Sur l’ambiguïté du négativisme

This paper is a clinical contribution to the problem of schizophrenic negativism. The author tries to highlight the ambiguity of this symptom, because both its semiological acceptation and his importance in schizophrenic symptomatology are not properly qualified. The study of its clinical manifestations leads to call into question both its accepted meaning and its interpretation. While most authors seem to agree that negativistic behavior is an effect of the withdrawal of object love and seems therefore to reinforce the autistic position of schizophrenic patient, the author underlines what is left unexplained by such theories: the common alternation between states of negativism and states of complete submission to an all-powerful object. This frequent reversal of the sign of the object relation shows that negativism could be precisely understood as an attempt to re-establish an object cathexis, that is to say, an attempt to heal.     

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.     

La pensée et le langage par le corps dans la schizophrénie

Connections between body and psyche are regularly studied in the field of psychosis. One of the reasons of that recurrence is the fact that schizophrenic psychosis deconstructs the discursive system and exposes its bodily roots. In the first part of this paper, we remind several authors (Dolto, Pankow, Aulagnier, Golse, Delion, Piaget, Stern i.e.), whose works are showing how the mind develops on the basis of sense - and bodily experiences. In the second part, we examine the specificity of the schizophrenia as regression to the autoerotism and we mention Freud's idea of the “organ's language”. The organ's language represents the use of bodily symbols into the discourse; those symbols have to be interpreted like dreams. Finally, two clinical examples illustrate those elements. We examine the idea that, even if the nosographic category “schizophrenia” has not necessarily to be defended, there is perhaps a common clinical feature defined by the place of the body in the discourse.     

Mortalité et surmortalité dans la schizophrénie

The aim of the present communication is to present an overview on mortality in schizophrenic patients. Recent meta-analyses have confirmed high rates of mortality in schizophrenic patients and, notably, the gap observed in the last three decades between mortality in the general population and that of schizophrenic patients. In this population mortality rates due to non-natural causes, essentially suicide, are 12 times higher than that of the general population, natural causes of mortality being due to cardiovascular and respiratory diseases. Atypical antipsychotics have been incriminated in the high rate of mortality among schizophrenic patients. Prevention was focused firstly on a decrease of the risk of suicide and secondly on poor living habits (smoking, obesity). The importance of a regular follow-up of the somatic health of schizophrenic patients was discussed.     

Étude des représentations sociales de la schizophrénie dans la population générale et dans une population de patients schizophrènes

This study aims to compare social representations of schizophrenia in a sample of schizophrenics patients and in the general population. This question is of considerable interest in clinical practice and in psychosocial intervention. On the one hand, most of the schizophrenics patients have been informed about their diagnosis. On the other hand it is well known that stigmatisation attached to the labeling of schizophrenia has major repercussions on the acceptation of the diagnosis for the patient and his family, the compliance to treatment and the quality of life. Understanding social representations of schizophrenia in a sample of schizophrenics may be useful in adapting psychoeducation techniques and preventing relapses. We have investigated these reprentations in a sample of 20 schizophrenics who were informed of their diagnosis and in a 20 matched sample in the general population. We have excluded the persons who had a previous contact with a schizophrenic. Results show that medical representations of the trouble occur in general population, which can be considered as a positive evolution of the representation of schizophrenic people who are considered as ill persons rather than just “mad”. With regard to stigmatising representations, it is surprising to note that schizophrenics and the general population share the same representations. We hypothesize that this attitude in schizophrenics may result from an internalization of the supposed stigmatisation about their illness.     

Hypothermie aux antipsychotiques : particularités chez le sujet âgé souffrant de schizophrénie

Hypothermia - an adverse drug reaction of antipsychotic drug use potentially severe - seems less well-known than the hyperthermic effects (for example, malignant neuroleptic syndrome) and thus underdiagnosed. Thermoregulation in elderly can be altered. Additionally, some patients suffering from schizophrenia are not able to control their own environment or physical status. Thus, risk factors for hypothermia must be identified and frequent measurements of body temperature must be performed in order to detect developing hypothermia. A case report of hypothermia in a 69 years old patient suffering from schizophrenia is published with this review.     

Les spécificités de la schizophrénie à début pendant l'enfance : aspects cliniques et conséquences nosographiques

Should child-onset schizophrenia be considered as included in schizophrenia or should it not? The authors have reviewed available clinical and nosographic data and this has led them to answer positively. They underline the specificities of clinical presentation and of diagnostic criteria in children.     

Le délire schizophrénique, entre approche objective et expérience subjective

The issue of delusion, both in current definitions and neurocognitive models, implies a wrong belief on objective world. Moreover, the presence of bizarre delusions is considered a sufficient clinical criterion of schizophrenia in the DSM-IV. Given the importance of this psychopathological concept, there is a surprising shortage of empirical and conceptual studies. Following a phenomenological approach, one may consider the notion of bizarreness as extending beyond the confines of delusion, as a general experiential dimension relevant to self-awareness, and attunement to others and the world.     

Stimulation magnétique transcrânienne répétée (rTMS) et symptômes négatifs de la schizophrénie

Purpose

The author has endeavoured to present a qualitative review of current data on the interest of repetitive Transcranial Magnetic Stimulation (rTMS) in the treatment of negative symptoms of schizophrenia, its therapeutic impact and processes that underlie it.

Method

The method consisted in a review of the literature by an extensive consultation of the computerized Medline database.

Results

Despite the small number of controlled studies and the small sample sizes, rTMS appears to be an effective therapeutic method in the treatment of negative symptoms of schizophrenia and also helps understanding the patho-physiologic processes that underlie them (hypofrontality, dopamine hypothesis and responsiveness of the HPA axis).

Conclusion

Before any conclusion may be reached about the effectiveness of this new technology more studies are required using larger parameters for active treatment and optimal placebos (alpha-TMS at least 110 % of the motor threshold, focused on the hypo-active area).     

Sur la question de l’ironie et de la mort dans la schizophrénie : le cas Hervé

Using the case of Hervé as a basis for his study, the author has emphasized the importance of the subjective attitude that is inherent to schizophrenic irony. This irony can be clinically detected in negativistic remarks, in the schizophrenic state of ambivalence, in mannerism, and it appears to be both a means of defence against a reality that is too close - the reality of death, for example - but also as a solution whereby the Other is kept at a “reasonable” distance, so that it does not pose a threat. This “private language” should borne in mind, and the therapist should react accordingly if he does not wish to become involved in the dual (and duel) relationship that the schizophrenic patient might attempt to introduce during treatment sessions.     

Un diagnostic méconnu : la schizophrénie chez l’enfant

Childhood-onset schizophrenia is rare: its prevalence is about 50 times lower than the one observed in adulthood. It is also frequently an unrecognized disorder, notably because its clinical aspect varies with age and intellectual functioning. Differential diagnosis with affective psychoses is also difficult because the high frequency of comorbid disorders. Its consequences on the child social functioning are nevertheless significant: schizophrenia leads to severe behavioral disorders, requiring more often the child hospitalization in a psychiatric department. Outcome studies suggest a continuity in the diagnosis of schizophrenia between childhood and adulthood, and show that its prognosis, although highly varying, is generally somewhat poor. All these data highlight the need for an early diagnosis, in order to start the treatment as precociously as possible.     

Langage et schizophrénie : l’intention en question

Language disorders in schizophrenia are of crucial importance for the social relationships and the living experience of schizophrenic patients. With notions such as context, intention and theory of mind, research devoted to language in schizophrenia is moving toward effective conditions of language production in this pathology, and to more specific troubles in the schizophrenic speech. Nevertheless, the usual cognitive and experimental paradigms ignore some of the fundamental dimensions in language: intentionality and inter-subjectivity. In a previous study, we stressed the importance of the social and inter-subjective bases of language, with a particular look at Vygotski’s works on schizophrenic speech and thinking. In the present paper, we have analysed more precisely the notion of intention in schizophrenic speech, and compared its meaning relative to cognitivism and phenomenology. Concerning cognitivism, Frith’s neuropsychological model is presented here paying specific attention to the main hypothesis: a deficit in the monitoring of intention. This deficit is supposed to affect both one’s intention (as in hallucination) and the ability to infer another’s intentions. Nevertheless, our core idea is the following: the intention, as conceptualized by cognitivists, can only be thought and studied by the means of a preliminary objectification, instead of by a foundation of subjectivity as in phenomenology. This particular point leads us to reconsider speech troubles in schizophrenia in the light of the subjective and lived side of language in this pathology. More precisely we have argued that language disorders in schizophrenia could be considered in the light of concepts such as empathy, conversion of meaning, and the splitting of intentionality itself. Indeed, language and intentionality in communication, as conceptualized by Husserl, cannot be reduced to mere transmitting of information. Two components are required: intention of signification, and intention of communication itself. These two dimensions lead, in each speech act, to a conversion from one side to another, between thought and language. In schizophrenia, this splitting of intentionality and the conversion of meaning could be extremely crucial to account for the inner links between the schizophrenic patient and his own speech, as we have tried to explain. In the same way, we have argued that the theory of mind, frequently invoked in schizophrenia, is here rather considered as a part of a more important notion, namely the notion of empathy. This point, as the previous one, cannot be reduced to a mere cognitive process by first involving the body in the process of communication. We have concluded by arguing that works on schizophrenic language should not ignore the subjectivity of intentionality, as well as the importance of the body dimension in inter-subjectivity, in order to obtain useful insights into the lived world of schizophrenic patients.     

Enquête sur la perception de l'observance dans la schizophrénie (EPOS)

From the patient's viewpoint, good quality compliance supposes a good relationship with his/her doctor; this relationship is directly linked to the therapist's heeding and interest shown to the patient, and not to the patient's symptoms alone. If individual motivation plays an important part at the outset, it will nevertheless be seriously influenced by the relationship between the doctor and his/her patient. It is one of the rare factors for which a positive correlation with compliance can be observed, as shown by practically all medical psychology research. To these well-known classical medical notions correspond average values of non-compliance, which may vary widely according to those concerned. These data are proof of the wide gap existing between what is expected and what is actually achieved. This discrepancy is felt by the patient as well as by his/her therapist, and involves many other factors linked to culture, to medical and religious background, medical anthropology, and the real or supposed proprieties of the Pharmakon. Compliance to antipsychotic medication in schizophrenia continues to be a significant and challenging question in terms of its prevalence as well as its significant impact on the rate of relapse and resource utilization. Most of the published reports, here again, confirm the significant contribution of attitudes towards treatment and their impact on adherence and clinical outcomes. Negative critical attitudes can be enduring and may require specific targeted behavioural interventions in addition to optimization of medication-based treatment. Systematic reviews and a meta-analysis of various approaches to enhance compliance with medication in schizophrenia have yielded inconsistent results, reflecting the many shortcomings of the studies included in the review and the meta-analysis. Most of the interventions tend to be rather complex and resource-intensive. One of the consistent findings has been the lack of impact of approaches based on psycho-education alone, without additional behavioural, family and economic support. Not only does the content of any compliance intervention approach seem to be important, but the time-course of outcome evaluation is also relevant. The need for “booster therapy” seems to be important for maintaining some of the beneficial effects of adherence-improvement therapies. Although second-generation anti-psychotics are subjectively better tolerated than first-generation anti-psychotics, their impact on compliance behaviour and improved attitudes towards treatment has not yet been systematically demonstrated in well-controlled studies. Similarly, differences between individual second-generation antipsychotic medications, in terms of impact on compliance behaviour, need to be explored. Our study aims at synthesizing the most recent data concerning this issue which is still at the core of numerous debates and hardly ever tackled in French language literature. Thanks to the summary of these data and to the testimony of 380 schizophrenic patients, we shall try to have a better understanding of what happens between the patient and his/her therapists from a relationships viewpoint.     

Déficits des fonctions exécutives dans la schizophrénie selon les dimensions positive, négative et de désorganisation

The aim of this study was to examine whether executive deficits underlie positive, negative and disorganisation of schizophrenia. The sample comprised 34 patients (30 males, 4 females) diagnosed with DSM-IV criteria (mean age = 35 ± 9.5 years; mean duration of illness since first psychotic symptoms = 10.2 ± 7 years; mean years of education = 11.7 ± 2.6). Evaluation of patients was performed after achieved sufficient remission (clinically stable for 4 weeks at least, no depressive symptoms at moment of cognitive testing and no medication change during the three last weeks). Symptom dimensions were evaluated using items drawn from the Positive And Negative Symptoms Scale (PANSS). The Negative factor comprised N1 (blunted affect), N2 (emotional withdrawal), N3 (poor contact), N4 (passive, apathetic), N6 (lack of spontaneity), G7 (stereotyped thinking) and G16 (active social avoidance). The Positive factor comprised P1 (delusions), P3 (hallucinatory behaviour), P5 (grandiosity), P6 (suspiciousness) and G9 (unusual thought content). The Disorganisation factor comprised P2 (conceptual disorganisation), N5 (difficulty in abstract thinking), G10 (disorientation) and G11 (poor attention). The mean total PANSS score was 63.3 ± 16 (mean of positive score = 14.3 ± 4.7; mean of negative score = 18.1 ± 6.3; mean of general score = 30.9 ± 8.5). Executive functions were examined through the Wisconsin Card Sorting Test (WCST), the Hayling Test (Tunisian version) and two semantic verbal fluency tasks (simple with one category “animals” and alternating with two categories “fruits and clothes”). Partial correlations between syndrome scores and cognitive scores were examined while holding the effects of other symptoms, age and education level constant. Severity of disorganisation symptoms correlated with high number of perseverative errors (r = 0.47, P < 0.05) and total errors in the WCST (r = 0.37, P < 0.05) and with reduced score of alternating semantic verbal fluency (r = -0.39, P < 0.05). Severity of both negative and positive dimensions uncorrelated with performance of any of the executive tasks. Also, scores of the Hayling Test (time part B minus time part A; errors part B) and semantic simple verbal fluency (total of correct words) were uncorrelated with symptoms. The present study provides evidence that disorganisation dimension of the PANSS correlates specifically with impaired cognitive flexibility as reflected by high number of perseveration in the WCST and reduced set-shifting in semantic alternating verbal fluency.