Compulsory admissions of patients with mental disorders: State of the art on ethical and legislative aspects in 40 European countries.

BACKGROUND: Compulsory admission procedures of patients with mental disorders vary between countries in Europe. The Ethics Committee of the European Psychiatric Association (EPA) launched a survey on involuntary admission procedures of patients with mental disorders in 40 countries to gather information from all National Psychiatric Associations that are members of the EPA to develop recommendations for improving involuntary admission processes and promote voluntary care. METHODS: The survey focused on legislation of involuntary admissions and key actors involved in the admission procedure as well as most common reasons for involuntary admissions. RESULTS: We analyzed the survey categorical data in themes, which highlight that both medical and legal actors are involved in involuntary admission procedures. CONCLUSIONS: We conclude that legal reasons for compulsory admission should be reworded in order to remove stigmatization of the patient, that raising awareness about involuntary admission procedures and patient rights with both patients and family advocacy groups is paramount, that communication about procedures should be widely available in lay-language for the general population, and that training sessions and guidance should be available for legal and medical practitioners. Finally, people working in the field need to be constantly aware about the ethical challenges surrounding compulsory admissions.

Is it time to revise the diagnostic criteria for apathy in brain disorders? The 2018 international consensus group.

BACKGROUND: Apathy is a very common behavioural and psychological symptom across brain disorders. In the last decade, there have been considerable advances in research on apathy and motivation. It is thus important to revise the apathy diagnostic criteria published in 2009. The main objectives were to: a) revise the definition of apathy; b) update the list of apathy dimensions; c) operationalise the diagnostic criteria; and d) suggest appropriate assessment tools including new technologies. METHODS: The expert panel (N = 23) included researchers and health care professionals working on brain disorders and apathy, a representative of a regulatory body, and a representative of the pharmaceutical industry. The revised diagnostic criteria for apathy were developed in a two-step process. First, following the standard Delphi methodology, the experts were asked to answer questions via web-survey in two rounds. Second, all the collected information was discussed on the occasion of the 26th European Congress of Psychiatry held in Nice (France). RESULTS: Apathy was defined as a quantitative reduction of goal-directed activity in comparison to the patient's previous level of functioning (criterion A). Symptoms must persist for at least four weeks, and affect at least two of the three apathy dimensions (behaviour/cognition; emotion; social interaction; criterion B). Apathy should cause identifiable functional impairments (criterion C), and should not be fully explained by other factors, such as effects of a substance or major changes in the patient's environment (Criterion D). CONCLUSIONS: The new diagnostic criteria for apathy provide a clinical and scientific framework to increase the validity of apathy as a clinical construct. This should also help to pave the path for apathy in brain disorders to be an interventional target.

[Psychiatric disorders in adult form of Niemann-Pick disease type C]. / Troubles psychiatriques dans la maladie de Niemann-Pick de type C chez l'adulte.

INTRODUCTION: Niemann-Pick type C disease (NPC) is a rare genetic disease with an extremely heterogeneous clinical presentation. The adult form of this disease is usually expressed with neurological symptoms; however, non-specific psychiatric disorders are often associated. This article presents a retrospective study on a cohort of NPC patients diagnosed in France with the objectives of researching the presence of psychiatric disorders and qualifying these disorders. METHODS: After carrying out a research within hospital records, a questionnaire was sent to patients or their relatives and their doctors. RESULTS: The cohort was made up of 22 patients. Fifty-two questionnaires were sent to 47 different doctors. We received 67% of answers from the doctors, with 42% of positive answers. The answer rate of the families was 27%. Among the 22 patients, we found the presence of psychiatric disorders in 86% of cases. Seventy-three percent of the patients presented behavior disorders. Among them, 27% exhibited psychomotor excitation or agitation, 23% aggressiveness, 18% intolerance to frustration, 27% sleep disorders and 23% apathy, listlessness and/or clinophilia. Fifty-five percent of patients presented psychotic symptoms, with 45% with delusions and 36% with hallucinations. Seventy-seven percent of patients presented with mood disorders: 36% suffered from depression and 27% from emotional lability or mood swings. Of the 22 patients, a diagnosis of psychiatric disease was made in 50% of cases. The main diagnoses were schizophrenia (27%) and depression (23%). The other diagnoses identified were acute delirium, dysthymia, infantile psychosis, intellectual disharmonic disability and personality disorder. The average age of emergence of the troubles was 17.1 years old for neurological symptoms and 20.9 years old for psychiatric symptoms. The median age was 18 years old for neurological symptoms and 20 years old for psychiatric ones. In 45% of cases, psychiatric occurred after neurological symptoms; in 27%, they occurred before and they were concomitant in 9%. In 50% of cases, psychiatric symptoms existed before the early diagnosis of NPC; in 9%, they occurred after and in 5%, they occurred during the diagnostic process. Fifty-five percent of the patients were followed by a psychiatrist, 50% of patients had been hospitalized at least once in a psychiatric department. Fifty-five percent of the patients received neuroleptics or antipsychotics, 41% received antidepressants, 41% received mood stabilizers or anticonvulsants, 45% received anxiolytics and 23% hypnotics. DISCUSSION: Whilst a small cohort, the low incidence of NPC (1/120,000 to 1/150,000) and the scale of a single-center study make the findings important. In our cohort, we found psychiatric disorders in most of the patients. The symptoms were varied and non-specific, and mainly found in late-onset forms of the disease. This incidence of disorder is much higher than the literature suggests, generally describing psychiatric disorders in approximately one third of NPC adult form. On the other hand, our results on schizophrenia are consistent with the updated recommendations for the diagnosis and management of NPC. According to our results, a retrospective study to develop a suspicion index to aid diagnosis of NPC suggests that psychotic symptoms are underestimated in this disease. In our cohort, we also found a significant rate of psychiatric hospitalizations and psychotropic drugs prescription that had not been previously described in the international literature. We did not have sufficient data on the effectiveness of symptomatic treatment in NPC; the literature was contradictory. It should be noted that despite the high rate of psychiatric patients in our cohort, only half of patients consulted a psychiatrist and a few of them have regular follow-up. To conclude, our study is in line with the current literature that suggests an under-estimation of psychiatric disorders in NPC, but also a likely under-diagnosis of NPC in psychiatric departments. All this data encourage us to keep alerting psychiatrists to identifying this disease in order to promote early and optimal care.

[Niemann-Pick type C disease and psychosis: Two siblings]. / Maladie de Niemann-Pick de type C et troubles psychiatriques : le cas d'une fratrie.

INTRODUCTION: Niemann-Pick type C disease (NPC) is a rare, neurovisceral, autosomal recessive disease, with an extremely heterogeneous clinical presentation. The adult form of the disease is usually expressed as a neurological form. Non-specific psychiatric symptoms are often associated with NPC. For some cases, it can also be expressed as an isolated psychiatric disorder form. Since 2009, the launching of a medicine called miglustat has helped to improve the disease evolution. CASE HISTORIES: We report two siblings followed-up in the same department of psychiatry and with an atypical psychotic symptomatology. Case 1 is a 27-year-old French male. He was hospitalised several times due to disordered behaviour, psychomotor excitation, mood instability and wandering. He was originally diagnosed with schizophrenia. However, the patient's psychosis proved refractory to treatment. He also exhibited a number of neurological signs (pyramidal signs and abnormal movements of the hands, head and limbs), which were considered related to his antipsychotic medication. Three years later, a full physical, neurological and neuropsychological examination revealed various neurological and visceral symptoms. He was diagnosed with NPC based on a classical biochemical NPC-phenotype following filipin staining in cultured skin fibroblasts. NPC1 gene sequencing revealed that he was a compound heterozygote for the p.S954L and p.N1156S mutations. The patient's psychiatric and neurological symptoms are currently stabilized by miglustat, allowing the patient to cease antipsychotic medication. Case 2 is the elder sister of Case 1. She was hospitalised several times due to acute delirium, hallucinations and suicidal tendencies. She was diagnosed with paranoid schizophrenia at 22 years of age. She has received a variety of typical and atypical antipsychotics. Many of these drugs proved initially effective but the patient's symptoms repeatedly returned. The patient shows persistent and worsening gait disorder and abnormal arm movements. A follow-up neurological examination at age 29 did not detect any ataxia, cataplexy or vertical supra-nuclear gaze palsy. Direct NPC1 gene sequencing detected a mutant NPC1 allele held in common with her brother, but full sequencing of both the NPC1 and NPC2 genes and multiplex ligation-dependent probe amplification (MLPA) did not detect any other pathogenic mutation or other anomalies. DISCUSSION: Because NPC is an autosomal recessive condition, heterozygous individuals carrying only one causal gene mutation are usually asymptomatic. Thus, while the accepted wisdom would suggest that patient 2 is not affected by the disease, it is interesting to consider why she has developed neurological and psychiatric disorders like her brother. Several hypotheses are discussed: mental expression in heterozygous genetic factor predisposing to schizophrenia, comorbidity or fortuitous association. It is not currently known whether a patient with a single NPC gene mutation can express NPC in full, partially, or perhaps just to a minimal degree. This case of a patient with a heterozygous "carrier" NPC genotype and neuropsychiatric disorders suggestive of the disease raises the possibility that symptomatic heterozygous NPC patients may exist. On the other hand, if the heterozygous genotype of patient 2 does not give rise to symptomatic disease, it is pertinent to question whether it could be a predisposing factor for the development of psychiatric pathologies. There are currently no published data on the occurrence of heterozygous NPC1 or NPC2 mutations among patients with atypical psychiatric presentations combined with neurological symptoms. Conversely, there are no published data demonstrating an increased frequency of psychiatric disorders in families affected by NPC. Finally, in view of the history of psychiatric disorders in this family, it is possible that psychosis simply occurred concomitantly with symptomatic NPC in patient 1 by chance, and that schizophrenia occurred simultaneously with an asymptomatic NPC carrier genotype in patient 2. To investigate this further, NPC patients' carrier family members (parents and siblings) should be fully screened for signs suggestive of the disease.

[Survey among academic teachers about psychiatric training in France]. / Enquête auprès des PU-PH sur la formation en psychiatrie en France.

INTRODUCTION: Given the results of resident psychiatrists' surveys conducted in France over the past 3 years, it has become essential to also examine the opinion of the academic psychiatrists in charge of psychiatry education. GOALS: To study the teachers point of view on psychiatric training in France, the weaknesses and strengths of the training, recent improvements and problems, and to compare their opinion with that of the residents. METHODOLOGY: A survey was conducted in April 2012 among 125 academic teachers professors hospital practitioners (PU-PH), in child & adolescent psychiatry and adult psychiatry. An anonymous online questionnaire including seven parts and three open questions was sent to the PU-PH. RESULTS: The questionnaire was answered by 79/125 psychiatric PU-PH (63%). Results show that a majority of PU-PH (78%) were willing to maintain a single training pathway including adult psychiatry and child psychiatry with a single diploma, with the addition of a DESC (specific and additional Diploma) in forensic psychiatry (72%) and old age psychiatry (62%). Almost all respondents suggested the implementation of an assessment of teaching and a formal mentorship program. Some aspects of training included more controversial issues: such as the length of the training, the opening of training to private practice physicians, or the European harmonization. CONCLUSION: The survey stressed some areas of improvement: such training in psychotherapy and research, access to supervision as well as barriers to improved training including an insufficient number of academic practitioners. Compared with other surveys, it emphasized that in addition to the need of diversifying the theoretical (thematic, interactive media and teaching, teachers, etc.) and the practical aspect (training sites), it is essential according to trainees and PU-PH, to implement an efficient supervision during residency.

[Adult onset Niemann-Pick type C disease and psychosis: literature review]. / Maladie de Niemann-Pick de type C chez l'adulte et troubles psychiatriques : revue de littérature.

INTRODUCTION: Niemann-Pick type C disease (NPC) is a rare hereditary disease, which psychiatrists do not face often in France. Indeed, only a couple of articles specifically describing the psychiatric-disorders in the adult form have been published. And for the most part, they were not written by psychiatrists. This comprehensive international literature review aims at providing knowledge on this disease to French psychiatrists. METHODS: To achieve this literature review, we used the "PubMed" search engine, looking for the following keywords: Niemann-Pick type C AND (schizophrenia OR psychosis). RESULTS: Niemann-Pick type C disease (NPC) is a rare, neurovisceral, autosomal recessive disease, with an extremely heterogeneous clinical presentation. It is characterized by a wide range of symptoms that are not specific, such as neurological, systemic or psychiatric symptoms. The adult form of the disease concerns a small proportion (5 %) of the people affected and is usually expressed as a neurological form. A variety of progressive and disabling symptoms are encountered, mainly cerebellar signs (cerebellar ataxia, impaired gait, dysarthria), but also movement disorders, cataplexy, seizures and dysphagia. Patients face constant cognitive deterioration, which can result in severe dementia. Abnormal saccadic eye movement is often the first manifestation of the disease. Supranuclear gaze palsy is considered to be a specific sign and should be systematically searched for. In terms of systemic signs, the usual infantile hepatosplenomegaly is very fickle in the adult form; if present, it is usually asymptomatic. Non-specific psychiatric symptoms are often associated with NPC disease. For one third of cases, it can also express as an isolated psychiatric-disorder form, such as schizophrenia-like psychosis (paranoid delusions, auditory hallucinations, interpretative thoughts, and disorganization), depression, bipolar disorder, obsessive-compulsive behaviour and behavioural problems (sleep disorders, hyperactivity, agitation, aggressiveness or self-mutilations). This psychiatric overview is mostly atypical and is accompanied by visual hallucinations, confusion, symptom fluctuations, treatment resistance or aggravation with neuroleptic drugs, catatonia, progressive cognitive decline, but also seizures. The late appearance of neurological manifestations is often wrongfully attributed to the effects of antipsychotic medication, which generates tardy diagnosis. Most of NPC affected patients die prematurely. NPC diagnosis is based on a filipin test on a fibroblast culture from a skin biopsy and also on a sequencing of the NPC1 and NPC2 genes. Routine laboratory biochemistry profiles are generally normal. The early diagnosis is fundamental to deploy the best follow-up care. The patient should therefore be in contact with a reference centre. Until recently, NPC treatment consisted in supportive therapies and symptomatic drugs, useful, however, with variable efficacy. The recent discovery of a medicine called Miglustat (N-butyldeoxynojirimycin; NB-DJN; Zavesca(®), Actelion Pharmaceuticals Ltd.) which improves the disease evolution, should encourage psychiatrists to look for it in every atypical psychosis.

Pacing strategy and VO2 kinetics during a 1500-m race.

We investigated the oxygen uptake response (V.O (2)) to a 1500-m test conducted using a competition race strategy. On an outdoor track, eleven middle-distance runners performed a test to determine V.O (2max), velocity associated with V.O (2max) (v-V.O (2max)) and a supramaximal 1500-m running test (each test at least two days apart). V.O (2max) response was measured with the use of a miniaturised telemetric gas exchange system (Cosmed, K4, Roma, Italy). The 1500-m running test was performed at a mean velocity of 107. 6 + 2 % v-V.O (2max). The maximal value of oxygen uptake recorded during the 1500-m test (V.O (2peak)) was reached by subjects at 75.9 + 7.5 s (mean + SD) (i.e., 459 +/- 59 m). The time to reach V.O (2max) (TV.O (2peak)) and the start velocity (200- to 400-m after the onset of the 1500 m) expressed in % v-V.O (2max) were negatively and significantly correlated (p < 0.05), but our results indicate that a fast start does not necessarily induce a good performance. These results suggest that V.O (2max) is reached by all the subjects at the onset of a simulated 1500-m running event and are therefore in contrast with previous results obtained during treadmill running.

Oxygen uptake response to an 800-m running race.

We tested the hypothesis that time course of O (2) uptake (VO (2)) measured during a supramaximal exercise performed in the field is driven to maximal oxygen uptake (VO (2max)). On an outdoor track, five middle-distance male runners first performed a test to determine VO (2max) and a supramaximal 800-m running test at least two days apart. VO (2) response was measured from the start to the end of exercise with the use of a miniaturised telemetric gas exchange system (Cosmed K4). VO (2max) was reached by all subjects 45 +/- 11 s (mean +/- SD) after the onset of the 800-m race (i.e., 316 +/- 75 m), and was maintained during the next 33 +/- 6 s (i.e., 219 +/- 41 m). The mean relative exercise intensity of the 800 m was 120 % VO (2max). An unexpected significant decrease in VO (2) (24.1 +/- 7.0 %; p < 0.05) was observed in all subjects during the final 38 +/- 17 s (i.e., the last 265 +/- 104 m). We concluded that, at onset of a simulated 800 m running event, VO (2) is quickly projected towards the VO (2max), and then becomes limited by the achievable VO (2max). This race profile shown by all athletes is in some contrast to what can be expected from earlier findings in a laboratory setting.

[Diogenes syndrome: a transnosographic approach]. / Le syndrome de Diogène, une approche transnosographique.

Diogenes syndrome is a behavioural disorder of the elderly. Symptoms include living in extreme squalor, a neglected physical state and unhygienic conditions. This is accompanied by a self-imposed isolation, the refusal of external help and a tendency to accumulate heteroclite objects. This particular geriatric syndrome has been described for the first time only quite recently, as the 2 primary descriptions by geriatricians and psychiatrists date from 1966 and 1975 respectively. Its rare occurrence contrasts with the fact that it is well-known, partly due to it being named after the Greek philosopher "Diogene de Sinope", who taught cynicism philosophy and a return to a natural way of life, and partly because of its rare characteristics. The Diogenes syndrome is a fascinating object of study for the clinician who takes care of patients living in uncommon conditions, on the edge of society and unaware of the particularity of their lifestyles. Patients suffering from Diogenes syndrome are usually discovered by chance, either because of a somatic illness, or as a result of social intervention related to their behavioural problems. Management of the syndrome is difficult and ethically challenging, as the patient does not seek help. Moreover, 46% of patients have a 5 year mortality rate. Hospitalisation has to be avoided whenever possible and ambulatory treatment and social measures should be favoured. Psychotropic treatment prescription may be necessary, depending on clinical features and the possible underlying psychiatric disease. Although several clinical hypotheses have been suggested, the true ethiopathogeny of the syndrome remains unclear. Most authors agree that this behaviour does not reflect free will and has consequently no theoretical relationship to the Greek philosopher. There is no true consensus about diagnostic criteria. They include the main features of the syndrome and exclude known psychiatric syndromes. Clark and Mankikar, who named this syndrome, reckon it may represent stress-related defence mechanisms of the elderly or may be related to natural ageing process. However, psychiatric pathologies as paranoid and paranoiac psychoses, mood disorders and obsessive and compulsive disorders have been described to be associated with it in the literature. Dementia, in particular temporo-frontal dementia, should be looked for and excluded clinically. Alcohol abuse seems to be an aggravating rather than a precipitating factor. Finally, the link between these pathologies and Diogenes syndrome is not yet determined: are they triggering, co-morbid or etiological factors? Should this syndrome be considered as a true illness or as a symptom? This paper presents Diogenes syndrome as a behavioural disorder and distinguishes 2 types: the "active type"--patients who collect from outside to clutter inside--and the "passive type"--patients who passively become invaded by their rubbish. Active type patients fill their home to fill in the vacuum of their life, as it deteriorates and looses its narcissical appeal. Passive type patients accumulate by default and emptiness. A psychopathological understanding is presented here, referring to psychoanalytical theories of the Moi-peau (ego-skin) described by Anzieu. The Moi-peau represents a structure of the psyche founded on the following principle: any psychic function develops itself according to a bodily function from which it transposes its functioning at a mental level. The skin has three functions: the containing shell, the protective barrier of the psyche, and a medium of exchange. The Moi-peau is organised as a double-wall acting both as a defence mechanism and as a filter between the psyche and the external world. It preserves the relationship and the cohesion "container-content". As a result of a narcissical wound, the Moi-peau is damaged and looses its function of a container. In the case of Diogenes Syndrome, the accumulated items repair the Moi-peau and the home becomes an "exterior-proof", thus playing the role of the Moi-peau. This behaviour therefore plays a repairing role for psychic functioning, allowing psychic survival.

Electromyogram as an indicator of neuromuscular fatigue during incremental exercise.

This study analysed the changes in the electromyographic activity (EMG) of the vastus lateralis muscle (VL) during an incremental maximal oxygen uptake test on a treadmill. A breakpoint in the integrated electromyogram (iEMG)-velocity relationship has already been interpreted in two ways: either as a sign of neuromuscular fatigue or as an expression of the iEMG-velocity relationship characteristics. The aim of this study was to test a method of distinguishing fatigue effects from those due to increases in exercise power. Eight well-trained male runners took part in the study. They completed a running protocol consisting of 4-min stages of increments in power output. Between each stage (about 15 s after the start of a minute at rest), the subjects had to maintain a standard effort: a 10-s isometric leg extension contraction [50% isometric maximal voluntary contraction (IMVC)]. The EMG was recorded during the running and isometric protocols, a change in the EMG signal during the isometric exercise being considered as the sign of fatigue. The iEMG-velocity relationships were strongly fitted by a second-order polynomial function for data taken at both the start (r = 0.98) and the end (r = 0.98) of the stage. Based on the stability of the 50%IMVC-iEMG relationship noted between stages, the start-iEMG has been identified as expressing the iEMG-velocity relationship without fatigue. The stage after which end-iEMG increased significantly more steeply than start-iEMG was considered as the iEMG threshold and was simultaneous with the ventilatory equivalent for carbon dioxide threshold. The parallel changes of minute ventilation and iEMG would suggest the existence of common regulation stimuli linked either to effort intensity and/or to metabolic conditions. The fall in intracellular [K+] has been discussed as being one of the main factors in regulating ventilation.

Planning for advanced EDI operations in materiel management--a case study.

Florida Hospital, a 1,462-bed organization in five locations in the central Florida area, wanted to implement an EDI system that would take redundancies, paper and FTEs out of their system. They hired a consultant to educate them about EDI and help them put together an EDI business plan. They decided to implement three initial transaction sets for a price catalog, purchase orders, and PO acknowledgments. Requesting departments will be able to order routine items directly from vendors via EDI. Future transaction sets will include advance ship notice with price (857) that will generate a receipt off of which the hospital will pay, and electronic funds transfer. Translation and communication software for their mainframe system was chosen to accommodate both the most and least electronically sophisticated trading partners, and negotiations/education on doing business with the hospital via EDI are ongoing.