Accessibilité de la remédiation cognitive en Île-de-France,en psychiatrie adulte et infanto-juvénile,et dispositifs de réhabilitation

Cognitive remediation (CR) aims to decrease cognitive deficits and provide palliative strategies for reintegration of patients with psychic disability. It is part of a personalized care program and requires multidisciplinary assessment and management, including eventually other psychosocial therapies. This study, carried out in 2016, aims to establish an inventory of accessibility and practice of the CR in Île-de-France, to promote broad access and systematize the integration of CR in a global and coherent course. The CR is proposed by nearly 58 % of the structures that answered the survey, but its implementation could be improved: it stands for 58 % in a specific project and the multidisciplinary evaluation before/after is carried out at 51 % in Adult Psychiatry and 20 % in Child and Teen Psychiatry (CTP), perhaps due to a lack of qualified staff (neuropsychologists). The programs used in CTP are nonspecific. The accommodation capacity should be increased by group programs. Despite a lack of knowledge to fill, there is an important interest for the CR with a will expressed by 12 structures to be trained. Other psychosocial therapies, although better known, would benefit from being more often proposed and labeled by the Regional Health Agency. Our results confirm a scarcity of psychiatric care's supply in 77, 91 and 93. Four rehabilitation units in the 77 and 3 in the 91 are being trained. Three structures in the 77 and 2 in the 91 are willing to get trained. Supporting them is all the more important as the good practice of CR has a direct effect on social costs’ benefits. Since then, in the entire region, 8 structures have proposed for a CR and rehabilitation platform.     

Robots de téléprésence et intersubjectivation

Objectives

The aim of this paper was to analyze the experiences of students to whom a telepresence robot was made available in periods during which they were prevented from attending university courses.

Psychiatrie phénoménologique,médecine de la personne et big data

Next to psychoanalysis, neurosciences and cognitivism is a historical trend in psychiatry, which lies in the minority and is not taught much: phenomenological psychiatry. Inspired by Husserl and Merleau-Ponty, it echoed in Ricoeur's work; carried by Binswanger, Minkowski, Tatossian, Lanteri-Laura, it still has its promoters and its researchers. The pathology thought as a lost of “pouvoir-être” allows oneself to consider the patient as his or her own norm. The whole analysis of the diagnostical process (between intuition and inference) and the “constructions” of the various theoretical resorts leading to practice are thus put to work. We will state how the everyday life of clinical psychiatry borrows more, sometimes without knowing it, from phenomenological psychiatry than from neurosciences or from the tools of clinical standardisation. Then, we would like to look into the possibility that this psychiatry inspired by philosophy might contribute to the dialogue between this medicine known as personalized or precision medicine (use of big data to come) as renewal of the Evidence-Based Medicine and, on the other side, the medicine of the person (cf. francophone observatory of the medicine of the person), which links with the Values Based Medicine we will examine.     

Télémédecine et troubles du spectre de l’autisme de l’enfant et de l’adolescent : guide théorique et pratique

ObjectivesThe development of telemedicine for children and adolescents is a real need because of difficult accessibility of mental health and the paucity of childhood psychiatrists. Thus the American Academy for Child and Adolescent Psychiatry (AACAP) published in 2008 good practice recommendations for telepsychiatry in children and adolescents based on clinical consensus and scientific evidence. In France the legal framework defines four practical modalities according to the presence or not of a health professional or a psychologist with the practitioner accomplishing the teleconsultation act. Data exist about the outcome of children and adolescents who benefited from therapeutic interventions with technological media. Effect size is modest but it doesn’t justify ruling out these techniques. Children who present with a developmental disorder or who cannot cooperate are evaluated with a certain degree of uncertainty. By contrast, some children with severe Attention Deficit with or without Hyperactivity (ADHD), social anxiety or Autism Spectrum Disorders (ASD) can be more easily engaged within a teleconsultation model. Teleconsultations in autism spectrum disorders (ASD) are feasible because of the nature of diagnosis and the type of care recommended in this disorder. The behavioral nature of the disorder and the behavioral therapeutic approaches recommended in North America culture highlight the potential interest of telemedicine because these disorders are easily observable. Literature suggests new opportunities in order to facilitate the care process for the ASD person and his family: the first one is diagnosis with use of validated instruments such as the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview (ADI). Parental accompaniment is the second opportunity. Development of telemedicine for ASD could be a complementary approach for diagnosis and medical care.MethodSince 2015, a program called PROMETTED (PROgramme MEdical de Télépsychiatrie pour enfants et adolescents présentant un Trouble Envahissant du Développement) was supported by Regional Health Agency of Île-de-France. It was developed and managed by the team of a Diagnosis Center Evaluation for Autism (DCEA) of Paris area in collaboration with a DCEA of Île-de-France region. Five medico-social structures for children and adolescents with autistic disorders and the two diagnosis centers of evaluation for autism co-elaborated a scheme of intervention with telemedicine. The remote evaluation is a 4-step process: a first teleconsultation structured around the medical history of the subject in order to complete his medical file and the observation of the young subject; a second teleconsultation structured around the ADI-R interview with parents; the third teleconsultation is a mixed teleconsultation associating the medical expert of the DCEA and a psychologist trained in the use of the Childhood Autism Rating Scale (CARS) and the Vineland Adaptive Behavior Scales (VABS). The fourth teleconsultation consists of the psychiatrist giving feed-back to parents about the results of the observations of the DCEA team.ResultsThe four-step program is well-accepted and the use of validated instruments for diagnosis or functional evaluation appears feasible. Medical data were completed for 44% of cases; complementary genetic or medical investigations were prescribed for 50% of cases; medical advice about psychotropic or vitaminic medication was given for 31% of cases. Mean duration of evaluation was 11.1 weeks ± 9.4.ConclusionsThe PROMETTED program empirically validates the concept of remote evaluation for children and adolescents with ASD. The need to extend the use of telemedicine to tele-expertise for medicine monitoring or behavioral disorder management has been noted.     

Ordalie,recherche de sensations et impulsivité. Analyse critique des définitions

BackgroundIn the fields of psychology and psychiatry, the use of the terms impulsivity, sensation-seeking and ordalie to refer to risk-taking behaviors can sometimes be confusing.ObjectiveThe objective of this study was to establish a clinical definition of the concepts of ordalie, sensation-seeking and impulsivity, in order to analyze the similarities and differences between these concepts.MethodsWe prioritized literature review articles with or without meta-analysis from the Medline database and supplemented with the Google-Scholar database. The articles were included in this review if their objectives were in line with ours. The research was conducted in November 2018.ResultsTwenty-seven articles were selected. There are similarities in the clinical definitions of these concepts with measurable heterogeneous constructions, and an exacerbation in adolescence for engagement in harmful behaviors, but there are also nuances that highlight their differences.ConclusionWe were able to describe areas of divergence and convergence between these three concepts but not to establish a quantitative diagram of the areas of divergence and convergence. It would seem that the coexistence of sensation-seeking and impulsivity in the same individual could explain that individual's involvement in ordalique behaviors. Further studies approaching this hypothesis would seem useful in terms of preventing risk-taking behaviors such as addictive behaviors.     

Psychédéliques,psychothérapie et symbolisation : une revue de littérature dans le champ de la dépression

AimThis article proposes a literature review focused on the so-called “classic” psychedelics (LSD, psilocybin, DMT, and mescaline) and, more specifically, on their use in the psychotherapy of major depressive disorders and the way they affect symbolization processes.MethodAfter some introductory remarks on psychedelics and depressive disorders, we describe some modern clinical trials, and then explore the peculiar phenomenology occurring in the psychedelic experience, as well as its therapeutic effects on depressive symptoms. The underlying mechanisms are discussed from a perspective at the crossroads of cognitive neurosciences and psychoanalysis. We conclude with some reflections on the crucial role of the setting.ResultsThe results already obtained suggest that a single dose, taken in a supportive environment, may be sufficient to produce significant and immediate therapeutic effects, which are still present six months after the dose, although less so for some patients. Clinical response depends on the subjective aspects of the individual experience. More specifically, it seems correlated with the ability to “let go” and to allow autobiographical memories to emerge, along with the intense emotions they carry. It also relies on the presence and intensity of mystical-type experiences, characterized by feelings of “ego dissolution,” unity with everything, transcendence of space and time, and ineffability.DiscussionPsychedelic-assisted therapy seems to promote the emergence of primary processes and the lifting of defense mechanisms. Psychedelics would thus catalyze the resumption of symbolization processes, favoring in particular the integration of unconscious conflicts as well as the remodeling of pathogenic object relationships. On the neurobiological level, these processes would be underpinned by a decrease in the activity of the default mode network – sometimes considered the primary biologic substrate of the Freudian ego –, associated with an increase in brain entropy and in neuroplasticity. These different elements entail a decrease in depressive symptomatology, particularly ruminations. Common factors identified as the cause of positive changes in classical psychotherapies appear naturally amplified in the psychedelic experience, which requires the containing function of a therapist and a supportive clinical setting to allow a resumption of symbolic processes. To ensure the perpetuation of the observed transformations, which often exceed the simple withdrawal of symptoms, an extended psychotherapeutic monitoring would be appropriate.ConclusionThe psychedelic substance acts as a catalyst, allowing an access to otherwise inaccessible unconscious materials, which can then be processed both spontaneously and within the therapeutic relationship. Considering the data discussed in this review, we emphasize the need for further research exploring the potential of this treatment, which also offers the hope of a renewed dialogue between psychiatry and psychology, neurosciences and psychoanalysis.     

Histoire de la kétamine et du psychédélisme

Ketamine's history begins in the fifties in Detroit, at Parke-Davis laboratories. In 1956, Maddox synthetized phencyclidine or PCP. Domino studied PCP effects in animals and in 1958, Greifenstein made the first trials of PCP in humans under the name of Sernyl. Sernyl elicited severe excitation with a prolonged postoperative recovery. Because of its psychedelic effects, it became a street-drug under the name of “angel dust”. Calvin Stevens synthesized ketamine in 1962. The drug was studied in humans in 1964, by Domino and Corssen who described the so-called “dissociative anesthesia”. Ketamine was patented in 1966 under the name of Ketalar for human use and was administered to soldiers during the Vietnam war. The psychedelic effects and the arrival of propofol prompted the shelving of ketamine. However, the discovery of the NMDA-receptor and its non-competitive inhibition by ketamine revolutionized the pathophysiology of hyperalgesia and mental functioning. In early 1990s, the discovery of opioid-induced hyperalgesia elicited a paradigm shift in the management of pain, and a comeback of ketamine, as an anti-hyperalgesic drug. Ketamine is nowadays under the spotlight in the field of treatment-resistant depression and has been proposed as a potential fast antidepressant in patients with high suicidal risk.     

Délire de revendication et quérulence : une revue de la littérature

Objective

This literature review set out to describe the history and the evolutions in German-, English- and French-speaking countries of a psychiatric notion, “litigious delusion”. The author focuses on a subgroup taking the form of querulent delusion or querulousness (a pathological tendency towards litigious behaviors).

Le sympathique régulateur de croissance et d'équilibre tissulaire

Résumé La fonction essentielle du système nerveux sympathique réside dans son action trophique, c'est-à-dire dans la régulation de croissance des organes et le maintien d'un équilibre harmonieux entre les divers tissus qui les composent.Ce rôle trophique est évident dans le cas de l'action des hormones morphogènes, où le facteur neuro-sympathique, support de la sensibilité à l'hormone est aussi nécessaire que l'hormone elle-même.Mais l'action trophique est absolument générale et un déséquilibre du système sympathique, périphérique ou central, peut engendrer des lésions proches ou lointaines de divers appareils.On peut expérimentalement provoquer l'apparition d'hémorragies, d'infarctus et la formation d'ulcères, de tumeurs bénignes, de tumeurs malignes complexes métastasiantes.Il est possible que l'étude des perturbations tissulaires consécutives aux lésions du sympathique apporte une contribution importante à la pathogénie du cancer.

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Summary The essential function of the sympathetic nervous system consists in its trophic reaction i. e. in the regulation of the growth of the organs and in the maintenance of the harmonic equilibrium between the different organic tissues.This trophic function is especially striking in the action of hormones in which the neurosympathetic factor for the regulation of the hormone's reaction is as necessary as the hormone itself.The trophic function is a general reaction so that a central or peripheric disturbance of the sympathetic system may damage organic tissues in the neighbourhood or far away.One is able to produce experimentally hemorrhages, infarcts and ulcers, benign and malign or metastatic tumors.It is possible that the study of tissue-damages which occur after lesion of the sympathetic nerve may bring some help in explorances of cancer-pathogenesis.

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Zusammenfassung Die essentielle Funktion des sympathischen Nervensystems besteht in seiner trophischen Wirkung, d. h. in der Regulation des Wachstums der Organe und in der Aufrechterhaltung eines harmonischen Gleichgewichtes zwischen den verschiedenen, die Organe aufbauenden Geweben.Diese trophische Funktion ist besonders augenfällig bei der Wirkungsweise der Hormone, bei der der neuro-sympathische Faktor für die Regulierung der Ansprechbarkeit auf das Hormon ebenso wichtig ist wie das Hormon selbst.Die trophische Funktion ist jedoch eine Gesamtreaktion, so daß eine Störung des sympathischen Systems, sei sie zentral oder peripher, örtlich nahe oder entfernte Organsysteme schädigen kann.Man kann experimentell das Auftreten von Hämorrhagien, Infarkten, die Bildung von Ulcera, benignen und malignen, metastasierenden Tumoren provozieren.Es ist möglich, daß die Erforschung der Gewebsstörungen, die auf eine Sympathikusläsion folgen, einen wichtigen Beitrag zur Pathogenese des Krebses bringen.

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Adolescence et séparation,un travail à l’épreuve du handicap et de sa temporalité originale

At the crossroads of adolescence and disability appears, specifying the work of subjective appropriation of the person handicapped, the question of the elaboration of time and the historicization. The adventure of the separation in the adolescence will allow us to approach this question of the possible disorders of time, through the symptomatic figures of difficult separation, or even impossible separation. The puberty offers the opportunity of reviving the work of time. This stage of the development proposes an original psychic work of relationship between the internal and external world, interpreted according to the past history of the infirmity. The puberty offers the opportunity of reviving the work of time. These complex connections are put in the service of the repair. The tone of these connections appears often brutally, whereas the thought of a separation sends back, both the adult and the teenager, to the suffering of the abandonment. When the teenager approaches the elaboration of a work of separation, the opportunity is offered to him to interpret again its handicap, on his behalf, in a real resumption of work of subjectivation.     

Sur la régulation neurovégétative de territoire et de système des vaisseaux

Résumé Les variations réflexes du tonus vasculaire, provoquées par la stimulation directe des vaisseaux, peuvent s'étendre à tous les vaisseaux d'un territoire vasculaire, ou bien se produise seulement dans les limites du système vasculaire stimulé; autrement dit il existe un réflexe vasculaire de territoire et un réflexe vasculaire de système. Il semble que les réflexes de territoire puissent être provoqués par la stimulation de l'adventice des artères et des veines, tandis que les réflexes de système semblent répondre à des stimulations de l'intime.

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Summary The reflex variations of the vascular tonus which may be caused by direct stimulation of the vessels may affect all the vascular sections or be limited to the regional vessels. We have namely a regional reflex and a systemic reflex. The regional reflex seems to be caused by stimulation of the arteries or veins adventitia, while the system reflexes seems to be caused by stimulation of the intima.

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Zusammenfassung Die reflektorischen Veränderungen des Gefäßtonus, die durch direkte Reizung der Gefäße hervorgerufen werden, können entweder alle entsprechenden Gefäße des Kreislaufsystems betreffen oder nur auf die des gereizten Bezirkes beschränkt bleiben.Man kann also einen regionalen und einen Systemreflex unterscheiden. Die regionalen Reflexe scheinen durch Reizungen der Adventitia ausgelöst zu werden, während die Systemreflexe mehr durch eine Reizung der Intima verursacht scheinen.

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Riassunto Le variazioni riflesse del tono vasale, provocabili con stimolazioni dirette dei vasi, possono estendersi a tutti i vasi di un territorio vasale, come possono verificarsi nei limiti del sistema vasale stimolato; si ha cioè un riflesso di territorio vasale e un riflesso di sistema vasale. I riflessi di territorio sembrano provocabili con stimolazioni dell'avventizia delle arterie e delle vene, mentre i riflessi di sistema sembrano provocabili con stimolazioni dell'intima.

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Avec 8 figures