[Mentalization based treatment and borderline personality disorder]. / Thérapie basée sur la mentalisation et le trouble de personnalité limite.

THEORETICAL BACKGROUND: The borderline personality disorder is a complex psychiatric disorder that represents a high number of patients in a psychiatric adult service. Even if some therapies have shown to be effective in the therapeutic care of the borderline personality disorder they only target certain symptoms (e.g. anxiety, sadness, self-mutilation). The aim of this paper is to introduce a therapeutic model little known in France: the mentalization based therapy (MBT) developed in 2004 by Bateman and Fonagy. This therapeutic model apprehends the borderline personality disorder in all its complexity and is based on two main concepts: Bowlby's attachment theory and the concept of mentalization. The MBT is based on the hypothesis that a deficit of mentalization leads to the development of borderline disorder. The capacity of mentalization, also known as reflexive function, is acquired in infancy through interpersonal relationships, in particular those of attachment, and is the ability to understand the mental state (emotions, needs, thoughts, etc.) of oneself and others which underlies explicit behaviour. This reflexive capacity is of a better quality when the person has a secure attachment style. Indeed, borderline patients have, mainly, a deficit of mentalization capacity associated with an insecure attachment style. Thus, the main objective of the Bateman and Fonagy approach is to develop and reinforce the mentalization capacity through a therapeutic relationship as a secure base, a group therapy and the concept of insight. THERAPY STRUCTURE AND TECHNIQUES: Classically, MBT is structured over a period of 18 months divided into 3 distinct phases distributed in two therapeutic axes: group and individual therapy. The initial phase aims to engage the patient in the therapy by evaluating attachment style, mentalization's ability, interpersonal functioning; providing psychoeducation about borderline disorder and establishing a therapeutic contract. To evaluate attachment style, the authors strongly recommend the use of the Relationship Scales Questionnaire. During the second phase, which includes individual and group therapy, the aim is to stimulate the capacity of mentalization through different techniques according to the patient's attachment style. These include therapeutic relationship, empathy, affect clarification and elaboration, positive and negative reinforcement. The final phase serves to review the patient's improvement and to prepare him progressively for the end of the therapy which can be experienced as an abandonment. CLINICAL TRIALS OF MBT AND DEVELOPMENTS: Effectiveness of MBT in treating borderline disorder has been shown in several studies with short and long term benefits. It can be adapted for other personality disorders and specific populations such as adolescents. CONCLUSION: This article introduces the key concepts and aims of mentalization based treatment. The therapy is briefly described in its different phases and the various techniques are discussed. Clinical trials have shown that MBT is effective in treating borderline disorder in adolescent and adult populations. Despite the effectiveness of this therapy, it is difficult to set up and requires substantial resources. Interpersonal therapy based on attachment provides a therapeutic model focused on problematic areas which can offer an alternative therapy and reduce the fields of investigations.

Benefit of contralateral hearing aid in adult cochlear implant bearers.

OBJECTIVES: The present study assessed the interest of a contralateral hearing aid (HA) in adult cochlear implant (CI) bearers. MATERIAL AND METHODS: The study recruited 10 French-speaking adult HA bearers with postlingual bilateral hearing loss, fitted for at least 2 years with a unilateral CI after loss of benefit from HA in one ear but continuing to use their contralateral HA: 4 male, 6 female; mean age, 58 years. All had regularly used bilateral HAs prior to CI. Audiometric assessment comprised: (1) individual ear hearing assessment on pure-tone audiometry and speech discrimination; and (2) free-field testing without aid, with CI only, with HA only and with CI plus HA, on pure-tone audiometry and speech discrimination with quiet background and on speech discrimination in noise. RESULTS: Speech discrimination was significantly improved in the bimodal condition (CI plus HA) as compared to CI alone, on all tests. In quiet, discrimination for disyllabic words was>50% in 7 cases with HA alone, in 2 cases with CI alone and in 1 case in with HA+CI. Under 0dB signal-to-noise ratio, discrimination was>50% in 1 case with HA alone, in 3 cases with CI alone and in 6 cases with HA+CI. CONCLUSION: The present results showed benefit in auditory perception in quiet and in noise with bimodal stimulation. When there is residual hearing in the non-implanted ear, a HA should be fitted; and in progressive bilateral hearing loss, CI should be suggested when HA benefit decreases in one ear.

[Performances and complications of cochlear implant in 134 adult patients implanted since 1990]. / Performances et complications de l'implant cochléaire chez 134 patients adultes implantés depuis 1990.

OBJECTIVE: The aim of this study was to analyse performance of cochlear implants in a retrospective series of adults with postlingually in order to search for predictive factors and identify complications. METHODS: Between 1990 and 2003, 134 adult patients were implanted: 129 patients on one side and 5 patients on both sides. Hearing benefit at 6, 12, 24 and 36 months and performance at 12 months were analyzed as function of the etiology, age at implantation, lipreading and speech coding strategy. RESULTS: Compared to performances before implantation, cochlear implants provided significant and rapid improvement at 6 months (p<0.0001). The results were not correlated with age at implantation, etiology or lipreading ability before implantation. Performances were worse in patients with meningitis (p<0.01), but the percentage of improvement was similar between the different etiologies. Major complications were rare: one case of regressive postoperative facial nerve weakness. CONCLUSION: Cochlear implants provide significant and rapid improvement, with low morbidity. Results are not correlated with age at implantation, etiology or lipreading ability.

[Quality of life after oropharyngectomy]. / Qualité de vie après buccopharyngectomie transmandibulaire.

OBJECTIVE: The purpose of this study was to assess direct or non-direct links between functional abilities of the patient evaluated objectively and his quality of life after oropharyngectomy, a surgery capable of engendering bad functional outcomes. METHODS: Praxies and speech were examined in 16 patients at 3, 6, 9 or 12 months after surgery and 2 self-evaluation questionnaires were proposed: One about health related quality of life of cancer patients (EORTC QLQ-C30 and H&N35) and, the other about oral communication handicap (VHI). RESULTS AND CONCLUSION: A correlation between quality of life and objective functional abilities can not always be found. Self-evaluation questionnaires might be a complementary approach in order to guide management in patient care after oropharyngectomy.

[Evaluation of the handicap by means of the EORTC scale in partial glossectomies]. / Evaluation du handicap au moyen des échelles de l'EORTC pour les glossectomies partielles.

OBJECTIVES: Different treatments for tongue cancer are more and more efficient but there are heavy functional and aesthetic sequels. The aim of this study was to evaluate the quality of life after partial glossectomy and to adapt the rehabilitation program after surgery. METHODS: Our population of 16 patients (5 females and 11 males), who underwent partial glossectomy, had to quote the auto questionnaire on quality of life (EORTC QOL-C30) and the specific head and neck cancer scale (H&N35). RESULTS: In our population, the patient's satisfaction for the global quality of life was 71%; the functioning scale was 83%, and the mean rate of generic symptoms was 13%. On the contrary, the specific Head & Neck symptom rate was high, with 76% of complains. CONCLUSIONS: The QOL scale could be considered as a good tool for patients to express their difficulties in daily life. It is a reliable and reproducible tool for a follow up study of patients. It allows proposing specific rehabilitation procedures in the post operative period.