Funcionamiento conyugal en padres de familia que llevan a sus hijos a una evaluación psiquiátrica / Marital functioning in parents who take their children in for a psychiatric evaluation

Antecedentes: Recientemente, la investigación en familias con psicopatología ha demostrado la relación entre los trastornos mentales infantiles y los problemas en el subsistema conyugal.Objetivo: Describir el ajuste conyugal de un grupo de padres de familia que solicitaron atención psiquiátrica para sus hijos, y asociarlo con la gravedad de la psicopatología presente en éstos.Método: Se incluyó a un grupo de 48 niños y adolescentes, y a 76 progenitores. La psicopatología infantil se evaluó por medio de la MINI-Kid y el ajuste conyugal se evaluó mediante la Escala de Ajuste Diádico (EAD-13).Resultados: El 72.9% de los menores tuvo al menos un progenitor que reportó un bajo ajuste diádico. La correlación entre las puntuaciones de la EAD-13 obtenidas de cada miembro de las parejas fue baja (p<0.05). Existió una correlación negativa (p<0.05) entre las puntuaciones de la EAD-13 contestadas por las madres (cuanto menos se puntúa, menor es el ajuste) y el número de diagnósticos presentes en los hijos. Sin embargo, al comparar las medias del número de diagnósticos presentes en los menores, según el grado de ajuste percibido por los padres (varones), se encontró que aquellos que presentaban un alto ajuste tenían hijos con un mayor número de diagnósticos psiquiátricos (p<0.05).Discusión y conclusión: El conflicto negado por parte del padre y las dificultades conyugales percibidas por la madre redundan en una mayor predisposición de los hijos a la psicopatología.Ignorar el conflicto conyugal tiene enormes implicaciones en la evolución, pronóstico y respuesta al tratamiento de los pacientes pediátricos.

Background: In recent decades, research on families with psychopathology has demonstrated the relationship between childhood mental disorders and problems in the marital subsystem.Objective: To describe the degree of marital adjustment in a group of parents who sought psychiatric care for their children and compare it with the severity of the psychopathology present in children.Method: The study included a group of 48 children and 76 parents. The children's psychopathology was assessed using the MINI-Kid, while their parents' degree of dyadic adjustment was evaluated through the Dyadic Adjustment Scale (EAD-13).Results: A total of 72.9% of the children had at least one parent who reported a low dyadic adjustment. The EAD-13 scores of each member of the couple showed low correlation (p<0.05). Moreover, there was a negative correlation (p<0.05) between the EAD-13 scores answered by the mothers (the lower the score, the lower the adjustment) and the number of diagnoses present in the children. However, a comparison of the means of the number of diagnoses present in the children, according to the degree of adjustment perceived by the fathers, showed that those with a high adjustment had children with a higher number of psychiatric diagnoses (p<0.05).Discussion and conclusion: The results suggest that denied or concealed conflict, at least by the father, and marital difficulties perceived by the mother, led to children's increased susceptibility to psychopathology.Ignoring marital conflict in the assessment of children and adolescents has huge implications in the evolution, prognosis and response to treatment of pediatric patients.

Características familiares y trastornos de la conducta alimentaria en una muestra de mujeres adolescentes internadas en un hospital psiquiátrico / Family characteristics and eating disorders in a sample of female adolescent inpatients in a psychiatric hospital

Background From the first descriptions of the eating disorders, researchers have found that the families of patients with anorexia nervosa or bulimia nervosa present high levels of family dysfunction. These families tend to differ from the control families, mainly because they present a greater frequency of conflicts and disorganization, less adaptability and cohesion, poor care of the parents towards their children, presence of overprotection, less orientation towards recreational activities and less emotional support. Several authors have suggested that a family adverse environment might represent an important etiologic factor for the development of an eating disorder. Nevertheless, the symptoms more related to degree of dysfunction or to quality of family environment in such patients have not been identified. Objective To describe the frequency of the eating disorders as well as eating disorder not otherwise specified in a sample of inpatient female adolescents; and to establish the relationship that functioning and quality of the family environment hold with the severity and/or characteristics of the eating psychopathology. Subjects and methods The study included a group of 36 female adolescents hospitalized due to any type of psychopathology in the Children's Psychiatric Hospital Dr. Juan N. Navarro. The study sample consisted of all the patients who wanted to be included and who fulfilled the inclusion criteria. A written informed consent was obtained from parents as approved by the Department of Research of the Children's Psychiatric Hospital Dr. Juan N. Navarro. Diagnostic categories in the sample, including eating disorders, were based on the Mini-International Neuropsychiatrie Interview -Kid (MINI-Kid). Those that presented an eating disorder not otherwise specified were diagnosed with a clinical interview based on DSM-IV criteria. In addition, the patients answered a series of self reports: the Eating Disorder Inventory, the General Functioning Subscale of the McMaster Family Assessment Device and the Child Figure Rating Scale. The body dissatisfaction was considered if the patient had negative scores (she wanted to be thinner) in the Child Figure Rating Scale. The score on the Global Family Environment Scale was obtained through a non-structured interview concerning the quality of the family environment (assessed in retrospect) and this information was complemented with that contained in each patient's medical chart. Results From the 36 patients included, 39% presented an eating disorder (17% a specific disorder and 22% an eating disorder not otherwise specified), 42% presented only body dissatisfaction and 19% of the sample was free of eating psychopathology. The average of the body mass index was within the normal range (23.2 kg/m²); nevertheless the average score of the Eating Disorder Inventory (58.22) was higher than what some authors have suggested as cut point score for anorexia nervosa. The average score of the General Functioning Subscale of the McMaster Family Assessment Device (2.16) was in the low normal limit and the Global Family Environment Scale showed an average (62.8) that would correspond to a moderately unsatisfactory family environment. The total sample was divided in two subgroups; the first included the patients who fulfilled the criteria for eating disorder (including an eating disorder not otherwise specified) and the second subgroup included the rest of the patients. There were not significant differences in the type or number of comorbid disorders. The mean scores of the Eating Disorder Inventory were higher in the subgroup with eating disorder with a statistically significant difference (p<0.01). In a similar way, the dissatisfaction with the weight and the current figure as well as the dissatisfaction to future showed statistically significant differences (p<0.01). The score in the scales of functioning and quality of the family environment did not show statistically significant differences. We also divided the whole sample in two subgroups, one with family dysfunction (as determined by the General Functioning Subscale of the McMaster Family Assessment Device ≥2.17), and the other without family dysfunction (scored <2.17). The group with family dysfunction presented a higher frequency of major depressive disorder and social phobia with a statistically significant difference (p<0.05). In a similar fashion, we divided the sample in two subgroups, one with high to moderate quality family environment (score in the Global Family Environment Scale >70) and a second one with low quality family environment (score <70). Nevertheless, these subgroups did not show statistically significant differences concerning psychopathological disorders. We found a positive correlation (r=0.34) among the total score of the Eating Disorder Inventory and the score of the General Functioning Subscale of the McMaster Family Assessment Device (p<0.05). The subscale of the Eating Disorder Inventory that had higher correlation was bulimic symptomatology (r=0.51) followed by ineffectiveness (r=0.43), both statistically significant (p<0.01). On the other hand, the Global Family Environment Scale did not show significant correlations with the Eating Disorder Inventory. Conclusions Eating disorders represent an important cause of morbidity in adolescent female inpatients; likewise, the patients were more frequently diagnosed with an eating disorders not otherwise specified than with anorexia nervosa and bulimia nervosa (in the sample recruited for the present study, we found that the eating disorders not otherwise specified represented 56% of the total of eating disorders), making the early detection necessary for the beginning of treatments directed to avoid the evolution to severe forms. We need to pay attention to «atypical¼ conditions that do not fulfill the full diagnostic criteria for anorexia or bulimia, as they may be in fact associated with important levels of dysfunction and comorbidity. The dissatisfaction with the weight and figure was shown by the majority of the patients who were hospitalized in a psychiatric unit. Adolescence can be accompanied by great dissatisfaction with self appearance; nevertheless, to determine the relevance of this phenomenon as a risk factor for the development of an eating disorder, follow-up studies with bigger samples are needed. Family dysfunction is a variable that relates to the severity of the eating disorders, mainly the bulimic symptoms. From this perspective these findings seem to support the psychodynamic interpretation of bulimia nervosa, where bingeing symbolizes the marked dependence to significant figures, and vomiting the desire to expel an evil introjected object. Nevertheless, given the impossibility to do inferences beyond a simple association among variables, another explanation could be that the aforementioned symptoms were damaging the family functioning, creating in this way a vicious circle. This finding may be important to determine which group of symptoms could be expected to improve after a family intervention directed to treat an eating disorder. The lack of correlations between the Global Family Environment Scale and the Eating Disorder Inventory could be explained by the fact that the Global Family Environment Scale evaluates functioning during the worst year of the patients' life, which could be during their first five years, thus its effect⁄impact on current psychopathology could not be established.

Introducción Desde las primeras descripciones de los trastornos alimentarios, los investigadores han encontrado que las familias de las pacientes con anorexia nerviosa o bulimia nerviosa presentan un alto nivel de disfunción familiar. Sin embargo, aún no se ha establecido qué síntomas se encuentran más relacionados con el grado de disfunción o con la calidad del ambiente familiar en este tipo de pacientes. Objetivo Describir la frecuencia de los trastornos de la conducta alimentaria, incluyendo los trastornos de la conducta alimentaria no especificados, en una muestra de pacientes adolescentes hospitalizadas por diversos tipos de psicopatología; y establecer el tipo de relación existente entre el funcionamiento-calidad del ambiente familiar y la gravedad y características de la psicopatología alimentaria. Material y métodos El estudio incluyó a un grupo de 36 pacientes mujeres adolescentes hospitalizadas debido a cualquier tipo de psicopatología en el Hospital Psiquiátrico Infantil Dr. Juan N. Navarro. Se realizó la entrevista Mini-Kid para determinar las categorías diagnósticas presentes en la muestra (los trastornos de la conducta alimentaria no especificados fueron diagnosticados a través de una entrevista no estructurada basada en los criterios del DSM-IV). Además, se aplicó el Eating Disorder Inventory, la Subescala de Funcionamiento General de la Familia, la Escala del Ambiente Familiar Global y la Escala de Figuras de Niños. Resultados El 39% de la muestra presentó un trastorno alimentario (17% un trastorno específico y 22% un trastorno no especificado), el 42% presentaba únicamente insatisfacción corporal y sólo el 19% de la muestra se encontraba libre de psicopatología alimentaria. El grupo con disfunción familiar (puntuación en la Subescala de Funcionamiento General de la Familia ≥2.17) presentó una mayor tendencia a cursar con episodio depresivo mayor y fobia social en contraste con el grupo sin disfunción familiar, con una diferencia estadísticamente significativa (p<0.05). El grupo de pacientes con alta-moderada calidad del ambiente familiar (puntuación en la Escala del Ambiente Familiar Global ≥70) no mostró diferencias estadísticamente significativas con el grupo de baja calidad del ambiente familiar en cuanto a los trastornos de la conducta alimentaria y el resto de las categorías diagnósticas obtenidas por el Mini-Kid. Se encontró una correlación positiva (r=0.34) entre la puntuación total del Eating Disorder Inventory y la puntuación de la Subescala de Funcionamiento General de la Familia (p<0.05). La subescala del Eating Disorder Inventory que tuvo mayor correlación fue la de sintomatología bulímica (r=0.51), seguida por la de inefectividad y baja autoestima (r=0.43), ambas estadísticamente significativas (p<0.01). Conclusiones Los trastornos de la conducta alimentaria representan una importante causa de morbilidad en las poblaciones clínicas de mujeres adolescentes; asimismo, los trastornos de la conducta alimentaria no especificados superan en prevalencia a la anorexia nerviosa y la bulimia nerviosa. La disfunción familiar es una variable que se relaciona con la gravedad de los trastornos de la conducta alimentaria, principalmente los síntomas bulímicos y la baja autoestima. Este hallazgo resulta relevante ante el hecho de poder determinar qué grupo de síntomas podrían mejorar inicialmente con una intervención familiar encaminada a tratar un trastorno alimentario. Al parecer, la calidad del ambiente familiar medido de forma retrospectiva no tiene un impacto específico en la presencia de un trastorno alimentario, lo que puede quizá solamente propiciar la presencia de variables mediadoras que se relacionen con la generación de psicopatología.

Edipo y sus psiquiatras. Evidencias históricas en contra de la originalidad del tópico freudiano: Joseph Raymond Gasquet (1837-1902) y el Edipo Rey de Sófocles / Oedipus and his psychiatrists

Introduction Over a hundred years have elapsed since Sigmund Freud's The Interpretation of Dreams was first published. Publication of this work obviously marked a new stage in the history of psychiatry and psychology. Since then, the Oedipus complex has been one of the pillars supporting the psychoanalytical view of the mind and a model for understanding the normal development of individuals as well as psychopathology. Many historians and psychoanalytic scholars believed that Freud was the first to suggest a pathway to understanding psychopathology by using characters from the theater as models for mental illness. However, in the second half of the nineteenth century, psychiatry had already considered the interface linking the sciences of the mind to the works of the great dramatists as a topic for study. Sigmund Freud and his desert island: The ignorance of the contributions of XIXth psychiatry How did Freud manage to chart a new course in an area that had already been explored and described by the psychiatrists that preceded him? The answer may lie in Freud's medical and intellectual isolation. A propos of this, there is an interesting analogy he draws between himself and a famous character: <> It is important to note that in Daniel Defoe's novel, Robinson Crusoe managed to live with at least some of the comforts available to the people of his time. Thanks to his ingenuity, he was able to obtain a series of artifacts. Likewise, Freud devised psychological theories and explanations that already existed in his time and even beforehand. The difference was that Freud thought he owned the patent. Joseph Raymond Gasquet (1837-1902) and a model to understand psychopathology: Oedipus Rex Born on 24 August 1837, Joseph Raymond Gasquet was the oldest son of Raymond Gasquet, a surgeon who spent most of his working life in London. Gasquet was a brilliant student, studying medicine at University College Hospital in London and graduating with distinction in 1859. After the opening of St. George's Retreat, Gasquet accepted the post of assistant physician and played an active role in the growth and development of this asylum. He was a great admirer of the work of Charcot, whom he regarded as <> As a result, Gasquet, like Freud, had a special interest in the phenomena of hypnosis and hysteria. He contributed to the dissemination of the knowledge of British psychiatry, writing for various publications. He spent his free time studying philosophy, theology, and universal literature, while his extensive knowledge of classical works enabled him to become familiar with ancient and modern schools of thought. In April 1872, Gasquet published an article on The Madmen of the Greek Theatre in the Journal of Mental Science and a few months later, in 1873, published a continuation of this work subtitled The Ajax and Oedipus of Sophocles. Both articles, published in a well-known specialist journal, were several years ahead of the psychoanalysts interested in looking to Greek theater for models for psychopathology. Gasquet published his observations on Oedipus 26 years before Freud, also contributing studies on Orestes, Hercules and Cassandra to the same journal. Gasquet vs. Freud: contrasts and similarities with psychoanalytic thought Due to Gasquet's significant contributions to the Dublin Review, two years after his death, a compilation of several of his works was published in a book called Studies Contributed to the <> This work included an article called Hypnotism written in April 1891, in which Gasquet attributes the start of the scientific study of hypnotism to Charcot. The most interesting fact about the article on Hypnotism is that Gasquet dealt with the issue of the unconscious nearly a decade before Freud published his descriptions. His deductions about the unconscious were so accurate and profound that, through Gasquet, we seem to be listening to the father of psychoanalysis. Another aspect worth mentioning is the seriousness with which Gasquet felt hypnosis should be used. Here we find an enormous contrast with Freud who, four years after Gasquet wrote this, would confess to his abuse of this form of therapy in Studies on Hysteria. Like Freud, Gasquet was a psychiatrist profoundly interested in the subject of religion. Gasquet analyzed the issue of religion in works such as The Physiological Psychology of St. Thomas, The Present Position of Arguments for the Existence of God, Lightfoot's St. Ignatius and the Roman Primacy, The Canon of the New Testament and The Cures at Lourdes. In this last work, Gasquet described his experience of examining several cases of miraculous cures of pilgrims that visited the city of Lourdes. It is also important to mention that Gasquet described slips of the tongue (lapsus linguae), attributing them to an unconscious origin, over a decade before Freud. In a footnote to his article Lightfoot's St. Ignatius and the Roman Primacy, written in 1887, Gasquet highlighted William Cureton's mistake in quoting a Greek text from a letter from St. Ignatius: <by >> Lastly, we should mention that Gasquet's interpretation of the myth of Oedipus significantly contrasted with Freud's a few years later. Gasquet did not highlight parricide and incest as Freud did but rather Oedipus's self-mutilation in the presence of a high degree of mental anguish. From Gasquet's perspective, this self-mutilating behavior, which some have called the <>, could well be an <> applicable to seriously disturbed patients and all the mentally ill that resort to self-injuries to certain extent.

Introducción Han transcurrido más de cien años desde que La Interpretación de los Sueños, de Sigmund Freud, apareció por primera vez. Podemos afirmar, sin temor a equivocarnos, que la publicación de esta obra marcó una nueva época en la historia de la psiquiatría y la psicología. Desde entonces, el complejo de Edipo ha sido uno de los pilares que sustentan la visión psicoanalítica de la mente y un modelo para entender tanto el desarrollo normal de los individuos como la psicopatología. Muchos historiadores y estudiosos del psicoanálisis creyeron que Freud marcó por primera vez un camino para comprender la psicopatología, al tomar a los personajes del teatro como modelos de la enfermedad mental. Sigmund Freud y su isla desierta: La ignorancia de las aportaciones de la psiquiatría decimonónica Freud ignoraba las aportaciones al estudio de la interfase de la psiquiatría y la creación literaria realizadas por algunos psiquiatras que lo antecedieron. ¿Cómo es que Freud creyó trazar un nuevo camino en un área ya explorada y descrita por los psiquiatras del siglo diecinueve? Quizá la respuesta esté en el propio aislamiento médico e intelectual de Freud. Respecto a esto, resulta interesante la analogía que él hace de sí mismo con un célebre personaje: <> Joseph Raymond Gasquet (1837-1902) y un modelo para entender la psicopatología: Edipo Rey En abril de 1872, Gasquet publicó en el Journal of Mental Science un artículo titulado Los locos del teatro griego, y unos meses más tarde, en enero de 1873, una continuación de dicho trabajo subtitulado Ayax y Edipo de Sófocles. Ambas publicaciones, aparecidas en una revista especializada y reconocida, se adelantaron por muchos años a la intención psicoanalítica de mirar hacia al teatro griego en busca de modelos de psicopatología. Gasquet publicó sus observaciones sobre Edipo veintisiete años antes que Freud, también publicó en la misma revista estudios sobre los personajes de Orestes, Hércules y Casandra. Hoy sabemos que el estudio de los personajes del teatro griego nace de la psiquiatría británica por influencia de Gasquet y no del psicoanálisis. Gasquet vs. Freud: contrastes y similitudes con el pensamiento psicoanalítico Al analizar el personaje de Edipo, Gasquet hizo un paralelismo con El Rey Lear de Shakespeare, en el sentido de que ambos dramas se inician con un rey que goza de poder y buena fortuna, sin que ambos sean capaces de vaticinar su infortunio. Gasquet resaltó, no el parricidio y el incesto como lo hizo Freud, sino la automutilación que ejecutó Edipo ante la presencia de un grado elevado de angustia mental. Este comportamiento automutilador, el cual ha sido llamado por algunos <> bien podría ser, desde la perspectiva de Gasquet, un <>, aplicable a pacientes gravemente perturbados y a todos aquellos enfermos mentales que en cierta medida incurren en autolesiones. Sin embargo, la principal interpretación que hizo Gasquet del mito de Edipo se centró en un aspecto positivo de la tragedia, un detalle no observado por Freud y que tiene gran relación con el concepto de resiliencia introducido por Rutter cien años más tarde. Gasquet asumió que Sófocles: <> Conclusión Contrariamente a lo que han creído los seguidores del psicoanálisis, no fue Freud el primer psiquiatra en estudiar la psicopatología de Edipo, ni en crear un puente entre la ciencia de la psiquiatría y las humanidades. Joseph Raymond Gasquet, prescindiendo de las teorías psicoanalíticas, supo explorar los terrenos que Freud más tarde creyó descubrir.