Évolution des patients traités dans un centre de jour spécialisé pour les troubles schizophréniques : une étude exploratoire

This exploratory study aims to evaluate the evolution of 25 patients during the time of a treatment in a day hospital specialized for schizophrenic disorders.Method. - In a naturalistic study, eligible patients were evaluated when entering and leaving for clinical profile, psychiatric history, nosognosia and compliance.Results. - The studied population presents a clinical profile indicating illness severity. Psychiatric hospitalizations, violence and suicide attempts diminish during the time of treatment. When leaving, 60 % of patients completed an employment or training project. The overall subjects present a significant decrease in positive symptomatology and a significant improvement in nosognosia and compliance to medication. On the contrary, a subgroup of 4 patients presents little improvement.Conclusion. - The treatment in the day hospital brings positive results for the majority of patients. They present significant possibilities of evolution in several domains. The limits of the study are discussed.     

Bilateral compartment syndrome after colorectal surgery in the lithotomy position

Lower limb compartment syndrome is an unusual but severe complication of prolonged surgery more than four hours in lithotomy position. It is usually a consequence of hypoperfusion of the lower extremities and muscle necrosis may occur. Several risk factors are pointed out: trendelenburg, the hardness of operating table, hypothermia, control hypotension, occlusion of arterial blood flow of the lower extremity, arteritis (and smoking), diabetes, obesity, arterial hypertension, myopathy and an important muscle mass. The symptoms are postoperative pain with neurological signs. A rapid diagnosis and aggressive management (i.e. resuscitation and aponevrotomy) is recommended. Neurological sequelae are sometimes invalidating. Reporting a case of bilateral syndrome, we reviewed the literature and describe the present diagnosis and therapeutic management as well as prevention modalities of this iatrogenic complication.     

Attribution d’états mentaux et schizophrénie

The cognitive neuropsychology proposes models to explore schizophrenics symptoms. The concept of theory of mind appeared in psychiatry fifteen years ago and is now a focus of research. Various comprehensive models of schizophrenia involving theory of mind have been proposed and explored by experimental tasks. Those models are useful to understand schizophrenic semiology and to explore brain by functional imaging. A review of these research is useful to understand their interest.     

Comment mesurer la charge des aidants naturels de personnes souffrant de schizophrénie ?

Since psychiatric institutions began discharging mentally ill patients into the community, families of patients suffering from schizophrenia were more and more involved in the therapeutic process. During the last decade psychoeducational programs were proposed to families, in order to help them having a better knowledge about the disease, more efficient coping strategies or less expressed emotional level. The adverse consequences of having at home a patient suffering from schizophrenia have been studied by a number of authors, and some of them published standardized questionnaires for evaluating “caregiver burden”. Very few of these questionnaires were elaborated from the caregiver’s point of view, only five of them have well documented psychometric properties and none of them has shown a good sensitivity to change. In this work we present an overview of the literature about caregiver burden questionnaires. Among the 30 questionnaires found in the literature, 16 only have been validated in caregivers of patients suffering from schizophrenia. The validation work is often partial: generally an evaluation of internal consistency. Only eight instruments have been validated with a factorial analysis, and in three of them a study of external validity study has been conducted. Sensitivity to change is described for none of the published questionnaires. These questionnaires may contain three great domains: a caregiver’s evaluation patient’s behavior or social functioning when considered as a burden, the consequences of care giving on caregiver’s life, the subjective perception of care giving by the caregiver. Some instruments evaluate only one domain, others two or three of them. The best validated instruments are the Experience of Caregiving Inventory (Szmuckler et al.), the Involvement Evaluation Questionnaire (Schene et al.), the Questionnaire of Family Attitude and Burden (Morosini et al.). The Social Behavior Assessment Scale (Platt et al.) is the most detailed and complex instrument, and many questionnaires derived from it. No international consensus has been found about the dimensions of such an instrument, the evidence about the usefulness of these instruments for evaluating psychoeducational or therapeutic programs is weak, the lack of information about sensitivity to change is a major problem. In addition to the analysis of the literature, we performed 33 interviews of relatives of French patients suffering from schizophrenia. The results of the qualitative analysis of the verbatim are presented in detail: a global evaluation, some items about patient’s behaviors mentioned as burdensome, items about relationships with patients, family and social relations, daily family routine, physical and mental health, satisfaction with psychiatric care, prospects and philosophy of life. As in the ECI and and the QFAB, some positive dimensions are found together with negative ones. A computer text data analysis has been further performed. The results show four great domains: (1) family routine and daily activities, (2) family and social relations, relationships with the patients, (3) satisfaction with psychiatric care, relationships with the patient, (4) a miscellaneous about the future for the patient as well as the caregiver, hope, fears… Items about mental health and psychological consequences of care giving are found in all dimensions. The comparison of experimental results and data from the literature shows the interest of a quality of life approach in caregivers. We further propose the development of a French language self-administered questionnaire for caregivers of patients suffering from schizophrenia.     

Schizophrenia and amphetamine dependence. A case report

Whereas observations of psychotic disorders induced by amphetamines are common, few observations described the impact of chronic amphetamine abuse on schizophrenic patients. We report the case of a schizophrenic patient who presented with amphetamine dependence for several years, without other accompanying addiction. CASE REPORT: During his adolescence, Mr. X. gradually developed delusional beliefs of persecution and telepathy. He believed that the other pupils and teachers spoke about him in malicious terms. At the age of 23, Mr. X began to consume 60-100 mg/week of amphetamines orally. He consumed amphetamines during 7 years. The delusions, in particular the auditory hallucinations worsened after the use of amphetamines. Subsequently, he married and was declared unfit for national service due to the psychotic disorders. Mr. X received neuroleptic treatment with moderate effects on the psychotic symptoms. Between the age of 24 and 30, the patient presented persecutory, megalomanic and physical transformation beliefs, delusions of being controlled as well as auditory, somatic-tactile and visual hallucinations. At the age of 30, while he had stopped his consumption of amphetamines for 9 months, the patient, overwhelmed with the delusions, murdered his wife. He was sent in jail for 13 months, and subsequently hospitalized for one year in a high security psychiatric department and 7 years in our psychiatric department. The neuroleptic treatment was effective, particularly against the hallucinations. Following stabilisation, the symptomatology of the patient was marked by a disorganization syndrome, including prominent thought disorder, disorganized speech, associative loosening, frequent derailments and negative signs of schizophrenia, in particular affective flattening and blunting of emotional expression. When the patient was 43, a trial discharge was authorized owing to improvement of his condition. The neuroleptic treatment was switched with single-drug olanzapine therapy, 10 mg/day which improved the negative symptoms. Mr. X. resumed part-time professional activities and remarried. DISCUSSION: The patient fulfilled the DSM IV criteria for schizophrenia and for amphetamine dependence assessed using the Composite International Diagnostic Interview (CIDI). He presented, in particular, withdrawal syndrome when amphetamines were discontinued. The amphetamine consumption was followed by a marked deterioration in the delusions, particularly the hallucinations. Worsening of the positive symptoms in schizophrenic patients by amphetamines has been established in single dose studies, in particular characterized by persecutory delusions and hallucinations. On the other hand, amphetamines tend to transiently and moderately reduce the negative symptoms. Some stu-dies have shown that amphetamine consumption promoted violent acting out in non-schizophrenic subjects. In our observation, the acting out may be not related to the acute effects of these substances, since it occurred 9 months after stated discontinuation of amphetamine consumption. However, the cerebral toxicity and psycho-behavioural disturbances related to amphetamines might be prolonged after withdrawal. In non-schizophrenic patients, the existence of prolonged neurotoxicity of amphetamines and related psycho-behavioral disturbances has been suggested. The prolonged administration of amphetamines to animals produces neuro-axonal degeneration in the striatum, the frontal cortex, the nucleus accumbens and the amygdala. In human, there are some evidence of persistant deteriorations of the serotoninergic and dopaminergic systems in the caudate nucleus, the putamen and the nucleus accumbens following amphetamine consumption. CONCLUSION: The neurobiological and psycho-behavioural effects of amphetamines may be prolonged following withdrawal in both schizophrenic and non-schizophrenic patients.     

The subjective quality of life of patients with schizophrenia: influence of psychopathology and patients' expectations. A comparative study

Most studies on the quality of life (Qol) of patients with schizophrenia deal with objective living conditions and how they are perceived by hospitalized patients. The few studies that compare Qol for patients treated in part time services with the Qol of ambulatory patients do not show any significant difference in terms of subjective Qol. Some stu-dies evaluate the influence of psychopathology and needs (or expectations) on the subjective Qol in these groups of patients. Available data indicate that the general well-being is influenced by psychopathology (positive, negative or depressive symptoms) and unmet needs in ambulatory patients. They also show that subjective Qol in certain life domains (social relations, family relations, leisure, health, law and security) is influenced by negative symptoms, anxiety and depression in patients treated in part-time services. The aim of this study is to compare the objective and subjective Qol of patients with schizophrenia treated in part time services (day hospital and day care center) to the Qol of out-patients treated on a purely ambulatory basis (out patient clinic). We studied the Qol of 2 groups of 30 patients with schizophrenia (ICD 10 criteria) treated in various centers. The first group was made of ambulatory patients, the second one was constituted of patients treated in a day hospital or a day care center. Patients were matched for age, duration of illness, number of hospitalizations. The instruments used for rating were the following: Clinical Global Impression (CGI), Global Assessment of Functioning (GAF), Positive And Negative Symptoms Scale (PANSS), Drug Attitude Inventory (DAI-10). The Qol was measured with a french version of the Lancashire Quality Of Life Profile (LQOLP) (Salomé, Germain, Petitjean, Demant and Boyer, 2000). This instrument measures the objective Qol as well as the subjective Qol. It does possess satisfying psychometric properties and offers the possibility to establish Qol profiles. All Qol ratings were carried out by a clinician who was not involved in the treatment of the patients. When the 2 groups are compared our results indicate that ambulatory patients are less symptomatic, have a better level of functioning and a better objective Qol in such domains as: finances, living situation, family relations and health. There is no significant difference in terms of anxiety and depression as measured by the respective items of the PANSS. Patients treated in part-time services present higher scores of positive symptoms. Our results indicate that there is no significant difference for subjective Qol variables between the two groups, except for general well-being, that tends to be higher in ambulatory patients. When exploring the influence of clinical data on the Qol in each group, we find negative correlations in ambulatory patients between various domains of subjective Qol and illness severity (law and security, family relations, social relations, general well-being), global functioning (family relations, social relation, health) and positive symptoms (living conditions, law and security, family relations, social relations, health). In this same group, the subjective Qol for family relations is significantly correlated with several expectations in terms of Qol improvement (leisure, social relations, family relations, transport, work). In these patients, the subjective Qol for social relations is also significantly correlated with their expectations in terms of Qol improvement (work, money, lodging, affective relations, transport). There is no significant correlation between subjective Qol and expectations in patients treated in part-time services. Our results indicate that part time services treat schizophrenic patients with a lower level of global functioning and a higher level of symptom severity compared with ambulatory patients. These results confirm other studies that show no significant difference between these 2 groups in terms of subjective Qol. The subjective Qol in the field of relations (family and social) in ambulatory patients seems particularly sensitive to illness severity, positive symptoms and global functioning level. This has also been reported by other studies. In patients treated in part-time services, the subjective Qol, particularly for living conditions and security, seems sensitive to anxiety and depression. This has also been shown by other studies. Finally, our results underline the importance of patients' expectations in terms of subjective Qol, particularly in the field of relations (family and social) for ambulatory patients.     

Trouble de l’humeur unipolaire dépressif. À propos d’un cas

The authors aimed to show how difficult the nosography seems to be between unipolar depression and paraphrenia, especially when treatments (even with ECT) were poorly effective. Mrs A. presented megalomania and persecution delusions and for years lived in a chronic delusional state. She suffered from delusions after three depressive relapses but she did not show any dissociation or cognitive impairment. The mechanisms were imaginative, intuitive, without hallucinations, but with little coherence, and delusions were constantly stable. This case brings to mind paraphrenia as an evolutionary state of a persistent major depressive period. It is as if a continuum exists between different kinds of psychosis. The report concerns paraphrenia as a secondary process with thymic disorders, discusses the place of chronic delusion in the nosography, and questions the concept of single psychosis.