El diagnóstico en psiquiatría: una discusión teórica y práctica para el abordaje clínico / (Diagnosis in psychiatry: a theoretical and practical discussion for clinical assessment)

ResumenEl artículo aborda las dificultades en el diagnóstico psiquiátrico por las características propias de estos trastornos que, junto con la definición de lo patológico desde la prescripción de lo moralmente aceptado y los conflictos de interés entre la psiquiatría y las compañías farmacéuticas, han llevado a cuestionar las categorías diagnósticas en este campo del saber. Se argumenta la necesidad de contar con categorías, aunque imperfectas, para el abordaje clínico inicial, para el disfrute de los derechos laborales y en atención médica, para la investigación en este campo y para la definición y asignación de recursos en políticas públicas basadas en evidencia. Se explica cómo el personal de salud debe evaluar la percepción subjetiva del padeciente acerca de su sintomatología, malestar y disfunción, aunado a una cuidadosa observación del comportamiento no verbal y paraverbal, para proponer un diagnóstico sindrómico presuntivo y el abordaje inicial. Los criterios diagnósticos del DSM o la CIE no se deben aplicar como un "checklist" que resulta en un diagnóstico final incuestionable.Por último, se hace un llamado a desestigmatizar las categorías psiquiátricas. Se ha demostrado que el temor a la estigmatización resultante del etiquetado en psiquiatría, contribuye a que las personas no busquen ayuda profesional para trastornos en los que el tratamiento psicoterapéutico y farmacológico mejoran el malestar, calidad de vida y funcionalidad.

AbstractThis article addresses the difficulties in psychiatric diagnoses together with the practical need for these labels. The characteristics of these disorders, the definition of what is considered pathological by morally prescribed standards and the conflicts of interest between psychiatry and pharmaceutical companies, have led to question the diagnostic categories in this field of knowledge. We argue that diagnostic categories are necessary, for the initial clinical approach; for access to medical care, disability and other legal rights; for research in this field; and for the definition and allocation of resources in evidence-based public policies. We discuss how clinical practitioners should assess the subjective perception of the sufferer of their symptoms, discomfort and dysfunction, together with a careful observation of non-verbal and para-verbal behavior, to propose a presumptive syndromic diagnosis and the initial approach. The diagnostic criteria of the DSM or ICD should not be applied as a "checklist" resulting in an unquestionable final diagnosis. Finally, we make a call to de-stigmatize the psychiatric categories. Fear of stigmatization resulting from psychiatric labels has been shown to contribute to sufferers not seeking professional help, for disorders in which psychotherapeutic and pharmacological treatment, improves symptomatology, quality of life and functionality.

Categorising Patients Mental Illness by Medical Surgical Nurses in the General Hospital Ward: A Focus Group Study.

AIM: To gain insight into medical surgical nurses' process(es) of categorising mental illness in general hospitals. BACKGROUND: Categorising patients is a daily social practice that helps medical surgical nurses understand their work and actions. Medical surgical nurses' categorising of mentally ill patients in general hospitals is a means in which they articulate their understanding of mental illness and perform their clinical practice. How medical surgical nurses categorise, and the impact that categorising can have on their work practices is poorly understood. DESIGN: A focus group study. METHOD: Focus group discussions (n=2) of medical surgical nurses' understanding and experience of delivering care to patients with mental illness in a general tertiary referral hospital were conducted in November 2014. Discourse analysis was used to analyse the transcribed data to uncover how participants made discursive evaluations and how this related to their daily clinical practice. RESULTS: The analysis uncovered participant's use of four categories of mentally ill patients: the managed, the unpredictable, the emotional and the dangerous. For participants these categories explained and justified their clinical practice as linked to the challenges and barriers they experienced in providing effective care within the larger healthcare organisation. CONCLUSION: The language used by medical/surgical reflects the wider discourse of managerialism in healthcare organisations. The recognition of these categories can be used by educators, liaison mental health services and policy makers to reconsider service design and learning opportunities for medical surgical nurses to reduce stigmatisation of patients with mental illness.

Typologies of Individuals Attending an Addiction Rehabilitation Center Based on Diagnosis of Mental Disorders.

OBJECTIVES: This study aimed to: (1) identify clusters based on the diagnostic status of mental disorders among individuals with problematic substance use treated in an addiction rehabilitation center (ARC), and (2) characterize these clusters according to socio-demographic variables, neighborhood characteristics, and health service utilization. METHODS: Data were compiled for 4526 individuals with problematic substance use who received services from an ARC in 2004. The data were compiled by merging four databases: the ARC data registry, the Quebec Health Insurance Board database, the Quebec provincial database for hospitalizations, and the Quebec National Institute of Public Health database. A two-step cluster analysis was performed to generate distinct groups based on diagnostic categories of mental disorders. Complementary comparative analyses were conducted to test differences among the clusters. RESULTS: Three clusters were identified. The first cluster consisted of individuals who did not receive any diagnosis of a mental disorder, including substance use disorders (SUDs), and who were low users of health services. The second cluster was composed of individuals who received a diagnosis of mental disorder, but not of SUD, and who primarily used mental health services. The third cluster included individuals who had a dual diagnosis (co-occurring SUD and mental disorder), and who were high users of acute care services. CONCLUSIONS: This study highlights the heterogeneity of individuals with problematic substance use treated in an ARC. Treatment will be more effective, overall, if tailored to the varying needs of individuals with problematic substance use. Recommendations of the study geared toward improving the effectiveness of care for this population include systematic diagnostic screening for SUDs by physicians, developing strong primary care for individuals with problematic substance use, and ensuring a continuing care model for individuals with a dual diagnosis.

Un nuevo método de valoración de la enfermedad psiquiátrica postraumática / A new assessment method of posttraumatic psychiatric pathology

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Validación de la versión española de la escala Screening for Somatoform Symptoms-2 para la evaluación de síntomas somáticos en Atención Primaria / Validation of the Spanish version of the Screening for Somatoform Symptoms-2 scale for use in Primary Care

OBJETIVO: Estudiar la validez diagnóstica y aportar los valores de sensibilidad, especificidad, valor predictivo positivo y valor predictivo negativo de la versión española de la escala Screening for Somatoform Symptoms-2(SOMS-2) en una muestra de pacientes de AP. DISEÑO: Estudio de validación. Emplazamiento: Centros de salud de AP de Aragón y Baleares. PARTICIPANTES: Ciento nueve pacientes somatizadores prodecedentes de un ensayo clínico previo y 56 pacientes no somatizadores incluidos para la validación de la escala. MEDICIONES PRINCIPALES: Sensibilidad, especificidad, valor predictivo positivo, valor predictivo negativo y α de Cronbach. RESULTADOS: De un total de 165 sujetos, el 75% fueron mujeres y el 60% presentó trastorno de somatización y/o trastorno de ansiedad o depresivo. La SOMS-2 de 53 ítems y con un punto de corte de 4 presentó una sensibilidad del 97%, una especificidad del 68%, un valor predictivo positivo del 85%, un valor predictivo negativo del 92% y una alta consistencia interna (α de Cronbach = 0,926). CONCLUSIONES: La versión española de la SOMS-2 constituye un instrumento de cribado eficaz, útil y de fácil administración para la evaluación de los trastornos somatomorfos en AP. Los resultados de sensibilidad, especificidad y consistencia interna son similares a los de estudios previos de validación de la SOMS-2 en otras lenguas europeas

OBJECTIVE: To study the diagnostic validity and to provide the sensitivity, specificity, positive predictive value and negative predictive value of the Spanish version of the Screening for Somatoform Symptoms-2 (SOMS-2) scale in a PC population sample. DESIGN: Validation study. SETTING: PC centres in Aragon and Balearic Islands, Spain. PARTICIPANTS: A sample of 109 patients from a clinical trial with somatoform disorders and 56 patients without somatoform disorder were included for the scale validation. Main outcome measures: Sensitivity, specificity, positive predictive value, negative predictive value and Cronbach's α coefficient. RESULTS: Of the total sample of 165 subjects, 75% were women and 60% had a diagnosis of somatization disorder and/or anxiety or depressive disorder. The 53-item version of the SOMS-2 with a cut-off point of 4 showed a sensitivity of 97%, a specificity of 68%, a positive predictive value of 85%, a negative predictive value of 92%, and high internal consistency (Cronbach α = 0.926). CONCLUSIONS: The Spanish version of the SOMS-2 seems to be a reliable screening tool, easy to complete and useful for the assessment of somatoform disorders in PC settings. The results for specificity, sensitivity, and internal consistency are similar to previous studies in other European languages

Allen Frances y la pureza del diagnóstico / Allen Frances and the purity of diagnosis

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Ejecución de medidas penales alternativas a la prisión / No disponible

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La responsabilidad penal y civil en el ámbito médico sanitario / No disponible

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Profiles of patients admitted to a psychiatric intensive care unit: secluded with or without restraint.

OBJECTIVE: To identify and describe the profiles of patients admitted to a psychiatric intensive care unit (PICU) as they relate to seclusion and restraint. METHOD: Multiple correspondence analysis (MCA) and cluster analysis were performed with data for 114 patients admitted to a PICU from June 8, 2010, to June 7, 2011. RESULTS: The MCA revealed that the presence or absence of seclusion and restraint was the main factor explaining the variance. Admitted patients fall into 5 profiles, 2 of which are significantly associated with seclusion and restraint: young psychotic men and women with bipolar disorder. CONCLUSIONS: The differentiation of patient profiles as they relate to seclusion and restraint should lead to the development of profile-specific interventions before, during, and after seclusion and restraint.

Objectif : Identifier et décrire les profils de patients hospitalisés dans une unité de soins psychiatriques intensifs (USPI) et leur relation à l'isolement et la contention. Méthode : Une analyse des correspondances multiples (ACM) et une analyse de groupe ont été effectuées sur les données de 114 patients hospitalisés dans une USPI du 8 juin 2010 au 7 juin 2011. Résultats : L'ACM a révélé que la présence ou l'absence d'isolement et de contention était le principal facteur expliquant l'inertie. Les patients hospitalisés se divisent en 5 profils, dont 2 sont significativement associés à l'isolement et la contention : les jeunes hommes psychotiques et les femmes souffrant du trouble bipolaire. Conclusions : La différentiation des profils des patients relative à l'isolement et à la contention devrait mener à l'élaboration d'interventions propres au profil, avant, durant et après l'isolement et la contention.

The "mental feature" in mental illness: difficulties that this reality poses for diagnosis and classification / O "mental" na doença mental: dificuldades que sua realidade impõe em relação a diagnóstico e classificação

Four points are considered in this article. In the first place, it is argued that the "settings" of psychiatric care express the need to respond to the degree of decrease in personal freedom of the patient. Then, the issue of how "the mental feature" of the mental pathology has been recognized and categorized since the 18th century is examined, pointing out the difficulties involved in considering the mental nature of the subject of psychiatry. In the third place, the issue of how current systems of diagnosis and classification are posed regarding this reality is briefly looked at. Finally, the characteristics of a working hypothesis that allows organizing consistent clinical facts providing a heuristic perspective are analyzed

Neste artigo, quatro pontos são considerados. Em primeiro lugar, argumenta-se que os "espaços" da atenção psiquiátrica expressam a necessidade de responder ao grau de diminuição da liberdade pessoal do paciente. Em seguida, são discutidas as formas como o "mental" da doença mental tem sido reconhecido e categorizado a partir do século 18, apontando para dificuldades envolvidas ao se considerar o caráter mental do objeto da psiquiatria. Em terceiro lugar, são discutidas brevemente as formas como os sistemas atuais de diagnóstico e classificação se posicionam sobre essa realidade. Finalmente, as características de uma hipótese de trabalho que permita organizar de modo coerente os fatos clínicos e que proporcione uma perspectiva que seja heurística são analisadas

Situacion en España del tratamiento ambulatorio involuntario (TAI) para enfermos mentales graves / Involuntary outpatient treatment (IOT) for severe mental patients: current situation in Spain

El tratamiento ambulatorio involuntario (TAI) pretende mejorar la adherencia al tratamiento y, por tanto, prevenirlas recaídas y el deterioro de las personas con enfermedad mental grave. Además de las posiciones manifestadas a favor y en contra con la introducción del TAI, los estudios publicados en la literatura médica obtienen también resultados contradictorios. En la mayoría de los países de nuestro entorno, se han producido cambios legislativos que regulan su aplicación. En la actualidad no existe en España una normativa legal, sin embargo, es posible su aplicación en el ámbito local de algunas ciudades españolas. En este artículo se pretende hacer una revisión del TAI en los países de nuestro entorno y España (AU)

Involuntary Outpatient Treatment (IOT) expects to improve treatment compliance and, therefore, prevent the impairment of patients with severe mental illness, as well as the risk for them and others. Besides IOT introduction defenders and opponent’s states, scientific literature offers contradictory results. Legislative changes have been taken in the vast majority of our neighbouring countries in order to regulate IOT application. There is no legal regulation in Spain; however, OIT application is possible in certain Spanish cities. This article reviews IOT in Spain and surrounding countries (AU)

Rehabilitación psiquiátrica en un hospital de cuidados psiquiátricos prolongados / Psychiatric rehabilitation in extended care psychiatric hospital

Objetivo: El cambio de un modelo de cuidados a un modelo de rehabilitación en Unidades de Cuidados Psiquiátricos Prolongados (UCPP) donde se pretenden generar perfiles de usuarios con enfermedad mental grave y duradera en los que se tenga en cuenta tanto el grado de afectación clínica y/o del desempeño psicosocial como el nivel de institucionalización (medido a partir de la estancia hospitalaria), todo con la finalidad de plantear un posible modelo de reorganización de los usuarios en base a estos criterios. Método: Por un lado, se ha tenido en consideración la variable, años de ingreso en la institución, para así tener una medida de la institucionalización y/o una medida que plasme posibles dificultades de reinserción en el medio comunitario. Por otra parte, se ha utilizado una variable que tuviese en cuenta factores clínicos y relacionados con el desempeño psicosocial y que es La Escala de Evaluación de la Actividad Global –EEAG- ( Eje V del DSM-IV-TR). A partir de las variables comentadas se ha realizado un análisis de conglomerados –clusters- con el paquete estadístico SPSS 19.0. Resultados: El análisis de conglomerados realizado muestra la existencia de cuatro grupos de diferente tamaño para el conjunto de usuarios que los componen. Estos cuatro grupos definirían prototipos de perfiles de pacientes ingresados en una UCPP: 1) Dependientes Institucionalizados –DI-, 2) Independientes Institucionalizados –II-, 3) Dependientes No Institucionalizados –DNI- e 4) Independientes No Institucionalizados –INI-. Conclusiones: El interés y la utilidad de clasificar los usuarios en diferentes niveles según su desempeño psicosocial se refleja en posibilidades de mejora en el tratamiento individualizado, adaptándolo a las necesidades de atención, asistencia y terapia de los usuarios(AU)

Objective: The shift from a model of care to a rehabilitation model in Extended Care Psychiatric Units, which aim to generate profiles of users with severe and enduring mental illness in which takes into account both the degree of clinical involvement and/or psychosocial functioning and the level of institutionalization (measured from the hospital stay), all in order to propose a possible model for the reorganization of users based on these criteria. Method: On the one hand, it has taken into account the variable years of admission into the institution in order to have a measure of institutionalization y a measure that reflects potential difficulties of returning to the community. Moreover, we have used a variable to take into account clinical factors related to psychosocial functioning and that is the Global Assessment Functioning Scale -GAF- (Axis V of DSM-IV-TR). Based on the variables discussed there has realized a cluster analysis using the statistical package SPSS 19.0 Results: Cluster analysis performed shows the existence of four different size groups for all users. These four groups define prototypes profiles of patients admitted to an Extended Care Psychiatric Unit: 1) Institucionalized Dependents, 2) Institucionalized Independents, 3) Non Institucionalized Dependents, and 4) Non Institucionalized Independents. Conclusions: The interest and usefulness to classify users in different levels according to their psychosocial functioning is reflected in improved opportunities for individual treatment, adapting to the needs of care, assistance and therapy of the users(AU)

The role of psychopathic personality disorder in violence risk assessments using the HCR-20.

Antisocial and psychopathic traits are essential to evaluate when assessing risk for violence using the HCR-20. The role of the PCL-R on the HCR-20 was investigated using a series of meta-analytic tests. Across 34 samples in which both tools were rated, AUCs for violence were similar (∼.69), and exclusion of the psychopathy item (H7) did not reduce the HCR-20's accuracy. Quantitative synthesis of results from multivariate analyses conducted in 7 raw datasets that used both tools demonstrated that the average probability of observing violence for every point increase on the HCR-20 (without H7), while controlling for the PCL-R, was 23%, whereas for the PCL-R it was -1%. The HCR-20 (without H7) added incremental validity to the PCL-R, whereas the converse was not true, and only the HCR-20 (without H7) possessed unique predictive validity. Results suggest the HCR-20's predictive validity was not negatively impacted by excluding the PCL-R. Areas for future study are discussed, including research on various ways to assess and incorporate into risk assessment personality traits related to violence.