Orientador: Maria Elena Guariento / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-14T03:48:42Z (GMT). No. of bitstreams: 1 Alberte_JosianeSouzaPinto_D.pdf: 6193745 bytes, checksum: 00fa9fe29e50c34be0a72f6988e849f4 (MD5) Previous issue date: 2009 / Resumo: Em vista da relevância que adquire o parâmetro qualidade de vida entre os indivíduos que estão envelhecendo, desenvolveu-se este trabalho que tem por objetivo avaliar e comparar os fatores que interferem na percepção da qualidade de vida (PQV) de dois grupos distintos de idosos que requerem um suporte institucional de duas instituições diferentes. Foram avaliados cento e seis pacientes entre sessenta e oitenta anos de ambos os sexos. Entre esses, 48 eram acompanhados no Ambulatório de Geriatria (AG) do Hospital de Clínicas da Faculdade de Ciências Médicas da UNICAMP. O outro grupo constituiu-se de 58 sujeitos do Grupo da Terceira Idade do Serviço Social do Comércio (SESC) de Campinas. Os instrumentos utilizados foram: ficha de avaliação de dados sócio-demográficos, prática de atividade física, doenças / estados mórbidos, número de medicamentos e fatores estressantes auto-relatados, bem como a percepção da qualidade de cada um dos ciclos de vida (infância, adolescência, idade adulta e velhice); International Neuropsychiatric Interview (MINI); questionário de qualidade de vida - WHOQOL-bref. Os resultados mostraram que a melhor percepção da qualidade de vida no domínio físico relacionou-se à prática de atividade física, ao não relato de dores, referência à boa infância e boa velhice, uso regular de menor quantidade de medicamentos. No domínio psicológico os idosos com melhor avaliação da qualidade de vida foram os que não apresentavam transtorno distímico, relatavam boa adolescência e velhice, usavam menor número de medicamentos e se consideravam felizes. No domínio social, a maior pontuação para qualidade de vida relacionou-se a: considerar-se feliz, não ter evidência de hipomania, negar solidão como evento estressante e referir boa adolescência. Quanto ao domínio ambiental, a referência à melhor qualidade de vida associou-se a: referir boa infância e velhice, maior nível de escolaridade e negar doença como evento estressante. Esses achados abrem para uma nova avaliação dos conceitos atuais sobre a velhice e processo de envelhecimento considerando-se os fatores que se associam a uma melhor percepção da qualidade de vida entre os idosos. Nesse estudo, verificou-se que a percepção da qualidade dos ciclos de vida, o uso de medicamentos, a prática de atividade física, a evidência de distimia e hipomania, o nível de escolaridade e a referência a dores, solidão e doença como eventos estressantes tinham interferência na percepção da qualidade de vida dos idosos avaliados / Abstract: Considering the relevance of life quality among aging individuals, this study has been developed with the aim to compare factors that interfere with the perception of lifequality (PLQ) between two distinct groups of elderly requiring the support of two different institutions. One hundred and six pacients have been assessed between ages sixty and eighty of both sexes. Among these, forty eight were followed closely by the Geriatric Ambulatory of the Hospital das Clínicas at the Faculty of Medical Sciences - UNICAMP. The other group consisted of fifty eight subjects from the group of elderly of the Serviço Social do Comércio (SESC) from Campinas. The instruments used were: a valuation card of sociodemographic data, ie, physical activity, diseases/morbid states, number of medicines taken, stress factors, as well as the perception of their life quality in each of the cycles of life, such as infancy, adolescence, adulthood and old age; The International Neuropsychiatric Interview (MINI); questionnaire on life quality - WHOQOL - BREF. The results showed that the best perception of quality of life in the physical domain were related to physical activity and absence of pain, a good activity and good age, regular minor use of medication. In the psychological area of the elderly, the best life quality valuation was of those who did not present distimic disorder, reported a happy adolescence and old age, used less medication, and considered themselves happy. In the social sphere the best valuation of life quality was related to considering oneself as happy, presenting an absence of hipomania, no stress on account of loneliness, a good adolescence. As for the environmental domain, the best quality of life was associated with a good childhood and old age, a higher level of education, no disease as stressful event. These findings lead to a new appraisal of the concepts on old age and the aging process, considering the possibilities associated with a better life quality for the elderly. In this study the perception of the life cycles'quality, the use of medication, physical activity, evidence of distimia and hipomania, level of education, reference to pains, solitude and disease as stressful events, interfered with the life quality of the valuated elderly / Doutorado / Saude Mental / Doutor em Ciências Médicas

Submitted by Cássia Santos (cassia.bcufg@gmail.com) on 2014-10-21T11:09:00Z No. of bitstreams: 2 Dissertacao Mestrado Final Wanessa Vieira Marques - 2014.pdf: 2424315 bytes, checksum: 43cfe85410f8246c32e9c3194794b2d6 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2014-10-23T11:19:39Z (GMT) No. of bitstreams: 2 Dissertacao Mestrado Final Wanessa Vieira Marques - 2014.pdf: 2424315 bytes, checksum: 43cfe85410f8246c32e9c3194794b2d6 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2014-10-23T11:19:39Z (GMT). No. of bitstreams: 2 Dissertacao Mestrado Final Wanessa Vieira Marques - 2014.pdf: 2424315 bytes, checksum: 43cfe85410f8246c32e9c3194794b2d6 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2014-04-03 / Conselho Nacional de Pesquisa e Desenvolvimento Científico e Tecnológico - CNPq / Patients with rheumatoid arthritis (RA) present higher prevalence of comorbidities. Such comorbidities are associated with different outcomes in RA patients, such as mortality risk, increase in disability, impact on RA specific treatment and higher medical costs. The purpose of this study was to assess the influence of comorbidities on the functional capacity and mobility of the affected individuals, and to identify, among the comorbidity indicators, the most appropriate to determine association between comorbidities and physical function on these patients. In a cross-sectional study we included 60 patients with RA fulfilling the American College of Rheumatology criteria (ACR, 1987) over a period of 11 months, both male and female between 43 and 80 years old. Comorbidities were assessed by means of three indicators: (i) total number of comorbidities (NCom) reported by the patients and listed on their medical records; (ii) the Charlson comorbidity index (CCI); and (iii) the functional comorbidity index (FCI). The activity of disease was evaluated by the Disease Activity Score, based on 28 joints and erythrocyte sedimentation rate value (DAS28/ESR). The participants’ functional capacity was measured using the Health Assessment Questionnaire (HAQ), and their mobility was measured using the chairrising test (CRT) and timed get up and go (TUG) test. Statistical analysis was performed using Log-Linear Stepwise multiple regression at 5% significance level. The prevalence of comorbidities in the investigated sample of patients with RA was 90% when the total number of comorbidities (NCom) was taken into consideration. In the final multiple regression model, the independent factors that influenced functional capacity (HAQ) were activity of disease (DAS28/ESR) and comorbidities, as assessed by FCI, which explained together 32.9% of the HAQ score variability (adjusted coefficient of determination [R2] = 0.329). With respect to the participants’ mobility (CRT and TUG), in the final model, only the independent factor comorbidities (FCI) exerted a significant influence on the results. The FCI scores explained 19.1% of the CRT variability (R2= 0.191) and 19.5% of the TUG variability (R2= 0.195). Among the comorbidity indicators used, the FCI was the main responsible for explain the physical function (HAQ) and mobility (CRT and TUG) variability at the final model in our sample. Comorbidities were highly prevalent in individuals with RA and exerted a negative influence on their functional capacity and mobility. FCI proved to be appropriate to determine the association between comorbidities and physical function in individuals with RA. / Pacientes com artrite reumatoide (AR) apresentam prevalência aumentada de comorbidades. A presença de comorbidades está associada a um pior desfecho clínico nesses indivíduos, tais como risco de mortalidade, comprometimento na funcionalidade, interferência no tratamento específico da AR e aumento nos custos médicos. O objetivo deste estudo foi investigar a influência das comorbidades na capacidade funcional e na mobilidade em pacientes com AR, e identificar, dentre os indicadores de comorbidade, aquele mais apropriado para determinar a associação entre comorbidades e desfecho funcional nesses indivíduos. Trata-se de um estudo transversal com a participação de 60 pacientes classificados com AR pelos critérios da American College of Rheumatology (ACR) de 1987 em um período de 11 meses, de ambos os gêneros e faixa etária entre 43 e 80 anos. As comorbidades foram avaliadas por meio de três indicadores: (i) número total de comorbidades (NCom) relatadas pelos pacientes e anotadas em prontuário médico; (ii) escore obtido no índice de comorbidade de Charlson (ICC); e escore obtido no índice de comorbidade funcional (ICF). A atividade da doença foi mensurada pelo Índice de Atividade da Doença baseado em 28 articulações e no valor do VHS (Disease Activity Score 28 – DAS28/VHS). A capacidade funcional e a mobilidade foram avaliadas por meio do escore obtido no Questionário de Avaliação da Saúde (Health Assessment Questionnaire – HAQ), no teste senta-levanta da cadeira cinco vezes (TSL) e no teste timed get up and go (TUG). A análise estatística dos dados foi realizada através de regressão múltipla Log-Linear Stepwise com nível de significância de 5%. Observou-se que a prevalência das comorbidades, analisada pelo indicador número total de comorbidades (NCom), foi de 90% em nossa amostra. No modelo final da análise múltipla os fatores determinantes da capacidade funcional (HAQ) foram a atividade da doença (DAS28/VHS) e as comorbidades, avaliadas pelo ICF, que em conjunto explicaram 32,9% da variabilidade do escore do HAQ (coeficiente de determinação [R2] ajustado = 0,329). Com relação à mobilidade (TSL e TUG), no modelo final, apenas as comorbidades (ICF) influenciaram significativamente o seu desempenho. O escore no ICF explicou 19,1% da variabilidade do TSL (R2 = 0,191)e 19,5% da variabilidade do TUG (R2 = 0,195). Dentre os indicadores de comorbidade utilizados, o indicador ICF foi o principal responsável por explicar no modelo final a variabilidade da capacidade funcional (HAQ) e da mobilidade (TSL e TUG) em nossa amostra. Conclui-se que as comorbidades são frequentes em pacientes com AR e influenciam negativamente a capacidade funcional e a mobilidade desses indivíduos. O ICF demonstrou ser um indicador de comorbidade apropriado para determinar a associação entre comorbidades e funcionalidade em pacientes com AR.

Embora adolescentes do sexo masculino e feminino consumam drogas na mesma proporção, a procura por tratamento especializado é maior entre o sexo masculino. Poucos são os estudos sobre as diferenças entre os sexos dos adolescentes usuários de drogas, principalmente no Brasil. O objetivo deste estudo é descrever as características e investigar possíveis diferenças entre os gêneros dos adolescentes usuários de drogas em tratamento quanto ao padrão de consumo de drogas, conseqüências do uso e evolução no tratamento. Foram avaliadas as diferenças entre os gêneros de 124 adolescentes em tratamento. As variáveis estudadas foram: idade de início do uso de drogas e quando procurou tratamento, companhia do primeiro uso, antecedente familiar, tipos de drogas consumidas, envolvimento em atos ilícitos, problemas com a polícia, atraso escolar, comorbidades, tempo de abstinência durante o tratamento e tempo de tratamento. O sexo masculino foi mais prevalente do que o feminino (81,5% e 18,5%, respectivamente). A idade média na admissão foi de 15,4 ± 1,3 ano e a idade de primeiro uso foi de 13,3 ± 1,5 ano. Setenta e oito porcento dos adolescentes tinham antecedente familiar de uso de drogas. A primeira droga ilícita consumida foi a maconha, sendo esta também a principal droga consumida no ano anterior ao tratamento. Aproximadamente 78% dos adolescentes tinham envolvimento em atividades ilegais, 1,6% tinham comorbidade com transtorno de déficit de atenção e hiperatividade e 5,6% com transtorno de conduta. A média de permanência em tratamento foi de 21,1 ± 19,7 semanas e ____ estavam abstinentes ao final do tratamento. Em todas estas variáveis não houve diferenças entre os gêneros. O sexo feminino apresentou maior prevalência de uso de benzodiazepínico na vida (17,4%), primeiro uso de drogas com familiares (21,1%), outros diagnósticos além do transtorno por uso de substância (25,4%), transtorno depressivo maior (43,5%), tentativa de suicídio (35,5%) e maior período de abstinência durante o tratamento (média de 30,2 ± 24,4 semanas). Entre o sexo masculino foi observado maior prevalência de repetência (87,1%) e problemas com a polícia (48,5%). As conseqüências do uso de drogas (problemas com a polícia e atraso escolar) são mais evidentes entre o sexo masculino, o que poderia explicar a maior prevalência do sexo masculino em tratamentos especializados. Apesar disso, o sexo feminino consome drogas e pratica atividades ilegais nas mesmas proporções do sexo masculino. Tentativas de suicídio e depressão são mais prevalentes entre o sexo feminino, o que parece ser um fator precipitante para a busca de tratamento especializado neste sexo. Estas diferenças observadas justificam a necessidade de diferentes abordagens terapêuticas para ambos os sexos, assim como o desenvolvimento de programas para ajudar a identificação de problemas relacionados ao uso de drogas principalmente entre o sexo feminino. / Although male and female adolescents consume drugs in the same proportion, male adolescents are referred for specialized treatment more frequently than females. There are a few studies about the differences among genders of adolescent drug abusers, especially in Brazil. The objective of this study is to describe the characteristics and access possible differences in the drug using between genders of adolescents in treatment considering the pattern of drug abuse, consequences of this use, and treatment outcome. The differences among genders of 124 adolescents in treatment were accessed. The following variables were accessed: age at the first drug use and they looked for treatment, with whom they first use drugs, family history of drug use, drugs ever consumed, illegal behaviours, court problems, scholar delay, co-morbidities, abstinence during treatment, and treatment period. Male were more prevalent than female (81.5% vs. 18.5%, respectively). The mean age at the admission to the program was 15,4 ± 1,3 years, the mean age at the first time they used illegal drug was 13,3 ± 1,5 years. Seventy eight percent had family history of drug use. The first illegal drug consumed was marijuana, and this was the most drugs consumed during the last year before the treatment admission, as well. Almost 78% of the adolescents had history of illegal behaviours, 5,6% had co-morbidity with conduct disorder and 1,6% had attention deficit and hyperactivity disorder. The mean permanence in treatment was 21,1 ± 19,7 weeks, and ____% was abstinent at the end of treatment. No differences between genders were found considering these variables. Among female adolescents there were more prevalence of benzodiazepine use, at least once in their lives (17,4%), first drug use with family members (21,1%), prevalence of co-morbidities (25,4%), major depression disorder (43,5%), suicidal attempt (35,5%), and period of abstinence during treatment (mean of 30,2 ± 24,4 weeks). Among males, scholar delay (87,1%) and court problems (48,5%) were more frequent than among females. Consequences of drug abuse (court problems and scholar delay) are much more evident among male, which could explain the higher prevalence of males in specialized treatment sets. However, females consume the same amount of drugs and engage in illegal behavior as males. Suicidal attempts and depression are higher among female abusers, which may be the precipitant factor for female specialized treatment. These differences may justify different treatment approach for each gender, as well as, the development of programs to identify problems related to drug use, especially among female adolescents.

Introdução: O Transtorno Obsessivo-Compulsivo (TOC) é reconhecido como um transtorno heterogêneo. Esta heterogeneidade dificulta a interpretação dos resultados dos estudos. A descrição de grupos de pacientes mais homogêneos pode facilitar a identificação desta busca, já que pode identificar fenótipos que sejam hereditários e válidos do ponto de vista genético. A abordagem categorial e dimensional são estratégias reconhecidas para a identificação de subgrupos mais homogêneos de pacientes. Dentro da abordagem categorial, o subgrupo de pacientes com início precoce dos sintomas obsessivo-compulsivo (SOC), e o subgrupo de TOC associado a transtorno de tiques apresentam características clínicas semelhantes, com evidências de sobreposição destas características entre os dois grupos. Os objetivos deste estudo foram: investigar características demográficas e clínicas dos pacientes com TOC de início precoce (GP) e TOC de início tardio (GT); e pesquisar características demográficas e clínicas dos pacientes com TOC de início precoce (GP) com tiques e pacientes com TOC de início precoce (GP) sem tiques. Metodologia: Trezentos e trinta pacientes com diagnóstico de TOC de acordo com o DSM-IV foram avaliados diretamente com os seguintes instrumentos: Entrevista Clínica Estruturada para o DSM-IV - Transtornos do Eixo I; Escala Yale-Brown de Sintomas Obsessivo-Compulsivos - Y-BOCS; Escala Dimensional para Avaliação de Presença e Gravidade de Sintomas Obsessivo-Compulsivos DY-BOCS; Escala de Avaliação Global de Tiques desenvolvida pelo Yale Child Study Center - YGTSS. Foi considerado TOC de início precoce se os sintomas dos pacientes tiveram início até os 10 anos de idade (160 pacientes). Os pacientes com início de sintomas entre 11 e 17 anos (95 pacientes) foram denominados grupo intermediário, enquanto aqueles após os 17 anos foram chamados grupo de início tardio (75 pacientes). Resultados: os pacientes do GP se diferenciaram dos pacientes do GT por apresentar maior freqüência do sexo masculino; maior freqüência de história familiar de SOC em familiares de primeiro grau; maiores escores da escala Y-BOCS para compulsões e Y-BOCS total; maior chance de ter obsessões de contaminação; maior chance de ter compulsões de repetição, colecionismo, diversas e compulsões do tipo tic-like; menor chance de ter compulsões de contagem; maior chance de apresentar sintomas da dimensão de \"colecionismo\"; maior gravidade nas dimensões de \"agressão/violência\", \"diversas\" e escore global da escala DY-BOCS; maior número médio de comorbidades; maior probabilidade de ocorrência de transtorno de ansiedade de separação, fobia social, transtorno dismórfico corporal e transtorno de tiques; menor chance de apresentar transtorno de estress pós-traumático; e maior chance de ter redução de 35% dos sintomas na escala Y-BOCS. O GP com tiques se diferenciou do GP sem tiques por apresentar maior prevalência de fenômenos sensoriais; menor chance e menor gravidade de ter a dimensão de \"contaminação/limpeza\" e menor gravidade no escore global da escala DY-BOCS; menor chance de apresentar transtorno de humor, transtorno unipolar, transtornos ansiosos, fobia social e skin picking, e maior a chance de apresentar diminuição de 35% dos sintomas na escala Y-BOCS. Os resultados sugeriram que as diferenças encontradas entre os grupos precoce, intermediário e tardio foram devidas à própria idade de início, e outras diferenças foram devidas à presença de tiques. / Introduction: Obsessive-compulsive disorder (OCD) is recognized as a heterogeneous condition. This heterogeneity obscures the interpretation of the results of the studies. The description of more homogeneous groups of patients can facilitate the identification of this search, since it can identify phenotypes that are hereditary and valid to the genetic point of view. Categorical and dimensional approaches are recognized strategies for the identification of more homogeneous subgroups of patients. Regarding the categorical approach, the subgroup of patients with early age at onset of the obsessive-compulsive symptoms (OCS), and the tic-related-OCD subgroup present similar clinical characteristics, with evidences of an overlap of these characteristics between the two groups. The aims of this study were: to investigate clinical and demographic characteristics of the early age at onset subgroup (EO), compared to the late onset subgroup (LO); and to investigate demographic and clinical characteristics of early age at onset OCD patients, with and without comorbid tic disorders. Methodology: Three hundred and thirty patients with the diagnosis of OCD according to the DSM-IV were directly assessed with the following instruments: Structured Clinical Interview for DSM-IV Axis I Disorders-patient edition - SCID-I/P; Yale-Brown Obsessive-Compulsive Scale - Y-BOCS; Dimensional Yale-Brown Obsessive-Compulsive Scale - DY-BOCS and Yale Global Tics Severity Scale - YGTSS. We considered early age at onset when OCS began before the age of 10 (160 patients). Patients with age at onset between 11 and 17 years old were termed intermediate group (95 patients), whereas those with age at onset after 17 years old were designated as late onset OCD (75 patients). Results: EO patients differed from LO patients in terms of presenting higher frequency of the male gender; higher frequency of a family history of OCS; higher Y-BOCS for compulsions and total Y-BOCS scores; higher chance of presenting contamination obsessions, repeating, hoarding, miscellaneous and tic-like compulsions; lower chance of having counting compulsions; higher probability of presenting symptoms of \"hoarding\" dimension; higher severity in \"aggression/violence\" and \"miscellaneous\" dimensions and global DY-BOCS scale score; higher mean number of comorbidities; higher probability of presenting separation anxiety disorder, social phobia, body dysmorphic disorder and tic disorders; lower chance of presenting posttraumatic stress disorder; and a higher chance of having a 35% reduction on the Y-BOCS scale. The EO subgroup with tic disorders differed from the EO without tics for presenting higher chance of having sensory phenomena, somatic obsessions; lower chance and lower score in the DY-BOCS scale; lower chance of presenting mood disorder, depressive disorder, anxiety disorders, social phobia and skin picking; higher chance of having a 35% reduction on the Y-BOCS scale. Results suggested that the differences found among early, intermediated and late onset groups with early onset were secondary to the own age at onset, and other differences were secondary to the presence of tics.

O objetivo deste estudo foi estimar prevalência dos transtornos mentais comuns (TMC) e bebedores problemas (BP) e também a utilização de serviços, a partir de estudo seccional, populacional com amostragem aleatória. Incluiu-se sujeitos com 16 anos e mais, avaliando-se aspectos sócio-demográficos, uso de álcool, saúde mental e utilização de serviços. A prevalência de TMC foi 21,7%, de BP foi 4,4%. Na ultima quinzena 14,6% procuraram serviço de saúde. As prevalências observadas confirmam achados da literatura: TMC e BP são importantes problemas de saúde pública, com implicações para a organização de serviços e formação de recursos humanos / The aim of this cross-sectional study was to estimate the prevalence of common mental disorders (CMD) and problem drinking (PD), as well as health services use in an unselected populational sample. Subjects over 16 years were included and aspects related to socio-demographic characteristics, alcohol use, mental health and services use were studied. The prevalence of CMD was 21.7%, of PD 4.4%. In the two weeks preceeding the interview, 14.6% had used a health service. The results are in accordance with the literature: CMD and PD are important health problems, with implications for health services organization and formation of health professionals

Abstract Background: Autism spectrum disorders (ASDs), defined as pervasive developmental disorders (PDDs) in DSM-IV and ICD-10, become manifest in childhood, ranging from a severe form, autism, to milder forms, Asperger syndrome (AS) and pervasive developmental disorder not otherwise specified (PDD-NOS)/atypical autism. AS is also specified in criteria by Gillberg and by Szatmari et al. Different diagnostic criteria sets, overlaps, inaccuracies and exclusion criteria of many comorbid psychiatric disorders in PDDs have caused confusion. In DSM-5, PDDs were replaced by one diagnosis called ASD. Aims and methods: This is an epidemiological study of 8-year-old children and a clinical study of 9- to 16-year-old high-functioning outpatients with AS/autism (HFA). The epidemiological target population (n = 4,422) was rated via the Autism Spectrum Screening Questionnaire (ASSQ) by parents and/or teachers and a screened sample was examined in order to estimate the prevalence of ASDs, to discover deficits in the diagnostic criteria of ASDs, to evaluate DSM-5 draft criteria for ASD, and to assess cut-off scores for the Finnish ASSQ. Comorbid psychiatric disorders were identified and overall level of functioning rated in 50 subjects with AS/HFA. Results: The prevalence of AS according to DSM-IV was 2.5, to ICD-10 2.9, to Gillberg 2.7, and to Szatmari et al. 1.6 per 1,000. The prevalence of autism was 4.1 and that of ASDs 8.4 per 1,000 (DSM-IV). DSM-5 draft criteria were less sensitive in detecting AS/HFA. For 7- to 12-year-old children (IQ ≥ 50), the optimal cut-off scores were 30 in clinical settings and 28 in total population screening using summed parent-rated and teacher-rated ASSQ scores. Comorbid psychiatric disorders were common (prevalence 74%) and often multiple; behavioral disorders in 44%, anxiety disorders in 42%, and tic disorders in 26%. Oppositional defiant disorder, depressive disorder and anxiety disorders as comorbidities indicated significantly lower levels of functioning. Conclusions: Our results indicate the need to standardize the diagnostic criteria. The ICD-11 criteria should be uniform and harmonize with DSM-5. Determining cut-off scores for ASD screening instruments in different languages and cultures is of utmost importance. Clinicians are reminded to investigate psychiatric comorbidity in ASDs in order to target treatment and rehabilitation precisely. / Tiivistelmä Lähtökohdat: Autismikirjon häiriöt, ICD-10:ssä ja DSM-IV:ssä nimellä laaja-alaiset kehityshäiriöt, ilmenevät lapsuudessa. Niihin luetaan autismi, Aspergerin oireyhtymä (AS) ja tarkemmin määrittelemätön laaja-alainen kehityshäiriö/epätyypillinen autismi. Gillberg sekä Szatmari työtovereineen ovat myös määritelleet AS:n kriteerit. Useat diagnostiset kriteerit, päällekkäisyydet, epätarkkuudet ja monien psykiatristen liitännäishäiriöiden poissulkeminen laaja-alaisissa kehityshäiriöissä ovat aiheuttaneet sekaannuksia. DSM-5:ssä laaja-alaiset kehityshäiriöt korvattiin yhdellä diagnoosilla: autismikirjon häiriö. Menelmät ja tavoitteet: Väitöstyö muodostui 8-vuotiaita lapsia koskeneesta epidemiologisesta tutkimuksesta sekä 9–16-vuotiaita AS- ja autistisia (HFA) lapsia ja nuoria koskeneesta kliinisestä tutkimuksesta. Vanhemmat ja/tai opettajat täyttivät epidemiologisen kohderyhmän lapsista (n = 4 422) suomennetun autismikirjon seulontalomakkeen (ASSQ), ja seuloutuneille tehtiin diagnostiset tutkimukset. Tämän jälkeen määritettiin autismikirjon esiintyvyys, kartoitettiin diagnostisten kriteerien puutteita, arvioitiin DSM-5-luonnoskriteerit autismikirjon häiriölle ja määritettiin ASSQ:n seulontarajat. Psykiatrinen komorbiditeetti ja sen merkitys toiminnalliseen tasoon tutkittiin AS-/HFA-lapsilla ja -nuorilla (n = 50). Tulokset: AS:n esiintyvyys oli 2,5/1000 DSM-IV:n, 2,9/1000 ICD-10:n, 2,7/1000 Gillbergin ja 1,6/1000 Szatmarin mukaan. Autismin esiintyvyys oli 4,1/1000 ja koko autismikirjon 8,4/1000 (DSM-IV). DSM-5-luonnoskriteerit olivat epäherkät tunnistamaan AS:ää ja HFA:ta. Parhaiten soveltuviksi ASSQ:n seulontarajoiksi alakouluikäisille (ÄO ≥ 50) osoittautuivat 30 kliinisiä tilanteita ja 28 väestöseulontoja varten laskemalla yhteen vanhempien arvioinnin ja opettajan arvioinnin pisteet. Psykiatrisia liitännäishäiriöitä oli 74 %:lla, ja monilla oli useita. Käytöshäiriöitä oli 44 %:lla, ahdistuneisuushäiriöitä 42 %:lla ja tic-häiriöitä 26 %:lla. Uhmakkuus- ja masennushäiriö sekä ahdistuneisuushäiriöt alensivat merkitsevästi toiminnallista tasoa. Päätelmät: Tulokset osoittivat diagnostisten kriteereiden yhtenäistämistarpeen. ICD-11:een on syytä laatia yhdenmukaiset kriteerit DSM-5:n kanssa. Autismikirjon seulontalomakkeille on tarpeen määrittää eri kieliin ja kulttuureihin soveltuvat pisterajat. Psykiatrisen komorbiditeetin selvittäminen autismikirjon häiriöissä on tärkeää, jotta hoito ja kuntoutus voidaan kohdentaa oikein.

Abstract Attention deficit hyperactivity disorder (ADHD) and disruptive behavior disorder (DBD) are two very common and co-occurring psychiatric disorders among children and adolescents. They are among the leading reasons for clinical referrals to child and adolescent mental health facilities worldwide and have many unfavorable consequences with a high cost to society. In this thesis, the potential early risk factors associated with ADHD and/or DBD were examined, the current well-being of the adolescent with ADHD and/or DBD was evaluated and the later education and the psychiatric morbidity of the adolescent were researched. The study population in this thesis is based on a subsample of the Northern Finland Birth Cohort 1986 (NFBC 1986) containing 457 study subjects, of which 91 (19.9%) were diagnosed with ADHD, 44 (9.6%) with DBD, 72 (15.6%) with comorbid ADHD and DBD and 250 (54.7%) with neither of these disorders. Confirmatory factor analysis, Kaplan-Meier survival analysis, Kruskal-Wallis one-way analysis of variance and several regression analyses were carried out in the study. This thesis contains four original publications. The results in the first publication indicated that there are different risk factors in childhood associating with different behavioral problems in adolescence. The differences between behavioral problems were also visible in the results of the second publication, where those adolescents who were diagnosed with both ADHD and DBD had more severe conduct disorder symptoms and had increased risks for many psychiatric disorders. The results from the third publication suggested that those adolescents who were diagnosed with both ADHD and DBD fared worse in school at the end of ninth grade and were later less likely to achieve higher than basic education. Finally, the fourth publication showed that the adolescents diagnosed with DBD (both with and without ADHD) seemed to have an increased risk for admittance to the psychiatric inpatient hospital. This thesis underlines the differences between children and adolescents diagnosed with ADHD and/or DBD and emphasizes the role of comorbidity between these disorders as an indicator of poorer outcomes later in life. / Tiivistelmä Tarkkaavaisuus- ja ylivilkkaushäiriö (attention deficit hyperactivity disorder, ADHD) sekä käytös- ja uhmakkuushäiriöt (disruptive behavior disorder, DBD) ovat hyvin yleisiä – ja usein yhtä aikaa ilmeneviä – lasten ja nuorten psyykkisiä häiriöitä. Nämä häiriöt ovat hyvin usein syynä lasten ja nuorten psykiatristen terveyspalveluiden käyttöön. Niillä on myös todettu olevan useita epätoivottuja seurauksia, joiden hoitaminen puolestaan nostaa yhteiskunnan kuluja. Tämä väitöskirjatyö tutkii mahdollisia varhaisia riskitekijöitä, jotka assosioituivat ADHD- ja/tai DBD-häiriöiden kanssa, arvioi näillä häiriöillä diagnosoitujen nuorten sen hetkistä hyvinvointia ja tutkii näiden nuorten kouluttautumista sekä muuta psykiatrista sairastavuutta. Tutkimusaineisto koostuu Pohjois-Suomen syntymäkohortti 1986 (Northern Finland Birth Cohort 1986, NFBC 1986) -aineiston osaotoksesta, johon kuuluu 457 henkilöä. Osaotoksesta 91:llä (19,9 %) oli diagnosoitu ADHD, 44:llä (9,6 %) DBD ja 72:lla (15,6 %) komorbidi ADHD ja DBD. 250 henkilöllä (54,7 %) osaotoksesta ei ollut diagnosoitu kumpaakaan diagnoosia. Aineiston analysoinnissa käytettiin konfirmatorista faktorianalyysiä, Kaplan-Meierin elossaolomenetelmää, Kruskal-Wallisin yksisuuntaista varianssianalyysiä ja useita regressioanalyysejä. Tämä väitöskirja koostuu neljästä osajulkaisusta. Ensimmäisen osajulkaisun tulokset osoittivat, että eri riskitekijät lapsuudessa assosioituivat eri käytösongelmiin nuoruudessa. Eri käytösongelmien eroavaisuudet olivat myös nähtävillä toisessa osajulkaisussa: niillä nuorilla, joilla oli diagnosoitu komorbidi ADHD ja DBD, todettiin olevan vakavampia käytöshäiriöiden oireita sekä kohonnut riski useisiin muihin psykiatrisiin sairauksiin. Kolmannen osajulkaisun tulokset viittasivat näiden nuorien, jotka oli diagnosoitu komorbidillä ADHD:lla ja DBD:llä, pärjäävän huonommin koulussa ja valmistuvan muita todennäköisemmin vain peruskoulusta. Lopuksi neljännessä osajulkaisussa todettiin, että DBD diagnoosin nuorena saaneilla (riippumatta ADHD diagnoosista) näytti olevan kohonnut riski psykiatriseen osastohoitoon joutumiselle. Tämä väitöskirjatyö alleviivaa tarkkaavaisuus- ja ylivilkkaushäiriöllä sekä käytös- ja uhmakkuushäiriöillä diagnosoitujen lasten ja nuorten eroavaisuuksia ja korostaa kyseisten häiriöiden komorbidin ilmenemisen roolia huonon lopputuloksen ennustetekijänä myöhemmin nuoren elämässä.

Abstract Personality disorders (PDs) are relatively common mental disorders associating with other psychiatric disorders and disability. The aim of the study was to determine the occurrence of PDs in a general population subsample and psychiatric hospital patients, the associations of PDs with childhood family structure, the co-occurrence of PD with common psychiatric disorders, and the associations between PDs and temperament. The study is part of the Northern Finland 1966 Birth Cohort Project (NFBC 1966), consisting of cohort members living in Oulu (N = 1,609) on 1st January 1997 (the Oulu Study). The study consisted of a two-stage psychiatric field survey with questionnaires and a structured clinical interview and analysis of the patient records in public outpatient care. Information concerning psychiatric illness of all cohort members (N = 12,058) was gathered from the Finnish Hospital Discharge register (FHDR). The best-estimate procedure was used for the assessment of psychiatric morbidity including PDs. Childhood family structure and other sociodemographic variables were drawn from questionnaires of the field study conducted during earlier follow-up studies. In this study PDs were classified into three clusters: Cluster A (paranoid, schizoid and schizotypal PD), Cluster B (antisocial, borderline, histrionic, and narcissistic PD), and Cluster C (avoidant, dependent, obsessive-compulsive, and passive-aggressive PD). The most common PDs in the Oulu Study sample were Cluster C PDs, whereas Cluster B PDs were most common in the hospital-treated sample. PDs were highly associated with mood, anxiety and substance use disorders. Single-parent family type in childhood was associated with PDs, especially Cluster B PDs in adulthood. PD clusters were associated with different profiles of temperament, but the temperament dimensions could not distinguish different PDs very well. These results indicated that it is important to recognize PDs and their comorbid psychiatric disorders. This will have implications in both general outpatient care and psychiatry. These results indicate the importance of recognition of childhood risk factors for PDs for the prevention of severe PDs. The results suggest a need for more studies about the aetiology and development of PDs. / Tiivistelmä Persoonallisuushäiriöt ovat yleisiä mielenterveyden ongelmia, joihin liittyy usein psykiatrista oheissairastavuutta ja toimintakyvyn laskua. Tämän tutkimuksen tarkoituksena oli arvioida persoonallisuushäiriöiden yleisyyttä nuorilla aikuisilla. tehtävänä oli arvoida yhteyksiä lapsuuden perherakenteeseen ja yleisimpiin psykiatrisiin häiriöihin sekä arvioida persoonallisuushäiriöiden yhteyksiä temperamenttitekijöihin. Tutkimus on osa Pohjois-Suomen vuoden 1966 syntymäkohortin psykiatrista osaprojektia, Oulu Studyä. Tutkimusaineiston muodostivat Oulu Studyn otokseen kuuluvat kaikki 1. tammikuuta 1997 Oulussa asuneet kohortin jäsenet (N = 1 609) sekä sairaalahoidossa olleiden persoonallisuushäiriö- diagnoosin saaneiden osalta koko alkuperäisen syntymäkohortin (N =  12 058) jäsenet. Tutkimus koostui kaksivaiheisesta psykiatrisesta kenttätutkimuksesta, jossa tietoja tutkittavilta kerättiin sekä kyselylomakkeiden ja haastattelututkimuksen avulla. Lisäksi tutkittavilta kerättiin tiedot heidän elinaikanaan toteutuneesta julkisten psykiatristen sairaala- ja avohoitopalvelujen käytöstä sairauskertomustietojen perusteella. Niin kutsutun best-estimated -menetelmän avulla arvioitiin tutkittavien psykiatrista sairastavuutta mukaan lukien persoonallisuushäiriöt. Tutkittavien lapsuuden perherakennetta ja sosiodemografisia tekijöitä arvioitiin aiempien seurantatutkimusten tietojen avulla. Tutkimuksessa persoonallisuushäiriöt luokiteltiin DSM-III-R-diagnoosiluokituksen mukaisesti kolmeen eri pääryhmään ja niiden mukaisiin alaryhmiin: Ryhmä A (epävakaa, eristäytyvä ja psykoosipiirteinen persoonallisuus), ryhmä B (epäsosiaalinen, epävakaa, huomionhakuinen ja narsistinen persoonallisuus) ja ryhmä C (estynyt, riippuvainen, pakko-oireinen ja passiivis-aggressiivinen persoonallisuus). Oulu Studyn väestöotoksessa yleisimpiä näistä olivat ns. C-ryhmän persoonallisuushäiriöt, kun taas sairaalahoidetuilla henkilöillä B-ryhmän persoonallisuushäiriöt olivat yleisimpiä. Persoonallisuushäiriöiden todettiin liittyvän yleisesti masennus- ja ahdistuneisuushäiriöihin sekä päihteiden käyttöön. Vanhemman yksinhuoltajuuden todettiin liittyvän persoonallisuushäiriöihin, etenkin B-ryhmän persoonallisuushäiriöihin. Persoonallisuushäiriöryhmät erosivat toisistaan temperamenttiprofiilien perusteella. Eri persoonallisuushäiriöistä kärsivillä tutkittavilla ei todettu tyypillisiä temperamenttiprofiileja. Johtopäätöksenä voidaan todeta, että persoonallisuushäiriöiden ja niihin yleisesti liittyvän psykiatrisen oheissairastavuuden tunnistaminen on tärkeää. Havainnot korostavat perusterveydenhuollon ja erikoissairaanhoidon yhteistyön merkitystä persoonallisuushäiriöistä ja psykiatrisista häiriöistä kärsivien henkilöiden tutkimuksessa ja hoidossa. Persoonallisuushäiriöille altistavien lapsuuden tekijöiden tunnistaminen on tärkeää vaikeiden persoonallisuushäiriöiden ehkäisemiseksi. Persoonallisuushäiriöiden etiologian ja kehittymisen selvittämiseksi tarvitaan uusia tutkimuksia.

The aim of this diploma thesis is to describe cooperation with clients / users of methamphetamine with a severe psychiatric disorder from the schizophrenic spectrum using case management methods. The theoretical part summarizes current knowledge of the negative consequences of using methamphetamine, focussing on serious psychiatric comorbidity from the schizophrenic spectrum. It includes research of current studies (both Czech and foreign), information on specific comorbid diagnoses and a description of the case management method, including its specific application within the SANANIM addictology ambulance. The practical part contains three case studies structured into six sections: (1) Initiation of the program entry, (2) The first contact and setting, (3) Entrance evaluation and indication, (4) Establishing a relationship and developing cooperation, (5) Cooperation with other experts and stakeholders (6) The results of cooperation focussed on changes in relation to: comorbid illness, severity and frequency of use of a primary drug and other addictive substances, social situation and relational healing. I chose AA SANANIM clients by a deliberate targeting method based on the following criteria: (1) 7-month co-operation with a minimum of 28 personal contacts (roughly equivalent to once a week), (2)...

Abstract Conduct disorder (CD) among girls is a common but seldom studied psychiatric disorder. The aim of this study was to examine risk factors for CD, the factor structure of CD symptoms, suicidal behaviour, comorbid disorders and nicotine dependence of adolescent girls with CD in an inpatient sample in Northern Finland. The study subjects were 508 12- to 17-year-old inpatients treated in an acute psychiatric ward, Unit 70, at Oulu University Hospital between April 2001 and March 2006. These adolescents were interviewed using the Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL) to obtain psychiatric diagnoses according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In addition, the European Addiction Severity Index (EuropASI) was used to obtain information on somatic health, family situation and delinquency. From the data collected, 63 girls and 92 boys fulfilled the criteria for current DSM-IV-diagnosed conduct disorder. It was observed that, although the number of symptoms and severity of CD was lower among girls compared to boys, the level of functioning was lowered to the same degree. Physical abuse increased the risk for violent CD, and living apart from at least one biological parent increased the risk for both violent and non-violent CD among girls. The results of this study also suggest a gender difference in the factor structure and developmental model of CD. Alcohol dependence increased the risk for suicide attempt and self-mutilation almost fourfold among girls with CD. Girls with CD had more comorbid affective and anxiety disorders than boys. Girls with CD also had more self-reported allergies. Finally, the number of CD symptoms was positively correlated with the level of nicotine dependence (ND) among both girls and boys, and a gender difference was found in the correlation between symptom subscales and the level of ND. The findings suggest that gender differences exist in conduct disorder. Special attention should be paid to the prevention, identification and treatment of CD among girls. It seems that, among girls with CD, the well-being of primary family is important in prevention. Alcohol dependence and depression in girls with CD should be treated with special care. DSM-IV might not always be sensitive enough to diagnose CD among girls, and this should be considered when behavioural symptoms are evaluated in girls. / Tiivistelmä Tyttöjen käytöshäiriö on vähän tutkittu mutta yleinen psykiatrinen häiriö. Tässä tutkimuksessa analysoitiin tyttöjen käytöshäiriön riskitekijöitä, oireiden faktorirakennetta, käytöshäiriöisten itsetuhoisuutta, samanaikaista psykiatrista ja somaattista sairastavuutta sekä nikotiiniriippuvuutta psykiatrisessa osastohoidossa olleiden alaikäisten nuorten keskuudessa. Tutkimusaineistoon kuului 508 12–17-vuotiasta nuorta, jotka olivat hoidossa psykiatrisella akuuttihoito-osastolla Oulun yliopistollisessa sairaalassa 1.4.2001–31.3.2006 välisenä aikana. Nuoret haasteteltiin käyttämällä puolistrukturoitua Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL) -haastattelua, jonka avulla määritettiin nuorten psykiatriset diagnoosit Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) -diagnoosiluokituksen mukaisesti. Lisäksi potilaat haastateltiin European Addiction Severity Index (EuropASI) -haastattelulla, josta saatiin tietoa fyysisestä terveydentilasta, perhetilanteesta ja rikollisuudesta. Aineiston nuorista 63 tyttöä ja 92 poikaa täyttivät käytöshäiriön kriteerit. Tämä tutkimus osoitti, että vaikka nykyisten DSM-IV-kriteerien perusteella tytöillä käytöshäiriön vaikeusaste oli aiempien tutkimusten tapaan poikia alhaisempi ja oireiden määrä vähäisempi, oli tyttöjen toimintakyky silti yhtä huono kuin poikien. Fyysinen perheväkivalta lisäsi tyttöjen riskiä väkivaltaiseen käytöshäiriöön ja asuminen erossa vähintään yhdestä biologisesta vanhemmasta lisäsi riskiä sekä väkivaltaiseen että ei-väkivaltaiseen käytöshäiriöön. Käytöshäiriöoireiden faktorianalyysi osoitti, että tytöillä ja pojilla oli eroa oireiden faktorirakenteessa eikä tyttöjen oireiden jako selkeästi noudattanut Loeberin esittämää polkumallia. Alkoholiriippuvuus lisäsi käytöshäiriöisillä tytöillä riskiä itsemurhan yrittämiseen ja itsensä vahingoittamiseen lähes 4-kertaiseksi. Käytöshäiriöisillä tytöillä oli poikia enemmän mieliala- ja ahdistushäiriöitä samanaikaisina psykiatrisina häiriöinä. Somaattisista häiriöistä käytöshäiriöiset tytöt raportoivat poikia enemmän allergioita. Käytöshäiriön oireiden määrä oli yhteydessä sekä tytöillä että pojilla nikotiiniriippuvuuden voimakkuuteen. Tyttöjen ja poikien välillä oli eroa nikotiiniriippuvuuteen korreloivissa oireryhmissä. Tämän tutkimuksen tulosten perusteella tyttöjen ja poikien käytöshäiriöllä on eroavaisuuksia. Tyttöjen käytöshäiriön ennaltaehkäisyyn, tunnistamiseen ja hoitoon tulee kiinnittää erityistä huomiota. Primaariperheen hyvinvointi näyttäisi olevan tärkeää ennaltaehkäisyssä. Käytöshäiriöisen tytön hoidossa tulee kiinnittää erityinen huomio alkoholin käyttöön sekä depression hoitoon itsetuhoisuuden ehkäisemiseksi. DSM-IV ei ehkä nykyisellään ole riittävän herkkä työkalu tyttöjen käytöshäiriön diagnosoimiseksi, ja tähän tulisi kiinnittää huomiota kun käyttäytymisellään oireilevia tyttöjä hoidetaan.