EEG Neurofeedback for Anxiety Disorders and Post-Traumatic Stress Disorders: A Blueprint for a Promising Brain-Based Therapy.

PURPOSE OF REVIEW: This review provides an overview of current knowledge and understanding of EEG neurofeedback for anxiety disorders and post-traumatic stress disorders. RECENT FINDINGS: The manifestations of anxiety disorders and post-traumatic stress disorders (PTSD) are associated with dysfunctions of neurophysiological stress axes and brain arousal circuits, which are important dimensions of the research domain criteria (RDoC). Even if the pathophysiology of these disorders is complex, one of its defining signatures is behavioral and physiological over-arousal. Interestingly, arousal-related brain activity can be modulated by electroencephalogram-based neurofeedback (EEG NF), a non-pharmacological and non-invasive method that involves neurocognitive training through a brain-computer interface (BCI). EEG NF is characterized by a simultaneous learning process where both patient and computer are involved in modifying neuronal activity or connectivity, thereby improving associated symptoms of anxiety and/or over-arousal. Positive effects of EEG NF have been described for both anxiety disorders and PTSD, yet due to a number of methodological issues, it remains unclear whether symptom improvement is the direct result of neurophysiological changes targeted by EEG NF. Thus, in this work we sought to bridge current knowledge on brain mechanisms of arousal with past and present EEG NF therapies for anxiety and PTSD. In a nutshell, we discuss the neurophysiological mechanisms underlying the effects of EEG NF in anxiety disorder and PTSD, the methodological strengths/weaknesses of existing EEG NF randomized controlled trials for these disorders, and the neuropsychological factors that may impact NF training success.

[Is the medication reconciliation achievable and relevant in Psychiatry?: Feedback on the implementation of medication reconciliation on hospital admission]. / La conciliation médicamenteuse est-elle réalisable et pertinente en Psychiatrie ? : Retour d'expérience sur la mise en place de la conciliation à l'admission.

OBJECTIVE: The health care pathway of patients suffering from mental disorders is complex and includes a risk of interruption of treatment. We implemented medication reconciliation at patients' admission to mental health care service in February 2017. The aim of this study was to achieve a feedback experience answering our questions about the feasibility and relevance of this process. METHOD: A prospective analysis of medication reconciliations over the first 7 months of implementation was carried out according to 3 activity indicators and 6 performance indicators. RESULTS: A total of 39 patients were reconciled and 56.4 % of them were in enforced hospitalization unit. All patients were interviewed by the pharmacist. Collected information during this interview was concordant with at least one of the other sources in 70.4 % of the cases. Thirteen patients were not reconciled within 72h after their admission because of their psychiatric pathology. The average number of unintentional medication discrepancy (UMD) detected was 0.97 per reconciled patient. The rate of major gravity UMD was 23.7 %. The number of UMDs per patient was significantly higher in enforced hospitalization unit (P<0.05). UMDs were essentially related to somatic drugs (81.6 %). Nearly 95 % of the detected UMDs resulted in a modification of prescription. CONCLUSION: These results show that medication reconciliation at patients' admission is feasible and relevant in psychiatry. To limit constraints related to psychiatric pathology, we propose to perform medication reconciliation of patients more than 72 hours after patient admission provided that their clinical condition allows it.

[Mindful neuropsychology: Mindfulness-based cognitive remediation]. / Mindful neuropsychology : repenser la réhabilitation neuropsychologique à travers la pleine conscience.

OBJECTIVES: Mindfulness based interventions (MBI) have recently gained much interest in western medicine. MBSR paradigm is based on teaching participants to pay complete attention to the present experience and act nonjudgmentally towards stressful events. During this mental practice the meditator focuses his or her attention on the sensations of the body. While the distractions (mental images, thoughts, emotional or somatic states) arise the participant is taught to acknowledge discursive thoughts and cultivate the state of awareness without immediate reaction. The effectiveness of these programs is well documented in the field of emotional response regulation in depression (relapse prevention), anxiety disorders, obsessive-compulsive disorder or eating disorders. Furthermore, converging lines of evidence support the hypothesis that mindfulness practice improves cognition, especially the ability to sustain attention and think in a more flexible manner. Nevertheless, formal rehabilitation programs targeting cognitive disturbances resulting from psychiatric (depression, disorder bipolar, schizophrenia) or neurologic conditions (brain injury, dementia) seldom rely on MBI principles. This review of literature aims at discussing possible links between MBI and clinical neuropsychology. METHODS: We conducted a review of literature using electronic databases up to December 2016, screening studies with variants of the keywords ("Mindfulness", "MBI", "MBSR", "Meditation") OR/AND ("Cognition", "Attention", "Executive function", "Memory", "Learning") RESULTS: In the first part, we describe key concepts of the neuropsychology of attention in the light of Posner's model of attention control. We also underline the potential scope of different therapeutic contexts where disturbances of attention may be clinically relevant. Second, we review the efficacy of MBI in the field of cognition (thinking disturbances, attention biases, memory and executive processes impairment or low metacognitive abilities), mood (emotional dysregulation, anxiety, depression, mood shifts) and somatic preoccupations (stress induced immune dysregulation, chronic pain, body representation, eating disorders, sleep quality, fatigue). In psychiatry, these three components closely coexist and interact which explains the complexity of patient assessment and care. Numerous studies show that meditation inspired interventions offer a promising solution in the prevention and rehabilitation of cognitive impairment. In the last part, we discuss the benefits and risks of integrating meditation practice into broader programs of cognitive remediation and therapeutic education in patients suffering from cognitive disorders. We propose a number of possible guidelines for developing mindfulness inspired cognitive remediation tools. Along with Jon Kabatt Zinn (Kabatt-Zinn & Maskens, 2012), we suggest that the construction of neuropsychological tools relies on seven attitudinal foundations of mindfulness practice. CONCLUSIONS: This paper highlights the importance of referring to holistic approaches such as MBI when dealing with patients with neuropsychological impairment, especially in the field of psychiatry. We advocate introducing mindfulness principles in order to help patients stabilize their attention and improve cognitive flexibility. We believe this transition in neuropsychological care may offer an interesting paradigm shift promoting a more efficient approach towards cognition and its links to emotion, body, and environment.

[Mindfulness-based interventions in obsessive-compulsive disorder: Mechanisms of action and presentation of a pilot study]. / Les interventions basées sur la pleine conscience dans le trouble obsessionnel compulsif : mécanismes d'action et présentation d'une étude pilote.

Obsessive-compulsive disorder (OCD) is a frequent and severe disease, potentially inducing a major impairment for the patient and burden for their family. Recent research in psychiatry and neuroscience have led to better comprehension of the disease's mechanisms and helped to improve its treatment. However, a large proportion of patients have refractory symptoms, including for traditional cognitive and behavioral therapy by exposure and response prevention (ERP), leading clinicians to look for new treatments. Mindfulness-based interventions (MBI) are a new type of approach, initially based on Buddhist meditation, which aims to provide better consciousness of the present moment. It has been successfully developed in some psychiatric diseases and other general medical conditions such as chronic pain. The two main programs using mindfulness meditation, Mindfulness-based stress reduction (MBSR) and Mindfulness-based cognitive therapy (MBCT), have shown effectiveness for the reduction of depressive and anxiety symptoms and relapses of depressive episodes in unipolar depression. It has no side effects and is well tolerated by patients. Its action relies on the specific correction of cognitive deficits in attention, emotion regulation and executive functions which are shared by OCD, GAD and depression. For OCD, we make the hypothesis that Mindfulness-Based Interventions could reduce the cognitive bias specifically existing in this pathology, such as dysfunctional beliefs, and therefore improve the symptoms. This article first reviews the existing literature on clinical trials involving Mindfulness-Based Interventions in OCD which comprises a small number of clinical studies based on very different types of protocols. At this time, and due to the lack of gold-standard studies with a large number of patients, no proof of the efficiency of mindfulness-based interventions in OCD has been shown. In a second section, following our hypothesis on the mechanisms of specific and non-specific action of this therapy in OCD, we propose a cognitive model of mindfulness-based therapy action in OCD involving the correction of OCD's cognitive bias. In this model, mindfulness-based therapy is supposed to treat specifically the cognitive aspects of the disease, while ERP is focused on its behavioral part. Then we present a clinical study aiming to prove the feasibility and the interest of the use of mindfulness in OCD, carried out in two different clinical centers. One of them used MBCT while the second used MBSR. Its results show the feasibility of mindfulness-based therapy in OCD patients and tend to prove that it could be more effective in young patients suffering from less severe forms of OCD. In parallel, attention tests and fMRI scans were done at the beginning and at the end of the therapy. Their results will be published separately. We also discuss the putative role of a specific form of MBCT adapted for OCD, specifically for its benefits in psychoeducation, which could reduce the dysfunctional beliefs present in OCD patients. Finally, we propose a therapeutic strategy in which the MBCT could complement the classical ERP therapy, as a "maintenance" treatment, aiming to extend the relapse of OCD symptoms. This article is a step further in the use of mindfulness-based therapy for OCD which could be added to the existing treatments reducing the patient's symptoms and improving their quality of life.

[Can the efficacy of behavioral and cognitive therapy for obsessive compulsive disorder be augmented by innovative computerized adjuvant?] / Peut-on augmenter l'efficacité de la thérapie cognitive et comportementale pour le trouble obsessionnel compulsif par un adjuvant informatique innovant ?

AIM: Cognitive behavioral therapy (CBT) is recognized as an effective treatment for obsessive-compulsive disorder (OCD). To maximize its effectiveness, we designed an "experimental" CBT defined by the addition of a computerized psychoeducative tool. METHOD: In a participative process involving patients through meetings of the French OCD association (AFTOC) and therapists through methodological workshops, we built a therapeutic tool from an experimental checking task. This task, which had been published in an earlier work, was adapted for its psychoeducative dimension. We here report on a randomized double-blind trial which included 35 patients with a moderate to severe OCD (Yale-Brown obsessive-compulsive scale, YBOCS between 16 and 25) predominant checking symptoms, no comorbidities, and 2-month stabilized or no treatment. Patients were randomly assigned to either "standard" versus "experimental" CBT. Both therapies were conducted by four CBT-experienced therapists specialized in OCD through weekly individualized sessions over 3 months. Therapy sessions of the experimental CBT were conducted as the standard CBT except for a short exercise with the computerized psychoeducative tool performed by the patient and debriefed with the therapist at the end of the sessions. Patients were assessed before, during, after therapy and again 6 months later using standard clinical tools and a neurobehavioral assessment based on an original symptom-provocation task with anxiety ratings including three types of photographs: neutral, generic inducing obsessions (e.g., doorknobs, electric wires…) and personalized (taken by the patients in their own environment). RESULTS: Clinically, "standard" and "experimental" CBT resulted in a significant but equivalent improvement (48% vs 45% reduction of the Y-BOCS score; P=0.36; d=0.12). Therapists were satisfied with the psychoeducative dimension of the computerized psychoeducative tool but reported variable acceptance across patients. Patients appreciated its usability. The clinical improvement was associated with a reduction of the task-induced anxiety (r=0.42, P<0.05), especially towards personalized items (-28,2% vs -20.41% for generic and -6.24% for neutral photographs, P<0.001). Mid-therapy response level was predictive of the final improvement (r=0.82, P<0.001). CONCLUSION: The computerized tool may provide a well-accepted therapeutic adjuvant even though it doesn't improve the therapeutic effect. Using a personalized symptom-provocation task reveals the parallel evolution of symptoms and neurobehavioral markers through CBT. Despite the difficulty of improving an evidence-based therapy, mid-therapy results call for investigating the possible adjustments of treatment strategies at an early stage.

Medication and aggressiveness in real-world schizophrenia. Results from the FACE-SZ dataset.

INTRODUCTION: The primary objective of this study was to determine if second-generation antipsychotic (SGA) administration was associated with lower aggressiveness scores compared to first-generation (FGA) in schizophrenia (SZ). The secondary objective was to determine if antidepressants, mood stabilizers, and benzodiazepines administration were respectively associated with lower aggressiveness scores compared to patients who were not administered these medications. METHODS: Three hundred thirty-one patients with schizophrenia (N = 255) or schizoaffective disorder (N = 76) (mean age = 32.5 years, 75.5 % male gender) were systematically included in the network of FondaMental Expert Center for Schizophrenia and assessed with the structured clinical interview for DSM-IV Axis I disorders and validated scales for psychotic symptomatology, insight, and compliance. Aggressiveness was measured by the Buss-Perry Aggression Questionnaire (BPAQ) score. Ongoing psychotropic treatment was recorded. RESULTS: Patients who received SGA had lower BPAQ scores than patients who did not (p = 0.01). More specifically, these patients had lower physical and verbal aggression scores. On the contrary, patients who received benzodiazepines had higher BPAQ scores than patients who did not (p = 0.04). No significant difference was found between BPAQ scores of patients respectively being administered mood stabilizers (including valproate), antidepressant, and the patients who were not. These results were found independently of socio-demographical variables, psychotic symptomatology, insight, compliance into treatment, daily-administered antipsychotic dose, the way of antipsychotic administration (oral vs long acting), current alcohol disorder, and daily cannabis consumption. CONCLUSION: The results of the present study are in favor of the choice of SGA in SZ patients with aggressiveness, but these results need further investigation in longitudinal studies. Given the potent side effects of benzodiazepines (especially dependency and cognitive impairment) and the results of the present study, their long-term prescription is not recommended in patients with schizophrenia and aggressive behavior.

[Treatment-resistant anxiety disorders: A literature review of drug therapy strategies]. / Troubles anxieux résistants : revue des stratégies de traitements médicamenteux.

Anxiety disorders are widespread psychiatric conditions with significant social and professional disability, poor quality of life, an increased risk of suicide, and frequent attendance of medical services. Serotonin reuptake inhibitors (SRI) and serotonin and norepinephrine reuptake inhibitors (SNRI) have demonstrated a rather robust efficacy for the treatment of most of anxiety disorders. Nevertheless a substantial number of patients are resistant or still suffer from residual symptoms despite this first line treatment. The objective of our paper is to review relevant studies for the pharmacologic management of anxiety disorders resistant to the first line treatment. For this purpose, we conducted a pubmed/medline search for double-blind placebo-controlled trials of treatment-resistant anxiety disorders. An adequate trial for a SRI in the treatment of obsessive-compulsive disorder (OCD) should continue for at least 12 weeks. Special considerations of the comorbidities and symptom profile could help in the choice of an appropriate pharmacotherapy. Several trials have highlighted the efficacy of antipsychotics as an add-on to SRI in treatment-resistant OCD such as haloperidol more so when comorbid with a tic disorder, or risperidone that can reduce OCD as well as depressive symptoms. Aripiprazole has been shown efficacious in two placebo-controlled double-blind trials, while the efficacy of quetiapine and olanzapine remains controversial. Other trials showed some efficacy of anticonvulsants (lamotrigine, topiramate), pindolol, memantin and N-acetylcystein as an adjunctive treatment to SRI for resistant OCD. Few trials have investigated selective serotonin reuptake inhibitors (SSRI) or SNRI resistant generalized anxiety disorder showing a failure of adjunctive therapy with olanzapine, quetiapine, ziprasidone and risperidone. These studies were underpowered and very limited in number. Adjunctive risperidone for resistant post-traumatic stress disorder (PTSD) showed benefit in some but not all trials. Olanzapine was beneficial for the reduction of the CAPS score in addition to the improvement of sleep disturbances. Furthermore, prazosin was efficacious by reducing PTSD symptoms, sleep disturbances, nightmares, and psychological distress. One double-blind placebo-controlled study was conducted to investigate treatment-resistant social phobia showing no benefit of pindolol add-on paroxetine. Our results demonstrate that the pharmacological management of treatment-resistant anxiety disorders is not sufficiently investigated in double-blind placebo-controlled trials, despite a growing evidence in favor of antipsychotics and some other pharmacological agents in resistant OCD and, to a lesser extent, PTSD. Hence, there is a crucial need for larger double-blind placebo-controlled trials for resistant anxiety disorders. Finally, being out of the scope of our review, we omitted studies of non-pharmacologic therapies.

Dynamics of psychotherapy-related cerebral haemodynamic changes in obsessive compulsive disorder using a personalized exposure task in functional magnetic resonance imaging.

BACKGROUND: Cognitive behavioural therapy (CBT) is a successful treatment of obsessive compulsive disorder (OCD). It is known to induce changes in cerebral metabolism; however, the dynamics of these changes and their relation to clinical change remain largely unknown, precluding the identification of individualized response biomarkers. METHOD: In order to study the dynamics of treatment response, we performed systematic clinical and functional magnetic resonance imaging (fMRI) evaluation of 35 OCD patients immediately before a 3-month course of CBT, halfway through and at its end, as well as 6 months after. To sensitize fMRI probing, we used an original exposure task using neutral, generic and personalized obsession-inducing images. RESULTS: As expected, CBT produced a significant improvement in OCD. This improvement was continuous over the course of the therapy; therefore, outcome could be predicted by response at mid-therapy (r 2 = 0.67, p < 0.001). Haemodynamic response to the task was located in the anterior cingulate and orbitofrontal cortices and was stronger during exposure to personalized obsession-inducing images. In addition, both the anxiety ratings and the haemodynamic response to the obsession-inducing images in the anterior cingulate and the left but not the right orbitofrontal clusters decreased with symptom improvement. Interestingly, haemodynamic activity continued to decrease after stabilization of clinical symptoms. CONCLUSIONS: Using an innovative and highly sensitive exposure paradigm in fMRI, we showed that clinical and haemodynamic phenotypes have similar time courses during CBT. Our results, which suggest that the initial CBT sessions are crucial, prompt us to investigate the anatomo-functional modifications underlying the very first weeks of the therapy.

Excessive checking for non-anxiogenic stimuli in obsessive-compulsive disorder.

BACKGROUND: Repetitive checking in obsessive-compulsive disorder (OCD) would serve to relieve obsession-related anxiety and/or to compensate memory deficit, but experimental literature on this subject is inconsistent. The main objective is to test the influence of obsession-related anxiety and memory on repetitive checking in OCD. METHODS: Twenty-three OCD checkers, 17 OCD non-checkers and 41 controls performed a delayed-matching-to-sample task with an unrestricted checking option. Some stimuli were obsession-related in order to measure the influence of anxiety on checking. A version of the task without checking possibility was used to assess memory abilities. RESULTS: OCD checkers had similar memory performances but checked more than the other groups when presented with non-anxiogenic stimuli. Level of anxiety associated to the stimulus did not influence the number of checks. CONCLUSIONS: Increased checking in OCD checkers, being independent of memory abilities and primary obsession-related anxiety, would, therefore, be closer to an automated behaviour than a coping strategy.

[Adjustment disorders with anxiety. Clinical and psychometric characteristics in patients consulting a general practitioner]. / Le trouble de l'adaptation avec anxiété. Caractéristiques cliniques et psychométriques chez des patients consultant en médecine générale.

BACKGROUND: The DSM-IV and ICD-10 descriptions of adjustment disorders are broadly similar. Their main features are the following: the symptoms arise in response to a stressful event; the onset of symptoms is within 3 months (DSM-IV) or 1 month (ICD-10) of exposure to the stressor; the symptoms must be clinically significant, in that they are distressing and in excess of what would be expected by exposure to the stressor and/or there is significant impairment in social or occupational functioning (the latter is mandatory in ICD-10); the symptoms are not due to another axis I disorder (or bereavement in DSM-IV); the symptoms resolve within 6 months, once the stressor or its consequences are removed. Adjustment disorders are divided into subgroups based on the dominant symptoms of anxiety, depression or behaviour. Adjustment disorder with anxiety (ADA) is a very common diagnosis in primary care, liaison and general psychiatry services but we still lack data about its specificity as a clinical entity. Current classifications fail to provide guidance on distinguishing these disorders from normal adaptive reactions to stress. METHOD: Ninety-seven patients with ADA according DSM-IV were recruited in this primary care study and compared with 30 control subjects matched for age and sex. The diagnosis was made according to the MINI questionnaire completed with a standardized research of stressful events and an assessment of anxiety symptoms using different scales: the Hamilton Anxiety rating Scale (HAM-A), the Hospital Anxiety and Depression scale (HAD), The Penn-State Worry Questionnaire (PSWQ), the Positive and Negative Emotionality scale, 31 items (EPN-31 scale) and the State-Trait Anxiety Inventory (STAI-S). RESULTS: Life events in relation to work were the most frequent (43%). In terms of symptomatology, results showed that ADA is associated with a level of anxiety close to those obtained in other anxiety disorders, particularly GAD, in relation to general symptoms (physical and somatic) as well as anxious rumination and negative emotions. CONCLUSION: Further research is needed to better understand the disorder and clarify its frontiers, which still remain a controversial issue with regard to the homeostatic response to stress and other types of anxiety disorders. The results of our study suggest that this sub syndromic entity should be recognized and adequately treated, especially in general practice where it is very common.

[Efficacy of a cognitive-behavioral group therapy in patients with fear of blushing]. / Résultats d'une thérapie comportementale et cognitive de groupe spécifique de l'éreutophobie.

INTRODUCTION: Cognitive behavioral therapy (CBT) has shown to be effective in the treatment of social anxiety disorders (SAD). However, fear of social blushing is almost never measured as a therapeutic outcome variable, even though some data suggest that this dimension constitutes a specific syndrome in social anxiety spectrum, justifying specific therapeutic strategies. For these reasons, we developed a group therapy program including a combination of task concentration training (TCT) and other CBT strategies targeting fear of blushing. AIM: We aimed to investigate the efficacy of this program in an open trial conducted in 55 patients suffering from SAD (Diagnostic and statistical manual of mental disorders IV criteria) with fear of blushing. METHOD: Throughout a program including eleven weekly sessions, systematic measurements of fear of blushing and other anxiety and personality dimensions were performed at inclusion, at the end of the therapy and 3 months later, in order to explore the therapeutic effects of the program on fear of blushing, social anxiety, and other dimensions (Liebowitz social anxiety scale, blushing propensity questionnaire, Rathus assertiveness scale, Rosenberg self-esteem scale, Hospital anxiety and depression scale, Sheehan disability scale). The statistical analyses compared the scores of all measurements at inclusion, at the end of the therapy, and 6 months later. We also calculated the effect size obtained after treatment, and performed a logistic regression to determine the factors associated with a remission of fear of blushing after therapy. RESULTS: The main outcome criterion - the Salpêtrière fear of blushing questionnaire (SFBQ) score - was significantly reduced after treatment (P<0.001) and remained stable at follow up. A satisfying effect size was obtained on this score after treatment (1.7), and 57.6% of subjects were considered in remission on the basis of a SFBQ score of 6 or less. Other measurements of blushing propensity, social anxiety, assertiveness, self-esteem, anxiety, depression and disability showed significant improvement after treatment and reductions remained stable at 3-month follow-up. To be a female and to have a low SFBQ score at inclusion appeared as two independent predictors of good improvement. DISCUSSION: Despite the preliminary nature of this study, our results suggest the efficacy of this specific group therapy program for erythrophobia. Further controlled and comparative trials are now required to confirm the program efficacy including a comparison between group and individual therapies.

Efficacy and specificity of computer-assisted cognitive remediation in schizophrenia: a meta-analytical study.

BACKGROUND: Cognitive remediation is frequently based on computerized training methods that target different cognitive deficits. The aim of this article was to assess the efficacy of computer-assisted cognitive remediation (CACR) in schizophrenia and to determine whether CACR enables selective treatment of specific cognitive domains. METHOD: A meta-analysis was performed on 16 randomized controlled trials evaluating CACR. The effect sizes of differences between CACR and control groups were computed and classified according to the cognitive domain assessed. The possible influences of four potential moderator variables were examined: participants' age, treatment duration, weekly frequency, and control condition type. To test the domain-specific effect, the intended goal of each study was determined and the effect sizes were sorted accordingly. The effect sizes of the cognitive domains explicitly targeted by the interventions were then compared with those that were not. RESULTS: CACR enhanced general cognition with a mean effect size of 0.38 [confidence interval (CI) 0.20-0.55]. A significant medium effect size of 0.64 (CI 0.29-0.99) was found for Social Cognition. Improvements were also significant in Verbal Memory, Working Memory, Attention/Vigilance and Speed of Processing with small effect sizes. Cognitive domains that were specifically targeted by the interventions did not yield higher effects than those that were not. CONCLUSIONS: The results lend support to the efficacy of CACR with particular emphasis on Social Cognition. The difficulty in targeting specific domains suggests a 'non-specific' effect of CACR. These results are discussed in the light of the possible bias in remediation tasks due to computer interface design paradigms.

Prevalence, characteristics and comorbidities of anxiety disorders in France: results from the "Mental Health in General Population" survey (MHGP).

PURPOSE: Only a few European countries have carried out large, community-based, national surveys about psychiatric morbidity. Here is presented the first national French survey, aiming to estimate the prevalence of anxiety disorders and associated comorbidities according to sociodemographic characteristics. MATERIALS AND METHODS: The Mental Health in General Population (MHGP) database is derived from a representative national survey of the French adult population (n=36,105), conducted between 1999 and 2003. Data collection was done using an anonymous face-to-face interview. The presence of anxiety disorders (generalized anxiety disorder, panic disorder, agoraphobia, social phobia and post-traumatic stress disorder) was assessed using the Mini International Neuropsychiatric Interview. RESULTS: The overall prevalence of anxiety disorders was estimated to be 21.6%, generalized anxiety disorder being the most prevalent one (12.8%). Women, young people, and people earning low income were identified as the more at risk. Major depressive episode, alcohol abuse and drug addiction frequently co-occur with anxiety disorders (28.3, 4.4 and 2.8% respectively). CONCLUSION: The MHGP study showed that anxiety disorders are highly prevalent in France with a high frequency of comorbidities. Our results highlight the need for considering anxiety disorders as a public health priority in France as well as in other European countries.

[Sociodemographic profiles, addictive and mental comorbidity in cannabis users in an outpatient specific setting]. / Facteurs sociodémographiques, conduites addictives et comorbidité psychiatrique des usagers de cannabis vus en consultation spécialisée.

CONTEXT: In the 1990s, cannabis consumption in France increased considerably. So, in 10 years, the number of adolescents reporting regular cannabis use (10 or more times during the last 12 months) tripled. In 2004, an official program to address problems related to cannabis addiction was implemented. As part of this program, specific outpatient settings for cannabis use disorders were created. OBJECTIVE: We present the sociodemographic characteristics, the prevalence of cannabis, alcohol and others psychoactive substances and the prevalence of mental disorders in 90 cannabis users seen at an outpatient specific setting for cannabis use disorders in the Lariboisière hospital (a university hospital in Paris). MEASURES: Twelve months prevalence of substance abuse and dependence, psychiatric diagnoses based on the DSM-IV and the Mini-International Neuropsychiatric Interview (MINI) results are described. RESULTS: The study population had the following characteristics: 67% male, mean age 27.5 (S.D.=8.4) years and 59% single or divorced. Approximately, two-thirds of the users (67%) were students or currently working and 32% were unemployed. Twenty-two percent of the cannabis users received unemployment, welfare or disability benefits and 11% declared no source of revenue. Most of the users (63%) decided on their own to seek care at the setting. Seventy-three percent of the subjects had seen a psychologist or a psychiatrist in the past, with or without relation to cannabis use. By far, most of the users were cannabis dependent (82%) and 9% cannabis abusers in the last 12 months according to DSM-IV criteria prior to their visit. Seven percent of the cannabis users had alcohol dependence and 7% were abusers. The 12 months prevalence of cocaine or ecstasy dependence was 2% and the prevalence of benzodiazepines, heroin or stimulants dependence 1%. The main substances used over lifetime were tobacco (99%); alcohol (96%); cocaine (41%); benzodiazepines and hypnotics (41%); ecstasy (40%) and heroin (23%). Four percent of cannabis users had a history of intravenous drug use. The main consumption mode of cannabis in France is the blunt. About three-quarters of the consumption is in the form of resin (hashish) and one-quarter as marijuana (grass). The average consumption of cannabis in the last six months was equivalent to 5.8 blunts per day (S.D.=4.4) and 12 g per week (S.D.=10.5), and the average monthly cost was 159 euro (S.D.=133) (234 USD, S.D.=196). The prevalence of psychiatric disorders according to DSM-IV criteria in the sample is high. A current mood disorder was present in 48% and an anxiety disorder in 55% of the cannabis users in the last 12 months. The prevalence of affective disorders in the last 12 months was major depressive disorder (38%), dysthymia (19%), hypomania (3%) and mania (1%). The prevalence of anxiety disorders in the last 12 months was social phobia (29%); generalised anxiety disorder (17%); panic disorder with or without agoraphobia (16%); obsessive compulsive disorder (12%); agoraphobia without panic disorder (9%) and post-traumatic stress disorder (5%). The prevalence of schizophrenia was 4%. The prevalence of bulimia was 4% and no anorexia. Women are more likely to report an affective disorder (64% versus 41%; p=0.04) or a post-traumatic stress disorder (17% versus 0%; p<0.001) in the last 12 months. The prevalence of family history for psychiatric disorders was 52% and for addiction, 59%. CONCLUSIONS: The cannabis users seen in our specific setting are a fairly homogeneous group and for the most part addicted to cannabis only, but with very high rates of dependence. Indeed, other than tobacco dependence, 80% of the users were only dependent on, or abused on cannabis in the last 12 months. In comparison with the cohort of French cannabis users (n=4202) seen at specific outpatient settings for marijuana users in 2005, cannabis users seen in Lariboisière Hospital are older, the percentage of females is greater, they are more dependent on marijuana and have a high prevalence of affective and anxiety disorders.

Psychometric properties of a French version of the junior temperament and character inventory.

The junior temperament and character inventory (JTCI) has been developed for the assessment of temperament and character dimensions in childhood based on Cloninger's model of personality. We evaluated the psychometric proprieties of a French child and parent-rated version of the JTCI based on a previous German version, and assessed the correlations between the JTCI dimension scores and the scores on the child behavior checklist (CBCL) in a community sample of French children and adolescents aged 10-16 years. We used data from 452 child-rated and 233 -parent-rated JCTI. The psychometric properties (internal consistency and external validity in relation to the emotionality activity sociability (EAS) questionnaire) of the French JTCI were adequate in the parent-rated version. The parent-rated JTCI had overall better psychometric qualities than the child-rated version, but for both versions of the JTCI the confirmatory factor analysis showed low fit between the observed data and the original model. Dimensions of the EAS model were significantly correlated with the temperament scales of the JTCI. Further studies are required to improve the psychometric properties of the child-rated JTCI, and to provide insight about lacking fit of our data with the theoretical model.

[Severe depression : which concept ? which criteria]. / Les dépressions sévères : quels concepts ? quels critères ?

Depression is a common disorder considered to be a serious public health problem although clinicians encounter very different levels of severity and the treatment strategies are tailored according to this variability. There are however no consensus criteria to define severe depression. This review presents and discusses the different possible qualitative and quantitative options. In the international classifications there are three levels of severity of episodes of major depression (mild, moderate, severe), which are defined above all on the number of diagnostic criteria found. There are other more qualitative severity factors : the presence of psychotic symptoms, melancholia and the presence of endogenous signs. Pronounced psychomotor retardation and risk of suicide are amongst the main clinical severity markers. Quantitative assessment scales for the severity of depression can also define severity thresholds for use for example in clinical studies. These thresholds are still poorly defined and vary between studies. Specific severity scales for melancholic depression or depression with psychomotor retardation can also be used in clinical studies for these factors, which are central to the concept of severe depression. Overall, the inclusion criteria for most studies combine severe depression with qualitative (clinicians' judgement) and quantitative (minimum score on a scale) aspects.

A multidisciplinary study of patients with early-onset PD with and without parkin mutations.

OBJECTIVE: To establish phenotype-genotype correlations in early-onset Parkinson disease (EOPD), we performed neurologic, neuropsychological, and psychiatric evaluations in a series of patients with and without parkin mutations. BACKGROUND: Parkin (PARK2) gene mutations are the major cause of autosomal recessive parkinsonism. The usual clinical features are early-onset typical PD with a slow clinical course, an excellent response to low doses of levodopa, frequent treatment-induced dyskinesias, and the absence of dementia. METHODS: A total of 44 patients with EOPD (21 with and 23 without parkin mutations) and 9 unaffected single heterozygous carriers of parkin mutations underwent extensive clinical, neuropsychological, and psychiatric examinations. RESULTS: The neurologic, neuropsychological, and psychiatric features were similar in all patients, except for significantly lower daily doses of dopaminergic treatment and greater delay in the development of levodopa-related fluctuations (p < 0.05) in parkin mutation carriers compared to noncarriers. There was no major difference between the two groups in terms of general cognitive efficiency. Psychiatric manifestations (depression) were more frequent in patients than in healthy single heterozygous parkin carriers but did not differ between the two groups of patients. CONCLUSION: Carriers of parkin mutations are clinically indistinguishable from other patients with young-onset Parkinson disease (PD) on an individual basis. Severe generalized loss of dopaminergic neurons in the substantia nigra pars compacta in these patients is associated with an excellent response to low doses of dopa-equivalent and delayed fluctuations, but cognitive impairment and special behavioral or psychiatric symptoms were not more severe than in other patients with early-onset PD.

[Efficacy and tolerability of escitalopram in anxiety disorders: a review]. / Efficacité et tolérance de l'escitalopram dans les troubles anxieux: revue de la littérature.

INTRODUCTION: Anxiety disorders are highly prevalent and disabling disorders, for which selective serotonin reuptake inhibitor (SSRI) antidepressants are an effective treatment. Escitalopram is the most selective SSRI available. Beyond its well-established efficacy in depression with or without anxiety, preclinical studies have demonstrated that escitalopram has a broad spectrum of anxiolytic activity. AIM OF THE REVIEW: This review focuses on the therapeutic use and the tolerability issues of escitalopram in the treatment of adult patients with panic disorder, generalized anxiety disorder (GAD), social anxiety disorder, and obsessive-compulsive disorder (OCD), on the basis of numerous recent short-term and long-term controlled studies in these disorders. In a 10-week randomised, double-blind trial in patients with panic disorder, escitalopram (flexible doses 5-10 mg/d) was significantly more effective than placebo in reducing the panic attack frequency, with a faster onset of action than citalopram. Fifty percent of escitalopram recipients and 38% of placebo recipients experienced no panic attacks, with a similar incidence of the most common adverse events for both groups. LITERATURE FINDINGS IN PD: In an open-label study in elderly (>65 years) patients with panic disorder, improvement in panic attack frequency and secondary efficacy variables occurred more rapidly in escitalopram than citalopram recipients. LITERATURE FINDINGS IN GAD: In four double-blind, comparative, eight- to 12-week studies in patients with GAD, escitalopram was more effective than placebo and at least as effective as paroxetine in reducing the mean Hamilton Rating Scale for Anxiety total score. Escitalopram 10-20 mg/d demonstrated continued efficacy in a 24-week extension study of short double-blind trials and in a placebo-controlled, double-blind, 24/76-week relapse-prevention study. In this trial, escitalopram recipients showed a significantly longer time to relapse and reduced risk of relapse than placebo recipients, and the risk of relapse was 4.04 times higher in the placebo group than in the escitalopram group. Escitalopram was well tolerated and only 7% patients withdrew, due to adverse events in the escitalopram group, versus 8% in the placebo group. LITERATURE FINDINGS IN SOCIAL PHOBIA: In two randomised, double-blind, 12- and 24-week studies in patients with social anxiety disorder (social phobia), escitalopram 10-20 mg/d was generally more effective than placebo and at least as effective as paroxetine in reducing the mean Liebowitz Social Anxiety Scale total scores. In a 24-week double-blind, placebo-controlled relapse-prevention study, escitalopram recipients had a longer time to relapse and reduced risk of relapse compared with placebo recipients, and significantly fewer escitalopram than placebo recipients relapsed (22% versus 50%). In these studies, the treatment effects of escitalopram were independent of gender, symptom severity and chronicity, and comorbid depressive symptoms, and the drug was tolerated well. LITERATURE FINDINGS IN OCD: Finally, in patients with OCD, escitalopram 20mg/d for 12 weeks was more effective than placebo, and at least as effective as paroxetine 40 mg/day, with respect to a mean reduction from baseline in the Yale-Brown Obsessive Scale total score. In a 24-week, randomised, placebo-controlled relapse-prevention study, the proportion of patients who relapsed in the escitalopram group (23%) was 2.74 times lower than in the placebo group (52%). In both groups, the majority of adverse events reported were mild to moderate. CONCLUSION: On the whole, numerous clinical data indicate that escitalopram, 10-20 mg/d, is an effective and well-tolerated first-line treatment option for the management of panic disorder, GAD, social anxiety and OCD. Beyond short-term demonstrations of efficacy in these disorders, several controlled relapse-prevention studies showed the necessity and utility of maintaining the treatment six months or more after the remission has been obtained.

A challenging task for assessment of checking behaviors in obsessive-compulsive disorder.

OBJECTIVE: The present study concerns the objective and quantitative measurement of checking activity, which represents the most frequently observed compulsions in obsessive-compulsive disorder (OCD). To address this issue, we developed an instrumental task producing repetitive checking in OCD subjects. METHOD: Fifty OCD subjects and 50 normal volunteers (NV) were administered a delayed matching-to-sample task that offered the unrestricted opportunity to verify the choice made. Response accuracy, number of verifications, and response time for choice taken to reflect the degree of uncertainty and doubt were recorded over 50 consecutive trials. RESULTS: Despite similar levels of performance, patients with OCD demonstrated a greater number of verifications and a longer response time for choice before checking than NV. Such behavioral patterns were more pronounced in OCD subjects currently experiencing checking compulsions. CONCLUSION: The present task might be of special relevance for the quantitative assessment of checking behaviors and for determining relationships with cognitive processes.