Day hospital program for anorexia nervosa in children and adolescents: Assessment, management and specific focus on early onset anorexia nervosa.

INTRODUCTION: The French day hospital program specialized in eating disorders (ED) opened in January 2018. Our study presents preliminary data on clinical profiles of patients with anorexia nervosa (AN). We describe more specifically clinical characteristics of patients with early onset AN and according to their therapeutics orientations. Then, we compare the weight gain of patients managed only in day-patient (DP) treatment with those managed initially inpatient (IP) treatment and relays in DP. METHODS: Ninety-two patients with AN, aged between 8 and 18 years, were evaluated with several questionnaires (EDI-2, EDE-Q, BSQ, EDS-R, CDI, STAI-Y, VSP-A, EPN-13). RESULTS: Patients with early onset AN, n = 23 (25.3%), presented more restrictive behaviors, less marked dietary symptomatology, a lower degree of clinical perfectionism and a less marked feeling of ineffectiveness than adolescent patients with AN. Regarding the choice of hospitalization modality (DP alone or IP-DP), the only difference highlighted was the severity of patient undernutrition. Among the patients who were treated (IP-DP n = 27 vs DP alone n = 25), the weight evolution after one month and at discharge was favorable for both groups. CONCLUSION: These preliminary data suggest the effectiveness of DP in the care of AN in children and adolescents.

Demographic, clinical, and service-use characteristics related to the clinician's recommendation to transition from child to adult mental health services.

PURPOSE: The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians' advice to continue treatment at AMHS. METHODS: Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians' transition recommendations. RESULTS: Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS. CONCLUSION: Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

[Improvement of the impulsive control in adolescents with attention deficit hyperactivity disorder (ADHD) after a cognitive behavioral therapy]. / Amélioration du contrôle impulsif chez les adolescents avec un trouble de l'attention avec hyperactivité (TDAH) ayant suivi une thérapie cognitive comportementale.

AIM: MPH is the more often prescribed stimulant for Attention Deficit Hyperactivity Disorder (ADHD), but it has been estimated that 30% of patients do not adequately respond or cannot tolerate it. Therefore, some other therapies are needed, such as cognitive behavioral therapy. Cognitive behavioral therapy is an intervention proposed over several sessions and aimed at modifying behavior by teaching different techniques that participants can re-use to control their symptoms. In our Institute, we used a program centered on attentional and metacognitive functions. It consists of a series of workshops performed in group at the rate of one workshop of 90minutes per week for 12 weeks. Positive effects on the behavior of adolescents with ADHD have been reported by parents and educators, but the effects of the program on specific cognitive processes have never been precisely investigated. METHOD: In the present study, we evaluated the impact of the program on impulsive control in adolescents with ADHD who are known to present impaired impulsive control. Impulsive control is required each time there is a conflict between an inappropriate prepotent action and a goal-directed action. At an experimental level, impulsive control can be studied with conflict tasks, such as the Simon reaction time task. Interpreted within the theoretical framework of the so-called « Dual-process activation suppression ¼ (DPAS) model, this task is a powerful conceptual and experimental tool to separately investigate the activation and inhibition of impulsive actions, which is almost never done in studies about impulsive control. Twenty adolescents followed the program and were tested before and at the end of the program by using dynamic analyses of performance associated with DPAS model. RESULTS: The results have shown an improvement of the impulsive control after three months of cognitive behavioral therapy, and this improvement was due to both a decrease of the propensity to trigger impulsive actions and an improvement of inhibitory processes efficiency. CONCLUSION: This program could be a relevant alternative to the stimulant medication, more particularly when parents are reluctant with medication or when the adolescent suffers from important side effects.

[Use of virtual reality in eating disorders]. / Utilisation de la réalité virtuelle dans les troubles des conduites alimentaires.

Virtual reality is a new technology that can be used to model an environment with which an individual can interact using all five senses. It is notably used in psychiatry for anxiety disorders and addictions, and its use in eating disorders has been growing in recent years. Indeed, virtual reality offers interesting advantages, such as its ability to personalize any environment, which is also more secure and controllable. Recent studies show promising results in the understanding, evaluation, and therapeutic management of eating disorders. The use of avatars in anorexia nervosa allows for a correct assessment of the perceptual (body image distortion) and cognitive-affective (body dissatisfaction) components of the body image disorder in a similar way to conventional methods, but also for a better understanding of them. Moreover, avatars allow the development of innovative therapeutic protocols and are thus used in the context of exposure therapy. The new body swapping protocol, based on a multisensory illusion, offers particularly promising results in the reduction of body image disorder. For bulimia nervosa and binge eating disorder, virtual reality has made it possible to better characterize the triggering mechanisms of binge eating episodes through studies that have observed different responses to food-related environments and stimuli. At the therapeutic level, virtual reality cue exposure therapy has the most empirical support. Its aim is to reduce or eliminate the anxiety and craving felt by a patient in response to exposure to food or other food-related cues by preventing the patient from consuming food, and results show clear reductions in anxiety, craving and binge eating episodes. While all these results seem to indicate a bright future for virtual reality in eating disorders, further studies are needed to validate the positive impact of its use, but also its limitations. Notably, cyber sickness could alter the smooth running of virtual reality therapy sessions by causing nausea and disorientation. Moreover, it is important to verify that a therapeutic protocol does not lose its effectiveness when it is transposed into virtual reality. However, virtual reality seems to be a therapeutic tool that is better accepted by patients, and even better by adolescents, which is very interesting for eating disorders since adolescents are the most affected. Virtual reality could therefore help motivate patients to pursue treatment and reduce the dropout rate while offering good therapeutic results. Thus, studies conducted in recent years have shown that virtual reality is a promising tool in the understanding, assessment and treatment of eating disorders, and future research should confirm this, particularly in the adolescent population.

[Adolescent sleep disorders associated with school absenteeism: The child and adolescent psychiatrist is often crucial for effective management in sleep consultation]. / Troubles du sommeil de l'adolescent associés à un absentéisme scolaire : le pédopsychiatre est souvent déterminant pour une prise en charge efficace en consultation de somnologie.

INTRODUCTION: Adolescent sleep is characterized by a physiological delayed sleep phase disorder frequently exacerbated by the intensive use of information and communication technologies. The sleep restriction thus induced during schooling has consequences on the physical and psychological health of the adolescent. On the other hand, the sleep complaint may correspond to psychiatric disorders in the adolescent. Thus, when this complaint is associated with school absenteeism, the management of sleep alone is often insufficient. In order to understand the reason for this inefficiency, we wanted to better characterize the profile of these adolescents. METHOD: We have developed a somnological and psychiatric "screening kit" resulting in a management decision tree. This kit was tested in 2017 as part of joint consultations at the Lyon Sleep Center in adolescents who presented a complaint of sleepiness or insomnia associated with school absenteeism. RESULTS: These preliminary results on 11 patients show the predominance of a delayed sleep phase syndrome or an absence of sleep diagnosis associated in more than 90 % of cases with anxiety-depressive difficulties ranging from the mood depressive disorder to the school refusal behavior and underlying anxiety disorders. Somatization is also common. CONCLUSION: These first data seem to confirm the need for a child and adolescent psychiatric assessment to deal with the psychological difficulties of these adolescents in parallel with their sleep complaint so as to offer them the best chances of improvement, re-schooling and social insertion.

[The schizophrenic's chilhood]. / Enfance du schizophrène.

Pathology of adolescence and young adult, schizophrenia can begin in very rare cases during childhood. Two early clinical forms of the disorder have been identified by epidemiological studies: one beginning at the age of 15; the other around 9 years old; While many questions remain unsanswered about the neurobiological and environmental factors - common or distinct - of these two clinical phenotype, both are related to a profoun and lasting alteration of the neurocognitive development whose origin would clearly go back to infancy or to the antenal period. Here we will present a possible story back of schizophrenia in the light of the latest neuroscientific studies in imagery and genetics from adolescence to antenal period.

[Very early onset schizophrenia]. / Schizophrénie à début très précoce.

Very early onset schizophrenia begins before the age of 13. This form of schizophrenia is particularly difficult to diagnose. The differential diagnosis is difficult because some psychotic signs can be passing or be representative of an anxious or depressive disorder. The differential diagnosis with the autistic spectrum disorder is also complex. Finally, other disorders are associated in the majority of the cases. It is a neurodevelopmental disorder with premature cerebral anomalies engendered by the interaction of genetic factors and environmental factors. There seems be a real continuity between the very early form and the adult form although very early onset schizophrenia is a severe form of the disorder which carries a relatively poor prognosis. Its outcome depends both on early screening, the quality of diagnosis and on the speed of multidisciplinary interventions offered.

[Contribution of mindfulness meditation in cognitive behavioral therapy for insomnia]. / Apport de la pleine conscience dans les thérapies cognitives et comportementales de l'insomnie.

INTRODUCTION: Insomnia is considered to be a serious public health issue affecting approximately 10% of adults. Chronic insomnia may increase the risk of health problem, psychological vulnerability and proneness to accidents. Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first line of treatment. Even though CBT-I is widely considered as an effective therapy, 20 to 30% of patients do not respond to this treatment. Mindfulness therapy, known to reduce rumination and stress, could be an interesting complement to enhance CBT-I. The aim of this study is to evaluate the efficacy of therapy combining mindfulness meditation and CBT-I for the treatment of chronic insomnia. METHODS: Thirty-three patients, diagnosed with chronic insomnia, aged 18 to 75 years (51±15 years) were recruited between October 2015 and June 2016 at the Sleep Center of Marseille. The patients were then divided into two groups according to their psychotherapy method: group CBT-I alone (17 patients) or a group therapy combining CBT-I and Mindfulness (16 patients). All participants were given five sessions of standard CBT during eight weeks. The patient-reported outcome measures were sleep onset latency, wake after sleep onset (WASO), total wake time, total sleep time, time in bed, sleep efficiency and number of awakening from sleep diaries before treatment (T0) and six weeks later (T1). Assessments were done using Pittsburgh Sleep quality index (PSQI), Insomnia severity Index (ISI), the Epworth sleepiness scale, the hospital anxiety and depression scale (HAD), the dysfunctional beliefs and attitude about sleep (DBAS-16); further, the use of sleeping pills was also recorded at T0 and T1. RESULTS: Out of the 33 participants who began the treatment, 29 completed all sessions and were included in the analyses (4 dropouts in the group CBT-I alone). The data shows that each treatment yielded significant improvements over time in sleep variables from the diary, PSQI, ISI, anxiety (P=0.004), DBAS 16, sleeping pill use and vitality measured by SF36 health survey (P=0.004). Comparing the results of the two therapy groups, the meditation associated to CBT-I shows significantly greater rates of reduction in WASO relative to CBT-I group (P=0.009). CONCLUSIONS: This study confirms the beneficial effects of CBT for patients suffering from insomnia on sleep parameters, anxiety symptoms and quality of life. Furthermore, this study suggests, for the first time, that combining CBT and mindfulness is a superior approach compared to that of only conventional CBT-I in improving sleep.

[Recognition of facial expressions of emotions by 3-year-olds depending on sleep and risk of depression]. / Reconnaissance émotionnelle chez les enfants de 3ans en fonction du sommeil et du risque de dépression.

INTRODUCTION: The emotional process is characterized by a negative bias in depression, thus it was legitimate to establish if they same is true in very young at-risk children. Furthermore, sleep, also proposed as a marker of the depression risk, is closely linked in adults and adolescents with emotions. That is why we wanted first to better describe the characteristics of emotional recognition by 3-year-olds and their links with sleep. Secondly we observed, if found at this young age, an emotional recognition pattern indicating a vulnerability to depression. MATERIAL AND METHOD: We studied, in 133 children aged 36 months from the AuBE cohort, the number of correct answers to the task of recognition of facial emotions (joy, anger and sadness). Cognitive functions were also assessed by the WPPSI III at 3 years old, and the different sleep parameters (time of light off and light on, sleep times, difficulty to go to sleep and number of parents' awakes per night) were described by questionnaires filled out by mothers at 6, 12, 18, 24 and 36 months after birth. Of these 133 children, 21 children whose mothers had at least one history of depression (13 boys) were the high-risk group and 19 children (8 boys) born to women with no history of depression were the low-risk group (or control group). RESULTS: Overall, 133 children by the age of 36 months recognize significantly better happiness than other emotions (P=0.000) with a better global recognition higher in girls (M=8.8) than boys (M=7.8) (P=0.013) and a positive correlation between global recognition ability and verbal IQ (P=0.000). Children who have less daytime sleep at 18 months and those who sleep less at 24 months show a better recognition of sadness (P=0.043 and P=0.042); those with difficulties at bedtime at 18 months recognize less happiness (P=0.043), and those who awaken earlier at 24 months have a better global recognition of emotions (P=0.015). Finally, the boys of the high-risk group recognize sadness better than boys in the control group (P=0.015). CONCLUSION: This study confirms that the recognition of emotion is related to development with a female advantage and a link with the language skills at 36 months of life. More importantly, we found a relationship between sleep characteristics and emotional recognition ability and a negative bias in emotional recognition in young males at risk for depression.

[Noninvasive cerebral stimulation for treatment of ADHD: A review of the literature]. / Stimulation cérébrale non invasive dans le traitement du trouble déficit de l'attention avec ou sans hyperactivité : une revue de la littérature.

OBJECTIVES: The aim of this review is to summarize the available data in the literature about the therapeutic applications of transcranial magnetic stimulation and transcranial direct current stimulation in attention-deficit hyperactivity disorder (ADHD). METHOD: The scientific literature search of international articles was performed in February 2016 using the PubMed electronic database. The following MeSH terms were employed: "attention-deficit disorder with hyperactivity" AND "transcranial magnetic stimulation", "attention-deficit disorder with hyperactivity" AND "transcranial direct current stimulation". RESULTS: Five studies were retained by the literature search and were included in the review about rTMS and ADHD. Except for one study, they all showed significant positive effects of rTMS on ADHD. Four studies were retained by the literature search and were included in the review about tDCS and ADHD. Three of them showed significant positive effects of tDCS on ADHD. Two of them used tDCS during sleep at a frequency<1Hz. Only low-level evidences are available to support treatment with rTMS or tDCS in patients with ADHD. Indeed, randomized controlled trials are rare in this field of research. CONCLUSION: Additional studies are needed to confirm the efficacy of rTMS and tDCS in ADHD. rTMS could be used as an alternative therapy when methylphenidate is not well tolerated or shows an insufficient efficacy. Nevertheless, the optimal target, frequency and duration remain to be determined. tDCS can modulate attention in healthy subjects but data are insufficient in ADHD to conclude. It could be interesting to study its use in association with cognitive remediation to enhance its cognitive efficacy.

[Attention deficit hyperactivity disorder and/or bipolar disorder?]. / Trouble déficitaire de l'attention et/ou trouble bipolaire ?

The attention deficit disorder and the bipolar disorder maintain a complex relation. Indeed, these two syndromes share numerous symptoms that engender numerous diagnostic difficulties. According to several studies, it seems that these two disorders are really different with significant differences at the functional and anatomical level. However, there are common cognitive deficits as well as relatively frequent co-morbidity which is necessary to know in order to adjust the treatment.

[Dissociative disorders and affective disorders]. / Troubles dissociatifs et troubles affectifs.

The phenomenology of dissociative disorders may be complex and sometimes confusing. We describe here two cases who were initially misdiagnosed. The first case concerned a 61 year-old woman, who was initially diagnosed as an isolated dissociative fugue and was actually suffering from severe major depressive episode. The second case concerned a 55 year-old man, who was suffering from type I bipolar disorder and polyvascular disease, and was initially diagnosed as dissociative fugue in a mooddestabilization context, while it was finally a stroke. Yet dissociative disorders as affective disorder comorbidity are relatively unknown. We made a review on this topic. Dissociative disorders are often studied through psycho-trauma issues. Litterature is rare on affective illness comorbid with dissociative disorders, but highlight the link between bipolar and dissociative disorders. The later comorbidity often refers to an early onset subtype with also comorbid panic and depersonalization-derealization disorder. Besides, unipolar patients suffering from dissociative symptoms have more often cyclothymic affective temperament. Despite the limits of such studies dissociative symptoms-BD association seems to correspond to a clinical reality and further works on this topic may be warranted.

[Cognitive profiles in pervasive developmental disorders]. / Les profils cognitifs dans les troubles envahissants du développement.

OBJECTIVE: This study investigated the cognitive skills in pervasive developmental disorders (PDD). METHODOLOGY: Two groups of children participated in this study, 39 individuals with autism and 18 individuals with Asperger syndrome. Each participant was assessed by the Wechsler scales: WPPSI-III, WISC-III or WISC-IV. RESULTS: Children with Asperger syndrome have VIQ more than PIQ and the children with autism have VIQ less than PIQ. The performances in "block design" task vary according to the cognitive level and not according to the PDD type. The high-functioning autistic children show high performance in "block design" task. Children with Asperger syndrome revealed impairments in the "understanding of social situations" task. DISCUSSION: Individuals with autism have a verbal intelligence quotient lower than individuals with an Asperger syndrome. Several hypotheses have tried to explain verbal differences between children with autism and Asperger syndrome. A first hypothesis proposed a developmental convergence between these two groups. A second hypothesis suggested that communication and social interaction impairments could be implicated in verbal skills. A third hypothesis supported that individuals with Asperger syndrome could develop a specific cognitive style. Children with autism have spatial and perceptive capacities better than verbal capacities. These performances could be interpreted as the expression of a specific cognitive style based on the visual analysis of the detail. CONCLUSION: The low-functioning children with autism have a cognitive profile with PIQ more than VIQ and high skills in spatial organization. The high-level children with autism have a cognitive profile with PIQ more than VIQ and high skills in spatial abstraction. Children with Asperger syndrome have a profile VIQ more than PIQ profile, they are particularly good in verbal learning notably vocabulary.

[Decision-making and schizophrenia]. / Prise de décision et schizophrénie.

Abnormalities involving the prefrontal cortex (PFC) have long been postulated to underpin the pathophysiology of schizophrenia. Investigations of PFC integrity have focused mainly on the dorsolateral PFC (DLPFC) and abnormalities in this region have been extensively documented. However, defects in schizophrenia may extend to other prefrontal regions, including the ventromedial PFC (VMPFC), and evidence of VMPFC abnormalities comes from neuropathological, structural and functional studies. Patients with acquired brain injury to the VMPFC display profound disruption of social behaviour and poor judgment in their personal lives. The Iowa Gambling Task (IGT) was developed to assess decision-making in these neurological cases : it presents a series of 100 choices from four card decks that differ in the distribution of rewarding and punishing outcomes. Whilst healthy volunteers gradually develop a preference for the two "safe" decks over the course of the task, patients with VMPFC lesions maintain a preference for the two "risky" decks which are associated with high reinforcement in the short term, but significant long-term debt. Interestingly, damage to VMPFC may cause both poor performance on the IGT and lack of insight concerning the acquired personality modification. Recently, our group reported a trait-related decisionmaking impairment in the three phases of bipolar disorder. In a PET study, VMPFC dysfunction was shown in bipolar manic patients impaired on a decision-making task and an association between decision-making cognition and lack of insight was described in mania. A quantitative association between grey matter volume of VMPFC and memory impairment was previously reported in schizophrenia. Research suggests that lack of insight is a prevalent feature in schizophrenia patients, like auditory hallucinations, paranoid or bizarre delusions, and disorganized speech and thinking. Because schizophrenia is associated with significant social or occupational dysfunction, previous research assessed decision-making function but indicates conflicting results. Thirteen studies have reported impaired IGT performance in patients with schizophrenia and, in seven reports, no significant differences in IGT performance between patient and healthy control groups were found. Those discrepancies may relate to multiple factors. First, most of the studies included small sample size and negative findings may be due to the large variance of net scores. Second, as suggested by Rodríguez-Sánchez et al., there is a wide disparity in performance by control subjects across studies. Third, intelligence quotient (IQ) score and level of education may be correlated with IGT performance, which may explain IGT performance differences in studies that did not control for educational or IQ score. Fourth, only two studies have systematically controlled for substance use disorder, a potential confounder. Fifth, only two studies assessed the impact of antipsychotic (AP) class on performance. Sixth, to our knowledge, no study assessed the impact of AP dosage on decision-making ability, while AP dose-reduction and dopamine increase, might lead to improvements, in cognitive functions in schizophrenia and in IGT performance in bipolar disorder, respectively. Finally, discrepancies between studies may be related to the heterogeneity of diagnostic groups. Two of the negative studies included schizophrenia and schizoaffective disorder while positive studies have generally included only patients with schizophrenia. Nevertheless, some studies that included only patients with schizophrenia failed to find differences between groups. Thus, further research should assess decision-making in schizophrenia by testing a large group of patients with homogeneity of diagnostic, in comparison with a large group of control subjects. Authors should control for IQ or level of education, substance use disorder and smoking status. While it is now accepted that DLPFC defects in schizophrenia may extend to VMPFC, future investigations should test for an association between memory, insight ability and IGT performance and assess the impact of antipsychotic dosage upon performance.

[Theory of mind and schizophrenia]. / Théorie de l'esprit et schizophrénie.

In social cognition, the notion of Theory of Mind (ToM) is widely studied among people with schizophrenia to give an account for intersubjective disturbances. ToM is classically defined as the ability to make inferences about other persons'mental states, as beliefs, thoughts or intentions. However, ToM is not understood or explored as a homogeneous notion. First, this review briefly describes main theoretical models, as well as experimental tasks of ToM. Second, clinical results strongly suggest that patients with schizophrenia present impaired ToM performances. However, the presence of a robust relationship between ToM and schizophrenic symptomatology, or clinical course, is still controversial. Third, we highlight main findings from functional brain imaging studies based on ToM. Finally and in a more critical perspective, we suggest a few theoretical and experimental limitations regarding impaired ToM as a core feature of schizophrenic disturbances in social interactions.

[Schizophrenia and cognition: a neurodevelopmental approach]. / Schizophrénie et cognition: perspective neurodéveloppementale.

Accumulating evidence supports the hypothesis of abnormal neurodevelopment in schizophrenia. According to this hypothesis, schizophrenia is the consequence of prenatal abnormalities resulting from the interaction of genetic and environmental factors. In line with this hypothesis, several studies indicate that pregnancy and birth complications are risk factors for developing schizophrenia. At the clinical level, multiple cognitive deficits can be found in schizophrenic patients before illness onset. The neurodevelopmental hypothesis considers these cognitive deficits as the expression of early abnormalities on the central nervous system development. Consistently, brain imaging data show early structural abnormalities and abnormal progressive brain changes in schizophrenia. Finally, genetic and histological data indicate that genes associated with schizophrenia are involved in brain development.