Scielo RSS <![CDATA[Salud mental]]> http://www.scielo.org.mx/rss.php?pid=0185-332520080002&lang=pt vol. 31 num. 2 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.mx/img/en/fbpelogp.gif http://www.scielo.org.mx <![CDATA[<b>How important is psychoneuroimmunology?</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Attention deficit hyperactivity disorder and pediatric bipolar disorder, comorbidity or overlap?: A review. </b><b>Part two</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200002&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Terminal <i>versus</i> non-terminal care in physician burnout: the role of decision-making processes and attitudes to death</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200003&lng=pt&nrm=iso&tlng=pt Introduction Physicians are often overloaded with high demands of patient care in an environment where organizational resources are frequently scarce, leading to occupational stress and physician burnout. When physicians suffer from these disorders, the potential negative influence on patient care is likely to be much greater and they are more prone to make errors of judgment in decision-making processes. Some authors have proposed that physicians perceive decision-making as the main stressor, especially in chronic and terminal care. Caring for the dying is a remarkably stressful work. Many physicians feel helpless in the face of a patient's struggle with terminal illness. In this context, some questions arise: What is the interplay role of attitudes to death in decision-making processes in physicians' suffering from burnout? Are there any differences according to attitudes to death, target patients (i.e., terminal patients), or the classic sociodemographic variables? To what extent? This study has attempted to examine these differences in the burnout process in physicians attending adult patients versus children, and terminal versus non-terminal cases, considering also the decision-making process and physicians' attitudes to death; to determine the core personal variables implied in this process, and to identify educational opportunities to improve physicians' well-being. Method A total of 130 physicians working in six general hospitals and two health centers in downtown Madrid completed and returned the questionnaire (response rate 72.2%). The sample resembles the overall area population in age distribution as well as in health status and sociodemographic characteristics. Participation was voluntary and anonymous; no incentives were offered to participants. Results Results suggested that the effects of burnout have more to do with chronic and terminal care than with the classic sociodemographic variables. Among the univariate tests for the first criterion variable doctors attending child versus adult patients, only avoidance of death was significantly higher in pediatricians. Univariate tests for scores of physicians working with terminal versus non-terminal patients (the second criterion variable) revealed significant effects for two of the ten variables. Physicians who attended terminal patients had higher exhaustion scores and lower scores in acceptance of death. Taking together both criterion variables, pediatricians' self-reports revealed significantly lower acceptance of death scores in the terminal care condition, whereas physicians working with adult patients had a significantly higher fear of choice scores in the terminal care condition. Additionally, through hierarchical regression analyses, anxiety about the decision-making process was the main precursor of burnout, controlling for age, gender and terminal versus non-terminal care of child versus adult patients. Attitudes to death, that is, acceptance or avoidance of death, were revealed as moderators of the relationship between decision-making processes and burnout. Conclusions Findings are discussed concerning the burnout process and the need for educational interventions in death and communication. The results were in keeping with the contention that, during explorations of career choice and even in the admission process, understanding of what the helping role implies should be increased, and the personal variables that are necessary to increase physicians' performance and well-being should be explicitly identified.<hr/>Introducción Como grupo profesional los médicos enfrentan frecuentemente una sobrecarga laboral con elevadas demandas en el cuidado de los pacientes y en un entorno en que muchas veces faltan recursos organizacionales. En ocasiones, lo anterior conduce al estrés ocupacional y al desgaste profesional (burnout). Actualmente, desde una perspectiva psicosocial y procesual, el síndrome del desgaste profesional se ha conceptualizado como una respuesta al estrés laboral crónico que se desarrolla por la interacción de características del entorno laboral y características personales. Como consecuencia, la presencia del desgaste profesional facilita el error médico, lo que, a su vez, contribuye a todo tipo de consecuencias negativas en el cuidado del paciente y, principalmente, en los procesos de toma de decisiones. Algunos autores han planteado la toma de decisiones como el principal estresor percibido en los médicos, principalmente en el cuidado crónico y terminal. El cuidado paliativo en el paciente terminal se convierte entonces en un trabajo potencialmente estresante. Muchos médicos se sienten impotentes ante la agonía de un paciente en fase terminal. En este contexto surgen algunas interrogantes: ¿Cuál es el papel de las actitudes ante la muerte en el complejo proceso de toma de decisiones en los médicos desgastados profesionalmente? ¿Existen diferencias procesuales en función de las actitudes hacia la muerte, el tipo de pacientes (v.gr., pacientes terminales) o las clásicas variables sociodemográficas relacionadas con el síndrome? ¿En qué medida? Este estudio intentará examinar estas posibles divergencias en el proceso de desgaste profesional en médicos que trabajan con adultos versus niños, en fase terminal versus no terminal, considerando asimismo los procesos de toma de decisiones y las actitudes hacia la muerte. De este modo se podrán determinar las variables personales implicadas en el proceso, que permitan desarrollar posteriormente programas de prevención y formación para aumentar el nivel de bienestar de estos profesionales. Método Un total de 130 profesionales médicos, que trabajaban en seis hospitales generales y en dos centros de salud de Madrid capital, rellenaron y devolvieron el cuestionario (tasa de respuesta de 72.2%). La muestra obtenida fue semejante en edad, estado de salud y otras características sociodemográficas a la población de referencia. La participación fue totalmente voluntaria y anónima sin ningún tipo de incentivos por la colaboración. Resultados Los resultados obtenidos sugieren que los efectos del desgaste profesional se encuentran más relacionados con el cuidado crónico y terminal que con las clásicas variables sociodemográficas. Mediante análisis univariados se observó que los médicos pediatras frente a los que trabajaban con adultos mostraron niveles significativamente mayores de actitudes de evitación ante la muerte. En cuanto a los médicos que trabajaban con pacientes terminales versus no terminales, los análisis univariados mostraron efectos significativos en dos variables. Aquellos médicos que atendían a pacientes en fase terminal mostraron niveles significativamente mayores de desgaste emocional y menores niveles de aceptación de la muerte. Finalmente, al cruzar ambas variables (médicos que atendían a pacientes niños vs. adultos, terminales vs. no terminales), los pediatras obtuvieron niveles significativamente menores de aceptación de la muerte en los niños en fase terminal, mientras que los especialistas que trabajaban con adultos en fase terminal puntuaron significativamente más alto en la dimensión de miedo a la elección del cuestionario de toma de decisiones. Por otra parte, mediante análisis de regresión jerárquica, la ansiedad ante la toma de decisiones resultó ser el principal precursor del desgaste profesional, una vez controlados los efectos debidos a la edad, el género y el grupo médico (atención a niños vs. adultos, terminales vs. no terminales), mientras que las actitudes ante la muerte (v.gr., aceptación o evitación de la muerte) mostraron un efecto moderador en la relación entre los procesos de toma de decisiones y el desgaste profesional. Conclusiones Los principales resultados encontrados con respecto al estudio del proceso de desgaste profesional reflejan la necesidad de realizar programas de prevención y formación en el afrontamiento de la muerte. Los resultados son congruentes con las reflexiones realizadas principalmente en contextos de formación y procesos de admisión donde se enfatiza la necesidad de aumentar la comprensión del rol de ayuda y su repercusión, e identificar explícitamente aquellas variables personales que permitan aumentar los niveles de rendimiento y bienestar de los profesionales médicos. <![CDATA[<b>A closer look at the history and genetics of Tourette syndrome</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200004&lng=pt&nrm=iso&tlng=pt Tourette syndrome (TS) was named after Georges Albert Edouard Brutus Gilles de la Tourette, who made its first formal description at the end of the 19th century. Nevertheless, some evidence indicates the disorder may have been recognised at least two thousand years ago. Tic like behaviours were recorded by Aretaeus of Cappadocia and several centuries later by Sprenger and Kraemer, followed by other descriptions. The English writer Samuel Johnson, author of the first English Language Dictionary, showed repetitive body twitches, facial grimaces, barks and grunts, among other tics. He was observed in situations such as going in or out at a door using a certain number of steps, from a certain point, which indicated he had also obsessive-compulsive behaviour. There was some evidence of features of TS as well as co-morbid conditions such as hyperactivity, obsessive-compulsive behaviour or rage attacks in other famous artists and world leaders. Some authors have even proposed that the creative, determined, competitive, and persistent nature of certain people may be related to the presence of TS. Clinicians have observed that some patients are particularly sensitive to the feelings and experiences of others, and more prone to outside stimuli. In this way, empathy could be a common quality in these patients. In 1825, Jean Marc Gaspard Itard made the first known medical description of TS based on two cases, one of which was later followed by Jean-Martin Charcot. In 1885 Gilles de la Tourette put together information from previous fragmented reports and wrote a complete and formal description, thus establishing a novel clinical entity. Behavioural abnormalities such as obsessions, compulsions, inattentiveness and hyperactivity, commonly observed in TS patients, were considered mental tics at the time. Current diagnostic criteria are very similar to Gilles de la Tourette's description. TS is characterized by the presence of multiple motor and one or more vocal tics. In this disorder, tics are not caused by the direct physiologic effects of a substance or a general medical condition. Tic symptomatology is persistent for over a year, and in this period, tics are not absent for more than three consecutive months. There is no exact consensus between the DSM-IV and the Tourette Syndrome Classification Study Group of whether the age of onset should be prior to 18 or 21 years of age, how cases of onset after 21 years should be diagnosed, and if marked distress or significant impairment caused by tics is necessary to define the condition as definite TS. However, the text revision of the DSM-IV (TR) no longer specifies that TS symptoms have to cause distress or impair the functioning of the patients. With respect to the age of onset, the ICD-10 Classification of Mental and Behavioural Disorders describes the onset almost always in childhood or adolescence, and in this way it would no longer exclude cases with later onset. Numerous studies confirmed in the 20th century that genetics plays an important role in the etiology of TS. Family studies proved that the disease runs in families. First-degree relatives of TS patients are indeed in greater risk for TS than the general population. Twin and adoption studies demonstrated that genes have an important role in the etiology of TS, and as much as 90% of the vulnerability to this syndrome could be affected by genes. In addition, environmental, epigenetic and even stochastic factors may affect the susceptibility to TS. At the molecular level, linkage in families and association in unrelated TS subjects have been the main methods used to search for vulnerability genes. Sequencing of almost the entire human genome made it possible to assess the gene expression of thousands of genes on a single chip; recent studies reported a preliminary specific profile in the blood of TS patients. If confirmed, this finding could be useful in the identification of genetic factors related with TS. Given the multi-factorial nature of TS, a thorough clinical description in large samples should be considered; besides association, linkage and sequencing studies, possible gene-gene and gene-environment interactions would also need to be analysed, as well as epigenetic factors, and gene expression patterns.<hr/>El síndrome de Gilles de la Tourette (SGT) se nombró asi en honor de Georges Albert Edouard Brutus Gilles de la Tourette, alumno de Charcot, quien realizó la primera descripción formal de esta entidad clínica a finales del siglo XIX. Sin embargo, hay evidencias que indican que probablemente el trastorno se había identificado de alguna manera desde hace por lo menos dos mil años. Areteo de Capadocia registró conductas similares a los tics, también descritas por Sprenger y Kraemer en el siglo XV y más adelante por otros. El escritor inglés Samuel Johnson, autor del primer Diccionario de la Lengua Inglesa, mostraba contorsiones en todo el cuerpo, muecas, ladridos y gruñidos, entre otros tics. Se le observaba entrando o saliendo por una puerta con un número determinado de pasos a partir de un punto dado, lo cual indica que también presentaba conducta obsesivo- compulsiva. Además, otros artistas y líderes mundiales han presentado características del SGT y de padecimientos comórbidos como el trastorno por déficit de atención e hiperactividad, el trastorno obsesivo-compulsivo o ataques de ira. Un grupo de autores ha llegado a considerar que la naturaleza creativa, determinada, competitiva y persistente en ciertas personas podría relacionarse con el SGT. Algunos especialistas del área médica han observado que ciertos pacientes con SGT son particularmente sensibles a los sentimientos y experiencias de otras personas y más propensos a los estímulos externos. Por lo tanto, la empatía podría ser una cualidad común en estos pacientes. En 1825, Jean Marc Gaspard Itard realizó la primera descripción médica conocida del SGT, basándose en dos casos, uno de los cuales fue estudiado más adelante por Charcot. En 1885, Gilles de la Tourette reunió fragmentos de información de reportes previos y redactó una descripción formal y completa del trastorno, con lo que estableció una nueva entidad clínica. Las anormalidades del tipo de obsesiones, compulsiones, inatención e hiperactividad se consideraban tics mentales en esa época. Los criterios diagnósticos actuales del SGT son muy similares a los publicados por Gilles de la Tourette. El SGT se caracteriza sobre todo por la presencia de dos o más tics motores y uno o más tics fónicos. En este trastorno, los tics no son causados por el efecto fisiológico directo de una droga o por una affeción médica general. La sintomatología de los tics persiste por más de un año y en este periodo los tics no se ausentan por más de tres meses consecutivos. No hay un consenso preciso entre el DSM-IV y el Grupo de Estudio de la Clasificación del Síndrome de Gilles de la Tourette en relación con la edad de inicio: si debe ser antes de los 18 o los 21 años, cómo deben considerarse casos de inicio posterior a los 21 años y si para definir un caso definitivo de SGT se requiere que la persona presente malestar o incapacidad importante a causa de los tics. Sin embargo, en el texto revisado del DSM-IV (TR) ya no se especifica que los síntomas del SGT deban causar necesariamente malestar o incapacidad en el funcionamiento diario de los pacientes. En cuanto a la edad de inicio, si la Clasificación de los Trastornos Mentales y de la Conducta (CIE-10) describe que la edad de inicio casi siempre es en la niñez o adolescencia, de esta manera ya no excluye la posibilidad de edades de inicio más avanzadas. Gracias a diversos estudios, durante el siglo XX se pudo confirmar que la genética es decisiva en la etiología del SGT. Por medio de estudios en familias se confirmó que el trastorno se concentra particularmente en ciertas familias. Los parientes en primer grado de un paciente con SGT se encuentran en mayor riesgo de presentar el trastorno que la población en general. Estudios realizados en pares de gemelos y personas adoptadas confirmaron que los genes tienen un peso importante en el aumento de la susceptibilidad al SGT. Se ha estimado que hasta 90% de la vulnerabilidad al trastorno podría estar afectada por los genes. Aunados a estos factores hereditarios que dependen directamente de la secuencia del ADN de nuestras células nucleadas, se encuentran otros factores que afectan en cierto grado la susceptibilidad al SGT, como los de tipo ambiental, epigenético o aleatorio. A nivel molecular, los principales diseños para el estudio del SGT y la búsqueda de genes de susceptibilidad han sido el enlace genético (linkage) en familias y los estudios de asociación en pacientes no emparentados. La secuenciación de prácticamente todo el genoma humano ha permitido, entre otras cosas, identificar la expresión de miles de genes en un solo chip. De acuerdo con estudios preliminares recientes, podría haber un patrón específico de expresión en sangre de pacientes con SGT. Si esto se llegara a confirmar, los hallazgos podrían emplearse para facilitar la identificación de factores genéticos de riesgo para el SGT. Tomando en cuenta la naturaleza multifactorial del SGT, se requiere además de estudios de enlace genético, asociación y secuenciación, análisis sobre interacciones de tipo gen-gen y gen-ambiente, así como la identificación de factores epigenéticos y de niveles de expresión genética en el SGT. <![CDATA[<b>Environmental protection and biosecurity program at the National Institute of Psichiatry Ramón de la Fuente</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200005&lng=pt&nrm=iso&tlng=pt Since the beginning, mankind has been subjected to various natural disasters such as floods, hurricanes, earthquakes, droughts and wildfires. Therefore, societies have to organize themselves in order to cope with nature, provide support to each other and to protect the most vulnerable individuals and their properties. Depending on their social organization, some countries have developed their response strategies in the field of civil protection faster than others. After September 19th, 1985, when an earthquake of Richter magnitude of 8.1 affected Mexico City, the Mexican government decided to establish the guidelines of the National Civil Protection System (SINAPROC). After a few years, the Environmental Protection and Ecological Equilibrium Law was published. This environmental protection regulation is specific and is directed to minimize the negative impact over the environment that could be generated through industrial activities, as well as from research centers, hospitals, and others institutions. To ensure full compliance with the Mexican regulations, in 1998 the Instituto Nacional de Psiquiatría Ramón de la Fuente (INPRF) initiated the Environmental and Civil Protection Program (ECPP). The aim of this program is to meet the legal and operational requirements applicable to an institution which has biomedical research, administration and hospitalization areas. In addition, the ECPP is in charge of giving workers training and generating specific strategies for environmental management in all activities that take place at the Institute. By establishing compliance guidelines to meet the government regulations on environmental and civil protection, the INPRF would develop strategies for minimizing risks, as well as staff training to enhance the use of institutional resources and reduce the response time to deal with emergencies. Objective Since its foundation, the environmental and civil protection program at the INPRF has had two basic objectives: 1. to attend the legal and operative requirements in a third level institution conformed by hospitalization, teaching, research and administrative areas, and 2. to offer continuous training to the internal population of a hospital in order to minimize work risks, to make an optimum use of the institutional resources and to reduce the response time of the workers in emergency situations. To develop and implement such an environmental and civil protection program, the following areas have been considered: Biohazardous wastes, saving electricity, use and optimization of drinking water, control of air emissions from stationary combustion equipment, radiation safety and emergency response procedures. The purpose of this work is to show the results achieved by ECPP after nine years since its inception. Results Biohazardous wastes (BW), by definition, are those materials generated during medical care which contain biological agents that may cause adverse effects to human health and the environment. BW are generated frequently in biomedical research areas, clinical laboratories and hospitals. In order to minimize risks and prevent accidents, INPRF implemented since 1997 an operating procedure for handling biohazardous wastes in all generating areas. Some of those strategies are directed to training medical personnel (physicians, nurses and clinical laboratory technicians) about the identification and classification of biohazardous wastes. Moreover, we have designed and distributed different kinds of written ads in order to help people to recognize and separate wastes correctly. Besides the latter actions, the INPRF hired a registered and certificated company which provides the proper recollection, treatment and final disposal of biological wastes, according to current legal ordinances. As a result of those strategies in the handling of biohazardous wastes in the Institution, the amount of wastes and their disposal costs have gradually decreased. Through staff training, personnel have learned to do a proper segregation of wastes, reducing the quantities of BW and therefore reducing risks. Energy saving. As a way to optimize the institutional resources, as well as reducing costs and creating awareness among the people, the INPRF's Energy Saving program was implemented in 2003. Since 2003, when ECPP began implementing the saving strategies, accumulated energy consumption per year had a 9.6% reduction between 2004 and 2005. Use of potable water. In the search for strategies to optimize the use of potable water that is received through the municipal network, in 2003 the INPRF-ECPP implemented measures aimed not only at reducing the per capita consumption of potable water but also to give it a proper use on the institution areas. As a result of these saving measures, there was a gradual decrease in the use of drinking water. So, from the 170 liters/person-day used in 2003, during 2006 only 98 liters/person-day were used. Radiological safety. Due to the adverse effects to human health that could result from exposure to radioactive materials, an institution that uses this kind of material in its basic biomedical research area must implement the necessary actions to minimize the risk of contamination for users and work areas. For that reason, the INPRF began the Radiological Safety Program, which had as its main objectives to minimize the risks and to prevent accidents involving radioactive materials based on regulation compliance. As a result of these strategies, the maximum value of the total dose accumulated per year of ionizing radiation received by personnel exposed who has carried out research in this institution in recent years has been of 3.14 mSv. Therefore, it had not exceeded the annual limit dose of ionizing radiation allowed for the total body by the Comisión Nacional de Seguridad Nuclear y Salvaguardas (CNSNS) of 50 mSv = 5rem. To date, there has been no accidents or contamination with radioactive materials or wastes in the INPRF. Emergency simulations. Considering the need of being prepared for emergencies and to comply with the regulation that establishes the compulsory conducting simulations in INPRF, the Internal Committee for Civil Protection (ICPC) conducts periodic training of employees on risk prevention, through courses and simulations of situations of earthquake, attempt of fire, handling of hazardous substances spills and first aid. As a result of the earthquake simulations that have been carried out at the INPRF, the time of evacuation of workers, hospitalized patients and floating population from buildings has gradually reduced. An additional advantage of conducting emergency simulations has been the early detection of systematic security features that need to be repaired or installed. Emissions to air. In recent years, increasingly strict regulation and monitoring of gaseous emissions generated by stationary and mobile sources in Mexico City has been established. In order to comply with the current regulations, it became necessary to develop a program of annual preventive and corrective maintenance of combustion equipment that is used to provide hot water, and to make periodic analysis of gaseous emissions. Among the parameters that have to be reported are: temperature of combustion gases, monoxide and dioxide carbon content, sulfur dioxide, nitrogen dioxide percentages and generated soot.<hr/>A partir de 1998, en el Instituto Nacional de Psiquiatría Ramón de la Fuente (INPRF) se iniciaron las actividades del Programa de Protección Ambiental y Civil (PPAyC). Sus objetivos son dar cumplimiento a los requisitos legales, prevenir riesgos, generar estrategias de atención a emergencias, capacitar a la población interna y mejorar el uso y aprovechamiento de los recursos institucionales. El propósito del presente trabajo es presentar los resultados obtenidos después de nueve años de trabajo del PPAyC en las áreas de manejo de residuos biológico-infecciosos, ahorro de energía eléctrica, uso y optimización de agua potable, control de emisiones a la atmósfera de los equipos fijos de combustión, seguridad radiológica y simulacros de emergencia. Residuos peligrosos biológico-infecciosos (RPBI). Con el objeto de reducir riesgos y prevenir accidentes, en el INPRF se implementó un procedimiento operativo para el manejo de los residuos peligrosos biológico-infecciosos en todas las áreas generadoras. Los resultados de las estrategias aplicadas muestran que la cantidad de los residuos y sus costos de manejo han disminuido gradualmente y se han observado mejores prácticas de manejo de residuos por parte de los trabajadores involucrados, con la consecuente reducción de riesgos. Ahorro de energía. Ante la necesidad de optimizar el uso de la energía, disminuir costos y crear conciencia entre la población, se implementó en todo el país el programa de ahorro de energía. Los resultados obtenidos muestran que, a partir de la implementación de las estrategias de ahorro en el INPRF, se obtuvo una reducción en el consumo de energía de 9.6% anual acumulado entre 2004 y 2005. Uso y aprovechamiento de agua potable. A partir de 2003, en el INPRF se implementaron medidas destinadas a disminuir el consumo per capita de agua potable que se recibe por la red municipal y optimizar su uso en las instalaciones. Como resultado se observó una disminución gradual en el uso de agua potable, de tal manera que, de los 170 litros/persona que se utilizaban en 2003, en 2006 únicamente se utilizaron 98 litros/persona. Seguridad radiológica. El programa de seguridad radiológica en el INPRF se inició con el objeto de minimizar los riesgos y efectos adversos que pudieran generar los materiales radiactivos en la salud del personal expuesto ocupacionalmente (POE), prevenir accidentes y cumplir con la normatividad. Como resultado de estas acciones, ningún POE ha excedido el máximo valor de dosis total acumulada (DTA) de radiaciones ionizantes permitido por la Comisión Nacional de Seguridad Nuclear y Salvaguardas (CNSNS) para cuerpo total. Por otro lado, a la fecha no se han registrado accidentes o contaminación con materiales o residuos radiactivos. Simulacros. En el INPRF se implementó un programa de protección civil, cuya labor principal fue la de capacitar periódicamente a los trabajadores para responder ante situaciones de emergencia. Como resultado de los simulacros de sismo que se han realizado (40 parciales y siete generales), se han reducido gradualmente los tiempos de desalojo de los inmuebles y la detección oportuna y sistemática de elementos de seguridad que requieren ser reparados o instalados. Emisiones a la atmósfera. En cumplimiento con la normatividad vigente en la Ciudad de México, en el INPRF se elaboró el programa de mantenimiento anual preventivo y correctivo de las dos calderas que dotan de agua caliente a la institución. Como resultado, se detectó la necesidad de sustituir los equipos por otros que utilizaran tecnología más limpia. Esto favoreció el cumplimiento de los límites máximos permitidos para emisiones gaseosas contaminantes y los costos de mantenimiento se redujeron. Discusión La implementación de diversas estrategias en materia de protección ambiental y civil y la capacitación reducen los riesgos del personal y protegen los bienes inmuebles y el entorno de la ciudad que habitamos. <![CDATA[<b>Preliminary study of a brief intervention program for adolescents who initiate alcohol and other drugs consumption</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200006&lng=pt&nrm=iso&tlng=pt During the last two decades, alcohol, tobacco and illicit drug consumption among young people has come to be regarded as a serious public health problem, both in Mexico and internationally. This recognition has resulted from a trend toward higher levels of use, greater diversification of the types of drugs used and abused, and increased drug marketing. Epidemiological data show that most users initiate drug use when they are about 16 years old. However, the age of first drug experimentation appears to be decreasing, with recent reports indicating an average age 12 or 13 years at present. The societal costs of adolescent drug use cut across different domains including physical and mental health, car crashes, and morbidity and mortality related to substance misuse. The personal costs of teen drug use include school failure, drop-out, and truancy. Moreover, aggressive behavior and crime, risky sexual behaviour, and many other behavioural problems have been shown to be associated with adolescent drug use. Research from many different disciplines has increased knowledge about (a) important dimensions of adolescent substance use and (b) the processes and variables related to the origin and maintenance of addictive behavior among teenagers. Despite this growing body of knowledge, few current prevention and treatment programs are based on empirical investigation. Moreover, many current intervention programs have not been adequately evaluated in regard to effectiveness. A recent development in the addiction field is brief intervention (BI). BIs have been demonstrated to be effective in the treatment of addictive behavior among adult problem drinkers, with the most successful programs based on the Theory of the Social Learning. Only recently have BIs been tried with adolescent populations. While promising, little empirical research exists about the effectiveness of brief treatment with adolescents. The primary goals of BIs are to (a) reduce or eliminate substance consumption and (b) to mitigate the adverse effects of using alcohol or other drugs (i.e., harm reduction). While the goals of BIs are clear, the effectiveness of such programs with adolescents, despite their promise, is not well researched. For this reason, it is important to develop and empirically test BI programs for adolescents demonstrating problematic alcohol or other drug consumption. Schools represent a particularly good place to access adolescents who would benefit from BIs, and BIs represent an attractive alternative to the typical strategies used by school to address student substance use (i.e., suspension or expulsion). The main goal of this investigation was to develop and to evaluate a brief intervention program for teenagers with substance abuse (but who have not developed substance dependence) between 14 and 18 years old. The intervention program tries to: (a) promote a change in drug consumption through establishing consumption goals (in the case of the alcohol, moderation or abstinence; in the case of illegal drugs, abstinence); (b) identify high-risk situations in which use is probable; and (c) develop alternative strategies to these situations. The theorical bases of the intervention include Self-control Theory, Motivational Interviewing, Relapse Prevention and <<The First Contact>>. Our brief intervention program consisted of six steps: 1. case detection, which involved the identification of adolescents who abuse alcohol or another drugs, by means of teacher's reports, legal and psychology personnel, trained by the investigators; 2. screening, which involved determining whether adolescents met inclusion criteria; 3. assessment, which addressed the frequency and amount of consumption and self-confidence to suitably face situation of probable drug; 4. induction to the program, the objective of which was to sensitize the adolescents about the importance of attending treatment; 5. intervention; and, 6. one, three and six months follow-up assessments. The intervention program consisted of four individual sessions with the participants in which they chose their own substance reduction goals, identified their high risk situations, developed coping plans for each high risk situation, and appraised the impact of their substance use on their own life-goals success. The researchers used a single-case design with 25 participants, 17 of whom had alcohol problems and eight of whom had marijuana problems. The age average of participants was 16 years (SD = 1.8), and 19 were male and six were female. The average age of first consumption was 14 years old (SD = 1.72); the average duration of substance use was 18 months. From the complete sample, 45% reported consumption one or twice per week, 22% reported daily consumption, and the remainder consumed once a month. Results indicated that from the 25 participants, 24 demonstrated changes from the baseline in their consumption pattern (measured by frequency and quantity) during intervention and at follow-up assessments. Self-efficacy levels (self-perceptions about the capability to abstain or use moderately in high risk situations) changed as well. Specifically, among the adolescents who consumed alcohol a one-way ANOVA revealed significant changes in average consumption between the baseline, treatment, and follow-up phases F(2.48) = 17.691, p < .001. Bonferroni's post-hoc tests showed differences between baseline (<img border=0 src="../../../../../img/revistas/sm/v31n2/a6s1.jpg"> = 8.89, SD = 3.55) and treatment (<img border=0 src="../../../../../img/revistas/sm/v31n2/a6s1.jpg"> = 4.46, SD = 3.27), and between baseline and the follow-up (<img border=0 src="../../../../../img/revistas/sm/v31n2/a6s1.jpg"> = 3.29, SD = 1.35). Student's t tests for each subject showed that 16 adolescents significantly reduced their alcohol consumption from the baseline to the follow-up. Only one participant demonstrated increased use (from five standard drinks per drinking occasion at the baseline to 5.90 standard drinks at the follow-up). Regarding consumers of marijuana, a one-way ANOVA showed significant changes in consumption across the baseline, treatment and follow-up phases F(2.21) = 8.219, p = .002. Bonferroni's post-hoc tests showed significant differences between the baseline (<img border=0 src="../../../../../img/revistas/sm/v31n2/a6s1.jpg"> = 18.23, SD = 16.62) treatment phases (<img border=0 src="../../../../../img/revistas/sm/v31n2/a6s1.jpg"> = 1.07, SD = 0.77), and between the baseline and the follow-up phases (<img border=0 src="../../../../../img/revistas/sm/v31n2/a6s1.jpg"> = 1.59, SD = 1.06). An additional one-way ANOVA revealed significant changes in self-efficacy. Specifically, participants demonstrated increased self-efficacy in situations including: Unpleasant emotions, Pleasant emotions, Testing personal control, Conflict with others, Social pressure, and Pleasant time with others (all p < .01), F(2.78) = 24.30, 12.47, 11.34, 11.02, 16.91 and 25.62, respectively. Self-efficacy in regard to Physical discomfort and Urges and temptations to drink also showed significant changes, but at p < .05 F(2.78) = 3.97 and 3.26, respectively. Finally, in order to evaluate the impact of the intervention on problems that participants associated with their alcohol use (or other drugs), seven areas were examined: School, Health, Cognitive, Interpersonal, Family, Legal and Economic. At the end of the treatment, there was a reduction in the number of problems related to these seven areas, compared with the baseline.<hr/>En las últimas décadas, el abuso de drogas legales e ilegales en los jóvenes ha sido considerado como un serio problema de salud pública, tanto en el ámbito internacional como en nuestro país. Los estudios epidemiológicos indican que la mayoría de los consumidores experimentan por primera vez con drogas alrededor de los 16 años, pero esta experimentación continúa disminuyendo presentándose en promedio a los 12 o 13 años. Esto representa altos costos para la sociedad y el individuo. Por ejemplo, en áreas de la salud se incrementan los costos de la atención médica, los servicios de salud mental y los tratamientos especializados, además de aumentar la probabilidad de accidentes y muertes relacionadas con el abuso; en el área escolar se presenta el fracaso y/o la deserción escolar, y la expulsión de los estudiantes por parte de las instituciones; y en el área social se pueden presentar conductas agresivas y/o delictivas, contacto sexual de riesgo y otros problemas de conducta relacionados con el consumo de sustancias. De los diferentes programas existentes, resaltan las intervenciones breves en el tratamiento de usuarios que abusan pero que no dependen de las sustancias. Este tipo de intervenciones se basan en la Teoría del Aprendizaje Social y están diseñadas para reducir los patrones de abuso de alcohol u otras drogas. Sin embargo, la aplicación de las intervenciones breves se ha realizado principalmente en adultos, y es hasta últimas fechas que éstas se han adaptado a población adolescente que abusa de las sustancias, sin tenerse todavía resultados concluyentes. Es por esto que es fundamental desarrollar programas de intervención breve como una alternativa para adolescentes que inician el abuso de alcohol u otras drogas. Otro punto que requiere atención es el desarrollo de estrategias para detectar los casos en las escuelas, con la finalidad de ofrecer los servicios de atención en las propias instituciones educativas sin que el adolescente tenga consecuencias como la suspensión o la expulsión. Ante este fenómeno se ha recomendado fortalecer acciones que se basan en la identificación temprana de patrones de consumo que ponen en riesgo al adolescente a diferentes problemas relacionados con el abuso de las drogas. Estos programas se deben caracterizar por ser costo-eficientes, breves y capaces de instrumentarse en una variedad de escenarios, así como de aplicarse a una variedad de culturas. Por lo tanto, el objetivo de esta investigación fue desarrollar y evaluar un programa de intervención breve para adolescentes de entre 14 y 18 años de edad, estudiantes de nivel medio y medio superior, que consumen alcohol en exceso u otras drogas, y que presentan problemas relacionados con este patrón de consumo pero sin cubrir los síntomas físicos de la dependencia. Para realizar la evaluación se utilizó un diseño de caso único con 25 réplicas, 17 casos de consumo de alcohol y 8 casos de consumo de mariguana. De los 25 adolescentes que participaron en el estudio, 24 mostraron una disminución en el patrón de consumo (cantidad y frecuencia de consumo), al comparar las mediciones de los datos recabados en las fases de línea base, tratamiento y seguimiento. Así mismo, se dieron cambios en el nivel de auto-eficacia (percepción de la capacidad de los sujetos para controlar sus situaciones de consumo), es decir, al finalizar el tratamiento los adolescentes se percibieron a sí mismos con mayor capacidad para controlar la cantidad de consumo en situaciones de riesgo. Además, al final del tratamiento los sujetos reportaron una reducción del número de problemas relacionados con su consumo. Esta investigación es uno de los primeros esfuerzos por demostrar el impacto de las intervenciones breves en el patrón de consumo de los adolescentes. Las limitaciones del estudio fueron que no se determinó el efecto específico de cada uno de los componentes del programa ni tampoco se evaluó la presencia de otras conductas problemáticas (comorbilidad). Sin embargo, esta investigación ofrece un apoyo empírico a los programas de intervención breve en población adolescente de nuestro país. <![CDATA[<b>Ethical considerations in community interventions: the pertinence of informed consent</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200007&lng=pt&nrm=iso&tlng=pt Ethics, understood as the study of moral norms in terms of its assumptions, origins, and changes over time, systematizes similarities and differences between various moral codes. It therefore serves as a meeting point between different perspectives, through dialogue, a fundamental characteristic of this discipline. One of its derivations, as applied ethics, is bioethics, defined by Van Rensselaer Potter as "New knowledge that provides knowledge on how to use knowledge for the good of society". Although bioethics emerged in the 1970s under the imperative of medical discourse, its development as a discipline reflecting human behavior surrounding health has permitted the combination of various types of knowledge, including the contribution of social sciences in this field. Thus bioethics deals with the dilemmas that may arise in social studies on health (such as addictions, violence and migrations). The aims of this manuscript are to systematize and explain some of the implications of the pertinence and adaptation of informed consent (IC) in a bi-national Mexico-United States study on mental health and migration. It also provides elements of analysis for the detection of ethical dilemmas in these community interventions in mental health in Mexico. It therefore attempts to answer the following questions: Within the context of bi-national research, how does one deal with the principle of autonomy and the notion of "voluntariness" included in the requirement of informed consent, in public mental health interventions in Mexican rural communities? Is it possible to respect the way participants in the host country make decisions while at the same time, meeting the demands of the ethics committee of the sponsor country? In order to arrive at the elements of analysis, the authors briefly explain the conceptualization of the terms ethics and bioethics, and explore some of the postulates put forward in both North American (principalism and casuism) and European bioethics (communitarianism), in addition to approaching other bioethical positions (ethics of responsibility and protection), by highlighting certain cultural elements that particularize the world views that give rise to the aforementioned ethical approaches. At the same time, the authors review the principal contributions of the various international codes, declarations and reports, including recommendations by the National Commission of Bioethics of Mexico that regulate the process of Informed Consent (IC) in Social Research. IC is a social process which, through active, respectful exchange provides information on research in a comprehensible way for the subject, in such a way that he is aware of the risks, benefits, consequences or problems that may occur during research. The researcher must ensure that the participant has properly understood all the information related to the project, has the opportunity to ask and be given answers to his doubts and is aware of his right to dissent (not adjust to someone's feeling or opinion) or express his will to collaborate by consenting (to allow or agree to something being done) without having been subjected to coercion, intimidation or undue influences of incentives. The process of informed consent (IC) is essentially verbal, and without underestimating this fact, given the importance of the decision about to be taken, as happens when one agrees to take part in a research project, it is sometimes necessary to leave a written record of this. In this respect, the process of informed consent consists of three elements: information, understanding and voluntariness. In itself, it involves the protection of the individual's freedom of choice and respect for his autonomy. One should therefore consider the context of development of different cultural groups from that of the researcher and his traditions regarding communication and decision and these procedures must be respected. The study also includes aspects that have rarely been discussed in the process of informed consent (PIC) such as the need to clarify the type of relationship and exercise of power that may occur between the researcher and the person being researched, the lack of questioning about whether the commitment acquired by the researcher to respect the participants' autonomy during the PIC helps or prevents people from regarding themselves as rights-holders. Finally, the study highlights the fact that, although social research is considered of "minimum risk", the information provided in the PIC may cause emotional distress classified as "psychological risks" such as stress anxiety, fear or lack of tranquility. In social research, as in no other, the implementation of PIC normative approach is extremely varied, due to the fact that one works with sectors prepared to participate (prostitutes, drug users, first-time offenders, etc.) on the condition that they will not sign any informed consent, thereby giving priority to the quality of the relationship established, rather than the format. This manuscript explains the reflection on certain ethical dilemmas that arose during a social research project, the aim of which was to identify the emotional distress associated with Mexico-United States international migration and the use of mental health services. The ethical analysis specifically focuses on the information obtained during the field work through the participatory observation technique, in a rural community in the state of Michoacan. The main conflictive situations experienced due to the notion of voluntariness and the principle of autonomy underpinning PIC include: • The fact that for some residents, discussing certain issues related to public mental health such as alcohol and drug consumption may be interpreted as "disloyalty" to their community and constitutes sufficient grounds for not participating. • Understanding that some researchers suffer the consequences of their colleagues' mistakes, as borne out by another of the arguments given for not participating: " We are fed up of fly-by-night researchers, who just come in, obtain their data and are never seen in the community again". It is also worth reflecting on whether this argument reflects a questioning of the researcher's authority and/or a loss of faith in social progress through science, but how can one speak of social progress with the residents of communities that lack drainage and electricity?<hr/>A pesar de que la bioética surge en la década de 1970, bajo el imperativo del discurso biomédico, su desarrollo como disciplina que reflexiona sobre el comportamiento humano en torno a la salud ha permitido la reunión de varios saberes, entre ellos, la aportación de las ciencias sociales en dicho campo. De esta forma, la bioética se ocupa de los dilemas que pueden presentarse en los estudios sociales sobre salud (adicciones, violencia, migraciones), incluso en aquellos que, por cuestiones de interés común, son de tipo binacional o multicéntrico. Los objetivos de este artículo son sistematizar y exponer algunas implicaciones de la pertinencia y adecuación del consentimiento informado (CI) en un estudio binacional México-Estados Unidos sobre salud mental y migración. Además, se aportan elementos de análisis para la detección de dilemas éticos en estas intervenciones comunitarias en salud mental en México. De esta forma, se intenta responder a las siguientes preguntas: En el contexto de una investigación binacional, ¿cómo encarar el principio de autonomía y la noción de "voluntariedad", insertos en el requerimiento de un consentimiento informado, en intervenciones de salud mental pública en comunidades rurales mexicanas? ¿Es posible respetar la manera en que los participantes del país anfitrión toman decisiones y cubrir, al mismo tiempo, las exigencias del comité de ética del país patrocinador? Para allegarse los elementos de análisis, se expone someramente la conceptualización de los vocablos ética y bioética, y se abordan algunos postulados planteados tanto de la bioética norteamericana como de la europea, además de aproximarnos a otras posturas bioéticas. Por otro lado, se revisan los principales aportes de los diversos códigos, declaraciones e informes internacionales, incluidas las recomendaciones de la Comisión Nacional de Bioética de México, que norman el proceso del consentimiento informado (CI) en investigación social. El CI es un "proceso social que, a través de un intercambio activo y respetuoso, brinda información sobre la investigación en forma comprensible para el sujeto, permite cerciorarse de que la entienda y tenga opción de preguntar y recibir respuestas a sus dudas, brinde oportunidad para negarse a participar o manifestar voluntad de colaborar y pueda expresarla oralmente o firmar un formulario, sin haber sido sometido a coerción, intimidación ni a influencias o incentivos indebidos". En este sentido, el proceso de consentimiento informado (PCI) protege la libertad de elección del individuo y el respeto de su autonomía. Por ello, también se debe considerar el contexto de desarrollo de grupos culturales diversos al del investigador, sus tradiciones en cuanto a comunicación y decisión, y se deben respetar estos procedimientos. En la investigación social, como en ninguna otra, la puesta en práctica de la normatividad del PCI es muy variada, debido a que se trabaja con sectores dispuestos a participar (prostitutas, usuarios de drogas, primo-delincuentes, etc.) a condición de no firmar ningún consentimiento escrito, lo que otorga prioridad a la calidad de la relación establecida y no sólo al formato. Este documento expone la reflexión sobre algunos dilemas éticos que se presentaron durante una investigación social cuyo objetivo fue identificar los malestares emocionales asociados a la migración internacional México-EUA y la utilización de servicios de salud mental. Específicamente, el análisis ético se centra en la información recabada en el trabajo de campo por medio de la técnica observación participante, en una comunidad rural en el estado de Michoacán. <![CDATA[<b>Researching of intercultural paths in indigenous migrants communities in Distrito Federal</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200008&lng=pt&nrm=iso&tlng=pt The migrant indigenous population living all over Mexico City is increasing. The settlement of families in a single piece of land has magnified their visibility and political participation in the city based on their kinship and <<compadrazgo>>* relationships. This family settlement has given the indigenous migrant population the opportunity to maintain its cultural patterns and to speak its mother tongue; but this collective coexistence often creates serious problems and conflicts among its members. However, these communities must concur with institutional criteria and with local social programs' requirements for gaining access to resources (mostly coming from welfare) such as land regulation, medical assistance, grants, groceries, house building, and so on. Those criteria and requirements are usually established from the outside, without a proper knowledge of the communities they attempt to benefit. They do not have enough sensitivity towards the community's social organization, this situation has created conflicts and breaking-offs among the allegedly favored communities, as well as alterations in their traditional forms of organization. Urban resources, for instance, tend to promote group organization among indigenous with a community leader who has to be an agent for getting resources; but he often acts on his own rather than as the traditional guide originally in charge of maintaining the community life inside the limits of the public agreements reached through assemblies. Another troublesome experience that indigenous people face in the city is the frequent inter-ethnic links they have with the academic community, which approaches them to <<study and to help them>>. Migrant Triquis, Otomies, Mazahuas, and other groups have a negative opinion of the academic community; they do not see it as an inter-ethnic link but as an inquiring one. Interviewers and pollsters from academic, government, ecclesiastic, news, and school agencies have asked them the same questions for many years: their school history, eating habits, income, occupation, and their reasons for migrating. Apparently researchers tend to believe that this population has an <<official answer>> for these questions. The use indigenous groups make of the <<official answer>> underlines their demands before the State about their right to work, to have a house, to medical attention, and to education and constitutes one of the few channels they have to be heard, though a lot remains unheard or in the dark. Even though they have received some attention, many of the places where they live in the city still are in dreadful health and living conditions, lacking the most basic services. After ten years, many of these indigenous camps have nothing but the poorest houses. On the other hand, recent non-indigenous migrants already have much better conditions. Indigenous communities living in the city often think that organizations use them, that they do nothing or very little to understand and benefit them, but that they can make things worse for them (for instance, breaking off their camps and generating more violence and alcohol use among their families). Although in the present there is a paradigm of egalitarian coexistence and multicultural tolerance in the urban centers, being part of an indigenous group still means disadvantage in comparison to a mixed race person. The idea that indigenous people are barbarians or savages still exists in the usual representations of mixed race society and their attention policy is filled with an integration thinking which considers indigenous societies as lower and incapable, as well as prone to be absorbed by the higher culture to finish the civilization process. The fundamental frame for knowing and understanding indigenous communities as well as their experiences in the way they experience them, is through the intercultural paths they are following in the city, their contact with resources, the inter-ethnic relationships they have from the moment they leave their homes until they arrive to the city. Achieving this goal implies that sponsors, researchers, and services providers stop looking at themselves as external observers and the communities as <<objects to study>> and start training informants in professional skills to become collaborators in the researches or in the social programs. Thus members of these <<cultural minorities>> could be part of the knowledge production in the enclosing culture without sacrificing neither their identity, nor their cultural values but revitalizing them instead. It is also needed that researchers do something more than just tackling indigenous communities' knowledge from the perspective of informants to capture their voice in the final reports, even being cautious not to publish material that could hurt them. The people who get involved in a research as subjects have very little influence on what is published so they do not feel represented. Even though using a classical research model helps to save time and to simplify responsibilities in managing funds and reporting research results, the challenge to access informants and gaining their trust still exists. Generally this approach creates skeptical reactions among participants who do not believe neither in the results nor in the purposes and products of a study because they do not feel part of the planning. It is necessary to practice alternative ways to relate to informants and to make more inclusive participant research projects. That way it would be possible to gradually involve subjects in every step of the research process to found a cooperative model where informants are trained during research to participate in designing, performing, analyzing, and reporting research results. This new team is the one that would present and conduct the research. Such new approach would guarantee that subjects' needs are covered and their experiences recognized. It would also help the researcher to access informants, to gain their trust, and to consider ethical aspects in treating them. This article describes some of the present problems involved in assisting and researching indigenous groups that live in Mexico City. The nature of the socio-cultural organization of indigenous groups living in the city is analyzed, as well as the transformation their communities experience when they contact with urban resources. A brief count of the elements involved in the meeting between indigenous people and the academic staff interested in studying them is presented. The usual failure in setting egalitarian inter-ethnic relationships, which has often resulted in damaging indigenous groups, is exposed. Finally, the need for alternative approaches in assisting and researching cultural minorities is discussed, especially from the perspective that there is an interest in creating equality, renewing their identities and their socio-cultural life, and improving their general living conditions based on the inter-cultural paths these groups follow in the big cities.<hr/>Cada vez más frecuentemente, una población indígena migrante reside en todas las unidades territoriales del Distrito Federal. Gracias a sus relaciones de parentesco y compadrazgo -el asentamiento por familias en un solo predio- se ha hecho más notoria su presencia y politización en el área urbana. Sin embargo, estas comunidades deben ajustarse a los criterios institucionales y administrativos de los programas sociales que se ofrecen en la ciudad para hacerse acreedores a recursos (predominantemente asistencialistas) como la regularización de los predios, el otorgamiento de servicios médicos, becas, despensas y construcción de viviendas, etc. Tales criterios son establecidos regularmente de forma externa sin incluir un conocimiento pertinente del funcionamiento de las comunidades a quienes intentan beneficiar. No se es sensible a las formas propias de organización social, lo que ha desencadenado entre los supuestos beneficiados, rupturas y conflictos al interior de las propias comunidades, así como una alteración de sus formas tradicionales de organización. Entre los triquis que migran a la Ciudad de México, al igual que sucede con otomíes, mazahuas y otras comunidades, existe una percepción negativa hacia la comunidad académica, a la que no se le ve como un vínculo interétnico sino como formada por interrogadores. Han sido muchos años en los que encuestadores y entrevistadores de instituciones académicas, de gobierno, eclesiásticas, reporteros y estudiantes, se les han aproximado para preguntarles "siempre lo mismo": su escolaridad, su alimentación, el monto de sus ingresos, su ocupación y las razones de su emigración entre otras cosas. Aun cuando algunos indígenas han conseguido hacerse oír, muchos predios urbanos donde habitan diversas etnias del país presentan aún condiciones deplorables de salud y subsistencia, careciendo de lo más elemental. Actualmente se tiende al paradigma de convivencia igualitaria de la multiplicidad de culturas en los grandes centros urbanos, sin embargo pertenecer a la categoría indígena aún coloca a quienes portan esa identidad en condiciones de desventaja respecto de los mestizos. El imaginario sobre el indígena como bárbaro o salvaje aún prevalece implícito en las representaciones comunes de la sociedad mestiza, y en su política de atención indigenista todavía priva el integracionismo que considera a las sociedades indígenas como incapaces e inferiores, susceptibles de ser asimiladas a la cultura mayoritaria para completar en ellas el proceso de "civilización del bárbaro". Los trayectos interculturales que los indígenas migrantes están recorriendo en la Ciudad, en el contacto con recursos, en las relaciones interétnicas que establecen desde que migran y se instalan en la urbe, es el marco fundamental para conocer y comprender en lo posible a las comunidades indígenas, sus experiencias y significados, tal como son sentidos por sus propios integrantes. En el presente trabajo se describen algunos de los problemas presentes en la atención y la investigación que han merecido grupos indígenas que residen en la Ciudad de México. Se aborda también la naturaleza de la organización social cultural de estos grupos indígenas y la transformación que sufren sus comunidades al vincularse con los recursos citadinos. Posteriormente se hace un breve recuento de los elementos que han caracterizado el encuentro entre indígenas y académicos que intentan aproximárseles para su estudio. Se evidencia el frecuente fracaso para un establecimiento de relaciones interétnicas propicias y equitativas entre ambos sectores, lo que ha resultado en perjuicio de esos grupos étnicos. Finalmente se discute la necesidad y la naturaleza de los abordajes alternativos hacia las minorías culturales, tanto para la prestación de servicios que requieren como cuando son tema de estudio o de conocimiento para los investigadores, reporteros, estudiantes o financiadores, etc., sobre todo si se pretende que las trayectorias interculturales que cursan tales minorías en los grandes centros urbanos de nuestra entidad, nutran y permitan, en igualdad de condiciones, la reelaboración de sus identidades, de su vida cultural social y el potenciamiento de sus condiciones de vida en general. <![CDATA[<b>Mnemonic, executive and attentional deficits as neurocognitive endophenotypes in bipolar disorder</b>: <b>A review</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200009&lng=pt&nrm=iso&tlng=pt Although many studies have demonstrated that bipolar disorder (BD) is heritable, the disorder's genetic basis remains elusive despite the substantial evidence. Hence, indicators of processes mediating between genotype and phenotype, known as endophenotypes, may be necessary to provide more information about this issue. Given that endophenotypes could provide information for elucidating the genetic underpinnings of BD, many studies have focused on one class of endophenotypic marker, the neuropsychological measures. In order for a cognitive measure to be considered an endophenotype, it has to 1. be highly heritable, 2. be associated with the illness, 3. be independent of the clinical state and, 4. the impairment must co-segregate with the illness within a family, with non-affected family members showing impairment relative to general population. In this sense, failures in attention, executive functions and verbal memory are the most consistently reported deficits with the characteristics for endophenotypes. With these factors in mind, the primary interest of this paper was to review the existing literature on neurocognitive functioning in BD as possible endophenotypes. Studies were identified by searching the major databases (MEDLINE and PSYCINFO) from 1990 to 2007 with the following key words: endophenotype, neurocognitive assessment, bipolar disorder, attention, memory, executive functions, neuropsychological assessment and neuroimaging. The titles and abstracts of the articles identified were examined and those that appeared to fullfil our inclusion criteria were retrieved. Articles were included if they met the following criteria: 1. included adult patients (aged: 16-65), 2. included a psychiatric or normal comparison group, 3. used well-established diagnostic criteria to ascertain diagnosis (DSM, 3rd. and 4th. eds.), 4. provided information about the clinical status of the patients being assessmed and 5. cognitive assessment was based on standardized or well established cognitive tasks. Declarative memory has been studied in BD patients through tests that imply learning of words and stories to evaluate immediate memory, delayed recall and recognition, also considering the kind of strategies that the patients use to evoke verbal material. It seems that BD patients in depressive phase present deficits in immediate memory and delayed recall, but recognition memory is preserved. This impairment is due to difficulties in the planning and evoking strategies used, associated to prefrontal dysfunction. In manic phase, the patients make a lot of irrelevant associations because the failure in the system to control impulses. In the absence of the depressive and maniac symptoms, patients continue with anomalies in memory. Euthymic patient can use a similar semantic clustering strategy so that they can recall and recognize fewer words than controls, suggesting impaired encoding of verbal information and there is lack of rapid forgetting, which suggests a relative absence of a storage deficit. Results of studies in declarative memory impairment in BD suggests that the impairments are consistent with deficits in learning, but do not appear to be related to different organizational strategies during learning, and do not appear to be secondary to clinical state. Rather, they are associated with the underlying pathophysiology of the illness. Regarding executive functions, patients with BD have deficiencies related to planning, organizational strategies, lack of control in the action, conceptual formation and cognitive flexibility. In depressive phase, patients have problems with concept formation, meanwhile the deficit in verbal fluency is due because they use phonemic rather than semantic clues. In maniac episodes, the executive functions are altered, and it is observed that concept formation and attentional shift are deficient and more evident in patients with a history of psychosis. These deficits explain why maniac persons engage in more risk behaviors, specifically in the inhibiting impulses system. Also in the absence of symptoms, euthymic bipolar disorder patients show no significant differences with respect to controls on attentional set-shifting, problem solving or planning. However, they show qualitative differences involving slower functioning on measures of speed and slower to initiate a response, and present more errors across measures of verbal fluency. With respect to attentional deficits in BD, several studies have pointed to deficits in sustained attention, also known as concentration, related to the capability to sustain the focus during a considerable amount of time. This attentional domain is deficient in manic patients because the lack of behavioral inhibition which is prevalent in this phase, the increased false responding (commission errors), perseveration and vigilance deficits. In contrast, when patients are depressive, they make more mistakes by omission of relevant stimuli. Also in euthymic patients, a deficit in the inattentive component of sustained attention is reported because of decreased target sensitivity (omission errors) and response time inconsistency. It is possible that the observed findings do not reflect dysfunction in one isolated brain area, rather a dysregulation of cortical modulation of subcortical networks is considered. In particular, a neuroanatomic model of mood regulation comprising the prefrontal cortex, amygdala-hippocampal complex, thalamus, basal ganglia, and their inter-connections has been proposed to be implicated in the pathophysiology of mood disorders. Functional neuroimaging studies also support evidence of these neurocognitive anomalies through the application of neuropsychological paradigms, in which metabolic increments in ventral striate and diminished function in prefrontal cortex during executives assignments is common. During maniac or hypomaniac episodes, an increment of activity in the ventral prefrontal cortex of the right hemisphere was observed; meanwhile, in depressive phase the patients show an increase in the same sector but in the left hemisphere compared to euthymic patients. During the depressive episodes of the BD type II, it is observed a reduction of the dorsolateral and medial prefrontal cortex metabolism, and an increase in thalamus and amygdala while resolving cognitive activities. Finally, there is a reduction of metabolism in ventral caudal and prefrontal cortex and an increase in amygdala in patients without depressive or maniac symptoms. This finding supports the hypothesis of permanent prefrontal dysfunction although the absence of clinical symptoms. Finally, as Glahn et al. (2004) have suggested, neurocognitive markers may indicate the presence of quantifiable deviation on a genetically influenced dimension that underlies BD. Such endophenotypes would not identify illness genes per se; rather they would indicate a realiably characterized heritable behavioral phenomenon. Nevertheless, at present it is not known which of the many candidate genes for BD may be associated with neurocognitive endophenotypes for the disorder. Some studies have reported promising preliminary findings indicating a relationship between executive performance and a brain-derived neurotrophic factor gene polymorphism. Given that this gene has been implicated in memory and learning as a function of its role in synaptic transmission, and other genetic association studies have linked this gene to risk for BD, allelic variation in this gene may be associated with cognitive dysfunction in BD.<hr/>En los últimos años se ha planteado la necesidad de identificar los procesos que median entre el genotipo y el fenotipo del Trastorno Bipolar (TB), dando importancia al estudio de los endofenotipos. Los endofenotipos tratan del fenotipo interno y que no se observa clínicamente, que se encuentra mas cercano a la etiología biológica de la enfermedad que sus signos y síntomas, y que se encuentra influenciado por uno o más genes susceptibles al trastorno. Para que un marcador pueda ser considerado como endofenotipo debe cubrir las siguientes características: 1) ser heredable, 2) estar asociado con la enfermedad, 3) ser independiente del estado clínico y 4) mostrar co-segregación familiar. Dentro de los métodos disponibles para identificar a los endofenotipos se encuentran las mediciones neuropsicológicas y cognitivas entre otras. Diversos autores han señalado la utilidad de identificar los endofenotipos neurocognitivos del TB para mejorar la capacidad de detección de los genes que predisponen a la aparición del trastorno y ayudar a una mejor definición de los criterios diagnósticos. En este sentido, se han señalado a las alteraciones en los dominios de atención selectiva, memoria verbal y funciones ejecutivas, como marcadores endofenotípicos más representativos del TB porque cumplen con los criterios antes mencionados. Por lo tanto, en el presente artículo se realizó una revisión de los estudios neuropsicológicos reportados en pacientes con TB en estos dominios cognitivos y la descripción de estas deficiencias, así como de los circuitos neuronales asociados con estas alteraciones. Se realizó una búsqueda de artículos en MEDLINE y psycINFO desde 1990 a 2007 con las siguientes palabras clave: endofenotipo, evaluación neuropsicológica, trastorno bipolar, atención, memoria, funciones ejecutivas, neurocognición y neuroimagen. Los títulos y resúmenes de los artículos identificados fueron examinados y se conservaron aquellos que cubrían nuestros criterios de inclusión. Los artículos se tomaron en cuenta si cubrían los siguientes criterios: 1) incluían pacientes adultos (edad: 16-65), 2) incluían un grupo de comparación psiquiátrico o normal, 3) utilizaban criterios diagnósticos bien establecidos para el diagnóstico (DSM 3ª. y 4ª. eds.), 4) describían información sobre el estado clínico del paciente al momento de la evaluación y 5) utilizaban evaluaciones cognitivas con tareas estandarizadas y bien establecidas. En relación a la memoria declarativa, los pacientes en un episodio depresivo muestran alteraciones en las pruebas de aprendizaje y de memoria de listas de palabras en las variables de recuerdo libre, tanto a corto como a largo plazo; estas subyacen a deficiencias en la planeación y en la memoria operativa o de trabajo, mismas que persisten después de la fase aguda de cualquier etapa de este padecimiento. Durante la manía se observa un pobre desempeño caracterizado por intrusiones y asociaciones verbales irrelevantes. Se ha señalado que durante la eutimia existen deficiencias asociadas con fallas en la codificación de la información y que no se deben al olvido o a deficiencias en su almacenamiento. Las evaluaciones que se han realizado de las funciones ejecutivas, coinciden al señalar incapacidad para planear, organizar y controlar la conducta en las fases depresivas y de manía/hipomanía, mientras que en la eutimia los pacientes únicamente muestran diferencias cualitativas en comparación con los sujetos sanos, caracterizadas por fallas ante tareas de fluidez verbal semántica y enlentecimiento en la velocidad de procesamiento. Con respecto a la atención selectiva, ha sido posible identificar que los pacientes con manía/hipomanía fallan porque presentan mayor cantidad de errores de comisión, asociado con impulsividad y deficiencias en la autorregulación; por otra parte, durante la fase depresiva se observa incapacidad para responder a estímulos importantes y mayor presencia de errores de omisión. Durante la eutimia, se encuentra alterado el componente de inatención debido a que obtienen menores puntajes en la detección del estímulo y requieren mayor tiempo de reacción. Los hallazgos neuropsicológicos antes descritos parecen reflejar la disregulación en la modulación cortical de las redes subcorticales, particularmente en el circuito que implica a la corteza prefrontal, al complejo amígdala-hipocampal, el tálamo, los ganglios basales y sus interconexiones; circuito que ha sido propuesto como un modelo neuroanatómico de la regulación afectiva. Además de la disregulación en este circuito, parecen estar involucradas disfunciones en los sectores laterales del lóbulo temporal durante las fases de manía/hipomanía. <![CDATA[<b>In Memoriam</b>: <b>Manuel Gregorio Camelo Martínez (1940-2008)</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200010&lng=pt&nrm=iso&tlng=pt Although many studies have demonstrated that bipolar disorder (BD) is heritable, the disorder's genetic basis remains elusive despite the substantial evidence. Hence, indicators of processes mediating between genotype and phenotype, known as endophenotypes, may be necessary to provide more information about this issue. Given that endophenotypes could provide information for elucidating the genetic underpinnings of BD, many studies have focused on one class of endophenotypic marker, the neuropsychological measures. In order for a cognitive measure to be considered an endophenotype, it has to 1. be highly heritable, 2. be associated with the illness, 3. be independent of the clinical state and, 4. the impairment must co-segregate with the illness within a family, with non-affected family members showing impairment relative to general population. In this sense, failures in attention, executive functions and verbal memory are the most consistently reported deficits with the characteristics for endophenotypes. With these factors in mind, the primary interest of this paper was to review the existing literature on neurocognitive functioning in BD as possible endophenotypes. Studies were identified by searching the major databases (MEDLINE and PSYCINFO) from 1990 to 2007 with the following key words: endophenotype, neurocognitive assessment, bipolar disorder, attention, memory, executive functions, neuropsychological assessment and neuroimaging. The titles and abstracts of the articles identified were examined and those that appeared to fullfil our inclusion criteria were retrieved. Articles were included if they met the following criteria: 1. included adult patients (aged: 16-65), 2. included a psychiatric or normal comparison group, 3. used well-established diagnostic criteria to ascertain diagnosis (DSM, 3rd. and 4th. eds.), 4. provided information about the clinical status of the patients being assessmed and 5. cognitive assessment was based on standardized or well established cognitive tasks. Declarative memory has been studied in BD patients through tests that imply learning of words and stories to evaluate immediate memory, delayed recall and recognition, also considering the kind of strategies that the patients use to evoke verbal material. It seems that BD patients in depressive phase present deficits in immediate memory and delayed recall, but recognition memory is preserved. This impairment is due to difficulties in the planning and evoking strategies used, associated to prefrontal dysfunction. In manic phase, the patients make a lot of irrelevant associations because the failure in the system to control impulses. In the absence of the depressive and maniac symptoms, patients continue with anomalies in memory. Euthymic patient can use a similar semantic clustering strategy so that they can recall and recognize fewer words than controls, suggesting impaired encoding of verbal information and there is lack of rapid forgetting, which suggests a relative absence of a storage deficit. Results of studies in declarative memory impairment in BD suggests that the impairments are consistent with deficits in learning, but do not appear to be related to different organizational strategies during learning, and do not appear to be secondary to clinical state. Rather, they are associated with the underlying pathophysiology of the illness. Regarding executive functions, patients with BD have deficiencies related to planning, organizational strategies, lack of control in the action, conceptual formation and cognitive flexibility. In depressive phase, patients have problems with concept formation, meanwhile the deficit in verbal fluency is due because they use phonemic rather than semantic clues. In maniac episodes, the executive functions are altered, and it is observed that concept formation and attentional shift are deficient and more evident in patients with a history of psychosis. These deficits explain why maniac persons engage in more risk behaviors, specifically in the inhibiting impulses system. Also in the absence of symptoms, euthymic bipolar disorder patients show no significant differences with respect to controls on attentional set-shifting, problem solving or planning. However, they show qualitative differences involving slower functioning on measures of speed and slower to initiate a response, and present more errors across measures of verbal fluency. With respect to attentional deficits in BD, several studies have pointed to deficits in sustained attention, also known as concentration, related to the capability to sustain the focus during a considerable amount of time. This attentional domain is deficient in manic patients because the lack of behavioral inhibition which is prevalent in this phase, the increased false responding (commission errors), perseveration and vigilance deficits. In contrast, when patients are depressive, they make more mistakes by omission of relevant stimuli. Also in euthymic patients, a deficit in the inattentive component of sustained attention is reported because of decreased target sensitivity (omission errors) and response time inconsistency. It is possible that the observed findings do not reflect dysfunction in one isolated brain area, rather a dysregulation of cortical modulation of subcortical networks is considered. In particular, a neuroanatomic model of mood regulation comprising the prefrontal cortex, amygdala-hippocampal complex, thalamus, basal ganglia, and their inter-connections has been proposed to be implicated in the pathophysiology of mood disorders. Functional neuroimaging studies also support evidence of these neurocognitive anomalies through the application of neuropsychological paradigms, in which metabolic increments in ventral striate and diminished function in prefrontal cortex during executives assignments is common. During maniac or hypomaniac episodes, an increment of activity in the ventral prefrontal cortex of the right hemisphere was observed; meanwhile, in depressive phase the patients show an increase in the same sector but in the left hemisphere compared to euthymic patients. During the depressive episodes of the BD type II, it is observed a reduction of the dorsolateral and medial prefrontal cortex metabolism, and an increase in thalamus and amygdala while resolving cognitive activities. Finally, there is a reduction of metabolism in ventral caudal and prefrontal cortex and an increase in amygdala in patients without depressive or maniac symptoms. This finding supports the hypothesis of permanent prefrontal dysfunction although the absence of clinical symptoms. Finally, as Glahn et al. (2004) have suggested, neurocognitive markers may indicate the presence of quantifiable deviation on a genetically influenced dimension that underlies BD. Such endophenotypes would not identify illness genes per se; rather they would indicate a realiably characterized heritable behavioral phenomenon. Nevertheless, at present it is not known which of the many candidate genes for BD may be associated with neurocognitive endophenotypes for the disorder. Some studies have reported promising preliminary findings indicating a relationship between executive performance and a brain-derived neurotrophic factor gene polymorphism. Given that this gene has been implicated in memory and learning as a function of its role in synaptic transmission, and other genetic association studies have linked this gene to risk for BD, allelic variation in this gene may be associated with cognitive dysfunction in BD.<hr/>En los últimos años se ha planteado la necesidad de identificar los procesos que median entre el genotipo y el fenotipo del Trastorno Bipolar (TB), dando importancia al estudio de los endofenotipos. Los endofenotipos tratan del fenotipo interno y que no se observa clínicamente, que se encuentra mas cercano a la etiología biológica de la enfermedad que sus signos y síntomas, y que se encuentra influenciado por uno o más genes susceptibles al trastorno. Para que un marcador pueda ser considerado como endofenotipo debe cubrir las siguientes características: 1) ser heredable, 2) estar asociado con la enfermedad, 3) ser independiente del estado clínico y 4) mostrar co-segregación familiar. Dentro de los métodos disponibles para identificar a los endofenotipos se encuentran las mediciones neuropsicológicas y cognitivas entre otras. Diversos autores han señalado la utilidad de identificar los endofenotipos neurocognitivos del TB para mejorar la capacidad de detección de los genes que predisponen a la aparición del trastorno y ayudar a una mejor definición de los criterios diagnósticos. En este sentido, se han señalado a las alteraciones en los dominios de atención selectiva, memoria verbal y funciones ejecutivas, como marcadores endofenotípicos más representativos del TB porque cumplen con los criterios antes mencionados. Por lo tanto, en el presente artículo se realizó una revisión de los estudios neuropsicológicos reportados en pacientes con TB en estos dominios cognitivos y la descripción de estas deficiencias, así como de los circuitos neuronales asociados con estas alteraciones. Se realizó una búsqueda de artículos en MEDLINE y psycINFO desde 1990 a 2007 con las siguientes palabras clave: endofenotipo, evaluación neuropsicológica, trastorno bipolar, atención, memoria, funciones ejecutivas, neurocognición y neuroimagen. Los títulos y resúmenes de los artículos identificados fueron examinados y se conservaron aquellos que cubrían nuestros criterios de inclusión. Los artículos se tomaron en cuenta si cubrían los siguientes criterios: 1) incluían pacientes adultos (edad: 16-65), 2) incluían un grupo de comparación psiquiátrico o normal, 3) utilizaban criterios diagnósticos bien establecidos para el diagnóstico (DSM 3ª. y 4ª. eds.), 4) describían información sobre el estado clínico del paciente al momento de la evaluación y 5) utilizaban evaluaciones cognitivas con tareas estandarizadas y bien establecidas. En relación a la memoria declarativa, los pacientes en un episodio depresivo muestran alteraciones en las pruebas de aprendizaje y de memoria de listas de palabras en las variables de recuerdo libre, tanto a corto como a largo plazo; estas subyacen a deficiencias en la planeación y en la memoria operativa o de trabajo, mismas que persisten después de la fase aguda de cualquier etapa de este padecimiento. Durante la manía se observa un pobre desempeño caracterizado por intrusiones y asociaciones verbales irrelevantes. Se ha señalado que durante la eutimia existen deficiencias asociadas con fallas en la codificación de la información y que no se deben al olvido o a deficiencias en su almacenamiento. Las evaluaciones que se han realizado de las funciones ejecutivas, coinciden al señalar incapacidad para planear, organizar y controlar la conducta en las fases depresivas y de manía/hipomanía, mientras que en la eutimia los pacientes únicamente muestran diferencias cualitativas en comparación con los sujetos sanos, caracterizadas por fallas ante tareas de fluidez verbal semántica y enlentecimiento en la velocidad de procesamiento. Con respecto a la atención selectiva, ha sido posible identificar que los pacientes con manía/hipomanía fallan porque presentan mayor cantidad de errores de comisión, asociado con impulsividad y deficiencias en la autorregulación; por otra parte, durante la fase depresiva se observa incapacidad para responder a estímulos importantes y mayor presencia de errores de omisión. Durante la eutimia, se encuentra alterado el componente de inatención debido a que obtienen menores puntajes en la detección del estímulo y requieren mayor tiempo de reacción. Los hallazgos neuropsicológicos antes descritos parecen reflejar la disregulación en la modulación cortical de las redes subcorticales, particularmente en el circuito que implica a la corteza prefrontal, al complejo amígdala-hipocampal, el tálamo, los ganglios basales y sus interconexiones; circuito que ha sido propuesto como un modelo neuroanatómico de la regulación afectiva. Además de la disregulación en este circuito, parecen estar involucradas disfunciones en los sectores laterales del lóbulo temporal durante las fases de manía/hipomanía. <![CDATA[<b>What would have happened if Freud and Janet had met?</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200011&lng=pt&nrm=iso&tlng=pt Although many studies have demonstrated that bipolar disorder (BD) is heritable, the disorder's genetic basis remains elusive despite the substantial evidence. Hence, indicators of processes mediating between genotype and phenotype, known as endophenotypes, may be necessary to provide more information about this issue. Given that endophenotypes could provide information for elucidating the genetic underpinnings of BD, many studies have focused on one class of endophenotypic marker, the neuropsychological measures. In order for a cognitive measure to be considered an endophenotype, it has to 1. be highly heritable, 2. be associated with the illness, 3. be independent of the clinical state and, 4. the impairment must co-segregate with the illness within a family, with non-affected family members showing impairment relative to general population. In this sense, failures in attention, executive functions and verbal memory are the most consistently reported deficits with the characteristics for endophenotypes. With these factors in mind, the primary interest of this paper was to review the existing literature on neurocognitive functioning in BD as possible endophenotypes. Studies were identified by searching the major databases (MEDLINE and PSYCINFO) from 1990 to 2007 with the following key words: endophenotype, neurocognitive assessment, bipolar disorder, attention, memory, executive functions, neuropsychological assessment and neuroimaging. The titles and abstracts of the articles identified were examined and those that appeared to fullfil our inclusion criteria were retrieved. Articles were included if they met the following criteria: 1. included adult patients (aged: 16-65), 2. included a psychiatric or normal comparison group, 3. used well-established diagnostic criteria to ascertain diagnosis (DSM, 3rd. and 4th. eds.), 4. provided information about the clinical status of the patients being assessmed and 5. cognitive assessment was based on standardized or well established cognitive tasks. Declarative memory has been studied in BD patients through tests that imply learning of words and stories to evaluate immediate memory, delayed recall and recognition, also considering the kind of strategies that the patients use to evoke verbal material. It seems that BD patients in depressive phase present deficits in immediate memory and delayed recall, but recognition memory is preserved. This impairment is due to difficulties in the planning and evoking strategies used, associated to prefrontal dysfunction. In manic phase, the patients make a lot of irrelevant associations because the failure in the system to control impulses. In the absence of the depressive and maniac symptoms, patients continue with anomalies in memory. Euthymic patient can use a similar semantic clustering strategy so that they can recall and recognize fewer words than controls, suggesting impaired encoding of verbal information and there is lack of rapid forgetting, which suggests a relative absence of a storage deficit. Results of studies in declarative memory impairment in BD suggests that the impairments are consistent with deficits in learning, but do not appear to be related to different organizational strategies during learning, and do not appear to be secondary to clinical state. Rather, they are associated with the underlying pathophysiology of the illness. Regarding executive functions, patients with BD have deficiencies related to planning, organizational strategies, lack of control in the action, conceptual formation and cognitive flexibility. In depressive phase, patients have problems with concept formation, meanwhile the deficit in verbal fluency is due because they use phonemic rather than semantic clues. In maniac episodes, the executive functions are altered, and it is observed that concept formation and attentional shift are deficient and more evident in patients with a history of psychosis. These deficits explain why maniac persons engage in more risk behaviors, specifically in the inhibiting impulses system. Also in the absence of symptoms, euthymic bipolar disorder patients show no significant differences with respect to controls on attentional set-shifting, problem solving or planning. However, they show qualitative differences involving slower functioning on measures of speed and slower to initiate a response, and present more errors across measures of verbal fluency. With respect to attentional deficits in BD, several studies have pointed to deficits in sustained attention, also known as concentration, related to the capability to sustain the focus during a considerable amount of time. This attentional domain is deficient in manic patients because the lack of behavioral inhibition which is prevalent in this phase, the increased false responding (commission errors), perseveration and vigilance deficits. In contrast, when patients are depressive, they make more mistakes by omission of relevant stimuli. Also in euthymic patients, a deficit in the inattentive component of sustained attention is reported because of decreased target sensitivity (omission errors) and response time inconsistency. It is possible that the observed findings do not reflect dysfunction in one isolated brain area, rather a dysregulation of cortical modulation of subcortical networks is considered. In particular, a neuroanatomic model of mood regulation comprising the prefrontal cortex, amygdala-hippocampal complex, thalamus, basal ganglia, and their inter-connections has been proposed to be implicated in the pathophysiology of mood disorders. Functional neuroimaging studies also support evidence of these neurocognitive anomalies through the application of neuropsychological paradigms, in which metabolic increments in ventral striate and diminished function in prefrontal cortex during executives assignments is common. During maniac or hypomaniac episodes, an increment of activity in the ventral prefrontal cortex of the right hemisphere was observed; meanwhile, in depressive phase the patients show an increase in the same sector but in the left hemisphere compared to euthymic patients. During the depressive episodes of the BD type II, it is observed a reduction of the dorsolateral and medial prefrontal cortex metabolism, and an increase in thalamus and amygdala while resolving cognitive activities. Finally, there is a reduction of metabolism in ventral caudal and prefrontal cortex and an increase in amygdala in patients without depressive or maniac symptoms. This finding supports the hypothesis of permanent prefrontal dysfunction although the absence of clinical symptoms. Finally, as Glahn et al. (2004) have suggested, neurocognitive markers may indicate the presence of quantifiable deviation on a genetically influenced dimension that underlies BD. Such endophenotypes would not identify illness genes per se; rather they would indicate a realiably characterized heritable behavioral phenomenon. Nevertheless, at present it is not known which of the many candidate genes for BD may be associated with neurocognitive endophenotypes for the disorder. Some studies have reported promising preliminary findings indicating a relationship between executive performance and a brain-derived neurotrophic factor gene polymorphism. Given that this gene has been implicated in memory and learning as a function of its role in synaptic transmission, and other genetic association studies have linked this gene to risk for BD, allelic variation in this gene may be associated with cognitive dysfunction in BD.<hr/>En los últimos años se ha planteado la necesidad de identificar los procesos que median entre el genotipo y el fenotipo del Trastorno Bipolar (TB), dando importancia al estudio de los endofenotipos. Los endofenotipos tratan del fenotipo interno y que no se observa clínicamente, que se encuentra mas cercano a la etiología biológica de la enfermedad que sus signos y síntomas, y que se encuentra influenciado por uno o más genes susceptibles al trastorno. Para que un marcador pueda ser considerado como endofenotipo debe cubrir las siguientes características: 1) ser heredable, 2) estar asociado con la enfermedad, 3) ser independiente del estado clínico y 4) mostrar co-segregación familiar. Dentro de los métodos disponibles para identificar a los endofenotipos se encuentran las mediciones neuropsicológicas y cognitivas entre otras. Diversos autores han señalado la utilidad de identificar los endofenotipos neurocognitivos del TB para mejorar la capacidad de detección de los genes que predisponen a la aparición del trastorno y ayudar a una mejor definición de los criterios diagnósticos. En este sentido, se han señalado a las alteraciones en los dominios de atención selectiva, memoria verbal y funciones ejecutivas, como marcadores endofenotípicos más representativos del TB porque cumplen con los criterios antes mencionados. Por lo tanto, en el presente artículo se realizó una revisión de los estudios neuropsicológicos reportados en pacientes con TB en estos dominios cognitivos y la descripción de estas deficiencias, así como de los circuitos neuronales asociados con estas alteraciones. Se realizó una búsqueda de artículos en MEDLINE y psycINFO desde 1990 a 2007 con las siguientes palabras clave: endofenotipo, evaluación neuropsicológica, trastorno bipolar, atención, memoria, funciones ejecutivas, neurocognición y neuroimagen. Los títulos y resúmenes de los artículos identificados fueron examinados y se conservaron aquellos que cubrían nuestros criterios de inclusión. Los artículos se tomaron en cuenta si cubrían los siguientes criterios: 1) incluían pacientes adultos (edad: 16-65), 2) incluían un grupo de comparación psiquiátrico o normal, 3) utilizaban criterios diagnósticos bien establecidos para el diagnóstico (DSM 3ª. y 4ª. eds.), 4) describían información sobre el estado clínico del paciente al momento de la evaluación y 5) utilizaban evaluaciones cognitivas con tareas estandarizadas y bien establecidas. En relación a la memoria declarativa, los pacientes en un episodio depresivo muestran alteraciones en las pruebas de aprendizaje y de memoria de listas de palabras en las variables de recuerdo libre, tanto a corto como a largo plazo; estas subyacen a deficiencias en la planeación y en la memoria operativa o de trabajo, mismas que persisten después de la fase aguda de cualquier etapa de este padecimiento. Durante la manía se observa un pobre desempeño caracterizado por intrusiones y asociaciones verbales irrelevantes. Se ha señalado que durante la eutimia existen deficiencias asociadas con fallas en la codificación de la información y que no se deben al olvido o a deficiencias en su almacenamiento. Las evaluaciones que se han realizado de las funciones ejecutivas, coinciden al señalar incapacidad para planear, organizar y controlar la conducta en las fases depresivas y de manía/hipomanía, mientras que en la eutimia los pacientes únicamente muestran diferencias cualitativas en comparación con los sujetos sanos, caracterizadas por fallas ante tareas de fluidez verbal semántica y enlentecimiento en la velocidad de procesamiento. Con respecto a la atención selectiva, ha sido posible identificar que los pacientes con manía/hipomanía fallan porque presentan mayor cantidad de errores de comisión, asociado con impulsividad y deficiencias en la autorregulación; por otra parte, durante la fase depresiva se observa incapacidad para responder a estímulos importantes y mayor presencia de errores de omisión. Durante la eutimia, se encuentra alterado el componente de inatención debido a que obtienen menores puntajes en la detección del estímulo y requieren mayor tiempo de reacción. Los hallazgos neuropsicológicos antes descritos parecen reflejar la disregulación en la modulación cortical de las redes subcorticales, particularmente en el circuito que implica a la corteza prefrontal, al complejo amígdala-hipocampal, el tálamo, los ganglios basales y sus interconexiones; circuito que ha sido propuesto como un modelo neuroanatómico de la regulación afectiva. Además de la disregulación en este circuito, parecen estar involucradas disfunciones en los sectores laterales del lóbulo temporal durante las fases de manía/hipomanía. <![CDATA[<b>Rafael Salín-Pascual</b>: <b>El lado oscuro del cerebro</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200012&lng=pt&nrm=iso&tlng=pt Although many studies have demonstrated that bipolar disorder (BD) is heritable, the disorder's genetic basis remains elusive despite the substantial evidence. Hence, indicators of processes mediating between genotype and phenotype, known as endophenotypes, may be necessary to provide more information about this issue. Given that endophenotypes could provide information for elucidating the genetic underpinnings of BD, many studies have focused on one class of endophenotypic marker, the neuropsychological measures. In order for a cognitive measure to be considered an endophenotype, it has to 1. be highly heritable, 2. be associated with the illness, 3. be independent of the clinical state and, 4. the impairment must co-segregate with the illness within a family, with non-affected family members showing impairment relative to general population. In this sense, failures in attention, executive functions and verbal memory are the most consistently reported deficits with the characteristics for endophenotypes. With these factors in mind, the primary interest of this paper was to review the existing literature on neurocognitive functioning in BD as possible endophenotypes. Studies were identified by searching the major databases (MEDLINE and PSYCINFO) from 1990 to 2007 with the following key words: endophenotype, neurocognitive assessment, bipolar disorder, attention, memory, executive functions, neuropsychological assessment and neuroimaging. The titles and abstracts of the articles identified were examined and those that appeared to fullfil our inclusion criteria were retrieved. Articles were included if they met the following criteria: 1. included adult patients (aged: 16-65), 2. included a psychiatric or normal comparison group, 3. used well-established diagnostic criteria to ascertain diagnosis (DSM, 3rd. and 4th. eds.), 4. provided information about the clinical status of the patients being assessmed and 5. cognitive assessment was based on standardized or well established cognitive tasks. Declarative memory has been studied in BD patients through tests that imply learning of words and stories to evaluate immediate memory, delayed recall and recognition, also considering the kind of strategies that the patients use to evoke verbal material. It seems that BD patients in depressive phase present deficits in immediate memory and delayed recall, but recognition memory is preserved. This impairment is due to difficulties in the planning and evoking strategies used, associated to prefrontal dysfunction. In manic phase, the patients make a lot of irrelevant associations because the failure in the system to control impulses. In the absence of the depressive and maniac symptoms, patients continue with anomalies in memory. Euthymic patient can use a similar semantic clustering strategy so that they can recall and recognize fewer words than controls, suggesting impaired encoding of verbal information and there is lack of rapid forgetting, which suggests a relative absence of a storage deficit. Results of studies in declarative memory impairment in BD suggests that the impairments are consistent with deficits in learning, but do not appear to be related to different organizational strategies during learning, and do not appear to be secondary to clinical state. Rather, they are associated with the underlying pathophysiology of the illness. Regarding executive functions, patients with BD have deficiencies related to planning, organizational strategies, lack of control in the action, conceptual formation and cognitive flexibility. In depressive phase, patients have problems with concept formation, meanwhile the deficit in verbal fluency is due because they use phonemic rather than semantic clues. In maniac episodes, the executive functions are altered, and it is observed that concept formation and attentional shift are deficient and more evident in patients with a history of psychosis. These deficits explain why maniac persons engage in more risk behaviors, specifically in the inhibiting impulses system. Also in the absence of symptoms, euthymic bipolar disorder patients show no significant differences with respect to controls on attentional set-shifting, problem solving or planning. However, they show qualitative differences involving slower functioning on measures of speed and slower to initiate a response, and present more errors across measures of verbal fluency. With respect to attentional deficits in BD, several studies have pointed to deficits in sustained attention, also known as concentration, related to the capability to sustain the focus during a considerable amount of time. This attentional domain is deficient in manic patients because the lack of behavioral inhibition which is prevalent in this phase, the increased false responding (commission errors), perseveration and vigilance deficits. In contrast, when patients are depressive, they make more mistakes by omission of relevant stimuli. Also in euthymic patients, a deficit in the inattentive component of sustained attention is reported because of decreased target sensitivity (omission errors) and response time inconsistency. It is possible that the observed findings do not reflect dysfunction in one isolated brain area, rather a dysregulation of cortical modulation of subcortical networks is considered. In particular, a neuroanatomic model of mood regulation comprising the prefrontal cortex, amygdala-hippocampal complex, thalamus, basal ganglia, and their inter-connections has been proposed to be implicated in the pathophysiology of mood disorders. Functional neuroimaging studies also support evidence of these neurocognitive anomalies through the application of neuropsychological paradigms, in which metabolic increments in ventral striate and diminished function in prefrontal cortex during executives assignments is common. During maniac or hypomaniac episodes, an increment of activity in the ventral prefrontal cortex of the right hemisphere was observed; meanwhile, in depressive phase the patients show an increase in the same sector but in the left hemisphere compared to euthymic patients. During the depressive episodes of the BD type II, it is observed a reduction of the dorsolateral and medial prefrontal cortex metabolism, and an increase in thalamus and amygdala while resolving cognitive activities. Finally, there is a reduction of metabolism in ventral caudal and prefrontal cortex and an increase in amygdala in patients without depressive or maniac symptoms. This finding supports the hypothesis of permanent prefrontal dysfunction although the absence of clinical symptoms. Finally, as Glahn et al. (2004) have suggested, neurocognitive markers may indicate the presence of quantifiable deviation on a genetically influenced dimension that underlies BD. Such endophenotypes would not identify illness genes per se; rather they would indicate a realiably characterized heritable behavioral phenomenon. Nevertheless, at present it is not known which of the many candidate genes for BD may be associated with neurocognitive endophenotypes for the disorder. Some studies have reported promising preliminary findings indicating a relationship between executive performance and a brain-derived neurotrophic factor gene polymorphism. Given that this gene has been implicated in memory and learning as a function of its role in synaptic transmission, and other genetic association studies have linked this gene to risk for BD, allelic variation in this gene may be associated with cognitive dysfunction in BD.<hr/>En los últimos años se ha planteado la necesidad de identificar los procesos que median entre el genotipo y el fenotipo del Trastorno Bipolar (TB), dando importancia al estudio de los endofenotipos. Los endofenotipos tratan del fenotipo interno y que no se observa clínicamente, que se encuentra mas cercano a la etiología biológica de la enfermedad que sus signos y síntomas, y que se encuentra influenciado por uno o más genes susceptibles al trastorno. Para que un marcador pueda ser considerado como endofenotipo debe cubrir las siguientes características: 1) ser heredable, 2) estar asociado con la enfermedad, 3) ser independiente del estado clínico y 4) mostrar co-segregación familiar. Dentro de los métodos disponibles para identificar a los endofenotipos se encuentran las mediciones neuropsicológicas y cognitivas entre otras. Diversos autores han señalado la utilidad de identificar los endofenotipos neurocognitivos del TB para mejorar la capacidad de detección de los genes que predisponen a la aparición del trastorno y ayudar a una mejor definición de los criterios diagnósticos. En este sentido, se han señalado a las alteraciones en los dominios de atención selectiva, memoria verbal y funciones ejecutivas, como marcadores endofenotípicos más representativos del TB porque cumplen con los criterios antes mencionados. Por lo tanto, en el presente artículo se realizó una revisión de los estudios neuropsicológicos reportados en pacientes con TB en estos dominios cognitivos y la descripción de estas deficiencias, así como de los circuitos neuronales asociados con estas alteraciones. Se realizó una búsqueda de artículos en MEDLINE y psycINFO desde 1990 a 2007 con las siguientes palabras clave: endofenotipo, evaluación neuropsicológica, trastorno bipolar, atención, memoria, funciones ejecutivas, neurocognición y neuroimagen. Los títulos y resúmenes de los artículos identificados fueron examinados y se conservaron aquellos que cubrían nuestros criterios de inclusión. Los artículos se tomaron en cuenta si cubrían los siguientes criterios: 1) incluían pacientes adultos (edad: 16-65), 2) incluían un grupo de comparación psiquiátrico o normal, 3) utilizaban criterios diagnósticos bien establecidos para el diagnóstico (DSM 3ª. y 4ª. eds.), 4) describían información sobre el estado clínico del paciente al momento de la evaluación y 5) utilizaban evaluaciones cognitivas con tareas estandarizadas y bien establecidas. En relación a la memoria declarativa, los pacientes en un episodio depresivo muestran alteraciones en las pruebas de aprendizaje y de memoria de listas de palabras en las variables de recuerdo libre, tanto a corto como a largo plazo; estas subyacen a deficiencias en la planeación y en la memoria operativa o de trabajo, mismas que persisten después de la fase aguda de cualquier etapa de este padecimiento. Durante la manía se observa un pobre desempeño caracterizado por intrusiones y asociaciones verbales irrelevantes. Se ha señalado que durante la eutimia existen deficiencias asociadas con fallas en la codificación de la información y que no se deben al olvido o a deficiencias en su almacenamiento. Las evaluaciones que se han realizado de las funciones ejecutivas, coinciden al señalar incapacidad para planear, organizar y controlar la conducta en las fases depresivas y de manía/hipomanía, mientras que en la eutimia los pacientes únicamente muestran diferencias cualitativas en comparación con los sujetos sanos, caracterizadas por fallas ante tareas de fluidez verbal semántica y enlentecimiento en la velocidad de procesamiento. Con respecto a la atención selectiva, ha sido posible identificar que los pacientes con manía/hipomanía fallan porque presentan mayor cantidad de errores de comisión, asociado con impulsividad y deficiencias en la autorregulación; por otra parte, durante la fase depresiva se observa incapacidad para responder a estímulos importantes y mayor presencia de errores de omisión. Durante la eutimia, se encuentra alterado el componente de inatención debido a que obtienen menores puntajes en la detección del estímulo y requieren mayor tiempo de reacción. Los hallazgos neuropsicológicos antes descritos parecen reflejar la disregulación en la modulación cortical de las redes subcorticales, particularmente en el circuito que implica a la corteza prefrontal, al complejo amígdala-hipocampal, el tálamo, los ganglios basales y sus interconexiones; circuito que ha sido propuesto como un modelo neuroanatómico de la regulación afectiva. Además de la disregulación en este circuito, parecen estar involucradas disfunciones en los sectores laterales del lóbulo temporal durante las fases de manía/hipomanía. <![CDATA[<b>Autoevaluación</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000200013&lng=pt&nrm=iso&tlng=pt Although many studies have demonstrated that bipolar disorder (BD) is heritable, the disorder's genetic basis remains elusive despite the substantial evidence. Hence, indicators of processes mediating between genotype and phenotype, known as endophenotypes, may be necessary to provide more information about this issue. Given that endophenotypes could provide information for elucidating the genetic underpinnings of BD, many studies have focused on one class of endophenotypic marker, the neuropsychological measures. In order for a cognitive measure to be considered an endophenotype, it has to 1. be highly heritable, 2. be associated with the illness, 3. be independent of the clinical state and, 4. the impairment must co-segregate with the illness within a family, with non-affected family members showing impairment relative to general population. In this sense, failures in attention, executive functions and verbal memory are the most consistently reported deficits with the characteristics for endophenotypes. With these factors in mind, the primary interest of this paper was to review the existing literature on neurocognitive functioning in BD as possible endophenotypes. Studies were identified by searching the major databases (MEDLINE and PSYCINFO) from 1990 to 2007 with the following key words: endophenotype, neurocognitive assessment, bipolar disorder, attention, memory, executive functions, neuropsychological assessment and neuroimaging. The titles and abstracts of the articles identified were examined and those that appeared to fullfil our inclusion criteria were retrieved. Articles were included if they met the following criteria: 1. included adult patients (aged: 16-65), 2. included a psychiatric or normal comparison group, 3. used well-established diagnostic criteria to ascertain diagnosis (DSM, 3rd. and 4th. eds.), 4. provided information about the clinical status of the patients being assessmed and 5. cognitive assessment was based on standardized or well established cognitive tasks. Declarative memory has been studied in BD patients through tests that imply learning of words and stories to evaluate immediate memory, delayed recall and recognition, also considering the kind of strategies that the patients use to evoke verbal material. It seems that BD patients in depressive phase present deficits in immediate memory and delayed recall, but recognition memory is preserved. This impairment is due to difficulties in the planning and evoking strategies used, associated to prefrontal dysfunction. In manic phase, the patients make a lot of irrelevant associations because the failure in the system to control impulses. In the absence of the depressive and maniac symptoms, patients continue with anomalies in memory. Euthymic patient can use a similar semantic clustering strategy so that they can recall and recognize fewer words than controls, suggesting impaired encoding of verbal information and there is lack of rapid forgetting, which suggests a relative absence of a storage deficit. Results of studies in declarative memory impairment in BD suggests that the impairments are consistent with deficits in learning, but do not appear to be related to different organizational strategies during learning, and do not appear to be secondary to clinical state. Rather, they are associated with the underlying pathophysiology of the illness. Regarding executive functions, patients with BD have deficiencies related to planning, organizational strategies, lack of control in the action, conceptual formation and cognitive flexibility. In depressive phase, patients have problems with concept formation, meanwhile the deficit in verbal fluency is due because they use phonemic rather than semantic clues. In maniac episodes, the executive functions are altered, and it is observed that concept formation and attentional shift are deficient and more evident in patients with a history of psychosis. These deficits explain why maniac persons engage in more risk behaviors, specifically in the inhibiting impulses system. Also in the absence of symptoms, euthymic bipolar disorder patients show no significant differences with respect to controls on attentional set-shifting, problem solving or planning. However, they show qualitative differences involving slower functioning on measures of speed and slower to initiate a response, and present more errors across measures of verbal fluency. With respect to attentional deficits in BD, several studies have pointed to deficits in sustained attention, also known as concentration, related to the capability to sustain the focus during a considerable amount of time. This attentional domain is deficient in manic patients because the lack of behavioral inhibition which is prevalent in this phase, the increased false responding (commission errors), perseveration and vigilance deficits. In contrast, when patients are depressive, they make more mistakes by omission of relevant stimuli. Also in euthymic patients, a deficit in the inattentive component of sustained attention is reported because of decreased target sensitivity (omission errors) and response time inconsistency. It is possible that the observed findings do not reflect dysfunction in one isolated brain area, rather a dysregulation of cortical modulation of subcortical networks is considered. In particular, a neuroanatomic model of mood regulation comprising the prefrontal cortex, amygdala-hippocampal complex, thalamus, basal ganglia, and their inter-connections has been proposed to be implicated in the pathophysiology of mood disorders. Functional neuroimaging studies also support evidence of these neurocognitive anomalies through the application of neuropsychological paradigms, in which metabolic increments in ventral striate and diminished function in prefrontal cortex during executives assignments is common. During maniac or hypomaniac episodes, an increment of activity in the ventral prefrontal cortex of the right hemisphere was observed; meanwhile, in depressive phase the patients show an increase in the same sector but in the left hemisphere compared to euthymic patients. During the depressive episodes of the BD type II, it is observed a reduction of the dorsolateral and medial prefrontal cortex metabolism, and an increase in thalamus and amygdala while resolving cognitive activities. Finally, there is a reduction of metabolism in ventral caudal and prefrontal cortex and an increase in amygdala in patients without depressive or maniac symptoms. This finding supports the hypothesis of permanent prefrontal dysfunction although the absence of clinical symptoms. Finally, as Glahn et al. (2004) have suggested, neurocognitive markers may indicate the presence of quantifiable deviation on a genetically influenced dimension that underlies BD. Such endophenotypes would not identify illness genes per se; rather they would indicate a realiably characterized heritable behavioral phenomenon. Nevertheless, at present it is not known which of the many candidate genes for BD may be associated with neurocognitive endophenotypes for the disorder. Some studies have reported promising preliminary findings indicating a relationship between executive performance and a brain-derived neurotrophic factor gene polymorphism. Given that this gene has been implicated in memory and learning as a function of its role in synaptic transmission, and other genetic association studies have linked this gene to risk for BD, allelic variation in this gene may be associated with cognitive dysfunction in BD.<hr/>En los últimos años se ha planteado la necesidad de identificar los procesos que median entre el genotipo y el fenotipo del Trastorno Bipolar (TB), dando importancia al estudio de los endofenotipos. Los endofenotipos tratan del fenotipo interno y que no se observa clínicamente, que se encuentra mas cercano a la etiología biológica de la enfermedad que sus signos y síntomas, y que se encuentra influenciado por uno o más genes susceptibles al trastorno. Para que un marcador pueda ser considerado como endofenotipo debe cubrir las siguientes características: 1) ser heredable, 2) estar asociado con la enfermedad, 3) ser independiente del estado clínico y 4) mostrar co-segregación familiar. Dentro de los métodos disponibles para identificar a los endofenotipos se encuentran las mediciones neuropsicológicas y cognitivas entre otras. Diversos autores han señalado la utilidad de identificar los endofenotipos neurocognitivos del TB para mejorar la capacidad de detección de los genes que predisponen a la aparición del trastorno y ayudar a una mejor definición de los criterios diagnósticos. En este sentido, se han señalado a las alteraciones en los dominios de atención selectiva, memoria verbal y funciones ejecutivas, como marcadores endofenotípicos más representativos del TB porque cumplen con los criterios antes mencionados. Por lo tanto, en el presente artículo se realizó una revisión de los estudios neuropsicológicos reportados en pacientes con TB en estos dominios cognitivos y la descripción de estas deficiencias, así como de los circuitos neuronales asociados con estas alteraciones. Se realizó una búsqueda de artículos en MEDLINE y psycINFO desde 1990 a 2007 con las siguientes palabras clave: endofenotipo, evaluación neuropsicológica, trastorno bipolar, atención, memoria, funciones ejecutivas, neurocognición y neuroimagen. Los títulos y resúmenes de los artículos identificados fueron examinados y se conservaron aquellos que cubrían nuestros criterios de inclusión. Los artículos se tomaron en cuenta si cubrían los siguientes criterios: 1) incluían pacientes adultos (edad: 16-65), 2) incluían un grupo de comparación psiquiátrico o normal, 3) utilizaban criterios diagnósticos bien establecidos para el diagnóstico (DSM 3ª. y 4ª. eds.), 4) describían información sobre el estado clínico del paciente al momento de la evaluación y 5) utilizaban evaluaciones cognitivas con tareas estandarizadas y bien establecidas. En relación a la memoria declarativa, los pacientes en un episodio depresivo muestran alteraciones en las pruebas de aprendizaje y de memoria de listas de palabras en las variables de recuerdo libre, tanto a corto como a largo plazo; estas subyacen a deficiencias en la planeación y en la memoria operativa o de trabajo, mismas que persisten después de la fase aguda de cualquier etapa de este padecimiento. Durante la manía se observa un pobre desempeño caracterizado por intrusiones y asociaciones verbales irrelevantes. Se ha señalado que durante la eutimia existen deficiencias asociadas con fallas en la codificación de la información y que no se deben al olvido o a deficiencias en su almacenamiento. Las evaluaciones que se han realizado de las funciones ejecutivas, coinciden al señalar incapacidad para planear, organizar y controlar la conducta en las fases depresivas y de manía/hipomanía, mientras que en la eutimia los pacientes únicamente muestran diferencias cualitativas en comparación con los sujetos sanos, caracterizadas por fallas ante tareas de fluidez verbal semántica y enlentecimiento en la velocidad de procesamiento. Con respecto a la atención selectiva, ha sido posible identificar que los pacientes con manía/hipomanía fallan porque presentan mayor cantidad de errores de comisión, asociado con impulsividad y deficiencias en la autorregulación; por otra parte, durante la fase depresiva se observa incapacidad para responder a estímulos importantes y mayor presencia de errores de omisión. Durante la eutimia, se encuentra alterado el componente de inatención debido a que obtienen menores puntajes en la detección del estímulo y requieren mayor tiempo de reacción. Los hallazgos neuropsicológicos antes descritos parecen reflejar la disregulación en la modulación cortical de las redes subcorticales, particularmente en el circuito que implica a la corteza prefrontal, al complejo amígdala-hipocampal, el tálamo, los ganglios basales y sus interconexiones; circuito que ha sido propuesto como un modelo neuroanatómico de la regulación afectiva. Además de la disregulación en este circuito, parecen estar involucradas disfunciones en los sectores laterales del lóbulo temporal durante las fases de manía/hipomanía.