Made available in DSpace on 2011-05-04T12:36:16Z (GMT). No. of bitstreams: 0 Previous issue date: 2009 / RESUMO: Estudos no Brasil relatam alta prevalência do diagnóstico de Transtorno Mental Comum (TMC) nas unidades básicas de saúde, e sua associação com o gênero feminino. O continuum de sintomas dos TMC (quadros depressivos, ansiosos, somáticos e dissociativos) guarda relação com as queixas inespecíficas da popular Doença dos Nervos por esta também apresentar sintomatologia comórbida, além de abranger um espectro genérico de mal-estar psíquico percebido subjetivamente. Apesar do sofrimento dos nervos ser uma avaliação pessoal do próprio estado de saúde (illness), e não uma classificação médica (disease), sua associação com os TMC remete a comprometimentos na esfera psíquica, funcional e na qualidade de vida de quem sofre. OBJETIVO: Conhecer as prevalências dos TMC e da representação do sofrimento dos nervos em 5 unidades do Programa de Saúde da Família (PSF) no município de Petrópolis-RJ; analisar as associações existentes entre ter TMC (considerando também sua intensidade), perceber-se portadora de sofrimento mental(considerando sua duração), e comparar seus impactos sobre os domínios de Qualidade de Vida (QV) estudados; verificar a associação da co-existência de ter TMC grave e ser sofredora crônica dos nervos com QV; verificar a associação de fatores sócio-demográficos e econômicos com TMC, sofrer dos nervos e QV; analisar a associação de rede de apoio social e empoderamento feminino com ter TMC, sofrer dos nervos e QV. METODOLOGIA: Foram avaliadas 969 mulheres atendidas em 2006 em 5 unidades de PSF, durante 1 mês, no município de Petrópolis. A prevalência geral dos TMC foi aferida pelo General Health Questionnaire (GHQ12), usando-se os pontos de corte 2/3 para os quadros leves, e 4/5 para os graves. A intensidade dos transtornos foi medida pelo GHQ contínuo. A percepção do adoecimento agudo e crônico dos nervos foi aferida através de 2 perguntas isoladas quanto à duração do sofrimento. Os dados sócio-demográficos foram coletados por um questionário geral. A mensuração dos níveis de QV em cada domínio foi feita pelo WHOQOLBref. A análise dos fatores associados a QV foi realizada através da regressão linear múltipla modelo stepwise-backward no programa SPSS. RESULTADOS: (...) / Studies in Brazil report a high prevalence of Common Mental Disorders (CMD)diagnosis in primary cares and its association with the female gender. CMD’s continuum of symptoms (depressive, anxious, somatic and dissociative frameworks) resembles unspecific complaints of the commonly known “Nervous Illness”. Its comorbid symptomathologies contain a generic spectrum of a subjectively perceived ill-being of the psyche. Despite “suffering of the nerves” being a personal evaluation of one owns state of health (illness) and not a medical classification (disease), its association with CMD entails distress in the psychic and functional spheres as well as the quality of life of those who suffer from it. Objective: To determine the prevalence of both CMD and “Nervous Illness” in 5 units of the Family Health Programme (FHP) in the municipality of Petropolis-RJ; to analyse possible associations between having CMD (taking the intensity of it into consideration) and self-perceived “Nervous Illness” (taking the duration of the illness into consideration), and to compare the impact of both on the studied range of quality of life (QL) estimators; to verify the interaction between having a grave form of CMD and suffering from chronic “Nervous Illness”; to verify the association between socio-demographic and economic factors with CMD, Nervous Illness and QL; analyse the association between female empowerment and the existence of a social protection network with CMD, Nervous Illness and QL. Methodology: During the year of 2006, 969 women were analysed in 5 units of the FHP in the municipality of Petropolis-RJ for one month. The general prevalence of CMD was determined using the General Health Questionnaire (GHQ12), with cutting points of 2/3 for light cases and 4/5 for the grave cases. The intensity of the disorder was measured by a continuous GHQ. The perception of acute and chronic “Nervous Illness” was inferred using 2 questions isolated in accordance with the duration of the illness. The socio-demographic data was collected via a general questionnaire. Measurements of QL levels, for each range, were done using WHOQOL-Bref. The analyses of factors associated with QL was done using a multiple linear regression, step-wise backward model, in SPSS.Results: Verified mean prevalence of: 61.7% for CMD; 44.6% for grave CMD; mean intensity of the disorder of 31.0, 47.5% for perceived acute “Nervous Illness”; 24.6% of perceived chronic “Nervous Illness”; and a 16.1% interaction between having a grave CMD and suffering from chronic “Nervous Illness”. Statistically significant association between having CMD, suffering from “Nervous Illness” and QL were shown, with each affecting differently the studied ranges. Grave CMD damaged QL the most, with the psychological range suffering the worst effects ( = -13.4; = 65.7) Followed by perceived acute Nervous Illness, specially in the health satisfaction range ( = -9.1; = 77.0). The interaction between grave CMD and chronic Nervous Illness, has shown a strong adverse impact on the physical range ( = -13.1; = 79.2) although it only ranked third on general negative impact on QL. Amongst the socio-demographic variables that show significant associations with QL were personal income ( = 1,9; = 79,2 in the physical range); head of family and education ( = 2,5 e = 3,9, respectively; = 79,2 in the health satisfaction range), demonstrating therefore the positive impact of female empowerment. Household income, civil status and principally religious frequency ( = 4.6; = 77.0 in the health satisfaction range) increased QL levels, by exerting the supportive effects of the social protection network.Conclusions: There is a high prevalence of grave CMD and perception of acute nervous illness amongst female participants of the FHP. Although the presence of CMD has the worst impact on QL, QL is too diminished by perception of Nervous Illness. Female empowerment and social protection networks have a positive effect on QL. Such results emphasize a need to consider subjective interpretations of self-well-being and not only diagnostic criteria when approaching health issues. Only in this way answers that are capable of contemplating a more comprehensive concept of health as quality of life, can be offered.

Made available in DSpace on 2016-06-02T19:42:35Z (GMT). No. of bitstreams: 1 COSTA_Lucio_2014.pdf: 1495926 bytes, checksum: 332ea16b46bc849d4aa06c806a74efaa (MD5) Previous issue date: 2014-08-25 / Financiadora de Estudos e Projetos / - / A presente dissertação tem como foco central os aspectos da proteção e dos direitos das pessoas com transtorno mental em conflito com a lei. Marcada pelo binômio crime/loucura, esta população vem sendo mantida apartada do novo regramento legal que dispõe sobre as garantias e o modelo de atenção psicossocial no País: a Lei Nº 10.216/2001, mais conhecida como Lei da Reforma Psiquiátrica Brasileira. Essa legislação orienta em suas diretrizes uma terapêutica contrária à lógica de asilamento e de segregação, apontando o processo de desinstitucionalização como o mecanismo que deve pautar as políticas públicas na área. Entretanto, milhares de brasileiros marcados pelo estigma da loucura e da criminalidade permanecem esquecidos em espaços de confinamento penal e internação psiquiátrica. Uma experiência inovadora conduzida pelo estado de Goiás vem mudando esse paradigma: o Programa de Atenção ao Louco Infrator (PAILI). Pautado pelas diretrizes estabelecidas pela Reforma Psiquiátrica Brasileira, o projeto tem alcançado índices de reincidência que o distingue sobremaneira dos demais modelos operados na área, constituindo uma possibilidade real de transformação na perspectiva do lidar com o binômio loucura/crime. A partir de um trabalho de campo orientado por entrevistas, além de pesquisa histórica e diálogo com algumas das principais linhas teóricas na área, procuramos situar o PAILI no contexto da desinstitucionalização psiquiátrica e dos desafios ainda presentes à plena efetivação dos direitos dessa população.

Introdução: Os transtornos mentais que ocorrem na comunidade e em culturas diversas são temas de grande interesse frente às constantes transformações sociais no mundo. A mudança do foco de pesquisa para os transtornos freqüentes na comunidade possibilitou aperfeiçoamentos metodológicos e desenvolvimento de instrumentos sensíveis para a sua detecção. A inclusão da variável cultural no estudo da psiquiatria, por sua vez, questiona o universalismo psicopatológico, a taxonomia ocidental e o diagnóstico de síndromes culturalmente específicas. Uma amostra desta visão psiquiátrica, ancorada na questão cultural e de transtornos da comunidade, são as pesquisas envolvendo neurastenia, um transtorno neurótico comum entre os chineses. O presente trabalho é um estudo observacional e transversal dos transtornos mentais comuns entre os indivíduos chineses da comunidade. Objetivo: Avaliar a psicopatologia não-psicótica dos chineses residentes na cidade de São Paulo, através de instrumentos padronizados. Material e Método: Os sujeitos da comunidade (n = 211), chineses e seus descendentes, preencheram um questionário de auto-avaliação e foram entrevistados por pesquisadores treinados. Os instrumentos utilizados foram: Chinese Health Questionnaire (CHQ-12), Escala de Sintomas Físicos, Escala de Eventos Vitais, Inventário de Depressão de Beck (BDI), Inventário de Ansiedade Traço-Estado (IDATE) e Schedule for Clinical Assessment in Neuropsychiatry (SCAN). Os dados foram analisados através de estatística descritiva, análise univariada (testes de qui-quadrado, Fisher e t de Student), análise multivariada (regressão logística), análise da curva ROC, análise fatorial exploratória (CHQ-12) e análise de correlação. Resultados: A probabilidade dos indivíduos pontuar alto no CHQ-12 ou ser casos prováveis de transtornos mentais comuns associou ao fato de ser do sexo feminino (OR = 2,31; IC95%: 1,12–4,75) e fluentes em chinês mandarim (OR = 3,37; IC95%: 1,68–6,78). Além disso, aqueles sujeitos com queixas físicas (OR = 4,20; IC95%: 1,70–10,40), relato de eventos-vitais no último ano (OR = 4,91; IC95%: 1,51–16,00) e pontuação alta no BDI (OR = 1,29; IC95%: 1,20–1,41) também tiveram maior chance de apresentar transtornos. O coeficiente de consistência interna &#61537; de Cronbach do CHQ-12 foi de 0,71 e a correlação item-total variou de 0,25 a 0,55, mostrando boa fidedignidade e homogeneidade deste instrumento. Adotando SCAN como critério-padrão, o melhor ponto de corte de CHQ-12 foi 2/3. Os seguintes indicadores de validade foram calculados a partir deste critério: sensibilidade 75%, especificidade 71%, valor preditivo positivo 55%, valor preditivo negativo 86% e taxa de classificação incorreta 28%. A curva ROC foi utilizada para avaliar a capacidade discriminante do instrumento, tendo uma área sob a curva de 0,728. O questionário CHQ-12 também se correlacionou significativamente com Escala de Sintomas Físicos (p < 0,005), Escala de Eventos Vitais (p < 0,005), BDI (p < 0,0005) e IDATE (p < 0,05). Na análise fatorial exploratória, três dimensões psicopatológicas explicaram 47,8% da variância total do CHQ-12. O conteúdo sintomatológico avaliado por este instrumento pode ser descrito como tridimensional, contendo fator somático, depressivo e de preocupação. As entrevistas do SCAN (n = 25) geraram diagnósticos de distimia, depressão e insônia não orgânica (CID-10). Os item-grupos “mau funcionamento subjetivo” (p < 0,005) e “características especiais de depressão” (p < 0,005) predominaram no perfil sintomatológico dos casos positivos de SCAN. Conclusão: Os transtornos mentais comuns predominantes na comunidade chinesa de São Paulo são os transtornos neuróticos, muito sugestivos de neurastenia. Os sujeitos chineses da comunidade apresentam uma psicopatologia própria, semelhante àquela dos indivíduos do seu país de origem. O CHQ-12 é um instrumento de rastreamento culturalmente sensível, que apresenta evidências de confiabilidade e validade para ser aplicado em outras populações de chineses. / Introduction: Community and culturally specific mental disorders have attracted much interest lately as a consequence of the constant social changes in the world. The shift of research focus to community-specific disorders has permitted methodological improvements and the development of tools for their detection. The inclusion of the cultural variable in the study of psychiatry questions psychopathological universality, Western taxonomy, and the diagnosis of culturally specific syndromes. The research of neurasthenia, a common neurotic disorder among the Chinese, is an example of the psychiatric approach based on cultural issues and on community disorders. This is an observational and transversal study of the common mental disorders among Chinese individuals in the community. Objective: to assess the non-psychotic psychopathology of the Chinese who live in the city of São Paulo, using standardized instruments. Materials and Methods: Individuals of the community (n = 211), Chinese and their descendants, filled out a self-evaluation questionnaire and were interviewed by trained researchers. The instruments used were: Chinese Health Questionnaire (CHQ-12), Physical Symptom Scale, Life Event Scale, Beck Depression Inventory (BDI), Trait-State Anxiety Inventory (STAI), and Schedule for Clinical Assessment in Neuropsychiatry (SCAN). The data were analyzed with descriptive statistics, univariate analysis (chi-square, Fisher and Student’s t tests), multivariate analysis (logistic regression), ROC curve analysis, exploratory factor analysis (CHQ-12), and correlation analysis. Results: The likelihood of an individual scoring high in CHQ-12 or having a probable common mental disorder is associated to the fact of being female (OR = 2.31; 95% CI: 1.12–4.75) and fluent in Mandarin Chinese (OR = 3.37; 95% CI: 1.68–6.78). Moreover, those with physical complaints (OR = 4.20; 95% CI: 1.70–10.40), reporting life events in the previous year (OR = 4.91; 95% CI: 1.51–16.00) and scoring high in BDI (OR = 1.29; 95% CI: 1.20–1.41) also had a greater likelihood of presenting disorders. CHQ-12’s Cronbach’s &#61537; coefficient of internal consistency was 0.71 and the item-total correlation ranged from 0.25 to 0.55, showing that this instrument is reliable and homogeneous. Using SCAN as a standard criterion, the best cut-off point for CHQ-12 was 2/3. The other validity indicators were calculated based on that criterion: sensitivity 75%, specificity 71%, positive predictive value 55%, negative predictive value 86%, and misclassification rate 28%. ROC curve was used to evaluate the discriminating capacity of the instrument, having an area under the curve of 0.728. CHQ-12 questionnaire also correlated significantly with the Physical Symptom Scale (p < 0.005), Life Event Scale (p < 0.005), BDI (p < 0.0005), and STAI (p < 0.05). In the exploratory factor analysis, three psychopathologic dimensions explained 47.8% of the total variance of CHQ-12. The symptomatological content evaluated by this instrument may be described as three-dimensional, including somatic, depressive and preoccupation factors. SCAN interviews (n = 25) led to diagnoses of dysthymia, depression and non-organic insomnia (ICD-10). The item-groups “poor subjective functioning” (p < 0.005) and “special features of depression” (p < 0.005) prevailed on the symptomatological profile of SCAN-positive cases. Conclusion: the most common mental disorders in São Paulo’s Chinese community are the neurasthenia-like neurotic disorders. The individuals of the Chinese community presented a unique psychopathology, resembling that of their country of origin. CHQ-12 is a culturally sensitive screening instrument, which seems to be reliable and valid enough to be used in other Chinese populations.

Background. Previous research suggests that individuals experiencing DSM-IV panic attacks (PA) are at increased risk for various forms of psychopathology, including anxiety, depressive and substance use disorders. However, little is known regarding whether the sole occurrence of fearful spells (FS-only; distressing spells of anxiety with less than four panic symptoms and/or lacking crescendo in symptom onset) similarly elevates the risk for subsequent psychopathology and could therefore be promising to identify high-risk groups for targeted preventive interventions. Thus, the current dissertation thesis aims to examine (a) whether FS-only predict incident mental disorders in addition to full-blown PA and whether their associations with subsequent psychopathology differ from those obtained for PA, (b) whether FS-only, PA, and panic disorder (PD) share similar etiologies, (c) which characteristics of initial FS/PA and other risk factors predict a progression to more severe panic pathology and other mental disorders, and (d) whether help-seeking/potential treatment in individuals with panic alters the risk for subsequent psychopathology. Methods. A representative community sample of adolescents and young adults (N=3021, aged 14-24 at baseline) was prospectively followed up in up to three assessment waves over a time period of up to 10 years. FS-only, PA, PD, and other mental disorders were assessed at each assessment wave using the DSM-IV-M-CIDI. Additional modules/questionnaires were used to assess characteristics of initial FS/PA (T1/T2), potential risk factors, and help-seeking/potential treatment. Logistic regressions were applied to test associations (Odds Ratios, OR) of FS-only and PA at baseline with incident mental disorders at follow-up as well as respective interactive effects with help-seeking at baseline. Associations (Hazard Ratios, HR) of putative risk factors with the onset of panic pathology (FS-only, PA, and PD) or the onset of subsequent anxiety/depressive vs. substance use disorders in those with panic pathology (aggregated data across assessment waves) were estimated with Cox regressions. Multinomial logistic regressions were used to test associations of initial FS/PA characteristics (aggregated from T1 and T2) with PA and PD (lifetime incidences aggregated across assessment waves). Results. FS-only at baseline predicted incident anxiety and depressive disorders at follow-up (OR 1.59-4.36), while PA at baseline predicted incident anxiety, depressive, and substance use disorders at follow-up (OR 2.08-8.75; reference group: No FS/PA). Merely any anxiety disorder (OR=3.26) and alcohol abuse/dependence (OR=2.26) were significantly more strongly associated with PA than with FS-only. Female sex, parental anxiety disorders, parental depressive disorders, behavioral inhibition, harm avoidance, lower coping efficacy, and parental rejection predicted FS-only, PA, and PD (HR 1.2-3.0), whereas the associations with other risk factors partially differed for FS-only, PA, and PD and tended to be more pronounced for PA and PD than for FS-only. Alcohol consumption, use of drugs/medication, and physical illness as perceived reasons for the initial FS/PA were associated with the occurrence of full-blown PA (without PD, OR 2.46-5.44), while feelings of anxiety/depression and having always been anxious/nervous as perceived reasons for the initial FS/PA, appraising the initial FS/PA as terrible and long-term irritating/burdensome, subsequent feelings of depression, avoidance of situations/places, and consumption of medication, alcohol, or drugs were associated with the development of PD (OR 2.64-4.15). A longer duration until “feeling okay again” was associated with both PA and PD (OR 1.29-1.63 per category). Moreover, partially different risk constellations in subjects with panic pathology (FS/PA/PD) predicted the onset of subsequent anxiety/depressive vs. substance use disorders. Panic pathology (FS/PA) and help-seeking/potential treatment at baseline interacted on predicting incident PD (OR=0.09) and depression (OR=0.22) at follow-up in a way that panic pathology only predicted these disorders in individuals not seeking help at baseline. Conclusions. Findings suggest that individuals with FS-only are at similar risk of developing subsequent psychopathology compared to individuals with full-blown PA. Specific initial FS/PA characteristics and additional risk factors may be used to identify sub-groups of individuals with panic pathology, which are at particular risk of progressing to more severe panic pathology or other mental disorders and might therefore profit from supplemental outcome-related preventive interventions in addition to panic-specific treatment. Future research may replicate the current findings and test the efficacy of targeted preventive interventions in panickers at elevated risk for PD and other forms of psychopathology.:CONTENT 0 Synopsis 10 1 Introduction 13 1.1 Current challenges in clinical psychology 13 1.2 Psychological models of mental disorders 13 1.3 Diagnostic approaches to psychopathology 15 1.4 Methodological issues 16 1.5 Preventive and early treatment interventions 17 2 Panic pathology 18 2.1 Definitions 18 2.2 Epidemiology 19 2.3 Etiology 20 2.4 Physiological, neurobiological, and genetic findings 21 2.5 Unresolved issues 22 3 Aims 24 4 Methods 26 5 Study I: Associations of fearful spells and panic attacks with incident anxiety, depressive, and substance use disorders: A 10-year prospective-longitudinal community study of adolescents and young adults 27 5.1 Abstract 27 5.2 Introduction 27 5.3 Materials and methods 28 5.4 Results 30 5.5 Discussion 35 6 Study II: Characteristics of initial fearful spells and their associations with DSM-IV panic attacks and panic disorder in adolescents and young adults from the community 37 6.1 Abstract 37 6.2 Introduction 37 6.3 Materials and methods 38 6.4 Results 41 6.5 Discussion 43 7 Study III: Risk factors for fearful spells and panic: A 10-year prospective-longitudinal study among adolescents and young adults 47 7.1 Abstract 47 7.2 Introduction 47 7.3 Materials and methods 49 7.4 Results 52 7.5 Discussion 60 8 Study IV: Does help-seeking alter the risk for incident psychopathology in adolescents and young adults with and without fearful spells or panic attacks? Findings from a 10-year prospective-longitudinal community study 63 8.1 Abstract 63 8.2 Introduction 63 8.3 Materials and methods 64 8.4 Results 66 8.5 Discussion 70 9 General discussion 73 9.1 Summary and discussion of main findings 73 9.2 Preventive interventions among individuals with panic pathology 75 9.3 Research implications 77 10 Conclusions 78 11 References 79 12 Appendix 94 12.1 Acknowledgements 94 12.2 Erklärung zu den Eigenanteilen an einzelnen Publikationen 95 12.3 Eigenständigkeitserklärung 96 / Theoretischer Hintergrund. Auf Grundlage früherer Forschungsbefunde ist anzunehmen, dass Personen mit DSM-IV-Panikattacken (PA) ein erhöhtes Risiko für zahlreiche psychische Störungen, einschließlich Angst-, depressiver und Substanzstörungen, aufweisen. Unklar ist jedoch, ob das alleinige Auftreten von Fearful Spells (FS-only, Angstanfälle mit weniger als vier Paniksymptomen und/oder fehlendem Crescendo in der Symptomentwicklung) das Risiko für Psychopathologie in ähnlicher Weise erhöht und hilfreich sein könnte, um Hochrisikogruppen für Präventivinterventionen zu identifizieren. Innerhalb der vorliegenden Dissertation wird daher untersucht, (a) ob FS-only zusätzlich zu PA inzidente psychische Störungen vorhersagen und ob sich Unterschiede in den Assoziationen von FS-only vs. PA mit nachfolgender Psychopathologie ergeben, (b) ob FS-only, PA und Panikstörung (PS) ähnliche Ätiologien teilen, (c) welche Merkmale initialer FS/PA und welche anderen Risikofaktoren die Entwicklung schwerer Panikpathologie und weiterer psychischer Störungen vorhersagen und (d) ob Hilfesuchverhalten/potenzielle Behandlung bei Personen mit Panik das Risiko für nachfolgende Psychopathologie verändert. Methodik. Eine repräsentative Bevölkerungsstichprobe Jugendlicher und junger Erwachsener (N=3021, 14-24 Jahre zur Baseline-Erhebung) wurde in bis zu drei Erhebungswellen über einen Zeitraum von bis zu 10 Jahren untersucht. FS-only, PA, PS und andere psychische Störungen wurden zu jeder Erhebungswelle mithilfe des DSM-IV-M-CIDI erfasst. Merkmale initialer FS/PA (T1/T2), mögliche Risikofaktoren sowie Hilfesuchverhalten/potenzielle Behandlung wurden mit weiteren Modulen und Fragebögen erhoben. Mithilfe logistischer Regressionen wurden Assoziationen (Odds Ratios, OR) von FS-only und PA zu Baseline mit inzidenten psychischen Störungen zum Follow-Up sowie diesbezügliche Interaktionen mit Hilfesuchverhalten zu Baseline getestet. Zusammenhänge zwischen möglichen Risikofaktoren und dem Auftreten von Panikpathologie (FS-only, PA und PS) bzw. nachfolgender Angst-/depressiver und Substanzstörungen bei Personen mit Panikpathologie (Verwendung von über die Erhebungswellen hinweg aggregierter Daten) wurden mithilfe von Cox-Regressionen geschätzt. Multinomiale logistische Regressionen wurden genutzt, um Assoziationen von Merkmalen initialer FS/PA (aggregiert über T1 und T2) mit PA und PS (über die Erhebungswellen hinweg aggregierte Lebenszeitinzidenzen) zu erfassen. Ergebnisse. FS-only zu Baseline sagten inzidente Angst- und depressive Störungen zum Follow-Up vorher (OR 1.59-4.36), wohingegen PA zu Baseline inzidente Angst-, depressive und Substanzstörungen zum Follow-Up vorhersagten (OR 2.08-8.75; Referenzkategorie: Keine FS/PA). Lediglich irgendeine Angststörung (OR=3.26) und Alkoholmissbrauch/-abhängigkeit (OR=2.26) waren signifikant stärker mit PA als mit FS-only assoziiert. Weibliches Geschlecht, elterliche Angst- und depressive Störungen, Verhaltenshemmung, Schadensvermeidung, geringere Coping-Erwartung und elterliche Zurückweisung sagten FS-only, PA und PS vorher (HR 1.2-3.0), während sich teils unterschiedliche Assoziationen anderer Risikofaktoren mit FS-only, PA und PS ergaben, die tendenziell stärker für PA und PS als für FS-only waren. Alkoholkonsum, Drogen-/Medikamentengebrauch und körperliche Erkrankungen als wahrgenommene Gründe für die initiale FS/PA waren mit dem Auftreten vollständiger PA assoziiert (ohne PS; OR 2.46-5.44), während Gefühle von Angst/Depression und die Einschätzung schon immer ängstlich/nervös gewesen zu sein als wahrgenommene Gründe für die initiale FS/PA, die Bewertung der initialen FS/PA als schrecklich und langfristig verunsichernd/belastend, nachfolgende Gefühle von Niedergeschlagenheit, Vermeidung von Situationen/Orten und Konsum von Medikamenten, Alkohol oder Drogen mit der Entwicklung von PS assoziiert waren (OR 2.64-4.15). Eine längere Dauer bis sich die betroffene Person wieder vollständig in Ordnung fühlte war sowohl mit PA als auch mit PS assoziiert (OR 1.29-1.63 pro Kategorie). Weiterhin sagten teils unterschiedliche Risikokonstellationen bei Personen mit Panikpathologie (FS/PA/PS) die nachfolgende Entstehung von Angst-/depressiven und Substanzstörungen vorher. Panikpathologie (FS/PA) und Hilfesuchverhalten/potenzielle Behandlung zu Baseline interagierten bei der Vorhersage von inzidenter PS (OR=0.09) und Depression (OR=0.22) zum Follow-Up; d.h. das Vorhandensein von Panikpathologie sagte diese Störungen nur bei Personen ohne, nicht aber bei Personen mit Hilfesuchverhalten zu Baseline vorher. Schlussfolgerungen. Die vorliegenden Ergebnisse implizieren, dass Personen mit FS-only im Vergleich zu Personen mit vollständigen PA ein ähnliches Risiko für die Entwicklung nachfolgender Psychopathologie aufweisen. Spezifische Merkmale initialer FS/PA und zusätzliche Risikofaktoren könnten zur Identifikation von Sub-Gruppen von Personen mit Panik genutzt werden, die sich durch ein besonderes Risiko für schwergradige Panikpathologie und andere psychische Störungen auszeichnen und demzufolge von Outcome-bezogenen Präventionen (ergänzend zu Panik-spezifischer Intervention) profitieren könnten. Zukünftige Studien sollten die vorliegenden Befunde replizieren und die Effektivität gezielter Präventivinterventionen bei Personen mit erhöhtem Risiko für PS und andere psychische Störungen testen.:CONTENT 0 Synopsis 10 1 Introduction 13 1.1 Current challenges in clinical psychology 13 1.2 Psychological models of mental disorders 13 1.3 Diagnostic approaches to psychopathology 15 1.4 Methodological issues 16 1.5 Preventive and early treatment interventions 17 2 Panic pathology 18 2.1 Definitions 18 2.2 Epidemiology 19 2.3 Etiology 20 2.4 Physiological, neurobiological, and genetic findings 21 2.5 Unresolved issues 22 3 Aims 24 4 Methods 26 5 Study I: Associations of fearful spells and panic attacks with incident anxiety, depressive, and substance use disorders: A 10-year prospective-longitudinal community study of adolescents and young adults 27 5.1 Abstract 27 5.2 Introduction 27 5.3 Materials and methods 28 5.4 Results 30 5.5 Discussion 35 6 Study II: Characteristics of initial fearful spells and their associations with DSM-IV panic attacks and panic disorder in adolescents and young adults from the community 37 6.1 Abstract 37 6.2 Introduction 37 6.3 Materials and methods 38 6.4 Results 41 6.5 Discussion 43 7 Study III: Risk factors for fearful spells and panic: A 10-year prospective-longitudinal study among adolescents and young adults 47 7.1 Abstract 47 7.2 Introduction 47 7.3 Materials and methods 49 7.4 Results 52 7.5 Discussion 60 8 Study IV: Does help-seeking alter the risk for incident psychopathology in adolescents and young adults with and without fearful spells or panic attacks? Findings from a 10-year prospective-longitudinal community study 63 8.1 Abstract 63 8.2 Introduction 63 8.3 Materials and methods 64 8.4 Results 66 8.5 Discussion 70 9 General discussion 73 9.1 Summary and discussion of main findings 73 9.2 Preventive interventions among individuals with panic pathology 75 9.3 Research implications 77 10 Conclusions 78 11 References 79 12 Appendix 94 12.1 Acknowledgements 94 12.2 Erklärung zu den Eigenanteilen an einzelnen Publikationen 95 12.3 Eigenständigkeitserklärung 96

Au Canada, les Commissions d'Examen des Troubles Mentaux de chaque province ont la responsabilité de déterminer les conditions de prise en charge des personnes déclarées Non Criminellement Responsables pour cause de Troubles Mentaux (NCRTM) et de rendre, sur une base annuelle une des trois décisions suivantes: a) détention dans un hôpital, b) libération conditionnelle, ou c) libération absolue. Pour favoriser la réinsertion sociale, la libération conditionnelle peut être ordonnée avec la condition de vivre dans une ressource d’hébergement dans la communauté. Parmi les personnes vivant avec une maladie mentale, l’accès aux ressources d’hébergement a été associé à une plus grande stabilité résidentielle, une réduction de nombre et de la durée de séjours d'hospitalisation ainsi qu’une réduction des contacts avec le système judiciaire. Toutefois, l’accès aux ressources d’hébergement pour les personnes trouvées NCRTM est limité, en partie lié à la stigmatisation qui entoure cette population. Il existe peu d’études qui traitent du placement en ressources d’hébergement en psychiatrie légale. Pour répondre à cette question, cette thèse comporte trois volets qui seront présentés dans le cadre de deux manuscrits: 1) évaluer le rôle du placement en ressources d’hébergement sur la réhospitalisation et la récidive chez les personnes trouvées NCRTM; 2) décrire les trajectoires de disposition et de placement en ressources d’hébergement, et 3) mieux comprendre les facteurs associés à ces trajectoires. Les données de la province du Québec du Projet National de Trajectoires d’individus trouvés NCRTM ont été utilisées. Un total de 934 personnes trouvées NCRTM entre le 1er mai 2000 et le 30 avril 2005 compose cet échantillon. Dans le premier manuscrit, l’analyse de survie démontre que les individus placés dans un logement indépendant suite à une libération conditionnelle de la Commission d’Examen sont plus susceptibles de commettre une nouvelle infraction et d’être ré-hospitalisés que les personnes en ressources d’hébergement. Dans le deuxième article, l'analyse de données séquentielle a généré quatre modèles statistiquement stables de trajectoires de disposition et de placement résidentiel pour les 36 mois suivant un verdict de NCRTM: 1) libération conditionnelle dans une ressource d’hébergement (11%), 2) libération conditionnelle dans un logement autonome (32%), 3) détention (43%), et 4) libération absolue (14%). Une régression logistique multinomiale révèle que la probabilité d'un placement en ressource supervisée comparé au maintien en détention est significativement réduite pour les personnes traitées dans un hôpital spécialisé en psychiatrie légale, ainsi que pour ceux ayant commis un délit sévère. D'autre part, la probabilité d’être soumis à des dispositions moins restrictives (soit le logement indépendant et la libération absolue) est fortement associée à des facteurs cliniques tels qu’un nombre réduit d'hospitalisations psychiatriques antérieures, un diagnostic de trouble de l'humeur et une absence de diagnostic de trouble de la personnalité. Les résultats de ce projet doctoral soulignent la valeur protectrice des ressources en hébergement pour les personnes trouvées NCRTM, en plus d’apporter des arguments solides pour une gestion de risque chez les personnes trouvées NCRTM qui incorpore des éléments contextuels de prévention du risque, tel que l’accès à des ressources d’hébergement. / In Canada, Provincial and Territorial Review Boards are mandated to evaluate the risk and custody decisions about individuals found Not Criminally Responsible on Account of Mental Disorder (NCRMD) and render one of three dispositions: (a) custody, (b) conditional discharge, or (c) absolute discharge. To promote community reintegration, conditional discharge can be ordered with the condition to live in supportive housing. Among individuals living with a mental illness, supportive housing in the community has been associated with increased housing stability, reduced number and length of hospitalization and reduced involvement with the criminal justice system. However, NCRMD accused face great barriers to housing access as a result of the stigma associated with the forensic label. To date, there is little information regarding the housing placement for the forensic mentally ill individuals, such as those found NCRMD. In order to address the dearth of literature on supportive housing for the forensic population, the goal of the present thesis is threefold and addressed through two manuscripts: 1) to evaluate of the role of housing placement on rehospitalization and recidivism among individuals found NCRMD; 2) to describe the disposition and housing placement trajectories of individuals found NCRMD, and 3) to explore the factors that predict such trajectories. Data from the Québec sample of the National Trajectory Project of individuals found NCRMD were used. A total of 934 individuals found NCRMD between May 1st 2000 and April 30th 2005 comprise this sample. In the first paper, survival analyses showed that individuals placed in independent housing following conditional discharge from the Review Board were more likely to be convicted of a new offense and to be readmitted for psychiatric treatment compared with individuals residing in supportive housing. In the second paper, sequential data analysis resulted in four distinct trajectories: 1) conditional discharge in supportive housing (11%), 2) conditional discharge in independent housing (32%), 3) detention in hospital (43%) and 4) absolute discharge (14%). A multinomial logistic regression revealed that the likelihood of a placement in supportive housing compared to being detained significantly decreased for individuals treated in a forensic hospital, as well as those with an increased index offense severity. On the other hand, less restrictive disposition trajectories (i.e. independent housing and absolute discharge) were significantly influenced by clinical factors such as reduced number of prior psychiatric hospitalizations, a diagnosis of mood disorder and an absence of a comorbid personality disorder diagnosis. The findings from this study point to the protective value that supportive housing can have on the community outcomes of forensic patients, and provides solid arguments for the development of a management strategy that incorporates contextual factors such as supportive housing.

Ce mémoire offre un nouvel éclairage sur la transition en cours de l’institution pénale contemporaine d’une fonction essentiellement morale et symbolique vers la gestion effective des risques dans la société. Nous estimons que c’est en juxtaposant ses différentes pratiques – pratiques discursives entourant la responsabilité criminelle des accusés atteints de troubles mentaux non psychotiques, pratiques en matière de criminalisation préventives et nouvelles pratiques en matière de peine – que cette transformation fonctionnelle est la plus appréciable. Afin d’illustrer ces différentes pratiques, nous proposons de suivre le parcours pénal réservé par l’institution pénale aux sujets autistiques. Tout en étant fortement déterminés dans leur développement moral, social, sexuel et émotionnel et dans leur capacité à se conformer à la loi pénale, ceux-ci demeurent toutefois minimalement réceptifs aux technologies pénales. Nous pensons que leur incorporation à l’intérieur de la logique pénale résulte essentiellement de cet attrait utile de la peine au prix même de la déformation de nos principes fondamentaux collectifs de justice. Ce mémoire offre la première analyse systématique de la jurisprudence concernant la responsabilité criminelle et la peine des personnes autistes au Canada ainsi qu’une synthèse des plus récentes découvertes juridico-cliniques sur l’autisme. L’intégrité physique et psychologique des personnes autistes étant menacée comme jamais auparavant par l’inflation du quantum des peines en raison de l’arrêt Friesen et des réformes du gouvernement Harper, nous invitons les juristes, les avocats, les experts cliniques à s’intéresser davantage à l’intervention de l’institution pénale envers ces personnes hautement vulnérables. / This thesis sheds new light on the ongoing transition of the contemporary penal institution from a moral and symbolic function to the effective management of risks in society. We believe that it is by juxtaposing its different practices – discursive practices surrounding the criminal responsibility of defendants with non-psychotic mental disorders, preventive criminalization practices and new sentencing practices – that this functional transformation is most appreciable. To illustrate these different practices, we propose to follow the penal circuit reserved by the penal institution for autistic subjects. While being strongly determined in their moral, social, sexual, and emotional development and in their ability to comply with penal law, they nevertheless remain minimally receptive to penal technologies. We think that their incorporation within the penal logic results from this useful attraction of the penalty at the very price of the deformation of our collective fundamental principles of justice. This thesis offers the first systematic analysis of the case law concerning the criminal liability and sentencing of persons with autism in Canada as well as a synthesis of the most recent legal and clinical findings on autism. As the physical and psychological integrity of people with autism is threatened like never before by the inflation of the quantum of sentences due to the Friesen decision and the legislative reform by the Harper government, we invite jurists, lawyers, clinical experts to take a greater interest in the intervention of the penal institution towards these highly vulnerable individuals.

This thesis examines how cultural competency operates as a regime of governmentality. Inspired by Foucauldian genealogy, institutional ethnography, and Said’s concept of contrapuntality, this thesis problematizes the seamless production of racialized bodies in relation to mental disorder. I begin by elaborating a theoretical framework for interpreting race and madness as mutually constructed ordering practices. I then analyze what cultural competence produces and sustains in a position paper published by the Ontario Federation of Community Mental Health and Addiction Programs. I argue the Federation dismisses ongoing institutional violence—suggesting it is simply the perception, as opposed to the everyday reality, of discrimination that causes problems such as low educational attainment among youth of colour. To further support this claim, I deconstruct narratives of low self-esteem, maladaptive coping, depression, and denial of mental illness in the community needs assessments of two of the Federation’s member organizations: Hong Fook and Across Boundaries.

This thesis examines how cultural competency operates as a regime of governmentality. Inspired by Foucauldian genealogy, institutional ethnography, and Said’s concept of contrapuntality, this thesis problematizes the seamless production of racialized bodies in relation to mental disorder. I begin by elaborating a theoretical framework for interpreting race and madness as mutually constructed ordering practices. I then analyze what cultural competence produces and sustains in a position paper published by the Ontario Federation of Community Mental Health and Addiction Programs. I argue the Federation dismisses ongoing institutional violence—suggesting it is simply the perception, as opposed to the everyday reality, of discrimination that causes problems such as low educational attainment among youth of colour. To further support this claim, I deconstruct narratives of low self-esteem, maladaptive coping, depression, and denial of mental illness in the community needs assessments of two of the Federation’s member organizations: Hong Fook and Across Boundaries.

Définie à l’origine comme l’aptitude à la sanction, la capacité pénale peut s’entendre plus largement comme résumant l’ensemble des aptitudes subjectives, c’est-à-dire propres au délinquant, indispensables à l’engagement et à la sanction de sa responsabilité pénale. Ces aptitudes sont de deux ordres. L’aptitude à l’infraction et l’aptitude à l’imputation de cette infraction conditionnent le jugement de responsabilité et contribuent à en assurer la dimension morale. L’aptitude à la sanction ou capacité pénitentiaire joue un rôle plus original puisqu’elle apparaît comme le fondement de la personnalisation de la peine, permettant d’adapter la sanction pénale à la personnalité et aux besoins de celui qui doit la subir. / Originally defined as the capacity to be punished, criminal capacity can be understood more widely as summarizing mental abilities that are required for criminal responsibility. Some are needed to commit the offense, others for criminal responsibility but both ensure the moral meaning of criminal law. Applied to the penalty, criminal capacity can be used to adapt the sentence to the personality and needs of those who must endure it.

改正精神衛生法時代の地域PSWの形成過程と推進要因を解明した．大阪府の実践を事例として，当時の保健所のPSW10名に面接調査をした．その結果，業務は，個別から集団へ，家族会の育成・支援から地域共同作業所の開設などへと進んでいた．また，推進要因としては,①自由，②主体性，③連帯，④意欲，⑤育成，⑥環境，⑦時代，があった．この実践は開拓型支援モデルと名づけられるものであった． / This is the study on the process and the factor of the progress of community mental health in the era of the Reform of the Mental Health Act. I interviewed the PSWs of Osaka public health center at that time. It was revealed that their work progressed from case work to group work, from the education for the client families to obtain community cooperative work place, etc. And the factors of promotion were ①freedom, ②autonomy,③cooperation,④eagerness,⑤training, ⑥environment and ⑦era. I called this practice Pioneer type support model. / 博士(社会福祉学) / Doctor of Philosophy in Social Welfare / 同志社大学 / Doshisha University