[Psychosurgical treatment of malignant OCD: three case-reports]. / Traitement psychochirurgical des TOC malins: à propos de trois cas.

Surgery can be proposed for some patients affected by psychiatric diseases such as severe, disabling and refractory affective disorders (depression), OCD and chronic anxiety states. It can be performed after a period of evolution of minimum 5 Years and after all other classical treatments have failed. For the last Years, different stereotactic techniques have been used: capsulotomy, cingulotomy, subcaudate tractotomy and limbic leukotomy, performed by radiofrequency thermolesions or radiosurgery (g rays). In the case of OCD, these procedures are supposed to affect some of the neural circuits between the frontal lobes and different structures of the limbic system, considered as central to OCD symptoms. As they cause smaller cerebral lesions than earlier surgical techniques (mostly open surgery techniques), modern stereotactic approaches have less clinical side effects, primarily less deficit in emotional reactivity and motivation. This type of treatment offers some hope to patients seriously disabled by OCD. These surgeries and especially their main side effects are mentioned briefly in this Article. The most current indications for psychosurgery are severe OCD and chronic major depressive disorder. The level of stress should be significant and assessed by clinical and social functioning scale scores (for the OCD: Y-BOCS>25, GAF>50). Patients affected by demential disorders, sociopathic or paranoiac personality disorder, substance abuse should be excluded as well as patients aged 65 Years over and less than 18 Years. Several studies evaluating the results of the surgical treatment showed significant improvement in 54% of cases. and a moderate improvement in 27% of them. These results seem unchanged a few Years later in 56% of cases. Despite the lack of controlled trials of neurosurgery and several bias in published reports, evidence suggests that the condition of intractable OCD patients may improve after this surgery. Although capsulotomy and cingulotomy are mainly used, the superiority of any of these four surgical techniques has not been established yet. In this Article, we reported 3 "malignant" OCD cases treated by different psychosurgery techniques: 2 of the cases showed a clinical improvement, whereas the third did not -benefit from surgery. All of them were suffering of OCD since childhood with a gradual clinical impairment, unless the -second patient who presented a severe impairment following an accident causing a ten-day coma. In all three cases social consequences of OCD were important: negative socio-professional and family-life consequences and depressive complication with suicide risk. All patients remained unresponsive or showed a very transient reaction to the other forms of therapy, including varied pharmacotherapy (potentiation pharmacotherapy strategies included), intensive psychotherapy, behavioural therapy and electro-convulsive therapy. Pre- and post-operative assessment included neurological, radiological, psychometric and neuropsychological examination. The free and informed consent of the patient was always required before surgery, notifying the nature of the procedure, the potential risks and outcome. The first patient benefited of a bilateral anterior cingulotomy by thermocoagulation in stereotactic conditions, followed, four years later, by a second complementary one because of a relapse which occurred a few months after the first intervention. A clinical improvement was noticed over a period of two years, though it was not sufficient according to the patient. The second patient benefited of a stereotactic cingulotomy associated with a limbic leucotomy: it was initially efficient on OCD as well as on thymic symptoms. Nevertheless the positive evolution on OCD is not perceived by the patient and has not been assessed until now by clinical rating scales. Anterior cingulotomy is undergone in the third case, who showed a significant improvement. Despite clomipramine administered secondary to the surgery, a slight relapse of obsessive ideas was noticed six months later. The postoperative side effects were transient and regressive after a few months; they were observed especially in the case of tractotomy (oedema and transient frontal syndrome). On the whole, morbidity seemed more important with extensive lesions, whereas recurrence rate may be higher with smaller lesions. We did not observe any consequences on personality or on cognitive functions of these patients. No additional -deficits were observed after surgery. Further research is needed in order to determine the optimal site and size of the lesions in terms of efficacy and safety. Although psychosurgery is still controversial from an ethical view point, this treatment appears to be an ultimate solution for these severe disabled patients. Psychosurgery is a safe and relatively effective treatment which should be carried out by an expert multidisciplinary team in these disorders; surgery should be considered as part of an entire treatment program including an appropriate psychiatric rehabilitation part. Research in this field is currently focused on MRI-guided basal ganglia stimulation techniques which would allow to target specific structures in a reversible way.

[Predictive factors of response to buprenorphine in the substitutive treatment of heroin addicts. Results of a multicenter study of 73 patients]. / Facteurs prédictifs de la réponse à la buprénorphine en traitement substitutif des héroïnomanies. Résultats d'une étude multicentrique sur 73 patients.

OBJECTIVE: Buprenorphine has a partial morphine-agonist pharmacological profile. It is proposed as alternative to methadone in opiate drug addicts with greater safety of use and less cost in terms of public health. The aim of this study was to determine the clinical factors of response to this molecule. METHOD: The study was conducted in 73 patients treated for 3 months with adaptable doses. Mean dose was 8.5 mg/d (range: 3 to 16 mg/d). Response to treatment was defined as: still in the study at 3 months and absence of opiates in 75% of urinary samples over the past month. RESULTS: Forty-eight patients responded and 25 did not. The determinating clinical variables of response were: opiate drug addiction less than 10 years, high score on the Addiction Severity Index (ASI), absence of depression according to the Minnesota Multiphasic Personality Inventory (MMPI) and low rate of disinhibition on Zukerman's sensation seeking scale. Conversely, the dose of buprenorphine within the limits specified in the Marketing Authorisation did not intervene in the response. CONCLUSION: In view of its partial agonist effect, administration of buprenorphine must be reserved for patients addicted to opiates for less than 10 years, non-depressive and with low disinhibition on Zukerman's scale.

[Validation of the French translation and factorial structure of the Tiffany and Drobes Smoking Urge Questionnaire]. / Validation de la traduction française et de la structure factorielle du Questionnaire sur l'urgence à fumer de Tiffany et Drobes (QSU).

UNLABELLED: Over the past 10 years researches and clinicians have made substantial progress in understanding and treating nicotine dependence. To demonstrate the effectiveness of these treatments, reliable and sensitive measures of change and outcome must be used. In the nicotine dependence treatment literature numerous outcome have been used: frequencies drug use, problems associated with substance use, psychiatric comorbidity, withdrawal severity, and craving. The term craving reflects the subjective reports of addicts regarding their attempts to abstain from drug use and the state of their minds at the point at which they attempt to fail. Exposure to cues previously associated with nicotine play a role in precipitating relapse in eliciting a conditioned craving/withdrawal response and can be measures by the Questionnaire of Smoking Urge (QSU). OBJECTIVE OF THE STUDY: Validation in a French translated version of the QSU published in 1991 by Tiffany and Drobes. METHODOLOGY: 42 male and 62 female participated in the study with the translated questionnaire: mean age was 36.7 years, mean age at starting and mean duration of tobacco consumption was respectively 20.2 years old and 16.5 years, daily consumption was 16.6 cigarettes per day. The French translation of the QSU was administered to smokers instructed to abstain from smoking one hour and a half to three hours. RESULTS: The back translation has been accepted by Tiffany because more than 85% of the items are similar to the original questionnaire. We founded the same factor analysis with two factors, "desire to smoke" and "intention to smoke" accounting for 34% and 11% of the items variance, respectively. These two factors were the same than those of the original questionnaire. CONCLUSION: The validation of the French translation of the QSU gives the opportunity to use a sensitive instrument to assess craving.

[The transsexualism syndrome: clinical aspects and therapeutic prospects]. / Le syndrome de transsexualisme: aspects cliniques et perspectives thérapeutiques.

The prevalence rate of transsexualism varies from 1 to 50,000, to 1 to 100,000. Although it remains an infrequent affliction, transsexualism generates usually major suffering and may be responsible of many complications like suicide, self-mutilations, affective disorders and social disabilities. Since the first descriptions of Esquirol in the nineteenth, the medical community has always been questioned on medical, legal, social or ethical aspects of transsexualism. The aetiology of the trouble is still unknown. In the absence of biological marker, the syndrome of transsexualism can be defined only with clinical criteria. The main differential diagnosis are sexual ambiguities and psychotic disorders. For the specialists, satisfying the patients demand of a surgical and social reassignment still remains the only way to improve their clinical condition and avoid the onset of many dramatic complications. Without any treatment, the evolution of the trouble is chronic, without remission. Longitudinal studies of transsexual patients with a five year follow-up demonstrated subjective improvement in two thirds of the patients and don't find either higher rates of suicides nor psychotic decompensations after surgery and hormonotherapy. Clinical and neuropsychological studies of sexually differentiated cognitive abilities of transsexual patients, before and after hormonotherapy, could allow us in improving the understanding of sexual differences of the brain.

Differences in the natural autoantibody patterns of patients with schizophrenia and normal individuals.

The expression of IgG and IgM autoantibodies directed against various autoantigens, either part of the central nervous system or not, was investigated in the sera of inpatients with schizophrenia (n = 10). An enzyme immunoassay was used to measure the levels of these autoantibodies in whole sera, IgG-depleted sera, and isolated IgG fractions. IgG and IgM antibodies, reacting with all the antigens tested, were present in the sera of patients with schizophrenia as well as in the sera of normal individuals. Among patients suffering from schizophrenia, IgM natural autoantibody reactivities could be higher (myoglobin, serotonin, tubulin), lower (dopamine), or even identical to those of normal individuals, depending on whether whole or fractionated sera were assayed and on the group of patients with schizophrenia (responders and nonresponders) considered. The isolated IgG fractions of patients suffering from schizophrenia had higher anti-DNA and antiserotonin reactivities than those detected in normal individuals.

[Treatment of heroin addicts by substitution with methadone. Importance, limits and experience in France]. / Les traitements de substitution des héroïnomanes par la méthadone. Intérêt, limites et pratiques en France.

The authors present a review of literature and their personal experience concerning the practice of methadone substitutive therapy for heroin addicts in France. In their experience, the use of methadone, within the frame of a controlled administration and in the perspective of a specific pharmaco-therapeutic profile, is a valuable therapeutical option. Otherwise, methadone could only induce a new and further pharmacological dependence. The use of methadone has often been the subject of controversies overlooking the clinical reality of drug addiction. Therefore, a controlled use of methadone remains a valuable therapeutic tool if its indications are strictly delimited.

[Mortality and cause of death in schizophrenia. Review of the literature]. / Mortalité et causes de décès dans la schizophrénie. Revue de la littérature.

Through a review of the literature, the average mortality in schizophrenia is twice higher than among the population. This over mortality is highest among the 20-40 years range of age and added risk tends to disappear after 60 years. All studies stress the unnatural causes of death, suicide or accidental deaths. However several studies found an over mortality caused by natural death. The pathologies most often involved are: infections, lung, gastrointestinal, urogenital and cardiovascular diseases. Cancer mortality in schizophrenic patients is still debated. Some studies point out a reduced mortality compared to the general population whereas other studies find similar or over mortality. Nevertheless mortality ratio is found to be near 1 in the majority of studies. So it can be admitted that schizophrenic patient do really not differ from the general population in regard to cancer mortality. Premature death is highly linked to suicide. The epidemiological indicators that enable us to estimate the importance of suicide mortality are: the rate of suicide per 105 patients per year varies between 150 and 500, the percentage of death by suicide range between 10 and 15 percent. Suicide risk factors are numerous. Some of them are accepted as valid and others are still discussed. The former are: male gender, young and medium age ten first years of the illness course, associated depressive symptoms, past history of suicide attempts, iterative relapses and post hospital discharge period. The latter are: social isolation, celibacy, unemployment, high level of instruction, delusional and hallucinatory activity and familiar rejection.

[Heroin addiction treated with methadone. Experience in 50 patients]. / Héroïnomanie traitée par méthadone. Expérience sur 50 malades.

The authors have reviewed the records of 50 heroin addicts treated with methadone, a drug which, in France, is delivered under strict and daily supervision to only few patients. This retrospective study yielded the following data: (1) the success rate of maintenance treatment with methadone exceeded 50 percent and remained the same in HIV positive patients; (2) social and environmental factors predictive of poor response to methadone were the absence of professional activity at the beginning of treatment and a painfully disturbed family context. A history of trouble with the law was not a factor of poor prognosis. These data raise the problem of importance of an early treatment which might have a strong influence on subsequent developments.

[Psychiatric manifestations and HIV infection. Apropos of a case]. / Manifestations psychiatriques et infection par le HIV. A propos d'un cas.

Psychiatric symptoms in AIDS have been noted in the literature. The case report of a young man with HIV showing psychotic features is presented. The course of the illness points to a possible schizophrenia incipiens. This raises two issues: the neurotropic potential of the virus and its involvement in the occurrence of these psychiatric troubles.

[Sleep deprivation and dexamethasone suppression test in healthy volunteers]. / Privation de sommeil et test de freination à la dexaméthasone chez des volontaires sains.

One night sleep deprivation in 10 healthy volunteers was performed: none of them presented an abnormal dexamethasone suppression test (DST) during the following afternoon. In this experimentation, a short deprivation of sleep does not alter DST. Etiopathogenic hypothesis of DST abnormalities (and other factors) have been discussed.