Uma avaliação das técnicas expressivas pela psicologia simbólica. Apresentação da técnica "marionetes do self" / An assessment of expressive techniques from the perspective of symbolic psychology. Presentation of the "marionettes of the self" technique / Una evaluación de las técnicas expresivas por la psicología simbólica. Presentación de la técnica "títeres del yo"

O autor compara a psicoterapia dinâmica exclusivamente verbal e aquela que emprega também técnicas expressivas dentro da perspectiva simbólica e transferencial. Considera que as técnicas expressivas aumentam consideravelmente o potencial da elaboração simbólica, pelo fato de serem ativados em maior extensão e profundidade os significados simbólicos, junto com uma maior possibilidade de vivenciá-los. Compara a técnica menos participativa e mais verbal com a mais participativa e menos verbal e favorece a segunda pela maior produção de significados, maior possibilidade de o terapeuta exercer a sua vocação e a sua criatividade, maior cooperação do paciente na terapia e maior possibilidade da Sombra da terapia (inclusive do terapeuta) surgir e ser elaborada. Chama a atenção para o maior perigo da projeção da Função Transcendente no analista se tornar defensiva com a terapia exclusivamente verbal e interativa. O autor conclui com um aviso sobre a necessidade de precaução no uso das técnicas expressivas, pois exatamente pelo seu poder de energização dos símbolos e das funções psíquicas, elas podem exacerbar as defesas e agravar os quadros clínicos. Na segunda parte, o autor descreve a técnica expressiva das Marionetes do Self e atribui sua originalidade à sua abrangência, que inclui a relação transferencial. Descreve as características das suas peças e da sua montagem. Esclarece que o seu uso pode ser terapêutico e pedagógico para ensino normal ou supervisão. Finalmente, na terceira parte, o autor tece considerações sobre as restrições à participação ativa do consciente na terapia psicodinâmica e as atribui basicamente ao seu redutivismo ao inconsciente, tanto por Freud (o reprimido e o Id) quanto por Jung (inconsciente coletivo). Baseado na proposta de ampliação do conceito de arquétipo para englobar também o consciente e do conceito de símbolo para englobar também o objetivo, o autor propõe a elaboração simbólica igualmente a partir da perspectiva consciente e inconsciente. Em função dessa ampliação, teoriza que as técnicas behavioristas, cognitivas e até mesmo a psicofarmacoterapia podem ser usadas também como técnicas expressivas da psicoterapia dinâmica, ao serem exercidas dentro da perspectiva simbólica e transferencial.

The author compares exclusively verbal dynamic psychotherapy with psychotherapy that also employs expressive techniques within a symbolic and transferential framework. As a result, expressive techniques are considered to substantially increase the potential of symbolic elaboration, due to the fact that symbolic meanings are activated to a greater extent and depth, along with a greater possibility of being experienced. The less participative and more verbal technique is compared with the more participative and less verbal technique and the second one is favored due to a greater production of meanings, a greater possibility for the therapist to exercise their vocation and creativity, the patient's greater cooperation in the therapy and a greater chance of the therapy's (including the therapist's) Shadow arising and being elaborated. Attention is drawn to the great danger of the projection of the Transcendent Function onto the analyst becoming defensive in exclusively verbal and interactive therapy. The author concludes with a warning about the need for caution in the use of expressive techniques, as precisely due to their power to energize symbols and psychic functions, they can exacerbate defenses and worsen clinical conditions. In the second part, the author describes the expressive technique of the Marionettes of the Self and attributes its originality to its scope, which includes the transferential relationship. The characteristics of its parts and its assembly are described and its use recommended for therapeutic and pedagogical purposes in regar teaching or supervision. Finally, in the third part, the author considers the restrictions on the active participation of the conscious in psychodynamic therapy and basically attributes them to its reductionism to the unconscious, both by Freud (repression and the Id) and by Jung (the collective unconscious). Based on the proposal to expand the concept of archetype to also encompass the conscious and the concept of symbol to also encompass the objective dimension, the author proposes the symbolic elaboration from the perspective of both the conscious and the unconscious. Due to this expansion, the author theorizes that behavioral and cognitive techniques and even psychopharmacotherapy may also be used as expressive techniques of dynamic psychotherapy when they are exercised within the symbolic and transferential perspective.

El autor compara la psicoterapia dinámica exclusivamente verbal y la que también emplea técnicas expresivas dentro de la perspectiva simbólica y transferencial. Considera que las técnicas expresivas aumentan considerablemente el potencial de elaboración simbólica, debido a que se activan en mayor medida y profundidad los significados simbólicos, así como una mayor posibilidad de experimentarlos. Compara la técnica menos participativa y más verbal con la técnica más participativa y menos verbal y favorece a la segunda por mayor producción de significados, mayor posibilidad para el terapeuta de ejercer su vocación y su creatividad, mayor cooperación del paciente en la terapia y mayor posibilidad de que la Sombra de la terapia (incluido el terapeuta) surja y se elabore. Llama la atención sobre el mayor peligro de que la proyección de la Función Trascendente sobre el analista se vuelva defensiva con la terapia exclusivamente verbal e interactiva. El autor concluye con una advertencia sobre la necesidad de cautela en el uso de técnicas expresivas, pues precisamente por su poder de dinamización de símbolos y funciones psíquicas, pueden exacerbar las defensas y empeorar el cuadro clínico. En la segunda parte, el autor describe la técnica expresiva de los Títeres del Yo y atribuye su originalidad a su alcance, que incluye la relación transferencial. Describe las características de sus partes y de su montaje. Aclara que su uso puede ser terapéutico y pedagógico para la enseñanza o supervisión normal. Finalmente, en la tercera parte, el autor considera las restricciones a la participación activa del consciente en la terapia psicodinámica y las atribuye básicamente a su reduccionismo al inconsciente, tanto de Freud (lo reprimido y el Id) como de Jung (inconsciente colectivo). Partiendo de la propuesta de ampliar el concepto de arquetipo para abarcar también lo consciente y el concepto de símbolo para abarcar también lo objetivo, el autor propone la elaboración simbólica por igual desde la perspectiva consciente e inconsciente. Debido a esta expansión, teoriza que las técnicas conductistas, cognitivas e incluso la psicofarmacoterapia también pueden ser utilizadas como técnicas expresivas de la psicoterapia dinámica, cuando se ejercen en la perspectiva simbólica y transferencial.

Psychodermatology: A comprehensive review.

Psychodermatology is an interesting domain of dermatology that overlaps with psychiatry. This arena in dermatology has received limited diligence, partly due to lack of training in this realm. We present here a comprehensive review of salient features and treatment updates in primary psychiatric dermatoses and have also discussed the role of psyche in psychophysiological cutaneous disorders. Secondary psychiatric morbidity is relatively common among patients visiting the dermatologists but often overlooked and uncared for. Dermatologist should be able to initiate basic pharmacotherapy, should be knowledgeable about various non-pharmacological treatments and know the right time to refer the patient to the psychiatrist. Awareness and pertinent treatment of psychodermatological disorders among dermatologists will lead to a more holistic treatment approach and better prognosis in this unique group of patients.

Use of Atypical Antipsychotics in Attention-Deficit Hyperactivity Disorder / 대한정신약물학회지

Psychopharmacotherapy is one of the effective treatments for the children and adolescents with attention-deficit hyperactivity disorder (ADHD). If there were a marginal improvement or significant adverse effects after having the first line medication such as psychostimulants and atomoxetine, the youth with ADHD can take alternative medications. If they have comorbidities such as disruptive behavior disorder, bipolar disorder, mental retardation and tic disorder, they need to have more medications. Recently, prescriptions of atypical antipsychotics were increasing among them. The efficacy, safety, and tolerability of atypical antipsychotics in the youth should be considered.

Psychopharmacologic Strategies for Women to Plan Pregnancy / 대한정신약물학회지

Clinicians are faced with major challenges when treating women with psychiatric disorders who are contemplating pregnancy or are pregnant. Recent data suggest that pregnancy has no protective effect on the course of psychiatric disorders and that discontinuation of psychotropic drugs is associated with a significant risk of relapse. This article reviews the major clinical dilemmas in managing women with psychiatric disorders who plan to conceive. Before pregnancy, clinical considerations for the interventions such as family planning, parental education and supporting, and antenatal care are important to reduce the risk of pregnancy complications. To treatment decision, clinicians should discuss with the woman the absolute and relative risks associated with not treated mental disorder and psychotropic drugs. Non-pharmacological treatment should be considered also. Treatment strategies, for each of the women with psychiatric disorders who plan to conceive are discussed.

Psychopharmacotherapy for Pregnant Women / 대한정신약물학회지

Authors reviewed the risk of psychopharmacotherapies during pregnancy. Psychopharmaotherapy in pregnants should be determined by considering the risk of disease recurrence in the mother and the impacts on the fetus. The American College of Obstetricians and Gynecologists does not recommend the routine use of antipsychotics in pregnancy, but risk-benefit assessments may indicate that such use is appropriate. Generally, antipsychotics are indicated for severe mental disorder, the benefits to the mother appear to outweigh the unknown risk. Folate (4 mg/day) has been recommended for women taking atypical antipsychotics because they may have a high risk of neural tube defects due to inadequate folate intake and obesity. Mood stabilizers should be avoided during pregnancy because of their potential teratogenicity. Lamotrigine or topiramate are relatively safe and combination with folate could be reduced the risk of neural tube defects. Antidepressants have been used in pregnant women with relative safety, but we should be considered the risk of major defects and neonatal syndrome. Especially, prenatal eochocardiography is recommended if it has been exposed in the first trimester of pregnancy. Paroxetine should be avoided in the first trimester of pregnancy due to the risk of congenital anomalies. There are many controversies in causal association between benzodiazepine and congenital defects. But, if the maternal condition requires the use of benzodiazepine during pregnancy, the lowest possible dose should be taken. Although no congenital malformation have been reported, data are too limited to confirm the risk of zolpidem for pregnancy, further evaluation are needed.

Overview of Psychopharmacotherapy for Cancer Patients / 신경정신의학

Cancer patients experience various physical and psychological symptoms, which can be alleviated by psychotropic medications. In the process of developing the recommendations for distress management in cancer patients, the Korean psycho-oncology research group performed systematic reviews on the oncological psychopharmacotherapy literature. This study describes the general principles and some practical suggestions.

Psychopharmacotherapy in Bipolar Depression, Present and Future / 대한정신약물학회지

This article reviews the characteristics and major pharmacological treatment modalities of bipolar depression, which is distinguished from unipolar depression by etiologic differences, symptomatic features, clinical courses, and treatment responses. Bipolar depression is often disabling and very challenging to treat. In acute and prophylactic phases, mood stabilizers such as lithium, divalproex, and lamotrigine are used as first-line treatment, unless the patient is psychotic or markedly dysfunctional. Carbamazepine and oxcarbazepine can be used as a second-line treatment or in a combination regimen. Depressive episodes that do not respond to mood stabilizers, as well as relapsing episodes despite prophylactic therapy, justify treatment with antidepressants. Many clinicians also advocate the early use of antidepressants and antipsychotics when depressive episodes are severe or psychotic. Selective serotonin reuptake inhibitors and bupropion are considered the first choices for use in combination with a mood stabilizer. Bupropion in particular yields stability against manic switches or cycle acceleration. Traditionally, clinicians have used antipsychotics as a combination option when treating patients with bipolar depression who exhibit psychotic features. However, extensive and well controlled recent studies have shown that atypical antipsychotics such as quetiapine, olanzapine, and an olanzapine/fluoxetine combination can yield therapeutic efficacy and good tolerability for treating bipolar depression with or without psychotic features. In particular, a randomized controlled trial (RCT) using quetiapine monotherapy to treat patients with bipolar depression yielded significantly reduced depressive symptomatology. Other atypical antipsychotics such as amisulpride, aripirazole, risperidone, and ziprasidone have yielded antidepressive efficacy, but no RCT trials have been conducted on patients with bipolar depression. Some preliminary studies have shown that newly developed agents such as dopamine agonist, agomelatine, riluzole, mefepristone, and uridine effectively improve mood symptoms among patients with bipolar depression. More extensive clinical trials are needed.

Psychopharmacotherapy in Bipolar Depression, Present and Future / 대한정신약물학회지

This article reviews the characteristics and major pharmacological treatment modalities of bipolar depression, which is distinguished from unipolar depression by etiologic differences, symptomatic features, clinical courses, and treatment responses. Bipolar depression is often disabling and very challenging to treat. In acute and prophylactic phases, mood stabilizers such as lithium, divalproex, and lamotrigine are used as first-line treatment, unless the patient is psychotic or markedly dysfunctional. Carbamazepine and oxcarbazepine can be used as a second-line treatment or in a combination regimen. Depressive episodes that do not respond to mood stabilizers, as well as relapsing episodes despite prophylactic therapy, justify treatment with antidepressants. Many clinicians also advocate the early use of antidepressants and antipsychotics when depressive episodes are severe or psychotic. Selective serotonin reuptake inhibitors and bupropion are considered the first choices for use in combination with a mood stabilizer. Bupropion in particular yields stability against manic switches or cycle acceleration. Traditionally, clinicians have used antipsychotics as a combination option when treating patients with bipolar depression who exhibit psychotic features. However, extensive and well controlled recent studies have shown that atypical antipsychotics such as quetiapine, olanzapine, and an olanzapine/fluoxetine combination can yield therapeutic efficacy and good tolerability for treating bipolar depression with or without psychotic features. In particular, a randomized controlled trial (RCT) using quetiapine monotherapy to treat patients with bipolar depression yielded significantly reduced depressive symptomatology. Other atypical antipsychotics such as amisulpride, aripirazole, risperidone, and ziprasidone have yielded antidepressive efficacy, but no RCT trials have been conducted on patients with bipolar depression. Some preliminary studies have shown that newly developed agents such as dopamine agonist, agomelatine, riluzole, mefepristone, and uridine effectively improve mood symptoms among patients with bipolar depression. More extensive clinical trials are needed.

Principios generales sobre la psicofarmacoterapia en niños y adolescentes. Una revisión

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Abstract: The work of Charles Bradley done in 1937, which reports the effects of Benzedrine in 30 pediatric patients that had behaviour problems, is a classic document considered by many as the beginning of child psychopharmacotherapy. In spite of a coordinated effort made by the National Institute of Mental Health in the United States carried out by a panel, called "Conferences on Infantile Research in Psychopharmacology", for many years this practice kept being inarticulate. Psychopharmacotherapy in adults with psychiatric diseases has had a different development. During the decade of 1950 substances such as chlorpromazine and tricycle antidepressives started to be used in clinical practice and between 1980 and 1990 new products were developed for treating schizophrenia, depression and mania. Even if there is no such as the "ideal drug", the new psychopharmacological developments have allowed patients to have a better quality of life. In pediatric population the difficulty to conduct controlled clinical tests has been a constant; for this reason the practice of child psychopharmacotherapy keeps facing challenges; also, in the United States several very strict norms have been dictated in order to endorse the security and efficacy of a product for infantile use. Other problems faced today in clinical practice are the excesive use of medications for minors prescribed by people without enough practice and academic information, and also the deficient therapeutic results provoked by wrong prescriptions. But the worst of all are the false promises made to relatives and patients, on the usage of products or substances that have not been tested by a rigorous scientific scrutiny, specially concerning diffused clinical problems such as the Attention Deficit Hyperac-tivity Disorder (ADHD) or Autism. These facts, most of all, determine the rejection and fear for medications and become an adverse variable that we must face continuously. The main objective of this work is to make a review about the general principles that are suggested for a good psychopharmaco-therapy on children and teen-agers, a practice that must always be part of a planned multimode treatment that follows an adequate paidopsychiatric evaluation. A right diagnose will always be important for the appropriate selection of the medication. The development of taxonomies such as those described in the Mental Disorders Statistics and Diagnostic Manual of the American Psychiatric Association or by the International Classification of Diseases of the World Health Organization, have allowed the existence of an order in the ela-boration of paidopsychiatric diagnosis, that even if being mainly descriptive, allow to make a more structured clinical work. The parameters for the psychiatric evaluation of children and teen-agers recommended by the American Academy of Child and Adolescent Psychiatry (AACAP) in 1997 is an example of the importance that proves the attention on minors, its objective is to give a guide without pretending to make it a golden standard. The selection of a medication must be based on two premises: a diagnose of the disorder itself, and on the other hand, the recognition of target symptoms. Considering this interrelation will allow a more acceptable evaluation on the risks and benefits of a phar-macological prescription for children and teenagers. Thus pediatric psychopharmacotherapy must be based on the correlation between the actions and effects of drugs and the biochemical and evolving aspects of the disorder, but it will also be necessary that the professional be aware of the changes that inevitably will take place in the dynamic of absorption, distribution and elimination of the medications according to the stage of the biological child's development. When someone deals with very small children, it is almost impossible for the child psychiatrist to get direct information as it is for children to understand the information that the expert would pretend to give them. This constrains to consider the cognitive and verbal realities proper of each stage of the development, so the direct evaluation of the small patient must be complemented with reports of a multi-informers system. It will be fundamental to consider also that small children have little differentiated emotions and that it must not be ignored that for them concepts such as time and space are difficult to understand. Clinical exploration through recreational activities will be a primordial tool in the daily work with children. It will also be recommendable that the plan of the treatment be organized jointly with the parents of the minor in order to inform them completely about the goals and objectives of the prescription of a drug; the participation of the small patient must be included too. It must not be forgotten that the pharmacological treatment is part of a more integral attention program in which other experts must participate, such as pedagogues, clinical psychologists or language therapists, a fact that will be more common than irregular. The therapeutic adherence is a variable that must be constantly checked. If it is carried out irregularly or the wrong dose of the recommended drug is taken, the presence of symptoms as a result of the abrupt interruption of the medication could be confused with the adverse collateral effects, which would make worse the clinical condition. Pediatric patients must have a complete medical history complemented by a physical and neurological evaluation, which must be included in the registry of vital constants as well as size and weight of the minor; other registers could be more convenient if they are considered to be needed. The support on laboratory surveys plays an important roll and at the present time the recommendation for making an electro-cardiography evaluation previous to the administration of some drugs is more accepted; in this sense it is undoubtedly important to consider the recommendations proposed by the American Association of Cardiology for monitoring the cardiovascular function of children and teen-agers who receive medications after prolonged periods of time. Polypharmacy is a common practice; due to this fact, the interaction between drug/ drug must be carefully valued. The child psychiatric evaluation must be made with the support of structured or semistructured interviews for the clinical diagnosis and with evaluation scales for measuring the severity of the specific symptoms or global clinical conditions. The strategy for choosing a plan of pharmacological treatment for the pediatric patient must be made individually; in this sense, the development of algorithms for the administration of medications on children and teenagers has been the result of many efforts in order to make prescriptions more rational and neat. The revision of controlled clinical tests on the efficacy and security of these agents in the pediatric population is fundamental for the election of a prescription. The responsibility of the professional that prescribes a medication devolves on structuring a plan of formal treatment and an individualized monitoring according to the stages of the treatment (beginning, maintenance and interruption ). As it is expected, the expert must reach the maximum therapeutic benefit in a child or an adolescent with the minimum of collateral effects, evaluating always the risk and the benefits. Some authors recommend the prescription of drugs on children and teen-agers only for short periods of time as the nondesirable effects in long terms are not quite well known. There are no specific times for stopping the administration of a drug. However, it is recommended that during the stages of the treatment, clinical changes in minors be watched and registered rigorously, in order to be able to reduce or stop the dose in the appropriate moment, even in cases of clinical conditions such as schizophrenia, depression or development generalized disorders. The main objective of this clinical work will be that the quality of life of the minor becomes optimum.

Treatment of Posttraumatic Stress Disorder / 신경정신의학

Posttraumatic stress disorder (PTSD) is a psychiatric disorder which cause is certain, and mechanism of PTSD has been studied actively for decades. The various kinds of therapy, based on the pathophysiology of PTSD, were applied and among them eye movement desensitization and reprocessing (EMDR), therapy for sleep, transcranial magnetic stimulation (TMS) and psychopharmacotherapy that showed considerable effect for patients with PTSD would be introduced.

Pharmacotherapy and the Proposal of the Integrative Therapy Model for Treatment Resistant Obsessive-Compulsive Disorder / 신경정신의학

There have been considerable advances in our understanding of the neurobiology and the treatment of obsessive-compulsive disorder (OCD). However, it seems that many patients with OCD are not met with proper treatment, and even the patients who receive sufficient therapy the response rate is not high. This paper reviews the pharmacological treatments of OCD with special focus on therapeutic options for treatment resistance cases. In treating a resistant case, the clinical characteristics including comorbid conditions of the patient should be reevaluated. Through until recently, there has been no standarized guideline to treat resistance cases and much is up to clinician's preference, but thoughtful selection and combination of drugs with optimized psychosocial approach may improve the response rate. We propose an integrative therapy model for treatment resistant OCD to emphasize the need for the expansion of treatment resources. Treatment resistant OCD deserves more clinical and socioeconomic attentions and needs further research for management.

Practical Issues in the Psychopharmacotherapy during Pregnancy and Lactation / 대한정신약물학회지

Although the pregnancy period has typically been viewed as a time of emotional well-being, recent data do not substantiate this optimistic view for women with prior histories of depression. This paper will review the natural history of depression in pregnancy. The potential risks to the mother and the fetus when the psychiatric illness goes untreated will be reviewed. Also to be discussed are: the potential teratogenicity of each class of psychotropic medication, the treatment dilemmas, the possible alternatives when prescribing psychotropic medications and the decision-making guidelines regarding the discontinuation of medications. The risk of major depression in the postpartum period in the overall population and the likelihood of recurrence will be reviewed, and prophylactic strategies will be covered also.

A Case of Chronic Fatigue Syndrome: Case Report & Literature Review / 신경정신의학

Chronic fatigue syndrome has been recency reconceptualized as a bio-psycho-social disorder. Although the up-to-date pathophysiological hypothesis of this disorder in Europe & America is based on viral origin, no medical therapy has been proven effective in patients with chronic fatigue syndrome. The authors report a case with chronic fatigue syndrome treated successfully with combined psychotherapy and antidepressant. Emphasizing the effectiveness and utility of the psychiatric treatment, we also review the related literatures about the treatment of chronic fatigue syndrome.