The vigilante, a romantic figure according to paranoid logic

When patients "transform" themselves into vigilantes, they respond only to their own law and logic. In two examples taken from fiction, "vigilante" characters have experienced an initial trauma.What is the situation in daily clinical practice and how can we open the treatment door for patients suffering from paranoia?     

Ictal impending danger--"sixth sense seizures"--in patients with benign focal epileptic seizures of adolescence

PURPOSE: We describe nine consecutive patients with diagnosis of benign focal epileptic seizures of adolescence (BFSA), who experienced an ictal sensation of impending danger. MATERIALS AND METHODS: We collected nine BFSA patients after a comprehensive clinical and laboratory investigation, video-EEG analysis and neuroimaging study. RESULTS: All patients displayed a distinct electro-clinical pattern of seizures characterized by a peculiar subjective feeling of impending danger coming from behind, followed by a coordinated behavior of "head-turning" toward the danger. This feeling was described in all patients as "a shadow behind me on one side" or "something or someone behind me". All of our patients explained that, at the beginning of their seizures, they felt an early warning of a high-risk situation. Electrophysiologic data favored a frontal origin of these seizures. CONCLUSION: We have described for the first time a distinct electro-clinical pattern of seizures in the context of BFSA, characterized by the ictal feeling of early warning of a high-risk situation, which we thought to term "sixth sense seizure". In the light of current neuro-anatomical knowledge, seizure discharge within anterior cingulate cortex (ACC) structures is the likely explanation for this situation. Further studies are needed to establish if this is an electroclinical variant of BFSA or a new distinct epileptic syndrome.     

"Biological markers" and psychiatric diagnosis: risk-benefit balancing using ROC analysis

Although the clinical interview retains a central role in psychiatric diagnosis, recent research has suggested that "biological markers" may ultimately increase the precision of clinicians' nosologic and therapeutic decisions. Evaluating and operationalizing diagnostic tests require mathematical techniques that reflect the tests' essential features and limitations, and that guide clinicians in particular clinical situations. In this article we describe a technique that combines signal detection theory and utility-based decision theory, and apply the technique to published data in which sleep architecture was used as a biological marker for depression. We show how outcome utilities influence the optimum REM latency cut-off and show how this relationship is influenced by the prevalence of depression in the population being tested. We also make specific calculations of the practical limits that must be imposed on uncertainties in utilities to operationalize a diagnostic test for a specific clinical situation.     

Measuring mother-child relationship: a German instrument for both self-assessment and assessment by others (SF-MKI)

Childbearing, from the standpoint of psychological medicine, is the most complex event in human experience. Recently delivered mothers are vulnerable to the whole spectrum of general psychiatric disorders, as well as those resulting from the physical and psychological changes of childbirth. Even if most depressed mothers do not have a relationship problem with their neonates, new mothers who are mentally ill may be dysfunctional and experience impaired communication with their newborns. There is growing evidence of possible long-term negative consequences for the cognitive and social development of a child in such a situation. This gives strength to the arguments for increased awareness and more specific treatment modalities. To evaluate the quality of mother-child interaction in clinical settings we constructed a questionnaire which enables mothers' self rating and staff rating of these child related behaviors. Statistical analyses show that the SF-MKI is a reliable instrument with three independent scales: "responsive interpersonal functioning", "general self-perception" and "self-care in interaction".     

Parkinson's disease and sleep

There are many reasons for patients with idiopathic Parkinson's disease to develop sleep disorders and subsequent daytime sleepiness. Important causes are reduction of total sleep duration and sleep efficiency, and an increase in respiratory and motor arousals. This daytime sleepiness at first glance seems different from the "sleep attacks" which caused motot vehicle mishaps reported recently in persons taking pramipexole and ropinirole. There is, however, only little evidence that we deal with a new phenomenon in a new clinical situation, i. e. cataplexy-like attacks after high doses of new non-ergot dopamine-agonists. Until now there is no single case of a proven cataplexy on one hand, and older dopamine agonists like pergolide as well as L-Dopa + carbidopa have been reported to induce sudden onsets of sleep, too.     

Move over LOCF: principled methods for handling missing data in sleep disorder trials

Missing data, e.g. patient attrition, are endemic in sleep disorder clinical trials. Common approaches for dealing with this situation include complete-case analysis (CCA) and last observation carried forward (LOCF). Although these methods are simple to implement, they are deeply flawed in that they may introduce bias and underestimate uncertainty, leading to erroneous conclusions. There are alternative principled approaches, however, that are available in statistical software namely mixed-effects models and multiple imputation. In this paper we introduce terminology used to describe different assumptions about missing data. We emphasize that understanding reasons for missingness is a critical step in the analysis process. We describe and implement both linear mixed-effects models and an inclusive multiple imputation strategy for handling missing data in a randomized trial examining sleep outcomes. These principled strategies are compared with "complete-case analysis" and LOCF. These analyses illustrate that methodologies for accommodating missing data can produce different results in both direction and strength of treatment effects. Our goal is for this paper to serve as a guide to sleep disorder clinical trial researchers on how to utilize principled methods for incomplete data in their trial analyses.     

Limb-girdle muscular dystrophy: clinical, hereditary and histological features: study of a family (author's transl)

The family of an "affected" subject with limb girdle dystrophy has been studied in order to assess the clinical-hereditary characteristics of the disease and to contribute to its definite genetic features (phenotypical expressiveness of the pathologic gene). The diagnosis of certitude was based on the anamnestic-clinical criteria and instrumental investigations, supported by histological and histochemical studies of the muscles. The clinical, electromyographic and biochemical data made it possible to distinguish the "affected" from the "subclinical" and the healthy subjects. The subjects that, without noticeable symptoms of neuromuscular disorders, showed a slight clinical expressiveness which didn't alter the normal social and working activities, have been defined "subclinical". The modalities of hereditary transmission of this form of muscular dystrophy are considered in the light of the genetics most present trends that are tending to overcome the dominant-recessive dualism. The possibility of a modality of transmission definable as "intermediate inheritance" is proposed. In the case of the examined family the hypothesis that a pathologic recessive autosomic gene gives rise to a clinical expressiveness in heterozygote subjects seems tenable. This situation definable as "incomplete recessive" is rarely found in the limb girdle dystrophy.     

The contemporary failure of nerve and the crisis in psychoanalysis

The American Academy of Psychoanalysis is undergoing an identity crisis at this time, which is at least to a large extent a function of the whole current identity crisis in the field of psychoanalysis itself. In order to better understand this crisis, in this article I have first reviewed a similar situation which occurred in the history of classical Greece. Plato's famous Academy underwent a progressive deterioration and disintegration and fragmentation, until it ended up merely the handmaiden of another discipline, Christian theology, for a thousand years. I then propose that the identity crisis in psychoanalysis today has to do with our failure of nerve in the teeth of the abusive behavior of insurance companies regarding the payment for psychoanalysis and the current cultural ambience demanding "fast-fast-fast" relief. I call in this article for a return to Freud's basic principles as a focus for our identity. Of course we cannot ignore new discoveries in neurobiology if they are well established, or what we learn from the study of enactments in the here-and-how of the analytic procedure. Certainly the findings of Freud that are contradicted by firmly accepted empirical findings in neurobiology and other disciplines call for revision of some of his ideas, as do his mistaken views on the psychology of women and on certain other topics such as art, religion, and evolutionary biology. But this should not be permitted to blur our continuing focus on the fundamental principles of the clinical practice of psychoanalysis as Freud developed them over his lifetime. In this article I briefly reviewed those basic principles and proposed that we employ them as the basis for our identity as psychoanalysts and psychoanalytic psychiatrists. It represents a failure of nerve to drift this way and that with current fads and with the continuously deteriorating ambiance of our culture as the world slides into rampant global capitalism. Franz Alexander said years ago that psychoanalytic psychotherapy is one of the last remnants of the humanistic ideal, focussing on the individual unique person and his or her transcendent possibilities as well as maladaptive pathology. This article represents a clarion call for a debate on the identity of the American Academy of Psychoanalysis and what it stands for, which can only be clarified if we have a sharp focus on what we basically mean by "psychoanalysis." As Saul Bellow puts it (Atlas, 2000) in discussing the disappointing current situation for the arts and the humanistic disciplines, the intelligent public is waiting to hear from these disciplines what it cannot hear from pure science: Out of the struggle at the center has come an immense, painful longing for a broader, more flexible, fuller, more coherent, more comprehensive account of what we human beings are, who we are, and what this life is for...the individual struggles with dehumanization for the possession of his soul, (p.462). Below points out, in talking about writers, and in a discussion equally applicable to psychoanalysts, that if we do not "come again into the center it will not be because the center is preempted. It is not. [We] are free to enter if [we] so wish" (p.462).     

Transferences and Countertransferences in the Analysis of Disorders of the Self

The experience of interiority is central to the psychoanalytic endeavor. Interiority represents the base from which we can recognize sameness and difference so that engagement with others does not obscure or negate a feeling of personal aliveness. We confront a tricky clinical situation when working with individuals who cannot access and articulate interior experience. I discuss the development of interior experience and the clinical dilemmas we face when our patient cannot contact or sustain inner process. In one clinical situation, my patient located desire in the Other and was unable to “find” his own wishes in the dyadic context. In the second, inner states were consistently attributed to the Other who was held in a sadistic position vis-à-vis the self. In both treatment situations, ordinary analytic work tended to recapitulate the patient's reliance on the Other for interior definition.     

Who are you talking about? Tracking discourse-level referential processing with event-related brain potentials

In this event-related brain potentials (ERPs) study, we explored the possibility to selectively track referential ambiguity during spoken discourse comprehension. Earlier ERP research has shown that referentially ambiguous nouns (e.g., "the girl" in a two-girl context) elicit a frontal, sustained negative shift relative to unambiguous control words. In the current study, we examined whether this ERP effect reflects "deep" situation model ambiguity or "superficial" textbase ambiguity. We contrasted these different interpretations by investigating whether a discourse-level semantic manipulation that prevents referential ambiguity also averts the elicitation of a referentially induced ERP effect. We compared ERPs elicited by nouns that were referentially nonambiguous but were associated with two discourse entities (e.g., "the girl" with two girls introduced in the context, but one of which has died or left the scene), with referentially ambiguous and nonambiguous control words. Although temporally referentially ambiguous nouns elicited a frontal negative shift compared to control words, the "double bound" but referentially nonambiguous nouns did not. These results suggest that it is possible to selectively track referential ambiguity with ERPs at the level that is most relevant to discourse comprehension, the situation model.     

Efficacy of New Antiepileptic Drugs

Regarding efficacy of new antiepileptic drugs (AEDs) for seizure control, there are three important clinical questions. How effective are new AEDs when corrected for the efficacy of placebo? And even more important: How do new AEDs fare in terms of seizure remission compared with established agents? And finally: Have patients seizure-free on new AEDs a better chance for lasting remission after withdrawal versus those withdrawing from older agents? The answers raise concerns. Although add-on therapy with marketed new AEDs is more effective than placebo, as expected, the treatment difference for becoming seizure-free is disappointingly small (6%; 95% CI: 4–8%; z = 6.47; p < 0.001). Although many, but not all, new AEDs have comparable efficacy to old standard drugs in well-controlled trials, none of the new AEDs is superior to old drugs in terms of seizure remission. So far, we have no antiepileptogenic treatments that prevent the development of epilepsy or modify its detrimental course. The sobering results suggest the need for novel experimental and clinical strategies for the development of more effective new AEDs that interrupt ictogenesis more effectively and prevent or abort epileptogenesis. Ideally, we need new drugs that block both ictogenesis and epileptogenesis, resulting in complete cure of epilepsy.Although a large number of new antiepileptic drugs (AEDs) that suppress or prevent seizures are now available, about 30 to 40 percent of the patients, children as well as adults, remain resistant to drug treatment (1). The situation is even worse for a range of severe epilepsy syndromes of infancy and adolescence. So far, we have no antiepileptogenic treatments that prevent the development of epilepsy or modify its detrimental course (2). The introduction of each new AED into the market raises valid expectations in patients and physicians for more effective treatment of epilepsy. Although safety, tolerability, and lack of interactions are important, better efficacy is a crucial feature for a new AED. This brief review is limited to a discussion of the efficacy of new versus old AEDs. In that respect, three questions are of particular clinical interest: How effective are new AEDs when corrected for the efficacy of placebo? And even more relevant: Are new AEDs more often leading to seizure remission compared with established agents? And finally: Can more patients maintain seizure remission after withdrawal of new AEDs compared with withdrawal of older agents? The following brief overview, which is not a comprehensive literature review, outlines the available evidence on the efficacy of modern AEDs based on randomized controlled trials of marketed modern AEDs.     

Dissociative identity disorder and pseudo-hysteria

The diagnostic validity of dissociative identity disorder (DID) continues to inspire controversy, with some commentators claiming that DID is a modern variant of "hysteria"; that is, attention-seeking behavior. The author asserts that DID is indeed a valid psychiatric disorder, and believes that this skeptical reaction can largely be attributed to a specific set of transference/countertransference interactions that these patients tend to inspire. The paper delineates several clinical features of DID that can easily be mistaken for hysterical phenomena, and attempts to find the roots of this confusion in the DID patients' experience of interpersonal powerlessness, which leads them to present their symptoms in an unconvincing, "hysterical" manner. Confusion between the vertical split seen in the dissociative disorders and the horizontal split characteristic of the classic hysterical personality is discussed, as is the powerful effect of observer bias in creating hysterical-appearing phenomena. The term "pseudo-hysteria" is used to denote a situation in which a genuine psychiatric disorder, DID, is perceived as an hysterical production.     

Classical conditioning of meaning--II. A replication and triplet associative extension

The meaning associated with verbal stimuli is modifiable by classical conditioning, suggesting that such "language conditioning" may be used clinically to modify a client's maladaptive associative history. The current research investigated the existence and generalizability of this phenomenon by attempting to replicate Staats and Staats' (1957) language conditioning effect and then extend it to a triplet conditioning paradigm (CS2----CS1----UCS). Previous research by the current authors replicated language conditioning, yet failed to extend it to a higher-order situation. Significant conditioning was obtained to the CS1, particularly for aware subjects, but no conditioning occurred to the CS2. Implications for verbal conditioning theory and clinical practice are discussed.     

Psychiatric aspects of Epilepsy

The classification of epileptic seizures is reviewed, emphasizing the clinical features of partial seizures with psychic symptoms. Psychiatric issues in epilepsy are also assessed, particularly affective disorders and psychosis. Although there currently is no internationally accepted syndromic classification for them, we expose recently proposed definitions. The concept of "epileptic personality" is reviewed, and the matter of aggression as well. Finally we include a case report that illustrates what we understand as the complexity for the clinical diagnosis.     

Le jeu vidéo à l’adolescence,entre mégalomanie et perte d’objet

Objectives

This article aims to explore the issues that underlie the excessive use of video games in adolescence. Conquest video games include the ability to change, grow and (transform) as if the teenager were using the game as a double, as a glove that would turn around: the teenager takes the image for his mirror in investing the image and making it live. It is only when he is lost in this tense mirror by mirroring himself as Narcissus in front of his reflection that the risk of a confusion exists: the cleavage between the internal and external worlds is exerted by the rejection of the constraints of the external world, leading to withdrawal, loss of temporality, depression and other potential disorders.

De l’incestuel à l’enfant-sorcier : des mots pour le dire

Aims

This paper sets out to explore the unconscious meanings and functions of the “witch-child” aetiology appearing in the discourse of families from sub-Saharan Africa (in the present instance Bamileke), and its possible links with an “incestuel” (as opposed to incestuous) family dynamic. We have sought to show the possible points of transition between concepts that belong to different resisters, using a singular clinical situation which is nevertheless just one of the possible manifestations of the link between the witch-child and an “incestuel” family climate. From this particular issue, we also seek to show the permanent articulation between psyche and culture, and the way each casts light on the other. This dimension appeared to us to be particularly important for the reflection of the clinician, for a finer understanding of the clinical setting, and thus for the psychotherapeutic process enacted with these families.

Analyse clinique au cours d’une marche simple et avec une double tâche chez une population de sujets âgés ambulatoires consultant en gériatrie

Introduction

Gait and balance often change with age. Few studies are available on gait analysis in the elderly. In our work, we have focused on slow walking and variation in pace. Since first introduced by Lundlin, the dual-task paradigm has been largely used to test for the risk of falls and to better understand the link between mild cognitive decline and variation in gait. To our knowledge, very few clinical data are available on the gait changes observed in the elderly in the dual-task situation. In this study, we compared changes in gait and balance between the simple task and the dual-task situation in a 10-m walk test conducted in community-dwelling old people.

Methods

Eighty-nine subjects attending a geriatric outpatient clinic (age 80.76 ± 2.82 years) were included in our protocol. Gait, balance and posture were systematically evaluated during a simple and dual-task 10-m walk using a specific 11-item clinical scale. Gait speed was noted.

Results

Few differences were found in the dual-task walk, only reduced speed, more stops during the walk and less compliance with instructions. These results were correlated with the Mini Mental Status (MMS) score. Systematic clinical analysis failed to identify any links with age, the MMS, the UPDRS, the Tinetti scale or gait speed except for the variables freezing, increased sustention polygon and ataxia.

Discussion

This kind of study appears to offer an attractive analytical approach but would require a more pertinent choice of variables for cognitive evaluation and a more exhaustive set of MRI criteria. Nonetheless, clinical gait analysis could improve our understanding of the consequences of mild cognitive impairment and aging.     

Between a psychiatric diagnosis and a familial diagnosis

If the idea of a biopsychosocial model is not going to be merely a phrase, then every clinical diagnosis and therapeutic vision need to consider the familial issues. Taking the family issues into consideration has evident gains; it allows for a better understanding of the patient and allows for actions which reduce the risk of a relapse of illness. The fact that such issues are not part of the therapeutic armament, despite the effectiveness of psychoeducation, is bewildering: on one hand the families are not always invited to co-operate, on the other hand--they often give up this co-operation. In such a situation, the relation between the patient's family and the personnel needs analysis, especially common, often unconscious emotions and prejudices. They can form a dysfunctional 'knot', which does not allow for a therapeutic alliance to be formed. How to come out from such an impasse and make a common positive alliance? Paradoxically, the therapeutic possibilities are bigger when--especially in the initial phase of treatment--the psychiatrist "is able to not know" and is capable of listening into the patient's family perspective, and has an interest in the 'family story'. It is only after the knowledge on the family is gained and the family perspective is accepted, that the deconstruction of that part of the family's story that forms the problem and a common search for "positive changes" are possible. Although it may not appear to be so, such an ordeal can be very difficult for the psychiatrist who is used to controlling the situation through psychiatric theory and diagnosis, psychiatric language and the psychiatric institution. The issue presented appears to be part of a universal dilemma: what is the range of "the language power" of the psychiatrist and when is the sharing of this power with the patient and the family beneficial for the therapy.     

Event related potentials recorded in normal and dyslexic subjects when reading in and out of context.

Clinical evidence has shown that expectancy or anticipatory reactions influence the ability to read. It is possible that the reading problems shown by dyslexic children could be due to the absence of anticipatory hypotheses when they decode verbal material. Research was therefore carried out into these clinical observations to see if they could be detected on an electrophysiological level using a technique for recording Event Related Potentials (ERPs). In this study, our intention was to observe if there were any differences between a sample population of normal children and one of dyslexic children in the ERPs recorded on the presentation of words both in and out of context. The words recorded during the reading in context were: the word "la" (the feminine article "the" in Spanish), an "intermediate" word and a "final" word in a series of sentences. The first two have a greater anticipatory load than the reading of the final word since this is the word that closes the meaning of the sentence. Furthermore, as a control, the ERPs that were produced when reading isolated words were recorded, a situation that does not require the presence of anticipatory processes. The control group was made up of subjects with adequate school performance and no pathological background, and the experimental group was composed of subjects whose performance on a psychoeducational battery, previously administered to 120 Mexican children, had been found to be two standard deviations below the established norms. Following the 10-20 international system, electrodes were placed in zones F3, Cz, P3, O1 and O2 and referred to both earlobes. Statistical analysis revealed significant differences between groups in the amplitude of the ERP recording in the left occipital zone for all conditions when reading in sentences ("la," "intermediate" and "final"). It is suggested that this cortical zone participates in decoding verbal material and that it is deficient in subjects with reading problems.     

Therapeutic management of sexual abuse allegations in custody and visitation disputes

Our experience is that in many cases, trying to assess the "truthfulness" or "falseness" of sexual abuse allegations that occur in the midst of custody and access disputes may not be possible. Instead therapeutic management of such cases is advocated. A case is presented in which sexual abuse was suspected because the recanting child displayed sexualized symptoms. Following a thorough assessment, which indicated that the child was abused, but could not confirm who the offender was, both the child and the mother were seen in psychotherapy on a regular basis. The father used counselling to achieve rights for visitations. The building of a therapeutic relationship allowed us to experiment with the situation to where we felt we could identify the potential offender who had to be kept away from the child. In addition, the therapeutic relationship enables this family to come to us to resolve their disputes rather than use the judicial system.