Telepsychiatry at the service of autism

Introduction

The authors report on the set-up of a telehealth system developed to facilitate exchanges between the Autism Resource Centre of Brittany (centre de ressources pour l’autisme [CRA]) located in Brest and an adult psychiatry structure of Vannes’ Hospital in the Morbihan region, these sites are about 200 kilometres distant.

Objectives

This coordinated work using computer networks aims at sustaining the action of a unit specialised in autistic patients. The goal is to both render a precise diagnostic (teleexpertise) and favour assistance and support to residents and their families while instituting a medical education tool for the health professionals of this unit.

Methods

The creation of this telehealth experience, using multiple contact video conferencing, was possible thanks to the existence of the Megalis network, a high speed telecommunication system deployed in the Britanny and Loire region. The connexion of the two sites is made through Cisco type routers. Both sites are linked to the network through urban fiber optics (2–40 MMytes/s output) or Integrated Services Digital Network (ISDN) Access (64 or 128 kbytes/s output). This virtual private network (VPN) style high speed link offers a transparent and secure connexion through the service provider (Novasight) which supervises the technical organisation and the management of the address books of the various listed sites, controls access to the network and manages the network speed. As far as appliances are concerned, (video camera, LCD screen, microphone, maintenance, training), the cost is about 11,000 euros. From their experience, the authors develop the following applications: tele-staffs are meetings of about 2 hours in length.

Discussion

The authors insist on some essential rules, such as putting on the agenda the items to be discussed at the meeting, handing out to everyone the documents needed for the meeting, and designating someone in charge of guaranteeing the good progress of the meeting. His/her functions are to guarantee a precise format for the meeting, to distribute speaking time fairly, to clearly formulate the decisions made (organisation of results, summing up diagnostic results and evaluation of competencies, common institutional actions, arrangement of projects, university research and trainings, scheduling future meetings). Still using their experiences, the authors put forward several recommendations on technology, video and audio links (framing, sound checks, multidirectional microphones, video quality – forcing people to limit rapid gestures…) but also insist on having fit for purpose rooms (soundproofing, neutral decor, homogenous lighting, neon for example…). Contact with patients and their family through video-conference: despite being used less, this technique has shown its pertinence especially for the evaluation of diagnostics and competencies. In practice, the families are joined by the health professionals in charge of the patient in that institution. A meeting chair must be nominated, in our case the doctor in charge of the unit for autistic persons. The doctor from the CRA sits in on the meeting as consulting expert and intervenes at the invitation of the chair. The plan for the meeting and the must-ask questions have to be determined beforehand by the two doctors, so as make sure the meeting will be fast flowing and all the relevant clinical and biographical data are collated. Families, seeing different institutions working together to help their family member despite the distances using high tech solutions, were very satisfied.

Conclusion

On the whole, the authors help us to have good insight into the obstacles (cultural, administrative, technological) and the benefits (availability of consultants with specific competencies, reduction in the waiting time, more efficient use of resources, reduction in costs and risks of travel and of CO₂ emissions…). They believe that health professionals cannot and should not completely avoid travel to the other sites because it is important to get to know the teams well, which is a prerequisite to a good video-conference meeting. This helps creating new directions for the future.     

Tempérament et créativité

The idea that there is a direct link between genius and madness has been a persistent theme from the early Greek times. The scientific literature provides a large body of evidence supporting the notion that the artistic output may be associated with a mental disorder. It appears that the enthusiasm for associating creativity and psychiatric disorders exceeds the scientific evidence. Indeed, most recent studies suggest that schizophrenia is incompatible with sustained writing creativity. However, soft bipolar disorders and cyclothymia are over-represented among writers. These results allow the generation of some hypotheses concerning the dimensions involved in creativity. Some data suggest that a form of affective instability may contribute to the emergence of creativity. Indeed, cognitive and emotional traits associated with some personality features, in particular with the cyclothymic temperament, are likely involved in the creation processes. Furthermore, the consistent reports of increased rates of mood disorders in creative people, and the existence of a genetic component involved in these disorders and in creativity, suggest that in an evolutionistic perspective, the bipolar disorder is necessary for society despite its high human cost. Thus, in clinical practice we need to investigate the consequences of treatments on creativity in bipolar patients.     

Rechute intracérébrale isolée dans la maladie de Hodgkin

Isolated brain relapse is uncommon in Hodgkin's lymphoma and often linked with advanced or refractory disease.

Case reports

We report two patients with stage IV Hodgkin's disease, previously treated with chemotherapy, who later developed neurological symptoms. Brain MRI demonstrated two different types of lesions. Histological findings were consistent with intracranial location of Hodgkin lymphoma. Both of the patients presented only with isolated CNS relapse of the lymphoma.

Conclusion

The two cases demonstrated the MRI appearance of intracranial involvement can be varied and mimic other disease processes in patients with a previous history of Hodgkin's lymphoma. Thus, a biopsy is necessary for diagnosis and correct treatment.     

Bevacizumab for the treatment of cerebral radionecrosis

Bevacizumab is a monoclonal antibody, which neutralizes the effect of vascular endothelium growth factor (VEGF) allowing regression of tumour vessels and a decrease in the permeability of the blood-brain barrier. Already used in oncology as adjuvant treatment for certain metastatic cancers and in second line for high-grade gliomas, it has been recently used as a treatment of cerebral radionecrosis resisting conventional drug treatment and hyperbaric oxygen. This article presents three patients with cerebral radionecrosis and treated by monthly infusions of bevacizumab (10 mg/kg per month). The patients had developed cerebral radionecrosis after radiation therapy for a malignant brain tumour. The radionecrosis was proved by magnetic resonance imaging and spectroscopy. The first patient received only one perfusion of bevacizumab, as the development of a lymphopenia prevented the patient from continuing with the treatment. The second patient received four infusions, but the absence of improvement of the clinical symptoms and progression of the radiolesion led to discontinuation of the treatment. The third patient developed several severe side effects, a transient ischemic accident and a perforated corneal ulcer, resulting again in premature discontinuation of treatment. The development of severe side effects, combined with the absence of notable clinical and radiologic improvements resulting from the use of bevacizumab as a treatment resulted in the premature interruption of such treatment, in all three patients.     

Apports des dispositifs robotisés à la rééducation du membre supérieur hémiplégique

Introduction

Poststroke rehabilitation care has evolved considerably over the last decade. The emergence of the concepts of brain plasticity and motor learning has led to the development of new therapeutic approaches. Most of the new strategies are based on movement therapy, which can have a real impact on neurological recovery, sometimes with significant functional benefit for the patient.

State of the Art

In this context of evolving practices, the hemiplegic arm is the subject of special attention. Considering the often unfavorable “natural” prognosis and the relatively limited impact of conventional therapies; researchers have focused work on new alternatives. Cooperation between developers of technological advances and the medical community has led to the development of innovative therapeutic options often based on the use of specific technological tools (functional electric stimulation, virtual reality, transcranial magnetic stimulation…) to solicit or facilitate movement.

Perspectives/conclusion

Robot-assisted rehabilitation lies within this scope. The positive results reported in the most recent publications and the growing interest for this type of therapy in the fields of medical and engineering research should open the way for extremely promising prospects. The technological performance of new robots has nevertheless raised a large number of unanswered questions, implying a significant amount of further research.     

L'inquiétante étrangeté à l'opéra. À propos du Tour d'écrou de Benjamin Britten

The concept of “disturbing weirdness” was first introduced in psychoanalysis by Freud based on a single opera: Offenbach's Hoffmann's Tales, but this work is far from being the only one to be built on such an atmosphere of “disturbing weirdness” (Unheimlichkeit, in German). Benjamin Britten's The Turn of the Screw, for instance, shows the same characteristics and suggests a new extension of the Freudian concept. The story, first written by Henry James, takes place in a strange English manor, where two children Miles, a boy, and Flora, a girl, seem to have been corrupted by a former female private tutor and a male servant who are supposed to be dead but who are still appearing as ghosts on a high tower or across a lake. Nobody is sure they are really dead, because they keep talking and singing to attract and seduce the children. Distress and anguish hang over the entire opera, which ends tragically for the boy who dies when the new governess tries to extract the secret she thinks he keeps in his mind from him. The author investigates all the possibilities of clarifying the situation and proves that this opera might suggest new meanings and new significations to the Freudian concept of “Unheimlichkeit”.     

L’anxiété préopératoire : manifestations cliniques, évaluation et prévention

Preoperative anxiety consists of physiological and psychological discomfort that manifests itself at the possibility of a surgical intervention. When the anxiety is weak or moderate, it is considered to be an adaptive response to a potentially anxiety producing situation. Prior research has established that high levels of preoperative anxiety increase the risk for postoperative complications as well as emotional and behavioral difficulties. Despite these sometimes severe medical and psychological consequences, very little literature exists aimed at French health care workers on the subject. The goal of this article is to synthesize the existing knowledge on preoperative anxiety, including its clinical manifestations and methods of evaluation and prevention.     

Fonctionnement cognitivo-émotionnel : le rôle de l’intensité émotionnelle chez les individus anxieux

Anxiety is an emotional disorder widespread in the general population and it seems to be linked to depression symptoms. The aim of this study is to test the hypothesis of relations between cognitivo-emotional functioning, anxiety and depressive symptoms. The study sample was formed from a group of 50 female subjects, aged from 18 to 65. Participants completed the Hospital Anxiety and Depression scale (HAD), the Affect Intensity Measure (AIM), the Emotional Expressivity Scale (EES) and the Levels of Emotional Awareness Scale (LEAS). The results show that strong positive correlations between anxiety symptoms affect intensity, emotional expressivity and the level of emotional awareness. To conclude, these results point out the importance of emotional variables in the study and treatment of subjects suffering from anxiety symptoms.     

Représentations étiologiques et problématique identitaire dans la schizophrénie : tentatives de sortie du tourbillon psychotique

This work explores identity in schizophrenia and the role of etiological representations in self-constitution. Identity of the schizophrenic patients is often regarded as defective. This vision, by its reifying aspect, does not take into account the dynamics of any identity constitution and the possibilities of leaving the psychotic crisis. The identity of patients is more a suspended or syncopated identity. Plunged in the swirl of schizophrenic crisis, patients try to reconnect with their own history. Among the means, which they use, representations of the causes of the disease have a paradigmatic place. Patients try to get back to the everyday life of the world, by using social representations of their ill being. But this exchange of representations they engage with their entourage is not a simple way of communication. Using Ricœur's analysis, we show that etiological representations are metaphorical utterances. Considering their central position in the creation of the plot, the etiological representations allow to re-open the constitution of narrative identity, and so the harmonious articulation between the two poles: sameness and ipseity.     

Les thérapies utilisant la réalité virtuelle dans les troubles phobiques

For the past 15 years, virtual reality has been increasingly used as a therapeutic tool in psychiatry. In particular, virtual reality exposure therapy (VRET) has been developed from and proposed as an alternative to standard cognitive behavioural therapy (CBT) for the treatment of phobic disorders. Using real-time computer graphics and visual displays, the patient is immersed in different computer-generated virtual environments specifically designed for different types of phobia. As imaginative or in vivo exposure therapy, VRET consists in a gradual presentation of phobic stimuli. The desensitization through VRET has been found to be efficient in different types of anxiety disorder, and in particular in phobic disorders. Moreover, it presents most of the advantages of both in vivo and imaginative exposure therapies without most of the inconveniences. Indeed, VRET can be tailored to individual progression. It takes place in the privacy of the therapist's office, ruling out all the problems of confidentiality. It can be repeated or prolonged easily, even for rare or dangerous situations. It is less time-consuming for the therapist and really more acceptable by the patients. This report presents the preliminary results of a controlled and randomised study suggesting a comparable efficacy of VRET and standard CBT for the treatment of panic disorder with agoraphobia. Moreover, new therapeutic targets are investigated, like fear of falling. As a conclusion, VRET represents an interesting alternative therapeutic method to standard CBT for the treatment of phobic disorders, but it is generally not sufficient and has to be included in a more global therapeutic project.     

Influence between early maladaptive schemas and depression

Introduction

Early maladaptive schemas developed during childhood are relatively stable. Once activated, these early maladaptive schemas could influence reality perceptions and create cognitive distortions. Previous studies showed that early maladaptive schemas are linked to depression: early maladaptive schemas could be a risk factor for depression (Young, 2001) and a vulnerability marker for depression (Dozoïs, 2007).

Objectives

The main objective of the present study was to explore the influence of early maladaptive schemas on depression severity among a French adult population.

Method

One hundred and sixty-two participants (mean age 29 years; SD = 13.86) were enrolled, 66 men (mean age 29 years; SD = 13.65) and 106 women (mean age 30; SD = 14.07). Participants were invited to complete the Young Schema Questionnaire, short version (YSQ–S1–Young 1994) and the Beck depression Inventory, 2nd version (BDI–II–Beck 1994). Fifty-six participants were randomly selected to complete a paper version of the scales, and 95 participants completed an online electronic version.

Results

Fifty-two percent of the participants were not depressed, 15% slightly depressed, 17% moderately depressed and 16% met criteria of severe depression. All 15 schemas scores were positively correlated to depression scores. Comparing schema scores and depression severity it can be noted that for severely depressed participants all schema scores were significantly higher, and six of 15 schemas were significantly higher in the case of moderate depression. In addition, three schemas (imperfection, vulnerability, fusional relation) are significantly and positively linked to depression scores, whereas one schema (everything is owed to me) appears to be a significantly negative predictor of associated depression.

Conclusion

This study confirms results of previous research concerning the link between early maladaptive schemas and depression. What is more, the results show that the importance of these schemas increases with depression severity. The most important variation was found on schemas concerning interpersonal relationships like “abandonment” or “social insulation and social exclusion” as well as schemas related to personal competence as for example “failure” or “dependence and incompetence”. Further research will be necessary to explore the role of depression as an activator or/and by reinforcing early maladaptive schemas.     

Facteurs de risque environnementaux à la schizophrénie

Schizophrenia is currently a major concern, its prevalence being estimated at around 1% and its social consequences being severe. The elucidation of the pathophysiology of the disease is difficult due to the great variability of clinical expressions, the instability of the clinical symptoms during the evolution and the absence of reliable biological markers. The existence of a familial aggregation in schizophrenia is well known, the risk of presenting the disease for first-degree relatives of patients being 5 to 10 times higher than the risk observed in the general population. The genetic component was further confirmed by twin and adoption studies. Although the concordance for the disease is higher (40 to 70%) among monozygotic twins as compared with dizygotic twins (15%) it does not reach 100%, which implies that environmental factors modulate the effects of the genotype. However, the role of these factors and especially their interaction with genetic factors remain unclear but the implications of some specific environmental factors are well documented by recent research data. The current literature on sex differences in schizophrenia is consistent. Several studies have suggested that male and female patients may differ in age at the onset and expression of clinical symptoms. Complications during pregnancy or birth-giving may increase the risk of developing schizophrenia later in life. The major complications are oxygen deprivation during pregnancy, bleeding, maternal malnutrition or infection (exposure to influenza, for example). A low birth weight is associated with an increased risk of schizophrenia. Psychoses are more common among people living in an urban environment and among those born during winter months. Schizophrenia is probably more prevalent in people who are living promiscuously, are subject to toxic abuse, poor nutrition and stress but here more precise data are needed. Moreover, immigrants have a higher risk of developing psychotic disorders. In addition, head traumas are associated with an increased risk of schizophrenia. Though they are contentious, some studies suggest that substance abuse (cannabis use in European countries) is related to the development of schizophrenia, especially in people with genetic vulnerability. Moreover, substance misuse may worsen the symptoms. If the environment is sufficiently stressful, people with a high genetic vulnerability will develop some degree of mental illness, including schizophrenia. Conversely, a less stressful or a protective environment may decrease the risk of its onset in persons with a predisposition to schizophrenia.     

Psychoéducation et attitude phénoménologique en psychothérapie de groupe

Objectives

Psychoeducation contains the risk of a misunderstanding in the effective experiences of recognition. We want to show that group psychotherapy can be a means to reconcile recommendations in disease prevention aimed by psychoeducative measures, the vivid and lively dimension of experience found in phenomenological attitudes and aspects, turned to the community world of therapeutic mediation.

Method

To articulate these various domains, we approach the principles of psychoeducation, the risks which this one can contain and the contributions of clinical phenomenology. Phenomenological method is different from what we call collectively clinical intuition which is always implicitly colored by the typical contexts of meanings of what appears (meanings which have a practical and effective reach for example) and stay, in spite of the critical distance which we can put it, stuffed with various emotional and theoretical predicates muddled between them. The phenomenological attitude aims as much as possible to a suspension of these predicates, that these predicates arise from the common sense of everyday life or that they arise from a detailed specialized knowledge, and this to remove the “coats of sense” which settled on the perception.

Results

The group, by its multiple interactions, aims at an optimization of the articulation of the self-relationship with relationship socially adapted to the others. The therapist constantly has to attend to dialectical dynamics which reigns between a certain self-dissolution in the group and a return to oneself from the meshing which build up itself within the group. For certain patients, it is particularly difficult to maintain a just balance between the two moments of identity, the one which is peculiar to oneself and the one which emanates from relations with the others towards which we are normally constantly turned. The interest of this psychotherapeutic work in group is here to offer to each of participants the possibility of holding, with a little more confindence, an existential position within a meshing of social links, that is a capacity to seize oneself as existing among the other beings having themselves an own existence. From there, the subjective capacities of each can be better recognized, what can also give place to adjustment of these capacities with individual aspirations. The active implication of patients, so looked for by psychoeducation, is all the more tangible as we were so able to appeal, by the phenomenological attitude, to what feels immediately and without distance as much in an intimate self-relation as in relationship to the others.

Conclusions

Phenomenological attitude allows not to get stuck in imaginary expert skills, in rational projects of organization and other methodical constructions of the science. This attitude is particularly interesting for group psychotherapy which privileges the opening rather than a work of elaboration. The stake is so the authenticity of a real therapeutic alliance based on fine regulations of the global situation of co-presence taking into account the interlacing of the implicit and the explicit in the exchanges which weave with the patients. We privilege a fertile step rather than rigorous observance of a method which would lead only to a systematization against the spirit of phenomenology. The clinical experience shows that this psychotherapeutic method allows in particular a regular attendance of the group, what is one of major ingredients of its efficiency.     

Les thérapeutiques non médicamenteuses en psychiatrie

Resistance to psychopharmacological and psychotherapeutic therapies is a frequent difficulty clinicians are confronted to, with a frequency of 20 to 30 % concerning depression disorders. Other therapeutic approaches hence seem unavoidable to optimize treatments: structured psychotherapies such as behavioural and interpersonal therapies have shown their efficiency in anxiety and depression disorders, psychoeducational approaches help better observance in chronic pathologies. Biological and non medicinal approaches such as electroconvulsive therapy are still a therapy of reference for treating mood disorders and remain an indication for resisting schizophrenic disorders.     

Séquelles délirantes d’une psychose puerpérale ancienne, un climat d’inquiétante étrangeté : observation clinique

Mr and Mrs P., recently settled in the area, are experiencing difficulties. Mr P. suffering from depression has to be admitted to the hospital. Mrs P., who suffered for years from bipolar trouble, is sent to the outpatients department for medical supervision of her lithium treatment. Discussions with her and the reading of a text she wrote years before bring back a delirious experience, which happened 20 years ago involving the disturbing strangeness of a world of goats. This looking back into the past becomes the starting point of an intense pictorial productivity on which the psychotherapy will be based… An eight months effort which will succeed in obtaining the normalization of family life and a better adaptability to reality.     

Réorganisation du cortex sensorimoteur dans le cadre de la paralysie cérébrale unilatérale : apports des neurosciences

Cerebral palsy (CP) is a non-progressive injury to the developing central nervous system and defines as permanent disorders of the development of movement and posture, causing activity limitation. This neurodevelopmental disorder may lead to spastic unilateral cerebral palsy after early unilateral brain lesions. Physical and rehabilitation medicine has a particular interest in the study of organization and reorganization of the sensorimotor cortex following early brain injury. From neuroscience standpoint, early brain lesions have been shown to induce substantial neural reorganization owing to the higher plasticity in the developing brain. Unilateral injuries either to the motor cortex or the corticospinal tract can lead to different patterns of reorganization of the sensorimotor cortex. Many patients develop ipsilateral corticospinal pathways to control the paretic hand with the non-lesioned hemisphere. This type of reorganization is often observed following unilateral periventricular brain lesions, which damage the corticospinal tracts in the periventricular white matter. In this group of patients, the primary motor cortex has been found to be represented in the non-lesioned precentral gyrus ipsilateral to the paretic side. Inversely, in patients with perinatal unilateral middle cerebral artery stroke, primary motor cortex remains organised in the lesioned precentral gyrus contralateral to the paretic hand. However, regardless of these inter- or intrahemispheric motor representations, the primary somatosensory cortex representation remains in the lesioned hemisphere in both groups. These two types of corticospinal reorganization could influence the efficacy of rehabilitation.     

La médiation de la musique en psychothérapie

The choice of music as a therapeutic mediation is justified through consideration about the human being and his musicality, and about the components of music. The concept of therapeutic mediation, referring to Winnicott’s works, may be applied with advantage to the field of Musictherapy. It leads us to characterize the specificity of the therapeutic relation, and to emphasize the complexity of techniques. We shall end with recalling the definition of Musictherapy taking into account all those elements.