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Estudio preliminar e identificación de un campamento de náufragos en el contexto de la Guerra del Brasil (1825-1828), Partido de Patagones, Buenos Aires
- Nicolás C. Ciarlo, Ana Castelli, Joaquín Rodríguez Saumell, Carlos G. Landa, Leonardo Dam, Diego Carabias Amor, Alasdair Brooks, Luis V. J. Coll, Rodrigo Torres
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- Latin American Antiquity , First View
- Published online by Cambridge University Press:
- 16 April 2024, pp. 1-20
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La navegación, la tecnología naval, la vida a bordo y las actividades llevadas a cabo en barcos de época moderna y contemporánea han sido temas ampliamente estudiados dentro de la arqueología marítima y náutica. Sin embargo, el devenir de los náufragos sobrevivientes de accidentes y las correspondientes evidencias materiales en la costa, no fueron abordados en grado semejante. Las investigaciones muestran un desarrollo dispar, destacando los trabajos realizados en el Pacífico occidental. En Latinoamérica, esta problemática se encuentra aún apenas esbozada. El estudio arqueológico de campamentos de náufragos puede aportar información novedosa para conocer las relaciones humanas, interpersonales e intergrupales, en situaciones de crisis. En este artículo, presentamos los primeros resultados del análisis arqueológico-histórico de la materialidad asociada al sitio Faro Segunda Barranca 4, localizado en el Partido de Patagones, Provincia de Buenos Aires, Argentina. A partir de una discusión de las diferentes líneas de evidencia, identificamos los restos como un campamento de náufragos en el marco de la Guerra del Brasil o Guerra de Cisplatina (1825-1828).
Validation of the Spanish translation Sheffield Profile for Assessment and Referral for Care (SPARC-Sp) at the Hospital Universitario San Jose of Popayan, Colombia
- Cindy V. Mendieta, Jose A. Calvache, Martín A. Rondón, Carlos Javier Rincón-Rodríguez, Sam H. Ahmedzai, Esther de Vries
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- Palliative & Supportive Care , First View
- Published online by Cambridge University Press:
- 27 March 2024, pp. 1-12
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Objectives
We determined the validity and reliability of the Spanish translation Sheffield Profile for Assessment and Referral for Care (SPARC-Sp) questionnaire to identify the palliative care (PC) needs of patients with chronic noncommunicable diseases (NCDs) in Colombia.
MethodsWe developed a cross-sectional observational study of scale assessment in adults with the aim of determining the validity and reliability of the SPARC-Sp questionnaire to identify the PC needs of patients with NCDs receiving outpatient or inpatient care at the Hospital Universitario San Jose of Popayan – ESE, Colombia, from 2021 to 2022.
ResultsWe applied a questionnaire consisting of demographic, clinical data, and SPARC-Sp to 507 participants. The constructed model explained 75% of the variance with an adequate fit according to the root mean square residual (0.03), the comparative fit index (0.98), and acceptable reliability (McDonald’s total omega 0.4–0.9). Opportunities for improvement are the reformulation and inclusion of particular words to improve the representativeness and clarity of the domains of communication and information, religious, and spiritual issues.
Significance of resultsThis research represents the first validation of SPARC in Spanish. SPARC-Sp is an instrument that allows initiating a conversation of the patient’s main needs through a systematic assessment of the patients’ main needs. Its psychometric validation demonstrated good fit and acceptable reliability.
22 Cognitive Reserve's Relationship to Brain Burden in Parkinson's Disease Without Dementia
- Lauren E. Kenney, Jared Tanner, Samuel J. Crowley, Thomas H. Mareci, Francesca V. Lopez, Adrianna M. Ratajska, Katie Rodriguez, Rachel Schade, Joshua Gertler, Catherine C. Price, Dawn Bowers
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 539-540
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Objective:
Individuals with Parkinson's disease (PD) have varying trajectories of cognitive decline. One reason for this heterogeneity may be "cognitive reserve": where higher education/IQ/current mental engagement compensates for increasing brain burden (Stern et al., 2020). With few exceptions, most studies examining cognitive reserve in PD fail to include brain metrics. This study's goal was to examine whether cognitive reserve moderated the relationship between neuroimaging indices of brain burden (diffusion free water fraction and T2-weighted white matter changes) and two commonly impaired domains in PD: executive function and memory. We hypothesized cognitive reserve would mitigate the relationship between higher brain burden and worse cognitive performance.
Participants and Methods:Participants included 108 individuals with PD without dementia (age mean=67.9±6.3, education mean=16.6±2.5) who were prospectively recruited for two NIH-funded projects at the University of Florida. All received neuropsychological measures of executive function (Trails B, Stroop, Letter Fluency) and memory (delayed recall: Hopkin's Verbal Learning Test-Revised, WMS-III Logical Memory). Domain specific z-score composites were created using data from age/education matched non-PD peer controls (N=62). For the Cognitive Reserve (CR) proxy, a z-score composite included years of education, WASI-II Vocabulary, and Wechsler Test of Adult Reading. At the time of testing, participants completed multiple MRI scans (T1-weighted, diffusion, Fluid Attenuated Inversion Recovery) from which the following were extracted: 1) whole-brain free water within the white matter (a measure of microstructural integrity and neuroinflammation), 2) white matter hyperintensities/white matter total volume (WMH/WMV), and bilaterally-averaged edge weights of white matter connectivity between 3) dorsolateral prefrontal cortex and caudate and 4) entorhinal cortex and hippocampi. Separate linear regressions for each brain metric used executive function and memory composites as dependent variables; predictors were age, CR proxy, respective brain metric, and a residual centered interaction term (brain metric*CR proxy). Identical models were run in dichotomized short and long disease duration groups (median split=6 years).
Results:In all models, a lower CR proxy significantly predicted worse executive function (WMH/WMV: beta=0.49, free water: beta=0.54, frontal edge weight: beta=0.49, p's<0.001) and memory (WMH/WMV: beta=0.42, free water: beta=0.35, temporal edge weight: beta=0.39, p's <0.01). For neuroimaging metrics, higher free water significantly predicted worse executive function (beta=-0.39, p=0.002) but not memory. No other brain metrics were significant predictors of either domain. Accounting for PD duration, higher free water predicted worse executive function for those with both short (beta=-0.49, p=0.04) and long disease duration (beta=-0.48, p=0.02). Specifically in those with long disease duration, higher free water (beta=-0.57 p=0.02) and lower edge weights between entorhinal cortex and hippocampi (beta=0.30, p=0.03) predicted worse memory. Overall, no models contained significant interactions between the CR proxy and any brain metric.
Conclusions:Results replicate previous work showing that a cognitive reserve proxy relates to cognition. However, cognitive reserve did not moderate brain burden's relationship to cognition. Across the sample, greater neuroinflammation was associated with worse executive function. For those with longer disease duration, higher neuroinflammation and lower medial temporal white matter connectivity related to worse memory. Future work should examine other brain burden metrics to determine whether/how cognitive reserve influences the cognitive trajectory of PD.
3 The Relationship Between Depression, Anxiety, and Autonomic Dysfunction in de novo Parkinson’s Disease Patients Over Time
- Adrianna M. Ratajska, Francesca V. Lopez, Lauren E. Kenney, Katie Rodriguez, Rachel Schade, Joshua Gertler, Dawn Bowers
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- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 109-110
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Objective:
Autonomic dysfunction is an important non-motor symptom of Parkinson’s disease (PD), with point prevalence estimates of approximately 50-70%. Common presentations include cardiovascular dysregulation, gastrointestinal dysfunction, impaired thermoregulation, and sexual dysfunction. In the present study, we sought to examine whether autonomic symptoms would predict trajectories of change in depression and anxiety over a 5-year period in newly diagnosed individuals with PD. Given that alterations in autonomic nervous system functioning (e.g., reduced heart rate variability, lower autonomic arousal) are frequently observed in individuals who have anxiety and depression, as well as the negative influence these symptoms can have on quality of life/functioning, we predicted that greater autonomic symptoms would be related to increased mood symptoms over time.
Participants and Methods:Participants included 414 individuals from the Parkinson’s Progression Markers Initiative, a prospective study of newly diagnosed and untreated individuals with PD. The PD participants (mean age=61.6+9.7, mean education=15.6+3.0, 92.5% non-Hispanic White) were followed annually for up to five years. Self-reported autonomic symptoms were measured using the Scales for Outcomes in Parkinson’s Disease-Autonomic Dysfunction (SCOPA-AUT), which consists of a total score and 6 subdomain scores (gastrointestinal, urinary, cardiovascular, thermoregulatory, pupillomotor, sexual). Mood measures included the Geriatric Depression Scale (GDS) and State-Trait Anxiety Inventory (STAI). Motor severity was assessed using the Unified Parkinson’s Disease Rating Scale (UPDRS) Part III. Bootstrapped linear regressions were performed to evaluate the relationship between autonomic symptoms (subdomains) and mood using data from the last visit (year 5). For longitudinal analyses, bootstrapped multilevel modeling was used to examine a) changes in SCOPA-AUT total over time (unconditional growth model only) and b) the relationship between mood and SCOPA-AUT total score over time, controlling for age/sex and motor severity.
Results:Autonomic symptoms explained 28.2% of the total variance in trait anxiety, with unique predictors of gastrointestinal (/3=.266, p<.001) and thermoregulatory (ß=.202, p=.004) symptoms. For depression, autonomic symptoms explained 27.9% of the total variance, with unique predictors of gastrointestinal (ß=.225, p=.012), thermoregulatory (ß=.178, p=.013), and cardiovascular (ß=.154, p=.012) symptoms. There was a gradual linear increase in total autonomic symptoms over time (b=0.86, p<.001). Greater total autonomic symptoms were associated with higher average trait anxiety (b=0.54, p<.001), slightly greater increase in trait anxiety over time (b=0.04, p<.05), and occasion-to-occasion fluctuations in trait anxiety (b=0.24, p<.001). Similarly, increased total autonomic symptoms were associated with higher average depressive symptoms (b=0.14, p<.001), minimally greater increase in depressive symptoms over time (b=0.01, p<.05), and occasion-to-occasion fluctuations in depressive symptoms (b=0.08, p<.001). Motor severity did not explain individual differences or trajectories of change in depression or trait anxiety.
Conclusions:Autonomic symptoms, particularly gastrointestinal, cardiovascular, and thermoregulatory dysfunction, were related to increased mood symptoms in PD patients and predicted increases in depression/anxiety over time. Our findings do not distinguish between two theoretical possibilities - whether autonomic symptoms lead to depression/anxiety versus involvement of co-occurring neural systems underlying both. Regardless, our study highlights the importance of treating autonomic dysfunction in early PD, and future work should incorporate additional measures of autonomic dysfunction (e.g., physiological probes).
20 Laterality of Motor Symptom Onset is Not Associated with Cognitive Performance or Mood Symptoms in a Sample of 600 Individuals with Idiopathic Parkinson’s Disease”
- Joshua Gertler, Lauren Kenney, Adrianna M Ratajska, Francesca V Lopez, Katie Rodriguez, Rachel Schade, Dawn Bowers
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- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 537-538
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Objective:
Parkinson’s disease (PD) is typically characterized by unilateral onset of motor symptoms (i.e., tremors, rigidity) which is caused by dopaminergic degeneration of the substantia nigra that influences basal ganglia-prefrontal circuitry. Over time, motor symptoms become more bilateral, though continue to remain asymmetric. Many neuropsychological studies suggest that laterality of motor onset may be linked to hemispheric specific cognitive or mood changes. Namely, worse verbal/language performance may be present in individuals with right body (left hemisphere) onset and conversely for visuospatial performance, with depression symptoms relating more so to individuals with right body (left hemisphere) onset. To date, findings are often inconsistent, with some studies showing evidence for laterality effects and others not. The basis for this inconsistency is unclear, though one possibility relates to small sample sizes and varying methodologies. Thus, the goal of this study was to examine potential cognitive and mood laterality effects in a large clinical sample of individuals with PD.
Participants and Methods:Participants included a convenience sample of 600 nondemented individuals with idiopathic PD from the University of Florida Fixel Institute Movement Disorders Center. As a group, participants were around 60 years of age (Mean Age=63.9+9.4), well educated (Mean years=14.9+2.7), predominantly male (70%), and white non-Hispanic (93%). Side of initial motor symptom onset was based on self-report: Right (N=337) and Left (N=263). Approximately 79% were tremor predominant. All received mood and neurocognitive measures as part of standard clinical care, including indices of executive function (Stroop Color-Word, Trails B, Letter Fluency), recent verbal memory (delayed recall: Hopkin’s Verbal Learning Test, WMS-III Logical Memory), language (Boston Naming Test, Animal fluency), visuospatial skills (Judgment of Line Orientation, Facial Recognition Test). Evaluation of emotion symptoms included: depression (Beck Depression Inventory-II), apathy (Apathy Scale), and anxiety (State-Trait Anxiety Inventory). Analyses used raw scores from these measures. Due to non-normality of most measures’ distributions, laterality effects were examined using bootstrapped multivariate methods (multivariate analysis of variance [MANOVA]). Separate MANOVA’s were run for each cognitive domain (i.e., EF, language, etc.) and mood measures.
Results:The right and left sided onset groups did not significantly differ in demographic (age, education, sex) or disease characteristics (duration, PD subtype). Results of the MANOVA’s with cognitive variables were all nonsignificant broadly (all with F’s ranging from .33 to .94) and at the single test level. Similarly, the left and right onset groups did not significantly differ (a=0.05) across standard scales of depression (F=0.031), anxiety (Trait F=0.463; State F=3.29), and apathy (F=0.74).
Conclusions:We found no evidence that laterality of initial motor symptoms influenced cognitive or mood symptoms in a large cohort of 600 individuals with PD. These findings raise questions about importance of motor onset laterality for cognitive and emotion related changes in PD. Future studies should move beyond self-report and behavioral motor scales for determining hemispheric contributions. In PD, use of refined metrics for determining the extent of asymmetric dopaminergic degeneration (e.g., DAT scan) at the hemispheric level coupled with sensitive neuropsychological measures may provide clearer understanding of potential neural circuitry relationships.
18 Regional patterns of mitochondrial function using phosphorus magnetic resonance spectroscopy in older adults at-risk for Alzheimer’s disease.
- Francesca V Lopez, Andrew O’Shea, Stacey Alvarez-Alvarado, Adrianna Ratajska, Lauren Kenney, Rachel Schade, Katie Rodriguez, Alyssa Ray, Rebecca O’Connell, Lauren Santos, Emily Van Etten, Hyun Song, Emma Armstrong, Tiffany Gin, Zhiguang Huo, Gene Alexander, Adam J Woods, Dawn Bowers
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- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 331-332
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Objective:
The brain is reliant on mitochondria to carry out a host of vital cellular functions (e.g., energy metabolism, respiration, apoptosis) to maintain neuronal integrity. Clinically relevant, dysfunctional mitochondria have been implicated as central to the pathogenesis of Alzheimer’s disease (AD). Phosphorous magnetic resonance spectroscopy (31p MRS) is a non-invasive and powerful method for examining in vivo mitochondrial function via high energy phosphates and phospholipid metabolism ratios. At least one prior 31p MRS study found temporal-frontal differences for high energy phosphates in persons with mild AD. The goal of the current study was to examine regional (i.e., frontal, temporal) 31p MRS ratios of mitochondrial function in a sample of older adults at-risk for AD. Given the high energy consumption in temporal lobes (i.e., hippocampus) and preferential age-related changes in frontal structure-function, we predicted 31p MRS ratios of mitochondrial function would be greater in temporal as compared to frontal regions.
Participants and Methods:The current study leveraged baseline neuroimaging data from an ongoing multisite study at the University of Florida and University of Arizona. Participants were older adults with memory complaints and a first-degree family history of AD [N = 70; mean [M] age [years] = 70.9, standard deviation [SD] =5.1; M education [years] = 16.2, SD = 2.2; M MoCA = 26.5, SD = 2.4; 61.4% female; 91.5% non-latinx white]. To achieve optimal sensitivity, we used a single voxel method to examine 31p MRS ratios (bilateral prefrontal and left temporal). Mitochondrial function was estimated by computing 5 ratios for each voxel: summed adenosine triphosphate to total pooled phosphorous (ATP/TP; momentary energy), ATP to inorganic phosphate (ATP/Pi; energy consumption), phosphocreatine to ATP (PCr/ATP; energy reserve), phosphocreatine to inorganic phosphate (PCr/Pi; oxidative phosphorylation), and phosphomonoesters to phosphodiesters (PME/PDE; cellular membrane turnover rate). All ratios were corrected for voxel size and cerebrospinal fluid fraction. Separate repeated measures analyses of variance controlling for scanner site differences (RM ANCOVAs) were performed.
Results:31p MRS ratios were unrelated to demographic characteristics and were not included as additional covariates in analyses. Results of separate RM ANCOVAs revealed all 31p MRS ratios of mitochondrial function were greater in left temporal relative to bilateral prefrontal voxel: ATP/TP (p < .001), ATP/Pi (p = .001), PCr/ATP (p = .004), PCr/Pi (p = .004), and PME/PDE (p = .017). Effect sizes (partial eta squared) ranged from 0.6-.20.
Conclusions:Consistent and extending one prior study, all 31p MRS ratios of mitochondrial function were greater in temporal as compared to frontal regions in older adults at-risk for AD. This may in part be related to the intrinsically high metabolic rate of the temporal region and preferential age-related changes in frontal structure-function. Alternatively, findings may reflect the influence of unaccounted factors (e.g., hemodynamics, auditory stimulation). Longitudinal study designs may inform whether patterns of mitochondrial function across different brain regions are present early in development, occur across the lifespan, or some combination. In turn, this may inform future studies examining differences in mitochondrial function (as measured using 31p MRS) in AD.
Perception of cognitive change by individuals with Parkinson’s disease or essential tremor seeking deep brain stimulation: Utility of the cognitive change index
- Katie Rodriguez, Rachel N. Schade, Francesca V. Lopez, Lauren E. Kenney, Adrianna M. Ratajska, Joshua Gertler, Dawn Bowers
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- Journal of the International Neuropsychological Society / Volume 30 / Issue 4 / May 2024
- Published online by Cambridge University Press:
- 06 October 2023, pp. 370-379
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Objective:
The Cognitive Change Index (CCI-20) is a validated questionnaire that assesses subjective cognitive complaints (SCCs) across memory, language, and executive domains. We aimed to: (a) examine the internal consistency and construct validity of the CCI-20 in patients with movement disorders and (b) learn how the CCI-20 corresponds to objective neuropsychological and mood performance in individuals with Parkinson’s disease (PD) or essential tremor (ET) seeking deep brain stimulation (DBS).
Methods:216 participants (N = 149 PD; N = 67 ET) underwent neuropsychological evaluation and received the CCI-20. The proposed domains of the CCI-20 were examined via confirmatory (CFA) and exploratory (EFA) factor analyses. Hierarchical regressions were used to assess the relationship among subjective cognitive complaints, neuropsychological performance and mood symptoms.
Results:PD and ET groups were similar across neuropsychological, mood, and CCI-20 scores and were combined into one group who was well educated (m = 15.01 ± 2.92), in their mid-60’s (m = 67.72 ± 9.33), predominantly male (63%), and non-Hispanic White (93.6%). Previously proposed 3-domain CCI-20 model failed to achieve adequate fit. Subsequent EFA revealed two CCI-20 factors: memory and non-memory (p < 0.001; CFI = 0.924). Regressions indicated apathy and depressive symptoms were associated with greater memory and total cognitive complaints, while poor executive function and anxiety were associated with more non-memory complaints.
Conclusion:Two distinct dimensions were identified in the CCI-20: memory and non-memory complaints. Non-memory complaints were indicative of worse executive function, consistent with PD and ET cognitive profiles. Mood significantly contributed to all CCI-20 dimensions. Future studies should explore the utility of SCCs in predicting cognitive decline in these populations.
Coronavirus disease 2019 is associated with long-term depressive symptoms in Spanish older adults with overweight/obesity and metabolic syndrome
- Sangeetha Shyam, Carlos Gómez-Martínez, Indira Paz-Graniel, José J. Gaforio, Miguel Ángel Martínez-González, Dolores Corella, Montserrat Fitó, J. Alfredo Martínez, Ángel M. Alonso-Gómez, Julia Wärnberg, Jesús Vioque, Dora Romaguera, José López-Miranda, Ramon Estruch, Francisco J. Tinahones, José Manuel Santos-Lozano, J. Luís Serra-Majem, Aurora Bueno-Cavanillas, Josep A. Tur, Vicente Martín Sánchez, Xavier Pintó, María Ortiz Ramos, Josep Vidal, Maria Mar Alcarria, Lidia Daimiel, Emilio Ros, Fernando Fernandez-Aranda, Stephanie K. Nishi, Oscar García Regata, Estefania Toledo, Jose V. Sorli, Olga Castañer, Antonio Garcia-Rios, Rafael Valls-Enguix, Napoleon Perez-Farinos, M. Angeles Zulet, Elena Rayó-Gago, Rosa Casas, Mario Rivera-Izquierdo, Lucas Tojal-Sierra, Miguel Damas-Fuentes, Pilar Buil-Cosiales, Rebeca Fernández-Carrion, Albert Goday, Patricia J. Peña-Orihuela, Laura Compañ-Gabucio, Javier Diez-Espino, Susanna Tello, Ana González-Pinto, Víctor de la O, Miguel Delgado-Rodríguez, Nancy Babio, Jordi Salas-Salvadó
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- Psychological Medicine / Volume 54 / Issue 3 / February 2024
- Published online by Cambridge University Press:
- 05 September 2023, pp. 620-630
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Background
The coronavirus disease 2019 (COVID-19) has serious physiological and psychological consequences. The long-term (>12 weeks post-infection) impact of COVID-19 on mental health, specifically in older adults, is unclear. We longitudinally assessed the association of COVID-19 with depression symptomatology in community-dwelling older adults with metabolic syndrome within the framework of the PREDIMED-Plus cohort.
MethodsParticipants (n = 5486) aged 55–75 years were included in this longitudinal cohort. COVID-19 status (positive/negative) determined by tests (e.g. polymerase chain reaction severe acute respiratory syndrome coronavirus 2, IgG) was confirmed via event adjudication (410 cases). Pre- and post-COVID-19 depressive symptomatology was ascertained from annual assessments conducted using a validated 21-item Spanish Beck Depression Inventory-II (BDI-II). Multivariable linear and logistic regression models assessed the association between COVID-19 and depression symptomatology.
ResultsCOVID-19 in older adults was associated with higher post-COVID-19 BDI-II scores measured at a median (interquartile range) of 29 (15–40) weeks post-infection [fully adjusted β = 0.65 points, 95% confidence interval (CI) 0.15–1.15; p = 0.011]. This association was particularly prominent in women (β = 1.38 points, 95% CI 0.44–2.33, p = 0.004). COVID-19 was associated with 62% increased odds of elevated depression risk (BDI-II ≥ 14) post-COVID-19 when adjusted for confounders (odds ratio; 95% CI 1.13–2.30, p = 0.008).
ConclusionsCOVID-19 was associated with long-term depression risk in older adults with overweight/obesity and metabolic syndrome, particularly in women. Thus, long-term evaluations of the impact of COVID-19 on mental health and preventive public health initiatives are warranted in older adults.
Using intonation to disambiguate meaning: The role of empathy and proficiency in L2 perceptual development
- Joseph V. Casillas, Juan José Garrido-Pozú, Kyle Parrish, Laura Fernández Arroyo, Nicole Rodríguez, Robert Esposito, Isabelle Chang, Kimberly Gómez, Gabriela Constantin-Dureci, Jiawei Shao, Iván Andreu Rascón, Katherine Taveras
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- Applied Psycholinguistics / Volume 44 / Issue 5 / September 2023
- Published online by Cambridge University Press:
- 17 August 2023, pp. 913-940
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The present study investigates the interplay between proficiency and empathy in the development of second language (L2) prosody by analyzing the perception and processing of intonation in questions and statements in L2 Spanish. A total of 225 adult L2 Spanish learners (L1 English) from the Northeastern United States completed a two-alternative forced choice (2AFC) task in which they listened to four utterance types and categorized them as either questions or statements. We used Bayesian multilevel regression and drift diffusion modeling to analyze the 2AFC data as a function of proficiency level and empathy scores for each utterance type. We show that learner response accuracy and sensitivity to intonation are positively correlated with proficiency, and this association is affected by individual empathy levels in both response accuracy and sentence processing. Higher empathic individuals, in comparison with lower empathic individuals, appear to be more sensitive to intonation cues in the process of forming sound-meaning associations, though increased sensitivity does not necessarily imply increased processing speed. The results motivate the inclusion of measures of pragmatic skill, such as empathy, to better account for intonational meaning processing and sentence comprehension in second language acquisition.
Group psychotherapy for patients with first-episode psychosis: Effect on the clinical status and use of resources
- P. Herrero Ortega, A. Oliva Lozano, J. Garde González, C. Bayón-Pérez, R. Mediavilla, M. P. Vidal-Villegas, B. Rodríguez-Vega, S. Cebolla, E. Román, E. V. Pérez Pérez, M. F. Bravo-Ortiz, O. B. O. AGES-Mind Group
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S635-S636
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Introduction
Psychotic disorders carry several economical, psychological and social consequences, both at individual and community levels. Early intervention programs after first-episode psychosis which combine pharmacological and psychosocial strategies are aimed at reducing symptoms, lowering costs in the use of health and non-health care resources and improving overall functioning. AGES-Mind study is based on manualized psychotherapeutic interventions for people with first-psychosis episodes.
ObjectivesThe aim of the study was to evaluate the effect of a group psychotherapeutic intervention on the clinical status and use of clinical resources in a sample of patients with first-episode psychosis at 12 and 24 months after the beginning of the intervention. This cohort will be compared to patients with first-psychosis episodes without group psychotherapeutic intervention.
MethodsLongitudinal, observational, retrospective study on a cohort of N=46 patients with first-episode psychosis within the last 5 years. Two groups of 23 patients each were formed. The participants of one of those groups received group psychotherapy in the context of the AGES-Mind study and the other group received treatment as usual without group intervention. Non-exposed patients were matched by age, gender and time elapsed since first-episode psychosis with those exposed to the intervention. Sociodemographic data, clinical status and use of clinical resources outcome variables were assessed.
ResultsNo significant differences were found in clinical status and use of resources between participants and non-participants in the psychotherapeutic group intervention after 12 and 24 months.
ConclusionsAfter controlling for potentially confounding variables as sociodemographic, age and time since first-episode, participating in a group psychotherapeutic program does not seem to improve clinical variables or use of resources. Further studies with larger samples would be necessary to explore other variables, such as symptoms, satisfaction with the intervention or social functioning.
Disclosure of InterestNone Declared
The impact of the COVID-19 pandemic on health outcomes in delusional disorder: A systematic review
- E. Román, M. Natividad, M. V. Seeman, E. Izquierdo, E. Martínez, E. Rial, A. Alvarez, A. Guàrdia, J. A. Monreal, A. González-Rodríguez
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S790
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Introduction
The health impact of the COVID-19 pandemic has been widely recognized in both physical and mental health. Relatively little attention has been paid to patients with delusional disorder (DD).
ObjectivesOur goal was to synthesize the known mental and physical health consequences of the COVID-19 pandemic in patients diagnosed with DD.
MethodsA systematic review was carried out using the PubMed and Scopus database (2019-October 2022) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Search terms: “delusional disorder” or “delusional disorder” AND “COVID-19 OR SARS-CoV2.” Inclusion criteria: 1)DD according to DSM/ICD, 2)languages: English, French, German and Spanish, 3)studies reporting health consequences of COVID-19 pandemic. From a total of 615 records, 6 were included: meta-analysis (n=1), cross-sectional studies (n=2), retrospective study (n=1), case reports (n=2).
ResultsA full third of patients with psychosis (including DD) presented with increased psychiatric symptom severity, reportedly activated by increased daily life stress. Suicidal behavior was reported in a previously undiagnosed DD patient in association with a worsening clinical picture. Perhaps surprisingly, admissions for DD in 2020 were lower than in 2019. The duration of hospitalization was, however, longer. There was a report of new onset DD with delusional material centred on COVID. There was also a report of COVID-19 symptoms being more severe in DD patients than in the larger community.
ConclusionsHealth emergencies affect the seriously mentally ill more than other community members. Awareness and outreach can help to maintain treatment adherence and minimize risk of psychotic exacerbation.
Disclosure of InterestNone Declared
Smoking treatments for patients with mental illness: case presentation and a brief literature review
- F. Garcia Sanchez, M. Gutierrez Rodriguez, C. Moreno Menguiano, M. A. Corral Alonso, J. J. Vazquez Vazquez, S. M. Bañon Gonzalez, V. Voces Domingo, J. A. Casado de la Hera
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S756
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Introduction
Smoking prevalence in patients with mental illness ranges between two to 4 times higher than general population. This higher prevalence has a multifactorial origin, and some of the possible causes are still unknown.
They have a higher prevalence of tobacco-associated diseases and higher mortality.
Additionally, these patients have greater difficulty in treating and quitting smoking.
A relationship has been found between severity of mental illness and smoking. Risk of suicide seems to be higher in patients with higher tobacco consumption. Schizophrenia is the mental illness that has been most closely related to smoking, with a prevalence close to 90%.
ObjectivesThe aim of this work is reviewing the current bibliography referring to smoking treatments for patients with mental illness
MethodsA literature search using electronic manuscripts available in PubMed database published during the last ten years and further description and discussion of a single-patient clinical case
ResultsThe treatment of tobacco dependence in patients with mental illnesses is sometimes waited until there is psychiatric stability, which can take a long time in those cases with more severe mental disorders, which can have negative physical and psychiatric consequences.
The combined treatment of cognitive behavioral therapy and pharmacological treatment is the most effective approach. Nicotine replacement therapy can be useful, while combined use of antidepressants or anxiolytics is also recommended.
Bupropion has shown efficacy. In patients with schizophrenia it does not seem to worsen positive symptomatology, but improving the negative one. It should not be used in patients with bipolar disorder or bulimia.
Varenicline has shown efficacy in the general population, but limitations were established in patients with mental illness, although it is the drug that has shown greater efficacy. However, is not currently available in our country.
Cytisine is a drug with limited number of studies in the psychiatric population but it may be a reasonable treatment alternative.
ConclusionsThe prevalence of tobacco use in patients with mental illness is higher than the general population, especially in paranoid schizophrenia. The consequences on physical health and the evolution of psychiatric illness are very relevant. Based on above, a multidisciplinary and coordinated management involving psychiatrists and other specialists in the treatment of these patients should be desirable.
Disclosure of InterestNone Declared
Unit for women with schizophrenia in a community mental health service: Description of current and projected programs and quality evaluation measures
- A. González- Rodríguez, M. V. Seeman, M. Natividad, P. Barrio, E. Román, A. Balagué, J. P. Paolini, J. A. Monreal
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S1123-S1124
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Introduction
Women with schizophrenia require health interventions and safe spaces sufficiently different from those of men.
ObjectivesTo describe units in two mental health outpatient services specialized in the treatment of women with schizophrenia and related disorders.
MethodsTwo units in Spain projected to treat women with schizophrenia and related disorders - Community Mental Health Programs (CMHU Rambla, CMHU Sant Cugat) will be described. Recruitment, assessment, intervention, and evaluation and satisfaction measures will be characterized, and the need to build-in safety precautions (policy/structural).
ResultsDemographics:(Preliminary 2021 data on the two services).
Patients attending (CMHU): 3,393. Forty-five per cent diagnosed with severe mental illness. Schizophrenia and related disorders: 873 patients. 58% women.
Staffing projected: 2 psychiatrists, 2 nurses, 1 clinical psychologist, 2 social workers.
Physical structure: Safe spaces for women/children.
Programs (offered currently and in planning stages): 1)Therapeutic Drug Monitoring/Adherence, 2)Individual/group patient/family sessions, 3)Perinatal Mental Health (preconception, pregnancy, lactation, postpartum, parent training/support), 4)Collaborative programs (primary care, medical specialties especially obstetrics/gynecology and endocrinology, trauma specialists, addiction experts), 5)prevention/intervention of suicide risk, 6)social services (single mothers, family issues, domestic abuse, sexual exploitation) 7)home-based services, 8)peer support, 9)physical activity, 10)psychoeducation for patients and families.
Planned quality evaluation measures: diagnostic assessment (reliability, long-term validity);regular treatment effectiveness evaluation (individualization of treatment plans, assessment of adverse effects of drugs, screening for metabolic syndrome/ physical health, family intervention, psychoeducation (individual/group) assessment of suicidal ideation and global functioning.
ConclusionsSpecific services for women with schizophrenia and related disorders represent an important resource to improve patient well-being and offer clinical care leading to individual recovery.
Disclosure of InterestNone Declared
Phenomenology, clinical aspects and therapeutic implications of delusional memories in Delusional Disorders: A Systematic Review
- A. González- Rodríguez, J. A. Monreal, M. Solmi, M. Balestrieri, M. Fornaro, A.-L. Panfil, F. Duval, M. V. Seeman
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S373
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Introduction
Delusional memories or retrospective delusions have been extensively reported in subjects during or after intensive care stays. In major psychoses, authors have classically observed delusional memories impacting the prognosis and mental well-being.
ObjectivesOur aim was to review the phenomenology, psychological/biological factors contributing to delusional memories in delusional disorder (DD), and potential treatment strategies.
MethodsSystematic review using PubMed, Scopus, SciELO and Web of Science electronic databases (inception-September 2022). Search terms: (“delusional memories” OR “retrospective delusions”) AND (“Schizophrenia, Paranoid”) [MeSH]. Studies were included if they reported psychopathology, clinical characteristics or treatment strategies of “delusional memories” in DD. Team members: AGR, JAM, MS, MB, MF, ACP, FD, MVS.
ResultsA total of 786 records were retrieved, including six studies. Psychogenesis:A novel cognitive neuropsychological research model (based on hypnosis) in erotomania delusions suggest a potential recall and reinterpretation of delusions beliefs in highly hypnotizable subjects. Biological basis: Frontal lobe (or executive) dysfunction does not seem to contribute to delusional memories in De Clérambault syndrome (erotomania). Phenomenology: 1)General knowledge was essentially intact, while the perceptual characteristics of delusional memories were stronger than real memories. 2)Correlations were found between delusional ideation, positive dimension of schizotypy (r=0.18), and false memories (r=0.27). 3)Jumping-to-conclusions and liberal acceptance bias influence delusional memories. Treatment:Efficacy of 1)Cognitive Behavioural Therapy (CBT) (significant reduction delusions), and 2)Metacognitive control over false memories.
ConclusionsThis is the first review exploring the genesis and management of delusional memories in DD. Memory deficits/executive dysfunctions do not seem to be the only cause of this phenomenon.
Disclosure of InterestNone Declared
Evaluation of factors that may influence the development of chronic kidney disease in patients with bipolar disorder treated with lithium.
- N. Gutiérrez Mora, J. Torres Cortés, I. Esteban Avendaño, V. Burguera Vion, J. M. Montes Rodríguez
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S83-S84
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Introduction
Bipolar disorder (BD) is a serious and chronic mental disease of mood. Lithium is used for treatment and studies have demonstrated that it is the most efficient drug, reducing suicide risk in a high percentage of patients. However, this drug has well known side effects, such as kidney damage. Lithium could cause chronic kidney disease, specially with the presence of other risk factors.
ObjectivesObservational and retrospective study of creatinine levels and glomerular filtration rates observed in blood analysis (follow-up period of 11 years). Sample size of 263 patients diagnosed of BD I and BD II in treatment with lithium. We used socio-demographic (age, sex) and clinic variables (diabetes mellitus, hypertension, use of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or diuretics) to generate bivariate and multivariate analysis.
MethodsOur main objective is to analyze the deterioration of kidney function and the development of chronic kidney disease that chronic treatment with lithium can induce in patients with BD. Our secondary objective is to determine variables which could promote the development of chronic kidney disease, and to assess if these variables could be considered as risk factors during the treatment with lithium.
Results11,3 % of patients in our study developed chronic kidney disease during monitoring. The deterioration of GFR in patients in treatment with lithium was significantly associated with female sex and NSAIDs consumption. A trend towards statistical significance was found regarding the use of diuretics (p=0,060). No statistical significance was found between diabetes mellitus, hypertension or type of BD and the deterioration of kidney function in our sample. An inverse association was found between the GFR decline and the age but no statistical significance was demonstrated.
ConclusionsWe conclude that female sex and use of NSAIDs are predicting factors of GFR decline in patients with BD in chronic treatment with lithium. We must take into account these drugs or even avoid concomitant treatment (lithium and NSAIDs) in order to prevent chronic kidney disease. In addition to it, we should recommend careful use of diuretics during treatment with lithium because of risk of dehydration. Diabetes mellitus and hypertension have universally been associated to increase risk of development of chronic kidney disease. However, we have not found statistical significance in our study. Therefore, research should be done in order to determine specific risk factors in this group of patients and, consequently, optimize their treatment.
Disclosure of InterestNone Declared
Alternative initiations of three-monthly and six-monthly paliperidone palmitate in a psychiatric hospitalization unit. About two clinical cases.
- V. Juárez Calvo, C. Rodríguez Villarino, M. Presa García
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S1091
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Introduction
Long acting injectable antipsychotics (LAIA) have been an important therapeutic advance. Due to poor adherence, in some patients the only way to ensure the continuity of outpatient care is to anticipate the use of a 3-monthly or 6-monthly LAIA. There is already experience of alternative initiations with 6-monthly and 3-monthly paliperidone palmitate with with an excellent tolerability and efficacy profile, following the same alternative initiation regimen used in these clinical cases.
ObjectivesThe aim of the present study is to describe the alternative initiations with 3-monthly paliperidone palmitate (PP3) and 6- monthly paliperidone palmitate (PP6) carried out at the brief hospitalization unit of psychiatry of Hospital Central de la Defensa Gómez Ulla, Centro Sanitario de Vida y de Esperanza
MethodsWe report two clinical cases. With regard to two patients diagnosed with schizophrenia, with poor adherence to treatment previously prescribed with monthly LAIA, refusal to take oral medication and with serious behavioral changes due to psychotic relapses, the process of psychopathological stabilization is described with an alternative initiation of PP6 and PP3.
ResultsBoth patients had a diagnosis of schizophrenia, being men of 32 and 28 years of age admitted to the brief hospitalization unit of psychiatry, who presented important behavioral alterations due to sensory-perceptive alterations and the delusional ideas they presented. Initially, psychopathological stability was achieved, remission of all symptoms, with oral paliperidone 12 mg in both patients. Subsequently, the alternative initiation scheme was followed, consisting of administering on the same day (day 1) 150 mg of 1-monthly paliperidone palmitate (PP1) together with 1000 mg of 6-monthly paliperidone palmitate in one of the patients, and in the other patient, on the same day (day 1) 150 mg of 1-monthly paliperidone palmitate and 525 mg of 3-monthly paliperidone palmitate. Both patients maintained psychopathological stability, allowing early hospital discharge and no decompensation occurring during the following 6 months of follow-up.
ConclusionsThere is an important group of patients with severe mental disorder that could benefit from an alternative initiation with 3/6-monthly paliperidone palmitate, rather than the standard initiation with monthly paliperidone palmitate. We present two patients who have greatly benefited from an alternative initiation, with the structure of PP1 150 mg + PP3 525 mg (both administered on day 1) and PP1 150 mg + PP6 1000 mg (both administered on day 1). The use of these alternative starts with PP3 and PP6 may be an important clinical tool for less adherent patients. More studies are needed to confirm these results.
Disclosure of InterestNone Declared
Relationship between CAINS negative symptoms and cognition, psychosocial functioning and quality of life in patients with a first psychotic episode of schizophrenia
- R. Rodriguez-Jimenez, L. García-Fernández, V. Romero-Ferreiro, M. Valtueña García, A. I. Aparicio, J. M. Espejo-Saavedra, L. Sánchez-Pastor, A. Nuñez-Doyle, M. Dompablo, O. Jiménez-Rodríguez, D. Rentero, P. Fernández-Sotos, I. Martínez-Gras, J. L. Santos
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, pp. S641-S642
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Introduction
Negative symptoms has been classically associated with cognition, psychosocial functioning and quality of life in patients with schizophrenia. But negative symptoms are not a unitary construct, encompassing two different factors: diminished expression, and motivation and pleasure. Few works have studied the relationship between these two different negative symptoms factors and cognition (neuro and social cognition), psychosocial functioning and quality of life, jointly, in patients with a first psychotic episode of schizophrenia.
ObjectivesThe objective of the present work was to study, in a sample of patients with a first psychotic episode of schizophrenia, the relationship between the negative symptoms (diminished expression and motivation and pleasure) and neurocognition, social cognition, functioning and quality of life.
MethodsThe study was carried out with 82 outpatients with a first psychotic episode of schizophrenia from two Spanish hospitals (“12 de Octubre” University Hospital, Madrid and “Virgen de la Luz” Hospital, Cuenca). The patients were assessed with the Clinical Assessment Interview for Negative Symptoms (CAINS) for evaluating diminished expression (EXP) and motivation and pleasure (MAP) symptoms, the MATRICS Consensus Cognitive Battery (MCCB) for evaluating neurocognition and social cognition, the Social and Occupational Functioning Assessment Scale (SOFAS), and the Quality of Life Scale (QLS).
ResultsA negative correlation was found between neurocognition and the two negative symptoms subscales: CAINS-EXP (r=-0.458, p<0.001) and CAINS-MAP (r=-0.374, p<0.001); but with social cognition only CAINS-EXP was correlated (r=-0.236, p=0.033). Also, it was found a high negative correlation between SOFAS scores and CAINS-MAP (r=-0.717, p<0.001); and a medium negative correlation with CAINS-EXP (r=-0.394, p<0.001). Finally, QLS score was high correlated with both CAINS subscales: CAINS-EXP (r=-0.681, p<0.001) and CAINS-MAP (r=-0.770, p<0.001).
ConclusionsThis study found a relationship between negative symptoms and neurocognition, social cognition, functioning and quality of life in a sample of patients with a first psychotic episode of schizophrenia. But the two different negative symptom factors, diminished expression, and motivation and pleasure, are associated differently with psychosocial functioning, but especially with social cognition where the relationship was only found with diminished expression symptoms.
Disclosure of InterestNone Declared
Two-year experience of the implementation of a psychiatric home hospitalization care service for acute mental illness
- A. Guàrdia, L. Marin, A. González-Rodríguez, V. Bañon, E. Izquierdo, L. Lafuente, X. Martinez-Bio, D. Llors, M. Natividad, L. Ros, J. A. Monreal
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- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S169
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Introduction
Psychiatric home hospitalisation is a service aiming to support people with mental illnesses in their acute stage at their own home. This care model has been recently implemented in our territory with the main objective of avoiding hospital admissions.
ObjectivesOur goal is to describe a cohort of patients followed up over 2-years in the context of a pilot mental health program within a community-based model (Mutua Terrassa University Hospital).
MethodsWe conducted a prospective longitudinal study including 125 patients attended from 01/11/2020 to 09/11/2022 in our reference area of 250,000 inhabitants. The team was formed by 1 psychiatrist and 1 mental health nurse. DSM-5 diagnoses, socio-demographic variables, mean stay and care trajectories were collected.
ResultsOne-hundred twenty-five patients were attended (women: 70). Mean age at consultation: 38.3 years-old. Mean stay: 24 days. The most frequent diagnoses: non-affective psychotic disorders (58%), affective disorders (30%), followed by anxiety and personality disorders. Referrals from Community Mental Health Outpatient Services (CMHS) (72%), Acute Inpatient Unit (25%), and Psychiatric Emergency Service (3%). Referrals after discharge: CMHS (83%), Adult Acute Inpatient Unit (13%), others (4%). Individualized mental health plans were carried out in all cases, in coordination with community mental health services. Follow-up adherence after discharge was about 95%. Patients with first-episode of psychosis showed the highest degree of satisfaction (N=46).
ConclusionsPatients with emerging psychosis were the profile of users who showed the highest benefit of our service. Women showed higher adherence, and loss to follow-up was lower than we expected.
Disclosure of InterestNone Declared
Attributional styles and other cognitive biases in patients with delusional disorder: A systematic review
- A. Guàrdia, A. González-Rodríguez, M. V. Seeman, X. Martinez-Bio, M. Natividad, J. A. Monreal
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- Journal:
- European Psychiatry / Volume 66 / Issue S1 / March 2023
- Published online by Cambridge University Press:
- 19 July 2023, p. S253
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Introduction
The accurate examination of attributional patterns and cognitive biases in delusional patients is relevant to explain the externalizing tendency in paranoid schizophrenia patients. In subjects with delusional disorder (DD), attributional styles and other cognitive bias have been poorly investigated.
ObjectivesOur main goal was to review the tendency to use external-internal attributions for negative events and the presence/absence of other cognitive biases in patients suffering from DD.
MethodsA systematic review was conducted in PubMed and ClinicalTrials.gov databases/registers up to September 2022 according to the PRISMA Guidelines. The following key-words were searched in the title and abstracts: (attributions OR attributional OR “cognitive” OR “cognition” OR “social cognition”) AND (“delusional disorder”). Additionally, references of included studies were manually examined to identify further studies.
ResultsA total of 144 records were identified (Pubmed, n=125; ClinicalTrials.gov, n=16; other sources, n=13), five studies met our inclusion criteria, reporting attributional styles (n=5) and other cognitive biases (n=2) in DD. (A)Attributional style in DD. Mainly excessive external attributions implying the ascribing of negative experiences to another person’s behavior or action. Other authors describe attributions of negative events to internal causes (n=2). (B)Cognitive biases: Jumping to conclusions bias or judgments made on inadequate evidence have been described in DD (n=2).
ConclusionsFindings in attributional patterns in DD are mixed. Several authors report external and stable attributions in DD, whereas others described internal attributes for negative events, suggesting that depressive vs. “pure” paranoid core dimensions may appear in DD.
Disclosure of InterestNone Declared
Assessment of beliefs and attitudes about electroconvulsive therapy posted on Twitter: An observational study
- L. de Anta, M. A. Alvarez-Mon, C. Donat-Vargas, F. J. Lara-Abelanda, V. Pereira-Sanchez, C. Gonzalez Rodriguez, F. Mora, M. A. Ortega, J. Quintero, M. Alvarez-Mon
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- Journal:
- European Psychiatry / Volume 66 / Issue 1 / 2023
- Published online by Cambridge University Press:
- 09 January 2023, e11
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Background
Electroconvulsive therapy (ECT) is an effective and safe medical procedure that mainly indicated for depression, but is also indicated for patients with other conditions. However, ECT is among the most stigmatized and controversial treatments in medicine. Our objective was to examine social media contents on Twitter related to ECT to identify and evaluate public views on the matter.
MethodsWe collected Twitter posts in English and Spanish mentioning ECT between January 1, 2019 and October 31, 2020. Identified tweets were subject to a mixed method quantitative–qualitative content and sentiment analysis combining manual and semi-supervised natural language processing machine-learning analyses. Such analyses identified the distribution of tweets, their public interest (retweets and likes per tweet), and sentiment for the observed different categories of Twitter users and contents.
Results“Healthcare providers” users produced more tweets (25%) than “people with lived experience” and their “relatives” (including family members and close friends or acquaintances) (10% combined), and were the main publishers of “medical” content (mostly related to ECT’s main indications). However, more than half of the total tweets had “joke or trivializing” contents, and such had a higher like and retweet ratio. Among those tweets manifesting personal opinions on ECT, around 75% of them had a negative sentiment.
ConclusionsMixed method analysis of social media contents on Twitter offers a novel perspective to examine public opinion on ECT, and our results show attitudes more negative than those reflected in studies using surveys and other traditional methods.
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