Exploring the boundaries between borderline personality disorder and suicidal behavior disorder.

OBJECTIVE: To compare clinical traits of suicidal vulnerability among in-patients with suicidal behavior disorder (SBD) with and without borderline personality disorder (BPD). METHOD: we recruited adult patients with SBD, consecutively and voluntarily hospitalized in a specialized unit for affective disorders and suicidal behavior between July and October 2016. Ninety-two inpatients having attempted suicide within the past 2 years were divided into two subgroups according to the presence or absence of BPD. Clinical vulnerability traits for suicidal behavior were assessed. RESULTS: Half of the patients with SBD also had BPD. Patients with BPD were nine times more likely to be major suicide repeaters compared to those without. They were also more likely to display clinical and psychological vulnerability traits for suicidal behavior, even after considering potential confounders. Emotional dysregulation, shame-proneness, impulsiveness, preoccupied attachment pattern, and childhood trauma were high in both groups, but significantly increased in those with (vs. without) BPD status. Psychological traits remained stable in SBD-BPD patients, regardless of the time since the last suicide attempt (i.e. SBD in recent vs. early remission). CONCLUSIONS: Clinical and psychological traits associated with suicidal vulnerability are present in all SBD patients compared to non-suicidal populations, but comorbidity with BPD is associated with particularly high scores. BPD could be considered as a specifier for SBD diagnoses.

Is it time for individualized testing in the electroencephalogram (EEG) laboratory?

BACKGROUND AND PURPOSE: The interictal electroencephalogram (EEG) has an important role in the classification and treatment of epilepsy. In busy EEG laboratories, valuable resources are used in order to comply with current recommendations regarding the length of EEG recordings. Our aim was to examine the time to first interictal epileptiform discharge (IED) in standard and sleep-deprived EEGs. METHODS: Standard and sleep-deprived EEG recordings with IEDs were retrospectively reviewed during a 2-year period. Bedside EEGs and long-term video-EEGs were excluded. IED latency according to EEG type, age group and inpatient/outpatient status was analyzed with the Kaplan-Meier estimator. RESULTS: The study group included 684 patients, 372 (54%) males, aged 0.2-89 years. Standard (n = 316) and sleep-deprived (n = 368) EEGs were performed in 245 inpatients and 439 outpatients. The EEG was requested in 96% of the inpatients following a seizure. Most IEDs were recorded whilst the patients were awake (43%) or drowsy (34%). Ninety percent of the IEDs were recorded within 18.5 min, earlier in standard (14.6 vs. 21.3 min) (P = 0.024) EEGs and in inpatients (14 vs. 21.3 min) (P = 0.002). IED latency was unaffected by age. CONCLUSIONS: Electroencephalogram type and admission status may be used for individual determination of the duration of EEG recording. Reducing the duration of standard and sleep-deprived EEGs may be considered especially in inpatients.

[Mixed states: evolution of classifications]. / États mixtes. Évolution des classifications.

The nosological position of mixed states has followed the course of classifying methods in psychiatry, the steps of the invention of the clinic, progress in the organization of care, including the discoveries of psychopharmacology. The clinical observation of a mixture of symptoms emerging from usually opposite clinical conditions is classical. In the 70s, a syndromic specification fixed the main symptom combinations but that incongruous assortment failed to stabilize the nosological concept. Then stricter criteriology was proposed. To be too restrictive, a consensus operates a dimensional opening that attempts to meet the pragmatic requirements of nosology validating the usefulness of the class system. This alternation between rigor of categorization and return to a more flexible criteriological option reflects the search for the right balance between nosology and diagnosis. The definition of mixed states is best determined by their clinical and prognostic severity, related to the risk of suicide, their lower therapeutic response, the importance of their psychiatric comorbidities, anxiety, emotional lability, alcohol abuse. Trying to compensate for the lack of categorical definitions and better reflecting the clinical field problems, new definitions complement criteriology with dimensional aspects, particularly taking into account temperaments.

[Short history of mixed states]. / Une approche historique des états mixtes.

The notion of mixed states is classically associated with descriptions and categories inherited from Kraepelin. However, simultaneous descriptions of depressive and manic manifestations can be traced back to ancient times. Semiology and definitions of these clinical associations have evolved across the times. We provide here a short insight on four distinct periods: Greek authors from ancient times, pre-Kraepelinian psychiatry (18th and 19th centuries), Kraepelin's conceptualization, and contemporary psychiatry (20th and 21st centuries).

[Clinical description of mixed mania]. / Clinique des manies mixtes.

DSM-IV mixed states have become the mixed mania and mixed depression in the new DSM-5. One noticeable point is the introduction of nine cations, among which the "with mixed features" specification. These non exclusive specifications may contribute to a more precise identification of mixed clinical pictures, and therefore to offer a more efficient therapeutic answer. Different dimensional approaches are widely documented. They allow the isolation of a mixed factor which is clinically associated with two other specifications: anxious distress and psychotic features. These severity markers may encourage clinicians to be alert about the risk of misdiagnosis, and cautious in the management of these clinical situations.

[Neurocognitive fuctioning in pure mania and mixed mania]. / Fonctionnement neurocognitif dans la manie pure et la manie mixte.

Neurocognitive dysfunction is increasingly recognized as a prominent feature of bipolar disorder. Cognitive function seems to be impaired across different states of bipolar illness. Nervertheless, research that studies neuropsychological functioning in acute phases is scarce. Acutely ill patients have shown dysfunctions in several cognitive areas. We reviewed the literature on neuropsychological studies of acute phases to highlight neurocognitive deficits in mixed and pure mania. The results show dysfunctions in sustained attention that are significantly more important in mixed mania rather than in pure mania. Impulsive pattern of responding seems to characterize pure manic state. We also found impairments in processing speed, verbal and spatial learning/memory and executive functions, including cognitive flexibility, inhibitory control, conceptual reasoning, planning and problem solving. Disturbance in executive functioning seems to be more important in pure mania rather than mixed mania.

[Antimanic treatments in bipolar mixed states]. / Traitements anti- maniaques dans les états mixtes.

INTRODUCTION: Mixed states present nosologic and diagnostic challenges with a relative paucity of evidence to guide treatment. Mixed bipolar states are difficult to treat and are associated with a high neuropsychiatric morbidity, a high risk of suicide and a poor outcome. In DSM- 5, the definition of mixed episode has been removed (in DSM- IV TR: "juxtaposed full manic and depressive episodes"). Mixed symptoms are captured under a broader concept called "mixed features" that is applied to mania and depression. The classification of mixed states as defined in DSM- 5 is less restrictive than in DSM- IV TR and challenges us at methodological and therapeutic levels. OBJECTIVE: The aim of this paper was to conduct an overview of the literature to ascertain the efficacy of pharmacotherapy of mixed states. METHOD: A systematic review of the literature was conducted using PubMed. RESULTS: Manic symptoms of mixed episodes seem to show a good response to second generation antipsychotics and to divalproate. There is no evidence of differential efficacy for second generation of antipsychotics (SGAs). Lithium and carbamazepine may be effective in mixed states in monotherapy and perhaps benefit in combination with SGAs as second line. Combination pharmacological treatment of SGAs and moodstabilizers are common in mixed states. This pattern has the best literature evidence. CONCLUSIONS: There is a few evidence to help us to choose the right treatment for patients with mixed state. In light with the DSM 5, more drugs specifically designed to treat mixed state are needed.

[Treatment of depressive mixed states]. / Le traitement des dépressions mixtes.

Mixed states are a frequent mood state characterized by the mixture of manic and depressive symptoms. Their clinical description has been studied for centuries but has known a renewal of interest recently. Several authors intend to redefine its diagnostic criteria to develop an appropriate therapeutic strategy. Current recommendations suggest to treat mixed depression as a mixed state whatever the dominant polarity is, and therefore according to the rules of therapeutic management of the manic state. Mood stabilizers and antipsychotic medications are indicated and have proven their effectiveness. Lithium, which was considered controversial, now appears to have some therapeutic value, especially in the prevention of suicidal behavior. The depressive component of mixed states, even pronounced, should not be an argument for a prescription of antidepressants, at the risk of aggravating clinical components such as irritability and impulsivity and increasing the danger of suicide attempt. Furthermore, electroconvulsivetherapy represents a real alternative ; psychotherapies have their place in relapse prevention and psychoeducation, but not during acute phases. Finally, an accurate assessment and appropriate management of suicide risk should be a constant concern for the clinicians.

[Pathophysiological models of mixed states]. / Modèles physiopathologiques des états mixtes.

Mixed states are complex manifestations of bipolar disorders. Pathophysiology of mixed states remains unclear. Several models have been proposed to understand the mechanisms underlying these mood states. These models describe mixed state either as a combinaison of depression and mania, as well as a transition between mania and depression, or mixed state as a severe type of depression or mania. Pathophysiological hypotheses involve temperaments or some personality disorders, psychiatric comorbidities as well as substance use disorders, or thyroid dysfunction. However, the formal demonstration of any specific genetic vulnerability to mixed state has not yet been provided.

[Recommendations for the treatment of mixed episodes in current guidelines]. / Recommandations sur le traitement des épisodes mixtes dans les guidelines actuels.

A literature search on the pharmacological treatment of acute bipolar mixed episodes in current guidelines shows that only seven of them address the acute management of mixed episodes as a separate condition, whereas the vast majority of these guidelines include the treatment of mixed episodes in the chapter of mania. As a general rule, most guidelines advise to stop antidepressant treatment and mention the superiority of valproate over lithium. Specific recommendations for the treatment of "mixed states" can be found in two guidelines, while specific recommendations for that of "mixed mania" are present in five of them. Recommendations for the treatment of "mixed depression" exist in only three guidelines. If some consensus may be found for the treatment of "mixed states" as a whole, recommendations for the treatment of "mixed mania" appear to be variable, whereas those for the treatment of "mixed depression" seem to be limited.

[Psychometric properties of the Activities Daily Life Scale (ADL)]. / Caractéristiques psychométriques de l'échelle des activités de la vie quotidienne (AVQ).

OBJECTIVE: Deficits in social functioning are an important core feature of mental health. Recently in France, the Activities Daily Life (ADL) scale has been proposed by the French authorities to assess social functioning for all hospitalized patients in a psychiatric ward. The perspective is to use this scale in the financing and organization of mental health services in France. The ADL scale is a 6-item (dressing/undressing, walking/mobility, eating/drinking, using toilets, behaviour, relationships/communication) heteroquestionnaire completed by a health care professional at the beginning of each hospitalization, assessing functioning of patients suffering from mental health diseases. However, limited consensus exists on this scale. The psychometric properties of the ADL scale have not been assessed. There is a pressing need for detailed examination of its performance. The aim of this study was to explore ADL psychometric properties in a sample of hospitalized patients in a psychiatric ward. METHOD: We retrospectively analyzed data for all episodes of care delivered to hospitalized patients in a psychiatric ward in our French Public Hospital from January 1, 2008 to June 30, 2008. The study involved retrospective review of administrative and medical databases. The following data were collected: age, gender, diagnoses based on the International Classification of Diseases - 10th version, ADL scale and Assessment of Social Self-Sufficiency scale (ASSS). The psychometric properties were examined using construct validity, reliability, external validity, reproducibility and sensitivity to change. Data analysis was performed using SPSS 15.0 and WINSTEP software. RESULTS: A total of 1066 patients completed the ADL scale. Among them, 49.7% were male, mean age was 36.5 ± 10.8, and 83.5% were single. Schizophrenia, schizotypal and delusional disorders (40.0%), mood disorders (27.9%) and mental and behavioural disorders due to psychoactive substance use (12%) were the most common diagnoses. Factor analysis with varimax rotation identified a 2-factor structure accounting for 82% of the total variance. The first dimension (ADL 1) comprised four items and represented personal care activities. The second dimension (ADL 2) comprised two items and represented social functioning. A floor effect was reported for ADL 1 and its unidimensionality was not satisfactory: two items showed an INFIT statistic outside the acceptable range. Internal consistency was satisfactory for the two dimensions: each item achieved the 0.40 standard for item-internal consistency. The correlation of each item with its contributory dimension was higher than with the other (item discriminant validity). Cronbach's alpha coefficients ranged over 0.70 in the whole sample. Concerning external validity, positive correlations were not systematically found between ADL and ASSS dimensions. The score of ADL 1 had medium to high correlations with four dimensions scores of the ASSS, while the score of ADL 2 were not at all or weakly correlated with ASSS dimension scores. Globally, ADL did not cover sentimental life and social relationships. There were statistical associations between ADL and age or gender: women and subjects older than 60 had a higher level of dependency. We didn't find any association with marital status or diagnoses. The ADL scale presented a good reproducibility but was not sensitive to change. CONCLUSION: The psychometric properties of the ADL scale were not sufficient for several parameters such as validity or sensitivity to change, contrary to other available French scales. The use of a heteroquestionnaire rather than a self-administered questionnaire should be discussed by professionals and the French authorities. These results should be taken into account in the use of the ADL scale for the economic and administrative management of psychiatry. Further research should be conducted to confirm these results.

[Compliance of long-acting atypical antipsychotics: from an image problem to a question of indication]. / La compliance aux antipsychotiques d'action prolongée: d'un problème d'image à une question d'indication.

UNLABELLED: This paper focuses on the questions asked to practitioners regarding compliance to new long-acting atypical antipsychotics (LAAA): how does the comprehensive approach of patients' and carers' attitudes facing treatment challenge it? OBJECTIVES: A review of recent literature shows that LAAA, are still suffering from an "image problem". We aim to describe these negative beliefs and suggest that LAAA indications be reconsidered. METHOD: Following a comprehensive approach, we interpreted our review on the basis of anthropological criteria. We focused on value-based health and disease models that organize the attitude of patients and carers regarding the depot injection. RESULTS: Multiple negative beliefs attached to the pain, side-effects, and stigmas are well-known to impair adhesion to treatment. Carers understand disease as a lack of insight. Patients experience it as a threat for the Self and a loss of autonomy. The nurse-patient relationship involving injections is an important factor of compliance. When time is devoted by the carer to paying attention to the patient's experience, in order to perceive the patient as a participant, patients are more likely to adopt the injectable route themselves. By doing so, the patient considers the injection as a "protective net" a "lesser evil" by integrating it within his(her) biography. DISCUSSION: A comprehensive approach links the lack of insight to the patient's perception of stigma. Hope for recovery is related by the person him(her)self to his(her) own ability for autonomy. Persons with schizophrenia usually struggle for norms (agonomia). This trend has to be taken into account. LAAA are better indicated when patients are compliant. There is no indication when patients are "pure agonomics" and fight to deny both stigma and medication.

Elevated circulating levels of IL-6 in schizophrenia.

Schizophrenia may result from immune or inflammatory disorders, which are mediated by cytokines. Data in this field are heterogeneous and often contradictory. We investigated circulating levels of IL-6 and TNF-alpha, two distinct proinflammatory cytokines. Using immunoassay, we assessed IL-6 and TNF-alpha in serum from chronic schizophrenic patients (n = 30) and normal controls (n = 15). Circulating levels of IL-6 were higher in patients than in controls; those of TNF-alpha were not significantly higher than in controls. In addition, IL-6 levels were higher in patients with acute exacerbation of schizophrenia than in patients with remissions. Our results suggest that immunologic abnormalities in schizophrenia may be related to a specific inflammatory process mediated by IL-6. An interesting line of research would be the evaluation of IL-6 cerebral production in CSF.

A new approach to discourse analysis in psychiatry, applied to a schizophrenic patient's speech.

OBJECTIVE: Progress in the science of data analysis and computer technology has led to the development of advanced methods for investigating structure discourse in the psychiatric field, where language constitutes a useful investigative and therapeutic tool. The purpose of this study was to present and use a computer-assisted method of discourse analysis (Alceste-software) to analyse the schizophrenic subject's oral contributions regularly collected for 3 months. METHOD: The method used consisted of modelling the main word distribution in spoken recordings pooled together and identifying the repetitive language patterns most frequently used by the speaker. RESULTS: Four main kinds of discourse emerged from the pool of schizophrenic's speech samples, on specific topics without any lack of ability to organize the material, but the technique analysis showed that the main kinds of discourse were interspersed with unexpected 'language satellites' consisting of a secondary short and specific discourse which was also well planned but had no relevance to the main discourse making for a lack of cohesion in the speech samples. This method allows us direct access to the inner experience of the patient. The technique highlighted a very poor pre-syntax linked to the choice of words and a tendency to make pronoun errors, possibly reflecting some confusion between the patient herself and others, mainly her mother, especially in the discourse about childhood. CONCLUSION: This method of discourse analysis made it possible to investigate various language disturbances at the same time and at different levels. It is particularly adapted for analysing the schizophrenic's speech. The data obtained were consistent with the assumption that schizophrenia involves 'thought disorders': these ones giving rise to the language impairments.

Possible involvement of the dopamine D3 receptor locus in subtypes of bipolar affective disorder.

The dopamine D3 receptor gene is of potential interest in the physiopathology of affective disorder because of its expression pattern in brain structures controlling various aspects of behaviour, cognition and emotions. Moreover, it encodes for a receptor protein that is a target for psychotropic drugs, which turn out to be efficient in the treatment of this disorder. Two polymorphisms have been described at this locus (the Bal I and the Msp I Restriction Fragment Length Polymorphisms) that are useful in genetic studies. We therefore researched these polymorphisms in 60 patients suffering from bipolar affective disorder who were compared with 60 healthy volunteers. No statistical difference was observed between the whole patient sample versus the controls. However, one subgroup [homozygous for the (2-2) Bal I polymorphism] exhibits a characteristic clinical pattern consisting of: manic monopolar form of bipolar disorder, low age of onset and initiation by an acute delusional episode. A gender distribution difference for the Bal I polymorphism (chi 2 = 6.61, degrees of freedom = 1, P = 0.01) was then noted, the bipolar females being preferentially heterozygous, and the males homozygous. These results could involve the dopamine D3 receptor locus as a minor effect gene in the manic depression condition.

Decrease in red blood cell L-tryptophan uptake in schizophrenic patients: possible link with loss of impulse control.

1. Kinetic parameters of erythrocyte L-tryptophan (TRP) uptake (Vmax, maximal velocity and Km, Michaelis constant) were determined in 19 neuroleptic-free schizophrenic patients and in 19 healthy volunteers. Both Vmax and Km values were significantly lower in schizophrenic patients than in controls. 2. Mean Vmax value was found to be lower in patients who had attempted suicide than in patients who had not. No difference was observed when patients were subdivided on the basis of the violence of suicide attempts. 3. A significant negative correlation was observed between Vmax and scores on the loss of impulse control item as assessed on the PANS scale. 4. Decrease in red blood cell L-TRP uptake reflects a disturbance in the peripheral metabolism of TRP that may result in a deficiency of the plasma L-TRP availability on which the central serotonin (5HT) synthesis closely depends. 5. In addition, the results suggest that the alteration in RBC L-TRP uptake is associated with loss of impulse control in schizophrenic patients.

Season of birth and schizophrenia: sex difference.

1. A statistically significant increased risk of schizophrenia for individuals born in winter has been reported. The increase risk is of the order of 5-15 percent. The seasonal effect is more marked among females. This winter birth effect suggests some environmental agents, probably a neuropathogen one, acting on the foetus. 2. The present study sought to test the environmental damage hypothesis by application of the family history of psychiatric disorder distinction to season of birth data divided according to sex and using a control population. 3. From computer records, all patients admitted to the psychiatric department of Marseilles Timone hospital between January 1984 and December 1989 who satisfied DSM III, DSM III R criteria for schizophrenia were identified. Patients were then classified into two groups: family history of psychiatric disorder versus no family history. Division according to the sex was carried on after two groups were formed. 4. The data show (I) a significant excess of births in the early months of the year (p < 0.05) for all patients with no family history of psychiatric disorder, (2) a significant excess of births for females (p < 0.05) with no family history. 5. These results provide indirect support for the neurodevelopmental theory of schizophrenia.

Lack of association between platelet tritiated imipramine binding and clinical status of depressed patients on chronic antidepressant treatment.

Platelet tritiated imipramine binding (Bmax) was studied in 33 depressed patients, before and after 1 and 4 weeks of antidepressant treatment, and in 34 healthy volunteers. The Bmax was significantly lower (-21%) in drug-free depressed patients than in controls and increased significantly as early as the first week of treatment to reach the control value, in parallel with a 38% decrease in the Hamilton depression rating scale (HDRS) score. After 4 weeks of treatment, the Bmax was still normal and remained significantly higher than the baseline value, while the clinical state of the patients had greatly improved (a 63% decrease in the HDRS score). However, an increase in the Bmax also occurred in non-responders to treatment. In addition, we observed that the ability of the treatment to increase the Bmax depended on the pharmacological profile of the drug used. The present results show that, in patients on antidepressant medication, platelet tritiated imipramine binding normalization cannot be considered as a marker of clinical remission.