Neuroimagerie de l’insight dans la schizophrénie : revue de la littérature

ObjectivesInsight in psychiatry has been defined and conceptualized in a number of ways but none of them was found to be self-explanatory. There has been an exponential rise in studies of insight, in part accelerated by the availability of several psychometric scales for measuring insight. Lack of insight has been associated in schizophrenia with low treatment adherence, a high number of relapses, increased number of hospital admissions, and subsequently poorer psychological and cognitive functioning. For this reason, there is considerable interest in understanding the underlying neural mechanisms of insight, which may have important implications for the development of future insight-oriented neuro-psychiatric treatment. Neuroimaging may be considered an important technique to help understand the anatomical, functional and metabolic neurocircuitry underlying poor insight in schizophrenia. Growing neuroimaging research provides evidence for underlying brain impairment in insight deficits in schizophrenia. In order to expose a panoramic view to the readers, this article reviews the neuroimaging studies conducted to date, which have investigated the neural bases of insight in schizophrenia.MethodsElectronic searches were performed in PubMed, PsycINFO, Sciencedirect and Web of Science databases, using the following keywords: Imaging; neuroimaging; Positron Emission Tomography (PET); spectroscopy; functional Magnetic Resonance Imaging (fMRI); structural Magnetic Resonance Imaging (MRI); Single Photon Emission Computed Tomography (SPECT); Voxel Based Morphometry (VBM); Diffusion Tensor Imaging (DTI); Computed Tomography (CT); Insight; schizophrenia; awareness of illness. Searches were also performed from the references of the systematic review articles on neurobiological correlates of insight in schizophrenia. Animal studies and single case reports were excluded. Twenty-five articles were selected for the present review. From these; 12 used structural MRI; 6 used VBM; 3 used fMRI; 2 used CT; 1 used DTI and 1 used VBM combined to DTI.ResultsThe search showed that studies in this area were published recently and that the neuroanatomic substrate of insight in schizophrenia has not yet been consolidated. This inconsistency could arise from the complex nature of insight and the use of a variety of insight assessments. Most of the studies analyzed in this review used structural neuroimaging techniques to assess brain abnormalities associated with poor insight. The functional neuroanatomy of insight has only recently been investigated and to our knowledge, there are only 3 studies that have examined brain activity with fMRI in relation to insight in schizophrenia.ConclusionThis review investigated the neural deficiencies underlying poor insight in schizophrenic patients. In spite of methodological differences among studies, results provide evidence of structural and functional brain abnormalities in frontal, parietal and temporal region related to insight deficits. Some studies have found a hemispheric asymmetry in relationship to poor in insight (the majority of brain abnormalities concern the right hemisphere). In addition, growing research indicated that the prefrontal cortex, particularly the dorsolateral prefrontal cortex, the anterior cingulated cortex, the insula, the precuneus and the cerebellum can also underlying insight in schizophrenia. It is interesting to mention that some authors have suggested that each dimension of insight can be specifically linked to certain brain structures. Taking together, data on the neuropsychological and neuroanatomical correlates of clinical insight suggested that lack of insight in schizophrenia could be conceived as a neurocognitive deficit, analogously to anosognosia in brain injury and dementia. On the contrary, to date, the neuroanatomical correlates of cognitive insight have been scarcely studied. Only two studies reported that Self-reflectiveness was positively related to gray matter volume of the right ventro-lateral prefrontal cortex, the BCIS composite index was positively correlated with total left hippocampal volume, and Self-certainty was inversely correlated with bilateral hippocampal volumes. However, it is important to note that neuroimaging research on cognitive insight in schizophrenia is in a preliminary, and the results on this are inconclusive. Further research is needed to better understand the causal relationships between brain abnormalities and degradation of insight in schizophrenia.     

Troubles de l’humeur et chirurgie de l’épilepsie : une revue de la littérature

AimsHistorically, there is a strong link between depression and epilepsy. Patients with epilepsy are four to five times more likely to develop a depressive syndrome. It seems that the link between epilepsy and depression is bidirectional. There is little data on mood disorders secondary to epilepsy surgery. The goal of epilepsy surgery is to reduce the number and frequency of attacks, which in turn would allow improvements in mood disorders and cognitive impairment.MethodsA systematic search of the international literature was performed using the bibliographic search engines PubMed and Embase. The following MESH terms were used: epilepsy surgery AND (depression OR depressive disorder OR mood disorder). We also used the “related articles” of PubMed, bibliography surveys, conference abstracts and Google Scholar to identify additional relevant papers.ResultsOf the 130 studies found by the systematic search, 112 are excluded because they did not take into account the mood disorders secondary to epilepsy surgery. Fifteen studies are included in this review of the literature with a case study. Depression is the psychopathological condition that is the most frequently studied. According to several studies, the prevalence of depression is approximately 30% with nearly 70% of cases diagnosed during the first three months following epilepsy surgery. The majority of patients presented depressive symptoms during the first 3 to 12 months after epilepsy surgery. In these studies, the risk of developing depression is correlated with the existence of previous depressive elements relative to the epilepsy surgery. A small number of studies reported cases of de novo depression. Studies have shown a correlation between very good to excellent control of epileptic seizures and a persistent improvement of mood disorders. It would seem that depressive symptoms post-surgery are more common when the surgical intervention concerns the temporal lobe and in particular mesial resections. There are only very few cases of maniac episodes. Hamid et al. showed an increased risk of suicide waning after the epilepsy surgery over a period of 5 years.ConclusionMood disorders are common psychiatric comorbidities in epilepsy surgery. The detection, prevention, and treatment of these symptoms in patients eligible for epilepsy surgery pose major challenges for psychiatrists and neurologists, requiring their close collaboration.     

Accompagner les professionnels de santé dans la révélation de l’erreur : de la révélation à soi à la révélation à l’autre

Error disclosure is now an ethical and professional obligation for health professionals and seeks to improve quality and safety in healthcare. Literature has highlighted the numerous benefits of error disclosure and several authors have described the options for handling this situation. However, it is not quite that simple to be honest and open and follow a protocol that instructs professionals to explain, support and apologise in situations where they are subject to criticism. While the many personal, institutional and social factors that hinder open disclosure have been identified, little attention has been paid to the obstacles associated with the psychological impact of disclosure, thereby limiting the debate on how professionals might be supported in their efforts to cope with error disclosure. The psychological impact of error on professionals is a well-established fact. Physicians are “second victims” likely to be emotionally affected by medical error. Emotional distress, anger, isolation, fear, guilt and shame can be intense, suggesting that, far from being an isolated act in professional practice, a medical error is a life event that modifies the psychological balance of a professional. Studies in the humanities have shown how work shapes individuals’ identities. The choice to heal and care for is indicative of the ideals related to professionals’ life histories, cultures, family models and representations of health and disease. Work and, more specifically, recognition at work from their peers, patients and relatives enables health professionals to support their ideals and establish a coherent identity, and to belong to a workgroup. The error foreshadows a rupture which plunges the professional and the team in a state of vulnerability that rules out the professional's or the team's possibility to be part of a process of disclosing the error. In these conditions, a policy of security of care also involves a guarantee of the caregiver's and the team's psychological security. The term psychological security was developed by the psychoanalysis who emphasised the individual's need to evolve in a “sufficiently good” protective environment that allows him/her to contain his/her emotions, while giving the individual the possibility to express and discuss them. This space implies a relation of trust between individuals. Trust refers to the idea that the individual can trust someone, it is based on the capacity to create relations. It is only through trust that the professional will be able to open him/herself to others and construct a space where the errors and the doubts that he/she has in the context of work are shared. But if trust is essential, it is also dangerous because it implies accepting the risk of being dependent on those considered as trustworthy and the risk that they will not live up to the professional's expectations. As a consequence, the professional will only have trust when he/she has evaluated the possibility of cooperation and more precisely, as stated by Hardin, a cooperation in which the professional's interests are “encapsulated interests”, in other words the interests of others. Therefore, this cooperation depends on each member of the team seeing his/her interests as being partially those of the others. Cooperation within a service reveals the relations of trust between the professionals and shows the relations of dependence that each one maintains with the others for the good administration of care. Thus the creation of relations of cooperation between the team members proves to be an important indicator to determine the professional's possibility to adhere to a process of disclosing the error. This approach shows that professionals must address multiple rather than single disclosures: to the self, and to others (colleagues, hierarchy, patients and families) who will mobilise specific knowledge, emotions and psychological defences. To avoid cases where disclosure takes on dimensions as tragic as the actual errors committed, it is important to pay attention to the psychic state of healthcare professionals by offering a space of free expression that enables them to better understand their feelings and gain a sense of support in order to restore their ideals and professional identities. Finally, it's important to emphasize that disclosure also depends on the preservation or restoration of the relations of cooperation within the team. Disclosure cannot be prescribed, it must emerge within a workgroup who allows the error to be thought over, communicated and shared. In this context, disclosure becomes a group rule that is known to all. A health professional who feels sufficiently supported might, in turn, support a patient and/or his/her relatives and engage in meaningful disclosure.     

De l’aménagement de la relation à la mobilisation thérapeutique des auteurs de violence sexuelle – À propos de l’Entretien Clinique de Lausanne

The therapist may have reactions of shock, rejection, fascination or defense when meeting with patients who are sex offenders, a response that is intuitively provoked by the patient's incarceration or the duty of care. Based on this observation, and on the clinical assessment questionnaires that are specifically developed for this population, this article presents the process of development and the theoretical foundations that were the basis for a new version of a clinical interview destined for sex offenders. This new framework for the clinical interview was created in relation to the three main functions of the questionnaire, in particular, for interpersonal mediation, investigation of psychological functioning and to identify therapeutic strategies. Thus, the goal of the Clinical Interview of Lausanne is to be an object for the mediation of the therapeutic relationship that can create a space where the manifestations of counter-transference by the therapist can be reduced, while still sufficiently respecting and containing the patient's subjectivity. In this way not only can the patient's psychological functioning in relation to his/her sexual offenses be assessed but also his/her disconnection and denial can be gradually resolved. Based on classic and recent psychoanalytical literature and the clinical experience with patients in the Service de Médecine et de Psychiatrie Pénitentiaires (SMPP) of the Centre Hospitalier Universitaire Vaudois (Switzerland), we present the hypotheses used to develop this new interview framework. This new version is in the process of being evaluated in a university research study to validate the theoretical elements presented in this article.     

Pourquoi la clinique de la douleur est-elle une clinique de la complexité ?

Easily understood on a daily basis as a signal for somatic disturbance, pain cannot be apprehended so easily. Definition and clinical of pain remind us of a key principle: there is no physical pain without psychological counterpart, and vice versa; and there is no psychological disorder without a physical correlation. However, the complex nature of the pain clinic does not stop there. We can distinguish is at least six dimensions allowing us to answer the uncertainty and the difficulty of its apprehension: through language, through culture, through representation, through personality organization, through pain's functions and other additional complications due to the confusion taking place in the designations, and through the different nosographic classifications. Pain is the limit of all knowledge, may it be medical, nursing, psychology, and invites us all to confront with other schools of thought and to work together to hear what is said and not said by the subject. In this singular clinic, the specificity of the psychologue and the importance of his view reside precisely in an appreciation of the psychic dynamics of the patient which interact with pain and which express itself within pain beyond somatic aspects.     

L’addictologie est-elle une spécialisation de la psychiatrie ?

The addictive behavior is defined as “a strong, long-lasting and excessive trend to make a commitment in behavior of production of pleasure or avoidance of negative affects” (A. Goodman). Epidemiological data show that patients receiving psychiatric care frequently have, besides the mental pathology for which they are followed, substance use disorders. It is thus particularly important to detect and to take care of the consumptions of psychoactive substances by the patients followed in psychiatry, not only to improve the forecast of the substance use disorder, prevent or handle the somatic complications, but also to improve the forecast of the associated psychiatric disorder. The integrated care seems the best adapted. We try to show it through a clinical illustration. In the discussion part, we try to highlight that addictology corresponds to a common, clinical, scientific and political approach of all the substance disorders and that this discipline becomes completely integrated into the field of psychiatry.     

À propos de l’expérience de la torture

The large influx of asylum seekers confronts public mental health services with the suffering resulting from extreme political violence. Among these patients, survivors of torture present a unique clinical profile of which clinicians should be made aware. While certain researchers have proposed useful concepts, the statements of witnesses and the writings of clinicians constitute the point of articulation between theory and practice. In this article, we will attempt to understand the ways in which torture results in psychosis (“a laboratory of psychosis”), notably through the specific and ambiguous role of the imaginary. A specific focus will be dedicated to the processes of humiliation, which illuminate a dialectic between the body and the mind, between the physical wounds and the long-lasting injuries inflicted on the soul; torture causing, intentionally, the possibility of a rupture between the ego and the ideal of the self. Finally, the article will critically examine the role of the therapist; so that clinicians will be able find a favorable resolution to the pathogenic conflicts involved.     

Le travail de la souffrance au cours d’une situation de handicap : le cas de la drépanocytose

ObjectiveSickle cell disease is the most common genetic disease in the world. Africa is the continent most affected by this disease, which is costly to manage for patients and their families. When not properly managed, it takes a huge toll in terms of suffering and disability on the sick person and their families. This article presents the results of a study which focused on the work of suffering, during a situation of disability, induced by this context of chronic and progressive pathology.Participants and methodOf the 12 patients solicited, 3 agreed to participate in this research. These 3 participants, whose ages ranged from 18 to 27 years, were interviewed in a hospital in Yaoundé. The data were collected via a clinical research interview recorded by a dictaphone. These anonymous data were subjected to a logical-semantic content analysis.ResultsThe analysis and the interpretation of data allowed us to observe that the work of suffering in these three participants takes on various aspects as heterogeneous as they are spectacular, made up of neurotic and manic arrangements, of conducts centered on the body or of theoretical constructions elaborated around the illness, the handicap and/or the filiation. The subjects powerless in the face of the chronicity and disabling nature of sickle cell disease are in a permanent process of searching for meaning concerning the disease and, of course, themselves as people affected by this disease. This permanent quest for meaning makes them more active against the disease and less powerless against it.ConclusionThe work of suffering, as put forward by the patients, can be thought of, therefore, as a manifestation of the global process of sexualization that phenomenological and psychoanalytical theories deal with. It opens on a redistribution of the libido, a rearrangement of the relation to the disease and the handicap. The position of narcissistic withdrawal which characterizes the situation of handicap, and the somatic attack is abandoned in favor of an effort of objectal reinvestment which the subject uses to get out of a handicapping position made of passivity, abandonment to the medical body, assignment to a stigmatizing status of sick or unfit. For the practitioner who works with patients, these results suggest various practical and therapeutic implications.     

Applications de la réalité virtuelle en psychiatrie légale : la perspective de l’autorégulation comme cadre théorique

IntroductionForensic psychiatry is the field whose expertise is the assessment and treatment of offending behaviours, in particular when offenses are related to mental illness. An underlying question for all etiological models concerns the manner in which an individual's behaviours are organized. Specifically, it becomes crucial to understand how certain individuals come to display maladaptive behaviours in a given environment, especially when considering issues such as offenders’ responsibility and their ability to change their behaviours.Virtual realityThanks to its ability to generate specific environments, associated with a high experimental control on generated simulations, virtual reality is gaining recognition in forensic psychiatry. Virtual reality has generated promising research data and may turn out to be a remarkable clinical tool in the near future. While research has increased, a conceptual work about its theoretical underpinnings is still lacking. However, no important benefit should be expected from the introduction of a new tool (as innovative as virtual reality) without an explicit and heuristic theoretical framework capable of clarifying its benefits in forensic psychiatry.ObjectivesOur paper introduces self-regulation perspective as the most suitable theoretical framework for virtual reality in forensic psychiatry. It will be argued that virtual reality does not solely help to increase ecological validity. However, it does allow one to grant access to an improved understanding of violent offending behaviours by probing into the underlying mechanisms involved in the self-regulation of behaviours in a dynamical environment. Illustrations are given as well as a discussion regarding perspectives in the use of virtual reality in forensic psychiatry.     

De l’aliénation mentale de l’enfant et de l’adolescent à la pédopsychiatrie dans les communications à la Société Médico-Psychologique de 1852 à 1937

In 1848, the Société Médico-Psychologique was founded. Its aims is to promote the study and improvement of mental pathology. During the 19th century, François Arnaud (1858–1927), Claude-Etienne Bourdin (1815–1886), Michel Catsaras (1860–1939), Louis Delasiauve (1804–1893), Eugène Dally (1833–1887), Jules Fournet (1812–1888), Paul Garnier (1848–1905), Valentin Magnan (1835–1916), Jacques-Joseph Moreau De Tours (1805–1884), Emmanuel Régis (1855–1918), Paul Sollier (1861–1933), Edouard Toulouse (1865–1947), Auguste Voisin (1829–1898) and Jules Voisin (1844–1920) were the alienists or not, French or foreigners who succeeded at the chair of the Société Médico-Psychologique. This later presented observations of children or teenagers. The communications and discussions but also the issues raised by the alienists, neuro-psychiatrists then child psychiatrists will contribute to the reflections of members of the Société Médico-Psychologique over the course of the last century. But, they also forced us to take a more perceptive look at the child's mental health. Its communications and their authors belong to their time and to a time or even a place where they emerged. Apart from to looking into the topics pursued (deficiency, dementia praecox, epidemic encephalitis, autism, etc.) concerning the infantojuvenile psychiatry, we will carry out a work of communications contextualization focused on the child's mental health at the Société Médico-Psychologique during 170 years.     

La place de la compréhension des proverbes et des métaphores dans la compréhension des troubles du cours de la pensée dans la schizophrénie : apport de l’évaluation clinique,de l’imagerie cérébrale fonctionnelle et de la neurophysiologie

According to Bleuler (1911), language impairments were indicative of thought disorders, a fundamental feature of schizophrenia. The objectives of the present review are twofold: (1) to present the clinical interest of the use of the tests of proverbs and metaphors comprehension for the evaluation of the characteristics of thought disorders in schizophrenia, and to highlight the heterogeneity of the forms of their interpretations; (2) to present the results from neuroimaging and neurophysiological studies of metaphor comprehension in order to identify the neurocognitive mechanisms underlying metaphorical language comprehension of patients with schizophrenic disorders. Results from the reviewed clinical applications of proverbs tests showed that thought disorders in individuals with schizophrenia are illustrated by different forms of proverb interpretations: literal, concrete, idiosyncratic, over-inclusiveness and unconventional. Results from the reviewed brain imaging and neurophysiological studies showed that these different forms of figurative misinterpretations may be related to different neurocognitive mechanisms: concreteness appears to be related to the dysfunction of the left inferior frontal gyrus and inverted brain lateralization during metaphor processing in individuals with schizophrenia compared to healthy individuals. During novel metaphor comprehension, which is highly effortful, individuals with schizophrenia, relative to controls, demonstrate increased activation of the right precuneus, a region that mediates complex and highly integrated functions including retrieval of episodic memory and mental imagery. These results may suggest that individuals with schizophrenia use mental imagery to support comprehension of both literal and metaphoric language. Furthermore, it was demonstrated that over-inclusive thinking, which is exhibited by individuals with schizophrenia during figurative language comprehension, could be related to very early right hemispheric hyper-activation (when a left early activation is expected) and to reduced bilateral brain activity during semantic processing. Such as reversed brain activation may explain why the individuals with schizophrenia are relatively over reliant on early-stage coarse or large semantic processing and may be prone to form meanings that are idiosyncratic and highly unconventional.