Avoidant restrictive eating disorder and panic attacks in an adult man: A case report / Trastorno evitativo restrictivo de la ingesta alimentaria y ataques de pánico en un hombre adulto: Reporte de caso

Abstract Avoidant or Restrictive Food Intake Disorder (ARFID) is an eating disorder (ED) not common in adults. In this article we present a clinical case of ARFID in a 37-year-old male patient treated in an ED center in Medellin, Colombia; displaying anxious symptoms that began a year earlier and concomitant weight loss, following a traumatic event causing an overall impairment with that patient. Several medical evaluations/examinations looking for organic causes, were excluded. Interventions were implemented by a psychiatry, a psychotherapist using cognitive-behavior therapy (CBT), and a nutritionist, all in face-to-face modality, which were carried out weekly for the first three months, then biweekly and subsequently quarterly. each lasting approximately 40-60 minutes. After the set of pharmacological interventions and psychotherapy, a great improvement in the functionality of the patient was observed. Improvement was found with respect to eating in public, food variation and panic attacks. In the absence of guidelines, it is important to use standardized and replicable treatments in this population.

Resumen El trastorno evitativo restrictivo de la ingesta (TERIA) es un trastorno alimentario (TCA) raro en adultos. Se presenta el caso de un hombre de 37 años con TERIA y trastorno de pánico atendido en un centro para TCA en Medellín, Colombia, quien presentó un año de síntomas ansiosos y pérdida de peso después de evento traumático, generando disfuncionalidad. Fue evaluada y excluida organicidad. Se realizaron intervenciones por parte de psiquiatría, psicoterapia con enfoque cognitivo conductual y nutrición, todas en modalidad presencial, las cuales se realizaron semanalmente los primeros tres meses, luego quincenalmente y posteriormente trimestralmente. Cada una con una duración de 40-60 minutos aproximadamente por sesión. Posterior al conjunto de intervenciones farmacológicas y psicoterapia, se observó una gran mejoría la funcionalidad del paciente, se encontró mejoría con respecto a comer en público, variación en los alimentos y ataques de panico. Ante la ausencia de guías de manejo de TERIA en adultos es relevante realizar tratamientos estandarizados que puedan ser replicados.

La Influencia de la Evitación Experiencial y la Fusión Cognitiva en Personas con Diagnóstico de Trastorno de Pánico y Agorafobia y TOC / The Influence of Experiential Avoidance and Cognitive Fusion in People Diagnosed with Panic Disorder and Agoraphobia and OCD

La terapia de aceptación y compromiso (ACT) pone de manifiesto la importancia de la evitación experiencial y la fusión cognitiva en un amplio espectro de problemas psicológicos. El propósito de este estudio es conocer cómo influyen la gravedad del trastorno de pánico y agorafobia (TPA) y la gravedad del trastorno obsesivo-compulsivo (TOC) en los niveles de evitación experiencial y fusión cognitiva. Se pretende examinar, además, si existen diferencias entre ambos grupos diagnósticos. La muestra estaba constituida por 67 personas diagnosticadas de TPA y TOC. Se utilizaron los siguientes instrumentos de evaluación: Acceptance and Action Questionnaire (AAQ), Cognitive Fusion Questionnaire (CFQ), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) y Beck Anxiety Inventory (BAI). Los resultados mostraron que los pacientes con TPA presentan mayores niveles de fusión cognitiva frente a los pacientes con TOC, que elevados niveles de ansiedad se asocian a mayor grado de evitación experiencial y que una mayor gravedad del TOC correlacionaba con elevados niveles de evitación experiencial y fusión cognitiva. Se propone una intervención temprana en pacientes con TOC para prevenir la cronicidad del trastorno y se recalca la importancia de los aspectos de aceptación en el trascurso de la terapia de estos pacientes (AU)

Acceptance and Commitment Therapy (ACT) highlights the importance of experiential avoidance and cognitive fusion in a wide spectrum of psychological problems. The purpose of this study is to know how the severity of panic disorder and agoraphobia (APT) and the severity of obsessive-compulsive disorder (OCD) influence levels of experiential avoidance and cognitive fusion. It is also intended to examine whether there are differences between the two diagnostic groups. The sample consisted of 67 people diagnosed with APT and OCD. The following assessment instruments were used: Acceptance and Action Questionnaire (AAQ), Cognitive Fusion Questionnaire (CFQ), Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and Beck Anxiety Inventory (BAI). The results showed that patients with APT present higher levels of cognitive fusion compared to patients with OCD, that high levels of anxiety are associated with a higher degree of experiential avoidance, and that greater severity of OCD correlated with high levels of experiential avoidance and fusion cognitive. Early intervention in OCD patients is proposed to prevent the chronicity of the disorder and the importance of the acceptance aspects is emphasized in the course of therapy of these patients (AU)

Inibição, sintoma e medo? Algumas notas sobre a Angst na psicanálise / Inhibition, symptom and fear? Notes on Angst within psychoanalysis / Inhibition, symptôme et peur? Quelques notes sur l'Angst en psychanalyse) / Inhibición, síntoma y miedo? Algunas notas sobre la Angst en el psicoanálisis)

A partir de questões suscitadas pela recente tradução de Renato Zwick do texto "Hemmung, Symptom und Angst" para "Inibição, sintoma e medo" (Freud, 1926/2016), o objetivo deste artigo é assinalar duas dimensões da Angst que não correspondem a uma mesma palavra em português. Após um apanhado teórico dos principais textos de Freud sobre o assunto, discute-se o transtorno de pânico, no campo da psicopatologia e clínica contemporânea, enfatizando essas duas dimensões afetivas.

Based on questions posed by Renato Zwick's recent translation of "Hemmung, Symptom und Angst" to "Inibição, Sintoma e Medo" (inhibitions, symptoms and fear) (Freud, 1926/2016), this paper's goal is to highlight two dimensions of Angst that do not correspond to a same word in Portuguese. Following a theoretical overview of Freud's main texts on this subject, panic disorder is discussed in the fields of contemporary psychopathology and clinical practice, emphasizing these two affective dimensions.

À partir de questions posées par la traduction récente de Renato Zwick de «Hemmung, Symptom und Angst¼ en portugais, «Inibição, sintoma e medo¼ [inhibition, symptôme et peur] (Freud, 1926/2016), cet article propose d'indiquer deux dimensions de la notion de Angst qui ne correspondent pas au même mot en portugais. Après un aperçu théorique des principaux textes de Freud sur ce sujet, le trouble panique est discuté, sous l'angle de la psychopathologie et de la pratique clinique contemporaines, en mettant l'accent sur ces deux dimensions affectives.

A partir de cuestiones planteadas por la reciente traducción, de Renato Zwick, del texto "Hemmung, Symptom und Angst" como "Inibição, Sintoma e Medo" (inhibición, síntoma y miedo) (Freud, 1926/2016), el objetivo de este artículo es señalar dos dimensiones de la Angst que no corresponden a una misma palabra en portugués. Luego de un recuento teórico de los principales textos de Freud sobre el asunto, se discute el trastorno de pánico, en el campo de la psicopatología y la clínica contemporánea, enfatizando en esas dos dimensiones afectivas.

Renato Zwicks Übersetzung von „Hemmung, Symptom und Angst" (Freud, 1926/2016) ins Portugiesische („Inibição, Sintoma e Medo") hat verschieden Fragen aufgeworfen. In diesem Artikel wird versucht, zwei Dimensionen des Begriffes der Angst zu beschreiben, für die zwei verschiedene Wörter auf Portugiesisch benutzt werden. Nach einem theoretischen Überblick von Freuds wichtigste Texte zum Thema diskutieren wir das Paniksyndrom unter dem Blickpunkt der Psychopathologie und der modernen Praxis, wobei diese beiden affektiven Dimensionen im Zentrum der Diskussion stehen.

Evaluación de modalidades de intervención en el ámbito público para población con trastorno de pánico / Assessment of intervention modalities in the public sphere for population with panic disorder

Se presentan los resultados de un proyecto de investigación clínica desarrollado en la Dirección General de Salud y Asistencia Social, UBA, que evaluó la eficacia terapéutica en el tratamiento del ataque de pánico. Para ello se compararon dos modalidades terapéuticas: Psicoterapia Focal de Orientación Psicoanalítica (POP) y Tratamiento Combinado (TC) -POP y Tratamiento Psicofarmacológico-. La muestra fue constituida por 55 sujetos con trastorno de pánico, según los criterios del DSM-IV TR, que recibieron aleatoriamente uno u otro tratamiento durante 12 sesiones a razón de una sesión semanal. Los resultados obtenidos demostraron que POP y el TC constituyen modalidades de intervención eicaces en el tratamiento del trastorno de pánico permitiendo reducir la sintomatología del mismo, mejorar la calidad de vida del paciente y mantener los resultados en el largo plazo. POP favorece la adherencia al tratamiento farmacológico. El TC no mostró diferencias significativas respecto de POP con relación a su eficacia.

We are presenting the conclusions of a clinical research project developed by the General Directorate for Health and Social Assistance, UBA, which assessed the therapeutic eficacy in the treatment of a panic attack. The results were based on the comparison of two therapeutic modalities: Focal Psychoanalytically Oriented Psychotherapy (POP) and Combined Treatment (TC) - POP and Psychopharmacological Treatment. The sample group was comprised of 55 subjects with panic disorder (based on DSM-IV TR panic disorder diagnosis) who randomly received one or another weekly treatment during a period of 12 weeks (one session per week). The results showed that POP and the TC are effective intermission methods for the treatment of panic disorder, the ability to reduce the symptoms, improve the quality of life of the patient, and maintain long term results. POP favors adherence to pharmacological treatment. The TC showed no significant differences with regard to POP with relation to its eficacy.

Factores que influyen la comorbilidad entre trastorno de pánico y estrés postraumático después de terremotos / Factors that influence comorbidity from panic disorder and PTSD after earthquakes

Objetivo Después del terremoto y tsunami de Chile (27-F), estudiamosel efecto de factores socio-demográficos, de exposición al evento y de ayuda estatal recibida en la comorbilidad entre trastorno de pánico (CAP) y estrés postraumático (TEPT). Método Encuestas que incluían la Escala de Trauma de Davidson(DTS)a 246 habitantes. Resultados Se encontró19,1% de comorbilidad (r=,583; R2=,340; p<,01). Quienes tienen mayor riesgo de sufrir CAP y TEPT son las mujeresdueñas de casa. La ayuda estatal se asocia amás casos de CAP. Conclusiones Diseñamos perfiles de riesgo/resistencia anteterremotos/tsunamis y uninstrumento (EP-TEPT) para detectar casos en riesgo de TEPT. Sugerimos pautas para que el Estado mejore su rol después de desastres.(AU)

Objective After the earthquake and tsunami in Chile (F-27), we studied the effect of socio-demographic factors, exposure to the event, and state aid received on comorbidity from panic disorder (PD) and posttraumatic stress disorder (PTSD). Method Surveys that include the administration of the Davidson Trauma Scale (DTS) to 246 inhabitants. Results 19.1 % comorbidity was found (r=.583, R2=.340, p<.01). Females homeowners have a higher risk of PD and PTSD. State aid is associated with more cases of PD. Conclusions We designed risk/resistance profilesagainst earthquakes/tsunamis and an instrument to detect cases at risk of PTSD. We suggest guidelines so that the government can improve its role after disasters.(AU)

[Panic disorder and atrial fibrillation]. / Trastorno de pánico y fibrilación auricular.

This paper studies the relationship between atrial fibrillation and panic disorder. There are often doubts on the differential diagnosis in emergency services and general medical settings. Panic disorder prevalence rates have been found to be high in patients suffering from atrial fibrillation. Various studies have observed that patients diagnosed with anxiety disorders frequently have higher cardiovascular disease rates compared to the general population. Usually, patients suffering from panic disorder exhibit somatic complaints suggesting coronary disease, such as chest pain or palpitations. The aim is to make the correct diagnosis and treatment for these different illnesses, and to decrease the costs due to misdiagnosis.

Funções cognitivas no transtorno do pânico: um estudo comparativo com controles saudáveis / Las funciones cognitivas en el trastorno de pánico: un estudio comparativo con controles sanos / Cognitive functions in panic disorder: a comparative study with a healthy control group

A interface entre a neuropsicologia e a psicopatologia vem sendo muito estudada. No entanto, há ainda uma grande demanda de caracterização do processamento de cada função cognitiva em pacientes com transtorno do pânico(TP). Neste trabalho, visou-se verificar se há diferenças de desempenho neuropsicológico entre adultos com TP econtroles saudáveis. Participaram deste estudo 30 adultos, 15 com TP clinicamente diagnosticado e 15 controles saudáveis emparelhados por escolaridade, idade, nível sociodemográfico e habilidades intelectuais. Administraramse os instrumentos NEUPSILIN, discurso narrativo e fluências verbais da Bateria MAC, subtestes do WAIS-III, Wisconsin, Hayling, Teste das Trilhas, Teste dos Sinos, Teste Stroop, RAVLT e Buschke. O desempenho foi comparado entre grupos pelo teste não-paramétrico Mann-Whitney (p≤0,05). Encontraram-se diferenças significativas no processamento de componentes executivos, velocidade de processamento, iniciação, inibição, assim como nas memórias episódica e de trabalho. Mais estudos são necessários com amostras clínicas maiores e mais homogêneas, controlando-se depressão e agorafobia.

The interface between neuropsychology and psychopathology has been studied with a growing frequency. Neverthelessthere is still a great demand of characterizing the cognitive profile of each process among patients with panic disorder (PD). In this study we aimed at verifying if there are differences in the neuropsychological performance between adults with PD and adults from a healthy control group. Thirty adults took part on this study, 15 with clinically diagnosed PD and 15 healthy control subjects, matched by education, age, sociodemographic level and intellectual abilities. A neuropsychological test battery was administered including NEUPSILIN, narrative speech and verbal fluency of MAC battery, WAIS-III subtests, Wisconsin, Hayling, Trail Making Test, Stroop Test, RAVLT, Buschke and Bells Test. The performance was compared between groups by means of the non-parametric test Mann-Whitney (p≤0,05). Wefound significant differences on executive components: processing speed, initiation, inhibition, episodic and working memory. Further enquires are necessary, with a larger and more homogeneous sample, controlling for depression and agoraphobia.

Si bien la relación entre la neuropsicología y la psicopatología ha sido bastante estudiada, aún existe la necesidad de caracterizar el procesamiento de las distintas funciones cognitivas en pacientes con trastorno de pánico (TP). Este trabajo tiene por objetivo verificar si existen diferencias en el desempeño neuropsicológico entre adultos con TP y controles sanos. Participaron de este estudio 30 adultos, 15 con TP clínicamente diagnosticado y 15 controles sanos, emparejados por educación, edad, condiciones sociodemográficas y habilidades intelectuales. Se administraron lossiguientes instrumentos: NEUPSILIN, discurso narrativo y fluencia verbal de la Batería MAC, subpruebas de la WAIS-III, Wisconsin, test de Hayling, Trail Making test, test de cancelación de campanas, Stroop test, Lista de Rey y Buschke. Los puntajes medios fueron comparados con el test no paramétrico de Mann-Whitney (p≤0,05). Se encontraron diferencias significativas en el procesamiento de componentes ejecutivos, velocidad de procesamiento,iniciación, inhibición y también en la memoria episódica y de trabajo. Ulteriores estudios con muestras clínicas más amplias y homogéneas son necesarios, en los que puedan controlarse las variables de agorafobia y depresión.

Transtorno de pânico: uma manifestação clínica do desamparo / Panic disorder: a clinical manifestation of helplessness / Trastorno de pánico: una manifestación clínica del desamparo

O contexto atual apresenta mudanças nos modos de organização subjetiva. As redefinições dos papéis do homem e da mulher, as novas formas de filiação e as novas configurações familiares tem implicado o redimensionamento do lugar do pai e se refletido no exercício de sua função, qual seja, inscrever a lei. Tal inscrição é fundamental à estruturação do ser humano e à convivência social. Na atualidade, o sujeito se vê convocado ao excesso, sem referências, e novas formas de desorganização psíquica emergem. O transtorno de pânico se destaca como uma figura paradigmática do desamparo na contemporaneidade. Como categoria psicopatológica, tal transtorno é recente; como quadro clínico psicanalítico, ele se associa às fobias. Este estudo teórico visa a descrever, do ponto de vista da psiquiatria, tal transtorno, e discutir, a partir da psicanálise, o estado de desamparo provocado pela fragilidade da lei simbólica, como característica dessa sintomatologia.(AU)

These days it is possible to observe changes in the subjective organization modes. The redefinition of the roles of men and women and the new modalities of filiation have changed the father’s role, and this has been reflected in the actual performance of being a father, namely, in passing the law. This is fundamental for the structuring of a human being and for his/her social co-existence. Nowadays, the self seems to have no sense of limits, no landmarks and new ways of psychic disorganization arise with that. Panic disorder can be seen as a main paradigm of helplessness in our time. As a psychopathologic category, this disorder is new; as a psychoanalytical clinical record, it is associated to phobias. The present study aims to describe, from a psychiatric point of view, such disorder and discuss, based on psychoanalysis, the state of helplessness, caused by the fragility of the symbolic law as a characteristic of this symptom.(AU)

El contexto actual presenta cambios en las formas de organización subjetiva. Las redefiniciones de las atribuciones del hombre y de la mujer, las nuevas formas de filiación y las nuevas configuraciones familiares han conllevado al redimensionamiento del lugar del padre y se han reflejado en el ejercicio de su función, la cual es la de inscribir la ley. Dicha transcripción es fundamental a la estructuración del ser humando y a la convivencia social. En la actualidad, el sujeto se ve convocado a lo extremo, sin referencias, y nuevas formas de organización psíquica emergen. El trastorno de pánico se destaca como una figura con características de paradigma del desamparo en la contemporaneidad. Como categoría psicopatológica, dicho trastorno es reciente; como cuadro clínico psicoanalítico, él se asocia a las fobias. Este estudio teórico tiene como objetivo describir, desde el punto de vista de la psiquiatría, dicho trastorno, y discutir, a partir del psicoanálisis, el estado de desamparo provocado por la fragilidad de la ley simbólica, como característica de esa sintomatología.(AU)

Transtorno de pânico: uma manifestação clínica do desamparo / Panic disorder: a clinical manifestation of helplessness / Trastorno de pánico: una manifestación clínica del desamparo

O contexto atual apresenta mudanças nos modos de organização subjetiva. As redefinições dos papéis do homem e da mulher, as novas formas de filiação e as novas configurações familiares tem implicado o redimensionamento do lugar do pai e se refletido no exercício de sua função, qual seja, inscrever a lei. Tal inscrição é fundamental à estruturação do ser humano e à convivência social. Na atualidade, o sujeito se vê convocado ao excesso, sem referências, e novas formas de desorganização psíquica emergem. O transtorno de pânico se destaca como uma figura paradigmática do desamparo na contemporaneidade. Como categoria psicopatológica, tal transtorno é recente; como quadro clínico psicanalítico, ele se associa às fobias. Este estudo teórico visa a descrever, do ponto de vista da psiquiatria, tal transtorno, e discutir, a partir da psicanálise, o estado de desamparo provocado pela fragilidade da lei simbólica, como característica dessa sintomatologia....(AU)

These days it is possible to observe changes in the subjective organization modes. The redefinition of the roles of men and women and the new modalities of filiation have changed the father’s role, and this has been reflected in the actual performance of being a father, namely, in passing the law. This is fundamental for the structuring of a human being and for his/her social co-existence. Nowadays, the self seems to have no sense of limits, no landmarks and new ways of psychic disorganization arise with that. Panic disorder can be seen as a main paradigm of helplessness in our time. As a psychopathologic category, this disorder is new; as a psychoanalytical clinical record, it is associated to phobias. The present study aims to describe, from a psychiatric point of view, such disorder and discuss, based on psychoanalysis, the state of helplessness, caused by the fragility of the symbolic law as a characteristic of this symptom....(AU)

El contexto actual presenta cambios en las formas de organización subjetiva. Las redefiniciones de las atribuciones del hombre y de la mujer, las nuevas formas de filiación y las nuevas configuraciones familiares han conllevado al redimensionamiento del lugar del padre y se han reflejado en el ejercicio de su función, la cual es la de inscribir la ley. Dicha transcripción es fundamental a la estructuración del ser humando y a la convivencia social. En la actualidad, el sujeto se ve convocado a lo extremo, sin referencias, y nuevas formas de organización psíquica emergen. El trastorno de pánico se destaca como una figura con características de paradigma del desamparo en la contemporaneidad. Como categoría psicopatológica, dicho trastorno es reciente; como cuadro clínico psicoanalítico, él se asocia a las fobias. Este estudio teórico tiene como objetivo describir, desde el punto de vista de la psiquiatría, dicho trastorno, y discutir, a partir del psicoanálisis, el estado de desamparo provocado por la fragilidad de la ley simbólica, como característica de esa sintomatología....(AU)

Evaluación de funciones cognitivas: atención y memoria en pacientes con trastorno de pánico / Cognitive function evaluation: attention and memory in panic disorder patients

Evidence from recent studies about the epidemiology of panic disorder (PD) indicates that it is present in 4.7% of general population. In Mexico City, 2.9% of females and 1.9% of males are affected by this disease. Due to the incidence cited above, it is considered an important mental health problem that has impacted social, labor and familiar areas. On the other hand, PD is frequently present in comorbidity with other disorders like major depression, social phobia and generalized anxiety disorder. Moreover, in some cases, it may lead to a suicide risk. PD is characterized by recurrent, unexpected panic attacks, and is commonly associated with agoraphobia. A panic attack is defined as a discrete period of fear or discomfort that includes physical, cognitive and behavioral symptoms. Physical symptoms comprise short breath, palpitations, sweating, dizziness, gastrointestinal discomfort, and chest pain. Cognitive symptoms are associated with catastrophic interpretation of bodily sensations; behavioral symptoms are mainly avoidant of different places, situations and actions that patient had associated with fear of loss of control. In the past few years there has been a growing interest in the neuropsychology of anxiety disorders. Neuropsychological evaluation is relevant because it implies an objective assessment of the cognitive and behavioral abilities and weaknesses that make possible the prediction of the course of the disorder and the effects of treatment modalities. One of the most important contributions of neuropsychological evaluation is the identification of stable patterns of cognitive profiles of a specific disorder considered as neurocognitive endophenotypes. Some recent studies have demonstrated the relationship between neuropsychological alterations and anxiety; nevertheless, most of them were observed in obsessive-compulsive disorder patients. On the other hand, studies examining neuropsychological functioning in PD patients are scarce and report conflicting results. The main objective of the present study was to evaluate whether PD patients with and without agoraphobia, who attended the National Institute of Psychiatry <

De acuerdo a Kessler, el 4.7% de la población general presenta Trastorno de Pánico (TP) a lo largo de la vida, específicamente en la Ciudad de México el TP tiene una prevalencia en la vida de 1.1% en los hombres y de 2.5% en las mujeres, por lo que se considera un problema de gran relevancia. Aunado a esto, uno de los grandes problemas de este padecimiento es el alto índice de comorbilidad que presenta con otros trastornos psiquiátricos como la depresión mayor, la fobia social, el trastorno por ansiedad generalizada y el abuso de sustancias. De acuerdo con el DSM-IV-TR, el TP se caracteriza por la aparición de crisis de angustia inesperadas y recurrentes, inquietud persistente por la posibilidad de tener más crisis, preocupación por las implicaciones de las mismas o sus consecuencias y/o un cambio significativo del comportamiento relacionado con ellas. La evaluación neuropsicológica es relevante, ya que a través de ésta es posible obtener una valoración objetiva que permite conocer las habilidades y déficits cognoscitivos y conductuales de los pacientes con trastornos psiquiátricos para hacer una predicción sobre el curso de la enfermedad, elegir el tipo de tratamiento de forma objetiva, identificar patrones estables de déficits neuropsicológicos así como establecer estrategias que mejoren el pronóstico del trastorno. Diversos estudios han demostrado recientemente la relación entre algunas alteraciones neuropsicológicas y la ansiedad; sin embargo, la mayoría de éstos se han centrado en el trastorno obsesivo-compulsivo. Aunado a esto, los resultados encontrados en investigaciones que han evaluado las funciones cognitivas en el TP, no han sido consistentes. El objetivo del presente estudio fue determinar si existen déficits neuropsicológicos en pacientes diagnosticados con TP con o sin agorafobia que acudieron al servicio de preconsulta del Instituto Nacional de Psiquiatría Ramón de la Fuente, en comparación con sujetos control en los dominios de atención, memoria y funciones ejecutivas. Se seleccionaron dos grupos: uno de 24 sujetos diagnosticados con TP, de acuerdo al DSM-IV-TR, sin tratamiento farmacológico y/o psicoterapéutico previo; y otro de 24 sujetos sanos comparados formando pares por sexo, edad y escolaridad con el primero. Se les aplicó una batería neuropsicológica (Neuropsi Atención y Memoria) que evalúa orientación, atención y concentración, memoria de trabajo, memoria verbal y visual, y funciones ejecutivas y motoras. El Neuropsi Atención y Memoria cuenta con normas obtenidas en la población mexicana, considerando la edad y la escolaridad. Las diferencias en el desempeño cognitivo entre el grupo control y el grupo con TP fueron analizadas por medio de un Análisis de Varianza (con p<0.05). Los resultados mostraron que los sujetos con TP puntuaron significativamente más bajo que los controles en el puntaje total de atención y memoria, en el puntaje del total de atención y funciones ejecutivas, y el total de memoria. El análisis de las subpruebas específicas reveló déficits en la memoria verbal, la memoria visoespacial inmediata y la evocada, y en diversas funciones ejecutivas: formación de categorías, fluidez verbal semántica y fonológica, y fluidez no verbal. Los hallazgos encontrados en este estudio apoyan la noción de que la ansiedad (específicamente el TP) afecta la memoria verbal y la visoespacial así como las funciones ejecutivas. Los pacientes con TP mostraron alteraciones significativas en tareas que requieren de la capacidad de cambiar de foco de atención, flexibilidad en los procesos cognitivos, capacidad de inhibir respuestas inadecuadas, memoria a corto plazo y memoria de trabajo.

Conocimientos acerca del trastorno de ansiedad generalizada y el trastorno de pánico con y sin agorafobia entre médicos residentes de medicina en entrenamiento durante el año 2009 / Knowledge of generalized anxiety disorder and panic disorder with and without agoraphobia among medical residents training during 2009

Objetivos: Estimar el grado de conocimiento que los médicos residentes de dos hospitales públicos tienen acerca del diagnóstico y tratamiento del trastorno de ansiedad generalizada (TAG) y el trastorno de pánico (TP). Material y Métodos: Se diseñó y validó, mediante revisión por jueces y un estudio piloto con médicos generales, un instrumento para evaluar conocimientos acerca del diagnóstico y manejo del TAG y el TP, el cual se aplicó a 70 médicos residentes de medicina de los Hospitales Cayetano Heredia y Arzobispo Loayza en enero del 2009. Resultados: El 22,9% de los participantes diagnosticó correctamente el TAG; 70%, el TP; y 20%, la agorafobia. Los psicofármacos mencionados como tratamiento de primera línea fueron las benzodiazepinas (78,5% para el TAG y 71,4% para el TP), seguidos de los antidepresivos, siendo los más comunes, fluoxetina (21,4% para el TAG y 20% para el TP) y sertralina (20% para el TAG y 17,1% para el TP). El 51,9% y el 52,4% de los participantes indicarían sólo benzodiazepinas para el TAG y el TP, respectivamente. El 80% y 88,6% de médicos residentes transferirían al Servicio de Psiquiatría los pacientes con TAG y TP, respectivamente. Conclusiones: Los médicos residentes diagnostican mejor el TP que el TAG o la agorafobia. Asimismo, en general consideran que estos trastornos requieren tratamiento farmacológico y tratarían a pacientes con estos cuadros si acudieran a su consulta; sin embargo, no indicarían un adecuado tratamiento. Por lo tanto, se debe mejorar la enseñanza sobre estos trastornos en el pregrado y la residencia.

Objective: To estimate the knowledge about diagnosis and management of generalized anxiety disorder (GAD) and panic disorder (PD) among medical residents from two public hospitals. Material and Methods: An instrument to evaluate knowledge about diagnosis and management of GAD and PD was designed and validated by means of expertsÆ review and pilot study with general practitioners. This instrument was administered to medical residents from Cayetano Heredia and Arzobispo Loayza Hospitals (Lima, Perú) during January 2009. Results: Twenty- three percent of participants correctly diagnosed GAD; 70%, PD; and 20%, agoraphobia. Psychotropic drugs considered as first line treatment were benzodiazepines (78.5% for GAD and 71.4% for PD) followed by antidepressant drugs, the commonest being fluoxetine (21.4% for GAD and 20% for PD) and sertraline (20% for GAD and 17.1% for PD); 51.9% and 52.4% of participants would prescribe benzodiazepines as monotherapy for GAD and PD, respectively. Eighty percent and 88.6% of medical residents would refer to a psychiatry service the patients with GAD and PD, respectively. Conclusions: Medical residents diagnose better PD than GAD or agoraphobia. In addition, generally they consider that these disorders require pharmacological treatment and would manage patients with these illnesses if they sought help in their office; however, there are deficiencies in the treatment that they would prescribe. Therefore, it is necessary to improve the education about these disorders in medical students and residents.

Agorafobia (con o sin pánico) y conductas de afrontamiento desadaptativas. Primera parte

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Abstract: The present paper examines the role of a type of coping strategy used by patients with agoraphobic disorders (AD) when they confront phobic stimuli. This strategy consists in a group of overt behaviors and thoughts (ritual behaviors, frequently) which allow agoraphobic patients (AP) to resist the presence of phobic scenes. Those behaviors function like a partial coping in the sense that they allow initially to confront the phobic stimuli, but later they transform themselves in non-adaptative coping behaviors that limit the therapeutic efficiency. The agoraphobic disorder (AD), with or without panic attack (CIE-10, F 40), is considered the more complex phobia and which produces the highest level of disability. Besides, this phobia, contrary to social or specific phobias, has a pervasive tendency (panphobia), reaching each time more situations and stimuli. The essential clinical aspects include anxiety, sensitivity, emotional responses of fear-anxiety-panic and shame, anticipatory responses, catastrophic thoughts, and avoidance and escape behaviors toward phobic scenes. There is an important volume of research about those clinical aspects. But there are only a few studies about the coping strategies used by AP when they need to resist a phobic situation. Traditionally, coping strategies considered were those used by AP to reduce anxiety and psychological distress: the avoidance behavior (to avoid the phobic stimuli) and the escape behavior (when the phobic stimulus is present). Additionally, it also includes behaviors targeted to avoid the negative physiological responses similar to those occurring in an anxiety crisis (interoceptive avoidance). Nevertheless, some experts have reported that AP used some other coping strategies that allowed them to accomplish partial and temporary confrontations toward phobic elements (elements that they needed to confront). In that sense, some authors have proposed other strategies beyond avoidance and escape behaviors, including those partial coping behaviors in the repertories used by agoraphobic patients. So, there are several classifications that take into account these behaviors, but under different terms: Distractions (thoughts or conducts that relieve anxiety in the presence of phobic stimuli). Calming strategies (behaviors that they use when they need to confront a phobic scenario). Searchingfor company (looking for the company of a relative, friend or pet). Safety behaviors or safety signs (behaviors adopted to limit the level of distress as a consequence of feeling "caught" in a phobic situation). Counter-phobic objects (objects or persons to which patients assign the ability to diminish the distress in the case of crisis). Different experts have denominated these strategies "defensive mechanisms", "useless coping strategies", "partial coping strategies" or "non-adaptative coping behaviors". This kind of behaviors and thoughts can be useful in the short-term, but in the long term they favor the continuity of anxiety and the avoidance cycle. These partial coping strategies allow patients with agoraphobia to confront and to resist the presence of the phobic stimuli, but this is done with a high cost, since the confrontations are only partial (they confront the phobic scenarios in certain contexts and with certain characteristics) and temporary, generalizing the use of these strategies to future confrontations. These strategies provide a certain apparent validity: the person is capable to resist the phobic element (that is not possible with both avoidance and escape strategies). Nevertheless, the information provided by these behaviors acts as a reinforcing mechanism and acquires by itself a value of discriminative stimulus about the circumstances in which are possible for confronting the phobic scenes. The role of these behaviors and thoughts in the development of agoraphobia in a chronic disorder is also evident. In this sense, they play a non-adaptative role. These strategies turn to be the unique ways to confront (some part of) phobic stimuli. Then, they generate a high degree of interference with both adaptive behaviors and thoughts that must be dominant in the therapeutic process. Finally, the partial coping strategies pass from being a resource that allows them to resist the phobic stimuli, to a therapeutic aim that clinicians must reduce and eliminate. Taking into account the state of the question, we propose in this paper a new classification of non-adaptative coping strategies used by agoraphobic patients, for including the partial coping strategies. The parameters for constructing a new taxonomy are three: (i) the coping strategies must be grouped according to its function role (i.e., to avoid anxiety and negative physiological responses, to reduce anxiety if it appears, to confront the stimuli with the lower level of distress). So, we prefer the term behavioral patterns, like a group of behaviors and thoughts which rule similar functions. (ii) The classification has to attend to the nature of behaviors, differentiating between overt (manifest) and covert (cognitive) behaviors. This distinction is elemental from an applied point of view. (iii) The third element is to identify the non-adaptative character of the confrontation behaviors, because they incapacitate and interfere in the normal development of the daily life. Additionally, a terminology question: there is several concepts that are being used in an indistinct manner, such as behavioral patterns, strategies or, even, styles. According to what the agoraphobic patients do (in an overt or covert way), we prefer the term behavior, in the sense that this term emphasizes what the people do (and not what they believe o what they would like to do). According to those three parameters, we propose four behavioral patterns. These behavioral patterns have two versions: overt and covert behavior. The components of each pattern share similar functions and they cover all of those strategies that can be used for persons with agoraphobia for coping with the different phobic scenes. The four behavioral patterns are as follow: Avoidance behaviors. This pattern includes all of those behaviors and thoughts that the agoraphobic patients do to avoid the phobic stimuli. Its function consists in to prevent the anxiety and psychological distress by means of avoidance of phobic elements. Interoceptive avoidance. This pattern refers to all behaviors and thoughts that try to avoid the interoceptive signs (negative physiological responses) similar to those that occur during an agoraphobic crisis. Its function consists to prevent physiological negative states by means of avoidance of those behaviors that can generate those states and can be interpreted like the beginning of a crisis. Escape behaviors. This group of behaviors refers to all behaviors and thoughts that are used to remove the patients from a phobic scene. So, its function consists in to reduce and to eliminate the anxiety states by means to run away from the phobic stimuli. Partial coping behaviors. Finally, this fourth behavioral pattern includes all of those strategies that allow AP to resist the presence of phobic elements. This resistance is doing according to some contexts and according to certain characteristics of those elements. The strategies consist on behaviors and thoughts, such as safety signs, distractions, or rituals that reduce the anxiety to tolerable levels. Its function consists to provide several resources that allow to a person with agoraphobia to cope with a phobic situation. Usually, the anxiety does not disappear, but the psychological distress does not reach disability levels. Frequently, the patients carry out these strategies because they are forced or need it. This approach is discussed according to the utility to take into account these four behavioral patterns, and not only the avoidance and escape behaviors. An special consideration have the partial coping strategies in the extent in which these behavior may suppose a false therapeutic progress, at the time that they turn into a resistant element that interferes with the therapeutic resources.

Técnicas cognoscitivo conductuales como ayuda de la farmacoterapia en el tratamiento del trastorno de Pánico / Cognitive behavioral techniques such as aid of Pharmacotherapy in the treatment of panic disorder

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