Applications de la réalité virtuelle en psychiatrie légale : la perspective de l’autorégulation comme cadre théorique

IntroductionForensic psychiatry is the field whose expertise is the assessment and treatment of offending behaviours, in particular when offenses are related to mental illness. An underlying question for all etiological models concerns the manner in which an individual's behaviours are organized. Specifically, it becomes crucial to understand how certain individuals come to display maladaptive behaviours in a given environment, especially when considering issues such as offenders’ responsibility and their ability to change their behaviours.Virtual realityThanks to its ability to generate specific environments, associated with a high experimental control on generated simulations, virtual reality is gaining recognition in forensic psychiatry. Virtual reality has generated promising research data and may turn out to be a remarkable clinical tool in the near future. While research has increased, a conceptual work about its theoretical underpinnings is still lacking. However, no important benefit should be expected from the introduction of a new tool (as innovative as virtual reality) without an explicit and heuristic theoretical framework capable of clarifying its benefits in forensic psychiatry.ObjectivesOur paper introduces self-regulation perspective as the most suitable theoretical framework for virtual reality in forensic psychiatry. It will be argued that virtual reality does not solely help to increase ecological validity. However, it does allow one to grant access to an improved understanding of violent offending behaviours by probing into the underlying mechanisms involved in the self-regulation of behaviours in a dynamical environment. Illustrations are given as well as a discussion regarding perspectives in the use of virtual reality in forensic psychiatry.     

Utilisation de l’activité physique pour la prise en charge thérapeutique de l’épisode dépressif caractérisé chez l’adulte

The impact of exercise has been the subject of significant work for two to three decades. The results of these studies have enabled national and international comities to issue specific recommendations. Their impact on physical health is now well documented. The effect of physical activity on mental health in general, and for the management of major depressive disorder in particular, is the subject of more recent interest. The purpose of this article is first to carry out a review of the literature on this subject in order to identify the level of evidence of the effectiveness of use of exercise in the treatment of major depressive disorder. Secondly, the known data on the impact of physical exercise on physical health are summarized. Finally, the article provides an update on the regulatory framework for its use in France and the methods of use in current practice by the clinician.     

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.

Accompagner les professionnels de santé dans la révélation de l’erreur : de la révélation à soi à la révélation à l’autre

Error disclosure is now an ethical and professional obligation for health professionals and seeks to improve quality and safety in healthcare. Literature has highlighted the numerous benefits of error disclosure and several authors have described the options for handling this situation. However, it is not quite that simple to be honest and open and follow a protocol that instructs professionals to explain, support and apologise in situations where they are subject to criticism. While the many personal, institutional and social factors that hinder open disclosure have been identified, little attention has been paid to the obstacles associated with the psychological impact of disclosure, thereby limiting the debate on how professionals might be supported in their efforts to cope with error disclosure. The psychological impact of error on professionals is a well-established fact. Physicians are “second victims” likely to be emotionally affected by medical error. Emotional distress, anger, isolation, fear, guilt and shame can be intense, suggesting that, far from being an isolated act in professional practice, a medical error is a life event that modifies the psychological balance of a professional. Studies in the humanities have shown how work shapes individuals’ identities. The choice to heal and care for is indicative of the ideals related to professionals’ life histories, cultures, family models and representations of health and disease. Work and, more specifically, recognition at work from their peers, patients and relatives enables health professionals to support their ideals and establish a coherent identity, and to belong to a workgroup. The error foreshadows a rupture which plunges the professional and the team in a state of vulnerability that rules out the professional's or the team's possibility to be part of a process of disclosing the error. In these conditions, a policy of security of care also involves a guarantee of the caregiver's and the team's psychological security. The term psychological security was developed by the psychoanalysis who emphasised the individual's need to evolve in a “sufficiently good” protective environment that allows him/her to contain his/her emotions, while giving the individual the possibility to express and discuss them. This space implies a relation of trust between individuals. Trust refers to the idea that the individual can trust someone, it is based on the capacity to create relations. It is only through trust that the professional will be able to open him/herself to others and construct a space where the errors and the doubts that he/she has in the context of work are shared. But if trust is essential, it is also dangerous because it implies accepting the risk of being dependent on those considered as trustworthy and the risk that they will not live up to the professional's expectations. As a consequence, the professional will only have trust when he/she has evaluated the possibility of cooperation and more precisely, as stated by Hardin, a cooperation in which the professional's interests are “encapsulated interests”, in other words the interests of others. Therefore, this cooperation depends on each member of the team seeing his/her interests as being partially those of the others. Cooperation within a service reveals the relations of trust between the professionals and shows the relations of dependence that each one maintains with the others for the good administration of care. Thus the creation of relations of cooperation between the team members proves to be an important indicator to determine the professional's possibility to adhere to a process of disclosing the error. This approach shows that professionals must address multiple rather than single disclosures: to the self, and to others (colleagues, hierarchy, patients and families) who will mobilise specific knowledge, emotions and psychological defences. To avoid cases where disclosure takes on dimensions as tragic as the actual errors committed, it is important to pay attention to the psychic state of healthcare professionals by offering a space of free expression that enables them to better understand their feelings and gain a sense of support in order to restore their ideals and professional identities. Finally, it's important to emphasize that disclosure also depends on the preservation or restoration of the relations of cooperation within the team. Disclosure cannot be prescribed, it must emerge within a workgroup who allows the error to be thought over, communicated and shared. In this context, disclosure becomes a group rule that is known to all. A health professional who feels sufficiently supported might, in turn, support a patient and/or his/her relatives and engage in meaningful disclosure.     

Nouvelles parentalités : l’enjeu de la parentalité psychique

We will put here the concept of psychic parenting to highlight the relevance of using it in the clinic of new parenthood. Indeed, the new ways of doing-family: homo-parenting, single parenthood and heteroparentality involve distinguishing biological infertility from social infertility. In the same way, the distinctions between biological parenthood, social parenting, psychic parenting are essential. On the occasion of the revision of the law of bioethics planned for 2018–2019 in France, we will thus try to nourish and enlighten the ethical debate essential to lead and at the heart of which we will place the child's interest.     

Place de la toxine botulique dans le traitement de la spasticité de l’enfant

IntroductionSpasticity is a motor disorder, which can be treated by botulinum toxin (BT). We found no studies describing BT management of spasticity in Tunisian children. The aim of our study was to determine the frequency of spastic children treated with BT in the Tunisian hospital population and to evaluate treatment efficacy.MethodsWe conducted a prospective study over a 5-year period including all children diagnosed with spasticity treated with BT and attending the “Movement Disorders and Botulinum Toxin” outpatient clinic of the National Institute of Neurology of Tunis.ResultsHundred and fifteen patients were included (31% of patients attending the “Movement Disorders and Botulinum Toxin” outpatient clinic). Mean age was 7.6 years and M:F sex ratio 1.7. Main clinical features were: spastic quadriplegia (48%), equinus deformity (70.4%) and cerebral palsy (88%). All patients were evaluated with the modified Ashworth score and were treated with BT. Other treatments were associated with BT: baclofene, physiotherapy, ortheses, plaster, and sometimes surgical treatment. The average percentage of improvement after BT was > 50%. The Ashworth score was significantly lower for the majority of injected muscles.Discussion and conclusionOur study is the first to describe BT management of spasticity in Tunisian children. Treatments of spasticity are numerous and vary according to location and extent of spasticity. BT is the main treatment for focal spasticity. Associated with physical therapy, BT allows optimal management of spastic children.     

Lecture des troubles de personnalité limite à travers la théorie de l’attachement

Borderline personality disorders concern clinicians and caregivers because of the violent and impulsive nature of their behavioral and affective reactions, which often confronts them to a feeling of helplessness and incomprehension. Indeed, it may be difficult to deal with self-harm, massive anxiety, intense affects and interpersonal ruptures, which are often present in the life course of the borderline patients. Their distress is particularly difficult to accept as it takes place in the therapeutic link, which reveals the core of the patient's attachment problematic. This paper aims to draw up an overview of borderline personality disorders, in light of attachment theory, which could help to clarify the involved mechanisms and gather the described behaviors in a coherent unit. Many studies relating to borderline personality disorder and attachment theory highlight what constitutes the specificity of these disorders through an integrative approach. Thus, the combination of an insecure attachment style, biological vulnerabilities and environmental stressors like traumatisms may induce the establishment of many defensive mechanisms, such as attachment system hyperactivation, emotional dysregulation or mentalization's failure. People suffering of borderline personality disorder activate these mechanisms as soon as they have to deal with real or imagined abandonments related to one of their attachment figures. However, in view of the massive anxiety and the severe disruption, those inefficient mechanisms cannot enable a good resolution of stressful situations. Consequently, borderline patients are likely to resort to new kind of emotional regulation such as suicidal, destructive and impulsive behaviors. Attachment based theories focus on these defensive mechanisms and inadequate attempts of emotional regulation, in order to propose an appropriate treatment for borderline personality disorder.     

De l’aliénation mentale de l’enfant et de l’adolescent à la pédopsychiatrie dans les communications à la Société Médico-Psychologique de 1852 à 1937

In 1848, the Société Médico-Psychologique was founded. Its aims is to promote the study and improvement of mental pathology. During the 19th century, François Arnaud (1858–1927), Claude-Etienne Bourdin (1815–1886), Michel Catsaras (1860–1939), Louis Delasiauve (1804–1893), Eugène Dally (1833–1887), Jules Fournet (1812–1888), Paul Garnier (1848–1905), Valentin Magnan (1835–1916), Jacques-Joseph Moreau De Tours (1805–1884), Emmanuel Régis (1855–1918), Paul Sollier (1861–1933), Edouard Toulouse (1865–1947), Auguste Voisin (1829–1898) and Jules Voisin (1844–1920) were the alienists or not, French or foreigners who succeeded at the chair of the Société Médico-Psychologique. This later presented observations of children or teenagers. The communications and discussions but also the issues raised by the alienists, neuro-psychiatrists then child psychiatrists will contribute to the reflections of members of the Société Médico-Psychologique over the course of the last century. But, they also forced us to take a more perceptive look at the child's mental health. Its communications and their authors belong to their time and to a time or even a place where they emerged. Apart from to looking into the topics pursued (deficiency, dementia praecox, epidemic encephalitis, autism, etc.) concerning the infantojuvenile psychiatry, we will carry out a work of communications contextualization focused on the child's mental health at the Société Médico-Psychologique during 170 years.     

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.     

Phénoménologie de la curiosité comme rupture temporelle : sur la route de la Beat Generation

Jack Kerouac's famous autobiographical novel “On the Road” tells the epic journey through the magnificent landscapes of the American continent through frantic, jazz-rhythmic writing. In this book, beyond the classical framework of a travel journal, Kerouac aspires to tell a style of existence through a style of writing. The perpetual feast of the senses and the erotic evokes the exalted adventure of the Beat Generation and testify to this style of existence characteristic of what phenomenology calls existential curiosity. In the midst of unexplored landscapes, unexpected encounters, in the aftermath of a flight to be pursued without ceasing, Kerouac aimed at the permanent improvisation, that of the “bebop”, that of the “instant literature”. The writing of a road that takes shape at the moment under the wheels of the car that traces its way as fast as it does erase it. And this is a perpetual quest for novelty, in openness to curiosity. It appears then that the phenomenological notion of this experience of curiosity, makes possible to approach the foundations and the wanderings of the beat generation, and more broadly the experience of the generations, which have succeeded.     

La naissance de la Société Médico-Psychologique. Mise en perspective et regard sur la naissance de l’American Psychiatric Association

The authors retrace the various stages of the birth of the Société Médico-Psychologique (SMP), which celebrated its 170th anniversary in 2022. They recall the context, notably a law enacted in 1838 that was considered as a foundation text for what was then called alienism and which would eventually become psychiatry. The work of Philippe Pinel and Jean Étienne Esquirol played an essential role in the founding of the SMP, and more broadly in the genesis of the discipline. Three phases can be distinguished in the foundation of the SMP: (1) the creation of the Annales Médico-Psychologiques (AMP), in 1843, a journal that would become the SMP bulletin; (2) the first constitution of the SMP which was announced by Jules Baillarger in the first issue of the AMP in 1848 and which included the first organizational rules and a first list of members; (3) For political reasons (The revolution of February 1848, a political coup d’état on December 2, 1851), the foundation of the SMP would officially first take place in 1852. A commission of members modified the first internal rules. A principle was established whereby the Society would be composed of physicians, philosophers, magistrates, clergymen, moralists, teachers, poets, etc. The professional journals announced at the time the establishment of a Society where “all the instruments of psychological analysis will be gathered and applied simultaneously”. The first meeting of the Society was held on the 26th of April 1852. The authors provide a list of the founding members, although there were some notable absences. The relations between the SMP and the Academy of Medicine, founded in 1820, are detailed. The first international members are mentioned. They came from The Netherlands, Spain, Italy, Russia, Austria and Germany, and at the end of the 19th century, from America as well During the same time period, similar learned societies were established, notably in the United Kingdom, Germany and Russia. The authors describe in detail the creation of the Association of Medical Superintendents of American Institutions for the Insane (ASAMSAII), the future American Psychiatric Association (APA), and of its Journal which would become the American Journal of Psychiatry. The details of joint meetings between the APA and the SMP in 1978 are reported. The birth of the SMP and of other learned societies in Germany, France and the United Kingdom marked the beginning of a discipline which was then called alienism and which would become Psychiatry.     

Effets de la ventilation en pression positive continue sur la dépression,l’anxiété et la qualité de vie au cours du syndrome des apnées-hypopnées obstructives du sommeil

IntroductionThe obstructive sleep apnea hypopnea syndrome (OSAHS) is a chronic stressor that may alter the emotional state and quality of life (QOL) of patients suffering from it. In this work, we proposed to estimate the prevalence of depression and anxiety, to assess the QOL in a Tunisian population of apneic patients, and to assess their evolution under continuous positive airway pressure (CPAP).MethodsWe conducted a prospective study, involving 33 apneic patients followed for SAHOS with moderate or severe class disease in the pneumology department at Hedi Chaker university hospital in Sfax, Tunisia. They received CPAP treatment for three months. We used an epidemiological record. Two scales, the Hospital Anxiety and Depression Scale (HADS) and the 36-item Short-Form Health Survey (SF-36), were completed before and after treatment to evaluate the effect of three months of treatment with CPAP.ResultsThe prevalence of depression in the study's patients, according to the HADS, was 45.5% and that of anxiety was 21.2%. After 3 months of CPAP, the prevalence of depression and anxiety had become 18.2% and 6.1%, respectively. QOL was impaired in 81.8% of cases before treatment, according to the SF-36. This figure had decreased to 69.7% after 3 months of treatment with CPAP. Apart from the third dimension (physical pain), all other dimensions were significantly improved after 3 months of CPAP treatment. The treatment with CPAP induced a significant improvement in the average scores of depression (P < 0.001), anxiety (P = 0.002) and QOL (P < 0.001).ConclusionsThese results attest to the importance of the frequency of anxio-depressive disorders as well as an altered QOL in patients with OSAHS. CPAP treatment was shown to be effective in improving these parameters, but this efficacy was partial. Specialized care may be needed in cases of residual anxio-depressive symptoms.     

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.     

Jean Garrabé et l’histoire de la psychiatrie dans les Annales Médico-Psychologiques

Jean Garrabé has published about 40 historical articles in the Annales Médico-Psychologiques. He has written on the history of the classifications, on the evolution of clinical entities (bipolar disorders) and of theoretical matters (psychopathology, politics, mondialization, antipsychiatry), on the relationships of psychiatry with artistic, literary and musical creation. But he has above all written many biographical notices of practitioners of mental medicine in France from the beginning of the 17th century (Montalto) to the end of the 20^th (Ey, Lacan). The personage of Pinel often appears in his papers like a central figure of the psychiatry, analyzed far from both hagiography and demolition. Garrabé can be considered like a “psychiatrist-historian”, erudite as well as critical.