Psicopatología y factores de riesgo durante la residencia / Risk factor for psycopathology during residency

Introducción. El estrés en la práctica médica es mayor durante la residencia, pues se establece por primera vez la relación con el paciente y es la etapa de aprendizaje más rápido, a lo que se añaden cambios vitales. El objetivo de este estudio es evaluar la prevalencia de trastornos psíquicos a lo largo de todo el período de formación y los factores de riesgo que lo condicionan. Metodología. Se realizó un estudio transversal en 145 residentes, de todas las especialidades y años de formación. Fueron valorados al principio de cada año, y a los que finalizaban ese año, también al final de su residencia. Se evaluaron datos sociodemográficos, antecedentes psíquicos, situaciones de estrés, psicopatología, rasgos de personalidad y conductas de adaptación utilizadas. Resultados. La prevalencia de trastornos psíquicos fue alta (49 %). En general eran trastornos poco severos y se asociaban a deseos de abandonar la profesión y falta de tiempo para la relación socio familiar. En el análisis discriminante, se asociaron a la psicopatología los rasgos de «neuroticismo», conductas de «autorreproche» y «distanciamiento», antecedentes psíquicos personales y nivel de estrés derivado principalmente de aspectos de la propia formación. Conclusiones. La asunción de ambos factores, individuales y contextuales, es importante para la salud mental y desarrollo profesional en esta etapa de formación médica. Conocer estos factores de riesgo facilitaría la puesta en marcha de programas preventivos que orienten a un manejo adecuado de las situaciones de estrés en este período (AU)

Introduction. Stress in medical practice is highest during the residency due to the relationship with the patient is established for the first time and the stage of learning is faster, in addition of life events. The aim of this study is to assess the prevalence of psychic disorders throughout the entire period of training and risk factors that determine them. Methods. Cross-sectional study was conducted on145 residents of all specialties and years of training. They were evaluated at the beginning of each year, and also at the end of that year if they ended the residency. We assessed sociodemographics data, psychic antecedents, stress, psychopathology, personality traits and coping behaviour used. Results. The prevalence of mental disorders was high (49%), but they were generally not very severe. They were associated with the wish to quit the profession and lack of time for social and familiar relationships. In the discriminant analysis, the psychopathology was mainly associated with traits “Neuroticism”, “Self-reproach” and“ Distancing” behaviors, personal psychic antecedents, and stress levels resulting mainly from aspects of the training itself. Conclusions. The assumption of both, individual and contextual factors, are important for mental health and career development at this stage of medical training. The knowledge of these risk factors would facilitate the implementation of preventive programs to guide the appropriate management of stress in this period (AU)

Pharmacological treatment of acute stress disorder with propranolol and hypnotics.

INTRODUCTION: Pharmacological treatment of traumarelated mobidity has neither the efficacy nor specificity desired. Thus, several attempts have been made to add new drugs to the usual treatments, in this case with propranolol and hypnotic drugs. METHOD: We offered this treatment to the victims of the March 11, 2004 terrorism attack who were attended within the first week of this attack for psychiatric reasons (n=21) and who also fulfilled criteria for acute stress disorder (ASD) (n=15) and had no contraindications for the treatment (n=3). Trauma intensity was measured with Horowitz impact of events scale (IES). Significant clinical data were collected. RESULTS: Propranolol treatment was associated with clinical remission of target symptoms in 63.6 % of the cases, partial response in 27.3 % and no response in 9.1%. Hypnotic treatment was also associated with clinical remission in 61.5 % and partial response in 38.5 %. Statistically significant correlations were found at the beginning for IES with disability, and after the first month with the propranolol and hypnotic responses. CONCLUSIONS: Propranolol and hypnotic treatments are useful in the decrease of ASD symptoms. IES is very useful to predict disability as well as poor response to propranolol or hypnotic drugs. More studies are needed to confirm the data obtained in our sample.

[Historical review of the borderline personality disorder concept]. / Revisión histórica del concepto de trastorno limítrofe de la personalidad (borderline).

INTRODUCTION: The concept of borderline syndrome is the subject of current debate because of its ambiguity and lack of homogeneity. Furthermore, the concept is rejected by many authors as a common category for atypical and non-specific disorders that cannot be classified elsewhere. The current use of the term borderline seems to be more a consequence of its historic use than its true clinical meaning. There is discrepancy on whether this term determines a level of severity, an organization of personality or a defined syndromic entity. In 1938, Stern was the first author to use the term borderline, and it was not introduced in the DSM III until 1980. OBJECTIVE: This work makes a historical review of the use of the term borderline and also of those terms that have been used to define patients with the same characteristics. CONCLUSION: The different schools (psychoanalytic, biological, eclectic and biosocial) have different concepts on the term borderline. There is still no concise and exact definition for the diagnostic criteria of borderline and it is even possible the best term for this group of patients has still not been determined. It will be important to consider the contributions of the DSM V or ICD 11 in the next years.

[Atypical anorexia nervosa without body image distortion: based on a clinical case]. / Anorexia nerviosa atípica sin alteración de la imagen corporal: a propósito de un caso clínico.

Eating disorders presents a lower prevalence in males than in females. Despite being mentioned in 1689 in the first case described by Richard Morton, anorexia nervosa in males has been relatively ignored. The diagnostica criteria for males with anorexia nervosa are similar to those for females although the sociocultural environment differs from birth between the sexes. Men and women perceive fatness differently. They have different ideas of shape and they value slimness differently.

Anorexia nerviosa atípica sin alteración de la imagen corporal: a propósito de un caso clínico / Atypical anorexia nervosa without body image distortion: based on a clinical case

Los trastornos de la conducta alimentaria tienen una menor prevalencia en los varones que en las mujeres. A pesar de que fue mencionada en el primer caso clínico descrito de anorexia nerviosa en 1689 por Richard Morton, la anorexia nerviosa en el varón ha sido relativamente ignorada. Los criterios diagnósticos son similares a los de las mujeres, aunque los factores ambientales y socioculturales son diferentes para ambos sexos desde el nacimiento. Hombres y mujeres perciben la grasa de manera diferente, tienen otros valores en relación a la forma y figura corporal y valoran de distinta manera la delgadez (AU)

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PET en neurología y psiquiatría I. PET con FDG en el estudio del SNC / PET in neurology and psychiatry I. Pet with FDG in the study of the CNS

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[Transcranial magnetic stimulation. Clinical trials in psychiatry: therapeutical use]. / Estimulación magnética transcraneal. Estudios clínicos en Psiquiatría: indicaciones terapéuticas.

Transcranial magnetic stimulation is the noninvasive application of localized pulsed magnetic field to the surface of the skull, to cause a depolarization of neurons in the underlying cerebral cortex (Daryl E., Bohning PH.D.). Based on Reciprocal Induction (Faraday, 1831), and the Ampere Maxwell Law, according to which electric energy is associated with magnetic energy and vice versa, transcranial magnetic stimulation has been used during the last fifteen years in the diagnosis of Central Nervous System dysfunctions, its safeness and good tolerance having been proven. Since 1876, when Dàrsonval discovered that the use of a similar apparatus caused vertigo, phosphenes and fainting, thousands of transcranial magnetic stimulation studies have been carried out in the fields of Neurology and Psychiatry. The present is a review of clinical studies carried out in Psychiatry, specifically related to Mood Disorders, Obsessive-Compulsive Disorder and Post traumatic-Stress Syndrome.

Estimulación magnética transcraneal. Estudios clínicos en Psiquiatría: indicaciones terapéuticas / Transcranial magnetic stimulation. Clinical trials in psychiatry: therapeutical use

Estimulación magnética transcraneal consiste en la aplicación, de forma no invasiva, de un campo magnético pulsante localizado sobre la superficie craneal, que en respuesta provoca la despolarización de las neuronas del córtex cerebral subyacente' (Daryl E., Bohning Ph.D.). Fundamentado sobre el principio de inducción recíproca (Faraday, 1831) y la Ley de Àmpere-Maxwell, según los cuales la energía eléctrica lleva asociada energía magnética, y viceversa, la estimulación eléctrica transcraneal se ha utilizado en los últimos quince años en el diagnóstico de disfunciones del sistema nervioso central, habiendo quedado probada su seguridad y buena tolerancia. Desde que Dársonval en 1896 utilizase por primera vez un ingenio semejante a la estimulación eléctrica transcraneal para su aplicación al sistema nervioso central, descubriendo que provocaba cuadros de vértigo, fosfenos y síncope, hasta la actualidad, son muchos los estudios realizados con estimulación magnética transcraneal, tanto en el terreno de la Neurología como en el de la Psiquiatría. Este trabajo contiene una revisión de los estudios clínicos realizados en Psiquiatría, en particular en trastornos del ánimo, el trastorno obsesivo-compulsivo y el trastorno por estrés postraumático. (AU)

[Psychopathology of bulimia nervosa: a multidimensional model]. / Psicopatología de la bulimia nerviosa: un modelo multidimensional1

INTRODUCTION: In recent years, a number of studies have been carried out with the intention of isolating clinical dimensions in the psychopathology of bulimia nervosa. Although borderline personality has been considered a core element of the bulimic psychopathology by most of the authors, it has not been incorporated into any of these models. In this context, the present study was aimed at testing the consistence of the more complex model proposed until now, including in the analysis borderline personality as a clinical variable. SAMPLE AND METHODS: A group of 66 female patients fulfilling DSM-IV criteria for bulimia nervosa were assessed using a set of clinical instruments. The isolated items were processed using factor analysis techniques. RESULTS: Five basic dimensions of bulimia nervosa were obtained: 1. body disatisfaction; 2. restrictive eating behaviors; 3. purging behaviors; 4. emotional instability; and 5. disocial behavior. CONCLUSIONS: Our results support the idea that bulimia nervosa is a multidimensional condition. In our model, the dimension emotional instability incorporated borderline features, which tended to be strongly associated to self-defeating behaviors and depressive symptoms.

[Fight against schizophrenia stigma]. / La lucha contra el estigma de la esquizofrenia.

Stigma, discrimination and prejudice against mental diseases, those who suffer from them and their families are common everywhere. To reduce stigma in schizophrenia is essential for a better outcome of the disease in each patient. Stigma interferes with the detection of the illness, with adherence to treatment, with rehabilitation and with social reinsertion. Stigma is everywhere in schizophrenia, from within the family itself to the health care system and into society at large. The WPA has developed a Program to fight the stigma of schizophrenia consisting on several modules: 1) Instructions on how to implement a campaign. 2) A monograph in schizophrenia. 3) A summary of the experiences in the sites where the program has been tested. 4) Further modules which include information on similar campaigns and material such as leaflets, books and videos and concrete examples of discrimination. A pilot study of the WPA Program was carried out in Madrid in 1999. A survey was undertaken to identify target population and specific messages, showing little knowledge about the disease and a small stigma amount. It was decided not to carry out an awareness campaign in the population, which has the risk of increasing stigma in parallel to being increased in awareness but to explore the amount of stigma in the environment closer to the patient such as patients themselves, relatives, neighbours and health services staff. The stigma degree was much more significant. Activities related to this group of people were undertaken specially by training psychiatrists to identify stigma and discrimination and to fight it. The outcome showed a great satisfaction among patients, relatives and physicians. A pilot media campaign was also undertaken. In previous years there was no information about schizophrenia in mass media only news on incidental problems of patients with schizophrenia. After the campaign news on the disease itself appeared in mass media. The Madrid experience shows that the WPA Program strategies, based on doing population research and adapting the campaign to local needs, are most appropriate and that an anti-stigma campaign can be carried out with succes. The same experience has been repeated in the year 2000 and part of 2001 in the whole of Spain. Health authorities of the Autonomous Community of Madrid, the City Council, the Department of Health and Consumption and the Department of Social Affairs and the INSALUD (National Institute of Health) were very helpful with the campaign. The program is supported by an unrestricted grant by Eli Lilly and various institutions and foundations have also collaborated.

Avances en neuroimagen en el trastorno obsesivo-compulsivo / Obsesive-compulsive disorder, new developments with neuroimaging techniques

La investigación con técnicas de neuroimagen sugiere que en el trastorno obsesivo-compulsivo (TOC) existe una disfunción que afectaría al circuito croteza prefrontalganglios de la base y tálamo más que a una única región cerebral. Los primeros estudios con tomografía y resonancia magnética demuestran cambios morfológicos en los ganglios de la base. En la actualidad y con el desarrollo de técnicas más sofisticadas se están comprobando estas alteraciones, en especial las relacionadas con el núcleo caudado. La hipótesis serotoninérgica sigue siendo necesaria pero no suficiente para explicar la patogénesis del TOC. La evidencia sigue centrándose en los ganglios de la base y su relación con el 5-HT/dopamina. Dado que los ganglios de la base reciben una rica inervación de neuronas 5-HT y dopaminérgicas, se ha postulado que el TOC se produciría por una disfunción del circuito orbitofrontal y ganglios de la base. La combinación de pruebas cognitivas y técnicas de neuroimagen permite un mejor estudio de la función cerebral de los pacientes y de los controles cuando son sometidos a estimulación. Además con estas técnicas se puede comprobar la respuesta al tratamiento con independencia de si es de tipo farmacológico o utilizando técnicas cognitivo-conductuales. Pero sin embargo no tenemos datos suficientes para entender los mecanismos anatómicos, fisiológicos y químicos que intervienen en el TOC (AU)

El reto de la psiquiatría actual en la atención al niño y al adolescente / The challenge of present day psychiatry in child and adolescent care

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[The problem of truth in psychiatry]. / El problema de la verdad en psiquiatría.

Psychiatry has forgotten too early about the problem of truth (Zutt). In the first treatises on delusions, these are described as pathological errors, as mistakes in the ability to judge reality. For French psychiatry, delusions are false ideas of pathological origin, resistant to logical argumentation that alter the ability to judge reality, a concept still present in DSM-IV, in which it is defined as wrong beliefs that normality imply a wrong interpretation of perceptions of experiences. As a consequence, delusions are classified according to its contents. German psychiatry however seeks for the structures underlying to all delusions, some authors have even defended the notion of a single psychosis. The Heidelberg School, so well analyzed by Laín, developed a psychopathology which dismantled the notion of delusion then accepted (falseness is a relative and accessory notion and the lack of information plays an important role, as well as cultural and religious factors). K. Schneider describes the two forms of delusion: delusional perception and delusional occurrence. Both concepts have been criticized, therefore it is necessary to consider truth as a process and not as a state and to take into account the contributions of the philosophy of science and psychoanalysis. The concept of truth of Aristotle (the adaptation of the logos to the thing) is the one that has prevailed along history. But, for Heidegger the truth as aletheia (the process of revealing) is deeper and allows, applied to psychopathology, the connection of truth, liberty and relationship between human beings. As a consequence, the error of delusion, its lack of liberty, is also a lack of communication. The process of getting closer to truth is marked by an ethical attitude of tolerance.

[New advances in neuroimaging in the diagnosis of obsessive-compulsive disorder]. / Avances en neuroimagen en el trastorno obsesivo-compulsivo.

Brain-imaging research provides evidence to suggest that the underlying disfunction in Obsessive-Compulsive Disorder (OCD) is likely to be in the prefrontal cortex-basal ganglia thalamic circuit rather then in any one single brain region. Early computerized tomography and magnetic resonance imaging studies have shown morphological changes in the basal ganglia. Now more sophisticated techniques are enhancing the information available, specially with regard to the caudate nucleus. The serotonergic hypothesis remains a necessary but not sufficient explanation for the pathogenesis of OCD. Most evidence remains focussed on the basal ganglia and on a 5-HT/dopamine inter-relationship. Given the basal ganglia receive such rich innervation from both 5-Th and dopamine neurones, it has been postulated that OCD is subserved by a neuronal dysfunction in the basal ganglia and orbitofrontal cortex circuit. Combining behavioural challenge with brain imaging may be a better approach to capturing brain function while patients with OCD and control subjects are actually observed. Using this techniques has made it possible to identified changes in response to treatment, whether the treatment is pharmacological or behavioural. However, there are not data enough that allow us to understand the anatomical, physiological and chemical mechanisms implicated in OCD.

[The teaching of medical psychology]. / La enseñanza de la psicología médica.

The teaching of the psychological aspects of medical practice are confronted with three great difficulties: 1) Not to turn into an introduction of the teaching of psychiatry, without leaving aside the importance of psychiatric pathology in the general medical practice. 2) To provide medical-psychological scientific knowledge to be applied to everyday medical practice. 3) To base the teaching on scientific foundations of neuroscience and of psychological and social sciences. These aspects are considered in several consensus documents (World Psychiatric Association, International Federation of Societies for Medical Education, Spanish Society for Psychiatry, etc.) which have served as guide for the writing of this new text on medical psychology.