Rosa Behar

Anorexígenos: indicaciones e interacciones

Antecedentes. Los anorexigenos generalmente no suelen ser de manejo habitual en la practica clinica psiquiatrica. Sin embargo, es frecuente indicar una amplia gama de psicofarmacos a pacientes a los cuales se les ha prescrito medicamentos supresores del apetito por otros profesionales. Esta combinacion farmacologica implica una serie de aspectos a considerar en relacion a las indicaciones, efectos adversos y fundamentalmente las interacciones propias de los agentes anorexigenos que en algunos casos pueden llegar a provocar complicaciones irreversibles y fatales. Objetivo. Puesta al dia de los principales farmacos anorexigenos disponibles en Chile describiendo su clasificacion, caracteristicas, farmacocinetica, indicaciones, contraindicaciones, efectos adversos e interacciones. Material y metodos. Revision actualizada de la literatura especializada. Resultados. Los anorexigenos son coadyuvantes en el tratamiento integral de pacientes obesos. El resultado del tratamiento es mejor si se acompana de una recuperacion de los habitos alimentarios. Poseen un alto potencial de abuso, dependencia, tolerancia y sindrome de privacion. Sus principales efectos son cardiovasculares, gastrointestinales y en el sistema nervioso central. Los mas utilizados en Chile entre 1997 y 1998 fueron fentermina, dietilpropion, fenproporex y dexfenfluramina. Discusion. La principal indicacion de los anorexigenos es la obesidad. Deben ser prescritos exclusivamente por medicos. Se recomienda su indicacion a corto plazo. Poseen importantes interacciones a considerar con IMAOs, ISRSs, descongestionantes, antitusigenos, antialergicos, anestesicos generales, sustancias ilicitas, alcohol y otras drogas metabolizadas por el citocromo P450. Se enfatiza la posibilidad de la produccion del sindrome serotoninergico. Chile, Argentina y Brasil se encuentran entre los principales paises consumidores de estimulantes

Consumo de alcohol y trastornos de la conducta alimentaria: evidencia, similitudes e implicancias

Antecedentes. Existe una contundente evidencia que apoya la co-ocurrencia entre trastornos de la conducta alimentaria y abuso de alcohol y otras sustancias. Metodo. Se revisa la literatura especializada disponible acerca de la asociacion entre ambas patologias, la presencia de abuso de alcohol en familiares de pacientes con desordenes alimentarios y las hipotesis que las relacionan etiopatogenicamente, considerando sus similitudes y diferencias. Resultados. El 27% de las pacientes con trastornos alimentarios presenta dependencia a alcohol. El abuso y/o dependencia de alcohol oscila entre el 0% al 6% en la anorexia nerviosa restrictiva, 10% y 28% cuando se demuestra la presencia de rasgos bulimicos, y hasta 50% en las pacientes bulimicas. Entre el 15% al 56% de las pacientes alcoholicas presenta un trastorno alimentario: 1,4% a 10% anorexia nerviosa, 10% comer compulsivo o trastorno por comilonas, pero principalmente bulimico, entre 6,2% a 50%. Abuso de alcohol parental se observa hasta en el 50% de pacientes bulimicas y solo hasta el 7% de pacientes anorecticas. Conclusiones. Las referencias publicadas claramente sugieren una comorbilidad entre trastornos de la conducta alimentaria y abuso de drogas, incluido el alcohol, cuya relacion aun permanece oscura. Mas del 30% de los pacientes con trastornos alimentarios puede exhibir un problema de abuso de sustancias concurrente, particularmente los pacientes portadores de bulimia nerviosa. La coexistencia de ambos desordenes posee implicancias clinicas, terapeuticas y pronosticas

Estudio multicéntrico para la validación de la versión en español del Eating Disorder Diagnostic Scale

BACKGROUND The Eating Disorders Diagnostic Scale (EDDS) is a self-administered low cost psychometric instrument with excellent levels of temporal reliability and validity. AIM To adapt and validate the EDDS in Chile. MATERIAL AND METHODS The factorial structure, internal consistency and test-retest reliability of the Spanish-language version of the EDDS was analyzed in a sample of 1964 university and high school students. The concurrent validity was tested in a sample of 50 primary care patients with ED and 59 controls, comparing its results with those of a structured psychiatric interview (CIDI). RESULTS The EDDS showed a high internal consistency, moderate test-retest reliability, an appropriate factorial structure (in women) and an excellent convergent validity. Also, the diagnosis of ED obtained with the EDDS is moderately consistent with the structured psychiatric interview. CONCLUSIONS The Spanish-language version of the EDDS showed a satisfactory psychometric behavior and a good capacity for detecting ED, according to the DSM criterion.Background: The Eating Disorders Diagnostic Scale (EDDS) is a self-administered low cost psychometric instrument with excellent levels of temporal reliability and validity. Aim: To adapt and validate the EDDS in Chile. Material and Methods: Thefactorial structure, internal consistency and test-retest reliability ofthe Spanish-language version of the EDDS was analyzed in a sample of1964 university and high school students. The concurrent validity was tested in a sample of 50 primary care patients with ED and 59 controls, comparing its results with those of a structured psychiatric interview (CIDI). Results: The EDDS showed a high internal consistency, moderate test-retest reliability, an appropriate factorial structure (in women) and an excellent convergent validity. Also, the diagnosis of ED obtained with the EDDS is moderately consistent with the structured psychiatric interview. Conclusions: The Spanish-language version of the EDDS showed a satisfactory psychometric behavior and a good capacity for detecting ED, according to the DSM criterion.

Trastorno dismórfico corporal: aspectos clínicos, dimensiones nosológicas y controversias con la anorexia nerviosa

There is strong evidence about the co-existence of body dysmorphic disorder (BDD) and eating disorders (ED), particularly with anorexia nervosa (AN). An exhaustive review of the specialised literature regarding these disorders was carried out. The results show that their co-occurrence implies a more complex diagnosis and treatment, a more severe clinical symptomatology and a worse prognosis and outcome. Both disorders display common similarities, differences and comorbidities, which allow authors to classify them in different nosological spectra (somatomorphic, anxious, obsessive-compulsive, affective and psychotic). Their crossover involves higher levels of body dissatisfaction and body image distortion, depression, suicidal tendency, personality disorders, substance use/abuse, obsessive-compulsive disorder, social phobia, alexithymia and childhood abuse or neglect background. Treatment including cognitive-behavioral psychotherapy and selective reuptake serotonin inhibitors are effective for both, BDD and ED; nevertheless, plastic surgery could exacerbate BDD. Clinical traits of BDD must be systematically detected in patients suffering from ED and vice versa.

Ascetismo y espiritualidad en la anorexia nerviosa: Un análisis psicosocial histórico

Background Asceticism is deeply related to spirituality and fasting practices that have been observed in anorexia nervosa (AN) through the history. Objective A psychosocial analysis of spirituality and asceticism within the historical context of the AN is made, from Middle Ages to XXI century, comparing the holy anorexia and the contemporary AN. Ad hoc illustrative cases are described. Method Medline/Pubmed, data bases and specialized textbooks were used to look for evidence on asceticism and spirituality in AN and its historical development. Results From a historical point of view, asceticism of medieval saints (holy anorexia) and that of modern anorectics, display common features; nevertheless, it is oriented to different goals: spirituality versus worldly appearance, respectively. Contemporary Puritanism and AN share distinctive characteristics of protestant ethics, mainly self-discipline, self-control, self-sacrifice, rationality, efficiency and goals achievement. Asceticism is significantly related to angry feelings, inmaturity features and purging. Discussion and conclusion Many medieval mystical women showed similar characteristics with present AN, nevertheless, while asceticism in saints were oriented to achieve the divine encounter, drive for thinness in contemporary young anorectics is rather related to sociocultural aesthetic ideals. The atemporal occurrence of the pathogenic essence of the anorectic syndrome suggests that factors like age, personality and/or psychosocial environment pathoplastically model it.

The delusional dimension of anorexia nervosa: phenomenological, neurobiological and clinical perspectives

Background Delusional characteristics have been largely ignored in patients suffering from anorexia nervosa (AN). Objectives To review the literature on delusional features in AN from phenomenological, neurobiological, and clinical viewpoints. Methods Data were obtained through searches of Medline, PubMed, SciELO and Cochrane Library. Results Distorted beliefs in AN may range from an overvalued idea to an overt delusion, involving affective, personality and/or psychotic disorders. Studies confirm alterations in monoaminergic systems. It has also been seen a decreased integration of visual/proprioceptive information, and alterations in neural networks involved in body processing. It is known that body image distortion may present “delusional proportions” as a consequence of great concern about body. Concomitantly, “embodied defence hypothesis” has been proposed. Restrictive AN exhibits higher levels of delusionality, and a particular delusional type of AN has been suggested, associated with a worse long-term outcome. Low doses of atypical antipsychotics are recommended combined with cognitive techniques. Discussion Delusional thinking in AN is likely a dynamic and dimensional phenomenon that can vary, both in nature and/or severity, whereas high insight levels, before and after refeeding, result in positive outcomes. Neurobiological research on this topic must be encouraged, since clinical and phenomenological approaches are comparatively more frequently reported.

Towards a neurobiological understanding of alexithymia

Although the specialized literature on the etiology of alexithymia is controversial, neurobiological research has shown relevant advances. The aim of this review is to analyze the available evidence regarding the neurophysiological bases of alexithymia. A comprehensive review of available articles from Medline/PubMed, EBSCO and SciELO was conducted. Previously, alexithymia was linked to a reduced interhemispheric brain connection. From a childhood traumatic perspective, the right prefrontal cortex and the default mode network would experience alterations, first hypermetabolic (dopaminergic and glutamatergic dysregulation) and then hypometabolic-dissociative (serotonergic and opioid dysregulation), resulting in a distorted interoceptive and emotional awareness. Mirror neurons are the essential neurobiological substrate of theory of mind and social cognition, intrinsically linked to alexithymia, involving parietal, temporal, premotor, and cingulate cortices, and inferior frontal gyrus. Other structures involved are the amygdala (facial expression and emotional reactivity), the insula (interoception, emotional integration and empathy) and the cerebellum (limbic cerebellum and somatosensory awareness). Molecular genetics has detected polymorphisms in genes of the serotonin transporter, in the enzyme genes of dopaminergic metabolism and brain-derived neurotrophic factor, while the role of oxytocin is controversial. To sum up, we found several studies demonstrating the overwhelming evidence of a neurobiological basis underlying alexithymia; nevertheless, research is still inconclusive and must include environmental, traumatic, social, and psychological factors that contribute to the origin of the alexithymia.

Funcionamiento psicosocial en pacientes agudos y crónicos no psiquiátricos en régimen hospitalario: depresión, alexitimia y falta de asertividad

Background: Depression, alexithymia, and lack of assertiveness interfere with individual psychosocial functioning and may result in longer hospitalization stay and poorer therapeutic results. Aim:To analyze the psychosocial functioning in acute and chronic patients and its association with psychological, clinical and sociodemographic variables.Material and methods: We performed a cross-sectional study that included 80 inpatients of both sexes with organic pathology, aged between 18 to 70 years old, without any current psychiatric disorder. Clinical and sociodemographic data were collected from a semi-structured interview and hospital records. Beck Depression Inventory-IA, Toronto Alexithymia Scale-20 and Rathus Assertiveness Scale were administered. Results: Fifty five percent of patients had some degree of depression, 33% alexithymia and 34% lack of assertiveness. The levels of depression, alexithymia and lack of assertiveness in chronic patients were significantly higher than those observed in acute patients. Women and participants older than 60 years exhibited the highest degrees of depression. Alexithymia and lack of assertiveness were associated with a lower educational level. A negative significant correlation between alexithymia and assertiveness scores was observed among acute patients. Conclusions: Participants with chronic diseases had a lower psychosocial functioning.Less educated patients showed more alexithymic and less assertive features. We emphasized the need of a better management of these aspects by the health team, since social functioning might interfere with the outcome of physical illnesses.