Rôle des équipes de soins dans l'évaluation et la prévention de l'agressivité

Aggressiveness and violence in psychiatric wards have been common for some time. Situations that incur risks may originate at different levels such as the feeling that one is not heard, a break with one's entourage, feelings of isolation, factors related to pathology, postponing a treatment, the prohibition of smoking in the rooms... Further to the analysis of the relative situation of the patient, it is of utmost importance that the team pay attention to it's own sentiments of fear, to its divisions, to its feelings of distress and of its difficulties with some patients. On the other hand, conversations, follow-up at patient's homes and out of hospital psycho-educative groups are set up to allow patients to better manage their treatment, to detect risk situations for themselves and to detect early signs of relapse so as to forestall crisis situations and to avoid re-hospitalisation.     

Le déni de grossesse : étude réalisée sur 75 dossiers de découverte tardive de grossesse

The denial of pregnancy is a vague and badly defined entity with no international consensus. Yet this phenomenon is often found by health professionals, provoking much questioning on its aetiology and how to treat it. The denial of pregnancy constitutes a potentially risky situation for both mother and child.     

Le suicide dans l'institution

More than 50 % of suicides are by patients who have been or are still followed-up. The prevalence of suicidal crises is high (32 %) and stable in populations of chronic psychiatric patients. Suicidal risk factors are well known, nevertheless they are more particularly high during acute crises and are lower when the psychiatric illness is chronic. Five percent of the suicides are committed during hospitalization. Most of them occur on the first month following admission, in the first week of an acute psychotic crisis, within the year after hospitalization, prior to the hospital discharge. The rate of suicide is particularly important in psychiatric institutions because most of their patients are suffering from schizophrenia and/or depression, two diseases with high rates of suicide. Some suicidal risk factors specific to schizophrenia have been identified such as the schizoid-affective form of the disease, patient care that has been delayed, a chronic disease with numerous acute episodes, short and frequent admissions in a hospital, involuntary hospitalisations, extrapyramidal side effects and disruption of treatment. The vulnerability appears to be maximum during the first week and/or the three months after discharge from the hospital, during the first year following the diagnosis and during acute episodes, especially the first one. In the second part of this work, we will examine the legal aspects, based on the main recent court cases relative to hospital liability. The fault usually consists in lack of surveillance and involves the liability of the hospital. The assessment of the adequacy of the measures taken for the medical care of a patient and in particular his/her supervision depends on the predictability of the suicidal act; the severity of the psychiatric illness and more particularly on previous suicidal attempts; previous fugues from the hospital and previous violent acting out especially on the occasion of previous hospitalisations. To avoid reciprocal projections when there is a suicidal act it is essential to work with family and attendants, to obtain clear and exact information about the psychiatric illness and to ensure both medical and administrative care.     

Évaluation du potentiel suicidaire chez les adolescents : lien entre fréquence, satisfaction et moyens utilisés par différents intervenants en pédopsychiatrie

Nowadays adolescents often express mourning by suicidal behaviour. It is therefore important to be able to provide suitable investigation tools. A study was carried out at a Department of Adolescent Psychiatry in the French-speaking region of Switzerland with the aim of gaining a better understanding of the present assessment techniques and in order to propose the introduction of a guide for the assessment of suicidal behaviour in both out and in patient units. A semi-structured questionnaire was developed in order to proceed to individual interviews in four clinical units. 62 professionals (medical doctors, psychologists, nurses, specialised teachers and social workers) participated in the study. The results show that during the three months before the study, 2/3 of the care providers had performed suicide risks assessments between one and ten times. Suicide risks must therefore be considered as a serious problem for the majority of care providers. Comparing the different interventions, it was observed that nurses and medical doctors performed suicide risk assessments more often than psychologists and social workers and that they generally took less time to do so. The study showed that the different techniques for performing suicide risk assessments corresponded to those quoted in almost all research studies relating to suicide risk factors: psychopathology, a previous suicide attempt, problems in the family, life events and negative social environment. When should suicide risks be assessed? For most of the participants in the study, a systematic suicide risk assessment is recommended for all patients and is a requirement for patients with a history of a suicidal risk. Among suicide risk assessment techniques, the most frequently quoted is that of a discussion with the team of care providers. Even if the care providers' level of satisfaction is relatively high, other potential techniques are also mentioned such as an interview guide, and ad hoc training and tests. It is interesting to note that only one care provider mentioned the use of a questionnaire whereas 30 care providers would have liked to introduce one. It is well known that questionnaires cannot predict a suicide attempt, but they can help provide an assessment of suicide risks in order to help care for patients. Care providers generally mentioned that they appreciated having time for discussions with patients and would like having even more time. The majority of care providers reported that they were relatively satisfied with their suicide risk assessment techniques but that they would have liked to have the possibility of using a more systematic assessment technique. In this context, it seems useful to complement existing techniques with a guide to help assess suicide risks in order to provide a common tool in institutions where communications between care providers is essential. The assessment technique developed by Terra and Séguin featuring specific training and a guide for helping to assess suicide risks was introduced in our Clinical Department to help care providers better assess this important problem.     

Le syndrome de Koro

Objective. - To investigate a rare psychiatric disorder called “Koro” which is usually described as a culture-specific syndrome in Asian cultures. This syndrome is manifested by intense anxiety associated with the fear of genital retraction and the belief that complete disappearance of the penis into the abdomen will result in death. Even though some cases have been reported in non-Asian subjects, it is often referred to as a culture-bound syndrome.Method. - A literature and case report review indexed 117 articles or summaries relating to the syndrome of Koro. In addition, the authors report six cases of Koro in Quebec from their clinical practice and open a discussion on clinical, epidemiological and etiological features.Results. - Koro is a relatively rare syndrome that is related to various etiological, clinical, diagnostic and cultural aspects leading to several controversial debates, letters to editors and comments on articles. This also includes the anthropological, psychodynamic and biological point of views. Even though only 19 cases in Hong Kong were diagnosed in fifteen years, this syndrome can sometimes take epidemic proportions as in Singapore where many cases appeared following a porcine infection or in Thailand where a thousand cases were listed after the Vietnam War. In the province of Juandong, two similar phenomena were clearly documented in 1984-1985 and 1987 where a total of two thousand cases were declared. This was also observed in India, a country culturally very different with a mainly Hindu and Muslim population. The authors also describe six cases in Quebec: 1- a 31-year-old man with no history of psychosis with anxiety related to problems in erection and ejaculation that had negative effects on his married life. Shortly after he reported that his penis retracted into his belly. 2- a 32-year-old American-Indian man, with history of violence and alcohol dependence developed Koro symptoms, which caused this patient to use strings around the penis to prevent its retraction into the belly. 3- an 18-year-old male diagnosed with paranoid schizophrenia expressed his extreme concern to see his penis decrease in size and retract during one of his hospitalisations. He believed that only masturbation and sex with prostitutes were capable of preventing this from happening. 4- a 25-year-old patient diagnosed with paranoid schizophrenia since the age of 16 arrived at the emergency with suicidal ideas. Upon interview, the patient was anxious and presented olfactory hallucinations of genital origin. He expressed concerns that his genitals would disappear inside his abdomen. 5- a 25-year-old man with paranoid schizophrenia presented with auditory hallucinations of death threats and fear that his penis would be removed by magic. After one month of hospitalisation, his anguish took an obsessive form that required him to go to the bathroom regularly to examine himself. 6- a 31-year-old man diagnosed with paranoid schizophrenia since the age of 19 arrived at the emergency with suicidal ideations under the influence of command hallucinations. He requested a treatment that would prevent his genitals from disappearing into his belly.Conclusion. - A distinction seems necessary between epidemic cases of Koro that are culture-specific and isolated cases, that given the right setting and stimulus could occur in any culture and are often present in comorbidity with severe psychopathologies or cerebral lesions.     

Incommodités de la vie et gêne présuicidaire

The presuicidal syndrome was first described by Professor E. Ringel in 1953. This Austrian psychiatrist devoted most of his research to the study of suicidal risk, and in the course of doing so also focused on the prevention of suicidal risk. One of his key articles, namely "Difficulties encountered in life and presuicidal malaise', published in 1967 and subsequently much commented upon or cited, has been translated into French for this issue. In the document in question, emphasis is placed upon the primary phenomenon of the presuicidal syndrome, that is to say, presuicidal malaise. How and why does it develop, and then become so overwhelming? On the basis of the distinction between cause and motive, the author then considers the possible means of psychopathological functioning that could trigger interactions between the actual personality of the subject and his existential situation. However, the latter state is not objectively linked to the facts of life: the way in which the subject perceives and lives out the events in question, and sometimes even causes them, appears to be a determining factor in the development of this particular syndrome. Several clinical examples are then given that subsequently lead the author to focus on the attitude of the social group towards suicide, which, if pertinent, can constitute one of the basic prophylactic elements. In conclusion, the original existential argument is again taken up with the hypothesis that although the emphasis on causality is interesting from a theoretical point of view, it should not prevent the therapist from being vigilant as regards this particular group of potentially suicidal individuals.     

Les troubles anxieux comme facteurs de risque pour la dépression et les troubles liés à l'utilisation d'alcool

The object of this paper is to specify the role of anxiety disorders taken as a group or separately (including panic disorder, social phobia, specific phobia, obsessive-compulsive disorder, generalized anxiety disorder and post-traumatic stress disorder) as potential causal risk factors for depression and alcohol use disorders. Several studies have consistently suggested that some anxiety disorders are primary to other mental disorders in a majority of co-morbid cases and could increase the risk of their onset. We performed a computerized search (Pubmed) on recent published studies on this subject. We focused on recent prospective studies. Several findings have confirmed that the number and severity of some primary anxiety disorders may significantly increase the risk of subsequent mental disorders (such as depression and alcohol use disorders). However, the authors are not unanimous on this subject. A precise determination of whether various anxiety disorders could constitute causal risk factors for subsequent mental disorders would permit a better understanding of disease aetiology, improve the efficiency of diagnosis and would allow development of effective interventions.     

Promotion et prévention en santé mentale chez les très jeunes enfants : revue de la littérature

This document describes a broad range of various projects among children between zero and six years in the 15 country of the European Community and Norway. The majority of them were developed and tested in disadvantaged areas and various cultures. The interventions with the children and the parents, the choice of the age range concerned, the strategy of realization vary according to the policy of health, the school system and the health care system of each country. Some of them concern the young children, even future parents ; the others concern children, teachers and the parents. These programs do not claim to treat children with clinical disorders but to bring elements to support the parents, in general especially those with difficulties because of their social condition.     

La notion de spectre bipolaire a-t-elle la même incidence en ville qu'à l'hôpital ?

The notion of bipolar spectrum was introduced by Klerman in 1980. It designates the group of disorders that include mood variations. It was included in the classification as defined by Pinto and Akiskal in 1987. The authors examine the incidence of these disorders on patients followed in public hospitals and in private practice.     

Fragilité psychologique de l’enfant en devenir et période prénatale

The authors have made a review of risk factors during prenatal time, which contribute to potential psychological vulnerability of the future child. They point out importance of negative transmissions and negative mandates and their repercussions on procreative conditions. Then, they discuss child’s vulnerability risk factors linked to non-elaboration of mother’s anguish, aggressive and depressive feelings. They point out the negative weight of maternal depression and of problematic birth conditions on early mother-child interactions. They propose preventive procedures to face potential negative mandates, to diagnostic and accompany better maternal and parental suffering during pregnancy and after child’s birth. At the end, they reflect on the links between prevention, clinical psychology and socio-political action. They suggest necessity to undertake actions-research on the same pattern of those developed in North American countries with the aim to demonstrate usefulness of primary prevention, which appear much better than remediation actions associated to secondary prevention and able to convince politic power.     

Le suicide dans la maladie de Huntington : état actuel des connaissances

Objectives

In 1872, George Huntington was the first to describe a genetic disease combining three types of disorder symptoms viz: motor, cognitive - evolving to cortical dementia and psychiatric. The purpose of this paper is to provide a selective review of the major issues and findings concerning suicide in Huntington's disease. The aim was to understand why patients with Huntington's disease have a higher suicide rate than those suffering from other neuro-developmental diseases.

Materials and methods

The present review is based on a MEDLINE survey of the relevant literature. The terms used in the search were: “Suicide”, “predictive genetic testing”, “suicidal risk factors” and “suicide attempt” all in combination with “Huntington's disease”. All abstracts were read and potentially relevant articles were examined in full. Various other important cross-references were included.

Results

Most of the authors found that suicidal occurrence in Huntington patients was four times higher than that in the general population. No specific individual risk factor was found except a lack of offspring and of psychological support. This review also considered the patient's attitude towards predictive genetic testing and its results. Reactions varied from psychological relief to paradoxical suicidal resurgence.

Conclusion

This paper emphasizes the need of appropriate psychiatric care for Huntington's patients in order to try to prevent suicidal behaviour.     

L' « Ouverture émotionnelle » dans les Troubles de la dépendance et les Troubles de la personnalité

Emotion processing is supposed to play an important role in psychological dysfunctions in alcohol and drug dependency disorders (DD), as well as in personality disorders (PD). The model of “Emotional Openness” (“Ouverture émotionnelle”) provides a multidimensional framework to analyze problematic patterns of emotion processing. Within this framework, it is suggested that drug- and alcohol-dependent patients as well as borderline and antisocial patients show reduced a) “cognitive/conceptual representation” of affective states; b) “emotion regulation”; and c) “expression and communication of emotion”; but d) increased “awareness of body internal indicators” of affectivity; and e) appropriate psychological treatment is supposed to improve these patterns. Drug-dependent patients with PD comorbidity (in particular borderline or antisocial) are supposed to present even stronger deficits in (a) and (b). The hypotheses are tested with the 36-item DOE questionnaire (“Dimensions of Openness to Emotional experiences”, trait version; [19]), assessing six main dimensions of emotion processing as represented by the subject (French and Italian version). The instrument presents satisfying reliability coefficients (mean alphas of the scales in two recent studies (N = 251; N = 435) vary between 0.74 and 0.82) and good factorial validity (6-factor PCA solutions with varimax rotation solutions in the two samples are highly coherent; the mean of Tucker's congruence coefficients is 0.93). Results of two clinical studies are presented, comparing N = 71 patients (21 drug-dependent without personality disorder; 30 drug-dependent with borderline or antisocial personality; 20 dependent in-patients receiving psychological therapy) with normal control subjects (N = 51 matched; N = 50 reference group), including one pre-post treatment comparison. Results confirm marked deficits of DD patients concerning “conceptual representation” and “emotion regulation”, as well as a reduction of “communication/expression of emotion” but an increased “awareness of body internal indicators” of affectivity. Differences of patients with a double diagnosis correspond to effect sizes of d = -1.33 for cognitive/conceptual representation of emotions and d = -1.25 for emotion regulation; differences in emotion communication and expression are also significant but less important d = -0.44. Awareness of body internal emotion indicators is increased (d = +0.27) but does not differ significantly from the control group. As supposed, patients with a double diagnosis (DD and PD) described significantly stronger deficits in conceptual representation and emotion regulation than the patients with dependency disorder only. In the second study, a group of DD patients receiving multi-component treatment, including individual and group therapeutic intervention, according to the client-centered approach, and working on emotion processing, showed marked differences from the reference group at the beginning of the treatment (d = -0.91 for cognitive/conceptual representation, d = -0.82 for emotion regulation and d = +0.46 for awareness of bodily internal indicators). As supposed, pre-post comparisons indicate improvement with change effect sizes of d = 0.99 for conceptual representation, d = 0.97 for emotion regulation, as well as d = 0.88 for emotion communication and expression. Furthermore, the changes following treatment are highly significant and substantial, except for the awareness of internal bodily indicators, which only slightly decreased. Patients “normalize” their emotion processing following treatment, describing increased conceptual representation and emotion regulation, as well as emotion communication and expression. Results underline the importance of dysfunctional modes of emotion processing in both pathologies, and underline the validity of applying the model and the DOE instrument. They are discussed with reference to the model of alexithymia.     

L'utilisation du système de santé avant une tentative de suicide : étude préliminaire dans un service d'urgences psychiatriques

Introduction

The aim of this preliminary report is to study the use of the health care system in the month prior to a suicide attempt (SA) of patients assessed during one year, following a SA, in the emergency wards of two hospitals from Liège, Belgium.

Methods

This prospective study searches for a possible link between the patients' diagnosis (axis I, DSM-IV), the type of SA and the existence of a contact/working relation with a professional caregiver in the month prior to the SA among 549 patients.

Results

The most frequent diagnoses (DSM-IV) were adjustment disorder and mood disorders, as well as ethanol abuse. In the month prior to the SA nearly 80% of patient's benefited from contact with a professional care giver, who was a general practitioner in 50% of the cases.

Discussion

The level of mental care provided one month prior to the SA is discussed taking into account the availability of the professionals in terms of time and the identification of a potential risk of SA.     

Les accidents vasculaires cérébraux du nouveau-né et de l’enfant

The clinical presentation, risk factors, causes, vital or functional prognosis, and acute management options for stroke occurring in neonates and children are specific, differing from those observed in young adults. Compared with the adult population, less is known about the epidemiology of stroke in the under-18 population where the disease could become more frequent because of advances in both neonatal resuscitation techniques for cerebral disorders and neuroimaging techniques enabling the diagnosis of small lesions. Clinical features are often delayed, especially in neonates, and unlike epilepsy or dystonia of the affected limb, which are frequent complications, aphasia is rather rare. The most frequent causes of stroke at the beginning of life are cardiac embolism, for ischemic stroke, and arteriovenous malformations, for intracerebral hemorrhage. Acute management at this age is specific. This article reviews the literature on the epidemiological and clinical features, the main causes, and the acute management guidelines of stroke occurring in newborn infants and children and highlights the need for neurologists to have comprehensive knowledge of this disease.     

Trouble bipolaire et comorbidités addictives

Comorbidity is particularly high in patients with bipolar disorders. Substance use disorders are higher in BP patients than in the general population in almost every epidemiological study. However, the physiopathology of this association remains obscure. The hypothesis in the literature is inconclusive, sometimes contradictory. This paper presents a brief review of this area of research and discusses the plausibility of each hypothesis. The role of subjective effects of cannabis and alcohol is particularly emphasized.