Évolution des patients traités dans un centre de jour spécialisé pour les troubles schizophréniques : une étude exploratoire

This exploratory study aims to evaluate the evolution of 25 patients during the time of a treatment in a day hospital specialized for schizophrenic disorders.Method. - In a naturalistic study, eligible patients were evaluated when entering and leaving for clinical profile, psychiatric history, nosognosia and compliance.Results. - The studied population presents a clinical profile indicating illness severity. Psychiatric hospitalizations, violence and suicide attempts diminish during the time of treatment. When leaving, 60 % of patients completed an employment or training project. The overall subjects present a significant decrease in positive symptomatology and a significant improvement in nosognosia and compliance to medication. On the contrary, a subgroup of 4 patients presents little improvement.Conclusion. - The treatment in the day hospital brings positive results for the majority of patients. They present significant possibilities of evolution in several domains. The limits of the study are discussed.     

Amélioration de la reconnaissance et de l’imitation d’expressions faciales chez des enfants autistes grâce à une présentation visuelle et sonore ralentie

An increasing amount of studies have demonstrated the existence of visual, auditive and motion integration deficit in individuals with autism, especially when movement is rapid. Since visual motion is intrinsically involved in social interactions through movements of the body and face, visual motion processing deficit could therefore account for their verbal and non-verbal comprehension and social interaction disorders. Besides, other studies have revealed the existence of speech integration deficit in this population which could also account for their verbal comprehension deficits. The aim of our study is to test whether slowing down sound flow and facial movement enhance facial recognition and imitation by autistic children compared to normal control children. Results show that a slow dynamic presentation enhances recognition and imitation of facial expressions by autistic children. Our perspective is to elaborate software that could simultaneously slow down facial movements and speech flow, and to assess its impact on the comprehension of words and instructions by autistic children.     

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.     

Étude des liens entre sommeil et mémoire épisodique chez le sujet jeune et âgé, et dans la maladie d’Alzheimer

Introduction

A large body of evidence indicates that sleep favors memory consolidation.

State of the art

This process would occur, mainly during slow-wave sleep, by means of a dialogue between the hippocampus and neocortical areas. Low levels of acetylcholine and cortisol are also needed to favor the transfer of memory traces toward the neocortex, where they will be stored for the long-term.

Perspectives

The aim of this article is, first, to give an overview of studies conducted in young healthy subjects and underpinning the hypothesis that sleep is involved in memory consolidation. Then, we will investigate the potential links between changes in sleep architecture and episodic memory impairment in both aging and Alzheimer's disease. Finally, we will see how these results can affect clinical practice.

Conclusion

Sleep-dependent memory consolidation is impaired both in aging and Alzheimer's disease. These findings suggest the importance of taking into account sleep when assessing memory function in patients.     

« Désorientation pour les personnes » au cours du vieillissement et des démences liées à l’âge

Disorientation towards people manifests itself during age-related dementia by hypo- or by hyperidentifications (false recognitions). The final stage during which the demented does not recognize his close relatives is sometimes preceded, as an heralding symptom of dementia, by an incomplete nonrecognition: Capgras’ syndrome, a delusion where a close relative is perceived as a double and an impostor. Current interpretation of these phenomena is based on the precepts of cognitive neuropsychology. Aged-related disorientation towards people, apart from naming difficulties, remains an opened question.     

Profils de personnalité et fonctionnement émotionnel dans les sports extrêmes : à propos d’une étude exploratoire chez des BASE-jumpers

This study examines relations between emotional factors (anxiety and depression), normal and pathological personality, and risk-taking behavior in 11 BASE-jumpers comparing to a control group (n = 11).

Method

All the subjects have been evaluated with self-report questionnaires measuring their emotional states before and after the jump, their involvement in risk-taking behavior, sensation seeking, personality disorders, anxious and depressive symptomatology. Results show a significant effect of BASE-jump practice on emotional state. They have higher scores on the thrill and adventure seeking subscale, they show more drug consumption and more accidents than control group. We found also clinical elements of pathological personality solely from cluster B of the DSM-IV-TR classification among BASE-jumpers. Emotional factors are correlated with borderline personality in this same group.

Discussion

We analyzed those results depending on emotional and behavioral dysregulation, and their specifics involvement in borderline personality, risk-taking behaviors, and also addiction. Sensation seeking could be especially reinforced on the base of a borderline personality with the possibility of a build-up of risk which may put individuals addict to it.     

Les conduites motrices innées des membres supérieurs. Observations – Études et recherches – Intérêts dans l’éducation thérapeutique

Several cerebral palsied patients suffer from disturbances of the motor regulation in execution of gestures, despite of a good representation of getting objects. A part of their difficulties lies in conveyance of the hand to the object and its adaptation regarding its shape. Beside of well known disturbances also exist disturbances of innate motor abilities. They are clinically identified through motor automatisms. Others are identified through coupling between motor, visual and hearing function. Anatomical lesions of connexion between cerebral areas where they are sitting would explain a lake of activity of the mirrors neurones. It would explain impairment in learning of motor activities. Clinical observation and studies, date from experimental researches allow us to explain those particular troubles. We have to take in account of those in therapeutic education of cerebral palsied infants.     

Les pratiques médicopsychologiques inspirées par la psychanalyse dans les services d’urgence - état des lieux et perspectives

The Emergency departments accommodate the clinical problems which classic hospital medicine do not wish to treat. The authors propose to clarify the place of medicopsychological treatment inspired by psychoanalysis within Emergency departments. The methodology of this research leans on the reading of works and documents on the hospital and the medicine, active participating observation within Emergency units, and semi-directive interviews and informal conversations with Emergency departments units staffs. Psychiatrists and psychologists treat new clinical categories, like suicidal or victim crisis, leaning on transitional analysis. Their relationships with emergency physicians are specific and contrasted, alternating proximity because of their marginality within hospital medicine and distance by the intertransference analysis and stakes which take place in interstitial spaces.     

Projet d’évaluation en continu des caractéristiques délictueuses, des aspects diagnostiques, de l’environnement social et de la prise en charge des auteurs d’infractions a caractère sexuel (AICS) au sein d’équipes de santé spécialisées en Région wallonne

The purpose of the study aims at determining the level of responsibility of the sex offenders like the recidivism rates. The study constitutes a research action of the prospective type in the long run. This one will be done from the implementation of an instrument evaluating the variables related on the offenses, the mental diagnoses, the socio-environmental parameters relating to the variables of responsibility. This instrument would allow a follow-up of the evolution of the sex offenders within the ambulatory care system (specialized teams) suggested in Walloon region. It would cover a big number of fields such as: static level of recidivism risk of the sex offender during its release; type of release; follow-up within one or several specialized teams of health; diagnostic criteria; characteristics related to the social environment in which sex offender evolves. These various dimensions are known as being predictive of a potential recidivism risk. They make it possible to also determine the needs for the sex offender as for a possible assumption of their level of receptivity.     

Projections privées, projections publiques : Contenus, objectifs et lieux des processus de délocalisation psychique dans les états psychotiques

The concept of projection has, in Freud writings, wide uses. By trying to clarify them, it appears: on one hand, that neurotic projection concerns representations, while psychotic projection concerns sensations, affects, and more generally somatic states; on the other hand, neurotic projection concerns especially mental elements relative to the object, while psychotic projection concerns mental elements relative to the ego. Thus, psychotic projection appears as the attribution to another ego of somatic-psychic states and representations that the ego refuses to recognize as his own experiences. Therefore, this projection always has a “public” character in the sense that, being by definition anthropomorphic, it requires the other human: another “ego”, receptacle of the projected parts of the ego. The relationship of this mechanism with the processes of « hominisation » is discussed. Grounded in this conception of projection, a hypothesis on the constitution of the category of the “subject” between the “ego” and the “object”, is outlined.     

Milnacipran et venlafaxine à posologie flexible (jusqu’à 200 mg/j) dans le traitement ambulatoire des épisodes dépressifs majeurs modérés à sévères de l’adulte : étude exploratoire de 24 semaines, randomisée en double insu

Introduction

Serotonin (HT) and noradrenaline (NA) reuptake inhibitors (SNRIs) are commonly used as first line treatment of major depressive disorders (MDD). As compared to tricyclic antidepressants, they have proved similar efficacy and better tolerability. Milnacipran (MLN) (Ixel^®) and venlafaxine (VLF) (Effexor^®) are two SNRIs pharmacologically differing by their NA/HT ratio of potency: 1:1 and 1:30, respectively.

Objectives

To investigate the efficacy and safety/tolerability of MLN and VLF administered at flexible doses (100, 150 or 200 mg/day) for 24 weeks (including 4 weeks of up-titration) in the outpatient treatment of adults with moderate-to-severe MDD.

Design

Multicentre, randomised, double blind, 2-parallel-arm, 24-week exploratory trial conducted in France by 50 psychiatrists.

Diagnosis and main inclusion criteria

Male or female outpatients, aged 18 to 70, meeting the DSM-IV-TR and related MINI criteria for recurrent, unipolar, moderate-to-severe MDD, with neither psychotic features nor severe suicidal risk. A Montgomery-Asberg depression rating scale (MADRS) score ≥ 23 was required at inclusion.

Treatment schedule

Patients were randomised to receive either MLN or VLF (1:1 ratio) for 24 weeks in double-blind conditions. Regardless of the treatment received, the following dosing schedule was applied: during the initial 4-week up-titration phase, the dosage was progressively increased from 25 mg/day (qd administration) to 150 mg/day (bid administration). At week 4, the dosage was either maintained at 150 mg/day, or adapted to 100 or 200 mg/day, based on the investigator's clinical judgement. At any time during the 20 following treatment weeks, the dose could be lowered for safety concerns until a minimal threshold of 100 mg/day. From Week 24, the dosage was decreased by 50mg/day every five days. After randomisation, eight assessment visits were organised at 2, 4, 6, 8, 12, 18, 24 weeks, and at study end (after the 5–15 days of down-titration and 10 days free of treatment). Efficacy evaluation ratings included the MADRS and global disease severity (CGI-S) total scores. Rates of MADRS response (reduction of initial score ≥ 50%) and remission (score ≤ 10) were calculated at Week 8 and Week 24 in the full analysis set as well as in the subgroups of patients with depressive disorder of severe DSM-IV intensity and with a MINI evaluation of suicidal risk (rated as required ‘moderate’ at the worst).

Statistical analysis

Standard distribution statistics (including mean and standard deviation [S.D.]) of scores and their changes from baseline, were calculated using the observed-case (OC) approach at all assessment times for the MADRS score, and the last-observation-carried-forward (LOCF) at 8 and 24 weeks for both MADRS and CGI-S scores. MADRS response and remission rates at 8 and 24 weeks were calculated using the LOCF approach by normal approximation of the binomial distribution. Bilateral exploratory statistical tests at 5% significance level were performed for results at 8 and 24 weeks of: (i) MADRS score changes from baseline, based on the score progress at each visit (mixed model for repeated measurements [MMRM]), and (ii) global MADRS response and remission rates (Chi²).

Results and patients

A total of 195 patients were randomly assigned MLN (n = 97) or VLF (n = 98) and 134 (68.7%: 61.9%/MLN and 75.5%/VLF) completed the trial. At the end of the up-titration, patients received 100 mg/day (11.4%/MLN, 10%/VLF), 150 mg/day (30.4%/MLN, 43.8%/VLF), or 200 mg/day (58.2%/MLN, 46.3%/VLF). Totals of 177 patients (90/MLN and 87/VLF) and 181 patients (90/MLN and 91/VLF) were analysed for efficacy and safety, respectively. Treatment groups were similar for baseline characteristics except a higher proportion of MLN patients with a severe depressive episode (63.3% versus 54%).

Results and efficacy

MADRS score (mean [S.D.] initial score: 31 [4.5]) progressively decreased all along the treatment course and similarly in both groups (Week 8-OC : –18.8 [7.7]/MLN and –18.6 [7.3]/VLF, p_MMRM = 0.95 ; Week 24-OC : −23.1 [7.8]/MLN and –22.4 [7.3]/VLF, p_MMRM = 0.37 ).At week 8-LOCF, MADRS response rates were similar in both groups (64.4%/MLN, 65.5%/VLF, p_chi2 = 0.88) as well as remission rates (42.2%/MLN, 42.5%/VLF p_chi2 = 0.97). At week 24 they remained non clinically and statistically different between groups (response rates: 70%/MLN, 77%/VLF, p_chi2 = 0.29; remission rates: 52.2%/MLN, 62.1%/VLF, p_chi2 = 0.19). In both “severe depressive episode” and “MINI mild or moderate suicidal risk” subgroups (n = 104 and 75, respectively), response and remission rates were non clinically different at both time points, however in the “MINI mild-to-moderate suicidal risk” subgroup, MLN tended to be more rapidly active (remission rate at week 8-LOCF: 44.7%/MLN, 35.1%/VLF). The changes in CGI-S were also indicative of a significant improvement of the global illness severity with both treatments.

Results and safety/tolerability

The tolerability profile of both drugs was in line with their pharmacological activity. About 70% of patients in both groups experienced at least one adverse event (AE). In both groups, the most common AEs were nausea, dizziness, headache and hyperhidrosis, and, in the male patients, genito-urinary problems: orgasmic disorders (VLF only) and dysuria (MLN only). These AEs were mostly responsible for definitive treatment discontinuation for tolerability concerns. None of the 6 serious adverse events (SAEs) on MLN and 4 of the 8 SAEs on VLF were related to the test drug.

Conclusion

MLN and VLF at flexible doses up to 200 mg/day globally exhibited similar efficacy and tolerability profiles in the long-term treatment of adults with MDD.