Methodological strategies for functional analysis and evaluation of obsessive-compulsive behavior / Estratégias metodológicas para avaliação e análise funcional do comportamento obsessivo-compulsivo / Estrategias metodológicas para evaluación y análisis funcional de la conducta obsesiva-compulsiva

The study aimed to identify the controlling variables of obsessive-compulsive behaviors of an adult participant, based on three evaluation strategies. For the first one, Indirect Functional Assessment, the researchers recovered records of therapy sessions attended by the participant, in which conditions favorable to obsessive-compulsive behaviors were described. For the second one, Descriptive Functional Assessment, the researchers observed the participant's behavior during sessions in which they presented tasks previously mentioned as triggering of the problem behavior. For the third one, Brief Functional Analysis - Single Function Test, the researchers manipulated a demand condition and a control condition, aiming to examine the functional hypothesis that the problem behavior would be maintained by escape/avoidance of tasks. Although dissonant, the results allowed the researchers to discard the negative reinforcement hypothesis. The pertinence of the adoption of different evaluation strategies for clinical practice and the frailties of interventions guided only by verbal reports are discussed.

O estudo teve por objetivo identificar variáveis controladoras de comportamentos obsessivo-compulsivos de um participante adulto, com base em três estratégias de avaliação. Na primeira, Avaliação Funcional Indireta, recuperaram-se registros de sessões de terapia frequentadas pelo participante, em que foram descritas condições favorecedoras dos comportamentos obsessivo-compulsivos. Na segunda, Avaliação Funcional Descritiva, observou-se o comportamento do participante em sessões nas quais se dispunham tarefas antes indicadas como desencadeantes do comportamento-problema. Na terceira, Análise Funcional Breve - Teste de Função Única, foram manipuladas condições de demanda e controle, a fim de examinar a hipótese funcional de que o comportamento-problema seria mantido por fuga/ esquiva de tarefas. Embora divergentes, os resultados das avalições permitiram descartar a hipótese de que o comportamento-alvo seria mantido pela retirada da tarefa. Discutem-se a pertinência da adoção de diferentes estratégias de avaliação no trabalho clínico e a fragilidade de intervenções unicamente orientadas por relatos verbais.

El estudio objetivó identificar variables controladoras de la conducta obsesiva-compulsiva de un participante adulto, basando-se en tres estrategias de evaluación. Por la primera, Evaluación Funcional Indirecta, fueran recuperados registros de sesiones de terapia frecuentadas por el participante, en que se describieron condiciones favorecedoras de los comportamientos obsesivo-compulsivos. Por la segunda, Evaluación Funcional Descriptiva, fue observada la conducta del participante en sesiones en las cuales se disponían tareas indicadas como desencadenantes de la conducta-problema. Por la tercera, Análisis Funcional - Prueba de Función Única, fueran manipuladas condiciones de demanda e control, objetivando examinar la hipótesis funcional de que la conducta problema sería mantenida por fuga/evasión de tareas. Aunque divergentes, los resultados permitirán descartar a la hipótesis de que la conducta objetivo sería mantenida por reforzamiento negativo. Se discute la pertinencia de la adopción de diferentes estrategias de evaluación del trabajo clínico, y debilidades de intervenciones únicamente orientadas por relatos verbales.

Trastornos Neuropsiquiátricos Autoinmunes Pediátricos Asociados a Estreptococo: Presentación de un caso / Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections: Presentation of a case

Los trastornos neuropsiquiátricos autoinmunes pediátricos asociados a estreptococo (PANDAS) fueron creados para describir un subgrupo teórico de casos de trastornos obsesivo compulsivos (TOC) y / o tics en los que el inicio o la exacerbación de los síntomas es desencadenado por infección del estreptococo hemolítico del grupo A (SBHGA) ; Si bien aún no hay datos de incidencia se estima que el trastorno afecta aproximadamente al 1% de niños menores de 12 años, porque es menos probable que tengan anticuerpos contra el estreptococo y probablemente esté infradiagnosticado. La existencia de este trastorno ha generado considerables avances clínicos y científicos, así como controversia. Fisiopatológicamente, PANDAS se propone ser un trastorno autoinmune postestreptocócico similar a corea de Sydenham, hipotetizandose mas específicamente que los tics y la sintomatología obsesivo compulsiva son el resultado de la activación del sistema inmune adaptativo por el estreptococo del grupo A. Se presenta el caso de un paciente masculino de 6 años, con cuadro de tres semanas de evolución de movimientos involuntarios en cabeza y miembros superiores, así como cambios de conducta, cuyo antecedente de importancia fue una infección respiratoria y en piel varias semanas previo al inicio de los síntomas..(AU)

Trastornos de la alimentación en hombres: cuatro subtipos clínicos / Eating Disorders in Males: Four Clinical Subtypes

Introducción: los trastornos de la alimentación, inicialmente considerados como prioritariamente femeninos, se encuentran igualmente en hombres. Su presentación, comorbilidades y evolución, parecen ser bastante similares a las descritas en muestras femeninas. Métodos: este trabajo presenta una serie de 21 casos con distintos cuadros de trastornos de la conducta alimentaria (TCA) y fobia a la comida. Resultados: se identifican variables comunes que pueden ayudar a la caracterización de por lo menos cuatro subtipos clínicos, tendientes a facilitar la evaluación y la intervención. Se plantean cuatro subtipos clínicos: restrictivo, impulsivo, evitativo y secundario a otras psicopatologías. Conclusiones: se discuten las implicaciones de este planteamiento.

Introduction: Eating disorders have been considered as essentially feminine, but they appear in men as well. Their presentation, comorbidities and evolution seem to be very similar to the ones in women. Methods: 21 cases of eating disorders and food phobia are described. Results: Common variables are identified that could be helpful in the characterization of at least four clinical subtypes, in order to facilitate clinical evaluation and treatment. Four clinical subtypes are presented: restrictive, impulsive, avoidant and secondary to other psychopathology. Conclusion: the implications of this outline are discussed.

Evaluación neuropsicológica y neurocirugía psiquiátrica

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Abstract: Neuropsychology, as a part of cognitive neurosciences should be incorporated to the process of evaluation of any patient considered to be needing psychiatric neurosurgery, in order to obtain objective information of the processes and functions that shape each one's cognitive system and of the changes that may take place after surgery. To attain this objective, the neuropsychologist doing the evaluation should be experienced in assessing patients with psychiatric disorders, as it is necessary to have a deep knowledge not only of the clinical characteristics of these ailments but also of the information processing models that typify each entity. Thus, by making an evaluation within a conceptual and empirical frame, an adequate interpretation of the results may be attained. At the same time it is necessary to know the neurochirugical techniques being applied in each case and also to be aware of the possible side effects that may take place. The need for this type of assessments is due to two reasons: to find the possible damage that surgery may cause and to consider the improvement that follows the decrease of clinical symptoms. The previous two facts are associated to clinical improvement as both have different temporal courses. The first will produce a behavioural effect more evident during the first post operative year while at further stages, the second will be made more evident with the decrease of clinical symptoms, thus reflecting on the neuropsychological performance. Another possibility to be considered in this type of cases is that the cerebral systems related with psychopathology as well as those underlying executive and cognitive performance will be distributed differently in the brain and, therefore, with this kind of treatment they will be affected in a different way, this makes it necessary to do not only previous but subsequent evaluations in order to asses accurately the changes in the cognitive processes. Also, should there be found more severe neuropsychological alterations than those expected for a specific psychiatric disorder, there is a risk of increasing post operative changes because any adverse surgical effect may interact or be added to the cognitive failures that typify the illness and, thus, prognosis will be worsened. Regarding the most relevant research on this field, Dougherty et al. report that 20% of their 44 patients with obsessive compulsive disorder (OCD) mentioned at least one adverse effect; of these patients 5% reported a loss of memory that was corrected after six to 12 months. Among the writings that include neuropsychological evaluation as such, it was found that Nyman's group in Sweden, proposes that, independently form the neurosurgical technique used in patients with OCD, the main objective of the operation is to counteract the lack of balance between the frontal sector and the sub cortical regions, as well as that of the basal nuclei and the limbic structures. Therefore, as a proposal, they explore the functions pertaining to the frontal region because they believe that following surgery there must be failures in this area. This belief is also based on a previous research in which they found that five from ten patients presented after surgery a larger number of preservative answers in the Wisconsin Card Sorting Test (WCST), a fact that points out a dysfunction in the encephalon's anterior sector. Nevertheless, they consider that this preservative pattern of responses in the WCST is not permanent; on the contrary, there is improvement after capsulotomy, as shown when the evaluation results are compared to other patients' evaluations, previous to capsulotomy. In another study they reported different failures depending of the surgical strategy being used; thus with frontal ventromedial lesion no alterations were found although when the ventral striated was involved, there were differences as to the number of categories and the conceptual level in WCST. Besides, the group with the worst ranging was the one with large lesions at dorsal level which gave place to visual spatial perception alterations, as well as to psychomotor slowness in a sequence task, and to intrusions in an associated learning task. This finding was expected because the extent of the regions affected by the lesion corresponds to the alterations observed. No differences were reported in another research, as to the WAIS ratings or the Memory Scale of Wechsler, neither before nor after the operation. Nevertheless, the WCST showed some differences in regard to the categories established in respect to the control group, which were interpreted as a lack of abstract reasoning and cognitive flexibility. In schizophrenic patients submitted to leucotomy because of their aggressive behaviour and lack of impulse control, follow up, while comparing their cognitive performance to that of other schizophrenic subjects who had not been operated, showed that there were negative effects on different cognitive aspects, although these, as part of the dysfunction expected for schizophrenia, were not caused by surgery. Up to this moment, in Mexico there is not an evaluation protocol for patients needing psychiatric neurosurgery , and therefore, solid and objective standards should be established for this purpose. For more than a decade, the Instituto Nacional de Psiquiatría Ramón de la Fuente (INPRF), has used neuropsychologic exploration protocols which are based not only on a wide clinical experience in the field of psychiatric disorders but also on the research carried out by our institution. Besides, integration of neuropsychological studies is based on international parameters designed to apply and interpret these instruments. As well, with the same tests it is possible to distinguish between the alterations pertaining to illness and those resulting from neurosurgery. This, in turn will be considered for establishing, if required, reasoned rehabilitation techniques. This battery is composed by the following tests: Wechsler Adult Intelligence Scale (WAIS), Integrated Program for Neuropsychological Exploration Test of Barcelona (Short Version), Rey's Complex Figure (Standarization for Mexican Population, Instituto Nacional de Psiquiatría), and Verbal Learning Test Spain Complutense (TAVEC). This battery must be applied before the procedure, and follow up should be made for a period of between three, six to eight months, continuing with this evaluation protocol for at least three years. Nevertheless, flexibility may be allowed in case there should be complaints from the patient that justify making an evaluation before the given time. On the other hand, considering the position and vulnerable condition in this type of surgical procedures paradigms that evaluate different functions of the frontal sector are proposed in order to obtain specific information of their functioning before and after intervention. We propose to use the Wisconsing Card Sorting Test (WCST), the Stroop Test and the Trail Making B. In addition to the previous statements, the personality changes that may appear ought to be considered, because some personality alterations associated with hypo-frontality have been reported in patients submitted to capsulotomty, although such alterations may be due to judgement errors that are typical of cognitive damage. Finally, we consider that within the selection and interdisci-plinary handling process for patients who may need psychiatric neurosurgery, information obtained from neuropsychological evaluation is necessary. Besides, it will allow the neuropsychologist, as part of the team in charge of these patients, not only to make realistic and objective suggestions regarding the therapeutic strate-gies to be used in each particular case, but also, to advise their relatives.

Tratamiento del trastorno obsesivo-compulsivo / Treatment of obsessive-compulsive disorder

El trastorno obsesivo-compulsivo (TOC) es una delas patologías más subdiagnosticadas y tratadasde forma equivocada en las últimas décadas.Como resultado hoy nos encontramos con unimportante número de pacientes que tienen altaresistencia a los tratamientos convencionales,presentándose un cuadro particular al quese denomina trastorno obsesivo-compulsivoresistente. En este trabajo queremos transmitir nuestra forma de pensar y abordar el tratamiento del TOC.

he Obsessive-CompulsiveDisorder is one of themost subdiagnosed and inadequately treateddisease of the last decades; therefore, nowadaysthere is an important number of patients thatoffer resistance to conventional treatments,arranging a particular clinical status namedObsessive-Compulsive Resistant Disorder. Inthis paper we wanted to share our way to think and treat the OCD.