Mudança narrativa: emergência e evolução de protonarrativas em terapia cognitivo - comportamental

Dissertação de mestrado integrado em Psicologia

Predictors of dropout in a controlled clinical trial of psychotherapy for moderate depression

A significant number of psychotherapy clients remain untreated, and dropping out is one of the main reasons. Still, the literature around this subject is incoherent. The present study explores potential pre-treatment predictors of dropout in a sample of clients who took part in a clinical trial designed to test the efficacy of narrative therapy for major depressive disorder compared to cognitive-behavioral therapy. Logistic regression analysis showed that: (1) treatment assignment did not predict dropout, (2) clients taking psychiatric medication at intake were 80% less likely to drop out from therapy, compared to clients who were not taking medication, and (3) clients presenting anxious comorbidity at intake were 82% less likely to dropout compared to those clients not presenting anxious comorbidity. Results suggest that clinicians should pay attention to depressed clients who are not taking psychiatric medication or have no comorbid anxiety. More research is needed in order to understand this relationship.

A Process Analysis of Males and Females who Attended a Community Based Addiction Treatment Service: Towards an Expanded Paradigm

A process analysis was conducted in a community - based treatment programme for alcohol abuse. The aims of the study were: to evaluate assessment instruments and measures; to measure change following treatment; to monitor gender differences; to assess the importance of early and current relationships; and to evaluate the effects of therapists. Subjects (n=145, males 83/females 62) completed a semi-structured interview schedule, Severity of Alcohol Dependency Questionnaire (SADQ), Short Alcohol Dependence Data Questionnaire (SADD); General Health Questionnaire (GHQ 12), and Alcohol Problems Questionnaire (APQ). A further three non-standardised self-rated measures were devised by the author. Included was the opportunity to obtain qualitative data. Follow up data was collected at 3, 9 and 15 months following first assessment. The SADD, APQ and consumption measures using detailed drink diaries proved the most relevant assessment measures. Following treatment, there was significant reduction in clients' dependency levels at 3 months, maintained through 9 and 15 months. Key client-rated changes were progress in reducing consumption and alcohol problems leading to a better quality of life and health. Qualitative data augmented these quantitative results. Psychological and acquired cognitive behavioural skills emerged as the main reasons for positive change and the treatment programme was found to have played a significant role in their acquisition. It appears that addressing marital problems can lead to a reduction in alcohol dependency levels. Gender analysis showed that males and females were similar in demographic characteristics, alcohol history details and dependence levels. It was concluded that the differences found did not necessitate different treatment programmes for women. Early family relationships were more problematic for females. Therapist performance varied and that variance was reflected in their clients' outcomes.This resource was contributed by The National Documentation Centre on Drug Use.

Características clínicas y tratamiento de la ansiedad académica y ante los exámenes como fobia específica de tipo situacional

L'ansietat acadèmica i davant els exàmens com a fòbia específica de tipus situacional és un trastorn infantil i juvenil d'efectes pertorbadors i negatius que repercuteixen sobre la salut mental i emocional, el rendiment acadèmic i la integració social de l'estudiant que la pateix. En aquest treball s'especifiquen les seves característiques clíniques. Així mateix, s'inclou un cas clínic d'un adolescent de 14 anys que patia d'aquest trastorn fòbic escolar, acompanyat de baixa autoestima personal i dificultats d'adaptació amb el seu grup-classe. Se li va aplicar una avaluació i tractament de tall cognitiu-conductual que ha tingut com a finalitat la superació de la fòbia, i la millora del seu rendiment acadèmic i social. D'entre totes les eines terapèutiques utilitzades destaquen: l'exposició en viu, i l'aprenentatge i utilització de mecanismes de control de l'ansietat (la relaxació Jacobson i la reestructuració cognitiva). Finalment, assenyalar que aquesta intervenció terapèutica ha estat possible gràcies a la participació coordinada i cooperant de l'equip interdisciplinari.

Beneficios de la terapia cognitivo-conductual y la presoterapia en pacientes obesos: ensayo clínico aleatorizado

OBJECTIVE. The purpose of this study was to analyze change of lifestyle in obese patients with cognitive behavior therapy and acupressure. METHODS. An experimental study was performed with placebo control group. Forty patients were randomly assigned to intervention group (cognitive behaviour therapy + acupressure) and control group (information session). Outcome measure was a questionnaire for the assessment and quantification of obesity related lifestyles. Measures were performed at baseline and, after 3-months intervention. RESULTS. After 3 months of treatment, the intervention group showed significant differences (p<0.05) in weight loss, diet and physical activity. CONCLUSION. In the obese patient, cognitive behavior therapy and acupressure, it has lost at least three kilograms over three months and has changed lifestyles related to obesity.

Assessing the link between coping patterns and interpersonal behaviors in depressed women

Aim. Stressful life events are an important contributor to the onset and course of depression. Coping strategies and interpersonal patterns have been found to mediate the effects of stress [1]. Methods. This study examined the relationship between coping patterns and interpersonal interactions in early psychotherapy sessions of 25 female patients with major depression. Transcripts were rated for coping patterns using the Coping Patterns Rating Scale (CPRS; [2]). Interpersonal patterns were assessed using the Structural Analysis of Social Behavior (SASB; [3]). Results. Significant correlations were found between coping patterns and markers of interpersonal functioning in selected contexts. Discussion. The implications of these findings in understanding an important aspect of vulnerability to depression and enhancing treatment outcome are discussed.

Incidència de l'aplicació d'un programa de control de la conducta violenta en joves infractors

En aquest estudi es pretén avaluar l'impacte de la intervenció de tres programes aplicats en centres educatius tancats de la Direcció General de Justícia juvenil per ajudar al jove al control de la seva conducta violenta. Aquest mateix programa s'ha aplicat a joves en medi obert que complien mesures imposades pel jutge de llibertat vigilada. La recerca intenta avaluar els resultats de l'aplicació i la seva perdurabilitat en el temps, un cop han passat uns anys des que van ser aplicats en els joves. El programa es plantejava el control de la conducta violenta dels joves a partir d'un plantejament cognitivo-conductual on les activitats proposades i desenvolupades amb els joves anaven encaminades al canvi i modificació d'aquests comportament. Per avaluar l'efectivitat d'aquests programes la recerca segueix a 31 joves que van fer el programa entre el 2002 i el 2004 i analitza el seu grau de satisfacció respecte la situació actual així com la taxa actual de reincidència. L'estudi aprofita per donar dades respecte el perfil socio-familiar, personal i criminològic dels joves que participen en les diferents aplicacions dels programes.

Pràcticum II de Psicologia Clínica i de la Salut

L'autor exposa el treball de camp dut a terme durant més de cent hores de pràctiques en un centre de salut mental, CSAM de Manresa. S'inicia amb una visió general del centre, la seva història i els seus òrgans de funcionament. Es fa una petita exposició dels motius de l'elecció per part de l'alumne, l'orientació teòrica del centre, així com la metodologia utilitzada i la temporalització amb la qual s'ha dut a terme la tasca i, finalment, un seguiment i alguns resultats obtinguts de les sessions que s'han dut a terme en les àrees infanto-juvenil i d'addicció i control d'impulsos en adults. Acaba el treball amb una reflexió per als futurs estudiants de psicologia, en l'àrea clínica: Lluiteu, lluitem tots junts "por un prácticum clínico que no convierta a los estudiantes de psicología en pedigüeños de las prácticas y los coloquen en la zozobra inquieta que les lleve a un peregrinaje absurdo por diversos centros públicos o privados, a la búsqueda de algún paciente al que puedan simplemente observar" (De Josep Mª Farré, Psiquiatre de l'Institut Dexeus, en el llibre de María Dolores Avia (dir), "Cartas a un joven psicólogo", en la seva segonda edició).

Low intensity vs. self-guided internet-delivered psychotherapy for major depression: a multicenter, controlled, randomized study.

BACKGROUND Major depression will become the second most important cause of disability in 2020. Computerized cognitive-behaviour therapy could be an efficacious and cost-effective option for its treatment. No studies on cost-effectiveness of low intensity vs self-guided psychotherapy has been carried out. The aim of this study is to assess the efficacy of low intensity vs self-guided psychotherapy for major depression in the Spanish health system. METHODS The study is made up of 3 phases: 1.- Development of a computerized cognitive-behaviour therapy for depression tailored to Spanish health system. 2.- Multicenter controlled, randomized study: A sample (N=450 patients) with mild/moderate depression recruited in primary care. They should have internet availability at home, not receive any previous psychological treatment, and not suffer from any other severe somatic or psychological disorder. They will be allocated to one of 3 treatments: a) Low intensity Internet-delivered psychotherapy + improved treatment as usual (ITAU) by GP, b) Self-guided Internet-delivered psychotherapy + ITAU or c) ITAU. Patients will be diagnosed with MINI psychiatric interview. Main outcome variable will be Beck Depression Inventory. It will be also administered EuroQol 5D (quality of life) and Client Service Receipt Inventory (consume of health and social services). Patients will be assessed at baseline, 3 and 12 months. An intention to treat and a per protocol analysis will be performed. DISCUSSION The comparisons between low intensity and self-guided are infrequent, and also a comparative economic evaluation between them and compared with usual treatment in primary. The strength of the study is that it is a multicenter, randomized, controlled trial of low intensity and self-guided Internet-delivered psychotherapy for depression in primary care, being the treatment completely integrated in primary care setting. TRIAL REGISTRATION Clinical Trials NCT01611818.

Early-onset acquired epileptic aphasia (Landau-Kleffner syndrome, LKS) and regressive autistic disorders with epileptic EEG abnormalities: the continuing debate.

Early-onset acquired epileptic aphasia (Landau-Kleffner syndrome) may present as a developmental language disturbance and the affected child may also exhibit autistic features. Landau-Kleffner is now seen as the rare and severe end of a spectrum of cognitive-behavioural symptoms that can be seen in idiopathic (genetic) focal epilepsies of childhood, the benign end being the more frequent typical rolandic epilepsy. Several recent studies show that many children with rolandic epilepsy have minor developmental cognitive and behavioural problems and that some undergo a deterioration (usually temporary) in these domains, the so-called "atypical" forms of the syndrome. The severity and type of deterioration correlate with the site and spread of the epileptic spikes recorded on the electroencephalogram within the perisylvian region, and continuous spike-waves during sleep (CSWS) frequently occur during this period of the epileptic disorder. Some of these children have more severe preexisting communicative and language developmental disorders. If early stagnation or regression occurs in these domains, it presumably reflects epileptic activity in networks outside the perisylvian area, i.e. those involved in social cognition and emotions. Longitudinal studies will be necessary to find out if and how much the bioelectrical abnormalities play a causal role in these subgroup of children with both various degrees of language and autistic regression and features of idiopathic focal epilepsy. One has to remember that it took nearly 40 years to fully acknowledge the epileptic origin of aphasia in Landau-Kleffner syndrome and the milder acquired cognitive problems in rolandic epilepsies.

Prevalence, pathophysiology, health consequences and treatment options of obesity in the elderly: a guideline.

The prevalence of obesity is rising progressively, even among older age groups. By the year 2030-2035 over 20% of the adult US population and over 25% of the Europeans will be aged 65 years and older. The predicted prevalence of obesity in Americans, 60 years and older was 37% in 2010. The predicted prevalence of obesity in Europe in 2015 varies between 20 and 30% dependent on the model used. This means 20.9 million obese 60+ people in the USA in 2010 and 32 million obese elders in 2015 in the EU. Although cut-off values of BMI, waist circumference and percentages of fat mass have not been defined for the elderly (nor for the elderly of different ethnicity), it is clear from several meta-analyses that mortality and morbidity associated with overweight and obesity only increases at a BMI above 30 kg/m(2). Thus, treatment should only be offered to patients who are obese rather than overweight and who also have functional impairments, metabolic complications or obesity-related diseases, that can benefit from weight loss. The weight loss therapy should aim to minimize muscle and bone loss but also vigilance as regards the development of sarcopenic obesity - a combination of an unhealthy excess of body fat with a detrimental loss of muscle and fat-free mass including bone - is important in the elderly, who are vulnerable to this outcome. Life-style intervention should be the first step and consists of a diet with a 500 kcal (2.1 MJ) energy deficit and an adequate intake of protein of high biological quality together with calcium and vitamin D, behavioural therapy and multi-component exercise. Multi-component exercise includes flexibility training, balance training, aerobic exercise and resistance training. The adherence rate in most studies is around 75%. Knowledge of constraints and modulators of physical inactivity should be of help to engage the elderly in physical activity. The role of pharmacotherapy and bariatric surgery in the elderly is largely unknown as in most studies people aged 65 years and older have been excluded.

Les troubles psychiatriques des patients âgés avec une maladie de Parkinson et leurs traitements [Psychiatric disorders in elderly patients with Parkinson's disease and their treatments].

Parkinson's disease (PD) is a neuropsychiatric disorder. During the course of PD, most patients develop at least one psychiatric syndrome. Depression is the most frequent disorder and affects nearly half of all patients. The use of an increasing number of new drugs, in particular the dopaminergic agents, puts these patients at risk of developing both delirium and psychosis. This article summarizes the different psychiatric syndromes seen in PD and gives an account of the various treatment possibilities.

Hippocampal and amygdalar volume changes in elderly patients with Alzheimer's disease and schizophrenia.

Patients with Alzheimer's disease (AD) and schizophrenia display cognitive, behavioural disturbances and morphological abnormalities. Although these latter reflect progressive neurodegeneration in AD, their significance in schizophrenia is still unclear. We explored the patterns of hippocampal and amygdalar atrophy in those patients and their associations with clinical parameters. Structural magnetic resonance imaging was performed in 20 elderly schizophrenia patients, 20 AD and 19 healthy older controls. Hippocampal and amygdalar volumes were obtained by manual segmentation with a standardized protocol and compared among groups. In both schizophrenia and AD patients, left hippocampal and amygdalar volumes were significantly smaller. The hippocampus/amygdala ratio was significantly lower in schizophrenia compared to both AD cases [2.4 bilaterally, 95% C.I. 2.2 to 2.7] and healthy controls bilaterally [2.5, 95% C.I. 2.3 to 2.9 in left and 2.7, 95% C.I. 2.4 to 3.1 in right hemisphere]. In schizophrenia patients, a significant positive correlation was found between age at disease onset and the right hippocampus/amygdala volume ratio (Spearman rho=0.56). Negative symptoms correlated with higher right/left amygdala volume ratio (Spearman's rho=0.43). Our data show that unlike AD, the hippocampus/amygdala ratio is abnormally low and correlates with the age at onset in schizophrenia, being a neurodevelopmental signature of the disease.

Multicontrast MRI Quantification of Focal Inflammation and Degeneration in Multiple Sclerosis.

INTRODUCTION: Local microstructural pathology in multiple sclerosis patients might influence their clinical performance. This study applied multicontrast MRI to quantify inflammation and neurodegeneration in MS lesions. We explored the impact of MRI-based lesion pathology in cognition and disability. METHODS: 36 relapsing-remitting MS subjects and 18 healthy controls underwent neurological, cognitive, behavioural examinations and 3 T MRI including (i) fluid attenuated inversion recovery, double inversion recovery, and magnetization-prepared gradient echo for lesion count; (ii) T1, T2, and T2(*) relaxometry and magnetisation transfer imaging for lesion tissue characterization. Lesions were classified according to the extent of inflammation/neurodegeneration. A generalized linear model assessed the contribution of lesion groups to clinical performances. RESULTS: Four lesion groups were identified and characterized by (1) absence of significant alterations, (2) prevalent inflammation, (3) concomitant inflammation and microdegeneration, and (4) prevalent tissue loss. Groups 1, 3, 4 correlated with general disability (Adj-R (2) = 0.6; P = 0.0005), executive function (Adj-R (2) = 0.5; P = 0.004), verbal memory (Adj-R (2) = 0.4; P = 0.02), and attention (Adj-R (2) = 0.5; P = 0.002). CONCLUSION: Multicontrast MRI provides a new approach to infer in vivo histopathology of plaques. Our results support evidence that neurodegeneration is the major determinant of patients' disability and cognitive dysfunction.

Standard care practices and psychosocial interventions aimed at reducing parental distress following stillbirth: A systematic narrative review

Objective: To summarise and critically evaluate the evidence informing the provision of standard care practices and psychosocial interventions following stillbirth. Background: Stillbirth is increasingly recognised as a significant bereavement experience with the potential to cause substantial psychological distress for parents. Standard care practices and psychosocial interventions to support parents have undergone dramatic changes, with limited basis in evidence. Methods: A systematic narrative review was conducted of quantitative studies examining interventions designed to reduce psychological distress in parents following the loss of a stillborn baby. Results: Twenty-five studies met the inclusion criteria for the review. Substantial methodological weaknesses were identified among reviewed studies, including small and heterogeneous loss samples, weak study designs and lack of clarity in reported methods and outcomes. Inadequate replication of many findings substantially limits the generalisability of the evidence. Conclusion: Tentative evidence was found for the provision of mementoes of the baby and information regarding the cause of the loss, support group attendance, and cognitive behavioural interventions for parents identified with clinical levels of distress. Contradictory findings for the impact of contact with the baby prevent the formation of clear conclusions for this practice. Due to the methodological weaknesses prevalent in the research identified, the current evidence base is not considered sufficiently able to reliably inform care practices and intervention approaches. High-quality research evidence in this field is urgently required.