Stress: Don´t lose control (Colección Salud)

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Data dictionaries and corresponding data bases were built for collection of data related to the documents themselves and to the patients admitted to the ICU during the period analysed. Basically, the discriminated information of each report was considered. Information was then typed into a data base and the evaluation strategy was determined. Logical Frame Methodology was deemed appropriate for this process. The information on the reports was analysed, which produced an analysis matrix with three basic components in relation to the patient, to the family and to the health personnel.

This matrix can be seen in the Results section. The information related to the users was evaluated by means of descriptive and correlational strategies. Finally, data bases were cleaned up and the analysis of results was performed. In order to analyse the results two aspects were considered; one qualitative in nature by using the methodology of Logical Frames BID, and content analysis. The other one was quantitative in nature, mainly by means of descriptive statistics, with the use of central tendency measurements mean, median, mode and dispersion measurements ranges, standard deviation in the information related to the users.

Correlational methods were also used Pearson and Spearman correlations, Kendall and contingency coefficients in order to establish relationships among relevant variables in the subject data. Descriptives of the sample. For this study, information was found on 1. With regard to the most relevant sociodemographic data, we found that the age group was the most represented The less represented group was that of ages between 0 and 10, with 0.

More patients were female, specially in the age groups , and , but a larger number of male patients was found in the age groups , and 91 or more. Only people reported their marital status. The sample ranged between illiteracy and high levels of education. Of the people that reported their education level, Education levels higher than undergraduate were reported only in patients older than 41 years. Nevertheless, lower levels of education and the highest levels of illiteracy were also reported in that very sample. As for remissions, we were able to establish that General Surgery Medical conditions were evaluated according to variables such as sedation, intubation, immobility and sepsis.

Psychological work was done with ICU patients. Companionship activities only were carried out with Out of patients with information, It is important to note here the evaluation that patients made of the psychological work and the sufficiency of the time devoted to attention. In the evaluations administered to patients after discharge from the ICU, it is important to point out some aspects related to the information and previous knowledge they had before admission to the ICU, who gave them that information, the evaluation they made of their stay and the attention received.

Concerning the topic of information they had before admission, out of reported cases, 70 This information, according to the patients, was obtained, in most cases Relationships among variables. After the descriptive analysis, a correlational one was performed that intended to determine the possible relationships among the relevant variables for this research. These variables were specifically related to preparation, communication and psychosocial aspects of the patients, the families and elements of the service given by the ICU. As for the nominal variables related to interval-level variables, the Eta coefficient, which indicates the direction of the measurements, was employed.

Table 1. Discussion of the results is made in light of the review of the specialized literature available and of the results from the analysis of reports and archives of the Humanization of Health Services project. Generally speaking, this documental research allowed us to establish the role of the psychologist in an ICU, which consists of individual attention to patients, attention to family members and companions, work with the medical and paramedic personnel and environmental design.

These conclusions are in accordance with those reported by Ramos and Pereira about the factors of intervention of the Psychologist in the ICU, factors referred to family, the individual and the hospital. In this line, Fontaine includes conditions derived from the pharmacological treatment into the category of biomedical conditions, which have important side effects such as cognitive and behavioural alterations — changes in state of consciousness, orientation, memory, attention, sensoperception and thought among them, some in the category of ICU psychiatric abnormalities.

In pragmatic terms, controlling these alterations as good as possible becomes necessary, because, as this author points out and as evidenced by this research, they may imply potential damages to the patients themselves or to the healthcare team in charge of them. When possible, the intervention should pose as little restrictions as possible and should appeal in minimum amounts to sedatives. Results are also consistent with what was described by authors such as Epstein and Breslow regarding anxiety in ICU patients and their families, so that it becomes important to pay attention to indications, both verbal and physiological, susceptible of being monitored by people that have contact with the patient.

Taking into account the importance of psychological variables in the quality of life of ICU patients, this research allowed for a reaffirmation of the need to know those variables as soon as possible, in order to be able to determine whether they are previous conditions or they are brought about by the stay at the ICU and the medical conditions. From the set of complaints and reports of distresses it can be concluded that the most frequent psychological stressors were pain, sleep deprivation, fear or anxiety and nudity.

It is important to observe how opportunity and effectiveness of psychological interventions may allow to break feedback cycle existing between environmental conditions and psychological conditions and the physiological conditions inherent to the morbid state, which can, together, make a naturally aversive stay worse, as described previously.

This aspect is related to psychoneuroimmunology, a specialty that has allowed for a gradually increasing understanding of that feedback cycle. These results are even more relevant when considering the high psychological, social and economic costs associated with ICU services. The project developed at the HUCSR did not examine any interventions for pain, which has been associated with effects on the neuro-endocrine and immune systems, and the psychological science has created intervention strategies for pain which use medication in minimum amounts and have shown benefits in diverse pathologies.

Relevance of psychological support provided to the patient was evidenced in the post-ICU measurements. A suggestion to the Psychology and Health Research Group would be to conduct follow-up evaluations of the interventions in a longer term, considering reports by Horta, Plazas and Serrano regarding the possibility of developing Posttraumatic Stress Disorder and other psychological abnormalities.

Concerning evaluation made about psychology work, in some cases by patients and in others by families, it is worth noting that most of them evaluated it as good, and claimed for more time of this service. It should be pointed out that psychologists were not full-time at the ICU, since the whole work was framed in a project-based practicum, with the already mentioned implication that few patients were prepared; this evidences the need for hospitals to have staff psychologists as ICU personnel.

The results of intervention with family and companions of the patient are also consistent with the literature reviewed, as it is regarded that family has a double function, the first one as supporters of the patient and the second as agents that ease the work of the healthcare personnel.

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The role of psychological intervention with the family in handling information and reducing the negative impact of ICU on the family was evident in this research, by enhancing communication with the patient and the healthcare team. A general conclusion worth noting of this is the change in beliefs held by family and companions about the psychological conditions of their hospitalized family members, going from considering them as completely biological entities, incapable of contact and influence by the environment, to understanding that despite their physiological condition they continue to be psychologically active beings.

In this way, the Psychological Preparation for ICU programme and the presence of the Psychologist during the visits were activities that should be highlighted. This research evidenced, with regard to the work of the professional team in the ICU, the need of building interdisciplinary groups in order to have a real impact on the quality of attention of the patient and the quality of life of the professionals. The difficulty reported in the documents on joint work leads to the conclusion that one of the jobs of the psychologists in the ICU is to be a part of said team, showing clear skills in their discipline and in the relationships between their discipline and the relevant biomedical disciplines.

One of the roles would then be to give orientation to the healthcare personnel as to improving the relationship with the patients and their families, which is in the way suggested by authors such as Laitinen , based on the importance, claimed by patients, of having a closer relationship with the professionals in charge; it is indicated that perceived tranquility and safety and acceptance feelings depend mostly on the quality of this presence.

Krueger et al. Despite not being documented in the reviewed reports, it is relevant to point out the encounter of the roles of each discipline with a presence in the ICU, especially between Nursing and Psychology. As mentioned previously, most publications about attention to critical patients come from Medicine and Nursing, the latter being mainly concerned with the effects of human interactions, so that the inclusion of psychologists in the ICU could have been perceived as invasive, with the subsequent implication of a role conflict of the nursing personnel.

Consequently, one suggestion is to clearly define the roles of each profession and comment them with the members of the team, in order to promote cooperative behaviours that ease, instead of interfering with, the quality of the service in the ICU, as well as the quality of the work environment. Another work front with the healthcare personnel was related to the design of interventions tending to reduce the impact of working at this kind of units and thus improving their quality of life. Noteworthy of that work is the effectiveness of the intervention in the hardy personality pattern control and challenge as a strategy for stress management and the improvement of interpersonal relationship conditions among ICU professionals.

There are numerous suggestions for future research. On the other hand, more research is needed on the improvement of the measures, including other sources of information different from patients and family members, that allow for validation of the work. Finally, it is worth considering the need of continued implementation of the proposals made in the reviewed reports, such as the ICU adaptation programme, as well as ensuring the continuity of the programmes when started.

The time variable is worth taking into account for further research, in the different dimensions included, length of stay in the ICU, visit length and time in contact with the healthcare team. Most reports of discomfort were made by patients that stayed between 1 and 7 days, in comparison to those with longer stays, which can be related to the process of adaptation; it would be hypothesized that, after a week, the patients would have recognized the conditions of the ICU, including environmental and relational ones, and would have got used to them, not implying any liking or satisfaction about their status of ICU patients.

Worth noting is the result on the evaluation of sufficiency of time devoted by the healthcare team, since while most regarded the time as sufficient, also considered the psychological intervention time and the visit time to be insufficient. Also related to the length of stay at the ICU, it is good to be important to discuss the results in light of the type of information required by family members. It seems that the longer the stay at the ICU, the more the needs of information deal with getting ready for a worse outcome, including the death of the patient.

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As a consequence, the role of the psychologist also includes situations of mourning. Finally, the Humanization of Health Services Project made an important contribution to the topic of quality of life upon considering it to be susceptible of being studied in critical patients. To date, quality of life had been a topic of interest in patients with chronic and terminal diseases, but not in ICU patients, probably because of the conditions inherent to their state.

Aldana, C. Programa de la Unidad de Cuidados Intensivos. Informe I Semestre. Faculty of Psychology, PUJ. Unpublished document. Ballestas, M. Bell, P. Environmental Psychology. Philadelphia: W. Biley, F. The effects on patient well-being of music listening as a nursing intervention: a review of the literature. Journal of Clinical Nursing, 9 5 , Blacher, R.

The psychological experience of surgery. New York: John Wiley and sons. Blanco, A. Madrid: Alianza. Bonebreak, K. A sound way to induce relaxation and natural sleep: a safe alternative to sedation. American Journal Electroneurodiagnostic Technology, 36 4 , Carlopio, J. Journal of Occupational Health Psychology, 1, Caro, S. Unidad de Cuidados Intensivos. Faculty of Psychology PUJ, unpublished document. Chlan, L. Effectiveness of a music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance. Heart and Lung, 27 3 , Cook, D.

Chest, 6 Supplement : SS. Costello, J. Davis, B. Milit Med. DeKeyser, F. Sedation of the Agitated, Critically ill patient without an artificial Airway. Critical Care Clinics, 11 4 , Epstein, J. The stress response of critical illness. Critical Care Clinics, 15, San Juan de Puerto Rico, junio. Fontaine, D. Non-pharmacological management of patient distress during mechanical ventilation. Critical Care Clinics, 10, Fowler, J. Application of a transactional model of stress and coping with critically ill patients. Dimensions of critical care nursing, 16, Granberg, A.

Acute confusion and unreal experiences in intensive care patients in relation to the ICU syndrome: part II. The subject is more complex than what it may appear at first glance. It can also happen that repetitive motor mannerisms can seem like compulsions of OCD and lead to an erroneous diagnosis.. The research coincide in that people with autism are clearly differentiated from people with anxiety disorders because of their persistent deficits in communication and in social interaction 10,11 : deficits in social and emotional reciprocity, deficits in non-verbal communication skills and deficits in developing and maintaining relationships that are appropriate for the level of development.

If restrictive interests and ritual behaviour present together alterations in social communication, and they have been present since early infancy, the traits are more likely to be part of the autistic syndrome. In contrast, the diagnosis of OCD makes more sense when these traits mark a milestone in the psychosocial functioning of the individual, from even pre-adolescence, in the teen years or in adult life.. This article offers keys for differentiating the obsessions and compulsions in OCD with traits found in ASD, such as the desire for sameness, stereotyped movements, stereotyped manipulation of objects, abnormal attachment to and concern about specific objects, rigid adherence to routines and rituals, a repetitive use of language and limited interests..

The first question that is appropriate to ask is: What are obsessions and compulsions? The thoughts are experienced as intrusive, invasive, unacceptable, uncontrollable and inappropriate. The individual suffers in the face of the presence of these thoughts and tries to reduce them and eliminate them through voluntary compulsions.. They are secondary manifestations— apparently more spectacular —that attempt, in a voluntary manner, to prevent or reduce the suffering and eliminate the obsession as a coping mechanism. Compulsions, then, have a relationship of functionality with obsessions when, with them, the individuals try to ignore or suppress these thoughts or impulses or to neutralise them through other ideas or activities.

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For example, a person plagued with doubts over whether he or she has shut off the gas attempts to neutralise the doubts by checking over and over to see if indeed the gas has been shut off.. Examples are spasmodic movements of individual facial muscles, blinking, shrugging one's shoulders, etc.. Stereotyped movements: rhythmic body movements, which are apparently voluntary, which are repeated constantly and are inappropriate to the situational context.

Examples are waving one's hands, rocking the body, snapping one's fingers, etc.. Self-aggression: repetitive actions that are topographically invariable and apparently voluntary that can cause pain or even physical injury to the person. Examples are hitting oneself in the head, biting oneself, etc. Stereotyped manipulation of objects: topographically invariable manipulation of objects repeated in a manner that is inappropriate to the normal nature or function of the object in question. Examples are spinning objects, examine a toy repeatedly, line objects up in rows, etc. Abnormal attachment to and concern toward specific objects: persistent attachment to or disproportionate concern over an object which is at times unusual or part of it that is not used to provide the person calmness or security in a normal way, Such as persistent concern to carry a stick, a rubber glove, etc..

Insistence on keeping the environment the same: insistence on keeping 1 or more characteristics of the environment exactly the same without there being a logical or apparent reason for it; any attempt to change causes resistance. Examples are insisting that the curtains remain open, that ornaments are always left in a specific position, always putting the same music on, etc..

Strict adhesion to routines and rituals: a routine or ritual to which the individual clings in all situations, characterised by complete invariability and inflexibility. An example is insisting on buying a newspaper each time that the individuals go to the newsagents, without it mattering if they had already bought one even when there is no interest in reading it.. Repetitive use of language: a phrase or linguistic expression copied from others or supposedly invented by the person, used repeatedly in different moments and situations.

Examples are immediate or delayed echolalia, repetitive use of the same phrases or questions palilalia and verbal rituals.. Limited interests : repetitive, absorbing search for a single, extremely limited subject or activity. An example is looking at maps and speaking every day even at all hours throughout the day about different countries and their flags although the person shows a lack of interest in seeing documentaries about these countries..

Except for the cases in which, truly, both disorder are comorbid, the keys to proceed in the differential diagnosis are based in the emotional valence of the thought and the compulsion; the content of the obsessions and compulsions; the function of the obsessive-compulsive behaviour and of the restrictive and repetitive patterns of behaviour; and the psychological theories that explain both disorders.. In autism, the restricted and repetitive patterns of behaviour, interests or activities represent a pleasurable affective experience, intrinsically motivating and reinforcing.

The individual likes to put them into motion: put things in order, constantly observe a detail of an object, comply with a fixed ritual to perform a specific activity, obsessively read and speak about a specific subject, collect objects and things related with that subject, etc. The answer is: no.

That is, they are perceived as intrusive and unwanted by the individual who has them, unpleasant and with a very clear objective of reducing or eliminating the threatening obsessive thought. Ego-dystonic refers to the sensation had by the person that the content of the obsession is foreign, out of their control and that it does not fit with the type of thoughts that she or he would expect to have.

Whatever way these obsessions and compulsions are experienced, they cause discomfort so significant that it forces the individuals to try to stop them and to put them away from their minds, considering them intrusive elements that invade them against their will. In this case, the definition of obsession does indeed correspond fully..

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Consequently, for the differential diagnosis it is important to evaluate the experience of anxiety and stress that the person undergoes in relation to with patterns of obsessive thought and the compulsions. In OCD obsessions are intrusive, unacceptable, uncontrollable, ego-dystonic and provoke resistance in the person to whom they appear. This is not so in ASD, except of course in the cases in which there is comorbidity. Nevertheless, in the first case, when we speak of infancy and adolescence, there is a possibility that such obsessions and compulsions are not totally ego-dystonic..

Some of the difficulties that can arise in determining the differential diagnosis are as follows: variability in the degree of ego-dystonia among the people with OCD, and the fact that emotional valence is not currently a criterion in the DSM-IV-TR for the diagnosis of childhood OCD, when the diagnosis of ASD is made.. These thoughts, impulses or images do not constitute simple excess worries about problems in the real world, such as momentary uneasiness or difficulties, or economic, work or school difficulties.

Consequently, it is rare that they are random with respect to content; the interests tend to group together in specific basic cognitive domains. These people usually like to talk about a specific subject, collecting things related to this subject or reading and compiling related information, in an obsessive and in-depth manner. None of these examples given are symptoms of OCD although they suggest certain similarities with it.. The intellectual functioning of the person with ASD also conditions the content of the restricted behaviour and interests. Those with greater cognitive deterioration tend to persist in stereotypes, adherence, fixation on or hoarding of specific objects, touching or rubbing a specific surface, etc.

Examples are the functioning of a system; the mechanical properties of inanimate objects; a fascination with subjects related to biology, mathematics, space and physics; taxonomies, classifications and lists: videogames and the internet; mechanical apparatus-gadgets; historical facts; technical guidelines; in brief, non-intentional physical systems, 15,18,19 which seriously interfere in personal daily activities and with others.

In both cases we seldom see interests centred on the area of the social world, such as what others tell us with their emotional expressions, forecasting how people will act, and understanding tricks, double meanings, lies, etc.. The level of interference is generally proportional to the qualitative alteration of the adaptive and social-communicative alteration..

The study by McDougle et al. The results showed that people with autism were less likely to manifest obsessive thoughts or somatic symptoms of cleanliness, checking and counting , but were more likely to manifest behaviour of repetition, touching, hoarding or self-injury in comparison with people with OCD. In relation to the different manifestations of repetitive behaviour and symptoms of anxiety in ASD, it was found that children with autism that exhibited a symbolic representation of the restrictive behaviours were more likely to display a great number of anxious symptoms such as OCD or generalised anxiety.

This result coincides with studies that propose that children who manifest repetitive, more symbolic type behaviours display more serious and more anxiety symptoms than children displaying other forms of repetitive behaviours such as reciting lists or learning fact by heart , in the same way that children without ASD face anxiety using symbolic games.

In OCD obsessions are associated with a significant increase in suffering, anguish or feeling of blame. This causes the triggering of compulsions that attempt to reduce the discomfort that the obsession provokes. However, these behaviours or mental operations are either not connected realistically with what the individual wants to neutralise, avoid or prevent, or the behaviours or mental operations are clearly excessive.. For example, the people obsessed with the possibility of contaminating themselves can relieve this mental discomfort by washing their hands until their skin gets wrinkled and cracked; people perturbed by the idea of having forgot to lock a door can feel the impulse to check the door every 5 min; people obsessed with unwanted blasphemous thoughts can find relief by counting times from 1 to 10 and from 10 to 1 for each of these undesired thoughts.

In some cases the individuals perform fixed or stereotyped acts in agreement with idiosyncratic personal rules without being able to indicate why they carry these acts out.. The behaviour serves as a strategy for coping with emotionally negative stimuli or events, and as distractors from sensations of distress or from possible perception of an environmental threat, given that they confer a sensation of organisation and predictability.

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Another hypothesis adds that restricted and repetitive behaviour reduces the anxiety that social demands cause. However, the common denominator is reflected in a social, sensorial world that becomes a potential source of stress and not of well-being. If that is how it is, it is normal for these ritualistic and stereotyped behaviours to increase in people with ASD who are susceptible to experiencing higher levels of anxiety..

One element of repetitive behaviour that has been well documented is the impact that it has on the general functioning of children with ASD, making it impossible for them to pay attention to other possible relevant information produced in their environment. The recent study by Wood and Gadow 24 contemplated the nosology and pathogenesis of anxiety disorders in young people with autism.

The researchers suggested that this anxiety could have 3 different roles: 1 an inherent consequence of the symptoms of ASD for example, the stress that perceiving social rejections causes ; 2 a moderator of the severity of the ASD symptoms such as deficits in social abilities and the exacerbation that may occur to the repetitive behaviours ; and 3 an indicator of the nuclear symptoms of ASD.. The debate that is created questions if the restricted and repetitive patterns of behaviour, interests or activities present in autism arise as a consequence of a low capacity for response to social stress and stimulation.

The high prevalence of anxiety in people with autism leads us to wonder whether these behaviours justify a separate diagnosis or whether they should be interpreted as part of autism. The current psychological theories that explain OCD fall in the framework of 2 orientations: the hypothesis of deficit in cognitive functioning and the hypothesis of inadequate assessment or interpretation that the person makes of the intrusive thoughts..

The hypothesis is expanded to general cognitive control, over and above the focus in memory and attention. For example, control over repeated intrusion of thoughts, or deficiencies in inhibitory mechanisms of irrelevant or unwanted stimuli, or deficiencies in being able to disregard the information that they are requested to ignore. With respect to memory, generalised deficiencies in memory or lack of confidence in how their memory works are found.

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With respect to attention, it is hypothesised that there is a selective attention towards stimuli related with the content of their obsessions, causing the person to be hypervigilant or making them unable to ignore the threatening information.. When this happens, the individual implements coping strategies of neutralisation, avoidance or compulsion that increase the sensation of control and reduce the discomfort. Consequently, these individuals enter a vicious circle that never ends and worsens the perturbing symptoms.

This is the point in which you can see that in ASD lacking comorbidity with OCD, of course the obsessive thought does not play any role and the compulsion lacks any effect of functionality with respect to these primary thoughts. There are no negative feelings or discomfort when they are experienced. The thoughts are not avoided but rather the total opposite, they do not threaten the individual's moral integrity or values, nor is there any need to control or reduce them..

In contrast, the psychological theories that restricted and repetitive patterns of behaviour, interests or activities in ASD currently focus on the theory of executive dysfunction as part of the explanation, but not in an absolute and convincing fashion. Russell et al. Executive functions EF represent a construct under which various functions are contemplated, such as planning abilities, working memory, impulse control and inhibition, change of attentional focus, flexibility, generativity, initiation and self-regulation of action, among others.

Although there may be nuances in the different definitions of what EF are, all of them share the central aspects that relate to the organisation of action and thought. An executive dysfunction can make it more difficult for the individual to carry out an independent life and have consistent behaviour; the dysfunction affects higher-order functions such as making decisions, mental abilities, resolving problems, emotional regulation, generalisation of learning, adapting to unforeseen or novel situations, etc.

The primary alterations in controlling and regulating voluntary behaviour could explain the characteristic presence of repetitive behaviour in people within the autistic spectrum. This would explain the desire for environmental stability and the rejection of new and unexpected situations, which are lived as terrifyingly novel, cognitively incomprehensible and emotionally unacceptable. This changes the behaviour of a personal with autism to very predictable and limited with respect to initiative, creativity, spontaneity, flexibility and adaptation to environments and situations, generation of plans for action and, in the worst case, continual repetition of a specific behaviour and the stereotyped and repetitive use of objects.

That is why an alteration of these processes of inhibition can also become the psychological substrate of the repetitive and stereotyped behaviour and of the desire for invariability that people with ASD have. If the individual is unable to inhibit thoughts or actions before or during an activity, there will be a tendency towards perseverance, rigidity and persistence. The result is as if the individuals were not in control of their ability to stop and direct their behaviour in another direction.

The degree of seriousness of the processes of behavioural inhibition predicts that the preservation can be differentiated between: persevering in the simple response, repeating the same sequence of behaviour, with repetition of low-level behaviours for example, stereotyped movements, stereotyped manipulation of objects, etc. At this point it is important to clarify that cognitive flexibility and problems with response inhibition are not specific to individuals with ASD, but can also be manifested in patients with OCD..

In studies with young people and adults with ASD and OCD, the neurocognitive processes related to executive functions that, hypothetically, underlie the repetitive behaviours in people with ASD received lower scores in the tasks that required generation of multiple responses; in contrast, people with OCD tended to display alterations in tasks that required inhibition of response.

In OCD the obsessions are intrusive, unacceptable, uncontrollable and ego-dystonic and provoke resistance against their appearance; in ASD this is not so except, of course, of cases in which there is comorbidity.. There are studies that have assessed cognitive-behavioural focuses adapted for people with ASD and comorbid anxiety disorders. Examples are visual strategies, externalising rules and social norms with lists, anticipating and clarifying expectations, etc.

It can be considered that the thoughts of individuals with ASD can also become abilities, skills or extraordinary or unusual capabilities related to mathematical skills they can multiply very large figures mentally in a short time ; great memory potential; complex understanding of rules, sequences and concepts; artistic skills; hyperlexia they decipher written language even before being able to understand it, at very early ages ; etc.

Many of these skills, far from having a function that serves them in life, become activities with certain mechanical overtones.


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Providing functionality and protagonism to these natural skills will improve the perception that we have of them, it offsets the negative view that autism provokes in them and it offers them the opportunity to receive reinforcement for something that they do and, on occasion, do very well. In addition, the development of areas affected can be strengthened towards those that show little interest: language, specific games and social interaction..

The prospect of research in autism should analyse whether the techniques of exposition and prevention of response to minimise the rituals and restricted interests are truly effective, Given that there is not experience of stress or anxiety, but quite the reverse. The person with ASD does not need a process of habituation to extinguish anxiety, because the stereotyped rituals or behaviours are pleasurable.

In contrast, habituation is indeed useful for people with OCD to reduce their compulsions.. In OCD the individualised cognitive conceptualisation of each case is the most efficient clinical strategy for treating the presentation idiosyncratic and heterogeneous of the symptoms. We can only speak of obsessions in autism —and consequently, of ASD-OCD comorbidity —if these: a are experienced as recurrent and unwanted mental intrusions; b significant effort is expended to suppress, control or neutralise the thoughts; c the thoughts are recognised as a product of one's own mind; d there is an elevated sensation of personal responsibility; e they involve ego-dystonic content; and f they tend to be associated with neutralising efforts..

The author has no conflict of interests to declare.. Rev Psiquiatr Salud Ment Barc. ISSN: Previous article Next article. Issue 4. Pages October - December More article options. Differential diagnosis between obsessive compulsive disorder and restrictive and repetitive behavioural patterns, activities and interests in autism spectrum disorders. Download PDF. This item has received. Article information. Introduction The obsessive compulsive disorder OCD and the restricted and repetitive patterns of behaviour, interests and activities inherent to autism spectrum disorders ASD share a number of features that can make the differential diagnosis between them extremely difficult and lead to erroneous overdiagnosis of OCD in people with autism.

Development In both cases there may appear to have a fixation on routine, ritualised patterns of verbal and nonverbal behaviour, resistance to change, and highly restrictive interests, which becomes a real challenge for differentiating rituals, stereotypes and adherence to routines in ASD from obsessions and compulsions in OCD.

This article provides key points to clarify this differential diagnosis through the analysis of emotional valence, content, function and psychological theories that explain the obsessions and compulsions in OCD, and the desire for sameness, stereotyped movements and limited interest in autism. When there is comorbidity between, exposure behavioural and response prevention techniques are then used, followed by others of more cognitive orientation if necessary.

Obsessive compulsive disorder. Restricted and repetitive patterns of behaviour, interests or activities. Palabras clave:. Trastorno obsesivo compulsivo. Comportamientos, intereses y actividades restrictivos y repetitivos. Introduction Obsessive compulsive disorder OCD and restricted and repetitive patterns of behaviour, interests and activities inherent to autism spectrum disorders ASD share a series of characteristics that can make their differential diagnosis extremely difficult.

It is in the last few years that there has been an increase in research that validates the effectiveness of these treatments in people with autism.


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It can also happen that repetitive motor mannerisms can seem like compulsions of OCD and lead to an erroneous diagnosis. In contrast, the diagnosis of OCD makes more sense when these traits mark a milestone in the psychosocial functioning of the individual, from even pre-adolescence, in the teen years or in adult life.

This article offers keys for differentiating the obsessions and compulsions in OCD with traits found in ASD, such as the desire for sameness, stereotyped movements, stereotyped manipulation of objects, abnormal attachment to and concern about specific objects, rigid adherence to routines and rituals, a repetitive use of language and limited interests. Development of the subject The first question that is appropriate to ask is: What are obsessions and compulsions? The individual suffers in the face of the presence of these thoughts and tries to reduce them and eliminate them through voluntary compulsions.

For example, a person plagued with doubts over whether he or she has shut off the gas attempts to neutralise the doubts by checking over and over to see if indeed the gas has been shut off. Examples are spasmodic movements of individual facial muscles, blinking, shrugging one's shoulders, etc. Examples are waving one's hands, rocking the body, snapping one's fingers, etc.

Abnormal attachment to and concern toward specific objects: persistent attachment to or disproportionate concern over an object which is at times unusual or part of it that is not used to provide the person calmness or security in a normal way, Such as persistent concern to carry a stick, a rubber glove, etc. Examples are insisting that the curtains remain open, that ornaments are always left in a specific position, always putting the same music on, etc.

An example is insisting on buying a newspaper each time that the individuals go to the newsagents, without it mattering if they had already bought one even when there is no interest in reading it. Examples are immediate or delayed echolalia, repetitive use of the same phrases or questions palilalia and verbal rituals.

An example is looking at maps and speaking every day even at all hours throughout the day about different countries and their flags although the person shows a lack of interest in seeing documentaries about these countries. Except for the cases in which, truly, both disorder are comorbid, the keys to proceed in the differential diagnosis are based in the emotional valence of the thought and the compulsion; the content of the obsessions and compulsions; the function of the obsessive-compulsive behaviour and of the restrictive and repetitive patterns of behaviour; and the psychological theories that explain both disorders.

The emotional valence of the thought and the compulsion In autism, the restricted and repetitive patterns of behaviour, interests or activities represent a pleasurable affective experience, intrinsically motivating and reinforcing. In this case, the definition of obsession does indeed correspond fully. Nevertheless, in the first case, when we speak of infancy and adolescence, there is a possibility that such obsessions and compulsions are not totally ego-dystonic.

Some of the difficulties that can arise in determining the differential diagnosis are as follows: variability in the degree of ego-dystonia among the people with OCD, and the fact that emotional valence is not currently a criterion in the DSM-IV-TR for the diagnosis of childhood OCD, when the diagnosis of ASD is made.

None of these examples given are symptoms of OCD although they suggest certain similarities with it. In both cases we seldom see interests centred on the area of the social world, such as what others tell us with their emotional expressions, forecasting how people will act, and understanding tricks, double meanings, lies, etc. The level of interference is generally proportional to the qualitative alteration of the adaptive and social-communicative alteration. However, these behaviours or mental operations are either not connected realistically with what the individual wants to neutralise, avoid or prevent, or the behaviours or mental operations are clearly excessive.

In some cases the individuals perform fixed or stereotyped acts in agreement with idiosyncratic personal rules without being able to indicate why they carry these acts out. If that is how it is, it is normal for these ritualistic and stereotyped behaviours to increase in people with ASD who are susceptible to experiencing higher levels of anxiety. The researchers suggested that this anxiety could have 3 different roles: 1 an inherent consequence of the symptoms of ASD for example, the stress that perceiving social rejections causes ; 2 a moderator of the severity of the ASD symptoms such as deficits in social abilities and the exacerbation that may occur to the repetitive behaviours ; and 3 an indicator of the nuclear symptoms of ASD.

With respect to attention, it is hypothesised that there is a selective attention towards stimuli related with the content of their obsessions, causing the person to be hypervigilant or making them unable to ignore the threatening information. The thoughts are not avoided but rather the total opposite, they do not threaten the individual's moral integrity or values, nor is there any need to control or reduce them. At this point it is important to clarify that cognitive flexibility and problems with response inhibition are not specific to individuals with ASD, but can also be manifested in patients with OCD.

In OCD the obsessions are intrusive, unacceptable, uncontrollable and ego-dystonic and provoke resistance against their appearance; in ASD this is not so except, of course, of cases in which there is comorbidity. In addition, the development of areas affected can be strengthened towards those that show little interest: language, specific games and social interaction. In contrast, habituation is indeed useful for people with OCD to reduce their compulsions.

We can only speak of obsessions in autism —and consequently, of ASD-OCD comorbidity —if these: a are experienced as recurrent and unwanted mental intrusions; b significant effort is expended to suppress, control or neutralise the thoughts; c the thoughts are recognised as a product of one's own mind; d there is an elevated sensation of personal responsibility; e they involve ego-dystonic content; and f they tend to be associated with neutralising efforts.

Conflict of interests The author has no conflict of interests to declare. Guillot, F. Furniss, A. Anxiety high-functioning children with autism. Autism, 5 , pp. Chalfant, R. Rapee, L. Treating anxiety disorders in children with high-functioning autism spectrum disorders: a controlled trial. J Autism Dev Disord, 37 , pp.

Van Steensel, S. Anxiety disorders in children and adolescents with autistic spectrum disorders: a meta-analysis. Clin Child Fam Psychol Rev, 14 , pp. Leyfer, S. Folstein, S. Bacalman, N. Davis, E.



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