Correlates of insight into different symptom dimensions in obsessive-compulsive disorder.

BACKGROUND: In this study, we evaluated insight into different obsessive-compulsive disorder (OCD) symptom dimensions and their impact on clinical and sociodemographic features of patients with OCD. METHODS: Sixty OCD patients were assessed with the Brown Assessment of Beliefs Scale (BABS), the Dimensional Yale-Brown Obsessive-Compulsive Scale-Short Version, the Beck Depression Inventory, and the Sheehan Disability Scale. Two methods of using BABS were employed: 1) a traditional approach, which considers a composite of the insight into existing OCD symptoms, and 2) an alternative approach, which includes assessments of insight into each OCD symptom dimension separately. RESULTS: Composite BABS scores correlated with global severity of OCD and depressive symptoms, and degree of interference on social life/leisure activities and family life/home responsibilities. Dimension-specific correlations between severity of symptoms and insight ranged from very high (P = .87, for hoarding) to moderate (P = .61, for miscellaneous symptoms). Greater severity of depression and concomitant generalized anxiety disorder were independently associated with lower levels of insight into aggressive/checking symptoms. While earlier-onset OCD was associated with lower insight into sexual/religious and symmetry symptoms, later-onset OCD displayed lower insight into hoarding. CONCLUSIONS: Assessing insight into dimension-specific OCD symptoms may challenge the existence of clear-cut OCD with fair or poor insight.

A randomized, naturalistic, parallel-group study for the long-term treatment of panic disorder with clonazepam or paroxetine.

This long-term extension of an 8-week randomized, naturalistic study in patients with panic disorder with or without agoraphobia compared the efficacy and safety of clonazepam (n = 47) and paroxetine (n = 37) over a 3-year total treatment duration. Target doses for all patients were 2 mg/d clonazepam and 40 mg/d paroxetine (both taken at bedtime). This study reports data from the long-term period (34 months), following the initial 8-week treatment phase. Thus, total treatment duration was 36 months. Patients with a good primary outcome during acute treatment continued monotherapy with clonazepam or paroxetine, but patients with partial primary treatment success were switched to the combination therapy. At initiation of the long-term study, the mean doses of clonazepam and paroxetine were 1.9 (SD, 0.30) and 38.4 (SD, 3.74) mg/d, respectively. These doses were maintained until month 36 (clonazepam 1.9 [SD, 0.29] mg/d and paroxetine 38.2 [SD, 3.87] mg/d). Long-term treatment with clonazepam led to a small but significantly better Clinical Global Impression (CGI)-Improvement rating than treatment with paroxetine (mean difference: CGI-Severity scale -3.48 vs -3.24, respectively, P = 0.02; CGI-Improvement scale 1.06 vs 1.11, respectively, P = 0.04). Both treatments similarly reduced the number of panic attacks and severity of anxiety. Patients treated with clonazepam had significantly fewer adverse events than those treated with paroxetine (28.9% vs 70.6%, P < 0.001). The efficacy of clonazepam and paroxetine for the treatment of panic disorder was maintained over the long-term course. There was a significant advantage with clonazepam over paroxetine with respect to the frequency and nature of adverse events.

The effectiveness of cognitive behavioral group therapy in treating bipolar disorder: a randomized controlled study.

OBJECTIVE: Recent studies suggest that, when combined with pharmacotherapy, structured psychotherapy may modify the course of bipolar disorder. However, there are few studies that have examined the effects of cognitive behavioral group therapy on the course of this disorder. The aim of the present study was to evaluate the effectiveness of 14 sessions of cognitive behavioral group therapy, combined with pharmacotherapy, on the treatment of patients with bipolar disorder, and to compare our results against those from the use of pharmacotherapy alone. METHOD: Forty-one patients with bipolar I and II disorder participated in the study and were randomly allocated to one of two treatment groups; thirty-seven patients remained in the study until its completion. Mood and anxiety symptoms were measured in all subjects. Statistical analysis was used to investigate if the groups differed with respect to demographic characteristics and the scores recorded in the pre- and post-treatment stages, as well as during treatment (intra/inter groups). RESULTS: Patients showed statistically similar population characteristics. The association of cognitive behavioral group therapy and pharmacological treatment proved to be effective. Patients who had undergone cognitive behavioral group therapy presented fewer symptoms of mania, depression and anxiety, as well as fewer and shorter mood change episodes. CONCLUSION: Cognitive behavioral group therapy sessions substantially contributed to the improvement of depression symptoms.

Validation of the Brazilian brief version of the temperament auto-questionnaire TEMPS-A: the brief TEMPS-Rio de Janeiro.

BACKGROUND: Over the last thirty years, Akiskal and collaborators have described and developed operationalized diagnostic criteria for five types of affective temperaments - cyclothymic, irritable, hyperthymic, depressive, and anxious. A 110-item, yes-or-no questionnaire, the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego (TEMPS-A), was specifically developed for measuring temperamental variation. The TEMPS-A was translated into more than 25 languages and cross-culturally valid versions are now available in Italian, French, German, Japanese, Turkish, Arabic, Polish, Hungarian, Spanish and Portuguese. Recent studies in the US and in Europe, however, have suggested that shorter versions of TEMPS-A can be just as efficient as the full ones while potentially enhancing the compliance of respondents. The main objective of the present study was to validate a brief Brazilian Portuguese version of TEMPS-A (brief TEMPS-Rio de Janeiro). METHODS: Our main sample consisted of 997 undergraduate students (female = 72.6%) from seven different universities located in the city of Rio de Janeiro, Brazil. An additional group of 167 healthy senior citizens (women = 83.8%) was recruited in senior community centers in the city of Rio de Janeiro, Brazil. All participants were asked to complete the 110-item, Brazilian translation of the full version of the TEMPS-A. RESULTS: An exploratory factor analysis (PCA type 2, Varimax rotation) vying for a five-factor solution yielded mixed results, with cyclothymic traits, physical symptoms of anxiety and preoccupation with the well-being of a family member loading together on the first factor. When a forced six-factor solution was attempted, cyclothymic, irritable, hyperthymic, and depressive were delineated as predicted by the theory. The original generalized anxious temperament was split into two sharply delimited components, a "worrying" subscale and an abbreviated anxious subscale, which included physical symptoms of anxiety and concerns with the well-being of relatives. Based on the tripartite model of anxiety and depression, we proposed that the abridged anxious subscale, which includes physical symptoms of anxiety, represents the "true" generalized anxious temperament, while the "worrying" subscale corresponds to the "general distress factor". The internal consistency of the six subscales thus identified was generally good, ranging from 0.67 (anxious subscale) to 0.81 (worrying subscale), with cyclothymic, irritable, depressive, and hyperthymic subscales exhibiting intermediate values (0.74, 0.74, 0.72, and 0.7, respectively). LIMITATIONS: The present study was based on a non-clinical sample that does not reflect accurately the characteristics of the Brazilian population. The relative uniformity of the sample in terms of age and education precluded a more in-depth analysis of the influence of these highly relevant factors. Further, we did not assess convergent, divergent or test-retest validity. CONCLUSIONS: We believe that the brief Brazilian version of the TEMPS-A auto-questionnaire will provide Brazilian researchers and clinicians with a psychometrically sound instrument and thus contribute toward the creation of a worldwide research network dedicated to the investigation of affective temperaments.

The effectiveness of cognitive behavioral group therapy in treating bipolar disorder: a randomized controlled study / A eficácia da terapia cognitivo-comportamental para o tratamento do transtorno bipolar: um estudo controlado e randomizado

OBJECTIVE: Recent studies suggest that, when combined with pharmacotherapy, structured psychotherapy may modify the course of bipolar disorder. However, there are few studies that have examined the effects of cognitive behavioral group therapy on the course of this disorder. The aim of the present study was to evaluate the effectiveness of 14 sessions of cognitive behavioral group therapy, combined with pharmacotherapy, on the treatment of patients with bipolar disorder, and to compare our results against those from the use of pharmacotherapy alone. METHOD: Forty-one patients with bipolar I and II disorder participated in the study and were randomly allocated to one of two treatment groups; thirty-seven patients remained in the study until its completion. Mood and anxiety symptoms were measured in all subjects. Statistical analysis was used to investigate if the groups differed with respect to demographic characteristics and the scores recorded in the pre- and post-treatment stages, as well as during treatment (intra/inter groups). RESULTS: Patients showed statistically similar population characteristics. The association of cognitive behavioral group therapy and pharmacological treatment proved to be effective. Patients who had undergone cognitive behavioral group therapy presented fewer symptoms of mania, depression and anxiety, as well as fewer and shorter mood change episodes. CONCLUSION: Cognitive behavioral group therapy sessions substantially contributed to the improvement of depression symptoms.

OBJETIVO: Estudos recentes sugerem que uma psicoterapia estruturada aplicada junto com a farmacoterapia pode alterar o curso do transtorno afetivo bipolar. Entretanto, poucos estudos investigam os resultados da terapia cognitivo-comportamental em grupo sobre este transtorno psiquiátrico. O objetivo desta pesquisa foi avaliar a eficácia de 14 sessões de terapia cognitivo-comportamental em grupo concomitante à farmacoterapia para bipolares e comparar com a farmacoterapia sozinha. MÉTODO: Quarenta e um pacientes com transtorno bipolar I e II participaram do estudo e foram alocados aleatoriamente para um dos dois grupos; trinta e sete preencheram todas as escalas. Os sintomas de humor e ansiedade de todos os participantes foram avaliados. A análise estatística foi utilizada para investigar se os grupos diferiam com relação aos dados demográficos e entre os escores pré-, durante e pós-tratamento (intra/intergrupos). RESULTADOS: Os participantes dos dois grupos mostraram-se similares nas características demográficas. A adição da terapia cognitivo-comportamental em grupo ao tratamento farmacológico foi efetiva. O grupo da terapia cognitivo-comportamental em grupo apresentou menos sintomas de mania, depressão e ansiedade, bem como uma redução na frequência e duração dos episódios de humor. CONCLUSÃO: As sessões de terapia cognitivo-comportamental em grupo foram especialmente importantes na melhora dos sintomas depressivos.

Second-generation antidepressants in social anxiety disorder: meta-analysis of controlled clinical trials.

RATIONALE: A growing number of controlled clinical trials suggest that different second-generation antidepressants (SGA) may be effective in the treatment of social anxiety disorder (SAD). OBJECTIVES: The aim of the present study is to evaluate the effectiveness of SGA in SAD and to investigate possible differences in their efficacy. METHODS: We performed a systematic review and meta-analysis of all double-blind, randomized, controlled clinical trials involving second-generation antidepressants in adult patients with SAD published on PubMed/MEDLINE, PsycINFO, and Current Controlled Trials databases until July 2009. Our analyses were based on changes in Liebowitz Social Anxiety Scale (LSAS), Clinical Global Impression (CGI), and standardized mean difference (SMD). RESULTS: Twenty-seven controlled clinical trials, comprising ten different SGA, were selected. When comparing the reduction of LSAS scores, the group receiving active drugs showed a significantly greater reduction compared to those observed in the placebo group [pooled weighted mean -11.9 (IC 95% -14.5 to -9.4)]. The combined relative risk (RR) for the different drugs revealed a 62% increase in treatment response (final CGI ≤2) for those using SGAs, compared to those receiving placebo [RR 1.62 (95% CI 1.44-1.81)]. The combined SMD for the SGAs was -0.43 (IC 95% -0.49 to -0.37). CONCLUSION: Second-generation antidepressants are efficacious treatment for patients with SAD. However, our results do not suggest differences of efficacy among different drugs.

EEG frontal asymmetry in the depressed and remitted elderly: is it related to the trait or to the state of depression?

BACKGROUND: Over the last 30 years, frontal EEG asymmetry has been investigated with regards to the study of emotion, motivation, and psychopathology. METHOD: We analyzed the frontal alpha asymmetry, depressive symptoms with a Beck Depression Inventory (BDI) and quality of life with a Short Form Health Survey-36® (SF-36®) in depressed (n=12), remitted (n=8) and non-depressed (n=7) elderly subjects. We also evaluated the correlation between the frontal EEG asymmetry and physical and mental aspects of SF-36®. RESULTS: The groups showed no difference regarding the frontal alpha asymmetry (F=0.37; p=0.69). Moreover, there was no significant correlation between frontal asymmetry and quality of life (mental and physical aspects). CONCLUSION: The results showed no evidence of a relationship between frontal asymmetry, quality of life and depression in the elderly. Future studies on frontal asymmetry should carefully consider the effects of age.

Efficacy and safety of electroconvulsive therapy in the treatment of bipolar disorder: a systematic review.

OBJECTIVES: : To evaluate the efficacy and safety of electroconvulsive therapy (ECT) in bipolar disorder (BPD). METHODS: : Clinical trials on the treatment of BPD with ECT were systematically reviewed. A comprehensive search of MEDLINE, PsycINFO, and ISI Web of Science databases was conducted in March 2010. RESULTS: : A total of 51 articles met our selection criteria. Only 3 controlled or comparative prospective trials addressed the treatment of mania with ECT. In these studies, which had small samples, ECT was superior to simulated ECT, lithium, or the combination of lithium and haloperidol. We did not find any controlled or comparative prospective trial on the efficacy of ECT in bipolar depression. In the 4 retrospective studies that compared ECT with antidepressants, no difference was observed between them. In 9 of 10 trials that compared bipolar with unipolar depressed patients, ECT was equally efficacious for both groups of patients. Of the 6 studies of patients with BPD that performed a comparison between pre-ECT versus post-ECT, only 1 study showed a worsening in cognition after the treatment. CONCLUSIONS: : There are no studies with adequate methodology on the treatment of BPD with ECT. The lack of scientific evidence contrasts with broad anecdotal clinical experience that suggests that ECT is an important tool in the treatment of BPD, especially in more severe or refractory cases. The marked stigma associated with ECT and the lack of large financial support may account for the paucity of ECT research.

Quality of life and symptom dimensions of patients with obsessive-compulsive disorder.

The aim of this study was to evaluate the impact of different dimensions of obsessive-compulsive symptoms, of co-morbid anxious depressive symptoms, and of sociodemographic characteristics on the quality of life of patients with obsessive-compulsive disorder (OCD). We evaluated 53 patients with OCD and 53 age- and gender-matched individuals from the community with a sociodemographic questionnaire, the Structured Clinical Interview for the Diagnosis of Diagnostic and Statistical Manual of Mental Disorders, fourth Edition, (DSM-IV), the Short-Form Health Survey-36 (SF-36), the Saving Inventory-Revised, the Obsessive-Compulsive Inventory-Revised, the Beck Depression Inventory and the Beck Anxiety Inventory. A series of stepwise linear regression analyses were performed, having the SF-36 dimensions as the dependent variables and the sociodemographic and clinical features as the independent ones. Patients with OCD displayed significantly lower levels of quality of life in all dimensions measured by the SF-36, except bodily pain. A model that included depressive symptoms, hoarding and employment status predicted 62% of the variance of the social functioning dimension of the quality of life of patients with OCD. Washing symptoms explained 31% of the variance of limitation due to physical health problems. Further, a series of models that included depressive, but not obsessive-compulsive symptoms, explained the remaining SF-36 dimensions. The severity of depressive and anxiety symptoms seems, therefore, to be powerful determinants of the level of quality of life in patients with OCD.

Tapering clonazepam in patients with panic disorder after at least 3 years of treatment.

High-potency benzodiazepines, such as clonazepam, are frequently used in the treatment of panic disorder (PD) because of their rapid onset of action and good tolerability. However, there is concern about their potential to cause withdrawal symptoms. We aimed to develop a protocol for safely tapering off clonazepam in patients with PD who had been receiving treatment for at least 3 years. A specific scale for judging withdrawal was also developed, the Composite Benzodiazepine Discontinuation Symptom Scale. We selected 73 patients with PD who had been asymptomatic for at least 1 year and who wished to discontinue the medication. The trial consisted of a 4-month period of tapering and an 8-month follow-up period. The dosage of clonazepam was decreased by 0.5 mg per 2-week period until 1 mg per day was reached, followed by a decrease of 0.25 mg per week. The mean dosage at the start of tapering was 2.7 +/- 1.2 mg/d. In total, 51 (68.9%) of the patients were free of the medication after the 4 months of tapering according to the protocol, and 19 (26.0%) of the patients needed another 3 months to be free of medication. Clonazepam discontinuation symptoms were mostly mild and included mainly: anxiety, shaking/trembling/tremor, nausea/vomiting, insomnia/nightmares, excessive sweating, tachycardia/palpitations, headache, weakness, and muscle aches. The improvement in PD and general well-being was maintained during both the taper and follow-up phases. Clonazepam can be successfully discontinued without any major withdrawal symptoms if the dose is reduced gradually. We recommend reducing the dosage of clonazepam after intermediate-term use by 0.25 mg/wk.

The Brazilian Portuguese version of the Saving Inventory-Revised: internal consistency, test-retest reliability, and validity of a questionnaire to assess hoarding.

Pathological hoarding results in clutter that precludes normal activities and creates distress or dysfunction. It may lead to an inability to complete household functions, health problems, social withdrawal, and even death. The aim of this study was to describe the validation of the Brazilian version of the hoarding assessment instrument, the Saving Inventory-Revised. Sixty-five patients with obsessive-compulsive disorder (OCD) and 70 individuals from the community were assessed using the Structured Clinical Interview for the Diagnosis of DSM-IV (clinical sample), the Saving Inventory-Revised, the Obsessive-Compulsive Inventory-Revised, the Beck Depression Inventory, and the Beck Anxiety Inventory. The Brazilian version of the Saving Inventory-Revised exhibited high internal consistency (Cronbach's alpha = .94 for OCD and .84 for controls), high to moderate test-retest reliability and, using the hoarding dimension of the Obsessive-Compulsive Inventory-Revised as a reference point, high to moderate convergent validity. The Saving Inventory-Revised total scores also correlated significantly with comorbid anxiety and depressive symptoms.

Double-blind comparison of 30 and 60 mg tranylcypromine daily in patients with panic disorder comorbid with social anxiety disorder.

Our objective was to explore the dose-response relationship in patients with panic disorder and social anxiety disorder comorbidity (DSM-IV). After 1 week of no-drug washout, 36 such patients were assigned to a double-blind controlled comparison of the effects of 30 mg and 60 mg of tranylcypromine, and were followed up for 12 weeks. The main instrument used to measure the number of panic attacks was the Sheehan Panic and Anticipatory Anxiety Scale. The primary outcome measure for social anxiety disorder symptoms was the mean change from baseline in the Liebowitz Social Anxiety Scale (LSAS). After 12 weeks of treatment, panic attacks were reduced 69.6% from baseline in the 30-mg group (n=19) compared with a 74.8% reduction in the 60-mg group (n=17). Twelve patients (70.6%) of the higher dose group and 14 patients (68.4%) of the lower dose were completely free of panic attacks. There was no difference in efficacy between the tranylcypromine groups in the panic disorder symptoms. The 60-mg dose was more efficacious as measured by the LSAS scores, showing a significant difference in relation to the lower group. Mean change from baseline in LSAS total score (mean+/-SD) for 30-mg group was 17.9+/-14.7 and for the 60-mg group was 35.0+/-14.8. The social anxiety symptom scale showed a two-fold greater change with the 60-mg dose, and the 30-mg dose group could be considered the equivalent of a placebo control group. Tranylcypromine--60 mg daily--was found effective in the treatment of panic disorder and social anxiety disorder comorbidity.

A five year follow-up study of 11 patients with bipolar disorder / Seguimento de 11 pacientes com transtorno bipolar por cinco anos

OBJECTIVE: To study the long-term follow-up of patients with bipolar disorder (BPD). METHOD: Eleven outpatients with BPD type I were followed up naturalistically for five years at a university teaching hospital. The Clinical Global Impression Scale (BPD version) was used to evaluate the occurrence of affective episodes, and the Strauss-Carpenter Outcome Scale was used to evaluate social and occupational functioning. RESULTS: The majority of patients were symptomatic most of the time, with predominantly depressive episodes. Overall, patients remained euthymic a mean of 47.7 percent of the time. Despite a low rate of hospitalization, social and occupational functioning was poor in the majority of patients. A poor disease course with respect to work-related functioning was associated with fewer months of euthymia with a longer duration of depressive episodes. The total number of months of euthymia negatively correlated with the patient's age and disease duration. CONCLUSION: Despite the small sample size, the present findings appear to corroborate previous studies on the evolution of BPD. Most of the patients had a poor disease course, with long symptomatic periods, particularly depressive episodes, and significantly impaired social and occupational functioning.

OBJETIVO: Estudar a evolução de longo prazo do transtorno bipolar (TB). MÉTODO: Onze pacientes com TB do tipo I foram acompanhados de forma naturalística em um ambulatório universitário por cinco anos. Foram utilizadas a Escala de Impressão Clínica Global (versão TB), para a avaliação dos episódios afetivos, e a Escala de Evolução Strauss-Carpenter, para a avaliação do funcionamento sócio-ocupacional. RESULTADOS: A maioria dos pacientes esteve sintomática a maior parte do tempo, apresentando predominantemente quadros depressivos. Em média, os pacientes ficaram em eutimia durante 47,7 por cento do tempo. Apesar do baixo índice de hospitalização, a maioria dos pacientes apresentou funcionamento deficiente quanto às atividades sociais e ocupacionais. Pior evolução quanto à vida ocupacional foi associada a menor número de meses em eutimia e a maior duração dos episódios depressivos. O número total de meses em eutimia se correlacionou negativamente com a idade e a duração da doença. CONCLUSÃO: Apesar do tamanho reduzido da amostra, nossos resultados parecem corroborar os da literatura. A maioria dos pacientes apresentou evolução desfavorável, com longos períodos sintomáticos, especialmente com episódios depressivos, e importante comprometimento sócio-ocupacional.

Eficácia do tratamento cognitivo e/ou comportamental para o transtorno de ansiedade social / Effectiveness of cognitive and/or behavioral therapy for social anxiety disorder

INTRODUÇÃO: Avaliar a eficácia do tratamento cognitivo e/ou comportamental no transtorno de ansiedade social quando comparado a outras intervenções terapêuticas, incluindo farmacoterapia. MÉTODO: Realizamos análise sistemática de todos os ensaios clínicos controlados randomizados envolvendo terapia cognitiva e/ou comportamental versus outras formas de tratamento, publicados até março de 2009, indexados nas seguintes bases de dados: MEDLINE, PsycINFO, Registro Cochrane de Ensaios Controlados, LILACS e ISI/Web of Science. RESULTADOS: Os estudos avaliados não demonstraram diferenças significativas entre a terapia cognitiva e/ou comportamental e a farmacoterapia. Esses tratamentos combinados não apresentaram maior eficácia do que as intervenções isoladamente. Quando comparada ao grupo controle, a terapia cognitiva e/ou comportamental é eficaz na redução dos sintomas de ansiedade social, tanto no seu formato padrão quanto nas novas formas de intervenção. A exceção foi o treino em habilidades sociais, que, isoladamente, não se mostrou eficaz. A terapia cognitiva e/ou comportamental também demonstrou ser superior aos outros tipos de psicoterapias. CONCLUSÃO: A terapia cognitiva e/ou comportamental mostrou-se eficaz na redução da ansiedade social em pacientes com transtorno de ansiedade social. No entanto, a heterogeneidade dos estudos avaliados, seja no que diz respeito a aspectos envolvendo o tratamento (duração do tratamento e protocolos utilizados) ou os pacientes avaliados (gravidade e forma de recrutamento), dificultaram a comparação dos resultados. Novos estudos de tratamento cognitivo e/ou comportamental e novas revisões envolvendo essas abordagens são necessários para melhor avaliação de nossos achados.

INTRODUCTION: To ascertain whether cognitive and/or behavioral treatment of patients with social anxiety disorder is superior in terms of efficacy than other types of therapeutic interventions, including pharmacotherapy. METHODS: Systematic analysis of all randomized clinical trials on cognitive and/or behavioral therapy vs. other forms of treatment, published until March 2009, indexed in the following databases: MEDLINE, PsycINFO, Cochrane Controlled Trials Register, LILACS and ISI Web of Science. RESULTS: The reported results do not suggest significant differences in the efficacy of cognitive and/or behavioral therapy and pharmacotherapy. Such treatments combined did not show higher efficacy than interventions alone. Compared with the control group, cognitive and/or behavioral therapy was superior in reducing social anxiety disorder, either in the classic model or in the newest propositions. The only exception was the social skills training, which was not effective for patients with social anxiety disorder. Cognitive and/or behavioral therapy was also superior to other psychotherapeutic interventions. CONCLUSION: Cognitive and/or behavioral therapy is an effective treatment for patients with social anxiety disorder. However, the heterogeneity of the clinical trials evaluated, with reference to treatment features (time of treatment and different protocols) or characteristics of the patients (severity of their clinical picture and how they were recruited) made comparison of results between different treatments difficult. More research on cognitive and/or behavior treatment and new reviews of these interventions are necessary to better assess our findings.

The diagnoses of schizophrenia, schizoaffective disorder, bipolar disorder and unipolar depression: interrater reliability and congruence between DSM-IV and ICD-10.

BACKGROUND: The present study investigated the interrater reliability of the diagnoses of schizophrenia (SCH), schizoaffective disorder (SAD), bipolar disorder (BPD) and unipolar depression (UPD) according to both DSM-IV and ICD-10, as well as the diagnostic congruence between the two classificatory systems. SAMPLING AND METHODS: Using the Composite International Diagnostic Interview, two trained psychiatrists simultaneously evaluated 100 inpatients and independently assessed the psychiatric diagnoses. The Cohen's kappa coefficient was employed to estimate interrater reliability and diagnostic congruence between DSM-IV and ICD-10. RESULTS: SCH was more frequent according to ICD-10 than DSM-IV criteria. Considering both diagnostic systems, all the four nosological categories, but ICD-10 SAD and DSM-IV UPD, were associated with interrater reliability coefficients above 0.50. The coefficient of the diagnostic congruence between DSM-IV and ICD-10 was inferior to 0.50 only for SAD. BPD was associated with the highest degrees of both interrater reliability and diagnostic congruence. CONCLUSIONS: The lack of an item excluding the occurrence of an affective syndrome among ICD-10 diagnostic criteria for SCH can account for: the larger frequency of SCH according to ICD-10 than DSM-IV; the unsatisfactory interrater reliability for the diagnosis of ICD-10 SAD, and the low diagnostic congruence for SAD.

Volitional disorders: a proposal for DSM-V.

In the DSM-IV-TR, specific impulse control disorders not elsewhere classified (ICD) have been designated following four principles: (1) through the addition of an adjective that emphasizes the aberrant character of an otherwise normal behaviour (e.g., pathological gambling); (2) by means of metaphors (such as in intermittent explosive disorder); (3) according to the presumably quintessential nature of their main signs and symptoms, such as impulsive (e.g., impulse control disorders not elsewhere classified), compulsive (e.g., compulsive shopping), or addictive (e.g., internet addiction); or (4) using Greek suffix mania (e.g., kleptomania, pyromania, and trichotillomania). Given this flagrant inconsistency, we argue that time has come to adopt a less arbitrary way of describing these disorders, at least until it becomes clearer whether they are really impulsive, compulsive or addictive or if the preoccupation with this distinction is valid. In keeping with DSM's emphasis on descriptive phenomenology rather than on unsupported theory, a less biased terminology is in order. Therefore, we would like to suggest: (1) the substitution of the term ICD by the more neutral expression 'volitional disorders not elsewhere classified'; (2) the use of the classical Greek suffix mania, already present in some DSM-IV-TR ICDs, as the main naming principle to be adopted in the DSM-V; and (3) the creation of compulsive, impulsive, and mixed subtypes of the 'volitional disorders not elsewhere classified', since they are beginning to be validated by treatment trials.

Terapias cognitivo-comportamentais, terapias cognitivas e técnicas comportamentais para o transtorno de ansiedade social / Cognitive behavioral-therapies, cognitive therapies and behavioral strategies for the treatment of social anxiety disorder

CONTEXTO: Pacientes com transtorno de ansiedade social respondem de forma distinta a diferentes tipos de terapias cognitivas e/ou comportamentais, o que motiva a avaliação das melhores técnicas para o tratamento desse transtorno. OBJETIVO: Realizar uma revisão sistemática de estudos controlados que avaliaram a eficácia das técnicas cognitivo e/ ou comportamentais na redução do transtorno de ansiedade social. MÉTODO: Análise sistemática de ensaios clínicos randomizados indexados nas seguintes bases de dados: PubMed/MedLine, PsycINFO, Registro Cochrane de Ensaios Controlados, LILACS, ISI/Web of Science e em artigos relacionados. RESULTADOS: Não se encontrou consenso sobre a eficácia da associação da terapia cognitiva com técnicas comportamentais. Novas técnicas (tratamento por realidade virtual, tarefa de casa via computador e autoterapia com assistência terapêutica) demonstraram ser tão eficazes quanto aquelas utilizadas na terapia cognitivo-comportamental (TCC) padrão. A associação da TCC com evitação de comportamentos de segurança e com o treino de habilidades sociais apresentou vantagem adicional em relação ao modelo convencional. Entre as técnicas comportamentais, o treino em tarefa de concentração e a exposição foram as estratégias mais eficazes. O tratamento individual foi mais efetivo do que em grupo e o modelo de sessões semanais foi mais eficaz do que sessões no mínimo quinzenais. CONCLUSÃO: Os estudos avaliados confirmaram que tanto técnicas cognitivas quanto comportamentais (convencionais e inovadoras) são eficazes no tratamento do transtorno de ansiedade social.

BACKGROUND: Patients with social anxiety disorder (SAD) exhibit distinctive patterns of response to different types of cognitive and/or behavioral treatment. Therefore, it is imperative to assess the best techniques used for the treatment of this disorder. OBJECTIVE: The aim of this paper is to perform a systematic review of controlled studies that evaluated the efficacy of cognitive and/or behavioral techniques on the treatment of SAD. METHOD: A systematic analysis of randomized clinical trials indexed in the following databases was made: PubMed/MedLine, PsycINFO, Cochrane Controlled Trials Register, LILACS, ISI Web of Science, and related articles. RESULTS: No consensus on the efficacy of associating cognitive and behavioral therapies was found. Novel techniques (such as virtual reality, bycomputerhomework,and self therapy with therapeuticassistance) werefoundto be as effectiveasstandardcognitivebehavioral therapy (CBT). The association of CBT with the avoidance of safety behaviors, as well as with social skills training was associated with an additional advantage. As for behavioral therapy, focus training and exposure therapy were considered to be the most effective techniques. Further, individual treatment was more effective than group therapy, and weekly sessions were associated with better results than those occurring at least every other week. DISCUSSION: Both cognitive and behavioral (standard and innovative) therapies are effective for treating social phobia.

Diretrizes da World Federation of Societies of Biological Psychiatry (WFSBP) para tratamento biológico de transtornos depressivos unipolares, 1ª parte: tratamento agudo e de continuação do transtorno depressivo maior / World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for biological treatment of unipolar depressive disorders, part 1: acute and continuation treatment of major depressive disorder

Estas diretrizes práticas para o tratamento biológico de transtornos depressivos unipolares foram desenvolvidas por uma Força-Tarefa internacional da Federação Mundial de Sociedades de Psiquiatria Biológica (WFSBP). O objetivo ao desenvolver tais diretrizes foi rever sistematicamente todas as evidências existentes referentes ao tratamento de transtornos depressivos unipolares e produzir uma série de recomendações práticas com significado clínico e científico, baseadas nas evidências existentes. Têm como objetivo seu uso por todos os médicos que atendam e tratem pacientes com essas afecções. Os dados usados para o desenvolvimento das diretrizes foram extraídos primariamente de várias diretrizes e painéis nacionais de tratamento para transtornos depressivos, bem como de metanálises e revisões sobre a eficácia dos antidepressivos e outras intervenções de tratamento biológico identificadas por uma busca no banco de dados MEDLINE e Cochrane Library. A literatura identificada foi avaliada quanto à força das evidências sobre sua eficácia e, então, categorizada em quatro níveis de evidências (A a D). Esta primeira parte das diretrizes abrange definição, classificação, epidemiologia e evolução dos transtornos depressivos unipolares, bem como tratamento das fases aguda e de manutenção. As diretrizes se referem primariamente ao tratamento biológico (incluindo antidepressivos, outros medicamentos psicofarmacológicos e hormonais, eletroconvulsoterapia, fototerapia, estratégias terapêuticas complementares e novas) de adultos jovens e também, embora em menor grau, de crianças, adolescentes e adultos idosos.

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.

Diretrizes da World Federation of Societies of Biological Psychiatry (WFSBP) para tratamento biológico de transtornos depressivos unipolares, 2ª parte: tratamento de manutenção do transtorno depressivo maior e tratamento dos transtornos depressivos crônicos e das depressões subliminares / World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for biological treatment of unipolar depressive disorders, part 2: maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions

Estas diretrizes práticas para o tratamento biológico de transtornos depressivos unipolares foram desenvolvidas por uma Força-Tarefa internacional da Federação Mundial de Sociedades de Psiquiatria Biológica (WFSBP). O objetivo ao desenvolver tais diretrizes foi rever sistematicamente todas as evidências existentes referentes ao tratamento de transtornos depressivos unipolares e produzir uma série de recomendações práticas com significado clínico e científico, baseadas nas evidências existentes. Têm como objetivo seu uso por todos os médicos que atendam e tratem pacientes com essas afecções. Os dados usados para o desenvolvimento das diretrizes foram extraídos primariamente de várias diretrizes e painéis nacionais de tratamento para transtornos depressivos, bem como de metanálises e revisões sobre a eficácia dos antidepressivos e outras intervenções de tratamento biológico identificadas por uma busca no banco de dados MEDLINE e Cochrane Library. A literatura identificada foi avaliada quanto à força das evidências sobre sua eficácia e, então, categorizada em quatro níveis de evidências (A a D). Esta primeira parte das diretrizes abrange definição, classificação, epidemiologia e evolução dos transtornos depressivos unipolares, bem como tratamento das fases aguda e de manutenção. As diretrizes se referem primariamente ao tratamento biológico (incluindo antidepressivos, outros medicamentos psicofarmacológicos e hormonais, eletroconvulsoterapia, fototerapia, estratégias terapêuticas complementares e novas) de adultos jovens e também, embora em menor grau, de crianças, adolescentes e adultos idosos.

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of the complete spectrum of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). The first part of these WFSBP guidelines on unipolar depressive disorders covered the acute and continuation treatment of major depressive disorder (Bauer et al., 2002). This second part of the guidelines covers the management of the maintenance-phase treatment of major depressive disorder, as well as the treatment of chronic and subthreshold depressive disorders (dysthymic disorder, double depression, minor depressive disorder and recurrent brief depression). These guidelines are primarily concerned with thebiological treatment (including antidepressants, lithium, other psychopharmacological and hormonal medications, and electroconvulsive therapy) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.