[Diabetes and pancreas or islet transplantation: psychological issues]. / Diabète et transplantation du pancréas ou d'îlots de Langerhans : enjeux psychologiques.

Diabetes is a chronic and progressive disease that affects an increasing number of patients. The prevalence of associated psychological comorbidities is high and often requires the implementation of targeted psychological interventions. Pancreas or islet transplantation remains a therapeutic option to consider, for a part of patients with type 1 diabetes unstable disease or established complications. From the clinical indication to the waiting period for a transplantation, then to the postoperative and long-term care, the diabetic patient is found to experience perpetual changes that may test his adaptability. In this article, the psychological aspects of the pancreas or islet transplantation, as well as the role of a liaison psychiatrist in a transplantation unit will be discussed.

Le diabète est une maladie chronique et évolutive atteignant un nombre croissant de patients. La prévalence des comorbidités psychiques associées est élevée et nécessite souvent l'implémentation d'interventions psychologiques ciblées. La transplantation du pancréas ou d'îlots de Langerhans est une option thérapeutique à considérer pour certains patients avec un diabète de type 1 instable ou des complications installées. De l'indication clinique à la période d'attente pour une greffe, puis des suites postopératoires jusqu'à la vie d'après la greffe, le patient diabétique vit des transitions multiples le mettant à l'épreuve. Dans cet article, nous discutons les aspects psychologiques de ces transplantations ainsi que les interventions du psychiatre de liaison au sein d'un service de transplantation.

[Maternal suicide, a little-known reality that can be prevented]. / Suicide maternel, une réalité méconnue que l'on peut prévenir.

While maternal suicide is an important cause of perinatal mortality, the assessment of this risk can be more difficult in the context of perinatality. Pregnancy acceptance problems and perinatal psychiatric disorders are major risk factors for maternal suicide. The -clinical evaluation focuses on the mental health of the mother on the one hand, but also on the quality of her interactions with the baby and the signs of psychological suffering of the latter during postpartum period. Coordinated and multidisciplinary management is recommended to prevent these fatal outcomes and the indication for hospitalization should always be discussed.

Alors que le suicide maternel est une cause importante de ­mortalité périnatale, l'évaluation de ce risque peut être plus ­ardue en contexte de périnatalité. Les problèmes d'acceptation de la grossesse et les troubles psychiatriques périnataux sont des facteurs de risque majeurs de suicide maternel. L'évaluation ­clinique porte sur la santé psychique de la mère d'une part mais également sur la qualité de ses interactions avec le bébé et les signes de souffrance psychique de ce dernier pendant la période de postpartum. Une prise en charge coordonnée et multidisci­plinaire est recommandée pour prévenir cette issue fatale, et l'indication d'une hospitalisation doit toujours être discutée.

[Artificial intelligence and psychiatry: questions from psychiatrists to ChatGPT]. / Intelligence artificielle et psychiatrie : questions de psychiatres à ChatGPT.

Psychiatrists and psychotherapists specialising in the fields of addiction, personality disorders, ADHD and suicidal crisis, we questioned the ChatGPT artificial intelligence program in order to form an opinion on the quality of its answers to questions on these subjects. Our aim is to satisfy our curiosity about these emerging tools. On the other hand, we want to assess the relevance of the answers in order to know whether relatives and patients can use them safely. In this article, we comment on the question-and-answer dialogue with the artificial intelligence program in the light of the literature.

Psychiatres et psychothérapeutes spécialisés dans les domaines de l'addiction, les troubles de la personnalité, le TDAH et la crise suicidaire, nous avons questionné le programme d'intelligence artificielle ChatGPT dans le but de nous faire une opinion sur la qualité de ses réponses à des questions sur ces sujets. Notre objectif est, d'une part, de satisfaire notre curiosité face à ces outils émergents. Nous voulons également évaluer la pertinence des réponses pour savoir si proches et patients peuvent les utiliser en sécurité. Dans cet article, nous commentons le dialogue de questions-réponses avec le programme d'intelligence artificielle à la lumière de la littérature spécialisée.

[Management of suicidal crisis: mentalizing as a team]. / Prise en charge de la crise suicidaire : mentaliser en équipe.

The hospital management of patients experiencing a suicidal crisis and suffering from a personality disorder is complex for caregivers. The care model must be adapted and applied by a multidisciplinary team. The emotional charge of these crisis situations makes it difficult for caregivers to maintain their ability to treat mental states with curiosity and without necessarily experiencing them as they appear to them. In other words, it could be difficult to mentalize. For example, an expressed desire to die may be much more complex in reality. Mentalizing abilities are challenged differently depending on our role with the patient. In this article we explore the specifics of interdisciplinary crisis work through the lens of mentalization-based therapy.

La prise en charge hospitalière de patients traversant une crise suicidaire et souffrant d'un trouble de personnalité est complexe pour les soignants. Le modèle de soin doit être adapté et applicable par une équipe pluridisciplinaire. La charge émotionnelle de ces situations de crise rend difficile aux soignants de préserver leur capacité à traiter les états mentaux avec curiosité et sans les vivre nécessairement tels qu'ils leur apparaissent, c'est-à-dire de pouvoir mentaliser. Ainsi, un désir exprimé de mourir peut s'avérer beaucoup plus complexe en réalité. Les capacités de mentalisation sont mises à mal différemment selon notre rôle auprès du patient. Nous explorons dans cet article les spécificités du travail interdisciplinaire de crise au travers du prisme de la thérapie basée sur la mentalisation.

[When the discontinuation of psychotropic drugs is necessary: clinical manifestations and therapeutic approach]. / Quand la discontinuation des psychotropes s'impose : manifestations cliniques et approche thérapeutique.

The reduction or suspension of psychotropic treatment may be necessary for various medical reasons. This can have serious consequences for patients, including clinical manifestations, both physical and psychological. These manifestations, which are often unpleasant, can compromise care during hospitalization and undermine the therapeutic alliance. Their early detection, readjustment of treatment, when necessary, as well as regular communication with the patient and among specialists are important tips to take into account from caregivers.

La diminution ou mise en suspens d'un traitement psychotrope peut être imposée par des raisons médicales diverses. Cela peut avoir d'importantes conséquences pour les patients, notamment des manifestations cliniques, tant physiques que psychologiques. Elles sont souvent désagréables, peuvent compromettre l'adhésion aux soins lors d'une hospitalisation et mettre à mal le lien thérapeutique. Leur détection précoce, le réajustement du traitement quand nécessaire, ainsi que la communication régulière avec le patient et entre spécialistes sont des éléments importants à prendre en compte lors de ces prises en charge.

[Contain psychomotor agitation in somatic units : implementation of a protocol at the HUG]. / Contenir l'agitation psychomotrice dans les unités somatiques : mise en place d'un protocole aux HUG.

Psychomotor agitation in somatic units is a medical and psychiatric emergency requiring rapid intervention by the team in charge of the patient and the liaison psychiatrist. Verbal de-escalation is attempted throughout the treatment. Securing the surroundings is needed to protect both the patient and the team. The etiology of the agitation, somatic and/or psychiatric, should be investigated to allow the administration of an adequate treatment. Antipsychotics and benzodiazepines are often recommended. Physical restraint measures can be applied as a last resort if necessary. The continuation of care is decided jointly between the team in charge and the liaison psychiatrist. An intervention protocol has been drawn up by the HUG liaison psychiatry team.

L'agitation psychomotrice dans les unités somatiques est une urgence médicale et psychiatrique qui nécessite une intervention rapide de l'équipe en charge et du psychiatre de liaison auprès du patient. Une désescalade verbale est tentée tout au long de la prise en charge. La sécurisation de l'environnement pour protéger le patient et l'équipe est primordiale. L'étiologie de l'agitation, somatique et/ou psychiatrique, doit être recherchée, ce qui permet l'administration d'un traitement adéquat. Les antipsychotiques et les benzodiazépines sont souvent préconisés. Des mesures de contention physique peuvent être appliquées en dernière intention si besoin. La poursuite des soins se décide en commun entre l'équipe en charge et le psychiatre de liaison. Un protocole d'intervention a été élaboré par l'équipe de la psychiatrie de liaison des HUG.

[Good Psychiatric Management for Borderline Personality Disorder - A Specialized Treatment Applicable in General Care]. / «Good Psychiatric Management¼ pour le trouble de la personnalité borderline - Un traitement spécialisé applicable aux soins généralistes.

This article presents basic notions of "Good Psychiatric Management" (GPM) for Borderline Personality Disorder (BPD). There have been several evidence-based psychotherapeutic treatments for BPD for several decades. Nevertheless, high requirements and motivation required sometimes have a discouraging effect for trainees. GPM aims at offering «good enough¼ and less difficult to implement care. This article presents the notion of Interpersonnal Hypersensitivity and its different attachment states (attached, threatened, abandoned, and desperate) describing internal coherence of BPD and founding therapeutic interventions. GPM is principle based, thus is highly adaptable, as can be seen in integration with other intervention models or implementation of stepped care.

Cet article présente les bases du «Good Psychiatric Management¼ (GPM) pour le trouble de la personnalité borderline. Il existe pour ce trouble différents traitements psychothérapeutiques fondés sur les preuves. Les exigences importantes que ceux-ci représentent en termes de formation et de motivation ont parfois comme effet de décourager les thérapeutes en formation. Le GPM décrit des soins «suffisamment bons¼, accessibles et moins difficiles à implanter. Cet article présente le concept d'hypersensibilité interpersonnelle qui décrit la cohérence interne du trouble et fonde les interventions thérapeutiques. Le GPM est basé sur l'application de principes, ce qui lui donne une adaptabilité importante, par exemple pour l'intégration avec d'autres modèles d'intervention ou des soins par paliers.

Psychiatric emergency admissions during and after COVID-19 lockdown: short-term impact and long-term implications on mental health.

BACKGROUND: The 'lockdown' measures, adopted to restrict population movements in order to help curb the novel coronavirus disease 2019 (COVID-19) pandemic, contributed to a global mental health crisis. Although several studies have extensively examined the impact of lockdown measures on the psychological well-being of the general population, little is known about long-term implications. This study aimed to identify changes in psychiatric emergency department (ED) admissions between two 8-week periods: during and immediately after lifting the lockdown. METHODS: Socio-demographic and clinical information on 1477 psychiatric ED consultations at the University Hospital of Geneva (HUG) were retrospectively analyzed. RESULTS: When grouped according to admission dates, contrary to what we expected, the post-lockdown group presented with more severe clinical conditions (as measured using an urgency degree index) compared to their lockdown counterparts. Notably, after the lockdown had been lifted we observed a statistically significant increase in suicidal behavior and psychomotor agitation and a decrease in behavior disorder diagnoses. Furthermore, more migrants arrived at the HUG ED after the lockdown measures had been lifted. Logistic regression analysis identified diagnoses of suicidal behavior, behavioral disorders, psychomotor agitation, migrant status, involuntary admission, and private resident discharge as predictors of post-lockdown admissions. CONCLUSIONS: Collectively, these findings can have implications concerning the prioritization of mental health care facilities and access for patients at risk of psychopathological decompensation in time of confinement policies, but above all, provide a foundation for future studies focusing on the long-term impact of the pandemic and its associated sanitary measures on mental health. TRIAL REGISTRATION: Research Ethics Committee of Geneva, Registration number 2020-01510, approval date: 29 June 2020.

COVID-19 Related Fears of Patients Admitted to a Psychiatric Emergency Department during and Post-Lockdown in Switzerland: Preliminary Findings to Look Ahead for Tailored Preventive Mental Health Strategies.

Background and Objectives: While the impact on mental health of 2019 coronavirus (COVID-19) has been extensively documented, little is known about its influence on subjective fears. Here, we investigate the COVID-19 impact and its related restrictions on fears of patients admitted to a psychiatric Emergency Department (ED) during and post-lockdown. Materials and Methods: A retrospective study on 1477 consultations at the psychiatric ED of the University Hospital of Geneva (HUG) was performed using a mixed-methods analysis. The first analysis section was qualitative, aiming to explore the type of fears, while the second section statistically compared fears (i) during lockdown (16 March 2020-10 May 2020) and (ii) post-lockdown (11 May 2020-5 July 2020). Fears were also explored among different patient-age sub-groups. Results: 334 patients expressed one/more fears. Both in lockdown and post-lockdown, fears mostly pertained to "containment measures" (isolation, loneliness). When compared lockdown vs. post-lockdown, fears about "work status" (deteriorating, losing work) prevailed in lockdown (p = 0.029) while "hopelessness" (powerless feeling, inability to find solutions) in post-lockdown (p = 0.001). "Self around COVID-19" (dying, getting sick) fear was relatively more frequent in youth (p = 0.039), while "hopelessness" in the elderly (p < 0.001). Conclusions: Collectively, these findings highlight that lockdown/post-lockdown periods generated temporally and demographically distinct COVID-19 related fears patterns, with special regard to youth and elderly, two particularly vulnerable populations when faced with sudden and unexpected dramatic events. For this reason, the particular ED "front-line service" status makes it a privileged observatory that can provide novel insights. From a mental health perspective, these latter can be translated into pragmatic, more personalized prevention strategies to reinforce specific resilience resources and mitigate the current and long-term pandemic's impact.

[To pretend or to really suffer ? Questions from caregivers about the factitious disorder]. / Faire semblant ou souffrir vraiment ? Questions des soignants face au trouble factice.

The diagnosis of factitious disorder can only emerge when caregivers are in difficulty in caring for their patient. This disorder is a real challenge for healthcare teams throughout the treatment, from its discovery to its treatment. Secrecy and self-inflicted injuries are components that we can be uncomfortable with as caregivers. The factitious problem requires well-coordinated care between the various specialists and often questions our practices. In this article we deal with the questions frequently asked by the care teams to the liaison psychiatrists that we are, by working on the identification of the problem in the clinic, the therapeutic issues and the attitude to adopt.

Le diagnostic de trouble factice ne peut émerger que lorsque les soignants sont en difficulté dans la prise en soins de leur patient. Ce trouble est un véritable défi pour les équipes soignantes tout au long de la prise en charge, de sa découverte à sa prise en soins. Mise en échec, secret et lésions auto-infligées sont autant de composantes avec lesquelles nous pouvons être mal à l'aise comme soignants. La problématique factice demande une prise en charge bien coordonnée entre les divers spécialistes et, souvent, questionne nos pratiques. Dans cet article, nous traitons des questions fréquemment posées par les équipes de soins aux psychiatres de liaison que nous sommes, en s'occupant de l'identification du problème en clinique, des enjeux thérapeutiques et de l'attitude à tenir.

[Psychological health and cardiovascular disease : interdependency and therapeutic opportunities]. / Corpus sanum in mente sana : stratégies de promotion de la santé psychique en cas de pathologie cardiovas.

Despite progress in primary and secondary prevention, pharmacological and device-based therapies, cardiovascular disease remains a leading cause of morbidity and mortality worldwide. The specifics of cardiac disorders being in the spotlight, less attention has been given to psychological health and its interdependent relation to cardiovascular disease. Psychological health issues can contribute to increase cardiovascular disease risk, and cardiovascular disease itself can promote development of mental health issues. Psychological health in patients with cardiovascular disease represents an underexplored opportunity for intervention, an endeavour that could be designed as behavioural cardiology, which would be synergistic with efforts aimed at primary and secondary prevention.

Malgré les progrès réalisés en prévention primaire et secondaire ainsi qu'en termes de traitements pharmacologiques et de dispositifs médicaux, les pathologies cardiovasculaires restent la cause principale de morbidité et de mortalité à travers le monde. L'attention médicale portant particulièrement sur les pathologies cardiaques elles-mêmes, la santé mentale du patient peut être l'objet d'une attention insuffisante. Les souffrances psychiques contribuent à une augmentation du risque de pathologie cardiovasculaire et, réciproquement, une pathologie cardiovasculaire rend vulnérable et peut favoriser l'apparition d'un trouble psychique. La prise en charge globale du sujet cardiopathe, en particulier de son vécu intrapsychique, représente une opportunité d'intervention largement sous-exploitée. Cette discipline, nommons-la cardiologie comportementale, pourrait être menée en parallèle des mesures de prévention primaire et secondaire.

Who Consult an Adult Psychiatric Emergency Department? Pertinence of Admissions and Opportunities for Telepsychiatry.

BACKGROUND AND OBJECTIVES: Psychiatric disorders constitute frequent causes of emergency department (ED) admissions and these rates are increasing. However, referring to ED a whole range of conditions that could or should be dealt with elsewhere is imposing itself as a problematic situation. We aimed: (1) to provide a descriptive picture of the socio-demographic and diagnostic characteristics of the visits among adults at the psychiatric ED; (2) to estimate the clinical pertinence of these visits. MATERIALS AND METHODS: Retrospective analysis of diagnostic/socio-demographic characteristics and clinical trajectories of patients admitted for a psychiatric condition at the adult psychiatric ED of the University Hospital of Geneva (HUG), Switzerland, during a 6-week timespan. RESULTS: In our sample (n = 763 total admissions for psychiatric conditions; n = 702 for inclusion of patients having received a medical evaluation), depression/anxiety, suicidal behavior (SB), psychotic episode, and substance use disorder (SUD), in descending order, were the most common diagnoses for referral. Patients belonged to younger age groups (≤65 years), had a familial status other than married/in couple, and did not present an unfavorable socio-demographic profile. Concerning the pertinence for a psychiatric ED, primary diagnosis of depression/anxiety is the only variable significantly associated with different grade of degree. By the examination of the patients' trajectory from admission to discharge, the clinical pertinence for a psychiatric ED admission existed for cases assigned to the Echelle Suisse du Tri (EST®) scale degree 1 (corresponding to most urgent and severe conditions), particularly for diagnoses of depression/anxiety associated with SB, SB as primary or comorbid diagnosis, and psychotic and manic/hypomanic episode. However, diagnoses of depression/anxiety without urgent and severe features (degrees 2, 3, 4) constituted the most frequent mode of presentation. CONCLUSIONS: Ambulatory and community-integrated settings could be more appropriate for the majority of patients admitted to adult psychiatric EDs. Moreover, the implementation of telepsychiatry strategies represents a very promising opportunity to offer these patients care continuity, reduce costs and filter the demand for psychiatric ED.

[Health crisis and suicidal crisis: mirrored lighting]. / Crise sanitaire et crise suicidaire†: éclairages en miroir.

The psychotherapeutic management of a suicidal crisis makes it possible to think of the health crisis linked to COVID-19 from a particular angle. In this article, we show the parallels but also the differences between these two types of crises. The sequential course of the crisis, the viral agent which acts as a triggering factor and the host of reactions which follow can thus evoke a suicidal crisis during which a subject often perceives an external event as a precipitating factor. However, unlike confinement in the case of the virus, it is the relationship, in particular the therapeutic relationship, which makes it possible to get through the crisis. This relationship should allow us to get to know our specific vulnerabilities, those on which the triggering factor has specifically acted.

La prise en charge psychothérapeutique d'une crise suicidaire permet de penser la crise sanitaire liée au COVID-19 sous un angle particulier. Dans cet article, nous montrons les parallèles mais également les différences entre ces deux types de crises. Le déroulement séquentiel de la crise, l'agent viral qui agit comme un facteur déclenchant et la foule de réactions qui s'ensuivent peuvent ainsi évoquer une crise suicidaire durant laquelle un sujet perçoit souvent un événement externe comme facteur précipitant. Toutefois, contrairement au confinement dans le cas du virus, c'est bien la relation, notamment la relation thérapeutique, qui permet de traverser la crise. Cette relation doit nous permettre de faire connaissance avec nos vulnérabilités spécifiques, celles sur lesquelles le facteur déclenchant a précisément agi.

[Facilitating access to somatic care for adults suffering from severe mental disabilities]. / Pour un accès facilité aux soins somatiques des adultes en situation de handicap mental sévère.

For the purpose of improving the management of somatic disorders among patients suffering from severe intellectual development and autism spectrum disorders, a specific admissions mechanism has been implemented at Geneva University Hospitals (HUG). The Adult Psychiatric Hospital Unit (UPHA), a complex intervention unit, collaborates with HUG's Disability Program. From May 2018 to May 2019, 29 requests for hospitalizations were accepted. These requests primarily originated from private practice physicians (42 %). In some cases, immediate admissions were urgently organized, and in others a 13-day waiting period was imposed. Hospitalizations were adapted to the patient: more often than not, these were short (48 %), with 6 hospitalizations extended for an average 103-day period. A clinical case illustrates the healthcare management provided.

Afin d'améliorer la prise en charge somatique des patients avec troubles sévères du développement intellectuel et du spectre de l'autisme, un dispositif d'accueil a été mis en place aux Hôpitaux universitaires de Genève (HUG). Dans ce dispositif, l'Unité de psychiatrie hospitalière adulte (UPHA), une unité d'intervention complexe (UIC), collabore avec le Programme Handicap des HUG. De mai 2018 à mai 2019, 29 demandes d'hospitalisation pour soins ou bilans somatiques, évaluées en amont, ont été acceptées. Ces demandes venaient prioritairement des médecins de ville (42 %). Un accueil rapide a été organisé en urgence ou avec un délai moyen de 13 jours. Les séjours étaient adaptés : le plus souvent courts (48 %), 6 séjours ont été prolongés, avec une durée moyenne de séjour de 103 jours. Un cas clinique illustre le type de prise en charge.

[Suicidal crisis and suicide prevention†: psychopharmacological aspects]. / Crise suicidaire et prévention du suicide†: aspects psychopharmacologiques.

Suicide is a common cause of death in Switzerland. It often occurs during a period of crisis marked by a disruption of the subject's intrapsychic, interpersonal or social balance. The management of this crisis is crucial and essentially psychotherapeutic. Drug therapy may be necessary for the management of acute symptoms or for the prevention of long-term suicidal risk. Benzodiazepines and atypical antipsychotics are often used for acute symptoms such as anxiety or sleep disorders while other molecules are recognized in reducing long-term suicidal risk. Some disorders, such as borderline personality disorder, account for more frequent suicidal behaviors. The pharmacological management of these specific situations is discussed.

Le suicide est une cause de mortalité fréquente en Suisse. Il survient souvent durant une période de crise marquée par une perturbation de l'équilibre intrapsychique, interpersonnel ou social du sujet. La prise en charge de cette crise est cruciale et essentiellement psychothérapeutique. Un traitement médicamenteux peut s'avérer nécessaire pour la gestion des symptômes aigus ou la prévention du risque suicidaire à long terme. Les benzodiazépines et les antipsychotiques atypiques sont souvent utilisés pour les symptômes aigus comme l'anxiété ou les troubles du sommeil. D'autres molécules sont reconnues dans la diminution du risque suicidaire à long terme. Certains troubles, comme le trouble borderline, rendent compte de comportements suicidaires plus fréquents. La prise en charge pharmacologique de ces situations spécifiques est discutée.

[Relationship difficulties with borderline patients in five questions]. / Les difficultés relationnelles avec les patients borderline en cinq questions.

Borderline personality disorder is a common and severe disorder that confronts health professionals with some of their limitations. Relational difficulties with these patients lead to discontinuation of follow-up or unnecessary or even deleterious care. We present here simple answers to the questions that will inevitably arise in the management of your borderline patients. They are applicable by both general practitioners and specialists, to better meet the challenge that these patients ask us. We insist on properly recognizing and detecting the disorder. We propose to disclose the diagnosis to the patient and provide the necessary explanations. This is the better way to anticipate the repeating crises. Finally, interacting with other caregivers is important to ensure an effective and sustainable care system for these patients.

Le trouble de la personnalité borderline est un trouble fréquent, sévère et qui confronte les professionnels de la santé à certaines de leurs limites. Les difficultés relationnelles avec ces patients entraînent des ruptures de suivi, des soins inutiles ou délétères. Nous proposons des réponses simples aux questions qui surgiront immanquablement dans la prise en charge des patients borderline. Elles sont applicables par les généralistes et les spécialistes, afin de relever au mieux le défi que ces patients nous posent. Nous insistons sur l'importance de reconnaître et dépister le trouble. Nous proposons d'en parler avec le patient et de fournir les explications nécessaires. Cela permet de se préparer aux crises. Enfin, interagir avec les autres soignants est important pour garantir un dispositif de soins efficace et durable pour ces patients.

[Psychotropic and liver enzyme's perturbation, conduct to hold]. / Psychotropes et perturbation des tests hépatiques : conduite à tenir.

Drug-induced liver injury (DILI) represents a complex clinical problem, both in terms of diagnosis and of therapeutic approach. When the suspected treatment is a psychotropic drug, the role of the liaison psychiatrist is not limited to the re-adaptation of the drug treatment. In this article, with a clinical case as an example, we will discuss the issues to deal with facing a perturbation of liver enzymes in a patient on psychotropic treatment. The risk and benefit assessment of a therapeutic window, as well as the overall care of the patient at the general hospital will be detailed.

Les atteintes hépatiques d'origine médicamenteuse représentent une problématique clinique complexe tant sur le plan du diagnostic que sur celui de l'approche thérapeutique. Quand le médicament suspecté est un traitement psychotrope, le rôle du psychiatre de liaison ne se limite pas à la réadaptation du traitement médicamenteux. Dans cet article, et à partir d'un cas clinique adapté, nous aborderons la conduite à tenir face à une perturbation des enzymes hépatiques chez un patient sous traitement psychotrope. L'évaluation du rapport risque-bénéfice d'une fenêtre thérapeutique, ainsi que la prise en charge globale du patient à l'hôpital général seront discutées.

Insomnia in adult attention-deficit/hyperactivity disorder: A comparison with borderline personality disorder population in a clinical setting and control participants.

OBJECTIVES: Many adults with attention-deficit/hyperactivity disorder (ADHD) report sleeping difficulties. The relationship between sleep and ADHD is poorly understood, and shows discrepancies between subjective and objective measures. In order to determine the specificity of sleep-associated symptoms in ADHD, subjective sleep assessments among ADHD adult patients were compared with control subjects and with individuals suffering from borderline personality disorder (BPD). METHODS: 129 outpatients with ADHD, 70 with BPD (including 17 patients with BPD and ADHD comorbidity), and 65 control participants were assessed for sleep quality, insomnia, and sleepiness, using the Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), and the Epworth Sleepiness Scale (ESS). RESULTS: ADHD- and BPD-sufferers achieved higher insomnia and lower sleep quality scores than control subjects. Clinical groups did not differ in terms of sleep quality, although insomnia was more severe among BPD patients. Depression scores explained most of sleep symptoms, but even when controlling for depression, ADHD sufferers showed higher sleep latency. Inattentive symptoms were associated with somnolence, while hyperactive/impulsive symptoms were associated with insomnia and lower sleep efficiency. CONCLUSION: Sleep-related symptoms associated with ADHD were partly explained by non-specific factors, especially depression symptoms. In a dimensional perspective, hyperactive and inattentive symptoms were associated with specific sleep symptoms.

[Mentalizing in liaison psychiatry ?] / Mentaliser en psychiatrie de liaison ?

In the past few years, there has been an increased and widespread interest for Mentalization-Based Therapies (MBTs). Although originally developed by Anthony Bateman and Peter Fonagy for the treatment of Borderline Personality Disorder (BPD), the scope of MBTs has now been broadened and is relevant in liaison psychiatry, not only to cope with personality disorders or phenomena such as emotional dysregulation and suicidal behaviours, but also because being ill and expericencieng a dependency-laden relationship with health workers tend to reduce mentalization capacities, thereby increasing the probability of misunderstandings, conflicts, treatment drop-outs or medical errors. We provide clinicians with clues to identify failures and reboot the mentalization process among their patients and colleagues.

Les thérapies basées sur la mentalisation (TBM), développées pour le trouble borderline, ont connu ces dernières années un essor important. Les techniques des TBM pourraient être utiles en psychiatrie de liaison au-delà des troubles de la personnalité et de phénomènes comme la dérégulation émotionnelle ou les conduites suicidaires. En effet, le vécu de la maladie et la relation de soin, qui activent puissamment les représentations d'attachement, affaiblissent les capacités de mentalisation du patient et du soignant et, de ce fait, augmentent le risque de malentendus, de conflits, d'interruptions de traitements ou d'erreurs médicales. Nous proposons aux cliniciens quelques pistes pour déceler les failles et restaurer le processus de mentalisation dans le contexte de la psychiatrie de liaison.

METHYLATION OF SEROTONIN RECEPTOR 3A IN ADHD, BORDERLINE PERSONALITY, AND BIPOLAR DISORDERS: LINK WITH SEVERITY OF THE DISORDERS AND CHILDHOOD MALTREATMENT.

BACKGROUND: Serotonin 3A receptor (5-HT3A R) is associated at the genetic and epigenetic levels with a variety of psychiatric disorders and interacts with early-life stress such as childhood maltreatment. We studied the impact of childhood maltreatment on the methylation status of the 5-HT3A R and its association with clinical severity outcomes in relation with a functional genetic polymorphism. METHODS: Clinical severity indexes of 346 bipolar, borderline personality, and adult attention deficit hyperactivity disorders patients were tested for association with the DNA methylation status of eight 5-HT3A R gene CpGs. Relationship between the functional variant rs1062613 (C > T) and methylation status on severity of the disorders were also assessed. RESULTS: Childhood maltreatment was associated with higher severity of the disease (higher number of mood episodes, history of suicide attempts, hospitalization, and younger age at onset) across disorders and within each individual disorder. This effect was mediated by two 5-HT3A R CpGs. Compared to T allele carriers, CC carriers had higher methylation status at one CpG located 1 bp upstream of this variant. CONCLUSIONS: This study shows that epigenetic modification of the 5-HT3A R is involved in the mechanism underlying the relationship between maltreatment in childhood and the severity of several psychiatric disorders in adulthood.