Search

OBJECTIVE To investigate how medical students' empathy is related to their mental health and burnout. METHODS This cross-sectional study included 886 medical students from curriculum years 1-6. The cognitive, affective, and behavioural dimensions of empathy were measured with self-report questionnaires and an emotion recognition test. Regressions were used to test the relationship between the empathy dimensions, depressive symptoms, anxiety, and burnout as well as the influence of curriculum year and gender. RESULTS Cognitive and behavioural empathy were significantly related to less mental health issues and burnout, whereas affective empathy was related to more mental health issues and burnout. Students in later curriculum years reported less mental health issues and burnout than students in earlier years, whereas no systematic difference could be observed for empathy. Female students reported more mental health issues and burnout as well as higher empathy, except for behavioural empathy for which male students scored higher. CONCLUSIONS The cognitive, affective, and behavioural dimensions of empathy were differently related to the mental health and burnout of medical students. Students presenting mental health issues or burnout might have more difficulty to adapt their behaviour in social situations and keep a certain distance when taking others' perspective.

Background: Depression may contribute to neurocognitive impairment (NCI) in people with HIV (PWH). Attributing NCI to depression rather than to HIV is complicated as depression may be both a causal factor and an effect of NCI. This study aimed to determine the association between depressive symptoms and NCI among PWH with well-controlled infection. Methods: The Neurocognitive Assessment in the Metabolic and Ageing Cohort study is an ongoing, prospective, longitudinal study of PWH aged ≥45 years old nested within the Swiss HIV Cohort Study. Neurocognitive Assessment in the Metabolic and Ageing Cohort study participants underwent neurocognitive assessment and grading of depressive symptoms using the Centre for Epidemiological Studies Depression Scale. Neurocognitive impairment categories were defined using Frascati criteria. Participants with NCI related to neurological or psychiatric confounders other than depression were excluded. The cross-sectional association between the Centre for Epidemiological Studies Depression score and neurocognitive impairment was examined taking Centre for Epidemiological Studies Depression score as a continuous variable and then as a binary variable using two score thresholds, 16 and 27. Results: Excluding 79 participants with confounding factors, 902 participants were studied: 81% were men; 96% had plasma viral loads

Liaison psychiatry consists of an activity of consultation for patients affected by somatic diseases and of an activity of liaison for clinicians. The liaison work can take different forms, such as teaching of patient-physician relationship, supervision or support. To illustrate psychiatric liaison research, we present four studies conducted in our service, which explore (a) the relations between medical students' mental health and their interpersonal competence, (b) the dreams of medical students and what they reveal of their subjectivities, (c) the stakes for primary care practitioners when asking for a specialist's consult, and (d) the situated clinical practice. These studies contribute to nourish psychiatric liaison, which can use their results for training or support of clinicians.La psychiatrie de liaison comprend une activité de consultation auprès des patient·es en soins somatiques et une activité de liaison auprès des clinicien·nes. La liaison psychiatrique peut prendre des formes diverses, tels l’enseignement de la relation soignant·e-soigné·e, des supervisions ou le soutien d’équipe. Dans cet article, nous présentons 4 études menées dans notre service qui s’intéressent : a) aux liens entre la santé mentale des étudiant·es en médecine et leurs compétences interpersonnelles ; b) à leurs rêves et à ce qu’ils révèlent de leur subjectivité ; c) aux enjeux de l’appel aux spécialistes pour les médecins de premier recours et d) à la pratique clinique en situation. Ces études contribuent à nourrir le travail de liaison qui peut s’appuyer sur leurs résultats dans la formation et le soutien des soignant·es.

BackgroundEmpathy in primary care settings has been linked to improved health outcomes. However, the operationalisation of empathy differs between studies, and, to date, no study has concurrently compared affective, cognitive, and behavioural components of empathy regarding patient outcomes. Moreover, it is unclear how gender interacts with the studied dimensions.AimTo examine the relationship between several empathy dimensions and patient-reported satisfaction, consultation’s quality, and patients’ trust in their physicians, and to determine whether this relationship is moderated by a physician’s gender.Design and settingAnalysis of the empathy of 61 primary care physicians in relation to 244 patient experience questionnaires in the French-speaking region of Switzerland.MethodSixty-one physicians were video-recorded with two male and two female patients. Six different empathy measures were assessed: two self-reported measures, a facial recognition test, two external observational measures, and a Synchrony of Vocal Mean Fundamental Frequencies (SVMFF), measuring vocally coded emotional arousal. After the consultation, patients indicated their satisfaction with, trust in, and quality of the consultation.ResultsFemale physicians self-rated their empathic concern higher than their male counterparts did, whereas male physicians were more vocally synchronised (in terms of frequencies of speech) to their patients. SVMFF was the only significant predictor of all patient outcomes. Verbal empathy statements were linked to higher satisfaction when the physician was male.ConclusionGender differences were observed more often in self-reported measures of empathy than in external measures, indicating a probable social desirability bias. SVMFF significantly predicted all patient outcomes, and could be used as a cost-effective proxy for relational quality.

Objective This paper reports on the continuation of an initial study that demonstrated the effectiveness, as rated by experts, of an undergraduate training in breaking bad news (BBN) using simulated patient (SP) and individual feedback. The current study aimed to further explore whether such an individualized training approach also has positive effects from the perspective of the patient, using the analogue patient (AP) methodology. Methods A subsample of 180 videotaped interviews with SPs were selected from the existing data set (N = 332), consisting of 60 pre- and post-training interviews of students benefiting from the individualized approach (intervention group) and 60 post-training interviews of students having small-group SP training and collective supervision (comparison group). Sixty-eight APs-healthy untrained observers-were asked to view the videotaped interviews while "putting themselves in the patient's shoes" and evaluate satisfaction, trust, liking, and the competence of medical students. Results The intervention group students improved significantly from pre- to post-training on several dimensions evaluated by the APs: patient satisfaction, trust in the student, liking of the student, and perceived medical competence. Increased AP satisfaction was related to different changes in students' communication behavior between pre- and post-training: increase in positive talk, emotional responsiveness, biomedical and psychosocial information, and biomedical counseling. There was no significant between-group difference at post-training. Conclusions AP evaluation showed significant improvement between pre- and post-training. This result provides additional and complementary evidence of the positive effects of individualized training in BBN from the AP perspective, a proxy of (real) patients.

We prospectively followed a cohort of 26 subjects for an average period of 41 months who benefited from occipital nerve stimulation (ONS) in the context of chronic refractory headaches. In 17 patients treated, the frequency of headache decreased, and quality of life scores improved significantly. Among these patients, the "very good" response rate was 34 %. In this cohort, treatment-related adverse events are relatively common (42 %) but not severe. While it is difficult to anticipate the risk factors for non-response to treatment, we estimate that the risk of failure may not be related to the duration of the disease, but rather to the number of different preventives attempted prior to ONS.Nous avons suivi prospectivement durant une période d’en moyenne 41 mois une cohorte de 26 patients romands qui ont bénéficié d’une stimulation du nerf occipital (ONS) dans le cadre de céphalées chroniques réfractaires. Chez 17 patients non explantés, la fréquence des céphalées a diminué et les scores de qualité de vie se sont améliorés de façon significative. Parmi ces patients, le taux de « très bonne » réponse est de 34 %. On constate dans cette cohorte que les effets indésirables liés au traitement sont relativement courants (42 %) mais non sévères. Même s’il est difficile d’anticiper les facteurs de risque de non-réponse au traitement, nous estimons que la probabilité d’échec ne serait pas corrélée à la durée de la maladie mais plutôt au nombre de traitements préventifs tentés avant l’ONS.

Patients suffering from burns, especially when they are extensive, benefit from specialized multidisciplinary care at the Lausanne University Hospital. In recent decades, major advances in medical research have made possible a significant reduction in morbidity and mortality. At the same time, the psychological needs of those patients have continued to increase, with the need for professional and individualized care. Intervention by the liaison psychiatrist face the challenge of integration within the complex somatic care.Au CHUV, le patient victime de brûlures, notamment lorsque celles-ci sont étendues, bénéficie d’une prise en charge pluridisciplinaire spécialisée. Ces dernières décennies, des avancées majeures au niveau de la recherche médicale ont rendu possible une réduction conséquente de la morbidité et de la mortalité. En parallèle, les besoins psychologiques de cette patientèle n’ont eu de cesse d’augmenter, avec par conséquent la nécessité d’un accompagnement professionnel et individualisé, dont l’articulation reste parfois complexe avec l’ensemble de la prise en charge somatique.

Objective The present study explores students’ perspective on the added value of a virtual patient (VP) simulation as part of a breaking bad news training in undergraduate medical education. Methods The VP simulation allows trying out and practicing different ways of disclosing a cancer diagnosis to a VP (avatar) and to react to emotionally-laden patient statements with the opportunity of self-observation through video recording. After testing the simulation, 23 students shared their experience in focus groups analyzed using thematic analysis. Results Self-observation is the most valued feature of the simulation, because it enables users to reflect on their behaviors and adjust them. The competences developed are otherwise technical (e.g., organization of information) and concern less interactional competences. Areas for improvement of the simulation are the interactivity, quality, and diversity of the VPs. Conclusion The findings show that VP simulations help develop technical communication competences and are best suited as add-ons to other forms of training, in which relational aspects can be targeted. Self-observation is especially valued because it allows for a critical view regarding one’s own communication behaviors in a stress-free environment. Practice implications The proposed simulation is beneficial as an add-on to lectures, supervision, and simulated patient interviews.

Contexte: Les symptomes neurologiques fonctionnels (non expliques par une cause structurelle ou pathologique) s'observent dans environ 30% des consultations ambulatoires en neurologie. Anciennement designes par le terme d'Hysterie et classiquement associes a des stress d'ordre psychologique, ces troubles se definissent actuellement par une incompatibilite avec une affection neurologique mise en evidence a l'examen clinique. En effet, la nouvelle classification du DSM-5 insiste sur cet aspect du diagnostic qui necessite la mise en evidence de signes dit « positifs » lors de l'examen clinique. Dans ce contexte, il est important de pouvoir etablir la validite de ces signes. Objectif: Le but de cette etude prospective est de valider les signes du sternocleidomastoidien et du peaucier, des signes peu etudies et dont la valeur scientifique n’est pas encore solide, en determinant leur specificite et sensibilite, seuls et combines. Methode: 30 patients presentant un diagnostic avere de troubles neurologiques fonctionnels (base sur les criteres du DSM-5) et 40 patients souffrant d’une lesion organique etablie ont ete inclus de maniere prospective. Les patients presentaient tous une paresie d’un membre mesuree sur l’echelle de cotation de la force (Medical Research Council Scale for muscle strength) a

Psychogenic polydipsia, as well referred to as « potomania », is a clinical entity that can be found in psychiatric as well as in physical care settings. Its diagnosis is based on the detection of an excessive fluid intake along with a polyuria, after excluding any potential somatic cause of this clinical presentation. Given the different somatic complications and care complexity, early detection and multidisciplinary interventions are necessary. This article offers a literature review on this topic.La polydipsie psychogène, également dénommée « potomanie », est une entité clinique que l’on rencontre en milieu psychiatrique, ainsi qu’en milieu somatique. Son diagnostic se base sur la détection d’une consommation excessive d’eau et d’une polyurie, après exclusion de toute cause somatique pouvant être à l’origine du tableau clinique. Vu les diverses complications somatiques et la complexité de la prise en charge, la nécessité de la détection précoce et d’une approche pluridisciplinaire est primordiale. Cet article propose une revue de la littérature scientifique sur ce sujet.

This article reports on what is at work during individual supervision of medical students in the context of teaching breaking bad news (BBN). Surprisingly, there is a relative lack of research and report on the topic of supervision, even though it is regularly used in medical training. Building on our research and teaching experience on BBN at the undergraduate level, as well as interviews of supervisors, the following key elements have been identified: learning objectives (e.g., raising student awareness of structural elements of the interview, emotion (patients and students) handling), pedagogical approach (being centered on student's needs and supportive to promote already existing competences), essentials (e.g., discussing skills and examples from the clinical practice), and enhancing reflexivity while discussing specific issues (e.g., confusion between the needs of the patient and those of the student). Individual supervision has been identified as crucial and most satisfactory by students to provide guidance and to foster a reflexive stance enabling them to critically apprehend their communication style. Ultimately, the challenge is to teach medical students to not only connect with the patient but also with themselves.

Team supervision is an important task in consultation liaison psychiatry. Supervision allows to exchange on a clinical situation with many different objectives that we describe here. The integration of a plurality of views on a situation, as well as the support of caregivers interpersonal skills are among the goals of utmost importance. Based on our experiences in different care settings of a university hospital, we propose some landmarks to guide the caregivers involved in this task renewed with each team encountered.La supervision d’équipes de soins par les intervenants de psychiatrie de liaison est une tâche importante au sein de l’activité de Consultation et Liaison. La supervision, dans ce qu’elle a d’essentiel, ouvre un espace de parole dont nous allons décrire les objectifs principaux. La mise en commun d’une pluralité de regards sur une situation, ainsi que le soutien des compétences interpersonnelles des soignants, constituent à nos yeux les objectifs prioritaires. Sur la base de nos expériences dans différents lieux de soins d’un hôpital universitaire, nous proposons quelques points de repère pour guider les intervenants qui se mobilisent dans cette tâche dont les contours sont renouvelés avec chaque équipe rencontrée.

Training is a central issue for consultation-liaison (C-L) psychiatrists and specialists in psychosomatic medicine (PM), firstly for their own education. There is a wide variety of training of residents and fellows in different countries. Guidelines for training were developed and agreed in the USA, in Australia and New Zealand, and in Europe.

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are both effective treatments for some patients with obsessive-compulsive disorder (OCD), yet little is known about the neurochemical changes related to these treatment modalities. Here, we used positron emission tomography and the α-[11C]methyl-l-tryptophan tracer to examine the changes in brain regional serotonin synthesis capacity in OCD patients following treatment with CBT or SSRI treatment. Sixteen medication-free OCD patients were randomly assigned to 12 weeks of either CBT or sertraline treatment. Pre-to-post treatment changes in the α-[11C]methyl-l-tryptophan brain trapping constant, K* (ml/g/min), were assessed as a function of symptom response, and correlations with symptom improvement were examined. Responders/partial responders to treatment did not show significant changes in relative regional tracer uptake; rather, in responders/partial responders, 12 weeks of treatment led to serotonin synthesis capacity increases that were brain-wide. Irrespective of treatment modality, baseline serotonin synthesis capacity in the raphe nuclei correlated positively with clinical improvement. These observations suggest that, for some patients, successful remediation of OCD symptoms might be associated with greater serotonergic tone.

The objective was to compare a brief interdisciplinary psychotherapeutic intervention to standard care as treatments for patients recently diagnosed with severe motor conversion disorder or nonepileptic attacks.This randomized controlled trial of 23 consecutive patients compared (a) an interdisciplinary psychotherapeutic intervention group receiving four to six sessions by a consultation liaison psychiatrist, the first and last sessions adding a neurological consultation and a joint psychiatric and neurological consultation, and (b) a standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dissociation Questionnaire (SDQ-20), Clinical Global Impression scale, Rankin scale, use of medical care, global mental health [Montgomery and Asberg Depression Rating Scale, Beck Depression Inventory, mental health component of Short Form (SF)-36] and quality of life (SF-36). We calculated linear mixed models.Our intervention brought a statistically significant improvement of physical symptoms [as measured by the SDQ-20 (P.02) and the Clinical Global Impression scale (P=.02)] and psychological symptoms [better scores on the mental health component of the SF-36 (P.05) and on the Beck Depression Inventory (P.05)] and a reduction in new hospital stays after intervention (P.05).A brief psychotherapeutic intervention taking advantage of a close collaboration with neurology consultants in the setting of consultation liaison psychiatry appears effective.

Introduction Gestational diabetes mellitus (GDM) carries prenatal and perinatal risk for the mother and her offspring as well as longer-term risks for both the mother (obesity, diabetes, cardiovascular disease) and her child (obesity, type 2 diabetes). Compared with women without GDM, women with GDM are twice as likely to develop perinatal or postpartum depression. Lifestyle interventions for GDM are generally limited to physical activity and/or nutrition, often focus separately on the mother or the child and take place either during or after pregnancy, while their results are inconsistent. To increase efficacy of intervention, the multifactorial origins of GDM and the tight link between mental and metabolic as well as maternal and child health need to be heeded. This calls for an interdisciplinary transgenerational approach starting in, but continuing beyond pregnancy. Methods and analysis This randomised controlled trial will assess the effect of a multidimensional interdisciplinary lifestyle and psychosocial intervention aimed at improving the metabolic and mental health of 200 women with GDM and their offspring. Women with GDM at 24–32 weeks gestational age who understand French or English, and their offspring and partners can participate. The intervention components will be delivered on top of usual care during pregnancy and the first year postpartum. Metabolic and mental health outcomes will be measured at 24–32 weeks of pregnancy, shortly after birth and at 6–8 weeks and 1 year after childbirth. Data will be analysed using intention-to-treat analyses. The MySweetHeart Trial is linked to the MySweetHeart Cohort (clinicaltrials.gov/ct2/show/NCT02872974). Ethics and dissemination We will disseminate the findings through regional, national and international conferences and through peer-reviewed journals. Trial registration number NCT02890693; Pre-results.

IntroductionGestational diabetes mellitus (GDM) carries prenatal and perinatal risk for the mother and her offspring as well as longer-term risks for both the mother (obesity, diabetes, cardiovascular disease) and her child (obesity, type 2 diabetes). Compared with women without GDM, women with GDM are twice as likely to develop perinatal or postpartum depression. Lifestyle interventions for GDM are generally limited to physical activity and/or nutrition, often focus separately on the mother or the child and take place either during or after pregnancy, while their results are inconsistent. To increase efficacy of intervention, the multifactorial origins of GDM and the tight link between mental and metabolic as well as maternal and child health need to be heeded. This calls for an interdisciplinary transgenerational approach starting in, but continuing beyond pregnancy.Methods and analysisThis randomised controlled trial will assess the effect of a multidimensional interdisciplinary lifestyle and psychosocial intervention aimed at improving the metabolic and mental health of 200 women with GDM and their offspring. Women with GDM at 24–32 weeks gestational age who understand French or English, and their offspring and partners can participate. The intervention components will be delivered on top of usual care during pregnancy and the first year postpartum. Metabolic and mental health outcomes will be measured at 24–32 weeks of pregnancy, shortly after birth and at 6–8 weeks and 1 year after childbirth. Data will be analysed using intention-to-treat analyses. TheMySweetHeart Trialis linked to theMySweetHeart Cohort(clinicaltrials.gov/ct2/show/NCT02872974).Ethics and disseminationWe will disseminate the findings through regional, national and international conferences and through peer-reviewed journals.Trial registration numberNCT02890693; Pre-results.

Motor conversion disorder (CD) entails genuine disturbances in the subjective experience of patients who maintain they are unable to perform a motor function, despite lack of apparent neurological damage. Abilities by which individuals assess their own capacities during performance in a task are called metacognitive, and distinctive impairment of such abilities is observed in several disorders of self-awareness such as blindsight and anosognosia. In CD, previous research has focused on the recruitment of motor and emotional brain systems, generally linking symptoms to altered limbic-motor interactions; however, metacognitive function has not been studied to our knowledge. Here we tested ten CD patients and ten age-gender matched controls during a visually-guided motor paradigm, previously employed in healthy controls (HC), allowing us to probe for motor awareness and metacognition. Participants had to draw straight trajectories towards a visual target while, unbeknownst to them, deviations were occasionally introduced in the reaching trajectory seen on the screen. Participants then reported both awareness of deviations and confidence in their response. Activity in premotor and cingulate cortex distinguished between conscious and unconscious movement corrections in controls better than patients. Critically, whereas controls engaged the left superior precuneus and middle temporal region during confidence judgments, CD patients recruited bilateral parahippocampal and amygdalo-hippocampal regions instead. These results reveal that distinct brain regions subserve metacognitive monitoring for HC and CD, pointing to different mechanisms and sources of information used to monitor and form confidence judgments of motor performance. While brain systems involved in sensory-motor integration and vision are more engaged in controls, CD patients may preferentially rely on memory and contextual associative processing, possibly accounting for how affect and memories can imbue current motor experience in these patients.

Les troubles dissociatifs au sens de la classification internationale des maladies de l’OMS (CIM-10) appartiennent aux troubles fonctionnels, qui constituent encore aujourd’hui une grande enigme pour la medecine. Dans cet article, nous nous centrons sur les correlats neurobiologiques des troubles disso-ciatifs moteurs tels qu’ils peuvent etre investigues au travers des nouvelles techniques en neuro-imagerie fonctionnelle. Il faut souligner qu’il y a eu etonnamment peu d’etudes conduites a ce jour, en comparaison avec celles menees pour des troubles psychiatriques tels que la depression ou la schizophrenie, probablement en lien a une clinique plus difficile a cerner, heterogene, et frontiere entre psychiatrie et neurologie. La recherche actuelle semble demontrer, un siecle apres Charcot et Freud, que les troubles moteurs dissociatifs (de conversion) sont en effet associes a une « lesion fonctionnelle dynamique » du systeme nerveux central. Ces phenomenes impliquent des regions liees aux symptomes eux-memes (par exemple moteurs), ainsi que plusieurs regions prefrontales, limbiques et de la ligne ventro-mediane. Le cortex prefrontal ventro-median implique dans les representations de soi, de concert avec le recrutement de regions limbiques comme l’amygdale, viendraient moduler le systeme moteur. Un tel modele est compatible avec la notion freudienne de conversion.

ObjectiveTo evaluate the efficacy of an early multidisciplinary (neurology and psychiatry) intervention for conversion disorder (CD).MethodsConsecutive patients newly diagnosed with CD from 2005 to 2007 were compared to a control group of newly diagnosed CD patients receiving usual care. At 3 years, a questionnaire evaluated self‐rated subjective outcome, symptom severity, SF‐36 scores, employment status and medical care use.ResultsData from 12 cases (mean age 25.5 ± 8.2; 9 females) and 11 controls (mean age 34.7 ± 13.5; 10 females) showed that 83% of cases had a good subjective outcome (symptom improved or cured) when only 36% of controls had a good outcome (p < 0.05). Cases significantly improved their SF‐36 scores on subscales involving physical complaints compared to controls. A minority (20%) of cases reduced or ceased professional activity when 70% of controls did (p < 0.001). Only 16% of cases sought further medical advice for the initial symptom when 73% of controls did. Both groups accepted psychiatric referrals (83% of cases and 73% of controls) and found it beneficial.ConclusionsEarly intervention involving both neurologists and psychiatrists is effective for CD in alleviating physical complaints, reducing sick leave and health care use.

In addition to providing psychiatric care to patients with somatic diseases, liaison psychiatry plays an important role in the teaching of the relational aspects of the clinical encounter between patients and clinicians. This series of three articles proposes a critical reflection on this topic, and presents examples of undergraduate and postgraduate teaching programs developed by the psychiatric liaison service at Lausanne University Hospital. This article describes the general context of undergraduate teaching, and focuses on our training with simulated patient of a breaking bad news situation, taking place during the fourth year of medical studies. Individual supervision, provided for each student, is discussed as a relatively unique opportunity within the curriculum of medical school.En plus des soins psychiatriques qu’elle propose aux patients pris en charge pour des problèmes de santé physique, la psychiatrie de liaison joue un rôle important dans la formation des médecins aux aspects relationnels de la pratique clinique. Dans cette série de trois articles, nous proposons d’une part une réflexion critique sur ces enjeux, et nous présentons, d’autre part, certaines des formations mises en place par le Service de psychiatrie de liaison du CHUV.Cet article évoque le contexte de l’enseignement prégradué et décrit l’exemple d’un enseignement pratique, centré sur la situation d’annonce de mauvaise nouvelle, destiné aux étudiants en médecine en 4

This continuation study evaluates from the patient perspective the effectiveness of an individualized training in Breaking Bad News (BBN) in undergraduate medical education. Our previous study showed that medical students benefited from a simulated patient (SP) encounter, followed by an individual supervision based on the filmed SP encounter, with a significant increase of their communication performance in BBN post-training as rated by experts. This continuation study aims to (i) explore the patient perspective on students’ improved communication behaviour and (ii) better understand the benefits of such trainings.

Objective Training medical students in breaking bad news (BBN) in oncology may be key to improve patient care in an area where many physicians tend to be uncomfortable. Given the lack of evidence in the literature, this study aimed to assess empirically the impact of two teaching strategies to prepare students for the task of BBN in oncology: one-to-one simulated patient (SP) training with individual feedback (intervention group) vs. small-group SP training with collective feedback (comparison group). Methods Fourth-year students (N = 236) were randomly assigned to the intervention or comparison group. SP videotaped interviews were analyzed with respect to: BBN communication performance, rated using the Calgary-Cambridge checklist of teaching objectives for BBN; verbal interaction behaviors, coded with the Roter Interaction Analysis System; and seven nonverbal behaviors. Results Students in the intervention group scored significantly higher after than before the training on the overall evaluation of the interview (P

Psychogenic neurologic disorders are common in clinical practice, but their underlying mechanisms are largely unknown. These disorders represent “functional” neurologic deficits, such as amnesia, paralysis, or somatosensory losses that are not explained by organic lesions in the nervous system but arise in the context of “psychogenic” stress or emotional conflicts. Therefore, even though the pathophysiology of the spectrum of these disorders is unclear, the patients fall in different psychiatric categories with possible psychological and psychodynamic etiologies. Recently, this topic has received increasing attention. Indeed, several studies have used functional brain imaging techniques in an attempt to identify specific neurologic hallmarks associated with conversion disorder and its multiple clinical manifestations. 1–3 For psychogenic dystonia, the clinical distinction between an organic and psychogenic origin is even more difficult because they frequently overlap. 4 Published studies remain inconclusive so far, but promising theories have been proposed. These theories are based on active inhibition of motor areas by limbic brain areas, 5–7 and on the concept of impaired movement conceptualization, 8 such as in psychogenic paralysis. Interestingly, hypnosis-induced paresis—a model of “functional” paresis— of the left leg showed enhanced cerebral blood flow in the right orbitofrontal and right anterior cingulate cortices (limbic system). This is accompanied by decreased activation of the right primary motor cortex in a positron emission tomography (PET) study. Both observations support the concept of modulation of sensorimotor representations by affective and stressful events via increased limbic input. 9 Following up on this concept, we present a clinical long-term follow up of Mrs. B, a 47 year-old female, who progressively developed psychogenic tetraparesis and bilateral upper limb dystonia. Both completely returned to normal under two specific conditions: initially under a short propofol-induced sedation, and later at an advanced stage of hepatic encephalopathy. We hypothesize that these two conditions interfered with the abnormal limbic input, allowing for the alleviation of the symptoms.

Psychogenic non epileptic seizures (PNES) look like epilepsy, but are not accompanied by the electrophysiological alterations found in epilepsy. The diagnosis requires a complex process at the interface between neurology and psychiatry. Diagnostic restitution to the patient and treatment of the condition should be a collaboration between neurologist and psychiatrist including as much as possible a general practitioner. Vulnerability and triggering psycho-social factors, as well as frequent psychiatric co morbidity implicate that psychiatric-psychological care is needed in a majority of situations, however this cannot be done without a strong "somatic back-up" with rapid access to somatic facility for advice and care when needed. The neurological presentation of the disease, with psychiatric causes underlying the condition, bear the risk for the patient that neither neurological nor psychiatric care is offered. Current knowledge about the condition is still scarce, but the field is progressively enriched by studies with stronger methodologies. Recent neuroimaging studies open fascinating avenues on our understanding of the interplay between emotional regulation, representation of the self, and dissociative symptoms. These new avenues help our understanding of these disorders which challenge classical frontiers between neurology and psychiatry. In this paper we try to formulate a framework for the care of patient with dissociative disorders including NEPS.

Chronic pain represents one of the most important public health problems and, in addition to classical analgesics, antidepressants are an essential part of the therapeutic strategy. This article reviews available evidence on the efficacy and safety of antidepressants in major chronic pain conditions; namely, neuropathic pain, headaches, low back pain, fibromyalgia, irritable bowel syndrome (IBS) and cancer pain. Studies, reviews and meta-analyses published from 1991 to March 2008 were retrieved through MEDLINE, PsycINFO and the Cochrane database using numerous key words for pain and antidepressants. In summary, evidence supports the use of tricyclic antidepressants in neuropathic pain, headaches, low back pain, fibromyalgia and IBS. The efficacy of the newer serotonin and norepinephrine reuptake inhibitors is less supported by evidence, but can be recommended in neuropathic pain, migraines and fibromyalgia. To date, evidence does not support an analgesic effect of serotonin reuptake inhibitors, but beneficial effects on well-being were reported in several chronic pain conditions. These results are discussed in the light of current insights in the neurobiology of pain, the reciprocal relationship between pain and depression, and future developments in this field of research.

Background: Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is a relatively newly identified autoimmune neuropsychiatric disorder that predominantly affects children and young adults. Although psychiatric symptoms are highly prevalent and frequently severe, it has mainly been reported in neurological, but not psychiatric, literature. Understanding this form of encephalitis, its quick diagnosis and which treatment to provide are of utmost importance for consultation-liaison (C-L) psychiatrists. The aim of this paper was to describe a case of anti-NMDAR encephalitis with severe psychiatric manifestations, who showed impressive recovery but required intensive involvement of the C-L psychiatry team. We emphasise the behavioural aspects, psychiatric symptoms and challenges faced by the CL consultant across the different phases of the treatment. Methods: We report the different treatment phases for a young woman with anti-NMDAR encephalitis who developed severe neuropsychiatric symptoms, with a focus on the role and challenges faced by the C-L psychiatrist. The literature is reviewed for each of these challenges. Results: This case illustrated that even extremely severely affected patients may show impressive recovery, but require long lasting psychiatric care. C-L psychiatrists are faced with numerous challenges where only little literature is available. Conclusion: C-L psychiatrists play a pivotal role throughout the multidisciplinary care of patients with anti-NMDAR encephalitis and should be informed about this entity.

Objective Delirium is highly prevalent in general hospitals but remains underrecognized and undertreated despite its association with increased morbidity, mortality, and health services utilization. To enhance its management, we developed guidelines covering all aspects, from risk factor identification to preventive, diagnostic, and therapeutic interventions in adult patients. Methods Guidelines, systematic reviews, randomized controlled trials (RCT), and cohort studies were systematically searched and evaluated. Based on a synthesis of retrieved high-quality documents, recommendation items were submitted to a multidisciplinary expert panel. Experts scored the appropriateness of recommendation items, using an evidence-based, explicit, multidisciplinary panel approach. Each recommendation was graded according to this process' results. Results Rated recommendations were mostly supported by a low level of evidence (1.3% RCT and systematic reviews, 14.3% nonrandomized trials vs. 84.4% observational studies or expert opinions). Nevertheless, 71.1% of recommendations were considered appropriate by the experts. Prevention of delirium and its nonpharmacological management should be fostered. Haloperidol remains the first-choice drug, whereas the role of atypical antipsychotics is still uncertain. Conclusions While many topics addressed in these guidelines have not yet been adequately studied, an explicit panel and evidence-based approach allowed the proposal of comprehensive recommendations for the prevention and management of delirium in general hospitals.

It is thanks to great advances in the field of neuroscience, which allowed identifying dysfunctions in neural networks as the cause of many psychiatric and neurological diseases, that the number of indications for deep brain stimulation (DBS) has quickly expanded. Although the precise mechanism of action of DBS is unknown, this method probably works by influencing the neural pathways through stimulation of deep targeted brain nuclei which behave as "hubs" in these complex networks. Currently, there is growing interest on DBS' potential benefit, especially in the psychiatric field. This review intends to tackle the current and future psychiatric and neurological indications of DBS.

To investigate the association between early depressive behavior after stroke onset and occurrence of poststroke depression (PSD) at 3- and 12-month follow-up evaluations.The study prospectively included 273 patients with first-ever single uncomplicated ischemic stroke. In the stroke unit, nurses scored crying, overt sadness, and apathy daily using an observational method to include patients with comprehension deficits. The Barthel Index was used to assess disability. Follow-up evaluation at months 3 and 12 included psychiatric assessment based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition.Crying (19.8%), overt sadness (50.5%), and apathy (47.6%) were observed. Of the patients observed crying, 4 showed pathologic crying, 19 emotionalism, and 12 catastrophic reactions. Crying and overt sadness, but not apathy, were associated with a subjective experience of depression (p0.05). Thirty of 52 (58%) patients observed crying, 12 of 19 (63%) patients with emotionalism, and 5 of 12 (41%) patients with catastrophic reactions developed PSD within the first year. Multiple logistic regression analysis showed that only severe functional disability (odds ratio [OR], 4.31; 95% CI, 2.41 to 7.69), crying behaviors (OR, 2.66; 95% CI, 1.35 to 5.27), and an age68 years (OR, 2.32; 95% CI, 1.30 to 4.13) were (p0.05) predictors of late PSD development (13% of the variance).In the stroke unit, crying and overt sadness are more reliable indicators of depressed mood than apathy. In patients with first-ever stroke, crying behaviors soon after stroke, a younger age, and severe disability are predictors of poststroke depression occurrence within the first year after stroke onset.

The semi-structured diagnostic interview for genetic studies (DIGS) was developed to assess major mood and psychotic disorders and their spectrum manifestations in genetic studies. Our research group developed a French version of the DIGS and tested its inter-rater and test-retest reliability in psychiatric patients. In this article, we present estimates of the reliability of substance use and antisocial personality disorders. High kappa coefficients for inter-rater reliability were found for drug and alcohol as well as antisocial personality diagnoses and slightly lower kappas for test-retest reliability. Combined with evidence of the reliability of major mood and psychotic disorders, these findings support the suitability of the DIGS for studies of familial aggregation and comorbidity of psychiatric disorders including substance use and antisocial personality disorders.

Besides benzodiazepine, antidepressant and neuroleptic agents, all of which have established roles in supportive care, other psychotropic drugs deserve consideration in selected conditions affecting patients with advanced cancer. This article briefly reviews relevant aspects of miscellaneous psychotropics available for second-line treatment, including nonbenzodiazepine sedative, hypnotic and anxiolytic drugs, anaesthetic agents, stimulants, and analgesic adjuvants acting on the central nervous system. The proper use of such subsidiary psychotropic agents requires that both their specificities and the particular characteristics of palliative care patients are taken into account.

OBJECTIVE: Although genetic factors have been implicated in the etiology of bipolar disorder, no specific gene has been conclusively identified. Given the link between abnormalities in serotonergic neurotransmission and bipolar disorder, a candidate gene association approach was applied to study the involvement of the monoamine oxidase A (MAOA) gene, which codes for a catabolic enzyme of serotonin, in the susceptibility to bipolar disorder.METHOD: In France and Switzerland, 272 patients with bipolar disorder and 122 healthy subjects were typed for three polymorphic markers of the MAOA gene: the MAOA-CA repeat, the MAOA restriction fragment length polymorphism (RFLP), and a repeat directly adjacent to the variable number of tandem repeats (VNTR) locus.RESULTS: A significant difference in the distribution of the alleles for the MAOA-CA repeat was observed between the female bipolar patients and comparison group.CONCLUSIONS: The results obtained in the French and Swiss population confirm findings from two st...