Influence of at-risk family interactions on the course of psychiatric care in adolescence

Dysparenting, referring to inappropriate parental attitudes, is a vulnerability factor for mental disorders during adolescence and a therapeutic leverage, yet clinicians lack reliable tools to assess it in daily clinical practice. Moreover, the effect of this dysparenting on the amount of psychiatric care remains unclear. The Family and Care study aims to develop the at-risk family interactions and levers (ARFIL) scale, a comprehensive 30-item clinical scale, and to assess in a cross-sectional design, the impact of these at-risk family interactions on the care of adolescents (n = 425) hospitalized in psychiatry and aged 13-19 years old. Factorial analysis shows that the ARFIL scale consists of three main dimensions associated with cohesion/conflicts, love/hostility, and autonomy/control with good psychometric properties. Multivariate regressions show that the ARFIL intensity score predicts the duration of hospital care, regardless of age, gender, medical severity on admission, assessed by the Global Assessment of Functioning scale, the presence of maltreatment and psychiatric diagnoses. Moreover, the ARFIL diversity score (number of items present regardless of their severity) predicts both the number and duration of hospitalizations. At-risk family interactions are a determining dimension of psychiatric adolescent care, and the ARFIL scale could constitute a valuable tool, not only for holistic evaluation and treatment, but also for prevention.

Personality trait risk factors for attempted suicide among young women with eating disorders

Objective

Clinical observations and a review of the literature led us to hypothesize that certain personality and character traits could provide improved understanding, and thus improved prevention, of suicidal behaviour among young women with eating disorders.

Method

The clinical group consisted of 152 women aged between 18 and 24 years, with DSM-IV anorexia nervosa/restrictive type (AN-R = 66), anorexia nervosa/purging type (AN-P = 37), bulimia nervosa/non-purging type (BN-NP = 9), or bulimia nervosa/purging type (BN-P = 40). The control group consisted of 140 subjects. The assessment measures were the Minnesota Multiphasic Personality Inventory—second version (MMPI-2) scales and subscales, the Beck Depression Inventory (BDI) used to control for current depressive symptoms, plus a specific questionnaire concerning suicide attempts.

Results

Suicide attempts were most frequent in subjects with purging behaviour (30.0% for BN-P and 29.7% for AN-P). Those attempting suicide among subjects with eating disorders were mostly students (67.8%). For women with AN-R the scales for ‘Depression’ and ‘Antisocial practices’ represented significant suicidal risk, for women with AN-P the scales for ‘Hysteria’, ‘Psychopathic deviate’, ‘Shyness/Self-consciousness’, ‘Antisocial Practices’, ‘Obsessiveness’ and ‘Low self-esteem’ were risk indicators and for women with BN-P the ‘Psychasthenia’, ‘Anger’ and ‘Fears’ scales were risk indicators.

Conclusion

This study provides interesting results concerning the personality traits of young women with both eating disorders and suicidal behaviour. Students and those with purging behaviour are most at risk. Young women should be given more attention with regard to the risk of suicide attempts if they: (a) have AN-R with a tendency to self-punishment and antisocial conduct, (b) have AN-P with multiple physical complaints, are not at ease in social situations and have antisocial behaviour, or (c) if they have BN-P and tend to be easily angered with obsessive behaviour and phobic worries. The MMPI-2 is an interesting assessment method for the study of traits indicating a risk of suicidal behaviour in young subjects, after controlling for current depressive pathology.

[Which psychiatric comorbidities in cannabis dependence during adolescence? Comparison of outpatients and controls]

BACKGROUND

The use of illicit substances, in particular cannabis, among French adolescents and young adults has become an important public health concern. A better understanding of the mechanisms involved in pathological substance use is nowadays critical. Psychiatric comorbidities have been previously reported in adult substance abusers but are less documented in adolescents, especially regarding cannabis dependence.

OBJECTIVES

We investigated mental health problems in adolescents and young adults, seeking treatment for their problematic cannabis use, comparatively to healthy controls, taking into account the participant's gender and age. Moreover, we explored the relationships between psychiatric diagnosis and substance use modalities.

METHODS

In total, 100 young patients (80 males - mean age 18.2 (SD=2.9; [14 to 25] years old)) with a cannabis dependence (DSM-IV-TR criteria) seeking treatment in an addiction unit, and 82 healthy control subjects (50 males - mean age 18.3 (SD=3.4; [14 to 25] years old)) with no substance misuse diagnostic other than for alcohol, participated in the study. The MINI was administered to evaluate cannabis dependence, and DSM-IV axis I comorbid diagnosis, and a semi-structured interview was used to determine psychoactive substance use.

RESULTS

Statistical analyses revealed that 79 % of the patients reported at least one other non-drug or alcohol comorbid diagnosis, versus 30.5 % in the control group (χ²=16.83; P<0.001). Logistic regression indicated that participants with a psychiatric diagnosis had an 8.6 times higher risk (P<0.001; OR 95 % CI=[4.38-16.81]) of being patients. Significant inter-group differences and OR were noted for several diagnoses: dysthymia over the previous 2years (χ²=14.06; P<0.001; OR=10.63; OR 95 % CI=[2.41-46.87]), life-time panic attack disorder (χ²=4.15; P<0.042; OR=3.59; OR 95 % CI=[0.98-13.19]), alcohol abuse (χ²=47.72; P<0.001; OR=66.27; OR 95 % CI=[8.87-495.11]) and dependence (V=0.230; P=0.001) and generalized anxiety disorder (χ²=7.46; P=0.006-OR=3.57; OR 95 % CI=[1.37-9.30]). On the whole, the females (n=20) of our clinical sample presented significantly more comorbid diagnoses than the males (n=80) (95 % versus 75 %; χ²=6.25, P=0.011). These significant gender differences were found for life-time eating disorder (V=0.352; P=0.007) and generalized anxiety disorder diagnoses (V=0.278; P=0.013). Moreover, young adult patients (19-25years old; n=35) presented, on the whole, significantly more comorbid diagnoses than adolescent patients (14-18years old; n=65) (70.8 % versus 94.3 %; χ²=7.58, P=0.006). These age inter-group differences were found for several diagnoses: alcohol dependence (6.2 % versus 20 %; V=0.211, P=0.047), dysthymia over the past 2years (13.8 % versus 34.3 %; χ²=5.73, P=0.017) and generalized anxiety disorder (12.3 % versus 40 %; χ²=10.17, P=0.001). Various associations were observed between psychiatric comorbid diagnosis and substance use indicators.

CONCLUSION

This study demonstrates that cannabis dependence in adolescents and young adults is related to great psychological distress and puts emphasis on the importance of substance use prevention as early as middle school. Moreover, the psychiatric features of adolescents and young adults need to be taken into consideration for treatment planning.

[Adolescent manic-depressive disorders: Clinical aspects]

More than 50% of bipolar disorders diagnosed among adults first appeared before the age of 18. It is well established that adolescence is the high-risk period for the onset of major mood episodes associated with bipolar disorders. Even though there are few early-onset bipolar disorders, they are very severe. The most robust risk factor predicting bipolar disorder is a positive family history. Morbidity, mortality, and suicidality are high and have a severe impact on overall functioning, professional integration, family life, and affective relationships. Improving diagnosis of early symptoms should ameliorate these patients' prognosis.

Pompe à GnRH : la grossesse à l’épreuve de l’anorexie mentale ?

Il est fréquent de penser que les femmes souffrant de trouble des conduites alimentaires (TCA) ne peuvent pas être enceintes (aménorrhée, irrégularités du cycle ovulatoire), mais plusieurs études [1–3] révèlent un nombre croissant de femmes souffrant d’un TCA parmi la population ayant recours aux divers traitements de l’infertilité. La stimulation ovarienne par pompe à GnRH est l’un des traitements de l’infertilité, étant très efficace avec un taux de réussite de 91,8 % , il a été conçu pour les femmes présentant une aménorrhée de type hypothalamohypophysaire, dont les deux principales causes sont le syndrome de Kalmann et un apport calorique insuffisant. L’objectif de cette étude est de diagnostiquer la prévalence d’un TCA parmi une population de femmes ayant recours à la pompe à GnRH. Nous avons créé un groupe « étude » constitué de femmes sous ce type de traitement, et un groupe « contrôle », constitué de femmes sous traitement par d’autres méthodes de procréation médicalement assistée (PMA). Nous avons utilisé le « Composite International Diagnostic Interview » (CIDI), un hétéro-questionnaire capable de diagnostiquer la présence d’un TCA, actuel ou passé. Chaque groupe est constitué de 21 patientes. Parmi les femmes en traitement sous pompe à GnRH, 20 sur 21 présentent un diagnostic positif de TCA, soit 95,2 % du groupe. Parmi celles traitant leur infertilité par d’autres méthodes de PMA, ce diagnostic a été établi chez seulement 5, soit 23,8 % du groupe (p = 0,00002). En conclusion de cette étude, nous souhaitons alerter la communauté scientifique et médicale : la périnatalité chez les femmes souffrant d’un TCA est un enjeu de santé publique. Il nous paraît nécessaire d’effectuer un dépistage dans les PMA et l’accès de ces femmes doit être réfléchi en cas d’un TCA actif. De plus, nous recommandons la mise en place d’équipes multidisciplinaires spécialisées pour les accompagner pendant le processus de périnatalité/maternité.

Actualités 2015 autour du trouble de la personnalité borderline

Le trouble borderline est le plus fréquent des troubles de la personnalité, et sa prise en charge reste un enjeu majeur pour les psychiatres d’adultes, mais aussi pour les psychiatres d’adolescents et d’enfants. Le trouble borderline, même s’il trouve pour partie son étiopathogénie dans certaines anomalies génétiques, est aussi profondément caractérisé par des facteurs environnementaux précoces de l’enfance. Nous commenterons les études les plus récentes qui, via une conception plus dimensionnelle du trouble, retrouvent un continuum entre les adultes borderline et certaines anomalies développementales chez l’enfant. Nous ferons également une description plus précise des profils de ces enfants, illustrant certaines données sur les fondements étiologiques du trouble borderline, et nous discuterons des possibilités de prévention de ce trouble. Les troubles liés à l’utilisation de substances sont une des comorbidités les plus fréquentes chez les adolescents présentant un trouble de la personnalité borderline, compliquant le suivi de ces jeunes patients, et pouvant entraîner retrait social et désinvestissement scolaire. Nous détaillerons la prévalence des différents troubles liés à l’utilisation de substances chez les adolescents borderline de notre étude, en comparant nos résultats à ceux décrits dans la littérature internationale. Les tentatives de suicide constituent une préoccupation constante pour les cliniciens, mais également un problème majeur de santé publique via le surcoût engendré (passages aux urgences, hospitalisations…). Aucun traitement psychotrope n’a prouvé son efficacité dans la prévention des tentatives de suicide chez les patients borderline, et certaines psychothérapies, comme la thérapie dialectique comportementale de M. Linehan, ont été développées spécifiquement diminuer la fréquence des passages à l’acte hétéro-agressifs de ces patients. Nous présenterons un dispositif innovant de prévention reposant sur la mise en place d’une permanence téléphonique spécifiquement dédiée à ces patients borderline adultes.

Mood disorders in eating disorder patients: Prevalence and chronology of ONSET

OBJECTIVES

In a clinical population, we estimated the frequency of mood disorders among 271 patients suffering from Anorexia Nervosa (AN) and Bulimia Nervosa (BN) in comparison to a control group matched for age and gender.

METHOD

The frequency of mood disorders was measured using the Mini International Neuropsychiatric Interview (MINI), DSM-IV version.

RESULTS

Mood disorders were more frequent among eating disorder (ED) patients than among controls, with a global prevalence of the order of 80% for each ED group. The majority of the mood disorders comorbid with ED were depressive disorders (MDD and dysthymia). The relative chronology of onset of these disorders was equivocal, because mood disorders in some cases preceded and in others followed the onset of the eating disorders.

LIMITATIONS

Our sample was characterized by patients with severe ED and high comorbidities, and thus do not represent the entire population of AN or BN. This also may have resulted in an overestimation of prevalence.

CONCLUSION

Mood disorders appear significantly more frequently in patients seeking care for ED than in controls. These results have implications for the assessment and treatment of ED patients, and for the aetio-pathogenesis of these disorders.

[Self-esteem, coping, perceived social support and substance use in young adults with a cannabis dependence disorder]

INTRODUCTION

Self-esteem, coping strategies and perceived social support play a role in the adaptive functioning of the human being: they allow the adjustment of the subject to his/her environment. These dimensions could be protective factors regarding multiple risks associated with adolescent development, and particularly substance use. Thus our objective was twofold: to evaluate self-esteem, coping strategies and perceived social support in adolescents and young adults with a cannabis dependence in comparison with subjects from the general population; to establish the correspondence between these psychological dimensions and the patients' substance use pattern.

METHOD

Data from 43 young patients (36 males; mean age=19.6±3), consulting for their cannabis dependence, and 50 young adults from the general population (39 males; mean age=19.7±3.4) were included. Participants completed the Rosenberg Self-Esteem Inventory, the Social Self-Esteem Inventory of Lawson, the Coping Inventory for Stressful Situation of Endler & Parker, and the Perceived Social Support Questionnaire of Sarason. The MINI was administered to evaluate cannabis abuse or dependence; a semi-structured clinical interview was given to determine psychoactive substance use.

RESULTS

Between-group comparisons (two independent sample t-tests) showed that the patients had significantly lower scores on global (P=0.002) and social (P=0.035) self-esteem, task-oriented coping (P<0.001) and both availability and satisfaction regarding perceived social support (respectively P=0.029 and P<0.001). Conversely, patients had significantly higher scores on emotion-focused coping subscale (P=0.003). Logistic regressions showed that the satisfaction regarding social support and task-oriented coping scores were the more powerful to distinguish the patients from the controls (respectively β=1.16, P=0.043 and β=1.06, P=0.015). Unvaried linear regression analyses revealed a negative association between the age of first cannabis use and the avoidant-social coping score (P=0.025), and positive associations between the length of daily cannabis use and emotion-focused coping score (P=0.028), and frequency of cannabis use and global self-esteem scores (P=0.028). Moreover, polysubstance misuse is associated with low distraction-avoidant coping scores. No association was found between clinical scores and tobacco and alcohol uses variables.

CONCLUSION

These results suggest that cannabis dependent patients may present a lack in individual and interpersonal resources. This clinical study underscores the potential contribution of maladaptive coping to the development or maintenance of substance use in young adulthood.

Borderline personality disorder and mental healthcare service use among adolescents

Borderline personality disorder (BPD) is believed to be frequent among adolescents. While several prospective studies have assessed the use of mental health services among adults who suffer from BPD, few studies have provided adolescent data. This paper presents findings from the first assessment point of the European Research Network on Borderline Personality Disorder (EURNET BPD) study. In this study, we describe lifetime treatment utilization for 85 adolescents with BPD (Mean age: 16.3 years old). In line with adult findings, adolescents with BPD reported greater mental healthcare service use (outpatient: 98%; inpatient: 79%) compared to controls. Phenothiazine, a sedative neuroleptic, was the most frequently prescribed treatment. 47% of patients had received psychotherapy; in one our of three cases this was psychodynamic therapy. Patients who had received psychotherapy did not differ on any psychopathological variables from those who did not receive psychotherapy; however, psychotherapy was more frequent among females.

[The Dependent Personality Questionnaire (DPQ): French translation and validation study in a population of 138 hospitalized psychiatric patients]

INTRODUCTION

Dependent personality disorder is a new diagnosis introduced in the third version of the DSM (DSM-III). Contrary to other disorders of personality, as the borderline or the schizotypal personalities, there are no specific interviews or questionnaires focusing on dependent personality. Thus the study of dependent personality disorder requires the use of global interviews or questionnaire as the SCID -II or SIDP-IV. Recently, Tyrer and colleagues (2004) have proposed an 8-item questionnaire, the DPQ (Dependent Personality Questionnaire). Each item of the DPQ is rated from 0 to 3 with a total score ranging from 0 to 24. Using a sample of 30 psychiatric patients presenting various diagnoses and a dependent personality disorder for the half of the sample, the authors have determined the cutoff score allowing the diagnosis of DSM-IV Dependent Personality Disorder. A cutoff of 10 was associated with the best sensitivity (87.5%), specificity (87.5%) and positive predictive value (87.5%). Moreover, the value of the Youden coefficient (Sensitivity+Specificity - 100) was 75.

OBJECTIVE

The aim of the study was to present the French version of the DPQ and to determine its psychometric properties as well as the cutoff score.

METHODS

One hundred and thirty-eight psychiatric inpatients (97 females, 41 males) with a mean age of 42.26 years were included in the study. The patients were hospitalized in an inpatients unit receiving mood disorders, neurotic disorders or suicide attempters. The subjects filled out the French versions of the DPQ and the Personality Disorders Questionnaire of Hyler, PDQ-4+. Using the PDQ-4+ two groups were built: 25 subjects filled out the diagnoses of dependent personality disorder and 20 subjects did not meet any criteria of dependent personality disorder. Then, for different values of the DPQ, sensitivity, specificity and positive predictive value and Youden indicia (Sensitivity+Specificity - 100) were calculated.

RESULTS

The best values of Youden indicia (74) were obtained for the cutoff of 13 on the DPQ. The corresponding sensitivity, specificity and positive predictive value were respectively 84, 90 and 91.3%.

CONCLUSION

The French version of the DPQ is now available and permits detection of dependent personality in French populations.

LIMITATIONS

Our results must be replicated using structured interviews of personality disorder instead of questionnaires (PDQ-4+) and other samples with different prevalence of dependent personality disorders must be used to test the potential cutoff scores of the DPQ.

The Bermond-Vorst Alexithymia Questionnaire cutoff scores: a study in eating-disordered and control subjects

BACKGROUND

The evaluation of alexithymic deficits has become increasingly desirable in health and psychopathology research. The purpose of this study was to calculate alexithymia cutoff scores for a recently developed self-report alexithymia questionnaire: the Bermond-Vorst Alexithymia Questionnaire Form B (BVAQ-B).

SAMPLING

Three hundred subjects (47 eating-disordered patients and 253 healthy individuals) completed the BVAQ-B and the 20-item Toronto Alexithymia Scale (TAS-20).

METHODS

The TAS-20 was used as a gold standard for this research, with its previously established cutoff scores serving as diagnostic criteria for determining the presence or absence of alexithymia. The BVAQ-B cutoff score selection was based on the examination of psychometric data (i.e., the sensitivity and specificity of the BVAQ-B scores and receiver operating characteristic curve analyses) and of clinical data (i.e., BVAQ-B mean score of the control subjects, who were mostly nonalexithymic, and BVAQ-B mean score of a group of patients with eating disorders, the majority of whom were alexithymic).

RESULTS

This research found that the most appropriate BVAQ-B cutoff scores for determining the absence and presence of alexithymia were 43 and 53, respectively.

CONCLUSION

In light of these findings, we believe that the BVAQ-B may also lend itself to a categorical evaluation of alexithymia, with these cutoff scores determining its absence or presence.

Resolving a disagreement in a clinical team: overcoming conflicting views about the role of family therapy in an outpatient treatment programme for anorexia nervosa

In the Adolescent Psychiatry Department at the Institut Mutualiste Montsouris, Paris, as is also observed in the literature, the outcome for anorexic patients can sometimes be catastrophic, regardless of treatments proposed. This disturbing finding led us to reassess our therapeutic treatment strategies, in an effort to improve patient outcome. The multidimensional treatment program implemented in the Department includes parent counselling, but not the whole family in a family therapy procedure. It has been demonstrated better outcome for patients who underwent family therapy in comparison to patients who underwent individual therapy. This raised the question of whether family therapy could improve our outpatient programme. This paper describes here how a research programme was developed to resolve a disagreement in our clinical team as to whether family therapy should be added to the existing care programme. The paper describes the difficulties encountered by our team, and the experimental design chosen to resolve the debate. Data will not be set out here.

Étude des relations entre alexithymie et anhédonie chez des femmes présentant des troubles du comportement alimentaire et chez des témoins

INTRODUCTION

Alexithymia and anhedonia both refer to a deficit in emotion regulation. Although these 2 concepts have been conceptualized to be closely linked, very few studies aimed at examining carefully their interrelations.

OBJECTIVES

Therefore, the purpose of the present study was to investigate the relationships between scores on alexithymia and anhedonia self-reports, and to assess whether the results were influenced by the presence of an emotional disorder.

LITERATURE FINDINGS

The 20-item Toronto Alexithymia Scale is the self-report most frequently used to assess alexithymia. Nevertheless, the results of recent studies comparing the psychometric properties of the TAS-20 and another alexithymia self-report - the Bermond-Vorst Alexithymia Questionnaire (BVAQ) - have recommended the BVAQ over the TAS-20.

DESIGN

Thus, both questionnaires were included in the present study. In addition, since depression and anxiety may influence the correlations between alexithymia and anhedonia scores, we also measured depression and anxiety and these scores were used to control for their potential confounding effect in the analyses. Two groups of participants were included in this study: 46 eating disordered female patients (ED) and 198 female control subjects. All the participants filled up the Bermond-Vorst Alexithymia Questionnaire-form B (BVAQ-B), the 20-item Toronto Alexithymia Scale (TAS-20), the Chapman and Chapman Social Anhedonia Scale (SAS) and Physical Anhedonia Scale (PAS), the 13-item Beck Depression Inventory (BDI) and the Spielberger State and Trait Anxiety Inventory (STAI-Y). The analyses consisted, first, in establishing the matrix of correlations between these self-reports total scores, using Pearson's coefficients of correlation. Then, TAS-20, BVAQ-B, SAS and PAS scores were correlated, adjusting for BDI and STAI scores, using partial correlation analyses. Mean scores comparisons according to the group of participants, and to the presence/absence of alexithymia, as well as to the presence/absence of anhedonia were performed using ANCOVAs or Mann-Whitney tests.

RESULTS

As predicted, BDI and STAI scores were found significantly and positively correlated with alexithymia and anhedonia scores in both participant groups. After controlling for depression and anxiety scores, TAS-20 and PAS scores remained significantly correlated, but not TAS-20 and SAS scores. BVAQ-B scores remained significantly correlated with PAS and SAS scores in the control group, but only with the PAS scores in the ED group. ED patients had higher alexithymia and anhedonia scores than the controls. In total, among the alexithymic individuals, 8.9% were social anhedonics, and 31.1% had a physical anhedonia. Conversely, among the participants with a physical anhedonia, two third were alexithymics. The same proportion of participants with a social anhedonia was alexithymic (66.7%).

CONCLUSION

The results of the present study are informed about the relationships between alexithymia and anhedonia. They also stress the need to rely on several alexithymia measurements, and they further demonstrate the necessity to compare the associations between different affect regulation dimensions in normal and psychopathological disorders.

[Selective serotonin reuptake inhibitors in major depressive disorder in children and adolescents (ratio of benefits/risks)]

Major depressive disorder in children and adolescents is associated with high risk of suicide and persistent functional impairment. While psychological treatments are used as a first line treatment in mild and moderately severe depression in this age group, the number of prescriptions for antidepressant medication (SSRI) has grown in recent years. Recently, FDA and MHRA advised that most of SSRI should not be used to treat MDD under the age of 18 years. They may increase the risk of suicidal thoughts and self harm. We reviewed the recent literature on efficacy and suicide risks of SSRI in depressed young people. Conflicting findings of SSRI efficacy have been reported in clinical studies. The discrepancies could be related to the heterogeneous samples and the absence of a standard definition of treatment effectiveness. In randomised placebo-controlled antidepressant clinical trials (RCT), the assessment of treatment effectiveness is commonly made with the CDRS-R (improvement of 20% or 30% or 40%) and CGI. SSRI demonstrated significantly, but modest, improvement compared with placebo in CGI score of 1 or 2: 10% more for sertraline, 16.8% more for paroxetine and between 16 to 24% more for fluoxetine. In adults, RCT studies have shown placebo response rates of 30% to 50%, drug response rates of 45% to 50% and drug-placebo differences of 18% to 25%. The highest placebo response rates, in young people, may be related to the highly selected group not representative of the general population of depressed patients and/or to the high youths' sensibility of psychotherapy. Patients participating in antidepressant clinical trials have a low BDI and CDI in Emslie's study for example (2002). In adults, previous reports suggest that SSRI use is associated with increased suicidal risk. But the analyse of 48 277 depressed patients participating in RCT for nine FDA approved antidepressants fail to support an overall difference in suicide risk between antidepressants (SSRI) and placebo treated subjects. An inverse relationship between regional change in use of antidepressants (increased) and suicide (decreased) is found in young -people in United States from 1990 and 2000. We can not draw a conclusion from few studies with few -participants. None suicide have been reported in pharmacological studies. And the link between "suicidality" and MDD can not be excluded. The instruments of assessment in depressed young patients are based on extensions of adult procedures. Whereas clinical picture of MDD in children, adolescents and adults have some differences. Depressed youngsters have more pronounced mood lability. Depressed adolescents have more anhedonia than depressed children. Future investigations into the efficacy and safety of treatments for children and adolescents depression should use specific instruments directly built on phenomenological and clinical picture of depressed children and adolescents. Comparison studies of pharmacotherapy, specific psychotherapies (not only CBT) and combined therapies are necessary to identify the adolescents who will benefit the most from specific or combined therapies. Further studies into the factors that influence treatment outcome including clinical picture (clinical dimensions, severity, duration, co morbidity), genetic factor, age, and i-llness course may help identify appropriate treatments for children and adolescents with MDD. Studies should include patients more severely ill, with associated psychiatric troubles, treatment resistance, history of relapses... In clinical studies, the link between "suicidality" and some clinical dimensions (which take part in clinical picture or not) must be analysed by assessing anhedonia, hopelessness feel, impulsive trait, borderline personality, familial inter-action, biological indices. New treatment should be expand and their efficacy and safety must be study: St John's worth, Bright light therapy, Trans-cranial Magnetic Stimulation.

IN PRACTICE

suicide and MDD have a strongest relation and it must be investigate syste-matically during the course of MDD. The suicide risk increases in the context of past history of suicide attempts, hopelessness, psychosis, impulsivity traits, substance abuse, familial dysfunction, life events, open access of arms. The use of SSRI in depressed children and adolescents is also the question of the quality and the support of the consultant and the mode of the prescription.

L’existence d’un épisode dépressif majeur est-elle liée à la présence de troubles anxieux chez les anorexiques et les boulimiques ?

The primaty objective is to determine whether the presence anxiety disorders is related to depressive comorbidity in subjects suffering from ED, while taking into account certain variables which may be related to depression [subjects' age, ED duration, prior incidents of anorexia nervosa in BN subjects, inpatient or outpatient status, nutritional state (as measured by Body Mass Index or BMI)]. Our secondary objective is to evaluate the relative chronology of the onset of anxiety disorders and depressive disorders in anorexic and bulimic subjects.

METHOD

We evaluated the frequency of depressive disorders in 271 subjects presenting with a diagnosis of either anorexia nervosa or bulimia, using the Mini International Neuropsychiatric Interview (MINI), DSM IV version.

RESULTS

While univariate analyses show that nearly all anxiety disorders are related to major depressive episode (MDE), a separate analysis of each anxiety disorder reveals that they do not all have the same influence in terms of risk of onset of MDE in anorexics and bulimics, when adjusted for univariate variables related to MDE (subjects' age, ED duration, prior incidents of anorexia nervosa in BN subjects, inpatient or outpatient status, nutritional state). Current generalized anxiety is significantly related to lifetime presence of MDE in AN subjects, and to current MDE in AN and BN subjects. Generalized anxiety is the most frequent disorder in AN and BN subjects to according our study; it also appears to be one of the principal predictive factors for MDE, which is 2.4 to 4.2 times more frequent when GAD is present. Diagnosis of OCD has its own particular effect on lifetime risk for MDE in AN subjects, regardless of GAD: it increases the risk of depression by 3.5. It is one of the most frequent anxiety disorders among AN subjects, present in nearly a quarter of them. In bulimics, when GAD is excluded, two factors are related to current diagnosis of MDE: panic disorder and subjects' inpatient or outpatient status. Hospitalized bulimics are diagnosed with current MDE 4.4 times more often than those seen as.

La fréquence des troubles anxio-dépressifs diffère-t-elle entre les types diagnostiques d’anorexie mentale et de boulimie ?

Our objective was to answer the following question: are there differences between diagnostic groups of eating disorders (ED) for the prevalence of depressive and anxiety disorders, when clinical differences between the groups are taken into account (ie age of subjects, ED duration, inpatient or outpatient status, and Body Mass Index)?

METHOD

We evaluated the frequency of anxiety disorders and depressive disorders in 271 subjects presenting with a diagnosis of either anorexia nervosa or bulimia, using the Mini International Neuropsychiatric Interview (MINI), DSM IV version. We compared the prevalences between sub-groups of anorexics (AN-R and AN-BN), between sub-groups of bulimics (BN-P and BN-NP) and between anorexics and bulimics while adjusting for the variables defined below.

RESULTS

Current or lifetime comorbidity of anxiety and depressive disorders did not differ between AN-Rs and AN-BNs, nor between BN-Ps and BN-NPs. Only current diagnoses of agoraphobia and obsessive-compulsive disorder were significantly more frequent in anorexics than in bulimics.

CONCLUSION

The greater frequency of comorbidity between obsessive-compulsive disorder and AN compared to BN, already well documented, is not questioned. The remaining anxiety disorders are equally frequent among all the diagnostic types of ED.

Predictive factors of social disability in anorexic and bulimic patients

OBJECTIVES

The purpose of this study was to determine whether subjects suffering from anorexia nervosa (AN) or bulimia nervosa (BN) would demonstrate more severe social disability than a control group; and whether social disability could be best explained as a function of the eating disorder itself or as a function of comorbid anxiety or depressive disorders.

METHOD

Subjects were 166 AN subjects, 105 BN subjects and 271 control subjects matched for age, sex and socio-economic status. Prevalence of anxiety or depressive disorders was assessed (through the Mini International Neuropsychiatric Interview), and social functioning was measured (through the Groningen scale).

RESULTS

The majority of AN and BN subjects demonstrated social disability in the "social role" (leisure time, time spent with friends) and the "occupational role" (work or educational activities). A regression analysis was employed to uncover predictive factors of social disability. Eating disorders (AN and BN), anxiety disorders and depression accounted for a large portion of social disability.

DISCUSSION

Anxiety and depressive disorders appear to play an important role in the type of social disability demonstrated in eating disorder patients. Therapeutic implications are discussed.

Validité du questionnaire d’alexithymie de Bermond et Vorst : étude chez des sujets présentant des troubles du comportement alimentaire et chez des témoins

Alexithymia core features are the difficulties in identifying and describing feelings; the difficulties in distinguishing feelings from the bodily sensations of emotional arousal; an impaired symbolization, as evidenced by a paucity of fantasies and other imaginative activity; and a tendency to focus on external events rather than inner experience. Several measures of alexithymia have been developed, including interviewer-rated questionnaires and self-report questionnaires. Among the self-report questionnaires, the 20-item Toronto Alexithymia scale (TAS-20) is the most commonly used, but it fails to measure all the core features of alexithymia. A recently developed instrument, the Bermond-Vorst Alexithymia Questionnaire (BVAQ), allows the measurement of the alexithymia core features, as well as an additional one. It appeared to present good psychometric properties, notably the abbreviated BVAQ-form B. The results of recent studies comparing the psychometric properties of the TAS-20 and the BVAQ have recommended the BVAQ over the TAS-20. However, this questionnaire needed further validation.

OBJECTIVES

Thus, the aim of the present study was to determine the convergent, discriminant and concurrent validity of the Bermond-Vorst Alexithymia Questionnaire -- form B (BVAQ-B) in a clinical sample of 59 eating disorder patients, as well as in 191 controls. The TAS-20 constituted the gold standard for the assessment of the BVAQ-B' convergent validity. To compare the concurrent validity of the BVAQ-B and the TAS-20, participants also completed several self-reports investigating different dimensions of emotion regulation capacities: the 13-item Beck Depression Inventory (BDI), the Spielberger State and Trait Anxiety Inventory (STAI-form Y), as well as the Chapman and Chapman Physical and Social Anhedonia Scales (PAS and SAS). One way analyses of variance were used for mean scores comparisons. Convergent validity was determined using Pearson coefficients of correlation.

RESULTS

Results of the analyses suggested the BVAQ-B has a satisfying convergent and discriminant validity. This was observed in both the clinical and control samples. Moreover, the comparison of the convergent validity of the BVAQ-B and the TAS-20 revealed several differences between these two alexithymia self-report questionnaires. The BVAQ-B appeared less sensitive to the subjective emotional state of the participants than the TAS-20. Whereas it was argued the TAS-20 overlaps with other emotional state scores, the BVAQ-B would allow to measure alexithymia more specifically. In addition, the present results allowed to further determine the relations between alexithymia and other dimensions of emotion regulation capacities. The analyses confirmed that alexithymia is linked to other emotion regulation dimensions such as depression and anxiety. Moreover, alexithymia was associated with physical and social anhedonia, two dimensions that received less interest in the alexithymia literature to date. This study also showed that control and clinical sample have different emotion regulation capacities. Eating disorder patients were not only more alexithymic and more depressed, but also more anxious and more anhedonic than the controls. Finally, this study revealed that alexithymia differs whether the alexithymic individuals are patients or controls. Healthy alexithymic individuals (ie, individuals categorized as alexithymic in the control group) seemed characterised by a selective deficit of emotional cognition, with sparing of emotional experience (Bermond's type II alexithymia). Alexithymics individuals of the eating -disorder group seemed particularly unabled to experience affect. This pattern could correspond to Bermond's type I alexithymia, which is characterised by the absence of emotional experience and, consequently, by the absence of the cognition accompanying the emotion. In summary, results of the present study add to the literature debating on whether alexithymia is similar in different types of population.

[Alexithymia, depression and drug addiction]

Alexithymia is a multidimensional concept associating an emotional component focused on the difficulty in identifying and describing feelings and a cognitive one centred on the use of a concrete and poorly introspective way of thinking. Alexithymia can be assessed by self-assessment instruments and in particular by the 20 items version of the Toronto Alexithymia Scale (TAS-20). Depressive disorders have complex relationships with the construct of alexithymia and there exist few experimental works on the subject. Epidemiological studies frequently raise an overlap between alexithymia and depression, in particular in the context of addiction. The main aim of this study was to confirm the high prevalence of alexithymia among drug addicted patients taking into account socio-demographic variables (sex, age, social and economic categories). The second aim of the study was to investigate the relationships between alexithymia and depression among drug addicted patients. A sample of 128 drug addicted patients answering DSM IV criteria of dependence to a psycho-active substance (alcohol excluded) was paired according to socio-demographic variables to a control sample of 128 normal subjects. Diagnostic assessment was made using the Mini International Neuropsychiatric Interview (MINI). Alexithymia and depression were assessed with the TAS-20 and with the short version of the Beck Depression Inventory (BDI-13). The results confirm the high prevalence of alexithymia among drug addicted patients (43.5%) compared to controls (24.6%). This difference is based namely on the emotional component of alexithymia, the cognitive component failing to show any difference between the two samples. Moreover, alexithymia appears to be independent from socio-demographic variables in our sample of drug addicted patients; 66.4% of drug addicted patients presents a depressive symptomatology (which is significantly more important in female patients), compared to 26% of the controls. Studies using the TAS and the BDI with 21 items have shown that from 10 to 20% of the variance of alexithymia is explained by depression. Our own results show a shared variance of 20% between the TAS-20 and the BDI, going in the direction of a moderated correlation between alexithymia and depressive symptomatology. Moreover, when we retain only subjects without depressive symptomatology at BDI, drug addicted (n=42) are not any more alexithymic than controls (n=114). Our results plead for a positive association between depression and alexithymia in drug addicted, depressed or healthy subjects. Alexithymia and depression would be two associated dimensions, the emotional component explaining alone this association. The emotional component of the alexithymia would be thymo-dependent, whereas the cognitive component (externally oriented thought) would be independent and constitute a stable clinical feature. These results are concordant with other studies in the literature suggesting that alexithymia in its emotional component is supported by depression. Alexithymia thus did not appear as an autonomous dimension which would discriminate between drug addicted and controls, independently of the absence of a depressive state. The Authors discuss the complexity of the relationships between alexithymia and depression and the correlations between TAS and BDI scales especially for the factor Difficulty Identifying Feelings. These results deserve further studies. The cross-sectional nature of this study do not allow to establish if alexithymia is a subjacent and preexistent in the form of a psychopathological dimension in addictive behaviours, so supporting its emergence, and/or if it develops once the dependence is installed and chronicized. Longitudinal studies remain to be realised.

Treatment of adolescent patients with eating disorders: description of a psychodynamic approach in clinical practice

Anorexia nervosa (AN) is now usually considered to be a multifactorial disorder, and there is a consensus among clinicians that its treatment should be aimed at restoring weight, altering anorexic attitudes, treating any medical complications, supporting and treating the family, enhancing autonomy, facilitating identity formation, and increasing self-esteem by means of psychotherapy. The practical aspects of such treatments not only vary from country to country, but sometimes also from one treatment team to another. International meetings dedicate considerable discussion to the subject but, as it seems to be relatively ignored in the published literature, we here describe the main elements of our own method.

Psychoactive substance consumption in eating disorders

Research investigating the comorbidity between eating disorders and substance-use disorders have reported positive but contrasting results. The aim of this study was to further explore this association by studying patterns of consumption of the entire range of psychoactive substances (alcohol, specific drugs, prescribed psychotropics) in a large sample (N=271) of eating-disorder DSM-IV subtypes. Results show that subjects suffering from anorexia of the restrictive type show significantly less drug-consumption behaviors and alcohol abuse and/or dependence disorders than purging anorexic and bulimic subjects. No difference was found in the total consumption of psychotropics among the four groups of eating disorders. However, more than half of eating-disorder subjects are regular consumers of psychotropics. Among these regular consumers, bulimics self-prescribe and increase their doses of psychotropics significantly more than anorexics. Features of impulsivity that are associated with purging and bulimic behaviors could play a specific role in these patterns of comorbidity and account for such differences.

Obsessive compulsive disorders in eating disorders

OBJECTIVE

The aim of this study is to explore current and lifetime prevalence of obsessive compulsive disorders (OCD) in eating disorder (ED) subgroups and subtypes defined by the DSM-IV and to study the chronology of appearance of these disorders taking into account the role played by denutrition.

METHOD

Current and lifetime prevalence were investigated using the Mini International Neuropsychiatric Interview (MINI) and the Yale-Brown Obsessive Compulsive Scale in a sample of 89 DSM-IV ED patients (58 AN and 31 BN) and 89 matched controls.

RESULTS

Current and lifetime prevalence of OCD in ED was significantly higher than in general population (15.7% and 19% vs. 0% and 1.1%, P<.05). Anorexic patients presented a slightly higher current and lifetime comorbidity than bulimic patients (19% and 22.4% vs. 9.7% and 12.9%, n.s.). Purging anorexia was the diagnostic subtype, which presented the higher prevalences (29% and 43%), followed by restrictive anorexia (16%) and purging bulimia (13%). In the great majority of cases (65%), OCD diagnosis preceded ED diagnosis. Finally, OCD current prevalence and Y-BOCS scores of underweight patients were not significantly higher than normal-weight patients, suggesting that there were only limited links between denutrition and obsessionality.

Binge eating behaviours, depression and weight control strategies

The aim of this paper was to explore the relationships between depressive symptoms and weight control strategies in DSM-IV eating disordered patients with binge eating behaviours. We hypothesised that weight control strategies characterised by a loss of control, such as vomiting and purging, may be clinically associated with increased levels of depression. The study population consisted of 402 consecutive outpatients: 27 with binge eating/purging anorexia nervosa (AN-BN), 213 with purging bulimia nervosa (BN-P), 73 with non-purging bulimia nervosa (BN-NP), and 89 with binge eating disorder (BED). The severity of depression was measured using the Beck Depression Inventory (BDI), and binge eating behaviours were investigated using the self-report scale for bulimic behaviours. In the sample as a whole, the severity of depression significantly correlated with the severity of binge eating behaviours, but no significant differences were found in the severity of depression by diagnostic sub-types. In order to avoid the confounding erasing effect of time, a smaller sample of patients with a short history of binge eating behaviours was further explored. Furthermore, because weight control strategies and the eating disorder diagnostic sub-types overlapped imperfectly, the patients were compared on the basis of presence or absence of strategies reflecting an active attempt to master the weight gain due to bingeing behaviours. The patients adopting active control strategies (N = 14) had significantly less severe depressive symptoms than those adopting non-active weight control strategies (N = 39). Finally, the Authors discuss some hypotheses concerning the defensive role of weight control strategies and the impact of illness duration on the clinical expression of depression in eating disordered patients.

[Validation study of the Depressive Experience Questionnaire]

Sidney Blatt, considering as being insufficient the categorical-symptomatic approach of depression, has worked out a theory of depression and psychopathology that integrates the contributions of psychoanalysis as well as cognitive and developmental psychology. Within a broad psychoanalytic framework, Blatt's formulation focus on the quality of interpersonal relationship, the nature of object representation and early life experiences. Personality development is viewed as the consequence of the interaction of 2 basic developmental tasks: the establishment of the capacity to form stable, enduring, mutually satisfying interpersonal relationships and the achievement of a differentiated, realistic, essentially positive identity. The relationship between these 2 developmental lines involves a complex dialectical process during which progress in each line is essential for progress in the other and which contributes to the development of both a sense of identity and the capacity for interpersonal relatedness. These developmental lines permit not only to define an during individual's primary personality configuration but also enable to identify cognitive structures that are inherent in various forms of psychopathology, including depression. Disruptions at different developmental stages create vulnerability to different subsequent psychological disturbances. Blatt characterised as anaclitic or dependent the axis concerned with interpersonal relationship and as introjective or self-critical the axis concerned with development of the sense of self and identity. Depressive Experience Questionnaire was developed by Blatt et al. to determine the validity of this model of psychopathology which emphazises continuities between normal and pathological forms of depression. The instrument was developed by Blatt et al. by assembling a pool of items describing experiences frequently reported by depressed individual. Sixty-six items were selected and administered to a large nonclinical sample (500 female and 160 male undergraduates). Principal component analysis within sex performed on the answers to DEQ confirmed his assumption in identifying two principal depressive dimensions. The first factor involved items that are primarily externally directed and refer to a disturbance of interpersonal relationships (anaclitism); the second factor consists of items that are more internally directed and reflect concerns about self-identity (self-criticism). A third factor emerged, assessing the good functioning of subject and confidence in his resources and capacities (efficacy). Scales derived from these factors have high internal consistency and substantial test-retest reliability. The solutions for men and women were highly congruent. Factor structure has been replicated in several nonclinical and clinical samples, supporting considerable evidence to the construct validity of the DEQ Dependency and Self-criticism scales. An adolescent form of DEQ (DEQ-A) has successively been developed. Factor analysis revealed three factors that were highly congruent in female and male students and with the three factors of the original DEQ. The reliability, internal consistency and validity of DEQ-A indicate that the DEQ-A closely parallels the DEQ, especially in the articulation of Dependency and Self-criticism as two factors in depression. These formulations and clinical observations about the importance of differentiating a depression focused on issues of self-criticism from issues of dependency are consistent with the formulations of others theorists which, from very different theoretical perspectives, posit 2 types of depression, one in which either perceived loss or rejection in social relationships is central and the other in which perceived failure in achievement, guilt or lack of control serves as the precipitant of depression. These 2 types of experiences have been characterized as dominant other and dominant goal , as anxiously attached and compulsively self-reliant and as sociotropic and autonomous . Our work presents the results of a validation study of both forms of Blatt's questionnaire (for adults--DEQ--and for adolescents--DEQA) translated in French in a large population of normal subjects, aged 15 to 45 years. DEQ and DEQ-A were compared by inspection of items loading strongly on each factor and by correlation of the three factors of adults and adolescents. The exploratory factor analysis of DEQ and DEQA revealed three orthogonal factors, corresponding with Blatt's original dimensions. Consistency and external validity were adequate for all 3 factors of DEQ and DEQ-A. Anaclitism and self-criticism dimensions of DEQ and DEQ-A correlate positively with measures of depression (DSM-IV, Beck Depression Inventory), consistently with the results obtained by Blatt. Differently from this author, anaclitism appears to be less differentiated in males than in females, suggesting that the concept of dependence could assume different relevance for men and women.

Involvement of cytokines in eating disorders: a critical review of the human literature

A number of findings from clinical and animal studies indicate that pro-inflammatory cytokines may play roles in eating disorders. The measurement of pro-inflammatory cytokines (IL-1, IL-6, TNFalpha), which are known to decrease food intake, provides highly variable data from which firm conclusions cannot be drawn. In most of the longitudinal studies where pro-inflammatory cytokines have been shown to be impaired in anorexia or bulimia nervosa, a return to normal values was observed after renutrition. However these findings do not exclude the possibility that pro-inflammatory cytokines might be overproduced in specific brain areas and act locally without concomitantly increased serum or immune production. It was also pointed out that the production of the major type-1 cytokines (especially IL-2) was depressed in anorexia nervosa. It remains unclear whether this is due to undernutrition or to a specific underlying cause common to eating disorders. The impaired cytokine profile observed in eating disorders could be related to several factors including impaired nutrition, psychopathological and neuroendocrine factors. More particular attention should be devoted to the deregulation of the anti/pro-inflammatory balance. Deregulation of the cytokine network may be responsible for medical complications in eating disorder patients who are afflicted with chronic underweight.

Suicide attempts in women with bulimia nervosa: frequency and characteristics

OBJECTIVE

This study aimed to estimate the lifetime frequency of suicide attempts in a large referred population of women with DSM-IV bulimia nervosa (BN), and to compare demographic and clinical characteristics of those who had attempted suicide and those who had not.

METHOD

A total of 295 women (202 with BN purging type, 68 with BN non-purging type and 25 with anorexia nervosa binge/eating purging type) were assessed using a semi-structured interview and self-rated questionnaires.

RESULTS

Suicide attempts were frequent (27.8% of women), often serious and/or multiple. Women who had attempted suicide differed significantly from those who had not for earlier onset of psychopathology, higher severity of depressive and general symptoms, and more impulsive disordered conducts, but not for the core symptoms or severity of BN.

CONCLUSION

Interventions targeting depressive and impulsive features associated with BN are essential to reduce the risk of suicide attempt in women with this disorder.

[French validation study of the levels of emotional awareness scale]

According to a thesis based on the idea of an influence of cognitions in the structuring of internal reality, emotional awareness, ie the capacity of representing your own emotional experience and that of others, is a cognitive process that goes into maturation. Defining this concept, Lane and Schwartz present a cognitivo-developmental model in five stages of the processes of symbolization, accounting for the differences in levels of emotional awareness observed in individuals. The organization of these cognitive processes would thus be structured in well differentiated stages, in which the development of the emotions would be inseparable from the development of ego and of the relation to others. These authors focus on the capacity of representing in a conscious way the emotional experience and consider that verbal representations used to describe the contents of what is experience constitute a good reflection of the organization structural of the emotional awareness. Therefore, they worked out an instrument of evaluation: the Levels of Emotional Awareness Scale (LEAS), which measures the capacity to describe your own emotional experience and the one you allow to others, in an emotional situation. The system of quotation of this scale is based on the analysis of the verbal contents of the provided answers, in direct reference to the authors' theory of the levels of differentiation and integration of the emotional experience. It is therefore an empirical measurement which is centered specifically on the structural organization of the emotional experience. The various studies of validation of this instrument show that it presents solid metrological properties. This work presents the validation of the French version of Lane and Schwartz's LEAS. Validity and fidelity were studied in a group of 121 healthy subjects. This setting is part of a larger clinical evaluation, also including a collection of socio-demographic and clinical data, and other instruments of self-evaluation (Beck Depression Inventory, BDI, Hospital Anxiety and Depression Scale, HAD, and Toronto Alexithymia Scale, TAS). The face validity appears correct: the questionnaire was well accepted and seemed easy to complete. A principal components analysis of the correlation matrix of the set of items was used as the method of extraction of the various factors and made it possible to confirm the unidimensionality of the instrument. The number of factors to be retained was given according to Kaiser and Cattell criteria. The internal consistency was evaluated through computation of the Cronbach coefficient, whose value is 0.75 for the scale's global score. The confidence interval of the margin of error of LEAS scores was also measured; for the global score it is IC=[m 6.1]. The measure given by this rating scale may therefore be considered sufficiently accurate, since this interval is weak. A study of the frequency of quotation of each item of the instrument was carried out, in order to check the homogeneity and the uniformity of quotations, as well as a diagram of distribution of the score, showing that it follows a law which is close to a normal law. The concurrent validity could only be studied via the similar concept of alexithymia, measured with the TAS, for there is not other instrument validated in French evaluating the levels of emotional awareness, and these two instruments seem to measure different notions, because none of the correlations between the scores of these two questionnaires are significant. Concerning discriminant validity, the Pearson correlation coefficients between the global score for the LEAS, the BDI score and the HAD sub-scores for depression and anxiety were measured; it is clear that the level of emotional awareness is independent from negative affects. Furthermore, the study of the reliability made it possible to highlight excellent intra-class correlation coefficients (r=0.993). The French version of the Levels of Emotional Awareness Scale thus appears to be valid and accurate and should allow the study of levels of emotional awareness on psychopathology. It is about an easily acceptable and simple questionnaire of use in varied clinical circumstances.

Cytokines and depression: an analogic approach

A growing body of evidence suggests that major depressive disorders may be accompanied by immune dysfunction and more particularly by an enhanced production of pro-inflammatory cytokines. The possible involvement of cytokines in depressive illness are based upon an analogic model. Pro-inflammatory cytokines are known to induce behavioral effects, and neuro-endocrine and immune activation similar to those observed in depression; these can be alleviated by antidepressant treatment. In this paper, we review research literature on the links between depressive illness and cytokine production and address further questions on this cytokine pathway. Further research is needed to see whether cytokines sustain specific depressive syndromes or whether cytokines induce depressive-like symptoms.

Factorial structure of the Sensation-Seeking Scale-Form V: confirmatory factorial analyses in nonclinical and clinical samples

OBJECTIVE

The factor structure of the Sensation-Seeking Scale (SSS)-Form V was studied in 2 large French samples, using confirmatory factorial analyses (CFA) to test the 4-dimensional model of sensation seeking postulated by Zuckerman.

METHOD

The study included 769 healthy subjects and 659 patients who met the DSM-IV criteria for substance use disorders or eating disorders and completed the SSS. The correlation matrices for each of the samples were analyzed using CFA.

RESULTS

In each sample, we found the 4-factor model to be replicable.

CONCLUSION

The multidimensionality of sensation seeking is supported by the results, and the 4-dimensional model of sensation seeking identified by Zuckerman can be explored in French-speaking people.

Electroconvulsive therapy in adolescents with mood disorder: patients' and parents' attitudes

The aim of the study was to assess retrospectively patients' and parents' experiences and attitudes towards the use of electroconvulsive therapy (ECT) in adolescence. The experiences of subjects (n=10) who were administered ECT in adolescence for a severe mood disorder and their parents (n=18) were assessed using a semi-structured interview after a mean of 4.5 years (range, 19 months to 9 years). Their attitudes were mostly positive and ECT was considered a helpful treatment. Concerns were frequently expressed, probably because ECT was not fully understood by the patients and their families. Most complaints were of transitory memory impairment. The parents were satisfied with the consent procedure, while all but one patient did not remember the consent procedure. We concluded that, despite negative views about ECT in public opinion, adolescent recipients and their parents shared overall positive attitudes towards the use of ECT in this age range.

[Current and lifetime prevalence of obsessive compulsive disorders in eating disorders]

A significant proportion of patients suffering from Eating Disorders (ED) present a comorbidity with anxiety disorders. Among the anxiety disorders, Obsessive Compulsive Disorders (OCD) are the third most frequently diagnosis observed in ED. However, prevalence rates from the literature are contradictory depending on the diagnostic criteria and evaluation tools used. Studies concerning the chronology of appearance of OCD and ED and the role played by denutrition are even rarer and equally contradictory.

OBJECTIVE

The aim of this study is to bring new empirical data to the study of the correlations between OCD and ED by exploring, in a significant clinical sample, the current and lifetime OCD comorbidity in the diagnostic sub-groups and sub-types of ED as defined by the DSM IV and to study the chronology of appearance of these disorders taking into account the role played by denutrition. We make the assumption that there should be a difference in the prevalence of obsessive compulsive disorders in the various ED sub-groups and sub-types and that purging anorexics should, at equivalent levels of denutrition, exhibit higher OCD prevalence rates than the other sub-types as a result of their more severe general psychopathology.

METHODS

Current and lifetime prevalence were investigated using the Mini International Neuropsychiatric Interview (MINI) and the Yale-Brown Obsessive Compulsive Scale in a sample of 89 DSM IV eating disorders in and out-patients aged between 15 and 30 (58 AN and 31 BN) and 89 matched controls. In order to increase the validity of the current diagnosis of OCD only patients presenting an OCD diagnosis on the MINI (excluding obsessions and compulsions related to food and body image) and a score of 16 or more on the Y-BOCS were included in the study.

RESULTS

Current and lifetime prevalence of OCD in ED is significantly higher than in general population (15.7% and 19% vs 0% and 1.1%, p < 0.05). Anorexic and bulimic patients do not show any difference in the current and lifetime comorbidity (19% and 22.4% vs 9.7% and 12.9%, ns). Concerning the diagnostic sub-types, following our assumption purging anorexics present the higher current and lifetime prevalences (29% and 43%), followed by restrictive anorexia (16%) and purging bulimia (13%). The only significant difference is found in the lifetime prevalence of OCD between purging and non purging anorexics. In the great majority of cases (65%) OCD diagnosis precedes ED diagnosis and OCD current prevalence and Y-BOCS scores of underweight patients are not significantly higher than normal weight patients, suggesting that there are only limited links between denutrition and obsessionality.

LIMITS

Some methodological limitations must be considered. First of all, the small sample size of the diagnostic sub-types of ED do not enable us to draw definitive conclusions concerning the prevalence of OCD in the clinical forms of ED. Some of the diagnostic sub-types of ED, as BN-NP, appear at different ages: in order to better investigate the prevalence of OCD in all the diagnostic sub-types, larger age ranges should be considered. Secondly, our sample of anorexics is almost made of hospitalized inpatients recrutated in a specialized university unit, whereas bulimics are all consulting outpatients. It is possible that the higher than normal rates of OCD in anorexics could be related to the severity of this sample. Comparisons with samples of consulting anorexics should be performed. Lastly, it is necessary to evoke the limitation represented by the choice of a healthy control group. OCD are rare in the general population and the differences found between the clinical and the control groups do not offer strong arguments to support the specificity of the association between OCD and ED, which would be better explored by using a pathological control group.

CONCLUSIONS

So far, none of the various models proposed to explain the comorbidity observed between ED and OCD appears completely satisfactory. ED and OCD would share a genetic vulnerability to a dysregulation of serotoninergic functioning which would predispose these subjects, depending on specific clinical and biological conditions, to develop an obsessional and compulsive symptomatology more or less focused on food and body image. The knowledge of the clinical and biological specificities of the ED diagnostic sub-types presenting an OCD comorbidity could point the way towards specific therapeutic interventions in these patients. Our study of the comorbidity of OCD in ED makes a further contribution to the identification of specific links between the OCD and the various clinical forms of ED. More clinical and biological studies are needed to further explore these relationships.

Eating disorders: psychodynamic approach and practice

In the psychodynamic approach we understand the defensive meaning of anorectic and bulimic conduct, and its value as a reorganizing of objective relations: difficulties in investing, antagonism between the objective inclination of these patients and the need to protect their narcissistic balance. The avoidance of depression linked to a compensatory juxtaposed narcissistic schema must be appreciated in order to understand the developing risks in these behaviours. The psychopathological significance of these behaviours, their stakes, and their therapeutic consequences are discussed.

Cytokines and anorexia nervosa

OBJECTIVE

Recent studies have indicated that the inflammatory cytokines could be implicated in anorexia nervosa and in its complications. To determinate the potential role of interleukins (IL-1, IL-2, IL-4, IL-6, IL-10), interferon (IFN gamma), tumor necrosis factor (TNF-alpha), and transforming growth factor (TGF-beta2) in anorexia nervosa, serum concentrations of these cytokines were measured in patients suffering from anorexia nervosa in comparison to healthy subjects.

METHOD

Twenty-nine anorexic women according to DSM-IV criteria participated in the study. The control group consisted of 20 healthy women without eating disorders, mood disorders, and immunological disorders.

RESULTS

We find that serum IL-2 and TGF-beta2 concentrations were both significantly decreased in anorexic patients, although the other cytokines did not differ significantly between the two groups.

CONCLUSION

Our results show that in patients with anorexia nervosa, there are lower levels of specific cytokines (especially IL-2 and TGF-beta2). These levels may reflect the combination of impaired nutrition and weight loss, therefore, the dysregulation of these cytokines may contribute in anorexia's complications. Follow-up studies should examine the effects of parameters such as starvation, psychopathologic factors, and psychoneuroendocrinological perturbation which could affect interplay between cytokines, neuropeptides, and neurotransmitters.

Factorial structure of the 20-item Toronto Alexithymia Scale: confirmatory factorial analyses in nonclinical and clinical samples

OBJECTIVE

The 20-item Toronto Alexithymia Scale (TAS-20) measures three intercorrelated dimensions of alexithymia: (1) difficulties identifying feelings (DIF), (2) difficulties describing feelings (DDF), and (3) externally oriented thinking (EOT). The aim of the study was to test the three-factor model of the TAS-20 using confirmatory factorial analyses (CFA).

METHOD

769 healthy subjects and 659 patients meeting the DSM-IV criteria for substance use disorders or eating disorders completed the TAS-20. The correlation matrices for each of the samples were analyzed with LISREL 7.16.

RESULTS

In each sample, the three-factor model was found to be replicable.

CONCLUSION

The three TAS-20 subcales can be used to explore the distinct facets of the alexithymia construct.

[Psychoactive drug use in a declared non-addicted control sample and comorbidity. Results of a study in 860 French-speaking subjects]

AIMS

This study, conducted within the framework of a broader research program of the INSERM 494013 Dependence Network, was designed to estimate illicit drug use and tobacco smoking in a declared non-addicted sample and to determine whether illicit drug users differ from non-users in terms of comorbidity.

METHODS

The study was conducted in an "all and sundry" sample of subjects. Patterns of drug use and comorbid factors (psychiatric disorders, suicide attempts, repeated accidents, social inadaptation) were assessed using a semi-structured interview (heteroevaluation, MINI DSM IV interview, Gröningen).

RESULTS

Among 860 subjects, 107 (12.4%) used illicit drugs and 26 of these 107 (24.3%) were dependent users or abusers. Specific analysis of non-dependent non-abuser subjects who had used illicit drugs (70 occasional and 11 regular users) showed a higher rate of use in younger subjects (12.7% in the 15-24 year group, 5.7% in the 24-49 year group) and men. Except for repeated accidents (OR=5.5 [1.6-18.5]), comorbid disorders were not more frequent in non-users than in users.

CONCLUSION

Besides use for recreational purposes, the rate of use of illicit drugs with abuse or dependence was high in our non-clinical sample. Although no specific comorbid psychiatric disorders were identified among non-dependent non-abuser subjects who had used illicit drugs, the frequency of repeated accidents evidenced the ill-fated side effects of illicit drugs and/or the specific biopsychological vulnerability of these subjects. This highlights the importance of not neglecting drug abuse.

[Pertinence of the addiction concept in eating behavior disorders]

From a psychodynamic perspective, dependence disorders, irrespective of the object of addiction, can be seen as the expression of the subject's neurobiological, psychopathological, cultural and social vulnerability. Since vulnerability strengthens and reorganizes the personality, it can drive these subjects to perpetuate pathological behaviors. In this light, behavior disorders belong to the field of addiction diseases, especially considering that the underlying psychopathological structures are close to those observed in addiction, that depression plays a central role, and that their development into toxic addictive behavior (drugs, alcohol, psychotrope) is frequent.

[Pregnancy and drug abuse: current situation and therapeutic strategies]

Drug abuse, a general public health problem, concerns a growing number of the pregnant women. Pregnancy in a drug addict is a high risk condition. The prevention of neonatal and pediatric complications involving both organic and psychological conditions, requires early individual medical, psychological and social support adapted to each pregnant addict. The risk for the mother and the fetus warrant prescription of substitution therapy during pregnancy. Published results concerning pregnancies in women on substitution therapy have been encouraging and clearly show a decrease in maternal and fetal complications. These studies are however difficult to conduct and carry a certain number of biases related to the social and economical context of the patients and also to the type of drug abuse (multiple drugs, drug combinations, psychostimulants, smoking, alcohol).

[Alexithymia and depression in eating disorders]

Patients suffering from eating disorder show elevated rates of alexithymia and depression. We compared alexithymia and depression ratings for non-hospitalized women meeting DSM IV criteria for anorexia nervosa (n = 32) and bulimia nervosa (n = 32) to healthy women (n = 74). Alexithymia was evaluated by the Toronto Alexithymia Scale (TAS-20) and depression by the Hospital Anxiety and Depression Scale (HAD). We found that TAS and HAD scores were significantly higher in anorexic compared to bulimic patients, although alexithymia and depression, as evaluated, were significantly and positively correlated with each other (r = 0.53, p = 0.001). Finally, a logistic regression with alexithymia and depression as independent variables showed a strong correlations between the HAD ratings and anorexia, but no correlations between TAS score and the eating disorder subgroups. In eating disorder patients, alexithymia, as evaluated by the Toronto Alexithymia Scale, seems to exhibit a thymo-dependent component which could be secondary to concurrent depression. Through recent studies and results of our research, we analyze and give several interpretations which may explain this correlation between alexithymia and depression.