Background: Attentional deficit hyperactivity disorder (ADHD) in adults is associated with borderline personality characteristics or cluster B (emotional instability), but in certain populations, such as medical students, it might be associated with cluster C traits (perfectionism, dependency, anxiety). This may be compensatory to ADHD. Aim: To analyze the association between ADHD and cluster C personality traits in medical students. Material and Methods: Biodemographic characteristics, the presence of ADHD and personality traits according to clusters A, B and C were evaluated in medical students. These characteristics were compared between students with unlikely diagnosis of ADHD (Group 1) and likely or very likely diagnosis of ADHD (Group 2). Results: We included 336 participants (44% women). A likely or very likely diagnosis of ADHD was present in 64% (Group 2). Concerning personality traits, 45% exhibited traits of cluster A, 57% of cluster B, and 67% of cluster C. Compared to their counterparts of Group 1, participants in Group 2 were more likely to have a history of psychiatric/psychological care, previous diagnosis of ADHD and traits of cluster B (37 and 68% respectively) and C (55 and 74% respectively). The odds ratio of having A, B or C traits when a likely or very likely ADHD was present, were 1.29 95% confidence interval (CI) [0.8-2.07], 3.79 95% CI [2.3-6.22] and 2.4 95% CI [1.46-3.96], respectively. Conclusions: Cluster C personality traits were frequent among medical students and were significantly associated with ADHD.

Introduction: Body-focused repetitive impulsive behaviors (BFRIB) are characterized by skin, nail and hair removing, scratching and/or biting, that configurate a mental disorder in some cases. Excoriation disorder (ED) or dermatillomania has been recently added as a specific disorder in DSM-5 obsessive-compulsive spectrum. Its phenomenology describes a behavior that emerges from anxiety, followed by a progressive psychic tension and then a pleasurable sensation, concluding in many times in guilt. Evidence has reported a greater incidence of ED in college students; however, studies in Latin America are scarce. Objective: To establish frequence and phenomenological features of BFRIB and ED in college students. Methods: We performed a cross-sectional study through the application of a self-administered questionnaire about ED aspects in college students. Results: 440 students were included; 22.2% felt always or almost always the impulse to scratch their skin until they were injured; 13.2% made these actions many times a day and 4.3% deployed considerable efforts in resisting them. Most frequent reported affects were guilt, shame, repentance, and self-reproach; 24.1% thought these behaviors were abnormal and 6.1% considered they constitute a pathology. According to DSM-5 and authors’ criteria, four cases of ED were found (0.91%), when psychiatric and medical comorbidities were discarded. Conclusion: Although BFRIB were frequent in college students, dermatillomania frequency was similar to general population. A characteristic phenomenology was described, similar to the evidence reported one.

Resumen Introducción: Las conductas repetitivas impulsivas orientadas hacia el cuerpo (CRIOC) se caracterizan por el rascado, mordido y/o remoción de uñas, pelos y piel, pudiendo llegar a constituir un desorden mental. El trastorno por excoriación (TE) o dermatilomanía ha sido recientemente incorporado como desorden específico al DSM-5 como parte del espectro obsesivo-compulsivo. Su fenomenología describe una conducta reactiva a la ansiedad, seguida de tensión psíquica progresiva y luego placentera al realizarla, finalizando muchas veces en culpa. Se ha reportado una mayor incidencia de TE en estudiantes universitarios, sin embargo, los estudios en Latinoamérica son escasos. Objetivos: Establecer la frecuencia y las características fenomenológicas de las CRIOC y del TE en población universitaria. Métodos: Se realizó un estudio transversal mediante la aplicación de un cuestionario de autorreporte sobre aspectos relacionados con el TE en estudiantes universitarios. Resultados: 440 estudiantes fueron incluidos. Un 22,2% sintió siempre o casi siempre el impulso de rascar su piel hasta lesionarse; 13,2% ejecutó estas acciones varias veces al día y 4,3% desplegó mucho esfuerzo en resistirlas. Los afectos más frecuentemente asociados fueron culpa, vergüenza, arrepentimiento y autorreproche. Un 24,1% creyó que estos comportamientos fueron anormales y 6,1% que constituyeron una patología. Según criterios DSM-5 y establecidos por los autores, se hallaron cuatro casos compatibles con TE (0,91%), al descartar patologías psiquiátricas y médicas comórbidas. Conclusión: Aunque las CRIOC fueron frecuentes en población universitaria, la frecuencia de TE fue similar a la de la población general, describiendo una fenomenología característica congruente con la reportada por la literatura.

Prenatal stress (PS) has been mainly investigated in animal models. It could trigger permanent neurobiological changes in the offpring through fetal programming, displayed as behavioral, cognitive, anxious, affective and psychotic disorders during infancy and adulthood. Main effects of PS have been related to the functioning of hypothalamic-pituitary-adrenal axis (HPA), serotonergic, glutamatergic and GABAergic systems, cortical (prefrontal, temporal and insular cortex) and subcortical structures (amygdala, hippocampus), cerebellum and placenta. Glucocorticoids are the most recognized transmission factors of maternal-fetal stress, with distinctive effects according to the moment of action, developmental stage and fetal gender. Alteration pattern of the HPA axis by PS would be similar to the one observed in some mental disorders. Other neuromodulators involved in the neurotoxicity of PS are nitric oxide and brain derived neurotrophic factor, associated to synaptic potentiation and depression. Also, serotonergic system has an important relationship with HPA axis, verifyinga decreased number of serotonin transporters and an impaired placental synthesis of the neurotransmitter, essential for fetal neurodevelopment. Other epigenenomic mechanisms would be the modulation of synaptic plasticity by neurotrophins, adhesion and membrane molecules. Treatment with selective serotonin reuptake inhibitors has shown controversial outcomes. PS would affect fetal programming causing significant and permanent neurobiological alterations with clinical manifestations. This complex phenomenon must be further investigated, especially in human models.

El estrés prenatal (EP), investigado mayoritariamente en modelos animales, podría desencadenar modificaciones neurobiológicas permanentes en la descendencia mediante la programación fetal, manifestadas como alteraciones conductuales, cognitivas, ansiosas y afectivas, hasta trastornos psiquiátricos durante la niñez y la adultez. Los principales efectos del EP se han hallado en el eje hipotalámico-hipofisiario-adrenal (HHA), los sistemas serotoninérgicos, glutamatérgicos y GABAérgicos, y en estructuras nerviosas corticales (corteza prefrontal, temporal, insular), subcorticales (amígdala, hipocampo), cerebelo y placenta. Los glucocorticoides son los factores de transmisión de estrés materno-fetal más estudiados, con efectos diferenciales según la temporalidad de su acción, la fase del desarrollo y el sexo fetal. El patrón de alteración del eje HHA ante el EP sería similar al observado en algunos desórdenes mentales. Otros neuromoduladores involucrados en la neurotoxicidad del EP son el óxido nítrico y el factor neurotrófico derivado del cerebro, implicados en los procesos de potenciación y depresión sináptica. A su vez, el sistema serotoninérgico posee una relación intrínseca con el eje HHA, verificándose una disminución en la cantidad de transportadores de serotonina y una alteración de la síntesis placentaria del neurotransmisor, esencial para el neurodesarrollo fetal. Otros mecanismos epigenéticos serían la modulación de la plasticidad sináptica mediante neurotrofinas, moléculas de adhesión y de membrana. El tratamiento con inhibidores selectivos de la recaptura de serotonina ha demostrado resultados controvertidos. El EP afectaría a la programación fetal provocando alteraciones neurobiológicas significativas y permanentes con un correlato clínico. Mayor investigación y difusión es necesaria en este complejo fenómeno, sobre todo, en modelos humanos.

The opinions about the relationship between antipsychotics and suicide are controversial due to differences on reported evidence about their specific action. One ofthe most discussed topics is the increase of depressive symptomatology and the impact of some secondary effects on suicidality, mainly akinesia, akathisia and tardive diskynesia. Another polemical topic is the paradoxical effect due to the decrease ofpositive symptoms when increasing insight. We performed a critical review of the available literature concerning to the use of antipsychotics in relation to suicide in the context of psychotic and affective disorders. When appraising psychotic disorders, there was no direct evidence to support a reduction in suicide rates when using first-generation antipsychotics, probably due to methodological issues and multifactoriality ofthe phenomenon. Nevertheless, second-generation antipsychotics could be protective against suicide risk, specifically clozapine, which is considered as an antisuicidal drug on schizophrenic disorders due to a direct antidepressant action and an indirect effect mediated by an improvement in cognitive functions. On the other hand, when appraising affective disorders, bipolar spectrum has demonstrated the greatest use of antipsychotics drugs, showing effectiveness in the management ofsuicide not greater than mood stabilizers. It becomes essential to identify the specific mechanism of action of antipsychotic drugs to assess their real effect on suicidality.

La relación entre antipsicóticos y suicidio es controversial debido a las diferencias expuestas en la literatura acerca de su acción específica. Uno de los puntos de discusión ha sido el aumento de la sintomatología depresiva y el impacto de algunos efectos secundarios sobre la suicidalidad, principalmente acinesia, acatisia y disquinesia tardía. Otro elemento controvertido es el efecto paradójico producto de la aminoración de los síntomas positivos al incrementar paralelamente la instrospección. Se revisará críticamente la principal evidencia disponible en torno al uso de antipsicóticos en relación al suicidio en el contexto de trastornos psicóticos y afectivos. No existe evidencia directa que avale una disminución en las tasas de suicidio con el uso de antipsicóticos de primera generación en trastornos psicóticos, probablemente por fallas metodológicas y por la multifactorialidad del fenómeno. En relación a los de segunda generación, podrían participar como protectores frente al riesgo suicida. En los trastornos esquizofrénicos se ha considerado a la clozapina como un fármaco antisuicida, debido a una acción antidepresiva directa y un efecto indirecto mediado por un mejoramiento en las funciones cognitivas. El mayor uso de antipsicóticos en los trastornos afectivos se observa en el espectro bipolar, sin reportarse mayor efectividad en el manejo del suicidio al compararse con estabilizadores del ánimo. Es crucial identificar el mecanismo de acción específico de los antipsicóticos para evaluar su real efecto sobre la suicidalidad.

ABSTRACT Background The United States Food and Drug Administration (FDA) has warned about the increased suicidality risk associated with the use of selective serotonin reuptake inhibitors (SSRI) and venlafaxine in children and adolescents. Objectives To critically appraise the available evidence supporting the FDA Black box warning concerning to the use of antidepressants in child and adolescents. Methods A critical review of articles in Medline/PubMed and SciELO databases regarding the FDA Black box warning for antidepressants, and the impact of FDA warnings on antidepressant prescriptions and suicide rates. Results The warning was based on surveys that did not report either cases of suicide nor a significant difference supporting an increased suicidality rate. The concept was defined in an ambiguous way and there is currently more available evidence to support such definition. The use of SSRI and venlafaxine has been associated to lower suicidality rates, but the prescription fall due to the warning increased suicide rates. Discussion Suicidality is an inherent feature of depressive disorders so it would be desirable to consider how much of the phenomenon may be attributed to antidepressants per se. It would be appropriate to consider that suicide rates might increase also as a consequence of the warning.

Lithium and anticonvulsants have been widely used as mood stabilizers (MS) in bipolar affective disorder (BAD), showing a reduction of suicide risk, even more, the anti-suicidal effect of lithium would be independent of its stabilizer property. The action mechanisms of the drug are not completely known and clinical research is hampered due to the heterogeneity of the studied samples, however, some mechanisms related to neurotransmitters metabolism and neurotrophic and neuroprotective factors have been proposed in order to explain its effect. Despite the current decline in the use of lithium as a MS it remains as the anti-suicidal drug of choice in bipolar patients.

El litio y los anticonvulsivantes han sido ampliamente empleados como estabilizadores del ánimo (EA) en el trastorno afectivo bipolar (TAB), demostrando además una reducción del riesgo de suicidio. En el caso particular del litio, dicho efecto sería independiente de su acción estabilizadora. Si bien los mecanismos de acción de la droga no son completamente conocidos y la investigación clínica se ve dificultada debido a la heterogeneidad de las muestras estudiadas, se han propuesto distintas vías que explicarían su efecto, relacionadas con el metabolismo de los neurotransmisores y con factores neurotróficos y neuroprotectores. Pese a la disminución actual en el uso del litio como EA, continúa siendo el fármaco antisuicida de elección en pacientes bipolares.

Suicide is an important worldwide death cause. Although 90% or more of those who commit suicide suffer from a psychiatric disorder, an isolated pathology does not fully explain the complex phenomenon of suicide. Because of the multifactorial behavior suicidal pattern, biological, psychological and social factors are implicated. Given the above, a single pharmacological management of the underlying disease or some symptoms such as anxiety and impulsivity, should not be enough to address or prevent suicidal behavior in its entirety. Because of the complexity and the interrelationship of risk factors for suicide, it is very unlikely that a single medication controls all the aspects involved; thereby it is difficult to ascribe the actual antisuicidal effect of a particular drug with certainty. However, the current literature despite its limitations supports an antisuicidal effect of particular drugs such as lithium and clozapine.

El suicidio es una importante causa de muerte a nivel mundial. Si bien el 90% o más de quienes cometen suicidio presenta un trastorno psiquiátrico, el ser portador de una patología no explica del todo el complejo fenómeno relacionado con él. Al ser un patrón de conducta multifactorial, intervendrán factores biológicos, psicológicos y sociales. Dado lo anterior, un manejo farmacológico de la patología de base o de algunos síntomas como la ansiedad o la impulsividad, no es suficiente para abordar o prevenir las conductas suicidas en su globalidad. Por la complejidad e interrelación de los factores de riesgo de suicidio, es muy poco probable que la mera medicación logre modular todos los aspectos involucrados; por ello, sería muy difícil poder atribuir con certeza el real efecto antisuicida a un fármaco en particular. Sin embargo, la literatura disponible, pese a sus limitaciones, frecuentemente apoya el efecto antisuicida de algunos psicofármacos como el litio y la clozapina.