Josep M. Peri

Documento de consenso sobre el diagnóstico y tratamiento de la fibromialgia en Cataluña

La fibromialgia (FM) es una enfermedad cronica y compleja que provoca dolores extensos que pueden llegar a ser invalidantes, y afecta a la esfera biologica, psicologica y social del paciente. La FM es un problema de salud dada su elevada prevalencia y morbilidad, su alto indice de frecuentacion y el elevado consumo de recursos sanitarios que provoca 1 . El Pla de Salut de Catalunya 1996-1998 ya recoge este problema, fruto del cual se elaboraron unos Criterios Comunes Minimos para la Atencion de Enfermos con Fibromialgia. Debido a la evolucion de los conocimientos que ha acontecido en los ultimos anos y a la confirmacion de su alta prevalencia y morbilidad, se ha constituido un grupo de trabajo multidisciplinario con la voluntad de redactar un documento orientativo, a modo de guia de practica clinica, que estructure y homogeneice los conceptos y actitudes que se pueden aplicar a estos pacientes.

Documento de consenso sobre el diagnóstico y tratamiento del síndrome de fatiga crónica en Catalunya

La fatiga prolongada, entendida como una sensación persistente de agotamiento o dificultad para realizar una actividad física o intelectual continuada, es un síntoma prevalente, tanto en atención primaria como especializada, además de motivo de considerable preocupación tanto para el paciente que la sufre como para el médico que le atiende. Se considera que de un 5 a un 20% de la población general puede presentar fatiga durante más de un mes en algún momento de su vida, hecho que suele estar en relación con enfermedades o situaciones intercurrentes1. Entendemos por fatiga crónica la que se presenta de forma continuada o intermitente durante más de 6 meses, lo que acontece entre un 1 y un 10% de la población general1. Si esta situación tiene una causa conocida o relacionable se denominará fatiga crónica secundaria. El síndrome de fatiga crónica (SFC) debe diferenciarse de las dos situaciones previamente referidas y su definición requiere el cumplimiento de unos criterios específicos2,3. Estos criterios incluyen la presencia de fatiga persistente o intermitente, inexplicada e invalidante, que no es producto de un esfuerzo excesivo y no mejora con el descanso. Además, el paciente debe presentar de forma crónica y concurrente 4 o más síntomas de los relacionados como criterios asociados en la definición establecida para esta enfermedad (tabla 1)4. Los pacientes que presentan fatiga crónica no explicada pero que no reúnen los criterios de SFC entrarían en la situación de fatiga crónica idiopática3. Aunque en España se desconoce la prevalencia real del SFC, en un estudio poblacional realizado en 1995 en Estados Unidos5 se objetivó que era de 75 a 267 casos por 100.000 habitantes. En otro estudio poblacional australiano efectuado en 1990 se objetivó una prevalencia de 37 casos por 100.000 habitantes6. Extrapolando las cifras obtenidas en estas series a la población catalana de más de 16 años, la prevalencia estimada en Catalunya oscilaría entre 2.012 y 13.429 casos3. En los últimos años hemos asistido a un notable incremento de consultas de pacientes con fatiga, algunos de ellos con fatiga prolongada o SFC. Este hecho, junto con la ausencia de una clara etiología de este proceso3,7,8 y, por tanto, de un tratamiento satisfactorio, la importante morbilidad asociada, así como la falta de una conducta y actitud diagnóstico-terapéutica homogéneas por parte del personal asistencial, ha movido a este grupo multidisciplinario de trabajo a elaborar este documento de consenso con el fin de constatar el estado del SFC en Catalunya, así como a confeccionar una guía práctica de actuación que facilite y homogeneice la conducta a seguir en este grupo de pacientes.

Pain locus of control predicts return to work among Spanish fibromyalgia patients after completion of a multidisciplinary pain program.

OBJECTIVE To assess the influence of the pain locus of control on return to work in fibromyalgia patients. METHODS Ninety-eight fibromyalgia patients on sick leave were enrolled in a multidisciplinary treatment program and were followed up for 12 months post-discharge. Treatment was considered successful at discharge in the case of patients who returned to work and unsuccessful in patients who remained sick listed. Treatment was considered successful during follow-up in patients who remained at work for at least the last 6 months of follow-up. Patients who took sick leave again and those lost to follow-up were considered failures. Logistic regression methods were used to define the best predictive models of treatment failure. RESULTS Fifty-eight patients were considered treatment successes at discharge and 50 at 12-month follow-up. The subscale Fate from the Multidimensional Health Locus of Control-Pain Scale and the Health Assessment Questionnaire predicted treatment failure at discharge (-2lnR=57.79; chi-square=74.74; df=2; P<.001). The predictive model of treatment failure at 12-month follow-up was unspecific. CONCLUSION Fibromyalgia patients undergoing a multidisciplinary treatment who were least likely to return to work at discharge were those with a pain locus of control characterized by more negative expectations about pain progression and a high perceived functional disability.

Psychometric Properties of the Spanish PID-5 in a Clinical and a Community Sample:

The Personality Inventory for DSM-5 (PID-5) measures the trait part (Criterion B) of the alternative model for personality disorders proposed in Section III of DSM-5. Although its psychometric properties have proven adequate thus far, evidence is limited in other languages and in clinical samples. The Spanish PID-5 was examined in two samples comprising 446 clinical and 1,036 community subjects. Facet scales showed good internal consistency in both samples (median α = .86 and .79) and were unidimensional under exploratory and confirmatory approaches. They were also able to distinguish between clinical and community subjects with a mean standardized difference of z = 0.81. All facets except for Risk Taking were unipolar, such that the upper poles indicated pathology and the lower poles reflected normality, rather than the opposite pole of abnormality. The entire PID-5 hierarchical structure, from one to five factors, was confirmed in both samples with Tucker’s congruence coefficients over .95.

Assessment of psychosocial factors and predictors of psychopathology in a sample of heart transplantation recipients: a prospective 12-month follow-up

BACKGROUND AND OBJECTIVES In the last decades, researchers of heart transplantation (HT) programs have attempted to identify the existence of psychosocial factors that might influence the clinical outcome before and after the transplantation. The first objective of this study is the prospective description of changes in psychiatric and psychosocial factors in a sample of HT recipients through a 12-month follow-up. The second goal is to identify predictors of psychopathology 1 year after HT. METHODS Pretransplant baseline assessment consisted of clinical form; Hospital Anxiety and Depression Scale (HADS); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Structured Clinical Interview; Coping questionnaire (COPE); Five Factors Inventory Revised; Apgar-Family questionnaire and Multidimensional Health Locus of Control (MHLC). The assessment 1 year after HT consisted of HADS, COPE, Apgar-Family and MHLC. RESULTS The sample included 78 recipients. During the waiting list period, 32.1% of them had a psychiatric disorder; personality factors profile was similar to the general population, and they showed adaptive coping strategies. Some changes in psychosocial factors were observed at 12 months after the surgery: lower scores of anxiety and depression, less necessity of publicly venting of feelings and a trend to an internal locus of control. Neuroticism and Disengagement pre-HT were predictors of psychopathology in the follow-up assessment. CONCLUSIONS Pretransplant psychosocial screening is important and enables to find out markers of emotional distress like Neuroticism or Disengagement coping styles to identify patients who might benefit from psychiatric and psychological interventions. Successful HT involved some positive changes in psychosocial factors 12 months after the surgery beyond physical recovery.

A hierarchical model of normal and abnormal personality up to seven factors.

Despite general support for dimensional models of personality disorder, it is currently unclear which, and how many, dimensions a taxonomy of this kind should include. In an attempt to obtain an empirically-based, comprehensive, and usable structure of personality, three instruments - The Temperament and Character Inventory-Revised (TCI-R), the Personality Diagnostic Questionnaire-4+(PDQ-4+), and the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ) - were administered to 960 outpatients and their scales factor-analyzed following a bass ackwards approach. The resulting hierarchical structure was interpretable and replicable across gender and methods up to seven factors. This structure highlights coincidences among current dimensional models and clarifies their apparent divergences, and thus helps to delineate the unified taxonomy of normal and abnormal personality that the field requires.

Seven basic dimensions of personality pathology and their clinical consequences: Are all personalities equally harmful?

OBJECTIVES Dimensional pathology models are increasingly being accepted for the assessment of disordered personalities, but their ability to predict negative outcomes is yet to be studied. We examine the relative clinical impact of seven basic dimensions of personality pathology through their associations with a wide range of clinical outcomes. METHODS A sample of 960 outpatients was assessed through a 7-factor model integrating the Cloninger, the Livesley, and the DSM taxonomies. Thirty-six indicators of clinical outcome covering three areas - dissatisfaction, functional difficulties, and clinical severity - were also assessed. The unique contribution of each personality dimension to clinical outcome was estimated through multiple regressions. RESULTS Overall, personality dimensions explained 17.6% of the variance of clinical outcome, but varied substantially in terms of their unique contributions. Negative Emotionality had the greatest impact in all areas, contributing 43.9% of the explained variance. The remaining dimensions led to idiosyncratic patterns of clinical outcomes but had a comparatively minor clinical impact. A certain effect was also found for combinations of dimensions such as Negative Emotionality × Impulsive Sensation Seeking, but most interactions were clinically irrelevant. CONCLUSIONS Our findings suggest that the most relevant dimensions of personality pathology are associated with very different clinical consequences and levels of harmfulness. PRACTITIONER POINTS The relative clinical impact of seven basic dimensions of personality pathology is examined. Negative Emotionality (Neuroticism) is 6-14 times as harmful as other pathological dimensions. The remaining dimensions and their interactions have very specific and comparatively minor clinical consequences. LIMITATIONS We examine only a handful of clinical outcomes. Our results may not be generalizable to other clinical or life outcomes. Our variables are self-reported and hence susceptible to bias. Our design does not allow us to establish causal relationships between personality and clinical outcomes.

Cross-sectional psychosocial evaluation of heart transplantation candidates.

INTRODUCTION AND OBJECTIVES Heart transplantation (HT) is a potentially life-saving procedure for people with terminal cardiac disease. In the last decades researchers of HT programs have attempted to identify the existence of psychosocial factors that might influence the clinical outcome before and after the transplantation. The main objective of this study was to describe epidemiological, psychiatric and psychological features of a large sample of HT candidates. METHODS Cross-sectional, observational and descriptive study. A psychiatric and psychological assessment of 125 adult patients was performed at the moment of being included in the HT waiting list, between 2006 and 2012. The assessment consisted in: Clinical, epidemiological and psychosocial form; Spanish version of Hospital Anxiety and Depression Scale; Structured Clinical Interview for DSM-IV axis I disorders; Coping questionnaire (COPE); Five Factors Inventory Revised (NEO-FFI-R); Apgar-Family questionnaire and the Multidimensional Health Locus of Control scale. RESULTS Axis I diagnoses were present in a 30.4% of patients. COPE showed that this group of patients used most frequently engagement strategies. Personality factors profile of NEO-FFI-R were similar to general population and locus of control scale also presented similar scores compared with other chronic diagnostic groups. Statistically significant associations were found between personality factors and COPE scales/dimensions and psychopathology, mainly neuroticism and disengagement. CONCLUSIONS This is the first study to assess systematically psychosocial factors in a large sample of HT candidates. We have found that around one third of these patients have a psychiatric disorder. Neuroticism and disengagement coping styles can serve as markers of emotional distress.

Patrón de déficit neuropsicológico en la demencia tipo Alzheimer y en la demencia vascular

Fundamento Algunos autores han postulado una division entre un patron de alteracionpredominantemente “cortical” para la demencia tipo Alzheimer y un patron de alteracion mas“subcortical” para la demencia vascular. El principal objetivo de este trabajo fue identificar unpatron de deterioro cognitivo neuropsicologico que discriminase el tipo de demencia en fases oestadios iniciales. Metodo Se compararon dos grupos de pacientes: uno con demencia, leve, tipo Alzheimer (DTA,n = 30) y otro con demencia vascular (DV, n = 30), administrando una bateria de tests neuropsicologicos.La bateria estaba compuesta por los siguientes tests: Orientacion Temporal (Bentonet al); Vocabulario, Semejanzas, Digitos, Clave y Kohs (WAIS); el test de Forma-Color deWeigl; el test del Trazo (A y B) (HRNB); el Tapping (McQuarrie); la Memoria Logica, MemoriaVisual y Aprendizaje Asociativo (WMS), y Memoria Diferida (Russell). Los dos grupos eran similaresen edad y caracteristicas socioculturales. Se compararon a traves de la nota z y su significacionestadistica con el test de Mann-Whitney y se realizo un analisis discriminante exploratoriopara clasificar a los pacientes en los dos grupos. Resultados En general, los resultados fueron mas pobres en el grupo DTA, no detectandose diferenciassignificativas en los tests neuropsicologicos, aunque en algunos casos (Memoria VisualInmediata y Cubos de Kohs) casi se alcanzo la significacion. A traves del analisis discriminanteexploratorio, se clasificaron correctamente un 67% de sujetos del grupo DTA y un 70%del grupo DV. Conclusiones En los estadios iniciales de las demencias es dificil diferenciar entre un patronde deficit cortical en la DTA y un patron de deficit subcortical en la DV. Cuando se usan testsneuropsicologicos complejos los rendimientos dependen de la coordinacion de multiples sistemasrelacionados. Estos hallazgos estan de acuerdo con los modelos holisticos de las funcionescorticales superiores.

Enrojecimiento facial súbito incontrolable: tratamiento mediante simpatectomía torácica por videotoracoscopia

Se realiza un estudio clinico en 94 pacientes afectados de blushing a los que se les realizo una simpatectomia toracica endoscopica bilateral. Todos los pacientes fueron visitados por un equipo multidisciplinario (dermatologo, psicologo y cirujano toracico) e informados detalladamente de los efectos secundarios y las expectativas de la intervencion. Los resultados a corto y medio plazo han sido excelentes: un 90,4% mostro un alto indice de satisfaccion; en el resto, el efecto fue solo parcial en un 7,5%, y un 2,1% de los pacientes considero la intervencion insatisfactoria; el aumento de la sudacion en otras areas del cuerpo se produjo en el 75,5% de los pacientes, pero solo en el 3,2% fue grave.