Rôle et place du gériatre en oncologie du sujet âgé

The geriatric population is characterised most of all by its wide variety. That being, other factors than age or pathology are predictive of the functional decline and the loss of autonomy of elderly persons, more particularly those with cancer. Following a number of works geriatricians have admitted that a systematic and rigorous pluridimensional approach is necessary to assess the elderly population; this is the SGE (Standardized Geriatric Evaluation). This trustworthy tool is all the more interesting in that it is reproducible as it is based on the use of scales that have all been validated to evaluate each patient in different domains, more particularly autonomy and the cognitive functions. The SGE will allow precocious detection of “risk factors” of the loss of autonomy that could compromise a satisfactory cancerological care. It is fully justified within a “fragile” elderly population (“fragility” itself also being a specifically geriatric concept that corresponds to precise criteria) and authorises setting up acts of prevention. Finally the interest of this method is in helping the clinician to avoid “situations of never-ending treatment or of therapeutic abandonment”. The SGE allows detection of either sick patient in a palliative situation (who will not benefit from a “heavy treatment”), or patients who, on the contrary whatever their age are “still in good health” (and can support a treatment similar to that of younger patients). Ideally, this process should be accomplished before the therapeutic decision (eventually after detection by the SEGA grid) but it can also be envisaged within the framework of care (of patients undergoing anticancerous treatments). However that may be, it is in this view that a collaboration between oncologists, psychiatrists and geriatricians is necessary.     

Le jeu comme « leurre » et le démenti

In the cure, according to our hypothesis, the games played by children obey different unconscious logics, which reveals the importance of envisioning the reception of different types of play in the cure. We propose a Freudian-inflected “structural classification of play,” drawing upon similar attempts made by Piaget for developmental psychology, and Caillois for sociology. We will consider that certain play follows a logic of negation (Verneinung) – play that we call “trompe-l’oeil” games; or a logic of disavowal (Verleugnung) – “decoy” games; or a logic of foreclusion (Verwerfung) – “suppléance” games. This article develops the type of play associated with the mechanism of disavowal: the game as decoy. We draw upon and analyse an example from the literature – that of Arpad, the “little chanticleer” received by S. Ferenczi in 1913. The examination of this case allows us to clarify the reasons for which such games can be an obstacle to the cure, as well as to the establishment and development of the transference. We will be led to cast doubt upon the possibility of considering such play to be “therapeutic” in the sense of winnicottian playing. Following the hypothesis that such play does not favour subjective change, we will propose a comparison with “trompe-l’oeil” and “suppléance” games.     

Prévalence de l’hypomanie dans les dépressions majeures récurrentes ou résistantes : enquêtes Bipolact

Bipolar II disorder is officially recognized as a mental disorder in DSM-IV-TR and defined by the presence of hypomanic episodes alternating with major depression. Despite data supporting clinical complexity and high morbidity and mortality rates, BP-II disorder is often overlooked or misdiagnosed as unipolar major depression or personality disorder. Moreover, many clinicians still regard it as a milder form of manic-depressive illness. These unsolved problems propose to investigate hypomania prevalence rates in resistant and recurrent depressions, at a large national scale, by means of three large surveys (Bipolact Surveys) carried out in both psychiatric and primary care settings. This research is a part of a national project for medical education on bipolar disorders established in September 2004. Screening of hypomania was done by self-assessment with the hypomania checklist HCL-20; hypomania cases were defined by a score greater or equal to 10 on the HCL-20. Inter-group comparisons (BP-II versus unipolar depression) and multiple logistic regression analyses were conducted on all demographic and clinical factors obtained. Data obtained in the “real world” medical practice (in total, 623 physicians and 2396 patients with major depression) revealed a high rate of hypomania around 62% in both recurrent depression samples (primary care and psychiatric settings) and 55% in resistant major depression. Additionally, the inter-group comparative data allowed drawing the BP-II disorder profile by selecting the most significant differences versus unipolars. “Ups and Downs” (cyclothymic traits) represented the most important and common (in all three different logistic models) risk factor of hypomania. In recurrent major depression, “ups and downs” seemed to act independently from another important risk factor, i.e. “family history of bipolarity”. “Mood switching” was the major risk factor for hypomania in patients with resistant depression; further risk factors were “substance abuse”, “young age of onset”, “agitated - mixed - atypical forms of depression”. These factors are meaningful at clinical and phenomenological levels, and can validate the dimensional approach of hypomania and the cut-off score on the HCL-20.     

L' « Ouverture émotionnelle » dans les Troubles de la dépendance et les Troubles de la personnalité

Emotion processing is supposed to play an important role in psychological dysfunctions in alcohol and drug dependency disorders (DD), as well as in personality disorders (PD). The model of “Emotional Openness” (“Ouverture émotionnelle”) provides a multidimensional framework to analyze problematic patterns of emotion processing. Within this framework, it is suggested that drug- and alcohol-dependent patients as well as borderline and antisocial patients show reduced a) “cognitive/conceptual representation” of affective states; b) “emotion regulation”; and c) “expression and communication of emotion”; but d) increased “awareness of body internal indicators” of affectivity; and e) appropriate psychological treatment is supposed to improve these patterns. Drug-dependent patients with PD comorbidity (in particular borderline or antisocial) are supposed to present even stronger deficits in (a) and (b). The hypotheses are tested with the 36-item DOE questionnaire (“Dimensions of Openness to Emotional experiences”, trait version; [19]), assessing six main dimensions of emotion processing as represented by the subject (French and Italian version). The instrument presents satisfying reliability coefficients (mean alphas of the scales in two recent studies (N = 251; N = 435) vary between 0.74 and 0.82) and good factorial validity (6-factor PCA solutions with varimax rotation solutions in the two samples are highly coherent; the mean of Tucker's congruence coefficients is 0.93). Results of two clinical studies are presented, comparing N = 71 patients (21 drug-dependent without personality disorder; 30 drug-dependent with borderline or antisocial personality; 20 dependent in-patients receiving psychological therapy) with normal control subjects (N = 51 matched; N = 50 reference group), including one pre-post treatment comparison. Results confirm marked deficits of DD patients concerning “conceptual representation” and “emotion regulation”, as well as a reduction of “communication/expression of emotion” but an increased “awareness of body internal indicators” of affectivity. Differences of patients with a double diagnosis correspond to effect sizes of d = -1.33 for cognitive/conceptual representation of emotions and d = -1.25 for emotion regulation; differences in emotion communication and expression are also significant but less important d = -0.44. Awareness of body internal emotion indicators is increased (d = +0.27) but does not differ significantly from the control group. As supposed, patients with a double diagnosis (DD and PD) described significantly stronger deficits in conceptual representation and emotion regulation than the patients with dependency disorder only. In the second study, a group of DD patients receiving multi-component treatment, including individual and group therapeutic intervention, according to the client-centered approach, and working on emotion processing, showed marked differences from the reference group at the beginning of the treatment (d = -0.91 for cognitive/conceptual representation, d = -0.82 for emotion regulation and d = +0.46 for awareness of bodily internal indicators). As supposed, pre-post comparisons indicate improvement with change effect sizes of d = 0.99 for conceptual representation, d = 0.97 for emotion regulation, as well as d = 0.88 for emotion communication and expression. Furthermore, the changes following treatment are highly significant and substantial, except for the awareness of internal bodily indicators, which only slightly decreased. Patients “normalize” their emotion processing following treatment, describing increased conceptual representation and emotion regulation, as well as emotion communication and expression. Results underline the importance of dysfunctional modes of emotion processing in both pathologies, and underline the validity of applying the model and the DOE instrument. They are discussed with reference to the model of alexithymia.     

Plaidoyer pour les cothérapies non-intégratives

The official way of taking care of the mentally disabled is by its principles, procedures and techniques a two-fold treatment. It will appear in this paper that our preference goes to the most traditional of the two options, the combined-therapies, in other words the “multisided therapies”, also called the “focus-shifting” strategies. The issue concerning combined therapies with two or three focuses being applied to severely disabeled patients is raised. This involves simultaneously an analytic investigation as well as behavioral psychotherapy, together with medication and support. Concerning the other more popular technique - the “integrating psychotherapies” - also known as the “psychotherapeutic movement for integration”, it will be critically examined. Our aim is to show that this integrative approach in psychotherapy is an offshoot from the eclectic and pragmatic american school of thought.It is not compatible with a psychoanlytical approach even when it tries to use its clinical and theoretical contribution.     

Les enjeux d’une « consultation rémission »

The temporality of the subject cannot be superimposed to the medical one: Remission time certainly tells it enough. What can be at stake in a remission support unit such as the one recently created at the Centre de Lutte Contre le Cancer in Reims, as it is organized on a pair-team basis with a cancer care experienced general practitioner and a psychologist-psychoanalyst? From the moment when the illusion of identity is broken by the diagnosis shock to the time of remission when the substitutive surface identity produced by the “framing-effect” of long-terms treatments collapses, landmarks are emerging for a clinical renewal in cancer care: Problematics of identity, prosthetic effect of the care institution, loss of dropping, maternal bereavement elaboration… For we approximately know what it is to be ill or not, but what do we know of the person who “has had a cancer”? The extension of Support Care to the phase of remission is probably necessary…     

La construction mimétique du soi-agent et les phénomènes de schizophrénie débutante

A new interpretation of the onset of schizophrenia is presented based on a mimetic and attributional model of the self as agent. Two separate independent perspectives on schizophrenia will be analyzed and criticized in relation to this model. The first one from the works of Henri Grivois, inspired by the general anthropology of René Girard is therefore oriented toward the mimetic dimension of interactions. The critique will focus on the gratuitous reduction of imitation to the domain of bodily motor functions when a much wider understanding of the concept is needed. The second perspective, proposed by Richard Bentall et al., deals with the attributional style of paranoids and is therefore mainly cognitive. The critique will focus on the reductionist and solipsistic vision of a self unduly equated with self-esteem. I intend to show that their respective mimetic and attributional foci are both needed in order to have a better understanding of the delusional subject, for these two dimensions define the inter-subjective space in which the self is built. As a matter of fact, the self is traditionally described as having two fundamental components, the me or object self and the I or agent self. But only the first one, the me, has been thoroughly investigated by the so-called “social mirror” research tradition which originates in Cooley’s “looking glass self” hypothesis. The “I” has constantly eluded scientific investigation and has therefore been virtually ignored by psychologists in the twentieth century. Many researchers have even proposed abandoning it to the realm of philosophy. However, as soon as the social mirror metaphor is understood as the imitation of others’ attributions to the object self, we may conceive of the agent self as the product of these imitations of attributions along the causal dimension. The “I”, characterized by the feeling of being the first cause of one’s own behavior, would therefore be of no less social origin than the “me”. Attributions of intention, responsibility or causality made by others to the self, when mimetically interiorized, will feed the causal self, the “I”. This unitary and psychological conception of self allows a new interpretation of some characteristic aspects of the onset of schizophrenia. The typical feeling of being a focus of attention of an entourage sometimes extended to the whole world can now appear as just the pathological version of the healthy “centrality” of the self in the « social mirror ». The question is: how does the bifurcation of the dynamics of self towards pathology happen? I hypothesize that if the causal attributions that normally “feed” the self along the agency dimension are too scarce, this will lead the self schema to an “abreaction” which consists of “hallucinating” personal causal attributions in the minute attentions, attitudes and messages provided by anonymous public social interactions. All these signs, when perceived and delusionally interpreted, will help the subject maintain the vital feeling of being a “cause” capable of “effects” which characterizes animated beings as opposed to pawns. Hence, the fact that paranoids are prone to perceive others as having malevolent intentions towards them, far from being explained by Bentall’s hypothesis - since a bad social self image doesn’t improve self-esteem - can be interpreted as their longing for causal attributions. In other words, accusations, malevolent attention and intentions are good for the feeling of agency. This conception might shed some new light on the specific susceptibility of adolescents regarding schizophrenia.     

L'expérience du corps vécu dans la paranoïa

The concept of Paranoia is almost synonymous with a certain “interpretative” style, whether it refers to emotionally disturbed or frankly manic states. This intellectualization, which is to a large extent a result of the psychopathological matrix from which Paranoia issued has in fact limited comprehension of the latter, in particular as regards the two following aspects: on the one hand, the distinction between a “sectorial” manic state that nevertheless has a marked confiscatory effect on the person's entire existence and a “network-associated” delirium that remains compatible with a certain social integration; and on the other hand, the marginalization of the hypochondria that is frequently observed in these patients and which may include a possible accusatory component (e.g. laying the blame on the therapist and associated structures for inadequate treatment) or a “neurosis” that sometimes replaces the patient's passionate or delirious attitude for a period of time. The phenomenological concept of the “opaque body” provides a certain reply to these questions: it shows that the body plays major role in Paranoia, as it represents the constitutive limit of the “truth” the paranoid subject seeks, and it also acts as a transmitter of signals - both mimico-gestural and verbal - through which the patient attempts to circumvent such a limit. The marginal role assumed by hypochondria then alters to become one of the body's possible means of physical expression of Paranoia; it does not manifest itself as an “other” illness that sometimes replaces the former, but rather as a continuation of the paranoid state including a reversal of roles, with the patient acting as persecutor and the therapist becoming the object of persecution. Thus one could qualify as Paranoia any pathological interpretative situation characterized by the persistence of an “opaque body”; and exclude the type of situations in which the body has become transparent to the patient's intuition as it has to the hallucinations of the paranoid subject.     

L’« hyperdatation » et sa fonction défensive dans la psychose

The question of time in psychoses has been studied more often as lived time (perceived) than as discursive time (abstract). The specificity of lived time in psychosis can disturb the modes of “intrigue setting” (‘mise en intrigue’ according to Ricœur seems to translate lived time into a narrative process), particularly as concerns lack of dating or excess of dating. In this paper, the authors study the phenomenon they have named “hyperdating” and its defensive function in psychosis. “Hyperdating” would be a function of overdating, illustrating the distance between the patient who “hyperdates” and the affective charge he feels. “Hyperdating” would then consist in a radical lack of the dating function. The purpose of dating would not be to tag events temporally in order to organize the narrative chronologically, but to proceed to evacuate the meaning out of the event by designating only its date. In fact, we suppose that the affect would be shifted onto this date, and thus disconnected with the representation of the event for which there are representational deficiencies and probably a very intensive original affective load. Dating is a vehicle of chronology, and is the manifestation of a faculty for the narrative of self to become an autobiography as temporal experience. We suppose that in psychosis, this process is inefficient. In fact, there is either a lack of dating of narrative events, or a “hyperdating” which overloads narrative with temporal pseudo-indicators, in particular through quasi-sacred dates. “Hyperdating” would therefore be a defensive psychic process against the traumatic load connected to the remembrance of the event, transferring the central characteristics to the date itself, which would then be exterior to any meaningful chronology. The authors propose to define this “hyperdating” phenomenon, and to investigate its psychic function. The methodology is qualitative, and based on two clinical cases, one of schizophrenia, the other of mania.

A single case of schizophrenia

We think that in schizophrenia the “hyperdating” phenomenon could be underlain by a schism between affect and representation. This is an isolating process which fits into a psychotic dissociation, recalling the break characterising schizophrenic temporality. The speech is centred on a time-based accuracy to the detriment of experience narration and its affective expression. It then seems that “hyperdating” enables the person to avoid the huge traumatic load related to the factual content in order to shift the affective load on the dating itself.

A single case of mania

Here “hyderdating” would be the expression of a game with dates in an omnipotent process. This game appears as a mosaic, a disjointed and blurred control attempt lacking a linear temporal trajectory. In mania, a cumulated series of dates does not ensure either temporal links or any necessary “temporalisation” for “intrigue setting”. Time is one of the forms of “discontinuity and hopping” frozen in instantaneity. “Hyperdating” reveals a need to control the temporal flux which can only fail and it is, under a chronological appearance, an expression of a temporality frozen on the return of the same. The lack of temporal succession and of alternatives to “temporalisation” of events by means of a date which freezes them and removes their affective dimension can only render the reflexive capture of an identity through a biographic narrative problematic.

Conclusion

Thus, other than the discrepancies related to the specificity of the “hyperdating” process in the psychic economy of psychotic patients, there would be some similarities concerning “hyperdatation” in psychoses such as abortive attempts of intrigue restoration, deadlock of the chronological function of dating, but also freezing of temporalisation on a number. These illustrate the schism or the instantaneity, devoid of any temporal flux and therefore of any link with “withholding” (apprehension of what has just occurred) and with “protention” (intuition of the immediate future), which characterise time experience according to Husserl. The limits of our study are rooted in the difficulty of identifying this phenomenon as it seems to occur less often than those concerning forgetting or lack of dating. Furthermore the links between “hyperdating” and the affect management process as well as the differences of those links within the different types of psychosis will need to be investigated more thoroughly. That is why the prospects of this study could be the following ones: interrogating the links between “hyperdating” and memory in psychoses. (Is the “hyperdating” phenomenon a failed attempt to recover memories, and/or an attempt to shape raw mnesic traces?); further investigations of the psychotic temporality issue; therapeutic contributions in the management of time and affects could be based on these previous points as far as it seems that it is only through the flexibility of such a defence that the patient will reach the affects and integrate them in an intersubjective relationship with the therapist.     

Note sur le négativisme schizophrénique

Schizophrenic negativism is the most frequently inferred into the negative way of psychosis. Here, we will attach importance to the subjective dimension into this schizophrenic characteristic symptom. After a brief return on overview of the literature dedicated to this subject, we will attempt - with the support of psychoanalytic theory - to account for this particular type of subjective response toward “jouissance”, his own - in excess - but also intrusive “jouissance” from the “great Other”, according to lacanian theory.     

Toc résistant : caractéristiques cliniques, facteurs prédictifs et influence des tempéraments affectifs

Background

Despite significant advances in clinical research, Obsessive Compulsive Disorder (OCD) represents a difficult to treat condition. The French Association of patients suffering from OCD (AFTOC) is highly concerned by this issue. A new survey was implemented with the aim of exploring Resistant Obsessive Compulsive disorder (ROC).

Method

Patients with OCD and members of the “AFTOC” were included in the survey. A self-rated file was elaborated in order to get the maximum of information on the clinical and therapeutic aspects and conditions of OCD. The full version of “TEMPS-A” was also included for assessment of affective temperaments. Statistical analyses were performed for inter-group comparison between “ROC” (resistant OCD) and good responders. Logistic regression analyses with “ROC” method were used to search for independent predictive factors to “ROC”.

Results

The new survey of “AFTOC”, “TOC & ROC” selected a sample of 360 patients, who are members of the association. The rate of “ROC” was 44.2%, 25.3% of Good Responders (GR), and 30.5% in between. Inter-group comparisons (“ROC” versus GR) showed significant higher rates of psychiatric admissions (49% versus 28%), and suicide attempts (26% versus 13%), greater numbers of doctors consulted (5.5 versus. 3.2), compulsions (4.6 versus 3.4), and psychiatric comorbidity (2.8 disorders versus. 2.0; notably agoraphobia, social anxiety and worry about appearance) in the “ROC” group. Assessment by full “TEMPS-A” scale revealed, significantly higher rates of Cyclothymic Temperament (63% versus 43%; p: 0.0003), Depressive Temperament (72% versus 53%; p: 0.004), and Irritable Temperament (21% versus 9%; p: 0.02) in the ROC group. Moreover, the mean global score on each of these temperaments was significantly higher in the “ROC” group. No difference was obtained in the rate or the mean score on the hyperthymic temperament scale. The most predictive factors of “ROC” were represented by “slow continuous course”, “worsening under SRI”, “worry about appearance”, current age above 40 years and psychiatric admission.

Conclusion

Our data provides a more precise clinical picture of “ROC”, which should be initially explored through baseline severity, compulsive dominance, hoarding, special comorbidity such as recurrent depression, obsession of appearance, agoraphobia, social anxiety, and complex mixture of unstable affective temperament (cyclothymic, irritable, and depressive), and course of illness. Furthermore, vigilance towards the notion of worsening linked to drug therapy, and the increased suicide risk is warranted in the clinical management of “ROC”.     

Le jeu comme trompe-l’œil et la dénégation

Contrarily to M. Klein and D.W. Winnicott, who, generally speaking, look favorably on play in the cure, for us it appears impossible to talk about play in general without considering that there exist several types of play. Also, following the examples of J. Piaget for developmental psychology and R. Caillois for sociology, we propose a Freudian “structural classification of play,” and we distinguish three types of plays: play based on the mechanism of negation (Verneinung), play based on the mechanism of disavowal (Verleugnung), and play based on the mechanism of foreclosure (Verwerfung). This article develops the first type of play based on the mechanism of negation – which is what studies of play typically allude to – that we will call “trompe-l’œil” play. In order to illustrate this category, we will study the horse game played by “Little Hans” in Freud's famous analysis, which immediately follows the young patient's phobia. We maintain that the transition from phobic symptom to play is the result of an intervention of the Law. Play based on the mechanism of negation veils the reality of castration, and succeeds the child to move beyond merely being played upon by his fantasy – as in the case of the phobic symptom – allowing him instead to play with his fantasy. Here, the “trompe-l’œil” game can be considered therapeutic, or, at least, its emergence can be considered the effect of the analyst's therapeutic intervention.     

Psycho-oncologie

Psycho-oncology is an emanation of consultation-liaison psychiatry and of medical psychology. The purpose of this evolution of the links between medicine and psychiatry is the coherence of a multi-disciplinary or “global” approach to the patient. Beyond the restricted field of “psy” working in cancerology, psycho-oncology concerns first of all the work of all health-care professionals and doctors in cancerology who have to be attentive to the patients, not only to the disease. These ten last years many texts have insisted on the relational aspects of care of patients and of the place of the “psychiatrists” in oncology. Nowadays, psychologists and psychiatrists are a part of cancer-care structures and so, logically psycho-oncology participates in supportive care. This first book will be devoted to psycho-oncology in general, a second one will approach aspects of the specificity of psycho-oncology for the elderly. It will gather the points of view of psychiatrists, oncologists and geriatrists illustrating the necessary inter-disciplinary approach of work in psycho-oncology.     

Les contraintes en rééducation : réflexions d’une psychologue

Motor reeducation of children with cerebral palsy comprehends some constraints, both physical and psychological. Through the observation of a number of young patients, we wish to show how they feel about these constraints, what are the motives and the aims of their participation and how their psychological development can be affected. We shall then consider what the use of these constraints implies for the health care team. Finally, the notion of “therapeutic alliance” will be presented and distinguished from “compliance”.     

Structure factorielle des obsessions-compulsions : résultats dans une population de 3?500 patients dépistés en médecine générale

Background - Recognition of Obsessive-Compulsive Disorder (OCD) in every day practice is a difficult task, especially in primary care, as few epidemiological surveys have been made of it in general medicine. Within this context, a recent survey was undertaken on a national level, involving more than 650 clinicians. The aim of the survey called « AR-TOC » was to show the feasibility of screening OCD in special population of patients presenting « Resistant Anxiety » to anxiolytics or to minor sedatives.Results - Data are presented in a cohort of 5?919 patients. They showed negative response on the screening questionnaire in 40,9 % of the total population, the presence of OCS (obsessive-compulsive syndrome) in 13,9 % and of OCD in 45,2 % (“probable OCD” in 31,2 % and “definite OCD” in 14 %).Principal component analyses were conducted in 3 498 cases presenting OCS or OCD. These analyses have concerned the clinical data which derived from clinician (OCD Screening Questionnaire, OCD-SQ) and self-rated questionnaires (Maudsley Obsessive-Compulsive Inventory, MOCI). Firstly, the results were concordant with the dimensional approach of OCD by identifying clinically meaningful separated subtypes. From the OCD-SQ, three factors were isolated such as “compulsive”, “obsessive” and “mixed” subtypes, and from the MOCI, four factors were identified such as “Property-Cleaning”, “Checking”, “Waste of Time” and “Obsessions with purity”. Factorial scores deriving from MOCI were highly correlated to respective OCD-SQ sub-types and capable to differentiate significantly the different diagnoses of OC phenomena (OCS, Probable OCD and Definite OCD).Conclusion -  “AR-TOC” have succeeded to show the feasibility of screening OCD in patients suffering from resistant anxiety. Moreover, the use of dimensional analyses had resulted in the characterization of separate subtypes based on the dominant obsessive and/or compulsive symptomatology.     

Le comportement d’observance des patients atteints de schizophrénie : impact du diagnostic et du traitement. Analyse phénoménologique de trois attitudes

The aim of this study is to analyze the different characteristics of three patient clusters defined according to their relationship toward their disease. Based on the 40 patients collected data, we were able to identify three patient groups: 23 patients were qualified as “active” as they showed a more collaborative participation in career venues and higher acceptance of comprehensive treatment plans (57.5 %). Seven patients were qualified as “passive” as they had less autonomy and therefore were less concerned with the treatment modalities (17.5 %). Ten patients were qualified “ambivalent” as they had a more conflicted understanding and insight of their disease, of their careers and their family dynamics (25 %). “Active” patients had a higher level of understanding of their diagnosis, were more aware of prescribed treatments and of the negative consequences of poor compliance. “Passive” patients were more willing to learn about their diagnosis, while having a significantly lower baseline knowledge of it, were more often prescribed an atypical neuroleptic and reported higher satisfaction with their medical treatment. “Ambivalent” patients had a higher propensity for disagreeing with the negative consequences of their disease, were more often prescribed two classic neuroleptics, reported higher rate of self-discontinuation of treatment and were overall less satisfied with their treatment. It appears that the disagreement with the understanding of the disease and its seriousness has a major impact on the acceptance of the treatment modalities and leads to reduced adherence to treatment plan.