Troubles de l’humeur et chirurgie de l’épilepsie : une revue de la littérature

AimsHistorically, there is a strong link between depression and epilepsy. Patients with epilepsy are four to five times more likely to develop a depressive syndrome. It seems that the link between epilepsy and depression is bidirectional. There is little data on mood disorders secondary to epilepsy surgery. The goal of epilepsy surgery is to reduce the number and frequency of attacks, which in turn would allow improvements in mood disorders and cognitive impairment.MethodsA systematic search of the international literature was performed using the bibliographic search engines PubMed and Embase. The following MESH terms were used: epilepsy surgery AND (depression OR depressive disorder OR mood disorder). We also used the “related articles” of PubMed, bibliography surveys, conference abstracts and Google Scholar to identify additional relevant papers.ResultsOf the 130 studies found by the systematic search, 112 are excluded because they did not take into account the mood disorders secondary to epilepsy surgery. Fifteen studies are included in this review of the literature with a case study. Depression is the psychopathological condition that is the most frequently studied. According to several studies, the prevalence of depression is approximately 30% with nearly 70% of cases diagnosed during the first three months following epilepsy surgery. The majority of patients presented depressive symptoms during the first 3 to 12 months after epilepsy surgery. In these studies, the risk of developing depression is correlated with the existence of previous depressive elements relative to the epilepsy surgery. A small number of studies reported cases of de novo depression. Studies have shown a correlation between very good to excellent control of epileptic seizures and a persistent improvement of mood disorders. It would seem that depressive symptoms post-surgery are more common when the surgical intervention concerns the temporal lobe and in particular mesial resections. There are only very few cases of maniac episodes. Hamid et al. showed an increased risk of suicide waning after the epilepsy surgery over a period of 5 years.ConclusionMood disorders are common psychiatric comorbidities in epilepsy surgery. The detection, prevention, and treatment of these symptoms in patients eligible for epilepsy surgery pose major challenges for psychiatrists and neurologists, requiring their close collaboration.     

La SEP de l’enfant : est-elle différente de celle de l’adulte ?

IntroductionMultiple sclerosis (MS) is not uncommon in children. The aim of this study was to compare early onset MS (EOMS) with adult onset MS (AOMS).MethodsA retrospective study including MS cases between 1997 and 2010. EOMS was defined by age at MS onset < 18 years. Data were collected using the EDMUS database (European Database of Multiple Sclerosis) including: sex, age at onset, disease duration, EDSS, score after relapse. The MSSS and the Progression Index were calculated. Patients with disease duration less than one year were excluded. MS symptoms at onset and at further relapses were also noted. These parameters were compared between the EOMS and the AOMS groups.ResultsTwo hundred fifty-nine cases were included including 31 EOMS (11.96%). The mean follow-up was 96 months. The relapsing-remittent form was significantly more frequent in the pediatric group (94% vs 79%). Mean EDSS and MSSS scores and the percentage of fast progressors (MSSS > 5) were lower in the EOMS group. Analysis of neurological symptoms at the first MS attack and further neurological events showed a lower frequency of gait disturbances, motor symptoms and bladder symptoms in the EOMS group compared with the AOMS group. The 10-year mean EDSS score was 1.9 for EOMS and 4.1 for AOMS, after 25 years it was 4.5, and 7.27 respectively.ConclusionThis study highlights the relative frequency of EOMS in our MS population. However, different severity scores showed less disability progression in EOMS patients compared with AOMS patient; irreversible disability was reached at an early age.     

Prise en charge de la crampe de l’écrivain : 14 ans d’expérience de la toxine botulique

IntroductionWriter's cramp is a focal dystonia; treatment remains disappointing. We report our 14-year experience with a population of 119 patients aged between 18 and 85 years (average age 43 years).MethodsTreatment was based on botulinum toxin injections (Dysport^®) and physiotherapy. Patients were reviewed every four to six months with clinical and video evaluation by three different observers and subjective analysis of the treatment efficiency by the patient (score of 1 to 3). The post-injection deficit, if present, was also quantified.ResultsIn the group treated with toxin and physiotherapy, cramps improved (score 2 and 3) in 61.6% of patients; a majority of patients (n = 14) reported they were moderately satisfied (score 2). In the group treated with toxin alone, 37.9% of patients were improved (score 2 and 3) with a majority (n = 18) very satisfied reporting normal writing (score 3). Age was not a predictor of therapeutic response. Good results were obtained with injections of the flexor carpi radialis followed by flexor digitorum profundus II and III and the flexor pollicis longus. Seventy-one per cent of injections caused moderate muscle weakness, minimally disabling compared to the benefit of injections. Twenty-seven patients were followed for more than two years and three patients, who had achieved score 3 with excellent response, were followed for 14 years with very efficient repeated injections. If the injections were not effective the first time, we re-assessed the situation and adjusted the injections; we considered that toxin treatment was unsuccessful after three injections without benefit.ConclusionThe choice treatment for writer's cramp remains well-targeted injections of botulinum toxin. Physiotherapy is useful when the toxin injections are ineffective in completely improving writing. This requires close cooperation between the injector, the physiotherapist and the patient.     

Psychédéliques,psychothérapie et symbolisation : une revue de littérature dans le champ de la dépression

AimThis article proposes a literature review focused on the so-called “classic” psychedelics (LSD, psilocybin, DMT, and mescaline) and, more specifically, on their use in the psychotherapy of major depressive disorders and the way they affect symbolization processes.MethodAfter some introductory remarks on psychedelics and depressive disorders, we describe some modern clinical trials, and then explore the peculiar phenomenology occurring in the psychedelic experience, as well as its therapeutic effects on depressive symptoms. The underlying mechanisms are discussed from a perspective at the crossroads of cognitive neurosciences and psychoanalysis. We conclude with some reflections on the crucial role of the setting.ResultsThe results already obtained suggest that a single dose, taken in a supportive environment, may be sufficient to produce significant and immediate therapeutic effects, which are still present six months after the dose, although less so for some patients. Clinical response depends on the subjective aspects of the individual experience. More specifically, it seems correlated with the ability to “let go” and to allow autobiographical memories to emerge, along with the intense emotions they carry. It also relies on the presence and intensity of mystical-type experiences, characterized by feelings of “ego dissolution,” unity with everything, transcendence of space and time, and ineffability.DiscussionPsychedelic-assisted therapy seems to promote the emergence of primary processes and the lifting of defense mechanisms. Psychedelics would thus catalyze the resumption of symbolization processes, favoring in particular the integration of unconscious conflicts as well as the remodeling of pathogenic object relationships. On the neurobiological level, these processes would be underpinned by a decrease in the activity of the default mode network – sometimes considered the primary biologic substrate of the Freudian ego –, associated with an increase in brain entropy and in neuroplasticity. These different elements entail a decrease in depressive symptomatology, particularly ruminations. Common factors identified as the cause of positive changes in classical psychotherapies appear naturally amplified in the psychedelic experience, which requires the containing function of a therapist and a supportive clinical setting to allow a resumption of symbolic processes. To ensure the perpetuation of the observed transformations, which often exceed the simple withdrawal of symptoms, an extended psychotherapeutic monitoring would be appropriate.ConclusionThe psychedelic substance acts as a catalyst, allowing an access to otherwise inaccessible unconscious materials, which can then be processed both spontaneously and within the therapeutic relationship. Considering the data discussed in this review, we emphasize the need for further research exploring the potential of this treatment, which also offers the hope of a renewed dialogue between psychiatry and psychology, neurosciences and psychoanalysis.     

Neuroimagerie de l’insight dans la schizophrénie : revue de la littérature

ObjectivesInsight in psychiatry has been defined and conceptualized in a number of ways but none of them was found to be self-explanatory. There has been an exponential rise in studies of insight, in part accelerated by the availability of several psychometric scales for measuring insight. Lack of insight has been associated in schizophrenia with low treatment adherence, a high number of relapses, increased number of hospital admissions, and subsequently poorer psychological and cognitive functioning. For this reason, there is considerable interest in understanding the underlying neural mechanisms of insight, which may have important implications for the development of future insight-oriented neuro-psychiatric treatment. Neuroimaging may be considered an important technique to help understand the anatomical, functional and metabolic neurocircuitry underlying poor insight in schizophrenia. Growing neuroimaging research provides evidence for underlying brain impairment in insight deficits in schizophrenia. In order to expose a panoramic view to the readers, this article reviews the neuroimaging studies conducted to date, which have investigated the neural bases of insight in schizophrenia.MethodsElectronic searches were performed in PubMed, PsycINFO, Sciencedirect and Web of Science databases, using the following keywords: Imaging; neuroimaging; Positron Emission Tomography (PET); spectroscopy; functional Magnetic Resonance Imaging (fMRI); structural Magnetic Resonance Imaging (MRI); Single Photon Emission Computed Tomography (SPECT); Voxel Based Morphometry (VBM); Diffusion Tensor Imaging (DTI); Computed Tomography (CT); Insight; schizophrenia; awareness of illness. Searches were also performed from the references of the systematic review articles on neurobiological correlates of insight in schizophrenia. Animal studies and single case reports were excluded. Twenty-five articles were selected for the present review. From these; 12 used structural MRI; 6 used VBM; 3 used fMRI; 2 used CT; 1 used DTI and 1 used VBM combined to DTI.ResultsThe search showed that studies in this area were published recently and that the neuroanatomic substrate of insight in schizophrenia has not yet been consolidated. This inconsistency could arise from the complex nature of insight and the use of a variety of insight assessments. Most of the studies analyzed in this review used structural neuroimaging techniques to assess brain abnormalities associated with poor insight. The functional neuroanatomy of insight has only recently been investigated and to our knowledge, there are only 3 studies that have examined brain activity with fMRI in relation to insight in schizophrenia.ConclusionThis review investigated the neural deficiencies underlying poor insight in schizophrenic patients. In spite of methodological differences among studies, results provide evidence of structural and functional brain abnormalities in frontal, parietal and temporal region related to insight deficits. Some studies have found a hemispheric asymmetry in relationship to poor in insight (the majority of brain abnormalities concern the right hemisphere). In addition, growing research indicated that the prefrontal cortex, particularly the dorsolateral prefrontal cortex, the anterior cingulated cortex, the insula, the precuneus and the cerebellum can also underlying insight in schizophrenia. It is interesting to mention that some authors have suggested that each dimension of insight can be specifically linked to certain brain structures. Taking together, data on the neuropsychological and neuroanatomical correlates of clinical insight suggested that lack of insight in schizophrenia could be conceived as a neurocognitive deficit, analogously to anosognosia in brain injury and dementia. On the contrary, to date, the neuroanatomical correlates of cognitive insight have been scarcely studied. Only two studies reported that Self-reflectiveness was positively related to gray matter volume of the right ventro-lateral prefrontal cortex, the BCIS composite index was positively correlated with total left hippocampal volume, and Self-certainty was inversely correlated with bilateral hippocampal volumes. However, it is important to note that neuroimaging research on cognitive insight in schizophrenia is in a preliminary, and the results on this are inconclusive. Further research is needed to better understand the causal relationships between brain abnormalities and degradation of insight in schizophrenia.     

Tempéraments affectifs prébipolaires dans les dépressions récurrentes : vers un dépistage de « fausse unipolarité »

IntroductionThe current categorical split of mood disorders into bipolar disorders and depressive disorders has recently been questioned after the widening of the bipolar spectrum. Recent studies have suggested that clinicians may under-diagnose bipolarity in a substantial proportion of depressed patients, and have proposed the existence of a “pseudo-unipolar” depression. On the other hand, many studies were made to identify factors correlated to bipolarity in depressive disorders. They have shown that the main clinical factors correlated to bipolarity are: pharmacological hypomania, puerperal depression, early age of onset, psychotic features, hypersomnia and psychomotor inhibition. In this context, it should be interesting to study temperaments as predictive factors of bipolarity in depression and to explore their correlation with those clinical predictors.ObjectivesThe aims of this study were to assess affective temperaments in patients with recurrent depressive disorders, and to explore the correlations between these temperaments and clinical features of depressive disorders.MethodsThe study was a cross-sectional one bearing on 91 recurrent depressive patients (40 men and 51 women, mean age: 46.8 ± 10.1 years), who were interviewed using the DSM-IV Structured Clinical Interview during the partial or total recovery period. Data was collected using available medical records. The evaluation of affective temperaments consisted in filling in the Akiskal and Mallya semi-structured questionnaire.ResultsThe depressive temperament obtained the higher mean score (12.3 ± 4.74), followed by the hyperthymic temperament (7.8 ± 4.5), the cyclothymic temperament (5.9 ± 5.8) and the irritable temperament (4.9 ± 3.3). A significant association was found between the onset of the first depressive episode during the postpartum period and the cyclothymic temperament score (7.4 ± 6.9 versus 3.3 ± 3.6, p = 0.04). The psychotic features in the last depressive episode were significantly associated with the hyperthymic (p = 0,001), the cyclothymic (p < 10^?3) and the irritable temperament scores (p < 10^?3). A significant link was found between suicide attempts during the last depressive episode and the cyclothymic temperament on the one hand (p < 10^?3) and the irritable temperament on the other hand (p = 0.01).ConclusionsThe recurrent depressive disorders with hyperthymic, cyclothymic and the irritable temperaments seem to have clinical features similar to those of bipolar disorders. These results point to the importance of evaluating these temperaments in depressed patients, considering the risk of polarity change and of misdiagnoses of unipolar depression.     

Impacts de la combinaison de programmes de soutien à l’emploi et de remédiation cognitive sur le maintien en emploi de personnes souffrant de schizophrénie : une méta-analyse

ObjectivesAbout 80% of people suffering from schizophrenia are not working despite their desire to obtain a job. The rate of employment and job tenure remain below the average of the non-clinical population even though supported employment programs (SE) were implemented. Cognitive deficits, among other factors, could influence the occupational functioning of people suffering from schizophrenia. Given that these deficits are highly prevalent in people who have experienced multiple episodes of psychosis, numerous studies have evaluated the efficacy of integrating cognitive remediation to SE programs. Our objective was to conduct a meta-analysis to evaluate the efficacy of these combined programs (SE+) in terms of job tenure.Material and methodsWe searched the literature in several databases (Medline, Embase, Pubmed, PsycInfo, et Cochrane Library) using different keywords (“schiz*”AND “vocation*” AND “rehabilitation or recovery” AND “cogniti*” AND “random* control*”). The selection of studies was limited to those written in French or English, using a randomized-controlled trial or prospective design, including participants with a schizophrenia-spectrum diagnosis, including and presenting work outcomes (e.g., work duration, job acquisition) of a program combining SE and cognitive remediation programs. Following data extraction, we calculated the Hedges’ g effect size for each study that reported job tenure outcomes. We used a random-effects model and evaluated heterogeneity with the Cochran's Q-statistic and the I2 index. Publication bias was estimated through the use of a funnel plot, the Rosenthal's fail-safe N and Egger's asymmetry test.ResultsWe identified 12 studies that presented different SE+ programs comprising 334 and 322 persons suffering from schizophrenia assigned to treatment and control conditions, respectively. Our quantitative results suggest that combining cognitive remediation and SE programs do not significantly impact job tenure. Although our analyses suggest the presence of heterogeneity and publication bias, it is still advisable to conduct a meta-analysis because it allows circumventing the biases introduced when using the vote counting technique (i.e., simply comparing the number of positive and negative studies). Our results should thus be considered as exploratory and future meta-analyses are encouraged when a significantly larger number of studies on the subject will be published.ConclusionsVarious improvements to the reviewed programs could be implemented in order to enhance job tenure, notably by integrating other components such as social skills training or by focusing the remediation on cognitive functions more closely related to job tenure.     

Utiliser les psychédéliques pour « guérir » des adolescents homosexuels ? Essai de thérapie de conversion,France, 1960

Between 1960 and 1962, a children's judge placed two French adolescents in a psychiatric hospital in Alsace. Described as “delinquent sexual perverts”, Michel, 15, and Bernard, 18, were in fact two young homosexuals. However, at the time, homosexuality was considered a psychiatric disorder that should be “cured”. With this in mind, psychiatrists set up shock or disgust therapies to push patients to become heterosexual. In this hospital, the chief doctor tested two new substances on them: mescaline and LSD. Injected in very high doses, the idea was to cause a powerful psychological shock in the hope of changing the adolescents’ sexual orientation. This type of placement as well as the treatment inflicted were then common (lobotomies or electroshocks were part of the “therapeutic” possibilities to “cure” homosexuality). Two aspects of these experiments are however particularly original: on the one hand, the use of substances such as mescaline and LSD, on the other hand, the very type of “therapy” implemented. It would thus seem, in the current state of knowledge on the use of LSD and mescaline in psychiatric therapy, that these experiences were isolated facts: the literature remains silent on the subject of the use of mescaline to “cure” homosexuality, and the few known therapies carried out using LSD were offered to adults and above all volunteers. Finally, these therapeutic methods were the opposite: psychotherapies in which particular attention was paid to patients and their well-being in the United States or in England and “psychic shocks” in Alsace. This hospital is the only French example of an attempt to “treat” homosexuality using psychedelics. The use of these substances by the French team therefore began in 1960; it involved administering mescaline or LSD in high doses (an exceptional characteristic in Europe where psychiatrists were in favor of therapy with low doses known as “psycholytic”) and in injections, ranging from 200 to 1200 mg for mescaline and for LSD from 100 to 800 micrograms. By way of comparison, a recreational dose is 300 to 500 mg for mescaline and 100 micrograms for LSD, administered orally. In order to create “psychic shock”, the effects of the substances were immediately stopped by the injection of chlorpromazine, a powerful neuroleptic. The authors noted that for all patients, “two modes of behavior are common: stupor and agitation”. They sometimes tore their sheets or pajamas or grabbed the examiner, asking for support. The sessions were linked: in 118 days, Bernard would undergo 16 of these sessions, one every 7 days on average. Michel, during one of the sessions, felt like he had been killed by his psychiatrists. Neither would subsequently become heterosexual. Elsewhere in the world, other forms of LSD conversion therapy have emerged. However, these were benevolent psychotherapies; the product was not injected but taken orally (therefore with more progressive effects), and the approach was not the same. Thus, acceptance of their homosexuality by patients was considered as desirable an option for therapists as was conversion to heterosexuality. For French practitioners, on the contrary, “healing” was the only objective. This article will highlight a double French specificity in the use of psychedelics: first, the refusal to introduce the new method of administering these substances, called “set and setting”, theorized from the late 1950s in Anglo-Saxon countries, and yet known and discussed by French experimenters. Then, it will show the use of these substances in shock therapy, particularly in the treatment of homosexuality.     

Validité cross-culturelle de la théorie cognitive de la dépression : une comparaison franco/nord-américaine

This prospective study provided a direct comparison of French and American samples on variables central to cognitive theory of depression. Using the Experience Sampling Method and identical measures across sites, subjects were signaled five times daily for one week to provide reports of negative events, attributions, and depressed moods. Controlling for effects associated with gender and trait anxiety and depression, significant differences emerged between French and American samples concerning the average severity of daily negative events, depressed moods, and causal attributions. However, the relationships between these variables (the fundamental hypothesis of cognitive theory) was largely unaffected by sample source. The results underscore the importance of cultural factors for the experience of specific variables, but provide support for the generalizability of the theory’s tenets across French and American populations.