Factitious hemiplegia and Munchausen's syndrome.

We report a case of a thirty-year-old woman suffering from chronic factitious disorder with hemiplegia. Such a pathomimia is very uncommon in Munchausen's syndrome. Indeed, most often, the clinical picture is characterised by acute abdominal pain, fainting, haemoptysis, precordialgia, hematemesis or dermatological lesions.     

De la pathomimie à la dépendance aux soins : approche dimensionnelle et perspectives thérapeutiques

Factitious disorder, or pathomimesis, is a clinical entity characterized by the intentional feigning of physical or psychological signs and symptoms in order to play the role of patient. Little is known about the psychopathology of these patients, and the treatment of pathomimesis is not well defined. Building on a clinical case, we will illustrate the diagnosis and treatment difficulties that are associated with this pathology. We will propose a dimensional approach based upon the concept of medical addiction and we will emphasize the therapeutic perspectives raised by this approach.     

Une clinique de l’accueil et de l’accompagnement. La prise en charge d’une famille demandeur d’asile politique réfugiée en France

The psychiatric and psychological consequences of traumas experienced by refugees represent an important public health problem, not to mention the social isolation, the loss of cultural references and identity, the disruption of family and social network, the difficulties in coping with economic, social and language barriers. One of the other main issues concerns the long uncertain administrative procedures asylum seekers must go through in order to be officially recognized as refugees. In this article, we will describe the follow-up of a refugee family from Chetchnya; we will illustrate our therapeutic group intervention with sequences of our clinical sessions with this family. Our work will continue for two years during which we will have a series of regular meetings with the family. In our experience, intervening with traumatized families should be a committed intervention, far from cold neutrality, which could reinforce the families’ feelings of isolation and prevent them from sharing their traumatic experiences. The therapeutic framework proposed seems essential in order to help the families cope with their psychological difficulties and face the emotional changes that they will be experiencing in the host country.     

Prise en charge d’une première crise épileptique de l’adulte : peut-on prévoir l’avenir ?

The new definition of epilepsy recently proposed by an international panel of experts relies on the association of a first clinically certain seizure and of an enduring predisposition of the brain increasing the likelihood of future seizures. In the first part of this review, we will expose and organize into a hierarchical order the risk factors of subsequent recurrence. The major factors are: seizure(s) prior to presentation, paroxysmal abnormalities on early EEG, a remote symptomatic etiology. In the second part of this review, we will address the issue of clinical uncertainty when assessing the epileptic origin of a first clinical paroxysmal event, the reasons of uncertainty and the means to minimize it. We will analyze successively: the accuracy of eyewitness observations of transient loss of consciousness, the reliability and predictive validity of clinical criteria used for seizure assessment, the issue of overlapping clinical features between seizure and other non epileptic paroxysmal events (such as psychogenic non epileptic seizures), and finally the reliability and diagnostic value of early EEG for seizure assessment. To conclude, seizure assessment and diagnosis of epilepsy cannot be dissociated from syndrome and etiology diagnosis, which should be periodically reassessed towards a greater accuracy during the course of the disease.     

Une nouvelle prise en charge de la sphère oro-faciale des enfants paralysés cérébraux par un jeu interactif en 3D

Rehabilitation of facial praxia in children affected by cerebral palsy is an important goal, although its efficiency remains hard to evaluate. We have listed difficulties encountered by a child during a session of classical rehabilitation, and we propose a novel technique of rehabilitation based on the use of an interactive avatar. In addition to the game-like use of this interactive tool, motions captures that will be recorded during work sessions will also be usable to get metric measurements of the buccofacial movements of children with cerebral palsy. For each child, we will be able to define their own characteristics, which will probably reflect the great heterogeneity of clinical aspects and movements developed by these children. This study will require that each patient will be his own control to evaluate the efficiency of this new protocol.     

Thérapeutique du syndrome de répétition chez l'enfant et l'adolescent victimes d'agressions sexuelles

We would like to insist upon the importance of systematic research of a psycho-traumatic syndrome among children and teenagers who have been sexually assaulted. The clinical element that reveals it is the repetition syndrome. Knowing that it works like “tableaux vivants”, we will show that it is the marker of perverse after-effects, demanding an adapted therapeutic strategy.     

La « démentification subjective » comme effet de l’idéologie Alzheimer

ObjectivesIn clinical practice, there is a strong tendency to interpret any elderly patient's disorder as dementia. The purpose of this paper is to identify the origins, the operating mechanisms, and the subjective consequences of this. It also seeks to propose a model for understanding and dealing with this gerontological doxa.MethodBased on our clinical experience in institutions, we will analyze the articulation between current geriatric ideology and subjective dementia assessments in gerontological practices. We will first outline the theoretical and contextualized reconceptualization of Alzheimer's disease, aging, and the cognitive symptom. Then, we will identify the impact of these conceptions in practices with elderly subjects. Finally, we will identify the individual and institutional attitudes that can result from this.ResultUntil the 1970s, the diversity of international geriatric conceptions was proportional to the clinical complexity of the aging process and to the demential state of the elderly subject. The reconceptualization of senile and pre-senile dementia as a disease that is specific to aging, combined with decisive socio-cultural transformations, imposed a biomedical reading of the problems of aging. Stemming from an American leadership that completely shaped the orientation of the emerging dominant discourse, the model of an expanded Alzheimer's disease is now conditioning the monocentric ways of approaching the variety of geriatric clinical phenomena. In practice, this results in the elderly adult's behavior being consistently interpreted as dementia, resulting in a subjective dementification.DiscussionSubjective dementification is what we refer to as the delirious psychic effects of this dementia interpretation as applied to clinical situations of the aging subject, regardless of whether or not there is a probable cerebral problem. It is the product of a double mechanism that we call psychic decerebration and push-to-dementia. The phenomenon of subtraction from the faculty of thinking is thus linked to the process of stripping meaning from the manifestations of the elderly subject and replacing them with dementia identity elements via the discourse and attitudes of the social circle. Depending on the clinical situation, this double operation will have various subjective effects that oscillate between two poles: an increase in symptoms in the case of a probable neurodegenerative pathology, and the creation of an artificial dementia-like picture that is more or less marked in the case of a misdiagnosis or abusive labeling. In this context, support for the elderly subject involves the need to treat the Other. In the vein of the etiological model supported by the British psychiatrist Martin Roth at the dawn of psychogeriatrics, we posit that only a simultaneous questioning of the organic, psychic, and toxic dimensions – through a clinical practice rooted in a relationship with the Other – can effectively grasp geriatric problems and challenges.ConclusionFaced with the diversity of aging disorders, clinical practice with geriatric subjects must, above all, be introspective. The guarantee of the subject's dignity and freedom is in fact conditioned by the ability of those who surround and accompany the elderly adult to resist Alzheimer's ideology.     

Residents' perceptions of inpatient psychiatric care

Psychiatric care on an inpatient unit entails the exposure of a patient to a multitude of experiences. It is generally intended that these experiences will be of benefit to the patient. A psychiatric clinician who functions in such a setting has a major responsibility for making decisions about the kinds of experiences to which any patient will be subject. He must also try to orchestrate the impact of these experiences in a way that will be of maximum benefit to the patient. This decision-making process must inevitably be influenced by the clinician's beliefs with respect to how much patients will benefit from these various experiences. These beliefs can be viewed as a set of expectations or as an ideology derived from many sources. In the course of his training, a clinician reads, learns from teachers, and deals with a variety of clinical materials and situations. Out of these emerges that analgam of experience, faith, and knowledge upon which he can draw when a decision is to be made. While reports by Myers and Rosen¹ and by Rubenstein and Laswell² have touched on this issue, relatively little is known about the patterns of beliefs held by psychiatric clinicians. In a previous report³ we described residents' perceptions of the benefit derived from psychiatric hospitalization.In this study we attempt (1) to assess the beliefs of psychiatric residents regarding what aspects of hospital care benefit patients, (2) to measure these beliefs at the beginning and at the end of a period of clinical training and experience, and (3) to compare these general beliefs or stereotypes against more individualized judgments of what it is that patients actually do benefit from.     

De l'adolescent déficient mental qui pose des actes sexuels transgressifs

Although they are not very frequent, cases of sexual transgressions of mentally handicapped teenagers, which today are recognized and taken into account, are nonetheless preoccupying due to the question they pose as to the relation between cognitive limitation and the transgression of limits. Teenagers are sometimes allowed to transgress the natural laws as well as the rules that any society makes for the best possible socialization of all. Sexual transgressions of mentally handicapped teenagers are still far from our mental perceptions and representations. Certain young people express an alarming sexuality that leads to abuses or perversions; among these we will examine the mentally handicapped. Their situation is to be taken seriously without stigmatisation or predictions of a heavy “psychopathological career”. This article proposes to examine the general considerations related to the sexuality and psychoemotional development of mentally handicapped teenagers. In the light of these aspects we will then question what brings handicapped teenagers to commit sexual transgressions. We will examine responsibilities and, in some situations, the search for a “sexualised mothering” echoing a massive anguish. The article will then elaborate on a clinical case examining the “supporting factors” and the subjective position of the young person. The last part of the article is devoted to the groundwork of assumptions related to diagnostic and therapeutic responsibility. How do we evaluate? With which criteria? Who do we meet? Can we establish a forecast? The evaluation then leads to the treatment based on two poles, the first, psychoeducational, the second, psychotherapeutic. The treatment, in its first pole will accompany the individual in his life and his relations, particularly in the field of sexuality. It will then approach, among others, the questions about the legitimate needs and desires of persons, the desired, realistic and realizable applications that can be possible. The treatment's intention consists in leading the young person, within the limits of his or her potentialities, to choose the right object, to manage his/her phantasms from the point of view of respect of the other. The second pole's psychotherapeutic object is to meet the young person in his existential difficulties; the idea is to offer him/her his/her own place of development adapted in function of the handicap and centred on the “environment and associations” caused by the transgression of a sexual nature. Finally, the aim of this article is to bring the clinical cases of mentally handicapped teenagers in our field of perceptions, our representations, and our developments in terms of accompaniment.     

La clinique schizophrénique à l'épreuve des neurosciences sociales

Bringing to light cognitive disorders and neurofunctional patterns that are specific of mental illnesses should result in a new way to define and assess clinical signs. The recent advances in social cognition contribute to a better understanding of the clinical dimensions of schizophrenia. The cerebral patterns of activation associated with several components of the mental processes underpinning social behavior, mentalizing and communication have been determined using neuroimaging techniques. Here, we will focus on the attribution of mental states to others that involves particularly the medial prefrontal cortex within a complex network of brain regions. We hypothesize that this mental activity is a key feature of human communication. Experimental evidences show that schizophrenic patients having formal thought disorders exhibit impaired performances on mentalizing tasks. We argue that psychiatric assessment constitutes a communication situation that is appropriate to elicit such disorders. Following Hardy-Baylé et al. proposal, we show that it is possible to define efficient means to assess schizophrenic communication disorders by imposing specific conversational constraints to the patients during clinical interviews.     

Le signe du miroir : reflets cliniques et théoriques

Paul Abely (1927-1930) and then Delmas (1929) described in three articles published in French what came to be called the miiror sign. Sadly psychiatry sold out to'management and “stastical gibberish” so that essential clinical discoveries fell by the wayside… In this article - the sythesis of a longer piece of research - we try to show that the mirror sign is the clinical and theoretical validation of the mirror phase (or stage) as theorised by H. Wallon, J. Lacan and others. We have called upon the history of art to show that the mirror sign is the key to understanding what seperates neurosis from psychosis. G. Rodenbach and his “freind from the mirror” will accompany us and explain the very experience of “the mirror sign…”.     

Alliance thérapeutique et engagement : une réflexion sur l’éthique de la prise en charge des patients suicidants en psychothérapie psychanalytique

The ethical questions involved in the treatment of patients who have attempted suicide will be addressed here on the basis of two contradictory positions, which appear in codes of deontology. On one hand, we find individual freedom and protection of the person; on the other, professional secret and shared secret. The reflection, developed along the lines of psychoanalytical theory, is enriched by contributions from crisis management. It is illustrated by means of clinical situations taken from clinical practice in the domain of suicide prevention. What is revealed is the fact that suicide does not correspond, in the case of our patients, to the exercise of freedom and as a consequence, it requires us to intervene. Suicide attempts are often associated with pathologies in which we can find a life history marked by separations, abandonments and trauma, corresponding to a failure of the environment which the treatment must be careful not to reproduce. This implies that, between the contradictory terms evoked above, we make the choice of protection of the person and of shared secret. As concerns the analytically based psychotherapeutic framework, the guidelines of traditional neutrality for the analyst, whose value remains complete, must be redefined toward a more interventionist counter-transferential position.     

Présentation de l’Entretien Semi-structuré Multiregistres

Whereas instruments are available to diagnose various psychiatric disorders and to rate their severity, there is a lack of instruments to assess the phenomenology of these disorders, i.e., a set of mental phenomena that compose subjective experience. Our objective is to present a new type of psychopathological interview, aimed to study the phenomenology of mental activity. In developing the Assess_Mind, we tried to integrate within one single instrument the qualities of unstructured clinical interviews, such as openness to unexpected information, and the qualities of structured interviews, such as adequate psychometric properties. The basic principle of the Assess_Mind is to explore various “registers” of mental activity: affects, fears, desires, memories, and associations of ideas. This exploration is based on open, but standardized, questions. A rigorously defined algorithm for interviewing indicates which question is to be asked, dependent on the responses of the patient and on the chronological progression of the interview. After the interview is completed, a rating module comprising specific scales allows to assess clinical information that has been collected. We expect that the Assess_Mind will contribute to help clinicians to perform initial assessments of patients and to follow the course of their clinical state.     

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.     

Étude des liens entre sommeil et mémoire épisodique chez le sujet jeune et âgé, et dans la maladie d’Alzheimer

Introduction

A large body of evidence indicates that sleep favors memory consolidation.

State of the art

This process would occur, mainly during slow-wave sleep, by means of a dialogue between the hippocampus and neocortical areas. Low levels of acetylcholine and cortisol are also needed to favor the transfer of memory traces toward the neocortex, where they will be stored for the long-term.

Perspectives

The aim of this article is, first, to give an overview of studies conducted in young healthy subjects and underpinning the hypothesis that sleep is involved in memory consolidation. Then, we will investigate the potential links between changes in sleep architecture and episodic memory impairment in both aging and Alzheimer's disease. Finally, we will see how these results can affect clinical practice.

Conclusion

Sleep-dependent memory consolidation is impaired both in aging and Alzheimer's disease. These findings suggest the importance of taking into account sleep when assessing memory function in patients.     

La contingence cybernétique : un « surgissement » au service de l’inconscient ?

Cybernetics is a “science of government” whose necessity follows from our difficulty to understand and to be understood by a binary machine. Science has evolved, and so have machines, confronting us more and more with their contingency. Today, cybernetics is the instrument of an “Appearance/Emergence” sufficiently operational to bring us to attribute some powers to it that it actually does not possess. With this monograph on Simon's case, we will try to show that the cybernetic appearing is meant to mobilize the refrained desire of the subject. This paper has the aim to analyse how “virtual acts” can be constituted as some multiform expressions of a fantasy. Cybernetic contingency suggests then a “shivering” which would testify that it would be possible for the subject to be able to magically reinvent across it his relationship to the object. As a consequence, this lure seems to promote cybernetics to the rank of a support, susceptible of favouring the psychical elaboration. The case of Simon would therefore testify that cybernetics can be considered a clinical operator, whose function would define a transfer relation hardly obtained through classical therapy.     

Odor di femina / Horreur du féminin. Remarques sur le processus de sublimation

The sexual will always have to debate with the infantile drives; it is this very experience of the unconscious which we have to take into account. A clinical case will allow us to illustrate the difficulties met by a patient in his inability to access the feminine. Sexual differentiation and homosexual experience will be examined from the works of Proust, necessary for associative listening. Recent psychoanalytical works will at the same time throw light on the winding ways taken by some subjects, who, like Proust, will succeed in sublimating the feminine, whereas others will truly be unable to develop their capacities of symbolization and will orient themselves to some impasses, revealing thereby actual pathological processes.