Is early management of psychosis designed for migrants? Improving transcultural variable collection when measuring duration of untreated psychosis

Asserting a Functional Neurological Symptom Disorder with a Complementary Diagnostic Approach: A Brief Report

INTRODUCTION

Functional neurological symptom disorder (FNSD) is a common diagnosis among adolescents. However, we feel it is a difficult diagnosis to assess because of the diversity of its clinical manifestations, the rapid changes in its nosography over the years, and its common imbrication with established somatic diagnoses. We would like to illustrate this hypothesis through a case presentation and the original diagnostic process that emerged from it.

METHODS

We chose to present our diagnosis approach through the case of an 11-year-old boy who showed a progressive loss of motor and sensory function to the point of total dependency, and then suddenly switched between this state and a "normal" physical presentation, while deliriously claiming to be an angel.

RESULTS

All possible infectious, autoimmune, metabolic, and toxic disorders were ruled out. After the successive therapeutic failures of antidepressants and neuroleptics, FNSD was diagnosed.

CONCLUSION

The DSM-5-TR classification was insufficient to explain the full clinical picture and a complementary approach (biblical, psychoanalytical, and historical) was used to analyze the cause of this atypical presentation.

Multimodal co-therapy for unaccompanied minors: a qualitative study

BACKGROUND

Unaccompanied refugee minors-or unaccompanied minors-are children and adolescents who have been separated from parents and other relatives and are not being cared for by an adult. Unaccompanied minors are a vulnerable population, with numerous stressors and complex psychiatric symptoms necessitating specialized mental health care. This study explores patients' experiences of a Multimodal Co-Therapy for Unaccompanied Minors (MUCTUM), which encompasses cultural, biological, narrative & institutional approaches to care.

METHODS

MUCTUM is a co-therapy program for unaccompanied minors, with a psychiatrist, psychologist, native-language interpreter, and caseworker for each patient. In this qualitative study, we interviewed adolescents about their experiences with MUCTUM and analyzed these semi-structured interviews using a phenomenological framework (Interpretative Phenomenological Analysis).

RESULTS

Qualitative analysis of 16 interviews discovered that unaccompanied minors felt misunderstood before participating in MUCTUM, describing a sense of strangeness and loneliness in relation to psychiatric symptoms. Several youths experienced triple stigmatization: of being unaccompanied minors, of suffering from psychotrauma, and of being mental health patients. We further describe three overarching domains that inform on MUCTUM support to unaccompanied minors: (1) A safe space for unaccompanied minors; (2) Helpful interventions during therapy; and (3) Narrating one's story can "set us free" if guided carefully by care providers.

CONCLUSION

This study suggests that MUCTUM therapy may efficiently support unaccompanied minors' mental health by acknowledging their hierarchy of needs. Psychotherapeutic strategies include creating a safe place, providing culturally appropriate care and patient-centered therapy, addressing concrete problems, supporting relationships, and making use of limited reparenting in therapy. Delayed and progressive inquiry about traumatic events may be beneficial. Replication of these findings and their field application is warranted.

The effects of childhood adversity on treatment delays and its components in first-episode psychosis

Apart from increasing risk for psychotic disorders, childhood adversity has been associated with worse outcomes. One way in which childhood adversity may worsen outcomes is by lengthening treatment delays, which are associated with negative impacts. We tested the influence of childhood trauma on treatment delays, measured as the duration of untreated psychosis (DUP), and its help-seeking and referral components, in a first-episode psychosis cohort (N = 203). We accounted for pertinent social (e.g., migrant status) and other determinants (i.e., age at onset, diagnosis, symptoms) of treatment delays. Multiple linear regression analyses revealed that for a one-unit increase in Childhood Trauma Questionnaire (CTQ) scores, average overall DUP increased by 25%. Higher CTQ scores also significantly predicted help-seeking and referral DUPs. Patients with schizophrenia-spectrum psychosis had longer help-seeking and total DUPs than those with affective psychosis. More severe positive symptoms predicted longer help-seeking DUPs, while more severe negative symptoms predicted longer referral DUPs. Indicators of social disadvantage did not affect DUP. Our results show that childhood trauma increases DUP by prolonging the help-seeking process and delaying access to mental healthcare even after help is sought. Early identification of psychosis among populations with trauma histories seems warranted and can likely positively impact outcomes.

Implementing organicity investigations in early psychosis: Spreading expertise

BACKGROUND

Many medical disorders may contribute to adolescent psychoses. Although guidelines for thorough organicity investigations (OI) exist, their dissemination appears scarce in nonacademic healthcare facilities and some rare disorders remain undiagnosed, many of them presenting without easily recognized phenotypes. This study aims to understand the challenges underlying the implementation of OI in non-academic facilities by practitioners trained in expert centers.

METHODS

Sixteen psychiatrists working at French non-academic facilities were interviewed about their use of OI for adolescents suspected of early psychosis. Interviews were analyzed with Grounded Theory.

RESULTS

Organicity investigations were found to be useful in rationalizing psychiatric care for the young patient all the while building trust between the doctor and the patient's parents. They also are reassuring for psychiatrists confronted with uncertainty about psychosis onset and the consequences of a psychiatric label. However, they commonly find themselves facing the challenges of implementation alone and thus enter a renunciation pathway: from idealistic missionaries, they become torn between their professional ethics and the non-academic work culture. Ultimately, they abandon the use of OI or delegate it to expert centers.

CONCLUSION

Specific hindrances to OI implementation must be addressed.

Clinical Lycanthropy, Neurobiology, Culture: A Systematic Review

Background: Culture can affect psychiatric disorders. Clinical Lycanthropy is a rare syndrome, described since Antiquity, within which the patient has the delusional belief of turning into a wolf. Little is known on its clinical or therapeutic correlates. Methods: We conducted a systematic review (PRISMA) on PubMed and Google Scholar, until January 2021. Case reports, data on neurobiological hypotheses, and cultural aspects were included. Language was not restricted to English. Results: Forty-three cases of clinical lycanthropy and kynanthropy (delusion of dog transformation) were identified. Associated diagnoses were: schizophrenia, psychotic depression, bipolar disorder, and other psychotic disorders. Antipsychotic medication may be an efficient treatment for this rare transnosographic syndrome. In case of depression or mania, the treatment included antidepressants or mood regulators. The neuroscientific hypotheses include the conception of clinical lycanthropy as a cenesthopathy, as a delusional misidentification of the self-syndrome, as impairments of sensory integration, as impairments of the belief evaluation system, and right hemisphere anomalies. Interestingly, there is a clinical overlap between clinical lycanthropy and other delusional misidentification syndromes. Clinical lycanthropy may be a culture-bound syndrome that happens in the context of Western cultures, myths, and stories on werewolves, and today's exposure to these narratives on cultural media such as the internet and the series. We suggest the necessity of a cultural approach for these patients' clinical assessment, and a narrative and patient-centered care. Conclusions: Psychiatric transtheoretical reflections are needed for complementaristic neurobiological and cultural approaches of complex delusional syndromes such as clinical lycanthropy. Future research should include integrative frameworks.

School Refusal or Truancy? A Qualitative Study of Misconceptions Among School Personnel About Absenteeism of Children From Immigrant Families

BACKGROUND

School refusal is a form of school attendance problem (SAP) distinct from truancy, school withdrawal, and school exclusion; it requires specific mental health care. Schools' identification and referral to care of school refusers depends on school personnel's interpretation of the reasons for absences. Because cultural factors can induce misunderstanding of the young people's behavior and of their parents' attitudes toward school attendance, school personnel can have difficulty understanding these reasons for children with transcultural backgrounds (migrants or children of migrants). The aim of this study was to explore the experiences and opinions of school personnel, mainly teachers, related to school refusal among these students.

METHODS

Grounded theory methodology was used to conduct 52 qualitative interviews of school personnel in two regions of France. Their daily practices with students presenting with school refusal were addressed in general (i.e., in response to absence of all youth) and in transcultural contexts (i.e., absence of migrant children or children of migrants). This study analyzed the interviews of the 30 participants who reported working with students from transcultural backgrounds.

RESULTS

Many school personnel reported experiencing difficulties, ambivalence, and destabilizing feelings in situations involving immigrant families whose school culture differed from their own. Talking about culture appeared to be taboo for most participants. These situations challenged the participants' usual strategies and forced them to devise new ones to deal with these young people and their families. Although some personnel were at risk of developing exclusionary attitudes, others dealt with school refusal with both commitment and creativity.

CONCLUSION

The tensions experienced by these participants reveal contradictions between the French universalist ideology and the reality of daily life in schools becoming increasingly multicultural. School personnel's attitudes toward children with transcultural backgrounds presenting with school refusal can affect children's access to care and shape social inequalities. Further research should develop, implement, and assess interventions including transcultural training of school personnel, improved use of interpreters at school for migrant families, and the addition of a transcultural dimension to SAP assessment scales, especially for school refusal.

Migrant Parents of Adolescents With School Refusal: A Qualitative Study of Parental Distress and Cultural Barriers in Access to Care

Introduction: School refusal is an important problem in adolescent psychiatry. However, little is known about the experience of school refusal among minority youth (migrants and minority ethnic groups). This study assesses how parents of various cultural backgrounds experience their adolescents' school refusal. Method: This qualitative study is based on interviews of 11 parents of teenagers diagnosed with school refusal at three adolescent outpatient mental health units in Paris and its suburbs. Interpretative phenomenological analysis was used for the thematic investigation. Results: The analysis found four themes: (i) confronting school and school refusal distresses parental representations; (ii) school refusal as a failure of the family's obligation to succeed after migration; (iii) representations of school that fluctuate with time since arrival: idealization, followed by mistrust and disappointment in the inequalities, even the racism; (iv) solutions envisioned for school refusal, confronting the healthcare system, stigma, and, again, inequality. Conclusion: All parents question their parenting choices when their children become school refusers. However, when families belong to minority groups, school refusal calls into question parents' relations with the French school system and their immigration choices. At the same time, the construction of a multicultural identity for children and adolescents in transcultural situations requires them to strike a balance between two worlds, and school refusal endangers this delicate negotiation. Subsequent misunderstandings can lead clinicians to misdiagnose school refusal as truancy. Clinicians must take the parents' culture and migration history into account to minimize the risk of complete failure of treatment for school refusal and the ensuing inequality of care and opportunity that can result.