographic characteristics of respondents were likewise determined. Respondents were members of the Neuropsychiatry unit staff.@*RESULTS@#The Neuropsychiatry unit staff generally presented with perceived stress levels of slightly higher than average. Most of the staff were female, aged thirty years old and below, single, with at least college level education. Birth order, the presence of night shifts, eight-hour shifts, length of service in years, and varying job designation in the unit were also identified. Majority of the respondents had not had any previous consultation with a mental health professional, and viewed having a support group in the workplace to be beneficial.@*CONCLUSION@#The staff members of the Neuropsychiatry unit perceived stress to be slightly higher than average.

Panorama general de la terapia electroconvulsiva: indicaciones y funcionamiento / Electroconvulsive Therapy Overview: Indications and How it Works

Resumen La terapia electroconvulsiva (TEC) constituye una de las modalidades terapéuticas disponibles para el tratamiento de padecimientos psiquiátricos como depresión, manía, esquizofrenia y estados de catatonia. Incluso se considera la terapia con resultados más eficaces y rápidos para pacientes con padecimientos como depresión resistente, ideación suicida recurrente, psicosis aguda y padecimientos que llegan a ser mortales como el síndrome neuroléptico maligno. La TEC es una terapia de estimulación cerebral en la cual la respuesta terapéutica se logra a través de la generación de un estímulo eléctrico con una intensidad suficiente para producir una crisis convulsiva encefálica controlada, logrando una respuesta neurobiológica y neuroquímica positiva favorable. Este artículo enfoca la utilidad de la TEC en el tratamiento de distintos padecimientos neuropsiquiátricos, sus principios fisiopatológicos, la técnica utilizada, sus principales complicaciones y, sobre todo, una descripción global de su utilización, su eficacia y seguridad, así como la experiencia de su uso en nuestra institución. Constituye uno de los pocos artículos en México con este contenido que consideramos fundamental como parte del conocimiento de todos los profesionales de la salud.

Abstract The electroconvulsive therapy (ECT) constitutes one of the many treatment modalities available for management of psychiatric illnesses like depression, mania, schizophrenia, and catatonic states. It is even considered the single most effective and fastest treatment modality for patients with conditions like antidepressant-resistant depression, recurring suicidal ideations, acute psychoses, and potentially fatal conditions like malignant neuroleptic syndrome. ECT is a brain-stimulation therapy in which the therapeutic goal can be achieved through generating an electrical stimulus with enough intensity to produce a controlled seizure, achieving a positive and favorable neurobiological and neurochemical response. This article focuses on the use of ECT in treating the various neuropsychiatric conditions, its pathophysiological principles, the employed technique, its main complications and overall a description of its use, its efficiency and safety, as to the experience of its employment in our institution. This comprises one of the few articles in Mexico with this kind of content that we deem fundamental as part of the general knowledge for healthcare professionals.

Sistemas de activación y de inhibición de conducta y su relación con el funcionamiento ejecutivo en excombatientes irregulares del conflicto armado colombiano / Behavior activation and inhibition systems and their correlation with executive functioning in ex-combatants of the Colombian armed conflicto / Sistemas de ativação e de inibição de conduta e sua relação com o funcionamento executivo em ex-combatentes irregulares do conflito armado colombiano

Objetivo: Explorar la relación entre los sistemas de activación de conducta (SAC) / sistema de inhibición de conducta (SIC) y funciones ejecutivas (FE) en excombatientes del conflicto armado colombiano. Metodología: Estudio observacional, exploratorio, con muestra no aleatoria de 39 excombatientes del programa de la Alta Consejería de la Presidencia para la Reintegración, residentes en Antioquia-Colombia, edad 35±7.6 años, 87.2% hombres, y escolaridad 10±2.8 grados; comparados con un grupo control de 14 no combatientes (edad 33±6.1 años, 71.4% hombres y escolaridad 10±2.7 grados). Se les administró un cuestionario de SAC/SIC, usando la sensibilidad a la recompensa (SR) y la sensibilidad al castigo (SC). Para la FE se aplicó la prueba Ineco Frontal Screening (IFS). Resultados: Hubo alteraciones específicas de la FE: en la ejecución de instrucciones conflictivas (IC), memoria de trabajo verbal (MTV) y control inhibitorio verbal (CIV). Se evidenciaron correlaciones directas, con coeficientes de moderados a altos entre el SAC (SR) y la capacidad de abstracción CA, el control motor inhibitorio (CMI), la MTV, la memoria de trabajo espacial (MTE) y el funcionamiento ejecutivo global (IFSTOT). Conclusiones: Los excombatientes presentaron un rendimiento inferior en la memoria de trabajo verbal y el control inhibitorio verbal, lo que impacta las capacidades de anticipación, establecimiento de metas, diseño de planes, iniciación de conductas voluntarias y el control inhibitorio. Lo anterior puede generar la toma de decisiones equivocadas.

Objective: To explore the correlations between behavior activation and inhibition systems (BAS/ BIS) and executive functions in ex-combatants of the Colombian armed conflict. Methodology: Observational, exploratory study, with a sample of 39 ex-combatants belonging to the "High Counseling of the Presidency for Reintegration" program, residents in Antioquia-Colombia, with an average of 35±7.6 year of age, 87.2% were males, with school grades of10±2.8; who were compared with a control group of 14 non-combatants, with ages between 33±6.1 years-old, 71.4% were males, and with school grades 10±2.7. The BAS/ BIS questionnaire was administered in order to score the Reward Sensitivity (RS) and Punishment Sensitivity (PS). The EF was evaluated with INECO-Frontal Screening (IFS). Results: There were specific alterations of EF in the execution of conflicting instructions (CI), verbal working memory (MTV) and verbal inhibitory control (CIV). Direct correlations, moderate to high coefficients between SAC (SR) and CA abstraction capacity, CMI inhibitory motor control, MTV, spatial working memory (MTE), and global executive functioning (IFSTOT). Conclusions: Colombian ex-combatants have lower performance in verbal working memory and verbal inhibitory control, which would affect anticipation, goal setting, plan design, initiation of voluntary behaviors and inhibitory control, which generates generation of wrong decisions.

Objetivo: Explorar a relação entre os sistemas de ativação de conduta (SAC) / sistema de inibição de conduta (SIC) e funções executivas (FE) em ex-combatentes do conflito armado colombiano. Metodologia: Estudo observacional, exploratório, com amostra não aleatória de 39 ex-combatentes do programa da Alto Conselho da Presidência para a Reintegração, residentes em Antioquia-Colômbia, idade 35±7.6 anos, 87.2% homens, e escolaridade 10±2.8 graus; comparados com um grupo controle de 14 não combatentes (idade 33±6.1 anos, 71.4% homens e escolaridade 10±2.7 graus). Se lhes administrou um questionário de SAC/SIC, usando a sensibilidade à recompensa (SR) e a sensibilidade ao castigo (SC). Para a FE se aplicou a prova Ineco Frontal Screening (IFS). Resultados: Houve alterações específicas da FE: na execução de instruções conflitivas (IC), memória de trabalho verbal (MTV) e controle inibitório verbal (CIV). Se evidenciaram correlações diretas, com coeficientes de moderados a altos entre o SAC (SR) e a capacidade de abstração CA, o controle motor inibitório (CMI), a MTV, a memória de trabalho espacial (MTE) e o funcionamento executivo global (IFSTOT). Conclusões: Os ex-combatientes apresentaram um rendimento inferior na memória de trabalho verbal e o controle inibitório verbal, o que impacta as capacidades de antecipação, estabelecimento de metas, desenho de planos, iniciação de condutas voluntárias e o controle inibitório. O anterior pode gerar a toma de decisões equivocadas.