Approche neurocognitive des troubles du vécu dans la schizophrénie

Lived experiences mentioned by patients with schizophrenia can be addressed with neurocognitive models. In particular, these models allow us to better understand self-consciousness and social cognition impairment that is a core feature of schizophrenia. Abnormal brain functioning related to this impairment has been shown. These data show that these symptoms are related to specific neurocognitive correlates. They shed a new light on the understanding of schizophrenic symptoms.     

Programme spécialisé pour les premiers épisodes psychotiques : analyse d’une cohorte de 100 patients

Background

The emergence of specialized programs for the treatment of first-episode psychoses in non-research settings calls for a better definition of this group of patients and of the psychological interventions offered.

Aims

The aim of this study is to describe a specialized program for first-episode psychotic patients and to define the patients referred to, their different distinguishing characteristics and their relative use of the different services offered them.

Method

From an initial population of 127 patients, 100 agreed to have their data used to determine their detailed socio-demographic and symptomatological characteristics, their treatment delays (duration of untreated psychosis, referral delay) and their use of specific treatment modalities offered.

Results

The sample is similar to others described in the current literature in terms of socio-demographics, diagnostic distribution, and duration of untreated psychosis. The referral delay is 1.66 year. The symptomatological and neuropsychological portraits observed are characterized by heterogeneity. Services offered appear clinically indicated for most patients referred to (81%), with different characteristics observed across the groups of patients referred to in the different modalities.

Conclusion

The heterogeneity of the clinical presentation and of needs observed implies that such a program has to include a detailed assessment of each patient and a basic range of interventions. The implementation of such interventions in a non-research setting, and eventually on a large scale, should be accompanied by an evaluation process that could help guide clinical work and the organization of psychiatric services for patients suffering from psychosis.     

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.     

Étude de l’évolution clinique et des modifications de fluidité membranaire chez des patients schizophrènes traités par neuroleptiques

Numerous physiopathological hypotheses were proposed concerning schizophrenia. The membrane hypothesis is one of them, which considers schizophrenia as a global pathology expressed in through all the cells of the body. The phospholipidic metabolism would be disrupted, associating an essential fatty acid deficit of incorporation in the membrane and an increase of their destruction. In addition, the membrane fluidity depends directly on the lipidic composition and consequently would be abnormal during the schizophrenia. Furthermore, the membrane fluidity is a property indispensable to the good functioning of the cell and more particularly of receptors. This synthesis of the data of literature allowed to envisage the following hypothesis : the evolution of the clinical state of patients suffering from schizophrenia, treated by neuroleptics, could be correlated with the evolution of the membrane fluidity in the course of time. To support this hypothesis, a study approved by the CCPPRB Auvergne wich is scheduled for one year has already included 11 patients over a period of five months. Patients corresponding to the criteria of inclusion enter the study while they are stabilized and are treated by risperidone or haloperidol. Their assent is obtained, a first measure of membrane fluidity is made on lymphocytes and erythrocytes, and scales of evaluation of the clinical state are past (BPRS and PANSS). The same protocol is applied to three months, six months, and in case of relapse. The first results show a modification of the membrane fluidity compared with the established standards as in the evolution during time.     

Stimulation magnétique transcrânienne répétée (rTMS) et symptômes négatifs de la schizophrénie

Purpose

The author has endeavoured to present a qualitative review of current data on the interest of repetitive Transcranial Magnetic Stimulation (rTMS) in the treatment of negative symptoms of schizophrenia, its therapeutic impact and processes that underlie it.

Method

The method consisted in a review of the literature by an extensive consultation of the computerized Medline database.

Results

Despite the small number of controlled studies and the small sample sizes, rTMS appears to be an effective therapeutic method in the treatment of negative symptoms of schizophrenia and also helps understanding the patho-physiologic processes that underlie them (hypofrontality, dopamine hypothesis and responsiveness of the HPA axis).

Conclusion

Before any conclusion may be reached about the effectiveness of this new technology more studies are required using larger parameters for active treatment and optimal placebos (alpha-TMS at least 110 % of the motor threshold, focused on the hypo-active area).     

Les troubles psychotiques post-traumatiques : un modèle physiopathologique de la schizophrénie

Traumatic Brain Injury (TBI) and later serious psychopathology have long been associated in the literature. Psychotic disorder following traumatic head injury is reported to occur in 0.7 to 9% of patients who sustain a head injury. This paper summarizes the recent literature about psychotic symptoms following TBI and try to articulate these psychotic disorders to a pathophysiological model of primary schizophrenia. Psychotic disorder due to a general medical condition (TBI) indicates that the hallucinations or delusions are the direct physical consequences of the medical condition. A contrario, schizophrenia-like psychosis is a secondary schizophreniform syndrom that must be differentiated from posttraumatic schizophrenia where the head trauma is an external factor furthering the onset of a primary psychosis. A dimensional approach could although take place for understanding pathophysiology. Head injury has been reported to increase the likelihood of the development of psychosis disorder due to TBI, schizophrenia-like psychosis and posttraumatic schizophrenia. While TBI is a major public health issue, schizophrenia following TBI is relatively rare and poorly studied. The onset of schizophrenia occurs most commonly from late adolescence to mid-adulthood, in an age group where head injury is more frequent. Even if early illness features of schizophrenia might increase exposure to TBI, posttraumatic schizophrenia could be the result of a gene-environment interaction. The pathophysiology research in psychotic disorders following TBI does not distinguish schizophrenia from other psychotic syndromes but have to consider a dimensional approach of these psychotic phenomena. Family history of schizophrenia and frontal or parietal lobe deficits was more common in patients with posttraumatic psychotic symptoms. Susceptibility to schizophrenia is believed to be due to multiple genetic and interacting factors and mild childhood head injury may play a role in the development and onset of schizophrenia in families with a strong genetic predisposition. The authors suggest hypotheses aimed at furthering the understanding of the physiologic mechanisms relating traumatic brain injuries to psychotic symptoms. Psychotic disorder following TBI, schizophrenia-like psychosis and posttraumatic schizophrenia are a potential interest to clinicians and neuroscientists, as it may provide clues to understanding primary psychotic disorders such as schizophrenia. Schizophrenia is a psychotic disorder commonly attributed to the interaction of genetic vulnerability and environmental events which implies that environmental factors modulate the effects of the genotype. Schizophrenia related to TBI could also be the result of a gene-environment interaction. Schizophrenia genes may increase exposure to head trauma (through agitation or cognitive impairment), with head trauma further increasing the risk for schizophrenia. Further studies are needed to articulate the links between secondary psychotic symptoms and primary schizophrenia in a structure/function paradigm. The new imaging techniques of magnetic resonance imaging, position emission tomography and single-photon emission computed tomography could aid in this sense.     

Adhésion au traitement prescrit et traits de personnalité dans une population de patients atteints de schizophrénie

Schizophrenia is one of the most important public health problems. It is a common, tragic and devastating mental illness that typically strikes young people when they are maturing into adulthood. Among schizophrenic out-patients, 24-63% of patients are non compliant as they failed to take the correct drug in the correct dosage. Clinical experience had demonstrated the existence of several groups of patients, some who comply with the medical regimen and others who do not adhere to treatment. Some of the factors that had been linked to poor compliance included low socio-economic status, unstable lifestyle, general negative attitudes towards one’s predicament, cognitive strategies and patient’s personal and psychological characteristics. As such, several studies have shown that three personality dimensions are particularly important for understanding schizophrenia which are extraversion, neuroticism and peculiarity. The aim of this study is to search for the possible association between personality traits or cognitive strategies and compliance to treatment in a sample of adult patients with schizophrenia. Eighty-three patients were screened for suitability for inclusion into the study. Patients who fulfilled the following criteria were recruited: aged 18 and more, who received a diagnosis of schizophrenia (Axis I DSM-IV), without severe cognitive impairment, without a diagnosis of personality disorder (Axis II DSM-IV), consulting their psychiatrist for a period of one year after dismissal of their psychiatric ward and having given their written informed consent. The final study sample consisted of 50 out-patients adults, 35 males and 15 females, age 19-59 years. After inclusion, patients were divided into two groups (Compliant-C and Non Compliant-NC) on the basis of their compliance to treatment. Mean age for the two groups is, respectively, 34.59 ± 9.62 and 27.29 ± 7.93. Compliance to treatment was measured by indirect methods such as the impression of the treating psychiatrist, interviewing patients, therapeutic outcome, counting the number of tablets remaining in a patient’s supply and objective criteria such as presence to medical and staff appointments or ending the follow-up. Personality traits were measured by the Rorschach Test, scored and interpreted according to Exner’s Comprehensive System. This psychological measure was selected for its ability to differentiate state and trait personality variables and its sound validity when used in the manner for which it was designed and intended. The selected trait variables in the Rorschach are: P < a + 1, which identifies tendencies to be passive and deferential in social situations; HVI index, which indicates a cautious, distant and mistrustful orientation to people ; EB which shows a cognitive style of decision making; Lambda > 0.99 which identifies a lack of adequate openness to experience and tendencies to view one’s world with an overly narrow focus of attention; and Fr + rF, associated with narcissistic marked tendencies to overvalue personal worth. The selected defense mechanisms in the Rorschach are: the intellectualization index (2AB + Art + Ay) used to keep emotion at a distance and minimize their impact. Denial (MP > MA) defines a predilection for escapist fantasy and prevents the impact of an unpleasant reality. Patients were contacted during their hospitalization period by the medical chief of staff who described the study in details. After they had consented, participants received the Rorschach test, before leaving the hospital. The Rorschach protocols have been scored by two Senior Rorschach practitioners. On the selected variables their scoring agreement percentage was 100%. Rorschach protocols were assigned to the C and NC groups by the end of the scoring process and once the medical team had finished the inclusion into the two groups (C and NC). The two Rorschach practitioners had worked single-blind on the set of Rorschach protocols. Group differences in Rorschach variables at the end of one year of medical follow-up were examined by using the χ² test. The significance level was set at P < 0.05. Results have shown that the C and NC groups differ significantly on the basis of schizophrenia subtypes. The Paranoid type (295.30) is more frequent in the C group whether the Disorganized type (295.10) is more frequent in the NC group (χ²= 12.16, P < 0.001). Compliant schizophrenic patients use significantly, more frequently the intellectualization defense mechanism (χ² = 6.17, P < 0.012). Non compliant patients appear to have significantly more marked narcissistic traits and tendencies to overvalue personal worth (χ² = 8.79, P < 0,003). These observations support the idea that paranoid delusions, even if persecutory, do not alter pervasively the ability of maintaining genuine relationships with some others, such as the treating psychiatrist, for instance. In Disorganized type patients, the orientation to people is overall disturbed, the interest in the therapeutic alliance more superficial and fragile. Due to narcissistic traits and tendencies to overvalue personal worth, non compliant patients display a sense of grandiosity and entitlement which distort the genuine perception of personal needs and that of their psychological states. Intellectualization acts as cognitive coping strategy aiming to mute the intensity of emotions and safeguard against distress. Shifting emotional experience to a cognitive level allows the schizophrenic patient to acknowledge his needs for medical therapy even if he does not recognize himself as being ill. The research presented here comprises a 1-year prospective study designed to test some associations between personality factors and compliance to treatment. The degree to which schizophrenic patients comply with the advice of health workers depends, among other factors, on their stable personality traits and coping mechanisms. Continued study of the links between personality traits and compliance to treatment in this population as well as regular psychological assessment of these patients may identify which therapeutic approaches are best for which patients. There is increasing interest in the role of psychological mechanisms in compliance behavior formation after the onset of illness and these models may also be useful in thinking about events before onset.     

Impact des déficits cognitifs dans les activités de la vie quotidienne des personnes souffrant de schizophrénie

It is now well-recognized that cognitive dysfonctions contribute to a decisive way to the difficulties of the everyday, social and professional life of the people with schizophrenia. The cognitive variables would explain between 16 and 30% of the variance in the functional status when assessed one to three and a half years later. However, the specificity of the complex relationships between the cognitive domains and the functional variables still remains to be identified. To this end, it is necessary to carry out studies by respecting various principles: selecting not multi-determined cognitive tasks; investigating specific daily-life tasks (e.g. shopping, choosing a menu, preparing a meal), in particular by an observation in real situation in order to identify the problematic components; this has to be made by determining a priori hypotheses regarding the cognitive nature of the difficulties; taking into account the heterogeneity of the cognitive deficits and the functional difficulties of people with schizophrenia. It also remains to investigate the presence of mediator variables of the relationships, such as the potential of learning, the social cognition, the metacognitive processes and the intrinsic motivation. Besides, other personal or environmental factors can also play a role in the functional status, as for example, the negative symptoms, the awareness that has the person of his(her) state and its consequences, or the critical attitude of relatives towards the person with schizophrenia.