L’éducation thérapeutique de patients souffrant de schizophrénie ayant commis ou pouvant commettre un ou des passage(s) à l’acte dangereux

Schizophrenia is a chronic mental pathology with polymorphous symptoms that have an invalidating impact on an emotional, interpersonal, behavioural and social level. In certain cases this pathology can increase the risk of self-harm or harm to others, making it necessary to put protocoles in place for specifically-adapted treatment, put forward notably by care units that deal with dangerous patients. The patient's therapeutic education, orientated towards acquiring knowledge about the illness and skills for dealing with it in day-to-day life, is now a recognised practice, having proven its effectiveness in the treatment of chronic psychiatric patients. There is significant interest in this method for treating dangerous mental patients. In this interview, the psychologist Diane Brulin-Solignac shares her knowledge and experience of this therapeutic practice.     

住院双相障碍与精神分裂症患者自知力水平的保护性因素

目的 探讨住院双相障碍与精神分裂症患者自知力水平及其保护性因素。方法 在广州市4家精神科住院部连续入组符合《国际疾病分类（第10版）》（ICD-10）双相障碍或精神分裂症诊断标准的患者465例。采用自编人口学及临床特征问卷、自知力与治疗态度问卷（ITAQ）进行调查，比较不同自知力水平患者的人口学和临床特征，采用两分类Logistic回归分析探讨自知力的保护因素。结果 年龄小（OR=0.977）、男性（OR=1.705）、曾经结婚或同居（OR=1.677）、诊断为双相障碍（OR=2.185）、最近一个月有悲观厌世（OR=2.663）、每天睡眠时间≥7小时（OR=1.620）、每周运动1~2次（OR=1.770）是住院双相障碍和精神分裂症患者自知力的保护因素。结论 住院双相障碍和精神分裂症患者自知力水平与多种人口学特征及临床特征相关。     

Phenomenology of OCD: Lessons from a large multicenter study and implications for ICD-11

This study aimed to investigate the phenomenology of obsessive–compulsive disorder (OCD), addressing specific questions about the nature of obsessions and compulsions, and to contribute to the World Health Organization's (WHO) revision of OCD diagnostic guidelines. Data from 1001 patients from the Brazilian Research Consortium on Obsessive–Compulsive Spectrum Disorders were used. Patients were evaluated by trained clinicians using validated instruments, including the Dimensional Yale–Brown Obsessive–Compulsive Scale, the University of Sao Paulo Sensory Phenomena Scale, and the Brown Assessment of Beliefs Scale. The aims were to compare the types of sensory phenomena (SP, subjective experiences that precede or accompany compulsions) in OCD patients with and without tic disorders and to determine the frequency of mental compulsions, the co-occurrence of obsessions and compulsions, and the range of insight. SP were common in the whole sample, but patients with tic disorders were more likely to have physical sensations and urges only. Mental compulsions occurred in the majority of OCD patients. It was extremely rare for OCD patients to have obsessions without compulsions. A wide range of insight into OCD beliefs was observed, with a small subset presenting no insight. The data generated from this large sample will help practicing clinicians appreciate the full range of OCD symptoms and confirm prior studies in smaller samples the degree to which insight varies. These findings also support specific revisions to the WHO's diagnostic guidelines for OCD, such as describing sensory phenomena, mental compulsions and level of insight, so that the world-wide recognition of this disabling disorder is increased.     

精神分裂症患者生活质量与自知力及精神症状的关系

目的:探讨精神分裂症患者自知力及精神症状对生活质量的影响。方法:选取符合美国精神疾病诊断与统计手册第4版(DSM-IV)中精神分裂症诊断标准的医院门诊和住院患者共180例。采用世界卫生组织生存质量测定量表简表(WHOQOL-BREF)、自知力评定量表(SAI)、阳性与阴性症状量表(PANSS)对患者进行评估。结果:生活质量的生理因子与依从性、疾病意识、精神症状标识及自知力总分显著负相关(r=-0.232,-0.243,-0.171,-0.274;P0.05);心理因子与疾病意识和自知力总分显著负相关(r=-0.219,-0.203;P0.01);生活质量总分与疾病意识和自知力总分负相关(r=-0.169,-0.175;P0.05),生活质量受自知力总分和阴性症状的影响(β=-0.312,P=0.000;β=-0.157,P=0.037),疾病意识对生活质量心理因子有预测作用(β=-0.291,P=0.003);生活质量总分受自知力总分的影响(β=-0.594,P=0.019)。结论:1自知力较好的患者生活质量较低;2心理因子受疾病意识的影响;3阴性症状对生活质量有影响。     

Clinical and cognitive insight in patients with acute-phase psychosis: Association with treatment and neuropsychological functioning

Background: The severity of psychopathology cannot fully explain deficits in the multi-dimensional construct of insight.

Aims: The aim of this study was to evaluate the correlates and associations of clinical and cognitive insight in patients in an acute phase of psychosis and to analyse the impact of acute treatment on these variables.

Methods: This study examined 47 inpatients who were recently hospitalized with acute exacerbation of schizophrenia. All subjects were assessed at both admission and discharge with the Positive and Negative Syndrome Scale (PANSS), Schedule for the Assessment of Insight-Expanded Version (SAI-E), Beck Cognitive Insight Scale (BCIS), and a neurocognition battery.

Results: Patients with schizophrenia gained clinical insight after treatment. Cognitive insight did not change significantly after treatment. Insight showed significant negative correlations with positive symptoms and general psychopathology, but not with negative symptoms. Clinical insight was not associated with neuropsychological functioning in this cohort.

Conclusion: Gaining clinical insight in the acute phase of illness was associated with the remission of positive symptoms, but not with neuropsychological functioning. Some significant correlations between clinical and cognitive insights were detected, which suggests that cognitive insight contributes to clinical insight but is not treatment-dependent. Long-term treatment may be required to understand the contribution of insight to the outcome of patients with schizophrenia.     

Correlates of insight with symptomatology and executive function in patients with first-episode schizophrenia-spectrum disorder: A longitudinal perspective

The present study aimed to examine the relationships of insight with symptomatology and executive function, both cross-sectionally and longitudinally in patients with first-episode schizophrenia-spectrum disorders. Ninety-two medication-naïve patients were recruited and 71 completed the assessments. Insight, symptoms and executive function were assessed at baseline, 6 months and 1 year. Insight was measured with the abridged version of Scale of Unawareness of Mental Disorder (SUMD). Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS). Executive function was measured with the Modified Wisconsin Card Sorting Test (MCST). The most significant improvement of insight and symptomatology was found over the first 6 months, whereas the perseverative errors of MCST were significantly improved between 6 and 12 months. Differential correlations of perseverative errors of the MCST and PANSS scores with SUMD were found at different time points. This suggests the involvement of different mechanisms in insight deficit at different stages of the illness. The baseline MCST perseverative errors were correlated significantly with the SUMD total score at 6 months and the change of SUMD scores over the first 6 months. Although the variance explained was small, it suggests better set-shifting capacity facilitates the improvement of insight at an early stage of the illness.     

Brain stimulation enables the solution of an inherently difficult problem

Certain problems are inherently difficult for the normal human mind. Yet paradoxically they can be effortless for those with an unusual mind. We discovered that an atypical protocol for non-invasive brain stimulation enabled the solution of a problem that was previously unsolvable. The majority of studies over the last century find that no participants can solve the nine-dot problem – a fact we confirmed. But with 10 min of right lateralising transcranial direct current stimulation (tDCS), more than 40% of participants did so. Specifically, whereas no participant solved this extremely difficult problem before stimulation or with sham stimulation, 14 out of 33 participants did so with cathodal stimulation of the left anterior temporal lobe together with anodal stimulation of the right anterior temporal lobe. This finding suggests that our stimulation paradigm might be helpful for mitigating cognitive biases or dealing with a broader class of tasks that, although deceptively simple, are nonetheless extremely difficult due to our cognitive makeup.     

Le concept de l’insight en psychiatrie

It was in France (particularly in the Société Médico-Psychologique 1869 to 1870) that the concept of insight into mental disorder began to appear around the middle of the 19^th century. Amongst other things, changing views concerning the nature of insanity, particularly the emergence of the notion of partial insanity, led to debates about the question of insight in patients with mental illness. Following a resurgence of interest in insight in psychiatry numerous empirical studies have sought to explore the relationship between patients’ insight and clinical variables. Results however have been variable and contradictory. Explanations for this can be found in the complexities inherent to the concept of insight. In order to tease these out, it is essential to distinguish between the concept and the phenomenon of insight and to view insight as a relational concept. Clarifying these issues around insight helps to define the ways and limits in which it is possible to capture insight empirically. In addition, it facilitates an understanding of insight as a mental state whose fluctuations are dependent on an interplay of psychological, pathological and wider sociocultural factors.     

多媒体干预对精神分裂症患者自知力的影响

目的探讨多媒体干预对精神分裂症患者自知力的影响。方法将80例首次住院精神分裂症患者随机分为两组,一组应用多媒体干预,另一组作对照,两组于治疗前和治疗后4周分别用自知力与治疗态度问卷表（ITAQ）和简明精神病评定量表（BPRS）进行评定和比较。结果两组治疗前后简明精神病评定量表（BPRS）评分均无差异,多媒体组治疗后自知力恢复明显优于对照组,两组治疗后自知力与治疗态度问卷表（ITAQ）评分有显著差异。结论多媒体干预可以促进精神分裂症患者自知力的康复。     

发病情景摄像回放式认知治疗对精神分裂症患者自知力恢复的作用研究

[目的]探讨发病情景摄像回放式认知治疗对精神分裂症患者自知力恢复的作用。[方法]按照CCMD-3的精神分裂症诊断标准,简明精神病评定量表(BPRS)评分≥35分为入组条件。原始入组患者102人,符合实验要求住院时间大于2个月的患者83人,年龄16～65岁,实验组39人,对照组44人。对照组患者入院后接受抗精神病药物治疗与一般支持性心理治疗。实验组患者除接受以上治疗外,还由专人对其在入院初期至缓解期间的典型发病情景进行摄像,在缓解期后(病情好转至出院)让患者观看本人发病情景的录像,并进行认知治疗。[结果]调查显示86.7%的患者入院时为非自愿治疗;实验组联合治疗后自知力与治疗态度问卷(ITAQ)得分较对照组有统计学差异;男性与女性患者ITAQ得分无统计学差异。[结论]发病情景摄像回放式认知治疗对改善患者自知力有重要的作用,自知力恢复稳定提高,对男性与女性患者有同样的疗效。