[Pseudo-dementia conversion and post-traumatic stress disorder]

BACKGROUND

Post-traumatic stress disorder (PTSD) is often associated with other psychiatric syndromes. However, studies exploring conversion and PTSD comorbidity are scarce.

CASE-REPORT

This paper reports the case of a 45 year-old patient without medical or psychiatric history. In 2003, he suddenly started suffering from amnesia and symptoms of delirium: he was at his office with a cup of coffee but he did not remember why. Aphasia, trembling, behavioural disorders appeared over the next hours and days. Numerous neurological examinations and laboratory tests (including cerebral imagery) were performed without evidence of any physical disease. Three psychiatric examinations were also negative, even if a possible psychogenic origin was hypothesized. Neurological or psychiatric diagnoses were discussed but without definitive conclusion. One year later, the symptoms were unchanged until the patient watched a movie ("Mystic River") that described the story of a man with sexual abuse in childhood. He suddenly remembered that he lived the same experience when he was 8 years old. At the end of the movie, his wife surprisingly noticed that he was walking and speaking normally. All the neurological symptoms disappeared. Unfortunately, symptoms of a severe PTSD appeared, as well as a major depressive disorder. The patient and his parents remembered that he had been more irritable, depressed and anxious at school and during the night, between 8 and 13 years of age, with a possible PTSD during this period. He always refused to talk with his parents about the traumatic event. When he was 13, the family moved house, the patient seemed to forget everything and the symptoms disappeared. About thirty years later, the symptoms were similar with the reexperien of the traumatic event through unwanted recollections, distressing images, nightmares, or flashbacks. He had also symptoms of hyperarousal with physiological manifestations, such as irritability, insomnia, impaired concentration, hypervigilance, and increased startle reactions. Hospitalisation became necessary because of a severe depressive disorder with suicidal ideation and suicidal attempt by hanging. After two failed treatments with SSRI antidepressants, the administration of clomipramine (200 mg/d) and a combined therapy with Eyes Movement Desensitization and Reprocessing (EMDR) led to a significant improvement of PTSD and depression symptoms.

DISCUSSION

Even if PTSD and conversion may share common dissociative mechanisms, the links between both syndromes have not yet been sufficiently explored. Our clinical case raises specifically the question of the initial manifestations of pseudo-dementia (why this type of symptoms, and why at this particular moment of his life, without any targeting events). Moreover, the case of this patient is particularly interesting because of the very long amnesia period between the traumatic event and the onset of PTSD.

CONCLUSION

The different phases of this case warrant more precise exploration of the links between PTSD and conversion, with clinical, epidemiological and cerebral imagery perspectives.

[Anxiety and depressive disorders in 4,425 long term benzodiazepine users in general practice]

Consumption rates of anxiolytic drugs, and especially of benzodiazepines, remain very high in France compared to other Western countries, whereas clinical guidelines limit their indications to short term treatments and only for some precise anxiety disorders. Recent epidemiologic surveys in the community indicated that more than 15% of people used once or more an anxiolytic drug in the past year. The issue of chronic treatments is particularly crucial because of their poor benefit/risk ratio in most anxiety disorders (limited efficacy, cognitive side effects, withdrawal and dependence problems). To address this important public health issue, and knowing that, in France, benzodiazepines are prescribed mainly by general physicians, our aims were to explore psychiatric diagnoses in GP's patients with chronic use of anxiolytic benzodiazepines. We included 4 425 patients consuming such drugs regularly for six months or more, and assessed their anxiety and depression symptoms through various clinical scales (Hospital Anxiety and Depressive scale - HAD, Clinical Global Impression scale - CGI, Sheehan Disability Scale - SDS, Cognitive Dependence to Benzodiazepines scale - CDB) and with the Mini International Neuropsychiatric Interview for DSM IV criteria. Only 2.2% of the subjects had neither anxious nor depressive symptoms as indicated by low scores on both subscores (less than 8) of the HAD scale, used as a screener. Nearly three quarters of the 4,257 subjects (73.2%), had CGI scores of at least 5 (markedly ill to extremely ill). Social and familial disability was also high in more than 40% of the sample (marked to extreme disruption according to SDS scores). About half of the sample had CDB scores suggesting a benzodiazepine dependence. According to the MINI, 85.1% of the patients had at least one current DSM IV diagnosis of affective disorder. The most frequent diagnoses were major depressive episode (60%), generalized anxiety disorder (61.2%), and panic disorder (22.5%). An anxiety and depressive comorbidity wad found in 41.9% of the subjects. Some methodological limitations must be taken into account in the discussion of our results, and especially the fact that the included patients were not supposed to be totally representative of all patients consuming anxiolytic benzodiazepines in general practice. However, the size of our sample is sufficiently large to limit possible biases in patient selection. The main result of this study is that a great majority of the patients had significant symptomatology, in particular major depressive episodes and generalized anxiety disorder, often with marked severity and disability. These data are in line with the knowledge of a lack of efficacy of benzodiazepines in depressive and most anxiety disorders, despite long term treatment. They also confirm the current guidelines which recommend prescribing serotoninergic antidepressants, and not benzodiazepines, when long term treatments are needed for severe and chronic affective disorders. This epidemiologic study leads to the conclusion that a specific and attentive diagnostic assessment should be done in all patients receiving benzodiazepines for more than three months, in order to purpose in many cases other long term therapeutic strategies.

Évaluation dimensionnelle des émotions en psychiatrie : validation du questionnaire Émotionnalité positive et négative à 31 items (EPN-31)

BACKGROUND

This paper reports the first validation study of the EPN-31 scale (Positive and Negative Emotionality scale, 31 items) in a French psychiatric sample. This questionnaire has been adapted by Rolland from an emotion inventory developed by Diener, and is also in accordance with Watson and Clark's tripartite model of affects.

METHODOLOGICAL ASPECTS

Respondents were asked to rate the frequency with which they had experienced each affect (31 basic emotional states) during the last month. The answer format was a 7-point scale, ranging from 1 "Not experienced at all" to 7 "Experienced this affect several times each day". Three main scores were calculated (positive affects, negative affects, and surprise affects), as well as six sub-scores (joy, tenderness, anger, fear, sadness, shame). Four hundred psychiatric patients were included in this study, and completed the EPN-31 scale and the Hospital Anxiety and Depression (HAD) scale. The Global Assessment of Functioning (GAF) scale was rated, as well as DSM IV diagnostic criteria. We performed a principal component analysis, with Varimax orthogonal transformation, and explored the factorial structure of the questionnaire, the internal consistency of each dimension, and the correlations between EPN-31 scores and HAD scores.

RESULTS

The factorial structure of the EPN-31 was well-defined as expected, with a three-factor (positive, negative and surprise affects) solution accounting for 58.2% of the variance of the questionnaire. No correlation was obtained between positive and negative affects EPN-31 scores (r=0.006). All alpha Cronbach coefficients were between 0.80 and 0.95 for main scores, and between 0.72 and 0.90 for sub-scores. GAF scores were significantly correlated with EPN-31 positive affects scores (r=0.21; p=0.001) and with EPN-31 negative affects scores (r=- 0.45; p=0.001). We obtained significant correlations between positive affects score and HAD depression score (r=- 0.45; p<0.001), and between negative affects score and HAD anxiety (r=0.56; p<0.001) and depression (r=0.45; p<0.001) scores. This pattern of correlation was in accordance with the Watson tripartite model of emotionality. Significantly higher EPN-31 positive affect mean scores were observed in females when compared to males (p<0.001). The third factor of the EPN-31 is less robust than the others and, the validity of the surprise score could hence be discussed.

CONCLUSION

In all, this study confirmed the validity and the interest of the EPN-31 use in psychiatric patients. Various clinical and research applications can be considered, such as infra-symptomatic studies of emotions in affective disorders and during treatment protocols or definition of phenotypic markers in genetic or neuro-imagery studies.

[Epilepsy and personality study among the Tamberma of Togo based on a general population survey using the Cloninger's Temperament and Character Inventory]

INTRODUCTION

There are many studies focusing on personality disorders of the patients with epilepsy in developed countries, using different methods. Such investigations with standardised tools like personality questionnaires lack in African populations in general and among the number of epileptic patients who have important psychosocial problems. In Togo, epilepsy still remains a shameful and contagious disease that leads often unfortunately to a "social death". The number of epileptic patients in this country is estimated around 45,000 and 90,000 and the situation is worst in some areas of the country like in Nadoba, chef-lieu of the Tamberma region where lives an homogenous and stable population that has kept its tradition.

DESIGN OF THE STUDY

This study was aimed to show the probable existence of specific personality disorder among the epileptics in Nadoba; 34 epileptics and 34 controls chosen among the closest relatives (parents or co-tenants) matched by age (more or less than ten years old) and sex have been interviewed using the Temperament and Character Inventory (TCI) of Cloninger et al., in its French version validated by Pélissolo and Lépine. The TCI is a self addressed questionnaire that has 226 items with dichotomous and forced answer (true or false) that explores 7 dimensions of personality, 4 concerning temperament and 3 concerning character. Regarding psychometric aspects, the TCI has the particularity to gather together, in a unique tool, the exploration of two complementary dimensions: temperament rather conditional and character that has been acquired. The scores of character allow to differentiate the subjects having a good level of adaptation (high scores, about 100%), from those who, because of an individual fragility, adapt themselves less well (low scores). The temperament profile is used on a second approach to locate the personality disorders, taking into account probable deviations. People participating in this study were also interviewed with the Goldberg anxiety and depression scale. For the statistical analysis, the comparison of means was achieved through bilateral Student't-test. A significance threshold of 0.05 has been used for the analysis.

RESULTS

Concerning the results, 67 questionnaires have been selected from 33 epileptics (3 men and 30 women), mean age 29.3 years+/-8.1 and 34 controls (4 men and 30 women), mean age 30.6 years+/-5.6. The average scores obtained from the different items of the TCI scale are summarised in chart 1. The comparison of average scores obtained at each item, sub-dimension and dimension of the TCI, did not show any significant difference between cases and controls. However cases were significantly different from controls (P<0.001) on average Goldberg's anxiety scores (4.6+/-1.5 and 2.6+/-1.3) and depression (4.4+/-2.2 and 0.8+/-0.8).

DISCUSSION

The average scores obtained in France in the course of the normative study in general population were rather different. The validation study of the French version of TCI showed differences with the population of North America, suggesting inter cultural differences while evaluating the personality and the necessity of using specific norms during each new translation of the instrument. However, the valued in the French-speaking populations (Belgium, Swiss, Lebanon) are in general very close to the French values. The character and behavioural disorders among are of interest and the difficulty in evaluating the part of hysteria in the manifestation of exhibiting pseudo-seizure of epilepsy is also underlined. This question is raised in Nadoba in women, called "Odueri" or "the women that fall", a particular form of tonico-clonic fits observed in that cultural setting. Is it a question of real epileptic seizure or are these phenomena a kind of trance? This investigation of the Tamberma in Togo urges to set up psychometric studies to define local norms. It also suggests the possible existence of personality traits specific to the "women that fall" but these aspects require further developments.

Thérapies comportementales et cognitives centrées sur les schémas de Young dans les troubles de la personnalité: étude pilote sur 14 cas

INTRODUCTION

Personality disorders are very frequent in the general population, and especially in psychiatric patients. Various types of psychotherapy are proposed to treat these disorders, directly or not, but some specific cognitive-behavioural therapies (CBT) have been developed for all personality disorders or some of them such as borderline personality disorder. Among the most known models, one can quote Beck, Young and Linehan's approaches. Young therapies are based on the concept of "early maladaptive schemas", and associate cognitive-behavioural techniques and a very specific work on emotions. The procedure consists in, initially, identifying the cognitive schemas involved in the current disorders, as well as their sources in childhood, in particular through memories of traumatic or emotionally disturbing events. The techniques used to modify these early maladaptive schemas include emotional catharsis and corrective emotional experience methods (eg re-parenting).

STUDY DESIGN

We carried out an exploratory and naturalistic study of the effects of this schemas therapy among 14 adult out-patients (12 women and 2 men) suffering of personality disorders according to DSM IV criteria. The majority of the disorders belonged to the clusters C (50%) and B (42.9%). The early maladaptive schemas, according to Young's classification, were especially those of the types "distrust/neglect" (35.7%), "neglect feeling" (21.4%) and "subjugation" (21.4%).

RESULTS

The mean duration of the therapies was 13 month, with 26.2 consultations per subject. The primary efficacy criterion selected was the Social Adaptation Scale (SAS-SR, Weissman) score, showing a significant improvement at the end of the therapy (21.3 versus 27.9; p=0.003). This favourable evolution was confirmed by the other scales used, assessing anxious, depressive and general psychopathology symptomatology.

CONCLUSION

As a conclusion, -schemas therapies represent a rich and complete psychotherapeutic approach, in particular for personality disorders. Further controlled studies on their efficacy and on the factors associated to a good response are necessary.

Les phobies sociales en psychiatrie : caractéristiques cliniques et modalités de prise en charge (étude Phœnix)

Only few clinical epidemiologic studies have been conducted on social phobia in France to date. It is however a frequent disorder, with often severe alteration of social adaptation and quality of life, and for which effective treatments exist. Thus, it seems really important to further explore how these patients are nowadays identified and treated in psychiatry. It was the objective of the Phoenix study. In this observational multi-center study, 952 psychiatric in- or out-patients, with a primary diagnosis of social phobia according to DSM IV criteria, were included. Numerous diagnostic and psychometric evaluations were carried out, in order to evaluate the comorbidity (Mini International Neuropsychiatric Interview, Hospital Anxiety and Depression Scale), the intensity of social anxiety (Liebowitz Social Anxiety Scale), and various aspects of the functional and emotional impact (Various Impact of Social Anxiety scale, Sheehan Disability Scale, SF-36, Positive and Negative Emotionality scale). The patients were in majority females (57.6%), with a mean age 37.5 years, and with a mean duration of social anxiety disorder 12.5 years. The mean scores of social anxiety on Liebowitz scale was 40.3 +/- 12.6 for the fear factor, and 38.3 +/- 13.6 for the avoidance factor. The generalized social anxiety subtype (anxiety in most social situations) was present in 67.8% of the patients. A major depressive disorder was found in 47.7% of the sample, and the prevalence of agoraphobia was even higher (49.2%). As known in clinical practice and in other studies, the prevalence rates of current alcohol dependence and substances abuse were also important in this population (respectively 10.6% and 12.7%). Mean scores of the Hospital Anxiety and Depression (HAD) sub-scales were 13.9 +/-3.8 for anxiety and 9.1 +/-4.5 for depression. About 15% of the patients had a history of suicide attempt, and a suicidal risk was present in nearly 40% of the sample. The psychosocial impact and the alteration of quality of life (with especially a poor physical health perception) were very significant, in the family, educational or occupational and social domains. Mean scores of the Sheehan Disability Scale were 6.1 +/- 2.6 for professional impairment, 5.0 +/- 2.7 for familial impairment, and 6.6 +/- 2.3 for social life impairment. In addition to the disability due to social phobia intensity, an important part of the burden was due to depressive symptoms. Approximately 60% of the patients had already a psychiatric treatment at the time of the survey (since 1,7 years in average), but only 17% had a cognitive behavioral therapy (CBT), and 48% had an antidepressant treatment. These proportions increased in a significant way after the consultation during which the investigation was carried out: an antidepressant was prescribed to 72% of the patients, and a CBT is proposed to 48%. On the whole, this study confirmed the severity and the morbidity of social phobia in a very large sample of French psychiatric patients. The depressive disorders, suicidal risk, and social impairment associated with this condition should incite to more detect and treat it. Seeing the long duration of the disease in our sample, and the lack of specific therapies in many cases, the identification and the treatment of social phobia must be improved, and the role of the psychiatrists in this process seems very important.

[Patients with a complete or partial remission of Major Depressive Episode as part of Recurrent Major Depressive Disorder: description of ECLAIR study population]

Some guidelines and expert consensus consider the way of care management practices for the recurrent depressive disorder, particularly according to different identified risk factors for recurrence. But, few data are available about the way that these risk factors influence the care management of depressive recurrent patients during the partial or complete remission phase. Eclair study is a longitudinal observatory multicentric and national study, which describes the different risk factors that influence the psychiatrist decision about the following of patients suffering form Major Depressive Disorder (at least 3 Major Depressive Episode (MDE) according to DSM IV). This article presents the inclusion data (V0) of patients, with a focus on their demography characteristics and history of trouble, diagnosis, symptomatology evaluation (with CGI-S, HAM-D, Carroll scale and Sheehan scale) and Cloninger's personality questionnaire (TCI). A total of 596 patients with a recurrent depression either on partial remission (PaR) or complete remission (ToR) to their last episode at the selection, have been included. Complete remission was defined by the presence of a maximum of two criteria of MDE (according to DSM IV) excepted depressed mood and diminished interest or pleasure during at least two months with a HAM-D (17 items) score < 7 and partial remission was defined by the persistence of depressed symptoms but not sufficient to complete a diagnosis of MDE (according to DSM IV) associated with a HAM-D (17 items) score between 8 and 13 included. Mean HAM-D scores at V0 were 10.3 +/- 1.6 for PaR group and 4.0 +/- 1.9 for the ToR group. Free time since last episode was 6.5 +/- 10.5 months in ToR group and 11.2 +/- 16.9 months in PaR group (n = 385). Residual symptomatology between prior episodes was systematically present for 47.6% patients in PaR group, and for 26.7% patients ToR group. The feel to have a stressful daily life persisted for 62.5% of patient in PaR group and 34.3% in ToR group; 70.3% patients in PaR group and 57.9% patients in ToR group reported persistence of causal factor. The main collected risk factors for recurrence were the number of prior depressive episodes (64.9%), familial conflict existence (52.9%) and recent events of life (45.1%). In the TCI, a significant difference in comparison with the French normative data has been found for 3 dimensions: Harm Avoidance, Cooperativeness and Self-Directedness. Some differences were obtained for Novelty Seeking, Reward Dependence, and Self-Transcendence, but without sufficient clinical significance.This study confirms various characteristics about the unipolar depressive disorder, particularly the high risk of recurrence in patients with high number of previous episodes. In the research of predictive depressive recurrence signs, it would be interesting to focus on discriminating elements between complete remitted patients and partial remitted patients.

[Dimensional personality assessment of the members of the French junior national team of road cycling]

The high-standard sport practice requires an optimum functioning level of the individual in all its physiological systems as a whole. If the physical program training progressed much these last years, the techniques of mental preparations are still very heterogeneous and are not based on any validated procedures, based only on individual practices. Nevertheless, the majority of athletes and trainers stress the major importance of "mental" in the realization of performances. One of the obstacles in the mental training of the athletes is the difficulty in finding tools making it possible to evaluate and measure the psychic state of the individual and its mode of coping and adjustment, apart from any psychopathology. Few studies have been carried out on applicability of the personality questionnaires derived from the current dimensional models in these populations. Our study aimed to describe the personality of the members of the french junior team of road cycling, using the Temperament and Character Inventory (TCI) developed by Cloninger to explore the seven dimensions of his psychobiologic model of personality. In this model, four dimensions are temperament factors, and three are character factors. The three main dimensions of temperament are Novelty Seeking (NS), ie the tendency towards excitement in response to novel or rewarding stimuli, Harm Avoidance (HA) hypothesized to represent the tendency to respond intensely to signals of adverse stimuli, and Reward Dependence reflecting the tendency to respond intensely to signals of reward and to maintain behavior previously associated with reward. These personality traits are hypothetically related to underlying neurotransmitter systems (especially NS to dopaminergic function and HA to serotonergic function). The two main dimensions of character are Self-Directedness (SD) and Cooperativeness (C), measuring maturity traits respectively concerning individual and social adaptation. In this study, we used a computerized version of the TCI in a sample of 18 racing cyclists, ie all the members of the french junior national team. Their results were compared to those of 26 male, young, community subjects, derived from the french normative validation sample of the TCI. Mean comparisons were performed with the Mann-Whitney test, with Bonferroni correction for multiple comparisons. A significant difference between subjects and controls was obtained for Reward Dependence (p<0.0001), attachment RD3 (p<0.0001), and dependence RD4 (p<0.0025). No significant difference appeared between both groups for the other temperament or character dimensions. Based on temperamental Cloninger typology, the type "passionate" appeared to be the most frequent in this sample (55.6%). These results suggested that the TCI can be easily and usefully used in athletes, and that the personality profile of young competitive cyclists is not abnormal except a high level of reward dependence. Numerous applications can be derived from this use: the development of specific and personalized mental training, the screening and prevention of psychological vulnerability.

[Anxiety disorders in private practice psychiatric out-patients: prevalence, comorbidity and burden (DELTA study)]

Few data are currently available on the prevalence and associated characteristics of anxiety disorders in psychiatric out-patients in France, in particular in the private health-care. However, this represents one of the principal systems of care for patients suffering from anxiety disorders, with a possible direct access and several types of treatments available (pharmacotherapy but also different kinds of psychotherapy). The aim of our study was to describe the prevalence of anxiety disorders in a large sample of patients consulting in the private sector, and in addition to study the comorbidity, the severity of the disorders, their consequences on quality of life and health care consumption. The studied patients were included and assessed by 501 psychiatrists from all the country, at the time of a first visit. Inclusions were to be made in a consecutive way, but with the exclusion of psychotic disorders and dementia. A sample of 1 955 patients was obtained, and all subjects had a standardized diagnostic assessment with the Mini International Neuropsychiatric Interview (MINI) and with various dimensional scales of symptomatology severity, quality of life, and health care consumption. On the whole, at least one current anxiety disorder was found in 64.3% of the patients, while 55% had a depressive disorder. Individually, the prevalence rates are 29.4% for generalized anxiety disorder, 25.9% for agoraphobia, 19.2% for panic disorder, 15.3% for social phobia, 11.4% for obsessive-compulsive disorder, and 5.4% for post-traumatic stress disorder (PTSD). A history of suicide attempts was found in 12-20% of patients, and an elevated suicide risk was found for example in 25% of PTSD patients. The scores of the symptomatic scales, adaptation and quality of life measure show a very significant anxious symptomatology, with serious functional consequences. Approximately 75% of patients had another medical consultation during the three previous months, and 9% have been hospitalized. An interruption of work was found in 25% of the patients during the last three months, in average for 35 days. Concerning drug consumption before the visit by anxiety disorders patients, the preponderance of anxiolytic use is notable (85 to 98% according to categories of anxiety disorders) when compared to that of antidepressants (20 to 40%). Moreover, 38.4% of the whole sample took an anxiolytic once a day for at least three months and about 40% of them had dependence symptoms. In conclusion, this study showed the quantitative importance of anxiety disorders among psychiatric out-patients in the private practice sector in France, all the categories of anxiety being represented, and the high level of severity and burden of these disorders. Compared to some data published before, the prevalence rates of these anxiety disorders seem to be increasing.

Personality dimensions in social phobics with or without depression

OBJECTIVE

This study investigated the personality traits of social phobics using the Temperament and Character Inventory (TCI).

METHOD

A sample of 178 social phobics was assessed with the TCI, and compared with controls. The patients were classified into two groups, according to the absence (SP group) or to the presence (SP+D group) of depression.

RESULTS

We found significant elevated scores for harm avoidance (HA) in social phobics when compared with controls (16.2 +/- 2.7), in both the SP (26.2 +/- 3.5), and the SP+D (28.9 +/- 4.7), groups. Lower self-directedness scores were found in the SP and in the SP+D groups when compared with the controls. Patients with the generalized type of social phobia had higher HA scores as compared with other social phobics.

CONCLUSION

The personality profile obtained in these social phobics, whatever their depressive symptomatology, reflects a dramatically anxious and avoidant temperament associated to an immature character.

Why take social anxiety disorder seriously?

Social anxiety disorder (social phobia) is a disabling psychiatric condition, characterized by a fear of negative evaluation by others. Epidemiological studies have shown a high prevalence of the condition in the general population; the disorder is more common in women than in men. Social anxiety disorder has a typical onset during adolescence and a chronic course; remission rarely occurs without therapeutic intervention. Comorbid psychiatric conditions such as depression and alcoholism commonly occur in patients with preexisting social anxiety disorder, and increase the burden of the condition. Two subtypes of social anxiety disorder have been identified: "nongeneralized" and "generalized"; the latter form causes greater disability and is more often associated with comorbidity. The socioeconomic impact of social anxiety disorder on both sufferers and the community is considerable. For a person with social anxiety disorder, quality of life is greatly reduced; work, social, and personal relationships are all affected. Social anxiety disorder demands increased recognition, so that sufferers receive the treatment they need, in order to improve their quality of life through better social functioning.

Familial factors influencing the consumption of anxiolytics and hypnotics by children and adolescents

Many hypotheses have been made to explain the high rate of benzodiazepine consumption in France, including a general cultural and/or familial tendency to use certain types of psychotropic drugs. This study explored the association between lifetime medication use by parents and their children. Two hundred and twenty-one young patients (158 boys and 63 girls) consulting at a child and adolescent psychiatry department, six to 16 years of age (mean = 9.7 years), were screened for lifetime use of psychotropic drugs using a structured interview. Parents were asked about their own consumption, as well as their children's. Lifetime consumption rates (at least once) were 22.2% in boys and 20.6% in girls, and 19.6% in children less than 11 years old. Higher rates were found in patients with emotional disorders (anxiety disorders and depression). In parents, 45.1% of mothers and 24.1% of fathers reported using medications at least once. A significant association was found between child and parental medication use: 34.1% of children had positive lifetime consumption when their mothers also used medications at least once versus only 13.6% in other children (odds ratio = 3.31 [1.68-6.50]; P = 0.001). The most significant association was found between medication use by girls and their mothers (odds ratio = 12.1 [2.38-61.5]; P = 0.003). These data point to the existence of a family pattern of psychotropic drug consumption, especially in females.

Normative data and factor structure of the Temperament and Character Inventory (TCI) in the French version

We explored the psychometric features of the French Temperament and Character Inventory (TCI) in a 602-subject community sample (263 men and 339 women), representative of the French population. The factor structures of the temperament and character dimensions, explored separately, were in agreement with the hypothesized constructs, except for the scales Novelty Seeking NS1 (exploratory excitability), Persistence, and Self-Directedness SD4 (self-acceptance). The internal consistency of the main dimensions was good (Cronbach alpha coefficients between 0.68 and 0.82), but weak for Persistence (0.49). The mean scores of the temperament dimensions were notably different from those published in other normative data - especially lower for Novelty Seeking (16.4+/-5.6) and higher for Harm Avoidance (16.1+/-7.2) when compared with US data - suggesting cross-cultural differences in personality assessment, and the necessity to use specific normative values with each translated instrument.

Social phobia in the community: relationship between diagnostic threshold and prevalence

This paper investigates the prevalence of symptoms and various diagnostic criteria of DSM-IV social phobia in a French national representative population of 12,873 subjects, aged 15 or more. Respondents filled out a mailed questionnaire based on the social phobia section of the Munich-Composite International Diagnostic Interview (M-CIDI) in the year 1996. Response rate was 80.5%. Sixty-seven point one percent of the sample acknowledge having at least once in their lifetime a strong fear of one or more of the six prototypical social fear situations that are used as the CIDI social phobia stem items. However, only a few fulfilled all DSM-IV diagnostic criteria for social phobia. Depending on the type of diagnostic algorithms used and the stringency in which these criteria are applied, the resulting prevalence varied between 1.9 and 7.3%. These findings provide some further evidence about the considerable effects of varying diagnostic criteria and thresholds on prevalence rates for social phobia, explaining why most recent surveys have reported considerably higher rates of social phobia than those in the early 1980s.

[Detection and diagnosis of anxiety]

Anxiety disorders are now defined by precise diagnostic criteria and their treatments are facilitated by the clinical and therapeutic studies undertaken during the past two decades with current classifications. However, their recognition in everyday clinical practice can be difficult because the patients do not always evoke their symptoms spontaneously, and the attention of the physician is generally attracted by other mental disorders, such as depressive syndromes. The high prevalence of anxiety disorders in the general population, and the handicap associated with severe forms, must incite to their systematic exploration, in order to propose specific therapeutic procedures to the patients. In addition to the clinical exploration of various anxiety syndromes, the clinician can be helped in this goal by assessment instruments, nowadays well validated and easily used, such as dimensional scales or structured diagnostic interviews.

[Use of hypnotics in children: description and analysis]

BACKGROUND

Sleep disorders are frequent in pre-school children and in the French population, often leading to the prescription of hypnotics or sedatives. Therefore, this represents an important health problem in this population.

PATIENTS AND METHODS

We studied the hypnotic consumption in children, aged between 1 month to 4 years (23 +/- 11.3 months), who complained of insomnia. Parents completed 203 sleep questionnaires including information on the hypnotics consumption of their offspring (112 boys and 91 girls). The questionnaire was also related to the parent's sleep patterns and hypnotics consumption. Seventy percent of the sample had received medication, at least once before the evaluation, and at any age. A positive correlation between hypnotics consumption in mothers and children, particularly boys (odds-ratio = 4.8; 1.1-8.7) was found.

CONCLUSION

These data confirm the early exposition to hypnotics of children in the French population, and the existence of a familial pattern of consumption, mostly influenced by the mother. These data should permit the identification of subgroups at risk for early exposition and to encourage non-pharmacologic approaches in the treatment of insomnia in young children.

Anxiolytic and hypnotic use by general hospital inpatients. The impact of psychopathology and general medical conditions

This study explored the relative impact of general medical conditions and psychopathology on the current and lifetime use of anxiolytic and/or hypnotic drugs by general hospital inpatients. One hundred and five consecutive patients, admitted to an internal medicine department, were assessed by a structured interview about current and lifetime use of anxiolytic and/or hypnotic drugs, and with somatic and psychopathology scales. Eighty percent of patients reported using anxiolytics and/or hypnotics at least once in a lifetime, 62.9% in the last year, 55.2% in the last 3 months, and 42.9% in the last week. Correlations were found between drug use and current levels of anxiety and depression, but not somatic pathology. Psychological suffering appeared to be a major determinant for anxiolytic and/or hypnotic use by patients with general medical conditions. Consumption rates were higher than in the general population, but there was no direct link between somatic morbidity and drug use.

Social phobia and alcoholism: a complex relationship

The relationship between social phobia and alcoholism is complex. Alcohol problems typically develop secondary to social phobia, with patients reporting that they find alcohol helpful in coping with the symptoms of anxiety. However, excessive alcohol consumption may actually precipitate anxiety symptoms, and thus a vicious circle of anxiety and alcoholism is established. The clinician must consider the possibility of comorbidity in patients presenting with either alcoholism or social phobia. Only when both components of the condition are adequately assessed and treated can the cycle of social phobia and alcohol abuse be broken.

Validation of a computerized version of the temperament and character inventory (TCI) in psychiatric inpatients

We wrote a Basic program for Macintosh and IBM-compatible computers in order to administer the 226 questions of the French Temperament and Character Inventory (TCI) automatically, and to obtain a personality profile instantaneously. Validity was assessed by comparing the results of 32 psychiatric inpatients who used this program and the paper-and-pencil form of the TCI over an interval of 4.8 days on average. No acceptability problem was met with the computerized version. Correlation coefficients between computer and paper-and-pencil scores varied from 0.78 to 0.91 for temperament dimensions, and from 0.71 to 0.82 for character dimensions. The mean scores of the two versions were not significantly different. These results suggest that a computerized version of the TCI can be a reliable and acceptable instrument for the assessment of personality dimensions in psychiatric patients.

Comorbidity and social phobia: clinical and epidemiological issues

Both epidemiological and clinical studies indicate that social phobia is highly comorbid with anxiety and affective disorders and, to a lesser extent, with substance use disorders. In epidemiological surveys, about one in five subjects with social phobia has been reported as having no other lifetime disorder. Other patterns of comorbidity with eating disorders, personality disorders and medical morbidity have been studied more recently and are reviewed here. Comorbidity has a strong influence on impairment, health-seeking behavior and suicidality. These results have major implications for improving the recognition, assessment and treatment of this disorder by physicians and for the design of new research perspectives.

[Treatment of negative symptoms in schizophrenia by amisulpride. Review of the literature]

The deficit forms of schizophrenia have given rise to important research and controversy for the last 15 years. It is now recognized that some negative symptoms in schizophrenia are part of a pure and primary deficit syndrome which could be related to decreased dopaminergic function and which is not well improved by standard antipsychotic drugs. Amisulpride is a substituted benzamide neuroleptic with an original pharmacologic profile. Prescription of high doses (600-1 200 mg/day) yields to an usual antipsychotic activity on positive symptoms, through the blockage of post-synaptic dopamine receptors. At low doses, amisulpride preferentially blocks presynaptic dopamine autoreceptors, with a poor affinity for striatal sites. Three recent double-blind placebo controlled studies have suggested an efficacy of low doses (50-300 mg/day) of amisulpride in deficit forms of schizophrenia. The first study was carried out in young never-treated schizophrenic patients, and showed a significant improvement of negative symptoms with a 6-week amisulpride treatment. In the second study, subjects with a long-course deficit schizophrenia were included after a 6-week wash-out period. Reduction of scores of negative symptoms (Andreasen's scale) was about twice as important in the amisulpride group compared to the placebo group, whereas positive symptoms, modest at inclusion, remained unchanged. Finally, the efficacy of amisulpride was shown in another double-blind long-term study over 6 months in patients with predominantly negative symptoms. The overall safety profile of amisulpride in these studies was good, in particular with a low incidence of extrapyramidal symptoms. Thus, amisulpride at low doses appeared to be a well tolerated treatment for various deficit forms of schizophrenia, with a short-term and long-term efficacy.

[Epidemiology of the use of anxiolytic and hypnotic drugs in France and in the world]

A higher anxiolytic and hypnotic consumption has been evidenced in France by recent international and national surveys. In an effort to counteract this pattern French Health authorities have enforced limitation to the prescription of these drugs. Understanding the causes of this overuse needs a careful analysis of the pattern of use of this medicine but also of the associated morbidity factors. In the last ten years several studies have attempted to address these issues. In the general population there were 25 to 30% of occasional or regular users with between 5 and 7% chronic users making french anxiolytic users two to three time superior to most industrialised countries. This high level of consumption is not the privilege of anxiolytic since the same pattern of use is observed for all medicine. Studies in primary care, in medical inpatients and psychiatric inpatients show as expected that anxiolytic use increase with the psychiatric morbidity and also with somatic disorder. The main risk factors for anxiolytic use are female sex, old age and psychic and somatic morbidity. Age seems to play a major role in subjects over 65: 17% are chronic users. Multiple factors might play a role in benzodiazepine use as medical care system, physician type of practice, cultural specific aspects but no proper simple explanation is available to explain the mechanism of the french high anxiolytic use. Given the poor global recognition of mental disorder observed in most countries it is suggested to privilege primary care physician training in psychiatry to optimize psychotropic drug use.

[Are beta-blockers really depressogenic?]

More than 25 years of the use of systemic beta-blockers in cardiovascular pathologies, but also in various other indications, have yielded a number of reports suggesting that these drugs was linked with the development of clinical depression. Some retrospective studies have been carried out with positive results, but the rare longitudinal prospective studies have failed to confirm the association between beta-blockers use and depression. Clinical, methodological and pharmacological problems may explain these discrepancies and are of great interest.

[The benzodiazepine receptor: the enigma of the endogenous ligand]

The structure of the benzodiazepine receptor is nowadays well established and its potentialisation of GABA neurotransmission is known as the main action mechanism of benzodiazepinic drugs. Three categories of ligands have been also identified with radically different effects: the agonists (like diazepam and other anxiolytics), the antagonists (like flumazenil) and the inverse agonists which are anxiogenic, pro-convulsant and alerting (like beta-carbolines). By analogy with opiates system, the existence of a possible endogenous ligand has been proposed, and if such a substance really exists, it could be an important biological support of anxiety regulation. Many compounds with benzodiazepine receptor affinity have been extracted from the brain, the cerebrospinal fluid and the urine of animals but also of humans. Among these, some are artefacts, like ethyl-beta-carbolin, or their affinity are to low to be physiologically relevant. N-desmethyl-diazepam has been purified from the brain of never treated humans, but probably comes from diet or gut bacteria. An important candidate is the DBI (Diazepam Binding Inhibitor), which displays inverse agonist activity and is present in human organism. Its role as a modulator of GABAergic transmission is questioned. Likewise, the intervention of endogenous agonist compounds is possible during acquisition tasks with stress or anxiety in animals. There are also reasonable arguments to involve an agonist (sedative) ligand in the pathogenesis of hepatic encephalopathy. On the other hand, inverse agonists are not implicated in benzodiazepine withdrawal and panic disorder mechanisms. Lastly, probably indirect interactions between benzodiazepine receptor and cholecystokinin system are important to be considered, with possible consequences on anxiety regulations.

[Social phobia: historical and conceptual perspectives]

Social phobia is individualized in international classifications only since 1980 with the DSM III, ten years after the publication by Marks of its phobic disorders classification. Nevertheless, many european authors, psychiatrists or psychologists, have raised the question of social anxiety as far back as the eighteenth century, with various points of view and appellations. The first report of an ereutophobia observation is due to Casper, in 1846, which described a serious social anxiety affecting a young man. Ereutophobia has been especially studied by Pitres and Regis, in 1807 and 1902, and by Claparede in a comprehensive review published in the same period. Janet has also proposed, in 1903, a classification of phobia including a section for social phobia. In 1910, Hartenberg has described several forms of social anxiety under the generic term of shyness (timidity, performance anxiety, personality disorders, etc.). Then, there is a relative silent period until 1960 even if the names of Kontaktneurosen or social neurosis are punctually mentioned in british and german literatures, and if Morita, in Japan, has taken an interest in social anxiety around 1930. The existence of social phobia as a valid syndrome A has been confirmed in the successive classifications since the DSM III. Several structured interview schedules or self-rating scales have been proposed for assessment of social phobia, such as Liebowitz or Davidson scales, but at present no one instrument has demonstrated superiority and the use of a battery of several scales is recommended. Moreover, some diagnostic issues are not yet completely solved, in particular concerning the validity of different subtypes of social phobia. To date, only the generalized type has been individualized in the classifications when circumscribed and performance types remain disputed. Delineation of social phobia with avoidant personality, shyness, performance and test anxiety, other phobic disorders and complications like alcoholism are discussed. Clinical, epidemiological and therapeutical implications of these questions are of importance from a theoretical but also practical point of view.