Un changement de paradigme au sein du DSM ? Le cas de la personnalité borderline à l’adolescence

The diagnosis of Borderline Personality Disorder in adolescence has recently been included into the Diagnostic and Statistical Manual (1994) and clinical studies showed that this disorder could be diagnosed reliably with this definition. Although the legitimacy of its place in the DSM is questioned. While DSM nosological approach assume to ensure that psychiatric diagnoses are reliable, it appears that other determinants are decisive in the process of legitimation of this pathology. Indeed, international literature shows that borderline personality disorder in adolescence has a weak construct validity that questioned the validity of this diagnosis in the context of Evidence Based Medicine. For the first time, this argument leads to a possible withdrawal of the category in the next version of the DSM. Authors hypothesize that this could be analyzed as a paradigm shift in the DSM. The issue is no longer the reliability produced by the diagnosis in a “paradigm of objectivity,” but its construct validity in a “paradigm of validity.” This would result in an increased visibility of the diagnostic utility in the nosological categorization.     

Mesurer la sévérité des problèmes des patients et leur évolution dans un secteur psychiatrique : une étude sur le terrain du Health of Nation Outcome Scales en français (HoNOS-F)

The Health of Nation Outcome Scales (HoNOS-F) are designed to measure severity of a large range of problems of psychiatric patients and their evolution. Behaviour, handicap, symptoms and social problems are considered. The aim of this field study is to examine the ability of the HoNOS-F to predict access to psychiatric care, use of services and mental health outcomes. 533 patients were evaluated in Lausanne in- and outpatient services. Results show a good acceptation of scales by clinicians ; grouping of problem profiles that suppose specific needs for some populations of patients ; differentiation of access to care through the number and severity of problems ; sensitivity to problems outcomes for inpatient care. Limitations of HoNOS are low tolerance to measurement errors, with only one scale for each dimension, and low progression margin when measuring change of moderate problems, particularly in outpatient psychiatric care.     

Le deuil,des signes à l’expérience. Réflexions sur la norme et le vécu de la personne endeuillée à l’heure de la classification du deuil compliqué

A growing body of literature underlines the existence of a specific nosographic category: the Prolonged Grief Disorder (PGD, Prigerson et al., 2009 [2]). This disorder might be included in the next DSM. Beyond the reflection of the relevance of such an inclusion, we question the potential gap between the objective scientific evaluation of any pathological grief, and the subjective appreciation of the grief experience. Could the intimacy of this experience, and sometimes the intimacy of the pathology correspond with the objective assessment? The identification of the quality of the grief reactions, of their “normality”, or complicated nature, soaks the specialized literature, but also the entire society through media, cinema and arts in general. These qualification and potential normalization are yet to be explored, depending on whether they proceed from a professional, or from the bereaved individual. To study this gap between the objective evaluation and the intimacy of grief, it might be necessary to first understand what happens deep inside oneself when a loved one is lost. This understanding is grounded on a phenomenological approach, in connection with recent psychological works in the bereavement field. The existing tools regarding the evaluation of the complicated grief are discussed, to bring out their limits and impact on the psychopathologic theory. This analysis helps us conceive the possibility of an articulation between psychopathological theories and phenomenological conceptualization of death, norms, and intimacy. The irreducible nature of the subjective experience with regard to the attempts of objectivation emerges at the end of this reflection.     

Des bêtises de l’enfant aux troubles du comportement

According to a model of reading and understanding of children foolishness, which recognizes a game side and a antisocial side, and from the experience of a public consultation addressed to “children who make foolishness”, we define the notion of “foolishness-symptom” which akin to behavior disorders of the child, like they are characterized in the standard psychiatric classifications. This concept is referred to a clinic with transgressive events and the use of action, thus indicating an overexpression of antisocial side compared to the game side. This last observation leads us, in the light of psychoanalytic theories about the emotional development of children, to consider the notion of “game” and realize its importance in dealing psychologically with the child.     

Remarques épistémologiques sur l’exploration cérébrale : à propos de l’IRM et l’EEG

Methods for in vivo brain investigation (MRI, EEG) daily contribute to the diagnosis in neurological or psychiatric diseases. For this reason, physicians who use them pay generally a very poor attention to their essential features and to the consequences of their properties. These consequences concern our conceptions about brain structure and its functioning. MRI is related to a visualist conception of medicine, and both notion spatial configuration and localization are central in this conception. By contrast, EEG appearance is organized in temporality and emphasizes the incredible plasticity and lability of brain processes as well as the cerebral suffering and death. So clear differences conduct to an epistemological thought about the nature of medical interpretation of EEG and MRI results.     

Spécificités des crises d’épilepsie chez le sujet âgé : proposition d’un score électro-radioclinique d’orientation

Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis… and because there are multiple differential diagnoses (syncope, transient ischemic attack, transient global amnesia…). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.     

Dysphasie et/ou psychose ?

Many children are diagnosticated psychotics because they present language disorders. A delay of language is often evocated. This work attempts to interrogate specific language disorders from dysphasia in comparison with psychotics language disorders. According to international classifications, dysphasia excludes psychotics disorders (or “pervasive developmental disorders”). Therefore, this point of view doesn’t make unanimity. After a short French overview on this subject, we’ll see that a partition can be clearly distinguished between dysphasia and psychosis. The only symptomatology from language disorders can’t be an assured guide for the diagnostic. At the end, we’ll bring a conceptual bridge between dysphasia and “debility” according to specific meaning gived by J. Lacan.     

Capacités d’adaptation et fonctionnement défensif dans les troubles du comportement alimentaire. Étude structurale comparée basée sur le codage optimal

Objectives

Considering classic and current theories relevant to stress and coping, we reflect on the interaction between dysfunctional coping strategies influenced by defensive functioning and the launching, respectively maintaining of eating disorders (ED). Our objectives are to verify: (a) if the coping strategies of patients with anorexia and bulimia nervosa are different from those of young women without a current eating disorder, (b) what are the latent dimensions underlying the privileged way of coping associated with both anorexia nervosa and bulimia nervosa. The latent dimensions can create meaning in a disparate distribution of variables and objects by analyzing their configuration in a two or three dimensional space.

Patients and methods

We present a comparative study between patients suffering from anorexia or bulimia nervosa (Total n = 41) and a control group of female students non affected by eating disorders. The mean age was 19.95 years (SD = 3.73) in women diagnosed with anorexia nervosa, 19.81 years (SD = 2.33) in women diagnosed with bulimia nervosa and 20.88 (SD 1.40) in women without a current eating disorder. The study is based on the SVF 120 (Stressverarbeitungsfragebogen, Stress Coping Questionnaire, by Janke, Erdmann and Kallus, 1997) and the MDBF (Multidimensionales Befindlichkeitsfragebogen, Multidimensional State Questionnaire, by Steyer et al., in 1997).

Results

The means of the three subgroups are compared with the help of Univariate Anovas, preferential coping strategies associated to anorexia and bulimia nervosa are studied through Logistic Regressions, whereas the comparative structural exploration is based on the Non Linear Principal Components Analysis (PRINCALS). We observe that our two clinical subgroups (patients with anorexia and patients with bulimia) do not try to cope with stress by implementing active strategies (problem-oriented coping strategies), that is to say, seeking a solution or planning stages of the solution. Instead, they tend to get overwhelmed by the unpleasant situation. Coping strategies based on satisfaction seeking (β = 0.87) and positive reframing (β = −0.33) make a significant contribution to prevalent coping strategies in women with anorexia nervosa, whereas change into triviality (β = 0.87), isolation (β = 0.50), use of psychotropic medications (β = 0.43), denial of responsibility (β = −0.33) as well as diversion (β = −0.46) are predictors of coping manners in women with bulimia nervosa. Whereas the general features of latent dimensions were similar in all three groups, these dimensions were nuanced differently according to the psychopathological profile. One dimension was focused on an active handling of the situation as opposed to passivity, another was focused on restoring narcissism as opposed to a sense of humiliation and self-degradation and a third one was focused on the reinterpretation of reality (cognitive restructuring) as opposed to other types of strategies. This interpretation of the meaning of the latent dimensions seems plausible at the light of recent theories of eating disorders, as well as at the light of the current state-of-the-art.

Conclusions

Our multidimensional comparative study allowed us to identify some specific profiles, concerning the use of coping strategies, while also showing some similarities between clinical subgroups and control group. The analysis of the results shows that the general assumption saying that patients suffering from eating disorders use above all emotion-oriented coping strategies is too categorical. The data of the study point rather to a dimensional approach of psychopathology. The interaction between the fact of changing coping strategies and maintaining, respectively abandoning pathological conducts should be studied through a prospective longitudinal study accompanying psychotherapeutic interventions.     

Le comportement d’observance des patients atteints de schizophrénie : impact du diagnostic et du traitement. Analyse phénoménologique de trois attitudes

The aim of this study is to analyze the different characteristics of three patient clusters defined according to their relationship toward their disease. Based on the 40 patients collected data, we were able to identify three patient groups: 23 patients were qualified as “active” as they showed a more collaborative participation in career venues and higher acceptance of comprehensive treatment plans (57.5 %). Seven patients were qualified as “passive” as they had less autonomy and therefore were less concerned with the treatment modalities (17.5 %). Ten patients were qualified “ambivalent” as they had a more conflicted understanding and insight of their disease, of their careers and their family dynamics (25 %). “Active” patients had a higher level of understanding of their diagnosis, were more aware of prescribed treatments and of the negative consequences of poor compliance. “Passive” patients were more willing to learn about their diagnosis, while having a significantly lower baseline knowledge of it, were more often prescribed an atypical neuroleptic and reported higher satisfaction with their medical treatment. “Ambivalent” patients had a higher propensity for disagreeing with the negative consequences of their disease, were more often prescribed two classic neuroleptics, reported higher rate of self-discontinuation of treatment and were overall less satisfied with their treatment. It appears that the disagreement with the understanding of the disease and its seriousness has a major impact on the acceptance of the treatment modalities and leads to reduced adherence to treatment plan.