Proposition pour une échelle d’évaluation du risque de répétition d’accidents chez l’adolescent

When confronted with situations of repeated accidents among teenagers, organicist physicians (emergency physicians, orthopaedists and general practitioners) need tools to discern sub-jacent psychopathological problems such as depression and anxiety. We have elaborated an Evaluation Scale of Risk Behaviour of the Teenager (ECRA) and we have compared its results to those obtained with different recognized scales currently in use in psychiatry. We have observed that teenagers with antecedents of accidents have scores that are far higher than those of first accident teenagers, notably in the depression, anxiety and impulsivity scales as well as in the ECRA. The ECRA is quite efficient in distinguishing teenagers without antecedents of accidents from those having had repeated accidents. This simple and rapid scale could be used as a tool by organicist physicians for detection but also for prevention as they are the first to be confronted with young people.     

La psychiatrie à l’ère des modèles

Based on an intuition by Gladys Swain, this article develops two paths in an epistemological research on modern psychiatry. We try to reinvestigate the concept of neuroleptic under it's most mythical form: the Largactil, not only as a molecule but as the very object of a discipline, founding a new notional cartography. A second path consists in interpreting this new epistemological deal and its structural patterns, mainly by questioning psychiatry as a “science of systems”; only then, can we ask the notion of meta-model the very problem it was basically meant to solve: a possible unification in psychiatric regions and areas.     

L’éthique de la recherche en psychiatrie adulte

Medical research aims to improve the human condition by developing a body of knowledge valid and reliable. The history of medicine over the centuries, however, was marked by numerous scandals showing the possible misuse of research when it is not framed with an ethical, or the law. The ethical debate is ongoing and researchers must continually examine their practices. In psychiatry, the object of research is a human being made vulnerable by his trouble. The aim of this article is examine the theoretical foundations of ethic in research on human being. It is therefore a reflection of the true significance of this concept, its history, its principles and particularities in the field of psychiatry.     

Prise en charge d’une première crise épileptique de l’adulte : peut-on prévoir l’avenir ?

The new definition of epilepsy recently proposed by an international panel of experts relies on the association of a first clinically certain seizure and of an enduring predisposition of the brain increasing the likelihood of future seizures. In the first part of this review, we will expose and organize into a hierarchical order the risk factors of subsequent recurrence. The major factors are: seizure(s) prior to presentation, paroxysmal abnormalities on early EEG, a remote symptomatic etiology. In the second part of this review, we will address the issue of clinical uncertainty when assessing the epileptic origin of a first clinical paroxysmal event, the reasons of uncertainty and the means to minimize it. We will analyze successively: the accuracy of eyewitness observations of transient loss of consciousness, the reliability and predictive validity of clinical criteria used for seizure assessment, the issue of overlapping clinical features between seizure and other non epileptic paroxysmal events (such as psychogenic non epileptic seizures), and finally the reliability and diagnostic value of early EEG for seizure assessment. To conclude, seizure assessment and diagnosis of epilepsy cannot be dissociated from syndrome and etiology diagnosis, which should be periodically reassessed towards a greater accuracy during the course of the disease.     

Validation de l’échelle d’insight Q8 et évaluation de la conscience de la maladie chez 121 patients hospitalisés en psychiatrie

Insight (awareness of disorder) is an important domain for research and practice in psychiatry. Several instruments to measure insight are currently used. We present here a short scale (8 items with open question) applied to a sample of 121 psychiatric inpatients which permitted to validate this questionnaire and to demonstrate its easiness and rapidity. This insight Q8 scale shows that insight is higher in free hospitalization (compared to compulsary hospitalization), in mood disorders (compared to schizophrenia), in dépression (compared to schizophrenia and mania), in married patients (compared to widowed and single patients), in case of good cognitive functions (MMSE score) and antecedents of attempted suicide. Awareness must be taken into account in all major mental disorders. Therapeutic alliance, treatment compliance, prognosis and risk of relapes depend largely on this dimension.     

Premiers éléments pour une étude psychométrique de la fixation-régression avec la McGill Object Relations Scale

Introduction

Psychosexual development is generally assessed clinically, that is to say, in a qualitative manner (Piper and Duncan, 1999). Dymetryszyn, Bouchard, Bienvenu, De Carufel, and Gaston (1997) recently proposed a more quantitative approach based on the overall maturity of the subject's object relations.

Background

Object-relation maturity is quantified using a profile that defines a score for each stage of an individual's psychosexual development : oral-narcissistic, oral-objectal, anal, phallic pre-oedipal, oedipal, and genital. The McGill Object Relations Scale (MORS) (Dymetryszyn et al., 1997) was adapted (Combalbert, Vautier, Bourdet-Loubère, Favard, & Bouchard, 2002) and then used to obtain the quantitative scores. The relationship between overall object-relation maturity and psychosexual development is complex. Psychosexual development is considered here to be a constant latent dimension. Accordingly, the higher the level of development, the greater the individual's possibility of establishing the object relations that correspond to more evolved stages. Inversely, the lower the level of development, the more the individual is forced to rely on object relations corresponding to earlier stages of development. However, the connection between the object-relation maturity profile and psychosexual development is made even more complex by the existence of the well-known phenomenon of fixation-regression.

Objectives

This article attempts to determine how fixation-regression is reflected in the structure of the profiles of a sample of individuals whose clinical diagnosis suggests probable regression to the anal stage.

Methods

The subjects chosen had borderline personality disorder coupled with either perversion or psychopathy. The data were modelled using an unfolding model. MORS was used on 60 criminal subjects who had been charged with, or convicted of, crimes against persons. The nosographic diagnosis was based on the psychiatric assessment of the prisoners. DSM IV diagnostic criteria were used as a reference to confirm or refute the pronounced diagnosis. Only subjects who met at least five criteria for borderline personality disorder were included in the sample. To assess the reliability of the individual scores, two expert judges blindly scored the 60 protocols.

Results

The results obtained with an unfolding model support the hypothesis that the observed ordinates for the oral-narcissistic, oral-objectal, phallic pre-oedipal, oedipal, and genital stages obey a law of synchrony that complies with the postulate of a continuum in psychosexual development. The second main result was the fact that the observed ordinates for the level corresponding to the anal stage could not be described by the model. Furthermore, this finding did not come from a possible scoring error, since inter-judge reliability was 0.93 for that level.

Discussion

These results are encouraging for the utilization of MORS as a technique for quantifying object relations. This study on a sample of individuals with a high probability of anal stage fixation-regression suggests that this type of phenomenon can be objectified by means of MORS profiles. However, the present study has some limitations of its own. The main methodological drawback pertains to the subjective aspect of the protocol scoring. The two judges had a great deal of joint experience in scoring other protocols on the MORS grid. This could explain the particularly high inter-judge correlations, compared to the within-class correlations published by Dymetryszyn et al. (1997).

Conclusion

One cannot rule out the possibility that our analyses would have had different outcomes had other independent judges scored the 60 protocols. Moreover, our results cannot be generalized without replication. A critical test would be to replicate our analyses on similar data, and to examine the unfolding model's behavior on data from a sample of ordinary adults diagnosed as not having strong fixation-regression tendencies. If the synchrony laws defined by the unfolding model are correct, the anal stage should be included in the arc formed by projecting the six stages on the factorial plane of the principal component analysis. Fundamental research based on the psychosexual theory of the libido and supported by statistical data can objectify the vicissitudes of psychosexual development (such as fixation-regression) or developmental differences across groups of individuals. This makes a strong case for pursuing MORS-based investigations.     

À propos de l’intégration des soins psychiatriques dans la ville, évaluation d’une structure d’hospitalisation à domicile sur un secteur de psychiatrie adulte

Home care tries to restore the patients into their social life. It points up the questioning about the place given by our societies to the patients suffering from mental diseases, as well as the questioning about the pertinence of the transfer of the care setting out of the hospital institutions. Home care is indeed integrated in the mental health district practice, as it has been developed in France during the seventy’s. Its practice is focused on the therapeutic relation and on the continuity of the care relation. In this way, it considers the patients within their progressive reality. Home care is recent in French psychiatry and exists in the psychiatric district 59G32 (Valenciennes, France) since June 2004. It constitutes a tool out of the hospital, completing the therapeutic units already existing on the district. After two years of existence, this study tries to evaluate the interests of home care and its contributions to the therapeutic possibilities in psychiatric district. With five places available, this structure can be seen as an alternative to full time hospitalisation. Home care offers indeed a graduated and individualized care within patient’s usual environment; and this is done, when it’s possible, with the participation of the patient’s relatives. This unit integrates a pluridisciplinary working team. The interventions take place several times weekly in the patient’s home, during a minimum period of one month, and with an average period initially planned to last three months. Home cares intervene before the moment when full time hospitalisation appears unavoidable, and also after hospitalisation in order to help the patients to come back to their usual environment. The aim is to maintain or to develop the autonomy of the patients, to promote or restore their social integration, to improve therapeutic alliance and treatment’s follow-up. It is a retrospective study, evaluating the interests of home care and its contributions into the psychiatric district 59G32. This study is realised after two years running, during the period of February and March 2006. It interviews the medical and paramedical team, as well as the patients and their relatives about their point of view concerning home care. Population studied: the patients entering into the selection’s criteria were those living on the 59G32 psychiatric district and who had home care before and during the study period. 1) All of the 21 patients of the population studied have been interviewed. Comparing men and women, the distribution was equivalent; 2) looking at the age’s distribution, two groups of patients were over represented: from 30 to 39, and from 50 to 59 years old, with each time 1/3 of the population studied. Those results are linked with the necessity to help those patients to develop a certain autonomy during the first years following their disease’s discovery, and when the needs are majorated for elder patients, at least until their admission into old people’s home; 3) the diagnosis found during this evaluation were, in majority (2/3 of the answers), psychotic disorders; 4) the evaluation has shown an amelioration about, on one hand: the therapeutic alliance, the information given about the diagnosis, and the treatment’s follow-up, and on the other hand: the patient’s integration and autonomy on the district, when this was possible. Finally, even if this kind of care is still not really developed within French adult psychiatric districts, such structures, complementing a full time hospitalisation offer, permit a better quality of life for the patients, and the development of actions of prevention as well as a better information about psychiatric disorders.     

La biologie et le futur de la psychanalyse : un nouveau cadre conceptuel de travail pour une psychiatrie revisitée

The American Journal of Psychiatry has received a number of letters in response to my earlier “Framework” article (1). Some of these are reprinted elsewhere in this issue, and I have answered them briefly there. However, one issue raised by some letters deserves a more detailed answer, and that relates to whether biology is at all relevant to psychoanalysis. To my mind, this issue is so central to the future of psychoanalysis that it cannot be addressed with a brief comment. I therefore have written this article in an attempt to outline the importance of biology for the future of psychoanalysis.     

Auto-immunité et ambivalence du corporel. Sur l’importance d’un rapprochement entre psychanalyse et médecine

Medicine and psychoanalysis converge on the same subject, the body and its suffering in disease. The resulting “splitting” of the body illustrates the complex relationships between these two practices, concerning their different thoretical basis and clinical approach. A specific exchange and transmission tool could, nevertheless, help to establish a dialogue between these approaches. Such a tool for a possible dialogue should consider some theoretical, logistic (concerning the hospital and its particular organisation) and political aspects (related to the normative definitions of health and its alterations). Although, this medical basis for a dialogue between medicine and psychoanalysis should respect the “ordinary” language: only the patient's language can constitute a pathway towards the multiple senses that make life possible. All these aspects, clearly recognisable in the clinical experience, have not always a well-developped theoretical basis. Aiming to give a place to subjectivity through the psychoanalytical work, the present article, based on a psychoanalytic collaboration experience within an immunology and rhumatology unit in a General Hospital in Santiago in Chile, explores the immunological concept of “Self” as well as the psychoanalytic construction of the body.     

La bipolarité épistémologique de la psychiatrie française

In this paper, we focus on the diversity of scientific approaches in French psychiatry, using several concepts inspired by the philosophy of sciences. The feeling of an internal crisis, regularly expressed on a public stage, alongside with the developments of neurosciences who contested a psychoanalytical supremacy amongst French psychiatrists suggest the beginning of a scientific revolution. However, several points indicate that French psychiatry has been evolving in a continuous paradigm since its emergence at the turn of the 19^th century. Since then, this discipline has been consistently suspended between two different scientific rationales. On the one hand, it relies on an explicative, experimental and generalizing approach. On the other hand, it refers to a comprehensive, inducitivist and singularity-orientated rationale. We coin the expression “epistemological bipolarity” to describe this specific scientific organization.     

Apport d’une démarche électroclinique dans le diagnostic de l’épilepsie chez une population de sujets âgés confus

Background

Delusion symptoms often occur in old people; epilepsy is one of the main reasons behind these acute episodes. Current guidelines and recommendations from the Academy of Medicine have proposed a double clinical and electroencephalographic approach. Recently, a working group of French experts has issued an electro-clinical scale. The aim of our study was to compare the usual approach with the new one based on the electro-clinical score.

Method

All EEG requests performed since December 2008 in Bretonneau Hospital for elderly people aged over 75 years for delusion syndromes were retained for this study.

Results

One hundred and fifteen old patients from a geriatric-hospital (age 83.5 ± 6.06 years) were included in this protocol. The classical diagnostic process yielded the diagnosis of epilepsy for 50 subjects. The electro-clinical scale confirmed the diagnosis of epilepsy in 30 patients and ruled it out in 29 patients.

Conclusion

This study underscores the importance of evidence-based medicine for the diagnosis of epilepsy in old people and points out the underuse of the new technical tool, EEG-monitoring, for the management of these patients.     

Souffrance psychosociale et risque suicidaire, quelle articulation entre médecine de ville et psychiatrie hospitalière ? Résultats d'une étude qualitative

Mental disorders are now becoming the first reason for consulting a general practitioner. These mental disorders include pathologies identified by psychiatry as well as a series of complaints linked to psychosocial distress. This latter, on the border between social field and medicine, does not benefit of a specialised clinical approach. Nevertheless, suicidal behaviour constitutes one of the complications of psychosocial distress which general practitioners have to face, though they have scant academic knowledge of it. A qualitative study examining an important oral material and 202 medical letters was realized in three of four Breton geographical departements. This study describes and analyzes the clinical attitude of general practitioners and their answers. Based on this study this article approaches the question of the articulation between private practice and hospital psychiatry.     

Intérêts et limites des échelles d’évaluation de la douleur chez l’enfant en situation de handicap

Accessing to a management of pain is now considered as peoples’ fundamental right. The pain should be evaluated before being treated. Pain is always a subjective phenomenon. Assessing pain of those who express in a singular way is a great challenge. Children and adolescents with intellectual disabilities, with cerebral palsy or with autism are now recognized as sensitive to pain as well as anyone. If some of them are able to use self-report tools, we have to apply disability-adapted scales to others. Like any assessment tools, they have advantages and limitations. We need to know them in order to make appropriate use for the care of vulnerable people.