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Less is known about the relationship between conduct disorder (CD), callous–unemotional (CU) traits, and positive and negative parenting in youth compared to early childhood. We combined traditional univariate analyses with a novel machine learning classifier (Angle-based Generalized Matrix Learning Vector Quantization) to classify youth (N = 756; 9–18 years) into typically developing (TD) or CD groups with or without elevated CU traits (CD/HCU, CD/LCU, respectively) using youth- and parent-reports of parenting behavior. At the group level, both CD/HCU and CD/LCU were associated with high negative and low positive parenting relative to TD. However, only positive parenting differed between the CD/HCU and CD/LCU groups. In classification analyses, performance was best when distinguishing CD/HCU from TD groups and poorest when distinguishing CD/HCU from CD/LCU groups. Positive and negative parenting were both relevant when distinguishing CD/HCU from TD, negative parenting was most relevant when distinguishing between CD/LCU and TD, and positive parenting was most relevant when distinguishing CD/HCU from CD/LCU groups. These findings suggest that while positive parenting distinguishes between CD/HCU and CD/LCU, negative parenting is associated with both CD subtypes. These results highlight the importance of considering multiple parenting behaviors in CD with varying levels of CU traits in late childhood/adolescence.
Even though the impact of COVID-19 in metropolitan areas has been extensively studied, the geographic spread to smaller cities is also of great concern. We conducted an ecological study aimed at identifying predictors of early introduction, incidence rates of COVID-19 and mortality (up to 8 May 2020) among 604 municipalities in inner São Paulo State, Brazil. Socio-demographic indexes, road distance to the state capital and a classification of regional relevance were included in predictive models for time to COVID-19 introduction (Cox regression), incidence and mortality rates (zero-inflated binomial negative regression). In multivariable analyses, greater demographic density and higher classification of regional relevance were associated with both early introduction and increased rates of COVID-19 incidence and mortality. Other predictive factors varied, but distance from the State Capital (São Paulo City) was negatively associated with time-to-introduction and with incidence rates of COVID-19. Our results reinforce the hypothesis of two patterns of geographical spread of SARS-Cov-2 infection: one that is spatial (from the metropolitan area into the inner state) and another which is hierarchical (from urban centres of regional relevance to smaller and less connected municipalities). Those findings may apply to other settings, especially in developing and highly heterogeneous countries, and point to a potential benefit from strengthening non-pharmaceutical control strategies in areas of greater risk.
This article assesses the nutritional status of Indigenous women from 14 to 49 years of age in Brazil.
Sample size was calculated for each region considering a prevalence of 50 % for all disease outcomes, a relative error of 5 % and a CI of 95 %. In the initial data analysis, the prevalence of excess weight and obesity was calculated according to independent variables. Multivariate multilevel hierarchical analyses were conducted based on a theoretical model of two ranked blocks.
The 2010 Indigenous population in Brazil was 896 000, with approximately 300 Indigenous ethnic groups, making Brazil one of the most ethnically diverse countries in the Americas and the world.
Of the total target sample of 6722 women evaluated by the National Survey, thirty did not participate, 939 were not eligible for analyses due to pregnancy or unknown pregnancy status, and thirty-nine were excluded due to missing anthropometric data.
The evaluation of nutritional status was completed for 5714 non-pregnant women (99·3 % of eligible participants for this outcome). High prevalence rates were encountered for both excess weight (46·2 %) and obesity (15·8 %) among the sampled women. In the multivariate analyses, higher socioeconomic indicators, market-integrated living conditions and less reliance on local food production, as well as increased age and parity were associated with excess weight and obesity.
Results point to distinct patterns of associations between socioeconomic indicators and the occurrence of excess weight and obesity among Indigenous women, which have potentially significant implications from a public policy perspective for Indigenous peoples in Brazil.
Sleep disturbance is recognized as an essential aspect of affective illness.
Multiple lines of evidence suggest that a change in sleep pattern may indicate an imminent mood change. In fact, the impaired sleep can be seen as a sign as well as a cause of manic episodes. Thus, sleep can be a predictor of mania or a marker of response and therapeutic target.
This retrospective study explores the role of insomnia in patients with Affective Bipolar Disorder presenting with current mania or hypomanic episode, based on ICD-10 criteria. It was randomly selected a sample of 61 adults admitted at Psychiatry Department of Hospital de São João between 2005-2007. It was assessed the presence of insomnia before and during the treatment and compared with the duration of the hospitalization, the number of attendances to the Emergency Department and hospitalizations one year after.
Given the importance of insomnia in bipolar illness, appropriate evaluation and management of sleep can be helpful in preventing relapses in this disorder. Therefore sleep improvement in mania may be clinically useful as therapeutic target.
The Human Immunodificiency Virus infects primarily the immune system. However, the infection may also affect the central nervous system, materialising itself, in this particular case, in neurological and neuropsychiatric disturbances.
The authors describe the case of a 48 year-old female patient with bipolar affective disease, identified since she was 21. She has a long history of regular examination in speciality consultations, including several psychiatric hospital stays. More recently, she is conducted to the psychiatric emergency department, being admitted for a maniform state. During the stay her general condition deteriorates progressively, being often taken to the regular emergency department. The serious weight-loss associates itself to altered states of consciousness, ataxia and disartry, as well as diahrrea, fever syndromes and breathing difficulty. As a consequence, the patient stays in bed. Despite several diagnosed infections and the histologic result of the cervical cancer biopsy, requested in an ambulatory regime (“lymphoproliferative disease involving the cervix”), she is always conducted to the psychiatric ward. She is admitted in the medicine ward only a month later and is, afterwards, transferred to the infectious diseases ward, with the aim of studying the neuropsychiatric condition in connection with the HIV/AIDS infection.
The authors come to the conclusion that, it is rather important that the anti-HIV antibodies research is included in the routines of complementary diagnosis examinations requested by psychiatrists.
They also reflect about the little relevance that other medicine areas give to the physical diseases of the psychiatric patients, weakening them even more.
The goal of the authors is to stimulate reflection on the distribution in continuum of compulsive and impulsive behaviours and highlight how important it is to constantly question psychiatric diagnoses, to avoid running the risk of dangerous categorisations.
They describe the case of a 31 year-old patient who attended the Emergency department of Coimbra University Hospitals complaining of depression and obsessive-compulsive symptoms that interfered with his daily life and with his sleep. He said that he used to attend psychiatry appointments and that he was “antisocial”, but added: “I'm as impulsive as much as I'm emotional”.
The patient's records show that he was always diagnosed with antisocial personality disorder, established by the first consultant he saw,specifically mentioning: “problems obeying rules”, “impulsiveness”, “getting into fights and brawls entailing legal action” with the obsessive-compulsive symptoms being secondary. However, the follow-up of the patient conduced by me revealed obsessive-compulsive symptoms in special compulsive checking rituals (which began in childhood), excessive concern with the size of his nose (and other parts of the body) that started in adolescence, as well as a personality marked by impulsiveness and a poor frustration tolerance, leading to highly aggressive episodes triggered by events/circumstances that he himself did not regard as particularly relevant. The results of the studies on the relationship between impulsiveness and compulsiveness could have a strong impact on reformulating the psychiatric nosology. Whenever we come across a new patient, as complete a clinical history as possible should be taken and easy diagnoses should be avoided.
In Portugal, Recognition, Validation and Certification of Competences (RVCC) allows adults to achieve recognition of competences acquired by formal and informal learning using a Competences Reference System. By creating a portfolio describing their life story, adults may explore and question their own living experiences.
This communication aims at promoting deep consideration on the importance of an RVCC process in promoting adult mental health. It analyses the relation between mental health and the RVCC process, and its benefits to prevention and rehabilitation. Methods include my experience as a psychologist at a Centra de Novas Oportunidades (New Opportunities Centre) and scientific literature on the subject. Adults are involved in activities which contribute to developing their social competences. They increase self-confidence and self-esteem, control over life choices and accountability for their actions. In Portugal, this process also involves patients with mental disorders and offers appropriate Key Competences Reference Systems. Adults suffering from mental disorder and undergoing a RVCC process re-establish their self-confidence, self-esteem, self-efficacy and gain a positive hope for the future. Empowerment leads them to cooperate more actively with mental health professionals in their own treatment and rehabilitation plan.
Despite being highly criticized as a system which only validates competences, such criticisms to this process are clearly reductive.
Combination therapy of peginterferon and ribavirin for HCV has been recommended as a first choice for chronic hepatitis C. INF therapy has been associated with various IFN-related adverse events, such as psychological disturbances. Beyond that preexisting mental disorders are considered risk factors for INF-alfa-induced severe psychiatric side effects such as depression and/or suicidality, consequently many of these patients remain untreated even tough they fulfil the medical criteria for antiviral treatment of chronic hepatitis C.
The authors relate the case of a patient, 56 year's old, sent to infecciology consultation because she had alterations in abnormal liver function tests. She had a previous history of mental disorder with neurotic personality traits and she was treated with psychiatric medication.
She had treatment for chronic hepatitis C with peginterferon and ribavirin as well psychiatric and psychotherapeutic support.
A low sustained virologic response was obtained however the depressive picture has been difficult to handle so she had had already had a psychiatric hospitalization. There were several adverse life events that can not be forgotten as they certainly trigger and exacerbate the depressive symptomatology.
We assume that psychiatric patients have more depressive symptoms before and during treatment compared with patients without no psychiatric history. This shows that this patients have an increase need for treatment with antidepressants and that a close cooperation with a psychiatrist is always needed.
Symptomatic neurosyphilis in immunocompetent patients is nowadays a rare diagnosis. Yet, if not properly diagnosed and treated, consequences for the patient's health are severe. Known as “the great imitator”, its detection involves both a high degree of suspicion and adequate diagnostic tests. Psychiatric symptoms are often the presenting symptoms of this illness.
The authors report four cases of neurosyphilis with psychiatric symptoms (general paresis) in immunocompetent patients. all four patients were initially referred for observation by a psychiatrist in the emergency room. Special diagnostic features of each case and potential diagnostic pitfalls are highlighted.
To raise awareness to the importance of this rare but highly disabling disease.
Review of clinical records and complementary exams.
All patients were male, two Caucasian and two African Black, with ages ranging from 41–56 years old. Clinical presentations were quite distinct, showing the symptomatic heterogeneity of paretic neurosyphilis. Blood VDRL test was negative in one case, CSF VDRL was negative in another case. TPHA was always positive in blood and CSF. White cell count and protein quantification in the CSF remains important to confirm diagnosis.
Current prevalence of symptomatic neurosyphilis in Western Europe is unknown. Atypical cases presenting with heterogeneous psychiatric and neurologic symptoms, with no previous history of mental illness, should undergo blood VDRL testing, and specific blood treponemal testing should be considered in specific situations. A high index of clinical suspicion is needed. Confirmation of diagnosis is only possible through further CSF analysis.
There is robust evidence recommending electroconvulsive therapy (ECT) in treating severe acute affective disorders. The clinical use of bitemporal electrode placement is still favoured to unilateral placement with just a relative disadvantage in cognitive side effects. Recently, bifrontal placement has gained popularity but there is still limited evidence on its relative benefits.
Compare bitemporal and bifrontal ECT efficacy in patients with pharmacologically resistant affective disorders, based on the number of acute phase treatments required to reach symptomatic remission.
Review of all patients' charts submitted to acute phase ECT, between June 2006 and June 2011. A total of 70 ECT treatment courses performed in a group of 67 patients met inclusion criteria. Thirty-eight of the total 70 courses received bitemporal ECT, and 32 received bifrontal ECT. A statistical analysis was performed. An attempt to use t-test was foiled due to breach of population variance homogeneity (p = 0,021). The non-parametric Mann-Whitney test was the alternative choice (M-W = 534;p = 0,377).
Bitemporal and bifrontal groups matched for age and sex. Bitemporal patients received on average five ECT treatments, while the average of bifrontal treatments to remission was six, but this difference was not statistically significant (p > 0.05).
Our results showed that bitemporal and bifrontal placements are equally effective. According to the largest randomised controlled trial conducted on ECT in depressive illness (Kellner et al,2010), bitemporal placement led to a faster rate of improvement. Additional studies and larger samples are required to understand if bifrontal placement's efficacy and cognitive advantages justify its popularity.
Self-harm is a major public health problem, being a frequent condition among youth and young adults. Psychiatric conditions, like borderline personality, depression, substance misuse and anxiety disorders, are commonly associated with self-harm. The effects of media and contagion are also important and the internet has an important role in divulging and sharing self-harm behaviors.
We pretend to study the role the internet in potentiating or preventing self-harm behaviors.
We used combined literature searches in PubMed and B-on using the terms “self-harm”, “self injury”, “self mutilation” and “internet” and we also present a clinical case from our service.
Most of the individuals that have self-harm behaviors may never present in psychiatric ward. Today, there is more information about self-harm available to the public domain than ever and web sites about self-harm include personal pages, forums, blogs, communities and even video-sharing sites. These web sites have supportive content that allow the users feeling that they are not alone, sharing feelings and narratives. However, most of them have potentially harmful material, including self-injury related tips, reinforcing messages and triggering material, normalizing or even glamorizing self-injury.
Most of the websites normalize and promote self-harm behaviors. Only the better knowledge of these phenomena would allow the use of internet as an effective tool for self-harm prevention, especially for socially-isolated and vulnerable individuals.
Executive functions (EF) are associated to frontal lobes and cognitive decline (CD) with worse results on EF tests.
Analyze if the Frontal Assessment Battery/FAB assessing EF discriminates elders with CD (vs. with no CD; Montreal Cognitive Assessment/MoCA), and if the results obtained with the Rey Osterreith Complex Figure Test/ROCF (copy's quality, immediate, and delayed memory) are associated with the CD presence/absence. Moreover, we wanted to assess if copy's quality and 3 minutes memory test are associated with FAB results, since these two tests are supposedly associated with EF and with frontal lobes assessed by the FAB, contrarily to the 20 minutes memory (supposedly related to the temporal area).
556 institutionalized elders (age: M ± SD =80.2 ± 5.23; range=60-100) filled in voluntarily a sociodemographic questionnaire, ROCF, MoCA and FAB.
FAB and all ROCF tests were associated with the absence/presence of CD. Regarding variables stratified by age and education, FAB was associated with immediate memory but not with copy's quality nor with delayed memory. With no stratified ROCF and FAB, correlations confirmed the previous associations, but also between FAB and copy's quality.
Results follow the literature regarding the association between immediate memory and EF (associated to frontal lobes), in contrast to the long-term memory which is associated with the temporal area and that was not associated with FAB. Results concerning copy's quality (ROCF) are not consensual.
Beginning with classic Hollywood melodramas of the1940s, cinema has maintained a prolific output of films with their own take on mental illnesses – none more so than the rare syndrome of Dissociative Identity Disorder (DID). The DSM-5 provides criteria to diagnose dissociative identity disorder, 'two or more distinct identities or personality states are present, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self”, is the main one.
A brief description and discussion about the controversies surrounding the diagnosis and approaches to treatment of Dissociative Identity Disorder are presented, followed by a reflection about the use of this disorder in cinema.
A non-systematic literature review was performed in PubMed, about Dissociative Identity Disorder. Only original articles in English language were included. An informal search about films contemplating DID and their plot was also conducted.
Clinical findings suggest that DID involves an authentic mental disorder related to factors as traumatization and disrupted attachment. A competing view indicates that DID is due to fantasy proneness, suggestibility and role-playing. As patients tend to switch personality states when there is a perceived psychosocial threat, the treatment goal is the fusion of the personality states while retaining the entire range of experiences contained in all of the alters. DID representations in cinema correspond closely to contemporary thinking about its phenomenology and aetiology.
Art imitates Life, but sometimes Life can fake the Art…DID may have had its turn…
Schizophrenia is a chronic syndrome of unknown etiology, predominantly defined by signs of psychosis. Over the years, schizophrenia is speculated to be associated with immune or inflammatory reactions mediated by cytokines. It is proposed that chronic inflammation might damage the micro-vascular system of brain and hamper cerebral blood flow. Lupus Erythematosus is an autoimmune disease with multiple manifestations in several organs and systems.
Aims and methods
To review the Inflammatory Hypothesis of Schizophrenia though the study of a case report.
We present a case of a 33-years-old with the diagnosis of Lupus Discoid since 17-years-old and with episodic psychotic symptoms developed within 2 years of the diagnosis of the autoimmune disease. He was admitted in our inpatient unit. Neuroimaging and laboratory tests were done in the inpatient unit without significant alterations. He was treated with Olanzapine, Quetiapine and Haloperidol with improvement of the psychotic symptoms and without important side effects. At the time of hospital discharge, psychotic symptoms had almost disappeared and no behavioral disorder was observed.
The comorbility between Schizophrenia and Autoimmune Diseases seems much more common than previously thought. Even when the autoimmune process does not seem to be the direct cause of the psychosis, the inflammatory setting may be considered an important further piece in the puzzle in a genetic-environmental diathesis model.
The co-occurrence of mania and delirium, named “delirious mania”, is an under-recognized entity not listed in major diagnostic classifications. Literature about this syndrome is still scarce and lacking evidence. Usually, reports of affective syndromes with delirium tend to be subdued in the manic descriptor
We report the case of a 44 year old female patient with a simultaneous affective episode and delirium.
To demonstrate the co-occurrence of depressive/mixed symptoms and delirium
Review of clinical records and complementary exams.
The patient was admitted after a three week long depressive syndrome with psychomotor agitation, followed by a week-long fluctuating pattern of delirious and mixed affective features. Shortly after admission the patient exhibited a stuporous state, with nocturnal agitation. A fluctuating pattern of symptoms ensued, with disorientation, disorganized behavior, cognitive impairment, anxiety and depressive features. the patient was put on mood stabilizers, antipsychotics and benzodiazepines. She was discharged symptom-free two months later and re-admitted 4 weeks later due to recurrence of symptoms. Electroconvulsive treatment was applied,with quick remission of affective symptoms. Yet, it took another two months until discharge, due to persistent cognitive symptoms. Medical conditions were excluded.
This case shows the simultaneous occurrence of an affective syndrome alongside delirium. the strongest treatment response occurred with ECT. the presence of depressed mood highlights the fact that this syndrome can begin without clear-cut manic symptoms. We suggest that its name should be changed to Delirious Affective Disorder, which might help to avoid misdiagnosis. Persistent cognitive deficits raise some questions in this case.
Bipolar mixed states were systematically described for the first time by Emil Kraepelin. Since then, their high prevalence has been repeatedly recognized, but they still remain poorly understood. These patients appear to be extremely difficult to treat, many being refractory to pharmacological approaches. Clinical experience supports the use of electroconvulsive therapy (ECT) in mixed states, but there is little information on its effectiveness in scientific literature.
Report our experience in using acute phase ECT (aECT) in mixed states.
The authors reviewed the clinical records of all patients submitted to aECT between June 2006 and June 2011. The inclusion criteria were: a) presence of a mixed state according to Akiskal's criteria (Akiskal et al,2005); b) completed treatment course with aECT. The following variables were collected: demographic characteristics, previous response to pharmacotherapy, presence of psychotic symptoms, number of aECT sessions, referral to continuation or maintenance ECT (c/mECT), number of readmissions. Relation between the diagnostics and the number of ECT sessions was validated with Eta-coefficient. Comparison between these two groups was carried out with One-Way-ANOVA.
Eighteen patients met inclusion criteria and were resistant to pharmacotherapy. Eight patients had psychotic features. All patients but one showed a positive clinical response, as documented on CGI. The average number of ECT sessions was five, while the mean of ECT treatments in manic and depressive patients was seven and six respectively. Thirteen patients were scheduled for c/mECT.
Our results confirm the effectiveness of ECT in medication nonresponsive patients experiencing a mixed state.
The majority of the European Countries are facing the challenge to address the very high prevalence of mental disorders with limited mental health resources. Some of them drafted mental health strategies with community based models of care with the aim to give the best care as possible. Mutualista Association is the largest Portuguese mutual association, one of the largest mutual associations in Europe. Is also a reference as an institution in the social economy sector and financial activity in Portugal. The commitment with all the mutual association members brings to the institution importante and unique solidarity values.
The authors reflect about the psychiatric response of the Mutualidade Terras de Santa Maria to the psychiatric community patients attending the Clinic. The project gives “voice” to a vulnerable communitie perceived as a “receptive social environment” and emphasise the need for greater attention to the impacts of context, culture and local resources on people's responses to adversity and illness. They present a social-demographic characterization of the population attended as well as local strategies put in action to the various clinical situations.
The authors highlight the role of potential partnerships such as National Health System and Community Groups that are able to recognize better their communities's needs and assist them in working for improved well-being. Respectful local-global alliances have a key role to play in this process.
The attention deficit is the main symptom of the Attention Deficit Hyperactivity Disorder (ADHD) in adults. This diagnosis is difficult in adults and comorbidity with substance abuse (SA) is high. As ADHD influences negatively the prognosis of the patients with SA, it is important to treat the ADHD in individuals with DS. Furthermore, it is common the use of substances to relieve ADHD and its comorbidities's symptoms.
It is known the paradoxical effect of amphetamines in individuals with ADHD and it was also described with cocaine. This characteristic is an important clinical clue to the diagnosis of ADHD and it is a predictor of a positive response to the therapeutics.
It is intended to approach the issues related to the psycopathology, differential diagnosis, prognostic and therapeutic implications when there is comorbidity between ADHD and SA in the adult.
Therapeutic implications of the comorbidity between ADHD and SA.
Materials and methods
Analyses of a clinical case and a non-systematic review of the literature was made.
A 23-year-old woman, lawyer, has the diagnosis of ADHD since childhood. She regularly used cocaine for the last 2 years, without doing any medication, as she felt quiet, relax and focused, being more productive at work. The treatment with prolonged-release methylphenidate allowed to stop the use of cocaine without a recurrence of cognitive symptoms.
The ADHA is an independent risk factor to the SA; The early detection and treatment of ADHD helps to prevent the substance abuse;
The incidence of depressive symptoms among adolescents has been increasing in the last years and several risk factors have been associated with depression which has become a major public health issue.
Assess the prevalence and determinants of depression in a Portuguese sample of adolescents.
A cross-sectional study was designed with a sample of 447 adolescents aged 12 to 19 years old, attending a public school in S tao, Portugal. A self-administered questionnaire with questions about socio-economic status, risk behaviours and sleep disorders was answered by adolescents. Depressive symptoms were assessed by the Portuguese validated version of the Beck Depression Inventory, and the cut-off point for depression was 13 points. We considered the following global scores: 0-13:minimal depression; 14-19:mild depression; 20-28:moderate depression; and 29-63:severe depression. Prevalence was expressed in proportions and compared by the Chi-square test.
The prevalence of depressive symptoms was 13.2%. According to the severity of depressive symptomatology, the prevalence of minimum, slight and moderate depressive symptoms was 57.4%, 5.4% and 2.3%, respectively. Depression was associated with insomnia (yes, OR=7.9 95%CI=3.1-19.9), residence area (urban, OR=1.4 95%CI=1.1-2.1), father’s educational level (<9yrs, OR=3.4 95%CI=1.1-10.2), alcohol consumption (OR=1.6 95%CI=1.1-2.2), coffee consumption (OR=1.4 95%CI=1.0-1.9) and smoking habits (OR=1.5 95%CI=1.2-1.8).
Adolescents who develop depression are also likely to develop insomnia. Depressive symptoms are associated with sociodemographic variables and addictive habits. Mental health promotion should be considered in school programmes in order to decrease the risk of depression and associated diseases.