The associative and limbic thalamus in the pathophysiology of obsessive-compulsive disorder: an experimental study in the monkey.

Obsessive-compulsive disorder (OCD) is a frequent psychiatric disorder characterized by repetitive intrusive thoughts and severe anxiety, leading to compulsive behaviors. Although medical treatment is effective in most cases, resistance is observed in about 30% of patients. In this context, deep brain stimulation (DBS) of the caudate or subthalamic nuclei has been recently proposed with encouraging results. However, some patients were unimproved or exhibited awkward side effects. Therefore, exploration of new targets for DBS remains critical in OCD. In the latter, functional imaging studies revealed overactivity in the limbic and associative cortico-subcortical loops encompassing the thalamus. However, the role of the thalamus in the genesis of repetitive behaviors and related anxiety is unknown. Here, we tested the hypothesis that pharmacological-induced overactivity of the medial thalamus could give rise to abnormal behaviors close to that observed in OCD. We modulated the ventral anterior (VA) and medial dorsal (MD) nuclei activity by in situ bicuculline (GABA(A) antagonist) microinjections in subhuman primates and assessed their pharmacological-induced behavior. Bicuculline injections within the VA caused significant repetitive and time-consuming motor acts whereas those performed within the MD induced symptoms of dysautonomic dysregulation along with abnormal vocalizations and marked motor hypoactivity. These findings suggest that overactivation of the VA and MD nuclei of the thalamus provokes compulsive-like behaviors and neurovegetative manifestations usually associated with the feeling of anxiety in OCD patients. In further research, this translational approach should allow us to test the effectiveness and side effects of these thalamic nuclei DBS in monkey and perhaps, in a second step, to propose a transfer of this technique to severely disabled OCD patients.

The glutamate-based genetic immune hypothesis in obsessive-compulsive disorder. An integrative approach from genes to symptoms.

Recent advances in multiple areas of research have contributed to the identification of several pathophysiological factors underlying obsessive-compulsive disorder (OCD). In particular, the glutamate transporter gene SLC1A1 has been associated with the diagnosis of OCD. Immunological and infectious studies have reported alterations of the immune system and the presence of immune complexes directed against the Borna disease virus in OCD patients. In addition, neuroimaging of OCD patients has demonstrated abnormalities in the anterior cingulate cortex, orbitofrontal cortex, thalamus, and the basal ganglia. Neuropsychological assessments have found several cognitive disruptions that have been identified in OCD, especially impairments in cognitive flexibility. Here, we attempt to bridge the gap between these remarkable findings through several previously unpredicted pathophysiological mechanisms. We propose an integrative hypothesis that indicates how genetic and environmental factors may contribute to the structural and functional alterations of cortico-subcortical circuits, leading to the characteristic cognitive disruptions underlying OCD symptoms.

[Atypical antipsychotics in first-episode psychosis: a review]. / Les antipsychotiques atypiques dans le premier épisode psychotique: revue de la littérature.

BACKGROUND: The management of patients with first-episode psychosis (FEP) is a difficult, but challenging task. Early and efficient treatment may influence long-term clinical outcome. Atypical antipsychotics (A-AP) are commonly prescribed in this population, but few data exist to establish their appropriate usage in the management of FEP. Our purpose is to review the literature and to summarize current data on the prescription of A-AP in FEP. METHODS: Studies assessing efficacy or safety of A-AP in FEP were identified by searches in Medline (up to April 2006). The following nine drugs were considered for this review: clozapine, olanzapine, risperidone, amisulpride, aripiprazole, quetiapine, ziprasidone, zotepine, and sertindole. RESULTS: Only four A-AP (clozapine, quetiapine, olanzapine, and risperidone) were evaluated as treatment of FEP. All of them show the same efficacy as conventional antipsychotics (C-AP). Clozapine has no benefit over C-AP in the treatment of naive patients. It entails a high rate of treatment discontinuation because of the need for regular white blood cell monitoring explained by the risk of agranulocytosis. Hence, clozapine may not be a first-line treatment of FEP. Tolerance to quetiapine and olanzapine is better than C-AP regarding extrapyramidal side effects, but weight gain induced by these two A-AP may be very disabling in a young population. Considering results from head-to-head comparative studies, olanzapine may be more effective than risperidone when an affective component is associated with the FEP symptomatology, but more data are needed to demonstrate this point. Risperidone is a relatively well-tolerated compound when it is prescribed at doses lower than 4 mg/d. It is the only A-AP that showed greater efficacy than C-AP to prevent relapse in patients with FEP. Unfortunately, information regarding the preventive efficacy of the other A-AP are lacking. CONCLUSIONS: Further studies, particularly longer-term studies, are needed to explore the impact of A-AP prescription in FEP on the course of psychotic disorders. The common use of A-AP as treatment of FEP is justified by a relatively better tolerance compared to C-AP, and by the hypothesis-not demonstrated-of a better effect on long-term outcome.

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.

[Improving the management of depression in primary care: review and prospects]. / Prise en charge de la dépression en soins primaires: revue et perspectives.

BACKGROUND: Depression is a common disorder, associated with significant social and functional impairment, and whose natural course tends to chronicity. The majority of the patients suffering from this disorder are attended in primary health care settings. General practitioners represent the greatest part of the prescribers of antidepressants. Unfortunately, there are many barriers with detection and with the treatment of depression, thus only a minority of patients profits from a treatment with effective posology and with sufficient duration. LITERATURE FINDINGS: Several programs of interventions directed by mental health professionals aim at improving the management of depression in primary care. There are single interventions consisting of an educational program to physicians or a single intervention to the patient. The assessments of an educational strategy find some contradictory results. Single interventions are not sufficient by themselves. On the other hand, programs associating several interventions are effective. These associations consist of an educational intervention to the physicians and an intervention or more to the patient treated by antidepressant. Interventions are generally carried out by nurses and supervised by a psychiatrist. Mental health professionals share their informations with general practitioners. Interventions can be telephone or in <>. Telephone interventions have the advantage of a low cost and appear quite as relevant as interventions in <>. RESULTS: But the effectiveness of these programs grows blurred in time, unless the program itself does continue. Moreover, this effectiveness is variable according to the severity of symptomatology. Indeed, the interest of this type of programs for the patients suffering from minor depression is limited. These various programs can be supplemented by the contribution of tools of detection or assessment of the depressive symptomatology to general practitioners, like by the contribution of oral and/or written informations to the patient concerning the disorder from which he suffers. The setting-up of such programs represents a considerable cost but depression is itself responsible for an important cost for our society. Several estimates concerning the setting-up of these programs find a good cost-effectiveness ratio; it should facilitate their installation taking into account their effectiveness. CONCLUSION: A close cooperation, based on the complementarity between general practitioners and mental health professionals is required to improve the management of depression.

[Present contribution of neurosciences to a new clinical reading of obsessive-compulsive disorder]. / Apport actuel des neurosciences à travers une nouvelle lecture clinique du trouble obsessionnel compulsif.

Obsessive-compulsive disorder (OCD), that affects 2 to 3% of the general population, is characterized by recurrent intrusive thoughts and repetitive, time-consuming behaviors. It is a severely incapacitating mental illness that causes profound impairment in psychosocial functioning and quality of life. Although the physiopathology of OCD is still far from resolved, the existence of a biological basis for OCD is now clearly established and should be interpreted from phenomenological considerations, on the one hand, and in the light of our increasing knowledge of the physiology of cortico-subcortical functional loops, on the other. In a phenomenological view, the heart of the obsessional process is the subject's underlying impression that "something is wrong". In other words, obsessions may be thought of as the permanent perception of a mistake and/or error in certain behavioral situations. Compulsions occur as behavioral responses aimed at relieving the tensions or anxiety generated by the situation. If obtained, this relief may be felt to be a form of reward. Nevertheless, it is only transient, thereby creating a feeling of considerable anxiety. This contributes to immediately reproducing the behavior in a cyclic manner, on the basis of an internal motivational state through an expectation of the reward. Therefore, it can be assumed that several malfunctioning processes are altered within the OCD: 1) error recognition; and, 2) emotion and motivation. This suggests that there is a dysfunction of the brain regions mediating these cognitive and emotional functions. Experimental neurophysiology in laboratory animals indicates the central role of the fronto-subcortical circuits originating in the orbitofrontal and anterior cingulate cortices, respectively. The orbitofrontal cortex (OFC) and ventromedial areas are involved in appraisal of the emotional and motivational values of environmental information, and in integrating the subject's prior experience, which is crucial in decision-making. The OFC also contributes to the selection, comparison and judgment of stimuli and error detection. The anterior cingulate cortex (ACC) is comprised of 1) a ventral or affective region that could keep attention on the internal emotional and motivational status and regulation of autonomic responses, and 2) a dorsal and cognitive region that serves a wide range of functions including attention, working memory, error detection, conflict monitoring, response selection, and anticipation of incoming information. Ventral striatum, that is intimately connected to the OFC and ACC, participates in the preparation, initiation and execution of behavioral responses oriented toward reward delivery following the cognitive and emotional integration of behaviorally relevant information at the cortical level. Functional imaging research in humans has shown an increased functional activity in the OFC, ACC, head of the caudate nucleus and thalamus in OCD patients. These functional abnormalities have been found in basal conditions and during provocation tests. Moreover, the therapeutic efficacy of antidepressants with preponderant serotonin-reuptake inhibiting properties and cognitive-behavioral therapies seems to be associated with a progressive reduction in activity of the OFC, ACC and the caudate nucleus. Therefore, these observations are suggestive of the responsibility of 5HT neurotransmission in the dysfunction of the frontal-subcortical loops that emanate from the OFC and ACC. However, several lines of research suggest that the dopamine system, with which 5HT interacts, may play a major role in the expression of OC symptoms. In conclusion, it seems that in OCD there is a dysfunction of the brain regions that belong to the orbitofrontal and anterior cingulate loops in view of evidence obtained from separate and complementary approaches.

Social phobia, fear of negative evaluation and harm avoidance.

This naturalistic, prospective investigation examined the role of fear of negative evaluation and the personality trait of harm avoidance in the anxiety levels of treated social phobia patients. One hundred and fifty-seven patients with DSM-IV social phobia were assessed before starting treatment and were then followed for up to two years. As expected, greater fear of negative evaluation and higher scores of harm avoidance were associated with greater anxiety at the 6 month follow-up, and harm avoidance remained a significant predictor at 24 months. However, no evidence was found for an interaction between the personality and cognitive variables examined. The findings are discussed in terms of the relative independence of these factors, as well as their potential implications for the treatment of this disorder.

[Neurobiology and pharmacotherapy of social phobia]. / Neurobiologie et pharmacothérapie de la phobie sociale.

Social phobia (also known as social anxiety disorder) is still not clearly understood. It was not established as an authentic psychiatric entity until the diagnostic nomenclature of the American Psychiatric Association DSM III in 1980. In recent years, increasing attention among researchers has contributed to provide important information about the genetic, familial and temperamental bases of social phobia and its neurochemical, neuroendocrinological and neuroanatomical substrates, which remain to be further investigated. Up to date, there have been several findings about the possible influence of variables, including particularly genetic, socio-familial and early temperamental (eg behavioral inhibition) factors that represent risk for the later development of social phobia. Clinical neurobiological studies, based on the use of exogenous compounds such as lactate, CO2, caffeine, epinephrine, flumazenil or cholecystokinin/pentagastrin to reproduce naturally occurring phobic anxiety, have shown that patients with social phobia appear to exhibit an intermediate sensitivity between patients with panic disorder and control subjects. No difference in the rate of panic attacks in response to lactate, low concentrations of CO2 (5%), epinephrine or flumazenil was observed between patients with social phobia and normal healthy subjects, both being less reactive compared to patients with panic disorder. However, patients with social phobia had similar anxiety reactions to high concentrations of CO2 (35%), caffeine or cholecystokinin/pentagastrin than those seen in patients with panic disorder, both being more intensive than in controls. Several lines of evidence suggest specific neurotransmitter system alterations in social phobia, especially with regard to the serotoninergic, noradrenergic and dopaminergic systems. Although no abnormality in platelet serotonin transporter density has been found, patients with social phobia appear to show an enhanced sensitivity of both post-synaptic 5HT1A and 5HT2 serotonin receptor subtypes, as reflected by increased anxiety and hormonal responses to serotoninergic probes. Platelet 5HT2 receptor density has also been reported to be positively correlated to symptom severity in patients with social phobia. During anticipation of public speaking, heart rate was elevated in patients with social phobia compared to controls. Norepinephrine response to the orthostatic challenge test or to the Valsalva maneuver was also greater in patients with social phobia. While normal beta-adrenergic receptor number was observed in lymphocytes, a blunted response of growth hormone to clonidine, an a2-adrenergic agonist, was reported. This suggests reduced post-synaptic a2-adrenergic receptor functioning related to norepinephrine overactivity in social phobia. Decreased cerebrospinal fluid levels of the dopamine metabolite homovanillic acid have also been observed. There are relatively few reports of involvement of the adrenal and thyroid functions in social phobia, and all that has been noted is that patients with social phobia show an exaggerated adrenocortical response to a psychological stressor. Recent advances in neuro-imaging have contributed to find low striatal dopamine D2 receptor binding or low dopamine transporter site density in patients with social phobia. They have also demonstrated the involvement of the cortico-limbic pathways, including the prefrontal cortex, hippocampus and amygdala, which show an increased activity in different experimental conditions. These brain regions have extensively been reported to play an important role in the cognitive appraisal in determining the significance of environmental stimuli, in the emotional and mnemonic integration of information, and in the expression of contextual fear-conditioned behaviors, which might be disrupted in the light of the phenomelogical aspects of social phobia. A substantial body of literature based on case reports, open and placebo-controlled trials, has now clearly examined the efficacy of major classes of psychotropic agents including monoamine oxidase inhibitors, beta-blockers, selective serotonin reuptake inhibitors and benzodiazepines in social phobia. Until recently, irreversible non-selective monoamine oxidase inhibitors, of which phenelzine was the most extensively evaluated, were considered as the most efficacious treatment in reducing the symptomatology associated with social phobia in 50-70% of cases after 4 to 6 weeks. However, side effects and dietary restrictions limit their use. This led to the development of reversible inhibitors of monoamine oxidase A, for which careful dietary monitoring is not required. Moclobemide has been the most widely studied but produced unconvincingly therapeutic effects on social phobic symptoms. To date, selective serotonin reuptake inhibitors may be considered as a reasonable first-line pharmacotherapy for social phobia. There is growing evidence for the efficacy of the selective serotonin reuptake inhibitors fluvoxamine, fluoxetine, citalopram, paroxetine and sertraline. They have beneficial effects with response rates ranging from 50 to 80% in social phobia. It has been recommended that the treatment period should be extended at least 6 months beyond the early improvement achieved within the first 4 to 6 weeks. The overall advantages include tolerability with a low risk of adverse events. The benzodiazepines clonazepam and alprazolam have also been proposed for the treatment of social phobia. Symptomatic relief occurred in 40 to 80% of the cases with a relatively rapid onset of action within the first two weeks. Untoward effects, discontinuation-related withdrawal symptoms and abuse or dependence liability constitute major concerns about the use of benzodiazepines, so they should be reserved for cases unresponsive to the safer medications cited above. Beta-blockers such as atenolol and propanolol have commonly been employed in performance anxiety, decreasing autonomic symptoms (eg, tachycardia, sweating and dry mouth). However, they are not effective in the generalized form of social phobia. Other pharmacologic alternatives seem helpful for the management of social phobia, including venlafaxine, gabapentin, bupropion, nefazodone or augmentation with buspirone. Preliminary studies point to promising effects of these agents. Larger controlled clinical trials are now needed to confirm their potential role in the treatment of social phobia.

Body dysmorphic disorder in a sample of cosmetic surgery applicants.

Body dysmorphic disorder (B.D.D.) consists of a preoccupation with an imagined or slight physical defect. This study is the first European report on prevalence and several clinical and functional characteristics of patients with B.D.D. in a cosmetic surgery setting. Comparisons with defect- and severity-matched subjects without B.D.D. were also performed.

[Seizure threshold and ECT. Importance for good clinical practice of ECT. A review of literature]. / Seuil épileptogène et électroconvulsivothérapie. Importance pour la pratique. Revue de la littérature et mise au point.

To induce a seizure for electroconvulsive therapy (ECT), an electrical charge is delivered above seizure threshold. The means and criteria used to determine the electrical dosage are subject to debate. Nonetheless this is an important issue because effectiveness and side effects have been shown to be influenced by the electrical charge used. The objective is to review data available in the literature on seizure threshold and ECT and determine the eventual consequences for practical determination of stimulus dosing. A comprehensive review of the literature is based on the search of electronic databases (Medline, INSIT) and a manual search; 72 references out of a total of 96 selected were used for this review. Seizure threshold varies widely between subjects receiving ECT (600% mean variation), however a majority of subjects of all ages have a threshold below 150 mC. Only a few individuals have very high thresholds (400 to 800 mC). ECT has an anticonvulsive effect as threshold increases during a course of ECT. Many factors influence threshold and all are not known. Among those that have been documented are: the characteristics of the current used (longer stimulus duration with same dosage gives lower thresholds); electrode placement (bilateral gives higher thresholds than unilateral placement); age (explains 12 to 26% of threshold variance); gender (which inconsistently gives higher thresholds for males); and other factors such as anesthetic drugs, concurrent psychotropics, and some morphological characteristics. Different methods are used to determine an individually adapted dosage. Two are recommended: titration and age. The age method is based on the fact that age is an important factor influencing threshold. The titration method is based on the observation of a very important variation in threshold between individuals that is not explained by age. We discuss the pros and cons of each method.

Experiencia con buprenorfina en Francia / Buprenorphine: experience in France

Objetivo: En 1995 la Agencia del Medicamento Francesa aprobó buprenorfina (disponible en comprimidos sublinguales de 0,4, 2 y 8 mg) para el tratamiento de la dependencia a opiáceos, y la comercialización del producto comenzó en febrero de 1996. Rápidamente aumentó el uso de buprenorfina, prescrito principalmente por médicos generales. A finales de los noventa se estimó que los médicos generales estaban tratando aproximadamente a 65.000 pacientes al año con buprenorfina y a otros 4.000 pacientes con metadona. En marzo de 2001 se calculó que 74.300 pacientes eran tratados con buprenorfina (tomando una dosis sublingual de 8 mg/día), y otros 9.600 pacientes lo eran con metadona (tomando una dosis oral de 65 mg/día). Cualquier médico puede empezar prescribiendo buprenorfina y cualquier farmacia puede dispensar la medicación. No hay requerimientos de ninguna clase de entrenamiento especializado. La duración máxima de buprenorfina prescrita es de 28 días y el número máximo de dosis para llevar a casa es de siete días, aunque el médico puede hacer caso omiso a esta regla y especificar que sean suministrados más de siete días al paciente. Es posible para las farmacias suministrar diariamente, supervisando la dosis con buprenorfina, si está especificado por el médico. Los estudios han demostrado que esto aumenta el cumplimiento del paciente y reduce la desviación del fármaco. Material y métodos: Se analiza la experiencia clínica del uso de buprenorfina en Francia. Resultados: Los resultados obtenidos de la base de datos de los seguros médicos franceses nos dan información útil sobre los pacientes tratados con buprenorfina. En todos estos estudios, el 80 por ciento o más de los pacientes sólo visita a un médico de manera regular y va a por la medicación a una farmacia. Del 10 al 20 por ciento visita a varios médicos y/o obtiene la medicación en varias farmacias. Menos del 10 por ciento visita a muchos médicos, y posiblemente representan un grupo problemático. En comparación, esto es inferior a la proporción de pacientes problemáticos comunicados en centros de abuso de substancias en Francia, incluyendo los pacientes tratados con metadona. La generalización de estos datos significaría que 20.000 médicos generales (de unos 100.000) están actualmente prescribiendo buprenorfina a 70.000 pacientes (de unos 150.000 a 200.000 con problemas de heroína).Conclusiones: La existencia del abuso y mal uso de buprenorfina está documentada en informes de individuos que utilizan buprenorfina por vía intravenosa. Los usuarios de buprenorfina intravenosa pueden ser bien pacientes en tratamiento que desvían su tratamiento, o individuos que no están en tratamiento y ocasionalmente se inyectan buprenorfina pero prefieren heroína o cocaína. Entre los que no están en tratamiento y usan la vía intravenosa, la mayoría prefiere usar heroína o cocaína cuando es posible. Entre los pacientes en tratamiento hasta el 20 por ciento usa la vía intravenosa en algún u otro momento. Esto se ha constatado tanto para pacientes en tratamiento con buprenorfina o metadona. No obstante, los pacientes de buprenorfina tienen más probabilidades de inyectarse su propio tratamiento de buprenorfina que los pacientes de metadona, que son más proclives a inyectarse heroína o cocaína. Desde 1995 a 1999 el número de muertes por sobredosis disminuyó en un 79 por ciento mientras el número total de individuos bien en tratamiento con buprenorfina o metadona aumentó más del 95 por ciento (de menos de 2.000 a 60.000 al año). Varios autores han comunicado muertes en las cuales fue sugerida la buprenorfina como factor contributivo o causal. Desde 1996 a 2000 han sido comunicadas un total de 137 de dichas muertes. En todos los casos, excepto en uno, fueron identificadas benzodiacepinas y/u otros depresores respiratorios del sistema nervioso central además de buprenorfina (AU)

Sensation seeking as a common factor in opioid dependent subjects and high risk sport practicing subjects. A cross sectional study.

OBJECTIVE: Animal research has outlined a vulnerability trait to drug dependence like behavior. The behavioral characteristic of this vulnerability is hyperactivity in response to a novel environment of which sensation seeking (SS) has been suggested as a possible equivalent in humans. If this is the case, SS should be more frequent in drug dependent and risky sports practicing subjects then controls. The objective of this study was to determine if opioid dependent subjects (ODS) and regular paragliders (RP) would be more SS then normal controls. DESIGN: Cross sectional study. PARTICIPANTS: Three groups of 34 individuals (total 102) matched for age and sex were selected from ODS seeking treatment, a paragliding club, and a college staff. MAIN OUTCOME MEASURES: Global and sub-scores of the Zuckerman sensation seeking scale (SSS). RESULTS: Non parametric statistics (Kruskal Wallis and Wilcoxon 2-Sample Tests) were used given the non-normal distribution of SSS scores in the ODS and RP groups. Significant differences were found across the three groups for the Thrill and Adventure Seeking (TAS) (P = 0.001), dishinibition (Dis) (P = 0.0003) and total score (P = 0.001). ODS and RP scored significantly higher than controls on two (Dis and the TAS scales). RP also scored significantly higher on the Boredom Susceptibility (BS) scale (P = 0.04). CONCLUSION: Our results show that RP and ODS differ from controls and have some similarities based on the SSS. In this study, the ODS and the RP could express different forms of a general tendency to seek intense and abrupt sensations through various behaviors. Our results in humans are in favor of the hypothesis that the behavioral trait of vulnerability to drug dependence behavior is expressed through SS.

[Anxiety disorders in private practice psychiatric out-patients: prevalence, comorbidity and burden (DELTA study)]. / Epidémiologie des troubles anxieux en psychiatrie libérale: prévalences, comorbidité et retentissement (étude DELTA).

Few data are currently available on the prevalence and associated characteristics of anxiety disorders in psychiatric out-patients in France, in particular in the private health-care. However, this represents one of the principal systems of care for patients suffering from anxiety disorders, with a possible direct access and several types of treatments available (pharmacotherapy but also different kinds of psychotherapy). The aim of our study was to describe the prevalence of anxiety disorders in a large sample of patients consulting in the private sector, and in addition to study the comorbidity, the severity of the disorders, their consequences on quality of life and health care consumption. The studied patients were included and assessed by 501 psychiatrists from all the country, at the time of a first visit. Inclusions were to be made in a consecutive way, but with the exclusion of psychotic disorders and dementia. A sample of 1 955 patients was obtained, and all subjects had a standardized diagnostic assessment with the Mini International Neuropsychiatric Interview (MINI) and with various dimensional scales of symptomatology severity, quality of life, and health care consumption. On the whole, at least one current anxiety disorder was found in 64.3% of the patients, while 55% had a depressive disorder. Individually, the prevalence rates are 29.4% for generalized anxiety disorder, 25.9% for agoraphobia, 19.2% for panic disorder, 15.3% for social phobia, 11.4% for obsessive-compulsive disorder, and 5.4% for post-traumatic stress disorder (PTSD). A history of suicide attempts was found in 12-20% of patients, and an elevated suicide risk was found for example in 25% of PTSD patients. The scores of the symptomatic scales, adaptation and quality of life measure show a very significant anxious symptomatology, with serious functional consequences. Approximately 75% of patients had another medical consultation during the three previous months, and 9% have been hospitalized. An interruption of work was found in 25% of the patients during the last three months, in average for 35 days. Concerning drug consumption before the visit by anxiety disorders patients, the preponderance of anxiolytic use is notable (85 to 98% according to categories of anxiety disorders) when compared to that of antidepressants (20 to 40%). Moreover, 38.4% of the whole sample took an anxiolytic once a day for at least three months and about 40% of them had dependence symptoms. In conclusion, this study showed the quantitative importance of anxiety disorders among psychiatric out-patients in the private practice sector in France, all the categories of anxiety being represented, and the high level of severity and burden of these disorders. Compared to some data published before, the prevalence rates of these anxiety disorders seem to be increasing.

[Lethal catatonia: clinical aspects and therapeutic intervention. A review of the literature]. / La catatonie léthale: aspects cliniques et conduite thérapeutique. Une revue de la littérature.

Lethal catatonia continues to occur and represents a nonspecific syndrome associated with diverse organic as well as functional conditions. From this perspective, neuroleptic malignant syndrome may be conceptualized as a neuroleptic-induced toxic or iatrogenic form of organic lethal catatonia. Neuroleptics appear ineffective in the treatment of lethal catatonia and should be stopped whenever this disorder is suspected. Existing data suggest that ECT is a safe and effective treatment for lethal catatonia. ECT also appears effective in the treatment of neuroleptic malignant syndrome.

[Case study--relationship between prevalence of shyness, social phobia and avoidant personality in male sexual disorders]. / Etude cas--témoins de la prévalence de la timidité, de la phobie sociale et de la personnalité évitante dans les troubles sexuels masculins.

UNLABELLED: Social phobia, avoidant personality disorder and shyness are very akin disorders, despite the fact that the first two are mental disorders, whereas the third is found mainly in lay or psychological literature. The relationship between these disorders and male sexual disorders can only be hypothesized from clinical studies and psychopathological theories. Social phobia, avoidant personality disorder, and shyness, share a probable indirect responsibility in sexual disorders because they impair the ability of subjects to meet partners. There are only a few direct studies of the negative impact of shyness on sexual behavior. OBJECTIVE: The objective of this study was to compare males with sexual disorders to non-sexual disorder males on diagnosis of social phobia, avoidant personality disorder and shyness. METHODS: We conducted a case-control study comparing a group of male patients seeking care for sexual disorders (n = 87) and a control group of male subjects without sexual disorder (n = 87), regarding the diagnosis of social phobia, avoidant personality disorder and shyness. Diagnoses were appreciated with a structured diagnostic interview (CIDI for the diagnosis of social phobia) or a list of criteria (DSM IV criteria for avoidant personality disorder) and through standardized scales (Fear Questionnaire, CBSHY, Cottraux male sexual problems questionnaire). Severity of shyness was evaluated through visual analog scales. RESULTS: We found strong significant statistical differences between cases and controls regarding the percentage in each group of social phobia, avoidant personality disorder and shyness. For shyness, the mean score at CBSHY was 16.2 (+/- 12.63) for the cases and 6.07 (+/- 6.67) for the controls (p < 0.0001), whereas the percentage of cases with a score of > 19.5 was 41.4% vs 6.9% for the controls (p < 0.001); 27.6% of the cases had a CIDI diagnosis of social phobia vs 8% of the controls (p < 0.001); 31% of the cases implemented DSM IV criteria for the diagnosis of avoidant personality disorder vs 6.9% of the cases (p < 0.001). CONCLUSION: Our results are in favor of one or several factors in common between social phobia, avoidant personality disorder and shyness, which would be strongly related to male sexual disorders.

[Sports, use of performance enhancing drugs and addiction. A conceptual and epidemiological review]. / Sport, dopage et addictions.

BACKGROUND: Both the general public and non-sports medicine health professionals have recently been made aware of a large use of performance enhancing drugs among sports practicing subjects. It has been suggested that this behavior is similar to that of substance dependence. Also some have reported that practice of a sport could be in itself an addictive behavior. OBJECTIVE: The main objective was to address the following question: is performance enhancing drug use in sports an addictive behavior? Methodology. We first reviewed the definition of performance enhancing drug use in sports and the diagnostic criteria of substance dependence as they are currently accepted and attempted to determine a possible common factor. Secondly we reviewed epidemiological data from the literature according to three approaches: RESULTS: Use of performance enhancing drugs is an important and increasing phenomenon among adolescents. It is sometimes associated to risk taking behaviors for health (syringe use and sharing). Competition participants are at increased risk (up to 20% according to some authors) and some substances (anabolic steroids) are also used by non-sports practicing individuals. It has not been shown that sports practicing subjects were more at risk of using addictive substances compared to non-sports practicing subjects. It is not established that practice of a sport is by itself a risk factor for substance use. However, it could be that a sub-group of individuals that practice certain types of sports in an intensive way, that use both performance enhancing drugs and addictive substances and that engage in health risk taking behaviors have an increased risk for developing a dependence syndrome to both addictive and performance enhancing drugs. This sub-group is even more at risk because some performance enhancing drugs (anabolic steroids) could increase the risk for occurrence of a substance dependence syndrome through neurobiological actions. Yet, the few available clinical studies show that at most only half of regular users actually meet criteria for dependence. Also, one study has reported an overrepresentation of sports professionals among patients seeking treatment for heroin addiction. CONCLUSION: The large majority of sports practicing subjects have no dependence to either performance enhancing or addictive drugs. However, a subgroup of individuals that practice sports intensely and makes use of both addictive and performance enhancing drugs appear to be at increased risk for developing a substance dependence syndrome.

Post-ECT agitation and plasma lactate concentrations.

This prospective study evaluated the hypothesis that emergence agitation after electroconvulsive therapy (ECT) could be caused by lactate-induced panic secondary to insufficient neuromuscular blockade. Plasma lactate levels were measured before and after 245 consecutive ECT sessions in 37 patients monitored for evidence of post-ECT agitation. ECT was administered using a brief-pulse, rectangular, constant-current device through bilaterally placed electrodes under general anesthesia and neuromuscular blockade. Agitation was observed in 7% of all ECT sessions. No significant difference could be found in pre-ECT lactate levels. However, mean post-ECT lactate levels in agitated sessions were significantly greater than those in nonagitated sessions (4.77 versus 2.54 mmol/l, p < 0.05). An increase (+27%) in the pre-ECT succinylcholine dose for those patients who previously had repeated post-ECT agitation resulted in cessation of post-ECT agitation and return of the formerly high post-ECT lactate levels to normal (1.61 versus 2.07 mmol/l). Although the number of patients who had post-ECT agitation was small, the data support the hypothesis that post-ECT agitation might be a manifestation of lactate-induced panic.

[Quantitative evaluation of sharing practices of materials at risk for infectious virus contamination by intravenous opiate users seeking treatment--application of the RAB(Risk for AIDS Behavior) self-administered questionnaire]. / Evaluation quantitative des pratiques de partage de matériel à risque de contamination infectieuse virale chez les usagers d'opiacés par voie intraveineuse faisant une demande de soins--utilisation de l'auto-questionnaire RAB.

The objective of this study was to quantify the occurrence of AIDS risk related sharing activities in i.v. opiate users seeking treatment using a self administered questionnaire. Subjects were recruited among first time consultants of an outpatient clinic and assessed using the Risk for AIDS Behavior questionnaire (RAB), a self administered questionnaire that assesses both needle-sharing and unprotected sexual activity; the Beck Depression Inventory (BDI) a self administered questionnaire that assesses depressive symptoms; and the Addiction Severity Index (ASI), a 45-min, structured interview that provides assessments of problem severity in seven functional areas commonly impaired among drug abusers. Among the 102 patients who came in for treatment, all 66 subjects reporting i.v. drug abuse agreed to participate. The study was based on the data collected from these 66 subjects of whom 49 were males (74%) and mean age +/- SD was 31 +/- 5. Fifty-eight-percent of theses subjects reported having shared needles or related paraphernalia over the past 6 months. Despite informational campaigns on the risks of sharing and despite the well spread knowledge of such a risk, most i.v. opiate users seeking treatment report having shared at least once over the previous 6 months.