Trouble déficit de l'attention-hyperactivité de l'enfant et l'adolescent : du diagnostic à la prise en charge

What is the scientific evidence to support ADHD as a disorder? What are the risks of the use of stimulant medication? These questions are frequently discussed and often with passion. The objective of this article is to present the conclusions and recommendations relative to these questions. The International Diagnosis criteria retained are those of DSM-IV which describe three subtypes of ADHD : ADHD primarily of the inattentive type ; primarily of the hyperactive-impulsive type and a combined type. Establishing a diagnosis of ADHD requires a rigorous strategy, and it should be operated by stages: one to receive requests, one to collect information, and one to confirm the diagnosis. The use of scale is a clinical option but cannot be a substitute to clinical diagnosis. A therapeutic approach must combine several modes of intervention such as the use of stimulants and psychosocial treatment. The treatment will have to be revised regularly according to beneficial effects.     

Déni,négation et dénégation : aspects psychopathologiques et cas cliniques

The word “denial” has several meanings; in psychoanalytically inspired psychopathology, it signifies a refusal to recognize sensory evidence, and it has a defensive function. Denial makes the perception of certain realities disappear from mental and unconscious life, whereas repression, while performing a similar task, integrates the intolerable reality into the unconscious. The term “negation” points to the negating of a psychic reality; it is the refusal to recognize a thought, a desire, or a feeling that is a source of intrapsychic conflict as one's own. Psychotic denial is multifactorial; it includes the existence of psychic troubles, but also the medico-legal behaviors that result from these. Neurotic denial is partial; it plays the role of a defense mechanism in that, it rejects the reality of a perception perceived as dangerous or painful for the ego. Perverse denial is characterized by the coexistence – within the same personality – of two contradictory judgments, unrelated to external reality. In order to maintain emotional stability in the face of anxieties concerning his physical or psychological soundness, the subject resorts to banalization and minimization. These mechanisms are not limited to the unconscious. The denial of an act and/or its consequences characterizes psychopathic denial; this also includes law and authority. Anosognosia is not a defense mechanism, but rather a pathological symptom, demonstrating a neuropsychological deficit or a cerebral dysfunction. “Insight” is an Anglo-Saxon term related to denial, anosognosia, and introspection, depending on the context. Two clinical examples illustrate different types of denial in different psychiatric pathologies.     

Apport diagnostic des marqueurs biologiques de la maladie d’Alzheimer (MA) dans une observation de dégénérescence lobaire fronto-temporale (DLFT)

Introduction

Cerebrospinal fluid biomarkers are a fundamental contribution for the diagnosis of Alzheimer disease, in particular for young people.

Case report

We report a case of Alzheimer disease of a 51-years old man whose clinical presentation corresponded to frontotemporal behavioural criteria. The clinical evaluation noticed some troubles in verbal memory. Only the CSF biomarkers confirmed the diagnosis.

Conclusion

There are different phenotypes of presenile Alzheimer disease and among them we note frontotemporal dementia. It is very important to identify them to introduce a specific treatment.     

Le test des gobelets : normes et propriétés de détection d’un trouble cognitif chez des sujets sélectionnés en population générale

Introduction

Most current tools exploring visuospatial memory abilities are poorly adapted to the elderly population. The Goblets test allows a brief evaluation of visuospatial memory abilities through an encoding phase in which the participant has to learn a particular sequence and a further delayed recall phase. The aim of the present work was to produce normative scores for this test and to study its properties in the detection of dementia.

Methods

Data were collected in a sample of 1002 agricultural retirees aged 65 years and over included in the AMI study, a population-based cohort study conducted in Gironde (southwestern France). The sample analyzed to establish normative data included 795 non-institutionalized and non-demented participants. Regarding the validity study, the sample analyzed included 912 participants of whom 76 subjects with a diagnosis of Alzheimer's disease.

Results

Normative scores were calculated according to age (65–74 years and 75 years and over) and educational level (primary school level not validated by a diploma, primary school level validated by a diploma and more than a primary school level). The normative scores of the learning phase were described using the percentiles while rates of success were reported for the delayed recall. Regarding the properties of the test, the Goblets test seemed to be more specific than sensitive and presented high negative predictive values. The Youden index showed that the better cut-off score was two trials (with 75.0% sensitivity and 83.0% specificity).

Conclusion

The Goblets test can be a helpful tool in screening for dementia. Nevertheless, like many other simple and quick cognitive tests, it cannot be used alone to establish the diagnosis of dementia. This test has the advantage to be easy to administer in clinical situations; the normative scores presented in this study could be used as an aid to interpret a patient's performance.     

Intérêt de la TMS au long cours au sein d’une population de patients âgés déprimés résistants

Repetitive transcranial magnetic stimulation treatment (rTMS) in elderly depressed subjects (>60 years) should be assessed in view of the absence of severe side effects. But most of the results in the literature were negative probably due to too short a duration of TMS treatment in this particular population. In this article, the authors report the results of an open study over a 6-month period: 1 month of curative treatment followed by an average of 5 months of maintenance sessions. Twelve refractory elderly depressed patients were included (five men and seven women, nine unipolar and three bipolar according to the DMS-IV criteria), aged between 60 and 78 years (70 ± 6.24) and no responders to at least two different antidepressants over 6 weeks. The average duration of depressive disease was 10.88 years (10.13) with an average of 3.82 (3.28) number of hospitalizations. All patients provided informed consent. During the first period, patients received a daily session of rTMS, 5 days a week for the first and second week then three sessions a week for the third and fourth week. The stimulation was performed on the left dorsolateral prefrontal cortex (10 Hz, 80 % of the motor threshold, 26 trains of 6 s with an interval of 30 s). In the second period, patients received one weekly session during the second month (M2), then one rTMS session each fortnight the following months. The Hamilton depression rating scale (17 items) was used to assess the intensity of depressive symptoms. Clinical ratings were assessed at baseline, each week during the first month and monthly for 5 months (M6). The authors used a 50 % reduction criteria in Hamilton Depression Rating Scale (HDRS) scores following treatment compared to baseline for responders, and HDRS <8 for patients in remission. The results show a significant drop in HDRS scores after 1 month of rTMS: at baseline 22.50 ± 2.84 versus at M1 10.25 ± 4.18, p < 0.001. Two no responders received only 1 month of rTMS treatment. The other responder patients (n = 10) had the possibility of receiving the treatment by rTMS maintenance for 5 months. The HDRS score showed no difference between the mean HDRS score at M1 and M6 (p > 0.05). We noted a high score in compliance to the TMS treatment in this sample: 75 % (n = 9) at M6 with only three drop-outs. No side effect was reported, except headache. The absence of cognitive effects is a strong argument in favor of TMS use in this population. Nevertheless, new double blind studies are needed to confirm this therapeutic tool and the benefits of rTMS in the treatment of elderly resistant depressed people.     

Du déni de grossesse au néonaticide : hypothèses diagnostiques autour d’un cas

Neonaticide and pregnancy denial concepts have to be more precisely defined. These concepts do not give us any information about the psychical status of mothers during their acting-out. The history of court sentences, showing a wide disparity ranging from acquittal to life sentences reflects the difficulties in analysis of these concepts.This case study reports on the psychic state of a young woman at the time of her committal of neonaticide, after she had denied her pregnancy. The report discusses the hypotheses of brief psychotic trouble, dissociative trouble or acute stress state during her heteroaggressive act.     

Génétique de la maladie d’Alzheimer : formes autosomiques dominantes

We propose a review devoted to the autosomal dominant forms of Alzheimer disease (AD). These forms are the consequences of either PSEN1 mutations (69%), APP mutations (1%), or APP duplication (7.5%), and exceptionally of PSEN2 mutations (2%). The main characteristic of these AD forms is the early age of onset usually before the age of 60 years. The first part of the review focuses on the identification of unusual clinical and neuropathological phenotypes enlarging the AD spectrum: intracrebral hemorrhages caused by severe amyloid angiopathy, spastic paraparesis, Lewy body dementia and exceptional cerebellar ataxia. The second part concerns the consequences of these mutations on Aβ processing, thus demonstrating the key role of the causal “amyloid cascade”.     

Dépistage des troubles bipolaires : une revue de la littérature

Objective

The aim of this article is to review the major instruments proposed for screening for bipolar disorder among clinical or general, adult or paediatric populations. They were developed in order to improve the detection of this illness which, far too often, remains unrecognized. Several of these screening instruments are already translated into several languages and validated.

Methodology

A systematic review of the literature published on this topic up to July 2007 was carried out, using the main electronic data base (Medline). The keywords employed included bipolar disorder, screening, questionnaire, diagnosis and early recognition.

Results

The studies reported here examine whether screening instruments perform similarly in various clinical and non-clinical samples. Different forms of the same questionnaire (like self-report or parent report used in paediatric samples) are sometimes compared, usually showing that parent reports supersede the adolescent self-report form. This is namely the case for the Mood Disorder Questionnaire (MDQ) which is a brief and widely tested tool, available both in adult and adolescent versions.The MDQ exhibits good psychometric properties in relation to sensitivity and specificity in adult psychiatric samples, but these are more limited in the general population. Moreover, it yields better sensitivity for BP type I than for other bipolar subtypes. This is also true for other screening instruments like the hypomania check list (HCL-32). In order to optimize the sensitivity for bipolar II disorders, proposals for changing the MDQ screening algorithm have been tested.

Discussion

Even though it does not replace a thorough clinical interview, the use of screening tools for bipolar disorder is widely advocated. We discuss the need for clinicians to rely upon instruments allowing for a rapid and economically feasible identification of this disorder. Involving family members in the evaluation process may also increase the rate of recognition. More studies are still required in order to improve diagnostic efficiency of the screening instruments.     

Séquelles délirantes d’une psychose puerpérale ancienne, un climat d’inquiétante étrangeté : observation clinique

Mr and Mrs P., recently settled in the area, are experiencing difficulties. Mr P. suffering from depression has to be admitted to the hospital. Mrs P., who suffered for years from bipolar trouble, is sent to the outpatients department for medical supervision of her lithium treatment. Discussions with her and the reading of a text she wrote years before bring back a delirious experience, which happened 20 years ago involving the disturbing strangeness of a world of goats. This looking back into the past becomes the starting point of an intense pictorial productivity on which the psychotherapy will be based… An eight months effort which will succeed in obtaining the normalization of family life and a better adaptability to reality.     

L’illusion des sosies de Capgras : une interprétation délirante d’un trouble spécifique de la reconnaissance affective des visages. Revue de la littérature et proposition d’un modèle séquentiel

Capgras’ syndrome is the first misidentification syndrome described. It was originally individualized in 1923 by the French psychiatrist Joseph Capgras who termed it “l’illusion des sosies”. The subject has the delusional belief that people emotionally close to him have been replaced by doubles physically similar to the originals, but psychologically different. The impostors are generally persecutors. There is sometimes double of the self. Capgras’ syndrome is the most common of the delusional misidentification syndromes (Fregoli syndrome, the syndrome of inter-metamorphosis and the syndrome of subjective double) but is relatively rare, occurring predominantly in the context of paranoid schizophrenia. However, more recently, it has been estimated that a quarter to a third of these cases are associated with neurological, toxic or other organic disorders. And the course of the Capgras syndrome generally follows the course of the basic illness. Thus, there is some discussion in the literature about whether the delusion of doubles should be considered as a syndrome or a symptom. Moreover, neuro-imaging exploration suggests a link between Capgras’ syndrome and right hemisphere abnormalities (particularly in the frontal and temporal regions). Neuropsychological research has reported the presence of impairments in facial processing (which is an established right hemisphere function). Ellis and Young adapted Bauer’s two routes to face recognition model: one ventral visual-limbic route for the overt recognition and one dorsal visual-limbic route for the covert recognition. These authors propose that Capgras patients present an intact ventral route which leads to physical face recognition, but a disconnected dorsal route which prevents the affective confirmation of this recognition. Capgras delusion would be the mirror of prosopagnosia resulting from the preserved overt recognition coupled with a loss of affective responses. After a review of the literature relative to the psychodynamic approaches of Capgras’ syndrome (feelings of depersonalization, problem of ambivalence, affective trouble, incestuous desires…), we have described an original case of Capgras’ syndrome occurring without an organic or psychiatric context. We suggest a re-examination of this curious trouble: the Capgras’ syndrome would be an autonomic entity, which could consist firstly in a functional deficit of affective identification face, this affectivity trouble could be rationalised by the patient and would lead secondly to a delusional interpretation. Capgras patients would recognise the intimate’s face physically but not affectively. The deficit of affective face identification could be caused by organic lesions or functional troubles (psychiatric troubles) or, in our case, by an isolated functional trouble. This loss of affective familiarity of a close relative could be explored by the Bruyer and Schweich face recognition Test. In the case we are considering, patients would attempt to explain this contradictory information by a delusion. This dissociated perceptual experience (known face but strangeness feelings) could be interpreted to make sense and would then produce Capgras delusion.     

Patients adultes traités par une association d’antiépileptiques pour une épilepsie focale en France : description et mode de prise en charge selon les nouveaux critères de définition de la pharmacorésistance (étude ESPERA)

Aims

To describe the adult population treated with antiepileptic drugs (AEDs) in combination for focal epilepsy according to the definition of AED resistance proposed by the International League Against Epilepsy (ILAE) in 2009 and to evaluate its implementation in current practice.

Methods

ESPERA was a multicenter, observational, cross-sectional study with a clinical data collection covering the past 12 months conducted by neurologists. Classifications according to AED responsiveness established by investigators for each enrolled patient were revised by two experts.

Results

Seventy-one neurologists enrolled 405 patients. Their mean age was 42.7 years (sex-ratio M/F 0.98). According to the investigators, 60% of epilepsies were drug-resistant, 37% drug-responsive and 3% had an undefined drug-responsiveness. After revision of experts, 71% of epilepsies were classified as drug resistant, 22% as responsive and 7% as undefined. Among the participating neurologists, 76% have made at least one error in classifying their patients according to the 2009 ILAE definition of AED resistance. Because of epilepsy, 24% of patients (age ≤ 65) were inactive and 42% could not drive (respectively 29 and 49% of patients with AED resistant epilepsy). Half of patients had at least one other chronic condition. Number of prescribed drugs in combination and health care resource utilisation were significantly higher in patients with drug-resistant epilepsies than in patients with drug responsive epilepsies.

Conclusion

ESPERA study shows that the use of new definition of drug-resistance in everyday practice seems difficult without any additional training and that the social and professional disability is frequent in adults with focal epilepsies treated with polytherapy.     

Evaluación de la función ejecutiva en una población escolar con síntomas de déficit de atención e hiperactividad

Objective

To identify impairment of executive functions (EF) in children with attention deficit hyperactivity disorder (ADHD).

Subjects and methods

A case-control study was performed on a sample of schoolchildren with low socioeconomic levels in Bogota, Colombia. ADHD was diagnosed using the DSM IV checklist and the Behavior Assessment System for Children scale. Children with cognitive deficits were excluded. We evaluated scores from six measurements of executive function (EF). We conducted a bivariate statistical analysis to compare the variables, a multivariate study controlled by sex and age, and a logistic regression analysis.

Results

The study sample included 119 children with ADHD and 85 controls, all aged between 6 and 12 years. Controlling by sex, age, and type of school showed that EF measurements in children with ADHD were significantly more impaired than in controls, especially for measurements of verbal and graphic fluency, Rey-Osterrieth Complex Figure, and cognitive flexibility. Comparison of ADHD subgroups showed that results in children with multiple deficits were similar to those in the global ADHD group. Graphic fluency impairment was the sole impairment in cases with only attention deficit or only hyperactivity-impulsivity manifestations.

Conclusions

EF measures in children with ADHD revealed more problems, particularly those having to do within planning, inhibition, working memory and cognitive control. Age and sex may affect the degree of EF impairment.     

Décrochage du sens moral au sein des forces armées en milieu opérationnel : une approche constructive

Despite the international ratification of Geneva Conventions, which define rules to protect people in situations of war, violence beyond the law of armed conflict is not uncommon. Fairly regularly, the subject makes the headlines. A notable example is the recent publication of confidential informations by Wikileaks. What is at stake is the coherence of UN mandates to western armies. This coherence contributes to the preservation of mental balance of military forces.     

Impact d’une campagne de sensibilisation sur le cancer sur un échantillon de femmes en traitement pour un premier cancer du sein

In 2007, the French National Cancer Institute initiated a cancer communication campaign entitled “We are two million ordinary heroes”. Aims of this study were to investigate perceptions about this campaign, for 34 women treated for breast cancer. Triangulation of the reports from narratives and assessment of psychological variables ensures better validity of the data. Three psychological identification processes have been identified: identification with the hero character with a value of emotional repression; adherence to content “ordinary” with low-level of perceived self-efficacy; no identification in response to a double-bind message, with sense-making process about traumatic event. These findings underscore the need to promote communication health campaigns taking into account possible effects of media discourse on individuals and families struggling with cancer.     

Première évaluation d’un programme de remédiation cognitive chez des patients atteints de sclérose en plaques : PROCOG-SEP

Background

Although cognitive disorders are well-known in multiple sclerosis (MS), even in earlier stages of the disease, their management may be overlooked. Our objective was to elaborate and evaluate the efficiency of a remedial program (PROCOG-SEP) designed for MS patients. The evidence-based program proposes exercises to both stimulate preserved functions and develop new abilities compensating for cognitive disabilities.

Design/Methods

Twenty-four patients with MS participated in 10/2-hour PROCOG-SEP sessions over a 6-month period. A neuropsychologist recorded BCcog-SEP performances before and after the PROCOG-SEP program. In addition, the same neuropsychologist conducted psychoclinical interviews to complete the before and after cognitive evaluations. The statistical analysis used the t-test performed with Excel.

Results

Compared with the initial levels, subtests of BCcog-SEP showing improvement after PROCOG-SEP were: verbal memory (SRT), visuospatial memory (10/36), verbal fluency (animal categories) and response to conflicting orders. Also, individual psychological interviews tended to be in favor of a general improvement in quality of life (more social interactions for instance).

Conclusions/Relevance

To our knowledge, the management program we have elaborated is the first designed to improve cognitive deficits in MS. These encouraging results suggest possibilities for improving cognition and thus quality-of-life in MS patients.     

La psychiatrie en milieu pénitentiaire : chronique d’une pratique psychiatrique au centre pénitentiaire de Bordeaux-Gradignan

We will start with a presentation of the prison population, followed by a review of aggravating factors for situations, which would be perceived as banal. We are confronted with the interface between, on the one hand, a rigid judicial and penitentiary structure and, on the other hand, according to the type of new inmates, can take many faces both from a clinical and a criminological viewpoint. The fact that new specialized bodies have been added (SMPR) and are still developing (UHSA) confirms the idea that prison cannot accommodate a specific psychopathological sample of our society which is then sent to a further exclusion-generating structure. As a result, prison is increasingly seen, as a factor for repetitive offending that is too often limited to a medical approach. The multiplication of legal texts centred around law-and-order is the expression of the current trend to push health professionals to go beyond their role of care.