Une clinique de l’apotemnophilie

IntroductionThe term of apotemnophily was used for the first time by Money in 1977 to name patients who desire an amputation of a healthy limb.CaseWe present a case report of a thirty-two years old military woman, who was hospitalized in a neurology service because of a chronic pain syndrome. The disorders began with a knee trauma complicated by chronic pain causing multiple complaints. At first sight, we are challenged by her desire to amputate her lower limb.DiscussionA literature review highlights controversial positions regarding the nosographic place of apotemnophily: initially classified within paraphilias, the desire to amputation of a healthy limb was later identified by some authors as a body integrity and identity disorders and then studied as a neurological disorder. The clinic of our patient open minded our diagnostic reasoning to other clinical entities such as a depressive disorder with melancholic and psychotic characteristics, an illness anxiety disorder, a body dysmorphic disorder.ConclusionBeyond the controversies, the main risk for these patients is to meet a doctor who decides to treat them with a mutilatory surgical gesture. The therapeutic challenge is to create the conditions of reception of this complaint and to hear the identity claim that it carries. The multidisciplinary approach associating psychiatrist, clinical psychologist and sometimes surgeons when it's appropriate, must prevent medical nomadism and must try to relieve the patient from the suffering of identity.     

Peur de l’intimité dans la relation amoureuse adolescente : implication de l’attachement parental et de l’attachement romantique

Teen dating is a developmental stage questioning dramatically the relationships to be expected with others, especially when feelings of tenderness and love are involved. It mobilizes parental attachment and the internal working models related to it, while being colored by the emerging romantic attachment and its brand new internal working models. Attachments are deeply shaped by a dynamic interaction whereby the self tries to figure out how to reach security and autonomy still taking the other into account. This considered, intimacy also implies a dynamic feature: on the one hand, closeness and sharing of feelings and/or experiences, and on the other hand, individuality and maintaining of one's ego. However, just like attachments may be insecure, a fear of intimacy cannot be underestimated during dating. Eventually, bearing in mind the societal and cultural components of attachment and intimacy, gendered explanations cannot be ignored, especially during adolescence.

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.     

Télémédecine et troubles du spectre de l’autisme de l’enfant et de l’adolescent : guide théorique et pratique

ObjectivesThe development of telemedicine for children and adolescents is a real need because of difficult accessibility of mental health and the paucity of childhood psychiatrists. Thus the American Academy for Child and Adolescent Psychiatry (AACAP) published in 2008 good practice recommendations for telepsychiatry in children and adolescents based on clinical consensus and scientific evidence. In France the legal framework defines four practical modalities according to the presence or not of a health professional or a psychologist with the practitioner accomplishing the teleconsultation act. Data exist about the outcome of children and adolescents who benefited from therapeutic interventions with technological media. Effect size is modest but it doesn’t justify ruling out these techniques. Children who present with a developmental disorder or who cannot cooperate are evaluated with a certain degree of uncertainty. By contrast, some children with severe Attention Deficit with or without Hyperactivity (ADHD), social anxiety or Autism Spectrum Disorders (ASD) can be more easily engaged within a teleconsultation model. Teleconsultations in autism spectrum disorders (ASD) are feasible because of the nature of diagnosis and the type of care recommended in this disorder. The behavioral nature of the disorder and the behavioral therapeutic approaches recommended in North America culture highlight the potential interest of telemedicine because these disorders are easily observable. Literature suggests new opportunities in order to facilitate the care process for the ASD person and his family: the first one is diagnosis with use of validated instruments such as the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview (ADI). Parental accompaniment is the second opportunity. Development of telemedicine for ASD could be a complementary approach for diagnosis and medical care.MethodSince 2015, a program called PROMETTED (PROgramme MEdical de Télépsychiatrie pour enfants et adolescents présentant un Trouble Envahissant du Développement) was supported by Regional Health Agency of Île-de-France. It was developed and managed by the team of a Diagnosis Center Evaluation for Autism (DCEA) of Paris area in collaboration with a DCEA of Île-de-France region. Five medico-social structures for children and adolescents with autistic disorders and the two diagnosis centers of evaluation for autism co-elaborated a scheme of intervention with telemedicine. The remote evaluation is a 4-step process: a first teleconsultation structured around the medical history of the subject in order to complete his medical file and the observation of the young subject; a second teleconsultation structured around the ADI-R interview with parents; the third teleconsultation is a mixed teleconsultation associating the medical expert of the DCEA and a psychologist trained in the use of the Childhood Autism Rating Scale (CARS) and the Vineland Adaptive Behavior Scales (VABS). The fourth teleconsultation consists of the psychiatrist giving feed-back to parents about the results of the observations of the DCEA team.ResultsThe four-step program is well-accepted and the use of validated instruments for diagnosis or functional evaluation appears feasible. Medical data were completed for 44% of cases; complementary genetic or medical investigations were prescribed for 50% of cases; medical advice about psychotropic or vitaminic medication was given for 31% of cases. Mean duration of evaluation was 11.1 weeks ± 9.4.ConclusionsThe PROMETTED program empirically validates the concept of remote evaluation for children and adolescents with ASD. The need to extend the use of telemedicine to tele-expertise for medicine monitoring or behavioral disorder management has been noted.     

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.     

De l’absence ou non de contrainte dans l’École Freinet

AimThe article raises the question of the bodily and therapeutic constraints that pervade the methods of Elise and Célestin Freinet, pedagogues in the Freinet School in Vence over time.MethodsThis paper is based on the work conducted by a team of researchers from Nancy, France, on the objectification of the educational practices of the Freinet School in Vence, including both historical-philosophical and ethno-didactic aspects.ResultsThis exploration, beyond the doxa of the “Freinet pedagogy”, demonstrates the existence of a specific dialectic between constraint and freedom in the history of the Freinet School pedagogy.DiscussionThis pervasiveness of the therapeutic constraint at Vence can be seen in the very organization of the educational environment in the school. It is fully articulated with the educational project.ConclusionAlthough the Freinet School has evolved since its opening in 1934 and its purchase by the State in 1991, and although the issue of therapeutic restraint has dwindled, a style of thinking has nevertheless remained in the educational practices. This strongly questions our educational habits.     

Tentative de suicide chez l’enfant et l’adolescent et bipolarité

Background

Child and adolescent psychiatrists are frequently confronted with suicide attempts and comorbid mood disorders. Diagnoses of juvenile bipolar disorders (BD) are rare and controversial and standardized assessment is helpful for a reliable diagnosis. The main objective of this study was to identify the number of juvenile bipolar disorder diagnoses according to DSM-5 criteria in a population of children and adolescents hospitalized for suicide attempts. Secondary objectives were the assessment of a patient's characteristics and the comparison of suicide attempt recurrence during 12 months of follow-up.

Cancer du sein en ligne : effets de l’utilisation des technologies de l’information et de la communication

Objectives

We want to know the effects of virtual exchanges places, on psychological adaptation of women patients to cancer pathology, and especially breast cancer.

Contribution à l’étude clinique des institutions de soins. Le fantasme de l’institution malfaisante

In France, the lens with which clinical psychology gazes through institutional matters seems limited to what happens between patients and professionals. It pays little interest to the interactions between the administration of the institution, i.e. organizational matters, and the daily clinical setting of mental health care. Unconscious institutional dynamics seem to receive much more attention from management sciences, which sometimes use psychoanalytical concepts to shed light on managerial and organizational problems. This article, based on an action-research study in a French university hospital, aims to shed light on one of the unconscious mental constructs which could be at the root of what several authors in psychiatry have identified as “institutional paranoia”: the fantasy of a malicious institution. We hypothesize that this fantasy, which attributes harmful intentions towards its agents to the institution, is a recurrent avatar of the typical problem institutional psychology deals with. It is therefore even more specific to hospitals, due to the abundantly documented tensions which they have been faced during the last two decades. We were initially appointed to conduct a “cooperative action research” project in a French University Hospital Centre between October 2018 and September 2019, in order to write a preliminary research report on the quality of working life as experienced by its personnel. Four ethnographic qualitative research techniques were used to assess the needs of healthcare professionals: individual and group interviews with teams from all departments (health care, administrative, logistical and technical), on formal or informal times, participant observations in services which were later recorded in a written logbook, interprofessional working groups called “thematic commissions” that met for five sessions of 3 hours each and the creation of a digital “suggestion box” accessible on the hospital's intranet. Our results show the fantasy of the malicious institution deserves to be isolated due to its three constitutive elements: 1) a blurry institutional governance and incarnation of the hospital's leadership; 2) the recognition of the symbolic power of the institution, including its coercive power; and 3) the attribution of negative intentions to the institution by aggressive projections, which in turn transform it into a persecuting object. We discuss the link between the feeling of belonging to the institution and the feeling of abandonment as experienced by staff in regards to the religious past of French hospitals, and indicate the necessity but also the caution with which research can and must investigate the weight of the personal history and vulnerability of each individual in his or her sensitivity to the representation of the malicious institution.     

Psychotraumatologie : manifestations psychologiques immédiates et post-immédiates de victimes de l’explosion de l’usine AZF de Toulouse

The explosion that took place at the AZF factory in Toulouse was a catastrophic event that had considerable human and material consequences. Many people were physically impacted and even more were affected psychologically. This article is a report on the immediate and post-immediate psychological manifestations as expressed by victims during consultation at the crisis centre that was set up in the wake of the explosion.     

Psychopathologie de l’énonciation dans le champ de la clinique de l’agir : la notion de subjectivité sans sujet

Objectives

To study the characteristics of a specific psychological mode of functioning, subjectivity without a subject, generating non-motivated behaviours, in a setting where consciousness and mental representations are erased in subjects having committed an offence or a crime, sexual or other.

Utilisation du midazolam dans l’état de mal épileptique réfractaire de l’enfant

Morbidity and mortality are high in children with refractory status epilepticus (RSE). Here, we assess the efficacy of midazolam for RSE in children.MethodsThis was a retrospective analysis of 29 children admitted to the Lille University Hospital pediatric intensive care unit (PICU) for RSE between May 2006 and July 2008. The onset of the study corresponded with a new therapeutic protocol applied in the PICU for RSE where midazolam was proposed as the first-line treatment (bolus ten continuous infusion until control) to be replaced by thiopenthal in case of failure.ResultsWe recorded 29 patients with RSE during the study period: 26 were treated with midazolam, including two where midazolam replaced thiopenthal because of hypotension. Midazolam successfully controlled RSE in 58% of patients. Mean delay to cessation of RSE was 48 ± 65 minutes. Hypotension was observed in 8% of midazolam-treated patients and 71% of thiopenthal-treated patients. Overall mortality was 15% (4/26). Two deaths occurred long after the cessation of RSE. None of the deaths occurred in midazolam-treated patients.ConclusionMidazolam is an efficient treatment for RSE in children. Morbidity and mortality appear to be lower with midazolam compared with other antiepileptic drugs used for the treatment of RSE.     

À propos de l’expérience de la torture

The large influx of asylum seekers confronts public mental health services with the suffering resulting from extreme political violence. Among these patients, survivors of torture present a unique clinical profile of which clinicians should be made aware. While certain researchers have proposed useful concepts, the statements of witnesses and the writings of clinicians constitute the point of articulation between theory and practice. In this article, we will attempt to understand the ways in which torture results in psychosis (“a laboratory of psychosis”), notably through the specific and ambiguous role of the imaginary. A specific focus will be dedicated to the processes of humiliation, which illuminate a dialectic between the body and the mind, between the physical wounds and the long-lasting injuries inflicted on the soul; torture causing, intentionally, the possibility of a rupture between the ego and the ideal of the self. Finally, the article will critically examine the role of the therapist; so that clinicians will be able find a favorable resolution to the pathogenic conflicts involved.     

Formations de l’idéal,Hikikomori et virtuel à l’adolescence

Goals

Withdrawal behaviours among teenagers have become a major topic in both clinical practice and the specialized literature. Known since the 1980s in Japan as Hikikomori, these behaviours are found across international nosographies in a variety of models. They are not always accompanied by intensive video gaming. There are varied uses of digital technology among teenagers, in terms of both quantity and quality. They can relate to the formation of an ideal, on the boundaries between virtual reality and illusion, it can also be a step toward the renewal of social relationship, since it enables a less threatening confrontation with the object.