Scielo RSS <![CDATA[Salud mental]]> http://www.scielo.org.mx/rss.php?pid=0185-332520080006&lang=pt vol. 31 num. 6 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.mx/img/en/fbpelogp.gif http://www.scielo.org.mx <![CDATA[<b>Is it justified an extended treatment with benzodiacepines?</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600001&lng=pt&nrm=iso&tlng=pt <![CDATA[<b>Genetic studies of bipolar disorder in patients selected by their treatment response</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600002&lng=pt&nrm=iso&tlng=pt Bipolar disorder (BD) is a major mood disorder with several genes of moderate or small effect contributing to the genetic susceptibility. It is also likely heterogeneous, which stimulated efforts to refine its clinical phenotype, studies investigating the link between BD susceptibility and response to a specific mood stabilizer appear to be one of the promising directions. In particular, excellent response to lithium prophylaxis has been described as a clinical marker of a more homogeneous subgroup of BD, characterized by an episodic course, low rates of co-morbid conditions, absence of rapid cycling, and a strong genetic loading. These results also suggest that lithium response clusters in families (independent of the increased familial loading for affective disorders), likely on a genetic basis. For almost 40 years, clinical studies have pointed to differences between lithium responders (LR) and non-responders (LNR). For instance, there is a higher frequency of BD in LR families. As well, investigations in offspring of LR and LNR probands show that the offspring of LR tend to manifest a higher frequency of affective disorders, less co-morbidity and an episodic course of the disorder, compared with the offspring of LNR, who had a broad range of psychopathology, a higher rate of co-morbidity and a chronic course of the disorder. A number of candidate genes have been studied in patients treated with lithium; of these, several showed an association in at least one study: cAMP responsive element binding protein (CREB), X-box binding protein 1 (XBP-1), inositol polyphosphate-1-phosphatase (INNP1), serotonin transporter gene (5-HTT), brain-derived neurotrophic factor (BDNF), phospholipase γ-1 (PLCγ-1), dopamine receptors (D2 and D4), polyglutamine tracts, tyrosine hydroxylase, inositol monophosphatase (IMPA), mitochondrial DNA, and breakpoint cluster region (BCR) gene. Clinical studies have shown as well that the treatment response and outcome appear to be specific for the different types of mood stabilizers. Patients who respond to lithium exhibit qualitative differences from patients responding to other medications, such as valproate, carbamazepine or lamotrigine. Responders to carbamazepine had atypical clinical features, such as mood-incongruent psychosis, an age at onset of illness below 30 years old, and a negative family history of mood disorders. Similarly, in a study comparing the phenotypic spectra in responders to lithium versus lamotrigine the probands differed with respect to clinical course (with rapid cycling and non-episodic course in the lamotrigine group) and co-morbidity, with the lamotrigine-responder group showing a higher frequency of panic attacks and substance abuse. In conclusion, pharmacogenetic studies may provide important clues to the nature of bipolar disorder and the response to long term treatment.<hr/>El trastorno bipolar (TB) es un trastorno afectivo con varios genes, de efecto leve o moderado, que contribuyen a su susceptibilidad. Es asimismo un trastorno heterogéneo, lo que ha estimulado diversas iniciativas para refinar el fenotipo de los pacientes con este trastorno. Particularmente en el TB, una respuesta excelente a la profilaxis con litio ha sido descrita como un marcador clínico en un subgrupo más homogéneo en TB, caracterizado por un curso episódico, baja prevalencia respecto a comorbilidad, ausencia de ciclado rápido y una carga genética importante. En relación con ello, y a pesar de que la totalidad de los estudios no coinciden, la mayor parte sugiere que seleccionar <<probandos>> de acuerdo con su respuesta al tratamiento incrementa la homogeneidad fenotípica. Estos resultados sugieren asimismo que la respuesta al litio <<se agrupa>> en familias (independientemente de la tasa familiar incrementada para trastornos afectivos), muy probablemente con bases genéticas. Por casi 40 años, los estudios clínicos han dilucidado las diferencias entre los respondedores a litio (LR) y los no respondedores (LNR). A este respecto, existe una frecuencia más alta de TB en familias LR; asimismo, las investigaciones en los descendientes de los probandos LR y LNR han demostrado que los descendientes de LR tienden a manifestar una mayor frecuencia de trastornos afectivos, menor comorbilidad, y un curso episódico del trastorno comparados con los descendientes de LNR, quienes muestran un amplio espectro de psicopatología, una alta tasa de comorbilidad, y un curso crónico del trastorno. Diversos genes candidatos han sido estudiados en pacientes tratados con litio, y varios de ellos han mostrado una asociación en al menos un estudio: proteína de unión al elemento de respuesta (cAMP responsive element binding protein, CREB), proteína de unión a X-box 1 (X-box binding protein 1, XBP-1), inositol polifosfato-1-fosfatasa (INNP1), transportador de serotonina (5-HTT), factor de crecimiento derivado del cerebro (brain-derived neurotrophic factor, BDNF), fosfolipasa γ-1(PLCγ-1), receptores dopaminérgicos (D2 y D4), poliglutamina, tirosina hidroxilasa, inositol monofosfatasa (IMPA), DNA mitocondrial y el gen BCR. Los estudios clínicos han demostrado que la respuesta al tratamiento y el pronóstico parecen ser específicos para los diferentes tipos de estabilizadores del ánimo. Los pacientes que responden al litio exhiben diferencias cualitativas respecto a los pacientes que responden a otros estabilizadores del ánimo, como valproato, carbamazepina o lamotrigina. Los respondedores a carbamazepina presentan características clínicas atípicas, como psicosis incongruente con el afecto, una edad de inicio del trastorno menor a 30 años de edad y no cuentan con historia familiar de trastornos afectivos. Finalmente, un estudio entre los respondedores al litio y los respondedores a lamotrigina demostró que los probandos difieren con respecto al curso clínico del trastorno (con ciclado rápido y un curso no episódico en los pacientes que responden a lamotrigina), así como en la comorbilidad, teniendo los pacientes que responden a lamotrigina una mayor frecuencia de crisis de angustia y abuso de sustancias. En conclusión, los estudios farmacogenéticos podrían proveer de hallazgos importantes respecto a la naturaleza del trastorno bipolar y la respuesta al tratamiento a largo plazo. <![CDATA[<b>Neuropsychological evaluation in patients with eating disorders</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600003&lng=pt&nrm=iso&tlng=pt Research related to neuropsychological evaluation on eating disorders (ED) has produced diverse results, being more abundant those which study attention, specifically using Stroop Test, both in the standard and the modified versions, using words related to food and body shape. In most of the cases, different clinical groups have not been used in the same research. Studies have not used other tests which evaluate cognitive areas besides those evaluated by Stroop Test; and most of researchers who have measured attention with Stroop Test have focused on measuring latency and not interference. Some studies have found deficits in attention, executive functions, and memory in patients with ED; however, other studies have not found deficits in attention. Because of this evidence, the present study proposed that patients with ED would show deficits in selective attention, perseverative thinking, working memory, and executive planning, compared to a control group without ED. Participants included 26 female patients with bulimia nervosa (BN) and 10 female patients with anorexia nervosa (AN), matched in age and education by the control group (n = 36). All patients met eating disorders criteria, and did not have a history of neuropsychological evaluation. Four neuropsychological tests were individually administered in two sessions with a counterbalanced approach: 1. Wisconsin Card Sorting Test, 2. Stroop Colors Test (developed in the program E-Prime with words related to food and body shape), 3. Rey-Osterrieth Complex Figure, and 4. Tower of London Test. There was a significant difference between three groups in the memory test, the execution total time and in the number of perseverative answers. In memory, the AN group had the worst performance, followed by the BN group. As for the executive planning, both AN and BN groups took longer to complete the test compared to the control group. Finally, AN and BN groups showed more perseverative answers than the control group. There was a statistically significant difference in the number of errors for negative words related to body shape. Post hoc indicated that AN and BN groups produced more errors than the control group, whereas BN group took longer to complete the negative word list related to body shape, in comparison to the control group. Results demonstrate a deficit in cognitive processing in AN and BN groups. The AN group showed a greater impairment in memory than BN group, in comparison to the control group; additionally, both groups of patients took longer to complete the Tower of London Test. This indicates the existence of problems of executive planning in these patients. What is more, in both groups of patients a greater perseverative thinking was observed; this indicates an impairment in the establishment of an appropriate strategy to solve problems, a characteristic of BN patients. Anorectic and bulimic patients showed an attentional deficit for words with negative valence related to body shape. In addition, the AN group showed an attentional bias both for words with positive valence and words with negative valence related to food, and the BN group produced more errors in the words with positive valence related to body shape. In this sense, it is proposed that the patients have general units of knowledge or <<schemes>> that determine what the most important aspects of a situation are and what sort of information will be stored and processed. From this perspective, body image alterations, and attentional, memory, and executive functions biases for stimuli related to food, shape, and weight represent different ways of information processing biases, because there is distortion in the way the patients perceive and interpret their experiences.<hr/>Los trabajos relacionados con la evaluación neuropsicológica de sujetos con trastornos alimentarios (TCA) han obtenido resultados diversos, y abundan más aquellos que estudian la atención, específicamente con la Prueba de Stroop, tanto en su versión estándar como en las modificadas, para lo cual emplean palabras relacionadas con la comida y la figura. En la mayoría de los casos, no se han utilizado diferentes grupos clínicos en la misma investigación. No se han utilizado tampoco otras pruebas que evalúen aspectos cognoscitivos, además de aquellos que evalúa la Prueba de Stroop; y la mayoría de las investigaciones que han medido la atención con ésta se han enfocado en medir la latencia y no la interferencia. Algunos estudios han encontrado déficits en la atención, funciones ejecutivas y en la memoria en pacientes con TCA, pero otros estudios no encontraron déficits en la atención. A la luz de estas evidencias, este trabajo hipotetiza que las pacientes con TCA presentan déficits en la atención selectiva, el pensamiento perseverativo, la memoria de trabajo y la planeación ejecutiva en comparación con un grupo de sujetos control sin TCA. El grupo de 36 pacientes de nuevo ingreso con TCA incluyó 26 mujeres con BN y 10 con AN. La muestra sin trastorno (n = 36) se emparejó por edad y nivel de estudios con la muestra de pacientes. Todas las pacientes cumplieron los criterios de TCA y no tenían historia de evaluación neuropsicológica. Se aplicaron cuatro pruebas neuropsicológicas de manera individual y contrabalanceada en dos sesiones: 1. Prueba de Ordenamiento de Tarjetas de Wisconsin, 2. Prueba de Colores de Stroop (desarrollada en el programa E-Prime, con palabras relacionadas con la comida y la figura corporal), 3. Prueba de la Figura Compleja de Rey-Osterrieth, y 4. Prueba de la Torre de Londres. Se observó una diferencia significativa entre los tres grupos en la prueba de memoria, en el tiempo total de ejecución y en el número de respuestas perseverativas. En la prueba de memoria, el grupo con AN tuvo el peor desempeño, seguido por el grupo con BN. Para la planeación ejecutiva, tanto al grupo con AN como el de BN les tomó más tiempo realizar la prueba. Finalmente, los grupos con AN y BN mostraron más respuestas perseverativas que el control. Se observó una diferencia estadísticamente significativa en el número de errores para palabras negativas relacionadas con la figura corporal. Los grupos con AN y BN cometieron más errores que el control, mientras que al grupo con BN le tomó más tiempo completar la serie de palabras negativas relacionadas con la figura y el peso corporal, en comparación con el control. Los resultados demuestran un deterioro en el funcionamiento cognoscitivo tanto en los sujetos con AN y BN. Las pacientes con AN presentaron un sesgo mayor en la memoria que el grupo con BN en relación con el grupo control. Adicionalmente, a los dos grupos de pacientes les tomó más tiempo realizar la Prueba de la Torre de Londres. Ello indica la existencia de problemas de planeación ejecutiva en estas pacientes. También en ambos grupos de pacientes se observó un mayor pensamiento perseverativo que señala déficits en el establecimiento de una estrategia adecuada para solucionar problemas, lo cual es característico de las pacientes con BN. Las pacientes anoréxicas y bulímicas mostraron un sesgo en la atención para palabras con valencia negativa relacionadas con la figura y el peso. Adicionalmente, el grupo con AN presentó un sesgo en la atención tanto para palabras con valencia positiva como con valencia negativa relacionadas con la comida, mientras que el grupo con BN cometió más errores en las palabras con valencia positiva relacionadas con la figura. En este sentido, se ha propuesto que las pacientes tienen unidades generales de conocimientos o <<esquemas>> que determinan qué aspectos de una situación son más importantes y qué información será almacenada y procesada. Desde esta perspectiva, las alteraciones en la imagen corporal, los sesgos en la atención, en la memoria y en las funciones ejecutivas para estímulos relacionados con la comida, la figura y el peso corporal representan distintas formas de sesgos en el procesamiento de información, debido a que existe una distorsión en la manera en que los individuos perciben e interpretan sus experiencias. <![CDATA[<b>Risk eating behaviors and social skills in a sample of Mexican adolescents</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600004&lng=pt&nrm=iso&tlng=pt Research about ED (eating disorder) has shown important advances in the last decades. We have distinguished two main ways of aproaching this topic. On the one hand there are several works in the clinical field, focused in studying the symptomatology, psychiatric taxonomy and treatment of those disorders. On the other hand, there is significant research on the epidemiological field, which is more focused towards the understanding of the phenomenon. In fact, this second approach led to the development of the preventive approach in the late 90s. This approach focuses in the population at risk and this work is framed in the preventive approach. The difference between a TCA and a risk factor is that the first one forms a syndrome, a set of symptoms (quantitatively and qualitatively) grouped as diagnostic criteria identified in the DSM-IV-TR. On the other hand, risk factors are those isolated manifestations or symptoms that appear with a lesser magnitude and frequency. For example, abnormal eating behavior like following a diet to control weight or excessive concern about personal body weight. One of the most important factors that occurs before the development of an ED is following a restricted diet. Hence, the risk for people on a diet of turning into clinical cases increases eight times. Moreover, such behavior has become a normative practice, specifically in Western societies. Thus, several authors have pointed out that patients show autonomy problems previous to the disorder. Examples include interpersonal problems such as introversion, insecurity, dependency, social anxiety, lack of assertiveness, difficulty to establish relationships with the opposite gender, inefficiency feelings, failure and lack of control in the academic, working and social fields. All these are indicators of a latent discrepancy of social skills. Considering that restricted dieting represents a fundamental risk factor on the development of an ED, and under the assumption that the deficit in social skills is a predisposing factor in such disorders, the aim of this work was to determine if there is a relation between various social skills and abnormal eating behaviors (following a restricted diet or concern about weight and food) in Mexican adolescent women. We worked with a sample of N = 700 women, coming from five different public middle schools mixed with <img border=0 src="../../../../../img/revistas/sm/v31n6/a4s1.jpg" > or = 12.81 years old and SD = 0.73. The data was collected through two instruments: Health and Nourishing Questionnaire, and Pluridimensional Assertive Behavior Scale, adapted to the Mexican population. Among the more relevant results we found a significant correlation between the following two variables: social skills and eating behaviors (dieting r = 0.148, p<0.01 and concern about weight and food r = 0.081, p< 0.05). Although the correlation was low, it can be interpreted as a tendency in the following way: <<the more problems in social skills the person has, the more restricted diets and concerns about weight and food we can observe>>. In a second analysis, in which extreme groups (high and low social skills) were compared, our results confirmed the theory about relating these two variables. The mean values indicate that in the first group (low social skills) restricted dieting was a greater problem [t (306) = -1.329, p= .002] than in the second group (high social skills). Other results showed that more than half of the participants (56%) have followed a restricted dieting in the past and 65% of them are concerned about their body weight. Additionally, a significant correlation between these two variables was found (r = 0.677, p<0.01), confirming that these behaviors have become normative among women at this age and these constitute a latent risk to the development of ED. Furthermore, it is a cause of concern that the findings of this study show that girls are involved in restricted dieting even at an early age (seven years old) and that at six years old they begin to be concerned about their body weight. These results are similar to other studies that show women starting practices that might produce eating disorders at very early stages nowadays, due to being more exposed and more vulnerable to social pressure that promotes the thinness culture. One of the most interesting contributions was the fact that among Mexican adolescent women, similarly to women in the western world (USA, France or Spain), we have found a relation between low levels in social skills and restricted dieting. This phenomenon increases the risk of suffering from an ED, and shows the effects of social pressure referring to the thinness culture in countries such as Mexico, with its still developing society. It is important to point out that, in order to make the relation clear, it is necessary to accomplish more research towards determining a causal relationship between the two variables. In this way, data can be obtained in order to build up prevention strategies in the following way: training in Social Skills (TSS) could act as a protection factor against the development of these disorders. If a deficit in social skills can predict weight control dieting, the TSS might decrease or eliminate the risk in adolescents frequently subdued to dieting and/or show risky eating behavior as a consequence of social pressure towards thinness. Among the limitations of this study we can mention that the results cannot be generalized from the particular study sample. For this purpose we propose working with probabilistic samples and with different features, as well as implementing a new analysis that could show the specific social skills in which the problem is accentuated. This would contribute to search the possible causal link between the variables <<social skills>> and <<risk eating behaviors>>.<hr/>En las investigaciones relacionadas con los trastornos de la conducta alimentaria (TCA) se distinguen dos vertientes principales. Por una parte proliferan los trabajos en el ámbito clínico, éstos se enfocan en la sintomatología, en esclarecer la taxonomía psiquiátrica y en el tratamiento de dichos trastornos. Por otra parte, se constata la investigación en el ámbito epidemiológico, la cual está más enfocada en la comprensión del fenómeno. De esta segunda vertiente se deriva, a principios de la década de los noventa, el enfoque preventivo, el cual centra su interés en la población de riesgo. Es en este enfoque en el cual se enmarca el presente trabajo. La distinción entre un TCA y un factor de riesgo es que el primero conforma un síndrome, un conjunto de síntomas (cuantitativa y cualitativamente) agrupados como criterios diagnósticos señalados en el DSM-IV-TR, mientras que los factores de riesgo son aquellas manifestaciones o síntomas aislados que se presentan con menor magnitud y frecuencia. El presente trabajo tuvo como objetivo determinar si existe relación entre las variables: habilidades sociales y conductas alimentarias anómalas (seguimiento de dieta restringida y preocupación por el peso y la comida) en mujeres adolescentes mexicanas. Se trabajó con una muestra de N = 700 mujeres de cinco distintas secundarias públicas mixtas con <img border=0 src="../../../../../img/revistas/sm/v31n6/a4s1.jpg" > o = 12.81 de edad y DE = 0.73. Los datos se recopilaron mediante dos instrumentos: el Cuestionario de Alimentación y Salud, y la Escala Pluridimensional de Conducta Asertiva adaptada a población mexicana. Entre los resultados de mayor relevancia se encontró una correlación significativa entre las variables: habilidades sociales y conductas alimentarias anómalas (dieta r = 0.148, p< 0.01 y preocupación por el peso y la comida r = 0.081, p< 0.05). Aunque la correlación fue baja resultó ser positiva, esto se puede interpretar como una tendencia en la siguiente dirección: <<A mayor problemática en habilidades sociales, mayor seguimiento de dieta restringida y mayor preocupación por el peso y la comida>>. En un segundo análisis en el cual se compararon grupos extremos (nivel alto y nivel bajo de habilidades sociales), se encontraron resultados que confirman la relación entre estas variables. El valor de las medias indica que en el grupo con nivel bajo de habilidades sociales se reportó una mayor problemática durante el seguimiento de una dieta restringida [t (306) = -1 .329, p = .002], comparado con el grupo de nivel alto de habilidades. Una de las aportaciones más interesantes fue el hecho de que entre las adolescentes mexicanas, a semejanza de mujeres que habitan en países de primer mundo como EU, Francia y España, se encontró una relación entre niveles bajos de habilidades sociales y el seguimiento de una dieta restringida. Este fenómeno incrementa el riesgo de padecer un TCA y pone de manifiesto el efecto de la presión social con referencia a la cultura de la delgadez en países como México, que es una sociedad en vías de desarrollo. <![CDATA[<b>Motivational protective factors for depression and drug abuse</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600005&lng=pt&nrm=iso&tlng=pt As a part of a innovative research line on mental health and addictions focused to operationalize the clinical approach of Maslow's motivational theory, this study is focused to prove a theoretical multi-factorial model that presuppose a relationship between a set of psycho-social protective factors and affective disorders, attraction to drugs, and severity of legal and illegal drug use, all them mediated by the satisfaction degree of deficit needs and its pleasurable associated sensations. The study was implemented with a cross-sectional, ex-post-facto design, with a 241 sample made out by urban young adults that were actual illicit drug users, which used more than five times one of the next drugs: marijuana, cocaine, crack, inhalants, heroin or metamphetamine. These subjects had a 24,5 mean age (SD= 5,1), with a ratio of almost eight men at of each woman. More than half of them were single, a third part was married or lived together and the fifth part was separated or divorced. Half of participants had high school studies, a fourth part had college and 8% had superior level. Half of the subjects were employed, 10% were students, 4% were housemakers, 5% studied and worked simultaneously, and a third part did not work. A fourth part were referred to previous treatment(s) for drug abuse. Based on the diagnosis, marijuana was identified as a drug of greater impact (29,9%), followed by cocaine (27,4%), inhalants (16,2%), heroin (12.0%), crack (10%) and crystal (4,6%). It was applied a battery of instruments that included: a) A scale to test the Severity of drug abuse (alpha = .953), that included items to evaluate issues such as: the incapacity to control drug use; intense desire to use; increase in the consumption; inability to reject drugs; changes in mood; transgression of the rules; residual symptoms; fights, and self injures. b) The Beck Depression Inventory (alpha = .918), conformed by two factors, Affective-cognitive depression (alpha = .867), with items related to feeling punished, failed and guilty, and Physiological-behavioral depression (alpha = .853) with items associated to insomnia, feeling tired, irritable, unsatisfied and hesitated. c) A multifactorial scale of Degree of Satisfaction of Deficit Needs of Health and security (alpha = .876), with items such as: tranquility, confidence, order and education; authenticity (alpha = .878), with items like honesty, sincerity, respect and freedom; affective (alpha = .780), with items like affection, friendship and love; self esteem (alpha = .825), with items like recognition, work, success and money; and enjoyment (alpha = .910), with items like joy, amusement, happiness, play, laugh, sing and dance. d) A multi-factorial risk and protection scale of drug use and related syndromes (alpha = .794), with the following factors: satisfactory family relations (alpha = .850), satisfactory relation with friends (alpha =927) and individual ability for satisfaction (alpha = .841). e) A multi-factorial scale related with the attraction for legal and illegal drugs (alpha = .949), with a factor for alcohol attraction (alpha = .933), other factor for tobacco attraction (alpha = .890) and a factor for alcohol attraction (alpha = .926). Furthermore, two models were developed with three antecedent manifest variables: individual ability for satisfaction, satisfactory family relations and satisfactory relation with friends. Both models showed that individual ability for satisfaction predicts 17% of variance of the satisfactory family relations and 10% of the satisfactory relation with friends. The mediating latent variable Satisfaction degree of deficit needs showed different forms in each model because the first one included a) satisfaction degree of health and security needs, b) satisfaction degree of self esteem needs and c) satisfaction degree of enjoyment needs, whereas the second model, more parsimonious, kept the first two factors. Both models incorporate, as consequent latent variables, depression (explained in 53% of its variance in model 2) as well as the manifest variable of: severity of drug abuse (explained in 45%) and the mediating latent variable attraction for legal and illegal drugs with an explained variance of 32% (for example: <<I like them, they help you to feel relax, they are tasty, they produce pleasure, they help you to have friends, to have fun, to make you laugh and to have joy>>). The models provide conceptual validity to the clinical approach of Maslow's theory, because it verifies that the unsatisfaction of deficit needs is related to: the presence of affective disturbance like depression; the attraction by legal and illegal drugs; and the severity of alcohol consumption and drugs. Model one includes among others the mediating variable satisfaction of the needs of self esteem, showing the influence of Jonah's complex usually related to the fear of recognition, success, etc. Model 2 is more parsimonious and reaffirms the importance of satisfying physiological and security needs, and its associated enjoinment. In adittion, it stands out that the individual capacity of satisfaction is related to the satisfaction of deficit needs causing the appearance of moments of joy, amusement and happiness, possibly associated with the Reward Circuit Activation. On the other hand, the individual capacity of satisfaction also maintains a direct relation with satisfactory relations with family and friends. Both variables have as well a positive influence in the satisfaction of deficit needs. Moreover, the individual capacity of satisfaction is related to the satisfaction of the deficit necessities, causing the appearance of moments of joy, amusement and happiness possibly associated with the reward circuit activation. On the other hand, the individual capacity of satisfaction also maintains a direct relationship with satisfactory relations with family and friends, which have also a positive influence to the satisfaction of the deficit needs and their associated enjoyment sensations, such as laugh, singing and dancing, that usually take place in social interactions. Also, it was shown how the individual aptitudes as well as relationships with others were substantial sources for satisfaction of deficit needs. Additionally, it was observed that a deficient degree of needs satisfaction was related to an increment in affection disturbances and in the severity of drug use, supporting the Maslow's psycho-pathogenesis construct. Finally, it was observed how a deficient degree of satisfaction also shows a direct relationship with the attraction to legal and illegal drugs, and is stand out how the presence of affection disturbances increases the attraction to drugs, which at the same time increases the severity of drug use.<hr/>Con el fin de someter a prueba un modelo teórico multifactorial basado en la aproximación clínica de la teoría de la motivación de Maslow -modelo en el que se presupone una relación entre un conjunto de variables psicosociales protectoras y algunos trastornos afectivos, la atracción por las drogas y la severidad de su consumo, mediadas por el grado de satisfacción de ciertas necesidades deficitarias (salud, seguridad y autoestima) así como sensaciones de disfrute asociado- se llevó a cabo un estudio transversal, ex post facto, con una muestra de 241 adultos jóvenes urbanos, consumidores actuales de drogas ilícitas. Se desarrollaron dos modelos estadísticos con base en las variables antecedentes: capacidad individual de satisfacción, relaciones satisfactorias con la familia y relaciones satisfactorias con los amigos. En ambos modelos se encontró que la capacidad individual de satisfacción predice en cierta medida las relaciones satisfactorias con la familia y con los amigos. La variable mediadora satisfacción de necesidades deficitarias se manifestó en forma distinta en ambos modelos, pues el primero incluyó: a) grado de satisfacción de las necesidades de salud y seguridad, b) grado de satisfacción de necesidades de estima y c) grado de satisfacción de necesidades de disfrute, mientras que el segundo, más parsimonioso, conservó sólo las dos primeras variables manifiestas. Ambos modelos incorporan como variables consecuentes la depresión (explicada en 53% en el modelo 2), así como la severidad del consumo de drogas (explicada en 45% de su varianza en el modelo 2). Además, el modelo incorpora como una variable mediadora la atracción por las drogas con una varianza explicada de 32% en el segundo modelo. Los dos modelos aportan validez conceptual a la vertiente clínica de la teoría de Maslow, pues se verificó que la insatisfacción de las necesidades de deficiencia se relaciona con el surgimiento de trastornos afectivos como la depresión, con el gusto por las drogas legales e ilegales y con la severidad del consumo de alcohol y drogas. Además, se destaca que en el modelo 1 se incluye entre otras la variable mediadora: satisfacción de las necesidades de estima, verificándose con ello la influencia del <<Complejo de Jonás>>, relacionado con el temor al reconocimiento, éxito, etc. El modelo 2, es más parsimonioso y reafirma la importancia de resarcir las necesidades fisiológicas y de seguridad y de su disfrute asociado, antes que proponerse incrementar la satisfacción de necesidades deficitarias de niveles más elevados. Así pues, fue evidente cómo la Capacidad individual de satisfacción se relaciona con la Satisfacción de las necesidades deficitarias, y propicia la aparición de momentos de alegría, diversión y felicidad, posiblemente asociados con la Activación del Circuito de Recompensa (ACR). Del mismo modo, la Capacidad Individual de Satisfacción también mantiene una relación di recta con las relaciones satisfactorias con la familia y con los amigos. Ambas variables tienen, a su vez, una influencia positiva en la satisfacción de las necesidades deficitarias y sensaciones de disfrute asociadas como la risa, el canto y el baile, que se producen en la interacción social. Además, se aprecia cómo en las aptitudes individuales y en las relaciones con el medio se encuentran fuentes sustantivas para la satisfacción de las necesidades deficitarias. También se observa congruencia con respecto al constructo de psicopatogénesis, dado que un grado deficiente de satisfacción de las necesidades se relaciona con un incremento en los trastornos del afecto y en la severidad del consumo de drogas. Finalmente, se detectó cómo un grado deficiente de satisfacción en las necesidades también presenta una relación directa con la atracción por las drogas y se destaca cómo la presencia de trastornos del afecto incrementa el desarrollo de la atracción por las drogas, lo cual aumenta la severidad del consumo de sustancias. <![CDATA[<b>Loss structure in elderly adults</b>: <b>A measurement proposal</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600006&lng=pt&nrm=iso&tlng=pt The term <<loss>> in this article refers to the lack of a significant adaptive resource that is a central part of the affective world of the subject. The absence of such resource can generate psychological distress. Old age is seen as a time in which numerous changes occur that are associated with losses in important areas of life and which, as a whole, constitute a major source of stress. These losses involve a series of physical, social and psychological changes that affect and define old age and that require the subject to develop a process of adaptation to many intense stressors. Loss structure can be defined as a set of significant objects (that can be grouped under different loss categories), perceived as being under threat of being lost, effectively lost, or whose existence is uncertain or ambiguous (conceived of as types of loss), and whose influence continues to define cognitions, affection and behaviors. The unprecedented loss structure found in elderly adults could set up different routes of maladjustment. Maladjustment appear in three fundamental areas: psychological, physical and social. Hence, frustration can lead to depression. Successive losses seen as a series of failures can generate feelings of despair; losses related to sources of affection can produce loneliness, etc. The Loss Structure Scale (LSS), proposed here is an instrument for exploring losses that usually occur in old age. It also allows a systematic exploration of a wide range of losses previously validated in the Mexican context as a first approach to possible psychosocial causes of psychological maladjustment in old age. Method The project was divided into two phases. The first corresponded to the design of the LSS, and the second to a psychometric evaluation. Four samples were used with subjects chosen by availability in Mexico City. One model of the scale was explored that consisted of 60 items linked to experiences of loss with three reply options for each item: No loss, Ambiguous loss, and Definite loss in a final sample of 193 subjects (69.34% women, N = 134). The following instruments were used: The Center of Epidemiological Studies Depression Scale; Beck's Anxiety Inventory; Hunter Opinions and Personal Expectations Scale; the perceived disease subscale of WHOQoL- Brief; The World Health Organization Quality of Life Assessment, Brief; the Lack of Emotional Wellbeing subscale of the Multifaceted Loneliness Inventory and the Anxiety About Aging Scale. Results Factor structure. A factor analysis was carried out using the principal components method with varimax rotation and eigen values greater than one. The final factor structure showed nine well defined factors covering 36 items with an internal alpha consistence of .91 explaining 67.4% of the variance. Alpha values for the internal consistence of the 9 factors fluctuated between .74 and .83. Construct validity. 1) Moderately high correlations were obtained between total score on the Loss Structure Scale and all psychological maladjustment variables (between r=.50 and r = .66; p<.01), with the exception of aging anxiety, which seems to point to the important pathogenic role of losses suffered in most of the maladjustment variables, 2) a negative association was found between the frequency of no losses and the afore mentioned variables, with depression (r = -.70, p<.01) and loneliness (r = -.68, p<.01), 3) ambiguous loss frequency correlated positively with depression (r=.54, p<.01), loneliness (r = .47, p<.01), anxiety (r = .42, p<.01) and aging anxiety (r = .40, p< .01), 4) the frequency of definite losses correlated strongly with loneliness (r = .53, p<.01), depression (r = .50, p<.01) and perceived disease (r=.47, p<.01). Predictive ability. In order to determine the degree to which the loss categories can predict psychological maladjustment, a multiple regression analysis was carried out taking these categories as independent variables. The better predicted variables were depression (R²adjusted=.487, gl=9, F = 21.22, p<.000), perceived disease (R²adjusted =.443, gl=9, F = 17.97, p<.000), loneliness (R²adjusted = .423, gl=9, F = 16.62, p<.000), anxiety (R²adjusted =.347, gl=9, F=12.33, p<.000) and despair (R²adjusted =.311, gl = 9, F=10.61, p<.000). Discriminant validity. The scale's ability to discriminate subjects with high and low levels of psychological maladjustment was analyzed. The scale proved to be useful for significantly discriminating the subjects in each type of loss in each maladjustment category. Normalization. Standard deviation ranges were calculated for the total natural scores on the LSS. Subjects with a natural score equal to or greater than 66, could be considered as having a higher loss structure than the majority of elderly adults that could, very well, be associated with high levels of psychological maladjustment. In regard to the empirical evidence reported here, the LSS provide a theoretical definition of a multivariable loss structure with stressor effects for the elderly adult that is closely linked to psychological maladjustment and can vary from subject to subject. This is a useful contribution to empirical knowledge of old age in Mexico and to research about health psychology, because it could contribute to evaluate the impact of losses in models that explore the effects of stress in elderly adults. The Loss Structure construct developed for the purpose of this research was the result of an analysis of the experience generated by losses suffered in old age. Elderly persons have to face losses which, as they accumulate, will demand constant readjustment of life conditions. The nine areas resulting from the Loss Structure Scale attempt to cover a broad spectrum of possible losses that can occur in old age.<hr/>La estructura de pérdidas puede ser definida como el conjunto de objetos significativos (susceptibles de ser agrupados en diferentes clases de pérdidas), percibidos bajo amenaza de ser perdidos, efectivamente perdidos, o cuya pertenencia es insegura o ambigua (concebibles como tipos de pérdidas), en una etapa determinada de la vida, y cuya influencia define cogniciones, afectos y conductas ante ella. La estructura de pérdidas presente en la adultez mayor, sin precedente en la vida del sujeto, podría definir diferentes rutas de desajuste. La Escala de Estructura de Pérdidas (EEP) propuesta aquí, es un instrumento cuyo propósito es permitir la exploración de las pérdidas que suelen ocurrir en la adultez mayor. La EEP permite la exploración sistemática de un abanico de pérdidas previamente validadas en un contexto latinoamericano, mexicano, como una primera aproximación a las posibles causas psicosociales del desajuste psicológico en la adultez mayor. La EEP propuesta aquí, obtuvo una estructura factorial compuesta de nueve factores bien definidos que en conjunto incluyeron 36 reactivos, con una consistencia interna alfa de .91 que explicó 67.4% de la varianza. La consistencia interna de los nueve factores fluctuó entre valores alfa de .74 y .83. Además, se obtuvieron correlaciones moderadamente altas entre el total del puntaje de la EEP con todas las variables de desajuste psicológico (entre r = .50 y r = .66; p<.01), excepto con la ansiedad ante el envejecimiento. Así, se encontró una asociación negativa entre la frecuencia de no pérdidas y dichas variables, destacando la depresión (r = -.70, p<.01) y la soledad (r = -.68, p<.01). La frecuencia de pérdidas ambiguas se correlacionó positivamente con Depresión (r=.54, p<.01), Soledad (r = .47, p<.01), Ansiedad (r = .42, p<.01) y Ansiedad ante el envejecimiento (r = .40, p<.01). La frecuencia de pérdidas consumadas se correlacionó de manera importante con soledad (r=.53, p<.01), depresión (r = .50, p<.01) y enfermedad percibida (r = .47, p<.01). La escala fue útil para discriminar sujetos con altos y bajos niveles de desajuste psicológico. Adicionalmente, se incluyeron valores normalizados de los distintos puntajes de la Escala de Estructura de Pérdidas. Asimismo, la EEP permitió definir teóricamente, a partir de la evidencia empírica reportada aquí, la existencia de una estructura multivariable de pérdidas, con efectos estresores para el adulto mayor, íntimamente ligada al desajuste psicológico y que puede variar de sujeto a sujeto. Esta es una aportación útil al conocimiento empírico de la vejez en nuestro país, y a la investigación en psicología de la salud, porque permite evaluar el impacto de las pérdidas en modelos de exploración de los efectos del estrés en adultos mayores. El constructo de Estructura de Pérdidas, desarrollado para esta investigación, fue resultado del análisis de la experiencia generada por las pérdidas sufridas en la adultez mayor. El viejo se enfrenta a pérdidas (a una estructura de pérdidas) que de manera acumulada exigirá de él un reajuste constante a sus condiciones de vida. Por lo tanto, las nueve áreas resultantes de la Escala de Estructura de Pérdidas pretenden cubrir un amplio espectro de las posibles pérdidas susceptibles de ocurrir en la adultez mayor. <![CDATA[<b>Episodic violence or intimate terrorism? An exploratory proposal to classify violence against women in the context of intimate couple relationships</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600007&lng=pt&nrm=iso&tlng=pt Introduction The concern of this paper comes from a reflection on the phenomenon of violence against women in the context of intimate couple relationships. Even though studies dealing with the issue tend to focus on the presence of physical violence, it should not be forgotten that in the same relationships several types of emotional and sometimes sexual violence may co-exist. Violent men intentionally aim to create a threatening climate against women. To do so, they resort to devaluations, insults, threats, maltreatment, shouting, contempt, intolerance, humiliations, jealousy and accusations. Nevertheless, women are often unaware of many of them given the social tolerance towards overall abuse and the lack of institutional alternatives. There are, however, some difficulties to operationalize these behaviours. It is particularly difficult to measure the characteristic pattern followed by these relationships as this may involve very subtle forms of violence. Likewise, results obtained in the physical and psychological dimensions are usually kept as separate areas or they are presented at best in a mixed form to show the prevalences from the different surveys carried out. This article is a theoretical and statistical exercise aimed at constructing a typology of male violence against women. Its starting point is a proposal posing that in heterosexual relationships two types of violence are present. The first one may be called episodic violence, where one or both members of the couple carry out some violent act without the desire to control or dominate the other partner. In the other one, defined as intimate terrorism, the man acts out with the clear purpose of exerting both a violent and non-violent control and dominion over the woman's actions, thoughts, and emotions. Although it is certainly arguable, it might be interesting to analyze this classification for it is risky to suppose that there are couple relationships where a symmetry in the use of violence exists both on the part of men and women -that is, that women are as violent as men. It is risky because it distorts violence's gender nature by presupposing that the same behaviour may be exerted with the same physical and symbolic strength and that it will have similar consequences. However, we think it is worth taking it into account as a starting point for this analysis. To do so, a database derived from a study conducted among a sample of women attending general medical consultation was used. The main analysis axis was the indicator of having experienced a physically violent behaviour on the part of the partner during the last year. This was related to five emotional violence dimensions which represent different modalities as to their intentionality and impact. The groups thus formed were analyzed considering some variables which were previously regarded as associated to this form of violence, including demographic features, and some other features related to household income participation and the distribution of household keeping chores in the women's families. Specific features regarding the violent relationship, such as the motives behind the physical violence episodes and the role played by alcohol abuse on the part of the male partner in these episodes, were also considered. Method A database derived from a transversal ex post facto study conducted with a 345-women sample attending first-time or subsequent medical attention in a first level institution was analyzed. A structured questionnaire made up of different areas was applied. The following areas were included in this study: 1. Socio-demographic variables from each woman, her male partner and her family. 2. A violence severity scale containing 22 different types of physically violent behaviours from men against women, and 36 emotional violence types. A previous analysis of the latter showed five conceptually congruous dimensions: Devaluation, Threatening behaviours, Intimidation, Hostility, and Abusive expectations. 3. Features of both the relationship and the violent episodes. 4. Alcohol abuse on the part of the partner. To construct the typology, women who had experienced at least one physical violence attack by their partners during the last twelve months were classified, regardless of the frequency and severity of such behaviour. With this sub-sample, a multidimensional escalation analysis was performed with the five emotional violence dimensions reported and these were considered as <<stimuli>>. Decisions were then taken as to the configuration obtained and the women were classified in three groups considering both the presence and severity of the physical violence experienced and the frequency of the different forms of emotional violence. Based on these groups classification, variance and chi square analysis were carried out with the variables selected to observe whether these effectively differentiated the women from each group. Results The resulting emotional violence dimensions allowed us to obtain a typology of the sub-sample of women who had experienced physical violence (30% of the total). With this, three groups were formed: 1. episodic physical violence, including women who did not report any threats nor intimidation or devaluation (12.5%); 2. intimidating physical violence, including women who reported threats and intimidation and some or no devaluation (12.5%), and 3. intimate terrorism, which refers to women who suffered very frequent threats and intimidations together with occasional to frequent devaluations (5%). The latter is the highest risk group. Women belonging to this group were older (35 years) than those from the other two groups and so were their partners (40 years). They reported having more children and having lived longer with the abusing partner. Three out of each five had a paid job, mainly informal, and took charge of the money income responsibility of their households. Male partners were the main income providers only in 40% of the instances. Role genders in these families were very traditional as the male partners seldom helped with household keeping cores. Male partners had alcohol abuse-related problems and, in fact, one out of each three got aggressive when he had had any alcohol. The main reasons behind physical violence were male drunkenness, jealousy, and women protecting their offspring. At the other end are the women we classified in the episodic violence group. These were the youngest in the study even when compared to non-abused and intimidating violence victims. These women and their couple's household income participation, and the family members' participation in household keeping cores were similar to those in the no violence group. Their partners had also used alcohol in a comparable amount to that of the intimidating violence group. The main reasons underlying physical violence were male anger and male jealousy, and drunkenness to a lesser degree. Conclusions A considerable amount of women, nearly one out of each three, had experienced some form of physical violence in their couple relationship during the last year, and one out of each five had suffered violence in an abusive context of threats, intimidation and devaluation. Given this, it is important to focus on any type of physical violence as a part of a primary preventive perspective.<hr/>El presente trabajo es un ejercicio teórico y estadístico para construir una tipología de la violencia masculina hacia la mujer. Parte de una propuesta que plantea que en las relaciones heterosexuales ocurren dos tipos de violencia física. Uno de éstos puede denominarse violencia episódica, donde uno o ambos integrantes de la pareja realizan algún acto violento sin que esté presente el deseo de controlar o dominar al otro integrante. En el otro, definido como terrorismo íntimo, el hombre actúa con una clara intención de ejercer un control y dominio tanto violentos como no violentos sobre las conductas, pensamientos y emociones de la mujer. Los grupos construidos se analizan según algunas variables que previamente se ha considerado que se pueden asociar con esta forma de violencia, como las características demográficas, las características relacionadas con la participación económica y la distribución de las labores domésticas en las familias de las mujeres y las características específicas de la relación violenta, en particular el uso de alcohol por parte de la pareja. Método Se analizó una base de datos derivada de un estudio transversal y ex post facto realizado con una muestra de 345 mujeres que asistieron a atención médica de primera vez o subsecuente a una institución del primer nivel en el Distrito Federal. Para construir la tipología, se eligió a las mujeres que habían sufrido al menos una manifestación de violencia física por su pareja en los últimos 12 meses, y se realizó un análisis de escalamiento multidimensional a partir de cinco dimensiones de la violencia emocional. Con base en la clasificación de grupos, se realizaron análisis de varianza y de chi cuadrada con variables demográficas, y otras que la bibliografía ha reportado como relevantes. Resultados Un 30% de las mujeres había sufrido algún episodio de violencia física en el último año. Éstos se clasificaron de la siguiente manera: 1. con violencia física episódica, que incluye a aquellas que no reportaron amenazas, ni intimidación y devaluación (12.5% de la población total); 2. violencia física intimidatoria, que incluye mujeres que reportaron amenazas e intimidación y poca o ninguna devaluación (12.5% de la población total); y 3. terrorismo íntimo, referido a mujeres que sufrieron amenazas e intimidaciones muy frecuentes junto con una devaluación que va de <<algo>> a <<muy frecuente>> (5% de la población total). Este último grupo es el de más alto riesgo; las mujeres que lo integraron fueron de mayor edad que las de los otros grupos, al igual que sus parejas. Reportaron tener más hijos y más años de vivir con el maltratador, en promedio 18. Tres de cada cinco mujeres tenía un trabajo remunerado, en su mayoría de manera informal, y llevaban la responsabilidad económica del hogar, así como la carga de las actividades domésticas. Sus parejas tenían un consumo de alcohol problemático; de hecho, uno de cada tres se ponía agresivo al ingerirlo. Conclusiones No encontramos relaciones físicamente violentas libres de violencia emocional, ya que, aun cuando la violencia episódica ocurrió sin manifestaciones de amenazas, intimidación y devaluación, las mujeres sí reportaron comportamientos hostiles y expectativas abusivas de parte de sus parejas. Los resultados obtenidos en torno a las variables sociodemográficas, las relacionadas con la participación económica y con las actividades domésticas de las mujeres y sus familiares, y el consumo de alcohol, pueden utilizarse para elaborar un instrumento breve que permita la detección de mujeres en situación de alto riesgo de violencia de pareja. Además, permiten reflexionar en la necesidad de plantear políticas públicas estructurales para enfrentar este problema, como la creación de empleos dignos y bien remunerados para las mujeres. Destaca igualmente la importancia de contar con programas que aborden el consumo de alcohol y la violencia en los hombres, considerando ambos aspectos como ejes de la construcción de la masculinidad tradicional. <![CDATA[<b>Impact of Duration of Untreated Psychosis (DUP) in the course and outcome of schizophrenia</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600008&lng=pt&nrm=iso&tlng=pt The duration of Untreated Psychosis (DUP), defined as the period of time between the onset of psychotic symptoms, such as hallucinations and delusions, and the first effective treatment, has been associated to prognosis of schizophrenia. It has been demonstrated that although psychotic symptoms are initially detected by relatives of patients with schizophrenia, they take a long time to seek specialized attention, which in turn leads to a delay in the diagnosis and treatment of the disorder. Schizophrenia has been considered by the World Health Organization as a public health problem and has been placed as the ninth cause of incapacity in the world. Thus, DUP represents part of this public health problem. In Mexico, the average DUP lasts 64 weeks, which is very similar to the average observed in other countries, where the mean DUP in psychotic patients varies between one and two years. One of the main reasons of a prolonged DUP is that patients and their families first assist with a general practitioner which, in many cases, does not perform an adequate diagnosis with the subsequent referral to a psychiatric facility, and the treatment given for the patient is based on sedative medication. This is also Mexico's case, where seeking help primarily involves religious groups, with very few referrals to psychiatric facilities and with inadequate treatment support, which delays care in specialized services. It has been established that early treatment is related to a better prognosis and outcome, while treatment delay has been related to a longer time to achieve symptom remission. These results support the hypothesis that the presence of psychotic symptoms for a long period of time may predispose to biological damage, which may in turn lead to predominant negative symptoms and severe cognitive deficits after the first psychotic episode. Also, some studies have found that a longer DUP is related to a more insidious illness onset, frequent relapses and psychiatric hospitalizations during the course of the disorder, with a poor response to antipsychotic medication. Through the use of neuroimaging, several studies have found the relation between DUP and brain morphology in patients with schizophrenia. Studies using Magnetic Resonance Imaging (MRI) have reported that patients with longer DUP show a significant reduction in the gray matter of the temporal planum, in the left middle, inferior temporal, left occipital and left fusiform cortices, with an increase of grey matter in the left basal ganglia, and a volume reduction of the caudate nucleus. These results may be related to the clinical course of the disorder in terms of a higher symptom severity and poor treatment response. In regard to psychosocial variables related to DUP, it has been observed that men have a longer DUP when compared to women and patients that are single and unemployed also have a longer DUP. Consequently, it has been found that there is a relationship between DUP and premorbid adjustment in patients with schizophrenia. Premorbid adjustment is defined as the psychosocial functioning in the educational, occupational, social and interpersonal relations areas before the evidence of positive characteristic symptomatology, where symptoms are not secondary to an organic cause and cover a period of six months before the first psychiatric hospitalization or contact with a psychiatric facility. In addition, it has been found that a prolonged DUP is related to a poor premorbid adjustment, especially during late adolescence and adulthood. This association may suggest the presence of prodromic symptoms secondary to the physiopathological process of psychosis. Consequently, if a patient shows some of the initial symptoms of the disorder, including psychosocial impairment, his/her abilities to be aware of the symptoms may be limited to seek for medical care, which may in turn increase DUP. Furthermore, some authors have reported that some variables related to the patient's environment are related with DUP. The main variable pointed out is: the previous experience with mental disorders and psychiatric facilities. Patients whose families had previous experience of a mentally ill relative, report a shorter DUP when compared to families with no previous history of an ill relative. Also, it has been analised that patients with an adequate social network have a shorter DUP compared to those patients whose social network is inadequate or limited. Based on these results, some authors have proposed two phenotypes for psychotic disorders: the first one characterized by males, poor premorbid adjustment, long DUP, insidious onset of the disorder and a stable pattern of negative symptoms. The second phenotype was one characterized by the following variables: females, good premorbid adjustment, a shorter DUP, acute illness onset and absence of a stable pattern of negative symptoms. This definition may be useful to determine the course of the disorder in patients with schizophrenia and may be able to predict the clinical outcome. Thus, DUP can be used as an indicator of prognosis in patients with schizophrenia and its evaluation should be promoted. Although these two phenotypes are very useful, caution should be warranted in their use to avoid generalization. By and large, the studies related to the clinical impact of DUP emphasized the need to reduce DUP through early detection programs, including psychoeducation. We believe that this approach will be useful to identify individuals at an early development of a psychotic illness so that interventions can begin before symptoms have reached a level of significant impairment for the patient and warranting referrals by the family, school or health providers. Based on the studies reviewed above, we can conclude that DUP has a definitive impact on the prognosis of patients with schizophrenia and that future studies should be performed including it not only as a predictor of clinical outcome, but also as an specific clinical target for mental health research. Increasing the knowledge about the relationship between DUP and clinical course of schizophrenia is crucial to create and promote early detection and intervention programs such as the ones that have started all over the world, where the main objective is to identify young people who are at risk of developing psychotic disorders, specially schizophrenia.<hr/>La duración de la psicosis no tratada (DPNT), definida como el período de tiempo entre la aparición de los síntomas psicóticos y el inicio de un tratamiento adecuado, está asociada al pronóstico de la esquizofrenia, enfermedad que ha sido considerada por la Organización Mundial de la Salud, como un problema de salud pública. El atraso en la búsqueda de tratamiento especializado conlleva a un retraso en el diagnóstico y tratamiento adecuados de la enfermedad. En México, el promedio de la DPNT es de 64 semanas, siendo éste similar al reportado en otros países, donde la media varía entre uno y dos años. Se ha comprobado que el retraso en el tratamiento adecuado del padecimiento está relacionado con un pobre pronóstico, lo cual apoya la hipótesis de que la presencia de síntomas psicóticos durante un largo período de tiempo puede predisponer a un daño biológico, generando así un predominio de síntomas negativos y mayores déficit cognitivos después del primer episodio psicótico. Además, se ha encontrado que una DPNT larga se relaciona con un inicio insidioso de la enfermedad, mayor número de recaídas y rehospitalizaciones psiquiátricas durante el curso de la enfermedad, además de una pobre respuesta al tratamiento farmacológico con antipsicóticos. En cuanto a las variables demográficas y psicosociales que se asocian con una DPNT prolongada encontramos: al sexo masculino, el no tener pareja u ocupación laboral. Asimismo, se ha reportado que los pacientes que presentan un mayor deterioro en su funcionamiento premórbido, son aquellos que muestran una mayor DPNT. Esta asociación sugiere que los pacientes con esquizofrenia pueden presentar síntomas prodrómicos mucho tiempo antes de que su funcionamiento se vea totalmente afectado por el proceso fisiopatológico de la psicosis. Asimismo, se han reportado variables relacionadas con el entorno del paciente asociadas a la DPNT. Entre ellas, destacan la experiencia previa con trastornos mentales y las redes sociales. Se ha observado que los pacientes de familias que han tenido una experiencia previa con otro familiar diagnosticado con alguna enfermedad mental, muestran una menor DPNT en contraste con aquellos cuyas familias no han tenido experiencias previas de enfermedades mentales. De igual forma, se ha informado que pacientes con una adecuada red social tienen una menor DPNT, comparados con aquellos cuya red social es limitada. A partir de estos hallazgos se han propuesto dos fenotipos para los trastornos psicóticos cuya definición puede ser útil para determinar el curso clínico de la enfermedad en pacientes con esquizofrenia. En este sentido, la DPNT se puede utilizar como un indicador para el pronóstico de pacientes con esquizofrenia, por lo que se sugiere promover su evaluación. Los estudios que se han llevado a cabo sobre el impacto clínico de la DPNT enfatizan la necesidad de reducirla mediante programas de detección temprana. Estos programas serían útiles para identificar personas en etapas iniciales de un trastorno psicótico y se podría realizar una intervención profesional antes de que los síntomas alcancen un nivel de deterioro significativo para el paciente. Con base en lo anterior, se puede concluir que la DPNT tiene un fuerte impacto sobre el pronóstico de los pacientes con esquizofrenia y que en el futuro se deben realizar estudios que la incluyan no sólo como un factor pronóstico, sino como un objetivo clínico específico de la investigación en salud mental, ya que la información que se genere puede ser la base para la creación y promoción de programas de detección e intervención tempranas. <![CDATA[<b>SALUD MENTAL within the corpus of Mexican medical journals: Its relevance for neuroscience</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600009&lng=pt&nrm=iso&tlng=pt The duration of Untreated Psychosis (DUP), defined as the period of time between the onset of psychotic symptoms, such as hallucinations and delusions, and the first effective treatment, has been associated to prognosis of schizophrenia. It has been demonstrated that although psychotic symptoms are initially detected by relatives of patients with schizophrenia, they take a long time to seek specialized attention, which in turn leads to a delay in the diagnosis and treatment of the disorder. Schizophrenia has been considered by the World Health Organization as a public health problem and has been placed as the ninth cause of incapacity in the world. Thus, DUP represents part of this public health problem. In Mexico, the average DUP lasts 64 weeks, which is very similar to the average observed in other countries, where the mean DUP in psychotic patients varies between one and two years. One of the main reasons of a prolonged DUP is that patients and their families first assist with a general practitioner which, in many cases, does not perform an adequate diagnosis with the subsequent referral to a psychiatric facility, and the treatment given for the patient is based on sedative medication. This is also Mexico's case, where seeking help primarily involves religious groups, with very few referrals to psychiatric facilities and with inadequate treatment support, which delays care in specialized services. It has been established that early treatment is related to a better prognosis and outcome, while treatment delay has been related to a longer time to achieve symptom remission. These results support the hypothesis that the presence of psychotic symptoms for a long period of time may predispose to biological damage, which may in turn lead to predominant negative symptoms and severe cognitive deficits after the first psychotic episode. Also, some studies have found that a longer DUP is related to a more insidious illness onset, frequent relapses and psychiatric hospitalizations during the course of the disorder, with a poor response to antipsychotic medication. Through the use of neuroimaging, several studies have found the relation between DUP and brain morphology in patients with schizophrenia. Studies using Magnetic Resonance Imaging (MRI) have reported that patients with longer DUP show a significant reduction in the gray matter of the temporal planum, in the left middle, inferior temporal, left occipital and left fusiform cortices, with an increase of grey matter in the left basal ganglia, and a volume reduction of the caudate nucleus. These results may be related to the clinical course of the disorder in terms of a higher symptom severity and poor treatment response. In regard to psychosocial variables related to DUP, it has been observed that men have a longer DUP when compared to women and patients that are single and unemployed also have a longer DUP. Consequently, it has been found that there is a relationship between DUP and premorbid adjustment in patients with schizophrenia. Premorbid adjustment is defined as the psychosocial functioning in the educational, occupational, social and interpersonal relations areas before the evidence of positive characteristic symptomatology, where symptoms are not secondary to an organic cause and cover a period of six months before the first psychiatric hospitalization or contact with a psychiatric facility. In addition, it has been found that a prolonged DUP is related to a poor premorbid adjustment, especially during late adolescence and adulthood. This association may suggest the presence of prodromic symptoms secondary to the physiopathological process of psychosis. Consequently, if a patient shows some of the initial symptoms of the disorder, including psychosocial impairment, his/her abilities to be aware of the symptoms may be limited to seek for medical care, which may in turn increase DUP. Furthermore, some authors have reported that some variables related to the patient's environment are related with DUP. The main variable pointed out is: the previous experience with mental disorders and psychiatric facilities. Patients whose families had previous experience of a mentally ill relative, report a shorter DUP when compared to families with no previous history of an ill relative. Also, it has been analised that patients with an adequate social network have a shorter DUP compared to those patients whose social network is inadequate or limited. Based on these results, some authors have proposed two phenotypes for psychotic disorders: the first one characterized by males, poor premorbid adjustment, long DUP, insidious onset of the disorder and a stable pattern of negative symptoms. The second phenotype was one characterized by the following variables: females, good premorbid adjustment, a shorter DUP, acute illness onset and absence of a stable pattern of negative symptoms. This definition may be useful to determine the course of the disorder in patients with schizophrenia and may be able to predict the clinical outcome. Thus, DUP can be used as an indicator of prognosis in patients with schizophrenia and its evaluation should be promoted. Although these two phenotypes are very useful, caution should be warranted in their use to avoid generalization. By and large, the studies related to the clinical impact of DUP emphasized the need to reduce DUP through early detection programs, including psychoeducation. We believe that this approach will be useful to identify individuals at an early development of a psychotic illness so that interventions can begin before symptoms have reached a level of significant impairment for the patient and warranting referrals by the family, school or health providers. Based on the studies reviewed above, we can conclude that DUP has a definitive impact on the prognosis of patients with schizophrenia and that future studies should be performed including it not only as a predictor of clinical outcome, but also as an specific clinical target for mental health research. Increasing the knowledge about the relationship between DUP and clinical course of schizophrenia is crucial to create and promote early detection and intervention programs such as the ones that have started all over the world, where the main objective is to identify young people who are at risk of developing psychotic disorders, specially schizophrenia.<hr/>La duración de la psicosis no tratada (DPNT), definida como el período de tiempo entre la aparición de los síntomas psicóticos y el inicio de un tratamiento adecuado, está asociada al pronóstico de la esquizofrenia, enfermedad que ha sido considerada por la Organización Mundial de la Salud, como un problema de salud pública. El atraso en la búsqueda de tratamiento especializado conlleva a un retraso en el diagnóstico y tratamiento adecuados de la enfermedad. En México, el promedio de la DPNT es de 64 semanas, siendo éste similar al reportado en otros países, donde la media varía entre uno y dos años. Se ha comprobado que el retraso en el tratamiento adecuado del padecimiento está relacionado con un pobre pronóstico, lo cual apoya la hipótesis de que la presencia de síntomas psicóticos durante un largo período de tiempo puede predisponer a un daño biológico, generando así un predominio de síntomas negativos y mayores déficit cognitivos después del primer episodio psicótico. Además, se ha encontrado que una DPNT larga se relaciona con un inicio insidioso de la enfermedad, mayor número de recaídas y rehospitalizaciones psiquiátricas durante el curso de la enfermedad, además de una pobre respuesta al tratamiento farmacológico con antipsicóticos. En cuanto a las variables demográficas y psicosociales que se asocian con una DPNT prolongada encontramos: al sexo masculino, el no tener pareja u ocupación laboral. Asimismo, se ha reportado que los pacientes que presentan un mayor deterioro en su funcionamiento premórbido, son aquellos que muestran una mayor DPNT. Esta asociación sugiere que los pacientes con esquizofrenia pueden presentar síntomas prodrómicos mucho tiempo antes de que su funcionamiento se vea totalmente afectado por el proceso fisiopatológico de la psicosis. Asimismo, se han reportado variables relacionadas con el entorno del paciente asociadas a la DPNT. Entre ellas, destacan la experiencia previa con trastornos mentales y las redes sociales. Se ha observado que los pacientes de familias que han tenido una experiencia previa con otro familiar diagnosticado con alguna enfermedad mental, muestran una menor DPNT en contraste con aquellos cuyas familias no han tenido experiencias previas de enfermedades mentales. De igual forma, se ha informado que pacientes con una adecuada red social tienen una menor DPNT, comparados con aquellos cuya red social es limitada. A partir de estos hallazgos se han propuesto dos fenotipos para los trastornos psicóticos cuya definición puede ser útil para determinar el curso clínico de la enfermedad en pacientes con esquizofrenia. En este sentido, la DPNT se puede utilizar como un indicador para el pronóstico de pacientes con esquizofrenia, por lo que se sugiere promover su evaluación. Los estudios que se han llevado a cabo sobre el impacto clínico de la DPNT enfatizan la necesidad de reducirla mediante programas de detección temprana. Estos programas serían útiles para identificar personas en etapas iniciales de un trastorno psicótico y se podría realizar una intervención profesional antes de que los síntomas alcancen un nivel de deterioro significativo para el paciente. Con base en lo anterior, se puede concluir que la DPNT tiene un fuerte impacto sobre el pronóstico de los pacientes con esquizofrenia y que en el futuro se deben realizar estudios que la incluyan no sólo como un factor pronóstico, sino como un objetivo clínico específico de la investigación en salud mental, ya que la información que se genere puede ser la base para la creación y promoción de programas de detección e intervención tempranas. <![CDATA[<b>Obesity and metabolic syndrome as public health problems: A reflection. First part</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600010&lng=pt&nrm=iso&tlng=pt The duration of Untreated Psychosis (DUP), defined as the period of time between the onset of psychotic symptoms, such as hallucinations and delusions, and the first effective treatment, has been associated to prognosis of schizophrenia. It has been demonstrated that although psychotic symptoms are initially detected by relatives of patients with schizophrenia, they take a long time to seek specialized attention, which in turn leads to a delay in the diagnosis and treatment of the disorder. Schizophrenia has been considered by the World Health Organization as a public health problem and has been placed as the ninth cause of incapacity in the world. Thus, DUP represents part of this public health problem. In Mexico, the average DUP lasts 64 weeks, which is very similar to the average observed in other countries, where the mean DUP in psychotic patients varies between one and two years. One of the main reasons of a prolonged DUP is that patients and their families first assist with a general practitioner which, in many cases, does not perform an adequate diagnosis with the subsequent referral to a psychiatric facility, and the treatment given for the patient is based on sedative medication. This is also Mexico's case, where seeking help primarily involves religious groups, with very few referrals to psychiatric facilities and with inadequate treatment support, which delays care in specialized services. It has been established that early treatment is related to a better prognosis and outcome, while treatment delay has been related to a longer time to achieve symptom remission. These results support the hypothesis that the presence of psychotic symptoms for a long period of time may predispose to biological damage, which may in turn lead to predominant negative symptoms and severe cognitive deficits after the first psychotic episode. Also, some studies have found that a longer DUP is related to a more insidious illness onset, frequent relapses and psychiatric hospitalizations during the course of the disorder, with a poor response to antipsychotic medication. Through the use of neuroimaging, several studies have found the relation between DUP and brain morphology in patients with schizophrenia. Studies using Magnetic Resonance Imaging (MRI) have reported that patients with longer DUP show a significant reduction in the gray matter of the temporal planum, in the left middle, inferior temporal, left occipital and left fusiform cortices, with an increase of grey matter in the left basal ganglia, and a volume reduction of the caudate nucleus. These results may be related to the clinical course of the disorder in terms of a higher symptom severity and poor treatment response. In regard to psychosocial variables related to DUP, it has been observed that men have a longer DUP when compared to women and patients that are single and unemployed also have a longer DUP. Consequently, it has been found that there is a relationship between DUP and premorbid adjustment in patients with schizophrenia. Premorbid adjustment is defined as the psychosocial functioning in the educational, occupational, social and interpersonal relations areas before the evidence of positive characteristic symptomatology, where symptoms are not secondary to an organic cause and cover a period of six months before the first psychiatric hospitalization or contact with a psychiatric facility. In addition, it has been found that a prolonged DUP is related to a poor premorbid adjustment, especially during late adolescence and adulthood. This association may suggest the presence of prodromic symptoms secondary to the physiopathological process of psychosis. Consequently, if a patient shows some of the initial symptoms of the disorder, including psychosocial impairment, his/her abilities to be aware of the symptoms may be limited to seek for medical care, which may in turn increase DUP. Furthermore, some authors have reported that some variables related to the patient's environment are related with DUP. The main variable pointed out is: the previous experience with mental disorders and psychiatric facilities. Patients whose families had previous experience of a mentally ill relative, report a shorter DUP when compared to families with no previous history of an ill relative. Also, it has been analised that patients with an adequate social network have a shorter DUP compared to those patients whose social network is inadequate or limited. Based on these results, some authors have proposed two phenotypes for psychotic disorders: the first one characterized by males, poor premorbid adjustment, long DUP, insidious onset of the disorder and a stable pattern of negative symptoms. The second phenotype was one characterized by the following variables: females, good premorbid adjustment, a shorter DUP, acute illness onset and absence of a stable pattern of negative symptoms. This definition may be useful to determine the course of the disorder in patients with schizophrenia and may be able to predict the clinical outcome. Thus, DUP can be used as an indicator of prognosis in patients with schizophrenia and its evaluation should be promoted. Although these two phenotypes are very useful, caution should be warranted in their use to avoid generalization. By and large, the studies related to the clinical impact of DUP emphasized the need to reduce DUP through early detection programs, including psychoeducation. We believe that this approach will be useful to identify individuals at an early development of a psychotic illness so that interventions can begin before symptoms have reached a level of significant impairment for the patient and warranting referrals by the family, school or health providers. Based on the studies reviewed above, we can conclude that DUP has a definitive impact on the prognosis of patients with schizophrenia and that future studies should be performed including it not only as a predictor of clinical outcome, but also as an specific clinical target for mental health research. Increasing the knowledge about the relationship between DUP and clinical course of schizophrenia is crucial to create and promote early detection and intervention programs such as the ones that have started all over the world, where the main objective is to identify young people who are at risk of developing psychotic disorders, specially schizophrenia.<hr/>La duración de la psicosis no tratada (DPNT), definida como el período de tiempo entre la aparición de los síntomas psicóticos y el inicio de un tratamiento adecuado, está asociada al pronóstico de la esquizofrenia, enfermedad que ha sido considerada por la Organización Mundial de la Salud, como un problema de salud pública. El atraso en la búsqueda de tratamiento especializado conlleva a un retraso en el diagnóstico y tratamiento adecuados de la enfermedad. En México, el promedio de la DPNT es de 64 semanas, siendo éste similar al reportado en otros países, donde la media varía entre uno y dos años. Se ha comprobado que el retraso en el tratamiento adecuado del padecimiento está relacionado con un pobre pronóstico, lo cual apoya la hipótesis de que la presencia de síntomas psicóticos durante un largo período de tiempo puede predisponer a un daño biológico, generando así un predominio de síntomas negativos y mayores déficit cognitivos después del primer episodio psicótico. Además, se ha encontrado que una DPNT larga se relaciona con un inicio insidioso de la enfermedad, mayor número de recaídas y rehospitalizaciones psiquiátricas durante el curso de la enfermedad, además de una pobre respuesta al tratamiento farmacológico con antipsicóticos. En cuanto a las variables demográficas y psicosociales que se asocian con una DPNT prolongada encontramos: al sexo masculino, el no tener pareja u ocupación laboral. Asimismo, se ha reportado que los pacientes que presentan un mayor deterioro en su funcionamiento premórbido, son aquellos que muestran una mayor DPNT. Esta asociación sugiere que los pacientes con esquizofrenia pueden presentar síntomas prodrómicos mucho tiempo antes de que su funcionamiento se vea totalmente afectado por el proceso fisiopatológico de la psicosis. Asimismo, se han reportado variables relacionadas con el entorno del paciente asociadas a la DPNT. Entre ellas, destacan la experiencia previa con trastornos mentales y las redes sociales. Se ha observado que los pacientes de familias que han tenido una experiencia previa con otro familiar diagnosticado con alguna enfermedad mental, muestran una menor DPNT en contraste con aquellos cuyas familias no han tenido experiencias previas de enfermedades mentales. De igual forma, se ha informado que pacientes con una adecuada red social tienen una menor DPNT, comparados con aquellos cuya red social es limitada. A partir de estos hallazgos se han propuesto dos fenotipos para los trastornos psicóticos cuya definición puede ser útil para determinar el curso clínico de la enfermedad en pacientes con esquizofrenia. En este sentido, la DPNT se puede utilizar como un indicador para el pronóstico de pacientes con esquizofrenia, por lo que se sugiere promover su evaluación. Los estudios que se han llevado a cabo sobre el impacto clínico de la DPNT enfatizan la necesidad de reducirla mediante programas de detección temprana. Estos programas serían útiles para identificar personas en etapas iniciales de un trastorno psicótico y se podría realizar una intervención profesional antes de que los síntomas alcancen un nivel de deterioro significativo para el paciente. Con base en lo anterior, se puede concluir que la DPNT tiene un fuerte impacto sobre el pronóstico de los pacientes con esquizofrenia y que en el futuro se deben realizar estudios que la incluyan no sólo como un factor pronóstico, sino como un objetivo clínico específico de la investigación en salud mental, ya que la información que se genere puede ser la base para la creación y promoción de programas de detección e intervención tempranas. <![CDATA[<b>New General Director of the INPRF</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600011&lng=pt&nrm=iso&tlng=pt The duration of Untreated Psychosis (DUP), defined as the period of time between the onset of psychotic symptoms, such as hallucinations and delusions, and the first effective treatment, has been associated to prognosis of schizophrenia. It has been demonstrated that although psychotic symptoms are initially detected by relatives of patients with schizophrenia, they take a long time to seek specialized attention, which in turn leads to a delay in the diagnosis and treatment of the disorder. Schizophrenia has been considered by the World Health Organization as a public health problem and has been placed as the ninth cause of incapacity in the world. Thus, DUP represents part of this public health problem. In Mexico, the average DUP lasts 64 weeks, which is very similar to the average observed in other countries, where the mean DUP in psychotic patients varies between one and two years. One of the main reasons of a prolonged DUP is that patients and their families first assist with a general practitioner which, in many cases, does not perform an adequate diagnosis with the subsequent referral to a psychiatric facility, and the treatment given for the patient is based on sedative medication. This is also Mexico's case, where seeking help primarily involves religious groups, with very few referrals to psychiatric facilities and with inadequate treatment support, which delays care in specialized services. It has been established that early treatment is related to a better prognosis and outcome, while treatment delay has been related to a longer time to achieve symptom remission. These results support the hypothesis that the presence of psychotic symptoms for a long period of time may predispose to biological damage, which may in turn lead to predominant negative symptoms and severe cognitive deficits after the first psychotic episode. Also, some studies have found that a longer DUP is related to a more insidious illness onset, frequent relapses and psychiatric hospitalizations during the course of the disorder, with a poor response to antipsychotic medication. Through the use of neuroimaging, several studies have found the relation between DUP and brain morphology in patients with schizophrenia. Studies using Magnetic Resonance Imaging (MRI) have reported that patients with longer DUP show a significant reduction in the gray matter of the temporal planum, in the left middle, inferior temporal, left occipital and left fusiform cortices, with an increase of grey matter in the left basal ganglia, and a volume reduction of the caudate nucleus. These results may be related to the clinical course of the disorder in terms of a higher symptom severity and poor treatment response. In regard to psychosocial variables related to DUP, it has been observed that men have a longer DUP when compared to women and patients that are single and unemployed also have a longer DUP. Consequently, it has been found that there is a relationship between DUP and premorbid adjustment in patients with schizophrenia. Premorbid adjustment is defined as the psychosocial functioning in the educational, occupational, social and interpersonal relations areas before the evidence of positive characteristic symptomatology, where symptoms are not secondary to an organic cause and cover a period of six months before the first psychiatric hospitalization or contact with a psychiatric facility. In addition, it has been found that a prolonged DUP is related to a poor premorbid adjustment, especially during late adolescence and adulthood. This association may suggest the presence of prodromic symptoms secondary to the physiopathological process of psychosis. Consequently, if a patient shows some of the initial symptoms of the disorder, including psychosocial impairment, his/her abilities to be aware of the symptoms may be limited to seek for medical care, which may in turn increase DUP. Furthermore, some authors have reported that some variables related to the patient's environment are related with DUP. The main variable pointed out is: the previous experience with mental disorders and psychiatric facilities. Patients whose families had previous experience of a mentally ill relative, report a shorter DUP when compared to families with no previous history of an ill relative. Also, it has been analised that patients with an adequate social network have a shorter DUP compared to those patients whose social network is inadequate or limited. Based on these results, some authors have proposed two phenotypes for psychotic disorders: the first one characterized by males, poor premorbid adjustment, long DUP, insidious onset of the disorder and a stable pattern of negative symptoms. The second phenotype was one characterized by the following variables: females, good premorbid adjustment, a shorter DUP, acute illness onset and absence of a stable pattern of negative symptoms. This definition may be useful to determine the course of the disorder in patients with schizophrenia and may be able to predict the clinical outcome. Thus, DUP can be used as an indicator of prognosis in patients with schizophrenia and its evaluation should be promoted. Although these two phenotypes are very useful, caution should be warranted in their use to avoid generalization. By and large, the studies related to the clinical impact of DUP emphasized the need to reduce DUP through early detection programs, including psychoeducation. We believe that this approach will be useful to identify individuals at an early development of a psychotic illness so that interventions can begin before symptoms have reached a level of significant impairment for the patient and warranting referrals by the family, school or health providers. Based on the studies reviewed above, we can conclude that DUP has a definitive impact on the prognosis of patients with schizophrenia and that future studies should be performed including it not only as a predictor of clinical outcome, but also as an specific clinical target for mental health research. Increasing the knowledge about the relationship between DUP and clinical course of schizophrenia is crucial to create and promote early detection and intervention programs such as the ones that have started all over the world, where the main objective is to identify young people who are at risk of developing psychotic disorders, specially schizophrenia.<hr/>La duración de la psicosis no tratada (DPNT), definida como el período de tiempo entre la aparición de los síntomas psicóticos y el inicio de un tratamiento adecuado, está asociada al pronóstico de la esquizofrenia, enfermedad que ha sido considerada por la Organización Mundial de la Salud, como un problema de salud pública. El atraso en la búsqueda de tratamiento especializado conlleva a un retraso en el diagnóstico y tratamiento adecuados de la enfermedad. En México, el promedio de la DPNT es de 64 semanas, siendo éste similar al reportado en otros países, donde la media varía entre uno y dos años. Se ha comprobado que el retraso en el tratamiento adecuado del padecimiento está relacionado con un pobre pronóstico, lo cual apoya la hipótesis de que la presencia de síntomas psicóticos durante un largo período de tiempo puede predisponer a un daño biológico, generando así un predominio de síntomas negativos y mayores déficit cognitivos después del primer episodio psicótico. Además, se ha encontrado que una DPNT larga se relaciona con un inicio insidioso de la enfermedad, mayor número de recaídas y rehospitalizaciones psiquiátricas durante el curso de la enfermedad, además de una pobre respuesta al tratamiento farmacológico con antipsicóticos. En cuanto a las variables demográficas y psicosociales que se asocian con una DPNT prolongada encontramos: al sexo masculino, el no tener pareja u ocupación laboral. Asimismo, se ha reportado que los pacientes que presentan un mayor deterioro en su funcionamiento premórbido, son aquellos que muestran una mayor DPNT. Esta asociación sugiere que los pacientes con esquizofrenia pueden presentar síntomas prodrómicos mucho tiempo antes de que su funcionamiento se vea totalmente afectado por el proceso fisiopatológico de la psicosis. Asimismo, se han reportado variables relacionadas con el entorno del paciente asociadas a la DPNT. Entre ellas, destacan la experiencia previa con trastornos mentales y las redes sociales. Se ha observado que los pacientes de familias que han tenido una experiencia previa con otro familiar diagnosticado con alguna enfermedad mental, muestran una menor DPNT en contraste con aquellos cuyas familias no han tenido experiencias previas de enfermedades mentales. De igual forma, se ha informado que pacientes con una adecuada red social tienen una menor DPNT, comparados con aquellos cuya red social es limitada. A partir de estos hallazgos se han propuesto dos fenotipos para los trastornos psicóticos cuya definición puede ser útil para determinar el curso clínico de la enfermedad en pacientes con esquizofrenia. En este sentido, la DPNT se puede utilizar como un indicador para el pronóstico de pacientes con esquizofrenia, por lo que se sugiere promover su evaluación. Los estudios que se han llevado a cabo sobre el impacto clínico de la DPNT enfatizan la necesidad de reducirla mediante programas de detección temprana. Estos programas serían útiles para identificar personas en etapas iniciales de un trastorno psicótico y se podría realizar una intervención profesional antes de que los síntomas alcancen un nivel de deterioro significativo para el paciente. Con base en lo anterior, se puede concluir que la DPNT tiene un fuerte impacto sobre el pronóstico de los pacientes con esquizofrenia y que en el futuro se deben realizar estudios que la incluyan no sólo como un factor pronóstico, sino como un objetivo clínico específico de la investigación en salud mental, ya que la información que se genere puede ser la base para la creación y promoción de programas de detección e intervención tempranas. <![CDATA[<b>Autoevaluación</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252008000600012&lng=pt&nrm=iso&tlng=pt The duration of Untreated Psychosis (DUP), defined as the period of time between the onset of psychotic symptoms, such as hallucinations and delusions, and the first effective treatment, has been associated to prognosis of schizophrenia. It has been demonstrated that although psychotic symptoms are initially detected by relatives of patients with schizophrenia, they take a long time to seek specialized attention, which in turn leads to a delay in the diagnosis and treatment of the disorder. Schizophrenia has been considered by the World Health Organization as a public health problem and has been placed as the ninth cause of incapacity in the world. Thus, DUP represents part of this public health problem. In Mexico, the average DUP lasts 64 weeks, which is very similar to the average observed in other countries, where the mean DUP in psychotic patients varies between one and two years. One of the main reasons of a prolonged DUP is that patients and their families first assist with a general practitioner which, in many cases, does not perform an adequate diagnosis with the subsequent referral to a psychiatric facility, and the treatment given for the patient is based on sedative medication. This is also Mexico's case, where seeking help primarily involves religious groups, with very few referrals to psychiatric facilities and with inadequate treatment support, which delays care in specialized services. It has been established that early treatment is related to a better prognosis and outcome, while treatment delay has been related to a longer time to achieve symptom remission. These results support the hypothesis that the presence of psychotic symptoms for a long period of time may predispose to biological damage, which may in turn lead to predominant negative symptoms and severe cognitive deficits after the first psychotic episode. Also, some studies have found that a longer DUP is related to a more insidious illness onset, frequent relapses and psychiatric hospitalizations during the course of the disorder, with a poor response to antipsychotic medication. Through the use of neuroimaging, several studies have found the relation between DUP and brain morphology in patients with schizophrenia. Studies using Magnetic Resonance Imaging (MRI) have reported that patients with longer DUP show a significant reduction in the gray matter of the temporal planum, in the left middle, inferior temporal, left occipital and left fusiform cortices, with an increase of grey matter in the left basal ganglia, and a volume reduction of the caudate nucleus. These results may be related to the clinical course of the disorder in terms of a higher symptom severity and poor treatment response. In regard to psychosocial variables related to DUP, it has been observed that men have a longer DUP when compared to women and patients that are single and unemployed also have a longer DUP. Consequently, it has been found that there is a relationship between DUP and premorbid adjustment in patients with schizophrenia. Premorbid adjustment is defined as the psychosocial functioning in the educational, occupational, social and interpersonal relations areas before the evidence of positive characteristic symptomatology, where symptoms are not secondary to an organic cause and cover a period of six months before the first psychiatric hospitalization or contact with a psychiatric facility. In addition, it has been found that a prolonged DUP is related to a poor premorbid adjustment, especially during late adolescence and adulthood. This association may suggest the presence of prodromic symptoms secondary to the physiopathological process of psychosis. Consequently, if a patient shows some of the initial symptoms of the disorder, including psychosocial impairment, his/her abilities to be aware of the symptoms may be limited to seek for medical care, which may in turn increase DUP. Furthermore, some authors have reported that some variables related to the patient's environment are related with DUP. The main variable pointed out is: the previous experience with mental disorders and psychiatric facilities. Patients whose families had previous experience of a mentally ill relative, report a shorter DUP when compared to families with no previous history of an ill relative. Also, it has been analised that patients with an adequate social network have a shorter DUP compared to those patients whose social network is inadequate or limited. Based on these results, some authors have proposed two phenotypes for psychotic disorders: the first one characterized by males, poor premorbid adjustment, long DUP, insidious onset of the disorder and a stable pattern of negative symptoms. The second phenotype was one characterized by the following variables: females, good premorbid adjustment, a shorter DUP, acute illness onset and absence of a stable pattern of negative symptoms. This definition may be useful to determine the course of the disorder in patients with schizophrenia and may be able to predict the clinical outcome. Thus, DUP can be used as an indicator of prognosis in patients with schizophrenia and its evaluation should be promoted. Although these two phenotypes are very useful, caution should be warranted in their use to avoid generalization. By and large, the studies related to the clinical impact of DUP emphasized the need to reduce DUP through early detection programs, including psychoeducation. We believe that this approach will be useful to identify individuals at an early development of a psychotic illness so that interventions can begin before symptoms have reached a level of significant impairment for the patient and warranting referrals by the family, school or health providers. Based on the studies reviewed above, we can conclude that DUP has a definitive impact on the prognosis of patients with schizophrenia and that future studies should be performed including it not only as a predictor of clinical outcome, but also as an specific clinical target for mental health research. Increasing the knowledge about the relationship between DUP and clinical course of schizophrenia is crucial to create and promote early detection and intervention programs such as the ones that have started all over the world, where the main objective is to identify young people who are at risk of developing psychotic disorders, specially schizophrenia.<hr/>La duración de la psicosis no tratada (DPNT), definida como el período de tiempo entre la aparición de los síntomas psicóticos y el inicio de un tratamiento adecuado, está asociada al pronóstico de la esquizofrenia, enfermedad que ha sido considerada por la Organización Mundial de la Salud, como un problema de salud pública. El atraso en la búsqueda de tratamiento especializado conlleva a un retraso en el diagnóstico y tratamiento adecuados de la enfermedad. En México, el promedio de la DPNT es de 64 semanas, siendo éste similar al reportado en otros países, donde la media varía entre uno y dos años. Se ha comprobado que el retraso en el tratamiento adecuado del padecimiento está relacionado con un pobre pronóstico, lo cual apoya la hipótesis de que la presencia de síntomas psicóticos durante un largo período de tiempo puede predisponer a un daño biológico, generando así un predominio de síntomas negativos y mayores déficit cognitivos después del primer episodio psicótico. Además, se ha encontrado que una DPNT larga se relaciona con un inicio insidioso de la enfermedad, mayor número de recaídas y rehospitalizaciones psiquiátricas durante el curso de la enfermedad, además de una pobre respuesta al tratamiento farmacológico con antipsicóticos. En cuanto a las variables demográficas y psicosociales que se asocian con una DPNT prolongada encontramos: al sexo masculino, el no tener pareja u ocupación laboral. Asimismo, se ha reportado que los pacientes que presentan un mayor deterioro en su funcionamiento premórbido, son aquellos que muestran una mayor DPNT. Esta asociación sugiere que los pacientes con esquizofrenia pueden presentar síntomas prodrómicos mucho tiempo antes de que su funcionamiento se vea totalmente afectado por el proceso fisiopatológico de la psicosis. Asimismo, se han reportado variables relacionadas con el entorno del paciente asociadas a la DPNT. Entre ellas, destacan la experiencia previa con trastornos mentales y las redes sociales. Se ha observado que los pacientes de familias que han tenido una experiencia previa con otro familiar diagnosticado con alguna enfermedad mental, muestran una menor DPNT en contraste con aquellos cuyas familias no han tenido experiencias previas de enfermedades mentales. De igual forma, se ha informado que pacientes con una adecuada red social tienen una menor DPNT, comparados con aquellos cuya red social es limitada. A partir de estos hallazgos se han propuesto dos fenotipos para los trastornos psicóticos cuya definición puede ser útil para determinar el curso clínico de la enfermedad en pacientes con esquizofrenia. En este sentido, la DPNT se puede utilizar como un indicador para el pronóstico de pacientes con esquizofrenia, por lo que se sugiere promover su evaluación. Los estudios que se han llevado a cabo sobre el impacto clínico de la DPNT enfatizan la necesidad de reducirla mediante programas de detección temprana. Estos programas serían útiles para identificar personas en etapas iniciales de un trastorno psicótico y se podría realizar una intervención profesional antes de que los síntomas alcancen un nivel de deterioro significativo para el paciente. Con base en lo anterior, se puede concluir que la DPNT tiene un fuerte impacto sobre el pronóstico de los pacientes con esquizofrenia y que en el futuro se deben realizar estudios que la incluyan no sólo como un factor pronóstico, sino como un objetivo clínico específico de la investigación en salud mental, ya que la información que se genere puede ser la base para la creación y promoción de programas de detección e intervención tempranas.