Catatonía: revisión narrativa de su desarrollo histórico, diagnóstico, fisiopatología y terapéutica / Catatonia: A narrative review of its historical development, diagnosis, pathophysiology, and therapeutics

Inicialmente la catatonía fue un componente clínico de algunas formas de esquizofrenia, pero la evidencia básica y epidemiológica demuestra su vinculación con múltiples cuadros somáticos y psiquiátricos. Se describen y analizan conceptos clínicos, etiológicos, fisiopatológicos y terapéuticos actuales respecto a la catatonía. Se realizó una revisión narrativa amplia de artículos publicados en MEDLINE/PubMed. El diagnóstico es clínico y puede apoyarse en exámenes complementarios, pero existen instrumentos psicométricos con distinto énfasis clínico. Los subtipos más validados son el inhibido y el excitado. Se asocia mayormente a patologías somáticas, neurológicas, afectivas, psicóticas y del espectro autista. En su fisiopatología se han estudiado factores genéticos relacionados con los oligodendrocitos. Algunos hallazgos señalan un desbalance en la neurotransmisión y densidad de receptores de GABA y dopamina, hecho concordante con su función en las vías motoras y la respuesta terapéutica con benzodiacepinas. Asimismo, se ha analizado la actividad glutamatérgica, desde el modelo fisiopatológico de la encefalitis autoinmune. Las vías córtico-corticales y córtico-subcorticales tendrían un rol central, incluyendo estructuras como las cortezas orbitofrontal y temporal, núcleos basales y tronco encefálico, involucradas en la toma de decisiones, regulación emocional, almacenamiento, planificación y elaboración motora. Las principales líneas terapéuticas son las benzodiacepinas y la terapia electroconvulsiva. Otras intervenciones estudiadas son el zolpidem, antipsicóticos, estabilizadores del ánimo, moduladores glutamatérgicos y estimulación magnética transcraneal. Los nuevos hallazgos neurobiológicos discuten los preceptos nosológicos y terapéuticos, renovando el ciclo en la conceptualización de la catatonía. Se destaca el componente afectivo del síndrome psicomotor y el rol de las intervenciones que apunten a su modulación.

Catatonia was initially a clinical presentation of certain types of schizophrenia, but basic and epidemiological evidence has demonstrated its association with multiple somatic and psychiatric conditions. We describe and discuss current clinical, etiological, pathophysiological, and therapeutic concepts regarding catatonia. We conducted a broad narrative review of articles published in MEDLINE/PubMed. The diagnosis is clinical and can be supported by additional tests, but there are psychometric instruments with different clinical focus. The most validated subtypes are inhibited and excited catatonia. It is mostly associated with somatic, neurological, affective, psychotic, and autistic spectrum disorders. Genetic factors related to oligodendrocytes have been studied in its pathophysiology. Some findings point to an imbalance in neurotransmission and density of GABA and dopamine receptors, consistent with their function in motor pathways and therapeutic response with benzodiazepines. Likewise, glutamatergic activity has been analyzed from the pathophysiological model of autoimmune encephalitis. The cortico-cortical and cortico-subcortical pathways would have a central role, including structures such as the orbitofrontal and temporal cortex, basal nuclei, and brainstem, involved in decision-making, emotion regulation, storage, planning, and motor processing. The main therapeutic lines are benzodiazepines and electroconvulsive therapy. Other interventions studied are zolpidem, antipsychotics, mood stabilizers, glutamatergic modulators, and transcranial magnetic stimulation. New neurobiological findings challenge nosological and therapeutic precepts, renewing the cycle in the conceptualization of catatonia. We highlight the affective component of the psychomotor syndrome and the role of interventions aimed at its modulation.

Posibles mecanismos de acción de la terapia electroconvulsiva en trastornos afectivos: revisión de la evidencia disponible en investigación con seres humanos

The mechanisms of action (MA) of electroconvulsive therapy (ECT) in affective disorders are poorly understood. We synthesized and discussed the evidence provided by primary studies and systematic reviews in humans. There are differences in the methylation of candidate genes involved in the response to ECT. Functioning of the hippocampal serotonin receptor 5-HT1B is associated with the response in patients with major depressive disorder (PMDD), while the striatal dopamine transporter would participate in the response of PMDD and in patients with bipolar disorders (BD). The only neurotrophic factor associated with ECT response was vascular endothelial growth factor. In BD, some oxidative stress metabolites had a clinical correlation, while tryptophan metabolism showed a clinical association in BD and PMDD. Furthermore, in PMDD, some neurodegeneration markers were implicated in the MA of ECT. There were no other biological dimensions associated with BD. In PMDD, multiple inflammatory mediators were associated with the clinical response (natural killer cells, tumor necrosis and growth factors, and interleukins 1, 4, 6, 10,1β). Likewise, some structures and circuits consistently involved at the morphological and functional level are the default mode network, cognitive control networks, frontal, temporal, cingulate, occipital and temporal cortices, frontal, temporal, precentral, fusiform and left angular gyri, hippocampus, thalamus and amygdala. Investigations are mostly focused on PMDD, are observational, and their samples limited, but they show relatively consistent results with clinical significance.

Eficacia del entrenamiento metacognitivo en una muestra chilena de personas con esquizofrenia / Efficacy of Metacognitive Training in a Chilean Sample of People with Schizophrenia

RESUMEN Introducción: El entrenamiento metacognitivo (EMC) de Moritz et al., una nueva dirección en terapia, es un programa de entrenamiento grupal manualizado, dirigido a corregir los sesgos cognitivos implicados en la formación y el mantenimiento de los síntomas psicóticos, principalmente los delirios. El objetivo de este estudio es evaluar la eficacia del EMC en una muestra chilena de personas con esquizofrenia. Métodos: Se aleatorizó a 50 pacientes ambulatorios del Hospital Del Salvador de Valparaíso, Chile, al grupo de intervención que recibió el EMC o al grupo de control que solo recibió el tratamiento habitual. Se evaluó a los sujetos al inicio y al término del estudio mediante la escala de los síndromes positivo y negativo (PANSS), el cuestionario de sesgos cognitivos para psicosis (CBQ) y la escala de insight cognitivo de Beck (BCIS). Resultados: En el grupo de EMC se registraron mayores mejorías estadísticamente significa tivas, tanto en síntomas y sesgos cognitivos como en insight cognitivo, que en el grupo de control. Al comparar ambos grupos, solo se observaron resultados significativos a favor del EMC en los síntomas positivos. Conclusiones: Los resultados de este estudio indican que el EMC es superior al tratamiento habitual en el tratamiento de los síntomas positivos. No fue posible demostrar su superio ridad en la mejoría de los sesgos cognitivos y el insight cognitivo.

ABSTRACT Introduction: Moritz et al.'s metacognitive training (MCT), a new development of cognitive therapy, is a manualized group training program, designed to correct cognitive biases involved in the formation and maintenance of psychotic symptoms, especially delusions. We report on the efficacy of MCT in a Chilean sample of people with schizophrenia. Methods: 50 outpatients from the Hospital Del Salvador at Valparaíso, Chile, were randomly assigned to the intervention group (MCT), or the control group, that only received treatment as usual (TAU). Subjects were assessed at the beginning and end of the study with the Positive and Negative Syndrome Scale (PANSS), Cognitive Biases Questionnaire for Psychosis (CBQ-P) and Beck Cognitive Insight Scale (BCIS). Results: In the MCT group, we found larger, statistically significant improvements, in symp toms, cognitive biases and cognitive insight, than in the control group. However, after a direct comparison of both groups, only the improvement in psychotic symptoms for the MCT group, remained significantly different. Conclusions: The results of this study suggest superiority of MCT over TAU in the amelioration of positive symptoms. We could not, however demonstrate its superiority in the improvement of the cognitive biases and cognitive insight.

A non-systematic, descriptive literature review of observational research on anxiety during the first COVID-19 pandemic phase / Revisión de la literatura no sistemática descriptiva de estudios observacionales sobre ansiedad durante la primera fase de la pandemia de COVID-19

Fear of contagion, together with the consequences of mitigation strategies, are often cited as causes of high levels of anxiety in the general population in the context of the COVID-19 pandemic. However, it is unclear whether published reports make it possible to distinguish between normal and pathological anxiety. We conducted a non-systematic, descriptive literature review on observational studies reporting the prevalence or frequency of anxiety symptoms in non-clinical settings published between July and December 2020. Seventy-six studies were included. Two were conducted through telephone contact while the remainder were conducted on the internet. Factors associated with greater presence/severity of anxiety symptoms were sociodemographic variables (e.g., age, gender, employment, place of residence, living conditions, marital status, and educational level). Thirty publications (39.4%) reported data on a comparison group, including samples of general populations from different geographic regions or in different periods. Only 16 studies (21%) included some estimation of the functional impairment of detected anxiety symptoms. Only seven of the studies that estimated functional impairment had comparison groups. None of the studies included in this review contain sufficient contextual or descriptive information to determine whether the reported high levels of anxiety are normal reactions of subjects in high-stress situations or actual psychiatric disorders.

El temor al contagio, junto con las consecuencias de las estrategias de mitigación, suelen citarse como causas de los altos niveles de ansiedad en la población general en el contexto de la pandemia de COVID-19. Sin embargo, no es claro si los informes publicados permiten una distinción entre la ansiedad normal y la patológica. Se realizó una revisión de la literatura no sistemática y descriptiva de los estudios observacionales que analizaron la prevalencia o la frecuencia de los síntomas ansiosos en contextos no clínicos publicados entre julio y diciembre de 2020. Se incluyeron setenta y seis estudios. Dos se realizaron mediante contacto telefónico con los participantes y el resto a través de internet. Los factores asociados a una mayor presencia/gravedad de los síntomas ansiosos fueron las variables sociodemográficas (e.g., edad, género, ocupación, lugar de residencia, condiciones de vida, estado civil y nivel educativo). Treinta publicaciones (39,4%) informaron datos sobre grupos de comparación, incluidas muestras de la población general de diferentes regiones geográficas o en diferentes períodos. Solo 16 estudios (21%) incluyeron alguna estimación de la alteración funcional asociada a los síntomas ansiosos. Solo siete de los estudios que estimaron la alteración funcional incluyeron grupos de comparación. Ninguno de los estudios incluidos en esta revisión contiene suficiente información contextual o descriptiva para determinar si los altos niveles de ansiedad son reacciones normales de personas en situaciones de alto estrés o trastornos psiquiátricos per se.

Posibles mecanismos de acción de la terapia electroconvulsiva en esquizofrenia: revisión de la evidencia disponible en investigación con seres humanos / A review about the putative mechanisms of action of electroconvulsive therapy in schizophrenia in human research

Electroconvulsive therapy (ECT) has multiple uses in psychiatry, but its mechanisms of action (MA) in patients with schizophrenia (PS) are poorly understood. We synthesize and discuss the available evidence in this regard. We conducted a search for primary human studies and systematic reviews searching MA of ECT in PS published in PubMed/Medline, SciELO, PsycInfo, and the Cochrane Library, including 24 articles. Genetic findings are scarce and inconsistent. At the molecular level, the dopaminergic and GABAergic role stands out. The increase in brain derived neurotrophic factor (BDNF) after ECT, is a predictor of positive clinical outcomes, while the change in N-acetyl aspartate levels would demonstrate a neuroprotective role for ECT. This intervention would improve inflammatory and oxidative parameters, thereby resulting in a symptomatic improvement. ECT is associated with an increase in functional connectivity in the thalamus, right putamen, prefrontal cortex and left precuneus, structures that play a role in the neural default mode network. A decrease in connectivity between the thalamus and the sensory cortex and an enhanced functional connectivity of the right thalamus to right putamen along with a clinical improvement have been reported after ECT. Moreover a volumetric increase in hippocampus and insula has been reported after ECT. These changes could be associated with the biochemical pathophysiology of schizophrenia. Most of the included studies are observational or quasi-experimental, with small sample sizes. However, they show simultaneous changes at different neurobiological levels, with a pathophysiological and clinical correlation. We propose that the research on ECT should be carried out from neurobiological dimensions, but with a clinical perspective.

¿Estar depresivo o tener depresión? El modelo biomédico y la diferencia entre estado de ánimo y enfermedad / Being Depressed or Having Depression. The biomedical model and the difference between mood and illness

Along with the increase in reported figures of depression in the world's population, organizations such as the WHO have begun to promote screening and pharmacological treatment of mild symptomatic cases. The problem in this context is that the manifestations of 'normal' and 'pathological' depressive mood do not differ much from each other, which creates difficulties at a diagnostic and scientific level. This article explores an approach that could facilitate the clinical and scientific task of differentiating between non-specific affective disturbances (depressive mood) and depression as an illness as such. It is proposed that various causal stressors interact with individual predispositions to trigger a transient change in mood as an adaptive response. In turn, the greater the intensity of the stressors (psychological, social, etc.), the greater the neuroinflammation, which would diminish neuronal plasticity and the possibilities of mood compensation and behavioral change of the subject. The existence of this neurobiological alteration (decreased neuronal plasticity), rather than depressive mood, would help us to categorize depression as a disease.

The Type of Information People with Schizophrenia Use in Ambiguous Social Situations / ¿Qué tipo de información usan las personas con esquizofrenia en situaciones sociales ambiguas?

ABSTRACT Background and objectives: Rather than focusing on the extensively studied social perception and recognition impairments in people with schizophrenia, this study focuses on the type of social information considered relevant by people with schizophrenia, and how they use it to arrive at conclusions about social situations. Methods: Participants included 50 outpatients with schizophrenia from the Hospital del Salvador at Valparaíso, Chile, and 50 healthy comparators matched by age and gender. Subjects completed the Social Information Preference Test (SIPT), which presents scenes depicting ambiguous social situations with faces, thoughts, and facts about the scene hidden from view. Participants were required to select a limited number of these items and then choose between possible interpretations of the scene (positive, neutral, or negative). Additionally, they are asked to provide a feeling of certainty in their answers, using a 7-point visual analogue scale. Results: People with schizophrenia, as well as controls had a strong preference for knowing the thoughts of the characters. Both groups were least likely to choose emotional expressions. Patients were significantly less likely to choose object/information than controls. Both groups showed a high certainty in their responses and no tendency to choose negative interpretations. Limitations: compensated clinical status of the patients may have influenced the results. Conclusions: The results of this study suggest that, despite difficulties perceiving clues about the mental state of others, people with schizophrenia use this information to make sense of social situations, and apparently, they do not have problems in understanding social interactions.

RESUMEN Objetivos: En lugar de los impedimentos en la percepción social, ampliamente estudiada en personas con esquizofrenia, centramos nuestra investigación en el tipo de información social considerada relevante por las personas con esquizofrenia y cómo la usan para llegar a conclusiones sobre situaciones sociales. Métodos: Se incluyó a 50 pacientes ambulatorios con esquizofrenia del Hospital del Salvador en Valparaíso, Chile, y 50 comparadores sanos, emparejados por edad y sexo. Los sujetos completaron la Prueba de Preferencia de Información Social (SIPT), que presenta escenas con situaciones sociales ambiguas en las que rostros, pensamientos y hechos sobre la escena están ocultos a la vista. Los participantes deben seleccionar un pequeño número de estos elementos y luego elegir entre posibles interpretaciones (positiva, neutral o negativa). Además, se les pide que proporcionen una sensación de certeza en sus respuestas, utilizando una escala analógica visual de 7 puntos. Resultados: Tanto las personas con esquizofrenia como los comparadores mostraron una fuerte preferencia por conocer los pensamientos de los personajes. La opción menos preferida por ambos grupos fue las expresiones emocionales, mientras que los pacientes escogieron menos objeto/información que los controles. Ambos grupos mostraron una alta certeza en sus respuestas y no se observó una tendencia a elegir interpretaciones negativas. Limitaciones: el estado clínico compensado de los pacientes puede haber influido en los resultados. Conclusiones: Los resultados de este estudio indican que, a pesar de las dificultades para percibir pistas sobre el estado mental de los demás, las personas con esquizofrenia usan esta información para dar sentido a las situaciones sociales y, aparentemente, no presentan problemas para comprender las interacciones sociales.

La depresión como enfermedad: en defensa del modelo biomédico en psiquiatría / In defense of the biomedical model in psychiatry. the case of depression

Defining what is meant by "mental illness" has three dimensions: (i) the ontological dimension, which attempts to answer the question of what is a mental illness in itself, (ii) the scientific dimension, which attempts to identify its causes, and (iii) the practical dimension, which will seek a treatment. This article uses depression to examine how various conceptual alternatives in contemporary literature attempted to tackle the problem of what is a mental illness. After evaluating the scope of their proposals in the three dimensions mentioned above, it is concluded that the biomedical model could become a good candidate for developing a useful framework for understanding, having a scientific explanation and treating depression.

Esquizofrenia resistente: Definiciones e Implicancias del concepto de Esquizofrenia Resistente a tratamiento / Treatment resistant schizophrenia: definitions and implications of the Treatment Resistant Schizophrenia concept

Resumen La esquizofrenia (EQZ) es una entidad clínica altamente heterogénea. Determina un severo impacto en la calidad de vida de los pacientes y un alto costo para la sociedad. Los antipsicóticos son la primera línea de tratamiento, sin embargo, hasta un tercio de los pacientes presentaran una esquizofrenia resistente a tratamiento (ERT). Se ha propuesto que la ERT podría corresponder a un grupo neurobiológicamente distinto de la enfermedad con una arquitectura genética particular y no solo al extremo del espectro de severidad de la misma. A pesar de ello, actualmente no existe consenso en la literatura en torno a la definición de ERT. En este trabajo presentamos una revisión de diferentes definiciones de ERT centrándonos principalmente en las guías clínicas publicadas. Además se discuten las alternativas terapéuticas en ERT y, finalmente, se proponen perspectivas futuras en torno a la necesidad de desarrollar predictores de respuesta a antipsicóticos de primera y segunda línea, así como también la posibilidad de comprender la neurobiología de la ERT.

Schizophrenia (SZ) is a highly heterogeneous clinical entity. It causes a severe disruption in quality of life, and it imposes a significant burden to society. Antipsychotics are the first line treatment, however up to a 30% of the patients will present resistance to treatment. Treatment resistant schizophrenia (TRS) could be a neurobiologically distinct disorder and not merely an extremely severe form of SZ. However, there is no consensus in the literature as to the definition of TRS. In the present work we review different definitions of TRS, mainly from clinical guidelines. Furthermore, we discuss therapeutic alternatives for TRS and suggest future perspectives regarding the identification of response predictors and understanding the neurobiology of TRS.

Percepción subjetiva del déficit cognitivo y desempeño en una batería neuropsicológica en personas con esquizofrenia / Subjective perception of cognitive deficit and performance in a neuropsychological battery in people with schizophrenia

Los resultados contradictorios de las investigaciones respecto a la capacidad de las personas con esquizofrenia, para percibir sus déficits cognitivos, podrían explicarse por factores metodológicos, en especial, por diferencias en los instrumentos empleados y las funciones evaluadas. Esta investigación reporta los resultados obtenidos comparando directamente, el desempeño cognitivo, con el reporte subjetivo de dificultades cotidianas derivadas del mismo. Método: Participaron 57 personas con diagnóstico de esquizofrenia, entre 18 y 55 años, clínicamente estables y con un déficit cognitivo demostrado. El funcionamiento cognitivo fue evaluado con la batería CogState, mientras que la percepción de los pacientes fue registrada con la Escala Subjetiva para Investigar la Cognición en la Esquizofrenia (SSTICS). Se correlacionó específicamente, los desempeños en cada función cognitiva con los ítems correspondientes de la escala. Resultados: Los puntajes reportados en la escala SSTICS, indican un grado de dificultad leve a moderado, en todos los funciones evaluadas, sin diferencias por edad o género. El análisis de correlación entre la batería Cogstate y la escala SSTICS, sólo muestra una asociación directa, estadísticamente significativa, entre las preguntas referidas a dificultades en la vida diaria y las evaluaciones de atención y resolución de problemas. Al examinar por funciones cognitivas específicas y puntación total en la SSTICS, no se encuentran asociaciones significativas. Discusión: La falta de correlación entre el desempeño en la batería Cogstate y la autoevaluación en la encuesta SSTICS, podría explicarse por la falta de percepción de los pacientes de sus déficits cognitivos...

The contradictory results of investigations into the ability of persons with schizophrenia, to perceive their cognitive deficits, could be explained by methodological factors, especially, differences in the instruments used and the functions evaluated. This study reports the results obtained by directly comparing, cognitive performance, and subjective report of daily difficulties arising from the same in a group of people with schizophrenia. Methods: 57 participants with a diagnosis of schizophrenia, between 18 and 55 years, clinically stable and with a demonstrated cognitive deficit. Cognitive performance was evaluated with the CogState battery, while the perception of patients was registered with the SSTICS scale. The performance in each cognitive function was specifically, correlated with the corresponding items of the scale. Results: The scores reported in the SSTICS scale, indicate a degree of mild to moderate difficulty, in all the functions assessed, without differences by age or gender. The analysis of correlation between the Cogstate battery and SSTICS scale, only shows a direct, statistically significant association, between the questions referring to difficulties in daily life and evaluations of attention and resolution of problems. Examining specific cognitive functions and the total score in the SSTICS, did not yield any significant associations. Discussion: The lack of correlation between the performance in the Cogstate battery and self-evaluation in the SSTICS scale, could be explained by the lack of perception of patients of their cognitive deficits...

Auto evaluación de personas enfermas de esquizofrenia empleando el Cuestionario Sevilla Calidad de Vida / Self-assessment of people with schizophrenia using the Sevilla Questionaire of Quality of Life

Objectives: To assess the subjective perception of quality of life in a group of persons with diagnosis of schizophrenia using the Sevilla Questionnaire. Methods: 50 patients answered the Sevilla questionnaire and completed a clinical and neuropsychological evaluation. Results: Most patients reported a high level of satisfaction with their lives. We found a statistically significant, inverse association, between the unfavourable subscale and the GAFF score and the negative symptoms, general psychopathology and the insight item of the PANSS. Conclusions: People with schizophrenia can adequately report about their Quality of Life. Vital satisfaction of the patients depends on factors different from the direct results of medical treatment.

Objetivos: conocer la percepción subjetiva de Calidad de Vida de un grupo de personas enfermas de esquizofrenia empleando el Cuestionario Sevilla y analizar su relación con variables clínicas y neuropsicológicas. Metodología: 50 pacientes respondieron el cuestionario Sevilla y fueron evaluados con una batería neuropsicológica y con las escalas PANSS y EEAG. Resultados: la mayoría de los pacientes manifestó un nivel elevado de satisfacción vital. Existe una relación inversa, estadísticamente significativa, entre la subescala desfavorable del Cuestionario Sevilla, los puntajes de la escala GAFFy los síntomas negativos, de psicopatología general y el ítem de Insight de la PANSS. Conclusiones: Las personas enfermas de esquizofrenia podrían informar adecuadamente respecto de su calidad de vida. La satisfacción vital de los pacientes depende de factores distintos de los resultados directos del tratamiento médico.