Des gènes circadiens à la sémiologie psychiatrique

Psychiatric disorders, such as bipolar disorder and autism spectrum disorders, are highly inherited. Many studies have reported a higher relative risk of developing these disorders than in general population when there is already an affected individual in the family. The heritability of these disorders varies from 70% to 90%. However, the identification of susceptibility genes to these disorders remains difficult, due to their high clinical and etiological heterogeneity. The combination of endophenotypes and environmental factors in genetic studies shed new lights on the biological pathways that are affected in subjects with psychiatric disorders. In particular, sleep disorders and circadian rhythm abnormalities have been frequently reported in these two disorders. Here, we summarize several associations between sleep disorders or circadian rhythm abnormalities and single nucleotide polymorphisms in circadian genes and in genes encoding enzymes of the melatonin synthesis pathway. In particular, we describe studies reporting that polymorphisms in the circadian genes TIMELESS and RORA may increase the risk of developing bipolar disorder by altering circadian rhythms. In addition, we describe studies showing that genetic variations in acetylserotonin methyltransferase (ASMT) identified in patients with psychiatric disorders affect its enzymatic activity. This approach may have therapeutic benefits in bipolar disorders, through the assessment of sleep and circadian rhythms, and a personal management of these alterations.     

Les progrès dans la réalisation de la classification quantitative de la psychopathologie

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad “spectrum level” dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the “problem of comorbidity” by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.     

Les bases de pharmacologie fondamentale du système sérotoninergique : application à la réponse antidépressive

If serotonin (5-hydroxytryptamin [5-HT]) is well known for its role in mood regulation, it also impacts numerous physiological functions at periphery. Serotonin is synthetized at the periphery into the gut by intestinal enterochromaffin cells and in the central nervous system (CNS) in the raphe nucleus from the essential amino acid tryptophan. Physiological effects of 5-HT are mediated by about 15 serotoninergic receptors grouped into seven broad families (5-HT₁, 5-HT₂, 5-HT₃, 5-HT₄, 5-HT₅, 5-HT₆, 5-HT₇ receptor families). Except 5-HT₃ receptor, a ligand-gated ion channels, all the others are G protein-coupled receptors. Serotonin's homeostasis involves serotoninergic autoreceptor such as 5-HT_1A, 5-HT_1B, 5-HT_1D, the enzymatic degradation of serotonin by monoamine oxidase A (MAO-A), and a transporter (serotoninergic transporter [SERT]). In the CNS, the SERT is a key target for various antidepressant drugs such as Selective Serotonin Reuptake Inhibitors (SSRI), Serotonin Norepinephrin Reuptake Inhibitors (SNRI) and tricyclics family. However, antidepressant activity of SERT inhibitors is not directly mediated by the SERT inhibition, but a consequence of postsynaptic 5-HT receptor activation following the increase in 5-HT levels in the synaptic cleft. In pharmacology, SSRIs are defined as indirect agonist of postsynaptic receptor. Among all the 5-HT receptors, 5-HT_1A, 5-HT_1B, 5-HT_1D, 5-HT_2B and 5-HT₄ receptors activation would mediate antidepressant effects. In the meanwhile, 5-HT_2A, 5-HT_2C, 5-HT₃, 5-HT₆ and 5-HT₇ receptors activation would induce opposite effects. The best serotoninergic antidepressant would directly activate 5-HT_1A, 5-HT_1B, 5-HT_1D, 5-HT_2B and 5-HT₄ and would block 5-HT_2A, 5-HT_2C, 5-HT₃, 5-HT₆ and 5-HT₇ receptor. If the chemical synthesis of such a compound may be compromised, SERT inhibition associated with the blockade of some but not all 5-HT receptor could shorten onset of action and/or improve antidepressant efficacy on the overall symptomatology of depression.     

Impact psychologique de la pandémie de la COVID-19 : comparaison entre des Français métropolitains et de l’île de La Réunion

ObjectivesThe COVID-19 pandemic raised a lot of anxiety around the world. France is composed of several overseas territories with major cultural differences but also with a different exposure to the COVID-19. Reunion Island is the most populated overseas French department, but few researches have focused on this population. Therefore, the main objective was to explore and compare the impact of the COVID-19 pandemic (perceived stress, risk and fear of being infected, severity, lockdown respect, perceived stress, quality of life, quality of relationship, loneliness, resilience) during the lockdown among residents of metropolitan France and of Reunion Island.Material and methodsA sample of 347 participants, aged from 18 to 78 (M = 37.90; DS = 13.20) replied to a questionnaire posted online during the last ten days of the lockdown in France. The sample is divided into 227 metropolitans (M = 38.24 DS = 13.41; 13.2% of men) and 120 residents of Reunion Island (M = 37.26; DS = 12.81; 31.7% of men). Resilience, loneliness and perceived stress have been assessed using validating scales while specific items have been created to assess COVID-19 impacts.ResultsThe majority of the total sample has been little exposed to the COVID-19, but the estimated severity was high throughout the sample. Several significant differences have been observed between overseas and metropolitans. The latter, who were more exposed, were more respectful of lockdown measures and felt more concerned about being contaminated. They also had different professional activities (work at home, stop working) since the lockdown than did the overseas sample. Non-significant higher scores of resilience and quality of life during the lockdown contrast in the overseas sample, who estimated risk, fear and severity similarly. In correlational analyses, many relationships were significant only in one sample. For example, in metropolitans the higher the loneliness, the higher the severity. In the other sample, the higher the perceived stress, the higher the respect of lockdown measures, while more metropolitans felt lonely the more they respected these measures. Regressional analysis showed different predictive variables of the scores of perceived stress and fear of being contaminated. In metropolitans, stress was explained by COVID-19 related variables (fear, severity, respect), loneliness and negatively by resilience and quality of life while in the other sample it was explained by fear of being infected and negatively by resilience. Fear of being infected was explained by risk and stress in the overseas, but also by quality of life in the metropolitan sample.ConclusionsThis study brings new data on the important psychosocial impact of the COVID-19 pandemic on two French samples. Observed differences highlight a higher fear of being infected among the metropolitans who were generally more exposed. Overseas from La Réunion did not feel more spared by this risk, despite the limited number of cases since the appearance of the first case in March 11th and the end of the lockdown in May 11th. Despite exposure, our results could be explained by several cultural differences such as way of life or beliefs. Overseas life in Reunion Island might bring more resilience and less loneliness given the particular familial, social and religious functioning. Given the limits of this study and the lack of similar comparisons, more work could highlight the protective factors of these populations.     

Les défis du droit pénal face à l’urgence sécuritaire

Following the attacks in January and November 2015, France passed laws specially turned to terrorism prevention, increasing the powers of judicial police and the prosecution, by the use of proactive investigations highly intrusive. New offenses relative to advocating terrorism revive the debate about the legitimacy of such offenses, including under the principal of legality of offenses and penalties.     

Processus de radicalisation en milieu carcéral : de la criminogenèse à la radicalogenèse

ObjectivesTo demonstrate the process of radicalisation within the prison environment, via the notion of radicalogenesis, by analogy with the concept of criminogenesis While the latter focuses on the pre-criminal situation and studies what prompts a subject to engage in criminal activity, for the genesis of radicalisation we concentrate on the post-criminal situation of individuals, in order to untangle the stages that can bring a prisoner to become radicalised.MethodAn analysis of the literature on the process of radicalisation, and on the genesis of criminality; this is backed up by the methodology of clinical follow-up in the context of the psychological/psychotherapeutic work undertaken with detainees over a period of six years in French prisons.ResultsThe results from the follow-up of detainees caught up in a process of radicalisation, and from the review of the literature show that the prison environment can facilitate radicalisation through a process whereby the identity of an individual becomes more vulnerable following a criminal act that leads to incarceration – an act that is sometimes traumatic for the perpetrator.DiscussionHaving summarised, in table form, the different theories of radicalisation, and discussed their points of similarity/difference, we describe four phases in the genesis of radicalisation: vulnerable identity, dis-identification, conversion and re-identification, radicalisation. We want to emphasise that this process is strictly individual and depends on the subjective structure of the person becoming radicalised.ConclusionsWe reiterate the importance of psychological/psychotherapeutic support in prisons, particularly for the more vulnerable individuals, and those made more vulnerable still by their acting-out. Without this support, the individual risks becoming radicalised in order to find a new pole of identification, as a means of survival.     

Étude CONFAMI : effets du confinement durant l’épidémie de la COVID-19 sur la vie des enfants et leur famille

ObjectivesThe aim of this study is to understand the changes within families during confinement motivated by the COVID-19 pandemic and to explore the psycho-emotional experiences of children and their parents in this new situation. Confinement necessarily induced significant changes in daily family routines, particularly for work, education, leisure and social activities. In the more vulnerable pediatric population, several authors have warned of the need to consider the impact of lockdown measures during COVID-19 on the psychological impact and well-being.MethodThis is an anonymous online survey with methodology combining quantitative and qualitative analyses. The questions targeted several themes such as life context, emotional experience and the impact on daily habits in children and adolescents, as perceived by parents. Participants are adults and parents of at least one child. They were recruited through social media and email.ResultsA total of 439 parents responded to the questionnaire. The families generally stayed in their usual place of residence and managed to adapt well. On average, the children's level of worry (as estimated by parents) was lower than the level of worry parents attributed to themselves. For the majority, the parents did not observe any change, the psychological state of the children and adolescents was generally stable, but for those who experienced more negative emotions than usual, it was an increase in boredom, irritability and anger. A decrease in the quality of sleep was also observed by a third of the respondents. On the other hand, an increase in autonomy was noted. Regarding the quality of family cohabitation, an important result showed that confinement had improved family relationships for 41% parents but at the expense of usual social ties inducing a feeling of deprivation. Indeed, the participants evoke a lack of “social link” and “social contact with friends”. Lack became synonymous with absence, a feeling of loneliness and separation.ConclusionOur results confirm European and international data collected in children in countries where strict lockdown measures have been applied. Despite the negative emotions felt in some children, confinement has helped develop new resources in most families. Families seem to have been successful in maintaining a stable and secure routine which has certainly been a protective factor against anxiety. Some reported factors, such as bonding, could be protective factors and constitute good leads in interventions to be offered to children and their families.     

Les facteurs liés aux actes d’homicide chez les patients tunisiens atteints de schizophrénie

IntroductionEvaluation of variables correlated to homicide is a fundamental issue for developing preventive and therapeutic strategies to deal with such criminal behavior.ObjectivesThe objectives of this study were to assess the characteristics of homicide in Tunisian patients suffering from schizophrenia and to determine the correlated socio-demographic, clinical and therapeutic variables.MethodsThe study included two groups of male patients with a DSM-IV diagnosis of schizophrenia who attended the “Razi” university psychiatric hospital of Tunis. The first group was composed of 36 patients hospitalized for homicide in the forensic unit between the first of January 2000 and the 30th of May 2012. The second group included 50 patients without any criminal record. Demographic, clinical and therapeutic variables were analyzed and compared between the two groups.ResultsNo differences were found between the two groups regarding the different socio-demographic variables. Significant differences were found with respect to a duration of untreated psychosis equal to or more than one year (p = 0.048), shorter duration of psychiatric care (p = 0.002), lower number of hospitalizations (p = 0.026), antecedent of forced hospitalization (p < 0.001), low degree of insight (p = 0.001), poor medication compliance (p < 0.001) and higher antipsychotic doses (p = 0.001).DiscussionDemographic variables as suggested by other studies are less valuable predictors of homicide in patients with schizophrenia.ConclusionInterventions for reducing such behavior should focus on clinical variables and integrate an early diagnosis of the disease and improvement of insight as well as medication compliance.     

Les enfants à haut potentiel en difficulté : apports de la recherche clinique

We have been sensitized to children with high intellectual potential (HIP) having difficulties given the number of children consulting in our outpatient medico-psychological centres for scholastic problems (possibly leading to school failure), anxiety disorders or behavioral disorders such as attention deficit/hyperactivity disorder (ADHD), and in which a high intellectual potential was discovered during psychological assessments. It is the contrast, and more precisely the paradox, between the high intellectual potential of these children and their scholastic difficulties (including school failure), and the psychic suffering expressed by some of them, which led us to question, challenge and propose therapeutic and educational care adapted to these children. It is in this context that we created in December 2005 the CNAHP (National Center for Assistance to High Potential children and adolescents) which is a public centre integrated into the hospital-university department of child and adolescent psychiatry at Rennes. It is noteworthy that not all children with HIP have difficulties, and children with school failure or behavioral problems are not always children with HIP. However, it is necessary not to minimize the problem raised by children with HIP with difficulties by ignoring its frequency or by considering that these children are “intelligent” enough to manage by themselves and do not need to be helped, whereas some of them can show school failure and even be de-scholarized. Indeed, based on the definition of the World Health Organization (WHO) of an intellectual Quotient (IQ) above 130 (level corresponding to a statistical threshold), the frequency of children with HIP represents 2.3% of the population of schoolchildren aged 6 to 16. The frequency is therefore not so rare. However, it remains to be determined by French epidemiological studies what is the actual frequency of children with difficulties within a population of children with HIP. The analysis of the CNAHP research data from a clinical population (children with HIP consulting for difficulties) highlights that children with HIP can show major school problems (including school failure, defined here as having or foreseeing repetition of a grade), which corresponds to 7.5% of 611 children with HIP consulting at the CNAHP) and socioemotional problems (emotional regulation disorders) in relation to their high intellectual potential. In particular, anxiety disorders were the most frequent psychiatric disorders observed in this population (40.5%) and were significantly associated with high verbal potential. This significant association requires further studies to avoid establishing a simplistic unidirectional and reductive linear cause-effect relationships. Indeed, a high verbal potential can elicit and/or reinforce anxiety-producing representations, but anxiety disorders may also lead to a defensive over investment of verbal language. The results are discussed in this article and suggest that scholastic and/or psychological difficulties encountered by some children with HIP can be related to their high intellectual potential. It is necessary to develop therapeutic and educational care adapted to these children from a better understanding, based on research results, of their possible difficulties but also cognitive abilities. Even when children with HIP have scholastic and/or psychological difficulties, some of their cognitive skills can be preserved contrary to appearances, with for example, as seen in the CNAHP results, excellent attentional capacities shown by cognitive tests contrasting with behavioral attention deficit reported by parents. These skills are important to identify as they are resources which support the therapeutic and educational project. It is probably through an articulation among professionals from national education, health and research, in alliance with the family (parents, child, and siblings), that advances will be made. In the same way that professionals have been interested in children with intellectual disabilities, it is important to be concerned by children with HIP and difficulties located at the other end of the continuum. It is a question of ethics which concerns both caregivers and teachers. It is also a societal issue that concerns all of us given that the expression of high intellectual and creative potential in children may be essential to the societal development of innovative strategies and each nation's future. Finally, the discussion can be extended to all children, independent of their potential. What we learn from children with HIP and difficulties can be applied to each child: it is important at family, school and societal levels to facilitate the expression of the potential of children, to value their skills, and to help them to remove possible inhibitions of their potential based on individualized projects. The acceptance of singularity and differences in children can contribute to tolerance and the development of creativity, in the interest of the subject and of society.     

L'influence du système neurovégétatif sur l'hyperglycémie par la glucagone et sur l'hypoglycémie par N-(4-méthyl-benzosulfonyl)-N'-butylurée

Résumé Les Auteurs, ayant déterminé chez le lapin de modifications de la glycémie après administration intraveineuse de substances douées d'action pharmacodynamique sur le système neuro-végétatif central (chloropromazine) ou périphérique (ergotamine et atropine), étudient les effets des mêmes substances sur l'hyperglycémie par la glucagone et sur l'hypoglycémie par la N-(4-méthyl-benzosulfonyl)-N'-butylurée (D 860). La chloropromazine à la dose de mg 5/kg et l'atropine à la dose de mg 50/kg par voie intraveineuse laissent inchangé chez le lapin l'hyperglycémie provoquée par l'injection intraveineuse de g 100/kg de glucagone et l'hypoglycémie par administration intraveineuse de mg 50/kg de D 860. Au contraire l'ergotamine en dose de mg 0,20/kg par voie intraveineuse empèche l'effet hyperglycémiant de la glucagone et renforce l'action hypoglycémiante du D 860.

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Zusammenfassung Nachdem die Autoren beim Kaninchen die Modifikationen der Glykämie nach intravenöser Verabreichung von Substanzen mit pharmakodynamischer Wirkung auf das zentrale (Chlorpromazin) oder periphere (Ergotamin und Atropin) neurovegetative Systeme klarlegten, wurden die Effekte derselben Substanzen auf die Glukagon-Hyperglykämie und auf die N-(4-methyl-benzosulfonyl)-N'-buthyl-Harnstoff (D 860)-Hypoglykämie untersucht. Das Chlorpromazin in der Dosis von 5 mg/kg und das Atropin in der Dosis von 50mg/kg lassen bei intravenöser Verabreichung beim Kaninchen die durch intravenöse Injektion von 100 g/kg Glucagon hervorgerufene Hyperglykämie und die durch intravenöse Applikation von 50mg/kg verursachte Hypoglykämie D 860 unverändert. Im Gegensatz hierzu verhindert das Ergotamin in einer Dosis von 0,20mg/kg bei intravenöser Verabreichung den hyperglykämisierenden Effekt des Glukagon und verstärkt die hypoglykämisierende Wirkung des D 860.

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Les critères d’Awaji : les nouveaux critères diagnostiques de la sclérose latérale amyotrophique

Amyotrophic lateral sclerosis is the most common motor neuron disorder in adults. Although the diagnosis appears obvious in theory, clinical practice shows the contrary as diagnosis is delayed in many patients; the average time between symptom onset and diagnosis can reach 12 months. The delay can be explained by the variability of the clinical presentation and by the absence of diagnostic markers. In order to standardize diagnosis for enrolment in clinical research, diagnostic criteria for ALS were created and revisited during the last 20 years. In 2006, the Awaji criteria for the diagnosis of ALS were proposed, adding two major points to the diagnostic criteria: electromyography is considered equivalent to clinical examination for the identification of LMN signs and fasciculation potentials resume their prominent place in the diagnosis. Comparisons of the accuracy of the revisited El Escorial and Awaji criteria support improved diagnostic sensitivity without any effect on specificity with the new classification. The only weakness of the new classification involves patients with UMN signs in one region and LMN in two regions; these patients were previously classified as laboratory-supported probable ALS and currently as possible ALS, a lower level of diagnostic certainty. In all other instances the accuracy appears to be improved by the Awaji criteria. Nevertheless, there is a body of evidence suggesting the need for a revision of these new criteria, giving more weight to clinical and complementary findings of UMN involvement. The need to diagnose and treat ALS quickly could be facilitated by the inclusion of complementary investigations that detect UMN signs.     

Les débuts de la Société Médico-Psychologique,entre philosophie et système nerveux central

French psychiatry around 1850 is characterized by the paradigm of unitary alienation (Pinel, Esquirol), the preeminence of the moral treatment, the secondary function of the brain (after the decline of the works of Georget and Bayle and of the phrenology), the development of the asylum system (distinct from general hospitals), the theoretical rivalry between sensationalism or “physiology” (Cabanis) and spiritualism or “psychology” (Maine de Biran). The founders of the Société Médico-Psychologique (Baillarger, Moreau de Tours, Brierre de Boismont) are inspired by the latter, politically conservative, beside their inquiries about the central nervous system. After a slow genesis, between 1843 and 1852, the society begins its reunions during the “authoritary” period of the 2nd Empire. They are characterized by the clinical (on monomania and hallucinations) and forensic discussions between alienists and philosophers around free will. During the decade 1860, the organic theories prevail, through hereditary degeneration (Morel), strengthened by the growth of fundamental sciences and cerebral anatomo-physiology. On the other hand, discussions on classifications and “folie raisonnante” allow the transition towards the paradigm of mental illnesses (J. Falret), later adopted in Germany by Kraepelin.     

Les discussions sur les classifications psychiatriques à la Société Médico-Psychologique (1860–2014)

The Société Médico-Psychologique has devoted in the 19th century two series of discussions during several months about psychiatric classification. In 1860–1861, the discourse of Jules Falret recommends to use the evolutive criteria rather than the psychological one (Delasiauve). It allows the transition from unitary mental alienation to several psychiatric diseases and the decline of the monomanias. The aetiological criteria of Morel are discussed. In the same way, in 1888–1889, the classification of Magnan, axed on mental degeneracy, presented by his pupil Paul Garnier, is not admitted by all. Its opponents propose symptomatic (Dagonet, Ball) or anatomic classifications (Voisin, Luys). The discussion came to nothing, but the word psychosis begins to be currently used. Only 75 years later, the Société Médico-Psychologique debates again about the nosology. Between 1966 and 2014, seven discussions, each during one day (two days in 1994), are brought by clinical innovations or by the publication of official classifications, either French, or international. In 1966, are discussed the progresses involved by psychopharmacology and statistics. In 1978, the French classification of the Inserm is compared with the ICD-9 and the DSM-III, in preparation. In 1988, the clinical applications of the DSM are discussed, but there are always communications about the French classification of delusional disorders and about the paraphrenias. In 1994, the transnosography tries to open the way from a “categorical” classification to a “dimensional” one. In 2001 and 2010, two revised versions of the CFTMEA (French Classification of Mental Disorders of Child and Adolescent) are presented. In 2014, a discussion is devoted to the DSM-5. There is an agreement since 50 years about the interest of “mixed” classifications (symptomatic, evolutive and aetiological), about the necessity to avoid too frequent revisions, to obtain a consensus and to simplify the nosology.     

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.     

Observation anatomo-clinique d'une encéphalite postvaccinale débutant deux jours après la vaccination

Résumé L'étude concerne un cas infantile d'encéphalite post-vaccinale débutant deux jours après la vaccination et d'une durée totale de douze jours.L'examen anatomo-pathologique souligne la discrétion de l'atteinte cérébrale dont les caractères correspondent à une encéphalite démateuse et différent de l'encéphalite microgliale classique. Cependant la prévalence de la composante réactive et proliférative gliale, sur la composante altérative, début d'une réaction péri-adventitielle permet le diagnostic différentiel avec une encéphalopathie.

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Zusammenfassung Es handelt sich um einen Fall von postvaccinaler Encephalitis bei einem Kind. Beginn: 2 Tage nach der Impfung. Dauer: insgesamt 12 Tage. Die pathologisch-anatomische Untersuchung unterstreicht die Geringfügigkeit des Gehirnbefalles, der in seinen Merkmalen einer ödematösen Encephalitis entspricht und von der klassischen mikrogliösen Encephalitis abweicht. Jedoch gestattet das Hervortreten einer reaktiven und proliferativen Gliabeteiligung sowie der Beginn einer periadvenitiellen Reaktion die Differentialdiagnose gegenüber einer Encephalopathie.

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Polyhandicap et accès aux soins : le modèle interventionnel des soins palliatifs

In order to improve the care of children with severe psychomotor impairment, this project proposed to apply the interventional model of pediatric palliative care to children without life threatening conditions. An initial semi-directive interview carried out at family homes made an inventory of the situation of the children and their families. The care needs identified led to interventions for 6 to 12 months. A care quality assessment questionnaire and an open satisfaction questionnaire were sent to the families. The 28 families included expressed difficulties and shortcomings in their health course. The needs relate to the medical, psychological, and social spheres, underlining the need for linking the different partners of care. The interventions mainly consisted of coordination, as well as the start of projects for requests for respite and training, particularly in pain assessment. The end-of-study questionnaires particularly show satisfaction with the initial interview, but no impact on quality of life was found. We found that the parents of children with severe psychomotor impairment are asking for an extended interview in their living environment to express their difficulties and their needs, as is usually offered by palliative care teams. The various requests from families can be answered by linking the different care partners, but also by setting up systems dedicated to severe psychomotor impairment.