Troubles disruptifs intrafamiliaux : données actuelles et perspectives de traitement

Child-to-parent violence is a form of family violence that is still a well-kept secret. Abused parents can be victims of different types of abuse. Children can use both physical and psychological violence such as financial threats to take control of the home. In this situation, parents often no longer dare to contradict their children by fear of triggering uncontrollable violence. Although the phenomenon recently drew the attention of the media, there is still little knowledge about its prevalence and clinical characteristics. Most families remain isolated for a long time and, even in case of consulting in a mental health setting, disclosure of the nature of the difficulties is often delayed. This article presents the specificities of these children and their clinical characteristics. It also studies the victimized parents, the entire family, and their relation to the external environment. When observing these young offenders oppositional defiant disorder, conduct disorder and attention deficit hyperactivity disorder are frequently found. The diagnosis of “conduct disorder confined to family context” defined in the ICD 10 is the most appropriate to describe them. But it is regrettable that there has currently been no study to validate it and to determine its specificity. Compared with other young children who have “classic” disruptive disorders, children involved in violence against their parents have more difficulties with affect regulation, impulse control, and interpersonal skills. These children also frequently have low self-esteem and difficulties interacting with their peers. They may be isolated and bullied. They feel more sadness than these other young people and use violence as a way to express their emotions. Within the family both girls and boys commit violence against their parents. Girls will mostly use psychological violence but can also be involved in physical aggression. The first victim of child-to-parent violence is the mother. As mothers are often more present at home and seen by their children as weaker than the father, they are seen as an “easy target”. If the “classic” conduct disorder is most frequently encountered in low social status families, intra familial disruptive behavior can be observed in families from all socio economic status. With respect to the parent-child relationship in those families, there are some relevant specificities. First, the quality of communication is bad, parents and children are not intimate and the tension is permanent. Furthermore, children do not respect their parents’ authority. They perceive parenting style as permissive and negligent without enough support and control, and they may want to restore a coherent authority in the family. It is important to mention that potential vulnerability factors such as older age, a history of mental illness and social isolation have been described in parents of these children. Thereby, victimized parents have all the more difficulty to stand up against their children or to cleverly adapt their authority to their behavior. Other types of inappropriate education can be the origin of the child-to-parent violence. There is a direct correlation between the high frequency of punishments and violent attitude of the children towards their parents. So, the family dynamic is characterized by an inversion of the family hierarchy, the parents’ fear of violent behavior from their child, and shame expressed by the parents with regards to the nature of familial relationships. Their fear and their shame will contribute to ensuring that their child's behavior is kept secret. Finally, several factors can therefore be at the source of the development of child-to- parent violence ; this study aims to raise awareness of clinicians of this impairing and frequently hidden condition. Due to the absence of specific studies, management of intra-familial disruptive disorder is likely to be less than optimal and heterogeneous. The development of a group of targeted parental psychoeducation is a promising management technique. We will describe the basic principles of « active parental control», a programme using techniques of « non-violent resistance» to help parents cope with violence and control children's behavior. The results of this programme are still being evaluated, but preliminary results seem promising since the parents included in the pilot group have described a significant improvement in the feeling of parental competence and, notably, self-control.     

Variabilité phénotypique et corrélations génotype-phénotype des dystrophinopathies : contribution des banques de données

The objective of this work was to study the natural history of dystrophinopathies and the genotype-phenotype correlations made possible by the development of the clinical part of the French DMD database. The collection of 70,000 clinical data for 600 patients with an average longitudinal follow-up of 12 years enabled clarification of the natural history of Duchenne and Becker muscular dystrophies and clinical presentations in symptomatic females. We were able to specify the phenotypic heterogeneity of motor, orthopedic and respiratory involvements (severe, standard and intermediary form), of the cardiac disorder (severe, standard or absent cardiomyopathy, absence of correlation between motor and cardiac involvements), and of brain function (mental deficiency in the patients with Becker muscular dystrophy, psychopathological disorders in dystrophinopathies). Phenotypic variability did not correlate with a specific mutational spectrum. We propose a model of phenotypic analysis based on the presence or not of muscular and cardiac involvements (described by age at onset and rate of progression) and brain involvement (described by the type and the severity of the cognitive impairment and of the psychological disorders). The methodology developed for the DMD gene can be generalized and used for other databases dedicated to genetic diseases. Application of this model of phenotypic analysis for each patient and further development of the database should contribute substantially to clinical research providing useful tools for future clinical trials.     

Psychotraumatologie de la guerre en Ukraine : la question de la prise en charge psychologique des victimes réfugiées ou restées en Ukraine

The war in Ukraine is a major poly-traumatic event, which leads to massive population displacements. The question of the evaluation and psychological care of psychotraumatised people is an urgent matter. As many countries hosting refugees are well endowed with a number of psychologists, some of these interested professionals should mobilise themselves and make themselves known to carry out these clinical acts. Priority should be given to trained and experienced psychologists to support victims. The language barrier will have to be overcome. Initially, it would be desirable to make contact or get closer to local and national refugee centres to facilitate these operations. Face-to-face or remote consultations, as developed during the Covid-19 pandemic, are possible. Reinforcements of available and dedicated psychologists, including remotely, from the countries hosting the most refugees are also desirable. The issue of detection, assessment and care of psychologically traumatised people who remained in the Ukrainian territory is probably even more massive. Whether non-combatants or combatants, part of the international psychological community should mobilise, in addition to local colleagues, to provide them with this psychological help. These humanitarian actions would be feasible depending on the evolution of the conflict. Whether it is psychological support for refugees or people still on the Ukrainian soil, models for organizing and coordinating these actions must be carefully thought out and implemented in an evolving way to optimise their effectiveness.     

Séjours courts et longs en ASPPI : comparaison des données cliniques et extracliniques issues de 250 certificats initiaux

Background

On July 5, 2011, France introduced a law permitting the involuntary admission of patients considered to be in “imminent danger” into psychiatric care without the consent of the family. This is known as “admission en soins psychiatriques pour péril imminent”(ASPPI). ASPPI authorizes all physicians to hospitalize a patient without his or her consent nor the consent of a third party. This differs from previous measures as only one certificate is needed. The law also requires involuntarily admitted patients to present themselves before a judge specialized in Liberties and Detentions (juge des libertés et des détentions), 12 days following their admission. Although there has been an increase in the number of ASPPI admissions when compared to other types of involuntary admission, patients admitted by ASPPI have been hospitalized for a shorter time than others. Some authors, however, have pointed out that decision criteria are frequently interpreted in a loose manner by physicians. This study was conducted at Sainte Anne hospital in Paris.

A Factor Analysis of Patients’ Views of Compulsory Community Treatment Orders: The Factors Associated with Detention

Quantitative analysis of patients’ views about compulsory community treatment has not been undertaken although qualitative analysis identifies some positive and negative themes. This research is designed to identify the factor structure of patients’ subjective experience of community detention in a quantitative fashion. The authors assessed 79 psychiatric patients either currently or previously detained under a compulsory community treatment order for in excess of 6 months. A structured questionnaire was used to assess patients’ views of community detention and exploratory factor analysis was performed. Principal component analysis with oblique rotation identified three factors associated with detention. Although overlapping, these factors represent interpersonal difficulties, intrapsychic threat and a safety factor associated with detention. The safety factor also loaded for unhappiness. These factors accounted for 60% of the variance in the data set. Recognizing these factors may improve the use of community treatment orders and make them more acceptable to patients.     

L’unité pour malades difficiles de Cadillac en Gironde : données d’activité, pathologies et approches thérapeutiques

This communication presents a high security facility in the hospital of Cadillac, near Bordeaux (France). This structure provides intensive psychiatric care for patients with mental disorders and often violent or criminal propensities, all of them compulsorily hospitalized, who need particular security measures. The objective of the study was to describe activity data, characteristics of patients, main diagnoses for year 2018. Among 125 patients, about half (48%) came from Nouvelle-Aquitaine, a large administrative area, and the other came from other regions of France. Most patients were addressed by general psychiatric services (73%). Some were declared not guilty for insanity after a crime (18%), or were detainees (9%). Schizophrenia was the most frequent diagnostic (60%), often associated with substance use disorder. We purpose a clinical approach of different profiles of patients, and a review of therapeutics.     

Les programmes de pairs aidants en santé mentale en France : état de situation et difficultés de mise en place

Objectives

Recovery is a process through which people experiencing mental illness learn to live with their disorder and reach social insertion and citizenship. This positive approach focuses on a person's competencies and strengths rather than on the symptoms. Within this philosophy, peer support has been unevenly developing in mental health services worldwide with roots in the South-American social programs for homeless people and in the American recovery circles in the field of addiction. Therapeutic efficiency of peer support has been proven by several studies including a control group, as being at least as good as traditional services and even better in some specific areas such as reduction of need for emergency services and ability to reach “difficult” patients. The integration of former psychiatric services users in mental health services can take several forms, from the participation to scientific research studies to the direct involvement in a professional team at mental health facilities. In this context, our research aims to sum up the situation in France in comparison with other countries.

Les proches aidants des personnes en état de conscience altérée : ruptures et continuité dans les relations

ObjectivesThis study seeks to better understand caregivers’ experience of the support their loved ones, with disorders of consciousness, receive in a dedicated unit.MethodsThe focus here is on the qualitative component of a larger study that also includes a quantitative component. An inductive and iterative approach was prioritized, i.e., one similar to grounded theory; a thematic analysis was used to analyze 20 comprehensive semi-structured interviews.ResultsThree main themes emerged: the discovery of a new world by a patient's loved ones, i.e., the disorders of consciousness; the psychological and somatic impact on loved ones; and the relationships between family caregivers and professionals of the dedicated unit.DiscussionThe new living situation of people with disorders of consciousness requires caregivers to engage in an intense psychological process. First, this process is necessary to their understanding of the situation and its consequences. Second, it allows them to cope with the reorganization of the emotional and relational ties between the patient and the caregiver, and in the entire family dynamic. Lastly, healthcare professionals consider that caregivers are also the witnesses of the patient's earlier life, capable of linking the past and present, and often the interpreters of patients’ emotional reactions according to their former personality.ConclusionCaregivers are affected by the frailty and somatic dependence of their loved ones; and they also bear the history and psychological continuity of patients. Professionals must take this double burden into account, which helps explain families’ psychological exhaustion and their need for help. Understanding these phenomena is crucial for improving patient care in dedicated units.     

Évaluation des troubles thymiques par l’étude des données passives : le concept de phénotype digital à l’épreuve de la culture de métier de psychiatre

Objectives

The search for objective clinical signs is a constant practitioners’ and researchers’ concern in psychiatry. New technologies (embedded sensors, artificial intelligence) give an easier access to untapped information such as passive data (i.e. that do not require patient intervention). The concept of “digital phenotype” is emerging in psychiatry: a psychomotor alteration translated by accelerometer's modifications contrasting with the usual functioning of the subject, or the graphorrhea of patients presenting a manic episode which is replaced by an increase of SMS sent. Our main objective is to highlight the digital phenotype of mood disorders by means of a selective review of the literature.

Efficacité et tolérance des IPDE-5 dans le traitement de la dysfonction érectile chez le patient schizophrène : une revue de la littérature

Introduction

Sexual dysfunction is an important public health problem in men and is associated with reduced quality of life. It is more common in patients with schizophrenia. It is well-established that antipsychotic drugs cause sexual dysfunction with consequences on the quality of life of patients, adherence to treatment, and public health costs. Phosphodiesterase type 5 inhibitors (PDE5 inhibitors) are indicated for the management of erectile dysfunction. However, there is little information on such treatment in schizophrenic patients. This literature review aimed to summarize the current data on the efficacy and tolerability of PDE-5 inhibitors in the erectile dysfunction in schizophrenic patients.

Les hyponatrémies sous ISRS/IRSNA : étude épidémiologique descriptive et comparative des taux d’incidence de cas notifiés à partir des données de la Banque nationale de pharmacovigilance et de l’Assurance maladie

Introduction

Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are frequently prescribed. These antidepressants can potentially induce serious hyponatremia through the SIADH syndrome. That seems to concern all molecules of these classes but the individual risk of each molecule is not well known. The aims of the study were to compare the incidence rate of each molecule in order to identify the existence of molecules more at risk of inducing hyponatremia and to characterize a profile of patients at risk for hyponatremia during a treatment with a SSRI or a SNRI.

Effets de la ventilation en pression positive continue sur la dépression,l’anxiété et la qualité de vie au cours du syndrome des apnées-hypopnées obstructives du sommeil

IntroductionThe obstructive sleep apnea hypopnea syndrome (OSAHS) is a chronic stressor that may alter the emotional state and quality of life (QOL) of patients suffering from it. In this work, we proposed to estimate the prevalence of depression and anxiety, to assess the QOL in a Tunisian population of apneic patients, and to assess their evolution under continuous positive airway pressure (CPAP).MethodsWe conducted a prospective study, involving 33 apneic patients followed for SAHOS with moderate or severe class disease in the pneumology department at Hedi Chaker university hospital in Sfax, Tunisia. They received CPAP treatment for three months. We used an epidemiological record. Two scales, the Hospital Anxiety and Depression Scale (HADS) and the 36-item Short-Form Health Survey (SF-36), were completed before and after treatment to evaluate the effect of three months of treatment with CPAP.ResultsThe prevalence of depression in the study's patients, according to the HADS, was 45.5% and that of anxiety was 21.2%. After 3 months of CPAP, the prevalence of depression and anxiety had become 18.2% and 6.1%, respectively. QOL was impaired in 81.8% of cases before treatment, according to the SF-36. This figure had decreased to 69.7% after 3 months of treatment with CPAP. Apart from the third dimension (physical pain), all other dimensions were significantly improved after 3 months of CPAP treatment. The treatment with CPAP induced a significant improvement in the average scores of depression (P < 0.001), anxiety (P = 0.002) and QOL (P < 0.001).ConclusionsThese results attest to the importance of the frequency of anxio-depressive disorders as well as an altered QOL in patients with OSAHS. CPAP treatment was shown to be effective in improving these parameters, but this efficacy was partial. Specialized care may be needed in cases of residual anxio-depressive symptoms.     

Justice résolutive de problèmes : efficacité des tribunaux en santé mentale aux États-Unis et présentation du dispositif lyonnais

People with mental disorders are over-represented in the criminal justice system. Mental Heath Courts are problem-solving oriented courts developed as a means of providing treatment to individuals with mental illness involved in the criminal justice system in order to avoid recidivism and to improve access to community mental health care services. MHCs are an alternative to the incarceration and the innovation behind his model is the collaboration between the judiciary and mental health services. The first MHC was created in 1997 in Florida; there are now more than 300 such courts in the United States. In Lyon, France, thought work with Canadian team at the Montreal Mental Health court, a new program called Contrainte Pénale Justice Thérapeutique was created in 2016. CPJT is also based on the collaboration of legal, social and pre-existing mental health services in order to treat recidivist offenders suffering from psychiatric and/or addictive disorder. The aim of this interview with Constance Baheux and Dr Sabine Mouchet–Mages is to present the results of American mental health court in terms of effectiveness and to introduce the French program Contrainte Pénale Justice Thérapeutique in Lyon according to French law.