Brazilian Psychiatric Association treatment guidelines for generalized anxiety disorder: perspectives on pharmacological and psychotherapeutic approaches

Generalized anxiety disorder is a highly prevalent mental disorder. Previous data indicate that more than 18 million Brazilians suffer from this condition. Traditionally, generalized anxiety disorder has been considered a mild mental health disorder, despite its links to lower life expectancy, cardiovascular disease, and suicide. The aim of this article is to combine elements of systematic and critical reviews to produce a synthesis of the best evidence about generalized anxiety disorder treatment. Systematic reviews, meta-analyses, and randomized controlled trials were included. The descriptor used in the search was "generalized anxiety disorder," which resulted in 4,860 articles and seven other studies, of which 59 were selected. Antidepressants and benzodiazepines were indicated, as was pregabalin, and atypical antipsychotics, such as quetiapine, have been studied. Individual cognitive behavior therapy (third wave) has proven effective. There is extensive literature on many effective treatments for generalized anxiety disorder. The present review summarizes the therapeutic possibilities, emphasizing those available in Brazil. Further studies are needed to compare other available medications, assess psychotherapies and new treatments in greater depth, as well as to assess the ideal duration of therapy. Registration number: PROSPERO CRD42021288323.

Multidisciplinary contributions towards an evolutive interpretation of bipolar disorders: could it be the pathological drift of a potentially adaptive condition?

This paper tries to summarize the results of studies from different areas of knowledge supporting the idea that temperamental traits, such as "reckless/hyper-exploratory" attitudes, commonly believed to be associated with psychopathology, surprisingly turn out as adaptive under specific stress conditions. In particular, this paper analyzes an ethologic line of research on primates suggesting models for a sociobiological interpretation of mood disorders in humans; a study that found high frequencies of a genetic variance associated with bipolar disorder in people without bipolar disorder but with hyperactivity/novelty-seeking traits; the outcomes of socio-anthropological-historical surveys on the evolution of mood disorders in Western countries in the last centuries; surveys on changing societies in Africa and African migrants in Sardinia; and studies that found higher frequencies of mania and subthreshold mania among Sardinian immigrants in Latin American megacities. Although it is not unequivocally accepted that the prevalence of mood disorders has increased, it would be logical to suppose that a nonadaptive condition should have disappeared over time; mood disorders, on the contrary, persist and their prevalence might have even increased. This new interpretation could lead to counter discrimination and stigma towards people suffering from the disorder and would be a central point in psychosocial treatments in addition to pharmacological therapy. Our aim is to hypothesize that bipolar disorder, strongly characterized by these traits, may be the result of the interaction between genetic characteristics, not necessarily pathological, and specific environmental conditions rather than a mere product of an aberrant genetic profile. If mood disorders were mere nonadaptive conditions, they would have disappeared over time; however, their prevalence paradoxically persists if not even increases over time. The hypothesis that bipolar disorder may result from the interaction between genetic characteristics, not necessarily pathological, and specific environmental factors seems more credible than considering bipolar disorder as a mere product of an aberrant genetic profile.

Impaired Decision-Making Capacity in the Elderly King David (c. 1040-970 BCE): Was Hypothyroidism the Underlying Cause?

It has been suggested in the medical literature that in the last period of his life King David (c. 1040-970 BCE) suffered from dementia, osteoporosis, hyperparathyroidism, Parkinson's disease, autonomic neuropathy, major depression, and malignancy. The goal of this study was to identify, based on the "Succession Narrative (SN)," a historically objective section of the Old Testament, the clinical syndrome presented by King David and to determine whether an impaired decision making capacity may have been manipulated by his courtiers to influence his succession's politics. The "SN" indicates that besides forgetfulness and trouble in thinking, King David suffered from marked cold intolerance and sexual dysfunction. The symptom triad consisting of cognitive impairment, cold intolerance, and sexual dysfunction is more strongly suggestive of hypothyroidism than of any other diagnoses proposed in the medical literature so far. We hypothesized that hypothyroidism was the underlying cause of the elderly King David's clinical picture and that his sometimes troubled thinking was successfully manipulated by the courtiers to favor his son Solomon's accession to the throne, with profound historical consequences.

Revisão sistemática sobre resolução de problema e mediação de conflito pela terapia cognitivo-comportamental / Systematic review on problem solving and conflict mediation by cognitive-behavioral therapy

RESUMO Objetivo: Na prática clínica, é importante diferenciar problema e conflito, porque os passos sugeridos na técnica de resolução de problemas costumam não ser suficientes para auxiliar o cliente a lidar com conflitos. Esta revisão sistemática teve como objetivos: investigar como a terapia cognitivo-comportamental (TCC) pode auxiliar na resolução de problemas e na mediação de conflito; sugerir uma estratégia que favoreça a melhor capacidade de mediar conflitos (QPD). Métodos: Foi realizada uma busca nas bases de dados: PubMed, PsycINFO, Web of Science (ISI) e Scopus. O método prisma foi utilizado, e foram selecionados para leitura na íntegra artigos experimentais. Resultados: Trezentos e sessenta e quatro ensaios clínicos aplicaram a resolução de problemas, apontando a eficácia dessa técnica juntamente com outras estratégias/intervenções da TCC. Livros-guias de TCC: não diferenciam problema e conflito; descrevem detalhadamente passos para resolução de problemas, focando na perspectiva do cliente, no momento presente e no uso da razão lógica; não abordam a mediação de conflitos pela TCC. Sugerimos uma estratégia que pode ajudar na mediação de conflitos: auxiliando na coleta/organização de informações; melhorando a comunicação - empática e assertiva; favorecendo escolhas com o intuito de causar o menor dano possível a todas as partes envolvidas no conflito. Conclusões: Para treinar terapeutas para aplicarem a resolução de problemas, há descrição detalhada dos passos a serem seguidos. Entretanto, para capacitar os terapeutas para mediarem conflitos, práticas clínicas que têm sido frequentemente descritas/utilizadas nas terapias cognitivas contextuais podem ser necessárias: aceitação psicológica, mindfulness , entender valores individuais, vivenciar/considerar a emoção em tomadas de decisão, ativar a compaixão/autocompaixão.

ABSTRACT Objective: It is important to differentiate between problem and conflict in clinical practice, because the steps suggested in the problem-solving technique are usually not enough to help patients deal with conflicts. This systematic review aimed to: investigate how cognitive-behavioral therapy (CBT) can help in problem solving and conflict mediation; suggest a strategy that can improve conflict mediate skills (QPD). Methods: A search was performed in the following databases: PubMed, PsycINFO, Web of science (ISI) and Scopus. Prisma flow diagram was used and experimental articles were selected for full reading. Results: Three hundred and sixty four clinical trials applied problem solving, showing the effectiveness of this technique with other CBT strategies/interventions. CBT guide books: do not differentiate between problem and conflict; describe in detail problem solving steps, focusing on the customer's perspective, the present moment and the use of logical reason; do not explore conflict mediation in the CBT. We suggest a strategy that can help in the mediation of conflicts: assisting in the collection/organization of information; improving communication - empathic and assertive; favoring choices that can cause the least possible harm to all parties in the conflict. Conclusions: There is detailed description of the steps to train therapists to apply problem solving. However, to improve therapeutic skills to mediate conflicts, clinical practices that have been frequently described/used in the contextual cognitive behavioral therapies may be necessary: psychological acceptance, mindfulness, understanding personal values, experiencing/considering emotion in decision making, activating compassion/self-compassion.

The Effects of Tyrosine Kinase Inhibitors (TKIs) in Monotherapy and with Add-on Treatments on Health-related Quality of Life of People with Chronic Myeloid Leukemia: A Systematic Review of Randomized-Controlled Trials.

Background: The era of establishing tyrosine kinase inhibitors (TKIs) in the treatment of chronic myeloid leukemia (CML) changed the outcome and the course of this life-threatening malignancy. People suffering from CML have now a better prognosis and a longer life expectancy due to the development of TKIs, even if it requires long-term, often lifelong, treatments that are nonetheless associated with improved Health-related Quality of life (HRQoL). However, data on the effects of TKIs on HRQoL are not always systematic; sometimes the data have been obtained by studies different from RCTs, or without a clear definition of what HRQoL is. The main purpose of this systematic review is to summarize all randomized-controlled trials (RCTs) including HRQoL as main or secondary outcome in patients with CML treated with TKIs or with TKIs plus an add-on treatment. Methods: A systematic review has been conducted by searching the relevant papers in PubMed/Medline and Web of Science with the following keywords: "quality of life" OR "health-related quality of life" OR "QoL" OR "HRQoL" OR "H-QoL" AND "chronic myeloid leukemia". Interval was set from January 2000 to December 2020. Results: 40 papers were identified through the search. Out of them, 7 RCTs were included. All the studies used standardized measures to assess HRQoL, even not always specific for CML. 5 RCTs randomized subjects to 2 or 3 arms to evaluate the effects of TKIs of the first, second and third generation in monotherapy. 2 RCTs randomized subjects to TKI therapy plus an add-on treatment versus TKI therapy as usual. The results of all these trials were examined and discussed. Conclusion: All the included RCTs pointed out significant findings regarding the positive effects of TKIs on HRQoL of people with CML, both when they were used in monotherapy or, notably, with an add-on treatment to enhance TKIs effects.

King George III of England and Queen Maria I of Portugal: bipolar disorder and prince regents as common features of their reigns

Abstract Humanity is sporadically subjected to leaders with deviant behavior, ego problems, or psychiatric disorders, potentially leading to social instability. Bipolar disorder is not common in all populations, but, coincidentally, studies suggest that it affected two sovereigns that were contemporaries, King George III of England, who died 201 years ago, and Queen Maria I of Portugal, who died 205 years ago. They lived during a time when Europe was in turmoil with the French Revolution and Napoleonic Wars, which also coincided with the rise of psychiatry. Both monarchs were forced to have prince regents rule in their place, due to their emotional decline, and they shared the same medical consultant, Francis Willis.

Binge Eating and Compulsive Buying During Cabergoline Treatment for Prolactinoma: A Case Report.

Prolactinomas are the most prevalent functional pituitary adenomas. They are usually treated clinically with dopamine agonists. The most widely used and suitable drug is cabergoline (CAB), a specific D2 dopamine agonists. Patients in prolactinoma treatment with CAB commonly report physical side effects, but aberrant behavioral changes such as increased impulsivity have also been reported recently. We report the case of a 47-year-old Brazilian woman with prolactinoma that developed compulsive buying, binge eating, and hypersexuality after four years of CAB treatment. In her psychiatric evaluation, the patient scored high levels on the following scales: Compulsive Buying Scale (CBS), Binge Eating Scale (BES), and Barratt Impulsiveness Scale-11 (BIS11). She also reported financial problems and weight gain in addition to her social and clinical problems. Impulsivity disorders may appear with the use of CAB and other dopamine agonists. We suggest that more observational studies with a large patient sample and specific regular psychiatric evaluations during treatment are necessary for patients in use of CAB, especially those treated for several years.

Dream-Reality confusion: differential psychiatric diagnosis in narcoleptic subjects / Confusão sonho-realidade: diagnóstico psiquiátrico diferencial em narcolépticos

Dream-reality confusion (DRC) is the consequence of hypnagogic content confusion with real events and memories. Narcoleptic subjects eventually have DRC and can be misdiagnosed as schizophrenic or with another disorder with delusional or hallucinatory symptoms. Although dream-related experiences and hallucinatory perception share neurophysiological pathways, they are phenomenologically distinct. The lack of phenomenological intentionality in Dreamrelated perceptions, the different cognitive pathways for delusion generation, and other differences between mental disorders psychopathology, and DRC-related phenomena are here discussed. The lived world and awake experience interpretation, and dream neurobiology in narcoleptic subjects related to DRC, might indicate some hints for the mind-brain gap issue that still exists in neurology and psychiatry.

A confusão entre realidade e sonho (CRS) é a consequência da confusão do conteúdo hipnagógico com eventos e memórias reais. Sujeitos narcolépticos eventualmente têm CRS e podem ser diagnosticados erroneamente como esquizofrênicos ou com outro transtorno com sintomas delirantes ou alucinatórios. Embora as experiências relacionadas ao sonho e à percepção alucinatória compartilhem vias neurofisiológicas, elas são fenomenologicamente distintas. A falta de intencionalidade fenomenológica nas percepções relacionadas ao sonho, as diferentes vias cognitivas para a geração do delírio e outras diferenças entre a psicopatologia dos transtornos mentais e os fenômenos relacionados à CRS são discutidos aqui. A interpretação do mundo vivido e da experiência de vigília, e a neurobiologia dos sonhos em sujeitos narcolépticos relacionados à CRS, podem indicar algumas dicas para a questão do gap mente-cérebro que ainda existe na neurologia e na psiquiatria.

Increased body sway in phobic patients exposed to images of spiders

Objective: The aim of the present study was to analyze the body sway response in specific phobia (SP) patients and healthy controls while viewing neutral, phobic, and disgusting images. Methods: The participants' heart rate (HR) and skin conductance were also recorded during the procedure. Nineteen patients with arachnophobia and 19 healthy volunteers matched by age, gender, and years of education underwent a postural control test on a stabilometric platform. Results: The platform recorded increased body sway in the SP group when exposed to spider images (SPI). The SP group presented increases in most parameters (SD, velocity, frequency, area, p ≤ 0.05) when viewing pictures of the SPI category. Psychometric measures of subjective anxiety (State-Trait Anxiety Inventory, STAI) and physiological states (HR; skin conductance responses; spontaneous fluctuations in skin conductance) showed increased anxiety (p ≤ 0.05) in the SP group compared to healthy volunteers. High anxiety levels were observed throughout the assessment, including the task of exposure to SPI (p ≤ 0.05). No significant effect or correlation was found between skin conductance and body sway measures (p > 0.05). Conclusions: The results of the postural control test suggest the occurrence of a defensive escape response in SP, in agreement with previous evidence.