A stenography of empathy: Toward a consensual model of the empathic process.

Empathy has gained popularity in the general population and the scientific world during the past decade. Recently, several researchers found a significant decrease in empathy scores of healthcare students (notably medical students) and recommend promoting empathy skills in several fields of education. The current paper presents a new model of the empathic process: a stenography of empathy compelling scientific data and contemporary conceptions. Indeed, we combined all pioneer researchers' conceptions of empathy (Davis, Decety, Batson, Preston & de Waal) into an integrative model. This model is centered on the empathizer (i.e., a person observing a target experiencing emotions) and displays how all empathy components are articulated, explaining the individuals' general functioning and how the process might become dysfunctional. We illustrated applications of the model with three clinical examples (i.e., burnout, psychopathy, and borderline personality disorders) to display how empathy is related to psychopathological symptoms. We believe this new dynamic and sequential model would be helpful in explaining how empathy works, which is of great interest to healthcare students, clinicians, researchers, and academics.

[When bariatric surgery "bypasses" controlled alcohol consumption]. / Quand la chirurgie bariatrique «bypasse¼ la consommation contrôlée d'alcool.

Obesity is a complex disease with significant morbidity and mortality. Its management is a major health issue. Obesity surgery is currently the most effective treatment for this condition. However, for several years, a link between bariatric surgery and the development of an alcohol use disorder seems to be emerging. As this psychiatric complication has also a high morbidity and mortality rate, it is important to consider prevention tools to limit its occurrence and specific therapeutic approaches for its management.

L'obésité est une maladie complexe associée à une importante morbi-mortalité. Sa prise en charge est un enjeu sanitaire capital. La chirurgie de l'obésité est actuellement le traitement le plus efficace de cette affection. Cependant, depuis plusieurs années, un lien entre la chirurgie bariatrique et le développement d'un trouble de l'utilisation de l'alcool semble se dessiner. Comme cette complication psychiatrique a elle-même une lourde morbi-mortalité, il convient de réfléchir à des outils de prévention visant à en limiter l'apparition et à des approches thérapeutiques spécifiques pour sa prise en charge.

[Tear your eyes out ! A case of bilateral auto-enucleation]. / «Arrache-toi les yeux !¼ À propos d'un cas d'auto-énucléation bilatérale.

Bilateral autoenucleation is an extremely rare form of ocular self-mutilation. This gesture usually occurs in psychotic patients. In a moment of madness, a 28-year-old man brutally tore out both of his eyes. He was in acute relapse of schizophrenia after having interrupted all neuroleptic treatment for 6 months. Four days after admission, surgical enucleation was the only possible outcome. Facing the complexity of this clinical case, the ophthalmologist has a central role in the organization of long-term surgical, neurological and psychiatric care.

L'auto-énucléation bilatérale est une forme d'automutilation oculaire rarissime. Ce geste est observé presque toujours chez des patients psychotiques. Dans un moment de folie, un homme de 28 ans, s'est brutalement arraché les deux yeux. Il se trouvait en rechute aiguë de schizophrénie après avoir interrompu tout traitement neuroleptique depuis 6 mois. Quatre jours après son admission, l'énucléation chirurgicale fut la seule issue possible. Face à la complexité de ce cas clinique, l'ophtalmologue aura un rôle central dans l'organisation des soins chirurgicaux, neurologiques et psychiatriques au long cours.

[«I am not pregnant !¼ About denial of pregnancy ]. / «Je ne suis pas enceinte !¼ A propos du déni de grossesse .

The term «denial of pregnancy¼, although used in current medical practice since 1970, does not yet have a universal definition. The literature allows to define it as «the non-recognition of a pregnancy beyond the first trimester, which can last until delivery and cover it¼. The changes related to pregnancy are biologically reduced or incorrectly perceived or even ignored. Although often wrongly considered as a rare phenomenon, the literature describes it as having a prevalence of 2 to 3 cases per 1.000 viable deliveries. This case report associated with a short review of the literature aims to optimise the clinician awareness, leading to the diagnosis as well as the potential perinatal consequences linked to this phenomenon.

Le terme de «déni de grossesse¼, bien qu'utilisé dans la pratique médicale courante depuis 1970, n'a, à ce jour, pas encore de définition universelle. La littérature permet de le définir comme la «non-reconnaissance d'une grossesse au-delà du premier trimestre, qui peut se prolonger jusqu'à l'accouchement et recouvrir ce dernier¼. Les changements liés à la grossesse sont biologiquement réduits et incorrectement perçus par la femme, ce qui fait passer son évolution sous silence. Bien que souvent considéré à tort comme un phénomène rare, la littérature le décrit, cependant, avec une prévalence de 2 à 3 cas pour 1.000 accouchements viables. Le cas clinique rapporté ici, accompagné d'une revue succincte de la littérature, vise à conscientiser les cliniciens quant aux circonstances de diagnostic d'un déni de grossesse et la morbi-mortalité périnatale qui y est, potentiellement, associée.

[Virtual reality exposure therapy for post-traumatic stress disorders, obsessive-compulsive disorders and anxiety disorders: Indications, added value and limitations]. / La thérapie par exposition en réalité virtuelle pour les états de stress post-traumatiques, les troubles obsessionnels compulsifs et les troubles anxieux : indications, plus-value et limites.

The exposure in cognitive behavioral therapy (CBT) is a well-known intervention, widely investigated in scientific research. Several studies have shown the benefits of this intervention in the treatment of anxiety disorders, obsessive-compulsive disorders (OCD) and post-traumatic stress disorders (PTSD). The different exposure techniques are mainly based on the emotional processing of fear theory and use an emotional stimulation of fear, following by its habituation. However, new approaches have emerged and are based on the inhibitory learning theory. The virtual reality technology allows emotional involvement from patients and represents a complementary approach to the classical modalities of exposure therapy (e.g., mental or in vivo expositions). This modern approach presents specific features that need to be taken into account by the therapist. Firstly, the presence feeling, which is defined as the "be there" feeling. This feeling is dependent on immersive technical features and personality factors. Secondly, virtual reality sickness, similar to motion sickness, represents a limitation that might prejudice a virtual therapy. The main scientific investigations of Virtual Reality Exposure Therapy (VRET) for treating social phobia, specific phobia, PTSD, and panic disorders are encouraging and demonstrate a similar effectiveness between both in vivo and in virtuo exposures. The scarce investigations on generalized anxiety disorders and OCD also suggeste a similar effectiveness between these exposures. However, further scientific investigations are needed to support these preliminary findings. The attrition rates and deteriorating states are similar to classical CBT approaches. Nevertheless, scientific literature presents several limits: 1) much of the research on this topic has interest conflicts (e.g., developers are also authors of a large number of studies); 2) there is a high heterogeneity of materials and virtual environments used; 3) important measures are not always taken into account in scientific research (e.g., the presence feeling); and 4) a massive use of waiting lists as a control measure. Despite these limitations, the VRET have strong silver linings: 1) the easy access to exposure (less limited than standard exposure techniques) and a cost reduction; 2) highly guaranteed security; 3) the anonymization of exposures (i.e., the patients do not risk meeting someone they know during the exposure therapy); 4) the therapist has a greater control of exposures; 5) a standardization of the exposures; 6) a greater involvement in therapy for technophile patients. Virtual exposure also seems to be generally more accepted by patients.

Decline of empathy among medical students: Dehumanization or useful coping process?

OBJECTIVES: Empathy is central in patient-physician interactions and understanding its development is decisive for education. However, scientific literatures report a striking decline of empathy among medical students during their study course. Firstly, we aimed to replicate this result on a Belgian population. Secondly, as well reported by literature, we expected higher empathy scores for women. Lastly, as central, we expected higher empathy levels for medical students than for "control" students (commercial students were used as a control group: social interactions without a curing aspect) at the beginning of their study course, suggesting that empathy drives students to select specific education fields. METHODS: Through a cross-sectional design, we assessed students from medical and commercial educations at different years of study with the Basic Empathy Scale (N=1602). We compared: (1) empathy scores at different scholar levels for both populations; (2) scores between men and women; (3) empathy scores between medical and commercial students in their first year of study. RESULTS: As expected, a significant empathy decline was displayed over time for medical students; women reported significant higher empathy scores than men; and, in their first year, medical students presented significant higher empathy scores than commercials. CONCLUSIONS: Replicating the empathy decline on several student populations is crucial, especially by using different tools. This decline is a multi-factorial process that mainly reflects self-representation changes. The empathy gender bias is a strong effect observed in several empathy-linked phenomena. Finally, empathy is not only central but also drives students to select specific education fields.

[Starving to death : the paradox of anorexia nervosa]. / Avoir faim au risque d'en mourir ? Le paradoxe de l'anorexie mentale.

Anorexia nervosa is a complex pathology that regularly leads clinicians to a therapeutic impasse. The origin of this disorder is multifactorial. It occurs most often in adolescence and affects mainly women. Paradoxically, hunger is present but dissociated from adequate food function. Somatic and psychological impact can be particularly heavy. The treatment is difficult and requires a multidisciplinary care. An eclectic and integrative approach, moving away from rigid therapeutic methods and integrating the plurality of techniques, seems to be particularly recommended to increase the chances of therapeutic success. This article summarizes the various theoretical models of anorexia nervosa and its modalities of treatment.

L'anorexie mentale est une pathologie complexe qui entraîne régulièrement les cliniciens dans une impasse thérapeutique. L'origine de ce trouble est plurifactorielle. Il survient le plus souvent à l'adolescence et touche principalement les jeunes femmes. Paradoxalement, la sensation de faim est présente, mais elle n'est plus au service d'une fonction nutritive adéquate. Les répercussions somatiques et psychiques peuvent être particulièrement lourdes. Le traitement de l'anorexie mentale reste difficile et nécessite une prise en charge pluridisciplinaire. Une approche éclectique et intégrative, s'écartant de méthodes thérapeutiques rigides et intégrant la pluralité des techniques, semble être particulièrement recommandée pour accroître les chances de succès thérapeutique. Cet article résume les différents modèles théoriques de l'anorexie mentale et ses modalités de prise en charge.

[Clinical study of the month: depressive pseudo-dementia]. / Le cas clinique du mois. Pseudo-démence dépressive.

We report the case of a man aged 62 suffering from a known type I bipolar disorder and referred by his attending psychiatrist because of a state of spatiotemporal disorientation, confusion and prostration evoking significant neurologic impairment. The interest of this case report is in the use of the 18-FDG PET-Scanner, which is increasingly widespread in clinical psychiatry, to support the differential diagnosis between a psycho-organic pathology like dementia or a functional psychiatric pathology like depressive pseudo-dementia (also named melancholic dementia), in which some patterns of dysfunction can now be identified by functional imaging.

[Can we treat sexual addiction ?]. / L'addiction au sexe, ça se soigne?

Sexual addiction or sexual dependence is characterized by hypersexuality, impaired regulation of sexual desire and sexual compulsivity, including having sex with uncontrolled excessive frequency (5 to 15 sexual acts per day for more than 6 months, from 15 years old). Between 3% and 6% of the adult population (> or =18 years) would have the characteristics of sexual addiction, disorder prevalent in the male population. The addictive processes affect three behavioral domains : motivation-reward, affect regulation and behavioral inhibition. Sex addiction is usually accompanied by other addictions, such as abuse of drugs or alcohol or sex toys that enhance sexual performance. Psychiatric comorbidities can be found : anxiety disorders, mood disorders. Several forms of treatment have been tried, using medication, cognitive-behavioral therapy and psychotherapy sessions alternated with exposure therapy in virtual reality. In this article, we will discuss the multiple definitions of hypersexuality and the possibilities of therapeutic approaches.

[Internet addiction? A new form of behavioral dependence?]. / Cyberdépendance? Une nouvelle forme d'addiction comportementale ?

The speed of development of new technologies of information and communication (I.C.T.) modified the mode of our intersubjective relations leading certain individuals to develop new forms of behavioral dependence. If the majority of the users consume the Internet with moderation, 1 to 2% of the general population would suffer from "problematic use of the Internet" and /or of "lnternet addiction". These figures are to be taken with caution because of the lack of reliable epidemiologic data. If, beside the classical forms of addictions to the psychoactive substances, the concept of "addictions without drugs" is more and more the subject of scientific works, it is appropriate, however, not to call pathological all these new behaviours. We will approach in this article the clinical reality related to the problematic or abusive use of new technologies with or without the Internet. We will then describe the possible therapeutic approaches that is ambulatory or in the form of day-hospitalization. Lastly, we will conclude with some recommendations to the attention of the relatives or the close friends.

Evidence that the Two-Way Communication Checklist identifies patient-doctor needs discordance resulting in better 6-month outcome.

OBJECTIVE: To assess an intervention aimed at reducing patient-professional carer needs discordance. METHOD: In a group of 460 patients with schizophrenia, the Two-Way Communication Checklist (2-COM), an instrument to rate needs, was completed at baseline, 2 months and 6 months by both the patient and the professional carer, allowing for the quantification of patient-carer needs discordance. RESULTS: Reduction in patient-reported 2-COM needs in the group with low baseline needs discordance was much greater at 2 and 6 months (2 months: beta = -0.65, P < 0.001; 6 months: beta = -1.00, P < 0.001) than in the group with high baseline discordance (2 months: beta = -0.35, P < 0.001; 6 months: beta = -0.49, P < 0.001). Reduction in needs discordance between baseline and 2 months (beta = -0.07, P = 0.004) as well between 2 and 6 months (beta = -0.05, P = 0.020) was associated with greater levels of CGI clinical improvement. CONCLUSION: The fact that patient-carer needs discordance impacts negatively, and its reduction positively, on 6-month outcome suggests that systematic inventory of patient-carer views on needs is necessary.

[When depression does not end. Resistant depression: recent clinical and therapeutic aspects]. / "Quand la dépression n'en finit pas... " Stratégies actuelles et perspectives thérapeutiques de la dépression résistante.

All over the world, depression represents a major public health issue. According to WHO, it is the fifth disease in the world (in years of illness), the second for people aged 15 to 44 and by 2020, it could become the second in the whole world population after cardiovascular diseases. Although increasingly safer and more efficient antidepressants are available, physicians are frequently confronted with the problem of resistant depression. Indeed, an estimated 30 to 45% of patients treated for major depressive disorder have either a partial response or no response at all to the antidepressive treatment. Residual symptoms are very common. Besides usual strategies such as lithium or thyroid hormones adding, some new approaches are now being used to improve the treatment of resistant depression. These are in particular pharmacological strategies such as switching or augmentation, psychotherapy and cerebral stimulation technology. This article reviews the latest clinical and therapeutic aspects of resistant depression.

[Borderline personality disorder: clinic approach of a psychopathology "without limits"]. / La personnalité borderline: clinique d'une psychopathologie "sans limites".

The borderline personality disorder is a common psychiatric entity, which is characterized by a varied symptomatology and a significant comorbidity. It seems that its etiologic is heterogeneous, comprising psychosocial factors as much as biological and genetic. So the best approach of the borderline personality disorder would be a multidisciplinary bio-psycho-social one. Through a clinical case, we illustrate this disorder and its treatment in outpatient clinic.

[Anemia by self-injury: the Lasthenie de Ferjol syndrome]. / L'anémie par spoliation sanguine volontaire: le syndrome de Lasthénie de Ferjol.

Patients with factitious disorders need to be ill and to defy physicians. These syndromes are difficult to diagnose because of the permanent disorder appearing inside the therapeutic relation. The case of a young woman who presents with a factitious anemia, also called Lasthenie de Ferjol syndrome, shows the complexity of such psychosomatic symptoms.

[Depression and coronary artery disease]. / Dépression et maladies coronariennes: quand les emotions nous brisent le coeur....

Depression and cardiovascular diseases represent a major public health problem worldwide. Recent studies have shown that depression is a risk factor for the development of coronary artery disease (CAD) in healthy people and also increases morbidity and mortality in depressed patients with CAD. Others studies have shown that selective serotonin inhibitors (SSRIs) constitute a safe and effective treatment for depressed patients with heart disease. There are also data suggesting that treating depression with SSRIs has a protective role in myocardial infarction and may improve outcomes, including mortality.

["Take this heart away!": from fear of rejection to post-transplant delirium]. / "Arrachez-moi ce coeur!": de la crainte du rejet au délire après transplantation cardiaque.

Orthotopic heart transplantation is a major surgical intervention inducing conscious and unconscious psychological distress. Though all reports indicated global improvement of quality of life from pre- to post-transplantation, most retrospective and longitudinal studies found a high prevalence of psychopathology before and after surgery. Post-operative acute psychotic disorders are uncommon but they severely hamper the medical progress and require an immediate psychiatric assistance. The case of Pascal, a young receiver who presented a brief persecution delusional disorder after the first transplantation, showed the dramatic character of such unexpected symptoms.

[Influence of heredity, sex and season on the type of episode of bipolar disorder]. / Influence de l'hérédité, du sexe et de la saison sur le type d'épisode dans le trouble bipolaire.

The aim of this work was to investigate if sex, age, family history, season and hypothyroidism have any influence on the type of episodes (manic, depressive, mixed) seen in bipolar patients. This retrospective study concerns a sample of 208 patients with a diagnosis of bipolar disorder (type I or II), who were admitted in one of two psychiatric centers between July 1996 and June 2000. The sex-ratio was 2.8 females for 1 male. Sex, family history and hypothyroidism were not associated with any type of episode. A higher percentage of depressive episodes was observed in the patients who were older than 50 and the average age of depressive patients was higher than that of other patients. There was no seasonal pattern in this study and the season did not influence the type of episode. The results indicate no influence of sex, season, family history and hypothyroidism on the type of episode presented. On the opposite, age seems to favour depression episode.

Psychological evolution and assessment in patients undergoing orthotopic heart transplantation.

BACKGROUND: Orthotopic heart transplantation (OHT) is a major surgical intervention inducing distress and anxiety. Psychiatric evaluation of organ transplant candidates is now routinely proposed. This study purposed to assess the psychological evolution in patients having received psychological and/or psychiatric assistance before and during 1-6 postoperative months. METHODS: Twenty-two consecutive transplant candidates were psychically evaluated as part of the preoperative protocol. In the waiting period, 1 and 6 months after OHT, they were asked to fill out the following questionnaires: the General Health Questionnaire, the Spielberger's State-Trait Anxiety Inventory, the Beck Depression Inventory, the Perceived Social Support Scale, the Toronto Alexithymia Scale and the Personal Reaction Inventory. RESULTS: A DSM-IV Axis I diagnosis was found in nine patients (41%); four patients (18%) presented with an Axis II diagnosis. One month after OHT, scores of depression, anxiety and general health significantly improved, while scores of social support, alexithymia and social desirability did not differ. In the sixth postoperative month, all psychological scores remained stable. CONCLUSIONS: A high prevalence of preoperative psychopathology was reported in 22 candidates who received OHT. Surgical intervention obviously improved the quality of life after cardiac transplantation. If the impact of psychological and/or psychiatric aid remains difficult to appraise, these results emphasize the positive impact of surgery on psychological status and the appropriateness of the psychosomatician's social support intervention on patients facing the transplant process.

Psychological distress of surgical patients after orthotopic heart transplantation.

Orthotopic heart transplantation (OHT) is a major surgical intervention inducing distress and anxiety. Psychological problems after OHT have been described in many studies. Little is known, however, about the relationship between the psychological state of the patient and time after surgery. The present study involved 41 consecutive OHT patients that underwent transplantation from January 1991 to December 1992, with a retrospective review of pretransplant psychiatric evaluations to define a Diagnostic and Statistical Manual of Mental Disorders, 3rd edn., revised (DSM III-R) Axis I diagnosis. Patients completed the Beck Depression Inventory (BDI-13), Spielberger's State Trait-Anxiety Inventory (STAI-Y), and the General Health Questionnaire (GHQ-28) between 1 and 41 months after transplantation. For comparison, 29 presumably healthy volunteers were given the same questionnaires. The study confirms the occurrence of abnormal psychological scores in the OHT group as compared to the reference population. Psychological scores, however, do not appear to be related to the time they were recorded after surgery.