Tratamiento del paciente con trastorno límite de la personalidad en urgencias : efectividad de los antipsicóticos atípicos /

Consultable des del TDXTítol obtingut de la portada digitalitzadaEl tratamiento de los pacientes con trastorno límite de la personalidad (TLP) es uno de los retos más difíciles para el psiquiatra en la práctica clínica. Su manejo es especialmente complejo en los servicios de urgencias psiquiátricas cuando acuden en situación de crisis y manifiestan los síntomas más severos como trastornos conductuales y elevado riesgo suicida. Según las recomendaciones de la Guía de la APA, el tratamiento principal para el TLP es la psicoterapia complementada con la farmacoterapia para aquellos síntomas que más alteran la calidad de vida. Sin embargo, hasta la fecha no existe ningún fármaco con la indicación oficial para el tratamiento del TLP. Aún sin indicación, en la práctica clínica los psiquiatras usan antipsicóticos para tratar pacientes con TLP especialmente en situación de crisis. Con la aparición de los antipsicóticos atípicos, se ha renovado el interés por su posible utilidad en el tratamiento del TLP. Los trabajos publicados hasta la fecha sugieren su posible eficacia, sin embargo, no existe un nivel de evidencia científica que apoye su recomendación. El objetivo general de la tesis es profundizar en el conocimiento de la práctica clínica habitual con pacientes con TLP en los servicios de urgencias y evaluar la efectividad de los antipsicóticos atípicos en el tratamiento de estos pacientes. Se han realizado trabajos observacionales que describen la práctica clínica que se realiza habitualmente en los servicios de urgencias psiquiátricas y ensayos clínicos farmacológicos con antipsicóticos atípicos. En primer lugar se analizó una muestra de más de 11.000 pacientes que acudieron a Urgencias de psiquiatría del Hospital del Mar durante 4 años. Se estudiaron las características clínicas y de manejo terapéutico de los pacientes diagnosticados de TLP incidiendo en los factores que predecían la necesidad de hospitalización como el riesgo de suicidio y de prescripción de fármacos. También se analizó la posible relación entre el fenómeno de la inmigración y el riesgo de ser diagnosticado de TLP. Destacó la menor prevalencia de TLP en pacientes inmigrantes y la importante influencia del lugar de origen del inmigrante en esta asociación ya que pacientes subsaharianos y asiáticos presentaron una tasa especialmente baja. A continuación se analizaron las características de los pacientes agitados que acudían a urgencias de psiquiatría del Hospital de la Santa Creu i Sant Pau y el manejo farmacológico que se realizaba. Destacó la elevada prevalencia de pacientes con diagnóstico de trastorno de personalidad (24%) y el elevado uso de antipsicóticos atípicos en la práctica clínica para tratar estos pacientes mostrándose como fármacos efectivos y seguros. Posteriormente se analizó la posible efectividad de los nuevos antipsicóticos atípicos en el tratamiento específico de pacientes con TLP. En primer lugar se realizó un estudio abierto no controlado con antipsicóticos atípicos intramusculares (olanzapina y ziprasidona) en el tratamiento de los pacientes con TLP que acudían a urgencias de psiquiatría en estado de agitación evidenciándose su utilidad y seguridad. Posteriormente, también se observó en un estudio no controlado la eficacia de la ziprasidona en pacientes con TLP que acudían a Urgencias en situación de crisis. Finalmente, ante las evidencias de eficacia en urgencias en estudios abiertos, se realizó un ensayo clínico controlado, aleatorizado, doble ciego y controlado con placebo para evaluar la eficacia de la ziprasidona en el tratamiento de mantenimiento de pacientes con TLP. En este estudio no se observaron diferencias significativas entre ziprasidona y placebo no mostrándose como un fármaco eficaz en el tratamiento de mantenimiento de pacientes con TLP.The treatment of patients with Borderline Personality Disorder (BPD) is one of the most difficult challenges a psychiatrist faces in clinical practice. Its management is especially complex in the psychiatric emergency services when patients come in crisis and show the most severe symptoms such as conduct disorders and high risk of suicide. Following the APA guideline's recommendations, the primary treatment for BPD is psychotherapy complemented by pharmacotherapy targeted to the symptoms that affect the quality of life. However, still there is not an officially established drug for BPD treatment. But even without indication, in clinical practice the psychiatrists use antipsychotics for treating patients with BPD, especially in crisis. Since the atypical antipsychotics appearance there has been a renewed interest in its possible utility for treating BPD. The studies published to date suggest its possible effectiveness, however it does not exist enough scientific evidence that supports its recommendation. The general aim of the thesis is to deepen our knowledge about the usual clinical practice with BPD patients in emergency services and to assess the effectiveness of atypical antipsychotics in the treatment of these patients. There have been observational studies that describe the usual clinical practice carried out in the psychiatric emergency services and pharmacological clinical trials with atypical antipsychotics. Firstly, a sample of more than 11,000 patients that came to the psychiatric emergency service of the Hospital del Mar over 4 years was analysed. The clinical features and therapeutic management of patients diagnosed with BPD were studied, emphasizing on the predictive factors of hospitalization, like the risk of suicide, and drug prescription. The possible association between the immigration and the risk of being diagnosed with BPD was also analysed. It stood out the less prevalence of BPD among immigrant patients and the important influence of the immigrant's region of origin in this association as the Sub-Saharan and Asian patients showed an especially low rate. Next were analysed the characteristics of the agitated patients that came to the psychiatric emergency services of the Hospital de la Santa Creu i Sant Pau and the pharmacological management carried out. It was showed the high prevalence of patients diagnosed with Personality Disorder (24%) and the high use of atypical antipsychotics in clinical practice for treating these patients, showing its effectiveness and security. Subsequently, the possible effectiveness of the new atypical antipsychotics in the specific treatment of patients with BPD was analysed. Firstly, an open not controlled study was carried out with intramuscular atypical antipsychotics (olanzapine and ziprasidone) in the treatment of patients with BPD that came to the psychiatric emergency service in a state of agitation proving its usefulness and security. Later, in a not controlled study, it was also observed the effectiveness of ziprasidone in patients with BPD that came to the emergency services in crisis. Finally, based on the evidence of effectiveness in the emergency service in open studies, a randomized, double-blind, placebo-controlled clinical trial was carried out to assess the efficacy of ziprasidone in the maintenance treatment of patients with BPD. In this study no differences were observed between ziprasidone and placebo, showing it was not an efficacy drug in the maintenance treatment of patients with BPD

Pharmacological Management of Borderline Personality Disorder and Common Comorbidities

Comorbidity between borderline personality disorder (BPD) and other mental disorders is common. Although no specific pharmacological treatments have been approved for the treatment of BPD, many drugs, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), mood stabilizers, second-generation antipsychotics, and even benzodiazepines, are routinely prescribed off label. Nonetheless, recommendations for off-label drugs in these patients are highly varied, with a notable lack of agreement among clinical guidelines. The most common reason for pharmacological treatment and polypharmacy in these patients is comorbidity with other psychiatric disorders. In this context, we reviewed major clinical guidelines and the available data on pharmacotherapy in patients with BPD to develop practical recommendations to facilitate decision-making in routine clinical practice, thus helping clinicians to select the optimal therapeutic approach in patients with BPD who have comorbid disorders. This review confirmed that no clear recommendations for the pharmacological treatment are available in clinical guidelines. Therefore, based on the available evidence, we have developed a series of recommendations for pharmacotherapy in patients with BPD who present the four most common comorbidities (affective, anxiety, eating, and drug use disorders). Here, we discuss the recommended treatment approach for each of these comorbid disorders. The prescription of medications should be considered only as an adjunct to BPD-specific psychotherapy. Polypharmacy and the use of unsafe drugs (i.e., with a risk of overdose) should be avoided. Our review highlights the need for more research to provide more definitive guidance and to develop treatment algorithms

Online psychological interventions to improve symptoms in multiple sclerosis : A systematic review

The aim of this systematic review was to assess the effectiveness of Internet-based psychological interventions in the treatment of physical, socio-affective and cognitive symptoms and quality of life (QoL) in people with multiple sclerosis (pwMS) to provide currently available evidence. Systematic searches for eligible studies were carried out in four databases (August 2021) using key words. Studies were screened, data extracted, quality appraised and analysed by three independent reviewers, using predefined criteria and following the PRISMA rules. Study quality was assessed using Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields QUALSYST tool. Physical, socio-affective and cognitive symptoms and QoL were the primary outcomes. Thirteen studies were included. Two principal approaches were reported: Cognitive behavioural therapy (CBT) and mindfulness-based interventions (MBI). Interventions varied from tailored versions to videoconference by a clinician, duration mean 8 weeks, delivered via individually and groups, all online. The review found that iCBT interventions were effective for improve depression, anxiety, fatigue and QoL, and slightly in cognitive functioning in pwMS, whereas MBI interventions reported benefits in depression, anxiety, stress and QoL, and less evidence in fatigue. Generally, study quality was acceptable in most studies; eleven of the studies scored a low risk of bias on all items in the Qualsyst Tool, whereas only two studies were considered unacceptable. Psychological online interventions may improve physical, socio-affective and cognitive symptoms as well as QoL in pwMS, overcoming the face-to-face barriers (i.e. disability). Contact with the therapist and groups sessions have been identified as enablers of the online interventions. Nevertheless, the limited number of studies and the heterogeneity of health outcomes reported made difficult to afford robust conclusions on psychological intervention effects in pwMS

“Skills for pills”: The dialectical-behavioural therapy skills training reduces polypharmacy in borderline personality disorder

Objective: Polypharmacy and overprescription of off-label medications are common in patients with borderline personality disorder (BPD). The aim of the present naturalistic study was to explore whether the skills training module of dialectical-behavioural therapy (DBT) can reduce polypharmacy in these patients in routine clinical practice. Methods: Retrospective, observational study of 377 patients with a primary diagnosis of BPD consecutively admitted to the BPD outpatient unit from 2010 through 2020. All patients were invited to participate in the DBT skills training module (DBT-ST). DBT-ST participants (n = 182) were compared with a control group who did not participate in DBT-ST (n = 195). Pre-post intervention changes in medication load and use of antidepressants, benzodiazepines, mood stabilizers, and antipsychotics were evaluated. Results: At baseline, most patients (84.4%) were taking at least one medication and 46.9% were on polypharmacy. Compared to controls, patients in the DBT-ST group presented a significant reduction in the number of medications (2.67–1.95 vs. 2.16–2.19; p < 0.001), medication load (4.25–3.05 vs. 3.45–3.48; p < 0.001), use of benzodiazepines (54.4%–27.5% vs. 40%–40.5%; p < 0.001), mood stabilizers (43.4%–33% vs. 36.4%–39.5%; p < 0.001), and antipsychotics (36.3%–29.1% vs. 34.4%–36.9%; p < 0.001). Conclusions: These findings suggest that patients with BPD can benefit from the DBT-ST module, which may reduce the medication load, particularly of sedatives. The results suggest that DBT-ST may be useful to treat overmedication in patients with BPD and could help to promote “deprescription” in clinical practice.This study was supported by Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM). The authors would like to thank Bradley Londres for professional English language editing

Relationship between Meditative Practice and Self-Reported Mindfulness: the MINDSENS Composite Index

Mindfulness has been described as an inherent human capability that can be learned and trained, and its improvement has been associated with better health outcomes in both medicine and psychology. Although the role of practice is central to most mindfulness programs, practice-related improvements in mindfulness skills is not consistently reported and little is known about how the characteristics of meditative practice affect different components of mindfulness. the present study explores the role of practice parameters on self-reported mindfulness skills. A total of 670 voluntary participants with and without previous meditation experience (n = 384 and n = 286, respectively) responded to an internet-based survey on various aspects of their meditative practice (type of meditation, length of session, frequency, and lifetime practice). Participants also completed the Five Facets Mindfulness Questionnaire (FFMQ), and the Experiences Questionnaire (EQ). the group with meditation experience obtained significantly higher scores on all facets of FFMQ and EQ questionnaires compared to the group without experience. However different effect sizes were observed, with stronger effects for the Observing and Non-Reactivity facets of the FFMQ, moderate effects for Decentering in EQ, and a weak effect for Non-judging, Describing, and Acting with awareness on the FFMQ. Our results indicate that not all practice variables are equally relevant in terms of developing mindfulness skills. Frequency and lifetime practice - but not session length or meditation type - were associated with higher mindfulness skills. Given that these 6 mindfulness aspects show variable sensitivity to practice, we created a composite index (MINDSENS) consisting of those items from FFMQ and EQ that showed the strongest response to practice. the MINDSENS index was able to correctly discriminate daily meditators from non-meditators in 82.3% of cases. These findings may contribute to the understanding of the development of mindfulness skills and support trainers and researchers in improving mindfulness-oriented practices and programs.Hosp Santa Creu St Pau, Dept Psychiat, Barcelona, SpainUniv Autonoma Barcelona, CIBERSAM, IIB ST PAU, E-08193 Barcelona, SpainCiber Fisiopatol Obesidad Nutr CIBERO, Santiago de Compostela, SpainUniv Jaume 1, Dept Psicol Basica Clin Psicobiol, Castellon de La Plana, SpainUniversidade Federal de São Paulo, Dept Prevent Med, Mente Aberta Brazilian Ctr Mindfulness & Hlth Pro, São Paulo, BrazilUniv Valencia, Dept Personalitat Avaluacio Tractaments Psicol, Valencia, SpainMiguel Servet Hosp, Dept Psychiat, Zaragoza, SpainUniv Zaragoza, Inst Aragones Ciencias Salud, REDIAPP, Zaragoza, SpainUniversidade Federal de São Paulo, Dept Prevent Med, Mente Aberta Brazilian Ctr Mindfulness & Hlth Pro, São Paulo, BrazilWeb of Scienc

Exploring the relation between childhood trauma, temperamental traits and mindfulness in borderline personality disorder

Background: Deficits in mindfulness-related capacities have been described in borderline personality disorder (BPD). However, little research has been conducted to explore which factors could explain these deficits. This study assesses the relationship between temperamental traits and childhood maltreatment with mindfulness in BPD. Methods: A total of 100 individuals diagnosed with BPD participated in the study. Childhood maltreatment was assessed using the Childhood Trauma Questionnaire (CTQ-SF), temperamental traits were assessed using the Zuckerman-Khulman Personality Questionnaire (ZKPQ), and mindfulness capabilities were evaluated with the Five Facet Mindfulness Questionnaire (FFMQ). Results: Hierarchical regression analyses were performed including only those CTQ-SF and ZKPQ subscales that showed simultaneous significant correlations with mindfulness facets. Results indicated that neuroticism and sexual abuse were predictors of acting with awareness; and neuroticism, impulsiveness and sexual abuse were significant predictors of non-judging. Temperamental traits did not have a moderator effect on the relationship between childhood sexual abuse and mindfulness facets. Conclusions: These results provide preliminary evidence for the effects of temperamental traits and childhood trauma on mindfulness capabilities in BPD individuals. Further studies are needed to better clarify the impact of childhood traumatic experiences on mindfulness capabilities and to determine the causal relations between these variables

Impact of different waves of COVID-19 on emergency medical services and out-of-hospital cardiopulmonary arrest in Madrid, Spain

Out-of-hospital cardiac arrest (OHCA) is one of the three leading causes of death in industrialized countries.[1,2] Some studies have described the impact of the first COVID-19 pandemic wave in terms of the number of cases and OHCA survival rates in various regions,[3-5] but few have addressed the relationship between the successive phases and how they affected OHCA.[6,7] The 14-d cumulative incidence peaked at more than 990 cases, with these rates remaining above 200 for an eight-month period between 15 March 2020 and 15 March 2021 in Madrid, Spain. The objectives of the current study were twofold. First, we sought to describe how the different waves in the first pandemic year aff ected the healthcare activity of the Spanish emergency medical services (EMS). Second, we compared effects of the pandemic year on OHCA care to those of the preceding non-pandemic year in terms of initiating cardiopulmonary resuscitation and survival in a community with a high incidence of COVID-19.post-print164 K

Emotional responses to a negative emotion induction procedure in Borderline Personality Disorder

The aim of this study was to determine if patients with Borderline Personality Disorder (BPD) present higher emotional response than healthy controls in a laboratory setting. Fifty participants (35 patients with BPD and 15 healthy controls) underwent a negative emotion induction procedure (presentation of standardized unpleasant images). Subjective emotional responses were assessed by means of self-reported questionnaires while biological reactivity during the procedure was measured through levels of salivary cortisol (sCORT) and alpha-amylase (sAA). Patients with BPD exhibited significant lower cortisol levels and higher sAA levels compared to controls. Self-reported emotional reactivity did not give rise to differences between groups but participants with BPD did present higher levels of negative emotional intensity at baseline and during the entire procedure. The findings do not give support to the emotional hyperreactivity hypothesis in BPD. However, BPD patients presented heightened negative mood intensity at baseline, which should be considered a hallmark of the disorder. Further studies using more BPD-specific emotion inductions are needed to confirm the trends observed in this studyEl presente estudio pretende determinar si existe o no una mayor reactividad emocional en el Trastorno Límite de la Personalidad (TLP) en un contexto de laboratorio. Se realizó una inducción emocional negativa (presentación de imágenes estandarizadas con contenido negativo) a cincuenta participantes (35 pacientes con TLP y 15 controles sanos). Para evaluar la respuesta emocional subjetiva se utilizaron cuestionarios auto-informados; los niveles de cortisol (sCORT) y alfa-amilasa (sAA) salivares se utilizaron para medir la reactividad biológica al procedimiento. En el grupo de TLP, se observaron niveles de sCORT más bajos y niveles de sAA más elevados en comparación al grupo control. No se observaron diferencias significativas en relación a la reactividad emocional auto-informada, pero los pacientes con TLP reportaron mayor intensidad de emociones negativas a nivel basal así como también durante todo el procedimiento. Los resultados no apoyan la hipótesis de hiperreactividad emocional en el TLP. Sin embargo, los pacientes con TLP presentaron mayor intensidad de emociones negativas a nivel basal, característica que debería ser considerada como esencial en el trastorno. Futuros estudios deberán incorporar otros paradigmas de inducción emocional más específicos para TLP con el fin de confirmar las tendencias observadas en el presente estudi

Effects of mindfulness training on different components of impulsivity in borderline personality disorder : results from a pilot randomized study

Impulsivity is considered a core characteristic of borderline personality disorder (BPD). Previous research on the effects of mindfulness training (MT) has shown that it might modify impulsivity-related aspects of BPD. Therefore, the aim of this study was to investigate the impact of MT on various facets of impulsivity in BPD patients. Subjects with BPD diagnosis (n = 64) were randomly assigned to 10 weeks of MT (n = 32) or interpersonal effectiveness skills training (IE; n = 32). All participants were assessed pre- and post-intervention with a self-reported measure of impulsivity and five behavioral neuropsychological tasks to evaluate response inhibition, tolerance for delay rewards, and time perception. An interaction effect of time × group was only observed for some of the behavioral paradigms used. Participants in the MT group improved their ability to delay gratification and showed changes in time perception, consistent with a decrease in impulsivity. No differences were observed between treatments in terms of trait impulsivity and response inhibition. Mindfulness training might improve some aspects of impulsivity but not others. Further study is warranted to better determine the effects of mindfulness training on the components of impulsivity. ClinicalTrials.gov Identifier: . The online version of this article (doi:10.1186/s40479-015-0035-8) contains supplementary material, which is available to authorized user