603 resultados para Psychosis
Resumo:
Este estudo teve como objetivo principal explorar dois conceitos importantes na teoria do psicanalista francs Andr Green: complexo de me morta e psicose branca. A decatexia provocada pelo afastamento emocional materno (complexo de me morta), induz um vazio interior (angstia branca). Esta sensao de vazio, de paragem, uma depresso sem afetos e a alucinao negativa, so manifestaes da psicose branca (estrutura matriz onde se observa o ncleo da psicose sem que esta necessariamente se manifeste). O mtodo utilizado foi o estudo de caso, de um sujeito do sexo masculino em regime de internamento. Os instrumentos de avaliao incluem a tcnica projetiva de Rorschach (aplicada no incio e no final do internamento) e o Thematic Apperception Test (aplicado no incio do internamento). Atravs do material colhido em contexto de acompanhamento individual e das tcnicas projetivas observaram-se pontos de contacto entre o conceito de psicose branca de Green, falso self de Winnicott e as personalidades as if de Helene Deutsch. A morte metafrica da me, o seu afastamento emocional, poder estar na origem destas perturbaes, onde se observa o ncleo da psicose. Nestas situaes clnicas, em que o vazio interno predomina, a prtica psicoteraputica requer um posicionamento particular do clnico, que no deve estar nem muito prximo (sentido como intrusivo) nem muito distante (sentido como abandnico) do seu paciente. / This work had the purpose of exploring two important concepts in the theory of the French psychoanalyst Andr Green: the dead mother complex and the blank psychosis. The decathexis caused by a maternal emotional withdrawal (dead mother complex) induces an internal void (blank anguish). This feeling of emptiness, stoppage, a depression without affects and the negative hallucination are manifestations of blank psychosis (a matrix structure where one can observe the psychotic kernel, even though without having a manifest psychosis). The applied method was the case study, with a young male institutionalized subject, and to support it we used the Thematic Apperception Test (applied in the early phases of treatment) and the Rorschach projective technique (applied at the beginning and ending of the treatment). Through the data collected in the therapeutic sessions and the projective techniques applied, we observed points of contact between blank psychosis, Winnicott`s False Self and Helene Deutsch as if personalities. The mothers metaphorical death, her emotional withdrawal, could be in the genesis of these disturbances, where we can observe the psychotic kernel. When we are dealing with this kind of patient, where the internal void prevails, the psychotherapeutic technique requires a special positioning from the therapist in relation to the patient, that shouldnt be too close (experienced as intrusive), nor too distant (experienced with feelings of abandonment).
Resumo:
Les dficits cognitifs sont centraux la psychose et sont observables plusieurs annes avant le premier pisode psychotique. Latteinte de la mmoire pisodique est frquemment identifie comme une des plus svres, tant chez les patients quavant lapparition de la pathologie chez des populations risque. Chez les patients psychotiques, ltude neuropsychologique des processus mnsiques a permis de mieux comprendre lorigine de cette atteinte. Une altration des processus de mmoire de source qui permettent dassocier un souvenir son origine a ainsi t identifie et a t associe aux symptmes positifs de psychose, principalement aux hallucinations. La mmoire de source de mme que la prsence de symptmes sous-cliniques nont pourtant jamais t investigues avant lapparition de la maladie chez une population haut risque gntique de psychose (HRG). Or, leur tude permettrait de voir si les dficits en mmoire de source de mme que le vcu dexpriences hallucinatoires sont associs lapparition de la psychose ou sils en prcdent lmergence, constituant alors des indicateurs prcoces de pathologie. Afin dtudier cette question, trois principaux objectifs ont t poursuivis par la prsente thse : 1) caractriser le fonctionnement de la mmoire de source chez une population HRG afin dobserver si une atteinte de ce processus prcde lapparition de la maladie, 2) valuer si des manifestations sous-cliniques de symptmes psychotiques, soit les expriences hallucinatoires, sont identifiables chez une population risque et 3) investiguer si un lien est prsent entre le fonctionnement en mmoire de source et la symptomatologie sous-clinique chez une population risque, linstar de ce qui est document chez les patients. Les rsultats de la thse ont permis de dmontrer que les HRG prsentent une atteinte de la mmoire de source cible lattribution du contexte temporel des souvenirs, ainsi que des distorsions mnsiques qui se manifestent par une fragmentation des souvenirs et par une dfaillance de la mtacognition en mmoire. Il a galement t observ que les expriences hallucinatoires sous-cliniques taient plus frquentes chez les HRG. Des associations ont t documentes entre certaines distorsions en mmoire et la propension halluciner. Ces rsultats permettent didentifier de nouveaux indicateurs cliniques et cognitifs du risque de dvelopper une psychose et permettent de soulever des hypothses liant lattribution de la source interne-externe de linformation et le dveloppement de la maladie. Les implications empiriques, thoriques, mthodologiques et cliniques de la thse sont discutes.
Resumo:
Several lines of evidence converge to the idea that rapid eye movement sleep (REMS) is a good model to foster our understanding of psychosis. Both REMS and psychosis course with internally generated perceptions and lack of rational judgment, which is attributed to a hyperlimbic activity along with hypofrontality. Interestingly, some individuals can become aware of dreaming during REMS, a particular experience known as lucid dreaming (LD), whose neurobiological basis is still controversial. Since the frontal lobe plays a role in self-consciousness, working memory and attention, here we hypothesize that LD is associated with increased frontal activity during REMS. A possible way to test this hypothesis is to check whether transcranial magnetic or electric stimulation of the frontal region during REMS triggers LD. We further suggest that psychosis and LD are opposite phenomena: LD as a physiological awakening while dreaming due to frontal activity, and psychosis as a pathological intrusion of dream features during wake state due to hypofrontality. We further suggest that LD research may have three main clinical implications. First, LD could be important to the study of consciousness, including its pathologies and other altered states. Second, LD could be used as a therapy for recurrent nightmares, a common symptom of depression and post-traumatic stress disorder. Finally, LD may allow for motor imagery during dreaming with possible improvement of physical rehabilitation. In all, we believe that LD research may clarify multiple aspects of brain functioning in its physiological, altered and pathological states.
Resumo:
Os sintomas psicolgicos nos indivduos consumidores de lcool o tema investigado neste trabalho, que se dedicou a analisar as diferenas entre grupos de indivduos alcolicos e no alcolicos homens e mulheres. A oportunidade desta investigao se originou no trabalho de psicologia clnica com pacientes alcolicos e, principalmente, frente s carncias bibliogrficas no mercado sobre o assunto. O presente trabalho, buscou, portanto, investigar-se, a partir das hipteses, a intensidade de problemas psicolgicos e sintomas psicopatolgicos em sujeitos alcolicos de ambos os sexos. Para tal, foram realizadas entrevistas orientadas para a aplicao do instrumento. O instrumento utilizado na pesquisa foi o SCL 90-R (Symptom Check List 90 - Revised) (DEROGATIS, 1983) que se prope a medir a intensidade dos sintomas, especificamente em casos de alcoolismo, sendo este instrumento validado no Brasil (LALONI, 2001). Os sintomas psicolgicos avaliados foram: Psicose, Relaes Interpessoais, Ansiedade, Ideao Paranide, Hostilidade, Depresso, Fobia e Obsessivo Compulsivo. A populao investigada abrangeu pessoas no consumidoras de lcool da comunidade e pessoas alcolicas pertencentes aos AA (Alcolicos Annimos). Os dois grupos pertencem Regio Metropolitana de Porto Alegre no Estado do Rio Grande do Sul, Brasil. A comparao foi abrangente em relao aos aspectos de gnero, pois alm de comparar o grupo de alcolicos e no alcolicos verificou as relaes de gnero, analisando as diferenas entre o grupo de homens e mulheres alcolicos e no alcolicos. Os resultados encontrados demonstram que os alcolicos so mais sintomticos que os no alcolicos e as mulheres apresentam-se em relao aos sintomas avaliados com mdias mais altas que os homens. Os alcolicos homens e mulheres no diferem de forma estatisticamente significativa em seus sintomas psicolgicos. Da mesma forma homens e mulheres no alcolicos no diferem em seus sintomas psicolgicos. / The subject of this research concerns about psychological symptoms on alcohol consuming individuals, analyzing the differences between groups of alcoholic and non alcoholic individuals, men and women. This investigation arose from the psychological clinic work with alcoholic patients in face of the lack of literature about this subject. Based on the hypothesis we investigated the intensity of psychological problems and psychopathological symptoms in alcoholic individuals of both sexes. We also evaluated the presence and intensity of psychological problems and psychopathological symptoms in non alcoholic individuals of both sexes. For this research we performed interviews oriented to the application of the instrument. The instrument employed in the research was SCL 90-R (Symptom Check List 90 - Revised) (DEROGATIS, 1983) which measures the intensity of the symptoms. The instrument was validated in Brazil (LALONI, 2001) and is specific to evaluate symptoms in case of alcoholism. The psychological symptoms we evaluated were: Psychosis, Interpersonal Relations, Anxiety, Paranoid Ideation, Hostility, Depression, Phobia, and Obsessive Compulsive. The population investigated is formed by non alcohol consuming people and alcoholics belonging to the Anonymous Alcoholics (AA). Both groups are from the Metropolitan Region of Porto Alegre in the southern sate of Rio Grande do Sul, Brazil. The comparison was comprehensive regarding the aspects of gender, since besides comparing the group of alcoholics and non alcoholics, it compared alcoholic men and women among themselves, and non alcoholic men and women as well. The results that were found demonstrate that alcoholics are more symptomatic than non alcoholics and women, regarding the evaluated symptoms, present themselves with higher averages than men. Alcoholic men and women do not expressively differ in their psychological symptoms, as non alcoholic men and women do not expressively differ in their psychological symptoms as well.
Resumo:
A simulao consiste na produo voluntria de sintomas fsicos e psicolgicos para obter compensaes externas. O presente estudo tem como objetivo avaliar a eficcia de um conjunto de instrumentos utilizados na identificao de situaes de simulao, bem como averiguar se esses instrumentos so sensveis a sintomas psicopatolgicos. Deste modo, espera-se que os resultados obtidos pelos grupos com depresso e sem depresso honestos difiram significativamente dos resultados obtidos pelo grupo sem depresso simulador. Para tal, foi recolhida uma amostra de 59 sujeitos, todos do sexo feminino, divididos por trs grupos: com diagnstico de depresso (n=19), sem diagnstico de depresso simuladores (n=20) e sem diagnstico de depresso honestos (n=20). O protocolo de avaliao incluiu o Test of Memory Malingering (TOMM: Tombaugh, 1996), o Structured Inventory Malingered Symptomatology (SIMS: Widows & Smith), os subtestes de Memria de Dgitos e dos Cubos da WAIS-III, (Wechsler, 1997) e a Figura Complexa de Rey (FCR: Rey, 1988). Os resultados no sugerem diferenas significativas no primeiro e segundo ensaios de aprendizagem do TOMM entre os grupos em estudo. No ensaio de reteno, o grupo sem diagnstico de depresso simulador difere significativamente do grupo sem diagnstico de depresso honesto. No SIMS, apenas a subescala Psicose (P) difere significativamente entre os grupos com diagnstico de depresso e sem diagnstico de depresso simulador. As subescalas Dfices Neurolgicos (NI), Perturbaes Afetivas (AF), P e Perturbaes Mnsicas (AM), com exceo da escala Capacidade Intelectual Reduzida (LI) diferem significativamente entre os grupos com diagnstico de depresso e sem diagnstico de depresso honesto e entre este e o grupo sem diagnstico de depresso simulador. No subteste de Memria de Dgitos verifica-se diferenas significativas entre os grupos sem diagnstico de depresso simulador e honesto. No subteste dos Cubos no foram encontradas diferenas significativas entre os grupos estudados e na cpia da FCR foram encontradas diferenas significativas entre os grupos com diagnstico de depresso e sem diagnstico de depresso simulador. Este estudo contribui para o enriquecimento da literatura nacional e internacional, uma vez que inclui um grupo clnico e alguns instrumentos que no so habitualmente utilizados numa avaliao de simulao. Para alm disso, estes resultados tm implicaes no contexto clnico e forense, no sentido preventivo e de conhecimento da doena mental.
Resumo:
Background and Aims: Women with bipolar disorder are vulnerable to episodes postpartum, but risk factors are poorly understood. We are exploring risk factors for postpartum mood episodes in women with bipolar disorder using a prospective longitudinal design. Methods: Pregnant women with lifetime DSM-IV bipolar disorder are being recruited into the Bipolar Disorder Research Network (www.BDRN.org). Baseline assessments during late pregnancy include lifetime psychopathology and potential risk factors for perinatal episodes such as medication use, sleep, obstetric factors, and psychosocial factors. Blood samples are taken for genetic analysis. Perinatal psychopathology is assessed via follow-up interview at 12-weeks postpartum. Interview data are supplemented by clinician questionnaires and case-note review. Potential risk factors will be compared between women who experience perinatal episodes and those who remain well. Results: 80 participants have been recruited to date. 32/61 (52%) women had a perinatal recurrence by follow-up. 16 (26%) had onset in pregnancy. 21 (34%) had postpartum onset, 19 (90%) within 6-weeks of delivery: 11 (18%) postpartum psychosis, 5 (8%) postpartum hypomania, 5 (8%) postpartum depression. Postpartum relapse was more frequent in women with bipolar-I than bipolar-II disorder (45% vs 17%). 62% women with postpartum relapse took prophylactic medication peripartum and almost all received care from secondary psychiatric services (95%). Conclusions: Rate of postpartum relapse is high, despite most women receiving specialist care and medication perinatally. A larger sample size will allow us to examine potential risk factors for postpartum episodes, which will assist in providing accurate and personalised advice to women with bipolar disorder who are considering pregnancy.
Resumo:
Background and Aims To determine the expression of autistic and positive schizotypal traits in a large sample of adults with bipolar disorder (BD), and the effect of co-occurring autistic and positive schizotypal traits on global functioning in BD. Methods Autistic and positive schizotypal traits were assessed in 797 individuals with BD recruited by the Bipolar Disorder Research Network (BDRN), using the Autism-Spectrum Quotient and Kings Schizotypy Questionnaire (KSQ), respectively. Differences in global functioning (rated using the Global Assessment Scale) during lifetime worst depressive and manic episodes (GASD and GASM respectively) were calculated in groups with high/low autistic and positive schizotypal traits. Regression analyses assessed the interactive effect of autistic and positive schizotypal traits on global functioning. Results 47.2% (CI = 43.750.7%) showed clinically significant levels of autistic traits. Mean of sample on the KSQ-Positive scale was 11.98 (95% CI: 11.3312.62). In the worst episode of mania, the high autistic, high positive schizotypal group had better global functioning than the low autistic, low positive schizotypal group (mean difference = 3.72, p = 0.004). High levels of co-occurring traits were associated with better global functioning in both mood states in individuals with a history of psychosis (GASM: p < 0.001; GASD: p = 0.055). Conclusions Expression of autistic and schizotypal traits in adults with BD is prevalent, and may be important to predict course of illness, prognosis, and in devising individualised therapies. Future work should focus on replicating these findings in independent samples, and on the biological and/or psychosocial mechanisms underlying better global functioning in those who have high levels of both autistic and positive schizotypal traits.
Resumo:
This short essay deals with literary representations of identity and of social reality, especially in relation to the novelistic works published by the Spanish writer Juan Jos Mills. The article is divided into three parts. The first section is dedicated to a general overview of the new perspectives brought by the contemporary linguistic turn in culture, which is currently considered as the product of different discourses and not as an ontological datum. The postmodern condition, on the other hand, is described as the age in which it has become radically difficult to rely on such ideas as nation and people for the construction of personal identity. The second part of the article identifies Mills poetics as an excellent example of describing the neurotic symptoms produced by the urban way of life in Western communities. Mills recognizes the separateness between language and material reality as the origin of the subject's isolation, especially in contemporary life. Finally, the third part handles with Lo que s de los hombrecillos, the last novel by Mills, in which we witness a significant switch from neurosis to psychosis in the mind of the protagonist who offers us a distorted realisation of his idea of community and plenitude.
Resumo:
Abstract and Summary of Thesis: Background: Individuals with Major Mental Illness (such as schizophrenia and bipolar disorder) experience increased rates of physical health comorbidity compared to the general population. They also experience inequalities in access to certain aspects of healthcare. This ultimately leads to premature mortality. Studies detailing patterns of physical health comorbidity are limited by their definitions of comorbidity, single disease approach to comorbidity and by the study of heterogeneous groups. To date the investigation of possible sources of healthcare inequalities experienced by individuals with Major Mental Illness (MMI) is relatively limited. Moreover studies detailing the extent of premature mortality experienced by individuals with MMI vary both in terms of the measure of premature mortality reported and age of the cohort investigated, limiting their generalisability to the wider population. Therefore local and national data can be used to describe patterns of physical health comorbidity, investigate possible reasons for health inequalities and describe mortality rates. These findings will extend existing work in this area. Aims and Objectives: To review the relevant literature regarding: patterns of physical health comorbidity, evidence for inequalities in physical healthcare and evidence for premature mortality for individuals with MMI. To examine the rates of physical health comorbidity in a large primary care database and to assess for evidence for inequalities in access to healthcare using both routine primary care prescribing data and incentivised national Quality and Outcome Framework (QOF) data. Finally to examine the rates of premature mortality in a local context with a particular focus on cause of death across the lifespan and effect of International Classification of Disease Version 10 (ICD 10) diagnosis and socioeconomic status on rates and cause of death. Methods: A narrative review of the literature surrounding patterns of physical health comorbidity, the evidence for inequalities in physical healthcare and premature mortality in MMI was undertaken. Rates of physical health comorbidity and multimorbidity in schizophrenia and bipolar disorder were examined using a large primary care dataset (Scottish Programme for Improving Clinical Effectiveness in Primary Care (SPICE)). Possible inequalities in access to healthcare were investigated by comparing patterns of prescribing in individuals with MMI and comorbid physical health conditions with prescribing rates in individuals with physical health conditions without MMI using SPICE data. Potential inequalities in access to health promotion advice (in the form of smoking cessation) and prescribing of Nicotine Replacement Therapy (NRT) were also investigated using SPICE data. Possible inequalities in access to incentivised primary healthcare were investigated using National Quality and Outcome Framework (QOF) data. Finally a pre-existing case register (Glasgow Psychosis Clinical Information System (PsyCIS)) was linked to Scottish Mortality data (available from the Scottish Government Website) to investigate rates and primary cause of death in individuals with MMI. Rate and primary cause of death were compared to the local population and impact of age, socioeconomic status and ICD 10 diagnosis (schizophrenia vs. bipolar disorder) were investigated. Results: Analysis of the SPICE data found that sixteen out of the thirty two common physical comorbidities assessed, occurred significantly more frequently in individuals with schizophrenia. In individuals with bipolar disorder fourteen occurred more frequently. The most prevalent chronic physical health conditions in individuals with schizophrenia and bipolar disorder were: viral hepatitis (Odds Ratios (OR) 3.99 95% Confidence Interval (CI) 2.82-5.64 and OR 5.90 95% CI 3.16-11.03 respectively), constipation (OR 3.24 95% CI 3.01-3.49 and OR 2.84 95% CI 2.47-3.26 respectively) and Parkinsons disease (OR 3.07 95% CI 2.43-3.89 and OR 2.52 95% CI 1.60-3.97 respectively). Both groups had significantly increased rates of multimorbidity compared to controls: in the schizophrenia group OR for two comorbidities was 1.37 95% CI 1.29-1.45 and in the bipolar disorder group OR was 1.34 95% CI 1.20-1.49. In the studies investigating inequalities in access to healthcare there was evidence of: under-recording of cardiovascular-related conditions for example in individuals with schizophrenia: OR for Atrial Fibrillation (AF) was 0.62 95% CI 0.52 - 0.73, for hypertension 0.71 95% CI 0.67 - 0.76, for Coronary Heart Disease (CHD) 0.76 95% CI 0.69 - 0.83 and for peripheral vascular disease (PVD) 0.83 95% CI 0.72 - 0.97. Similarly in individuals with bipolar disorder OR for AF was 0.56 95% CI 0.41-0.78, for hypertension 0.69 95% CI 0.62 - 0.77 and for CHD 0.77 95% CI 0.66 - 0.91. There was also evidence of less intensive prescribing for individuals with schizophrenia and bipolar disorder who had comorbid hypertension and CHD compared to individuals with hypertension and CHD who did not have schizophrenia or bipolar disorder. Rate of prescribing of statins for individuals with schizophrenia and CHD occurred significantly less frequently than in individuals with CHD without MMI (OR 0.67 95% CI 0.56-0.80). Rates of prescribing of 2 or more anti-hypertensives were lower in individuals with CHD and schizophrenia and CHD and bipolar disorder compared to individuals with CHD without MMI (OR 0.66 95% CI 0.56-0.78 and OR 0.55 95% CI 0.46-0.67, respectively). Smoking was more common in individuals with MMI compared to individuals without MMI (OR 2.53 95% CI 2.44-2.63) and was particularly increased in men (OR 2.83 95% CI 2.68-2.98). Rates of ex-smoking and non-smoking were lower in individuals with MMI (OR 0.79 95% CI 0.75-0.83 and OR 0.50 95% CI 0.48-0.52 respectively). However recorded rates of smoking cessation advice in smokers with MMI were significantly lower than the recorded rates of smoking cessation advice in smokers with diabetes (88.7% vs. 98.0%, p<0.001), smokers with CHD (88.9% vs. 98.7%, p<0.001) and smokers with hypertension (88.3% vs. 98.5%, p<0.001) without MMI. The odds ratio of NRT prescription was also significantly lower in smokers with MMI without diabetes compared to smokers with diabetes without MMI (OR 0.75 95% CI 0.69-0.81). Similar findings were found for smokers with MMI without CHD compared to smokers with CHD without MMI (OR 0.34 95% CI 0.31-0.38) and smokers with MMI without hypertension compared to smokers with hypertension without MMI (OR 0.71 95% CI 0.66-0.76). At a national level, payment and population achievement rates for the recording of body mass index (BMI) in MMI was significantly lower than the payment and population achievement rates for BMI recording in diabetes throughout the whole of the UK combined: payment rate 92.7% (Inter Quartile Range (IQR) 89.3-95.8 vs. 95.5% IQR 93.3-97.2, p<0.001 and population achievement rate 84.0% IQR 76.3-90.0 vs. 92.5% IQR 89.7-94.9, p<0.001 and for each country individually: for example in Scotland payment rate was 94.0% IQR 91.4-97.2 vs. 96.3% IQR 94.3-97.8, p<0.001. Exception rate was significantly higher for the recording of BMI in MMI than the exception rate for BMI recording in diabetes for the UK combined: 7.4% IQR 3.3-15.9 vs. 2.3% IQR 0.9-4.7, p<0.001 and for each country individually. For example in Scotland exception rate in MMI was 11.8% IQR 5.4-19.3 compared to 3.5% IQR 1.9-6.1 in diabetes. Similar findings were found for Blood Pressure (BP) recording: across the whole of the UK payment and population achievement rates for BP recording in MMI were also significantly reduced compared to payment and population achievement rates for the recording of BP in chronic kidney disease (CKD): payment rate: 94.1% IQR 90.9-97.1 vs.97.8% IQR 96.3-98.9 and p<0.001 and population achievement rate 87.0% IQR 81.3-91.7 vs. 97.1% IQR 95.5-98.4, p<0.001. Exception rates again were significantly higher for the recording of BP in MMI compared to CKD (6.4% IQR 3.0-13.1 vs. 0.3% IQR 0.0-1.0, p<0.001). There was also evidence of differences in rates of recording of BMI and BP in MMI across the UK. BMI and BP recording in MMI were significantly lower in Scotland compared to England (BMI:-1.5% 99% CI -2.7 to -0.3%, p<0.001 and BP: -1.8% 99% CI -2.7 to -0.9%, p<0.001). While rates of BMI and BP recording in diabetes and CKD were similar in Scotland compared to England (BMI: -0.5 99% CI -1.0 to 0.05, p=0.004 and BP: 0.02 99% CI -0.2 to 0.3, p=0.797). Data from the PsyCIS cohort showed an increase in Standardised Mortality Ratios (SMR) across the lifespan for individuals with MMI compared to the local Glasgow and wider Scottish populations (Glasgow SMR 1.8 95% CI 1.6-2.0 and Scotland SMR 2.7 95% CI 2.4-3.1). Increasing socioeconomic deprivation was associated with an increased overall rate of death in MMI (350.3 deaths/10,000 population/5 years in the least deprived quintile compared to 794.6 deaths/10,000 population/5 years in the most deprived quintile). No significant difference in rate of death for individuals with schizophrenia compared with bipolar disorder was reported (6.3% vs. 4.9%, p=0.086), but primary cause of death varied: with higher rates of suicide in individuals with bipolar disorder (22.4% vs. 11.7%, p=0.04). Discussion: Local and national datasets can be used for epidemiological study to inform local practice and complement existing national and international studies. While the strengths of this thesis include the large data sets used and therefore their likely representativeness to the wider population, some limitations largely associated with using secondary data sources are acknowledged. While this thesis has confirmed evidence of increased physical health comorbidity and multimorbidity in individuals with MMI, it is likely that these findings represent a significant under reporting and likely under recognition of physical health comorbidity in this population. This is likely due to a combination of patient, health professional and healthcare system factors and requires further investigation. Moreover, evidence of inequality in access to healthcare in terms of: physical health promotion (namely smoking cessation advice), recording of physical health indices (BMI and BP), prescribing of medications for the treatment of physical illness and prescribing of NRT has been found at a national level. While significant premature mortality in individuals with MMI within a Scottish setting has been confirmed, more work is required to further detail and investigate the impact of socioeconomic deprivation on cause and rate of death in this population. It is clear that further education and training is required for all healthcare staff to improve the recognition, diagnosis and treatment of physical health problems in this population with the aim of addressing the significant premature mortality that is seen. Conclusions: Future work lies in the challenge of designing strategies to reduce health inequalities and narrow the gap in premature mortality reported in individuals with MMI. Models of care that allow a much more integrated approach to diagnosing, monitoring and treating both the physical and mental health of individuals with MMI, particularly in areas of social and economic deprivation may be helpful. Strategies to engage this hard to reach population also need to be developed. While greater integration of psychiatric services with primary care and with specialist medical services is clearly vital the evidence on how best to achieve this is limited. While the National Health Service (NHS) is currently undergoing major reform, attention needs to be paid to designing better ways to improve the current disconnect between primary and secondary care. This should then help to improve physical, psychological and social outcomes for individuals with MMI.
Resumo:
Several lines of evidence converge to the idea that rapid eye movement sleep (REMS) is a good model to foster our understanding of psychosis. Both REMS and psychosis course with internally generated perceptions and lack of rational judgment, which is attributed to a hyperlimbic activity along with hypofrontality. Interestingly, some individuals can become aware of dreaming during REMS, a particular experience known as lucid dreaming (LD), whose neurobiological basis is still controversial. Since the frontal lobe plays a role in self-consciousness, working memory and attention, here we hypothesize that LD is associated with increased frontal activity during REMS. A possible way to test this hypothesis is to check whether transcranial magnetic or electric stimulation of the frontal region during REMS triggers LD. We further suggest that psychosis and LD are opposite phenomena: LD as a physiological awakening while dreaming due to frontal activity, and psychosis as a pathological intrusion of dream features during wake state due to hypofrontality. We further suggest that LD research may have three main clinical implications. First, LD could be important to the study of consciousness, including its pathologies and other altered states. Second, LD could be used as a therapy for recurrent nightmares, a common symptom of depression and post-traumatic stress disorder. Finally, LD may allow for motor imagery during dreaming with possible improvement of physical rehabilitation. In all, we believe that LD research may clarify multiple aspects of brain functioning in its physiological, altered and pathological states.
Resumo:
Introduccin y objetivo: La enfermedad de Parkinson (EP) es una enfermedad neurodegenerativa, la segunda con mayor prevalencia, despus de la enfermedad de Alzheimer (EA). La enfermedad presenta tanto sntomas motores como no motores, entre los que se encuentra disfuncin autonmica, dolor, deterioro cognitivo, ansiedad, depresin, entre otros. El dolor en la EP, a pesar de su frecuencia, sigue siendo un sntoma infravalorado, infradiagnosticado e infratratado. Nuestro objetivo principal es evaluar la frecuencia y configuracin del dolor en la EP y sus implicaciones afectivas y autonmicas. Pacientes, material y mtodos: Estudio multicntrico, transversal, de carcter retrospectivo y prospectivo. Se incluyeron 407 pacientes con enfermedad de Parkinson (EP) de los que un 70% estaban en una situacin leve-moderada (estadios 2 o 3 de Hoehn y Yahr), con edad media de 65,01 aos y 7,07 aos de duracin de la EP. Se administraron las escalas SCOPA-Motor, SCOPA-Autonmica, SCOPA-Cog, Parkinsons Psychosis Rating Scale modificada, Hoehn & Yarh, las Escala Hospitalaria de Ansiedad y Depresin, Dolor (EVA frecuencia), EQ-5D y estudios neurofisiolgicos especficos de Sistema Nervioso Autnomo (SNA). El anlisis estadstico se ha realizado con el programa de clculo estadstico SPSS versin 22. Resultados: En nuestro estudio encontramos una prevalencia del dolor elevada (72%) y los pacientes afirman mayoritariamente (79,2%) que su dolor tiene relacin con la EP. La duracin de la enfermedad se correlaciona con la intensidad y frecuencia del dolor (dolor intensidad: r: 0,138; p< 0,01; dolor frecuencia: r: 0,168; p< 0,01 ). A mayor evolucin de la EP mayor es la percepcin del dolor. El 60% de los pacientes de EP manifiestan sentir dolor cuando aparecen episodios de rigidez y tirantez en alguno de los miembros superiores o inferiores frente a un 40% que no. Curiosamente un nmero mayor (el 76% de los pacientes) siente dolor durante los episodios de discinesias frente a un 24% que no lo percibe. Sin embargo, en la EP el dolor se relaciona ms con la situacin afectiva que con la motora, como hemos podido demostrar la relacin entre el Dolor Total y la HADS (Depresin) Total y la Escala Hoehn & Yahr. El coeficiente de contingencia es mayor en la depresin (C: 0,894; N=403) que en la situacin motora (C: 0,637; N=401). El dolor evoluciona y se percibe de forma paralela a otros sntomas no motores (nimo, nicturia, alteracin del control vesical, estreimiento, etc.) pero con lo que se relaciona ms es con la situacin afectiva del paciente parkinsoniano (ansiedad (r: 0,40; p < 0,01), depresin (r: 0.28; p < 0,01). La mayor asociacin se encuentra entre la ansiedad y el dolor, seguida de la depresin y en menor grado nicturia y sialorrea. Existe una correlacin positiva entre las dos subescalas de la HADS (depresin y ansiedad). Existe una alta prevalencia de alteracin de la memoria inmediata como sntoma no motor (SNM) en nuestra serie (96,5%). En base a nuestros resultados el sexo femenino se asocia al dolor en la EP. Con respecto a la fenomenologa el dolor en la EP es muy variable. Se percibe con mayor frecuencia como una corriente elctrica (64%), calor (60%), frialdad (60%), punzante (52%), difuso (52%), interno (40%), acorchamiento u hormigueo (40%), La frecuencia de la cantidad de tipos de dolor es la siguiente: un tipo de dolor (12%), dos tipos de dolores (16%) y tres tipos de dolores (72%). La media de tipos de dolor en nuestro estudio es superior a 2 tipos (x : 2,60 0,63; rango: 1-3). En los casos que toman levodopa les sigue unas tres cuartas partes que lo perciben como palpitante, tirante, punzante. En los casos que toman agonista dopaminrgico lo perciben en un 75% como adormecimiento, interno, descarga elctrica, frialdad y calor. El dolor en la EP respecto a su configuracin es multimodal. Los parmetros neurofisiolgicos estn relacionados con los umbrales de dolor. La actividad simptica y la sensibilidad nociceptiva estn disminuidas en la EP. Los enfermos con EP tienen un umbral menor para el fro segn los datos del estudio del Cold-Ice. En lo referente a la teraputica el tratamiento dopaminrgico es eficaz para el control del dolor en el 48% de los pacientes mientras que el tratamiento analgsico estndar prescrito mejora el dolor en un 78,8%. Por ltimo, casi la mitad de la poblacin de nuestro estudio (47,52%) evaluada con la EQ-5D tiene problemas en alguna de las dimensiones de la calidad de vida. Hay una relacin positiva entre la escala analgica visual del dolor (EVA) y la EQ-5D que evala la CVRS y entre la intensidad de dolor y la CVRS (r:-0,298; p < 0,01). Es decir, una mayor vivencia de dolor empeora la CVRS del paciente con EP. Conclusiones: En la enfermedad de Parkinson el dolor es un sntoma no motor de elevada prevalencia, ntimamente relacionado con la afectacin de los sistemas afectivos y autonmicos medido con test neuro-vegetativos especficos. El presente estudio confirma su relacin con el lado ms afecto de la enfermedad, las fluctuaciones motoras, el tiempo de evolucin, con la situacin anmica (depresin y ansiedad) y con el sexo femenino, as como su carcter multimodal y gran variedad de expresin sintomtica. Es muy llamativa su asociacin con el dficit mnsico. Por ltimo esta vivencia repercute en forma llamativa en la calidad de vida relacionada con la salud por lo que sera importante conocer y manejar mejor estos aspectos de la enfermedad de Parkinson.
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Dissertao de Mestrado apresentada no Instituto Superior de Psicologia Aplicada para obteno do grau de Mestre na especialidade de Psicologia Clnica
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Lisolement avec ou sans contention (IC) en milieu psychiatrique touche prs dun patient sur quatre au Qubec (Dumais, Larue, Drapeau, Mnard, & Gigure-Allard, 2011). Il est pourtant largement document que cette pratique porte prjudice aux patients, aux infirmires et lorganisation (Stewart, Van der Merwe, Bowers, Simpson, & Jones, 2010). Cette mesure posant un problme thique fait lobjet de politiques visant la restreindre, voire lliminer. Les tudes sur lexprience de lisolement du patient de mme que sur la perception des infirmires identifient le besoin d'un retour sur cet vnement. Plusieurs quipes de chercheurs proposent un retour post-isolement (REPI) intgrant la fois lquipe traitante, plus particulirement les infirmires, et le patient comme intervention afin de diminuer lincidence de lIC. Le REPI vise lchange motionnel, lanalyse des tapes ayant men la prise de dcision dIC et la projection des interventions futures. Le but de cette tude tait de dvelopper, implanter et valuer le REPI auprs des intervenants et des patients dune unit de soins psychiatriques aigus afin damliorer leur exprience de soins. Les questions de recherche taient : 1) Quel est le contexte dimplantation du REPI? 2) Quels sont les lments facilitants et les obstacles limplantation du REPI selon les patients et les intervenants? 3) Quelle est la perception des patients et des intervenants des modalits et retombes du REPI?; et 4) Limplantation du REPI est-elle associe une diminution de la prvalence et de la dure des pisodes dIC? Cette tude de cas instrumentale (Stake, 1995, 2008) tait ancre dans une approche participative. Le cas tait celui de lunit de soins psychiatriques aigus pour premier pisode psychotique o a t implant le REPI. En premier lieu, le dveloppement du REPI a dabord fait lobjet dune documentation du contexte par une immersion dans le milieu (n=56 heures) et des entretiens individuels avec un chantillonnage de convenance (n=3 patients, n=14 intervenants). Un comit dexperts (ltudiante-chercheuse, six infirmires du milieu et un patient partenaire) a par la suite dvelopp le REPI qui comporte deux volets : avec le patient et en quipe. Lvaluation des retombes a t effectue par des entretiens individuels (n= 3 patients, n= 12 intervenants) et lexamen de la prvalence et de la dure des IC six mois avant et aprs limplantation du REPI. Les donnes qualitatives ont t examines selon une analyse thmatique (Miles, Huberman, & Saldana, 2014), tandis que les donnes quantitatives ont fait lobjet de tests descriptifs et non-paramtriques. Les rsultats proposent que le contexte dimplantation est dfini par des normes implicites et explicites o lutilisation de lIC peut gnrer un cercle vicieux de comportements agressifs nourris par un profond sentiment dinjustice de la part des patients. Ceux-ci ont limpression quils doivent se conformer aux attentes du personnel et aux rgles de lunit. Les participants ont exprim le besoin de crer des opportunits pour une communication authentique qui pourrait avoir lieu lors du REPI, bien que sa pratique soit variable dun intervenant un autre. Les rsultats suggrent que le principal lment ayant facilit limplantation du REPI est lapproche participative de ltude, alors que les obstacles rencontrs relvent surtout de la complexit de la mise en uvre du REPI en quipe. Lors du REPI avec le patient, les infirmires ont pu explorer ses sentiments et son point de vue, ce qui a favoris la reconstruction de la relation thrapeutique. Quant au REPI avec lquipe de soins, il a t peru comme une opportunit dapprentissage, ce qui a permis dajuster le plan dintervention des patients. Suite limplantation du REPI, les rsultats ont dailleurs montr une rduction significative de lutilisation de lisolement et du temps pass en isolement. Les rsultats de cette thse soulignent la possibilit doutrepasser le malaise initial peru tant par le patient que par linfirmire en systmatisant le REPI. De plus, cette tude met laccent sur le besoin dune prsence authentique pour atteindre un partage significatif dans la relation thrapeutique, ce qui est la pierre dassise de la pratique infirmire en sant mentale. Cette tude contribue aux connaissances sur la prvention des comportements agressifs en milieu psychiatrique en documentant le contexte dans lequel se situe lIC, en proposant un REPI comportant deux volets de REPI et en explorant ses retombes. Nos rsultats soutiennent le potentiel du dveloppement dune prvention tertiaire qui intgre la fois la perspective des patients et des intervenants.
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Dissertao de Mestrado apresentada no Instituto Superior de Psicologia Aplicada para obteno de grau de Mestre na especialidade de Psicologia Clnica
