Olivier Cottencin

10 – Thérapies systémiques brèves et contrainte psychiatrique… familiale, sociale, judiciaire…

Si les therapies breves sont une methode alternative aux approches traditionnelles et permettent une solution rapide pour un certain nombre de troubles psychologiques, elles bouleversent toutefois la relation daide dans le domaine psychologique, medical et psychiatrique mais aussi social. Cest pourquoi il est necessaire dapporter au therapeute un eclairage clinique approfondi lui permettant de mieux maitriser toutes les dimensions de ces therapies. n nPar leur approche tres pragmatique de ces differentes situations, les auteurs repondent ainsi aux questions que se posent les therapeutes sur des themes aussi varies que les troubles anxieux, la depression, lalcoolisme, lutilisation de la therapie breve sous contrainte dans un service ferme ou avec des patients psychotiques.Pour cette nouvelle edition, entierement mise a jour et augmentee, laccent est mis sur lapport des therapies breves dans les troubles du comportement alimentaires – anorexie, boulimie, vomissements – et dans larret du tabac. Un chapitre est par ailleurs consacre desormais a la theorie du mimetisme et des neurones miroirs et son interet dans la mise en place des therapies breves. n nCet ouvrage sadresse ainsi aux psychiatres, psychologues, psychotherapeutes, equipes soignantes et travailleurs sociaux.

9 – Thérapie systémique brève et psychose

Si les therapies breves sont une methode alternative aux approches traditionnelles et permettent une solution rapide pour un certain nombre de troubles psychologiques, elles bouleversent toutefois la relation daide dans le domaine psychologique, medical et psychiatrique mais aussi social. Cest pourquoi il est necessaire dapporter au therapeute un eclairage clinique approfondi lui permettant de mieux maitriser toutes les dimensions de ces therapies. n nPar leur approche tres pragmatique de ces differentes situations, les auteurs repondent ainsi aux questions que se posent les therapeutes sur des themes aussi varies que les troubles anxieux, la depression, lalcoolisme, lutilisation de la therapie breve sous contrainte dans un service ferme ou avec des patients psychotiques.Pour cette nouvelle edition, entierement mise a jour et augmentee, laccent est mis sur lapport des therapies breves dans les troubles du comportement alimentaires - anorexie, boulimie, vomissements - et dans larret du tabac. Un chapitre est par ailleurs consacre desormais a la theorie du mimetisme et des neurones miroirs et son interet dans la mise en place des therapies breves. n nCet ouvrage sadresse ainsi aux psychiatres, psychologues, psychotherapeutes, equipes soignantes et travailleurs sociaux.

Antipsychotics Management in Addictive Disorders

Abstract: Several authors have hypothesized that antipsychotics could down-regulate the activation of dopamine receptors in the mesolimbic pathway, thus decreasing the occurrence and the intensity of addiction-related symptoms. We conducted a critical review of the theoretical arguments that have been published on this subject and evaluated how they compare to the published clinical data. Despite interesting findings, the effects of antipsychotics may not be as compelling as what would be theoretically expected. Thus far, antipsychotics have shown no efficacy in treating addictive disorders alone. Nevertheless, effective strategies for the use of antipsychotics against addictions are available and discussed. To treat individual vulnerability factors to addictions, such as psychiatric comorbidities (schizophrenia or bipolar disorder) that share vulnerability factors with addictive disorders and contribute to triggering addictive behaviors are among the strategies. The evidence for using antipsychotics is still the best in subjects with comorbid schizophrenia and alcohol or substance use disorder. Additionally, in some clinical situations of major impulsivity, the off-label prescription of atypical antipsychotics is worth exploring, but should be further investigated in a clinical setting.

Catatonia in diagnostic and statistical manual of mental disorders, fifth edition

As international scholars of catatonia, we are concerned that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) proposes to delete the codes 295.2 (schizophrenia, catatonic type) and 293.89 (catatonia secondary to a medical condition) and to substitute a noncoded “catatonia specifier” as the principal identifier. We believe that these changes will badly serve clinical practice and research. We advocate a unique and broadly defined code for catatonia in DSM-V. n nCatatonia is common among hospitalized psychiatric patients, including adults, adolescents, and occasionally children. In the 10 principal prospective studies from sites around the world, catatonia syndrome was identified in a mean (SEM) percentage of 9.8% (1.4%) of adult admissions (Table 1). These patients have multiple signs of catatonia (commonly >5); 68% (6%) are mute, and 62% (3%) are negativistic or withdrawn. Some are unable to eat, requiring parenteral nutrition and/or medication. n n n nTABLE 1 n nProspective Studies of the Incidence of Catatonia n n n nOnce catatonia is recognized, first-line treatment with benzodiazepines usually brings prompt relief, although high doses may be needed. If catatonia persists, electroconvulsive therapy is often rapidly beneficial. Every prospective study confirms that catatonia syndrome exists, occasionally becomes malignant, and requires prompt treatment. n nUnder the proposed new guidelines for DSM-V, patients with catatonia syndrome will lack an informative diagnosis. Mutism, negativism, and withdrawal prevent assessment for mood, cognitive, and psychotic symptoms and impede proper delineation of episodes of prior illness. Without findings for a specific diagnosis, it is rational to use a provisional diagnosis of the catatonia syndrome to allow tests and treatments to proceed. Lacking recognition and treatment, catatonia may persist or worsen with adverse or life-threatening results. On the other hand, when patients with catatonia are identified and treated, they become verbal and interactive, allowing interviews and more definitive diagnoses, regardless of the primary pathological findings. n nWhen patients cannot provide information, clinicians may conflate or misdiagnose catatonia with schizophrenia (as in the DSM-IV schema), impute a psychotic process, foster the unproven use of neuroleptics, and risk adverse effects, such as conversion to malignant catatonia or the neuroleptic malignant syndrome. Similarly, assignment of catatonia to “psychosis not otherwise specified” (298.9, DSM-IV and DSM-V) would be erroneous because these patients often either lack hallucinations and delusions or cannot be assessed for them. n nThe proposed elimination of DSM-IV “catatonia due to a general medical condition” (293.89) renders the coding for catatonia arising from general medical conditions problematic. At clinical presentation, the medical/toxic factors are rarely known, as time is often needed to identify these etiologies. n nWe also note that noncoded specifiers are not useful for research on nosology, treatment, and outcome. n nTo address all these issues, we urge inclusion in DSM-V of a specific diagnostic code for catatonia. One simple option is to retain the 293.89 code but revise its formulation to broadly encompass the catatonia syndrome without imputing a link to either primary psychiatric or general medical conditions. A unique and broadly defined code would foster recognition of the catatonia syndrome and permit research on nosology, treatment, and outcome. These goals are not met with the DSM-V plan for noncoded modifiers.

Catatonia in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [Editorial]

As international scholars of catatonia, we are concerned that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) proposes to delete the codes 295.2 (schizophrenia, catatonic type) and 293.89 (catatonia secondary to a medical condition) and to substitute a noncoded “catatonia specifier” as the principal identifier. We believe that these changes will badly serve clinical practice and research. We advocate a unique and broadly defined code for catatonia in DSM-V. n nCatatonia is common among hospitalized psychiatric patients, including adults, adolescents, and occasionally children. In the 10 principal prospective studies from sites around the world, catatonia syndrome was identified in a mean (SEM) percentage of 9.8% (1.4%) of adult admissions (Table 1). These patients have multiple signs of catatonia (commonly >5); 68% (6%) are mute, and 62% (3%) are negativistic or withdrawn. Some are unable to eat, requiring parenteral nutrition and/or medication. n n n nTABLE 1 n nProspective Studies of the Incidence of Catatonia n n n nOnce catatonia is recognized, first-line treatment with benzodiazepines usually brings prompt relief, although high doses may be needed. If catatonia persists, electroconvulsive therapy is often rapidly beneficial. Every prospective study confirms that catatonia syndrome exists, occasionally becomes malignant, and requires prompt treatment. n nUnder the proposed new guidelines for DSM-V, patients with catatonia syndrome will lack an informative diagnosis. Mutism, negativism, and withdrawal prevent assessment for mood, cognitive, and psychotic symptoms and impede proper delineation of episodes of prior illness. Without findings for a specific diagnosis, it is rational to use a provisional diagnosis of the catatonia syndrome to allow tests and treatments to proceed. Lacking recognition and treatment, catatonia may persist or worsen with adverse or life-threatening results. On the other hand, when patients with catatonia are identified and treated, they become verbal and interactive, allowing interviews and more definitive diagnoses, regardless of the primary pathological findings. n nWhen patients cannot provide information, clinicians may conflate or misdiagnose catatonia with schizophrenia (as in the DSM-IV schema), impute a psychotic process, foster the unproven use of neuroleptics, and risk adverse effects, such as conversion to malignant catatonia or the neuroleptic malignant syndrome. Similarly, assignment of catatonia to “psychosis not otherwise specified” (298.9, DSM-IV and DSM-V) would be erroneous because these patients often either lack hallucinations and delusions or cannot be assessed for them. n nThe proposed elimination of DSM-IV “catatonia due to a general medical condition” (293.89) renders the coding for catatonia arising from general medical conditions problematic. At clinical presentation, the medical/toxic factors are rarely known, as time is often needed to identify these etiologies. n nWe also note that noncoded specifiers are not useful for research on nosology, treatment, and outcome. n nTo address all these issues, we urge inclusion in DSM-V of a specific diagnostic code for catatonia. One simple option is to retain the 293.89 code but revise its formulation to broadly encompass the catatonia syndrome without imputing a link to either primary psychiatric or general medical conditions. A unique and broadly defined code would foster recognition of the catatonia syndrome and permit research on nosology, treatment, and outcome. These goals are not met with the DSM-V plan for noncoded modifiers.