Contexte : Une tentative de suicide antérieure et les troubles mentaux constituent d’importants facteurs de risque de suicide. Les services de santé ont un rôle important à jouer en matière de prévention. Objectif : Analyser les patrons de recours aux services à des fins de santé mentale avant et après une hospitalisation pour tentative de suicide chez les résidents montréalais qui ont reçu un diagnostic de schizophrénie ou de dépression. Méthode : Les données proviennent de la banque médico administrative jumelée de l’Agence de Montréal. Les caractéristiques des patients et les taux de contacts avec les services trois mois avant et après l’hospitalisation index furent comparées. L’échantillon représentatif compte 525 Montréalais hospitalisés à la suite d’une tentative de suicide (avr. 2003-déc. 2004) qui ont reçu un diagnostic de schizophrénie ou de dépression. Résultats : Le recours aux services a augmenté de manière significative suivant l’hospitalisation index. Les patients déjà en contact avec les services et les hommes avec comorbidité en termes d’abus de substances semblent en contact avec les services au cours des trois mois suivant leur hospitalisation contrairement aux femmes avec comorbidité. Le profil « urgence » de recours aux services semble prédire une absence de recours aux services. Conclusions : Les services de santé répondent aux tentatives de suicide, particulièrement chez les hommes avec troubles d’abus de substances. Cependant, des interventions sont requises en vue d’améliorer la coordination des services, principalement pour les personnes qui se présentent l’urgence, les femmes avec troubles d’abus de substances et les patients en marge du système avant leur hospitalisation. / Background: Mental health disorders and suicide attempts are important risk factors for suicide. Health care services have an important role to play in preventing these deaths. Objective: To analyze patterns of service use for a mental health purpose before and after a hospitalisation following a suicide attempt among Montreal’s residents diagnosed with schizophrenia or depression. Method: Data was taken from the linked administrative database of the Montreal’s Agency. Patient’ characteristics and contacts rates with services three months before and after the index hospitalisation were compared. The representative sample includes all 525 patients living in Montreal, who were hospitalised following a suicide attempt (Apr. 2003-Dec. 2004) and who were diagnosed with schizophrenia or depression. Results: Intensity of care increased significantly after the index hospitalisation. Patients in contact with services before and comorbidity of substance abuse disorder among men predicted a contact with services for a mental health purpose three months after the index hospitalisation contrary to women with comorbidity. Besides, the emergency room profile of service use predicted a lack of service utilisation. Conclusions: Health services respond to suicide attempts, including in men with substance abuse. However, there is an opportunity for increased aftercare coordination for suicidal individuals, in particular for those presenting at the emergency room, those with no previous contact with services and for women with substance abuse.

L’objectif principal de ce mémoire consiste à déterminer s’il existe une association entre la détresse psychologique et les problèmes cardiovasculaires chez les travailleurs, suite à l’influence de certains facteurs professionnels. Les données proviennent de l’Enquête sur la santé dans les communautés canadiennes (cycle 3.1 de l’ESCC), menée par Statistique Canada en 2005. Notre échantillon est composé de 15 394 canadiens et canadiennes en emploi de 15 ans et plus, représentatif sur le plan de l’âge, du genre et de la distribution géographique du lieu de résidence. Les analyses de régressions logistiques montrent que quatre facteurs professionnels présentent une association significative avec la détresse psychologique : les demandes psychologiques, la menace de perdre son emploi, le soutien social au travail, la satisfaction au travail. Puis, trois facteurs s’avèrent être reliés au développement de problèmes cardiovasculaires, soit l’utilisation des compétences, la satisfaction au travail ainsi que le nombre d’heures travaillées. Les analyses de variances multiples (MANOVA) révèlent que la détresse psychologique est associée aux problèmes cardiovasculaires et que ces deux problèmes de santé peuvent se retrouver en situation de comorbidité. Selon les résultats, on observe que cinq facteurs sont significativement corrélés à la présence de détresse psychologique en même qu’un problème cardiovasculaire : les demandes psychologiques, la menace de perdre son emploi, le soutien social au travail, la satisfaction au travail ainsi que le nombre d’heures travaillées. Par ailleurs, l’utilisation des compétences, l’autonomie décisionnelle et les exigences physiques de travail ne sont pas significativement associés à la détresse psychologique et à la présence de problèmes cardiovasculaires. / The main objective of this thesis is to determine whether there is an association between psychological distress and cardiovascular problems among workers, due to the influence of certain professional factors. The data came from the Canadian Community Health Survey (cycle 3.1 of CCHS), conducted by Statistics Canada in 2005. Our sample consists of 15 394 employed Canadians aged 15 and over, representative of age, gender and geographic distribution of place of residence. The logistic regression analysis showed that four professional factors have a significant association with psychological distress: psychological demands, job insecurity, social support at work, and job satisfaction. In addition, three factors appear to be related to the development of cardiovascular problems; the use of skills, job satisfaction, and the number of hours worked. The multiple analysis of variance (MANOVA) showed that psychological distress is associated with cardiovascular problems and that these two health problems may be apparent in situations of comorbidity. According to the results, we find that five factors present a significant correlation between the presence of psychological distress and a cardiovascular problem: psychological demands, job insecurity, social support at work, job satisfaction and the number of hours worked. However, the use of skills, decisional authority at work and physical demands of work are not significantly associated with psychological distress and the presence of cardiovascular problems.

Le biais de confusion est un défi majeur des études observationnelles, surtout s'ils sont induits par des caractéristiques difficiles, voire impossibles, à mesurer dans les banques de données administratives de soins de santé. Un des biais de confusion souvent présents dans les études pharmacoépidémiologiques est la prescription sélective (en anglais « prescription channeling »), qui se manifeste lorsque le choix du traitement dépend de l'état de santé du patient et/ou de son expérience antérieure avec diverses options thérapeutiques. Parmi les méthodes de contrôle de ce biais, on retrouve le score de comorbidité, qui caractérise l'état de santé d'un patient à partir de médicaments délivrés ou de diagnostics médicaux rapportés dans les données de facturations des médecins. La performance des scores de comorbidité fait cependant l'objet de controverses car elle semble varier de façon importante selon la population d'intérêt. Les objectifs de cette thèse étaient de développer, valider, et comparer les performances de deux scores de comorbidité (un qui prédit le décès et l’autre qui prédit l’institutionnalisation), développés à partir des banques de services pharmaceutiques de la Régie de l'assurance-maladie du Québec (RAMQ) pour leur utilisation dans la population âgée. Cette thèse vise également à déterminer si l'inclusion de caractéristiques non rapportées ou peu valides dans les banques de données administratives (caractéristiques socio-démographiques, troubles mentaux ou du sommeil), améliore la performance des scores de comorbidité dans la population âgée. Une étude cas-témoins intra-cohorte fut réalisée. La cohorte source consistait en un échantillon aléatoire de 87 389 personnes âgées vivant à domicile, répartie en une cohorte de développement (n=61 172; 70%) et une cohorte de validation (n=26 217; 30%). Les données ont été obtenues à partir des banques de données de la RAMQ. Pour être inclus dans l’étude, les sujets devaient être âgés de 66 ans et plus, et être membres du régime public d'assurance-médicaments du Québec entre le 1er janvier 2000 et le 31 décembre 2009. Les scores ont été développés à partir de la méthode du Framingham Heart Study, et leur performance évaluée par la c-statistique et l’aire sous les courbes « Receiver Operating Curves ». Pour le dernier objectif qui est de documenter l’impact de l’ajout de variables non-mesurées ou peu valides dans les banques de données au score de comorbidité développé, une étude de cohorte prospective (2005-2008) a été réalisée. La population à l'étude, de même que les données, sont issues de l'Étude sur la Santé des Aînés (n=1 494). Les variables d'intérêt incluaient statut marital, soutien social, présence de troubles de santé mentale ainsi que troubles du sommeil. Tel que décrit dans l'article 1, le Geriatric Comorbidity Score (GCS) basé sur le décès, a été développé et a présenté une bonne performance (c-statistique=0.75; IC95% 0.73-0.78). Cette performance s'est avérée supérieure à celle du Chronic Disease Score (CDS) lorsqu'appliqué dans la population à l'étude (c-statistique du CDS : 0.47; IC 95%: 0.45-0.49). Une revue de littérature exhaustive a montré que les facteurs associés au décès étaient très différents de ceux associés à l’institutionnalisation, justifiant ainsi le développement d'un score spécifique pour prédire le risque d'institutionnalisation. La performance de ce dernier s'est avérée non statistiquement différente de celle du score de décès (c-statistique institutionnalisation : 0.79 IC95% 0.77-0.81). L'inclusion de variables non rapportées dans les banques de données administratives n'a amélioré que de 11% la performance du score de décès; le statut marital et le soutien social ayant le plus contribué à l'amélioration observée. En conclusion, de cette thèse, sont issues trois contributions majeures. D'une part, il a été démontré que la performance des scores de comorbidité basés sur le décès dépend de la population cible, d'où l'intérêt du Geriatric Comorbidity Score, qui fut développé pour la population âgée vivant à domicile. D'autre part, les médicaments associés au risque d'institutionnalisation diffèrent de ceux associés au risque de décès dans la population âgé, justifiant ainsi le développement de deux scores distincts. Cependant, les performances des deux scores sont semblables. Enfin, les résultats indiquent que, dans la population âgée, l'absence de certaines caractéristiques ne compromet pas de façon importante la performance des scores de comorbidité déterminés à partir de banques de données d'ordonnances. Par conséquent, les scores de comorbidité demeurent un outil de recherche important pour les études observationnelles. / Confounding is an important challenge in observational studies given that they are induced by characteristics difficult, if not impossible, to measure in administrative claims databases. Prescription channelling is a frequent source of confounding in pharmacoepidemiologic studies, and occurs when the selection of one treatment over another is influenced by overall health status and patient's experience with other treatment options. Among the methods available to control for this bias, comorbidity scores are frequently used. Most of the comorbidity scores published in the literature assess the patients’ health status through drug dispensing or diagnostic codes included in physicians’ billings. These comorbidity scores, however, are controversial since their performance appears to vary according to the population of interest ( example: elderly vs. adult). The objectives of this thesis were to develop, validate and compare the performance of two comorbidity scores (the Geriatric Comorbidity Score based on death, and a comorbidity score based on institutionalization) derived from dispensing data for use in the community-dwelling elderly population. Furthermore, this thesis aimed to evaluate whether the inclusion of characteristics not usually included in administrative claims databases or with a low validity (such as sociodemographic characteristics, sleep or mental disorders) improves the performance of the Geriatric Comorbidity Score. A nested case-control analysis was conducted within a cohort that consisted of a random sample of 87,389 elderly distributed into a construction cohort (n=61,172; 70%) and a validation cohort (n=26,217; 30%). Sources of data consisted of the databases of the Régie de l’assurance maladie du Québec (RAMQ). To be included in the study, subjects had to be 66 years and older and covered by the public drug insurance program of Quebec between 1st January 2000 and 31st December 2009. Scores were developed using the Framingham Heart Study method, and their performances were assessed using the c-statistics and receiver operating curves (ROC). For the last objective, a prospective cohort study was performed using the participants in the Étude sur la Santé des Aînés (ESA) (n=1,494) which covered the period ranging from 2005 to 2008. Study variables included marital status, social support, mental health as well as sleep disorders. The comprehensive literature review conducted in the thesis and our results revealed that factors associated with death greatly differed from those associated with institutionalization, which supported the need to develop two distinct scores. Performances of the institutionalization score were, however, not statistically different from the death score (institutionalization c-statistic = 0.79; 95% CI: 0.77-0.81; death c-statistic= 0.75; 95% CI: 0.73-0.78). The Geriatric Comorbidity Score (death score) revealed a better performance than the Chronic Disease Score, which has been widely used in the literature (c-statistic= 0.47; 95%CI: 0.45-0.49). The inclusion of variables not recorded in claims databases yielded an improvement of the death score of only 11%, with marital status and social support being mainly responsible for the improvement. In terms of achievement, this thesis made three contributions. First, it was shown that the performance of comorbidity scores based on death vary according to the study population, reinforcing the need for specific scores, such as the Geriatric Comorbidity Score which was developed here. Second, factors associated with the risk of institutionalization were different than those associated with the risk of death in the elderly population, which supported the development of an institutionalization score. Even if the performance of death and institutionalization scores were similar, the latter would be preferred in studies that aim at assessing the effect of drugs on institutionalisation in the elderly. Lastly, the results indicate that the absence of some characteristics in the administrative databases do not appear to have a major impact on the performance of scores based on claims data. Consequently, comorbidity scores based on drug dispensing data remain important research tools for pharmacoepidemiologic studies conducted through health claims databases.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal.

Ce mémoire est rédigé dans le cadre d’une recherche multidisciplinaire visant à développer de meilleurs outils d’intervention et politiques en santé mentale au travail. L’objectif principal de cette étude était de cibler les déterminants de l’épuisement professionnel et des troubles musculosquelettiques et leur cooccurrence chez une population policière. Un échantillon de 410 policiers du Service de Police de Montréal (SPVM) a été sondé à l’aide d’un questionnaire basé sur des outils standardisés en santé mentale au travail. Les conditions organisationnelles, variables indépendantes de cette étude, ont été identifiées à partir de modèles théoriques validés. L’analyse segmentée de chacun des grands concepts (latitude décisionnelle, soutien social au travail, demandes, justice distributive et sur engagement) révèle que l’effet des conditions organisationnelles ne se manifeste pas également sur chacune des trois dimensions de l’épuisement professionnel (l’épuisement émotionnel, le cynisme et l’efficacité professionnelle). De plus, on observe que les trois formes de récompenses de justice distributive tirées du modèle « Déséquilibre-Efforts-Récompenses » (Siegrist, 1996) ne sont pas distribuées également selon les dimensions de l’épuisement professionnel. Selon nos données, la justice distributive d’estime de soi et le sur engagement s’avèrent significatifs dans tous les cas en regard des dimensions de l’épuisement professionnel et de son indice global. Finalement, nos résultats révèlent que la justice distributive d’estime de soi a un lien significatif sur la cooccurrence de l’épuisement professionnel et des troubles musculosquelettiques. Par contre, on note que des outils de recherche plus spécifiques permettraient une analyse approfondie de l’effet des conditions organisationnelles sur les troubles musculosquelettiques et sur l’effet de cooccurrence entre les deux problèmes à l’étude. / This thesis was written in the scope of a multidisciplinary research aiming to develop better intervention tools and policies for management of mental health in the workplace. The main objective was to identify the determining factors of burnout, musculoskeletal disorders, and their associated comorbidity within a population of police officers. Four hundred and ten officers from the Service de Police de la Ville de Montreal (SPVM) were interrogated using a questionnaire based on standard tools in work-related mental health research. The organizational conditions (main independent variables for this study) were derived from validated theoretical models. The data analysis consists of a segmented approach that looks at the effect of each concept (decisional latitude, social support, demands, rewards, and overcommitment). This revealed that the effects of organizational conditions were unevenly distributed among the three dimensions of burnout (emotional exhaustion, cynicism and personal accomplishment). Moreover, it was observed that three different types of rewards described in the “Effort-Reward Imbalance Model” (Siegrist, 1996) also had uneven effects on the likelihood of burnout. According to our data, self-esteem rewards and the overcommitment phenomenon had the most significant impact on each of the three dimension of burnout and on its global index. Finally, our results show that self-esteem rewards are significantly related to the comorbidity of musculoskeletal disorders and burnout. However, we note that more specific research tools would enable further analysis of the effect of organizational conditions on musculoskeletal disorders and more detailed explanation of the comorbidity relationship between the two disorders.

L’existence d’un sous-type dissociatif de schizophrénie a été suggérée par plusieurs auteurs pour rendre compte des présentations symptomatologiques d’un groupe de personnes dont le diagnostic principal est dans le spectre de la schizophrénie mais qui présentent aussi des symptômes dissociatifs (Ross, 2004; Şar et al., 2010; Van der Hart, Witztum, & Friedman, 1993). D’origine traumatique, ce type de portrait clinique où symptômes psychotiques et dissociatifs s’entremêlent aurait été décrit il y a déjà plus d’un siècle (Janet & Raymond, 1898) mais serait disparu dans les années ’30, assimilé au concept de « schizophrénie » (Rosenbaum, 1980). C’est dans un nouveau contexte nosographique que le concept de schizophrénie dissociative refait surface. En effet, la nosographie psychiatrique a pris un tournant en 1980 lorsque l’approche préconisée par le DSM est devenue descriptive plutôt que basée sur des conceptualisations psychanalytiques. Du coup, les affections d’alors ont été divisées en troubles dont les symptômes ont tendance à se manifester ensemble (Cooper, 2004) et la comorbidité entre les troubles a augmenté. Étant donné la comorbidité fréquemment rapportée entre les troubles psychotiques et dissociatifs, la similarité phénoménologique de leurs symptômes, ainsi que leur possible étiologie traumatique, Ross (2004) a proposé une série de critères permettant de diagnostiquer une schizophrénie dissociative. L’objectif principal de cette thèse est donc d’établir si la schizophrénie dissociative, telle que définie par Ross (2004), existe. Le premier article porte sur la problématique et le contexte théorique ayant mené à la question de recherche. Il vise à faire un survol des enjeux entourant la question de la schizophrénie dissociative et rend compte des écrits scientifiques sur la symptomatologie similaire entre les troubles psychotiques et dissociatifs, sur leur étiologie traumatique et sur les études sur la dissociation et la schizophrénie. Le deuxième article est quant à lui un article empirique rendant compte de la méthodologie utilisée pour répondre à la question de recherche. En effet, aucune étude jusqu’ici n’a testé systématiquement les critères de la schizophrénie dissociative. Nos résultats démontrent que 24% de notre échantillon (N=50) pourrait recevoir le diagnostic de schizophrénie dissociative avec les critères proposés par Ross (2004). Toutefois, ces critères posant problème, une modification a été proposée et une prévalence de 14% a alors été trouvée. Des vignettes cliniques sont présentées afin de comparer nos participants avec ceux rapportés ailleurs. Les liens entre symptômes psychotiques et dissociatifs sont discutés en essayant de conceptualiser la schizophrénie dissociative de différentes manières, soit comme une nouvelle entité clinique, comme un trouble comorbide ou dans un contexte nosographique psychodynamique. / The existence of a dissociative subtype of schizophrenia has been suggested by several authors to account for the symptomatology of a group of people whose primary diagnosis is in the schizophrenia spectrum but have in addition dissociative symptoms (Ross, 2004; Sar et al, 2010; Van der Hart, Witztum, & Friedman, 1993). Of traumatic origin, this type of clinical picture where psychotic and dissociative symptoms are intertwined was first described more than a century ago (Janet & Raymond, 1898) but disappeared in the 30’s, having been incorporated to the concept of "schizophrenia" (Rosenbaum, 1980). It is in a new nosographic context that the concept of dissociative schizophrenia resurfaced. Indeed, psychiatric nosography took a turn in 1980 when the approach advocated by the DSM became descriptive rather than based on psychoanalytic conceptualizations. The psychiatric conditions of the time were divided into disorders whose symptoms tended to occur together (Cooper, 2004). Consequently, the presence of comorbid disorders increased. Given the frequently reported co-occurrence of psychotic and dissociative disorders, the phenomenological similarity of their symptoms and their potential traumatic etiology, Ross (2004) proposed a criteria set for the diagnosis of dissociative schizophrenia. The main objective of this thesis is to determine whether the dissociative schizophrenia, as defined by Ross (2004), exists. The first article focuses on the problem and the theoretical background that led to the research question. It aims at providing an overview of the issues surrounding the question of dissociative schizophrenia. It also reports on the literature pertaining to symptoms found in both psychotic and dissociative disorders, their traumatic etiology and studies on dissociation and schizophrenia. The second article is of empirical nature and reports the methodology used to answer the research question. Indeed, no study to date has systematically tested the criteria for dissociative schizophrenia. Our results show that 24 % of our sample (N = 50) could receive a diagnosis of schizophrenia with dissociative criteria proposed by Ross (2004). However, the criteria set was problematic so a modification was proposed and a prevalence of 14% was then found. Clinical vignettes are presented to compare our participants with those reported elsewhere. The links between psychotic and dissociative symptoms are discussed in trying to conceptualize dissociative schizophrenia in different ways, either as a new clinical entity, as a comorbid disorder or in a psychodynamic nosographic context.

The issue of psychiatric co-morbidity is a serious public health problem occurring more and more frequently in the treatment of addiction and bringing with it various complications and often premature termination of treatment. The scoring system with a fixed set regime is still being used as the main instrument for treatment of addicted clients on the most specialized departments of psychiatric hospitals, although the effectiveness of the scoring system has not yet been clinically verified. The aim of this pilot study is to demonstrate and verify of the individual cases of clients with different categories of dual diagnosis, how they perceive the balance of the sanctions and rewards and fair setting in the context of the scoring system. Other goals are to find out and verify what is the influence of the scoring system on the motivation to change the behavior and success of treatment, what weaknesses clients with dual diagnosis perceive in this system and how they represent the treatment system, which would make them more fit and motivated to change behavior. Further, this study seeks to establish whether difficulties and obstacles on the way to stand up and go through the scoring system are different for individual dual diagnoses. A qualitative approach is used in the research part of the thesis....

Poruchy příjmu potravy ve spojitosti s jinými diagnózami. Eating Disorders in Connection with other Diagnoses Bc. Marie Vavrušková The aim of this thesis, which focuses on the topic "Eating Disorders in Connection with Other Diagnoses," is to introduce the different types of eating disorders that have been previously diagnosed (anorexia nervosa, bulimia nervosa, psychogenic overeating and new forms of eating disorders), to specify the medical treatment offered to patients in the Czech Republic, and in particular to describe what other mental or somatic disorders are most commonly associated with eating disorders. The empirical part of the thesis presents a questionnaire which analyses the following aspects: type of eating disorder from which the clients of Centrum Anabell Praha suffer most frequently, where their medical treatment takes place, whether they suffer from another mental or somatic disorder associated with eating disorders, and whether eating disorders have a negative impact on their lives. The empirical part also presents a case report, which describes the life story, history and prognosis of a man who suffers from an eating disorder and other associated disorders.

Revisión por pares

A dor crônica (DC) é um problema global de saúde. A incidência da DC no mundo oscila entre 7 e 40% da população e, como consequência da mesma, cerca de 50 a 60% dos que sofrem dela ficam parcial ou totalmente incapacitados, de maneira transitória ou permanente, comprometendo de modo significativo a qualidade de vida. Sabe-se que a divisão pré-límbica (PrL) do córtex pré-frontal medial (CPFM) é uma região importante na elaboração da dor e de seus aspectos cognitivos e emocionais. Há evidências que a DC de origem neuropática (DN) é capaz de provocar mudanças morfológicas, resultando em uma reorganização nas redes neurais do CPFM, e existe alta relação de comorbidade entre ansiedade e DC. Sendo assim, necessita-se de estudos que forneçam aprimoramento dos modelos animais em DC para que, assim, investiguem-se as bases neuroanatômicas, neurofisiológicas e psicofarmacológicas da DN e a participação de áreas corticais na gênese e manutenção da dor. Para isso, o presente trabalho foi dividido em três etapas: 1) Avaliação dos aspectos nociceptivos, motores e afetivo-cognitivos de ratos submetidos a um modelo adaptado de injúria por constrição crônica do nervo isquiático (CCI: uma ligadura) comparando com o modelo clássico de Bennett e Xie (CCI: quatro ligaduras): nossos resultados mostraram que o modelo adaptado de CCI produziu hipersensibilidade ao frio (teste de acetona) e alodinia mecânica (teste de von Frey) semelhante ao causado pelo modelo de CCI com quatro ligaduras. Ambos os grupos CCI apresentaram comportamento do tipo ansioso, depressivo e déficits cognitivos, utilizando-se o modelo de campo aberto (open field), teste de nado forçado e teste de reconhecimento de objeto, respectivamente. Contudo, o modelo adaptado pode ser uma melhor opção, visto que uma simples ligadura não provoca prejuízos motores, nem tampouco o comportamento de autotomia, diferentemente dos animais com CCI em que foram realizadas 4 ligaduras. 2) A - Estudo do efeito da Indometacina (2mg/kg), um antiinflamatório não-esteroidal, administrada por via periférica (IP) sobre a DN: a indometacina diminuiu a alodinia mecânica no primeiro, segundo e quarto dias, mas não no décimo quarto, vigésimo primeiro e vigésimo oitavo dias após a CCI adaptada (1 ligadura). Esses dados sugerem que a COX-1 e a COX-2 estão envolvidas na mediação da indução, mas não na manutenção da DN. B - Envolvimento do córtex PrL sobre a geração, potencialização e manutenção da DN, através da microinjeção local de cloreto de cobalto (CoCl2: 1mM/200nL), um bloqueador do influxo de cálcio (causando bloqueio de sinapses). O CoCl2 atenuou a alodinia mecânica no vigésimo primeiro e vigésimo oitavo, mas não no sétimo e décimo quarto dias após a CCI com 1 ligadura. Nossos dados também indicam que córtex PrL participa na elaboração da fase tardia da alodinia mecânica em nosso modelo adaptado de DN. C - Investigação do papel do sistema glutamatérgico, endocanabinoide e endovaniloide do córtex PrL sobre a alodinia mecânica 21 dias após a CCI adaptada. Os presentes resultados mostraram que a microinjeção do agonista N-metil D-Aspartato (NMDA), nas concentrações de 1 e 4 nmol, foi capaz de aumentar a alodinia mecânica durante o teste de von Frey, enquanto que um antagonista de receptores de aminoácidos excitatórios do tipo NMDA, o LY235959, diminuiu a alodinia mecânica quando microinjetado na maior dose (8nmol) no córtex PrL. O AM251, um antagonista de receptores endocanabinoides do tipo CB1, aumentou a alodinia mecânica em todas as doses (50, 100 e 200pmol) quando microinjetado no PrL. O tratamento do PrL com a menor concentração de anandamida (AEA: 5pmol) não alterou a alodinia mecânica; contudo, a administração de AEA no PrL nas doses intermediárias (de 50 e de 100pmol) reduziu a alodinia mecânica, e este efeito foi bloqueado pelo pré-tratamento do PrL com AM251 (200pmol). Digno de nota, o tratamento do PrL com a maior dose de AEA (200pmol) aumentou a alodinia mecânica, no entanto, este efeito foi atenuado pelo bloqueio prévio de receptores de potencial transitório vaniloide do tipo 1 (TRPV1), com microinjeções de 6 Iodo-nor-di-hidrocapsaicina (6-I-CPS) na dose de 3pmol no PrL. Esses dados sugerem que o córtex PrL está envolvido na potenciação e manutenção da DN crônica (DNC), através da ativação dos receptores NMDA e dos receptores TRPV1. O efeito da atenuação da alodinia mecânica foi causado pela ativação dos receptores endocanabinoides do tipo CB1 em roedores com DNC após 21 dias da CCI. 3) Investigação da comorbidade entre a DNC com ansiedade/pânico e o efeito dos agonistas e antagonistas de receptores NMDA e CB1 no PrL em roedores confrontados com serpente após 21 dias da CCI pelo método adaptado: o confronto entre roedores e serpentes constrictoras induziu nos ratos respostas relacionadas ao medo, tais como avaliação de risco, imobilidade defensiva e fuga em animais com DNC e Sham. Além disso, após terem sido confrontados com a serpente, os animais com DNC tiveram a alodinia mecânica aumentada. O pré-tratamento do PrL com NMDA (4nmol) aumentou o índice e porcentagem de avaliação de risco e a porcentagem de fuga, e a dose intermediária de NMDA (1nmol) aumentou o índice de fuga em animais neuropáticos confrontados com uma serpente constrictora. Além disso, a alodinia mecânica foi intensificada após o confronto em animais que receberam NMDA (4nmol) no PrL. Adicionalmente, os animais tratados com LY235959 diminuíram os comportamentos defensivos apresentados por animais com DNC quando confrontados com a salamanta. Além disso, esses animais pré-tratados com o antagonista de receptores NMDA tiveram seus limiares de von Frey aumentados após o confronto. O bloqueio de receptores endocanabionoides do tipo CB1, com o antagonista AM251, aumentou o comportamento de avaliação de riscos dos animais com DN crônica durante a exposição com a serpente e tiveram seus limiares de retirada de pata no teste de von Frey diminuídos após o confronto. Contudo, o pré-tratamento do PrL com AEA (100pmol) diminuiu os comportamentos defensivos de avaliação de risco, imobilidade defensiva e de fuga dos animais com DNC confrontados com a serpente, e esses animais também apresentaram aumento do limiar de retirada de pata no teste de von Frey após o confronto. Interessantemente, a dose de AEA (200pmol) não alterou comportamento defensivo, mas agravou DNC, através da diminuição do limiar de alodinia mecânica, apresentando um clássico efeito em \"U invertido\", pois menor e a maior dose de AEA (50 e 200pmol) induziram valores de comportamentos defensivo elevados, semelhante ao controle (veículo). Concluindo, os presentes dados obtidos no nosso trabalho, sugerem que o modelo adaptado de CCI, através da realização de uma ligadura do nervo isquiático, é um modelo animal eficaz para se estudarem as comorbidades entre DC e alterações cognitivas e emocionais. A diminuição da atividade das enzimas COX-1 e COX-2 atenuou a alodinia mecânica apenas durante a gênese da DN. Além disso, evidenciou-se que o córtex PrL é recrutado para elaborar a DN durante sua manutenção e potencialização. A ativação dos receptores glutamatérgicos do tipo NMDA e vaniloides do tipo TRPV1 potencializam a DNC e o sistema endocanabinoide via receptor CB1 a diminui. Finalmente, roedores com DNC tiveram seus limiares de alodinia mecânica diminuídos após o confronto com a serpente. Os comportamentos defensivos foram intensificados em animais com DNC, mostrando, assim, o estabelecimento da comorbidade entre DC e ansiedade/pânico e a participação do neocórtex na elaboração da DNC, em um modelo de neuropatia periférica induzida pela constrição crônica no nervo isquiático em ratos Wistar. A comorbidade entre ansiedade/pânico e DNC sensibiliza os animais, agravando o quadro de dor crônica. / Chronic pain (CP) is a global health problem. The incidence of CP in the world ranges from 7 to 40% of the population and, as a consequence, about 50% to 60% of those suffering from it are partially or totally incapacitated, in a transitory or permanent manner significantly compromising the quality of life. The prelimbic (PrL) division of the medial prefrontal cortex (mPFC) is an important region for the elaboration of cognitive and emotional aspects of pain. In addition, chronic neuropathic pain (CNP) can induce morphological changes, resulting in a reorganisation in the mPFC neurons. Moreover, there is an intrinsic relation between CP and anxiety disorder. Our study aims to investigate the effects of a modification of an animal model of CP and evaluate the neuroanatomical and pharmacological bases of neuropathic pain (NP). The role played by PrL cortex in the modulation of CNP was also investigated. Thus, the present work was divided into three steps: 1) Ethological analysis of nociceptive, motor and affective-cognitive aspects of rats submitted to an adapted model of chronic constriction of the ischiadicus nervus (CCI: a simple ligature) compared with the classic CCI model performed by Bennett and Xie (CCI: four ligatures): our results showed that the adapted-CCI model produced cold hypersensitivity and mechanical allodynia similar to those described in laboratory animals submitted to the model with four ligatures of the ischiadicus nervus. Both CCI groups displayed anxiety- and depression-like responses, and cognitive deficits, in the the open field test, forced swim test and object recognition test, respectively. However, the adapted model of CCI used in the present work may be a better choice, since a simple ligature of the ischiadicus nervus cause neither motor deficits, nor autotomy behaviour, unlike the animals with CCI induced by four ligatures of spinal nerves. 2) A- Effect of Indomethacin (2mg/kg) a non-steroidal anti-inflammatory drug peripherally administered (IP) on NP: The peripheral treatment with indomethacin reduced mechanical allodynia on the first, second, and fourth days, but not on the fourteenth, twenty-first, and twenty-eighth days after adapted CCI. These findings suggest that COX-1 and COX-2 are involved in the mediation of NP induction, but not in the maintainance of NP. B- Involvement of the PrL cortex on the generation, potentiation and maintenance of DN, through the microinjection of cobalt chloride (CoCl2: 1mM/200nL), a calcium influx blocker (synapse blocker): CoCl2 attenuated mechanical allodynia at twenty-first and twenty-eighth, but not at seventh and fourteenth days after CCI. Our data also indicate that PrL cortex participates in the elaboration of the chronic phase of mechanical allodynia in our adapted NP model. C- The role of the glutamatergic, endocannabinoid and endovanniloid systems of the PrL cortex on mechanical allodynia 21 days after CCI: The present data showed that microinjection of the N-methyl D-Aspartate agonist (NMDA), in a dose of 1 and 4nmol, was able to increase the mechanical allodynia threshold during mechanical stimulation by von Frey test filaments, whereas the NMDA receptors antagonist LY235959 decreased mechanical allodynia when microinjected at the highest dose (8nmol) in the PrL. The PrL cortex pretreatment with the CB1-cannabinoid receptor antagonist AM251 increased mechanical allodynia at all doses (50, 100 and 200 pmol). Microinjections of anandamide (AEA) at the smaller dose (5pmol) in PrL did not cause influence in the mechanical allodynia. However, the PrL treatment with AEA at the intermediate doses (50 and 100pmol) reduced mechanical allodynia and that effect were blocked by the pretreatment of the PrL cortex with AM251 (200pmol). Interestingly, the higher dose of AEA (200pmol) increased mechanical allodynia. Furthermore, this effect was attenuated by the PrL pretreatment with the transient potential receptor antagonist type 1 (TRPV1) ion channel selective antagonist 6 Iodonordihidrocapsaicin (6-I-CPS) in a dose of 3 pmol. These findings suggest that the PrL cortex is involved in the potentiation and maintenance of CNP through the activation of NMDA receptors and TRPV1 receptors in PrL cortex. The effect of attenuation of mechanical allodynia was caused by the activation of CB1 endocannabinoid receptors in rodents with CNP after 21 days of CCI. 3) Investigation of the comorbidity between CNP with anxiety/panic and the effect of NMDA glutamatergic and CB1 endocannabinoid receptors on PrL cortex after 21 days of CCI in rodents. The confrontation between a constrictor snake and the rodent elicited innate fear-related responses in prey, such as risk assessment, defensive immobility, and escape behaviour that were enhanced in CNP rodents and Sham. Also, after a confrontation with a potential predator, the CNP animals increased their mechanical allodynia thresholds. In adition, the microinjection of NMDA (4nmol) PrL, increased innate fear-related responses, such as risk assessment, and the treatment of PrL with NMDA at 1nmol incresed escape behaviour in rodents with CNP. The treatment of the PrL with NMDA in a dose of 4nmol increased the mechanical allodynia threshold during mechanical stimulation by von Frey test filaments, after confrontantion, whereas PrL pretreatment with LY235959 decreased innate fear-related responses, such risk assessment, defensive immobility, and escape behavior and decreased mechanical allodynia when microinjected (4 and 8nmol). The PrL Pretreatment with the CB1-cannabinoid receptor antagonist AM251 (all doses) increased unconditioned fear-related responses, such as risk assessment. Moreover, AM251 (100 and 200pmol) microinjections in the PrL increased mechanical allodynia after prey versus predator confrontation. The microinjections of AEA (100pmol) in the PrL decreased risk assessment, defensive immobility, and escape behaviour and reduced mechanical allodynia. Interestingly, the pretreatment of the PrL with the higher dose of AEA (200pmol) did not change the fear-induced behaviour elicited by predators, but increased the CNP. There was a classical inverted U-shape curve from the lower to the higher dose of AEA. These data suggest that the anxiety/panic and pain comorbidity increases CNP symptoms. The present findings also indicate that the CCI-adapted model, by ischiadicus nervus ligation with a single ligature is an effective animal model for studying comorbidities between CP and cognitive/emotional disturbances. In conclusion, we observed that nonsteroidal anti-inflammatory drugs are efficient to attenuate the mechanical allodynia only during NP genesis. The PrL cortex is recruited during the maintenance and potentiation of NP. The PrL glutamatergic system via NMDA activation and endovaniloid mechanisms related to TRPV1 ion channel activation potentiate CNP, and the endocannabinoid mechanisms via CB1 receptors recruitment decrease the CNP. Finally, rodents with CNP had their mechanical allodynia thresholds decreased after the confrontation with wild snakes. In addition, their defensive behaviours were itemised, thus showing the anxiety/panic and CNP potential comorbidity and the participation of the neocortex in the elaboration of CP in a model of peripheral neuropathy induced by injury of the ischiadicus nervus through its chronic constriction in Wistar rats.