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Resume Quatre-vingt-dix-sept patients repondant au diagnostic de trouble de l’adaptation avec anxiete (TAA) ont ete recrutes dans cette etude multicentrique realisee en medecine generale et compares a 30 sujets temoins apparies pour l’âge et le sexe. Le diagnostic etait pose a partir de la passation du Mini-International Neuropsychiatrie Interview (MINI) completee d’une recherche standardisee des evenements stressants et d’une evaluation de la symptomatologie anxieuse au moyen de differents instruments d’evaluation : echelle de la symptomatologie anxieuse et depressive (HAD), echelle d’evaluation de l’anxiete de Hamilton (HAM-A), questionnaire sur les inquietudes du Penn-State (QIPS), inventaire d’anxiete etat de Spielberger (STAI-S), echelle d’emotionnalite positive et negative a 31 items (EPN-31). Les resultats montrent que les evenements concernant le domaine de la vie professionnelle sont les plus frequemment en cause (43 %). Sur le plan de la symptomatologie, les resultats montrent que le TAA presente un niveau d’anxiete — tant sur le plan general (physique et somatique) que des ruminations et des emotions negatives — proche des resultats obtenus avec les autres troubles anxieux, particulierement le trouble anxieux generalise. Des recherches futures permettront d’apporter les elements necessaires pour mieux connaitre le trouble et en preciser les limites diagnostiques qui restent encore un sujet a controverse, particulierement vis-a-vis de la reponse homeostatique au stress et les autres categories de troubles anxieux. Les resultats de notre etude plaident pour que cette entite sub-syndromique soit reconnue et prise en charge, particulierement en medecine generale ou elle est tres frequente.

INTRODUCTION: Toxoplasma gondii is the most common protozoan parasite in developed nations. Up to 43% of the French population may be infected, depending on eating habits and exposure to cats, and almost one third of the world human's population may be infected. Two types of infection have been described: a congenital form and an acquired form. Although the medical profession treats these latent cases as asymptomatic and clinically unimportant, results of animal studies and recent studies of personality profiles, behavior, and psychomotor performance have led to reconsider this assumption. PRECLINICAL DATA: Among rats: parasite cysts are more abundant in amygdalar structures than those found in other regions of the brain. Infection does not influence locomotion, anxiety, hippocampal-dependent learning, fear conditioning (or its extinction) and neophobia in rats. Rats' natural predator is the cat, which is also T. gondii's reservoir. Naturally, rats have an aversion to cat urine, but the parasite suppresses this aversion in rats, thus influencing the infection cycle. Tachyzoites may invade different types of nervous cells, such as neurons, astrocytes and microglial cells in the brain, and Purkinje cells in cerebellum. Intracellular tachyzoites manipulate several signs for transduction mechanisms involved in apoptosis, antimicrobial effectors functions, and immune cell maturation. Dopamine levels are 14% higher in mice with chronic infections. These neurochemical changes may be factors contributing to mental and motor abnormalities that accompany or follow toxoplasmosis in rodents and possibly in humans. Moreover, the antipsychotic haloperidol and the mood stabilizer valproic acid most effectively inhibit Toxoplasma growth in vitro with synergistic activity. CLINICAL DATA: The effects of the parasite are not due to the manipulation in an evolutionary sense but merely due to neuropathological or neuroimmunological effects of the parasite's presence. Toxoplasmosis and schizophrenia: epidemiological studies point to a role for toxoplasmosis in schizophrenia's etiology, probably during pregnancy and early life, this association being congruent with studies in animal models indicating that animal exposures of the developing brain to infectious agents or immune modulating agents can be associated with behavioral changes that do not appear until the animal reaches full maturity. Psychiatric patients have increased rates of toxoplasmic antibodies, the differences between cases and controls being greatest in individuals who are assayed near the time of the onset of their symptoms. The increase of dopamine in the brain of infected subjects can represent the missing link between toxoplasmosis and schizophrenia. Toxoplasmosis and Obsessive Compulsive Disorder (OCD): the seropositivity rate for anti-T. gondii IgG antibodies among OCD patients is found to be significantly higher than the rate in healthy volunteers. Infection of basal ganglia may be implicated in the pathogenesis of OCD among Toxoplasma seropositive subjects. Toxoplasmosis and personality: infected men appear to be more dogmatic, less confident, more jealous, more cautious, less impulsive and more orderly than others. Conversely, infected women seem warmest, more conscientious, more insecure, more sanctimonious and more persistent than others. It is possible that differences in the level of testosterone may be responsible for the observed behavioral differences between Toxoplasma-infected and Toxoplasma-free subjects. CONCLUSION: In the future two major avenues for research seem essential. On one hand, prospective studies and research efforts must still be carried out to understand the mechanisms by which the parasite induces these psychiatric disorders. On the other hand, it has not yet been demonstrated that patients with positive toxoplasmic serology may better respond to haloperidol's or valproic acid's antiparasitic activity. These results may appear as a major issue in the drug's prescribing choices and explain variability in response to the treatment of patients with schizophrenia that is not explained by the genetic polymorphism.

A striking reduction in hospital beds can be seen as the defining characteristic of mental health services in many western countries during the last 30 years. The politic of shortening hospital stays for persons with psychosis has been questioned by a number of authors. Studies of patients returning to the community compared to those remaining in institutions show not only better quality of life and larger friendship networks, but also reductions in dependence on pharmacotherapies and lower mortality rates. An interesting comparison between three contrasting mental care systems in Holland, Italy and Australia concluded not surprisingly that hospital stays are shortest where community care is more developed, although long term hospitalization will always be required for a small number of very severe patients. The general conclusion was that shorter stays work best if and only if there is high quality community care which comes into play immediately on discharge. The central issue appears to be that the beneficial effects of short stays are modulated by conditions of discharge. That is, in the absence of a planned discharge policy, patients appear to be better off staying longer, in order that a structured rehabilitation plan may be put in place. The process of deinstitutionalisation has been driven by a variety of forces. One is to reduce costs, since hospital inpatient costs are very high. Generally, between one- and two-thirds of the total health care cost of schizophrenia is for hospitalization, even in countries that have already substantially reduced their inpatient provision. Recent years have seen a trend toward mental health services provided from community-based settings for defined catchment areas. The development of these services has a heavy cost, with the opening of replacement accommodation and other community facilities and large teams. While few patients or clinicians would contest today that a return to normal community life is preferable to institutionalization, the adoption of shorter hospital stays was not an evidence-based policy and no adequate evaluation study was ever put in place to predict the social, clinical and economic consequences of this widespread practice.

Resume Au cours des dernieres annees, la plupart des pays industrialises ont mis en place, pour les patients souffrant de schizophrenie, des programmes de desinstitutionalisation s’accompagnant d’une baisse importante du nombre de lits en intrahospitalier, les soins s’orientant vers des prises en charge en extrahospitalier. Mais cette reduction des durees d’hospitalisation a de nombreuses repercussions qui sont encore mal connues. Les hospitalisations au cours d’une annee seraient plus nombreuses mais la question qui est de savoir si le nombre total de jour d’hospitalisation sur une annee a ete modifie reste non resolue. Par ailleurs, de nombreux facteurs lies aux patients et aux traitements sont impliques dans les variations de la duree de sejour. Ces facteurs sont actuellement peu pris en compte dans les prises en charge des patients. Enfin, les repercussions de ces diminutions des durees de sejours sont encore discutees. La plupart des auteurs vont dans le sens d’une amelioration de la qualite de vie avec une meilleure reinsertion socioprofessionnelle mais soulignent l’importance d’etre vigilant sur le risque suicidaire et la necessite d’un accompagnement soutenu en extrahospitalier.

Resume Le modele de la conscience des troubles dans les troubles mentaux graves propose par Amador et Strauss et le developpement corollaire de la Scale to Assess Unawareness of Mental Disorder (SUMD) constituent la reference theorique et clinique dans l’approche multidimensionnelle de l’insight. Neanmoins, cette approche repose essentiellement sur une analyse phenomenologique de ce concept. Dans la seconde partie de cette revue, nous nous proposons d’exposer l’evolution des modeles explicatifs qui tentent d’en rendre compte. Quatre approches seront decrites comme suit : les troubles de l’insight comme resultant, soit de mecanismes de defense ou d’adaptation aux stresseurs environnementaux, qui sont les premiers modeles explicatifs, de biais cognitifs de traitement de l’information, de deficits fonctionnels neuropsychologiques lies a des anomalies cerebrales notamment, prefrontales ou plus recemment, comme etant la consequence de deficits metacognitifs. Il ressort des differentes etudes qu’aucune explication unique ne semble pouvoir expliquer les deficits de l’insight. Les explications psychologiques en terme de mecanismes de defense ou d’adaptation (mecanismes de coping) aux consequences de la maladie ont ete peu etudiees et meriteraient d’etre davantage explorees. Cependant, cette approche se confronte au fait que la litterature ne rapporte aujourd’hui aucun argument en faveur d’un lien entre severite de la symptomatologie ou de l’etat emotionnel du patient schizophrene et la presence ou l’absence de la conscience des troubles. A l’oppose, les recherches en neuropsychologie et en psychologie cognitive presentent des resultats consistants permettant d’impliquer cognitivement un deficit des fonctions executives et anatomiquement des anomalies des lobes frontaux. De nouvelles etudes concernant les distorsions du traitement de l’information et la cognition sociale ouvrent actuellement de nouvelles perspectives dans ce phenomene multidimensionnel et multidetermine qu’est la conscience des troubles dans la schizophrenie.

The rational use of pharmacological treatment in generalized anxiety disorders is still a matter of debate due to the uncertainties concerning the nature, diagnostic criteria and target-symptoms of this frequent and potentially invalidating disorder. If benzodiazepines may still be prescribed for a limited amount of time (i.e. 6 to 12 weeks) due to the fluctuating nature of generalized anxiety, the chronic evolution of this disorder in most patients often justifies the long-term prescription of serotoninergic (5-HT) or dual-action (5HT-NA) antidepressants and sometimes of 5HT-la partial agonists like buspirone. Imipramine, a tricyclic antidepressant was the first to demonstrate its efficacy in carefully selected patients; however, due to the side-effects of this molecule recent guidelines based on controlled clinical trials, suggest to use either serotonergic antidepressants (SSRIs) or venlafaxine as a first-line treatment of generalized anxiety disorders. Because of its pharmacological profile buspirone remains however a useful option in patients with cognitive or addictive problems, especially alcoholics. If most SSRIs have demonstrated efficacy over placebo, head to head comparisons remain limited except for escitalopram which appear better tolerated than paroxetine in this indication. More recently, an anticonvulsant, pregabaline also demonstrated its efficacy in several clinical trials but the symptomatic profile of generalized anxiety patients likely to respond to this GABA analog compared to other psychotropic treatments remain to be established. The traditional use of other psychotropic agents such as hydroxyzine, an H1 histaminergic receptor antagonist, is only supported by limited scientific data; this is also the case of sedative typical antipsychotics which benefit/risk ratio should be carefully evaluated before being prescribed to generalized anxiety patients resistant to other psychotropic agents. However, the possible use of atypical antipsychotics with a better tolerance profile than the typical ones in this indication is presently under investigation in several countries. At last it is important to realize that most clinical trials in this field only include patients with non-comorbid generalized anxiety and that their conclusion may not always be generalizable to most psychiatric patients who are usually characterized by a high rate of comorbidity. In this population the indication of specific pharmacological treatments should rely on a careful evaluation of the patients drug treatment history, of the duration, evolution and functional consequences of their symptoms and of the nature of their possible comorbidity. The treatment of resistant generalized anxiety disorders remains a question for future research but the use of imipramine or sedative antipsychotics could be an option when other treatments have failed to induce any improvement.

Introduction – Les troubles neuro-psychiatriques constituent une des principales causes de morbidite et d'incapacites liees au vieillissement. Le projet Esprit a pour but d'etudier l'etiologie complexe des troubles psychiatriques chez le sujet âge pour une meilleure prise en charge. Objectifs – 1) determiner la prevalence (en actuel et au cours de la vie) et l'incidence des troubles psychiatriques en population generale âgee ; 2) evaluer les facteurs de risque de ces troubles, leur poids relatif et leurs interactions ; 3) etudier l'heterogeneite clinique ; 4) estimer les probabilites de transition vers un etat subsyndromique ou vers la maladie ; 5) construire des modeles etiologiques predictifs. Methode - L'etude longitudinale Esprit porte sur 1863 personnes non institutionnalisees de 65 ans et plus, recrutees par tirage au sort sur listes electorales. Depuis l'inclusion en 1999, ces sujets ont deja ete revus deux fois a 2 ans d'intervalle. Ils ont ete soumis a differents questionnaires (socio-demographiques, antecedents medicaux, incapacites, expositions, survenue d'evenements traumatiques), examens neurologiques ainsi qu'a un enregistrement polysomnographique a domicile. Une DNAtheque et une serotheque ont ete constituees et certains parametres biochimiques doses (lipides, cortisol...). La pathologie psychiatrique a ete evaluee au cours d'un entretien structure, le MINI (fonde sur les criteres diagnostiques du DSM IV), la symptomatologie depressive par la CES-D et le niveau d'anxiete via l'echelle de Spielberger. D'autres questionnaires ont ete utilises afin d'evaluer la personnalite colerique (Spielberger-anger), l'impulsivite (Barratt), l'agressivite (Buss-Durkee) et la survenue de traumatismes dans l'enfance. Resultats - Les troubles psychiatriques sont frequents chez les sujets âges et au cours de leur vie ils ont touche pres d'une personne sur deux. La prevalence des troubles actuels est elevee notamment pour les phobies (10,7%), l'anxiete generalisee (4,6%) et les ideations suicidaires (9,8%). Pour la plupart des troubles psychiatriques, les prevalences sont pres de 2 fois plus elevees chez la femme. Nos premieres analyses montrent l'importance de certains facteurs de risque jusque-la peu explores, facteurs environnementaux comme les evenements de vie traumatiques ou facteurs biologiques comme le statut hormonal au cours de la vie reproductive ou le role des systemes de regulation du stress (e.g. activite secretoire de l'axe HPA). L'insomnie est egalement un facteur de risque de troubles depressifs ou anxieux. Conclusion - L'etude longitudinale Esprit constitue une base de donnees relativement exhaustive sur les troubles psychiatriques en population generale francaise âgee. L'approche multifactorielle (prenant en compte facteurs environnementaux, psychosociaux, biologiques, genetiques, pharmacologiques ou cliniques et leurs interactions) devrait permettre la construction de modeles etiologiques complexes susceptibles d'etre valides au sein d'etudes cliniques et ouvrir de nouvelles perspectives dans le champ de la sante mentale du sujet âge.