The Elephant in the Room: A Systematic Review of the Application and Effects of Psychological Treatments for Pregnant Women with Dual Pathology (Mental Health and Substance-Related Disorders).

PURPOSE: Maternal mental health and substance use, referred to as dual pathology, represent significant concerns associated with adverse pregnancy and birth outcomes, a prevalence higher than commonly anticipated. Nonetheless, a notable dearth exists ofevidence-based treatment protocols tailored for pregnant women with dual pathology. METHODS: A systematic review, adhering to the PRISMA methodology, was conducted. RESULTS: Out of the 57 identified papers deemed potentially relevant, only 2were ultimately included. Given the limited number of studies assessing the efficacy of psychological interventions utilizing randomized controlled trials (RCTs) for both mental health and substance misuse, and considering the diverse objectives and measures employed, definitive conclusions regarding the effectiveness of psychological interventions in this domain prove challenging. CONCLUSIONS: Maternal mental health appears to be the proverbial "elephant in the room". The development of specialized and integrated interventions stands as an imperative to effectively address this pressing issue. As elucidated in the present review, these interventions ought to be grounded in empirical evidence. Furthermore, it is essential that such interventions undergo rigorous evaluation through RCTs to ascertain their efficacy levels. Ultimately, the provision of these interventions by psychology/psychiatric professionals, both within clinical practice and the RCTs themselves, is recommended to facilitate the generalizability of the results to specialized settings.

Perceived Stressful Life Events and Suicide Risk in Adolescence: The Mediating Role of Perceived Family Functioning.

AIM: Suicidal behavior is a serious public health problem and a major cause of death among adolescents. Three categories of major risk factors have been identified: psychological factors, stressful life events, and personality traits. Severe and objective stressful life events (SLEs), such as childhood mistreatment or abuse, have been clearly associated with higher rates of suicide risk. However, the relationship between suicide risk and adolescents' perceptions of the SLE impact is not as clear. This paper studies the relationship between SLE impact perception and suicide risk and the possible mediating role of perceived family functioning in this relationship. The need for longer-term or more intense psychological or psychiatric treatment in relation to SLE impact perception is also addressed. METHOD: One hundred forty-seven adolescents aged 11-17 were consecutively recruited from the Child and Adolescent Mental Health Outpatient Services Department of a general hospital in Madrid, Spain. Self-informed questionnaires were used to assess suicide risk, SLEs, and family functioning. In addition, the clinical records of the participants were consulted to collect information about their treatment histories, including the number of appointments and the duration of follow-up. RESULTS: SLE impact perception correlates significantly with suicide risk, the number of clinical appointments, the duration of treatment, and the perceived level of family functioning. The mediation model of the family functioning perception variable in the relationship between SLE impact perception and suicide risk is significant. The linear regression model of SLE impact perception and family functioning perception on suicide risk is also significant, accounting for 25.7% of the variance. CONCLUSIONS: Beyond the clear and proven effect of serious and objective SLEs, the perceived impact of SLEs reported by adolescents is related to an increased risk of suicide and more intense psychological and/or psychiatric follow-up. This relationship is mediated by the perceived level of family functioning. Adolescents' perceptions of their life experiences and perceived family support may be key determinants of suicide risk prevention.

Interpersonal theory of suicide and stressful life events in a clinical sample of adolescents in Spain.

AIMS: The interpersonal theory of suicide (ITPS) provides a theoretical model for suicidal behaviour. It includes two interpersonal variables, thwarted belongingness (TB) and perceived burdensomeness (PB). This study tested the relationship between ITPS interpersonal variables and suicide risk (presence/absence of suicidal ideation and suicide attempts throughout life) in a clinical sample of Spanish adolescents. We also assessed the potential mediation effect of these variables in the well-established relationship between stressful life events (SLE) and suicide risk. METHODS: We recruited 147 adolescents aged 11-17 from the Child and Adolescent Mental Health Outpatient Services of the Jiménez Díaz Foundation (Madrid, Spain). Different questionnaires were administered to assess suicidal behaviour and SLE (SITBI, The Stressful Life Events Scale) and to calculate proxy measures for ITPS interpersonal factors (SDQ, STAXI-NA, CDI). RESULTS: TB and PB significantly correlated with suicide risk. PB played a mediating role in the relationship between SLE and suicide risk: adolescents reporting SLE were more likely to enact suicide behaviours when they experienced higher PB. Patients scoring higher PB were more likely to receive more intense treatment but tended to abandon intervention promptly. CONCLUSIONS: ITPS seems useful for predicting suicide risk in an adolescent clinical sample. The results suggest an important role for PB in the SLE-suicide risk relationship and may impact the treatment process. Our exploratory findings should be addressed in future studies.

Relationship between cognition and suicidal behavior in recent-onset psychosis.

Suicidal behavior (SB) is common in first-episode psychosis (FEP), and cognitive impairment has also been described in psychosis. Despite well-established risk factors for SB in psychosis, the role of cognition and insight remains unclear. This study aimed to explore the relationship between history of SB and cognition in recent-onset FEP, distinguishing between neurocognition, social cognition, and metacognition, and including cognitive insight (CI) as a metacognitive variable. The sample consisted of 190 participants with recent-onset FEP recruited from two multicentric studies. Two groups were formed based on presence/absence of a history of SB. Demographic, clinical, and cognitive data were compared by group, including significance level adjustments and size effect calculation. No differences were found regarding demographic, clinical, neurocognitive, social cognition, and metacognitive variables except for CI (18.18 ± 4.87; t = -3.16; p = 0.0020; d = -0.635), which showed a medium effect size. Small to medium effect size were found for attributional style (externalizing bias) (1.15 ± 3.94; t = 2.07; d = 0.482), theory of mind (ToM) (1.73 ± 0.22; t = 2.04; d = -0.403), jumping to conclusions bias (JTC) (23.3 %; X2 = 0.94; V = 0.178). In recent-onset psychosis, neurocognitive functioning was not related to the history of SB. As novelty, individuals with previous SB showed higher CI. Also, regarding social cognition and metacognition, individuals with prior SB tended to present extremely low externalizing bias, better ToM, and presence of JTC.

Substance use, mental health and dual disorders on pregnancy: Results of prevalence and treatment rates in a developed country. / Salud mental, abuso de sustancias y trastornos duales en el embarazo: Tasas de prevalencia y tratamiento en un país desarrollado.

Smoking and substance use during pregnancy are major preventable causes of mortality and morbidity, having a bidirectional and deleterious relationship with the mental health of the mother and child. As part of the WOMAP (Woman Mental Health and Addictions on Pregnancy) initiative, our study aimed to describe the prevalence of co-occurring mental illness and substance use problems, diagnoses and severity of those considered at risk and rates of treatment.A screening of 2,014 pregnant women was done using the AC-OK scale and they were asked about their smoking habits and services use for mental health/substance abuse. Of these, 170 women were considered at risk of co-occurring mental illness and substance use problems (≥ 2 positive responses to the AC-OK-Mental Health subscale, ≥ 1 positive response to the AC-OK-Substance Abuse subscale and/or smoking more than once a month and no use of specialized services) and were assessed with a more extensive battery of measures (Patient Health Questionnaire [PHQ-9], General Anxiety Disorder [GAD-7], Posttraumatic stress disorder [PTSD] Checklist for DSM-5 [PCL-5], Alcohol Use Disorders Identification Test [AUDIT], Drug Abuse Screening Test [DAST] and Fagerström).In the last year, 614 women (30.5%) smoked tobacco (42.5% daily) and 9.8% were positive for both substance use and mental illness per the AC-OK. Only 11.1% of them received specific treatment in the previous three months while another 13.6% were scheduled to attend services in the following month. From the subsample assessed in depth, 62(36.5%) endorsed at least moderate depression, 35(20.6%) endorsed at least moderate anxiety, 32(18.8%) endorsed PTSD on the PCL, and 37 out of 88 alcohol users scored above the threshold in AUDIT (≥ 3). In conclusion, high prevalence and low treatment rates suggest that effective detection mechanisms should be integrated into usual care, allowing for early interventions.

El tabaquismo y el consumo de sustancias durante el embarazo son importantes causas prevenibles de morbimortalidad, teniendo una relación bidireccional y deletérea con la salud mental de la madre y el niño. Como parte de la iniciativa WOMAP (Woman Mental Health and Addictions on Pregnancy), se estudiaron 2.014 embarazadas buscando describir la prevalencia de trastornos mentales y por uso de sustancias concurrentes, las tasas de tratamiento y los diagnósticos y la gravedad. Las participantes fueron evaluadas con la escala AC-OK y se les preguntó sobre sus hábitos tabáquicos y uso de servicios de salud mental/sustancias. De las participantes, 170 mujeres resultaron positivas para un trastorno mental y por uso de sustancias concurrentes (≥ 2 positivos a la subescala AC-OK-Salud Mental, ≥ 1 positivos a la subescala AC-OK-Sustancias y/o fumar más de una vez al mes y no estar en tratamiento) y fueron evaluadas en profundidad mediante una batería de escalas (Patient Health Questionnaire [PHQ-9], General Anxiety Disorder [GAD-7], Post-traumatic stress disorder Checklist [PCL-5], Alcohol Use Disorders Identification Test [AUDIT], Drug Abuse Screening Test [DAST] y Fagerström).En el último año, 614 mujeres (30,5%) fumaron tabaco (42,5% diariamente) y el 9,8% fueron positivas para problemas por uso de sustancias y salud mental según la AC-OK. Solo el 11,1% había recibido tratamiento en los tres meses previos y solo un 13,6% tenía una cita en el siguiente mes. De las 170 pacientes evaluadas secundariamente, 62(36,5%) presentaron al menos depresión moderada, 35(20,6%) al menos ansiedad moderada, 32(18,8%) fueron positivas a la PCL-5, y 37 de las 88 que reconocieron uso de alcohol puntuaron por encima del umbral en AUDIT (≥ 3). En conclusión, la combinación de una prevalencia significativa junto con bajas tasas de tratamiento, remarcan la necesidad de mecanismos de detección efectivos en la atención habitual, permitiendo una intervención temprana.

Salud mental, abuso de sustancias y trastornos duales en el embarazo: Tasas de prevalencia y tratamiento en un país desarrollado / Substance use, mental health and dual disorders on pregnancy: Results of prevalence and treatment rates in a developed country

El tabaquismo y el consumo de sustancias durante el embarazo son importantes causas prevenibles de morbimortalidad, teniendo una relaciónbidireccional y deletérea con la salud mental de la madre y el niño.Como parte de la iniciativa WOMAP (Woman Mental Health and Addictions on Pregnancy), se estudiaron 2.014 embarazadas buscando describir la prevalencia de trastornos mentales y por uso de sustancias concurrentes, las tasas de tratamiento y los diagnósticos y la gravedad. Lasparticipantes fueron evaluadas con la escala AC-OK y se les preguntó sobre sus hábitos tabáquicos y uso de servicios de salud mental/sustancias.De las participantes, 170 mujeres resultaron positivas para un trastornomental y por uso de sustancias concurrentes (≥ 2 positivos a la subescalaAC-OK-Salud Mental, ≥ 1 positivos a la subescala AC-OK-Sustancias y/ofumar más de una vez al mes y no estar en tratamiento) y fueron evaluadas en profundidad mediante una batería de escalas (Patient Health Questionnaire [PHQ-9], General Anxiety Disorder [GAD-7], Post-traumatic stress disorder Checklist [PCL-5], Alcohol Use Disorders Identification Test [AUDIT], Drug Abuse Screening Test [DAST] y Fagerström).En el último año, 614 mujeres (30,5%) fumaron tabaco (42,5% diariamente) y el 9,8% fueron positivas para problemas por uso de sustancias ysalud mental según la AC-OK. Solo el 11,1% había recibido tratamientoen los tres meses previos y solo un 13,6% tenía una cita en el siguientemes. De las 170 pacientes evaluadas secundariamente, 62(36,5%) presentaron al menos depresión moderada, 35(20,6%) al menos ansiedadmoderada, 32(18,8%) fueron positivas a la PCL-5, y 37 de las 88 quereconocieron uso de alcohol puntuaron por encima del umbral en AUDIT (≥ 3).En conclusión, la combinación de una prevalencia significativa junto conbajas tasas de tratamiento, remarcan la necesidad de mecanismos de detección efectivos en la atención habitual, permitiendo una intervencióntemprana. (AU)

Smoking and substance use during pregnancy are major preventablecauses of mortality and morbidity, having a bidirectional and deleterious relationship with the mental health of the mother and child.As part of the WOMAP (Woman Mental Health and Addictions onPregnancy) initiative, our study aimed to describe the prevalence ofco-occurring mental illness and substance use problems, diagnosesand severity of those considered at risk and rates of treatment.A screening of 2,014 pregnant women was done using the AC-OKscale and they were asked about their smoking habits and servicesuse for mental health/substance abuse. Of these, 170 women wereconsidered at risk of co-occurring mental illness and substance useproblems (≥ 2 positive responses to the AC-OK-Mental Health subscale, ≥ 1 positive response to the AC-OK-Substance Abuse subscaleand/or smoking more than once a month and no use of specialized services) and were assessed with a more extensive battery of measures(Patient Health Questionnaire [PHQ-9], General Anxiety Disorder[GAD-7], Posttraumatic stress disorder [PTSD] Checklist for DSM-5[PCL-5], Alcohol Use Disorders Identification Test [AUDIT], DrugAbuse Screening Test [DAST] and Fagerström).In the last year, 614 women (30.5%) smoked tobacco (42.5% daily) and9.8% were positive for both substance use and mental illness per theAC-OK. Only 11.1% of them received specific treatment in the previousthree months while another 13.6% were scheduled to attend services inthe following month. From the subsample assessed in depth, 62(36.5%)endorsed at least moderate depression, 35(20.6%) endorsed at leastmoderate anxiety, 32(18.8%) endorsed PTSD on the PCL, and 37 outof 88 alcohol users scored above the threshold in AUDIT (≥ 3).In conclusion, high prevalence and low treatment rates suggest thateffective detection mechanisms should be integrated into usual care,allowing for early interventions. (AU)

The Mediating Role of Impulsivity in the Relationship Between Suicidal Behavior and Early Traumatic Experiences in Depressed Subjects.

Background: Depressed patients with early traumatic experiences may represent a clinically and biologically distinct subtype, with worse clinical outcomes and greater risk of suicide. Since early traumatic experiences alter development of systems that regulate the stress response, increasing sensitivity to stress and mood disorders later in life, certain personality features may influence coping strategies, putting individuals with depression and a history of early traumatic experiences at greater risk of suicidal behavior. Objective: To determine whether impulsivity mediates the relationship between early traumatic experiences and suicidal behavior in patients with major depressive disorder (MDD). Methods: The total sample consists of 190 patients [mean age (SD) = 53.71 (10.37); females: 66.3%], with current MDD (DSM-5 criteria). The Childhood Trauma Questionnaire-Short Form (CTQ-SF), the List of Threatening Experiences (LTE), and the Barratt Impulsiveness Scale-11 (BIS-11) were used to assess childhood and adulthood adverse life events and impulsivity, respectively. We developed mediation models by bootstrap sampling methods. Results: Eighty-one (42.6%) patients had a history of previous suicide attempts (SA). CTQ-SF-Total and BIS-11-Total scores were significantly higher in MDD patients with previous SA. Correlation analyses revealed significant correlations between the CTQ-SF-Total and BIS-11-Total, CTQ-SF-Total and HDRS-Total, and BIS-11-Total and HDRS-Total scores. Regression models found that CTQ-SF-Total, BIS-11-Total, and HDRS-Total scores were associated with SA. Mediation analyses further revealed the association between CTQ-SF-Total and SA was mediated by the indirect effect of the BIS-11-Total score (b = 0.007, 95% CI = 0.001, 0.015), after statistically controlling for sex, the HDRS-Total, and the LTE-Total. Discussion: Data suggest that impulsivity could mediate the influence of childhood trauma on suicidal behavior. This will help understand the role of risk factors in suicidal behavior and aid in the development of prevention interventions focused on modifiable mediators when risk factors are non-modifiable.

SDQ Dysregulation Profile and Its Relation to the Severity of Psychopathology and Psychosocial Functioning in a Sample of Children and Adolescents With ADHD.

Objective: A substantial number of children and adolescents with ADHD show severe affective and behavioral dysregulation. A dysregulation profile (DP) distinguishes those participants at a higher risk of comorbidity, dysfunction, and a poorer response to treatment. It was identified as high scoring in certain subscales of the Strengths and Difficulties Questionnaire (SDQ-DP). We developed a cross-sectional study to assess the clinical utility of the SDQ-DP in ADHD. Method: Two hundred fifty clinic-referred children and adolescents with ADHD were assessed. Univariate and linear regression analyses were performed to compare those participants with high levels of SDQ-DP with those with low levels, as well as to examine the association between the SDQ-DP and clinical variables. Results: In all, 28% of ADHD participants had high levels of SDQ-DP. These participants showed higher functional impairment and clinical severity. Conclusion: The use of the SDQ-DP will enable identification of those ADHD patients at greater risk.

El perfil de disregulación del SDQ y su relación con conductas y pensamientos de suicidio en adolescentes evaluados en contexto clínico / The SDQ dysregulation profile is associated with self-injurious thoughts and behaviors in adolescents evaluated at a clinical setting

Introducción: La ideación suicida, la conducta suicida y las conductas autolesivas sin intención suicida (autolesiones) son un grave problema de salud pública en la adolescencia. Una proporción significativa de de adolescentes evaluados en contexto clínico muestran un perfil de disregulación (DP). El DP se caracteriza por inquietud, irritabilidad, «tormentas afectivas», inestabilidad emocional y agresiones que aparecen de forma desproporcionada ante determinadas situaciones, y parece estar relacionado con un mayor riesgo de pensamientos y conductas suicidas y autolesivas. Métodos: Doscientos treinta y nueve adolescentes del Centro de Salud Mental Infantojuvenil del Servicio de Psiquiatría de la Fundación Jiménez Díaz fueron evaluados con la Escala de Fortalezas y Dificultades para obtener el DP y con la entrevista estructurada sobre suicidio y autolesiones; se recogió también información sociodemográfica. Resultados: Estudios de regresión logística mostraron que los adolescentes con elevación del DP tenían más riesgo de presentar planes de suicidio, gestos suicidas e intentos suicidas. Igualmente, mostraron más riesgo de autolesiones. Conclusiones: Los resultados apuntan a dificultades de autorregulación tras la presencia de planes de suicidio, gestos suicidas, intentos de suicidio y autolesiones. De cara al futuro, estudios longitudinales permitirían esclarecer la dirección de dicha relación

Introduction: Suicidal ideation, suicidal behavior, and non-suicidal self-injury behavior are serious public health problems among adolescents. A significant proportion of adolescents evaluated in clinical settings meet criteria for the dysregulation profile (DP). DP is characterized by restlessness, irritability, "affective storms", mood instability, and aggression in a disproportionate grade to the situation. This DP might be related to increased risk of self-injurious thoughts and behaviors. Methods: Two hundred and thirty-nine adolescents from the Child and Adolescent Outpatient Psychiatric Services of the Jimenez Diaz Foundation, Madrid, were assessed with the Strengths and Difficulties Questionnaire-Dysregulation Profile, the Self-Injurious Thoughts and Behaviors Interview and socio-demographic questionnaires. Results: Logistic regression showed that DP adolescents were at increased risk for suicide plans, gestures, and suicide attempts. They also tended to present more self-injurious behaviors than adolescents without DP. Conclusions: Our results point to the role of self-regulatory problems in the presence of suicide plans, suicide gestures, suicide attempts, and in non-suicidal self-injury behavior. Longitudinal studies are needed to confirm the relationship between the Strengths and Difficulties Questionnaire-Dysregulation Profile and self-injurious thoughts and behaviors

The SDQ dysregulation profile is associated with self-injurious thoughts and behaviors in adolescents evaluated at a clinical setting. / El perfil de disregulación del SDQ y su relación con conductas y pensamientos de suicidio en adolescentes evaluados en contexto clínico.

INTRODUCTION: Suicidal ideation, suicidal behavior, and non-suicidal self-injury behavior are serious public health problems among adolescents. A significant proportion of adolescents evaluated in clinical settings meet criteria for the dysregulation profile (DP). DP is characterized by restlessness, irritability, "affective storms", mood instability, and aggression in a disproportionate grade to the situation. This DP might be related to increased risk of self-injurious thoughts and behaviors. METHODS: Two hundred and thirty-nine adolescents from the Child and Adolescent Outpatient Psychiatric Services of the Jimenez Diaz Foundation, Madrid, were assessed with the Strengths and Difficulties Questionnaire-Dysregulation Profile, the Self-Injurious Thoughts and Behaviors Interview and socio-demographic questionnaires. RESULTS: Logistic regression showed that DP adolescents were at increased risk for suicide plans, gestures, and suicide attempts. They also tended to present more self-injurious behaviors than adolescents without DP. CONCLUSIONS: Our results point to the role of self-regulatory problems in the presence of suicide plans, suicide gestures, suicide attempts, and in non-suicidal self-injury behavior. Longitudinal studies are needed to confirm the relationship between the Strengths and Difficulties Questionnaire-Dysregulation Profile and self-injurious thoughts and behaviors.

The Strengths and Difficulties Questionnaire -Dysregulation Profile, Non-Suicidal Self-Injury Behaviors and the Mediating Role of Stressful Life Events.

Non-suicidal self-injury (NSSI) behaviors are self-injurious behaviors inflicted without intending death. Literature has shown the relationship between stressful life events (SLE) and NSSI behaviors. The Strengths and Difficulties Questionnaire-Dysregulation Profile (SDQ-DP) is defined as an index of self-regulatory problems, related to higher risk for suicidal ideation and attempts in adolescents. In this study the relationship between SDQ-DP and NSSI behaviors, mediated by SLE in a clinical sample of children and adolescents is analyzed. A cross-sectional study was conducted on 239 subjects (aged from 11 to 17) to test the mediation model. SDQ-DP significantly correlates with NSSI behaviors (Wald = 6.5477, p = .0105); SDQ-DP significantly correlates with SLE (T = 5.7229, p < .001); SLE significantly correlates NSSI behaviors, and the relation remains significant whilst controlling for SDQ-DP (Wald = 4.1715, p = .041); the relation between SDQ-DP and NSSI behaviors stops being significant whilst controlling for the potential mediator (SLE) (Wald = 2.9951, p = .0835). Study of indirect effect supports the mediation model (.0585 CI [.0016, .1266]). Findings are compatible with the complete mediation scenario. These results point out the importance of self-regulatory problems in coping strategies with regards to SLE and the development of NSSI behaviors.

The strengths and difficulties questionnaire - dysregulation profile, non-suicidal self-injury behaviors and the mediating role of stressful life events

Non-suicidal self-injury (NSSI) behaviors are self-injurious behaviors inflicted without intending death. Literature has shown the relationship between stressful life events (SLE) and NSSI behaviors. The Strengths and Difficulties Questionnaire-Dysregulation Profile (SDQ-DP) is defined as an index of self-regulatory problems, related to higher risk for suicidal ideation and attempts in adolescents. In this study the relationship between SDQ-DP and NSSI behaviors, mediated by SLE in a clinical sample of children and adolescents is analyzed. A cross-sectional study was conducted on 239 subjects (aged from 11 to 17) to test the mediation model. SDQ-DP significantly correlates with NSSI behaviors (Wald = 6.5477, p = .0105); SDQ-DP significantly correlates with SLE (T = 5.7229, p < .001); SLE significantly correlates NSSI behaviors, and the relation remains significant whilst controlling for SDQ-DP (Wald = 4.1715, p = .041); the relation between SDQ-DP and NSSI behaviors stops being significant whilst controlling for the potential mediator (SLE) (Wald = 2.9951, p = .0835). Study of indirect effect supports the mediation model (.0585 CI [.0016, .1266]). Findings are compatible with the complete mediation scenario. These results point out the importance of self-regulatory problems in coping strategies with regards to SLE and the development of NSSI behaviors

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Biological and environmental predictors of the dysregulation profile in children and adolescents: the story so far.

Most children and adolescents attending mental health services exhibit severe affective and behavioral dysregulation. The dysregulation profile (DP) seems to be an indicator of self-regulatory problems, overall psychopathology, symptom severity, and functional impairment. Although there are studies signaling its importance as a marker of severe psychopathology and long-term impairment, little is known about its predictors. We reviewed the existing literature and found biological and environmental factors associated with the DP. The DP seems to have high heritability rates, blunted hypothalamic-pituitary-adrenal axis responses at stress tasks, and attention problems regardless of emotional context. Some family factors (such as abnormal qualities of upbringing, lower effortful control, parental hostility, and parental substance use disorders) are also related to the DP. More research about specific predictors of the DP is clearly needed. Longitudinal studies would help identify them more clearly.

Prolonged social withdrawal disorder: a hikikomori case in Spain.

BACKGROUND: The Japanese term hikikomori means literally 'to be confined'. Social withdrawal can be present in severe psychiatric disorders; however, in Japan, hikikomori is a defined nosologic entity. There have been only a few reported cases in occidental culture. MATERIAL: We present a case report of a Spanish man with prolonged social withdrawal lasting for 4 years. DISCUSSION: This is a case of prolonged social withdrawal not bound to culture, as well as the second case of hikikomori reported in Spain. We propose prolonged social withdrawal disorder as a disorder not linked to culture, in contrast to hikikomori. CONCLUSION: Further documentation of this disorder is still needed to encompass all cases reported in Japan and around the world.

Sibship size, birth order, family structure and childhood mental disorders.

PURPOSE: The aim of this study was to determine the role that birth order, sibship size and family structure have as risk factors in the development of common childhood mental disorders. METHOD: A case-control study design was conducted (N = 16,823). The group under study consisted of all those subjects who had consulted with a psychiatrist/psychologist and had received a clinical diagnosis at public mental health centres within the Region of Madrid (Spain), between 1980 and 2008. A multiple logistic regression was used to explore the independent association with each diagnosis: emotional disorders (ED) with onset specific to childhood, attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), mental retardation (MR), and pervasive developmental disorder (PDD). RESULTS: Birth order and family structure significantly predicted the risk of being diagnosed with ED or ADHD. In addition, sibship size and sex predicted the risk of being diagnosed with a childhood mental disorder. CONCLUSIONS: We concluded that being the middle child and living with both biological parents appear to be protective factors against the development of ED or ADHD. Living in large families appears to increase the risk of receiving a CD, MR, or PDD diagnosis. Further research is warranted.