A paralisia cerebral é definida como uma alteração permanente do desenvolvimento da postura e movimento, causando limitações nas atividades, que são atribuídas a um distúrbio não progressivo que ocorre precocemente no encéfalo em desenvolvimento. A presença de comorbidades psiquiátricas traz piora funcional e na qualidade de vida dessas crianças e seu reconhecimento e tratamento deveriam fazer parte da rotina de centros de reabilitação. Este projeto tem como objetivo estudar as comorbidades psiquiátricas na paralisia cerebral. Foram avaliados 550 indivíduos com diagnóstico de paralisia cerebral, procedentes de um centro terciário de reabilitação física. A comorbidade psiquiátrica mais frequentemente observada foi a deficiência intelectual. Outras comorbidades psiquiátricas frequentes foram os transtornos ansiosos, transtornos do comportamento, transtorno do déficit de atenção e hiperatividade, transtorno do espectro autista e depressão. Embora não fosse o objetivo deste trabalho estudar a ocorrência de epilepsia nessa população, observamos que 43,2% dos nossos pacientes apresentaram essa associação. A presença de transtornos do espectro do autismo foi significativamente maior nos pacientes com epilepsia. A presença de um transtorno psiquiátrico impactou significativamente a percepção da funcionalidade das crianças com paralisia cerebral. Pensar na reabilitação desses sujeitos é levar em conta a presença de transtornos psiquiátricos. A pesquisa ativa de comorbidades deve ser prática rotineira dentro de centros de reabilitação terciários. Pensar em reabilitação do paciente com paralisia cerebral deve extrapolar os objetivos físicos e olhar com a mesma atenção para os aspectos emocionais, comportamentais, acadêmicos e sociais / Cerebral palsy is defined as a permanent change of posture and movement development, causing limitations in activities that are assigned to a non-progressive disorder that occurs early in the developing brain. The presence of psychiatric comorbidity brings functional deterioration and worsens quality of life of these children and their recognition and treatment should be part of routine of rehabilitation centers. This project aims to study psychiatric comorbidities in cerebral palsy. We evaluated 550 individuals diagnosed with cerebral palsy coming from a tertiary physical rehabilitation center. The most frequent psychiatric comorbidity was intellectual disability. Other frequent psychiatric comorbidities were anxiety disorders, behavioral disorders, attention deficit hyperactivity disorder, autism spectrum disorder and depression. Although it was not the objective of this work to study the occurrence of epilepsy in this population, we observed that 43.2% of our patients had this situation. The presence of autism spectrum disorders was significantly higher in patients with epilepsy. The presence of a psychiatric disorder significantly impacted the functionality of children with cerebral palsy. Thinking about the rehabilitation of these subjects is to take in account the presence of psychiatric disorders. The active search of comorbidities should be a routine practice in tertiary rehabilitation centers. Thinking about the rehabilitation of patients with cerebral palsy should extrapolate the physical goals and look with the same attention to the emotional, behavioral, academic and social aspects

Background Multimorbidity, the co-existence of multiple health conditions in an individual, is a significant Public Health challenge. However, it has no consensus definition or measure, and its determinants and outcomes are not fully understood. Resilience may be a mechanism by which the experience of multimorbidity can be improved but there has been little study of this. Aim To define and measure the prevalence of multimorbidity and resilience to multimorbidity, to assess the role of mental health and childhood socio-economic status (SES) and to investigate the long-term outcomes. Objectives 1. To determine how multimorbidity and resilience to multimorbidity should be defined and measured in Public Health research 2. To assess the prevalence of multimorbidity and resilience to multimorbidity using the measures identified in objective one 3. To assess the role of mental health conditions and childhood SES in the occurrence of multimorbidity and resilience to multimorbidity 4. To assess the impact of multimorbidity and resilience to multimorbidity on long-term outcomes Method Systematic reviews of the literature were conducted to address objective one. The analysis of two contrasting study populations was used to address objectives two to four. These were the Australian cross-sectional Diamond study and the Aberdeen Children of the 1950s cohort study. Results Multimorbidity was defined as the presence of two or more conditions and was measured by patient self-report and healthcare administrative data. Resilience was the presence of good self-reported outcomes despite multimorbidity. Multimorbidity prevalence ranged from 3% to 38%. Mental health conditions led to an increased burden of multimorbidity and a reduced prevalence of resilience. Childhood SES and other SES factors were associated with multimorbidity. Childhood SES and other SES factors were associated with multimorbidity. Multimorbidity was associated with poorer outcomes. Conclusion The findings in this thesis can be used to improve consensus approaches to studying multimorbidity and resilience, and to develop interventions to tackle these.

O uso problemático de álcool tem sido apontado como problema de saúde pública. A prevalência de dependência de álcool é maior em pessoas com transtornos psiquiátricos. Esta comorbidade pode trazer sérias implicações para a identificação, tratamento e reabilitação do indivíduo doente. O presente estudo teve como objetivo identificar o uso problemático de álcool em pacientes com transtornos psiquiátricos, a partir da realidade clínica assistencial terciária de um serviço universitário. Foi realizado um estudo transversal, com uma amostra clínica ambulatorial composta por 127 indivíduos em tratamento por um dos seguintes diagnósticos: esquizofrenia, transtorno afetivo bipolar, depressão e transtornos de ansiedade. Os dados foram colhidos através de entrevista com o paciente e também através do prontuário. As informações coletadas foram: dados sócio-demográficos, história psiquiátrica, problemas de saúde, características familiares e registros do prontuário relacionados ao diagnóstico do paciente e ao consumo de álcool. Foi aplicado o instrumento de rastreamento CAGE e realizada a entrevista estruturada em conformidade com os diagnósticos da CID-10 para uso nocivo e dependência de álcool. A fim de aumentar a sensibilidade do CAGE,trabalhou-se com o ponto de corte ¡Ý1. Da amostra total, 6,3% fazem uso nocivo de álcool e 3,9% são dependentes, de acordo com os critérios da CID-10. Quarenta e três pessoas (33,9%) pontuaram positivo no CAGE, o que indica a possibilidade de uso problemático de álcool em algum momento de suas vidas. Os fatores sócio-demográficos que mostraram relação com o uso problemático de álcool foram: ser homem, ter menos de 40 anos de idade, não ter companheiro(a) e não ser praticante de religião. Ao se comparar médias de escore no CAGE, entre os quatro grupos diagnósticos estudados, encontrou-se que a maior média foi a do grupo de esquizofrenia, seguida pelo de transtornos ansiosos, transtorno afetivo bipolar e, por último, depressão. Foi encontrada uma relação entre pontuação no CAGE e idade de início da enfermidade. Entre os pacientes que pontuaram positivo no CAGE, 60,5% não tinham registros, em seus prontuários, de uso de álcool. Sugere-se a disseminação de informações a respeito da comorbidade entre transtornos psiquiátricos e uso problemático de álcool na formação de profissionais de saúde, assim como treinamento para uso de instrumentos de rastreamento do uso problemático de álcool. / The problematic use of alcohol is becoming recognised as a serious public health problem. The prevalence of alcohol dependence is higher in persons with a psychiatric disorder. This comorbidity has serious implications for the identification, treatment and rehabilitation of the person. The aim of this research is to identify the problematic use of alcohol among individuals with psychiatric disorders by evaluating patients attending a psychiatric outpatient clinic at a university hospital. A transversal study was carried out, with a clinical sample composed of 127 individuals in treatment for one of the following disorders: schizophrenia, bipolar disorder, depression and anxiety disorders. The data was gathered from the patient’s records and through interview. The information collected was: sociodemographic data, psychiatric history, health problems, family characteristics and information from the records concerning the patient’s diagnosis and their previous alcohol use. The screening instrument CAGE was applied along with a structured interview based on the ICD-10 criteria for harmful use and alcohol dependence. In order to increase the sensitivity of CAGE the cut off point ¡Ý1 was used. It was found that 6.3% of patients met the criteria for harmful alcohol use and 3.9% for dependence (ICD-10). Forty-three persons (33,9%) scored positive with CAGE, indicating the possibility of problematic use of alcohol at a point in their lives. The sociodemographic factors that showed an association with problematic use of alcohol were: to be male, to be less than 40 years of age, to be without a partner and not to be practicing a religion. When the mean averages of CAGE scores for the four studied diagnostic groups were compared, the schizophrenia group scored higher, followed by the anxiety disorder group, bipolar disorder group and the depression group. A relationship was found between CAGE scores and patient age at the onset of the disorder. Among patients that scored positive with CAGE, 60,5% did not have any history, in their records, of alcohol use. It is suggested that information regarding comorbidity between psychiatric disorders and problematic use of alcohol be disseminated among health professionals, in conjunction with training in the use of screening instruments for problematic use of alcohol.

Binge eating is a harmful, maladaptive behavior associated with comorbid psychopathology. Theory posits that increases in maladaptive, transdiagnostic emotions following binge eating in individuals with BN may predict the experience of comorbid symptoms. The current study served as a laboratory test of the first part of this theory: whether state increases in maladaptive emotions occur following engagement in binge eating behavior in women with BN compared with healthy controls. Women (n = 51) were recruited from the community if they met DSM-5 criteria for BN or OSFED BN (of low frequency) (n = 21) or were free of lifetime disordered eating and current psychopathology (n = 30). Participants completed questionnaires assessing eating disorder symptoms (preoccupation with weight and shape, urge to vomit), state shame, and state negative affect before and after consuming a test meal in which they were instructed to binge. Women with BN endorsed significantly greater preoccupation with weight and shape and urge to vomit following test meal consumption compared with controls. Women with BN reported significant increases in state shame, but not state negative affect, following test meal consumption, compared with controls. Results are consistent with a model indicating binge eating precipitates increases in state shame among women with BN. Given shame’s status as a transdiagnostic risk factor, future work should clarify whether state shame following binge eating predicts increases in comorbid symptoms.

Language impairment (LI) and ADHD are two relatively common developmental disorders that frequently co-occur and have thus been said to be comorbid. The overall aim of this research is to investigate the nature of comorbidity between LI and ADHD in a large population-based sample. The project comprises two parts. The first study aims to quantify the extent of comorbidity between LI and ADHD, and asks whether there is any evidence for a shared liability between the two disorders on the basis of family history data. The second study hypothesizes that comorbidity between LI and ADHD arises because the two disorders share a common genetic etiology. Genetic variants previously associated with ADHD are tested for association to LI. Association is found with the dopamine receptor D4 (DRD4) and the serotonin transporter gene (SLC6A4). Implications for this in relation to language are discussed with respect to reinforcement and associative learning.

Attention-Deficit/Hyperactivity Disorder (ADHD) is comorbid with a range of other disorders in clinical and community samples, including anxiety disorders. The outcomes of the Multimodal Treatment Studies of ADHD (MTA Cooperative Group, 1999) highlight the importance of this comorbidity, as children with anxiety responded differently to treatments than did children with ADHD only. At present there are few tested theoretical explanations of the etiological processes and developmental trajectories associated with their co-occurrence. The aim of this research was to put forward and examine different explanations for the comorbidity of these two disorders in children according to the framework provided by Lilienfeld (2003). This was achieved by examining the covariation of ADHD symptoms and anxiety symptoms in a community sample of 499 children aged 8-13. Dimensional assessments of psychopathology were conducted via self-report questionnaires given to children, parents and teachers. The results were analysed via structural equation modelling approaches using AMOS (Arbuckle, 2003). Consistent with the hypotheses, positive associations at Time 1 between ADHD and anxiety symptoms were linked with inattention symptoms and were particularly pronounced for girls. The concurrent positive associations observed at each time period could not be completely accounted for by overlapping symptoms across measures or by method covariance explanations. The link between ADHD and anxiety symptoms could be explained by a common factor in reporting whereby ADHD and anxiety symptoms were both associated with noncompliance and negative affect for parents' reports, and negative affect for children???s' reports. Despite the concurrent associations, there was no support for the hypothesis that ADHD symptoms predicted the development of anxiety symptoms over time, nor the alternative hypothesis that anxiety symptoms predicted the development of ADHD symptoms over time, when the stability of symptoms across time was taken into account. It was concluded that ADHD symptoms (particularly inattention) and anxiety symptoms are covarying phenomena that are linked with common features of an irritable temperament and disruptive behaviour. Future research should investigate the role of these common factors in treatment outcome and cognitive research, which has previously found differences between ADHD children with and without anxiety.

Suicide attempts and opioid dependence are important clinical issues, as both are associated with a high degree of psychiatric morbidity and elevated risk of mortality. Research has identified a number of risk factors for suicide attempts among the general population, and to a lesser extent, among heroin users. Due to a lack of case-control studies, however, it is still not known to what extent opioid dependence per se is a risk factor for suicide attempts. This thesis comprised the first study to directly examine whether opioid dependence is a unique risk factor of suicide attempts. This thesis examined suicide attempts, associated risk factors, and related comorbidity among an opioid-dependent case group and a non-opioid-dependent control group. A structured interview was used to collect data from 726 opioid-dependent cases and 399 non-opioid-dependent controls. This thesis identified a number of important findings. Firstly, although opioid-dependent individuals were more likely to report lifetime suicide attempts compared to controls, the risk factors were largely the same for both groups. It appeared that opioid-dependent individuals were characterised by a higher likelihood of the same risk factors for suicide attempts, rather than having different risks. Cases appeared to be at increased risk of suicide attempts because of increased levels of multiple risk factors. Secondly, borderline personality disorder (BPD) and impulsivity were identified as important risk markers for suicidal behaviour, especially among opioid-dependent individuals. The study concluded that the treatment of BPD should be prioritised among this group. Third, self-mutilation was identified as a clinically significant problem in its own right, however, when combined with a history of attempted suicide, the psychological dysfunction observed was found to be very high. Fourth, non-fatal opioid overdose and suicide attempts were found to be distinct behaviours. The risk factors for each were completely different. While drug-related risks were associated with non-fatal overdose, the risk markers for suicide attempts were related to the presence of psychological disorders. This thesis has highlighted important areas of concern for clinical interventions as well as for future research to explore. Considering this is the first study of its kind, future research should focus on its replication.

Research on aging indicates that older adults do not, as a group, report decreased health-related quality of life (HRQOL) despite age-related declines in physical health status. Several cognitive adaptation strategies have been suggested to underlie HRQOL stability in this population. Studies of older cancer patients nevertheless show substantial variance in post-treatment HRQOL outcomes, although cognitive mechanisms for individual differences have received little attention. The current study expanded on a developmental adaptation of self-regulation theory in which aging influences both self-vulnerability and perceptions of disease. A model was tested in which older age was hypothesized to predict better HRQOL via less severe illness perceptions in men treated for localized (Stage I and II) PC. Results indicated that age was not directly associated with HRQOL. However, older age was indirectly associated with better HRQOL via less severe PC perceptions. Further, this indirection association helped account for the positive association between age and HRQOL that three risk factors (income, comorbid disease burden, and sexual function) were shown to suppress. Perceptions of PC may promote HRQOL stability by mitigating age-related declines in health and income status. Disease perceptions thus represent critical components of health assessments and interventions for PC survivors of all ages, but particularly for men facing difficulties adapting to complex health profiles or normative lifespan challenges.

This study investigated the impact of family factors on individual differences in the social and emotional development of children with autism and their families. Based on the modifier model hypothesis suggested by Mundy, Henderson, Inge, and Coman (2007), family factors may serve as a modifier that contributes to the variability in the phenotypic presentation of children with higher functioning autism. Results indicated that Expressed Emotion (EE) was associated with parent-reported hyperactivity and anxiety in children and adolescents. Family cohesion was associated with parent-reported aggression and depression. These results differed for typically developing and HFA children; higher EE or lower cohesion was associated with greater impairment in the HFA group and less impairment in the typically developing children. Family factors were not associated with social symptoms, indicating these effects may be more related to the development of comorbidity than to the core symptoms of autism. Expressed emotion was related meaningfully to neutral attributions on the FMSS and provided validity for the measure. Family factors were not associated with parental stress, which was not expected. Implications for clinical interventions and future directions are discussed.

Thesis (Ph.D.)--University of Missouri-Columbia, 2006. / The entire dissertation/thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file (which also appears in the research.pdf); a non-technical general description, or public abstract, appears in the public.pdf file. Title from title screen of research.pdf file viewed on (February 26, 2007) Vita. Includes bibliographical references.