Abstract The study describes adult patients' experiences of psychosis and being helped in an inpatient setting. The method is qualitative and the approach phenomenological. The study was carried out at the psychiatric clinic of a Finnish university hospital in 1998. The participants were men and women aged 23-57 coping with different types of psychosis. The data consists eight people's interviews (n=14), which were tape-recorded (except one). The data was analysed using the method developed by Amedeo Giorgi and Juha Perttula. Patients experienced psychosis as an uncontrollable sense of self, which included emotional and physical feelings of a change and a loss of control over one's self. Uncontrollable sense of self increased sensitivity with self, others, the significant others were important and meaningful and coping with daily life was difficult and varied individually. The onset of psychosis was experienced situational, the progress of psychosis as holistic and exhaustive, and the admission into the treatment as difficult but inevitable. The care was experienced as helpful but unstructured. The care should be based on patients' experiences of psychosis with self, others and life. When patients have uncontrollable sense of self the care should be protection from vulnerability to more integrated inner world supporting individual empowerment and coping. / Tiivistelmä Tutkimuksessa kuvaillaan aikuisten potilaiden kokemuksia psykoosin ja autetuksi tulemisen todellisuudesta psykiatrisen sairaalahoidon aikana. Tutkimuksen lähestymistapa on fenomenologinen. Keräsin tutkimusaineiston yliopistosairaalan psykiatrian klinikassa avoimilla haastatteluilla vuonna 1998. Tutkimukseen osallistuneet olivat erilaisia psykooseja kokeneita ja niistä selviytyneitä tai selviytymässä olevia, 25-57-vuotiaita naisia ja miehiä. Tutkimusaineistona on kahdeksan erimuotoista psykoosia kokeneen potilaan haastattelut (n=14), jotka nauhoitettiin (yhtä lukuun ottamatta). Analysoin aineiston Amedeo Giorgin kehittämällä ja Juha Perttulan Giorgin analyysimenetelmään liittämän muunnelman mukaan. Potilaat kokivat psykoosin hallitsemattomana minuutena, mikä tarkoitti emotionaalista ja fyysistä minän muuttumisen ja itsehallinnan menetyksen tunnetta. Hallitsematon minuus merkitsi herkistyneisyyden lisääntymistä itsen ja muiden suhteen, omaisten ja ystävien tärkeyttä ja vaihtelevaa vaikeutta selviytyä jokapäiväisestä elämästä. Elämäntilanteeseen liittyvä hallitsematon minuus oli kokonaisvaltainen ja uuvuttava kokemus. Tällöin sairaalahoito koettiin vaikeana, mutta välttämättömänä. Autetuksi tuleminen oli helpottavaa ja välttämätöntä, mutta hoito jäi jäsentymättömäksi omaan sisäiseen tilanteeseen, hoitotoimintojen ja minuuden hallitsemattomuuden / hallinnan suhteen. Autetuksi tuleminen tarkoitti potilaiden kokemana haavoittuvuudelta suojaamisesta eheytyneemmäksi tuloa siten, että yksilöllistä voimaantumista ja selviytymistä tuetaan.

Abstract Schizophrenia is associated with a shortened life expectancy and increased somatic comorbidity with e.g. cardiovascular disorders. The purpose of this study was to evaluate hyperlipidemia and metabolic syndrome in schizophrenia and thus find specific risk factors for excess mortality and morbidity. The study population was a subsample of the Northern Finland 1966 Birth Cohort, a general population-based birth cohort. In 1997, 8,463 members of the cohort were invited to a clinical examination, where e.g. blood samples were taken after an overnight fast. Total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL) and triglycerides (TG) were determined. The following psychiatric diagnostic categories were used: 1) DSM-III-R schizophrenia (n = 31), 2) other psychoses (n = 21), 3) non-psychotic disorders (n = 104), 4) comparison group (n = 5,498), having no psychiatric hospital treatment. Mean TC (5.5 mmol/l) and TG (1.5 mmol/l) were significantly higher in the schizophrenia group than in the comparison group (5.1 mmol/l and 1.2 mmol/l, respectively). To evaluate serum lipid levels in subjects with and without antipsychotic medication the sample was analyzed according to used medication. The prevalence of hypercholesterolemia, high LDL cholesterol and hypertriglyceridemia was high in persons using antipsychotic medication (31%, 20% and 22%, respectively) compared to persons without such medication (12%, 10% and 7%, respectively). We found higher triglyceride levels in patients who were ≤ 20 years old at the onset of schizophrenia (mean 1.7 mmol/l; N = 17) as compared with patients with later onset (mean 1.4 mmol/l; N = 14) or non-hospitalized controls (mean 1.2 mmol/l; N = 5,453). The difference between the first and third group was significant (p < 0.01), and there was a negative correlation between the age at onset and the level of serum triglycerides (r = -0.35, p = 0.05). To evaluate the prevalence of metabolic syndrome, the subjects were assessed for the presence of metabolic syndrome according to the criteria of the National Cholesterol Education Program. The prevalence of metabolic syndrome was high in subjects with schizophrenia compared with the comparison group (19% vs. 6%, p = 0.010). The results indicate an elevated risk for hyperlipidemia and metabolic syndrome in persons with schizophrenia or on antipsychotic medication. Regular monitoring of weight, serum lipid and glucose levels and blood pressure is important. Comprehensive efforts directed at controlling weight and improving physical activity are needed.

Orientadores: Cláudio Eduardo Muller Banzato , Clarissa de Rosalmeida Dantas / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-27T15:11:19Z (GMT). No. of bitstreams: 1 Silva_LuizFernandodeAlmeidaLimae_M.pdf: 4787027 bytes, checksum: 41b58615628a8ce9c086589e9db94ca8 (MD5) Previous issue date: 2015 / Resumo: O transtorno afetivo bipolar (TAB) é uma morbidade mental crônica e grave, que habitualmente se manifesta na adolescência ou início da vida adulta. Sua forma mais prevalente de apresentação é a de episódios maníacos ou hipomaníacos, intercalados por episódios depressivos ou períodos de eutimia. Modernamente, uma miríade de medicações possuem aprovação para o tratamento do TAB, porém o lítio ainda é considerado um dos fármacos de primeira linha no tratamento de manutenção do transtorno. Como a resposta ao lítio não é uniforme, a tentativa de identificar possíveis preditores de resposta terapêutica vem sendo alvo de diversos estudos. Neste contexto, um grande desafio é avaliação da melhora clínica de pacientes tratados fora de um protocolo estrito de pesquisa. Para contornar este problema, a escala ALDA vem se mostrando como um valioso instrumento nos trabalhos publicados na literatura. OBJETIVOS: estudar a confiabilidade da escala ALDA, avaliar de forma padronizada a resposta terapêutica ao lítio no tratamento de manutenção do TAB e identificar possíveis preditores clínicos e epidemiológicos de resposta. MÉTODOS: quarenta pacientes em tratamento ambulatorial com diagnostico confirmado de TAB e história de uso de lítio foram avaliados, com revisão minuciosa dos prontuários médicos. Um instrumento padronizado (a escala ALDA), que se baseia em informações clínicas obtidas de forma retrospectiva, foi usado para avaliar a melhora clínica global e possíveis fatores confundidores. Foram também coletados dados acerca de variáveis clínicas e sociodemográficas, para avaliar possíveis fatores preditores de resposta ao tratamento. Também aferimos a confiabilidade interavaliadores para o escore total e para cada um dos itens da escala ALDA, por meio do Coeficiente de Correlação Intraclasse (ICC), entre dois pesquisadores que realizaram suas avaliações de modo independente. RESULTADOS: nosso estudo encontrou uma relação inversa entre o número de episódios de humor com sintomas psicóticos e melhor desfecho no tratamento com lítio (PE -1,24241). Também constatamos a relação direta entre uso atual ou prévio de tabaco e melhora clínica com lítio (PE 7,66608). Com relação ao estudo de ICC nos diferentes itens da escala ALDA, encontramos valores que variaram de 0,610 a 0,833. CONCLUSÃO: nossos achados apontam que a escala ALDA pode ser uma ferramenta útil e confiável para a avaliação padronizada da resposta terapêutica em pacientes com TAB. Os resultados obtidos reforçam a hipótese que o lítio parece ser menos eficaz em pacientes que manifestam sintomas psicóticos, além de nos levarem a questionar o papel do tabaco no prognóstico de pacientes com transtorno bipolar / Abstract: Bipolar disorder (BD) is a chronic and severe mental illness, that usually manifest its first symptoms in early adulthood. The most prevalent clinical form of the disorder is the occurrence of episodes of mania or hypomania, interspersed with episodes of depression and periods of euthymia. Currently, a myriad of drugs have approval for treating BD, nevertheless lithium still stands as a gold standard in the prophylactic treatment of the disorder. Since lithium response is not uniform between patients, different studies have been trying to identify possible predictors of response to the treatment. In this scenario, accessing clinical improvement in patients not treated following a strict research protocol is a great challenge. To solve this issue, the ALDA scale appeared as a valuable tool in different published studies. OBJECTIVES: to study the reliability of the ALDA scale, to systematically access the response of prophylactic lithium treatment in BD and to identify possible clinical and epidemiological predictors of lithium response. METHODS: forty outpatients in treatment for confirmed clinical diagnose of BD, and with history of lithium use, were accessed with a thorough review of their medical charts. A standardized instrument (the ALDA scale), which is based on clinical information obtained retrospectively, was used to evaluate clinical improvement and possible confounding factors. In this process, we have obtained other clinical and sociodemographic data, to investigate possible predictive variables to treatment response. We have also used the Interclass Correlation Coefficient (ICC) to determine the inter-rater reliability between two independent researchers, for the ALDA scale total score and each of its sub items. RESULTS: our study found an inverse relation between the number of mood episodes with psychotic symptoms and improvement with lithium therapy (PE -1,24241). We have also found a direct relation between current or previous tobacco use and clinical improvement with lithium (PE 7,66608). Concerning the ICC for each of the ALDA scale sub items, we found values ranging between 0,610 and 0,833. CONCLUSION: our findings suggest that the ALDA scale can be a useful and trustworthy instrument in the standardized evaluation of clinical response in patients with BD. Our results also reinforce the hypothesis that lithium treatment seems to be less efficacious in patients with psychosis, and lead us to speculate the role of tobacco use in the outcome of patients with bipolar disorder / Mestrado / Saude Mental / Mestre em Ciências Médicas

People with psychotic disorders die earlier than expected due to physical illnesses such as cardiovascular diseases, diabetes, and cancer. Despite substantial evidence about managing physical health to improve quality of life and reduce morbidity and mortality, there is limited research from the perspectives of people living with psychotic disorders. Since discourses are attached to all areas of knowledge, I situated myself within the critical social paradigm to understand factors that subjugate voices of people with psychotic disorders in research, practices, and policies. I used postcolonial theory as a lens for my research to show power asymmetry that often oppresses and dominates patients based on exclusion. Postcolonial theory in general and Spivak’s theory more specifically helped draw the parallel between systems of power such as colonization and patriarchy that silence the subaltern in the context of colonization and people with mental illness in psychiatry. Committing to Spivak’s theory of subalternity for self-representation, I chose digital storytelling as a methodological approach for generating transformative knowledge that exposes forces that mediate health and illness. Digital storytelling has an epistemological commitment to self-representation and critical reflection through visual, audio, and other forms of expression that facilitate more accurate articulations of experiences. The overarching purpose of this thesis was to explore the process of digital storytelling with people with psychotic disorders as a means of expressing their voices and to understand how nurses and healthcare leaders engage with the digital stories and foresee the use of digital stories in healthcare practices and policies. Six short videos capturing personal stories of people with psychotic disorders about their physical health needs and concerns were produced. Digital stories are audio-visual vignettes of approximately 2-5 minutes in length, presenting first-person stories in conjunction with audiovisual material (photos, images, soundtracks, etc.). The digital stories were presented in 2 focus group sessions to understand their impact on nurses and nursing leaders (n=15). Findings from this research brought forth stories that spoke of deep struggles people with psychotic disorders experience in addressing their physical health concerns within the psychiatric system. Participants talked about their embodied experiences and invisibility in the healthcare system in their digital stories. They expressed that healthcare providers had paternalistic approaches when addressing their physical health problems and revealed how they compensated for their lack of power and loss of identity. Story makers embedded their experiences with notions of powerlessness and despair and the associated negative impact on significant aspects of their lives. By reflecting on the digital stories and placing the content of stories within the larger context of the psychiatric system and current practices, nurses were able to expose power relations and structures such as quantitative approaches to care, stigma, and the biomedical model of care that excluded the experiences of people with psychotic disorders in psychiatry. Meanwhile, reflecting on the stories exposed nurses’ passive stance in challenging and resisting the dynamics that exclude patients’ voices at every level of care. In this research, Spivak’s theory helped highlight the thematic centrality of epistemic violence and the role of the digital stories in overcoming epistemic injustice and opening a line of communication with those in positions of power in psychiatry.

In this thesis, we developed prognostic models of clinical outcomes, specific to violent and criminal outcomes in psychiatry, and predictive models of treatment response at an individual level. Overall, we demonstrate that evidence-based risk factors, protective factors, and treatment status variables were able to prognosticate prospective physical aggression at an individual level; 2) prognostic models of clinical and violent outcomes in psychiatry have largely focused on clinical and sociodemographic variables, show similar performance between identifying true positives and true negatives, although the error rate of models are still high, and further refinement is needed; 3) within treatment response prediction models in MDD using EEG, greater performance was observed in predicting response to rTMS, relative to antidepressants, and across models, greater sensitivity (true positives), were observed relative to specificity (true negatives), suggesting that EEG prediction models thus far better identify non-responders than responders; and 4) across randomized clinical trials using data-driven biomarkers in predictive models, based on the consistency of performance across models with large sample sizes, the highest degree of evidence was in predicting response to sertraline and citalopram using fMRI features. / Dissertation / Doctor of Philosophy (PhD)

Yes / Current NHS policy encourages an integrated approach to provision of mental and physical care for individuals with long term mental health problems. The 'PARTNERS2' complex intervention is designed to support individuals with psychosis in a primary care setting. The trial will evaluate the clinical and cost-effectiveness of the PARTNERS2 intervention. This is a cluster randomised controlled superiority trial comparing collaborative care (PARTNERS2) with usual care, with an internal pilot to assess feasibility. The setting will be primary care within four trial recruitment areas: Birmingham & Solihull, Cornwall, Plymouth, and Somerset. GP practices are randomised 1:1 to either (a) the PARTNERS2 intervention plus modified standard care ('intervention'); or (b) standard care only ('control'). PARTNERS2 is a flexible, general practice-based, person-centred, coaching-based intervention aimed at addressing mental health, physical health, and social care needs. Two hundred eligible individuals from 39 GP practices are taking part. They were recruited through identification from secondary and primary care databases. The primary hypothesis is quality of life (QOL). Secondary outcomes include: mental wellbeing, time use, recovery, and process of physical care. A process evaluation will assess fidelity of intervention delivery, test hypothesised mechanisms of action, and look for unintended consequences. An economic evaluation will estimate its cost-effectiveness. Intervention delivery and follow-up have been modified during the COVID-19 pandemic. The overarching aim is to establish the clinical and cost-effectiveness of the model for adults with a diagnosis of schizophrenia, bipolar, or other types of psychoses. / PARTNERS2 is funded by the National Institute for Health Research (NIHR) under its Programme Grant for Applied Research Programme (grant number: RP-PG- 200625). This research was also supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust.

O presente estudo investigou a prevalência e a validade de construto das experiências psicóticas (EPs) na gestação e os fatores de risco associados em uma amostra comunitária do município de São Paulo. Foram investigados fatores de risco sociodemográficos, ambientais, transtornos psiquiátricos no presente e ao longo da vida, violência doméstica, capacidade intelectual e histórico familiar de transtornos psiquiátricos. Foram também avaliados desfechos da gestação e do parto. Trata-se de um estudo prospectivo, com início no 3º trimestre de gestação. As entrevistas de avaliação foram realizadas por psicólogos treinados. Para a avaliação das EPs, foi utilizado o instrumento de entrevista diagnóstica padronizada breve - Mini International Neuropsyquiatric Interview (M.I.N.I), validado para a realidade brasileira. Para os fatores de risco sociodemográficos, foram aplicados: questionário socioeconômico (QSE), densidade demográfica (DM) e utilizado o critério de classificação econômica do Brasil CCEB, pela Associação Brasileira de Empresas de Pesquisa (ABEP) e World Health Organization - WHO para violência doméstica. Foi realizada a avaliação da capacidade intelectual através da Escala de Inteligência Wechsler para adultos, terceira versão (WAISS-III) e investigado o histórico familiar para transtornos mentais através do The Family History Screen (FHS). Os resultados apontaram uma prevalência de 19,22% das EPs na gestação e compartilhando os fatores de risco presentes na esquizofrenia, como: urbanicidade, gestantes jovens, o uso de drogas e álcool, desvantagem socioeconômica, baixo nível de escolaridade, exposição à situações de violência, a presença dos transtornos psiquiátricos como depressão e ansiedade, e histórico familiar para qualquer condição psiquiátrica. Este estudo, realizado em uma região urbana da cidade de São Paulo, com altos índices de vulnerabilidade social, indica que a prevalência de EPs em gestantes é alta, afetando cerca de 1 em 6 mulheres. A presença de EPs associa-se fortemente com psicopatologia geral e com amplos fatores de risco. Neste sentido, a presença de EPs pode se constituir em um importante indicador de risco a ser avaliado em ambientes clínicos durante a gestação. Estudos futuros que possam investigar a sua utilidade para indicação de intervenções são necessários, assim como estudos que investiguem o curso de EPs apos o período gestacional e a sua associação com desfechos de saúde nas mulheres e em seus filhos / This research investigated the prevalence and construct validity of psychotic experiences (PEs) during pregnancy and the risk factors in a community sample in the city of São Paulo. Sociodemographic and environmental risk factors, psychiatric disorders, domestic violence, intellectual capacity and family history of psychiatric disorders in the present and throughout life were the investigated elements. Pregnancy and delivery outcomes were also evaluated. This is a prospective research, starting in the 3rd trimester of pregnancy. The evaluation interviews were conducted by trained psychologists. For the evaluation of PEs, the brief standardized diagnostic interview tool was used - Mini International Neuropsyquiatric Interview (M.I.N.I), validated for the Brazilian reality. For the sociodemographic risk factors, both socioeconomic questionnaire (SEQ) and population density (PD) were applied and the criterion of economic classification in Brazil (CECB) was used by the Brazilian Association of Research Companies (BARC) and World Health Organization - WHO for domestic violence. The intellectual capacity evaluation was carried out, using the Wechsler Intelligence Scale for Adults, third version (Waiss-III), and the family history of mental disorders was investigated through The Family History Screen (FHS). The results indicated a prevalence of 19.22% of PEs during pregnancy and sharing the risk factors present in schizophrenia, such as urbanicity, young pregnant women, use of drugs and alcohol, socioeconomically disadvantaged, low educational level, exposure to situations of violence, the presence of psychiatric disorders such as depression and anxiety, and family history of any psychiatric condition. This research, conducted in an urban area of the city of São Paulo, with high social vulnerability, indicates that the prevalence of PEs in pregnant women is high, affecting about 1 in 6 of them. The presence of PEs is strongly associated with general psychopathology and broad risk factors. In this sense, the presence of PEs may constitute an important risk factor to be evaluated in clinical environments during pregnancy. Future researches intending to look into its usefulness for indication of interventions are needed, as well as studies to search into the course of PEs after pregnancy and its association with health outcomes for women and their children

O presente estudo investigou a prevalência e a validade de construto das experiências psicóticas (EPs) na gestação e os fatores de risco associados em uma amostra comunitária do município de São Paulo. Foram investigados fatores de risco sociodemográficos, ambientais, transtornos psiquiátricos no presente e ao longo da vida, violência doméstica, capacidade intelectual e histórico familiar de transtornos psiquiátricos. Foram também avaliados desfechos da gestação e do parto. Trata-se de um estudo prospectivo, com início no 3º trimestre de gestação. As entrevistas de avaliação foram realizadas por psicólogos treinados. Para a avaliação das EPs, foi utilizado o instrumento de entrevista diagnóstica padronizada breve - Mini International Neuropsyquiatric Interview (M.I.N.I), validado para a realidade brasileira. Para os fatores de risco sociodemográficos, foram aplicados: questionário socioeconômico (QSE), densidade demográfica (DM) e utilizado o critério de classificação econômica do Brasil CCEB, pela Associação Brasileira de Empresas de Pesquisa (ABEP) e World Health Organization - WHO para violência doméstica. Foi realizada a avaliação da capacidade intelectual através da Escala de Inteligência Wechsler para adultos, terceira versão (WAISS-III) e investigado o histórico familiar para transtornos mentais através do The Family History Screen (FHS). Os resultados apontaram uma prevalência de 19,22% das EPs na gestação e compartilhando os fatores de risco presentes na esquizofrenia, como: urbanicidade, gestantes jovens, o uso de drogas e álcool, desvantagem socioeconômica, baixo nível de escolaridade, exposição à situações de violência, a presença dos transtornos psiquiátricos como depressão e ansiedade, e histórico familiar para qualquer condição psiquiátrica. Este estudo, realizado em uma região urbana da cidade de São Paulo, com altos índices de vulnerabilidade social, indica que a prevalência de EPs em gestantes é alta, afetando cerca de 1 em 6 mulheres. A presença de EPs associa-se fortemente com psicopatologia geral e com amplos fatores de risco. Neste sentido, a presença de EPs pode se constituir em um importante indicador de risco a ser avaliado em ambientes clínicos durante a gestação. Estudos futuros que possam investigar a sua utilidade para indicação de intervenções são necessários, assim como estudos que investiguem o curso de EPs apos o período gestacional e a sua associação com desfechos de saúde nas mulheres e em seus filhos / This research investigated the prevalence and construct validity of psychotic experiences (PEs) during pregnancy and the risk factors in a community sample in the city of São Paulo. Sociodemographic and environmental risk factors, psychiatric disorders, domestic violence, intellectual capacity and family history of psychiatric disorders in the present and throughout life were the investigated elements. Pregnancy and delivery outcomes were also evaluated. This is a prospective research, starting in the 3rd trimester of pregnancy. The evaluation interviews were conducted by trained psychologists. For the evaluation of PEs, the brief standardized diagnostic interview tool was used - Mini International Neuropsyquiatric Interview (M.I.N.I), validated for the Brazilian reality. For the sociodemographic risk factors, both socioeconomic questionnaire (SEQ) and population density (PD) were applied and the criterion of economic classification in Brazil (CECB) was used by the Brazilian Association of Research Companies (BARC) and World Health Organization - WHO for domestic violence. The intellectual capacity evaluation was carried out, using the Wechsler Intelligence Scale for Adults, third version (Waiss-III), and the family history of mental disorders was investigated through The Family History Screen (FHS). The results indicated a prevalence of 19.22% of PEs during pregnancy and sharing the risk factors present in schizophrenia, such as urbanicity, young pregnant women, use of drugs and alcohol, socioeconomically disadvantaged, low educational level, exposure to situations of violence, the presence of psychiatric disorders such as depression and anxiety, and family history of any psychiatric condition. This research, conducted in an urban area of the city of São Paulo, with high social vulnerability, indicates that the prevalence of PEs in pregnant women is high, affecting about 1 in 6 of them. The presence of PEs is strongly associated with general psychopathology and broad risk factors. In this sense, the presence of PEs may constitute an important risk factor to be evaluated in clinical environments during pregnancy. Future researches intending to look into its usefulness for indication of interventions are needed, as well as studies to search into the course of PEs after pregnancy and its association with health outcomes for women and their children

L’objectif de cette thèse sur articles était d’identifier des facteurs de risque environnementaux (FRE) associés à la survenue et au maintien des troubles psychotiques non-affectifs, dans un contexte français. Nous nous sommes appuyé sur les modèles socio-développemental-cognitif de Howes et Murray, et de la sensibilisation. Nos résultats ont montré l’implication d’un FRE populationnel, la fragilité économique, et de plusieurs aspects d’un FRE individuel, les traumatismes infantiles, dans l’accroissement du risque de développer ou de survenue d’un trouble psychotique. Concernant l’évolution de la maladie : nous avons identifié les expériences traumatiques infantiles et la consommation de cannabis comme étant deux facteurs modificateurs du cours évolutif de la maladie. Nous avons enfin cherché à montrer les apports de la théorie de la dissociation structurelle de la personnalité, pour intégrer les résultats issus de nos deux modèles initiaux dans un cadre bio-psycho-social. Nos travaux indiquent que des FRE populationnels et individuels sont associés à la survenue et au maintien des troubles psychotiques. Ils ouvrent la voie à de nouvelles stratégies thérapeutiques. / This article thesis aimed to identify environmental risk factors (ERF) that are associated with the onset and the prognosis of non-affective psychotic disorders, in a French context. We based our work on Howes and Murray’s sociodevelopmental-cognitive model, and the sensitization model. Our results showed that one area-level environmental risk factor, namely the economic deprivation, and several aspects of childhood traumas, an individual ERF, are associated with an increased risk to develop psychotic disorders. Furthermore, we identified childhood traumas and cannabis consumption as modifier factors for these disorders. Finally, we sought to link our previous results, the two original models, and conceptual inputs from the theory of structural dissociation of personality in a coherent, clinically useful, and biopsychosocial framework. Our results suggest that both arealevel and individual environmental risk factors are involved in the onset and poor prognosis of psychotic disorders. They open perspectives for new therapeutic strategies.

A maioria dos estudos sobre o papel da família na continuidade do tratamento após o primeiro episódio psicótico investigam os casos de abandono de tratamento e apontam para aspectos \"negativos da família\". Poucos estudos investigam o papel da família nos casos de pacientes que se mantém no tratamento. Objetivo: Compreender a experiência de cuidar de um familiar no PEP e evidenciar as motivações para manter-se no cuidado. Método: Trata-se de pesquisa qualitativa que utilizou a teoria sistêmica familiar como referencial teórico e a narrativa como referencial metodológico. Foram entrevistados 13 familiares cuidadores de 12 pacientes. Para a realização das entrevistas em profundidade com enfoque narrativo foi utilizada a seguinte questão norteadora: Nós sabemos que poucos familiares se mantêm no tratamento em saúde mental junto ao seu jovem familiar adoecido após o primeiro episódio psicótico. Se manter no tratamento conjuntamente ao paciente e cuidar do mesmo é chamado por nós de engajamento. São ações como levar nas consultas, administrar a medicação, modo de se relacionar, cuidar da higiene e assim por diante. Sendo assim, gostaríamos que você nos contasse sobre o que te motiva a permanecer cuidando e tudo que você e sua família fazem pelo seu familiar adoecido. Para a exploração das narrativas foi utilizada a técnica de análise de conteúdo indutiva. Resultados: A análise das narrativas definiu o engajamento familiar em três grandes categorias interdependentes. Uma é relacionada ao contexto de sentimentos envolvidos no cuidar denominada \"Motivações para o engajamento\", as outras duas referem-se às ações relacionadas ao cuidar denominadas \"As ações de engajamento\" e \"Avaliação constante do cuidar\". Conclusão: A pesquisa contribui com o conhecimento ao apresentar famílias ativamente envolvidas no cuidado com o jovem em tratamento para o primeiro episódio psicótico. O referencial teórico - metodológico possibilitou destacar e valorizar as histórias, experiências e as relações familiares envolvidos no cuidado de um ente querido. Os cuidados foram descritos e contextualizados nos valores culturais das famílias. Verificamos que os familiares percebem o cuidado como uma responsabilidade do seu papel na família / Most studies of the family\'s role in the continuity of treatment after the first epidode psychosis investigate cases of abandonment treatment and point to \"negative aspects of family\". Few studies have investigated the role of the family in cases of patients who remain in treatment. Objective: Understand the experience of caring of a familiar in PEP and highlight the motivations to remain in care. Method: This is a qualitative research that used the systemic family theory as the theoretical framework and the narrative as a methodological framework. 13 family caregivers of 12 patients were interviewed. To carry out the interviews with narrative approach was used the following question: We know that few families remain in mental health treatment of their sick young familiar after the first episode psychosis. Maintain the treating and taking care of the patient is called engagement. These are actions like take into consultations, administer medications, so as to relate, take care of hygiene and so on. Therefore, we would like you to tell us what motivates you to stay caring after everything you and your family are sickened by his family. For the exploration of the narratives was used the inductive content analysis technique. Results: The analysis of the narrative set the familiar engagement in three major interdependent categories. One is related to the context of feelings involved in the care called \"Motivations for engagement,\" the other two refer to actions related to care called \"The engagement actions\" and \"The assessment of care.\" Conclusion: The study contributes to the knowledge to present actively involved families in caring of the young in treatment of first episode psychosis. The theoretical - methodological possible highlight and enhance the stories, experiences and family relations involved in the care of a loved one. Care were described and contextualized in the cultural values of families. We found that family members perceive care as a responsibility of their role in the family