Impact des déficits cognitifs dans les activités de la vie quotidienne des personnes souffrant de schizophrénie

It is now well-recognized that cognitive dysfonctions contribute to a decisive way to the difficulties of the everyday, social and professional life of the people with schizophrenia. The cognitive variables would explain between 16 and 30% of the variance in the functional status when assessed one to three and a half years later. However, the specificity of the complex relationships between the cognitive domains and the functional variables still remains to be identified. To this end, it is necessary to carry out studies by respecting various principles: selecting not multi-determined cognitive tasks; investigating specific daily-life tasks (e.g. shopping, choosing a menu, preparing a meal), in particular by an observation in real situation in order to identify the problematic components; this has to be made by determining a priori hypotheses regarding the cognitive nature of the difficulties; taking into account the heterogeneity of the cognitive deficits and the functional difficulties of people with schizophrenia. It also remains to investigate the presence of mediator variables of the relationships, such as the potential of learning, the social cognition, the metacognitive processes and the intrinsic motivation. Besides, other personal or environmental factors can also play a role in the functional status, as for example, the negative symptoms, the awareness that has the person of his(her) state and its consequences, or the critical attitude of relatives towards the person with schizophrenia.     

Connaissance des nouveaux mots de la langue française dans les troubles cognitifs légers de type amnésique et la maladie d’Alzheimer

Introduction

The first decline in cognitive performance in Alzheimer's disease can appear when assessing semantic memory and can be detected long before the typical symptoms of Alzheimer's disease (AD), appearing with Mild Cognitive Impairment (MCI).

Patients and method

We propose the French version of the New Words Interview (fNWI) using 22 words to investigate semantic knowledge. The fNWI uses 11 words, which entered the French dictionary between 1996 and 1997, and 11 other words, which entered between 2006 and 2007. Words were paired according to orthographic and semantic criteria. Each word was associated with three sub-tests: free evocation, discrimination of the best definition from three propositions, and recognition of the accurate word context (two sentences were proposed). Regarding evocation, we distinguished conceptual definition, life situation examples or examples by use. We tested 12 patients with AD, 12 patients with amnesic Mild Cognitive Impairment (aMCI) and 72 controls (12 were paired with patients for age and education level).

Results

MCI patients and AD patients exhibited lower performance than controls in the three sub-tests and for the words of both periods. From the early stage of MCI, the patients were more impaired in the fNWI than in the context recognition task, and they failed to provide conceptual definitions of new words. Therefore, MCI patients suffer from semantic impairments before obvious clinical signs of AD.

Conclusion

In patients with AD, performance worsened on all subtests, and more strongly in the definition discrimination task, which suggests the impairment of stored semantic knowledge. They provided fewer conceptual definitions and failed to use the strategy observed in MCI patients, who compensated for conceptual difficulties by providing examples.     

Dépistage des troubles bipolaires : une revue de la littérature

Objective

The aim of this article is to review the major instruments proposed for screening for bipolar disorder among clinical or general, adult or paediatric populations. They were developed in order to improve the detection of this illness which, far too often, remains unrecognized. Several of these screening instruments are already translated into several languages and validated.

Methodology

A systematic review of the literature published on this topic up to July 2007 was carried out, using the main electronic data base (Medline). The keywords employed included bipolar disorder, screening, questionnaire, diagnosis and early recognition.

Results

The studies reported here examine whether screening instruments perform similarly in various clinical and non-clinical samples. Different forms of the same questionnaire (like self-report or parent report used in paediatric samples) are sometimes compared, usually showing that parent reports supersede the adolescent self-report form. This is namely the case for the Mood Disorder Questionnaire (MDQ) which is a brief and widely tested tool, available both in adult and adolescent versions.The MDQ exhibits good psychometric properties in relation to sensitivity and specificity in adult psychiatric samples, but these are more limited in the general population. Moreover, it yields better sensitivity for BP type I than for other bipolar subtypes. This is also true for other screening instruments like the hypomania check list (HCL-32). In order to optimize the sensitivity for bipolar II disorders, proposals for changing the MDQ screening algorithm have been tested.

Discussion

Even though it does not replace a thorough clinical interview, the use of screening tools for bipolar disorder is widely advocated. We discuss the need for clinicians to rely upon instruments allowing for a rapid and economically feasible identification of this disorder. Involving family members in the evaluation process may also increase the rate of recognition. More studies are still required in order to improve diagnostic efficiency of the screening instruments.     

La connotation dans les paroles de patients atteints de la maladie d’Alzheimer : une méthode d’écoute

The change of the semantic memory in the Alzheimer's disease makes complex the understanding speech of patients. The very important lexical reduction in this disease does not allow to understand the sense of speech. These patients keep an intact phonological capacity. It will be separated of what is pronounced of the whole verbal exchange. The said is often qualified as semantic no sense. The questions of nurses and families to clarify the requests fail. The patient is only repeating his request. For example, the patients ask to see a dead person (her mother) or a requirement (take a taxi). The explicit, literal sense (denotation), does not any more allow to understand this phonological production. It is impossible to act for these pressing requests. For us, these words are full of sense but condensed. The concept of connotation (say it) allows to seize the wide sense of the intention. From clinical examples, we propose answers according to the connotation of what is pronounced. So, we determine a first method of care to understand the requests of these persons.     

Carence en vitamine B12, ataxie cérébelleuse et troubles cognitifs

Introduction

Vitamin B12 deficiency is often associated with neurological disorders of which combined sclerosis of the spinal cord is a common manifestation.

Case report

We report the case of a woman who presented cerebellar ataxia and cognitive deficits associated with leukoencephalopathy on the brain MRI. These symptoms were associated with vitamin B12 deficiency due to Biermer's disease. Vitamin B12 supplementation led to symptom improvement. Later her treatment was discontinued and the patient's clinical status worsened to a bedridden status.

Conclusion

Ataxia cerebellar dementia and leukoencephalopathy can result from vitamin B12 deficiency. To limit the risks of sequelae, vitamin B12 supplementation should be started at an early stage.     

Aspects nosologiques des troubles bipolaires maniaco-dépressifs. Considérations critiques

Critical revue of the concept of bipolar disorders and spectrum and the categories in DSM-IV and ICD10.     

Contribution de la mesure de la pression intra-orale pour la compréhension des troubles de la coordination pneumophonique dans la dysarthrie parkinsonienne

Introduction

Parkinsonian dysarthria can alter oral communication of the patients in the long-term. Subthalamic nucleus (STN) stimulation represents an interesting therapeutic option, although it does not seem to improve axial signs, of which dysarthric speech. The objective of our study was to contribute to the evaluation of STN stimulation effects on speech impairment and in particular on pneumophonic coordination: this latter parameter can be assessed indirectly by evaluating the temporal progression of the intraoral pressure (IOP) during the expiratory phase; thus, IOP represents the transient expression of subglottal pressure (SGP).

Patients and method

Using a dedicated system (EVA2), 20 parkinsonian patients were recorded in ON and OFF STN stimulation conditions in order to evaluate IOP on three measurement points (2nd, 4th and 6th consonants P) during realization of the sentence “Papa ne m’a pas parlé de beau-papa” (“Daddy did not speak to me about daddy-in-law”) which corresponds to a breath group. Eleven control subjects were recorded in parallel in order to define reference measurements.

Results

STN stimulation improved significantly IOP at the level of the initial measurement points (2nd P and 4th P), with an effect of convergence at the level of the third point (6th P) where the difference between OFF and ON STIM conditions was not significant any more. In addition, the performance of the patients ON STIM remained much lower than that of the control subjects.

Conclusion

Our results raise the significant concept that IOP measurement can be regarded as a relevant indicator for dysarthria in Parkinson's disease. They also show that the improvement of pneumophonic coordination by STN stimulation is restricted to the initial period of the expiratory phase, confirming again the mitigated and controversial effect of STN stimulation on axial signs.     

Critères de prise de décision aux urgences de l’hospitalisation sans le consentement

In the current context of the new French bill on the rights and protection of persons under psychiatric care, clinical practice in the emergency setting requires that mental healthcare professionals better clarify the criteria they use for the decision of involuntary hospitalization. After defining the concept of consent for treatment and a brief literature review, this study examined the impact of clinical and contextual characteristics on the decision to admit patients whether involuntarily or voluntarily to inpatient psychiatric units. Data was collected from 442 successive patients admitted in hospital for care from five psychiatric emergency facilities in Paris and covered sociodemographic information, previous hospitalizations, recent treatment, clinical diagnosis, Global Assessment of Functioning scale (GAF) and insight measured by the Q8 Bourgeois questionnaire. Patients were also assessed based on criteria established by the French healthcare agency (HAS) for the severity of mental disorders and the necessity of emergency care. Using multivariable logistic regression, diagnosis does not affect the decision of hospitalization. Agitation, aggressiveness toward others, being under the influence of drugs or alcohol, being married or divorced as well as being referred by a doctor are all factors that increase the risk of involuntary hospitalization. Last, low Q8 and GAF scores are strong predictors for involuntary admission. This supports using insight and GAF evaluation in clinical practice for clarifying assessment and decision-making in emergency setting about involuntary hospitalization.     

Traitements pharmacologiques des troubles psychocomportementaux dans la maladie d’Alzheimer

Behavioural symptoms are common in Alzheimer's disease and may affect up to 90% of patients. Different drug therapies may be indicated and these symptoms need correct evaluation before prescribing. Management is complex and based on therapeutic strategy such as nonpharmacologic and pharmacologic treatment. The first step should always be nonpharmacologic but some drugs such as cholinergic therapy and psychotropic have shown efficacy on these symptoms. When prescribed, they need careful evaluation of risk/benefit.     

Étude sur la prise en charge des auteurs de violence sexuelle auprès d’une cohorte de psychiatres hospitaliers en France en 2011

The management of sexual offenders requires clinical, criminological and legal knowledges. On the basis of a self-assessment, our study highlights the shortcomings of practitioners in a complex and constantly evolving field. Expectations are many legitimate, it is urgent to train practitioners accepting these delicate tasks.     

Facteurs de vulnérabilité génétique des troubles bipolaires

Bipolar disorder is an often devastating illness characterized by the implication of genetic, environmental and developmental factors. Although family, twin and adoption studies consistently indicate a strong genetic component, studies aiming at identifying genetic vulnerability factors produced conflicting results. This chapter gives an overview of linkage, case/control and Whole Genome Association studies in bipolar disorder. Chromosomal regions with the best evidence for the presence of vulnerability factors are presented and synthesized. These include areas on chromosome 1q, 4q, 5p, 7q, 8q, 10p, 11p, 12q, 13q, 16p, 17q, 18p, 18q, 21q, 22q and Xq, with consistent independent linkage and association results with candidate genes.     

Les mouvements oculaires comme moyen de contourner l’insight lors de l’évaluation des comportements de vérification dans le trouble obsessionnel compulsif (TOC)

Rotge et al. [2] demonstrated that asking patients with obsessive compulsive disorder to compare separately presented images was a good way to assess the intensity of their checking behavior. However, the patients with good insight could consciously refrain from checking (Jaafari et al. [1]). To get rid of this problem, the images were presented simultaneously while the patients’ eye movements were recorded. Whatever their insight patients made more gaze moves to compare the images than controls. The patients’ checking behavior was actually related to a reduced working memory span.     

L’enfant et le conflit de loyauté : une forme de maltraitance psychologique

Domestic (or conjugal) violence, conflictual separation and conflict of loyalty are closely linked and constitute fertile ground for a form of psychological abuse against children. They have diverse symptoms related to the process of loyalty cleaved. The text develops a discussion from the parental and family conflict situations marked increase. Prey to emotional blackmail, inevitably the child knows the anxiety and guilt in many cases generating trauma in some future impact. In addition to elements specific to this child and other family related context important to consider when evaluating, the author suggests some characteristics of the therapeutic support of conflict of loyalty, true to form emotional abuse.     

Apport des approches inspirées de la neuropsychologie au diagnostic d’autisme chez l’adulte : une étude de cas

Given that autism spectrum disorders are highly heterogeneous in their clinical presentation, diagnostic assessment in adults, whose symptoms may be complicated by the presence of various comorbidities and developmental trajectories, is not easily practiced in a clinical psychiatric setting. The present study aims at describing diagnostic assessments inspired by current research on cognition in autism. Core cognitive traits, such as theory of mind, executive function and weak central coherence, thought to be endophenotypic traits, are analyzed. Moreover, the utility of screening scales, constructed on the basis of these cognitive traits, is discussed. We describe the case of a 29-year-old French man, referred by his occupational physician, due to the onset of anxiety attacks in his workplace. During the first outpatient psychiatric assessment, he seemed inhibited, and revealed that social situations fueled his anxiety attacks. He was therefore diagnosed with personality avoidance disorder, depression and social anxiety. Although depression and anxiety decreased after Buspirone and Milnacipran were prescribed, some clinical symptoms, such as lack of interest in social situations, ritualized behavior, narrow specific interests (i.e., astronomy, history), and a very good memory for factual information, remained. According to the patient, these symptoms appeared during his infancy. These symptoms, consistent with Asperger Syndrome diagnosis, led to the administration of two screening scales: the Autism Quotient (AQ) and the Empathy Quotient (EQ). The results obtained in these scales were consistent with Asperger Syndrome diagnosis. They indicated the presence of qualitative difficulties in social interactions, a lack of spontaneous empathy and attention switching, among other behaviors. À comprehensive diagnostic assessment was then proposed. The Diagnostic Interview for Social and Communication disorders (DISCO), a semi-structured interview with parents, was used in order to gather developmental and behavioral information. A neuropsychological assessment was conducted with the patient. Both assessments revealed developmental and neurocognitive particularities consistent with Asperger Syndrome diagnosis. Among these cognitive traits, (i) episodic memory peculiarities, such as idiosyncratic encoding and retrieval strategies and impaired encoding of complex visual stimuli (ii) absence of significant difference between the verbal and the performance scales of the WAIS III, but significant differences among subtests, (iii) executive dysfunction found in flexibility and generativity tasks, (iv) perceptive focalization on details, and most importantly (v) significant impairment on theory of mind tasks are worth noting In conclusion, numerous adults with Asperger Syndrome were not diagnosed during childhood. This is probably due to the relatively recent changes in nosography, and their cognitive development, which is not characterized by language delay, in opposition to high functioning autism. Therefore, screening for autism spectrum disorders in a clinical psychiatric setting is important. Screening can lead to a more comprehensive assessment pinpointing developmental history, cognitive profile, and comorbidities, given that these three factors are indispensable for an effective therapeutic follow-up.     

Prévalence des troubles psychotraumatiques en France métropolitaine

Introduction

Trauma-related disorders are disabling affections of which epidemiological data change according to the country, population and measuring instruments.The prevalence of posttraumatic stress disorder (PTSD) appears to have increased over the past 15 years, but one cannot tell whether it has indeed increased or whether the standardized procedure has improved. Moreover, very few epidemiologic studies among the general population have been conducted in Europe, notably in France.

Design of the study

The “Santé mentale en population générale” (SMPG) survey, that took place in France between 1999 and 2003 among more than 36 000 individuals, gives an estimation of the prevalence of psychotraumatic disorders in the general population. Multi-varied analyses were performed on PTSD-related variables and comorbid disorders. The instantaneous prevalence (past month) of PTSD was of 0.7% among the whole SMPG sample, with almost the same proportion of men (45%) and women (55%). There was a high rate of comorbidity among PTSD individuals, notably with mood disorders, anxiety disorders and addictive behaviour. There was an obvious relationship with suicidal behaviour, with 15-fold more suicide attempts during the past month among the PTSD population.

Results

This survey analysed the consequences of a psychic traumatism over and above complete PTSD according to DSM-IV criteria, observing for instance the consequences for people exposed both to a trauma and suffering from at least one psychopathological symptom since the trauma. Those who suffered from a psychotraumatic syndrome, according to our enlarged definition, represented 5.3% of the population, half suffered from daily discomfort and a third of them used medication.Then, we compared those psychotraumatic syndromes to complete PTSD from a sociodemographic, functional and type of care point of view. There was little difference in prevalence of PTSD between men and women in the SMPG survey (45% vs 55%), which is clearly distinct from the other epidemiologic surveys named above. Regarding age, as in the ESEMeD survey, anxiety disorders appeared to be more frequent among younger people.The originality of the SMPG survey is obviously in the fact that it studied the functional impact of the psychic disorder, the type of care and the satisfaction level after care. Only 50% of the PTSD population feels sick which is, however, twice as high as for the psychotraumatized population. This doesn’t fit either with the fact that 100% of the PTSD population say they feel uncomfortable with other people. The type of care is in the same vein: 50% of psychotherapies and 75% of medication, but also 25% of mild medicines and 25% of traditional medicines. Moreover, among the drugs, antidepressants (that are still the first choice treatment in all international recommendations) represent only 30%, whereas anxiolytics, hypnotics and phytotherapy represent the remaining 70%.

Discussion

Regarding the type of care, the differences between the psychotraumatized population and the PTSD population are obvious. They are obvious in that which concerns the type of care, since the medication is similar. From a very global point of view, patients suffering from a subsyndromal PTSD rarely choose medical care (religion, mild or traditional medicine), while full PTSD patients definitely choose classical medical care (drugs, psychotherapy, and 30% of hospitalization). The prevalence of those who ask for care is very close to that observed in the ESEMeD survey, which was four individuals out of 10 suffering from PTSD.

Conclusion

The SMPG data show that its necessary to maintain the distinction between subsyndromal PTSD and full PTSD since the populations differ, but both need care.     

Syndrome démentiel dans les suites d’une bipolarité

Introduction

Converging evidence suggests that people with bipolar disorder (BPD) exhibit persistent cognitive impairment independently from the emotional state. In old age BPD, the cognitive decline is more severe and can fulfill the criteria of dementia. However, the characteristics of bipolar disorder dementia are still unknown.

Aim of the study

The aim of the study was to characterise the cognitive and imaging profile of the dementia following bipolar disorder.

Method

Patients fulfilling criteria of dementia and followed-up in the memory unit for at least two years were included. Patients with substance abuse were excluded. A battery of specific (assessing verbal memory, attention, frontal executive function, construction and visuospatial impairment), and global (MMSE and Mattis dementia rating scale) neuropsychological tests, behavioural assessment using the frontotemporal behavioural scale, MRI and HMPAO–SPECT imaging were performed in all patients during euthymic state.

Results

We included 13 patients with bipolar disorder (9W/4M). The mean age was 70.8 years (±7.7). Dementia began in average 29.2 years (±10.1) after the onset of the bipolar disorder. The mean score of MMSE was 24.0 (±4.3). The mean score of the Mattis dementia rating scale was 122.5 (±8.9). After an average of 6.1 years (±2.8) of follow-up, the mean score of MMSE was 23.5 (±3.2). The annual MMSE score decrease was of 0.5 (±4.4) per year. In more than 75% of the patients, Trail-Making Test-part B, Go-nogo test, Stroop test, delayed free recall in verbal explicit long-term memory test, category fluency tasks and code test were impaired. In more than 50% of patients, free recall, delayed cued recall, clock test, visuospatial battery and temporal orientation were impaired. On the other hand, spatial orientation and recognition were within the standards. The mean of the BREF score was 10.6 (±3.2). A moderate frontal behavioural syndrome was observed, but never persistent hallucinations. Seven patients had been treated with lithium and seven with antipsychotics, but none during the neurological assessment. Moderate extrapyramidal signs were reported in 10 patients, of which the seven patients treated in the past with antipsychotics. MRI showed no focal atrophy and no vascular lesions. Functional imaging conducted in 10 patients always showed uptake decrease in the frontotemporal regions and sometimes in the parietal region too. After six years of follow-up, no patient fulfilled the probable criteria for the main dementia, Alzheimer disease, vascular dementia, frontotemporal dementia and dementia with Lewy bodies.

Conclusion

The data of this study support a possible specific dementia postbipolar disorder and not only mild cognitive decline. This hypothesis could be tested in a prospective study. Such dementia could be a main differential diagnosis from long lasting frontotemporal dementia. The pathogenic process of this dementia could also be determined.     

The 5-word test in 37 depressed patients compared with 36 normal controls and 35 patients with mild Alzheimer's disease

Objectives

Patients with major depression (MD) express frequent memory complaints leading to consultations in memory clinics. The 5-word test (5WT) is a verbal memory test with semantic cueing, which has shown its sensitivity and its specificity in identifying patients with Alzheimer's disease (AD). Our objective was to evaluate memory performances of aged patients with MD compared with controls and AD patients.

Methods

Characteristics of the 5WT were investigated in a sample of 37 patients with MD (66.8 ± 7.5 years) compared with 36 normal controls (67.3 ± 6.8 years) and 35 mild AD patients (67.5 ± 6.1 years).

Results

Duration of depression was 15.3 ± 11.5 years. Memory complaints of MD patients were ancient (4.6 ± 5.5 years) and severe (McNair memory questionnaire = 47.6 ± 20.7). The Total score of MD patients did not differ from controls but was greater than those of AD patients. Learning and Memory scores of MD patients were significantly lower than those of controls and significantly greater than those of AD patients. Forgetting rate between Learning and Memory scores was more important in AD (72.4%) than in controls (2.8%) and MD (13.6%). No intrusions were recorded in controls, three MD patients each made one intrusion, whereas 80% of AD patients made between one to six intrusions (mainly during cued delayed recall). Receiver operating characteristic curves determined the most significant cut-off scores of the Total score. It appeared easy to discriminate AD patients from controls (cut-off = 9, sensitivity = 94.3%, specificity = 100%) or MD patients (cut-off = 8, sensitivity = 88.5%, specificity = 89.2%) whereas it was more difficult to discriminate MD patients from controls (cut-off = 10, specificity = 88.9%, sensitivity = 37.8%).

Discussion

MD patients had significant difficulties with the 5WT as compared to controls, without being of the magnitude of those observed in AD patients.

Conclusion

The 5WT allows a reliable evaluation of memory in MD patients. The presence of true memory deficits with the 5WT could not be ascribed to depression but to other pathological conditions. Consequently, further memory testing should be conducted.     

Information et vécu parental du diagnostic de l’autisme II. Effets des troubles et qualité de vie

This article is part two of a study whose aim is to provide the current state of knowledge concerning the parental contribution in early identification and diagnostic patterns of children with autism spectrum disorder. The first article was an update on the age of recognition of early symptoms by parents and the initial diagnosis as well as the nature of concerns. The purpose of this one is to evaluate the psychosocial repercussions of child's trouble on parents, and therefore on their quality of life and their strategies used to cope with the disorder. Our aim is also to analyze the factors that determine the differences. We assume that the knowledge of these effects is also involved in the knowledge and diagnosis of the autistic spectrum disorder.