[Adult ADHD - recommendations for clinical management in general practice]. / Trouble du déficit d'attention/hyperactivité (TDAH) chez l'adulte - Recommandations de prise en charge par le médecin de premier recours.

Adult Attention-Deficit/Hyperactivity Disorder (ADHD) is frequently found in the general population and it negatively impacts the quality of life of those that suffer from this disorder. Although the general practitioner occupies a primordial role in the detection as well as in the management of this disorder, the lack of training as well as the stigma surrounding ADHD make it not always obvious how to approach the patient with or possibly suffering from ADHD. In this article, we propose to present a few lines of good clinical practice applicable in primary medicine for the detection, diagnosis and management of ADHD in adults.

Le trouble du déficit d'attention/hyperactivité (TDAH) chez l'adulte est fréquemment rencontré dans la population générale et impacte négativement la qualité de vie de celui qui en souffre. Bien que le médecin de premier recours occupe un rôle primordial dans la détection ainsi que dans la prise en charge de ce trouble, le manque de formations ainsi que le stigma qui entoure le TDAH font qu'il n'est pas toujours évident pour le médecin de premier recours de savoir comment aborder un patient souffrant ou possiblement souffrant d'un TDAH. Dans cet article, nous présentons quelques bonnes pratiques cliniques applicables en médecine de premiers recours pour une détection, un diagnostic et une prise en charge du TDAH chez le sujet adulte.

Group intervention for family members of people with borderline personality disorder based on Dialectical Behavior Therapy: Implementation of the Family Connections® program in France and Switzerland.

BACKGROUND: Families and significant others of people with borderline personality disorder (BPD) show increased levels of psychological distress. Family Connections®, a 12-week group intervention based on the principles of Dialectical Behavior Therapy, was designed to provide families with both information about the disorder and emotion regulation skills. It has been progressively implemented in French-speaking European countries. METHODS: We conducted an observational, multicenter study in France and Switzerland. In total, 149 participants of the Family Connections program were included among five centers. Burden, depression, coping, and emotion regulation were assessed before and after the intervention. RESULTS: One-way repeated measures MANOVA showed that the burden, depressive symptoms, emotion regulation and coping all changed significantly after the intervention (p < 0.001, partial η2 = 0.297). T-tests showed that the burden significantly decreased after the intervention (p < 0.0001, d = -0.48), as did depressive symptoms (p < 0.0001, d = -0.36) and difficulties in emotion regulation (p < 0.0001, d =-0.32) whereas coping improved (p < 0.0001, d = 0.53). Two-way mixed ANOVA showed that burden reduction was stronger among female than male participants (p = 0.048, η2 = 0.027). Before the intervention, the burden was higher for female than male participants (p < 0.001). An initial linear regression showed the burden reduction to be associated with a decrease in the resignation of the participants (ß = 0.19, p = 0.047). A second linear regression showed the burden reduction to be associated with the intensity of the relatives' symptoms at baseline (ß = 0.22, p = 0.008) and improvement of emotional clarity of the participants (ß = 0.25, p = 0.006). CONCLUSION: This Dialectical Behavior Therapy-Based psychoeducational intervention is an appropriate way to support French-speaking European families of people with BPD.

Link between History of Childhood Maltreatment and Emotion Dysregulation in Adults Suffering from Attention Deficit/Hyperactivity Disorder or Borderline Personality Disorder.

Childhood maltreatment (CM) may have a long-term effect on emotion regulation. This study aimed to explore the relationship between CM and emotion dysregulation (ED) in a heterogeneous population. Four hundred seventy French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 ADHD + BPD, N = 61 clinical controls) completed the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), the Childhood Trauma Questionnaire (CTQ), and the Relationship Scales Questionnaire (RSQ). Reports of childhood maltreatment experiences were significantly associated with increased levels of emotion reactivity in all our groups and in the whole population, with a greater use of non-adaptive cognitive emotion regulation strategies and insecure attachment patterns. Emotional abuse showed the strongest effect. Further analysis indicated that an anxious attachment style significantly mediated the relationship between CM and the use of non-adaptive cognitive emotion regulation strategies and emotion reactivity. The results of our study suggest an impact of CM on ED and a potentially marked effect of emotional abuse. They also indicate a potentially mediating role of insecure attachment in the relationship between a history of childhood abuse and emotion reactivity and a higher use of non-adaptive cognitive emotion regulation strategies in adulthood.

Emotion dysregulation in adults suffering from attention deficit hyperactivity disorder (ADHD), a comparison with borderline personality disorder (BPD).

BACKGROUND: Emotional dysregulation (ED) is now considered as an important symptom of attention deficit hyperactivity disorder (ADHD). It is believed to have a considerable impact on the severity of the disorder, one's global functioning, and the prognosis. Our research aimed to evaluate and compare ED and cognitive emotional regulation strategies between ADHD and borderline personality disorder (BPD) patients. METHODS: Four hundred six French-speaking outpatients (N = 279 ADHD, N = 70 BPD, N = 60 BPD + ADHD) were assessed with the Emotion Reactivity Scale (ERS), the Cognitive Emotional Regulation Questionnaire (CERQ), The Basic Empathy Scale (BES-A), the Adult ADHD Self-Report Scale (ARSV-v1.1) and the Beck Depression Inventory II (BDI-II). ADHD, BPD and comorbid patients were compared with each other and with samples of controls extracted from already published data. RESULTS: ADHD patients, although having higher ED than samples derived from the general population, had less ED, better control over their emotions with higher use of adaptive cognitive strategies and lesser use of non-adaptive strategies than BPD patients. However, ADHD subjects had similar scores as BPD subjects when looking at difficulties in perceiving self and others. ED generated considerable distress in all groups and was also positively associated with ADHD symptomatology. ADHD patients with comorbid BPD had the highest scores of ED. CONCLUSIONS: Our results suggest that there may be similarly inefficient cognitive emotional regulation skills leading to ED in both disorders (ADHD and BPD). However, ADHD patients showed a higher use of adaptive cognitive emotional strategies and a lower level of ED than BPD patients.

Reducing Delusional Conviction through a Cognitive-Based Group Training Game: A Multicentre Randomized Controlled Trial.

OBJECTIVE: "Michael's game" (MG) is a card game targeting the ability to generate alternative hypotheses to explain a given experience. The main objective was to evaluate the effect of MG on delusional conviction as measured by the primary study outcome: the change in scores on the conviction subscale of the Peters delusions inventory (PDI-21). Other variables of interest were the change in scores on the distress and preoccupation subscales of the PDI-21, the brief psychiatric rating scale, the Beck cognitive insight scale, and belief flexibility assessed with the Maudsley assessment of delusions schedule (MADS). METHODS: We performed a parallel, assessor-blinded, randomized controlled superiority trial comparing treatment as usual plus participation in MG with treatment as usual plus being on a waiting list (TAU) in a sample of adult outpatients with psychotic disorders and persistent positive psychotic symptoms at inclusion. RESULTS: The 172 participants were randomized, with 86 included in each study arm. Assessments were performed at inclusion (T1: baseline), at 3 months (T2: post-treatment), and at 6 months after the second assessment (T3: follow-up). At T2, a positive treatment effect was observed on the primary outcome, the PDI-21 conviction subscale (p = 0.005). At T3, a sustained effect was observed for the conviction subscale (p = 0.002). Further effects were also observed at T3 on the PDI-21 distress (p = 0.002) and preoccupation subscales (p = 0.001), as well as on one of the MADS measures of belief flexibility ("anything against the belief") (p = 0.001). CONCLUSION: The study demonstrated some significant beneficial effect of MG.

Functions and timescale of self-cutting in participants suffering from borderline personality disorder.

The purpose of this study was to examine the meanings and timescale of self-cuttings in a cohort of 22 outpatients suffering from borderline personality disorder. Sixty-one events were recorded using the newly developed self-cutting-checklist (SCUC) designed to investigate the severity of self-cuttings, and intent to die, suicidal ideation, inner tension, sense of relief and anesthesia, and consequences associated with this behavior. We found that typical self-cuttings were associated with a decrease in inner tension and suicidal ideation. Moreover self-cuttings associated with a desire to die differentiated from those associated with no desire to die by significantly less reduction in inner tension. Finally, self-cuttings occurred significantly more often during evenings and nights than during daytime. In conclusion, self-cuttings can be reasonably addressed by self-report. Attention to specific issues such as intent to die and the time of the self-cuttings may improve the outcome of these particularly high-risk subjects.

"Michael's Game," a card game for the treatment of psychotic symptoms.

OBJECTIVE: "Michael's Game" is a card game which aims at familiarizing healthcare professionals and patients with cognitive therapy of psychotic symptoms. The present study tests the feasibility and the impact of the intervention in naturalistic settings. METHODS: 135 patients were recruited in 11 centres. They were assessed pre- and post-tests with the Beck Cognitive Insight Scale (BCIS) and the Peters Delusion Inventory-21 items (PDI-21). RESULTS: Data about 107 patients were included in the entire analyses. Significant improvements were observed on BCIS subscales as well as a reduction of severity of conviction and preoccupation scores on the PDI-21. The intervention has a moderate effect on the PDI-21 preoccupation and conviction as well as the BCIS subscales. Patients who benefit the most from the program are patients who have a low degree of self-reflectiveness and patients who are concomitantly preoccupied by their symptoms. CONCLUSION: The present study supports the feasibility and effectiveness of "Michael's Game" in naturalistic settings. PRACTICAL IMPLICATIONS: The game seems to be a useful tool for patients with psychotic disorders.

Predictors of response and drop-out during intensive dialectical behavior therapy.

The purpose of this study was to examine the effectiveness, and predictors of response and drop-out during a four-week course of intensive dialectical behavior therapy (I-DBT) in 447 outpatients suffering from borderline personality disorder (BPD), over a 10-year period. Assessments included a diagnostic interview, the International Personality Disorder Examination Screening Questionnaire, the Beck Depression Inventory, and the Beck Hopelessness Scale. Among these participants, 103 started a second course of treatment. In agreement with previous reports, I-DBT was effective in reducing levels of depression and hopelessness with a trend of increasing effectiveness over the study period. High schizoid scores and low narcissistic score predicted poor response. Treatment completion rate was high, and low education predicted dropout. A discussion on the usefulness of a second course of treatment should be held with patients and staff as it was not effective in reducing depression and hopelessness.