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Biomedical subjects

G Vaiva

Publications and source records attributed to G Vaiva.

25 records · Page 2Linked to original sources

[The concept of supersensitivity psychosis. The particular case of clozapine].

Neuroleptics are the main biological treatment for psychotic patients. The brutal withdrawal of a neuroleptic treatment may induce an important aggravation of the psychotic symptoms. A few of those relapses may occur very early after the interruption of treatment; they are often associated with a modification of the symptoms and an unfavorable evolution in the course of the illness. Using those clinical observations a few authors have developed the concept of supersensitivity psychosis to explain those kinds of relapses and to formulate hypothesis about tolerance and resistance to neuroleptics. They focus on the possible correlation between supersensitivity psychosis and tardive dyskinesia. We report three cases of a dramatic aggravation of the psychotic symptomatology following the withdrawal of clozapine in three schizophrenic patients resistant to classical neuroleptic treatment. According to the clinical data and to the physiopathological hypothesis, the concept of supersensitivity psychosis can have implications in the therapeutic management of resistant schizophrenic patients.

Adult↗

[Post-traumatic stress, post-traumatic depression and major depressive episode: literature].

Although they are likely to add their effects, physical and psychic traumata (or traumas) can provoke in different ways the appearance of depressive symptoms sometimes common. Post-traumatic depression, reactional depression, major depressive disorder and post-traumatic stress disorder represent different clinical and nosographic disorders in despite of their occasionally common symptomatic core. Historically, it is interesting to note during the XXth century the true semantic change of the terms of trauma from the somatic field to the psychic sphere. Physical traumatism is often represented by a material shock for the subject and by its organic consequences. It is defined as an event that leaves its mark which itself inflicts and handicaps the vital trajectory of the subject. It primarily comprises brain and rachis injuries, whose evolution is frequently characterized by the occurrence/appearance of a depressive disorder, whose genesis rests on psychological but also neurobiologic and physical arguments. Thus major depressive disorders are often present in the course of various physical traumatisms mainly related to nervous system. In accordance with several studies, the prevalence of major depressive disorders ranges from 25% to 50%. These mood disorders occur in the year which follows the accidental event. Their average time of revelation is estimated at four months and their average duration lies between three and six months. Lastly, although these depressive illnesses present clinical symptoms comparable with those observed in other contexts, some nuances can be raised. Nonetheless, they confine sometimes with true clinical forms depending on the intensity, the form, the circumstances or the consequences of the trauma. Psychic traumatism doesn't have the same profile and rests for much dedicated with the reexperiencing. Thus for some authors, depression illness represents a disorder that occurs after a traumatic event whereas others see a differential diagnosis which exludes or which represents a comorbidity with post-traumatic stress disorder. The review of the literature allows us to emphasize the complexity of the links as well as the clinical and epidemiologic differences between stress disorder and major depressive disorder. From the clinical point of view, the major features of PTSD are articulated around a triad of symptoms. They include the reexperiencing symptoms of the traumatic event such as intrusive memories and recurrent nightmares, the protective reactions such as avoidance of the stimuli associated with the trauma and emotional numbing, and the arousal symptoms such as the startled response and hypervigilance. The complexity of this syndrom is due to the frequent combination of these symptoms with other nonspecific ones. As far as the mood is concerned (the mood symptoms are concerned), the regrouping of some of these symptoms allows the clinician to sometimes releave a depressive symptomatology without being able to assess the DSM diagnosis of major depressive disorder. Epidemiologic studies dealing with the risk of installation of a PTSD after a traumatic event reveal differences in the prevalence depending on the nature of the traumatic events: ranging from 1% in general population to 80% following some situations of extreme and durable psychic suffering. Between both poles, one finds a prevalence ranging between 20 and 50% following other events such as serious accidents, natural disasters or criminal assaults. The clinical features of depressive episodes comorbid or associated with PTSD have some characteristics making it possible to individualize various clinical forms as a function of traumatic event type: asthenic, characterial or with somatic symptoms. According to the majority of authors, the co-occurrence of post-traumatic stress disorder and major depressive disorder is high although differential diagnosis is sometimes difficult. However, conceptual differences remain and two conceptions are distinguished. For some authors, like Bleich and Shalev, there would not be true chronological evolution from PTSD to MDD. Moreover the presence of symptoms considered as pertaining to the mood register within the criteria of PTSD would be clearly predictive of the occurrence and the severity of the diagnosis but not of the chronicity. For others, there would be a continuity between post-traumatic stress disorder and major depressive disorder. It is the case in many studies of veterans but also for civilian traumatic events. It is also the case for the American national study of comorbidity in which Kessler concludes that for 78% of the subjects who present a comorbidity PTSD/MDD (comorbidity raised for 48% of the 5,877 subjects included), the mood disorder is secondary to PTSD. (ABSTRACT TRUNCATED)

Comorbidity↗

[A case of acute psychotic episode after a single dose of ecstasy].

Over the last 10 years or so in Europe, there has been a development of the "ecstasy" phenomenon, which is the symbol of "recreational" drugs in general. Users, either alone or in private parties, are on the increase. The phenomenon is most frequent in England and in the Netherlands, with an estimated incidence of 13-18% amongst the 18-25 years old, which may reach 52% in "exposed populations", such as individuals who go to "techno" night clubs. In France, the prevalence is uncertain, but estimated at least 5% of males between 18 and 23 years old. Several substance, with more or less the same effects, are grouped together by the term "ecstasy", the best-known one being 3,4-methylenedioxymethamphetamine (MDMA), but there are also an N-demethylated derivative (MDA), methylenedioxyethylamphetamine (MDEA), N-methyl-benzodioxazolylbutanamine (MBDB) and 4-bromo-2,5-dimethoxyphenylethylamine (2-CB or Nexus). The psychopathological consequences of MDMA in man are relatively poorly understood. On the basis of series of cases reported in the literature, acute psychosis, chronic psychosis similar to paranoid delusions, flash-back phenomena similar to with LSD, anxiety/panic states and depressive mood disorders may occur. The case which we report is therefore that of an acute psychotic episode, with residual symptomatology 6 months later, which occurred suddenly following absorption of toxic substances (alcohol and ecstasy), at least 12 hours after taking the ecstasy tablet without his knowing it, in an individual without any previous psychopathology, other than moderate social phobia. Twelve cases of acute psychotic episodes after ecstasy have been reported in the literature. Two of them occurred after a single dose and one after 2 doses. No author was able to examined the previous history of the individuals accurately, nor any possible psychopathological history. Our patient did not have any previous history of psychosis, using a standardized validated interview, which his peers and family confirmed. He did however fulfil the criteria of "social phobia". Retrospectively, we noted the extent of his psychomotor disinhibition with ecstasy, which seemed to be proportional to the intensity of his previous social inhibition. This point does not explain the psychotic episode. From a neurobiologic point of view, acute psychotic disorders are often related to dysfunction of the mesolimbic dopaminergic system. During the first 3 hours, the effect of absorption of MDMA is a massive release of the serotonin, dopamine and noradrenaline stocks. Later, an acute hyposerotoninergic state is present. In our observation, the psychotic disorder appeared at least 12 hours after taking ecstasy, during the reduction phase of the intoxication. Toxicological analysis of the blood was negative (this detection is only positive for 24 hours). Like other authors, our hypothesis is that serotoninergic dysregulation affects the dopaminergic system. Sudden disappearance of serotoninergic feedback on the dopaminergic pathways, may contribute to an increase in the mesolimbic hyperdopaminergic state. In animals, it has been shown that serotonin depletion induced by MDMA, unmasks the effects of a hyperdopaminergic state. In addition, although it has not been mentioned much in the literature, MDMA disturbs dopaminergic function either directly, or through the peptidergic systems (neurotensin, substance P, dynorphines). A consistent series of arguments therefore suggest that there is a sudden central hyperdopaminergic state, which may be related to the appearance, sometimes de novo, of an acute psychotic disorder. From the published cases, psychotic disorders following absorption of ecstasy, appear to become chronic. Most of the cases occurred in individuals, who either abused multiple substances or were chronic ecstasy users. In a case like the one we report, in an individual with good general health, who is not a drug user and who has an acute episode following a single dose, the prognosis should be good. Similarly, a team from Milan has described the experience of 3 friends who had a brief psychotic episode, following ingestion of substances containing ecstasy. These episodes resolved completely, after rehydration and anxiolytic treatment. However, after 6 months' follow-up, our patient still has psychotic symptoms, albeit mild, but which were not present before the intoxication. The patient and his psychiatrist do not envisage changing or stopping his antipsychotic treatment. Other authors have described a lesion in the serotoninergic neurons, by making a parallel with toxic effects described in animals, in particular in primates, with MDMA. Degradation of the serotoninergic cell bodies and nerve endings has been suggested to occur with high doses and/or repeated doses of MDMA. Other authors show the large variations in MDMA and MDA metabolism. (ABSTRACT TRUNCATED)

Adult↗

[Value of a consultation center and crisis intervention in addressing psychiatric disorders in the perinatal period].

The Psychiatry department of the University Hospital Centre of Lille has developed, over the last 10 years, a treatment network for psychiatric disorders during pregnancy or in the post-partum period. There are liaison consultations in the maternity department, screening and management of psychopathological disorders in the perinatal period, training of midwives, support of patients seeking genetic counselling, collaboration with teams providing "medically-assisted procreation", etc. For severe disorders of the post-partum period (severe depression, serious alteration of mother-child interaction, puerperal psychosis), the Psychiatry department has a specialized unit where 3 "mother-child" groups can be admitted. This unit is particularly effective if the patients and their family understand this healthcare system and stick to it to a certain extent. Even if improvements are always possible, cases in which situations occur as an emergency, are when dysfunctions are most frequently seen. On 7th December 1998, a Crisis Intervention Unit (CIU) was created with 15 short-term beds, for stays up to 72 hours. The CIU was opened in the Psychiatry department, close to the main Accident and Emergency department, with 2 aims: firstly to provide a setting and resources for a number of emergency psychiatric situations, and secondly to provide a place and time for crisis situations which we admit to the unit, with a view to facilitating interaction and to propose in certain cases a process of crisis intervention, which later continues on an outpatient basis. After being open for a year, the CIU has proved to be an improvement to all of the healthcare services which are available. It should be noted that the situations which need highly specialized resources in such a short time, are those which cause the most acute problems. This is at times when the emergency services network, with its internal logic, require another network based on a different logic, that the interface problems are at their most acute. The situations reported here, which require a fluid interface between the emergency services and the "mother-child" networks, are examples. We report 3 clinical situations, which illustrate 3 possibilities of action: the first, in which 2 successive stays in the CIU allowed an admission to the "mother-child" unit in satisfactory conditions, the second, in which overall management was based on hospitalization in the Obstetrics department and several visits to our Unit, and the last one, in which the whole medico-psycho-social approach was set up after a single stay of 3 days. Since the opening of Crisis Intervention Unit, around 1,000 patients have been treated there; 37 were women with difficulties with their pregnancy, 17 of whom required direct intervention by the "mother-child" team. The contexts were: 5 prenatal depressions, 4 post-partum depressions, 3 cases of hyperemesis gravidarum, 5 rejections of pregnancy and/or situations at risk of infanticide. The almost constant suicidal risk should be noted, or even attempted suicide, at the time of admission to the CIU. The other 20 women had psychopathological disorders linked to sterility, medically-assisted pregnancy, termination of pregnancy or pregnancy in women suffering from long-term somatic illnesses (insulin-dependent diabetes, lupus, etc.). When a psychopathological episode occurs during pregnancy, it is essential to preserve the developing relationship with the child in an intermediate place, in a healthcare perspective and to prevent any future impairment of the quality of the mother-child relationship by the psychiatric disorder. The Crisis Intervention Unit is not an emergency "mother-child" unit. Other French experiences have been reported, an example being mother-baby hospitalization in a crisis centre. The aim of our interventions is not the same, and our local context, together with the availability of a healthcare network on different floors, which is specific and close-by, allows this approach. Also, the contribution of Liaison Psychiatry in emergency situations should not be minimized. It is necessary to work in collaboration with the obstetricians. In fact, the chance to work with us was given by asking for a hospitalization in the Obstetric unit, during the prepartum period of pregnancies with a psychiatric risk. This way of proceeding allows somatic monitoring in hospital to be performed, whenever the risk run by the mother and/or the child requires it. This "analogue" procedure, however preventative it may be, does not always allow specific treatment of the psychiatric disorders to be given, despite liaison psychiatry interventions. Our interventions are not a specialized "mother-child" unit, or a substitute for Liaison Psychiatry, but they are specifically aimed at the context of the crisis. Obviously, it is precisely this dimension of the crisis which makes the other types of management temporarily unsuitable. This new working framework, with the simple possibility of admitting women and interacting with them in a crisis situation, with the aid of the competence of "mother-child" teams, most often seems to allow an alternative to hospitalization in the Psychiatry department, at the same time keeping up quality management of problems linked to the pregnancy or post-partum period. The specificity of the CIU, with its project of taking the special psychiatric vulnerability of pregnancy into account, makes sure that the psychopathological aspects of the crisis situation and the physiological aspects of adaptation reactions to the perinatal period are not neglected, but that are respected by this type of interaction/intervention.

Adult↗

[A case of delusional melancholia: "a variant of loss of psychological self-activation"?].

A 62 year-old man presented with melancholia with delusions, possibly resulting from lenticular lesion in the left and frontal damages in the right. Atypical signs of our observation led us to consider our patient not as suffering of affective disorder. We suggest that melancholia could be a consequence of a certain type of stereotyped mental activity, and we would compare this stereotyped mental activity to mental compulsive activity described in "loss of psychic self activation" of D. Laplane. In this perspective our observation would be a variant of "Loss of psychic self-activation". Heuristic value of this concept is discussed.

Arousal↗

[Erythrocyte superoxide dismutase (eSOD) determination in positive moments of psychosis].

Dysregulation of free radical metabolism has been supposed to be involved in schizophrenia etiopathogeny. Recently, Wang et al. showed a red blood cell super oxide dismutase increase in positive schizophrenia (Crow's type I), but neither in negative schizophrenia (Crow's type II) nor in controls. The study included 28 in-patients suffering from acute positive psychosis who were compared with 15 controls. We confirmed the results of Wang. We found a significantly red blood cell Super oxide dismutase increase in positive psychosis, in comparison to negative psychosis and controls (p = 0.0001). This SOD increase was in relationship with the degree of clinical psychomotor excitement. After 21 days of neuroleptic treatment, SOD activity decreased and reached standard values. These results support the hypothesis of striking relationships between catecholaminergic hyper-metabolism and SOD increase, in positive psychosis. These could account for psychotic positive symptoms improvement with neuroleptic treatment, which blocks dopamine pathways.

Adult↗

[Value of the determination of erythrocyte haloperidol ketone reductase activity in the evaluation of haloperidol therapy].

Serum levels of haloperidol and reduced haloperidol as well as the reduced haloperidol/haloperidol ratios were determined in nine acute schizophrenics on oral haloperidol medication and correlated over 21 days with psycho pathology and extra-pyramidal symptom scores. We have investigated red blood cells haloperidol reductase activity in the group of patients. Significant correlations were found between haloperidol plasma levels and positive sub scale for each patient (r = 0.86 and p < 0.01; r = 0.70 and p < 0.05). We found a correlation between red blood cells reductase activity and the improvement of the psychotic anxiety scale (r = 0.64/and p < 0.05; r = 0.67 and p < 0.05), but not with reduced haloperidol/haloperidol ratios in plasma. The knowledge of reductase activity could predict the treatment response in acute schizophrenic patients. We suggest that the reported inter individual and inter ethnic differences in haloperidol and reduced haloperidol and in clinical response and adverse effects may be a reflection of genetic control of the two oxidative pathways mediated by cytochrome P450 isozyme and/or the reductase pathway mediated by haloperidol reductase in individual subject.

Adult↗