La distimia femenina y los fenómenos de amor y desamor / Female dysthymia and the phenomena of love and heartbreak

Aunque el término distimia fue acuñado por Kahlbaum, su significado actual se inició en 1980, cuando aparece en el Manual Diagnóstico de la Asociación Americana de Psiquiatría (DSM) designando una depresión crónica de leve intensidad, distinguible de la depresión mayor. Objetivo: En este trabajo se estudian los casos de dos mujeres con este diagnóstico (según CIE-10) y se examinan los "componentes subjetivos" que sustentan los síntomas depresivos y que habitualmente no se mencionan en las publicaciones. Material y métodos: Se emplea el "Método de Abordaje de la Subjetividad" (MAS), consistente en realizar entrevistas no-directivas y registrar las expresiones verbales de modo fiel, al tiempo que se prescinde de cualquier alusión a teorías, creencias particulares, juicios de valor, etc. Resultados: Se reconoce en estas pacientes una desinserción sentimental respecto al objeto de amor, un convivir desencantado con sus parejas e imposibilidad de separación, al tiempo que aparecen insidiosamente los síntomas depresivos. Este fenómeno tiene como base la caída del "ideal romántico" al que aspiran, que sostiene sus vidas y que funciona como una "agarradera" o "ancla de personalidad", razones por las que no mejoran su sintomatología. Estas originales apreciaciones cuestionan la noción clásica sobre el duelo. Conclusiones: Para que este tipo de pacientes mejoren sintomáticamente hace falta que hablen y se den cuenta de lo que realmente les está sucediendo. El estudio aquí descrito muestra las coordenadas subjetivas que se requiere conocer para poder conducir una adecuada intervención psicoterapéutica.

Objectives: Although the term dysthymia was coined by Kahlbaum, its current clinical meaning originated in the 1980s, when it appears in the American Psychiatric Association Diagnostic and Statistical Manual (DSM) designating a chronic mild depression distinguishable from Major Depression Disorder. In this article, the cases of two female patients with this disorder (according to the CIE-10) are presented and the "subjective components" that sustain the depressive symptoms, not usually mentioned in the publications, are examined. Material and methods: The Approach to Subjectivity Method (MAS) was used; it consists of non-directive interviews writing down the patient’s exact verbal expressions, and avoiding any allusion to theories, particular beliefs, values, judgments, etc. Results: We concluded that these two women have a sentimental distancing from their love object, even though they are unable to separate from or leave him while depressive symptoms appear in an insidious way. This drives them to fall off the romantic ideal they were looking for as a guide for their lives and an anchor of their personality, and it can also explain why their symptoms do not improve. This point of view questions to some extent the classic notions about "mourning". Conclusions: To improve symptomatically, the dysthymic patients need to talk about and realize what is really happening to them. What is found here shows the subjective coordinates that are necessary in order to conduct an adequate psychotherapeutic intervention.

Função e disfunção sexual na depressão: uma revisão sistemática / Sexual function and dysfunction: a systematic review

RESUMO Objetivo Revisar sistematicamente as informações disponíveis acerca da função sexual e/ou disfunção sexual em pacientes com transtorno depressivo maior (TDM) e/ou distimia (DIS). Métodos Foi realizada uma busca sistematizada na base eletrônica Medline por estudos que avaliavam a função/disfunção sexual em pacientes com TDM e DIS. Foram incluídos estudos publicados até junho de 2017. Artigos relevantes presentes nas referências dos artigos foram pesquisados manualmente e incluídos nesta revisão. Resultados Vinte estudos foram elegíveis para análise. Foi observada uma grande diversidade de resultados decorrente da heterogeneidade dos delineamentos empregados e devido aos diferentes métodos de avaliação utilizados. De forma geral, os dados provenientes demonstraram uma redução das principais funções sexuais em pacientes com TDM e DIS, tais como: libido (31%-32%), drive (31%-87%), excitação (29%-85%), ereção (18%-46%), lubrificação (18%-79%) e orgasmo (26%-81%). Aumento de libido (15%-22%) também foi descrito em alguns estudos. Conclusão A disfunção sexual é altamente prevalente na DIS e no TDM. Foram notadas diversas alterações de funcionamento sexual na população estudada. Discrepâncias acerca de suas prevalências podem ter ocorrido devido às variadas metodologias de análise utilizadas nos estudos.

ABSTRACT Objective To review the available data on the evaluation of sexual function and/or sexual dysfunction in patients with major depressive disorder (MDD) and/or Dysthymia (DYS) without pharmacological and psychotherapeutic treatment. Methods A systematic electronic search was conducted in the Medline database for studies that evaluated sexual function/dysfunction in patients with MDD and DYS. We included studies published up to June 2017. Relevant articles present in the articles references were manually searched and included in this review. Results Twenty studies were eligible for analysis. It was observed a variety of results due to the heterogeneity of the studies and due to the different evaluation methods used. In general, the data from these studies demonstrated a reduction of the main sexual functions in patients with MDD and DYS such as: libido (31%-32%), drive (31%-87%), arousal (29%-85%), erection (18%-46%), lubrication (18%-79%) and orgasm (26%-81%). Increased libido (15%-22%) has also been described in some studies. Conclusion Sexual dysfunction is highly prevalent in DYS and in MDD. Several sexual functioning alterations were observed in this study population. Prevalence discrepancies may have occurred due to the varied methodologies used in the studies.

Evaluación neuropsicológica de los procesos cognitivos básicos en pacientes distímicos con intento de suicidio / Neuropsychological assessment of basic cognitive processes in dysthymic patients attempted suicide

La distimia incluye síntomas crónicos que interfieren en el funcionamiento y bienestar de la persona, pudiendo traer consecuencias fatales como el intento de suicidio, así como alteraciones neuropsicológicas en los procesos afectivos y cognitivos que afectan el comportamiento. En el municipio de Guisa, Provincia Granma, existe un alto número de pacientes distímicos que son infradiagnosticados, por lo que las conductas suicidas se tornan más frecuentes. Por este motivo se realizó la investigación que se muestra bajo el título “Evaluación neuropsicológica de los procesos cognitivos básicos en pacientes distímicos con intento de suicidio”, con el objetivo de caracterizar el estado neuropsicológico de dichos procesos. Se aplicaron métodos del nivel teórico: análisis-síntesis y el inductivo-deductivo, así como las siguientes técnicas: entrevista inicial, anamnesis, observación, Inventario de Beck, test Gestáltico Bisomotor, Tarea de denominación de objetos, Tarea go/no go, Series gráficas y motoras alternantes, Test de memoria acortado y el Test de la figura compleja de Rey. A través de los cuales se obtuvo que el estado neuropsicológico de los procesos cognitivos básicos en estos pacientes está alterado, manifestando déficits en la percepción, atención y memoria, sustentados en posibles hallazgos biológicos en determinadas áreas cerebrales. Este trabajo investigativo es de vital importancia, permitirá diseñar intervenciones terapéuticas acertadas para el tratamiento, convirtiéndose de esta manera la exploración neuropsicológica en un elemento clave para el diagnóstico e intervención en los pacientes.

Dysthymia includes chronic symptoms that interfere with the functioning and well-being of the person and can bring fatal consequences such as suicide attempt, and neuropsychological alterations in affective and cognitive processes that affect behavior. In the municipality of Guisa, Granma Province there is a high number of dysthymic patients are underdiagnosed, so suicidal behavior become more frequent. For this reason, research shown under the title "Neuropsychological assessment of basic cognitive processes in dysthymic patients attempted suicide" in order to characterize the neuropsychological status of basic cognitive processes in these patients was performed. Analysis-synthesis and inductive-deductive and the following techniques: initial interview, anamnesis, observation, Inventory Beck, test Gestalt Bisomotor,Task object naming, Task go / no go, graphics series theoretical methods were applied and alternating motor, shortened memory test and test the complex figure of Rey. Through which was obtained that the neuropsychological status of basic cognitive processes in these patients is altered, showing deficits in perception, attention and memory, sustained in possible biological findings in certain brain areas. This research work is vital, it will allow designing successful therapeutic interventions for treatment, thus becoming the neuropsychological a key for diagnosis and intervention in these patient’s element.

A construção da subjetividade contemporânea e sua relação / com a depressão / The construction of contemporary subjectivity and its relation to depression

O artigo destaca as transformações subjetivas que estão intimamente relacionadascom o aumento das formas contemporâneas de depressão. Partimos de leituras que privilegiamo declínio da força normativa das grandes narrativas que serviam de guia moral para a constru-ção da subjetividade moderna e que evidenciam as mudanças na relação do sujeito com o corpoe com o cuidado de si, tomando-as como elementos fundamentais na formação das antinomiaspsicológicas atuais. As transformações estão associadas à passagem do homem moderno para ohomem pós-moderno, que se caracteriza pela busca de satisfação extremamente orientada emdireção ao prazer e a estímulos sensórios em detrimento do aperfeiçoamento sentimenta

Cognitive conflicts and symptom severity in dysthymia: "I'd rather be good than happy" / Conflictos cognitivos y gravedad de los síntomas en la distimia: "Prefiero ser bueno que feliz"

A method for studying cognitive conflicts using the repertory grid technique is presented. By means of this technique, implicative dilemmas can be identified, cognitive structures in which a personal construct for which change is wished for implies undesirable change on another construct. We assessed the presence of dilemmas and the severity of symptoms in 46 participants who met criteria for dysthymia and compared then to a non-clinical group composed of 496 participants. Finally, an analysis of the specific content of the personal constructs forming such dilemmas was also performed. Implicative dilemmas were found in almost 70% of the dysthymic participants in contrast to 39% of controls and in greater quantity. In addition, participants in both groups with this type of conflict showed more depressive symptoms and general distress than those without dilemmas. Furthermore, a greater number of implicative dilemmas was associated with higher levels of symptom severity. Finally, content analysis results showed that implicative dilemmas are frequently composed of a constellation of moral values and emotion, indicating that symptoms are often related to moral aspects of the self and so change processes may be hindered. Clinical implications of targeting implicative dilemmas in the therapy context are discussed.

En este estudio se presenta un método para el estudio de los conflictos cognitivos utilizando la técnica de rejilla. Por medio de ella, se identificaron los dilemas implicativos, una estructura cognitiva en la que un constructo personal en el que se desea un cambio se asocia con otro constructo en el que el cambio no es deseable. Se evaluó la presencia de dilemas y la gravedad sintomatológica en una muestra de 46 participantes que cumplían criterios diagnósticos para la distimia y se comparó con un grupo control compuesto por 496 participantes. Por último, se llevó a cabo un análisis del contenido de los constructos personales que forman los dilemas. Se encontraron dilemas en casi 70% de la muestra clínica frente a 39% de la muestra control y en mayor cantidad. Por otro lado, los participantes de ambos grupos con este tipo de conflicto mostraron un nivel mayor de sintomatología depresiva y malestar general que aquellos sin dilemas. Además, se encontró una alta correlación entre el número de dilemas implicativos y la gravedad de los síntomas. Los resultados del análisis de contenido mostraron que los dilemas estaban frecuentemente formados por una constelación de valores morales y constructos emocionales indicando que a menudo los síntomas están asociados a aspectos positivos del sí mismo, por lo que el proceso de cambio puede verse bloqueado. Se discuten las implicaciones clínicas de abordar los dilemas en el contexto terapéutico.

Sintomatología depresiva y función reflexiva en la psicoterapia psicodinámica con pacientes distímicas: comparación de tres casos / Depressive symptoms and reflective function of dysthymic patients in a psychodynamic psychotherapy: a comparison of three single cases

El estudio examina empíricamente la relación entre el estado de ánimo depresivo y la mentalización en el curso de la terapia. Las preguntas de investigación fueron: ¿Pueden observarse cambios en el estado de ánimo depresivo y / o en la mentalización en el curso de la terapia? ¿Puede observarse una relación entre el síntoma depresivo cardinal y la mentalización? Método: La muestra se compuso de tres casos únicos homogéneos en cuanto a sexo, edad, diagnóstico y resultado del tratamiento. La terapia incluyó como mínimo 50 sesiones. Los instrumentos utilizados fueron Profile of Mood States (POMS) para medir la Depresión y Reflective Functioning Scale para medir la Función Reflexiva (Reflective Function, RF). Para el análisis estadístico se utilizó la correlación de rangos de Spearman. Resultados: En los tres casos se observó una tendencia descendente para la variable Depresión. La RF disminuyó en un caso, y en dos casos no se modificó. Sólo en un caso se halló una correlación (negativa) entre Depresión y RF. Conclusiones: En estudios futuros deberá investigarse una muestra más amplia y homogénea. Se recomienda la utilización de un diseño de investigación y de métodos estadísticos más complejos, así como la inclusión de diversas variables de proceso.

Sintomatología depresiva y función reflexiva en la psicoterapia psicodinámica con pacientes distímicas: comparación de tres casos / Depressive symptoms and reflective function of dysthymic patients in a psychodynamic psychotherapy: a comparison of three single cases

El estudio examina empíricamente la relación entre el estado de ánimo depresivo y la mentalización en el curso de la terapia. Las preguntas de investigación fueron: ¿Pueden observarse cambios en el estado de ánimo depresivo y / o en la mentalización en el curso de la terapia? ¿Puede observarse una relación entre el síntoma depresivo cardinal y la mentalización? Método: La muestra se compuso de tres casos únicos homogéneos en cuanto a sexo, edad, diagnóstico y resultado del tratamiento. La terapia incluyó como mínimo 50 sesiones. Los instrumentos utilizados fueron Profile of Mood States (POMS) para medir la Depresión y Reflective Functioning Scale para medir la Función Reflexiva (Reflective Function, RF). Para el análisis estadístico se utilizó la correlación de rangos de Spearman. Resultados: En los tres casos se observó una tendencia descendente para la variable Depresión. La RF disminuyó en un caso, y en dos casos no se modificó. Sólo en un caso se halló una correlación (negativa) entre Depresión y RF. Conclusiones: En estudios futuros deberá investigarse una muestra más amplia y homogénea. Se recomienda la utilización de un diseño de investigación y de métodos estadísticos más complejos, así como la inclusión de diversas variables de proceso.(AU)

La distimia en el contexto clínico / Dysthymia in the Clinical Context

La distimia se define como un trastorno afectivo crónico que persiste por lo menos dos años en adultos y un a ño en adolescentes y niños. Según el DSM IV-TR, se clasifica en dos subtipos: la distimia de inicio temprano, antes de los 21 años, y la de inicio tardío después de los 21 años. Generalmente antes de los 21 años se puede observar trastornos de conducta, déficit de atención e hiperactividad y algunos síntomas vegetativos. Es importante distinguir tempranamente la distimia de otros tipos de depresión, a fin de brindar un tratamiento oportuno que atenúe el impacto continuo de síntomas caracterizados por pobre conciencia del estado de ánimo, pensamiento negativo, baja autoestima y anergia, lo que deteriora progresivamente la calidad de vida. La etiología es compleja y multifactorial, dados los variados mecanismos biológicos, psicológicos y sociales involucrados. Varias hipótesis tratan de explicar la etiología de la distimia; destacan la hipótesis genética que incluye además factores ambientales y la hipótesis aminérgica, que apunta a una deficiencia de serotonina, noradrenalina y dopamina en el sistema nervioso central. Desde nuestro punto de vista, no se puede concebir la distimia como un simple trastorno depresivo leve; es una entidad diferente caracterizada por un trastorno depresivo crónico que puede persistir toda la vida, con importantes repercusiones en la calidad de vida, tanto del sujeto que la padece como de sus familiares.

Dysthymia is defined as a chronic mood disorder that persists for at least two years in adults, and one year in adolescents and children. According to DSM IV-TR, Dysthymia is classified into two subtypes: early-onset, when it begins before 21 years-old, and late onset Dysthymia, when it starts after this age. Before age 21, symptoms of conduct disorder, attention deficit disorder and hyperactivity with a few vegetative symptoms are usually present. It is important to distinguish it from other types of depression, as earlier as possible. This would allow providing these patients with the appropriate treatment to attenuate the impact of symptoms, such as poor awareness of self-mood, negative thinking, low self-esteem, and low energy for social and family activities, which progressively deteriorate their life quality. The etiology of Dysthymia is complex and multifactorial, given the various biological, psychological and social factors involved. Several hypotheses attempt to explain the etiology of Dysthymia, highlighting the genetic hypothesis, which also includes environmental factors, and an aminergic hypothesis suggesting a deficiency in serotonin, norepinephrine and dopamine in the central nervous system. From our point of view, dysthymia cannot be conceived as a simple mild depressive disorder. It is a distinct entity, characterized by a chronic depressive disorder which could persist throughout life, with important repercussions on the life quality of both patients and families.

[Dysthymia in the Clinical Context]. / La distimia en el contexto clínico.

Dysthymia is defined as a chronic mood disorder that persists for at least two years in adults, and one year in adolescents and children. According to DSM IV-TR, Dysthymia is classified into two subtypes: early-onset, when it begins before 21 years-old, and late onset Dysthymia, when it starts after this age. Before age 21, symptoms of conduct disorder, attention deficit disorder and hyperactivity with a few vegetative symptoms are usually present. It is important to distinguish it from other types of depression, as earlier as possible. This would allow providing these patients with the appropriate treatment to attenuate the impact of symptoms, such as poor awareness of self-mood, negative thinking, low self-esteem, and low energy for social and family activities, which progressively deteriorate their life quality. The etiology of Dysthymia is complex and multifactorial, given the various biological, psychological and social factors involved. Several hypotheses attempt to explain the etiology of Dysthymia, highlighting the genetic hypothesis, which also includes environmental factors, and an aminergic hypothesis suggesting a deficiency in serotonin, norepinephrine and dopamine in the central nervous system. From our point of view, dysthymia cannot be conceived as a simple mild depressive disorder. It is a distinct entity, characterized by a chronic depressive disorder which could persist throughout life, with important repercussions on the life quality of both patients and families.

Endofenotipos de Distimia: uso racional de psicofármacos / Endophenotypes of Dysthymia: rational use of psychiatric drugs

El trastorno distímico es una patología subdiagnosticada, que genera un malestar clínicamente significativo con deterioro social, laboral o de otras áreas importantes de la actividad de un individuo. La interrelación entre la genética y la influencia ambiental hace que surjan determinadas etiologías de un trastorno psiquiátrico, que se manifiestan con características clínicas diferentes. A éstas las llamamos “características endofenotípicas”. El endofenotipo determinará también una genética psiquiátrica particular, resultante de la relación que haya entre éste y el pool génico del individuo en cuestión, como así también una respuesta a los fármacos utilizados durante el tratamiento. En la Distimia el afrontamiento maladaptativo es un síntoma central; genera sentimientos negativos llevando a la deserción, fracaso o aumento de la respuesta fisiológica al estrés. La diferente modalidad de afrontamiento, predominando o no la ansiedad como síntoma capital, genera dos endofenotipos de esta patología: Distimia Ansiosa (con ansiedad) y Distimia Anérgica (sin ansiedad). Entre los endofenotipos, las diferencias se reflejan en tratamientos específicos: para la Distimia Anérgica se debe modular el sistema noradrenalina/dopamina. Los IRSS no serían la primera elección. Sí, en cambio, fármacos como el bupropion, la venlafaxina, la amisulprida y los antidepresivos tricíclicos; en la Distimia Ansiosa, se deben utilizar antidepresivos que mejoren la neurotransmisión noradrenérgica/serotoninérgica; los Inhibidores de la Recaptación de la Serotonina y la Noradrenalina (SNRI) tienen una mejor respuesta que los Inhibidores Selectivos de la Recaptación de la Serotonina (IRSS), aunque estos también otorgan una buena alternativa.

Dysthymic disorder is an underdiagnosed pathology characterized by clinically significant distress, and impairment in the social, occupational, or other important areas of activity of an individual. The inter relationship between genetics and the environmental influence cause the emergence of certain etiologies from a psychiatric disorder, which manifest with different clinical characteristics. These are called "endophenotypic characteristics". The endophenotype will also determine a particular psychiatric genetics, which results from the relationship between it and the gene pool of the individual in question, as well as a response to the psychiatric drugs used during the treatment. Within dysthymia, maladaptive coping is a central symptom, it generates negative feelings that led to desertion, failure, or to an increase in the physiological response to stress. Each coping modality, whether anxiety prevails as the central symptom or not, generates two endophenotypes of this pathology: anxious dysthymia (dysthymia with anxiety) and Anergic Dysthymia (dysthymia without anxiety). Among the endophenotypes, differences are reflected in specific treatments: in the case of Anergic Dysthymia, the noradrenaline/dopamine system has to be modulated. SSRls would not be the firest choice, but rather, drugs such as bupropion, venlafaxine, amisulpride and tryciclic antidepressants, for the treatment of Anxious Dysthymia, antidepressants have to be used that imporve the noradrenergic/serotoninergic neurotransmission, Serotonin and Noradrenalin Reuptake inhibitors (SNRIs) have a better response than Selective Serotonin Repuptake Inhibitors (SSRIs) have a better response than Selective Serotonin Reuptake Inhibitors (SSRIs), although the latter also provide a good alternative.

Endofenotipos de Distimia: uso racional de psicofármacos / Endophenotypes of Dysthymia: rational use of psychiatric drugs

El trastorno distímico es una patología subdiagnosticada, que genera un malestar clínicamente significativo con deterioro social, laboral o de otras áreas importantes de la actividad de un individuo. La interrelación entre la genética y la influencia ambiental hace que surjan determinadas etiologías de un trastorno psiquiátrico, que se manifiestan con características clínicas diferentes. A éstas las llamamos ¶características endofenotípicas÷. El endofenotipo determinará también una genética psiquiátrica particular, resultante de la relación que haya entre éste y el pool génico del individuo en cuestión, como así también una respuesta a los fármacos utilizados durante el tratamiento. En la Distimia el afrontamiento maladaptativo es un síntoma central; genera sentimientos negativos llevando a la deserción, fracaso o aumento de la respuesta fisiológica al estrés. La diferente modalidad de afrontamiento, predominando o no la ansiedad como síntoma capital, genera dos endofenotipos de esta patología: Distimia Ansiosa (con ansiedad) y Distimia Anérgica (sin ansiedad). Entre los endofenotipos, las diferencias se reflejan en tratamientos específicos: para la Distimia Anérgica se debe modular el sistema noradrenalina/dopamina. Los IRSS no serían la primera elección. Sí, en cambio, fármacos como el bupropion, la venlafaxina, la amisulprida y los antidepresivos tricíclicos; en la Distimia Ansiosa, se deben utilizar antidepresivos que mejoren la neurotransmisión noradrenérgica/serotoninérgica; los Inhibidores de la Recaptación de la Serotonina y la Noradrenalina (SNRI) tienen una mejor respuesta que los Inhibidores Selectivos de la Recaptación de la Serotonina (IRSS), aunque estos también otorgan una buena alternativa.(AU)

Dysthymic disorder is an underdiagnosed pathology characterized by clinically significant distress, and impairment in the social, occupational, or other important areas of activity of an individual. The inter relationship between genetics and the environmental influence cause the emergence of certain etiologies from a psychiatric disorder, which manifest with different clinical characteristics. These are called "endophenotypic characteristics". The endophenotype will also determine a particular psychiatric genetics, which results from the relationship between it and the gene pool of the individual in question, as well as a response to the psychiatric drugs used during the treatment. Within dysthymia, maladaptive coping is a central symptom, it generates negative feelings that led to desertion, failure, or to an increase in the physiological response to stress. Each coping modality, whether anxiety prevails as the central symptom or not, generates two endophenotypes of this pathology: anxious dysthymia (dysthymia with anxiety) and Anergic Dysthymia (dysthymia without anxiety). Among the endophenotypes, differences are reflected in specific treatments: in the case of Anergic Dysthymia, the noradrenaline/dopamine system has to be modulated. SSRls would not be the firest choice, but rather, drugs such as bupropion, venlafaxine, amisulpride and tryciclic antidepressants, for the treatment of Anxious Dysthymia, antidepressants have to be used that imporve the noradrenergic/serotoninergic neurotransmission, Serotonin and Noradrenalin Reuptake inhibitors (SNRIs) have a better response than Selective Serotonin Repuptake Inhibitors (SSRIs) have a better response than Selective Serotonin Reuptake Inhibitors (SSRIs), although the latter also provide a good alternative.(AU)

Depressão / Depression

Os transtornos depressivos se caracterizam principalmente por alteração do humor do paciente em direção ao pólo depressivo. Os sintomas apresentados pelos pacientes são influenciados pela faixa etária em que o problema ocorre, bem como pela presença de outras condições clínicas associadas. Assim, o presente trabalho abordará as principais características dos transtornos depressivos em situações clínicas específicas, tanto no que tange à apresentação clínica como no que diz respeito aos aspectos de tratamento. Os transtornos depressivos englobam sintomas que precisam ser reconhecidos pelos médicos de todas as especialidades. O tratamento clínico é realizado com antidepressivos até a remissão completa dos sintomas depressivos. Depois do tratamento agudo, o seguimento se divide em duas fases. Inicialmente, deve-se manter o tratamento na dose eficaz (com a qual o paciente apresentou remissão dos sintomas) por um período igual ou maior a um ano. Depois desse período de uso do antidepressivo, pode-se reduzir gradualmente a dose até a sua suspensão. Em um segundo episódio depressivo, a medicação antidepressiva deve ser utilizada por um período mínimo de dois anos após a remissão dos sintomas. No caso de risco elevado de recorrência, deve-se considerar uma fase de tratamento de manutenção preventiva, com uso de antidepressivo por período indeterminado.

La depresión: ¿un trastorno dimensional o categorial?

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Summary One of the crucial subjects, either for the clinical or scientific activity, is the dimensional or categorical character of depression and other mental diseases. Each approach is different from the theoretical and epistemological points of view. At presence, the categorical model for the definition and estimation of the presence of a disorder are reflected in the data on epidemiology, the results of investigations, instruments and the interventions. These elements are related to a system of thinking which results in a particular form of conceiving the psychopathology and intervention. Nevertheless, the strong influence of the categorical model in which the disorders are defined as a group of accomplished criteria has not prevented from development of a dimensional model. The latter postulates the existence of a continuum between the normality and pathology which correspond with dimensions, levels and severity related to the certain behaviours, traits or even symptoms. The interest in the dimensional approach to psychopathology, in general and in mood disorders, is caused by the observation in clinics which indicate, for example, that many patients do not improve with medicines and present residual symptoms during long periods of time. For these reasons, some personality factors which would explain the chronic symptoms of disorders have been proposed in Psychology and Psychiatry. Although the diagnostic manuals consider different types of mood disorders, many investigations have showed the possibility to consider depression as a continuum, where the least severe extreme would be the depressive personality and the most severe, major depression. According to the abovementioned proposal, it is possible that some people present certain vulnerability which would explain the different answers in case of depression. Cognitive factors, together with social and genetic factors increase the risk of chronic depressive symptoms. The catastrophic perception of self, the world and future, the dichotomous thinking and tunnel vision are the cognitive factors associated with the presence of the mood disorders symptoms. Additionally, some studies show the importance of gender, as women are more prone to develop depression and similar disorders which is related to traditional social roles. This can be caused by the need to sacrifice the professional career to dedicate time to housework, or to assume multiple roles. Concerning the genetic factors, the presence of first degree relatives with mood disorders increases the risk of development of depression or dysthymia. The consideration of depressive personality is based on the presence of symptoms which do not fulfil the criteria of severity and frequency of major depression but do affect the mood. The presence of these stable traits is related to major chronicity and worse prognosis. This condition has been described in manuals as dysthymia. Nevertheless, as it remains relatively stable in time it could be understood as a personality disorder. The disorder would be a continuum with the normality similar to this described as neuroticism in which some entities are qualitatively and quantitatively different which represent the categories. The analysis of what has been described above shows the possibility of differentiation between the mood disorders which are related to the dimensional focus where some traits increase the vulnerability to develop them. On the other hand, the categorical focus requires the accomplishment of the diagnostic criteria. The cognitive models also support the existence of depressive personality disorder. These models emphasize the importance of schemes in thinking which are created in childhood together with the attachment to the caretaker. The schemes are the basis for the future relationships which in case of mood disorders are always perceived with continuous thread of abandonment and lost. On the other hand, the behavioural models emphasize the patterns of negative interpersonal interaction in childhood, as the factors which predispose to the development of depression, whereas the psychodynamic theories establish the successive lost during the lifetime as the principal cause of mood disorders. All these theories show the existence of unfavourable emotional conditions which cause a certain vulnerability to develop symptoms of depression. The dimensional focus on depression is also supported by the evidence on the distinction between the disorders according to the severity. The difference between the normality and the psychopathology is not as clear as in the categorical focus. There is a necessity to develop new forms of evaluation which would enable the differentiation between the stable traits and punctual states of mood. At presence, most of the questionnaires are based on the categorical classification which makes the estimation from the dimensional point of view more difficult. On the other hand, the measures which provide differentiation between the traits and states are an alternative to estimate the stable conditions which would be related to the depressive personality and also specific reactions which depend on the present situation. Most of the instruments have been developed on the basis of the categorical model in which the diagnosis is the presence or absence of a disorder according to the diagnostic criteria. For this reason they do not have sufficient sensitivity to determinate less severe levels which are also important in clinical interventions as they allow the estimation of the improvements and decrease of symptomatology. The dimensional focus allows the preventive interventions in mood disorders which are very important to solve this serious health problem in the population.

Evaluación del componente afectivo de la depresión: análisis factorial del ST/DEP revisado

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Abstract: Depression is a main Public Health problem due to its high prevalence and to the costs for intervention and treatment. Therefore, it is necessary to identify strategies that allow an adequate assessment that would let us obtain a more precise and useful diagnosis. Nevertheless, animportant obstacle for this task, is a lack of theoretical clarity in regard to diagnostic criteria or, especially, to symptoms which are relevant for depression. This fact is obvious in the scales focused on depression assessment, which have a broad variety of symptoms to assess, and it is possible to overestimate some areas or to underestimate others, related to theoretical criterions which were involved in test construction. So, depression is evaluated in accordance with the questionnaire that is used and, of course, depending of theoretical framework that supports this tool. Therefore, depression is defined in line with the criteria which evaluates it, with regard to assessment s criteria, which could explain the usual difficulty to identify common symptoms when some tools are used, which are then identified as genuine symptoms of depression. As the aim of this paper is to improve some of this limitations, the State/Trait Depression Questionnaire (ST/DEP) is showed as an useful tool for clinical and research work. It offers an assessment of one of the component of depression, the affective one, providing two measures: State and Trait. This allows to differentiate between intensity and frequency. Main-axis factor analysis has been made and the results have shown two main factors in affectivity: Dysthymia (negative affection) and Euthymia (positive affection). The interest on positive affection assessment aims to obtain a more precise tool. So, when scores are inverted in positive items, it is possible to obtain a measurement of low levels on affectation. The relevance of this fact is emphasized because it has been neglected in most of depression scales, that only identify presence or absence, a fact that limits the ability to estimate slight modifications. This issue is very useful at two levels: clinic and research. At a clinical level because it permits to identify slight changes in affectation, which could be important as measurement oftherapeutic efficacyand ofsymptoms remission. In research, because it offers the possibility to dispose of one able tool to differenciate of low levels of affectation, which allow a more accurate estimation of the depression symptoms, specially when working with a nonclinical population. The present study was carried out with a sample of 300 participants (103 males and 197 females), with mean age of 21.82 (2.74 s.d.) for males and 22.26 (3.66 s.d.) for females. It was an instrumental study where the Spanish Experimental Version of Stat-Trait Depression (ST/DEP) was used. All participants received information about research and they answered the questionnaires voluntarily. The findings are shown separately for the two scales (State and Trait) and for the two sub-scales (Dysthymia and Euthymia). Data indicated significant differences between males and females, being the highest scores for females. This is an evidence related to the higher prevalence of depression in women. It is very important to remark that essentially the same strong state and trait factors were found for both males and females, according to the factor structure of the Spanish Experimental Version of the State-Trait Depression Questionnaire (ST/DEP). These factors explained the 54% variance for females and of 53% for males. The Promax Rotation differentiated two factors clearly: Dysthimia and Euthymia. That was similar to what was found in the original English form of the ST-DEP. The factorial structure was then confirmed, because of the bifactorial structure which differentiated the negative and positive affectivity of Depression. Another positive result was the test ability to detect slight changes on affectivity, which will be useful to differentiate between clinical and non clinical population. It is important to point out that the ST/DEP is a measurement of one component of depression: affectivity, which has been identified as a relevant component in this disorder, but this tool is not enough to diagnose depression. This fact is relevant, because some tools for depression assessment are used as a diagnostic criteria, a fact that increases confusion in making a differential diagnostic between anxiety and depression or some other symptoms and clinical problems. All this results provide evidences of the psychometric properties of the Spanish ST-DEP, and make this scale a fruitful and useful assessment instrument.