Comment penser l’évaluation des psychothérapies dans le contexte général de l’évaluation des thérapeutiques ?

The methodology of evaluation of medicinal products is well established. Is this also the case with psychotherapies? The opinions are divided. Four key methodological points related to the evaluation of therapeutics will be successively approached in a first time: what are the therapeutics that will be compared? Who are the patients included? How to evaluate the effectiveness of the treatments? How to ensure the comparability of the treatments groups? We will see that the evaluation of medicinal products or psychotherapies remain basically on the same methodology. We will see in a conclusion that the evaluation of medical treatments is presently in a kind of revolution, with a decline of the role of randomized controlled trials. Curiously, this revolution has been anticipated by certain methodologies used in the evaluation of psychotherapies.     

Considérations théoriques sur la dynamique des agressions sexuelles sérielles,le paradigme mélancolique et son processus identificatoire en négatif comme piste de réflexion ?

Objectives

This paper intended to offer a theoretical model about the psychodynamic at stake during serial sexual offenses. We first focused our attention on a marginal violent act, cannibalism, in order to highlight some aspects of the identifying process at work within it. As put by Meloy, the act would look like a primitive psychotic attempt to “master” internalization failures at early stage of the psychological development. We then, extended our hypothesis to sexual serial acts, as we think that it is not an ingested body part, but the internalization of the interaction between the offender and the victim that truly matters, a narcissistic triumph felt by the offender that would provide a sense of completeness.

Methods

Due to considerable difficulties in accessing those kinds of data in France, we could not develop an empirical study based on enough patients to be a scientifically valid model. Our model will thus be a theoretical and illustrative one, with case studies of individuals met throughout our clinical and forensic experience.

Results

The melancholia paradigm was used to illustrate the identifying process, and we made a parallel with antisocial behaviors found in psychopathy, the latter being characterized by a failure of internalizations, and use of violent acting outs. Those violent behaviors could be seen as a way to stem a psychotic breakdown and preserve the Grandiose-Self structure of personality. Where the melancholic would take his ego as an object dedicated to be sacrificed in order to preserve the environment of a catastrophe, the “psychopathic” individual would use a self-object within the environment as a sacrifice to preserve his own Grandiosity.

Conclusions

This model will serve as an illustrative way of thinking the quality of the interaction that happens during sexual serial offenses. Further researches are needed in this field in France.     

Classification des styles de coping dans une population d’anciens combattants âgés

The purpose of this study was to propose a classification of coping styles reported by veterans, 50 years after the actual events, compared with a late manifestation of the posttraumatic stress disorder (PTSD). We have evaluated the coping strategies using the French version of the situational version of the Brief COPE and PTSD using the French version of the posttraumatic checklist scale (PCLS). The subjects were 223 veterans of the Algeria war who completed these questionnaires as part of a broader investigation. Our results confirm general outcomes about coping strategies in veterans. They show a five-factor model of the 14 saturating strategies and explaining 67.5% of the total variance. Strategies have been grouped into active strategies focused on problem solving, avoidance strategies focused on emotions, active strategies focused on the sharing of emotions, avoidance of factors that affect confronting and humour. Furthermore, strategies used by veterans to cope with difficulties encountered decades ago may act as mediators of consequences of a traumatic event. Only two strategies (positive reformulation and coping restricted) show a lack of positive correlation with the recurrence of PTSD and, as such, suggest that they were most effective in responding to war experienced events. The Brief COPE could be consider as a tool for measuring adaptation to traumatic events among veterans, and more generally in the elderly reporting potentially traumatic events, witch can contribute to a suspicion of PTSD from the score 52.     

Ressenti des sages-femmes dans la prise en charge en suites de couche des patientes avec troubles psychiques sévères : une analyse qualitative

BackgroundA significant proportion of women with Severe Mental Illness (SMI) will become mothers during their reproductive life. These pregnancies are, however, more at risk of psychiatric, obstetrical and neonatal complications (increased risks of post-partum depression, relapse, suicide, gestational diabetes, placental abnormalities or low birth weight). Midwives often feel isolated and resourceless when taking care of these women. Specialized units such as mother-infant psychiatric units or the Transversal Unit of Perinatal Care (UTAP) in the Grenoble Alpes University Hospital (CHUGA) enhance the coordination between psychiatric and obstetrical teams and have shown effectiveness in improving maternal and child outcomes.Objectivesi) to assess midwives’ feelings about the postpartum care of women with SMI; ii) to determine UTAP's impact on this feeling and its determinants; iii) to look for unmet needs.MethodsThis study is a prospective, exploratory, qualitative analysis. Twenty midwives from Grenoble Alpes University Hospital who took care of one of the selected patients participated in this study. Two women had schizophrenia and one bipolar disorder. Interviews realized with a semi-structured guide were fully transcribed, anonymized and thematically analyzed. Topics have been structured according to the number of occurrences to build a thematic tree.ResultsMidwives felt insecure and resourceless when the postpartum care was unclear, insufficiently anticipated and in case of a danger for the women or the children. They felt uneasy when not feeling able to provide usual care to these patients (due to lack of specific knowledge about SMI and to the impossibility to consider their patient otherwise than through their pathology). Midwives felt at ease and secure when the postpartum care was anticipated. UTAP was identified as a resource for midwives. Specific training and improvements in the organization of the pre and post-natal care could improve midwives’ feelings when taking care of women with SMI.     

L’IRM est-elle utile dans le suivi des patients atteints de sclérose en plaques ? Non

Is regular MRI monitoring useful in clinical practice in multiple sclerosis patients treated with disease modifying therapy (DMT) drugs? My answer is no. Tacking a DMT drug is not by itself a pertinent criterion for requiring a systematic MRI monitoring in MS patients. Five clinical criteria should be taken into consideration before prescribing regular MRI examinations. The clinical form of the disease: MRI monitoring in DMT treated patients, has been demonstrated as useful only in pure relapsing-remitting MS patients. Up to now, there is no convincing demonstration of therapeutic efficacy with any DMT drug, neither first-line nor second-line drugs in patients with primary or secondary progressive MS disease. The duration of the disease, epidemiological data leading to the concept of a two-stage disability progression in MS, emphasizes the importance of treating as early as possible RRMS patients in order to stop accumulation of new focal MRI CNS lesions. In this regard, an annual monitoring for the 5 first years of the disease looks reasonable in order to better personalize the treatment choice among the few approved DMT drugs. The duration of the treatment: a first MRI assessment at month 6 after initiating a new DMT drug is adequate in order to better distinguish responder versus no responder. The persistence of Gado + lesions at 6 months is a strong indication for considering alternative treatment. The disease activity: both criteria, clinical and MRI, are needed to recognized very active or aggressive relapsing MS patients, leading to decide a rapid use of second-line treatment therapy. The treatment choice: in JC positive MS patients treated with natalizumab, the risk of PML is as high as more than 1 % in those JC + MS patients that are treated continuously more than 24 months. A regular MRI monitoring (3 or 6 months) is recommended in order to detect as early as possible MRI abnormalities suggesting PML.     

Les comorbidités psychiatriques dans le transsexualisme : étude sur une population de transgenres libanais

IntroductionThe question of whether gender dysphoria is associated with psychiatric comorbidity has been addressed in several studies. Several cohort studies have shown that psychiatric comorbidity is one of the main features of poor prognosis following sex change therapy. Gender dysphoria is rare, with an estimated prevalence of 0.001% to 0.002% globally. The literature shows a high prevalence of psychiatric comorbidities in people with gender dysphoria, and that they are more common in male to female transsexuals. Data on long-term mortality show that transsexuals present a 51 % increase in mortality compared to the general population. This is mainly attributed to a six-fold increase in the number of suicides and a higher rate of psychiatric disorders and risky behaviors leading to HIV infection and substance abuse.PurposeAssess psychiatric comorbidity in a population of Lebanese transgender individuals and compare it to the general population. The hypothesis of our study is that the Lebanese transgenders suffer from more psychiatric comorbidities than the general population. Our second objective was to determine the specific mental health needs of this population in order to adapt our services to their medical needs and their specific concerns.MethodsOur objective was to acquire 20 transgender participants and 20 control subjects. We chose a snowball sampling method. The evaluation consisted of three questionnaires including a general demographic questionnaire, the MINI 5.0.0 Arabic version for axis I disorders and the SCID-II for axis II disorders.ResultsThe mean age of both groups was 23.55 years. Fifty-five percent (n = 11) transgender participants had active suicidal thoughts against 0 % in controls. Within the group of transgender, 45 % (n = 9) had a major depressive episode, 5 % (n = 1) had a generalized anxiety disorder, 5 % (n = 1) had a posttraumatic stress disorder and 10 % (n = 2) had a major depressive episode with comorbid posttraumatic stress disorder. We noted a significant difference between the two groups regarding the presence of suicidal ideation (P = 0.000) and the presence of axis I disorders (P = 0.039).DiscussionIn our study, we noted demographic and economic characteristics specific to the population of transgender individuals. We found a significant difference in the level of education, economic status and household composition. Transgender individuals suffer from more psychiatric pathologies compared to the general population. This may be due to social and familial discrimination and ostracism. These results demonstrate the vulnerability of this population. An awareness program for mental health professionals is essential in order to adapt care to the specific needs of this population. A list of non “transphobic” mental health professionals should be established.     

L’IRM est-elle utile dans le suivi des patients atteints de sclérose en plaques ? Oui

The place of magnetic resonance imaging (MRI) in the monitoring of patients with multiple sclerosis (MS) is not codified except during the diagnostic phase. Several studies in the literature have shown that lesion load measured on an MRI done at the beginning of the disease or its increase during the first years had a predictive value, although moderate, on the occurrence of long-term disability as measured by the EDSS. Early worsening of brain atrophy during the early stages of the disease is predictive of worsening cognitive impairment in the following years. Perform an MRI is not required when setting up a first-line disease-modifying therapy (DMT) such as an immunomodulatory treatment but it is useful because it can be used as a reference scan in case of treatment failure. The indications of second-line DMTs, whether prescribed in naive patients with an active disease or after failure of a first-line DMT, are based on combined criteria incorporating MRI data acquired in the previous 3 months compared with a recent MRI. Thus the practical criteria for failure of first-line DMTs are partly based on MRI. During interferon therapy, identification of disease activity on an MRI conducted 1 year after the start of the treatment can predict treatment failure in combination with clinical criteria, such as relapses occurring during the first year. Finally, MRI is essential to the safety monitoring of patients on natalizumab to detect progressive multifocal leukoencephalopathies (PML). In patients at high risk for PML, tested positive for JC virus antibodies and having received natalizumab for more than 2 years, it could be proposed to do a short MRI with FLAIR and diffusion weighted imaging sequences every 3 months to detect preclinical PML.     

Le centrage des hanches au moyen de sièges moulés – études et résultats

Background

Musculo-skeletal disorders and hip deformity play a key role on future development of motor and adaptive functions in children with cerebral palsy (CP). Lateral migration of the femoral head increases on average of 7.7% per year and may progress to hip dislocation. Conservative preservation of muscle length and balance may prevent or reduce femoral head migration and acetabular dysplasia. A prospective comparative non randomized study was conducted to determine the effect of a siège moulé postural management, in association with a physiotherapy program, on the progression of hip displacement in children with CP. Thirty-five patients with bilateral CP and so-called hip at risk (migration percentage [MP] of over 10% but less than 40%) were included into the study and evaluated by neurofunctional assessment, Gross Motor Function Classification System (GMFCS), Tardieu scale and radiological measurements (MP by Reimers). Eighteen children were treated with therapeutic education and postural management 4 hours a day, and 17 children (control group) were treated with NDT alone.

Results

A significant difference was found between MP values of case group and control group after 1 year (T1) and 2 years of treatment (T2) (p = 0,001). The rate of hip displacement was reduced by 5 % in the treatment group after the first year and by 7 % at second follow-up.

Conclusion

Our data show a progressive reduction of MP values measured in the treated group confirming the significant benefit from combined non-surgical approach. The study supports the evidence that conservative management of hip deformity can be successful if implemented before the development of hip dysplasia.     

Usage de Jeux de hasard et d’argent et d’Internet dans une population de patients en demande de soins en addictologie–Étude multicentrique

BackgroundTransversal grouping of addictions under the heading “Substance related and addictive disorders” in the DSM-5 has led to a common policy on addictions and the promotion of addiction services covering all types of addictions, including behavioral addictions.Material and methodsThe main objective of this study was to describe the prevalence of problem gambling in a population of patients seeking treatment in addictive disorders center. Secondary objectives were: to describe the use of Internet and the prevalence of gaming disorder, sexual addiction and compulsive buying online ; to describe a population of patients consulting in addictive disorders center; to explore associated factors related to problem gambling. A self-questionnaire was built, evaluating the socio-demographic elements, the addiction pathway, problem gambling and Internet use with a focus on video game disorder, sexual addiction and compulsive buying. It was offered to consultants from five addictology centers in Brittany.Results252 patients seeking treatment for addictive disorders were included. Problem gambling was present in 9.9 % of patients. Problem gamblers were more likely to have been asked about their gambling by the addictology team than other patients. The rate of identification of gambling habits, whether in addiction or outside, was generally low. Internet use was 83 %. The prevalence of other online behavioral addictions was low.Discussion and conclusionThe prevalence of problem gambling is almost 4 times higher among addictology consultants, compared to the general population, probably related to addictive comorbidities. The identification of gambling habits concerned a small proportion of the patients included, whether in specialized care or outside. There is significant room for improvement in the identification of problem gambling, in addictology and beyond. It is important to question gambling habits for any reason for addiction consultation and to repeat this identification over time. As the Internet is widely used by addictology consultants, it can represent a key element in care, both in the identification of behavioral addictions and in follow-up.     

La réaction à la nouveauté : un indice de dépistage précoce de l’autisme ?

A certain number of autistic children seem to develop normally for the first 12 months of their lives to regress then or have their development stop, and manifest a pathology of autism near 18months. From the data present in the literature, and our clinical observation in this article we will attempt to demonstrate that it is possible to diagnose the autistic pathology within the aforementioned category of infants before the appearance of the obvious symptoms, that is to say during their 1st year as well as to propose a reflection on the aptitudes that fall into place during this period and which prepare the sequel of their development, and finally, to examine the possible role of the reaction to the novelty of the stimuli in the early diagnosis of this pathology. It has to be said that the clinical observation of autistic children, the testimony of their parents and of young high level autistic adults underline a recurrent symptom in this population, whatever their age or level of achievement: It is the difficulty or even the impossibility they experience when faced with new situations, demonstrated by a marked resistance to changes in their daily routine. These subjects appear to present an obsessive and anguished need to preserve a stable environment without the slightest transformation. It seems that they have an extremely intense reaction to the novelty of stimuli. Does this particularity exist in the infant who will become an autistic child, could parents identify this particularity, and could it constitute a sign for the early diagnosis of autism? Around 60 % of these children “become” autistic after their first birthday. In some, the developmental curve shifts and the signs of autism appear gradually. In others, a phenomenon of regression is described at the same time as the emergence of behavioral problems. The fields where this regression is most obvious are language and social interaction. Our hypothesis is that the syndrome of autism does not suddenly appear at the age of eighteen months, but that its ‘emergence’ is in the making during the infant's first months through a series of dysfunctional phenomena, that are unobtrusive and so go unnoticed by the parents. We have explored these phenomena, using the cognitive genesis habitually described in children with a typical development. We arrived at the conclusion that the subtle disorders relative to the perceptive-sensorial treatments have since the beginning gradually invaded the sphere of their relation to the surrounding world, perturbing their experience of closeness and bonding. Anomalies which lead to faults in the pattern of expected aptitudes, faults which undermine and weaken the foundations, leading to a movement of reversal during the second year and to the massive actualization of the signs of autism, which had previously been latent because the aptitudes, which should have been the base on which the subsequent ones stand, cannot develop due to the missing support of the previous ones, so that the evolutional dynamics are interrupted. Communicational and social behavioral disorders in autistic subjects might come, at least in part, from a major difficulty early on, in processing new aspects of their environment, which are often saturated with dynamic informations. Our study leads us to think that the abnormal reaction of patients with autism faced with the novelty of a situation constitutes one of the key deficits of autism and could be a sign for the diagnosis of this pathology in the first months of life.     

Iter institutionnel de patients hospitalisés a l'hopital psychiatrique de Bergamo: une comparaison entre patients hospitalisés en 1963 et en 1973

Résumé Les auteurs présentent une étude comparative entre deux groupes de patients hospitalisés à l'Hôpital psychiatrique de Bergamo en 1963 et 1973, c'est-à-dire avant et après la loi 431/68 qui encourageait l'extension des dispensaires extra-hospitaliers. L'étude montre qu'à la suite de l'application de la loi et de la réorganisation de l'intervention psychiatrique par secteurs on a pu assister à une diminution importante du nombre de patients psychiatriques hospitalisés et bénéficier d'une utilisation plus qualifiée de l'hôpital psychiatrique.

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A comparison of admissions to Bergamo mental hospital in 1963 and 1973

Summary Two groups of patients, admitted to the mental hospital of Bergamo in 1963 and 1973, that is to say, before and after legislation encaeraging the extension of the Mental Health Centers, have been compared. The study shows that the reorganisation, with the establishment of catchment areas, produced a substantial decrease in the number of psychiatric inpatients and led to a more judicious use of the mental hospital.

     

Prévalence des troubles psychiatriques et addictologiques auprès de trois générations successives de migrants : résultats d’une étude menée en population générale

Introduction

Mental health of migrant populations has become a major public health issue since these populations more often suffer from mental health problems than host populations. The influence of the migration process on the emergence of these disorders and its impact on future generations is uncertain. This study provides an estimate of the prevalence of mental disorders among three generations of migration.