Mortalité et surmortalité dans la schizophrénie

The aim of the present communication is to present an overview on mortality in schizophrenic patients. Recent meta-analyses have confirmed high rates of mortality in schizophrenic patients and, notably, the gap observed in the last three decades between mortality in the general population and that of schizophrenic patients. In this population mortality rates due to non-natural causes, essentially suicide, are 12 times higher than that of the general population, natural causes of mortality being due to cardiovascular and respiratory diseases. Atypical antipsychotics have been incriminated in the high rate of mortality among schizophrenic patients. Prevention was focused firstly on a decrease of the risk of suicide and secondly on poor living habits (smoking, obesity). The importance of a regular follow-up of the somatic health of schizophrenic patients was discussed.     

Attribution d’états mentaux et schizophrénie

The cognitive neuropsychology proposes models to explore schizophrenics symptoms. The concept of theory of mind appeared in psychiatry fifteen years ago and is now a focus of research. Various comprehensive models of schizophrenia involving theory of mind have been proposed and explored by experimental tasks. Those models are useful to understand schizophrenic semiology and to explore brain by functional imaging. A review of these research is useful to understand their interest.     

Production d’émotions faciales dans la schizophrénie

Converging evidences revealed that facial pattern recognition is severely impaired in schizophrenia. The present article focuses on recognition of their own facial expression by patients with schizophrenia. It seems that schizophrenia is related with a dissociation between facial expression and emotional feeling. Recent experimental data are discussed.     

Insight et interventions psychoéducationnelles dans la schizophrénie

Poor insight is consistently present in schizophrenia and is among the most discriminating symptoms for differentiating schizophrenia from other mental disorders. Patients are unable to see the most obvious symptoms of their illness, despite the fact that their family members can recognize thought disorder, mania or hallucinations. Results suggest that lack of insight is a part of the disorder itself, rather than an adaptive strategy. Poor insight in schizophrenia has been described as a lack of awareness of suffering from an illness, of the symptoms of the illness, of the consequences of the disorder, and of the need for treatment. Similarly to some negative symptoms lack of insight predisposes to an increased number of relapses and hospitalizations, to deteriorating social skills and quality of social relationships, and to a worsening course of illness. Unawareness is among the best predictions of non-adherence to treatment. Patients do not want to take medicine for an illness they do not think they have. The ways in which patients think about their illness experiences have been associated with a variety of behaviours and emotional responses. In schizophrenia, the study of beliefs about mental illness has generally been centered on people's interpretations of experiences and how these interpretations contribute to the development and maintenance of symptoms. There are less studies of other beliefs such as the causes of the experience, beliefs about treatment, consequences, and how long the illness is likely to last. The need to understand the way in which a patient appraises his/her own experiences has been recognized. People who integrated their experiences more fully, accepting that they had experienced a psychotic episode, actually showed higher levels of depression. This may reflect the demoralization and stigma that patients associate with mental illness. Many clinicians believe that lack of insight is very often a consequence of denial, a defensive mechanism. Terms such as defensive denial, and lack of insight often reflect underlying conceptual differences. Psychoeducational interventions were developed to increase patients’ knowledge of, and awareness about their illness, there is a focus on knowledge. Education is a process by which a patient gains understanding through learning. Patients have a right to an accurate and complete knowledge regarding their illness and treatment. The assumption is that this increased knowledge and insight will enable patients to cope in a more effective way. Learning implies changes in behaviour, skill or attitude. There is some suggestion that psychoeducation may improve compliance with medication and have a positive effect on a patients’ quality of life. Psychoeducational approaches involve interaction between the caregiver and the mentally ill person. Patient education can take a variety of forms and objectives. It may take place in groups or on a one-to-one basis and it may involve the use of videotapes, self-help or other media. The goal may be to better manage the patient's treatment, illness or condition to help him/her attain an improved level of health. Psychoeducational interventions address the illness from a multidimensional viewpoint, including familial, social and pharmacological information. Patients are provided with support, information and management strategies. Interventions may include elements of behavioural training, social and life skills training, or education performed by professional caregivers. This review studies the links between insight and various psychoeducational interventions: health and treatment education, psychosocial skills training, familial intervention, and intervention focused on subjective illness experience.     

La pensée et le langage par le corps dans la schizophrénie

Connections between body and psyche are regularly studied in the field of psychosis. One of the reasons of that recurrence is the fact that schizophrenic psychosis deconstructs the discursive system and exposes its bodily roots. In the first part of this paper, we remind several authors (Dolto, Pankow, Aulagnier, Golse, Delion, Piaget, Stern i.e.), whose works are showing how the mind develops on the basis of sense - and bodily experiences. In the second part, we examine the specificity of the schizophrenia as regression to the autoerotism and we mention Freud's idea of the “organ's language”. The organ's language represents the use of bodily symbols into the discourse; those symbols have to be interpreted like dreams. Finally, two clinical examples illustrate those elements. We examine the idea that, even if the nosographic category “schizophrenia” has not necessarily to be defended, there is perhaps a common clinical feature defined by the place of the body in the discourse.     

La fonction cicatrisante du délire dans la schizophrénie

Psychoanalytic epistemology considers psychosis to be linked to the resurgence of traumatic experiences that have not been assimilated by subjectivity. The hallucinatory return of this primitive agony faces the psychotic subject with a driving encroachment that attacks his body and disintegrates its unitary organisation. Considering this reliving of traumatic experiences, the authors will present schizophrenic delusion less as a pathological result than as a subjective response that aims to treat the psychic over tension, which fractures the subject's body identity. Based on several clinical studies, this article will question the healing effect of delusion in schizophrenia. It is therefore concerned with investigating the different functions of delusion and identifying their incidence on the subject's body image. Using the different clinical examples cited, the authors will then attempt to develop certain therapeutic applications, which contribute to a possible reduction of the body disintegration phenomena in schizophrenia.     

Intérêt d’un nouvel instrument dans l’évaluation cognitive dans la schizophrénie

Background

An increasing interest in the study of cognition in Schizophrenia has developed within the last few years although cognitive problems have been described in this disorder since the beginning of the 20th century. Presently, various data tend to assert that cognitive disorders are the core disturbance in schizophrenia and that their severity is predictive of the course of the disease. Indeed, studies have shown that the disturbances measured in cognitive tests are neither the consequences of positive or negative symptoms, nor related to motivation or global intellectual deficit, nor to anti-psychotic medication. It is also presently known that the severity of cognitive symptoms is a better indicator of social and functional outcome than the severity of the negative or positive symptoms. The patients who have the most severe cognitive deficits during the first episode of the disease are most likely to present a chronic and severe form later on. The aspects of cognition that are specifically impaired in schizophrenia are verbal memory, working memory, motor function, attention, executive functions, and verbal fluency. Cognitive disturbances are thus very important in several fields of research in schizophrenia such as: understanding the psychopathology, epidemiology (indicators of vulnerability), genetics (endophenotypes), neuro-imaging (including functional neuro-imaging), and psychopharmacology (they can be used as a parameter of evaluation in therapeutic trials with new molecules, or cognitive psychotherapy).

Limits of cognition assessments

However, there are some methodological limits to these cognitive evaluations. First, schizophrenia is a heterogeneous disease and there are no specificities of the different subgroups in terms of cognition. Secondly, the time chosen to evaluate the abilities of the patient is also a limiting factor. But most of all, the batteries of tests used in different studies are not standardized.

Brief Assessment of Cognition in Schizophrenia

It is therefore of great interest to create an available and easily used battery of validated tests. This would enable one to measure the different cognitive deficits and to repeat the tests, and assess evolution through longitudinal follow up of the patients. The BACS is a new instrument developed by Keefe et al. in the Department of Psychiatry and Behavioural Sciences at the University of Duke Medical Centre. It evaluates the cognitive dimensions specifically altered in schizophrenia and correlated with the evolution of the disease. This test is simple to use, requiring only paper, pencils and a stopwatch. It can be administered by different carers. The duration of the test session is approximately 35 min. This battery of tests was validated on a sample of 150 patients compared with a sample of 50 controls, matched for age, parent education and ethnic groups. This aim of this study is to create a French adaptation of the BACS (translation and back translation approved by the Department of Psychiatry and Behavioural Sciences at the University of Duke Medical Centre) and then to test its easiness of administration and its sensitivity, performing correlation analysis between the French Version of the BACS (version A) and a standard battery. Its adaptation and validation in French would at first be useful for the French-speaking areas and then would add some new data for the pertinence of using the BACS.

Methods

35 French stabilized schizophrenic patients were recruited from the inpatient and outpatient facilities at the Clermont-de-L’Oise Mental Health Hospital (Picardie area, France) in Dr Boitard‘s Psychiatric Department (FJ 5.) Patients were required to meet DSM-IV criteria for schizophrenia or schizoaffective illness. The patients were tested on two separate days by two independent clinicians with less than two weeks between the two assessments. During the first test session, subjects received the French A version of the BACS and during the second session, they were administered the standard battery of cognitive tests including: the Rey Auditory-Verbal learning test, the Wechsler Adult Intelligence Scale, third edition, subtests (Digit inverse sequencing, Digit Symbol-Coding), the Trail-Making A, Verbal Fluency (Controlled Oral Word Association Test, Category Instances), and the Wisconsin Card Sort Test (128 card version). The factor structure of the French BACS A Version was determined by performing a principal components analysis with oblique rotation. The relationship between the French BACS sub-scores and the standard battery sub-scores was determined by calculating Pearson's correlations among the sub-scores, with a level of significance of α < 0.05.

Results

All the 35 patients completed the standard battery and each subtest of the French BACS A Version without interruption and with good understanding of the instructions. The average duration of the BACS test sessions was 36.51 min (S.D. = 12.14.) compared to the standard battery in which the sessions lasted more than one hour with more difficulty during the Wisconsin tests. The factor analysis conducted on the data collected from patients suggests that there is a single dimension, a factor of general cognitive performance, which accounted for the greatest amount of variance. The BACS thus permits an assessment of overall cognitive function as a global score, more than some individual specific cognitive domains. The sub-scores from the French BACS A Version were strongly correlated with the standard battery corresponding sub-scores. We observed significant correlations for all the subtests evaluating: verbal memory (Pearson = 0.83; p < 0.001; IC [0.69; 0.91]), working memory (Pearson = 0.67; p < 0.001; IC[0.43; 0.80]), verbal fluency (semantic: Pearson = 0.64; p < 0.001; IC[0.40; 0.80]), alphabetical (Pearson = 0.87; p < 0.001;IC[0.77; 0.93]), attention and speed of information processing (Pearson = 0.69; p < 0.001; IC[0.47; 0.83]), executive function (Pearson = 0.64; p < 0.001; IC[0.39; 0.80]). We almost found a significant correlation for motor speed (Pearson = −0. 32; p = 0.06; IC [−0.59; −0.014]).

Conclusion

The French adaptation of the BACS scale is easier to use in schizophrenic patients with French as mother tongue, with a completion rate equal to 1, and also with less than 35 min to complete and check. We obtained significant correlations for all domains except motor speed, which is almost significant. The BACS is as sensitive to cognitive impairment in patients with schizophrenia as a standard battery of tests that required over 2 h to complete. Moreover, these results demonstrate that the BACS, the global score of which may be the most powerful indicator of functional outcome, can also be a good neuropsychological instrument for assessing global cognition in patients with schizophrenia.     

Étude des représentations sociales de la schizophrénie dans la population générale et dans une population de patients schizophrènes

This study aims to compare social representations of schizophrenia in a sample of schizophrenics patients and in the general population. This question is of considerable interest in clinical practice and in psychosocial intervention. On the one hand, most of the schizophrenics patients have been informed about their diagnosis. On the other hand it is well known that stigmatisation attached to the labeling of schizophrenia has major repercussions on the acceptation of the diagnosis for the patient and his family, the compliance to treatment and the quality of life. Understanding social representations of schizophrenia in a sample of schizophrenics may be useful in adapting psychoeducation techniques and preventing relapses. We have investigated these reprentations in a sample of 20 schizophrenics who were informed of their diagnosis and in a 20 matched sample in the general population. We have excluded the persons who had a previous contact with a schizophrenic. Results show that medical representations of the trouble occur in general population, which can be considered as a positive evolution of the representation of schizophrenic people who are considered as ill persons rather than just “mad”. With regard to stigmatising representations, it is surprising to note that schizophrenics and the general population share the same representations. We hypothesize that this attitude in schizophrenics may result from an internalization of the supposed stigmatisation about their illness.     

Implication du stress oxydant dans la physiopathologie de la schizophrénie : revue de la literature

Background

Schizophrenia is a devastating psychiatric disorder with a broad range of behavioural and biologic manifestations. There are several clinical characteristics of the illness that have been consistently associated with poor premorbid adjustment, long duration of psychosis prior to treatment and prominent negative symptoms. The etiopathogenic mechanisms of lack of insight in patients with schizophrenia are to date unknown, although several hypotheses have been suggested. A point of convergence for the theoretical models occurs with regard to the neuronal membrane. Neuronal membrane contains a high proportion of polyunsaturated fatty acid and is the site for oxidative stress. Oxidative stress is a state when there is unbalance between the generation of reactive oxygen species and antioxidant defence capacity of the body. It is closely associated with a number of diseases including Parkinson's disease, Alzheimer-type dementia and Huntington's chorea. Accumulating evidence points to many interrelated mechanisms that increase production of reactive oxygen or decrease antioxidant protection in schizophrenic patients.

Objectives

This review aims to summarize the perturbations in antioxidant protection systems during schizophrenia, their interrelationships with the characteristic clinics and therapeutics and the implications of these observations in the pathophysiology of schizophrenia are discussed.

Literature findings

In schizophrenia there is evidence for deregulation of free radical metabolism, as detected by abnormal activity of critical antioxidant enzymes (superoxide dismutase, glutathione peroxidase and catalase). Many studies conclude in the decrease in the activity of key antioxidant enzymes in schizophrenia. A few studies have examined levels of non enzymatic antioxidants such as plasma antioxidant proteins (albumin, bilirubine, uric acid) and trace elements. How showed decreased levels in schizophrenic patients. Others studies have provided evidence of oxidative membrane damage by examining levels of lipid peroxidation products. Such abnormalities have been associated with certain clinical symptoms and therapeutic features. Negative symptoms have been associated with low levels of GSH-Px. Positive symptoms have been positively correlated with SOD activity. Plasma TAS was significantly lower in drug-free and haloperidol treated patients with schizophrenia. A low erythrocyte SOD activity has been found in never-treated patients, but with haloperidol treatment, SOD activity increased.

Discussion

These results demonstrate altered membrane dynamics and antioxidant enzyme activity in schizophrenia. Membrane dysfunction can be secondary to free a radical-mediated pathology, and may contribute to specific aspects of the schizophrenia symptomatology. Membrane defects can significantly alter a broad range of membrane functions and presumably modify behavior through multiple downstream biological effects. Phospholipid metabolism in the brain may be perturbed in schizophrenia, with reduced amounts of phosphatidylcholins and phosphatidylethanolamine in post-mortem brain tissue from schizophrenic patients, and large amounts of lipofuscin-like materiel in the oligodendrocytes. The existence of these products within cell membranes results in an unstable membrane structure, altered membrane fluidity and permeability and impaired signal transduction. Recent findings suggest that multiple neurotransmitter systems may be faulty. CNS cells are more vulnerable to the toxic effects of free radicals because they have a high rate of catecholamine oxidative metabolic activity. Neurotransmitters, like glutamate, can induce the same metabolic processes that increase free radical production and can lead to impaired dopamine-glutamate balance. These results question the role of this imbalance in the biochemical basis evoked in the etipathogenic mechanisms of schizophrenia, as well as the role of antioxidants in the therapeutic strategy and their implication in preventive and early intervention approaches in populations at risk for schizophrenia.     

Insight cognitif et schizophrénie

Schizophrenia is usually associated with severe and chronic lack of knowledge of mental illness. This lack of insight is found to be correlated to hypofrontality but not related to the disorder outcome or to the intelligence quotient. The cognitive insight was defined as the difference between self-reflectiveness and self-certainty. This ability is described as decreased in schizophrenia but increased in depression. Thus, schizophrenia with depressive comorbidity is associated with a higher level of insight. The authors discuss how greater awareness of psychotic illness can be lived as traumatic, which appears to be a risk factor for depression and suicide.     

Intérêt du programme éducationnel Soleduc pour la prévention des rechutes dans la schizophrénie

Informing schizophrenic patients of their disease is supposed to enhance compliance to antipsychotic treatments and hence to reduce the number of relapses. However, it is not clear whether the provision of psychoeducation changes schizophrenic patients’ behaviour. Recently, a two-year study of 220 schizophrenic patients was designed to evaluate the impact of a psychoeducational program (Soleduc^®) on the rate of relapses (new hospitalizations). This was a multicentric French clinical trial (51 centers) of phase IV, open, controlled, randomized, consisting in two parallel groups: the Soleduc group (N = 111) and the control group (N = 109). All schizophrenic patients were treated with the same antipsychotic drug (amisulpride). The Soleduc^® program contents were presented in 21 sessions, seven were programmed at the beginning of the study, seven at six months later and seven at 12 months. Patients in the control group received usual information on the disease during a period equivalent to the Soleduc^® program. The risk of relapse was significantly reduced for patients who followed at least five modules. In conclusion, attendance of at least five out of 21 program sessions was required to see a modest but significant two-year relapse prevention in schizophrenia. Other well-designed studies are required to evaluate the medical impact of patient's education programs.