Attitudes of Medical Students Towards Psychiatry in Venezuela: a 6-Year Longitudinal Study.

OBJECTIVE: The authors evaluated changes in attitude towards psychiatry of medical students in one medical school in Venezuela. METHODS: Balon's modified questionnaire was administered to first and sixth-year medical students to analyze their attitude towards psychiatry. The answers were compared with McNemar's test. RESULTS: The students' negative perception of psychiatry increased by the end of medical school with 45% of sixth-year students reportedly feeling uncomfortable when working with patients with psychiatric illness compared to only 8.3% of first-year medical students. Interest in specializing in psychiatry decreased from 2.6% in first-year medical students to 0% in sixth-year medical students (p=0.001). CONCLUSION: Different factors may lead to the loss of interest in psychiatry of medical students in Venezuela, such as little time spent with patients, being in contact only with patients with psychosis, stigma about psychiatry among medical doctors and friends, feeling more comfortable with other specialties, and other specialties having a higher perceived status and being better paid.

Joint hypermobility is also associated with anxiety disorders in the elderly population.

BACKGROUND: Anxiety disorders (AD) are very prevalent in the elderly, tend to compromise quality of life, and generate substantial costs. Considering that the prevention and early detection of anxiety may be relevant to increase health gains in older adults, it would be of great interest to identify whether the joint hypermobility syndrome (JHS) is also related to anxiety disorders in this age range. METHODS: Cross-sectional data was collected in a sample of 108 subjects in a rural town in Spain. Instruments included Spielberger STAI, a modified Wolpe Fear Survey Schedule, General health Questionnaire (GHQ)-28, and the anxiety and mood disorders section of the SCID, to assess past year prevalence of anxiety disorders. JHS was evaluated by trained examiners using the "Hospital del Mar criteria". RESULTS: Among the 108 subjects (55% women, 45% men) over 60 years old, 21.3% meet criteria for JHS. These subjects scored significantly higher in both State (F = 5.53; p = 0.02) and Trait (F = 4.68; p = 0.03) anxiety and the GHQ 28 (F = 6.29; p = 0.01). Compared with non JHS subjects, they had more AD (34.8% vs. 11.8%; x2  = 6.90; p = 0.02) and mood disorders (30.4% vs. 10.6%; x2  = 5.65; p = 0.041) in the past year prevalence. A multiple logistic regression analysis showed that both JHS (ß = 0.196; p = 0.04) and fears (ß = 0.34; p = 0.001) are predictors of AD (r2  = 188; p = 0.001) in this population. CONCLUSIONS: Joint hypermobility syndrome is associated with anxiety in the elderly population, and it may be used as a physical marker for AD among subjects within this age range. Copyright © 2017 John Wiley & Sons, Ltd.

Low- and high-anxious hypermobile Ehlers-Danlos syndrome patients: comparison of psychosocial and health variables.

Despite the frequent co-ocurrence of hypermobile Ehler-Danlos syndrome (hEDS) and pathological anxiety, little is known about the psychosocial and health implications of such comorbidity. Our aim was to explore the association between high levels of anxiety and psychosocial (catastrophizing, kinesiophobia, somatosensory amplification, social support and functioning), health (pain, fatigue, BMI, tobacco/alcohol use, depression, diagnosis delay, general health), and sociodemographic factors in people with hEDS. In this cross-sectional study, 80 hEDS patients were divided into two groups according to self-reported anxiety levels: low and high. Psychosocial, sociodemographic and health variables were compared between the groups. Forty-one participants reported a high level of anxiety (51.2%). No differences were found in the sociodemographic variables between high-anxious and low-anxious patients. The percentage of participants with severe fatigue and high depressive symptomatology was significantly higher in the high-anxious group (80.5 vs 56.4; 26.8 vs 12.8%, respectively). High-anxious hEDS patients also showed significantly higher levels of pain catastrophizing, somatosensory amplification as well as a poorer social functioning and general health. Multivariate analyses showed that somatosensory amplification, pain catastrophizing and poor social functioning are variables that increase the probability of belonging to the high-anxious group. Despite limitations, this first study comparing high-anxious versus low-anxious hEDS patients with respect to health aspects, highlight the importance of considering the psychosocial factors (many susceptible to modification), to improve the adjustment to this chronic condition and provide support to those affected through a biopsychosocial approach.

Psychiatric and psychological aspects in the Ehlers-Danlos syndromes.

There is increasing amount of evidence pointing toward a high prevalence of psychiatric conditions among individuals with hypermobile type of Ehlers-Danlos syndrome (JHS/hEDS). A literature review confirms a strong association between anxiety disorders and JHSh/hEDS, and there is also limited but growing evidence that JHSh/hEDS is also associated with depression, eating, and neuro-developmental disorders as well as alcohol and tobacco misuse. The underlying mechanisms behind this association include genetic risks, autonomic nervous system dysfunction, increased exteroceptive and interoceptive mechanisms and decreased proprioception. Recent neuroimaging studies have also shown an increase response in emotion processing brain areas which could explain the high affective reactivity seen in JHS/hEDS. Management of these patients should include psychiatric and psychological approaches, not only to relieve the clinical conditions but also to improve abilities to cope through proper drug treatment, psychotherapy, and psychological rehabilitation adequately coupled with modern physiotherapy. A multidimensional approach to this "neuroconnective phenotype" should be implemented to ensure proper assessment and to guide for more specific treatments. Future lines of research should further explore the full dimension of the psychopathology associated with JHS/hEDS to define the nature of the relationship. © 2017 Wiley Periodicals, Inc.

[Detecting and measuring functional and organic disease in general population: Development and validation of TOPYPS clinical scale]. / Detección y medición de la enfermedad funcional y orgánica en población general: desarrollo y validación de la escala clínica TOPYPS.

OBJECTIVE: To develop and validate the TOPYPS scale, an instrument designed to: (i)detect with a high degree of suspicion the most frequent functional pathologies according to standard diagnostic criteria, and (ii)to assess the physical health in the general population quickly, comprehensive and reliable. DESIGN: Validation of a scale. LOCATION: Primary Care Centre, Barcelona. PARTICIPANTS: The scale was administered to 67 randomly selected adults. MEASUREMENTS: TOPYPS scale was administered to 67 adults randomly selected from a primary care setting in Barcelona, Spain. TOPYPS has six sections based on body systems, each one scored according to the degree of interference in daily activity, type of treatment received, and prognostic of the reported illnesses in each section. Test-retest reliability completions were on two separate occasions one week apart. Validity was then tested by comparing the results with the clinical examination conducted by two different specialists in general practice (gold standard). RESULTS: Repeatability (test-retest) and inter-rater agreement for each of the six sections and for the total score were satisfactory. Validity was acceptable both for content and construct, according to their correlation with the gold standard. CONCLUSIONS: TOPYPS displayed good psychometrical properties. It is a suitable tool to detect and measure functional and organic diseases in general population.

Joint hypermobility, anxiety and psychosomatics: two and a half decades of progress toward a new phenotype.

The strong association between a heritable collagen condition and anxiety was an unexpected finding that we first described in 1988 at the Hospital del Mar in Barcelona. Since then, several clinical and nonclinical studies have been carried out. In this paper, after summarizing the concept and diagnosis of joint hypermobility (hyperlaxity), we review case-control studies in both directions (anxiety in joint hypermobility and joint hypermobility in anxiety disorders) as well as studies on nonclinical samples, review papers and one incidence study. The collected evidence tends to confirm the strength of the association described two and a half decades ago. The common mechanisms that are involved in this association include genetics, autonomic nervous system dysfunctions and interoceptive and exteroceptive processes. Considering clinical and nonclinical data, pathophysiological mechanisms and the presented nosological status, we suggest a new Neuroconnective phenotype, which around a common core Anxiety-Collagen hyperlaxity, includes five dimensions: behavioral, psychopathology, somatic symptoms, somatosensory symptoms, and somatic illnesses. It is envisaged that new descriptions of anxiety disorders and of some psychosomatic conditions will emerge and that different nosological approaches will be required. The Neuroconnective model is a proposal that is under study and may be useful for clinical practice.

Conditioned Subjective Responses to Socially Relevant Stimuli in Social Anxiety Disorder and Subclinical Social Anxiety.

UNLABELLED: Although enhanced fear conditioning has been implicated in the origins of social anxiety disorder (SAD), laboratory evidence in support of this association is limited. Using a paradigm employing socially relevant unconditioned stimuli, we conducted two separate studies to asses fear conditioning in individuals with SAD and non-clinical individuals with high social anxiety (subclinical social anxiety [SSA]). They were compared with age-matched and gender-matched individuals with another anxiety disorder (panic disorder with agoraphobia) and healthy controls (Study 1) and with individuals with low social anxiety (Study 2). Contrary to our expectations, in both studies, self-report measures (ratings of anxiety, unpleasantness and arousal to the conditioned stimuli) of fear conditioning failed to discriminate between SAD or SSA and the other participant groups. Our results suggest that enhanced fear conditioning does not play a major role in pathological social anxiety. KEY PRACTITIONER MESSAGE: We used a social conditioning paradigm to study fear conditioning in clinical and subclinical social anxiety. We found no evidence of enhanced fear conditioning in social anxiety individuals. Enhanced fear conditioning may not be a hallmark of pathological social anxiety.

Clinical observation, pharmacotherapy and referral on discharge of patients with anxiety disorder in a psychiatric emergency service.

INTRODUCTION: To analyze factors associated with clinical observation, pharmacotherapy and referral on discharge of patients with anxiety disorder (AD) seeking care at a psychiatric emergency unit. METHOD: A total of 5003 consecutive visits were reviewed over a three-year period at a psychiatric emergency service in a tertiary university hospital. Data collected included sociodemographic and clinical information as well as the Global Assessment of Functioning (GAF) and the Severity Psychiatric Illness (SPI) scale scores. RESULTS: Of all the visits, 992 (19.8%) were diagnosed of AD. Of these, 19.6% required clinical observation and 72.2% were referred to a psychiatrist at discharge. Regression analysis showed that referral to psychiatry was associated with being male, native, psychiatric background, greater severity, lower global functioning, and behavioral disorders. Clinical observation (in a box) was associated with being female, greater severity, and psychotic or behavioral symptoms. Prescription of benzodiazepines was associated with anxiety, no history of addiction, and lower global functioning. Antidepressants were associated with being a native, anxiety with no history of addiction, and lower functioning. Antipsychotics were associated with being native, psychiatric background (not addiction), anxiety, and lower functioning. CONCLUSION: Behavior, psychiatric background and illness severity were determinants of referral to a specialist. Besides these, psychotic symptoms and non-specific clinical symptoms were determinants of observation. Drug prescription in AD is less frequent if the main complaint is not anxiety and depends more on the level of functioning than on that of severity.

Ectomorphic somatotype and joint hypermobility are linked in panic and agoraphobic patients: a case-control study.

OBJECTIVE: To test whether there is an association between somatotype measures, joint hypermobility (JH), and panic and/or agoraphobia (PA). METHOD: Sociodemographic characteristics, somatotype, and JH status were assessed in 60 patients (30 men and 30 women) with PA and 60 non-clinical controls, matched by age and gender. RESULTS: Patients and controls categorized by gender did not differ in terms of age, educational degree, marital status, or labour situation. There were significant differences between mean somatotype groups both in men and women. Men and women somatotype patients were significantly less endomorphic and more ectomorphic than controls. Hypermobility was significantly more frequent in both male and female patients. In the entire sample, 38.3% of patients and 13.3% of controls were categorized as ectomorphic (χ(2) = 8.5, p = 0.004). After adjusting for age and sex, ectomorphic somatotype was independently related to JH status [OR = 3.25, 95% CI 1.35-7.8, p = 0.008]. CONCLUSIONS: Since PA may be associated with JH, it is suggested that the relationship found between panic and ectomorphic somatotype might be mediated through JH.

Effectiveness of cognitive-behavioral group therapy for panic disorder in a specialized unit.

INTRODUCTION: The efficacy of cognitive-behavior therapy for panic disorder (PD) with or without agoraphobia is well established, but few data exist on its effectiveness using a group format. The goal of the present study was to assess the effectiveness of group CBT in a sample of PD patients in a specialized unit. METHODS: Treatment consisted of nine weekly group sessions. Patients with PD (n=56) were assessed at baseline, after the treatment and in one and three-months followups. RESULTS: There were significant reductions in panic/agoraphobia symptoms and related variables between baseline and post-treatment, and these reductions were maintained in three-month follow-up. No differences were observed between those patients who received only CBT and those who received pharmacological treatment as well as CBT. Only initial panic/agoraphobia symptoms were significant predictors of treatment response at the end of treatment (a greater severity was associated with a worse response to CBT). CONCLUSIONS: Our results show that group CBT in a specialized unit is effective for PD patients.

Joint hypermobility and sport: a review of advantages and disadvantages.

Joint hypermobility (JH) is a feature observed in several inherited conditions in which joints have a range of motion beyond normal limits. Such inherent flexibility makes it relatively easy for hypermobile people to perform certain physical activities, so this characteristic is particularly convenient for certain athletes. However JH also can carry some disadvantages: it has been associated to a higher risk of injury and to states of anxiety. The aim of this article is to provide an overview of the current evidence concerning the advantages and disadvantages of JH in the field of sport. We emphasize the importance of detecting JH in athletes in order to intervene appropriately through injury prevention programs, and emphasize how inherent anxiety may have a negative impact on sporting performance.

EROL scale: a new behavioural olfactory measure and its relationship with anxiety and depression symptoms.

INTRODUCTION: The main objective of this study was to develop and validate a new olfactory measure that assesses the influence of olfaction on several emotional, behavioural, and cognitive issues: The Relational Scale of Olfaction (EROL). A secondary objective was to explore the relationship between the olfactory function and the anxiety and depression symptoms by means of EROL and the Hospital Anxiety and Depression Scale (HADS). A positive relationship between anxiety symptoms and the olfactory function was hypothesized. Regarding depressive symptoms, a significant relationship with the olfactory scores was not expected. METHOD: Psychometric properties of EROL scale and correlations between HADS and EROL were tested in a sample from the general population. RESULTS: EROL showed an adequate level of test-retest reliability (ICC=.748) and good internal consistency (Cronbach's alpha=.761). Convergent validity with other olfactory measures was satisfactory. A one-factor solution was found for the scale. HADS showed a significant relationship with EROL (r=.280, p<.01), but the analysis through dimensions revealed that only the anxiety subscale correlated significantly and moderately with the olfactory measure (r=.325, p<.001), whereas the correlation with the depression subscale was non-significant (r=.146, p>.05). CONCLUSIONS: Given that EROL displayed good psychometrical properties, it appears as a suitable tool to assess the olfactory function in general population. The relationship between this olfactory scale and anxiety symptoms found in this study is an interesting issue that requires further research.

Joint hypermobility, fears, and chocolate consumption.

Our purpose was to evaluate joint hypermobility, an inherited disorder of the connective tissue significantly associated with anxiety disorders, in a sample of nonclinical students in relation to the frequency of severe fears and consumption of chocolate, coffee, cigarettes, and alcohol. One hundred fifty students completed the Hakim and Grahame Simple Questionnaire to detect hypermobility and the self-administered modified Wolpe Fear Scale (100 items). Severe fears and daily consumption of cigarettes, alcohol, coffee, and chocolate were compared with the hypermobility scores. We found significant differences when comparing severe fears between the groups with and without hypermobility (7.6 vs. 11; p = 0.001), reinforcing the hypothesis that the intensity of fears is greater in subjects with hypermobility. Only the frequency of chocolate intake was significantly higher among subjects with hypermobility (31.2% vs. 51.2%; p = 0.038) and may correspond to attempts of self-treatment of the collagen condition.

Both anxiety and joint laxity determine the olfactory features in panic disorder.

Previous research showed a high sensitivity in sensorial modalities in panic disorder (PD). This disorder has been consistently associated to the joint hypermobility syndrome (JHS). In non-clinical samples, this collagen alteration has been also related to an enhanced sensitivity in some sensorial modalities. The main aim of this study is to explore the olfactory functioning in PD in relation to JHS. Sixty patients with PD and sixty healthy controls performed the Sniffin' Sticks Test (SST) (threshold subtest), and completed the Affective Impact of Odors scale (AIO), the Relational Scale of Olfaction (EROL), and the Odor Awareness Scale (OAS). Clinical symptom rating scales and JHS assessment were also obtained. PD patients showed enhanced odor acuity, greater reactivity to smells and also increased odor awareness compared to the healthy controls. Within the patients group, those suffering from JHS displayed higher functioning in all olfactory domains compared to the non-JHS ones. The JHS and anxiety measures emerged as predictor variables of the olfactory function. The present findings highlight the importance of the olfactory function in PD and underline that both, JHS and anxiety, determine the olfactory characteristics in this disorder.

Assessing body awareness and autonomic reactivity: Factor structure and psychometric properties of the Body Perception Questionnaire-Short Form (BPQ-SF).

Body awareness and reactivity dysfunction are characteristic of a range of psychiatric disorders. Although the neural pathways communicating between the body and brain that contribute to these experiences involve the autonomic nervous system, few research tools for studying subjective bodily experiences have been informed by these neural circuits. This paper describes the factor structure, reliability, and convergent validity of the Body Awareness and Autonomic Reactivity subscales of the Body Perception Questionnaire-Short Form (BPQ-SF). Exploratory and confirmatory factor analyses were applied to data from three samples collected via the internet in Spain and the US and a college population in the US (combined n = 1320). Body awareness was described by a single factor. Autonomic reactivity reflected unique factors for organs above and below the diaphragm. Subscales showed strong reliability; converged with validation measures; and differed by age, sex, medication use, and self-reported psychiatric disorder. Post hoc analyses were used to create the 12-item Body Awareness Very Short Form. Results are discussed in relation to the distinct functions of supra- and sub-diaphragmatic autonomic pathways as proposed by the Polyvagal Theory and their potential dysfunction in psychiatric disorders.

Psychometric Properties of the Spanish Version of the Panic Disorder Severity Scale.

The Panic Disorder Severity Scale (PDSS) is a well-established measure of panic symptoms but few data exist on this instrument in non north-American samples. Our main goal was to assess the psychometric properties (internal consistency, test re-test reliability, inter-rater reliability, convergent and divergent validity) and the factor structure of the Spanish version. Ninety-four patients with a main diagnosis of panic disorder were assessed with the Spanish version of PDSS, the Anxiety Sensitivity Index-3 (ASI-3), the Panic and Agoraphobia Scale (PAS), the Beck Anxiety Inventory (BAI), the Beck Depression Inventory-II (BDI-II) the PDSS self-rating form and the Clinical Global Impression-Severity scale (CGI). The Spanish PDSS showed acceptable internal consistency (α = .74), excellent test-retest (total score and items 1-6: α > .58, p .90) and medium to large convergent validity (r = .68, 95% CI [.54, .79], p < .01; r = .80, 95% CI [.70, .87], p < .01; r = .48, 95% CI [.28, .67], p < .01; BAI, PAS and ASI-3 total scores respectively). Data on divergent validity (BDI-II total score: r = .52, 95% CI [.34, .67], p < .01) suggest some need for refinement of the PDSS. The confirmatory factor analysis suggested a two-factor modified model for the scale (nested χ2 = 14.01, df = 12, p < .001). The Spanish PDSS has similar psychometric properties as the previous versions and is a useful instrument to assess panic symptoms in clinical settings in Spanish-speaking populations.

Mind-Body Interactions in Anxiety and Somatic Symptoms.

Anxiety and somatic symptoms have a high prevalence in the general population. A mechanistic understanding of how different factors contribute to the development and maintenance of these symptoms, which are highly associated with anxiety disorders, is crucial to optimize treatments. In this article, we review recent literature on this topic and present a redefined model of mind-body interaction in anxiety and somatic symptoms, with an emphasis on both bottom-up and top-down processes. Consideration is given to the role played in this interaction by predisposing physiological and psychological traits (e.g., interoception, anxiety sensitivity, and trait anxiety) and to the levels at which mindfulness approaches may exert a therapeutic benefit. The proposed model of mind-body interaction in anxiety and somatic symptoms is appraised in the context of joint hypermobility syndrome, a constitutional variant associated with autonomic abnormalities and vulnerability to anxiety disorders.

Joint hypermobility and the heritable disorders of connective tissue: clinical and empirical evidence of links with psychiatry.

OBJECTIVE: The heritable disorders of connective tissue (HDCTs) are a group of genetic disorders affecting connective tissue matrix proteins. Fragility, laxity of tissues and joint hypermobility (JH) are commons features of HDCT for which the prognosis may range from benign to life threatening. JH and HDCTs, especially joint hypermobility syndrome, Ehlers-Danlos syndromes and Marfan syndrome, have been associated with psychiatric symptomatology. We explored the existing knowledge concerning this association in order to provide an overview of mental disorders linked to JH/HDCT, as well as the hypotheses proposed to explain such association. METHOD: A comprehensive search of scientific online databases and references lists was conducted, encompassing publications based on quantitative and qualitative research, including case reports. RESULTS: Psychiatric conditions in which there is some evidence of an association with JH/HDCT are anxiety disorders, depression, schizophrenia, neurodevelopmental disorders (autism, attention deficit/hyperactivity disorder, and developmental coordination disorder), eating disorders, personality disorders and substance use/misuse. CONCLUSION: Despite the need of more research, the available data highlight the importance of examining psychiatric symptoms in those affected by JH/HDCT and the importance of providing interventions with a multidisciplinary approach. The relationship between JH/HDCT and mental disorders merits further attention in order to improve current knowledge and clarify a possible common etiology.

The neuroanatomical basis of panic disorder and social phobia in schizophrenia: a voxel based morphometric study.

OBJECTIVE: It is known that there is a high prevalence of certain anxiety disorders among schizophrenic patients, especially panic disorder and social phobia. However, the neural underpinnings of the comorbidity of such anxiety disorders and schizophrenia remain unclear. Our study aims to determine the neuroanatomical basis of the co-occurrence of schizophrenia with panic disorder and social phobia. METHODS: Voxel-based morphometry was used in order to examine brain structure and to measure between-group differences, comparing magnetic resonance images of 20 anxious patients, 20 schizophrenic patients, 20 schizophrenic patients with comorbid anxiety, and 20 healthy control subjects. RESULTS: Compared to the schizophrenic patients, we observed smaller grey-matter volume (GMV) decreases in the dorsolateral prefrontal cortex and precentral gyrus in the schizophrenic-anxiety group. Additionally, the schizophrenic group showed significantly reduced GMV in the dorsolateral prefrontal cortex, precentral gyrus, orbitofrontal cortex, temporal gyrus and angular/inferior parietal gyrus when compared to the control group. CONCLUSIONS: Our findings suggest that the comorbidity of schizophrenia with panic disorder and social phobia might be characterized by specific neuroanatomical and clinical alterations that may be related to maladaptive emotion regulation related to anxiety. Even thought our findings need to be replicated, our study suggests that the identification of neural abnormalities involved in anxiety, schizophrenia and schizophrenia-anxiety may lead to an improved diagnosis and management of these conditions.