Fernando Ramos Asbahr

Transtornos de ansiedade

A ansiedade e o medo passam a ser reconhecidos como pa-tologicos quando sao exagerados, desproporcionais em rela-cao ao est imulo, ou qualitativamente diversos do que se obser-va como norma naquela faixa etaria e interferem com a quali-dade de vida, o conforto emocional ou o desempenho di ario doindividuo.

Obsessive-compulsive symptoms among patients with Sydenham chorea

BACKGROUND Among patients with tic disorders, a distinctive clinical profile of obsessive-compulsive symptomatology has been described. The present investigation was designed to document the phenomenology of obsessive-compulsive symptoms (OCS) among patients with Sydenham chorea (SC), the neurologic variant of rheumatic fever. We hypothesized that OCS occurring in association with SC would be similar to those among patients with tic disorders. METHODS The authors studied the presence of OCS in 73 patients with SC by using the Yale-Brown Obsessive-Compulsive Scale at the Pediatric Clinics of the University of Sao Paulo Medical Center in Sao Paulo, Brazil (n = 45) and at the National Institute of Mental Health in Bethesda, Maryland (n = 28). RESULTS The most frequent symptoms observed among subjects with comorbid SC and OCS were aggressive, contamination, and somatic obsessions and checking, cleaning, and repeating compulsions. A principal component factor analysis yielded a five-factor solution (accounting for 64.5% of the total variance), with contamination and symmetry obsessions and cleaning compulsions loading highly. CONCLUSIONS The symptoms observed among the SC patients were different from those reported by patients with tic disorders but were similar to those previously noted among samples of pediatric patients with primary obsessive-compulsive disorder.

The place of and evidence for serotonin reuptake inhibitors (SRIs) for obsessive compulsive disorder (OCD) in children and adolescents: Views based on a systematic review and meta-analysis☆

Serotonin reuptake inhibiting drugs (SRI) have been used in the treatment of paediatric obsessive-compulsive disorder over the past 30 years. We performed a systematic review and meta-analysis of the literature to discuss the place of and evidence for the use of SRI in paediatric OCD, based on 14 publications of methodologically sound, randomized and controlled studies. Both SRI and specific SRIs were examined and comparisons of SRI, placebo, cognitive behaviour therapy (CBT), combined (COMBO) treatments (SRI+CBT) made to investigate their relative efficacy. Using the Cochrane methodology, and as measures of effect size mean difference and Hedges g, SRIs proved to be superior to drug placebo, with a modest effect size. From direct comparisons of CBT and SRI treatments, we conclude that CBT has the superior efficacy. COMBO versus CBT shows that SRI treatment adds little to concomitant CBT, while COMBO shows favourable outcome versus SRI alone. In pre-trial partial treatment responders, those who failed a SRI had better outcome from adding CBT as compared to continuing a SRI. Those who failed CBT treatment did as well with continued CBT as with switching to a SRI. The studies of combinations and sequences of treatments need to be developed further.

Brain SPECT imaging in children and adolescents with obsessive-compulsive disorder

Summary.Objective: To evaluate the patterns of regional cerebral blood flow (rCBF) in cortical and subcortical regions by Brain SPECT imaging, in children and adolescents with obsessive-compulsive disorder (OCD) before and after treatment.Method: Fourteen OCD patients (6 to 17 years old) underwent brain SPECT; ten of those subjects were reexamined after successful treatment. rCBF ratios were correlated with clinical parameters on the 14 patients in symptomatic state, and we compared rCBF ratios of the ten patients before and after treatment.Results: There was no statistically significant difference in average ratios of rCBF before and after treatment. There were significant clinical correlations between current age and age of onset of OCD and rCBF in the bilateral superior frontal, and bilateral parietal cortical regions.Conclusions: Further investigations on abnormal neurodevelopment of cortical-subcortical circuits possibly involved in symptomatology of paediatric OCD are warranted.

Obsessive–compulsive symptoms in adults with history of rheumatic fever, Sydenham's chorea and type I diabetes mellitus: preliminary results

Objective:  Rheumatic fever (RF) associated with Sydenhams chorea (a neurological variant of RF), but not RF without chorea, has been acutely related to obsessive–compulsive symptomatology/disorder (OCS/OCD). This study investigated the presence of OCS in adults who had RF with or without chorea in childhood.

Comparison Among Clomipramine, Fluoxetine, and Placebo for the Treatment of Anxiety Disorders in Children and Adolescents

OBJECTIVE The purpose of this study was to test the efficacy of clomipramine and fluoxetine, controlled by placebo, and compare their action in children and adolescents with anxiety disorders. METHOD Thirty subjects (ages 7-17 years), who were diagnosed with generalized anxiety disorder and/or separation anxiety disorder and/or social phobia, were submitted to a 12 week double-blind, randomized, placebo-controlled trial of clomipramine and fluoxetine. The instruments included: the Schedule for Affective Disorders and Schizophrenia, the Multidimensional Anxiety Scale for Children, the Childrens Depression Inventory, the Clinical Global Impressions, and the Childrens Global Assessment Scale. RESULTS All groups (clomipramine [n=9], fluoxetine [n=10], placebo [n=11]) showed a significant improvement after 12 weeks of treatment. There were significant differences between the fluoxetine and placebo groups in some ratings of anxiety severity and impairment. No significant differences were observed between clomipramine and placebo groups or between fluoxetine and clomipramine groups. CONCLUSIONS Treatment with placebo showed an unusual high response rate. Clomipramine showed similar efficacy compared with fluoxetine, although it was not superior to placebo.

Terapia cognitivo-comportamental da fobia social

OBJECTIVE: This article reviews relevant aspects of social phobia and the stages of treatment within cognitive-behavioral therapy in children and adolescents, as well as in adults. METHOD: A review of the literature published on the treatment of social phobia using cognitive-behavioral treatments was performed using the Medline database. RESULTS: A review of the literature suggests that social phobia is a chronic and prevalent condition, characterized by social inhibition and excessive shyness. Diagnosis and treatment of the disorder are usually determined by distress level and functional impairment. Population studies indicate that lifetime prevalence rates for social phobia range from 2.5 to 13.3%. The main techniques used in cognitive-behavioral therapy for social phobia are described and exemplified in a case report. CONCLUSIONS: There is a general consensus in the literature that cognitive-behavioral therapy is efficacious in the treatment of youth and adults with social phobia. Because of the early onset associated with social phobia, the identification of children at high risk for the development of social phobia should be prioritized in future investigations.

Selective mutism and the anxiety spectrum--a long-term case report.

We report a case of SM in a 17-year-old girl whose symptoms started when she was 4 years old and have persisted during adolescence. She stopped talking to everyone after a haircut. She panicked every time her mother went out or when she was left at school. She didn’t talk for 45 days, and then progressively recovered, talking first to her sisters, then to other relatives. One year later, she stopped talking again after her bike had been stolen. Three months later, she started to chat with relatives and two close friends. She hasn’t talked to anyone else since then. Despite this fact, she regularly goes to school and has friends of her age, with whom she communicates through e-mails and mimics. Neither academic nor cognitive impairment have been detected along all school years. She likes to dance and to play handball. When she needs something that requires talking, her mother does it on her behalf, which prevents her from being exposed and increases avoidance of anxiety situations. According to DSM-IV criteria, a diagnosis of SM was made. Assessed through a semi-structured interview (Schedule for affective disorders and schizophrenia for school-age children, K-SADS), she met diagnostic criteria for Separation Anxiety Disorder (in the past), current diagnosis of Specific Phobia. She didn’t have any other anxious (including social anxiety), affective or psychotic symptoms.Before her referral, she was treated with psychodynamic therapy and took paroxetine (20 mg/daily) for 12 months without improvement. At our service, she was treated with cognitive-behavioral therapy (CBT) for 10 months with poor outcome. Then, CBT was associated with sertraline (150 mg/daily). After 3 months, the level of anxiety on CBT exposures lowered. She started to shout when playing handball, she talks louder to her mother in public places, and talks to friends through lips movements. Though she isn’t talking to many people yet, she is clearly less anxious.There is some controversy whether SM is an anxiety disorder (AD) or an independent diagnosis. Previously, SM was considered an oppositional behavior, a psychotic symptom or a dissociative disorder. In DSM-IV, SM is classified under Other Disorders of Childhood. SM has many aspects in common with AD: pre-morbid temperament (shyness, behavioral inhibition), parent-child overdependence, overlapping diagnoses with other AD (social phobia, separation anxiety), and high prevalence of parents with AD.

Child-focused treatment of pediatric OCD affects parental behavior and family environment

This study aimed to investigate the impact of child-focused pediatric OCD treatment on parental anxiety, family accommodation and family environment. Forty-three parents (72.1% female, mean age±SD=43.1±5.6 years) were evaluated at baseline and after their childrens (n=33, 54.5% female, mean age±SD=12.9±2.7 years) randomized treatment with Group Cognitive-Behavioral Therapy or fluoxetine for 14 weeks. Validated instruments were administered by trained clinicians. Parents were assessed with the State-Trait Anxiety Inventory (STAI), the Family Accommodation Scale (FAS) and the Family Environment Scale (FES). The Yale-Brown Obsessive-Compulsive Scale was administered to children. Significant findings after the childrens treatment include decreased family accommodation levels (participation, modification and distress/consequences domains); increased cohesion and active-recreational components of the family environment. In addition, changes in the FAS distress/consequences and the FES cohesion subscores were correlated with the childrens clinical improvement. These results suggest that child-focused OCD treatment may have a positive impact on family accommodation and family environment. Future studies should further clarify the reciprocal influences of pediatric OCD treatment and family factors.

Brief treatment for nighttime fears and co-sleeping problems: A randomized clinical trial

Sixty-eight 4-6 year old children who co-slept with their parents and who avoided sleeping alone due to intense nighttime fears were randomized to a brief combined parent-based intervention (CBT-based bibliotherapy plus doll) or a wait list control group. After the waiting period, the wait list participants were offered treatment. Co-sleeping patterns, sleep records, anxiety, general fears, and behavior problems were assessed with parent-report measures. Nighttime fears were assessed with parent-report measures and a single item visual analogue scale for the young children. Assessments were completed pre-treatment, post-treatment, and at 3 months following treatment. Results showed that the combined intervention was superior to the wait list control condition and that treatment effects were maintained at 3-month follow-up. This study provides initial support for use of CBT-based bibliotherapy plus doll in the treatment of nighttime fears. Such a treatment might be used to supplement standard CBT approaches in routine clinical practice or in a stepped care approach to treatment.