Peine, douleur et dépression

Kierkegaard contrasts pain, which proceeds from a fate beyond individuals, with suffering which is internalized within a subjective memory. This analysis can be useful to tackle depression with the cognitive theory of representation. We outline a framework to construct a representational space as a subjective universe defined from memory. Suffering can be linked to a splitting of the representational space and retardation corresponds to a retraction of this space into what can be described as a well. Beyond an apparent accident, the depressive retraction can only be explained as a wound of a founding area of representational space, involving an original pain. Several degrees of melancholy can be defined within this conceptual framework. We underline the hazards of extracting the original pain when it unifies the whole representational space.     

Schémas dépressogènes et espace subjectif

The concept of schema used in cognitive psychotherapy is an heuristic tool that has more a metacognitive value than a psychological value: it doesn't involve directly the cognitive processes and the representations in memory. Therefore, the understanding of the therapeutic action is limited and insufficient for a satisfying account of the complex clinical data observed during the course of treatment of resistant depression. To overcome this problem, we propose a conceptual framework that describes a subjective universe as a representational space that is displayed from memory. From this point of view, depression is equivalent to a retraction of the subjective space. This retraction is primed by the reactivation of some past traumatic events. We show the influence of early painful situations on the Home Image, which is an essential area for the unification of the representational space. This conceptual framework allows us to define the representational structures underlying the cognitive model of learned helplesness of Abramson et al. [1]. Two levels of schemas are specified: (1) the symbolic structures that constitute the “web” of the subjective space and correspond to the schemas of the cognitive psychology; (2) the metaschemas that are the constructs of the therapist. The formation of the depressogenic schemas during the personal story is linked to the development of metaschemas of vulnerability, gratitude, and control. A therapeutic block is defined as a closing of the therapeutic space - that is, the intersubjective world constructed between the patient and the therapist. Such a block indicates the necessity of a global restructuration to release the memory from a depressogenic metaschema. In this case, the therapeutic strategy requires a technical adaptation to mobilize the mass of the subjective space. The therapeutic medium needs to resonate with the core of the depressogenic metaschema that is deeply buried in memory. The patient should also actively grasp the processes of the symbolic structuration of his/her subjective space. This conceptual framework allows us to account of the concept of insight as a spatial feeling of unification and widening that is associated to a restructuration. Thus, a cognitive therapy can be analyzed as a succession of phases that mirrors in reverse order the development of the depressogenic metaschemas. A case study confirms the relevance of this approach and we underline the crucial function of the therapist's creativity to overcome the therapeutic blocks. We insist also on the carefulness that is necessary to approach the early painful situations deeply buried in memory.     

Espace phobique et levier thérapeutique

Introduction

The spatial experience in phobic disorders needs to be better understood in order to account for the pathogenic effect of a local phobogenic situation on the whole subjective world. Such an understanding could be useful for the treatment of resistant phobias which are hampered by therapeutic blocks that require a global restructuration of the subjective world.

Objectives

Three objectives are addressed in this paper: (1) a clarification of the experience of space in phobic disorders; (2) an account of the impact power of the phobogenic situation; (3) an analysis of levers in cognitive psychotherapy that may help to overcome therapeutic blocks in resistant phobias. To tackle these objectives, we bring in the conceptual framework of representational spaces that proposes some tools to describe a subjective world as grounded in the spatial experience. According to the model of phobic disorders that we build up in this framework, the phobogenic situation behaves like a probe that reveals some strains disturbing in depth the subjective representational space. These strains depend on past traumatic situations that have resulted in the development of phobic cores. Thus, the phobogenic situation materializes some dimensions of the representational space that makes it vulnerable to a traumatic agent. In this framework, a therapeutic lever can be defined as a key-situation that favors a global reorganization of the representational space from a local work on it. Three conditions appear to be necessary to the works of such a lever: (1) the key-situation needs to resonate through the representational space with a central phobic core; (2) the patient should actively grasp the processes of the symbolic structuration of his/her space; (3) the therapeutic lever should only be operated at the suitable time of the therapeutic course by taking account of the subjective defences.

Patient and method

Our model is exemplified with a case study that describes the behavioral and cognitive therapy of a patient that suffers from a phobic disorder since his adolescence. The technical method notably uses a work on the cognitive schemas that starts from the patient story.

Results

The method used to overcome therapeutic blocks reveals some phobic cores that are related to traumatic situations in childhood and adolescence. Therapeutic levers are operated when key-situations relative to the familial story can be addressed and elaborated by an active work of the patient, with a feeling of global restructuration of his psychic space.

Conclusions

The conceptual framework of the representational spaces is interesting to clarify the spatial experience in phobic disorders and to explain the impact of the phobogenic situation. Moreover, in complex phobias, this framework offers some useful tools to conceptualize the therapeutic levers that could be efficient to move the whole subjective world. Such levels can only be used during a long-term therapy.     

Douleur,souffrance et intenable

ObjectivesFor a subject inserted into a world that is displayed from a singular memory, the concept of mental suffering can take on many meanings: inner affect, fundamental impairment of the being's potentialities (e.g., through an illness), extreme constriction of the subjective space. In order to clarify these meanings we outline a conceptual framework where a subjective universe is described as a representational space.MethodIn contrast to the pain that is associated with the actual tension – the relief of which can increase the potential tension – we define the fundamental suffering as a defensive closure that tends to limit the unification of the representational space. An area of the representational space is untenable when the tension is too strong to remain within this area, and a subject is confronted with the Untenable when she/he is locked in an untenable area from which she/he is unable to escape. Supported by Kierkegaard's distinction, anxiety can be considered as the dynamic of presentification of an objective misfortune that supplies the pain through the representational space.ResultsWithin this conceptual framework, we briefly analyze some dimensions that underlie the necessity of a therapeutic encounter: blockage, helplessness, vulnerability, isolation, fascination.DiscussionThe richness of this conceptual framework is confirmed by tackling two situations where the suffering increases until reaching the Untenable because of some external conditions involving the suffering of another subject – the Unsupportable – or an objective misfortune – the Unbearable.ConclusionThis conceptual framework is able to deepen the singular meaning of suffering by specifying the intuitive concept of a subjective universe.     

The fragmentation of representational space in schizophrenia

Existent neurocognitive models of schizophrenia converge towards a core of impairments involving working memory, context processing, action planning, controlled and intentional processing. However, the emergence of this core remains itself difficult to explain and more specific hypotheses do not explain the heterogeneity of schizophrenia. To overcome these limits, we propose a new paradigm based on representational theory from cognitive science. Some recent developments of this theory enable us to describe a subjective universe as a representational space which is displayed from memory. We outline a conceptual framework to construct such a representational space from analogical -representations that can be activated in working memory and are connected to a network of symbolic structures. These connections are notably made through an analytic process of the analogical fragments, which involves the attentional focus. This framework allows us to define rigorously some defense processes in response to traumatic tensions that are expressed on the representational space. The fragmentation of representational space is a consequence of a defensive denial based on an impairment of the analytic process. The fragmentation forms some parasitic areas in memory which are excluded from the main part of the representational space and disturb information processing. The key clinical concepts of paranoid syndromes can be defined in this conceptual framework: mental automatism, delusional intuition, acute destructuration, psychotic dissociation, and autistic withdrawal. We show that these syndromes imply each other, which in return increases the fragmentation of the representational space. Some new concepts emerge naturally in this framework, such as the concept of "suture" which is defined as a link between a parasitic area and the main representational space. Schizophrenia appears as a borderline case of fragmentation of the representational space. This conceptual framework is compatible with numerous etiological factors. Multiple clinical forms can be differentiated in accordance with the persistence of parasitic areas, the degree of fragmentation, and the formation of sutures. We use this approach to account for an empirical study concerning the analysis of analogical representations in schizophrenia. We used the Parallel Visual Information Processing Test (PVIPT) which assesses the analysis of interfering visual information. Subjects were asked to connect several small geometric figures printed on a transparency. The transparency was displayed above four photographs which were the interfering material. Then, subjects completed three tasks concerning the photographs: a recognition task, a recall task, and an affective qualification task. Using a case-by-case study, this test allows us to access the defense processes of the subjects, which is not possible with the usual methods in cognitive psychopathology. Twelve clinically-stable schizophrenic subjects participated in the study which also included a self-assessment of alexithymia by the Toronto Alexithymia Scale. We obtained 2 main results: (a) creation of items in recall or false recognition by 8 subjects, and (b) lack of the usual -negative correlations between the alexithymia score and the recall, recognition and affective qualification scores in the PVIPT. These 2 results contrast with what has been previously observed for alexithymia using the same methodology. The result (a) confirms an interfering activation in schizophrenic memory, which can be interpreted in our framework as indicative of parasitic areas. The creation of items suggests the formation of sutures between the semantic content of photographs and some delusional fragments. The result (b) suggests that the apparent alexithymia in schizophrenia is a defense against interfering activation in parasitic areas. We underline the interest of individual protocols to exhibit the dynamic interplay between an interfering activity in memory and a defensive flattening of affects.     

Bruno et le fou sacré : Mythe, Mimesis et la transmission des mémoires traumatiques

Interest in PTSD and traumatic memory extends beyond psychiatry. Over the last two decades, “trauma theory” has emerged as an influential discourse within the humanities and social sciences. The theory is based on an unlikely combination of sources: Freud's accounts of traumatic neurosis in Beyond the Pleasure Principle and Moses and Monotheism; Bessel van der Kolk's research into the neurophysiology of PTSD and somatic memory; and post-modern writing on collective memory. Trauma theory writers are intensely interested in explaining how traumatic memories are transmitted between and within generations. Explanations focus on the roles of contagion as a mode of transmission and the Holocaust as a shared collective trauma. This chapter argues that the clinical and cultural phenomena that are being explained by these writers are better understood in terms of mimesis or imitation. The argument is illustrated with the help of a fraudulent Holocaust ‘memoir’ by Benjamin Wilkomirski, and an analysis of audience responses once the fraud was exposed. This chapter underlines important concerns regarding the clinical epistemology of posttraumatic stress disorder.     

Le jeu chez l’enfant victime d’événements traumatiques

The authors work lies within the framework of medicopsychological emergency activities and of specialized consultation the vocation of which is to insure the care of victims of traumatic events that they be of a deliberate (violence, wars) or non-deliberate nature (natural disasters, accidents). Interventions led close to the events with grown-up victims are well organized nowadays whereas the specific coverage of children is still not envisaged in immediate interventions. Nevertheless, children may be affected as much as the adults by the trauma and can present disorders, which must be tracked down, estimated and taken care of. We propose a reflection on a symptom of reviviscence susceptible to be expressed by children victims of traumatic events: The post-traumatic game. We suggest envisaging the post-traumatic game as a clinical entity testifying of a symptom of reviviscence, which can express itself at three levels: The traumatic game, the abreactive game, the re-enactment. - 1 - The traumatic game: Rather than the ’post-traumatic’ expression because in this activity the child is still in the trauma without being able to get free of it. The traumatic game is to be understood as a symptom situated close to reviviscence because the child ’plays’ by repeating the traumatic scene, which was lived through, as a kind of automatic, repetitive and monotonous production that can become a real compulsion, without any decrease of the fear. This expression, to which no pleasure is attached, is due to the complete overwhelming of the mechanisms of defence, to the failure of the psychic devices in metabolising the influx of excitements, in the fixation of the psyche at the moment T of the trauma. The child, in a state of ’emotional petrifaction’, is the prisoner of a deadly activity from which it cannot release itself. The traumatic game is a game in ’white’. - 2 - The abreactive game: This activity marks an evolution with regard to the traumatic game because here, the child is capable of developing it’s scenario until some kind of end without being blocked in a compulsion of rehearsal of the trauma. Each rehearsal staged in the abreactive game is accompanied with feelings, thoughts, sensations and a physical recall of the initial state of distress but here the child succeeds in partially freeing itself of it and sometimes in avoiding suffering. The dimension of auxiliarity of the processes of symbolization is partially restored. The abreactive game has a dimension of emotional discharge, exorcizing the suffering and allowing the restoration of the capacity to support the processes of representation and symbolization. Contrary to the post-traumatic game, which testifies to the failure of any possibility of elaboration, the abreactive game authorizes the reorganization of the psychic contents and restores temporality: the child is not petrified in an instant T of the trauma any more but succeeds in reaching beyond in an ’after traumatic’ mode. The child repeats with the same intensity and in an active mode, via the game, the trauma it experienced passively so as to succeed in mastering it. The abreactive game authorizes the reorganization of what it lived passively on an active mode so as to succeed in mastering it and this reproduction of the experience, by modifying its status, allows its assimilation. The abreactive game then allows the child to resume control over what it underwent and to assimilate its own reactions and feelings: Its mechanisms of defence are not overwhelmed any more: They are restored. - 3 - Re-enactment play such as defined by Terr is characterized by the expression a posteriori of traumatic traces through the game and by the investment of the child. This acting of the traumatism it lived through a posteriori intervenes while the child recovers a certain psychic balance. It is not an automatic rehearsal of the event in its global nature but only a rehearsal of certain aspects of the trauma. The child spends a period of intense stages of psychic suffering through certain activities and by recalling the ancient traumatic memories encrypted in its unconscious. The expression of the re-enactment does not present the rigidity of the traumatic game but is more difficult to track down. We shall then discuss the interest of observing the game for the diagnosis and for the understanding of the child’s psychodynamique traumatic traces. These various modalities of expression show the intensity of ’the after-effect activity of the traumatism’ and the underlying dynamic processes. They are to be understood as symptoms giving evidence of the persisting suffering in the symbolization of these traumatic traces. Distinguishing between the various meaningful activities of the child after a traumatic event offers us the possibility of observing the child to better estimate the impact of the trauma and to perceive if what he/she shows can likely or not play the role of ’psychic prosthesis’ for certain psychic functions having failed due to the event. The distinction between these three post-traumatic expressions is still easy because the child can, on the basis of the same post-traumatic scenario, appeal to these various modalities of expression. This is particularly the case for the children victims of serious and repeated violence (sexual violence, war). We will discuss what it is in the traumatic game, in the abreactive game and in re-enactment, in the process at work in the passage from the passivity in front of the traumatic experience to the activity of the game that aims at cancelling the loss undergone and at retroactively giving meaning to the traumatic scene.     

Tentative de suicide médicamenteuse : la quadrature du cercle des poètes non disparus

In November 2008, the suicidal gestures met in a general hospital in Lyon were within 79.9% of cases of acute drug overdoses (n = 174). These behaviors have a function that cannot be summarized in one simple search of death. The overdose is designed to immobilize a suffering process. In this, it can be compared to the writing process. The commentary on Plato's Phaedrus by J. Derrida, shows a Pharmakon (medication/poison) function of writing. By analogy, it is informative on the choice of using drug for suicide attempters. Writing and suicide are seen by the subject who commits them, as remedies for memory. But they are also its poison. The reversibility of the drug powers hints the fact that suicide attempt obeys a rollover process. The psychiatrist's role may be to subvert this process by causing the patient to rebel against the role of scapegoat (Pharmakos) of his own suffering. The choice to take refuge in the medication is an evidence of the transfer from the patient to the doctor (Pharmakeus). If we want to catch to the original principle of reversibility that we see at work in the drug committed suicide, we must consider the question of time. The overdose would represent the quest of a safe place away from time. The issue of suicidal psychiatric care then becomes the creation of spaces where reversibility is negotiable, sometimes manageable. Of places such as speech, movement which is to balance a network of ambiguities.     

E. Weiss et G. Perec, ou la nécessité psychique de l’écriture autofictionnelle

This article is a comparative analysis of two autofictions: The Trial by Fire (Die Feuerprobe) by Ernst Weiss and W by Georges Perec. Both writers, who are well-versed in psychoanalysis, decide to search for their unconscious by writing autofiction. To Weiss and Perec, only this process will allow them to access the memory that has stored traumatic events occulted by childhood amnesia. The writers share a phantasmic — yet, anonymous — agreement with their attentive reader. In both texts, the analyst reader observes the figure of an inner witness who writes in order to capture a child lost in the writer's unconcious. This infantile part is psychotic, as it is caused by an early-childhood trauma, possibly the father's death, and it focuses on primary narcissism. It also involves an anal bunker that is supposed to serve as a protective barrier against any traumatic memory surge. The mental state of the child threatens the psychogenic integrity of the two writers. A clinical reading of the two works unveils the secret of autofictional writing: the inner witness, identified with Freud, becomes the mother/father analyst for the lost child. Thus, under the protective fantasy of self-procreating, a psychical rapport with the child has been recreated. As the inner witness brings back the father's law into the rules of language, the primitive scene is extirpated from amnesia and opens up to desire, even if only during the writing process. Thus, autofictional writing saves a precarious and borderline psychical equilibrium.     

Un nouveau cadre conceptuel de travail pour une psychiatrie revisitée ? Introduction à deux articles de E. Kandel

In two articles which appeared in the American Journal of Psychiatry and that were subsequently translated for Évolution Psychiatrique, E. Kandel examines the bases for a reinterpreted psychiatry that is prepared to confront the major challenge of the 3rd millenium: that of insight into the mind and brain. This requires a major reorganization of the discipline, which involves a reinvestment of the scientific approach and a critical  assessment of the data provided by psychoanalytical psychiatry and cognitive neurosciences. Seven concepts have therefore been proposed for interactive re-examination: consciousness, the unconscious, memory, emotion, development, desire, impulse. The dynamic relations existing between genetics and the environment allow one to see how evolutions are possible from actions at different levels, both psychotherapeutic and pharmacological. Imaging and other techniques provide additional objective information to the process of human interaction which remains the basis of psychiatry. A common framework for psychiatry and the neurosciences, a reconsideration and renewal of the psychoanalytical approach are both possible and necessary.     

Application de l’EMDR au deuil traumatique après une collision de train

The aim of this exploratory study is to test the application of therapy EMDR in case of traumatic bereavement. The traumatic bereavement, which corresponds to the brutal loss of “other significant”, answers a precise clinical picture whose principal characteristics are the intrusive thoughts concerning the late one and of the difficulties of adjustment to the loss (feeling of vacuum, difficulties of recognizing the death, irritability, lack of reactivity, etc). The eight participants all of this study are of the members of the family of the victims of the train collision, which took place on October 12, 2006 in Zoufftgen. The subjects, old on average 35.2 years (S.D. = 11.1) and including 75 % women, followed between eight to 15 meetings (m = 10.75, S.D. = 2.21) answering protocol EMDR. The effectiveness of the therapy was evaluated starting from several criteria including traumatic bereavement, anxiety, depression and psychological distress. Five evaluations were carried out: before the therapy (T0), after six meetings (T1), at the end of the therapy (T2), then in three months (T3) and 12 months (T4) after the end of the therapy. The principal results seem to indicate an effectiveness of the therapy EMDR. Indeed, we observe a reduction in all the indicators between the beginning (T0) and the end of the therapy (T2). Moreover, when this reduction does not continue to three and 12 months, it remains, at least, stable at one year. These observations are very encouraging especially when it is known that 10 to 15 % of the patient develops a chronic depression.     

La fragilité de la ;Chair dans la clinique et la psychopathologie de la schizophrénie. Approches de la relation chez Bin Kimura et Erwin Straus

We are trying to study in what way schizophrenia would be a pathology of the Flesh connected with the inability of some patients to Feel. Feeling is a pre-intentional act which cannot be restricted to the simple passivity of receptivity. It is also a noetic act which introduces distance and differentiation between the Self and the Other. This act at the fundament of one's link with the world and the relationships to the others is weakened among the patients suffering from schizophrenia. In reference to Merleau-Ponty, the Flesh refers to the capacity or the incapacity the patient has in keeping with being-in-relation with the Self, the others and the world. As an external space, it refers to the world and as an internal one it refers to the living. One speaks about ‘own body’ or ‘living body’ or Leib, according to Husserl. Flesh and Leib, belong to what is felt before what is thought, to the world of life. This dual link to the living and to the world allows us to compare these two notions to the notion of Aida that we find in Kimura's work. Aida is a virtual space of relationship on the level of the constitution of a Self as well as on the level of the constitution of the world. According to Kimura, schizophrenia is a ‘pathology of Aida’, coming from a failing relation between the Self and the core of life and altering consequently the relationship the patient can have to the others and to the world. It is this essential link at the core of life which, according to Kimura, enables the constitution of the ipseity. But in schizophrenia, this first link does not allow a satisfactory constitution of the Self inducing a disturbed temporality and spatiality. First, the intentionality of consciousness suffers from some distortions; then the modes of spatialization are blending. This confusion between two spaces would be, according to Straus, on the one hand, the beginning of the autistic turning in on the patient's own world or idios cosmos and on the other hand, the beginning of morbid rationalism. These two phenomena lead to losing the Feeling as the mode of relation to the common world or koinos cosmos and consequently a difficulty of being in the Flesh of the world. These phenomena certainly visible with a clinical approach are significantly identifiable with the Rorschach test. On the clinical level, this approach opens onto the setting up of the therapeutic Aida making it possible for the patient to redefine the space and the time which would enable him to be in the field of Feeling and thus in a common space of relation that the therapist brings at the same time as the patient. This is why we will be able to see the specific modes of constitution characterizing the schizophrenic-being and what a proper understanding can bring to the clinical study of schizophrenia.     

Délires de reduplication mnésique : connaissance de soi et perplexité identitaire

Objective

An inconsistency in the sense of self does not necessarily follow from a deficit of autobiographical memory.

Patients and methods

We report two cases of memory reduplication with delusion, one concerning an event reduplication memory, the other one a spatial reduplication memory.

Results

The first patient, J.M., presents with a confusion of identity, which forces him to search for some evidence in his imaginary memory. The second patient, R.B., remembered having juxtaposed two separate geographical sites, became aware of his false conviction, and finally attempted to find explanations for this perceptual illusion.

Conclusion

Impairment of self-knowledge can be caused not only by a memory deficit, but also by a difficulty of subject to incorporate an imaginary history in his memory (narrative identity), particularly when reality is not coherent with the imaginary history.     

Prise en charge non spécifique de l’état de mal épileptique convulsif

The systemic consequences of status epilepticus occur in two stages: the first stage is a hyperadrenergic period (high blood pressure, tachycardia, arrhythmia, hyperventilation, hypermetabolism, hyperthermia), the second stage a collapsus period, sometimes with acute circulatory failure, and hypoxemia. Symptomatic resuscitation aimed at restoring vital functions should be undertaken. Resuscitation must be started immediately before hospital transfer, by a trained emergency team. Respiratory care includes at least oxygen intake, but it can also require oral intubation (crash induction) and mechanical ventilation. The arterial blood gas objectives are SaO₂ ≥ 95%, and 35 mmHg ≤ PaCO₂ ≤ 40 mmHg. Fluid and electrolyte care includes intravenous infusion of normal saline, with control of sodium and calcium levels as well as blood pH within normal limits. Heart rate and blood pressure must be monitored. Mean blood pressure must be kept between 70 and 90 mmHg, first by means of plasma volume expansion, and then norepinephrine if necessary. Hyperthermia must be corrected to prevent further neuronal damage. Cerebromeningeal sepsis should be ruled out. Capillary glucose (most often elevated) must be corrected using a pre-established insulin infusion algorithm. Rhabdomyolysis is rare, but can result in hyperkaliemia, acidosis, and acute renal failure. In case of associated intracranial hypertension (traumatic, vascular or infectious injury), status epilepticus is considered as a secondary insult for the brain, that can worsen neuronal damage. Numerous compounds have experimental neuroprotective properties, but none have proven significant efficacy in clinical conditions. Nevertheless, convulsion cessation is considered as a neuroprotective measure.     

Connaissance des nouveaux mots de la langue française dans les troubles cognitifs légers de type amnésique et la maladie d’Alzheimer

Introduction

The first decline in cognitive performance in Alzheimer's disease can appear when assessing semantic memory and can be detected long before the typical symptoms of Alzheimer's disease (AD), appearing with Mild Cognitive Impairment (MCI).

Patients and method

We propose the French version of the New Words Interview (fNWI) using 22 words to investigate semantic knowledge. The fNWI uses 11 words, which entered the French dictionary between 1996 and 1997, and 11 other words, which entered between 2006 and 2007. Words were paired according to orthographic and semantic criteria. Each word was associated with three sub-tests: free evocation, discrimination of the best definition from three propositions, and recognition of the accurate word context (two sentences were proposed). Regarding evocation, we distinguished conceptual definition, life situation examples or examples by use. We tested 12 patients with AD, 12 patients with amnesic Mild Cognitive Impairment (aMCI) and 72 controls (12 were paired with patients for age and education level).

Results

MCI patients and AD patients exhibited lower performance than controls in the three sub-tests and for the words of both periods. From the early stage of MCI, the patients were more impaired in the fNWI than in the context recognition task, and they failed to provide conceptual definitions of new words. Therefore, MCI patients suffer from semantic impairments before obvious clinical signs of AD.

Conclusion

In patients with AD, performance worsened on all subtests, and more strongly in the definition discrimination task, which suggests the impairment of stored semantic knowledge. They provided fewer conceptual definitions and failed to use the strategy observed in MCI patients, who compensated for conceptual difficulties by providing examples.     

Première évaluation d’un programme de remédiation cognitive chez des patients atteints de sclérose en plaques : PROCOG-SEP

Background

Although cognitive disorders are well-known in multiple sclerosis (MS), even in earlier stages of the disease, their management may be overlooked. Our objective was to elaborate and evaluate the efficiency of a remedial program (PROCOG-SEP) designed for MS patients. The evidence-based program proposes exercises to both stimulate preserved functions and develop new abilities compensating for cognitive disabilities.

Design/Methods

Twenty-four patients with MS participated in 10/2-hour PROCOG-SEP sessions over a 6-month period. A neuropsychologist recorded BCcog-SEP performances before and after the PROCOG-SEP program. In addition, the same neuropsychologist conducted psychoclinical interviews to complete the before and after cognitive evaluations. The statistical analysis used the t-test performed with Excel.

Results

Compared with the initial levels, subtests of BCcog-SEP showing improvement after PROCOG-SEP were: verbal memory (SRT), visuospatial memory (10/36), verbal fluency (animal categories) and response to conflicting orders. Also, individual psychological interviews tended to be in favor of a general improvement in quality of life (more social interactions for instance).

Conclusions/Relevance

To our knowledge, the management program we have elaborated is the first designed to improve cognitive deficits in MS. These encouraging results suggest possibilities for improving cognition and thus quality-of-life in MS patients.     

« Hors les lois de la guerre ». À propos du traumatisme psychique chez quatre soldats auteurs de meurtres en situation opérationnelle

Objectives

Following an aggressive situation, can the aggressors, as for the victims, suffer from a traumatic breakdown. As Military Psychiatrists, we have met veteran military murderers. All these patients present with a state of Post-Traumatic Stress Disorder with either severe alcoholism or severe depression (melancholy). We also compared the effects of treatment within the two groups, i.e. murders, and victims.

Patients

We chose four patient observations murderers. Their acts were committed “Except for the laws of war”, that is to say, forbidden by the Geneva Conventions. The alcoholic patients: Guillaume is a 45-year-old veteran from the wars in Indochina and Algeria. He has undergone several unsuccessful detoxification programs. One day, he finally tells the most significant episode of his history. While in Algeria, his lieutenant asked him to execute a prisoner. Since then, he has nightmares where he sees the scene, and calms his anxiety with alcohol. He was hospitalized and commenced psychotherapeutic treatment during which he relived his childhood, adolescence and his military career. Two months later, he is cured from his post-traumatic stress condition and alcoholism. Another veteran from Algeria, who was also a severe alcoholic: whilst there, he was ordered by his chief to execute three prisoners. A few years later, by chance he meets his former boss who tells him that the three victims were brothers. He is very shocked because he comes from a region of “vendettas” where it is said that one does not eliminate a family. These nightmares and his alcoholic career started there. Treatment will prove ineffective. The melancholic patients: Andre is a former veteran of Indochina. There, he participated in the massacre of villagers who had hidden enemies. He returned to France after his time engagement, married, had five children, and resumed his profession as industrial painter. After 5 years, he is assailed by nightmares and cannot stop to tell of the horrors to those around him. His wife eventually threw him out and he became a hobo (tramp) in his small town. Gradually during the night, he has hallucinations: he hears his Vietnamese enemies lurking around him waiting for a day to take revenge. He was hospitalized and fairly gradually, the nightmares disappear and then, slowly, his depressive state. Yanis is a 40-year-old veteran of the French Foreign Legion. He lives in Paris and gradually felt he was the center of a complot by Arab youths in the capital. He became aware of surprised looks and conversations, which indicated that they want to kill him. He took refuge in the Military Hospital, where he recounted the circumstances in which, in Africa, he killed a teenager. This act was the result of a misunderstanding, but he saw himself as a murderer of children. Again, the psychotherapeutic treatment resulted in healing.

Results

In three of our patients, the disappearance of the syndrome of repetition (repetition syndrome) and the alcohol and the melancholic state was achieved quickly. Probably because the “enjoyment” attached to traumatic images when the patient is a victim, here is outweighed by the horror of an act that the person has committed itself. Thus, the patient is willing much faster than when a victim, to get rid of the repetition syndrome.

Conclusion

Patient murderers feel themselves as guilty, which turn them to alcohol and ideas of persecution. Despite the severity of the conditions of post-traumatic stress presented by criminal murderers, do not hesitate to commence psychotherapeutic therapy.     

Trouble déficit de l'attention-hyperactivité de l'enfant et l'adolescent : du diagnostic à la prise en charge

What is the scientific evidence to support ADHD as a disorder? What are the risks of the use of stimulant medication? These questions are frequently discussed and often with passion. The objective of this article is to present the conclusions and recommendations relative to these questions. The International Diagnosis criteria retained are those of DSM-IV which describe three subtypes of ADHD : ADHD primarily of the inattentive type ; primarily of the hyperactive-impulsive type and a combined type. Establishing a diagnosis of ADHD requires a rigorous strategy, and it should be operated by stages: one to receive requests, one to collect information, and one to confirm the diagnosis. The use of scale is a clinical option but cannot be a substitute to clinical diagnosis. A therapeutic approach must combine several modes of intervention such as the use of stimulants and psychosocial treatment. The treatment will have to be revised regularly according to beneficial effects.