Le déni de grossesse : étude réalisée sur 75 dossiers de découverte tardive de grossesse

The denial of pregnancy is a vague and badly defined entity with no international consensus. Yet this phenomenon is often found by health professionals, provoking much questioning on its aetiology and how to treat it. The denial of pregnancy constitutes a potentially risky situation for both mother and child.     

Caractéristiques des enfants ayant une épilepsie suivis au CHU de Marrakech

Introduction

Epilepsy is one of the most frequent neurological diseases in the pediatric population. Many epidemiological studies have been published, but with rather discordant results, because of methodological differences. In our context, epilepsy constitutes a public health problem. National epidemiological data are scarce.

Objectives

To describe the characteristics of children with epilepsy, to analyze the risk factors and to assess the impact of the disease on schooling.

Methods

This was a retrospective study concerning 592 children attending the Mohammed VI university hospital center pediatric unit A outpatient clinic for epilepsy from August 2003 to December 2007.

Results

Epileptic syndromes were classified according to the criteria of the International League Against Epilepsy of 1989. Prevalence of epilepsy was 8.5%. Average age was 6 years 7 months. Age of seizure onset ranged from 2 months to 14 years. Male gender predominated. Antecedents were dominated by peri- and neonatal complications. Parental consanguinity and a family history of epilepsy were found in 19.2 and 11.6% of cases, respectively. Schooling was perturbed in more than one-third of the school-age children. Generalized seizures were most common (70.5%). Association with cerebral palsy was present in 18.6% of cases, with mental retardation in 4.7%. The epilepsy was idiopathic for 41% of the children, symptomatic for 39% and cryptogenic for 20%. Generalized epileptic syndromes were the most frequent, epilepsy absence (12%), Lennox-Gastaut syndrome (6%), West syndrome (5.5%) and myoclonic epilepsy (4%). The most common partial epileptic idiopathic syndrome was benign childhood epilepsy with centrotemporal spikes. Single-drug therapy was the rule for first intention treatment (96.8%). Sodium valproate was the antiepileptic drug most widely used (82%). Treatment led to resolution of the seizures in 76% of the children.

Conclusion

Preventive measures should be reinforced in our context with a considerable proportion of children presenting neonatal risk factors. Efforts should be made to improve schooling for children with epilepsy.     

Approche épidémiologique de la toxicomanie en milieu universitaire à Marrakech (Maroc)

Introduction

Drug-addiction, an universal medico-social problem, starts to spread in Morocco. Even if it appeared a long time ago, one is unaware of the real characteristics of this plague in our country.

Objectives

The aim of our work is to study the prevalence of drug-addictions (tobacco, cannabis and alcohol) among students at the University Cadi Ayyad of Marrakech, trying to approach the epidemiological aspect and the impact of this consumption.

Patients and methods

Our study is an epidemiologic approach of drug-addiction in the University of Marrakesh. After having prepared a questionnaire allowing the study of toxic consumption (tobacco, cannabis and alcohol) and the evaluation of the depression among consumers; we carried out an investigation near 418 students from Caddi Ayyad University.

Results

The analysis of the results obtained makes it possible to establish the following characteristics: 24,6% of the students of our sample were consumers of tobacco, 9,8% were consumers of cannabis and 17,5% were alcohol consumers. Male consumption is prevalent, with 86.4% of smokers, 97.6% of hashish consumers and 86.3% of alcohol consumers. The age of the first consumption of drug coincides with adolescence. The mode of consumption was regular for 100% of smokers, 51.2% of hashish users and for 11% of alcohol consumers. 86.4% of smokers were dependent on tobacco, 76,6% on cannabis and 16,4% on alcohol. 28.1% of the dependent smokers on tobacco presented a moderated to severe depression. It was the same for 35.4% of the cannabis dependent and for 58.3% of those dependent on alcohol.

Conclusion

A plan fighting drug-addiction is essential; especially in its preventive shutter, so as to limit this phenomenon and to minimize its repercussions on young population.     

Des états dissociatifs vers une clinique des troubles dissociatifs

Dissociation can be defined as a dysfunction of the normally integrated functions like memory, consciousness and perception of environment. The history of dissociative disorders rejoins the history of hysteria with the work of Charcot, Janet and Freud at the end of the 19^th century and the beginning of the 20^th century. The concept of hysteria disappeared from the international classifications of mental disorders (DSM-III and DSM-IV, ICD-10) which stimulate a regain of interest in the past 20 years for the field of somatoform and dissociative disorders. After discussing the clinical and etiological issues of the concept of dissociation, we emphasize the interest for the clinician to recognize dissociative states and dissociative disorders, while insisting on the differential diagnosis and the psychiatric comorbidities. Dissociation is now considered as a trans-nosographical entity that can be observed in many psychiatric disorders, such as anxiety and mood disorders, personality disorders, substance-related disorders and even some organic disorders. Substantial progress has been recently made in diagnosing and treating these disorders, allowing the development of sensitive (DES - Dissociative Experience Scale, DQ - Dissociation Questionnaire) and specific (DDIS - Dissociative Disorder Interview Schedule, SCID-D-R - The Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised) diagnostic tools. Despite important differences found in the epidemiological studies, the prevalence of the dissociative disorders being around 10 % in the general population, there is a consensus in the literature concerning the importance of precocious detection of these disorders, in order to improve the management of the patients.     

Adaptation française de l’échelle Problematic Internet Use Questionnaire

Objectives

This research proposes a French adaptation of the Problematic Internet Use Questionnaire (PIUQ) (Démétrovics et al., 2008) for young adults.

Methods

The translation and adaptation followed the major steps recommended by Vallerand (1989), which mean a work of face validity with a back translation, a psychometric study with exploratory, confirmatory and fidelity analyses. This research included four studies with a total of 484 subjects.

Results

Component Principal Analysis (CPA) shows that the French adaptation of the PIUQ is composed of 12 items. Confirmatory factorial analysis in studies 3 and 4 shows a satisfactory indicator and confirms a structure of four dimensions. Correlations between the score of the PIUQ-F-12 and the anxiety, in one hand and the Internet Addiction Test (IAT), on the other hand, is meaningful and positive what reinforces the validity of this tool.

Conclusion

This questionnaire (PIUQ-F-12) will be able to assess the presence of the problematic use of the Internet in a population of teenagers or young adults. With its short number of items, it can be quickly used at intake to support the evaluation. It will be as interesting to test this tool for a Problematic Internet Use screening in a clinical setting.     

Patients adultes traités par une association d’antiépileptiques pour une épilepsie focale en France : description et mode de prise en charge selon les nouveaux critères de définition de la pharmacorésistance (étude ESPERA)

Aims

To describe the adult population treated with antiepileptic drugs (AEDs) in combination for focal epilepsy according to the definition of AED resistance proposed by the International League Against Epilepsy (ILAE) in 2009 and to evaluate its implementation in current practice.

Methods

ESPERA was a multicenter, observational, cross-sectional study with a clinical data collection covering the past 12 months conducted by neurologists. Classifications according to AED responsiveness established by investigators for each enrolled patient were revised by two experts.

Results

Seventy-one neurologists enrolled 405 patients. Their mean age was 42.7 years (sex-ratio M/F 0.98). According to the investigators, 60% of epilepsies were drug-resistant, 37% drug-responsive and 3% had an undefined drug-responsiveness. After revision of experts, 71% of epilepsies were classified as drug resistant, 22% as responsive and 7% as undefined. Among the participating neurologists, 76% have made at least one error in classifying their patients according to the 2009 ILAE definition of AED resistance. Because of epilepsy, 24% of patients (age ≤ 65) were inactive and 42% could not drive (respectively 29 and 49% of patients with AED resistant epilepsy). Half of patients had at least one other chronic condition. Number of prescribed drugs in combination and health care resource utilisation were significantly higher in patients with drug-resistant epilepsies than in patients with drug responsive epilepsies.

Conclusion

ESPERA study shows that the use of new definition of drug-resistance in everyday practice seems difficult without any additional training and that the social and professional disability is frequent in adults with focal epilepsies treated with polytherapy.     

Maladie de Parkinson : une maladie à forte composante environnementale ?

Parkinson's disease (PD) is the most common cause of the parkinsonian syndromes and the most frequent neurodegenerative disease after Alzheimer's disease. Only a minority of PD cases is due to a single factor, in particular a genetic mutation. In the large majority of cases, it is considered that PD is a complex or multifactorial disease that results from the effect of multiple risk or protective factors, either genetic or environmental, and, possibly, from their interaction. Epidemiological studies, through a variety of approaches, have brought important evidence in favour of the contribution of environmental factors to the etiology of PD. In this review, we will present current evidence by focusing on specific illustrative examples.     

La biologie et le futur de la psychanalyse : un nouveau cadre conceptuel de travail pour une psychiatrie revisitée

The American Journal of Psychiatry has received a number of letters in response to my earlier “Framework” article (1). Some of these are reprinted elsewhere in this issue, and I have answered them briefly there. However, one issue raised by some letters deserves a more detailed answer, and that relates to whether biology is at all relevant to psychoanalysis. To my mind, this issue is so central to the future of psychoanalysis that it cannot be addressed with a brief comment. I therefore have written this article in an attempt to outline the importance of biology for the future of psychoanalysis.     

États de mal épileptiques : épidémiologie, définitions et classifications

The annual incidence of status epilepticus based on the definitions of the International League Against Epilepsy (1993) ranges from 10.3 to 41 per 100,000 inhabitant. Half of the cases of status epilepticus concern epileptic patients. In all studies, incidence is higher in epileptic patients, young children and the elderly. It is estimated that 13% of patients with status epilepticus will experience recurrence during the two first years. The three leading etiologies are low-dose antiepileptic drugs, non-acute brain lesions and acute stroke. Seizures are generalized in 9 to 33% of patients and focal in 25 to 75%. Secondary generalized seizures can be observed in 19 to 66% of patients. Mortality ranges from 7.6 to 39% and varies as a function of inclusion of postanoxic encephalopathies and difference in initial care. The definition retained and the classification adopted for status epilepticus also affect mortality estimates. Status epilepticus is defined as the existence of a prolonged seizure or a series of seizures during which the patient does not recover, or incompletely recovers, consciousness. The duration parameter used to distinguish status epilepticus from a seizure remains controversial. At the present time, there is general agreement in the literature distinguishing two definitions based on different durations according to the clinical type of status epilepticus and its potential severity: (i) a status epilepticus is defined by a seizure lasting more than 30 minutes or recurrent seizures without recovery of consciousness over a period of 30 minutes; (ii) considering its severity, tonic-clonic status epilepticus has a specific definition leading to earlier therapeutic management. This operational definition is continuous, generalized, convulsive seizure lasting more than five minutes or two or more seizures during which the patient does not return to baseline consciousness. Several types of background can be used to establish a classification for status epilepticus: clinical manifestations, prognostic and therapeutic course, epidemiological data, pathophysiological mechanisms… At the present time, the classifications most commonly used in France for status epilepticus are derived from the syndromic epileptic classification, the seizure classification or the classification proposed by the French consensus workshop on status epilepticus. For routine clinical practice, an operational classification can be used to adopt therapeutic strategies adapted to probable prognosis: short-term life-threatening, mid-term life-threatening, not life-threatening.     

Épidémiologie des usages de substances addictives : résultats d’études réalisées en France et perspectives internationales

Addiction to drugs is an important public health concern. Describing the frequency of dependence, abuse and use of substances in a country allows a monitoring and helps in the design of an appropriate healthcare system. We will present studies describing the prevalence of use of tobacco, alcohol, and illicit drugs in France, with a comparison to European or International studies. They show a decrease in the use of tobacco and cannabis, while there is an increase in alcohol use in young adults. We also observe that the difference in substances use between females and males is tightening, especially in young people. We have less studies of analytic epidemiology trying to describe risk or protective factors associated with substances’ use in France. Further studies on addicted people's pathway (from use to abuse and to dependence, as well as from dependence to recovery, with or without medical support) are warranted.     

Troubles du sommeil : caractéristiques sociodémographiques et comorbidités anxiodépressives. Étude (Baromètre santé INPES) chez 14 734 adultes en France

Aim

Several studies have identified a high prevalence of sleep disorders and insomnia in the French population; however these studies especially focused on sleep did not give enough details on the sociodemographic and occupational characteristics of subjects with sleep disorders. The aim of this study was to characterize adults complaining of sleep disorders in a vast population-based health demographics study (Baromètre Santé, Institut national pour l’éducation à la santé [INPES]).

Method

Fourteen thousand seven hundred and thirty-four adults aged from 18 to 65 years old were interviewed by telephone and “subjects with severe sleep disorders in the last 8 days” were isolated and compared with the others regarding sociodemographic and occupational aspects and with regard to psychiatric disorders. The sleep items were extracted from the Duke and WHOQOL (brief form) questionnaires. Depressive disorders were recognized based on the Composite International Diagnostic Interview (CIDI) Short-Form (CIDI-SF) and the ISD 10.

Results

Among the subjects, 12.5% were concerned. Women, young or subjects after 45, low income, employees and unemployed categories had significantly more sleep disorders. Sleep disorders in the last 8 days were also significantly linked to previous depressive episodes, anxiety disorders and history of suicide.

Conclusion

Assessing sleep disorders in the last 8 days seems to be a good method to identify severely affected subjects in general population surveys.     

La consultation psychologique spécialisée pour les sujets souffrant de syndromes psychotraumatiques : premiers éléments d'évaluation

There are currently a large number of results published in English concerning the question of evaluating the therapeutic care of posttraumatic stress states, in particular since their international recognition by the DSM in 1980. Overall, the studies reveal no difference in effectiveness between various recognized therapeutic methods while cognitive therapies seem to lead to even better results. Operating within the framework of emergency psycho-medical units, we have set up a consultation facility specializing in the psychological treatment of posttraumatic stress states intended for individuals who do not suffer from serious personality disorders or any major associated psychiatric problems. The technical aspects of this psychological consultation take their inspiration from the psychodynamically-based model of short term psychotherapy. This consultation is accompanied by medical and social care given by a psychiatrist who is responsible for prescribing the treatment and for relations with the social, professional and possibly also legal institutions. The aim of this study was to evaluate the effects of this specific care on the improvement of the psychotraumatic symptoms and the general health of these patients. The population consisted of 20 initial patients (mean age = 43 years) who had been the victims of a variety of traumatic events (eight physical assaults and 12 accidents). The criteria used for the evaluation of the clinical change were: (a) symptomatic criteria relating to the improvement of the posttraumatic symptoms (DSM-IV criteria); (b) criteria relating to the improvement in general mental health; (c) criteria relating to the evaluation of the change by the therapist and the patient; (d) criteria relating to the evaluation of the psychotherapy taking account of the notion of therapeutic alliance. The subjects were assessed at the end of the psychotherapy and then again three and a half months later. Both self-evaluation and external evaluation questionnaires were used (DSM-IV criteria for the posttraumatic stress state, the Steinitz and Crocq posttraumatic stress state inventory (1992), L. Crocq’s posttraumatic stress state self-evaluation scale (1990), Luborsky’s health-sickness scale, the Penn Helping Alliance Questionnaire Method (Alexander and Luborsky, 1986). The results showed that only four of the 20 subjects still exhibited a posttraumatic stress state three and a half months after the therapy. These non-improving subjects also suffered from associated pathologies (major depression and somatization), a conflictual problem that predated the trauma and numerous problems at the social level. Furthermore, in the patients who did exhibit an improvement, the “alertness state” concerning those cues that risked provoking recall of the trauma continued to be of moderate intensity. The improvement in the symptoms was accompanied by a general improvement in the mental health of the subjects who were able to reinvest in their social lives and relations. The study, therefore, shows that the subjects’ improvement is correlated with two dimensions of the helping alliance method (working alliance with therapists and feeling of having been understood and supported) and the subjects’ capability of acting independently. Finally, the speed with which psychological care is initiated following the traumatic event seems to be a determining factor for patient improvement: the earlier care is administered, the faster subjects are able to regain their balance. The proposed evaluation is subject to a certain number of limits: therapists involved in the evaluation and the brief evaluation interval (three and a half months after the psychotherapy) which does not necessarily allow us to conclude that the improvement is permanent or assess possible relapses.