Revista Trends - Edição 3/2013 by APRS

Trends in Psychiatry and Psychotherapy

Volume 35 – Issue 3 – July-September 2013

ISSN 2237-6089

Curso

APRS & Instituto Tavistok

Aprendendo a formular

hipóteses psicodinâmicas Informações do curso O curso ocorrerá na sede da APRS; O material teórico, elaborado pelos professores e pesquisadores do Instituto Tavistok, será disponibilizado aos alunos anteriormente via e-mail;

A discussão do material teórico e a supervisão do material clínico, trazido pelos alunos, serão realizadas com a Dra. Shirley Borghetti Hiscock – Psicanalista, professora e supervisora do Instituto Tavistok – as discussões serão em português; Os encontros serão quinzenais às segundas-feiras, das 7h30min às 8h30min;

Organização Dr. Matias Strassburger

O início será na segunda quinzena de setembro de 2013, totalizando cinco encontros;

Coordenador do Departamento de Psicoterapia da APRS

O certificado será emitido pelo Instituo Tavistok aos alunos que obtiverem 80% de participação;

Dra. Lúcia Helena Freitas Ceitlin

Somente para associados da APRS;

Psiquiatra Associada da APRS

Vagas limitadas.

e Professora Associada da UFRGS Departamento de Medicina Legal

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Trends in Psychiatry and Psychotherapy Editor-in-Chief Marcia 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)

n n

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

versidade Católica do Rio Grande do Sul – PUCRS)

José Roberto Goldim (UFRGS)

Luis Augusto Paim Rhode (UFRGS)

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)

n n

Carlos Alexandre

Flávio Pechansky (UFRGS)

Ivan Figueira (UFRJ)

Francisco M.

Ivan Izquierdo (Pontifícia Uni-

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

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

Marcelo Pio de Almeida Fleck (UFRGS)

J. Botega (Universidade Estadual de Campinas – UNICAMP)

Maria Lucréscia Zavaschi (UFRGS)

Patrícia Picon (PUCRS)

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)

Romualdo Romanowski (Sociedade Psicanalítica de Porto Alegre – SPPA)

Valentim Gentil Filho (USP)

Sidney Schestatsky (UFRGS)

Wagner Farid Gattaz (USP)

International Editorial Board André Green (France)

Andrew A. Nierenberg (USA)

Antonino Ferro (Italy)

Boris Birmaher (USA)

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)

Júlio Licínio (USA)

Robert Michels (USA)

Lakshmi N. Yatham (Canada)

Robert N. Emde (USA)

Otto Kernberg (USA)

Roger K. Pitman (USA)

Ricardo Bernardi (Uruguay)

Timothy J. Crow (UK)

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 / EBSCO Tiragem: 900 exemplares Impressão: Contigraf 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. 3 (julho/setembro 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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Associação de Psiquiatria do Rio Grande do Sul Av. Ipiranga, 5311/202 90610-001 Porto Alegre RS Fone/fax: (51) 3024.4846 Celular: (51) 8116.5896 Home Page: www.aprs.org.br E-mail: trends@aprs.org.br

Trends in Psychiatry and Psychotherapy

Table of contents Editorial

DSM-5: what is new and what is next? ........................................................................................................................ 149 DSM-5: o que é novo e o que vem por aí?

Luis A. Rohde, Marcia Kauer-Sant’Anna

Trends

Atypical antipsychotics in the treatment of pathological aggression in children and adolescents: literature review and clinical recommendations .................................................................. 151 Antipsicóticos atípicos no tratamento da agressividade patológica em crianças e adolescentes: revisão da literatura e recomendações clínicas

Eduardo Henrique Teixeira, Antonio Jacintho, Heloisa Valler Celeri, Paulo Dalgalarrondo

Review Article

The Iowa Gambling Task (IGT) in Brazil: a systematic review .......................................................................... 160 O Iowa Gambling Task (IGT) no Brasil: uma revisão sistemática

André Rutz, Amer Cavalheiro Hamdan, Melissa Lamar

Original Articles

Cross-cultural adaptation and preliminary psychometric properties of the Affective Reactivity Index in Brazilian Youth: implications for DSM-5 measured irritability..................................... 171 Adaptação transcultural e propriedades psicométricas preliminares do Affective Reactivity Index em jovens brasileiros: implicações para a irritabilidade medida pelo DSM-5

Diogo Araújo DeSousa, Argyris Stringaris, Ellen Leibenluft, Silvia Helena Koller, Gisele Gus Manfro, Giovanni Abrahão Salum

Beginning and end of treatment of patients who dropped out of psychoanalytic psychotherapy...... 181 Início e fim de tratamento de pacientes que abandonaram a psicoterapia psicanalítica Simone Isabel Jung, Fernanda Barcellos Serralta, Maria Lucia Tiellet Nunes, Cláudio Laks Eizirik

Cultural aspects in dementia: differences in the awareness of Brazilian caregivers................................ 191 Aspectos culturais na demência: diferenças na consciência da doença de cuidadores brasileiros

Translation, adaptation, and preliminary validation of the Brazilian version of the Behavior Problems Inventory (BPI-01)............................................................................................................ 198 Tradução, adaptação e validação preliminar da versão brasileira do Behavior Problems Inventory (BPI-01)

Gisele da Silva Baraldi, Johannes Rojahn, Alessandra Gotuzo Seabra, Luiz Renato Rodrigues Carreiro, Maria Cristina Triguero Veloz Teixeira

Assessment of changes in nicotine dependence, motivation, and symptoms of anxiety and depression among smokers in the initial process of smoking reduction or cessation: a short-term follow-up study.............................................................................................................................................. 212 Avaliação de mudanças na dependência da nicotina, motivação e sintomas de ansiedade e depressão em fumantes no processo inicial de redução ou cessação do tabagismo: estudo de seguimento de curto prazo

Raquel L. Santos, Maria F. B. de Sousa, Ana C. Ganem, Thais V. Silva, Marcia C. N. Dourado

Luciana Rizzieri Figueiró, Cassandra Borges Bortolon, Mariana Canellas Benchaya, Nadia Krubskaya Bisch, Maristela Ferigolo, Helena Maria Tannhauser Barros, Denise Conceição Mesquita Dantas

Who are the children and adolescent patients of a national referral service of eating disorders in Brazil? A cross-sectional study of a clinical sample......................................................... 221 Quem são os jovens pacientes de um serviço de referência nacional em transtornos alimentares no Brasil? Estudo transversal de uma amostra clínica

Vanessa Dentzien Pinzon, Gizela Turkiewicz, Denise Oliveira Monteiro, Priscila Koritar, Bacy Fleitlich-Bilyk

Brief Communication

Twenty years of electroconvulsive therapy in a psychiatric unit at a university general hospital...... 229 Vinte anos de eletroconvulsoterapia em enfermaria psiquiátrica de hospital geral universitário

Amilton dos Santos Jr., Maitê Cruvinel Oliveira, Tiago dos Santos Andrade, Rosana Ramos de Freitas, Cláudio Eduardo Muller Banzato, Renata Cruz Soares de Azevedo, Neury José Botega

Instructions for Authors

Trends in Psychiatry and Psychotherapy

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Trends

Editorial

in Psychiatry and Psychotherapy

DSM-5: what is new and what is next? DSM-5: o que é novo e o que vem por aí? Luis A. Rohde,1 Marcia Kauer-Sant’Anna2

The DSM-5 came out after all. It came with important changes, but with less innovation than some would

need further study, e.g., attenuated psychosis syndrome and non-suicidal self-injury.

expect. In the beginning of the review process, the DSM5 was announced as a paradigm change in psychiatry, by linking diagnosis to pathophysiology.1 However, the neurobiological findings available were not robust enough to allow inclusion in the classification system. Also, any proposed modification was carefully examined to protect psychiatric diagnosis, keeping a balance between sensitivity and specificity of diagnoses in psychiatry, and also to avoid deleterious consequences of any changes to criterion validity.2 However, classifications in psychiatry still lack predictive value and are not consistently associated with a causative explanation of phenomena in comparison with other areas of medicine. Despite the caveats inherent to any classification system, the importance of the DSM-5 is undeniable, compiling information and facilitating clear communication in clinical and research fields. The major changes in DSM-5 classification were: a) focus on dimensional and developmental perspectives (in all disorders rather than only in a subgroup previously categorized as diagnoses first evidenced in childhood and adolescence); b) reordering of disorders and new grouping based on shared etiological factors; c) abandonment of the multi-axial structure; d) changes in existing diagnostic criteria for several disorders (after 5 years of evidence review); e) new diagnoses (i.e., hoarding disorders, disruptive mood dysregulation disorder (DMDD), binge eating disorder, premenstrual dysphoric disorder); and f) a chapter on disorders that

Among the new diagnoses, DMDD is perhaps the most remarkable and controversial entity. Noteworthy, it is included in the depressive disorders chapter, calling attention to the fact that most children with DMDD develop major depressive disorder (not bipolar disorder) or generalized anxiety disorder when adults.3 The rationale behind this new diagnostic category takes into account the debate that rates of bipolar disorder in children and adolescents have increased much faster than in adults.4 Some studies have attributed such high rates to changes in diagnostic practices, with children who lack traditional manic symptoms being diagnosed as bipolar on the basis of alternative symptoms – especially irritability.5 In this context, the diagnosis of severe mood dysregulation (SMD) emerged a decade ago6 as a differential diagnosis for bipolar disorder, given their different courses in adulthood. The DMDD diagnosis includes children and adolescences who present with hyperarousal along with irritability and frequent temper outbursts.7 Of all changes made to existing diagnostic criteria, two are of particular impact: the elimination of mixed episodes from the bipolar disorders chapter and the modification of age of onset for attention-deficit/hyperactivity disorder (ADHD). Instead of mixed episodes, now ‘with mixed features’ is a possible specifier of any mood episode, recognizing the fact that there should always be a predominant polarity, with or without symptoms of the opposite pole (mixed features). This change brings

Department of Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. Institute for Developmental Psychiatry for Childhood and Adolescence, Brazil. 2 Bipolar Disorder Program and Laboratory of Molecular Psychiatry, National Science and Technology Institute for Translational Medicine (INCT-TM), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Hospital de Clínicas de Porto Alegre (HCPA), Faculdade de Medicina, Universidade UFRGS, Porto Alegre, RS, Brazil. 1

Conflicts of interest: Luis A. Rohde was on the speakers’ bureau and/or acted as a consultant for Eli-Lilly, Janssen-Cilag, Novartis, and Shire over the last 3 years. He also received travel awards (air tickets and hotel costs) from Novartis and Janssen-Cilag in 2010 for taking part of two child psychiatric meetings. The ADHD and Juvenile Bipolar Disorder Outpatient Programs chaired by Luis A. Rohde received unrestricted educational and research support from the following pharmaceutical companies in the last 3 years: Abbott, Eli-Lilly, Janssen-Cilag, Novartis, and Shire. Marcia Kauer-Sant’Anna is on the speakers’/advisory boards for, or has received research grants from NARSAD, Stanley Medical Research Institute, CNPq-Universal, CNPq/INCT-TM, FIPE-HCPA, and Eli-Lilly. Suggested citation: Rohde LA, Kauer-Sant’Anna M. DSM-5: what is new and what is next? Trends Psychiatry Psychother. 2013;35(3):149-50.

Trends Psychiatry Psychother. 2013;35(3) – 149-150

Editorial

criteria closer to what was observed in clinical practice and improves the diagnosis of mixed features, with great implications for treatment approach. In ADHD, the DSM-5 now requires that symptoms should be present before 12 years of age (not anymore 7 years of age, as in the DSMIV). Several studies found no differences in phenotypic presentation, neuropsychological impairment, course, severity, or treatment response between children with onset of symptoms before or after 7 years of age.8 The medical and general community have voiced concerns that such a change may artificially increase the prevalence of ADHD, but evidence from population studies does not support this claim.9 A number of other changes were made to the DSM-5, and reviewing them is beyond the scope of this editorial. Complete reviews have been published elsewhere.1 In this issue of Trends in Psychiatry and Psychotherapy, an important article from DeSousa et al. provides methodological support to further studies on the new diagnosis proposed in the DSM-5, namely DMDD.10 This is highly warranted, and will contribute to the understanding of the clinical value of this new diagnostic category in different cultures. As per the DSM-5 preface, it was designed first and foremost to be a useful guide to clinical practice. And, as an official nomenclature, it must be applicable in a wide diversity of contexts.11 The DSM may also be a tool for collecting and communicating accurate mental health statistics. After all, in our view, it has achieved the goal of producing the best available evidence-based tool for the classification and description of mental disorders. There is always room for enhancement and updating. Even DSM-5 limitations have contributed to the acknowledgement that, in fact, the field of psychiatry has produced only modest progress over the last years. Clinical and basic research has grown, but is still a start-off area in psychiatry when compared to other areas of medicine. The expectations of greater input into the classifications coming from neurobiological research will depend on the success of future initiatives like the Research Domain Criteria (RDoC) project, proposed by the National Institute

150 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2013;35(3)

of Mental Health (NIMH). The rationale of RDOC and DSM-5 are in opposite directions: the latter comes from the clinical observation of syndromes towards an understanding of their pathophysiology, and the former comes from the observation of basic neurobiological functions (or domains) towards an understanding of shared clinical features.12

References 1. Machado JD, Caye A, Frick PJ, Rohde LA. DSM-5. Major changes for child and adolescent disorders. In: Rey JM, editor. IACAPAP e-textbook of child and adolescent mental health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2013. 2. Kraemer HC, Kupfer DJ, Clarke DE, Narrow WE, Regier DA. How reliable is reliable enough? Am J Psychiatry. 2012;169:13-5. 3. Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, et al. Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry. 2006;60:991-7. 4. Blader JC, Carlson GA. Increased rates of bipolar disorder diagnoses among U.S. child, adolescent, and adult inpatients, 1996-2004. Biol Psychiatry. 2007;62:107-14. 5. Leibenluft E. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. Am J Psychiatry. 2011;168:129-42. 6. Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS. Defining clinical phenotypes of juvenile mania. Am J Psychiatry. 2003;160:430-7. 7. Zepf FD, Holtman M. Disruptive mood dysregulation disorder. In: Rey JM, editor. IACAPAP e-textbook of child and adolescent mental health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions; 2012. 8. Kieling C, Kieling RR, Rohde LA, Frick PJ, Moffitt T, Nigg JT, et al. The age at onset of attention deficit hyperactivity disorder. Am J Psychiatry. 2010;167:14-6. 9. Polanczyk G, Caspi A, Houts R, Kollins SH, Rohde LA, Moffitt TE. Implications of extending the ADHD age-of-onset criterion to age 12: results from a prospectively studied birth cohort. J Am Acad Child Adolesc Psychiatry. 2010;49:210-6. 10. DeSousa DA, Stringaris A, Leibenluft E, Koller SH, Manfro GG, Salum GA. Cross-cultural adaptation and preliminary psychometric properties of the Affective Reactivity Index in Brazilian Youth: implications for DSM-5 measured irritability. Trends Psychiatry Psychother. 2013;35(3):171-80. 11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). Washington: APA; 2013. 12. Martin A, Volkmar FR, Lewis M. Lewisâ&#x20AC;&#x2122;s child and adolescent psychiatry: a comprehensive textbook. Philadelphia: Lippincott Williams & Wilkins; 2007.

Trends

in Psychiatry and Psychotherapy

Atypical antipsychotics in the treatment of pathological aggression in children and adolescents: literature review and clinical recommendations Antipsicóticos atípicos no tratamento da agressividade patológica em crianças e adolescentes: revisão da literatura e recomendações clínicas Eduardo Henrique Teixeira,1 Antonio Jacintho,2 Heloisa Valler Celeri,3 Paulo Dalgalarrondo4

Abstract

Resumo

Objective: To review the literature about the use of atypical antipsychotics in the treatment of pathological aggression in children and adolescents. Method: The databases MEDLINE, SciELO, and LILACS were searched for publications in Portuguese or English from 1992 to August 2011 using the following keywords: mental disease, child, adolescent, treatment, atypical antipsychotic, aggressive behavior, aggression, and violent behavior. Results: Sixty-seven studies of good methodological quality and clinical interest and relevance were identified. Studies including children and adolescents were relatively limited, because few atypical antipsychotics have been approved by the Food and Drug Administration (FDA). All the medications included in this review (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole and clozapine) have some effectiveness in treating aggression in children and adolescents, and choices should be based on clinical indications and side effects. Conclusions: There are few studies about the effectiveness and safety of atypical antipsychotics for the pediatric population, and further randomized controlled studies with larger groups of patients and more diagnostic categories, such as severe conduct disorder and oppositional defiant disorder, should be conducted to confirm the results reported up to date and to evaluate the impact of long-term use. Keywords: Aggression, violence, atypical antipsychotics, behavioral disorders, children, adolescents.

Objetivo: Realizar uma revisão sistemática da literatura científica sobre o uso de antipsicóticos atípicos (APAs) no tratamento da agressividade patológica em crianças e adolescentes. Método: Foi realizada busca eletrônica nas bases de dados MEDLINE, SciELO e LILACS, de 1992 a agosto 2011, considerando artigos publicados em língua inglesa e portuguesa. Foram utilizadas associações das seguintes expressões: mental disease, child, adolescent, treatment, atypical antipsychotic, aggressive behaviour, aggression e violent behavior. Resultados: Foram identificados 67 artigos de boa qualidade metodológica, de relevância e interesse clínico para o tema em foco. De modo geral, os estudos são relativamente limitados para esta faixa etária, resultado do fato de poucos APAs terem sido aprovados pela Food and Drug Administration (FDA). Dentre as medicações consideradas nesta revisão (risperidona, olanzapina, quetiapina, ziprazidona, aripiprazol e clozapina), todas elas podem ter alguma efetividade no tratamento da agressividade em crianças e adolescentes, ficando a escolha baseada na indicação clínica e perfil de efeitos colaterais. Conclusão: O número ainda limitado de estudos acerca da efetividade e segurança na população pediátrica demanda pesquisas futuras com grupos maiores de pacientes e com mais categorias diagnósticas (como, por exemplo, as formas graves de transtorno de conduta e transtorno desafiador de oposição), desenhadas de forma randomizada e controlada. Assim poderão ser confirmados os achados até o momento e o impacto do uso em longo prazo. Descritores: Agressão, violência, agentes antipsicóticos, transtornos do comportamento, infância, adolescência.

Psychiatrist, specialist in Forensic Psychiatry. MSc and PhD in Psychiatry, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil. Professor, School of Medicine, Pontifícia Universidade Católica de Campinas (PUC-Campinas), Campinas, SP, Brazil. 2 Psychiatrist, specialist in Child and Adolescent Psychiatry. Head of the Child and Adolescent Psychiatry Outpatient Unit at Hospital de Clínicas da Universidade Estadual de Campinas (HC-Unicamp), Campinas, SP, Brazil. 3 Psychiatrist, specialist in Child and Adolescent Psychiatry. Head of the Child and Adolescent Psychiatry Outpatient Unit at HC-Unicamp, Campinas, SP, Brazil. Professor, Department of Medical Psychology and Psychiatry, School of Medical Sciences, UNICAMP, Campinas, SP, Brazil. 4 Psychiatrist. Professor, Department of Medical Psychology and Psychiatry, School of Medical Sciences, UNICAMP, Campinas, SP, Brazil. 1

Financial support: none. Submitted Jan 30 2011, accepted for publication Jul 02 2012. No conflicts of interest declared concerning the publication of this article. Suggested citation: Teixeira EH, Jacintho A, Celeri HV, Dalgalarrondo P. Atypical antipsychotics in the treatment of pathological aggression in children and adolescents: literature review and clinical recommendations. Trends Psychiatry Psychother. 2013;35(3):151-9.

Trends Psychiatry Psychother. 2013;35(3) – 151-159

Atypical antipsychotics to treat pathological aggression â&#x20AC;&#x201C; Teixeira et al.

Introduction Pathological aggression or morbid aggressive behaviors may be symptoms of numerous mental disorders that affect children and adolescents. It is the main cause of visits to psychiatric emergence services and of hospitalizations of children and adolescents in specialized psychiatric wards.1-3 It is classified as a psychopathological symptom when not an adaptive behavior, as well as when it clearly clashes with cultural standards of the social group to which the child or adolescent belongs.4 Neurobiologically, impulsive/affective aggression may be explained as a lack of equilibrium between prefrontal mechanisms of top-down control (orbitofrontal cortex and anterior gyrus cinguli) and the bottom-up limbic stimuli (amygdala and other limbic areas), in which several neurotransmitters, such as serotonin, dopamine, noradrenalin and others, may be involved and may, therefore, be managed pharmacologically.5,6 Several studies have demonstrated that aggression is a result of the combination of socioenvironmental, psychological and biological factors, and that an environment favorable to personal development may modulate unfavorable genetic characteristics.7,8 However, biological factors of aggressive behaviors may and should be carefully managed because of probable mid- and long-term impairments and the progression into severe psychiatric disorders in adulthood.9-11 Clinically, aggression is usually approached in one of two ways: primarily approaching the underlying psychiatric disorder, or directly approaching the aggressive behavior as the main clinical sign of the outlying disorder and the main treatment target.12 According to Pappadopulos et al., 40% of the children and adolescents hospitalized and receiving treatment to control aggression were administered two or more drugs, and most often one of them as an atypical antipsychotic (AAP). Other drugs used were anticonvulsants, lithium, psychostimulants, selective serotonin reuptake inhibitors (SSRI), anxiolytics, alpha-agonists, beta-blockers and other sedative drugs.13 This study reviewed the scientific literature to analyze studies about pharmacological treatments using AAP for impulsive and affective aggression in children and adolescents, regardless of their underlying disease and the different treatments of this symptom, and to describe results and possible limitations. Moreover, at the end of the review, the authors make clinical suggestions that may be useful for healthcare professionals involved in providing mental health care to children and adolescents. Predatory or proactive aggression has not been included in this study because it has a different meaning

152 â&#x20AC;&#x201C; Trends Psychiatry Psychother. 2013;35(3)

and demands a specific approach, different from the one used for impulsive or affective aggression. So far, studies have found little evidence of the benefits of pharmacological interventions in predatory aggression, which is more often found in environments of the justice system.12 Up to the time when this study was written, no review of this topic had been found in the literature. Therefore, this review may be useful as a basis for the use of AAP in the psychiatric and pediatric clinical practice.

Method MEDLINE, SciELO and LILACS databases were searched for articles in English or Portuguese published from 1992 to August 2011. The search included studies about pharmacological treatments of aggression in the different diseases and syndromes that affect children and adolescents. Combinations (AND, OR, NOT) of the following keywords were used for the search: mental disease, child, adolescent, treatment, atypical antipsychotic, aggressive behavior, aggression, violent behavior. Although the number of studies about the use of antipsychotic drugs for children and adolescents has increased, few controlled studies have been conducted, because of the high withdrawal rates, short duration of interventions, and sample selection biases.14 Some studies with adults have been used as the basis for the initial tests with children and adolescents, but our review classified them only as parameters for a careful analysis of results, particularly for topics still not studied in the pediatric population, such as the risk of metabolic changes.15 Of the 77 studies retrieved, 67 were selected because of their higher methodological quality and greater relevance and clinical interest for the topic under study. The studies were selected by all the authors together, and all had access to abstracts. After that, the full articles were divided into two groups: clinical results and adverse events. Inclusion criteria were: 1) randomized, placebo controlled studies; 2) case reports of children and adolescents, or of adults that were used as the basis for the administration of AAP to children and adolescents; 3) review of studies about aggression and its treatment. This review did not establish grades of evidence (as defined by task forces), but only identified differences between controlled clinical studies (randomized, doubleblind), case series reports and clinical experience (lowest level of consistency).

Atypical antipsychotics to treat pathological aggression – Teixeira et al.

Results Overall, the predominant view is that educational and psychosocial approaches should be implemented first and should not be discontinued after the introduction of medication.13,16 At the same time, the first medication used should be directed to the primary diagnosis, and only one drug should be used whenever possible. In the case of nonsuccess and when there are risks to the patients or the people that live with them, the treatment should include approaches directed to the aggressive behavior specifically.12,17-19 The use of psychopharmacologic drugs for patients in this age group should take into consideration the characteristic of their metabolism, drug pharmacokinetics and pharmacodynamics, and the risk of specific drug interactions. Children and adolescents, in general, are rapid metabolizers and, therefore, need antipsychotic doses that are proportionally higher in relation to their weight.20 Despite a significant increase in the use of AAP for children and adolescents in the last years,21 up to the time this study was concluded only four AAP had its use in the pediatric population approved by the Food and Drug Administration (FDA) (latest update on August 2011, according to www.fda.gov), as shown in the table below (Table 1). Although not recommended by FDA, the first four AAP in Table 1 have been studied by several authors in the last decade. They investigated the control of aggression in conduct disorder and classified these medications as safe and efficient despite their side effects and the limitations of their studies.22 The use of AAP should be seen as a first tool to control aggression when non-pharmacological approaches fail.13 Several studies have compared the use of AAP and typical antipsychotics (TAP) in adolescents and young individuals and found that AAP should be the first choice

because they have fewer side effects and lower risks of tardive dyskinesia, neuroleptic malignant syndrome, cognitive impairments and extrapyramidal symptoms (EPS),23-25 although the consequences of the metabolic and endocrine changes due to the use of AAP have not been clarified, especially not in children and adolescents.1 According to the November 2003 consensus of the American Association of Psychiatry and the American associations of endocrinologists and the associations for the study of diabetes and obesity, AAP had a clear benefit in psychiatric treatments. However, caution was recommended, and its use should be constantly monitored because of the risks of metabolic and hormonal disorders and weight gain.26 Studies have not found differences in the response to treatment between different AAP, and the choice of a specific drug should be based on patient tolerability and adverse events, the most common of which are weight gain, drowsiness, EPS and hyperprolactinemia.27 All AAP may cause drowsiness, particularly at high doses, and, because of that, AAP should be carefully administered: the dose should be accurately adjusted, and its toxicity and drug interactions should be re-evaluated at short time intervals.28 Although the occurrence of EPS due to the use of AAP among young patients is not negligible, it is less frequent than that of TAP.29 In studies designed to investigate schizophrenia starting in childhood, among AAPs, clozapine and quetiapine have been associated with lower rates of EPS, similarly to what is observed among adults.30,31 According to the Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY), based on studies available and specialist consensus, treatment should begin with low doses that are then increased gradually, and its efficacy should be evaluated at the most two weeks later. In the case of risperidone, the mean dose

Table 1 – Atypical antipsychotics approved for use in children and adolescents by the FDA and the Brazilian ANVISA and their indications

Drugs

Schizophrenia Bipolar affective disorder (13-17 year-olds) (10-17 year-olds) FDA ANVISA FDA ANVISA

Irritability in autism FDA ANVISA

Conduct disorder* FDA ANVISA

Risperidone + + + +

+ + (5-16) (5-16)

- -

Aripiprazole + + + +

+ + (6-17) (6-17)

- -

Olanzapine + +

+ + (13-17) (13-17)

Quetiapine

- -

Clozapine

- -

ANVISA = Brazilian National Health Surveillance Agency; FDA = U.S. Food and Drug Administration. * Neither FDA nor ANVISA has any regulation about the use of drugs for the diagnostic category conduct disorder or to control aggression for any undefined diagnosis.

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Table 2 – Differences between atypical antipsychotic active doses and the impact on aggression and psychotic symptoms

Drugs

Aggression

Starting dose (mg)

Child

Risperidone 0.25-0.5 Clozapine

6.5-25

Psychotic symptoms

Adolescent

Child

1.5-2 2-4 150-300 200-600

Adolescent

3-4 3-6 150-300 200-600

Source: Adapted from TRAAY–II, table 3 of Pappadopulos et al.

to control aggression is smaller than (about half) the dose necessary to control psychotic symptoms, differently from clozapine, in which case the mean dose to treat aggression is similar to that of antipsychotic drugs, as seen in Table 2. Data about ideal doses to control aggression are not available for other AAP (Table 2).13 Studies about AAP are still limited, and, therefore, special attention should be paid to possible adverse

using a mean dose of 1.5 mg/day, which was effective in the control of aggression for the next six months when compared with the placebo group.22,33,34 In the analysis of safety of its use for long periods of time, five studies investigated the use of risperidone in a total of 700 children and adolescents aged 5 to 15 years and found no influence on growth or sexual maturity, although there were changes in the levels of prolactin.35

events and interactions with other medications. Still according to the TRAAY Part II recommendations, vital signs, weight, prolactin levels and metabolic changes should be constantly monitored, and ECG should be used to monitor patients at regular intervals during dose adjustment, because cardiac changes are dosedependent.13,32 In the analysis of metabolic changes (weight gain, risk of diabetes and dyslipidemia), studies with adults found that there are differences between the several AAP medications, although results are still relatively discordant, according to Table 3.26

A retrospective study including 80 individuals with autism who used risperidone to control aggression or impulsivity found that over 60% had a positive result after six months of treatment. The most common adverse effect was weight gain, followed by drowsiness, the adverse event most often associated with treatment discontinuation.36 A review37 has demonstrated that these findings are confirmed in double-blind, placebo-controlled studies and case reports of autism and pervasive developmental disorders, in which aggression was a relatively serious symptom. In a double-blind study with 101 children with autism who were administered a mean dose of 1.8 mg/day of risperidone, 69% of the children were classified as responders after eight weeks, whereas only 12% in the placebo group responded satisfactorily. The most common adverse event was weight gain and hypersalivation, and there were no differences in EPS and tardive dyskinesia between groups.38 Similar results were found in a placebo-controlled study with 79 children, in which the mean dose was 1.2 mg/day.39 The comparison with other AAPs revealed that risperidone was the medication that resulted in the highest prolactin elevation among adults with schizophrenia (n = 218) in a study that followed up patients for five years.40

Risperidone Two double-blind studies with children and adolescents, one with a group of individuals with conduct disorder and the other with conduct disorder associated with subaverage intelligence, compared risperidone and placebo and found that risperidone is a well-tolerated and efficacious medication for aggression.33,34 Those studies found that the most common adverse events were drowsiness, headache and weight gain. The symptoms of aggression were controlled in 3 to 4 weeks

Table 3 – Atypical antipsychotics and risk of secondary metabolic changes in adults

Drugs

Weight gain

Risk of diabetes

Worsened lipid profile

Clozapine +++

Olanzapine +++

Risperidone ++

Quetiapine ++

Aripiprazole* +/-

Ziprasidone +/-

Source: Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes, 2004.26 * New drugs with limited long-term follow-up studies. + = increase; - = no effect; D = discordant results.

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Atypical antipsychotics to treat pathological aggression â&#x20AC;&#x201C; Teixeira et al.

Olanzapine An open-label prospective trial was conducted with 16 adolescents with disruptive behavioral disorders and subaverage intelligence. Olanzapine was effective in the control of irritability when used at a mean dose of 13.7 mg/day, but weight gain led to treatment discontinuation in 4 of the 16 cases.41 Similar findings were reported in a review of medical charts of 23 adolescents with conduct disorder and no response to other treatments. Olanzapine was efficacious in 60% of the patients, and the most common adverse events were weight gain and sedation.42 A double-blind, open-label prospective study of aggression control in autism and other autistic disorders found similar results.43 In a study that compared the use of olanzapine with that of haloperidol in 12 children with autism for six weeks, olanzapine was more efficacious in the control of aggression, but resulted in greater weight gain.44 In some emergency situations that require aggression control, the IM injection of a rapid-acting medication may be necessary. Ziprasidone and olanzapine may be used in such cases, and their safety and efficacy has been demonstrated for use in adults in randomized double-blind studies.45,46 However, no data from clinical controlled studies are available to support the IM administration of AAP to children and adolescents.

Quetiapine A study conducted by Findling et al. with 17 moderately aggressive children with a diagnosis of conduct disorder for 8 weeks found that quetiapine was efficacious and well tolerated at a mean dose of 150 mg/ day. The most frequent adverse events were fatigue and weight gain. No EPS or changes in prolactin levels were found during the study,47 which continued with nine children for another 26 weeks. Positive results in the control of aggression were seen along all this time, and mean weight gain was 2.3 kg.48 An open-label prospective study with 24 aggressive adolescents with a diagnosis of attention deficit hyperactivity disorder and conduct disorder, who did not respond satisfactorily to treatment with methylphenidate alone, found that 79% improved their pattern of aggression when administered a maximum dose of 600 mg/day. The most common adverse event was drowsiness, and mean weight gain was 1.2 kg after nine weeks.49 The results of quetiapine in the control of aggression in autism have been heterogeneous. In an open-label study with six children receiving a mean dose of 225 mg/day for four months, only two had improvements in

their pattern of aggression.50Another open-label study with nine adolescents used doses of 100 to 450 mg/day for 12 weeks. Only six adolescents completed the study, and only two of them were responders in the analysis of aggression.51 In the two studies, the most common adverse events were drowsiness and weight gain, the reasons why three patients discontinued treatment.

Ziprasidone Few studies have been published about the use of ziprasidone in children and adolescents. In a case series with 12 children with autism or other autistic disorders who received doses of 20 to 120 mg/day for at least six weeks, six children were responders for the control of aggression, as well as of agitation and irritability. Sedation was the most common adverse event, and weight gain was found in only one child. Five children lost weight, which was associated with the discontinuation of previous medication that had resulted in weight gain.52 For emergency situations in the control of aggression, ziprasidone has an additional resource, which is an IM rapid-acting formulation, as described above,45 although no controlled studies or clinical reports have evaluated its use in children or adolescents.

Aripiprazole In a case series with five children and adolescents with autism who received doses of 10 to 15 mg/day for a mean time of 12 weeks, all five were judged responders for aggression control, as well as for agitation and irritability. Sedation was a transient adverse event, and weight changes were variable: two children lost weight, which was associated with the discontinuation of previous medication that had resulted in weight gain.53 Similar results were replicated in another case series with 32 children and adolescents with a diagnosis of autism, autistic disorders and mental retardation, who received a mean dose of 10.55 mg/day for six to 15 months. There was a reduction in target symptoms (aggression, impulsivity, hyperactivity and self-injury) in 56% of the cases. Sedation was the most frequent adverse effect, and there were no significant changes in body weight.54

Clozapine Few studies have evaluated the use of clozapine, particularly because of the risk of agranulocytosis and the need of rigorous monitoring of blood cell counts, which is a laborious task because of the little collaboration of children and adolescents, depending on their disease.37

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Atypical antipsychotics to treat pathological aggression – Teixeira et al.

In an open-label study about the impact of clozapine on treatment-refractory aggression in 20 children and adolescents with schizophrenia, the use of emergency medication and seclusion events were analyzed after the introduction of clozapine and compared with the previous period of time. Clozapine had greater efficacy than other AAP or TAP. Patients were evaluated for at least six months, and mean clozapine dose on the 12th week was 405 mg/day. The study found a decrease in the frequency of administration of injectable medication and seclusion.55 Two series of case reports of patients with autism and severe treatment-refractory aggression previously receiving other medications found that clozapine was efficacious for most cases when administered at mean doses of 200 and 400 mg/day. In the first study, three patients aged 8 to 12 years had a significant improvement of aggression, hyperactivity and irritability with the administration of 100 to 200 mg/day. In the second study, the pattern of aggression improved for a 17-year-old patient receiving a mean final dose of 275 mg/day. The major adverse events in the three studies were drowsiness, constipation, weight gain and hypersalivation.56,57 The analysis of the risk of agranulocytosis suggests that children may run a greater risk than adults.58 In an open-label retrospective study with 172 children (schizophrenia: 139; bipolar disorder: 25; others: 2) using clozapine, 13% had neutropenia, and one, agranulocytosis. In the same study, the most common adverse events were weight gain and changes in lipid metabolism.59 The safety of clozapine in relation to the levels of prolactin in children and adolescents was greater than that of other AAPs. A double-blind study with 35 children and adolescents with a diagnosis of schizophrenia compared clozapine with haloperidol and olanzapine and found that the three substances increased the levels of prolactin, but clozapine led to increases that were still within normal levels. After six weeks of treatment, all ten patients receiving haloperidol had increases above the normal limits, and seven of the ten using olanzapine had similar increases, but none of the 15 patients using clozapine had increases above the normal range.32 According to current TRAAY recommendations, if all other treatment options fail to control severe aggression, the use of clozapine should be considered in cases of schizophrenia and bipolar disorder in children and adolescents, despite the fact that clozapine has not yet been approved by FDA for use in these two age groups. There are no explicit recommendations for its use, and it has not even been studied for aggression in severe conduct disorders, although its potential usefulness

156 – Trends Psychiatry Psychother. 2013;35(3)

seems plausible because of data from studies with other diagnostic groups.13,60,61 Pappadopulos et al. suggested that, if the response is only partial, the combination of clozapine and a mood stabilizer should be considered. However, such recommendation is not supported by studies with children and adolescents specifically.13 Table 4 shows data about the scientific studies included in this review, which administered AAP to children and adolescents to control aggression. The studies were divided into case reports, open-label trials and controlled (randomized or double-blind) studies.

Discussion The treatment of pathological aggression, both in clinical practice and in research, is a great challenge, particularly when in its severe or extreme forms in children and adolescents. The establishment of an adequate and accurate psychiatric diagnosis, and therefore, the administration of the best possible treatment, involves a considerable degree of complexity. In these age groups, ethical issues regarding the treatment of people still in a stage of full development and who still have to be legally represented by their guardians becomes particularly difficult, complex and a matter of concern for clinicians. The studies included in this review, particularly those conducted with children and adolescents, have several limitations as a consequence of that, in addition to the effects of comorbidities, multiplicity of drugs taken, and the necessary association with other therapeutic approaches, such as parental guidance, psychoeducation, institutional and environmental management, legal counseling and others. The limitations of clinical and research results are associated with the small number of patients, who are usually studied in case series reports, with the heterogeneity of the diagnostic groups under study, with the short follow-up time14 and, finally, with the large dependence on adult clinical data and psychopharmacology, as the psychiatry of children and adolescents often only “borrows” data from adult psychiatry because it has not yet autonomously generated consistent knowledge based on original and carefully conducted studies. Despite these limitations, these studies allow us to reach some tentative conclusions. The development of more modern and safer medications has given rise to different ways to deal with the aggressive behaviors of children and adolescents.12 There does not seem to be any doubt about the use of medication as a necessary intervention, particularly in severe and extreme cases. Studies have already demonstrated that severe aggression may result in significant harm to patients

Atypical antipsychotics to treat pathological aggression â&#x20AC;&#x201C; Teixeira et al.

Table 4 â&#x20AC;&#x201C; Case reports, open-label trials or controlled studies about the use of atypical antipsychotic drugs in children and adolescents to control aggressive behaviors

Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Clozapine

Schizophrenia CR/OL - - - - - N=1 (n = 23)55 CS

- - - - - -

Autism CR/OL - N = 2 N = 2 N = 1 N = 2 N=2 (n = 8)43 (n = 6)50 (n = 12)52 (n = 5)53 (n = 3)56 (n = 12)44 (n = 9)51 (n = 32)54 (n = 1)57 CS/OL

N = 3 (n = 80)36 (n = 101)38 (n = 79)39

Conduct disorder CR/OL - N = 2 N = 2 - - (n = 16)41 (n = 16)47 (n = 23)42 (n = 24)*49 CS

N = 2 - - (n = 118)33 (n = 10)34

Mental retardation CR/OL - - - - + (n = 18) + (n = 8) CS + (N = 1) - - - - - = no studies; CR = case report; CS = controlled (randomized or double-blind) study; n = number of cases; N = number of studies; OL = open label trial. * Conduct disorder + attention deficit hyperactivity disorder.

and their families and favor the development of serious psychiatric disorders in adulthood.9,10 AAPs seem to be good tools, and there is evidence that they are safe medications for use in children and adolescents with different diagnosis,13,22-25 in addition to being effective in the control of aggression in adults.15,62-64 Studies with children and adolescents that used these medications, particularly for patients with schizophrenia and autism, reported favorable results.55,57,65 However, only longitudinal prospective studies will be able to

investigated. In addition to methodological issues, these studies raise both clinical and ethical research problems, as they involve children and adolescents. Particularly important are the ethical and politicalideological issues that pharmacological control of severe pathological aggression raises in clinical practice and in research with children and adolescents. It should always be stressed that pharmacological interventions should mandatorily be combined with careful psychosocial evaluations and approaches, such as parental and family

demonstrate the real impact of AAP on this population, particularly in terms of metabolic and hormone changes1,26 associated with growth and development, although adverse events are well tolerated and manageable.27-29,66 Studies that analyzed metabolic changes, such as weight gain, dyslipidemia and the risk of diabetes, have recommended that these medications should be used carefully, and that a proactive attitude should be adopted, with systematic monitoring using laboratory tests, weight control and nutritional interventions.13,14,29,32 Studies about the treatment of pathological aggression, particularly severe or extreme forms of it, in children and adolescents, remain limited. Therefore, there are no solid scientific bases for clinical decisions at a higher degree of safety. However, this is a topic of strategic relevance and that should be broadly

counseling, psychotherapy, psychoeducation, school guidance and environment management, interventions that should be, whenever possible, based on controlled studies that have evaluated their short- and long-term efficacy. There are few randomized, double-blind studies specifically designed to evaluate aggression control in children and adolescents, particularly severe aggression and in individuals with autistic and conduct disorders.

Recommendations and suggestions psychopharmacological management

All the medications included in this review (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole and clozapine) seem to have some degree of effectiveness Trends Psychiatry Psychother. 2013;35(3) â&#x20AC;&#x201C; 157

Atypical antipsychotics to treat pathological aggression – Teixeira et al.

for children and adolescents, despite the limitations discussed in the text. Except for clozapine, studies did not find differences in their potency, and choices should be based on their adverse events.27 The most common adverse events after the use of AAP were two: drowsiness and weight gain. Risperidone was more frequently associated with increases in prolactin levels,40 and the use of ziprasidone was only partially associated with weight gain.52 Data about quetiapine and aripiprazole are still too limited to provide a minimally consistent evaluation of their adverse events.47-51,53,54 As clozapine has a specific profile of action and adverse events, and its efficacy in treating aggression has already been demonstrated,15,55,64 it should become the focus of more detailed investigations.13,61,67 Case report findings are favorable for the control of aggression in patients with schizophrenia, autism and mental retardation. Adverse events have been monitored and controlled in a relatively safe way.56,57,59,62 Although clozapine has not been formally approved by FDA for use in children and adolescents, the clinical experience of the authors suggests that it may be an important tool in the control of severe or extreme aggression in cases in which the control of this symptom may be fundamental for successful planning and treatment. This is often the case of children and adolescents with severe forms of conduct disorders.

Conclusion The limited number of studies about the efficacy and safety of AAP use in the pediatric population warrants future studies with larger groups of patients and more diagnostic categories, such as severe forms of conduct disorder and oppositional defiant disorder. Future studies may confirm findings reported to this date, as well as the impact of the use of these drugs in the long term.

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6. Siegel A, Bhatt S, Bhatt R, Zalcman SS. The neurobiological bases for development of pharmacological treatments of aggressive disorders. Curr Neuropharmacol. 2007;5:135-47. 7. Bordin IA, Offord DR. Transtorno de conduta e comportamento anti-social. Rev Bras Psiquiatr. 2000;22(Supl II):12-15. 8. Mendes DD, Mari Jde J, Singer M, Barros GM, Mello AF. Study review of biological, social and environmental factors associated with aggressive behavior. Rev Bras Psiquiatr. 2009;31(Suppl 2):S77-85. 9. Nestor PG. Neuropsychological and clinical correlates of murder and other forms of extreme violence in a forensic psychiatric population. J Nerv Ment Dis. 1992;180:418-23. 10. Bernstein DP, Cohen P, Skodol A, Bezirganian S, Brook JS. Childhood antecedents of adolescent personality disorders. Am J Psychiatry. 1996;153:907-13. 11. Blair RJ, Peschardt KS, Budhani S, Mitchell DG, Pine DS. The development of psychopathy. J Child Psychol Psychiatry. 2006;47:262-76. 12. Soller MV, Karnik NS, Steiner H. Psychopharmacologic treatment in juvenile offenders. Child Adolesc Psychiatr Clin N Am. 2006;15:477-99. 13. Pappadopulos E, Macintyre Ii JC, Crismon ML, Findling RL, Malone RP, Derivan A, et al. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II. J Am Acad Child Adolesc Psychiatry. 2003;42:145-61. 14. James AC. Prescribing antipsychotics for children and adolescents. Adv Psychiatr Treat. 2010;16:63-75. 15. Cohen SA, Underwood MT. The use of clozapine in a mentally retarded and aggressive population. J Clin Psychiatry. 1994;55:440-44. 16. Jensen PS. The role of psychosocial therapies in managing aggression in children and adolescents. J Clin Psychiatry. 2008;69(Suppl 4):37-42. 17. Rutter M, Taylor EA. Child and Adolescent Psychiatry. Massachusets: Blackwell Publishment; 2002. 18. Connor DF, Glatt SJ, Lopez ID, Jackson D, Melloni RH Jr. Psychopharmacology and aggression. I: a meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD. J Am Acad Child Adolesc Psychiatry. 2002;41:253-61. 19. Heyneman EK. The aggressive child. Child Adolesc Psychiatr Clin N Am. 2003;12:667-77. 20. Brasil HH, Belisário Filho JF. Psicofarmacoterapia. Rev Bras Psiquiatr. 2000;22(Supl II):42-7. 21. Olfson M, Blanco C, Liu L, Moreno C, Laje G. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Arch Gen Psychiatry. 2006;63:679-85. 22. Findling RL. Atypical antipsychotic treatment of disruptive behavior disorders in children and adolescents. J Clin Psychiatry. 2008;69(Suppl 4):9-14. 23. Campbell M, Armenteros JL, Malone RP, Adams PB, Eisenberg ZW, Overall JE. Neuroleptic-related dyskinesias in autistic children: a prospective, longitudinal study. J Am Acad Child Adolesc Psychiatry. 1997;36:835-43. 24. Toren P, Laor N, Weizman A. Use of atypical neuroleptics in child and adolescent psychiatry. J Clin Psychiatry. 1998;59:644-56. 25. Gilberg C. Typical neuroleptics in chil and adolescent psychiatry. Eur Child Adolesc Psychiatry. 2000;9(Suppl I):2-8. 26. American Diabetes Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004;27:596-601. 27. Correll CU. Antipsychotic use in children and adolescents: minimizing adverse effects to maximize outcomes. J Am Acad Child Adolesc Psychiatry. 2008;47:9-20. 28. Correll CU. Assessing and maximizing the safety and tolerability of antipsychotics used in the treatment of children and adolescents. J Clin Psychiatry. 2008;69(Suppl 4):26-36. 29. Correll CU, Penzner JB, Parikh UH, Mughal T, Javed T, Carbon M, et al. Recognizing and monitoring adverse events of second-generation antipsychotics in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2006;15:177-206.

Atypical antipsychotics to treat pathological aggression – Teixeira et al.

30. Kumra S, Frazier JA, Jacobsen LK, McKenna K, Gordon CT, Lenane MC, et al. Childhood-onset schizophrenia. A doubleblind clozapine-haloperidol comparison. Arch Gen Psychiatry. 1996;53:1090-7. 31. Shaw P, Sporn A, Gogtay N, Overman GP, Greenstein D, Gochman P, et al. Childhood-onset schizophrenia: a doubleblind, randomized clozapine-olanzapine comparison. Arch Gen Psychiatry. 2006;63:721-30. 32. Wudarsky M, Nicolson R, Hamburger SD, Spechler L, Gochman P, Bedwell J, et al. Elevated prolactin in pediatric patients on typical and atypical antipsychotics. J Child Adolesc Psychopharmacol. 1999;9:239-45. 33. Aman MG, De Smedt G, Derivan A, Lyons B, Findling RL. Double-blind, placebo-controlled study of risperidone for the treatment of disruptive behaviors in children with subaverage intelligence. Am J Psychiatry. 2002;159:1337-46. 34. Findling RL, McNamara NK, Branicky LA, Schluchter MD, Lemon E, Blumer JL. A double-blind pilot study of risperidone in the treatment of conduct disorder. J Am Acad Child Adolesc Psychiatry. 2000;39:509-16. 35. Dunbar F, Kusumakar V, Daneman D, Schulz M. Growth and sexual maturation during long-term treatment with risperidone. Am J Psychiatry. 2004;161:918-20. 36. Lemmon ME, Gregas M, Jeste SS. Risperidone use in autism spectrum disorders: a retrospective review of a clinicreferred patient population. J Child Neurol. 2011;26:428-32. 37. McDougle CJ, Stigler KA, Erickson CA, Posey DJ. Atypical antipsychotics in children and adolescents with autistic and other pervasive developmental disorders. J Clin Psychiatry. 2008;69(Suppl 4):15-20. 38. McCracken JT, McGough J, Shah B, Cronin P, Hong D, Aman MG, et al. Risperidone in children with autism and serious behavioral problems. N Engl J Med. 2002;347:314-21. 39. Shea S, Turgay A, Carroll A, Schulz M, Orlik H, Smith I, et al. Risperidone in the treatment of disruptive behavioral symptoms in children with autistic and other pervasive developmental disorders. Pediatrics. 2004;114:e634-41. 40. Eberhard J, Lindström E, Holstad M, Levander S. Prolactin level during 5 years of risperidone treatment in patients with psychotic disorders. Acta Psychiatr Scand. 2007;115:268-76. 41. Handen BL, Hardan AY. Open-label, prospective trial of olanzapine in adolescents with subaverage intelligence and disruptive behavioral disorders. J Am Acad Child Adolesc Psychiatry. 2006;45:928-35. 42. Masi G, Milone A, Canepa G, Millepiedi S, Mucci M, Muratori F. Olanzapine treatment in adolescents with severe conduct disorder. Eur Psychiatry. 2006;21:51-7. 43. Potenza MN, Holmes JP, Kanes SJ, McDougle CJ. Olanzapine treatment of children, adolescents, and adults with pervasive developmental disorders: an open-label pilot study. J Clin Psychopharmacol. 1999;19:37-44. 44. Malone RP, Cater J, Sheikh RM, Choudhury MS, Delaney MA. Olanzapine versus haloperidol in children with autistic disorder: an open pilot study. J Am Acad Child Adolesc Psychiatry. 2001;40:887-94. 45. Daniel DG, Potkin SG, Reeves KR, Swift RH, Harrigan EP. Intramuscular (IM) ziprasidone 20 mg is effective in reducing acute agitation associated with psychosis: a double-blind, randomized trial. Psychopharmacology (Berl). 2001;155:128-34. 46. Meehan K, Zhang F, David S, Tohen M, Janicak P, Small J, et al. A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating acutely agitated patients diagnosed with bipolar mania. J Clin Psychopharmacol. 2001;21:389-97. 47. Findling RL, Reed MD, O’Riordan MA, Demeter CA, Stansbrey RJ, McNamara NK. Effectiveness, safety, and pharmacokinetics of quetiapine in aggressive children with conduct disorder. J Am Acad Child Adolesc Psychiatry. 2006;45:792-800. 48. Findling RL, Reed MD, O’Riordan MA, Demeter CA, Stansbrey RJ, McNamara NK. A 26-week open-label study of quetiapine in children with conduct disorder. J Child Adolesc Psychopharmacol. 2007;17:1-9.

49. Kronenberger WG, Giauque AL, Lafata DE, Bohnstedt BN, Maxey LE, Dunn DW. Quetiapine addition in methylphenidate treatment-resistant adolescents with comorbid ADHD, conduct/oppositional-defiant disorder, and aggression: a prospective, open-label study. J Child Adolesc Psychopharmacol. 2007;17:334-47. 50. Martin A, Koenig K, Scahill L, Bregman J. Open-label quetiapine in the treatment of children and adolescents with autistic disorder. J Child Adolesc Psychopharmacol. 1999;9:99-107. 51. Findling RL, McNamara NK, Gracious BL, O’Riordan MA, Reed MD, Demeter C, et al. Quetiapine in nine youths with autistic disorder. J Child Adolesc Psychopharmacol. 2004;14:287-94. 52. McDougle CJ, Kem DL, Posey DJ. Case series: use of ziprasidone for maladaptive symptoms in youths with autism. J Am Acad Child Adolesc Psychiatry. 2002;41:921-7. 53. Stigler KA, Posey DJ, McDougle CJ. Aripiprazole for maladaptive behavior in pervasive developmental disorders. J Child Adolesc Psychopharmacol. 2004;14:455-63. 54. Valicenti-McDermott MR, Demb H. Clinical effects and adverse reactions of off-label use of aripiprazole in children and adolescents with developmental disabilities. J Child Adolesc Psychopharmacol. 2006;16:549-60. 55. Kranzler H, Roofeh D, Gerbino-Rosen G, Dombrowski C, McMeniman M, DeThomas C, et al. Clozapine: its impact on aggressive behavior among children and adolescents with schizophrenia. J Am Acad Child Adolesc Psychiatry. 2005;44:55-63. 56. Zuddas A, Ledda MG, Fratta A, Muglia P, Cianchetti C. Clinical effects of clozapine on autistic disorder. Am J Psychiatry. 1996;153:738. 57. Chen NC, Bedair HS, McKay B, Bowers MB Jr, Mazure C. Clozapine in the treatment of aggression in an adolescent with autistic disorder. J Clin Psychiatry. 2001;62:479-80. 58. Gogtay N, Rapoport J. Clozapine use in children and adolescents. Expert Opin Pharmacother. 2008;9:459-65. 59. Gerbino-Rosen G, Roofeh D, Tompkins DA, Feryo D, Nusser L, Kranzler H, et al. Hematological adverse events in clozapinetreated children and adolescents. J Am Acad Child Adolesc Psychiatry. 2005;44:1024-31. 60. Pappadopulos EA, Siennick SE, Jensen PS. Antipsychotics for aggressive adolescents: barriers to best practice. Expert Rev Neurother. 2003;3:85-98. 61. Findling RL, Frazier JA, Gerbino-Rosen G, Kranzler HN, Kumra S, Kratochvil CJ. Is there a role for clozapine in the treatment of children and adolescents? J Am Acad Child Adolesc Psychiatry. 2007;46:423-8. 62. Gobbi G, Pulvirenti L. Long-term treatment with clozapine in an adult with autistic disorder accompanied by aggressive behaviour. J Psychiatry Neurosci. 2001;26:340-1. 63. Kraus JE, Sheitman BB. Clozapine reduces violent behavior in heterogeneous diagnostic groups. J Neuropsychiatry Clin Neurosci. 2005;17:36-44. 64. Smith H, White T. The effect of clozapine on the social behaviour schedule in patients attending a forensic psychiatry day hospital. Med Sci Law. 2004;44:213-6. 65. Sikich L. Efficacy of atypical antipsychotics in earlyonset schizophrenia and other psychotic disorders. J Clin Psychiatry. 2008;69(Suppl 4):21-5. 66. Correll CU. Metabolic side effects of second-generation antipsychotics in children and adolescents: a different story? J Clin Psychiatry. 2005;66:1331-2. 67. Stigler KA, McDougle CJ. Pharmacotherapy of irritability in pervasive developmental disorders. Child Adolesc Psychiatr Clin N Am. 2008;17:739-52. Correspondence Eduardo Henrique Teixeira Rua Dona Rosa de Gusmão, 412, Guanabara 13073-141 – Campinas, SP – Brazil Tel./Fax: +55 (19) 3243.1374 E-mail: eduardo@psiquiatriaforense.com.br

Trends Psychiatry Psychother. 2013;35(3) – 159

Trends

Review Article

in Psychiatry and Psychotherapy

The Iowa Gambling Task (IGT) in Brazil: a systematic review O Iowa Gambling Task (IGT) no Brasil: uma revisão sistemática André Rutz,1 Amer Cavalheiro Hamdan,2 Melissa Lamar3

Abstract

Resumo

Background: Decision-making is a complex, multidimensional cognitive function that requires the choice between two or more options and also the predictive analysis of its consequences. One of the tools most widely used to assess decision-making in neuropsychological research is the Iowa Gambling Task (IGT). Objective: To conduct a systematic review of articles reporting empirical IGT studies based in Brazil. Method: Articles were obtained from multiple journal databases including ISI Web of Knowledge, Scopus, SciELO, LILACS, and Scholar Google. Results: Thirty-six studies were included in this review and divided into four categories according to main subject matter (psychiatry & personality; demographic & cultural variables; medical/clinic; and psychometric properties & test administration standardization). In general, there was a significant growth in research employing IGT (χ2 = 17.6, df = 5, p = 0.0003), but this growth was restricted to a few geographic areas of Brazil. The psychiatry & personality subject matter was the most abundant, accounting for 14 publications (39% of the total sample). Conclusion: Since its first adaptation to Brazilian Portuguese in 2006, a growing interest in decision-making as measured by the IGT can be observed, with psychiatry & personality topics representing a large portion of the scientific inquiry to date. Nevertheless, in order to extend the initial results of Brazilian IGT decision-making research, more studies are necessary – across a more diverse range of topics, including demographic & cultural variables, and psychometric properties & test administration standardization, the areas least studied –, as is the dissemination of the IGT to more regions of the country. Keywords: Neuropsychological tests, systematic review, Iowa Gambling Task, decision-making.

Contexto: A tomada de decisão é uma função cognitiva complexa e multidimensional que envolve a escolha entre duas ou mais opções, bem como a análise preditiva das suas consequências. Um dos instrumentos de pesquisa mais amplamente utilizados para avaliar a tomada de decisão em neurociência é o Iowa Gambling Task (IGT). Objetivo: Realizar uma revisão sistemática de artigos empíricos conduzidos com o IGT no Brasil. Método: Os artigos foram obtidos através de busca nos bancos de dados ISI Web of Knowledge, Scopus, SciELO, LILACS e Scholar Google. Resultados: Trinta e seis estudos foram incluídos e divididos em quatro categorias de acordo com o tema principal (variáveis demográficas e culturais; psiquiatria e personalidade; variáveis médico-genéticas e saúde geral; e propriedades psicométricas e padronização de aplicação). Em geral, houve um crescimento significativo da pesquisa utilizando o IGT (χ2 = 17,6, gl = 5, p = 0,0003), porém restrito a algumas áreas geográficas brasileiras. O eixo temático de psiquiatria e personalidade foi o que mais produziu estudos, contabilizando 14 publicações (39% da amostra total). Conclusão: Desde sua primeira adaptação para o português brasileiro em 2006, pode-se observar um crescente interesse pela tomada de decisão medida pelo IGT, sendo assuntos relacionados ao tema psiquiatria e personalidade responsáveis por grande parte dos estudos realizados até o momento. No entanto, para ampliar os resultados iniciais da pesquisa nacional com o IGT, mais estudos são necessários – com uma amplitude maior de áreas temáticas, incluindo as categorias menos estudadas até o momento: variáveis demográficas e culturais e propriedades psicométricas e padronização de aplicação – bem como uma maior disseminação do IGT em outros centros regionais do país. Descritores: Testes neuropsicológicos, revisão sistemática, Iowa Gambling Task, tomada de decisão.

Psychologist. Master’s Program in Psychology, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil. Curitiba, PR, Brazil. 3 Associate professor, Department of Psychiatry, University of Illinois, Chicago, IL, USA. Financial support: none. 1

Professor, Department of Psychology, UFPR,

Submitted Jan 31 2013, accepted for publication May 31 2013. No conflicts of interest declared concerning the publication of this article. Suggested citation: Rutz A, Hamdan AC, Lamar M. The Iowa Gambling Task (IGT) in Brazil: a systematic review. Trends Psychiatry Psychother. 2013;35(3):160-70.

Trends Psychiatry Psychother. 2013;35(3) – 160-170

The Iowa Gambling Task in Brazil – Rutz et al.

Introduction Decision-making can be defined as a complex, multidimensional cognitive function that involves choosing between two or more options.1,2 The Iowa Gambling Task (IGT) is an instrument designed to evaluate decisionmaking in a manner similar to real-life circumstances. It simulates the uncertainty of rewards and punishments by presenting a choice between small rewards/small punishments vs. sporadic larger rewards and even larger punishments. The IGT is considered the international gold standard in the assessment of decision-making,3 deriving much of its brain-behavior associations from human lesion and neuroimaging studies.4,5 These studies suggest that the IGT requires prefrontal structure (i.e., ventromedial/ orbitofrontal) and function (i.e., executive functions such as impulse inhibition and reward processing), in addition to other neural correlates, such as the cerebellum and basal ganglia. The IGT was created in 1994 by Bechara et al.4 at the Spence Laboratory, Department of Psychology and Neuroscience, University of Iowa, Des Moines, USA. It was originally designed to test the somatic marker hypothesis, formulated by Damasio et al.5 According to this hypothesis, making decisions would involve the activation of a complex network of body signals (known as somatic markers) that integrate emotion and reason. Determined in great part by learning from previously chosen outcomes, somatic markers such as the “gut feeling” implied in emotions that arise in betting decisions, for example, are the integration of body states directly linked to visceral sensations, i.e., physiological sensations that add the emotional weight necessary to make a decision viable in situations with a high degree of uncertainty and complexity. Thus, somatic markers influence behavior by modulating reasoning within an emotional context to prompt a choice. While it can be administered by hand, IGT application is typically computerized. It consists of a ‘gambling’ game in which the participant is asked to choose a card from 1 of 4 decks of cards (A, B, C, or D) for a total of 100 trials. For every choice made, the participant is awarded a cash value that varies in magnitude according to the chosen deck, but it may also be combined with a punishment in the form of monetary loss deducted from the amount of money accumulated over the course of the task. Two decks (A&B) are initially more attractive because of the high initial gains, but they also cause large monetary losses. The other two decks (C&D) offer modest rewards and losses in the immediate term but are more advantageous over time because they do not cause the losses of the other decks. Thus, the most advantageous strategy in the IGT is to avoid riskier decks (A&B) and prefer the more mundane albeit consistent ones (C&D).

The participant’s decision-making profile is rendered by a net score (total choices of decks C&D minus total choices of decks A&B) that implies either advantageous (positive net score) or disadvantageous (negative net score) decision-making. Additionally, performance may be analyzed using a block of 20 cards to assess strategy learning over time. Some authors6 argue that decisionmaking as measured by the IGT comprises three different components: motivation to gain and to ignore losses; learning rate; and attention to recent outcomes/ response sensitivity. Across neurological and neuropsychiatric studies,4 decision-making measured by the IGT has been shown to differ according to psychiatric diagnosis. For example, impairments in impulsivity and reward processing in decision-making were identified in different types of psychiatric disorders: attention deficit hyperactivity disorder (ADHD),3,7 bipolar disorder (BD),8-10 obsessive-compulsive disorder (OCD),11-14 drug and alcohol abuse,15-18 internet abuse,19 pathological gambling, borderline personality disorder,20 patients with a suicide attempt history,8,9 post-traumatic stress disorder (PTSD),12 and generalized anxiety disorder (GAD).10 In addition, the incorporation of genetics to IGT-based investigations of these psychiatric diagnoses has shown promising results for a better understanding of the biological substrates of social behavior, e.g., the association between genotypes and impulsivity (5-HTTLPR polymorphism)21 and analysis of the brainderived neurotrophic factor (BDNF) gene.14 In addition to the expansion of decision-making research with neologisms such as “decision neuroscience,”22 international adaptations, including those conducted in Brazil, have allowed to extend this work across languages, countries, and continents. The IGT was adapted to Brazilian Portuguese by two distinct research groups: one from Universidade Federal do Rio Grande do Sul (UFRGS),1 southern Brazil, in 2006, and the other by Universidade Federal de Minas Gerais (UFMG),3 southeastern Brazil, in 2008. This has led to the creation of two regionalized versions of the IGT, with minor linguistic differences in the instructions but a common reward schedule identical to that of the original task. Both research groups stated that their test adaptations were developed in close partnership with the author of the original test.4 The aim of this study was to conduct a systematic review of empirical research conducted with IGT in Brazil. This article summarizes some of the key topics of research on decision-making and aims to provide the reader with a brief overview of the current state of scientific debate in Brazil as it relates to the IGT. Plus, it intends to discuss possible directions for future research.

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The Iowa Gambling Task in Brazil – Rutz et al.

Methods

survey. Another survey was conducted in Google Scholar using the keywords [“Iowa Gambling Task” and “Brazil”], and the links for the first 10 result pages were manually inspected, adding another 17 studies. As a result, a total of 30 studies were selected using the three survey methods. The next step was to browse for other publications by the first authors of each of the 30 articles on the Scopus database and the Lattes platform, to ensure that other studies by the same authors using the IGT would not be overlooked. With this procedure, two additional articles were located (n = 32). Finally, the two research groups responsible for the adaptation of the IGT to Brazil were

Search strategy The first studies surveyed were identified on the ISI Web of Science, Scopus, LILACS, and SciELO databases using the following descriptors: [“IGT” and “Brazil”] or [“IGT” and “Brasil”] or [“Iowa Gambling Task” and “Brasil”]. Thirteen studies were initially identified. From this starting point, a reverse search was performed in the references of the selected articles to locate further empirical studies that had not been pinpointed by the initial

Table 1 – Empirical IGT empirical studies conducted in Brazil: descriptive data

Gender (M/F)

Author (year)

Samples (N)

Schneider et al. (2006)1

n = 82 adults: 42 elderly: 40 n = 11 ACoA adults: 1 controls: 10 n = 101 ADHD adults: 50 controls: 51 n = 97 n = 20 elderly group I: 10 elderly group II: 10 n = 75 non-English proficient adults: 25 English fluent adults: 25 ADHD adults: 25 n=1

2/18

Leite et al. (2007)23 Malloy-Diniz et al. (2007)7 Schneider et al. (2007)24 Bakos et al. (2008)25 Malloy-Diniz et al. (2008)3

Rocha et al. (2008)20 Rocha et al. (2008)11 Salgado et al. (2008)15 Malloy-Diniz et al. (2009)8 Wagner et al. (2009)26 Wagner et al. (2009)27 Bakos et al. (2010)28 Bakos et al. (2010)29

Borges et al. (2010)30 Cardoso et al. (2010)31 Coutinho et al. (2010)19 Borges et al. (2011)12

Age

Control

Education (years)

27/55

adults: 24±4.43 elderly: 68±5.01

Yes

11/-

ACoA adults: 45 years controls: match

Yes

high school (incomplete): n = 10 graduation (incomplete): n = 30 graduation (complete): n = 42 ACoA adults: controls: match

48/53

ADHD adults: 33.7±11.7 controls: 32.2±12.9

Yes

ADHD adults: 12.95±2.1 controls: 13.27±2.4

35/62

elderly group I: 69.68±8.27 elderly group II: 70.59±8.16 elderly group III: 68.60±5.02 elderly group I: 62±2.1 elderly group II: 79.6±3.3

Yes

group I: 15.52±2.85 group II: 14.94±5.54 group III: 13.80±2.98 14.05±2.5

33/42

non-English proficient adults: 32.1±8.5 English fluent adults: 28.5±6.5 ADHD adults: 31.8±9.1

Yes

non-English proficient adults: 13.9±2.3 English fluent adults: 13±2.2 ADHD adults: 13.3±2.4

1/-

adult: 27 years

7 years

n = 49 OCD adults: 49

23/26

Yes

adults group I: 11.74±5.21 adults group II: 10.85±5.30

n = 61 alcohol-dependent adults: 31 healthy adults: 30 n = 92 BPI adults: 39 healthy adults: 53

46/15

OCD adults group I: 29.44±13.68 OCD adults group II: 31.19±12.10 alcohol-dependent adults: 49.97±6.1 healthy adults: 46.93±8.3 BPI adults: 40.9±13.0 healthy adults: 36.9±9.8

Yes

n = 37 MCI elderly: 10 non-MCI elderly: 27 n = 44 elderly group I: 27 elderly group II: 17 n = 72 adults: 36 elderly: 36 n = 70 Brazilians (adults: 10, elderly: 25) Americans (adults: 10, elderly: 25) n=3 young: 1 adults: 2 n = 50

4/33

MCI elderly: 70.2±6.3 non-MCI elderly: 69.6±6.2

Yes

alcohol-dependent adults: 10.55±2.6 healthy adults: 11.07±4.0 BPI adults: 48.7% high school (complete) healthy adults: 52.8% high school (complete) MCI elderly: 9.2±4.6 non-MCI elderly: 10.4±5.3

3/41

elderly group I: 69.6±6.2 elderly group II: 70.59±8.15

Yes

elderly group I: 10.4±5.3 elderly group II: 14.91±5.53

19/53

adults: 29.86±4.63 elderly: 66.89±5.19

Yes

adults: 14.69±2.81 elderly: 12.75±3.39

34/58

18/52

1/2 15/35

n=2

2/-

n = 118 post-traumatic OCD: 16 pre-traumatic OCD: 18 non-traumatic OCD: 67 controls: 17

47/71

BA: BE: AA: AE:

32.35±3.72 68.16±5.40 32.35±3.72 68.16±5.40

Yes

BA: BE: AA: AE:

16.05±2.42 13.98±2.97 16.05±2.42 13.98±2.97

young: 19 years women: 34 years men: 29 years adults: 36.50±19.55

No No

young: graduation (incomplete) women: graduation (complete) men: graduation (complete) adults: 14.34±3.92

young I: 16 years young II: 19 years post-traumatic OCD: 39.2±12.4 pre-traumatic OCD: 41.2±12.3 non-traumatic OCD: 33.0±13.2 controls: 29.9±7.9

Yes

post-traumatic OCD: 11.6±4.2 pre-traumatic OCD: 13.6±4.3 non-traumatic OCD: 13.1±3.4 Controls: 14.0±2.7 (cont.)

162 – Trends Psychiatry Psychother. 2013;35(3)

The Iowa Gambling Task in Brazil – Rutz et al.

contacted, and the principal investigators were asked to review our list of 32 studies for possible omissions. Both groups made additions to the list: the UFRGS group added three studies, and the UFMG one (n = 36). We are fairly confident that our final sample of 36 studies represents all empirical IGT studies conducted in Brazil from March 2006 to June 2012.

Inclusion and exclusion criteria Any Brazilian empirical IGT study employing IGT alone or combined with other instruments was included in our

review. Theoretical studies, literature reviews, letters to the editor, dissertational studies, and unpublished doctoral theses were excluded. As the studies were included in the sample, they were assigned a topic category and subjected to data inspection and analysis.

Data extraction and analysis Descriptive data of the studies included are presented in Table 1. To ensure greater accuracy, data inspection and extraction were performed by one reviewer and checked by a second one, blind to the results of this study.

Table 1 – Empirical IGT empirical studies conducted in Brazil: descriptive data (cont.)

Author (year)

Samples (N)

Cunha et al. (2011)16

n = 30 drug-dependent adults: 15 controls: 15 n = 267 subclinical hypothyroidism adults: 89 controls: 178 n = 73 temporal lobe epilepsy adults: 35 controls: 38 n=1

Fernandes et al. (2011)32 Gois et al. (2011)33 Gonçalves et al. (2011)17 Lage et al. (2011)21 Lage et al. (2011)34 Lage et al. (2011)35 Rocha et al. (2011)13 Rocha et al. (2011)14 Carvalho et al. (2011)36 Scheffer et al. (2011)37 Malloy-Diniz et al. (2011)9 Cardoso et al. (2012)38

Viola et al. (2012)18 Carvalho et al. (2012)39 Couto et al. (2012)10 Lage et al. (2012)40 Carvalho et al. (2012)41

Gender (M/F)

Age

Control

Education (years)

drug-dependent adults: 25.67±6.53 controls: 26.60±6.62 subclinical hypothyroidism adults: 35.40±14.12 controls: 33.34±13.22

Yes

drug-dependent adults: 11.20±1.66 controls: 10.53±2.36 subclinical hypothyroidism adults: 9.56±4.87 controls: 9.26±5.28

34/39

temporal lobe epilepsy adults: 39.82±9.05 controls: 28.61±9.00

Yes

1/-

adult: 30 years

high school (complete)

n = 127

52/75

adults: 29.5±11.8

Yes

n = 22

9/13

adults: 22.5±4.2

graduation (incomplete): n = 86 graduation (complete): n = 41 graduation (incomplete): n = 22

youngsters: 17.45±0.5

OCD adults: 28.40±14.12 controls: 29.33±13.22

Yes

OCD adults: 10.87±4.75 controls: 10.26±5.02

OCD & Met-allele: 28.40±14.12 OCD & non-Met-allele: 29.33±13.22

Yes

OCD & Met-allele: 10.56±4.87

low education adults: 25.23±4.63 high education adults: 26.30±6.40 men: 60.90±8.93 women: 60.44±11.57 BD adults: 41±12 controls: 32±13

Yes

OCD & non-Met-allele: 10.26±4.90 low education adults: 15.73±2.69 high education adults: 7.45±0.99

Yes

men: 9.85±4.46 women: 11.27±5.86 BD adults: 46.3% graduation level controls: 59.6% graduation level

2/0

case I: 53 case II: 54

case I: 20 case II: 11

23/22

crack-dependent adults: 30.37±10.06 controls: 27.20±7.47 adults group I: 38.55±19.84 adults group II: 25.38±5.15

Yes

crack-dependent adults: 7.77±2.28 controls: 8.47±2.10 adults group I: 12.83±4.42 adults group II: 12.76±4.98

30/65

BD adults: 42.71±12.21 BD & GAD adults: 39.59±12.45

Yes

n = 81

34/47

adults: 23.6±3.8

Yes

n = 80 adults: 40 elderly: 40

28/52

adults : 25.50±4.70 elderly: 67.40±5.02

Yes

30/48/219

n = 11 -/11 youngsters: 11 n = 214 114/100 OCD adults: 107 controls: 107 n = 122 65/57 OCD & Met-allele adults: 40 OCD & non-Met-allele adults: 82 n = 60 36/24 low education adults: 20 high education adults: 40 n = 19 frontal stroke adults: 19 n = 189 BD adults: 95 controls: 94 n=2 right-hemisphere lesion adult: 1 left-hemisphere lesion adult: 1 n = 45 crack-dependent adults: 30 controls: 15 n = 89 group I: 60 group II: 29 n = 95 BD adults: 41 BD & GAD adults: 54

10/9 70/119

49/40

Yes

BD adults: high school (complete) - n = 26 BD & GAD adults: high school (complete) - n = 38 graduation (incomplete): n = 81 adults : 15.74±2.69 elderly: 14.68±2.80

AA = American adults; ACoA = anterior communicant artery aneurysm; ADHD = attention deficit hyperactivity disorder; AE = American elderly; BA = Brazilian adults; BD = bipolar disorder; BE = Brazilian elderly; BPI = bipolar disorder type I; F = female; GAD = generalized anxiety disorder; IGT = Iowa Gambling Test; M = male; MCI = mild cognitive impairment; OCD = obsessive-compulsive disorder.

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Results

2012 were not included in this analysis because the year was not complete at the time of data collection).

The 36 empirical studies identified in this systematic review covered a wide range of topics and experimental designs. All selected studies used the IGT: in seven of them (19%), the IGT was the only assessment tool employed; in the other 29 (81%), it was part of a neuropsychological assessment battery, i.e., combined with other instruments to assess executive functions. The most frequent association was with the Continuous Performance Task (CPT-II), present in 16 of the 29 studies (55%). The second most frequent neuropsychological test combined with the IGT was the Wisconsin Card Sorting Test (WCST), mentioned in a total of 12 studies (41%).

Subject matter The 36 articles were divided into four subject matter categories, as follows: demographic & cultural variables; psychiatry & personality; medical/clinic; and psychometric properties & test administration standardization. Some articles also addressed issues relative to other categories, but here only the key feature of the study was considered (i.e., the topic most focused on by the authors throughout the paper) to ensure better accuracy and interpretation of statistical data. No cutoff point for concordance between the authors was employed. Subjective consensus was established to form the categories of analysis in this review.

Geographic distribution In order to trace the geographic dispersion of IGT studies, we considered the state of origin of the first author’s academic affiliation as cited in each paper. Summing up all study locations, four Brazilian states emerged as major centers of IGT research: Minas Gerais (16/36, 44.4%), Rio Grande do Sul (15/36, 41.7%), Rio de Janeiro (3/36, 8.3%), and São Paulo (2/36, 5.6%). Results of the chi-square test indicated a statistically significant difference regarding research productivity according to geographic distribution (χ2 = 18.8, df = 3, p = 0.0003), favoring the two first states where IGT adaptation to Brazil was performed.

Demographic & cultural variables

Chronological distribution Concerning publication date, the chi-square test indicated a statistically significant difference regarding the number of publications by year (χ2 = 17.6, df = 5, p = 0.0035), with year 2011 showing the majority of Brazilian IGT publications, as shown in Figure 1 (articles published as of

Figure 1 – Evolution of Brazilian publications per year since first adaptation of the IGT to Brazilian Portuguese 164 – Trends Psychiatry Psychother. 2013;35(3)

Cultural and demographic variables were analyzed in depth in six studies (16%).1,25,28,29,36,41 Age was among the most frequently explored demographic characteristics explored: five articles1,25,28,29,41 analyzed the effect of this variable on IGT performance. Only one of these studies25 reported a significant difference in IGT net scores, with older adults (62.0±2.1 years old) showing higher net scores than the elderly (79.6±3.3 years old) (t[18] = 3.34, p = 0.04, d = 1.52) – the difference occurred only in decisionmaking (IGT). One possible caveat for such difference relative to other studies is the limited sample analyzed (n = 10). While two studies28,41 found no differences in IGT net scores, both pointed to differences in the learning process in the different age groups tested (young/old, p = 0.02628; and young [25.5±4.7 years old] vs. elderly [67.4±5.2 years old], p = 0.02141). Another study1 found no differences in either net scores or the learning process. One study analyzing age and country of origin29 found that, even though there was no interaction between the two variables, there was a significant influence of culture (country of origin) on IGT net scores (country, p ≤ 0.001; age, p = 0.134; country vs. age, p = 0.291). Only one study emphasized gender differences, but it was included in the medical/clinic category because its key topic was frontal stroke. The authors stated that gender differences should be considered when planning psychotherapy and cognitive rehabilitation for frontal stroke patients.37 In total, the 36 studies analyzed 1,004 men (39.97%) and 1,508 women (60.03%). Only one article36 focused on education as the main topic of research. The authors reported no significant differences in IGT net scores between groups with high (9.15±25.7) and low (9.00±16.46) education levels

The Iowa Gambling Task in Brazil – Rutz et al.

(p = 0.98). This finding corroborates the still scarce international scientific literature about the topic, which seems to converge to the conclusion that schooling does not significantly influence performance on IGT.42-44

Psychiatry & personality This appeared to be the most productive topic in empirical IGT studies in Brazil, with 14 scientific publications (39%).7-20 The studies addressed personality and psychiatry disorders as well as addictions and substance abuse. Some studies also analyzed genetic components of psychiatric disorders. Four studies11-14 examined OCD, given their neuroanatomical focus on regions known to contribute to successful IGT performance, including the orbitofrontal cortex.45 These studies reported controversial results for IGT performance and little similarities in targeted genetic markers of disease. For example, one study involving 107 individuals with OCD13 found impaired performance on the IGT net scores of these patients (-4.96±12.85) when compared to healthy controls (6.42±21.88; p < 0.01), whereas another study12 did not find differences between patients with OCD and healthy controls. When incorporating genetic information, a subgroup of OCD patients (those with S and/or LG alleles) exhibited low performance on the IGT.11 Participants of the high expressing group performed significantly better on the third, fourth, and fifth blocks and also on total net scores. That study was the first to demonstrate a significant association between 5-HTTLPR and decisionmaking processes in OCD patients. Another study investigating individuals with OCD who were carriers of the dominant form of the BDNF gene14 found deficits in the initial blocks of the IGT, suggesting that the deficits in these individuals were related to decision-making in ambiguous situations only, where there was no clear indicative of the consequence associated with the choice. Several of the other studies under the psychiatry & personality domain focused on BD,8-10 given its neuroanatomical link to the inferior prefrontal cortex and subcortical structures known to facilitate IGT performance.46 One study8 reported significant differences between clinical groups and controls (z = -4.63, p = 0.0001). Notwithstanding, it did also report that a positive history of past suicide attempt(s) was predictive of worse IGT net scores as well as worse performance in block 3 when compared to individuals with BD and a negative history of suicide attempts. Another study9 reported significant differences between clinical cases and controls in net score (20.57±23.61 vs. 24.28±3.89, z = -4.56, p < 0.001), which also correlated with a positive history of suicide attempt(s). Another study10 assessed GAD associated

with BD vs. BD alone and found no significant differences between the clinical groups in terms of net scores (z = -1.15, p = 0.251). Another well-developed axis of psychiatry & personality studies has been the area of addiction, particularly drug and alcohol abuse.15-18 One study19 assessed internet addiction, given the overlapping reward circuitry impairments implicated in these disorders.47 The four studies of drug and alcohol abuse indicated a significant difference favoring advantageous decision-making in controls vs. those with addiction on IGT net score classifications. One study15 indicated that alcoholics in abstinence for ≤ 120 days differed from controls in net scores (1.03±6.14 vs. 10.19±22.7, z = -3.70, p = 0.0001). Another study16 reported that crack/cocaine dependents in abstinence for 2 weeks made more disadvantageous choices on the IGT when compared with a control group of 15 healthy individuals (volunteers recruited in the city of São Paulo), and these results were correlated with a higher level of social dysfunction according to the Social Adjustment Scale Self-Report (SAS-SR) in crack/cocaine users. Finally, in the study19 about internet addiction, one of the two cases analyzed displayed an impaired performance on the IGT. Two other studies3,7 approached impulsivity. The first study7 focused on impulsivity as it pertains to adults with ADHD. Significant correlations were found between self-reported impulsivity in the ADHD group (Barratt Impulsiveness Scale, BIS-11) and performance on the IGT.48 Another report of ADHD3 found that a group of 25 individuals with the disorder had significantly different IGT net scores compared to groups of healthy controls (25 healthy volunteers with proficiency in English = 21.28±23.15 vs. 25 healthy volunteers without proficiency in English = 21.13±21.99 vs. ADHD group = 5.01±23.93; F = 9.323, p = 0.0001). It should be noted, however, that the IGT version in question was a cultural adaptation, and not the original IGT (this study was included in the psychometric properties & test administration standardization category, please refer to it for more details). Of note, one study investigated borderline personality disorder in a case report. A 27 year-old man with this disorder had his performance compared with asymptomatic male controls matched for age and years of education. The criterion for altered results was a 2 standard deviation difference between the patient’s score and the healthy controls. According to the authors, the patient made more non-profitable choices on the IGT, suggesting deficits in decision-making.20

Medical/clinic Health-related issues were analyzed in 11 publications (31%)21,23,26,30,32-35,37,38,40 and covered a variety of neurological

Trends Psychiatry Psychother. 2013;35(3) – 165

The Iowa Gambling Task in Brazil – Rutz et al.

issues. Three studies23,37,38 focused on stroke and its impact on decision-making, with one study addressing treatment implications. One of these studies focused on the impact of right vs. left hemisphere stroke,38 reporting that both types of patients achieved an adequate performance on the IGT. Another study37 addressed the effects of frontal stroke and gender on decision-making. While IGT results did not differ significantly between men and women, both groups showed a preference for risky choices (B cards) and failed to show consistent learning during the task. The only significant sex difference between groups was related to total BIS11 scores48 (U = 15.5, z = -2.42, p = 0.013) and its nonplanning subscale (U = 18.0, z = -2.22, p = 0.028). Data indicated a higher lack of planning (non-planning) among women. Lastly, the study addressing treatment23 examined cognition and behavior before and after the administration of methylphenidate in a patient with anterior communicant artery aneurysm. The first neuropsychological assessment was performed 48 months after stroke, after which the administration of methylphenidate (40 mg/day) was begun, followed by another neuropsychological assessment with the same instruments but another version of the IGT (win IGT/lose IGT)43 6 months later. Methylphenidate improved executive functions, attention, and decision-making abilities. Performance on the IGT varied from pre-treatment levels (win IGT, 1st assessment net score = -8 vs. lose IGT, 2nd assessment net score = 7). Another study30 addressed three cases of dysexecutive syndrome, two resulting from traumatic brain injury and the other due to developmental problems. Impairments on IGT performance were identified in all three cases. Several studies appeared to be the only one of their kind conducted in Brazil, including an isolated study on mild cognitive impairment. An analysis of older adults with and without mild cognitive impairment found no differences in IGT net scores but suggested an impaired learning during IGT in individuals with MCI.26 These results, however, are implied, as the authors did not describe the statistical results of their repeated-measures analysis of variance, but rather preferred to graphically display the differences between groups. Likewise, in a study investigating temporal lobe epilepsy, the authors did not report IGT testing results.33 Despite being an isolated report, a recent publication on cognitive impairment due to subclinical hypothyroidism32 had the largest sample (n = 267) of all Brazilian IGT studies. The study reported differences in cognitive flexibility measured by the WCST and in sustained attention measured by the CPT-II (omission errors), but IGT scores (net score and blocks) showed no statistically significant differences between those with and without subclinical hypothyroidism. Another study21 investigating impulsivity and genetics failed to find a

166 – Trends Psychiatry Psychother. 2013;35(3)

relationship between genetic polymorphism 5-HTTLPR and decision-making (considered by those authors as equivalent to cognitive impulsivity) based on IGT net scores in 127 individuals (t[73] = 0.63, p = 0.87). General health issues were analyzed in three publications.34,35,40 They focused mainly on motor control as determined in sports, including technical fouls and impulsivity in female handball. The study40 focused on the relationship between different facets of impulsivity and the motor control of aiming movements. They concluded that motor impulsivity (measured by the CPT-II) is more related to motor control than cognitive impulsivity (measured by the IGT). They also stated that IGT net scores were used as a dependent measure of cognitive (decision-making) impulsivity. Unlike CPT-II scores, high scores on the IGT indicated a low level of impulsivity. One study34 relating motor performance and non-planning impulsivity did not find any significant correlations. Another study35 found a significant correlation between performance on the IGT and offensive technical fouls committed by female handball players in 11 matches. These studies (especially the former34) concluded that the impact of motor impulsivity is greater than the impact of cognitive impulsivity on motor control.

Psychometric properties & test administration standardization The psychometric properties of IGT and its administration standardization were analyzed in five Brazilian studies (14%).3,24,27,31,39 Several studies3,24,27 focused on changes in task administration, the majority of which – not surprisingly – found significant differences in performance results when comparing the changed task with the original IGT. In one study,24 the authors varied the amount of monetary feedback given over the course of the task. In another,27 visual feedback cues were altered: even though there were no differences in the mean number of cards selected from each deck between the changed and the original IGT, there were significant differences in risk aversion, with alterations in visual cues resulting in better sensibility to loss frequency and a less risky behavior than that seen in the original IGT (F[5.85] = 1, p = 0.02). The last study3 addressed the adaptation of the IGT to Brazilian Portuguese by a research group from UFMG, in Minas Gerais, southeastern Brazil. The goals were to describe the cross-cultural adaptation process and to assess the discriminant validity of the resulting version. The authors applied the original IGT (English version) to a group of healthy volunteers proficient in English, and

The Iowa Gambling Task in Brazil â&#x20AC;&#x201C; Rutz et al.

the IGT-BR (Brazilian adapted version) to two groups, one with healthy volunteers not proficient in English and another with ADHD patients not proficient in English. No differences between the two first groups (healthy volunteers) were found, with similar outcomes for the original English version and the Brazilian adaptation. The translation of the IGT was also discussed in that study. The authors found a kappa coefficient (Cohen) of Ć&#x2122; = 0.81, indicating that the translation was appropriate. Based on these data, the authors concluded that the adapted IGT-BR version was adequate. Other studies31,39 addressed test-retest reliability and construct validity of the IGT. Test-retest results31 pointed to a positive, significant correlation in net scores between time 1 and time 2 (with intervals ranging from 1 to 6 months), with a linear Pearson coefficient of r = 0.43 (p = 0.002). Construct validity39 was assessed by correlating IGT scores with other executive function tasks, including the WCST, the Trail Making Test (TMT), and the Hayling Test. Of these, only the Hayling Test (time part B) correlated with IGT performance, suggesting a direct relationship between inhibition speed and advantageous decision-making.

Discussion The IGT is the task most widely used to evaluate the process of decision-making.3 It was first adapted to Brazilian Portuguese in 2006,1 and then again in 2008,3 by different research groups, leading to the generation of two regionalized versions. Following the expansion in decision-making neuroscientific research using the IGT, this assessment tool has been used in a wide variety of studies. We conducted a systematic review of empirical research conducted in Brazil with the IGT to provide the reader with a brief overview of current studies and to discuss directions for future research. This review revealed a focus of Brazilian-based IGT studies on clinical populations with neuropsychiatric and personality disorders, which can probably be explained by the fact that the IGT is considered one of the few instruments sensitive to specific (ventromedial/orbito) frontal deficits, and many of the studies in psychiatry have focused on populations with such prefrontal involvement.4,28 In fact, orbitofrontal cortex neural networks located in the prefrontal cortex are key circuits to both the cognitive process of decision-making and the regulation of social behavior.20 Insults to this part of the cortex are associated with the onset of several behavioral disorders, including OCD and substance abuse, both of which show a negative impact on decision-making.15-18 In continuing these applications to the field of mental

health diagnosis, genetic vulnerabilities and treatment outcomes may prove promising fields of psychiatric research in Brazil. Demographic variables were also analyzed rather intensively in Brazilian IGT studies. One of the main variables of interest was age. Findings on the effect of aging on decision-making remains controversial, hindering the development of a consensus on the issue. One possible explanation for this discrepancy is the fact that age groups and healthy aging criteria used while composing samples have not been fully explored. Given the complex array of factors involved in aging,49 including vascular risk and subclinical depression,50 much work needs to be done before we can understand the impact of these variables on aging and decision-making in Brazil. Additionally, cognitive aging does not follow a linear trend; concepts such as neuroplasticity, cognitive reserve, and compensation can have different impacts on the aging population. Future studies should consider these aspects of aging when assessing IGT performance, but will require large sample sizes to enable robust conclusions. Given the impact that decision-making has on the autonomy and protection of older people, expert knowledge on the neuropsychology of aging and decision-making will become increasingly important as the Brazilian population of older adults increases. Some cultural factors beyond aging were also addressed in Brazilian IGT studies, e.g., the impact of education on decision-making.3,29,36 As expected, individuals with lower education levels performed worse on the IGT than those with higher levels of education; however, these results are from one study only and need replication and additional work. The concern with tailoring the IGT to our country and to regional cultural differences will only add assessment accuracy via crosscultural adaptation. In additional to regional validity, other psychometric properties were also verified,31 such as test-retest reliability and construct validity, but these results also await replication. Research on the psychometric properties of the IGT will become increasingly important, especially if research on this task in Brazil is to further incorporate the theoretical model of the somatic marker hypothesis.51 It is worth noting that the majority of IGT studies conducted in Brazil continue to take place in the same geographic locations that originally adapted the task for use in Brazil, i.e., the southern and southeastern regions of Brazil. This indicates the need for an increased dissemination of the IGT task and its use in other Brazilian states through scientific cooperation between research centers. Such increased collaboration would lead to a more precise picture of the population parameters that influence decision-making through larger sample sizes

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and greater access to patient populations via multisite studies of particular disorders. Thinking about the national future of decision-making research, studies should publish detailed results including statistical findings and group means whenever possible. This will assist other Brazilian investigators in i) conducting power calculations to determine adequate sample sizes for their own work; ii) determining which version of the IGT task was used in individual studies; and iii) determining how results obtained for net scores and task blocks may play out in their own studies. Greater transparency in published IGT data will also allow for future meta-analyses in this area and hopefully lead to a higher degree of consensus in results across clinical populations. Incorporating a larger neuropsychological test battery into the study of IGT performance in Brazil is also desirable in future studies. Sixteen studies7-11,13-15,19-21,30,32,34,35,40 incorporated the CPT-II and found significant associations between the two tasks. This suggests common cognitive constructs involving impulsivity in attentional and motor dimensions in both the IGT and the CPT-II. Studies conducted in Brazil appear to provide support for a convergence of Bechara’s concept of cognitive impulsivity42 and Barratt’s concept of non-planning impulsivity.48 Bechara’s model proposes a functional and structural difference between motor impulsivity, which would be related to inhibition of pre-potent responses, and decisionmaking, which in one instance has also been referred to as cognitive impulsivity. This conceptualization seems to be analogous to Barratt’s non-planning impulsivity concept, because both models consider the tendency to act with less forethought (i.e., in the decision-making context, IGT measures the preference for long-term advantageous choices vs. more short-term disadvantageous choices, and the BIS-11 non-planning subscale measures the lack of ‘futuring’). A more detailed discussion on this topic is available elsewhere.7 Given the applicability of IGT as a measure of cognitive impulsivity related to impulsivity in the sporting arena, Brazilian scientists may be in a unique position to delve further into the convergence of cognitive and motor impulsivity using the IGT and real-world situations of reward and punishment.34,35,40 In the future, the growing amount of studies analyzing the implications of motor control and decision-making in the sports arena could potentially create the fifth independent category of the IGT scenario: decision-making in sports, covering some of the studies currently in the general health branch of research. Another neuropsychological instrument frequently associated with the IGT was the WCST, in 12 studies.8,12,15-17,26,30,32,33,36,37,39 Even though correlations between the two instruments appear to be weak (e.g., perseverative WCST errors vs. performance on the first

168 – Trends Psychiatry Psychother. 2013;35(3)

block of the IGT), investigators39 have suggested that this relationship remains inconclusive. While the IGT is considered a classical instrument in the evaluation of high emotional influence and the WCST has a higher preponderance of low emotional influence,26,52 additional work using more tasks of high and low emotional as well as executive influence are needed to confirm this tentative association in the IGT literature. As neuropsychological IGT research advances in Brazil, the goal should be to address weaknesses of previous studies and to generate normative data that is culturally compatible29 with this country. For example, on the one hand, the IGT is a computerized instrument; on the other, much of the IGT work conducted in Brazil focuses on the elderly. Not every elder has access to or familiarity with computers; this should be considered in future works on aging. A suggestion for such studies would be the preliminary survey of the participants’ familiarity with the use of personal computers. Another relevant issue for future research is the use of neuroimaging as a basic investigation tool. Only one isolated study20 (3% of the total sample) employed this resource (magnetic resonance imaging, MRI) in decisionmaking investigation in Brazil, a limitation that is partly explained by the difficult access to this type of equipment. Few university laboratories currently have these devices, but we strongly recommend that future research should include neuroimaging, especially functional magnetic resonance imaging (fMRI), as the somatic marker hypothesis itself was based on neuroimage validity convergence.5 This improvement will also underscore the need to employ more advanced statistics in the studies, with voxelmetrics and multivariate data modeling techniques to better evaluate cognitive neurobiological findings using IGT. Furthermore, another important resource, still underemployed in decision-making studies in Brazil, is genotyping. Only four studies9,11,14,21 (11% of the total sample) described genetic data. The continuous and fast advance observed in genetics, studying how individual variations in hormones and genes can influence reward processing and decision-making is at the top of the agenda for future research. The development of more robust experiments that can address some of the weak points in the somatic marker hypothesis,51 as well as further explore the construct of decision-making,6 will be most welcome. The trend observed in the course of this review regarding IGT publication history in Brazil indicates a strong increase in decision-making research using this task in recent years. With interest and productivity on the rise, it is our hope that awareness of the strengths and weaknesses of previous work here highlighted, the humble suggestions made for future research, and

The Iowa Gambling Task in Brazil – Rutz et al.

an increased collaboration across research centers will strengthen Brazil’s position in the IGT research community and continue to build knowledge in this important area of research in the coming years.

Acknowledgments To Rochele Paz Fonseca (Pontifícia Universidade Católica do Rio Grande do Sul, PUCRS) and Leandro Fernandes Malloy-Diniz (UFMG) for their invaluable contribution providing articles, suggestions, and revising the preliminary list of articles selected for review.

References 1. Schneider DG, Parente MA. O desempenho de adultos jovens e idosos na Iowa Gambling Task (IGT): um estudo sobre a tomada de decisão. Psicol Reflex Crit. 2006;19:442-50. 2. Alves GS, Rosenthal M. Avaliação neuropsicológica dos circuitos pré-frontais relacionados à tomada de decisão na esquizofrenia: uma revisão sistemática da literatura. Rev Psiquiatr Rio Gd Sul. 2006;28:330-41. 3. Malloy-Diniz LF, Leite WB, Moraes PH, Corrêa H, Bechara A, Fuentes D. Brazilian Portuguese version of the Iowa Gambling Task (IGT): transcultural adaptation and discriminant validity. Rev Bras Psiquiatr. 2008;30:144-8. 4. Bechara A, Damasio AR, Damasio H, Anderson SW. Insensitivity to future consequences following damage to human prefrontal cortex. Cognition. 1994;50:7-15. 5. Damasio A. O erro de Descartes: Emoção, razão e cérebro humano. São Paulo: Companhia das Letras; 1996. 6. Yechiam E, Busemeyer JR, Stout JC, Bechara A. Using cognitive models to map relations between neuropsychological disorders and human decision making deficits. Psych Sci. 2005;16:973-8. 7. Malloy-Diniz LF, Fuentes D, Leite WB, Corrêa H, Bechara A. Impulsive behavior in adults with attention deficit hyperactivity disorder: characterization of attentional, motor and cognitive impulsiveness. J Int Neuropsychol Soc. 2007;13:1-6. 8. Malloy-Diniz LF, Neves FS, Abrantes SS, Fuentes D, Corrêa H. Suicide behavior and neuropsychological assessment of type I bipolar patients. J Affect Disord. 2009;112:231-6. 9. Malloy-Diniz LF, Neves FS, Moraes PH, De Marco LA, RomanoSilva MA, Krebs M, et al. The 5-HTTLPR polymorphism, impulsivity and suicide behavior in euthymic bipolar patients. J Affect Disord. 2011;133:221-6. 10. Couto TC, Neves FS, Machado MC, Vasconcelos AG, Corrêa H, Malloy-Diniz LF. Assessment of impulsivity in bipolar disorder (BD) in comorbidity with generalized anxiety disorder (GAD): revisiting the hypothesis of protective effect. Clin Neuropsychiatry. 2012;9:102-6. 11. Rocha FF, Malloy-Diniz LF, Lage NV, Romano-Silva MA, De Marco LA, Corrêa H. Decision-making impairment is related to serotonin transporter promoter polymorphism in a sample of patients with obsessive-compulsive disorder. Behav Brain Res. 2008;195:159-63. 12. Borges MC, Braga TD, Iêgo S, D’alcante CC, Sidrim I, Machado MC, et al. Cognitive dysfunction in post-traumatic obsessive-compulsive behaviour. Aust N Zeal J Psychiatry. 2011;45:76-85.

13. Rocha FF, Alvarenga NB, Malloy-Diniz LF, Corrêa H. Decisionmaking impairment in obsessive-compulsive disorder as measured by the Iowa Gambling Task. Arq Neuropsiquiatr. 2011;69:642-7. 14. Rocha FF, Malloy-Diniz LF, Lage NV, Corrêa H. The relationship between the Met allele of the BDNF Val66Met polymorphism and impairments in decision making under ambiguity in patients with obsessive-compulsive disorder. Genes Brain Behav. 2011;10:523-9. 15. Salgado JV, Malloy-Diniz LF, Campos VR, Abrantes SS, Fuentes D, Bechara A, et al. Avaliação neuropsicológica do comportamento impulsivo de sujeitos dependentes de álcool em abstinência. Rev Bras Psiquiatr. 2008;31:4-9. 16. Cunha PJ, Bechara A, Andrade AG, Nicastri S. Decision-making deficits linked to real-life social dysfunction in crack cocainedependent individuals. Am J Addiction. 2011;20:78-86. 17. Gonçalves HA, Cardoso CO, Araújo RB. Funções executivas na dependência de crack: um estudo de caso. Rev Neuropsicol Latinoam. 2011;3:7-13. 18. Viola TW, Cardoso CO, Francke ID, Gonçalves HA, Pezzi JC, Araújo RB, et al. Tomada de decisão em dependentes de crack: um estudo com o Iowa Gambling Task. Estud Psicol. 2012;17:99-106. 19. Coutinho G, Mattos P, Miele F, Borges M. The cognitive profile and different presentations of internet addiction in teenagers: two case reports. Clin Neuropsychiatry. 2010;7:164-9. 20. Rocha FF, Malloy-Diniz LF, de Souza KC, Prais HA, Correa H, Teixeira AL. Borderline personality features possibly related to cingulate and orbitofrontal cortices dysfunction due to schizencephaly. Clin Neurol Neurosurg. 2008;110:396-9. 21. Lage GM, Malloy-Diniz LF, Matos LO, Bastos MA, Abrantes SS, Corrêa H. Impulsivity and the 5-HTTLPR polymorphism in a non-clinical sample. PLoS One. 2011;6:e16927. 22. Shiv B, Bechara A, Lewin I, Alba JW, Bettman JR, Dube L, et al. Decision neuroscience. Mark Lett. 2005;16:375-86. 23. Leite WB, Malloy-Diniz LF, Corrêa H. Effects of methylphenidate on cognition and behaviour: ruptured communicant aneurysm of the anterior artery. Aust N Zeal J Psychiatry. 2007;41:555-6. 24. Schneider DG, Wagner GP, Denburg N, Parente MA. Iowa Gambling Task: administration effects in older adults. Dement Neuropsychol. 2007;1:66-73. 25. Bakos DS, Couto MC, Melo WV, Parente MA, Koller SH, Bizarro L. Executive functions in the young elderly and oldest old: a preliminary comparison emphasizing decision making. Psychol Neurosci. 2008;1:183-9. 26. Wagner GP, Trentini CM, Parente MA. O Desempenho de idosos com e sem declínio cognitivo leve nos testes Wisconsin de classificação de cartas e Iowa Gambling Task. PSICO. 2009;40:220-6. 27. Wagner GP, Parente MA. O desempenho de idosos quanto a tomada de decisão em duas variações do IGT. Psic Teor Pesq. 2009;25:425-33. 28. Bakos DS, Parente MA, Bertagnolli AC. A tomada de decisão em adultos jovens e em adultos idosos: um estudo comparativo. Psicol Cienc Prof. 2010;30:162-73. 29. Bakos DS, Denburg NL, Fonseca RP, Parente MA. A cultural study on decision making performance differences on the Iowa Gambling Task between selected groups of Brazilians and Americans. Psychol Neurosci. 2010;3:101-7. 30. Borges M, Coutinho G, Miele F, Malloy-Diniz LF, Martins R, Rabelo B, et al. Síndromes disexecutivas do desenvolvimento e adquiridas na prática clínica: três relatos de caso. Rev Psiquiatr Clin. 2010;37:285-90. 31. Cardoso CO, Carvalho JC, Cotrena C, Bakos DG, Kristensen CH, Fonseca RP. Estudo de fidedignidade do instrumento neuropsicológico Iowa Gambling Task. J Bras Psiquiatr. 2010;59:279-85.

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32. Fernandes RS, Alvarenga NB, Silva TI, Rocha FF. Disfunções cognitivas em pacientes com hipotireoidismo subclínico. Arq Bras Endocrinol Metab. 2011;55:224-8. 33. Gois J, Valente K, Vicentiis S, Moschetta S, Kuczynski E, Fiore L, et al. Assessment of psychosocial adjustment in patients with temporal lobe epilepsy using a standard measure. Epilepsy Behav. 2011;20:89-94. 34. Lage GM, Malloy-Diniz LF, Fialho JV, Gomes CM, Albuquerque MR, Corrêa H. Correlação entre as dimensões da impulsividade e o controle em uma tarefa motora de timing. Braz J Motor Behav. 2011;6:39-46. 35. Lage GM, Gallo LG, Cassiano GJ, Lobo IL, Vieira MV, Salgado JV, et al. Correlations between impulsivity and technical performance in handball female athletes. Psychology. 2011;2:721-6. 36. Carvalho JC, Bakos DS, Cotrena C, Kristensen CH, Fonseca RP. Tomada de decisão no IGT: comparação quanto a variável escolaridade. RIDEP. 2011;32:171-86. 37. Scheffer M, Monteiro JK, Almeida RM. Frontal stroke: Problem solving, decision making, impulsiveness and depressive symptoms in men and women. Psychol Neurosci. 2011;4:267-78. 38. Cardoso CO, Kristensen CH, Carvalho JC, Gindri G, Fonseca RP. Tomada de decisão no IGT: estudo de caso pós-avc de hemisfério direito versus esquerdo. Psico-USF. 2012;17:11-20. 39. Carvalho JC, Cardoso CO, Cotrena C, Bakos DS, Kristensen C, Fonseca RP. Tomada de decisão e outras funções executivas: um estudo correlacional. Cien Cogn. 2012;17:94-104. 40. Lage GM, Malloy-Diniz LF, Neves FS, Moraes PH, Corrêa H. A kinematic analysis of the association between impulsivity and manual aiming control. Hum Movement Sci. 2012;31:811-23. 41. Carvalho JC, Cardoso CdeO, Schneider-Bakos D, Kristensen CH, Fonseca RP. The effect of age on decision-making according to the Iowa Gambling Task. Span J Psychol. 2012;15:480-6. 42. Bechara A, Damasio H, Damasio AR. Emotion, decision and the orbitofrontal cortex. Cereb Cortex. 2000;10:295-307. 43. Bechara A, Tranel D, Damasio H. Characterization of the decision-making deficit of patients with ventromedial prefrontal cortex lesions. Brain. 2000;123:2189-202.

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44. Fry Y, Greenop K, Tunrbull O, Bowman C. The effect of education and gender on emotion-based decision-making. S Afr J Psychol. 2000;39:122-32. 45. Maia TV, Cooney RE, Peterson BS. The neural bases of obsessive-compulsive disorder in children and adults. Dev Psychopathol. 2008;20:1251-83. 46. Strakowski SM, Delbello MP, Adler CM. The functional neuroanatomy of bipolar disorder: a review of neuroimaging findings. Mol Psychiatry. 2005;10:105-16. 47. Goldstein RZ, Volkow ND. Drug addiction and its underlying neurobiological basis: Neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry. 2002;159:1642-52. 48. Patton JH, Stanford MS, Barratt ES. Factor structure of the Barratt Impulsiveness Scale. J Clin Psychol. 1995;51:768-74. 49. Drag LL, Bieliauskas LA. Contemporary review 2009: cognitive aging. J Geriatr Psichychiatry. 2010;23:75-93. 50. Lamar M, Charlton RA, Morris RG, Markus HS. The impact of subcortical white matter disease on mood in euthymic older adults: a diffusion tensor imaging study. Am J Geriatr Psychiatry. 2010;18:634-42. 51. Dunn BD, Dalgleish T, Lawrence AD. The somatic marker hypothesis: a critical evaluation. Neurosci Biobehav Rev. 2006;30:239-71. 52. Krain AL, Wilson AM, Arbuckle R, Castellanos FX, Milham MP. Distinct neural mechanisms of risk and ambiguity: A metaanalysis of decision-making. Neuroimage. 2006;32:477-84.

Correspondence André Figueiras Rutz R. Marechal Deodoro, 430/63, Centro 80010-010 – Curitiba, PR – Brazil Tel.: +55 (41) 9993.6886 E-mail: rutzaf@gmail.com

Trends

Original Article

in Psychiatry and Psychotherapy

Cross-cultural adaptation and preliminary psychometric properties of the Affective Reactivity Index in Brazilian Youth: implications for DSM-5 measured irritability Adaptação transcultural e propriedades psicométricas preliminares do Affective Reactivity Index em jovens brasileiros: implicações para a irritabilidade medida pelo DSM-5 Diogo Araújo DeSousa,1 Argyris Stringaris,2 Ellen Leibenluft,3 Silvia Helena Koller,4 Gisele Gus Manfro,5 Giovanni Abrahão Salum5

Abstract

Resumo

Objective: To describe the cross-cultural adaptation of the Affective Reactivity Index (ARI) to Brazilian Portuguese and to investigate preliminary psychometric properties of the adapted version. Methods: Cross-cultural adaptation was based on the investigation of the theoretical and operational equivalences of the original ARI in the Brazilian context, followed by a process of translation, back-translation, and review by a committee of experts. Data analysis was carried out in a community sample of 133 schoolchildren aged 8 to 17 years to investigate the following characteristics of the ARI: 1) factor structure; 2) internal consistency; 3) construct validity comparing differential relationships between irritability and anxiety dimensions and impairment; and 4) item response theory (IRT) parameters. Results: A final Brazilian Portuguese version of the instrument was defined and is presented. Internal consistency was good, and our analysis supported the original single-factor structure of the ARI. Correlations of the ARI with distress-related anxiety dimensions were higher than with phobic-related anxiety dimensions, supporting its construct validity. In addition, higher ARI scores were associated with higher irritability-related impairment. IRT analysis underscored frequency of loss of temper as essential to inform about pathological states of irritability. Conclusion: The Brazilian Portuguese version of the ARI seems to be very similar to the original instrument in terms of conceptual, item, semantic, and operational equivalence. Our preliminary analysis replicates and extends previous evidence confirming promising psychometric properties for the ARI. Keywords: Affective Reactivity Index, irritability, cross-cultural adaptation, psychometrics, item response theory.

Objetivo: Descrever a adaptação transcultural do Affective Reactivity Index (ARI) para o português do Brasil e investigar propriedades psicométricas preliminares da versão adaptada. Método: A adaptação transcultural foi baseada na investigação das equivalências teórica e operacional da versão original do ARI no contexto brasileiro, seguida do processo de tradução, retrotradução e revisão por comitê de especialistas. A análise dos dados foi realizada em uma amostra comunitária de 133 escolares com idade entre 8 e 17 anos para investigar as seguintes características do ARI: 1) estrutura fatorial; 2) consistência interna; 3) validade do construto, comparando as relações diferenciais entre irritabilidade e as dimensões de ansiedade e prejuízo; e 4) parâmetros de teoria da resposta ao item (TRI). Resultados: Uma versão final em português do Brasil do instrumento foi definida e é apresentada. A consistência interna foi boa, e nossa análise confirmou a estrutura unifatorial original do ARI. As correlações do ARI com as dimensões de ansiedade relacionadas a sofrimento foram maiores do que com as dimensões de ansiedade relacionadas a fobias, reforçando a validade do construto. Além disso, escores mais altos no ARI foram associados a maior prejuízo relacionado à irritabilidade. A análise do TRI enfatizou a frequência de perda de controle como essencial para determinar estados patológicos de irritabilidade. Conclusão: A versão em português do Brasil do ARI parece ser muito semelhante ao instrumento original em termos de equivalência conceitual, de itens, semântica e operacional. Nossa análise preliminar reproduz e estende evidências anteriores que confirmam propriedades psicométricas promissoras para o ARI. Descritores: Affective Reactivity Index, irritabilidade, adaptação transcultural, psicometria, teoria da resposta ao item.

PhD candidate, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. 2 MD, PhD, Institute of Psychiatry, King’s College London, London, United Kingdom. 3 MD, Section on Bipolar Spectrum Disorders, Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, USA. 4 PhD. UFRGS, Porto Alegre, RS, Brazil. 5 MD, PhD. UFRGS, Porto Alegre, RS, Brazil. 1

This study was carried out at the Anxiety Disorders Outpatient Program for Child and Adolescent Psychiatry (PROTAIA), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil, and Center for Psychological Studies on At-Risk Populations (CEP-Rua), Institute of Psychology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. Financial support: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Submitted Jul 17 2013, accepted for publication Aug 07 2013. No conflicts of interest declared concerning the publication of this article. Suggested citation: DeSousa DA, Stringaris A, Leibenluft E, Koller SH, Manfro GG, Salum GA. Cross-cultural adaptation and preliminary psychometric properties of the Affective Reactivity Index in Brazilian Youth: implications for DSM-5 measured irritability. Trends Psychiatry Psychother. 2013;35(3):171-80. © APRS

Trends Psychiatry Psychother. 2013;35(3) – 171-180

Brazilian Portuguese version of the Affective Reactivity Index – DeSousa et al.

Introduction The adequate investigation of irritability is important to the field of mental health because irritability is a characteristic of multiple psychiatric diagnoses1 and the core feature of a new diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), namely, disruptive mood dysregulation disorder (DMDD).2 In addition, one important difference between the DSM-IV and the DSM-5 is that the latter recognizes the importance of dimensional assessments of psychopathology to complement traditional binary diagnoses.2 A dimensional assessment of psychopathological symptoms can focus on several dimensional features, e.g., number, duration, and intensity of symptoms, and impairment related to them. It can therefore provide information about the disorder severity and about changes in symptoms over time through repeated measurements. Hence, valid and reliable instruments to dimensionally assess the irritability latent trait are needed. The Affective Reactivity Index (ARI) is a concise instrument developed to measure irritability in childhood and adolescence.3 The ARI investigates three aspects of irritability: a) threshold for an angry reaction; b) frequency of angry feelings/behaviors; c) duration of such feelings/ behaviors. The conceptualization of the ARI defines irritability as a mood of easy annoyance involving anger and temper outbursts.4 Importantly, the ARI was developed to measure specifically irritable mood, rather than related constructs such as aggressive behavior, because irritable mood can be present in the absence of aggressive behavior. In Brazil, a few recognized instruments measure aggressive behaviors in childhood and adolescents.5 However, to our knowledge, no instruments with documented validity and reliability specifically assess irritability. The ARI has been shown to have adequate psychometric properties in American and British samples,3 encouraging further validation in different cultures. This study describes the process of cross-cultural adaptation of the ARI to the Brazil setting and reports preliminary psychometric properties of the Brazilian Portuguese version of the instrument, including factor structure, internal consistency, and construct validity. We also extend previous research3 by investigating item response theory (IRT) parameters.

Method Cross-cultural adaptation process The adaptation process can be divided into three major steps. First, the instrument was analyzed in terms

172 – Trends Psychiatry Psychother. 2013;35(3)

of conceptual, item, and operational equivalence between the original and target contexts. Equivalence was assessed by two Brazilian experts in the field. The objectives were to investigate if: 1) the relationship between the ARI and its underlying concept (i.e., irritability) in the original setting would be the same in Brazil (conceptual equivalence); 2) the items comprising the original ARI would remain relevant in the Brazilian context (item equivalence); and 3) the instructions, method of administration, questionnaire format, and measurement methods used in the original ARI would be suitable to the Brazilian context (operational equivalence). Second, a process of translation and back-translation was performed. The ARI was translated from English into Brazilian Portuguese by two independent translators, and a third one synthesized both translations into a single version in Brazilian Portuguese. Then, this synthesized translation was back-translated independently by two other translators, and a third one synthesized both back-translations into a single version in English.6 All translators involved in this process were fluent in both languages. Third, results from the equivalence investigation and from the translation and back-translation process were reviewed by a committee of four experts, including one of the authors of the original instrument. The committee assessed if the translation was adequate and if the translated items were both semantically equivalent to the original ARI and relevant to the Brazilian context.6 Adjustments of the items in the Brazilian Portuguese version were performed after a consensus was reached among the members of the committee.

Participants and procedures Participants were 133 schoolchildren aged 8 to 17 years old (mean ± standard deviation [SD] = 11.01±1.61), 54.1% girls. Students came from one private (n = 103) and one public (n = 30) Brazilian school. According to school records, youths in the private school came from middle socioeconomic-level families, and youths in the public school came from low socioeconomic-level families. School approval and child and adolescent assent were obtained before participation, as well as parental written informed consent. All youths were asked to complete the self-report instruments during their classroom period. Research assistants explained the research objectives and instructions before each data collection session. This study is part of a larger project whose protocol was approved by the Ethics Committee of the Institute of Psychology of Universidade Federal do Rio Grande do Sul (protocol no. 22264).

Brazilian Portuguese version of the Affective Reactivity Index – DeSousa et al.

Instruments The Affective Reactivity Index (ARI)3 is a selfreport measure of irritability symptoms in childhood and adolescence. The instrument comprises six items assessing feelings and behaviors related to irritability and one follow-up item assessing impairment due to irritability (Table 1). Respondents rate each item using a 3-point scale (0 = not true; 1 = somewhat true; 2 = certainly true). Total ARI scores refer to the first six items and range from 0 to 12, with higher scores reflecting higher levels of irritability. The Spence Children’s Anxiety Scale (SCAS) is a self-report measure of anxiety symptoms in childhood and adolescence.7 The instrument comprises 38 items assessing anxiety symptoms related to six different dimensions/subscales: generalized anxiety (GAD), social anxiety (SoAD), separation anxiety (SeAD), panic/ agoraphobia (PD), obsessive-compulsive problems (OCD), and fears of physical injury (FEARS). Respondents rate each item using a 4-point scale (never = 0; sometimes = 1; often = 2; always = 3). Total SCAS scores range from 0 to 114, with higher scores reflecting higher levels of anxiety. The SCAS has been cross-culturally adapted to Brazil8 and was used to identify anxiety symptoms in the sample and assess construct validity.

Data analysis Confirmatory factor analysis (CFA) was used to evaluate whether the single-factor structure of the original ARI fit to the Brazilian context. To take into account the categorical nature of the items in the scale, the weighted least square mean variance (WLSMV) estimation method was employed in the Mplus software. For fit indices, the following indices were calculated: chisquare, comparative fit index (CFI), Tucker-Lewis index (TLI), root mean square error of approximation with 90% confidence interval (RMSEA-90%CI), and weighted root mean square residual (WRMR). A non-significant chi-square result (p > 0.05) represented a good fit. Similarly, CFI and TLI values above 0.90 or close to 0.95 represented a good fit. RMSEA values close to or below 0.05 represented a good fit, and those below 0.08 represented an acceptable fit. WRMR values below 0.60 represented a good fit.9 Descriptive statistics of frequencies, means, and SDs were calculated for the ARI items and total score. Age group (children and adolescents), gender (boys and girls), and school type (private and public) differences were examined using analysis of variance (ANOVA). We also used ANOVA to investigate differences in ARI scores among three categories of the ARI impairment item. To

investigate item-by-item associations with the categories of impairment, logistic regression analyses were conducted using each ARI item as the independent variable and the seventh item (impairment) as the outcome variable, with two different thresholds (at least somewhat and certainly impaired). After that, we also conducted stepwise logistic regression analyses followed by all-possible-subsets (APS) logistic regression analyses to explore, considering the ARI items altogether, the set of items that best predicted impairment. APS analyses help in selecting the best subset from a larger set of highly intercorrelated predictors. In such situations, different subsets may present almost equivalent associations with the outcome variable, and a conventional stepwise regression analysis may select a suboptimal subset due to minor differences in bivariate associations. To overcome this problem, APS analyses generate results for a large number of different models with a fixed number of predictors, determined by the previous logistic regression analyses. We analyzed the five best models generated by the APS to investigate which ARI items best predicted the impairment outcome variable. Pearson correlations were calculated between ARI scores and SCAS subscale scores to investigate construct validity. It was hypothesized that the correlation between the ARI score and distress-anxiety (measured by SCASGAD subscale) would be stronger than the correlations between the ARI score and phobic-anxiety (measured by the SCAS-SoAD, -SeAD, and -FEARS subscales), PD or OCD symptoms, given previous evidence linking childhood irritability to a later development of distress disorders such as GAD, dysthymia, and depression.10 Furthermore, Cronbach’s alpha coefficient was calculated to evaluate the internal consistency of the ARI score. An item response theory (IRT) analysis was conducted using the graded response model with different item discrimination.11 The latent trait of irritability was represented by θ, centered on 0 with a SD of 1. The maximum marginal likelihood estimation implemented in the ltm package of the R software was used to estimate item parameters of discrimination (the slope, α) and severity (difficulty; category thresholds, β1 and β2).12 The discrimination parameter (α) represents the ability of each item to discriminate people at different levels of θ (in this case, different severity levels of irritability). A higher α therefore indicates that the item performs better discriminating subjects at different severity levels. The severity parameters (β1 and β2) represent the θ level at which there is 50% probability of endorsing a given category or higher (in this case, β1 = endorsing somewhat true OR certainly true, and β2 = endorsing certainly true). For instance, an item with a β2 of +1 indicates that a subject at 1 SD above the mean θ has

Trends Psychiatry Psychother. 2013;35(3) – 173

Brazilian Portuguese version of the Affective Reactivity Index – DeSousa et al.

Table 1 – Translation and back-translation of the ARI to Brazilian Portuguese

Original ARI

Translation 1 (BP)

Translation 2 (BP)

Final translation (BP)

Backtranslation 1 (E)

Backtranslation 2 (E)

Final backtranslation (E)

Affective Reactivity Index

Índice de Reatividade Afetiva

Affective Reactivity Index

Parent version: “In the last 6 months and compared to others of the same age, how well does each of the following statements describe the behavior/ feelings of your child? Please try to answer all questions.”

Instruções Versão para os pais: “Considerando os últimos seis meses e comparando o(a) seu(ua) filho(a) com outras crianças da mesma idade, o quão bem cada uma das seguintes afirmações descreve o comportamento/ sentimentos dele(a)? Por favor, tente responder todas as questões.”

Instruções Versão para pais: “Nos últimos 6 meses e em comparação com outras crianças da mesma idade, quão bem as afirmações seguintes descrevem o comportamento/ os sentimentos do(a) seu/ sua filho(a)? Tente responder a todas as perguntas.”

Instruções Versão para pais: “Nos últimos seis meses, comparando o(a) seu(ua) filho(a) com outras crianças da mesma idade, o quão bem cada uma das seguintes afirmações descreve o comportamento/ os sentimentos dele(a)? Por favor, tente responder todas as questões.”

Instructions Parents version: “Comparing your son/daughter to other children of the same age, how well do these statements describe his/ her feelings or behaviors in the last six months? Please, try to answer all the questions.”

Instructions Parents version: “In the last six months, comparing your child with other children of the same age, how well does each of the following statements describe his/ her behavior/ feelings? Please try to answer to all the questions.”

Instructions Parent version: “In the last six months, comparing your child with other children of the same age, how well does each of the following statements describe his/ her behavior/ feelings? Please try to answer all the questions.”

Self-report version: “In the last 6 months and compared to others of the same age, how well does each of the following statements describe your behavior/ feelings? Please try to answer all questions.”

Versão de autorrelato: “Considerando os últimos seis meses e comparando-se a outras crianças da mesma idade, o quão bem cada uma das seguintes afirmações descreve o seu comportamento/ sentimentos? Por favor, tente responder todas as questões.”

Versão “selfreport”: “nos últimos 6 meses e em comparação com outras crianças/pessoas da mesma idade, quão bem as afirmações seguintes descrevem o seu comportamento/ seus sentimentos?”

Versão de autorrelato: “Nos últimos seis meses, em comparação com outras crianças da mesma idade, o quão bem cada uma das seguintes afirmações descreve o seu comportamento/ seus sentimentos? Por favor, tente responder todas as questões.”

Self-report version: “Comparing yourself with other children of the same age, how well do these phrases describe your behaviors or feelings in the last six months? Please, try to answer all the questions.”

Self-report version: “In the last six months, comparing with other children of the same age, how well does each of the following statements describe your behavior/ your feelings? Please try to answer to all the questions.”

Self-report version: “In the last six months, comparing with other children of the same age, how well does each of the following statements describe your behavior/your feelings? Please try to answer all the questions.”

1. Easily annoyed by others

Facilmente irritado pelos outros

É perturbado facilmente por outras pessoas

Easily disturbed by other people

Easily get disturbed by other people

2. Often lose temper

Frequentemente perde a calma

Perde a calma frequentemente

Often lose the temper

Frequently lose temper

Often lose the temper

3. Stay angry for a long time

Fica irritado por um longo tempo

Permanece irritado por muito tempo

Fica irritado por muito tempo

Get angry for a long time

Stay irritated for a long time

Stay angry for a long time

4. Angry most of the time

Irritado na maior parte do tempo

Está irritado a maior parte do tempo

Está irritado na maior parte do tempo

Is angry most of the time

Irritated most of the time

Is angry most of the time

5. Get angry frequently

Irrita-se frequentemente

Often get angry

Frequently get irritated

Often get angry

6. Lose temper easily

Perde a calma facilmente

Easily lose the temper

Easily lose temper

Overall, irritability causes him/her (‘me’) problems.

De modo geral, sua irritabilidade lhe (‘me’) causa problemas

De forma geral, a irritabilidade causa problemas a ele/ela (“mim”)

De modo geral, a irritabilidade causa problemas a ele/ ela (‘a mim’)

Generally, irritability causes problems to him/ her (‘to me’)

In a general way, irritability causes problems to him/ her (‘to me’)

Generally, irritability causes him/her (me) problems

0 - Not true

0 - Falso

0 - Não é verdade

0 - Not true

1 - Somewhat true

1 - De algum modo verdadeiro

1 - Um pouco verdade

1 - Somewhat true

2 - Certainly true

2 - Certamente verdadeiro

2 - Certamente verdade

2 - Certainly true

2 - Definitely true

2 - Certainly true

ARI = Affective Reactivity Index; BP = Brazilian Portuguese; E = English.

174 – Trends Psychiatry Psychother. 2013;35(3)

Brazilian Portuguese version of the Affective Reactivity Index – DeSousa et al.

Table 2 – Preliminary psychometric properties of the Brazilian Portuguese version of the ARI

A) Confirmatory factor analysis 1-factor model

χ² χ (df)

CFI

TLI

RMSEA (90%CI)

WRMR

9.753 (9); p = 0.371

0.999

0.998

0.025 (< 0.001-0.103)

0.398

B) Frequency of each response options, item discrimination, item severity, and factor loading Response option (%)

IRT

Somewhat Certainly Factor Item Not true true true Α β1 β2 LOC loading 1. Easily annoyed by others 2. Often lose temper 3. Stay angry for a long time 4. Angry most of the time 5. Get angry frequently 6. Lose temper easily Impairment item

45.9 39.8 14.3 1.72 -0.165 1.481 0.658 0.467‡ 43.9 37.1 18.9 3.43 -0.222 0.947 0.363 0.739‡ 45.1 35.3 19.6 1.91 -0.230 1.086 0.428 0.545‡ 69.7 17.4 12.9 2.11 0.651 1.492 1.072 0.571‡ 56.4 29.3 14.3 2.27 0.183 1.344 0.764 0.590‡ 46.2 29.5 24.2 2.66 -0.106 0.833 0.364 0.689‡ 50.4 29.8 29.8

C) Item-by-item associations with impairment

Somewhat or certainly impaired, OR (95%CI) Certainly

Certainly impaired, OR (95%CI)

Item

Somewhat

APS

Somewhat

Certainly

APS

1. Easily annoyed by others

3.01 17.68 0.2 (1.39-6.52)† (3.69-84.72)‡

1.58 5.30 (0.57-4.35) (1.61-17.43)†

0.2

2. Often lose temper

3.33 7.26 0.2 (1.49-7.44)† (2.47-21.40)‡

5.73 13.88 (1.51-21.73)† (3.40-56.62)‡

0.2

3. Stay angry for a long time

4.18 11.29 1 (1.83-9.54)‡ (3.64-35.00)‡

3.34 13.75 (0.96-11.67) (3.85-49.12)‡

4. Angry most of the time

1.81 (0.72-4.57)

6.04 0.2 (1.61-22.69)†

1.386 10.97 (0.40-4.78) (3.37-35.72)‡

0.2

5. Get angry frequently

2.36 (1.07-5.22)*

5.75 0.2 (1.72-19.21)†

1.16 8.00 (0.39-3.48) (2.55-25.11)‡

0.2

6. Lose temper easily

7.53 8.82 0.2 (3.02-18.73)‡ (3.27-23.81)‡

6.00 15.92 (1.51-23.86)* (4.09-61.98)‡

0.2

D) Gender, age group, and school type differences and internal consistency

By gender

Total

Boys

Girls

ARI score, mean (SD)

4.00 (3.37)

3.49 4.42 (2.88) (3.69)

By age group

By school type

Child Adolesc

Private Public

3.78 4.51 (3.36) (3.38)

Cronbach’s α

3.65 5.24 (3.33) (3.26)

0.843

E) Pearson correlation between the ARI score and the SCAS subscale scores

Total

SCAS score r

0.525 0.586 0.464 0.397 0.334 0.385 0.339‡ ‡

GAD ‡

PD ‡

SoAD ‡

SeAD ‡

OCD

FEARS

‡

95%CI = 95% confidence interval; Adolesc = adolescents; APS = all-possible-subsets logistic regression analysis; ARI = Affective Reactivity Index; CFI = comparative fit index; df = degrees of freedom; FEARS = specific phobias; GAD = generalized anxiety disorder; IRT = item response theory; LOC = location; OCD = obsessive compulsive disorder; OR = odds ratio; PD = panic disorder; RMSEA (90%CI) = root mean square error of approximation with 90% confidence interval; SCAS = Spence Children’s Anxiety Scale; SD = standard deviation; SeAD = separation anxiety disorder; SoAD = social anxiety disorder; TLI = Tucker-Lewis index; WRMR = weighted root mean square residual. * p ≤ 0.05; † p ≤ 0.01; ‡ p ≤ 0.001

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Brazilian Portuguese version of the Affective Reactivity Index – DeSousa et al.

50% of probability of answering certainly true to this item. The mean of both thresholds was computed to provide an estimate of the item difficulty, i.e., the item location in the severity continuum represented by θ.

0.6 0.4 0.2

Cross-cultural adaptation

0.0 1

Both experts agreed that the theoretical rationale that served as the basis for the original ARI was relevant and adequate to the Brazilian context (conceptual equivalence). The items representing the irritability construct were also deemed relevant and important to the Brazilian context (item equivalence). Finally, the selfreport format, instructions, and method of assessment and measurement were also considered appropriate to the objectives of the instrument (operational equivalence). Concerning the review by the committee of experts, the synthesized translation was approved with only one major concern: the translation of the word “annoyed” (item 1, “Easily annoyed by others”) into “irritado” by translator 1 and “perturbado” by both translator 2 and the third, synthesizer translator. The concern was based on the fact that “perturbado” was back-translated as “disturbed” rather than “annoyed” by all backtranslators. The committee then agreed to replace the translation of the word “annoyed” to “incomodado.” The committee agreed that, in its last version, the translated Brazilian Portuguese items of the ARI reflected the same concepts related to the irritability construct as the original instrument, with semantic equivalence (see Table 1 for the complete set of translations and back-translations).

BR US UK

0.8

Mean

Results

1.0

Item Item 1, Easily annoyed by others; Item 2, Often lose temper; Item 3, Stay angry for a long time; Item 4, Angry most of the time; Item 5, Get angry frequently; Item 6, Lose temper easily.

Figure 1 – Comparison between mean Affective Reactivity Index item scores in the Brazilian (BR) sample, in the United States (US), and in the United Kingdon (UK)

ANOVA results showed that the ARI score did not differ between boys and girls (F(1, 129) = 2.47, p = 0.118) or between children and adolescents (F(1, 129) = 1.29, p = 0.258). Conversely, participants from the public school presented higher scores than those from the private school (F(1,129) = 5.22, p = 0.024). None of the interactions between these variables differentiated groups (all p-values > 0.10). Table 2 shows the means and SDs of the ARI scores obtained for the total sample and for each demographic group. The ARI score differed significantly among the categories of the ARI impairment item (F(2, 126) = 25.84; p < 0.001). Post hoc analyses revealed that increased impairment was significantly associated with increased irritability symptoms among all combinations of the ARI impairment categories (Figure 2).

Preliminary psychometric properties

176 – Trends Psychiatry Psychother. 2013;35(3)

Mean ARI (SEM)

Table 2 shows the preliminary psychometric properties of the Brazilian Portuguese version of the ARI. CFA results showed that the single-factor model fit the Brazilian sample very well, with all indices supporting good fit of the model. Furthermore, all items presented loadings above 0.45 (mean ± SD = 0.600±0.099). Considering item response option frequencies, lose temper easily was most frequently endorsed as certainly true, whereas being angry most of the time was the least likely to be endorsed as somewhat/certainly true (Table 2). Mean item scores ranged from 0.43±0.71 (item 4 mean score) to 0.78±0.81 (item 6 mean score). Figure 1 shows a descriptive comparison between item mean scores obtained in our sample and in the original study of the ARI.3

8 6 4 2 0

Not true

Somewhat true Certainly true

Impairment Category ARI = Affective Reactivity Index; SEM = standard error of mean.

Figure 2 – Association between ARI scores and ARI impairment categories

Brazilian Portuguese version of the Affective Reactivity Index – DeSousa et al.

Table 2 also shows the results of item-by-item logistic regression analyses. The stepwise logistic regression model revealed that a set of two items captured all the variance associated with impairment in both thresholds: at least somewhat impaired (Nagelkerke R2 = 0.314), and certainly impaired (Nagelkerke R2 = 0.394). Therefore, APS logistic regression analyses investigated all sets of two-by-two item combinations. When analyzing the frequency of each item included in the five best sets of predictors according to R2 in the APS analyses, item 3 (stay angry for a long time) was present in all of them in both thresholds, suggesting that this is the item most strongly associated with impairment (Table 2). Pearson correlations showed that all SCAS subscale scores correlated with the ARI score (Table 2).

Pearson Correlation Coefficient (r), SE

0.8 0.6 0.4 0.2 0.0

GAD

SoAD

SeAD

OCD

Fears

SCAS Sub-scales ARI = Affective Reactivity Index; FEARS = specific phobias; GAD = generalized anxiety disorder; OCD = obsessive compulsive disorder; PD = panic disorder; SCAS = Spence Children’s Anxiety Scale; SE = standard error; SeAD = separation anxiety disorder; SoAD = social anxiety disorder.

Correlations presented small to moderate magnitudes, with Z tests showing that the correlation between the ARI score and the SCAS-GAD subscale score was stronger than correlations between the ARI score and the SCASSoAD (p = 0.049), SeAD (p = 0.011), OCD (p = 0.038), and FEARS (p = 0.012) subscale scores. The correlation between ARI score and SCAS-PD subscale score did not differ from any other correlations assessed. Figure 3 graphically represents the correlation magnitudes. The Cronbach’s alpha coefficient of the ARI score was good (α = 0.843). IRT analysis demonstrated that ARI items concentrate their potential to differentiate subjects between -2 and +2 in the latent trait (91.25% of the test information), provide some information for those between +2 and +4 (7.82% of the test information), and have very low ability to differentiate those between -4 and -2 (0.73% of the test information). With respect to the discrimination parameter, item 2 (often lose temper) presented the highest α (Table 2), indicating that it is best able to discriminate people with different severity levels of the irritability latent trait. An analysis of the severity parameters revealed that items 2 and 6 presented the lowest severity estimates, whereas item 4 (angry most of the time) presented the highest severity estimate (Table 2). This indicates that subjects who endorse higher categories of item 4 have relatively higher levels of the irritability latent trait than those who endorse higher categories of items 2 and 6. Figures 4 to 6 provide graphic information on IRT analysis.

Figure 3 – Graphic representation of correlation magnitudes between the ARI score and SCAS subscale scores

item 1 item 2 item 3 item 4 item 5 item 6

Item 1, Easily annoyed by others; Item 2, Often lose temper; Item 3, Stay angry for a long time; Item 4, Angry most of the time; Item 5, Get angry frequently; Item 6, Lose temper easily.

Figure 4 – Affective Reactivity Index test information function (A) and item information curves (B)

Trends Psychiatry Psychother. 2013;35(3) – 177

Brazilian Portuguese version of the Affective Reactivity Index – DeSousa et al.

Item 1, Easily annoyed by others; Item 2, Often lose temper; Item 3, Stay angry for a long time; Item 4, Angry most of the time; Item 5, Get angry frequently; Item 6, Lose temper easily.

Figure 5 – Affective Reactivity Index item operation characteristic curves

1, Not true; 2, Somewhat true; 3, Certainly true; Item 1, Easily annoyed by others; Item 2, Often lose temper; Item 3, Stay angry for a long time; Item 4, Angry most of the time; Item 5, Get angry frequently; Item 6, Lose temper easily.

Figure 6 – Affective Reactivity Index item response category characteristic curves

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Brazilian Portuguese version of the Affective Reactivity Index â&#x20AC;&#x201C; DeSousa et al.

Discussion The present study described the cross-cultural adaptation of the ARI to Brazilian Portuguese and investigated preliminary psychometric properties of the adapted version. A final Brazilian Portuguese version of the instrument was defined and is presented. Our analysis supports the original single-factor structure and finds good internal consistency and adequate construct validity. The IRT analysis underscored the importance of frequency of loss of temper in identifying pathological states of irritability. When a foreign instrument is to be used in a new cultural setting, a careful and methodologically adequate process of cross-cultural adaptation is mandatory.6 Regarding the psychometric properties investigated, the single-factor structure fit the Brazilian sample very well, supporting the original theoretical conceptualization of the ARI.3 All items presented good factor loadings, and the ARI score demonstrated good internal consistency, in line with previous research.3 Also in line with previous research,3 no significant differences were found between gender and age groups in mean ARI scores, while a significant association was found between higher ARI scores and greater impairment due to irritability symptoms. The pattern of correlations between the ARI score and SCAS subscale scores was in the hypothesized direction: the correlation between the ARI and the SCASGAD was the strongest, consistent with previous evidence linking irritability symptoms to distress disorders such as GAD, depression, and dysthymia.10 It is interesting to point out that the mean ARI score obtained in our sample was relatively high when compared to ARI scores described for other settings.3 In fact, our Brazilian community sample scored as high as the U.S. sample of children meeting criteria for bipolar disorder in the work of Stringaris et al.3 Even though these two samples cannot be compared directly due to methodological differences between studies, the fact that Brazilian children presented relatively high ARI scores is consistent with previous research indicating that, among youths from 42 societies, Brazilian youths had the highest mean total Child Behavior Checklist problem scores.13 However, it can also be hypothesized that the Brazilian cultural context allows Brazilian children to express themselves more easily, not having to focus on selfcontrol when dealing with some circumstances in public and private situations, which may have led to a looser reactivity reflected on the high scores found. Anyhow, this finding indicates the importance of properly evaluating psychopathological symptoms in Brazilian youth. It also stresses the fact that cross-cultural research on psychopathology should be based on the development

of assessment instruments that are validated and applied across and within cultures14 â&#x20AC;&#x201C; as in the case of the ARI. Further cross-cultural research might focus on investigating culturally universal, shared symptomatology (etic orientation) and notions that are part of experiences within a specific culture (emic orientation).14 Findings from the IRT analysis build on the original study reporting the development and investigation of the psychometric properties of the ARI.3 By analyzing the discrimination parameter of the items, we were able to demonstrate that item 2 (often lose temper) was the best discriminative item. This is consistent with both the theoretical definition of irritability in the ARI and the cardinal features of DMDD (even though DMDD also requires anger between outbursts).2 By analyzing the severity parameter of the items, we were able to demonstrate that item 4 (angry most of the time) was the most severe item. To endorse such description, it is expected that the subject will present a relatively high level of the irritability latent trait and therefore this item may be best for differentiating subjects with high levels of the irritability latent trait. Findings from the APS logistic regression analyses, however, revealed that item 3 (stay angry for a long time) was the one most strongly associated with a higher probability of impairment. Even though severity levels and impairment are not necessarily interchangeable, it could be expected that the most severe item would be the one also most strongly associated with impairment. Therefore, this finding calls for further investigations with larger and more representative samples using IRT and classical theory psychometric analyses to increase our understanding of the functioning of the ARI measure at the item level. The present study has some limitations. For instance, future studies are needed to examine further psychometric properties of the Brazilian Portuguese version of the ARI, such as convergent and divergent validity, discriminant validity, test-retest reliability, and sensitivity to treatment responses. Also, all children and adolescents in this study were part of a school sample, and therefore future studies should try to replicate these findings in clinical samples and investigate the clinical utility of the Brazilian Portuguese version of the ARI. In conclusion, the ARI is a new instrument available to assess irritability symptoms in Brazilian youth. Our results demonstrate that the Brazilian Portuguese version of the ARI measure is very similar to the original ARI in terms of cross-cultural equivalence. Also, preliminary psychometric analyses showed good evidence of validity and reliability. If future studies demonstrate other adequate psychometric properties of the instrument, the Brazilian Portuguese version of the ARI could be an important tool in research and clinical settings to assist in the investigation of irritability in youth.

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Brazilian Portuguese version of the Affective Reactivity Index – DeSousa et al.

Acknowledgement Dr. Argyris Stringaris gratefully acknowledges the support of the Wellcome Trust.

References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Washington: APA; 2000. 2. American Psychiatric Association. DSM-5 development. Arlington: American Psychiatric Association; 2012. http:// www.dsm5.org/. Accessed 2013 May 13. 3. Stringaris A, Goodman R, Ferdinando S, Razdan V, Muhrer E, Leibenluft E, et al. The Affective Reactivity Index: a concise irritability scale for clinical and research settings J Child Psychol Psychiatry. 2012;53:1109-17. 4. Stringaris A. Irritability in children and adolescents: a challenge for DSM-5. Eur Child Adolesc Psychiatry. 2011;20:61-6. 5. Borsa JC, Bandeira DR. The use of psychological measures of child aggressive behavior: analysis of Brazilian scientific production. Aval Psicol. 2011;10:193-203. 6. Gjersing L, Caplehorn JR, Clausen T. Cross-cultural adaptation of research instruments: language, setting, time and statistical considerations. BMC Med Res Methodol. 2010;10:10-13. 7. Spence SH. A measure of anxiety symptoms among children. Behav Res Ther. 1998;36:545-66.

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8. DeSousa DA, Petersen CS, Behs R, Manfro GG, Koller SH. Brazilian Portuguese version of the Spence Children’s Anxiety Scale (SCAS-Brasil). Trends Psychiatry Psychother. 2012;34:147-53. 9. Yu CY. Evaluating cutoff criteria of model fit indices for latent variable models with binary and continuous outcomes. Los Angeles: University of California, Los Angeles; 2002. 10. Stringaris A, Cohen P, Pine DS, Leibenluft E. Adult outcomes of youth irritability: a 20-year prospective community-based study. Am J Psychiatry. 2009;166:1048-54. 11. Samejima F. Estimation of latent ability using a response pattern of graded scores [monograph]. Richmond: Psychometric Society; 1969. http://www.psychometrika. org/journal/online/MN17.pdf. Accessed 2013 May 13. 12. Rizopoulos D. ltm: An R package for latent variable modelling and item response theory analyses. J Stat Softw. 2006;17:1-25. 13. Rescorla L, Ivanova MY, Achenbach TM, Begovac I, Chahed M, Drugli MB, et al. International epidemiology of child and adolescent psychopathology II: integration and applications of dimensional findings from 44 societies. J Am Acad Child Adolesc Psychiatry. 2012;51:1273-83. 14. Draguns JG, Tanaka-Matsumi J. Assessment of psychopathology across and within cultures: issues and findings. Behav Res Ther. 2003;41:755-76.

Correspondence Diogo Araújo DeSousa Rua Ramiro Barcelos, 2600, sala 104, Santa Cecília 90035-003 – Porto Alegre, RS – Brazil Tel./Fax: +55 (51) 3308.5150 E-mail: diogo.a.sousa@gmail.com

Trends

Original Article

in Psychiatry and Psychotherapy

Beginning and end of treatment of patients who dropped out of psychoanalytic psychotherapy Início e fim de tratamento de pacientes que abandonaram a psicoterapia psicanalítica Simone Isabel Jung,1 Fernanda Barcellos Serralta,2 Maria Lucia Tiellet Nunes,3 Cláudio Laks Eizirik4

Abstract

Resumo

Introduction: Even though it is expected that patients and therapist will agree on when to terminate psychotherapy, quite often patients discontinue treatment on their own. This study aims to better understand dropout in psychoanalytic psychotherapy (PP). Method: Baseline and post-treatment interviews were conducted with six adult women classified by their therapists as dropout patients at a PP outpatient clinic. Results were analyzed using Bardin’s content analysis. Results: Content analysis generated five categories (reasons for treatment, goals, readiness to change, previous treatment, transference) for the baseline interviews and three categories (change process, results, interruption) for post-treatment interviews. Unclear treatment goals, low readiness to change, early signs of negative transference and resistance, and absence of recognition of their own participation in problems emerged in baseline interviews. In most cases, the patient’s evaluation of the therapeutic relationship was not determinant of dropout. Therapeutic gains, dissatisfaction, and resistance during the psychotherapeutic process seemed to be associated with noncompliance. Conclusions: Decisions to initiate, continue, or quit PP depend on multiple factors, such as initial goals, readiness to change, insight capacity, awareness of personal problems, resistance, and transference. However, these factors should be considered in view of the methodological limitations of this study. Further investigation of PP dropout is still necessary. Keywords: Patient dropout, psychoanalytic psychotherapy, qualitative research, mental health services.

Introdução: Embora se espere que pacientes e terapeuta concordem sobre o momento da alta ou fim do tratamento, a interrupção por conta própria do paciente é bem comum. O objetivo deste estudo é compreender melhor o abandono de tratamento em psicoterapia psicanalítica (PP). Método: Entrevistas foram conduzidas no início e após o tratamento com seis mulheres adultas classificadas por seus terapeutas como tendo abandonado o tratamento em uma clínica de PP. Os resultados foram analisados utilizando-se o método de análise de conteúdo de Bardin. Resultados: A análise de conteúdo deu origem a cinco categorias (razões para o tratamento, objetivos, disposição para mudar, tratamento prévio, transferência) nas entrevistas iniciais e três categorias (processo de mudança, resultados, interrupção) nas entrevistas pós-tratamento. Objetivos terapêuticos obscuros, pouca disposição para mudar, sinais de transferência negativa e resistência, e o não reconhecimento da própria participação nos problemas surgiram nas entrevistas iniciais. Na maioria dos casos, a avaliação da paciente sobre a relação terapêutica não foi determinante para o abandono. Ganhos terapêuticos, insatisfação e resistência durante o processo psicoterapêutico pareceram estar associados com a não aderência. Conclusões: As decisões de iniciar, continuar ou interromper a PP dependem de múltiplos fatores, como objetivos iniciais, disposição para mudar, capacidade de insight, consciência de problemas pessoais, resistência e transferência. No entanto, esses fatores devem ser considerados em vista das limitações metodológicas deste estudo. Mais investigações com foco no abandono da PP são necessários. Descritores: Abandono de tratamento, psicoterapia psicanalítica, pesquisa qualitativa, serviços de saúde mental.

Psychologist. PhD candidate, Medical Sciences: Psychiatry, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. Professor, Faculdades Integradas de Taquara (FACCAT), Taquara, RS, Brazil. 2 Psychologist. PhD in Medical Sciences: Psychiatry, UFRGS, Porto Alegre, RS, Brazil. Professor, Universidade do Vale do Rio dos Sinos (UNISINOS), São Leopoldo, RS, Brazil. 3 Psychologist. PhD, Freie Universität Berlin, Berlin, Germany. Professor, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil. 4 Psychoanalyst. PhD in Medicine. Associate professor, UFRGS, Porto Alegre, RS, Brazil. 1

This paper is part of the first author’s doctoral dissertation project, entitled “Dropout in psychoanalytic psychotherapy: qualitative study,” currently under way at the Graduate Program in Medical Sciences: Psychiatry, at Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil. Financial support: none. Submitted Dec 11 2012, accepted for publication Jun 03 2013. No conflicts of interest declared concerning the publication of this article. Suggested citation: Jung SI, Serralta FB, Nunes ML, Eizirik CL. Beginning and end of treatment of patients who dropped out of psychoanalytic psychotherapy. Trends Psychiatry Psychother. 2013;35(3):181-90.

Trends Psychiatry Psychother. 2013;35(1) – 181-190

Dropout in psychoanalytic psychotherapy – Jung et al.

Introduction Even though it is expected that patients and therapist will agree about when to terminate psychotherapy, quite frequently patients discontinue psychotherapy on their own, in many ways and for many reasons. The very definition of this phenomenon is not a consensus, and terms such as premature discontinuation, premature termination, unilateral termination, and dropout are all used, sometimes with different forms of operationalization. So, when studying dropout, one of the problems faced is choosing among the definitions available. Premature termination or dropout can be defined as unilateral treatment termination, i.e., when the patient decides to end psychotherapy contrary to both the therapist’s recommendation and the initial agreement made between patient and therapist. Another dropout situation is when the patient starts treatment but discontinues it prior to recovering from the problems that led to treatment, i.e., without meeting the therapeutic goals.1 Psychotherapy approaches differ in terms of treatment goals, psychotherapy length, dropout definition, and criteria for success.2 Psychoanalytic psychotherapy (PP), for example, is typically directed to the analysis of defenses, transference, and conflicts, aiming to help the patient become aware of them.3 Therefore, PP requires from the patient ego strength or resources, the ability to withstand the revival of painful situations, insight capacity, and motivation to explore thoughts, emotions, and current conflicts in order to link them with past situations and thus expand self-knowledge. Except for brief psychodynamic models, PP is considered a long-term insight-oriented therapy that ideally terminates when both patient and therapist agree that the therapeutic goals have been achieved. This criterion clearly involves a good deal of subjectivity of both patient and therapist. Regardless of the criterion used to define therapy dropout, reports indicate high rates of the phenomenon1,4 in different ages, diagnostic groups, and treatment modalities. In a recent meta-analysis, Swift & Greenberg1 reported that one in five patients discontinued therapy. In mental health services in Brazil, dropout rates are comparable to those found in other contexts.5,6 These estimates provide grounds for concern, especially when one takes into consideration everything implied in the premature termination of treatment. Most patients who drop out of therapy eventually ask to return, making it necessary to restart the entire process. The psychological, financial, and time investments made fuel the patient’s frustration, leading to hopelessness in receiving aid with this type of treatment.7 The therapist is not immune to frustration either, especially those less experienced, who may be overwhelmed by feelings of

182 – Trends Psychiatry Psychother. 2013;35(3)

inadequacy and incompetence. Thus, the negative impact of discontinuation is felt by all the parties involved. Despite many studies investigating psychotherapy dropout, several inconsistencies remain in research findings about this phenomenon. Nevertheless, in most investigations, patients who dropped out of psychotherapy: showed low motivation (in counseling therapy,8 cognitive behavioral therapy [CBT],9,10 and psychosocial treatment11); had limited expectations of results (in psychosocial treatment11 and CBT12); were younger (in different types of therapy1); presented low socioeconomic and educational levels (in different types of therapy4); poor therapeutic alliance (in psychosocial treatment,11 CBT, and experiential and interpersonal therapies13); and more resistance to treatment (in CBT,9,13 psychosocial treatment,11 and experiential and interpersonal therapies13). As psychoanalytically oriented therapists, we believe that the length and depth required for the therapeutic work (of both patient and therapist) in PP may reveal an even greater level of complexity for the issue of psychotherapy dropout. Thus, it is possible that the factors associated with dropout in this therapeutic modality are not the same as those found in other therapies. Looking specifically at studies that have examined PP, we found that patients who discontinued treatment had: less willingness to start psychotherapy14-16; a concept of “cure” that diverged from the therapist’s ideas17; less insight18,19 and less psychological mindedness16; lower levels of therapeutic alliance20,21; more frequent use of immature defenses, especially narcissistic ones19,22; a less dynamic work and less involvement in the exploration of problems20; high levels of aggressiveness15,23; low selfesteem15,23; poor object relations15,16,23; deficits in the ability for introspection and in frustration tolerance24; and maladaptive personality functioning.25 Qualitative studies on PP dropout are rare. For example, searching for articles published in Brazilian journals on the Virtual Health Library (www.bireme.br) and on the Scientific Electronic Library Online (www. scielo.br), only one article was found focusing on dropout in adult individual outpatient PP. In that study,26 conducted with six borderline patients, impulsiveness, manipulation, and affective dissociation were prominent in the three cases that dropped out of therapy. In international journals, searched on PsycINFO (www.apa.org/psycinfo), qualitative investigations are also scarce, even when the search is extended to include studies with children, adolescents, groups, and inpatients. One of these studies, conducted with six adult patients seen at an outpatient clinic, revealed that dropouts sought psychotherapy as part of shopping around for a suitable psychotherapy or wanting to try a particular type of psychotherapy and see if they could

Dropout in psychoanalytic psychotherapy – Jung et al.

tolerate it or benefit from it.27 In another qualitative study on this topic, the reasons for premature termination of psychotherapy were investigated. Twelve patients, four of which had undergone PP, were interviewed. Results revealed that dropouts who had positive experiences with the termination reported a strong therapeutic alliance and positive psychotherapy results. Psychotherapy ended mainly for logistic or financial reasons, and the feelings aroused in this process were discussed with the therapists. In contrast, dropout patients with negative experiences with the termination reported weaker alliance and mixed results. In these cases, psychotherapy generally ended abruptly, and its end was rarely discussed or planned in advance with therapists.28 Studies evaluating treatment termination in PP may shed light on the understanding of dropout. For example, in two studies, 22 cases of termination were interviewed with a focus on what was useful and what hindered PP. According to the therapists’ point of view, factors relevant for therapeutic success included the development of a close, safe, confident relationship with patients, based on genuine interest in their problem, technical flexibility, and non-retaliation to criticism.29 According to the patients’ perspective, therapeutic success was due to their felling of having a special place to talk about themselves and to have new experiences, as well as mutual collaboration while exploring conflicts.30 In contrast, patients’ difficulties in talking about themselves, not receiving help to solve practical problems, therapist passivity, a feeling that something was “missing” in treatment,30 and fear of having a close relationship with the therapist29 were seen as factors that hinder PP. Treatment dropout still needs to be better explained, especially in PP, which is much less studied than other modalities.31 Specifically, a regional issue must be taken into account: in Brazil, PP is generally practiced without much concern with measuring processes or results. Usually, therapists are very reluctant to use any type of register apart from the traditional “dialogued interviews,” i.e., transcripts of the dialog held between patient and therapist, recorded by the therapist (by memory), after each session. This culture is obviously not very friendly to research and imposes many methodological difficulties to empirical investigation in psychotherapy. Moreover, studies on dropout in Brazil are generally conducted at university services, with therapists that are not yet licensed, i.e., undergraduates under clinical training. Therefore, in order to better understand factors associated with the unilateral termination of PP, this study analyzed the beginning and end of treatment of patients seen at a PP outpatient clinic and considered as dropouts by their therapists (licensed professionals of psychology and medicine).

Methods This was a naturalistic, qualitative study. It was approved by the Research Ethics Committee of Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil (protocol no. 20035). All participants signed an informed consent form prior to being included in the study. Participants were six women (here referred as P1, P2, P3, P4, P5, and P6) treated by therapists of the same sex, randomly selected from a database of 29 patients that had interrupted PP at an outpatient clinic located in southern Brazil that trains health professionals in PP at the graduate level. This database was created to study outcomes in PP and included 34 adult patients of both sexes who had attended at least 18 sessions of psychotherapy. Of these, five patients completed therapy and 29 dropped out of treatment at some point after the first 18 sessions. In both groups, the invitation to participate in the study was made by regular mail, followed by a phone call, at least 6 months after the end of treatment (after either completion or dropout). The 6 months elapsed between the end of psychotherapy and the interviews were planned to allow sufficient time for patients to process and reflect on what had occurred in treatment. Other details of the original database can be obtained elsewhere.32 In this study, describing a subsample of six dropout cases, treatment length ranged from 7 to 18 months (mean ± standard deviation = 12.8±4.62). Because the database did not include cases with less than 18 sessions attended, all cases here analyzed can be considered late dropouts. The number of participants was defined by saturation,33 i.e., the inclusion of new participants was suspended when the data began to show redundancy or repetition. Participants were adults with a mean age of 29.8±5.71 years. Five patients were single and three had higher education degrees (the other three had high school degrees). Socioeconomic level was medium to low. Psychotherapists were licensed professionals of psychology (n = 5) and medicine (n = 1) with a mean age of 32.2±10.3 years. All were trainees in PP, with 1 to 5 years of psychotherapy experience at the time (mean = 2.83±3.06). Psychotherapy was insight-oriented, face to face, nonmanualized, delivered twice a week in two cases and weekly in the other four. Data were collected using two interviews. The first one was the archived baseline interview, conducted by the patient’s therapist as usual. This is an open-ended interview subsequently recorded by memory (dialogued interview), as usually seen in PP treatments in our context. The other interview was a posttreatment interview held at the same institution where

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treatment was conducted, on average 19 months after psychotherapy. This second interview was carried out by the first author and lasted for approximately 45 minutes. It was recorded in audio and subsequently transcribed. Post-treatment interviews were semi-structured and sought information about the end of treatment, the reasons for interruption, the relationship with the therapist, and the results obtained with psychotherapy. All interviews were analyzed using Bardin’s content analysis,34 as follows: 1) the first author read all interviews in detail; 2) registration units (RUs), i.e., significant fragments of the patients’ discourse, were selected; 3) RUs covering similar topics were grouped, generating categories (to increase methodological reliability, two independent examiners evaluated the pertinence of RUs in each category); 4) data interpretation.

Results The corpus of baseline interviews amounted to 43 pages and generated five categories and 13 subcategories, as shown in Table 1. Category A. Reason for treatment. The reasons that led the participants of this study to seek PP were grouped into three subcategories: problems in interpersonal relationships, complaints concerning the depression spectrum, and difficulties with impulse control. All patients reported interpersonal problems (subcategory A.1), especially with romantic partners and family of origin (“I live with my boyfriend, but we just fight... and now it’s very bad, that’s when I decided to come” [P1]). Participants also mentioned depressionlike symptoms (subcategory A.2), such as sadness, loneliness, low self-esteem, and emptiness (“I have no

desire for anything, life has gone stale for me, nothing else matters, only my son” [P2]). Another reason for seeking psychotherapy was impulse control difficulties (subcategory A.3: “I was angry, lost control... I just lost it” [P3]). Category B. Goals. We found that all therapists directly questioned what were the goals and expectations of the patient with therapy. This category includes all answers given to this question. Comments were addressed in varied aspects and grouped into the following subcategories: past issues, support and guidance, and internal changes. Patients sought psychotherapy to resolve past issues (subcategory B.1), e.g., to forget painful events and to avoid repeating the story of parents (“I want to forget, to live from now on, erase my memory of this scar, I am very hurt” [P2]). They also sought psychotherapy to speak and to receive support and guidance (subcategory B.2: “I think I’ll come here once a week, I’ll talk to you and you will give me your professional opinion” [P3]). Patients also mentioned seeking psychotherapy to make internal changes (subcategory B.3), e.g., know themselves, enhance femininity and self-esteem, develop the capacity to be alone, control impulses, and gain self-knowledge (“I want to regain that glow, you know, to take care of myself, to like myself” [P2]). Only P3 mentioned the expectation of gaining self-understanding (“I want to find myself, to get to know me... I want to learn to know myself”). Category C. Readiness to change. This category includes all the participants’ statements regarding their readiness to change, with the subcategories insight, resistance, and referral. Participants showed some insight of their psychological condition (subcategory C.1), somehow recognizing their suffering and need of treatment (“I cannot

Table 1 – Baseline interview categories

Categories Subcategories Category A (reason for treatment)

A.1 Interpersonal A.2 Depression A.3 Impulse control

Category B (goals)

B.1 Past issues B.2 Support and guidance B.3 Internal changes

Category C (readiness to change)

C.1 Insight C.2 Resistance C.3 Referral

Category D (prior treatment)

D.1 Evaluation of goals D.2 Prior psychotherapist

Category E (transference)

E.1 Positive transference E.2 Negative transference

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stand these things in my life... I saw that alone I’m not able to carry on” [P1]). Furthermore, P1 and P5 recognized their participation in the issues presented (“I also do not want to be only complaining about my parents... I have to resolve what is not right with me” [P5]). Early manifestations of overt resistance (subcategory C.2) were found in various fragments of speech (“I do not really want to come, I was very reluctant. Yesterday I even thought about calling to cancel. I spoke with a friend and said that I would not go, then she asked what was the excuse and that’s exactly it, an excuse” [P1]). Finally, dropout patients also mentioned that the therapeutic treatment had been recommended by friends, relatives, or health professionals (subcategory C.3: “My colleagues talked to me and told me that I needed help” [P6]). Category D. Prior treatment. Four participants had undergone previous psychological treatment. They gave their opinions and evaluations concerning that treatment (subcategory D1) and therapist (subcategory D.2). Patients mentioned partial improvements in the problems that led them to seek psychotherapy. However, a negative effect of prior psychotherapy was also referred (subcategory D.1: “I already underwent treatment before, nothing changed; I think things even got worse” [P2]). As per the relationship with the previous therapist (subcategory D.2), P4 reported discrepancies between her expectations and the therapist’s attitudes (“I expected her to tell me what I had to do and she only listened to me”). Category E. Transference. This category includes all manifestations of transference found in the baseline interviews. The category was subdivided into positive transference (subcategory E.1), including libidinal impulses and their derivatives, especially affectionate and friendly feelings, and negative transference (subcategory E.2), with a predominance of aggressive drives and their derivatives, e.g., envy, jealousy, idealization, among others. Positive transference manifestations were identified (“Yes I will come back, I liked you a lot” [P2]), but negative transference manifestations (subcategory E.2) were much more evident (“I’ll tell you more when I feel more comfortable” [P4]). P2 and P3 presented both

positive and negative transference manifestations, the latter ones mainly in the form of idealization. Data in the post-treatment interviews amounted to 92 pages that generated three categories and seven subcategories, as shown in Table 2. Category F. Change Process. This category includes patients’ general remarks about the process of change occurring during psychotherapy. Three subcategories provide an understanding of the process of change: insight, therapeutic relationship, and resistance. Patients reported developing a new understanding of their difficulties during psychotherapy (subcategory F.1: “There I reflected and went within me, and I could see... I had really understood what was hindering” [P2]). The ability to work on psychological issues on their own was addressed by P2 and P3 (“I can now evaluate myself by myself, when something is happening I remember the sessions” [P3]). The participants described the negative and positive aspects experienced in the relationship with their therapists (subcategory F.2). Patients (except P4) reported positive aspects of the therapeutic relationship (e.g., learning with the therapist) (“It was very nice, we had an affinity that was great... well, relationship with her was very good” [P3]). P4 defined her relationship with the therapist as consisting of criticism and nonunderstanding (“There was a negative side... depending on how it is said, it can be shocking to the patient... all of a sudden the patient does not accept this”). Resistance (subcategory F.3) became evident in all patients. These manifestations included perceiving psychotherapy as a sacrifice, as an ordeal, or as a waste of time (“I missed various sessions; I felt it was an ordeal to go there... I have two sides, the need to go and the desire to stay at home, so that I will not have to show what is inside of me” [P1]; “There were those days you just did not want to go, which is the resistance itself... we have a very high resistance to treatment, we must be careful, because if not, we will escape... when you’re being poked... it is poking the wound, because in the treatment you will actually get to know you better and sometimes you do not want to know you better” [P3]).

Table 2 – Post-treatment interview categories

Categories Subcategories Category F (change process)

F.1 Insight F.2 Therapeutic relationship F.3 Resistance

Category G (results)

G.1 Overall satisfaction G.2 Specific benefits

Category H (interruption)

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Category G. Results. This category bears all comments made by participants concerning their personal evaluation of psychotherapy results. The evaluation encompassed satisfaction with treatment goals and expectations (subcategory G.1) and specific benefits obtained or not (subcategory G.2). Participants expressed satisfaction with treatment results and recognition of the help received (subcategory G.1), partially achieving their goals, except for P6, who mentioned being a 100% satisfied with therapeutic gains (“I think I was able to improve a lot, not resolve, but greatly improve” [P3]). Moreover, the interviewees described diverse benefits associated with psychotherapy (subcategory G.2). After treatment, they found they were more mature, secure, confident, spontaneous, less impulsive, and less depressive, in addition to improvements in interpersonal relationships. It is noteworthy, however, that some of these benefits were perceived as partial (“I can already hold myself back more often... I was very impulsive” [P3]). Participants also mentioned having obtained benefits in both their professional life and physical health, attributing these changes to the therapeutic experience. Category H. Interruption. All comments addressing psychotherapy interruption were included in this category, including the reasons for termination (subcategory H.1) and the way in which the process was carried out (subcategory H.2). Several reasons (subcategory H.1) were associated with psychotherapy interruption, e.g., dissatisfaction with the therapist or the psychotherapy, improvements, and resistance. Coded as resistance in this investigation, financial issues were brought up by P1 and P3. Resistance was the most evident reason for PP discontinuation (“I was unemployed, had this great excuse so to speak...” [P1]). Conversely, P2 and P6 stated that they decided to discontinue psychotherapy because they were feeling well. Dissatisfaction was referred by P4 and P5 as a reason for termination. Finally, we found that most participants underwent a final session (subcategory H.2) with their therapists in which the reasons for dropping out were mentioned (“I explained why I was leaving the sessions and she understood me, told me to be happy, for me to try, she said that she would be available if I ever wanted to return” [P6]). The exception was P4, who did not explain the real reason for interruption, because she did not feel comfortable to do so.

Discussion In this study, the most common complaints that led the participants to seek psychotherapy (category A)

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were interpersonal problems, especially difficulties in relationships with partner and family, and depressive symptoms. These motives are similar to those found in other investigations.35,36 What the patient wants and expects from treatment has been considered as an important indicator of therapeutic results, regardless of the theoretical approach of psychotherapy.12,37 Goals and expectations in psychotherapy can have varying origins: magical or realistic, positive or negative, great or even nonexistent.38,39 We observed that the goals of most dropout patients (category B) were specific and magical (e.g., “erase my memory of this scar...” [P2], “you will give me your opinion” [P3]). Only one of them mentioned the expectation of gaining self-understanding, one of the main goals of PP. For PP to be successful, patients should aim not only for specific objectives, but also broad ones, such as enhancing mental abilities and self-awareness.19 Thus, specific goals, especially those associated with the desire to make magical changes, may be a sign of low commitment to PP. It is striking that, even though complaints associated with interpersonal relationships were the main reason for seeking treatment, when questioned by therapists, patients did not mention goals and expectations in this area. This controversial finding may suggest that treatment goals and expectations were unclear for these patients. Another hypothesis is that these patients may have depressive features (see reason for treatment), which could lead them to have low expectations of themselves, and consequently of the treatment. Depressed patients are more doubtful about their therapy and require a higher degree of persuasion at the beginning of treatment. Only after believing that the treatment can bring change will they be able to effectively engage in it.12 The contents of baseline interviews revealed information about the patients’ readiness to change (category C). Readiness to change was related to the patient’s insight capacity (subcategory C.1) about their emotional condition, i.e., the recognition that one is afflicted with a mental illness or problems of an emotional nature for which one can seek solutions.40 Studies have shown that successful results in psychotherapy depend on the patient’s acceptance of their own involvement in the difficulties that have led to treatment,41 and that changes depend mostly of their own effort.42,43 In general, respondents admitted psychological distress, but only P1 and P5 acknowledged their involvement in the problems presented. This may be one of the factors explaining the subsequent dropout. Participants came to psychotherapy as a result of the recommendation of others, and not based solely on their

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own will (subcategory C.3). Furthermore, significant resistance to psychotherapy was observed in baseline interviews (subcategory C.2). This calls us to reflect on the ambivalence of the patients’ messages and concealed resistance to treatment. In order for PP to provide an effective improvement, genuine motivation to undertake a process of change is indispensable,18,19 which does not seem to be present in the first sessions of the patients interviewed. The termination of treatment, especially in PP, is often characterized by a later return to treatment.44 Four of the patients interviewed had previously undergone PP without reaching their goals (category D), which could be indicative of a greater likelihood of dropout. One of the participants also revealed a negative effect of previous psychotherapy, denoting a mismatch that could be repeated in the new treatment. This would be one aspect to clarify with the patient in the initial phase of psychotherapy, as a way to anticipate this possible repetition. Aspects of transference, both positive and negative (category E), were evidenced in the first interview. Positive transference promotes and supports the early development of therapeutic alliance. Conversely, early negative transference may interfere with the alliance.45 Our participants presented more evidence of negative transference than of positive transference, which may have hindered the development of therapeutic alliance in early psychotherapy. Early negative transference manifestations are certainly a warning that the therapist should be aware of, so as to deal with them in psychotherapy. Negative transference in the form of idealization can be difficult to handle at the beginning of psychotherapy. Even though it may be necessary for the patient to begin treatment, idealization usually hides aggressive drives and wishes of manipulation and control. Early interpretation of the unconscious meaning of this type of transference can lead the patient to a deep feeling of helplessness,46 and consequently, to treatment dropout. In post-treatment interviews, the participants revealed the development, at varying levels, of an understanding of their difficulties (subcategory F.1) during psychotherapy. However, the ability to work by oneself, cited as an important factor for the successful completion of treatment,47 was presented only by P2 and P6. Even though all participants discontinued their treatment, qualitative differences were observed in the relationships held with therapists (subcategory F.2). For example, one patient made several comments suggesting lack of harmony and rapport with her therapist as a major characteristic of the entire psychotherapy. Other participants, in turn, made many positive comments on their therapeutic relationship. Therefore, our results

do not support findings that indicate that therapeutic alliance is weaker in dropouts.11,13,20,21 Rather, as also pointed out by Tyron & Kane,48 the therapeutic alliance assessed by the patient dropping out was similar to that described by patients who complete psychotherapy. Resistance appeared in the post-treatment interviews of all patients (subcategory F.3). As Freud postulated,49 resistance accompanies the treatment step by step (p. 138). However, participants showed little willingness to overcome resistance, being defensive about possible changes and trying to maintain the status of the disorder. Even though we have no data to assess how the therapists worked patient resistance, we can assume that difficulties in this work may have contributed to dropout. Resistance is no longer seen only as an obstacle to be removed: it is a way the patients have to reveal how their previous experiences influence their behavior here/ now.50 So, helping patients understand their resistance is an essential task of therapists in PP.3 With regard to therapeutic results, all patients showed overall satisfaction with treatment (subcategory G.1); even though they stopped psychotherapy, most of them partially achieved their goals and expectations. One patient revealed that all her goals were achieved when she interrupted psychotherapy, which may reflect a symptomatic improvement that contributes to premature termination of psychotherapy. Patients may understand that they no longer need professional help because what has been reached so far corresponds to their expectations and their sense of well-being.51 Specific benefits from psychotherapy (subcategory G.2) were also mentioned by participants, although some reported having obtained only partial benefits. Additionally, patients sought treatment for a specific reason and eventually improved other areas of their lives, a result also found in other studies.47,52 In general, patients were satisfied with treatment results, in spite of its presumed premature termination. Therapists tend to seek broad and substantial improvements for their patients, even when the patient’s own goals have been reached. This is the same as saying that the number of cases considered ready for termination is often underestimated by therapists.32,52 Divergences in what patients and what therapists consider as cure are associated with dropout in PP.17 In this respect, it is necessary to highlight that the therapists treating our cases were inexperienced, which may have led them to have perfectionistic expectations more easily, e.g., aspiring to a transference resolution that is not compatible with the patient’s reality. One could even consider errors of countertransference, when a therapist fails to support termination due to their own personal ambitions, in most cases much greater than the patient’s ambitions.44

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Another consideration is the possibility that our participants may represent a subgroup of patients who achieved the best results among those who dropped out of treatment. In this case, patients who were not found or who refused to participate (see details in Jung et al.32) could be the ones for whom treatment failed. It is also important to note that in the post-treatment interview, participants developed a friendly relationship with the investigator, which may have favored the manifestation of the positive aspects of treatment rather than the negative ones. Even though the number of patients who leave treatment without giving a reason for premature termination tends to be significant,53,54 in this study only P4 did not expose, in the post-treatment interview, her reason for dropping out (subcategory H.1). In a recent publication on reasons for psychotherapy termination, Westmacott & Hunsley55 found that the motive most often reported by patients was that they were feeling better. The percentage of patients who terminate treatment for being satisfied with its results ranges from 14%54 to 43.4%55 and even 45%.56 In our sample, feeling well and wanting to enjoy the improvements achieved was mentioned as the reason for termination by P2 and P6. In another study conducted in Brazil, Vargas & Nunes57 found that when patients are asked to reveal the reason for dropping out of treatment, they tend to report financial difficulties. Studies in other countries have also emphasized the financial issue, however not as the main motivation.55,56 Our data suggest that resistance was main reason for dropping out of therapy. It is also known that many patients decide to terminate psychotherapy because they are not satisfied with the therapist or the psychotherapy.55,56 In our study, dissatisfaction was referred by P4 and P5 as motives to termination. Psychotherapy dropout may occur when the patient is not prepared to respond to the therapist’s interventions, which reactivate negative feelings involving the repetition of a previously experienced event.58

Conclusion The baseline interview is a crucial moment in psychotherapy, especially because it can offer a basis to forecast the future of the therapeutic relationship.46,59 In our study, unclear treatment goals, low readiness to change, a limited recognition of the patients’ participation in their own problems, as well as premature signs of negative transference and resistance were prominent in the initial sessions of all dropout PP patients. As psychotherapists, we acknowledge that these patient characteristics can also be found in completers. Defining

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the extent to which these characteristics are more intense in patients who drop out of psychotherapy lies beyond the scope of this study. Also, we should bear in mind that patient characteristics are not isolated features. Competent therapists presumably will help patients overcome resistance and develop psychological mindedness. Moreover, it is assumed that therapists will perform an exhaustive examination of the patient’s expectations, motivations, and objectives, and try to establish goals together with them, which could prevent the intensification of negative transference and resistance, and consequently, the discontinuation of psychotherapy. In order to clarify the possible association between patient and therapist factors in PP dropout, we strongly suggest further studies, including the analysis of transcripts or videos of patient-therapist interactions. Data from our interviews also suggest that dropouts are very ambivalent about PP. Following Freud,60 we can infer that interruption may occur in association with the therapist’s misperception of the indication of PP. Finding a way of transforming magic into realistic goals, more coherent with the problems that led to psychotherapy, seems to be the major challenge faced by therapists of patients with less insight and who seek more focused changes. It is known that therapist abilities, for example their technical flexibility, are associated with positive results in different psychotherapies.61,62 Our data did not include therapist characteristics, so it was not possible to assess whether there was an association between rigid adherence to the psychoanalytic psychotherapy model by the psychotherapists and the patients’ decision to interrupt treatment. However, this is a hypothesis that could be analyzed in future investigations. Nevertheless, based on the present results, we recommend that therapists pay more attention to the patients’ psychological characteristics and to their expectations with psychotherapy in order to adjust the therapeutic plan. This could possibly prevent psychotherapy dropout. It is noteworthy that all participants, despite having dropped out of psychotherapy, mentioned positive overall results, specific benefits, partial achievement of goals and expectations, and improvements in areas of life that they had not planned to change. This reinforces the idea that patients, even those who drop out of psychotherapy, may obtain several benefits with psychotherapy, and that the quality of the results is unique to each patient. Post-treatment interviews showed that therapeutic gains, dissatisfaction, and resistance all seemed to be associated with dropout. However, in most cases, the patient’s evaluation of the therapeutic relationship was not determinant of dropout. This study offers some hypotheses or explanations for the complex phenomenon of dropout in PP. Overall,

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it suggests that the decision to start, continue, or stop psychotherapy depend on multiple factors, e.g., initial goals, readiness to change, insight capacity, recognition of one’s own problems, resistance, and transference. These explanations should, however, be considered in view of the methodological limitations of this study. First of all, this was a naturalistic study. Even though naturalistic studies are a useful complement to controlled trials (especially by better representing what is effectively done in clinical practice), they have limited accuracy. Moreover, we used baseline interviews transcribed from memory by the therapists. Even though this kind of record is consistent with the usual practices of PP, it offers less reliability than audio/video recordings. Finally, the long time elapsed between the end of treatment and posttreatment interviews may have generated a recall bias. The fact that therapists were trainees in PP is another limitation. However, we could argue that this in fact increases the technical validity of the study, considering that training psychotherapists are under systematic supervision and receiving rigorous theoretical and technical guidance. It is worth mentioning that in most psychoanalytic investigations conducted in Brazil, therapists are psychology undergraduates or licensed PP under training, i.e., students or professionals with little experience in conducting therapy. Indeed, the time has come for experienced psychoanalytic therapists to set aside skepticism and the vision that research interferes negatively with the psychotherapeutic process. There is no doubt that combining the intersubjectivity of the psychoanalytic process with the objectivity of scientific research can be very difficult; notwithstanding, seeing it as an obstacle, ignoring the scientific development of the field, and continuing “comfortably protected” behind fantasy and resistance is no longer an option.63 Diminishing the distance between therapists and investigators is a challenge for both. In view of the strengths and weaknesses of this investigation, we recognize that additional research on dropout in PP is still needed.

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24. Frayn DH. Assessment factors associated with premature psychotherapy termination. Am J Psychother. 1992;46:250-61. 25. Ingenhoven TJ, Duivenvoorden HJ, Passchier J, van den Brink W. Treatment duration and premature termination of psychotherapy in personality disorders: predictive performance of psychodynamic personality functioning. J Psychiatr Pract. 2012;18:172-86. 26. Tanesi PH, Yazigi L, Fiore ML, Pitta JC. Adesão ao tratamento clínico no transtorno de personalidade borderline. Estud Psicol. 2007;12:71-8. 27. Wilson M, Sperlinger D. Dropping out or dropping in? A reexamination of the concept of dropouts using qualitative methodology. Psychoanal Psychother. 2004;18:220-37. 28. Knox S, Noah A, Adrians N, Everson E, Hess S, Hill C, et al. Clients’ perspectives on therapy termination. Psychother Res. 2011;21:154-67. 29. Lilliengen P, Werbart A. Therapists’ view of therapeutic action in psychoanalytic psychotherapy with young adults. Psychotherapy (Chic). 2010;47:570-85. 30. Lilliengren P, Werbart A. A Model of therapeutic action grounded in the patients’ view of curative and hindering factors in psychoanalytic psychotherapy. Psychotherapy (Chic). 2005;42:324-39. 31. Gabbard GO. Introduction. In: Levy RA, Ablon JS, editors. Handbook of evidence-based psychodynamic psychotherapy. New York: Humana; 2009. p. 25-33. 32. Jung S, Nunes MLT, Eizirik CL. Avaliação de resultados da psicoterapia psicanalítica. Rev Psiquiatr Rio Gd Sul. 2007;29:184-96. 33. Denzin NK, Lincoln YS. Handbook of qualitative research. Thousand Oaks: Sage Publications; 1994. 34. Bardin L. Análise de conteúdo. Lisboa: Edições 70; 1995. 35. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095-105. 36. Montado G. Psicoterapia focal psicoanalítica: investigación de proceso y resultados. In: Bernardi R, editor. Psicoanálisis focos y aperturas. Montevideo: Ágora/Psicolibros; 2001. p. 248-61. 37. Safren SA, Heimberg RG, Juster HR. Clients’ expectancies and their relationship to pretreatment symptomatology and outcome of cognitive-behavioral group treatment for social phobia. J Consult Clin Psychol.1997;65:694-8. 38. Bosch MF. Doing psychotherapy. New York: Basic Books; 1980. 39. Ceitlin LH, Cordioli AV. O início da psicoterapia. In: Cordioli AV, editor. Psicoterapia abordagens atuais. Porto Alegre: Artmed; 2008. p. 125-37. 40. Cordioli AV, Gomes F. As condições do paciente e a escolha da terapia. In: Cordioli AV, editor. Psicoterapias abordagens atuais. Porto Alegre: Artmed; 2008. p. 103-24. 41. Krause M, De la Parra G, Arístegui R, Dagnino P, Tomicic A, Valdés N, et al. The evolution of therapeutic change studied through generic change indicators. Psychother Res. 2007;17:673-89. 42. Delsignore A, Schnyder U. Control expectancies as predictors of psychotherapy outcome: a systematic review. Br J Clin Psychol. 2007;46:467-83. 43. Pfingsten U, Hinsch R. Prediction of therapeutic effects of a social skills training in groups. In: Minsel W, Herff W, editors. Proceedings of the First European Conference on Psychotherapy Research. Frankfurt: Lang; 1982. p. 204-9. 44. Gabbard GO. Elaboração e término. In: Gabbard GO, editor. Psicoterapia psicodinâmica de longo prazo: texto básico. Porto Alegre: ArtMed; 2005. p. 161-78.

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45. Caligor E, Kernberg O, Clarkin J. Psicoterapia dinâmica das patologias leves da Personalidade. Porto Alegre: Artmed; 2008. 46. Zimerman DE. Fundamentos psicanalíticos. Porto Alegre: Artmed; 1999. 47. Nilsson T, Svensson M, Sandell R, Clinton D. Patients’ experiences of change in cognitive behavioral therapy and psychodynamic therapy: a qualitative comparative study. Psychother Res. 2007;17:5533-66. 48. Tryon GS, Kane AS. Relationship of working alliance to mutual and unilateral termination. J Counsel Psychol. 1993;40:33-6. 49. Freud S. Dinâmica da transferência (1912). In: Edição standard brasileira das obras psicológicas completas de Sigmund Freud. Rio de Janeiro: Imago; 1989. p. 131-43. 50. Friedman L. A reading of Freud’s papers on technique. Psychoanal Q. 1991;60:564-95. 51. Swift JK, Callahan JL. A delay discounting measure of great expectations and the effectiveness of psychotherapy. Prof Psychol Res Pr. 2008;39:581-88. 52. Leuzinger-Bohleber M, Stuhr U, Ruge B, Beutel M. How to study the quality of psychoanalytic treatments and their longterm effects on patients’ well-being: a representative, multiperspective followup study. Int J Psychoanal. 2003;84:263-90. 53. Barbato A, D’Avanzo, B. Efficacy of couple therapy as a treatment for depression: a meta-analysis. Psychiat Quart. 2008;79:121-32. 54. Todd DM, Deane FP, Bragdon RA. Client and therapist reasons for termination: a conceptualization and preliminary validation. J Clin Psychol. 2003;59:133-47. 55. Westmacott R, Hunsley J. Reasons for terminating psychotherapy: a general population study. J Clin Psychol. 2010;66:965-77. 56. Roe D, Dekel R, Harel G, Fennig S. Clients’ reasons for terminating psychotherapy: a quantitative and qualitative inquiry. Psychol Psychother. 2006;79:529-38. 57. Vargas F, Nunes ML. Razões expressas para o abandono de tratamento psicoterápico. Aletheia. 2003;17:155-8. 58. Coutinho J, Ribeiro E, Hill C, Safran J. Therapists’ and clients’ experiences of alliance ruptures: a qualitative study. Psychother Res. 2011;21:525-40. 59. Thomä H, Kächele H. A entrevista inicial e os terceiros na aliança. In: Thomä H, Kächele H. Teoria e prática da psicanálise: fundamentos teóricos. Porto Alegre: Artmed; 1992. p. 185-230. 60. Freud S. Sobre o início do tratamento (1912). In: Edição standard brasileira das obras psicológicas completas de Sigmund Freud. Rio de Janeiro: Imago; 1989. p. 163-87. 61. Serralta FS, Pole N, Tiellet Nunes ML, Eizirik CL, Olsen C. The process of change in brief psychotherapy: effects of psychodynamic and cognitive-behavioral prototypes. Psychother Res. 2010;20:564-75. 62. Castonguay LG, Goldfried Mr, Wiser S, Raue PJ, Hayes AM. Predicting effects of cognitive therapy for depression. A study of unique and common factors. J Consult Clin Psychol. 1996;64:497-504. 63. Jung SI. É possível fazer pesquisa de resultados em psicoterapia psicanalítica? Bol Inf Estud Integr Psicoter Psicanal. 2004;7:6. Correspondence Simone Isabel Jung Rua Emílio Lúcio Esteves, 1187/303 95600000 – Taquara, RS – Brazil E-mail: simoneisabeljung@gmail.com

Trends

Original Article

in Psychiatry and Psychotherapy

Cultural aspects in dementia: differences in the awareness of Brazilian caregivers Aspectos culturais na demência: diferenças na consciência da doença de cuidadores brasileiros Raquel L. Santos, Maria F. B. de Sousa, Ana C. Ganem, Thais V. Silva, Marcia C. N. Dourado*

Abstract

Resumo

Objective: To explore differences in disease awareness in participants of a psychoeducational group designed for Latin American caregivers of people with dementia. Method: We assessed participants of a group developed at an outpatient unit for Alzheimer’s disease. Interpretative phenomenological analysis was used to analyze differences in the caregivers’ reports. Results and Discussion: The participants, mostly spouses and daughters, presented moderate caregiver burden and different levels of awareness (aware, partially aware, or unaware). Disease awareness and the development of coping strategies were influenced by familism, religiosity, and duty. Becoming a caregiver was considered positive in some cases, due to religious convictions and beliefs related to the importance of caregiving. Caregiver unawareness may reflect an attempt to maintain integrity of the patient’s identity. Conclusions: Our data allow some comparisons across cultures, which may be valuable in assessing the influence of different psychosocial environments on the knowledge about dementia. Keywords: Caregiver, dementia, awareness, intervention, qualitative study.

Objetivo: Examinar diferenças na consciência da doença em participantes de um grupo psicoeducacional direcionado a cuidadores latino-americanos de pessoas com demência. Método: Foram avaliados participantes de um grupo desenvolvido em um serviço para doença de Alzheimer. Utilizouse análise fenomenológica interpretativa para analisar diferenças nos relatos dos cuidadores. Resultados e Discussão: Os participantes, em sua maioria esposas e filhas, apresentaram sobrecarga moderada e diferentes níveis de consciência da doença (preservada, parcial ou inexistente). A consciência da doença e o desenvolvimento de estratégias de enfrentamento foram influenciados pelo familismo, religiosidade e sentimento de obrigação moral. Tornar-se um cuidador também foi considerado positivo em alguns casos, por convicções religiosas e crenças relacionadas à importância do cuidar. A ausência de consciência pode refletir uma tentativa de manter a identidade do paciente. Conclusão: Os dados permitem algumas comparações entre culturas, as quais podem ser valiosas para avaliar a influência de diferentes contextos psicossociais no conhecimento sobre a demência. Descritores: Cuidador, demência, consciência da doença, intervenção, estudo qualitativo.

* Center for Alzheimer’s Disease and Related Disorders, Institute of Psychiatry, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. Financial support: Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ) (grant no. E-26/101.030/2007). Submitted Jul 21 2012, accepted for publication Nov 14 2012. No conflicts of interest declared concerning the publication of this article. Suggested citation: Santos RL, de Sousa MF, Ganem AC, Silva TV, Dourado MC. Cultural aspects in dementia: differences in the awareness of Brazilian caregivers. Trends Psychiatry Psychother. 2013;35(3):191-7.

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Differences in awareness among dementia caregivers – Santos et al.

Introduction Disease awareness is defined as the recognition of changes caused by deficits related to the disease process.1-3 It encompasses three dimensions: the ability to recognize a specific deficit; emotional response to difficulties; and the ability to understand the impact of impairment on activities of daily living.4 One of the approaches that have been taken to assess the level of patients’ awareness consists of calculating the discrepancy between the patient’s own account of the perceived difficulties and that of the patient’s spouse or caregiver. In general, proxies tend to judge patient awareness to be lower than the patient’s own judgement.5 As a result, first-person evaluations tend to be employed only as a supplement to third-person ratings provided by a caregiver.5 However, the caregiver may be more or less aware of the patient’s behavioral and functional disorders. Awareness has a complex nature and may also be subjectively determined.6 Regarding the caregiver’s point of view, the subjective aspect of their awareness is influenced by how the clinical situation is presented, the degree of kindred and family ties, and caregiver factors such as time dedicated to the patient, burden of care, psychological health, and educational status.7 Caregiver awareness may also be determined by their motivations to provide care for people with dementia. Motivations can emerge from internal desires or beliefs but also from external pressures, playing a key role in determining both the social impact of the disease and the risks of stigmatization and discrimination. The cultural context can be considered an internal determinant that influences caregiving at multiple levels throughout the caregiving experience, mainly in regard to the meaning of being a caregiver. Consequently, it can be assumed that cultural justification for caregiving may reflect the cultural values and beliefs of a given group that can influence elder care provision and potentially increase or decrease emotional growth. It can also be assumed that motivations to provide care may partially determine the caregiver’s awareness of the disease and thereby increase the risk of – or protect against – emotional distress and burden.8 It is necessary to consider that the caregiver’s ability to recognize symptoms and the way how they interpret and act on them are central to redefining and reorganizing family relations and constitute an important and neglected aspect of the illness experience. Contrasting the caregiving experience of different individuals and groups can enhance the theoretical understanding of this experience by distinguishing between universal elements and those mediated by the norms, expectations, or experiences of a given cultural group.9 Caregiver disease awareness may be also determined by cultural beliefs, significantly affecting the

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type of care offered and the sustainability of outcomes in patients with dementia. In view of the above, and considering the likely implications of these considerations for clinical practice, this study aimed to explore differences in disease awareness and motivations to provide care among participants of a psychoeducational group designed for Latin American caregivers of people with dementia. Considering the complex relationship between awareness and cultural background, it seems appropriate to adopt an exploratory approach that considers how caregivers understand what is happening to them and how this experience, in turn, influences coping and adjustment.

Method Ethical issues This study was approved by the Ethics Committee of the Institute of Psychiatry at Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil. All caregivers signed an informed consent form prior to the first group session.

Design This was a qualitative study involving accounts of caregivers who participated in a psychoeducational group intervention. Session transcripts were subjected to interpretative phenomenological analysis (IPA)10 in order to identify the key elements of the participants’ understanding and experience. We chose to use IPA in this study because it has been described as particularly relevant for understanding subjective responses to illness. IPA is considered both phenomenological, because it aims to explore the participant’s view on the topic being investigated, and interpretative, because it acknowledges that the participant’s perceptions are elicited as part of a dynamic, interactive process in which the investigator’s own beliefs and understandings also play a role as the investigator engages in interpretative activity to make sense of the participant’s subjective world.10 All authors participated of the initial analysis, shared the same theoretical background, and were psychologists trained in psychoeducational interventions.

Study participants This study included dementia caregivers (n = 18; 2 males, 16 females) who were participants in a psychoeducational group developed at the outpatient

Differences in awareness among dementia caregivers – Santos et al.

unit of the Center for Alzheimer’s Disease and Related Disorders, Institute of Psychiatry, UFRJ, Brazil. Dementia patients (n = 18; 7 males, 11 females) had been diagnosed with Alzheimer’s disease (AD) and vascular dementia (VD), and their mean age was 78.09 years. They presented a mean of 7.63 years of formal education and a mean of 5.18 years since the onset of the disease. The majority of patients scored 1 on the Clinical Dementia Rating (CDR), which means that they presented mild dementia. The CDR is a numeric scale used to quantify the severity of dementia. Each patient lived at home with his/ her family. All patients were on cholinesterase inhibitors.

Intervention Selected participants were referred to the psychoeducational group following evaluation by a doctor. A baseline interview was conducted in which sociodemographic data were collected. Scales assessing caregiver burden and depression were also used. Finally, we collected data about the patient’s premorbid history, history of disease, the context of family ties and relationships, and the main problems and difficulties related to the participant’s daily activities as a caregiver. The psychoeducational approach was used to offer information about the disease and emotional support to the caregivers. Caregivers had the opportunity to interact with one another, exchanging useful information and providing mutual support. The intervention followed the STARCaregivers model,11,12 in which an attempt is made to help caregivers identify, reduce, and manage the behavioral symptoms of people with dementia (these symptoms have been described as the main cause of caregiver burden, distress, and depression). The model follows five basic steps11,12: 1) identifying behavioral symptoms that are very difficult to manage by describing them and detecting their frequency; 2) identifying precedents of each problem and their consequences; 3) tracing modifying strategies; 4) working on the communication between the caregiver and the patient with dementia; and 5) creating pleasurable events for caregiver and patient. The intervention group consisted of a weekly, 90-minute session over 6 months. Sessions started with a warm-up to allow time for the participants to make comments or raise questions about the events that occurred in the past

week in relation to their general state or to the care for the patients. Based on the caregivers’ conversations, one specific topic was chosen as the main topic, with subsequent exchange of experiences, expressions of feelings related to the situations presented, and, finally, development of new strategies to solve the problems that had emerged in each experience. The group also held discussions following lectures with educational contents decided on by the participants in agreement with the group coordinator. Even though the presentations were educational, the group was motivated to talk about emotional issues raised by the topic discussed. The sessions were part of a closed program, i.e., new participants were not allowed to enter the group. All group sessions were transcribed by memory, immediately after the sessions, by the group coordinator. The coordinator was a psychologist with expertise in aging studies and trained in group techniques, with 4 years of experience in psychoeducational group interventions involving caregivers of patients with dementia.

Data analysis Qualitative analysis was conducted so as to achieve a rigorous, comprehensive description of topics, by highlighting quotes to illustrate each topic and, where possible, use the participants’ own words to label the topics. Initially, we read and revised each transcript a number of times to become familiar with the content. We took notes and compiled a summary list of key points, reproducing as much as possible the participants’ words. This formed the basis for identifying topics emerging in each transcript, as key points were grouped together. At this stage, two investigators grouped key points independently, which permitted to compare the resulting data. Similarities and differences were examined, and differences were discussed until a consensus was reached. Closely related topics were grouped together under appropriate headings and clustered into sets. The result was a complete, hierarchically organized summary list of topics. Once the investigators had developed an agreed upon a final set of topics, all the transcripts were analyzed accordingly, and a full list of extracts related to each topic was compiled. Afterwards, we undertook the interpretative process of understanding how these extracts integrated with or challenged the current theory. The final list of key points is shown in Table 1.

Table 1 – Key topics and subtopics

Topics Subtopics Reasons to become a caregiver Awareness of dementia symptoms Awareness of patient’s sense of identity

Duty, feelings of gratitude, familism, and religiosity Difficulties in recognizing cognitive and functional impairment Management of BPSD Maintenance of patient’s past identity

BPSD = behavioral and psychological symptoms of dementia.

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Results Caregivers’ and patients’ sociodemographic data are summarized in Table 2. All participants were family members, with a greater frequency of spouses and daughters living with the patient. There was a predominance of the female gender (n = 9; 81.8%), probably as a result of the cultural stigma according to which caregiving activities are the responsibility of women.13 Caregiver burden was considered moderate as assessed by the Zarit Burden Interview.14 Table 2 – Sociodemographic data

Caregivers Patients Mean ± SD Mean ± SD

Age 61.27±8.91 Educational level Disease duration Zarit Burden Interview

78.09±10 11.63±3.2 - 31.18±13.7

7.63±4.69 5.18±2.92

n (%)

Gender Female 16 (88.9) 11 (61.1) Male 2 (11.1) 7 (38.9) Kinship degree Daughters 10 (55.6) Spouses 6 (33.3) Distant relatives 2 (11.1) SD = standard deviation.

Disease awareness and reasons to become a caregiver The primary caregiver is usually chosen based on his/her relationship with the patient and with the whole family and also depending on personality characteristics, family issues, and sociocultural aspects.15 In caregiving, a person may be motivated to provide care for many reasons, e.g., feelings of duty and responsibility. Our data suggest that the main factor involved in the decision to become the main caregiver is a feeling of responsibility for the patient. According to the tradition spread throughout generations, especially in the Latin American culture, adult children are responsible for their parents when they get old.16 This is a natural process, in which the caregiver feels the opportunity to repay a past debt to the care recipient. Sometimes, becoming a caregiver is considered positive, due to stronger beliefs related to the importance of caregiving. My mother and I weren’t close when I found out she was in very bad conditions. She didn’t eat properly, she didn’t do her laundry, the house was dirty and her aggressive behavior was driving my stepfather crazy. 194 – Trends Psychiatry Psychother. 2013;35(3)

My stepfather is more than 90 years old and he is going blind. Besides, I’m her daughter and must take on this responsibility of being her caregiver. And you know what? After I started caring for her, we finally became closer again, and I feel good about it... (M.B., 65 years old) Latin American people have distinct worldviews with regard to general assumptions about reality and values. Especially, familism is a core cultural value, referring to a strong commitment to the family as a system of support, learning, socialization, and assistance.9 The relationship between caregiving and perceived familial duty is common in Latin American societies. Family caregiving is considered a natural aspect of family life, even when the premorbid relationship has never been good. Familism may be a cultural aspect responsible for a deficit in caregiver awareness. My mother was a very busy professor and didn’t care so much about me. Our relationship has never been good, but it’s my obligation to be her caregiver because I’m her daughter. However, I’m not sure if such an active and well educated person can really have Alzheimer’s disease. (M.T., 61 years old) Another important aspect to be considered is religiosity,16 a strong motivation for taking care of a disabled person. Latino caregivers tend to be more engaged in positive religious coping than their Caucasian counterparts, by finding a meaning in the caregiving process and perceiving lower degrees of caregiver burden and strain.17 We observed that positive religious coping helps in finding a meaning for caregiving tasks. According to my religion, when you have to do something such as becoming a caregiver, it’s because God sends you an opportunity to learn something. It’s like a mission, you know? That’s why you have to accept it with love. (S.C., 62 years old) Conversely, religiosity can decrease caregiver awareness, as the carer may consider that dementia symptoms are caused by divine will. In these cases, instead of following medical prescriptions, the caregiver may think that dementia requires a spiritual treatment: I spent too much time before I searched for a doctor and for the right treatment, because, when my wife started showing the first dementia symptoms, I thought she was disturbed by an evil force and needed a spiritual treatment. (J.S., 60 years old) Latin American cultural values such as familism and religiosity can influence the reasons to become

Differences in awareness among dementia caregivers – Santos et al.

a caregiver; notwithstanding, the same values may arouse feelings of ambivalence. The caregiver may feel entrapped in a sort of moral obligation which pushes them to take on the responsibility of caregiving, even though they do not want to become the patient’s main caregiver for several reasons. When caregivers feel this type of ambivalence, they may fail in finding a meaning for their caretaking activities, with the possible effects such as developing anxiety and depressive symptoms or even neglecting the care recipient.

Also, caregivers tend to observe whether their relatives with dementia have a certain level of awareness of the disease or not.

Disease awareness and dementia symptoms

Moreover, caregivers may be either aware, partially aware, or unaware of the disease.2,4 In fact, caregiver unawareness may be an attempt to maintain the integrity of the patient’s identity. When confronted with the diagnosis of dementia and the various losses provoked by the disease, the family caregiver may experience an increased burden caused by anticipatory grief.21 Moreover, the caregiver may deny the disease and loss of roles, increasing their emotional distance with the patient.

The majority of caregivers tend to have difficulties coping with the behavioral and psychological symptoms of dementia (BPSD).18 It has been reported that symptoms such as delusions, agitation/aggression, anxiety, irritability/lability, and dysphoria/depression are strongly associated with higher caregiver burden.19 These symptoms may arouse negative feelings, such as entrapment, shame, or guilt, which may lead to higher levels of depression and physical symptoms.20 He’s started thinking that the mirror is one of his colleagues from the army, and he talks with this imaginary friend. His wife got desperate, and she has decided to take the mirror out of their bedroom… (L.B., 60 years old) Caregivers have difficulties distinguishing between dementia symptoms and the patient’s personality. I never know when my mother’s behavior is motivated by her personality or by the symptoms of dementia. Sometimes I think she wants to call my attention and disturb me. She doesn’t accept any kind of help, but she’s always been bossy throughout all her life. What’s from the disease and what comes from my mother herself? (M.T., 61 years old)

Awareness of patient’s sense of identity Caregivers often feel confronted with cognitive and functional impairment, facing the idea that their family members are losing their sense of identity. This may result in a loss of identity of the caregivers themselves. When someone asks my wife’s full name, she mentions the family name she used to have when she was single. One day I was driving, she looked at me and asked who I was. I told her I was her husband, but she said she wasn’t married. I know that it is a consequence of the disease, but I feel sad that nowadays I am not indispensable to my wife anymore. (C.A., 72 years old)

She has been a professor, she has read a lot of books, and her house has a huge library. When someone talks to her, she tries to show she has a wide vocabulary and she is still that woman from the past. I do not think she is aware of her deficits. She always says that she is okay. (M.T., 61 years old)

My mother is forgetful, but she can get a bus by herself and go to my sister’s house in another city. I just have to tell the bus driver she has dementia and give him emergency phone numbers. However, I feel worried: the last time, the driver had to stop the bus, and she got agitated. A passenger called me, my mother got calmer and continued the trip. Well, I think it won’t happen anymore. My mother has some memory problems, but she still does many things. It was just a moment of confusion. (E.B., 56 years old)

Discussion We explored differences in awareness among dementia caregivers considering some cultural aspects that may have influenced the information participants received about the disease and the development of their ways of coping. The three overarching topics that emerged from the participants’ accounts reflected a tension between acknowledging the responsibility and the stress of caring for the dementia patient and wanting to maintain one’s sense of identity. Caregiving may be considered as having both positive and negative aspects and a wide range of outcomes. The motivation to provide care is determined by both cultural and individual aspects and may influence disease awareness, depending on whether caregivers are able to identify negative or positive aspects related to the activities of caring. Social representations of family and religion are additional cultural aspects that may influence caregiver

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awareness. For instance, tradition and spirituality, subtopics of reasons to become a caregiver, are considered social norms, especially in Latin American countries. It should be observed that the motivations described by caregivers are based on a belief that legitimizes this symbolic universe. This may stem from religious beliefs and practices common in Latin American people (e.g., “for it is in giving that we receive” and the practice of making promises). The idea constantly expressed as “bearing the cross that God lays on your shoulders” leads to the question of divine punishment (crime and punishment), representing the risk that one incurs by not complying with God’s commands. Faith often appears as a source of support to face difficulties and suffering, offering strength to overcome them. Even though our Latino group tended to consider caregiving as a meaningful role, due to their religiosity and their sense of gratitude towards the care recipient, we also observed that they failed in improving their own mental health when compared with European American caregivers.9 In this sense, the present findings may help develop specific interventions for different groups, according to cultural aspects. Also, the group sessions showed that family caregiving may be primarily motivated by affection, altruism, social norms of responsibility, and even egotistic motivations.22 Ambivalent feelings were frequently present and were inherent to the caregiving task, manifested by the counterpoint of physical and emotional exhaustion on the one hand – “being on the verge of a breakdown” – and satisfaction about doing one’s duty on the other. Meaning is conceptualized here as a mediator of the stress process, as “management of the meaning of the situation,” and is viewed as a coping mechanism.23 Failure to find meaning may potentially have negative outcomes for both caregiver and care recipient. The caregiver may experience feelings of despair or hopelessness, which could in turn impact on the care recipient’s well-being.24 Even though the participants’ awareness of the disease was evident, this was often partial, as there was considerable confusion in some domains, especially with regard to BPSD and maintenance of the patients’ sense of identity. As caregivers witness the patient’s successive losses, they may feel that they themselves are losing their identities too. The relationship between the caregivers’ understandings of dementia and their daily experience was reflected in the topics of awareness of dementia symptoms and awareness of the patient’s sense of identity. These topics encapsulate a range of dilemmas that our caregivers faced as they developed an understanding of dementia, considered its implications for the patients’ sense of identity, and negotiated a range of social situations and relationships with them. Cultural stereotypes associated

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with aging and coexisting medical problems also seem to have influenced the concepts of caregivers. Prior information and biomedical concepts about dementia supported the caregivers’ interpretations about the disease, thus influencing their reactions, the problem itself, and intrafamily arrangements. Our group participants showed moderate burden of care. Even though the determinants of caregiver burden are well known,8 cultural background and the resulting attitudes toward the disease may also partially determine the caregiver’s investment in the care of their loving ones and thus increase the burden of care. A recent study8 has shown a link between negative attitudes towards the disease and feelings of burden experienced by caregivers of AD patients. The psychoeducational intervention that we found relevant to test involved three basic techniques: information provision, role clarification, and belief clarifications. In the first technique, group participants were provided with presentations, readings, in a workshop environment, welcoming questions about the disease and about its effects on the care recipient’s daily life. Role clarification, in turn, emphasized the caregiver’s role, which includes assuring security and comfort to the care recipient and helping him/ her find joyful activities. This type of intervention helps caregivers understand that their role is not associated with rehabilitation or retarding the course of the disease. Finally, psychoeducational interventions could also provide belief clarifications, in which caregivers are stimulated to view their situation with some distance, developing strategies to deal with immediate and recurrent caregiving situations and, as a result, becoming more aware of the emotional impact of their actions on the patient. Ideally, a psychoeducational group intervention should involve miscellaneous techniques, helping caregivers become more aware of the disease and of their role in the relationship with the patient, as well as offering them a suitable environment for the exposure of feelings related to the caretaking experience. A recent systematic review25 has investigated a model based on miscellaneous techniques. In comparison with groups which provide only information about the disease, the ones based on multiple components offer better results in decreasing caregiver burden as well as depressive and anxiety symptoms. Therefore, a mixture of the techniques above seems to deserve investigation as a unique psychoeducational group intervention method, based on rigorous, structured steps developed according to the participants’ cultural characteristics. Some limitations of our study should be mentioned. First, we had a small sample of caregivers, with homogeneous sociodemographic characteristics, including a majority of women (spouses or daughters). Conversely, our sample was quite heterogeneous in terms of level of burden,

Differences in awareness among dementia caregivers – Santos et al.

depressive and anxiety symptoms. On the one hand, we could argue that this characteristic was beneficial for the development of the group dynamics, as caregivers had the opportunity to share experiences among themselves. On the other hand, however, if methodological issues are taken into consideration, it becomes evident that a bigger, randomized sample would be better. Also, the caregivers included in the study were demonstrably seeking help: they were referred to the group after medical evaluation, and all of them were willing to contribute to their patients’ treatment and to be a part of the psychoeducational intervention. Therefore, our results cannot be considered representative of the effects of the same type of intervention applied to caregivers who are not help-seekers. Finally, we are unable to objectively measure to which extent the caregivers participating in the treatment group acquired new knowledge or appropriate skills from the practice acquired with daily activities with the patients. A clinical implication of our results is the important role and the value of fully involving the caregiver in psychoeducational interventions, providing information about the condition, its prognosis, and ways of coping with it, all of which may be important for improving awareness.25 Because it is necessary to identify which coping styles are affected by cultural differences, psychoeducational interventions with caregivers should include culturally-bound positive coping techniques, i.e., an exploratory approach that considers the cultural background that influences the way how caregivers understand what is happening to them and how this, in turn, influences coping and adjustment.

References 1. Zanetti O, Vallotti B, Frisoni GB, Geroldi C, Bianchetti A, Pasqualetti P, et al. Insight in dementia: when does it occur? Evidence for a nonlinear relationship between insight and cognitive status. J Gerontol B Psychol Sci Soc Sci. 1999;54:100-6. 2. Dourado M, Laks J, Rocha M, Soares C, Leibing A, Engelhardt E. Consciência da doença na demência: resultados preliminares em pacientes com doença de Alzheimer leve e moderada. Arq Neuropsiquiatr. 2005;63:114-118. 3. de Sousa MF, Santos RL, Brasil D, Dourado M. Consciência da doença na demência do tipo Alzheimer: uma revisão sistemática de estudos longitudinais. J Bras Psiquiatr. 2011;60:50-56. 4. Dourado M, Marinho V, Soares C, Engelhardt E, Laks J. Awareness of disease in Alzheimer’s dementia: description of a mild to moderate sample of patient and caregiver dyads in Brazil. Int Psychogeriatr. 2007;19:733-44. 5. Trigg R, Wats S, Jones R, Tod A. Predictors of quality of life ratings from persons with dementia: the role of insight. Int J Geriatr Psychiatry. 2011;26:83-91. 6. Clare L, Wilson B, Carter G, Roth I, Hodges JR. Assessing awareness in early-stage Alzheimer’s disease: Development and piloting of the Memory Awareness Rating Scale. Neuropsychol Rehabil. 2002;12:341-62.

7. Onor ML, Trevisiol M, Negro C, Aguglia E. Different perception of cognitive impairment, behavioral disturbances, and functional disabilities between persons with mild cognitive impairment and mild Alzheimer’s disease and their caregivers. Am J Alzheimers Dis Other Demen. 2006;21:333-8. 8. Zawadzki L, Mondon K, Peru N, Hommet C, Constans T, Gaillard P, et al. Attitudes towards Alzheimer’s disease as a risk factor for caregiver burden. Int Psychogeriatr. 2011;23:1451-61. 9. McCallum TJ, Sorocco KH, Fritsch T. Mental health and diurnal salivary cortisol patterns among African American and European American female dementia family caregivers. Am J Geriatr Psychiatry. 2006;14:684-93. 10. Smith J, Jarman M, Osborn M. Doing interpretative phenomenological analysis. In: Murray M, Chamberlain K, editors. Qualitative health psychology: theories and methods. London: Sage Publications; 1999. p. 218-240. 11. Logsdon R, McCurry S, Teri L. STAR-Caregivers: a community-based approach for teaching family caregivers to use behavioral strategies to reduce affective disturbances in persons with dementia. Alzheimers Care Q. 2005;6:146-56. 12. Teri L, McCurry SM, Logsdon R, Gibbons LE. Training community consultants to help family members to improve dementia care: a randomized controlled trial. Gerontologist. 2005;45:802-11. 13. Karsch UM. Idosos dependentes: famílias e cuidadores. Cad Saude Publica. 2003;19:861-6. 14. Zarit SH, Orr NK, Zarit JM. The hidden victims of Alzheimer’s disease: families under stress. New York: New York University Press. 1985. 15. Gaugler JE, Zarit SH, Pearlin LI. The onset of dementia caregiving and its longitudinal implications. Psychol Aging. 2003;18:171-80. 16. Gómez M. Estar ahí, al cuidado de un paciente con demencia. Invest Educ Enferm. 2007;25:60-71. 17. Rabinowitz YG, Hartlaub MG, Saenz EC, Thompson LW, Gallagher-Thompson D. Is religious coping associated with cumulative health risk? An examination of religious coping styles and health behavior patterns in Alzheimer’s dementia caregivers. J Relig Health. 2010;49:498-512. 18. Melo G, Maroco J, de Mendonça A. Influence of personality on caregiver’s burden, depression and distress related to the BPSD. Int J Geriatr Psychiatry. 2011;26:1275-82. 19. Huang SS, Lee MC, Liao YC, Wang WF, Lai TJ. Caregiver burden associated with behavioral and psychological symptoms of dementia (BPSD) in Taiwanese elderly. Arch Gerontol Geriatr. 2012;55:55-9. 20. Martin Y, Gilbert P, McEwan K, Irons C. The relation of entrapment, shame and guilt to depression, in carers of people with dementia. Aging Ment Health. 2006;10:101-6. 21. Holley CK, Mast BT. The impact of anticipatory grief on caregiver burden on dementia caregivers. Gerontologist. 2009;49:388-96. 22. Doty P. Family care of the elderly: the role of public policy. Milbank Q. 1986;64:34-75. 23. Pearlin LI, Mullan JT, Semple SJ, Skaff MM. Caregiving and the stress process: an overview of concepts and their measures. Gerontologist. 1990;30:583-94. 24. Quinn C, Clare L, Woods RT. The impact of motivations and meanings on the wellbeing of caregivers of people with dementia: a systematic review. Int Psychogeriatr. 2010;22:43-55. 25. Santos RL, de Sousa MF, Brasil D, Dourado M. Intervenções de grupo para sobrecarga de cuidadores de pacientes com demência: uma revisão sistemática. Rev Psiq Clin. 2011;38:161-7. Correspondence Raquel Luiza Santos Rua Constança Barbosa, 140/504, Meier 20735-090 – Rio de Janeiro, RJ – Brazil Tel./Fax: +55-21-7929-1133 E-mail: raquelluizasantos@yahoo.com.br

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Trends

Original Article

in Psychiatry and Psychotherapy

Translation, adaptation, and preliminary validation of the Brazilian version of the Behavior Problems Inventory (BPI-01) Tradução, adaptação e validação preliminar da versão brasileira do Behavior Problems Inventory (BPI-01) Gisele da Silva Baraldi,1 Johannes Rojahn,2 Alessandra Gotuzo Seabra,3 Luiz Renato Rodrigues Carreiro,4 Maria Cristina Triguero Veloz Teixeira5 Abstract

Resumo

Introduction: Children with atypical development often present behavior problems that impair their psychosocial adaptation. Objective: To describe the cultural adaptation to Brazilian Portuguese of the Behavior Problems Inventory (BPI-01), as well as preliminary indicators of instrument reliability and validity. Methods: The process involved translation, back-translation, and cultural adaptation of the instrument. Psychometric properties (reliability and validity) were assessed comparing scores obtained with the BPI-01, the Wechsler Intelligence Scales for Children and Adults, the Child Behavior Checklist for Ages 6-18 (CBCL/618), and the Autism Screening Questionnaire (ASQ). The sample comprised 60 children (30 typically developing and 30 atypically developing). Results: The cultural adaptation process was considered adequate. Internal consistency of the BPI-01 was satisfactory, with a Cronbach’s alpha of 0.65 for the self-injurious behavior scale, 0.82 for stereotyped behaviors, and 0.91 for aggressive/destructive behaviors. Considering a mean frequency of 0.5, the receiver operating characteristic (ROC) curve revealed 80% sensitivity and 3% specificity in the stereotyped behavior scale, 50 and 10% in aggressive/destructive behaviors, and 76 and 6% in self-injurious behaviors, respectively. Low-to-moderate correlations were observed between BPI-01, ASQ, and CBCL/6-18 scores. Conclusion: BPI-01 showed good psychometric properties, with satisfactory preliminary indicators of reliability, convergent validity, and sensitivity for the diagnosis of atypical development. Keywords: Intellectual disability, inventory, reliability, validity, behavior problems, psychological assessment.

Introdução: Crianças com desenvolvimento atípico frequentemente apresentam problemas de comportamento que prejudicam sua adaptação psicossocial. Objetivo: Descrever o processo de adaptação cultural para português do Brasil do Behavior Problems Inventory (BPI-01), bem como indicadores preliminares de sua fidedignidade e validade. Método: O processo envolveu as etapas de tradução, retrotradução e adaptação cultural do instrumento. Para a verificação das propriedades psicométricas (fidedignidade e validade), foram comparados os escores obtidos com o BPI-01, as Escalas de Inteligência Wechsler para Crianças e Adultos, o Inventário dos Comportamentos de Crianças e Adolescentes de 6 a 18 anos (CBCL/6-18) e o Questionário de Rastreamento de Autismo (Autism Screening Questionnaire, ASQ). A amostra foi composta por 60 crianças (30 com desenvolvimento típico e 30 com atípico). Resultados: O processo de adaptação cultural foi considerado adequado. A consistência interna do BPI-01 foi satisfatória, com alfa de Cronbach de 0,65 para a escala de comportamentos autoagressivos, 0,82 para comportamentos estereotipados e 0,91 para comportamentos agressivos/destrutivos. Considerando-se uma frequência média de 0.5, a curva receiver operating characteristic (ROC) verificou sensibilidade de 80% e especificidade 3% na escala de comportamentos estereotipados, 50 e 10% para comportamentos agressivos/destrutivos, e 76 e 6% para comportamentos autoagressivos, respectivamente. Foram verificadas correlações de baixas a moderadas entre os escores do BPI-01, do ASQ e do CBCL/6-18. Conclusões: O BPI-01 apresentou boas características psicométricas, com indicadores preliminares satisfatórios de fidedignidade, validade convergente e sensibilidade para o diagnóstico de desenvolvimento atípico. Descritores: Deficiência intelectual, inventário, fidedignidade, validade, problemas de comportamento, avaliação psicológica.

Psychologist. MSc in Developmental Disorders, Graduate Program in Developmental Disorders, Universidade Presbiteriana Mackenzie, São Paulo, SP, Brazil. 2 Psychologist. PhD in Clinical Psychology. Professor, Applied Developmental Psychology Program, Department of Psychology, George Mason University, Fairfax, VA, USA. 3 Psychologist. MSc and PhD in Experimental Psychology, Universidade de São Paulo (USP), São Paulo SP, Brazil. Professor, Graduate Program in Developmental Disorders, Universidade Presbiteriana Mackenzie, São Paulo, SP, Brazil. 4 Psychologist. MSc and PhD in Human Physiology, Institute of Biomedical Sciences, USP, São Paulo SP, Brazil. Professor, Graduate Program in Developmental Disorders, Universidade Presbiteriana Mackenzie, São Paulo, SP, Brazil. 5 Psychologist. MSc and PhD in Psychology and Philosophy of Healthcare, Center of Health Sciences, Universidade Federal de Santa Catarina (UFSC), Florianópolis, SC, Brazil. Professor, Graduate Program in Developmental Disorders, Universidade Presbiteriana Mackenzie, São Paulo, SP, Brazil. 1

Financial support: Fundo Mackpesquisa, Universidade Presbiteriana Mackenzie, São Paulo, SP, Brazil. Submitted May 08 2012, accepted for publication Nov 21 2012. No conflicts of interest declared concerning the publication of this article. Suggested citation: Baraldi GS, Rojahn J, Seabra AG, Carreiro LR, Teixeira MC. Translation, adaptation, and preliminary validation of the Brazilian version of the Behavior Problems Inventory (BPI-01). Trends Psychiatry Psychother. 2013;35(3):198-211.

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Validation of Brazilian version of the BPI-01 – Baraldi et al.

Introduction People with intellectual disability often present a typical behavioral repertoire with varying degrees of severity, including aggression, self-injury, and stereotyped behaviors. Behavior problems can cause physical injury to the aggressors themselves and to other individuals, impairing adaptation to social environments, including the family and school1-5 – a scenario that underscores the importance of assessing this phenomenon and plan interventions when necessary. Some examples of typical aggressive responses are kicking, pushing, biting, scratching, and destroying things. With regard to self-injury, the responses most commonly reported are self-biting, self-hitting (different body parts), selfscratching, self-pinching, inserting foreign bodies into body openings, skin picking, hair pulling, and teeth grinding. Among stereotyped behaviors, the body, gestural, and verbal behaviors most widely investigated include oddly moving parts of the body, whirling, rubbing hands, clapping, screaming, smelling objects or parts of the body, and staring firmly at parts of the body and/or objects.2,5 Many of the instruments designed to assess behavior problems related with aggression, self-injury, stereotyped behaviors, irritability, and other indicators of social adaptation in people with intellectual disability are available in English language only. Examples include the Adaptive Behavior Scale,6 the Reiss Screen for Maladaptive Behaviors,7 Assessment of Dual Diagnosis,8 Repetitive Behavior Scale – Revised,9 Modified Overt Aggression Scale,10 and the Behavior Problems Inventory (BPI-01).1 In Brazil, two studies have described the cross-cultural adaptation and preliminary validation of instruments that assess overall indicators of behavior problems, namely, the Aberrant Behavior Checklist (ABC)11 and the Child Behavior Checklist for Ages 6-18 (CBCL/6-18).12 The latter instrument has undergone preliminary validation of the version for ages 4-18 and can be used in children with both typical and atypical development,13 as it assesses different behavior problems characteristic of children with both types of development (withdrawal, anxiety, thought problems, aggression, self-injury, stereotyped behaviors, challenge, and attention problems, among others).12 For the ABC,11 in turn, only partial data are available regarding its cross-cultural adaptation to Brazilian Portuguese. ABC scales assess irritability/agitation/ crying, lethargy/social withdrawal, stereotypic behavior, hyperactivity, and inappropriate speech. According to previous studies, this instrument allows to measure

these behavior problems and to evaluate treatment response.11 Notwithstanding, it does specifically assess behavioral repertoires associated with aggression, selfinjury, and stereotyped behaviors often observed in people with intellectual disability and requiring close monitoring.14 The availability of standardized instruments focusing on these behavior problems could help identify and treat these problems. In contrast, the absence of such instruments poses difficulties to many healthcare and education professionals.6,11 Differently from the ABC,11 the BPI-01 was specifically developed to assess aggression, self-injury, and stereotyped behaviors. The BPI-01 is aimed at people with intellectual disability and severe psychiatric disorders of different ages and adaptive functioning levels.1 BPI-01 items were developed based on literature reviews of other reference instruments, which helped compose its scales (self-injurious behavior, stereotyped behavior, and aggressive behavior).15 The present study was motivated by the need still observed in Brazil for standardized instruments to assess specific behavior problems. The objectives of the study were divided into two stages, as follows: 1) to describe the translation and cultural semantic adaptation of the BPI-01 into Brazilian Portuguese; and 2) to describe preliminary indicators of instrument validity. The first page involved translation, back-translation, and conceptual review of the instrument. The second stage assessed preliminary indicators of internal consistency, convergent validity, sensitivity and specificity of the adapted instrument. Psychometric data are considered preliminary due to the small sample size analyzed.

Method Data collection The present study was approved by the Research Ethics Committee of Universidade Presbiteriana Mackenzie (protocol no. CEP/UPM no. 1219/04/2010 and CAAE no. 0027.0.272.000-10). The author of the original version of the BPI-01 authorized the translation and cultural adaptation of the instrument into Brazilian Portuguese. Data collection was conducted in two stages. In the first page, the instrument was translated into Brazilian Portuguese, back-translated into English, and then each item was conceptually revised to generate the final writing of the Brazilian version of the inventory. In the second stage, a pilot study was conducted to assess preliminary indicators of validity of the adapted instrument.

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Translation protocol

Instruments

Data obtained during instrument translation, backtranslation, and conceptual review were analyzed according to the recommendations of Pasquali21 for psychological scales. Translation and back-translation were performed independently by bilingual professionals with expertise in development and developmental disorders. Following translation, the inventory was backtranslated into English. Finally, each item comprising the inventory was subjected to conceptual review to compare translated and back-translated items against the original version of the instrument. This step was carried out with the participation of the two translators involved and the group of authors. The clarity and objectivity of each item included in the resulting Portuguese version was also

All the scales used in the study are described below. Wechsler Intelligence Scales for Children Aged 6-16 (WISC-III)16 and Wechsler Intelligence Scales for Adults over Age 16 (WAIS-III).17 These scales were used to assess mental disability and/or normal intelligence development in the groups. The participants’ intelligence quotient (IQ) was calculated based on results obtained with the block design and vocabulary subtests.18,19 Translated Brazilian version of the BPI-01.1 This questionnaire was answered by the caretakers. The BPI01 includes 52 items divided into three scales covering three types of behavior problems. The translated, adapted version of the instrument resulting from the

evaluated by a focal group lasting for approximately 1 hour and including eight mothers of children with atypical development. The final Brazilian Portuguese version of the BPI-01 is presented in Appendix 1.

first stage of the study as described below was used. Each behavior problem item was rated according to its frequency (never = 0, monthly = 1, weekly = 2, daily = 3, hourly = 4) and severity (mild = 1, moderate = 2, severe = 3). The self-injurious behavior scale includes 14 items; the stereotyped behavior scale, 24; and the aggressive/ destructive behavior scale, 11 items. The caretaker is asked to rate only those behaviors that have occurred at least once over the past 2 months. In addition to the behaviors described, each scale includes one item where the informer can report any other behavioral problems not covered by the instrument. Brazilian version of the CBCL/6-18.12 This instrument was also answered by the caretakers, with a focus on the children’s behavior in the past 6 months. The CBCL/6-18 assesses different competences in the areas of activities, social relationship, and academic performance, and also covers behavior problems through different scales. Raw scores are converted into standardized T scores according to the child’s/adolescent’s age and

Participants A total of 60 children and adolescents aged 6 to 18 years and their caretakers (parents and/or guardians) were included. The only caretaker inclusion criterion was being with the child for at least 6 hours daily. Children were divided into two groups paired by sex and age. One group included 30 children and adolescents with atypical development and different developmental disorders diagnosed by pediatric neurologists and geneticists. Of these, 22 attended regular schools and eight attended special schools. The other group comprised 30 children and adolescents with typical development and no mental disability. Overall characteristics of both groups are presented in Table 1.

Table 1 – Overall characteristics of participants according to age, type of development, and diagnosis

Group/diagnosis

Male Female

Atypical development (n = 30) (mean age: 11.3±2.9) Williams syndrome 9 Autism 4 Down syndrome 1 Prader-Willi syndrome 4 Idiopathic mental retardation 1 Typical development (n = 30) (mean age: 11.4±2.8) No disorder 19 Total (n = 60) 38

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9 0 1 1 0 11 22

Validation of Brazilian version of the BPI-01 – Baraldi et al.

sex.12 These T scores, in turn, allow to classify behavioral profiles into three categories, namely, normal, threshold, and clinical. The behavior problems assessed by the CBCL/6-18 include syndrome-based scales for anxiety/ depression, withdrawal/depression, somatic complaints (this scale was excluded from the analysis), social problems, thought problems, attention problems, rulebreaking behavior, and aggressive behavior. In addition, the following scales are based on the Diagnostic and Statistical Manual of Mental Disorders (DSM): affective problems, anxiety problems, somatic problems, attention deficit/hyperactivity problems, oppositional defiant problems, and conduct problems. Other measures include internalizing problems (including anxiety/depression, somatic complaints, and withdrawal/depression), externalizing problems (rule-breaking behavior and aggressive behavior), and the total emotional/behavioral problem scale.12 This inventory was included in our study to assess preliminary indicators of the validity of the Brazilian version of BPI-01, as the internalizing, externalizing, and total problem scales contain items that measure constructs similar to those of the BPI-01, e.g., self-injury, stereotyped repetitive movements, odd behaviors, cruelty, destructive behavior, and aggressive behavior towards others, among others. Autism Screening Questionnaire (ASQ).20 This questionnaire includes 40 questions organized into the following scales: reciprocal social interaction, social communication, and repetitive stereotyped behavior. Questions are closed and each can be scored with 0 (behavior absent) or 1 (behavior present). A score of 15 is considered the cutoff point for the presence of invasive development or autism spectrum disorders, and a score of 22 is considered enough to diagnose autism. The questionnaire should be answered by the parents or guardians of individuals aged 4 years or older with suspected autism spectrum disorders.20 The ASQ includes items that are compatible with those present in the BPI01 for the assessment of stereotyped behaviors, e.g., mannerisms, odd ways of moving hands and/or fingers, moving parts of the body, etc. This questionnaire was included so that we could assess preliminary indicators of validity of the Brazilian Portuguese version of the BPI-01.

Data analysis Internal consistency was measured using Cronbach’s alpha coefficients, with item-total correlation and alpha coefficient (in case an item had to be excluded). Coefficients were interpreted as follows: alpha values above 0.80 were considered desirable; values between 0.60 and 0.80 were considered recommended for clinical practice; and values below 0.60 were considered

acceptable for use in research only (not recommended for clinical practice). As a result, any alpha value above 0.60 was interpreted to indicate satisfactory internal consistency within the scope of the present study.22 The occurrence of behavior problems in the group with atypical development vs. the control group was compared using the nonparametric Mann-Whitney test, with significance set at p < 0.05. This nonparametric test was used because the requirements for the use of parametric tests were not met, i.e., the measures employed did not show a normal distribution and were not of interval, as they resulted from the conversion of Likert scales into scores. Because of our small sample size, in this analysis we chose to dichotomize the frequency of behavior problems assessed by the BPI-01 into 1 and 0, with score 1 accounting for the presence of behaviors monthly, weekly, daily, and hourly, and 0 accounting for the absence of behaviors (never). Convergent validity was assessed using Spearman’s correlation coefficient, comparing BPI-01 scores vs. ASQ and CBCL/6-18 scores. Results showing p < 0.05 were considered statistically significant. Sensitivity and specificity were assessed using the receiver operating characteristic (ROC) curve for different frequency cutoff points. This measure was used to distinguish between children in the atypical development group and those in the other group. For this analysis, dichotomized mean scores obtained in each of the three scales comprising the BPI-01 were calculated, followed by calculation of the arithmetic mean of each scale of the BPI-01.

Results Translation, back-translation, and conceptual review During conceptual review of the translated and back-translated versions in comparison with the original version of the instrument, three non-compatible items were identified in the back-translated version of the stereotyped behavior scale. In two of them, the translation choice was maintained, but in the third case and adaptation was deemed necessary, as follows: the original “Spinning own body” was translated as “Girar o próprio corpo” and back-translated as “Spinning,” however the translated version was maintained as was; the original “Maintaining bizarre body postures” was translated as “Manter posturas corporais estranhas” and back-translated as “Maintain weird body postures,” but again the final translated version was maintained as was; conversely, the original item “Gazing at hands or objects” was translated as “Esfregar-se” and back-translated as

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“Gaze steadily at one’s hands or objects” – this item was adapted and rendered in the final translated version as “Esfregar-se com as mãos ou com objetos.” Mothers taking part in the focal group considered unclear item 5 of the self-injurious behavior scale. In the original English version, this item was rendered as “Vomiting and rumination (deliberate regurgitation of swallowed food with rumination).” Following the backtranslation and conceptual review stages, this item was presented in Brazilian Portuguese as “Vomitar e ruminar, vômito deliberado da comida ingerida com ruminação.” Based on the considerations made in the focal group, it was rewritten and rendered as “Vomitar e ruminar, regurgitar de propósito comida ingerida com ruminação.”

Pilot study for the preliminary assessment of internal consistency, convergent validity, sensitivity, and specificity of the translated instrument Preliminary indicators of internal consistency (instrument reliability) revealed a Cronbach’s alpha of 0.65 in the self-injurious behavior scale. Item-total correlations were low to moderate overall, which may explain the relatively low coefficient obtained, probably a result of the great variety of behaviors included in this category. In the stereotyped behavior scale, Cronbach’s alpha was 0.91, revealing adequate internal consistency. Finally, the Cronbach’s alpha coefficient obtained for the aggressive/destructive behavior scale was 0.82, also satisfactory. Assessment of mental disability and/or normal intelligence development using the WISC-III16 and WAIS-III17 allowed to identify two samples, namely, one without mental disability and the other with mental disability of varying degrees according to the DSM-IV, i.e., IQ below 80 (compatible with the classification of intellectually disabled).23 The number of participants with intellectual disability was distributed as follows in the atypical development group: six children showed moderate mental disability (mean IQ = 47.8), 18 mild mental disability (mean IQ = 60.9), two children had borderline mental disability (mean IQ = 77), and four children showed a mean IQ value of 82.7, corresponding to absence of mental disability but intelligence below the average. The 30 children with typical development presented IQ values ranging from 80 to 129 (mean = 122.3), corresponding to absence of mental disability. Comparison of behavior problems between the two groups revealed that all frequency means obtained in the BPI-01 scales were higher in the group with mental disability than in the group without disability, pointing to a higher number of behavior problems in the former

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Table 2 – Mean frequency and severity of behavior problems in the two groups (n = 30 each)

BPI-01 scales/groups

Mean ± SD

Self-injurious behaviors Frequency Atypical 1.73±1.62 Typical 0.07±0.25 0.001 Severity Atypical 1.73±1.62 Typical 0.07±0.25 0.001 Stereotyped behaviors Frequency Atypical 3.43±4.52 Typical 0.07±0.37 0.001 Severity Atypical 3.43±4.52 Typical 0.07±0.37 0.001 Aggressive/destructive behaviors Frequency Atypical 1.57±2.18 Typical 0.20±0.76 0.002 Severity Atypical 1.57±2.18 Typical 0.20±0.76 0.002 BPI-01 = Behavior Problems Inventory; SD = standard deviation. Mann-Whitney nonparametric test.

group, with statistically significant differences in terms of both frequency and severity of the problems assessed (Table 2). Table 3 shows Spearman’s correlation coefficients obtained for BPI-01 scores vs. ASQ and CBCL/6-18 scores. Preliminary indicators of convergent validity of the BPI-01 in relation to the ASQ revealed adequate coefficients for the self-injurious and stereotype behavior scales, whereas the aggressive/destructive behavior scale showed poorer correlations. With regard to the CBCL/6-18, most scales showed positive and statistically significant correlations with BPI-01. Sensitivity and specificity, analyzed based on the area under the ROC curve, yielded values of 0.86 for the self-injurious behavior scale, 0.88 for the stereotyped behavior scale, and 0.70 for the aggressive/destructive behavior scale. Preliminary results of the pilot study conducted to establish possible cutoff points to differentiate between the groups are shown in Table 4. In all scales, a frequency of 0.5 was the one that best allowed to distinguish between the group with atypical development and the control group, with 80% sensitivity and 3% specificity in the stereotyped behavior scale, 50% sensitivity and 10% specificity in the aggressive/ destructive behavior scale, and 76% sensitivity and 6% specificity in the self-injurious behavior scale.

Validation of Brazilian version of the BPI-01 – Baraldi et al.

Table 3 – Spearman correlation coefficients between BPI-01, ASQ, and CBCL/6-18 scores

BPI-01 - Self- injurious behaviors

BPI-01 - Stereotyped BPI-01 - Aggressive/ behaviors destructive behaviors

Rho p Rho p Rho p

ASQ 0.42 < 0.001 0.49 < 0.001 0.28 0.03 CBCL/6-18 Syndrome-based scales Anxiety/depression 0.47 < 0.001 0.47 < 0.001 0.13 NS Withdrawal/depression 0.38 0.003 0.46 < 0.001 0.38 0.011 Social problems 0.64 < 0.001 0.73 < 0.001 0.45 < 0.001 Thought problems 0.68 < 0.001 0.77 < 0.001 0.47 < 0.001 Attention problems 0.64 < 0.001 0.72 < 0.001 0.46 < 0.001 Rule-breaking behavior 0.42 0.001 0.45 < 0.001 0.32 0.012 Aggressive behavior 0.55 < 0.001 0.54 < 0.001 0.50 < 0.001 DSM-oriented scales Affective problems 0.51 < 0.001 0.52 < 0.001 0.23 NS Anxiety problems 0.53 < 0.001 0.57 < 0.001 0.27 0.035 Attention deficit/hyperactivity problems 0.57 < 0.001 0.61 < 0.001 0.42 0.001 Oppositional defiant problems 0.46 < 0.001 0.42 < 0.001 0.31 0.014 Conduct problems 0.41 0.001 0.48 < 0.001 0.53 < 0.001 ASQ = Autism Screening Questionnaire; BPI-01 = Behavior Problems Inventory; CBCL/6-18 = Child Behavior Checklist for Ages 6-18; DSM = Diagnostic and Statistical Manual of Mental Disorders; NS = non-significant.

Table 4 – Sensitivity and specificity (ROC curve) considering frequencies of behaviors assessed in the BPI01 (cutoff points to distinguish between children with typical vs. atypical development)

BPI-01 scales

Behavior frequency cutoff points

Stereotyped behaviors Aggressive/destructive behaviors Self-injurious behaviors

Sensitivity

Specificity

0.50 0.80 0.03 1.50 0.40 0.03 2.50 0.33 0.00 3.50 0.30 0.00 6.00 0.23 0.00 8.50 0.16 0.00 10.00 0.13 0.00 11.50 0.06 0.00 14.50 0.03 0.00 18.00 0.00 0.00 0.50 0.50 0.10 1.50 0.33 0.03 2.50 0.26 0.03 3.50 0.23 0.03 4.50 0.10 0.00 5.50 0.06 0.00 7.00 0.03 0.00 9.00 0.00 0.00 0.50 0.76 0.06 1.50 0.43 0.00 2.50 0.30 0.00 4.00 0.10 0.00 5.50 0.03 0.00 7.00 0.00 0.00

BPI-01 = Behavior Problems Inventory; ROC = receiver operating characteristic.

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Discussion In the first stage of this study, which consisted of the translation and back-translation of the BPI-01, most of the back-translated items were equivalent to their original versions in English. Results of the focal group were positive with regard to the conceptual review undertaken, as only one item raised doubts, whereas all the remainder were adequately understood by participating mothers. Assessment of instrument reliability based on Cronbach’s alpha coefficients showed adequate indicators of internal consistency for two of the scales comprising the BPI-01, namely, stereotyped behaviors and aggressive/destructive behaviors, and acceptable ones for the third scale, self-injurious behavior scale. It is possible that our small sample size has caused aggressive/destructive behaviors to vary greatly and, as a result, show poor internal consistency. This hypothesis should be confirmed in future studies conducted in Brazil with larger samples (for instance, Lundqvist4 assessed 915 subjects with intellectual disability and observed better internal consistency indicators for the BPI-01, also using Cronbach’s alpha coefficients). Inter-group comparison revealed a higher number of behavior problems in the atypically developing group, which is compatible with previous findings.24 In addition, as also described by Rojahn et al.,1 stereotyped and selfinjurious behaviors were more frequent in the group of atypically developing children. Convergent validity indicators based on the analysis of correlations between BPI-01 and ASQ scores showed that only self-injurious and stereotyped behaviors as assessed by the BPI-01 showed moderate coefficients with the ASQ. Different results were observed for the aggressive/destructive behavior scale, where a low correlation was found. To some extent, we did not expect to find moderate correlations among all scales, as not all the constructs measured by the BPI-01 are also found in the ASQ (for example, the latter does not include items specifically directed at the assessment of aggression). Notwithstanding, the ASQ includes items that assess self-injurious and stereotyped behaviors, both gestural and verbal, which may have contributed to the higher correlations obtained for a mean frequency of 0.50 in the self-injurious behavior and especially in the stereotyped behavior scales of the BPI-01. Convergent validity between CBCL/6-18 and BPI01 scores revealed positive, statistically significant correlations for most scales. The CBCL/6-18 has been used to describe behavioral profiles of children with developmental disorders and mental or intellectual disability.25-29 Based on the correlations found, we could

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argue that the presence of behavior problems identified by the BPI-01 may suggest the presence of other behavior problems assessed by the CBCL/6-18. The ROC curve, more precisely the area under the curve, was used in an attempt to identify cutoff points to differentiate between children with typical and atypical development. A test is sensitive when it is able to detect individuals with a given characteristic. Specificity, in turn, for diagnostic purposes, refers to the test’s ability to accurately detect the absence of a diagnosis. Taking into consideration that no data are currently available on the sensitivity and specificity of the English, original version of the BPI-01,1 the present ROC analyses indicate possible cutoff points to distinguish between behavior problems in children with typical vs. atypical development (despite the preliminary nature of such analyses given our small sample size). We should also emphasize that the values here assessed reflect dichotomized mean scores obtained for each scale. Of the three scales comprising the BPI-01, the selfinjurious behavior scale was the one with the highest specificity. Indeed, these are behavioral problems more frequently observed in people with atypical development or chronic psychotic disorders.30-32 Future studies are warranted to assess larger samples, broader age ranges, levels of education, as well as other types of neurobehavioral developmental disorders. Future studies should include larger samples and calculate correlations for the frequency and severity of each behavior problem. On the one hand, aggressive behaviors may occur rarely but with extreme severity; on the other, it is possible to find reports of frequent episodes of self-biting, however of mild severity. Because the BPI-01 evaluates behavior considering these two criteria (frequency and severity), it can help in the decision-making process, favoring more objective treatment decisions based on individual needs.1

Conclusion Within the goal of producing a Brazilian Portuguese version for the BPI-01, the conceptual review of all items after their translation and back-translation allowed to check back-translated items against the regional scale and make adjustments where necessary. Moreover, the focal group contributed to further adapting the instrument and making it accessible to the caretakers of children with atypical development included in the pilot study. Application of this new, adapted version to a small sample showed that the correlation between BPI01, CBCL/6-18, and ASQ scores was adequate, i.e.,

Validation of Brazilian version of the BPI-01 – Baraldi et al.

that preliminary convergent validity indicators were acceptable. Notwithstanding, future studies should be conducted to identify other psychometric indicators. In addition, the ROC curve here obtained revealed that self-injurious behavior problems were the ones that best allowed to differentiate between children with typical and atypical development. In the other two scales, in turn, cutoffs were higher and did not show a satisfactory relationship between sensitivity and specificity. Future studies with larger and more heterogeneous samples are warranted to validate and further standardize the instrument for use in the Brazilian population. These studies will allow to assess the influence of other factors (e.g., age, education level, sex, intelligence level, adaptive functioning, psychosocial stimulation, type of developmental disorder, and speech abilities, among others) on the presence of behavior problems, especially self-injurious and stereotyped behaviors, in children with both typical and atypical development.

References 1. Rojahn J, Matson JL, Lott D, Esbensen AJ, Smalls Y. The Behavior Problems Inventory: an instrument for the assessment of self-injury, stereotyped behavior and aggression/destruction in individuals with developmental disabilities. J Autism Dev Disord. 2001;31:577-88. 2. American Academy of Pediatrics, Committee on Children With Disabilities. Developmental surveillance and screening of infants and young children. Pediatrics. 2001;108:192-6. 3. González ML, Dixon DR, Rojahn J, Esbensen AJ, Matson JL, Terlonge C, et al. The Behavior Problems Inventory: reliability and factor validity in institutionalized adults with intellectual disabilities. J Appl Res Intellect Disabil. 2009;22:223-35. 4. Lundqvist LO. Psychometric properties and factor structure of the Behavior Problems Inventory (BPI-01) in a Swedish community population of adults with intellectual disability. Res Dev Disabil. 2011;32:2295-303. 5. Smith KR, Matson JL. Behavior problems: differences among intellectually disabled adults with co-morbid autism spectrum disorders and epilepsy. Res Dev Disabil. 2010;31:1062-9. 6. Mayfield KL, Forman SG, Nagle RJ. Reliability of the AAMD adaptive behavior scale-public school version. J Sch Psychol. 1984; 22:53-61. 7. Reiss S. Comments on the Reiss screen for maladaptive behaviour and its factor structure. J Intellect Disabil Res. 1997;41:346-54. 8. Matson JL, Bamburg JW. Reliability of the assessment of dual diagnosis (ADD). Res Dev Disabil. 1998;19:89-95. 9. Lam KS. The Repetitive Behavior Rating Scale - Revised: independent validation and the effects of subject variables [dissertation]. Columbus: The Ohio State University; 2004. 10. Yudofsky SC, Silver JM, Jackson W, Endicott J, Williams D. The Overt Aggression Scale for the objective rating of verbal and physical aggression. Am J Psychiatry. 1986;143:35-9. 11. Losapio MF, Silva LG, Pondé MP, Novaes CM, Santos DN, Argollo N. Adaptação transcultural parcial da escala Aberrant Behavior Checklist (ABC), para avaliar eficácia de tratamento em pacientes com retardo mental. Cad Saude Publica. 2011;27:909-23. 12. Achenbach TM, Rescorla LA. Manual for the ASEBA School-Age Forms & Profiles. Burlington: University of Vermont; 2001. 13. Bordin IA, Mari JJ, Caeiro MF. Validação da versão brasileira do Child Behavior Checklist (CBCL) (Inventário

de Comportamentos da Infância e Adolescência): dados preliminares. Rev ABP-APAL. 1995;17:55-66. 14. de Winter CF, Jansen AA, Evenhuis HM. Physical conditions and challenging behaviour in people with intellectual disability: a systematic review. J Intellect Disabil Res. 2011;55:675-98. 15. Hill J, Powlitch S, Furniss F. Convergent validity of the aberrant behavior checklist and Behavior Problems Inventory with people with complex needs. Res Dev Disabil. 2008;29:45-60. 16. Wechsler D. WISC-III: Escala de inteligência Wechsler para crianças. Manual. São Paulo: Casa do Psicólogo; 2002. 17. Nascimento E. Adaptação, validação e normatização do WAIS-III para uma amostra brasileira. In: David Wechsler, orgs. WAIS-III: manual para administração e avaliação. São Paulo: Casa do Psicólogo; 2004. 18. Wagner F, Trentini CM. Estratégias de avaliação rápida da inteligência através das Escalas Wechsler. Rev Neuropsicol Latinoam. 2010;2:47-54. 19. Mello CB, Argollo N, Shayer BP, Abreu N, Godinho K, Durán P, et al. Versão abreviada do WISC-III: correlação entre QI estimado e QI total em crianças brasileiras. Psicol Teor Pesq. 2011;27:149-155. 20. Berument SK, Rutter M, Lord C, Pickles A, Bailey A. Autism screening questionnaire: diagnostic validity. Br J Psychiatry. 1999;175:444-51. 21. Pasquali L. Princípios de elaboração de escalas psicológicas. Rev Psiquiatr Clin. 1998;25:206-13. 22. Sampieri RH, Collado CF, Lucio PB. Metodologia de pesquisa. São Paulo: McGraw-Hill; 2006. 23. American Psychiatric Association. Manual Diagnóstico e Estatístico de Transtornos Mentais (DSM-IV). 4ª ed. Porto Alegre: Artes Médicas; 2002. 24. Brosnan J, Healy O. A review of behavioral interventions for the treatment of aggression in individuals with developmental disabilities. Res Dev Disabil. 2011;32:437-46. 25. Mesquita ML, Brunoni D, Neto JM, Kim CA, Melo MH, Teixeira MC. Fenótipo comportamental de crianças e adolescentes com síndrome de Prader Willi. Rev Paul Pediatr. 2010;28:63-9. 26. Teixeira MC, Monteiro CR, Velloso Rde L, Kim CA, Carreiro LR. Behavioral and cognitive phenotype of children and adolescents with Williams-Beuren syndrome. Pro Fono. 2010;22:215-20. 27. Hartley SL, Sikora DM, McCoy R. Prevalence and risk factors of maladaptive behaviour in young children with Autistic Disorder. J Intellect Disabil Res. 2008;52:819-29. 28. Douma JC, Dekker MC, Verhulst FC, Koot HM. Self-reports on mental health problems of youth with moderate to borderline intellectual disabilities. J Am Acad Child Adolesc Psychiatry. 2006;45:1224-31. 29. Garzuzi Y. Comparação dos fenótipos comportamentais de crianças e adolescentes com síndrome de Prader-Willi, síndrome de Williams-Beuren e síndrome de Down [dissertação]. São Paulo: Universidade Presbiteriana Mackenzie; 2009. 30. Teixeira MC, Emerich DR, Orsati FT, Rimério RC, Gatto KR, Chappaz IO, et al. A description of adaptive and maladaptive behaviour in children and adolescents with Cri-du-chat syndrome. J Intellect Disabil Res. 2011;55:132-7. 31. Brown EC, Aman MG, Havercamp SM. Factor analysis and norms for parent ratings on the Aberrant Behavior ChecklistCommunity for young people in special education. Res Dev Disabil. 2002;23:45-60. 32. Dykens EM. Psychiatric and behavioral disorders in persons with Down syndrome. Ment Retard Dev Disabil Res Rev. 2007;13:272-78. Correspondence Profa. Maria Cristina Triguero Veloz Teixeira Centro de Ciências Biológicas e da Saúde Universidade Presbiteriana Mackenzie Rua da Consolação, 896, prédio 28, 1º andar, Consolação 01302-000 – São Paulo, SP – Brazil Tel./Fax: +55-11-2114-8707 E-mail: cris@teixeira.org Trends Psychiatry Psychother. 2013;35(3) – 205

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Anexo

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Trends

Original Article

in Psychiatry and Psychotherapy

Assessment of changes in nicotine dependence, motivation, and symptoms of anxiety and depression among smokers in the initial process of smoking reduction or cessation: a short-term follow-up study Avaliação de mudanças na dependência da nicotina, motivação e sintomas de ansiedade e depressão em fumantes no processo inicial de redução ou cessação do tabagismo: estudo de seguimento de curto prazo Luciana Rizzieri Figueiró,1 Cassandra Borges Bortolon,1 Mariana Canellas Benchaya,1 Nadia Krubskaya Bisch,1 Maristela Ferigolo,1 Helena Maria Tannhauser Barros,1 Denise Conceição Mesquita Dantas2

Abstract

Resumo

Introduction: The first days of a quit attempt represent an important challenge to long-term abstinence, especially because of the changes that take place over this period. Objective: To examine whether smokers who have recently changed their smoking behavior show changes in the intensity of nicotine dependence, motivational stage, or symptoms of anxiety and depression relative to smokers without recent changes in smoking behavior. Methods: Smokers attending a support group for smoking cessation in Porto Alegre, southern Brazil, were invited to participate. The program consisted of four weekly sessions. Smokers answered questionnaires covering intensity of nicotine dependence, stage of motivation, and symptoms of anxiety and depression at baseline and in the fourth week. Urine was collected at both time points, tested for cotinine concentration, and used to determine the final status of smokers. Results: Of the 54 smokers included in the study, 20 (37%) stopped smoking or decreased tobacco use. Both smokers who stopped or reduced tobacco use and those who did not change their behavior presented a decrease in nicotine dependence scores (p = 0.001). Conversely, only the smokers who changed behavior presented an increase in scores in the maintenance stage (p < 0.001). Conclusion: When modifying tobacco use, smokers face a difficult process, marked by several changes. A better understanding of these changes and their implications for treatment are discussed. Keywords: Smoking cessation, tobacco use disorder, motivation, anxiety, depression.

Introdução: Os primeiros dias de uma tentativa de parar de fumar representam um desafio importante para a abstinência a longo prazo, especialmente por causa das mudanças que ocorrem nesse período. Objetivo: Examinar se fumantes que mudaram recentemente seu hábito de fumar mostram mudanças na intensidade da dependência à nicotina, no estágio motivacional ou nos sintomas de ansiedade e depressão em comparação com fumantes sem mudanças recentes em seu hábito de fumar. Métodos: Fumantes participando de um grupo de apoio para a cessação do tabagismo em Porto Alegre, sul do Brasil, foram convidados a participar do estudo. O programa consistia de quatro sessões semanais. Os fumantes responderam a questionários que avaliaram a intensidade da dependência à nicotina, o estágio motivacional e sintomas de ansiedade e depressão no início do programa e na 4ª semana. Amostras de urina foram coletadas nos dois momentos para avaliar a concentração de cotinina para determinar o status final dos fumantes. Resultados: Dos 54 fumantes incluídos no estudo, 20 (37%) pararam de fumar ou reduziram o uso de tabaco. Tanto os fumantes que pararam ou reduziram o uso de tabaco quanto aqueles que não mudaram seu hábito apresentaram diminuição nos escores de dependência à nicotina (p = 0,001). Por outro lado, apenas os fumantes que mudaram seu hábito apresentaram aumento nos escores do estágio de manutenção (p < 0,001). Conclusão: Ao modificar o uso de tabaco, os fumantes enfrentam um processo difícil, marcado por várias mudanças. Um melhor entendimento dessas mudanças e suas implicações para o tratamento são discutidas. Descritores: Abandono do hábito de fumar, transtorno por uso de tabaco, motivação, ansiedade, depressão.

VIVAVOZ Call Center, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil. 2 UFCSPA, Porto Alegre, RS, Brazil.

Financial support: Secretaria Nacional de Políticas sobre Drogas (SENAD) and Associação Mário Tannhauser de Ensino, Pesquisa e Assistência (AMTEPA). HMTB receives a 1C Research Productivity Grant from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Submitted Nov 06 2012, accepted for publication Feb 25 2013. No conflicts of interest declared concerning the publication of this article. Suggested citation: Figueiró LR, Bortolon CB, Benchaya MC, Bisch NK, Ferigolo M, Barros HM, et al. Assessment of changes in nicotine dependence, motivation, and symptoms of anxiety and depression among smokers in the initial process of smoking reduction or cessation: a short-term follow-up study. Trends Psychiatry Psychother. 2013;35(3):212-20.

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Changes associated with smoking reduction or cessation â&#x20AC;&#x201C; FigueirĂł et al.

Introduction Tobacco smoking is the leading cause of preventable death worldwide, whereas quitting smoking is an effective way to prevent many diseases and premature mortality.1 An increasingly large body of information about the harms of smoking and a greater availability of treatment programs has led to a growing effort among smokers to quit, however more than 95% of smoking cessation efforts fail within a year.2 Moreover, even though more than 70% of smokers report that they are interested in quitting, most continue smoking.3 One factor that may hinder smoking cessation is the presence of depression symptoms and anxiety. The positive reinforcing effects of nicotine may improve mood, cognition, and anxiety. Abstinence, in turn, may exacerbate these symptoms. Despite the higher prevalence of anxiety and depression in smokers, studies conducted with Brazilian populations have been unsuccessful to demonstrate the association between these symptoms and failure to stop smoking.4,5 In order for a smoker to quit, nicotine dependence needs to be counterbalanced by a high degree of motivation to stop smoking. Because smoking cessation may be a very difficult goal for those unable or unwilling to quit smoking, a reduction in cigarette consumption can be an initial step towards changing behavior and achieving complete abstinence.6-8 Smoking reduction may increase the chance of future cessation because it reduces dependence, discontinues conditioning, and increases self-efficacy.8,9 Thus, reduced tobacco use signals that the smoker is motivated to change, and should therefore be considered a positive outcome.7 About two-thirds of the smokers trying to quit fail in the first week. This rate is similar for both treated10 and untreated smokers.2,11 The first days post-quit day seem to be the most difficult ones, because, in addition to learning a new behavior, smokers have to cope with withdrawal symptoms and cognitive and emotional difficulties.12 Notwithstanding, resisting smoking in the first moments after quitting is essential, as these symptoms tend to remain stable.13 Smokers who manage to remain abstinent and survive the first days without tobacco are more likely to succeed in the long term11,14 and less likely to have lapses or to relapse,10 probably because they feel encouraged and motivated.2,10 Conversely, it is very common, in the treatment setting, to have patients that stop attending therapeutic group activities or consultations because they have failed to quit smoking or have relapsed.15 In view of the above, most attempts to quit smoking fail prematurely, and our understanding of this process remains inaccurate. In this sense, a better understanding of the behavioral changes taking place

in the first days of a quit attempt is key to predicting early success and helping smokers who present more difficulties as early as possible. Moreover, achieving and maintaining tobacco abstinence may be compromised by biopsychosocial risk factors.16,17 Finally, the relationship between these changes and biochemical markers of exposure to tobacco, currently underestimated, may provide additional information on the changes taking place during the process of stopping or reducing smoking and determining abstinence or relapse. Therefore, the objective of this study was to examine whether smokers attending a support group for smoking cessation and showing recent changes in their smoking behavior (quitting or reducing consumption) also show changes in measures such as intensity of nicotine dependence, motivational stage, and anxiety and depression symptoms, when compared to smokers that did not change their smoking habits.

Methods Procedures This short-term cohort study was conducted in a freeof-charge program for smoking cessation between July 2007 and November 2009. The program consisted of four weekly group meetings involving 8 to 12 participants and led by health professionals trained in cognitivebehavioral and motivational interviewing methods. Each session lasted for about 2 hours and was structured so as to provide information about the consequences of cigarette smoking, methods for quitting, stages of change, benefits of cessation, tobacco withdrawal symptoms, coping strategies, and relapse prevention. In each session, the participants received written materials structured according to the American Cancer Society18 and the Brazilian National Cancer Institute.19 At the beginning of the first session, participants were asked to sign an informed consent form. Subsequently, they answered a self-administered questionnaire covering sociodemographic characteristics, smoking history, nicotine dependence, motivational stages, and anxiety and depression symptoms. The second session focused on planning the quitting attempt and provided information on withdrawal signs and symptoms, risk situations, coping strategies, and relaxation exercises. In this session, the quit day for each participant was set. In the third session, difficulties faced during the attempt to stop smoking were approached, and strategies to maintain abstinence were reinforced. The last session focused on relapse prevention and reinforcement of skills and strategies for those who did not achieve abstinence.

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In the last session, participants filled out the same instruments used in the first session and were asked to inform whether they had stopped smoking, decreased tobacco use, or continued smoking the same amount of cigarettes. In addition to the questionnaires, urine samples were collected in the first and fourth sessions of the program and tested for cotinine. The Research Ethics Committee of Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) approved the study protocol (protocol no. 219/07).

Subjects Participants were male and female smokers aged at least 18 years living in Porto Alegre, southern Brazil. Smokers were recruited from the community by newspaper and radio advertisements of a study comprising a support group for smoking cessation. By telephone, smokers received a description of how the group sessions would be conducted; participation in a group session was scheduled if the smoker chose to participate. Groups were offered at different times, including outside office hours, and participants could choose what time worked best. The individuals included were current cigarette smokers, or smokers who had stopped within the last week, and who showed up on the scheduled date. Smokers under 18 years of age or those who reported current illicit drug use, nicotine replacement therapy, bupropion treatment, presence of debilitating conditions that could interfere with group participation, as well as those who provided incomplete data on the questionnaires, preventing data analysis, were excluded from the sample. A total of 183 smokers attended the first session. After application of our inclusion and exclusion criteria, 163 smokers were enrolled in the study. Only two

Assessed for eligibility (n = 183)

Enrollment (n = 163)

Attended first session (n = 163)

smokers had quit smoking before starting the support group, and they were not more than 7 days abstinent. Only 54 smokers (33.1%) completed the four sessions of the study. Figure 1 shows the patient selection process and dropout rates.

Measures Nicotine dependence. The intensity of nicotine dependence was measured using the Fagerström Test for Nicotine Dependence (FTND),20,21 which comprises six questions related to smoking. Summing the results of all questions provided a total score ranging from 0 to 10 points, with higher scores indicating higher nicotine dependence. Motivational stage. The motivational stage was measured by the University of Rhode Island Change Assessment Scale (URICA)22,23 and the Contemplation Ladder.24,25 URICA assesses the degree to which participants are willing to change their smoking behavior by asking whether they agree or disagree with certain presented statements. Responses are rated using a Likert scale. Based on the answers, one can evaluate scores for the stages of precontemplation, contemplation, action, and maintenance, as well as calculate a total score by adding the mean scores obtained for contemplation, action, and maintenance, and subtracting the mean score of the precontemplation subscale. The Contemplation Ladder, used in a brief form, presented five statements, and participants had to indicate the statement that best characterized their thinking in relation to smoking at the time. According to the statement chosen, a score raging from 0 to 10 was assigned to each response, with higher scores indicating higher motivation. Anxiety symptoms. The Beck Anxiety Inventory (BAI) comprises 21 items describing various symptoms

Excluded (n = 20) Not meeting inclusion criteria (n = 2) Meeting exclusion criteria (n = 14) Bupropion or nicotine replacement therapy (n = 7) Illicit drug abuse (n = 6) Illiterate (n = 1) Questionnaire incomplete (n = 4)

Attended second session (n = 102) (adherence: 63%)

Attended fourth session (n = 54) (adherence: 33%) Figure 1 – Flowchart describing the selection of smokers and showing dropout rates in different sessions of the smoking cessation support group 214 – Trends Psychiatry Psychother. 2013;35(3)

Changes associated with smoking reduction or cessation – Figueiró et al.

of anxiety. Subjects marked the level of intensity of each symptom using a range of 0 to 3. The final score is obtained by summing all the items and matching that sum to a standardized severity level, as follows: minimum (0 to 11 points), mild (12 to 19), moderate (20 to 35), or severe (36 to 63).26,27 Depression symptoms. Symptoms of depression were assessed using the Beck Depression Inventory (BDI), a measure comprising 21 items and four response options for each item, ranging from 0 to 3, corresponding to increasing intensity of depression. The total score is obtained by summing individual scores and is used to classify between levels of depression, i.e., minimum (0 to 10 points), mild (11 to 19), moderate (20 to 30), or severe (31 to 63).27,28 Smoking status. When filling out the questionnaire in the fourth session, smokers classified themselves as having quit, reduced tobacco intake, or maintained intake based on recent smoking habits. To confirm selfreported smoking status, cotinine urine concentration was assessed at the pharmacology laboratory of the Basic Health Sciences Department of UFCSPA using the colorimetric technique as described by Peach et al.29 This method was chosen because it shows good sensitivity and specificity in distinguishing between smokers and nonsmokers. Moreover, the method is sensitive to changes in smoking behavior, as it measures the concentrations of cotinine and other nicotine metabolites.30,31 Cotinine has a half-life of approximately 20 hours,32 and it derives solely from the metabolism of tobacco.33 Even though more specific and sensitive methods are available, they are also more expensive, time-consuming, and often unavailable in clinical biochemistry laboratories in developing countries.30

Statistical analysis Baseline data were analyzed considering all enrolled smokers. Conversely, the analysis of changes in smoking behavior included only retained smokers, i.e., those who attended all four sessions of the support group. For the analysis of retained smokers, groups were created based on self-reported smoking habits, confirmed by cotinine concentrations in urine samples. As a result, smokers were divided into two groups: 1) smokers who kept smoking (similar cotinine urinary concentrations in the first and fourth sessions); and 2) smokers who completely quit smoking, or at least reduced tobacco intake (confirmed by a 40% or greater reduction in cotinine concentrations from the first to the fourth session). Because an expressive reduction in smoking can cause changes in many biopsychosocial factors, it was deemed appropriate to combine quitters

and reducers in the same group. Within each group, results were divided into baseline (first session) and final (fourth session) measures. The Kruskal-Wallis test or one-way analysis of variance (ANOVA) followed by Tukey’s test were used to assess differences in the variables between our four resulting groups. Association tests were performed using the chisquare test, and correlation tests were performed using Pearson’s or Spearman’s correlation coefficients. Missing data were excluded analysis by analysis. Statistical analyses were performed using the PASW Statistics version 18. Differences were considered significant when p < 0.05.

Results Table 1 shows the characteristics of the smokers included in the study, as well as characteristics of retained smokers, divided according to change in smoking habit reported and confirmed by urinary cotinine levels (smoking or abstinence/reduction) in the fourth week. The majority of enrolled smokers were female, married, with incomplete or complete high school (8 to 11 years of study), were employed or had some type of income. They also reported having one or more than one tobacco-related disease, being non-drinkers, and having attempted to quit smoking previously. These characteristics did not differ between retained or nonretained smokers (except for age) or between abstinent/ reduced smokers and non-quitting retained smokers. As usual, they started to smoke during adolescence. The level of depression was similar between non-retained and retained smokers (median = 12 [8-21] and 10 [7-17], respectively; p = 0.116), but anxiety levels were higher in non-retained smokers than in retained ones (median 13 [6-24] and 8 [4-13], respectively; p = 0.004). Intensity of nicotine dependence was positively correlated with baseline urinary cotinine concentrations (r = 0.364; p < 0.001). Cotinine levels rose in association with responses indicating greater nicotine dependence on FTND. Four questions of the FTND were able to predict differences in the biochemical marker (Table 2); time to first cigarette and number of cigarettes per day were the ones that best predicted urinary cotinine concentration. Testing at the fourth week of follow-up revealed a correlation between baseline urinary cotinine concentrations and the difference between final and baseline concentrations (r = -0.555, p < 0.001, Figure 2). The greatest changes in cotinine concentrations between the two tests were observed in smokers who had higher baseline concentrations. Statistical analysis showed that only FTND and maintenance stage (URICA scale) scores differed after

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attendance of the four sessions of the smoking cessation program (p = 0.001 and p < 0.001, respectively) (Table 3). Correlating these scores with differences in urinary cotinine concentrations revealed similar changes in both parameters, regardless of whether or not the smokers had changed their tobacco consumption habits (Figure 3).

The study also evaluated the authenticity of selfreported smoking status. Cotinine urinary concentrations showed that 61% (28/46) of the smokers reporting changes in their smoking habits had not actually reduced consumption, and that 25% (2/8) of the smokers denying changes showed a decrease in cotinine concentrations.

Table 1 – Demographic characteristics of the smokers included in the study, n (%)

Enrolled smokers

Retained smokers

Abstinence/ Total* Retained† Non-retained† Smoking† reduction† (n = 163) (n = 54) (n = 109) p (n = 34) (n = 20)

Gender Female 105 (64.4) 35 (33.3) 70 (66.7) 24 (68.6) 11 (31.4) Male 58 (35.6) 19 (32.8) 39 (67.2) 1.000 10 (56.6) 9 (47.4) 0.376 Marital status Single 35 (21.5) 8 (22.9) 27 (77.1) 5 (62.5) 3 (37.5) Married/living with a partner 81 (49.7) 31 (38.3) 50 (61.7) 19 (61.3) 12 (39.7) Divorced 33 (20.2) 9 (27.3) 24 (72.7) 6 (66.7) 3 (33.3) Widowed 14 (8.6) 6 (42.9) 8 (57.1) 0.291 4 (66.7) 2 (33.3)

0.989

Education (4 missing) ≤ 8 years 41 (25.1) 15 (36.6) 26 (63.4) 9 (60.0) 6 (40.0) 8-11 years 62 (38.0) 17 (27.4) 45 (72.6) 11 (64.7) 6 (35.3) > 11 years 46 (28.2) 18 (39.1) 28 (61.9) 0.633 12 (66.7) 6 (32.3)

0.762

Occupation (17 missing) Paid work 101 (61.7) 30 (29.7) 71 (71.3) 16 (53.3) 14 (47.7) Pensioner 20 (12.7) 9 (45.0) 11 (55.0) 6 (66.7) 3 (33.3) Housewife 16 (9.8) 5 (31.3) 11 (68.8) 5 (100.0) 0 (0.0) Others 9 (5.5) 2 (22.2) 7 (77.8) 0.544 2 (100.0) 0 (0.0)

0.175

Health conditions Drinking (3 missing) Quit attempt (3 missing) Age (mean ± SD)

1.000 0.161 0.754 0.226

114 (69.9) 39 (34.2) 75 (65.8) 70 (42.9) 25 (35.7) 45 (64.3) 127 (79.4) 38 (29.9) 89 (70.1) 49.2±11.4 47.6±12.2‡ 52.4±8.6

0.719 0.616 0.211 0.004

24 (61.5) 13 (52.0) 24 (63.2) 53.7±9.1

15 (38.5) 12 (48.0) 14 (36.8) 50.7±7.6

SD = standard deviation. * Percentages refer to the column. † Percentages refer to the total value (row). ‡ p < 0.01.

Table 2 – Urinary cotinine concentrations divided according to FTND responses (n = 163)

FTND question

Cotinine concentration

1. How soon after you wake up do you smoke

Within 30 minutes: After 31 minutes or more:

your first cigarette?†

16.5±1.1 µg/mL

10.3±0.9 µg/mL

< 0.001

2. Do you find it difficult to refrain from smoking in places where it is forbidden, etc.?*

Yes: 18.9±2.2 µg/mL

No: 12.9±0.8 µg/mL

0.014

The first one in the morning: All others: 14.7±1.1 µg/mL 14.9±1.4 µg/mL

0.907

3. Which cigarette would you hate most to give up? 4. How many cigarettes/day do you smoke?

11 or more: 15.6±1.0 µg/mL

10 or less: 9.3±1.6 µg/mL

0.009

5. Do you smoke more frequently during the first hours after waking than during the rest of the day?

Yes: 15.5±1.1 µg/mL

No: 14.1±1.2 µg/mL

0.412

6. Do you smoke if you are so ill that you are in bed most of the day?*

Yes: 15.9±1.1 µg/mL

No: 12.0±1.4 µg/mL

0.038

†

FTND = Fagerström Test for Nicotine Dependence. Cotinine concentrations expressed as mean ± standard error of mean. * p < 0.05. † p < 0.01.

216 – Trends Psychiatry Psychother. 2013;35(3)

Diference in urinary cotinine concentrations

Changes associated with smoking reduction or cessation – Figueiró et al.

10.0

-10.0

-20.0

.0 10.0 20.0 30.0 Baseline urinary cotinine concentrations (ug/ mL)

Figure 2 – Relationship between baseline urinary cotinine concentrations and the difference between final and baseline urinary cotinine concentrations in retained smokers (n = 54; r = -0.550, p < 0.001) Table 3 – Scores obtained for nicotine dependence, motivation, and comorbidity scales in the different groups of smokers

Baseline Final Abstinence/ Abstinence/ Smoking reduction Smoking reduction (n = 34) (n = 20) (n = 34) (n = 20)

Significance†

FDNT* 5 (4-7) 4.5 (4-7) 3 (1-5.25)a 1.5 (0-5) H = 16.14, p URICA-PC 12.6±3.4 10.8±3.2 11.5±3.3 11.7±5.0 F(3,102) = 1.185, URICA-C 29.9±2.6 29.9±3.1 29.4±3.1 30.3±4.0 F(3,102) = 0.379, URICA-A 28.4±3.1 28.0±4.6 28.2±3.0 29.4±4.3 F(3,102) = 0.628, URICA-M* 24.4±4.6b 19.8±6.1a,c,d 26.0±4.1b 25.0±5.7b F(3,102) = 6.892, URICA - Total 10.0±1.4 9.6±1.4 10.3±1.2 10.4±1.9 F(3,102) = 1.540, Contemplation Ladder 8.9±2.0 8.3±1.9 9.2±1.6 9.1±1.6 H = 4.748, p BAI 9 (5-15) 7 (4-12) 7.5 (4-16) 5 (1.5-12.5) H = 1.674, p BDI 12 (8-17) 8 (5-17) 10 (7-15) 5 (4-15) H = 7.011, p c,d

a,b

= 0.001 p = 0.319 p = 0.768 p = 0.599 p < 0.001 p = 0.209 = 0.191 = 0.643 = 0.072

BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; FTND = Fagerström Test for Nicotine Dependence; URICA = University of Rhode Island Change Assessment Scale (PC = precontemplation; C = contemplation; A = action; M = maintenance). Values expressed as mean ± standard deviation or median (25th-75th percentiles). Superscript letters are used to indicate differences between groups: a p < 0.05 compared to group baseline smoking; b p < 0.05 compared to group baseline abstinence/reduced smoking; c p < 0.05 compared to group final smoking; d p < 0.05 compared to group final abstinence/reduced smoking. * p < 0.05. † Letters H and F refer to the statistical test performed in each case: H = Kruskal-Wallis; F = one-way ANOVA.

B Difference in maintenance stages scores (URICA)

2 0 -2 -4 -6 -8 -10

-20.0

-10.0

10.0

Difference in urinary cotinine concentrations (ug/mL)

Smoking - - - - -

Abstinence / reduced smoking

5 -0 -5 -10

-15 -20.0 -10.0 .0 10.0 Difference in urinary cotinine concentrations (ug/mL)

Figure 3 – Relationship between differences in urinary cotinine concentrations and A) differences in the intensity of nicotine dependence in smokers according their situation (n = 54; r = 0.041, p = 0.82 [smoking]; r = 0.052, p = 0.827 [abstinence/ reduction]); B) differences in maintenance stage scores in smokers according their situation (n = 54; r = -0.026, p = 0.889 [smoking]; r = -0.028, p = 0.906 [abstinence/reduction])

Trends Psychiatry Psychother. 2013;35(3) – 217

Changes associated with smoking reduction or cessation – Figueiró et al.

The concordance of self-reported smoking status and urinary cotinine concentrations had a kappa index of 0.60, indicating only moderate agreement (p = 0.445). As a result, only 24 of the 54 retained smokers were able to correctly identify their final smoking status. The comparison between smokers’ self-reports and biochemical markers yielded an accuracy of 44% for self-report data.

Discussion The first days of an attempt to quit smoking represent an important challenge for long-term abstinence. This study found that more than 60% of the smokers are unable to achieve their goal of changing tobacco consumption patterns, even when they had fully attended a smoking cessation program. Worst of all, only 12% of those who attended the first program meeting were able to effectively stop or reduce smoking, either because they did not attend the whole program or because they did not remain abstinent. Better news is that, for smokers who were able to at least reduce the amount of tobacco smoked daily, the intensity of nicotine dependence decreased and scores of motivational maintenance increased. In the FTND scale, time to the first cigarette of the day and number of cigarettes smoked per day seemed to provide the best information for assessing intensity of nicotine dependence; data originating from these questions added appreciably to the prediction of biochemical levels of cotinine. In fact, some questionnaires use only these two questions to measure nicotine dependence, but the other questions contained in the FTND may serve to improve our understanding of smokers’ behaviors.21 Nicotine dependence is frequently pointed out as a powerful predictor of the failure to achieve abstinence. Smokers who do not quit usually have higher levels of nicotine dependence.34-36 In the same way, smokers who reach cessation are supposedly those who are less nicotine dependent. Nevertheless, our results do not corroborate these statements. Evidently, FTND scores decreased with the smokers’ attempts to reduce or quit smoking, indicating that they had changed something in their behavior and had consequently reduced their physical dependence. Unexpectedly, however, the smokers who maintained their usual consumption (as confirmed biochemically) also showed a decrease in their FTND scores. We also observed many smokers who claimed reduction or cessation of the habit, however not confirmed by urinary cotinine levels. Smokers who engaged in the program to quit smoking initiated the process of change by demonstrating their desire to quit smoking; however, they had not yet changed their behavior. One may think that the smokers saw themselves changing their habit (i.e., feeling abstinent or less dependent on tobacco), but their behavior

218 – Trends Psychiatry Psychother. 2013;35(3)

did not correspond to these expectations. Moreover, it is known that the dose of nicotine absorbed depends on the depth and frequency of puffs, and that smokers learn to titrate nicotine levels to manipulate plasma concentrations according to their needs.37 Thus, a slight decrease in the number of cigarettes smoked may not reflect a real decrease in nicotine exposure; this would explain the maintenance of urinary cotinine concentrations. Similar misclassification rates among self-reported tobacco users have been shown in different populations.38-41 The low accuracy of self-reported measures and the contradiction between such measures and biochemical measures underscore the great difficulty involved in quitting smoking, even when tobacco users are aware of the harmful effects of tobacco and of the need to change the habit. Finally, smokers may underreport smoking not to disappoint the health professional and to be socially accepted. Even though cotinine tests are not 100% accurate, they serve well to indicate changes in tobacco exposure. The more prominent decrease in cotinine concentrations among smokers with higher baseline levels is an empirically logical result, as higher initial concentrations allow for greater reductions. Data obtained with the URICA scale and the Contemplation Ladder showed that motivational scores remained stable regardless of whether the patient quit smoking. The exception to this was the maintenance stage of the URICA, whose scores increased for smokers who reduced or quit smoking. This increase demonstrates their commitment to remaining abstinent or smoking less. The association between advanced motivational stages and smoking reduction or cessation has been identified in previous studies,42,43 but not in our sample. Smokers who did not change their tobacco consumption presented higher baseline maintenance stage scores when compared to smokers who reduced tobacco consumption or quit, which suggests that even highly motivated smokers may not be fully ready to stop smoking. Similarly, Boardman et al.44 showed that smokers who did not manage to quit presented high levels of motivation and self-efficacy due to the hope of quitting in the next attempt. In this study, anxiety symptoms did not show a relationship with the cessation/reduction process. Our result diverges from others found in the literature that report higher numbers of anxiety symptoms in more dependent smokers, especially women, and a decreased anxiety among individuals who remain abstinent.16,45 This could be related to limitations of the study, including the small sample size and the short period of analysis. Moreover, another study by our group found that higher anxiety levels were associated with a lower probability of the smoker keeping the treatment.46 Here it is important to consider that we included in this analysis only

Changes associated with smoking reduction or cessation – Figueiró et al.

smokers who remained in the support group for 4 weeks, which may explain the lower anxiety levels observed. Zvolensky et al.47 pointed out that anxiety symptoms per se do not influence the chance of early smoking relapse, except in smokers with anxiety disorders. Investigation of depression symptoms and other variables related to the treatment showed a lower intensity of depression among the smokers who joined the treatment vs. those smokers who did not join the program. This means that high levels of depression may hinder treatment adherence48 and affect the process of smoking cessation in those who seek interventions to change their habit, heightening the probability of failure or relapse.49 Nicotine is known to act on neural circuits associated with affect regulation,50 and individuals will smoke to relieve feelings of sadness or negative affect, effectively using nicotine as a remedy for depression symptoms.51 As a result, quitting is more difficult for those who are depressed, who would have to learn a new skill to cope with sadness symptoms. Our results, however, did not uncover any differences among the groups in the periods analyzed, probably because the smokers who remained in treatment had low levels of depression symptoms to begin with. Despite the recognized efficacy of group therapy for smoking cessation, adherence to group programs is a barrier to tobacco control; 23% of the participants leave treatment within the first month, and around 45% leave it within 2 months.48,52 In our study, adherence to the support group was even lower, with only 33.1% of the individuals attending all the meetings over 1 month. Poor adherence is also a problem in group treatment of other addictions; for example, only around 20% of alcoholics in Brazil continue attending Alcoholics Anonymous meetings after 6 months of follow-up.53 Comparing the approaches used here with studies conducted in other countries may be disappointing, mainly due to intrinsic characteristics of support groups in Brazil. Usually, recruitment is carried out reactively, and the participation of patients is not subject to any kind of incentive, especially financial ones. The results of the present study should be considered with care. First, the small sample size, combined with the large number of dropouts, limits generalization of the findings. Also, we did not include a diagnostic assessment of past or present psychopathology or a more fine-grained analysis of the personal characteristics of patients, which may have interfered with smoking cessation. Also, the study included subjects who enrolled in a clinical setting, and therefore not be representative of all smokers. Smoking cessation is a dynamic process. The early period of cessation typifies a moment of personal challenge, as behaving in a new way requires effort and not overcoming withdrawal signs and symptoms may preclude immediate success. This work showed

that smokers who reduced or quit smoking, as well as those who did not change their habits, diminished the intensity of nicotine dependence, whereas only the ones who changed their habits raised their scores on the maintenance stage of the URICA scale. Whether the patients who did not reduce or quit tobacco smoking learned to report lower levels of dependence is a factor deserving further investigation. Greater knowledge about the motivation, dependence and comorbidity related to smoking will allow professionals to be better prepared to treat smokers, with more effective treatment plans and interference strategies tailored to these characteristics.

References 1. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008 – The MPOWER package. Geneva: WHO; 2008. http://www.who.int/tobacco/mpower/mpower_ report_full_2008.pdf. 2. Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction. 2004;99:29-38. 3. Carlini EA, Galduróz JC, Noto AR. II Levantamento domiciliar sobre o uso de drogas psicotrópicas no Brasil: estudo envolvendo as 108 maiores cidades do país – 2005. Brasília: Secretaria Nacional Antidrogas; 2007. 4. Azevedo RC, Fernandes RF. Factors relating to failure to quit smoking: a prospective cohort study. Sao Paulo Med J. 2011;129:380-6. 5. Lopes FL, Nascimento I, Zin WA, Valença AM, Mezzasalma MA, Figueira I, et al. Smoking and psychiatric disorders: a comorbidity survey. Braz J Med Biol Res. 2002;35:961-7. 6. Benowitz NL. Smoking less as a treatment goal for those who cannot stop smoking. Am J Med. 2004;116:203-5. 7. Peters EN, Hughes JR. The day-to-day process of stopping or reducing smoking: a prospective study of self-changers. Nicotine Tob Res. 2009;11:1083-92. 8. Stead LF, Lancaster T. Interventions to reduce harm from continued tobacco use. Cochrane Database Syst Rev. 2007;(3):CD005231. 9. Hughes JR, Carpenter MJ. Does smoking reduction increase future cessation and decrease disease risk? A qualitative review. Nicotine Tob Res. 2006;8:739-49. 10. Ferguson SG, Gitchell JG, Shiffman S, Sembower MA. Prediction of abstinence at 10 weeks based on smoking status at 2 weeks during a quit attempt: secondary analysis of two parallel, 10-week, randomized, double-blind, placebocontrolled clinical trials of 21-mg nicotine patch in adult smokers. Clin Ther. 2009;31:1957-65. 11. Powell J, Dawkins L, West R, Powell J, Pickering A. Relapse to smoking during unaided cessation: clinical, cognitive and motivational predictors. Psychopharmacology (Berl). 2010;212(4):537-49. 12. Weinberger AH, McKee SA, George TP. Changes in smoking expectancies in abstinent, reducing, and non-abstinent participants during a pharmacological trial for smoking cessation. Nicotine Tob Res. 2010;12:937-43. 13. Tomson T, Toftgard M, Gilljam H, Helgason AR. Symptoms in smokers trying to quit. Tob Induc Dis. 2006;3:44-58. 14. Herd N, Borland R, Hyland A. Predictors of smoking relapse by duration of abstinence: findings from the International Tobacco Control (ITC) Four Country Survey. Addiction. 2009;104:2088-99.

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15. Aguiar M, Todo-Bom F, Felizardo M, Macedo R, Caeiro F, Sotto-Mayor R, et al. Four years’ follow up at a smoking cessation clinic. Rev Port Pneumol. 2009;15:179-97. 16. McClave AK, Dube SR, Strine TW, Kroenke K, Caraballo RS, Mokdad AH. Associations between smoking cessation and anxiety and depression among U.S. adults. Addict Behav. 2009;34:491-7. 17. Mykletun A, Overland S, Aaro LE, Liabo HM, Stewart R. Smoking in relation to anxiety and depression: evidence from a large population survey: the HUNT study. Eur Psychiatry. 2008;23:77-84. 18. American Cancer Society. Freshstart. Georgia: ACS; 1996. 19. Brasil, Ministério da Saúde. Ajudando seu paciente a deixar de fumar. Rio de Janeiro: Instituto Nacional do Câncer; 1997. 20. Carmo JT, Pueyo AA. A adaptação do português do Fagerström Test for Nicotine Dependence (FTND) para avaliar a dependência e tolerância à nicotina em fumantes brasileiros. Rev Bras Med. 2002;58:73-80. 21. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The Fagerström Test for Nicotine Dependence: a revision of the Fagerström Tolerance Questionnaire. Br J Addict. 1991;86:1119-27. 22. Figlie NB. Metodologia de pesquisa em dependência química. In: XIV Congresso Brasileira de Alcoolismo, Tabagismo e Outras Dependências; Gramado, Brazil; 2001. 23. McConnaughy EA, Prochaska JO, Velicer WF. Stages of change in psychotherapy: measurement and sample profiles. Psychother Theory Res Pract. 1983;20:368-75. 24. Biener L, Abrams DB. The Contemplation Ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol. 1991;10:360-5. 25. Terra MB, da Silveira DX, Moreira TC, Ferigolo M, Mazoni C, Arena FX, et al. Convergent validation study of the Contemplation Ladder for application via telephone in tobacco users. J Bras Psiquiatr. 2009;58:143-9. 26. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56:893-7. 27. Cunha JA. Manual da versão em português das escalas Beck. São Paulo: Casa do Psicólogo; 2001. 28. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-71. 29. Peach H, Ellard GA, Jenner PJ, Morris RW. A simple, inexpensive urine test of smoking. Thorax. 1985;40:351-7. 30. Okayama A, Sato T. Assessment of smoking status among workers using an improved colorimetric method. Ind Health. 2004;42:348-51. 31. Smith RF, Mather HM, Ellard GA. Assessment of simple colorimetric procedures to determine smoking status of diabetic subjects. Clin Chem. 1998;44:275-80. 32. Taylor P. Agents acting at the neuromuscular junction and autonomic ganglia. In: Brunton LL, Lazo JS, Parker KL, editors. Goodman and Gilman’s the pharmacological basis of therapeutics. 11th ed. New York: McGraw-Hill; 2006. 33. Cope G, Nayyar P, Holder R, Gibbons J, Bunce R. A simple near-patient test for nicotine and its metabolites in urine to assess smoking habit. Clin Chim Acta. 1996;256:135-49. 34. Asfar T, Weg MV, Maziak W, Hammal F, Eissenberg T, Ward KD. Outcomes and adherence in Syria‘s first smoking cessation trial. Am J Health Behav. 2008;32:146-56. 35. Chatkin JM, Mariante de Abreu C, Haggsträm FM, Wagner MB, Fritscher CC. Abstinence rates and predictors of outcome for smoking cessation: do Brazilian smokers need special strategies? Addiction. 2004;99:778-84. 36. Hagimoto A, Nakamura M, Morita T, Masui S, Oshima A. Smoking cessation patterns and predictors of quitting smoking among the Japanese general population: a 1-year follow-up study. Addiction. 2010;105:164-73. 220 – Trends Psychiatry Psychother. 2013;35(3)

37. Hukkanen J, Jacob P, Benowitz NL. Metabolism and disposition kinetics of nicotine. Pharmacol Rev. 2005;57:79-115. 38. Balhara YP, Jain R, Sundar AS, Sagar R. Use of cotinine urinalysis to verify self-reported tobacco use among male psychiatric out-patients. Lung India. 2012;29:217-20. 39. Connor Gorber S, Schofield-Hurwitz S, Hardt J, Levasseur G, Tremblay M. The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status. Nicotine Tob Res. 2009;11:12-24. 40. Noonan D, Jiang Y, Duffy SA. Utility of biochemical verification of tobacco cessation in the Department of Veterans Affairs. Addict Behav. 2013;38:1792-5. 41. Pérez-Stable EJ, Marín G, Marín BV, Benowitz NL. Misclassification of smoking status by self-reported cigarette consumption. Am Rev Respir Dis. 1992;145:53-7. 42. Helgason AR, Tomson T, Lund KE, Galanti R, Ahnve S, Gilljam H. Factors related to abstinence in a telephone helpline for smoking cessation. Eur J Public Health. 2004;14:306-10. 43. Peters EN, Hughes JR, Callas PW, Solomon LJ. Goals indicate motivation to quit smoking. Addiction. 2007;102:1158-63. 44. Boardman T, Catley D, Mayo MS, Ahluwalia JS. Self-efficacy and motivation to quit during participation in a smoking cessation program. Int J Behav Med. 2005;12:266-72. 45. Nerín I, Beamonte A, Gargallo P, Jiménez-Muro A, Marqueta A. Ganancia ponderal al dejar de fumar y su relación con la ansiedad. Arch Bronconeumol. 2007;43:9-15. 46. Figueiró LR. Características de fumantes associadas à adesão ao tratamento e à mudança de comportamento [dissertação]. Porto Alegre: Universidade Federal de Ciências da Saúde de Porto Alegre; 2010. 47. Zvolensky MJ, Stewart SH, Vujanovic AA, Gavric D, Steeves D. Anxiety sensitivity and anxiety and depressive symptoms in the prediction of early smoking lapse and relapse during smoking cessation treatment. Nicotine Tob Res. 2009;11:323-31. 48. Curtin L, Brown RA, Sales SD. Determinants of attrition from cessation treatment in smokers with a history of major depressive disorder. Psychol Addict Behav. 2000;14:134-42. 49. Glassman AH, Covey LS, Stetner F, Rivelli S. Smoking cessation and the course of major depression: a follow-up study. Lancet. 2001;357:1929-32. 50. Picciotto MR. Common aspects of the action of nicotine and other drugs of abuse. Drug Alcohol Depend. 1998;51:165-72. 51. Park ER, Chang Y, Quinn V, Regan S, Cohen L, Viguera A, et al. The association of depressive, anxiety, and stress symptoms and postpartum relapse to smoking: a longitudinal study. Nicotine Tob Res. 2009;11:707-14. 52. Camarelles F, Asensio A, Jiménez-Ruiz C, Becerril B, Rodero D, Vidaller O. Efectividad de la intervención grupal para la deshabituación tabáquica. Ensayo clínico aleatorizado. Med Clin (Barc). 2002;119:53-7. 53. Terra MB, Barros HM, Stein AT, Figueira I, Palermo LH, Athayde LD, et al. Do alcoholics anonymous groups really work? Factors of adherence in a Brazilian sample of hospitalized alcohol dependents. Am J Addict. 2008;17:48-53.

Correspondence Luciana Rizzieri Figueiró VivaVoz – Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA) Rua Sarmento Leite, 245, sala 316, Centro 90050-170 – Porto Alegre, RS – Brazil Tel./Fax: +55 (51) 3303.8764 E-mail: rizzieri@ufcspa.edu.br

Trends

Original Article

in Psychiatry and Psychotherapy

Who are the children and adolescent patients of a national referral service of eating disorders in Brazil? A cross-sectional study of a clinical sample Quem são os jovens pacientes de um serviço de referência nacional em transtornos alimentares no Brasil? Estudo transversal de uma amostra clínica Vanessa Dentzien Pinzon,1 Gizela Turkiewicz,1 Denise Oliveira Monteiro,2 Priscila Koritar,3 Bacy Fleitlich-Bilyk4

Abstract

Resumo

Objectives: To investigate the sociodemographic and clinical profile of patients receiving treatment at a specialized service for children and adolescents with eating disorders (ED) in São Paulo, Brazil, and to compare data with the relevant literature. Methods: This cross-sectional study assessed male and female patients with ED up to 18 years of age. All data were collected upon admission. Results: A total of 100 subjects were assessed. Mean age was 15.41±0.18 years, and mean age at ED onset was 13.5±0.19 years. Mean disease duration was 21.06 ±1.67 months. Of the total sample, 82% of the patients were female, 84% were Caucasian, 64% came from A and B economic tiers. Moreover, in 60% ED started at 14 years of age or less, and 74% had psychiatric comorbidities. Anorexia nervosa was the most prevalent diagnosis (43%). Hospitalized patients had lower body mass index, longer ED duration, and more severe scores on the Children’s Global Assessment Scale than outpatients (p < 0.05). Conclusions: Our young Brazilian patients with ED present epidemiological and symptomatic characteristics very similar to those found in the scientific literature, including a high prevalence of psychiatric comorbidities. The higher frequency of full syndrome ED, the predominance of cases with an early onset, the delay in beginning specialized treatment, and the more severe state of inpatients provide grounds for concern because these factors differ from what has been reported in reference studies and indicate greater ED severity. Keywords: Anorexia nervosa, bulimia nervosa, eating disorders, children, adolescents.

Objetivos: Investigar o perfil sociodemográfico e clínico de pacientes de um serviço especializado no tratamento de crianças e adolescentes com transtornos alimentares (TA) em São Paulo, Brasil, e comparar os dados com a literatura científica relevante. Métodos: Este estudo transversal avaliou pacientes com diagnóstico de TA de ambos os sexos, com idade até 18 anos. Os dados foram coletados na admissão dos pacientes ao serviço. Resultados: A amostra foi composta por 100 sujeitos. A idade média foi de 15,41±0,18 anos, e a média de idade ao início dos TA foi de 13,5±0,19 anos. O tempo médio de duração da doença foi de 21,06±1,67 meses. Da amostra total, 82% dos pacientes eram meninas, 84% eram brancos, 64% provinham das classes econômicas A e B. Além disso, 60% iniciaram a patologia com 14 anos ou menos e 74% tinham comorbidades psiquiátricas. A forma total da anorexia nervosa foi o diagnóstico mais prevalente (43%). Os pacientes hospitalizados tiveram menor índice de massa corporal, mais tempo de TA e escores mais graves na Escala de Avaliação Global de Crianças quando comparados com pacientes do ambulatório (p < 0,05). Conclusões: Os pacientes brasileiros jovens com TA avaliados no presente estudo apresentaram características epidemiológicas e sintomatológicas muito semelhantes aos dados da literatura científica, inclusive com relação à alta prevalência de comorbidades psiquiátricas. A maior frequência das síndromes totais dos TA, o predomínio de quadros de início precoce, o longo tempo decorrido até iniciar tratamento especializado e a maior gravidade dos pacientes hospitalizados observados nesta amostra chamam atenção por diferirem do que tem sido relatado em estudos semelhantes e também por indicarem uma maior gravidade do TA. Descritores: Anorexia nervosa, bulimia nervosa, transtornos alimentares, crianças, adolescentes.

1 Psychiatrist, Institute of Psychiatry, Universidade de São Paulo (USP), São Paulo, SP, Brazil. 2 Psychologist, Institute of Psychiatry, USP, São Paulo, SP, Brazil. 3 Nutritionist, Institute of Psychiatry, USP, São Paulo, SP, Brazil. 4 Psychiatrist, Outpatient and Inpatient Eating Disorders Program, Child and Adolescent Psychiatry Department, Institute of Psychiatry, USP, São Paulo, SP, Brazil.

This article was based on the dissertation entitled “Impact of psychiatric comorbidities and other risk factors on the response of children and adolescents with eating disorders to treatment,” presented at the Department of Experimental Pathophysiology, School of Medicine, Universidade de São Paulo (USP), São Paulo, SP, Brazil, in September 2012. Financial support: none. Submitted Feb 04 2013, accepted for publication May 06 2013. No conflicts of interest declared concerning the publication of this article. Suggested citation: Pinzon VD, Turkiewicz G, Monteiro DO, Koritar P, Fleitlich-Bilyk B. Who are the children and adolescent patients of a national referral service of eating disorders in Brazil? A cross-sectional study of a clinical sample. Trends Psychiatry Psychother. 2013;35(3):221-8.

Trends Psychiatry Psychother. 2013;35(3) – 221-228

Cross-sectional study of pediatric Brazilian patients with eating disorders – Pinzon et al.

Introduction Anorexia nervosa (AN) is currently the third most common chronic disease among female adolescents.1 It is the disorder with the highest crude mortality rate among all psychiatric disorders (5.6% in 10 years), which is 6 to 12.82 times higher than the expected rate for similar healthy populations.2-4 More than half of the deaths occur due to medical complications of eating disorders (ED).5 Bulimia nervosa (BN) seems to have a more favorable prognosis, but with a relapse rate of 30 to 50%.2,6 A complicating factor in adolescence is that diagnostic criteria are originally designed for adults; as a result, 50 to 70% of the adolescent patients are diagnosed with atypical or partial presentations of ED, delaying diagnosis and appropriate treatment.2,7 Young subjects with ED may present serious biological, psychological, and social outcomes, with a great impact on their development.4 ED are prevalent in both developed and developing countries.2,8 Notwithstanding, the sociodemographic and clinical characteristics of these young patients are better known in developed countries,9-12 and there are few studies with large samples including only children or adolescents, as is the case of the present study.2 In Brazil, the characteristics of this population are not completely known, and there are still few specialized childhood and adolescence ED services.13,14 The alarming number of patients awaiting treatment and the long time on waiting lists (on average, 22 months for a referral service in Brazil13) leads to a severe, chaotic situation. Longer periods of ED symptoms seem to be associated with an unfavorable prognosis, with a direct influence on treatment compliance and possibly on morbidity and mortality rates.15 Knowledge of the sociodemographic and clinical profile of the young Brazilian population with ED may help plan more effective therapeutic strategies and optimize treatment. It may also help create qualified services for these patients, within our country and culture, contributing to maximize the currently scarce allocation of resources. The objective of this study was to assess the sociodemographic profile and clinical characteristics of children and adolescents seen at a multidisciplinary service specialized in the treatment of children and adolescents with ED in São Paulo, Brazil,14 and to compare data with the reference scientific literature.

Methods Setting The study was performed at the Outpatient and Inpatient Eating Disorders Program (PROTAD) at Institute

222 – Trends Psychiatry Psychother. 2013;35(3)

of Psychiatry, Universidade de São Paulo (USP), São Paulo, Brazil.

Ethical issues The study was approved by the Research Ethics Committee of Hospital das Clínicas da Universidade de São Paulo (protocol no. 0800/08). All patients and their legal guardians signed a free and informed consent form prior to their inclusion in the study.

Sampling The sample comprised 106 male and female children and adolescents aged up to 18 years and diagnosed with ED (full and partial syndromes) according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR),16 with or without psychiatric comorbidities, referred for outpatient or inpatient multidisciplinary or family-based treatment at PROTAD from November 2001 to December 2009. Patients with mental retardation or invasive developmental disorders, pregnant girls, and those without a legal representative were excluded from the study. Eleven patients were admitted at PROTAD for an observational study of family-based treatment, a method developed and described elsewhere17; for these patients, inclusion criteria were being female, having a diagnosis of full or partial AN syndrome, and having both parents present during follow-up.

Study design and data collection This was a cross-sectional study with assessments performed at the beginning of the treatment program at PROTAD. The following instruments were used: Development and Well-Being Assessment (DAWBA), Brazilian Version18; Social-Economic Questionnaire (SEQ); Brazil Economic Classification Criterion, 2000 (Critério de Classificação Econômica Brasil, CCEB)19; and the Children’s Global Assessment Scale (CGAS).20 The standardized clinical, psychiatric, and nutritional records available at PROTAD helped obtain additional information when data were missing. Weight and height were measured by trained professionals, using anthropometric procedures. The body mass index (BMI) of each patient was calculated by dividing the weight in kilograms by the square of the height in meters. Each subject’s nutritional status was assessed based on the BMI/age percentile, according to the World Health Organization.21 Seven different economic tiers determined by the CCEB19 were grouped into two wider tiers. One group

Cross-sectional study of pediatric Brazilian patients with eating disorders – Pinzon et al.

comprised tiers A + B (A1, A2, B1, and B2 tiers, with a monthly income above R$ 1,669.00); the other group comprised tiers C + D + E, with a monthly income from R$ 207.00 to R$ 1.668.99).19 An intact family was a family in which both parents lived with the patient. Age at ED onset was calculated in years, considering the date when the symptoms began. This parameter was used based on literature data (before this age, the disease is considered precocious, or early-onset ED).22 ED duration was calculated in months, and was measured from the month when ED started to the date of enrollment at PROTAD. Analysis of type of treatment only included patients admitted at PROTAD as of October 2006, when this department started having both inpatient and outpatient facilities. The outpatient category considered patients who underwent only outpatient treatment; the inpatient category included patients who underwent only inpatient treatment and also patients who required hospitalization at some point of the treatment. Previous treatment was any in- or outpatient psychological, nutritional, and/or medical treatment for ED. The time-relationship between ED onset and the beginning of psychiatric comorbidities was classified as “before” (comorbidities whose symptoms started before ED symptoms) and “during” (comorbidities whose symptoms started after the onset of ED symptoms). The following ED symptoms were classified as positive according DSM-IV-TR diagnostic specifications: fear of gaining weight, food restriction, compulsion, excessive physical exercises, vomiting, and menstruation.16 The variables collected and analyzed were distributed into five groups: – Sociodemographic factors: age, gender, ethnicity, and economic class; – Family factors: type of family, person responsible for treatment, degree of education of the person responsible for treatment, family history of ED, and/or other psychiatric disorders; – Clinical factors: ED diagnosis, age at onset and duration of ED, type of treatment (in- or outpatient), previous treatments, weight, height, BMI, BMI/age percentile, and menstrual periods; – Psychiatric comorbidities: prevalence and temporal relationship with ED; – ED impact on patient global function, with or without comorbid psychiatric disorders. Subjects were divided in two ED subgroups. The AN group included young subjects with AN, both full and partial syndromes according to DSM-IV-TR criteria.16 The BN group included patients with both full and partial BN, also according to DSM-IV-TR criteria.16 The analysis was performed in the total sample and also in the two ED subgroups. The eleven patients admitted for family

treatment were excluded from the analyses of gender, person responsible, and ED diagnosis. In order to identify the presence of significant differences between treatment types, a comparison between PROTAD inpatients and outpatients was performed as of October 2006.

Statistical analysis All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 14.0. Firstly, a descriptive analysis of the sample was performed. Frequencies and percentages of all categorical variables were calculated. For the continuous variables, summary statistics were calculated (minimum, maximum, mean, and standard error). Descriptive analysis also made it possible to characterize the sample regarding ED subgroups. Fisher’s exact test was used to assess possible associations between two binary categorical variables. For variables with more than two categories, the chi-square test or the chi-square test with Monte Carlo simulation were used. Continuous variables between the two ED groups were compared using the Student t test or Mann-Whitney’s test. Statistical significance was set at 5% (p < 0.05).

Results A total of 106 patients were enrolled in PROTAD with a diagnosis of full or partial ED. Six subjects were excluded due to insufficient data. As a result, 100 patients comprised the final sample. Of these, 77 (77%) subjects were included in the AN group, and 23 (23%) in the BN group. The sociodemographic profile of the sample is detailed in Table 1. One patient with partial BN was 9 years old upon enrollment in PROTAD. This was the youngest patient enrolled. The female/male ratio was approximately 12:1. The most prevalent family structure was the intact one (69%). In 88% of the cases, the mother took responsibility for the patient’s treatment. Most of the legal representatives (64%) had an educational level of complete high school or above. A positive family history of psychiatric disorders (ED, mood disorders, anxiety disorders, and substance addiction) was observed in 67% of the cases. No statistically significant differences were found between the two ED subgroups in terms of family data (p > 0.05). The prevalence of full AN syndrome was 43%; of these, 32% were of the restrictive and 12% of the purgative subtype. The prevalence of full BN syndrome

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was 17%. The sum of full AN and full BN syndromes was 60%. The prevalence of partial AN was 32%; of these, 8% were restrictive and 14% purgative, and the prevalence of partial BN was 9%; the sum of both partial ED syndromes was 41%. ED clinical features are described in Table 2. Illness duration and the search for previous treatment were significantly different between the two ED groups (p < 0.01). In terms of nutrition, both ED groups were mostly eutrophic: 67.5% in the AN group and 56.5% in the BN group. Regarding ED symptoms, the most frequent compensatory behaviors were food restriction in both groups, excessive physical exercises in the AN group (36%), and vomiting in the BN group (69.6%). The BN

group had a higher frequency of compulsion and vomiting as compared to the AN group (p < 0.01). Among the 82 girls of the sample, 46 (49.5%) had been amenorrheic for at least 3 months, five (5.4%) had not had their first period yet, and 42 (45.2%) had had at least one period over the last 3 months, 22 (31%) in the AN group and 20 (90.9%) in the BN group. The absence of menstrual periods was more frequent in the AN group (p < 0.01). Of the total sample, 74 (74%) patients presented a psychiatric comorbidity. The prevalence of comorbidities is shown in Table 3. Table 4 describes the temporal relationship between psychiatric comorbidities and ED. In one patient, anxiety disorder started before ED, and in the two other patients, the disorder started during ED.

Table 1 – Sample sociodemographic profile

Sociodemographic characteristics Mean age (years)

AN (n = 77)

BN (n = 23)

15.19

16.18

0.02*

Gender, n (%) Female 60 (91) 22 (95.7) Male 6 (9) 1 (14.3)

1.00†

Ethnicity, n (%) Caucasian 65 (86.7) 19 (86.04) Other 10 (13.3) 3 (13.60)

0.97†

Economic tier, n (%) Tiers A + B 49 (67.1) 15 (68.2) Tiers C + D + E 24 (32.9) 7 (31.8)

0.93†

AN = anorexia nervosa; BN = bulimia nervosa. * Student’s t test. † Chi-square test.

Table 2 – Clinical features of the eating disorders

Clinical characteristics Mean Mean Mean Mean

weight (kg) BMI (kg/m2) age at ED onset (years) duration of illness (months)

AN (n = 77)

BN (n = 23)

43.59 17.09 13.54 18.26

58.63 22.86 13.36 30.43

< 0.01* < 0.01* 0.69* < 0.01†

Previous treatments, n (%) Yes 57 (74) 9 (39.1) No 20 (26) 14 (60.9) Relapses, n (%) Yes No

2 (2.6) 75 (97.9)

1.00‡

0 (0) 23 (23)

Age at ED onset, n (%) ≤ 14 years 43 (55.8) 17 (73.9) > 14 years 34 (44.2) 6 (26.1) AN = anorexia nervosa; BMI = body mass index; BN = bulimia nervosa; ED = eating disorders. * Student’s t test. † Mann-Whitney’s test. ‡ Chi-square test.

224 – Trends Psychiatry Psychother. 2013;35(3)

< 0.01‡

0.12‡

Cross-sectional study of pediatric Brazilian patients with eating disorders – Pinzon et al.

Table 3 – Psychiatric comorbidities

AN (n = 55)

BN (n = 19)

Comorbidities, n (%) MD 41 (74.5) 15 (78.9) AD 32 (58.2) 8 (42.2) MD + AD 18 (32.7) 4 (21.1) Other disorders† 0 (0) 2 (10.6) Total of patients with comorbidities 55 (100) 19 (100)

1.00 0.40 0.40 1.00 -

Types of MD, n (%) Depressive episodes 38 (93) 10 (67) Other depressive episodes 0 (0) 1 (7) Bipolar disorder 3 (8) 4 (27) Total 41 (74.5) 15 (78.9)

0.19 0.26 0.07 -

Types of AD, n (%) Specific phobia 6 (19) 2 (25) Social phobia 7 (22) 1 (13) GAD 10 (32) 2 (25) OCD 7 (22) 3 (38) SAD 4 (13) 0 (0) PTSD 0 (0) 1 (13) Panic disorder 1 (4) 0 (0) Agoraphobia 1 (4) 0 (0) Other AD 7 (22) 2 (25) Total 32 (58.2) 8 (42.20)

1.00 0.68 0.72 0.71 0.57 0.26 1.00 1.00 1.00 -

AD = anxiety disorders; AN = anorexia nervosa; BN = bulimia nervosa; GAD = general anxiety disorder; MD = mood disorders; OCD = obsessive-compulsive disorder; PTSD = post-traumatic stress disorder; SAD = separation anxiety disorder. * Statistical significance: chi-square test. † Other disorders: oppositional defiant disorder, attention-deficit/hyperactivity disorder, trichotillomania, and body dysmorphic disorder.

Table 4 – Temporal relationship between psychiatric comorbidities and ED

Psychiatric comorbidities and ED

AN (n = 55)

BN (n = 19)

Onset of MD in relation to ED, n (%) Before ED 7 (17) 3 (20) During ED 34 (83) 11 (74) Total of patients with MD 41 (74.5) 15 (94)

0.90

Onset of AD in relation to ED, n (%) Before ED 25 (79) 5 (63) During ED 6 (19) 2 (25) Before and after ED 0 (0) 1 (13) Total of patients with AD 32 (58.2) 8 (42.2)

0.21

Psychiatric disorders before ED, n (%)† AD 19 (73) 6 (66) MD 1 (3.8) 3 (33.4) AD + MD 6 (23.2) 0 (0) Total of patients 26 (100) 9 (100)

0.06

†

AD = anxiety disorders; ED = eating disorders MD = mood disorders. * Statistical significance: chi-square test. † Psychiatric comorbidities that started before ED.

All CGAS scores obtained in the sample were below 70, i.e., out of normal function. There was no statistically significant difference between the ED subgroups; 68.9% of the patients in the AN group and 65.2% in the BN group had scores between 41 and 60 (p > 0.05).

Of the 37 patients enrolled in PROTAD as of October 2006, 16 received outpatient treatment only: 15 patients in the AN group and one in the BN group. Another 21 were hospitalized: 20 AN patients and one BN patient. Hospitalized patients had statistically significantly lower

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BMI, longer ED duration and a lower number of CGAS scores varying between 31 and 40 as compared to nonhospitalized patients (p < 0.05). Notwithstanding, most of the variables investigated did not show statistically significant differences between types of treatment (p > 0.05).

Discussion Sociodemographic and family profile The sociodemographic results of the present study were in agreement with most of the scientific data available.2,10,12,23-25 With these results, it was possible to show that young Brazilian subjects with ED have characteristics that are very similar to those of other ED populations in developed countries. Both in Brazil and in developed countries, samples are mostly comprised of female, Caucasian subjects, coming from higher income classes, intact families, and with parents with higher educational levels. Even though most of the patients have this profile, ED is not restricted to it. According to Pamela & Julie,24 the creation of a ED stereotype may put “different” subjects at risk, as they may be misdiagnosed. The idea that higher economic classes are overrepresented in some countries due to the structure, functioning, and rules of the health care system is defended by Hoek8 and may also be applicable to the Brazilian health care structure, deficient in terms of specialized professionals and public services for the treatment of ED. However, studies with Brazilian adolescent females26 and with Latin women24 have shown a relationship between ED and economic level, excluding the confusion factor of the health care system. Less favored economic tiers were present in the sample, confirming that ED is not exclusive of higher economic tiers.10,24,25 Also, similarly to the relevant literature, a family history of psychiatric disorders was very frequent.2,9

Clinical profile The higher prevalence of full ED syndromes in this sample is in disagreement with most clinical trials, which point to partial forms as more common among adolescents.7,27,28 The long duration of ED before treatment among Brazilian patients (mean: 21 months) as compared to a mean of 11 to 15 months in other studies,29,30 in addition to the difficult access to specialized treatment for ED, may have been responsible for the higher number of patients with clinical presentations reaching diagnostic criteria for the full AN and BN syndromes. A 2003 study with patients on a waiting

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list at the same unit where the present research was conducted had already reported a similar finding: the mean waiting time for treatment was then 22 months, and 61.2% of the subjects had full ED syndromes.13 The fact that these samples were selected at a tertiary psychiatric service probably explains the more severe disorders found compared to samples recruited at community services, primary or secondary services. The partial forms of ED had a significant prevalence, even though they were not predominant. This may have been due to two symptoms observed in this sample that were part of the diagnostic criteria of DSM-IV-TR for AN and were reassessed in DSM-5.7,29 One of them, present in 67.5% of the AN group, was an eutrophic nutritional profile rather than the expected malnutrition.7,27,29 According to the literature, this may occur at this age due to a downshift in the BMI/age percentile curve, which may indicate an acute ED even within a normal wide percentile range.7,27,29 Therefore, an eutrophic nutritional profile should not exclude the diagnosis of AN.31 Another symptom that has been questioned by the scientific community is amenorrhea.7 Five girls from this sample had not had their first period, and 22 girls already had menstrual cycles at the beginning of the trial. In this sample, full and partial AN syndromes, especially of the restrictive subtype, were more frequent in younger subjects (mean age: 15.19 years), whereas full and partial BN syndromes were more common in older adolescents (mean age: 16.18 years).31-33 The only exception was a 9-year-old female patient with partial BN who had an important ED family history. Our patients presented symptoms characteristic of ED in childhood and adolescence, which is in agreement with the literature.12,29 Food restriction was the most prevalent symptom, followed by exercises in the AN group and vomiting in the BN group. Compulsion occurred mostly in the BN group.9,29 The AN and BN groups were different in terms of weight, BMI, nutrition, and menstrual periods, mostly due to the typical clinical presentation of each disorder according to DSM-IV-TR criteria.16 Some results were highlighted due to their importance and potential implications. Patients admitted to PROTAD had an early onset of ED, at approximately 13 years of age, and were therefore part of a different ED subgroup, called early-onset group.22 Moreover, it took our patients almost 24 months to get to a specialized service, much longer than the time reported in developed countries (11 to 15 months).29,30 The interval was even longer in the BN group, probably because in this disorder symptoms tend to remain secret and their physical consequences unnoticed. Patients with AN, a more evident disease due to the weight loss and organic changes involved, had tried other services before, but without success.

Cross-sectional study of pediatric Brazilian patients with eating disorders â&#x20AC;&#x201C; Pinzon et al.

When comparing different types of treatment, hospitalized patients showed more pronounced physical damage, as indicated by BMI indices. ED duration was almost three times longer among admitted patients as compared to nonhospitalized ones.

Psychiatric comorbidities Psychiatric comorbidities were very frequent in our patients. Mood disorders were the most prevalent comorbidity, and major depressive disorder the most common diagnosis in both ED subgroups. In most cases, the affective disorder started during ED, which is in accordance with the literature.34-36 This finding may corroborate the hypothesis that mood disorders occur more frequently as a consequence of ED, due to complex interactions between several biological, psychological, and relationship factors.34,35 Anxiety disorders were also frequent. In both groups, general anxiety disorder, social phobia, obsessivecompulsive disorder, and non-specified anxiety disorders were the most frequent comorbidities, however at different frequencies. In general, anxiety disorders started after ED, which again is in line with previous studies.9,37,38 These findings confirm the hypothesis that ED and anxiety disorders may share the same etiologic factors, and that anxiety disorders may increase the risk of ED.35,36 Comorbidities usually have negative influences on the course and prognosis of ED.7,37 In addition, as confirmed in this study, they influence treatment strategies: diagnostic assessments have to be detailed and comprehensive in order to identify these disorders. Finally, they require treatment adaptations, both in drug treatment and in psychotherapy techniques, and even the reassessment of treatment goals over the followup. Anxiety disorders are very frequent in community samples of Brazilian children and adolescents39 and require early intervention, considering, among others, the risk of development of an ED.

Impact In our sample, all patients presented a significant impact on function due to ED, regardless of the presence of psychiatric comorbidities. This was even more evident among hospitalized patients, whose CGAS scores showed a significantly limited functional capacity at home, at school, or in society. In fact, the higher number of patients who required this type of treatment may serve as an alert to the severity that ED may reach, even among very young patients, as shown in other studies.2,10,31,39 In addition, it indicates that these patients only received specialized treatment after their symptoms became severe.

All the findings above point to a precarious, unprepared health care structure, whose slowness in diagnosing and treating ED in childhood and adolescence may be responsible for a worse prognosis and potentially more serious consequences. In addition, the costs of chronic diseases are high for society as a whole, imposing financial burdens related with long treatments, medication use, hospitalizations, and parental unemployment. Most of these subjects could probably have been treated in the outpatient setting, with much lower financial, personal, and social costs, had they been diagnosed earlier. Unfortunately, the Brazilian health care system seems to be going in an opposite direction from established scientific knowledge, which recommends early treatment of psychiatric disorders in childhood and adolescence, including ED.2,10,13,31,39 This study has limitations inherent to cross-sectional trials, especially the difficulty establishing a temporal relationship between the study variables and the outcome (ED). Other limitations were the use of a clinical sample, which makes it difficult to extrapolate results to community subjects, and the inclusion of both outpatient and inpatient subjects, with different disease severities.

Conclusion This cross-sectional study allowed us to improve our knowledge about the sociodemographic and clinical characteristics of young Brazilian patients with ED, as well as to compare them with other data available in the relevant literature. Our population was similar to others in most of the parameters assessed. The high prevalence of psychiatric comorbidities, the early onset of ED, the long time elapsed between ED onset and the start of specialized treatment, and the higher severity observed in hospitalized patients show that ED in childhood and adolescence is still a challenge for health care services and professionals in Brazil. We believe that our results may contribute to reinforce the importance of ED as a diagnostic hypothesis in clinical practice at primary health centers and hospitals, help promote the development of more rational and effective investigational, diagnostic, and treatment strategies, and finally help establish new services for Brazilian children and adolescents with ED.

Acknowledgments The authors would like to thank all patients and their families for their collaboration, as well as the entire PROTAD team (Outpatient and Inpatient Eating Disorders Program) at Institute of Psychiatry, USP, Brazil.

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References 1. Misra M, Aggarwal A, Miller KK, Almazan C, Worley M, Soyka LA, et al. Effects of anorexia nervosa on clinical, hematologic, biochemical, and bone density parameters in communitydwelling adolescent girls. Pediatrics. 2004;114:1574-83. 2. American Psychiatry Association. Treatment of patients with eating disorders, third edition. Am J Psychiatry. 2006;163:4-54. 3. Papadopoulos F, Ekbom A, Brandt L, Ekselius L. Excess mortality, causes of death and prognostic factors in anorexia nervosa. Br J Psychiatry. 2009;194:10-7. 4. Moya T, Cominato L. Complicações clínicas. In: Weinberg C, editor. Transtornos alimentares na infância e adolescência: uma visão multidisciplinar. São Paulo: Sá Editora; 2008. p. 89-114. 5. Sullivan PF. Mortality in anorexia nervosa. Am J Psychiatry. 1995;152:1073-4. 6. Fairburn CG, Cooper Z, Doll HA, Norman P, O’Connor M. The natural course of bulimia nervosa and binge eating disorder in young women. Arch Gen Psychiatry. 2000;57:659-65. 7. Bravender T, Bryant-Waugh R, Herzog D, Katzman D, Kreipe RD, Lask B, et al. Classification of child and adolescent eating disturbances. Workgroup for Classification of Eating Disorders in Children and Adolescents (WCEDCA). Int J Eat Disord. 2007;40:S117-22. 8. Hoek HW. Distribution of eating disorders. In: Fairburn CG, Brownell KD, editors. Eating disorders and obesity – a comprehensive handbook. 2nd ed. New York: The Guilford Press; 2002. p. 210-4. 9. Fleitlich-Bilyk B, Lock J. Eating disorders. In: Banaschewski T, Rohde LA, editors. Biological child psychiatry – recent trends and developments. Basel: Karger; 2008. p. 138-52. 10. Nielsen S. Epidemiology and mortality of eating disorders. Psychiatr Clin North Am. 2001;24:201-14. 11. Nicholls D. Eating disorders in children and adolescents. Adv Psychiatr Treat. 1999;5:241-9. 12. Klein DA, Walsh T. Eating disorders: clinical features and pathophysiology. Physiol Behav. 2004;81:359-74. 13. Moya T, Fleitlich-Bilyk B. Waiting list for treatment of eating disorders in childhood and adolescence. Rev Bras Psiquiatr. 2003;25:259-60. 14. Pinzon V, Gonzaga AP, Cobelo A, Labaddia E, Belluzzo P, Fleitlich-Bilyk B. Peculiaridades do tratamento da anorexia e da bulimia nervosa na adolescência: a experiência do PROTAD. Rev Psiq Clin. 2004;31:167-9. 15. Steinhausen H. The outcome of anorexia nervosa in the 20th century. Am J Psychiatry. 2002;159:1284-93. 16. American Psychiatry Association (APA). Diagnostic and Statistical Manual of Mental Disorders (DSMIV). 2nd ed. Washington DC: APA; 2002. 17. Turkiewicz G, Pinzon V, Lock J, Fleitlich-Bilyk. Feasibility, acceptability, and effectiveness of family-based treatment for adolescent anorexia nervosa: an observational study conducted in Brazil. Rev Bras Psiqiatr. 2010;32:169-72. 18. Goodman R, Ford T, Richards H, Gatward R, Meltzer H. The Development and Well-Being Assessment: description and initial validation of an integrated assessment of child and adolescent psychopathology. J Child Psychol Psychiatry. 2000;41:645-55. 19. Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de Classificação Econômica Brasil (CCEB) 2003. http://www.abep.org. 20. Brasil HH, Bordin IA. Convergent validity of K-SADS-PL by comparision with CBCL in a portuguese speaking outpatient population. BMC Psychiatry. 2010;10:83. 21. World Health Organization (WHO). Growth reference data for 5-19 years: BMI-for-ages percentiles, 2007. http://www. who.int/growthref/en/. 22. Bryant-Waugh R, Lask B. Overview of the eating disorders. In: Lask B, Bryant-Waugh R, editors. Eating disorders in

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childhood and adolescence. 3rd ed. London: Routledge Taylor & Francis Group; 2007. p. 35-50. 23. Keski-Rahkonen A, Raevuori A, Hoek HW. Epidemiology of eating disorders: an update. In: Wonderlich S, Mitchell JE, Zwaan M, Steiger H, editors. Annual Review of Eating Disorders. Part 2. Oxford: Radcliffe Publishing; 2008. p. 58-68. 24. Keel PK, Gravener JA. Sociocultural influences on eating disorders. In: Wonderlich S, Mitchell JE, Zwaan M, Steiger H, editors. Annual Review of Eating Disorders. Part 2. Oxford: Radcliffe Publishing; 2008. p. 43-57. 25. Lewinsohn PM, Striegel-Moore RH, Seeley JR. Epidemiology and natural course of eating disorders in young women from adolescence to young Adulthood. J Am Acad Child Adolesc Psychiatry. 2000;39:1284-92. 26. Moya T, Fleitlich-Bilyk B, Goodman R. Brief report: young people at risk for eating disorders in southeast Brazil. J Adolesc. 2006;29:313-7. 27. Nicholls D, Chater R, Lask B. Children into DSM don’t go: a comparison of classification systems for eating disorders in childhood and early adolescence. Int J Eat Disord. 2000;28:317-24. 28. Machado PP, Machado BC, Gonçalves S, Hoek HW. The prevalence of eating disorders not otherwise specified. Int J Eat Disord. 2007;40:212-7. 29. Lock J, Agras S, Bryson S, Kraemer HC. A comparison of short– and long-term family therapy for adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatry. 2005;44:632-9. 30. Zonnevylle-Bender MJS, Goozen SHM, Cohen-Kettenis PT, Elburg A, Wildt MD, Stevelmans E, et al. Emotional functioning in anorexia nervosa patiens: adolescents compared to adults. Depress Anxiety. 2004;19:35-42. 31. Peebles R, Wilson JL, Lock JD. How do children with eating disorders differ from adolescents with eating disorders at initial evaluation? J Adolesc Health. 2006;39:800-5. 32. Moya T. Criação e análise da sessão de transtornos alimentares do DAWBA (levantamento sobre o desenvolvimento e bemestar de crianças e adolescentes) [dissertation]. São Paulo: Universidade de São Paulo; 2004. 33. Hoek HW, Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord. 2003;34:383-96. 34. Stice E, Burton EM, Shaw H. Prospective relations between bulimic pathology, depression, and substance abuse: unpacking comorbidity in adolescent girls. J Consult Clinl Psychol. 2004;72:62-71. 35. O’Brien K, Vincent N. Psychiatric comorbidity in anorexia and bulimia nervosa: nature, prevalence, and causal relationships. Clin Psychol Rev. 2003;23:57-74. 36. Keel PK, Klump KL, Miller KB, McGue M, Iacono WG. Shared transmission of eating disorders and anxiety disorders. Int J Eat Disord. 2005;38:99-105. 37. Overas M, Winje E, Lask B. Eating disorders in children and adolescents. In: Wonderlich S, Mitchell JE, Zwaan M, Steiger H, editors. Annual Review of Eating Disorders. Part 2. Oxford: Radcliffe Publishing; 2008. p. 110-24. 38. Herzog DB, Eddy KT. Comorbidity in eating disorders. In: Wonderlich S, Mitchell JE, Zwaan M, Steiger H, editors. Annual review of eating disorders. Part 1. Oxford: Radcliffe Publishing; 2007. p. 35-50. 39. Costello EJ, Egger H, Angold A. 10-year research update review: the epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. J Child Psychol Psychiatry. 2005;44:972-86.

Correspondence Vanessa Dentzien Pinzon Rua Simão Álvares, 51 05417-030 – São Paulo, SP – Brazil Tel.: +55 (11) 3031.7543, +55 (11) 99173.9968 E-mail: vdpinzon@gmail.com

Trends

Brief Communication

in Psychiatry and Psychotherapy

Twenty years of electroconvulsive therapy in a psychiatric unit at a university general hospital Vinte anos de eletroconvulsoterapia em enfermaria psiquiátrica de hospital geral universitário Amilton dos Santos Jr.,1 Maitê Cruvinel Oliveira,1 Tiago dos Santos Andrade,1 Rosana Ramos de Freitas,1 Cláudio Eduardo Muller Banzato,2 Renata Cruz Soares de Azevedo,2 Neury José Botega2

Abstract

Resumo

Objective: To describe the sociodemographic and clinical profile of patients who underwent electroconvulsive therapy (ECT) at a university general hospital. Method: In this retrospective study, records from all patients undergoing ECT between January 1988 and January 2008 at the psychiatric unit of the general hospital of Universidade Estadual de Campinas (UNICAMP) were reviewed. Telephone contact was made with patients/relatives to collect follow-up data. Results: A total of 200 charts were reviewed. The majority of patients were women, with a mean age of 39 years, and history of psychiatric hospitalization. The main indications for ECT were depression and catatonia. Complications were observed in less than half of the cases, and most were temporary and not severe. There was a good psychiatric outcome for 89.7% of the patients, especially for catatonic patients (100%, p = 0.02). Thirtyfour percent of the cases were later contacted by telephone calls, at a mean of 8.5 years between the procedure and the contact. Among these, three (1.5%) reported persistent memory disorders and 73% considered ECT a good treatment. Conclusion: ECT has been performed according to international guidelines. In the vast majority of cases, undesirable effects were temporary and not severe. Response to ECT was positive in most cases, particularly in catatonic patients. Keywords: Electroconvulsive therapy, treatment outcome, psychiatric somatic therapies, treatment, general hospital psychiatry.

Objetivo: Descrever o perfil sociodemográfico e clínico de pacientes submetidos a eletroconvulsoterapia (ECT) em um hospital geral universitário. Método: Neste estudo retrospectivo, foram revisados os prontuários de todos os pacientes submetidos a ECT entre janeiro de 1988 e janeiro de 2008 na unidade psiquiátrica do hospital geral da Universidade Estadual de Campinas (UNICAMP). Os pacientes/familiares foram contatados por telefone para a coleta de dados de seguimento. Resultados: Um total de 200 prontuários foram revisados. A maioria dos pacientes era do sexo feminino, com uma idade média de 39 anos e história de hospitalização psiquiátrica prévia. As principais indicações para ECT foram depressão e catatonia. Complicações foram observadas em menos de metade dos casos, e a maioria delas teve caráter temporário e não grave. Houve resultado psiquiátrico favorável em 89,7% dos pacientes, especialmente os catatônicos (100%, p = 0,02). Trinta e nove por cento dos casos foram contatados por telefone, a uma média de 8,5 anos decorridos entre o procedimento e o contato. Entre estes, três (1,5%) relataram transtornos amnésticos persistentes e 73% consideraram a ECT um bom tratamento. Conclusão: A ECT foi realizada de acordo com diretrizes internacionais. Na grande maioria dos casos, efeitos indesejáveis foram temporários e não graves. A resposta à ECT foi positiva na maioria dos casos, especialmente em pacientes catatônicos. Descritores: Eletroconvulsoterapia, resultado de tratamento, tratamentos somáticos em psiquiatria, tratamento, unidade psiquiátrica em hospital geral.

MD. Department of Medical Psychology and Psychiatry, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil. 2 MD, PhD. Department of Medical Psychology and Psychiatry, School of Medical Sciences, UNICAMP, Campinas, SP, Brazil. 1

Part of the results of this article were presented at 18th European Congress of Psychiatry, held in 2010 in Munich, Germany. Financial support: Programa Institucional de Bolsas de Iniciação Científica (PIBIC). Submitted Sep 11 2012, accepted for publication Apr 14 2013. No conflicts of interest declared concerning the publication of this article. Suggested citation: Santos Jr A, Oliveira MC, Andrade TS, Freitas RR, Banzato CE, Azevedo RC, et al. Twenty years of electroconvulsive therapy in a psychiatric unit at a university general hospital. Trends Psychiatry Psychother. 2013;35(3):229-33.

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Cross-sectional study of pediatric Brazilian patients with eating disorders – Pinzon et al.

Introduction

Method

The American Psychiatric Association has established guidelines for the use of electroconvulsive therapy (ECT).1-3 Even though some resistance is still observed, ECT is the first-choice treatment in the following cases: when a fast, consistent response is needed, when the risks of other treatment modalities are greater, or when there is previous history of poor response to drugs and/or good response to ECT.1-4 ECT is recognized as a biological therapy by the Brazilian Federal Medical Council5 and is strongly recommended as a treatment for severe depression, both unipolar and bipolar, especially in the presence of psychotic symptoms, high risk of suicide, physical deterioration, or resistance/ refractoriness to antidepressants. It is also useful for rapid control of catatonic symptoms and severe manic states.1-3,6 Studies show no absolute contraindications to ECT. However, some situations of potential risk have been described, e.g., intracranial lesions or conditions associated with increased intracranial pressure, history of stroke, recent myocardial infarction with complications, severe arterial hypertension, presence of risk factors for intracranial hemorrhage, and conditions associated with a 4 or 5 risk score according to the American Society of Anesthesiologists (ASA) classification.3 Regarding adverse effects, the current technique is associated with low morbidity-mortality rates. Mortality ranges from 2-4.5 deaths per 100,000 procedures, which is comparable to the anesthetic risk of small surgeries.7 Major complications include confusion, delirium, transient headache, muscle pain, nausea, vomiting, prolonged seizures, teeth damages, and circulatory failure. Benign arrhythmias are frequent during application and in the immediate postictal period.3 The most important adverse effect of ECT is memory deficit, which may manifest as postictal confusion, anterograde and/or retrograde amnesia, or, in a minority of patients, long-term subjective memory deficit.8 Amnesiac episodes may persist from 1 to 6 months after the end of sessions; acquisition and retention of new memories are not impaired.9 Despite the relevance of ECT for patients with severe mental disorders, there are still few Brazilian studies investigating patients’ profiles, appropriate indications, outcomes, and undesirable effects.10,11 This study aimed to describe data collected at a service with 20 years of experience in ECT, with a focus on the efficacy and safety of this treatment modality.

The clinical charts of all patients undergoing ECT between January 1988 and January 2008 at the psychiatric unit of the general hospital of Universidade Estadual de Campinas (UNICAMP) were reviewed. The 14-bed psychiatric unit is part of a high-complexity hospital serving an area with approximately 5,000,000 inhabitants.12 It provides clinical care for inpatients with severe mental disorders and with a high rate of clinical comorbidities. In addition, it is the only service offering ECT in the region. The following data were collected from patient records: sociodemographic information, clinical profile (diagnosis, previous psychiatric hospitalizations, family history of mental disorders, presence of clinical comorbidities), and ECT data, i.e., number of sessions, complications during and immediately after the procedure (within 72 hours), late complications (more than 72 hours after the procedure), and treatment response. Treatment outcome was categorized into four levels (excellent, good, indifferent, or poor), taking into account both the psychiatrists’ reports of mental examinations conducted with each patient after the procedure and their mental status at the time of hospital discharge. To assure accuracy of treatment outcome information, the category assigned to each case was discussed among the investigators. Reports of excellent and good responses were later grouped together, as well as reports of indifferent and poor responses, in order to investigate differences in treatment response among the main diagnostic groups treated with ECT. The chi-square and Fisher’s exact tests were used to compare the two groups, at a statistical significance of p < 0.05. Followup telephone contacts were performed with patients and relatives. Descriptive data analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 11.5. The study was approved by the Ethics Committee of the School of Medical Sciences of UNICAMP (protocol no. 130074), with exemption of the need to obtain informed consent for the consultation of medical records. During follow-up telephone contacts, a consent statement was read to the patient and/or relative prior to the interview. All patients contacted by telephone agreed to undertake the interview.

Results Over the 20-year period studied, 212 inpatients underwent ECT, but 12 charts (5.6%) could not be found. Of the 200 patients, 20 underwent ECT in two different

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Cross-sectional study of pediatric Brazilian patients with eating disorders – Pinzon et al.

hospitalizations; five in three occasions; and one in four cycles, amounting to 26 repeaters. Mean age of the participants was 39.4 years (standard deviation [SD] = 17.3; median = 35), and 125 (62.5%) were female. Previous psychiatric hospitalizations were mentioned in 50% of the cases (mean = 2.6; minimum = 1; maximum = 13), and 49% had a family history of mental Table 1 – Demographic characteristics, psychiatric diagnoses, and electroconvulsive therapy-related adverse effects and complications

Age (years) 13-30 72 36.0 31-50 72 36.0 > 50 56 28.0 Education (years) < 8 109 66.9 ≥ 8 54 31.1 Marital status Single 77 41.6 Married 78 42.2 Divorced/widow 30 16.2 Occupational status Economically active 41 Economically inactive 98

29.5 70.5

Primary psychiatric diagnosis Depression with psychotic features 73 Depression without psychotic features 62 Catatonic schizophrenia 38 Mania 37

36.5 31.0 19.0 18.5

Adverse effects during the procedure None 108 54.0 Arrhythmia 42 21.0 Prolonged seizure 23 11.5 Hypertension peak 22 11.0 Anesthetic problems 12 6.0 Vomit 6 3.0 Tooth fracture 4 2.0 Immediate complications* None 92 Mental confusion 45 Headache 30 Gastrointestinal disorders 23 Lacunar amnesia 20 Sleeping disorders 15 Retrograde amnesia 14

46.0 22.5 15.0 11.5 10.0 7.5 7.0

disorders. Comorbid physical conditions were found in 71.5% of the patients, especially arterial hypertension (49.5%) and diabetes (25.5%). The mean number of sessions in each ECT cycle was 7.6 (SD = 3.8; minimum = 1; maximum = 24 sessions). Application was unilateral in 80 participants (46.2%), bilateral in 40 (23.1%), and both unilateral and bilateral in 53 (30.6%) (n = 173 with this information available). Table 1 shows information about diagnoses and undesirable effects recorded for every patient’s first or only hospitalization requiring ECT. Patients who underwent ECT in two or more hospitalizations (n = 26) did not differ from those receiving only one ECT cycle in any sociodemographic, clinical, or ECT-related variable. Response to ECT was considered excellent in 75 cases (38.9%), good in 98 (50.8%), indifferent in 15 (7.8%), and poor in 5 (2.6%). Among patients with a primary diagnosis of catatonic schizophrenia, response to ECT was reported as excellent (54.1%) or good (45.9%) in all cases. Taking together excellent/good responses vs. indifferent/poor ones, ECT showed a statistically superior response rate in this diagnostic group when compared to patients with other diagnoses (chi-square and Fisher’s exact test, p = 0.02). Telephone contact was successful in 68 cases (34%). In eight cases, information was collected exclusively from relatives: in four cases, patients were hospitalized at the time of the phone call, and the other four patients had died (two from cancer, one suicide, and one of an unknown cause). Time elapsed between ECT and the telephone call varied from 1.1 to 20 years (mean = 8.5, SD = 5.5). Most patients (84.1%) were still under psychiatric treatment, and 47.5% did not require psychiatric hospitalizations after ECT; 39% had 1-3 subsequent hospitalizations; and 13.6% had four or more. Three patients (1.5%) reported persistent ECT undesirable effects: two reported memory impairment within 6 months after the procedure (already remitted), and one complained of persistent memory impairment. Seventy three percent considered ECT a good treatment, 14.3% did not considered it good, and 12.7% did not express an opinion.

Late complications† Discussion None 162 81.0 Lacunar amnesia 10 5.0 This study describes data collected over 20 years of Mental confusion 9 4.5 ECT in a psychiatric unit of a university general hospital, Retrograde amnesia 8 4.0 comprising one of the largest samples of cases in Brazil Headache 7 3.5 and contributing information to the national data bank * Within 72 hours after the procedure. † on this procedure. More than 72 hours after the procedure.

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Cross-sectional study of pediatric Brazilian patients with eating disorders – Pinzon et al.

* Statistically superior response rate compared to patients with other diagnoses (chi-square and Fisher’s exact test, p = 0.02).

Figure 1 – Responses to electroconvulsive therapy

Patient profiles, mean number of sessions per patient and diagnoses for which the procedure was indicated are in concordance with international standards.3,11 Almost 20% of the patients who underwent ECT were catatonic, a first-line indication for ECT, where the fast relief of symptoms is essential to prevent lethality due to severe psychomotor retardation or refusal of food and drink.2,13 The complications reported by our patients were the same already documented in previous studies. Most of them were mild and reversible, and occurred mainly during or immediately after the procedure. Some may be related to the anesthesia, e.g., nauseas, prolonged seizures, and postictal confusion.7,9,14-16 The response to ECT was positive (good/excellent) in the vast majority of cases (89.7%), reinforcing the importance of this therapeutic method in the treatment of severe mental disorders. This finding is in concordance with other recent studies9,17-19 that show that ECT, when well applied and accurately indicated, is effective and safe, and can lead to improvements in quality of life through the rapid mitigation of symptoms. Despite its great clinical value, ECT is still underestimated in Brazilian public health policies, because of prejudice and misconceptions spread by the media and lay press.1,10 Follow-up telephone calls reinforced the low prevalence of undesirable effects and the patients’ long-lasting positive opinion about the procedure.17 A limitation of this study was its retrospective nature, based on information not collected using a standardized

232 – Trends Psychiatry Psychother. 2013;35(3)

assessment form, but rather mostly from medical records.11 However, we could argue that the study was performed at a university service, which increases the reliability of data due to the constant discussion and supervision of all cases by experienced professors. Moreover, cases causing doubts about the type of response to treatment were carefully discussed among the investigators. Another limitation was that telephone contact was successful in only one-third of the cases. This bias happened because of the long time elapsed between ECT and the phone call (mean of 8.5 years) and also due to changes in telephone numbers and addresses (which is very common in Brazil). These factors may have contributed to the limited body of follow-up data collected. ECT has been performed in UNICAMP according to international guidelines regulating the application and monitoring of clinical response and adverse side effects.20 Satisfactory clinical results were observed in the majority of cases, both at the time of the procedure and during the follow-up. Undesirable effects, in most cases, were temporary and not severe. Despite mental health policies that may reprobate or even prevent its use, it is necessary to recognize that, when well indicated and carefully performed, ECT is a very effective treatment option and should be made available for selected patients. Our results reinforce the important role played by this therapy in the treatment of severe and often life-threatening mental disorders.

Cross-sectional study of pediatric Brazilian patients with eating disorders – Pinzon et al.

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11. Azi LA, Dalgalarrondo P, Botega NJ. Electroconvulsive therapy: a retrospective study of 50 cases. J Bras Psiquiatr. 1999;48:493-98. 12. Dalgalarrondo P, Botega NJ, Banzato CE. Pacientes que se beneficiam de internação psiquiátrica em hospital geral. Rev Saude Publica. 2003;37:10-20. 13. Petrides G, Tobias KG, Kellner CH, Rudorfer MV. Continuation and maintenance electroconvulsive therapy for mood disorders: review of the literature. Neuropsychobiology. 2011;64:129-40. 14. Baghai TC. Möller HJ. Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci. 2008;10:105-17. 15. Pagnin D, de Queiroz V, Pini S, Cassano GB. Efficacy of ECT in depression: a meta-analytic review. J ECT. 2004;20:13-20. 16. Mathys M, Mitchell BG. Targeting treatment-resistant depression. J Pharm Pract. 2011;24:520-33. 17.Antunes PA, Rosa MA, Abreu PSB, Lobato MIR, Fleck MP. Electroconvulsive therapy in major depression: current aspects. Rev Bras Psiquiatr. 2009;31:S26-33. 18. Braga RJ, Petrides G. Terapias somáticas para transtornos psiquiátricos resistentes ao tratamento. Rev Bras Psiquiatr. 2007;29:S77-84. 19. Bharadwaj V, Grover S, Chakrabarti S, Avasthi A, Kate N. Clinical profile and outcome of bipolar disorder patients receiving electroconvulsive therapy: a study from north India. Indian J Psychiatry. 2012;54:41-7. 20. Scott AI. Electroconvulsive therapy, practice and evidence. Br J Psychiatry. 2010;196:171-2.

Correspondence Amilton dos Santos Júnior Departamento de Psicologia Médica e Psiquiatria – FCM-Unicamp Cidade Universitária Zeferino Vaz, Distrito de Barão Geraldo 13083-970 – Campinas, SP – Brazil Tel.: +55 (19) 3521.7514 E-mail: amilton@fcm.unicamp.br

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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.

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