Stigma and discrimination against people with schizophrenia related to medical services.

OBJECTIVE: To investigate whether people with schizophrenia experience discrimination when using health care services. METHODS: A cross-sectional survey in 27 countries in centres affiliated to the INDIGO Research Network, using face-to-face interviews with 777 participants with schizophrenia (62% male and 38% female). We analysed the data related to health issues, including health care, disrespect of mental health staff, and also personal privacy, safety and security, starting a family, pregnancy and childbirth. Discrimination was measured by the Discrimination and Stigma Scale (DISC), which consists of 36 items comprising three sub-scales: positive experienced discrimination; negative experienced discrimination; and anticipated discrimination. RESULTS: More than 17% of patients experienced discrimination when treated for physical health care problems. More than 38% of participants felt disrespected by mental health staff, with higher ratings in the post-communist countries. CONCLUSIONS: Mental health service providers have a key role in decreasing stigma in their provision of health care, and by doing more against stigmatizing and discriminating practices on the therapeutic and organizational level. This will require a change of attitudes and practices among mental and physical health care staff.

Comorbid substance abuse in first-episode schizophrenia: effects on cognition and psychopathology in the EUFEST study.

UNLABELLED: Studies and meta-analyses investigating the influence of substance use disorder (SUD) (substance abuse or dependence) on psychopathology and neurocognitive function in schizophrenia patients have revealed controversial results. Most studies did only have small samples and did not focus exclusively on first-episode schizophrenia patients. METHOD: In a post-hoc analysis of the European First Episode Schizophrenia Trial (EUFEST) psychopathology and cognitive performances of patients with (FE-SUD, N=119, consisting of N=88 patients with persisting SUD at baseline and N=31 patients with previous SUD) and without SUD (FE-non-SUD, N=204) were compared at baseline and 6 months follow-up. Neurocognitive assessment included the Rey Auditory Verbal Learning Test (RAVLT); Trail Making Tests A and B (TMT), Purdue Pegboard and Digit-Symbol Coding. RESULTS: In total 31.1% of patients reported SUD, and 22.2% of patients used cannabis. There were no significant differences between patients with and without SUD concerning PANSS scores, extrapyramidal motor symptoms or neurocognitive measures except better performance in psychomotor speed (TMT-A, p=0.033, Cohen's d=0.26) in patients with SUD at 6 months follow-up. Interestingly, SUD patients with ongoing substance use at follow-up showed elevated positive symptoms (PANSS positive score, p=0.008, Cohen's d=0.84) compared to those who abstained. PANSS scores at baseline were increased in patients with an onset of SUD before the age of 16 years. In addition we found a correlation between longer duration of cannabis use and higher cognitive performance as well as reduced symptom improvement and more extrapyramidal motor symptoms in patients with higher frequency of cannabis consumption. CONCLUSIONS: FE-SUD and FE-non-SUD show similar psychopathology and neuropsychological performances at baseline and during the first 6 months of antipsychotic treatment.

Depressive-type emotional response pattern in impulsive-aggressive patients with borderline personality disorder.

INTRODUCTION: Borderline personality disorder (BPD) is typically characterized by severe affective dysregulation leading to impulsive behaviors. Accordingly, preliminary data suggest the hypothesis that BPD patients could have a specific and altered pattern of subjective emotional response to stimuli. The nature of the emotional response in BPD can be compared with other affective disorders and provide further insight on the nosological proximity with other psychiatric disorders. METHODS: Subjective emotional response was investigated in 19 patients with DSM-IV BPD with no current depressive episode and in 19 healthy control subjects by using the International Affective Picture System (IAPS). The intensity of arousal, valence and dominance was rated in response to 60 images categorized as pleasant, unpleasant and neutral by using a self-assessment instrument. ANOVA of multiple factors was used for between-groups comparisons. RESULTS: The obtained pattern showed that BPD patients considered the unpleasant and neutral images as less aversive than controls, but the activation that these images induced was higher. Patients showed significantly greater arousal than controls for unpleasant and neutral images (p<0.05) but presented greater valence (more positive emotion) for these images (p<0.05). In addition, BPD patients showed lower dominance (greater insecurity and dyscomfort) for positive images (p<0.05). CONCLUSIONS: The subjective emotional response pattern of BPD patients suggests a trait of vulnerability to pleasant stimuli and is similar to the pattern found in depressive patients in previous studies. This supports the evidence that BPD could in part be related with the spectrum of the affective temperament and affective disorders.

Orbitofrontal dysfunction related to depressive symptomatology in subjects with borderline personality disorder.

OBJECTIVE: In order to explore the relationships of fronto-limbic dysfunction with the clinical features of borderline personality disorder (BPD), the authors investigated brain electrophysiological activity in BPD patients following stimulation with emotionally arousing images. METHODS: Seventeen non-medicated patients with borderline personality disorder were studied with magneto-encephalography. Regional cortical activities were obtained by minimum norm estimate (MNE) of steady-state visual evoked fields (ssVEFs). Linear regression models were conducted to explore clinical correlates of brain activity. RESULTS: Although no interaction group × picture category × brain region was found, a significant interaction group × brain region appeared for orbito-frontal cortex (OFC). BPD patients showed significantly reduced magnetocortical activity in left OFC across all picture categories (F = 26.4; p<.05; F = 31.4). Left OFC activity was inversely correlated with depression score in the BDI (r: -0.48, p < 0.05), with score in the Cornell Dysthymia rating scale (r: -0.52, p < 0.05) and with the number of criteria met for depressive personality disorder (r: -0.44, p < 0.05). Left orbitofrontal activity was also inversely correlated with the global score in the GAF (r-0.63, p < 0.01). No correlations were found between OFC activity and impulsivity or global severity of BPD symptoms. CONCLUSIONS: Abnormal functioning at orbitofrontal areas in BPD could be related to the presence of affective symptomatology and is associated with greater functional deterioration of patients.

Diagnostic features of the cycloid psychoses in a first psychotic episode sample.

INTRODUCTION: The cycloid psychoses have not been included in the modern classifications-what makes scientific research difficult. The aim of the present study is to investigate the presence and specific characteristics of the cycloid psychoses in a broad sample of first psychotic episodes. METHODS: Seventy patients diagnosed with one-year first schizophrenia episode, schizophreniform disorder, or schizoaffective disorder were studied (mean age, 27.9 years old; SD±6.34). The detection of the possible cases of cycloid psychosis was done according to the Perris and Brockington operational criteria. Two groups of "cycloid" (n=11) and "non cycloid" (n=59) patients were compared according to demographic and clinical variables, and possible diagnostic variables were evaluated by the ROC curves. RESULTS: Significant differences were found between cycloid and non cycloid groups for a number of clinical variables: prodromic symptoms (p<0.001), PANSS total score (p=0.003), PANSS-P (p=0.009), PANSS-GP (p=0.001), total score for mania by EVMAC (p=0.001), and CDSS for depression (p=0.004). ROC curves were significant for PANSS-GP (AUC=0.791, p=0.002), EVMAC (AUC=0.938, p=0.001), and CDSS (AUC=0.770, p=0.005). A sensitivity/specificity study demonstrated a negative predictive value for PANSS-GP (93.88%), EVMAC (96.30%), and CDSS (93.88%). CONCLUSIONS: According to these results, cycloid psychoses might represent differentiated and well-defined clinical entity.

Pain as a symptom of depression: prevalence and clinical correlates in patients attending psychiatric clinics.

BACKGROUND: The need to assess the prevalence and characteristics of painful symptoms among depressed patients attended by psychiatrists in their regular clinical practice. METHODS: A multi-centre, cross-sectional study was carried out in a large sample (n=3566) of patients attending out-patient psychiatric facilities in Spain. All types of DSM-IV-TR depressive disorders were included. Data on the diagnosis, specific symptoms, intensity of depression and antidepressant and analgesic drug treatments were collected. The presence and characteristics of significant pain (visual analogue scale score>40) at the time of the study were also recorded. RESULTS: The prevalence of pain in depressed patients was 59.1% (CI 95%: 57.7%; 60.7%). Factors associated independently with the existence of significant pain were: being female, presence of loss of energy and the diagnosis of dysthymia or depression induced by physical disorders. In addition, age and the intensity of depression were two risk factors, where each year of age and each point in the Hamilton scale increased the risk of having pain by 2% and 8% respectively. The presence of anhedonia and the diagnosis of depression induced by illegal drugs were factors inversely related to pain. LIMITATIONS: The cross-sectional naturalistic characteristics of the study. CONCLUSION: Our data show a high prevalence of pain among depressive patients attending psychiatric clinics. Painful symptoms are modulated differently depending on the type of depression and the presence of specific symptoms, such as loss of energy or anhedonia. Psychiatrists should ask their depressive patients for the presence of pain on a regular basis.

[Analysis of brain complexity and mental disorders]. / Análisis de complejidad de la actividadcerebral y trastornos mentales.

The knowledge of the brain processes underlying mental disorders has significantly increased during the last decades, but in spite of this very important research effort a biological marker is not available for such disorders. For example, neurophysiological techniques (EEG and MEG),have been broadly utilized in the investigation of the most important psychiatric syndromes such as schizophrenia, major depression, bipolar disorder or obsessive/compulsive disorder. The outcomes of some of those neurophysiological studies allowed the building of statistical models with very high sensitivity and specificity, although those models did not reach day-to-day clinical practice. A potential explanation for this situation is an inadequate analysis procedure which might be missing some important quantums of information contained in brain signals. In this vein, new methods of non-linear analysis have been proposed for the investigation of neurophysiological data. Particularly, the analysis of brain signals' complexity has been broadly utilized in the investigation of psychiatric disorders. Parameters of EEG-MEG complexity usually estimate the predictability of brain oscillations and/or the number of independent oscillators underlying the observed signals. More importantly, complexity parameters seem to be sensitive to the temporal components of brain activity, and therefore might reflect the dynamical nature of psychiatric disorders. This paper reviews some of the most relevant studies within this field, especially those focusing on the diagnosis, follow-up and prediction of response to treatment.

Análisis de complejidad de la actividad cerebral y trastornos mentales / Brain Complexity analysis and mental disorders

El conocimiento sobre los procesos cerebrales que subyacentras los trastornos mentales ha incrementado significativamente en las últimas décadas, pero a pesar del importante esfuerzo investigador no disponemos de ningún marcador biológico para estos trastornos. Por ejemplo, las técnicas neurofisiológicas (EEG o MEG) se han utilizado ampliamente en la investigación de los síndromes psiquiátricos más importantes como la esquizofrenia, la depresión mayor, el trastorno bipolar o el trastorno obsesivo/compulsivo. Los resultados de algunos de estos estudios permitieron la construcción de modelos estadísticos con alta sensibilidad y especificidad, aunque estos modelos no han alcanzado la práctica clínica diaria. Una posible explicación para está situación sería la utilización de procedimientos de análisis inadecuados que podrían perder elementos importantes de la información contenida en la señal cerebral. En este sentido se han propuesto nuevos métodos de análisis no lineal para los datos neurofisiológicos. De particular interés resulta el análisis de complejidad de la señal cerebral que se ha utilizado ampliamente en la investigación de trastornos psiquiátricos. Los parámetros de complejidad EEG o MEG generalmente estiman la predictibilidad de las oscilaciones cerebrales y/o el número de osciladores independientes que subyacen tras las señales observadas. Más importante aun, los parámetros de complejidad parecen ser sensibles a los componentes temporales de la actividad cerebral y por tanto podrían reflejar bien la naturaleza dinámica de los trastornos psiquiátricos. Este artículo revisa alguno de los estudios más importantes dentro de este campo, en especial aquellos que se centran en el diagnóstico, el seguimiento y la respuesta al tratamiento (AU)

The knowledge on the brain processes underlying mental disorders has significantly increased during the last decades, but in spite of this very important research effort a biological marker is not available for such disorders. For example, neurophysiological techniques (EEG and MEG), have been broadly utilized in the investigation of the most important psychiatric syndromes such us schizophrenia, major depression, bipolar disorder or obsessive/compulsive disorder. The outcomes of some of those neurophysiological studies allowed the building of statistical models with very high sensitivity and specificity, although those models did not reach a day to day clinical practice. A potential explanation for this situation is an inadequate analysis procedure which might be missing some important quantums of information contained in brain signals. In this vein, new methods of non-linear analysis have been proposed for the investigation of neurophysiological data. Particularly, the analysis of brain signals’ complexity have been broadly utilized in the investigation of psychiatric disorders. Parameters of EEG-MEG complexity usually estimate the predictability of brain oscillations and/or the number of independent oscillators underlying the observed signals. More importantly, complexity parameters seem to be sensitive to the temporal components of brain activity, and therefore might reflect the dynamical nature of psychiatric disorders. This paper reviews some of the most relevant studies within this field, especially those focusing on the diagnosis, follow-up and prediction of response to treatment (AU)

Sustained attention as a potential endophenotype for bipolar disorder.

OBJECTIVE: Nowadays, it is accepted that to identify the biological basis of psychiatric illnesses it would be useful to deconstruct them into the most basic manifestations, such as cognitive deficits. The aim of this study was to set attention deficit as a stable vulnerability marker of bipolar disorder. METHOD: Sustained attention was evaluated by the Continuous Performance Test (DS-CPT) in 143 euthymic bipolar patients and 105 controls. To estimate the influence of clinical profile in attention, patients completed a semi-structured interview. RESULTS: Bipolar patients showed a deficit in attention during euthymic periods. This disturbance correlated with years of evolution, age of onset and age of first hospitalisation; and was not influenced by other clinical data. CONCLUSION: Sustained attention may be considered as an endophenotype of the illness.

Tratamiento para la esquizofrenia. Revisión crítica sobre la farmacología y mecanismos de acción de los antipsicóticos / Schizophrenia treatment. Critical review on the drugs and mechanisms of action of antipsychotics

El tratamiento de la esquizofrenia ha evolucionado a lo largo de la segunda mitad del siglo pasado, principalmente gracias al desarrollo de los fármacos antipsicóticos. A pesar del gran avance realizado, que ha permitido la disponibilidad y uso de nuevos y diferentes fármacos, éstos continuan constituyendo tres grupos básicos (atipsicóticos típicos, atípicos y agonistas parciales dopaminérgicos), y todos ellos tienen como principal mecanismo de acción, la actuación sobre los sistemas dopaminérgicos. Se cree que una gran parte de los antipsicóticos de segunda generación (antipsicóticos atípicos y agonistas parciales dopaminérgicos) ofrecen ventajas añadidas a los de primera generación en el tratamiento de la esquizofrenia. No obstante, las propiedades farmacológicas y terapéuticas que confieren respecto a los de primera generación no están claras, y ciertos efectos colaterales pueden todavía, afectar a la salud y calidad de vida del paciente. Además, la eficacia de los antipsicóticos es limitada, lo que ha llevado a la utilización de medicaciones adyuvantes para potenciar los efectos del tratamiento. Por otro lado, se ha trabajado en el desarrollo de nuevas líneas de investigación para el desarrollo de nuevos fármacos antipsicóticos no dopaminérgicos, siendo los resultados poco exitosos. Este artículo realiza una breve revisión crítica sobre el actual arsenal terapéutico para la esquizofrenia, estrategias de desarrollo de fármacos, y teorías sobre los mecanismos de acción de los antipsicóticos, centrándose en las nuevas dianas terapéuticas para el desarrollo de futuros tratamientos (AU)

Schizophrenic treatment was developed during the second half of the last century, mainly within the context of the development of antipsychotic drugs. Even though there has been significant progress due to the availability and use of multiple drugs, these can still be classified into three basic groups of antipsychotic drugs (atypical antipsychotics, typical antipsychotics and dopamine partial agonist antipsychotics). Their primary antipsychotic mechanism is still the action on the dopamine systems. Many of the second-generation antipsychotics are believed to offer advantages over first-generation agents in the treatment for schizophrenia. However, the drug properties that provide the different therapeutic effects from those of the first generation are not clear and some adverse effects may still affect the patient’s health and quality of life. Furthermore, the efficacy of the antipsychotics is limited. This has led to the use of adjuvant medications to strengthen the treatment effects. On the other hand, work is being done on the development of new research lines to develop new nondopaminergic antipsychotic drugs, with not very successful results. The aim of this paper is to make a brief review on the current therapeutic armamentarium for schizophrenia, the strategies to develop drugs, and theories of mechanisms of action of antipsychotics. Emphasis is placed on the new therapeutic targets for the development of future treatments (AU)

[Neuropsychological dysfunctions in personality borderline disorder: detection strategies]. / Alteraciones neuropsicológicas en el trastorno límite de la personalidad: estrategias de detección.

INTRODUCTION: Borderline personality disorder (BPD) is characterized by emotional instability and impulsivity. However, there is evidence that neurocognitive alterations have a relevant role in the clinical features of these patients. The present study investigates cognitive function in BPD in order to search for a specific profile of neuropsychological alterations. METHODS: Based on previous research and cognitive complaints reported by patients, a neuropsychological assessment protocol focused on prefrontal functioning was applied. The applied neuropsychological battery included tests assessing the following cognitive domains: memory (fixation, consolidation and recovery processes) categorical evocation, cognitive flexibility, sustained attention, processing rate, inhibitory control and working memory. The patient sample was recruited from an outpatient BPD unit and was composed by 26 patients (14 women, 12 men) diagnosed of BPD. RESULTS: In comparison to the normative values, BPD patients have a deficit in the execution of most of the neuropsychological tests. This deficit was especially present in the following: recovery processes of the immediate and differed memory, working memory, sustained attention and processing rate, verbal fluency, impulse control, cognitive flexibility, abstraction and planning. CONCLUSIONS: BPD patients could present a pattern of neurocognitive alterations that suggests a specific impairment of the prefrontal areas and requires a more detailed study. The neuropsychological dysfunctions could partially explain the behavioral alterations in BPD patients.

[Neuropsychological rehabilitation in patients with borderline personality disorder: a case series]. / Rehabilitación neuropsicológica en pacientes con trastorno límite de personalidad: una serie de casos.

Recent research studies have been confirming the evidence that patients with personality borderline disorder (BPD) suffer significant neuropsychological disorders. Neurocognitive dysfunction of BPD seems to mainly affect the functions characteristic of the prefrontal areas that participate in information processing and management and in the regulation of complex behavioral responses. Neuropsychological disorders not only are seen in the specific tests but are also reflected and could play an important role in the clinical manifestations of borderline disorder, such as emotional dysregulation and impulsive behaviors. Neurocognitive rehabilitation therapy has been used successfully in psychiatric disorders such as schizophrenia, also characterized by the presence of neuropsychological dysfunctions. Thus, it can be expected that rehabilitation of the neurocognitive functions affected in BPD contributes to the patient's functional improvement. The present work describes a series of five patients with BPD who presented important neuropsychological dysfunctions and who were treated successfully with a specific program of neurocognitive rehabilitation. The results observed justify the performance of controlled clinical studies on the efficacy of this technique in the treatment of BPD.

Estimulación cerebral profunda en los trastornos del humor: ¿tan fácil como parece? / Deep brain stimulation in mood disorders: is it as easy as it seems?

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Alteraciones neuropsicológicas en el trastorno límite de la personalidad: estrategias de detección / Neuropsychological dysfunctions in personality borderline disorder: detection strategies

Introducción. Los síntomas más característicos del trastorno límite o «borderline» de la personalidad (TLP) son la inestabilidad afectiva y la impulsividad. No obstante, existen indicios de que las alteraciones neurocognitivas podrían tener un papel relevante en la clínica de estos trastornos. El objetivo del presente estudio es investigar la función cognitiva en el TLP y buscar un patrón específico de alteraciones neuropsicólogicas. Metodología. Sobre la base de investigaciones anteriores y de las quejas cognitivas referidas por los pacientes, se ha aplicado un protocolo de evaluación neuropsicológica centrado en las funciones prefrontales. La batería neuropsicológica aplicada estaba compuesta por diferentes pruebas que evalúan los siguientes dominios cognitivos: memoria (procesos de fijación, consolidación y de recuperación), evocación categorial, flexibilidad cognitiva, atención sostenida, velocidad de procesamiento, control de inhibición y memoria de trabajo. Se han evaluado 26 pacientes diagnosticados de TLP, de los cuales 14 eran mujeres y 12 hombres, todos ellos pertenecientes al Servicio de Psiquiatría del Hospital Clínico San Carlos. Resultados. En comparación con los valores normativos, los pacientes con TLP presentan un déficit en la ejecución de la mayoría de las pruebas neuropsicológicas utilizadas, especialmente en los procesos de recuperación de memoria inmediata y diferida, memoria de trabajo, atención sostenida y velocidad de procesamiento, fluidez verbal, control de impulsos, flexibilidad cognitiva, abstracción y planificación. Conclusiones. El TLP podría presentar un patrón de alteraciones neurocognitivas que sugiere una afectación específica de áreas prefrontales y que precisa ser estudiado con mayor detalle. Las disfunciones neuropsicológicas podrían explicar parcialmente las alteraciones conductuales de estos pacientes (AU)

Introduction. Borderline personality disorder (BPD) is characterized by emotional instability and impulsivity. However, there is evidence that neurocognitive alterations have a relevant role in the clinical features of these patients. The present study investigates cognitive function in BPD in order to search for a specific profile of neuropsychological alterations. Methods. Based on previous research and cognitive complaints reported by patients, a neuropsychological assessment protocol focused on prefrontal functioning was applied. The applied neuropsychological battery included tests assessing the following cognitive domains: memory (fixation, consolidation and recovery processes) categorical evocation, cognitive flexibility, sustained attention, processing rate, inhibitory control and working memory. The patient sample was recruited from an outpatient BPD unit and was composed by 26 patients (14 women, 12 men) diagnosed of BPD. Results. In comparison to the normative values, BPD patients have a deficit in the execution of most of the neuropsychological tests. This deficit was especially present in the following: recovery processes of the immediate and differed memory, working memory, sustained attention and processing rate, verbal fluency, impulse control, cognitive flexibility, abstraction and planning. Conclusions. BPD patients could present a pattern of neurocognitive alterations that suggests a specific impairment of the prefrontal areas and requires a more detailed study. The neuropsychological dysfunctions could partially explain the behavioral alterations in BPD patients (AU)

Rehabilitación neuropsicológica en pacientes con trastorno límite de personalidad: una serie de casos / Neuropsychological rehabilitation in patients with borderline personality disorder: a case series

La evidencia de que los pacientes con trastorno límite de la personalidad (TLP) padecen alteraciones neurospicológicas significativas se ha ido confirmando en recientes estudios de investigación. La disfunción neurocognitiva del TLP parece afectar principalmente a funciones propias de las áreas prefrontales que participan en el procesamiento y manejo de la información y en la regulación de las respuestas conductuales complejas. Las alteraciones neuropsicológicas no sólo se evidencian en los tests específicos sino que se reflejan y podrían tener un papel importante en las manifestaciones clínicas del trastorno límite, como la disregulación emocional y las conductas impulsivas. La terapia de rehabilitación neurocogntiva ha sido utilizada con éxito en trastornos psiquiátricos como la esquizofrenia, caracterizada también por la presencia de disfunciones neuropsicológicas. Por ello es esperable que la rehabilitación de las funciones neurocognitivas afectadas en el TLP contribuya a la mejoría funcional de los pacientes. En el presente trabajo se describe una serie de cinco pacientes con TLP que presentaban disfunciones neuropsicológicas notables y que fueron tratados con éxito mediante un programa específico de rehabilitación neurocognitiva. Los resultados observados justifican la realización de estudios clínicos controlados de la eficacia de esta técnica en el tratamiento del TLP (AU)

Recent research studies have been confirming the evidence that patients with personality borderline disorder (BPD) suffer significant neuropsychological disorders. Neurocognitive dysfunction of BPD seems to mainly affect the functions characteristic of the prefrontal areas that participate in information processing and management and in the regulation of complex behavioral responses. Neuropsychological disorders not only are seen in the specific tests but are also reflected and could play an important role in the clinical manifestations of borderline disorder, such as emotional dyregulation and impulsive behaviors. Neurocognitive rehabilitation therapy has been used successfully in psychiatric disorders such as schizophrenia, also characterized by the presence of neuropsychological dysfunctions. Thus, it can be expected that rehabilitation of the neurocognitive functions affected in BPD contributes to the patient’s functional improvement. The present work describes a series of five patients with BPD who presented important neuropsychological dysfunctions and who were treated successfully with a specific program of neurocognitive rehabilitation. The results observed justify the performance of controlled clinical studies on the efficacy of this technique in the treatment of BPD (AU)

APOE, ACT and CHRNA7 genes in the conversion from amnestic mild cognitive impairment to Alzheimer's disease.

We have investigated whether the -86 C/T promoter polymorphism in CHRNA7 gene, the signal peptide polymorphism of the alpha1-antichymotripsin (ACT) gene or the APOE genotype are associated with an increased risk of mild cognitive impairment (MCI) or affect the risk of evolution to Alzheimer's disease (AD). We have followed up 89 patients with initial diagnoses of amnestic MCI for 49 months. Patients were separated into three groups: 27 subjects who remained with MCI, 40 that converted to AD before 20 months and 22 that converted to AD after. To assess the risk associated to each genotype a control group (n=90) without cognitive impairment was included. APOE4 allele was associated with an increased risk of MCI (OR: 6.04, 95% CI: 2.76-3.23; p<0.001) but did not have an effect on the probability of evolving AD. ACT or CHRNA7 genotypes were not associated with MCI but both appear to modify the risk of progression to dementia in opposing manners: ACT polymorphism increasing the risk to evolve to AD before 20 months (HR=2.03; 95% CI: 1-4.6; p=0.06) and CHRNA7 polymorphism protecting from evolution to dementia. Cox regression model demonstrated that ACT genotype confers a higher risk of rapid evolution to dementia than age or years of schooling. We conclude that APOE is a risk gene for amnestic MCI and that ACT and CHRNA7 may act in these patients as modifier genes for the time of progression to AD.

Aprender a comunicarse con el paciente y con su entorno / Learning to communicate with the patient and the people around them

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The founding of the first psychiatric hospital in the World in Valencia.

Several hospitals, countries and cultures claim the privilege of being the first to have provided care to people suffering mental illnesses. Among them, the <> (Hospital of the Innocents) founded in Valencia in 1410 stands out due to its originality and there are historic and cultural reasons to recognize its primacy. Furthermore, the organization and functioning of this institution and the model, spread like wildfire through the entire Iberian Peninsula during the 15th Century and shortly after through American Spanish speaking countries. For centuries, these establishments were considered exemplary and were copied in other European Countries. At the beginning of the 19th Century in Spain a forced sale of the Catholic Church properties or their disamortization among other a large number of hospitals establishments took place. This lead to a terrible collapse of health care for the mentally. From then on it took more than one century to recover a decent standard. The vicissitudes of the creation and progress of the hospital of Valencia and others which followed the example that allows to affirm that it was really the first psychiatric hospital in the World are analyzed in this present work.

Risperidona intramuscular de acción prolongada en el trastorno límite de la personalidad resistente al tratamiento. Un estudio piloto / Long-acting injectable risperidone in treatment resistant borderlinepersonality disorder. A small series report

Introducción. El uso de fármacos antipsicóticos de segunda generación en combinación con fármacos anticomiciales en el trastorno límite de la personalidad (TLP) es común, pero muchos pacientes obtienen con ellos una mejoría muy limitada. Uno de los inconvenientes principales del tratamiento es el deficiente cumplimiento debido a la propia psicopatología impulsiva de los pacientes con TLP. Métodos. Doce pacientes con TLP grave y refractarios a tratamientos de combinación previos durante 3 meses fueron tratados con risperidona intramuscular de acción prolongada por un período de 6 meses. Se evaluaron los cambios clínicos mediante la Impresión Clínica Global (CGI), la Brief Psychiatric Rating Scale, las escalas de ansiedad y de depresión de Hamilton y la escalas de agresión. Se evaluó la mejoría funcional mediante la evolución de la Escala de Funcionamiento Global (GAF) del DSM-IV. Resultados. El tratamiento durante 6 meses se asoció a una mejoría significativa reflejada en la CGI (t: 5,7; gl: 10;p<0,01) y en la GAF (t: –4,5; gl: 10; p<0,01) que comenzó a consolidarse a partir del primer mes de tratamiento. No se registraron efectos extra piramidales relevantes, con excepción de un moderado enlentecimiento psicomotor que requirió ajustes de dosis en cuatro pacientes. Conclusiones. El uso de risperidona intramuscular de larga duración durante 6 meses se asoció a una significativa mejoría clínica y funcional y a una excelente tolerancia en un grupo de pacientes con TLP resistentes a tratamientos previos, lo que sugiere la conveniencia de investigar este efecto en ensayos clínicos controlados (AU)

Introduction. Borderline personality disorder (BPD) is usually treated with a combination of antipsychotic and anticonvulsant drugs although only limited efficacy is obtained in many patients. A major problem in the treatment of BPD is the lack of compliance derived form the pathological impulsivity of BPD patients. Methods. Twelve severe BPD patients refractory to previous treatment with drug combinations for three months were treated with intramuscular long-acting risperidone for a six-month period. Clinical changes were rated with the Clinical Global Impression (CGI), the Brief Psychiatric Rating Scale, anxiety and aggression scales. Functional improvement was evaluated with the Global Assessment of Functionng (GAF).Results. Six-month treatment with IM risperidone was associated with significant improvement of CGI (t: 5.7; gl: 10; p<0.01) and of GAF (t: –4.5; gl: 10; p < 0.01).Clinical improvement was robust after the first month of treatment. No relevant extrapiramidal side effects were reported with the exception of mild psychomotor slowing which requires dose adjustments in four patients. Conclusions. Treatment with i. m. long acting risperidone during six months was associated with significant clinical and functional improvement and excellent tolerability yin a group of BPD patients refractory to previous treatment. The results indicate that the effect of IM risperidone in BPD should be further investigated in large placebo-controlled trials (AU)