Expériences et enjeux de la psychiatrie militaire en opération

For the French army, Afghanistan is a new challenge, especially for the French health service. That theatre is very different from other which the army knows better like Africa or Yugoslavia. The threat is constant, provided by fight, improvised explosive device, terrorism in the cities and rockets aiming the bases. Since 2009, a French military psychiatrist is based with the NATO Hospital at Kabul Airport. The mains problems are the consequences of three threats: fight with Talibans, risk of explosion on the road by improvised devices and attack by rockets on the camps. For each, the psychic reactions are different. Combats provide among the men postoperational stress and for some of them a risk of moral disengagement. But for the most part of them theses symptoms disappears quickly. The improvised explosives devices are the threat feared the most by troops, especially for the logistic convoy. The frequent symptoms are burn out, exhaustion and stress. Rockets like explosives devices are a blind threat and aren’t feared. But when some of them fall on a camp, the people presents sleep troubles, continual stress and PTSD. Alcohol or moral disengagement are not specific of Afghanistan but constitute other challenges. Each of the cases we described is an illustration of these observations of our experience during three months in Afghanistan.     

Accessibilité de la remédiation cognitive en Île-de-France,en psychiatrie adulte et infanto-juvénile,et dispositifs de réhabilitation

Cognitive remediation (CR) aims to decrease cognitive deficits and provide palliative strategies for reintegration of patients with psychic disability. It is part of a personalized care program and requires multidisciplinary assessment and management, including eventually other psychosocial therapies. This study, carried out in 2016, aims to establish an inventory of accessibility and practice of the CR in Île-de-France, to promote broad access and systematize the integration of CR in a global and coherent course. The CR is proposed by nearly 58 % of the structures that answered the survey, but its implementation could be improved: it stands for 58 % in a specific project and the multidisciplinary evaluation before/after is carried out at 51 % in Adult Psychiatry and 20 % in Child and Teen Psychiatry (CTP), perhaps due to a lack of qualified staff (neuropsychologists). The programs used in CTP are nonspecific. The accommodation capacity should be increased by group programs. Despite a lack of knowledge to fill, there is an important interest for the CR with a will expressed by 12 structures to be trained. Other psychosocial therapies, although better known, would benefit from being more often proposed and labeled by the Regional Health Agency. Our results confirm a scarcity of psychiatric care's supply in 77, 91 and 93. Four rehabilitation units in the 77 and 3 in the 91 are being trained. Three structures in the 77 and 2 in the 91 are willing to get trained. Supporting them is all the more important as the good practice of CR has a direct effect on social costs’ benefits. Since then, in the entire region, 8 structures have proposed for a CR and rehabilitation platform.     

Impact de la formation théorique et clinique sur les attitudes de stigmatisation des étudiants en médecine envers la psychiatrie et la pathologie psychiatrique

Objective

The aim of the study was to explore whether a medical student education program and clinical posting in psychiatry had an impact on medical students’ stigmatizing attitudes towards psychiatry and psychiatric disorders.

Psychotraumatologie de la guerre en Ukraine : la question de la prise en charge psychologique des victimes réfugiées ou restées en Ukraine

The war in Ukraine is a major poly-traumatic event, which leads to massive population displacements. The question of the evaluation and psychological care of psychotraumatised people is an urgent matter. As many countries hosting refugees are well endowed with a number of psychologists, some of these interested professionals should mobilise themselves and make themselves known to carry out these clinical acts. Priority should be given to trained and experienced psychologists to support victims. The language barrier will have to be overcome. Initially, it would be desirable to make contact or get closer to local and national refugee centres to facilitate these operations. Face-to-face or remote consultations, as developed during the Covid-19 pandemic, are possible. Reinforcements of available and dedicated psychologists, including remotely, from the countries hosting the most refugees are also desirable. The issue of detection, assessment and care of psychologically traumatised people who remained in the Ukrainian territory is probably even more massive. Whether non-combatants or combatants, part of the international psychological community should mobilise, in addition to local colleagues, to provide them with this psychological help. These humanitarian actions would be feasible depending on the evolution of the conflict. Whether it is psychological support for refugees or people still on the Ukrainian soil, models for organizing and coordinating these actions must be carefully thought out and implemented in an evolving way to optimise their effectiveness.     

Image et culture dans la prise en charge de mineurs isolés étrangers

Aims

Through the implementation of photographic mediation, we aim to show the advantages of the use of a mediation-based group system in a migratory context. The focus is on the expression of affects within a group and the articulation between the subject and the group in the setting of this particular type of treatment.

Diagnostic clinique et moléculaire de la myopathie facioscapulo-humérale de type 1 (FSHD1) en 2012

IntroductionDiagnosis of facioscapulohumeral dystrophy type 1 (FSHD1) is supported by a suggestive clinical presentation and associated with a heterozygous contraction of the D4Z4 repeat array on chromosome 4q35.State of the artThe FSHD1 phenotype has a widely variable course with great inter- and intrafamilial heterogeneity. Three clinical forms can be distinguished: the classical phenotype associated with four to seven repeat units (RU) and a variable course, a severe infantile form with one to three RU, and a mild phenotype associated with borderline UR (8 to 10 RU). At the molecular level, for D4Z4 contraction to be pathogenic, it needs to occur on a specific chromosomal background, namely on the 4qA allelic variant of chromosome 4. In most cases, once FSHD is clinically suspected, the diagnosis can be genetically confirmed with a DNA test using Southern Blotting and hybridization to a set of probes. However, diagnosis of FSHD1 remains challenging. Firstly, some patients may present with an atypical phenotype with highly focal or unusual symptoms. Secondly, there are potential pitfalls in the genetic diagnosis of FSHD resulting in false positive or false negative results. In the absence of genetic confirmation, other investigations, mainly EMG and muscle biopsy, are needed to rule out another diagnosis. In cases with no clear diagnosis and a permissive chromosome without contraction, FSHD2 may be suspected.PerspectivesMolecular combing is a new technique which permits visualization and sizing of the D4Z4 repeat array on its genetic background on stretched single DNA fibers by fluorescence microscopy. This tool will improve genetic diagnosis in FSHD patients.ConclusionDiagnosis of FSHD1 is mainly supported by clinical features. Clinicians need to be aware of unusual presentations of this disease. The wide spectrum of intrafamilial variability and the lack of good correlation between genotype and phenotype present challenges for genetic counseling and prognostication. More studies are needed concerning penetrance and genotype–phenotype correlation.     

Origine et évolution de la bipédie

During around five millions years our ancestors, who were arboreal primates, became progressively occasional, frequent and permanent terrestrial bipeds. Thus, they restricted their locomotor repertoire from polyvalence to specialization. We show that the adaptation to bipedalism is the result of two different processes, the result of natural selection and the result of learning to walk. The characters of our skeleton, heritage of natural selection, affected first pelvis and vertebral column and then cranial base, body proportions and feet. Since reaching bipedal balance is a very demanding constraint in the face of gravity, we describe the “epigenetic” characters which develop in association with learning to walk. Important femoral angular modifications result in the adduction of lower limbs. The angle of pelvic incidence, which defines the sagittal pelvic morphology, increases with gait acquisition in tight association with the formation of lumbar curvature. A link can be established between these genetic modifications and these epigenetic acquisitions. As an illustration we show how the pelvis and spine became a functional unit during the transition from facultative to permanent bipedalism, probably during the evolution of the large group of Homo erectus.     

Tolérance à la détresse et expérience de la douleur chronique

IntroductionChronic pain is a highly prevalent condition that is associated with distressing somatic and emotional experiences. Consequently, an individual's distress tolerance, the perceived capacity to tolerate negative psychological and physical states, may influence their pain experience. This effect could be explained in part by a reduction in the catastrophic interpretation of pain which is associated with increased pain intensity and interference in everyday activities.AimsThe first aim of this study was to explore the association between the components of the 5-factor model of distress tolerance and (1) pain intensity and (2) pain interference in everyday activities. The secondary aim was to assess the potential mediating effect of pain catastrophizing in the eventual association between components of distress tolerance and (1) pain intensity or (2) pain interference in everyday activities.MethodThis is a cross-sectional study of adult (18 years or older) university students and staff with chronic pain (3 months). They were invited to complete the online questionnaire through an email invitation. Pain intensity and interference in everyday functioning were assessed with the corresponding subscales of the Brief Pain Inventory. The following instruments were used to assess the components of the 5-factor model of distress tolerance: Ambiguity Tolerance Scale (tolerance to ambiguity), Intolerance to Uncertainty Scale (reversed score: tolerance to uncertainty), Discomfort Intolerance Scale (reversed score: discomfort tolerance), Distress Tolerance Scale (tolerance to negative emotions), Frustration Discomfort Scale (tolerance to frustration). Participants also completed the Pain Catastrophizing Scale.ResultsEighty participants were recruited (57 % women, mean age = 33.09; standard deviation = 12,87). Tolerance to negative emotions was the only component of distress tolerance that was associated with pain (ß = ?0.04; 95% CI): ?0.07–?0.01; t (78) = ?3.06, p < 0.01) or pain interference in everyday functioning (ß = ?0.07; 95% CI: ?0.10–?0.03; t (78) = ?3.97, p < 0.01), independently of the others. Combined with age, these factors explained 16.2 % of the variance in pain intensity and 19.4 % of the variance in pain interference. Pain catastrophizing partially mediated the association between tolerance to negative emotions and pain interference in everyday functioning, but it was not involved in the association between tolerance to negative emotions and pain intensity.ConclusionTolerance to negative emotions appears to be the most relevant aspect of distress tolerance in the context of chronic pain and is a potential clinical target that is independent and complementary from pain catastrophizing.     

TDAH et comorbidités en pédopsychiatrie. Pathologies psychiatriques,affections médicales,troubles de l’apprentissage et de la coordination

ADHD is a common disorder for children and is highly comorbid with a number of psychiatric and somatic disorders, which leads to important social consequences. Therefore, it is important to screen for the presence of other disorders when a diagnosis of ADHD is considered. Because of the associated pathologies, the clinical picture of the ADHD is more complex and represents a diagnostic challenge. Furthermore, the prognostic and the future of children with a comorbid ADHD is much more unfavorable than that of children with ADHD only. It is thus necessary to recognize the presentation of ADHD associated with various and frequently comorbid pathologies knowing that those will change according to age and the developmental stage. The objective of this article is to describe these comorbidities. We are going to discuss pathologies most often associated with ADHD and the impact of its symptomatology on psychiatric disorders, medical affections and other disorders such as learning disorder and developmental coordination disorder. Along these lines, we carried out a mini review of ADHD and comorbidities. Results showed that comorbid psychiatric disorders such as conduct disorders, mood disorders and anxiety are among the most frequently associated with ADHD in clinical practice. Disruptive disorders are the most common comorbidities found with ADHD. Among these disorders, oppositional defiant disorder must be distinguished from conduct disorders. Conduct disorders are highly comorbid with ADHD (in more than a third of the cases) and increase the severity of the clinical picture. When children show at the same time ADHD and a conduct disorder, they are at risk to have an antisocial personality disorder as well as addictive disorders in adulthood. Depressive disorders can be triggered by ADHD since these young patients have to face numerous failures and difficulties in their family, social and school lives. With respect to bipolar disorders, links exist with ADHD. Bipolar disorder and ADHD treatment is complex: both thymoregulators and medication of ADHD are necessary. Finally, anxiety disorders are concomitant in 33 % of ADHD children, an association which deteriorates the symptoms of inattention and distractibility. Furthermore, there is also some overlap between ADHD and addictive behavior, obsessive-compulsive disorder, tics, sleeping disorder and specific learning disorder. There is a high prevalence of the association between ADHD and addictive behaviors in connection with impulsiveness, lack of control, automedication and similarity in the neurobiological circuits. Children with an obsessive-compulsive disorder have ADHD in 33 % of the cases. Although treatments of ADHD and obsessive-compulsive disorder differ, they must be taken simultaneously. It seems that sleeping disorders are not co-occurring with ADHD but intrinsic. Besides, sleeping disorders during childhood can mime an ADHD and complicate the diagnosis to be established, in particular when restless legs syndrome or sleep apnea is present. The comorbidity of ADHD and specific learning disorders is high. Children with specific learning disorders have difficulties staying attentive and their academic performance is often below their full potential, just like the ADHD children. Therefore, clinicians who assess patients for ADHD have to systematically screen for the presence of specific learning disorders and vice versa. Likewise, autistic spectrum disorder and eating disorder are more and more recognized as comorbid entities. The DSM-IV made impossible the concomitance between autism spectrum disorders and ADHD. However, the DSM-5 did recognize the existence of this comorbidity. The association of those two pathologies results in more severe dysfunction for the children, but the treatment of ADHD is going to facilitate the medical care of autism spectrum disorders. ADHD is described as a risk factor for eating disorders. Besides, the co-occurrence of obesity with ADHD is connected to impulsiveness and the tendency to addictive behaviors. Relationships of ADHD with posttraumatic stress disorder and attachment disorder have also been noted. Similarities between ADHD and posttraumatic stress disorder can cause diagnostic errors. Indeed, for both disorders we find the following: agitation, irritability, hypervigilance, sleeping disorders, attention disorders and disorders in the executive functions. Therefore, during the assessment of a child with a clinical picture of ADHD, anamnesis must be completed with the search of traumatic events. On the other hand, attachment disorder can also be confused with ADHD. Difficult temperament can disrupt the process of attachment and is associated with a bigger risk of ADHD. Finally, other medical issues should be considered in the assessment of ADHD: brain injury, epilepsy and obesity for example. ADHD children with a co-occurring condition may be severely impaired and treatment is more complex. ADHD is strongly comorbid with a large number of psychiatric and physical pathologies. It is probably more a set of affections than a homogeneous clinical entity. The longitudinal studies of children with one or several comorbidities showed that the outcome of these children was unfavorable, the association of pathologies causing an important dysfunction. The explanations proposed for this strong tendency of comorbidity with ADHD are that comorbidities have the same risk factors (genetic and environmental) and/or that one of the disorder is a subcategory of another. This leads us to conclude that a better comprehension of the high rates of comorbidities with ADHD is essential to optimize treatment of this condition and prevent some of the negative outcomes associated with comorbid ADHD.     

Place de la psychothérapie intégrative dans la prise en charge des problématiques de radicalisation

Recent waves of attacks in France have led health and justice professionals to meet, exchange and work together, with a goal that is common: the care of people with radicalization issues. The operationalization of this objective macro makes it possible to distinguish the missions of the different actors at stake. Thus, the question of care requires the definition of the object of intervention, the purpose, rehabilitative and/or therapeutic, and the means available. In this interview, members of the ARCA, Erwan Dieu and Olivier Sorel evoke the place of integrative psychotherapy in the management of radicalization issues. The purpose of this discussion is to clarify the functions and objectives of each of the actors at the interface of people presenting this form of radicalism.     

La naissance de la Société Médico-Psychologique. Mise en perspective et regard sur la naissance de l’American Psychiatric Association

The authors retrace the various stages of the birth of the Société Médico-Psychologique (SMP), which celebrated its 170th anniversary in 2022. They recall the context, notably a law enacted in 1838 that was considered as a foundation text for what was then called alienism and which would eventually become psychiatry. The work of Philippe Pinel and Jean Étienne Esquirol played an essential role in the founding of the SMP, and more broadly in the genesis of the discipline. Three phases can be distinguished in the foundation of the SMP: (1) the creation of the Annales Médico-Psychologiques (AMP), in 1843, a journal that would become the SMP bulletin; (2) the first constitution of the SMP which was announced by Jules Baillarger in the first issue of the AMP in 1848 and which included the first organizational rules and a first list of members; (3) For political reasons (The revolution of February 1848, a political coup d’état on December 2, 1851), the foundation of the SMP would officially first take place in 1852. A commission of members modified the first internal rules. A principle was established whereby the Society would be composed of physicians, philosophers, magistrates, clergymen, moralists, teachers, poets, etc. The professional journals announced at the time the establishment of a Society where “all the instruments of psychological analysis will be gathered and applied simultaneously”. The first meeting of the Society was held on the 26th of April 1852. The authors provide a list of the founding members, although there were some notable absences. The relations between the SMP and the Academy of Medicine, founded in 1820, are detailed. The first international members are mentioned. They came from The Netherlands, Spain, Italy, Russia, Austria and Germany, and at the end of the 19th century, from America as well During the same time period, similar learned societies were established, notably in the United Kingdom, Germany and Russia. The authors describe in detail the creation of the Association of Medical Superintendents of American Institutions for the Insane (ASAMSAII), the future American Psychiatric Association (APA), and of its Journal which would become the American Journal of Psychiatry. The details of joint meetings between the APA and the SMP in 1978 are reported. The birth of the SMP and of other learned societies in Germany, France and the United Kingdom marked the beginning of a discipline which was then called alienism and which would become Psychiatry.     

Histoire de la kétamine et du psychédélisme

Ketamine's history begins in the fifties in Detroit, at Parke-Davis laboratories. In 1956, Maddox synthetized phencyclidine or PCP. Domino studied PCP effects in animals and in 1958, Greifenstein made the first trials of PCP in humans under the name of Sernyl. Sernyl elicited severe excitation with a prolonged postoperative recovery. Because of its psychedelic effects, it became a street-drug under the name of “angel dust”. Calvin Stevens synthesized ketamine in 1962. The drug was studied in humans in 1964, by Domino and Corssen who described the so-called “dissociative anesthesia”. Ketamine was patented in 1966 under the name of Ketalar for human use and was administered to soldiers during the Vietnam war. The psychedelic effects and the arrival of propofol prompted the shelving of ketamine. However, the discovery of the NMDA-receptor and its non-competitive inhibition by ketamine revolutionized the pathophysiology of hyperalgesia and mental functioning. In early 1990s, the discovery of opioid-induced hyperalgesia elicited a paradigm shift in the management of pain, and a comeback of ketamine, as an anti-hyperalgesic drug. Ketamine is nowadays under the spotlight in the field of treatment-resistant depression and has been proposed as a potential fast antidepressant in patients with high suicidal risk.     

De la clinique au « terrain fétide et palpitant de la vie » : une mise en perspective psychiatrique de la physiologie clinique

Claude Bernard, and his master François Magendie, by the constitution of physiological science, has brought the establishment of a unifying representation system in the field of medicine. According to these representations, the diseases and the therapeutics would be considered by medical doctors as following the same laws of physiology. Physiology would be the condition of a real scientific medicine. How this positioning may be applied to psychiatry? To answer this question, this article proposes first of all to summarize the principal concepts structuring clinical physiology since Claude Bernard. These concepts are those of the “milieu intérieur”, its stability and its regulation. The principles of this regulation system introduced by Claude Bernard lead us to consider him as the first modern systemic physiologist. Moreover these principles of regulation offer the possibility to understanding in an original way the processes of adaptation and acclimatization of an organism. This article then to analyze how these physiological concepts can be applied to psychiatry, including a discussion on the distinction of normal and pathological (by underlining that the difficulty in defining the disease is not specific to mental disorders), by providing a physiological perspective of the notion of syndrome for linking together in a practical way, the requirements of scientific medicine to that of rigorous clinical medicine.