Hypothèses pharmacologiques et prise en charge thérapeutique des troubles de la marche de la maladie de Parkinson

Gait disorders form part of the axial symptoms observed in Parkinson's disease (PD) and also represent a major source of therapeutic failure in the later stages of PD, with the appearance of freezing of gait (FOG) and falls. Double-blind clinical trials and, above all, clinical experience have demonstrated that l-DOPA is effective in reducing FOG. Dopaminergic agonists appear to be less effective than l-DOPA and lack formal proof of their efficacy. The enzyme inhibitors provide modest benefits, which need to be confirmed. Hence, these symptoms appear to be partially doparesistant and justify investigation of other major neurotransmission systems. Of the various drugs with partial noradrenergic activity, methylphenidate may improve FOG and attention disorders. Memantine has shown some value in improving motor symptoms and gait in fluctuating parkinsonian patients - possibly by reducing the effect of glutamatergic hyperactivation of the subthalamic nucleus on the pedunculopontine nucleus (PPN). The PPN's dense cholinergic innervation also suggests that cholinesterase inhibitors may be of use, although any benefits must be set against a potential aggravation of rest tremor. The many interactions between the serotoninergic and dopaminergic systems require the implementation of clinical studies on the complex motor impact of serotoninergic treatments, which may aggravate the parkinsonian syndrome while improving gait (as is the case with paroxetine and ritanserin). This review seeks to develop the various pathophysiological hypotheses prompted by the results of fundamental studies and pilot clinical trials, with a view to justifying the implementation of confirmatory, double-blind, placebo-controlled therapeutic trials.     

Prise en charge somatique des patients en accueil familial thérapeutique. Une dimension de la réhabilitation

Foster care is a therapeutic specificity of Ainay-le-Chateau Hospital (Allier, France). The goal of foster care is to promote the rehabilitation and reintegration of the patient. It combines support by a care giver and institutional care. It offers to patients who cannot live alone, but do not justify in-patient care, a therapeutic care in a stable family environment. An initial treatment plan determines the duration of the stay, more or less long term. In addition to psychiatric care, a somatic treatment of patients is organized by qualified practitioners in general medicine. These practitioners provide medical monitoring of patients. Every patient benefits from a treatment plan including monitoring of medication side effects, medical comorbidities and prevention. General practitioners work in collaboration with the nearby General Hospital when an admission is needed for any medical or surgical condition. They can also admit patients in a 10 beds unit within our institution. The hospital specializes Ainay-le-Chateau has adopted a medical organization that provides follow-up for major comorbidities according to present recommendations in this field, thus adding an important element of rehabilitation. Medical consultation assesses vital parameters of patients, monitoring of side effects, nutritional evaluation, and prevention of malnutrition (in partnership with a dietician), assessment of pain, psychiatric comorbidities. Screening protocols are organized for cancer. These protocols are established in accordance with the recommendations of the High Authority of Health. In addition to general medical activity, two consultations have been implemented and validated by the decision-making bodies of the hospital, a follow-up consultation for chronic pain and a specific evaluation of daily autonomy. Pain in psychiatry is often difficult to assess in-patients with mental illness and the usual scales of assessment may be difficult to implement. This consultation provides weekly monitoring of chronic pain patients and the adaptation of analgesics, in partnership with psychiatrists to avoid drug interactions with psychotropic drugs. This consultation also allows anticipating possible hospitalizations and allowing patients to take maximum advantage of the rehabilitation project of foster care. Considering the relatively high proportion of elderly patients, a specific consultation has been established to evaluate daily autonomy in this age group, in order to prepare admissions in institutions for old age patients whenever necessary. During this consultation are evaluated cognitive abilities of the patient, the risk of fall, nutritional parameters, independence from the grid resource AGGIR iso 2 and occupational activities. Care givers provide information to complete this assessment.     

La perspective du travail comme média thérapeutique en psychiatrie : étude psychodynamique de trois patientes schizophrènes en soins de réadaptation

Patients often solicit the psychiatry services about their future especially concerning their social integration and their job. This question is as a problem as a help for care especially when it comes from schizophrenic patients. The psychiatric response is the psychosocial rehabilitation. In a psychodynamic conception, the author studies the evolution of three schizophrenic women in treatment in a care service of rehabilitation psychosocial. The author outlines the importance of the work project as a therapeutic medium. Some important characteristics are pointed out: the signification of the “job” for each patient and his family; the familial context; the effects of the job project’s on their psychopathology, the effects on their psychical organization of the reality of job and the importance of the protection in their social rehabilitation. These elements imply a multidimensional approach for the psychologist working in a psychosocial rehabilitation care service.     

Évolution des mécanismes de défense au cours d’un traitement bref psychanalytique. Une étude de cas

The main goal of this case study is to examine the stability versus mobility of defensive functioning during a brief psychoanalytic face-to-face psychotherapy (five sessions) on a crisis situation. It proposes the study of mobilized specific mechanisms and their evolution in terms of frequency during the intervention process. The sessions were rated according to J.-C. Perry's Defense Mechanism Rating Scale. The overall defensive functioning reached, at the end of the treatment, a higher maturity level (another neurotic) than that initially observed (narcissistic). This change is discussed in terms of narcissistic wound related to the crisis and involving a temporary regression. This study tends to confirm the thesis, advanced by theorists of short therapies and usually observed in this type of practice, of the plasticity of the psychic apparatus.     

Évaluation des besoins des patients et éducation thérapeutique

Therapeutic education aims at helping patients acquire of maintain competencies they need to cope with chronic illness. It goes further than simple information because its objective is to improve autonomy and quality of life, not just treatment observance. Therapeutic education is an important instrument for psychiatric rehabilitation, notably in foster home care. Because of the various possible themes of therapeutic education, our institution worked toward the identification of situation needing a structured program of therapeutic education. A pluridisciplinary group was set up, aiming at building structured therapeutic education programs and following their implementation. This group built a questionnaire for mental health team members, care givers and patients. Mental health team members expressed their views during a focus group. They identified several issues such as: food and overweight, digestive problems, medication side effects, smoking, diabetes. The questionnaire was sent by post to foster caregivers: 63% of them answered. Sixty-four percent of the answers identify one or several problems encountered by patients: lack of information concerning treatment (27%), stress due to vexation (26%), medication side effects (18%), lack of information concerning mental illness (9%). Twenty-four patients were interviewed, expressing their difficulties: over sedation, loneliness and boredom, anxiety, food, information concerning medication and mental illness. Patients expressed specific needs: Food and overweight, information on medication and illness, activities, smoking cessation. This questionnaire, requiring approximately 45 minutes interview, was living positively by patients. This preliminary inquiry led to identification of difficult themes for therapeutic education: medication and illness, smoking, nutritional balance. In order to both identify unmet needs, we decided to use an instrument developed in Lausanne, called ELADEB (Lausanne instrument to evaluate patients’ needs and difficulties)     

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.     

Prise en charge thérapeutique du syndrome de Gilles de la Tourette chez l’enfant et chez l’adulte

Tourette's syndrome is a neuro-psychiatric disorder which starts in childhood and is characterized by the association of motor and vocal tics of which the frequency, type and location vary in time. The numerous ways of neurotransmission of the physiopathology of this illness have been tested. Several psychiatric comorbidities have been described at length among which the attention deficit hyperactivity disorder and obsessional compulsive disorder are the most frequent. The decision to initiate a treatment must take into account numerous factors and notably the repercussions of the pathology on the social and occupational life of the patient which rest on an individual valuation of the illness. Care must first start with psychoeducation allowing a better understanding of the syndrome by the patients and their family. Medicinal therapeutics then intervenes to treat the weak to severe tics affecting the daily life of the patients. The choice of the molecule will differ according to the severity of the illness, to the age of the patient and to the comorbid associations. Psychotherapies such as behavior therapy and supportive therapy are an alternative to pharmacologic treatment. They can be employed alone and may be sufficient for some patients. They can be also associated with classic therapeutics in order to increase therapeutic effectiveness. Finally, deep cerebral stimulation may constitute a new and interesting way, but it is in its developmental stage and needs to be assessed. This treatment is restricted for the time being to cases resistant to the classical treatments and to patients meeting the requirements of eligibility for such treatment.     

Étude de la dépression,des événements de vie,de l’impulsivité et du lieu de contrôle au sein d’une population nouvellement incarcérée

Introduction

During the first days of incarceration, the “shock prison” may encourage the appearance of symptomatology reaction with the presence of depressive disorders. Several studies in prisons showed the presence of certain socio-demographic characteristics, psychological and legal in this population life course singular susceptible to weaken against the event that represents an incarceration.

Objective

The present study is twofold. This is firstly to assess depression, life events, impulsivity and locus of control in a newly incarcerated population and secondly to compare the results with depressed people those do not show depression.

Method

Maintenance of semi-structured research was proposed to 46 inmates in the unit of outpatient consultations in a prison in 2010. This interview was completed by placing two questionnaires (Beck Depression Questionnaire, Eysenck Impulsivity Questionnaire) and scale (Multidimensional locus of control scale of Levenson).

Results

Of the forty four inmates incarcerated for less than 10 days, who participated in the study twenty-six had a depression, a significant number of incarceration, psychiatric history, certain life events (personal and maternal abuse, parental alcoholism), as well as significantly higher scores with regard to empathy and external locus of control type “powerful character”.

Conclusion

Home maintenance is a systematic critical time. Newly incarcerated population, with a depression score above the standard psychological characteristics show support from the idea of a unique formation of the personality associated with the presence of life events and highlights particularly difficult childhood susceptible to weaken, especially to cope with the event that is incarceration.     

Alliance thérapeutique avec les mères et évolution clinique des enfants d'un hôpital de jour

This two-year prospective study in a French child psychiatry day hospital assesses relationship between therapeutic alliance and clinical progress. Thirty-three 3-10 year-old children (18 with pervasive developmental disorders and 15 with mixed behaviour disorders) were assessed regarding their symptom status and developmental progress, while receiving multi modal intervention package. Independently, the treatment staff assessed the therapeutic alliance with the parents by standardized ratings on the French modified Helping Alliance questionnaire from Luborsky. The statistical study shows that a mother's good therapeutic alliance correlate significantly with the social functioning improvement but not regarding the symptom status. As North-American therapeutic alliance adult's studies, this first child psychiatry unit study seems to show that the parent therapeutic alliance is a predictor factor of child outcome independently of age and pathological child status.     

Étude des enjeux psychologiques dans la pratique féminine des sports à risques

Studies investigating risk-taking behaviours in the sports domain have often been conducted with men. It was not known if women reacted in a similar manner when confronted with risk. In order to better understand their motives and individual personality characteristics, we investigated the psychological actual experience of women involved in risk-taking sports. The research sample comprised 16 women in two separate groups: 1) hazardous sport professions: mountain guide, skydiving instructor, rally pilot, sailor (n = 10, Mage = 34,2 ± 9,81) ; 2) high risk sports: alpinist, BASE jumper, ski bump (n = 6, Mage = 26.8 ± 1.47). Semi-structured interviews were conducted using Patton's qualitative evaluation methodology (1990). The hierarchical theme analyses which were carried out emphasized several factors: 1) relationship with risks; 2) emotional regulation; 3) need for gratefulness; 4) relationship with parents; 5) gender identity. Contrarily to quantitative studies, the results underline the fact that the sensation seeking personality factor is not the major one for women involved in high risk sports: the emotional factors seem to be more important. Indeed, for non-professionals, hazardous sports are lived as a means of forgetting one's emotional distress and uneasy feelings momentarily, and as a way of getting away from everyday life, whereas professionals master potentially dangerous situations much better in hazardous sports, anticipating and preparing themselves more efficiently for the events. Professionals do not use risk as a means of escape from themselves or from any possible emotional problems. In summary, emotional regulation appears to be a central concept in risk-taking behaviours, and extreme sports could be used to promote a positive construction of identity. Extreme sports could give individuals the opportunity to feel more in charge of their practice. These results plead in favour of setting up specific processes in the psychology of risk-taking of women in sports.     

Évaluation des troubles comportementaux hyper- et hypodopaminergiques dans la maladie de Parkinson

The common perception that Parkinson's disease patients tend to be depressed, anxious, apathetic and harm-avoiding has currently been challenged by the recognition that they can also exhibit a hedonistic, novelty-seeking personality. Thus, Parkinson's disease patients may indulge in their passions in an irresponsible and disinhibited manner, and engage in repetitive, compulsive behaviors that may be harmful and destructive to their social or professional lives. The dopamine dysregulation syndrome includes hypersexuality, pathological gambling, and compulsive shopping; it is associated with addiction to dopaminergic medication. However, not all behavioral changes are necessarily accompanied by a dopaminergic addiction. After antiparkinson treatment is initiated, patients enter a ‘honeymoon period’ during which changes in mood and behavior reflect a return to the patients’ premorbid personality. The increased motivation and higher level of activity in professional as well as leisure activities are considered positive changes by both the patients and their relatives. With prolonged and increased dopaminergic treatment, these positive behavioral changes can become excessive and evolve into nocturnal hyperactivity and stereotyped, repetitive and time consuming behaviors which ultimately disorganize the patient's everyday routine and herald behavioral addictions. These drug-induced behavioral changes are under-appreciated by neurologists and under-reported by the patients who neither complain about the behaviors nor understand the relationship between motivated behavior and dopaminergic medication. For these reasons, we propose a new scale for the assessment of behavior and mood to quantify and track changes related to Parkinson's disease, to dopaminergic medication, and to non-motor fluctuations. This scale is based on the concept of hypo- and hyperdopaminergic mood and behavior. The scale consists of 18 items addressing non-motor symptoms, grouped in four parts: general psychological evaluation, apathy, non-motor fluctuations and hyperdopaminergic behaviors. The rating in five points (0-4 from absent to severe) is carried out during a semi-structured interview. Open-ended questions introduce each item, allowing patients to express themselves as freely as possible. Close-ended questions permit the rating of severity and intensity. This new instrument can be used by psychologists, psychiatrists or neurologists familiar with Parkinson's disease. Designed to detect changes in mood and behavior of Parkinson's disease patients resulting either from the disease or its treatment, this tool can be used in conjunction with the neurocognitive evaluation, to help tailor the treatment of motor and non-motor symptoms to each individual's needs.     

Étude longitudinale de la qualité de vie dans la sclérose en plaques : corrélation aux paramètres morphométriques de l’imagerie

Introduction

Health related quality of life (HRQOL) is often affected in multiple sclerosis (MS). Nevertheless, to our knowledge, there is no longitudinal study in the literature about the correlation between MRI parameters and HRQOL in MS patients.

Methods

We included 28 patients with clinically definite relapsing remitting MS. All patients initiated subcutaneous interferon beta-1a therapy. To assess HRQOL, we used the SEP-59 scale, the French validated translation of MSQOL-54, and the MusiQoL scale. Conventional MRI was performed every year. Lesion load (LL) and brain atrophy were automatically measured using SepINRIA, a free software developed by INRIA in Sophia Antipolis.

Results

The mean EDSS score was 1.7 and disease duration was 2.5 years. Our results revealed that HRQOL was significantly correlated to T1 and T2-LL with both SEP-59 and MusiQoL scales. T1-LL was better correlated with physical dimensions and T2-LL was better correlated with mental components. At 1-year follow-up, patients whose MRI showed either an increase of T1 LL or at least one gadolinium enhancing lesion had a worse HRQOL at the end of the study. Initial brain parenchymal fraction (BPF) measure was also correlated with the long-term follow-up HRQOL. EDSS scored at the end of the study had not significantly changed (1.3; P > 0.05).

Conclusion

Our study revealed pertinent clinicoradiological correlations between HRQOL and MRI parameters in our cohort.     

La loi du 4 mars 2002 « relative aux droits des malades et à la qualité du système de santé » : une loi protéiforme au carrefour de l’évolution sociale et médicale

The French law n° 2002-303 of march 4, 2002 is considered in France as a fundamental stage of the French medical right, a bridge between the past and the future of the relations between sick people and doctors. It testifies to a sociological evolution of relationship between doctor and patient and makes us pass from a paternalist medicine to a medical consumerist practice, who makes place with the patient as a consumer and an actor of his care. This law is a protean law which makes move the rights recognized to the patient, the assent or the professional secrecy. It establishes the direct access to the file of the patient and imposes the information of the sick person. The law of March 4, 2002 is a general law which deals with very practical medical, without specificity for psychiatry. Only some points concerning the hospitalization of the mental patient are clarified there. It preaches a medical democracy and seeks to develop the quality of the system of health. Its essential contribution will be surely the device set up for the compensation for the therapeutic risk.     

Vers une gestion autonome de la médication en psychiatrie ? Approche anthropologique

From the patient’s viewpoint, a good quality of compliance supposes a good relationship with his/her doctor; this relationship is directly linked to the heeding and the interest shown to the patient, and not to his/her 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 psychological research. These well-known classical medical notions meet with average values of non-compliance, which may vary widely. 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 the medical and religious background, to medical anthropology, and to the real or supposed proprieties of the Pharmakon. 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. Based on the summary of these data and on the testimony of 135 persons involved in this dynamic (patients, families, doctors, nurses, members of pharmaceutical industry), we shall try to obtain a better understanding of what happens between the patient and his/her therapists from an anthropological viewpoint. Social isolation remains one of the greatest losses in mental disease. For many authors, people with schizophrenia can have no friends, no spouse, and sometimes no family. Two thirds of the patients with schizophrenia return to their parents’ house when discharged from a hospital after the first psychosis. Family members generally receive very little education as to what they can expect. They may not even know the importance of medication compliance. Family members are the primary victims of violence from psychotic individuals, usually their own son or daughter, and most families cannot believe their own son or daughter would be capable of such violence. Although families are usually the main care givers at the beginning of schizophrenia they often find their experience very frustrating for a number of reasons, and consequently relationships suffer. Family education and support have been shown to improve outcomes considerably and family education is the second strongest factor in relapse prevention. Without education and good relapse prevention families often disintegrate. Most of the homeless mentally ill in downtown city cores have lost their family relationships. It is not a reflection on their families so much as the lack of adequate treatment and support. The families tried again and again but finally lost their sick relative. These reflections show how information of and about the psychiatric patient is necessary, and underlines the importance of the relationships between the patient and his family. Our article also insists on this theme which is rarely developed in the literature.     

Architecture,théorie du soin en psychiatrie et politique. De la forme au sens

When evoking the insane asylum, Esquirol wrote in 1822 : “In the hands of a skillful physician it is the most powerful agent against mental illnesses”, he did not refer only to the architectural space arrangement of the asylum but to its global conception of the care environment, and this notion of care environment is more complex than it seems. The significant link he introduced could lead to confuse that which belongs to care and that which depends on the environment in which it is given. Moreover, history shows this subtle exchange between psychiatry and architecture. Within the research of the therapeutic impact that an ideal society could have on mental illness, the link between moral treatment and the architecture of the classical asylum is well known as is that between the village hospital with institutional psychotherapy. But, on the other hand, who remembers that the debate between Marxism and psychoanalysis within psychiatry had important repercussions on the architectural and environmental modalities provided to care for the mentally ill ?