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1.
Braz. J. Psychiatry (São Paulo, 1999, Impr.) ; 42(1): 87-104, Jan.-Feb. 2020. tab
Artigo em Inglês | LILACS | ID: biblio-1055353

RESUMO

Objective: Trichotillomania (TTM) is characterized by the pulling out of one's hair. TTM was classified as an impulse control disorder in DSM-IV, but is now classified in the obsessive-compulsive related disorders section of DSM-5. Classification for TTM remains an open question, especially considering its impact on treatment of the disorder. In this review, we questioned the relation of TTM to tic disorder and obsessive-compulsive disorder (OCD). Method: We reviewed relevant MEDLINE-indexed articles on clinical, neuropsychological, neurobiological, and therapeutic aspects of trichotillomania, OCD, and tic disorders. Results: Our review found a closer relationship between TTM and tic disorder from neurobiological (especially imaging) and therapeutic standpoints. Conclusion: We sought to challenge the DSM-5 classification of TTM and to compare TTM with both OCD and tic disorder. Some discrepancies between TTM and tic disorders notwithstanding, several arguments are in favor of a closer relationship between these two disorders than between TTM and OCD, especially when considering implications for therapy. This consideration is essential for patients.


Assuntos
Humanos , Masculino , Feminino , Tricotilomania/classificação , Síndrome de Tourette/classificação , Transtorno Obsessivo-Compulsivo/classificação , Tricotilomania/etiologia , Tricotilomania/terapia , Neurobiologia , Comorbidade , Resultado do Tratamento , Manual Diagnóstico e Estatístico de Transtornos Mentais , Neuropsicologia
2.
Braz J Psychiatry ; 42(1): 87-104, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31576938

RESUMO

OBJECTIVE: Trichotillomania (TTM) is characterized by the pulling out of one's hair. TTM was classified as an impulse control disorder in DSM-IV, but is now classified in the obsessive-compulsive related disorders section of DSM-5. Classification for TTM remains an open question, especially considering its impact on treatment of the disorder. In this review, we questioned the relation of TTM to tic disorder and obsessive-compulsive disorder (OCD). METHOD: We reviewed relevant MEDLINE-indexed articles on clinical, neuropsychological, neurobiological, and therapeutic aspects of trichotillomania, OCD, and tic disorders. RESULTS: Our review found a closer relationship between TTM and tic disorder from neurobiological (especially imaging) and therapeutic standpoints. CONCLUSION: We sought to challenge the DSM-5 classification of TTM and to compare TTM with both OCD and tic disorder. Some discrepancies between TTM and tic disorders notwithstanding, several arguments are in favor of a closer relationship between these two disorders than between TTM and OCD, especially when considering implications for therapy. This consideration is essential for patients.


Assuntos
Transtorno Obsessivo-Compulsivo/classificação , Síndrome de Tourette/classificação , Tricotilomania/classificação , Comorbidade , Manual Diagnóstico e Estatístico de Transtornos Mentais , Feminino , Humanos , Masculino , Neurobiologia , Neuropsicologia , Resultado do Tratamento , Tricotilomania/etiologia , Tricotilomania/terapia
3.
Behav Modif ; 44(1): 70-91, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30117327

RESUMO

The purpose of this study was to examine acceptance and commitment therapy (ACT) as a standalone treatment for trichotillomania in a randomized controlled trial of adults and adolescents. Participants consisted of a community sample of treatment seeking adults and adolescents with trichotillomania. Of the eligible 39 participants randomized into treatment and waitlist groups, 25 completed treatment and were included in the final analysis. Treatment consisted of a 10-session ACT protocol. Multiple mixed models repeated measures analyses were utilized to evaluate changes in trichotillomania symptom severity, daily number of hairs pulled and urges experienced, and experiential avoidance from pretreatment to posttreatment. Findings indicated significant changes in symptom severity and daily hairs pulled, but not daily urges experienced or psychological flexibility. However, psychological flexibility saw a 24.5% decrease in the treatment group and reduced from clinical to subclinical levels on average. This study suggests that ACT alone is an effective treatment for adults and adolescents with trichotillomania. Outcomes appear to be similar to trials that combined ACT and habit reversal training (HRT).


Assuntos
Terapia de Aceitação e Compromisso , Tricotilomania/terapia , Adolescente , Adulto , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Resultado do Tratamento , Tricotilomania/diagnóstico , Tricotilomania/psicologia , Adulto Jovem
4.
Pediatr Dermatol ; 36(6): 803-807, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31588617

RESUMO

Trichotillomania can present in childhood, with many families seeking initial evaluation by a dermatologist for hair loss. Prompt and accurate diagnosis by dermatologists is crucial, as children can suffer from academic or social impairments as well as mental health sequelae. Children are especially vulnerable to lasting psychological distress from appearance-related bullying. This article reviews the psychosocial impacts of pediatric trichotillomania and the current interventions studied in this population. Included are studies evaluating behavioral therapies as well as pharmacologic options. This review highlights the importance of early and appropriate identification, intervention, and the need for more treatment studies in the pediatric population.


Assuntos
Tricotilomania/diagnóstico , Tricotilomania/terapia , Acetilcisteína/uso terapêutico , Criança , Terapia Cognitivo-Comportamental , Humanos , Hipnose , Psicoterapia de Grupo , Dispositivos Eletrônicos Vestíveis
5.
Bull Menninger Clin ; 83(4): 399-431, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31380699

RESUMO

Trichotillomania (TTM) involves the chronic pulling out of hair to the point of hair loss or thinning, which continues despite repeated attempts to stop. Behavior therapy is a promising treatment for the condition, but studies have been limited by the lack of a credible control condition, small sample sizes, follow-up periods of short duration, and low participation by underrepresented populations. In the current article, the authors describe the theoretical rationale for an acceptance-enhanced form of behavior therapy for TTM in adults and describe the methodology used to test the efficacy of this intervention against a psychoeducation and supportive control condition. In addition, the authors discuss the importance of and difficulties encountered with enrolling minority participants into TTM research, as well as strategies used to enhance minority recruitment. Finally, the authors discuss the instruments, procedures, and related outcomes of the fidelity measures used in the randomized controlled trial.


Assuntos
Afro-Americanos/etnologia , Terapia Comportamental/métodos , Avaliação de Processos e Resultados em Cuidados de Saúde , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Tricotilomania/etnologia , Tricotilomania/terapia , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Garantia da Qualidade dos Cuidados de Saúde , Wisconsin/etnologia , Adulto Jovem
6.
Bull Menninger Clin ; 83(1): 97-104, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30888852

RESUMO

A recent review on the use of electroconvulsive therapy (ECT) in obsessive-compulsive-related disorders (OCRDs) identified reports of trichotillomania (TTM) in only three patients, but it did not describe the specific effect of ECT on hair-pulling behaviors. The authors present a case report of Mrs. A, a 77-year-old widowed housewife with a lifelong history of episodic TTM and bipolar disorder who was effectively treated with ECT. However, on each attempt to withdraw ECT, her condition deteriorated. Eventually, a decision was made to maintain ECT (one session every week), which resulted in no further relapse over the followup period. ECT shows some potential promise for reducing hair-pulling behaviors in the context of severe depression.


Assuntos
Transtorno Bipolar/terapia , Eletroconvulsoterapia/métodos , Tricotilomania/terapia , Idoso , Transtorno Bipolar/epidemiologia , Comorbidade , Feminino , Humanos , Tricotilomania/epidemiologia
7.
Clin Exp Dermatol ; 44(6): 658-660, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30689239

RESUMO

Trichotillomania is a condition characterized by the pulling of hair from anywhere on the body and is classified as an obsessive-compulsive and related disorder. Patients with hair disorders are commonly referred to psychodermatology services, and can represent a management challenge. Few publications exist that report outcomes for patients with trichotillomania in real clinical practice. We report 12 such patients seen within our own psychodermatology service, who were managed using a variety of treatment strategies. The rate of defaulting of appointments was high, but improvements were seen in patients engaging with services.


Assuntos
Delírio de Parasitose/psicologia , Transtorno Obsessivo-Compulsivo/psicologia , Tricotilomania/psicologia , Tricotilomania/terapia , Adulto , Idoso , Terapia Cognitivo-Comportamental/métodos , Comorbidade , Delírio de Parasitose/etnologia , Dermatologia , Meio Ambiente , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Psicologia , Estudos Retrospectivos , Inibidores de Captação de Serotonina/uso terapêutico , Tricotilomania/etnologia
8.
Artigo em Inglês | MEDLINE | ID: mdl-30336171

RESUMO

BACKGROUND: Symptom severity in trichotillomania clinical trials is typically rated using the Massachusetts General Hospital Hair Pulling Scale (MGH-HPS) and the National Institute of Mental Health Trichotillomania Severity Scale (NIMH-TSS). There are no universal definitions of treatment response on these scales. The absence of empirically supported definitions of treatment response hampers advances in trichotillomania treatment. METHODS: PubMed and CENTRAL databases were searched for trichotillomania clinical trials. A total of 14 studies were identified and 7 provided adequate data to be included in the meta-analysis (n = 270). Meta-DiSc software was employed. The Youden index and distance to corner were used to determine the optimal cut-point. Response was defined by the Clinical Global Impressions Improvement scale score ≤ 2. RESULTS: The optimal cut-points for identifying response on the MGH-HPS was a 35% percent reduction [Youden Index 0.48; distance to corner 0.37] or a seven-point reduction [Youden Index 0.43; distance to corner 0.40]. The optimal cut-points for the NIMH-TSS was a 50% reduction [Youden Index 0.57; distance to corner 0.34] or a six-point reduction [Youden Index 0.53; distance to corner 0.36]. The optimal cut-points were similar when the analysis was confined to only trichotillomania trials involving adult subjects, but the scales appeared to have improved ability to define treatment response when pediatric subjects were excluded. CONCLUSION: This study provides empirically determined cut-points of treatment response on the MGH-HPS and NIMH-TSS. These data-driven cut-points will benefit future research in trichotillomania by providing definitions of treatment response that can be defined a priori in clinical trials.


Assuntos
Tricotilomania/diagnóstico , Tricotilomania/terapia , Humanos , Resultado do Tratamento
9.
Bull Menninger Clin ; 82(4): 288-307, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30589578

RESUMO

Trichotillomania (TTM) is a poorly understood condition that causes significant impairment, but effective behavioral management strategies exist. The phenomenology of TTM is complex and requires an individualized treatment approach, and there are some important facets of TTM that have only recently been recognized. Specifically, contemporary research indicates that hair pulling is often performed to regulate aversive sensations and provide somatosensory reward. In this article, we describe the complex phenomenology of TTM, evidence-based treatment options, and illustrate a case of sensory-based TTM treated effectively with a comprehensive behavioral intervention.


Assuntos
Terapia Comportamental/métodos , Transtorno Obsessivo-Compulsivo/terapia , Tricotilomania/terapia , Adulto , Feminino , Humanos
10.
Clin Dermatol ; 36(6): 728-736, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30446196

RESUMO

Recommendations are provided for the assessment and treatment of trichotillomania (hair pulling disorder, or HPD) and excoriation disorder (skin picking disorder, or SPD), two body-focused repetitive behavior (BFRB) disorders, based on their severity, comorbidities, and behavioral style. Habit reversal training (HRT) and stimulus control are first-line behavioral treatments that can be used in cases of all severity levels and may be particularly helpful when pulling or picking is performed with lowered awareness/intention. Acceptance and commitment therapy (ACT) and dialectical behavior therapy (DBT) are behavioral treatments that can be employed to augment HRT/stimulus control, especially when negative emotions trigger the pulling or picking. There are currently no FDA-approved pharmacologic treatments for HPD or SPD, though certain medications/supplements have shown varying degrees of efficacy in trials. N-acetylcysteine (NAC) should be considered for all severity levels and styles given its moderate gain/low side effect profile. Other pharmacologic interventions, including selective serotonin reuptake inhibitors (SSRIs), should be considered in cases with significant comorbidities or previous behavioral/NAC treatment failure.


Assuntos
Transtorno Obsessivo-Compulsivo/diagnóstico , Transtorno Obsessivo-Compulsivo/terapia , Comportamento Autodestrutivo/diagnóstico , Comportamento Autodestrutivo/terapia , Tricotilomania/diagnóstico , Tricotilomania/terapia , Acetilcisteína/uso terapêutico , Adolescente , Antipsicóticos/uso terapêutico , Terapia Cognitivo-Comportamental , Feminino , Depuradores de Radicais Livres/uso terapêutico , Humanos , Transtorno Obsessivo-Compulsivo/psicologia , Comportamento Autodestrutivo/psicologia , Inibidores de Captação de Serotonina/uso terapêutico , Pele/lesões , Ferimentos e Lesões/etiologia , Adulto Jovem
11.
Artigo em Inglês | MEDLINE | ID: mdl-30476371

RESUMO

Trichotillomania (TTM) is a disorder characterized by recurrent episodes of hair pulling that affects a growing and diverse patient population. The behavior is a result of conscious or unconscious stimuli aimed at alleviating stress. TTM can be diagnosed, typically by a psychiatrist or dermatologist, with various assessment tools and scales. Although researchers continue to discover new pharmacologic regimens and nonpharmacologic therapies, there is no single, effective, US Food and Drug Administration-approved option available for patients. Treatment of TTM with the least occurrence of relapse consists of a combination of pharmacologic and nonpharmacologic options and calls for the involvement of a multidisciplinary team along with family members and friends. This review provides an analysis of the current treatment modalities in the management of TTM and highlights the need for further epidemiologic, genetic, neuroimaging, and dietary research to better understand the complicated nature of the disorder.


Assuntos
Tricotilomania/terapia , Animais , Humanos , Tricotilomania/diagnóstico , Tricotilomania/epidemiologia , Tricotilomania/fisiopatologia
13.
Tidsskr Nor Laegeforen ; 138(10)2018 06 12.
Artigo em Norueguês | MEDLINE | ID: mdl-29893105

RESUMO

Trichotillomania, or hair-pulling disorder, is a mental disorder that typically strikes in adolescence and has a chronic course. The condition is frequently accompanied by significant limitations as life unfolds. Comorbidity with depression and anxiety disorders is common.


Assuntos
Tricotilomania , Adolescente , Antidepressivos/uso terapêutico , Terapia Comportamental , Comorbidade , Humanos , Transtornos Mentais/epidemiologia , Tricotilomania/tratamento farmacológico , Tricotilomania/epidemiologia , Tricotilomania/etiologia , Tricotilomania/terapia
14.
G Ital Dermatol Venereol ; 153(4): 557-566, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29667792

RESUMO

Habit reversal training (HRT) is a clinically effective treatment for body-focused repetitive disorders (BFRDs) such as trichotillomania, onychophagia, and dermatillomania. Despite many dermatology providers knowing the term HRT, very few understand what HRT is and how it actually works. In this article, we give a detailed explanation of HRT and walk the reader through a six-session HRT protocol. We will briefly discuss adjunct interventions for BFRDs, including pharmacological approaches. We aim to make dermatologists more comfortable in offering basic HRT within their clinics and to close the gap that currently exists between patients who are HRT candidates and those who receive HRT treatment.


Assuntos
Terapia Comportamental/métodos , Comportamento Compulsivo/terapia , Hábitos , Dermatologistas , Humanos , Hábito de Roer Unhas/terapia , Resultado do Tratamento , Tricotilomania/terapia
15.
Rev Chil Pediatr ; 89(1): 98-102, 2018 Feb.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29664510

RESUMO

Resumen: Introduction: Trichobezoars are an intraluminal accumulation of ingested hair. The Rapunzel syndrome refers to the presence of gastric trichobezoars which extend to the small intestine together with trichotillomania and trichophagia, that occur predominantly in psychiatric patients of pediatric age. OBJECTIVE: To analyze the clinical course and resolution of this syndrome in a case report. Likewise, we provide information about the family environment and psycho-emotional context of the patients and help the reader identify similar circumstances in their clinical practice. CASE REPORT: Female 14-year-old patient with history of trichotillomania and trichophagia of two years of evolution, who consulted for epigastric pain associated with weight loss, nausea, and postprandial fullness. During the physical examination, the patient was found to have bald patches in the scalp along with a palpable mass that seemed to be confined to the gastric limits. Imaging studies revealed gastric occupation due to a bezoar formation. The patient was treated surgically with laparotomy and gastrostomy, and two simultaneous trichobezoars were removed from the patient´s stomach and duodenum, the patient also underwent psycho-emotional professional counseling. CONCLUSION: Rapunzel´s syndrome, far for being a merely surgical entity, also requires psychoemotional assessment to prevent it recurrence and limit its severity.


Assuntos
Bezoares/diagnóstico , Duodeno , Estômago , Tricotilomania/diagnóstico , Adolescente , Bezoares/psicologia , Bezoares/terapia , Feminino , Humanos , Síndrome , Tricotilomania/psicologia , Tricotilomania/terapia
16.
Psychiatr Danub ; 30(1): 79-84, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29546862

RESUMO

BACKGROUND: The main goal of this study was to analyse and show clinical characteristics and psychiatric comorbidity in 38 participants aged between 10 and 17 with DSM-IV diagnoses of Trichotillomania (TTM) that we were treating at Children's Hospital Zagreb from 2008 to 2017. SUBJECTS AND METHODS: We analyzed the data obtained from semi-structured interviews by the criteria of DSM-IV, Youth Self Report (YSR) (Achenbach & Rescorla 2001) and survey that we created. RESULTS: From 38 participants 21 were girls. The activities during which the participants state that they mostly pull hairs are as follows: doing homework and learning, working on PC, in the toilet, watching TV etc. The most common sites on the body from which participants pulled hair were scalp and among nonscalp sites eyebrows and eyelashes. We found nail biting in more than a half of participants. In 22 participants one or more comorbid disorder has been found, of which ADHD (n=6) and tics (n=5) are most co-occurring disorders. The internalized and externalized problems were nearly evenly represented. Trichophagia was reported by two participants. The results indicate that more than two thirds of participants isolate themselves during hair pulling and half of them try to hide consequences. Median time from the first occurrence of the symptoms to the first visit to a child psychiatrist caused by TTM problem was 9 months (min 5; max 24) what we consider a very long period of time that increased the probability of complications. CONCLUSIONS: Knowledge about this disorder and cooperation among pediatric experts is extremely important for recognizing it at an early stage and starting the treatment especially considering habit-forming mechanism, the burden of an emotional distress and frequent comorbidity. Further research is needed.


Assuntos
Transtornos Mentais/epidemiologia , Transtornos Mentais/psicologia , Tricotilomania/epidemiologia , Tricotilomania/psicologia , Adolescente , Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Transtorno do Deficit de Atenção com Hiperatividade/psicologia , Transtorno do Deficit de Atenção com Hiperatividade/terapia , Criança , Comorbidade , Croácia , Feminino , Humanos , Masculino , Transtornos Mentais/diagnóstico , Transtornos Mentais/terapia , Hábito de Roer Unhas/psicologia , Hábito de Roer Unhas/terapia , Estudos Prospectivos , Tiques/diagnóstico , Tiques/epidemiologia , Tiques/psicologia , Tiques/terapia , Tricotilomania/diagnóstico , Tricotilomania/terapia
17.
J Appl Behav Anal ; 51(2): 255-262, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29468679

RESUMO

We used a biobehavioral treatment consisting of melatonin and a standardized bed and wake time to decrease one girl's head and mouth touches associated with sleep-related trichotillomania and trichophagia. We remotely coached the girl's caregiver to implement all procedures and monitored response to treatment using a DropCam Pro video camera equipped with night-vision capabilities. Head and mouth touches decreased, and her sleep pattern improved with the combination of treatment strategies. We discuss our use of a novel mode of service delivery to treat sleep-related problem behavior.


Assuntos
Terapia Comportamental/métodos , Melatonina/uso terapêutico , Pica/tratamento farmacológico , Pica/terapia , Telemedicina/métodos , Tricotilomania/tratamento farmacológico , Tricotilomania/terapia , Pré-Escolar , Terapia Combinada , Feminino , Humanos , Sono/efeitos dos fármacos
18.
Psychiatry Res ; 262: 20-27, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29407564

RESUMO

Evidence suggests that trichotillomania is characterized by impairment in response inhibition, which is the ability to suppress pre-potent/dominant but inappropriate responses. This study sought to test the feasibility of computerized response inhibition training for children with trichotillomania. Twenty-two children were randomized to the 8-session response inhibition training (RIT; n = 12) or a waitlisted control (WLT; n = 10). Primary outcomes were assessed by an independent evaluator, using the Clinical Global Impression-Improvement (CGI-I), and the NIMH Trichotillomania Severity (NIMH-TSS) and Impairment scales (NIMH-TIS) at pre, post-training/waiting, and 1-month follow-up. Relative to the WLT group, the RIT group showed a higher response rate (55% vs. 11%) on the CGI-I and a lower level of impairment on the NIMH-TIS, at post-training. Overall symptom reductions rates on the NIMH-TSS were 34% (RIT) vs. 21% (WLT) at post-training. The RIT's therapeutic gains were maintained at 1-month follow-up, as indicated by the CGI-I responder status (= 66%), and a continuing reduction in symptom on the NIMH-TSS. This pattern of findings was also replicated by the 6 waitlisted children who received the same RIT intervention after post-waiting assessment. Results suggest that computerized RIT may be a potentially useful intervention for trichotillomania.


Assuntos
Controle Comportamental/métodos , Inibição Psicológica , Tricotilomania/terapia , Adolescente , Criança , Estudos de Viabilidade , Feminino , Humanos , Masculino , Índice de Gravidade de Doença , Resultado do Tratamento , Tricotilomania/psicologia , Listas de Espera
19.
Behav Cogn Psychother ; 46(1): 1-20, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28903787

RESUMO

BACKGROUND: Not all patients suffering from trichotillomania (TTM) recover completely using CBT and of those that do, only a few maintain their recovery over time. AIMS: The purpose of the present study was to investigate the effectiveness of metacognitive methods combined with habit reversal (MCT/HRT) in trichotillomania with a relatively long-term follow-up. METHOD: A case series (n = 8) and a randomized wait-list controlled trial (n = 34) design were conducted in this study. In the case series, three of the eight patients dropped out of the study. Therefore, TTM-related symptoms were evaluated in five patients suffering from TTM before and after brief metacognitive plus habit reversal therapy during 1-month, 6-month, and 12-month follow-ups. The treatment consisted of detached mindfulness (DM) techniques, ritual postponement and habit reversal training (HRT) in eight sessions. RESULTS: All patients were responders at post-treatment in case series. After the 12-month follow-up, the results were associated with higher pre-treatment levels of self-esteem and global functioning and lower pre-treatment levels of depression and anxiety with nearly complete abstinence from hair pulling immediately after treatment. A randomized wait-list controlled trial with experimental (n = 17) and waiting list group (n = 17) was then conducted to confirm the case series results. There were significant differences between the two groups regarding changes in MGH-HPS, Y-BOCS-TM, RSES, GAF, BDI, BAI and self-monitoring. Therefore, the MCT/HRT treatment was found to be more effective than the waiting list group. CONCLUSIONS: A combined treatment including metacognitive and habit reversal techniques is remarkably effective in patients with TTM.


Assuntos
Hábitos , Metacognição , Tricotilomania/psicologia , Tricotilomania/terapia , Adulto , Ansiedade/complicações , Terapia Combinada , Depressão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Plena , Autoimagem , Resultado do Tratamento , Listas de Espera
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