El uso combinado de la exposición a realidad virtual en el tratamiento de la agorafobia / The combined use of virtual reality exposure in the treatment of agoraphobia

Introducción. Este estudio compara la eficacia diferencia de tres grupos de tratamiento para la agorafobia: paroxetina en combinación con terapia cognitivo-conductual, paroxetina en combinación con terapia cognitivo-conductual y exposición de realidad virtual, y un grupo sólo con paroxetina. Metodología. Fueron seleccionados 99 pacientes con agorafobia. Ambos grupos de tratamiento combinado recibieron 11 sesiones de terapia cognitivo-conductual y uno de los grupos también fue expuesto a 4 sesiones de tratamiento de realidad virtual. Los tratamientos se aplicaron en sesiones individuales una vez a la semana durante 3 meses. Resultados. Los tres grupos de tratamiento mostraron mejoras estadísticamente significativas. En algunas de las medidas, los grupos de tratamiento combinado mostraron mayores mejoras y el grupo tratado con la exposición de realidad virtual mostró una mayor capacidad de enfrentar los estímulos fóbicos. Conclusiones. Los tratamientos que combinaron terapia psicofarmacológica y psicológica mostraron una mayor eficacia. Aunque el uso de las nuevas tecnologías dio lugar a una mejoría mayor, siguen existiendo problemas relacionados con la adherencia al tratamiento

Introduction. This study compares the differential efficacy of three groups of treatments for agoraphobia: paroxetine combined with cognitive-behavioral therapy, paroxetine combined with cognitive-behavioral therapy and virtual reality exposure, and a group with only paroxetine. Methodology. 99 patients with agoraphobia were finally selected. Both combined treatment groups received 11 sessions of cognitive-behavioral therapy, and one of the groups was also exposed to 4 sessions of virtual reality treatment. Treatments were applied in individual sessions once a week for 3 months. Results. The three treatment groups showed statistically significant improvements. In some measures, combined treatment groups showed greater improvements. The virtual reality exposure group showed greater improvement confronting phobic stimuli. Conclusions. Treatments combining psychopharmacological and psychological therapy showed greater efficacy. Although the use of new technologies led to greater improvement, treatment adherence problems still remain

The combined use of virtual reality exposure in the treatment of agoraphobia.

INTRODUCTION: This study compares the differential efficacy of three groups of treatments for agoraphobia: paroxetine combined with cognitive-behavioral therapy, paroxetine combined with cognitive-behavioral therapy and virtual reality exposure, and a group with only paroxetine. METHODOLOGY: 99 patients with agoraphobia were finally selected. Both combined treatment groups received 11 sessions of cognitive-behavioral therapy, and one of the groups was also exposed to 4 sessions of virtual reality treatment. Treatments were applied in individual sessions once a week for 3 months. RESULTS: The three treatment groups showed statistically significant improvements. In some measures, combined treatment groups showed greater improvements. The virtual reality exposure group showed greater improvement confronting phobic stimuli. CONCLUSIONS: Treatments combining psychopharmacological and psychological therapy showed greater efficacy. Although the use of new technologies led to greater improvement, treatment adherence problems still remain.

Factors associated with hospitalization after suicide spectrum behaviors: results from a multicenter study in Spain.

The objective of this study was to identify factors associated with hospital admission after suicide spectrum behaviors. Patients' characteristics, the nature of the suicidal behavior, admission rates between centers, and factors associated with admission have been examined in suicide spectrum presentations to emergency departments in 3 Spanish cities. The intent of the suicidal behavior had the greatest impact on hospitalization. Older age, living alone, self-harm method not involving drug overdose, previous history of suicide spectrum behaviors, and psychiatric diagnosis of schizophrenia, mood, or personality disorder were independently associated with being admitted. There was a 3-fold between-center difference in the rate of hospitalization. Widespread differences in the rate of hospitalization were primarily accounted for by characteristics of the individual patients and their suicidal behavior.

Beliefs about illness and their relationship with hopelessness, depression, insight and suicide attempts in schizophrenia.

BACKGROUND: Although the negative appraisals of the illness may be related to suicidal thinking and behaviours in schizophrenia, this has been insufficiently studied. The aim of this study was to analyze the relationship between schizophrenic patients' cognitions about their illness and past suicidal behaviours. The relationship between patients' beliefs about their illness with potential mediators of suicidal behaviours such as depressive symptoms, hopelessness and insight was also investigated. SUBJECTS AND METHODS: A group of 60 patients diagnosed with schizophrenia according to ICD-10 criteria belonging to a follow-up study were assessed one year after their last psychiatric admission. Psychopathological variables were assessed by the Calgary Depression Scale, Beck Hopelessness Scale and the first three items of the Scale to Assess Unawareness of Mental Disorder. The appraisals of the illness were assessed by the Personal Beliefs about Illness Questionnaire. RESULTS: Negative appraisals were associated with hopelessness and depressive symptoms. Negative expectations and stigma showed the strongest associations. Contrary to our expectations, this scale was not able to differentiate between patients with and without past suicidal behaviour. CONCLUSIONS: Negative appraisals of the illness in patients with schizophrenia seem to have psychopathological consequences such as greater hopelessness and depression. Since these psychopathological features are linked to suicidal risk, the psychotherapeutic approach counteracting negative beliefs about the illness may reduce the risk of suicide.

Are there subtypes of suicidal schizophrenia? A prospective study.

BACKGROUND: Tragically, suicide is not uncommon in schizophrenia. The principal objective of this study was to examine possible subtypes of suicidal schizophrenic patients and identify their clinical and psychopathological profiles at long-term follow-up. METHOD: The study involved 62 patients diagnosed with schizophrenia according to ICD-10 criteria, who were consecutively admitted following a suicide attempt. Of these subjects, 47 (75.8%) could be re-evaluated after 1 year. Sociodemographic, general clinical, and psychopathological variables were evaluated. RESULTS: Two predominant subgroups were identified according to suicidal motivation: psychotic motivation and depressive motivation. At re-evaluation after 1 year, the depressive motivation subgroup showed higher depression and hopelessness scores. This subgroup also had greater educational level, age, and duration of illness, and more frequent existence of previous suicide attempts compared to the psychotic motivation subgroup. Of note in the psychotic motivation subgroup was the presence of hopelessness. The variables of educational level, duration of illness, and previous suicide attempts were the ones that best distinguished these subgroups. CONCLUSION: These findings reinforce the notion that meaningful subgroups occur among suicidal schizophrenic patients. The different psychopathological profiles of the two prominent subgroups suggest the need for a different management approach in each case. The identification of these profiles in both subtypes at long-term follow-up may facilitate their detection by clinicians and, therefore, foster the adoption of appropriate preventive measures against subsequent suicidal behavior.

Agorafobia (con o sin pánico) y conductas de afrontamiento desadaptativas. Primera parte

resumen está disponible en el texto completo

Abstract: The present paper examines the role of a type of coping strategy used by patients with agoraphobic disorders (AD) when they confront phobic stimuli. This strategy consists in a group of overt behaviors and thoughts (ritual behaviors, frequently) which allow agoraphobic patients (AP) to resist the presence of phobic scenes. Those behaviors function like a partial coping in the sense that they allow initially to confront the phobic stimuli, but later they transform themselves in non-adaptative coping behaviors that limit the therapeutic efficiency. The agoraphobic disorder (AD), with or without panic attack (CIE-10, F 40), is considered the more complex phobia and which produces the highest level of disability. Besides, this phobia, contrary to social or specific phobias, has a pervasive tendency (panphobia), reaching each time more situations and stimuli. The essential clinical aspects include anxiety, sensitivity, emotional responses of fear-anxiety-panic and shame, anticipatory responses, catastrophic thoughts, and avoidance and escape behaviors toward phobic scenes. There is an important volume of research about those clinical aspects. But there are only a few studies about the coping strategies used by AP when they need to resist a phobic situation. Traditionally, coping strategies considered were those used by AP to reduce anxiety and psychological distress: the avoidance behavior (to avoid the phobic stimuli) and the escape behavior (when the phobic stimulus is present). Additionally, it also includes behaviors targeted to avoid the negative physiological responses similar to those occurring in an anxiety crisis (interoceptive avoidance). Nevertheless, some experts have reported that AP used some other coping strategies that allowed them to accomplish partial and temporary confrontations toward phobic elements (elements that they needed to confront). In that sense, some authors have proposed other strategies beyond avoidance and escape behaviors, including those partial coping behaviors in the repertories used by agoraphobic patients. So, there are several classifications that take into account these behaviors, but under different terms: Distractions (thoughts or conducts that relieve anxiety in the presence of phobic stimuli). Calming strategies (behaviors that they use when they need to confront a phobic scenario). Searchingfor company (looking for the company of a relative, friend or pet). Safety behaviors or safety signs (behaviors adopted to limit the level of distress as a consequence of feeling "caught" in a phobic situation). Counter-phobic objects (objects or persons to which patients assign the ability to diminish the distress in the case of crisis). Different experts have denominated these strategies "defensive mechanisms", "useless coping strategies", "partial coping strategies" or "non-adaptative coping behaviors". This kind of behaviors and thoughts can be useful in the short-term, but in the long term they favor the continuity of anxiety and the avoidance cycle. These partial coping strategies allow patients with agoraphobia to confront and to resist the presence of the phobic stimuli, but this is done with a high cost, since the confrontations are only partial (they confront the phobic scenarios in certain contexts and with certain characteristics) and temporary, generalizing the use of these strategies to future confrontations. These strategies provide a certain apparent validity: the person is capable to resist the phobic element (that is not possible with both avoidance and escape strategies). Nevertheless, the information provided by these behaviors acts as a reinforcing mechanism and acquires by itself a value of discriminative stimulus about the circumstances in which are possible for confronting the phobic scenes. The role of these behaviors and thoughts in the development of agoraphobia in a chronic disorder is also evident. In this sense, they play a non-adaptative role. These strategies turn to be the unique ways to confront (some part of) phobic stimuli. Then, they generate a high degree of interference with both adaptive behaviors and thoughts that must be dominant in the therapeutic process. Finally, the partial coping strategies pass from being a resource that allows them to resist the phobic stimuli, to a therapeutic aim that clinicians must reduce and eliminate. Taking into account the state of the question, we propose in this paper a new classification of non-adaptative coping strategies used by agoraphobic patients, for including the partial coping strategies. The parameters for constructing a new taxonomy are three: (i) the coping strategies must be grouped according to its function role (i.e., to avoid anxiety and negative physiological responses, to reduce anxiety if it appears, to confront the stimuli with the lower level of distress). So, we prefer the term behavioral patterns, like a group of behaviors and thoughts which rule similar functions. (ii) The classification has to attend to the nature of behaviors, differentiating between overt (manifest) and covert (cognitive) behaviors. This distinction is elemental from an applied point of view. (iii) The third element is to identify the non-adaptative character of the confrontation behaviors, because they incapacitate and interfere in the normal development of the daily life. Additionally, a terminology question: there is several concepts that are being used in an indistinct manner, such as behavioral patterns, strategies or, even, styles. According to what the agoraphobic patients do (in an overt or covert way), we prefer the term behavior, in the sense that this term emphasizes what the people do (and not what they believe o what they would like to do). According to those three parameters, we propose four behavioral patterns. These behavioral patterns have two versions: overt and covert behavior. The components of each pattern share similar functions and they cover all of those strategies that can be used for persons with agoraphobia for coping with the different phobic scenes. The four behavioral patterns are as follow: Avoidance behaviors. This pattern includes all of those behaviors and thoughts that the agoraphobic patients do to avoid the phobic stimuli. Its function consists in to prevent the anxiety and psychological distress by means of avoidance of phobic elements. Interoceptive avoidance. This pattern refers to all behaviors and thoughts that try to avoid the interoceptive signs (negative physiological responses) similar to those that occur during an agoraphobic crisis. Its function consists to prevent physiological negative states by means of avoidance of those behaviors that can generate those states and can be interpreted like the beginning of a crisis. Escape behaviors. This group of behaviors refers to all behaviors and thoughts that are used to remove the patients from a phobic scene. So, its function consists in to reduce and to eliminate the anxiety states by means to run away from the phobic stimuli. Partial coping behaviors. Finally, this fourth behavioral pattern includes all of those strategies that allow AP to resist the presence of phobic elements. This resistance is doing according to some contexts and according to certain characteristics of those elements. The strategies consist on behaviors and thoughts, such as safety signs, distractions, or rituals that reduce the anxiety to tolerable levels. Its function consists to provide several resources that allow to a person with agoraphobia to cope with a phobic situation. Usually, the anxiety does not disappear, but the psychological distress does not reach disability levels. Frequently, the patients carry out these strategies because they are forced or need it. This approach is discussed according to the utility to take into account these four behavioral patterns, and not only the avoidance and escape behaviors. An special consideration have the partial coping strategies in the extent in which these behavior may suppose a false therapeutic progress, at the time that they turn into a resistant element that interferes with the therapeutic resources.

Evaluación de niños y adolescentes con trastorno por déficit de atención con hiperactividad/trastornos hipercinéticos (TDAH) / Evaluation of children and adolescents with attention deficit/hyperactivity disorders (ADHD)

Según el DSM-IV hay tres tipos de trastorno por déficit de atención con hiperactividad (TDAH): predominantemente inatento, predominantemente hiperactivoimpulsivo, y combinado, que en el CJE-IO se engloban en los Trastornos Hipcrcinéticos. Su evaluación incluye entrevistas clínicas y escalas de puntuación estandarizadas de padres y maestros. Normalmente se requiere realizar una valoración de coeficiente intelectual y de rendimiento académico. Los puntos fundamentales del tratamiento son el apoyo y la educación de los padres, ubicaciones adecuadas en el colegio y la farmacología. Otros tratamientos, tales como la modificación de conducta, la intervención escolar, la terapia familiar y los grupos de psicoterapia permiten abordar síntomas remanentes (AU)

DSM-IV classifies three types of Attention Deficit Hyperactivity Disorder (ADHD): predominantly inattentive type, predominantly hyperactive-impulsive type, and combined type, whereas ICD-1O comprises them as Hyperkinetic Disorders. Assessment includes clinical interviews and standardized rating scales from parents and teachers. Testing of intelligence and academic achievement usually are required. The cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms (AU)

Nuevas perspectivas farmacológicas en el trastorno por déficit de atención/hiperactividad / News pharmacological perspectiva in the treatment of attention déficit/hyperactivity disorders

El Trastorno por Déficit de Atención con Hiperactividad es una patología heterogénea, cuya etiología es sólo parcialmente conocida. Por otra parte, constituye uno de los problemas clínicos y de salud más importantes en niños y adolescentes, debido tanto a su morbilidad como a la incapacidad que conlleva. A pesar de ello, el tratamiento del trastorno con estimulantes presenta una serie de limitaciones en nuestro país, que contrasta con la gran importancia de sus síntomas y de sus consecuencias familiares, sociales, académicas y personales. Hay una cantidad relativamente importante de estudios que documentan la eficacia de nuevos tratamientos, estimulantes de acción prolongada y no estimulantes, en el TDAH, con resultados prometedores. En este artículo se revisan los ensayos más relevantes en este sentido con vistas a evaluar su eficacia e implicaciones clínicas, así como futuras líneas de estudio en este campo (AU)