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The aim was to evaluate the efficacy of a manualized cognitive-behavioural program based on habit reversal for the management of chronic tic disorder (CTD) and habit disorder (HD). Forty-seven CTD and 43 HD received a 4-month treatment program. Thirty-eight (22 CTD, 16 HD) were placed on a waitlist control group, which subsequently received treatment. The treatment approach combined awareness training, relaxation (including modification of a tension-producing style of action), and habit-reversal training, with more general cognitive restructuring of anticipations linked to ticcing. Sixty-five percent of completers reported between 75 and 100% control over the tic. At 2-year follow-up, 52% rated 75-100% control. There were also significant changes post-treatment in measures of self-esteem, anxiety, depression and style of planning action. Successful tic/habit modification was associated in CTD and HD groups with successful change in style of planning action. There were no consistent differences in any outcome measures between CTD and HD groups. [C] 2001 Elsevier Science Ltd. All rights reserved. Keywords: Tics; Habit disorders; Cognitive behavioural treatment; Habit reversal

Exposure is considered to be an essential ingredient of cognitive-behavioral therapy treatment of social phobia and of most anxiety disorders. To assess the impact of the amount of exposure on outcome, 30 social phobic patients were randomly allocated to 1 of 2 group treatments of 8 weekly sessions: Self-Focused Exposure Therapy which is based essentially on prolonged exposure to public speaking combined with positive feedback or a more standard cognitive and behavioral method encompassing psychoeducation, cognitive work, working through exposure hierarchies of feared situations for exposure within and outside the group. The results show that the 2 methods led to significant and equivalent symptomatic improvements which were maintained at 1-year follow-up. There was a more rapid and initially more pronounced decrease in negative cognitions with the Self-Focused Exposure Therapy, which included no formal cognitive work, than with the more standard approach in which approximately a third of the content was cognitive. In contrast, decrease in social avoidance was more persistent with standard cognitive-behavior therapy which involved less exposure. The results indicate that positive cognitive change can be achieved more rapidly with non cognitive methods while avoidance decreases more reliably with a standard approach rather than an approach with an exclusive focus on exposure. [ABSTRACT FROM AUTHOR]

The objective of this survey was to assess the beliefs of Swiss psychiatrists about the risks associated with cannabis, and to assess their prohibitive attitudes toward their patients. Eighty-two doctors agreed to fill-up the questionnaire. Cluster analysis retained a 3-cluster solution. Cluster 1: 'Prohibitionists' believed that cannabis could induce and trigger all forms of psychiatric disorder, and showed a highly prohibitive attitude. Cluster 2: 'Causalists' believed that schizophrenia, but not other psychiatric disorders, could be induced and triggered. Cluster 3: 'Prudent liberals' did not believe that psychiatric disorders could be induced by cannabis, and were generally less prohibitive. [ABSTRACT FROM AUTHOR]

Background: Whereas Generalized Anxiety Disorder (GAD) is a psychiatric disorder, the majority of GAD patients who engage in treatment do so with a primary care physician. But physicians do not always provide effective diagnosis, information, or treatment of mental illnesses. This is a major challenge for psychiatric institutions in training GPs with regard to the specific needs of GAD patients infrequently seen in psychiatric settings. The objective of the present survey was to evaluate the basic knowledge about GAD and its treatment in GPs and psychiatrists and the effect of an interactive 3-hours-training module developed by the Swiss Society of Generalized Anxiety Disorders.Methods: From 85 physicians working in private practice and attending the training, 64 participated in the pre-post-training evaluation, using identical questions on the appropriateness of different substances in GAD. The training emphasizes, among others, the utilization of newer antidepressants, and especially paroxetine and venlafaxine, the two antidepressants that are approved for the indication in Switzerland.Results: Compared to the responses given prior to the training, participants rated tricyclic antidepressants after the training as less appropriate (P< 0.05) for GAD, venlafaxine (P< 0.001) and paroxetine (P< 0.001) as more appropriate. Also, conventional antipsychotics were rated as significantly less appropriate (P < 0.001).Limitations: The main limitations of the survey are the pre-post-test design compared to a controlled study, and the short latency until post-training evaluation, assessing only short-term effects.Conclusions: A 3-hour interactive educational module shows some efficacy in modifying the perceived appropriateness of different treatments for GAD in primary care physicians at least in the short term. [ABSTRACT FROM AUTHOR]

Objective: To examine the efficacy and tolerability of clomipramine compared with the selective serotonin reuptake inhibitors (SSRIs) in the treatment of obsessive-compulsive disorder (OCD), bearing in mind the recent Expert Consensus Guidelines recommendation to use clomipramine after 2 to 3 failed SSRI trials.Method: The literature on the pharmacotherapy of OCD was critically examined.Results: The available research evidence is not conclusive but suggests that clomipramine possesses greater anti-obsessional efficacy than do the SSRIs. In addition, when clomipramine is presented to patients in a positive way, and properly used in small initial doses with gradual increases, it seems to be tolerated as well as the SSRIs.Conclusion: Recently expressed opinions that clomipramine should be used to treat OCD after 2 to 3 failed SSRI trials are not supported by research evidence. Both clomipramine and the SSRIs may be used as first-line treatments for OCD. [ABSTRACT FROM AUTHOR]

Abstract Objective The purpose of this study was to assess whether severe overweight schizophrenic treated patients differ from controls and from pairs in binge eating symptomatology. Method Current body mass index (BMI) and the binge eating status were assessed cross- sectionally in 40 schizophrenic outpatients and 40 non-psychiatric controls. In each group half of the subjects were severe overweight (BMI ≥ 28) or obese. Results Pearson Chi-square analysis shows a higher number of subjects with binge symptomatology in the group of patients with schizophrenia having BMI ≥ 28 (Pearson Chi-square = 8.67, p = 0.034). Among subjects with BMI ≥ 28, 60% of patients with schizophrenia and 30% of controls have binge eating symptomatology. Conclusion This result may odds to the understanding of weight gain associated with antipsychotics and underscores the importance of assessing binge eating behaviour during treatment and prevention of obesity in this population.

Objective To propose some key steps to facilitate the process of creating mental health smartphone applications (apps). Methods Brief presentation of the potential interest of apps and proposition of key steps for the creation of apps. The paper is based on a narrative review, a testimonial experience and some expert works. Results Apps have ubiquitous features that are particularly appealing for the mental health field. Potentially connected to multiple technologies, mobile and available at all times, they allow great design flexibility. In order to increase the chances of effectiveness and good dissemination of a given app, 9 principles could usefully guide the design of apps, in particular a good integration of end users around well-defined target objectives during the entire process of creating such tools. Conclusion The proposed key steps could facilitate the process of creating mental health apps.

This essay attempts to describe and discuss the major changes in values and fundamental beliefs related to clinical practice within the Département de psychiatrie de l'Université de Montréal since its creation fifty years ago.Being an essay, the methods include shared recollections, discussions with colleagues, especially between the co-authors, and the study of some documents related to the practice of psychiatry 40 to 50 years ago.Five major axes of change are proposed: 1- From psychoanalysis to brain diseases, 2- From "Can a non-physician practice psychoanalysis?" to "Can a psychiatrist still perform psychotherapy?" 3- From continuity of care to episodes of treatment, 4- From treatment first to repeated assessments of patients, 5- From love that can heal and repair to a taboo of love.Finally it is suggested that the increasing emphasis on psychopharmacology and on DSM classifications has contributed to a shift from attempts to understand the intimate nature of symptoms and suffering to a priority given to rather mechanical clinical assessments in search of "objective" criteria.

Some components of generalized anxiety disorder, such as physical symptoms, are thought to reflect autonomic nervous system arousal. This study primarily assessed the relationships between psychophysiological and clinical measures using venlafaxine extended release or applied relaxation, and secondarily, the impact of combination treatment in patients not remitting after 8 weeks. Fifty-eight patients were randomly assigned to 8 weeks of treatment with either venlafaxine or applied relaxation (Phase I). Non-remitted patients received combination treatment for an additional 8 weeks (Phase II). Assessments included the Hamilton Anxiety Scale (HAM-A), Beck Depression Inventory, Penn State Worry Questionnaire and the Stroop Color-Word Task coupled with electrophysiological measures (skin conductance and frontalis electromyography (EMG)). In Phase 1, a time effect was found for the clinical and skin conductance measures. Thirteen patients from each group were in remission. In Phase 2, seven additional patients remitted. Baseline psychophysiological measures were not associated with baseline clinical variables or with clinical outcomes. Independently of treatment allocation, a reduction in frontal EMG values at week 4 was significantly associated with a decrease in HAM-A scores at week 8. At week 4, responders from the applied relaxation group had lower electrophysiological activity than the venlafaxine group. Baseline psychophysiological measures were not linked with clinical measures at study inclusion or with treatment response. Frontal EMG response at week 4 is a possible predictor of treatment response. Treatment combination enhances treatment response after initial failure.

Objective: To test the hypothesis that repeated preconscious (masked) priming of personalized positive cognitions could augment cognitive change and facilitate achievement of patients' goals following a therapy., Methods: Twenty social phobic patients (13 women) completed a 36-weeks study beginning by 12 weeks of group behavioral therapy. After the therapy, they received 6 weeks of preconscious priming and 6 weeks of a control procedure in a randomized cross-over design. The Priming condition involved listening twice daily with a passive attitude to a recording of individualized formulations of appropriate cognitions and attitudes masked by music. The Control condition involved listening to an indistinguishable recording where the formulations had been replaced by random numbers. Changes in social cognitions were measured by the Social Interaction Self Statements Test (SISST)., Results: Patients improved following therapy. The Priming procedure was associated with increased positive cognitions and decreased negative cognitions on the SISST while the Control procedure was not. The Priming procedure induced more cognitive change when applied immediately after the group therapy., Conclusion: An effect of priming was observed on social phobia related cognitions in the expected direction. This self administered addition to a therapy could be seen as an augmentation strategy.

Objective: Cognitive behavior therapy (CBT) and medication can be administered in combination in treating tic disorders but there are no studies evaluating the effectiveness of CBT with and without medication. The current study compares the efficacy of CBT in combination with medication and without medication., Method: CBT was administered in a consecutively referred sample of 76 people diagnosed either with Gilles de la Tourette Syndrome or chronic tic disorder. The sample was divided into a medicated and a non-medicated group. Twenty three were stabilized on medication and 53 were not receiving medication. Measures administered pre- and post-CBT in both groups included: main outcome measure of Tourette Syndrome Global Scale and measures of mood., Results: Repeated measures analysis of variance on the initial sample revealed no difference between medicated and non-medicated groups in outcome. A further analysis comparing the 23 receiving medication with 23 not receiving medication matched on baseline clinical variables also yielded no significant group differences, either in treatment outcome on main tic outcome measures or on other clinically relevant questionnaires., Discussion: CBT for tic disorders is an effective treatment administered either in combination with medication or alone.

Few randomized controlled trials have included panic disorder patients with moderate to severe agoraphobia. Therefore, this population was studied using pharmacotherapy as well as psychotherapy. At the time of the study, imipramine was widely used as a pharmacological treatment. Also, current practice guidelines for patients with panic disorder find selective serotonin reuptake inhibitors and tricyclic antidepressants roughly comparable in terms of efficacy. Therefore, the main objective of this study is to compare four psychosocial treatments-cognitive and graded in vivo exposure treatments, graded in vivo exposure, cognitive treatment, and supportive therapy-to evaluate the benefits of combining cognitive therapy with exposure in vivo. These treatments were combined with imipramine or placebo for a total of eight experimental conditions. Participants presented moderate to severe agoraphobia. The method involved a randomized, double-blind, placebo-controlled trial with 137 participants who completed a 14-session protocol involving the treatments just mentioned. Measures were taken at baseline and posttreatment and at 3-, 6-, and 12-month follow-up. All treatment conditions were statistically and clinically effective in reducing self-reported panic-agoraphobia symptoms over the 1-year follow-up. No statistical differences were observed between imipramine and placebo conditions. This study found that all treatment modalities helped reduce panic and agoraphobic symptomatology over a 1-year follow-up period. These surprising results support the need to document the relations among the various components of an intervention. This would make it possible to assess the relative efficacy of the treatment components rather than of the intervention as a whole.

The first aim of the present study was to compare performance of people with tic disorders (TD) and controls on executive function and a range of skilled motor tests requiring complex performance, guided movements, hand co-ordination, and fine control of steadiness. The second aim was to investigate the effect of cognitive behaviour therapy (CBT) on motor performance. A total of 55 patients with TD were recruited at baseline from participants in a behavioural management programme. A comparison group of 55 patients suffering from a variety of habit disorders (HD) involving complex manual movements, were matched on age and level of education to 34 non-psychiatric controls. Participants were evaluated pre- and post-treatment and post-waitlist with a neuropsychological evaluation focusing on executive function (Wisconsin Card Sorting Test, WCST) and skilled motor performance (Purdue Pegboard, Hole Steadiness Test, and the Groove Test). Results revealed WCST scores in the normal range, while motor performance differed significantly on the Purdue Pegboard Tests in both TD and HD as compared to the control group. Cognitive-behavioural treatment selectively improved motor performance in both clinical groups compared to waitlist control, and this improvement related to clinical outcome measures.

Background: Overweight and obesity are common concerns in individuals with severe mental disorders. In particular, antipsychotic drugs (AP) frequently induce weight gain. This phenomenon lacks current management and no previous controlled studies seem to use cognitive therapy to modify eating and weight-related cognitions. Moreover, none of these studies considered binge eating or eating and weight-related cognitions as possible outcomes., Aim: The main aim of this study is to assess the effectivity of cognitive and behavioural treatment (CBT) on eating and weight-related cognitions, binge eating symptomatology and weight loss in patients who reported weight gain during AP treatment., Method: A randomized controlled study (12-week CBT vs. Brief Nutritional Education) was carried out on 61 patients treated with an antipsychotic drug who reported weight gain following treatment. Binge eating symptomatology, eating and weight-related cognitions, as well as weight and body mass index were assessed before treatment, at 12 weeks and at 24 weeks., Results: The CBT group showed some improvement with respect to binge eating symptomatology and weight-related cognitions, whereas the control group did not. Weight loss occurred more progressively and was greater in the CBT group at 24 weeks., Conclusion: The proposed CBT treatment is particularly interesting for patients suffering from weight gain associated with antipsychotic treatment.

Objective: The purpose of this study was to assess whether severe overweight schizophrenic treated patients differ from controls and from pairs in binge eating symptomatology., Method: Current body mass index (BMI) and the binge eating status were assessed cross-sectionally in 40 schizophrenic outpatients and 40 non-psychiatric controls. In each group half of the subjects were severe overweight (BMI > or = 28) or obese., Results: Pearson Chi-square analysis shows a higher number of subjects with binge symptomatology in the group of patients with schizophrenia having BMI > or = 28 (Pearson Chi-square = 8.67, p = 0.034). Among subjects with BMI > or = 28, 60% of patients with schizophrenia and 30% of controls have binge eating symptomatology., Conclusion: This result may odds to the understanding of weight gain associated with antipsychotics and underscores the importance of assessing binge eating behaviour during treatment and prevention of obesity in this population.

Background: Co-morbid substance misuse is common in psychiatric disorders, has potentially severe adverse consequences and may be frequently undetected., Aims: To measure the prevalence of substance use among patients admitted to a Swiss psychiatric hospital and to examine the potential utility of routine urine drug screening in this setting., Method: 266 inpatients were included. 238 patients completed the interview and 240 underwent a urine drug screening., Results: Lifetime prevalence of substance use among psychiatric patients was very high for alcohol (98%; 95% CI: 96-100), benzodiazepines (86%; 95% CI: 82-91) and cannabis (53%; 95% CI: 47-60), but also for "hard drugs" like cocaine (25% ; 95% CI: 19-30) or opiates (20%; 95% CI: 15-25). Regular current use of alcohol (32%; 95% CI: 26-38) or cannabis (17%; 95% CI: 12-22) was the most frequent. Substance use was associated with male sex, younger age, unmarried status and nicotine smoking. Urine screening confirms reports from patients on recent use, and remained positive for cannabis during hospitalisation, but not for cocaine nor for opiates., Conclusion: Substance use is frequent among psychiatric patients. Systematic interviewing of patients about their substance use remains essential, and is usually confirmed by urine screening. Urine screening can be useful to provide specific answers about recent use.

Psychiatric hospitalization constitutes a moment of major stress to the point that occurrences of posttraumatic stress disorders have been described. Feelings of coercion are usual, whatever the legal status of admission. Patients may also consider afterwards that they needed hospitalization even if they refused it initially. A cross-sectional survey has been conducted among the inpatients of a Swiss psychiatric hospital to assess their subjective view of admission with emphasis on legal status, perceived coercion and need for hospitalization. Eighty-seven questionnaires were completed and analyzed. Results indicated that 74% of patients felt that they had been under pressure to be hospitalized, whether or not they were involuntarily admitted. Seventy percent felt their admission was necessary. More involuntary patients reported a subjective lack of improvement. Clinicians could decrease feelings of coercion of their patients while discussing need for hospitalization, legal status and subjective feeling of coercion as different dimensions. An argument is presented to favor positive pressure from social environment over legal involuntary commitment in many hospitalizations.

Objective: This study examined electrophysiological indices of preparation (readiness potential, RP) and execution (movement-associated potential, MAP) during automated and controlled reaction time (RT) in 13 chronic tic disorder, 17 habit disorder, and 14 control participants., Background: Both tic and habit disorders are hypothesized to involve states of heightened activation, which could impede initiation and the control of complex motor actions., Method: The electrophysiological signal was recorded from 4 electrodes (Fz, C3, C4, Pz) during a fixed 4-second foreperiod reaction time task., Results: During automated responses, controls showed a shorter RP peak onset, and during controlled responses a longer MAP peak onset, compared with both clinical groups. The controls were the only group who showed a consistent linear relationship between RP and RT., Conclusions: Patients with chronic tic as well as habit disorder may not modulate cortical activation optimally in planning and executing both automated and controlled responses.

Coercion is still frequently used in psychiatry and tends to be considered a necessity, when a patient at risk has lost his/her ability to judge. The aim of this article is to report and discuss current scientific knowledge on this topic. The different steps associated with coercion contribute, along with the illness, to the degree of stress experienced by the patient and might compromise his/her level of adherence to the treatment offered. Clinicians need to consider three dimensions: the coercion applied, the legal status and the subjective feeling of coercion. Pressure that is symbolically negative, positive or legal is exerted on the patients, thereby raising questions about the development of alternatives to the use of coerced treatment. The introduction of the advance directives to Swiss cantonal laws could give rise to different forms of collaboration that are more acceptable to patients.

Purpose: - The objective of the study was to determine the level of involuntary treatment that mood disorder patients and their families wish in the event of a manic or hypomanic episode., Method: - A survey was conducted within two self-help organizations during two conventions gathering over 500 patients, along with families and caregivers. A clinical vignette depicting an uncollaborative hypomanic patient beginning to endanger his professional and financial situation and to put undue stress upon his family was presented and followed by an eight-item questionnaire. The level of coercive treatment seen as appropriate was measured by visual analogue scales., Results: - The 503 respondents disagreed partially with the statement that the patient should decide by himself about his hospitalization and partially favored some involuntary treatment over treatment refusal. There was no difference between patients, relatives and caregivers related to acceptance of coercive hospitalization and treatment. Respondents assigned a major role to treating teams and family members in decisions for coercive treatment., Conclusion: - Most respondents (including a majority of patients) support a moderate degree of coercive treatment in the event of a hypomanic or manic state. Surveys of opinions from concerned people could influence, practice, legislation and possibly advance directives that could be written by patients or patients organizations.

The field of anxiety disorders shows a considerable evolution in the last decades concerning the overall conceptualization of the disorders and concerning their treatment. However many questions remain open. For instance, what is the importance of anxiety disorders in terms of public health? What is their influence on other factors affecting populations' health, e.g. substance abuse, and especially smoking? Questions also remain concerning the underlying mechanisms, whether biological or psychological. For instance, is it possible to identify cognitive schemas leading to pathological anxiety? What are the physiological manifestations of the hypervigilance and hyperreactivity that are described clinically? Despite the successive classifications, some issues are unsettled concerning the delimitation of anxiety disorders. For instance, do obsessive-compulsive disorders belong to anxiety disorders or preferably to a different family of mental disorders constituting a spectrum of obsessive-compulsive disorders? Several practical issues remain open for clinicians: what is the importance of specific therapeutic factors in cognitive-behavioral therapies? Is there a psychoanalytical method and a psychopharmacological therapy specific to anxiety disorders? Concrete questions also deserve attention in relation with therapeutic modalities. Are group treatments superior to individual ones? What is the role of emotion in cognitive-behavioral treatment? Is it useful to associate self-regulation strategies like meditation? Do self-help organizations, that are numerous and helpful in that field, have a role concerning psychotherapy?

Anxious people often show a particular attentional focus towards potentially threatening stimuli. Like any other emotion, anxiety goes along with physiological reactions, which may be more or less noticeable, and may impair behavior and physical wellness. In view of the psychophysiological reactions related with anxiety and anxiety disorders, it seems important to examine potential correlations between psychophysiological activity and the phenomena of hypervigilance. In fact, selective psychophysiological activation has repeatedly been found as a reaction to pathology-specific threatening stimuli in patients with anxiety disorders, whereas their psychophysiological responses appeared often to be blunted when they were submitted to neutral stimuli.