Trends - Edição 2/2013

ISSN 2237-6089

Trends in Psychiatry and Psychotherapy

Volume 35 – Issue 2 – April-June 2013

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ESPECIALISTA

Por que Gramado nos 75 anos da APRS? Gramado sempre foi a cidade que acolheu jornadas inesquecíveis para todos nós. Nos 75 anos da APRS, pensamos que não haveria lugar melhor para resgatarmos o clima das “velhas” jornadas, aliado à efervescência científica que o Rio Grande do Sul sempre produziu.

Esperamos poder confraternizar com todos vocês nesta charmosa cidade, festejando nossa história e oportunizando contato com o que há de mais novo e atual na psiquiatria.

Convidados internacionais Irritabilidade e as Fronteiras do Transtorno Bipolar na Infância

Contextual - Ligando o Cérebro à Experiência

Psicopatologia

O Cérebro Incansável: Atividade Intrínseca e Variabilidade Comportamental no TDAH

Uma Visão Translacional sobre a Disfunção Dopaminérgica na Esquizofrenia

Psicopatologia e Cultura

A Entrevista de Enfoque Psicodinámico na Psiquiatria

Como o Epigenoma Contribui Para o Desenvolvimento de Transtornos Psiquiátricos

Quinta-feira / 5 de setembro 17:30-19:00 / Sala 1

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Sábado / 7 de setembro 08:00-09:30 / Sala 1

Sexta-feira / 6 de setembro 17:30-19:00 / Sala 1

Quinta-feira / 5 de setembro 15:30-17:00 / Sala 1

Sábado / 7 de setembro 10:00-12:30 / Sala 1

Sábado / 7 de setembro 08:30-09:30 - 10:30-12:30 Sala 3

Sábado / 7 de setembro 18:30-19:30 / Sala 1

Dra. Ellen Leibenluft

Dr. Jim van Os

Dr. Francisco Castellanos

Dra. Anissa Abi-Dargham

Dr. Jorge Bruce

Dr. Humberto Persano

Dr. Timothy Bredy

Dr. Jesse H. Wright

Dra. Nora Volkow

Professor de teoria psicanalítica da PUCP e do Instituto da Sociedade Peruana de Psicanálise

Professor da Faculdade de Medicina da Universidade de Buenos Aires.

Psicanalista didata da Associação Psicanalítica Argentina

Diretor do Psychiatric Epigenomics Laboratory do Queensland Brain Institute da University of Queensland (Austrália)

Especialista em TCC e Diretor do Depression Center da Columbia University of Louisville (EUA)

Diretora do National Institute on Drug Abuse (NIDA) no National Institutes of Health (NIH)

Chefe da Seção de Transtornos do Espectro Bipolar do National Institute of Mental Health (NIMH) (EUA)

Professor do Departamento de Psiquiatria e Psicologia da Maastricht University Medical Center (Holanda)

Diretor de Pesquisa do Child Study Center da New York University New York (EUA)

Diretora Associada do PET Center da Columbia University e do New York State Psychiatric Institute (EUA)

Visite o site da XI Jornada de Psiquiatria da APRS.

www.jornadaaprs.org.br

Workshop TCC para Doença Mental Grave

Conversando com Nora Volkow Entrevista Gravada

Trends in Psychiatry and Psychotherapy Editor-in-Chief Márcia Kauer-Sant’Anna Universidade Federal do Rio Grande do Sul – UFRGS

Associate Editors Elisa Brietzke Universidade Federal de São Paulo – Escola Paulista de Medicina – UNIFESP-EPM

Jair Segal Hospital de Pronto Socorro de Porto Alegre

Maurício Kunz Universidade Federal do Rio Grande do Sul – UFRGS

Giovanni Abrahão Salum Universidade Federal do Rio Grande do Sul – UFRGS

Field Editors Sérgio Lewkowicz (Sociedade Psicanalítica de Porto Alegre, Brazil) – Psychotherapy Benício Noronha Frey (McMaster University, Canada) – Neurosciences Humberto Correa (Universidade Federal de Minas Gerais, Brazil) – Clinical Psychiatry National Editorial Board Aldo Lucion (Universidade Federal do Rio Grande do Sul – UFRGS) Janeiro – UFRJ) Netto (UFRGS)

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Aristides Volpato Cordioli (UFRGS) Cláudio Laks Eizirik (UFRGS)

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versidade Católica do Rio Grande do Sul – PUCRS)

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José Roberto Goldim (UFRGS)

Luis Augusto Paim Rhode (UFRGS)

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Antônio E. Nardi (Universida de Federal do Rio de

Beny Lafer (Universidade de São Paulo – USP)

Eurípides Miguel Filho (USP)

Salzano (UFRGS) n Gisele Gus Manfro (UFRGS) n Hélio Elkis (USP) Jerson Laks (UFRJ)

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Carlos Alexandre

Flávio Pechansky (UFRGS)

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Ivan Izquierdo (Pontifícia Uni-

Jair de Jesus Mari (Universidade Federal de São Paulo – UNIFESP)

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Luis Alberto Hetem (USP – Faculdade de Medicina de Ribeirão Preto)

Marcelo Pio de Almeida Fleck (UFRGS)

J. Botega (Universidade Estadual de Campinas – UNICAMP)

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Maria Lucréscia Zavaschi (UFRGS)

Patrícia Picon (PUCRS)

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Neury

Paulo Mattos (UFRJ) n Paulo Roberto

Zimmermann (PUCRS) n Paulo Silva Belmonte Abreu (UFRGS) n Ricardo Primi (Universidade São Francisco) n Rodrigo Bressan (UNIFESP)

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Romualdo Romanowski (Sociedade Psicanalítica de Porto Alegre – SPPA)

Valentim Gentil Filho (USP)

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Sidney Schestatsky (UFRGS)

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Wagner Farid Gattaz (USP)

International Editorial Board André Green (France)

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Andrew A. Nierenberg (USA)

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Antonino Ferro (Italy)

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Boris Birmaher (USA)

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Christhopher

Bollas (USA) n David Tuckett (UK) n Eduard Vieta (Spain) n Gary S. Sachs (USA) n George Woody (USA) n German E. Berrios (UK) n Glen O. Gabbard (USA) n Gustavo Turecki (Canada) n Host Kächele (Gemany) n Jorge Folino (Argentina) n Joseph Biedermann (USA)

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Otto Kernberg (USA)

Roger K. Pitman (USA)

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Timothy J. Crow (UK)

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Gestão 2012/2013 Eugenio Horacio Grevet / Presidente Carlos Augusto Ferrari Filho / Diretor Administrativo Fernando Muhlenberg Schneider / Diretor de Finanças Rogéria Recondo / Diretora do Exercício Profissional Rodrigo Grassi-Oliveira / Diretor Científico Ana Lúcia Duarte Baron / Diretora de Normas Igor Dias de Oliveira Alcantara / Diretor de Divulgação Conselho Fiscal Fernando Lejderman Laís Knijnik Paulo Roberto Zimmermann

Expediente Secretária: Sandra Maria Schmaedecke (Reg. Prof. 1464) Managing editor e preparação de texto: Denise Arend Editoração: Marta Castilhos / Editoras Associadas

Fontes de Consulta e Indexação ABEC Associação Brasileira de Editores Científicos BIOSIS Publisher of Biological Abstracts and Zoological Record LILACS Index Medicus Latino-Americano PsycINFO American Psychological Association SciELO Brasil Scientific Electronic Library Online Embase / Scopus / Latindex / Redalyc Tiragem: 900 exemplares Impressão: Contgraf Preço da assinatura anual: R$ 75,00 Dados Internacionais de Catalogação na Publicação (CIP) Trends in Psychiatry and Psychotherapy / Associação de Psiquiatria do Rio Grande

do Sul. v. 35, n. 2 (abril/junho 2013)-.Porto Alegre: Associação de Psiquiatria

do Rio Grande do Sul, 2013.Trimestral.

Continuação da: Revista de Psiquiatria do Rio Grande do Sul. Título abreviado: Trends Psychiatry Psychother.

Fontes de consulta e indexação: ABEC Associação Brasileira de Editores Científicos;

BIOSIS Publisher of Biological Abstracts and Zoological Record; Embase;

Latindex; LILACS Index Medicus Latino-Americano; PsycINFO American

Psychological Association; SciELO Scientific Electronic Library Online; Redalyc Scopus.

ISSN 2237-6089 1. Psiquiatria – Periódicos. 2. Saúde Mental – Periódicos. I. Associação de

Psiquiatria do Rio Grande do Sul.

CDU: 616.89(05)

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Trends in Psychiatry and Psychotherapy

Table of contents Trends

The “mental feature” in mental illness: difficulties that this reality poses for diagnosis and classification ............................................................................................................................................................................... 87 O “mental” na doença mental: dificuldades que sua realidade impõe em relação a diagnóstico e classificação

Humberto L. Casarotti

Review Article

Systematic review of the prevalence of bipolar disorder and bipolar spectrum disorders in population-based studies ..................................................................................................................................................... 99 Revisão sistemática da prevalência do transtorno bipolar e do espectro bipolar em estudos de base populacional

José Caetano Dell’Aglio Jr., Lissia Ana Basso, Irani Iracema de Lima Argimon, Adriane Arteche

Original Articles

Association between anxiety symptoms and problematic alcohol use in adolescents........................... 106 Associação entre sintomas ansiosos e uso problemático de álcool em adolescentes

Jandira Rahmeier Acosta, Rafaela Behs Jarros, Carolina Blaya, Lísia Von Diemen, Gisele Gus Manfro

Impairment in psychosocial functioning in patients with different subtypes of eating disorders..... 111

O prejuízo no funcionamento psicossocial de pacientes com diferentes subtipos de transtorno

alimentar Carolina Meira Moser, Maria Inês Rodrigues Lobato, Adriane R. Rosa, Emi Thomé, Julia Ribar, Lucas Primo,

Prevalence of body image dissatisfaction and associated factors among physical education students.. 119 Prevalência de insatisfação com a imagem corporal e fatores associados em universitários de educação física

Ana Carolina Faedrich dos Santos, Miriam Garcia Brunstein

Elisa Pinheiro Ferrari, Edio Luiz Petroski, Diego Augusto Santos Silva

Epidemiological profile of suicide in the Santa Catarina Coal Mining Region from 1980 to 2007..... 128 Perfil epidemiológico do suicídio na Região Carbonífera Catarinense de 1980 a 2007

Carolina H. Portella, Gustavo P. Moretti, Ana P. Panatto, Maria I. Rosa, João Quevedo, Priscyla W. T. A. Simões

Transdiagnostic treatment using a unified protocol: application for patients with a range of comorbid mood and anxiety disorders................................................................................................................... 134 Tratamento transdiagnóstico utilizando um protocolo unificado: aplicação em pacientes com diferentes transtornos de humor e ansiedade comórbidos

Ana Claudia C. de Ornelas Maia, Arthur Azevedo Braga, Cristiane Aparecida Nunes, Antonio Egidio Nardi, Adriana Cardoso Silva

Mood self-assessment in bipolar disorder: a comparison between patients in mania, depression, and euthymia........................................................................................................................................................................... 141 Autoavaliação do estado de humor no transtorno bipolar: uma comparação entre pacientes em mania, depressão, e eutimia

Rafael de Assis da Silva, Daniel C. Mograbi, Luciana Angélica Silva Silveira, Ana Letícia Santos Nunes, Fernanda Demôro Novis, Paola Anaquim Cavaco, J. Landeira-Fernandez, Elie Cheniaux

Book Review

O uso de antidepressivos na clínica médica, by Carlos Alberto Crespo de Souza (editor).................. 146

Lisieux Elaine de Borba Telles

Instructions for Authors

Trends in Psychiatry and Psychotherapy

Our Cover

Author: Ana Balad達o Title: no title Year: 1999 Technique: oil on canvas Size: 70x50cm

Image kindly supplied by Ana Balad達o, Otto Sulzbach, and Arte&Fato Galeria.

Trends

Trends

in Psychiatry and Psychotherapy

The “mental feature” in mental illness: difficulties that this reality poses for diagnosis and classification O “mental” na doença mental: dificuldades que sua realidade impõe em relação a diagnóstico e classificação Humberto L. Casarotti*

Abstract

Resumo

Four points are considered in this article. In the first place, it is argued that the “settings” of psychiatric care express the need to respond to the degree of decrease in personal freedom of the patient. Then, the issue of how “the mental feature” of the mental pathology has been recognized and categorized since the 18th century is examined, pointing out the difficulties involved in considering the mental nature of the subject of psychiatry. In the third place, the issue of how current systems of diagnosis and classification are posed regarding this reality is briefly looked at. Finally, the characteristics of a working hypothesis that allows organizing consistent clinical facts providing a heuristic perspective are analyzed.

Keywords: Psychiatric care, problems in diagnosis and classification, organic-dynamic hypothesis.

Neste artigo, quatro pontos são considerados. Em primeiro lugar, argumenta-se que os “espaços” da atenção psiquiátrica expressam a necessidade de responder ao grau de diminuição da liberdade pessoal do paciente. Em seguida, são discutidas as formas como o “mental” da doença mental tem sido reconhecido e categorizado a partir do século 18, apontando para dificuldades envolvidas ao se considerar o caráter mental do objeto da psiquiatria. Em terceiro lugar, são discutidas brevemente as formas como os sistemas atuais de diagnóstico e classificação se posicionam sobre essa realidade. Finalmente, as características de uma hipótese de trabalho que permita organizar de modo coerente os fatos clínicos e que proporcione uma perspectiva que seja heurística são analisadas.

Descritores: Atenção psiquiátrica, problemas de diagnóstico e classificação, hipótese orgânico-dinâmica.

* Psychiatrist, neurologist, coroner. Translator of Henry Ey’s work into Spanish.

Financial support: none.

No conflicts of interest declared concerning the publication of this article.

Suggested citation: Casarotti HL. The “mental feature” in mental illness: difficulties that this reality poses for diagnosis and classification. Trends Psychiatry Psychother. 2013;35(2):87-98.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 87-98

The “mental feature” in mental illness – Casarotti

Introduction Psychiatry, as pointed out by Henry Ey,1 is the response from physicians to the need of giving “special” care to mentally-ill patients in order to cure “their psychic illnesses.” “Special” treatments and care settings are based on the fact that these illnesses are neither entirely psychic nor organic in a vegetative way.

Which is the subject of this “special medicine,” different from other medical specialties such as cardiology, pneumology, endocrinology? Its subject are the disorganizations of psychism determined by disorders in nervous system integration (somatosis), or, in other words, which puts into evidence the immaturity or the disorganization of psychic functions in inter-human relationships. As it will be observed throughout the present paper, this “mental” subject, which has determined the progressive organization of the health care psychiatric system, poses several difficulties regarding the diagnosis and the classification of mental illnesses.

This article may be supplemented with the reading of some of the many existing studies on diagnosis and classification in psychiatry, published before2-4 and after5-7 the introduction of the DSM-III.

Settings of psychiatric care The tacit or explicit recognition that “the mental feature” of mental illnesses is what, beyond hypotheses and discussions on its reality and nature, has determined the fact that the care for this pathology is provided by similar care systems in different countries. Care services that, although being carried out at physical settings similar to those used in the care for patients with vegetative diseases (cardiorespiratory, digestive, etc.): doctor’s office, emergency room and hospital, are different because the specific “settings” of psychiatric care are “settings” with a primarily relational, and not spatial, nature.

Psychiatrists should make two types of decision concerning those who consult them. On one hand, just like physicians from the other medical fields, they should decide the therapeutic plan, which depends on the type de psychopathological structure, the evolutionary phase, and the causative process of the morbidity. However, on the other hand, psychiatrists should decide in which care setting this care can and should be provided, “settings” that are determined not primarily by diagnosis but by the degree of freedom the patient has lost or, –put it another way– by the degree of autonomy he or she still has. H. Ey referred to the psychiatric pathology as a “pathology of freedom,” and W. Blankenburg8 named the degree of

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preserved freedom as the “other” diagnosis. This is the degree of freedom that enables the type of relationship psychiatrist and patient can establish.

This “other” diagnosis, which determines the care settings and represents the more global mental aspect characterizing psychiatric patients and their evaluation, is more an intuitive act rather than a reflexive one, because personal freedom, just like rationality, emerges directly from the contact with others.

Psychiatric patients, grouped according to their degree of autonomy, i.e., considered from the point of view of this “other” diagnosis, are distributed into 4 care “settings,” according to the somatic or psychological treatment required in the evolutionary stage patients are in. a) When their autonomy is similar to that of a nonmentally ill person (“other conditions that may be a focus of clinical attention”: V codes of DSM and Z codes of ICD, character disorders, “neurotic patients with or without symptoms,” etc.) and the goal is that the patient functions better than before, the relationship established is similar to that maintained by two adults who freely agree on what to do. The “setting” in which this goal may be achieved is that of the doctor’s office. b) When the decrease in personal autonomy that determines the illness process negatively biases patient’s decisions regarding his or her well-being (schizophrenias of slow evolution, bipolar disorders; character disorders; alcoholic and drug-addictions; dementias, etc.), the relationship established has the non-paternalistic parental style that an adult maintains with an adolescent child, aiming to prevent the increase in functional impairment. This relationship, which introduces different nuances to the psychiatrist-patient relationship in comparison to the previous group, can develop in several “settings” (doctor’s office with family follow-up, day hospitals, therapeutic communities, drug control services, etc.). c) In cases in which the reduction in autonomy represents a state of transient disability (acute psychotic episodes, severe anxiety crises, several chronic psychotic decompensations, alcohol and drug detoxification, etc.), the psychiatrist-patient relationship that can be established requires the psychiatrist, in order to solve the disorder as soon as possible, to work with emergency or hospitalization services the same way an adult works with someone temporarily disabled. d) Finally, with impaired patients in whom the autonomy is minimal or almost non-existent (severe oligophrenias, chronic psychosis with long-term evolution, severe character disorders, etc.), the psychiatrist-patient relationship is that one has with severely disabled people. Consequently, it is necessary

The “mental feature” in mental illness – Casarotti

to provide protected accommodation, appropriate nutrition, solution to medical emergencies, etc. These “custodial” goals, which traditionally were achieved by putting patients into an institution (“involuntary civil commitment”* or institutionalization), currently tend to be achieved, according to socioeconomic possibilities, through other protective “custodial” means.

The fact that the psychiatric care system is similar in different countries seems to be contradictory to the fact that technicians working in this field have different hypotheses. However, this contradiction disappears when one considers not the hypotheses with which different technicians work but what they do regarding their patients. And what they do with their patients, when they behave responsibly, is basically related to the “other” diagnosis,” which depends on the type of illness, the evolutionary moment,† ‡ as well as on several circumstantial factors.

Let us see now how this psychic reality of mental illnesses, which in fact formats the psychiatric care system, has been recognized and what difficulties this reality poses regarding diagnosis and classification.

Evolution of psychiatry regarding diagnosis and classification “The mental feature” of the acute mental illness understood as a vegetative symptom Mental illnesses were initially identified in their acute forms. The sudden onset of mental changes that characterizes these forms could not go unnoticed, both due to its qualitative difference from normal psychic experiences and to its relationship with evident pathological processes. The pathological mental changes

recognized by medicine since the beginning of its history were another chapter of the pathology of the organs of vegetative life (pulmonary, cardiac, digestive, etc.), i.e., they were not recognized as having a mental specificity.

In order to understand the meaning of this statement, one should consider the birth of medicine.

Medicine was born with Hippocrates in the 5th century BC, when it was found that patients’ complaints were the expression of a bodily disorder.9 Patient’s complaints are no longer considered an out-of-body phenomenon and begin to be understood as an in-body phenomenon, “in its organization.” Physiologists (the philosophers of the “physis”) found that illnesses were natural rather than supernatural phenomena and that they were “disorganizations in the organization of the body,” of the “organism.” Its disorganization reveals its construction order and so the pre-technical medicine (that of the shamans) turned into a technical knowledge (“iatrike tekhne”). Since then, this finding of the existence of a bodily disorder (subject of the diagnosis of the organic process or “somatosis”) in and thorough clinical manifestations (subject of the semiological diagnosis) represented the scheme applied to all pathologies (Figure 1). This scheme presents realities of different

clinical manifestations SEMIOLOGY

organic-clinical gap

disorder of the organism ORGANIC PROCESS Figure 1 – Scheme representing pathologies

*

In mental disease care, it is convenient to differentiate the relational structure of the hospital setting to that of the custodial setting, referring, in the first case, to “hospitalization”, and in the second, to “involuntary civil commitment” or “institutionalization”. The use of both terms makes reference, on one hand, to the existence of different healthcare contexts and, on the other hand, to the fact that both “settings” are not physical locations but two types of psychiatrist-patient relationship (which can take place in different formats according to socioeconomic conditions). †

Psychiatrists who work with psychotherapy at a doctor’s office may think of the cause of the morbidity according to an exclusively “psychogenetic” hypothesis, but if, at a given moment, their patient becomes severely depressed and threatens to commit suicide, they, being responsible for their patient, will refer him or her to a psychiatrist who works at a hospital setting. In turn, this other technician, who works with an “organogenetic” hypothesis, may treat the patient at the hospital without taking into special account to the biographical aspects of the patient, which will have a practical meaning again when the patient improves from his or her acute depressive state and resumes psychotherapy. The same happens to a psychiatrist who treats schizophrenic patients and, in certain cases and on certain occasions, in order to treat them, should incorporate their family into the psychiatrist-patient relationship. This “change of relational setting” essentially modifies aspects related to written agreement, confidentiality, and voluntary treatment. What is important to point out here is that, with their behavior, technicians provide evidence that, beyond hypotheses, their patients need several “care settings”, according to the evolutionary phase of their condition. ‡

The organization of the psychiatric field in care and teaching activities requires taking into account the different care settings. Since patients need these settings according to the type of mental disease they suffer from, and especially according to their evolutionary phase, the organization of teaching activities, as well as the adoption of administrative decisions regarding the structure of the care system, requires knowledge on the different patients who need these different settings. Behaving differently means, on one hand, limiting learning to a single part of mental pathology (to chronic patients or to acute patients), and, on the other, risking the organization of the health care system according to a single part of psychiatric disease, i.e., by considering partial hypotheses as the organizational criteria.

Trends Psychiatry Psychother. 2013;35(2) – 89

The “mental feature” in mental illness – Casarotti

nature, among which there is an “organic-clinical gap” (“écart organo-clinique”) that can be covered from two directions: either in the direction taken by clinicians in their semiological work, in which they find the somatosis based on symptoms, or like pathologists do, from somatosis to manifestations.

This scheme enables to distinguish, on one hand, two diagnoses, the semiological one and that of the organic disorder (or somatosis) and, on the other, because of the organic-clinical gap, two classifications. In addition, it enables to differentiate causality between “causes of the organic disorder” and “causes of the symptoms.”

The causes of the organic disorder correspond, since Hippocrates’ and Galen’s time, to the external or procatartic cause and to the dispositive or proegumene cause, which, when combined, constitute the so-called joint or synectic cause, in fact the “lesion,” the somatosis or disorganization of the body.§10 Conversely, the causes of symptoms are different. These causes or factors that “build” symptoms have a double relationship with somatosis, both directly, as symptoms of functional deficit, and indirectly, as symptoms-reactions. However, they are also essentially related to the physician/patient relationship, in which the symptoms are “built” in the dialogue that takes place in this anthropologic setting.

Pain, as an example of a subjective symptom, as a patient’s complaint, “becomes objective” in the body through a dialogue that depends both on the physician and on the patient.

Semiological diagnosis and diagnosis of the organic disorder Semiological diagnosis consists of the analysis of the manifestations (symptoms and signs) of the condition, i.e., “perceiving” the disorder affecting the body. It is a technical activity in which manifestations are “observed” and in which this perceived totality (gestalt) is categorized according to the pathological knowledge of the physician. The semiological diagnosis is a continuous oscillation between what physicians perceive and what they know, between what they observe and the illness they know, it is seeing and knowing, in short, it is “knowing how to see” the illness. The symptoms of the illness are the result of functional deficits, but are also, and mainly, reactions of the organism in its attempt to recover the lost order. The complexity of the technical act of diagnosis is directly related to the organic-clinical gap, to this “distance” or “interval” that exists between somatosis and its manifestations. When this gap is very “broad,” i.e., the “farthest” the symptoms are from the bodily disorder, the more difficulty it is for the physician

§

to “see,” “apprehend” the organic disorder “through” clinical manifestations.

On the other hand, the diagnosis of the organic disorder or somatosis requires working with a hypothesis about the reality of the organism. In order to know the nature of this vegetative organism, it was necessary to know about its different diseases. This was the way medicine shifted from knowing cadaver anatomy to being real knowledge on the “anatomy” of the living body.

Once vegetative disease was found as a natural reality, medicine progressively evolved, but in a very chaotic way.

This situation determined, in the 16th century, Thomas Sydenham’s proposal to diagnose and classify diseases only on the basis of their clinical manifestations, i.e., the “semiological forms,” without arbitrary hypotheses about morbid processes. However, Sydenham himself could not be entirely faithful to this principle. As the reality of the body became understood through vegetative disease, this knowledge led to the development of different models of morbid process: initially anatomopathological, then physiopathological, and finally etiologic.11 In vegetative pathology, the organic-clinical gap is smaller, in the sense that functional manifestations “are very close” to the body. Moreover, due to this “closeness,” although “semiological diagnosis” is always at the first place and is the way to “perceive” somatosis, in fact there was a trend to think directly of the organic process or somatosis. In practice and also in theorization, the symptoms and the semiological diagnosis are analyzed, but this analysis considers the diagnosis of the organic process. Whereupon, the semiological diagnosis of the vegetative condition is replaced with the diagnosis of somatosis and is also validated by this diagnosis. Hence, the character of vital reaction related to the disease process is blurred, and disease, which is the “living reaction” of the suffering patient and what the physician perceives, begins to be considered as an anatomic lesion, a laboratory finding, or a toxic, infectious, etc. factor.

History has shown that this approach becomes acceptable in daily medicine. However, it should be criticized in a medicine that aims to be properly anthropological, i.e., in a medicine that understands disease not as an organic disorder but essentially as a way of life.9 Double classification Every classification should be empirical and logical.12 Firstly, it should be empirical, i.e., based on the facts that one aims to classify, which implies integrating inductive and deductive processes to establish what allows to identify these facts. And secondly, it should be logical, i.e., emerge from ranking criteria that differentiate the

Which G.E. Berrios (from Cambridge, UK) designates as “biological signal”(cf. ref. 10).

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The “mental feature” in mental illness – Casarotti

facts and, at the same time, enrich them by expanding the perception of reality. Generally speaking, purely logical classifications did not remain over time because they are not based on reality, and purely empirical classifications without ranking criteria are not useful because, although this approach make “the facts speak,” they end up telling nothing.

Even though the two diagnoses of vegetative disease generate two classifications, one of semiological diagnosis and other of the diagnosis of somatosis, one actually works only with the classification of anatomopathological, physiopathological or etiological processes. It is worth considering whether it is possible to behave similarly in psychiatry, i.e., working with a single classification, with this being the classification of organic processes (e.g., genetic). Later on, we will provide a negative answer to this question.

As previously pointed out, the mental illness observed since the beginning of medicine consisted of some acute presentations recognized as more or less typical semiological forms. These forms, integrating a broad presentation that today could be named as “confusing confusion,” highlighted two features of mental illnesses: firstly, they encompass psychic structures that are qualitatively different from normal psychic experiences, and secondly, they are clearly pathological. The grouping of these acute episodes, although inaccurate, represented indeed a vague acknowledgement of their unity. The term “confusing confusion” is not derogatory but expresses some essential features of acute mental presentations (mania, melancholia, and delirious episodes): their fairly sudden onset, alteration in consciousness, and their episodic or transient nature.** In acute mental episodes, “the mental feature,” stereotyped and usually little individualized, reflects the existence of a small organic-clinical gap. For the same reason, in vegetative disease praxis, there is a trend to identify the semiological diagnosis (e.g., mental confusion) with the diagnosis of the organic process and according to the determining causative factor (metabolic, toxic, infectious encephalopathy).

However, as shown later in this paper, even in these “monotonous and organic” acute manifestations in which the organic-clinical gap is smaller, it is not possible to replace the semiological diagnosis with that of the somatic disorder. This impossibility is explained when psychiatry is understood exactly what it is: a specifically mental medical knowledge, and thus complex. Even when the complexity of acute mental illness is not that of personal ideo-affective process of chronic mental illness.

It is worth pointing out that, during this long period preceding the discovery of mental illness in the 17th century, psychological reflections of philosophical nature arose. In the high Middle Ages (13th century), philosophers, reflecting inductively, provided rational psychological and partly empirical analyses. For instance, Saint Thomas Aquinas, considering the many factors of “involuntariness” of the voluntary act, presented a primitive form of psychopathology,13 although the mental data used were those which subsequently will be named “psychology of folklore.”

Progressive apprehension of the “mental feature” of chronic mental illness Discovery of mental illness and institutionalization of psychiatry (17th-18th centuries) After the 17th century, chronic manifestations were added to the recognized acute manifestations, and with them medicine incorporated those pathological mental forms in which “the mental feature” appears determined from “within” the person.

Thus, besides the two features of mental illness, i.e., being mental variations qualitative different from normal mental variations and being pathological, a third feature was added: the fact that manifestations appear determined by “internal forces,” more “endogenous” in the sense that they are essentially related to the biopsychological constitution of the individual.

Psychiatry was born in the “complex” situation of contrasts that marked Renaissance (L. Vives, Erasmus of Rotterdam, Thomas Moro, among others). By oscillating between setting men’s imagination free14 and restricting their freedom (persecution of heretics and witches, established by the Malleus Maleficarum,15 etc.), mental illness evidenced itself in its reality. Due to the confluence of several historical and cultural factors, facing the acknowledgment of man as a “creator of values” and thus free and responsible, it became evident that some men were pathologically diminished in this properly human ability.16 Among other authors, Paolo Zacchias and John Weyer stated that these mental variations were not a consequence of benign or malignant supernatural actions, but were rather natural phenomena. The psychism discovered by mental illnesses became evident as a vulnerable reality, i.e., as a body order different from that of the vegetative organism. Within the order of the organism, it was possible to perceive the reality of the another organism, the “psychic body.”

**

This way of inaccurately conceptualizing the multiplicity of acute episodes is still used by non-psychiatrist physicians, including neurologists, whose diagnostic interest is differentiating this acute semiology from “comatose diseases” (urgency) and from dementia syndromes (definite disability).

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This late discovery of mental illness, 22 centuries after the birth of medicine, shows that it was not easy to recognize and accept that some mental variations are pathological. The dualistic thinking of men that makes it difficult to apprehend a reality that is “illness” and “mental” at the same time was and is expressed by the cultural trend for not perceiving and even denying the difference between mental illness and health.

Additionally, unlike the “deviations from the type,” which are easy to observe in vegetative diseases, it is not easy to establish the pathological nature of an experience or a behavior, since the subject is the center of endless variations.

Psychiatry, working with this different mental “clinical mass,” which was progressively identified, developed, on one hand, as a theoretical and practical science of the relationships between biological and mental features (“physical and moral features” referred to in the context of nervous physiology (Cabanis)17 and, on the other, as a practical knowledge that should respond to the organizational and legal problems posed by the existence of mentally-ill patients.18 Identification of mental illness as the specific subject of psychiatry (from the 19th century to the present day) During the 19th century, chronic mental disorders were initially studied with the idea that there was only one mental illness, “alienation,” and that its different manifestations were the expression of the different evolutionary moments of this “single psychosis.” In the second half of the century, psychiatry began to consider mental manifestations as multiple diseases.

On both moments, the study of mental illnesses (Pinel,19 Esquirol,20 etc.), which were considered organic disorders, due to the lack of concrete knowledge about these processes, focused on the semiological study of “the mental feature.”

This analysis of “the mental feature” of mental illnesses was performed according to the context of the medical thinking of the time. In the strictly mental sense, these analyses have provided a specific semiology, with a detailed description of the symptoms, but, as there was no accurate idea of what a “symptom” was in psychiatry yet, analyses represented only, as stated by E. Minkowski, a “pathological reading of the psychological feature.”21 Based on a picture of what was psychologically normal, pathological manifestations, e.g., of the mood, when compared to this picture, were called “hyperthymia,” “hypothymia,” or “dysthymia.”

And, although the manifestations of chronic mental illness evidenced the existence of an organic-clinical gap that the mental activity of the patients “filled,” they

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disappeared as subjects, because their experiences and mental processes were considered from the point of view of vegetative disease. A point of view that –with some degree of violence– could be applied to acute mental illness but not to chronic mental illness.

When analyzing the status of psychology in the 19th century, G. Lanteri-Laura22 points out that, during that century, the scientific developments revealed an intrinsic difficulty of mental illness. Due the unitary nature of mental life, some people tend to think of mental illness as a “unitary psychosis,” and other people recognize the existence of different mental illnesses. This dual way of thinking the concrete existence of mental illness represents a particular aspect of the phenomenon, and the predominant choice is usually related to the aspect of mental life most emphasized by who classifies it.

When normal mental life is perceived and considered as a unit and organic aspects are minimized, there is a trend to consider mental illness only as “one illness” or, which occurs more often, as being constituted by some very comprehensive syndromes (e.g., syndromes like “somatic symptom disorder,” which is currently proposed in the DSM-5 project). This perception of psychic unity corresponds to the primary experience the practical psychiatrist has when capturing the nature of totality implied by the mentally-ill subject. In turn, when mental life is considered as an integration of evolutionary functions of an organic development, there is a trend for advocating for the existence of several mental illnesses.

This perception corresponds to the experience of the psychiatrist who captures the disintegrative procedural effects of the psychic unity in the different syndromes.

The classification of mental illness should solve this tension, and this was achieved according to the prevailing trend, either “grouping” (the “lumpers”) or “separating” (the “splitters”), which explains the flowing and reflowing between very broad and very limited diagnostic categories. The practical solution to this problem is acknowledging that, due to its organicity, regressive mental life presents itself in several forms of mental illness, and, at the same time, due to the unitary nature of psychism, not multiplying unnecessarily the number of pathological forms.

Within this “unity / multiplicity” tension, mental illness continued to be classified, just like it had been happening since the 17th century, based on different criteria: according to symptoms, according to its evolution, and usually merging etiological assumptions.

From the end of the 19th century to the mid-20th century, psychiatry made an essential discovery: it achieved to comprehend what is the reality of “the mental feature” that is disorganized in mental illness.

This conceptual revolution developed according to two

The “mental feature” in mental illness – Casarotti

orientations and based on different clinical materials: the psychiatric clinical orientation made it in psychosis and the psychoanalytic orientation in neurosis.

The clinical orientation, studying the psychic manifestations as an expression of a somatosis, has recognized, in mental organization, the types of deficits determined by organic processes. From these clinical developments, focused on the study of chronic psychosis, four time points should be highlighted: a) Firstly, E. Kraepelin23,24 argued that heterogeneous patients from the point of view of their manifestations (patients with dementia praecox as described by Morel, hebephrenic as described by Hecker, catatonic as described by Kahlbaum, and most of chronic delirious patients) represented one illness: Dementia Praecox.

Although Kraepelin sensed the reality of a deficit in the psychic organization (which he inaccurately expressed as “disorders in essential psychic functions” or “relaxation of the affective forces that maintain the coherence of the psychism”), his approach was still closely related to the vegetative model of thinking the illness. The unity that Kraepelin provided to these manifestations of different semiology was stating that all of them were the expression of a process of somatic disorganization, clinical forms of the same organic process. b) E. Bleuler25 took a step further: he aimed to capture the unity of the different forms of early dementia, not in the fact that they were manifestations of the same somatic process, but rather in the own mental structure. Thus, he found that the unity of this symptomatic variability was what constituted a special psychic state. These different manifestations were not unified by an organic process (the Kraepelinian somatosis of early dementia) but rather by a unity of mental process. Hence the absolute need of changing the name (these patients, stated Bleuler, “are not mentally ill because they are schizophrenic”), since what characterizes these manifestations is not an organic process that points out a terminal defect but rather the fact of presenting themselves as a special type of mental activity in which the clinical forms of this pathological structure are secondary. This Bleulerian development meant several essential aspects. Firstly, it represented a clinical analysis of the psychism as such, i.e., in its “own thickness” (thus the inclusion of Freudian concepts in his work) and, consequently, psychiatry became psychopathological. Secondly, this psychic analysis of the pathological feature determined that Bleuler talked about essential symptoms (clivage or Spaltung, autism, dereistic thinking, etc.) and accessory symptoms (e.g., acute syndromes), the first being the expression of the infrastructural disorder determined by somatosis, and the second the facultative manifestations of the mental reaction to disorganization. With this

distinction, Bleuler recognized the organic-clinical gap that exists in mental illness between somatosis and its clinical expression. Thirdly, with the subtitle of his book: “group of schizophrenias,” he pointed out that the unity and diversity of schizophrenia as a mental process could be the expression of different somatoses. c) The third step, opened by the Bleulerian conception, was the progressive use of a semiological phenomenological-structural method.26-28 Thus, it was possible to capture, in the variety and in the atypia of manifestations, the typical feature of each of the different psychic deficits. With this method, a “psychological reading of the pathological reality” was achieved, which enabled to describe the psychopathological structures (which make “one” symptom to be the manifestation of “such” structure) and also to classify them according to strictly psychological criteria. d) The fourth movement was done using the phenomenological method and consisted of facing and solving the difficulties implied in acute mental illness. Acute delirious manifestations, although being known since the birth of medicine, were not accurately conceptualized nor coherently integrated with other psychiatric manifestations. Considered by Kraepelin as a second-order remainder of the “actual insanity,” they were in turn valued by Bleuler as a problem to be solved in the future and were addressed by Henry Ey as the central focus of his work. He dedicated the third volume of his Études Psychiatriques29 to the research and the discovery of the unity of the pathology of the field of consciousness. Breaking with the tradition of basing psychopathological studies on chronic pathology, Ey described the array of acute disorders (mania, depression, acute delirious psychosis, and mental confusion) as “levels of destructuration of the field of consciousness.”

Three features that accurately but vaguely identify “mental illnesses” were previously pointed out: being different from normal psychic variations, being the expression of somatic disorders and also being the manifestation of internal (“endogenous”) events. The above-mentioned clinical investigations were able to specify these three features of mental illnesses. 1) Their pathological nature has been objectified by the rupture in inter-subjective communication and by the understanding of psychic manifestations. The somatic disorder objectified by the phenomenological method evidenced the existence of a specifically mental body order. 2) The analysis of the “mental feature” reveals its categorical nature, since the qualitative difference of the somatic process also expresses itself qualitatively in the psychopathological structuration 3) whose manifestations can be explained when procedural disorder is added to

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the psychic construction of the symptoms or psychic pathogenesis by which mental illnesses are “mental.”

The above-mentioned scientific developments, working on the nature of the “endogenous feature,” have made psychiatry a medical knowledge that is properly psychological, psychopathological, and in which the “mental feature” as the subject of its knowledge and praxis is the disorganization of the “bodily-mental” level.

An infrastructural mental reality that, when organized, enables the facultative psychic movements of normal life, and, when disorganized by somatosis, determines the psychic construction of the syndromes that are clinically diagnosed as forms of regressive mental life.

These syndromes, which represent the primary objective of psychiatry, are characterized: a) by being evolutionary levels, with each of them, due to the unitary nature of the psychism, not excluding the overand underlying levels ( “spectral” nature of semiological diagnoses)30; b) by being syndromes that express somatosis and consequently, similar to the latter, are qualitatively different from normal psychic manifestations (they are categorical and require a specific method to be known); c) by being syndromes that are “useful” from the clinical point of view, due to a certain degree of evolutionary and prognostic homogeneity (recovery, worsening, social disability, possibilities of treatment, etc.)31; d) by being syndromes that are “naturally” organized according to two subgenera of mental illness: acute mental illness, whose episodes are experienced as “accidents,” and chronic mental illness, in which disorders “blend” with the person; e) by being syndromes that, even though evidencing the organic disorder, are valid by themselves, and therefore should not and cannot be replaced with the diagnosis of the organic disorder.

Through the phenomenological clinical approach, psychiatry has found the “thickness” of mental life and consequently the amplitude of the organic-clinical gap shown by mental illness. The reality of this gap, which is fulfilled by psychic activity, determines that in mental pathology–differently from what happens in vegetative disease–it is necessary to work with two diagnosis and therefore with two classifications. It means that in mental pathology there is a demand to organize (classify) separately semiological diagnoses and the diagnoses of the generating organic processes (as an example of this need of two diagnosis and thus two classifications, one can consider evolution with regard to genetic causality in psychiatry).32 In summary, during the 70 years, from 1890 to 1960, psychiatry achieved an identity for its theoretical and practical subject, perceiving the existence of an infrastructural psychic order (an organized somatopsychic “thickness”), through facultative mental manifestations.

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The psychoanalytical orientation, both Freudian and Jungian, by finding the forms of drive organization of the diseased mental life, allowed to understand the laws that build the symptoms. The fact that patients are the “unconscious agents” of their disorders was naturally integrated into the evolution of psychiatry (as Bleuler did in his work) and psychoanalysis became an important part of psychological investigation in psychiatry and one of the forms of treatment. However, when psychoanalysis became hegemonic, it ended up being considered, by physicians and also by the “men of culture,” as if it was psychiatry.33 This psychoanalytical psychiatry, based on unconscious drive and on the idea of conflict, was moving its praxis towards the mental health field in which both concepts are widely accepted. This meant a growing lack of interest in diagnosis, i.e., in the perception of the structural differences between health and illness. Since psychiatry became progressively occupied with people with existential conflicts but who were not properly mentally-ill and lost its interest in diagnosis, the ability of diagnosing was lost.

On the other hand, psychoanalysis, due to its focus on how symptoms were built, blurred the concept of mental illness that was so hardly achieved by clinical evolution, and, because it worked with the hypothesis of psychic causality, divided the psychiatric field into organic genetic and psychogenic mental illness.

Current diagnosis and classification systems (DSM-IV,34 ICD-10,35 and DSM-5 project36) The above-mentioned state of affairs, together with the emergence of efficient therapies and thus of the possibility of differential treatment plans, determined a crisis that motivated an interest in diagnosis and classification. This reaction “in favor of diagnosis,” initiated and conducted by an “invisible college,”37 was crystallized in 1980 with the DSM-III.38 This guidebook and the changes it has undergone since 1980 have positive and negative aspects.39 Among the first ones, it should be pointed out: a) the fact that they grounded the need for a psychiatric diagnosis; b) the need for distinguishing, in terms of concept and practice, the diagnosis of psychic syndromes (psychopathological) and that of diseases processes and causes; c) the use of diagnostic criteria and rules (algorithmic) that enable the apprehension of the phenomena in their “psychic reality,” and that increase the agreement between technicians; d) the proposal of abandoning the organic / psychic dichotomy, and e) the multiaxial codification

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that, although being still mostly heteroclite, points out the acknowledgment of the need for two classifications.

Among the questionable aspects, it is worth highlighting: a) the lack of a critical analysis regarding the use of “operational symptom”40; b) the fact that semiology and etiology are still mixed in axis I; and c) the fact that, although some changes in axis II cover more than the classic character disorders and make it close to Ey’s concept of “disorder in personality development,” this axis still has no clear psychopathological robustness.

The reaction in favor of diagnosis and classification that took place in psychiatry since the 1970’s has vitalized the evolution of psychiatry. However, the successive changes to DSM-III (DSM-III-R, DSM-IV, DSM-IV-TR, and the current DSM-5) seem to indicate that something is missing in this reaction in order to achieve a more stable result. Among these deficiencies, maybe the most relevant is the lack of an accurate identity for mental illness, adding other difficulties to the highlighted intrinsic ones, which constitute “false problems,” because they were already solved but remain implicit by erroneous hypotheses.

The first false problem is generated by the questioning whether the diagnoses should be categorical or dimensional. As previously seen, the qualitative difference of somatosis is necessarily expressed in manifestations, and thus psychopathological structures should only be categorical, qualitatively different from healthy mental variations. Stating that the semiological diagnosis is not dimensional does not mean that one should not take into account essential dimensions for the evaluation of a concrete patient. However, insisting that diagnosis can be dimensional is a consequence of not operating with the specific semiological method and continuing to project the dimensional experiences provided by introspection, similar to what was done in the 19th century. In other words, it is the result of neither acknowledging nor integrating the change in the semiological method that is specific of psychiatry,41 and is thus maintaining oneself “outside” the reality of mental illness.

The second false problem, which is very linked to the psychoanalytical hypothesis, is the traditional question of whether the causality of mental illness is organic or psychic. Since this pathology is a “pathology of the psychic reactivity,”42 i.e., a disorganization of the mental infrastructure of the psychic organism, the question can be answered only by distinguishing “organic causes of somatosis” (mental illness is a disorder of the psychic reactivity), and “causes of the symptoms” (causality that is always psychic and thus sociocultural).

The third false problem consists of stating that: “semiological diagnoses should be validated by somatic diagnoses.” This statement can only be based on the capture of the gap that exists in mental pathology between organic process and clinical manifestations.

This gap, fulfilled by psychic activity, differently from what happens in a vegetative disease, determines that the semiological diagnosis cannot be replaced with the diagnosis of somatosis (anatomopathological, physiopathological or etiologic). This false problem is today related to the “bottom-up” scheme of most of the current neurobiology.†† These difficulties, linked to the “mental” nature of mental illness, are now “enhanced” by other scientific developments: 1) the reductive method of neurobiology, which, although being ambiguously presented by some authors,43 ends up representing a new “ideology,” as psychoanalysis did before; 2) the fact that psychoanalysis returns to psychiatry without criticizing the negative aspects of its hypothesis regarding diagnosis; 3) the entry of Anglo-Saxon analytic philosophers in the psychopathological field,44,45 who, although appropriately questioning the “securities” of the reductive models, tend to replace empirical psychiatric knowledge with a deductive knowledge, due to their own methodology46; 4) the fact that psychiatrists find themselves with the problem of having to balance their concrete clinical duties with others goals that, due to their economic weight, require to be prioritized (pharmacological investigations, organization of healthcare and prevention services, health insurance costs, “malpractice” demands, etc.).

Need for a psychiatric working hypothesis like that of Henry Ey The research outlined in this article shows the need of working with a psychiatric hypothesis that, to be valid, should comply with three rules.47 Firstly, it should be empirical, that is, codify the observed clinical facts and the results of the experiment (i.e., be the result of a long clinical experience). Secondly, it should be logical, that is, constitute a coherent system regarding the structure of the psychic being as well as the causality of morbid phenomena (i.e., be the result of a reflection on the relationships between body and mind). Thirdly, it should be heuristic, that is, involve practical corollaries, which should take into account the practical problems that are part of the definition of their subject, i.e., be practically efficient, making it easier for clinicians to respond to the different situations they may face.

††

Scheme that leads one to think, for example, that it is also possible to use kappa index values in psychiatry (which, in vegetative pathology, are related to genetic, biomarkers, EEGs, etc.).

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This article was developed following exactly the principles of a hypothesis that comply with these three features: the psychiatric working hypothesis proposed

by Henry Ey.48-51 The core of this hypothesis is that it responds to the two aspects of reality that “mental illness” is, being an organic disorder and being of “mental” expression.‡‡ A reality that should be considered by psychiatry as it is: a somatopsychic reality, which, in order to be conceived, requires to go against the natural Cartesian way of thinking of man that states that if something is a disease cannot be mental and that if something is mental cannot be a disease. Ey points out that the prodromes of his organic-dynamic conception of psychiatry appear repeatedly in the psychiatric studies of several authors (from Maine de Biran to Moreau, Ribot, Jackson, Janet, Freud, Bleuler, etc.), which sometimes constitute the axis of its development.

Four proposals organize this working hypothesis.

The first one (or psychological thesis) refers to the organization of the psychic being or mental organism in which mental illness is virtual. Virtuality that should be understood in two senses. On one hand, virtual meaning the power of falling mentally ill (“lethal latency” as stated by Bichat), and requiring a morbid process to become actual. On the other, virtual in the sense of “driving contents” that, when “controlled,” i.e., integrated, comply with their function in normal psychic structures and, when “uncontained,” build the symptoms of each type of psychopathological structure. The second thesis asserts that mental illness is essentially regressive and that this negative nature that supports it requires a phenomenological analysis, which is what evidences the rupture of the relationships of understanding and what allows to understand mental illness as a destructuration of the system that organizes reality. Thirdly, Ey states that mental illnesses, due to their structure and evolution, are typical forms of the levels of dissolution of the psychic organism, which he names as “psychic body.”

This thesis is what made Ey’s contribution relevant, since the phenomenological analysis of mental pathology has enabled him to find that the psychic organism is the articulation of two dimensions: the current awareness field (the “field of consciousness”) and the dynamic personality development (the “Self”), and that this dual nature of mental life, which is not perceived in health (when it disappears, due to its integration,), is revealed, in turn, by mental illness. A dual nature that

‡‡

constitutes the natural order to classify the different forms of regressive mental life: as acute pathology (the crises as destructurations of the current awareness field) and as chronic diseases (as “pathologic balances” of the personality development, when the relationships of the Self and the Other, i.e., the “ways of being the Other that the Self should not be” are inverted or merged). In the fourth thesis, Ey asserts that mental illnesses depend on organic processes in the sense that their proper causality is the disorganization of the psychic being.

A disorganization that, in the form of a “third person process,” disorganizes the unity and the power of the “first-person subject,” which always builds the symptoms (psychic pathogeny) in the organic-clinical gap that exists between somatosis and psychic manifestations.

The working hypothesis schematically presented appears as a model that, responding to the clinical facts, constitutes a theoretical and practical background very useful in the current moment of confusion experienced by psychiatry.

This hypothesis enables: 1) to distinguish organic disorder and clinical manifestations, and thus to operate with two diagnoses and two classifications; 2) to recognize, in face of the trend to uniqueness, the existence of a nonexcessive number of “psychopathological structures”; 3) to understand that these psychopathological structures are qualitatively different from normal psychic variations (which are categorical and not dimensional); 4) to recognize that such forms of regressive mental life are naturally organized according to the two structures that, when articulated, constitute the mental organism (the field of consciousness and personality development); 5) to state that semiologic diagnoses are validated by structural analysis and not by the diagnoses of the organic processes; 6) to differentiate between “causes of organic disorder” and “causes of the construction of mental symptoms” and thus to assert that every mental illness is “organogenic and “psychogenic” (“exogenous” and “endogenous”); 7) to operate with two classifications, which allows one to freely and creatively move in the different objectives that should be achieved in the fields of psychiatry and “mental health.”

Conclusions 1) Throughout the evolution of diagnosis and classification in mental pathology, two types of difficulties

This disorder is the result of a generating process, i.e., a procedural disorganization of the body, of the ‘psychic body’. The neo-Jacksonian model of Henry Ey, achieved through the phenomenological analysis of mental pathology, expresses that this disorganization: (a) is the dissolution of the life of relationship, i.e., of the integration function of the nervous system (different from the neurological dissolutions of integrated and focusable functions according to the concept of localization, non-applicable to mental diseases) and (b) is a deficitary, but essentially reactive, dissolution, a real and living psychic construction of the subject.

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that are related to “the mental feature” of mental illnesses have been stressed.

Some of these difficulties have been solved once psychiatry, abandoning the initial medical scheme that is valid for the pathology of vegetative life functions, has turned into a specifically mental model, in which “the mental feature” refers not to the manifested symptoms but rather to what they show: the reality of an infrastructural “mental” organization. A reality that is only revealed by the phenomenological analysis of the facultative mental movements of the subject. This “psychic thickness” that fulfills the organic-clinical gap and has a “somatopsychic” nature mediates between somatic disorganization, which is determined by the morbid process, and the facultative manifestations built psychically. The phenomenological analysis of the different forms of mental pathology enabled Henry Ey to find the dual structure of the conscious being: as the current field of consciousness and as the development of the personality.

These difficulties, originated in the nature of “the mental feature” of mental illness, will always be present in the psychiatric reflection. The first difficulty is motivated by the fact that mental illness is a real phenomenon and not a mythical one, and that its manifestations are qualitatively different from the endless healthy mental variations. The second, by the fact that, although mental life is unitary, when it becomes disorganized, this happens through several diseases. The third, by the fact that, in order to answer coherently to the several questions raised by practice, it is necessary to recognize the need of working with two diagnoses, one semiological and the other related to the organic process, and also with two classifications that do not merge both diagnoses.

Other difficulties were solved as psychiatry evolved, but are reasserted because they do not incorporate the achieved solutions. These methodological difficulties are: first, insisting that the semiological diagnosis should be dimensional; second, reasserting that the validity of the semiological diagnosis should be established by knowing the diagnoses of the “somatosis”; and third, stating that psychic factors, besides building the symptoms, can also cause the organic disorder.

In fact, these difficulties constitute “false problems,” since its proposal, not corresponding to the reality of mental pathology, has no other solutions than those achieved by psychiatry.

2) The highlighted difficulties, which are intrinsic to the reality of mental pathology, and the abovementioned false problems that originate from partial hypotheses, show the need for psychiatry to work with a hypothesis that is based on facts, coherent, learnable and teachable, and that responds to the needs of the

clinician. The working hypothesis organized by Henry Ey (the “organic-dynamic” model) responds to these demands. On one hand, it is a solid theoretical base for dealing with psychiatric diagnosis and its classificat​ion.

On the other, it constitutes a very useful framework for practical psychiatrists who, in their work, need to create “new and adequate” answers to the suffering of their patients, answers that they cannot find in “therapeutic guidelines.”

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24. Kraepelin E. Dementia Praecox and paraphrenia. New York: Krieger; 1919. (reprint 1971).

25. Bleuler E. Dementia Praecox or the Group of schizophrenias (translated by Joseph Zinkin). New York: International Universities Press; 1950. [trad. al español, Buenos Aires: Polemos; 2011].

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Minkowski E. Traité de psychopathologie. Paris: Presses Universitaires de France; 1966.

27. Spiegelberg H. Phenomenology in psychology and psychiatry.

Evanston: Northwestern University Press; 1972.

28. Rollo M, Angel E, Ellenberger HF. Existencia. Nueva dimensión en psiquiatría y psicología. Madrid: Gredos; 1977.

29. Ey H. Etudes psychiatriques, t.III. Paris: Desclée de Brouwer; 1954. [trad. española vol II, Buenos Aires: Polemos; 2008].

30. Casarotti H. Espectros en psiquiatría desde la perspectiva órgano-dinámica de Henri Ey. Vertex. 2007;18(supl 3):1723.

31. Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatry.

2003;160:4-12.

32. Casarotti H. Semiología psiquiátrica y endofenotipos. Rev Soc Psiq Biol Urug. 2007:3-12.

33.

Casarotti H. Relaciones entre psiquiatría y psicoanálisis (desde finales del siglo XIX hasta el momento actual). Rev Psiquiatr Uruguay. 2010:74:103-15.

34. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - 4th edition (DSM-IV).

Washington: APA; 1994.

35. Décima revisión de la Clasificación Internacional de las Enfermedades (CIE-10). Trastornos mentales y del comportamiento (descripciones clínicas y pautas para el diagnóstico. Madrid: Forma; 1992.

36.

American Psychiatric Association. DSM-5 development. http://www.dsm5.org 37. Klerman GL. The significance of DSM-III in American psychiatry. In: Pichot P, editor. DSM-III et psychiatrie française. Paris: Masson; 1985. p. 19-39.

38. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - 3rd edition (DSM-III).

Washington: APA; 1980.

39. Casarotti H. La aportación de H. Ey al diagnóstico de las psicosis delirantes. In: Ey H. Estudio sobre los delirios, 1950.

Madrid: Triacastella; 1998.

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40.

Parnas J, Sass LA. Varieties of “phenomenology”: on description, understanding and explanation in psychiatry.

In: Kendler KS, Parnas J, editors. Philosophical issues in psychiatry. Explanation, phenomenology and nosology.

Baltimore: The Johns Hopkins University Press; 2008. p.

239-85.

41. Flavell JH. La psicología evolutiva de Jean Piaget. Buenos Aires: Paidós; 1968.

42. Ey H. La notion de “réaction” en psychopathologie (Essai critique). Confront Psychiatr. 1974;12:43-62.

43. Kandel ER. A new intellectual framework for psychiatry. Am J Psychiatry. 1998:155:457-69.

44.

Graham G, Stephens GL. Philosophical psychopathology.

Massachusetts: MIT Press; 1994.

45. Radden J, editor. The philosophy of Psychiatry. New York: Oxford University Press; 2004.

46. Piaget J. Sabiduría e ilusiones de la filosofía. Barcelona: Flamma; 1970.

47.

Ey H. Outline of an organo-dynamic conception of the structure, nosography, and pathogenesis of mental diseases.

In: Natanson M, editor. Psychiatry and philosophy. Berlin: Springer; 1969. p. 111-61.

48. Ey H, Rouart J. Essai d’application des principes de Jackson à une conception dynamique de la neuropsychiatrie.

Encéphale. 1936;31(1):313-56, 31(2):30-60, 96-123.

49. Ey H. Principes d’une conception organo-dynamiste de la psychiatrie. In: Ey H. Etudes psychiatriques, t.I, 7:157-86.

Paris: Desclée de Brouwer; 1952.

50. Ey H. Le modèle organo-dynamique. In: Ey H. Traité des hallucinations, VIIème partie: 1069-1342. Paris: Masson; 1973 [trad al español, Buenos Aires: Polemos; 2o tomo, p.

1153-454].

51. Ey H. Des idées de Jackson à un modèle organo-dynamique en psychiatrie. Toulouse: Privat; 1975.

Correspondence Dr. Humberto L. Casarotti Presidente Berro, 2531 11600 - Montevideo - Uruguay E-mail: humberto.casarotti@gmail.com

Trends

Review Article

in Psychiatry and Psychotherapy

Systematic review of the prevalence of bipolar disorder and bipolar spectrum disorders in population-based studies Revisão sistemática da prevalência do transtorno bipolar e do espectro bipolar em estudos de base populacional José Caetano Dell’Aglio Jr.,1 Lissia Ana Basso,2 Irani Iracema de Lima Argimon,3 Adriane Arteche3

Abstract

Resumo

This paper describes the findings of a systematic literature review aimed at providing an overview of the lifetime prevalence of bipolar disorder and bipolar spectrum disorders in populationbased studies. Databases MEDLINE, ProQuest, Psychnet, and Web of Science were browsed for papers published in English between 1999 and May 2012 using the following search string: bipolar disorders OR bipolar spectrum disorders AND prevalence OR cross-sectional OR epidemiology AND population-based OR non-clinical OR community based. The search yielded a total of 434 papers, but only those published in peer-reviewed journals and with samples aged ≥ 18 years were included, resulting in a final sample of 18 papers. Results revealed rather heterogeneous findings concerning the prevalence of bipolar disorders and bipolar spectrum disorders. Lifetime prevalence of bipolar disorder ranged from 0.1 to 7.5%, whereas lifetime prevalence of bipolar spectrum disorders ranged from 2.4 to 15.1%. Differences in the rates of bipolar disorder and bipolar spectrum disorders may be related to the consideration of subthreshold criteria upon diagnosis. Differences in the prevalence of different subtypes of the disorder are discussed in light of diagnostic criteria and instruments applied.

Keywords: Bipolar disorders, prevalence, epidemiology, systematic review.

O presente artigo descreve os achados de uma revisão sistemática da literatura cujo objetivo foi oferecer uma visão geral sobre a prevalência de transtorno bipolar e transtornos do espectro bipolar em estudos populacionais. A busca foi realizada nas bases de dados MEDLINE, ProQuest, Psychnet e Web of Science, com foco em estudos publicados em inglês entre 1999 e maio de 2012, utilizando-se a seguinte estratégia de busca: bipolar disorders OR bipolar spectrum disorders AND prevalence OR cross-sectional OR epidemiology AND population-based OR non-clinical OR community based. Foram encontrados 434 artigos, mas apenas publicações em revistas científicas com processo de revisão por pares (peer review) e envolvendo participantes com 18 anos ou mais foram incluídos, gerando uma amostra final de 18 estudos.

Encontraram-se dados bastante heterogêneos sobre a prevalência do transtorno bipolar e de transtornos do espectro bipolar. A taxa de prevalência do transtorno bipolar ao longo da vida variou entre 0,1 e 7,5%, enquanto a taxa dos transtornos do espectro bipolar variou entre 2,4 e 15,1%. As diferenças entre as prevalências de transtorno bipolar e de transtornos do espectro bipolar parecem estar relacionadas à consideração de formas subliminares no momento do diagnóstico. As diferenças de prevalência dos diferentes subtipos do transtorno são discutidas em relação aos critérios diagnósticos e instrumentos utilizados.

Descritores: Transtorno bipolar, prevalência, epidemiologia, revisão sistemática.

Psychiatrist. PhD candidate, Graduate Program in Psychology, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil.

Psychologist. Specialist in Cognitive Behavioral Psychotherapy, WP Centro de Psicoterapia Cognitivo-Comportamental, Santa Maria, RS Brazil. 3 Psychologist.

PhD in Psychology. Professor, PUCRS, Porto Alegre, RS, Brazil.

1 2

This study is part of the first author’s PhD dissertation, presented at Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil, in August 2012.

Financial support: José Caetano Dell’Aglio Jr. holds a research grant from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES).

Submitted Aug 27 2012, accepted for publication Jan 28 2013. No conflicts of interest declared concerning the publication of this article.

Suggested citation: Dell’Aglio Jr JC, Basso LA, Argimon II, Arteche A. Systematic review of the prevalence of bipolar disorder and bipolar spectrum disorders in population-based studies. Trends Psychiatry Psychother. 2013;35(2):99-105.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 99-105

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Introduction Bipolar disorder (BD) is among the most debilitating and severe mental illnesses, and it is still underestimated as a public health problem. Historically, according to Kraepelin’s unitary phenomenological view of mental illnesses, in which mania and depression would be two parts of one same episode, has been undergoing review.

In the 1960s, with the emergence of formal literature and the release of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), the so-called bipolar disorder started to be seen as a dichotomous concept, subdivided into BD type I and BD type II. This description remained unchanged until the 1990s, when Goodwin & Jamison,1 Angst,2 and Akiskal & Pinto3 returned to the Kraepelinian idea of a bipolar spectrum (BS) that would include not only the classical forms of bipolar disorders but also milder forms, e.g., mood disorders that do not fully meet the diagnostic criteria currently set forth in the ICD-10 and in the 4th, revised edition of the DSM (DSM-IV-TR).

Over the last few years, in addition to a growing interest in mood disorders, especially recurrent major depression disorder (MDD), and the questions raised about the specificity of this diagnostic category, a strong shift has been observed towards the investigation of both BD and BS (rather than BD only). Even in subsyndromal or subthreshold presentations, BD has the potential to cause negative social and functional outcomes, in both adolescents4 and adults.5 Moreover, it is likely that the high rates of comorbidity with alcohol abuse and substance abuse/dependence, as well as with anxiety disorders, will maximize the negative consequences of BD.6 Therefore, the identification of patients with BS disorders is extremely relevant, at both clinical, social, and economic levels.7,8 Similarly, the epidemiological investigation of this disorder is essential for the development of policies aimed specifically at the mentally ill and at the general population.

Lifetime prevalence rates reported for BD in population-based studies published between 1978 and 1998 have ranged from 0.3 to 3.5%.8-11 The prevalence of BD I is estimated to range from 0.2 to 1.5%,1012 compared to 0.5 to 3.0% for BD II.10-13 Estimated prevalence rates for BS disorders range from 3.0 to 8.3%.2,8,11,12 Cross-sectional studies can provide useful information on the prevalence of and factors associated with mental illnesses,14 but the large discrepancy in BD rates reported in large-scale population-based cross-sectional studies15-21 vs. prospective longitudinal studies22 suggests that data originating from population-based cross-sectional studies

100 – Trends Psychiatry Psychother. 2013;35(2)

may underestimate the real prevalence of BD. Prospective studies, in turn, have shown that symptom criteria and diagnostic thresholds established for BD are too restrictive to detect BD in the general population, particularly in young adults, when the disorder is still evolving.

In spite of inaccurate definitions, recent studies5,22 have included subthreshold manifestations of mood disorders in their analysis and suggested that this dimensional notion of the disorder, or BS disorders, could double the number of individuals diagnosed with BD. In this scenario, the social problems associated with BD seem to be much greater than currently estimated, as a result of the traditional non-consideration of subthreshold forms of BD at the moment of diagnosis.

In addition to the differences between diagnostic criteria and the focus on the categorical vs. spectral forms of the disorder, methodological biases such as the use of clinical samples, which lead to extremely high rates, may explain the discrepancies observed in the literature. Therefore, in an attempt to achieve a better understanding of the epidemiological situation of BD and BS, the objective of this study was to conduct a systematic review of articles published between 1999 and 2012 with regard to prevalence rates reported in population-based studies that adopt both conservative/categorical and spectral/dimensional diagnostic approaches.

Method The present project was reviewed and approved by the Psychology Science Commission and the Research Ethics Committee of Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil (protocol no. 09/04910).

The following search strategy was used: bipolar disorders OR bipolar spectrum disorders OR prevalence OR systematic review OR cross-sectional OR epidemiology OR population-based OR non-clinical OR community based. Databases MEDLINE, ProQuest, Psychnet, and Web of Science were browsed. The search was limited to studies published in English between January 1999 and May 2012. The initial search yielded a total of 442 studies, of which 34 were selected after abstract reading.

In two cases, the full texts were not available, and our attempts to contact the authors failed. Another 14 texts were excluded after full-text reading. As a result, a final sample of 18 papers were included in the analysis.

The following inclusion criteria were taken into consideration: a) community studies using probability sampling techniques; b) samples with ≥ 18 years of age (four studies23-26 had mixed adolescent/adult samples; in those cases, only data on the adult subsample

Prevalence of bipolar disorder – Dell’Aglio Jr. et al.

442 articles found

34 articles selected

408 excluded after reading abstract 2 full texts unavailable

32 full texts obtained

14 excluded after reading full text

18 articles included in the analysis Figure 1 – Article selection process

were considered in the present analysis); c) use of operationalized diagnostic criteria and identification of cases based on either standardized instruments or clinical diagnosis. Prevalence rates, including percentages, and prevalence rates according to sex and age were all extracted from the studies reviewed.

Figure 1 illustrates the article selection process.

Results The following instruments were used in the 18 articles analyzed: 11 used the Composite International Diagnostic Interview (CIDI); one used the Mood Disorder Questionnaire (MDQ); one combined the MDQ and the Primary Care Evaluation of Mental Disorders (PRIME-MD), an interview based on the mood symptom module of the CIDI; another study also used the MDQ combined with the Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS) and a semistructured interview for non-clinical samples based on SCID, called SCID-IV-NP; one used the Diagnostic Interview Schedule (DIS); two used semistructured interviews based on the DSM-IV; and one study used the Mini-International Neuropsychiatric Interview (MINI).

The fact that most studies used the CIDI reveals similar methodologies and consequently an easy comparison of results. The use of the CIDI in epidemiological studies seems to be associated with increased diagnostic accuracy, as this is a totally structured questionnaire.

The CIDI was developed for both epidemiological/ cross-cultural and clinical settings. Notwithstanding, it is important to emphasize the need to compare results

across studies with care, as only the use of similar instruments is not enough to ensure data homogeneity: the concept assessed in each study also needs to be investigated.

Table 1 presents the characteristics of the 18 population-based studies reporting prevalence rates for BD and BS. The prevalence of BD ranged from 0.1 to 7.5% in the articles included in this systematic review. The study with the lowest rate, 0.1%, was the one conducted in Japan.30 According to the authors, this very low rate was due to two main factors: a very low response rate and the fact that the instrument used (CIDI) has not been validated for use in Japanese language.

The highest prevalence, namely 7.5%, was observed a Brazilian study.25 The authors considered that the high rates found for mania (7.5%) probably reflect the young age of the population (15-24 years) and the high rate of other mental illnesses in the sample, particularly anxiety disorders and substance abuse. According to the same authors, high rates are expected in younger cohorts, in both population-based and clinical studies. Similar prevalence rates were found in one of the Canadian studies,38 which reported 3.9% of manic episodes. One explanation for this rate was that the authors reduced the time criterion in the diagnosis of mania to several days or more.

If we subtract the Japanese30 and the Canadian38 studies from the 11 that used the CIDI, the resulting prevalence of BD will range from 0.5 to 2.1%.23,27,28,30,31,32,33,35,39 This finding indicates that these nine studies used consistent methodologies and robust sample sizes, in addition to a renowned, complete instrument, based on DSM criteria.

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Table 1 – Prevalence rates reported for BD and BS

Study

Country

Sample size Methodology BD (%) BS (%) Main limitations

Kringle et al.27 Norway 2,066 CIDI 1.6 -

- Limited age range and sample representativeness

ten Have et al.28 The Netherlands 7,076 CIDI 1.9 - - No information available

regarding the presence of

personality disorders

- Limited sample representativeness Jonas et al.29 U.S. 7,667 DIS 1.6 - - Prevalence rates based on

retrospective data

- Non-clinician interviewers Jacobi et al.23 Germany 4,773 CIDI 1.0 Kawakami et al.30 Japan 1,029 CIDI 0.1 - Low response rate

- Japanese version of CIDI not validated Moreno & Andrade31 Brazil 1,464 CIDI 1.7 8.3 - Lay interviewers

- Not very representative

sample, limited to two areas of

São Paulo Nagash et al.32 Ethiopia 2,152 CIDI 0.5 - - Low response rate

- Age range limited to 49 years Schaffer et al.24 Canada 36,984 CIDI 2.2 - - Lay interviewers

- Limited sample representativeness,

with some groups and regions

not covered Vicente et al.33 Chile 2,978 CIDI 1.9 - Prevalence rates based on

retrospective data

- Lay interviewers

- Time difference in data collection Fisher et al.34 Australia 3,015 MDQ 2.5 - Merikangas et al.35 U.S. 9,282 CIDI 2.1 4.4 - Lay interviewers

- No information available

regarding mixed states, rapid

cycling, and short episodes Bogren et al.36 Sweden 3,563 DSM-IV 0.4 - Prevalence rates based on

retrospective data

- Non-uniform sources of data collection

- Age over 40 years only

- Inclusion of psychotic BD only Lee et al.37 China 3,016 DSM-IV 2.2 15.1 - Prevalence rates based on

retrospective data

- Telephone interview

- Rigid semistructured interview (yes/no)

- Sociodemographic information

not available Kozloff et al.38* Canada 5,673 CIDI 3.8 - Jansen et al.25 Brazil 1,560 MINI 7.5 12.8 - Limited age group (18-24 years) Merikangas et al.39 11 countries 61,392 CIDI 1.0 2.4 - Prevalence rates based on

retrospective data

- Variable BS rates as a result of the

participation of different countries

- No information available

regarding mixed states, rapid

cycling, and short episodes Zutshi et al.40* Australia 3,034 PRIME-MD, MDQ 1.5 3.3 - Response rates based on three

data collection time points

- Instruments not focused on screening Carta et al.26 Italy 3,398 MDQ, ANTAS 3.0 - ANTAS = Advanced Neuropsychiatric Tools and Assessment Schedule; BD = bipolar disorder; BS = bipolar spectrum disorder; CIDI = Composite International Diagnostic Interview; DIS = Diagnostic Interview Schedule; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition; MDQ = Mood Disorder Questionnaire; MINI = Mini-International Neuropsychiatric Interview; PRIME-MD = Primary Care Evaluation of Mental Disorders. * Studies with samples ≥ 15 years.

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Prevalence of bipolar disorder – Dell’Aglio Jr. et al.

Conversely, looking at the studies that used the MDQ, rates ranged between 1.5 and 3.0%.26,34,40 It is important to observe that these rates are very similar to those obtained with the CIDI, even though the former has shown a low sensitivity (0.28) and a high specificity (0.97) for population-based studies.41 Also, in the Australian study,34 where a 2.5% was reported, a different version of the MDQ was used, not yet validated for the Australian population.

Finally, the three studies with the largest sample sizes, namely 61,392,39 36,984,24 and 9,28235 participants, reported prevalence rates ranging from 1.5 to 2.2%, suggesting that sample size did not have an influence on the sensitivity of the instrument most frequently used (CIDI).

Prevalence of bipolar spectrum disorders In the six population-based studies reporting data on BS, prevalence ranged from 2.4 to 15.1%.25,31,35,37,39,40 The highest prevalence, 15.1%,37 comprised the diagnoses of manic episode (2.2%), hypomanic episode (2.2%), and soft hypomanic episode (10.7%). The latter was diagnosed by reducing the time criterion to 2-3 days (different from the 4 days required according to DSM-IV criteria).

The study reporting the second highest prevalence rate25 calculated the final result by adding manic episodes (7.5%) and hypomanic episodes (5.3%) in a population of young adults (15-24 years). Weighing here referred to the aspects mentioned above for the categorical diagnosis of BD, i.e., a very young population and a high rate of other mental illnesses. Similarly to the study conducted in Pelotas,25 southern Brazil, the third highest prevalence rate for BS (8.3%) was found in another Brazilian population.31 These high rates in Brazilian studies can be explained by the fact that both samples had similar characteristics, e.g., were much younger and had a lower socioeconomic status when compared with populations from other countries included in this review. It is important to emphasize that, in the study conducted in São Paulo,31 the number of interviewees aged 18 to 24 years was higher than the percentage of participants in other age groups.

When these three studies with significantly higher rates are excluded from the analysis, the prevalence of BS drops to 2.4-4.4% (4.4,35 3.3,40 and 2.4%39). One explanation for this reduction is that these studies were conducted in developed countries (U.S. and Australia), which offer better conditions for research. Moreover, differently from the samples showing high rates, these studies showed a uniform age distribution.

The discrepant results observed for BS are also due to the different concepts used to define subthreshold forms of the disorder. In one of the Brazilian studies,31 two

definitions were used, namely, subsyndromal hypomania, defined as the presence of clinically relevant manic syndrome according to the CIDI (2 or more of a total of 9 manic symptoms combined with irritable or euphoric mood), and manic symptoms, defined as the presence of manic syndrome according to the CIDI, however not reaching clinical relevance criteria. Conversely, in an American study,35 three definitions were used: subthreshold recurrent hypomania (up to two cluster B symptoms plus all other hypomania criteria) in the presence of intermittent MDD; recurrent hypomania (up to two episodes) in the absence of recurrent MDD with or without subthreshold symptoms of MDD; and recurrent subthreshold hypomania in the absence of recurrent MDD with or without subthreshold MDD. In the other Brazilian study,25 DSM and ICD criteria, rather than the MINI, were used to define mania and hypomania. In a study involving 11 countries,39 a subthreshold hypomania criterion was adopted (one symptom of mania and failure to meet full criteria for hypomania). In the Australian study,40 MDQ threshold and higher results were considered to define BS (seven or more yes answers occurring simultaneously and creating moderate to severe problems).

Factors associated with bipolar disorder and bipolar spectrum disorders Sex. The majority of the 18 studies (13) failed to find significant differences between males and females.24-26,28-32,35,36,38-40 Only one study showed significantly higher prevalence rates among males,34 whereas four studies showed a significantly higher prevalence in females23,28,33,37; one of these latter articles showed a trend to higher rates of BD I and BS among females.37 Age. The studies revealed a higher prevalence of both BD and BS in younger individuals (10 of the 18 studies).

Among the studies showing results for different age groups, a bimodal division in the distribution of participants’ ages was observed. In four studies, mean age ranged between 20 and 29.5 years.23,24,32 In three other studies, mean age was higher, between 35 and 49 years.30,34,37 The studies conducted in Canada24 and Ethiopia32 revealed a mean age of 22 years at the onset of the disorder.

Education level. In most studies, education level did not have a significant influence on the prevalence rates of BD and BS. In three studies, however, low education levels had a significant impact on the prevalence of both BD27,32 and BS.35 In two studies, higher education and full-time study were present.38,40 In another study,31 higher education was more frequently present in subsyndromal groups (BS).

Marital status. Six studies clearly showed a significantly higher prevalence of bipolar mood and a higher severity of symptoms in single, separated,

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divorced, or widowed individuals.23,29,31,33-35,37 In one study, married subjects showed a higher rate of disorder when compared with single subjects.32 Income. In seven studies, the prevalence of BD was significantly higher in low-income populations.23-25,28,29,32,37 One study denied the influence of income on the prevalence of BD.35

Discussion The results of this systematic review reflect the findings of epidemiological studies conducted over the last 13 years to assess the prevalence of BD and BS in representative samples from different countries and different socioeconomic levels. It is important to emphasize that 11 of the 18 articles meeting inclusion criteria for the present review were published in the last 6 years, attesting to the growing interest of the scientific community in this topic.

When reporting prevalence rates for BD, caution is needed while analyzing data across different studies, as differences and variations may reflect not only different criteria and thresholds used to define diagnoses (categorical vs. dimensional approach), but also the use of different instruments (SCID-IV, MINI, CIDI, MDQ, ANTAS, DIS, PRIME-MD). Most of these instruments have shown excellent psychometric properties, with adequate sensitivity and specificity for the disorder assessed, except for the MDQ, which has been described as little specific in the recent literature.42 Our results show virtually no differences between males and females, with few studies pointing to a higher prevalence or trend towards higher rates in females. With regard to age group, in turn, in both BD and BS, younger individuals clearly show higher prevalence rates. This finding is in agreement with the young cohorts assessed in both population-based and clinical samples.43,44 The prevalence of BD and BS was also higher in low-income populations and in individuals without a partner (single, separated, divorced, or widowed subjects). These results corroborate previous large-scale studies that have reported a significant influence of these independent variables on the prevalence rates of BD.43,45 Conversely, education level does not seem to have any influence on the prevalence of the disorder.

The results of the present review revealed lifetime prevalence rates as high as 15.1% for BS. It is important to underscore that, of the six studies investigating the prevalence of BS, two found quite higher rates than those reported in the pioneer 20-year cohort study conducted by Angst, were a rate of 8.3%2 was reported; moreover, one study reported a similar prevalence rate.

This finding may reflect methodological differences and

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the consideration of an increasingly broadened notion of the bipolar spectrum, but it could also indicate an actual increase in the prevalence of the disorder. When using the concept of BD, based on the more restrictive, categorical diagnostic criteria set forth in the DSM-IV, the prevalence observed in this review ranged from 0.1 to 7.5%, with the highest rate observed in the Brazilian population – also the only study using the MINI. Excluding this highest rate, the maximum prevalence rate observed for BD was 3.8%.

Differences in the rates reported for BD and BS can be explained by the presence of softer symptomatic patterns in BS, which in general tend to be observed in the early onset of the disorder. Being aware of such differences is extremely important, as recognizing these milder, shorter presentations will allow for early diagnosis and thus adequate drug treatment and preventive measures in relation to hospitalizations and the cognitive impairment caused by the disease. Another important aspect is related to the minimum rates found for BS (2.4%), which are double the mean minimum rate found using more restrictive, categorical criteria. Therefore, on the one hand, from a spectral perspective, it is likely that, at present, a large number of patients with bipolar symptoms remain undiagnosed and consequently untreated. On the other hand, caution is needed when diagnosing BS, and the measures used for assessment should be carefully selected so as to minimize false positive results and avoid (drug) treating patients without clinically relevant symptoms. Finally, the need for a standardized use of instruments and their validation for use in national samples is essential to an adequate comparison of estimated prevalence rates in different countries.

A limitation of this study is the inclusion of articles written in English only, probably ignoring data from other countries, especially developing ones. Future studies assessing results available for those populations, as well as including clinical samples, children and adolescents, are warranted to further improve our knowledge of the prevalence of BD and BS.

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15. Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Ruan WJ, et al. Prevalence, correlates, and comorbidity of bipolar I disorder and axis II disorders: results from de National Epidemiologic Survey on Alcohol and Related conditions. J Clin Psychiatry. 2005;66:1205-15.

16. Pini S, de Queiroz V, Pagnin D, Pezawas L, Angst J, Cassano GB, et al. Prevalence and burden of bipolar disorders in European countries. Eur Neuropsychopharmacol. 2005;15:425-34.

17. Waraich P, Goldner EM, Somers JM, Hsu L. Prevalence and incidence studies of mood disorders: a systematic review of the literature. Can J Psychiatry. 2004;49:124-38.

18. Angst J. Bipolar disorder: a seriously underestimated health burden. Eur Arch Psychiatry Clin Neurosci. 2004;254:59-60.

19.

Tohen M, Angst J. Epidemiology of bipolar disorders.

In: Tsuang M, Tohen M, editors. Textbook in psychiatric epidemiology. 2nd ed. New York: John Willey & Sons; 2002. p. 327-444.

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Wittchen HU, Mhlig S, Pezawas L. Natural course and burden of bipolar disorders. Int J Neuropsychopharmacol.

2003;6:145-54.

21. Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA. 1996;276:293-9.

22. Coryell W, Solomon D, Turvey C, Keller M, Leon AC, Endicott J, et al. The long-term course of rapid-cycling bipolar disorder. Arch Gen Psychiatry. 2003;60:914-20.

23. Jacobi F, Wittchen HU, Holting C, Hofler M, Pfister H, Müller N, et al. Prevalence, co-morbidity and correlates of mental disorders in the general population: results from the German Health Interview and Examination Survey (GHS). Psychol Med. 2004;34:597-611.

24. Schaffer A, Cairney J, Cheung A, Veldhuizen S, Levitt A. Community survey of bipolar disorder in Canada: lifetime prevalence and illness characteristics. Can J Psychiatry.

2006;51:9-16.

25. Jansen K, Ores LC, Cardoso T, Lima RC, Souza LD, Magalhães PV, et al. Prevalence of episodes of mania and hypomania and associated comorbidities among young adults. J Affect Disord. 2011;130:328-33.

26. Carta MG, Aguglia E, Balestrieri M, Calabrese JR, Caraci F, Dell’Osso L, et al. The lifetime prevalence of bipolar disorders and the use of antidepressant drugs in bipolar depression in Italy. J Affect Disord. 2012;136:775-80.

27. Kringlen E, Torgersen S, Cramer V. A Norwegian psychiatric epidemiological study. Am J Psychiatry. 2001;158:1091-8.

28. ten Have M, Vollebergh W, Bijl R, Nolen WA. Bipolar disorder in the general population in The Netherlands (prevalence, consequences and care utilization): results from The Netherlands Mental Health Survey and Incidence Study (NEMESIS). J Affect Disord. 2002;68:203-13.

29. Jonas BS, Brody D, Roper M, Narrow WE. Prevalence of mood disorders in a national sample of Young American adults. Soc Psychiatry Psychiatr Epidemiol. 2003;38:618-24.

30. Kawakami N, Shimizu H, Haratani T, Iwata N, Kitamura T. Lifetime and 6-month prevalence of DSM-III-R psychiatric disorders in an urban community in Japan. Psychiatry Res. 2004;121:293-301.

31. Moreno DH, Andrade LH. The lifetime prevalence, health services utilization and risk of suicide of bipolar spectrum subjects, including subthreshold categories in the São Paulo ECA study. J Affect Disord. 2005;87:231-41.

32. Negash A, Alem A, Kebede D, Deyessa N, Shibre T, Kullgren G. Prevalence and clinical characteristics of bipolar I disorder in Butajira, Ethiopia: a community-based study. J Affect Disord. 2005;87:193-201.

33. Vicente B, Kohn R, Tioseco P, Saldivia S, Levav I, Torres S. Lifetime and 12-month prevalence of DSM-III-R disorders in the Chile psychiatric prevalence study. Am J Psychiatry.

2006;163:1362-70.

34. Fischer LJ, Goldney RD, Grande ED, Taylor AW, Hawthorne G. Bipolar disorders in Australia: a population-based study of excess costs. Soc Psychiatry Psychiatr Epidemiol. 2007;42:105-9.

35. Merikangas KR, Akiskal HS, Angst J, Greenberg, MA, Hirschfeld RM, Petukhova M, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2007;64:543-52.

36. Bogren M, Mattisson C, Isberg PE, Nettelbladt P. How common are psychotic and bipolar disorders? A 50-year follow-up of the Lundby population. Nord J Psychiatry. 2009;63:336-46.

37. Lee S, Ng KL, Tsang A. A community survey of the twelve month prevalence and correlates of bipolar spectrum disorder in Hong Kong. J Affect Disord. 2009;117:79-86.

38. Kozloff N, Cheung AH, Schaffer A, Cairney J, Dewa CS, Veldhuizen S, et al. Bipolar disorder among adolescents and young adults: results from an epidemiological sample. J Affect Disord. 2010;125:350-4.

39. Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson N, et al. Prevalence and correlates of bipolar spectrum disorder in the World Mental Health Survey Initiative. Arch Gen Psychiatry. 2011;68:241-51.

40. Zutshi A, Eckert KA, Hawthorne G, Taylor AW, Goldney RD. Changes in the prevalence of bipolar disorders between 1998 and 2008 in an Australian population. Bipolar Disord.

2011;13:182-8.

41. Hirschfeld RM, Holzer C, Calabrese JR, Weissman M, Davies M, Frye MA, et al. Validity of the mood disorder questionnaire: a general population study. Am J Psychiatry. 2003;160:178-80.

42. Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Young D, Dalrymple K, et al. Screening for bipolar disorder and finding borderline personality disorder. J Clin Psychiatry.

2010;71:1212-7.

43. Kessler RC, Rubinow DR, Holmes C, Abelson JM, Zhao S. The epidemiology of DSM-II bipolar I disorder in a general population survey. Psychol Med. 1997;27:1079-89.

44. Chengappa KN, Kupfer DI, Frank E, Houck PR, Grochocinski VI, Cluss P, et al. Relationship of birth cohort and early age at onset of illness in a bipolar disorder case registry. Am J Psychiatry. 2003;160:1636-42.

45. Bland RC. Epidemiology of affective disorders: a review. Can J Psychiatry. 1997;42:367-77.

Correspondence Adriane Arteche Programa de Pós-Graduação em Psicologia, PUCRS Av. Ipiranga, 6681, Prédio 11, sala 925, Partenon 90619-900 - Porto Alegre, RS - Brazil Tel.: +55 (51) 3320.7739 E-mail: adriane.arteche@pucrs.br Trends Psychiatry Psychother. 2013;35(2) – 105

Trends

Original Article

in Psychiatry and Psychotherapy

Association between anxiety symptoms and problematic alcohol use in adolescents Associação entre sintomas ansiosos e uso problemático de álcool em adolescentes Marianna de Abreu Costa,1 Giovanni Abrahão Salum Junior,2 Luciano Rassier Isolan,3 Jandira Rahmeier Acosta,1 Rafaela Behs Jarros,2 Carolina Blaya,4 Lísia Von Diemen,5 Gisele Gus Manfro6

Abstract

Resumo

Background: Anxiety disorders are highly prevalent, affecting approximately 10% of individuals throughout life; its onset can be detected since early childhood or adolescence. Studies in adults have shown that anxiety disorders are associated with alcohol abuse, but few studies have investigated the association between anxiety symptoms and problematic alcohol use in early ages.

Objective: To evaluate if anxiety symptoms are associated with problematic alcohol use in young subjects.

Methods: A total of 239 individuals aged 10-17 years were randomly selected from schools located in the catchment area of Hospital de Clínicas de Porto Alegre. The Screen for Child Anxiety-Related Emotional Disorders (SCARED) was used to evaluate the presence of anxiety symptoms, and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), to evaluate alcohol use.

Results: One hundred twenty-seven individuals (53.1%) reported having already used alcohol. Of these, 14 individuals showed problematic alcohol use (5.8%). There was no association between lifetime use of alcohol and anxiety symptoms, but mean SCARED scores in individuals with problematic alcohol use was higher if compared to those without problematic use, even after adjustment for age and gender (29.9±8.5 vs. 23.7±11.8, p < 0.001).

Conclusions: Despite the limitation of a cross-sectional design, our study suggests that anxiety symptoms are associated with problematic alcohol use early in life.

Keywords: Child, adolescent, anxiety, alcohol drinking.

Introdução: Os transtornos de ansiedade possuem alta prevalência, afetando aproximadamente 10% dos indivíduos ao longo da vida; seu início pode ser detectado já na infância e na adolescência. Estudos em adultos demonstram que a ansiedade está associada ao abuso de álcool. No entanto, poucos estudos investigaram a associação entre sintomas ansiosos e o uso problemático de álcool em indivíduos jovens.

Objetivo: Avaliar se os sintomas de ansiedade estão relacionados com uso problemático de álcool em jovens.

Métodos: Um total de 239 indivíduos com idade de 10-17 anos foram aleatoriamente selecionados em escolas pertencentes à área de abrangência do Hospital de Clinicas de Porto Alegre. A escala Screen for Child Anxiety-Related Emotional Disorders (SCARED) foi utilizada para avaliar a presença de sintomas ansiosos, e a escala Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), para avaliar o uso de álcool.

Resultados: Cento e vinte e sete indivíduos (53,1%) já haviam utilizado bebida alcoólica. Desses, 14 indivíduos mostraram uso problemático de álcool (5,8%). Não foi observada associação entre ter usado álcool na vida e sintomas ansiosos. Porém, o escore médio da SCARED em indivíduos com uso problemático de álcool foi maior quando comparado com o escore daqueles sem uso de álcool problemático, mesmo após ajuste para idade e gênero (29,9±8,5 vs. 23,7±11,8, p < 0,001).

Conclusões: Apesar das limitações impostas pelo desenho transversal, nosso estudo sugere que sintomas de ansiedade estão associados com o uso problemático de álcool em indivíduos jovens.

Descritores: Criança, adolescente, ansiedade, etanol.

Anxiety Disorders Program for Child and Adolescent Psychiatry (PROTAIA), Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. 2 PROTAIA, HCPA, UFRGS, Porto Alegre, RS, Brazil. National Institute of Developmental Psychiatry for Children and Adolescents (INPD), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Graduate Program in Medical Sciences: Psychiatry, HCPA, UFRGS, Porto Alegre, RS, Brazil. 3 PROTAIA and Graduate Program in Medical Sciences: Psychiatry, HCPA, UFRGS, Porto Alegre, RS, Brazil. 4 PROTAIA, HCPA, UFRGS, Porto Alegre, RS, Brazil.

Department of Clinical Medicine: Psychiatry, Universidade Federal de Ciências Médicas de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil. 5 Center for Drug and Alcohol Research, HCPA, UFRGS, Porto Alegre, RS, Brazil. 6 PROTAIA, HCPA, UFRGS, Porto Alegre, RS, Brazil. INPD, CNPq. Graduate Program in Medical Sciences: Psychiatry, HCPA, UFRGS, Porto Alegre, RS, Brazil. Graduate Program in Neuroscience, Health Basic Sciences Institute (ICBS), UFRGS, Porto Alegre, RS, Brazil.

1

Financial support: Fundo de Incentivo à Pesquisa – Hospital de Clínicas de Porto Alegre (FIPE-HCPA), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS).

Submitted Jun 21 2012, accepted for publication Aug 16 2012. No conflicts of interest declared concerning the publication of this article.

Suggested citation: Costa MA, Salum GA, Isolan LR, Acosta JR, Jarros RB, Blaya C, et al. Association between anxiety symptoms and problematic alcohol use in adolescents. Trends Psychiatry Psychother. 2013;35(2):106-10.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 106-110

Anxiety symptoms and alcohol use in adolescents – Costa et al.

Introduction

Materials and methods

Anxiety disorders are among the most prevalent psychiatric conditions, affecting approximately 28.8% of individuals throughout life.1 Moreover, these disorders are characterized by having an early onset, affecting almost 5.2% of subjects aged 7 to 14 years according to a Brazilian epidemiological study.2 Studies evaluating adult samples have demonstrated that anxiety disorders are associated with problematic alcohol use,3 but few studies have investigated this association early in life.

Alcohol is the drug most widely used in the general population and also among adolescents. Laranjeira et al. reported a prevalence of 28% of heavy alcohol use, 3% of alcohol abuse, and 9% of dependence in a Brazilian adult sample.4 Lifetime prevalence of alcohol use among Brazilian adolescents has been informed to range from 345 to 62%,6 reaching higher rates in females. While 6.7% of the population is comprised of heavy users, the rate of frequent use reaches 11.7%.7 Furthermore, alcohol consumption has accounted for 80,000 deaths per year from 2001 to 2005 in the U.S., and is considered one of the most common preventable causes of death.8 Comorbidity between anxiety disorders and alcohol use in adults is well described in the literature. Degenhardt et al. showed that the association between alcohol use and anxiety in adults shows a J-shaped curve, with light users having the lowest rates of anxiety disorders, and those with dependence showing the highest rates of anxiety.9 Moreover, the frequency of alcohol use as a self-medication in anxious individuals differs depending on the type of anxiety disorder.

For example, studies have shown a prevalence of 3.3% in individuals with specific phobia,10 7.9% in those with social anxiety disorder/public speaking subtype,11 and 18.310 to 35.6%11 in patients diagnosed with generalized anxiety disorder. In a representative sample of 43,093 U.S. adults, Schneier et al. found a positive association between social anxiety disorder and alcohol dependence (OR = 2.8) and alcohol abuse (OR = 1.2).12 Fewer studies have investigated this association in adolescents. Saban et al. described a prevalence of 43% of anxiety disorder in 43 adolescents hospitalized for alcohol dependence or use.13 Data from community studies investigating earlier patterns of this comorbidity are lacking.

The aim of this study was to investigate whether anxiety symptoms were associated with problematic alcohol use in a community sample of adolescents. Our hypothesis was that adolescents with anxiety symptoms would show higher rates of alcohol use and would use it more frequently when compared with those without anxiety symptoms. Also, we hypothesize that anxiety symptoms are associated with problematic alcohol use in adolescence, as already demonstrated in adult samples.

Students aged 10 to 17 years and attending schools located in the catchment area of the primary care unit of Hospital de Clínicas de Porto Alegre, in the city of Porto Alegre, southern Brazil, were enrolled in the study from April 2008 to September 2009, resulting in a total sample of 2,537 individuals. Detailed information about the study design and sample is described elsewhere.14 Before the study, both students and their parents received written information about the study; parents who did not want their children to participate were required to sign an informed dissent form. In addition, written informed consent was obtained from all participating schools.

The study design was reviewed and approved by the Ethics Committee of Hospital de Clínicas de Porto Alegre (protocol no. 08-017).

Of the initial sample, 239 individuals were randomly selected to answer the Screen for Child Anxiety-Related Emotional Disorders (SCARED), for the assessment of anxiety symptoms, and the Alcohol, Smoking and Substance Involvement Screening Test, modified for self-application (ASSIST), to evaluate alcohol use.

The SCARED is a screening scale widely used to assess anxiety symptoms in children and adolescents.15,16 It consists of five subscales (somatic/panic, generalized anxiety, separation anxiety, social phobia, and school phobia) and a total of 41 questions that have to be answered with regard to symptom frequency using a 3-point scale, as follows: 0 (almost never), 1 (sometimes), and 2 (often). The SCARED total score, derived by summing the responses of the 41 items, may range from 0 to 82. The SCARED has been validated for use in Brazilian children and adolescents and has shown good psychometric properties.17 The ASSIST was developed by the World Health Organization and is used to screen for different levels of problems with substances in general. It has been validated in Portuguese language and comprises seven questions related to the frequency and lifetime use of substances, problems and concerns of others regarding substance use, impairment in tasks, and unsuccessful attempts to stop or reduce substance use (either nicotine, alcohol, marijuana, cocaine, inhalants, or other substances).18 The ASSIST final score may suggest abuse and/or dependence for each drug assessed. Each question has different options of answers, with different ratings.18 The sample was dichotomized according to problematic alcohol use assessed by questions 2 to 7 of the ASSIST scale, where individuals scoring 0 to 10 were considered as no problematic alcohol use, and those scoring 11 or above were considered to present problematic use. Individuals

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scoring from 11 to 26 were grouped together with those scoring higher than 27, as only three individuals showed scores ≥ 27 (insufficient statistical power for an individual analysis of this more severe group). Lifetime alcohol use and frequency of use were also calculated according to the ASSIST scale. As a result, individuals answering never and 1 or 2 times (in lifetime) were considered as presenting a low frequency of alcohol use, and those answering weekly and every day or almost every day were considered as high frequency. The response monthly was considered as low frequency in males and as high frequency in females, taking into consideration the different amounts of alcohol used to determine substance use and risk patterns between genders.19

Statistical analysis Normal distribution and equality of variance were assessed prior to any statistical analysis using the Kolmogorov-Smirnov test and Levene’s test. Data are presented as count (%), mean (M), and standard deviation (SD). Prevalence ratio (RP) and 95% confidence interval (95%CI) were calculated. ASSIST results were dichotomized, and the chi-square test was used to assess the association between gender and problematic alcohol use. The Student t test was used to assess associations between age and problematic alcohol use and also between SCARED results and gender.

The association of problematic alcohol use with gender, age, and SCARED scores was assessed using Poisson regression. Variables showing an association with problematic alcohol use or SCARED scores equivalent to p < 0.2 were included in the analysis. Poisson regression was also used to assess associations between different anxiety symptoms and problematic alcohol use in a multivariate model.

All analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 17.0.

Significance was set at p < 0.05.

Results A total of 239 individuals were evaluated, and 131 (54.8%) were females. Mean age in the whole sample was 14.2±2.40 years. A total of 127 individuals (53.1%) reported lifetime use of alcohol. Of these, 14 individuals showed problematic alcohol use, accounting for 5.9% of the sample.

Lifetime use of alcohol was not significantly associated with SCARED scores (p = 0.681). However, individuals whose alcohol use was rated as highly frequent showed higher scores on the SCARED scale when compared to those

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with a lower frequency of alcohol use, even after adjustment for age and gender (M = 28.1 vs. 22.9, p = 0.02).

In the bivariate analysis, individuals with problematic alcohol use differed from those with no problematic use in being older (16.4±2.2 vs. 14±2.3 years, p < 0.001) and more frequently male (71.4 vs. 43.11%, p = 0.043). Mean SCARED score in the total sample was 24.1±11.76, and it was higher among individuals with problematic alcohol use as compared to those without problematic use, but the difference was marginal considering the probability value (29.92±8.5 vs. 23.75±11.8, p = 0.057). After controlling for confounders (gender and age), anxiety symptoms were significantly associated with problematic alcohol use (PR = 1.054, 95%CI 1.02-1.08, p < 0.001).

The anxiety symptoms most often associated with alcohol problems in separated multivariate models adjusted for age and gender were: generalized anxiety symptoms (PR = 1.22, 95%CI 1.13-2.1, p < 0.001), separation anxiety symptoms (PR = 1.21, 95%CI 1.111.31, p < 0.001), and panic symptoms (PR = 1.11, 95%CI 1.01-1.23, p = 0.03). School phobia symptoms (PR = 1.04, 95%CI 10.65-1.66, p = 0.86) and social anxiety symptoms (PR = 1.08, 95%CI 0.96-1.2, p = 0.18) were not associated with problematic alcohol use in our sample.

Discussion The prevalence of alcohol use in our sample was 53.1%, which is in agreement with other studies that have reported prevalence rates ranging from 345 to 62%6 among adolescents. We found a higher prevalence of alcohol use in male and older adolescents, as also previously reported.5 Moreover, corroborating our initial hypothesis, we found a higher prevalence of anxiety symptoms in individuals with problematic alcohol use after adjustment for confounders.

The literature describes different patterns of alcohol use according to different types of anxiety disorders.10,11,20,21 Our data showed a higher prevalence of problematic alcohol use in the presence of symptoms of panic disorder and generalized anxiety disorder, which is in agreement with previous studies.10,11,20-22 However, we did not find an association between social phobia symptoms and problematic alcohol use, as reported in some studies assessing adults10 and adolescents.22 These controversial findings could be due to methodological differences in the assessment of anxiety. For instance, while previous studies have reported associations between alcohol use and different diagnoses of anxiety disorders, we evaluated anxiety symptoms using a screening scale. As a result, our study did not confirm

Anxiety symptoms and alcohol use in adolescents â&#x20AC;&#x201C; Costa et al.

the association between a diagnosis of anxiety disorder and alcohol use, but rather the association between anxiety symptoms and problematic alcohol use. Other possible explanation for these differences between the findings could be a beta error in our study, as only five individuals showed social anxiety symptoms.

Recognizing the association between anxiety symptoms and problematic alcohol use in a population of youth may prevent alcohol-related morbidity and mortality through strategies focused on individuals with anxiety symptoms and thus the early recognition of individuals at a greater risk for developing alcohol problems. Higher levels of alcohol use have been reported for 52% of deaths among Brazilians aged 15 to 54 years.23 In addition, in 2000, 40% of the fatalities in traffic accidents in the U.S. were related to alcohol use.9 Students who commit suicide are more often under the acute effect of alcohol,24 and the use of this substance has been shown to quadruplicate the chance of violence among men.24 The risk of death by drowning, falls, and suicide is higher in alcoholic subjects.9 At an early age, alcohol consumption increases the chance of using tobacco and other drugs, and also of worsening its own pattern of use.6 Finally, alcohol is also a risk factor for different medical conditions.23,25 The literature has demonstrated that non-recognition and non-treatment of anxiety disorders may pose difficulties to and even cause the failure of alcoholism treatment.12 Some studies have shown that anxiety can contribute to the maintenance and relapse of alcohol abuse and dependence disorders.3,26 In addition, anxiety may worsen alcohol abuse and dependence.12 Anxious individuals who use alcohol as a self-medication have an increased chance of developing other comorbidities, e.g., mood disorder,11,12 substance use disorder,11 suicidal ideation and suicide attempt,11 and personality disorder.10 Moreover, they tend to have a poorer quality of life27 and increased rates of health care system use.27 The direction of the association between anxiety and problematic alcohol use is controversial in the recent literature: while some studies suggest that alcohol precedes anxiety,3 others indicate that anxiety disorder precedes problems with alcohol.3,21 Alcohol can be used as a selfmedication in anxious individuals with social interaction difficulties (pro-exposure factor). Falk et al. showed that social anxiety disorder and specific phobia usually precede problematic alcohol use.21 In a sample with adults, social anxiety disorder preceded alcohol dependence in 79.7% of comorbid cases.12 Conversely, anxiety may result from problematic alcohol use or even from the withdrawal syndrome. Alcohol abuse or dependence tends to occur prior to generalized anxiety disorder and panic disorder.22

Because our study has a cross-sectional design, our results do not allow to suggest a causal relationship between problematic alcohol use and anxiety symptoms.

The lack of association between lifetime alcohol use and anxiety symptoms in our study may possibly be explained by a beta error due to our small sample size, as well as because we analyzed different types of anxiety. Moreover, we could not evaluate other confounding comorbidities, such as depression, because this information was not available. Another limitation is the use of self-report instruments, even though most studies have suggested that self-report instruments provide valid information on the use of alcohol by adolescents.28 Finally, an additional limitation refers to the fact that analysis was based on symptoms rather than on diagnosis. It is interesting to note that, even in the absence of a full-blown disorder, the presence of anxiety symptoms allowed to identify individuals already at risk for developing alcohol-related disorders. This finding becomes even more important if we consider that alcoholism is a more difficult disease to treat when compared to anxiety disorders.29 We did not find an association between lifetime alcohol use (experimentation) and anxiety symptoms, but the latter was associated with problematic and highly frequent alcohol use. Adolescence is an important stage, marked by impulsivity, family conflicts, and transgression.

Those characteristics reflect the omnipotence and curiosity typically observed in youths and may lead one to engage in risk behaviors by searching for new sensations and pleasures.30 In addition, alcohol products are widely offered31 and used,32 easily accessible,31 although forbidden for adolescents in Brazil. Thus, the higher rate of alcohol experimentation observed in our sample is consistent with characteristics inherent to adolescence and maybe to the Brazilian setting, regardless of the presence of anxiety symptoms.

From a different standpoint, however, our findings do suggest that frequent and problematic use of alcohol may represent a condition potentially associated with pathological traits such as anxiety symptoms.

In sum, this study corroborates data previously described for adults and shows that the association between anxiety and alcohol problems can be detected within a dimensional perspective, i.e., in the presence of anxiety symptoms, not necessarily disorders. This finding can contribute to the design and implementation of preventive efforts among individuals at risk. Longitudinal studies that identify the presence of anxiety disorders in children and, subsequently, evaluate the development of alcohol-related disorders, are needed to confirm our findings.

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Anxiety symptoms and alcohol use in adolescents – Costa et al.

Acknowledgments We thank Cristiano Tschiedel Belem da Silva, MD, for reviewing this manuscript, and Marilyn Agranonik, MSc, for the statistical analyses.

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19. De Fiellen DA, Reid C, O’Connor PG. Outpatient management of patients with alcohol problems. Ann Inter Med. 2000;133:815-27.

20. Arch JJ, Craske MG, Stein MB, Sherbourne CD, Roy-Byrne PP. Correlates of alcohol use among anxious and depressed primary care patients. Gen Hosp Psychiatry. 2006;28:37-42.

21. Zimmermann P, Wittchen HU, Höfler M, Pfister H, Kessler RC, Lieb R. Primary anxiety disorders and the development of subsequent alcohol use disorders: a 4-year community study of adolescents and young adults. Psychol Med. 2003;33:1211-22.

22.

Falk DE, Yi HY, Hilton ME. Age of onset and temporal sequencing of lifetime DSM-IV alcohol use disorders relative to comorbid mood and anxiety disorders. Drug Alcohol Depend. 2008;94:234-45.

23. Zaridze D, Brennan P, Boreham J, Boroda A, Karpov R, Lazarev A, et al. Alcohol and cause-specific mortality in Russia: a retrospective case-control study of 48,557 adult deaths. Lancet. 2009;373:2201-14.

24. Zaleski M, Pinsky I, Laranjeira R, Ramisetty-Mikler S, Caetano R . Intimate partner violence and alcohol consumption. Rev Saude Publica. 2010;44:53-9.

25. Thun MJ, Peto R, Lopez AD, Monaco JH, Henley SJ, Heath Jr CW, et al. Alcohol consumption and mortality among middleaged and elderly U.S. adults. N Engl J Med. 1997;337:1705-14.

26. Kushner MG, Abrams K, Thuras P, Hanson KL, Brekke M, Sletten S. Follow-up study of anxiety disorder and alcohol dependence in comorbid alcoholism treatment patients.

Alcohol Clin Exp Res. 2005;29:1432-43.

27. Robinson JA, Sareen J, Cox BJ, Bolton JM. Correlates of selfmedication for anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Nerv Ment Dis. 2009;197:873-8.

28. Needle R, McCubbin H, Lorence J, Hochhauser M. Reliability and validity of adolescent self-reported drug use in a family-based study: a methodological report. Int J Addict.

1983;18:901-12.

29. Wesner RB. Alcohol use and abuse secondary do anxiety.

Psychiatr Clin North Am. 1990;13:699-713.

30. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking and associated health risk behaviors among high school students. Pediatrics. 2007;119:76-85.

31.

Laranjeira RR. Brazil’s market is unregulated. BMJ. 2007;335:735.

32. Galduróz JC, Carlini EA. Use of alcohol among the inhabitants of the 107 largest cities in Brazil – 2001. Braz J Med Biol Res. 2007;40:367-75.

Correspondence Gisele Gus Manfro Anxiety Disorders Program for Child and Adolescent Psychiatry (PROTAIA) Hospital de Clínicas de Porto Alegre (HCPA) Rua Ramiro Barcelos, 2350 90035-903 - Porto Alegre, RS - Brazil Tel./Fax: +55 (51) 3359.89.83 E-mail: gmanfro@gmail.com

Trends

Original Article

in Psychiatry and Psychotherapy

Impairment in psychosocial functioning in patients with different subtypes of eating disorders O prejuízo no funcionamento psicossocial de pacientes com diferentes subtipos de transtorno alimentar Carolina Meira Moser,1 Maria Inês Rodrigues Lobato,2 Adriane R. Rosa,3 Emi Thomé,1 Julia Ribar,1 Lucas Primo,1 Ana Carolina Faedrich dos Santos,1 Miriam Garcia Brunstein1

Abstract

Resumo

Objective: To examine psychosocial functioning in eating disorder (ED) patients with restrictive and purgative subtypes.

Method: Forty-four adult female patients with a diagnosis of ED were divided into restrictive (RP) and purgative (PP) groups according the presence of purgative symptoms. Functioning was assessed using the Functioning Assessment Short Test (FAST) and the Global Assessment of Functioning Scale (GAF).

Results: No differences were found in total FAST scores or in specific domains between the RP (39.58±11.92) and PP (45.75±11.75) groups (p = 0.19). However, PP showed more severe functional impairment than RP in the financial domain (p < 0.01). There were no differences in comorbidity with mood disorders, depressive symptoms, or general psychiatric symptoms between the two ED subtypes.

Conclusions: The similarities found between PP and PR in overall functioning and in autonomy, cognition, work, interpersonal relationships, and leisure seem to reflect the use of an objective scale that corresponds to the clinical impression. In fact, the assessment of psychosocial functioning in ED patients using self-report instruments requires careful consideration because results may reflect the egosyntonic nature of symptoms commonly observed in these patients, particularly in the restrictive subtype.

Keywords: Eating disorders, anorexia nervosa, bulimia nervosa, psychosocial factors.

Objetivo: Avaliar o funcionamento psicossocial de pacientes com subtipos restritivo e purgativo de transtorno alimentar (TA).

Métodos: Quarenta e quatro pacientes adultas com TA foram divididas em grupos restritivo (RP) e purgativo (PP) conforme a presença de sintomas purgativos. O funcionamento foi avaliado com a Functioning Assessment Short Test (FAST) e a Global Assessment of Functioning Scale (GAF).

Resultados: Não houve diferenças nos escores totais nem nos domínios da FAST entre os grupos RP (39,58±11,92) e PP (45,75±11,75) (p = 0,19). No entanto, o grupo PP demonstrou maior prejuízo funcional no domínio finanças (p < 0,01). RP e PP foram semelhantes em comorbidade com transtornos de humor, sintomas depressivos e sintomas psiquiátricos em geral.

Conclusões: As semelhanças encontradas entre os grupos PP e RP no funcionamento geral e nos domínios autonomia, cognição, trabalho, relacionamentos interpessoais e lazer parecem refletir o uso de uma escala objetiva que corresponde à impressão clínica. De fato, é necessário cautela ao avaliar funcionamento psicossocial em pacientes com TA com escalas autoaplicáveis, porque estas costumam refletir a natureza egossintônica dos sintomas comumente observados nesses pacientes, especialmente no subtipo restritivo.

Descritores: Transtornos alimentares, anorexia nervosa, bulimia nervosa, fatores psicossociais.

Adult Eating Disorders Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil. Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. 2 HCPA and UFRGS, Porto Alegre, RS, Brazil. 3 Bipolar Disorders Program, Clinical Institute of Neuroscience, Hospital Clinic of Barcelona, Barcelona, Spain.

1

This article is part of the master’s thesis entitled Functioning in adult patients with eating disorders (Avaliação da funcionalidade em pacientes adultos com transtornos alimentares), presented in 2011 at Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.

Partial results of this article were presented at the Rio International Eating Disorders and Obesity Conference, 19-20 November, 2010.

Financial support: This research was supported by Fundo de Incentivo à Pesquisa – Hospital de Clínicas de Porto Alegre (FIPE-HCPA), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) (GPPG/HCPA protocol no. 08-065), and has received the Cyro Martins Research Incentive Award from Associação de Psiquiatria do Rio Grande do Sul (APRS).

Submitted Apr 06 2012, accepted for publication Aug 19 2012. No conflicts of interest declared concerning the publication of this article.

Suggested citation: Moser CM, Lobato MI, Rosa AR, Thomé E, Ribar J, Primo L, dos Santos AC, et al. Impairment in psychosocial functioning in patients with different subtypes of eating disorders. Trends Psychiatry Psychother. 2013;35(2):111-8.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 111-118

Psychosocial functioning and eating disorders – Moser et al.

Introduction Treatment outcome measurement in eating disorders (ED) has traditionally focused on changing behavior and improving symptoms. Patients are assessed for outcomes such as a reduction in purging behavior or the achievement of a healthy body weight rather than broader areas such as role functioning or quality of life (QoL).1 The impact of EDs, including partial forms, on broader life functioning is well documented2-9 and comparable to that of anxiety disorders,4 affective disorders,4 and schizophrenia.9 Moreover, poor psychosocial functioning has been linked to premature death in ED.10-12 Among ED behaviors, the use of extreme weightcontrol methods, particularly self-induced vomiting, has been associated with the highest levels of impairment.4 Patients with the restrictive type of anorexia nervosa typically report an inflated QoL early in treatment, similar to what is observed with healthy controls.13 This observation would suggest that non-purging patients may have better functioning than those who purge.

However, there is also objective evidence of adverse effects on health and functioning in restrictive forms of ED. Inflated QoL scores may be an artifact of the egosyntonic nature of symptoms in these patients, which are difficult to capture with self-report instruments.13-15 Most studies use generic instruments to assess health-related QoL in ED patients, such as the World Health Organization Brief Quality of Life Assessment Scale (WHOQoL-Bref)16 and the Medical Outcomes Short Form-SF Health Survey 36 (SF-36).17 Although valuable, these measures were originally developed to assess the impact of physical illnesses on everyday functioning, and may therefore miss important aspects of psychopathology specific to psychiatric diagnoses such as ED. To avoid these limitations, an instrument – the Clinical Impairment Assessment – has been developed to specifically assess the personal, cognitive, and social impact of ED; however, this is a self-report questionnaire, and thus subject to the limitations already mentioned.2 In this scenario, functioning could be a more suitable and consistent construct to measure the impact of psychopathology in ED. Assessing the impact of psychiatric disorders is important for at least two reasons: first, impairment leads people to seek help, and therefore a goal of treatment should be to reduce impairment18; second, the presence of clinically significant impairment is required for a diagnosis of mental disorder.19 However, the concept of functioning is complex and involves many different domains, including the ability to work, live independently, engage in recreation, experience romantic life, and study effectively.20 These aspects have been recently integrated in a new and easily

112 – Trends Psychiatry Psychother. 2013;35(2)

administered scale, the Functioning Assessment Short Test (FAST), which fulfills the need for an assessment of multiple domains of psychosocial functioning in mental disorders. The FAST comprises 24 items and allows for the evaluation of six specific areas of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time.

Considering that the aforementioned items were identified as the main problems experienced by mentally ill patients, and taking into account the performance and psychometric proprieties of the FAST instrument in subjects with bipolar disorder,20 the aim of the present study was to examine psychosocial functioning in patients with different subtypes of ED using the FAST. Our hypothesis was that this scale could identify impairments in multiple domains of functioning in this population and reveal possible differences between the restrictive and purgative subtypes of ED.

Methods Design and participants A sample of female out- and inpatients with a diagnosis of anorexia nervosa, bulimia nervosa, or partial syndromes of anorexia nervosa or bulimia nervosa referred to the Adult Eating Disorders Program of Hospital de Clínicas de Porto Alegre (HCPA) and a group of healthy controls were recruited from August 2008 to August 2011.

Patients with the purgative subtype of anorexia nervosa, partial purgative ED syndrome, and bulimia nervosa formed the group of purgative patients (PP).

Patients with the restrictive subtype of anorexia nervosa and partial restrictive ED syndromes composed the group of restrictive patients (RP). Healthy women formed the control group (C).

Psychiatric diagnoses were established according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR).

A semistructured interview based on the Mini-International Neuropsychiatric Interview (MINI) – validated for use in Brazilian populations - was applied by a psychiatrist to investigate psychiatric disorders according to DSM-IV TR criteria.21 Patients presenting neurodegenerative disorders, psychotic symptoms, or mental retardation were excluded.

Healthy women were recruited among workers and students at HCPA and Universidade Federal do Rio Grande do Sul (UFRGS). Control subjects were screened to rule out history of ED or other psychiatric conditions.

All participants were informed about the study goals and were asked to sign an informed consent

Psychosocial functioning and eating disorders – Moser et al.

form. All procedures were conducted in agreement with the Brazilian National Health Council (Resolution no.

196/1996) and with the Declaration of Helsinki. The study protocol was approved by the Research Ethics Committee of the institution.

Instruments Clinical and sociodemographic assessment Clinical assessment included the following scales of ED psychopathology: the Eating Attitudes Test (EAT26),22,23 for evaluating eating habits and dietary practices; the Body Shape Questionnaire (BSQ),24,25 for assessing body satisfaction; and the Bulimic Investigatory Test of Edinburgh (BITE),26,27 for evaluating purgative behavior and binge eating. EAT-2623 and BITE26 have been validated to Portuguese, and the BSQ25 has been translated into Portuguese. In addition, the Symptom Checklist-90 (SCL-90)28,29 was used to evaluate general

psychological distress, the 17-item Hamilton Depression Rating Scale (HDRS-17)30 for depressive symptoms, and a questionnaire specifically designed to collect sociodemographic information. Although broadly used in Brazilian studies, instruments SCL-90 and HDRS-17 have not effectively validated for use in Brazilian Portuguese.

Height and weight were measured as part of the intake assessment and enabled calculation of the body mass index (BMI; kg/m2).

EAT, BITE, BSQ, and SCL-90 are self-report scales.

The FAST and HDRS-17 instruments are intervieweradministered.

Functioning assessment Impairment in role functioning was assessed using the FAST20 and the Global Assessment of Functioning Scale (GAF).31 The FAST (Figure 1) is an interviewer-administered questionnaire designed to evaluate overall function

ESCALA BREVE DE FUNCIONAMENTO (FAST)

Por favor, pergunte ao paciente as frases abaixo e responda a que melhor descreve seu grau de dificuldade.

Para responder utilize a seguinte escala: (0): nenhuma, (1): pouca, (2): bastante ou (3): muita.

AUTONOMIA

1. Ser responsável pelas tarefas de casa

2. Morar sozinho

3. Fazer as compras de casa

4. Cuidar-se de si mesmo (aspecto físico, higiene)

( ( ( (

0 0 0 0

) ) ) )

( ( ( (

1 1 1 1

) ) ) )

( ( ( (

2 2 2 2

) ) ) )

( ( ( (

3 3 3 3

) ) ) )

TRABALHO

5. Realizar um trabalho remunerado

6. Terminar as tarefas tão rápido quanto era necessário

7. Obter o rendimento previsto no trabalho

8. Trabalhar de acordo com seu nível de escolaridade

9. Ser remunerado de acordo com o cargo que ocupa

( ( ( ( (

0 0 0 0 0

) ) ) ) )

( ( ( ( (

1 1 1 1 1

) ) ) ) )

( ( ( ( (

2 2 2 2 2

) ) ) ) )

( ( ( ( (

3 3 3 3 3

) ) ) ) )

COGNIÇÃO

10. Concentrar-se em uma leitura, um filme

11. Fazer cálculos mentais

12. Resolver adequadamente os problemas

13. Lembrar o nome de pessoas novas

14. Aprender uma nova informação

( ( ( ( (

0 0 0 0 0

) ) ) ) )

( ( ( ( (

1 1 1 1 1

) ) ) ) )

( ( ( ( (

2 2 2 2 2

) ) ) ) )

( ( ( ( (

3 3 3 3 3

) ) ) ) )

FINANÇAS

15. Administrar seu próprio dinheiro

16. Fazer compras equilibradas

(0) (0)

(1) (1)

(2) (2)

(3) (3)

RELAÇÕES INTERPESSOAIS

17. Manter uma amizade

18. Participar de atividades sociais

19. Dar-se bem com pessoas a sua volta

20. Convivência familiar

21. Relações sexuais satisfatórias

22. Capaz de defender os próprios interesses

( ( ( ( ( (

( ( ( ( ( (

( ( ( ( ( (

( ( ( ( ( (

LAZER

23. Praticar esporte ou exercícios

24. Ter atividades de lazer

(0) (0)

0 0 0 0 0 0

) ) ) ) ) )

1 1 1 1 1 1

) ) ) ) ) )

(1) (1)

2 2 2 2 2 2

) ) ) ) ) )

(2) (2)

3 3 3 3 3 3

) ) ) ) ) )

(3) (3)

Figure 1 – Functioning Assessment Short Test (FAST) in Brazilian Portuguese

Trends Psychiatry Psychother. 2013;35(2) – 113

Psychosocial functioning and eating disorders – Moser et al.

across multiple domains in psychiatric patients. The FAST was shown to be a reliable and valid measure in patients with bipolar disorder20,32 and subjects experiencing a first psychotic episode.33 The FAST scale consists of 24 items covering six specific areas of functioning, as follows: 1) autonomy (patient’s ability to do things alone and make individual decisions); 2) occupational functioning (ability to maintain a paid job, efficiency in performing tasks at work, working in the field in which the patient was educated, and earning according to the level of the position); 3) cognitive functioning (ability to concentrate, perform simple mental calculations, solve problems, learn new information, and remember learned information); 4) financial issues (ability to manage finances and spending in a balanced way); 5) interpersonal relationships (relations with friends, family, involvement in social activities, sexual relations, and the ability to defend ideas and opinions); and 6) leisure time (ability to perform physical activities and to enjoy hobbies).

The FAST was developed by the Bipolar Disorder Program of the University of Barcelona Hospital Clinic.

Items are rated using a 4-point scale ranging from 0 (no difficulty) to 3 (severe difficulty), with a total score ranging between 0 and 72 (higher scores indicate poorer functioning). The original authors suggested a cut-off point of ≥ 11 in Spanish subjects with bipolar disorder as a measure of disability, as it improved the discriminant properties of the test to a sensitivity of 72% and a specificity of 87%.20 One hundred outpatients with bipolar disorder and one hundred controls were recruited for the FAST validation study in Brazil.32 That study showed high internal consistency (Cronbach’s alpha was 0.95 for the whole scale and 0.82 or higher for the subscales). Test-retest reliability for total FAST scores was excellent (r = 0.90; p < 0.001). Concurrent validity was based on functional impairment according to the GAF scale, which assesses only overall functioning (higher scores on the GAF suggest better functioning).32 Total FAST scores were strongly correlated with GAF scores (rho = -0.70, p < 0.001). The FAST scale is available in several languages, including Portuguese, as used in our sample. A single interviewer (C.M.M.), a psychiatrist with 8 years of training and clinically experienced with scales, examined all patients and controls.

Statistical analysis The Shapiro-Wilk test was used to investigate data distribution in the sample. Symmetric variables were expressed as means and standard deviation (SD).

Asymmetric variables were expressed as medians and interquartile range (Q1-Q3). For asymmetric variables,

114 – Trends Psychiatry Psychother. 2013;35(2)

data were transformed using a logarithmic function to allow the use of parametric tests and thus modify the distribution of variables.

Sociodemographic and clinical variables (comorbidities) were evaluated using descriptive statistics (frequency and percentage).

Age, BMI, scores obtained in EAT, BSQ, BITE, SCL90, FAST total, all FAST domains, and GAF variables were compared across the PP, RP, and C groups using the Kruskal-Wallis test. Age at onset of ED was analyzed using Mann-Whitney’s test, and HDRS-17 scores were compared between PP and RP using a t test. Total FAST scores were analyzed using one-way analysis of variance (ANOVA).

Demographic data and comorbidity with psychiatric disorders were analyzed using the chi-square test and Fisher’s exact test. Internal consistency of FAST scores was analyzed using Cronbach’s alpha. The correlation between FAST and GAF scores was calculated using Spearman’s correlation coefficient.

All analyses were performed using the Statistical Package for the Social Sciences (SPSS), version 18.0.

Statistical significance was set at p < 0.05 (95% power).

Results A total of 44 ED patients were recruited, namely, 12 RP (eight with restrictive anorexia nervosa and four with a partial syndrome of restrictive anorexia nervosa) and 32 PP (10 with purgative anorexia nervosa, 19 with bulimia nervosa, and three with partial purgative syndromes).

The control group included 37 healthy women.

As shown in Table 1, there were no significant age differences across the three groups. The sample comprised 90.6% of outpatients in the PP group and 58.3% of inpatients in the RP group. The majority of ED patients (RP and PP groups) had completed high school.

Most RP were single, and 43.8% of PP had a partner.

Ninety-eight percent of the total sample was Caucasian.

As expected, BMI was significantly lower in the RP group when compared with the other two groups (p < 0.01). The two groups of patients did not show significant differences in terms of age at onset, age at diagnosis, or HDRS-17 scores. EAT and SCL-90 scores were significantly lower in controls (p < 0.01), but similar between the PP and RP groups. BITE and BSQ scores were significantly higher in the PP group when compared with the RP and C groups (p < 0.01) (Table 1).

The internal consistency coefficient obtained for FAST in our sample was high, with a Cronbach’s alpha of 0.892 for the total scale, indicating that the items were sufficiently homogeneous for this population. A strong

Psychosocial functioning and eating disorders – Moser et al.

Table 1 – Demographic and clinical characteristics of subjects

Variable

PP (n = 32)

RP (n = 12)

C (n = 37)

p

Age* 30 (21.5-44.75) 30 (21.25-44) 24 (20.5-31) 0.09 Education‡ Incomplete elementary school 4 (12.5%) 1 (0.83%) 0 (0%) 0.001 Complete elementary school 8 (25%) 1 (0.83%) 0 (0%) Complete high school 18 (56.3%) 8 (67.7%) 22 (59.5%) Complete college 2 (6.3%) 2 (16.7%) 15 (40.5%) Household income‡§ < US$ 320 6 (18.8%) 3 (25%) 0 (0%) 0.001 US$ 321-1600 24 (75%) 7 (58.3%) 3 (8.1%) > US$ 1601 2 (6.3%) 2 (16.7%) 34 (91.9%) Marital status‡ Single 18 (56.3%) 9 (75%) 30 (81.1% ) 0.074 With partner 14 (43.8%) 3 (25%) 7 (18.9) BMI (kg/m²)*† 22.09 (19.6-27.31) 17.90 (16.29-19.58) 20.82 (20.12-22.15) PP, C > RP Age at onset*|| 15.5 (14-22) 18.5 (13.75-31.5) 0.36 Age at diagnosis¶|| 27.84 (12.19) 28.08 (10.49) 0.37 Rating scales* EAT-26† 35 (26-39) 12.25 (4.25-31.5) 5 (3-10) PP, RP > C BITE† 21.5 (14.25-25) 7 (5-16) 4 (2-8) PP > RP, C BSQ† 161.5 (115.75-186) 62 (45.5-151.5) 61 (49-80) PP > RP, C SCL-90† 185 (134-214.4) 111 (46.25-206.25) 20 (7.5-36.5) PP, RP > C HDRS-17|| 16.63 (7.05) 16.42 (8.07) 0.83 †

Data expressed as absolute frequency (percentage), * median (interquartile range: Q1-Q3), or ¶ mean (standard deviation).

Data analyzed using † ANOVA, ‡ the chi-square test, or || Student’s t test. § Exchange rate at the time of the study: US$ 1.00 = R$ 2.00.

BITE = Bulimic Investigatory Test of Edinburgh; BMI = body mass index; BSQ = Body Shape Questionnaire; C = control group; EAT-26 = Eating Attitudes Test; ED = eating disorders; HDRS-17 = 17-item Hamilton Depression Rating Scale; PP = purgative patients; RP = restrictive patients; SCL-90 = Symptom Checklist-90; SD = standard deviation.

Table 2 – Scores obtained for FAST total, FAST domains, and GAF

Variable FAST autonomy FAST work FAST cognition FAST finances FAST relationships FAST leisure FAST total† GAF total

PP 6 (3.25-7.75) 14.5 (9-15) 10 (6-13) 5 (3-6) 10.5 (8-13) 4.5 (2-6) 45.75 (11.75) 40.5 (31-45)

RP 6 (3.25-8.75) 15 (5.25-15) 6.5 (4-10.75) 1.5 (0.25-2.75) 11 (5.25-16.5) 2 (2-3) 39.58 (16.76) 44.5 (32-57.25)

C Tukey* 1 (0-2) 1 (0-2) 2 (1-5) 1 (0-2) 1 (0-3) 1 (0-2) 8.66 (5.18) 95 (90.5-100)

PP, RP > PP, RP > PP, RP > PP > RP, PP, RP > PP, RP > PP, RP > PP, RP >

C C C C C C C C

Data expressed as median (interquartile range: Q1-Q3) or † mean (standard deviation).

C = control group; FAST = Functioning Assessment Short Test; GAF = Global Assessment of Functioning Scale; PP = purgative patients; RP = restrictive patients. * p < 0.05.

and significant correlation was also observed between FAST and GAF scores (r = -0.89; p < 0.01), i.e., patients with poor functioning obtained high scores on FAST and low ones on GAF. No differences were found in total FAST scores between the RP and PP groups. However, PP scores were higher than RP ones in the financial domain (p < 0.01), revealing a more severe impairment in this area among PP (Table 2). As expected, mean FAST scores were significantly higher in ED patients than in healthy subjects in all domains (autonomy, work, cognition,

finances, relationships, and leisure).

The prevalence of comorbidities in the RP and PP groups was high, as shown in Table 3. Only the PP group presented indications of alcohol and substance abuse.

Moreover, the proportion of subjects with a history of suicide attempts was significantly higher in the PP group.

Additionally, the PP group showed a statistical tendency toward having more phobias (agoraphobia, specific phobia, and social phobia) than the RP group. Other measures were not significantly different between the groups.

Trends Psychiatry Psychother. 2013;35(2) – 115

Psychosocial functioning and eating disorders – Moser et al.

Table 3 – Comorbidities in restrictive and purgative eating disorders (Fisher’s exact test)

Major depression Dysthymia Suicide attempts Panic disorder Phobias Agoraphobia

Social phobia Specific phobia Obsessive compulsive disorder Post-traumatic stress disorder Generalized anxiety Substance abuse Alcohol abuse Somatoform disorders

PP (n = 32) %

RP (n = 12) %

p

56.2 50 0.74 53.1 58.3 1 65.6 25.0 0.02 59.4 41.7 0.32 65.6 33.3 0.08 50 33.3 0.49 40.6 25 0.48 31.3 16.7 0.46 34.4 41.7 0.73 12.5 8.3 1 37.5 41.7 1 12.5 0 25.0 0 43.8 41.7 1

PP = purgative patients; RP = restrictive patients.

Discussion Our study demonstrated that patients with both the restrictive and purgative subtypes of ED showed similar overall impairment and presented deficits in multiple domains of functioning. However, ED patients with the purgative subtype (PP) revealed a more severe degree of impairment in the financial domain.

These results confirm findings of previous studies demonstrating that individuals with ED (including partial forms) show poor psychosocial adjustment8 and impairment in a number of domains, including interpersonal relationships, family functions, work, and finance. Furthermore, follow-up studies have shown that impairment in social functioning associated with bulimia nervosa34 and anorexia nervosa35 may persist even after remission of ED psychopathology and constitutes a significant predictor of mortality.11 Patients with restrictive subtypes of ED are known to have a tendency to underestimate the impact of their illness on daily activities and often continue to work and maintain an active lifestyle even at extreme levels of starvation.6,15 Some authors have reported better QoL scores for patients with the restrictive type of anorexia than patients with all other types of ED; the same patients also reported less subjective impairment. Even after controlling for general psychological distress, their scores were similar to those of the general population.13,14,36 These findings are not surprising, considering that these patients may perceive weight loss as an improvement in their QoL6 and that often the central purpose of these patients’ lives is the maintenance of their emaciated state.13 The results of those studies can be explained by the egosyntonic nature of symptoms commonly observed in restrictive subtypes of ED, underscoring 116 – Trends Psychiatry Psychother. 2013;35(2)

the importance of using instruments that objectively assess functioning rather than relying on the patients’ reports of subjective feelings. In fact, self-reported instruments and QoL scales may not be reliable in these patients because they may reflect the severity of their psychopathology. In the present study, patients in the RP group scored similar to controls on BSQ, suggesting that patients with restrictive ED were as “satisfied” with their body shape as healthy women. Also, even though our RP reported high levels of restraint food intake upon clinical evaluation, they scored lower on the EAT than expected. In contrast, PP showed higher EAT and BSQ scores, probably because they had a greater awareness of their ED symptoms.

With the application of an objective scale such as the FAST, the restrictive and purgative subtypes of ED displayed similar levels of overall functioning impairment. Impacts on specific areas of functioning, such as autonomy, work, cognition, relationships, and leisure, were very similar between the two subtypes of ED. The PP group showed a more severe impairment in the financial domain, which may be explained by higher levels of impulsivity. Additionally, the PP group showed significant comorbidity with alcohol and drug abuse and more frequently showed a history of suicide attempts.

Consistent with other studies investigating women with ED,37,38 most of our ED patients had at least one comorbid psychiatric diagnosis, with anxiety39 and affective disorders40 being the most common ones.7 Our PP and RP groups showed similar rates of comorbidities with major depression, panic disorder, obsessive compulsive disorder, and somatoform disorders.

Considering that ED patients with the purgative subtype tend to have more egodystonic symptoms than restrictive ED patients, the fact that the vast majority

Psychosocial functioning and eating disorders – Moser et al.

of individuals enrolled in our treatment program (Adult Eating Disorders Program, HCPA) presented with the purgative subtype of ED may not be due to chance.

Furthermore, the fact that there were more inpatients in the RP group may reflect their resistance to seek specific outpatient treatment.

To our knowledge, this is the first study to apply the FAST in individuals with ED. This instrument is a simple, rapid, interviewer-administered scale that assesses functional impairment while focusing on the main difficulties experienced by patients suffering from mental disorders. Studies using the GAF scale have also observed functional impairment in patients with restrictive subtypes of ED,7,8 but GAF scores do not reveal impacts on specific areas of functioning. Higher scores on the FAST and lower scores on the GAF represent higher levels of disability,20 and a negative correlation between these scales was also demonstrated in our sample. A potential advantage of the FAST over other measures designed specifically to evaluate impairment in ED patients is the potential to compare their functioning to that of patients with other psychiatric disorders.

The main limitation of our study was the small sample size, particularly in the RP group. Also, the proportion of out- and inpatients differed between the two groups.

Moreover, RP and PP groups differed in relation to diagnosis (anorexia nervosa and bulimia nervosa), and some results may reflect this difference. Differences in household income and education level could also be an issue; however, this may be a consequence of better functioning in individuals without psychiatric disorders.

Conclusion Our results highlight the importance of evaluating multiple domains of functioning in ED patients using an objective instrument. The findings can be used for targeted treatment planning and to enhance the patients’ motivation to change. Our study also suggests that new treatment strategies may be needed to attain better results in functional outcomes in ED patients.

Acknowledgements The authors would like to thank Dr. Flavio Kapczinski for his assistance in the project and for revising this manuscript.

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Correspondence Carolina Meira Moser Rua Padre Chagas, 147/1403 90570-080 - Porto Alegre, RS - Brazil Tel.: +55 (51) 3264.0470 E-mail: cmeiramoser@gmail.com

Trends

Original Article

in Psychiatry and Psychotherapy

Prevalence of body image dissatisfaction and associated factors among physical education students Prevalência de insatisfação com a imagem corporal e fatores associados em universitários de educação física Elisa Pinheiro Ferrari,1 Edio Luiz Petroski,2 Diego Augusto Santos Silva2

Abstract

Resumo

Objective: To determine the prevalence of and factors associated with body image dissatisfaction among physical education students enrolled in a public university.

Methods: This study evaluated 236 students and assessed body image perception (silhouette scale), sociodemographic variables (sex, age, parental education, marital status, university course, work, living arrangement, study shift, and income), physical activity level (International Physical Activity Questionnaire - Short Version), dietary habits, tobacco use, excessive intake of alcohol (questions from the tobacco, alcohol and drugs, and nutrition domains of the FANTASTIC instrument), and nutritional status (body mass index [BMI]). Descriptive analysis, the chi-square test, Fisher’s exact test, and crude and adjusted multinomial regression were used.

Results: The prevalence of body image dissatisfaction was 69.5%; 44.1% were dissatisfied with excess weight. BMI ≥ 25.0 kg/m² was associated with dissatisfaction with excess weight; factors associated with dissatisfaction with slimness were being male, eating an unhealthy diet, and smoking tobacco.

Conclusion: Our findings suggest that female college students with a BMI ≥ 25.0 kg/m² are more likely to present dissatisfaction with excess weight. Being male, eating an unhealthy diet, engaging in physical activity for < 739.61 min/week and smoking tobacco were the variables associated with dissatisfaction with thinness.

Keywords: Physical activity, nutritional status, students, body image.

Objetivo: Verificar a prevalência e os fatores associados à insatisfação com a imagem corporal em universitários de educação física de uma universidade pública federal.

Métodos: Foram avaliados 236 universitários. Foram mensurados a percepção da imagem corporal (escala de silhueta), variáveis sociodemográficas (sexo, idade, escolaridade dos pais, estado civil, curso universitário, trabalho, moradia, turno de estudo e renda), nível de atividade física (Questionário Internacional de Atividade Física - Versão Curta), hábitos alimentares, uso de tabaco, consumo excessivo de bebidas alcoólicas (questões dos domínios tabaco, álcool e drogas, e nutrição do questionário Fantástico) e estado nutricional [índice de massa corporal (IMC)]. Utilizou-se análise descritiva, o teste do qui-quadrado, o teste exato de Fisher e regressão multinomial bruta e ajustada.

Resultados: A prevalência de insatisfação com a imagem corporal foi de 69,5%; 44,1% eram insatisfeitos por excesso de peso.

IMC ≥ 25,0 kg/m² esteve associado a insatisfação por excesso; os fatores associados à insatisfação por magreza foram sexo masculino, alimentação inadequada e tabagismo.

Conclusão: Os resultados sugerem que acadêmicos do sexo feminino e com IMC ≥ 25,0 kg/m² têm mais chances de apresentar insatisfação por excesso de peso. Sexo masculino, alimentação inadequada, prática de atividade física < 739,61 min/semana e uso de tabaco foram as variáveis associadas a insatisfação por magreza.

Descritores: Atividade motora, estado nutricional, estudantes, imagem corporal.

Departamento de Educação Física, Centro de Desportos, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil. Núcleo de Pesquisa em Cineantropometria e Desempenho Humano, UFSC, Florianópolis, SC, Brazil. Programa de Pós-Graduação em Educação Física, Centro de Desportos, UFSC, Florianópolis, SC, Brazil. Bolsista, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). 2 Departamento de Educação Física, Centro de Desportos, UFSC, Florianópolis, SC, Brazil. Núcleo de Pesquisa em Cineantropometria e Desempenho Humano, UFSC, Florianópolis, SC, Brazil. Programa de Pós-Graduação em Educação Física, Centro de Desportos, UFSC, Florianópolis, SC, Brazil.

1

Financial support: none.

Submitted Jan 12 2012, accepted for publication Sep 18 2012. No conflicts of interest declared concerning the publication of this article.

Suggested citation: Ferrari EP, Petroski EL, Silva DA. Prevalence of body image dissatisfaction and associated factors among physical education students. Trends Psychiatry Psychother. 2013;35(2):119-27.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 119-127

Body image dissatisfaction in physical education students – Ferrari et al.

Introduction Factors such as urbanization, economic growth, and recent technological and cultural changes have motivated an increased intake of saturated fat, with the consequent development of overweight and obesity in the Brazilian population.1 Conversely, the beauty ideals promoted in the mass media point to increasingly slimmer silhouettes and heavily muscled bodies (for females and males, respectively) as the only acceptable or pleasing patterns, provoking body image dissatisfaction in those who are unable to comply with them. This phenomenon has been widely observed and has been referred to as a negative subjective assessment of one’s physical appearance.2 In the transition from adolescence to adult age, a phase frequently observed among university students, new individual and social skills are being acquired, including insertion in a new social environment, imposition of new obligations, and less contact with family members.

Moreover, the vulnerability to predominant social models and representations commonly observed in this stage tends to predispose this population to the development of body image dissatisfaction.3 Both the Brazilian and the international literature have reported prevalence rates of body image dissatisfaction above 50% among university students.4-7 In courses where physical appearance is important, e.g., physical education, high levels of dissatisfaction are even more common, reflecting the interest of these students in body-related issues.8 This finding has provided grounds for concern, as high levels of body image dissatisfaction may lead to the development of eating disorders, low self-esteem, and excessive physical activity, especially among women striving to achieve the slim body ideal imposed by society.9,10 Health-related behaviors, including excessive alcohol use, physical activity, dietary habits, and tobacco use, are important when discussing body image dissatisfaction, as they may be adopted in the search for an ideal body weight.5,11,12 Also, several studies have investigated sociodemographic characteristics, such as sex, age, parental education, marital status, university course, work, living arrangement, study shift, and income.5,6,13,14 Some of those studies failed to find an association between body image and study shift, income, and occupation among university students.5,15 Other studies, in turn, found associations between income and body image, i.e., women with a higher income were shown to present higher levels of body image dissatisfaction.14 Sex has also been associated with body image dissatisfaction, with women showing a desire to become

120 – Trends Psychiatry Psychother. 2013;35(2)

slimmer and men a desire to increase their body outline.6 In this sense, and based on the lack of consensus in the relevant literature, the assessment of factors associated with body image dissatisfaction in this specific population becomes extremely relevant, so that we can achieve a better understanding of the variables associated with this phenomenon among university students, as well as the direction of existing associations.

The objective of the present study was to assess the prevalence of body image dissatisfaction and its association with sociodemographic characteristics (sex, age, parental education, marital status, university course, work, living arrangement, study shift, income), health-related behaviors (physical activity, dietary habits, tobacco use, excessive alcohol intake), and nutritional status in physical education students enrolled in a public university.

Methods This study used data from the database of a research project designed to investigate physical fitness and health among students attending Universidade Federal de Santa Catarina (UFSC), a public university in Florianópolis, southern Brazil. The research protocol was approved by the Research Ethics Committee of the same institution (protocol no. 096/2007).

Population and sample The study population comprised 565 university students (300 males) attending the course of physical education in 2008 at UFSC; 182 were enrolled in the bachelor’s specialty, and 383 in the teaching specialty.

All subjects enrolled in both specialties were invited to participate in the study and were asked to sign an informed consent form prior to their inclusion.

Data collection lasted for 1 week and was conducted online at the sports department’s computer laboratory.

This collection method was chosen in an attempt to reduce the number of errors during instrument application, and also for logistic reasons, as the database was automatically created and updated as instruments were filled, excluding the possibility of typing errors.

The team responsible for data collection remained available to students throughout the session to clarify any doubts that might come up while answering the questionnaire. A total of 236 students attended the data collection sessions, namely, 127 males and 109 females, accounting for 41.8% of the total target population (42.3% of males and 41.1% of females).

Body image dissatisfaction in physical education students – Ferrari et al.

Instruments and procedures Dependent variable Data related to perceived body image were obtained using a scale comprising nine body silhouettes, numbered 1 to 9, representing a continuum from thinness (silhouette 1) to severe obesity (silhouette 9).16 The set of silhouettes was shown to students, and then the following questions were asked: 1) which of these silhouettes best represents your current physical appearance? 2) which of these silhouettes would you like to have? Body image dissatisfaction was assessed based on the difference between the current and ideal silhouettes indicated. Differences equal to zero indicated satisfaction, and differences different from zero, dissatisfaction. Positive differences were considered suggestive of dissatisfaction with excess weight, whereas negative differences indicated dissatisfaction with slimness.

Independent variables The following independent variables were assessed: sociodemographic characteristics (sex, age, parental education, marital status, university course, work, living arrangement, study shift, and income); health-related behaviors (level of physical activity, dietary habits, tobacco use, and excessive intake of alcohol); and nutritional status.

Sociodemographic information was obtained using a self-report questionnaire. Variables were categorized as follows: sex (male and female), age (> 20 and ≤ 20 years), parental (mother and father) education (> 8 and ≤ 8 years of education), marital status (single and married), university course (bachelor and teaching), work (yes and no), living arrangement (living with someone and alone), and study shift (morning and evening).

Income was assessed by asking what the family income was and offering five answer options, as follows: up to one minimum wage, one to three, three to six, six to 10, and over 10 minimum wages (the Brazilian minimum wage in 2008 was R$ 415.00, equivalent to US$ 207.50).

Taking into consideration the distribution previously observed, income categories were dichotomized into up to six minimum wages and over six minimum wages.

With regard to health-related behaviors, the level of physical activity was measured using the International Physical Activity Questionnaire (IPAQ), version 8 (short version, last week).17 In line with the current physical activity recommendation of 150 minutes per week, the present study considered as little active individuals who did not engage in physical activities for a minimum of 150 minutes per week. In our sample, the percentage

of physically inactive university students was 0.4%.

Because of the low-frequency of physical inactivity, data were categorized into quartiles according to the weekly number of minutes spent engaging in physical activity, as follows: quartile 1 (0-600 min/week), quartile 2 (6011,025 min/week), quartile 3 (1,026-1,740 min/week), and quartile 4 (> 1,740 min/week). For statistical analysis purposes, subjects in the first quartile were referred to as the least active, those in the second quartile active intermediate I, in the third, active intermediate II, and in the last quartile, the most active.18 Dietary habits, tobacco use, and excessive intake of alcohol were assessed using specific questions of the nutrition, tobacco, and alcohol and drugs domains, respectively, of the FANTASTIC instrument,19 translated and validated for use in Brazilian young adults.20 Dietary habits were assessed using the statement “I eat a balanced diet.” According to the questionnaire, a balanced diet consists of 5 to 12 daily portions of grains and cereal, 5 to 10 daily portions of fruits and vegetables, 2 to 3 portions of meat or alternatives, and 2 to 4 daily portions of milk and derivatives. Five options of answers were available for this question: almost never, rarely, sometimes, often, and almost always. This variable was also dichotomized into healthy diet, including almost always and often, and unhealthy diet, including almost never, rarely, and sometimes.

Tobacco use was analyzed using the “I smoke cigarettes” statement. This variable was categorized into smoker (those smoking over 10 cigarettes a day and 1-10 cigarettes a day) and non-smokers (those who denied having smoked any cigarette in the last 6 months, last year, and in the last 5 years). Studies have defined smokers as people who report having smoked one or more cigarettes in the last 30 days.21,22 Excessive intake of alcohol was assessed using the statement “My weekly intake of alcohol is...” A dose of alcohol was defined as a can of beer (340 ml), or a glass of wine (142 ml), or a dose of distilled spirit (42 ml). Again, alcohol intake may be classified into five categories, but in this study only two were considered, namely, excessive intake of alcohol (over 20 doses and 13-20 doses) and non-excessive intake of alcohol (1112 doses, 8-10 doses, and up to 7 doses). The literature defines as an excessive intake of alcohol the consumption of ≥ 14 doses/week.23,24 Body mass and height were self-reported. The validity of these measures has been demonstrated in the Brazilian adult population.25 Body mass index (BMI) was stratified using the cutoff points established by the World Health Organization (WHO).26 Because of the low frequencies observed for underweight and obesity, BMI

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was divided into two categories, namely, normal weight (underweight and normal weight) and excess weight (overweight and obesity).

Statistical analysis Data were analyzed using descriptive statistics, and results expressed using relative and absolute frequencies. Associations between body image perception and sociodemographic characteristics, health-related behaviors, and nutritional status were assessed using the chi-square test and Fisher’s exact test.

Multinomial logistic regression was used to estimate the association between different independent variables and the dependent variable body image perception, categorized into satisfied with body image (reference category), dissatisfied with excess weight, and dissatisfied with slimness. Odds ratios (OR) and respective 95% confidence intervals (95%CI) were calculated. First, crude analysis was conducted to assess the effect of variables on perceived body image. Subsequently, the analysis was adjusted for all independent variables. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 15.0. Significance was set at 5%.

Results Table 1 shows sample distribution according to perceived body image and independent variables. The prevalence of body image dissatisfaction was 69.5%; in this group, 44.1% were dissatisfied with excess weight, and the remaining 25.4% with slimness. Most of the university students assessed were male (53.8%), aged > 20 years (56.8%), had a family income above six minimum wages (51.7%), reported over 8 years of education for mothers (90.3%) and fathers (87.7%), were single (94.9%), were enrolled in the teaching specialty (52.5%), were not employed (61%), lived with someone (93.2%), studied in the morning (58.1%), ate a healthy diet (81.4%), were non-smokers (85.8%), had normal weight (79.2%), and did not consume excessive amounts of alcohol (93.6%).

Table 2 shows the associations between perceived body image and the independent variables assessed. The results revealed that dissatisfaction with excess weight was more prevalent among women, non-smokers, and those with excess weight. Conversely, male students, those eating an unhealthy diet, smoking, and showing a healthy nutritional status more frequently reported dissatisfaction with slimness.

In the crude multinomial regression analysis, a BMI ≥ 25.0 kg/m² was associated with dissatisfaction with excess weight. In the adjusted analysis, factors

122 – Trends Psychiatry Psychother. 2013;35(2)

Table 1 – Sample distribution according to perceived body image, sociodemographic characteristics, health-related behaviors, and nutritional status

Variable

n %

Body image perception Satisfied 72 Dissatisfied with excess weight 104 Dissatisfied with slimness 60 Sex Female 109 Mal 127 Age > 20 years 134 ≤ 20 years 102 Family income > 6 minimum wages 122 ≤ 6 minimum wages 114 Mother’s education level > 8 years 213 ≤ 8 years 23 Father’s education level > 8 years 207 ≤ 8 years 29 Marital status Married 12 Single 224 Course specialty Bachelor 112 Teaching 124 Work Yes 92 No 144 Living arrangement Lives with someone 220 Lives alone 16 Study shift Morning 99 Evening 137 Physical activity Most active 51 Active intermediate II 60 Active intermediate I 58 Least active 67 Diet Healthy 192 Unhealthy 44 Tobacco use No 226 Yes 10 Nutritional status Normal weight 187 Excess weight 44 Excessive alcohol intake No 221 Yes 15

30.5 44.1 25.4 46.2 53.8 56.8 43.2 51.7 48.3 90.3 9.7 87.7 12.3 5.1 94.9 47.5 52.5 39.0 61.0 93.2 6.8 41.9 58.1 21.5 25.3 24.5 28.3 81.4 18.6 95.8 4.2 79.2 18.6 93.6 6.4

Body image dissatisfaction in physical education students – Ferrari et al.

Table 2 – Prevalence of dissatisfaction with slimness and excess weight according to the independent variables assessed, % (n)

Variable Satisfied

Dissatisfied with excess weight

Dissatisfied with slimness

Sex Female 30.3 (33) 54.1 (59) 15.6 (17) Male 30.7 (39) 35.4 (45) 33.9 (43) Age > 20 years 33.6 (45) 42.5 (57) 23.9 (32) ≤ 20 years 26.5 (27) 46.1 (47) 27.5 (28) Family income > 6 minimum wages 27.0 (33) 43.4 (53) 29.5 (36) ≤ 6 minimum wages 34.2 (39) 44.7 (51) 21.1 (24) Mother’s education level > 8 years 29.6 (63) 45.5 (97) 24.9 (53) ≤ 8 years 39.1 (9) 30.4 (7) 30.4 (7) Father’s education level > 8 years 30.0 (62) 43.5 (90) 26.6 (55) ≤ 8 years 34.5 (10) 48.3 (14) 17.2 (5) Marital status Married 8.3 (1) 75.0 (9) 16.7 (2) Single 31.7 (71) 42.4 (95) 25.9 (58) Course specialty Bachelor 29 (36) 41.9 (52) 29 (36) Teaching 32.1 (36) 46.4 (52) 21.4 (24) Work Yes 33.3 (48) 41.0 (59) 25.7 (37) No 26.1 (24) 48.9 (45) 25 (23) Living arrangement Lives with someone 31.4 (69) 44.5 (98) 24.1 (53) Lives alone 18.8 (3) 37.5 (6) 43.8 (7) Study shift Morning 32.3 (32) 46.5 (46) 21.2 (21) Evening 29.2 (40) 42.3 (58) 28.5 (39) Physical activity Most active 27.5 (14) 51.0 (26) 21.6 (11) Active intermediate II 43.3 (26) 38.3 (23) 18.3 (11) Active intermediate I 27.6 (16) 48.3 (28) 24.1 (14) Least active 23.9 (16) 40.3 (27) 35.8 (24) Diet Healthy 33.3 (64) 44.3 (85) 22.4 (43) Unhealthy 18.2 (8) 43.2 (19) 38.6 (17) Tobacco use No 31.4 (71) 44.7 (101) 23.9 (54) Yes 10 (1) 30 (3) 60 (6) Nutritional status Normal weight 34.2 (64) 35.8 (67) 29.9 (56) Excess weight 13.6 (6) 84.1 (37) 2.3 (1) Excessive alcohol intake No 30.8 (68) 43 (95) 26.2 (58) Yes 26.7 (4) 60 (9) 13.3 (2)

p 0.002*†

0.493†

0.263†

0.378†

0.556†

0.091‡

0.408†

0.411†

0.228‡

0.450†

0.111†

0.040*†

0.045*‡

< 0.001*†

0.458‡

* p < 0.05. † Chi-square test. ‡ Fisher’s exact test.

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Body image dissatisfaction in physical education students – Ferrari et al.

Table 3 – Odds ratio and confidence intervals of crude and adjusted multinomial logistic regression analysis of body image perception (reference category = satisfied with body image), OR (95%CI)

Variable

Dissatisfied with excess weight Crude analysis Adjusted analysis*

Dissatisfied with slimness Crude analysis Adjusted analysis*

Sex Female 1 1 1 1 Male 0.64 (0.35-1.18) 0.32 (0.15-0.69) 2.14 (1.03-4.43) 2.73 (1.16-6.45) Age > 20 years 1 1 1 1 ≤ 20 years 1.37 (0.74-2.54) 1.42 (0.67-3.03) 1.46 (0.73-2.93) 1.69 (0.71-4.05) Family income > 6 minimum wages 1 1 1 1 ≤ 6 minimum wages 0.81 (0.45-1.49) 1.32 (0.64-2.75) 0.56 (0.28-1.13) 0.50 (0.22-1.15) Mother’s education level > 8 years 1 1 1 1 ≤ 8 years 0.50 (0.18-1.42) 0.44 (0.11-1.72) 0.92 (0.32-2.65) 1.69 (0.45-6.37) Father’s education level > 8 years 1 1 1 1 ≤ 8 years 0.96 (0.40-2.31) 1.02 (0.33-3.22) 0.56 (0.18-1.75) 0.67 (0.16-2.85) Marital status

Married 1 1 1 1 Single 0.15 (0.02-1.2) 0.13 (0.13-1.24) 0.41 (0.04-4.62) 0.16 (0.01-2.13) Course specialty

Bachelor 1 1 1 1 Teaching 1 (0.55-1.82) 1.66 (0.38-7.27) 0.67 (0.33-1.33) 0.70 (0.14-3.44) Work

Yes 1 1 1 1 No 1.52 (0.82-2.85) 1.77 (0.83-3.75) 1.24 (0.61-2.54) 1.23 (0.53-2.86) Living arrangement Lives with someone 1 1 1 1 Lives alone 1.41 (0.34-5.82) 1.52 (0.31-7.33) 3.04 (0.75-12.31) 2.79 (0.59-13.13) Study shift

Morning 1 1 1 1 Evening 1.01 (0.55-1.84) 1.82 (0.40-8.27) 1.49 (0.73 - 3.00) 1.17 (0.23-6.09) Physical activity

Most active 1 1 1 1 Active intermediate II 1.85 (0.93-3.68) 0.61 (0.23-1.63) 0.54 (0.19-1.55) 0.59 (0.18-1.94) Active intermediate I 0.94 (0.38-2.30) 1.29 (0.46-3.62) 1.11 (0.38-3.24) 1.53 (0.44-5.31) Least active 0.91 (0.37-2.23) 0.88 (0.31-2.49) 1.91 (0.69-5.25) 2.16 (0.66-7.00) Diet Healthy 1 1 1 1 Unhealthy 1.79 (0.74-4.34) 1.37 (0.49-3.86) 3.16 (1.25-7.98) 2.56 (0.90-7.27) Tobacco use No 1 1 1 1 Yes 2.11 (0.21-20.69) 3.80 (0.34-41.95) 7.89 (0.92-67.48) 3.80 (0.34-41.90) Nutritional status Normal weight 1 1 1 1 Excess weight 5.89 (2.33-14.9) 11.80 (3.99-34.88) 0.19 (0.02-1.63) 0.101 (0.01-1.00) Excessive alcohol intake

No 1 1 1 1 Yes 1.61 (0.48-5.44) 2.19 (0.54-8.80) 0.59 (0.10-3.32) 2.19 (0.55-8.80) 95%CI = 95% confidence interval; OR = odds ratio.

Values in bold are significant (p < 0.05). * Adjusted for all independent variables.

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Body image dissatisfaction in physical education students – Ferrari et al.

associated with dissatisfaction were a BMI ≥ 25.0 kg/ m² (OR = 11.80; 95%CI 3.99-34.88) and being male (OR = 0.32; 95%CI 0.15-0.69). Male sex showed an inverse association with dissatisfaction with excess weight, suggesting that females were more frequently dissatisfied with excess weight (Table 3).

In the crude analysis of dissatisfaction with slimness (Table 3), the following factors were associated with the outcome: male sex, engaging in physical activity for < 739.61 min/week, eating an unhealthy diet, and smoking. In the adjusted analysis, male sex (OR = 2.73; 95%CI 1.16-6.45) and engaging in physical activity for < 739.61 min/week (OR = 2.39; 95%CI 1.01-5.68) remained associated with dissatisfaction with slimness.

Also, excess weight (OR = 0.10; 95%CI 0.01-1.01) showed an inverse association with dissatisfaction with slimness, suggesting that subjects with normal weight were more frequently dissatisfied with slimness.

Discussion The main findings of the present study were a higher frequency of body image dissatisfaction with excess weight among females and students with a BMI ≥ 25.0 kg/m², as well as a higher degree of dissatisfaction with slimness among male students, smokers, and students eating an unhealthy diet.

With regard to body image dissatisfaction, the prevalence observed in our sample (69.5%) is in line with data reported for physical education students attending Universidade Estadual de Ponta Grossa, state of Paraná, among whom 61.2% were dissatisfied.5 Another study assessing students enrolled in several courses at UFSC found a prevalence of 77.6% of body image dissatisfaction.6 These results suggest that, regardless of the field of study, university students present high prevalence rates of body image dissatisfaction, providing grounds for concern with regard to the consistent association between this phenomenon and the development of eating disorders, depression, low selfesteem, and a negative quality of life perception.27 Regarding the association between perceived body image and BMI, our study identified that overweight/ obesity was associated with the desire to reduce the silhouette. This finding corroborates previous studies6,10,28 and shows that the ideal body image among university students reflects the same slim and muscled patterns (for females and males, respectively) currently praised in sociocultural contexts, where fat or a higher body weight are seen as a stigma of ugliness, causing individuals with a higher BMI to feel uncomfortable and concerned with their body image. This finding is especially important if

we take into consideration that BMI has been shown to strongly influence the adoption of abnormal behaviors, anorexia, bulimia, and vigorexia: even after adjustment for socioeconomic and demographic variables, the risk of developing such behaviors was two-fold higher in subjects with a BMI ≥ 25.0 kg/m².29 When analyzing the association between perceived body image and sex, evidence suggests that, whereas men tend to show dissatisfaction with slimness, women tend to report dissatisfaction with excess weight.5,6 In our study, being male was associated with a higher likelihood of showing dissatisfaction with slimness. Conversely, being female was associated with a higher chance of dissatisfaction with excess weight. These results reflect differences instilled in body image patterns praised in the mass media for males and females. In this sense, reflexive actions should be implemented in the university setting to discuss strategies aimed at improving body image self-acceptance; the literature has pointed to the effectiveness of different types of interventions in reducing the levels of body image dissatisfaction, e.g., strategies aimed at reducing cognitive dissonance30 and minimizing the effects of body images praised in the internet and mass media.31 In our sample, no association was observed between the level of physical activity and perceived body image.

A previous study involving physical education students from Universidade Estadual de Ponta Grossa also failed to find this association.5 Conversely, another study assessing young adults from the U.S. via telephone calls observed that individuals not satisfied with their weight showed lower levels of physical activity when compared with satisfied ones.13 This lack of consensus may be explained by methodological differences across the studies. For example, in the former study,5 a silhouette scale was used, whereas in the latter,12 body image dissatisfaction was assessed using the question “How do you feel in relation to your body weight at this moment?”

Despite the controversial results available, a possible explanation for the absence of association between body image dissatisfaction and physical activity levels in our sample could be the fact that being physically active or inactive did not influence perceived body image in the students here analyzed, suggesting a stronger effect of other factors on the outcome of interest.

The adoption of health-related behaviors such as eating an unhealthy diet or smoking has been associated with body image dissatisfaction. Some studies have indicated that dissatisfied individuals tend to start smoking and eating an unhealthy/restrictive diet as a means to obtain a slimmer or more muscled body.11,12 In the present study, the crude effect of these two variables (diet and tobacco use) on perceived body image was not confirmed in the adjusted

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analysis, suggesting a role of other variables, e.g. level of physical activity and nutritional status, in the association between dietary habits and tobacco use and body image dissatisfaction. Moreover, the lack of association between excessive alcohol intake and perceived body image in our students may also be explained by the presence of other variables in the analysis.

Sociodemographic variables (age, parental education, marital status, university course, work, living arrangement, study shift, and income) were not associated with body image perception. These results are in line with previous studies that also failed to identify associations between perceived body image and age, study shift, occupation, and income.5,15 Conversely, they differ from other studies that have reported associations with age and income.14 Further studies are warranted to continue investigating this topic so as to identify the direction of associations between body image perception and different sociodemographic variables.

Some limitations deserve to be discussed. First and foremost, the cross-sectional design of the study prevents us from establishing a causal relationship between the variables. Second, the use of a silhouette scale to assess body image is limited by the two-dimensional nature of the images, which therefore do not represent the individual as a whole and do not reflect the distribution of subcutaneous fat and other anthropometric aspects implicated in the concept of body image.

Notwithstanding, previous studies have suggested strong correlations between BMI and perceived body image.4 Third, the instrument used to assess dietary habits did not allow to identify whether diet inadequacy was characterized by excessive intake (beyond the recommended daily portions), or deficient intake (below the recommended portions).

Conversely, a strength of the study is that our findings can be used to alert physical education professionals with regard to the need to implement interventions

126 – Trends Psychiatry Psychother. 2013;35(2)

based on the ideals praised in the media, which usually contribute to increase body image dissatisfaction and to the adoption of unhealthy, even noxious, habits.

Another strength was the use of an online questionnaire, which allowed the automatic creation and update of the database, as questions were answered, and eliminated typing errors.

Conclusion The prevalence of body image dissatisfaction among the university students assessed was high. Dissatisfaction with excess weight was associated with female sex and a BMI ≥ 25.0 kg/m². Being male, eating an unhealthy diet, and smoking were the variables associated with dissatisfaction with slimness.

Our results underscore the need to implement interventions aimed at increasing self-acceptance and self-awareness in the academic setting through the adoption of healthy behaviors, such as regular physical activity and a balanced diet. These interventions could, in turn, help improve body image satisfaction, reduce BMI in people above normal weight, and motivate a more reflexive attitude towards body image ideals praised in society, especially in terms of their association with healthy vs. unhealthy habits. We strongly believe that this type of strategy could promote the adoption of healthier habits and thus improve daily living.

Future studies should analyze the influence of healthrelated behaviors (physical activity, dietary habits, and tobacco use) on perceived body image among university students, in order to confirm the findings here reported and further improve our knowledge on the topic. Such studies could also help decrease the rates of body image dissatisfaction and the adoption of noxious habits resulting from difficulties self-accepting one’s own body image.

Body image dissatisfaction in physical education students – Ferrari et al.

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3. França CB, Colares VA. Estudo comparativo de condutas de saúde entre universitários no início e no final do curso. Rev Saude Publica. 2008;42:420-7.

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Coqueiro RS, Petroski EL, Pelegrini A, Barbosa AR. Insatisfação com a imagem corporal: avaliação comparativa da associação com estado nutricional em universitários. Rev Psiquiatr Rio Gd Sul. 2008;30:31-8.

5. Rech CR, Araújo EDS, Vanat JR. Autopercepção da imagem corporal em estudantes do curso de educação física. Rev Bras Educ Fis Esporte. 2010;24:285-92.

6. Quadros TMB, Gordia AP, Martins CR, Silva DAS, Ferrari EP, Petroski EL. Imagem corporal em universitários: associação com estado nutricional e sexo. Motriz Rev Educ Fis. 2010;16:78-85.

7. Grossbard JR, Lee CM, Neighbors C, Larimer ME. Body image concerns and contingent self-esteem in male and female college students. Sex Roles. 2008;60:198-207.

8. O’Brien KS, Hunter JA. Body esteem and eating behaviors in female physical education students. Eat Weight Disord.

2006;11:57-60.

9. Almeida GA, Santos JE, Paisan SR, Loureira SR. Percepção de tamanho e forma corporal de mulheres: um estudo exploratório. Psicol Estud. 2005;10:27-35.

10. Kakeshita IS, Almeida SS. Relação entre índice de massa corporal e a percepção da auto-imagem em universitários.

Rev Saude Publica. 2006;40:497-504.

11. Clark MM, Croghan IT, Reading S, Schoroeder DR, Stoner SM, Patten CA, et al. The relationship of body image dissatisfaction to cigarette smoking in college students. Body Image. 2005;2:263-70.

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Jaworowska A, Bazylak G. An outbreak of body weight dissatisfaction associated with self-perceived BMI and dieting among female pharmacy students. Biomed Pharmacother.

2009;63:679-92.

13. Kruger J, Chong-Do L, Ainsworth BE, Macera CA. Body size satisfaction and physical activity levels among men and women. Obesity. 2008;16:1976-9.

14. Wardle J, Griffith J. Socioeconomic status and weight control practices in British adults. J Epidemiol Community Health.

2001;55:185-90.

15. Costa LCF, Vasconcelos FAG. Influência de fatores socioeconômicos, comportamentais e nutricionais na insatisfação com a imagem corporal de universitárias em Florianópolis, SC. Rev Bras Epidemiol. 2010;13:665-76.

16. Stunkard A, Sorensen T, Schulsinger F. Use of the Danish Adoption Register for the study of obesity and thinness. In: Kety SS, Rowland LP, Sidman RL, Matthysse SW, editors. The genetics of neurological and psychiatric disorders. New York: Raven Press; 1983. p. 115-20.

17. Matsudo S, Araujo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, et al. Questionário Internacional de Atividade Física (IPAQ): estudo de validade e reprodutibilidade no Brasil. Rev Bras Ativ Fis Saude. 2001;6:5-18.

18.

IPAQ Executive Committee. The International Physical Activity Questionnaire: summary report of the reliability and validity studies. http://www.ipaq.ki.se/questionnaires/ IPAQSummaryReport03-01.pdf. Accessed 2012 Sep 18.

19.

Wilson DMC, Nielsen E, Ciliska D. Lifestyle assessment: testing the FANTASTIC instrument. Can Fam Physician.

1984;30:1863-6.

20. Rodriguez-Añez CR, Reis RS, Petroski EL. Brazilian version of a lifestyle questionnaire: translation and validation for young adults. Arq Bras Cardiol. 2008;91:92-8.

21. Halty LS, Hunntnner MD, Oliveira-Netto I, Fenker T, Paqualini T, Lempek B, et al. Pesquisa sobre tabagismo entre médicos de Rio Grande, RS: prevalência e perfil do fumante. J Pneumol. 2002;28:77-83.

22. Malcon MC, Menezes AM, Chatkin M. Prevalência e fatores de risco para tabagismo em adolescentes. Rev Saude Publica.

2003;37:1-7.

23. Souza DPO, Areco KN, Silveira Filho DX. Álcool e alcoolismo entre adolescentes da rede estadual de ensino de Cuiabá, Mato Grosso. Rev Saude Publica. 2005;39:585-92.

24. Vieira DL, Ribeiro MR, Laranjeira RR. Álcool e adolescentes: estudo para implementar políticas municipais. Rev Saude Publica. 2007;41:396-403.

25. Coqueiro RS, Borges LJ, Araújo VC, Pelegrini A, Rodrigues AB. Medidas auto-referidas são válidas para avaliação do estado nutricional na população brasileira? Rev Bras Cineantropom Desempenho Hum. 2009;11:113-9.

26. World Health Organization (WHO). Obesity: preventing and managing the global epidemic. Geneva: WHO; 1998. p. 276.

27.

Gucciardi E, Celasun N, Ahmad F, Stewart DE. Eating disorders. Womens Health. 2004;4(suppl 1):1-6.

28. Bosi ML, Uchimura KY, Luiz RR. Eating behavior and body image among psychology students. J Bras Psiquiatr.

2008;58:150-5.

29. Nunes MA, Olinto MTA, Barros FC, Camey S. Influência da percepção do peso e do índice de massa corporal nos comportamentos alimentares anormais. Rev Bras Psiquiatr.

2001;23:21-7.

30.

Stice E, Mazotti L, Weibel D, Agras WS. Dissonance prevention program decreases thin-ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptoms: a preliminary experiment. Int J Eat Disord.

2000;27:206-17.

31. Zabinski MF, Pung MA, Wilfley DE, Eppstein D, Winzelberg AJ, Celio A, et al. Reducing risk factors for eating disorders: targeting at-risk women with a computerized psychoeducational program. Int J Eat Disord. 2001;29:401-8.

Correspondence Elisa Pinheiro Ferrari Universidade Federal de Santa Catarina - Centros de Desportos Núcleo de Cineantropometria e Desempeno Humano - UFSC/ CDS/NuCIDH Campus Universitário, Trindade, Caixa Postal 476 88040-900 - Florianópolis, SC - Brazil E-mail: elisaferrari_@hotmail.com

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Trends

Original Article

in Psychiatry and Psychotherapy

Epidemiological profile of suicide in the Santa Catarina Coal Mining Region from 1980 to 2007 Perfil epidemiológico do suicídio na Região Carbonífera Catarinense de 1980 a 2007 Carolina H. Portella,1 Gustavo P. Moretti,1 Ana P. Panatto,1 Maria I. Rosa,1 João Quevedo,2 Priscyla W. T. A. Simões1

Abstract

Resumo

Background: Suicide is a public health problem worldwide. Estimates have indicated that over 1 million people commit suicide every year all over the world. Brazil has a moderate suicide death rate (4.1 per 100,000 inhabitants), but the fact that it is a large country leads to the coexistence of diverse characteristics and levels of development across the different Brazilian regions. In this sense, the South region has been shown to present suicide rates above the national average.

Objective: To estimate the profile of suicide in municipalities comprising the Santa Catarina Coal Mining Region from 1980 to 2007.

Methods: This ecological, time-series, descriptive study sought to characterize epidemiological aspects related to suicide method, marital status, sex, age, and occupation in the municipalities of the region in the years 1980 to 2007.

Results: A total of 474 suicides occurred in the period, yielding a mean death rate of 10.83 per 100,000 inhabitants. There was a predominance of males, at a 5:1 ratio, and a peak rate in the 5564-year age group (11.31 per 100,000 inhabitants). The suicide method most commonly used was hanging (72%) and the most frequent occupation was hard labor work (11.60 %); in relation to marital status, married subjects (48%) were the ones with the highest rates of suicide.

Conclusions: The Santa Catarina Coal Mining Region has suicide mortality rates above the national average. This study highlights specific characteristics of suicide in the region and may contribute to the development of preventive measures.

Keywords: Suicide, epidemiology, southern Brazil.

Introdução: O suicídio é um problema mundial de saúde pública. Estimativas apontam que, anualmente, mais de 1 milhão de pessoas cometem suicídio em todo o mundo. O Brasil possui um coeficiente mediano de suicídio (4,1 por 100 mil habitantes), porém o fato de ser um país de grandes dimensões faz com que características e níveis de desenvolvimento variem grandemente em diferentes regiões. Nesse aspecto, o sul do país se destaca por possuir índices acima da média nacional.

Objetivos: Estimar o perfil do suicídio nos municípios da Região Carbonífera Catarinense no período de 1980 a 2007.

Metodologia: Estudo ecológico, temporal, descritivo, que buscou caracterizar os aspectos epidemiológicos em relação aos meios empregados para cometer suicídio, estado civil, gênero, faixa etária e ocupação nos municípios da região nos anos de 1980 a 2007.

Resultados: Ocorreram 474 suicídios no período, o que gerou um coeficiente médio de 10,83 por 100.000 habitantes. Houve predomínio masculino, na proporção de 5:1, e pico na faixa etária entre 55 e 64 anos (11,31 por 100.000 habitantes). O meio mais utilizado foi o enforcamento (72%), e a ocupação mais frequente foi a dos trabalhadores braçais (11, 60%); em relação ao estado civil, os casados foram os que mais cometeram suicídio (48%).

Conclusão: A Região Carbonífera Catarinense apresenta coeficientes de mortalidade por suicídio acima da média nacional.

O presente estudo destaca características próprias do suicídio na região, podendo contribuir para o desenvolvimento de ações preventivas.

Descritores: Suicídio, epidemiologia, sul do Brasil.

Laboratório de Epidemiologia, Programa de Pós-Graduação em Ciências da Saúde, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil. National Science and Technology Institute for Translational Medicine (INCT-TM). 2 Laboratório de Neurociências, Programa de PósGraduação em Ciências da Saúde, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, SC, Brazil. INCT-TM. 1

This paper is based on the first author’s final monograph, presented at the School of Medicine of Universidade do Extremo Sul Catarinense in the first semester of 2010. An abstract of the manuscript has been presented at a science internship conference held at the same university in the second semester of 2010.

Financial support: none.

Submitted Mar 07 2012, accepted for publication Sep 26 2012. No conflicts of interest declared concerning the publication of this article.

Suggested citation: Portella CH, Moretti GP, Panatto AP, Rosa MI, Quevedo J, Simões PW. Epidemiological profile of suicide in the Santa Catarina Coal Mining Region from 1980 to 2007. Trends Psychiatry Psychother. 2012;35(2):128-33.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 128-133

Suicide in the Santa Catarina Coal Mining Region – Portella et al.

Introduction Early statistical data on suicide date back to the 19th century, published by French sociologist Emile Durkheim.1 The mortality rate for suicide in Brazil has been estimated at 4.1 per 100,000 inhabitants for the general population, ranging from about 1.8 among females to 6.6 among males.2 These rates are among the lowest ones reported worldwide, especially when compared with European countries, where suicide rates reach over 40 deaths per 100,000 inhabitants.3 Between 1980 and 2006, a 29.5% increase was observed in the number of suicides in Brazil.4 Higher mean rates have been observed in the South (9.3 per 100,000 inhabitants) and Central West regions (6.1 per 100,000 inhabitants). The southern municipalities of Porto Alegre (7.3 per 100,000 inhabitants) and Florianópolis (6.5 per 100,000 inhabitants) ranked second and third, respectively, among all state capitals.4 The term suicide derives from the Latin expression sui caedere, which means to kill oneself, and was first used in 1717 by Desfontaines. Sometimes referred to as voluntary death, intentional death, or self-inflicted death, suicide means a deliberate, intended act committed by an individual and resulting in his/her own death.5 For Durkheim, suicide is applied to all cases of death resulting directly or indirectly from a positive or negative act of the victim him/herself, which he knows will produce this result.1 Suicide is a public health problem, with underestimated effects due to the limited number of studies assessing Brazilian and international statistic data on suicide rates.

Estimates from the World Health Organization (WHO) have shown that over 1 million people commit suicide every year worldwide, making this phenomenon rank third among main causes of death in people aged 15 to 44 years.6 According to the literature, in most countries there is a predominance of males among people who commit suicide, at a mean male to female ratio of 3:1, even though this ratio may change in different countries.7 Conversely, women are four times more common among suicide attempters than men. These results may be explained by the fact that men use more aggressive and potentially lethal methods in their suicide attempts (e.g., firearms and hanging) when compared with women.7 China is the only country where suicide rates among women are higher than among men, in rural areas; in urban areas, rates are approximately the same. These differences are believed to be associated with socially determined behaviors.8,9 Suicide is among the five main causes of death in the 15-19-year age group worldwide, especially among males.

Moreover, an increased risk for suicide has been reported

for elderly people (aged over 65 years) and young adults (15 to 30 years). Recent data have suggested an increase in suicide rates among middle-aged men.10 The objective of the present study was to estimate the epidemiological profile of suicide in the municipalities comprising the Santa Catarina Coal Mining Region between 1980 and 2007, with emphasis on suicide method, marital status, sex, age group, and occupation.

Methods This ecological, time-series, descriptive study was approved by the Research Ethics Committee of Universidade do Extremo Sul Catarinense (protocol no.

175/2009). The following variables were assessed: suicide method, marital status, sex, age group, and occupation.

The study population comprised all cases of suicide occurring in the municipalities of the Santa Catarina Coal Mining Region. This region was chosen for being know to present high rates of mortality for suicide and because of its favorable location.

The Santa Catarina Coal Mining Region is a microregion located in the southeast area of the state of Santa Catarina. According to the Brazilian Institute of Geography and Statistics (IBGE), this region has a population of 384,577 inhabitants and comprises the municipalities of Cocal do Sul, Criciúma, Forquilhinha, Içara, Lauro Muller, Morro da Fumaça, Nova Veneza, Orleans, Siderópolis, Treviso, and Urussanga. The region’s economy has been based on the extraction of coal over the past few decades, which explains the name given to the microregion. In the 1960s and 1970s, the region experienced industrial diversification and started to manufacture ceramics, clothing, food, shoes, construction, plastic, and metal-mechanic products. At present, the main activities in the region are clothing, plastic, ceramic, and metal mechanic industries.11 Time-series analyses were conducted for the period ranging from 1980 to 2007, for which death data were available at the Brazilian Mortality Information System (Sistema de Informações sobre Mortalidade, SIM) and at IBGE, both through the Information Technology Department of the Brazilian Unified Health System (DATASUS; www.datasus.gov.br).

Age was stratified according to age groups defined by the WHO, namely, 5-14, 15-24, 25-34, 35-44, 4554, 55-64, and 65-74 years. Occupation was categorized according to the Brazilian Classification of Occupations (Classificação Brasileira de Ocupações, CBO-2002), also used at SIM.12 In an attempt to standardize occupation categories, farming workers and hard labor workers were grouped in the same category, as were housewives/

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househusbands and other domestic workers, and cases in which occupation was not informed or ignored.

Crude death rate was calculated by dividing the number of deaths by the population living in the area in the same period and multiplying it by 100,000. Proportional and standardized ratios were calculated according to sex, age group, suicide method, and municipality with data available on both SIM and IBGE. For occupation and marital status, population data were lacking, and therefore only the proportional ratio was calculated.

Data related to each of the variables above were searched on the DATASUS and/or IBGE databases. The number of suicide cases occurring from 1980 to 1995 was calculated using the Ninth Revision of the International Classification of Diseases (ICD-9),13 which includes the following categories: – E950 – Suicide and self-inflicted poisoning by solid or liquid substances; – E951 – Suicide and self-inflicted poisoning by gases in domestic use; – E952 – Suicide and self-inflicted poisoning by other gases and vapors; – E953 – Suicide and self-inflicted injury by hanging, strangulation, and suffocation; – E954 – Suicide and self-inflicted injury by submersion (drowning); – E955 – Suicide and self-inflicted injury by firearms, air guns, and explosives; – E956 – Suicide and self-inflicted injury by cutting and piercing instrument; – E957 – Suicide and self-inflicted injuries by jumping from high place; – E958 – Suicide and self-inflicted injury by other and unspecified means; – E959 – Late effects of self-inflicted injury.

For the subsequent period, from 1996 to 2007, the Tenth Revision of the ICD (ICD-10)14 was used, including categories X60 to X84, which cover intentional self-inflicted harm, and Y87.0, which accounts for sequelae of selfinflicted harm. Categories X60 to X84 are described below: – X60 – Intentional self-poisoning by and exposure to nonopioid analgesics, antipyretics, and antirheumatics; – X61 – Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism, and psychotropic drugs not elsewhere classified; – X62 – Intentional self-poisoning by and exposure to narcotics and psychodysleptics (hallucinogens) not elsewhere classified; – X63 – Intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system; – X64 – Intentional self-poisoning by and exposure to other and unspecified drugs, medicaments, and biological substances;

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– X65 – Intentional self-poisoning by and exposure to alcohol; – X66 – Intentional self-poisoning by and exposure to organic solvents and halogenated hydrocarbons and their vapors; – X67 – Intentional self-poisoning by and exposure to other gases and vapors; – X68 – Intentional self-poisoning by and exposure to pesticides; – X69 – Intentional self-poisoning by and exposure to other and unspecified chemicals and noxious substances; – X70 – Intentional self-harm by hanging, strangulation, and suffocation; – X71 – Intentional self-harm by drowning and submersion; – X72 – Intentional self-harm by handgun discharge; – X73 – Intentional self-harm by rifle, shotgun, and larger firearm discharge; – X74 – Intentional self-harm by other and unspecified firearm discharge; – X75 – Intentional self-harm by explosive material; – X76 – Intentional self-harm by smoke, fire, and flames; – X77 – Intentional self-harm by steam, hot vapors, and hot objects; – X78 – Intentional self-harm by sharp object; – X79 – Intentional self-harm by blunt object; – X80 – Intentional self-harm by jumping from a high place; – X81 – Intentional self-harm by jumping or lying before moving object; – X82 – Intentional self-harm by crashing of motor vehicle; – X83 – Intentional self-harm by other specified means; – X84 – Intentional self-harm by unspecified means.

Because of the differences between the two ICD versions, similar forms of self-harm were grouped together. For example, hanging included categories E953 from ICD-9 and X70 from ICD-10, firearm included categories E955 and X72-75, etc.

Data were accessed and analyzed using Tabnet and Tabwin software version 3.6. Descriptive analysis was conducted using Excel® version 2007.

Results From 1980 to 2007, a total of 474 suicide deaths occurred in the municipalities of the Santa Catarina Coal Mining Region. The mean crude death rate over the period assessed was 10.83 per 100,000 inhabitants (Table 1).

Forquilhinha showed the lowest (6.17 per 100,000 inhabitants) and Nova Veneza the highest (15.37 per

Suicide in the Santa Catarina Coal Mining Region – Portella et al.

100,000 inhabitants) suicide rates over the period assessed. Of the 28 years analyzed, 2007 showed the peak rate (31.35 per 100,000 in habitants); the lowest rate was found in 1985 (1.02 per 100,000 inhabitants).

Mean suicide death rate among males increased from 6.4 in 1980 to 13.6 per 100,000 inhabitants in 2007, adding it up to a 112.5% increase; among females, mean death rate increased from 1.8 to 2.1 per 100,000 inhabitants in the same years, at an increase of 11.66%. Comparison of the rates observed for the two sexes suggests a male to female ratio of 4:1 in 1980 and of 6:1 in 2007.

With regard to age group, a progressive increase was observed in the mean number of death rates in the first younger age groups. The highest mean rate was found in the 55-64-year age group, namely, 13.9 per 100,000 inhabitants. When analyzed according to age group and sex, the same age group was the one with the highest mean death rate among males, at 11.31 per 100,000 inhabitants. Among females, in turn, the highest rate was observed in the 65-74-year age group, namely, 2.55 per Table 1 – Mean mortality rates for suicide in the municipalities of the Santa Catarina Coal Mining Region between 1980 and 2007

Rate per 100,000 No. of Municipality inhabitants deaths Cocal do Sul Criciúma Forquilhinha Içara Lauro Muller Morro da Fumaça Nova Veneza Orleans Siderópolis Treviso Urussanga Total

6.84 13 10.53 224 6.17 15 7.52 47 12.57 24 14.14 24 15.37 24 13.42 38 9.27 17 8.27 4 15.01 44 10.83 474

100,000 inhabitants (Table 2). A 20-fold increase was observed from 1980-1988 to 1999-2007 in the rate of suicide deaths in males aged 15 to 24 years, increasing from 0.32 to 6.89, respectively (Table 2).

Analysis of the methods used to commit suicide showed that hanging was most commonly used, in 72% of the cases (category E953 on ICD-9 and X70 on ICD10). When men and women were analyzed independently, this was also the most frequent suicide method, accounting for 76 and 57% of deaths, respectively. The use of firearms ranked second, corresponding to 15% among males and 25% among females, followed by selfpoisoning in 5.5% of males and 9.3% of females.

Hard labor workers comprised the occupation group that most frequently committed suicide (11.6%), followed by housewives/househusbands (10.5%), who showed virtually the same rate as those for whom occupation was not informed (11.2%).

With regard to marital status, married individuals were the ones who most frequently committed suicide (48%), followed by single (35%) and widowed subjects (6.5%). A moderate positive correlation was observed among single subjects (r = 0.665), married (r = 0.448), and divorced ones (r = 0.551), suggesting an increase in the rate of suicides with time (p < 0.001). Proportional ratios for all the variables analyzed in the study are presented in Table 3.

Discussion The highest mean mortality rates for suicide were found among subjects aged 55 to 64 years (13.9 per 100,000 inhabitants). Notwithstanding, in absolute numbers, suicide was more prevalent in the 35-44-year

Table 2 – Mortality rates for suicide according to age group and sex

Sex/age group (years)

1980-1988 No. deaths* Rate

1989-1998 No. deaths* Rate

1999-2007 No. deaths* Rate

Male 5-14 0 0.00 2 0.33 1 0.17 15-24 16 0.32 26 5.05 38 6.89 25-34 13 3.27 37 7.00 35 7.39 35-44 11 4.42 32 8.73 40 8.79 45-54 10 6.42 13 6.30 27 9.16 55-64 6 7.15 24 18.14 18 11.10 65-74 1 2.13 9 12.54 8 8.26 Female 5-14 0 0.00 4 0.65 0 0.00 15-24 3 0.61 2 0.38 4 0.71 25-34 6 1.49 7 1.35 8 1.72 35-44 4 1.99 10 2.41 17 3.66 45-54 4 2.64 5 2.30 3 1.04 55-64 3 3.26 4 2.93 3 1.93 65-74 1 1.65 2 2.60 4 4.14 * Number of deaths per 100,000 inhabitants, standardized for sex and population in the period.

Trends Psychiatry Psychother. 2013;35(2) – 131

Suicide in the Santa Catarina Coal Mining Region – Portella et al.

Table 3 – Suicide profile in the population assessed

Year, n (%) Variable 1980-83 1984-87 1988-91 1992-95 1996-99 2000-03 2004-07 Municipality Cocal do Sul 0 (0.00) 0 (0.00) 0 (0.00) 1 (0.21) 6 (1.26) 3 (0.63) 3 (0.63) Criciúma 16 (3.37) 21 (4.43) 36 (7.59) 26 (5.48) 38 (8.01) 40 (8.43) 47 (9.91) Forquilhinha 0 (0.00) 0 (0.00) 3 (0.63) 2 (0.42) 3 (0.63) 2 (0.42) 5 (1.05) Içara 1 (0.21) 2 (0.42) 7 (1.47) 8 (1.68) 8 (1.68) 11 (2.32) 10 (2.10) Lauro Muller 1 (0.21) 0 (0.00) 5 (1.05) 2 (0.42) 3 (0.63) 8 (1.68) 5 (1.05) Morro da Fumaça 7 (1.47) 2 (0.42) 4 (0.84) 2 (0.42) 0 (0.00) 5 (1.05) 4 (0.84) Nova Veneza 0 (0.00) 2 (0.42) 5 (1.05) 3 (0.63) 4 (0.84) 6 (1.26) 4 (0.84) Orleans 2 (0.42) 2 (0.42) 7 (1.47) 5 (1.05) 6 (1.26) 5 (1.05) 11 (2.32) Siderópolis 1 (0.21) 1 (0.21) 2 (0.42) 5 (1.05) 1 (0.21) 2 (0.42) 5 (1.05) Treviso 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) 2 (0.42) 2 (0.42) Urussanga 1 (0.21) 9 (1.89) 6 (1.26) 10 (2.10) 7 (1.47) 4 (0.84) 7 (1.47) Age group (years) 5-14 0 (0.00) 0 (0.00) 2 (0.42) 3 (0.63) 2 (0.42) 0 (0.00) 0 (0.00) 15-24 7 (1.47) 10 (2.10) 11 (2.32) 10 (2.10) 11 (2.32) 17 (3.58) 23 (4.85) 25-34 5 (1.05) 9 (1.89) 22 (4.64) 17 (3.58) 15 (3.16) 16 (3.37) 22 (4.64) 35-44 3 (0.63) 10 (2.10) 17 (3.58) 13 (2.74) 20 (4.21) 26 (5.48) 25 (5.27) 45-54 5 (1.05) 8 (1.68) 6 (1.26) 7 (1.47) 8 (1.68) 15 (3.16) 13 (2.74) 55-64 8 (1.68) 1 (0.21) 10 (2.10) 8 (1.68) 12 (2.53) 8 (1.68) 11 (2.32) 65-74 1 (0.21) 0 (0.00) 5 (1.05) 5 (1.05) 3 (0.63) 3 (0.63) 8 (1.68) Suicide method Hanging 20 (4.21) 27 (5.69) 52 (10.97) 46 (9.70) 56 (11.81) 67 (14.13) 74 (15.61) Firearm 4 (0.84) 7 (1.47) 19 (4.00) 15 (3.16) 13 (2.74) 15 (3.16) 7 (1.47) Self poisoning 0 (0.00) 3 (0.63) 3 (0.63) 2 (0.42) 4 (0.84) 3 (0.63) 15 (3.16) Marital status Single 8 (1.68) 16 (3.37) 24 (5.06) 27 (5.69) 26 (5.48) 30 (6.32) 37 (7.80) Marriage 16 (3.37) 22 (4.64) 39 (8.22) 30 (6.32) 45 (9.49) 40 (8.43) 36 (7.59) Widowed 4 (0.84) 1 (0.21) 7 (1.47) 3 (0.63) 2 (0.42) 6 (1.26) 7 (1.47) Divorced 0 (0.00) 0 (0.00) 2 (0.42) 0 (0.00) 2 (0.42) 3 (0.63) 9 (1.89) Other 0 (0.00) 0 (0.00) 1 (0.21) 1 (0.21) 1 (0.21) 2 (0.42) 3 (0.63) N/A 1 (0.21) 0 (0.00) 2 (0.42) 3 (0.63) 0 (0.00) 6 (1.26) 11 (2.32) Sex Male 23 (4.85) 27 (5.69) 59 (12.44) 52 (10.97) 64 (13.50) 72 (15.18) 82 (17.29) Female 6 (1.26) 12 (2.53) 16 (3.37) 12 (2.53) 12 (2.53) 16 (3.37) 21 (4.43) age group (71 cases). When stratified for sex, the 55-64year age group showed the highest mean rate of deaths among males (11.31 per 100,000 inhabitants), compared with the 65-74-year age group among females (2.55 per 100,000 inhabitants). Different values have been reported by similar studies conducted in other regions of the state of Santa Catarina. One of such studies analyzed suicide in the Metropolitan region of Florianópolis15 from 1991 to 2005 and found the highest absolute number of suicides in the 20-25-year age group (66.2%). Another study, performed in the extreme west of the state16 and focusing on the period from 1980 to 2005, found the highest absolute values in the 20-39-year age group (n = 101), even though mean death rates were progressively higher as age increased.

Despite the divergences found in the state of Santa Catarina, the results here reported for the state’s Coal Mining Region are similar to rates described for most countries, with higher rates among the elderly.17-22 In this specific subpopulation, suicide seems to be associated with psychiatric disorders, especially depression.18 Diminished cognitive ability and physical agility, lack 132 – Trends Psychiatry Psychother. 2013;35(2)

of independence, in addition to conditions that are inherent to the aging process, are important factors contributing to suicide as of the sixth decade of life.17,21 Notwithstanding, this pattern seems to be changing, and a gradual increase in suicide rates seems to be occurring among young adults, especially males, probably as a result of a higher frequency of psychoactive substance abuse, social stressors, and depressive disorders.23,24 Hanging was the method most commonly used to commit suicide (72%), which is similar to the results reported for the west of the state (70%)16 but higher than the Brazilian average (25%).25,26 Also, hard labor workers accounted for 11.60% of suicide cases, followed by housewives/househusbands (10.54%). A previous Brazilian study had already reported high means of suicide among hard labor workers (16.3 per 100,000 inhabitants),27 which may probably be explained by the precarious working conditions and the economic instability faced by these workers.

With regard to marital status, our study revealed that married subjects showed the highest rates of suicide

Suicide in the Santa Catarina Coal Mining Region – Portella et al.

(48.10%), a finding that contrasts with the literature.

In fact, for some authors, being married is a protective factor against suicide, as a result of the affective bonding and responsibility that married implies.28-30 Our study is biased in that no suicide data were available on SIM for females in the year 1982. This flaw may have been the result of an operational problem during data collection or entry into the system, or it could reflect the real absence of female suicides in that year.

Therefore, in our analysis, we considered that there were zero suicides among females in the year 1982. Moreover, in the analysis of marital status and occupation, only the proportional ratio could be calculated, as IBGE did not reveal sufficient data for the calculation of standardized ratios for all years. Another possible limitation of our study is related to its design: this was an ecological study where the units of analysis were groups rather than individuals. Future studies should investigate the causes that may have led to the statistics here presented.

The true incidence of suicide may be underestimated worldwide as a result of the fact that this is a highly stigmatized phenomenon, surrounded by myths and taboos, and also due to the unavailability of adequate technical equipment to determine the precise cause of death, resulting in a large number of unspecified records.

All these factors contribute to making suicide statistics strongly influenced by undernotification.31,32 Finally, the epidemiological characterization of suicide in the Santa Catarina Coal Mining Region points to peculiarities of the region, which are probably different from other regions in the same state and in other Brazilian states. Nevertheless, we strongly believe that the present findings can be used to guide the planning of future studies and development of healthcare interventions aimed at minimizing this public health problem, especially in a state showing one of the highest suicide rates in Brazil.

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Accessed 2011 Nov. 7. Arantes-Gonçalves F, Coelho R. À procura de marcadores biológicos no comportamento suicidário. Acta Med Port. 2008;21:89-98.

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12. Brasil, Ministério do Trabalho e Emprego. Classificação brasileira de ocupações. 2002. http://www.mtecbo.gov.br/cbosite/pages/ home.jsf. Accessed 2012 Sep 18.

13. World Health Organization. International statistical classification of diseases, injuries, and causes of death. 9th ed. Geneva: WHO; 1975.

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15. Kliemann DV. Estudo epidemiológico de óbitos por suicídio na região da grande Florianópolis de 1991 a 2005 [monograph].

Florianópolis: Universidade Federal de Santa Catarina; 2007.

16. Schmit R, Lang, MG, Quevedo J, Colombo T. Perfil epidemiológico do suicídio no extremo oeste do estado de Santa Catarina, Brasil.

Rev Psiquiatr Rio Gd Sul. 2008;30:115-23.

17. Harwood D, Hawton K, Hope T, Jacoby R. Psychiatric disorder and personality factors associated with suicide in older people: a descriptive and case-control study. Int J Geriatr Psychiatry.

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18. Conwell Y, Duberstein P. Suicide in older adults: determinants of risk and opportunities for prevention. In: Hawton K, editor.

Prevention and treatment of suicidal behaviour. New York: Oxford University; 2005. p. 221-37.

19. Chiu HF, Yip PS, Chi I. Elderly suicide in Hong Kong - a case controlled psychological autopsy study. Acta Psychiatr Scand.

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20. Duberstein PR. Openness to experience and completed suicide across the second half of life. Int Psychogeriatr. 1995;7:183-98.

21. Waern M, Rubenowitz E, Runeson B. Burden of illness and suicide in elderly people: case-control study. BMJ. 2002;324:1355-7.

22. Harwood D, Howton K, Hope T. Life problems and physical illness as risk factors for suicide in older people: a descriptive and casecontrol study. Psychol Med. 2006;36:1265-74.

23. Mello-Santos C, Bertolote JM, Wang Y. Epidemiology of suicide in Brazil (1980-2000): characterization of age and gender rates of suicide. Rev Bras Psiquiatr. 2005;27:131-4.

24. Diekstra RF, Garnefski W. On the nature, magnitude and causality of suicidal behavior on international perspective. Suicide Life Threat Behav. 1995;25:36-57.

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Marín-León L, Barros MB. Suicide mortality: gender and socioeconomic differences. Rev Saude Publica. 2003;37:357-63.

26. Santos SM, Barcellos C, Carvalho MS, Flores R. Detecção de aglomerados espaciais de óbitos por causas violentas em Porto Alegre, Rio Grande do Sul, Brasil, 1996. Cad Saude Publica.

2001;17:1141-51.

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Meneghel SN, Victora CG, Faria NM, Carvalho LA, Falk JW. [Epidemiological aspects of suicide in Rio Grande do Sul, Brazil].

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28. Serrano AI. Impactos da modernidade sobre as pulsões autodestrutivas: ciências sociais e intervenção psiquiátrica [dissertation]. Florianópolis: Universidade Federal de Santa Catarina; 2003.

29. Jenkins CD. Injuries and violence. In: Building better health: a handbook of behavioral change. Washington: PAHO; 2009. p.

237-52. (Scientific and Technical Publication No. 590). http:// www.paho.org/English/DD/PUB/BBH_Injuries_Violence.pdf.

Accessed 2011 May 21.

30. Chuang H, Huang W. A reexamination of sociological and economic theories of suicide: a comparison of the USA and Taiwan. Soc Sci Med. 1996;43:421-3.

31. Minayo MC. A autoviolência, objeto da sociologia e problema de saúde pública. Cad Saude Publica. 1998;14:421-8.

32. Corrêa H, Barrero SP. Suicídio: uma morte inevitável. Rio de

Janeiro: Atheneu; 2006.

Correspondence Priscyla Waleska Targino de Azevedo Simões Avenida Universitária, 1105 - Curso de Medicina, Bairro Universitário 88806-000 - Criciúma, SC - Brazil E-mail: pri@unesc.net Trends Psychiatry Psychother. 2013;35(2) – 133

Trends

Original Article

in Psychiatry and Psychotherapy

Transdiagnostic treatment using a unified protocol: application for patients with a range of comorbid mood and anxiety disorders Tratamento transdiagnóstico utilizando um protocolo unificado: aplicação em pacientes com diferentes transtornos de humor e ansiedade comórbidos Ana Claudia C. de Ornelas Maia, Arthur Azevedo Braga, Cristiane Aparecida Nunes, Antonio Egidio Nardi, Adriana Cardoso Silva* Abstract

Resumo

Objective: To evaluate the effectiveness of a unified cognitive-behavioral therapy protocol for group treatment of patients with a range of comorbid mood and anxiety disorders.

Methods: In this open-trial study, the unified protocol was followed for the psychotherapeutic treatment of 16 patients with comorbid mood and anxiety disorders, confirmed by the Mini International Neuropsychiatric Interview. Beck Depression and Anxiety Inventories, the World Health Organization Quality of Life evaluation instrument, and the ARIZONA scale of sexual function were used to evaluate progress in patients throughout the therapeutic process.

Results: All patients showed unipolar depressive disorder. Comorbidity with anxiety disorders was distributed as follows: generalized anxiety disorder, 13 (81.3%); panic disorder, 3 (18.8%); social anxiety disorder, 1 (6.3%); and post-traumatic stress disorder, 1 (6.3%). Improvement was observed in the signs and symptoms of depression (F = 78.62, p < 0.001) and anxiety (F = 19.64, p < 0.001), overall quality of life (F = 39.72, p < 0.001), physical domain (F = 28.15, p < 0.001)), psychological variables (F = 9.90, p = 0.007), social functioning (F = 36.86, p < 0.001), environmental variables (F = 27.63, p < 0.001), and sexuality (F = 13.13; p < 0.005).

All parameters showed highly significant correlations (p < 0.01).

Conclusion: An effort to establish one unified treatment protocol for a whole family of emotional disorders (primarily mood and anxiety disorders) showed benefits in the field of clinical psychology and for the treatment of patients. No other data were found in the literature describing the implementation of the unified protocol in a transdiagnostic group. Our results revealed statistically significant improvement in all variables, suggesting that the protocol proposed can become an important tool to improve quality of life, sexuality, and anxiety/depression symptoms in patients with different diagnoses.

Keywords: Protocol, transdiagnostic approach, anxiety, depression.

Objetivo: Avaliar a eficácia de um protocolo unificado de terapia cognitivo-comportamental para tratamento em grupo de pacientes com diferentes transtornos de humor e ansiedade comórbidos.

Métodos: Neste estudo aberto, o protocolo unificado foi seguido no tratamento psicoterápico de 16 pacientes com transtornos de humor e ansiedade comórbidos, confirmados pelo Mini International Neuropsychiatric Interview. Os Inventários de Depressão e Ansiedade de Beck, o instrumento de avaliação de qualidade de vida da Organização Mundial da Saúde e a escala ARIZONA de função sexual foram utilizados para avaliar o progresso em pacientes ao longo de todo o processo terapêutico.

Resultados: Todos os pacientes tinham transtorno depressivo unipolar. A comorbidade com transtornos de ansiedade apresentou a seguinte distribuição: transtorno de ansiedade generalizada, 13 (81,3%); transtorno do pânico, 3 (18,8%); fobia social, 1 (6,3%); e transtorno do estresse pós-traumático, 1 (6,3%). Foi observada melhora nos sinais e sintomas de depressão (F = 78,62, p < 0,001) e ansiedade (F = 19,64, p < 0,001), na qualidade de vida geral (F = 39,72, p < 0,001), no domínio físico (F = 28,15, p < 0,001)), em variáveis psicológicas (F = 9,90, p = 0,007), funcionamento social (F = 36,86, p < 0,001), variáveis ambientais (F = 27,63, p < 0,001) e sexualidade (F = 13,13; p < 0,005). Todos os parâmetros demonstraram correlações altamente significativas (p < 0,01).

Conclusão: O esforço para estabelecer um protocolo unificado de tratamento para toda uma família de transtornos emocionais (especialmente humor e ansiedade) mostrou benefícios na área da psicologia clínica e no tratamento dos pacientes. Não foram encontrados outros dados na literatura descrevendo a implementação do protocolo unificado em um grupo transdiagnóstico. Nossos resultados revelaram uma melhora estatisticamente significativa em todas as variáveis, sugerindo que o protocolo proposto pode se tornar uma ferramenta importante para melhorar qualidade de vida, sexualidade e sintomas de ansiedade/ depressão em pacientes com diferentes diagnósticos.

Descritores: Protocolo, abordagem transdiagnóstica, ansiedade, depressão.

* Institute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. National Science and Technology Institute for Translational Medicine (INCT-TM).

Financial support: none.

Submitted Oct 02 2012, accepted for publication Feb 04 2013. No conflicts of interest declared concerning the publication of this article.

Suggested citation: Ornelas Maia AC, Braga AA, Nunes CA, Nardi AE, Silva AC. Transdiagnostic treatment using a unified protocol: application for patients with a range of comorbid mood and anxiety disorders. Trends Psychiatry Psychother. 2013;35(2):134-40.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 134-140

Transdiagnostic treatment using a unified protocol – Ornelas Maia et al.

Introduction The prevalence of anxiety and mood disorders is estimated to be 25% in the general population.1 In parallel, there is a greater awareness of the need to treat these clinical conditions, as they can affect social coping skills and make it difficult for an individual to be successful in society.1-3 However, much of the population lacks sufficient financial resources to pay for individual medical treatment.

Studies on the use of cognitive-behavioral therapy (CBT) in group treatment settings have demonstrated satisfactory results,4-7 and a meta-analysis8 has indicated significant positive results of CBT in mixed disorders (d = 0.26, 95% confidence interval = 0.44 to 0.08). Treatment effectiveness is also influenced by the adjustment to a group situation, indicating that dysfunctional thoughts associated with anxiety disorders are usually damaging to the effectiveness of group therapy.5,6 Anxiety disorders as comorbidities in a group appear more exacerbated than mood disorders. Fear, worry, or decision-making are characteristics of thought that seem to be common in these patients.5-8 However, in group psychotherapy, a primary treatment focus has to be elected, so that therapists can focus on connecting symptoms and follow the patient’s experience during the process, promoting open communication in terms of both social skills and cognitive restructuring.7-11 In recognition to the empirical origin of CBT, the treatment protocol usually provides measures for patients to focus on during their treatment and assist them in determining their progress.12 There is currently much interest, both clinically and scientifically, in the active ingredients of CBT, and in how therapists might focus their interventions to be effective across diagnoses. Given the significant rates of comorbidity encountered in clinical practice, the notion of formulating and intervening with transdiagnostic underlying cognitive and behavioral processes has become the subject of increasing attention.12-14 The protocol can be a guide for the therapist and the patient to analyze treatment progress, and should include four therapy components: 1) psychoeducation/ boosting motivation (increasing self-knowledge and becoming a partner in therapy); 2) cognitive reappraisal (learning to think accurately about one’s own thinking); 3) preventing emotional avoidance (accepting emotional experience and increasing emotional literacy); and 4) changing behavioral habits in the context of exposure treatment (facing fears and learning new habits).13,14 The conceptual clinical process requires the setting of goals and their inclusion in the treatment.1-6,12 The unified protocol can be applied individually or in groups and consists of therapeutic procedures

that enable patients with severe multiple disorders to participate in the same group. Emotions are recognized, regulated and restructured through scientific techniques that reinforce new knowledge and behavior before the patient’s problems surface.13,14 There are few published studies that evaluate the results of the unified protocol, especially in a group intervention setting.

Therefore, the objective of the present study was to evaluate the effectiveness of a unified CBT protocol for group treatment of patients with a range of comorbid mood and anxiety disorders.

Method This longitudinal study used the transdiagnostic unified protocol as the therapeutic intervention, with a focus on CBT, to treat patients diagnosed with unipolar mood disorder of mild to moderate severity and comorbidity with anxiety disorders. The following inclusion criteria were adopted: diagnosis of depression by a psychiatrist and confirmed using the Mini International Neuropsychiatric Interview (MINI)14,15; at least one diagnosis of anxiety disorder confirmed using the MINI; no changes in psychopharmacology drugs or dosages in the 4 months prior to or during the psychotherapeutic protocol (to ensure medication stability throughout the therapeutic process); attending and completing the initial interview; having enough cognitive ability to understand the instructions; and being at least 18 years old.

Initially, 148 patients who had voluntarily sought medical treatment at a public health service and were in a waiting list for group treatment were invited to participate in screening for possible inclusion in this study. According to the inclusion criteria mentioned above, patients should have both unipolar depression and an anxiety disorder. Moreover, they could not have neurological problems, cognitive deficits, or personality disorders. Patients were assessed based on referral by the health center psychiatrist and on MINI interview results, applied by trained psychologists. Of all patients who agreed to be evaluated for possible inclusion in this study, 16 fulfilled the criteria and were selected to receive treatment with a unified transdiagnostic protocol.

Selected patients were divided into two groups of eight, all of whom participated in the whole treatment process (total of 12 sessions).

Treatment followed the four components described above, i.e., psychoeducation/boosting motivation (to identify and understand emotions), cognitive reappraisal (to learn with the emotions and understand the influence of thought on reactions and behaviors), preventing emotional avoidance (to understand and confront

Trends Psychiatry Psychother. 2013;35(2) – 135

Transdiagnostic treatment using a unified protocol – Ornelas Maia et al.

physical emotions), changing behavioral habits in the context of exposure treatment (to learn how to confront in exposure treatment and to solve problems).

The protocol was applied in the two groups over 12 sessions lasting for 2 hours each. The main procedures followed in each section are described below.

Session 1 Orient the patient to treatment and apply scales to assess anxiety, mood, quality of life, and sexual functioning. Orientation to treatment is conducted after providing information on the group CBT model for the treatment of anxiety and mood disorders. The aim is to demonstrate to patients the importance of setting goals and accomplishing tasks at home, such as reading information about the characteristics of signs and symptoms of anxiety and depression prepared by the therapist.

Session 2 Identify emotions. At this stage, patients get in touch with their emotions by reading about the disorders presented as complaints. This session is called bibliotherapy, and it begins with a group discussion on the development of behavioral strategies for troubleshooting and overcoming obstacles in the treatment based on goals.

Session 3 Understand emotions. Based on the reports of situations encountered by patients during the previous week, the consciously recognized feelings of each participant are identified in the group. Thereafter, group participants understand their feelings and the situations in which they are raised and reinforced. Thus, psychoeducation and a correct understanding of thoughts and feelings are achieved, and emotion regulation and self-monitoring symptoms become the focus.

Session 4 Learn to observe emotions and subsequent reactions.

Patients at this stage of treatment already know their automatic thoughts and recognize feelings related to anxiety and mood. Based on this understanding, an intervention using psychoeducation and cognitive correction is conducted, enabling the analysis of thoughts, emotion regulation, and the introduction of self-monitoring relaxation techniques for self-correction when not in the therapy group.

136 – Trends Psychiatry Psychother. 2013;35(2)

Session 5 Understand the influence of thoughts: thinking the worst and risk estimates. Thoughts have a direct influence on emotions and behavior. This psychoeducational intervention introduces the cognitive restructuring of thoughts, the analysis of emotion regulation and selfmonitoring, and the management of anxiety and stress with relaxation techniques. The search for evidence of automatic thoughts is introduced, and finally, the evaluation of social skills begins with routine situations in the patient’s lives, which differ in terms of aggression, passivity, and assertiveness.

Session 6 Understand the behavior and the influence of emotion.

Identify the relationship between thoughts, feelings, and behaviors. This psychoeducational intervention enables patients to understand what is real and what is imaginary. Emotion regulation, self-monitoring of thoughts, feelings, and actions, and the management of anxiety and stress with relaxation and cognitive restructuring are discussed. Finally, social skills training is conducted, beginning with real situations experienced by each patient and discussion of the most appropriate response in each case.

Session 7 Understand behavior and emphasize the influence of emotion on behavior. In this phase of treatment, it is important to monitor mood and anxiety. Here, the psychoeducational intervention promotes emotion regulation, cognitive restructuring, the management of anxiety and stress with relaxation, and social skills training, beginning with real situations experienced by each patient, choosing the most appropriate response and applying it, and therefore promoting problemsolving.

Session 8 Understand and confront physical sensations. In this step, the identification of emotions and thoughts through self-monitoring are already functional responses and assist in the management of anxiety. Each patient begins to have the confidence necessary to confront anxiogenic situations and learns that practicing relaxation and training social skills are essential for dealing with physiological symptoms.

Transdiagnostic treatment using a unified protocol – Ornelas Maia et al.

Session 9 Put into practice the understanding of the influence of emotion on thinking and behavior. This psychoeducational intervention aims to regulate the emotional state and restructure the beliefs of the group. Management of anxiety and stress via different relaxation techniques is promoted, and social skills are practiced, leading to the resolution of problems.

deviation. WHOQoL-bref, BDI, BAI, and ARIZONA results were expressed as means and standard deviation.

Treatment results were assessed using repeated measures analysis of variance (ANOVA) followed by Greenhouse-Geisser correction to avoid an increase in type I error. Significance was set at p < 0.01.

This research project was approved by the Research Ethics Committee of Universidade Federal do Rio de Janeiro (UFRJ), and all patients signed an informed consent form.

Session 10 Put learned responses and behaviors into practice in situations that provoke a dysfunctional emotional state. At this time, patients are able to assess thoughts and feelings that change the signs and symptoms of anxiety and depression. Group treatment reinforces recent learning about emotions and behavior. The functional response of self-monitoring promotes the relief of depressive and anxiogenic symptoms and the implementation of social skills. Treatment is reaffirmed with the introduction of relapse prevention using situations that will possibly be faced in the future and the correction of patterns of thoughts and dysfunctional beliefs.

Session 11 Motivate continuous learning through problem situations and future relapse prevention. The group reviews the emotional change obtained with treatment and self-monitoring, which promoted the learning of functional responses for the relief of symptoms experienced at baseline. Relapse prevention, including future situations, and the correction of patterns of thoughts and dysfunctional beliefs are also reviewed.

Session 12 Finish treatment, but promote continuing therapeutic practices. At this stage, measures taken at baseline are reviewed. The group compares the scores obtained at the beginning and end of treatment using the unified protocol.

Patients’ sociocultural data were collected and included sex, age, occupation, religion, education, comorbidities, and drug use. The following instruments were used: MINI version 5.0,14,15 Beck Depression Inventory (BDI),16 Beck Anxiety Inventory (BAI),17,18 the World Health Organization Instrument for the assessment of quality of life (WHOQoL-bref),19 and the ARIZONA scale of sexual function.20 Descriptive statistics were used to analyze sociodemographic data, expressed as the absolute frequencies and percentages or as means and standard

Results Sample characteristics for sex, age, occupation, religion, education, comorbid anxiety disorders, and drug use are presented in Table 1.

Table 1 – Sample characteristics

No. (%)

Sex Female 14 (87.5) Male 2 (12.5) Age* 35.63±12.09 (18-58) Occupation Student 4 (25) Housewife/househusband 3 (18.8) Unemployed 1 (6.3) Employed 5 (31.3) Autonomous 3 (18.8) Religion Atheist 1 (6.3) Catholic 5 (31.3) Evangelical 4 (25) Spiritualist 6 (37.5) Other 2 (1.9) Education Elementary school 2 (12.5) High school 14 (87.6) Comorbidities Generalized anxiety disorder 13 (81.3) Panic 3 (18.8) Social phobia 1 (6.3) Post-traumatic stress disorder 1 (6.3) Medications Antidepressants 9 (56.3) Anxiolytics 4 (25) Other 3 (18.8) * Mean ± standard deviation.

Comparison of the results obtained for signs and symptoms of anxiety, depression, sexuality, overall quality of life, and specific domains before and after treatment are shown in Table 2. Patients made excellent progress in all areas.

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Transdiagnostic treatment using a unified protocol – Ornelas Maia et al.

Table 2 – Results at the beginning and end of treatment and comparison of measurements obtained in the two periods

Baseline

End of treatment

Quality of life Physical Psychological Social relationships Environment Anxiety Depression Sexuality

94.00±8.94 27.06±4.07 21.56±2.15 12.44±2.15 29.56±3.07 9.19±7.46 8.25±7.24 11.75±7.28

75.81±15.07 21.81±5.39 17.88±4.39 8.56±2.70 23.69±4.71 19.56±14.35 20.94±11.64 15.50±9.07

Type III sum of squares df 2646.28 220.50 108.78 120.12 276.12 861.125 1287.78 112.50

Mean square

1 2646.28 1 220.50 1 108.78 1 120.12 1 276.12 1 861.125 1 1287.78 1 112.50

F

p

η2

39.72 < 0.001 0.73 28.15 < 0.001 0.65 9.90 0.007 0.39 36.86 < 0.001 0.71 27.63 < 0.001 0.65 19.64 < 0.001 0.57 78.62 < 0.001 0.84 13.13 0.003 0.47

df = degrees of freedom.

Discussion The primary objective of this study was to evaluate the effectiveness of a unified CBT protocol in the group treatment of patients with a range of comorbid mood and anxiety disorders. Secondary objectives were the reduction of signs and symptoms of anxiety and depression and improvement in quality of life, which will be evaluated in light of the patient’s status.

At the start of treatment, patients evaluated in both groups showed depression and anxiety ranging from moderate to severe according to the scores obtained using the Beck inventories. After 12 treatment sessions with the unified CBT protocol, all indicators reduced, attesting to the effectiveness of the protocol and to its superiority in group settings compared to other proven clinical approaches to anxiety disorders,7,8,21,22 e.g., mood23,24 and apathy.25 In this study, we verified the effectiveness of group CBT treatment for patients with a variety of mood, anxiety, and comorbid disorders, as the intervention model provided benefits for both the patient and the therapist.

Psychoeducational strategies, self-monitoring of thoughts, exposure, prevention and management of responses have all shown good results in previous studies22,26,27 and were part of the techniques applied in the unified protocol of group CBT. These techniques facilitate the identification of thoughts that influence emotions and behaviors and that are generators of anxiety or depression; such awareness gives patients the security necessary to face situations and make decisions.

Implementing the unified protocol in group CBT with patients with a range of disorders allowed for reflection on treatment practices, with an emphasis on the feasibility of not separating groups according to specific disorders. Such separation is usually adopted because each therapy is aimed at treating a single disorder, and as a result a group of patients receives one single treatment according to the investigated problem21,22,25-30 (for example, a treatment group for mood disorders or social phobia).

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In the present study, significant improvement in quality of life was observed for all the participants in the sample (F = 39.72, p < 0.001), including the physical (F = 28.15, p < 0.001), social (F = 36.86; p < 0.001), psychological (F = 9.90, p = 0.007), and environmental domains (F = 27.63, p < 0.001). Studies have shown that the relationships established in treatment groups promote the instillation of hope and enhance quality of life, especially when individuals learn how to recognize and regulate their emotions through anxiety management during interpersonal interactions.4-7 These phenomena were observed in our group and may have contributed to the good results obtained.

When the unified CBT protocol is adopted in group treatment settings, including patients with a range of disorders, quality of life and its domains become the focus of intervention, as the experience of the group resembles the daily lives of patients. The skills learned in this group setting, including social skills and assertiveness training, are practical and translate into real life experiences outside the treatment setting.

The results obtained for all variables related to quality of life, in addition to signs and symptoms of anxiety and depression, were satisfactory in patients who underwent to the unified protocol. Treatment helped them identify thoughts, emotions, and behaviors that promote safety, express feelings in an assertive manner, and learn skills for handling stress and anxiety, thus restructuring their emotional state.31-33 These achievements are fundamental to the goals of cognitive-behavioral group treatment using the unified protocol.12-14 Improvement was also observed in sexual functioning: there was a statistically significant difference between ARIZONA scores obtained at the beginning vs. at the end of treatment (F = 13:13, p < 0.003). Surveys have shown that sexual functioning is associated with anxiety and depression.34,35 Dissatisfaction with overall sex life (37.5%) and sexual anxieties (44.2%) were substantial in our subjects, corroborating previous findings.34 Also, increased depression and anxiety levels were associated

Transdiagnostic treatment using a unified protocol – Ornelas Maia et al.

with a disturbed body image and with decreased levels of sexual satisfaction (86.98±23.63).35 This result suggests the need for further study about sexual functioning in individuals with mood and anxiety disorders and on the therapeutic effects of the unified protocol on sexuality, even when these areas are not targeted in the same approach.

As limitations of the present study we can mention the small sample size (only 16 participants) and the fact that it was an open trial. This is the first study to evaluate the effectiveness of a new treatment protocol in a Brazilian population. Therefore, despite the small sample, results were important and showed good results both in reducing signs and symptoms of depression and anxiety and in improving the patients’ quality of life in various aspects. Also, the study did not adopt a protocol to measure treatment adherence.

The fact that patients were using psychotropics could also be considered a limitation. In order to ensure that the findings would be a result of the therapeutic process under investigation rather than of medication use, only patients without any change in medication in the 4 months preceding the study and with stable clinical conditions were included. Moreover, none of the patients changed the type or dosage of the medication used over the course of the psychotherapeutic treatment. In view of these measures, we have reason to believe that the improvements observed were a result of the therapeutic process using the unified protocol. Future studies, with larger samples, should be conducted, especially randomized clinical trials, to confirm our preliminary findings.

Conclusion The use of a unified transdiagnostic protocol in treatment groups allows for a greater number of patients to benefit from treatment with trained therapists, at a lower cost, and with greater treatment efficiency.

Moreover, it offers the advantages of social learning through the exchange of experiences among patients.

In our opinion, several factors favored success of this unified protocol treatment, e.g., its focus on treatment, the possibility to express feelings and flexibly interact with the therapists, the patients’ willingness to actively participate in the evaluation of problems, their ability to recognize that symptoms have a psychological origin, the group’s curiosity about one’s self, openness to new ideas, realistic expectations regarding treatment results, and their willingness to make a reasonable sacrifice for a short time (3 months), of either money or time, to address issues commonly found to be unpleasant.

Given the positive results here described, refinement of an effective treatment program for groups of patients with different mild to moderate anxiety and mood disorders is warranted, as there are few studies describing CBT approaches in groups of patients with a range of disorders. It is important to note that, in this context, strategies and techniques known to be successful in individual treatments should be adapted to groups. Specifically, a group setting provides more examples for making connections between thoughts and feelings than can be obtained in individual therapy.

The patients who participated in the unified CBT protocol for group treatment obtained good results in the elimination and management of anxiety and phobic symptoms, coping with anxiogenic situations, troubleshooting, and restoring previous mood states.

In addition to these achievements, they improved their quality of life, especially with regard to the physical domain, social relationships, and the environment. In fact, environmental variables promoted an increase in social skills and led to increased self-esteem and motivation for life.

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5. McEvoy PM, Nathan P. Effectiveness of cognitive behavior therapy for diagnostically heterogeneous groups: a benchmarking study. J Consult Clin Psychol. 2007;75:344-50.

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9. Hood HK, Antony MM, Koerner N, Monson CM. Effects of safety behaviors on fear reduction during exposure. Behav Res Ther. 2010;48:1161-9.

10. Cape J, Whittington C, Buszewicz M, Wallace P, Underwood L. Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression. BMC Med. 2010;25:8-38.

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11. Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007;1:CD001848.

12. Donker T, Griffiths KM, Cuijpers P, Christensen H. Psychoeducation for depression, anxiety and psychological distress: a meta-analysis. BMC Med. 2009;16:7-79.

13. Schramm E, Hautzinger M, Zobel I, Kriston L, Berger M, Härter M. Comparative efficacy of the cognitive behavioral analysis system of psychotherapy versus supportive psychotherapy for early onset chronic depression: design and rationale of a multisite randomized controlled trial. BMC Psychiatry. 2011;11:134.

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15. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59:22-33.

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19. Cunha JA. Manual da versão em português das escalas Beck.

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20. Vaz Serra A, Canavarro MC, Simões MR, Pereira M, Gameiro S, Quartilho MJ, et al. Estudos psicométricos do instrumento de avaliação da qualidade de vida da Organização Mundial de Saúde (WHOQOL-Bref) para português de Portugal. Rev Psiquiatr Clin. 2006;27:41-9.

21. Craske MG, Farchione TJ, Allen LB, Barrios V, Stoyanova M, Rose RD. Cognitive-behavioral therapy for panic disorder and comorbidity: more of the same or less of more? Behav Res Ther. 2007;45:1095-109.

22. Hofmann SG, Smits JAJ. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69:621-32.

23. Chorpita BF. Modular cognitive-behavioral therapy for anxiety disorders. New York: Guilford; 2007.

24. Tolin DF. Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clin Psychol Rev. 2010;30:710-20.

25. McGahuey CA, Gelenberg AJ, Laukes CA, Moreno FA, Delgado PL, McKnight PK, et al. The Arizona Sexual Experience Scale (ASEX): reliability and validity. J Sex Marital Ther. 2000;26:1, 25-40.

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Erickson DH. Group cognitive-behavioral therapy for heterogeneous anxiety disorders. Cogn Behav Ther.

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27. Norton PJ, Hope DA. Preliminary evaluation of a broadspectrum cognitive-behavioral group therapy for anxiety. J Behav Ther Exp Psychiatry. 2005;36:79-97.

28. Johnston L, Titov N, Andrews G, Spence J, Dear BF. An RCT of a transdiagnostic internet-delivered treatment for three anxiety disorders: examination of support roles and disorder-specific outcomes. PLoS One. 2011;6:e28079. Epub 2011 Nov 23.

29. Roy-Byrne DP, Craske MG, Stein MB, Sullivan G, Bystritsky A, Katon W. A randomized effectiveness trial of cognitivebehavioral therapy and medication for primary care panic disorder. Arch Gen Psychiatry. 2005;62:290-8.

30. Sullivan G, Craske MG, Sherbourne C, Edlund MJ, Rose RD, Golindle D. Design of the Coordinated Anxiety Learning and Management (CALM) study innovations in collaborative care for anxiety disorders. Gen Hosp Psychol. 2007;29:379-87.

31. Donker T, Griffiths KM, Cuijpers P, Christensen H. Psychoeducation for depression, anxiety and psychological distress: a meta-analysis. BMC Med. 2009;16:7-79.

32. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitivebehavior therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA. 2000;283:2529-36.

33. Barlow DH, Allen L, Choate M. Toward a unified treatment for emotional disorders. Behav Ther. 2004;35:205-30.

34. Köhler B, Kleinemeier E, Lux A, Hiort O, Grüters A, Thyen U, et al. Satisfaction with genital surgery and sexual life of adults with XY disorders of sex development: results from the German clinical evaluation study. J Clin Endocrinol Metab. 2012;97:577-88.

35. Oyekçin DG, Gülpek D, Sahin EM, Mete L. Depression, anxiety, body image, sexual functioning, and dyadic adjustment associated with dialysis type in chronic renal failure. Int J Psychiatry Med. 2012;43:227-41.

Correspondence Ana Claudia C. de Ornelas Maia Institute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), INCT-TM Rua Visconde de Pirajá, 407/702 22410-003 - Rio de Janeiro, RJ - Brazil Tel.: +55 (21) 2521.6147 Fax: + 55 (21) 2523.6839 E-mail: acornelas@mvmaia.com.br

Trends

Original Article

in Psychiatry and Psychotherapy

Mood self-assessment in bipolar disorder: a comparison between patients in mania, depression, and euthymia Autoavaliação do estado de humor no transtorno bipolar: uma comparação entre pacientes em mania, depressão, e eutimia Rafael de Assis da Silva,1 Daniel C. Mograbi,2 Luciana Angélica Silva Silveira,3 Ana Letícia Santos Nunes,3 Fernanda Demôro Novis,3 Paola Anaquim Cavaco,3 J. Landeira-Fernandez,4 Elie Cheniaux5

Abstract

Resumo

Background: Some studies indicate that mood self-assessment is more severely impaired in patients with bipolar disorder in a manic episode than in depression.

Objectives: To investigate variations in mood self-assessment in relation to current affective state in a group of individuals with bipolar disorder.

Methods: A total of 165 patients with a diagnosis of bipolar disorder type I or type II had their affective state assessed using the Clinical Global Impressions Scale for use in bipolar illness (CGI-BP), the Positive and Negative Syndrome Scale (PANSS), and the Global Assessment of Functioning (GAF). In addition, participants completed a self-report visual analog mood scale (VAMS). Patients were divided into three groups (euthymia, mania, and depression) and compared with regard to VAMS results.

Results: Manic patients rated their mood similarly to patients in euthymia in 14 out of 16 items in the VAMS. By contrast, depressed patients rated only two items similarly to euthymic patients.

Conclusion: Patients with bipolar disorder in mania, but not those in depression, poorly evaluate their affective state, reinforcing the occurrence of insight impairment in the manic syndrome.

Keywords: Insight, mood, self-assessment, bipolar disorder.

Contexto: Alguns estudos indicam que a capacidade de autoavaliação do estado de humor está mais comprometida em pacientes com transtorno bipolar na mania do que na depressão.

Objetivo: Estudar variações na autoavaliação do humor em relação ao estado afetivo atual em indivíduos com transtorno bipolar.

Método: Um total de 165 pacientes com diagnóstico de transtorno bipolar tipo I ou tipo II tiveram seu estado afetivo avaliado utilizando os instrumentos Clinical Global Impressions Scale for use in bipolar illness (CGI-BP), Positive and Negative Syndrome Scale (PANSS) e Global Assessment of Functioning (GAF). Além disso, foi aplicada um instrumento de autoavaliação, a escala visual analógica do humor (EVAH). Os pacientes foram divididos em três grupos (eutimia, mania e depressão) e comparados quanto aos resultados da EVAH. Resultados: Dos 16 itens da EVAH, 14 foram avaliados pelos pacientes em mania de forma semelhante aos pacientes em eutimia.

Em contraste, em apenas dois itens, os deprimidos mostraram escores semelhantes aos eutímicos.

Conclusão: Pacientes bipolares em mania, mas não os deprimidos, avaliam de forma não fidedigna seu estado afetivo, o que reforça o comprometimento do insight na síndrome maníaca.

Descritores: Insight, humor, autoavaliação, transtorno bipolar.

Instituto Municipal Philippe Pinel (IMPP), Rio de Janeiro, RJ, Brazil. Instituto de Psiquiatria – Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, RJ, Brazil. 2 Pontifícia Universidade Católica do Rio de Janeiro (PUC-Rio), Rio de Janeiro, RJ, Brazil. 3 IPUB/UFRJ, Rio de Janeiro, RJ, Brazil. 4 PUC-Rio, Rio de Janeiro, RJ, Brazil. Universidade Estácio de Sá (UNESA), Rio de Janeiro, RJ, Brazil. 5 IPUB/UFRJ, Rio de Janeiro, RJ, Brazil. School of Medical Sciences, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil.

1

This study was carried out at the Laboratory for Bipolar Mood Disorder, Instituto de Psiquiatria – Universidade Federal do Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, RJ, Brazil.

Financial support: none.

Submitted Nov 29 2012, accepted for publication Mar 11 2013. No conflicts of interest declared concerning the publication of this article Suggested citation: Silva RA, Mograbi DC, Silveira LA, Nunes AL, Novis FD, Cavaco PA, et al. Mood self-assessment in bipolar disorder: a comparison between patients in mania, depression, and euthymia. Trends Psychiatry Psychother. 2013;35(2):141-5.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 141-145

Mood self-assessment in bipolar disorder – Silva et al.

Introduction Self-report scales are rarely used to assess manic states. Cognitive impairment (affecting primarily attention, insight, and criticism), the lack of cooperation, and the negation observed in patients in manic states make self-assessment unreliable.1 Platman et al.2 observed that, among individuals with bipolar disorder, mood self-assessment results more frequently overlapped with objective measurements made by investigators when patients were in depression than when they were in mania.

Jamison et al.,1 in turn, investigated self-perceived mood states in 69 patients with bipolar disorder. In that study, patients were tested using 22 pairs of opposite adjectives (e.g., good/bad, weak/strong, complex/simple), presented as extreme opposites over a continuum. Self-assessment of patients in depression, but not of hypomanic patients, showed significant differences in relation to the results obtained for euthymic patients. The authors concluded that self-assessment is substantially compromised in manic states, but not in depression. These results have been published in a book chapter, but not in a journal article, to the best of the authors’ knowledge.

The present study was designed to prospectively assess mood self-assessment in individuals with bipolar disorder in relation to current affective state, i.e., euthymia, mania, or depression. Our null hypothesis was that patients in mania, but not those in depression, would self-assess their mood similarly to euthymic patients.

Method Sample Our sample comprised 165 patients with a diagnosis of bipolar disorder (154 type I and 11 type II). All patients received treatment at the outpatient unit of Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, over a 2-year period, from November 2008 to November 2010. The following inclusion criteria were taken into consideration: being 18 years old or older; having a diagnosis of type I or type II bipolar disorder; and agreeing to sign an informed consent form. Personal and sociodemographic data were collected from each patient. The research protocol was approved by the local research ethics committee.

Clinical assessment The psychiatric diagnosis of bipolar disorder was established using the Structured Clinical Interview for DSM Disorders (SCID) according to criteria from the

142 – Trends Psychiatry Psychother. 2013;35(2)

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR).3 At each visit, the patient’s affective state was assessed using the Clinical Global Impressions Scale for use in bipolar illness (CGI-BP),4 with scores ranging from 1 (normal) to 7 (very severely ill). In order to be considered euthymic, the patient had to present a score below 3, which corresponds to minimally improved in both the mania and the depression subscales. A diagnosis of mania or depression therefore required a minimum score of 3. At each visit, the patient’s affective state was determined as either euthymia, mania, depression, or a mixed state. The occurrence of manic and depressive episodes and their severity were assessed using the CGI-BP, considering the highest severity score as the final result. Assessments determining mixed states were disregarded.

Two additional instruments were used to assess illness severity, namely, the positive symptom subscale of the Positive and Negative Syndrome Scale (PANSS-p)5 and the Global Assessment of Functioning (GAF).6 PANSS-p scores range from 1 (absent) to 7 (extreme), and the instrument was useful to assess the presence and severity of psychotic symptoms among patients.

In the present study, psychosis was considered to be present when delirium or hallucinations were observed.

The GAF scale, in turn, assesses social, occupational, and psychological functioning over a continuum that ranges from 1 (poor functioning) to 100 (best functioning).

In parallel, a self-report instrument was applied to assess the occurrence of mood swings, namely, the visual analog mood scale (VAMS),7 which has been translated into Brazilian Portuguese and adapted to the Brazilian reality.8 This scale comprises 16 items, each including two adjectives with opposite meanings, as follows: alert-drowsy, calm-excited, strong-feeble, clear-headedmuzzy, well-coordinated-clumsy, energetic-lethargic, contented-discontented, tranquil-troubled, quickwitted-mentally slow, relaxed-tense, attentive-dreamy, proficient-incompetent, happy-sad, amicable-antagonistic, interested-bored, and gregarious-withdrawn. In the VAMS, each adjective is separated from its opposite by a 10 cm line on which the subject has to mark the point which best describes his feelings at the time. In this type of scale, responses are given over a continuum rather than following predetermined intervals.

The main analysis of our study involved the investigation of possible relationships between different affective states, as assessed by CGI-BP, and VAMS results. With this goal in mind, patients were divided into three groups, namely, euthymia, mania, depression.

Each patient was assigned to one single group only.

The following criteria were taken into consideration: 1) euthymia, only patients classified as euthymic at

Mood self-assessment in bipolar disorder – Silva et al.

all visits, and only the first VAMS results used in the analysis; 2) mania, patients who showed at least one episode of mania throughout the study period, first VAMS results obtained during a manic episode used in the analysis; and 3) depression, patients who showed at least one episode of depression and no episode of mania throughout the study period, first VAMS results obtained during a depressive episode used in the analysis.

Statistical analysis Differences between the groups in terms of VAMS scores were explored using one-way analysis of variance (ANOVA). Cases showing differences in ANOVA were adjusted for pairwise comparisons with Bonferroni correction.

Differences observed in sociodemographic and clinical characteristics across the groups were also tested. Educational level, age, and scores obtained on PANSS-p, GAF, and CGI-BP were assessed using oneway ANOVA, whereas gender and frequency of psychotic symptoms were tested using the chi-square test. Again, pairwise comparisons following Bonferroni adjustment were carried out whenever differences were observed in the initial analyses.

Results Of the 165 patients assessed, only 16 were classified as euthymic, manic, and depressive at different moments. One hundred patients presented the same affective state at all assessments: 59 in euthymia, 15 in mania, and 26 in depression. Moreover, 15 patients were euthymic and showed episodes of mania but no depressive episodes, and 26 were euthymic and showed episodes of depression but no manic episodes. Finally, only eight patients showed both manic and depressive episodes but were never classified as euthymic.

Patient distribution according to the criteria previously established was as follows: 59 in the euthymia group, 54 in the mania group, and 52 in the depression group.

Demographic and clinical data obtained for each group are presented in Table 1. Sociodemographic variables were statistically similar across the three groups.

Notwithstanding, gender showed a trend toward difference, with a higher female-to-male ratio in the depression group when compared with the other two groups. A higher frequency of psychotic symptoms and higher PANSS-p scores were observed in manic patients when compared with euthymic and depressed ones. Analysis also showed higher CGI-BP and lower GAF scores in patients in mania and depression when compared with euthymic individuals.

One-way ANOVA revealed significant differences between the groups for the following variables on VAMS: alert-drowsy, F (2, 162) = 9.47, p < 0.001; calm-excited, F (2, 162) = 10.80, p < 0.001; strong-feeble, F (2, 162) = 19.86, p < 0.001; clear-headed-muzzy, F (2, 162) = 7.28, p = 0.001; well-coordinated-clumsy, F (2, 162) = 15.15, p < 0.001; energetic-lethargic, F (2, 162) = 15.40, p < 0.001; contented-discontented, F (2, 162) = 21.50, p < 0.001; tranquil-troubled, F (2, 162) = 7.80, p = 0.001; quick-wittedmentally slow, F (2, 162) = 10.30, p < 0.001; relaxed-tense, F (2, 162) = 5.73, p = 0.004; attentive-dreamy, F (2, 162) = 11.87, p < 0.001; proficient-incompetent, F (2, 162) = 17.47, p < 0.001; happy-sad, F (2, 162) = 18.99, p < 0.001; interested-bored, F (2, 162) = 30.50, p < 0.001; gregariouswithdrawn, F (2, 162) = 17.60, p < 0.001. The amicableantagonistic variable did now show significant differences: F (2, 162) = 0.93, p = 0.397.

As shown in Table 2, 14 of the 16 items comprising the VAMS showed similar scores in the euthymia and mania groups. Of these 14 items, 11 showed differences between euthymia/mania and depression, two did not show differences across the three groups, and one showed similar results for mania and depression, but differences between euthymia and depression. In only two of the 16 items, differences were found between the euthymia and mania groups: in the interested-bored item, the euthymia group showed differences also in relation to the depression group; in the calm-excited item, euthymic patients performed similarly to depressive ones. As a result, the depression group was similar to the euthymia group in only two of the 16 items comprising the VAMS.

Table 1 – Comparison between the three groups of patients according to sociodemographic and clinical characteristics

Euthymia

Mania

Variable

(n = 59)

(n = 54)

Depression (n = 52)

p

Gender (female/male), % Educational level (years), mean ± SD (mv: 5) Age (years), mean ± SD (mv: 1) GAF (total score), mean ± SD CGI-BP (total score), mean ± SD PANSS-p (total score), mean ± SD Frequency of psychotic symptoms, %

54.2/45.8 11.8±4.2 42.9±13.9 76.7±12.5 1.5±0.5 7.7±1.4 3.4

68.5/31.5 12.3±2.8 45.8±11.3 54.4±11.9 3.7±0.7 13.5±4.4 35.2

75.0/25.0 11.6±4.1 46.4±12.5 59.0±9.8 3.7±0.8 8.2±1.8 11.5

0.061 0.645 0.300 < 0.001 < 0.001 < 0.001 < 0.001

CGI-BP = Clinical Global Impressions Scale for use in bipolar illness; GAF = Global Assessment of Functioning; mv = missing values; PANSS-p = Positive and Negative Syndrome Scale, positive symptom subscale; SD = standard deviation.

Trends Psychiatry Psychother. 2013;35(2) – 143

Mood self-assessment in bipolar disorder – Silva et al.

Table 2 – Comparison between the groups of patients in euthymia (n = 59), mania (n = 54), and depression (n = 52) with regard to the mean results obtained in the visual analog mood scale (VAMS)

Scale item

Group

Mean ± standard

Alert-drowsy Euthymia 3.23±2.84†

Mania 3.67±3.13†

Depression 5.67±3.34* Calm-excited Euthymia 2.74±2.78

Mania 5.42±3.16*†

Depression 3.88±3.27 Strong-feeble Euthymia 3.38±2.56†

Mania 3.79±2.67†

Depression 6.47±3.07* Clear-headed-muzzy Euthymia 7.28±2.76†

Mania 5.90±3.27

Depression 4.93±3.75* Well-coordinated-clumsy Euthymia 2.92±2.92†

Mania 3.35±3.01†

Depression 5.90±3.20* Energetic-lethargic Euthymia 6.48±2.86†

Mania 6.86±2.84†

Depression 3.84±3.46* Contented-discontented Euthymia 3.94±3.15†

Mania 3.59±3.25†

Depression 7.16±2.85* Tranquil-troubled Euthymia 5.30±3.42†

Mania 4.46±3.36†

Depression 2.80±3.28* Quick-witted-mentally slow Euthymia 6.27±2.93†

Mania 5.94±3.04†

Depression 3.76±3.40* Relaxed-tense Euthymia 5.43±3.08†

Mania 4.12±3.07

Depression 3.44±3.35* Attentive-dreamy Euthymia 3.29±2.91†

Mania 3.19±2.92†

Depression 5.81±3.61* Proficient-incompetent Euthymia 7.28±2.43†

Mania 7.14±2.82†

Depression 4.33±3.49* Happy-sad Euthymia 3.69±3.00†

Mania 3.51±3.32†

Depression 6.74±2.77* Amicable-antagonistic Euthymia 6.89±2.84

Mania 6.10±3.40

Depression 6.60±3.07 Interested-bored Euthymia 3.09±2.99†

Mania 1.77±2.01*†

Depression 6.03±3.44* Gregarious-withdrawn Euthymia 6.13±3.25†

Mania 7.27±3.03†

Depression 3.62±3.43* * Different from euthymic patients (p < 0.05). † Different from depressive patients (p < 0.05).

Discussion In our study, most of the items assessed in the VAMS were scored similarly by patients in mania and euthymia, whereas depressive patients self-assessed their mood differently than manic and euthymic patients.

These results confirmed our expectations and are in line

144 – Trends Psychiatry Psychother. 2013;35(2)

with those reported by Jamison et al.1 In that study, of a total of 22 pairs of opposite adjectives, only two showed significant differences in the self-assessment of hypomanic vs. euthymic bipolar patients.

Another study, conducted by Platman et al.,2 also found that, among individuals with bipolar disorder, mood selfassessment is more reliable during depression than during mania. Eleven patients were assessed using the Emotions Profile Index, a scale designed to assess primary emotions.

Self-reported results obtained in depressed patients overlapped with objective assessments made by members of the healthcare team. Nevertheless, a great level of disagreement was observed between self-assessment made by manic patients and the team’s objective measures.

It seems evident that patients in mania do not reliably assess their own affective state, probably as a result of insight impairment, a phenomenon that is not observed in depressive episodes in the same extent.9-16 In a study involving 156 patients with bipolar disorder, insight impairment was assessed according to different affective states using the Scale for Manic States. A higher degree of insight impairment was observed in mania when compared with depression, euthymia, or mixed states.9 A similar study assessed 54 patients with mood disorder, including bipolar and unipolar depression, in both manic and depressive states, using the Spanish version of the Manual for the Assessment and Documentation of Psychopathology.

The authors observed that patients in mania had more severely impaired insight when compared with patients in depression. Conversely, patients with psychotic depression showed more severe insight impairment than those with depression and no psychotic features. Notwithstanding, the presence or absence of psychotic symptoms did not reveal differences among manic patients.16 Another study used the Scale to Assess Unawareness of Mental Disorder (SUMD) to assess 147 bipolar patients and 30 patients with unipolar depression with psychotic features.17 Those authors concluded that insight was related with episode polarity, where patients in a manic episode showed a higher degree of insight impairment than patients in mixed episodes or in bipolar/unipolar depression.12 Insight impairment is also observed in other mental disorders. Some studies17-19 have compared schizophrenic, schizoaffective, and bipolar patients with regard to their insight into illness using the SUMD. Amador et al.17 and Pini et al.18 observed more severe insight impairment in patients with schizophrenia.

Pini et al.,19 in turn, found that schizophrenic patients showed more severely impaired insight when compared with schizoaffective patients and those with unipolar depression with psychotic features. Conversely, the insight of schizophrenic patients was as severely compromised as that of bipolar patients.

Mood self-assessment in bipolar disorder – Silva et al.

The unreliability of mood self-assessment as measured by the VAMS in patients in mania could be related to certain clinical characteristics observed in these individuals, such as cognitive impairment, particularly related to attention and executive functions,20 in addition to impulsivity.21 In this sense, the manic patients assessed in our study may have filled the scale too fast, without much reflection. From a different perspective, however, it remains unclear why their self-assessment errors, induced by impulsivity and hurry, have specifically reproduced the results obtained with euthymic patients rather than random results.

One possible limitation of our study is the fact that the group of patients in mania showed more frequent and more severe psychotic symptoms when compared with patients in depression or euthymia. Because the presence of psychotic symptoms is associated with increased insight impairment,16 the possible influence of these symptoms on the less reliable self-assessment results obtained in manic patients should not be discarded. Another limitation relates to the fact that the same patient was not assessed while in different affective states. A longitudinal study13 involving patients with bipolar disorder assessed using the SUMD reported insight improvement after the resolution of manic episodes. Another similar study following 65 patients with bipolar disorder over 2 years also reported more severe insight impairment in a patient during a manic episode and less severe impairment in the same patient during euthymia or depression.10 The instrument used in that study was the Schedule of Assessment of Insight-Expanded version (SAI-E). The same study showed that insight returned to pre-episode levels in patients who had experienced only one manic episode, but not in patients with multiple episodes of mania, suggesting that insight could become increasingly impaired as a result of successive affective episodes.

Látalova20 found an association between higher levels of insight and improved treatment response in bipolar disorder. According to that author, this relationship is probably mediated by a higher level of adherence to drug treatment, resulting in improvement of psychopathological symptoms and consequently to less severe insight impairment. These findings underscore the importance of psychoeducation in bipolar disorder, leading to increased treatment adherence as a result of improved insight.

Conclusion Our findings suggest that patients with bipolar disorder in manic episodes, but not those in depressive episodes, do not reliably assess their mood state, which probably reflects the more severe insight impairment observed in the manic syndrome. Future studies that control for the occurrence of psychotic symptoms and that assess the same individual at different phases of bipolar disorder are warranted and would greatly contribute to corroborate our findings.

References 1. Jamison KR. Personalidade, transtornos da personalidade e funcionamento interpessoal. In: Goodwin FK, Jamison KR. Doença maníaco-depressiva: transtorno bipolar e depressão recorrente. 2ª ed. Porto Alegre: Artmed; 2010. p. 376-411.

2.

Platman SR, Plutchik R, Fieve RR, Lawlor WG. Emotion profiles associated with mania and depression. Arch Gen Psychiatry. 1969;20:210-4.

3. Del-Ben CM, Vilela JA, Crippa JA, Hallak JE, Labate CM, Zuardi AW. Confiabilidade da Entrevista Clínica Estruturada para o DSM-IV--Versão Clínica traduzida para o português.

Rev Bras Psiquiatr. 2010;23:156-9.

4. Spearing MK, Post RM, Leverich GS, Brandt D, Nolen W. Modification of the Clinical Global Impressions (CGI) Scale for use in bipolar illness (BP): the CGI-BP. Psychiatry Res. 1997;73:159-71.

5. Chaves AC, Shirakawa I. Positive and Negative Syndrome Scale – PANSS and its use in Brazil. Rev Psiquiatr Clin. 1998;25:337-43.

6. Hall RC. Global Assessment of Functioning. A modified scale.

Psychosomatics. 1995;36:267-75.

7. Norris H. The action of sedatives on brain stem oculomotor systems in man. Neuropharmacology. 1971;10:181-91.

8. Zuardi AW, Karniol IG. Estudo transcultural de uma escala de autoavaliações para estados subjetivos. J Bras Psiquiatr.

1981;31:403-6.

9. Cassidy F. Insight in bipolar disorder: relationship to episode subtypes and symptom dimensions. Neuropsychiatr Dis Treat. 2010;6:627-31.

10. Yen CF, Chen CS, Ko CH, Yen JY, Huang CF. Changes in insight among patients with bipolar I disorder: a 2-year prospective study. Bipolar Disord. 2007;9:238-42.

11. Yen CF, Chen CS, Yeh ML, Yang SJ, Ke JH, Yen JY. Changes of insight in manic episodes and influencing factors. Compr Psychiatry. 2003;44:404-8.

12. Dell’Osso L, Pini S, Cassano GB, Mastrocinque C, Seckinger RA, Saettoni M, et al. Insight into illness in patients with mania, mixed mania, bipolar depression and major depression with psychotic features. Bipolar Disord. 2002;4:315-22.

13. Bressi C, Porcellana M, Marinaccio PM, Nocito EP, Ciabatti M, Magri L, et al. The association between insight and symptoms in bipolar inpatients: an Italian prospective study.

Eur Psychiatry. 2012;27:619-24.

14.

Ghaemi SN, Rosenquist KJ. Is insight in mania statedependent? J Nerv Ment Dis. 2004;192:771-5.

15. Weiler MA, Fleisher MH, McArthur-Campbell D. Insight and symptom change in schizophrenia and other disorders.

Schizophr Res. 2000;45:29-36.

16. Peralta V, Cuesta MJ. Lack of insight in mood disorders. J Affect Disord. 1998;49:55-8.

17. Amador XF, Flaum M, Andreasen NC, Strauss DH, Yale SA, Clark SC, et al. Awareness of illness in schizophrenia and schizoaffective and mood disorders. Arch Gen Psychiatry.

1994;51:826-36.

18. Pini S, Cassano GB, Dell’Osso L, Amador XF. Insight into illness in schizophrenia, schizoaffective disorder, and mood disorders with psychotic features. Am J Psychiatry. 2001;158:122-5.

19. Pini S, de Queiroz V, Dell’Osso L, Abelli M, Mastrocinque C, Saettoni M, et al. Cross-sectional similarities and differences between schizophrenia, schizoaffective disorder and mania or mixed mania with mood-incongruent psychotic features.

Eur Psychiatry. 2004;19:8-14.

20.

Látalova K. Insight in bipolar disorder. Psychiatr Q. 2012;83:293-310.

21. Adida M, Clark L, Pomietto P, Kaladjian A, Besnier N, Azorin JM, et al. Lack of insight may predict impaired decision making in manic patients. Bipolar Disord. 2008;10:829-37.

Correspondence Rafael de Assis da Silva Rua Largo do Machado, 29/411, Catete 22221-020 - Rio de Janeiro, RJ - Brazil E-mail: rafaelpsiq@gmail.com Trends Psychiatry Psychother. 2013;35(2) – 145

Trends

Book Review

in Psychiatry and Psychotherapy

O uso de antidepressivos na clínica médica The use of antidepressants in medicine Carlos Alberto Crespo de Souza (editor) Porto Alegre, Sulina, 2011

Lisieux Elaine de Borba Telles*

The high prevalence of depressive disorders requires physicians of the different specialties to get into contact with patients who have this pathology and its different comorbidities. Appropriate treatment of this disorder initially requires a correct diagnostic evaluation and the rational prescription of medications.

According to a very appropriate statement by Prof.

João Romildo Bueno in the Preface of the book O uso de antidepressivos na clínica médica, we should be alert against transforming the use of pharmaceutical drugs into commonplace. The author also stated that works should be written about the correct use of antidepressant substances. The book here reviewed has appeared to satisfy this need. It was published by the Sulina publishing house in 2011, with 13 chapters written by the organizer and well-known colleagues from different national academic centers. In addition to their technical quality, the chapters have broad, up-to-date reviews that are very useful for physicians working in primary care, residents, specialists in different fields of medicine, and experienced psychiatrists.

In Chapters 1 and 2, which are rather extensive, the organizer describes the history and development of the use of these drugs, as well as practical information about their use, dosage, interactions and contraindications, discontinuation syndrome, risk of cholinergic effects, and toxicity. The use of antidepressants at different times

of the life cycle, in different medical specialties, and in the most prevalent pathologies is described, and topics of clinical relevance to modern medicine are discussed, always with clear, easily understandable language.

In Chapters 3 and 4, written by Carlos Alberto Crespo de Souza, pharmacogenomics and the HapMap Project are discussed in a logical and didactic way, making it easy for future psychiatrists to understand the use of genotyping. According to the reading of these texts, this future is very near to us, and will enable genetic testing before the use of antidepressants. This will allow a more appropriate choice and less adverse effects.

Chapter 5, by Gibsi Maria Possapp Rocha, focuses on the use of antidepressants in adolescence. She alerts to the early onset of signs of depression and to the comorbidities present in this phase, such as anxiety disorders, psychoactive substance abuse, and disruptive disorders. She also calls the reader’s attention to the risk of suicide at different times over the course of the disorder and its treatment. The chapter also contains a review of the most appropriate drugs for this period in life.

In Chapter 6, the organizer discusses the use of antidepressants in gastroenterology. The most prevalent “functional diseases” are studied one by one, and the interface between gastroenterology and psychiatry is carefully reviewed. Other topics of interest are presented, such as the adequate use of antidepressants in patients

* MD, PhD. Forensic psychiatrist, Instituto Psiquiátrico Forense Dr. Maurício Cardoso, Porto Alegre, RS, Brazil. Supervisor, Forensic Psychiatry Residency, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil. lisieux@telles.med.br Financial support: none.

Submitted Jan 10 2013, accepted for publication Jan 28 2013. No conflicts of interest declared concerning the publication of this review.

Suggested citation: Telles LE. O uso de antidepressivos na clínica médica [book review]. Trends Psychiatry Psychother. 2013;35(2):000-000.

© APRS

Trends Psychiatry Psychother. 2013;35(2) – 146-147

Book Review

with liver disease and inflammatory bowel disease, side effects of antidepressants on the digestive tract, drug interactions and discontinuation in such situations.

Chapter 7, written by Mauro Barbosa Terra, discusses antidepressants in chemical addictions. In this chapter, the reader finds a complete review of interactions and beneficial effects of these drugs on both dependence on different psychoactive substances and frequent comorbid pathologies.

The authors of Chapter 8, Alfredo Cataldo Neto, Aroldo Ayud Dargél, Cristiano Tschieldel Belém da Silva, and Eduardo Lopes Nogueira, writing about the use of antidepressants in the elderly, highlight the difficulties involved in diagnosing depression in this phase of the life cycle; they also discuss the frequent use of multiple drugs and subtherapeutic doses of antidepressants. They provide readers with a broad review of the conscientious use of these drugs.

Another vulnerable population that deserves attention is organ transplant patients, in whom the long duration of the disease, combined with uncertainties about the future, contribute to the onset of depression.

Treatment with drugs is very sensitive in these cases and requires care and adaptation to the specific type of organ transplanted. These items are dealt with in Chapter 9 by Alcir Tadeu Giglio.

The use of antidepressants in medical situations that are complex due to difficulties performing diagnosis and/ or treatment, e.g., patients with chronic pain/fibromyalgia or eating disorders, is meticulously described in Chapter 10 by Rogério Gottert Cardoso and in Chapter 11 by the organizer and Guilherme Modkovski. In the latter

chapter, the presence of comorbidities and physiological changes resulting from pathological eating behaviors and their effects on the use of antidepressants are discussed, with emphasis on the extra care needed in these cases, such as the performance of laboratory tests to follow vital functions.

Chapter 12, written by the organizer, together with Miguel Abib Adad and Luciane Miozzo, is dedicated to a significant expression of human behavior: sexuality. This chapter studies antidepressants and sexual dysfunction, with an interesting investigation of the characteristics that distinguish human sexuality from that of animals, the influences of culture, religion, and even politics on the organization of rules and standards regulating this construct. Other aspects are also explored, e.g., the history of the study of sexuality, its evolution among humans, sexual cycle and its physiology, hormones responsible for physiological effects, definition of sexual dysfunction, determining factors, and therapeutic measures available at present.

Finally, but not less important, the organizer writes a few comments and conclusions about the texts presented, concluding that the book was conceived to become part of modern medicine, sharing recent studies and research, so that it will provide our fellow physicians from different related specialties with alternatives for a better understanding and use of up-to-date knowledge, while at the same time providing valuable contributions found in the history of medicine.

I wish you all good reading, certain that this book will provide knowledge, up-to-date information, and an incentive for good daily medical practice.

Trends Psychiatry Psychother. 2013;35(2) – 147

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8) Book Reviews: Critical review of recently published books, including a commented synopsis and opinions so as to provide an overview of the publication and guide the reader regarding its characteristics and potential uses. These texts should be brief and written by experts in the field. Complete bibliographic information on the book should be provided before the text, and the name, academic degree and affiliation of the author submitting the book review should be included following the text.

Title page The following information should appear on the title page: 1) title of the article, which should be concise and complete, with the corresponding translation into Brazilian Portuguese, if possible; 2) short title; 3) names of the authors (typed exactly as they should appear in print), profession and main affiliation;

4) full address information for every author; 5) name of the department and institution with which the work is associated; 6) identification of the corresponding author, providing full postal address (including ZIP code), phone and fax numbers, and e-mail address; 7) financial support disclosure, if applicable; 8) conflict of interest statement; 9) information on the use of informed consent and on the approval of the study protocol by the institution’s ethics committee; 10) copyright transfer statement; 11) articles based on academic theses or dissertations should provide the title of the original work, year and name of the institution where the work has been presented; 12) papers previously presented at scientific meetings should provide the name, location and date of the event; 13) word count of main text (not including title page, abstract, references, and tables/figures); 14) type of article being submitted (original article, review article, case report, letter, etc.); 15) date of the last literature review performed by the author(s) on the manuscript topic.

Abstract and keywords After the title page, an abstract should be provided following the word limits and structure defined for each type of article (see above). Three to six keywords should be provided following the abstract. Keywords should be compliant with the Medical Subject Headings (MeSH, http://www.nlm.nih.gov/mesh/meshhome.html), published by the National Library of Medicine. If possible, a Brazilian Portuguese translation of the abstract (resumo) and keywords (palavras-chave) should also be provided; in this case, the palavras-chave should be compliant with the DeCS database (DeCS – Descritores em Ciências da Saúde) published by BIREME. Statistical analysis Authors should demonstrate that the statistical procedures employed in the study were not only appropriate to test the hypotheses of the study but also correctly interpreted. Levels of statistical significance (e.g., p < 0.05, p < 0.01, p < 0.001) should be provided.

Abbreviations Abbreviations should be spelled out in the text at first mention. Thereafter, only the abbreviation should be used.

Drugs Drugs should be referred to by their generic name only.

Acknowledgments This section should disclose any sources of financial support received by the study. In addition, this section should acknowledge people, groups or institutions which have made important contributions to the study but do not meet the criteria for authorship (e.g., technical assistance, statistical analysis, writing, etc.).

References References should be numbered consecutively in the order in which they are first mentioned in the text, using superscript Arabic numerals, avoiding the use of author names. References cited only in tables or figure legends should be numbered consecutively respecting their first mention in the text.

References should be listed at the end of the article according to their order of citation in the text and should comply with the ICMJE norms. The accuracy of references is the responsibility of the authors, both in the sense of making sure that all works cited in the text appear in the list and vice-versa, and in the sense of respecting the norm.

For journal articles, we adopt the ICMJE format that omits issue number, day and month of publication (only year should be informed).

Example: Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

Tables and figures Tables should not be submitted as images. Instead, they should be created using word processor tools specifically designed for this purpose. Do not underline or draw lines inside the tables. Do not insert spaces to separate columns.

Explanatory notes should be presented as table footnotes, identified by the following symbols, in this sequence: *, †, ‡, §, ||

, ¶, **,

, etc. Tables should be numbered consecutively using Arabic numerals. Each table should appear on a separate

††

page and have a concise title. Tables should be cited in the text and should not duplicate information contained in the text.

Figures (photographs, illustrations, graphs, drawings, etc. – all referred to as figures) should also be numbered consecutively using Arabic numerals, and should be submitted as separate files (preferably .tif), with a minimum resolution of 300 dpi. Photographs should not allow patient identification. Each figure should include a legend, containing the title of the figure and explanatory notes when necessary. All figure legends should appear together on one separate page at the end of the text file.

Previously published tables and figures should be accompanied by written permission of the copyright holder.

Instruções aos autores Setembro de 2012

Objetivo A revista Trends in Psychiatry and Psychotherapy é uma publicação multidisciplinar revisada por pares (peer-reviewed) que garante publicar com rapidez artigos originais e revisões sólidas com foco na interação entre pesquisa experimental e pesquisa clínica na área de psiquiatria e saúde mental. Outros tipos de artigos que tenham como objetivo principal ajudar a traduzir descobertas fundamentais da pesquisa básica para a realidade da prática clínica psiquiátrica também serão considerados (ver a seguir os tipos de artigos aceitos). Os artigos podem verter sobre processos psicológicos e comportamento, neuropsicologia, psicofarmacologia, neurociência clínica, psicoterapia e outras áreas de relevância para um ou mais aspectos da psicopatologia e psiquiatria.

A revista tem como objetivo publicar pesquisa atual e original em áreas que cubram o amplo espectro da psiquiatria clínica e ciência básica, produzida por autores e instituições nacionais e internacionais com expertise em sua área de atuação.

A Trends é publicada trimestralmente e é a publicação oficial da Associação de Psiquiatria do Rio Grande do Sul (APRS).

Estas normas foram desenvolvidas com base nos Uniform Requirements for Manuscripts Submitted to Biomedical Journals: Writing and Editing for Biomedical Publication, documento produzido e atualizado pelo International Committee of Medical Journal Editors (ICMJE). O texto integral do documento, em inglês, está disponível on-line no endereço http:// www.icmje.org/.

A Trends está de acordo com as políticas para registro de ensaios clínicos da Organização Mundial da Saúde (OMS) e do ICMJE, reconhecendo a importância dessas iniciativas para o registro e divulgação internacional de informações sobre estudos clínicos, em acesso aberto. Sendo assim, seguindo as orientações da BIREME/OPAS/OMS para a indexação de periódicos na LILACS e SCIELO, somente serão aceitos para publicação artigos de pesquisas clínicas que tenham sido cadastrados em um dos Registros de Ensaios Clínicos validados pelos critérios estabelecidos pela OMS e ICMJE, cujos

endereços estão disponíveis no site do ICMJE: http://www.icmje.org/faq.pdf. O número de identificação do registro deverá ser informado ao final do resumo.

Envio do manuscrito As submissões à Trends devem ser feitas exclusivamente através do sistema on-line ScholarOne Manuscripts, disponível no endereço http://mc.manuscriptcentral.com/trends. É necessário efetuar o registro dos dados de acesso (login e senha) antes de realizar a submissão.

O sistema apresenta vários campos obrigatórios e alguns campos opcionais. Um dos campos obrigatórios diz respeito à indicação de potenciais revisores para o manuscrito submetido. Os autores deverão informar nome, email e instituição/ afiliação para cinco potenciais revisores, ou seja, experts no assunto, atuantes no Brasil ou no exterior, que não apresentem conflito de interesse para executar a tarefa (por exemplo, os indicados não podem ser do mesmo grupo de trabalho dos autores). A decisão final sobre quais revisores serão convidados para avaliar cada manuscrito fica a cargo dos editores.

Para obter suporte ao uso do siste ma e informações sobre artigos submetidos, favor contatar Denise Arend no email trends.denise@gmail.com ou no telefone (51) 9829.1725. Para obter outras informações sobre a revista, favor contatar a secretaria da APRS no telefone (51) 3024.4846.

Idioma de publicação Os artigos submetidos à Trends devem ser escritos preferencialmente em língua inglesa. Artigos em português também poderão ser submetidos, mas sua aceitação ficará condicionada à tradução da versão final para inglês, ficando os custos sob a responsabilidade dos autores (a revista pode indicar contatos de tradutores/revisores). Somente serão submetidos à revisão por pares (peer review) manuscritos escritos em linguagem clara e compreensível.

Processo de revisão (peer review) Os artigos submetidos à Trends serão, inicialmente, avaliados pelos editores quanto à conformidade entre o conteúdo apresentado e a linha editorial da revista. Se o artigo se enquadrar na política editorial da Revista e estiver de acordo com as instruções para autores, o trabalho será submetido a análise por dois revisores escolhidos pelos editores; os revisores escolhidos serão mantidos no anonimato. Dentro de 60 dias, os autores serão informados a respeito da aceitação ou das modificações sugeridas pelo Conselho Editorial. Cópias dos pareceres dos revisores serão enviadas aos autores. Os manuscritos aceitos condicionalmente serão enviados para os autores para que sejam efetuadas as modificações. Os autores deverão retornar o texto com as modificações solicitadas, no prazo máximo de 30 dias, devendo justificar caso alguma das solicitações não tenha sido atendida. A ausência de manifestação do autor no prazo citado será entendida como desistência de seguimento do processo de submissão. Após as modificações, o artigo será, então, enviado novamente aos revisores, que emitirão um novo parecer, definindo a aceitação, a necessidade de novas correções ou a recusa do artigo. Baseada nos pareceres, a decisão final caberá aos editores.

Normas gerais de publicação 1. Artigos que apresentarem inconformidades com as normas descritas a seguir serão devolvidos para correção antes de serem submetidos à revisão por pareceristas.

2. Os artigos submetidos à Trends são aceitos com base no pressuposto de que o material é original, ou seja, não foi publicado anteriormente no todo ou em parte e não foi nem está sendo submetido simultaneamente para publicação em outra(s) revista(s). A prévia apresentação do trabalho sob a forma de resumo ou pôster em encontros científicos (congressos, jornadas, etc.) é permitida, mas deve ser informada na folha de rosto do artigo.

3. Todos os autores devem ter participado ativamente da concepção do trabalho, da análise e interpretação dos dados e da redação ou revisão crítica do artigo. Além disso, todos os autores devem ter lido e aprovado a versão final do texto.

4. Uma vez que o artigo é publicado, os direitos autorais sobre a publicação passam automaticamente à Trends, e a reprodução do texto no todo ou em parte passa a requerer autorização por escrito dos editores. Os conceitos e declarações contidos nos trabalhos são de total responsabilidade dos autores.

5. A Trends é publicada em forma impressa e também on-line, no SciELO. 6. Um autor deverá ser identificado como responsável pela correspondência, informando endereço completo (incluindo CEP), fone, fax e e-mail de contato.

7. Quaisquer conflitos de interesse (por exemplo, profissionais, financeiros e benefícios diretos e indiretos) devem ser mencionados na carta e na folha de rosto do artigo.

8. Nos ensaios clínicos, o anonimato deve ser preservado, e os autores devem descrever claramente, na metodologia, a existência e aplicação do consentimento informado, assim como a aprovação do protocolo pelo comitê de ética da instituição na qual o estudo foi realizado. Uma declaração informando que o ensaio foi cadastrado em um dos Registros de Ensaios Clínicos validados pelos critérios estabelecidos pela OMS e ICMJE (endereços disponíveis em http://www.icmje.org/faq.pdf) também deve ser incluída. Essas informações têm que estar presentes tanto na carta quanto na folha de rosto do artigo.

9. Os artigos devem ser digitados em um processador de texto para PC (Word ou similar) em folha A4, fonte Arial 12 e espaço duplo (incluindo tabelas e referências), com margens de 3 cm em todos os lados. Todas as páginas devem ser numeradas.

Conflitos de interesse Todos os autores deverão informar qualquer conflito de interesse real ou em potencial relacionado à publicação do artigo, incluindo relações financeiras, pessoais ou de outra natureza com outras pessoas ou empresas que possam influenciar de forma inapropriada, ou que possam ser percebidas como possivelmente influenciando, os resultados do seu trabalho (ver exemplos abaixo). Na ausência de conflitos de interesse, os autores devem incluir a seguinte declaração na folha de rosto: “Os autores declaram que não há conflitos de interesse associados à publicação deste artigo”. Em caso de dúvida, consulte a secretaria editorial.

Exemplos de conflitos de interesse financeiros

• Reembolsos, taxas, financiamentos ou salários recebidos de uma organização que possa de alguma forma ganhar ou perder financeiramente a partir da publicação do artigo, agora ou no futuro.

• Ações ou quotas em uma organização que possa de alguma forma ganhar ou perder financeiramente a partir da publicação do artigo, agora ou no futuro.

• Reembolsos, taxas, financiamentos ou salários recebidos de uma organização detentora de patentes ou que solicitou o registro de patentes relacionadas ao conteúdo do artigo.

Exemplos de conflitos de interesse não financeiros

Qualquer interesse político, pessoal, religioso, ideológico, acadêmico, intelectual, comercial ou de outra natureza relacionado com o artigo.

Tipos de artigos publicados 1) Editoriais: Comentários críticos e aprofundados, preparados pelos editores e/ou a convite dos editores, por pessoas com notória experiência no assunto abordado.

2) Trends: Esta seção oferece ao autor a oportunidade de apresentar críticas ou abordar controvérsias em algum tópico atual. Os artigos da seção Trends normalmente são publicados mediante convite, mas qualquer autor interessado pode entrar em contato com o Editor.

3) Artigos Originais: Apresentam resultados inéditos de pesquisa e devem conter todas as informações relevantes necessárias para que o leitor possa repetir o experimento se assim desejar, além de avaliar seus resultados e conclusões.

Sua estrutura formal deve apresentar as seguintes divisões: Introdução, Método, Resultados, Discussão, Conclusão e outras subdivisões, se necessárias. Os artigos podem conter até 6.000 palavras para o texto propriamente dito e podem ter, no máximo, seis tabelas ou figuras. Para esses artigos, deve-se apresentar um resumo estruturado com no máximo 250 palavras e subdivisões obedecendo a apresentação formal do artigo.

4) Comunicações Breves: Artigos com dados originais, porém mais curtos, com resultados preliminares ou de relevância imediata. Devem conter no máximo 2.000 palavras, uma tabela ou figura e ser compostas das seções Introdução,

Método, Resultados e Discussão. Para esses artigos, deve-se apresentar um resumo estruturado com no máximo 200 palavras e subdivisões obedecendo a apresentação formal do artigo.

5) Artigos de Revisão: Revisões sistemáticas e atuais sobre temas relevantes para a linha editorial da revista. Esses artigos se destinam a englobar e avaliar criticamente os conhecimentos disponíveis sobre determinado tema, comentando trabalhos de outros autores. Devem ter até 7.000 palavras, e a soma de tabelas e figuras não deve ultrapassar o total de seis. Não há um formato fixo para a estrutura formal do texto, porém os artigos devem ser acompanhados de um resumo não-estruturado com até 250 palavras.

6) Relatos de Caso: Apresentação de experiência profissional, através de estudos de caso único ou de um conjunto de casos peculiares com comentários sucintos de interesse à atuação de outros profissionais da área. Devem conter no máximo 1.500 palavras. O autor deverá empregar todos os esforços para preservar o anonimato do paciente, sem distorcer dados científicos relevantes. Deve ser feita menção explícita à existência de consentimento livre e esclarecido do paciente para a publicação dos dados (em meio impresso e eletrônico) ou justificativa do autor para a ausência do consentimento. Relatos de caso devem ser acompanhados de um resumo de até 200 palavras estruturado com as subdivisões Objetivo, Descrição do caso e Comentários.

7) Cartas aos Editores: Opiniões e comentários sobre material publicado na revista, sua linha editorial, temas de relevância científica, observações clínicas ou dados novos. Os textos devem ser breves, com no máximo 500 palavras.

Apenas uma tabela e uma figura são permitidas.

8) Resenhas: Revisão crítica de livros recém-publicados, com um resumo comentado e opiniões que possam dar uma visão geral da obra e orientar o leitor quanto a suas características e usos potenciais. Devem ser breves, preparadas por especialistas da área. Antes do texto, deve-se incluir a referência bibliográfica completa da obra, e no final, a assinatura, titulação acadêmica e afiliação institucional do autor da resenha.

Folha de rosto As seguintes informações devem constar na primeira página: 1) título do artigo, que deve ser conciso e completo, com a respectiva versão em inglês; 2) título abreviado; 3) nomes dos autores na forma como deverão ser publicados, categoria profissional e afiliação institucional principal; 4) endereço completo de todos os autores; 5) nome do departamento e instituição aos quais o trabalho deve ser atribuído; 6) indicação do autor responsável pela correspondência e dados completos para contato; 7) nome da agência de fomento que concedeu auxílio, se houver; 8) indicação de conflitos de interesse; 9) indicação de obtenção de consentimento informado e de aprovação do protocolo pelo comitê de ética; 10) declaração de transferência de direitos autorais; 11) se o artigo foi baseado em tese acadêmica, indicação de título da tese, ano e instituição onde foi apresentada; 12) se o artigo foi apresentado em reunião científica, indicação do nome do evento, local e data da realização;\ 13) contagem de palavras do texto do artigo (sem incluir página de rosto, abstract, resumo, referências e tabelas/figuras); 14) classificação do tipo de artigo que está sendo submetido (artigo original, artigo de revisão, relato de caso, carta, etc.); 15) data da última revisão bibliográfica realizada pelo(s) autor(es) sobre o assunto.

Resumo e palavras-chave Após a folha de rosto, deve ser apresentado um resumo em português e um abstract em inglês de acordo com os limites de palavras e estrutura definidos para cada tipo de artigo (ver acima). Após o resumo e o abstract, devem ser indicados três a seis descritores em português, de acordo com os Descritores em Ciências da Saúde (DeCS, http://decs. bvs.br) publicados pela BIREME, e 3 a 6 descritores em inglês, de acordo com os Medical Subject Headings (MeSH, http:// www.nlm.nih.gov/mesh/meshhome.html) publicados pela National Library of Medicine.

Análise estatística Os autores devem demonstrar que os procedimentos estatísticos utilizados foram não somente apropriados para testar as hipóteses do estudo, mas também corretamente interpretados. Os níveis de significância estatística (por exemplo, p < 0,05, p < 0,01, p < 0,001) devem ser mencionados.

Abreviações As abreviações devem ser definidas no texto no momento de sua primeira utilização. Em seguida, não se deve repetir o nome por extenso.

Medicamentos Devem ser mencionados apenas por seu nome genérico.

Agradecimentos Nesta seção devem ser citadas todas as fontes de apoio financeiro recebidas pelo estudo. Além disso, deve-se listar pessoas, grupos ou instituições que merecem reconhecimento mas que não têm justificadas suas inclusões como autores (por exemplo, auxílio técnico, análise estatística, redação, etc.)

Referências A citação das referências no texto deve ser numérica e sequencial, conforme a ordem de aparecimento, utilizando algarismos arábicos sobrescritos, evitando indicar o nome dos autores. A numeração de referências citadas em tabelas e legendas de figuras deve respeitar a ordem sequencial considerando o ponto onde a tabela/figura foi mencionada no texto.

Referências devem ser listadas no final do artigo conforme a ordem de citação no texto, de acordo com as normas do ICMJE. A exatidão das referências é responsabilidade dos autores, tanto no sentido de garantir que todos os trabalhos citados no texto constam na lista e vice-versa, quanto no sentido de respeitar a norma seguida pela revista.

Para artigos de periódico, adotamos a forma sugerida pelo ICMJE sem menção ao número e ao mês/dia de publicação (apenas o ano deve ser informado).

Exemplo: Halpern SD, Ubel PA, Caplan AL. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7 Tabelas e figuras Tabelas não devem ser submetidas como imagens, e sim produzidas utilizando a ferramenta específica para este fim disponível no processador de texto. Não sublinhar ou desenhar linhas dentro das tabelas, não usar espaços para separar colunas. Explicações complementares às tabelas devem ser apresentadas como notas de rodapé, identificadas pelos seguintes símbolos, nesta sequência: *, †, ‡, §, ||, ¶, **,

, etc. As tabelas devem ser numeradas em ordem consecutiva,

††

com algarismos arábicos. Cada tabela deve constar em uma folha separada, com um título conciso. Devem ser citadas no texto, sem duplicação de informação.

Figuras (fotografias, ilustrações, gráficos, desenhos, etc., todos denominados de figuras) também devem ser numeradas em ordem consecutiva, com algarismos arábicos, e devem ser enviadas em arquivos separados (.tif, preferencialmente), com resolução mínima de 300 dpi. Fotografias de pacientes não devem permitir sua identificação. Cada ilustração deve ter uma legenda, incluindo o título da figura e explicações complementares, quando necessário. As legendas de figuras devem ser apresentadas reunidas em uma única página ao final do arquivo de texto.

Tabelas e figuras retiradas de trabalhos já publicados devem ser acompanhadas de autorização por escrito do detentor do direito autoral.

LUAN COMUNICAÇÃO

Palestrantes internacionais W. Vaughn McCall, M.D., M.S. Dr. McCall é Case Distinguished Professor e Chairman of the Department of Psychiatry and Health Behavior na Georgia Health Sciences University. médica e pós-graduado na Duke University. Mestre em epidemiologia na Wake Forest University.

Doutor Jair. C. Soares Doutor em Medicina pela Escola de Medicina da Universidade de São Paulo, Brasil.

Residencias em Psiquiatria Geral na Universidade de São Paulo e na Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center. Pós-doutorado em pesquisa de neuroimagem no departamento de Psiquiatria da Yale School of Medicine.

Professor and Chairman of Psychiatry and Behavioral Sciences, na University of Texas Medical School em Houston, diretor executivo da University of Texas Health Harris County Psychiatric Center, co-diretor da University of Texas Health Center of Excellence on Mood Disorders. Cátedra Pat R. Rutherford, Jr in Psychiatry na UTHealth.

Renato D. Alarcón, M.D., M.P.H. Professor Emérito e Consultor em psiquiatria da Clinica Mayo e de sua escola de Medicina em Rochester (Minnesota – EUA), Titular da Cátedra Honório Delgado, da Universidade peruana Cayetano Heredia (UPCH), em Lima (Perú). Médico Cirurgião na UPCH, Residência Psiquiátrica no Hospital John Hopkins, Mestre em Saúde Pública da Escola de Higiene e Saúde Pública de Hopkins. Professor de psiquiatria da Universidade do Alabama (Birmingham) e subchefe do Departamento de Psiquiatria da Universidade de Emory em Atlanta (Georgia).

Philip W. Gold Chief, Clinical Neuroendocrinology Branch Intramural Research Program NIH/NIMH NIH Clinical Center

Judith S. Beck, Ph.D. Judith S. Beck, Ph.D, é presidente do Beck Institute for Cognitive Behavior Therapy, organização sem fins lucrativos fundada em 1994 na Filadélfia, cujo co-fundador é Aaron T. Beck, M.D. Através do Instituto ela treinou milhares de profissionais das áreas da saúde e saúde mental, tanto a nível nacional como internacional. Ela é também Professora Clínica Associada de Psicologia e Psiquiatria na Universidade da Pennsylvania. Dra. Beck obteve seu doutorado pela Universidade da Pennsylvania em 1982 e atualmente ocupa seu tempo entre ensino e supervisão, administração, trabalho clínico, desenvolvimento de programas, pesquisa e escrevendo.

Dra. Beck escreveu cerca de 100 artigos e capítulos e fez centenas de apresentações, em nível nacional e internacional, sobre uma variedade de tópicos relacionados à terapia cognitivo-comportamental.

Dr. Fernando IvanovicZunic Ramírez Médico psiquiatra da Escola de Pósgraduação da Universidade do Chile Bacharel em Filosofia da Pontifícia Universidade Católica do Chile Professor associado na Faculdade de Medicina da Universidade do Chile Professor associado da Escola de Psicologia, na Faculdade de Ciências Sociais da Universidade do Chile.

Chefe de pós-graduação da Clinica Psiquiátrica Universitária da Faculdade de Medicina da Universidade do Chile.

Chefe da Unidade de Transtornos Bipolares da Clinica Psiquiátrica Universitária da Faculdade de Medicina da Universidade do Chile.

Presidente da Sociedade de Neurologia, Psiquiatria e Neurocirurgia do Chile (SONEPSYN)

Informações: www.cbpabp.org.br