Crise suicidaire et maladie d’Alzheimer débutante : intérêt d’une analyse neuropsychologique détaillée

IntroductionThe role of Alzheimer's disease as a risk factor for suicide is unclear. The aim of this study was to understand neuropsychological component of the suicidal crisis in Alzheimer's disease.MethodUsing an extensive neuropsychological battery, different aspects of cognitive inhibition were particularly examined: Access to relevant information (using the Reading with distraction task), suppression of no longer relevant information (Trail Making Test, Rule Shift Cards), and restraint of cognitive resources to relevant information (Stroop test, Hayling Sentence Completion test, Go/No-Go). One female Alzheimer depressed case was assessed before and after a suicide attempt.ResultsTen days after the patient's suicide attempt, dementia was still moderate with a MMSE score at 21/30 but with a worsening of executive functions (FAB at 8/18) in the context of depression and suicide. The Hamilton-Depression Rating Scale was at 24 (maximal score at 52), and the Cornell Scale for Depression was at 21 (maximal score at 38). Suicidal intent was moderate with a score of 9 on the Beck Suicide Intent Scale (maximal score at 25). The patient did not present a delirium, psychotic symptoms, or anosognosia. Her episodic memory was altered as shown by her semantic performance on verbal fluency (naming 12 animals in 120 seconds) and on lexical fluency (naming 8 words beginning with the letter P). Initially preserved, executive function declined during a suicidal crisis in a context of depression in Alzheimer's disease case. Neuropsychological testing confirmed a dysexecutive syndrome (FAS at 8/18), with an impairment in her conceptualization capacity (MCST) and a deficit in cognitive inhibition and its access (reading task in the presence of distractors), deletion (TMT) and restraint (Stroop, Go/No-Go, Hayling) functions. Computed tomography has shown no signs of intracranial expansive process.ConclusionAssessing predictors of suicide and means of completion in patients with dementia may help the development of interventions to reduce risk of suicide among the growing population of individuals with dementia. Because of Alzheimer's-related cognitive inhibition impairment, identification and intervention addressing the complex issues of depression, executive dysfunction and dementia may help clinicians to mitigate the risk of suicide in patients with Alzheimer's disease.     

Anticipation et dépression

Depression can be seen as an anticipation disorder. Anticipation is a psychological mecanism underlying project. The study of depressed elderly with the “anticipation test” of M. Berta accentuates the psychic polarisation and implies the hypothesis of a “container” for the anticipation functioning.     

Malformation vasculaire cérébrale découverte dans le bilan pré-thrombolyse d’un infarctus cérébral. Impact sur la décision thérapeutique

Intravenous recombinant tissue plasminogen activator for acute ischemic stroke is contraindicated in patients harboring an asymptomatic intracranial vascular malformation, whether it is incidentally discovered at the time of the initial cerebral imaging or previously known. Because thrombolysis is associated with a risk of serious intracerebral hemorrhage, it is theoretically possible that this treatment increases the risk of bleeding or rupture of these malformations. However, this risk seems very low in clinical practice. We report two cases, one with a probable brainstem cavernous malformation treated with alteplase for a supratentorial ischemic stroke who developed just after treatment a fatal brainstem hemorrhage, and another one with asymptomatic dural arteriovenous fistula, treated by endovascular thrombectomy solely. This approach was safe and effective, and the patient had an endovascular embolization of the fistula one month later as it became symptomatic. Based on the literature, we discuss the bleeding risk of asymptomatic intracranial vascular malformations in acute ischemic stroke patients treated with alteplase, depending on the type of malformation (intracranial aneurysm, arteriovenous and cavernous malformation or fistula), and the alternative therapeutic options.     

Le rôle des facteurs psychologiques dans la réalisation d’une démarche de dépistage du VIH

Objectives

Despite of regional, national and international plans which have been implemented to struggle against the Human Immunodeficiency Virus (HIV), the global prevalence of this disease continues to increase. While the General Assembly of the United Nations is aiming at putting an end to the Acquired Immune Deficiency Syndrome (AIDS) epidemic in the world by 2030, it appears necessary to draw up the list of the main factors involved in the HIV test process. Indeed, a better knowledge of the factors, facilitating or hindering the uptake of a HIV screening test, enables to make more effective prevention campaigns which aim at improving people's knowledge of their serological status. The purpose of this article is to underline the impact of psychological factors involved in the HIV test process. From the literature reviews already established, the main psychological factors, facilitating or hindering the uptake of a HIV screening test have been identified.

Psychédéliques,psychothérapie et symbolisation : une revue de littérature dans le champ de la dépression

AimThis article proposes a literature review focused on the so-called “classic” psychedelics (LSD, psilocybin, DMT, and mescaline) and, more specifically, on their use in the psychotherapy of major depressive disorders and the way they affect symbolization processes.MethodAfter some introductory remarks on psychedelics and depressive disorders, we describe some modern clinical trials, and then explore the peculiar phenomenology occurring in the psychedelic experience, as well as its therapeutic effects on depressive symptoms. The underlying mechanisms are discussed from a perspective at the crossroads of cognitive neurosciences and psychoanalysis. We conclude with some reflections on the crucial role of the setting.ResultsThe results already obtained suggest that a single dose, taken in a supportive environment, may be sufficient to produce significant and immediate therapeutic effects, which are still present six months after the dose, although less so for some patients. Clinical response depends on the subjective aspects of the individual experience. More specifically, it seems correlated with the ability to “let go” and to allow autobiographical memories to emerge, along with the intense emotions they carry. It also relies on the presence and intensity of mystical-type experiences, characterized by feelings of “ego dissolution,” unity with everything, transcendence of space and time, and ineffability.DiscussionPsychedelic-assisted therapy seems to promote the emergence of primary processes and the lifting of defense mechanisms. Psychedelics would thus catalyze the resumption of symbolization processes, favoring in particular the integration of unconscious conflicts as well as the remodeling of pathogenic object relationships. On the neurobiological level, these processes would be underpinned by a decrease in the activity of the default mode network – sometimes considered the primary biologic substrate of the Freudian ego –, associated with an increase in brain entropy and in neuroplasticity. These different elements entail a decrease in depressive symptomatology, particularly ruminations. Common factors identified as the cause of positive changes in classical psychotherapies appear naturally amplified in the psychedelic experience, which requires the containing function of a therapist and a supportive clinical setting to allow a resumption of symbolic processes. To ensure the perpetuation of the observed transformations, which often exceed the simple withdrawal of symptoms, an extended psychotherapeutic monitoring would be appropriate.ConclusionThe psychedelic substance acts as a catalyst, allowing an access to otherwise inaccessible unconscious materials, which can then be processed both spontaneously and within the therapeutic relationship. Considering the data discussed in this review, we emphasize the need for further research exploring the potential of this treatment, which also offers the hope of a renewed dialogue between psychiatry and psychology, neurosciences and psychoanalysis.     

La découverte des propriétés antidépressives de la kétamine

Background

Depression is a frequent disease with a significant medico-economic impact. Conventional antidepressants have a delayed action and are ineffective in one third of cases. Discovery of ketamine's antidepressant effects these last years opens new perspectives for treatment-resistant depression.

Histoire de la kétamine et du psychédélisme

Ketamine's history begins in the fifties in Detroit, at Parke-Davis laboratories. In 1956, Maddox synthetized phencyclidine or PCP. Domino studied PCP effects in animals and in 1958, Greifenstein made the first trials of PCP in humans under the name of Sernyl. Sernyl elicited severe excitation with a prolonged postoperative recovery. Because of its psychedelic effects, it became a street-drug under the name of “angel dust”. Calvin Stevens synthesized ketamine in 1962. The drug was studied in humans in 1964, by Domino and Corssen who described the so-called “dissociative anesthesia”. Ketamine was patented in 1966 under the name of Ketalar for human use and was administered to soldiers during the Vietnam war. The psychedelic effects and the arrival of propofol prompted the shelving of ketamine. However, the discovery of the NMDA-receptor and its non-competitive inhibition by ketamine revolutionized the pathophysiology of hyperalgesia and mental functioning. In early 1990s, the discovery of opioid-induced hyperalgesia elicited a paradigm shift in the management of pain, and a comeback of ketamine, as an anti-hyperalgesic drug. Ketamine is nowadays under the spotlight in the field of treatment-resistant depression and has been proposed as a potential fast antidepressant in patients with high suicidal risk.     

Kétamine,dépression et suicide : vers une nouvelle classe d’antidépresseurs ?

Objectives

Major depressive disorder is a frequent and serious disease, which can result in suicide. Treatment resistance is frequent in this pathology and actual antidepressants need a few weeks before having a clinical efficacy. Ketamine is an NMDA antagonist used in anaesthesia for decades, and has shown since several years a fast and efficient antidepressant effect in patients with treatment-resistant depression.