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Infante S, Behn A, González M, Pintor L, Franco E, Araya P, Maldonado JR. Reliability and Validity of the Spanish Adaptation of the Stanford Proxy Test for Delirium in Two Clinical Spanish-Speaking Communities. J Acad Consult Liaison Psychiatry 2024; 65:136-147. [PMID: 37806639 DOI: 10.1016/j.jaclp.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Delirium is the most prevalent neuropsychiatric syndrome experienced by patients admitted to inpatient clinical units, occurring in at least 20% of medically hospitalized patients and up to 85% of those admitted to critical care units. Although current guidelines recommend the implementation of universal prevention strategies, the use of management strategies largely depends on constant surveillance and screening. This allows for the timely diagnosis and correction of its underlying causes and implementation of management strategies. OBJECTIVE It was to adapt and analyze the Spanish adaptation of the Stanford Proxy Test for Delirium (S-PTDsv) instrument for its use among Spanish-speaking populations. The S-PTD is an instrument consisting of 13 observational items to be completed by a clinician observer, usually the patient's nurse. The completion of the questionnaire takes about 1 minute and does not require the active participation of the person evaluated, which has important clinical advantages compared to other available instruments (e.g., the Confusion Assessment Method). METHODS The psychometric properties of the S-PTDsv were evaluated in a population of 123 patients using a quantitative, cross-sectional design. All subjects were over 18 years of age and hospitalized in various inpatient medico-surgical and intensive care unit services, either at the Barcelona Clinical Hospital (Barcelona, Spain) or the UC-Christus Health Network Clinical Hospital (Santiago, Chile, S.A.). The ultimate diagnosis of delirium was made by a member of the Psychiatry Consult Service by means of an independent neuropsychiatric evaluation based on the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria, published in 2013, which is the latest version of the diagnostic manual. All study tests were performed by study personnel who were blinded to each other's test results within an hour of each other. RESULTS In the receiver operator characteristic (ROC) curve analysis, the S-PTDsv demonstrated excellent classification qualities when compared with the DSM-5 as the classification reference standard. Using a cutoff point of ≥3, the S-PTDsv had a sensitivity of 94% and a specificity of 97%. The area under the curve indicator was equal to 0.95, suggesting the S-PTDsv has an excellent overall performance in accurately identifying cases of delirium. Accordingly, the S-PTDsv's positive predictive value = 0.93, and the negative predictive value = 0.97. The internal reliability measured with Cronbach's alpha was 0.96. Confirmatory factor analysis revealed a 1-dimensional structure with high loadings (>0.72), demonstrating that all items similarly contribute to the total diagnostic dimension, suggesting adequate construct validity. This provided evidence of convergent validity. CONCLUSIONS The performance of the S-PTDsv, as compared to a blinded neuropsychiatric assessment based on DSM-5, indicates that it is an effective instrument for the detection of delirium, in the Spanish-speaking populations. These results are comparable and consistent with previously published studies in the English language version.
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Affiliation(s)
- Sanndy Infante
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile; Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile; School of Psychology, Pontifical University of Chile, Santiago, Chile.
| | - Alex Behn
- Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile; School of Psychology, Pontifical University of Chile, Santiago, Chile
| | - Matías González
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile; Health Service of Reloncaví, Puerto Montt, Chile
| | - Luis Pintor
- Department of Psychiatry, Hospital Clinic of Barcelona, Barcelona, Spain; School Medicine, University of Barcelona, Barcelona, Spain
| | - Eduardo Franco
- Research Department, Universidad Maria Auxiliadora, Lima, Peru
| | - Pablo Araya
- Department of Psychiatry, Pontifical Catholic University of Chile School of Medicine, Santiago, Chile
| | - José R Maldonado
- Division of Medical Psychiatry, Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Stanford, CA.
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Zimmermann R, Konjufca J, Sakejo P, Kilonzo M, Quevedo Y, Blum K, Biba E, Mosha T, Cottin M, Hernández C, Kaaya S, Arenliu A, Behn A. Mental Health Information Reporting Assistant (MHIRA)-an open-source software facilitating evidence-based assessment for clinical services. BMC Psychiatry 2023; 23:706. [PMID: 37784115 PMCID: PMC10544613 DOI: 10.1186/s12888-023-05201-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 09/18/2023] [Indexed: 10/04/2023] Open
Abstract
Evidence-based assessment (EBA) in mental health is a critical aspect of improving patient outcomes and addressing the gaps in mental health care. EBA involves the use of psychometric instruments to gather data that can inform clinical decision-making, inform policymakers, and serve as a basis for research and quality management. Despite its potential, EBA is often hindered by barriers such as workload and cost, leading to its underutilization. Regarding low- and middle-income countries (LMIC), the implementation of EBA is recognized as a key strategy to address and close the prevalent mental health treatment gap.To simplify the application of EBA including in LMIC, an international team of researchers and practitioners from Tanzania, Kosovo, Chile, and Switzerland developed the Mental Health Information Reporting Assistant (MHIRA). MHIRA is an open-source electronic health record that streamlines EBA by digitising psychometric instruments and organising patient data in a user-friendly manner. It provides immediate and convenient reports to inform clinical decision-making.The current article provides a comprehensive overview of the features and technical details of MHIRA, as well as insights from four implementation scenarios. The experience gained during the implementations as well as the user-feedback suggests that MHIRA has the potential to be successfully implemented in a variety of clinical contexts and simplify the use of EBA. However, further research is necessary to establish its potential to sustainably transform healthcare services and impact patient outcomes.In conclusion, MHIRA represents an important step in promoting the widespread adoption of EBA in mental health. It offers a promising solution to the barriers that have limited the use of EBA in the past and holds the potential to improve patient outcomes and support the ongoing efforts to address gaps in mental health care.
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Affiliation(s)
- Ronan Zimmermann
- Psychiatric University Hospitals of Basel, Basel, Switzerland.
- Faculty of Psychology, University of Basel, Basel, Switzerland.
| | - Jon Konjufca
- Faculty of Psychology, University of Basel, Basel, Switzerland
- University of Prishtina "Hasan Prishtina", Pristina, Kosovo
| | - Peter Sakejo
- Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Mrema Kilonzo
- Faculty of Psychology, University of Basel, Basel, Switzerland
- Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Yamil Quevedo
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
| | - Kathrin Blum
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
| | | | | | - Marianne Cottin
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
- Universidad Finis Terrae, Santiago, Chile
| | - Cristóbal Hernández
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
- Universidad Adolfo Ibáñez, Santiago, Chile
| | - Sylvia Kaaya
- Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | | | - Alex Behn
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
- Pontificia Universidad Católica de Chile, Santiago, Chile
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3
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Davanzo A, D Huart D, Seker S, Moessner M, Zimmermann R, Schmeck K, Behn A. Study Features and Response Compliance in Ecological Momentary Assessment Research in Borderline Personality Disorder: Systematic Review and Meta-analysis. J Med Internet Res 2023; 25:e44853. [PMID: 36920466 PMCID: PMC10131785 DOI: 10.2196/44853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/17/2023] [Accepted: 01/31/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Borderline personality disorder (BPD) is characterized by frequent and intense moment-to-moment changes in affect, behavior, identity, and interpersonal relationships, which typically result in significant and negative deterioration of the person's overall functioning and well-being. Measuring and characterizing the rapidly changing patterns of instability in BPD dysfunction as they occur in a person's daily life can be challenging. Ecological momentary assessment (EMA) is a method that can capture highly dynamic processes in psychopathology research and, thus, is well suited to study intense variability patterns across areas of dysfunction in BPD. EMA studies are characterized by frequent repeated assessments that are delivered to participants in real-life, real-time settings using handheld devices capable of registering responses to short self-report questions in daily life. Compliance in EMA research is defined as the proportion of prompts answered by the participant, considering all planned prompts sent. Low compliance with prompt schedules can compromise the relative advantages of using this method. Despite the growing EMA literature on BPD in recent years, findings regarding study design features that affect compliance with EMA protocols have not been compiled, aggregated, and estimated. OBJECTIVE This systematic meta-analytic review aimed to investigate the relationship between study design features and participant compliance in EMA research of BPD. METHODS A systematic review was conducted on November 12, 2021, following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analyses of Observational Studies in Epidemiology) guidelines to search for articles featuring EMA studies of BPD that reported compliance rates and included sufficient data to extract relevant design features. For studies with complete data, random-effect models were used to estimate the overall compliance rate and explore its association with design features. RESULTS In total, 28 peer-reviewed EMA studies comprising 2052 participants were included in the study. Design features (sampling strategy, average prompting frequency, number of items, response window, sampling device, financial incentive, and dropout rate) showed a large variability across studies, and many studies did not report design features. The meta-analytic synthesis was restricted to 64% (18/28) of articles and revealed a pooled compliance rate of 79% across studies. We did not find any significant relationship between design features and compliance rates. CONCLUSIONS Our results show wide variability in the design and reporting of EMA studies assessing BPD. Compliance rates appear to be stable across varying setups, and it is likely that standard design features are not directly responsible for improving or diminishing compliance. We discuss possible nonspecific factors of study design that may have an impact on compliance. Given the promise of EMA research in BPD, we also discuss the importance of unifying standards for EMA reporting so that data stemming from this rich literature can be aggregated and interpreted jointly.
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Affiliation(s)
- Antonella Davanzo
- Escuela de Psicología, Pontificia Universidad Católica de Chile, Instituto Milenio para la Investigación en Depresión y Personalidad, Santiago, Chile
| | - Delfine D Huart
- Department of Child and Adolescent Psychiatry Research, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Süheyla Seker
- Department of Child and Adolescent Psychiatry Research, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Markus Moessner
- University Hospital Heidelberg, Center for Psychotherapy Research, Heidelberg, Germany
| | - Ronan Zimmermann
- Department of Child and Adolescent Psychiatry Research, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Klaus Schmeck
- Department of Child and Adolescent Psychiatry Research, University Psychiatric Clinics, University of Basel, Basel, Switzerland
| | - Alex Behn
- Escuela de Psicología, Pontificia Universidad Católica de Chile, Instituto Milenio para la Investigación en Depresión y Personalidad, Santiago, Chile
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Ellison WD, Huprich S, Behn A, Goodman M, Kerr S, Levy KN, Nelson SM, Sharp C. Attitudes, Clinical Practices, and Perceived Advocacy Needs of Professionals With Interests in Personality Disorders. J Pers Disord 2023; 37:1-15. [PMID: 36723421 DOI: 10.1521/pedi.2023.37.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Experts in personality disorders (PDs) generally prefer dimensional diagnostic systems to categorical ones, but less is known about experts' attitudes toward personality pathology diagnoses in adolescents, and little is known about public health shortfalls and advocacy needs and how these might differ geographically. To fill these gaps, the International Society for the Study of Personality Disorders surveyed 248 professionals with interests in PDs about their attitudes toward different diagnostic systems for adults and adolescents, their PD-related clinical practices, and perceived advocacy needs in their area. Results suggested that dimensional diagnostic systems are preferable to categorical and that skepticism about personality pathology in adolescents may not be warranted. The most pressing advocacy need was the increased availability of PD-related services, but many other needs were identified. Results provide a blueprint for advocacy and suggest ways that professional societies can collaborate with public health bodies to expand the reach of PD expertise and services.
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Affiliation(s)
| | - Steven Huprich
- Department of Psychology, University of Detroit Mercy, Detroit, Michigan
| | - Alex Behn
- School of Psychology, Pontificia Universidad Católica de Chile and Millennium Institute for Research in Depression and Personality, Santiago, Chile
| | - Marianne Goodman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, Bronx, New York
| | - Sophie Kerr
- Department of Psychology, University of Houston, Houston, Texas
| | - Kenneth N Levy
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania
| | - Sharon M Nelson
- Serious Mental Illness Treatment, Resource, and Evaluation Center, Veterans Health Administration, Ann Arbor, Michigan
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, Texas
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5
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Natoli AP, Bach B, Behn A, Cottin M, Gritti ES, Hutsebaut J, Lamba N, Le Corff Y, Zimmermann J, Lapalme M. Multinational evaluation of the measurement invariance of the Level of Personality Functioning Scale-brief form 2.0: Comparison of student and community samples across seven countries. Psychol Assess 2022; 34:1112-1125. [PMID: 36107669 DOI: 10.1037/pas0001176] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2024]
Abstract
The Diagnostic and Statistical Manual of Mental Disorders-fifth Edition's (DSM-5) Level of Personality Functioning Scale (LPFS) was introduced as a dimensional rating of impairments in self- and interpersonal functioning, and the LPFS-Brief Form (LPFS-BF) was the first published corresponding self-report. The updated LPFS-BF 2.0 has been translated into several languages and international research supports many of the instrument's psychometric properties; however, its measurement invariance has only been evaluated across a few countries. This study expands previous studies as an introductory step in a global evaluation of the LPFS-BF 2.0s measurement invariance. Archival data (N = 5,618, 57% female) from seven countries (Canada, Chile, Denmark, Germany, Italy, United Arab Emirates, United States of America) were used for this study. Participants were recruited from both community (n = 4,677) and student (n = 941) populations. After confirming adequate model fit separately in the community and student samples, we evaluated a series of increasingly stringent model comparisons to test three aspects of measurement invariance (configural, metric, scalar) and then examined latent mean differences across countries. Full scalar invariance was supported in the community sample and partial scalar invariance was supported in the student sample. Evaluation of latent mean differences revealed multiple significant differences. Overall, the LPFS-BF 2.0 appears to assess self- and interpersonal functioning impairment similarly across the included countries. Findings are discussed through the lenses of the cultures from which participants were recruited, as well as in the context of alternative explanations. Limitations, plans for future research, and implications for both research and clinical practice are offered. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Adam P Natoli
- Department of Psychology and Philosophy, Sam Houston State University
| | - Bo Bach
- Center for Personality Disorder Research, Psychiatric Research Unit, Region Zealand
| | - Alex Behn
- School of Psychology, Pontificia Universidad Catolica de Chile
| | - Marianne Cottin
- Millennium Institute for Research in Depression and Personality
| | - Emanuela S Gritti
- Department of Developmental Psychology and Socialization, University of Padova
| | | | - Nishtha Lamba
- Department of Psychology, Middlesex University Dubai
| | - Yann Le Corff
- Groupe de Recherche et d'Intervention sur les Adaptations Sociales de l'Enfance, Departement d'Orientation Professionnelle, Universite de Sherbrooke
| | | | - Mélanie Lapalme
- Groupe de Recherche et d'Intervention sur les Adaptations Sociales de l'Enfance, Departement de Psychoeducation, Universite de Sherbrooke
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6
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Cottin M, Blum K, Konjufca J, Quevedo Y, Kaaya S, Behn A, Schmeck K, Sharp C, Zimmermann R. Digital use of standardised assessment tools for children and adolescents: can available paper-based questionnaires be used free of charge in electronic format? BMC Psychiatry 2022; 22:379. [PMID: 35659275 PMCID: PMC9166519 DOI: 10.1186/s12888-022-04023-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022] Open
Abstract
QUESTION Most adolescents live in low- and middle-income countries (LMIC), and about 10% of them face mental problems. The mental health provision gap in low- and middle-income countries could be addressed by evidence-based practices, however costs are implementational barriers. Digitalization can improve the accessibility of these tools and constitutes a chance for LMIC to use them more easily at a low cost. We reviewed free and brief evidence-based mental health assessment tools available for digital use to assess psychopathology across different domains in youth. METHODS For the current study, instruments from a recent review on paper-based instruments were re-used. Additionally, a systematic search was conducted to add instruments for the personality disorder domain. We searched and classified the copyright and license terms available from the internet in terms of free usage and deliverability in a digital format. In the case that this information was insufficient, we contacted the authors. RESULTS In total, we evaluated 109 instruments. Of these instruments, 53 were free and digitally usable covering 11 mental health domains. However, retrieving information on copyright and license terms was very difficult. CONCLUSIONS Free and digitally adaptable instruments are available, supporting the strategy of using instruments digitally to increase access. The instrument's authors support this initiative, however, the lack of copyright information and the difficulties in contacting the authors and licence holders are barriers to using this strategy in LMIC. A comprehensive, online instrument repository for clinical practice would be an appropriate next step to make the instruments more accessible and reduce implementation barriers.
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Affiliation(s)
- Marianne Cottin
- grid.488997.3Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile ,grid.443909.30000 0004 0385 4466Department of Psychiatry East Campus, Faculty of Medicine, University of Chile, Santiago, Chile ,grid.440629.d0000 0004 5934 6911School of Psychology, Finis Terrae University, Santiago, Chile ,grid.7870.80000 0001 2157 0406School of Psychology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Kathrin Blum
- grid.6612.30000 0004 1937 0642Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals of the University of Basel, Basel, Switzerland
| | - Jon Konjufca
- grid.449627.a0000 0000 9804 9646University of Prishtina, Pristina, Kosovo ,grid.6612.30000 0004 1937 0642Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Yamil Quevedo
- grid.488997.3Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile ,grid.443909.30000 0004 0385 4466Department of Psychiatry East Campus, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Sylvia Kaaya
- grid.25867.3e0000 0001 1481 7466Department of Psychiatry and Mental Health, School of Medicine, Muhimbili University of Health and Allied Science, Dar es Salaam, Tanzania ,grid.266436.30000 0004 1569 9707Department of Psychology, University of Houston, Houston, TX USA
| | - Alex Behn
- grid.488997.3Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile ,grid.7870.80000 0001 2157 0406School of Psychology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Klaus Schmeck
- grid.6612.30000 0004 1937 0642Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals of the University of Basel, Basel, Switzerland ,grid.6612.30000 0004 1937 0642Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Carla Sharp
- grid.266436.30000 0004 1569 9707Department of Psychology, University of Houston, Houston, TX USA
| | - Ronan Zimmermann
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals of the University of Basel, Basel, Switzerland. .,Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland.
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Krause M, Behn A. Case formulation as a bridge between theory, clinical practice, and research: A commentary. J Clin Psychol 2022; 78:454-461. [PMID: 35194795 DOI: 10.1002/jclp.23328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 11/10/2022]
Abstract
This commentary section is based on a comparative analysis of the five articles and case examples presented in this special issue. The place of Case Formulation in the field of psychotherapy is conceptualized as a necessary bridge between diagnostic systems and clinical practice. The common aspects of the five approaches included in the issue, as well as of the cases to which they were applied, are discussed to explore their possible cross-theoretical nature, especially in psychotherapy with more severe cases. All the clients presented in this section have experienced traumas, which manifest themselves as difficulties in their interpersonal relationships. We discuss the value of Case Formulation in the context of clinical practice and research as well as the challenges of fostering the cross-theoretical approach of this tool.
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Affiliation(s)
- Mariane Krause
- Millennium Institute for Research in Depression and Personality, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alex Behn
- Millennium Institute for Research in Depression and Personality, Pontificia Universidad Católica de Chile, Santiago, Chile
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Hernández C, Cottin M, Parada F, Labbé N, Núñez C, Quevedo Y, Davanzo A, Behn A. Watching the world from my screen: A longitudinal evaluation of the influence of a problematic use of the internet on depressive symptomatology. Computers in Human Behavior 2022. [DOI: 10.1016/j.chb.2021.106995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Ronningstam E, Simonsen E, Chanen A, Herpertz SC, Huprich S, Newton-Howes G, Behn A, Doering S, Zanarini MC, Sharp C, Oldham J. ISSPD: Past, Present, and Future. J Pers Disord 2021:1-18. [PMID: 34491079 DOI: 10.1521/pedi.2021.35.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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10
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Gloger S, Vöhringer PA, Martínez P, Chacón MV, Cáceres C, Diez de Medina D, Cottin M, Behn A. The contribution of early adverse stress to complex and severe depression in depressed outpatients. Depress Anxiety 2021; 38:431-438. [PMID: 33621410 DOI: 10.1002/da.23144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/16/2020] [Accepted: 02/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess whether linear effects or threshold effects best describe the association between early adverse stress (EAS) and complex and severe depression (i.e., depression with treatment resistance, psychotic symptoms, and/or suicidal ideation), and to examine the attributable risk of complex and severe depression associated with EAS. METHODS A cross-sectional study was conducted using deidentified clinical data (on demographics, presence of complex and severe depression, and exposure to seven types of EAS) from 1,013 adults who were seen in an outpatient mental health clinic in Santiago, Chile, for a major depressive episode. Multivariate logistic regressions were fitted to estimate odds ratios (ORs), using a bootstrap approach to compute 95% bias-corrected confidence intervals (95% BC CIs). A detailed examination of the cumulative risk score and calculations of the attributable risk was conducted. RESULTS Exposure to at least five EASs was reported by 3.6% of the sample. In the multivariate logistic regression models, there was a marked increase in the odds of having complex and severe depression associated with exposure to at least five EASs (OR = 4.24; 95% BC CI: 1.25 to 9.09), according to a threshold effect. The attributable risk of complex and severe depression associated with exposure to at least one EAS was 36.8% (95% BC CI: 17.7 to 55.9). CONCLUSIONS High levels of EAS distinctively contribute to complex clinical presentations of depression in adulthood. Patients with complex clinical presentations of depression and history of EAS should need a differentiated treatment approach, particularly those having high levels of EAS.
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Affiliation(s)
- Sergio Gloger
- Psicomedica, Clinical & Research Group, Santiago, Chile.,Departamento de Psiquiatría y Salud Mental Campus Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Paul A Vöhringer
- Psicomedica, Clinical & Research Group, Santiago, Chile.,Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile.,Departamento de Psiquiatría y Salud Mental, Hospital Clínico Universidad de Chile, Santiago, Chile.,Mood Disorders Program, Tufts Medical Center, Boston, Massachusetts, USA.,Department of Psychiatry, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Pablo Martínez
- Psicomedica, Clinical & Research Group, Santiago, Chile.,Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile.,Departamento de Psiquiatría y Salud Mental, Hospital Clínico Universidad de Chile, Santiago, Chile.,Núcleo Milenio para Mejorar la Salud Mental de Adolescentes y Jóvenes (Imhay), Santiago, Chile
| | - M Victoria Chacón
- Psicomedica, Clinical & Research Group, Santiago, Chile.,Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
| | - Cristian Cáceres
- Psicomedica, Clinical & Research Group, Santiago, Chile.,Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
| | | | - Marianne Cottin
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile.,Escuela de Psicología, Pontificia Universidad Católica de Chile, Santiago, Chile.,Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Escuela de Psicología, Universidad Finis Terrae, Santiago, Chile
| | - Alex Behn
- Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile.,Escuela de Psicología, Pontificia Universidad Católica de Chile, Santiago, Chile
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Cottin M, Hernández C, Núñez C, Labbé N, Quevedo Y, Davanzo A, Behn A. "What If We Get Sick?": Spanish Adaptation and Validation of the Fear of Illness and Virus Evaluation Scale in a Non-clinical Sample Exposed to the COVID-19 Pandemic. Front Psychol 2021; 12:590283. [PMID: 33776833 PMCID: PMC7990903 DOI: 10.3389/fpsyg.2021.590283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/25/2021] [Indexed: 11/17/2022] Open
Abstract
Distinct sources of stress have emerged during the COVID-19 pandemic. Particularly, fear is expected to generate significant psychological burden on individuals and influence on either unsafe behavior that may hinder recovery efforts or virus-mitigating behaviors. However, little is known about the properties of measures to capture them in research and clinical settings. To resolve this gap, we evaluated the psychometric properties of a novel measure of fear of illness and viruses and tested its predictive value for future development of distress. We extracted a random sample of 450 Chilean adult participants from a large cross-sectional survey panel and invited to participate in this intensive longitudinal study for 35 days. Of these, 163 ended up enrolling in the study after the demanding nature of the measurement schedule was clearly explained to them. For this final sample, we calculated different Confirmatory Factor Analyses (CFA) to evaluate the preliminary proposed structure for the instrument. Complementarily, we conducted a content analysis of the items to qualitatively extract its latent structure, which was also subject to empirical test via CFA. Results indicated that the original structure did not fit the data well; however, the new proposed structure based on the content analysis did. Overall, the modified instrument showed good reliability through all subscales both by its internal consistency with Cronbach's alphas ranging from 0.814 to 0.913, and with test-retest correlations ranging from 0.715 to 0.804. Regarding its convergent validity, individuals who scored higher in fears tended to also score higher in depressive and posttraumatic stress symptoms at baseline. Furthermore, higher fears at baseline predicted a higher score in posttraumatic stress symptomatology 7 days later. These results provide evidence for the validity, reliability, and predictive performance of the scale. As the scale is free and multidimensional potentially not circumscribed to COVID-19, it might work as a step toward understanding the psychological impact of current and future pandemics, or further life-threatening health situations of similar characteristics. Limitations, practical implications, and future directions for research are discussed.
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Affiliation(s)
- Marianne Cottin
- Facultad de Medicina, Universidad de Chile, Santiago, Chile
- Escuela de Psicología, Universidad Finis Terrae, Santiago, Chile
- Instituto Milenio para la Investigación en Depresión y Personalidad, MIDAP, Santiago, Chile
| | - Cristóbal Hernández
- Instituto Milenio para la Investigación en Depresión y Personalidad, MIDAP, Santiago, Chile
- Escuela de Psicología, Universidad Adolfo Ibáñez, Santiago, Chile
| | - Catalina Núñez
- Instituto Milenio para la Investigación en Depresión y Personalidad, MIDAP, Santiago, Chile
- Facultad de Ciencias Sociales, Escuela de Psicología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicolás Labbé
- Instituto Milenio para la Investigación en Depresión y Personalidad, MIDAP, Santiago, Chile
- Facultad de Ciencias Sociales, Escuela de Psicología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Yamil Quevedo
- Instituto Milenio para la Investigación en Depresión y Personalidad, MIDAP, Santiago, Chile
- Departamento de Psiquiatría y Salud Mental Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Antonella Davanzo
- Instituto Milenio para la Investigación en Depresión y Personalidad, MIDAP, Santiago, Chile
- Facultad de Ciencias Sociales, Escuela de Psicología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alex Behn
- Instituto Milenio para la Investigación en Depresión y Personalidad, MIDAP, Santiago, Chile
- Facultad de Ciencias Sociales, Escuela de Psicología, Pontificia Universidad Católica de Chile, Santiago, Chile
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Gloger S, Martínez P, Behn A, Chacón MV, Cottin M, Diez de Medina D, Vöhringer PA. Population-attributable risk of adverse childhood experiences for high suicide risk, psychiatric admissions, and recurrent depression, in depressed outpatients. Eur J Psychotraumatol 2021; 12:1874600. [PMID: 34025917 PMCID: PMC8118528 DOI: 10.1080/20008198.2021.1874600] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Population-attributable risk (PAR) may help estimate the potential contribution of adverse childhood experiences (ACEs) to serious clinical presentations of depression, characterized by suicidality, previous psychiatric admissions, and episode recurrence. Objective: To determine the PAR of ACEs for serious clinical presentations of depression (high suicide risk, previous psychiatric admissions, and recurrent depression) in outpatients with ICD-10 clinical depression. Method: Systematic chart review of 1,013 adults who were assessed and/or treated in a mental health clinic in Santiago, Chile for a major depressive episode. Data were collected on demographics and clinical characteristics of depression. Exposure to ACEs was determined with the Brief Physical and Sexual Abuse Questionnaire, assessing seven types of ACEs. Multivariable logistic regression analysis was used to assess the association between exposure to ACEs and suicidality, previous psychiatric admissions, and recurrence. Predicted probabilities were used for calculations of PAR. Results: Of the 1,001 study participants with complete data, 53.3% had recurrent depression, 13.5% had high suicide risk, and 5.0% had previous psychiatric admissions. Exposure to at least one ACE was recorded for 69.0% of the sample. Exposure to at least one ACE and specific types of ACEs (i.e. childhood sexual abuse and traumatic separation from caregiver) were associated with serious clinical presentations of depression. A dose-response relationship was observed between cumulative exposure to ACEs and the most serious clinical presentations of depression. ACEs were attributed to a significant proportion of disease: 61.6% of previous psychiatric admissions, 45.0% of high suicide risk, and 14.5% of recurrent depression. Conclusions: A substantial proportion of serious clinical presentations of depression among outpatients are associated with ACEs. Early detection of depressive episodes associated with ACEs, and tailored treatment for these patients, may potentially reduce the incidence of serious complications in this population.
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Affiliation(s)
- Sergio Gloger
- Psicomedica, Clinical & Research Group, Santiago, Chile.,Departamento de Psiquiatría y Salud Mental Campus Oriente, Facultad de Medicina, Universidad de Chile, Santiago, Chile.,ANID, Millennium Science Initiative Program, Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
| | - Pablo Martínez
- Psicomedica, Clinical & Research Group, Santiago, Chile.,ANID, Millennium Science Initiative Program, Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile.,Departamento de Psiquiatría y Salud Mental, Hospital Clínico Universidad de Chile, Santiago, Chile.,ANID, Millennium Science Initiative Program, Millennium Nucleus to Improve the Mental Health of Adolescents and Youths, Imhay, Santiago, Chile.,Escuela de Psicología, Facultad de Humanidades, Universidad de Santiago de Chile, Santiago, Chile.,CITIAPS, Universidad de Santiago de Chile, Santiago, Chile
| | - Alex Behn
- ANID, Millennium Science Initiative Program, Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile.,Escuela de Psicología, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - M Victoria Chacón
- Psicomedica, Clinical & Research Group, Santiago, Chile.,ANID, Millennium Science Initiative Program, Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile
| | - Marianne Cottin
- ANID, Millennium Science Initiative Program, Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile.,Escuela de Psicología, Pontificia Universidad Católica de Chile, Santiago, Chile.,Facultad de Medicina, Universidad de Chile, Santiago, Chile.,Escuela de Psicología, Universidad Finis Terrae, Santiago, Chile
| | | | - Paul A Vöhringer
- Psicomedica, Clinical & Research Group, Santiago, Chile.,ANID, Millennium Science Initiative Program, Millennium Institute for Depression and Personality Research (MIDAP), Santiago, Chile.,Departamento de Psiquiatría y Salud Mental, Hospital Clínico Universidad de Chile, Santiago, Chile.,Mood Disorders Program, Tufts Medical Center, Boston, MA, USA.,Department of Psychiatry, Tufts University School of Medicine, Boston, MA, USA
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Behn A, Vöhringer PA, Martínez P, Domínguez AP, González A, Carrasco MI, Gloger S. Validación de la versión en español del Childhood Trauma Questionnaire-Short Form en Chile, en una muestra de pacientes con depresión clínica. Rev Med Chil 2020; 148:336-343. [DOI: 10.4067/s0034-98872020000300336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/18/2020] [Indexed: 11/17/2022]
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Behn A. Working with clients at the intersection of depression and personality dysfunction: Scientific and clinical findings regarding complex depression. J Clin Psychol 2019; 75:819-823. [PMID: 30811603 DOI: 10.1002/jclp.22758] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Depression is often complicated by concurrent personality dysfunction, which poses significant challenges for clinicians and researchers. Complicated depression is thus broadly presented as a useful clinical and scientific entity, describing clients presenting with depressive symptoms that are further complicated by personality dysfunction or personality pathology. The article introduces a collection of research-based papers addressing the clinical management of patients with complicated depression. The articles in the issue provide an up-to-date framework for understanding different forms of complicated depression and provide useful clinical information to illuminate the treatment of clients presenting with difficulties at the intersection of depression and personality dysfunction.
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Affiliation(s)
- Alex Behn
- School of Psychology, Pontificia Universidad Católica de Chile, Santiago, Chile.,Millennium Institute for Research in Depression and Personality (MIDAP), Santiago, Chile
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Fischer C, Cottin M, Behn A, Errázuriz P, Díaz R. What makes a difficult patient so difficult? Examining the therapist's experience beyond patient characteristics. J Clin Psychol 2019; 75:898-911. [PMID: 30811612 DOI: 10.1002/jclp.22765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 01/28/2019] [Accepted: 01/28/2019] [Indexed: 11/09/2022]
Abstract
The primary aim of this study is to improve our understanding of therapists' experience of a "difficult patient" and consider the different variables involved in this label. What makes a patient be perceived as difficult by a therapist in public health services? Results of our analysis of 10 qualitative semistructured interviews of therapists working in public health service in Chile indicated that therapists' perceptions of a "difficult patient" depend on variables that go beyond the patient's intrinsic characteristics, including patients' negative attitude toward the therapist and treating team, patients' negative effects on therapists, and a difficult treatment context (e.g., work overload, scarce resources, limited number, and frequency of sessions). We illustrate the interaction of these dimensions and focus on the impact of the treating context on therapists' experience of a "difficult patient" through the case of a therapist working with a patient with complex depression in the public health system of Chile.
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Affiliation(s)
- Candice Fischer
- Department of Clinical Psychology, School of Psychology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Marianne Cottin
- Faculty of Medicine, Graduate school, Universidad de Chile, Santiago, Chile
| | - Alex Behn
- Department of Clinical Psychology, School of Psychology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Paula Errázuriz
- Department of Clinical Psychology, School of Psychology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ruben Díaz
- Faculty of Medicine, Graduate school, Universidad de Chile, Santiago, Chile
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Behn A, Davanzo A, Errázuriz P. Client and therapist match on gender, age, and income: Does match within the therapeutic dyad predict early growth in the therapeutic alliance? J Clin Psychol 2018; 74:1403-1421. [PMID: 29573351 DOI: 10.1002/jclp.22616] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 01/09/2018] [Accepted: 01/21/2018] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Because of the importance of the therapeutic alliance across psychotherapeutic treatments, it is important to study variables that predict the development of a positive therapeutic alliance. This study investigates if different levels of gender, age, and income match between therapists and clients predict early development of the therapeutic alliance. METHOD The sample consisted of 28 therapists and 547 adult clients receiving individual psychotherapy for depressive symptoms. There were no exclusion criteria and no control over treatment delivery. Session-to-session assessments of the therapeutic alliance were collected and a growth mixture modeling framework with a priori identified classes corresponding to different levels of therapist-client match was utilized to examine differential alliance growth trajectories. RESULTS No differential effect of match on any level was found on initial ratings of the alliance. Across levels of attribute match, clients tend to rate the alliance positively. Regarding growth, a "youth effect" and an "affluence effect" was noted. Dyads where the therapist is younger than the client, and dyads where the therapist is from a higher income status than the client, show additional growth in the alliance beyond positive initial ratings. This is effect is not constant across sessions. CONCLUSIONS Matching on gender, income, and age can be used for case assignment heuristic, in particular to produce additional growth in the alliance beyond initial positive ratings. Clinical and scientific consequences of the study are discussed.
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Affiliation(s)
- Alex Behn
- Pontificia Universidad Católica de Chile.,Millennium Institute for Research in Depression and Personality (MIDAP)
| | | | - Paula Errázuriz
- Pontificia Universidad Católica de Chile.,Millennium Institute for Research in Depression and Personality (MIDAP)
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Errázuriz P, Opazo S, Behn A, Silva O, Gloger S. Spanish Adaptation and Validation of the Outcome Questionnaire OQ-30.2. Front Psychol 2017; 8:673. [PMID: 28559857 PMCID: PMC5432756 DOI: 10.3389/fpsyg.2017.00673] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 04/13/2017] [Indexed: 11/23/2022] Open
Abstract
This study assessed the psychometric properties of a Spanish version of the Shortened Outcome Questionnaire (OQ-30.2, Lambert et al., 2004) validated with a sample of 546 patients in an outpatient mental health clinic and 100 non-clinical adults in Chile. Our results show that this measure has similar normative data to the original measure, with a cutoff score for the Chilean population set at 43.36, and the reliable change index at 14. This Spanish OQ-30.2 has good internal consistency (α = 0.90), has concurrent validity with the Depressive, Anxious, and Somatoform disorders measuring scale (Alvarado and Vera, 1991), and is sensitive to change during psychotherapy. Consistent with previous studies, factorial analyses showed that both, the one-factor solution for a general scale and the three-factor solution containing three theoretical scales yielded poor fit estimates. Overall, our results are similar to past research on the OQ-45 and the OQ-30. The short version has adequate psychometric properties, comparable to those of the OQ-45, but provides a gain in application time that could be relevant in the setting of psychotherapy research with large samples, frequent assessments over time, and/or samples that may require more assistance completing items (e.g., low-literacy). We conclude that this measure will be a valuable instrument for research and clinical practice.
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Affiliation(s)
- Paula Errázuriz
- Department of Psychology, Pontificia Universidad Católica de ChileSantiago, Chile.,National Research Center for Integrated Natural Disaster ManagementSantiago, Chile.,Millennium Institute for Research in Depression and PersonalitySantiago, Chile
| | - Sebastián Opazo
- Department of Psychology, Pontificia Universidad Católica de ChileSantiago, Chile
| | - Alex Behn
- Department of Psychology, Pontificia Universidad Católica de ChileSantiago, Chile.,Millennium Institute for Research in Depression and PersonalitySantiago, Chile
| | - Oscar Silva
- Psicomédica Clinical and Research GroupSantiago, Chile
| | - Sergio Gloger
- Millennium Institute for Research in Depression and PersonalitySantiago, Chile.,Psicomédica Clinical and Research GroupSantiago, Chile.,Department of Psychiatry, Universidad de ChileSantiago, Chile
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Behn A, Hartl L, Schweizer G, Wenzel G, Baumer M. QTL mapping for resistance against non-parasitic leaf spots in a spring barley doubled haploid population. Theor Appl Genet 2004; 108:1229-1235. [PMID: 14740087 DOI: 10.1007/s00122-003-1559-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2003] [Accepted: 11/24/2003] [Indexed: 05/24/2023]
Abstract
Phenotypic variability for resistance against non-parasitic leaf spots (NPLS) has been observed between varieties. For the genetic characterization of NPLS resistance, a population with 430 doubled haploid (DH) lines was developed from the cross between the NPLS-resistant Hordeum vulgare breeding line IPZ24727 and the NPLS-sensitive barley cultivar Barke. A molecular map was constructed based on 164 AFLPs, 30 SSRs and one STS marker derived from the mlo gene. Field trials were performed over four environments in which NPLS and other agronomic traits were assessed. Estimates of genotypic variance were highly significant for NPLS. Moreover, no transgression was found for the trait. Quantitative trait loci (QTLs) for NPLS resistance were mapped in the DH population on chromosomes 1H, 4H, and 7H, with the most important effect on chromosome 4H. The QTLs for NPLS explained together 39% of the phenotypic and 49% of the genotypic variance, thereby showing additive gene action. Consequently, marker-assisted selection for improving NPLS resistance is possible.
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Affiliation(s)
- A Behn
- Institut für Pflanzenbau und Pflanzenzüchtung, Bayerische Landesanstalt für Landwirtschaft, Am Gereuth 6, 85354 Freising, Germany
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Armstrong RD, Behn A, Myles A, Panayi GS, Welsh KI. Histocompatibility antigens in polymyalgia rheumatica and giant cell arteritis. J Rheumatol 1983; 10:659-61. [PMID: 6413689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Fifty-five Caucasoid patients with polymyalgia rheumatica or giant cell arteritis were typed for HLA, A, B, C and DR locus antigens. In the total patient group, DR4 had a significantly increased frequency. The prevalence of CW3 and CW6 was also significantly increased, the rise of CW3 possibly being attributable to its well-documented linkage disequilibrium with DR4. The rise in CW6 cannot be attributed to its known linkage disequilibrium with DR7.
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