Scielo RSS <![CDATA[Salud mental]]> http://www.scielo.org.mx/rss.php?pid=0185-332520110004&lang=pt vol. 34 num. 4 lang. pt <![CDATA[SciELO Logo]]> http://www.scielo.org.mx/img/en/fbpelogp.gif http://www.scielo.org.mx <![CDATA[<b>Clinical and electrophysiological effect of right and left repetitive transcranial magnetic stimulation in patients with major depressive disorder</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400001&lng=pt&nrm=iso&tlng=pt Major Depressive Disorder (MDD) is a common psychiatric disorder that represents one of the main public health problems worldwide. It has been projected that for 2020 it will be the second cause of disability-adjusted life years just below ischemic heart disease. Quantitative electroencephalogram provides the opportunity to study cortical oscillatory activity across the different frequency bands. It constitutes an accessible tool to explore the clinical and neurophysiologic correlates underlying psychiatric disorders as well as the effect of diverse therapeutic options and the performance through cognitive tasks. Repetitive transcranial magnetic stimulation is a technique that allows the stimulation of the cerebral cortex noninvasively, relatively painlessly and with fairly few side effects. The vast majority of rTMS studies target left dorsolateral prefrontal cortex (DLPFC) based on imaging studies showing that left prefrontal cortex dysfunction is pathophysiologically linked to depression. However, there is some evidence implicating right PFC in the pathophysiology of depression. Comparison of antidepressant efficacy of diverse stimulation frequencies is relevant since a main concern around rTMS is its potential to induce seizures; hence we consider that frequency of stimulation is an important aspect to be studied. For this study we aimed to elucidate the clinical efficacy of rTMS comparing two groups of depressed patients stimulated over DLPFC, one over the left (at 5 Hz) and other over the right (at 1 Hz). We also meant to know if there were clinical and electroencephalographic differential long-term after-effects between those groups of treatment. We included twenty right-handed patients with a DSM-IVR diagnosis of MDD. They were assigned into two groups of treatment. Group 1 received 5Hz rTMS over the left DLPFC. Group 2 received 1Hz rTMS over the right DLPFC. We obtained two EEG measurements in order to analyze Z score of broad-band spectral parameters and cross-spectral. No statistical differences among groups were found in response to treatment after weekly comparisons of clinimetric scores and significant differences between baseline and final assessment by HDRS, MADRS, BDI and HARS. The major rTMS effect on EEG was observed in the group that received 1 Hz over the right DLPFC and no significant effects were observed for the group that received 5 Hz over the left DLPFC. Our results propose that administration of 15 sessions on either left (5 Hz) or right (1 Hz) rTMS over DLPFC is sufficient to reach response to treatment, assessed by HDRS, MADRS, BDI and HARS in subjects with MDD. Moreover, in both cases rTMS was able to induce an equivalent antidepressant effect. The major effect of rTMS on EEG was observed in the right 1 Hz rTMS group where changes were elicited mainly over frontal, central and temporal regions on alpha and particularly beta frequency bands. In a lesser extent for left 5 Hz rTMS group the main effect was observed on anterior regions for beta and particularly alpha frequency bands. We believe it is pertinent to continue exploring the therapeutic potential of lower stimulation frequencies, for what further research including larger samples is still necessary to confirm these trends.<hr/>El trastorno depresivo mayor es una entidad psiquiátrica que representa uno de los principales problemas de salud pública a nivel mundial. Se ha proyectado que para el año 2020 será la segunda causa de discapacidad únicamente por debajo de la cardiopatía isquémica. La utilización del electroencefalograma cuantitativo ofrece la oportunidad de estudiar la actividad oscilatoria cortical a través de las diferentes bandas de frecuencias. Éste constituye una herramienta para explorar las características clínicas y neurofisiológicas que subyacen a los trastornos psiquiátricos, así como un instrumento para evaluar el efecto de diversas opciones terapéuticas y el desempeño de los sujetos durante la realización de tareas cognitivas. La estimulación magnética transcraneal repetitiva (EMTr) es una técnica que permite la estimulación de la corteza cerebral de manera no invasiva, relativamente sin dolor y con pocos efectos secundarios. Con base en los estudios de neuroimagen que vinculan la fisiopatología de la depresión con disfunción en la corteza prefrontal dorsolateral (CPFDL), la mayoría de las investigaciones se han enfocado en estimular dicha corteza en el hemisferio izquierdo. No obstante, existen pruebas que implican a la corteza prefrontal derecha con la fisiopatología de la depresión. La relevancia de comparar la eficacia antidepresiva de diversas frecuencias radica en el hecho de que un tema de interés particular alrededor de la EMTr es su potencial para inducir convulsiones, por ello consideramos que la exploración de las diversas frecuencias de estimulación con efecto terapéutico constituye un aspecto importante de estudio. Para este trabajo nos propusimos determinar la eficacia antidepresiva de la EMTr comparando dos grupos de pacientes que fueron estimulados en la CPFDL derecha a 1 Hz o en la izquierda a 5 Hz. También buscamos dilucidar si existen diferencias clínicas y electroencefalográficas a largo plazo entre grupos de tratamiento. Para este estudio se incluyeron 20 pacientes con diagnóstico de trastorno depresivo mayor de acuerdo con los criterios del DSM-I V. Los sujetos fueron asignados aleatoriamente a uno de dos grupos de tratamiento. Un grupo recibió EMTr sobre la CPFDL izquierda a 5Hz; el otro recibió estimulación a 1 Hz sobre la corteza contralateral. Se obtuvieron dos registros electroencefalográficos, uno basal y otro final, con el fin de comparar las medidas espectrales de banda ancha y estrecha, pretratamiento y postratamiento. Se realizaron evaluaciones clinimétricas con las escalas de Hamilton para Depresión y Ansiedad, la escala de Depresión de Montgomery-Asberg y el Inventario de Beck. No encontramos diferencias significativas al comparar la respuesta a la EMTr entre ambos grupos. Los pacientes de ambos grupos presentaron respuesta a tratamiento (disminución de ≥50% de la sintomatología depresiva) medida por clinimetría. El efecto más importante de la EMTr sobre el EEG se observó en el grupo de estimulación derecha a 1 Hz donde encontramos disminución postratamiento en los valores Z de banda estrecha alfa y beta, principalmente en regiones fronto-centro-temporales. Aunque en menor proporción, en el grupo de estimulación izquierda a 5 Hz encontramos incrementos significativos post EMTr, predominantemente en las bandas beta y alfa sobre todo en regiones anteriores. No se encontraron resultados significativos en el análisis de banda ancha. Nuestros resultados sugieren que la administración de 15 sesiones de EMTr ya sea sobre la CPFDL derecha (1 Hz) o izquierda (5 Hz) es capaz de lograr respuesta antidepresiva. Nuestros hallazgos electrofisiológicos sugieren que uno de los efectos a largo plazo de la EMTr es la reorganización de los circuitos neuronales implicados en la depresión. <![CDATA[<b>Factors related to the academic performance in medical students: a one year follow-up</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400002&lng=pt&nrm=iso&tlng=pt The study and analysis of different factors related to the academic performance of medical students remains a topic of interest, either for selection processes or for the establishment of strategies and interventions to support students who may need it. It is said that there are two groups of features associated with academic performance: the academic (high school grades, scores on entrance exams) and non-academic (personality traits, presence or absence of psychopathology, sociodemographic aspects) characteristics. The purpose of this study was to identify the influence that different features of a group of medical students from the High Academic Performance Program (HAPP) at Universidad Nacional Autonoma de Mexico (UNAM) had on their school performance. Materials and methods This paper presents the one year follow up of a cohort of students initially studied during the selection process to entry the HAPP of Medicine School at UNAM. We evaluated all first-year medical students of UNAM who, during 2009-2010, continued to be part of the HAPP and who agreed to participate in this research. At the end we studied 94 students (48 men, 46 women) with a mean age of 18.3 years. The analyzed variables were: academic performance, demographic factors, academic background, personality, abstract thinking, creative thinking, mental disorder. For the initial evaluation at the entrance to University we used the Minnesota Multiphasic Personality Inventory -2 (MMPI-2), the sub-scale of abstract reasoning from the Differential Aptitude Test (DAT), a semi-structured interview to investigate demographic and academic characteristics, and the figural test from the Torrance Test of Creative Thinking. In a second assessment (at the end of the first year), we applied the MMPI-2 (for a second time with the intention to avoid the pressure that students could have during the selection process to enter the HAPP) and Mini-International Neuropsychiatric Interview (MINI) to assess the presence of psychopathology. Also, final grades were collected from the academic file of each student. For statistical analysis we used ANOVA, multiple linear regression models, bivariate correlations and cluster analysis. Results The general knowledge test was presented as the only significant predictor for both the final average for all subjects separately, and for the final general average. Results: The general knowledge test was the only significant predictor for both the final average and the final grades for each subject. Characteristics of creative thinking (e.g fluency) or personality traits (such as MMPI-2 Mania scale) were significant predictors for the final average for most of the subjects, however they were not consistent at all. Anatomy (r= 859), developmental biology (r=852), biochemistry (r=. 893) and cell biology and tissue (r=.889) were subjects whose average had a high correlation with the global final average, while public health (r=.696) and medical psychology (r=.670) showed a moderate correlation. The score of abstract thinking (r=.029) had not any correlation with the final average that these students got at the end of the year. A comparison between the two measurements (one at the entrance to Medicine School and the other one year later) of the MMPI-2 was made and we found that there was a pattern of consistency between measurements and all correlations among the different scales that shape the inventory were significant (p<.001). Hypochondriasis, Depression, Hysteria and Psychasthenia scales, tended to rise significantly. In order to evaluate the presence of psychopathology in these students at the end of the first year of Medicine School, the MINI it was used. Of the 96 students, it was found that 77 (80.20%) had no psychopathology, and that 19 (19.79%) had one or more mental disorders at the moment of the interview. The disorders that presented the participants were: major depressive disorder (n=15), generalized anxiety disorder (n=7), bipolar disorder (n=1) and anorexia nervosa (n=1). To determine the influence of the presence of psychopathology on the students final grades, we analyzed the differences between the group of students without any mental disorder and the group with psychopathology. There was no statistically significant difference in the general final average (U=678 500, Z0-.503, p=0.615), and it was a characteristic that only made a difference for the final grades of Anatomy (U=475, Z=-2.50, p=0.012) and Public Health (U=544, Z=-2.007, p=0.045). None of the socioeconomic aspects influenced the students' academic performance. Discussion For the group of the evaluated students, we only found that the general test scores of knowledge is a significant and consistent predictor for average subjects in the first year and the final general average. Conclusions The general knowledge test was a useful predictor for final grades because it seems to summarize many of the skills and habits related to student academic success.<hr/>Antecedentes El estudio y análisis de los factores relacionados con el desempeño escolar de los estudiantes de Medicina continúa siendo un tema de interés, ya sea con fines de selección o para el establecimiento de estrategias o intervenciones de apoyo para los alumnos. El propósito de este estudio fue identificar la influencia que tenían las diferentes características de un grupo de estudiantes del Programa de Alta Exigencia Académica (PAEA) al finalizar el primer año de la carrera de Medicina en la Universidad Nacional Autónoma de México (UNAM) en su rendimiento escolar. Material y métodos En este artículo se presenta el seguimiento a un año de una cohorte de alumnos del PAEA inicialmente estudiada a su ingreso a la Facultad de Medicina de la UNAM. En total se estudiaron 94 alumnos (48 hombres, 46 mujeres), con una media de edad de 18.3 años. Las variables evaluadas fueron: desempeño académico, factores sociodemográficos, trayectoria académica, rasgos de personalidad, pensamiento abstracto, pensamiento creativo, trastorno mental. Estas se midieron a través del Inventario Multifásico de la Personalidad Minnesota-2 (MMPI-2), la sub-escala de razonamiento abstracto del Test de Aptitudes Diferenciales (DAT); una entrevista semi-estructurada, la prueba figural del test de Pensamiento Creativo de Torrance, y la Mini-entrevista Neuropsiquiátrica Internacional (MINI). Para el análisis estadístico se emplearon ANOVA, modelos de regresión lineal múltiple por pasos hacia atrás, correlaciones bivariadas y análisis de clusters. Resultados El Examen General de Conocimientos se presentó como el único predictor significativo tanto para el promedio final de todas las asignaturas por separado, como para el promedio final general. Características del pensamiento creativo (como la fluidez) o de los rasgos de personalidad (como la escala de Manía del MMPI-2) se mostraron como predictores significativos para el promedio final de la mayoría de las materias, sin embargo no fueron constantes en todas. Anatomía (r=859), biología del desarrollo (r=852), bioquímica (r=.893) y biología celular y tisular (r=.889) fueron asignaturas cuyo promedio tuvo una correlación elevada con el promedio final general; mientras que salud pública (r=.696) y psicología médica (r=.670) presentaron una correlación moderada, y el puntaje de pensamiento abstracto (r=.029) no tuvo ninguna correlación con el mismo. Se realizó una comparación entre las mediciones (inicial y un año después) del MMPI-2 y se observó que existía un patrón de constancia entre las mediciones y todas las correlaciones resultaron significativas (p<.001). De los 96 alumnos evaluados un 19.79% resultó positivo para algún trastorno mental (el depresivo mayor fue el más frecuente). Sin embargo esto sólo afectó en el promedio de Anatomía (U=475, Z=-2.50, p=0.012) y en el de Salud Pública (U=544, Z=-2.007, p=0.045). Ninguno de los aspectos socioeconómicos influyó en el desempeño académico de los estudiantes. Discusión Para el grupo de alumnos evaluados, sólo se encontró al puntaje del examen general de conocimientos como un predictor significativo y constante para el promedio de las asignaturas del primer año y el promedio final general. Conclusiones El examen general de conocimientos se mostró como una evaluación de utilidad pues parece resumir muchas de las habilidades y hábitos del estudiante que se relacionan con un buen desempeño académico. <![CDATA[<b>Timing of progesterone and allopregnanolone effects in a serial forced swim test</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400003&lng=pt&nrm=iso&tlng=pt The forced swim test (FST) is commonly employed to test the potency of drugs to reduce immobility as an indicator of anti-despair. Certainly, antidepressant drugs reduce the total time of immobility and enlarge the latency to the first immobility period. FST is preceded by the open field test (OFT) to discard any influence of changes in general motor activity that could interfere with immobility in the FST. Albeit progesterone and its a-reduced metabolite allopregnanolone produce antidepressant-like effects in the FST, the timing of actions is unknown. We hypothesized that the latency and duration of effects produced by progesterone and allopregnanolone may be characterized by repeated FST sessions; we therefore devised a serial-FST experimental design to evaluate the timing effects of these steroids on immobility, locomotion in the open field test, and grooming in the later as an indicator of response to stress. We included fifty-one ovariectomized adult Wistar rats weighing 200-250 g at the beginning of the experiments. They were ovariectomized by abdominal approach under anesthesia. Rats were housed six per cage, at room temperature (25 ± 1°C) under a 12 h/12 h light/dark cycle (lights ON at 7:00 a.m.) with ad libitum access to purified water and food. All of the experimental procedures followed National Institutes of Health Guidelines. The local Ethics Committee (Biomedical Research Institute, Universidad Nacional Autónoma de México) approved the experimental protocol. A first group received vehicle (2-hidroxypropyl-γ-cyclodextrin dissolved in injectable sterilized water to obtain a 35% solution, control group n=17), the second group progesterone (1.0 mg/kg, n=17), and the third group allopregnanolone (1.0 mg/kg, n=17). All single injections were applied by intraperitoneal route at a volume of 0.8 ml/kg. The effects of treatments were evaluated in the serial-FST at 0.25, 0.5, 1, 2, 4, 6, and 24 h after injection, in a rectangular pool (height, 60 cm; length, 30 cm; width, 50 cm), with 24 cm deep water (25 ± 1°C). We evaluated the total time of immobility, during 5 min, considered as the principal indicator of an anti-despair effect. Before each session of serial-FST, locomotion was evaluated in the OFT during 5 minutes. The apparatus consisted on an acrylic box (height, 20 cm; length, 44 cm; width, 33 cm), with twelve squares delineated on the floor (11x11 cm). In the same OFT sessions, grooming was evaluated as an indicator of response to stress. Statistical analysis consisted in two-way analysis of variance (ANOVA) and Student-Newman-Keuls as post hoc test. Total time in immobility was the highest and remained at similar levels only in the control group throughout the seven sessions of the serial-FST. In the allopregnanolone group a reduction in immobility was observed beginning 0.5 h after injection and lasted approximately 1.5 h. Similarly, progesterone reduced immobility beginning 1.0 h after injection, and the reduction lasted for approximately 5.0 h. In all groups, locomotion in the OFT was reduced after the first serial-FST session and remained at similar low levels during the serial-FST. In the control group, grooming was reduced after the first serial-FST session and lasted 24 h, but grooming did not change in the progesterone-or allopregnanolone-treated rats. From a serial-FST design, we conclude that progesterone and allopregnanolone exert short time-dependent reductions in immobility and anti-stress-like effects no longer than 24 hrs, and seemingly a reduction in the response to stress, which may have some clinical applications.<hr/>Introducción La progesterona y su metabolito activo alopregnanolona se han estudiado ampliamente en modelos experimentales de ansiedad y depresión, y por su propiedad de ser sintetizadas en el cerebro se les considera como neuroesteroides. Entre las pruebas que permiten determinar la potencia antidepresiva de ciertos fármacos se encuentra la prueba de nado forzado, la cual se diseñó originalmente para detectar la potencia de sustancias con propiedades antidepresivas. Estas sustancias reducen el tiempo de inmovilidad y alargan la latencia al primer periodo de inmovilidad, lo cual es considerado como un efecto antidepresivo. Usualmente, la prueba de nado forzado se aplica dos veces, una sesión de preprueba que dura 15 minutos, en la cual la rata o ratón desarrolla el estado de desesperanza. La preprueba es seguida de la sesión de prueba que se realiza 24 horas después durante 5 minutos. En ella se evalúa el efecto de las sustancias con propiedades antidepresivas. Además, la prueba de nado forzado es precedida por la prueba de campo abierto con la finalidad de identificar cambios en la actividad motora general (hipoactividad o hiperactividad) que pudiera interferir con la interpretación de las variables evaluadas en la prueba de nado forzado. Algunos esteroides, como la progesterona y alopregnanolona, reducen la inmovilidad y alargan la latencia a la primera inmovilidad en la prueba de nado forzado, lo que indica su efecto tipo-antidepresivo. Sin embargo, la latencia y la duración de los efectos farmacológicos son desconocidas. La hipótesis de este trabajo fue que, si utilizábamos la prueba de nado forzado de forma repetida, podríamos identificar el tiempo de duración de los efectos de estos esteroides. Por lo tanto, diseñamos un experimento con la prueba de nado forzado seriada para evaluar el tiempo de permanencia de los efectos de progesterona y alopregnanolona en esta prueba conductual. Materiales y métodos Sujetos: En este estudio se incluyeron 51 ratas adultas ovariectomizadas de la cepa Wistar, con peso entre 200 y 250 g al inicio de los experimentos. Las ratas fueron anestesiadas y ovariectomizadas por aproximación ventral y fueron alojadas en cajas de acrílico trasparente (n=6), con una temperatura ambiente de 25 ± 1°C y con un ciclo de luz-oscuridad de 12 ×12 h (la luz se encendió a las 7:00 am). Las ratas tuvieron libre acceso al agua purificada y al alimento (Purina). Todos los procedimientos realizados en este estudio fueron de acuerdo con las normas éticas en el uso de animales de experimentación, basándonos en la Guía del National Institute of Health, y el protocolo fue aprobado por el Comité de Ética del Instituto de Investigaciones Biomédicas de la Universidad Nacional Autónoma de México. Grupos y tratamientos: Las ratas del grupo control recibieron el vehículo (solución al 35% de 2-hidroxipropil-g-ciclodextrina), el segundo grupo recibió progesterona (1.0 mg/kg) y el tercero recibió alopregnanolona (1.0 mg/kg) por vía intraperitoneal, en un volumen de 0.8 ml/kg. Pruebas conductuales: El efecto de los tratamientos fue evaluado en la prueba de nado forzado a las 0.25, 0.5, 1, 2, 4, 6 y 24 horas después de la administración. Utilizamos un estanque rectangular (base 50 × 34 cm, altura 60 cm), con agua a 25°C y una altura de 24 cm. Sólo se evaluó el tiempo total de inmovilidad, considerando que es el principal indicador de un efecto antidesesperanza. Antes de cada sesión de nado forzado se evaluó la actividad motora (cuadros deambulados) y el acicalamiento en campo abierto. Esta prueba consistió en colocar a la rata en una caja de acrílico (base 33 × 44 cm, altura 20 cm) con el piso dividido en 12 cuadros de 11 × 11 cm. Los resultados obtenidos de ambas pruebas fueron evaluados por medio de una ANOVA de dos vías y como prueba post hoc se aplicó Student-Newman-Keuls. Resultados La prueba de nado forzado aplicada de forma repetida resultó ser útil para evaluar los efectos temporales producidos por dos esteroides con potencia antidepresiva. Las ratas del grupo control mostraron los valores más altos de inmovilidad en la prueba de nado forzado, los cuales se mantuvieron así durante las sesiones de prueba. En los grupos tratados con progesterona o alopregnanolona hubo una reducción de la inmovilidad, gradual y temporal. Los animales tratados con alopregnanolona redujeron la inmovilidad a partir de las 0.5 horas después de la administración, efecto que se mantuvo por un periodo de 1.5 h. Los animales tratados con progesterona redujeron la inmovilidad a partir de 1.0 hora después de la administración, efecto que se mantuvo por un periodo de 5.0h. En campo abierto, independientemente del tratamiento, hubo una reducción del número de cuadros cruzados después de la primera sesión de nado forzado, efecto que permaneció hasta las 24h. En el acicalamiento, se observó que sólo los animales del grupo control redujeron significativamente el tiempo empleado en esta conducta, mientras que los animales inyectados con progesterona o alopregnanolona no modificaron esta variable. Es decir, mantuvieron niveles semejantes durante todas las sesiones de prueba y estuvieron por arriba de los valores encontrados en los animales control. Conclusión La progesterona y la alopregnanolona ejercen un efecto antidesesperanza de breve latencia, no mayor a 24 horas. Este hallazgo podría tener implicaciones clínicas en pacientes con depresión refractaria al tratamiento convencional. <![CDATA[<b>Expressive vocabulary in a sample of preschoolers with psychiatric disorders and a group of children with typical development</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400004&lng=pt&nrm=iso&tlng=pt Introduction Expressive language problems are common amongst preschoolers both in the general population (15-20%) and in clinical settings (50-75%); furthermore, these problems are often not detected. Language problems require attention since they are associated with severe developmental disorders such as autism (Au), Asperger's syndrome (AS), attention-deficit hyperactivity disorder (ADHD) and mental retardation. In theory, language development, specifically expressive vocabulary, associated to psychiatric disorders could be identified with a scale that measures expressive language. Objectives 1. To determine the frequency of language delay in a sample of Mexican children with typical development in the community. 2. To determine the vocabulary level for autism, Asperger's syndrome, ADHD and other psychiatric disorders through the use of the Language Development Survey (LDS). 3. To analyze if differences in vocabulary ratings among the clinical subgroups can be detected with this instrument. Materials and methods The sample consisted of: A community group with typical development (TDG) (n=302) and a clinical group (CG) (n=55); both groups had an age range of 2-5 years. The clinical group was subdivided into 4 clinical subgroups based on DSM-IV criteria for: autism, Asperger's syndrome, ADHD and other psychiatric disorders (OPD) (enuresis, encopresis, separation anxiety). Exclusion criteria were: deafness, hypoacusia and other sensorial disorders and mental retardation. A semi-structured interview based on DSM-IV criteria was designed ad hoc to diagnose: autism, Asperger's syndrome, ADHD (inattentive, combined or hyperactive impulsive varieties), specific phobia disorder, tics (transitory, chronic and Tourette's syndrome), dysthymic disorder, depression, enuresis, separation anxiety disorder based on parent information. The clinical evaluation included a semi-structured play session with age-appropriate didactic material. Discrepancies in diagnosis were resolved by consensus. All interviews were conducted by an experienced clinician. The number of bulbs in the household was used to measure socioeconomic status (SES). The LDS is a list of words that explores children's vocabulary based upon parental report. The original survey has a Cronbach's alpha coefficient of 0.99, test-retest coefficient of 0.97-0.99, and a sensitivity and specificity of 86-90%. Language delay (LD) was defined as ≤50 words, as recommended by several researchers. All parents signed an informed consent form and answered the LDS. Statistical analysis. Categorical data was analyzed using a χ2 analysis; continuous data such as age, socioeconomic status, and LDS score, were analyzed using t-tests. To analytically compare the LDS group medians, a Kruskal-Wallis test was used, since the variable distribution violated the normality distribution requirements for parametric tests. For the post hoc tests, a Tamhane analysis was used for groups of different sizes. Differences were considered statistically significant if they had a p<0.05. Results The groups were similar for variables such as child's age, parents' age and the LDS median between the normal development group and the clinical group t(355)=1.12, p=.26. The proportion of male children was greater in the clinical group (CG) than in the TDG, 76.4% vs. 53%, χ2(1,N=357)=10.63, p<.001. SES was higher for the TDG (M=7.2, SD=4.2) than for the CG (M=5.8, SD=3), p<.005. The father's age (r=.15, p<.009), the mother's age (r=.16, p<.003) and the SES (r=.13, p<.01) were correlated to the LDS score. Additionally, father's and mother's age were strongly correlated (r=.72, p<.0001) and the mother's age showed small correlations with the socioeconomic status (r=.15, p<.004). The mother's age was correlated with the child's vocabulary for both sexes (males: r=.16, p<.04, females: r=.16, p<.02), and vocabulary was significantly correlated with the SES, only for the males. Language delay frequency in the TDG was 21.2%, and 23.6% for the CG, χ2(1,N=352)=1.03, p<0.59. By sex, males in both groups exhibited a greater frequency of LD [TDG: 21.6% males vs. 20.7% females, χ2(1,N=302)=.154, p<0.926; CG: 26.2% males vs. 15.4% females, χ2(1,N=55)=.642, p<0.423]. The autism subgroup had the lowest vocabulary rating (M=85, SD=78.68), followed by the OPD subgroup (M=149, SD=121), whose rating was very similar to the typically development group (M=179, SD=105). The Asperger group (M=259, SD=27) had a similar score to the ADHD group (M=286, SD=100.2), which had the highest vocabulary score of all. The Kruskal-Wallis test for median differences was significant [H(4)=17.47, p<.002]. Multiple contrast comparisons and Tamhane's post hoc analysis showed that only the contrast between the autism and the ADHD subgroups (means: 85 vs. 286, respectively) was significant (ANOVA Tamhane post hoc, p<.01).<hr/>Introducción Aun cuando los problemas de lenguaje expresivo son muy comunes tanto en la población general (15-20%) como en la clínica (50-75%), su detección es insuficiente. Los problemas de lenguaje requieren atención debido a su comorbilidad con problemas graves del desarrollo como el autismo, el trastorno de Asperger, el trastorno por déficit de la atención e hiperactividad (TDAH) y el retraso mental. En teoría, el vocabulario asociado a estos trastornos psiquiátricos podría identificarse con un instrumento que midiera el vocabulario expresivo. Objetivos 1. Determinar la frecuencia de atraso del lenguaje (AL) (SDL ≤50 palabras) en un grupo con desarrollo típico de la comunidad. 2. Determinar el nivel de vocabulario para los subgrupos de: autismo, trastorno de Asperger (TA), TDAH y otros trastornos psiquiátricos (OTP) por medio del sondeo del desarrollo del lenguaje (SDL). 3. Analizar si el SDL puede discriminar entre los subgrupos clínicos. Sujetos y método La muestra estuvo compuesta por: un grupo de la comunidad con desarrollo típico (GDT) (n=302), y un grupo clínico (GC) (n=55), con un rango de edad de 2-5 años. Se formaron cuatro subgrupos clínicos: autismo, trastorno de Asperger, TDAH y un grupo de OTP (enuresis, encopresis, ansiedad de separación). El SDL es una lista de palabras que identifica el padre sobre el vocabulario de los niños que tiene un coeficiente de alpha de Cronbach de (.99), un test-retest de .97 a .99 y una sensibilidad y especificidad de 86-90%. Se utilizó la definición de atraso de lenguaje (AL) basada en un punto de corte de ≤50 palabras. Análisis estadístico. Los datos categóricos fueron analizados mediante la prueba de chi-cuadrada y para las medidas continuas como la edad, el MSE y el puntaje del SDL se usaron pruebas t de Student. Para el análisis del contraste de las medianas del SDL de los grupos se aplicó una prueba de Kruskal-Wallis. Resultados Los grupos fueron semejantes para las variables como edad del niño, edad de los padres y la media del SDL. La frecuencia de AL (≤50 palabras) fue de 21.2% para el GDT y de 23.6% para la población clínica. Por sexo, los varones presentaron mayor frecuencia de atraso de lenguaje (GDT): 21.6% masculino vs. 20.7% femenino (p<0.926), GC: 26.2% masculino vs. 15.4% femenino (p<0.423). El vocabulario del grupo de autismo fue el menor de todos (Mdn=85, DE=78.68) seguido del grupo de OTP (Mdn=149, DE=121.0) que presentó un desempeño muy semejante al grupo de la comunidad (GDT) (Mdn=179, DE=105.0). El grupo de Asperger (Mdn=259, DE=127) tuvo un puntaje cercano al grupo de TDAH (Mdn=286, DE=100.25). La prueba de Kruskal-Wallis para la diferencia en las medianas fue significativa (p<.002) pero sólo el contraste entre el grupo de autismo y de TDAH (Mdn=85 vs. Mdn=286, p<.01) fue significativo. Discusión La frecuencia de AL para el GDT fue de 21.6% y para el GC fue de 23.6%. El SDL fue sensible en la detección del nivel de vocabulario entre los grupos y los resultados fueron congruentes con el desempeño esperado con algunas excepciones. Los niños con TDAH expresaron un mayor número de palabras comparados con el GDT. El único contraste significativo fue la comparación entre el grupo de TDAH y el autismo. El vocabulario del grupo de Asperger fue mejor que el de autismo, pero esta diferencia no alcanzó significancia estadística. Conclusiones La versión mexicana del SDL es un instrumento de tamizaje útil para identificar el atraso del lenguaje en los niños preescolares. Este estudio muestra que el atraso de lenguaje en un niño preescolar con TDAH es una indicación para profundizar en el diagnóstico del autismo. Tampoco deben pasarse por alto otros trastornos que pueden acompañar o no el TDAH como los trastornos del lenguaje específicos (pronunciación, expresión, comprensión). El SDL mide el vocabulario y no identifica alteraciones del lenguaje cualitativas más complejas asociadas al trastorno de Asperger. <![CDATA[<b>Validity of the kessler 10 (k-10) scale in detecting depression and anxiety disorders in the primary care services. Psychometric properties</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400005&lng=pt&nrm=iso&tlng=pt According to studies conducted in different countries, it is estimated that approximately 30% to 50% of people with mental health problems are not recognized by the general practitioner. Given this situation, it has been proposed that the practitioner at the primary care services must play a decisive role in the early detection of cases by establishing a definitive diagnostic and a timely treatment. Several organizations have pointed out that one of the first actions that need to be implemented to fulfill the aims in the care of people with mental disorders is to prepare the first-contact doctors and to have a brief, low cost, self-applied, valid and reliable scale. The studies mention that using screening tests at the primary care level is crucial for the success of the programs. The detection and recognition of psychiatric symptomatology rates vary depending on the type of scale applied. The tools that have been widely used are the Goldberg's General Health Questionnaire (GHQ), Zung Self-Rating Depression Scale, Beck Depression Inventory, the Depression Symptom Checklist (DS 20), the Hopkins Symptom Checklist (SCL), the Hamilton Depression Scale, the Center for Epidemiologic Studies Depression Scale (CES-D), the Montgomery-Asberg Depression Rating Scale, the Geriatric Depression Scale (GDS), the self-administered computerized assessment (PROQSY), the criteria of the 3rd revised edition of the Diagnostical and Statistical Manual of Mental Disorders (DSM-III-R), the Structured Clinical Interview for DSM-IV (SCID), and the criteria of the Symptom Driven Diagnostic System for Primary Care (SDDS-PC), among others. The preliminary results confirm the existence of a high percentage of possible psychiatric cases (46.9%), but only 4% of cases are referral. The low capability of the general practitioner at the primary care level in detecting these pathologies has been confirmed as well. These scales have been applied in different scenarios and to different types of population. Although the dominating criteria for choosing the tool are sensitivity and specificity, some authors mention that strategies for adequately handling cases, such as the confirmation of the diagnosis and follow-up of the patients, are required once the treatment has started. In this paper, we present the psychometric characteristics of the Kessler (K-10) scale in detecting depression and anxiety disorders in the primary care. Material and methods The study is a methodological process that aims to validate the Kessler Psychological Distress scale (K-10). It was conducted in two health care centers of primary care level in Mexico City. The subjects were 280 individuals who requested attention at the mentioned centers and to whom the K-10 test was applied after giving their informed consent. Later on, the computerized version of the International Neuropsychiatric Interview (MINI), which uses the diagnostic criteria of the DSM-IV, was applied to the subjects in order to confirm the diagnostics for depression and anxiety. The MINI is a version adapted to Latin American Spanish by the National Institute of Psychiatry Ramon de la Fuente Muñiz. The diagnostic accuracy was processed following the MINI diagnoses for depression and anxiety closely, and the scores on the scale K-10 as a predictor. The sensitivity and specificity were calculated for all possible cut points in order to establish the optimal cut off point. The efficiency and maximum likelihood ratios were also calculated. The area under the ROC curve as well as the probability quotients, positive and negative (LR+ and LR-), were also calculated. The K-10 is a brief screening tool that can be easily applied by the primary care personnel which measures the psychological distress of a person during the four weeks prior to the application. It consists of ten questions with Likert-like answers that range from 1 to 5 and are categorized in a five level ordinal scale: Always, Very Often, Sometimes, Rarely, Never; where «Never» has an assigned value of 1, and «Always» has assigned value of 5. It has a minimum score of 10 and a maximum of 50. The ranges of the instrument are four levels: low (10-15), moderate (16-21), high (22-29) and very high (30-50). The instrument showed an internal consistency of 0.90 and it has been used in various population studies promoted by the World Health Organization as well as government organizations in Australia, Spain, Colombia and Peru. Results Out of 280 individuals to whom the tool was applied, 78.9% (221) were female and 21.1% (59) male. These values represent the proportion of patients attending the primary care services (95% confidence interval=±5.4%). The mean age of women was 39 years, and the mean age of men was 41. The 70.6% of the women manifested more psychological distress than men (52.5%)[χ2(1)=6.05,p=0.014. No other socio-demographic variable showed significant differences. The instrument is highly precise, it can detect up to 87% of depression cases, and 82.4% of anxiety cases. The scale was compared with the MINI and it presented a prevalence of 26.8% and 10.6%, respectively. Of the total of depression cases, 26.4% also presented anxiety; these represent a co-morbidity of 5.4%. The construct validity presented one factor alone that explains the 53.4% of the total variance, this is why the scale is considered as one-dimensional. In other words, the scale only measures the construct of the psychological distress. The internal consistency was α=0.901. Once the sensitivity and specificity for all cut off points had been determined using the MINI as a golden rule, it was observed that the cut off point for maximum sensitivity and specificity corresponded to 21 for the diagnosis of depression, and 22 for anxiety. Conclusions The K-10 is a good instrument for the detection of depression and anxiety cases at the primary care level which meets the criteria of validity and reliability. However, given that only one diagnosis was considered for all the range of anxiety disorders, the scale must be chosen carefully for all the other disorders that are not included in this paper. The use of the instrument is recommended for the general practitioners at the primary care level, mainly for diagnosing depression. Various studies in which other screening instruments have been used for the detection of depressive disorder at primary care point out that any screening method are useful in making the diagnosis. By using these instruments, the depression diagnosis at primary care level increases from 10% to 47%. The latter supports the fact that the selection of a good instrument turns out to be effective in detection, treatment and clinical outcomes of the entity. Since this recommendation is only one of the activities required in primary care level for good handling of detected cases, it is noteworthy to mention that a comprehensive care model that encompasses both the detection as well as the pharmacological and psychosocial treatments is required.<hr/>De acuerdo con estudios realizados en diferentes países se estima que aproximadamente hay entre 30% a 50% de personas que presentan algún problema de salud mental que no es reconocido por el médico general. En virtud de esta situación se ha propuesto como estrategia a la atención primaria como base del sistema de salud, lo que permitiría la detección temprana de pacientes con algún trastorno psiquiátrico. Diferentes organismos señalan que una de las primeras acciones para cumplir con los objetivos en la atención de personas con algún trastorno mental, consiste en contar con una escala breve, autoaplicable, válida y confiable y de bajo costo. En este trabajo se presentan las características psicométricas de la escala Kessler (K-10) para detectar trastornos depresivos y ansiosos. La K-10 es un instrumento de tamizaje breve y de fácil aplicación por el personal del primer nivel de atención y ha sido utilizada en diferentes estudios a nivel poblacional. En Australia, en 1997, se aplicó la K-10 en una encuesta de salud, por medio del Consejo Nacional de Encuestas de Salud Mental. Material y métodos Se trata de un estudio de proceso metodológico, cuyo objetivo fue la validación de la escala de malestar psicológico K-10 de Kessler. El estudio se llevó a cabo en dos Centros de Salud del primer nivel de atención en la Ciudad de México. Los participantes fueron 280 personas que acudieron a la consulta externa de dichos centros. Se utilizaron los criterios del DSM-IV para la confirmación del diagnóstico de depresión y de ansiedad, por medio de la Mini International Neuropsychiatric Interview (MINI), en su versión computarizada, adaptada al español latinoamericano en el Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz. La validez diagnóstica se procesó utilizando los diagnósticos de la MINI para depresión y ansiedad como regla de oro y las puntuaciones obtenidas en la escala K-10 como predictor. Se calculó la sensibilidad y especificidad para todos los posibles puntos de corte con el fin de establecer el óptimo. Se calculó adicionalmente la eficiencia y las razones de máxima verosimilitud, así como el área bajo la curva ROC y los cocientes de probabilidad, positivo y negativo (LR+ y LR-). Resultados Del total de personas a quiénes se les aplicó la escala, el 78.9% (221) fueron mujeres y 21.1% (59) hombres. Estos valores representan la proporción en que los pacientes acuden a los servicios de primer nivel (IC 95%=±5.4%). El 70.6% de las mujeres presentaron mayor malestar psicológico en comparación con los hombres que representaron el 52.5% [χ²(1)=6.05,p=0.014]. En ninguna otra variable socio-demográfica se presentaron diferencias significativas. El instrumento tiene una alta precisión, ya que puede detectar hasta el 87% de los casos de depresión y un 82.4% de los casos de ansiedad. La escala se comparó con el MINI en español y presentó una prevalencia de 26.8% y 26.4%, respectivamente. Conclusiones El instrumento cumple con los criterios de validez y confiabilidad, por lo que se recomienda su uso por los médicos generales en el primer nivel de atención. Dado que esta recomendación sólo es una de las actividades que se requieren en la atención primaria para un buen manejo de los casos que se detecten, es necesario señalar que se requiere de un modelo de atención integral que incorpore tanto la detección como el tratamiento farmacológico y psicosocial. <![CDATA[<b>Study of translation into Spanish and psychometric properties of a measure to evaluate internalized stigma among patients with severe mental disorders</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400006&lng=pt&nrm=iso&tlng=pt Introduction Mental illness is one of the most stigmatized health problems. The stigma related to mental health disorders can be experienced from two different perspectives: i) social stigma (perpetrated by the general population) and ii) personal stigma (internalized by the affected). Research on stigma and discrimination among patients with mental health problems has been centered on the social viewpoint, that is, what the general population sets over people who suffer the condition. Nonetheless, the investigation that focuses on the way people with psychiatric illness experience adverse reactions (i.e. rejection) has received little attention and hence been poorly assessed. Until now there was no internalized stigma measuring instrument, validated in Mexican population, nothing that could allow us to score the level of stigma perceived by these patients. Thus, the objectives of the present study were to translate into Spanish the internalized stigma scale (ISS) created by King et al., and to evaluate its basic psychometric properties among Mexican patients with severe mental disorders. The ISS has 28 items to answer in a five-point Likert scale, ranging from «strongly agree» to «strongly disagree», to assesses stigma through three different sub-scales: i) discrimination, ii) disclosure, and iii) positive aspects of mental illness. The discrimination subscale contains items that refer to the negative reactions of other people, including acts of discrimination by health professionals, employers and police; the disclosure subscale includes questions regarding embarrassment or feeling bad about the illness and managing disclosure to avoid discrimination. Finally, the positive aspects subscale asks about how patients accept their illness and perceive themselves as less affected by stigma. A higher score means greater stigma, due the answer to items that explore positive aspects of mental illness are reversed. Method Subjects: One hundred severe mentally ill Mexican subjects were included in the study. All of the patients had been receiving psychiatric attention at the Mental Health Integral Attention Center, Long stay division of the Mental Health Institute in Jalisco (Instituto Jalisciense de Salud Mental), which is part of the health office of such State. They all had at least two years of diagnosis and treatment. None was suffering an acute process of the illness at the moment of administration of the instruments. Measures and procedure: The ISS was translated into Spanish by translation-back- translation method and then administered by a psychiatrist together with the global assessment functional scale (GAF) and the clinical global impression scale (CGI). Data analysis: Cronbach's alpha and varimax rotation factor analysis were employed in order to examine internal consistency and construct valididty of the main components of the scale. Results From the total one hundred patients that integrated the studied sample, 67 (67%) were males; most of them single (62%) and unemployed (70%). The most commonly diagnosis was schizophrenia (47%); the time of illness was between 2 and 44 years, while the duration of the treatment was 1 to 44 years. Along the evolution of the illness, 81 (81%) had been hospitalized due to the psychiatric condition at least once. The mean functional global assessment score was 58.4, and the mean score in the CGI scale was 3.78 points. Regarding the management, 89% (n= 89) were under treatment with some kind of antipsychotic; the most used kind were first generation ones (n= 68, 68%), particularly haloperidol, either in immediate release or intramuscular depot presentations. ISS score was drawn and compared to the one obtained for the original English version; both measurements were alike (60.15 vs. 62.6, respectively). Each of the subscales in the ISS also showed similar results respect the ones obtained in the original version (discrimination 27.6 vs. 62.6; disclosure 22.1 vs. 29.1 and positive aspects 10.3 vs. 8.8, respectively). Additionally, the Spanish version of the ISS has shown a proper internal consistency with Cronbach's alpha scores higher than 0.60 in all of the sub-scales; the whole being similar to the ones identified for the original version of the measurement (Spanish version: discrimination subscale=0.83, disclosure=0.76 and positive aspects= 0.60; Original version: discrimination subscale= 0.87, disclosure= 0.85 and positive aspects=0.64). The unidimensional construct of the instrument showed a 0.87 Cronbach's alpha, being highly reliable. Regarding the factor validity, three main components were obtained confirming the original structure. The first factor (discrimination) explains 25.46% of the variance, the second (disclosure), 10.08%, and the last one (positive aspects) explains 7.24%. Conclusions The present study reports the psychometric data of ISS-Spanish version among severe mentally ill patients. We demonstrated that is a measure with appropriate internal consistency for the whole version as well as for all the sub-scales; it has, in addition, factor validity. Thus, it is possible to state that now we count with a valid and reliable instrument to assess internalized stigma of mental illness to be used for the evaluation of Mexican population with clinical and research purposes.<hr/>Introducción Se ha demostrado que la enfermedad mental es una de las condiciones que generan más estigma. El estigma producido por los trastornos psiquiátricos se puede experimentar desde la perspectiva social y la personal (estigma internalizado). La forma en que las personas con padecimientos psiquiátricos experimentan las reacciones adversas de los otros ha sido poco estudiada. Hasta ahora no existía una escala validada en la población mexicana que permitiera la medición del estigma percibido por este tipo de pacientes. El objetivo del presente trabajo fue traducir al español y determinar la consistencia interna y la validez factorial de la Escala de estigma de King et al. Método Sujetos: Se incluyeron 100 pacientes mexicanos con diagnósticos de trastornos mentales graves y persistentes (TMSP) que reciben atención en el Centro de Atención Integral en Salud Mental de Estancia Prolongada del Instituto Jalisciense de Salud Mental (SALME), con un mínimo de dos años de evolución y que no se encontraran cursando con un episodio agudo de su enfermedad. Instrumentos y procedimiento: Se aplicó la escala de estigma internalizado de King et al. (EEI) y las escalas de evaluación de la actividad global (EEAG) y de impresión clínica global (CGI). Análisis de datos: Se evaluó la consistencia interna de la EEI mediante el coeficiente alpha de Cronbach y la validez de constructo con base en un análisis factorial de componentes principales con rotación varimax. Resultados La muestra estuvo integrada por 100 pacientes, 67 (67%) eran hombres, mayoritariamente solteros (62%) y desempleados (70%). La mayoría contaba con un diagnóstico principal de esquizofrenia (47%); el tiempo de enfermedad y de tratamiento fue de dos a 44 años y de uno a 44 años, respectivamente. El 81% había sido hospitalizado en una institución psiquiátrica al menos en una ocasión. Respecto al funcionamiento global, la media fue de 58.4 puntos, y la puntuación promedio del CGI fue de 3.78. El 89% (n=89) se encontraba medicado con algún tipo de antipsicótico, más frecuentemente típico (n= 68, 68%). El promedio del nivel de estigma obtenido se comparó con el puntaje de la validación de la escala original; dichos valores fueron muy similares (60.15 y 62.6, respectivamente). La versión en español de la EES se caracterizó por una adecuada consistencia interna, con alphas superiores a .60 en todas las sub-escalas. La evaluación unidimensional del constructo resultó altamente confiable, con un coeficiente de 0.87. Se obtuvieron tres factores principales congruentes con la versión original, lo que da prueba de su validez. Conclusiones El presente estudio es el primero en reportar las propiedades psicométricas de la versión en español de la EES en pacientes mexicanos con trastornos mentales graves y persistentes. Con base en nuestros hallazgos es posible concluir que la EES-español cuenta con una adecuada consistencia interna total y en todas las sub-escalas; además da prueba de validez factorial, por lo que es posible recomendarla para su uso con fines clínicos y/o de investigación. <![CDATA[<b>Rationale and state of the art in early detection and intervention in psychosis</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400007&lng=pt&nrm=iso&tlng=pt Schizophrenia-spectrum disorders have a chronic and episodic course that results in impairment of all life domains. Pharmacological and psychosocial treatments provide symptom relief, but there is not a cure for schizophrenia and many patients suffer chronic impairment. In addition, it is expensive both in economical terms and also in terms of personal costs for both patients and their families. International interest has grown over the past 15 years in the prognostic potential of early identification and intervention in the prodromal and first-episode phases of psychotic illness. This focus is associated with increasing optimism about the benefits of implementing treatment as early as possible in the course of psychosis at least to help improve the course of illness, reducing its long-term impact. The most recent epidemiological studies have shown that patients with longer duration of untreated psychosis (DUP) have worse short-term outcomes in terms of treatment response, positive symptoms, negative symptoms, and global functioning. Neuroimaging studies have also indicated that prolonged untreated illness is associated with more pronounced structural brain abnormalities, while this is less prominent earlier in the course of the disorder. Therefore, early detection aims to reduce treatment delay in the hope of improving prognosis and reducing illness severity. Early intervention in psychotic disorders has gained momentum in the last decades, and there is now an estimated 200 centers worldwide offering specialized services for young people experiencing their first episode of psychosis. Each of these programs has unique characteristics and distinctive features in terms of treatment modalities and assessment tools, but most have a number of common elements and goals: a) early detection of new cases, b) reducing DUP, and c) providing better and continued treatment during the «critical period» of the early years of the disease. Moreover, the role of family work in early psychosis can be crucial given that relatives are the main informal caretakers of persons with mental health problems. Family interventions in early psychosis usually offer psychoeducation and/or individual and group family therapy, communication and problem solving training, which can help to develop coping strategies and reduce distress and burden. Intervention programs in early psychosis are usually composed by interdisciplinary teams, providing a wide range of integrated services that typically include psychoeducation, clinical case management, and group interventions. Specific interventions generally include pharmacotherapy, stress management, relapse prevention, social and employment rehabilitation support, and cognitive and family therapy. Given the complex etiology and clinical manifestation of psychosis, treatment packages for people experiencing early psychosis need to be individually tailored to specific needs rather than applied homogenously across early psychosis patients. The current challenge in the implementation of psychological interventions in the early stages of psychosis are: 1. to adapt treatment modalities that have been proven effective in stable and residual stages of the disease to its early stages; 2. to develop new forms of therapy tailored to the specific characteristics of these early stages of psychosis (prodromal and ultra high-risk phase, onset and first episode psychosis, and «critical period» or post-crisis psychosis); and 3. treatment packages need to be individually tailored to their specific needs rather than applied homogenously across a group of patients. The aims of this paper are: 1. to present the basic concepts, rationale and state of the art of the early detection and intervention paradigm; 2. to review and present the main detection and intervention programs in early psychosis and 3. to provide an overview of the current psychotherapeutic approaches in early psychosis.<hr/>Los trastornos del espectro psicótico presentan un curso crónico y episódico que provoca alteraciones en todas las áreas de la vida, generando importantes grados de discapacidad, pérdida de funciones psicosociales, grandes costos económicos, una comorbilidad considerable y sufrimiento tanto para los pacientes como para sus familias. A pesar de que los tratamientos farmacológicos y psicosociales han ayudado a aliviar los síntomas y mejorar la calidad de vida, en muy pocas ocasiones se logra una recuperación satisfactoria a nivel psicológico y funcional. Durante los últimos 15 años, el optimismo creciente sobre la posibilidad de mejorar el pronóstico de la psicosis y alterar con ello el tradicional curso negativo de la enfermedad ha producido una reforma sustancial en la práctica clínica y en el desarrollo de estrategias de intervención temprana en muchos países. De esta manera, el desplazamiento del foco de atención desde las fases estables o residuales de la psicosis hacia los inicios de la misma está suponiendo una serie de innovaciones y avances, tanto en la evaluación y diagnóstico como en las modalidades terapéuticas y en la consiguiente reordenación de los servicios asistenciales. Los estudios epidemiológicos más recientes han mostrado que los pacientes con mayor duración de la psicosis no tratada tienen peor respuesta al tratamiento farmacológico, mayor gravedad de síntomas positivos, síntomas negativos y peor funcionamiento global. Por otra parte, los estudios de neuroimagen también indican que un periodo prolongado de enfermedad no tratada produce anormalidades estructurales cerebrales más pronunciadas. Es por esto que la detección temprana en psicosis tiene como objetivo reducir la demora del tratamiento para mejorar el pronóstico y reducir la gravedad del trastorno. La detección temprana y la aplicación del tratamiento específico más eficaz para cada fase inicial del trastorno son dos elementos que diferencian la intervención temprana de las formas habituales de asistencia actuales. Cada vez existen más grupos en todo el mundo dedicados a establecer programas clínicos e iniciativas de investigación centradas en la psicosis temprana. Cada uno de estos programas tiene características particulares y rasgos propios en cuanto a las modalidades de tratamiento o los instrumentos de evaluación, pero la mayoría tiene una serie de elementos y objetivos en común: a) detectar de forma precoz nuevos casos; b) reducir el periodo de tiempo desde que el paciente presenta una sintomatología claramente psicótica hasta que recibe un tratamiento adecuado y c) proporcionar un mejor y continuo tratamiento en el «periodo crítico» de los primeros años de la enfermedad. En el contexto de la prevención e intervención temprana, el trabajo con la familia puede ser crucial, ya que los familiares son los principales cuidadores informales y son una parte fundamental para la recuperación del paciente. La mayoría de las intervenciones familiares ofrecen psicoeducación y/o terapia familiar que ayudan a desarrollar estrategias de adaptación y afrontamiento, disminuir el estrés y la carga a largo plazo, así como mejorar la comunicación y la resolución de problemas. Los programas de intervención en la psicosis temprana están habitualmente formados por equipos interdisciplinarios que proporcionan una amplia serie de servicios integrados que suelen incluir psicoeducación, manejo clínico de casos e intervenciones grupales. Las intervenciones específicas incluyen generalmente farmacoterapia, manejo de estrés, prevención de recaídas, apoyo y rehabilitación social y laboral, así como terapia cognitiva y familiar. Dada la compleja etiología y manifestación clínica de la psicosis, los tratamientos para personas con psicosis incipiente deben ser adaptados individualmente a las necesidades específicas en lugar de aplicarlos homogéneamente a todos los pacientes por igual. El desafío actual en la aplicación de intervenciones en la psicosis temprana consiste en: 1. conseguir adaptar aquellas modalidades de tratamiento que ya han demostrado su eficacia en las fases estables y residuales de la enfermedad a los inicios de la misma; 2. integrar y desarrollar nuevas formas de terapia que se adapten a las características específicas de cada una de las fases iniciales de la psicosis (fase prodrómica o de alto riesgo, inicio de la psicosis o primer episodio de psicosis y «fase crítica» o poscrisis) y 3. adecuar los tratamientos de manera individual en vez de aplicarlos de forma homogénea. Los objetivos del presente artículo son: 1. presentar los conceptos básicos, la justificación y el estado de la cuestión del paradigma de detección e intervención temprana en psicosis; 2. hacer una revisión y presentar los principales programas de detección e intervención temprana en psicosis y 3. proporcionar una visión general de los enfoques psicoterapéuticos actuales en psicosis incipiente. <![CDATA[<b>A systematic review of addiction treatment in Mexico</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400008&lng=pt&nrm=iso&tlng=pt The consumption of substances with addictive potential is a relevant health problem. In Mexico, the abuse is spreading and the use of services is unfrequent. To extend the offer and accessibility to treatment means to increase the coverage and to guarantee that efficient and effective models are used to treat the patients. The aim of the paper was to learn what has been investigated in this respect; a systematic review of the studies was undertaken to evaluate the treatment research through clinical trials. Methods A review of the published literature from 1980 to 2010 in databases and specialized documentation centers was undertaken. Reports of clinical trials to evaluate interventions for the consumption of alcohol, tobacco and drugs were included. The criteria proposed by CONSORT were used as indicators. Results Two hundred and twenty publications were located on treatment in Mexico, of which only 26 (11.8 %) corresponded to clinical trials to evaluate the impact of different interventions. The most used type of treatment was the cognitive-behavioral brief one, followed by its combination with therapy of replacement, pharmacological therapy and individual psychotherapy or group therapy. Trials also included evaluation of motivational brief therapy, the program «La familia enseñante» (teaching family) and psychotherapy, as well as the therapy centered on solutions. Discussion Most of the clinical trials localized do not comply with the criteria or do it partially. Additionally they have short scopes due to the limited size of the samples. The results reveal that the reports published of investigations are very scanty to evaluate programs of treatment. There is a need to implement programs of treatment directed to specific populations and to the use of different types of drugs, and to evaluate the interventions.<hr/>El consumo de sustancias con potencial adictivo es un problema relevante de salud. En México el abuso se está extendiendo y el uso de servicios es poco frecuente. Ampliar la oferta y la accesibilidad al tratamiento significa aumentar la cobertura y garantizar que se apliquen modelos eficaces y efectivos. Con el propósito de conocer qué es lo que se ha investigado en este sentido, se desarrolló una revisión sistemática de los estudios realizados para evaluar los programas de tratamiento. Método Se realizó una revisión de la bibliografía publicada de 1980 a 2010 en bases de datos y centros de documentación especializados. Se incluyeron reportes de estudios para evaluar intervenciones y tratamientos para el consumo de alcohol, tabaco y drogas. Se utilizaron como indicadores los criterios propuestos por Moher et al., del CONSORT. Resultados Se localizaron 220 publicaciones sobre tratamiento en México, de las cuales solo 26 (11.8%) correspondieron a ensayos clínicos para evaluar el impacto de diferentes intervenciones. El tipo de tratamiento más utilizado fue el cognitivo-conductual breve, seguido por su combinación con terapia de reemplazo, terapia farmacológica y psicoterapia. También se evaluó la terapia breve motivacional, el programa de «La familia enseñante» y la terapia centrada en soluciones. Discusión y conclusiones Al analizar las publicaciones se encontró que la mayoría no cumple con los criterios de los ensayos clínicos aleatorizados o lo hace parcialmente. Adicionalmente tienen cortos alcances debido al reducido tamaño de las muestras. Los resultados revelan que aún son muy escasos los reportes publicados de investigaciones para evaluar programas de tratamiento. Se enfatiza la necesidad de implementar programas dirigidos a poblaciones específicas y acordes a cada tipo de droga, así como la relevancia de generar investigación científica aplicada a la evaluación de las intervenciones. <![CDATA[<b>DSM-V. </b><b>Lights and shadows of an unpublished manual. Challenges and expectations for the future</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400009&lng=pt&nrm=iso&tlng=pt Throughout its history, one of the most fascinating topics of psychiatry has been that of the causes and consequences of mental disorders. The desire to strengthen the reliability of diagnosis in this area has led to significant advances in two important fields: psychopathological description and the formulation of an integral diagnosis. Classifications allow the definition of categories and in the case of the two most read taxonomies in the field of mental health, Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), these provide the most commonly used criteria for diagnosis. The revised fourth edition of the DSM is now insufficient to cover the ever greater clinical challenges and research. For over ten years, work has been carried out on the structure of DSM-V (the fifth edition), but despite the planning, organization, prediction, and the contributions of guest experts, it is feared that all the requirements of modern psychiatry will not be met. The first edition of DSM was published in the 1950s. It was based on the terminology developed by William Meninger. This version of the manual and the following, published several years later, reflected the psychodynamic psychiatry which prevailed at the time. The third edition was published in 1980 and its revised edition seven years later. The emphasis here was on descriptive and syndromatic considerations. The fourth edition appeared several years later. The most striking change in this edition was the inclusion of variables resulting from empirical studies. A later edition was published in the year 2000. The first attempts to put together DSM-V started in 1999. From 1999 until 2007 work was done on the planning of the investigation and technical documentation of DSM-V and the inclusion of the so called investigation schedules. The second phase of the project, known as «the refinement of the research program for DSM-V», was carried out between 2004 and 2007. A pilot test was undertaken between January and May 2010, among different segments of the population and different settings, to evaluate the revisions proposed by the working teams. Between March and April 2011, as a result of the field tests, the proposed criteria for diagnosis were reviewed. The dimensional measurements and the criteria for diagnosis will be reviewed again during the rest of 2011. The year 2012 will see the preparation of the final version of the text, and finally, in May 2013, DSM-V will be presented at the annual meeting of the American Psychiatric Association in San Francisco, California. Several external and independent authors have offered numerous proposals on topics related to psychopathology in general to the working groups formed for the preparation of DSM-V. Only some of these are mentioned below. One of the first factors to be taken into consideration in the revision of the manual is the need to distinguish between empirical questions or approaches and those of a more conceptual or philosophical nature, which should, by no means, be excluded. Another point to be evaluated is the advisability of defining phases according to the development of the condition, which would ideally create a schema focused on prevention. One of the expectations of psychiatry is that eventually laboratory criteria of diagnosis could be established, which could be measurable and would lead to clear statistics of psychiatric pathologies. As far as somatomorphic disorders are concerned, many practitioners agree that the current terminology and the systems of classification are inaccurate. One proposal is that this category should be eliminated altogether and that diagnoses should be made using an additional multidimensional description. One of the most interesting features of DSM is that it has had to accommodate changes brought about by new technologies. These advances go hand in hand with a new series of pathologies which need to be classified, as is the addiction to Internet. Undoubtedly, one of the greatest dilemmas facing DSM is how to classify eating disorders, as many people feel that the rather simplistic distinction between nervous anorexia and bulimia is not altogether convincing. There are two interesting proposals to consider in DSM-V: one is known as night eater syndrome and obesity, as in this case there is a compulsive consumption of food and an inability to limit this intake, in spite of a desire to do so. With regard to the compulsive, obsessive disorder, most experts believe that it is necessary to see the disorder as a spectrum, but defining criteria. Undeniably, a grave current problem which makes no distinctions is suicide. Different researchers recommend that suicidal behavior be considered and documented as a separate diagnosis in a sixth axis of the multiaxis schema. Another important aspect concerns the giving of quality attention to patients. This has led to the proposal to expand DSM-V to include indicators for situations which could eventually be a cause for treatment. The proposal is to structure something different from what can be found in axis I V. In the case of paraphilias, it is deemed necessary that DSM-V should deal not only with the strictly descriptive aspect, but also with the semantic and linguistic. The importance of post-traumatic stress has been described, but there exists the doubt whether it is necessary to experience an adverse incident for this to be triggered. There has been a suggestion that the term «pre-traumatic» stress disorder be included in DSM-V to diagnose this condition. In the case of anxiety disorders, some authors advise the creation of a category known as «disorders caused by stress and fear», which would allow linking the diagnostic classification with etiology and thus define a «true» anxiety nosology. It would be advisable that the DSM-V included a category for «seasonal affective disorder» as such, and not simply as a variant in the «specification of the seasonal pattern» of depression. In the field of substance consumption, it has been argued that it is necessary to establish a classification which is not only categoric but also dimensional so as to improve its taxonomic usefulness. The organization of mental disorders in DSM-IV-TR and ICD-10 (tenth edition) is complex and this has led to exploring the feasibility of developing a meta-structural system of classification based on risk and clinical factors. For disorders originated in infancy, childhood and adolescence, it has been suggested that the disorder known as «temperament disorder by disphoria» be included in the forthcoming taxonomy, as well as the use of the terms insensitive/emotionless for behavioral disorders, among others. In the case of attention deficit hyperactivity disorder (ADHD), the current criteria are considered insufficient and it has been suggested that the starting age for this disorder be increased from 7 to 12 years of age. It is suggested that autism be considered autistic spectrum, thus eliminating the other disorders covered in this section, including Asperger syndrome. The question as to whether this taxonomic-diagnostic system, to be implemented world-wide, will be both valid and reliable enough to cover all variations and particular characteristics of different cultures, ethnic groups, social groups and geographical regions in Mexico is another matter of concern, due to the lack of tools available for daily clinical work, except for the International Classification of Diseases of the World Health Organization. There are, at present, a number of doubts and queries which will need to be laid open and evaluated in all seriousness in order to obtain concrete and integral answers, given that the manual will continue to be used for clinical purposes in different parts of the world. The challenge will be to find the best way to apply diagnostic criteria, avoiding omissions and oversimplifications and taking into account the cultural and social context worked in.<hr/>Un tema de gran interés a lo largo de la historia de la psiquiatría, ha sido el relacionado a los sistemas diagnósticos. El Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM por sus siglas en inglés) y la Clasificación Internacional de Enfermedades (CIE), integran los criterios diagnósticos comúnmente utilizados en la práctica psiquiátrica. El DSM en su cuarta edición revisada, es ya insuficiente para el trabajo clínico actual, por lo que se ha estado trabajando en la configuración de lo que será el DSM-V (quinta edición); no obstante, aún y con toda la planeación, se teme que no se logren cubrir todas las necesidades de la psiquiatría moderna. La primera edición del DSM fue publicada en la década de 1950; esta versión del manual, y la subsiguiente, reflejaban la psiquiatría psicodinámica de esa época. En la década de 1980 se publicó la tercera edición y su versión revisada, en las que predominaban las consideraciones descriptivas y sindromáticas. Años después fue publicada la cuarta versión y una revisión posterior de este manual en el año 2000. Los primeros esfuerzos para iniciar el proceso de integración del DSM-V se iniciaron desde 1999. Desde ese año, hasta el 2007, se planificó la investigación y la documentación técnica por medio de un programa de investigación. Del año 2004 al 2007 se llevó a cabo la segunda fase del proyecto denominada «perfeccionamiento del programa de investigación para el DSM-V». De enero a mayo del 2010 se efectuó una prueba piloto con diferentes poblaciones y las revisiones propuestas por los grupos de trabajo. En el 2011 se revisarán los criterios diagnósticos propuestos y las medidas dimensionales. En el año 2012 se preparará el proyecto de texto final, y en mayo del 2013 se planea presentar el DSM-V en la Reunión Anual de la Asociación Psiquiátrica Americana, en San Francisco, California. Han sido numerosas las propuestas de autores externos e independientes para el desarrollo del DSM-V, como es el caso de la conveniencia de definir estadios de acuerdo a la progresión de la enfermedad o bien establecer criterios diagnósticos de laboratorio, e incluso favorecer una estadificación clara de las patologías psiquiátricas. En cuanto a los trastornos somatomorfos, muchos clínicos están de acuerdo en eliminar esta entidad y elaborar los diagnósticos con una descripción multidimensional adicional. Algunos expertos proponen integrar un diagnóstico denominado «adicción al Internet». Diferentes investigadores recomiendan que el comportamiento suicida sea considerado como un diagnóstico separado y documentado en un sexto eje del esquema multiaxial. Hay dos propuestas interesantes para el DSM-V, una es el síndrome del comedor nocturno y la otra la obesidad, al existir en estos casos un consumo compulsivo de alimentos y una dificultad para restringirlos, lo que podría tener implicaciones adictivas. En el caso de las parafilias se plantea la necesidad de que se trabaje en el aspecto descriptivo, semántico y lingüístico. Se ha descrito la importancia del estrés postraumático, pero se sugiere también un trastorno de estrés «pre-traumático» como diagnóstico en el DSM-V. En los trastornos de inicio en la infancia, niñez y adolescencia, se ha planteado incluir en la próxima taxonomía el denominado «trastorno por disregulación del temperamento con disforia». En lo referente al trastorno por déficit de atención e hiperactividad (TDAH) se considera que los criterios actuales son insuficientes, y se propone incrementar la edad de inicio del trastorno. Para el autismo se sugiere considerarlo como espectro autista, eliminando el trastorno de Asperger. Finalmente en opinión de los autores de este trabajo, existe por el momento una diversidad de cuestionamientos que deberá valorarse con seriedad, toda vez que el manual evidentemente seguirá siendo de uso clínico continuo en diferentes latitudes. El desafío será establecer la mejor forma de aplicar los criterios diagnósticos tomando en cuenta el contexto cultural y social en el que se trabaja, lo que, por lo revisado, sigue siendo un punto pendiente para los encargados de revisar la próxima versión del manual. <![CDATA[<b>The cronophaenomenology: The subjective time and the elastic clock</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400010&lng=pt&nrm=iso&tlng=pt Throughout its history, one of the most fascinating topics of psychiatry has been that of the causes and consequences of mental disorders. The desire to strengthen the reliability of diagnosis in this area has led to significant advances in two important fields: psychopathological description and the formulation of an integral diagnosis. Classifications allow the definition of categories and in the case of the two most read taxonomies in the field of mental health, Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), these provide the most commonly used criteria for diagnosis. The revised fourth edition of the DSM is now insufficient to cover the ever greater clinical challenges and research. For over ten years, work has been carried out on the structure of DSM-V (the fifth edition), but despite the planning, organization, prediction, and the contributions of guest experts, it is feared that all the requirements of modern psychiatry will not be met. The first edition of DSM was published in the 1950s. It was based on the terminology developed by William Meninger. This version of the manual and the following, published several years later, reflected the psychodynamic psychiatry which prevailed at the time. The third edition was published in 1980 and its revised edition seven years later. The emphasis here was on descriptive and syndromatic considerations. The fourth edition appeared several years later. The most striking change in this edition was the inclusion of variables resulting from empirical studies. A later edition was published in the year 2000. The first attempts to put together DSM-V started in 1999. From 1999 until 2007 work was done on the planning of the investigation and technical documentation of DSM-V and the inclusion of the so called investigation schedules. The second phase of the project, known as «the refinement of the research program for DSM-V», was carried out between 2004 and 2007. A pilot test was undertaken between January and May 2010, among different segments of the population and different settings, to evaluate the revisions proposed by the working teams. Between March and April 2011, as a result of the field tests, the proposed criteria for diagnosis were reviewed. The dimensional measurements and the criteria for diagnosis will be reviewed again during the rest of 2011. The year 2012 will see the preparation of the final version of the text, and finally, in May 2013, DSM-V will be presented at the annual meeting of the American Psychiatric Association in San Francisco, California. Several external and independent authors have offered numerous proposals on topics related to psychopathology in general to the working groups formed for the preparation of DSM-V. Only some of these are mentioned below. One of the first factors to be taken into consideration in the revision of the manual is the need to distinguish between empirical questions or approaches and those of a more conceptual or philosophical nature, which should, by no means, be excluded. Another point to be evaluated is the advisability of defining phases according to the development of the condition, which would ideally create a schema focused on prevention. One of the expectations of psychiatry is that eventually laboratory criteria of diagnosis could be established, which could be measurable and would lead to clear statistics of psychiatric pathologies. As far as somatomorphic disorders are concerned, many practitioners agree that the current terminology and the systems of classification are inaccurate. One proposal is that this category should be eliminated altogether and that diagnoses should be made using an additional multidimensional description. One of the most interesting features of DSM is that it has had to accommodate changes brought about by new technologies. These advances go hand in hand with a new series of pathologies which need to be classified, as is the addiction to Internet. Undoubtedly, one of the greatest dilemmas facing DSM is how to classify eating disorders, as many people feel that the rather simplistic distinction between nervous anorexia and bulimia is not altogether convincing. There are two interesting proposals to consider in DSM-V: one is known as night eater syndrome and obesity, as in this case there is a compulsive consumption of food and an inability to limit this intake, in spite of a desire to do so. With regard to the compulsive, obsessive disorder, most experts believe that it is necessary to see the disorder as a spectrum, but defining criteria. Undeniably, a grave current problem which makes no distinctions is suicide. Different researchers recommend that suicidal behavior be considered and documented as a separate diagnosis in a sixth axis of the multiaxis schema. Another important aspect concerns the giving of quality attention to patients. This has led to the proposal to expand DSM-V to include indicators for situations which could eventually be a cause for treatment. The proposal is to structure something different from what can be found in axis I V. In the case of paraphilias, it is deemed necessary that DSM-V should deal not only with the strictly descriptive aspect, but also with the semantic and linguistic. The importance of post-traumatic stress has been described, but there exists the doubt whether it is necessary to experience an adverse incident for this to be triggered. There has been a suggestion that the term «pre-traumatic» stress disorder be included in DSM-V to diagnose this condition. In the case of anxiety disorders, some authors advise the creation of a category known as «disorders caused by stress and fear», which would allow linking the diagnostic classification with etiology and thus define a «true» anxiety nosology. It would be advisable that the DSM-V included a category for «seasonal affective disorder» as such, and not simply as a variant in the «specification of the seasonal pattern» of depression. In the field of substance consumption, it has been argued that it is necessary to establish a classification which is not only categoric but also dimensional so as to improve its taxonomic usefulness. The organization of mental disorders in DSM-IV-TR and ICD-10 (tenth edition) is complex and this has led to exploring the feasibility of developing a meta-structural system of classification based on risk and clinical factors. For disorders originated in infancy, childhood and adolescence, it has been suggested that the disorder known as «temperament disorder by disphoria» be included in the forthcoming taxonomy, as well as the use of the terms insensitive/emotionless for behavioral disorders, among others. In the case of attention deficit hyperactivity disorder (ADHD), the current criteria are considered insufficient and it has been suggested that the starting age for this disorder be increased from 7 to 12 years of age. It is suggested that autism be considered autistic spectrum, thus eliminating the other disorders covered in this section, including Asperger syndrome. The question as to whether this taxonomic-diagnostic system, to be implemented world-wide, will be both valid and reliable enough to cover all variations and particular characteristics of different cultures, ethnic groups, social groups and geographical regions in Mexico is another matter of concern, due to the lack of tools available for daily clinical work, except for the International Classification of Diseases of the World Health Organization. There are, at present, a number of doubts and queries which will need to be laid open and evaluated in all seriousness in order to obtain concrete and integral answers, given that the manual will continue to be used for clinical purposes in different parts of the world. The challenge will be to find the best way to apply diagnostic criteria, avoiding omissions and oversimplifications and taking into account the cultural and social context worked in.<hr/>Un tema de gran interés a lo largo de la historia de la psiquiatría, ha sido el relacionado a los sistemas diagnósticos. El Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM por sus siglas en inglés) y la Clasificación Internacional de Enfermedades (CIE), integran los criterios diagnósticos comúnmente utilizados en la práctica psiquiátrica. El DSM en su cuarta edición revisada, es ya insuficiente para el trabajo clínico actual, por lo que se ha estado trabajando en la configuración de lo que será el DSM-V (quinta edición); no obstante, aún y con toda la planeación, se teme que no se logren cubrir todas las necesidades de la psiquiatría moderna. La primera edición del DSM fue publicada en la década de 1950; esta versión del manual, y la subsiguiente, reflejaban la psiquiatría psicodinámica de esa época. En la década de 1980 se publicó la tercera edición y su versión revisada, en las que predominaban las consideraciones descriptivas y sindromáticas. Años después fue publicada la cuarta versión y una revisión posterior de este manual en el año 2000. Los primeros esfuerzos para iniciar el proceso de integración del DSM-V se iniciaron desde 1999. Desde ese año, hasta el 2007, se planificó la investigación y la documentación técnica por medio de un programa de investigación. Del año 2004 al 2007 se llevó a cabo la segunda fase del proyecto denominada «perfeccionamiento del programa de investigación para el DSM-V». De enero a mayo del 2010 se efectuó una prueba piloto con diferentes poblaciones y las revisiones propuestas por los grupos de trabajo. En el 2011 se revisarán los criterios diagnósticos propuestos y las medidas dimensionales. En el año 2012 se preparará el proyecto de texto final, y en mayo del 2013 se planea presentar el DSM-V en la Reunión Anual de la Asociación Psiquiátrica Americana, en San Francisco, California. Han sido numerosas las propuestas de autores externos e independientes para el desarrollo del DSM-V, como es el caso de la conveniencia de definir estadios de acuerdo a la progresión de la enfermedad o bien establecer criterios diagnósticos de laboratorio, e incluso favorecer una estadificación clara de las patologías psiquiátricas. En cuanto a los trastornos somatomorfos, muchos clínicos están de acuerdo en eliminar esta entidad y elaborar los diagnósticos con una descripción multidimensional adicional. Algunos expertos proponen integrar un diagnóstico denominado «adicción al Internet». Diferentes investigadores recomiendan que el comportamiento suicida sea considerado como un diagnóstico separado y documentado en un sexto eje del esquema multiaxial. Hay dos propuestas interesantes para el DSM-V, una es el síndrome del comedor nocturno y la otra la obesidad, al existir en estos casos un consumo compulsivo de alimentos y una dificultad para restringirlos, lo que podría tener implicaciones adictivas. En el caso de las parafilias se plantea la necesidad de que se trabaje en el aspecto descriptivo, semántico y lingüístico. Se ha descrito la importancia del estrés postraumático, pero se sugiere también un trastorno de estrés «pre-traumático» como diagnóstico en el DSM-V. En los trastornos de inicio en la infancia, niñez y adolescencia, se ha planteado incluir en la próxima taxonomía el denominado «trastorno por disregulación del temperamento con disforia». En lo referente al trastorno por déficit de atención e hiperactividad (TDAH) se considera que los criterios actuales son insuficientes, y se propone incrementar la edad de inicio del trastorno. Para el autismo se sugiere considerarlo como espectro autista, eliminando el trastorno de Asperger. Finalmente en opinión de los autores de este trabajo, existe por el momento una diversidad de cuestionamientos que deberá valorarse con seriedad, toda vez que el manual evidentemente seguirá siendo de uso clínico continuo en diferentes latitudes. El desafío será establecer la mejor forma de aplicar los criterios diagnósticos tomando en cuenta el contexto cultural y social en el que se trabaja, lo que, por lo revisado, sigue siendo un punto pendiente para los encargados de revisar la próxima versión del manual. <![CDATA[<b>Autoevaluación</b>]]> http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0185-33252011000400011&lng=pt&nrm=iso&tlng=pt Throughout its history, one of the most fascinating topics of psychiatry has been that of the causes and consequences of mental disorders. The desire to strengthen the reliability of diagnosis in this area has led to significant advances in two important fields: psychopathological description and the formulation of an integral diagnosis. Classifications allow the definition of categories and in the case of the two most read taxonomies in the field of mental health, Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), these provide the most commonly used criteria for diagnosis. The revised fourth edition of the DSM is now insufficient to cover the ever greater clinical challenges and research. For over ten years, work has been carried out on the structure of DSM-V (the fifth edition), but despite the planning, organization, prediction, and the contributions of guest experts, it is feared that all the requirements of modern psychiatry will not be met. The first edition of DSM was published in the 1950s. It was based on the terminology developed by William Meninger. This version of the manual and the following, published several years later, reflected the psychodynamic psychiatry which prevailed at the time. The third edition was published in 1980 and its revised edition seven years later. The emphasis here was on descriptive and syndromatic considerations. The fourth edition appeared several years later. The most striking change in this edition was the inclusion of variables resulting from empirical studies. A later edition was published in the year 2000. The first attempts to put together DSM-V started in 1999. From 1999 until 2007 work was done on the planning of the investigation and technical documentation of DSM-V and the inclusion of the so called investigation schedules. The second phase of the project, known as «the refinement of the research program for DSM-V», was carried out between 2004 and 2007. A pilot test was undertaken between January and May 2010, among different segments of the population and different settings, to evaluate the revisions proposed by the working teams. Between March and April 2011, as a result of the field tests, the proposed criteria for diagnosis were reviewed. The dimensional measurements and the criteria for diagnosis will be reviewed again during the rest of 2011. The year 2012 will see the preparation of the final version of the text, and finally, in May 2013, DSM-V will be presented at the annual meeting of the American Psychiatric Association in San Francisco, California. Several external and independent authors have offered numerous proposals on topics related to psychopathology in general to the working groups formed for the preparation of DSM-V. Only some of these are mentioned below. One of the first factors to be taken into consideration in the revision of the manual is the need to distinguish between empirical questions or approaches and those of a more conceptual or philosophical nature, which should, by no means, be excluded. Another point to be evaluated is the advisability of defining phases according to the development of the condition, which would ideally create a schema focused on prevention. One of the expectations of psychiatry is that eventually laboratory criteria of diagnosis could be established, which could be measurable and would lead to clear statistics of psychiatric pathologies. As far as somatomorphic disorders are concerned, many practitioners agree that the current terminology and the systems of classification are inaccurate. One proposal is that this category should be eliminated altogether and that diagnoses should be made using an additional multidimensional description. One of the most interesting features of DSM is that it has had to accommodate changes brought about by new technologies. These advances go hand in hand with a new series of pathologies which need to be classified, as is the addiction to Internet. Undoubtedly, one of the greatest dilemmas facing DSM is how to classify eating disorders, as many people feel that the rather simplistic distinction between nervous anorexia and bulimia is not altogether convincing. There are two interesting proposals to consider in DSM-V: one is known as night eater syndrome and obesity, as in this case there is a compulsive consumption of food and an inability to limit this intake, in spite of a desire to do so. With regard to the compulsive, obsessive disorder, most experts believe that it is necessary to see the disorder as a spectrum, but defining criteria. Undeniably, a grave current problem which makes no distinctions is suicide. Different researchers recommend that suicidal behavior be considered and documented as a separate diagnosis in a sixth axis of the multiaxis schema. Another important aspect concerns the giving of quality attention to patients. This has led to the proposal to expand DSM-V to include indicators for situations which could eventually be a cause for treatment. The proposal is to structure something different from what can be found in axis I V. In the case of paraphilias, it is deemed necessary that DSM-V should deal not only with the strictly descriptive aspect, but also with the semantic and linguistic. The importance of post-traumatic stress has been described, but there exists the doubt whether it is necessary to experience an adverse incident for this to be triggered. There has been a suggestion that the term «pre-traumatic» stress disorder be included in DSM-V to diagnose this condition. In the case of anxiety disorders, some authors advise the creation of a category known as «disorders caused by stress and fear», which would allow linking the diagnostic classification with etiology and thus define a «true» anxiety nosology. It would be advisable that the DSM-V included a category for «seasonal affective disorder» as such, and not simply as a variant in the «specification of the seasonal pattern» of depression. In the field of substance consumption, it has been argued that it is necessary to establish a classification which is not only categoric but also dimensional so as to improve its taxonomic usefulness. The organization of mental disorders in DSM-IV-TR and ICD-10 (tenth edition) is complex and this has led to exploring the feasibility of developing a meta-structural system of classification based on risk and clinical factors. For disorders originated in infancy, childhood and adolescence, it has been suggested that the disorder known as «temperament disorder by disphoria» be included in the forthcoming taxonomy, as well as the use of the terms insensitive/emotionless for behavioral disorders, among others. In the case of attention deficit hyperactivity disorder (ADHD), the current criteria are considered insufficient and it has been suggested that the starting age for this disorder be increased from 7 to 12 years of age. It is suggested that autism be considered autistic spectrum, thus eliminating the other disorders covered in this section, including Asperger syndrome. The question as to whether this taxonomic-diagnostic system, to be implemented world-wide, will be both valid and reliable enough to cover all variations and particular characteristics of different cultures, ethnic groups, social groups and geographical regions in Mexico is another matter of concern, due to the lack of tools available for daily clinical work, except for the International Classification of Diseases of the World Health Organization. There are, at present, a number of doubts and queries which will need to be laid open and evaluated in all seriousness in order to obtain concrete and integral answers, given that the manual will continue to be used for clinical purposes in different parts of the world. The challenge will be to find the best way to apply diagnostic criteria, avoiding omissions and oversimplifications and taking into account the cultural and social context worked in.<hr/>Un tema de gran interés a lo largo de la historia de la psiquiatría, ha sido el relacionado a los sistemas diagnósticos. El Manual Diagnóstico y Estadístico de los Trastornos Mentales (DSM por sus siglas en inglés) y la Clasificación Internacional de Enfermedades (CIE), integran los criterios diagnósticos comúnmente utilizados en la práctica psiquiátrica. El DSM en su cuarta edición revisada, es ya insuficiente para el trabajo clínico actual, por lo que se ha estado trabajando en la configuración de lo que será el DSM-V (quinta edición); no obstante, aún y con toda la planeación, se teme que no se logren cubrir todas las necesidades de la psiquiatría moderna. La primera edición del DSM fue publicada en la década de 1950; esta versión del manual, y la subsiguiente, reflejaban la psiquiatría psicodinámica de esa época. En la década de 1980 se publicó la tercera edición y su versión revisada, en las que predominaban las consideraciones descriptivas y sindromáticas. Años después fue publicada la cuarta versión y una revisión posterior de este manual en el año 2000. Los primeros esfuerzos para iniciar el proceso de integración del DSM-V se iniciaron desde 1999. Desde ese año, hasta el 2007, se planificó la investigación y la documentación técnica por medio de un programa de investigación. Del año 2004 al 2007 se llevó a cabo la segunda fase del proyecto denominada «perfeccionamiento del programa de investigación para el DSM-V». De enero a mayo del 2010 se efectuó una prueba piloto con diferentes poblaciones y las revisiones propuestas por los grupos de trabajo. En el 2011 se revisarán los criterios diagnósticos propuestos y las medidas dimensionales. En el año 2012 se preparará el proyecto de texto final, y en mayo del 2013 se planea presentar el DSM-V en la Reunión Anual de la Asociación Psiquiátrica Americana, en San Francisco, California. Han sido numerosas las propuestas de autores externos e independientes para el desarrollo del DSM-V, como es el caso de la conveniencia de definir estadios de acuerdo a la progresión de la enfermedad o bien establecer criterios diagnósticos de laboratorio, e incluso favorecer una estadificación clara de las patologías psiquiátricas. En cuanto a los trastornos somatomorfos, muchos clínicos están de acuerdo en eliminar esta entidad y elaborar los diagnósticos con una descripción multidimensional adicional. Algunos expertos proponen integrar un diagnóstico denominado «adicción al Internet». Diferentes investigadores recomiendan que el comportamiento suicida sea considerado como un diagnóstico separado y documentado en un sexto eje del esquema multiaxial. Hay dos propuestas interesantes para el DSM-V, una es el síndrome del comedor nocturno y la otra la obesidad, al existir en estos casos un consumo compulsivo de alimentos y una dificultad para restringirlos, lo que podría tener implicaciones adictivas. En el caso de las parafilias se plantea la necesidad de que se trabaje en el aspecto descriptivo, semántico y lingüístico. Se ha descrito la importancia del estrés postraumático, pero se sugiere también un trastorno de estrés «pre-traumático» como diagnóstico en el DSM-V. En los trastornos de inicio en la infancia, niñez y adolescencia, se ha planteado incluir en la próxima taxonomía el denominado «trastorno por disregulación del temperamento con disforia». En lo referente al trastorno por déficit de atención e hiperactividad (TDAH) se considera que los criterios actuales son insuficientes, y se propone incrementar la edad de inicio del trastorno. Para el autismo se sugiere considerarlo como espectro autista, eliminando el trastorno de Asperger. Finalmente en opinión de los autores de este trabajo, existe por el momento una diversidad de cuestionamientos que deberá valorarse con seriedad, toda vez que el manual evidentemente seguirá siendo de uso clínico continuo en diferentes latitudes. El desafío será establecer la mejor forma de aplicar los criterios diagnósticos tomando en cuenta el contexto cultural y social en el que se trabaja, lo que, por lo revisado, sigue siendo un punto pendiente para los encargados de revisar la próxima versión del manual.