De la spécificité du cancer et de ses effets psychiques

The singularity of cancer lies in the imagination, and more particularly it is due to this fact that a certain number of manifestations may be met in patients suffering from cancers. Actually the confrontation with the illness sets up the individual's capacity of adaptation, arousing reactions, troubles and even psychiatric decompensations. Clinical research in psycho-oncology studies the possible consequences of this neoplastic illness on a subjective plane. This article proposes a synthesis of psychiatric troubles in cancerology.     

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.     

La loi du 4 mars 2002 « relative aux droits des malades et à la qualité du système de santé » : une loi protéiforme au carrefour de l’évolution sociale et médicale

The French law n° 2002-303 of march 4, 2002 is considered in France as a fundamental stage of the French medical right, a bridge between the past and the future of the relations between sick people and doctors. It testifies to a sociological evolution of relationship between doctor and patient and makes us pass from a paternalist medicine to a medical consumerist practice, who makes place with the patient as a consumer and an actor of his care. This law is a protean law which makes move the rights recognized to the patient, the assent or the professional secrecy. It establishes the direct access to the file of the patient and imposes the information of the sick person. The law of March 4, 2002 is a general law which deals with very practical medical, without specificity for psychiatry. Only some points concerning the hospitalization of the mental patient are clarified there. It preaches a medical democracy and seeks to develop the quality of the system of health. Its essential contribution will be surely the device set up for the compensation for the therapeutic risk.     

Comparaison de l’échographie et de l’électroneurographie pour le diagnostic du syndrome du canal carpien en pratique courante

Introduction

Many studies had been performed in the last years to prove the usefulness of ultrasonographic measurements of the median nerve in the diagnosis of carpal tunnel syndrome (CTS). We wanted to determine its reliability and to compare this technology with electromyography (EMG) in ordinary diagnostic conditions.

Methods

The study involved 90 wrists with suspected CTS, 35 controlateral wrists and 52 control wrists. The diagnosis of CTS was confirmed in 81 cases by the hand symptom diagram and the Tinnel and Phalen sign. The EMG examination evaluated medianulnar sensory latency difference to the ring finger and wrist-to-palm sensory conduction velocity. For the ultrasound diagnosis, the cross sectional area of the median nerve at the level of the pisiform bone, was considered. The sensitivity and specificity of the two techniques was calculated.

Results

Sensitive electroneurographic parameters showed a sensibility and specificity respectively of 79 and 80%. The cut-off point for ultrasound sensibility and specificity using ROC analysis was 11 mm² for mean cross-sectional area. Sensitivity and specificity found in this way were 72% and 56%. Reliability was good with intra- and inter-reader intraclass correlation coefficients of 0.99, and interobserver coefficient of 0.88. Sonography found seven CTS among the 17 clinical CTS with normal electrophysiological findings. A statistically correlation was found between the cross-sectional section and the sensitive electrophysiologic parameters (r = 0.43, p < 0.001).

Conclusions

In our study, ultrasonographic diagnostic value are not as good as electrophysiological value, like found in recent literature, probably because of the composition of our group of patients which is including many causes of acroparesthesias. This can mean that in clinical practice, sonography is a complementary tool instead, for example in cases of equivocal EMG.     

La médiation de la musique en psychothérapie

The choice of music as a therapeutic mediation is justified through consideration about the human being and his musicality, and about the components of music. The concept of therapeutic mediation, referring to Winnicott’s works, may be applied with advantage to the field of Musictherapy. It leads us to characterize the specificity of the therapeutic relation, and to emphasize the complexity of techniques. We shall end with recalling the definition of Musictherapy taking into account all those elements.     

Impact des déficits cognitifs dans les activités de la vie quotidienne des personnes souffrant de schizophrénie

It is now well-recognized that cognitive dysfonctions contribute to a decisive way to the difficulties of the everyday, social and professional life of the people with schizophrenia. The cognitive variables would explain between 16 and 30% of the variance in the functional status when assessed one to three and a half years later. However, the specificity of the complex relationships between the cognitive domains and the functional variables still remains to be identified. To this end, it is necessary to carry out studies by respecting various principles: selecting not multi-determined cognitive tasks; investigating specific daily-life tasks (e.g. shopping, choosing a menu, preparing a meal), in particular by an observation in real situation in order to identify the problematic components; this has to be made by determining a priori hypotheses regarding the cognitive nature of the difficulties; taking into account the heterogeneity of the cognitive deficits and the functional difficulties of people with schizophrenia. It also remains to investigate the presence of mediator variables of the relationships, such as the potential of learning, the social cognition, the metacognitive processes and the intrinsic motivation. Besides, other personal or environmental factors can also play a role in the functional status, as for example, the negative symptoms, the awareness that has the person of his(her) state and its consequences, or the critical attitude of relatives towards the person with schizophrenia.     

Critères de prise de décision aux urgences de l’hospitalisation sans le consentement

In the current context of the new French bill on the rights and protection of persons under psychiatric care, clinical practice in the emergency setting requires that mental healthcare professionals better clarify the criteria they use for the decision of involuntary hospitalization. After defining the concept of consent for treatment and a brief literature review, this study examined the impact of clinical and contextual characteristics on the decision to admit patients whether involuntarily or voluntarily to inpatient psychiatric units. Data was collected from 442 successive patients admitted in hospital for care from five psychiatric emergency facilities in Paris and covered sociodemographic information, previous hospitalizations, recent treatment, clinical diagnosis, Global Assessment of Functioning scale (GAF) and insight measured by the Q8 Bourgeois questionnaire. Patients were also assessed based on criteria established by the French healthcare agency (HAS) for the severity of mental disorders and the necessity of emergency care. Using multivariable logistic regression, diagnosis does not affect the decision of hospitalization. Agitation, aggressiveness toward others, being under the influence of drugs or alcohol, being married or divorced as well as being referred by a doctor are all factors that increase the risk of involuntary hospitalization. Last, low Q8 and GAF scores are strong predictors for involuntary admission. This supports using insight and GAF evaluation in clinical practice for clarifying assessment and decision-making in emergency setting about involuntary hospitalization.     

Psychiatrie de liaison en milieu pénitentiaire : organisation, moyens, psychopathologies et réponses thérapeutiques

The rise of the psychiatry practice in prison is recent. It corresponds to the setting places, since the law of January 18, 1994, of interventions by teams of sector psychiatry in the penal establishments, to supplement the action of the SMPR established two or three per region. The practice of psychiatry in prison must take account of a particular private clinic where acting out and psychopathology of deprivation dominates. The model of the consultation-liaison psychiatry such as it was developed in general care is completely appropriate to these working conditions. It allows not only one rewriting necessary of the psychiatric private clinic, but also a taking into account of the specific difficulties to this work environment (monitoring, insulation, risk of cleavage…). Lastly, an adaptation of the therapeutic assumption of responsibility is necessary not only according to pathologies present, but also according to the framework and to the limited duration of the assumptions of responsibility. The role of the maintenance of reception is of primary importance on this level.     

Conduites à risques et variation de l’estime de soi chez les adolescents : l’exemple du parkour

The aim of this study was to explore the relationships between general self-esteem, physical self-worth, sport competence, physical condition, an attractive body, physical strength and the involvement in a risk-taking sport: The parkour. This sport may be included in gymnastics and acrobatics but it is practised outside of the gymnasium. Indeed, serious parkouristes are tremendous athletes who practice their stunts in a controlled environment such as a gymnasium, with mats, pads and foam pits. Many of these participants have some gymnastics or martial arts training, and they are also fully aware of the risks involved in practicing this sport. It consists of finding new and potentially dangerous ways to traverse the city landscape. Parkour is said to be the art of moving fluidly from one part of the environment to another. It may also be known as: the art of movement, free running, urban-running or obstacle coursing. This activity is a way of using obstacles in one's path in order to jump and perform acrobatics. It involves the scaling of walls, roof-running and leaping from building to building. These multiple acrobatics are submitted to peers appreciation considering fluidity, aesthetics and originality. Self-perception is of great importance in the construction of self-esteem. This concept has been identified as a state which evolved depending on spatiotemporal factors of the environmental context. It can be measured with the Physical-Self Inventory (PSI). This is a six-item questionnaire especially developed for repeated measurements. It measures six dimensions hierarchically organized Global Self-Esteem (GSE), Physical Self-Worth (PSW), Physical Condition (PC), Sport Competence (SC), Attractive Body (AB), Physical Strength (PS). Seventy-six male participants were asked to take part in the study: Group 1: Parkour (n = 32, M_age = 15.07 years, E.t. = 1.98) and Group 2: acrobatics (n = 41, M_age = 14.96 years, E.t. = 2.01). The PSI-6 was taken at three different times: Time 1 (T1, pre-test before practicing parkour), Time 2 (T2, just after having stopped the parkour), Time 3 (T3, two hours after T2). As expected, and with the exception of PC and PS, the data confirmed the prediction that, compared to Group 2, Group 1 would score significantly higher on each subscale of the PSI, including GSE, PSW, SC, and AB. That is to say, skydiving could de used as a way to regulate self-esteem, this confirms our assumption. Self-esteem has recurrently been invoked as a contributing or explanatory factor for socially problematic behavioural outcomes (i.e., risk-taking behaviours such as restrictive or dysfunctional eating, substance abuse, aggression). In relation to our results, sports could bring an extra dimension to studies on risk-taking especially among adolescents. Indeed, risk-taking sports are usually perceived as an intrinsically gratifying practice that is socially adapted and accepted. However, benefits in self-esteem regulation derived from an engagement in a risk-taking sport must be put into perspective. Although the results indicated for Group 1: a lower level of self-esteem before practice and a higher level after, the retention test shows that these results do not last more than two hours. This finding suggests that, even if the emotion regulation produced by parkour is positive, one session is not enough for adolescents to experience positive rewards from their engagement in a risk-taking behavior. Thus, in order to recreate the positive emotional state they were in, they may possibly put themselves in another risk-taking situation. However, the link with addiction cannot be made directly as it implies several factors which have not been measured in this study. Future research should take this interesting point in account and use a longitudinal methodology. This will authorize authors to draw out our assumptions and emphasize the possible link between addiction and risk-taking sports.     

L'expertise psychiatrique pénale : audition publique de la Fédération Française de Psychiatrie selon la méthode de la Haute Autorité de Santé

The French Federation of Psychiatry, at the request of the General Direction of Health, was at the origin of a public audition on the penal psychiatric expertise practice according to the method of the High Authority of Health. The hearing commission, made up of 20 members, psychiatrists, professionals of justice, sociologists and representatives of families of patients and the civil company studied the problem arising in France by the evolution of the practice of the expertise penal and suggested a whole of recommendations for the practice of the expertise.     

À propos de la notion de structure dans l’enseignement de Jacques Lacan : un éclairage par la clinique des psychoses

The work of Jacques Lacan is based on the concept of structure as much as it is a subversion of it. Introducing the dimension of the subject of the unconscious, Lacan makes it possible to question the very foundation of clinical approach: “what do we mean by talking”? “What do we call a dialogue”? The Lacan's teaching sets up a certain number of invariants in the nature of language: the network of signifiers, the place of the Other, the Name of the Father and object “a”, so many items that are revealed in their pure form in the clinic of psychosis. Today, these results enable us to isolate a number of purely structural entities in our practice, just as the authors emphasize the clinical validity of forgotten syndromes such as Cotard or Frégoli syndrome.     

Les outils de repérage pour les troubles de l’usage du cannabis et leur adaptation au DSM-5 : une revue de littérature

ObjectivesCannabis use is widespread in France, particularly among adolescents and young adults, and can induce severe somatic, psychiatric and social consequences. Early identification and appropriate care of cannabis use disorders thus constitute a major public health issue. Standardized questionnaires based on patient self-reporting are recognized as the best option for identifying cannabis use disorders because of their reliability and simplicity.MethodsWe conducted a narrative literature review on cannabis use assessment tools on PubMed and selected cannabis-specific questionnaires, validated for adolescent and/or adult populations, from scientific articles in English or French between 1995 and 2010.ResultsSixteen questionnaires were found according to the inclusion criteria. The CAGE-cannabis, the CAST, the CUDIT and its revised version the CUDIT-R, the PUM and the SDS are the only ones that have good characteristics for a short screening tool adapted to daily clinical practice, namely to be brief (fewer than 10 questions) and quick handover (less than 10 minutes). Only the CAST has been validated in French, and the CUDIT-R is currently being validated. In the DSM-5, diagnoses of abuse or addiction have been grouped into a single diagnosis of cannabis use disorders with different levels of severity. It is relevant that tools used for screening take into account these new diagnostic concepts. The CUDIT-R is currently the only one to be validated based on DSM-5 diagnostic criteria.ConclusionAmong the many questionnaires available, few are suited for daily clinical practice in France because of their complexity, their long duration or the absence of a validated French translation. The CUDIT-R has good psychometric characteristics, is simple to use, and has been validated according to the criteria of DSM-5. These questionnaires are obviously not a substitute for a clinical diagnosis and must be followed by a specialist's evaluation. However, they remain an interesting mediation, encouraging a patient's awareness and commitment to care.     

Pour une théorie du sujet : commentaires sur les « Variantes de la cure type » de Jacques Lacan

This text, written by Lacan, was for the benefit of physicians whereas the speech given in Rome (which dealt with the same subject) was aimed at trainee analysts. The theories of the Ego were called into question to the benefit of a theory of the Subject. Resistance was to be looked for in the discourse and not in the Ego. For Freud, the Ego, an Ego that is based on the aggressive narcissic relationship, is built like a symptom and not like an objectivized Subject. Nevertheless, the Ego is not to be rejected, as is done by some phenomenologist-psychoanalysts who also reject the subconscious. The role of didactic analysis is to allow the analyst “to recognize symptoms of his ignorance in his own knowledge”. Ignorance not being here a “non-knowledge”. Listening is not directed by knowledge but by practice freed from speech. Hence the expression of “cure phenomena” in the shape of equations and axioms; Lacan was building up the theory of transference, not the theory of the subconscious. He transcribed what he listened to and not what he knew. Lacan's genius was to have introduced the logic of the signifier in the therapy phenomena at a time when symbolic logic was almost becoming independent from the objects existing in the world, and at the time when syntax and semantics appeared to be independent from the subject, because, at this time, psychoanalysis, which by definition develops from the ordinary language of the patient in a transference situation, was coming close to analytical logic which itself was now concentrating on ordinary language and not on scholarly language. Lacan came close to the Anglo-Saxon analytical philosophy of Bertrand Russell, Frege, Whitehead or Wittgenstein. This is a psychoanalysis which does not go beyond language and logic but where the sense of reality remains vital during the session. Therefore Lacan's approach to the transmission of psychoanalysis confronts us with the attitude of semioticians who encourage us to leave aside what tempts us most in the practice we are talking about: the “factual experience”. It is of course impossible to set aside painful factual experience in psychiatry and psychotherapy, but we should combine empathy and semiotics in order to tackle the issue efficiently. We have to give life to the mind by the letter and not to the letter by the mind.     

Validation de l’échelle d’insight Q8 et évaluation de la conscience de la maladie chez 121 patients hospitalisés en psychiatrie

Insight (awareness of disorder) is an important domain for research and practice in psychiatry. Several instruments to measure insight are currently used. We present here a short scale (8 items with open question) applied to a sample of 121 psychiatric inpatients which permitted to validate this questionnaire and to demonstrate its easiness and rapidity. This insight Q8 scale shows that insight is higher in free hospitalization (compared to compulsary hospitalization), in mood disorders (compared to schizophrenia), in dépression (compared to schizophrenia and mania), in married patients (compared to widowed and single patients), in case of good cognitive functions (MMSE score) and antecedents of attempted suicide. Awareness must be taken into account in all major mental disorders. Therapeutic alliance, treatment compliance, prognosis and risk of relapes depend largely on this dimension.     

De l’intérêt du profilage cytochromique en psychiatrie : à propos de trois situations cliniques

A successful drug treatment, and particularly psychotropic medication, depends on its biochemical action. Moreover, it varies according to reaction or modulation of the target organism with this molecule and its properties. Indeed, drug metabolism is very fluctuating from one individual to another. It follows in particular genetic variants of cytochrome-P450, which may result in abnormally fast or slow metabolizers profiles depending on the molecules used. However, this individual variability relates near one for five patients, and in the daily practice of a psychiatrist, it can be translated in terms of efficacy, safety, or worse like iatrogenic symptoms. After a short summary of current knowledge on the issue, the authors propose to illustrate three situations. It is current practice for three patients with mood disorders and atypical symptoms like negative symptoms of psychosis. It appears that the analysis of clinico-pharmacological history allows the hypothesis of side effects in the case of an individual with metabolic changes before to find an effective and well-tolerated treatment. These three situations illustrate the interest of the individual genotyping for cytochrome-P450 in daily practice of psychiatry, or, at least, how the inclusion of such possible variations is critical to justify psychopharmacological new strategies.     

Le comportement de simulation dans le contexte particulier de l’expertise : vers une meilleure compréhension du processus de victimologie

In expertise context, the psychological or psychiatric assessment occurs in a particular and different way than the usual practice in psychotherapy. In this context, malingering has a specific dimension that we study in this article. As the domain of malingering is very huge, our article focuses on situations of damages compensations. After a definition of malingering, we analyse this behaviour through the study of the victimology process, the circle influence, the existent psychological tests and the expert's role. The victim position in which the injured persons are placed or place their self seems to be a factor involved in their reconstruction process and by this way, in the use of malingering. The family circle has also a strong influence on the management of the traumatic incident and by this way, on the (conscious or unconscious) choice of malingering, particularly for children (by example, in the Munchausen by proxy syndrome). Finally, the role and the attitude of the expert are central in the functioning and the interaction of the two mechanisms (management of the event/reconstruction by the victim and malingering). Although psychological tests can be used in order to discover malingering, a meticulous assessment, empathy, and neutral and benevolent attention are indispensable elements in order to respect the suffering of the person and by this way, assure authentic complaints and thus prevent malingering.     

Altération de la matrice proprioceptive et psychose naissante : une hypothèse

The aim of this text is to develop a line of thought which articulates elements coming, on one hand, from clinical studies of incipient psychoses, and on the other hand from experimental and developmental psychology concerning the genesis of perception. More precisely, the aim is to emphasize the truly central role of proprioceptive coupling in the constitution of operationally effective concerned agency, and consequently to encourage the study of this systemic coupling and its possible manipulation in clinical practice. This genetic role (genetic in the sense of “genesis”) of proprioceptive coupling is double: firstly, it makes it possible to ground the perceptual space on the basis of a dynamic, bodily space; secondly, it ensures an operation of differentiation between reafferent and exafferent sensory flows. This differentiation appears to be a condition of viability for the subject, which explains why its genesis occurs very early, probably during fetal life. Taking into consideration the fact that one of the characteristic traits of schizophrenia that we will refer to concerns the difficulties of these patients to identify the causal origin of events occurring in the course of their perceptual experience, we suggest that these serious problems relating to concerned involvement may stem in part from problems either in the constitution of the proprioceptive matrix itself, or in the integration of multisensory flows into the context of this matrix.     

À propos de l’intégration des soins psychiatriques dans la ville, évaluation d’une structure d’hospitalisation à domicile sur un secteur de psychiatrie adulte

Home care tries to restore the patients into their social life. It points up the questioning about the place given by our societies to the patients suffering from mental diseases, as well as the questioning about the pertinence of the transfer of the care setting out of the hospital institutions. Home care is indeed integrated in the mental health district practice, as it has been developed in France during the seventy’s. Its practice is focused on the therapeutic relation and on the continuity of the care relation. In this way, it considers the patients within their progressive reality. Home care is recent in French psychiatry and exists in the psychiatric district 59G32 (Valenciennes, France) since June 2004. It constitutes a tool out of the hospital, completing the therapeutic units already existing on the district. After two years of existence, this study tries to evaluate the interests of home care and its contributions to the therapeutic possibilities in psychiatric district. With five places available, this structure can be seen as an alternative to full time hospitalisation. Home care offers indeed a graduated and individualized care within patient’s usual environment; and this is done, when it’s possible, with the participation of the patient’s relatives. This unit integrates a pluridisciplinary working team. The interventions take place several times weekly in the patient’s home, during a minimum period of one month, and with an average period initially planned to last three months. Home cares intervene before the moment when full time hospitalisation appears unavoidable, and also after hospitalisation in order to help the patients to come back to their usual environment. The aim is to maintain or to develop the autonomy of the patients, to promote or restore their social integration, to improve therapeutic alliance and treatment’s follow-up. It is a retrospective study, evaluating the interests of home care and its contributions into the psychiatric district 59G32. This study is realised after two years running, during the period of February and March 2006. It interviews the medical and paramedical team, as well as the patients and their relatives about their point of view concerning home care. Population studied: the patients entering into the selection’s criteria were those living on the 59G32 psychiatric district and who had home care before and during the study period. 1) All of the 21 patients of the population studied have been interviewed. Comparing men and women, the distribution was equivalent; 2) looking at the age’s distribution, two groups of patients were over represented: from 30 to 39, and from 50 to 59 years old, with each time 1/3 of the population studied. Those results are linked with the necessity to help those patients to develop a certain autonomy during the first years following their disease’s discovery, and when the needs are majorated for elder patients, at least until their admission into old people’s home; 3) the diagnosis found during this evaluation were, in majority (2/3 of the answers), psychotic disorders; 4) the evaluation has shown an amelioration about, on one hand: the therapeutic alliance, the information given about the diagnosis, and the treatment’s follow-up, and on the other hand: the patient’s integration and autonomy on the district, when this was possible. Finally, even if this kind of care is still not really developed within French adult psychiatric districts, such structures, complementing a full time hospitalisation offer, permit a better quality of life for the patients, and the development of actions of prevention as well as a better information about psychiatric disorders.     

Le suivi psychologique de sportifs de haut niveau : enjeux et réalité

In recent years, numerous studies have shown that the intensive practice of sport was not without psychopathological risks. Act No. 99-223 of 23 March 1999 relative to the protection of athletes’ health and to the fight against doping has, for the first time, taken into consideration the psychological dimension of sport regardless of the concept of performance. Since then, the 16 June 2006 decree amending the decree of 11 February 2004 established the nature and frequency of medical examinations under Articles L.3621-2 and R.3621-3 of the Public Health Code. The interest of this review is to allow the athlete, who is an object of so many desires on the part of his parents, of his coach, of the public and of the society of spectacle, etc., to regain his place as an individual within the time of an interview. During this interview the professional will establish a link allowing the athlete to register his sport in a “life project” (athlete, academic, professional, family, etc.) and in a sphere of which sport is only an aspect. By allowing the athlete to “be”, during and after his sport career, the professional will try to locate him/her outside the “sports play-acting”, which is a source of vulnerability to the disease of “doing” (drug addiction, alcoholism, addiction gestures, etc.). Furthermore this interview is also an opportunity to seek personal vulnerabilities and to elaborate a psychopathological epidemiology of high-level sport, which has hitherto not been undertaken. This legislative progress integrated into the longitudinal medical monitoring is an important advance in the care of athletes who have gone from hero status to that of participating in an industry of recreation and sports spectacle. However, these texts leave many issues untreated, more especially that so far this assessment has been launched in a parsimonious and disparate way (method, processes, stakeholders, professional sportsmen, etc.) according to the sports federations and institutions that often resist its implementation.