Características de pacientes con diagnóstico de primer episodio psicótico internados en un hospital universitario

RESUMEN Introducción: la esquizofrenia y otros trastornos psicóticos constituyen la mayor parte de los diagnósticos realizados en el Departamento de Emergencias y Admisión del Servicio de Psiquiatría del Hospital de Clínicas de la Universidad Nacional de Asunción, seguidos por los trastornos depresivos y los trastornos de ansiedad. Objetivo: determinar las características de los pacientes con diagnóstico de primer episodio psicótico, siendo esta información relevante en el contexto de la atención que pueda brindarse a los mismos y a la información epidemiológica que proporciona. Metodología: estudio observacional, descriptivo, con muestreo no probabilístico, temporalmente retrospectivo. Se incluyó las historias clínicas de pacientes del Servicio de Psiquiatría del Hospital de Clínicas, de ambos sexos, que hayan sido hospitalizados con síntomas de un primer episodio psicótico entre 2014 y 2019. Resultados: se analizaron las historias clínicas de 143 pacientes. El 62,8% era del sexo femenino. La edad media fue 31 ± 13 años. El 48,9% tenía historial de diagnósticos psiquiátricos en su familia. El 66,43% era de nivel económico medio, el 32,17% nivel bajo y el 1,4% nivel alto. El pensamiento desorganizado fue el síntoma más frecuente (86%) encontrado en el examen del estado mental. Conclusiones: la mayoría de los pacientes con diagnóstico de primer episodio psicótico provenía del Departamento Central de Paraguay, residía en zonas urbanas, era del sexo femenino, era de nivel económico medio, aproximadamente la mitad con antecedentes de trastornos mentales en la familia y presentaba casi dos meses de evolución de la enfermedad. El pensamiento (ideas delirantes), el afecto, la introspección, el humor, el lenguaje y la sensopercepción (alucinaciones) fueron los indicadores más frecuentemente alterados del examen mental.

ABSTRACT Introduction: Schizophrenia and other psychotic disorders make up the majority of diagnoses made in the Emergency and Admission Department of the Psychiatry Service of the "Hospital de Clínicas" of the National University of Asunción, followed by depressive disorders and anxiety disorders. Objective: The objective of the present study was to determine the characteristics of the patients diagnosed with a first psychotic episode. This information is relevant in the context of the care that can be provided to patients and the epidemiological information provided. Methodology: This was an observational, descriptive study, with non-probabilistic sampling, temporarily retrospective. The medical records of male and female patients of the Psychiatry Service of the "Hospital de Clínicas" who have been hospitalized with symptoms of a first psychotic episode were included. Results: The medical records of 143 patients were analyzed, 62.8% of them was female. The mean age was 31.5 ± 13.6 years, 48.9% had a history of psychiatric diagnoses in their family, 66.43% had medium economic level, 32.17% low level and 1.4% high level. distortion in thinking was the most frequent symptom (86%) found in the mental state exam. Conclusions: The majority of patients diagnosed with the first psychotic episode came from the Central Department of Paraguay, resided in urban areas, were female, had medium economic status, approximately half had a history of mental disorders in the family and had almost two months of disease evolution. Thought (delusions), affection, introspection, humor, language, and perception (hallucinations) were the most frequently altered indicators of the mental examination.

Electroconvulsoterapia en el primer episodio de esquizofrenia: impacto en la evolución / Electroconvulsoterapia in the first episode of schizophrenia: impact on evolution

La esquizofrenia es una patología que evolucionade forma crónica, proclive al deterioro, siendo este último variable de acuerdo con comorbilidades presentes y adherencia al tratamiento integral. Genera alteraciones cognitivas e influye negativamente en el desempeño de quienes la padecen, causando detrimento global de los pragmatismos. La electroconvulsoterapia es una opción terapéutica ampliamente utilizada en nuestro país para tratar sintomatología del humor y episodios psicóticos agudos, entre otros. En la actualidad se sabe que la detección e intervención precoz de un episodio psicótico agudo —el cual puede corresponder al primer episodio psicótico de esquizofrenia —mejora el pronóstico a largo plazo. El objetivo es demostrar si existe un vínculo entre la indicación de electroconvulsoterapia durante el primer episodio psicótico de esquizofrenia y la duración del intervalo libre de internación. Este es un estudio de tipo analítico, observacional, retrospectivo (cohorte histórica) que busca aumentar las evidencias en este amplio campo de investigación. Observamos que el tiempo libre de internación luego de la primera hospitalización no tuvo relación con el hecho de si recibieron electroconvulsoterapia o no; sin embargo, al realizar el análisis de potencia estadístico surge que los resultados no son concluyentes. Se destaca el importante porcentaje de patología dual en este grupo de usuarios: un 39%.

Schizophrenia is a chronic disease, prone todeterioration, the latter being variable accordingto comorbidities and treatment adherence. It generates cognitive impairment and adverselyaffects overall performance, causing deterioration of pragmatisms. Electroconvulsive therapy is awidely used therapeutic option in our countryfor acute affective and psychotic episodes. It iswell known that early detection and interventionof an acute psychotic episode —which maycorrespond to the first psychotic episode of schizophrenia— improves long-term prognosis.This study intended to show whether there is alink between early indication of electroconvulsive therapy during the first episode and timeto relapse and hospital readmission. This is ananalytical, observational, retrospective (historical cohort) study, which aims to increase theevidence in this broad research field. As a resultthere was no link between time to relapse and electro convulsive therapy in the first episode; nevertheless after a post hoc analysis resultsare not conclusive. Dual diagnosis stands outin this group and corresponds to 39%.

Predictors of short-term course in Mexican first-episode psychosis patients / Predictores de curso temprano en pacientes mexicanos con primer episodio psicótico

Background and objectives The identification of prognostic factors in patients with schizophrenia and related psychotic disorders should enhance our understanding of the aetiology of these disorders and improve their treatment. The first years following an initial episode of psychosis are a <

Antecedentes y objetivos La identificación de factores pronósticos en pacientes con esquizofrenia y otros trastornos psicóticos relacionados podría facilitar la comprensión de la etiología de estos trastornos así como mejorar los tratamientos existentes. Los primeros años a partir del primer episodio psicótico son un <

Dimensiones de temperamento y carácter en pacientes con primer episodio de depresión mayor / Temperament and character dimensions in first-episode depressed patients

Unipolar depression is considered as one of the main psychiatric diagnosis related to psychosocial functioning impairment. It has been documented that personality features exert a direct influence on how people with depression cope and adapt to the disorder. The relationship between personality traits and depression has been studied in several models. As depressed patients usually exhibit several personality features of more than one personality disorder, a multidimensional theoretical perspective may increase the clinical description of prototypical diagnosis provided by current categorical criteria. The psychobiological model of personality proposed by Cloninger takes into account the respective contribution of neurobiologically-based mechanisms related to adaptative behaviors in response to danger, avoidance and reward, formulating four main temperamental dimensions and three characterological dimensions centered in conscious learning about self-concepts. The four temperament dimensions are: Novelty Seeking (NS) is thought to be related to the behavioral activation system; Harm Avoidance (HA) to the behavioral inhibition system; Reward Dependence (RD) is defined as a bias toward the maintenance of ongoing behaviors; and Persistence (PE) is defined as a tendency to perseverance despite frustration and fatigue. The character dimensions are: Self-directedness (SD) refers to the ability of an individual to control, regulate and adapt behavior to fit the situation in accordance with personal goals and values; Cooperativeness (CO), account for individual differences in identification with and acceptance of other people; and Self-transcendence (ST) refers to spiritual maturity, transpersonal identification and creativity. Several studies that used the psychobiological model or personality reported that personality differences are detectable among persons with a current major depressive disorder when compared to non-depressed. The most frequent finding reported is the association between higher scores in harm avoidance (HA) and depression. Nevertheless, other studies have found that depression is also related with high scores in the temperamental dimension: reward dependence (RD). In terms of character dimensions, it has been reported that depressed patients exhibit low self-directedness (SD) and low cooperativeness (CO). Objetive The aims of the present study were to determine the reliability of the Temperament and Character Inventory (TCI) in a sample of Mexican depressed patients and healthy controls and to compare TCI dimensions between both groups. Method A total of 40 first-episode depressed patients and 40 healthy controls matched by gender, age and length of education were recruited. All patients were recruited from the outpatient service at the Instituto Nacional de Psiquiatría Ramón de la Fuente. Patients were excluded if they had received any psychotropic medication for the treatment of depression, if they had concomitant medical or neurological illness, current substance abuse or a history of substance dependence, history of bipolar disorder; high risk for suicide or were agitated. Healthy controls were recruited from a public university and were not enrolled if they presented any psychiatric disorder or scored ≥ 2 points in any SCL-90 subscale, or verbally reported any aggressive behavior in the week prior to the assessment. Diagnosis of depression was done according to DSM-IV criteria and confirmed by clinical consensus. The Montgomery & Asberg Depression Rating Scale (MADRS) was used to measure depressive symptom severity. Personality dimensions were assessed using the Temperament and Character Inventory (TCI). Results Personality dimensions of the TCI showed moderate to high reliability. Internal consistency was higher for the character dimensions than for the temperament dimensions in both groups. Patients with major depression showed higher scores in the temperament dimension harm avoidance when compared to healthy controls. No significant differences emerged between groups in the dimensions: novelty seeking, reward dependence and persistence. Significant differences emerged between groups in terms of character dimensions. Depressed patients exhibit: lower self-directedness, lower cooperativeness and lower self-transcendence when compared to healthy controls. Discussion Personality assessment in patients with their first depressive episode offers the advantage of reducing biases secondary to the falsification of retrospective report, the effects of illness chronicity and pharmacological treatment on personality. Our results support the idea that the temperament dimension harm avoidance can be consider as an intermediate phenotype for major depression, as it can be a risk factor or may have a direct influence in the way depression is manifest. In terms of character dimensions, lower scores of self-direct edness may be reflected in patients lack of control responses in situations where mature and effectives responses are required. In this way, patients with low self-direct edness may exhibit irresponsible behaviors and a poor impulse control. Low cooperativeness in patients with depression may represent a state characterized by a limited empathy and can be reflected as social intolerance or social isolation. These behavioural changes are frequent depressive symptoms that can be observed by persons that share the environment with the patient. The result of a low self-transcendence in patients with depression raises the possibility that certain beliefs can modify patients' behavior when they cannot conceive their existence as a part of a unified whole. This, in conjunction with lack of transpersonal identification may explain the presence of self-destructive thoughts and behaviors, such as suicide ideation, frequent symptoms observed in patients with depression. In conclusion, our results show that the temperament dimension HA can be associated with vulnerability to depression, while severity of depression may lay in the interaction between constitutional factors and the subjectivity of illness experience conferred by character.

La depresión unipolar se ha considerado como uno de los trastornos mentales que tiene un mayor impacto en el funcionamiento psicosocial de los individuos. Se ha documentado que los rasgos de la personalidad influyen directamente sobre la forma en como las personas con depresión mayor se adaptan y enfrentan este padecimiento. Diversos estudios que han empleado el abordaje multidimensional de la personalidad mediante el modelo psicobiológico de la personalidad de Cloninger, han considerado que la personalidad es un constructo que diferencia a los sujetos que cursan con un trastorno depresivo mayor de los sujetos sin esta patología. El hallazgo más reportado en la bibliografía ha mostrado que una elevada Evitación al Daño (HA) se asocia con la depresión. Sin embargo, otras investigaciones han encontrado que la depresión mayor también se asocia con una mayor Dependencia a la Recompensa (RD). En cuanto a las dimensiones de carácter, se ha encontrado que los pacientes con depresión muestran una Baja Autodirección (SD) y una Baja Cooperatividad (CO). Objetivo Los objetivos del presente estudio fueron determinar la confiabilidad del Inventario de Temperamento y Carácter (ITC) en una muestra mexicana de pacientes con trastorno depresivo mayor y sujetos control, y comparar las dimensiones del ITC entre ambos grupos. Método Se incluyeron 40 pacientes que estuvieran cursando con su primer episodio de depresión mayor y 40 sujetos controles comparados por el método de pares por género, edad y nivel de escolaridad. Los pacientes fueron reclutados del servicio de consulta externa del Instituto Nacional de Psiquiatría Ramón de la Fuente. Los sujetos control fueron reclutados de una universidad pública de la Ciudad de México. El diagnóstico de los pacientes se realizó a partir de los criterios del DSM-IV y fue confirmado mediante consenso clínico. La severidad de los síntomas de depresión fue evaluada mediante la Escala de Depresión de Montgomery & Asberg (MADRS). Las dimensiones de la personalidad en pacientes y controles fue evaluada mediante el Inventario de Temperamento y Carácter (ITC). Resultados Las dimensiones del ITC mostraron una confiabilidad de moderada a alta. Se observaron diferencias significativas entre grupos en la dimensión de temperamento: Evitación al Daño (HA) y en las dimensiones de carácter Autotrascendencia (ST), Cooperatividad (CO) y Autodirección (SD). Discusión La evaluación de la personalidad en pacientes con un primer episodio de depresión permite excluir la falsificación del reporte retrospectivo así como los efectos que la cronicidad del padecimiento o el tratamiento farmacológico tienen sobre la personalidad. La dimensión de temperamento HA puede ser considerada un factor de vulnerabilidad en el desarrollo de la depresión, mientras que la severidad de la depresión podría estar relacionada con la interacción de los factores constitucionales del sujeto y la subjetividad de la experiencia del padecimiento a partir de la conformación del carácter.

Revisión actualizada de la relación BDNF, cognición y esquizofrenia/psicosis / BDNF, cognition and schizophrenia/psychosis: an updated review

El Factor Neurotrófico Derivado del Cerebro (BDNF) se ha relacionado con los síntomas cognitivos de la esquizofrenia, lo que se ha documentado en revisiones previas. Sin embargo, recientemente el foco de la investigación neurobiológica ha pasado de estudiar la esquizofrenia como enfermedad a estudiar las psicosis como grupo. El objetivo de esta investigación fue realizar una revisión actualizada de las publicaciones de los últimos cinco años (2013 a 2018) respecto a BDNF y síntomas cognitivos, tanto en esquizofrenia como en psicosis en general. Para esto se revisaron en PubMed los artículos con las palabras clave BDNF, cognitive y schizophrenia, y luego se repitió este proceso con la palabra psychosis. Como resultado, en el desarrollo del artículo se describe la manera en que distintos estudios, tanto en seres humanos como en modelos animales, dan cuenta de la relación entre BDNF y cognición, y de cómo influyen en ella elementos importantes como por ejemplo el género o el ejercicio. Sin embargo, se constata que aún la mayor parte de la investigación respecto a BDNF y síntomas cognitivos en psicosis se realiza en torno a la esquizofrenia como enfermedad. Por lo tanto, es necesario ampliar el estudio de la relación entre BDNF y síntomas cognitivos a cuadros psicóticos de distintos estadios y orígenes

Brain Derived Neurotrophic Factor (BDNF) has been linked to cognitive symptoms of schizophrenia, which has been documented in previous reviews. However, recently the focus of neurobiological research has moved from studying schizophrenia as a disease to studying psychosis as a group. The main aim of this research was to carry out an updated review of all relevant publications in the last 5 years (2013 to 2018) regarding BDNF and cognitive symptoms, both in schizophrenia and in psychosis. In order to achieve this, the keywords BDNF, cognitive and schizophrenia were reviewed in PubMed, and then this process was repeated with the word psychosis. As a result, in this article we describe the way in which different studies, both in human beings and in animal models, account for the relation between BDNF and cognition, and for the way in which important elements such as gender or exercise influence it. However, we found that still most of the research regarding BDNF and cognitive symptoms in psychosis is done around schizophrenia as a disease. Therefore, it is necessary to expand the study of the relationship between BDNF and cognitive symptoms to psychotic illnesses of different stages and origins

Impacto de la duración de la psicosis no tratada en pacientes con primer episodio psicótico: estudio de seguimiento a un año / Impact of the duration of untreated psychosis among patients with a first episode: a one year follow-up study

Antecedentes: El retraso en la atención especializada conlleva a implicaciones pronósticas en los pacientes con trastornos psicóticos. La duración de la Psicosis No Tratada (DPNT) es un parámetro importante con valor pronóstico. Una DPNT larga se asocia con un peor pronóstico clínico. Objetivo: Determinar la DPNT en un grupo de pacientes con primer episodio psicótico y determinar su influencia en los índices de recuperación y recaída a un año de seguimiento. Material y métodos: Se incluyeron 66 pacientes en su primer episodio psicótico que agrupados en psicosis afectivas y no afectivas. El diagnóstico se efectuó con el SCAN. Se registró la DPNT y se evaluó la severidad de los síntomas psicóticos y afectivos con instrumentos validados en nuestro medio. Resultados: Se observó mejoría sindromática global en los grupos diagnósticos. Los pacientes con DPNT larga presentaron menor ajuste psicosocial global y menor índice de recuperación. La suspensión del tratamiento fue el principal predictor de las recaídas. Conclusiones: la DPNT es un importante factor asociado al pronóstico. El modelo de los estudios de detección temprana permite reducir el tiempo que tarda en tratarse la psicosis, e identificar oportunamente a los pacientes que han tenido el primer episodio psicótico.

BACKGROUND: The delay on the onset of specific treatment has several prognostic implications for psychotic patients. Duration of untreated psychosis (DUP) has been considered a prognostic variable. A longer DUP has been associated with a poor clinical outcome. OBJECTIVE: To determine the DUP in a sample of first-episode psychotic patients and its relationship with recovery and relapse on a one-year follow-up study. MATERIAL AND METHODS: A sample of 66 first-episode psychotic patients was recruited and divided according to their diagnoses in affective and non-affective psychoses. Diagnoses were obtained with SCAN and DUP was registered for each patient. A clinical assessment for psychotic and affective symptoms was performed using standardized instruments. RESULTS: All patient studied showed clinical improvement during follow-up. Patients with a longer DUP showed poorer psychosocial adjustment and lower recovery indexes. Treatment suspension was the main variable associated with relapse. CONCLUSIONS: DUP is an important prognostic variable. Early detection programs are required to decrease the period between illness onset, diagnosis and treatment in first-episode psychotic patients.

Disfunción estructural del lóbulo temporal en pacientes con un primer episodio psicótico de esquizofrenia

resumen está disponible en el texto completo

Abstract: Magnetic resonance imaging (MRI) has been useful in revealing subtle structural differences in the brains of schizophrenic patients compared with healthy controls. MR structural analyses have revealed a number of brain abnormalities including ventricular enlargement, total brain volume reduction, and regional reductions in brain volume in frontal, parietal and temporal regions. However, it is still unknown whether the brain abnormalities observed with MRI in schizophrenia are confounded by chronicity or whether there is a continual degenerative process. Evaluation of the brain structure during the first episode of psychosis (FEP) is a powerful strategy for investigating these fundamental questions. The first-episode design avoids the confusion of chronicity of illness, longstanding substance abuse, and the effects of treatment. Structural MRI studies of patients experiencing a first-episode psychosis have revealed a similar pattern of brain abnormalities as in samples of chronic patients, although deficits may be less extensive. The temporal lobe, a brain structure traditionally implicated in the pathophyisiology of schizophrenia, has been examined often in first-episode studies. Many studies have reported significant abnormalitites in the medial areas and superior temporal gyri. However, most studies examining the whole temporal lobe have been unable to show such significant abnormalities. In the light of the increasing amount of ambiguous findings regarding structural temporal lobe abnormalities in patients with schizophrenia experiencing their first-episode of psychosis, a quantitative review of the existing literature was needed to better characterize the temporal lobe deficits observed with MRI in those patients. Thus we conducted a systematic review of structural MRI studies of patients with first-episode schizophrenia in which volume measurements of temporal lobe structures were reported. Using meta-analytical methods, we carried out an analysis of the temporal lobe volumes in these FEP patients and the comparison subjects. In addition to solving the problems of traditional narrative reviews, a meta-analysis provides tools for integrating quantitative data from multiple studies, improving the overall effect size of variables of interest, and increasing statistical power. Eighteen studies were identified as suitable for the present analysis. These studies included 575 FEP patients and 738 control subjects. The average number of patients across studies was 32. The majority of patients in the studies were male (62%) and the average age of patients was 27 years old. In terms of structural brain findings, and assuming a volume of 100% in the comparison group, we found that the mean temporal volume of subjects with FEP was smaller (95%), as well as the analysis of regional structures such as left amygdala (95%), hippocampus-amygdala (left 92%, right 94%), hippocampus (left 85%, right 96%), and left temporal lobe (97%). Right temporal lobe volume was slightly greater (104%) and there was no difference in the volume of the right amygdala. Although this review was focused on evaluating the findings on temporal lobe deficits in patients with a first episode of psychosis, other brain region volumes were analyzed. The whole brain volume (95%) and frontal lobe volume (right 98%, left 99%) were lower in patients than in the comparison subjects. It is important to consider several potential limitations of this study. The first one has to do with the methodology employed to analyze structural MRI data. The method of choice in investigating the distribution of subtle cerebral pathology in schizophrenia has been an examination of anatomically defined regions of interest (ROI) within the brain. This method has some limitations, including the manual tracing of ROI on successive brain slices, a time consuming process that does not easily allow for the comparison of many brain regions or for the examination of volume differences in large samples of subjects. Furthermore, the question of validity is relevant as the ROI is investigator-determined and depends on the complex interindividual variability of the brain. The other method used in two studies included in this review is the voxel-based morphometry (VBM). This is an automated statistical method for examining structural MR images of the brain. VBM methodology makes voxel-wise comparisons of the local concentrations of grey matter between two groups of subjects and offers a more rapid and extensive survey of grey matter abnormalities in patients than ROI analysis. An important limitation of this methodology is that it has less regional sensitivity compared to the ROI technique and that these differences have to be considered in the interpretation of the results. Secondly, although our review only considered studies with patients experiencing a first episode of psychosis in schizophrenia (and not affective psychotic disorders), the fact that different investigators used somewhat different criteria when making their diagnoses could have introduced a potential bias in our inclusion process. Thus, it is possible that our results can not be generalized to the full population of first-episode patients. For instance, although most of the studies included used either DSM-IV diagnostic criteria (16 studies) or the Research Diagnostic Criteria (2 studies), variability may arise because many authors did not consider previous psychotic episodes in which patients were treated with antipsychotic medications for less than 30 days. In conclusion, this meta-analysis suggests that schizophrenic patients present temporal lobe differences, mainly diminished volume values in mesial temporal lobe structures during the initial presentation of a first episode of their illness. However, our results indicated that there was also evidence of global volume changes and regional volume decreases in the frontal lobes of these patients. This data, derived from patients in the early courses of their illness, is compatible with developmental hypotheses of schizophrenic abnormalities and with the view of schizophrenia as a neuropsychiatric disorder with marked deficits in the temporal lobes. However, the central questions in schizophrenia research regarding which brain abnormalities are independent of psychosis and which evolve before and after psychosis begins still remain unanswered. We think that these questions can be addressed by longitudinal neuroimaging studies beginning in the prodromal phase of the illness or by evaluating high-risk subjects during the critical period of transition to first-episode psychosis.