Response to methylphenidate by adult and pediatric patients with attention-deficit/hyperactivity disorder: the Spanish multicenter DIHANA study.

BACKGROUND: The purpose of this multicenter Spanish study was to evaluate the response to immediate-release methylphenidate by children and adults diagnosed with attention-deficit/hyperactivity disorder (ADHD), as well as to obtain information on current therapy patterns and safety characteristics. METHODS: This multicenter, observational, retrospective, noninterventional study included 730 patients aged 4-65 years with a diagnosis of ADHD. Information was obtained based on a review of medical records for the years 2002-2006 in sequential order. RESULTS: The ADHD predominantly inattentive subtype affected 29.7% of patients, ADHD predominantly hyperactive-impulsive was found in 5.2%, and the combined subtype in 65.1%. Overall, a significant lower Clinical Global Impression (CGI) score and mean number of DSM-IV TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision) symptoms by subtype were found after one year of treatment with immediate-release methylphenidate; CGI decreased from 4.51 to 1.69, symptoms of inattention from 7.90 to 4.34, symptoms of hyperactivity from 6.73 to 3.39, and combined subtype symptoms from 14.62 to 7.7. Satisfaction with immediate-release methylphenidate after one year was evaluated as "very satisfied" or "satisfied" by 86.90% of the sample; 25.75% of all patients reported at least one adverse effect. At the end of the study, 41.47% of all the patients treated with immediate-release methylphenidate were still receiving it, with a mean time of 3.80 years on therapy. CONCLUSION: Good efficacy and safety results were found for immediate-release methylphenidate in patients with ADHD.

Aripiprazol en el autismo: seguridad y tolerancia / Aripiprazole in autism: safety and tolerability

El objetivo de este estudio es hacer una revisión sobre la eficacia y seguridad de aripiprazol en el tratamiento de los síntomas de irritabilidad asociados al trastorno autista. También se revisa la mejoría en otros síntomas de la escala Aberrant Behavior Checklist (ABC). Para ello hemos revisado tres estudios. Dos son aleatorizados, doble ciego y multicéntricos, 8 semanas de duración, que evaluaban la eficacia de aripiprazol a dosis fijas (5mg/d, 10mg/d, 15mg/d) y a dosis flexibles (2-15mg/d) comparados con placebo. El tercer estudio fue un análisis post hoc de los dos anteriores y evaluó el efecto del aripiprazol en los 58 ítems de la escala ABC. Los resultados fueron significativos con aripiprazol en comparación con placebo en los siguientes ítems de la escala ABC y con todas las dosis de aripiprazol usadas: cambios rápidos de humor, gritos, patadas, movimientos repetitivos, bullicioso, constantemente corre o salta y tiende a ser excesivamente activos. Con la dosis de 15 mg /d se obtuvieron resultados significativos en un mayor número de items

The aim of this study is to do a review on the efficacy and security of aripiprazole in the treatment of symptoms of irritability associated with autistic disorder. Improvements in other symptoms included on the Aberrant Behavior Checklist (ABC) are revised as well. In order to do this we have reviewed three studies. The first two are 8-week, randomized, double-blind, multicenter trials to evaluate the efficacy of both aripiprazole fixed doses (5 mg/d, 10mg/d, 15mg/d) and flexible doses (2-15mg/d) versus a placebo. The third study was a post hoc analysis of the two former, and it evaluated the effect of aripiprazol on the 58 items the ABC scale. The results were significant with aripiprazole versus a placebo on the following ABC scale items and with all aripiprazole doses used: mood changes quickly, cries/screams, stamps feet, repetitive movement, boisterous, constantly runs or jumps, and tends to be excessively active. Furthermore with the 15mg/d dose significant results were obtained for a greater number of items

[GEITDAH consensus on attention deficit hyperactivity disorder]. / Consenso del GEITDAH sobre el trastorno por deficit de atencion/hiperactividad.

In this article, the GEITDAH -the Spanish abbreviation of the Special Interest Group on Attention Deficit Hyper-activity Disorder (ADHD)- presents a consensus reached by experts in the management of ADHD from all over Spain. The consensus concerns fundamental aspects that should be the starting point for future local or regional consensus guides. Another aim of this consensus is also to reduce the amount of variability that occurs in the health care offered to patients with ADHD in our country, as well as to act as a stimulus in educational matters. That fact that it is not very long will make it more popular among greater numbers of people and this will allow these goals to be reached more effectively. The conclusions in the consensus guide have been constructed around an introduction dealing with basic aspects and recommendations for diagnosis, treatment (both pharmacological and psychotherapeutic), patient flow and organisational aspects.

Fármacos para el trastorno por déficit de atención/hiperactividad / Drugs for attention deficit hyperactivity disorder

Se encuentran diferencias entre los diversos fármacos aprobados en España para el trastorno por déficit de atención/hiperactividad en estudios de tipo cuantitativo. No hay claras diferencias en estudios de tipo cualitativo. El número de pacientes a tratar para que uno alcance remisión completa (NNT) del metilfenidato (MTF) es de 2,2 a 5, y el tamaño del efecto (TE), de 0,9. La atomoxetina tiene un NNT de 4 y un TE de 0,7. Las ventajas del MTF de liberación inmediata (MTF-LI) respecto al de liberación prolongada (MTF-LP) residen en su bajo coste, su flexibilidad y mejores resultados en estudios cuantitativos. Por contra, el MTF-LP presenta un menor riesgo de abuso, precisa un menor número de tomas, una menor necesidad de terceros para el control de éstas y un menor riesgo de estigmatización. La combinación o cambio de MTF-LI y MTF-LP y la combinación de MTF con atomoxetina son en ocasiones necesarias para ajustar la posología de día laborable o de fin de semana. Iniciar el tratamiento con MTF-LI para luego mantener o cambiar a MTF-LP aporta ciertas ventajas en seguridad, ajuste de dosis y posología. La atomoxetina es la mejor alternativa si hay antecedente de eventos adversos con estimulantes en dosis bajas o moderadas, o falta de respuesta a los estimulantes en dosis altas. En caso de ansiedad comórbida importante, tanto el MTF como la atomoxetina tienen igual nivel de indicación. Si hay riesgo de abuso de sustancias, tanto la atomoxetina como el MTF-LP son de primera elección. Para el resto de indicaciones, el MTF constituye la primera elección (AU)

Quantitative studies have highlighted differences in several drugs approved for use in Spain in the treatment of attention deficit hyperactivity disorder. No clear differences are observed, however, in the case of qualitative studies. The number of patients needed to be treated in order for one to reach complete remission (NNT) of methylphenidate (MTF) is from 2.2 to 5, and the effect size (ES) is 0.9. Atomoxetine has an NNT of 4 and an ES of 0.7. The advantages of immediate-release MTF (IR-MTF) over the extended-release version (ER-MTF) lie in its low cost, its flexibility and the better results obtained in quantitative studies. In contrast, ER-MTF offers a lower risk of abuse, needs to be taken fewer times with less need for third parties to control administration, and there is a lower risk of stigmatisation. Combination or changes of IR-MTF and ER-MTF and the combination of MTF with atomoxetine are sometimes necessary to adjust the weekday or weekend doses. Starting treatment with IR-MTF and then maintaining or changing to ER-MTF offers certain advantages as regards safety, dose adjustments and dosage. Atomoxetine is the best alternative if there is a background of adverse events with low or moderate doses of stimulants, or lack of response to high doses of stimulants. In cases of notable comorbid anxiety, both MTF and atomoxetine have the same level of indication. If there is a risk of substance abuse, both atomoxetine and ER-MTF are the preferred treatment. For the other indications, MTF is the preferred treatment (AU)

[Drugs for attention deficit hyperactivity disorder]. / Farmacos para el trastorno por deficit de atencion/hiperactividad.

Quantitative studies have highlighted differences in several drugs approved for use in Spain in the treatment of attention deficit hyperactivity disorder. No clear differences are observed, however, in the case of qualitative studies. The number of patients needed to be treated in order for one to reach complete remission (NNT) of methylphenidate (MTF) is from 2.2 to 5, and the effect size (ES) is 0.9. Atomoxetine has an NNT of 4 and an ES of 0.7. The advantages of immediate-release MTF (IR-MTF) over the extended-release version (ER-MTF) lie in its low cost, its flexibility and the better results obtained in quantitative studies. In contrast, ER-MTF offers a lower risk of abuse, needs to be taken fewer times with less need for third parties to control administration, and there is a lower risk of stigmatisation. Combination or changes of IR-MTF and ER-MTF and the combination of MTF with atomoxetine are sometimes necessary to adjust the weekday or weekend doses. Starting treatment with IR-MTF and then maintaining or changing to ER-MTF offers certain advantages as regards safety, dose adjustments and dosage. Atomoxetine is the best alternative if there is a background of adverse events with low or moderate doses of stimulants, or lack of response to high doses of stimulants. In cases of notable comorbid anxiety, both MTF and atomoxetine have the same level of indication. If there is a risk of substance abuse, both atomoxetine and ER-MTF are the preferred treatment. For the other indications, MTF is the preferred treatment.

Aditivos y trastorno del déficit de atención. Actualización / Additives and upheaval of the attention deficit. Update

En 1975 se abrió el debate sobre si el consumo de ciertos aditivos podría aumentar la hiperactividad o tener efectos perniciosos en la atención, conducta y aprendizaje, ya en población normal, ya en pacientes con trastorno por hiperactividad. Si bien los resultados han sido negativos durante decenios de investigación, desde el 2004 se ha reabierto el debate con más fuerza gracias a un nuevo metanálisis y a dos investigaciones cuyos últimos resultados se publican en septiembre del 2007. Estos artículos aportan datos positivos sobre un efecto neurobiológico leve de estos aditivos en población normal y según metanálisis también en TDA. Este efecto neurobiológico implicaría al menos un aumento de la hiperactividad. Los estudios necesitan ser replicados por otros equipos de investigadores y afinar problemas metodológicos pero por el momento cambian nuestra perspectiva sobre la influencia de estos aditivos en la hiperactividad y sobre sus efectos neurobiológicos (AU)

Artificial food colours and other food additives (AFCA) have long been suggested to affect behaviour in children.. The main putative effect of food additives is to produce overactive, impulsive, and inattentive behaviour. Despite the failure of early studies along 30 years to identify the range of proposed adverse affects, a recent meta-analysis4 of double-blinded, placebo-controlled trials and two new researches has shown a significant effect of food additives on the behaviour of children with ADHD. This effect should be to increase hyperactivity. Although these studies need to be replicated, have changed our view point about this issue (AU)

[Swallowing phobia: symptoms, diagnosis and treatment]. / Fobia a tragar: clínica, diagnóstico y tratamiento.

INTRODUCTION: Choking phobia (or swallowing phobia) is characterized by a fear of swallowing foods, liquids or pills, sometimes after an episode of choking on food. METHODS: Forty-one case reports on swallowing phobia from 1978 to 2005 were studied. Clinical and therapeutic variables of the disorder were studied. RESULTS: It appears to occur more often in females (two-thirds of the cases) and has a high comorbidity with anxiety disorders (panic disorder, 41 %; obsessive conditions, 22 %, and separation anxiety, 15 %). Life-events and eating traumatic antecedents are frequently present (44% and 56% cases, respectively). Cognitive-behavioral treatments have been of proven efficacy, as well as anti-panic drugs (alprazolam, lorazepam, bromazepan, imipramine, clomipramine, fluoxetine, paroxetine) with a remission rate of 58.5%. Gender and treatment differences are also analyzed.

Fobia a tragar: clínica, diagnóstico y tratamiento / Swallowing phobia: symptoms, diagnosis and treatment

Introducción. La fobia a tragar (o a atragantarse) se caracteriza por miedo a atragantarse al ingerir comida, líquidos o pastillas, a veces tras un episodio de atragantamiento con comida. Métodos. Se han analizado las publicaciones entre 1978 y 2005 en las que se recogían 41 casos con fobia a tragar. Se estudiaron las variables clínicas y terapéuticas del trastorno. Resultados. Parece suceder más en mujeres (dos tercios de los casos) y tiene una alta comorbilidad con trastornos de ansiedad (pánico, 41 %; patología obsesiva, 22 %, y ansiedad de separación, 15 %). Con frecuencia existen antecedentes traumáticos en la ingesta o sucesos vitales (56 y 44%, respectivamente). Se han mostrado eficaces los tratamientos cognitivo- conductuales, así como fármacos antipánico (alprazolam, lorazepam, bromazepam, imipramina, clomipramina, fluoxetina, paroxetina) con una tasa de remisiones completas del 58,5 %. Estudiamos las diferencias por sexo y por tratamientos utilizados

Introduction. Choking phobia (or swallowing phobia) is characterized by a fear of swallowing foods, liquids or pills, sometimes after an episode of choking on food. Methods. Forty-one case reports on swallowing phobia from 1978 to 2005 were studied. Clinical and therapeutic variables of the disorder were studied. Results. It appears to occur more often in females (twothirds of the cases) and has a high comorbidity with anxiety disorders (panic disorder, 41 %; obsessive conditions, 22 %, and separation anxiety, 15 %). Life-events and eating traumatic antecedents are frequently present (44% and 56% cases, respectively). Cognitive-behavioral treatments have been of proven efficacy, as well as anti-panic drugs (alprazolam, lorazepam, bromazepan, imipramine, clomipramine, fluoxetine, paroxetine) with a remission rate of 58.5%. Gender and treatment differences are also analyzed

Aspectos evolucionistas de los trastornos afectivos, revisión crítica y propuesta de un nuevo modelo / Evolutionary aspects of affective disorders, critical review and proposal of a new model

La psicopatología evolucionista enfoca la psicopatología bajo el prisma de la teoría de la evolución, generando nuevas hipótesis etiológicas de los trastornos mentales. Para la psicopatología evolucionista las emociones son sistemas de respuesta o formas especiales de funcionamiento prefijados genéticamente, producto de la evolución, que nos permiten adaptarnos al ambiente, a sus amenazas y oportunidades, y que ejercen su función mediante una serie de cambios coordinados a nivel fisiológico, cognitivo y conductual. Existen varios modelos evolucionistas que intentan explicar la función adaptativa de la depresión: reacción ante la pérdida de jerarquía en la lucha social, escenificación de la sumisión o rendición, forma de lograr el cambio de motivación al no lograr un objetivo, función de búsqueda de apoyo social, paralelismos con la fase de desesperación del experimento de separación de crías de monos de sus madres, hibernación, etc.Nuestro modelo intenta explicar la depresión, los estados maníacos, hipomaníacos y otros estados afectivos. A nuestro juicio la mayoría de los trastornos afectivos son procesos patológicos (y no adaptativos) que surgen de un mecanismo desencadenante innato (MDI) que inicialmente sí es adaptativo, pero se ha alterado, y cuya función es regular el nivel de energía y actividad a partir de la intensidad y duración de luz (MDI-A). Este MDI-A desencadena respuestas vegetativas, endocrinas y conductuales presentes tanto en humanos como en animales filogenéticamente más antiguos. Más recientemente en la filogenia se han acoplado a este MDI-A otros mecanismos (MDI-AA). En el hombre los desencadenantes de los MDI-AA son de índole social y se han añadido nuevas respuestas (como el humor) a las respuestas más antiguas del MDI-A

Evolutionary psychopathology incorporates psychiatry into biology via theory of evolution, generating new etiological hypothesis for mental disorders. For evolutionary psychopathology emotions are a response system or a genetically programmed, specialized state of functioning, formed by natural selection, that allows us to adapt to the environment, increasing the ability to cope with threats and opportunities. Emotions exert their function by coordinated physiological, psychological and behavioral changes. Many functions have been suggested for low mood or depression, including communicating a need for help, signaling yielding in a hierarchy conflict, fostering disengagement for commitments to unreachable goals, regulating patterns of investment, parallelism with despair phase of separation from mother situation in monkeys, hibernation, etc. ;;Despite other evolutionary models, our model not only tries to explain depression but mania, hypomania and other affective disorders as well. For us, most affective disorders are pathological states (and not adaptive ones), due to dysfunction of an innate precipitating mechanism (IPM). IPM function is to regulate energy and activity levels according to intensity and duration of light (namely IPM-A). This IPM-A is responsible for vegetative, endocrine and behavioral responses that are present in humans and more ancient phylogenetic animals. More recently in the phylogeny, other mechanisms (IPM-AA) have coupled to this IPM-A. In the human being, the precipitating factors of IPM-AA are predominately social. IPM-AA add new responses (such as mood) to the older responses of IPM-A

Violence in mental disorders and community sample: an evolutionary model related with dominance in social relationships.

The major risk determinants of violence are to be young and male, to have low socioeconomic status and suffering substance abuse. This is true whether it occurs in the context of a concurrent mental illness or not; i.e., mental disorders are neither necessary, nor sufficient causes for violence. Intense motivation is a facilitating factor for violence in clinical and non clinical samples. This explains why 'normal' people, are implicated in planned violence at higher rates than mentally ill (e.g. in criminal acts against property). However mentally ill patients are more easily implicated in impulsive violence or in violence without obvious cause due to veiled motivation fuelled by unidentified symptoms. Subjective or real awareness of competitive disadvantage increases motivation for violence (e.g. paranoid, narcissistic symptoms, etc.). Many psychiatric disorders as antisocial disorder, borderline, schizophrenia, have most of the factors that facilitate the appearance of violence. Antisocial disorder is a good model to study determinants of violence in normal samples as it is present in young males that do not have any psychotic symptom, have stable symptomatology, self control under scrutiny, and their motivations are similar to normal samples. Our evolutionary model suggests that there is a non random association of genetic factors (genes, pseudogenes, promoting areas, etc.), that is, a genetic cluster (cluster DO), whose phylogenetic function is to motivate to be the dominant in social relationships. To be the dominant is a major psychological feature present in many social groups of animals, included primates. DO cluster have sense from an evolutionary viewpoint: when expressed in no pathological way it increases inclusive fitness (transmission of the genes of a person genotype whether by oneself or by relatives reproduction). Features of cluster DO in humans are expressed differently according to sex, age, moral education, level of intelligence, etc. Cluster DO has higher phenotypical expression in males and young people. Primary antisocial personality disorder and other related disorders (cluster B personality disorders, disocial, defiant disorder, etc.), are a pathological manifestation of this cluster DO. Some other genetic clusters that causes the genetic liability to some disorders (e.g. attention deficit disorder) are non random associated with cluster DO, thus explaining clinical comorbidity. According to our model, motivation for dominance usually prevails over motivation for material benefit or antinormative behaviour, this explains some incongruent behaviour in antisocial patients not elucidated by other models. Along with the primary expressed feature of dominance of cluster DO there are other secondary features that have been identified by psychobiological studies: novelty seeking, intolerance for frustration, impulsiveness, fearless, aggressiveness, higher threshold for activation of the sympathetic system, lack of empathy, egoism, non acceptance of rules, defiant and rebellious behaviour, manipulation in social interactions, selfishness and deficits in altruism or in social co-operation.

Revisión crítica de la eficacia y seguridad de atomoxetina / Efficacy and safety of atomoxetine: A critical review

La atomoxetina es un fármaco que inhibe la recaptación de noradrenalina, y que se está estudiando para el tratamiento del trastorno de déficit de atención con hiperactividad (TDAH) en España. Se han publicado con este ármaco en países anglosajones, diversos estudios pre- y post-comercialización, tanto abiertos como aleatorizados, doble ciego y controlados con placebo, en niños y adolescentes y en adultos. Señalamos sus propiedades farmacológicas y sus indicaciones, así como los datos publicados sobre su eficacia en TDAH y trastornos comórbidos, y revisamos críticamente su perfil de efectos adversos y las últimas cuestiones sobre su seguridad (AU)

Atomoxetine is a drug that inhibits the noradrenaline reuptake and that is being studied for treatment of attention- deficit/hyperactivity disorder (ADHD) in Spain. So far, a variety of pre- and post-marketing, open-label and randomised, double-blind, placebo-controlled trials have been published, in children and adolescents and in adults. Its pharmacological properties and indications, and published evidences on efficacy on ADHD and comorbid disorders are presented, and its adverse effects profile and last safety concerns are critically reviewed (AU)

[Treatment of Tourette syndrome and its comorbidity: experience with 17 cases]. / Tratamiento del síndrome de Tourette y su comorbilidad: presentación de 17 casos.

INTRODUCTION: Clinical characteristics and comorbid disorders of Tourette syndrome (TS) are reviewed along with a presentation of our experience with 17 cases. MATERIAL AND METHODS: We carried out a retrospective study of pediatric patients with TS admitted from 1998 to 2004 in Fundación Hospital Alcorcón. RESULTS: Seventeen patients were obtained, 16 of whom were men and there was only 1 woman. Present age ranged from 7 to 17 years old. Most frequent comorbid disorders were attention deficit disorder (ADD) in 9 patients, (53%), obsessive-compulsive disorder in 8 (48%) and anxiety in 7 (41%). Learning disorders were found in 7 patients (41%), 5 of whom have concurrent ADD and 1 severe obsessive compulsive disorder. Psychopharmacological treatment was withdrew in the 2 cases treated with halloperidol due to the presence of severe extrapyramidal symptoms (EPS) and in 3 of the 7 cases treated with pimozide (one of them was withdrawn due to EPS). No EPS was found with atypical neuroleptics, but sedation and weight gain was common. Methylphenidate was administered to 7 patients without an increase in tics. CONCLUSIONS: In our sample the most common comorbid disorders were ADD, obsessive-compulsive disorders, anxiety and learning disorders. Atypical neuroleptics were better tolerated than classic ones, although the incidence of side effects is elevated. Methylphenidate was not associated with tic worsening.

El uso de los nuevos antipsicóticos atípicos en el síndrome de Gilles de la Tourette / Use of atypical antipsychotics in Tourette´s syndrome

El síndrome de GiIles de la Tourette (SGT) es un trastorno neuropsiquiátrico con tics motores y vocales crónicos y una elevada comorbilidad y síntomas secundarios. Se han venido usando agonistas alfa-2 (clonidina) o antipsicóticos clásicos (haloperidol, pimocida) con buena eficacia pero mala tolerancia (Efectos adversos). Revisamos la literatura existente sobre eficacia y tolerancia de los nuevos antipsicóticos (clozapina, risperidona, olanzapina, quetiapina, amisulpride, ziprasidona) en esta patología

Tourette's syndrome is a neuropsychiatric disorder characterized by chronic motor and vocal tics and a high comorbidity and associated symptoms. Usually, alpha-2 agonists (clonidine) or typical antipsychotics (haloperidol, pimozide) have been used with a good efficacy but they are poorly tolerated (adverse effects). We review here the existing evidences on efficacy and tolerance for the new antipsychotics (clozapine, risperidone, olanzapine, quetiapine, amisulpride, ziprasidoné) on this disorder

Cólicos neonatales y psicopatología: ¿existe una relación? / Colic the newborn and psychopathology: is there a relationship?

El objetivo de esta revisión es aclarar el concepto de cólico neonatal e investigar si este llanto excesivo se asocia con un riesgo mayor de hiperactividad o problemas de conducta en la vida posterior. Asimismo se discuten la persistencia de problemas en la interacción paterno-filial, o familiar, y sus implicaciones

The purpose of this review is to clarify the concept of infantile colic and to investigate if this excessive crying is associated with an increased risk for hyperactivity or behaviour problems in later life. Persistence and implications of parent-infant, or family interaction problems are also discussed

Presentación clínica, comorbilidad y tratamiento habitual del síndrome de Gilles de la Tourette: estudio de 17 casos / Clinical presentation, comorbídíty and usual treatment of Gilles de la Tourette's syndrome: study of 17 cases

Introducción: El síndrome de Gilles de la Tourette (SGT) es un trastorno neuropsiquiátrico de inicio infantil caracterizado por tics vocales y motores múltiples y crónicos. Es frecuente la comorbilidad con trastornos psiquiátricos, sobre todo trastorno de déficit de atención con hiperactividad (TDAH), trastornos de ansiedad y trastorno obsesivo-compulsivo (TOC). Metodología: Estudiamos de modo retrospectivo 17 pacientes en edad pediátrica atendidos en consulta externa neuropediátrica o psiquiátrica, entre 1998 y 2003. Se estudiaron las variables: edad, sexo, síntomas clínicos, edad de inicio, antecedentes familiares, comorbilidad, tratamiento recibido y datos de evolución. Resultados: Todos los casos menos uno eran varones, de edad media 10 años pero edad media de inicio 5 años y 9 meses. Había comorbilidad en 82,3% de pacientes (TDAH 53%, trastornos de ansiedad 41,1 %, patología TOC 58,7%). Había antecedentes familiares en 72% de casos: 41,1 % tics y 17,6% patologías TOC. Los tratamientos más prescritos fueron antipsicóticos (n=15) y metilfenidato (n=7). El tratamiento con metilfenidato no aumentó los tics. Hubo efectos adversos en 16 pacientes, conduciendo a abandonar haloperidol (n=2) o pimocida (3 de los 7 casos) por efectos secundarios neurológicos o cardiacos. Risperidona y olanza pina produjeron aumento de peso y somnolencia pero fueron mejor tolerados. La tasa de remisión completa fue 64,7%. Conclusión: el tratamiento de SGT debería considerarse en los casos graves fijándonos también en trastornos comórbidos

Background: Tourette's syndrome (TS) is a childhood-onset neuropsychiatric disorder characterized by chronic multiple motor and vocal tics. Comorbid psychiatric disorders, particularly attention deficit hyperactivity disorder (ADHD), anxiety disorders and obsessive compulsive disorder (OCD) often are present. Methods: Seventeen pediatric cases attending an outpatient neuropediatric or psychiatric clinic from 1998 to 2003 and suffering from Tourette's disorder are retrospectively studied. Age, sex, clinical symptoms, age of onset, family history, comorbidity, treatment strategies and outcome data are described. Results: All but one case were male; mean age was 10 years but mean age of onset was 5 years and 9 months. Comorbidity was present in 82,3% of patients (ADHD 53%, anxiety disorders 41,1%, OCD spectrum 58,7%). Family history was positive in 72% of cases: 41,1% for tics and 17,6% for OC conditions. Treatments mostly prescribed were antipsychotics (n=15), and meti1phenidate (n=7). Treatment with meti1phenidate did not exacerbate tics. Adverse effects were present in 16 patients, allowing to withdraw ha1operido1 (n=2) or pimocide (3 out of 7 cases) because of neuro1ogic y/o heart side effects. Risperidone and o1anzapine produced weight gain and somno1ence but were better to1erated. The rate of total remission was 64,7%. Conclusion: treatment of TS should be considered in severe cases, focusing also on comorbid disorders

Valoración de la cooperación mediante el dilema del prisionero en niños con trastornos por déficit de atención con hiperactividad / Evaluation of the cooperation using the prisoners' dilemma in children with attention deficit with hyperactivity disorder

El problema de la cooperación social es central para la naturaleza humana. En este estudio la evaluamos en pacientes con trastorno por déficit de atención y trastorno negativista desafiante (TDAH-TND). Usaremos para ello diseñado por nuestro equipo, llamado Dilema del Prisionero por ordenador para evaluar cooperación (DPOC). Este test intenta evitar los sesgos de respuesta en tests de lápiz y papel mediante una simulación de situaciones de intercambio social. Las comparaciones de estos niños con un grupo control muestran que el patrón de respuesta es completamente caótico y por tanto no cooperador sin un tratamiento que logre estabilización (entendiendo como tal una mejoría de 4 puntos en una escala Likert de 7 valorada por los padres y puntuaciones en escalas de Conners y Eyberg por debajo de puntos de corte para patología). Una vez estabilizados con metilfenidato a dosis de 0,6-1 mg/kg más psicoterapia aparece respecto a un grupo control de la comunidad un patrón de respuestas más errático y menos cooperativo, con respuestas más impulsivas y más dificultad para entender el test cuando este se vuelve más complejo

Concept of cooperation in essential for understanding human nature. In our study we evaluate cooperation in patients with attention deficit disorder with hyperactivity plus defiant disorder (ADH+DD). We used a test designed by us, called computerised Prisoners' dilemma to evaluate cooperation (DPOC). This test tries to avoid response bias in test based on questionnaires with a simulation by computer of a social interchange. Comparisons of ADHD+DD with community control group show that their cooperative behaviour is chaotic in absence of a treatment stabilization (defined as an improvement of 4 in a Likert scale for parents and a score below diagnosis point in Conners and Eyberg test). Once stabilization was reached with metilphenidate 0,6- lmg/kg plus psycotherapy, ADHD+DD case have a more erratic and less cooperative behavior than a control group, with more impulsive responses and difficulty to understand the test when it becomes more complex

Tratamiento del síndrome de Tourette y su comorbilidad: presentación de 17 casos / Treatment of Tourette syndrome and its comorbidity: experience with 17 cases

Introducción. Presentamos las características clínicas y trastornos comórbidos asociados y evaluamos los resultados de los tratamientos farmacológicos empleados en 17 pacientes con síndrome de Tourette (ST). Material y métodos. Revisión retrospectiva de los pacientes pediátricos diagnosticados de ST en nuestro hospital entre 1998 y 2004. Resultados. De los 17 pacientes, 16 son varones y sólo 1 mujer, con edades actuales comprendidas entre 7 y 17 años. Los trastornos comórbidos más frecuentes fueron el trastorno por deficit de atención con hiperactividad (TDAH) en 9 pacientes (53 Ofo), conductas obsesivo-compulsivas en 8 (48 %) Y ansiedad en 7 (41 %). Presentaban problemas de aprendizaje 7 (41 %), de los cuales 5 asociaban un TDAH y 1 un trastorno obsesivo-compulsivo (TOC) severo. Encontramos efectos farmacológicos adversos severos que obligaron a la retirada de la medicación en los 2 casos tratados con haloperidol (ambos de tipo extrapiramidal) y en 3 de los 7 (43 %) de los tratados con pimozida (1 de ellos de tipo extrapiramidal). No ocurrieron efectos extrapiramidales con los neurolépticos atípicos, pero fueron frecuentes la sedación y el aumento de peso. Siete pacientes fueron tratados con metilfenidato, sin empeoramiento de los tics. Conclusiones. En nuestra serie los trastornos comórbidos más frecuentes fueron el TDAH, conductas obsesivo-compulsivas, ansiedad y dificultades en el aprendizaje. Los neurolépticos atípicos fueron mejor tolerados que los clásicos, aunque la incidencia de efectos adversos es también elevada. El metilfenidato no se ha asociado a empeoramiento de los tics

Introduction. Clinical characteristics and comorbid disorders of Tourette syndrome (TS) are reviewed along with a presentation of our experience with 17 cases. Material and methods. We carried out a retrospective study of pediatric patients with TS admitted from 1998 to 2004 in Fundación Hospital Alcorcón. Results. Seventeen patients were obtained, 16 of whom were men and there was only 1 woman. Present age ranged fram 7 to 17 years old. Most frequent comorbid disorders were attention deficit disorder (ADD) in 9 patients, (53 %), obsessive-compulsive disorder in 8 (48 %) and anxiety in 7 (41 %). Learning disorders were found in 7 patients (41 %), 5 of whom have concurrent ADD and 1 severe obsessive compulsive disorder. Psychopharmacological treatment was withdrew in the 2 cases treated with halloperidol due to the presence of severe extrapyramidal symptoms (EPS) and in 3 of the 7 cases treated with pimozide (one of them was withdrawn due to EPS). No EPS was found with atypical neuraleptics, but sedation and weight gain was common. Methylphenidate was administered to 7 patients without an increase in tics. Conclusions. In our sample the most common comorbid disorders were ADD, obsessive-compulsive disorders, anxiety and learning disorders. Atypical neuroleptics were better tolerated than classic ones, although the incidence of side effects is elevated. Methylphenidate was not associated with tic worsening

Fobia a tragar: presentación clínica de una serie de nueve casos / Chocking phobia: clinical presentation of nines cases

Introducción: La fobia a tragar es un miedo a tragar sólidos y/o líquidos que suele responder a tratamiento conductual. Metodología: estudiamos nueve casos de fobia a tragar tratados ambulatoriamente. Se describen edad, sexo, historia familiar, comorbilidad, y datos sobre tratamiento y evolución, entre otros. Resultados: un 55% eran mujeres, edad media 25 años. El 33% tenía antecedentes familiares psiquiátricos,88% tenía comorbilidad con trastorno de pánico, patología obsesivo-compulsiva o personalidad evitativa. Los tratamientos eficaces fueron terapia cognitivo-conductual (n = 9), clomipramina (n = 2), paroxetina (n = 2) y benzodiacepinas (n = 5). Conclusión: la fobia a tragar tiene una alta comorbilidad con trastornos ansiosos, lo que condiciona el abordaje terapéutico

Introduction: Choking (swallowing) phobia is a fear of swallowing food and/or fluids that usually respondsto behaviour therapy.Methods: Nine cases attending an out patient clinic and suffering from choking phobia are retrospectively studied. Age, sex, family history, comorbidity, treatment strategies and outcome data are described. Results: Fifty-five percent of patients were female, mean age 25 years. A total of 33% had psychiatric family history, 88% had comorbidity with panic disorder, obsessive-compulsive disease or avoidant personality. Effective treatments were cognitive-behavioural therapy (n = 9), clomipramine (n = 2), paroxetine (n = 2) and benzodiazepines (n = 5). Conclusion: Swallowing (choking) phobia has a high comorbidity rate with anxious disorders, suggesting certain treatment strategies

Fobia a atragantarse en la infancia y adolescencia / Choking phobia in childhood and adolescence

Introducción: La fobia a tragar (o a atragantarse) se caracteriza por miedo a atragantarse al ingerir comida, líquidos o pastillas, a veces tras un episodio de atragantarniento con comida. Pretendemos describir las características de esta fobia en niños y adolescentes y compararlas con las que presenta en adultos. Se han analizado las publicaciones entre 1978 y 2005 en las que se recogían 13 casos con fobia a tragar en niños y adolescentes y 28 casos en adultos. Se estudiaron las variables clínicas y terapéuticas del trastorno. Resultados: En el grupo de niños y adolescentes, hubo un 53,8% de mujeres; la edad media fue 1l,23:t2,3l años (rango 8-15 años). Hubo antecedentes de atragantamiento en 53,8% de casos y problemas previos con alimentación en 23% casos y se identificaron sucesos vitales estresantes en 30,7% de casos. El tiempo hasta acudir a consulta era de 14,43:t27,86 meses. Existía comorbilidad en 76,85% de casos, sobre todo con ansiedad de separación (38,4%), pánico (23%), trastornos depresivos u obsesivos (15,4% cada uno). Recibieron tratamiento cognitivo-conductual el 100% de casos, solo (61,54%) o asociado a fármacos (imiprarnina, clomipramina, fluoxetina, paroxetina) y tardaron en mejorar 3,85+-1,86 meses. El porcentaje de casos con remisión completa fue 30,77%. Diferencias por edad: en el grupo de adultos, había mayor porcentaje de mujeres, el inicio de la fobia se asociaba a veces a enfermedad física o suceso durante la ingesta, el tiempo hasta acudir a consulta era mayor y tenía mayor comorbilidad con trastorno de pánico, un 39,28% se trató sólo con fármacos, y el porcentaje de sujetos con remisión completa fue mayor (71,43%). Discusión: la fobia a tragar presenta un perfil clínico diferente en niños o adolescentes, y adultos

Background: Choking phobia (or swallowing phobia) is characterized by a fear of swallowing foods, liquids or pills, sometimes after an episode of choking on food. We pretend to describe the characteristics of this phobia in children and adolescents and to compare them to tose presented in adult cases. Methods: Thirteen child and adolescent and twenty-eight case reports on swallowing phobia from 1978 to 2005 were studied. Results: Child and adolescent group: there was 53.8% of females, mean age was 11.23:t2.3l years (range 8-15 years). There were previous choking in 53.8% of cases and previous eating problems in 30.7% of cases. Time delay to consultation was l4.43:t27.86 months. Comorbidity appeared in 76.85% of cases, mainly separation anxiety (38.4%), panic disorder (23%) or depressive or obsessive conditions (15.4% each). A hundred percent of cases received cognitive-behavioural treatment, alone (61.54%) or combined to drugs (imipramine, c10mipramine, fluoxetine, paroxetine) and time to improval was 3.85:t1.86 months. Complete remission appeared in 30.77% of cases. Age differences: in the adult group, there was a higher female ratio, phobia onset was associated sometimes to organic disease or an event during eating, time delay to consultation was higher and there was a higher comorbidity with panic disorder; a 39.28 percent of cases was treated only with drugs and proportion of cases reaching complete remission was higher (71.43%). Discussion: choking phobia has a differential c1inical profile in children/adolescents and in adults