Des états dissociatifs vers une clinique des troubles dissociatifs

Dissociation can be defined as a dysfunction of the normally integrated functions like memory, consciousness and perception of environment. The history of dissociative disorders rejoins the history of hysteria with the work of Charcot, Janet and Freud at the end of the 19^th century and the beginning of the 20^th century. The concept of hysteria disappeared from the international classifications of mental disorders (DSM-III and DSM-IV, ICD-10) which stimulate a regain of interest in the past 20 years for the field of somatoform and dissociative disorders. After discussing the clinical and etiological issues of the concept of dissociation, we emphasize the interest for the clinician to recognize dissociative states and dissociative disorders, while insisting on the differential diagnosis and the psychiatric comorbidities. Dissociation is now considered as a trans-nosographical entity that can be observed in many psychiatric disorders, such as anxiety and mood disorders, personality disorders, substance-related disorders and even some organic disorders. Substantial progress has been recently made in diagnosing and treating these disorders, allowing the development of sensitive (DES - Dissociative Experience Scale, DQ - Dissociation Questionnaire) and specific (DDIS - Dissociative Disorder Interview Schedule, SCID-D-R - The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised) diagnostic tools. Despite important differences found in the epidemiological studies, the prevalence of the dissociative disorders being around 10 % in the general population, there is a consensus in the literature concerning the importance of precocious detection of these disorders, in order to improve the management of the patients.     

Apport d’une démarche électroclinique dans le diagnostic de l’épilepsie chez une population de sujets âgés confus

Background

Delusion symptoms often occur in old people; epilepsy is one of the main reasons behind these acute episodes. Current guidelines and recommendations from the Academy of Medicine have proposed a double clinical and electroencephalographic approach. Recently, a working group of French experts has issued an electro-clinical scale. The aim of our study was to compare the usual approach with the new one based on the electro-clinical score.

Method

All EEG requests performed since December 2008 in Bretonneau Hospital for elderly people aged over 75 years for delusion syndromes were retained for this study.

Results

One hundred and fifteen old patients from a geriatric-hospital (age 83.5 ± 6.06 years) were included in this protocol. The classical diagnostic process yielded the diagnosis of epilepsy for 50 subjects. The electro-clinical scale confirmed the diagnosis of epilepsy in 30 patients and ruled it out in 29 patients.

Conclusion

This study underscores the importance of evidence-based medicine for the diagnosis of epilepsy in old people and points out the underuse of the new technical tool, EEG-monitoring, for the management of these patients.     

Approche épidémiologique de la toxicomanie en milieu universitaire à Marrakech (Maroc)

Introduction

Drug-addiction, an universal medico-social problem, starts to spread in Morocco. Even if it appeared a long time ago, one is unaware of the real characteristics of this plague in our country.

Objectives

The aim of our work is to study the prevalence of drug-addictions (tobacco, cannabis and alcohol) among students at the University Cadi Ayyad of Marrakech, trying to approach the epidemiological aspect and the impact of this consumption.

Patients and methods

Our study is an epidemiologic approach of drug-addiction in the University of Marrakesh. After having prepared a questionnaire allowing the study of toxic consumption (tobacco, cannabis and alcohol) and the evaluation of the depression among consumers; we carried out an investigation near 418 students from Caddi Ayyad University.

Results

The analysis of the results obtained makes it possible to establish the following characteristics: 24,6% of the students of our sample were consumers of tobacco, 9,8% were consumers of cannabis and 17,5% were alcohol consumers. Male consumption is prevalent, with 86.4% of smokers, 97.6% of hashish consumers and 86.3% of alcohol consumers. The age of the first consumption of drug coincides with adolescence. The mode of consumption was regular for 100% of smokers, 51.2% of hashish users and for 11% of alcohol consumers. 86.4% of smokers were dependent on tobacco, 76,6% on cannabis and 16,4% on alcohol. 28.1% of the dependent smokers on tobacco presented a moderated to severe depression. It was the same for 35.4% of the cannabis dependent and for 58.3% of those dependent on alcohol.

Conclusion

A plan fighting drug-addiction is essential; especially in its preventive shutter, so as to limit this phenomenon and to minimize its repercussions on young population.     

Épidémiologie des usages de substances addictives : résultats d’études réalisées en France et perspectives internationales

Addiction to drugs is an important public health concern. Describing the frequency of dependence, abuse and use of substances in a country allows a monitoring and helps in the design of an appropriate healthcare system. We will present studies describing the prevalence of use of tobacco, alcohol, and illicit drugs in France, with a comparison to European or International studies. They show a decrease in the use of tobacco and cannabis, while there is an increase in alcohol use in young adults. We also observe that the difference in substances use between females and males is tightening, especially in young people. We have less studies of analytic epidemiology trying to describe risk or protective factors associated with substances’ use in France. Further studies on addicted people's pathway (from use to abuse and to dependence, as well as from dependence to recovery, with or without medical support) are warranted.     

Premiers éléments pour une étude psychométrique de la fixation-régression avec la McGill Object Relations Scale

Introduction

Psychosexual development is generally assessed clinically, that is to say, in a qualitative manner (Piper and Duncan, 1999). Dymetryszyn, Bouchard, Bienvenu, De Carufel, and Gaston (1997) recently proposed a more quantitative approach based on the overall maturity of the subject's object relations.

Background

Object-relation maturity is quantified using a profile that defines a score for each stage of an individual's psychosexual development : oral-narcissistic, oral-objectal, anal, phallic pre-oedipal, oedipal, and genital. The McGill Object Relations Scale (MORS) (Dymetryszyn et al., 1997) was adapted (Combalbert, Vautier, Bourdet-Loubère, Favard, & Bouchard, 2002) and then used to obtain the quantitative scores. The relationship between overall object-relation maturity and psychosexual development is complex. Psychosexual development is considered here to be a constant latent dimension. Accordingly, the higher the level of development, the greater the individual's possibility of establishing the object relations that correspond to more evolved stages. Inversely, the lower the level of development, the more the individual is forced to rely on object relations corresponding to earlier stages of development. However, the connection between the object-relation maturity profile and psychosexual development is made even more complex by the existence of the well-known phenomenon of fixation-regression.

Objectives

This article attempts to determine how fixation-regression is reflected in the structure of the profiles of a sample of individuals whose clinical diagnosis suggests probable regression to the anal stage.

Methods

The subjects chosen had borderline personality disorder coupled with either perversion or psychopathy. The data were modelled using an unfolding model. MORS was used on 60 criminal subjects who had been charged with, or convicted of, crimes against persons. The nosographic diagnosis was based on the psychiatric assessment of the prisoners. DSM IV diagnostic criteria were used as a reference to confirm or refute the pronounced diagnosis. Only subjects who met at least five criteria for borderline personality disorder were included in the sample. To assess the reliability of the individual scores, two expert judges blindly scored the 60 protocols.

Results

The results obtained with an unfolding model support the hypothesis that the observed ordinates for the oral-narcissistic, oral-objectal, phallic pre-oedipal, oedipal, and genital stages obey a law of synchrony that complies with the postulate of a continuum in psychosexual development. The second main result was the fact that the observed ordinates for the level corresponding to the anal stage could not be described by the model. Furthermore, this finding did not come from a possible scoring error, since inter-judge reliability was 0.93 for that level.

Discussion

These results are encouraging for the utilization of MORS as a technique for quantifying object relations. This study on a sample of individuals with a high probability of anal stage fixation-regression suggests that this type of phenomenon can be objectified by means of MORS profiles. However, the present study has some limitations of its own. The main methodological drawback pertains to the subjective aspect of the protocol scoring. The two judges had a great deal of joint experience in scoring other protocols on the MORS grid. This could explain the particularly high inter-judge correlations, compared to the within-class correlations published by Dymetryszyn et al. (1997).

Conclusion

One cannot rule out the possibility that our analyses would have had different outcomes had other independent judges scored the 60 protocols. Moreover, our results cannot be generalized without replication. A critical test would be to replicate our analyses on similar data, and to examine the unfolding model's behavior on data from a sample of ordinary adults diagnosed as not having strong fixation-regression tendencies. If the synchrony laws defined by the unfolding model are correct, the anal stage should be included in the arc formed by projecting the six stages on the factorial plane of the principal component analysis. Fundamental research based on the psychosexual theory of the libido and supported by statistical data can objectify the vicissitudes of psychosexual development (such as fixation-regression) or developmental differences across groups of individuals. This makes a strong case for pursuing MORS-based investigations.     

Trouble psychotique révélant une épilepsie associée à une tumeur dysembryoplasique neuroépithétliale de l’hippocampe gauche

Introduction

Psychotic symptoms are a rare but well-known complication of epilepsy. The prevalence is estimated between 4 and 9%.

Patient

We report a case of a 40-year-old patient, unrecognized epileptic, who presented an acute psychotic syndrome which seemed to be of functional origin, the EEG performed during the episode, and the cerebral CT scan being normal. Nevertheless, the clinical presentation, especially the sudden ending of delusions, led to further investigations. Careful history taking and repeated EEG recordings allowed the diagnosis of partial epilepsy that had begun 17 years earlier and symptomatic of a dysembryoplastic tumour of the left hippocampus revealed by MRI.

Discussion and conclusion

Search for an epileptic origin of an acute psychotic syndrome must always be undertaken by systematic EEG. The possibility of a symptomatic temporal tumor must not be overlooked.     

Prévalence et caractéristiques des douleurs chroniques avec caractère neuropathique en population générale à Parakou au nord du Bénin en 2012

The burden of chronic and neuropathic pain is high making it an important public health problem. The epidemiology is not well known in the general population in sub-Saharan Africa. We aimed to determine the prevalence of chronic pain with a neuropathic component at Tititou in Parakou in northeastern Benin. A cross-sectional study was conducted from 1st April to 31 May 2012 and included 2314 people in a door-to-door survey. Chronic pain was defined as pain occurring for more than three months. Neuropathic pain was assessed with the DN4 score. A neurological exam was performed by a young physician for all people with chronic pain. During the interview, sociodemographic data, past medical history, weight and height were recorded. Multivariate logistic regression was performed to analyze the main associated factors. Among the 2314 people included in this survey, 49.7% were male. The mean age was 32.3 ± 13.1 years. Nine hundred seven reported pain occurring for more than 3 months. The prevalence of chronic pain was 39.2% (CI95%: 29.3–34.7). It was more frequent in females, older people, among diabetics, people with a history of any surgery, stroke, brain trauma, and alcoholism. The prevalence of chronic pain with a neuropathic component was 6.3% (CI95%: 5.0–7.9). The main associated factors were age, matrimonial status, professional occupation, body mass index, diabetes, history of zoster, history of any surgery, brain trauma. People with neuropathic pain often reported pain with burning (87.6%), prickling (82.8%), numbness (66.9%), tingling (63.4%), and lightning pain (48.3%). The main locations were the lower limbs and low back pain. This study suggested the high frequency of chronic neuropathic pain in the general population in Parakou compared with rates reported in western countries.     

L’épilepsie insulaire : l’expérience montréalaise

In this article, we review recently published data on the role of the insula in refractory partial epilepsy and summarize our own experience in the investigation and treatment of this entity. Case studies and evoked responses obtained from insular cortical stimulation reveal a wide array of clinical manifestations which may mimic temporal, frontal or parietal lobe seizures. Clinicians should hence lower their threshold to sample the insula with intracerebral electrodes. Lack of recognition of insular seizures may explain part of epilepsy surgery failures. Advances in microneurosurgery open the way to safer insular resection.     

Patients adultes traités par une association d’antiépileptiques pour une épilepsie focale en France : description et mode de prise en charge selon les nouveaux critères de définition de la pharmacorésistance (étude ESPERA)

Aims

To describe the adult population treated with antiepileptic drugs (AEDs) in combination for focal epilepsy according to the definition of AED resistance proposed by the International League Against Epilepsy (ILAE) in 2009 and to evaluate its implementation in current practice.

Methods

ESPERA was a multicenter, observational, cross-sectional study with a clinical data collection covering the past 12 months conducted by neurologists. Classifications according to AED responsiveness established by investigators for each enrolled patient were revised by two experts.

Results

Seventy-one neurologists enrolled 405 patients. Their mean age was 42.7 years (sex-ratio M/F 0.98). According to the investigators, 60% of epilepsies were drug-resistant, 37% drug-responsive and 3% had an undefined drug-responsiveness. After revision of experts, 71% of epilepsies were classified as drug resistant, 22% as responsive and 7% as undefined. Among the participating neurologists, 76% have made at least one error in classifying their patients according to the 2009 ILAE definition of AED resistance. Because of epilepsy, 24% of patients (age ≤ 65) were inactive and 42% could not drive (respectively 29 and 49% of patients with AED resistant epilepsy). Half of patients had at least one other chronic condition. Number of prescribed drugs in combination and health care resource utilisation were significantly higher in patients with drug-resistant epilepsies than in patients with drug responsive epilepsies.

Conclusion

ESPERA study shows that the use of new definition of drug-resistance in everyday practice seems difficult without any additional training and that the social and professional disability is frequent in adults with focal epilepsies treated with polytherapy.     

Le déni de grossesse : étude réalisée sur 75 dossiers de découverte tardive de grossesse

The denial of pregnancy is a vague and badly defined entity with no international consensus. Yet this phenomenon is often found by health professionals, provoking much questioning on its aetiology and how to treat it. The denial of pregnancy constitutes a potentially risky situation for both mother and child.     

Spécificités des crises d’épilepsie chez le sujet âgé : proposition d’un score électro-radioclinique d’orientation

Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis… and because there are multiple differential diagnoses (syncope, transient ischemic attack, transient global amnesia…). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.     

Le botulisme alimentaire au Maroc, à propos de 15 cas. Valeur diagnostique de l’électrophysiologie

Introduction

Botulism is a rare but serious disease, which affects the peripheral autonomous nervous system, potentially with a fatal outcome. In Morocco, botulism is exceptional.

Patients and method

This was a prospective analysis of the epidemiological, clinical, neurophysiological and toxicological features of 15 cases of food-borne botulism identified among a series of 45 highly suspect cases collected in Morocco during an epidemic in August 1999.

Results

The 15 patients (eight females, seven males) included in the protocol were aged 3 to 49 years (average 18.8 years). One-third of the cases occurred in a familial context. The clinical presentation was typical and complete in nine cases; respiratory failure was noted in four patients. Botulinum toxins were found in nine cases. Outcome was less than favorable, with total recovery in seven cases, persistence of motor sequelae in three and death in five. Electrophysiological investigations showed an incrementing response at high frequency in 73.3%, a decrement at lower frequency in 60% and low motor amplitudes in 93%. These findings constituted a very sensitive and specific triad for botulism diagnosis.

Discussion/conclusion

These findings illustrate the gravity of botulism and the important diagnostic value of neurophysiological results, especially incrementation, which can provide a very pertinent diagnostic contribution, especially in seronegative patients.     

Conséquences psychopathologiques de l'épilepsie. À partir de l'analyse de 10 observations

From the analysis of clinical data and the viewpoint of the bibliographic data, bringing out the comorbidity epilepsy/mental health, frequency of personality disorders during epilepsy and constancy of behavioural troubles are outlined. However, results of works, dealing with behavioural disorders, are often contradictory. Association with mental retardation shows a problem of imputability. Depressive mood, often concomitant with anxiety disorders, represent the psychiatric comorbidity frequently associated with epilepsy; recent works assess the factors of seriousness of depression. As for the relationship between psychosis and epilepsy, the term ”epileptic psychosis” indicates today specific entity. Psychotic patients who suffer from epilepsy are not in that concept frame. Alcoholism does not seem more frequent in people suffering from epilepsy than in general population. The social disqualification assessed by the scales of quality of life is frequent with people suffering from epilepsy.     

Bases physiopathologiques des états de mal épileptiques

The mechanisms that induce epileptic activity and make it durable, leading to status epilepticus (SE), are poorly known. They probably result from an imbalance between the activating systems of neuronal depolarisation (excitatory amino acids release with postsynaptic N-methyl-d-aspartate [NMDA] receptor activation, spreading depolarisation following abnormal progression) and the inhibiting systems (GABAergic synapses). Status epilepticus leads to many direct and indirect cerebral disorders, as well as systemic disorders, with intertwined mechanisms and consequences. These disorders are more frequent in case of convulsive SE with generalized tonic-clonic seizures. Direct neuronal damage (selective neuronal loss and epileptogenesis) results mostly from excitotoxicity, which arises from enhanced and extended neuronal activation. Indirect neuronal damage results from the inability of the circulatory system to supply sufficient oxygen and glucose contribution compared to the high metabolism level of the highly depolarized and synchronized neurons. This energetic deficit is usually patent after 30 minutes of SE, when systemic compensation mechanisms (cardiac output increase) are exhausted. Understanding these pathophysiologic aspects is essential for effective treatment of SE.     

États de mal épileptiques : épidémiologie, définitions et classifications

The annual incidence of status epilepticus based on the definitions of the International League Against Epilepsy (1993) ranges from 10.3 to 41 per 100,000 inhabitant. Half of the cases of status epilepticus concern epileptic patients. In all studies, incidence is higher in epileptic patients, young children and the elderly. It is estimated that 13% of patients with status epilepticus will experience recurrence during the two first years. The three leading etiologies are low-dose antiepileptic drugs, non-acute brain lesions and acute stroke. Seizures are generalized in 9 to 33% of patients and focal in 25 to 75%. Secondary generalized seizures can be observed in 19 to 66% of patients. Mortality ranges from 7.6 to 39% and varies as a function of inclusion of postanoxic encephalopathies and difference in initial care. The definition retained and the classification adopted for status epilepticus also affect mortality estimates. Status epilepticus is defined as the existence of a prolonged seizure or a series of seizures during which the patient does not recover, or incompletely recovers, consciousness. The duration parameter used to distinguish status epilepticus from a seizure remains controversial. At the present time, there is general agreement in the literature distinguishing two definitions based on different durations according to the clinical type of status epilepticus and its potential severity: (i) a status epilepticus is defined by a seizure lasting more than 30 minutes or recurrent seizures without recovery of consciousness over a period of 30 minutes; (ii) considering its severity, tonic-clonic status epilepticus has a specific definition leading to earlier therapeutic management. This operational definition is continuous, generalized, convulsive seizure lasting more than five minutes or two or more seizures during which the patient does not return to baseline consciousness. Several types of background can be used to establish a classification for status epilepticus: clinical manifestations, prognostic and therapeutic course, epidemiological data, pathophysiological mechanisms… At the present time, the classifications most commonly used in France for status epilepticus are derived from the syndromic epileptic classification, the seizure classification or the classification proposed by the French consensus workshop on status epilepticus. For routine clinical practice, an operational classification can be used to adopt therapeutic strategies adapted to probable prognosis: short-term life-threatening, mid-term life-threatening, not life-threatening.