Trouble déficit d’attention/hyperactivité (TDA/H) et émotions : de la labilité émotionnelle au trouble bipolaire

This article aims to review the literature about emotional symptoms associated with ADHD. Emotional symptoms are frequent in Attention Deficit Hyperactivity Disorder (ADHD) and range from mild/moderate to severe emotional lability, but are not specific to ADHD. Severe emotional lability in ADHD patients or association between emotional under-control and mood symptoms should urge clinicans to screen for co-occurring oppositional defiant disorder, mood disorders (depressive disorders, bipolar disorder) and disruptive mood dysregulation disorder. Although this latter diagnosis still lacks validity and may be difficult to differentiate from severe oppositionality in ADHD patients, it will draw attention to the emotional aspects of disruptive behavior disorders and the need to implement specific treatments for emotional hyperreactivity and under control. A better understanding of the relationships between behavior and mood and of the role of environmental stressors is needed to improve prevention of full-blown mood disorders in children with ADHD and emotional lability.     

Mise au point des études cliniques sur le rapport « veille-sommeil » dans le trouble déficit de l’attention/hyperactivité de l’enfant

Since 1970, a certain number of studies have reported sleep disturbances in children with ADHD. Data from questionnaires and parental reports showed behavioural difficulties occurring at wake-sleep transition such as bed-time refusal, delayed sleep-onset, early awakenings, suggesting the occurrence of specific abnormalities in the mechanisms of alertness maintainance.Few polysomnographic studies have been conducted in ADHD children considering the prevalence and the importance of the disorder in the field of child psychopathology. The majority of these studies produced heterogenous and conflicting data and no clear abnormalities of non-rapid eye movement or REM sleep were found.Polysomnographic data, however supports the evidence of sleep-wake-transition abnormalities in ADHD children. Modifications in sleep-onset-latencies, number of stage shifts, have previously been reported using all-night polysomnography.One study performed Multiple latency tests in ADHD children and concluded that ADHD had daytime sleep abnormalities when compared with controls.One other important issue concerns motor activity during sleep in hyperactive children which was found to be increased in studies using actigraphy or video analysis. These findings could lead to important clinical and therapeutic applications as stimulants could help to normalise sleep or motor behaviour during sleep in some ADHD children.     

Facteurs de risque précoces et trajectoires développementales du trouble déficit de l’attention/hyperactivité (TDAH)

Attention Deficit/Hyperactivity Disorder (ADHD) is associated with a set of early genetic and environmental risk factors. Genetic risk factors, of which existence is supported by genetically informed (i.e. Twin) and molecular studies, are yet partially identified. They do not constitute diagnostic markers or therapeutic targets for preventive interventions. Early environmental risk factors exist and could represent targets for early interventions. However, their causal nature is not determined yet. In addition, early environmental risk factors are distal factors compared with later risk factors, which makes difficult the understanding of their direct links with the ADHD phenotype. Developmental trajectories of ADHD are interesting to study in order to take into account the dimensional and developmental nature of ADHD. Investigating the link between early risk factors and developmental trajectories could allow a better understanding of their interactions along time. The experiment of preventive interventions of ADHD could lead to disentangle mechanisms and provide new tools to treat ADHD.     

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.     

L’autisme à l’âge adulte : bilan diagnostique et aspects thérapeutiques

Diagnostic assessment of autism spectrum disorders includes psychiatric examination, semi-structured interviews as well as standardized tools. Work-up should allow to establish diagnosis and comorbidities and to evaluate the patient's skills and difficulties. Assessment should offer suggestions about the help that may be proposed to patients in the personal and social fields. In this article, we present the way our team carry on diagnostic assessment. Afterwards, we give a synopsis about the support mental health professionals can propose to adult patients with autism spectrum disorders. The main forms of support are fitting out patient's environment, emotion (especially anger and anxiety) management, social skills training, and medication.     

Expression phénotypique du TDAH en fonction de l’âge

Attention-deficit/hyperactivity disorder is considered as a developmental disorder, with inappropriate levels of inattention and hyperactivity/impulsivity, which typically emerge during preschool-age and often persist into adulthood, causing functional disability throughout the lifespan. ADHD and comorbid disorders symptoms variability depend on the age group affected. Developmental models of ADHD and assessment of phenotypic expression of ADHD according to age, offer new therapeutic and preventive issues in ADHD.     

Philosophie de l’esprit et théorie de l’esprit: Une approche de l’épistémologie clinique comparative

The notion of philosophy of the mind has a connotation which throws back to different theoretical elaborations depending on whether we are interested in the European contribution or in the English-American contribution. In recent years, the central problem has been thought by many to be a basic distinction between mind and body, mind and matter. This paper provides an overview of recent developments in philosophy and theory of mind and an epistemological analysis of the successive North American conceptions of the philosophy of the mind.     

Clinique du syndrome de Gilles de la Tourette et comorbidités psychiatriques associées chez l’enfant

Tourette's syndrome is recognised of affecting one per cent of school-aged children. Its severity ranges from mild and simple motor and vocal tics, to severely intrusive movement disorder, with marked fluctuations. It frequently cooccurs with attention deficit/hyperactivity disorder and obsessive compulsive disorder, and mood and anxiety disorders. These comorbid conditions are often the major source of impairment for the affected child.     

Le paradigme du « corps psychique » à l’aune de la pratique clinique et de la progression des connaissances

“The psychic body paradigm” of Henri Ey is a model of mind, elaborated on the basis of clinical psychiatric practice, when confronted with the advancements in knowledge and their impact on previous models and on-going theories. The author, a philosopher and a metaphysician of knowledge, is a major figure of the French anthropological psychiatry of the 20th century.     

Membre supérieur de l’enfant atteint de paralysie cérébrale. Utilisation de la toxine botulinique : évaluation,stratégies thérapeutiques

Since a few years the botulinum toxin is used at the level of the upper limb of the child affected by cerebral palsy. A precise evaluation of the driving possibilities of the child is indispensable to target at best the muscles to be injected. This treatment, in its functional objective is always associated with an intensive reeducation. A protocol of follow-up accompanies the management.     

Prise en charge de l’état de mal tonicoclonique généralisé : stratégies thérapeutiques

Increasing duration of generalized tonic-clonic status epilepticus increases the risk of neuronal damage and systemic complications. It is also a recognized contributing factor to drug resistance. The most indispensable quality an anticonvulsive medication is expected to have in this situation is therefore a rapid therapeutic effect, achieved without severe depressive, neurological, cardiovascular or respiratory side effects. The anticonvulsive strategy proposed here takes into account these prerequisites, as well as previously published research findings which remain limited on a number of aspects. The duration of the convulsions before medication must be taken into account when deciding on the initial treatment. If this is less than 30 min, a single drug regimen with benzodiazepine would be appropriate and sufficient initially. If lorazepam, which is unavailable in France, cannot be used, the pharmacokinetically similar clonazepam should be preferred. Beyond 30 min, a combination of benzodiazepine and an anticonvulsive with long-lasting effects —phenobarbital or fosphenytoin— is indicated. The choice between these two latter drugs depends on their respective contraindications and the circumstances surrounding the occurrence of the status epilepticus. The persistence of seizures beyond 20 min after beginning the phenobarbital infusion or 30 min after starting fosphenytoin signals a failure of the initial treatment and requires the immediate introduction of a second line of therapy. This may be an anticonvulsive with long-lasting effects providing the convulsions have been present for less than an hour, there is no suspicion of an acute cerebral lesion and there is no associated systemic factor of cerebral aggression. If not, the employment of anesthetic medication is immediately required.     

Psychopathologie et répercussions de la douleur chronique : conséquences pour la pratique clinique et recommandations thérapeutiques

Objectives

The first aim of this paper was to analyze the Minnesota Multiphasic Personality Inventory (MMPI)-2 profiles of chronic pain patients using a hierarchical cluster method, in order to find subgroups of patients with differing psychopathological profiles and then to assess variations in the intensity and repercussions of pain among the subgroups. The Visual Analogue Scale (VAS) is a measurement technique commonly used in the assessment of intensity and repercussions of pain in chronic pain patients. The second aim was to examine the relationship between VAS measures of repercussions and scale scores on the MMPI-2. The final goal was to give recommendations to improve therapeutic decision-making for each patient. The best-known classification, the P.A.I.N. cluster typology, is based on the first version of the Minnesota Multiphasic Personality Inventory (MMPI). Keller and Butcher reviewed the data on patients with chronic pain obtained from the first version of the MMPI. In the same publication, they used a hierarchical cluster analysis, basing their process of agglomeration on the MMPI clinical scales of the second version (MMPI-2) to classify the patients into different groups whose members shared characteristics on the MMPI clinical scales. In Table 1, we have summarized and classified cluster labels used in the literature with the MMPI-2 since Keller and Butcher's MMPI-2 work.

Patients and methods

Patients (148) went into hospital for a one-day assessment. The assessment included the validated French version of the MMPI-2 and Visual Analogue Scale for pain intensity and repercussions. The local ethics committee approved this study, conducted in agreement with the declaration of Helsinki. We used a hierarchical cluster method to establish subgroups of patients with different psychopathological profiles and evaluated variations between the subgroups on measures of intensity and repercussions of pain.

Results

Figs. 1 to 2 show scale profiles for three- and four-cluster hierarchical analyses. A three-cluster solution best fitted the data (Fig. 1 and Table 2). The three clusters, which were of approximately equal size, were: (1) “Within Normal Limits”; (2) “Conversion-V”; and (3) “General Elevation”. We found significant differences between the “General Elevation” and “Within Normal Limits” clusters on the VAS measures of activity, sadness and depression. The only significant difference between the “Within Normal Limits” and “Conversion-V” clusters was on the activity scale. Patients in the “General Elevation” cluster were in the most urgent need of psychiatric help – it could be called a high distress, high disturbance cluster as Baker has described it. The four-cluster analysis of the MMPI-2 clinical scales (Fig. 2 and Table 2) gave four patterns showing the same “Conversion-V” and “Within Normal Limits”, but the “General Elevation” divided into a “Hypochondriac Depressive” cluster with 2-D scale elevated but with 1-Hs at the same level as the depressive scale, and the rest of “General Elevation” cluster could be split in a five-cluster solution into two very small subgroups, a “Psychotic V” cluster with a true V-shaped psychotic pattern with scores above those of the V-shaped neurotic triad scales, and a “Depressive General Elevation” cluster where the 2-D scale was the highest score in the profile but with all other scales also elevated except 9-Ma

Conclusions

These results showed that, firstly, different profiles of psychopathology were found even though there were no significant differences between the clusters in the level of pain intensity and pain duration; secondly, patients reporting more repercussions on the VAS measures showed profiles with more psychopathology. They were the patients most in need of psychological treatment. Finally, these results and the recommendations given could improve the therapeutic decision for each patient's subgroup.     

« Désorientation pour les personnes » au cours du vieillissement et des démences liées à l’âge

Disorientation towards people manifests itself during age-related dementia by hypo- or by hyperidentifications (false recognitions). The final stage during which the demented does not recognize his close relatives is sometimes preceded, as an heralding symptom of dementia, by an incomplete nonrecognition: Capgras’ syndrome, a delusion where a close relative is perceived as a double and an impostor. Current interpretation of these phenomena is based on the precepts of cognitive neuropsychology. Aged-related disorientation towards people, apart from naming difficulties, remains an opened question.     

Enjeux actuels de l’évaluation psychologique dans la clinique de l’enfant et de l’adolescent : vers une approche intégrée de la psychopathologie

This article will discuss different theoretical approaches and methods of data collection in view of the psychological assessment of children and adolescents. There are generally two different approaches; one being the single case study using a subjective method and the second consisting of clinical interviews and psychological tests using the objective method. In our opinion, psychological assessments should rely on two main axes. The first should be based on an updated knowledge of psychopathology, integrating new models and scientific findings with the methodology of Evidence Based Medicine (EBM). The second axis should be concerned with the psychological assessment combining subjective and objective methods. For example, the use of standardized tools such as scales or projective tests is essential to understand the interaction between multiple clinical variables influencing child psychopathology as well as to understand family and social interactions. The diversity of risk factors (e.g. family, personality, social, biological factors, etc.), implicated in mental illness shows the multi-dimensional aspects of psychopathology. Different theoretical approaches have been developed to study psycho-pathological mechanisms (neuro-psychology, psychoanalysis, biological psychiatry approaches, etc.). Therefore an integrative approach of psychopathology using different models and factors is needed to understand psychiatric disorders. A thorough psychological assessment is essential to the comprehension of mental illness in children and adolescents and is the first step to tailor treatments to individual needs. In order to answer these objectives, psychological assessments must be multi-modal, multi-disciplinary and multi-source: - Multi-disciplinary: For a better clinical assessment, psychologists and psychiatrists will need information from other professionals such as speech therapists, psychomotor therapists, neurologists… - Multi-modal: This aspect is crucial in clinical assessment. It characterizes all tools that clinicians will use in their assessment practice: Psychological tests, clinical interviews or clinical scales. - Multi-source: A comprehensive assessment of child and adolescent psychopathology includes assessments of different informants and sources (family, teachers…). These different approaches will be discussed in the perspective of the actual stakes of psychological assessment in children and adolescents. Developing integrative assessment approaches seems to be a promising field for the future in mental health services, allowing the tailoring of specific therapeutics for each child.     

Comorbidité TDA/H (Trouble du Déficit de l’Attention avec ou sans Hyperactivité) et TSA (Troubles du Spectre autistique)

The publication of the fifth version of the DSM in May 2013 officially recognized comorbidity between Attention-Deficit Disorder with or without Hyperactivity (ADD/ADHD) and Autism Spectrum Disorders (ASD). Indeed, the DSM-IV didn’t allow concomitant diagnosis. However, there is a clinical, neuropsychological and genetic overlap between these two disorders. Thus, 30–80 % of patients with ASD fill criteria for ADD/ADHD and in 20–50 % of patients with ADD/ADHD are found the diagnostic criteria for ASD. These observations raise the question of the link between ADD/ADHD and ASD: Is ADD/ADHD a minor form of ASD? Are ASD and ADD/ADHD different manifestations from a single neurodevelopmental disorder? Finally, are they two distinct developmental disorders whose clinical expressions would approach? Recent studies seem to distinguish two types of situations: Comorbid patients with less severe symptoms of ASD do not differ qualitatively from ADD/ADHD patients alone, which argues for a continuum between ADD/ADHD and ASD. Patients with ASD symptoms predominate are qualitatively different subjects from ADD/ADHD alone, thus corresponds to the hypothesis of two distinct nosological entities. Anyway, when ADD/ADHD and ASD are associated, there are specific clinical expression of developmental pathways and prognosis. Thus, these comorbid patients suffer more frequently from other psychiatric disorders, have a poorer quality of life, poorer adaptive functioning and clinical expression is more persistent over time. The modalities of treatment of comorbid patients may associate psychoeducational, psychotherapeutic approaches and medication (methylphenidate, atomoxetine, guanfacine, risperidone, aripiprazole).