Mise au point des études cliniques sur le rapport « veille-sommeil » dans le trouble déficit de l’attention/hyperactivité de l’enfant

Since 1970, a certain number of studies have reported sleep disturbances in children with ADHD. Data from questionnaires and parental reports showed behavioural difficulties occurring at wake-sleep transition such as bed-time refusal, delayed sleep-onset, early awakenings, suggesting the occurrence of specific abnormalities in the mechanisms of alertness maintainance.Few polysomnographic studies have been conducted in ADHD children considering the prevalence and the importance of the disorder in the field of child psychopathology. The majority of these studies produced heterogenous and conflicting data and no clear abnormalities of non-rapid eye movement or REM sleep were found.Polysomnographic data, however supports the evidence of sleep-wake-transition abnormalities in ADHD children. Modifications in sleep-onset-latencies, number of stage shifts, have previously been reported using all-night polysomnography.One study performed Multiple latency tests in ADHD children and concluded that ADHD had daytime sleep abnormalities when compared with controls.One other important issue concerns motor activity during sleep in hyperactive children which was found to be increased in studies using actigraphy or video analysis. These findings could lead to important clinical and therapeutic applications as stimulants could help to normalise sleep or motor behaviour during sleep in some ADHD children.     

Le trouble déficit de l’attention/hyperactivité à l’âge adulte : concept, tableau clinique, stratégies diagnostiques et thérapeutiques

Attention Deficit/Hyperactivity Disorder (ADHD) was considered, for a long time, as a disorder affecting children and adolescents, and was most often identified in the early development. It was less known that ADHD can be found in adults. Several arguments (clinics, neuropsychology, neuroanatomy, genetics, longitudinal studies and pharmacology) confirm that ADHD persists in adulthood for most of children and should be still treated, as long as the disorder leads to impairments. Nevertheless, ADHD in adults is considerably misdiagnosed in France. In fact, this can be explained by controverse, by its difficulty to be diagnosed, by a lack of consideration of developmental aspects… Diagnosis is based on clinical aspects, developmental and familial histories, adaptative strategies and functional alteration. Clinical interview put forward particularities in adulthood: decreasing (or change) of hyperactivity and impulsivity, persistance of attentional deficit, increasing of dysexecutive syndrome because demands in planification, social relationships and emotional management are often higher when people grow up. Several domains can be impaired: raising children, driving cars, working, taking care of themselves, daily managing… One of the most difficult issue about adult ADHD concerns criteriology. Although some authors (Wender, Hallowell and Ratey) have developped criteria based on more specific features of adulthood than those described in DSM-IV, criteria have still to be discussed: age-of-onset, number of symptoms required… Assesment scales can help clinicians to evaluate ADHD symptoms and impairments of their adult patients. Main scales are: Conners Adult ADHD Rating Scale (CAARS) and Adult ADHD Self-Report Scale (ASRS) for detection, ADHD behaviour checklist and ADHD rating scale IV for diagnosis, Wender Utah Rating Scale (WURS) for retrospective diagnosis in childhood and Brown Attention Deficit Disorder Scale for a better evaluation of executive functions. This evaluation should be completed by neuropsychological testing. The results can confirm the diagnosis and guide the treatment according to the neuropsychological profile. The more salient tasks for the diagnosis of adult ADHD seem to be: Continuous Performance Test (CPT) for selective and sustained attention, Trail making Test part B for cognitive flexibility, Stroop color/word interference test for inhibition capacity, verbal fluency and processing speed in WAIS-R. It is thus extremely important: (i) to recognize that ADHD affects also adults, at high rate (4% of general population), (ii) to keep in mind that developmental particularities make the disorder more “cognitive” than “behavioral”, (iii) to clarify the link between adult ADHD and the others psychiatric disorders, especially bipolar disorder, (iv) and to know that most of the adults with ADHD can be successfully treated by psychostimulants and psychotherapy, as in childhood. In France, only few teams evaluate ADHD in adulthood. So, one of the purpose of our article is to enable a better consideration of adult ADHD in our country.     

Trouble déficit d’attention/hyperactivité (TDA/H) et émotions : de la labilité émotionnelle au trouble bipolaire

This article aims to review the literature about emotional symptoms associated with ADHD. Emotional symptoms are frequent in Attention Deficit Hyperactivity Disorder (ADHD) and range from mild/moderate to severe emotional lability, but are not specific to ADHD. Severe emotional lability in ADHD patients or association between emotional under-control and mood symptoms should urge clinicans to screen for co-occurring oppositional defiant disorder, mood disorders (depressive disorders, bipolar disorder) and disruptive mood dysregulation disorder. Although this latter diagnosis still lacks validity and may be difficult to differentiate from severe oppositionality in ADHD patients, it will draw attention to the emotional aspects of disruptive behavior disorders and the need to implement specific treatments for emotional hyperreactivity and under control. A better understanding of the relationships between behavior and mood and of the role of environmental stressors is needed to improve prevention of full-blown mood disorders in children with ADHD and emotional lability.     

Profil psychologique et comportemental de vulnérabilité à la dépendance à l’exercice et au risque de pratiques dopantes chez les sportifs amateurs : l’exemple des semi-marathoniens

Introduction

Most research on doping behaviors in sportsmen is relative to professionals. However, high-risk behaviors can also be observed in amateur sportsmen. Exercise dependence corresponds to an unsuitable practice of physical exercise which leads to complications characterized by a need to increase the amount of exercise significantly, the presence of tiredness or anxiety when discontinuing the exercise, the loss of control, the increase in the time spent in exercises, the restriction of other fields of activity and the maintenance of the exercise even with a recurring physical or mental problem (Veale, 1995). It appears that exercise dependent subjects have specific representations of physical activity (Davis et al. 1993, 1995). Our objective is to study the relationship between doping practices and behavioral dependence to physical exercise in amateur sportsmen. We hypothesize that high-risk doping amateur sportsmen have the following specific profile: A threshold of consumption of physical exercises, a particular representation of the sport, a restriction of the fields of activities apart from the sport.

Method

Mental representations and physical exercise habits of 317 semi-marathon runners were studied through semi-structured interviews. The sample consisted of 257 men and 60 women 20 to 60 years old. (i.e. 62 individuals from 20 to 30 years old, 116 from 30 to 40, 93 from 40 to 50, and 46 over 50 years old). All the participants were amateurs practicing foot racing in competition as principal sport. The participants were asked to answer to a self-questionnaire assessing: Their relation to physical activities, the number of hours of weekly physical exercises, the type of practice, the environment extra-sportsman, the representations of the sport, the importance given to the practice of the sport, the consumption of other products, the possibility of a consumption of doping products, their capacity to be abstinent to their physical activity. We determined an indicator of risk of doping, from different questions related to a possibility of consuming doping products. The indicator which appears most sensitive is the question: "Would you be ready to take doping products under medical control".

Results

The majority (75%) of the semi-marathonians practice their physical activity between 1 and 5 hours weekly whatever their age. The median observed is equal to 4. A discriminating analysis does not make it possible to show a good capacity of classification of the individuals saying it self ready to take doping products under medical control according to the only criterion of the number of hours of physical practice. 11.7% of the subjects reported that they would agree to take doping substances if they had the opportunity to do so under medical control. The mental representations and behavioral characteristics of this subgroup are the following: 1) A pervasive search of a surpassing of themselves through physical exercise; 2) An every day life predominantly focused on physical exercise; 3) The onset of negative feelings and irritability related to exercise discontinuation; 4) Paradoxically, a moderate amount of time spent exercising (59.5% reported exercising less than 5 hours weekly).

Discussion

In amateur sportsmen, the reported propensity to use doping substances is not correlated to the intensity of physical exercise measured by the amount of time weekly spent exercising. This propensity seems to occur in a specific sub-population of vulnerable subjects characterized by a behavioral dependence to physical exercise with a specific representation of their physical activity. These specific characteristics of high-risk individuals are independent from the age of the subjects. In a perspective of prevention, it is important to identify high-risk subjects to modify their manner of perceiving the sport, and to preserve other social investments.     

Neurosciences et phénoménologie - I : dans le bocal à mouches

In this first part, we describe how the scientific method is organized according to a circular structure and generates paradigms, constraining the researches in sciences like a fly bottle limits the displacements of flies in the bottle. Then, we analyze the neuroscientific paradigm using the Weawer's paper about the increase of complexity in sciences underlying an amazing paradox: Neurosciences appear funded on the paradigm of physics since they belong to biology. This paradox has significant epistemological consequences.     

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.     

Les mouvements oculaires comme moyen de contourner l’insight lors de l’évaluation des comportements de vérification dans le trouble obsessionnel compulsif (TOC)

Rotge et al. [2] demonstrated that asking patients with obsessive compulsive disorder to compare separately presented images was a good way to assess the intensity of their checking behavior. However, the patients with good insight could consciously refrain from checking (Jaafari et al. [1]). To get rid of this problem, the images were presented simultaneously while the patients’ eye movements were recorded. Whatever their insight patients made more gaze moves to compare the images than controls. The patients’ checking behavior was actually related to a reduced working memory span.     

Cannabis et trouble bipolaire : recherche d’une association à partir d’une revue de la littérature

Introduction

It has been established that cannabis use is involved in the emergence and evolution of psychotic disorders. Although cannabis use is very frequent in mood disorders, there has been a considerable debate about the association observed between these two disorders. This review aims to clarify the relation between cannabis use and bipolar disorder, in order to unveil a possible causality and find the effect of cannabis on the prognosis and expression of bipolarity.

Methods

The review used MedLine database using the keywords “cannabis” or “marijuana” and “bipolar” or “mania” or “depression”. This search found 36 articles who were clinically relevant to the subject and were included and discussed in this review.

Results

The first studies discussing the link between cannabis use and psychotic disorders reveal manic features in the substance abuse group, hence suggesting a possible association between cannabis use and bipolar disorder, in favor of triggering a manic episode. According to the studies, between 25 and 64% of bipolar patients are cannabis users, and the prevalence is higher in younger and male patients. The risk of developing a mood disorder is higher among cannabis users compared to the general population. This substance abuse in bipolar disorders would increase the frequency and duration of manic episodes without changing the total duration of mood episodes. In a first episode of bipolar disorder, the use of cannabis would increase the rate of relapses of manic episodes and worsen the prognosis of the disorder.

Discussion

The frequency of substance abuse in bipolar disorders is higher than the prevalence in the general population, and cannabis is one of the most used illegal substances in the worldwide. Hence, the association between cannabis use and bipolar disorders is frequent. Cannabis users may experience euphoria, relaxation and subjective feelings of well-being; this substance may also have antiepileptic effect, which may explain some of the effects of cannabis on bipolar disorders. In fact, the use of cannabis would increase the frequency and duration of manic episodes in bipolar patients without increasing the total duration of mood episodes, suggesting a possible antidepressing and mood stabilizing effects. This impact of cannabis on mood disorders and its possible pharmacological effect is still controversial and needs further experiencing to be proved.     

Relations entre dimensions émotionnelles et symptômes somatiques : effets médiateurs de la dépression et de l’alexithymie

Objectives

The aim of the present study was first to complete previous research on negative affectivity, alexithymia, depression and somatic symptoms by testing a theoretical model of their relations. It was second to investigate potential mediating effect on the relations between negative emotionality (i.e. neuroticism) and somatic symptoms.

Patients and method

A sample of 309 subjects (77% F et 23% M; mean age = 20, 61 ± 1.55) completed the following questionnaires: the Positive and Negative Emotion questionnaire-31 items (EPN-31), the Toronto Alexithymia Scale 20 items (TAS-20), the Center for Epidemiological Studies Depression scale (CES-D), and the Symptom Check List Revised, 90 items (SCL-90 R). Theoretical model and mediating effects were tested using structural equation modeling, and bootstrapping method.

Results

Three measurement models were tested: First, a direct effect model did not fit the data. Second, a partially mediated model fit partially the data for some indices, but not for others, and was rejected for lack of parsimony. Finally, a full mediation model showed the best adjustment with results confirming the good fit of this structural model including (Chi² = 10.245, P = 0.069, ns; CFI = 0.989 > 0.95, RMSEA = 0.058 < 0.07 [90% IC = 0.000–0.100], SRMR = 0.026 < 0.08). So as, our results show that alexithymia and depression are full mediators of the negative affectivity–somatic symptoms relation. In other words, when depression and alexithymia are introduced in the relation between negative affectivity and somatic symptoms, the direct effect of negative affectivity becomes non-significant, and turns to an indirect effect. Moreover, depression as a stronger effect on somatic symptoms than alexithymia, which seems to confirm previous research on the distinction between both constructs. These results are compatible with that of previous works on somatic symptoms and negative affectivity, and on somatic symptoms and alexithymia.

Conclusion

The propensity to experiment negative emotional states may contribute to develop negative emotion regulation strategies such as alexithymia, which as a direct effect on somatic symptoms. But more precisely, we can hypothesize that alexithymia is not fully efficient as a defense against negative emotions, and that depression remains a strong characteristic of subjective emotional experience for some subjects, constituting a strong contributor to declarative somatic symptoms. Implications for psychotherapy are discussed, supporting the enhancement of negative emotions regulations strategies for subjects showing somatic complaints.     

Recherche de sensations, désinhibition et pratique de sports à risque : quelques pistes de réflexion

Sensation seeking is at the root of different behaviours. Skydivers, artists, drug addicts and criminals somehow share the same need for stimulation. But are there drug-addicted skydivers? Are there different ways to seek sensations? Studies on risky sport practices and disinhibition are contradictory. While some find risk-taking athletes do not consume substances, others maintain these athletes are indeed the most uninhibited of all. Diversity and the type of activities supposedly depend on what exactly an athlete seeks from a psychological point of view. The analysis of different sensation seekers’ personality traits helps to better understand the choice and role of one or several sources of activation. Based on a review of studies, we will discuss three sensation seeker profiles. Depressed “escapists” primarily seek sensations through substance use in order to regulate their negative affects. This “passive” stimulation mode seems better suited than practising risky sports for these individuals lacking in energy. Conversely, extraverted “hedonists” comfort their positive affectivity by seeking multi-faceted pleasure in risky sports or the “social” use of substances. They are not characterized by negative affects but by alexithymia. Some probably bypass their difficulty to understand their feelings by seeking various readily available sensations that need not be mentally interiorised (purportedly found in disinhibition or risky sports). Finally, “compensatory” types are adventurers who seek sensations in high-risk sports only. They are not characterized by depression, anxiety, disinhibition, extraversion or alexithymia. They seek to enhance and build up their personality by confronting the natural environment and danger. While all athletes seek sensations, these might not be essential to escapist and compensatory types who use them only as a mere means to escape and compensate. Extraverted hedonists seem to be the “true” sensation seekers inasmuch as stimulations are worthwhile in themselves. This strong need for hedonistic sensations might lead to an addictive process, a common answer to psychic sufferings that may also derive from boredom or a need for sensations and pleasure.     

La demande du tiers et la validité de l’hospitalisation à la demande d’un tiers : les difficultés à surmonter

This paper following another article aimed at the implementation of the hospitalization at the request of a third party (hospitalisation à la demande d’un tiers — HDT) shows that the third party request for hospitalization, a compulsory component for validity of the process of hospitalization at the request of a third party, proves sometimes to be a difficult stage, source of great teething troubles and cancellation of many hospitalizations, not to say start of legal proceedings. The legal jargon and rhetoric reveal after their interpretation, a big gap between the spirit of the law, the practice of care and the precedents. Then, are suggested amendments of the practice relating to the hospitalization at the request of a third party, even of the law that banned long ago, the words: Commitment, internment and placement. Mainly, we suggest an ease of the validity of the thirds liable to formulate the request and a concentration on the spirit of the law, aiming more at the protection of the patients than an unproductive suspicion of the staff.     

Milnacipran et venlafaxine à posologie flexible (jusqu’à 200 mg/j) dans le traitement ambulatoire des épisodes dépressifs majeurs modérés à sévères de l’adulte : étude exploratoire de 24 semaines, randomisée en double insu

Introduction

Serotonin (HT) and noradrenaline (NA) reuptake inhibitors (SNRIs) are commonly used as first line treatment of major depressive disorders (MDD). As compared to tricyclic antidepressants, they have proved similar efficacy and better tolerability. Milnacipran (MLN) (Ixel^®) and venlafaxine (VLF) (Effexor^®) are two SNRIs pharmacologically differing by their NA/HT ratio of potency: 1:1 and 1:30, respectively.

Objectives

To investigate the efficacy and safety/tolerability of MLN and VLF administered at flexible doses (100, 150 or 200 mg/day) for 24 weeks (including 4 weeks of up-titration) in the outpatient treatment of adults with moderate-to-severe MDD.

Design

Multicentre, randomised, double blind, 2-parallel-arm, 24-week exploratory trial conducted in France by 50 psychiatrists.

Diagnosis and main inclusion criteria

Male or female outpatients, aged 18 to 70, meeting the DSM-IV-TR and related MINI criteria for recurrent, unipolar, moderate-to-severe MDD, with neither psychotic features nor severe suicidal risk. A Montgomery-Asberg depression rating scale (MADRS) score ≥ 23 was required at inclusion.

Treatment schedule

Patients were randomised to receive either MLN or VLF (1:1 ratio) for 24 weeks in double-blind conditions. Regardless of the treatment received, the following dosing schedule was applied: during the initial 4-week up-titration phase, the dosage was progressively increased from 25 mg/day (qd administration) to 150 mg/day (bid administration). At week 4, the dosage was either maintained at 150 mg/day, or adapted to 100 or 200 mg/day, based on the investigator's clinical judgement. At any time during the 20 following treatment weeks, the dose could be lowered for safety concerns until a minimal threshold of 100 mg/day. From Week 24, the dosage was decreased by 50mg/day every five days. After randomisation, eight assessment visits were organised at 2, 4, 6, 8, 12, 18, 24 weeks, and at study end (after the 5–15 days of down-titration and 10 days free of treatment). Efficacy evaluation ratings included the MADRS and global disease severity (CGI-S) total scores. Rates of MADRS response (reduction of initial score ≥ 50%) and remission (score ≤ 10) were calculated at Week 8 and Week 24 in the full analysis set as well as in the subgroups of patients with depressive disorder of severe DSM-IV intensity and with a MINI evaluation of suicidal risk (rated as required ‘moderate’ at the worst).

Statistical analysis

Standard distribution statistics (including mean and standard deviation [S.D.]) of scores and their changes from baseline, were calculated using the observed-case (OC) approach at all assessment times for the MADRS score, and the last-observation-carried-forward (LOCF) at 8 and 24 weeks for both MADRS and CGI-S scores. MADRS response and remission rates at 8 and 24 weeks were calculated using the LOCF approach by normal approximation of the binomial distribution. Bilateral exploratory statistical tests at 5% significance level were performed for results at 8 and 24 weeks of: (i) MADRS score changes from baseline, based on the score progress at each visit (mixed model for repeated measurements [MMRM]), and (ii) global MADRS response and remission rates (Chi²).

Results and patients

A total of 195 patients were randomly assigned MLN (n = 97) or VLF (n = 98) and 134 (68.7%: 61.9%/MLN and 75.5%/VLF) completed the trial. At the end of the up-titration, patients received 100 mg/day (11.4%/MLN, 10%/VLF), 150 mg/day (30.4%/MLN, 43.8%/VLF), or 200 mg/day (58.2%/MLN, 46.3%/VLF). Totals of 177 patients (90/MLN and 87/VLF) and 181 patients (90/MLN and 91/VLF) were analysed for efficacy and safety, respectively. Treatment groups were similar for baseline characteristics except a higher proportion of MLN patients with a severe depressive episode (63.3% versus 54%).

Results and efficacy

MADRS score (mean [S.D.] initial score: 31 [4.5]) progressively decreased all along the treatment course and similarly in both groups (Week 8-OC : –18.8 [7.7]/MLN and –18.6 [7.3]/VLF, p_MMRM = 0.95 ; Week 24-OC : −23.1 [7.8]/MLN and –22.4 [7.3]/VLF, p_MMRM = 0.37 ).At week 8-LOCF, MADRS response rates were similar in both groups (64.4%/MLN, 65.5%/VLF, p_chi2 = 0.88) as well as remission rates (42.2%/MLN, 42.5%/VLF p_chi2 = 0.97). At week 24 they remained non clinically and statistically different between groups (response rates: 70%/MLN, 77%/VLF, p_chi2 = 0.29; remission rates: 52.2%/MLN, 62.1%/VLF, p_chi2 = 0.19). In both “severe depressive episode” and “MINI mild or moderate suicidal risk” subgroups (n = 104 and 75, respectively), response and remission rates were non clinically different at both time points, however in the “MINI mild-to-moderate suicidal risk” subgroup, MLN tended to be more rapidly active (remission rate at week 8-LOCF: 44.7%/MLN, 35.1%/VLF). The changes in CGI-S were also indicative of a significant improvement of the global illness severity with both treatments.

Results and safety/tolerability

The tolerability profile of both drugs was in line with their pharmacological activity. About 70% of patients in both groups experienced at least one adverse event (AE). In both groups, the most common AEs were nausea, dizziness, headache and hyperhidrosis, and, in the male patients, genito-urinary problems: orgasmic disorders (VLF only) and dysuria (MLN only). These AEs were mostly responsible for definitive treatment discontinuation for tolerability concerns. None of the 6 serious adverse events (SAEs) on MLN and 4 of the 8 SAEs on VLF were related to the test drug.

Conclusion

MLN and VLF at flexible doses up to 200 mg/day globally exhibited similar efficacy and tolerability profiles in the long-term treatment of adults with MDD.     

Comorbidité TDA/H (Trouble du Déficit de l’Attention avec ou sans Hyperactivité) et TSA (Troubles du Spectre autistique)

The publication of the fifth version of the DSM in May 2013 officially recognized comorbidity between Attention-Deficit Disorder with or without Hyperactivity (ADD/ADHD) and Autism Spectrum Disorders (ASD). Indeed, the DSM-IV didn’t allow concomitant diagnosis. However, there is a clinical, neuropsychological and genetic overlap between these two disorders. Thus, 30–80 % of patients with ASD fill criteria for ADD/ADHD and in 20–50 % of patients with ADD/ADHD are found the diagnostic criteria for ASD. These observations raise the question of the link between ADD/ADHD and ASD: Is ADD/ADHD a minor form of ASD? Are ASD and ADD/ADHD different manifestations from a single neurodevelopmental disorder? Finally, are they two distinct developmental disorders whose clinical expressions would approach? Recent studies seem to distinguish two types of situations: Comorbid patients with less severe symptoms of ASD do not differ qualitatively from ADD/ADHD patients alone, which argues for a continuum between ADD/ADHD and ASD. Patients with ASD symptoms predominate are qualitatively different subjects from ADD/ADHD alone, thus corresponds to the hypothesis of two distinct nosological entities. Anyway, when ADD/ADHD and ASD are associated, there are specific clinical expression of developmental pathways and prognosis. Thus, these comorbid patients suffer more frequently from other psychiatric disorders, have a poorer quality of life, poorer adaptive functioning and clinical expression is more persistent over time. The modalities of treatment of comorbid patients may associate psychoeducational, psychotherapeutic approaches and medication (methylphenidate, atomoxetine, guanfacine, risperidone, aripiprazole).     

Réflexion psychopathologique sur la pédopornographie : le fantasme de l’altérité

Child pornography might be not only a support for pedophile's fantasies satisfaction. It might be a remedy against anxiety used by subjects in search of identity. Based on this idea, we made a reflection on the motivation to view this type of images. Analyzing the context in which the child pornographer acts, we conducted a parallel assessment with the analytical framework to understand what the purpose is if it is not sexual. He projects himself in the image. He becomes spectator and actor of the scene. Therefore, the child pornographer could have a control over images and looks. Images could be a support to the development of his childhood and teenage fantasies.     

De la médiation picturale dans le traitement de la schizophrénie

With schizophrenic patients, the use of the pictorial mediation during individual session of psychotherapy makes easier the display of the transferential y counter-transferential relationship. These creations are truly a way to say what the patient is unable to express differently. The use of a media: mediator, mediation, malleable medium, constitutes a first level of symbolization. It is used as an intermediary between nonsense feelings and their elaboration through the speech. In addition, these pictorial productions throw light on the question of ideality in psychosis and on this kind of archaic transference of the narcissistic pathologies.     

Réflexions sur l’usage de langues dans l’évaluation psycho(patho)logique appliquée à la création littéraire (S. Beckett, J. Green, V. Nabokov)

Our comment is based upon the Freudian hypothesis stating that repression is a defect in translation. Applying this statement to bilingual subjects using foreign languages, the second language, because it's less burdened with emotional repressions than native language, can turn into source of language troubles by arousing defense mechanisms, or, for the best, through an avoidance of repression, can reveal the subjects individual potential that had been repressed into/by the native language. The very complex relationships that J. Green, V. Nabokov and S. Beckett had with their native language show how the avoidance of repression related to their native language could be liberating for their writings. In the intercultural clinical psychopathology, this operation of translation rather entails defense mechanisms, instead of being a real vector of creation.     

Risque d’homicide et troubles mentaux graves : revue critique de la littérature

Introduction

Tragic and high profile killings by people with mental illness have been used to suggest that the community care model for mental health services has failed. It is also generally thought that schizophrenia predisposes subjects to homicidal behaviour.

Objective

The aim of the present paper was to estimate the rate of mental disorder in people convicted of homicide and to examine the relationship between definitions. We investigated the links between homicide and major mental disorders.

Methods

This paper reviews studies on the epidemiology of homicide committed by mentally disordered people, taken from recent international academic literature. The studies included were identified as part of a wider systematic review of the epidemiology of offending combined with mental disorder. The main databases searched were Medline. A comprehensive search was made for studies published since 1990.

Results

There is an association of homicide with mental disorder, most particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. However, it is not clear why some patients behave violently and others do not. Studies of people convicted of homicide have used different definitions of mental disorder. According to the definition of Hodgins, only 15% of murderers have a major mental disorder (schizophrenia, paranoia, melancholia). Mental disorder increases the risk of homicidal violence by two-fold in men and six-fold in women. Schizophrenia increases the risk of violence by six to 10-fold in men and eight to 10-fold in women. Schizophrenia without alcoholism increased the odds ratio more than seven-fold; schizophrenia with coexisting alcoholism more than 17-fold in men. We wish to emphasize that all patients with schizophrenia should not be considered to be violent, although there are minor subgroups of schizophrenic patients in whom the risk of violence may be remarkably high. According to studies, we estimated that this increase in risk could be associated with a paranoid form of schizophrenia and coexisting substance abuse. The prevalence of schizophrenia in the homicide offenders is around 6%. Despite this, the prevalence of personality disorder or of alcohol abuse/dependence is higher: 10% to 38% respectively. The disorders with the most substantially higher odds ratios were alcohol abuse/dependence and antisocial personality disorder. Antisocial personality disorder increases the risk over 10-fold in men and over 50-fold in women. Affective disorders, anxiety disorders, dysthymia and mental retardation do not elevate the risk. Hence, according to the DMS-IV, 30 to 70% of murderers have a mental disorder of grade I or a personality disorder of grade II. However, many studies have suffered from methodological weaknesses notably since obtaining comprehensive study groups of homicide offenders has been difficult.

Conclusions

There is an association of homicide with mental disorder, particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. Most perpetrators with a history of mental disorder were not acutely ill or under mental healthcare at the time of the offence. Homicidal behaviour in a country with a relatively low crime rate appears to be statistically associated with some specific mental disorders, classified according to the DSM-IV-TR classifications.