Tempéraments affectifs prébipolaires dans les dépressions récurrentes : vers un dépistage de « fausse unipolarité »

IntroductionThe current categorical split of mood disorders into bipolar disorders and depressive disorders has recently been questioned after the widening of the bipolar spectrum. Recent studies have suggested that clinicians may under-diagnose bipolarity in a substantial proportion of depressed patients, and have proposed the existence of a “pseudo-unipolar” depression. On the other hand, many studies were made to identify factors correlated to bipolarity in depressive disorders. They have shown that the main clinical factors correlated to bipolarity are: pharmacological hypomania, puerperal depression, early age of onset, psychotic features, hypersomnia and psychomotor inhibition. In this context, it should be interesting to study temperaments as predictive factors of bipolarity in depression and to explore their correlation with those clinical predictors.ObjectivesThe aims of this study were to assess affective temperaments in patients with recurrent depressive disorders, and to explore the correlations between these temperaments and clinical features of depressive disorders.MethodsThe study was a cross-sectional one bearing on 91 recurrent depressive patients (40 men and 51 women, mean age: 46.8 ± 10.1 years), who were interviewed using the DSM-IV Structured Clinical Interview during the partial or total recovery period. Data was collected using available medical records. The evaluation of affective temperaments consisted in filling in the Akiskal and Mallya semi-structured questionnaire.ResultsThe depressive temperament obtained the higher mean score (12.3 ± 4.74), followed by the hyperthymic temperament (7.8 ± 4.5), the cyclothymic temperament (5.9 ± 5.8) and the irritable temperament (4.9 ± 3.3). A significant association was found between the onset of the first depressive episode during the postpartum period and the cyclothymic temperament score (7.4 ± 6.9 versus 3.3 ± 3.6, p = 0.04). The psychotic features in the last depressive episode were significantly associated with the hyperthymic (p = 0,001), the cyclothymic (p < 10^?3) and the irritable temperament scores (p < 10^?3). A significant link was found between suicide attempts during the last depressive episode and the cyclothymic temperament on the one hand (p < 10^?3) and the irritable temperament on the other hand (p = 0.01).ConclusionsThe recurrent depressive disorders with hyperthymic, cyclothymic and the irritable temperaments seem to have clinical features similar to those of bipolar disorders. These results point to the importance of evaluating these temperaments in depressed patients, considering the risk of polarity change and of misdiagnoses of unipolar depression.     

Un cas d’ophtalmoplégie horizontale bilatérale : le syndrome 1 + 1

IntroductionOculomotor deficiencies in multiple sclerosis (MS) are frequently characterized by internuclear ophthalmpoplegia or isolated abduction or adduction palsies. Complete unilateral conjugate gaze paralysis and the “one and a half” syndrome are rare. Complete bilateral horizontal gaze paralysis has been exceptionally reported.ObservationHere, we describe an unusual oculomotor paralysis as a suspected first event of MS. A 24-year-old woman with an uneventful medical history presented for sudden onset of binocular diplopia. On examination, abduction and adduction saccades were impossible, whereas vertical eye saccades and convergence were normal. Oculocephalic reflex failed to improve horizontal eye movement. No nystagmus and no other sign of brainstem dysfunction were observed. Visual acuity was 4/10 in the right eye and 6/10 in the left eye. A sign of Marcus Gunn was noted in the right eye. Blood samples and cerebrospinal fluid were normal, no oligoclonal bands were detected. Visual evoked potentials were significantly impaired in both eyes and argued for bilateral optic neuritis. Brain MRI scans showed white matter T2-hypersignal abnormalities, which fulfill Barkhof criteria for MS. A small symmetric lesion was noted in the posterior part of the medial pontine tegmentum. As a first episode of MS was suspected, treatment with methylprednisolone 1000 mg/d for 3 days was started, and was followed by complete recovery of eye movements and visual acuity after 3 weeks.DiscussionTo our knowledge, only two cases of complete horizontal bilateral ophthalmoplegia have been reported in the literature. Both were associated with peripheral facial nerve palsy as a first event in MS. In our case report, we describe for the first time a complete bilateral horizontal ophthalmoplegia with no other brainstem dysfunction. By analogy with the “one and a half” syndrome, such complete horizontal gaze paralysis could be named a “one and one” syndrome and seems to be specifically related to a first event of MS.     

Validation de la batterie rapide de dénomination (BARD) chez 382 témoins et 1004 patients d’une consultation mémoire

IntroductionThe Rapid BAttery of Denomination (BARD) is a short 10-item naming test derived from the 60-item Boston Naming Test. It is easily performed in less than 15 seconds by normal controls independently of age, gender and education (Croisile, 2005, Croisile, 2007, Croisile, 2008). Our aim was to evaluate the BARD in various conditions seen in a memory clinic.Patients and methodsThe BARD was used in 382 normal subjects (165 men and 217 women, aged from 20 to 97 years) and 1004 patients attending a memory clinic. Three groups of 505 patients with Alzheimer's disease (AD) were compared: mild patients (n = 402), moderate patients (n = 84) and moderately severe patients (n = 19). The BARD was also used in 499 patients with a Mini Mental Status (MMSE) ≥ 20: 173 patients with amnestic Mild Cognitive Impairment (aMCI), 56 patients with frontotemporal dementia (FTD), 41 patients with Lewy Body dementia (LBD), 36 patients with nonfluent primary progressive aphasia (NFPPA), 27 patients with semantic dementia (SD), 16 patients with posterior cortical atrophy (PCA), 150 patients with anxiety or depression (ADD).ResultsThe performance of the patients was not affected by age, gender or education. aMCI had a score of 9.97 ± 0.18, ADD a score of 9.97 ± 0.2. A mild anomia was observed in three groups: mild AD (9.78 ± 0.5), FTD (9.79 ± 0.65) et LBD (9.98 ± 0.16). A more pronounced anomia was present in moderate AD (9.10 ± 1.06), moderately severe AD (8.05 ± 1.27), PCA (8.12 ± 3.28) and NFPPA (8.44 ± 1.61). The anomia was severe in SD (5.85 ± 2.46). The 10 items were perfectly named by 98 % of ADD, 96.53 % of aMCI, 82.09 % of mild AD, 87.5 % of FTD patients, 97.56 % of LBD patients, 68.75 % of PCA patients, but only 45.24 % moderate AD, 5.26 % of moderately severe AD, 27.78 % of NFPPA, and 3.7 % of SD. In the patients with MMS ≥ 20, Anova showed that the BARD scores of the ADD, aMCI, mild AD, FTD and LBD groups were significantly greater than the BARD scores of NFPPA, SD and PCA. PCA and NFPPA groups did not differ for BARD scores whereas they were significantly better than SD. A ROC curve comparing the 822 mild anomic patients (AD, FTD, LBD, aMCI, ADD) with the 79 more anomic patients (NFPPA, SD, PCA) showed that for a BARD score of 10, sensitivity was 72.2 %, specificity was 89.2 %, and 87.7 % of the patients were correctly classified.ConclusionThe BARD is a quick and useful tool for identifying naming disorders in a memory clinic. In patients with MMSE ≥ 20, making one error at the BARD is highly abnormal and significantly characteristic of cognitive disorders: the more frequent the errors are, the more probable is the presence of a visual agnosia (PCA), an aphasia (NFPPA), or a semantic disorder (SD).     

Comment « défusionner » de la scène traumatique ? La pratique du « défusing » : trente ans de discours spécialisé psychiatrique et psychologique

BackgroundNotably organized by the medical-psychological emergency cells (CUMP) in France, the immediate care offered after confronting a potentially psychotraumatic event has been able to spill a lot of ink between those who adulate them or those who hate them, as much in the specialized press as through the media intended for the general public. Indispensable practice aimed at treating psychological wounds for some, charlatanism providing worsening of post-traumatic symptoms for others, medico-psychological recommendations have long remained cryptic in the face of the absence of studies of enough level of scientificity. Thirty years after its first formalizations, no study has offered a critical synthesis of the notion of “defusing”.ObjectivesOur main objective is to study the specialized discourse concerning “defusing” as defined and relayed by psychiatrists and psychologists in French-language journals. We seek to identify the stages of the construction of this treatment time, the maturation of its practice by synthesis of the “defusing type” and the theorization of its therapeutic mechanisms.MethodsFrench-language articles published between January 1, 1990 and December 31, 2019 were selected from the entry of the keyword “defusing” in five search engines as well as in the thesauri of the interuniversity library of medicine and the central library of the army health service. The extracted data combine: the number of article (s) per year of publication, the names of the journals and the authors (research team, place of practice, statutes). The titles, summaries and body of texts were examined by three speech analysis software programs with quantification of textual units and facilitation of return to text by keyword.ResultsLess than 30 articles mention the notion of “defusing” in French-speaking literature, of which only 2 are in their titles and finally, no reference is fully dedicated to it. Compared to the adjacent chapters dealing with the organization of CUMPs, the emergency clinic, and debriefing, the articles referenced do little to address the notion of “defusing”. If the conception of psychological trauma is popularized by its clinical and etiopathogenic dimensions (essentially psychopathological, ignoring neurobiological or socio-anthropological aspects), immediate treatment is only sketched out (by its organizational, theoretical and practical developments). All these notions turn out to be approached in a segmental fashion via adjacent paragraphs with no obvious links between them. Very few articulations are advanced with the concepts of psychiatry or general psychology, or the inclusion of defusing within a global theory of psychotherapy. Materializing numerous literal repetitions from one article to another, the synthesis organizing the qualitative data revealing the practical definition of defusing is rather brief. All references combined, only a few sentences briefly addressing the notions of language recovery and capacities of levels of representation can enlighten us on the supposed therapeutic processes. In addition, certain areas are barely addressed: little mention of family traumas, relative silence concerning specificities in children, absence of scientific studies concerning the effectiveness of defusing.DiscussionIn the referenced texts, if the part devoted to the organization of care is significant in terms of volume, it is because it participates conceptually in the appeasement by restitution of an environment allowing to get out of the traumatic scene. Then, the apparent simplicity of the therapeutic concepts in reality reveals cardinal prerequisites: clinical analysis, permanent adjustment of the right relational distance, ability to receive the suffering of others, sustained attention over time, technical skill in particular inter-transferential mobilizations, ability to develop adaptive skills. The attitude and words of the practitioner are based above all on their experiences in clinical analysis and psychotherapeutic care in general. This is undoubtedly the main reason for the absence of scientific studies on defusing facing the same material difficulties as the evaluation of psychotherapy. While only the nonspecific factors of effectiveness of psychotherapies appear to be recognized today, first and foremost the flexibility of the practitioner in the face of his theoretical references, would it be possible to recognize principles specifically effective in the treatment of post-traumatic symptoms?ConclusionWhile several authors still bring together defusing and debriefing to the point of speaking of “immediate and post-immediate debriefing”, the confusion induced is perhaps only relative in view of specific therapeutic mechanisms aimed at appeasing dissociation. Speech constitutes the tool, the cement allowing to bridge dissociative fractures, to connect the psychic, neuropsychic and social spaces which were previously disjointed. Prompted or even guided by the practitioner, this therapeutic word deserves to be qualified as “maieutics”, from the name of the science of childbirth: thought is not developed here prior to its elocution, but the inaugural word, as it arises, as it is expressed, creates thought. By “giving” his word, by “lending” his language, the practitioner actively listens to the mentally injured person and guides them to find the words that they are not able to speak spontaneously. Thanks to the development of a partly common discourse, resulting from intersubjectivity, the capacities of singular elaborations and mentalizations are enhanced, on the side of the patient, and on the side of the practitioner, without the created senses necessarily being the same.     

Utiliser les psychédéliques pour « guérir » des adolescents homosexuels ? Essai de thérapie de conversion,France, 1960

Between 1960 and 1962, a children's judge placed two French adolescents in a psychiatric hospital in Alsace. Described as “delinquent sexual perverts”, Michel, 15, and Bernard, 18, were in fact two young homosexuals. However, at the time, homosexuality was considered a psychiatric disorder that should be “cured”. With this in mind, psychiatrists set up shock or disgust therapies to push patients to become heterosexual. In this hospital, the chief doctor tested two new substances on them: mescaline and LSD. Injected in very high doses, the idea was to cause a powerful psychological shock in the hope of changing the adolescents’ sexual orientation. This type of placement as well as the treatment inflicted were then common (lobotomies or electroshocks were part of the “therapeutic” possibilities to “cure” homosexuality). Two aspects of these experiments are however particularly original: on the one hand, the use of substances such as mescaline and LSD, on the other hand, the very type of “therapy” implemented. It would thus seem, in the current state of knowledge on the use of LSD and mescaline in psychiatric therapy, that these experiences were isolated facts: the literature remains silent on the subject of the use of mescaline to “cure” homosexuality, and the few known therapies carried out using LSD were offered to adults and above all volunteers. Finally, these therapeutic methods were the opposite: psychotherapies in which particular attention was paid to patients and their well-being in the United States or in England and “psychic shocks” in Alsace. This hospital is the only French example of an attempt to “treat” homosexuality using psychedelics. The use of these substances by the French team therefore began in 1960; it involved administering mescaline or LSD in high doses (an exceptional characteristic in Europe where psychiatrists were in favor of therapy with low doses known as “psycholytic”) and in injections, ranging from 200 to 1200 mg for mescaline and for LSD from 100 to 800 micrograms. By way of comparison, a recreational dose is 300 to 500 mg for mescaline and 100 micrograms for LSD, administered orally. In order to create “psychic shock”, the effects of the substances were immediately stopped by the injection of chlorpromazine, a powerful neuroleptic. The authors noted that for all patients, “two modes of behavior are common: stupor and agitation”. They sometimes tore their sheets or pajamas or grabbed the examiner, asking for support. The sessions were linked: in 118 days, Bernard would undergo 16 of these sessions, one every 7 days on average. Michel, during one of the sessions, felt like he had been killed by his psychiatrists. Neither would subsequently become heterosexual. Elsewhere in the world, other forms of LSD conversion therapy have emerged. However, these were benevolent psychotherapies; the product was not injected but taken orally (therefore with more progressive effects), and the approach was not the same. Thus, acceptance of their homosexuality by patients was considered as desirable an option for therapists as was conversion to heterosexuality. For French practitioners, on the contrary, “healing” was the only objective. This article will highlight a double French specificity in the use of psychedelics: first, the refusal to introduce the new method of administering these substances, called “set and setting”, theorized from the late 1950s in Anglo-Saxon countries, and yet known and discussed by French experimenters. Then, it will show the use of these substances in shock therapy, particularly in the treatment of homosexuality.     

Le Test des cinq mots dans les formes légères de maladie d’Alzheimer : comparaison du score total,du Score Total Pondéré, du Score d’apprentissage et du Score de mémoire dans trois classes d’âge (60 ans, 70 ans, 80 ans)

IntroductionThe five-word test (5WT) is a serial verbal memory test with semantic cuing. It is proposed to rapidly evaluate memory of aging people and has previously shown its sensitivity and its specificity in identifying patients with AD. It measures the efficacy of free and cued recalls during a procedure of immediate and delayed recalls.MethodsThe 5WT was compared in a group of 202 normal subjects and a group of 302 mild AD patients (MMS of 20 or more) aged from 60 to 92 years, in three age classes (60 years, 70 years, 80 years). Nine scores were measured (Total Score, Total Weighted Score, Free Immediate Recall, Learning Score = total of Immediate Recalls, Free Delayed Recall, Memory Score = total of Delayed Recalls, Forgetting Rate, Percentage of Immediate Cuing, Percentage of Delayed Cuing) as well as the presence of intrusions. For each age class, Receiver Operating Characteristic curves determined the most significant cut-off scores.ResultsFor each score of the 5WT, AD patients differed significantly from controls. The cut-off scores were not the same according to age. For the Total Score, the cut-off scores were 10 (60 years), 9 (70 years) and 8 (80 years), whereas the cut-off scores of the Total Weighted Score were 17 (60 years), 16 (70 years) and 14 (80 years). As suggested by Cowppli-Bony et al. (2005), the Total Weighted Score (which gives a higher coefficient to free recalls) was better than the Total Score for discriminating mild AD. The 5WT is useful to discriminate normal controls and mild AD patients. Normal aged subjects displayed good encoding, efficient stocking and consolidation (few forgetting, efficient cued recall), intrusions were rare. Mild AD patients were characterized by weak encoding of words and severe deficit for stocking and consolidation (important forgetting, impaired cued recall), they made numerous intrusions. This psychometric profile is characteristic of the amnestic hippocampal syndrome found in AD.ConclusionThe 5WT is a simple and reliable test for investigating memory in elderly people above 60 years old. According to age, different cut-offs are needed for the Total Score and the Total Weighted Score, the latter appearing more discriminating than the Total Score for the diagnosis of mild AD. It is also interesting to evaluate the presence of intrusions. Lastly, it is important to consider the forgetting rate (between Learning and Memory Scores) in order to confirm the presence of a hippocampal amnesia.     

Étudiants à risque de décrochage selon le profil de personnalité : Resilients,Overcontrollers et Undercontrollers

IntroductionPreventing students from dropping out of higher education, and particularly university, requires understanding the different factors that can lead to individuals failing to complete their studies. The role of personality in academic success or failure remains poorly understood. Block's personality profile model (Resilients, Overcontrollers, Undercontrollers) has been used to link personality traits to academic performance. The objective of this study is to apply this model to the risk factors of dropping out of higher education courses, including psychological vulnerability, level of autonomy, and the feeling of not being able to keep up. This involved validating Block's profiles in relation to the Big Five personality traits (Extraversion, Agreeableness, Conscientiousness, Neuroticism and Openness), and their links with the risk factors for dropping out.MethodsThis study is based on a quantitative survey of 196 students (mean age 21.32 years ± 3.11 years, with 63% females) taking higher education courses in France. Three measuring instruments were used: a French scale of Autonomy-situnomy, the French version of the Big Five Inventory (BFI-Fr) for personality traits, and the French version of the General Health Questionnaire (GHQ-28) for psychiatric morbidity. One item empirically evaluated the feeling of not being able to keep up. Data was processed using a k-average cluster analysis to establish the personality profiles, then by analysis of variance measures to evaluate the differences between them, and Bravais-Pearson correlation coefficient to identify links between risk factors and profiles.ResultsConscientiousness (Control) was the trait most strongly associated with high autonomy and a low feeling of not being able to keep up. There was also a positive influence of Extraversion and Agreeableness on autonomy. On the other hand, Neuroticism scores were related to greater psychiatric morbidity, a greater feeling of not keeping up, and lower autonomy. The results for personality profiles confirm the stability of Block's profiles (Resilients, Overcontrollers and Undercontrollers) and their relevance in higher education contexts. Resilients and Overcontrollers had greater autonomy and a lower feeling of not keeping up, but Resilients had the lowest psychiatric morbidity. Undercontrollers were associated with the greatest risk factors: lowest autonomy, the highest psychiatric morbidity and the strongest feeling of not keeping up. Gender comparisons indicated that women were more affected by psychiatric morbidity, but had higher Conscientiousness and autonomy.     

Amélioration de l’adaptation à l’effort d’enfants polyhandicapés non marchants : quelle faisabilité ? Quels intérêts ?

In the past decade, respiratory care of severely disabled people has been developing. Certainly, considerations are moving beyond the issue of airway clearance: restriction of respiratory capacity and night ventilation problems are considered, instruments and devices, such as non-invasive ventilation, open up new therapeutic possibilities. Physical activity remains very limited in subjects with severe disabilities; however, it develops the capacity for adaptation towards these efforts. We questioned ourselves about the possible effects of sustained active solicitation in these types of cases. Could we modify the adaptive capacities of children with multiple-disabilities who are not walking through a motor-exercise program in an Educational Medical Institute? We implemented a protocol for four children over a two-month period to try to answer our question, understand the difficulties and overcome the lack of evidence in this topic.     

La dangerosité : un concept psychopathologique ?

Dangerousness, recent concept towards the reality it seeks to identify, can be defined as the statistical quantification of a risk of acting out. It appears in a border location, both for the subject by questioning the uncertain passage of an impulsive violence of psychic life in a violence acted out in external reality, and in its reports to his environment, which would be threatened by his potential dangerousness. The dangerousness first appears as a medico-legal concept, about which we question here the relevance in the field of clinic and psychopathology. If the problem of acting out seems central, various perspectives of understanding are outlined, particularly by formulating the hypothesis of a dangerousness understood as the subjective response to a feeling of vital threat: the dreaded acting out would not belong as much to the register of attack and aggressiveness as an expression of defense and safeguard response of the subject in front of danger of a threatening object. The impossibility of adjusting the distance between subject and object requires the control of the latter until engage its possible destruction in order to restore a constantly broken balance between narcissistic investment and objectal investment. If it seems possible to identify subjective stakes in the concept of dangerousness, it is especially to deconstruct its structure in clinical practice to grasp the meaning it could cover for a subject tackled in his singularity.     

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.