Borderline personality disorder and mental healthcare service use among adolescents.

Borderline personality disorder (BPD) is believed to be frequent among adolescents. While several prospective studies have assessed the use of mental health services among adults who suffer from BPD, few studies have provided adolescent data. This paper presents findings from the first assessment point of the European Research Network on Borderline Personality Disorder (EURNET BPD) study. In this study, we describe lifetime treatment utilization for 85 adolescents with BPD (Mean age: 16.3 years old). In line with adult findings, adolescents with BPD reported greater mental healthcare service use (outpatient: 98%; inpatient: 79%) compared to controls. Phenothiazine, a sedative neuroleptic, was the most frequently prescribed treatment. 47% of patients had received psychotherapy; in one our of three cases this was psychodynamic therapy. Patients who had received psychotherapy did not differ on any psychopathological variables from those who did not receive psychotherapy; however, psychotherapy was more frequent among females.

[Differential indications for psychotherapies in borderline personality disorder]. / Indication différentielle des psychothérapies adaptées au trouble de la personnalité limite.

BACKGROUND: Borderline personality disorder (BPD) accounts for 10% of outpatient psychiatric practice. The risk of suicide attempts is high and the psychosocial impairment significant. Different theoretical streams have suggested psychotherapeutical approaches for BPD. OBJECTIVE: to examine the efficacy of psychotherapy for BPD patients on affective symptoms, behavioural outcomes, interpersonal and social functioning, as well as BPD criteria. METHODS: We reviewed the medical literature from 1990 to 2008 on Medline by combining the following keywords "borderline personality disorder" and "psychotherapy" (inclusion criteria). We restricted the analysis to "randomised control trial" or "meta analysis". RESULTS: Of the 39 abstracts that came out from the search, we selected 17 (44%) after applying the exclusion criteria. According to our review, different types of psychotherapies have shown some efficacy on reducing affective symptoms and BPD criteria, as well as improving behavioural outcomes and psychosocial functioning. Dialectical behavioural therapy presents the best-documented efficacy, notably on reducing self-mutilating and suicidal behaviours (five randomized controlled trials [RCT]). Mentalization based treatment seems to be efficient on the four types of outcomes, but has been the object of only one RCT. Finally, some evidence suggests that Manual Assisted Cognitive Treatment and Systems Training for Emotional Predictability and Problem Solving are the most cost-effective and easiest to be implemented. CONCLUSION: According to our review, some evidence supports an efficiency of psychotherapies in the management of several features of BPD. It is likely that, depending on the target symptoms, one type of therapy might be more efficient than another. The acceptability of these long-term treatments is however unknown.

Factors predictive of ten-year mortality in severe anorexia nervosa patients.

OBJECTIVE: Little is known concerning mortality and predictive factors for anorexia nervosa in-patients. This study aimed to establish mortality rates and identify predictors in a large sample of adults through a 10-year post in-patient treatment follow-up. METHOD: Vital status was established for 601 anorexia nervosa (DSM-IV) consecutive in-patients with initial evaluation at admission. Standardized mortality ratio (SMR) was calculated. Cox analyses for hypothesized predictors of mortality were performed. RESULTS: Forty deaths were recorded. SMR was 10.6 [CI 95% (7.6-14.4)]. Six factors at admission were associated with death: older age, longer eating disorder duration, history of suicide attempt, diuretic use, intensity of eating disorder symptoms, and desired body mass index at admission. CONCLUSION: Anorexia nervosa in-patients are at high risk of death. This risk can be predicted by both chronicity and seriousness of illness at hospitalization. These elements should be considered as warnings to adapt care provision and could be targeted by treatment.

Assessment of Anxiety in Clinical Trials with Depressed Patients Using the Hamilton Depression Rating Scale.

BACKGROUND: The Hamilton Depression Rating Scale (HAMD17) is an outcome measure widely used in major depressive disorder (MDD) clinical trials. The objective of this analysis was to assess the validity of the anxiety/somatisation factor of the HAMD17 as a measure of anxiety in patients with MDD. METHODS: We pooled data from 1466 outpatients with MDD from four 8-week controlled studies of duloxetine. We performed a factor analysis of the HAMD17 to investigate the anxiety/somatisation factor. RESULTS: The HAMD17 factor analysis yielded 6 factors, but did not yield the pre-specified anxiety/somatisation factor. This latter factor showed weak correlation with the Hamilton Anxiety Scale total and subscale scores at baseline (0.46), but higher correlation coefficients over the trials up to 0.81. We identified another anxiety factor that included the hypochondriasis item in this sample. CONCLUSION: Findings from this large sample suggest that the factor structure of the HAMD17 is unstable in MDD and that the anxiety/somatisation subscale should not be routinely used for anxiety assessment in depressed patients.

[Validation of the French version of the expanded Brief Psychiatric Rating Scale with anchor BPRS-E(A)]. / Validation de la version française de l'échelle abrégée d'appréciation psychiatrique étendue avec ancrage, BPRS-E(A).

INTRODUCTION: The Brief Psychiatric Rating Scale was initially developed as a rapid method to assess symptom change in psychiatric inpatients of various diagnoses. The original version was expanded to an 18-item version and thereafter to a 24-item version to increase sensitivity to a broader range of psychotic and affective symptoms. The latest version of the expanded 24- item BPRS provides probe questions and detailed anchor points for the ratings for each item. LITERATURE FINDINGS: Studies have shown the expanded and anchored 24-item BPRS to be a sensitive and effective measure of psychiatric symptoms with good interrater reliability that can be maintained over time. To our knowledge, there are eight published papers including factor analyses of the BPRS-E(A). While many similarities are evident between these studies, inconsistencies are apparent that may have been due to sample size, characteristics and / or methodological differences in the factor analysis computation. Among these studies, six provided a four-factor solution. There was no French version of this scale available. METHODS: After its translation into French and back translation, we investigated the validity of the French BPRS-E(A) version. We carried out a component analysis on the data of 111 participants of various diagnoses, mostly hospitalised for a first psychotic episode, yielding to a three-factor solution (positive symptoms--disorganisation; depression-anxiety and negative symptoms). RESULTS: A good internal consistency and interrater reliability were found. These results confirm the psychometric value of the BPRS-E(A) in its French version. We compared those findings to earlier reports; similarities and differences are discussed.

[Evaluation of perturbed body image in eating disorders using the Body Shape Questionnaire]. / Evaluation des préoccupations corporelles dans les troubles des conduites alimentaires par le Body Shape Questionnaire.

INTRODUCTION: Eating disorders are characterized by severe disturbance in eating behavior. A disturbance in perception of body shape and weight is an essential feature of both anorexia nervosa (AN) and bulimia nervosa (BN). Eating disorder patients demonstrate the same characteristic attitude about body image, such as fear of fatness or pursuit of thinness. BACKGROUND: Moreover, perturbed body image is a common diagnostic category of anorexia and bulimia (DSM-IV-TR, CIM-10). Cooper et al. [Int J Eat Disord 6 (1987) 485-94] developed a one-dimensional, 34 items questionnaire in order to measure the worries about weight and shape of the body, called the "Body Shape Questionnaire" (BSQ). Its concurrent validity has been shown using the corporal dissatisfaction subscale of the eating disorders inventory (EDI) [Int J Eat Disord 2 (1983) 15-34], the drive for thinness and body dissatisfaction and the Eating Attitude Test (EAT) [Psychol Med 9 (1979) 273-79]. The total score of the BSQ ranges from 34 to 204. Lower scores indicate lower concerns about body shape. The BSQ provides a means of exploring the role of extreme obsession about the body's appearance in the development, pursuit and treatment of eating disorders. From this point of view, the BSQ is a tool widely used in research on the eating disorders. Recently, It has been validated in a French non-clinical population [Encephale 31 (2005) 161-73]. However, the validity of the BSQ has not been reported in patients with eating disorders in France. This was addressed in the present study. OBJECTIVES: The first aim of this study was to assess perturbed body image with the French version of the BSQ in eating disorder patients. The second aim was to assess the sensitivity to change. METHOD: The sample was composed of patients hospitalized for eating disorders (DSM-IV-TR). During their hospitalization, they were submitted to this questionnaire at the beginning and at the end of their care. The BSQ was compared with commonly used heteroquestionnaires such as the body dissatisfaction and drive for thinness subscale of the Eating Disorder Inventory (EDI-2), the Eating Attitude Test (EAT) and the Clinical Global Impression (CGI). Sensitivity to change was assessed by comparing total score at inclusion and at the end of hospitalization. Statistical analyses included Pearson's correlation coefficients, analysis of variance and t test. As Body Mass Index (BMI) can interfere with the BSQ score, it was included as confounding variables in the model in all analyses. RESULTS: Forty-five patients were included in the study. There were 21 patients with restricting subtype of AN, 17 patients with purging subtype of AN and seven BN. The mean age was 27.2+/-6.8 years, the mean length of hospital stay was 3.7+/-1.4 months, and the mean duration of the disorders was 10.7+/-6.3 years. The global BSQ score was high in the three groups of patients: 131.6+/-11.2. There was no significant difference between groups. There was no influence of the BMI on the BSQ scores. Correlation coefficient was significant for all scales with the BSQ except with the CGI. The higher correlation (r) was 0.58 with the drive for thinness subscale of the EDI-2. The change in scores between Day 0 and the end of hospitalization was significant (p<0.0001). CONCLUSION: The French version of the BSQ thus appears to be valid and accurate and should permit the study of perturbed body image in French eating disorder patients. However, sensitivity to change remains to be confirmed to evaluate response to treatment. Studies measuring this variable at different stages of the illness and recovery should be conducted.

[Borderline personality disorder, self-mutilation and suicide: literature review]. / Personnalité borderline, automutilations et suicide : revue de la littérature.

INTRODUCTION: Borderline personality disorder (BPD) is a serious public health problem. It is associated with high levels of mental health service utilization, an important degree of psychosocial impairment and a high rate of suicide (10%). BPD is a common psychiatric disorder and the most frequent personality disorders. Approximately, 15 to 50% of psychiatric inpatients and 11% of psychiatric outpatients meet current criteria for BPD. Recurrent suicidal threats, gestures or behaviour or self-mutilation are common in patients suffering from borderline personality disorder. However, despite their similarities, self-mutilation behaviour differs from suicide attempts by the lack of systematic suicidal intentions. The purpose of our study is to examine the relationships between self-mutilations, suicide and related therapeutic approach. METHODS: We have reviewed the literature published from January 1980 to October 2006, using the following keywords: self-mutilation, suicide, borderline personality (44 articles) with five other additional articles. RESULTS: Self-mutilation refers to the deliberate, direct destruction or alteration of one's body tissue without conscious suicidal intent. This pattern of behaviour is common in BPD (50 to 80% of cases) and is frequently repetitive (more than 41% of patients make more than 50 self-mutilations). The most common form of self-mutilation behaviour is cutting, but bruising, burning, head banging or biting are not unusual. The functions of self-mutilation are variable: it provides relief from negative mood states, reduces distress, obtains care from other people as well as therapists and expresses emotions in a symbolic fashion. The rate of suicide in clinical samples of BPD is of around 5 to 10%. This rate is about 400 times that of the general population. Authors estimated that 40 to 85% of borderline patients carry out suicide attempts that are usually multiple (average=3). The relationships between self-mutilation and suicide are paradoxical. Some authors identify self-mutilation as a protective factor against suicide. Self-mutilation behaviour can be defined as an attenuated form of suicide ("focal suicide"). In this way, self-mutilation plays the role of an anti-suicide act, allowing patients to emerge from their dissociation and to feel that they are living again. The risk of suicide will not increase so long as self-mutilation produces the expected relief. Nevertheless, most of the authors exhibit self-mutilation as a risk factor of completed suicide. DISCUSSION: Thus, borderline patients with history of self-mutilation behaviour have about twice the rate of suicide than those without. Repetitive self-mutilations may increase dysphoria, which will only be relieved by suicidal gestures. Self-mutilating suicide attempters may be at greater risk for suicide for several reasons: they experience more feeling of depression and hopelessness, they are more aggressive and display more affective instability, they underestimate the lethality of their suicidal behaviour and finally, they are troubled by suicidal thoughts for longer and more frequent periods of time. Treatment of these patients requires a multidisciplinary approach. Psychoanalytic/psychodynamic therapy and dialectal behaviour therapy (DBT) have been shown to lower rates of attempted suicide among BPD patients. Pharmacotherapy focuses on key symptoms: aggression, irritability and depressed mood (selective serotonin reuptake inhibitors), behavioural dyscontrol and affective dysregulation (mood stabilizers), anxiety, psychoticism and hostility (antipsychotics). CONCLUSION: These findings highlight the possibility of self-mutilation as a risk factor of suicide in borderline personality disorder. Nevertheless, to reinforce this assertion, further studies on large sample of borderline patients, with or without self-mutilation, are needed. Moreover, prospective controlled studies on the various treatment models in suicidal BPD patients are necessary.

Switching to the bingeing/purging subtype of anorexia nervosa is frequently associated with suicidal attempts.

OBJECTIVE: Anorexia nervosa has the highest suicide mortality ratio of psychiatric disorders, suicide being associated with many factors. We assessed the first lifetime occurrence of these factors taking into account their possible overlap. METHOD: Three hundred and four in- and out-patients with anorexia nervosa (DSM-IV) were systematically recruited in three hospitals of Paris suburbs, between December 1999 and January 2003. Patients were assessed by a face-to-face interview (DIGS). Current eating disorder dimensions were measured, and patients interviewed by a trained clinician to assess minimal BMI and, retrospectively, the age at which anorexia nervosa, major depressive disorder, anxiety disorders and switch to bingeing/purging type occurred for the first time, if applicable. RESULTS: Major depressive disorder (p<0.001) and subtype switch from the restrictive to the bingeing/purging type (p<0.001) were the two factors significantly more frequently occurring before suicidal attempts, and remained involved when a multivariate analysis is performed, whether syndromic or dimensional measures are being used. Taking into account lifetime occurrence with a survival analysis, the switch to bingeing/purging type of anorexia appears as a major predictive factor, with a large increase of the frequency of suicidal attempts (OR=15) when compared to patients with neither major depressive disorder nor bingeing/purging type. CONCLUSIONS: Bingeing/purging type of anorexia nervosa is largely associated with suicidal attempts, and may deserve specific attention. If confirmed on a prospectively designed study, these results would argue for early detection and/or more intensive and specific therapeutic intervention on this aspect of bingeing and purging behaviors.

[Validity of vascular depression as a specific diagnostic: a review]. / Validité du concept de dépression vasculaire: une revue de la littérature.

INTRODUCTION: A number of authors have suggested that cerebrovascular disease may predispose, precipitate, or perpetuate some geriatric depressive syndromes. These "vascular depressions" may result from damage of striato-pallido-thalamo-cortical pathways which frequently occurs in cerebrovascular disease. METHOD: We have searched the English and French literature published between 1996 (when the "vascular depression" hypothesis was first stated) and December 2004 through the Medline computer database and examined the validity of the concept of "vascular depression" thanks to four levels of validity: face validity, descriptive validity, construct validity and predictive validity. The face validity is the extent to which experts agree about the existence of a nosological entity. RESULTS: The reviews published in this field broadly support the concept of "vascular depression" as a specific disorder. However many authors highlighted the fact that depression has been shown to precede vascular diseases and that depression and vascular diseases may both share some pathogenic or genetic determinants. These interactive and co-morbid relationships between depression and cerebrovascular diseases are difficult to disentangle. The descriptive validity refers to the degree of the clinical specificity of a disorder. It appears only moderate regarding the clinical studies carried out on this issue. However, a late-onset, the absence of a family history of mental illness, the lack of insight, lassitude, psychomotor retardation, a greater disability and particular neuropsychological dysfunctions may be associated with vascular depression. The construct validity, which refers to the degree to which the physiopathological processes involved in an illness are understood, appears difficult to establish because of the complex interactive relationships between cerebrovascular disease and depression. However, cerebrovascular diseases may contribute to the occurrence of depressive symptoms independently of its psychosocial burden. The predictive validity refers to the degree to which a syndrome is characterized by a specific response to treatment or a specific natural history. As regards response to treatment, vascular depression appears rather specific in the sense of a worse response to antidepressants and electroconvulsive therapy. The studies on the natural history of vascular depression lead to inconsistent results. According to some authors, this relative resistance to treatment may be explained by structural rather than functional, and thus potentially irreversible disruption in neural networks. CONCLUSION: In conclusion, the systematic review of the validity of vascular depression broadly supports this concept. However, further studies are needed to decipher the relationships between depression and cerebrovascular disease. Finally, we suggest that it could be more relevant for future researches in this field if the diagnostic criteria for vascular depression were narrowed and required the presence of both neuro-imaging changes and cerebrovascular disease.

[Frontotemporal dementia: a review]. / La démence frontotemporale: revue de la littérature.

CLINICAL CHARACTERISTICS: Frontotemporal dementia (FTD) is a neurological disorder characterised by the progressive degeneration of the frontal and anterior temporal cortex. FTD, as well as nonfluent progressive aphasia and semantic dementia, belongs to the more generic entity of frontotemporal lobe degeneration. Considering the involvement of the frontal lobe, the initial clinical presentation of FTD may be psychiatric, such as changes in personality or behavioural disorders. Psychiatrists, therefore, have to establish the differential diagnosis with late-onset schizophrenia or affective disorders. An accurate history of the onset of symptoms, thanks to the patient and especially to his/her family, is essential to recognize this dementia. In addition to behavioural changes, memory impairment, and speech disturbances are often present from the beginning. Consensus criteria have been proposed in 1998 that help to bring this diagnosis to mind in clinical practice. The progressive occurrence of personality changes or inappropriate social conducts in the fifth or sixth decade must prompt cognitive evaluation. NEUROCOGNITIVE AND BRAIN IMAGING DATA: A brief cognitive evaluation, such as the frontal assessment battery (FAB) may help to identify a dysexecutive syndrome and to prompt a thorough neuropsychological evaluation. The pattern of neuropsychological impairment reflects the involvement of the frontal lobe and appears different from that of other degenerative diseases, such as Alzheimer's dementia, which involves hippocampal damage. Additional investigations should however be made to detect a potentially curable dementia. Cerebral imaging is essential to the differential diagnosis and also shows evidence for the positive diagnosis of FTD. Structural MRI may initially not show the bilateral atrophy of the frontal lobe, but functional imaging may be helpful in the early stages of the illness by showing evidence of abnormalities in the anterior cerebral hemisphere. PATHOPHYSIOLOGICAL FINDINGS: In recent years, significant advances in the understanding of the pathological characteristics of FTD were made with genetic contribution, especially the discovery of the tau protein involvement. In fact, neuropathological examination with immunohistochemical analysis defines Pick's disease with Pick bodies that belong to tauopathies. Ubiquitinated intraneuronal inclusions may also be found, and some types of FTD have no distinctive pathological feature. However, although a definite diagnosis would only be established after postmortem pathological examination, the clinical, neuropsychological and imaging data enable the early identification of patients with FTD and, subsequently, the appropriate management. THERAPEUTICS: Although the prevalence of FTD reaches 1 Alzheimer's disease (AD) to 1.6 FTD in the general population between 45- and 64-year old, only few studies have focused on the treatment of FTD. Some evidence supports the positive effect of serotonergic agents, especially with regard to behavioural symptoms. Selective serotonin reuptake inhibitors or trazodone should therefore be prescribed in preference to acetylcholinesterase medications as in AD. However, no drug yet has the ability to stop or slow down the degenerative process. The management of daily life also bears specificities related to the younger age of these patients and to their behavioural disorders. Caregivers should receive some education about the characteristics of this dementia and should be helped in social management. As concerns aggressive behaviour, neuroleptics should generally be avoided because of poor tolerance. Finally, the outcome is characterized by a rapid loss of autonomy and sometimes by a premature institutionalisation.

[Comparative evaluation of quality of life in patients with schizophrenia treated with conventional versus atypical neuroleptics: results of a transversal study]. / Evaluation comparative de la qualité de vie de patients schizophrènes traités par neuroleptiques classiques et neuroleptiques atypiques: résultats d'une étude transversale.

AIM: The World Health Organization has defined quality of life as "the perception of an individual, his/her place in life, in the context of the culture and the system of values in which he/she lives and in relation to his/her objectives, expectations, standards and concerns". The quality of life of the schizophrenic patients has been largely studied for the evaluation of their medical, social and therapeutic needs. The impact of neuroleptics, in particular atypical neuroleptics, on the subjective quality of life of these patients remains to be specified. The aim of this study was to compare the subjective quality of life of schizophrenic patients treated with classical neuroleptics (CN) or atypical neuroleptics (AN). METHODS: One hundred patients meeting DSM IV criteria for the diagnosis of schizophrenia (American Psychiatric Association, 1994) were included in the study. Sixty-four schizophrenic patients were treated with CN and thirty-six with AN. The symptomatology of the patients was assessed using the Positive And Negative Syndrome Scale, (PANSS, Kay et al., 1987) and the Schedule for the Deficit Syndrome (SDS, Kirkpatrick et al., 1989). The extra-pyramidal symptoms were assessed using the Extrapyramidal Symptom Rating Scale (Chouinard et al., 1980). The Subjective quality of life was studied using the Lehman Quality of Life Interview (QOLI, Lehman, 1988) translated and validated in France. RESULTS: The patients treated by CN did not differ from the patients treated by AN in terms of severity of the positive and negative symptoms. The patients treated with AN presented significantly less extrapyramidal side effects than the patients treated with CN. No significant difference in terms of quality of life was found between both groups of patients. CONCLUSION: The kind of neuroleptic (CN vs AC) does not seem to influence the quality of subjective life of schizophrenic patients.

[Bipolar depression: a review of current therapeutic strategies]. / Traitement pharmacologique des dépressions bipolaires.

It is now acknowledged that depressive symptoms dominate the natural history of bipolar affective disorder. Treating bipolar depression therefore represents a major therapeutic issue that has paradoxically been understudied compared to the treatment of acute manic or hypomanic episodes. Thanks to a computerized and manual bibliographic search, we reviewed the literature pertaining to the somatic treatments of bipolar depression. It is initially advisable to implement or optimize the thymoregulator treatment by carrying out a blood titration and by adjusting the therapeutic rates as well as possible towards the upper recommended levels. In the second place, the adjunction of another mood stabilizer may be necessary to obtain euthymia while preventing a mood switch to mania. Atypical antipsychotics may have some efficacy in treating bipolar depression, but further evidence is needed. Antidepressants are generally prohibited due to the risk of induction of mania or rapid cycling. Their use is generally limited to severe cases in which the association of at least two mood stabilizers has failed.

[Pregnancy, breast feeding and mood stabilisers: review and recommendations for practice]. / Grossesse, allaitement et thymorégulateurs: eléments de décisions et règles pour la pratique.

INTRODUCTION: The high prevalence of bipolar affective disorder, the early age of onset and the even sex ratio imply that numerous women of childbearing age raise the question of mood stabilisers during pregnancy and breast feeding. LITERATURE FINDINGS: Some data suggest that giving appropriate answers to bipolar women who want to have children is an unmet need. We reviewed the risks and therapeutic options of this period of life in women with bipolar disorder. The generally accepted idea that pregnancy protects from relapses in bipolar disorders may be untrue and even deceitful. Lithium is the only mood stabiliser that can be prescribed in some cases during the first three months of pregnancy. DISCUSSION AND GUIDE LINES: We give explicit criteria that allow to consider this option: a severe illness prior to lithium prescription, a highly favourable outcome since initiation of lithium, no relapse during the last 18 months. When such conditions are satisfied, a reflection of the patient and at best of the couple must be proposed and associated with very complete information, both oral and written when possible, on the risks and benefits of the interruption and/or continuation of lithium. The teratogenic risks with anticonvulsants have been demonstrated and their prescription during the first three months of pregnancy should be avoided. Besides, there is some concern about the psycho-motor development of children born from women who were under anticonvulsants during pregnancy. The more recent mood stabilisers are not recommended either due to insufficient data. Breast feeding is not recommended under lithium, but seems safe under carbamazepine or valproate and its derivatives.

[A food cognition questionnaire]. / Elaboration d'un questionnaire sur les cognitions alimentaires.

BACKGROUND: Many authors evoke the role of cognition in the persistence of symptoms or in relapse. In pathology the cognitions produced by the patients are called dysfunctional or erroneous. The content of the cognitions are words or images issued from the treatment of information. In emotional disorders, the structure of thoughts named dysfunctional "schemata" involves a biased treatment of information and leads to erroneous cognitions. Several studies have attempted to elicit the most specific cognitions of different diseases. In this field, Hollon and Kendall found 36 cognitions specific to depression gathered in the automatic thoughts questionnaire (ATQ). In the same spirit, Beck et al. gathered 14 cognitions of anxiety and 12 depressed cognitions in the cognition check list (CCL). In the etiology and maintenance of eating disorders the cognitions take a large place. Around 1980 cognitive dysfunctioning was described and concerned food, interpersonal relationship and body shape. A few years later, some experimental studies explored these processes. The Stroop test, a categorization task, showed specific cognitive impairment in with patients eating disorders versus normal control subjects. It was then established that cognitive errors were based on food cognitions in restrictive patients, whereas they were based on body shape cognitions in bulimic patients. In several famous papers, Garner described typical cognitions of eating disorder patients and distinguished food-cognitions, eating-cognitions using case reports. As far as we know there is no clinical tool concerning such cognitions in France. That is the main motivation of the authors. AIM OF THE STUDY: The aim of this paper was to determine the characteristic cognitions of anorexic, anorexic-bulimic and bulimic patients and to compare them with those of normal control subjects. The goal of the study was to create a food cognition questionnaire. FIRST STEP METHODS: In the first step, food cognitions were collected among female eating disorder patients and normal female control subjects during systematic investigation. Ninety-two women were assessed and provided more than 3 000 food cognitions. Two independent psychologists identified the most frequent cognition per group and thus retained 115 food items. These items were randomly assigned. This provided the questionnaire. To illustrate the latter, here are the first five items: 1) Apricots are good for the health because they are rich in vitamins. 2) Pears are big fruit, difficult to digest. 3) Canned fruit is soaked with sugar. 4) Banana is a fruit which makes one put on weight. 5) White coloured food give the impression that it is not alive... The list of possible answers was: never, rarely, sometimes, often enough, often, always. SECOND STEP METHODS: In the second step, the food cognition questionnaire was proposed to 217 women including 131 eating disorder patients (53 anorexic, 50 anorexic bulimic, 28 bulimic) and 86 normal control subjects. The values of body mass index and the eating attitude test differed when we compared the two groups, and the mean age was close to 26 years in both groups. RESULTS: The statistic analysis highlighted six discriminative variables: two clinical criteria (weight and height) and four food-items given below: Q24: When I see food being fried, I feel the grease all over my body. Q76: When I start a cookie packet, I eat it up. Q102: When I feel anxious, I crave for food to fill my body. Q106: Eating pastry gives me heart-burn and makes me belch. The statistical model allowed us to differentiate eating disorder patients from normal control subjects. The content of the four food items is in agreement with experimental and clinical data. All these items included some aspects of the quality or quantity of food and also the negative consequences of food consumption on the body. CONCLUSION: To conclude, the model can help clinicians identify the patients and then initiate treatment. We also insist on the fact that this study is new and empirical, and should be extended by determining some food items for example, which would clarify the difference of behaviour between anorexics and bulimics.

[The costs of bipolar disorder]. / Coût du trouble bipolaire: revue de la littérature.

INTRODUCTION: According to the estimates of the World Bank and the World Health Organization bipolar disorder is the sixth leading cause of handicap throughout the world. The burden of this disease is similar to the one of schizophrenia. But cost-of-illness studies are too seldom. Although preventive treatments of bipolar disorder are available for more than fifty years, their economic impact has rarely been studied. LITERATURE FINDINGS: This review shows that the yearly cost of bipolar disorder is between 10,000 and 16,000 euro (12,000 and 18,000 US dollars). Eighty percent are indirect costs, 15% are linked to hospitalization and 5% to drugs. Hospitalization costs are lower in Health Maintenance Organization or general population studies than in studies performed on populations receiving care from psychiatric institutions or with a low socio-economic status. DISCUSSION: The use of mood stabilizers has a substantial impact on direct costs which are halved and consequently on indirect costs. But different surveys all agree on the dramatic under-use of mood stabilizers which may be adequately prescribed to only a quarter of bipolar patients. CONCLUSION: Therefore, the optimization of mental health system resources should prompt incentives to better screen, diagnose, and treat patients with a bipolar disorder.

[Peritraumatic distress prospectively predicts PTDS symptoms in assault victims]. / L'intensité de la détresse péritraumatique prédit la survenue des symptômes post-traumatiques parmi des victimes d'agressions.

INTRODUCTION AND OBJECTIVES: Among the peritraumatic reactions after a traumatic event, one best identifies dissociation as a predictor of serious post-traumatic problems. The dimension of emotional distress is recent in the literature and we have attempted to identify how it may contribute to the prediction of the evolution of post-traumatic symptoms. METHOD: 1. Population. Victims of individual aggression and those of a hold-up were recruited consecutively in the Paris area from five consulting centers. Individuals who had lost consciousness, had psychotic or dementia problems, or had a serious somatic patho-logy were excluded. Overall, we included 101 individuals with a traumatic experience (DSM IV criteria) that took place in the past 12 months. Two evaluations with a six-month interval were made. The first involved a face-to-face consultation with a clinician and the second required the individuals to complete self-reports. 2. Instruments. The Peritraumatic Distress Inventory (PDI) was administered to measure peritraumatic emotional distress, in the first phase. The Peritraumatic Dissociative Experience Questionnaire (PDEQ) was used to measure the intensity of the trauma and the dissociation, in this first phase. The Impact of Event Scale Revised (IES-R) was administered to assess the severity of the PTSD symptoms, in the first phase and at six months. The Mini International Neuropsychiatry Interview (MINI) was used in diagnosing depression and PTSD. RESULTS: Among the 63 subjects who were followed-up after the initial meeting and completed the second half of the study, 29 were victims of physical assault, 20 of a hold-up, 7 of a robbery, and 5 were confronted with another menacing situation; thus 40 were victims of aggression. According to the first consultation, 46 individuals presented symptoms of PTSD and 22 presented an episode of major depression. Between those who were followed-up for the whole study and those who dropped out after the initial consultation there were no significant differences with regards to gender, type of aggression, initial PDI scores (t=0.38, df=96, p=.7), PDEQ scores (t=0.7, df=96, p=0.94), or IES-R scores (t=0.23, df=97, p=0.082). Individuals who were victims of physical or sexual assault showed higher scores on the IES-R than individuals who claimed no such assault. The scores for peritraumatic dissociation were correlated with the initial IES-R scores with a correlation coefficient of 0.50. The scores from the PDEQ and the initial PDI were correlated with the IES-R scores at six months with a coefficient of 0.63. Using a multi-hierarchical linear regression controlling for type of experience, it appeared that the score of peritraumatic distress improved the variance by 14% in predicting the IES-R score at six months, compared to the prediction of the score of the initial IES-R. DISCUSSION: This is the first study using a prospective inquiry to demonstrate the power of the peritraumatic emotional distress score. Our results suggest that the type of trauma is a strong predictor of prognosis at six months. Despite our small sample size, the absence of significant differences between the drop-out group and our subjects reduces the probability of a bias in our selection criteria to explain our results. This study points to the fact that the measurement of peritraumatic emotional distress (PDI) is a good predictor of PTSD symptoms six months down the road. This study underlines the importance of an initial psychotraumatic consultation to identify the type of trauma and to measure the intensity of the peritraumatic symptoms in order to predict the severity of the evolution.

Inter-rater reliability of the French version of the core index for melancholia.

BACKGROUND: Assuming that psychomotor disturbances represent the core and are specific of melancholia, Parker et al. have developed the CORE, an 18-item scale assessing retardation, agitation and non-interactivity by behavioural observation which is able to distinguish melancholia from other depressive disorders. We report an inter-rater reliability study of the French version of the CORE. METHODS: 35 French-speaking in-patients, with ICD-10 criteria for major depression underwent a video-recorded interview aimed to rate the CORE. Each patient's recording was rated by 5 psychiatrists. We tested the inter-rater reliability of the total CORE score and of each of its three subscales' scores using the intra-class correlation coefficient (ICC). A cut-off score for melancholia was established against the opinion of the psychiatrist in charge of the patient using a ROC curve. We used Cohen's kappa to assess the agreement between raters as to rate patients above the cut-off, namely the allocation of melancholia. RESULTS: The global ICC for the total score was 0.88 and ranged from 0.97 to 0.75 for the varying rater dyads. A ROC curve yielded an optimal cut-off of 5 for melancholia. The global kappa for the agreement on melancholia allocation was good (0.65). LIMITATIONS: The five raters had not exactly the same condition of quotation. The agreement for the "agitation" subscale was poor. CONCLUSION: The French version of the CORE, has a good to excellent inter-rater reliability for the total score as for the allocation of melancholia according to a cut-off. Further validation studies are required to allow research application.

[Mixed states in bipolar disorders: a review of current therapeutic strategies]. / Traitement des états mixtes dans le trouble bipolaire de l'humeur.

Mixed states are characterized by the mixture or rapid alternation, within hours, of manic and depressive symptoms. They bear a high suicidal risk and therefore represent a major therapeutic issue. We performed a computerized bibliographic search and reviewed the efficacy of the available treatments of mixed states. It confirmed the recognized poor efficacy of lithium and the need to discontinue antidepressants. Among mood stabilizers, divalproate and its derivatives are those with the highest level of evidence. As regards new anticonvulsants, the data are yet too limited to recommend them as first line treatments. They may however be used as second line or adjunct treatments in case a monotherapy with a reference treatment has failed. Among antipsychotic drugs, clozapine has demonstrated its efficacy but also remains a second line treatment due to its high risk of neutropenia and agranulocytosis. Electroconvulsive therapy is a useful alternative in treatment resistant cases or when there is an imminent risk for suicide. Some degree of uncertainty remains for the treatment of the so called "agitated depressions" as no study has yet focused on this issue with a specifically selected sample of patients. Such a study would also enlighten the uncertain nosological status of this clinical entity and would answer as to whether they belong to the category of mixed states.