Álvaro Frías Ibáñez

Trauma, posttraumatic stress disorder and psychosis: etiopatho­genic and nosological implications

Background and Objectives: The relationship between trauma, post-trau- matic stress disorder (PTSD), and psychosis has promoted heterogeneous research lines, in both etiopathogenic and nosological areas. The main aim of this review is to provide a systematic framework that encompasses this theoretical gap in the literature. Methods: A literature research was carried out through PubMed and PsycINFO be- tween 1980 and May 2013. One hundred and thirteen articles were recruited. A first part of this review describes the role of trauma in the development of psychosis. The second part focuses on research about PTSD and psychosis. Results : Longitudinal and cross-sectional studies with clinical and community samples confirm that childhood trauma (CT) is a vulnerability factor for schizophrenia and psy- chotic-like symptoms in adulthood. More empirical research is needed in order to assess the role of trauma as precipitant of acute psychosis. There is also preliminary evidence with cross-sectional samples that suggests that PTSD and psychosis are a risk factor for each other, with studies about post-psychotic PTSD (PP-PTSD) being outstanding. Final- ly, results from different comparative research studies postulate a subtype of PTSD with psychotic features (PTSD-SP). Conclusions: The role of trauma in psychosis is more conclusive as predispositional rather than as trigger factor. Nosological status of acute psychoses remains a focus of con- troversy unresolved. The association between PTSD and psychosis is complex, requiring more prospective research in order to determine causal relationships between these pathologies. Also, research in nosological status of PTSD-SP must encourage more com- parative studies not limited to neurobiological variables.

Motivation for change as a predictor of treatment response for dysthymia

OBJECTIVE Dysthymia constitutes a chronic, mild affective disorder characterized by heterogeneous treatment effects. Several predictors of clinical response and attendance have been postulated, although research on the role of the psychological variables involved in this mental disorder is still scarce. METHOD Fifty-four adult patients, who met criteria for dysthymia completed an ongoing naturalistic treatment based on the brief interpersonal psychotherapy (IPT-B), which was delivered bimonthly over 16 months. As potential predictor variables, the therapeutic alliance, coping strategies, perceived self-efficacy, and motivation for change were measured at baseline. Outcome variables were response to treatment (Clinical Global Impression and Beck’s Depression Inventory) and treatment attendance. RESULTS Stepwise multiple linear regression analyses revealed that higher motivation for change predicted better response to treatment. Moreover, higher motivation for change also predicted treatment attendance. Therapeutic alliance was not a predictor variable of neither clinical response nor treatment attendance. CONCLUSIONS These preliminary findings support the adjunctive use of motivational interviewing (MI) techniques in the treatment of dysthymia. Further research with larger sample size and follow-up assessment is warranted.

Traumatismo craneoencefálico en pacientes con síndrome psicótico: etiopatogenia y estatus nosológico

Introduccion. Uno de los debates nosologicos mas controvertidos en el ambito de la Neuropsiquiatria versa sobre el diagnostico diferencial entre psicosis adquiridas e idiopaticas”(esquizofrenia) en pacientes que previamente han sufrido un traumatismo craneoencefalico (TCE). Caso clinico. Se expone el caso de un varon de 15 anos, sin antecedentes psiquiatricos personales ni familiares, que a los 5 meses de sufrir un TCE con perdida de conciencia desarrollo un sindrome psicotico cronico caracterizado por sintomatologia positiva, siendo esta resistente a todos los tratamientos psicofarmacologicos prescritos. No se evidencio lesion cerebral focalizada a traves de neuroimagen estructural. Discusion. El TCE puede actuar como agente etiopatogenico primario (psicosis debida a un TCE) o precipitante (esquizofrenia) en los cuadros psicoticos manifestados. Los dos criterios externos que contribuyen en mayor medida a la distincion de ambos trastornos son la escasa sintomatologia negativa y la baja vulnerabilidad genetica entre las personas con psicosis debida a un TCE. Con relativa frecuencia, tanto el periodo de latencia TCE-psicosis como los correlatos neurocognitivos y neurobiologicos asociados apenas permiten esclarecer el estatus nosologico del sindrome psicotico. Son necesarios ensayos clinicos controlados para valorar la eficacia de los antipsicoticos en aquellos sujetos con psicosis debida a un TCE.

Eventos traumáticos en pacientes con trastorno obsesivocompulsivo: implicaciones etiopatogénicas, nosológicas y terapéuticas

El trastorno obsesivo-compulsivo -TOC- es una patologia neuropsiquiatrica en donde se propugna un papel accesorio de los factores de riesgo psicosociales. A pesar de ello, existe un subgrupo de pacientes cuya etiopatogenia, fenomenologia, diagnostico y terapeutica se halla condicionada por la presencia de eventos traumaticos -ET-. CASO CLINICO. Se expone el caso de una mujer adulta joven que desarrollo una psicopatologia compatible con TOC y trastorno por estres postraumatico -TEPT- tras sufrir abusos sexuales durante la adolescencia temprana. Aunque se implementaron tratamientos farmacologicos y psicoterapeuticos convencionales, su curso fue fluctuante, exacerbandose en el contexto de una nueva agresion sexual. CONCLUSIONES. Los ET constituyen un factor de riesgo inespecifico para el TOC, ya sea como variable predisponente o precipitante. Adicionalmente, pueden determinar su patoplastia, siendo el ejemplo mas paradigmatico la presencia de obsesiones de polucion mental tras sufrir abusos sexuales. A nivel nosologico, existen evidencias preliminares para postular una entidad clinica nueva -trastorno obsesivo-compulsivo postraumatico-, la cual englobe aquellos sujetos con comorbilidad entre TOC y TEPT tras un ET. En el plano interventivo, los pacientes con obsesiones de polucion mental precisan estrategias psicoterapeuticas adicionales a las implementadas en sus homologos de naturaleza mas neurobiologica.