Estelle Louët

Troubles bipolaires de type I de l'adolescent: controverses et devenir à l'âge adulte

BACKGROUND Little is known on the phenomenology and potential prognosis factors of bipolar episodes in adolescents. In particular, very few studies examine this issue on inpatients in the European context of free access to care. OBJECTIVE To assess the follow-up in adulthood of acute manic and mixed episodes in hospitalized adolescents and the predictive value of psychological testing. METHODS 80 subjects, aged 12 to 20 years, consecutively hospitalized for a manic or mixed episode between 1994 and 2003, were contacted in 2005-2006 for a follow-up assessment. 5 patients refused, 20 were lost, 55 patients were assessed by direct and complete interview (67%) or by phone and treating psychiatrist (33%). RESULTS At index episode, the sample was characterized by severe impairment, high rates of psychotic features (N = 50, 62,5%), a long duration of stay (mean = 80,4 days), and an overall good improvement at discharge from hospital (86% very much or much improved). Half had a psychological testing before discharge. At follow-up (mean average 5 years), 35 patients still had a diagnosis of bipolar disorder. Eight changed life-time diagnosis for schizoaffective disorder and 11 for schizophrenia. Mortality and morbidity were severe with one subject who died from cardiac failure, and 91% of patients who had at least one relapse. Patients without relapse (N = 5) and patients showing a good social functioning (N = 19) remained with a diagnosis of bipolar disorder. Using a clinical global impression method, psychological testing (blind with follow-up status) was significantly correlated with transition to schizophrenia spectrum disorder. CONCLUSION Contrarily to what is seen in less severe sample of bipolar disorder, changes in life time diagnosis can occur during follow-up after a manic or mixed episode in adolescence, as many patients are in the schizophrenia spectrum in adulthood.Resume Contexte Le trouble bipolaire de l’enfant et de l’adolescent a donne lieu ces dernieres annees a de nombreuses controverses liees a l’usage extensif de ce diagnostic chez l’enfant prepubere. Pourtant, les etudes dans sa forme la mieux caracterisee – a savoir le trouble bipolaire de type I de l’adolescent – restent rares et les donnees sur le devenir a l’âge adulte limitees. Objectifs Decrire la phenomenologie des episodes maniaques et mixtes de l’adolescent et leur devenir a l’âge adulte dans une cohorte francaise. Methodes Quatre-vingt sujets, âges de 12 a 20 ans, hospitalises pour un episode maniaque ou mixte entre 1994 et 2003 ont ete recrutes. Les donnees cliniques et socio-demographiques de l’episode index ont ete colligees retrospectivement sur dossier. Tous les patients ont ete contactes en 2005-2006 pour une evaluation du devenir. Cinq ont refuse, 20 ont ete perdus et 55 ont pu etre evalues lors d’un examen standardise (67%) ou indirectement par telephone et via leur psychiatre traitant (33%). Resultats A l’episode index, l’echantillon etait caracterise par une tres grande severite, une proportion elevee de symptomes psychotiques (N = 50, 62.5%), une duree d’hospitalisation longue (moyenne = 80,4 jours), et dans l’ensemble une bonne amelioration symptomatique a la sortie. Plus d’episodes maniaques que mixtes ont ete diagnostiques chez les adolescents migrants et chez ceux presentant un retard cognitif. A distance (en moyenne 5 annees apres leur sortie), 35 patients avaient toujours un diagnostic vie entiere de trouble bipolaire. Huit ont change de diagnostic pour un trouble schizoaffectif et 11 pour une schizophrenie. La mortalite et la morbidite sont apparues severes puisqu’un sujet est decede d’un arret cardiaque, et que 91% des patients ont eu au moins une rechute. Les patients sans rechutes (N = 5) et ceux qui temoignaient du meilleur niveau de fonctionnement social (N = 19) appartenaient tous au groupe qui maintenait un diagnostic vie entiere de bipolarite. Bien que preliminaire, nos premieres donnees suggerent que l’examen psychologique associant evaluations cognitive et projective pourrait etre un indice pronostique du risque de transition schizophrenique. Conclusion Ces donnees suggerent que les episodes maniaques et mixtes de l’adolescent necessitent souvent une hospitalisation prolongee pour consolider l’amelioration en phase aigue. Contrairement aux donnees de la litterature sur les formes moins severes, des transitions du diagnostic vie entiere vers les troubles du spectre de la schizophrenie sont frequentes. Des analyses complementaires sont en cours pour determiner les facteurs pronostics de cette transition.

Diagnostic transition towards schizophrenia in adolescents with severe bipolar disorder type I: An 8-year follow-up study

BACKGROUND The diagnosis of bipolar disorder-I (BD-I) is currently well-established. However, more studies exploring diagnostic stability and psychosocial adaptation during follow-up in adulthood are needed. OBJECTIVES We assessed factors at follow-up (FU): (1) the diagnostic stability of manic/mixed episodes from adolescence to adulthood, (2) psychosocial adaptation, and (3) factors associated with psychosocial adaptation. METHODS A sample of 80 adolescents hospitalized in a university hospital between 1993 and 2004 for a manic or mixed episode were contacted for an FU assessment on average 8 years after the index episode. Assessments included socio-demographic data, mortality, lifetime psychiatric diagnosis, the Social Adaptation Scale, negative life events and insight. RESULTS Of the 64 patients with available information, one patient died from a heart attack. Of the 55 patients available for an FU assessment, 35 (63.6%) still presented a diagnosis of BD-I at FU, whereas 20 (36.4%) had changed diagnosis towards a schizophrenia spectrum disorder. Psychosocial adaptation was moderate to poor for most patients, and 91% of the patients had at least one relapse. A low socio-economic status, intellectual disability, negative life events, a history of sexual abuse, and treatment with classical antipsychotics at FU were significantly associated with poorer psychosocial adaptation. In contrast, better insight, a family history of depression and a diagnosis of BD-I at FU were associated with better psychosocial adaptation. CONCLUSION BD-I in adolescent inpatients can lead to important morbidity and mortality during outcome. Diagnostic stability is high, but a high proportion of patients also show a transition towards a schizophrenia spectrum disorder.

The benefits and tolerance of exercise in myasthenia gravis (MGEX): study protocol for a randomised controlled trial

BackgroundResearch exploring the effects of physical exercise in auto-immune myasthenia gravis (MG) is scarce. The few existing studies present methodological shortcomings limiting the conclusions and generalisability of results. It is hypothesised that exercise could have positive physical, psychological as well as immunomodulatory effects and may be a beneficial addition to current pharmacological management of this chronic disease. The aim of this study is to evaluate the benefits on perceived quality of life (QOL) and physical fitness of a home-based physical exercise program compared to usual care, for patients with stabilised, generalised auto-immune MG.MethodsMGEX is a multi-centre, interventional, randomised, single-blind, two-arm parallel group, controlled trial. Forty-two patients will be recruited, aged 18–70 years. Following a three-month observation period, patients will be randomised into a control or experimental group. The experimental group will undertake a 40-min home-based physical exercise program using a rowing machine, three times a week for three months, as an add-on to usual care. The control group will receive usual care with no additional treatment. All patients will be followed up for a further three months. The primary outcome is the mean change in MGQOL-15-F score between three and six months (i.e. pre-intervention and immediately post-intervention periods). The MGQOL-15-F is an MG-specific patient-reported QOL questionnaire. Secondary outcomes include the evaluation of deficits and functional limitations via MG-specific clinical scores (Myasthenia Muscle Score and MG-Activities of Daily Living scale), muscle force and fatigue, respiratory function, free-living physical activity as well as evaluations of anxiety, depression, self-esteem and overall QOL with the WHO-QOL BREF questionnaire. Exercise workload will be assessed as well as multiple safety measures (ECG, biological markers, medication type and dosage and any disease exacerbation or crisis).DiscussionThis is the largest randomised controlled trial to date evaluating the benefits and tolerance of physical exercise in this patient population. The comprehensive evaluations using standardised outcome measures should provide much awaited information for both patients and the scientific community. This study is ongoing.Trial registrationClinicalTrials.gov, NCT02066519. Registered on 13 January 2014.

Narcissisme et fonctionnements limites à l'adolescence à travers l'étude du TAT

A partir de l’etude approfondie de deux protocoles de TAT d’adolescents qui presentent un fonctionnement limite, les auteurs se proposent d’en degager les modalites defensives et les problematiques en utilisant la feuille de depouillement du Nouveau manuel du TAT (ed. 2003). En s’etayant sur les procedes CN (Investissement narcissique) et CL (Instabilite des limites), les auteurs se sont interroges sur l’expression des problematiques de perte d’objet et leur articulation avec le narcissisme. Les qualites du narcissisme leur ont paru un point nodal pour degager differentes modalites de fonctionnement limite.