Approche dimensionnelle de la personnalité schizotypique : étude comparative de deux populations estudiantines française et tunisienne

Object. - The schizotypal personality questionnaire (SPQ) conceived by Raine in 1992 is a psychometric assessment tool measuring the 9 DSM-IV features of schizotypal personality : “Ideas of reference”, “Magical thinking”, “Unusual perceptual experiences”, “Paranoid ideation”, “Social anxiety”, “No close friends”, “Constricted affect”, “Odd behaviour” and “Odd speech”. Validation of this questionnaire was studied on ethnically different populations. The aim of this study was to compare the SPQ scores (total scores and 9 subscales) between French and Tunisian students populations.Methodology. - It is about a comparative transverse study of two groups of students : a first group constituted by 198 students of the medicine university of Monastir (Tunisia). The second group containing 232 students of Lyon I University (France). We compared the mean total scores and mean scores at the 9 sub-scales of the SPQ between two groups.Results. - The mean total score in Tunisian group was higher 25.2 ± 12.3 vs 23.1 ± 12.1 in the French group. The difference was not significant (P < 0.07). Mean total score was significantly higher in Tunisian woman's group regard to French women group (26.6 ± 11,6 vs 22.3 ± 11.2, P = 0.005). There was no difference between Tunisian and French man's group. Concerning the scores in SPQ subscales, the Tunisian group scored significantly higher in: “social anxiety” (P = 0,001), “no close friends” (P < 0.0001), “constricted affect” (P < 0.001) and “paranoid ideation” (P < 0.0001), which corresponds to the negative dimension of schizotypy. While, French group scored significantly higher in: “unusual perceptive experiences” (P < 0.0001) and “odd speech” (P = 0.003), which corresponds to the positive dimension of schizotypy. Almost the same result was found in woman's and man's groups separately. Tunisian woman's group scored significantly higher in “social anxiety” (P = 0.01), “no close friends” (P < 0.0001), “constricted affect” (P < 0.0001) and “paranoid ideation” (P < 0.0001). French woman's group had significantly higher scores in “unusual perceptive experiences” (P = 0.04). Similarly, Tunisian man's group scored significantly higher in “social anxiety” (P = 0.03), “no close friends” (P < 0.0001) and “paranoid ideation” (P = 0.0002). French man's group scored significantly higher in “unusual perceptive experiences” (p < 0.0001) and “odd speech” (P = 0.001).Comments and conclusion. - Our results showed differences between French and Tunisian students in expression of schizotypy dimensions. Tunisian students seem to express more negative schizotypy and French students express more positive schizotypy. It evokes the possible influence of sociocultural context, which may be different between French and Maghrebian societies. Influence of drug use which is more frequent in European countries than in Maghreb, seems to be associated with positive symptoms of schizotypy. The results emphasize also the necessity of adaptation of such instruments : SPQ and other tool of assessment of personality disorders. The role of biological and especially the genetic factors in expression of schizotypy can be also evoked.     

Faisabilité de l'autoévaluation dans le dépistage de l'hypomanie

The Hypomania Checklist (HC) is a 20-item questionnaire, which is easy to fill in and designed to help clinicians collect data for diagnosing bipolar disorder. This tool could be very useful in primary care where type II bipolar disorder is under-diagnosed, however, to date no suitable cut-off score correlating with a high probability of bipolar II disorder diagnosis has yet been validated.

Method

In a French clinico-epidemiological multi-center survey (EPIDEP) a national sample of patients with DSM-IV major depressive episode (MDE) was recruited and assessed at admittance and four weeks later. Diagnoses of unipolar or bipolar disorder were made according to a semi-structured interview adapted from the DSM-IV. In addition, the HC and questionnaires on affective temperament were administered at the second interview. In the analyses, the diagnostic accuracy was computed in terms of sensitivity, specificity, predictive positive value and predictive negative value, by varying cut-off scores on the HC. The Receiver Operating Characteristic (ROC) statistical technique was used to compare the diagnostic value of HC with the semi-structured interview adapted from the DSM-IV.

Results

Of the 493 patients with a MDE DSM-IV diagnosis, 468 filled in the HC, from which the six following groups were formed: strict unipolar disorder (UP, N = 201), bipolar I disorder (BP-I, n=39), bipolar II disorder (BP-II, N = 141), patients with mania or hypomania secondary to an antidepressant treatment (N = 51), cyclothymia (N = 14) and hyperthymia (N = 22). Comparing the BP-II patient group (N = 141) with the strict UP group (N = 201) the most discriminating HC score was 9, which identified 81% of patients correctly, with a sensitivity of 86.5, a specificity of 77.1, a predictive positive value of 72.6 and a predictive negative value of 89.1. Some cases identified as cyclothymic and hyperthymic temperaments by the affective temperament questionnaire but meeting DSM-IV criteria for major depressive disorder were included in the unipolar group (N = 237). The same score of 9 was validated, identifying a percentage of patients with correct diagnosis of unipolar depression of 78.3%, a sensitivity of 86.5, a specificity of 73.4, a predictive positive value of 66.0 and a predictive negative value of 90.1. If patients with mania or hypomania secondary to an antidepressant treatment were included as a subgroup of BP-II, a score of ten appeared as the most relevant, with a percentage of patients with correct diagnosis of 79.0 %, a sensitivity of 80.2, a specificity of 78.1, a predictive positive value of 74.8 and a predictive negative value of 83.0. ROC curves confirmed these values. Lastly when BP-I patients (N = 39) were compared to the strict UP group (N = 201) the most discriminating HC score was 11, with a percentage of patients with correct diagnosis of 86.3%, a sensitivity of 74.4, a specificity of 88.6, a predictive positive value of 55.8 and a predictive negative value of 94.7, but the BP-I group was too small to validate the score of 11.

Conclusions

These results indicate that a score of 9 on the HC is highly correlated with a BP-II diagnosis (and a score of 10 if patients with mania induced by antidepressants are considered as BP-II), and suggest that a wider use of the HC in primary care associated with strong GP/Psychiatrist networks could improve the detection, and with appropriate treatment, the prognosis of Bipolar II disorder.     

Le surgissement de l'originaire et le « retrait hallucinatoire » dans les formes délirantes de l'éveil de coma

The clinical investigation of delirious and hallucinatory states during the awakening from a coma reveals hallucinated representations of a polymorphic nature. The diversity of their contents suggests the implication of differentiated etio-pathogenic processes. The assumption followed here, based on the conceptualizations of P. Aulagnier, is that the emergency care awakening traumatism causes a prevailing reinvestment of various operating modes, from the recovery of a “pictographic production” due to the abolition of conscience, to the fantastical scenario characterising primary education that remobilises and upsets the identity bearing layers in which the essential moments of the instinctual history were elaborated. These symptomatic constructions thus express this “in-more” generated by the psychotic processes which combine the double movement of a regression and of a “redeployment” of the traces of the Primal. This second period fulfils the paramount requirement of a primitive development of the coma awakening experience following the “postulate” of the dominance of the Primal according to which any psychic object is seen initially metabolized in a pictographic representation. The stratification noted within these dreamlike formations reveals: on the one hand modes of composition of images similar to those of the night dream; and on the other a deployment of various imagos of archaic states of the parcelled out body; and finally “psychic residues” that re-appear in the form of “parasitic” reminiscences, analysable as resurgences of psychic activities resulting from the coma phase. Thus a representation of the data of the Primal is then generated and although these data are psychic they remain forever heterogeneous and external to the Unconscious and to the I. The common clinical term which supports this analysis is “hallucinated feeling” which, according to Aulagnier, emerges sometimes within a schizophrenic patient which could be understood as equivalent to an autistic withdrawal which we suppose to be here at the heart of the deliriousness of the awakening from the coma. Thus the proposal that two etio-pathogenic logics are at work in these acute episodes: 1/ one that is initiated in a movement of decomposition of the I, due to the multiple traumatic effects of the primary affection and of the emergency care awakening process, balanced by the variations of the state of consciousness of the patient. At the time of this regression the projective mechanism, combined with other defences such as rejection or cleavage, reveals scenarios in the psychic space which mobilize images of the body and perceptive or mnemonic fragments. 2/ the other trajectory is comparable to this dynamics of the “withdrawal in the hallucination”. The re-establishment of the specific processes of the primary and secondary agencies imposes a requirement of specific psychic work consisting in metabolizing this resurgence of the pictographic representations that originate in the (quasi) nothing of the coma.     

Évaluation du risque de récidive en Belgique francophone : données préliminaires d’analyse factorielle de la « Sex Offender Recidivism Appraisal Guide » (SORAG) et de la Statique-99

In order to assess the internal structure of risk assessment of sexual recidivism of the Sex Offender Risk Appraisal Guide (SORAG), and the STATIC-99, a principal components analysis followed by promax rotation was conducted. In a data set including adults forensic sex offenders, three interpretable components were identified both with the SORAG (n = 79) and the STATIC-99 (n = 254): “past criminal behaviour”, “demographic characteristics”, and “antisocial personality” for the SORAG and “criminal past behaviour”, “aggressor-victim relationship” and “sexual offence” for the STATIC-99. Prospective data were available (SORAG: n = 133; STATIC-99: n = 137). For both instruments, the “criminal past behaviour” factor was the only one predicting general recidivism, violent recidivism and sexual recidivism.     

Étude de l’influence des troubles mentaux sur les difficultés de réinsertion sociale

The psychiatric problems of the “homeless” population are now recognized. The aim of this article is to focus the study on a sample of this population (n = 999) asking for help in their social insertion. The results on clinical disorders (Axis I of the DSM-IV) and personality disorders (Axis II of the DSM-IV) are compared to estimations on general population and to other studies on “homeless” in France. These comparisons show the prevalences of some disorders whose symptoms involve problems in social rehabilitation. At last, measures of interaction and impact (multiplicative interactions, odd ratio, etiologic fractions) shows that these morbid associations increase the problems in the attempts to social rehabilitation.     

Caractéristiques psychologiques des patients coronariens en situation de gestion de la frustration

Objectives

The aim of the present study is to investigate psychological characteristics of frustration management and their consequences in coronary patients.

Methods

A sample of N = 58 myocardial infarction patients completed questionnaires measuring self-efficacy (Schwarzer), negative affectivity and social inhibition (type D, Denollet), coping strategies (Coping Questionnaire for Coronary Patients [CQCP], Maës); Anxiety and depression (Hospital Anxiety and Depression Scale [HADS], Zigmond and Snaith), quality of life after myocardial infarction (MacNew Heart Disease Health-related Quality of Life Questionnaire, Hillers) and frustration management (Picture Frustration Study [PFS], Rosenzweig).

Results

The results show that frustration management in coronary patients differs significantly from that of the reference population. During frustration management the coronary patients present comparatively higher levels of culpability (high I answers) or denial of the responsibility of others (high M answers), as well as lower levels of aggressiveness (low E answers) than the reference population. Furthermore, myocardial infarction patients tend to rather repress their feelings (few ED answers) and to look for active solutions (high NP answers) (Table 1). Patients with a high self-efficacy score look significantly more for active solutions in their frustration management (NP) (r = 0.27), whereas patients with negative affectivity and social inhibition look for fewer solutions (respectively r = -0.31, r = -0.26). The social inhibition is significantly associated with answers of “Obstacle Dominance” (OD) (r = 0.28). Within the four coping strategies studied, only the focusing on the problem resolution one is significantly linked to the frustration management responses. Patients using a problem-focused strategy show lower levels of “Ego Defence” for frustration management (r = -0.31) and higher levels of “Need-Persistence” (NP) (r = 0.31). Furthermore, results show that “Ego Defence” (ED) is positively related to anxiety (r = 0.27), whereas “Need persistence” (NP) is negatively linked to anxiety (r = -0.28) and negatively to depressive affects (r = -0.29). Patients indicating more extrapunitive answers (E) report significantly lower levels of quality of life (r = -0.29), whereas non-punitive answers (M) are associated with higher degrees of quality of life (r = 0.31). No other significant associations were found between frustration answers and quality of life.

Conclusions

Emotional repression may be a short-term efficient strategy for the patients, allowing a distancing from the myocardial infarction trauma and increasing the quality of life. In the long-term, however, high levels of emotional repression could have negative effects on the global quality of life and the health of the patients.     

L'évolution du concept de mythomanie dans l'histoire de la psychiatrie

During the l9th century, morbid lying and imaginative exuberance are pointed out in several forms of the mental alienation: Intellectual monomania (Esquirol, 1819), hereditary madness (Morel, 1860), megalomania (Dagonet, 1862 and 1876), grandiose delusion (Foville, 1871) — with ideas of filiation — and over all hysterical madness (J. Falret, 1866; Lasègue, 1881). Several historical personages reincarnated (false Joan of Arc, false Louis XVII) have likely suffered from these disorders. For the first time in Germany, Delbrück isolates an autonomous form of pathological lying that he calls “pseudologia fantastica” (1891). The French alienist E. Dupré (1862-1921) describes in 1905 the mythomania and its three forms: 1) vain (fantastic boasting, criminal autoaccusation, malingering); 2) mischievous (hoax, slanderous accusation, anonymous letters); 3) perverse (swindlers, seducers, wandering mythomania). Dating from 1910, Dupré characterizes the delusions based on “imaginative” mechanisms, with grandiose ideas, either chronic (autosuggestion, confabulation), or acute (often symptomatic of delirium, dementia, amnestic or mood disorders). In 1919, he considers mythomania as the basis of hysteria, through its “constitutional” (or “temperamental”) theory of mental disorders. These conceptions are accepted by Delmas and Boll (1922), Heuyer (“délire de rêverie”, 1922), Vinchon (1926) and Dide (1935), but criticized by the pupils of Charcot (Janet), the phenomenologists (K. Schneider) and the “structuralist” school (Ey). Kraepelin's confabulatory and fantastic paraphrenias are compared with Dupré's imaginative delusions by the pupils of H. Claude (Nodet, 1937). But the intuition is separated from the imagination as an autonomous delusional mechanism (1931), whereas Delay (1942) and then Guiraud (1956) distinguish confabulation from mythomania. Since the DSM-III (1980), the word mythomania is no more retained into psychiatric classifications. The clinical entity of Dupré is divided in delusional disorders (grandiose type), facticious disorders, antisocial, narcissistic and borderline personality disorders. On the other hand, pathological lying is nowadays differentiated from malingering, delusions, Ganser's syndrome and confabulation. Its boundaries with histrionic personality disorder are not clear.     

Le père, le fils et la mère Russie : un portrait psycho-social de l'intelligentsia Russe dans le roman d'Andreï Bitov : La Maison Pouchkine

Andrei Bitov's seminal novel “The Pushkin House” provides a psychosocial portrait of the Russian intelligentsia under the totalitarian Communist regime. The attack on the intelligentsia comes not simply in the form of physical extermination, but also in stamping out critical mentality as such. Bitov depicts a society in which the relationship to the country's history, the literary tradition and even to one's own family legacy are all seriously distorted. Memory and language lose their meaning since it is subject to change as per latest governmental mandate. Continuity with the past is severed. Not being able to come to terms with its past, the society ceases to evolve, and its development stops. The “new man” promised by social engineering turns out to experience identity diffusion, emotional lability and intense dependence on others. The protagonist of “The Pushkin House,” described in a way not unlike an extended case study, reflects the immaturity of his society that is fostered by the existing political order. Ironically, it is when the protagonist of the novel is finally able to look at himself critically and attempts to assume responsibility of his actions, that his functioning within that society is threatened.     

« L'expertise » de fin d'hospitalisation d'office médicolégale (article L 3213-8 du code de la santé publique)

The “expertise” required by article L. 3213.8 of the Code of Public Health is exceptional within the statute of “compulsory hospitalization” (Police-instructed compulsory hospitalisation in France corresponds to the juridical or court-ordered hospitalisation in Anglo-Saxon law). This paper proposes a critical analysis of this “expertise” and of the ensuing situation of pathological criminals based on an extended practice of expertise and taking into consideration the recent evolution of the concept of dangerousness.     

Déficits des fonctions exécutives dans la schizophrénie selon les dimensions positive, négative et de désorganisation

The aim of this study was to examine whether executive deficits underlie positive, negative and disorganisation of schizophrenia. The sample comprised 34 patients (30 males, 4 females) diagnosed with DSM-IV criteria (mean age = 35 ± 9.5 years; mean duration of illness since first psychotic symptoms = 10.2 ± 7 years; mean years of education = 11.7 ± 2.6). Evaluation of patients was performed after achieved sufficient remission (clinically stable for 4 weeks at least, no depressive symptoms at moment of cognitive testing and no medication change during the three last weeks). Symptom dimensions were evaluated using items drawn from the Positive And Negative Symptoms Scale (PANSS). The Negative factor comprised N1 (blunted affect), N2 (emotional withdrawal), N3 (poor contact), N4 (passive, apathetic), N6 (lack of spontaneity), G7 (stereotyped thinking) and G16 (active social avoidance). The Positive factor comprised P1 (delusions), P3 (hallucinatory behaviour), P5 (grandiosity), P6 (suspiciousness) and G9 (unusual thought content). The Disorganisation factor comprised P2 (conceptual disorganisation), N5 (difficulty in abstract thinking), G10 (disorientation) and G11 (poor attention). The mean total PANSS score was 63.3 ± 16 (mean of positive score = 14.3 ± 4.7; mean of negative score = 18.1 ± 6.3; mean of general score = 30.9 ± 8.5). Executive functions were examined through the Wisconsin Card Sorting Test (WCST), the Hayling Test (Tunisian version) and two semantic verbal fluency tasks (simple with one category “animals” and alternating with two categories “fruits and clothes”). Partial correlations between syndrome scores and cognitive scores were examined while holding the effects of other symptoms, age and education level constant. Severity of disorganisation symptoms correlated with high number of perseverative errors (r = 0.47, P < 0.05) and total errors in the WCST (r = 0.37, P < 0.05) and with reduced score of alternating semantic verbal fluency (r = -0.39, P < 0.05). Severity of both negative and positive dimensions uncorrelated with performance of any of the executive tasks. Also, scores of the Hayling Test (time part B minus time part A; errors part B) and semantic simple verbal fluency (total of correct words) were uncorrelated with symptoms. The present study provides evidence that disorganisation dimension of the PANSS correlates specifically with impaired cognitive flexibility as reflected by high number of perseveration in the WCST and reduced set-shifting in semantic alternating verbal fluency.     

Une phénoménologie de la dépendance à l'alcool. Une expérience primordiale de la « nostrité »

The phenomenological approach to alcoholism interestingly focuses on specific dynamics of interpersonal relationships displaying the founding of the Self from a primary “us” and its original basis in the human feast. Priorities for treatment intervention recommend to involve social setting and relationships of the patients, reaching their active participation to a motivational and long term group treatment, underlying the specific therapeutic effect of world exchanges. Biopsychosocial determination of alcoholism could be primarily based on components of interpersonal relationships. Regarding social background, drinking is one of the most famous supports for the achievement of the feast, a founding marker of present time. Taking an existential point of view, the feast appears as the heart of mankind because it presents a primary “us”, a plural state which indicates the beginning and founding of the Self from the others. During the feast, we regularly have to reach our Self from the “us” while avoiding two main dangers, drunkenness, an increase in the dizziness of upright verticality, and addiction, an opposite vertical surrender to alcohol and falling into in the alcoholic relapse, both situations imply a spatial domination and the disappearance of others. Treatment programs of alcohol addicts need to integrate the necessity of reaching the existential basic trust from the support of a group to the appropriation of the community which can be defined as an original “usness”.     

La situation des auteurs d'infractions souffrant de troubles psychiatriques dans les systèmes judiciaire et pénitentiaire de la ville de New York (États-Unis)

Over the last few years, a growing number of mentally ill offenders has been involved in New York City criminal justice system (NY, USA). The effects of de-institutionalization and the enforcement of a “zero tolerance” policing, are among other reasons, responsible for the criminalization of this population, leading to a massive incarceration of mentally ill offenders in New York city jails and state prisons. The importance attached to health and social care within the correctionnal facilities show the attention heeded to “mentally ill” offenders in general. The lack of discharge planning in the city jails and the persistence of the “revolving door” phenomenon have yet given rise to innovative approaches, making the New York experience a place worthy of serious study.