Predictive factors for the outcome of emotional and/or behavioural disorders in 18- to 48-month-old children after parent-child psychotherapy: Protocol of a European prospective cohort study.

OBJECTIVES: Several studies have shown that in young children, behavioural and/or emotional disorders are more difficult to manage than regulatory disorders. Moreover, data are lacking on outcome predictive factors. This article presents a short synthesis of previous research about outcome predictive factors in child psychiatry. It also describes the protocol of a longitudinal observational European multicentre study the main objective of which was to identify predictive factors of behavioural and emotional disorder outcome in toddlers after parent-child psychotherapy. The secondary objectives were to study predictive factors of the outcome in parents (anxiety/depression symptoms) and parent-child relationship. METHOD: In order to highlight medium-effect size, 255 toddlers (age: 18 to 48 months) needed to be included. Outcomes will be assessed by comparing the pre- and post-therapy scores of a battery of questionnaires that assess the child's symptoms, the parents' anxiety/depression, and the parent-child relationship. Multivariate linear regression analysis will be used to identify predictive factors of the outcome among the studied variables (child age and sex, socio-economic status, life events, disorder type, intensity and duration, social support, parents' psychopathology, parents' attachment, parent-child relationships, therapy length and frequency, father's involvement in the therapy, and therapeutic alliance). EXPECTED RESULTS AND CONCLUSION: This study should allow identifying some of the factors that contribute to the outcome of externalizing and internalizing disorders, and distinguishing between pre-existing and treatment-related variables. It should also help to identify children at higher risk of poor outcome who require special vigilance on the part of the therapist. It should confirm the importance of therapeutic alliance. TRIAL REGISTRATION: ID-RCB 2008-A01088-47.

[Catatonia in a 14 year-old girl: treatment with clorazepam and carbamazepine, a 10-year follow-up]. / Catatonie chez une adolescente de 14 ans: traitement par clorazépam et carbamazépine et évolution à dix ans.

INTRODUCTION: Child and adolescent catatonia has been poorly investigated. Moreover, diagnosis criteria only exist for adult psychiatry, and there are no therapeutic guidelines. The aim of this paper is to describe the case of a 14-year-old girl presenting an overlap between psychogenic and neuroleptic induced catatonia, acute treatment and ten year's follow-up. CASE REPORT: A 14-year-old Caucasian French girl, Elsa, was admitted in February 1998 to a University adolescent mental health center with an acute psychotic disorder. She showed agitation, impulsivity (sudden engagement in inappropriate behaviour), paranoid delusions, visual and auditory hallucinations, diurnal and nocturnal urinary incontinence, lack of self-care, inadequate food intake because of fear of poisoning, and vomiting after meals leading to rapid weight loss of 5 kg. Clinical examination, laboratory tests, EEG and RMI were normal. Toxicological tests were negative. Her IQ, assessed six months before admission, was in the dull average range (70-75). Elsa was treated with loxapine 150 mg per day for one week without improvement and this was then replaced by haloperidol 30 mg per day. One week after the start of haloperidol her agitation, impulsivity, and hallucinatory symptoms decreased. Twenty four days after loxapine introduction and 17 days after the haloperidol, her condition deteriorated rapidly over less than 48 hours. She exhibited immobility, minimal response to stimuli, staring and catalepsy with waxy flexibility. The diagnosis of catatonia was established. Examination revealed tremulous extremities, tachychardia (110 pm) and apyrexia. Creatine phosphokinase levels were 106 UI/l (normal range 0-250). Human immunodeficiency virus, hepatitis, listeria and Lyme serology were negative. Cerebrospinal fluid analysis was normal. Haloperidol was stopped and intravenous clonazepam 5mg/kg was begun. It was not possible to obtain signed consent from the two parents for Electroconvulsive therapy. The patient was transferred to a pediatric intensive care unit. The treatment was standard parenteral nutrition, nursing, intravenous clonazepam 0.05 mg/kg, with regular attendance by a child psychiatrist. Elsa stayed three weeks in this condition. She then began to notice the child psychiatrist, and a few days later she was able to carry out simple requests. Elsa was transferred to an adolescent psychiatric unit. As soon as she could eat by herself again, carbamazepine 400mg per day was begun. Her agitation reduced at a carbamazepine level of 7 mg/l. One month later her condition was stable. However, language difficulties persisted for a further six months. One year after the episode she scored 66 on a repeat IQ test and her RMI was normal. She exhibited no significant residual symptoms except some cognitive impairment. She integrated into a special education facility. These attempts to stop the carbamazepine were followed by depressed mood, aggressiveness and impulsivity; carbamazepine was finally stopped successfully after seven years. Ten years later, Elsa is the mother of two young children and is able to take care of them. She has never had a relapse of her psychotic disorder or catatonic state. DISCUSSION: The etiopathogenic diagnosis is problematic. Some indices in the familial history may suggest a traumatic event. But one to the total residual amnesia it was never confirmed, and traumatic catatonia are extremely rare. Normal CPK levels, with autonomic disturbance limited to tachycardia and the lack of resolution after discontinuance of medication, argues against a diagnosis of neuroleptic malignant syndrome (NMS). But CPK levels are non specific, and NMS without pyrexia has been described. The occurrence of the catatonic syndrome 21 days after the first dose of a neuroleptic could be diagnostic. This case involved a non organic catatonic psychosis followed by neuroleptic induced catatonia. Catatonia is described as a risk factor for the development of NMS and some consider NMS to be a variant of malignant catatonia. The interest of this report is (1) it reinforces the need to be cautious before prescribing neuroleptics in adolescents presenting with symptoms of catatonia; (2) the complete recovery from catatonia after treatment with intensive care and more than three weeks of intravenous clonazepam without the use of ECT and (3) the effectiveness of carbamazepine over a long period of follow-up. Although trials on carbamazepine in catatonia are published, there are no data available for the control of residual symptoms or the long term prognosis, especially in child and adolescent psychiatry.

Whole blood serotonin content, tryptophan concentrations, and impulsivity in anorexia nervosa.

BACKGROUND: We hypothesized that anorectics with or without bulimic features would differ on impulsivity and indices of central serotoninergic function (high impulsivity being correlated with reduced serotoninergic function). METHODS: For all patients impulsivity rating scales and questionnaires detailing severity of eating disorder were assessed, and whole blood serotonin concentration (5-HT), free and total tryptophan (TT) concentrations, and large neutral amino acids (LNAA) were assayed. RESULTS: Nineteen patients with anorexia nervosa were included, 10 presented associated bulimic features and nine did not. Twelve healthy matched controls were also included. Our hypothesis was not verified. However, tryptophan concentration and the ratio of tryptophan concentration to LNAA allow us to separate controls from anorectics, whereas 5-HT concentration does not. Two significant and positive correlations were found: between impulsivity and anxiety in the total anorectic population, and between anxiety and serotonin in the impulsive group. CONCLUSIONS: All measured peripheral biologic indices except 5-HT concentration may be of interest in this pathology. Impulsivity and anxiety seem to be two personality components involved in anorexia nervosa. This study lead us to the necessity of redefining impulsivity in anorexia nervosa.

Tryptophanemia and tyrosinemia in adolescents with impulsive behavior.

Tryptophan (TRP) and tyrosine (TYR), respectively the circulating precursors of the central serotonergic (5-HT) and catecholamine systems, were measured in eight adolescents with impulsive behavior regardless of the exact type of disorder. The 6 week study period included weekly blood sampling and clinical evaluation. The ratios of TRP and TYR to large neutral amino acids (LNAA), which indicate the availability for the synthesis of neurotransmitters, were calculated. Comparison of results with eight hospitalized controls of the same age (12.5 to 18 years) revealed lower total TRP levels in four adolescent patients, a lower TRP/LNAA ratio in three adolescents, and a lower free TRP concentration in six adolescents with discretely enhanced albuminemia. A slight increase in TYR and the TYR/LNAA ratio was noted in nearly all of the adolescent patients. Despite the heterogeneity of individual biological results, the impulsive behavior subjects in this study seemed to present abnormalities in neurotransmitter precursors.

Relationship between impulsivity and platelet serotonin content in adolescents.

The relationship between impulsivity and serotonin function was explored in impulsive and non-depressed adolescents. Platelet serotonin content was chosen as a peripheral indicator of central serotonin function. Impulsivity was assessed with a questionnaire. All measures were performed once a week over a 6-week period for all subjects. Subjects comprised eight adolescent inpatients who were hospitalized as a result of their impulsive acts and eight healthy age- and sex-matched control subjects. Mean platelet serotonin concentration was significantly higher in the impulsive group than in the control group. Platelet serotonin concentration was positively correlated with the intensity of impulsivity in the patient group.

The composite scale of morningness: further psychometric properties and temporal stability.

OBJECT: To assess the temporal stability of the French version of the Composite Scale of Morningness (CSM), and to replicate our previous findings in an independent sample in order to confirm the good internal properties of this instrument. METHOD: Sixty nursing students (11 males and 49 females) filled out the Composite Scale of Morningness on two occasions over a 13-month period. RESULTS: The scale's reliability is high: Cronbach's alpha = 0.874 in males and 0.904 in females. The CSM total scores are normally distributed and independent of gender. They do not differ between occasions, and are highly correlated: r = +0.885 in males and r = +0.930 in females. CONCLUSION: The French version of the CSM is stable over time and psychometrically reliable. These are the characteristics of a personality trait. Further studies should explore its personality, biological and genetic correlates.

Psychometric properties of the French version of the composite scale of morningness in adults.

The objective of this study was to provide a reliable instrument to measure morningness for upcoming studies in French samples, using the Composite Scale of Morningness (CSM), which has been translated into French. Nursing students (n = 356) completed the questionnaire between February and March 1997. The total score obtained was independent of age and gender, and normally distributed. The reliability was high (Cronbach's alpha = 0.85), and factorial analysis confirmed the unidimensionality of the scale. Evening-type subjects are thought to score under 31, and morning-type subjects are thought to score above 44. As an external validation, morningness was associated, on weekdays and weekends, with early rising times and bedtimes and early peak times of physical and mental performance. In conclusion, we found that the English and the French versions of the Composite Scale of Morningness gave identical results. The scale is reliable and can be used for French-speaking adult samples. Nevertheless, normative data and other external validity criteria are needed.

[Neurological tolerance of lithium-psychotropic drugs association (author's transl)]. / Tolerance neurologique de l'association lithium-psychotropes. A partir de 265 cures associatives.

The authors have studied the neurological tolerance from the combination of lithium-psychotropic drugs from 265 associated cures carried out on 132 patients between 1971 and 1978. The risk of neurological inability to assimilate is not greater when haldol is combined with lithium by comparison with other combinations where it is not included. Only the presence of cerebral organicity presents a risk factor. The 117 associated cures were preceded by preliminary treatments during which either the lithium or the psychotropic drugs were used to the same extent during the treatment. This series seems to allow on one hand to demonstrate that the incidence of neurological signs is multiplied by two by the combination, on the other hand to note that the intensity of the neurotoxic effects increases.

[Hysteria in children]. / Hystérie de l'enfant.

Hysteria can be found in childhood but as all nevrotic problems during the life period, it is not a fixed entity and cannot presume for the personality to come. Diagnosis is often difficult and is mostly made in pediatric unit in front of conversions symptomatology. The difference between transitory somatizations (frequent during childhood) and conversions is important to make. As part of the diagnosis, finding the underlying personality is necessary. Hysteria is mostly found during the latency period and around puberty period. Awareness is important when the diagnosis is made, to be sure to recognize all the cases and only the real one. Two common situations could be isolated: 1. when a symptom cannot be related to a somatic disorder; 2. when the seduction behavior of a maiden creates counter-attitudes of the medical team and family.

[Two-dimensional immuno-electrophoresis of cephalospinal fluid proteins wih a study of the IgG/albumin ratio in psychiatry (author's transl)]. / Immunoélectrophorèse bidimensionnelle des protéines du liquide céphalo rachidien (LCR) avec étude du rapport IgG/albumine en psychiatrie.

The purpose of this study (about 187 adult psychiatric patients) is to investigate correlations between "organic brain syndrome" (vascular or abiotrophic) and values of CSF proteins (technique of two-dimensional immunoelectrophoresis). The authors show positive correlations between 'vascular' brain syndrome and increase of one alpha 2 globulin, between 'abiotrophic' brain syndrome and decrease in all globulins, the importance of brain damage and increase of IgG/albumin ratio.

[Clinical significance of the erythro-plasmatic ratio of lithium (author's transl)]. / Signification clinique du rapport érythro-plasmatique du lithium.

Six hundred erythrocyte-plasma lithium ratios have been gathered from 67 patients presenting affective disorders. Ratios values in relapse period are not altered regarding those in remission phase as between periods with neuroleptic associations and those without. Ratios values are not noticeably modified by personality, sex and the evolution of affective disorders. But lithium preventive action is essentially found in patients with high erythrocyte-plasma.