A presente dissertação analisa o conteúdo dos diários e cartas de Virginia Woolf para avaliar se um algoritmo de classificação de texto poderia identificar um padrão escrito relacionado aos dois meses anteriores ao suicídio de Virginia Woolf. Este é um estudo de classificação de texto. Comparamos 46 entradas de textos dos dois meses anteriores ao suicídio de Virginia Woolf com 54 textos selecionados aleatoriamente do trabalho de Virginia Woolf durante outro período de sua vida. O texto de cartas e dos diários foi incluído, enquanto livros, romances, histórias curtas e fragmentos de artigos foram excluídos. Os dados foram analisados usando um algoritmo de aprendizagem mecânica Naïve-Bayes. O modelo mostrou uma acurácia de 80,45%, sensibilidade de 69% e especificidade de 91%. A estatística Kappa foi de 0,6, o que significa um bom acordo, e o valor P do modelo foi de 0,003. A Área Sob a curva ROC foi 0,80. O presente estudo foi o primeiro a analisar a viabilidade de um modelo de machine learning, juntamente com dados de texto, a fim de identificar padrões escritos associados ao comportamento suicida nos diários e cartas de um romancista. Nossa assinatura de texto foi capaz de identificar o período de dois meses antes do suicídio com uma alta precisão / The present study analyzes the content of Virginia Woolf’s diaries and letters to assess whether a text classification algorithm could identify written pattern related to the two months previous to Virginia Woolf’s suicide. This is a text classification study. We compared 46 texts entries from the two months previous to Virginia Woolf’s suicide with 54 texts randomly selected from Virginia Woolf’s work during other period of her life. Letters and diaries were included, while books, novels, short stories, and article fragments were excluded. The data was analyzed by using a Naïve-Bayes machine-learning algorithm. The model showed a balanced accuracy of 80.45%, sensitivity of 69%, and specificity of 91%. The Kappa statistic was 0.6, which means a good agreement, and the p value of the model was 0.003. The Area Under the ROC curve was 0.80. The present study was the first to analyze the feasibility of a machine learning model coupled with text data in order to identify written patterns associated with suicidal behavior in the diaries and letters of a novelist. Our text signature was able to identify the period of two months preceding suicide with a high accuracy.

The purpose of this research was to determine family patterns which limit the optimal functioning of the child in middle childhood with Bipolar Disorder and Cerebral Palsy. To achieve this goal a thorough literature study was performed with regard to the child with Bipolar Disorder and Cerebral Palsy. The nature, causes and state of these two conditions in the family were investigated. Cresswell's combined model of research namely the "dominant-less-dominant" model of investigation was used. The less dominant part of the research was quantitative where the "Hudson scale: Index of Parental Attitudes" was used. This is a standardised questionnaire that aims to measure the attitudes of parents. The qualitative part of the research produced more information regarding the above-mentioned aspects. Unstructured interviews with the family, as well as the multi-disciplinary team currently involved with the family were conducted. The "One shot case study" was used to determine the significance of negative family patterns. This is an in-depth study of a single unit and required that the researcher become part of the family and family activities for a specific period of time. From this specific family, patterns were identified which limit the child with Bipolar Disorder and Cerebral Palsy to optimal functioning. From the results it was clear that significant family patterns exist in this family which limit the child. The research question could therefore be answered and certain themes could be identified. With regard to dimensions of family functioning, significant patterns around affection, behaviour control, value transmission, structure, communication and external systems were identified which limit the child to optimal functioning. Through this the researcher comes to the conclusion that family functioning has a significant influence on the optimal functioning of the child with an affective disorder and disability. With these results in mind, it is important that families are guided in the handling of children with affective disorders and disabilities, so that these children too, can reach optimal functioning. / Thesis (MSD (Play Therapy))--University of Pretoria, 2004. / Social Work and Criminology / unrestricted

Bakgrund: Bipolär sjukdom är en psykisk sjukdom som påverkar det vardagliga livet hos den sjuke personen. För att som sjuksköterska ska kunna behandla och hjälpa enperson med bipolär sjukdom eller för att en anhörig ska kunna förstå sin sjuke familjemedlem är det viktigt med ett gott bemötande och ett stort tålamod då sjukdomen karaktäriseras olika hos alla individer. Syfte: Att beskriva personers upplevelser av att leva med bipolär sjukdom. Metod: Detta är en litteraturstudie med deskriptiv design som baseras på nio utvalda vetenskapliga artiklar till litteraturstudiens resultat. Huvudresultat: Resultatet visade att personer med bipolär sjukdom upplevde stora svårigheter i sin vardag på grund av skiftande stämningslägen och symtom som påverkade personernas självkänsla vilket resulterade i deras tillbakadragande i relationer och handlingar. Upplevelser av stigmatisering av sjukdomen gjorde det svårt för personerna att öppna upp sig för andra på grund av upplevelser av uteslutande och diskriminering. Farmakologisk behandling och terapi var behandlingar som personerna upplevde hjälpa dem för att stabilisera sin impulsivitet och hitta olika sätt för att hanteraoch känna igen sina utlösningsfaktorer, vilket i sin tur upplevdes hjälpa dem i sin återhämtning. Slutsats: Att leva med bipolär sjukdom kan medföra stora svårigheter för den drabbade personen. Därför är det viktigt att lyfta fram sjukdomen och personers upplevelse för att minska stigmatiseringen och medföra ökade kunskaper för vårdpersonal, anhöriga och andra personer som lider av samma sjukdom. / Background: Bipolar disorder is a mental illness that affects the everyday life of the sick person. To be able to treat and help a person with bipolar illness as a nurse or to be able to understand their sick family member as a relative it’s important to have a good contact and a great patience as the disease is characterized differently in all individuals. Purpose: To describe people's experiences of living with bipolar disorder. Method: This is a literature study with descriptive design. The result of this study is based on nine studies. Main results: The result showed that people with bipolar disorder experienced great difficulties in their everyday lives due to changing moods and symptoms that affected persons' self-esteem which resulted in their withdrawal in relationships and selfmanagement. Experiences of stigmatizing of the disease made it difficult for people to open themselves to others because of the feelings of exclusion and discrimination.Pharmacological treatment and therapy were treatments that they experienced helping them to stabilize their impulsivity and finding different ways to manage and recognize their triggering factors that in turn were experienced to help them in their recovery. Conclusion: Living with bipolar disorder can cause great difficulties for the affected person. Therefore, it is important to highlight the illness and people's experience in order to reduce the stigmatization and bring increased knowledge to health professionals, family and other people suffering from the same disease.

Background: Reports of subjective sleep impairments have been replicated in adults with bipolar disorder (BD) and young BD patients. Furthermore, circadian rhythm alterations are a core feature of BD. Despite the impairment in circadian rhythms and altered sleep included in various heuristic developmental models of BD, thus far, biomarkers in population at risk for BD have not been sufficiently objectively validated. Thus, we conducted: a) Explorative study of sleep and rest-activity circadian rhythm among offspring of BD parents. b) Study of sleep and rest-activity circadian rhythm among offspring of BD parents without the presence of psychopathology (except depression and anxiety disorders) based on our exploratory findings. Methods: a) 14 days of actigraphic assessment and subjective scales (Pediatric Sleep Questionnaire, PSQ; the Morningness/Eveningness Questionnaire, MEQ; and The General Behavior Inventory Sleep Subscale, GBISS) to assess circadian preference, and to identify sleep impairment symptoms. Psychopathology was assessed using psychiatric interview. b) ≥ 14 days of actigraphic assessment with advanced methods to assess the chronotype, social jet lag and sleep macrostructure, psychiatric interview and subjective psychometric scales to assess the full psychopathology profile. Results:...

Objective: To explore the measurement of subsyndromal mood symptoms in relation to studies of maintenance therapy for bipolar disorder. Methods: Literature review of the Medline database using the following selection criteria: (1) ‘bipolar disorder’ plus ‘inter-episode or interepisode or subsyndromal or subclinical or residual or subthreshold’ and (2) ‘bipolar disorder’ plus ‘maintenance or prophylaxis or longitudinal’. Studies of children or adolescents and non-English-language reports were excluded. Results: Of the studies published between 1987 and October 2007, 77 articles about subsyndromal mood symptoms and 257 studies of maintenance therapy agents were found. Only 11 of the 257 studies of maintenance therapy agents discussed subsyndromal mood symptoms. Of the 77 articles, two thirds were published after 2000. Inconsistent definitions of subsyndromal mood symptoms and different evaluation tools and methodologies were used in the studies. Conclusions: There is a need to standardize definitions and validate measuring approaches for subsyndromal mood symptoms. However, when measured in both naturalistic studies and clinical trials, subsyndromal mood symptoms were frequently reported by patients receiving maintenance therapy and were associated with poor functioning. As with other chronic illnesses, knowledge of the patient’s perspective of daily morbidity is important for improving the clinical outcome. Studies of maintenance therapy for bipolar disorder, regardless of the approach, should measure subsyndromal mood symptoms as an additional outcome. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

The study was exploratory in nature, with 62 adult participants participating in this research. The aim of the study was to determine the level of ego impairment, if any, among a group of patients diagnosed with Bipolar Disorder. The data obtained from this sample was subjected to the Rorschach-based Ego Impairment Index-2 (EII-2). An in-depth analysis of the composite variables of this index was performed, allowing a comprehensive grasp of the implications of ego impairment in everyday functioning. The study was conducted in order to ascertain the nature of the psychological dynamics at play amongst this population group. The value of using the EII-2 is seen in its ability to establish various strengths and weaknesses in areas of ego functioning that are a core component of the personality, rather than behavioural manifestations that are sporadic and subject to change. Thus the results will reflect traits that are enduring and fundamental when considering the personality. In addition, the areas of psychological functioning that were determined were linked to the current conceptualisation of Bipolar Disorder, which, at present, is primarily conceived of as a biological disorder. The results of the EII-2 yielded from this sample indicated an overall moderate ego impairment falling within the moderate range, indicating that for this population, an impairment of ego was evident. Particularly, the domains of reality testing, cognitive functioning and object relatedness seemed to be most impaired. / Dissertation (MA)--University of Pretoria, 2010. / Psychology / Unrestricted

Bakgrund: Bipolär sjukdom är en allvarlig psykisk sjukdom som kännetecknas av skiftande tillstånd av återkommande maniska och depressiva episoder. Sjukdomen är en av de mest utmanande psykiska störningarna att hantera, och bidrar till en komplex livssituation för patienten. Genom en ökad förståelse kring bipolär sjukdom kan sjuksköterskan förbättra bemötandet i vården och därmed lindra lidande och förebygga hälsa hos patienten. Metod: En litteraturöversikt baserad på tio kvalitativa artiklar, för att bidra till evidensbaserad omvårdnad. Syfte: Syftet var att beskriva patienters erfarenheter av att leva med bipolär sjukdom. Resultat: I resultatet framkom sex teman. Dessa är: blandade känslor kring diagnosen, informationens betydelse för ökad förståelse, terapins roll för välbefinnande, att möta okända symtom och stigmatisering, påverkan på relationer och arbete, samt varierande vårderfarenheter. Konklusion:Patienter med bipolär sjukdom upplever starka känslor som har en stor inverkan på patientens livsvärld. För att förstå sin sjukdom krävs en tydlig och öppen kommunikation där patienten kan känna trygghet och tillit till sin vårdare. / Background: Bipolar disorder is a serious mental illness characterized by varying states of recurrent manic and depressive episodes. The disease is one of the most challenging mental disorder to deal with and contributes to a complex life situation. Through an increased understanding of bipolar disorder, the nurse can improve treatments within care, thereby contributing to alleviation of suffering and improvement in patient health. Method: A literature review was used, in which ten qualitative articles were selected, to contribute to evidencebased nursing. Aim: This study aimed to describe patients’ experiences of living with bipolar disorder. Findings: The analysis resulted in six themes. These are: mixed feelings about the diagnosis, the importance of information for increased understanding, the role of therapy for well-being, meeting unknown symptoms and stigmatizations, the impact on relationships and work, and varying care experiences. Conclusion: Patient’s with bipolar disorder experience strong emotions that have a major impact on their life world. Understanding their illness requires clear and open communication where the patient can feel safe and have confidence in their caregiver.

Bipolar disorders (BD) are characterized by symptoms of grandiosity, decreased need for sleep, pressure to keep talking, flight of ideas, distractibility, increased goal-directed activities, psychomotor agitation, and excessive involvement in pleasurable activities. Those with a bipolar disorder have a high degree of psychiatric comorbidity including substance use disorders, and they also experience increased mortality. Despite the widespread recognition of BD as an important psychiatric condition, available population-based estimates for BD prevalence differs across data sources. Cannabis is one of the most widely-used illicit substances. Evidence supports it as a risk factor for psychotic symptoms and disorders. Because populations with psychotic disorders and populations with bipolar disorder share genetic characteristics, cannabis may increase risk for bipolar disorders through the same pathways as it does with psychotic disorders. Limited and conflicting evidence regarding the association of cannabis use and bipolar disorder is currently available. This dissertation investigates cannabis use as a risk factor for incident manic symptoms and bipolar disorders in a large nationally representative longitudinal cohort. The first aim of this dissertation is to evaluate the implications for manic, hypomanic and major depressive episode prevalence estimates arising from the different approaches to assessing DSM-IV criterion between two national surveys. Differences in the assessment of impairment strongly influence manic or hypomanic classification within the NESARC. Compared to multiple imputation estimates (19.7% [95% CI: 19.3-20.1]) which treat depressed mood and anhedonia as separate symptoms, symptom assessment in the NESARC substantially underestimates major depressive episode prevalence (16.9% [95% CI: 16.1-17.6]). The second research objective examined self-reported cannabis use as a risk factor for incident manic symptoms, bipolar spectrum disorders (including manic and hypomanic episodes) and SCID-based recalibrated BD I and II. Cannabis use risk was assessed in the population as a whole and in sub-populations defined by age, substance abuse/dependence status, and family history. Among those reporting no lifetime major depressive or manic symptoms at baseline, self-reported past-year cannabis use was associated with increased odds of an incident week of extremely elevated or irritable mood accompanied by at least two manic episode criterion B symptoms (adj. OR 1.69, 95% CI: 1.08-2.65, p=.02) over the three year follow-up period. Among adults (ages 26 to 45) >=1 reported use(s) of cannabis per week was associated with incident manic or hypomanic episodes (adjusted OR 2.52, 95% CI: 1.32-4.80, p=.006). Among those endorsing no major depressive symptoms, substance abuse/dependence, or anti-social traits in their first degree relatives, past year cannabis use is associated with increased risk for incident bipolar spectrum disorders (adjusted OR 2.27, 95% CI: 1.01-5.10, p=.05) and CIDI recalibrated BD I and II (adjusted OR 5.49, 95% CI: 1.38-21.9, p=.02). Past year cannabis use risk for DSM-IV manic or hypomanic episodes among those aged 26 to 45 is concentrated in those with a baseline history of a substance use disorder (adj. OR 2.00, 95% CI: 1.10-3.66, p=.02) as compared to those with no such history (adj. OR 1.87, 95% CI: 0.49-7.21, p=.36). The third research objective of this dissertation was a sensitivity analysis using externally-predicted categorized exposures and continuous cannabis use propensities. The sensitivity analysis found evidence of exposure misclassification. Exposures defined by external propensity scores had improved cross-sectional association with bipolar spectrum disorders compared to reported use when both were compared to an external standard. No significant risk estimates were found for categorized predicted cannabis use among groups that were previously found to have significant risk from reported exposure. However, among adults 18 to 45 years of age with no manic or major depressive symptoms at baseline, past year cannabis use propensity (as a log transformed continuous measure) was associated with incident manic or hypomanic episodes (adj. OR 1.49, 95% CI: 1.10-2.03, p=.01). Elevated risk for high cannabis use propensity (>=1 use/week in the past year) was also found in this same group (adj. OR 1.33, 95% CI: 1.03-1.72, p=.03). Among those with no reported history of depression, substance abuse/dependence, or anti-social traits among their first-degree relatives, propensity for past year cannabis use (adj. OR 1.61, 95% CI: 1.11-2.32, p=.01) and propensity for >=1 use/week of cannabis in the past year (adj. OR 1.38, 95% CI: 1.03-1.85, p=.03) were associated with incident manic or hypomanic episodes. Among those without a substance use history at baseline, propensity for past year cannabis use (adj. OR 1.63, 95% CI: 1.33-1.55, p=1 use/week of cannabis in the past year (adj. OR 1.54, 95% CI: 1.26-1.88, p The findings of the first aim support the conclusion that the AUDADIS substantially under-estimated lifetime major depressive episode prevalence compared to an imputed estimate that treated anhedonia and depressed mood as separate and concurrent MDE symptoms. The operationalization of impairment for manic disorders in both the AUDADIS and CIDI strongly influences case identification, with the CIDI having suppressed manic and hypomanic prevalence estimates. Evidence was found supporting the conclusion that self-reported cannabis use is a significant risk factor for incident bipolar spectrum outcomes within subpopulations in a nationally representative cohort. A sensitivity analysis finds evidence that supports the conclusion that increasing cannabis use propensity is associated with increased risk of bipolar spectrum outcomes within population subgroups, with the greatest increased risk among those with the lowest innate risk. Under-reporting of illicit substance use is a major limitation in this dissertation; further study is needed with improved exposure measures.

L'objectif de cette thèse est d'explorer les corrélats électrophysiologiques du traitement des émotions à différents niveaux : la perception, la réactivité et la régulation émotionnelles, chez des patients bipolaires. La plupart des études portant sur le traitement des émotions dans cette population clinique se sont focalisées sur le traitement des émotions faciales. Ces études ont mis en évidence un dysfonctionnement des processus de réactivité et de régulation émotionnelles. Cependant, peu d'études se sont intéressées au traitement de la prosodie émotionnelle chez ces patients. Or, la prosodie émotionnelle joue un rôle central dans les interactions sociales. C'est pourquoi il apparaît important d'étudier les corrélats électrophysiologiques des processus mis en œuvre à un stade pré-attentionnel, au niveau de la détection de changements survenant dans notre environnement auditif et de l'orientation de l'attention, étapes précoces du traitement des émotions (Scherer, 2001). A notre connaissance, aucune étude ne s'y est intéressée chez les patients bipolaires. Par ailleurs, un grand nombre d'études montrent que ces patients présentent une hyperréactivité émotionnelle ainsi qu'un défaut de régulation émotionnelle, en lien avec des anomalies telles qu'une hyperactiviation amygdalienne et/ou une hypoactivation du cortex préfrontal. Cependant, les corrélats électrophysiologiques de la réactivité et de la régulation émotionnelles sont peu connus chez ces patients comme dans la population générale. L'objet de ce travail est de proposer deux expériences en électroencéphalographie afin d'étudier le décours temporel des processus de détection de la nouveauté et d'orientation non volontaire de l'attention et de processus de réactivité et de régulation émotionnelles à l'aide des potentiels évoqués. Dans la première expérience, nous utilisons un paradigme Oddball afin d'étudier la détection de la nouveauté et l'orientation non volontaire de l'attention : le matériel élaboré spécialement pour cette étude est constitué de voyelles (/a/, /i/, /u/) produites avec une prosodie de joie, de peur, de tristesse ou neutre. Dans la seconde expérience, nous avons repris le paradigme d'induction émotionnelle à l'aide d'images (Schönfelder et al., 2013), dans lequel les participants observent passivement les images ou utilisent une stratégie de régulation émotionnelle (distraction, réinterprétation cognitive). Les principaux résultats ce cette thèse montrent des anomalies de traitement des émotions chez les patients bipolaires, dès les étapes précoces de détection de la nouveauté et d'orientation non volontaire de l'attention. Si les participants contrôles présentent une MisMatch Negativity (négativité de discordance) plus ample pour certaines émotions (la peur) que pour d'autres (la joie), ce n'est pas le cas des patients. Par ailleurs, ces derniers ne présentent pas de modulation de la P3a par le changement d'émotions, ce qui indique une anomalie de l'orientation non volontaire de l'attention vers des stimuli émotionnels. Néanmoins, ils réagissent plus rapidement au changement d'émotions que les contrôles. À des étapes plus tardives, les patients bipolaires témoignent d'une réactivité émotionnelle importante pour les stimuli neutres, ce qui n'est pas le cas des contrôles. Enfin, les patients ne parviennent pas à réguler les émotions positives à l'aide d'une stratégie fondée sur le mécanisme de redéploiement attentionnel. Ces résultats suggèrent que les patients bipolaires présentent des anomalies de traitement des émotions dès les premiers processus perceptifs, n'impliquant pas de mécanismes d'attention volontaire, jusqu'à des niveaux de traitement plus contrôlés (réactivité et régulation émotionnelle volontaires). Cette thèse apporte de nouvelles données concernant la perception, la réactivité et la régulation émotionnelles et contribue à une meilleure connaissance des bases neurophysiologiques du traitement des émotions chez les patients bipolaire / This thesis investigates electrophysiological correlates of emotion processing from perception to reactivity and emotion regulation in adult with bipolar disorders. Most studies with such patients have focused on the processing of facial emotion. They showed impairment of facial recognition as well as emotional reactivity and regulation. However, few studies investigated the processing of emotional prosody and preattentive stage of processing in patient with bipolar disorders. Given that emotional prosody plays a crucial role in social interactions, it is important to better understand neurophysiological correlates of novelty detection and involuntary orientation of attention which constitute early stages of emotional processing (Scherer, 2001). To our knowledge, no study has yet addressed this issue in bipolar disorder. Moreover, patients with bipolar disorder have abnormal emotional reactivity and a deficit in emotion regulation along with hyperactivation of amygdala and hypoactivation of prefrontal cortex. Also, electrophysiological correlates of emotional reactivity and regulation are not well known in patients with bipolar disorders and in general population. For this purpose, two experiments were run in the present thesis in order to investigate the time course of novelty detection, involuntary orientation of attention, emotion reactivity and emotion regulation using evoked potentials responses. In the first experiment, an Oddball paradigm was used to assess novelty detection and orientation of attention. The linguistic material specifically designed for this study consists of French vowels (/a/, /i/, /u/) produced with happiness, fear, sadness or neutral prosodies. In the second experiment, an emotional induction paradigm (Schönfelder et al., 2013) was employed. Participants watched affective or neutral pictures or used an emotion regulation strategy (i.e., distraction or cognitive reappraisal). Taken together, the results of the present thesis indicate that patients with bipolar disorders show impairment in emotion processing even at preattentive stages such as novelty detection and involuntary orientation of attention. Healthy participants show a larger MisMatch Negativity in response to fear than to happiness, whereas patients did not. These patients did not show modulation of the P3a in response to emotion change, suggesting dysfunctioning of orientation of attention towards emotional stimuli. However, they were more sensible to emotion change than control as indicating by faster response in the case of such change. At a later stage, patients present greater emotional reactivity in response to neutral stimuli than controls. Moreover, they fail to regulate positive emotions using a regulation strategy based on attentional deployment (distraction). Overall, these results suggest that patient with bipolar disorder already show dysfunctioning at a perceptive level of emotional processing. A dysfunctioning was also attested at a more controlled processing (e.g. emotional reactivity and emotion regulation). Our work enriches the understanding on perception, reactivity and emotion regulation and contributes to a better understanding of neurophysiological bases of emotion processing in patients with bipolar disorder.

[pt] O presente trabalho investiga preditores clínicos de incapacidade e especificidade episódica da memória autobiográfica no Transtorno Bipolar (TB). Além disso, investiga a relação entre incapacidade e insight nesses indivíduos. Os resultados destacam o impacto da depressão e o papel generalizado da perda de insight no TB, indicando que o insight pode levar ao aumento da incapacidade e reforça a associação entre sintomas depressivos e incapacidade, o que tem sido consistentemente relatado na literatura. Além disso, os resultados deste estudo indicam que sintomas mais graves de depressão, maior nível de ideação suicida e menor gravidade da doença atuam como preditores de prejuízos na habilidade de recordação de detalhes autobiográficos no TB. Preditores clínicos são frequentemente usados na prática clínica para identificar pacientes em risco de resultados adversos. Portanto, esta pesquisa visa contribuir para o avanço da compreensão da doença com relevância direta para avaliação clínica e possíveis intervenções. / [en] The current work explores clinical predictors of disability and autobiographical memory episodic specificity in bipolar disorder (BD). In addition, it investigates the relationship between disability and insight in this disease The results highlight the impact of depression and pervasive role of loss of insight in BD, indicating that it may also lead to increased disability and reinforces the association between depressive symptoms and disability, which has been consistently reported in literature. Additionally, the results of this study indicate that more severe symptoms of depression, higher level of suicidal ideation and lower illness severity act as predictors of impaired recall of specific autobiographical details in BD. Clinical predictors are frequently used in clinical practice to identify patients at risk of adverse outcomes. Therefore, this research aimed at contributing to advance the understanding of the disease with direct relevance for clinical assessment and possible interventions.