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patoplasty of vascular headaches

Prof. Enrique Rojas, Prof. Joseph A. Dr. Miguel Gutierrez Ariza and Pérez-Camacho Duque *

* Revised text. And added to the original work, treatment and classification of vascular headaches by Dr. Miguel Duque Pérez-Camacho.

headaches show a rich vascular plasticity symptomatology. The most common of all migraine whose diagnosis is usually straightforward when it appears with the typical characteristics. The atypical problems of differential diagnosis with other vascular headaches, chronic vasomotor headache, the eritroposopalgia, temporal arteritis, and general mental tension headaches and depression. The diagnosis of migraine headaches should be equivalent with great caution. He has a great interest to know the replacement and alternation of symptoms around the various forms of headache. These mutations described a genuine transition substitute symptoms. INTRODUCTION



headaches patoplasty offer a rich vascular clinic, which coincides with high variability phenomena that all headaches. Possibly more than 70% of the patients we see are complaining of a headache. In each, the symptoms take different forms, as befits their different etiologies. The most common of all is the headache.
For example, in England there are over ten million migraines, according to research by Harvey-Suterland , over two hundred thousand people have to stay in bed one day a week for this reason; an estimated ten million working days are lost because of this year. Grimes , fifteen thousand patients of general practices found that about 10% complained of significant headaches. The statistics of Friedman and Lennox are higher.

of migraine should also consider other less common: vasil artery migraine, cluster headache of the Horton, called cervical headache, the headache caused by inflammation of the temporal artery is considered akin to collagen diseases and psychic headache is usually bilateral, in the pathogenesis should be considered an important vascular factor and the contraction of the muscles of the neck.

FEATURES OF MIGRAINE TODAY

The classical descriptions of migraine rarely present diagnostic problems, provided that the development of clinical history data are properly collected. Friedman and Storch required to make the diagnosis of migraine following conditions:

1 .- What is throbbing headache, usually recurrent and

hemicranial.
2 .- In the intercritical periods there is a full recovery in regard to headache, although it is easily recognizable personality pathology: hypersensitivity to light, noise, etc., excessive order in all its actions, people very fond of cleaning, stubborn, inflexible while shy and retiring. Perfectionist zeal. They always want to do more and better. As Marcus says Wolff : make their qualities, defect. Approach, therefore, the obsessive and enequéticos. 3 .-
neurological disorders also appear consistent visual aura in the form of photophobia, scotomata, and even hemianopsia. 4 .-
Vegetative disorders: nausea, vomiting, dizziness, diarrheal plunges, polyuria, etc.. 5 .-
have a hereditary family. 6 .-
or deleted is relieved pain in 95% of cases with ergot preparations.

Despite these general characteristics, there are many occasions when the clinical picture does not meet these conditions, leading to different varieties of vascular headache-type headache. That is, the classic problems with prodrome (in which the patient feels lethargic, weak, without strength and with some anguish in the background, and ill-shaped enclosure), aura (which in some stories do not appear, sometimes not because they do not exist, but because it has been questioning the patient, can be:

a) Hearing: tinnitus, temporary hearing loss, tinnitus, etc.;
b ) Olfactory : subjective perception of odors;
c) Buds : special flavors strangers
d) Sensitive : paresthesia as affecting half of the body opposite the headache, sometimes involving the face, hands, lower limbs, etc.

The most common type of aura is the lens: scotoma blind small at first, gradually increases. It is sometimes associated with or alternating with scintillating scotoma. There are times when this is not true, and everything is reduced to a few bright spots or moving ("floaters").

Then comes the headache crisis itself: pain in the form of oppression, frontal or fronto-temporal, which increases gradually until it becomes hemicranial. The nature of pain and accompanying clinical phenomena make the diagnosis is simple. Now there are atypical falling within the circle of depression. The relationship between migraine headaches and depression is the same as that entered the equivalent of depression and psychosomatic illnesses. What we see clinically is that there is a transition between migraine headaches and depression, with intermediate concrete cases that match the features of one or the other, making it very difficult differential diagnosis. In fact, migraineurs are predominantly psychological symptoms of depression.

Gans says that migraine and neurasthenia only differ in one symptom that has the first and the second one does not have the headache. We must also differentiate timopáticas headaches described by López Ibor, where the pain is so intense, has a larger location, appearing many times during sleep and relief throughout the day. In the same story of the patient referred to a weight on his brain that produces a clear inhibition, decrease of vitality and reducing their ability to concentrate. Locations are very common in the neck.

symptoms analysis allows us to set transitions into the distressing to the depressive or predominantly into the vessel. Some patients may even see a gradual spectrum ranging from sensory and vital feelings. It is as if the pain becomes a feeling of sadness infancy.

There are differences also those frontal headaches migraines diffuse, with a headache not as strong and which are those that usually happen in the course of endogenous depression. There is a feature of interest in these: the patient has trouble not only tell what it feels like he has, but even locate it, since it is more of a paresthesia.

It also has a more distressing. Everything becomes clear when the patient says he fears going mad or suffering from an incurable mental illness or who fears that he may have a fit, and they mean a shift of emphasis towards depressed than anxious. The fear of losing control is to López Ibor of great significance.

The cranial tumor headaches often have a very cropped picture both as regards the pain itself as complementary examinations, the neurological examination, fundus, skull radiographs, the course of symptoms and the type and location of the pain we clarify the diagnosis.

is important to emphasize the rhythm of headaches when we have problems diagnoses. The circadian rhythm of morning worsening and improvement in the evenings we will be driven towards depressive headaches. The cyclical pattern, with a sadness masked background, we will think of an equivalent depression. The agonizing headaches are usually the pain in the twilight hours. Other times the rate of pain did not meet any particular standard, but a somewhat anarchic and capricious. In these cases we investigate symptoms aids and the presentation. Sometimes there is a kind of alternating rhythm: a few days with migraine headache, nausea, nausea and vomiting, there is some strange euphoria. Other days, when he removes the headache, feel saddened, with great fatigue and a huge concern. This is so true-soul cefalárgico sift syndrom.

migraine attacks in the vascular factor in the pathogenesis is essential, but we note also the role of psychological factors in triggering them. The cycle established by Rowbothan still relevant to the phenomena of migraine headaches circle.

Clinically there is some correlation between migraine and epilepsy. Also in seizure headache and anxiety as there are elements of the seizure aura. Follow, therefore, a similar cycle, but these coincidences are not nuclear.

Finally there is a clinical form of migraine, the headache of the lower half of the face, facial migraine, which was included in a group of neuralgias of doubtful clinical staff independently. They the precise boundaries are erased, neuralgia can be treated in the spheno-palatine ganglion, the nerve neuralgia vidian, Charlin syndrome or syndrome-Benisti Mombrun . Sometimes these patients have a history of migraines, seizures alternating with these other atypical typical. They associate the congetión of ocular and nasal mucous membranes, tearing, nasal packing, hidrorrea, etc., Being able to confuse or be very difficult differential diagnosis of cluster headache Horton. According to Mark Lanzarot and Cerdan, patients suffering from typical migraine crisis in youth and at maturity have this form of facial neuralgia.


equivalents include headache ( Liveing, Moebius ) are highlighting certain vasomotor rhinitis, dizziness (which statistically are the most common, referring either to the medication ergotamine), some trigeminal neuralgia neuralgias and certain nonspecific. Less common are paroxysmal tachycardia, precordial migraine. In children, abdominal migraine can occur without headache or go unnoticed at the box striking the abdomen. All these crises in which there is no headache or it is in the background, must be diagnosed with great caution because that may be symptoms of another illness.


OTHER VASCULAR HEADACHE

Among other vascular headaches of interest in this vein, we find chronic vasomotor headache ( Heyck ) at which lacks the typical features of migraine (the presentation of the crisis, the type of pain, etc.)..
The vast majority are psychogenic. The eritroposopalgia also called cluster headache of Horton, vidian neuralgia, ciliary neuralgia and headache craniofacial independently.
Americans ( Kunkle Macropopulum Friedman, Schiller ) given their clinical characteristics have adopted the name of cluster headache can be translated as "cluster headaches or group or crowd." The pain may spread to the face, which can be confused with trigeminal neuralgia. For a long time it was thought that this was a different location neuralgia: ciliary ganglion, sphenopalatine nerve, nasociliary, etc. Today is thought to be due to a vegetative deregulation at the territory of the internal carotid artery. But it is often difficult to find an organic cause in this and other similar headaches. Thus, between 500 headaches Cohen studied, only 20% were organic, with the remaining 80% of psychological origin. The cluster headache is more common in men, not starting before forty years, with the crisis provoked by cold, heat and especially by the ingestion of alcoholic beverages. The challenge test is the safest of histamine.

temporal arteritis may be confused with any of those mentioned above. Here the throbbing pain located temporo-occipital area, adding a cutaneous hyperesthesia, local erythema and edema. The temporal artery is thickened, hard and painful, something that never occurs in migraine, there is often pain in the temporomandibular joint jaw when chewing ("intermittent claudication jaw). Today is considered (Marcos and Cerdan ) as a local symptom of a widespread disease. Thus, it is common that these patients also have intermittent claudication, gastrointestinal hemorrhage due to obstruction of the celiac trunk, etc.

The basilar artery migraine described in 1961 by Bickerstaff is a very controversial syndrome that usually presents no problems for his complete reversibility. The so-called cervical migraine described by Barre and Liéou the name of "posterior sympathetic syndrome" is usually accompanied of dizziness. The pain starts in the neck and radiating to the parietal region and retro-ocular. Differential diagnostic problem raises the headaches anxious to appear as nucalgias. The radiographic signs can clarify the problem: next to the loss of physiological cervical lordosis, Kyphotic angles, intervertebral disc injuries or spondyloarthritis. These injuries can cause a complication that is interesting to note: to narrow the foramina, can compress the vertebral artery, causing a headache of a coronary artery.

In recent years there has been a lot about the fact that many neuralgia are due to chronic states of anxiety and unresolved conflict situations. In our experience this is not always so, as the clinical examination reveals a muscular contracture that often does not exceed the normal limits. Sometimes the headaches trying Tenson differences of vascular headaches is not possible, even in some patients is associated both mechanisms: vascular muscle, giving way to a combined headaches. Their frequency has increased dramatically today. It is not uncommon in some cases alternate migraine with this form. Usually bilateral, frontal or occipital and is accompanied by great anxiety, occurring between Y40 20 years. This headache can land in a traffic headache clinical depressive with a pretty clean, so that antidepressant treatments caused a clear improvement, although being a secondary depressive symptoms, total remission I require a thorough investigation of conflicts originating and their ability to digest such circumstances. In this regard the substitution and the alternating cephalalgic syndromes presents a very broad plasticity, so that some symptoms are clinically followed each other. This dynamic development of symptoms and even their confluence, it is not only enrich the knowledge and natural history of disease. Hence we should talk about a diagnosis metablética born of these mutations and symptomatic changes. Lopez-Ibor Dressing, have spoken on occasions "changes in syndromes" to refer to these issues. Spiegelberg of syndromalternation. Groen et al. displacement syndromes. Sometimes the same treatment as their excessive power or simply because of their habitual action that originates Landolt has called "the phenomenon of forced normalization", ie that the treatment modifies the clinical picture by removing a symptom and leaving clear path to another or moving geographically headache from one place to another, with the consequent change in symptoms added.

Thus, certain cephalic paresthesias become digestive symptoms, for example, then head back pain, but with a different nature. In many paintings of this type there is a phasic rhythm, we may speak of depressive equivalent. In others there this year, but in the background of the clinical picture there is a vital sadness perceptible phenomenologically, we speak of masked depression.

One last question, can you talk a teleological movement syndromes? This is not always given in a particular way, or even with an objective external causes. The transition takes symptom substitution, sometimes unsuspected directions, but sometimes this is not so and costs catamnésica predict the evolution of the patient. Within the area of \u200b\u200btension headaches is something we should not forget: to remove the headache without resolving the conflict that caused it can happen that will break the existing balance and thus originating new symptoms with a function also rehabilitation. SUMMARY



The demostrate a rich vascular Headaches sintomatologic platicity. The most frequent-of the migraine, Whose simple diagnosis Tends to Be When It applas with the typical characteristics. The atypical forms present differents diagnostic problems with other vascular headache-the chronic headache vasomotora , the headache histaminic of Horton, the arithis of the temporal- in general with the headaches due to psyquic tension and depression. The diagnosis of the equivalent of migraine should be done with great caution. Et is of great interest to know the supplency and alternation of symptoms with regards around of headaches. These mutacions describe an authentic substitution syntomatologic transition.


BIBLIOGRAFIA

• Barré, J. Soc. d´O.N.O. Fr. de Strasb.
• Bickerstaff, E. R. Lancet 1,15
• Cohen, H. Intracranial causes of headache . Brit. Med., II, 713
• Friedman, A., Von Storch, T., Merritt, H. - Neurology, 4.773
• Friedman, Background not migraine. Cochrane.
• Heyck, H. - Headaches. Ed Marin. Barcelona.
• Kunkle, EC, Arch Neurol. Psychiat, 81.135
• Lennox WG, Lennox, MA - Epilepsy and related disorders. Little Brown. Boston
• Living, E. - On migraine, sick headache and Some alien disorders. Churchill. London
• López Ibor, JJ blues. Paz Montalvo. Madrid-Influence of new drugs in psychiatric nosology. International Congress of Neuro-pharmacology. Munich.
• López Ibor, JJ and Lopez Alina-Ibor, JJ organischen Krankheiten bei Depression. Valdener Symposium.
• Alina Lopez-Ibor, JJ Los depressive equivalents. Paz Montalvo. Madrid. • Lazarot
Marcos, M. Jaquecas. Rev. Clin. Esp. 56, 302
Lazarot • Mark M. and Cerdan Vallejo A. The migraine Sandoz, Barcelona. •
Marcasen, R, M, Wolf JAMA Migraine HS, 139.198. •
Moebius, E. Die Migraine. Vienna •
Rowbotham, GF Migraine and the sympathetic nervous pathways. Brit. Med. H., 4470, 319. •
Spiegelberg, U. - Zur Psychosomatic December Shift Syndrome (Feldwechsel). Hamburger Gespräche.


ANTIMIGRAÑOSOS (Treatments)

Analgesics and anti-inflammatory estoroídicos

Aspirin and paracetamol are considered as first choice, being effective mainly in pictures moderate, especially if taken at the beginning of the attack. Used at doses of 500 - 1000 mg and have a very similar efficiency. It is preferable to use liquid forms of analgesics to achieve more rapid effects (lysine acetylsalicylate, or effervescent tablets).
more intense in the tables can also be used aintiinflamatorios drugs (NSAIDs) that have a rapid onset of action. Examples are ibuprofen (400-800 mg), naproxen (750mg), naproxen sodium (825 mg = 3 tablets of 275 mg once), ketoprofen (75 mg), ácidomefenámico (500 mg) or flufenamic acid.
may also be interesting given metoclopramide (10 mg) 10 to 30 minutes before the analgesic. Avoid gastric stasis that can impede the absorption of the analgesic, relieves nausea and vomiting and may have antimigraine action itself. This is especially important in patients where vomiting is an important element in the migraine attack.
Ergotamine


respecting contraindications, ergotamine is effective in a number of severe cases not responding to painkillers. The effectiveness can be the order of 50%. Caffeine enhances the effect, but other combinations are worth much more dubious. The main drawback is the toxicity (ergotism). Do not exceed 10-12 mg per week or repeated treatments with an interval less than three days.
oral absorption is quite irregular. The rectal suppositories much better and can give results in cases not responding to oral treatment. The sublingual route, the parenteral or inhalation are also very effective but there is no ready market in our country.
The previous administration of metoclopramide (see above) may improve oral absorption and contributes to alleviating the vomiting that sometimes occur as a side effect. Are due to central chemoreceptor stimulation and therefore also occur with rectal ergotamine preparations. Dihydroergotamine

is less potent than ergotamine, which means it is less effective but also has fewer side effects. Other countries have enough acceptance by injection or intranasal, but Spain is only available orally, relatively little use.

Almotriptan, Eleptriptán, Naratriptan, frovatriptan, rizatriptan, sumatriptan and zolmitriptan .

Ergotamine most likely acts by stimulating serotonin receptors. Sumatriptan is a stimulant of 5-HT 1B / D, more effective than ergotamine and with fewer side effects. The combination of very high efficiency (almost 90%), low rate of adverse effects and relieve indecently fast attack phase where it has been converted to the SC injection of sumatriptan in a favorite in the emergency treatment. However it should not be administered to patients receiving ergotamine or dihydroergotamine for the additive toxic effects. It is therefore appropriate to ask about the medication prior to the emergency. Orally the action is somewhat slower and the response rate is lower, but is the highest in the migraine (50-75%). Its main drawback is that in 40% of cases the attack is played at 24-48 hours (although it responds to a second dose).

-called "second-generation triptans" , have better oral pharmacokinetic conditions that sumatriptan. Its bioavailability is higher (45-75%) and therapeutic plasma levels are reached more rapidly (30-60 min). Half-lives are also higher. The basic pharmacological profiles are similar to that of sumatriptan, except that show greater activity on the 5-HT 1B / D and a higher lipophilicity and brain penetration. Thus, in addition to peripheral vasoconstriction and inhibition of perivascular trigeminal terminals, these new "triptans" act directly attenuate the excitability of cells within the trigeminal nucleus. As regards its power to enter into the coronary arteries is similar to that of sumatriptan. Naratriptan has earlier onset of effect than sumatriptan, although with slightly lower responses, but sample produces a lower recurrence of migraine attacks and is better tolerated. Zolmitriptan , almoptriptán, eletriptan, frovatriptan and rizatriptan are also well tolerated and at least as effective, or even something else that sumatriptan. In a meta-analysis of 53 clinical trials controlados1 including more than 24,000 migraine patients concluded that all employees triptans are effective and reasonably well tolerated, although eleptriptán (80 mg), rizatriptan (10 mg) and almotriptan (12 , 5 mg) 1 appear to show greater consistency in the response.

antidopaminergic

are quite effective in cases of urgency or refractory tables although the mechanism of action is unknown. The most useful is the injection of 10 mg of metoclopramide to intravenously. Effective, but less comfortable are three IV dose of chlorpromazine ( 0.1 mg / kg) spaced 15 minutes.

Opioid Analgesics

Use in emergency cases where the above treatment is ineffective. is often used morphine or methadone, sometimes associated with promethazine which acts as a sedative and antiemetic.

Corticosteoides

Dexamethasone oral or depot injection may be useful in tables exceeding 24 hours. There is desirable to repeat the treatment before three weeks. Preventive Treatment



The goal of treatment is reduced to less than half the frequency of attacks. Consider preventive treatment applied to patients suffering three or more attacks per month. Try on therapeutic possibilities in case of failure before. Beta blockers



often effective in 60% -70% of cases and the rate of side effects is quite low if contraindications are respected. Keep in mind that not all beta blockers are effective in migraine. Choose from propranolol, atenolol, metoprolol, and nadolol . Are totally ineffective oxpenolol, acebutolol and prenolol and moderately effective (and therefore less desirable) pinolol and timolol. The dose must be adjusted individually and sometimes much higher than necessary to complete adrenergic blockade (eg, propanolol begins with 40-80 mg / day but sometimes you need 320 mg / day). Reaching high-dose beta-blockers before leaving as ineffective. One option that works in many cases refractory is to associate the beta-blocker with amitriptyline (individually adjust the latter) but perhaps should be tested before the second and third chances.


1 Ferrari, Roon KI, Lipton RB, Goadsby PJ. Oral triptans (serotonin 5-HT (1B/1D) agonists in acute migraine treatment: a meta-analysis of 53 trials. Lancet 2001, 358 (9294): 1668-75.


antiserotonin

pizotifen is effective in a large number of patients (40-60% according to some authors, 70% according to others). Produce drowsiness (minimized by giving it in single dose at bedtime) and stimulation of appetite, which is a slight disadvantage compared with beta-blockers . Cyproheptadine is very similar and especially effective in children. Adults often complain of excessive sleepiness.

Calcium antagonist

have similar effectiveness to that of pizotifen (around 50%) and may take 6-8 weeks to take effect. Decreases the frequency of the attacks, but not the intensity. Cerebral vasodilatdora action can sometimes cause headaches resembling migraine. It is used for exercising flunarizine antimigraine action without producing peripheral vasodilation.

Valproic Acid

The mechanism of action is poorly understood but the antimigraine efficacy has been demonstrated by several clinical trials. As above, further decreased the frequency of attacks the intensity or duration and the response rate is around 50%. It usually starts with 250 mg twice daily and adjusted gradually to 500 mg, 2 times a day. Especially useful is the prophylaxis of tables with prolonged aura or basilar migraine. Topiramate



antiepileptic drug that has received its approval for use in the prophylaxis of migraine. The recommended total daily dose of migraine prophylaxis is 100 mg / day in two divided doses (50 mg every 12 hours). You should start with 25 mg daily, administered at night, during the first week. Subsequently increase dose, at weekly intervals in 25 mg / day to reach the optimal dose of 100 mg. Antidepressants



Tricyclic antidepressants (amitriptyline is the most studied) has a preventive action of migraine, regardless of whether or not the patient is depressed. The mechanism of action is unknown but possibly antiserotonin action, and the dose must be adjusted individually (for amitriptyline is 25 to 300 mg a day, a night shot). The efficacy is similar to propranolol. Especially useful in mixed syndromes (migraine combined with tension headaches) or in patients who abuse painkillers or ergotamine.

MAOIs are also effective, but because of the possibility of side effects should be considered drugs of last resort. Analgesics



NSAIDs have shown efficacy in migraine prophylaxis. Can be tested for example 250 mg of naproxen twice or three times a day, but can also be used idnometacina, ketoprofen and mefenamic acid. The best application of NSAIDs is the prevention of menstrual migraine. Treatment (with ketoprofen or mefenamic acid) should begin 3 days before menstruation and continuing throughout the lifetime of the battery.




N02CA: Antimigraine: Ergot alkaloids

Action and mechanism:

migraine treatments, semisynthetic ergot alkaloids (ergot). At therapeutic doses, produces peripheral vasoconstriction by stimulating alpha-adrenergic receptors. At the level of abnormally dilated carotid artery bed, vasoconstriction of that is useful for eliminating the attack associated migraine.

Paradoxically, at higher doses of dihydroergotamine has competitive blocking activity of alpha-adrenergic receptors.

Pharmacokinetics: Oral: Its bioavailability is very low values \u200b\u200bhave been 0.1-1.5%. Is absorbed in an irregular and incomplete (Tmax = 45 min - 2 h). The degree of protein binding is 90%. It is extensively metabolized, probably in the liver. It is mainly eliminated via bile in the feces. Its half-life is 21 h. Intranasal

: Dihydroergotamine is rapidly absorbed after intranasal administration (Tmax = approx. 45 min.) Bioavailability absolute intranasal dihydroergotamine is approx. A 43 + - 24%. Between 70 and 80% of the plasma is related to the unchanged drug, indicating a lower metabolism of unchanged drug that obtained after oral administration. It binds 93% to plasma proteins. The apparent volume of distribution at steady state is about 800 l. The total body clarification is approx. 1.5 l / min, reflecting primarily the liver clarification. The main route of excretion is biliary tract with the feces. Following intranasal administration, the urinary excretion of unchanged drug and its metabolites amounted to 2%.

To optimize the nasal absorption and prevent loss of drug, we recommend a 15-minute interval between two consecutive doses.

International Classification of Headache,
The International Classification of Headache Disorders, 2nd Edition. Headache Classification Subcommittee of the International Headache Society.

1. Migraine.
• 1.1 Migraine without aura.
• 1.2 Migraine with aura. Or 1.2.1
typical migraine aura. Aura 1.2.2
typical or non-migraine headache.
or without headache 1.2.3 Typical aura.
familial hemiplegic migraine or 1.2.4.
sporadic hemiplegic migraine or 1.2.5. 1.2.6
or basilar type migraine.
• 1.3 Childhood periodic syndromes that are commonly precursors of migraine. Cyclic Vomiting
or 1.3.1. 1.3.2
or abdominal migraine.
or 1.3.3 Benign paroxysmal vertigo of childhood.
• 1.4 Retinal migraine.
or 1.5 Complications of migraine.
chronic migraine or 1.5.1. 1.5.2 State
or bad migraine.
or persistent Aura without infarction 1.5.3. 1.5.4
or migrainous infarction. 1.5.5
or triggered seizure migraine.
• 1.6 probable migraine. 1.6.1
or probable migraine without aura. 1.6.2
or probable migraine with aura.
probable chronic migraine or 1.6.5.
2. Tension-type headache (CT).
• 2. Tension-type headache (CT).
or 2.1 Infrequent episodic CT. 
CT 2.1.1 Infrequent episodic pain associated with pericranial tenderness. 
CT 2.1.2 Infrequent episodic pain not associated with pericranial tenderness.
frequent episodic or 2.2 CT. 
CT 2.2.1 Frequent episodic pain associated with pericranial tenderness. 
2.2.2 Frequent episodic CT not associated with hypersensitivity pericranial painful.
chronic or 2.3 CT.  2.3.1 CT
chronic pain associated with pericranial tenderness.  2.3.2 CT
chronic pain associated with pericranial tenderness. CT or 2.4
likely. 
probable infrequent episodic CT 2.4.1. 
probable frequent episodic CT 2.4.2.  2.4.3
chronic CT probable.
3. Cluster headache and other trigeminal-autonomic headaches.
• 3.1 Cluster headache.
or 3.1.1 Episodic cluster headache.
or 3.1.2 Chronic cluster headache. Paroxysmal Hemicrania
• 3.2. 3.2.1
or episodic paroxysmal hemicrania.
or 3.2.2 Chronic paroxysmal hemicrania.
• 3.3 SUNCT (Short-lasting unilateral headache Neuralgiform Attacks with Conjunctival injection and Tearing). • 3.4 Headache
trigeminal autonomic likely. 3.4.1
or probable cluster headache. 3.4.2 Paroxysmal Hemicrania
or probable. 3.4.3
or probable SUNCT.
4. Other primary headaches.
• 4.1 primary stabbing headache.
• 4.2 Primary cough headache. • 4.3 Headache
primary exercise.
• 4.4 Headache associated with primary sexual activity. Preorgasmic
or 4.4.1 Headache. 4.4.2
or orgasmic headache. • 4.5 Hypnic
Headache.
• 4.6 Bursting headache (thunderclap) primary. • 4.7 Hemicrania
continuous. • 4.8
chronic headache from the start.
5. Headache attributed to cranial trauma, cervical, or both.
• 5.1 Acute post-traumatic headache. 5.1.1
or acute post-traumatic headache attributed to moderate or severe head injury. 5.1.2
or acute post-traumatic headache attributed to mild head injury.
• 5.2 post-traumatic chronic headache.
or 5.2.1 Chronic post-traumatic headache attributed to moderate or severe head injury.
or 5.2.2 Chronic post-traumatic headache attributed to mild head injury.
• 5.3 Headache attributed to acute WAD. • 5.4
chronic headache attributed to whiplash.
• 5.5 Headache attributed to traumatic intracranial hematoma.
or 5.5.1 Headache attributed to epidural hematoma.
or 5.5.2 Headache attributed to subdural hematoma.
• 5.6 Headache attributed to other head injury, cervical, or both.
or 5.6.1 Headache attributed to acute head injury, cervical, or both.
or 5.6.2 Headache attributed to chronic head injury, cervical, or both.
• 5.7 post-craniotomy headache.
5.7.1 Headache or Acute post-craniotomy.
or post-craniotomy headache 5.7.2 Chronic.
6. Headache attributed to cranial or cervical vascular disorder. • Headache
6.1 attributed to ischemic stroke or transient ischemic attack.
or 6.1.1 Headache attributed to ischemic stroke (stroke).
or 6.1.2 Headache attributed to transient ischemic attack (TIA).
• 6.2 Headache attributed to traumatic intracranial hemorrhage.
or 6.2.1 Headache attributed to intracerebral hemorrhage.
or 6.2.2 Headache attributed to subarachnoid hemorrhage.
• 6.3 Headache attributed to vascular malformation does not rotate.
or 6.3.1 Headache attributed to saccular aneurysms.
or 6.3.2 Headache attributed to arteriovenous malformation.
or 6.3.3 Headache attributed to dural arteriovenous fistula.
or 6.3.4 Headache attributed to cavernous angioma.
or 6.3.5 Headache attributed to encephalotrigeminal or leptomeningeal angiomatosis (Sturge Weber syndrome).
• 6.4 Headache attributed to arteritis.
or 6.4.1 Headache attributed to giant cell arteritis.
or 6.4.2 Headache attributed to primary angiitis of the central nervous system.
or 6.4.3 Headache attributed to secondary angiitis of the central nervous system. • 6.5
carotid or vertebral artery pain.
or 6.5.1 Headache or facial pain attributed to cervical arterial dissection. 6.5.2
or post-endarterectomy headache. 6.5.3 Headache
or carotid angioplasty.
or 6.5.4 Headache attributed to intracranial endovascular procedures. 6.5.5 Headache
or angiography.
• 6.6 Headache attributed to cerebral venous thrombosis.
• 6.7 Headache attributed to other intracranial vascular disorder. 6.7.1
or cerebral autosomal dominant arteriopathy subcortical conInfartos and leukoencephalopathy (CADASIL).
or 6.7.2 Mitochondrial Encephalopathy, Lactic Acidosis and Stroke-like episodes (MELAS).
or 6.7.3 Headache attributed to benign angiopathy of the central nervous system.
or 6.7.4 Headache attributed to pituitary apoplexy.
7. Headache attributed to nonvascular intracranial disorder.
• 7.1 Headache attributed to increased cerebrospinal fluid pressure.
or 7.1.1 Headache attributed to idiopathic intracranial hypertension.
or 7.1.2 Headache attributed to intracranial hypertension secondary to metabolic causes, toxic or hormonal.
or 7.1.3 Headache attributed to intracranial hypertension secondary to hydrocephalus.
• 7.2 Headache attributed to decreased cerebrospinal fluid pressure. 7.2.1
or post-lumbar puncture headache. 7.2.2 Headache
or cerebrospinal fluid fistula.
or 7.2.3 Headache attributed to decrease in idiopathic cerebrospinal fluid pressure (or spontaneous).
• 7.3 Headache attributed to noninfectious inflammatory disease.
or 7.3.1 Headache attributed to neurosarcoidosis.
or 7.3.2 Headache attributed to meningitis aseptic (non-infectious).
or 7.3.3 Headache attributed to other non-infectious inflammatory disease.
or 7.3.4 Headache attributed to lymphocytic hypophysitis.
• 7.4 Headache attributed to intracranial neoplasm.
or 7.4.1 Headache attributed to increased intracranial pressure or hydrocephalus caused by neoplasm.
or 7.4.2 Headache attributed directly to the tumor.
or 7.4.3 Headache attributed to carcinomatous meningitis.
or 7.4.4 Headache attributed to hypersecretion or hyposecretion hypothalamic or pituitary.
• 7.5 Headache attributed to intrathecal injection.
• 7.6 Headache attributed to epileptic seizure. 7.6.1 Hemicrania
or epileptic. 7.6.2 Headache
or post-critical.
• 7.7 Headache attributed to type I Chiari malformation
• 7.8. Syndrome of transient Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (handle).
• 7.9 Headache attributed to other intracranial vascular disorder.
8. Headache attributed to a chemical or deletion.
• 8.1 Headache induced by acute exposure to use or unasustancia.
or 8.1.1 Headache induced by nitric oxide donors.  8.1.1.1
Headache induced by nitric oxide donors immediately.  8.1.1.2
Headache induced by nitric oxide donors deferred.
or 8.1.2 Headache induced by phosphodiesterase inhibitors.
or 8.1.3 Headache induced by carbon monoxide. 8.1.4
or alcohol-induced headache.  8.1.4.1
alcohol-induced immediate headache.
 8.1.4.2 Delayed alcohol-induced headache.
or 8.1.5 Headache induced by food components and additives.  8.1.5.1
MSG-induced headache.
or 8.1.6 Headache induced by cocaine.
or 8.1.7 Headache induced by cannabis. 8.1.8
or histamine-induced headache.
 8.1.8.1 Immediate histamine-induced headache.
 8.1.8.2 Delayed histamine-induced headache.
or 8.1.9 Headache induced gene-related peptide of calcitonin (CGRP).  8.1.9.1
Headache CGRP-induced immediate.
 8.1.9.2 Delayed CGRP-induced headache. 01.08.1910
or acute headache as an adverse event attributed to medication-induced headache 01/08/1911
or other use or acute exposure to a substance. • 8.2
medication overuse headache. 8.2.1
or ergotamine overuse headache. 8.2.2
or triptan overuse headache. 8.2.3
or analgesic overuse headache.
or 8.2.4 Headache attributed to opioid abuse. 8.2.5 Headache
or abuse of various medications.
or 8.2.6 Headache attributed to abuse of other medications. 8.2.7
or medication overuse headache probable.
• 8.3 Headache as an adverse event attributed to medication chronic.
or 8.3.1 Headache induced by exogenous hormones.
• 8.4 Headache attributed to the removal of substances.
or 8.4.1 Headache attributed to caffeine withdrawal. 8.4.2 Headache
or opiate withdrawal. 8.4.3 Headache
or estrogen withdrawal.
or 8.4.4 Headache attributed to withdrawal after chronic use of other substances
9. Headache attributed to infection.
• 9.1 Headache attributed to intracranial infection.
or 9.1.1 Headache attributed to bacterial meningitis.
or 9.1.2 Headache attributed to lymphocytic meningitis.
or 9.1.3 Headache attributed to encephalitis.
or 9.1.4 Headache attributed to brain abscess.
or 9.1.5 Headache attributed to subdural empyema.
• 9.2 Headache attributed to systemic infection.
or 9.2.1 Headache attributed to systemic bacterial infection.
or 9.2.2 Headache attributed to systemic viral infection.
or 9.2.3 Headache attributed to other systemic infection.
• 9.3 Headache attributed to HIV / AIDS.
• 9.4 post-infectious chronic headache. 9.4.1
or chronic headache after bacterial meningitis.
10. Headache attributed to disorder of homeostasis.
• 10.1 Headache attributed to hypoxia, hypercapnia or both. 10.1.1 Headache
or high altitudes. 10.1.2 Headache
or diving. 10.1.3 Headache
or sleep apnea.
• 10.2 Dialysis headache.
• 10.3 Headache attributed to arterial hypertension.
or 10.3.1 Headache attributed to phaeochromocytoma.
or 10.3.2 Headache attributed to hypertensive crisis without hypertensive encephalopathy.
or 10.3.3 Headache attributed to hypertensive encephalopathy.
or 10.3.4 Headache attributed to pre-eclampsia.
or 10.3.5 Headache attributed to eclampsia.
or 10.3.6 Headache attributed to acute pressor response to an exogenous agent.
• 10.4 Headache attributed to hypothyroidism.
• 10.5 Headache attributed to fasting. • 10.6 Headache
heart.
• 10.7 Headache attributed to other disorder of homeostasis.
11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures ...
• 11.1 Headache attributed to disorder of cranial bone.
• 11.2 Headache attributed to disorder of the neck.
or 11.2.1 Cervicogenic headache.
or 11.2.2 Headache attributed to retropharyngeal tendonitis.
or 11.2.3 Headache attributed to craniocervical dystonia.
• 11.3 Headache attributed to ocular disorder.
or 11.3.1 Headache attributed to acute glaucoma.
or 11.3.2 Headache attributed to refractive errors.
or 11.3.3 Headache attributed to heterophoria or heterotropia.
or 11.3.4 Headache attributed to ocular inflammatory disorder.
• 11.4 Headache attributed to disorder ears.
• 11.5 Headache attributed to rhinosinusitis.
• 11.6 Headache attributed to disorder of teeth, jaws or related structures.
• 11.7 Headache or facial pain attributed to disorder of the temporomandibular joint.
• 11.8 Headache attributed to other disorder of the skull, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures.
12. Headache attributed to psychiatric disorder.
• 12.1 Headache attributed to somatization disorder.
• 12.2 Headache attributed to psychotic disorder.
13. Cranial neuralgias and central causes of facial pain.
• Neuralgia 13.1 trigeminal.
or 13.1.1 Classical trigeminal neuralgia. 13.1.2
or symptomatic trigeminal neuralgia.
• Glossopharyngeal neuralgia 13.2.
or 13.2.1 Classical glossopharyngeal neuralgia.
or 13.2.2 Symptomatic glossopharyngeal neuralgia.
• intermediate nerve neuralgia 13.3.
• 13.4 superior laryngeal neuralgia. • 13.5 nasociliary
Neuralgia.
• 13.6 Supraorbital neuralgia.
• 13.7 Other terminal branch neuralgias.
• occipital neuralgia 13.8. • 13.9
neck-tongue syndrome.
• External compression headache 13.10. • Headache
stimuli 13.11 cold. 13.11.1Cefalea
or attributed to external application of a cold stimulus
. 13.11.2Cefalea
or attributed to ingestion or inhalation of a cold stimulus
.
• 13.12 Constant pain caused by compression, irritation or distortion
cranial nerves or upper cervical roots by structural lesions
. • Optic neuritis
13.13.
ocular diabetic neuropathy • 13.14. 13.15
• Headache or facial pain attributed to herpes zoster. 13.15.1
or headache or facial pain attributed to acute herpes zoster. 13.15.2
or post-herpetic neuralgia.
• 13.16 Tolosa-Hunt syndrome.
• 13.17 "Migraine" ophthalmoplegic.
• 13.18 Central causes facial pain. 13.18.1Anestesia
or painful. 13.18.2Dolor
or central post-stroke. 13.18.3Dolor
facial or attributed to multiple sclerosis. 13.18.4Dolor
or persistent idiopathic facial. 13.18.5Síndrome
or burning of the mouth.
• 13.19 Other cranial neuralgia or other centrally mediated facial pain.
14. Other types of headache, cranial neuralgia, central or primary facial pain.
• 14.1 Headache not elsewhere classified.
• 14.2 Headache unspecified.

REFERENCES 1 .- Catalog Medicines.

Prepared by the technical department of the General Council of Official Colleges of Pharmacists. 2 .- Memorix

, particularly Neurology. Peter Berlit. Grass editions

Dr. Miguel Perez-Camacho Duque

ICAPSI

Director of

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The Ethos of Psychiatry (2 nd part)

SUMMARY

At best part of the moral and medical ethics, attempt to elucidate the basic principles and more specific "ethos" of psychiatry.

The relevance of psychiatry and medical psychology in the field of medical humanism, the plight of the values \u200b\u200bof modern civilization, the repeated declarations of human rights, etc ... are among many others, the motivations that lead us to an analysis of the substrate of ethics, codes of morality, ie, the "ethos". Before visions

monopole of psychiatric medical practice that run from the pessimism of the degradation exaltation to the most unlikely of ripening attempts to present the "ethos" present the same with the greatest objectivity related to the past and present of the historical development of ethical awareness, and particularly with the recent "universal declarations of rights humans. "

dynamic reality, and thus, changing the man, forced to watch for signs of the times to be lit whenever the valid characters of the "ethos" in this case of psychiatry, and it can be well aware that set at any time the conduct of all those involved with this medical specialty in a way must always be present in every act of health.

THE ETHOS OF PSYCHIATRY

Prof. Dr. D. Alfonso Ruiz-Mateos M ª Jiménez de Tejada



CONTENTS 1. Introduction.

2. Ethos: feelings versus noesis.

3. Basic tenets of the ethos of psychiatry.


1. Introduction.

Within the broad framework of medical ethics and moral interests have always lit the basic principles and more specific to the ethos of psychiatry. Its relevance and of medical psychology in the field of medical humanism, the plight of the values \u200b\u200bof modern civilization; the repeated declarations of human rights, etc ... are, among many others, the motivations that lead us to an analysis of the substrate of ethics, codes, etc ... that is the ethos. To visions of medical practice monopolar psychiatric pessimism flowing from the degradation to the most unlikely of maturation exaltation; try to present the current ethos of it as objectively related to the past and present historical development of ethical awareness and particularly with the recent "universal declarations of human rights." Dynamic reality and thus, changing man requires to be Watch for signs of the times to always have clarified the ethos valid characters-in this case of psychiatry, and well aware that they can be configured at any time the conduct of all those involved with this medical specialty, in a way , must always be present in every act of health.

2. Ethos: feeling versus noesis.

When specifically specify the location of the ethos within the complexity of the human person, the Western tradition has pried the intellect and volition. Our position, however, prefers the hegemony of deep feelings. Although the ethos of the person to surface as reality unitary does not consider that his first existential intelligence, but deep feelings. In the latter lies the conception, gestation and birth of the world of ideas, specific formulations of the rules of conduct. From this perspective, we assume the following qualifications that Ortega y Gasset makes between ethos, ethics and morality: "I understand ethos simply moral reaction system operating in the spontaneity of each individual, class, people, period. The ethos is no ethics or morals that we have. Ethics are the ideological justification of a moral and, ultimately, a science. Morality is the ideal set of rules that might accept to mind, but often do not deliver. More or less the moral is always a Utopia. The ethos, by contrast, would be like the real moral, effective and in fact spontaneous reports every life "(1954)

Towards a clarification of concepts have an influence on what we have come to call passion and defect defined. Mean by ethos: the set of autonomous deep feelings, and only accidentally conditioned to emerge from the privacy of the person in relation to the world of values, their hierarchy and commitment to them.

points out: Deep in the sense that the semantics of the term mystical has Hondón and in a way, Endon of psychiatric nosology as these terms refer to roots (set of backgrounds, interests, habits or effects that are firm and stable one thing), in contrast, for both sentimental feelings fleeting or superficial as noetic regulations originating from mere socio-cultural inclinations. Autonomous: with this we note that there are intrinsic feelings of the human condition, feelings associated with their own selfhood, unchanged in its essential core of which are very irritating to exogenous stimuli that they face in their historic journey. Values: in the sense of the scope of the meaning and importance from any reality as seen from the greater or less relevance to the harmonious integration and maturant of the individual and groups.

3. Basic tenets of the ethos of psychiatry.

The most peculiar qualitative distinction of psychiatry branch is to be the quintessential humanistic or anthropological medicine. Psychiatry and Medical Psychology must be considered as "substantially" in any medical act. Anthropological significance of this arises with maximum emphasis the uniqueness and relevance of the ethos of both disciplines.

The aim of medicine is the person, or be really patient, if we consider preventive medicine, but the particular object of the medical act constitutes the dual phenomena and interactions of interpersonal encounter. On this fact rests the core of the medical ethos and are the Psychiatry and Psychology in charge of science research and teaching of this phenomenon, the most complex and sublime, no doubt, of medical practice. The meeting brings

as unambiguous ethical traits: respect sacred, fidelity, reverence, sincerity, trust, etc ... You can only view of the ideal posture, which comes from the reception open to the boundless respect, commitment to the highest value intramundane and integrating it. These qualities should be further enhanced as the you-the specifics of psychiatry, is a patient, suggestive but imprecisely called mentally ill. His status as a person, as such, unrepeatable uniqueness and personality changes will force more emphasis on maintaining a holistic approach, open to any sign clarifier with explicit awareness of the aphorism: "In homine nunquam satis."

The ethos of Psychiatry expresses its full meaning when it is this that "the most intense experience of personal freedom is love. It is paradoxical that while the subject is itself its center and it belongs only to itself is not really even himself. But when it comes out of himself and takes over the other to himself, receive from his hand his true self "(Romano Guardini, 1954)

consider among the most dire violations of the ethos of psychiatry positions that seek to make tight what is merely ontic and parcel in all. The history of psychiatry remains a sad spectacle of isolated, folded and loaded into single-colored visions of bravado and aggression. The ethos that emanates from the consciousness of the person as essentially true mystery and therefore incomprehensible to all professional forces of psychiatry to maintain an attitude of scientific humility, eclectic and open to any clarification. Somatogenic dimensions, psychogenic and sociogenic of the person with his character immanent and inescapable religious significance, are premises that can not be ignored for the correct formation of the ethos and practice of psychiatry.

The psychiatry professional shall maintain a special warning that its ethos is not manipulated by outside interests of his own scientific work and humanitarian. It must be aware that when psychiatry branch of medical humanism par excellence, is the favorite target of interest bastards intrusions originating from political, economic, pseudo, etc ... We can not accept the claim with confidence to those who believe that psychiatric ethics can only be accommodated in particular areas. Thus we find the more extreme options that run from the prying of exclusivist form of private medicine, even those who only support the hospitals. We believe in it, and we place a major emphasis, that the ethos of psychiatry and its correct implementation, where there will be a pro with a properly formed conscience and committed, able to maintain their beliefs over all the constraints that can come from the environment or its own fragility.


* Professor of Psychiatry, Neurology Alfonsiana-Rome University, Doctor of Theology, Sociology and Medicine, President of the Royal Academy of Medical Writers and Member of Scientific Committee of the Canarian Institute of Psychiatry.

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THE ETHOS OF PSYCHIATRY

(1 ª part)

Prof. Dr. D. Alfonso Ruiz-Mateos M ª Jiménez de Tejada (*).


With this contribution of Professor. D. Alfonso Maria Ruiz-Mateos on Ethos of Psychiatry ICAPSI the grandstand is enriched in wisdom and knowledge, which is why all of us in the Institute does not have the words to thank you for your generous, generous and selfless cooperation.

Once again we show your great humanity, generosity, kindness and good nature.

On behalf of the Institute, thank you very much and a hug with my friend.

Miguel Pérez-Camacho Duque
ICAPSI Director of

CONTENTS 1. Ethos.

2. Ethos: The primacy of feeling.

3. Basic tenets of the ethos of psychiatry.

- Ethos relevance of psychiatry in the field of medicine.

- Considerations on the ethos of the psychiatrist.

- The formation of the ethos.


"Considering that freedom, justice and peace in the world are based on the recognition of the inherent dignity and of all equal and inalienable rights of all members of the human family."

"Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of humanity (...)"

Let me are these two preambles of the Universal Declaration of Human Rights adopted and proclaimed the December 10th of 1948 by the General Assembly of the United Nations, to spearhead this contribution. Together with them I would also note that the medical profession, if we leave aside the strictly religious, has been the first to ensure its "ethos" with promises, oaths and codes of ethics or conduct. The "Hippocratic Oath" does go into medical awareness since its first formulation in the fourth century BC Today, most medical schools still continue the tradition of commitment or explicit pledge, use the Geneva Declaration approved by the Association World Medical in September 1948. This statement is mainly based on the classic Hippocratic Oath. Just want to highlight two postulates:

- "I shall exercise my profession with conscience and dignity"
- "The health of my patient will be my first concern."

From the "Hippocratic Oath", unions and similar institutions and, in recent decades, the WHO ., Have tried to capture the ethos doctor and adapt to the different requirements of the process of civilization by formulations Codes , declarations, letters, etc ... (See pages of notes an overview of the main contributions in this regard from the year 1947) (1)

1. Ethos.

In the Hellenic world the word "ethos" conjures up different meanings. The most primitive means "dwelling", "residence", "place where one lives." In this respect has been highlighted by the current particularly existentialist M. Heidegger: "dwelling place of being," "human style of dwelling and dwelling." The acceptance, however, more common and has been imposed, especially after the influence of thought artistotélico, refers to "character" or "way of being" (2) even more, "he pointed out the semantics of the" ethos ", it should be noted that when he was writing" Epsilon "(" e "soon) referred to the concept of" usual "whereas if it was written with" eta "(" e "long) are designated" confidential. " These two contents would later be joined in the Latino culture in one word: "we", but with the serious danger to the ethic that has greater resonance meaning "custom" than "character." (3) St. Thomas and went the passage of this danger:

"Mos can mean two things: sometimes has the usual meaning, other means a natural or near natural inclination to do something, in this sense it is said that the animals are accustomed. For this double meaning in Latin is a word, but in Greek has two words "(4)

The contemporary writers in the ethical and moral issue, giving more importance in the nuclear configuration of this science to the" ethos "character" that the "ethos" custom. "

But at this point we want to clarify the meaning of character. It is interesting to see how the philosophers of ethics rely on this subject to the contributions of medicine, particularly psychiatry and psychology, as was presumably have found ambiguity and ambiguous reality with which the word "character" goes through these sciences. Recall, by way of example, the attempt to Kretschemer to differentiate the different temperaments under the generic title: "Constitution and Character."

The desire to define the terms "temperament" and "character" appears in most writers. The tension seemed sedated with simplistic to relegate to a word like so many semantic resonances the "temperament" plots that seemed lowest in the mind, that is, apparently linked to the somatic substrate: the sensitive, instinctive and emotional. Leaving located under the term "character" (from "thickets", "jaracter" burn, carve, mark) the phenomena considered above: the volition and intellect. The character would, therefore, to mean behavior, behavior in the person's usual responses, according to the dictates of the will and intellect. With these constraints the "ethos" could have found its proper place within the complexity leaving human stereotyped in the world of volition and intellect, that simple. But, of course, these abstractions are faced again with the ends of an infinitely more sophisticated knot which tied the yoke to the chariot of the king launches Phrygians, the Gordian immortalized. The phenomenon of the human person is presented, first as a singular originality and unity, but on the other, or better, and for all, as unfathomable mystery, a microcosm of the macrocosm, or, if preferred, the reverse.

As the subject of psychiatry has "the whole man." But who would not shudder that goal, which evokes apprehension vaunted courage and presumptuous as impossible.

is logical that we have made use of all techniques at our disposal for dissection. After the continuous search for clarifying stratifications - (remember the most recent the Rothacker, Kleist and Braun, Hartmann, Hoffmann, Ortega , etc ...)- conclude once again that it is useless: the human being beyond all attempts to subdivisions. Herein lies the greatness and the risk "tragic" in the sense-of Psychiatry krestschemeriano. The recurring waves of tests to capture and systematize the infinite resonance of the person hitting the seawall will nebulous mystery-what. Eventually paraphrasing end one way or another Janet synthesis :

"Il n'est pas juste dire que l'homme of thought are cerveau avec, ce n'est pas avec are cerveau c'est qu'il pense avec are corps tout entier. Il pense avec ses doigts, il pense avec ses pieds, avec are ventre avec comme il pense are cerveau, il pense avec l'ensemble "(5)

Synthesis, indeed, very poor because you miss nothing less than the dimension history of the human journey, past and future draft of this ambiguous anchor.

Where is, therefore, located the "ethos"? M. Vidal highlights the contributions in this regard Aranguren of JLL relating the "ethos" (moral) with the "pathos" (spirit).

"The ethical and the pathic have an affinity that deserves special attention. The same could be said for the aesthetic, according to the formulas 'nulla aestethica ethica sine' and 'sine nulla ethica aestethica'. " (6)

The author considers that it has been Aranguren who has studied more originality with the notion of "spirit" and its relationship to the "personality" (7)

"The" pathos "or spirit is our way of find good, bad, sad, confident, fearful, desperate, etc, in reality. The "pathos" is not dependent on us, on the contrary, we who are with him and in him. That's exactly why Heidegger was able to speak the "Geworfenheit." We have been set in the world "dumped" on him, or rather sent to him with a hope or anxiety radical, permanent fund that leaves little to the surface of the changing moods, feelings and passions "(8) Before

this last statement: "leaves little to the surface, I think that practitioners of psychiatry Aranguren would invite some contacts, but other than passengers, to clinical reality. The author continues:

"Facing the main irrationalism of Heidegger the mood is not the first existential, not our first opening to the reality or world, it naturally assumes the" intelligence "understood as being in reality and as the constitution of that world after the "pathos" is going to color emotionally cold or burning range, with a dark palette or burning "(9)
pathos and ethos, spirit and character, are thus correlative concepts. If "pathos" or spirit is by nature how to deal with reality, "ethos" or character is the way the habit of dealing with that same reality ... Mood and character are therefore two opposite poles of the ethical life; premoral one, the other truly moral. But it matters much to note that are separable only by abstraction ... The man is a radical unity that involves feelings of intelligence itself, nature and morality, spirit and character "(10)

2. Ethos: The primacy of feeling.

The concept of "spirit" in Aranguren, hegemony, he gives as the first existential intelligence and the fact of reducing the complex phenomenon of the "ethos" to how to deal with the habit "reality" requires, in my opinion, great qualifications.

Clearly, as we have noted, that any attempt to dissect the vital unity of human beings is only possible through the power of abstraction of the intellect.

Abstraction is always the basic tool of all sciences, including anthropology. We can not do without it. But we must remain always on alert, especially in psychological and psychiatric sciences-not to make a real finding, but plot in ontic and absolute. Here lies, in my opinion, one of the most dismal failures, the one that has produced tensions within the "ethos" of psychiatry. (11)

bipolar tension between pathos and ethos, spirit and character, and the status of "pre-moral" for the first come to influence the Socratic conception of the man who has exerted so much influence on Western civilization . Remember how St. Paul picked up the knowledge of his time about giving a Christian orientation:

"For the flesh has desires against the spirit and the spirit against the flesh, as being antagonistic to each other, so do not do what you would. But if you are led by the Spirit, ye are not under the law "(12)

The dichotomy between "lust" and "why" question in our conception of man. Attempts to new approaches have only achieved most of the time, falling into the playful world of semantic changes.

remember the "Lustprincip" or the pleasure principle and the "Realitatsprincip" or the reality principle of Freudian phenomenology.

Particularly eloquent in this respect is the reference to "estimate of instincts and instinctive change" of E. Kretschemer :

"Man is the tragic animal. While his instincts have not been modified and not nearly remain in an archaic level, their intellectual development is completed so quickly that all the works of reason becomes an instrument of destruction. The animal man is tragic. Today, although part so as primitive and extol So instinctive is not enough to govern with confidence, not reason enough to take over the instincts. Are we so chanting slogans and disparaging fashion right? Never again!. The reason has more downside than most men do not have it in far enough "(13)

I think we need a different orientation to illuminate the substrate deepest ethos. Tension "pathos" - "ethos" sins of the simplistic dichotomy referred to above, because the dialectical drama hangs the so-called "lower psyche" (feeling, instinct, inclination) against the "superior psyche" (intellect, volition) but any of the layers of the human person. We could look instincts versus instinct affectivity versus affective, etc ... I agree with the statement López Ibor :

"The truth is not in the dilemma but in the copulative (...) layer theory is just that: a theory used to better interpret and describe the facts , and only the heuristic value is taken in these pages. These differences in description and drawings of separation of the layers show its relativity: if human beings were formed, really, for three overlapping blocks, there would be doubts about the topography of the fissures separating blocks "(14)

In Indeed, the authors mentioned above also support this line of thought. But the issue of the overlapping of "ethos", but to surface the person as unitary reality, does not consider that his first existential intelligence, but deep feelings. The "ethos" has experienced, especially in the West, a course similar to the word culture. The old Socratic thesis that human behavior is the sequel expressive world of ideas has been highlighted in a primary-say, overwhelming, in our civilizations. If we take a dictionary of the languages \u200b\u200bof our countries we see that the word "culture" is referred to in preference to the noesis or ideological enrichment. Our lability of equating culture with bookish and information is evident. How often in contact with people "illiterate" but in balance with "nature-natural" as we say today, I found its existential meaning and behavior to the big questions of human metaphysics to the point of questioning: Who are the educated or cultivated; them illiterate or I appointed my bookish background?

psychiatric anthropology long ago discovered that the real driving force of the person, both individual and collective dynamics, is affected. "What is the actual emotional" is an aphorism that I like to bring up whenever I can. Recall Augustine's outburst: "Amor meus pondus meum!"

"Every body weight tends to place his own. The weight tends not just down, but into place. Tends the fire up, down the stone. Your weight carries, at its own site van. Spilled oil on the water rises above the water, and water spilled over the oil under the oil húndese; carries weight, go to your own site. What is restless messy, once ordered to rest. My weight is love, takes me wherever I am born "(15)

apparently only the noetic, the concrete world of ideas is what triggers the inventions, great and small revolutions. But I think being consistent in saying that the real managers and Birth "of ideas are deep feelings. Moreover, the feeling is one that allows the opening and reception of the receiver, which achieves the vital counterpoint which is the encounter of all aesthetic pleasure. The ideas we slide if they fail to stimulate the resonances of our emotional life. We are faced with complex circles of interactions and reciprocal influences arising from the unity of the person charged with a wide range of springs and resonances. But if we raise the issue in the field of priorities, in the sense of the primacy hierarchy when punching the psychic world of the person, and even in a chronological order, our position is tilted strongly for the priority of feelings . The old scholastic argument that human beings are born "tamquam tabula rasa" has been sufficiently overcome by the present knowledge about the "genetic memory." The term "memory" also runs the danger of being referred primarily to the world of the ideal. Not so. Physiologically, the formation of engrams affects primarily in the complex world of feelings. Mean by "engrafía" according to Semon:

"the process by which the stimuli cease definitive and permanent traces in the protoplasm of the cells" (16)

features therefore can be hereditary. Have enjoyed much CG Jung with current contributions of science to have a physiological substrate to justify the possibility of "collective unconscious" and "archetypes" realities that otherwise arouse the sentiments: the irrationality in the depths of the human. (17)

rational psychology found that habits are the result of repeated acts. That statement is a part of the truth and, without doubt, the most insignificant. Is valid when it comes to the plot of the nervous system mainly responsible for learning, improving coordination and voluntary exercise. The virtuosity of the pianist would be impossible without a prior persistent repetition. But the formation of engrams at the core of the brain substrate of feelings, do not follow the assumption of repeated acts as prerequisite. A single stimulus celebrated with great emotional intensity can be much more efficient to leave an indelible mark that repeating the same without emotional resonance. Still in the learning and development of voluntary exercise is necessary to emphasize the importance of attention and interest, phenomena linked to full affect. In short, when I say that "the affective is the actual" no attempt to marginalize any other aspect of personal events, but stress the primacy that have deep feelings in a holistic perspective of human dynamics. If so, is the deep feelings that we must consider the roots more originating in the formation of the "ethos." From these observations admit Ortega makes differentiation between "ethos", "ethical science" and "morality."

"I understand" ethos "is simply the system of moral reactions that act in the spontaneity of each individual, class, people, period. The "ethos" is not the ethics or morality we have. Ethics are the ideological justification of a moral and, ultimately, a science. Morality is the ideal set of rules that may accept with the mind, but often do not deliver. More or less the moral is always a utopia. The "ethos", however, would be like the real moral, effective and in fact spontaneous reports every life. " (18)

The need to initial feelings of awareness when the "ethos" of psychiatry seems more urgent since most have had the same risk of being marginalized by certain currents of contemporary psychology. Contain much of the recent real lines:

"If something quickly and effectively characterized the psychological reality of man in his natural size, are the feelings. However, scientific psychology soon dispensed of this important human dimension. Behaviorism, first, due to its attempt to rely exclusively on the stimulus-behavior and cognitive psychology later, due to its complex system of computer interpretation of human behavior, feelings left the field of philosophy "(19)

Before concluding this section fall into what I once called passion and define default yes, throwing a definition of the term "ethos": the set of autonomous and conditioned deep feelings that emerge from the privacy of the person in relation the world of values, their hierarchy and commitment to them.

points out:

"Deep" in the sense that the semantic mysticism has given the word "Hondón" and, in some way, the "endo", "Endon", "endogeneity" of psychiatric nosology, as these words refer to "roots": "set of backgrounds, interests, habits, or effects that are firm and stable one thing or prevent its replacement or amendment." In contrast, for both sentimental feelings fleeting or superficial as mere rules noetic native socio-cultural inclinations.

"autonomous" to we want to emphasize that feelings are intrinsic to the human condition, feelings associated with their own selfhood, unconditioned or ininfluenciables in its essential core that are very irritated by exogenous stimuli.

"The archetypes have had engendered in the human being and not merely as a residue of past experiences. This is something that corresponds to the essential properties of being. If there is the myth of the hero is because there is a tendency in man power and the irrational parent domain. In my view, we must not forget the needs or responsibilities of the human being or, what is, 'the irrational in man' "(20)

"Securities" within the meaning of "scope of the meaning and importance of any reality" as seen from the degree of relevance and maturant harmonious integration of individuals and groups.

3. Basic tenets of the ethos of psychiatry.

- Ethos relevance of psychiatry in the field of medicine

To B. Häring ethos:

"includes those attitudes that characterize distinctive culture or as a professional group or profession that this culture holds a position that demonstrates the commitment to certain values \u200b\u200band hierarchy of values" (21)

What we want to emphasize is the relationship that the author makes between "ethos" and profession:

"A truly significant use of the term" ethos "includes membership of a profession, understood as a vocation in the sense of irrevocable to the community service and dedication to values \u200b\u200brather than financial gain (...) The "ethos" arises within the profession and more specifically formulated for those who represent a common way, for those who through history have been as models for the profession "(22)

is clear that my concept of" ethos "no coincides with that of Häring, but I think that his reference to the professional it can be useful to delve and specifically in the field of psychiatry. Alonso Fernández

begins his book "Fundamentals of Current Psychiatry," with these words:

"The qualitative and quantitative importance of psychiatry indicates that we have a discipline that is not simply a more medical specialty. Its most distinctive qualitative distinction is to be humanistic or anthropological branch of medicine par excellence "(23)

using scholastic terminology I like to say that psychiatry and his inseparable companion medical psychology, are the substantial form of all medical procedures. The object of medicine is the patient, or the presumed patient, if we consider the preventive dimension, but the object of the medical act constitutes the dual phenomenon and interacted personal encounter.

"Meeting is more than the mere juxtaposition of things and living beings, where the interactions come conditioned by the corresponding forms of relationship. Such a way of being together is done continuously in the lives of men since the crash and fall to their very complicated processes of social mechanism.
But I find something very different. Meeting means that the man was taken to a thing or a living and above all to another man, considers its form, sees its core value, is wounded by his power ... So I can I find the sea or a tree: a man who until now was unknown to me or who had been to many times. I am struck by lightning of his being, I am touched by their action. The relationship was consummated when the other man also "found" and I just. Then there is the found and determined to be mutual.
The man then is made not only for the interaction with other beings, but for the meeting and confirmation is made. There is reference to the other and the other, and while "referred to to "be done is built up and he gets to eat (...) While" you "whole community enters, walks to the real" me. " The most intense experience of personal freedom is love. It is paradoxical that while the subject is the center itself and only itself is still not properly part of himself. But when it comes out of himself and takes over the other to himself, receive from his hand his true self. (24)

If the core of the medical task is the "interpersonal encounter" and Psychiatry and Medical Psychology is the science charge research and teaching of this reality, without a doubt the most sublime and transcendent sound not to boast that consider the "substantial form" of a "material object" in this case would be the whole of medicine. When you do not like the scholastic terminology of coprincipios metaphysical sense I can accept it in analog or if you prefer, metaphorical.

In this pillar, "interpersonal encounter" is supported by the "ethos" of psychiatry with characters that go beyond any possibility of synthesis.

- Considerations on the ethos of the psychiatrist.

The person-to-person and plunges us phenomenon in the incomprehensible and the realities mysteric intramundane.

Before the "you" only be an ideal position, which stems from the reception open to the elusive respect, commitment and integration. These qualities should be heightened, exalted, when the "you"-the specific-psychiatry is sick, but vaguely suggestive dominated, mentally. Its status as such person, unrepeatable uniqueness and personality altered, requires, further, to an open attitude to any sign clarifier with explicit awareness in the aphorism: "In homine nunquam satis."

"What dialogue is essentially personal. Is "you" oriented toward a "you" with whom contact is through the word. On the other hand is something essentially ineffable as it is rooted in the mysterious world of interiority. Any person implies a being and a being that is, to some extent, common to others. In this sense the person is communicable. But also includes something that is simple yet one time. In this other sense the person is incommunicable because language can not convey, but common values. The person is incommunicable both the level of being and in knowledge. Can not be fully understood. Certainly a person can be treated as a thing in nature, but it is a sad fate, which in our world, get to do the "you" thing. " (Buber ). Since in this case the person ceases to be itself a person. A person can never be in the hands of others, but just opposite. Everyone is necessarily closed in on itself. Can not be forced from outside (...) The personal is therefore still view things naturally, a terrifying mystery that can not be known and analyzed intellectually, but only lived with mutual love and treatment "(25)
From these reflections
denounce one of the violations, in my opinion, most unfortunate of the "ethos" psychiatrist. Trying to convert what is merely plot in ontic and absolute dogmatism affecting even paradoxical. And welcome to the libido, overcome, the ancestral, etc ... all contributions from a dimension somatogenic, psychogenic or sociogenic, etc ... But please, be unable to maintain the scientific spirit that comes from true humility that man is overwhelming and that any attempt to close it down into small tight connotes typical bravado of ignorance or, worse yet, of evil? (26) The eclectic positions can be considered as products of faint-hearted or half-hearted spirits. But the eclectic, understood as an attitude radically open to any suggestions that might help to clarify the true mystery of the human being is not the position of cowards but born of an "ethos" conscious and coherent.

Alongside this phenomenon should also release the report of the tremendous tensions that exist among many professionals in psychiatry originating from motives which I sincerely miss. I understand that the psychiatrist, like any professional experience in overcoming embarrassment justified towards chairs or other leadership positions. This is cause for some behavior disorders, given the structure of the society we live in, it happens in all fields thereof. But I want to point to not know what kind of demons are all aware that there are "giving a very negative image of our profession, especially when we dare to throw it, justifiably, as the quintessential branch of humanism and medical anthropology.

Sometimes I have the impression that we have become to psychiatry in a sort of twit whose Pandorga or Claymore or lashes need to be a bit too clever or committed to escape. Anyone who has come to this area by vocation, not easy to stand up to the value of it, and willing to fight a common front in which every effort will always be insufficient, the danger of discouragement with the sad reality of disunity of the most obligations are mutual or integration.

Another serious threat to the ethos of the psychiatrist latitudes comes from foreign to our discipline. Notice how the current controversy of psychiatry has exceeded its own hurdles and becomes the target of sociological theories, economic, political, etc ... In them we show that psychiatry is the branch humanistic par excellence, as such, the more weightless and, therefore, the more helpless for any upstart. Little chance to penetrate and attack are presented to political ideologues, for example, handle specialties such as ophthalmology and otolaryngology from his own scientific work.

But, gentlemen, good will speak out on behalf of all who want to do psychiatry, psychiatry, anthropology open to all, cry out that enough of rude intrusions, which are too long ears not to assume the wolf that sustains them.

cudgels on behalf of the "ethos" of the thousands of professionals who each day are torn between anguish, anxiety, delusions, irreversible damage ... seem unnecessary. But observing that lurks easy wit and irony to sarcasm referring to our patients and, of course, the psychiatrist, we seemed to poor box Velázquez thousand spears. I remember when a venerable teacher found out that I had done my psychiatrist after raids theological and anthropological, whatever occurred to him say was: "Please, a psychiatrist is not nothing but a mad doctor or a doctor crazy." While the joke laughed paraphrased the Pauline phrase:

"For myself would be" crazy "(anathema) from Christ for my brethren, my kinsmen according to the flesh ..." (27)

For all they know of anguish in the flesh, mostly comments. To the stranger who ignore it, we waited until the anguish he was struck in an unexpected turn a corner unexpectedly.

- The formation of the ethos.

Psychiatry long ago discovered that the only skeleton key able to open the privacy of individuals, to the point of being able to achieve therapeutic conversion was not the clarification or noetic imposition of rationalizations, but the emotional empathy, appropriate management transference and countertransference, the empowerment of all crack integrator "Hondón." Not to undervalue the information - would be absurd! - But again exclusive on the polarization it entails an impoverishment of the "ethos" of the consequences seems to resent greatly the current practice of psychiatry.

numerous voices are rising aim to raise awareness that we are witnessing a profound and rapid deterioration of medical ethics and specifically psychiatry especially in the core: doctor-patient relationship.

Perhaps the "ethos" and psychiatric humanism may apply to the same criticism that M. Heidegger was the knowledge of man.

No era has been much discussion of humanism as ours, none has had so many media to propagate their ideas and convictions as ours and no desire pessimistic, perhaps none is attending a higher degradation. Clearly that is not falter even information that lately, in most of our faculties, the Ethics as a subject has ceased to exist.

I think the "ethos" is fermented and stimulates the need for original and innate in man's inner and learn and shapes what you have to acquire, primarily through contact with authentic teachers. This line of thought is the venerable colleagues who have supported and led them to resist the ethics as a subject of the race. For them the only effective teacher ethos and ethics was the climate that all medical students had to breathe in every corner of their respective faculties.

personally think that both aspects are necessary for the formation of the "ethos", but also give primacy to the latter.

finish this work dedicating my admiration and reverence to all colleagues, true masters of psychiatry, who, faithful to its commitment to the ethos in store us the opportunity to be focused and not get lost in the fog.



NOTES

1. - International Code Nuremberg, on human experimentation, in response to abuses during the war were made in experiments on human beings.
2 .- Geneva Declaration (ratified in Sydney in 1,968). 3 .- Code

London (III General Assembly of the World Medical Association).
4 .- Declaration of the Principles on Medical Certificates.
5 .- Rules of Ethics for wartime.
6 .- Declaration of Helsinki (revised in Tokyo in 1975 by the XXIX General Assembly of the WMA)
7 .- Ethical Principles of Social Medicine (ratified in Madrid for the XXI General Assembly in 1967)
8 .- Medical Letter Social Nuremberg.
9 .- Letter of Doctors Hospital of the Standing Committee of Doctors of the European Economic Community.
10 .- Charter of Salaried Doctors (Brussels).
11 .- Letter of Medical Work (Brussels).
12 .- Oslo Declaration (on therapeutic abortion).
13 .- Tokyo Declaration (on torture).
14 .- Declaration of Hawaii (on psychological treatments). Simultaneously

are changing the various national codes.

In Spain, approving the Code of Ethics developed and sponsored by the General Council of Official Colleges of Physicians and sanctioned in April 1979 by the Ministry of Health and Social Security.

As background to these attempts at codification, we have in Spain Medical Ethics Rules established in a circular of the Supreme Board of Health in 1964. This circular sets out the social role of the physician, regarding it as "health officer" officially required to report situations that involve damage to health.

hospital patient's constitution

"recently approved by the Council of Europe, a document which broadly reflects the fundamental rights of the sick and hospitalized. Among other points they specify the right to religious freedom philosophy, the right to claim and be informed about the state of health, the right to accept or refuse medical intervention and the possibility of seeking advance information on possible risks, respect for privacy, the dignity of the individual in a word, the right to be cared for properly.

The preparation of the letter has taken several years of discussions and studies and a large number of expert meetings. The principles that inspire it emerged from the universal declaration of human rights, the European Social Charter, the international convention of the United Nations on economic, social and cultural rights and the resolutions of the Organization World Health Organization, WHO, adopted in this regard. Its real implementation at national level requires a domestic regulation. Hospitals, in turn, must acquire the means to implement them. "

15. Aranguren, JLL: "Ethics." Madrid, 1972 (21-25)

16. Vidal, M.: "Moral Attitudes" Volume I. Madrid, 1981 (19-20)

17. St. Thomas, "Summa Theologica I-II, 9.58 to 1

18. Confer: Lopez-Ibor, JJ, "Lessons of Medical Psychology." Madrid, 1968 (Volume I -23)

19. Vidal, M.: 1c (23-24)

20. Ibd. 24

21. Aranguren, JLL: 346
1.c
22. Ibd.

346 23. Ibd. 348-349

24. I have discussed the issue at greater length: "Medical Ethics and New Constraints of Culture." Proceedings of the Second Conference: Ethics, Law and Medicine. Medical College of Madrid. 21 to 25 May 1979.

25. San Pablo ad Galatas: V ,17-18; ad Romans VII, 19.

26. Confer: Witbrecht, HJ: "Manual of Psychiatry." Madrid, 1970 (627)

27. Lopez-Ibor, JJ: 1.c 23-24.

28. St. Augustine: "Confessions" XIII, 10 (Vega) 442-3

29. Dorland: "Dictionary Medical Sciences. " Buenos Aires, 1,965 "engram", "engrafía."

30. Confer the importance given to the "irrationality" against the "technological rationality of our historical moment."
Ballbe, R. "The psychiatrist and contemporary man." Actas Luso-English Neurology and Psychiatry, 1981 9.2 (89-102)

31. Ortega y Gasset, J.: "Different Destinations." Works. Madrid, 1954 (506-507)

32. Cruz Hernández, M.: "The problem of feelings." Journal Ya 12 February 1982. This is a criticism of the work C. Recent Gurméndez: "Theory of feelings." Madrid, 1981

33. Lopez-Ibor, JJ: "Living" is just dreaming? Daily "ABC" in Madrid January 13, 1982

34. Häring, B.: "Moral and Medicine." Madrid, 1972 (31)

35. Ibd. 32

36. Alonso Fernandez, F., "Fundamentals of Current Psychiatry. Madrid, 1976 1

37. Romano Guardini: "Freedom, grace, and Fate" (S. Schost, 1954) 38.39

38. Schurr, V.: "preaching Christianity in the twentieth century." Madrid, 1956 (112)

39. Ruiz-Mateos, AM: "Medicine, Psychiatry and Morality." Whit # 50 from July to September. Madrid, 1977 (217) (In this work I have tried more complete discussion).

40. San Pablo. Rom. 9.3


* Professor of Psychiatry, Neurology Alfonsiana-Rome University, Doctor of Theology, Sociology and Medicine, President of the Royal Academy of Medical Writers and Member of Scientific Committee of the Canarian Institute of Psychiatry.