[Is assessing for borderline personality disorder useful in the referral after a suicide attempt?]. / La recherche d'un diagnostic de trouble de personnalitéborderline chez les suicidants est-elle utile aux urgences?

BACKGROUND: Management of suicide attempters accounts for 10% of the psychiatric activity in the emergency room. In this population, the prevalence of borderline personality disorder (BPD) is high (10 - 55%). These patients present poorer psychosocial outcome and more frequent suicide attempts repetitions. However, the utility of the assessment of BPD in the referral to a specific treatment plan has not been yet studied. OBJECTIVE: To examine the association between the assessment of a diagnosis of BPD after a suicide attempt and the referral from the emergency room to a specific treatment plan. HYPOTHESIS: Suicide attempters with BPD, according to clinicians diagnosis, differ in terms of severity from those without more risk factors of suicide attempt repetitions and poorer psychosocial functioning, and in psychiatric referral from the emergency room. METHOD: Our case-control study took place during 10 months in the Geneva general hospital. We continuously enrolled patients admitted to the emergency room for deliberate self poisoning and separated them into two groups (BPD and control) according to the clinician's diagnosis. Data from medical records were systemically and anonymously gathered. We compared BPD patients' socio-demographic and clinical characteristics, as well as psychiatric referral, with the control group. RESULTS: Of the 478 subjects admitted to the emergency room for deliberate self-poisoning, 99 (22.6%) were diagnosed BPD by clinicians. Compared to controls, they were more frequently female (OR=3.9) and living alone (OR=3.8) and more often resorted to psychiatric care (OR=2.9), notably to emergency care (OR=3.8). Past history of suicide attempt was also more frequent (OR=1.9) as was the use of neuroleptics in the attempt (OR=2.7). No difference was detected in terms of psychiatric referral after emergency room care. CONCLUSION: Even if borderline personality disorder in suicide attempters is associated with more severity criteria, it is not associated with a referral to a specific treatment plan.

[Predictive factors of suicidal behaviour recurrence in borderline personality disorder patients]. / Facteurs prédictifs de la récidive du comportement suicidaire chez des patients souffrant d'un trouble de personnalité borderline.

OBJECTIVES: The high prevalence of suicidal behavior (SB) in patients with borderline personality disorder (BPD) raises clinical questions in terms of screening and prevention, particularly for an emergency psychiatric department. The purpose of this prospective study was to determine the risk factors of the recurrence of SB during a one year follow-up in BPD patients consulting the emergency unit of the University Hospitals of Geneva (HUG) following a suicide attempt. METHODOLOGY: All subjects included in the study (age 18-65) had been diagnosed with BPD according to DSM IV criteria. Furthermore, they all consulted the emergency psychiatric unit after a suicide attempt. The exclusion criteria were the presence of cognitive, bipolar or psychotic disorders. Almost all SB patients from the Canton of Geneva (350 000 inhabitants) are directed to the HUG emergency department. After one year, 95 subjects were included in the study, while the total number of emergency psychiatric consultations was of about 10 000. During the emergency consultations, the clinicians checked the DSM IV criteria for BPD and current Major Depressive Episode, following the usual guidelines, independently of the study. The clinicians were specifically trained to set up the diagnosis of BPD by means of the International Personality Disorder Examination (IPDE). The gravity of depressive disorders was assessed with the Hamilton Depression Rating Scale (HDRS). The recurrence of SB was recorded for every patient during one year. RESULTS: Among the 95 patients included in the study, 34 patients (36%) were re-admitted to the emergency unit for one or several SB during the first year after inclusion. The recurrence of the SB was significantly higher in women (OR=9.8), in patients with past history of SB (OR=8.9) and in patients living alone (OR=2.5). Interestingly, the presence of a farewell letter seems to be a protective factor (OR=0.1) for SB. Furthermore, low economic status appears to be associated with a higher recurrence risk, but the trend is not statistically significant. Recurrence and intensity (HDRS) of the major depressive episode, drug addiction, and other disorders on axis I of DSM IV did not differ statistically in patients with or without SB recurrence. CONCLUSION: In this preliminary study, we tried to identify patients at risk for SB, relating to early secondary prevention, starting from the first assessment at the emergency unit.

[Agitation in prehospital setting: view of emergency physicians]. / Prise en charge des états d'agitation extrahospitaliers: le point de vue de l'urgentiste.

Agitation is a behavioral emergency that can have numerous underlying causes, organic as well as psychiatric. The presence of a clinician and well-trained staff determine the quality of care, thus facilitating the dialog with the patient and, if needed, ensuring the safe application of medication and physical restraint. Outside the hospital, an emergency physician is best suited to manage such situations in collaboration with paramedics and police. "De-escalation" without medication or physical restraint should be the preferred end-point of an intervention in agitation. When necessary, medication and restraint should be applied, in order to enable medical evaluation of a patient. Calming without sedation seems the most advised endpoint of intervention, according to expert-opinion.

[Behavior disturbances in emergency psychiatry or fronto-temporal dementia diagnosis? A challenge for psychiatrists]. / Troubles du comportement aux urgences, ou démence fronto-temporale? Un défi pour les psychiatres.

INTRODUCTION: The diagnosis of fronto-temporal dementia (FTD) represents a challenge for the psychiatrist, especially since this insidious pathology partly mimics other psychiatric diseases. CASE-REPORT: We present a clinical case that illustrates the difficulty of FTD diagnosis particularly well. A 32 year-old woman without previous medical history presented with psychomotor agitation, logorrhea and flight of ideas. The criteria for bipolar disorder according to DSM IV were met and the patient was referred to an outpatient clinic where a mood stabilizer was initiated (lithium, 400 mg/day). An in-depth interview with her husband revealed mild but progressive modification of her personality and behavior over the course of two years. She showed signs of mild fatigue and irritability that evolved into a loss of interest for both leisure and domestic activities. In addition, she showed increasing erratic behavior and emergence of frequent episodes of verbal abuse. After the birth of her second child, the patient's clinical state worsened with the appearance of uninhibited behavior, loss of personal hygiene, sleep disturbances and nightmares. The patient was forced to stop her work as a cleaner, a steady employment that she had maintained for 10 years. The hypomanic state worsened and psychotic symptoms such as delusions and echolalia appeared within a few weeks. These events culminated in a first hospitalization in a psychiatric unit. We evoked both diagnoses of schizoaffective disorder and psychotic disorder not otherwise specified. In the following months, we conducted neurological examinations on account of the progressive deterioration of her cognitive functions. Neuroradiological results (CT scan with contrast agents, MRI, cerebral scintigraphy) coupled with her clinical evolution (neurological examination and neuropsychological testing) permitted diagnosis of fronto-temporal dementia. DISCUSSION: Fronto-temporal dementia usually presents itself as an autosomal dominant disease in 89% of reported cases, with an insidious onset associated with thymic symptoms and behavioral disturbances. The first consultation often concludes with a suspicion of a psychiatric disorder in 33% of the cases (unipolar and bipolar depressive disorders, psychotic disorders, alcohol dependence). The clinical description of such a heterogenic and neuro-psychiatric disorder should be widely disseminated, so that psychiatrists can distinguish early symptoms and diminish the risk of misdiagnosis of FDT. CONCLUSION: Such case reports emphasize the importance for psychiatrists to be aware of the clinical prodromal FDT symptoms, particularly since the neuro-imaging data of dementia are often delayed.

[Dissociative disorders: clinical, neurobiological and therapeutical approaches]. / Troubles dissociatifs: aspects cliniques, neurobiotogiques et thérapeutiques.

Dissociation is a dysfunction of normally integrated functions like memory, consciousness and perception of environment. This review discusses the clinical and etiological issues of dissociative disorder and highlights the importance of differential diagnosis and psychiatric comorbidities, with special attention for the development of reliable evaluation instruments and treatment guidelines. New approaches of dissociative disorder focus on the importance of the integration of anatomical and functional neuroimaging data, combined with endocrinological and biological studies (lipids), in order to develop some specific neurobiological models. Beyond the inherent singularity of psychotherapeutic intervention, the therapeutic approach varies according to frequently associated comorbidities.

Erectile dysfunction: to prescribe or not to prescribe?

Even with the help of modern pharmacology, treatment of erectile dysfunction often remains complex, and requires taking into account the social, psychological, and behavioral dimensions of the disorder. This brief report presents a case study highlighting this complexity.

[Alpha-thalassemias and bipolar disorders: a genetic link?]. / Alpha-thalassémies et troubles bipolaires: liens génétiques possibles?

After a previous paper discussing the possible association between beta-thalassemias and bipolar disorder, this article considers a possible association between alpha-thalassemia and the bipolar disorder. We report the case of a 36 year old woman with bipolar disorder and alpha-thalassemia. The patient, native of Reunion Island, has a family history of bipolar disorder (both parents, one brother, and a paternal uncle). The severity of the bipolar disorder type I in her family, is illustrated by the suicides of both parents, one brother and the paternal uncle, in intervals of only a few years. After a Medline review (1980-2004) we found only two studies suggesting a possible relationship between bipolar disorders and alpha-thalassemias, but without clinical case report information. Some genetic studies described the existence of possible genetic susceptibility for bipolar disorder on the short arm of chromosome 16, close to the gene involved in certain alpha-thalassemias, on the region 16p13.3. An interesting finding is that the sequencing of 258 kb of the chromosome region 16p13.3 not only allowed the identification of genes involved in the alpha-thalassemia and in the vulnerability to bipolar disorders, but also the identification of genes implicated in tuberous sclerosis, in polycystic kidney disease, in cataract with microophtalmia, and in vulnerability genetic factors for ATR-16 syndrome, asthma, epilepsy, certain forms of autism and mental retardation. Numerous clinical descriptions and some familial studies on linkage suggested a possible relationship between tuberous sclerosis, polycystic kidney disease, cataract with microophtalmia, ATR-16 syndrome, asthma, epilepsy, certain forms of autism, mental retardation and bipolar disorder, given the closeness of these vulnerability genes on the short arm of the chromosome 16. A vulnerability gene of alcohol dependence was also identified on this same chromosome region (16p13.3), by a study concerning 105 families. Taking into account the methodological difficulties due to the clinical and genetic heterogeneity of bipolar disorder, we suggest that linkage techniques should be used to confirm the presence of susceptibility genetic factor for bipolar disorders on chromosome 16. Thus a known genetic disease (alpha-thalassemia) could contribute to confirming the presence on the short arm of chromosome 16 of a susceptibility genetic factor for bipolar disorders. Linkage studies should be performed in families with a strong association for both diseases. Thanks to linkage techniques, one could hope for an improvement in understanding the physiopathology of bipolar disorder, with possible implications at a therapeutic level.

[Persistent psychotic disorder following bilateral mesencephalo-thalamic ischaemia: case report]. / Trouble psychotique persistant après ischémie mésencéphalo-thalamique bilatérale: à propos d'un cas clinique.

A 38-year old male patient with no history of psychiatric illness developed a progressive psychotic disorder after bilateral (predominantly left) mesencephalo-thalamic cerebral ischaemia. The reason of the emergency hospitalization was the sudden onset of a confusional state, culminating in a fluctuating comatose status. The neurological examination found mild right hemiparesia, praxic disorders and reactive left mydriasis with paresia of the downward vertical stare, leading to the hospitalisation in the neurology department for suspicion of a cerebral vascular ischaemic accident. The psychiatric symptoms started with acoustic-verbal hallucinations, poorly structured paranoid delusions, progressively developed over two weeks, followed by behavioural disorders with psychomotor agitation and heteroaggressivity. The patient was transferred to the psychiatric department, because of the heteroaggressive risk and lack of morbid consciousness, in spite of recovering from the confusional status. An intensive psychiatric management was proposed, combining a psychotherapeutic approach with 4 mg of risperidone and adjustable doses of benzodiazepine according to the psychomotor agitation. During the next days, there was a net recovery of the behavioural disorders, in spite of the persistence of the ideas of persecution. All the neurological symptoms also decreased. An anomaly of the polygon of Willis was found on a cerebral arteriography (the posterior cerebral arteries had a foetal origin, dependent on carotidal axes and not on the vertebro-basilar system). The main emboligen risk factor was the presence of a permeable foramen ovale, discovered during a transoesophageal echography. The patient underwent a surgical correction of the permeable foramen ovale. The psychiatric hospitalization for three months was continued by ambulatory follow-up. The initial positive symptoms (delusions, acoustic-verbal hallucinations) progressively diminished while negative symptoms became predominant after few months. One year after the first hospitalization the patient presented a second psychotic decompensation, with delusions of persecution, jealousy and behavioural disorders with heteroaggressivity, that required an emergency psychiatric hospitalization. The wife of the patient decided to divorce, because she was "frightened by the threats of death" from her husband. A neurological assessment during the second hospitalization in psychiatry did not find new ischaemic lesions after the cardiac surgery for the permeable foramen ovale, nor relevant changes in cerebral perfusion. The final diagnosis after the psychiatric follow-up of 14 months was: psychotic disorder with delusional ideas, due to cerebral ischaemia (DSM IV). There are relatively few data in the literature regarding persistent psychotic disorders in the context of ischaemic mesencephalo-thalamic lesions. However, several authors support the hypothesis of a possible disconnection of the thalamic nuclei, the frontal lobes and limbic system as a risk factor or a triggering factor for psychotic disorders in cerebral ischaemia. Observations concerning the occurrence of psychotic disorders following cerebral--especially localised--ischaemia may help to better understand the neuro-physiological mechanisms triggering or accompanying the psychiatric symptomatology. The role of functional cerebral imagery in the detection of possible structural lesions related to clinical observations must be emphasised. The slow progression (over a year) to psychotic disorder with predominantly negative symptoms emphasized the importance for long-term prospective studies. Isolated clinical observations arouse the interest for a specific scale for psychotic disorders occurring after cerebral ischaemia, similar to existing specific scale for post-ischaemic depressive disorders. The necessity of systematic psychiatric examination and re-evaluations in thalamic cerebral ischaemia is to be highlighted, both for the differential diagnosis and for the early psychiatric care.

[Comparison between Swiss and foreign patients characteristics at the psychiatric emergencies department and the predictive factors of their management strategies]. / Etude comparative des caractéristiques sociodémographiques et des facteurs prédictifs de soins de patients suisses et étrangers consultant un service d'urgences psychiatriques.

UNLABELLED: Many studies are searching clinical and social-demographic predictive factors of the management options in psychiatric emergency. The greater part of these researches are published in US and are seeking about patients and about conditions of psychiatric practice different of the European circumstances. Such differences have motivated us to perform a comparison between the characteristics of the native Swiss and of the foreign patients in the psychiatric emergencies. The other aim of the study was to detect, if differences are proven, some predictive factors of their management strategies. This study describes the social-demographic and clinical characteristics of a sample of 1 028 unduplicated consultations and investigates possible relationships between these clinical characteristics and different management strategies, with a particular focus on the foreign patients, covering 46.5% of all consultations. Because quite half of the psychiatric emergency visits occur with foreigners, it plays a potentially important role in searching the disparities in diagnosis and management. To verify these differences, we studied two specific questions: 1) are there nationalities differences in diagnosis with respect to the Swiss native population, and 2) are there nationality differences in management of patients visiting a psychiatric emergency service? METHODOLOGY: Demographic and clinical data were obtained prospectively from the psychiatric emergency service of Geneva, located in the county general hospital, during a 13 weeks period. The study involved all patients aged between 18 and 65 years, inhabitants of county of Geneva-Switzerland, presented at the psychiatric emergency service of the general hospital. To limit the bias of screening the chronic patients, we have included only once, at the first examination, the patients with more than one emergency consultation in the considered interval. RESULTS: As a general trend, the probability for the foreign patients to consult the emergency psychiatrist is greater than for the Swiss natives: OR=1.44, p=0.000. The social-demographic factors show significant differences between the foreigners and Swiss population: the immigrating population is younger, more active and clustered to a familial structure. Despite the availability and use of the same clinical criteria, foreign patients are disproportionately differently diagnosed, with less alcohol abuse (14.7% for foreigners versus 23.9% in the Swiss population), less personality disorders (8.1% versus 13%), more affective disorders (54.7% versus 43%) and more anxious disorders (18.4% versus 12.3%). Furthermore, on the sum of all diagnoses, the single statistically significant difference in management is found in respect to the recommendation for a Short-term Therapeutic Centre , done more frequently for the foreigners: 15.5% versus 11.3%. Some immigration-related predictive factors of diagnosis and management are found and detailed. DISCUSSION: The apparent habit of the foreigners to appeal to the hospital emergencies could be, at least partially, due to a minority or cultural factor: the patients seem to be easily appealing to a great hospital rather than to a territorial policlinic by failure to find a psychiatrist into the Swiss health network. This hypothesis is to be confirmed by further studies. The inexistence of significant differences in management of the patients with the same diagnosis between the two patient groups suggests the equality of resources spent for the two patient groups. The main methodological limit of this study consists of the gathering of different immigrated nationalities in a unique patient group in order to find, if any, significant differences in comparison to the Swiss patients, whereas may be matter of heterogeneous populations. CONCLUSION: These observations suggest that further researches are needed to clarify the decision-making process in diagnosis and patient management in psychiatric emergency department, especially for foreigners, and to distinguish different cultural groups rather than different nationalities. The reassessment of all patients with their clinical evolution and the allocated health resources could lead to the question on the relevance of health management decisions in psychiatric emergency circumstances, as well as to the question on the influence of the foreigner status on therapeutic decisions.

Functional integration in schizophrenia: too little or too much? Preliminary results on fMRI data.

The disconnectivity hypothesis proposes that schizophrenia results from poor or miswired anatomical connections. Theoretically, its functional counterpart should be disintegration. Integration is thought to allow segregated neurons to interact as a coherent whole, referred to as the "core", while the non-interacting part of the brain is referred to as the "rest". In this study, it is suggested that schizophrenia is the result of rest noise interfering with core activity. Two possible causes are assessed: (i) defective core integration, making the core more vulnerable to noise from the rest, or (ii) the rest being too highly integrated, meaning that it can interfere with the core. These hypotheses were tested using fMRI data acquired from 13 stabilized medicated schizophrenic subjects compared to 11 matched controls. Subjects were required to perform a series of lexical decision and retrieval tasks in separate sessions. The brain was divided into 90 components. Integration was defined as the amount of information shared between the components of a sub-system. An iterative aggregation procedure made it possible to identify a core on the basis of the functional clustering index, which assesses the integration of the core relative to its integration with the rest. Correlation of component-pairs within the core was also compared between the two groups. This procedure was repeated for each subject and for each task. Cores did not differ between the two groups, either in terms of integration or in terms of functional clustering index. However, the core was still highly integrated with the rest and the rest was overly integrated in schizophrenic subjects. Both anomalies were correlated with the negative symptoms. These findings were consistent regardless of the task considered. Furthermore, within the core, anterior-posterior correlations were lower in patients (between the frontal and the parietal and posterior cingulate cortices), whereas frontal left-right correlations were excessive. No significant correlation was found with the medication. Thus, it appears that schizophrenia entails a deleterious combination of too much "noisy" integration (from the rest) and too little "significant" integration (anterior-posterior functional connectivity).