[Units for difficult patients in the mental health care system]. / Les unités pour malades difficiles dans le dispositif de soins en santé mentale.

The links between mental pathologies and violent acts, which can go as far as homicide, are a major concern for many mental health professionals. Psychiatric and psychological care of pathological perpetrators of such violence can be carried out under certain conditions in units for difficult patients.

[Management of patients with addictions in units for difficult patients]. / Prise en charge de patients présentant des addictions en unité pour malades difficiles.

The links between mental pathologies and violent acts, which can go as far as homicide, are a major concern for many mental health professionals. Addictive co-morbidities, which are increasingly frequent, are an additional risk factor for some of these patients to commit dangerous acts. Psychiatric and psychological care for pathological perpetrators of such violence can be provided under certain conditions in units for difficult patients, with addiction treatment if necessary.

[Clinic of suicidal crisis]. / Clinique de la crise suicidaire.

Nearly 5% of the general population experiences a suicidal crisis every year in France. It is essential for any caregiver to learn to recognize it and intervene appropriately. This crisis most often occurs in a context of stress combined with individual vulnerability factors that causes the individual to lose their balance. The clinical presentation for suicidal crisis vary from one subject to another. It is usually fluctuating and temporary. The subject does not want to die; he wants to stop suffering. The suicidal act is the dreaded but not systematic outcome of the suicidal crisis. Here we will set out the general principles of the assessment of the suicidal crisis.

[Suicides with suicide pacts]. / Suicides avec pactes suicidaires.

In the vast majority of cases, people who commit suicide do so alone. Exceptionally, suicides can be carried out by mutual agreement between two or more people. These are called suicide pacts. The motivations and operating methods of these rare acts are multiple.

[Acting out in the four psychic structures]. / Les rouages du passage à l'acte dans les quatre structures psychiques.

To try to understand acting out, it depends of conciliation between the reality of the act and the psychic life. For that, it is necessary to listen the word of the criminal authors. What transgression represents for them? Based on clinical experience in a correctional center, this article takes a closer look about prisoner, incarcerated after having committed criminal acts. This clinical material could help to raise a new perspective around modern psychopathology. What is the act's difference between neurosis, perversion, borderline and psychosis? Our research will try to differentiate the psychic issues.

A new evolutionary model for the vertebrate actin family including two novel groups.

Database surveys in the vertebrate model organisms: chicken (Gallus gallus), western clawed frog (Xenopus tropicalis), anole lizard (Anolis carolinensis) and zebrafish (Danio rerio) indicate that in some of these species the number of actin paralogues differs from the well-established six paralogues in mouse (Mus musculus). To investigate differential functions of actins and for establishing disease models it is important to know how actins in the different model organisms relate to each other and whether the vertebrate actin family is truly limited to six groups. Primarily through synteny analyses we discovered that the vertebrate actin family consists of eight instead of six orthologous actin groups for which we propose improved gene nomenclature. We also established that α-skeletal muscle, γ-enteric smooth muscle and γ-cytoplasmic actin genes originated prior to tetrapods contradicting an earlier and widely accepted model of actin evolution. Our findings allow a more reliable predictive classification of actin paralogues in (non-mammalian) vertebrates and contribute to a better understanding of actin evolution as basis for biomedical research on actin-related diseases.

[Perinatal bereavement, legal and social aspects]. / Le deuil périnatal, aspects juridiques et sociaux.

Since 2008, upon presentation of a medical certificate attesting to birth, parents are able to request a stillbirth certificate and the registration of their baby in the family record book, and to choose his or her funeral. In addition to the acknowledgement of the memory of this stillborn baby, certain rights are granted, subject to conditions, to the parents, such as maternity and paternity leave, pension entitlements and the birth allowance.

[Suicidal thoughts and suicide attempts in adolescence among migrants]. / Idées suicidaires et tentatives de suicide à l'adolescence en contexte migratoire.

Migration is an experience with a creative and dynamic potential, but it can also serve to further isolate people. Migrant adolescents and ethnic minorities with a migrant background are particularly vulnerable to suicidal ideation and suicidal behaviour. International studies show a significant prevalence of suicide attempts among migrants and their children. Intergenerational conflicts and the family environment, for example poor communication and lack of parental support, are risk factors for suicidal behaviour in migrant adolescents. The valorisation of the culture of origin could contribute to the feeling of 'cultural continuity' which is a protective factor of the suicidal risk.

[Links between self-harm and suicidal behaviour in adolescents]. / Liens entre conduites automutilatoires et suicidaires chez les adolescents.

Nonsuicidal self-injury (NSSI) and suicidal behaviour (SB) are both important issues in adolescent health care. The fact that they frequently coexist means that it is important to consider the nature of the link between them and the ways they are understood. Suicide and self-injury share the same risk factors. Integrated models envisage NSSI as a gateway enabling teenagers to acquire a capability for suicide. The act short-circuits the thought process and the intention to die underlying the act appears difficult to assess.

[Support groups, preventing violence and dangerousness]. / Groupes de parole, prévenir la violence et la dangerosité.

A support group brings together several people around a common theme. It aims to favour the expression of experiences, suffering, conflicts, problems as well as discussions about potential improvements or solutions. The themes of these supervised exchanges are varied and numerous. They might cover violent acts against oneself or others in order to lessen or prevent such violence and dangerousness. Support groups are often supervised and facilitated by psychologists, frequently accompanied by nurses when they take place within a healthcare setting.

[Anorexia and borderline personality disorder : bonds pathology]. / Anorexie mentale et trouble borderline : une pathologie du lien.

Comorbidity with a borderline personality disorder is far from rare in patients suffering from eating disorders. Clinically, this presents as chronic instability in many areas: interpersonal relationships, self-image, emotions, mood and acting out. Treatment is mainly based on a containing and reassuring therapeutic framework. A care plan may be put in place that incorporates reducing impulsive harmful, eating and self-harming behaviours. Dialectical behaviour therapy is intended in particular to prevent suicide risk in borderline personality disorder patients.

[Terrorist acting out, narcissism and psychopathology of identifications]. / Passage à l'acte terroriste, narcissisme et psychopathologie des identifications.

The impact of wounds and narcissistic conflicts can favour a murderous acting out. From a psychoanalytical point of view, narcissistic positions tinged with cynicism and envy in particular are identified, on a background of a pathology of ideals and the melancholisation of the social link. This article looks back at the attack in Paris in January 2015 through statements taken from social discourse.

[Contract for improving professional practices: What is the impact perceived by GPs?]. / Le contrat d'amélioration des pratiques individuelles (CAPI) : quels impacts perçus par les médecins généralistes sur leurs pratiques ?

BACKGROUND: The CAPI (contract for improving professional practices) is a voluntary pay for performance scheme for primary care physicians introduced in France in 2009. Our objective was to analyze general practitioners' (GPs) perceptions of the impact of the CAPI on their healthcare practices. METHOD: The methodology was both qualitative, using thematic analysis of responses to three items of a questionnaire mailed to GPs in 2011, and quantitative using thematic multiple correspondence analysis of responses together with cluster analysis based on the ward aggregation criterion. RESULTS: A total of 1050 general practitioners answered, 31% had signed a CAPI. For CAPI-participating GPs, the contract was mostly related to changing practices for drug prescription. GPs who did not participate in the CAPI focused on ethical issues. They denounced a conflict of interest between the doctor and the patient and also the risk of patient selection. They connected these concepts to selected indicators. Due to their relationship with the health insurance fund, they feared their freedom of practice would be restricted. CONCLUSION: GP involvement in designing indicators would favor better balance between economic goals and values of care. The patients' viewpoint should be studied. Pay for performance has been renewed in the 2011. Further studies will analyze the impact of this new scheme in a medical and economic perspective.

[Temporality and trauma: Towards an articulation between the judicial, educational and psychological times in repeat teenage offenders]. / Temporalité et trauma : vers une articulation des temps judiciaire, éducatif et psychologique chez des adolescents multirécidivistes.

Within the past few years, the problem of repeat teenage offenders has raised troubling questions among the various institutions in charge of this population. The temporalities of these adolescents are marked by immediacy, urgency, and repetition that circumvent a linear view of time and the programs set up to handle them. Studies on repeat teenage aggressors (notably, sexual aggressors) have shown that these young people often have a history of an acknowledged or unacknowledged trauma. The fact of having been a victim of abuse during childhood is thought to be a factor leading to later acting out. Our objective is to inquire into these juvenile delinquents and their treatment using a temporal framework of their life pathway that will influence the ways in which they are treated by professionals. By tracing back through the lives of these young authors of violence, we can find out whether they were themselves victims. Repeated acts of violence by a youth could then be seen not as isolated acts but as expressions of ill-being, of having been a victim, whether recognized or not. The act thus represents a link between the present and the past that can be analyzed by looking at occurrences of acting out. It would be interesting, moreover, to reflect upon how continuity could be created there where disruption strikes the youth and often the institutions too. We provide a detailed description of the notion of trauma by recalling its definition and its possible immediate and deferred effects on these youths. In the immediate time frame, the subject may present a physical reaction to the trauma. The psychological reaction will determine a psychic time frame expressed in several ways, whether immediately or at a distance from the traumatic event. Posttraumatic reactions may hamper the development of the teenager's personality. Some traumatized adolescents will express their ill-being by aggressiveness, as they replay the traumatic scene by staging violent and dangerous actions. Next we examine the different intertwined and interacting temporalities of the concerned institutions - namely, the legal, educational, and psychological therapeutic time frames - and how they contribute to creating a link between the past and the present in order to reconstruct the subject's life history. Legal time corresponds to the time during which the committed act is put into words, its significance is determined and judged, and a penal response to the offense is issued. Judgment time constitutes a waiting period for the subject; once the legal decision is made, the subject can mentally return to the present. The subject may experience this waiting period as a time to think about his/her act, in which case it may initiate a time for psychotherapy. Other youths will deny the posited act, thereby preventing any projection into the future. Educational time can only become fully meaningful once the legal decisions have been announced; its purpose is to help these youths project into a future in which their acts will repeatedly end in failure. Lastly, psychological therapy time can constitute a period of reconstruction and repair by making sense out of the acted-out events in the subject's life history. Repetition of delinquent acts, then, should be understand not as the repetition of isolated acts leading to disruptions that call for a response each time, but more as a means of finding meaning by reintegrating a repressed history that perturbs the present and prevents the adolescent from making a life plan. The complexity and interaction of these different temporalities (legal, educational, and psychological) prompt us to reflect upon the interconnections that should be set up, in the form of networks, to best accompany these teenagers and make their time meaningful, notably by enabling them to project into the future.

[Compensation of unforeseeable medical complications following cosmetic surgery finally made possible by ONIAM]. / L'indemnisation enfin possible par l'ONIAM des aléas thérapeutiques après un acte de chirurgie esthétique.

In the absence of any proven medical fault by a plastic surgeon, the patient could not obtain compensation through national solidarity (as stipulated by the Law of March 4th 2002). Indeed ONIAM (France's National Office for Medical Accidents' Compensation) has always rejected any claims on the grounds that cosmetic surgery differs from medical care. Through its judgment of February 5th 2014, France's final Court of Appeals settled the question and considered cosmetic surgery as medical care; in case of serious injuries following unforeseeable medical complications, the patient may be compensated by ONIAM, as with any other medical act. This jurisprudence will certainly result in medical liability insurers be no longer those only responsible for compensation of injuries following cosmetic surgery. Plastic surgeons' insurance premiums should logically become cheaper.

[Patient's consent to the medical act]. / Le consentement à l'acte médical.

The right to consent has become over time a fundamental right in both French and international law. Even if it is not formalized, the patient's consent is now required for each medical act. Moreover, it is always revocable. This article proposes to outline the historical evolution of consent in French legal texts.

Repetition and breakdown: Freud, Winnicott, and death.

Freud's "repetition compulsion" and Winnicott's "breakdown" are two divergent concepts that both arise out of an effort to think the unthinkable of death and annihilation. The relationship between these concepts will be examined in terms of their clinical, psychoanalytically theoretical, and philosophical aspects. Freud spoke of the "fright" of trauma, which threatens the functioning of the psychic apparatus, but then he devised a representational conception of death, leading to the hypothesis of the death drive. Winnicott rejected the latter yet he made direct reference to Freud in his theory of trauma. A clinical vignette will show how a represented element (repetition) and an unrepresented element (breakdown) interact in repetition compulsion, leading to the thesis that the compulsory nature of repetition compulsion originates in the threat of breakdown, which also involves the environment (the analyst). This leads to further reflections on the different and yet mutually expository paths that Freud and Winnicott took to make death and annihilation available to thought. An investigation into the temporal structures of repetition and breakdown shows that breakdown involves a breakdown of represented time and therefore cannot be assigned to any point in time. Lastly, on the basis of clinical material, the question is raised as to how an action that represents breakdown can come about: witnesses who interpret an event as an intentional action play a decisive role here. The paper concludes with comments on the implications for treatment.

[From the prohibition of practice to the decree of nursing acts]. / De l'interdit d'exercer au décret d'actes infirmiers.

Nursing care, which is a common life-sustaining practice, has been slowly legalized through the creation of a list of purely technical procedures, which many people see as a limitation on professional practice. However, nursing care is much more than a list of procedures. Moreover, the status of medical assistants, formalized during the first half of the 20th century, slowed down the evolution of the nursing function in its desire for autonomy and left an indelible mark on it. Certain events led the legislator to designate care in a list of autonomous acts and acts under delegation.

[Units for difficult patients]. / Les unités pour malades difficiles.

The ten French units for difficult patients are secure psychiatric services which receive people suffering from mental pathologies who could have committed or have committed dangerous acts. Among the mental health structures presented in this dossier, the units for difficult patients are those which admit prisoners with psychological disorders and problems of dangerousness for the longest period of time. As fully-fledged care facilities, they offer intensive and multi-professional care.

[Psychiatric intensive care units]. / Les unités de soins intensifs psychiatriques.

The intensive psychiatric care units are intermediate health structures between the sector psychiatric services and the units for difficult patients. Prisoners can be treated there under article D. 398 of the Code of Criminal Procedure.