Emotion coping strategies and dysfunctional sleep-related beliefs are associated with objective sleep problems in young adults with insomnia.

BACKGROUND: Though insomnia is associated with affected emotion regulation and dysfunctional ideas about sleep, little is known about the relation of these problems with objective sleep disruption. We aimed to explore this relationship in young adults with and without insomnia. METHODS: Twenty young adults with diagnosed insomnia disorder (aged 27.7 ± 8.6 years) and twenty age-matched individuals without insomnia (26.7 ± 7.0 years) completed questionnaires, measuring sleep-related thoughts and emotions and emotion regulation. Objective sleep measurements were collected through 10-days actigraphy as a representative sample of nights, and analyzed for sleep onset latency, sleep efficiency total sleep time. T-tests and multivariate analyses of variance (MANOVA) were conducted for sample characterization and analysis of the association of sleep-related thoughts and emotions and emotion regulation with objective sleep data. RESULTS: As expected, young people showed more dysfunctional sleep-related thoughts and emotions (all ps ≤ 0.025) and dysfunctional emotion regulation strategies (all ps ≤ 0.040). Surprisingly, MANOVA results showed that only emotion coping strategies after a stressful event (p = 0.017) and dysfunctional beliefs about sleep (p = 0.012), but not other factors of arousal or sleep reactivity, were associated with overall worse sleep, especially sleep onset latency (all ps ≤ 0.012) and sleep efficiency (all ps ≤ 0.010). CONCLUSIONS: Maladaptive emotion coping strategies after a stressful event and dysfunctional sleep-related beliefs and attitudes affect objective sleep onset latency and sleep efficiency in young adults, highlighting the importance of targeting these features in the prevention and treatment of chronic insomnia and improving actual sleep quality.

Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults.

Attention deficit with or without hyperactivity disorder (ADHD) is one of the most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast with many European countries, the identification and management of adult ADHD remains underdeveloped in France, and a subject of controversy. This review provides a practical update on current knowledge about ADHD in adults for French-speaking professionals who have to detect or manage adult patients with ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of the international diagnostic classification. While symptoms and impairment due to ADHD are frequently severe during childhood, they often evolve as children grow older, with frequent persistent disabilities in adulthood. In adulthood, the clinical presentation, as in childhood, involves the symptom triad of inattention, hyperactivity and impulsivity. However, differences are noted: hyperactivity is more often internalized, symptoms of inattention may be masked by anxiety symptoms or obsessive-like compensation strategies. ADHD is often diagnosed during childhood, but it is not rare for the diagnosis to be made later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively well-developed compensation factors could be two underlying reasons for the long delay until diagnosis. Other symptoms, such as emotional deregulation or executive function-related symptoms are also usually observed in adults. In addition, in adults, ADHD is often associated with other psychiatric disorders (in 80% of cases); this makes the diagnosis even more difficult. These disorders encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety disorders, and other neurodevelopmental disorders and personality disorders, especially borderline and antisocial personality disorder. Substance-use disorders are very common, either as a consequence of impulsivity and emotional dysregulation or as an attempt at self-treatment. Sleep disorders, especially restless leg syndrome and hypersomnolence, could share common pathophysiological mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for serious functional impairment, in various domains, leading to academic, social, vocational, and familial consequences. The impact on other psychiatric disorders as an aggravating factor should also be considered. The considerable disability and the poorer quality of life among adults with ADHD warrant optimal evaluation and management. The diagnostic procedure for ADHD among adults should be systematic. Once the positive diagnosis is made, the evaluation enables characterisation of the levels of severity and impairment at individual level. A full examination should also assess medical conditions associated with ADHD, to provide personalized care. In recent years, a growing number of assessment tools have been translated and validated in French providing a wide range of structured interviews and standardized self-report questionnaires for the evaluation of core and associated ADHD symptoms, comorbidities and functional impairment. The treatment of ADHD in adults is multimodal, and aims to relieve the symptoms, limit the burden of the disease, and manage comorbidities. The most relevant and validated psychological approaches are psycho-education, cognitive-behavioural therapy and "third wave therapies" with a specific focus on emotional regulation. Cognitive remediation and neurofeedback are promising strategies still under evaluation. Medications, especially psychostimulants, are effective for alleviating ADHD symptoms with a large effect size. Their safety and tolerance are satisfactory, although their long-term clinical benefit is still under discussion. In France, methylphenidate is the only stimulant available for the treatment of ADHD. Unfortunately, there is no authorization for its use among adults except in continuation after adolescence. Hence the prescription, which is subject to the regulations on narcotics, is off-label in France. This article aims to provide practical considerations for the management of ADHD and associated disorders in adults, in this particular French context.

EEG neurofeedback research: A fertile ground for psychiatry?

The clinical efficacy of neurofeedback is still a matter of debate. This paper analyzes the factors that should be taken into account in a transdisciplinary approach to evaluate the use of EEG NFB as a therapeutic tool in psychiatry. Neurofeedback is a neurocognitive therapy based on human-computer interaction that enables subjects to train voluntarily and modify functional biomarkers that are related to a defined mental disorder. We investigate three kinds of factors related to this definition of neurofeedback. We focus this article on EEG NFB. The first part of the paper investigates neurophysiological factors underlying the brain mechanisms driving NFB training and learning to modify a functional biomarker voluntarily. Two kinds of neuroplasticity involved in neurofeedback are analyzed: Hebbian neuroplasticity, i.e. long-term modification of neural membrane excitability and/or synaptic potentiation, and homeostatic neuroplasticity, i.e. homeostasis attempts to stabilize network activity. The second part investigates psychophysiological factors related to the targeted biomarker. It is demonstrated that neurofeedback involves clearly defining which kind of relationship between EEG biomarkers and clinical dimensions (symptoms or cognitive processes) is to be targeted. A nomenclature of accurate EEG biomarkers is proposed in the form of a short EEG encyclopedia (EEGcopia). The third part investigates human-computer interaction factors for optimizing NFB training and learning during the closed loop interaction. A model is proposed to summarize the different features that should be controlled to optimize learning. The need for accurate and reliable metrics of training and learning in line with human-computer interaction is also emphasized, including targeted biomarkers and neuroplasticity. All these factors related to neurofeedback show that it can be considered as a fertile ground for innovative research in psychiatry.

Facial emotion recognition in children with or without Attention Deficit/Hyperactivity Disorder: Impact of comorbidity.

OBJECTIVES: This study sought to assess facial emotion recognition deficit in children with Attention Deficit/Hyperactivity Disorder (ADHD) and to test the hypothesis that it is increased by comorbid features. METHOD: Forty children diagnosed with ADHD were compared with 40 typically developing children, all aged from 7 to 11years old, on a computerized facial emotion recognition task (based on the Pictures of Facial Affect). Data from parents' ratings of ADHD and comorbid symptoms (on the Conners' Revised Parent Rating Scale) were also collected. RESULTS: Children with ADHD had significantly fewer correct answer scores than typically developing controls on the emotional task while they performed similarly on the control task. Recognition of sadness was especially impaired in children with ADHD. While ADHD symptoms were slightly related to facial emotion recognition deficit, oppositional symptoms were related to a decrease in the number of correct answers on sadness and surprise recognition. CONCLUSION: Facial emotion recognition deficit in children with ADHD might be related to an impaired emotional process during childhood. Moreover, Oppositional Defiant Disorder seems to be a risk factor for difficulties in emotion recognition especially in children with ADHD.

[What do virtual reality tools bring to child and adolescent psychiatry?] / Qu'apportent les outils de réalité virtuelle en psychiatrie de l'enfant et l'adolescent ?

Virtual reality is a relatively new technology that enables individuals to immerse themselves in a virtual world. It offers several advantages including a more realistic, lifelike environment that may allow subjects to "forget" they are being assessed, allow a better participation and an increased generalization of learning. Moreover, the virtual reality system can provide multimodal stimuli, such as visual and auditory stimuli, and can also be used to evaluate the patient's multimodal integration and to aid rehabilitation of cognitive abilities. The use of virtual reality to treat various psychiatric disorders in adults (phobic anxiety disorders, post-traumatic stress disorder, eating disorders, addictions…) and its efficacy is supported by numerous studies. Similar research for children and adolescents is lagging behind. This may be particularly beneficial to children who often show great interest and considerable success on computer, console or videogame tasks. This article will expose the main studies that have used virtual reality with children and adolescents suffering from psychiatric disorders. The use of virtual reality to treat anxiety disorders in adults is gaining popularity and its efficacy is supported by various studies. Most of the studies attest to the significant efficacy of the virtual reality exposure therapy (or in virtuo exposure). In children, studies have covered arachnophobia social anxiety and school refusal phobia. Despite the limited number of studies, results are very encouraging for treatment in anxiety disorders. Several studies have reported the clinical use of virtual reality technology for children and adolescents with autistic spectrum disorders (ASD). Extensive research has proven the efficiency of technologies as support tools for therapy. Researches are found to be focused on communication and on learning and social imitation skills. Virtual reality is also well accepted by subjects with ASD. The virtual environment offers the opportunity to administer controlled tasks such as the typical neuropsychological tools, but in an environment much more like a standard classroom. The virtual reality classroom offers several advantages compared to classical tools such as more realistic and lifelike environment but also records various measures in standardized conditions. Most of the studies using a virtual classroom have found that children with Attention Deficit/Hyperactivity Disorder make significantly fewer correct hits and more commission errors compared with controls. The virtual classroom has proven to be a good clinical tool for evaluation of attention in ADHD. For eating disorders, cognitive behavioural therapy (CBT) program enhanced by a body image specific component using virtual reality techniques was shown to be more efficient than cognitive behavioural therapy alone. The body image-specific component using virtual reality techniques boots efficiency and accelerates the CBT change process for eating disorders. Virtual reality is a relatively new technology and its application in child and adolescent psychiatry is recent. However, this technique is still in its infancy and much work is needed including controlled trials before it can be introduced in routine clinical use. Virtual reality interventions should also investigate how newly acquired skills are transferred to the real world. At present virtual reality can be considered a useful tool in evaluation and treatment for child and adolescent disorders.

Neurofeedback: One of today's techniques in psychiatry?

OBJECTIVES: Neurofeedback is a technique that aims to teach a subject to regulate a brain parameter measured by a technical interface to modulate his/her related brain and cognitive activities. However, the use of neurofeedback as a therapeutic tool for psychiatric disorders remains controversial. The aim of this review is to summarize and to comment the level of evidence of electroencephalogram (EEG) neurofeedback and real-time functional magnetic resonance imaging (fMRI) neurofeedback for therapeutic application in psychiatry. METHOD: Literature on neurofeedback and mental disorders but also on brain computer interfaces (BCI) used in the field of neurocognitive science has been considered by the group of expert of the Neurofeedback evaluation & training (NExT) section of the French Association of biological psychiatry and neuropsychopharmacology (AFPBN). RESULTS: Results show a potential efficacy of EEG-neurofeedback in the treatment of attentional-deficit/hyperactivity disorder (ADHD) in children, even if this is still debated. For other mental disorders, there is too limited research to warrant the use of EEG-neurofeedback in clinical practice. Regarding fMRI neurofeedback, the level of evidence remains too weak, for now, to justify clinical use. The literature review highlights various unclear points, such as indications (psychiatric disorders, pathophysiologic rationale), protocols (brain signals targeted, learning characteristics) and techniques (EEG, fMRI, signal processing). CONCLUSION: The field of neurofeedback involves psychiatrists, neurophysiologists and researchers in the field of brain computer interfaces. Future studies should determine the criteria for optimizing neurofeedback sessions. A better understanding of the learning processes underpinning neurofeedback could be a key element to develop the use of this technique in clinical practice.

[Diagnosing the hyperactive child who snores]. / Que faire devant un enfant ronfleur et hyperactif ?

Attention deficit hyperactivity disorder (ADHD) is a common disorder, often associated with sleep disorders. Patients with primary sleep disorders often present hyperactivity and/or attention deficit symptoms. Indeed, obstructive sleep disorder breathing (snoring, hypoventilation disorder, and obstructive sleep apnea syndrome) with poor sleep quality can mimic ADHD in children. In this case, inattention and hyperactivity behavior are induced by sleep disorders but do not constitute a clinical diagnosis of ADHD. Therefore, it can sometimes be difficult for the clinician to distinguish between a diagnosis of ADHD with comorbid sleep disorder and a sleep disorder that mimics ADHD symptoms. The objective of this article is to review the relations between ADHD and obstructive sleep disorder breathing and propose a decision tree to help diagnosis.

[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.

[Predictive factors of suicide? an 8-year-long prospective longitudinal study of 200 psychiatric inpatients]. / Les facteurs prédictifs du suicide: étude prospective sur 8 ans de 200 patients hospitalisés en psychiatrie.

Suicide is the most dramatic complication of psychiatric disorders. Certain risk factors are generally accepted by practitioners. Mental disorders increase (tenfold) suicidal risk. However, this "statistically rare event" renders very difficult the definition of predictive factors. A personal prospective longitudinal study of 200 psychiatric inpatients followed up during an 8-year period found 5% of deaths by suicide. Amongst the various risk factors reputed predictive for suicide, only 2 were found statistically more frequent in the suicidal group: familial antecedents (1st degree relatives) of suicide and hospitalization in psychiatry. Impulsivity was also more frequent but could be imputed to the younger age of the suicide victims. Therefore, it was impossible to find determinants of suicide. This makes difficult preventive measures, excepted that psychiatric patients are at a much greater risk and should be diagnosed and correctly treated. There are also increasing legal aspects of responsibility for psychiatrists and psychiatric institutions in charge of these patients.