Less structured movement patterns predict severity of positive syndrome, excitement, and disorganization

Disorganized behavior is a key symptom of schizophrenia. The objective assessment of disorganized behavior is particularly challenging. Actigraphy has enabled the objective assessment of motor behavior in various settings. Reduced motor activity was associated with negative syndrome scores, but simple motor activity analyses were not informative on other symptom dimensions. The analysis of movement patterns, however, could be more informative for assessing schizophrenia symptom dimensions. Here, we use time series analyses on actigraphic data of 100 schizophrenia spectrum disorder patients. Actigraphy recording intervals were set at 2 s. Data from 2 defined 60-min periods were analyzed, and partial autocorrelations of the actigraphy time series indicated predictability of movements in each individual. Increased positive syndrome scores were associated with reduced predictability of movements but not with the overall amount of movement. Negative syndrome scores were associated with low activity levels but unrelated with predictability of movement. The factors disorganization and excitement were related to movement predictability but emotional distress was not. Thus, the predictability of objectively assessed motor behavior may be a marker of positive symptoms and disorganized behavior. This behavior could become relevant for translational research.

Cognitive deficits, length of illness and symptom severity in schizophrenia

Background Research using neuropsychological testing has demonstrated that patients with schizophrenia show deficits in multiple neurocognitive domains. The aim of this study is to identify cognitive deficits that correlate with length of illness and symptom severity. Method Twenty clinically stable outpatients with chronic schizophrenia (18M : 2F) and 14 healthy controls (13M : 1F), matched on age, gender and parental education, were administered a neuropsychological battery consisting of the Hayling Sentence Completion Test (HSCT), WMS-III Verbal Paired Associates & Letter Number Sequencing, Modified Card Sort Test (MCST), Pyramids & Palm Trees Test, National Adult Reading Test (NART), Controlled Oral Word Association Test (COWAT), and WAIS-III. Severity of symptoms was rated with the Structured Clinical Interview – Positive and Negative Syndromes Scale (SCI-PANSS). Results In comparison to controls, patients showed significant deficits on all of the neuropsychological tasks except for the COWAT. MCST total categories, NART, Verbal IQ and arithmetic, similarities & digit symbol of the WAIS-III had the largest effect size between the groups. The longer the illness duration, the poorer the performance on WAISIII block design and the lower the performance IQ score. The poorer the performance on WMS-III letter number sequencing, the greater the positive symptoms, negative symptoms and general psychopathology. Conclusion Compared to controls, patients showed large effect sizes on measures of executive functioning, intelligence, working memory, verbal comprehension and speed of processing. The findings suggest that impairment in executive functioning and performance IQ is associated with length of illness, while impairment in working memory is associated with heightened symptom severity.

Maus tratos na infância e relação com a memória, a afectidade negativa e positiva

RESUMO: A presente investigação tem por objectivo estudar a relação entre os maus tratos na infância, a memória, e a afectividade negativa e positiva, em jovens residentes (N=55) em diversos LIJ e RA de duas Instituições da Grande Lisboa, comparando-os com um grupo de controlo (N= 39), de duas Escolas, uma Básica e outra Secundária, também da Grande Lisboa. Foram recolhidas respostas de 47 rapazes e 47 raparigas entre os 12 e os 16 anos, com uma média etária de 14.47 (DP= 1.37). As medidas utilizadas foram a Figura Complexa de Rey, para avaliação da Memória e o PANAS C, para a Afectividade Negativa e Positiva. A análise dos dados permitiu concluir que existem diferenças estatisticamente significativas entre os dois grupos para as dimensões em estudo, tendo piores resultados os jovens que sofreram maus tratos na infância o que corrobora a literatura sobre os danos causados por aqueles, a nível do sistema límbico, sede da afectividade e da memória. ABSTRACT: The present investigation aims at studying the relation between maltreatment in childhood, memory, negative and positive affectivity in youngsters (N=55) living in several Childhood and Youth Homes, as well as in Host Residences of two Institutions located in Greater Lisbon, in comparison to a control group (N=39) of two Schools, an Elementary School and a High School, also located in Greater Lisbon. Answers have been collected from 47 boys and 47 girls, between 12 and 16 years old, with an average range of 14.47 years old (SD= 1.37). The measures used were the Rey Complex Figure, for Memory assessment and PANAS C, for Positive and Negative Affectivity. The data analysis has enabled to conclude that there are statistically significant differences between these two groups for the dimensions in study, having worst results the youngsters that have suffered from maltreatment, confirming the reading about damages caused by it, at limbic system level, the seat of affectivity and memory.

Quality of life assessment of patients with schizophrenic spectrum disorders from Psychosocial Care Centers

OBJECTIVE: Assessing the quality of life and the clinical and social-demographic factors associated in schizophrenic spectrum patients (ICD-10 F20-F29) attending CAPS at the programmatic area 3.0. METHODS: A cross-sectional study was carried out in a sample of schizophrenic spectrum patients who have been enrolled in 2008 in CAPS in programmatic area (AP) 3 at Rio de Janeiro city, using MINIPLUS to assess schizophrenia spectrum disorder and use of psychoactive substances, Positive and Negative Symptoms Scale (PANSS) to assess psychiatric symptoms and Quality of Life Scale (QLS-BR) to assess the quality of life. RESULTS: Seventy nine patients were included, of whom 74 (93.7%) presented some impairment in quality of life. The most frequently affected area was occupational performance. Variables that showed a significant association with severe impairment of quality of life were: marital status, race, occupation, who patients lived with, homelessness, having children, previous psychiatric hospitalization, negative symptoms and symptoms designated as not applicable (being characterized by a lack of typical positive and negative symptoms). CONCLUSION: The knowledge of these factors should be crucial to implement health policies and psychosocial rehabilitation programs focused on improving the quality of life of these patients.

A randomized controlled trial of the effectiveness of a Computer-Assisted Cognitive Remediation (CACR) program in adolescents with psychosis or at high risk of psychosis: Short term and long term outcomes

The present study investigates the short- and long-term outcomes of a computer-assisted cognitive remediation (CACR) program in adolescents with psychosis or at high risk. 32 adolescents participated in a blinded 8-week randomized controlled trial of CACR treatment compared to computer games (CG). Clinical and neuropsychological evaluations were undertaken at baseline, at the end of the program and at 6-month. At the end of the program (n = 28), results indicated that visuospatial abilities (Repeatable Battery for the Assessment of Neuropsychological Status, RBANS; P = .005) improved signifi cantly more in the CACR group compared to the CG group. Furthermore, other cognitive functions (RBANS), psychotic symptoms (Positive and Negative Symptom Scale) and psychosocial functioning (Social and Occupational Functioning Assessment Scale) improved signifi cantly, but at similar rates, in the two groups. At long term (n = 22), cognitive abilities did not demonstrated any amelioration in the control group while, in the CACR group, signifi cant long-term improvements in inhibition (Stroop; P = .040) and reasoning (Block Design Test; P = .005) were observed. In addition, symptom severity (Clinical Global Improvement) decreased signifi cantly in the control group (P = .046) and marginally in the CACR group (P = .088). To sum up, CACR can be successfully administered in this population. CACR proved to be effective over and above CG for the most intensively trained cognitive ability. Finally, on the long-term, enhanced reasoning and inhibition abilities, which are necessary to execute higher-order goals or to adapt behavior to the ever-changing environment, were observed in adolescents benefi ting from a CACR.

Cognitive efficacy of quetiapine in early-onset first-episode psychosis: a 12-week open label trial.

Twenty-three adolescents with psychotic disorders, aged from 13 to 18 years, participated in a 12-week open label trial (17 adolescents completed the study) in order to examine the impact of quetiapine on clinical status and cognitive functions (encompassing processing speed, attention, short-term memory, long-term memory and executive function). An improvement in Clinical Global Impression and Positive and Negative Symptom Scale (P's ≤ 0.001) was observed. In addition, after controlling for amelioration of symptoms, a significant improvement was observed on one executive function (P = 0.044; Trail Making Part B). The remaining cognitive abilities showed stability. In addition, we observed an interaction between quetiapine doses (>300 mg/day or <300 mg/day) and time, where lower doses showed more improvement in verbal short-term memory (P = 0.048), inhibition abilities (P = 0.038) and positive symptoms (P = 0.020). The neuropsychological functioning of adolescents with psychotic disorders remained mainly stable after 12 weeks of treatment with quetiapine. However, lower doses seemed to have a better impact on two components of cognition (inhibition abilities and verbal short-term memory) and on positive symptoms.

Self-presentational motives in eating disorders : a known groups difference approach

Self-presentation reflects the processes by which individuals attempt to monitor and control the impressions others form of them (Schlenker & Leary, 1982). Concerns over impressions conveyed have been linked to numerous health behaviors (Crawford & Eklund, 1994; Martin, Leary, & O'Brien, 2001). The present study investigated the role of cognitive manifestations of dispositional and situational self presentational motivation (SPM) in 131 females with known groups differences on a measure of eating disorders. Participants were classified as in-treatment (IN = 39); at risk (AT = 46); and not at risk (NOT = 46) for eating disordered behaviour. Each participant completed The Brief Fear of Negative Evaluation Scale (FNE; Leary, 1983), the Public Self-Consciousness Scale (PSC; Fenigstein, Sheier, & Buss, 1975), and the Social Physique Anxiety Scale (SPA; Hart, Leary, & Rejeski, 1989), as measures of dispositional SPM. Situational SPM was assessed through Self-Presentational Efficacy (SPE; Gammage, Hall, & Martin, 2004), and the Exercise Motivation Inventory-2 (Markland & Ingeldew, 1997). Significant differences emerged on the measure of eating disorder behaviour between AT and NOT. To determine if group differences existed on measures of trait SPM an ANOVA was conducted. Results indicated that the NOT group experienced less FNE, PSC and SPA than the IN and AT groups, and the AT group experienced less FNE and PSC than the IN group. Pearson bivariate correlations were conducted on measures of trait SPM and EMI-2 subscales theoretically linked to SPM. It was found that FNE, PSC and SPA were all positively correlated with weight management for the NOT group. To determine if group differences existed on selfpresentational exercise motives independent samples I-tests were conducted. Results revealed that the AT group was more motivated to exercise for weight management, and appearance, and social recognition than the NOT group. To determine if group differences existed on the state measure of self-presentational efficacy a series of ANOVA's were conducted. Results revealed that the NOT group experienced significantly greater self-presentational efficacy expectancy and self-presentational outcome value than the AT group. Finally, a discriminant function analysis was conducted to determine if trait SPM would predict group membership. Results revealed that 63.4% of participants were correctly classified, with SPA, PSC, and FNE differentiating the NOT group from the AT and IN groups and FNE and PSC differentiating the AT group from the IN group. Thus self-presentation motivation appears to have an influence on females who have an eating disorder and those at risk for an eating disorder. Potential applications of the influence of self-presentational motives on eating disorders and future research directions are discussed.

Esquizofrenia: intervenção em Instituição Pública de Saúde

Les premiers concepts de schizophrénie comprenaient des définitions non-spécifiques sur le trouble schizophrénique. Ce n est qu en 1980 que Crow a proposé la classification la plus connue pour ce trouble: la distinction en soustypes I et II, de symptomatologie positive ou négative, les symptômes du syndrome positif correspondant aux hallucinations et aux délires et ceux du syndrome négatif au repli affectif et à la pauvreté du discours. Bien que la thérapie médicamenteuse présente des avancées dans le traitement de la maladie, la psychothérapie est la plus indiquée pour remédier aux préjudices sociaux et interpersonnels que celle-ci provoque. L objectif de cette étude est de relater une intervention comportementale, dans un Centre de Soins Psychosocial, auprès d une patiente de 19 ans, en utilisant des Exercices de Réadaptation Psychosociale (SAT) en tant que la possibilité de traitement de la schizophrénie. Ce processus a contribué à une réduction du stéréotype de la maladie chez la jeune patiente, considérant qu elle a élargi son répertoire social et a rendu possible des avancées dans les sphères psychologique, sociale et professionnelle.

O bem-estar subjetivo e os valores humanos em músicos e advogados da cidade de João Pessoa

Are there values that predict health? Moreover, would the absence of health motivate deterioration in the subjective well-being? This research has attempted to find answers to these questions by verifying in which proportion human values explain the subjective well-being experienced by people in different contexts of value reference. Both musicians and lawyers have been studied. In a preliminary study, composed of two researches, it was attempted to overcome the lack of bibliography in order to make known the current context of these professions in João Pessoa, Paraíba, through newspaper articles from the Correio da Paraíba and interviews with privileged informers. The technique of content analysis was then used identifying the main dilemmas of the professions as well as their socio-occupational contexts. In the second and main study, the aim was to verify the existing relations among the variables of subjective well-being and the human values for these professionals adopting the socioeconomical panorama of the occupations to support the analysis. 387 professionals took part in this study: 148 musicians (31.8% instrumentalists) and 239 lawyers (36.8% civil), with ages varying from 18 up to 77 years old (M=35.9; SD=12.35), and from 22 up to 79 years (M =38.6; SD=12.31), respectively, answered the Basic Human Values (BHV); Positive and Negative Affect Scale; Vitality Scale; General Health Questionnaire GHQ-12; Satisfaction with Life Scale and the socio-demographic questions. The SPSS Statistical Package for the Social Sciences was used and it could be observed that, for the musicians, the importance of the type of existence/bio-social value stands out just as an indicator of vitality. The type of value Accomplishment/Power, showed itself important for the positive affection and for vitality, while the types Accomplishment/Self-direction and Normative haven t had any influence in the subjective well-being. Only the relation between the Existence/Bio- Social type and vitality was mediated by the sex and marital status variables. As for the lawyers, the type of predictor value of the subjective well-being was the normative [F(1,219) = 11,8, p ≤ 0,001; Rmultiple = 0,23, R2adjusted = 0,05]. On the other hand, the type Existence/Bio social presented a direct relation with vitality but inverse with depression. It was then concluded that the congruency of personal values with those promoted in the social context of reference may be an indicator of subjective well-being, given the existence of a social value context well demarcated

Facing the dreaded: does mindfulness facilitate coping with distressing experiences? A moderator analysis

Increasing evidence shows that mindfulness is positively related to mental health; however, the nature of this relationship is not fully understood. The current study used structural equation modeling to investigate the hypothesis that mindfulness moderates the association between the occurrence of unavoidable distressing experiences (UDE) and mental health. Participants from a community sample (N = 376) completed the Freiburg Mindfulness Inventory, the Positive and Negative Affect Scale, the Brief Symptom Inventory, the Inventory of Approach and Avoidance Motivation, and the Incongruence Scale. Results indicated that mindfulness moderated the association between unavoidable distressing events and psychopathological symptoms/negative affect. Thus, mindfulness may contribute to enhance the ability to cope with UDE and thus mitigate the detrimental effects of these experiences on mental health.

Actigraphic monitoring of physical activity in clinical trials in schizophrenia

Schizophrenia is still associated with poor outcome, which is mainly related to negative symptoms, reduced physical activity and low quality of life. Physical activity can be objectively measured without distress using wrist actigraphy. The activity levels during the wake periods of the day have been informative on psychopathology and antipsychotic medication. Several studies demonstrated prominent negative symptoms to be associated with reduced activity levels with strongest correlations in chronic patients. Particularly, the avolition score is correlated with reduced activity levels. Moreover, activity levels differ between DSM-IV schizophrenia spectrum disorders and subtypes as well as between patients treated with olanzapine or risperidone. The longitudinal course of activity levels during an psychotic episode demonstrates considerable variance between subjects. During a psychotic episode patients with low activity levels at baseline experience an amelioration of negative symptoms. In contrast, patients with high activity levels at baseline have stable low negative syndrome scores. Between psychotic episodes less variance is observed. Actigraphy is easily applied in schizophrenia and allows collecting large amounts of crosssectional or longitudinal data. With larger numbers of subjects in controlled trials, continuous recording of activity would foster the detection of different outcome trajectories, which may prove as useful groups to target interventions. In clinical trials, activity monitoring may supplement and validate measures of the negative syndrome and its avolition factor or serve as an outcome marker for physical activity, which is important for metabolic issues and quality of life.

Smoking and schizophrenia: is symptom profile related to smoking and which antipsychotic medication is of benefit in reducing cigarette use?

Smoking rate is disproportionately high among patients with schizophrenia, resulting in significant morbidity and mortality. However, cigarette smoking has been reported to have beneficial effects on negative symptoms, extrapyramidal symptoms, cognitive functioning and mood symptoms. Therefore, smoking cessation may worsen disability in schizophrenia. The association between smoking and these key clinical parameters was examined. Additionally, severity of smoking across four different antipsychotic treatment groups was explored. One hundred and forty-six patients with schizophrenia were assessed for smoking using expired carbon monoxide and smoking history. They were administered the Positive and Negative Symptom Scale, The Extrapyramidal Symptom Rating Scale, the Barnes Akathisia Rating Scale, Reitans Trail-making Test (A and B) and General Health Questionnaire-28. There was no difference in the chlorpromazine equivalent dose of any of the medications studied. Atypical agents were associated with significantly lower levels of smoking when compared with typical medications. There was no difference in smoking severity between the individual atypical medications examined. Similarly, there were no significant differences between smoking and non-smoking groups with regard to Positive and Negative Symptom Scale, Extrapyramidal Symptom Rating Scale, Trail-making Test and General Health Questionnaire-28. However, there was a significant difference between these groups with the smoking group demonstrating less akathisia. Smoking is not associated with positive, negative cognitive and mood symptoms in schizophrenia. Smoking is associated with lower levels of antipsychotic induced akathisia. Clinicians should not be discouraged from helping patients stop smoking for fear of worsening symptoms. However, akathisia may emerge upon cessation of smoking. Switching patients from typical to atypical antipsychotics may assist patients with schizophrenia to give up smoking.

De Relatie tussen Hechting en Welbevinden bij Ouderen: De mediërende Invloed van Mindfulness en Zingeving

Empirische studies hebben aangetoond dat bij ouderen een veilige hechting positief samenhangt met het niveau van welbevinden. Hechting is een relatief stabiel en moeilijk te beïnvloeden persoonlijk kenmerk en daarom is het belangrijk om mediatoren van het verband tussen hechting en psychologische uitkomstmaten te vinden die met interventies te beïnvloeden zijn. De vraagstelling van de studie luidde: ‘Welk verband bestaat er tussen hechting en welbevinden bij ouderen en wordt dit verband gemedieerd door mindfulness en zingeving?’. De huidige studie was een survey met één meetmoment. De 210 respondenten waren 65 jaar of ouder (M = 71.25, SD = 5.42) en thuiswonend. Daarnaast mochten ze geen ernstige geheugenproblemen of een psychiatrische stoornis hebben. Via de sneeuwbalmethode werden de respondenten mondeling of schriftelijk door de onderzoeker benaderd. De vragenlijst kon anoniem online of op papier worden ingevuld. Hechting werd gemeten met de Experiences in Close Relationships-Revised (ECR-R), mindfulness met de Five Facet Mindfulness Questionnaire (FFMQ), zingeving met de Meaning in Life Questionnaire, subschaal ‘Presence of meaning in life’ (MLQ-P) en welbevinden met de Positive Affect Negative Affect Scale (PANAS) en de Satisfaction With Life Scale (SWLS). Zowel hechtingsgerelateerde angst (‘angst’) als hechtingsgerelateerde vermijding (‘vermijding’) bleek in correlatieanalyses negatief samen te hangen met mindfulness, zingeving en welbevinden. Tussen mindfulness, zingeving en welbevinden werden positieve verbanden gevonden. De (seriële) mediatieanalyse werd uitgevoerd met behulp van de macro PROCESS 2.13. Zowel het verband tussen ‘angst’ en welbevinden als tussen ‘vermijding’ en welbevinden werd volledig (serieel) gemedieerd door mindfulness en zingeving.

Relation entre la représentation de la maladie et le bien-être subjectif et psychologique chez des patients atteints de cancer

L’annonce d’un diagnostic de cancer a un impact important sur l’individu. En se basant sur des informations sociales, environnementales et personnelles, celui-ci tentera de se représenter la maladie. Cette représentation constitue une grille d’informations cognitives et émotionnelles servant à donner un sens à la maladie et y réagir. Le modèle d’autorégulation de Leventhal propose qu’en fonction de sa représentation de la maladie, un individu mettra de l’avant différentes stratégies d’adaptation; ultimement, ces stratégies auront un impact sur l’issue de la maladie dont le niveau de bien-être. La présente recherche propose de considérer l’avenue tant hédonique qu’eudémonique du bien-être, en y incluant le bien-être subjectif, correspondant aux affects positifs et négatifs et à la satisfaction de vie et le bien-être psychologique correspondant à un état d’épanouissement personnel. L’étude a pour objectif principal de documenter les liens entre les dimensions cognitives et émotionnelles de la représentation de la maladie et les dimensions du bien-être subjectif (avenue hédonique) et le bien-être psychologique (avenue eudémonique). Plus précisément, les hypothèses postulent qu’une représentation plus positive de la maladie a pour effet d’augmenter le bien-être subjectif et psychologique. Les hypothèses postulent que la dimension de la représentation émotionnelle de la maladie joue un rôle médiateur entre les dimensions cognitives de la représentation de la maladie et le bien-être subjectif et psychologique. Pour atteindre ces objectifs, 70 participants âgés entre 31 et 75 ans ayant été atteints de cancer dans les cinq dernières années ont été recrutés. Les données ont été recueillies à l’aide de questionnaires autorapportés : un questionnaire sociodémographique, les versions francophones du Revised Illness Perception Questionnaire (IPQ-R : Moss-Morris et al., 2002), du Positive and Negative Affect Scale (PANAS ; Watson, Clark, & Tellegen, 1988), du Satisfaction with Life Scale (Diener, Emmons, Larsen, & Griffin, 1985) et du The Scales of Psychological Well-Being (Ryff & Essex, 1992). Des analyses statistiques de régressions multiples et de médiation ont été réalisées à l’aide du logiciel Statistical Package for Social Sciences (SPSS). Les résultats indiquent que seulement certaines dimensions de la représentation de la maladie exercent un effet unique sur le bien-être subjectif et/ou psychologique soit le contrôle personnel perçu, la représentation émotionnelle de la maladie, les conséquences perçues de la maladie et le cours aigu/chronique de la maladie. La représentation émotionnelle de la maladie semble exercer un effet médiateur complet entre certaines dimensions cognitives de la représentation de la maladie et les niveaux de bien-être. C’est le cas pour l’identité, le cours aigu/chronique de la maladie, le cours cyclique de la maladie, les conséquences perçues de la maladie et l’efficacité perçue du traitement, lorsque mis en lien avec les affects négatifs. C’est aussi le cas pour l’identité et le cours cyclique de la maladie, lorsque mis en lien avec la satisfaction de vie, et pour le cours cyclique de la maladie et les conséquences perçues de la maladie, lorsque mis en lien avec le bien-être psychologique. Les affects positifs associés au volet affectif du bien-être subjectif ne sont pas affectés par la représentation de la maladie.

Qualidade de vida e suporte social em doentes com esquizofrenia

A Esquizofrenia é considerada pela OMS como uma das dez doenças mais incapacitantes. Sendo uma perturbação complexa e de caráter crónico, gera prejuízos significativos na qualidade de vida dos pacientes. O interesse por este tema surge aquando da desinstitucionalização dos doentes psiquiátricos, contudo os avanços no tratamento desta patologia nem sempre vêm acompanhados de melhora na qualidade de vida, fator este que levou a ter também em consideração, aspetos psicossociais. Assim, pretende-se com este estudo contribuir para a compreensão do nível de satisfação com o suporte social e qualidade de vida destes doentes, comparando-os com indivíduos sem psicopatologia. A amostra é composta por 202 participantes, os quais se dividem em dois grupos, indivíduos com esquizofrenia, que frequentam hospitais na zona norte, centro e sul do país (n=101) e indivíduos sem psicopatologia (n=101), com idades compreendidas entre os 20 e os 75 anos. Os participantes responderam a um protocolo de investigação composto por quatro instrumentos: um questionário sociodemográfico; o WHOQOL-Bref, que avalia a qualidade de vida; a escala de satisfação com o suporte social; e a escala de afeto positivo e negativo. Os resultados principais evidenciam a pouca literatura existente, mostrando que existem diferenças significativas no que refere à qualidade de vida e satisfação com o suporte social entre os indivíduos com esquizofrenia e indivíduos sem patologia psiquiátrica, sendo que os valores mais baixos destas variáveis se concentram nos indivíduos com esquizofrenia. Para estes doentes, verificou-se que a qualidade de vida está positivamente correlacionada com o suporte social e com o afeto positivo, estando também correlacionada negativamente com o afeto negativo. Contudo, não se verificaram correlações da qualidade de vida com a escolaridade, o número de internamentos e o tempo de doença. A satisfação com o suporte social e o afeto positivo e negativo revelaram-se preditores de qualidade de vida nos indivíduos com esquizofrenia. No sentido de promover a melhoria da qualidade de vida destes doentes deverão ser tidas em consideração em vários contextos, intervenções psicossociais.