Prévalence de l’hypomanie dans les dépressions majeures récurrentes ou résistantes : enquêtes Bipolact

Bipolar II disorder is officially recognized as a mental disorder in DSM-IV-TR and defined by the presence of hypomanic episodes alternating with major depression. Despite data supporting clinical complexity and high morbidity and mortality rates, BP-II disorder is often overlooked or misdiagnosed as unipolar major depression or personality disorder. Moreover, many clinicians still regard it as a milder form of manic-depressive illness. These unsolved problems propose to investigate hypomania prevalence rates in resistant and recurrent depressions, at a large national scale, by means of three large surveys (Bipolact Surveys) carried out in both psychiatric and primary care settings. This research is a part of a national project for medical education on bipolar disorders established in September 2004. Screening of hypomania was done by self-assessment with the hypomania checklist HCL-20; hypomania cases were defined by a score greater or equal to 10 on the HCL-20. Inter-group comparisons (BP-II versus unipolar depression) and multiple logistic regression analyses were conducted on all demographic and clinical factors obtained. Data obtained in the “real world” medical practice (in total, 623 physicians and 2396 patients with major depression) revealed a high rate of hypomania around 62% in both recurrent depression samples (primary care and psychiatric settings) and 55% in resistant major depression. Additionally, the inter-group comparative data allowed drawing the BP-II disorder profile by selecting the most significant differences versus unipolars. “Ups and Downs” (cyclothymic traits) represented the most important and common (in all three different logistic models) risk factor of hypomania. In recurrent major depression, “ups and downs” seemed to act independently from another important risk factor, i.e. “family history of bipolarity”. “Mood switching” was the major risk factor for hypomania in patients with resistant depression; further risk factors were “substance abuse”, “young age of onset”, “agitated - mixed - atypical forms of depression”. These factors are meaningful at clinical and phenomenological levels, and can validate the dimensional approach of hypomania and the cut-off score on the HCL-20.     

De l’intentionnalité à l’anticipation dans la démence de type Alzheimer

Intentionality is not anticipation or planning. It is always “aimed towards…” without prejudging the object towards which it moves. Intentionality is what characterizes the psychic activity of the subject in what is always beyond itself, it differs from a purely biological reality. Intentionality is a priori unspecified energy, a movement which spreads out secondarily in an object to become anticipation i.e. action resulting from an individuality. The dementia patient stigmatized by degradation of cognitive functions is still capable of this “tension towards” and of simultaneously collecting the fruits of this dash towards the future which defines anticipation. For this reason he/she remains a person i.e. capable to be beyond himself and of what he/she shows of his/her biological reality. Three Alzheimer patients were met via the Anticipation test, each one twice at two months interval. The materials collected show how the selected images express a non-random movement. The intentions of a subject are profiled behind the pathological pattern, thus confirming former work, indicating that psychic activity cannot be identified with the neurobiological substrate.     

Évolution clinique de la dépression post-accident vasculaire cérébral à Kinshasa

Objectives

To describe the evolution of the clinical profile of post-stroke depression over a period of one year and to determine factors associated with changes in post-stroke depression.

Methods

Prospective cohort study with a follow-up of 1 year including 30 consecutive eligible patients. The severity of depression was assessed with the patient health questionnaire (PHQ9).

Results

The mean age was 55.87 ± 12.67 years. Seventy percent of patients were men. The two assessments for neurological status, perceived health status and test results of attention were not statistically different. The rate of depressive symptoms was 26.67% in 2011 and 20% in 2012. Disability and apathy were significantly improved. The average for disability increased from 2.77 ± 1.19 to 2.46 ± 2.19 (P = 0.002). From 66.7% in 2011, the proportion of patients able to walk without assistance rose to 93.3% in 2012 (P = 0.03). In addition, the proportion of patients apathetic decreased from 43.3% to 13.3% (P = 0.01). Greater age, female sex, sleep disorders and post-stroke apathy remained associated with DPAVC between the two assessments, with an increase in the strength of the association for apathy.

Conclusions

The frequency of post-stroke depression is high and remains stable over time. Disability is the clinical feature that evolved more favorably. The association with apathy, present at the beginning, of the study was strengthened one year later.     

R4P – Un réseau régional de professionnels dédié à l’enfant en situation de handicap

A regional health network for children and teenagers with disabilities (R4P) was created in Rhône-Alpes region (France) in 2007 with the aim to improve the quality of care provided to those patients. The main projects of the R4P concern training, harmonization of care and communication. R4P is a very special regional health network in France because of two particularities. First, it concerns all types of disabilities; secondly, it includes each kind of professionals concerned by children with disabilities: health care professionals of hospital and ambulatory care, social workers, administrations and education professionals. Decompartmentalization and collaboration between all kinds of professionals is necessary to improve global care of children and teenagers with disabilities. Today, 750 professionals are participating in the R4P network.     

Neurofeedback dans le trouble déficit de l’attention avec hyperactivité : de l’efficacité à la spécificité de l’effet neurophysiologique

Clinical guidelines for attention deficit/hyperactivity disorder (ADHD) recommend a multimodal treatment encompassing pharmacological medication with methylphenidate, cognitive-behavioral therapy (CBT) and family treatments. Methylphenidate is the most effective treatment, though the relatively high rate of partial responders, and the possible parental reluctance against the pharmacological treatment. Thus, it is interesting to consider new non-pharmacological therapies based, such as CBT, on the learning capacity of children to self-regulate their behavior. Neurofeedback is interesting insofar as it would allow children to acquire self-control over certain brain activity patterns to improve the regulation of their behavior in daily-life situation. Early studies on neurofeedback in ADHD are nearly 30 years old. Two training protocols were created, based on EEG abnormalities in ADHD. First training allows the modulation of EEG frequency bands: increased activity in the beta band, or decreased activity in the theta rhythm. The second allows an increase in a slow cortical potential. In both protocols, feedback of the brain activity patterns is given to children in real time as a kind of computer game, and changes that are made in the desired direction are rewarded, i.e., positively reinforced. The evidence-based level of the neurofeedback is still unclear. But, unlike other mental disorders, many studies have investigated the effect of this treatment on symptoms of ADHD. Thus, we propose to analyze the data of literature and especially recent studies. A meta-analysis and randomized controlled studies seem to confirm the efficacy and the possible place of neurofeedback in the multimodal treatment strategies of ADHD. But, if this treatment supposes to allow self-regulation of children behavior by learning the control of EEG activity, the specific mechanisms of action on brain activity remains problematic. Thus, we propose to identify methodological and neurophysiological areas for future research on this therapy involving the subject and electrophysiology in psychiatry.     

Infarctus cérébraux secondaires à une hyperstimulation ovarienne à l’ère de la thrombolyse

Ischemic stroke is a very rare complication but classic ovarian hyperstimulation. We report the cases of three young women aged 35, 37 and 27 years. All three were victims of ischemic formed by proximal occlusion of the middle cerebral artery secondary to ovarian hyperstimulation. The first and the third had a proximal occlusion of the right middle cerebral artery occlusion and the second of the left middle cerebral artery. The last two have benefited from a patient intravenous thrombolysis. The first patient did not receive thrombolysis because it was out of time. Against by their evolution was different. The first has almost recovered its deficit, the second sequelae quite heavy after craniectomy and the third died despite her craniectomy.     

Étude comparative de l’évaluation clinique de l’angle poplité en décubitus dorsal versus décubitus latéral asymétrique,chez des sujets infirmes moteurs cérébraux et polyhandicapés (paralysés cérébraux)

Clinical assessment of lengthening possibilities of hamstring muscles is of great importance for cerebral palsied patients because of progressive and early diminution and its functional and orthopaedic consequences. Traditionally, a clinical assessment is carried out by measuring the popliteal angle with the patient in supine position and hip flexed at 90°. Nevertheless, for patients with CP, able to understand orders, popliteal angle data can change from one clinician to the other because of varying resistance of the muscles at lengthening. On the other hand, more patients relax spontaneously when lying in a lateral and asymmetrical position with the lower limb examined flexed, than in a supine position. In the case where the relaxed state is insufficient, we can use a specific maneuver in order to relax him more. The aim of this article is to report the results of a study made to compare popliteal angle in supine position versus lateral and asymmetrical position. Throughout the maneuvers, the degrees of contraction of the muscles were recorded by a surface electromyography. Variations of the angles were measured with electrical goniometers and verified, on obtaining the final popliteal angle by a mechanical goniometer. Data obtained at the end of the study with a group of 12 patients from 8 to 15 years old, showed that for all patients the angle is higher in the lateral and asymmetrical position than in the supine position, that is to say between 20° to 40° more. These results contest the choice of the decubitus dorsal position to assess the popliteal angle allowed by intrinsic lengthening possibilities (visco-elasticity) of the hamstring muscles and not active resistances due to muscular contraction from diverse pathological factors.     

Le réseau cérébral par défaut : rôle cognitif et perturbations dans la pathologie

Introduction

A “resting state” or “default mode network” has been highlighted in functional neuroimaging studies as a set of brain regions showing synchronized activity at rest or in task-independent cognitive state.

State of the art

A considerable and increasing number of studies have been conducted over the last few years so as to unravel the cognitive function(s) of this brain network.

Perspectives

This review gives an overview of anatomical, physiological and phenomenological data regarding the default mode network. Different hypotheses have been proposed regarding the role of this network. Several studies have highlighted its involvement in autobiographical memory, prospection, self, attention, and theory of mind. The influence of the attention level and consciousness onto resting state brain network activity has also been discussed. Specific changes have been described in normal aging, Alzheimer's disease (AD) and multiple sclerosis (MS).

Conclusions

These studies altogether contribute to a better definition of the default mode network, in terms of implicated brain structures, subtending mechanisms, and potential cognitive roles. For instance, similarities and relationships were found between self-related brain activity and resting-state activity in regions belonging to this network, namely posterior cingulate and prefrontal areas that may reflect introspective activity experienced, more or less consciously, when the brain is not specifically engaged in a cognitive task. As a whole, the default mode network appears as a non human-specific intrinsic functional network, active all over the life from birth until aging where it is progressively modified, and sensitive to different pathologies including AD and MS. On the other hand, many points remain to be clarified concerning this network, such as the exact part of its activity dedicated to self-related cognitive processes (introspection, imaginary mental scenario based on past autobiographical experiences) and that involved in a sentinel-like attentional process designated to react to possible environmental events. Indeed, it seems that this network is functional even in case of low level of consciousness, i.e., during light sleep. Conversely, a loss of self and environment perception as in coma, deep sleep or anesthesia might modulate its connectivity along the anteroposterior axis, i.e., frontal activity disappearance associated with a parietal reinforcement of connectivity. Since studies aiming at highlighting these points are still uncommon to date, exhaustive and objective explorations are needed to better understand all these resting state processes.     

Attachement narratif,fonction réflexive et régulation émotionnelle chez des sujets déprimés

The attachment theory and its evolution in the area of adult attachment, offers a new paradigm to study the mental processes laying underneath the attachment representations, through the reading of different forms of enunciation as well as the way subjective experiences are told. The main objective of our study was to find and unveil the different types of discourse in depressed subjects, through an analysis procedure of semi-structured interviews. This procedure is inspired from Edicode, an attachment paradigm. The study involves a group of 23 women suffering from depression along with another group of 20 women with a melanoma history. Both groups took part in semi-structured interviews, which were then transcribed and analyzed following the Edicode method and double cotation. The results were then compared to another reference witness group. The results show an obvious fall of adequation factor in depressed subjects, which in the Edicode protocole indicate a preoccupied attachement. Also a drop in the reflexivity and coherence dimensions in both somatic and depressed groups as opposed the reference witness group. We can discuss, on one hand, the links between preoccupied attachment in depressed subjects along with the difficulties in treating cognitive and emotional informations when it comes to present and past relations. On the other hand, it seems that there are difficulties in regulating and in mentalizing in both groups as opposed to the reference witness group and results show anxiety and lack of certainty when it comes to the disease and its evolution. The latter leads us to consider more specifically the present psychological state of the subject and the way he manages and deals with the disease along with aspects of the therapeutic alliance in the medical environment.     

Méthode et résultats du test de perfusion dans l’hydrocéphalie à pression normale : revue de la littérature

Introduction

The cerebrospinal (CSF) infusion test is used to analyze the dynamics of CSF circulation. We describe the technique and report test results obtained in subjects with normal pressure hydrocephalus.

State of the art

The CSF infusion test is based on pressure monitoring during a continuous infusion of saline solution into the CSF space via a lumbar puncture. The main parameters are: intracranial pressure, resistance to CSF outflow (Rout), and compliance of the cranial enclosure estimated by the pressure-volume index. Our review of the recent literature dealing with the results of infusion test in normal pressure hydrocephalus indicates that the positive predictive value is about 80 % for Rout greater than 12 mmHg/ml per minute, i.e. shunt response is observed in 80 % of patients. The information available in the literature for assessing negative predictive value of Rout and usefulness of compliance is limited.

Perspectives and conclusion

The CSF infusion test may be helpful for the diagnosis of normal pressure hydrocephalus, as supplemental testing when the diagnosis is not certain. We propose a procedure, which includes the infusion test, for identifying shunt-responsive patients.     

Une tentative de réponse partielle à l’échappée psychotique

Confrontation with a psychotic episodes invariably remains a particular and demanding task. Most often, once the effect of surprise or even the feeling of anxiety or uneasiness is over, the therapist is tempted to react by providing a unifying and reassuring response to deal with the expression of a psychotic episode, which takes the form of outburst or loss of control, and to propose a reconstructive context. Thus at the institutional level, this approach psychosis leads the therapist to respond to the fragmentation by its apparent opposite, that is to say by developing a structural approach based on a stable unity. However, although this approach seems at first sight to be called for, and although its capacity to contain the psychotic episode may have a certain pertinence it often remains superficial, and above all it does not take into account the psychotic response itself. In fact, from this viewpoint imaginary control takes over the place of symbolization.We have put forward the hypothesis of another form of treatment response, i.e. that is incomplete and partial, which takes into account the irreducible nature of the psychotic condition, and which considers the very expression of the psychosis as an attempt at symbolization. From the frequent perplexity that is encountered at the onset of the psychosis to a full comprehension of the paranoid individual, the forms of psychic construction in psychotic individuals are varied, mobile, and finally are always specific to the subject as far as their actual presentation is concerned. They can be considered as “solutions” which the subject expresses according to the given moment in his psychosis, and may provide support for the treatment response that has been proposed. The attentive presence of the therapist and the treatment team, and an approach that is based on non-intentionality is essential.     

Joueurs de machines à sous dans une population française : étude de la dépression, de l’alexithymie et de la recherche de sensations

There are a multitude of factors implied in the acquisition, the development and the maintenance of gambling behavior. Among them, sensation seeking occupies an important place. Zuckerman originally suggested a relationship between sensation seeking and gambling. However, studies in this area have provided heterogeneous results. To explain these discrepancies, Zuckerman emphasized the fact that the type of gambling may be a crucial factor in the relationship with sensation seeking. Nevertheless, few studies have evaluated the link between the different types of gambling and problem behaviors. Furthermore, few studies were interested specifically on slot machines. While recent research has found high-levels of alexithymia in individuals with substance use and eating disorders only two studies have investigated the relationship between alexithymia and pathological gambling. Thus, these studies were focused on students. It is therefore important to study alexithymia in adult gamblers. Empirical data has shown that alexithymia levels may be influenced by negative mood states, especially depression. Some studies have found a positive correlation between alexithymia and depression scores, particularly in people with addictive behaviours. Nevertheless, studies found heterogeneous results. The main objective of this research was to evaluate scores on sensation seeking, alexithymia and depression (and the link between those variables) in gamblers of slot machines. Thus, slot machines gamblers were selected in the casino of Enghien-les-Bains, which is Paris nearest casino. Among them one distinguishes: regular gamblers (n = 45) from which were extracted pathological gamblers (n = 27), and occasional gamblers (n = 19). The South Oaks Gambling Screen and the criteria of the DSM-IV were used to measure the intensity of gambling behavior; sensation seeking was evaluated by the Sensation Seeking Scale form V; alexithymia by the Toronto Alexithymia Scale (TAS-20) and the depression by the Beck Depression Inventory. No differences appeared significant between the three groups of gamblers for the sensation seeking scores. Pathological gamblers obtained higher alexithymia scores than occasional gamblers. Nevertheless, these findings didn’t remain stable when controlling for the effect of depression. Among pathological gamblers, the BDI score is positively correlated to the ‘difficulty identifying feelings’ factor. This result is consistent with the literature, which shows that alexithymia is closely related to depression in addictive behaviors. Indeed, the ‘difficulty identifying feelings’ factor seems to be explained by depression severity. These results suggest that the emotional component of alexithymia would be thymo-dependent, whereas the cognitive component would be independent and constitute a stable clinical feature. Pathological gamblers who play slot machine are low sensation seekers who shun the more dramatic and extraverted form of sensation seeking. They play to reduce or avoid unpleasant emotional states like depression. Pathological gambling could therefore be in part a maladaptive coping strategy to deal with affective disturbances; the game may function as a self-medication to treat emotional states, which the gambler finds no other way of treating. According to previous studies, slot machine gambling is referred to as ‘escape’ gambling, where gamblers may dissociate.     

Modélisation clinique du maintien de l’intensité du lien à l’alcool dans un échantillon de sujets en cure de désintoxication

The aim of this article is to study the changes in the relation to alcohol among a sampling of alcoholics (n = 40) under detoxification treatment. These patients were invited to fill in a file composed of four self-assessed questionnaires: the QHPBA questionnaire by Pelc, dealing with alcohol consumption habits; the Outcome questionnaire by Lambert et al. (1996) estimating the importance of the improvement and the Symptom Checklist 90r by Derogatis (1977, 1981) measuring the psychological difficulties. The results obtained were processed statistically by a specific software package the SPSS^® that enabled the author to establish a matrix of meaningful correlations among the various items. This correlation matrix was used as a basis to analyse regressions step by step so as to produce a model of psychological persistence of this sample validated by a Structural Equation Modelling software (Amos^®) and then to discuss this model with regards to clinical experience.