Impact de la durée de psychose non traitée sur la qualité de vie et les fonctions cognitives

ObjectivesThe duration of untreated psychosis is defined as the interval between the first psychotic symptoms and the first starting treatment. The duration of untreated psychosis is highly variable but often prolonged and may be influenced by several factors. Some studies suggested that duration of untreated psychosis is associated with poor outcome. The objectives of this study were to assess the duration of untreated psychosis in a Tunisian cohort and its impact on the quality of life and the cognitive functions of schizophrenic patients at 2 years.MethodsWe conducted a cross sectional study at Razi Hospital between January 2014 and June 2014 that included patients with Schizophrenia diagnosis as defined in the DSMIV-TR with regular monitoring for at least 2 years. Eligible participants are those who had been hospitalized for the first time, between January 2011 and December 2012 for a first psychotic episode. Data were collected from medical records and by interviewing the patients and their family. Duration of untreated psychosis was determined using the Symptom Onset in Schizophrenia Inventory. The quality of life was assessed by the ‘Short Form-36 Health Survey’ scale in its Arabic version. All patients were evaluated with ‘The Tunisian Cognitive Battery’ composed of 7 tests. Patient scores are expressed as ‘Z scores’, which represents the position of the scores in a term of standard deviation from the mean of healthy subjects established by the authors of the battery. We divided the population into two groups based on the duration of untreated psychosis median. A short duration of untreated psychosis was lower than the median, and a long duration of untreated psychosis was equal to or greater than the median.ResultsOur sample involved 42 patients with a mean age of 31.38 years. The average duration of untreated psychosis was 75.38 weeks with a range from 2 to 364 weeks and a median duration of 47.5 weeks. Patients with a short duration of untreated psychosis had a better quality of life with better scores for the majority of the dimensions and a significant difference in the limitations score due to the mental state (P = 0.01). For cognitive function, the short duration of untreated psychosis was significantly correlated with a free recall of ‘Hopkins Verbal Learning Test’.ConclusionOur study suggest that the average duration of untreated psychosis in Tunisia is comparable to the one reported in the literature and that a short duration of untreated psychosis is correlated with better outcomes in terms of quality of life and verbal learning.     

Insight et dangerosité psychiatrique : revue de la littérature

Introduction

Violence committed by individuals with severe mental illness has become an increasing focus of concern among clinicians, policy makers, and the general public, often as the result of tragic events. Research has shown in the past two decades an increased risk of violence among patients with mental disorder. Nevertheless, of those suffering from mental illness, perpetrators of other directed violence form a minority subgroup. The means by which there is this association between mental illness and violence has remained controversial. Factors such as positive psychotic symptoms, medication non-adherence, alcohol or psychoactive substance abuse and antisocial personality were found to be predictive of violence. Overall, literature provides support to the assertion that violent behavior of mentally ill patients is a heterogeneous phenomenon that is driven by multiple inter-related and independent factors. Furthermore, psychiatrists are often asked to predict an individual's future dangerousness, in a medical or a legal context. In the process of risk assessment of dangerousness, more focus has been placed on dynamic risk factor. In this context, lack of insight has established itself both as a part of violence risk models and as a clinical item in structured approaches to measure dangerousness. However, few studies have tested these associations. The main purpose of this paper is to review the literature concerning the relationship between insight and dangerousness and discuss the contributions of the insight in the assessment of dangerousness in patients with mental illness. We included twenty studies that evaluated the association between insight and variable such as physical or verbal violence, aggressiveness, hostility or sexual aggression.

Thérapie basée sur la mentalisation et le trouble de personnalité limite

Theoretical background

The borderline personality disorder is a complex psychiatric disorder that represents a high number of patients in a psychiatric adult service. Even if some therapies have shown to be effective in the therapeutic care of the borderline personality disorder they only target certain symptoms (e.g. anxiety, sadness, self-mutilation). The aim of this paper is to introduce a therapeutic model little known in France: the mentalization based therapy (MBT) developed in 2004 by Bateman and Fonagy. This therapeutic model apprehends the borderline personality disorder in all its complexity and is based on two main concepts: Bowlby's attachment theory and the concept of mentalization. The MBT is based on the hypothesis that a deficit of mentalization leads to the development of borderline disorder. The capacity of mentalization, also known as reflexive function, is acquired in infancy through interpersonal relationships, in particular those of attachment, and is the ability to understand the mental state (emotions, needs, thoughts, etc.) of oneself and others which underlies explicit behaviour. This reflexive capacity is of a better quality when the person has a secure attachment style. Indeed, borderline patients have, mainly, a deficit of mentalization capacity associated with an insecure attachment style. Thus, the main objective of the Bateman and Fonagy approach is to develop and reinforce the mentalization capacity through a therapeutic relationship as a secure base, a group therapy and the concept of insight.

Accessibilité de la remédiation cognitive en Île-de-France,en psychiatrie adulte et infanto-juvénile,et dispositifs de réhabilitation

Cognitive remediation (CR) aims to decrease cognitive deficits and provide palliative strategies for reintegration of patients with psychic disability. It is part of a personalized care program and requires multidisciplinary assessment and management, including eventually other psychosocial therapies. This study, carried out in 2016, aims to establish an inventory of accessibility and practice of the CR in Île-de-France, to promote broad access and systematize the integration of CR in a global and coherent course. The CR is proposed by nearly 58 % of the structures that answered the survey, but its implementation could be improved: it stands for 58 % in a specific project and the multidisciplinary evaluation before/after is carried out at 51 % in Adult Psychiatry and 20 % in Child and Teen Psychiatry (CTP), perhaps due to a lack of qualified staff (neuropsychologists). The programs used in CTP are nonspecific. The accommodation capacity should be increased by group programs. Despite a lack of knowledge to fill, there is an important interest for the CR with a will expressed by 12 structures to be trained. Other psychosocial therapies, although better known, would benefit from being more often proposed and labeled by the Regional Health Agency. Our results confirm a scarcity of psychiatric care's supply in 77, 91 and 93. Four rehabilitation units in the 77 and 3 in the 91 are being trained. Three structures in the 77 and 2 in the 91 are willing to get trained. Supporting them is all the more important as the good practice of CR has a direct effect on social costs’ benefits. Since then, in the entire region, 8 structures have proposed for a CR and rehabilitation platform.     

Tolérance à la détresse et expérience de la douleur chronique

IntroductionChronic pain is a highly prevalent condition that is associated with distressing somatic and emotional experiences. Consequently, an individual's distress tolerance, the perceived capacity to tolerate negative psychological and physical states, may influence their pain experience. This effect could be explained in part by a reduction in the catastrophic interpretation of pain which is associated with increased pain intensity and interference in everyday activities.AimsThe first aim of this study was to explore the association between the components of the 5-factor model of distress tolerance and (1) pain intensity and (2) pain interference in everyday activities. The secondary aim was to assess the potential mediating effect of pain catastrophizing in the eventual association between components of distress tolerance and (1) pain intensity or (2) pain interference in everyday activities.MethodThis is a cross-sectional study of adult (18 years or older) university students and staff with chronic pain (3 months). They were invited to complete the online questionnaire through an email invitation. Pain intensity and interference in everyday functioning were assessed with the corresponding subscales of the Brief Pain Inventory. The following instruments were used to assess the components of the 5-factor model of distress tolerance: Ambiguity Tolerance Scale (tolerance to ambiguity), Intolerance to Uncertainty Scale (reversed score: tolerance to uncertainty), Discomfort Intolerance Scale (reversed score: discomfort tolerance), Distress Tolerance Scale (tolerance to negative emotions), Frustration Discomfort Scale (tolerance to frustration). Participants also completed the Pain Catastrophizing Scale.ResultsEighty participants were recruited (57 % women, mean age = 33.09; standard deviation = 12,87). Tolerance to negative emotions was the only component of distress tolerance that was associated with pain (ß = ?0.04; 95% CI): ?0.07–?0.01; t (78) = ?3.06, p < 0.01) or pain interference in everyday functioning (ß = ?0.07; 95% CI: ?0.10–?0.03; t (78) = ?3.97, p < 0.01), independently of the others. Combined with age, these factors explained 16.2 % of the variance in pain intensity and 19.4 % of the variance in pain interference. Pain catastrophizing partially mediated the association between tolerance to negative emotions and pain interference in everyday functioning, but it was not involved in the association between tolerance to negative emotions and pain intensity.ConclusionTolerance to negative emotions appears to be the most relevant aspect of distress tolerance in the context of chronic pain and is a potential clinical target that is independent and complementary from pain catastrophizing.     

La théorie de la dissociation structurelle de la personnalité pour conceptualiser et traiter la psychose dissociative : deux études de cas

ObjectivesWe present the theory of the structural dissociation of the personality as a way to conceptualize dissociative psychosis and illustrate this with two case studies. This theory was developed to help understand trauma related disorders, i.e. dissociative disorders. In line with Janet's work, this theory states that a traumatic event can lead to a division (dissociation) of the personality in two or more parts: an apparently normal part of the personality deals with daily life activities and avoids the traumatic memories, and one or more emotional parts of the personality stay fixated on the traumatic experience and can reach a certain autonomy as in dissociative identity disorder. Dissociative psychosis is understood as the intrusion of emotional parts into the apparently normal part, which gets overwhelmed, with psychotic-like intrusions. In the most severe cases, an emotional part takes over the executive role over a long period of time.Patients/methodsThe first case study is a male patient suffering from repetitive (at least once a year) psychotic episodes with a normal nonpsychotic functioning between episodes. Main psychotic symptoms are mystic delusions, verbal auditory hallucinations and disorganized thinking. Hypnotherapeutic interventions allowed an evaluation of a possible structural dissociation, which then led to the diagnostic of dissociative psychosis. A psychotherapy based on the theory of structural dissociation was then engaged. The second case study is a female patient with depersonalization disorder and a dissociative psychosis several weeks after the traumatic birth of her twin children. Psychotic symptoms were mystic, referential and persecutory delusions.ResultsIn the first case, after three years of adapted psychotherapy, the patient showed no relapse of dissociative psychosis and did not need any hospitalization. A single risk of relapse was avoided with one session of adapted hypno-imaginative interventions. In the second case, after three sessions of hypnotherapeutic treatment based on the theory of the structural dissociation of the personality, the patient was symptom free, also at two and half years follow up.ConclusionsThe theory of the structural dissociation of the personality is useful in conceptualizing dissociative psychosis. Hypnotherapeutic and hypno-imaginative interventions with a light trance and adapted to this theory can be useful in the treatment of such a disorder. Such interventions can help clinicians enter the patient's inner world to better understand the meaning of the symptoms and then suggest a resolution for the trauma related emotional parts involved in the expression of the psychotic-like symptoms. We discuss the necessity of an official diagnostic for this disorder that could be better named reactive dissociative psychosis or reactive dissociative disorder with psychotic features. Clinicians need to be aware of this specific diagnostic that may benefit from specific psychotherapeutic interventions, probably better adapted than those needed for real psychotic disorders.     

Les courants épistémologiques dans les travaux et discussions de la Société Médico-Psychologique

IntroductionThe term epistemology was first used by the Scottish metaphysician James Frederick Ferrier (1808–1864), in his book Epistemology or Theory of Knowing (1854). The generalization of its use will not occur until the end of the 19th century in the texts of English and continental philosophers and scientists, and thereafter in North America. The discussions of the members of the Société Médico-Psychologique, created in 1852, were not reflected in the Annales Médico-Psychologiques until 1853, and questions related to epistemology were then assigned to the fields of the philosophy of knowledge or the philosophy of science.MethodologyThis article is based on the approach of comparative epistemology (G.G. Granger), on an historical and clinical approach, on the critical analysis of language, and on the authors’ own research. Epistemology is “a critical study of the principles, hypotheses and results of the various sciences, intended to determine their logical (non-psychological) origin, their value, and their objective significance.”AnalysesThe authors employ the chronological score proposed by G. Lantéri-Laura by showing in parallel the evolution of the questions treated by the philosophy of science, then by epistemology. They analyze successively the impact of the philosophy of science on the Société Médico-Psychologique during the 19th century during the period of 1852–1902, then the anchoring of the epistemological tradition at the Société Médico-Psychologique due to the contribution of Pierre Marchais, and finally, the incursion of the North American approach at the beginning of the 21st century.ConclusionIt is illusory to seek a single, definitive scientific method, which is applicable in all situations, because the scientific objective does not dispense with the relationship to the concrete. For psychiatry, whatever knowledge is presented as new, problems arise from different perspectives, in different contexts, because the dynamics of the development of each discipline or sub-specialty are updated periodically.     

Origine et évolution de la bipédie

During around five millions years our ancestors, who were arboreal primates, became progressively occasional, frequent and permanent terrestrial bipeds. Thus, they restricted their locomotor repertoire from polyvalence to specialization. We show that the adaptation to bipedalism is the result of two different processes, the result of natural selection and the result of learning to walk. The characters of our skeleton, heritage of natural selection, affected first pelvis and vertebral column and then cranial base, body proportions and feet. Since reaching bipedal balance is a very demanding constraint in the face of gravity, we describe the “epigenetic” characters which develop in association with learning to walk. Important femoral angular modifications result in the adduction of lower limbs. The angle of pelvic incidence, which defines the sagittal pelvic morphology, increases with gait acquisition in tight association with the formation of lumbar curvature. A link can be established between these genetic modifications and these epigenetic acquisitions. As an illustration we show how the pelvis and spine became a functional unit during the transition from facultative to permanent bipedalism, probably during the evolution of the large group of Homo erectus.     

Eugène Dally (1833–1887) et les liens historiques entre la Société Médico-Psychologique et la Société d’Anthropologie de Paris

The Société Médico-Psychologique (SMP) was founded in 1852, while the Société d’Anthropologie, with the later addition “de Paris” (SAP), was founded in 1859 under the auspices of Broca. Several of its members, including some of the more eminent ones, came from the SMP. These two societies remain very active to this day.ObjectivesThe objectives of these two societies and the issues, which concerned the scientific world, are researched in the work and philosophical options of Dr. Dally (1833–1887), who was an active member and president of the two societies.Materials and methodsThe work of Eugène Dally has been compiled in the collections of the Annales Médico-Psychologiques and in the Bulletins et mémoires de la Société d’Anthropologie de Paris.ResultsEugène Dally followed in the footsteps of his father Nicolas Dally as both physiotherapist – propagating in France the benefits of gymnastics – and polygraph. A disciple of Littré and an intransigent defender of the positivist doctrine, he was also a convinced anticlerical and he defended his ideas within these two societies which he joined the same year, at the age of 27 years. His career in the SAP was brilliant (he held its chair in ethnology) in the footsteps of Broca, of whom he was a fervent disciple. After his translation of Man's Place in Nature by Th Huxley, which allowed him to defend Darwin's ideas, he introduced the concept of transformism to France and shifted Broca's anti-evolutionist stance. He defended the close links between Man and the higher apes more consequently than Huxley, anticipating the modern works of the primatologists (Frans de Waal). At the SAP he was also a critical adversary of the extrapolations made from dubious anomalies discovered upon examining the brains of criminals with the aim of considering them ill and thus explaining their acts. His arrival in the SMP coincided with the opening, which had been agreed (in sign of goodwill to the new conservative power) to non-medical members from the fields of philosophy, law, history and even religion. His work and his interventions were those of a polemicist battling in the clan of physiologists and materialists against the spiritualists and metaphysicians. Hence he took clear-cut, violently anticlerical positions when the issue of the soul was put on the agenda. The deadlock in the debates on such subjects most likely explains the gradual abandoning of multidisciplinarity within the SMP membership. During discussions in 1863, which brought together all the leading lights of the SMP on the issue of criminal responsibility, Dally equally supported an unequivocal position, setting hardened criminals alongside the ill. Thus he defended – in a conscious manner – a theoretical position which considered social defence only.ConclusionsEugène Dally is the most committed representative of a generation of anticlerical doctors obstinately pursuing the Voltairien combat. His positivist, scientific convictions most likely met with the approval of several members of the SMP who found in him their spokesman. He can be considered to be a forerunner of the movement for social defence and his position on the close ties between Man and the higher apes has more recently proved its relevance.     

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.     

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.     

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.     

Histoire de la kétamine et du psychédélisme

Ketamine's history begins in the fifties in Detroit, at Parke-Davis laboratories. In 1956, Maddox synthetized phencyclidine or PCP. Domino studied PCP effects in animals and in 1958, Greifenstein made the first trials of PCP in humans under the name of Sernyl. Sernyl elicited severe excitation with a prolonged postoperative recovery. Because of its psychedelic effects, it became a street-drug under the name of “angel dust”. Calvin Stevens synthesized ketamine in 1962. The drug was studied in humans in 1964, by Domino and Corssen who described the so-called “dissociative anesthesia”. Ketamine was patented in 1966 under the name of Ketalar for human use and was administered to soldiers during the Vietnam war. The psychedelic effects and the arrival of propofol prompted the shelving of ketamine. However, the discovery of the NMDA-receptor and its non-competitive inhibition by ketamine revolutionized the pathophysiology of hyperalgesia and mental functioning. In early 1990s, the discovery of opioid-induced hyperalgesia elicited a paradigm shift in the management of pain, and a comeback of ketamine, as an anti-hyperalgesic drug. Ketamine is nowadays under the spotlight in the field of treatment-resistant depression and has been proposed as a potential fast antidepressant in patients with high suicidal risk.     

Trouble de personnalité borderline et temps vécu

Objectives

Starting from the semiological heterogeneousness of borderline patients, we try to understand the everyday life of such subjects, and to determine the psychopathological structure of Borderline Personality Disorder.

La faible estime de soi est corrélée à l’intentionnalité suicidaire,indépendamment de la sévérité de la dépression

Introduction

Suicide is a major Public Health concern, and low self-esteem might represent a major risk factor. Our main objective was to assess the correlation between self-esteem and suicide intent. More specifically, we aimed to examine the relationship between the different dimensions of self-esteem (total, general, familial, professional and social) and suicide intent. We also sought the role of depression in the relationship of self-esteem to suicide intent.