Journal Article Annotations
2021, 4th Quarter

Hispanoamerican Psychiatry

Annotations by Katiuska Ramirez, MD and Carlos Fernandez Robles, MD
December, 2021

The Psychiatric Misdiagnosis of Behavioral Variant Frontotemporal Dementia in a Colombian Sample.
Epidemiology and factors associated with acute stress disorder in burned patients: a case-control study.

PUBLICATION #1 — Hispanoamerican Psychiatry

The Psychiatric Misdiagnosis of Behavioral Variant Frontotemporal Dementia in a Colombian Sample.

Lina Zapata-Restrepo, Juan Rivas, Carlos Miranda, Bruce L Miller, Agustín Ibanez, Isabel E Allen, Katherine Possin

Abstract: Front Neurol. 2021 Nov 15;12:729381. doi: 10.3389/fneur.2021.729381. eCollection 2021.

Objective:
To describe the demographic characteristics, initial psychiatric diagnoses, and the time to reach a diagnosis of probable behavioral variant frontotemporal dementia (bvFTD) in a public psychiatric hospital in Cali, Colombia.

Methods:
We retrospectively reviewed the medical records of 28 patients who were diagnosed with probable bvFTD based on a multidisciplinary evaluation that included a structural MRI, neuropsychological testing, functional assessment, and neurological exam. Prior to this evaluation, all patients were evaluated by a psychiatrist as part of their initial consultation at the hospital. The initial consultation included the Neuropsychiatric Inventory and diagnoses based on the DSM-V. Demographics, clinical features, and initial psychiatric misdiagnoses were extracted from clinical records and summarized in the full sample and by gender.

Results:
The study sample had a mean education of 10.0 years (SD = 4.9) and 68.0% were female. In the full sample, 28.6% were initially diagnosed with dementia, and 71.4% with a psychiatric disorder. The psychiatric diagnosis at initial consultation differed by gender. Women were most likely to be diagnosed with depression (26.3%) or bipolar disorder (26.3%), while the men were most likely to be diagnosed with anxiety (33.3%) or a psychotic disorder (22.2%). Psychotic symptoms were common (delusions, 60.7% and hallucinations, 39.3%), and the pattern of neuropsychiatric symptoms did not differ by gender.

Conclusions:
This is one of few case series of bvFTD in a Colombian population, where bvFTD is a recognizable and prevalent disorder. In this psychiatric hospital, the majority of patients with bvFTD were initially diagnosed with a primary psychiatric condition. There was a gender difference in psychiatric diagnosis, but not in neuropsychiatric symptoms. In this sample, the rate of psychiatric misdiagnosis, as well as the psychotic symptoms, were higher compared to rates described in other countries. These results highlight the need for interventions to improve bvFTD diagnosis in under-represented populations.

Annotation

The finding:
This is a retrospective study of 28 patients, consisting of 19 women and 9 men, diagnosed with probable behavioral variant frontal temporal dementia (bvFTD) at a public psychiatric hospital in Cali, Columbia. Of the study population, 71.4% of patients were incorrectly diagnosed with psychiatric disorders at the time of their initial evaluation. Women were more likely to be initially diagnosed with depression and bipolar disorder while men were more likely to be diagnosed with an anxiety disorder or a psychotic disorder. The average amount of time between the onset of neuropsychiatric symptoms to the diagnosis of bvFTD was 4.3 years, which is similar to prior North American and European studies. Additionally, the study demonstrated a disproportionate level of caregiver burden for women caring for patients with bvFTD compared to male caregivers.

Strength and weaknesses:
The retrospective nature of this study is a potential limitation given possible deficits in documentation or variations in diagnostic assessments. Having assessments completed by psychiatrists may also introduce a diagnostic bias into the study design. Additionally, the distribution of men and women in the study was skewed, which may limit generalizability. A notable strength of the study is its use of a diverse Latin American population with Indigenous, African, and European backgrounds and lower socioeconomic status and educational background.

Relevance:
C-L psychiatrists are frequently asked to help distinguish between primary mood or psychotic disorders and other neuropsychiatric disorders or general medical conditions. Behavioral variant frontotemporal dementia (bvFTD) can be especially challenging in this regard given overlapping symptoms seen in bvFTD and primary psychiatric disorders. In the study, rates of misdiagnosis were found to be higher in this population compared to studies conducted in higher-income countries. The authors explore potential causes of this discrepancy including lower public awareness about dementia, a gap in professional training in this area, and limited access to resources including biomarkers used in diagnostic work-up.

PUBLICATION #2 — Hispanoamerican Psychiatry

Epidemiology and factors associated with acute stress disorder in burned patients: a case-control study.

Alejandra Tamayo-Gómez, Juliana Velásquez-Suárez, Lina Páramo-Duque, Diana Ortiz-Carmona, Lina Escobar-Gómez, Vladimir Cortés-López, Carlos Federico Molina-Castaño, Carlos Cardeno-Castro

Abstract: Burns. 2021 Oct 4;S0305-4179(21)00272-2. doi: 10.1016/j.burns.2021.09.024. Online ahead of print.

Introduction:
A burn injury is a very painful experience, with subsequent emotional problems, which have been gaining relevance to the extent that survival from burns has improved. Among the alterations of the mental sphere in this population is Acute Stress Disorder (ASD) that has been described in up to one-third of patients with major burns.

Methodology:
A nested case-control study was carried out in a cohort of hospitalized patients in a burn referral unit, in patients over 16 years of age. A total of 135 patients, 41 cases, and 94 controls were included. All of them underwent a psychiatric interview, a standardized form was filled out on sociodemographic and clinical information, and the PID-5-BF scale was applied to evaluate associated personality elements. The diagnosis of acute stress was made with the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria.

Results:
The incidence of acute stress was 23.4%. When the clinical and sociodemographic characteristics of both the cases and the controls were compared, the risk factors were subsidized insurance, flame burn, burn in a special area, third-degree burn, high pain, stay in the Intensive Care Unit (ICU), peritraumatic amnesia and life threat. Patients also had a higher percentage of burned body surface, higher average pulse, longer hospital length of stay, higher average in the negative affect variable and in the psychoticism variable of the PID-5-BF scale. But for the multivariate analysis using logistic regression, the model that best explains the presence of acute stress only includes the variables life threat (Odds Ratio adjusted (ORa): 117.0; Confidence Interval (CI): 10.9-1258.5), severe pain (ORa: 9.9; CI: 1.8-52.8), electrical burn (ORa: 20.8; CI: 17.2-250), burn in a special area (ORa: 8.9; CI: 1, 0-76.8), third-degree burn (ORa: 10.4; CI: 0.7-166.7).

Conclusion:
Acute stress disorder is frequent in the hospitalised burn population, and is more frequent than in other types of trauma. Associated factors with the presentation of Acute Stress Disorder are the feeling of life threat at the time of the burn, having pain classified as strong (Visual Analog Scale (VAS) 5-10), electrical burn, and burns in special areas.

Keywords: Acute stress disorder; Burn; Risk factors.

Annotation

The finding
Acute stress disorder (ASD) in hospitalized burn patients was 23.4%, comparable to other studies and higher than reported for other forms of trauma such as car accidents and rape victims. A feeling of life-threat (an individual’s subjective interpretation of the risk of death) was the highest risk factor for the development of ASD. This personal experience is independent of the severity of the injury. Other factors associated with the presentation of ASD in the burned patient include severe pain, electrical burn, and burn in special areas such as the face, hands, genitals, and joints.

Strengths and weaknesses
This well-designed and well-powered nested case-control study carried out in a burn unit allows for the early and adequate collection of information and close monitoring of each case and adequately analyses the different observed variables. One of the significant limitations is that most severe cases missed enrolment requirements due to sedation related to prolonged ICU stays or could not provide potentially valuable information. Finally, objective evaluation of reliability was not carried out among the evaluators; however, all raters were trained CL psychiatrists, which may mitigate this issue.

Relevance
This is a high-quality study with the largest number of participants in a disorder (ASD) that is poorly described in the scientific literature. Given that this study was conducted entirely in an inpatient burn unit is of crucial importance to C-L psychiatrists. They should use these findings to inform their treatment decisions and plan for early interventions, particularly for those identified as high risk for ASD. In turn, these early interventions can help reduce rates of PTSD in this population. This work reflects the high-quality research being conducted in South America and the opportunity for meaningful collaborations in C-L psychiatry across national borders.