Actualité en neuro-imagerie du Trouble Déficit d’Attention/Hyperactivité

An increasing number of neuroimaging (in particular, magnetic resonance imaging [MRI]) studies has been published in the last two decades with the aim to elucidate the brain correlates of Attention-Deficit/Hyperactivity Disorder (ADHD). The amount of available evidence has allowed researchers to pool such body of studies in meta-analyses, which provide more reliable information than single and often underpowered studies. Meta-analytic evidence from structural MRI studies shows that, compared to non-ADHD controls, individuals with ADHD present with significant differences in the volume of fronto-parietal, striatal, thalamic and cerebellar regions, involved in inhibition, self-adjustment and goal-directed behaviors, functions typically impaired in ADHD. Converging evidence from diffusion tensor imaging studies also shows ADHD-related white matter alterations in fronto-striatal-cerebellar circuits as well as in parieto-temporal-occipital regions. Evidence from structural studies has been complemented by task-based functional MRI studies pointing to dysfunctions in the same brain regions. The relatively recent introduction of resting-state MRI has allowed the detection of complex patterns of dysfunctional interactions, at rest, among several brain networks, including the default and task-positive networks, in individuals with ADHD. To date, most of the neuroimaging literature in ADHD has focused on group comparisons; therefore, its results are not applicable at the single-patient level. However, the recent development of support vector machine and similar analytical approaches promises to turn the field towards useful application in terms of diagnosis and prognosis at the single-patient level, thus being informative for daily clinical decisions.     

Traitement d’induction dans la sclérose en plaques : place du natalizumab

Background

Current treatment options for first-line immunotherapy in relapsing-remitting multiple sclerosis (MS) are recombinant interferon-β and glatiramer acetate. However, these therapies are only partially effective and certain patients may fail to respond. For this reason, it is important to elaborate alternative treatment strategies. Induction therapy represents a more aggressive approach in which powerful drugs are used right from the beginning to tackle the disease process hard and early. Natalizumab is a powerful monoclonal antibody approved for the treatment of relapsing-remitting MS and is known to silence disease activity.

Methods

We describe here the early outcome at 1 month and at 6 months of three patients treated with natalizumab for relapsing-remitting MS.

Results

All three patients had a high disease activity before the initiation of natalizumab, with 4, 8 and 5 gadolinium-enhancing lesions on brain MRI respectively. On the MRI scans made at 1 month after the first infusion, and at 6 months, there was no more gadolinium-enhancement and no new T2-lesion. Clinically, they did not experience any relapse.

Discussion

In these three cases, natalizumab showed a dramatic efficacy: the patients became “disease activity free” right from the first infusion. To our knowledge, natalizumab is not classically used as an induction therapy, unlike mitoxantrone. However, this treatment has potential hematological and cardiac toxicity and its use can be limited. Thus, in JC virus negative patients, natalizumab could be an interesting alternative treatment.

Conclusion

Our report suggests that induction strategy with natalizumab may be applicable in patients with aggressive multiple sclerosis. A study of more similar cases may be interesting to confirm these preliminary results.     

Prise en charge non pharmacologique des troubles du comportement dans la maladie d’Alzheimer

Psychological and behavioural symptoms of dementia such as agitation, aggressiveness, opposition, psychotic symptoms (hallucinations or delusions) are often documented by health care aids or nurses while caring for aged persons. Considering the limited efficiency and the extent of secondary effects observed during treatment by psychotropic substances, the majority of existing directives emphasize the importance of nonpharmaceutical treatments. The aim of this article is to describe the methodological problems met in the studies of nonpharmaceutical treatments and to present the nonpharmaceutical treatment study in dependent old people's homes, based on a randomised trial in 16 dependent old people's homes.     

Processus d’installation du tai-chi, technique corporelle thérapeutique adjuvante, en psychiatrie hospitalière

The authors describe the introduction of the practice of tai-chi-chuan in a in-patient setting. The presentation of this component of traditional Chinese medicine includes its martial, medical and cultural aspects. A clinical vignette illustrates how one of the first patients reacts to this bodily technique. While somatic benefits of tai-chi are well-known, the authors try to show two major contributions to the improvements of the well-being of traumatized inpatients: Growing mindfulness and active relaxation.     

La chose en voie d’existence

Pushing aside the strong glare, the blinding meaningfulness, and striving to restore a shadowy area will no doubt be the aim of treatment whenever – as is the case with psychotic patients – meaning, experienced as overwhelming, becomes disembodied and abusive. At that point, classic psychoanalytic treatment implies that the paradigm of transference interpretation be postponed for what may turn out to be a considerable length of time. We therefore have to revise our conceptions of the links not only between what is interpreted and what is not but also between destructiveness, creation and construction. Taking something in does not imply understanding but rather accepting that some part of the self needs to be changed. Initially, accepting the transference and its horrendous power does not have interpretation as its aim, but rather the shaping of the intense flow of the transference without becoming completely lost. The analyst will yield to an immaterial part of him- or herself – perhaps even to a kind of transparency – while waiting for the fragile texture of that web to become stronger. Access to the proximity of the object and to feelings requires a gradual restoring of the flexibility of regression that lies at the very heart of the transference encounter. The road is thereafter open towards a distant interaction with nothingness, sheltered by the founding experience of an indestructible link to the object.     

Les fausses allégations d’enlèvement d’enfant : la pratique du FBI appliquée dans un nouveau protocole d’intervention du département des Sciences du Comportement de la Gendarmerie nationale

Cases in which a child has been falsely reported as missing or abducted are very difficult to solve for an investigative team. It is a big challenge for law enforcement to lead this kind of investigation. The FBI conducted a very interesting study about these cases. Seventy-one cases were analyzed, involving 66 victims. They conclude that the mean age for the victim is around 5 years old. The major point they found is about the kind of family or parents who are able to do that. They observed that the family was most of the time unstable, with many problems like alcohol, drug abuse, financial problems…Following the result, they created an assessment process to determinate if it could be a false allegation. Then if it is positive and if the credibility of the parents or caregivers is doubtful, they built a specific investigative strategy. Sharing their experience, their study and their process with the Behavioral Sciences Unit of the French Gendarmerie nationale, we adapted the process to their own investigative methodology. In the same time, in January 2013, the murder case of Typhaine went to the trial. In June 2009, this 5-year-old little girl died under the hits of her mother and her boyfriend, and one week later, they called the police to report that she disappeared in the town center of Maubeuge during a walk. Looking at the case by the index of the study, all criteria of a false allegation of child abduction were present, but a specific tool to lead the investigation did not exist at this time. Law enforcement spent 6 months on working on the case, since the boyfriend confessed the murder of both of them and the body disposal. These cases are uncommon fortunaletely. Because of this exceptionnal nature, investigators are not really ready to manage them, but now, with the new protocol, the French BAU will be skilled and in that helpful in these situations.     

Le FOUR score en français, un nouveau score d’évaluation de la profondeur du coma

Background

Comatose state is a major cause for admission to the intensive care unit. The most commonly used assessment score is the Glasgow coma scale (GCS). Although widely accepted, this score has several limitations. Recently, the full outline of unresponsiveness score (FOUR) has been validated and tested as reliable as the GCS.

Methods

We translated this score in French and tested its reliability in a neurological critical care unit. This study included eight critical care patients and eight intensive care patients. The patients were successively evaluated by two neurologists, four experienced nurses and five inexperienced nurses; a total of 176 evaluations were performed. The weighted kappa (κ_W) was used to determine the reliability of the evaluation for both the FOUR score and the GCS.

Results

The mean age of the patients was 62 years. The interobserver reliability of the French version of the FOUR score was high (κ_W = 0.86; IC 95%: 0.83-0.89) comparable to that of the GCS (κ_W = 0.85; IC 95%: 0.82-0.88).

Conclusion

The French version of the FOUR score has an excellent interobserver reliability. This score is easy to perform and well accepted, only requiring simple and short training.     

Évaluation du dispositif d’injonction de soins pour les auteurs de violences sexuelles en Indre-et-Loire (France)

In France, sex offenders can be condemned to a therapeutic injunction, instead of or after an imprisonment period. In order to reinforce the prevention and punishment of sexual offences, the condemnation law (June 17, 1998) obliges a sexual convict to submit to surveillance and assistances measures and, in some cases, to mandatory medical care (a treating physician, psychiatrist or psychologist, and a coordinating physician, the intermediary between medicine and the courts). The aim of this research was to assess the therapeutic injunction functioning (n = 16) and to identify the obstacles in coordinating medical and judicial professionals. Therefore, we conducted a local survey that involved in-person interviews with medical (treating physicians and coordinating physicians) and judicial (sentencing judge) professionals in charge of the 16 sex offenders (non incestuous paedophiles) condemned to a therapeutic injunction. The treating physicians and the coordinating physicians were very different in their settings and in their understanding of the therapeutic injunction procedure. Health and judicial professionals criticized the lack of interactions between professionals, but not the therapeutic injunction itself. This work highlighted the necessity of (1) a better coordination between health and justice professionals, (2) the creation of a treatment and assessment centre for sex offenders.     

Le soin en famille d’accueil : théories du « care » et quotidienneté

Receiving people in situation of psychological vulnerability in foster families implies, beside a shared everyday life, a concern for these persons and for their well-being, in other words a form of care, different from cure treatments. The current development of “theories of care”, in the field of moral and political philosophy, helps to specify the dimensions of care, including its intrinsic ethical dimension. These ones turn out to be relevant in the context of foster families. People take care not only of other people, but also of the shared and everyday world in which they live together. This care of the shared world is to be itself shared.     

L’exemple d’un dispositif de soins en psychiatrie du sujet âgé au sein du Réseau pour la promotion de la santé mentale Yvelines-Sud

The goal of the Mental Health Care Network of the Yvelines-Sud region (RPSMYS) is to reorganise mental health care on the basis of a partnership and thus to improve care for people within this field. Its sphere of activity is both well-defined and wide ranging: it does not replace the existing health care offer, but it is required for situations in which there are no satisfactory answers despite a well identified need or when the level of interdependence between the different actors is high or in situations where compartmentalisation is stronger.     

Consommations d’alcool et de drogues, et migrations en Amérique du Nord : revue critique de la littérature

Quite a lot of research has been conducted in North America to study the relationship between alcohol and drug use (alcohol and drug consumption and/or substance related disorders) and migration. A review of the epidemiological studies is proposed with the example of research on Mexican Americans in the United States. Two models were used initially: acculturation and cultural identification. Acculturation refers to the processes of change in artifacts, customs and beliefs that result from the contact of societies with different cultural traditions or the results of such changes. A large number of acculturation scales have been created, but the use of objective variables (e.g., place of birth, age at arrival and years residing in host country, primary language use including a measure of the proficiency of the second language) is now recommended by a majority of the authors. Culture simply cannot be reduced to a measurable variable. The main limits of the studies reviewed are linked: 1) to the validity problems of ethnic or cultural groups studied; 2) to the cross-cultural applicability of diagnosis and assessment of substance use disorders, as the attitudes of societies to alcohol and drug use affects the use of criteria and the elaboration of diagnoses; and 3) to the frequent confusion between cultural factors and socio-economic, environmental or discrimination and racism factors. Even though these studies are not transposable to other contexts, they tend to show that substance use and substance related disorders prevalence are higher in non-migrants than in migrants and that this difference is correlated with time of residence. Exposure to mainstream American society often leads to patterns of alcohol and drug use among long term immigrants that approximate that of the native born population. These findings should not overshadow the migrants’ vulnerability and the importance of addressing cultural issues in the designing of treatment, in improving their accessibility to mental health care and to a better global quality of life.     

Psychopathologie du tueur en série

Although serial killers have always existed, individualizing this concept as well as giving a consensual definition and universal typology is still a problem nowadays. The authors present an overview based on the current literature, more specifically on definitions, categorization, epidemiology and clinical area. Psychopathological aspects are also developed and focused on different topics: psychopathy, sexual sadism, fantasies, and childhood. Serial murder is a world-wide phenomenon which has an increasing incidence even in the countries where the global criminality rate is decreasing, as for example in the United-States. The reasons are numerous and often lead to inconvenient explanations. A serial killer is generally a Caucasian, aged between 20 and 40, who is often socially and familiarly well integrated, often suffering from personal and especially familial psychiatric conditions. Many serial killers act alone, and plan their crime a long time in advance. They choose their next victims with highly precise criteria, approached then and win their trust. Few serial killers act in an impulsive way and do not select their victims. In this precise case, these are very often psychotic. Generally, serial killers have a psychopathic personality disorder with a sexual sadistic dimension. Psychopathy implies a lack of affection and a loss or a total absence of empathy. A gravely offended childhood with physical and psychological violence, a chaotic familial dynamic, and lot of sexual, violent and dead fantasies are the common denominator of these murderers. Nowadays, even if they are regularly on the highlights of the media, serial killers still remain an enigma. Neurobiological and neurophysiological approaches, through the functional neuroimagery for example, could be interesting paradigms in order to try to understand and decode how these people work and, in this way, prevent their emergences.     

Expérience d’un groupe d’habiletés sociales : une année de pratique avec trois adolescents porteurs du syndrome d’Asperger

Though individuals with Asperger's syndrome may develop academic skills, their cognitive particularities often affect their adaptative behaviors. As adolescents, the deficits in communication observed in infancy are generally improved, but difficulties persist in interactions with pairs and in the domain of autonomy. This article illustrates the experience of a social skills training group including three adolescents with Asperger's syndrome. The training went from formal comprehension of interactions to concrete situations in order to increase the autonomy of the adolescents with Asperger's syndrome.