Souffrance psychosociale et risque suicidaire, quelle articulation entre médecine de ville et psychiatrie hospitalière ? Résultats d'une étude qualitative

Mental disorders are now becoming the first reason for consulting a general practitioner. These mental disorders include pathologies identified by psychiatry as well as a series of complaints linked to psychosocial distress. This latter, on the border between social field and medicine, does not benefit of a specialised clinical approach. Nevertheless, suicidal behaviour constitutes one of the complications of psychosocial distress which general practitioners have to face, though they have scant academic knowledge of it. A qualitative study examining an important oral material and 202 medical letters was realized in three of four Breton geographical departements. This study describes and analyzes the clinical attitude of general practitioners and their answers. Based on this study this article approaches the question of the articulation between private practice and hospital psychiatry.     

Rôle des équipes de soins dans l'évaluation et la prévention de l'agressivité

Aggressiveness and violence in psychiatric wards have been common for some time. Situations that incur risks may originate at different levels such as the feeling that one is not heard, a break with one's entourage, feelings of isolation, factors related to pathology, postponing a treatment, the prohibition of smoking in the rooms... Further to the analysis of the relative situation of the patient, it is of utmost importance that the team pay attention to it's own sentiments of fear, to its divisions, to its feelings of distress and of its difficulties with some patients. On the other hand, conversations, follow-up at patient's homes and out of hospital psycho-educative groups are set up to allow patients to better manage their treatment, to detect risk situations for themselves and to detect early signs of relapse so as to forestall crisis situations and to avoid re-hospitalisation.     

Dépendance physiologique et fonctionnement émotionnel chez les jeunes adultes : affectivité, intensité émotionnelle et alexithymie dans la consommation de substances psychoactives

Objectives

The objective of this study is to describe the emotional functioning of individuals addicted to psychoactive substances, and verify that the dependent subjects are more sensitive to emotional dimensions and variables considered as non-dependent subjects.

Patients and methods

We recruited 268 subjects students. They filled out a protocol, first, a questionnaire assessment measuring dependencies (tobacco, alcohol, cannabis), and a second part consisting of four questionnaires: the Hospital Anxiety Depression (HAD) scale (anxiety and depression), the Émotionalité Positive et Négative (EPN-31) (affectivity), the Affect Intensity Measure (AIM) (affect intensity), and the Toronto Alexithymia Scale (TAS-20) (alexithymia). The 268 subjects were divided into: 69 subjects dependent (D) representing 25.7% of the sample, and 199 non-dependent (ND) subjects, representing 74.3%. It consisted of 224 women and 44 men, mean age was 22.23 years (standard deviation [S.D.]: 5.45, range: 18–56 years). There was no significant difference in gender (P > 0.05) between groups or in age (P < 0.05). The scores of anxiety and depression were significantly different between groups. We therefore conducted analysis of covariance (ANCOVA) including the total score of anxiety-depression as a covariate and as dependent variables, scores of emotions, emotional intensity and alexithymia with SPSS 11.5^®.

Results

The results show that dependent subjects have scores more important to the HAD than non-dependents, depression has been well regarded as a confounding factor. After controlling for this variable, they are more emotionally responsive, more sensitive to the emotional intensity, and alexithymia more than non-dependent. Activation and the emotional intensity appear to be dispositional variables may play a central role in emotional processing in the dependent subjects, associated with alexithymia. They could be located upstream of the processing of emotion, they would account for the gross apprehension felt by the subject, leading secondarily to the representation of emotion. The proportion of alexithymic subjects is 44.9% in this group of subjects, while only 13.6% among non-dependent subjects. They have greater difficulty in identifying emotions. This supports the idea of the existence of an emotional deficit in individuals addicted to psychoactive substances. This proportion is also larger than that found in general population.

Conclusions

The alexithymia seems to be a central variable emotional functioning dependent subjects, regardless of its relationship with depression, it could match the emotional processing mode preferred by the subjects dependent. Personality in this study seemed to reflect a vulnerability factor, which alexithymia represents a secondary dimension, even defensive. This could account for a mode of emotional regulation. The limitations of the study and possible openings will be discussed.     

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.     

Les psychothérapies de la dépression entre effet curatif et effet préventif : y a-t-il une place à privilégier ?

Many patients having suffered from depression undergo unipolar depression relapses during the five years following the treatment. Therefore international guidelines, including pharmacological and psychological interventions, were published to prevent these relapses. Nowadays a combined treatment is most often prescribed. This paper presents the results of cognitive and behaviour therapies in the prevention of relapses in uni-polar depressed patients. A psychotherapy associated with pharmacotherapy resulted in a better prevention than pharmacotherapy alone (with a gain of over than 35%). New cognitive and behaviour programmes were developed during ten years with recurrently depressed patients, these included additional booster sessions sometimes combined with well-being therapy and even with mindfulness-based cognitive therapy. The new approaches were assessed in pilot studies and their results will have to be confirmed.