Trastornos adaptativos y su manejo desde atención primaria / Adaptive disorders and their management in primary care

Introducción: El trastorno de adaptación describe una respuesta emocional y conductual desproporcionada a uno o más estresores psicosociales identificables. Existen múltiples situaciones capaces de generarnos una situación de estrés agudo. Sin embargo, uno de los requisitos necesarios para poder hablar de trastorno adaptativo es que ese o esos factores estresantes supongan un deterioro en el funcionamiento normal del individuo. Objetivos: El objetivo principal de este trabajo es analizar, mediante una revisión bibliográfica, el diagnóstico y abordaje de los trastornos adaptativos dentro del ámbito de Atención Primaria. El objetivo secundario es destacar la importancia de la detección y el tratamiento precoces, así como de la gestión multidisciplinar y la promoción de la salud mental. Resultados: Los principales factores de riesgo de los trastornos adaptativos son el desempleo, los bajos ingresos,el escaso apoyo social, las enfermedades físicas y la salud mental. La prevalencia es mayor en jóvenes,especialmente entre las mujeres, y existe un riesgo aumentado de suicidio en el subtipo de estado de ánimo depresivo. El Cuestionario Internacional de Trastornos Adaptativos es actualmente la principal herramienta diagnóstica, por establecer sus criterios diagnósticos en base a la definición teórica establecida por la CIE-11. El manejo de estos trastornos se realiza principalmente mediante terapia cognitivo-conductual. Conclusiones: Los trastornos de adaptación surgen como respuestas anormales ante ciertas situaciones estresantes. El papel de los médicos de Atención Primaria en el abordaje de este trastorno es primordial, siendo necesaria su detección y manejo precoz para disminuir los niveles de ansiedad disfuncionales que presentan los pacientes.(AU)

Introduction: Adjustment disorder describes a disproportionate emotional and behavioral response to one or more identifiable psychosocial stressors. There are multiple situations capable of generating an acute stressful situation. However, one of the requirements to be able to speak of an adaptive disorder is that the stressor(s) in question should lead to an impairment of the individual's normal functioning.Objectives: The main objective of this work is to analyze , through a literature review, the diagnosis and approach to the diagnosis and management of adaptive disorders in the Primary Care setting. The secondary objective is toemphasize the importance of early detection and treatment, as well as multidisciplinary management and mentalhealth promotion. Results: The main risk factors for adjustment disorders are unemployment, low income, low social support, physical illness, and personal history of mental health. The International Questionnaire of Adaptive Disorders is currently the principal diagnostic tool, as it establishes its diagnostic criteria based on the theoretical definition established by the ICD-11. The management of these disorders is mainly through cognitive behavioural therapy.Conclusions: Adjustment disorders arise as abnormal responses to certain stressful situations. The role of primary care physicians in dealing with this disorder is essential, and early detection and management are necessary to reduce the levels of dysfunctional anxiety that patients present.(AU)

The Mediating Effects of Academic Performance between Screen Time, Executive Function Difficulty and School Adjustment.

The purpose of this study was to verify the mediating effects of academic performance on the relationship between screen time, executive function difficulty, and school adjustment. This study analyzed secondary data of the 8th Panel Survey on Korean Children. The 8th Panel Survey was the first measurement of children's academic performance, executive function difficulty, and school adjustment through large sampling. Accordingly, it is possible to provide a large amount of data that can verify the relationship between them. The respondents were parents and teachers of students. The total number was 1,031. Data were analyzed by descriptive, t-test, analysis of variance, Pearson correlation, and three-steps multiple regression statistics. As a result, screen time has a full mediating effect on school adjustment through academic performance. The executive function difficulty has a partial mediating effect on school adjustment through academic performance. The results of this study will contribute to the development of the school adjustment improvement program.

Theory of psychological adaptive modes.

When an individual is facing a stressor and normal stress-response mechanism cannot guarantee sufficient adaptation, special emotional states, adaptive modes, are activated (for example a depressive reaction). Adaptive modes are involuntary states of mind, they are of comprehensive nature, they interfere with normal functioning, and they cannot be repressed or controlled the same way as many emotions. Their transformational nature differentiates them from other emotional states. The object of the adaptive mode is to optimize the problem-solving abilities according to the situation that has provoked the mode. Cognitions and emotions during the adaptive mode are different than in a normal mental state. These altered cognitions and emotional reactions guide the individual to use the correct coping skills in order to deal with the stressor. Successful adaptation will cause the adaptive mode to fade off since the adaptive mode is no longer necessary, and the process as a whole will lead to raised well-being. However, if the adaptation process is inadequate, then the transformation period is prolonged, and the adaptive mode will turn into a dysfunctional state. Many psychiatric disorders are such maladaptive processes. The maladaptive processes can be turned into functional ones by using adaptive skills that are used in functional adaptive processes.

Binge eating in bariatric surgery candidates: The role of insecure attachment and emotion regulation.

Binge eating has a high prevalence among bariatric patients and is associated with post-surgical weight gain. This study examined the potential mediating role of emotion regulation difficulties in the relation between attachment insecurity and binge eating among this population. Participants were 1388 adult pre-bariatric surgery candidates from an accredited bariatric surgery assessment centre in Toronto, Ontario. Participants completed measures of psychological functioning, including attachment style and emotion regulation. Mediation analyses revealed that difficulties with emotion regulation mediated a positive association between insecure-anxious attachment and binge eating. An insecure-avoidant attachment was found to have a non-significant association with binge eating when examining the total effect. However, when difficulties with emotion regulation were controlled for in the model to examine its role as a mediator, this association became significant, and emotion regulation difficulties also mediated the relationship between attachment avoidance and binge eating. These findings suggest that difficulties in emotion regulation may be an important clinical issue to address in order to reduce binge eating in adult bariatric surgery candidates.

Protocol for economic evaluation alongside a cluster-randomised controlled trial of a psychoeducational intervention for the primary prevention of postnatal mental health problems in first-time mothers.

INTRODUCTION: Postnatal mental health problems, which are an international public health priority, are a suitable target for preventive approaches. The financial burden of these disorders is borne across sectors in society, including health, early childhood, education, justice and the workforce. This paper describes the planned economic evaluation of What Were We Thinking, a psychoeducational intervention for the prevention of postnatal mental health problems in first-time mothers. METHODS AND ANALYSIS: The evaluation will be conducted alongside a cluster-randomised controlled trial of its clinical effectiveness. Cost-effectiveness and costs-utility analyses will be conducted, resulting in estimates of cost per percentage point reduction in combined 30-day prevalence of depression, anxiety and adjustment disorders and cost per quality-adjusted life year gained. Uncertainty surrounding these estimates will be addressed using non-parametric bootstrapping and represented using cost-effectiveness acceptability curves. Additional cost analyses relevant for implementation will also be conducted. Modelling will be employed to estimate longer term cost-effectiveness if the intervention is found to be clinically effective during the period of the trial. ETHICS AND DISSEMINATION: Approval to conduct the study was granted by the Southern Health (now Monash Health) Human Research Ethics Committee (24 April 2013; 11388B). The study was registered with the Monash University Human Research Ethics Committee (30 April 2013; CF12/1022-2012000474). The Education and Policy Research Committee, Victorian Government Department of Education and Early Childhood Development approved the study (22 March 2012; 2012_001472). Use of the EuroQol was registered with the EuroQol Group; 16 August 2012. TRIAL REGISTRATION NUMBER: The trial was registered with the Australian New Zealand Clinical Trials Registry on 7 May 2012 (registration number ACTRN12613000506796).

Soldiers' perceptions of resilience training and postdeployment adjustment: validation of a measure of resilience training content and training process.

Group randomized trials of a resilience training program (formerly Battlemind training) demonstrated effectiveness of the program in reducing postdeployment adjustment problems among military personnel. These results are promising, but program evaluation is a dynamic, multifaceted task, and many questions remain. This article is designed to address one component of resilience training program evaluation: soldiers' perceptions of the training. Specifically, a self-report measure assessing attitudes and satisfaction in domains theorized to be important to resilience training was developed. This measure was administered to 782 soldiers who participated in a 1-hr resilience training session at 4-months postdeployment. Several mental health outcomes (e.g., alcohol problems, posttraumatic stress symptoms, physical health symptoms, unit morale) were assessed before training and 6 months later. Structural validity, internal consistency, concurrent validity, and predictive validity of the measure were examined. Analyses identified two factors reflecting attitudes toward Training Content and Training Process. The factors demonstrated good internal consistency, and both correlated with overall training satisfaction and mental health-related attitudes. In addition, both factors predicted significant positive change in a set of mental health outcomes at 6-month follow-up. Implications for postdeployment resilience training are discussed.

Validation study of the Questionnaire on School Maladjustment Problems (QSMP).

The aim of this study was to analyze the exploratory and confirmatory structure, as well as other psychometric properties, of the Cuestionario de Problemas de Convivencia Escolar (CPCE; in Spanish, the Questionnaire on School Maladjustment Problems [QSMP]), using a sample of Spanish adolescents. The instrument was administered to 60 secondary education teachers (53.4% females and 46.6% males) between the ages of 28 and 54 years (M= 41.2, SD= 11.5), who evaluated a total of 857 adolescent students. The first-order exploratory factor analysis identified 7 factors, explaining a total variance of 62%. A second-order factor analysis yielded three dimensions that explain 84% of the variance. A confirmatory factor analysis was subsequently performed in order to reduce the number of factors obtained in the exploratory analysis as well as the number of items. Lastly, we present the results of reliability, internal consistency, and validity indices. These results and their implications for future research and for the practice of educational guidance and intervention are discussed in the conclusions.

Development of a universal psycho-educational intervention to prevent common postpartum mental disorders in primiparous women: a multiple method approach.

BACKGROUND: Prevention of postnatal mental disorders in women is an important component of comprehensive health service delivery because of the substantial potential benefits for population health. However, diverse approaches to prevention of postnatal depression have had limited success, possibly because anxiety and adjustment disorders are also problematic, mental health problems are multifactorially determined, and because relationships amongst psychosocial risk factors are complex and difficult to modify. The aim of this paper is to describe the development of a novel psycho-educational intervention to prevent postnatal mental disorders in mothers of firstborn infants. METHODS: Data from a variety of sources were synthesised: a literature review summarised epidemiological evidence about neglected modifiable risk factors; clinical research evidence identified successful psychosocial treatments for postnatal mental health problems; consultations with clinicians, health professionals, policy makers and consumers informed the proposed program and psychological and health promotion theories underpinned the proposed mechanisms of effect. The intervention was pilot-tested with small groups of mothers and fathers and their first newborn infants. RESULTS: What Were We Thinking! is a psycho-educational intervention, designed for universal implementation, that addresses heightened learning needs of parents of first newborns. It re-conceptualises mental health problems in mothers of infants as reflecting unmet needs for adaptations in the intimate partner relationship after the birth of a baby, and skills to promote settled infant behaviour. It addresses these two risk factors in half-day seminars, facilitated by trained maternal and child health nurses using non-psychiatric language, in groups of up to five couples and their four-week old infants in primary care. It is designed to promote confidence and reduce mental disorders by providing skills in sustainable sleep and settling strategies, and the re-negotiation of the unpaid household workload in non-confrontational ways. Materials include a Facilitators' Handbook, creatively designed worksheets for use in seminars, and a book for couples to take home for reference. A website provides an alternative means of access to the intervention. CONCLUSIONS: What Were We Thinking! is a postnatal mental health intervention which has the potential to contribute to psychologically-informed routine primary postnatal health care and prevent common mental disorders in women.

Terrorism-related perceived stress, adolescent depression, and social support from friends.

BACKGROUND: Terrorism leads to adolescent depression, but little is known about protective factors. We investigated 90 adolescents (in grades 7-9) residing in Dimona, Israel, before and after their exposure to a suicide bombing. OBJECTIVE: To examine the prospective effect of social support from friends, parents, and school personnel on the link between bombing-related perceived stress and adolescent depression. METHODS: Seven months prior to the suicide bombing, adolescents completed questionnaires as part of an ongoing investigation of youth risk/resilience under stress. The focus of the present study was on the Perceived Social Support Scale. One month subsequent to the suicide bombing, participants were interviewed by telephone about their bombing-related perceived stress (a 1-item measure) and depression (the Center for Epidemiologic Studies Child Depression Scale). RESULTS: Bombing-related perceived stress was associated with an increase in continuous levels of depression from before to after the bombing (beta = .29; P = .006). Prebombing social support from friends buffered against this effect (beta = -.29; P = .010). Adolescents reporting high bombing-related perceived stress evinced an increase in depression if they reported low levels of friends' support (beta = .61; P < .001) but not high levels of friends' support (beta = .00; P = .98). In addition, social support from friends predicted an increase in adolescent depression over time when bombing-related perceived stress was low (beta = .34; P = .026). CONCLUSION: In adolescence, social support from friends might protect against the depressogenic effect of terrorism-related perceived stress.

A preliminary assessment of adjustment disorder among first-year college students.

Using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (American Psychiatric Association, 2000) criteria, we investigated whether the diagnosis adjustment disorder (AD) described first-year college students' adjustment problems. We found that a substantial portion of students experienced a set of adjustment symptoms meeting the AD criteria. Another portion of students reported adjustment concerns that were problematic but did not meet the AD diagnosis threshold. Female students tended to report more symptoms than do male students. College counseling implications are presented.

Outcomes from the Resources for Enhancing Alzheimer's Caregiver Health (REACH) program for bereaved caregivers.

Although preventive efforts for bereaved individuals have not been shown to be particularly effective in past studies, it has been suggested that intervention effects might be underestimated due to methodological issues such as short follow-up assessments. Thus, the present study aimed to assess the efficacy (as whole intervention packages and as component parts) of the Resources for Enhancing Alzheimer's Caregiver Health (REACH) interventions in preventing complicated grief, normal grief, and depressive symptoms at a longer term follow-up assessment among bereaved caregivers (N = 224). On average, active interventions showed a statistically significant effect on normal grief symptoms (d = 0.28), exhibited a trend toward improvement on complicated grief symptoms (d = 0.25), and demonstrated little impact on depressive symptoms (d = 0.09). Interestingly, the examination of intervention components revealed differential effects, whereby cognitive and behavioral strategies were most effective at reducing levels of complicated grief, information and emotional support were most effective for addressing normal grief, and environmental modifications were most effective for ameliorating depressive symptoms. These findings suggest that different preloss interventions might be warranted depending on a caregiver's unique clinical presentation and combination of risk factors.

Mother-child relationship quality and effective discipline as mediators of the 6-year effects of the New Beginnings Program for children from divorced families.

This study examines whether program effects on mother-child relationship quality and effective discipline mediated the 6-year longitudinal effects of the New Beginnings Program (NBP) to improve mental health and competence outcomes in 218 adolescents from divorced families in a randomized experimental trial. The NBP is a theory-based and parenting-focused preventive intervention to help children adjust to divorce, and it has previously shown significant main and/or Program x Baseline Risk interaction effects to reduce adolescents' mental health and social adaptation problems and to promote competence. Mediation analyses were conducted using single- and two-group (high and low baseline risk) structural equation modeling. A multiple-methods and multiple-informants approach was used to assess the putative mediators and adolescents' outcomes. Results indicated that program-induced improvement in maternal effective discipline at posttest mediated the intervention effect on adolescents' GPA at the 6-year follow-up. Moreover, program-induced improvement in mother-child relationship quality mediated the intervention effect on adolescents' mental health problems for those with high baseline risk for maladjustment. The discussion focuses on the implications of the mediation findings for advancing the developmental theories that informed the design of the NBP and the implications for implementation of the NBP in community settings.

Predictors of incident depression after hip fracture surgery.

OBJECTIVE: Depression after hip fracture surgery is prevalent and associated with increased mortality rates and impaired functional recovery. The incidence of new-onset depressive symptoms in patients initially not depressed after hip fracture surgery and their relationship with functional recovery is unknown. METHODS: A cohort of 139 nondepressed elderly patients (>60 years) hospitalized for hip fracture surgery were followed up for six months. Clinically significant depressive symptoms were defined as a score of 7 or more on the 15-item Geriatric Depression Scale. RESULTS: The authors found a cumulative incidence rate of 20.5% adjusted for dropouts. Multiple Cox-regression analyses yielded the presence of subthreshold symptoms of depression, anxiety, pain, and cognitive impairment at baseline, the premorbid level of mobility, and a history of (treated) depression as risk factors for incident depression (p <0.05). A forward, conditional procedure identified postoperative pain (hazard ratio [HR] = 1.32, 95% confidence interval [CI]: 1.14-1.53, Wald chi(2) = 13.57, df = 1, p <0.001) and baseline anxiety (HR = 1.25, 95% CI: 1.08-1.44, Wald chi(2) = 8.86, df = 1, p = 0.003) as the strongest independent risk factors. Incident depression was associated with a less favorable outcome at 3 months follow-up. CONCLUSION: This exploratory study identified two treatable baseline characteristics that predicted incident depression in nondepressed patients after hip-fracture surgery.

Laying the foundations of well being: a creative psycho-educational program for young children.

Dysfunctional cognitive schemata and pessimistic explanatory styles are usually held responsible for some of the commonest features of depressed mood such as feelings of meaninglessness, resignation, and underachievement which seem to affect even young children. This pilot study investigates the applicability and efficacy of an interactive, creative psycho-educational program for preschoolers that aims at enhancing mastery and shaping optimistic explanatory styles. Twenty preschoolers participated in once-a-week hourly sessions which took place in their school and lasted for one school year. The intervention consisted of several playful tasks and novel creative activities specially designed to meet the needs and abilities of preschoolers, while satisfying the objectives of the school curriculum. The tasks were based on the principles of cognitive behaviour theory. Qualitative and quantitative analyses of our results support the efficacy of the intervention for preschoolers.

Treatment decision difficulties and post-operative distress predict persistence of psychological morbidity in Chinese women following breast cancer surgery.

BACKGROUND: The patterns and determinants of longer-term psychological morbidity in women following breast cancer surgery have not been described for Chinese populations. METHODS: Chinese women were assessed at 3-days, 4-months and 8-months following breast surgery, on treatment decision-making difficulty (TDMD), satisfaction with treatment outcome (E-OI), self efficacy (GSeS), optimism (C-LOT-R), consultation satisfaction (C-MISS-R), physical symptom distress (PSD) and psychological morbidity (CHQ-12) and compared using polynomial logistic models. RESULTS: Of 303/405 women providing complete data, 33% received chemotherapy and 26% radiotherapy. GSeS, CLOTR and TDMD scores were moderate. Though the proportion of women meeting psychological morbidity case-criteria declined from 78% (95% Confidence Interval 73-83%) at Baseline to 64% (59-69%) at 8-months, almost 50% (44-54%) of women remained distressed over the 8-month period. After adjustment for demographic and clinical factors, severity of psychological morbidity at 4-months was predicted by PSD, disappointment and higher Baseline CHQ12, and among moderate/severe cases only, greater TDMD and pessimistic outlook. At 8-months, CHQ12 scores were predicted by PSD, Baseline CHQ-12, and difficulties with TDM. CONCLUSION: TDM difficulties, early post-surgical psychological and physical symptom distress indicate risk for prolonged distress in Chinese women following breast cancer surgery.