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The digital revolution is turning lifestyles and mentalities upside down. The intuitiveness, immediacy and connectivity which characterise new information and communication technologies appeal to teenagers who find in them ways to gain recognition from their peers and to exchange with each other, without having to yield to adults. However, they expect mental health professionals to talk to them, to be engaged in their discussions and to agree to use connected tools as platforms for exchange. A wide variety of such methods can form part of the therapeutic relationship, from smartphones to chat rooms, from teleconsultations to 'cybertherapies', and from video games to serious games.

The digital revolution is turning lifestyles and mentalities upside down. The intuitiveness, immediacy and connectivity which characterise new information and communication technologies appeal to teenagers who find in them ways to gain recognition from their peers and to exchange with each other, without having to yield to adults. However, they expect mental health professionals to talk to them, to be engaged in their discussions and to agree to use connected tools as platforms for exchange. A wide variety of such methods can form part of the therapeutic relationship, from smartphones to chat rooms, from teleconsultations to 'cybertherapies', and from video games to serious games.

Depressive, anxiety and obsessive symptoms frequently co-occur with anorexia nervosa (AN). The relationship between these clinical manifestations and the biological changes caused by starvation is not well understood. It has been hypothesised that reduced availability of tryptophan (TRP) could reduce serotonin activity and thus trigger these comorbid symptoms. The aim of this study, during re-feeding in individuals with AN, was to analyse covariations across measures of nutritional status, depressive and anxiety symptoms, and peripheral serotonin markers. Depressive and anxiety symptoms, nutritional status and serotonin markers--whole blood serotonin content, plasma TRP and the ratio between TRP and large neutral amino acids--were assessed for 42 AN participants at admission to inpatient treatment and after re-feeding. Biological measures were compared to those obtained in 42 non-eating disordered subjects. For those with AN, psychological, nutritional and biological parameters improved significantly during hospitalisation. Levels of serotonin markers were significantly lower in the AN group compared to the control group, at admission and at discharge. Increase in the TRP/LNAA ratio was correlated with a decrease in depressive symptoms. In addition, there was a positive correlation between serotonin levels and symptoms of both anxiety and depression at discharge. We speculate that enhanced TRP availability during re-feeding, as a result of the increase in the TRP/LNAA ratio, could restore serotonin neurotransmission and lead to a decrease in depressive symptoms. The association between serotonin and anxiety and depressive symptoms would be consistent with numerous observations indicating abnormal functioning of the serotoninergic system in AN.

Chaque annee, en France, elles sont des milliers d’adolescentes et de jeunes adultes a etre admises a l’hopital a la suite d’une tentative de suicide. L’auteur revisite ce qui se joue ainsi en urgence et aux Urgences, entre rupture et revendication identitaire, afin de mieux prendre en charge ces jeunes filles en souffrance.

RESUME Le suicide est la deuxieme cause de mortalite chez les moins de vingt-cinq ans. En France, chaque annee, 550 adolescents se donnent la mort et au moins 40 000 tentent de le faire. Un sujet sur trois recidive dans l’annee qui suit, sans compter les prises de risque inconsiderees auxquelles un grand nombre d’entre eux s’expose, notamment sur la route (premiere cause de mortalite). Les deces par suicide concernent trois garcons pour une fille, du fait des moyens employes (pendaison ou arme a feu, sept fois sur dix). Les tentatives de suicide concernent, elles, trois filles pour un garcon, et resultent d’intoxications medicamenteuses volontaires dans neuf cas sur dix. Face a ce triste constat, un meilleur depistage des jeunes en situation de mal-etre et une prise en charge mieux adaptee de ceux qui sont passes a l’acte sont des priorites de sante publique. Du cote du reperage, l’auteur a effectue avec Marie Choquet, epidemiologiste et directrice de recherche a l’Inserm, une etude en milieu scolaire qui degage un certain nombre de facteurs de risque aisement identifiables mais qui ne sont pas encore toujours reconnus comme tels par les professionnels de sante et du champ medico-social. L’auteur se propose de passer en revue ces facteurs. Du cote de la prise en charge, l’auteur indique a travers l’experience de son equipe datant de vingt ans, qu’entre l’evaluation initiale d’un jeune en detresse et le choix de l’orientation therapeutique la plus adaptee, une periode intermediaire d’observation suffisante devrait etre proposee afin de determiner les raisons de la crise suicidaire. L’auteur se propose d’en decrire les moyens et les modalites.

Apres avoir rappele et illustre l’impact de la tentative de suicide d’un adolescent sur ses proches, l’auteur montre que l’hospitalisation meme breve du jeune peut etre l’occasion de reconnaitre la detresse des familles et de les associer a la prise en charge proposee.

Le suicide (« meurtre de soi-même ») pose à tous une question essentielle: qu'est-ce que l'expression manifeste du désir de mort mobilise en soi et chez les autres? Cette interrogation s'avère particulièrement difficile à soulever pour l'aidant ou le soignant confronté à la mort volontaire d'un client ou d'un patient. À travers l'histoire d'un suicide en institution, les auteurs évoquent la nature des mécanismes défensifs mis enjeu par l'équipe soignante. Sidération traumatique, dénégation, déni, culpabilité, mouvements dépressifs sont autant de réactions individuelles et collectives qui s'opposent au travail du deuil, et menacent la cohésion institutionnelle. Les membres de l'« institution en crise » ont à réguler leurs tensions, en évitant de répondre par le retrait, la banalisation, la hantise du suicide, ou l'instauration de pseudo-solutions « pragmatiques ». Il s'agit d'éviter en particulier l'annulation ou le déplacement d'une nécessaire reflexion de tous sur la genèse, les implications et les conséquences du suicide intra-institutionnel. Les auteurs rappellent les principaux fondements et les modalités d'une exploration en équipe de ces phénomènes qui - en l'absence de « travail de la crise » - risquent de situer l'institution dans l'impasse d'un questionnement consistant seulement à savoir à quel moment, faute de s'être retournée, elle se serait détournée de son patient en souffrance., Suicide ("the killing of one's self) raises one crucial question: what does the manifest desire of death bring out in oneself and in others? For those providing care and support who are confronted with the voluntary death of a client or patient, the question is particularly difficult to address. Using the story of a suicide in an institution, the authors reveal the nature of defense mechanisms at play within the group of caregivers. Whether it be a traumatic daze, denial, guilt or depression, these individual and collective reactions to the event hinder the mourning process and threaten cohesion within the institution. Members of an "institution in crisis" must try to relieve their tensions by refraining from withdrawal, banalities, being haunted by suicide and implementing pseudo-solutions. The purpose of such an exercise is especially to avoid the cancellation or displacement of necessary thougt process about the origins, implications and consequences of a suicide taking place within an institution. The authors discuss the founding principles and guidelines for group exploration of these phenomena. Without this coming-to-terms with the crisis, the authors point out that the institution could find itself in a rut where discussion focuses only on when and where things went wrong, and how it turned its back on a suffering patient.

Dans une societe ou les limites s’estompent et ou l’apparence tient lieu de passeport identitaire, la plupart des adolescents cherchent a se distinguer des adultes et a partager entre pairs des marques ayant valeur de codes d’integration. Ils le font a travers vetements et parures, et sont tentes de marquer la peau elle-meme (piercing et, a un moindre degre, tatouage). Mais ces signes de reconnaissance ne suffisent pas, au moins dans leur forme usuelle, aux adolescents qui souffrent de failles narcissiques et identitaires. Eux cherchent a se demarquer dans la rupture en exagerant cet autoetiquetage et/ou en se maltraitant la peau. Autour de 16 ans, ils sont entre 5 et 10 % a reconnaitre se faire mal volontairement, avec une nette predominance feminine. Les garcons heurtent plutot leur peau contre des surfaces dures, tandis que les filles la scarifient et, moins souvent, l’abrasent ou la brulent. L’auteur decrit ces formes de violence et distingue les lesions en fonction de leur caractere typique ou atypique, observations cliniques a valeur diagnostique et pronostique selon que l’attaque de la peau s’inscrit dans une impasse temporaire de l’œdipe pubertaire ou qu’elle revele des troubles plus profonds et plus structuraux. Il expose en quoi les violences cutanees auto-infligees constituent un langage de l’indicible visant a la fois l’apaisement et la figuration inconsciente des souffrances psychiques, et interroge tour a tour les fonctions d’expression, d’inscription et de communication de ces actes-symptomes.

This chapter describes the development and use of digital avatars in the prevention of suicide with teenagers and young adults. Twenty years ago, in November 1992, we created the first hospital unit in France specifically dedicated to caring for suicidal adolescents and young adults (Pommereau et al., 1994). Located downtown in a satel- lite building of the Centre Hospitalier Universitaire de Bordeaux, this unit and two others (a child psychiatry unit for pre-adolescents and a unit for anorexic and bulimic youths) form the Pole Aquitain de l’Adolescent, which also includes a department for outpatient consul- tation. This 15-bed “suicidology” unit is an open institution that cares for suicidal adolescents brought in by emergency and intensive care services as a back-up to psychiatric care (80 per cent of the patients admitted), and young people admitted as a preventative measure following repeated serious behaviours that we consider suicidal, even if the person committing these acts does not recognize them as such (alcoholic comas, running away and threatening suicide, intentional reckless driving, unprotected or non-consensual sex, etc.). Stays are deliberately brief, around three weeks, and the multidisciplinary team of psychiatrists, psychologists, nurses and social workers has three objectives: (a) conduct a thorough medical-psychological assessment of the young patient, bringing in family members and speaking with them; (b) work on expressing emotions and suffering, both in one- on-one and group sessions; and (c) improve acceptance of psychiatric care so that this patient group, known for disregarding follow-up recommendations, becomes more cooperative with later outpatient care.

In France, suicide is the second cause of death among young people. Each year, 550 people under 25 years of age take their own lives, and at least 40,000 attempt suicide. One in three young people who attempt suicide relapse during the following year. A related concern is at-risk behavior, particular on the roads (vehicle accidents are the leading cause of death among young people). Death by suicide is three times more frequent among boys than girls, because of diferences in the methods used (hanging or gunshot, in seven out of ten cases), whereas attempted suicide is three times more frequent among girls than boys and involves drug overdose in nine out of ten cases. Better screening of young people at risk is urgently required The author proposes easily recognizable risk factors that he and Marie Choquet (Inserm) identified through a study conducted in schools. These factors are not always recognized by professionals who deal with adolescents. Regarding hospital management, the author advocates a well-defined assessment period to determine the reasons for the crisis, interposed between the initial evaluation and the choice of the most appropriate therapeutic option.

The digital universe, from the internet to video games, arouses mixed feelings in parents of adolescents. However, it is possible to use the growing "digitisation" of the relationships between young people to develop care tools. Avatars or virtual characters, for example, make it possible to develop a relationship with adolescents hospitalised in child psychiatry units.

Der selbstmörderische jugendliche : beenden mit was ? Selbstmord ist heute die zweite Todesursache bei den Jugendlichen unter 25. Jedes Jahr in Frankreich verüben 800 Jugendliche Selbstmord und 40 000 versuchen es. Mindestens jeder Dritte wird im darauffolgenden Jahr einen neuen Versuch machen. Anhand seiner Erfahrung und der Erfahrung seines Teams vom Abadie Zentrum, der ersten französischen Krankenhausabteilung spezifisch für die Betreuung junger Selbstmörder, versucht der Autor zu zeigen, dass das Verständnis dieser Verzweiflungstaten weit über die Gewissheit dieses oder jenes auslösenden Faktors hinaus geht. Fernab des Zieles der •Selbstvernichtung“ bedeuten die selbstmörderischen Verhalten im Jugendalter sowohl einen Versuch, einem unerträglichen Identitätsleiden zu entkommen, als auch eine tragische existentielle Forderung, die, tragisches Paradox, zu sterben beabsichtigt... um anders zu leben., The suicidal adolescent : to put and end to what ? Nowadays, suicide is the second leading cause of death for young people under the age of 25. In France, every year, 800 adolescents commit suicide and 40 000 make a suicide attempt. One subject on three will make another attempt the following year. Based on his own practice and that of his team of the Abadie centre, the first French hospital unit taking charge of young people with suicidal tendencies, the author attempts to show that the understanding of the acts of distress goes far beyond the evidence of such and such triggering factor. Far from aiming to •self-destruction” the suicidal tendencies during adolescence constitute an attempt to evade both an unbearable suffering for identity and a tragic existential claim which, tragic paradox aims at death… to live differently., Le suicide est aujourd’hui la deuxième cause de mortalité chez les moins de 25 ans. En France, chaque année, 800 adolescents se donnent la mort et 40 000 tentent de le faire. Au moins un sujet sur trois récidivera dans l'année qui suit. À partir de sa pratique et de celle de son équipe du centre Abadie, première unité hospitalière française spécifiquement dévolue à la prise en charge des jeunes suicidants, l’auteur tente de montrer que la compréhension de ces actes de détresse dépasse largement l’évidence de tel ou tel facteur déclenchant. Loin d’avoir pour objectif la «néantisation de soi», les conduites suicidaires à l’adolescence constituent à la fois une tentative d’échapper à une souffrance identitaire intolérable et une tragique revendication existentielle qui, terrible paradoxe, vise à mourir… pour vivre autrement., El adolescente suicida : ¿ Acabar con qué ? El suicidio es hoy la segunda causa de mortandad entre los menores de 25 años. En Francia, cada año, 800 adolescentes se toman la vida y 40 000 intentan hacerlo. Al menos uno de cada tres reincidirá en el año siguiente. A partir de su práctica y de la de su equipo del centro Abadie, primera unidad hospitalaria francesa específicamente dedicada a hacerse cargo de los jóvenes suicidas, el autor intenta demostrar que la comprensión de estos actos de desesperación va mucho más allá de la evidencia de uno u otro factor desencadenante. Lejos de tener como objetivo la •aniquilación de sí”, las conductas suicidas en la adolescencia constituyen a la vez un intento de escapar a un insoportable sufrimiento de identidad y una trágica reivindicación existencial que, trágica paradoja, apunta a morir... para vivir de otra manera., Pommereau Xavier. L’adolescent suicidaire : en finir avec quoi ?. In: Agora débats/jeunesses, 34, 2003. Les jeunes face à la mort. pp. 42-48.

OBJECTIVE: The authors present an analysis of findings for the 65 years and over age group from the WHO/EURO Multicentre Study of Suicidal Behaviour (1989-93). METHODS: Multinational data on non-fatal suicidal behaviour is derived from 1518 subjects in 16 European centres. Local district data on suicide were available from 10 of the collaborating centres. RESULTS: Stockholm (Sweden), Pontoise (France) and Oxford (UK) had the highest suicide attempts rates. In most centres, the majority of elderly who attempted suicide were widow(er)s, often living alone, who used predominantly voluntary drug ingestion. Non-fatal suicidal behaviour decreased with increasing age, whereas suicide rates rose. The ratio between fatal and non-fatal behaviours was 1:2, that for males/females almost 1:1. In the years considered, substantial stability in suicide and attempted suicide rates was observed. As their age increased, suicidal subjects displayed only a limited tendency to repeat self-destructive acts. Moreover, there was little correlation between attempted suicide and suicide rates, which carries different clinical implications for non-fatal suicidal behaviour in the elderly compared with younger subjects in the same WHO/EURO study.

The World Health Organization/EURO Multicentre Project on Parasuicide is part of the action to implement target 12 of the WHO programme, "Health for All by the Year 2000', for the European region. Sixteen centres in 13 European countries are participating in the monitoring aspect of the project, in which trends in the epidemiology of suicide attempts are assessed. The highest average male age-standardized rate of suicide attempts was found for Helsinki, Finland (314/100,000), and the lowest rate (45/100,000) was for Guipuzcoa, Spain, representing a sevenfold difference. The highest average female age-standardized rate was found for Cergy-Pontoise, France (462/100,000), and the lowest (69/100,000) again for Guipuzcoa, Spain. With only one exception (Helsinki), the person-based suicide attempt rates were higher among women than among men. In the majority of centres, the highest person-based rates were found in the younger age groups. The rates among people aged 55 years or over were generally the lowest. For the majority of the centres, the rates for individuals aged 15 years or over decreased between 1989 and 1992. The methods used were primarily "soft' (poisoning) or cutting. More than 50% of the suicide attempters made more than one attempt, and nearly 20% of the second attempts were made within 12 months after the first attempt. Compared with the general population, suicide attempters more often belong to the social categories associated with social destabilization and poverty.

Les tentatives de suicide par intoxication medicamenteuse, les fugues et les scarifications sont des conduites d’agir frequentes a l’adolescence. Au meme titre que d’autres conduites de rupture, nous les envisageons comme des figurabilites corporelles qui s’ancrent, tant dans la forme que dans le fond, bien davantage du cote des productions psychiques que des passages a l’acte reputes court-circuiter la pensee. Ces conduites relevent pour une part d’une intentionnalite consciente, incarnant l’effacement ou l’evacuation hors de soi des tensions internes, leur « reprise en main » synonyme de maitrise, la transposition de la souffrance psychique en percepts sensibles et visibles et la recherche d’effets sur l’entourage dans l’attente d’une reconnaissance et de remaniements favorables. Elles sont aussi inconscientes et tres condensees, realisant des tentatives de figuration qui donnent forme et consistance aux representations psychiques que le sujet en souffrance identitaire tente ainsi d’eviter ou d’escamoter.Dans la mesure ou la plupart des adolescents concernes ne peuvent mettre en mots cette souffrance, et pour les preparer a s’engager dans un travail psychique, nous pensons necessaire d’allier progressivement l’affect a la representation et l’acte a la parole par l’intermediaire d’actes therapeutiques s’offrant comme autant de supports de figuration pouvant favoriser la reliaison. Nous en fournissons des exemples a partir de l’experience de notre equipe qui, depuis quinze ans, amenage de brefs sejours hospitaliers pour les jeunes suicidaires au sein d’une unite specialisee.

THE TORUS MANDIBULARIS Summary. — The torus mandibularis is an outgrowth of the mandible alveolar bone. It is located on the anterior and medial part of the horizontal branch. It consists of more or less large nodules, that realize sometimes the sight of an horizontal hum. Its maximum development is always situated against P3-P4 and its area from I2-C to M2-M3. Free of mandibular anatomical coefficients, its origin is probably genetic., Résumé. — Le torus mandibularis est une excroissance de l'os alvéolaire de la mandibule. Il est situé à la face médiale de la partie antérieure de la branche horizontale de cet os. Il est composé de nodules plus ou moins volumineux réalisant parfois l'aspect d'une bosse horizontale. Son développement maximum est toujours situé en regard de P3-P4 et son étendue de I2-C à M2-M3. Indépendant des constantes anatomiques mandibulaires, son origine est probablement génétique., Reginato A., Roques J.C., Pommereau X., Calen S., Bonjean P. Le torus mandibularis. In: Bulletins et Mémoires de la Société d'anthropologie de Paris, XIV° Série. Tome 4 fascicule 1, 1987. pp. 25-32.

In most Western countries, more than two-thirds of attempted suicides are among women suffering from drug overdoses. Explanations for women's use of less violent methods include the wish to avoid disfiguration, the influence of upbringing, and sex differences in cultural expectations. Many women under stress have a weaker intention to die, and their suicidal act is generally less a deliberate search for death than a desire to live another life, indicating a need to escape from a difficult situation. In this respect, the suicidal woman's desire to sleep through an overdose coma is very significant. We call to mind the strength of the kinship between death and sleep. Reinterpreting the fairy tale "Snow White" and making a parallel with some contemporary clinical cases, we show that the illusion of a nondefinitive death is often assimilated, in Western culture, with a step toward rebirth.

International audience; Introduction: Low BMD is frequent in anorexia nervosa (AN), depression, and during SSRI treatment but relation between these elements in AN is not established. The aims of this study were to assess the relationships between depression and anxiety, SSRI prescription, and (1) low BMD during inpatient treatment and (2) BMD change 1 year after hospital discharge. Methods: From 2009 to 2011, 212 women with severe AN have been included in the EVHAN study (EValuation of Hospitalisation for AN). Depression, anxiety and obsessive–compulsive symptoms and comorbidity were evaluated using psychometric scales and CIDI-SF. BMD was measured by dual-energy X-ray absorptiometry. Results: According to the CIDI-SF, 56% of participants (n = 70) had a lifetime major depressive disorder, 27.2% (n = 34) had a lifetime obsessive–compulsive disorder, 32.8% (n = 41) had a lifetime generalized anxiety disorder and 25.6% (n = 32) had a lifetime social phobia disorder. Half of the sample (50.7%; n = 72) had a low BMD (Z score ≤ − 2). In multivariate analysis, lifetime lowest BMI was the only determinant significantly associated with low BMD (OR = 0.56, p = 0.0008) during hospitalization. A long duration of AN (OR = 1.40 (0.003–3.92), p = 0.03), the AN-R subtype (OR = 4.95 (1.11–26.82), p = 0.04), an increase of BMI between the admission and 1 year (OR = 1.69 (1.21–2.60), p = 0.005) and a gain of BMD 1 year after the discharge explained BMD change. Conclusion: We did not find any association between depression and anxiety or SSRI treatment and a low BMD or variation of BMD. Level of evidence: Level III, cohort study.

International audience