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PurposeAdolescents and young adults’ mental health problems are an important health issue. However, the current organisation of the care pathway is not robust enough and transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) has been identified as a period of risk. The paper aims to discuss these issues.Design/methodology/approachA retrospective survey was conducted in Montpellier University Hospital concerning transitions organised between CAMHS and AMHS between 2008 and 2009. The aim was to assess if transitions met four criteria identified in literature as warranting an optimal transition.FindingsIn total, 31 transitions were included. Transition was accepted by AMHS in 90 per cent of cases but its organisation was rarely optimal. Relational continuity and transition planning were absent in 80 per cent of cases. The age boundary of 16 often justified the triggering of the transition regardless of patient’s needs. Discontinuity was observed in 48 per cent of transition cases, with an average gap of three months without care. Psychiatrists reported difficulties in working together. Finally, at the moment of the survey (one to three years later), 55 per cent of patients were lost to follow-up.Research limitations/implicationsThis is a retrospective study on a small sample but it reveals important data about transition in France.Practical implicationsTransition process should include collaborative working between CAMHS and AMHS, with cross-agency working and periods of parallel care.Social implicationsTransition-related discontinuity of care is a major socioeconomic and societal challenge for the EU.Originality/valueData related to the collaboration between CAMHS and AMHS services are scarce, especially regarding the transition in France.

This chapter focuses on several different research strategies, to characterize the clinical and biological nature of panic disorder. It explores new data regarding the phenomenological and longitudinal features of the disorder are presented. The chapter describes biological and psychophysiologic correlates of anxiety are reviewed in relation to research from our laboratory investigating the sleep architecture, pain perception, glucose metabolism and platelet receptor function in patients with panic disorder. It discusses the data from the pharmacologic challenges in humans with clonidine, yohimbine, and caffeine are discussed within the context of current biological theories of anxiety. Agoraphobia with panic attacks is an anxiety syndrome complicated frequently by the presence of depression. Preliminary data from the sleep laboratory suggest that panic patients may have increased motor activity during the sleep.

Objective: Describe and analyse the experience of family physicians in managing current psychiatric disorders to obtain a better understanding of the underlying reasons of under-detection and inadequate prescribing identified in studies. Methods: A qualitative study using in-depth interviews. Sample of 15 practicing family physicians, recruited by telephone from a precedent cohort (Sesame1) with a maximum variation: sex, age, single or group practice, urban or rural. Qualitative method is inspired by the completed grounded theory of a verbatim semiopragmatic analysis from 2 experts in this approach. Results: Family physicians found that current psychiatric disorders were related to psychological symptoms in reaction to life events. Their role was to make patients aware of a psychiatric symptom rather than establish a diagnosis. Their management responsibility was considered in contrasting ways: it was claimed or endured. They defined their position as facilitating compliance to psychiatrist consultations, while assuring a complementary psychotherapeutic approach. Prescribing medication was not a priority for them. Conclusions: The identified under-detection is essentially due to inherent frontline conditions and complexity of clinical forms. The family physician role, facilitating compliance to psychiatrist consultations while assuring a support psychotherapy is the main result of this study. More studies should be conducted to define more accurately the clinical reality, management and course of current psychiatric disorders in primary care.

Background Clinical insight in schizophrenia patients is partly associated with familial environment but has been poorly studied to date. We aimed to explore (1) the relationship between parents' cognitive insight and their offspring's; (2) the relationship between parents' cognitive insight and their clinical insight into the disease of their offspring; and (3) the clinical and cognitive determinants of cognitive insight in parents. Methods Cognitive insight was assessed in 37 patient–biological parent pairs/dyads with the Beck Cognitive Insight Scale (BCIS). Other measures included the Scale to assess Unawareness of Mental Disorder and cognitive assessments. Results We found no significant association between parents' cognitive insight and their offspring's. Conversely, a positive association between parents' cognitive insight and parents' insight into their offspring's symptoms was found. Better awareness of their offspring's specific symptoms was associated with lower levels of overconfidence in one's beliefs and with BCIS total score. BCIS Self-Certainty and BCIS total score were associated with better executive functioning and verbal comprehension. Conclusions Better insight into their offspring's symptoms is associated with cognitive insight in biological parents of schizophrenia patients. Our results support the integration of cognitive intervention targeting parents' cognitive flexibility in family psychoeducational programs and provide an important first step towards developing a more refined understanding of the factors involved in insight into symptoms of illness in parents of schizophrenia patients.

The positive association between memory self-efficacy (MSE), defined as the beliefs about one's ability to use memory effectively, and memory performance is highly documented in the literature but has not yet been explored in schizophrenia. In the current study the relationship between MSE and objective memory measures was explored in thirty schizophrenia patients and twenty healthy controls. Compared to healthy controls, schizophrenia patients presented lower MSE, which was associated with depression. Among controls, but not patients, MSE was positively related to memory performance. This result suggests that normal relationship between MSE and memory functioning is disrupted in schizophrenia.

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.

International audience; Apathy, described as impaired motivation and goal-directed behavior, is ă a common yet often overlooked multidimensional psychopathological state ă in schizophrenia. Its underlying cognitive processes remain largely ă unexplored. Data was drawn from a longitudinal hospital study of ă patients with a DSM-IV diagnosis of schizophrenia; 137 (82.5%) ă participated at the 1-month follow-up and 81 (59.1%) at the 1-year ă follow-up. Apathy was assessed with the Lille Apathy Rating Scale, ă validated in French and in schizophrenia. Severe apathy, overall (total ă score > -13) and on 4 previously identified distinct dimensions, was ă considered. Episodic verbal learning was assessed with the California ă Verbal Learning Test, executive functioning with the Trail Making Test, ă the Six Element Test and the Stop Signal Paradigm and working memory ă with the Letter-Number Sequencing Test. After controlling for ă confounding variables, only episodic verbal learning was associated with ă severe overall apathy in the cross-sectional study. At 1 year, working ă memory was associated with an increased risk of severe overall apathy, ă adjusting for baseline apathy. Using a dimensional approach to apathy, ă specific types of cognition were found to be associated with specific ă dimensions of apathy. Our findings confirm the need for a ă multidimensional approach of negative symptoms in schizophrenia. ă Moreover, cognitive functioning could be a risk factor for developing ă severe apathy. Cognitive remediation may thus be a useful ă non-pharmacological intervention for treating apathy in schizophrenia ă patients.

The efficacy and tolerability of Lu AA21004 in the prevention of relapse of major depressive disorder (MDD) in patients in remission after acute treatment was evaluated. Patients ( n=639) aged 18–75 years with a primary diagnosis of MDD with a current major depressive episode (MDE) ≥4 weeks’ duration, at least one prior MDE and a MADRS total score ≥26 received 12-week, open-label Lu AA21004 at 5 or 10mg/day. Patients in remission (MADRS ≤10) at both weeks 10 and 12 were assigned to double-blind treatment with either placebo or Lu AA21004 (fixed dose from Week 8).Patients (n=396) were treated, after random assignment to placebo (n=192) or Lu AA21004 (n=204). The primary analysis of time to relapse (full-analysis set, Cox proportional hazard model) showed a statistically significant difference in favour of Lu AA21004 versus placebo with a hazard ratio of 2.01 (95% confidence interval: 1.26–3.21; p=0.0035). The proportion of patients who relapsed was 13% in the Lu AA21004 group ( n=27) and 26% in the placebo group ( n=50). The withdrawal rates due to adverse events were 8% (open-label), and 3% (placebo) and 8% (Lu AA21004) (double-blind). Thus, Lu AA21004 was effective in preventing relapse of MDD and was well tolerated as maintenance treatment.

Epidemiologie La prevalence du trouble sur la vie entiere en France est estimee entre 1,4 et 2,2 %. Le sex-ratio est de sept femmes pour un homme, les symptomes apparaissent habituellement entre 30 et 50 ans.

Objectifs: L'objectif principal a été de mener la validation française de la Scale to Assess Unawareness of Mental Disorder (SUMD) auprès d'une population souffrant de schizophrénie. Méthode: Cent patients souffrant de troubles schizophréniques ont été inclus. Nos analyses statistiques ont évalué la fidélité inter-juges, la validité théorique, la validité convergente ou divergente. Finalement, une analyse factorielle exploratoire a été conduite. Résultats: Nos résultats montrent que la version francophone de la SUMD possède de bonnes qualités métrologiques. La fidélité inter-juges (CCI variant de 0,68 à 1,00) et la cohérence interne des facteurs (α de Cronbach > 0,70) sont satisfaisantes. La validité convergente ou divergente a été confirmée par des corrélations élevées entre les scores de la SUMD et le score G12 de l'échelle des syndromes positif et négatif (PANSS). Nous ne rapportons que peu de liens entre les scores de la SUMD et les variables cliniques. Enfin, nos analyses factorielles ACP confirment l'hypothèse de deux dimensions distinctes de l'insight (conscience, attribution) dans leurs aspects actuel et passé. Conclusion: La version française de la SUMD est une mesure fiable et valide de l'insight dans la schizophrénie. L'importance de mesurer l'insight et le développement d'interventions psychosociales afin d'améliorer l'insight des personnes souffrant de schizophrénie sont discutés.

To investigate if treatment outcome for severely depressed patients depends on their baseline level of anxiety.Patients with a primary diagnosis of severe major depressive disorder (n = 459) were randomised to 24 weeks of double-blind treatment with escitalopram (20 mg) or paroxetine (40 mg). Post hoc analyses of efficacy in patients with a baseline HAM-A total scoreor =20 (n = 171) or20 (n = 280) were based on analysis of covariance (ANCOVA) (ITT, LOCF).At week 24, the mean change from baseline in MADRS total scores was -24.2 for escitalopram-treated patients (n = 141) and -21.5 for paroxetine-treated patients (n = 139) (p0.05) in high baseline anxiety patients and the mean change from baseline in HAM-A total score was -17.4 (escitalopram) and -15.1 (paroxetine) (p0.05). When examining the proportion of complete remitters (CGI-S = 1) after 24 weeks of treatment, there was an increasing treatment difference as a function of baseline HAM-A total score in favour of escitalopram (ITT, LOCF). There was no treatment difference in the low baseline anxiety group. Significantly more patients (p0.01) withdrew from the paroxetine group (31%) than from the escitalopram group (17%), partly as the result of significantly more withdrawals due to AEs (p0.05). Incidence of AEs and withdrawals were not related to baseline anxiety and there were no significant differences in the incidence of individual AEs with escitalopram compared to paroxetine.The post hoc nature of these analyses, the absence of placebo control group, and the requirement that patients should be suffering from severe depression, limit the generalisability of the results.Patients with severe depression together with comorbid anxiety symptoms responded significantly better to treatment with escitalopram 20 mg compared with paroxetine 40 mg. Contrary to paroxetine, escitalopram maintained its efficacy with increasing baseline anxiety levels.

International audience; Objective: Recent research has revealed that schizophrenia patients are impaired in remembering the past and imagining the future. In this study, we examined patients' ability to engage in scene construction (i.e., the process of mentally generating and maintaining a complex and coherent scene), which is a key part of retrieving past experiences and episodic future thinking. Method: 24 participants with schizophrenia and 25 healthy controls were asked to imagine new fictitious experiences and described their mental representations of the scenes in as much detail as possible. Descriptions were scored according to various dimensions (e.g., sensory details, spatial reference), and participants also provided ratings of their subjective experience when imagining the scenes (e.g., their sense of presence, the perceived similarity of imagined events to past experiences). Results: Imagined scenes contained less phenomenological details (d = 1.11) and were more fragmented (d = 2.81) in schizophrenia patients compared to controls. Furthermore, positive symptoms were positively correlated to the sense of presence (r = .43) and the perceived similarity of imagined events to past episodes (r = .47), whereas negative symptoms were negatively related to the overall richness of the imagined scenes (r = −.43). Conclusions: The results suggest that schizophrenic patients' impairments in remembering the past and imagining the future are, at least in part, due to deficits in the process of scene construction. The relationships between the characteristics of imagined scenes and positive and negative symptoms could be related to reality monitoring deficits and difficulties in strategic retrieval processes, respectively.

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.

Au cœur d’une societe ou les valeurs sont en mutation, le malade irresponsable, jusqu’alors ecarte des procedures, se voit integre dans le processus judiciaire penal. Meme si le Code penal et le Code civil sont a ce jour inchanges, le Code de procedure penale connait un remaniement majeur. Le Code de sante publique pourrait egalement connaitre une revision prochaine. Ainsi, si la loi du 25 fevrier 2008 clot une quinzaine d’annees de reflexion et d’evolution autour de la notion de l’irresponsabilite penale pour trouble psychique, elle ouvre parallelement tout un champ de nouvelles pratiques. La presence du patient psychiatrique lors du proces pose une difficile question d’equilibre. Pour le malade d’abord, entre respect de ses particularites et de son statut de citoyen a part entiere qui doit repondre de ses actes lorsque son etat le permet. Pour les victimes ensuite : equilibre entre le respect de leur place nouvelle si durement acquise au coeur des procedures judiciaires et le sens fondamental de l’action judiciaire qui ne peut considerer que les interets individuels. Ces remaniements nous font nous interroger sur le role du medecin psychiatre aupres du malade et de la societe.

Purpose First- and second-generation antipsychotics commonly cause mild gastrointestinal hypomotility. Intestinal necrosis may be a consequence of such gastrointestinal perturbations. Material and Methods We reviewed all the observations of ischaemic colitis and gastrointestinal necrosis notified to the French Pharmacovigilance database (FPD) between 1997 and the end of 2006. Results Thirty-eight cases of ischaemic colitis and gastrointestinal necrosis associated with antipsychotics were analysed. The average age of the patients was 42.7 ± 14.7 years (15–77 years). The digestive complication was an intestinal necrosis in 27 cases, an ischaemic colitis in 10 cases (with perforation in three cases), and one perforation. Surgical procedure (partial or total resection of the colon and/or small intestine) was performed in 24 patients. Six patients died despite surgery. Among the whole population, the outcome was fatal in 14 patients, 13 patients recovered with sequelae, six patients fully recovered, and the outcome remained unknown in five cases. In 55.2% of the cases, the patients were treated with more than one antipsychotic medication. The most frequently involved antipsychotics were: clozapine, levomepromazine, cyamemazine, haloperidol. Associated antimuscarinic drugs (excluding antipsychotics) were found in 68.4% of patients. Discussion/Conclusion Intestinal necrosis associated with antipsychotics is very rare; however mortality is high, with a rapid worsening of patients towards septic shock in spite of mild clinical symptoms. It is therefore essential to monitor the patients receiving antipsychotics especially when they are prescribed concomitant medications. The occurrence of non-specific clinical symptoms such as abdominal pain associated with vomiting and/or diarrhea should draw attention. Copyright © 2009 John Wiley & Sons, Ltd.

Objective: The capacity to consent to treatment or research of patients with severe mental disorders is the focus of important ethical and clinical debate. Many studies evaluate the links between clinical symptoms and the capacity to consent. The aim of this study was to explore the correlations existing between the competence to consent to treatment and the level of awareness of the disease (insight) in patients suffering from schizophrenia in a cross-sectional study. Method: Participants included 60 outpatients meeting the criteria for a DSM-IV diagnosis of schizophrenia. Measures included the MacArthur Competence Assessment tool for Treatment (MacCAT-T), the Scale to Assess Unawareness of Mental Disorder (SUMD) and psychopathology rating scales including the Positive and Negative Syndrome Scale (PANSS). Results: The MacCAT-T dimension “Understanding” was found to be negatively correlated with negative and total PANSS scores but was not found to be correlated with any of the SUMD dimensions. However a systematic negative correlation was observed between the MacCAT-T “Appreciation” and “Reasoning” dimensions and the five SUMD dimensions. Finally, the MacCAT-T “Expressing a choice” dimension was found to be negatively correlated with two SUMD dimensions: “Having a mental disorder” and “consequences of the mental disorder”. Conclusions: These findings suggest an important correlation between the competence to consent to treatment and insight, a clinical variable currently assessed by clinicians. We hypothesized that this link could be mediated by cognitive impairments in schizophrenia. Emphasis should be placed on developing prospective studies comparing the courses of insight, cognitive disorders and capacity to consent in schizophrenia.

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.

International audience; What leads healthy individuals to abnormal feelings of contact with schizophrenia patients remains obscure. Despite recent findings that human bonding is an interactive process influenced by coordination dynamics, the spatiotemporal organization of the bodily movements of schizophrenia patients when interacting with other people is poorly understood. Interpersonal motor coordination between dyads of patients (n = 45) or healthy controls (n = 45), and synchronization partners (n = 90), was assessed with a hand-held pendulum task following implicit exposure to pro-social, non-social, or anti-social primes. We evaluated the socio-motor competence and the feeling of connectedness between participants and their synchronization partners with a measure of motor coordination stability. Immediately after the coordination task, all participants were also asked to rate the likeableness of their interacting partner. Our results showed greater stability during interpersonal synchrony in schizophrenia patients who received pro-social priming, inducing in their synchronization partner greater feelings of connectedness towards patients. This greater feeling of connectedness was positively correlated with stronger motor synchronization between participants suggesting that motor coordination partly underlies patients' social interactions and feelings of contact with others. Pro-social priming can have a pervasive effect on abnormal social interactions in schizophrenia patients.

Aricle disponible en ligne à l'adresse : http://www.nature.com/articles/srep08156; International audience; What leads healthy individuals to abnormal feelings of contact with schizophrenia patients remains obscure. Despite recent findings that human bonding is an interactive process influenced by coordination dynamics, the spatiotemporal organization of the bodily movements of schizophrenia patients when interacting with other people is poorly understood. Interpersonal motor coordination between dyads of patients (n = 45) or healthy controls (n = 45), and synchronization partners (n = 90), was assessed with a hand-held pendulum task following implicit exposure to pro-social, non-social, or anti-social primes. We evaluated the socio-motor competence and the feeling of connectedness between participants and their synchronization partners with a measure of motor coordination stability. Immediately after the coordination task, all participants were also asked to rate the likeableness of their interacting partner. Our results showed greater stability during interpersonal synchrony in schizophrenia patients who received pro-social priming, inducing in their synchronization partner greater feelings of connectedness towards patients. This greater feeling of connectedness was positively correlated with stronger motor synchronization between participants suggesting that motor coordination partly underlies patients' social interactions and feelings of contact with others. Pro-social priming can have a pervasive effect on abnormal social interactions in schizophrenia patients.

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.

OBJECTIVE Escitalopram has proven efficacy in the short-term treatment of generalized social anxiety disorder (SAD). The present relapse prevention study investigated relapse rates during a 24-week, randomized, double-blind, placebo-controlled period in patients with generalized SAD who had responded to 12-week open-label treatment with escitalopram. METHOD A total of 517 patients with a primary diagnosis of generalized SAD (per DSM-IV criteria) and a Liebowitz Social Anxiety Scale (LSAS) total score of > or = 70 received 12 weeks of open-label treatment with flexible doses (10-20 mg/day) of escitalopram. Of these patients, 371 responded (Clinical Global Impressions-Improvement scale [CGI-I] score of 1 or 2) and were randomly assigned to 24 weeks of double-blind treatment with escitalo-pram (10 or 20 mg/day) (N = 190) or placebo (N = 181), continuing with the dose level administered at the end of the open-label period. Relapse was defined as either an increase in LSAS total score of > or = 10 or withdrawal due to lack of efficacy, as judged by the investigator. The study was conducted from January 2001 to June 2002. RESULTS Survival analysis of relapse and time to relapse showed a significant advantage for escitalopram compared to placebo (log-rank test: p < .001). The risk of relapse was 2.8 times higher for placebo-treated patients than for escitalopram-treated patients (p < .001), resulting in significantly fewer escitalopram-treated patients relapsing (22% vs. 50%), at both doses. Escitalopram was well tolerated during double-blind treatment of generalized SAD, and only 2.6% of the escitalopram-treated patients withdrew because of adverse events. The overall discontinuation rate, excluding relapses, was 13.2% for patients treated with escitalopram and 8.3% for patients treated with placebo. CONCLUSION Escitalopram was effective and well tolerated in the long-term treatment of generalized SAD.

ResumenLas personas que acudieron (n = 124, tasa de respuesta: 84%) a cinco médicos generales en Montpellier completaron cuestionarios sobre salud (razón para la visita, causa del problema, GHQ-12), discapacidad (WHODAS II) y uso de los servicios (CSRI). Para cada paciente, el médico general rellenó un breve impreso que incluía una evaluación de la gravedad de la enfermedad física y psicológica. En conjunto, el médico general clasificó al 30,6% de los pacientes como casos de GHQ, que indica probable morbilidad psiquiátrica no psi-cótica, y evaluó que el 58,9% tenía una enfermedad física. Los pacientes con morbilidad psiquiátrica mostraron niveles tan altos de discapacidad como los que tenían una enfermedad física con un número mayor, sin embargo, de dominios vitales afectado. Tenían también un número mucho mayor de días de discapacidad y utilizaban los servicios en mayor medida que las personas sin morbilidad psiquiátrica, siendo más fuertes estos vínculos que con la enfermedad física. El uso del WHODAS II y el CSRI no se ha comunicado antes en Francia. Este estudio muestra que podrían ser instrumentos útiles para describir la discapacidad y el uso de los servicios en la práctica general. Los hallazgos de este estudio inicial indican la necesidad de más investigación en atención primaria que se centre en la detección precisa y el tratamiento de los pacientes, de manera que se pueda reducir la discapacidad y el uso excesivo de los servicios asociados con la morbilidad psiquiátrica.

BackgroundFrance has high rates of psychotropic drug consumption and suicide in the elderly population, but it has not yet been possible to determine whether this is due to exceptionally high morbidity rates.AimsTo describe the first longitudinal population study of psychiatric disorder undertaken in France, and to estimate current and lifetime prevalences and age of onset of psychiatric disorder.MethodA study group of 1873 non-institutionalised persons aged 65 years and over was randomly recruited from the Montpellier district electoral rolls. The Mini International Neuropsychiatric Interview was used to assess current and lifetime symptoms. Cases identified by the application of DSM–IV criteria were reexamined by a clinical panel.ResultsForty-six percent of the study population had experienced a mental disorder in their lifetime, and 3.7% had made a suicide attempt. Lifetime prevalence of major depression was 26.5% and 30% for anxiety disorders. Current prevalence rates were 14.2% for anxiety disorders, 10.7% for phobia, 3% for major depression and 1.7% for psychosis.ConclusionsResults show very high rates of lifetime but not current major depression. Rates of current phobia and suicidal ideation in the very elderly are also high compared with other studies. The rates reported are likely to be underestimates.

We screened 124 individuals for single nucleotide polymorphisms of the alpha1, beta3 and gamma2 genes of the GABA(A) receptor in the regions corresponding to the ligand-binding domains on the protein level. In a patient with chronic insomnia, a missense mutation was found in the gene of the beta3 subunit. This mutation results in the substitution of the amino acid residue arginine for histidine in position 192 (beta3(R192H)). The patient was found to be heterozygous for this mutation. Functional analysis of human alpha1beta3(R192H)gamma2S GABA(A) receptors using ultra fast perfusion techniques revealed a slower rate of the fast phase of desensitization compared with alpha1beta3gamma2S GABA(A) receptors. Additionally, current deactivation [a major determinant of inhibitory postsynaptic current (IPSC) duration] was faster in the mutated receptors. This raises the possibility of decreased GABAergic inhibition contributing to insomnia, as some members of the patient's family also suffer from insomnia. The mutation beta3(R192H) might, therefore, be linked to this condition. The intron/exon boundaries of the alpha1 subunit gene were also established and three additional variants were found in the alpha1 and beta3 genes.

International audience; La question de la capacité à consentir à un traitement ou à la recherche se pose pour tous les patients, mais peut-être de façon plus cruciale pour les patients souffrant de troubles mentaux. Afin de répondre à cette question, plusieurs auteurs se sont intéressés aux liens entre les symptômes cliniques de la schizophrénie et la capacité à consentir. Le but de notre étude est d’évaluer les liens entre la capacité à consentir et un symptôme d’un grand intérêt dans la schizophrénie, la conscience des troubles. Pour cela, nous avons inclus 60 patients souffrant de schizophrénie selon les critères du DSM-IV. La mesure de la capacité à consentir s’est faite grâce au MacArthur Competence Assessment tool for Treatment (MacCAT-T), et la mesure de l’insight grâce à la Scale to Assess Unawareness of Mental Disorder (SUMD). La symptomatologie a été évaluée par la Positive and Negative Syndrome Scale (PANSS). Nos résultats montrent que la dimension « compréhension » du MacCAT-T est négativement corrélée avec les scores de la dimension symptomatologie négative de la PANSS et avec le score total, mais avec aucune dimension de la SUMD. En revanche, les dimensions « appréciation » et « raisonnement » du MacCAT-T corrèlent de façon négative avec toutes les dimensions de la SUMD, et la dimension « exprimer un choix » avec les dimensions « conscience d’avoir un trouble mental » et « conscience des conséquences sociales du trouble » de la SUMD. Ces résultats confirment donc une idée « intuitive » qui est qu’il existe un fort lien entre capacité à consentir au traitement et conscience des troubles. Nous faisons l’hypothèse que ce lien pourrait se faire par le biais des troubles cognitifs.

International audience; Poor insight is found in up to 80% of schizophrenia patients and has been associated with multiple factors of which cognitive functioning, social and environmental factors. Few studies have explored associations between patient insight and that of their biological parents', and the influence of parental factors. Insight was assessed in 41 patients and their biological parents with Amador's Scale for the assessment of Unawareness of Mental Disorder (SUMD). Parents' knowledge about schizophrenia and critical attitudes were assessed with validated self-report questionnaires. Both groups underwent cognitive assessments for working memory and executive functioning. Insight in patients and their parents was not associated for any of the SUMD dimensions but a significant correlation was found between patient and parent awareness of treatment effect for patient-parent dyads with frequent daily contact. Low parental critical attitude was associated with higher patient awareness of symptoms and a high parental memory task score with high patient insight. Our study is the first to suggest a possible influence of parental factors such as critical attitudes and cognitive performance on patient insight.

Resume L’apathie est presente lors des differentes phases de la schizophrenie. Ses consequences sur le fonctionnement global des patients sont importantes. Actuellement, la definition de l’apathie dans la schizophrenie est encore sujette a de nombreuses questions et notamment celle de son amalgame avec d’autres symptomes tels que l’avolition, l’apragmatisme, ou l’athymhormie. En effet, dans la litterature, certains auteurs decrivent les patients apathiques en utilisant le terme d’avolition ou d’apragmatisme. Mais l’apathie est un syndrome qui necessite pour sa comprehension une approche multidimensionnelle. Or les autres symptomes s’attardent uniquement sur l’observation d’un comportement ou les processus emotionnels, cognitifs et d’auto-activation ne sont tous pris en compte. Par ailleurs, non seulement l’apathie est souvent confondue avec ces symptomes, mais sa distinction avec la depression demeure problematique, d’autant l’absence de donnees dans la schizophrenie. L’evaluation de l’apathie se fait avec des outils specifiques et non specifiques fondes sur des conceptions divergentes, faisant peu reference a des modeles valides et operatoires. Ni la definition, ni les echelles d’evaluation de l’apathie ne prennent en compte les raisons d’un comportement apathique, seules ses consequences fonctionnelles sont evaluables. L’objectif de cette revue est par consequent d’apporter un eclaircissement clinique sur le syndrome d’apathie mais egalement de proposer des pistes de recherches et d’interventions.

International audience; Semantic priming tasks are classically used to influence and implicitly promote target behaviors. Recently, several studies have demonstrated that prosocial semantic priming modulated feelings of social affiliation. The main aim of this study was to determine whether inducing feelings of social affiliation using priming tasks could modulate nonverbal social behaviors in schizophrenia. We used the Scrambled Sentence Task to prime schizophrenia patients according to three priming group conditions: pro-social, non-social or antisocial. Forty-five schizophrenia patients, diagnosed according to DSM-IV-TR, were randomly assigned to one of the three priming groups of 15 participants. We evaluated nonverbal social behaviors using the Motor-Affective subscale of the Motor-Affective-Social-Scale. Results showed that schizophrenia patients with pro-social priming had significantly more nonverbal behaviors than schizophrenia patients with antisocial and non-social priming conditions. Schizophrenia patient behaviors are affected by social priming. Our results have several clinical implications for the rehabilitation of social skills impairments frequently encountered among individuals with schizophrenia.

International audience; This study explored the mediation effect of metacognitive beliefs on the relationship between intrusive thoughts and emotional distress in schizophrenia (N=49) and obsessive-compulsive disorder (OCD) (N=35). Intrusive thoughts impact on anxiety and depression through beliefs about uncontrollability and danger of thoughts in schizophrenia. Negative beliefs in general mediated the effect of intrusive thoughts on anxiety in obsessive-compulsive disorder. The results suggest that metacognitive beliefs may be a vulnerability factor for emotional and psychological disorder.

International audience; Depuis les premières descriptions cliniques datant de la fin du XIXe siècle, montrant l’intérêt médical relativement récent pour l’anxiété, les symptômes anxieux et les troubles anxieux, les concepts ont considérablement évolué au cours du XXe siècle pour aboutir aux classifications syndromiques en vigueur dans la nosographie actuelle. Pourtant, un certain nombre de questions demeurent, par exemple sur l’existence d’un continuum entre une anxiété normale et adaptative et une anxiété pathologique, la nature de la réactivité émotionnelle dans les troubles anxieux par rapport à celle décrite dans les troubles bipolaires, etc...La première partie d’ouvrage présente les diverses approches actuelles pour comprendre les troubles anxieux : modèles émotionnels, approche évolutionniste, psychodynamique, théorie de l’attachement, génétique, neurobiologie, neuropsychologie, électrophysiologie et neuro-imagerie.Sont ensuite exposés les différents troubles anxieux (attaque de panique, phobie sociale, trouble anxieux généralisé, hypocondrie, état de stress post-traumatique, TOC, etc.) et les associations co-morbides (dépression, conduites suicidaires, troubles bipolaires, addictions, etc...).Réunissant plus d’une quarantaine de spécialistes reconnus, riche d’une trentaine tableaux et schémas explicatifs et d’un index détaillé, cet ouvrage offre un état des connaissances et des recherches sur les troubles anxieux.

This study assessed the efficacy, tolerability and safety of vortioxetine versus placebo in adults with recurrent major depressive disorder. This double-blind, randomized, placebo-controlled study included 608 patients [Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≥ 26 and Clinical Global Impression - Severity score ≥ 4]. Patients were randomly assigned (1 : 1 : 1 : 1) to vortioxetine 15 mg/day, vortioxetine 20 mg/day, duloxetine 60 mg/day or placebo. The primary efficacy endpoint was change from baseline in MADRS total score at week 8 (mixed model for repeated measurements). Key secondary endpoints were: MADRS responders; Clinical Global Impression - Improvement scale score; MADRS total score in patients with baseline Hamilton Anxiety Rating Scale ≥ 20; remission (MADRS ≤ 10); and Sheehan Disability Scale total score at week 8. On the primary efficacy endpoint, both vortioxetine doses were statistically significantly superior to placebo, with a mean difference to placebo (n = 158) of -5.5 (vortioxetine 15 mg, P0.0001, n = 149) and -7.1 MADRS points (vortioxetine 20 mg, P0.0001, n = 151). Duloxetine (n = 146) separated from placebo, thus validating the study. In all key secondary analyses, both vortioxetine doses were statistically significantly superior to placebo. Vortioxetine treatment was well tolerated; common adverse events (incidence ≥ 5%) were nausea, headache, diarrhea, dry mouth and dizziness. No clinically relevant changes were seen in clinical safety laboratory values, weight, ECG or vital signs parameters. Vortioxetine was efficacious and well tolerated in the treatment of patients with major depressive disorder.

le document est disponible en ligne : http://www.sciencedirect.com/science/article/pii/S0920996414002254; International audience; BackgroundApathy in schizophrenia patients is linked to marked functional impairments and can be defined as a quantitative reduction of voluntary, goal-directed behaviors. If there are now convincing arguments to consider apathy as a multidimensional psychopathological state (cognitive, emotional, and behavioral), there is a lack of validated and standardized instruments for detecting apathy and assessing its multidimensional aspects in schizophrenia. The Lille Apathy Rating Scale (LARS) is a semi-structured interview, yielding a global score and composite subscores for the different domains of apathy and has been validated in several different contexts but not in schizophrenia patients.ObjectiveThe aim of this study is to examine the psychometric properties of the LARS and identify the distinct components of apathy in a sample of schizophrenia patients.MethodsOne hundred-and-twelve schizophrenia patients were included and they completed the LARS, The Calgary Depression Scale in Schizophrenia, the Positive and the Negative Syndrome Scale and the Scale for the Assessment of Negative Symptoms. The patient group was compared to 51 healthy control subjects.ResultsPrincipal component analysis showed that the LARS proved a single construct which forms the root of an oblique factor structure reflecting four dimensions: novelty and social life, behavioral involvement, emotional involvement, and judgment skills. The main psychometric properties of the LARS were satisfactory.ConclusionsOur findings show that the LARS has satisfactory psychometric properties when used in a different setting than the original version. The LARS is a promising instrument to examine apathy in schizophrenia through a multidimensional framework.