Ansiedade em transgêneros acompanhados em um ambulatório de sexualidade maranhense / Anxiety in transgenders accompanied in a maranhão sexuality outpatient clinic / Ansiedad en transgéneros acompañada de una ambulatoria de sexualidad maranhena

O objetivo deste estudo foi avaliar os sintomas ansiosos em indivíduos transexuais atendidos em um ambulatório de gênero e sexualidade. Caracteriza-se como um estudo descritivo, de corte transversal e abordagem quantitativa, adotando amostra por conveniência (n=46). Foi realizado nas dependências de um Hospital Universitário Nordestino mediante aplicação do Inventário de Ansiedade de Beck (BAI) e formulário sociodemográfico, os dados coletados foram trabalhados no EpiInfo. Os resultados revelaram trans em sua maioria jovens, de cor parda, solteiros, com ensino médio completo, estudantes, residiam com pais e/ou parentes, não religiosos, e metade com vínculo empregatício. A ansiedade leve esteve presente em 21,7% e mínima em 34,8% dos pacientes, enquanto, a moderada em 28,3% e a grave 15,2%. Identificou-se relevância estatística na associação entre ansiedade e idade (p= 0,0072), e de ansiedade com vínculo empregatício (p=0,0039). Portanto, demonstrou-se que a maioria dos entrevistados apresentaram com menor severidade sintomas ansiosos, podendo ter relação com seu maior grau de instrução, presença de suporte social e presença de vínculo de trabalho.

The objective of this study was to evaluate anxious symptoms in transgender individuals attended in an outpatient clinic of gender and sexuality. It is characterized as a descriptive, cross-sectional and quantitative study, adopting a sample for convenience (n=46). It was carried out in the premises of a Northeastern University Hospital by applying the Beck Anxiety Inventory (BAI) and sociodemographic form, the data collected were worked on at EpiInfo. The results revealed that the majority of them were young, of a brown color, single, with a full high school education, students, resided with parents and/or relatives, non-religious, and half with employment. Mild anxiety was present in 21.7% and minimal in 34.8% of the patients, while moderate in 28.3% and severe in 15.2%. Statistical relevance was identified in the association between anxiety and age (p= 0.0072), and anxiety with employment (p=0.0039). Therefore, it was demonstrated that the majority of the interviewees presented with less severity anxious symptoms, which may have a relationship with their higher degree of education, presence of social support and presence of a work bond.

El objetivo de este estudio fue evaluar los síntomas ansiosos en los individuos transgénero atendidos en una clínica ambulatoria de género y sexualidad. Se caracteriza por un enfoque descriptivo, transversal y cuantitativo, tomando una muestra para su conveniencia (n=46). Se realizó en las instalaciones de un Hospital Universitario del Noreste, aplicando el Inventario de Ansiedad Beck (BAI) y el formulario sociodemográfico, los datos recogidos se trabajaron en EpiInfo. Los resultados revelaron transexuales en la mayoría de los jóvenes, de color marrón, solteros, estudiantes de secundaria, que vivían con padres y/o parientes, no religiosos y la mitad con un vínculo laboral. La ansiedad leve fue del 21,7% y mínima del 34,8% de los pacientes, mientras que la moderada fue del 28,3% y la grave del 15,2%. Se identificó la relevancia estadística en la asociación entre ansiedad y edad (p= 0,0072) y ansiedad con relación al empleo (p=0,0039). Por lo tanto, se demostró que la mayoría de los entrevistados presentaban síntomas menos ansiosos, que podían tener relación con su nivel de educación superior, la presencia de apoyo social y la presencia de un vínculo de trabajo.

Analysis of the care provided over a six-month period by the liaison psychiatry unit at a general hospital in Lima, Peru.

INTRODUCTION: Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units. AIM: To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions. METHODS: Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted. RESULTS: In a total of 400 referrals evaluated, the average age was 58 ±â€¯17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety. CONCLUSIONS: The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Caracterización de las atenciones de la unidad de psiquiatría de enlace durante seis meses en un hospital general de Lima, Perú / Analysis of the Care Provided Over a Six-Month Period by the Liaison Psychiatry Unit at a General Hospital in Lima, Peru

Resumen Introducción: La psiquiatría de interconsulta y enlace es un área de la psiquiatría clínica cuya función es que psiquiatras lleven a cabo una serie de actividades dentro de un hospital general. En el contexto internacional, el número de unidades de psiquiatría de enlace se ha incrementado significativamente, situación que está repercutiendo en Perú. Sin embargo, este desarrollo es heterogéneo y desconocido, por lo que se requieren reportes de estudios recientes que revelen las características y los detalles de los servicios de atención clínica de estas unidades. Objetivo: Examinar y reportar las características sociodemográficas y clínicas de los pacientes evaluados en la Unidad de Psiquiatría de Enlace del Hospital Nacional Guillermo Almenara Irigoyen (HNGAI) de Lima, Perú, y analizar la naturaleza de los cuadros sintomáticos y sindrómicos presentes. Métodos: Estudio descriptivo y transversal de las interconsultas recibidas por la Unidad de Psiquiatría de Enlace del HNGAI entre mayo y octubre de 2019; se aplicó un análisis factorial de los síntomas. Resultados: En el total de 400 pacientes vistos en interconsulta, la media de edad fue 58 ± 17,09 arios. El 61,5% eran mujeres. La tasa de derivación fue del 2,73%. El servicio con el mayor número de referencias fue Medicina Interna (13,9%). Los trastornos más frecuentes fueron de naturaleza ansiosa (44%); los síntomas más frecuentes fueron ánimo depresivo (45,3%), insomnio (44,5%) y afecto ansioso (41,3%). Con respecto al tratamiento, el más prescrito fue con antidepresivos (44,3%). El análisis factorial exploratorio de los síntomas mostró 3 factores o componentes sindrómicos importantes: delirio, depresión y ansiedad. Conclusiones: El paciente típico de esta muestra es una mujer al final de su quinta década de vida, con enfermedad médica no psiquiátrica y con evidencia de trastornos ansiosos como diagnóstico principal resultante de la interconsulta psiquiátrica.

ABSTRACT Introduction Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units. Aim To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyze the symptomatic and syndromic nature of the identified conditions. Methods Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted. Results In a total of 400 referrals evaluated, the average age was 58 ± 17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety. Conclusions: The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Desensibilización y reprocesamiento por movimientos oculares (EMDR) para trastornos ansiosos y depresivos en niños y adolescentes: revisión de la evidencia disponible / Eye movement desensitization and reprocessing (EMDR) for anxiety and depressive disorders in children and adolescents: a review of the available literature

Resumen Introducción: la desensibilización y reprocesamiento por movimientos oculares (EMDR) tiene abundante evidencia de eficacia en desórdenes del espectro traumático. Su eficacia en trastornos ansiosos (TA) y depresivos (TD) en niños, niñas y adolescentes ha sido escasamente estudiada. Método: se realizó una revisión narrativa para describir la evidencia disponible sobre eficacia de EMDR en TA y TD en población infantojuvenil. Se buscaron artículos disponibles en PubMed/Medline, SciELO, PsycINFO y Cochrane Library. Se incluyeron todos los artículos primarios y secundarios que evaluaron el efecto de EMDR en TA y TD en población infantojuvenil. Se revisaron sus referencias como segundo método de inclusión. Resultados: se identificaron nueve estudios (cinco en TA y cuatro en TD); tres fueron observacionales y seis experimentales. Todos tuvieron tamaños muestrales reducidos. En TA, los estudios corroboraron la eficacia de EMDR sobre el temor fóbico en fobia a las arañas, pero no sobre la conducta evitativa, donde sería superior la exposición in vivo. Dos series de casos expusieron la utilidad de EMDR en fagogobia y en TA asociados a epilepsia. En TD, EMDR fue eficaz en la reducción de sintomatología depresiva en el contexto del trastorno depresivo mayor, trastorno de estrés agudo y trastornos conductuales. EMDR fue comparable a terapia cognitivo-conductual. Conclusiones: la evidencia corrobora la eficacia de EMDR en TA y TD en niños, niñas y adolescentes. Sin embargo, es muy escasa y cuenta con limitaciones metodológicas. Es necesario realizar estudios experimentales con protocolos estandarizados y especializados de EMDR para TA y TD en población infantojuvenil.

Introduction: Eye movement desensitization and reprocessing (EMDR) has abundant evidence of efficacy in traumatic spectrum disorders. Its efficacy in anxiety disorders (AD) and depressive disorders (DD) in children and adolescents has been scarcely studied. Methods: We conducted a narrative review to describe the available evidence on the efficacy of EMDR in AD and DD in children and adolescents. We searched for articles available in PubMed/Medline, SciELO, PsycInfo and the Cochrane Library. All primary and secondary studies evaluating the effect of EMDR on AD and DD in children and adolescents were included. Their references were reviewed as a second method of inclusion. Results: nine studies were identified (five in AD and four in DD); three were observational and six experimental. All had small sample sizes. In AD, studies corroborated the efficacy of EMDR on phobic fear in spider phobia, but not on avoidance behavior, where in vivo exposure would be superior. Two case series reported the efficacy of EMDR in choking phobia and AD associated with epilepsy. In DD, EMDR was effective in reducing depressive symptomatology in the context of major depressive disorder, acute stress disorder, and conduct disorders. EMDR was comparable to cognitive behavioral therapy. Conclusions: The evidence corroborates the efficacy of EMDR in AD and DD in children and adolescents. However, it is very scarce and has methodological limitations. It is necessary to carry out experimental studies with standardized and specialized EMDR protocols for AD and DD in the child and adolescent population.

Analysis of the Care Provided Over a Six-Month Period by the Liaison Psychiatry Unit at a General Hospital in Lima, Peru. / Caracterización de las atenciones de la unidad de psiquiatría de enlace durante seis meses en un hospital general de Lima, Perú.

INTRODUCTION: Consultation-liaison psychiatry is a branch of clinical psychiatry that enables psychiatrists to carry out a series of activities within a general hospital. The number of liaison psychiatry units around the world has increased significantly, and Peru is no exception. However, this development is heterogeneous and unknown, so recent study reports are required to reveal the characteristics and details of the clinical care services provided by these units. AIM: To describe and report the socio-demographic and clinical characteristics of patients evaluated in the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital in Lima, Peru, and to analyse the symptomatic and syndromic nature of the identified conditions. METHODS: Cross-sectional descriptive study. Referrals to the Liaison Psychiatry Unit of the Guillermo Almenara Irigoyen National Hospital between May and October 2019 were studied, and a factor analysis of the symptoms was conducted. RESULTS: In a total of 400 referrals evaluated, the average age was 58±17.09 years and 61.5% of the patients were women. The rate of psychiatric consultation was 2.73%. Internal medicine (13.9%) was the service that most frequently requested a psychiatric consultation. The disorder most frequently diagnosed was anxiety (44%), and the symptoms most frequently found were depression (45.3%), insomnia (44.5%), and anxiety (41.3%). The most used treatments were antidepressants (44.3%). The exploratory factor analysis of the symptoms showed three syndromic components: delirium, depression, and anxiety. CONCLUSIONS: The typical patient of this sample is a woman in her late 50s, suffering from a non-psychiatric medical illness, and with anxiety disorders as the main diagnosis resulting from the psychiatric consultation.

Actualización en Trastornos Ansiosos en niños y adolescentes: Ansiedad de Separación-Ansiedad Social-Ansiedad Generalizada / Update on anxious disorders in children and adolescents: separation anxiety-social anxiety-generalized anxiety

Resumen: Los trastornos ansiosos en niños y adolescentes tienen una prevalencia de vida de un 15-20%, con una edad promedio de comienzo de 11 años (1). En Chile la prevalencia en la población general es de 8,3 %. Trastorno por Ansiedad de Separación (TAS) 4,8% Ansiedad social (TA social) 3,7% y Ansiedad Generalizada (TAG) 3,2% (2). Es así como TAS, TA social y TAG están dentro de las enfermedades de salud mental más frecuentes en este grupo etario, tienen una menor edad de comienzo que otros trastornos psiquiátricos internalizantes, están asociados con un gran impacto en la funcionalidad y tienden a persistir hacia la adultez (3). Si estos trastornos ocurren en la infancia y/o adolescencia predicen la ocurrencia de otros trastornos en la adultez, como: trastornos ansiosos, del ánimo, abuso de sustancias y conducta disruptiva.TAS, TASocial y TAG constituyen un grupo heterogéneo de trastornos con síntomas que se sobreponen (síntomas somáticos, dificultades para dormir, conductas evitativas), están frecuentemente en comorbilidad y tienen una respuesta positiva al tratamiento con terapia cognitivo conductual y fármacos antidepresivos (3). La detección temprana y el tratamiento de los trastornos ansiosos en niños y adolescentes puede prevenir el impacto sustancial en el desarrollo y la Funcionalidad; el tratamiento precoz también puede prevenir el posterior desarrollo de trastornos psiquiátricos en el adulto (3).

Abstract: Anxiety disorders in children and adolescents have a life prevalence of 15-20%, with an average presentation age of 11 years (1). In Chile the prevalence in the general population is 8.3%; separation anxiety disorder (TAS) 4.8% social anxiety (social TA) 3.7% and generalized anxiety (TAG) 3.2%. (2). TAS, social TA and TAG are within the most common mental health disorders in this age group, have a younger age of onset than other psychiatric disorders, are internalizing disorders, are associated with a major impact on functionality and they tend to persist into adulthood (3). When these disorders appear in childhood or adolescence, they predict the occurrence of other disorders in adulthood, such as: anxiety, mood, substance abuse and disruptive behavior disorders. TAS, social TA and TAG constitute a heterogeneous group of disorders with symptoms that overlap (somatic symptoms, difficulty sleeping and avoidant behavior), they are frequently comorbid and have a positive response to treatment with cognitive behavioral therapy and antidepressant drugs (3). Early detection and treatment of anxious disorders in children and adolescents can prevent the substantial impact on development and functionality; early treatment can also prevent further development of psychiatric disorders in adults (3).

Violencia escolar y su relación con síntomas ansiosos / Bullying and its association with anxiety symptoms

INTRODUCCIÓN: Violencia escolar es la persecución física o psicológica de un alumno o alumna contra otro, convirtiéndolo en víctima de repetidos ataques. Es un importante marcador de riesgo de conductas antisociales futuras, y se relaciona con mayor prevalencia de síntomas ansiosos. OBJETIVO: Establecer si existe asociación entre la presencia de ansiedad patológica y la práctica de violencia escolar. MATERIAL Y MÉTODOS: Estudio descriptivo observacional y transversal. Se estudió a 166 alumnos de cuarto a octavo básico, de un colegio particular subvencionado de la comuna de Lo Barnechea, en Santiago de Chile. De ellos, 77 fueron hombres y 89 mujeres, entre 9 y 16 años. Se aplicó la escala de Autoreporte de Ansiedad para Niños y Adolescentes (AANA) y el cuestionario de Maltrato entre Iguales por Abuso de Poder (MIAP). Además, se recopilaron datos tales como sexo, edad, número de personas que viven en el hogar y si vive o no con sus padres. RESULTADOS: De los estudiantes evaluados, el 46,99 por ciento clasificó como testigo de violencia escolar, 19,28 por ciento víctima, 10,84 por ciento agresor, 10,84 por ciento víctima-agresor, y un 12,05 por ciento no clasificó en ninguna categoría. Se obtuvo un 36,1 por ciento de prevalencia de ansiedad patológica en el total de individuos; un 41,67 por ciento en agresores y 30,61 por ciento en no agresores, con chi-cuadrado P > 0,05.DISCUSIÓN: La prevalencia de ansiedad patológica en agresores de violencia escolar es mayor que en quienes no la practican; sin embargo, esta asociación no llega a valores estadísticamente significativos.

INTRODUCTION: Bullying is the physical or psychological persecution of one student against another, making him a victim of recurrent attacks. It is one of the most important risk markers for future antisocial behavior, which has also been associated with higher prevalence of anxiety symptoms. OBJECTIVE: Establish if there is an association between pathological anxiety and bullying. METHODS: This is a descriptive, observational and transversal study. 166 students from fourth to eight grades were studied from a semi private school from Lo Barnechea, Santiago, Chile. From this population, 77 were male and89 female, between 9 and 16 years old. The Anxiety Scale for Children and Adolescents (AAA) and the Survey of High School Bullying Abuse of Power questionnaires were applied. Also, data such as sex, age, number of people who are living in their homes and whether they live with their parents or not was collected. RESULTS: From the students evaluated, 46.99 percent classified as bullying witnesses, 19.28 percent as victims, 10.84 percent as aggressors, 10.84 percent aggressor-victim and 12.05 percent didn't classify in any category. A 36.1 percent prevalence of pathologic anxiety was obtained from the totality of individuals. In the aggressor category 41.67 percent had pathological anxiety and 30.61 percent in non-aggressors, with a chi-square P > 0.05. DISCUSSION: Prevalence of pathological anxiety is higher in the aggressor than in the non-aggressor group, however this association is statistically non-significant

Autorreporte de Ansiedad en Niños y Adolescentes Chilenos no Consultantes: Análisis de sus Dimensiones / Anxiety self-report on non-consulting chilean children and adolescents: dimensional analysis

Los trastornos ansiosos en la población chilena infantojuvenil son de alta prevalencia y frecuentemente subdiagnosticados. Han existido variados intentos para crear instrumentos que ayuden a su tamizaje, dentro de estos el SCARED es uno de los más utilizados. Para la población hispanoamericana se adaptó este autoreporte de niños y adolescente (AANA) con características psicométricas adecuadas. El objetivo del presente trabajo es analizar la capacidad para discriminar entre Trastorno ansioso y sus distintas dimensiones (pánico/somático, ansiedad de separación, ansiedad generalizada, fobia social y fobia escolar) del AANA en población infantojuvenil chilena no consultante. Los resultados obtenidos mostraron que el instrumento estudiado es capaz de determinar un único constructo (ansiedad) y que los distintos ítems logran determinar las 5 dimensiones encontradas en el estudio original. De acuerdo a los resultados es posible concluir que el AANA es un instrumento adecuado para pesquisar trastornos ansiosos en la población infantojuvenil chilena estudiada. Palabras Claves: Trastornos ansiosos, ansiedad, infantojuvenil, AANA, Análisis factorial exploratorio.

Anxiety disorders in chilean children and adolescents are highly prevalent and often underdiagnosed. Various attempts have been made to design tools which contribute in the screening of these conditions, among these the SCARED is one of the most popular ones. An adaptation of this instrument has been developed for hispanic population, the AANA (anxiety self-report for children and adolescents), which has proven adequate psychometric characteristics. The aim of this article is to analyzethe AANA's discriminant capacity for anxiety disorders and its various dimensions (panic / somatic, separation anxiety, generalized anxiety, social phobia and school phobia) in Chilean non consulting children and adolescents. Our results showed that this instrument was able to determine a single construct (anxiety) and its items succeeded in identifying the 5 dimensions found in the original study. According to these results, we can conclude that the AANA is a suitable instrument for anxiety disorders screening in the chilean child and adolescent population studied. Key words: Anxiety disorders, self-reporting, SCARED, exploratory factor analisys,children and adolescents.

Evaluación de síntomas ansiosos y etnicidad en población escolar de la comuna de San Pedro de Atacama / Assessment of anxiety symptoms and ethnicity in students from the San Pedro de Atacama district

La comuna San Pedro de Atacama (SPA) tiene alta población rural y étnica, grupos vulnerables, según la literatura, a problemas de salud mental. El objetivo de este trabajo es conocer la prevalencia de síntomas ansiosos en escolares e investigar sus diferencias respecto de variables étnicas, de edad y género. Para ello se utilizó la escala de auto reporte de ansiedad para niños y adolescentes (AANA). La muestra quedó constituida por 416 alumnos, de ellos se analizaron 335 escalas, cuya media de edad fue de 10 años. Un 60,3 por ciento obtuvo sobre el punto de corte para sospecha de trastorno de ansiedad. El género femenino tenía mayor sintomatología ansiosa, junto con el grupo etario de 7 a 11 años. No existió diferencias significativas para la variable étnica. Respecto a las subescalas, la distribución etaria de la fobia social fue diferente a lo reportado en la literatura, lo que podría derivar del contexto sociocultural, necesario de investigaren futuros trabajos.

The San Pedro de Atacama (SPA) district has an important number of rural and ethnic population, which according to the literature, is more vulnerable to mental health problems. The aim of this research is to determine the prevalence of anxiety symptoms in school age children and to study its differences in relation to ethnicity, age and gender. The AANA (self report anxiety scale for children and adolescents) was applied in a sample of 416 students, from which 335 questionnaires were analyzed (mean age: 10 years). A 60.3 percent of the students were above the cut point for suspicion of an anxiety disorder. Females had a higher number of symptoms of anxiety, as did the group with ages 7 to 11 years. There were no statistically significant differences for ethnicity. In the subscales, the age distribution for social phobia was found to be different from the one previously reported; this could be explained by the sociocultural context, which remains to be studied in future research.

Desrregulación emocional, ¿una variable del temperamento y desorden ansioso en su esencia? / Emotional dysregulation, a temperamental trait and anxiety disorder in its essence?

La Desrregulación Emocional ha sido propuesta como una entidad nosográfica por su relevancia clínica, al ser un diagnóstico diferencial de una enfermedad bipolar. El objetivo de este trabajo es evaluar, en un grupo de pacientes, la psicopatología de la desrregulación emocional y analizar sus historias del desarrollo. En el presente trabajo se analiza una serie clínica de pacientes, recopilados en el transcurso de 10 años y vistos desde la perspectiva del desarrollo, hecho que está ausente en la bibliografía actual. Postulamos como hechos centrales de esta condición psicopatológica, una variable del temperamento y desde el punto de vista clínico, como un cuadro en esencia, en la línea ansiosa.

Emotional dysregulation has been proposed as a nosographic entity because of its clinical relevance, and as a differential diagnosis of bipolar disorder. The aim of this paper is to evaluate the psychopathological development of a group of child with emotion dysregulation. In this paper, we analyze a clinical series of patients collected over 10 years, seen from the perspective of development, a fact that is absent in the current literature. We can conclude that the emotional dysregulation is a disorder that has, as main features, characteristics of temperament, and is a disorder related with anxiety from the clinical point of view.