Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome?

Objective: Disorders characterized by "distressing unexplained somatic symptoms" are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample. Methodology: As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed. Results: The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with "being a BSS" case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72). Conclusion: Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

Virtual reality exposure therapy for fear of driving: analysis of clinical characteristics, physiological response, and sense of presence

Objective: To investigate the reactions of women with driving phobia to a therapeutic program of scheduled virtual reality exposure treatment (VRET) sessions. Methods: The study intervention consisted of a computer game with car-driving scenarios that included several traffic situations. We investigated the participants' sense of presence, subjective distress, and physiological responses during eight virtual-reality exposures. We also evaluated clinical characteristics, driving cognitions, and quality of life in the participants. Results: Thirteen women were selected. Eight were able to complete the protocol. After VRET, there was a decrease in the frequency of distorted thoughts and state anxiety scores, as well as a slight improvement in quality of life. Subjective discomfort scores, heart rate variation, and sense of presence scores confirmed that there was sense of presence in the virtual reality environment. Conclusion: All patients showed some degree of improvement and demonstrated different levels of anxiety in subsequent in vivo driving experiences. Our findings suggest that VRET could be used to facilitate in vivo exposure, because it can induce presence/immersion and reduce anxiety in patients with specific phobia. Furthermore, VRET is not associated with any type of risk.

The joint structure of major depression, anxiety disorders, and trait negative affect

Background: Dimensional models of psychopathology demonstrate that two correlated factors of fear and distress account for the covariation among depressive and anxiety disorders. Nevertheless, these models tend to exclude variables relevant to psychopathology, such as temperament traits. This study examined the joint structure of DSM-IV-based major depression and anxiety disorders along with trait negative affect in a representative sample of adult individuals residing in the cities of São Paulo and Rio de Janeiro, Brazil. Methods: The sample consisted of 3,728 individuals who were administered sections D (phobic, anxiety and panic disorders) and E (depressive disorders) of the Composite International Diagnostic Interview (CIDI) 2.1 and a validated version of the Positive and Negative Affect Schedule. Data were analyzed using correlational and structural equation modeling. Results: Lifetime prevalence ranged from 2.4% for panic disorder to 23.2% for major depression. Most target variables were moderately correlated. A two-factor model specifying correlated fear and distress factors was retained and confirmed for models including only diagnostic variables and diagnostic variables along with trait negative affect. Conclusions: This study provides support for characterization of internalizing psychopathology and trait negative affect in terms of correlated dimensions of distress and fear. These results have potential implications for psychiatric taxonomy and for understanding the relationship between temperament and psychopathology. .

Trastornos de ansiedad en el DSM-5 / [Anxiety disorders in DSM-5].

The fifth edition of Diagnostic and Statistical Manual, the DSM-5 appeared officially in May 2013 during the development of the 166th Annual Meetingof the American Psychiatric Association (APA) in San Francisco. The drafting process was long and complex; much of the debate became public so that the expectations were great. And it must be said that the new edition did not disappoint, as many changes were made in relation to their predecessors. In Chapter of Anxiety Disorders, which is reviewed in this article, the changes were significant. Obsessive-compulsive disorder and Stress-related disorders were excluded and new clinical pictures, such as separation anxiety disorder and selective mutism, were included. And took place was the long awaited split between panic disorder and agoraphobia, now two separate disorders.

Dissociative disorders and other psychopathological groups: exploring the differences through the Somatoform Dissociation Questionnaire (SDQ-20)

OBJECTIVE: The Somatoform Dissociation Questionnaire is a self-report questionnaire that has proven to be a reliable and valid instrument. The objectives of this study were to validate the Portuguese version and to determine its capability to distinguish patients with dissociative disorders from others with psychopathological disorders. METHOD: 234 patients answered the translated version of Somatoform Dissociation Questionnaire. The Portuguese Dissociative Disorders Interview Schedule was used to validate clinical diagnosis. Patients with dissociative disorder (n = 113) were compared to a control group of 121 patients with various anxiety and depression disorders. RESULTS: Reliability measured by Cronbach's a was 0.88. The best performance of the Portuguese form was at a cut-off point of 35, which distinguishes between dissociative disorder and neurotic disorders with a good diagnostic efficacy (sensitivity = 0.73). The somatoform dissociation was significantly more frequent in dissociative disorder patients, conversion disorder patients and post-traumatic stress disorder patients. CONCLUSIONS: These findings suggest that dissociative disorders can be differentiated from other psychiatric disorders through somatoform dissociation. The Portuguese version of the Somatoform Dissociation Questionnaire has fine psychometric features that sustain its cross-cultural validity.

OBJETIVO: O objetivo deste estudo foi adaptar, validar e determinar a confiabilidade da versão portuguesa do Somatoform Dissociation Questionnaire e determinar a sua capacidade de discriminar doentes que dissociam de outros doentes. Método: O Somatoform Dissociation Questionnaire foi traduzido para o português e retrovertido para o inglês de forma a garantir a sua base conceitual. Os sujeitos responderam também à versão portuguesa do Dissociative Disorders Interview Schedule de forma a validar o seu diagnóstico clínico. O estudo incluiu 234 sujeitos divididos entre 113 doentes com patologias dissociativas e 121 doentes com outras patologias do foro ansioso e depressivo. RESULTADOS: O Somatoform Dissociation Questionnaire versão portuguesa mostrou o seu melhor desempenho no ponto de corte 35, apresentando uma sensibilidade de 0,73. O alfa de Cronbach revelou uma consistência interna de 0,88. A dissociação somatoforme foi significativamente mais freqüente nos doentes com patologias dissociativas, patologias conversivas e distúrbio de stress pós-traumático. CONCLUSÕES: A versão portuguesa do Somatoform Dissociation Questionnaire mostrou-se um instrumento útil para discriminar doentes com patologia de foro dissociativo de outros doentes.

Animal defense strategies and anxiety disorders

Anxiety disorders are classified according to symptoms, time course and therapeutic response. Concurrently, the experimental analysis of defensive behavior has identified three strategies of defense that are shared by different animal species, triggered by situations of potential, distal and proximal predatory threat, respectively. The first one consists of cautious exploration of the environment for risk assessment. The associated emotion is supposed to be anxiety and its pathology, Generalized Anxiety Disorder. The second is manifested by oriented escape or by behavioral inhibition, being related to normal fear and to Specific Phobias, as disorders. The third consists of disorganized flight or complete immobility, associated to dread and Panic Disorder. Among conspecific interactions lies a forth defense strategy, submission, that has been related to normal social anxiety (shyness) and to Social Anxiety Disorder. In turn, Posttraumatic Stress Disorder and Obsessive-Compulsive Disorder do not seem to be directly related to innate defense reactions. Such evolutionary approach offers a reliable theoretical framework for the study of the biological determinants of anxiety disorders, and a sound basis for psychiatric classification.

Os transtornos de ansiedade são classificados conforme a sintomatologia, decurso temporal e resposta terapêutica. Paralelamente, a análise experimental dos comportamentos de defesa identificou três estratégias comuns a diferentes espécies de animais, desencadeadas por situações de perigo predatório potencial, distal ou proximal, respectivamente. A primeira consiste na investigação cautelosa do ambiente, avaliando o risco. Supõe-se que a emoção que a acompanha seja a ansiedade e sua patologia, o Transtorno de Ansiedade Generalizada. A segunda é expressa pela fuga orientada ou pela inibição comportamental, sendo a emoção correlata o medo, e a patologia representada pelas Fobias Específicas. Finalmente, a terceira estratégia consiste na fuga desordenada ou na total imobilidade, relacionando-se com o pavor e o Transtorno de Pânico. Nas interações entre indivíduos da mesma espécie, aparece uma quarta estratégia de defesa, a submissão, que tem sido relacionada com o Transtorno de Ansiedade Social. Já o Transtorno de Estresse Pós-Traumático e o Transtorno Obsessivo-Compulsivo não estão diretamente relacionadoscom reações de defesa inatas. Esta abordagem evolucionária oferece um paradigma teórico confiável para o estudo dos determinantes biológicos dos transtornos de ansiedade, que pode melhor fundamentar a classificação psiquiátrica.

Dificuldades na utilizacao de escalas de avaliacao de sintomas ansiosos em psicofarmacologia clinica e experimental / Difficulties on the use of rating scales of anxiety symptoms in clinical and experimental psychopharmacology

Escalas de avaliacao de sintomatologia psiquiatrica ainda sao o principal instrumento de mensuracao em pesquisa psiquiatrica. As reformulacoes conceituais e nosograficas encontradas na area dos transtornos neuroticos (ansiosos), bem como disputas ideologicas, levam a proliferacao de instrumentos e consequentemente a problemas de validade, alem de dificultar a comparacao de resultados de diferentes centros. Outros problemas comuns sao erros: sistematicos (vies) ou aleatorios. Fontes de erro incluem a formulacao de itens da escala, variaveis do ambiente onde esta e utilizada e problemas relacionados ao avaliador (hetero ou auto-avaliacao). O papel do treinamento adequado para avaliadores e enfatizado

Comentarios do debatedor: escalas de avaliacao de ansiedade / Chairman comments: anxiety rating scales

Apesar de as escalas de avaliacao de sintomas ansiosos serem muito utilizadas em pesquisas clinicas, nao ha acordo em relacao ao grupo de escalas mais indicado para a avaliacao sintomatologica em cada transtorno especifico. O treinamento em psicopatologia fenomenologica e a aplicacao criteriosa de escalas em ensaios clinicos podem favorecer uma melhor sistematizacao de dados. A objetividade e a fidedignidade caminham juntas e sao tao importantes quanto a validade da escala. O questionamento clinico deve sempre estar presente ao se observar a utilizacao ou os resultados de uma escala

Transtornos depresivos y transtornos de ansiedad: dos entidades de frecuente consulta

La ansiedad y la depresión deben ser entendidas en un contexto biopsicosocial y en este sentido, su tratamiento debe ser integral, basado no en un solo enfoque sino mediante un abordaje ecléctico que tome lo mejor de cada una de las alternativas terapeuticas existentes

Trastorno obsesivo compulsivo

Este niño consultó por múltiples dolores cambiantes y por incomodidad en la vida social del colegio porque tenía dificultades con profesores y compañeros. Se empezó su estudio determinando que padecía de un trastorno de ansiedad, relacionado con su discapacidad para la educación física, la cual no informó y mantuvo en silencio por su competitividad. Entre los antecedentes tuvo una hemorragia cerebral del lactante y como secuela una hemiparesia. Se encontró que padecía una psicopatología estable y crónica que es el trastorno obsesivo-compulsivo desde los cinco años de edad. Respondió con remisión al tratamiento disminuyendo la angustia pero persistiendo los fenómenos obsesivos-compulsivos

Trastorno con panico / Panic disease

Esta comunicacion presenta un criterio actualizado de los Estado de Ansiedad segun el DSM-III-R; una breve descripcion de los mismos, para abordar luego un cuadro de frecuente consulta en la actualidad: el trastorno con panico y la utilizacion de la medicacion homeopatica y/o psicoterapia a los fines de su resolucion

Tratamiento de la ansiedad en niños

Se trata de un estudio descriptivo sobre el diagnóstico, antecedentes, estado general y resultado del tratamiento de 33 pacientes que fueron atendidos por ansiedad en el Hospital Pediátrico de La Misericordia entre junio de 1991 y junio de 1992. Los pacientes son 55 por ciento mujeres y 45 por ciento hombres, en promedio tenían 10 años y estaban cursando 5o. grado. Al hacer la diferencia por el tipo de ansiedad se encontró que la mayoría padecían de hiperansiedad (33 por ciento) seguidos por ansiedad postraumática (27 por ciento) y luego los otros tipos de ansiedad. La mejoría se presentó, en promedio, 30 días luego de iniciar el tratamiento. Los motivos de consulta que condujeron al estudio son muy diversos. Se hicieron diagnósticos pediátricos en el 67 por ciento de los niños. El 90 por ciento de los niños no tenían trastorno del desarrollo. En cambio el estrés psicosocial al cual estaban sometidos fue de severo a moderado en la mayoría. En casi todos los niños su funcionamiento global estaba seriamente deteriorado por el trastorno. Los pacientes se trataron con psicoterapia individual, información a la familia y psicotrópicos. Del grupo mejoraron 28 pacientes que representan el 85 por ciento y la mejoría se mantuvo al año de terminado el tratamiento.

Da neurose de ansiedade ao distúrbio de ansiedade generalizada / From anxiety neurosis to generalized anxiety

Este artigo pretende aclarar a visäo atual do conceito de neurose de ansiedade definido por Freud em 1894, hoje conhecido como distúrbio de ansiedade generalizada (DAG), sugerindo que o mesmo seja subdividido em DAG-estado e DAG-traço, sendo este último um transtorno de personalidade. Propöe também que o DAG-traço, por sua cronicidade, deva ser abordado de forma integrada com a associaçäo de cloridrato de buspirona e psicoterapia

Trastorno de ansiedad en los niños

La ansiedad es una de las sensaciones experimentales con mayor frecuencia por el ser humano; semiológicamente es un continuum que va desde la ansiedad existencial cotidiana, pasando por la ansiedad experimentada ante eventos traumáticos y terminando en estados francamente patológicos no correlacionados con eventos ambientales externos. Su sintomatología generalmente tiene elementos mixtos somáticos y psicológicos. En los niños se encuentran algunos trastornos de ansiedad específicos como el trastorno de ansiedad de separación, el trastorno de ansiedad excesiva y el trastorno por evitación en la infancia y de la adolescencia; también comparten algunos trastornos con los adultos como el trastorno de pánico, el trastorno de estrés post-traumático y el trastorno de adaptación con afecto ansioso. Desde el punto de vista etiológico y terapéutico se hace un enfoque biopsicosocial lográndose un adecuado control en la mayoría de los pacientes.

Ansiedad ante el acto quirúrgico:un estudio en pacientes y sus familiares / Anxiety before the surgical act: a study with patients and their relatives

Con el objeto de comparar cualitativamente la angustia ante el acto quirúrgico en los pacientes dispuestos a ser intervenidos y sus familiares, se estudiaron, mediante escalas de Taylor y de Hamilton, dos grupos, uno de 40 pacientes y otro de 40 familiares. En el grupo de pacientes se realizó una evaluación post-operatoria adicional. Con la Escala de Taylor, los valores preoperatorios de angustia fueron similares en ambos grupos, mientras que, con la de Hamilton, fueron mayores en el grupo de familiares. Con esta última escala, se demostró, en los pacientes, una disminución de la angustia en un 60% tras ocurrir el acto operatorio. En ambos grupos, la mujeres desarrollaron más angustia que los varones. Los pacientes y familiares más jóvenes reaccionaron con mayor angustia. En el grupo de familiares, los profesionales, mostraron menos angustia que los no profesionales (en los pacientes la relación fue inversa) y los de menor grado de instrucción más que los de grado superior. Los ítems de la Escala de Hamilton más frecuentemente calificados como positivos fueron los referentes a ánimo angustioso, síntomas gastrointestinales, síntomas vegetativos e insomnio; en el grupo de familares fue también común el ánimo depresivo. Los resultados subrayan la participación del grupo familiar en la dinámica de la angustia pre-operatoria y sugieren un estudio más acucioso de la misma