Experiencia del abordaje multidisciplinar aplicado en el hospital de día de neuropsiquiatría del hospital mare de déu de la mercè (años 2016, 2017 y 2018) / Multidisciplinary approach experience of the neuropsychiatry day hospital of the hospital mare de deu de la merce (period 2016 to 2018)

Introducción: El hospital de día de Neuropsiquiatría es un dispositivo sanitario especializado que atiende a personas adultas que presentan sintomatología cognitiva derivada de un daño cerebral sobrevenido, trastorno por uso de sustancias, enfermedad de Huntington y demencias degenerativas de inicio precoz. Se presenta la experiencia del abordaje multidisciplinar entre los años 2016 y 2018. Métodos: La información ha sido obtenida a partir de las valoraciones realizadas según los protocolos de evaluación multidisciplinar del hospital. Se ha realizado una estadística descriptiva y se ha utilizado la prueba t para medias de dos muestras emparejadas para evaluar diferencias significativas entre las valoraciones al ingreso y al alta. La muestra es de 179 pacientes, con una media de edad de 50.47 años, de las cuales 75 (41.90%) son mujeres. Como instrumentos de medida se han utilizado pruebas de despistaje cognitivo, de evaluación de la conducta, del equilibrio y funcionalidad, y un cuestionario de calidad de vida. Resultados: Se objetiva una mejoría significativa de las pruebas de despistaje cognitivo, de valoración de la conducta y de la sobrecarga del cuidador. En los pacientes con trastorno por uso de sustancias hay también una mejoría significativa del equilibrio. En los pacientes con enfermedad de Huntington hay una mejoría significativa de la apatía. Conclusiones: La intervención multidisciplinar del hospital de día de Neuropsiquiatría parece ser válida para mejorar las habilidades cognitivas, la conducta y disminuir la sobrecarga del cuidador. Hay que destacar la mejoría de la apatía en los pacientes con enfermedad de Huntington dado que es un síntoma refractario al tratamiento farmacológico. Se propone incluir grupos de rehabilitación física en otros recursos de la red de tóxicos

Introduction: The Neuropsychiatry day hospital is a specialized health care service that attends adults who present cognitive symptoms in the context of acquired brain damage, substance use disorder, Huntington's disease and early onset dementias. The manuscript exhibits the multidisciplinary approach experience from the period 2016 to 2018. Methods: The information has been obtained from the assessments made according to the multidisciplinary evaluation protocols of the hospital. A descriptive statistic has been performed and the t-test for means of two paired samples has been used to assess significant differences between admission and discharge assessments. A sample of 179 patients, with an average age of 50.47 years, of which 75 (41.90%) were women, is presented. As measuring instruments, tests of cognitive screening, behavioral assessment, balance and functionality, and a quality of life questionnaire have been used. Results: There is a significant improvement in the tests of cognitive screening, behavior assessment and caregiver burden. In patients with substance use disorder there is also a significant improvement in balance. In patients with Huntington's disease there is a significant improvement in apathy. Conclusions: The Neuropsychiatric day hospital intervention seems to be effective to improve cognitive abilities, behavior and caregiver burden. It is noteworthy the improvement of apathy in Huntington' disease patients, because it is a pharmacological refractory symptom. It is proposed to include physical rehabilitation groups in substance abuse programs

[Interest of extrahospital multidisciplinary unit of neuro-psycho-geriatric intervened in nursing home: Analysis of 288 interventions]. / Intérêt d'une unité mobile multidisciplinaire extra-hospitalière de neuro-psychogériatrie intervenant en EHPAD : analyse de 288 interventions.

INTRODUCTION: Geriatrics Mobile Units are a new organisation operating in nursing homes. Their mission is to propose globally oriented neuro-psychiatric and geriatric care. The purpose of the study is to assess their activity and impact over a 21-month period. METHOD: A prospective single center study of UMNPG's data including intervention characteristics, patient characteristics, recommendations and reassessment after intervention. The Neuropsychiatric Inventory Nursing Home version (NPI-NH) was measured during intervention and reassessed after 30 days (Student's t-test). RESULTS: From March 2014 to December 2015, UMNPG conducted 288 interventions mainly for medical advices (81%), clinical assessments (54%) and health care team support (46%). The average age was 84.6±7.3years, 73.3% of whom were women. The patients were dependent (62% of GIR 1 or 2) with dementia (60%) and under several medications (83.7%). The symptoms were mainly agitation/aggression (76.4%), anxiety (75%), depression (66.7%), irritability (60.4%), aberrant motor behaviour (55.9%) and delusions (48.6%). The main proposals of UMNPG were a change in treatment (79.5%), a health care team support (85.4%) and hospitalization (8.4%). The rate of follow-up on recommendation was 83% on the 15th day and 80% on the 30th day. The rate of avoided hospitalizations was 16%. The average NPI-NH decreased (on day 0 NPI=50±19.2; on day 30 NPI=33.9±19.6, p<0.001). CONCLUSION: UMNPG-EHPAD intervenes for frail elderly residents with multiple disorders in crisis situations. Medical recommendations help to support people in nursing homes and decrease NPI-NH. UMNPG-EHPAD is part of geriatric network strengthening the city/hospital connection.

Neuropsychiatry: Towards a Philosophy of Praxis.

Neuropsychiatry is a specialized clinical, academic and scientific discipline with its field located in the borderland territory between neurology and psychiatry. In this article, we approach the theoretical definition of neuropsychiatry, and in order to address the practical aspects of the discipline, we describe the profile of a neuropsychiatric liaison service in the setting of a large hospital for neurological diseases in a middle-income country. An audit of consecutive in-patients requiring neuropsychiatric assessment at the National Institute of Neurology and Neurosurgery of Mexico is reported, comprising a total of 1212 patients. The main neurological diagnoses were brain infections (21%), brain neoplasms (17%), cerebrovascular disease (14%), epilepsy (8%), white matter diseases (5%), peripheral neuropathies (5%), extrapyramidal diseases (4%), ataxia (2%), and traumatic brain injury and related phenomena (1.8%). The most frequent neuropsychiatric diagnoses were delirium (36%), depressive disorders (16.4%), dementia (14%), anxiety disorders (8%), frontal syndromes (5%), adjustment disorders (4%), psychosis (3%), somatoform disorders (3%), and catatonia (3%). The borderland between neurology and psychiatry is a large territory that requires the knowledge and clinical skills of both disciplines, but also the unique expertise acquired in a clinical and academic neuropsychiatry program.

Integrating Neuroscience Knowledge and Neuropsychiatric Skills Into Psychiatry: The Way Forward.

Increasing the integration of neuroscience knowledge and neuropsychiatric skills into general psychiatric practice would facilitate expanded approaches to diagnosis, formulation, and treatment while positioning practitioners to utilize findings from emerging brain research. There is growing consensus that the field of psychiatry would benefit from more familiarity with neuroscience and neuropsychiatry. Yet there remain numerous factors impeding the integration of these domains of knowledge into general psychiatry.The authors make recommendations to move the field forward, focusing on the need for advocacy by psychiatry and medical organizations and changes in psychiatry education at all levels. For individual psychiatrists, the recommendations target obstacles to attaining expanded neuroscience and neuropsychiatry education and barriers stemming from widely held, often unspoken beliefs. For the system of psychiatric care, recommendations address the conceptual and physical separation of psychiatry from medicine, overemphasis on the Diagnostic and Statistical Manual of Mental Disorders and on psychopharmacology, and different systems in medicine and psychiatry for handling reimbursement and patient records. For psychiatry residency training, recommendations focus on expanding neuroscience/neuropsychiatry faculty and integrating neuroscience education throughout the curriculum.Psychiatry traditionally concerns itself with helping individuals construct meaningful life narratives. Brain function is one of the fundamental determinants of individuality. It is now possible for psychiatrists to integrate knowledge of neuroscience into understanding the whole person by asking, What person has this brain? How does this brain make this person unique? How does this brain make this disorder unique? What treatment will help this disorder in this person with this brain?

Proceso creativo, arte y psicopatología / Creative process, art and psycopathology

Se presenta una reflexión sobre el proceso creativo y sus manifestaciones psicopatológicas en artistas. Se intenta responder a las siguientes preguntas: 1) ¿Existe relación entre el proceso creativo y la “locura”? 2) ¿Hasta qué punto los artistas y los genios son (están) “locos”? 3) ¿Podemos conocer la psicopatología de los artistas a través de sus producciones artísticas? 4) ¿Puede diferenciarse la angustia neurótica de la psicótica en los cuadros y creaciones artísticas? Por último se analizan textos y obras creativas que apoyan dichas reflexiones (AU)

This article presents a reflection on the creative process and its psychopathologycal manifestations in artists. It seeks to answer the following questions: 1) Is there any relationship between the creative process and “madness”?2) Up to what point are artists and geniuses “mad”? 3) Can we know the artists’ psychopathology through their artistic productions? 4) Is it possible to differentiate the psychotic’s neurotic distress in pictures and other artistic creations? Finally, creative texts and creative works are analyzed in order to support these reflections (AU)

Análisis psicodinámico breve en un caso de dependencia del alcohol / Brief Psychodynamic analysis in a case of alcohol dependence

Se presenta el caso de un paciente masculino de 41 años de edad diagnosticado con dependencia del alcohol, con el objetivo de elaborar un juicio diagnóstico y pronóstico desde el punto de vista psicodinámico, y descubrir, en la medida de lo posible, “quién” es el paciente, qué desarrollo vital le ha llevado a ser lo que actualmente es y derivando de esta concepción, qué sentido tiene su “enfermar” (AU)

We report a case of a client diagnosed of alcohol dependence with the aim of developing a psychodynamic approach to study his diagnosis and prognosis. In addition, we pretend to address “who” is the patient, the biographic development that led him to have his current “self” and, in relation with this concept, to what extent his mental disorder is related with the whole biographical picture (AU)

Eventos traumáticos en pacientes con trastorno obsesivocompulsivo: implicaciones etiopatogénicas, nosológicas y terapéuticas / Traumatic events in patients with obsessive-compulsive disorder: Etiopathogenic, nosological, and therapeutic implications

INTRODUCCIÓN. El trastorno obsesivo-compulsivo (TOC) es una patología neuropsiquiátrica en donde se propugna un papel accesorio de los factores de riesgo psicosociales. A pesar de ello, existe un subgrupo de pacientes cuya etiopatogenia, fenomenología, diagnóstico y terapéutica se halla condicionada por la presencia de eventos traumáticos (ET). CASO CLÍNICO. Se expone el caso de una mujer adulta joven que desarrolló una psicopatología compatible con TOC y trastorno por estrés postraumático (TEPT) tras sufrir abusos sexuales durante la adolescencia temprana. Aunque se implementaron tratamientos farmacológicos y psicoterapéuticos convencionales, su curso fue fluctuante, exacerbándose en el contexto de una nueva agresión sexual. CONCLUSIONES. Los ET constituyen un factor de riesgo inespecífico para el TOC, ya sea como variable predisponente o precipitante. Adicionalmente, pueden determinar su patoplastia, siendo el ejemplo más paradigmático la presencia de obsesiones de “polución mental” tras sufrir abusos sexuales. A nivel nosológico, existen evidencias preliminares para postular una entidad clínica nueva (“trastorno obsesivo-compulsivo postraumático”), la cual englobe aquellos sujetos con comorbilidad entre TOC y TEPT tras un ET. En el plano interventivo, los pacientes con obsesiones de “polución mental” precisan estrategias psicoterapéuticas adicionales a las implementadas en sus homólogos de naturaleza más neurobiológica (AU)

INTRODUCTION. Obsessivecompulsive disorder (OCD) is a neuropsychiatric condition where an accessory role of psychosocial risk factors is advocated. However, there is a subgroup of obsessive patients whose etiology, phenomenology, diagnosis and therapeutic features are conditioned by the presence of traumatic events (TE). CLINICAL CASE. A young adult woman developed OCD and posttraumatic stress disorder (PTSD) after suffering sexual abuse during early adolescence. Although psychotropic and psychotherapeutic conventional treatments were implemented, the course was fluctuating, exacerbated in the context of a new sexual assault. CONCLUSIONS. TE constitute a nonspecific risk factor for OCD, either predisposing or precipitating variable. Additionally, they can determine their pathoplasty, the best example being the presence of “mental pollution” obsessions after suffering sexual abuse. There is preliminary evidence to postulate a new clinical entity (“posttraumatic obsessive-compulsive disorder”), which encompasses subjects with OCD and PTSD comorbidity after TE. Obsessions in patients with “mental pollution” require additional psychotherapeutic strategies compared to neurobiological homonyms (AU)

Saber objetivo sobre la subjetividad en psiquiatría, desde la filosofía y el psicoanálisis / Objective knowledge about subjectivity in psychiatry, from philosophy and psychoanalysis

Se propone que para no perder la identidad de la psiquiatría debe mantenerse la interdisciplinariedad entre los distintos modos de acceder a lo mental y al sentido la existencia, más allá de lo biológico. Intentando un "saber objetivo sobre la subjetividad", ya que la ciencia actual no aborda adecuadamente aspectos relativos a la existencia, al sujeto, al pensamiento no científico, ni mucho de lo que constituye el funcionamiento psíquico. En este sentido, también se hará referencia a la reciente investigación neurocientífica sobre el apego en la infancia, que apoya la constitución temprana de las bases neurológicas de los patrones de relación intersubjetiva que luego caracterizan al individuo (AU)

It is proposed that to keep the identity of psychiatry should be kept interdisciplinarity between different ways of access to the mental and to the sense of the existence, beyond the biological. Trying an "objective knowledge about subjectivity", since modern science does not adequately address current issues relating to the existence, the subject, the non-scientific thinking, and not much of what constitutes mental functioning. In this regard, reference will be made to recent neuroscience research on attachment in infancy, which supports the early establishment of the neural basis of intersubjective patterns that subsequently characterize the individual (AU)

El español en los congresos internacionales / The spanish language in International Meetings

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Conducta explosiva homicida en un caso con alteraciones en el electroencefalograma / Explosive homicidal behavior in a case with alterations in the electroencephalogram

La epilepsia se caracteriza por la aparición de diversos tipos de crisis que se acompañan de alteraciones específicas en el EEG en forma de brotes paroxísticos. Durante los periodos intercríticos el registro puede ser normal. En ocasiones, pueden evidenciarse alteraciones en respuesta a mecanismos de activación específicos. El diagnóstico de las crisis no convulsivas puede ser difícil de establecer. En algunos tipos de epilepsia, especialmente en la del lóbulo temporal, se han descrito conductas agresivas durante las crisis. Exponemos el caso de un homicida, varón de 20 años, sin antecedentes de conductas conflictivas, que presentó una conducta violenta explosiva que junto con su especial vivencia de los hechos llevó a la sospecha de la existencia de organicidad. El EEG evidenció una alteración compatible con epilepsia que podría explicar la aparición de la conducta agresiva (AU)

Epilepsy is characterized by the onset of various types of crisis which are accompanied by specific alterations in EEG as paroxysmal outbreaks. Registration may be normal during intercritical periods. Sometimes, alterations in response to specific activation mechanisms can be evidenced. Diagnosis of the non-convulsive crises can be difficult to establish. In some types of epilepsy, especially in that of the temporal lobe, aggressive behaviors during the crises have been described. We present the case of a 20 year-old male, a murderer with no previous deviant behavior, who displayed an explosive violent behavior. His particular experience of the events led to the suspicion of the existence of organicism. EEG showed an alteration compatible with epilepsy that might explain the onset of the aggressive conduct (AU)

Prevalencia de síntomas neuropsiquiátricos en pacientes institucionalizados con diagnóstico de demencia y factores asociados: estudio transversal multicéntrico / Prevalence of neuropsychiatric symptoms and associated factors in institutionalised dementia patients: a multicentre cross-sectional study

Objetivo. El objetivo fue estimar la prevalencia y la gravedad de los síntomas neuropsiquiátricos en los pacientes con demencia ingresados en centros residenciales, evaluando su asociación con ciertos factores que podrían influir en su aparición. Material y métodos. Se realizó un estudio transversal. Se incluyeron todos los ancianos diagnosticados de demencia degenerativa, vascular o mixta, en estadios 4 a 7 de la Global Deterioration Scale de Reisberg (GDS), y residentes en 6 centros residenciales de la provincia de Ourense (España). Se calculó un tamaño de muestra de 120 individuos. La evaluación de los síntomas se realizó utilizando el Neuropsychiatric Inventory-Nursing Home (NPI-NH). La influencia de los factores considerados se analizó mediante el análisis de regresión lineal y logística. Resultados. Fueron incluidos 212 casos con una media de edad de 85,7 (6,7) años. La prevalencia de síntomas neuropsiquiátricos fue 84,4%. El síntoma más común fue la apatía, seguido por la agitación y el delirio; los menos frecuentes fueron la euforia y las alucinaciones. El síntoma que producía más interrupción ocupacional fue la agitación. El análisis multivariante mostró que una mayor puntuación en el NPI-NH estaba asociada con mayor puntuación en la escala GDS y el uso de neurolépticos, inhibidores de la colinesterasa y memantina. Conclusiones. En los pacientes con demencia institucionalizados los síntomas neuropsiquiátricos que presentan prevalencia elevada se asociaban con la gravedad de la demencia GDS, el uso de neurolépticos, inhibidores de la colinesterasa y memantina(AU)

Objective. The aim was to estimate the prevalence and severity of neuropsychiatric symptoms in patients with dementia in nursing homes, assessing their association with certain factors that may influence their occurrence. Material and methods. A cross-sectional study was carried out, and included all elderly patients diagnosed with degenerative, vascular, or mixed dementia, stage 4 to 7 on the Global Deterioration Scale of Reisberg (GDS), and residents in 6 nursing homes in the province of Ourense (Spain). A sample size of 120 individuals was determined to be necessary. The assessment of symptoms was performed using the Neuropsychiatric Inventory-Nursing Home test. The influence of the determined factors was investigated using logistic and linear regression analysis, and subsequently corrected for possible confounding factors. Results. A total of 212 cases were included, with a mean age of 85.7 (SD=6.7) years. The prevalence of neuropsychiatric symptoms was 84.4%. The most common symptom was apathy, followed by agitation and delirium, and the least frequent were euphoria and hallucinations. The symptom that produced most occupational disruption was agitation. Multivariate analysis showed that a higher score on the NPI-NH was associated with a higher score on the Global Deterioration Scale of Reisberg, the use of neuroleptics, cholinesterase inhibitors, and memantine. Conclusions. In nursing home patients, prevalence of neuropsychiatric symptoms was high, and associated with the severity of dementia (GDS), the use of neuroleptics, cholinesterase inhibitors, and memantine(AU)