Validation de l’échelle d’insight Q8 et évaluation de la conscience de la maladie chez 121 patients hospitalisés en psychiatrie

Insight (awareness of disorder) is an important domain for research and practice in psychiatry. Several instruments to measure insight are currently used. We present here a short scale (8 items with open question) applied to a sample of 121 psychiatric inpatients which permitted to validate this questionnaire and to demonstrate its easiness and rapidity. This insight Q8 scale shows that insight is higher in free hospitalization (compared to compulsary hospitalization), in mood disorders (compared to schizophrenia), in dépression (compared to schizophrenia and mania), in married patients (compared to widowed and single patients), in case of good cognitive functions (MMSE score) and antecedents of attempted suicide. Awareness must be taken into account in all major mental disorders. Therapeutic alliance, treatment compliance, prognosis and risk of relapes depend largely on this dimension.     

Psychothérapies cognitivo-comportementales de l’hypocondrie

This paper reviews the cognitive-behavioural strategies of psychotherapy applied to hypochondria. Cognitive mechanisms of hypochondria are the tendency to amplify body manifestations (pain, fatigue…) and to interpret them in a catastrophic manner. The persistence of anxiety is due to a confirmatory bias, which increases the importance given to information congruent with anxiety. The exposure-response prevention model is an important technique in the treatment of hypochondria. This model has been validated in patients presenting obsessive compulsive disorders. Patients are invited to confront ideas or thoughts that induce fear. This confrontation is repeated or prolonged in order to induce the extinction of anxiety. Another cognitive approach is the step-by-step cognitive “modelling”. During the first step the patient assesses his stress-inducing thoughts concerning his health, he also has to assess the frequency of inadequate medical treatments. During the next step, the therapist helps the patient correct automatic thoughts and false beliefs concerning his illness. The last step is a phase of consolidation. The therapist identifies factors triggering anxiety and excessive medical care. All these behavioural cognitive therapies can be performed in individual or in-group processes. Therapies proposed to patients presenting generalized anxiety disorders can be adapted to hypochondriacs. Lastly, hypochondria can be understood and treated as a form of addiction to medicine characterised by a craving for medical care, for biological exams and for different forms of medication. According to this conception, the treatment can be conducted as a form of detoxification: patients identify the frequency of their pathological behaviour and find strategies to reduce and/or control them.     

De l’esprit et des modes de classification en psychiatrie

A classification is a system of classes designed to represent the mental disorders according to a fixed rule. The author stresses the paradox of the growing number of mental disorders versus the absence of a natural classification and then defines what a classification is, why it exists, how it is established, and what its evolution is like.The principle of classification is similar in all sciences, but it is more complex in psychiatry, because of the nature of the objects studied.Classification seems desirable for general reasons of representation, communication and action, as well as for singular reasons related to person and milieu which incite to elaborate it.Its construction depends on the agonistic-antagonistic paradigms chosen (relations which are real vs virtual, formal vs dynamics, qualitative vs quantitative) and on the way the data are collected (linear or circular steps, ontological or operational bipartition, type of reasoning).Its evolution shows its successive openings, passing from the concept of disease to the concept of grouping of criteria which are associated according to the underlying dynamic processes and finally to combinations of functional disorders.A conclusion leads rapidly to the intrinsic and extrinsic consequences.     

Les troubles mentaux dans les écrits médicaux anciens : méthodes de caractérisation et application aux consultations françaises du xvi siècle au xviii siècle

Objectives

Like cross-cultural studies, research on ancient medical writings allows psychiatrists to identify constant and variable expressions of mental disorders; this may in turn allow discrimination between pathogenesis mainly of a biological nature and that mainly of a socio-cultural nature. However, the study of these writings presents many problems which require the development of specific and rigorous research methodologies. In particular, close attention is needed for the identification and characterization of mental disorders, a process which is usually referred to as “retrospective diagnosis”. This paper tackles the difficult problem of retrospective diagnosis and pathological categorization of mental disorders described in historical medical writings and proposes a pragmatic and operational approach to these issues.

Patients and methods

We propose going beyond the simplistic contraposition of essentialist and constructivist approaches to mental disorders. First, history research questions involving individual diagnosis, either to ascertain whether a given disease or nosological entity is present in a given historical population (situations A1) or to understand a behavior of an individual or group in a given historical context (situations A2), should be distinguished from questions in which the health of a population or a subgroup is of interest (situations B). Situations of type (A1) require the use of all medical knowledge to make a tentative retrospective diagnosis; situations of type (A2) require considering retrolective diagnoses which could have been made at the time the disorder was managed/reported; and situations of type (B) require using robust pathological categorizations and classifications like those used in contemporary epidemiology to allow comparisons between populations. This conceptual and methodological framework was applied to the study a corpus of more than 2000 reports of consultations of French physicians, written during 16th–18th centuries. Retrospective diagnosis was attempted by a group of psychiatrists and historians on the basis of DSM-IV-TR diagnostic criteria for common mental disorders.

Results

Mental disorders accounted for nearly 4% of the medical conditions dealt with in the consultations; there was no trend for change during the study period. Minor mental disorders, such as depressive, anxiety and somatoform disorders were the most frequent. Serious conditions, characterized by symptoms corresponding to the contemporary categories of bipolar disorder, major depressive disorder and schizophrenia, were also suggested.

Conclusions

This study evidences the presence, in the early modern French population, of many mental disorders fitting into the categories of contemporary psychiatric nosology. It also demonstrates the feasibility of pathological categorization, and in some cases retrospective diagnosis, of mental disorders described in historical medical writings. These findings have implications for historical research in psychiatry.     

Application de la résolution de problème dans une unité de suicidants et suicidaires : premiers résultats auprès de 53 patients hospitalisés

Suicidal behaviour is a clinical problem that has posed major challenges to efforts in its understanding and treating. There are many studies on the various mental disorders presumed to underlie suicidal behaviour. Less than 50 randomized clinical trials have been conducted evaluating treatments aimed specifically at treating individuals with high suicidal risk. There is sparse data regarding treatments for primary mental disorders, which actually reduce the risk of suicide attempts or of suicidal ideation. The authors think that focussing efforts on treatment of suicidal behaviours may improve our understanding of the mechanisms related to suicidal behaviour and mining them for ideas will lead to effective interventions. For over a year the authors introduced the problem-solving therapy in their broad program for treating suicidal inpatients. In this pilot study the authors observed that assisting patients in developing a more positive problem-solving orientation may modify customary attitudes of avoiding problems and reduce tendencies to respond in an impulsive or careless manner.     

La rémission sans traitement : état de la question pour une consommation problématique d’alcool

This article pursues the double goal of a review of the literature and of an update of the documentation on remission without treatment for individuals with dual diagnosis disorders. It has been elaborated from a selection of 26 publications among the 95 selected listed references. The difficulties in the responsibility of taking charge of patients, the increase in demand, the low rate of success of the treatment are all elements that made natural recovery seem an impossible phenomenon. This article explores the items related to natural recovery and provides the groundwork for a better definition of this phenomenon : must one regard natural recovery as a reduction in the volume of alcohol consumed, as a reduction in the clinical signs of alcohol disorders ? What is the time required before one can assume the stability of the phenomenon and the avoidance of relapses ? These questions must be considered as empirical studies show that the majority of people with a problematic use of alcohol never consult a physician, but that a substantial part does reach a state of remission. How can we understand this data ? The studies show that remission without treatment, observed on a range of serious disorders related to alcohol, happens more often with people whose problems are less serious and who have intrinsic resources. The studies show that rather than a formal model of abstinence, natural recovery may be a pathway out of addiction in which certain forms of consumption remain present (except in cases of severe problematic use where complete abstinence is mandatory). This data thus questions the capacity of reaching these populations and also questions the current objectives of treatments. A compilation of several studies has allowed us to propose an estimate of the rate of prevalence of remission without treatment. Finally, a summary of the principal instigating factors and of the duration of remissions based on quantitative and qualitative studies is proposed as well as a comparison with other substances. In brief, this phenomenon shows alcoholism in a different light. Pathways of change are multiple and heterogeneous and may be found without calling for rehabilitation services. However, important gaps remain on the operational level of the concept and on the methods to reach this hidden population. Nevertheless, the main explanatory factors emphasize the determinism of the environment and more particularly the negative consequences of consumption on health and on financial resources.     

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.     

Le concept de test relationnel en psychothérapie : origines, développements et applications aux troubles de la personnalité

The test concept (Weiss and Sampson, 1986 [16]) is presented. Its origins in Freud's works are briefly evoked and its place within the theory of pathogenic beliefs by Weiss presented. We present also the remaining elements of Weiss’ psychoanalytic theory which are objectives, obstacles, traumas and insight. Every step of the reflection is illustrated with case examples, drawn from the literature. A recent development of the test concept is presented and applied to the psychotherapy of personality disorders (Sachse, 2003 [14]). Finally, the authors give brief examples of tests having occurred in their own practice as psychotherapists and discuss the models by comparing them among each other. Conclusions are drawn concerning the usefulness of the test concept for psychotherapy practice and research.     

Secteurs psychiatriques et circuits de l'information en matière de précarité

The public service for mental health has been facing a conjuncture with necessary modifications to be made. In this context, we felt that it would be appropriate to carry out a survey in 2000, and then in 2002, on how much psychiatric districts know and are informed about access to general medical care and rehabilitation. Psychiatric staff seemed indeed to pay particular attention to those who may benefit from existing social systems and not only in connection to new legislations. According to our estimates, 19 % of patients under psychiatric care benefit from the Universal Medical Coverage (Couverture Médicale Universelle, CMU). The CMU was considered to be a good measure for patients by most medical and social partners polled. The latter emphasised the relevance of covering hospital fees and making access to general medical and dental care, which is otherwise often disregarded, easier. Moreover, districts themselves suffer from institutional “precariousness”. Tensions occur in the first place when, despite their willingness to deal with issues or problems, they are unable to do so.     

Souffrance psychosociale et risque suicidaire, quelle articulation entre médecine de ville et psychiatrie hospitalière ? Résultats d'une étude qualitative

Mental disorders are now becoming the first reason for consulting a general practitioner. These mental disorders include pathologies identified by psychiatry as well as a series of complaints linked to psychosocial distress. This latter, on the border between social field and medicine, does not benefit of a specialised clinical approach. Nevertheless, suicidal behaviour constitutes one of the complications of psychosocial distress which general practitioners have to face, though they have scant academic knowledge of it. A qualitative study examining an important oral material and 202 medical letters was realized in three of four Breton geographical departements. This study describes and analyzes the clinical attitude of general practitioners and their answers. Based on this study this article approaches the question of the articulation between private practice and hospital psychiatry.     

Conséquences psychopathologiques de l'épilepsie. À partir de l'analyse de 10 observations

From the analysis of clinical data and the viewpoint of the bibliographic data, bringing out the comorbidity epilepsy/mental health, frequency of personality disorders during epilepsy and constancy of behavioural troubles are outlined. However, results of works, dealing with behavioural disorders, are often contradictory. Association with mental retardation shows a problem of imputability. Depressive mood, often concomitant with anxiety disorders, represent the psychiatric comorbidity frequently associated with epilepsy; recent works assess the factors of seriousness of depression. As for the relationship between psychosis and epilepsy, the term ”epileptic psychosis” indicates today specific entity. Psychotic patients who suffer from epilepsy are not in that concept frame. Alcoholism does not seem more frequent in people suffering from epilepsy than in general population. The social disqualification assessed by the scales of quality of life is frequent with people suffering from epilepsy.     

Maladie de Parkinson : de la physiopathologie des troubles psychiques à la maîtrise du traitement dopaminergique

Introduction

Behavioral changes in Parkinson's disease are complex and their pathophysiology is not yet fully understood. The dopaminergic system seems to play a major role and most of the behavioral disorders in Parkinson's disease can be classified into either hypodopaminergic if related to the disease itself or hyperdopaminergic if related to dopaminergic treatment.

State of the art

Subthalamic stimulation, which enables withdrawal of dopaminergic medication at an advanced stage in the disease, provides a model for the study of certain nonmotor, dopamine-sensitive symptoms. Such a study has shown that apathy, which is the most frequent behavioral problem in Parkinson's disease, is part of a much broader hypodopaminergic behavioral syndrome which also includes anxiety and depression. Nonmotor fluctuations - essentially fluctuations in the patient's psychological state - are an expression of mesolimbic denervation, as shown in positron emission tomography. Drug-induced sensitization of the denervated mesolimbic system accounts for hyperdopaminergic behavioral problems that encompass impulse control disorders that can be alternatively classified as behavioral addictions. The association of impulse control disorders and addiction to the dopaminergic medication has been called dopamine dysregulation syndrome. While L-dopa is the most effective treatment for motor symptoms, dopamine agonists are more effective in improving the nonmotor levodopa-sensitive symptoms. On the other hand, L-dopa induces more motor complications and dopamine agonist more behavioral side effects. There is increasing data and awareness that patients’ quality of life appears to be dictated by hypo- and hyperdopaminergic psychological symptoms stemming from mesolimbic denervation and dopaminergic treatment rather than by motor symptoms and motor complications related to nigrostriatal denervation and dopaminergic treatment.

Perspectives

Better management requires knowledge of the clinical syndromes of hyper- and hypodopaminergic behaviors and nonmotor fluctuations, a better understanding of their underlying mechanisms and the development of new evaluation tools for these nonmotor symptoms.

Conclusions

The neurologist who strives to gain mastery of dopaminergic treatment needs to fine tune the dosage of levodopa and dopamine agonists on an individual basis, depending on the presence of motor and nonmotor signs respectively.     

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.     

La perception de la douleur d’autrui

Modern medical practice, which is largely focused on diagnosis and disease origins, has long viewed pain mainly as an indicator for identifying the potential causes of a disease. Even though today, a patient's pain appears to be better accounted for – especially due to the widespread use of rating scales – the overall estimation of pain severity is still subject to a number of variables that may impede the quality of medical care and pain alleviation.     

La douleur chronique en psychiatrie : comorbidité et hypothèses

Over previous decade, psychiatry has become peripheral to pain management and anaesthesiology has moved onto centre stage with ever more sophisticated interventions, including radiofrequency neurolysis, implanted medication pumps, and spinal cord stimulators. However, a sizeable sample of patients with chronic pain is not achieving satisfying remission. With regard to the high prevalence of psychiatric disorders among those patients, psychiatry has an important amount to offer this field, at least as much as any other single discipline. Since Freud’s psychodynamic theory of hysteria, as an explanation for chronic pain without a located physical basis, other important contributions from psychiatry have been made, including the concept of pain-prone disorder as a variant of depression and the liaison psychiatrist George Engel’s biopsychosocial medical model.Nineteen consecutive patients with chronic pain, 12 females and 7 males, were admitted to a 5- or 10-days inpatient program in a psychiatric department. None of those patients were working at the time of their admission. The main purpose of this program was to examine psychiatric comorbidity and the need for further psychiatric follow-up. This sample is described in terms of the two first axes of the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th edition) nosology. Diagnoses were retrospective for 10 patients (52.6%) and prospective for the others (47.4%). The retrospective diagnoses were those mentioned in the patient file. Results regarding personality disorders are with the exclusion criteria not applied for other personality disorders.Not surprisingly, with chronic pain disorder excepted, depressive disorders were the most frequent diagnoses on axis I (diagnosed in 52.6%). Major depressive disorder was diagnosed in 36.8% (current episode = 26.3%), while dysthymic disorder was diagnosed in 15.8%. Anxious disorders as social phobia, post-traumatic stress disorder and generalised anxiety were each respectively diagnosed in 15.8%. Substance misuse or dependence was diagnosed in 21.1%. Schizophrenia and dementia were each respectively diagnosed in 5.2%. Among somatoform disorders, chronic pain disorder was diagnosed in 78.9%. 10.5% had no diagnosis on axis I. Personality disorder was diagnosed in 73.7%. Histrionic personality disorder and avoidant personality disorder were each respectively diagnosed in 26.3%. Other diagnoses on axis II are detailed.Previous studies have shown such a positive association between pain and depression. Those results are summarised. Evidence supporting a direct link between these two variables is less robust. Although chronic pain as a variant of depression is a useful psychodynamic concept in some individual cases, it seems insufficient as a general model of chronic pain. Other hypothesis are reviewed, especially those which conceptualise both depression and chronic pain as relevant to a unique underlying process. This process may be conceptualised as a proneness to generalise negative events as acute pain or fear. Previously, Swanson advanced that chronic pain may belong to the category of emotions. According to such a model, analogies can be used to compare acute and chronic pain with fear and anxiety and also with sadness and depression. This proneness to generalise negative emotional events may be adequately described by a unique personality trait like Eysenck’s Neuroticism or Cloninger’s Harm Avoidance. Previous results supporting this hypothesis are reviewed. The last six patients were given the Temperament and Character Inventory—Revised (TCI-R). Preliminary findings are discussed. Despite several limitations, those results are consistent with our hypothesis, showing homogenous Harm Avoidance scores.     

Les antidépresseurs dans le traitement de l’état de stress post-traumatique

Posttraumatic stress disorder (PTSD) can be a prevalent, often chronic and disabling condition with major consequences for the individual and society. Diverse therapeutic approaches made the object of controlled and randomized studies: the pharmacological approach, the psychotherapic approach (essentially cognitivobehavioral), and the approaches combining pharmacology and psychotherapy. This article tries to review the available empirical data on antidepressant approaches to PTSD (selective serotonin re-uptake inhibitors, monoamine-oxydase inhibitors, tricyclic antidepressants, serotonin-norepinephrine re-uptake inhibitor) and to provide some recommendations for clinical practice. Although a comprehensive search of PubMed/Medline databases revealed a great number of case reports and open-label trials, we decided to focus primarily on evidence obtained from randomized controlled trials to determine the most effective antidepressant treatments for PTSD. Antidepressant pharmacotherapy seems to have positive effect on certain symptoms of PTSD but their short-term efficacy is partial and there remains unknown data on their long-term effectiveness. The available data supports antidepressant medication as the first-line pharmacotherapy for PTSD, with selective serotonin re-uptake inhibitors monotherapy having the strongest body of empirical support. Other potential options include, serotonin-norepinephrine re-uptake inhibitor, selective alpha-2 presynaptic serotoninergic inhibitors, monoamine-oxydase inhibitors or tricyclic antidepressants, and the combination with other pharmacotherapy in refractory PTSD cases. It seems to exist a certain consensus on the fact that the treatment should be continued for one prolonged length of time, exceeding largely the three months duration usually used in the controlled and randomized studies. A 12-month treatment seems indicated in chronic PTSD with residual symptoms.     

Stimulation cérébrale profonde et troubles de la marche dans la maladie de Parkinson

Introduction

Gait disorders and freezing of gait (FOG) are seen in most patients with advanced Parkinson disease. Response to levodopa and deep brain stimulation is variable across patients.

State of art

Thalamic stimulation is ineffective on gait and can even worsen balance when bilaterally applied. Pallidal stimulation moderately improves gait disorders and FOG although this effect tends to wane after three to five years. Stimulation of the subthalamic nucleus (STN) improves levodopa-responsive gait disorders and FOG. However, some patients worsen after STN stimulation and others are better improved under levodopa than under STN stimulation. Synergistic effects of the two treatments have been reported. As for pallidal stimulation, there is a failure of long-term STN stimulation to improve gait, probably due to the involvement of non-dopaminergic pathways as the disease progresses. Levodopa-resistant gait disorders and FOG do not usually benefit from STN stimulation. In the rare cases of levodopa-induced FOG, STN stimulation may be indirectly effective, as it enables reduction or arrest of the levodopa treatment.

Perspectives

Pedunculopontine nucleus stimulation has recently been performed in small groups of patients with disabling gait disorders and FOG. Although encouraging, the first results need to be confirmed by controlled studies involving larger series of patients.

Conclusions

Overall, gait disorders remain a motor PD symptom that is little improved, or only temporarily, by current pharmacological and surgical treatments. Patient management is complex.