La schizophrénie dissociative : nouvelle entité clinique, trouble comorbide ou autres considérations nosographiques

L’existence d’un sous-type dissociatif de schizophrénie a été suggérée par plusieurs auteurs pour rendre compte des présentations symptomatologiques d’un groupe de personnes dont le diagnostic principal est dans le spectre de la schizophrénie mais qui présentent aussi des symptômes dissociatifs (Ross, 2004; Şar et al., 2010; Van der Hart, Witztum, & Friedman, 1993). D’origine traumatique, ce type de portrait clinique où symptômes psychotiques et dissociatifs s’entremêlent aurait été décrit il y a déjà plus d’un siècle (Janet & Raymond, 1898) mais serait disparu dans les années ’30, assimilé au concept de « schizophrénie » (Rosenbaum, 1980). C’est dans un nouveau contexte nosographique que le concept de schizophrénie dissociative refait surface. En effet, la nosographie psychiatrique a pris un tournant en 1980 lorsque l’approche préconisée par le DSM est devenue descriptive plutôt que basée sur des conceptualisations psychanalytiques. Du coup, les affections d’alors ont été divisées en troubles dont les symptômes ont tendance à se manifester ensemble (Cooper, 2004) et la comorbidité entre les troubles a augmenté. Étant donné la comorbidité fréquemment rapportée entre les troubles psychotiques et dissociatifs, la similarité phénoménologique de leurs symptômes, ainsi que leur possible étiologie traumatique, Ross (2004) a proposé une série de critères permettant de diagnostiquer une schizophrénie dissociative. L’objectif principal de cette thèse est donc d’établir si la schizophrénie dissociative, telle que définie par Ross (2004), existe. Le premier article porte sur la problématique et le contexte théorique ayant mené à la question de recherche. Il vise à faire un survol des enjeux entourant la question de la schizophrénie dissociative et rend compte des écrits scientifiques sur la symptomatologie similaire entre les troubles psychotiques et dissociatifs, sur leur étiologie traumatique et sur les études sur la dissociation et la schizophrénie. Le deuxième article est quant à lui un article empirique rendant compte de la méthodologie utilisée pour répondre à la question de recherche. En effet, aucune étude jusqu’ici n’a testé systématiquement les critères de la schizophrénie dissociative. Nos résultats démontrent que 24% de notre échantillon (N=50) pourrait recevoir le diagnostic de schizophrénie dissociative avec les critères proposés par Ross (2004). Toutefois, ces critères posant problème, une modification a été proposée et une prévalence de 14% a alors été trouvée. Des vignettes cliniques sont présentées afin de comparer nos participants avec ceux rapportés ailleurs. Les liens entre symptômes psychotiques et dissociatifs sont discutés en essayant de conceptualiser la schizophrénie dissociative de différentes manières, soit comme une nouvelle entité clinique, comme un trouble comorbide ou dans un contexte nosographique psychodynamique.

A review of the dissociative disorders: from multiple personality disorder to the posttraumatic stress

In this paper we review the idea of dissociation, dissociative disorders and their relationship with the processes of consciousness. We will deal specifically with multiple personality disorder and posttraumatic stress disorder. Both polarize the discussion of diagnostic categories with dissociative symptoms. This review compares the initial ideas (one century old) with the current scenario and emerging trends in research, which are relating cognitive processes and dissociative phenomena and disorders from a neuroscientific approach. We discuss the ideas on dissociation, hypnosis and suicide associated with these disorders. There seems to be a lack of consensus as to the nature of dissociation with theoretical, empirical and clinical implications.

Depersonalization and personality in panic disorder

Background: Prevalence and clinical correlates of depersonalization symptoms have been associated with panic disorder. Personality traits might increase the likelihood of experiencing depersonalization symptoms or depersonalization disorder in panic patients. Aims: The objectives of this study are to establish the prevalence of depersonalization symptoms during the panic attack and in depersonalization disorder and to examine the personality factors associated with the presence of depersonalization in patients with panic disorder. Methods: The sample comprised 104 consecutive adult outpatients with panic disorder, diagnosed according to the Semistructured Clinical Interview for DSM-IV (Axis I/II disorders). Participants were assessed with the Cambridge Depersonalization Scales, the Temperament and Character Inventory, and the Panic and Agoraphobia Scale. Results: Forty-eight percent of the sample had depersonalization symptoms during the panic attack, whereas 20% of patients had a depersonalization disorder. Women presented more depersonalization disorders than did men (P = .036). Patients with panic disorder with depersonalization disorder had a more severe panic disorder (P = .002). Logistic regression analysis showed that self-transcendence trait (odds ratio, 1.089; 95% confidence interval, 1.021-1.162; P = .010) and severity of panic (odds ratio, 1.056; 95% confidence interval, 1.005-1.110; P = .032) were independently associated with depersonalization disorder. Conclusions: A high prevalence of depersonalization symptoms and depersonalization disorder was confirmed in patients with panic disorder, supporting a dosage effect model for understanding depersonalization pathology. Self-transcendence trait and severity of panic disorder were reported as risk factors for depersonalization disorder. (C) 2011 Elsevier Inc. All rights reserved.

Mutism and Amnesia following High-Voltage Electrical Injury: Psychogenic Symptomatology Triggered by Organic Dysfunction?

Background: Mutism and dense retrograde amnesia are found both in organic and dissociative contexts. Moreover, dissociative symptoms may be modulated by right prefrontal activity. A single case, M.R., developed left hemiparesis, mutism and retrograde amnesia after a high-voltage electric shock without evidence of lasting brain lesions. M.R. suddenly recovered from his mutism following a mild brain trauma 2 years later. Methods: M.R.'s neuropsychological pattern and anatomoclinical correlations were studied through (i) language and memory assessment to characterize his deficits, (ii) functional neuroimaging during a standard language paradigm, and (iii) assessment of frontal and left insular connectivity through diffusion tractography imaging and transcranial magnetic stimulation. A control evaluation was repeated after recovery. Findings: M.R. recovered from the left hemiparesis within 90 days of the accident, which indicated a transient right brain impairment. One year later, neurobehavioral, language and memory evaluations strongly suggested a dissociative component in the mutism and retrograde amnesia. Investigations (including MRI, fMRI, diffusion tensor imaging, EEG and r-TMS) were normal. Twenty-seven months after the electrical injury, M.R. had a very mild head injury which was followed by a rapid recovery of speech. However, the retrograde amnesia persisted. Discussion: This case indicates an interaction of both organic and dissociative mechanisms in order to explain the patient's symptoms. The study also illustrates dissociation in the time course of the two different dissociative symptoms in the same patient.

Crises non épileptiques psychogènes: le défi des troubles fonctionnels en neurologie

Psychogenic non epileptic seizures (PNES) look like epilepsy, but are not accompanied by the electrophysiological alterations found in epilepsy. The diagnosis requires a complex process at the interface between neurology and psychiatry. Diagnostic restitution to the patient and treatment of the condition should be a collaboration between neurologist and psychiatrist including as much as possible a general practitioner. Vulnerability and triggering psycho-social factors, as well as frequent psychiatric co morbidity implicate that psychiatric-psychological care is needed in a majority of situations, however this cannot be done without a strong "somatic back-up" with rapid access to somatic facility for advice and care when needed. The neurological presentation of the disease, with psychiatric causes underlying the condition, bear the risk for the patient that neither neurological nor psychiatric care is offered. Current knowledge about the condition is still scarce, but the field is progressively enriched by studies with stronger methodologies. Recent neuroimaging studies open fascinating avenues on our understanding of the interplay between emotional regulation, representation of the self, and dissociative symptoms. These new avenues help our understanding of these disorders which challenge classical frontiers between neurology and psychiatry. In this paper we try to formulate a framework for the care of patient with dissociative disorders including NEPS.

Limbic brain responses in mothers with post-traumatic stress disorder and comorbid dissociation to video clips of their children.

Maternal dissociative symptoms which can be comorbid with interpersonal violence-related post-traumatic stress disorder (IPV-PTSD) have been linked to decreased sensitivity and responsiveness to children's emotional communication. This study examined the influence of dissociation on neural activation independently of IPV-PTSD symptom severity when mothers watch video-stimuli of their children during stressful and non-stressful mother-child interactions. Based on previous observations in related fields, we hypothesized that more severe comorbid dissociation in IPV-PTSD would be associated with lower limbic system activation and greater neural activity in regions of the emotion regulation circuit such as the medial prefrontal cortex and dorsolateral prefrontal cortex (dlPFC). Twenty mothers (of children aged 12-42 months), with and without IPV-PTSD watched epochs showing their child during separation and play while undergoing functional magnetic resonance imaging (fMRI). Multiple regression indicated that when mothers diagnosed with IPV-PTSD watched their children during separation compared to play, dissociative symptom severity was indeed linked to lowered activation within the limbic system, while greater IPV-PTSD symptom severity was associated with heightened limbic activity. Concerning emotion regulation areas, there was activation associated to dissociation in the right dlPFC. Our results are likely a neural correlate of affected mothers' reduced capacity for sensitive responsiveness to their young child following exposure to interpersonal stress, situations that are common in day-to-day parenting.

Comparison of Brazilian spiritist mediumship and dissociative identity disorder

We studied the similarities and differences between Brazilian Spiritistic mediums and North American dissociative identity disorder (DID) patients. Twenty-four mediums selected among different Spiritistic organizations in Sao Paulo, Brazil, were interviewed using the Dissociative Disorder Interview Schedule, and their responses were compared with those of DID patients described in the literature. The results from Spiritistic mediums were similar to published data on DID patients only with respect to female prevalence and high frequency of Schneiderian first-rank symptoms. As compared with individuals with DID, the mediums differed in having better social adjustment, lower prevalence of mental disorders, lower use of mental health services, no use of antipsychotics, and lower prevalence of histories of physical or sexual childhood abuse, sleepwalking, secondary features of DID, and symptoms of borderline personality. Thus, mediumship differed from DID in having better mental health and social adjustment, and a different clinical profile.

Perception of a hectic hospital environment at admission relates to acute stress disorder symptoms in myocardial infarction patients.

OBJECTIVE Hospital crowding is a public health problem that may impact on the quality of medical treatment and increase the risk of developing traumatic stress, e.g., after myocardial infarction (MI). This study examines whether subjective appraisal of crowding at hospital admission due to MI is associated with acute stress disorder (ASD) symptoms. METHOD We investigated 102 consecutive patients with acute MI within 48h after having reached stable circulatory conditions. The appraisal of crowding was measured by the retrospective assessment of the perception of a hectic hospital environment at admission. Furthermore, patients completed the Acute Stress Disorder Scale to rate the psychological stress reaction. RESULTS The perception of a hectic hospital environment was associated with the development of ASD symptoms (r=0.254, P=.013) independently of demographic, peritraumatic and medical factors. Post hoc analysis revealed associations with dissociative (r=0.211, P=.041), reexperiencing (r=0.184, P=.074) and arousal (r=0.179, P=.083) symptoms. CONCLUSION The findings suggest that, besides objective circumstances, the way hospital admission due to MI is perceived by the patient may influence the development of MI-triggered ASD symptoms. The psychological and physiological long-term outcomes of the perception of a hectic hospital environment and the role of preventive interventions need further examination.

Shame, Dissociation, and Complex PTSD Symptoms in Traumatized Psychiatric and Control Groups: Direct and Indirect Associations With Relationship Distress

Objectives: Elevated shame and dissociation are common in dissociative identity disorder (DID) and chronic posttraumatic stress disorder (PTSD) and are part of the constellation of symptoms defined as complex PTSD. Previous work examined the relationship between shame, dissociation, and complex PTSD and whether they are associated with intimate relationship anxiety, relationship depression, and fear of relationships. This study investigated these variables in traumatized clinical samples and a nonclinical community group.

Method: Participants were drawn from the DID (n = 20), conflict-related chronic PTSD (n = 65), and nonclinical (n = 125) populations and completed questionnaires assessing the variables of interest. A model examining the direct impact of shame and dissociation on relationship functioning, and their indirect effect via complex PTSD symptoms, was tested through path analysis.

Results: The DID sample reported significantly higher dissociation, shame, complex PTSD symptom severity, relationship anxiety, relationship depression, and fear of relationships than the other two samples. Support was found for the proposed model, with shame directly affecting relationship anxiety and fear of relationships, and pathological dissociation directly affecting relationship anxiety and relationship depression. The indirect effect of shame and dissociation via complex PTSD symptom severity was evident on all relationship variables.

Conclusion: Shame and pathological dissociation are important for not only the effect they have on the development of other complex PTSD symptoms, but also their direct and indirect effects on distress associated with relationships.

[insomnia Symptoms, Daytime Naps And Physical Leisure Activities In The Elderly: Fibra Study Campinas].

The practice of physical activities contributes to reducing the risk of chronic diseases and improves sleep patterns in the elderly. This research aimed to investigate the association between insomnia symptoms and daytime nap and the participation in physical leisure activities in elderly community residents. Data from the Studies Network of the Fragility in Brazilian Elderly (Campinas site), were used. Information from 689 elderly was analyzed, regarding sociodemographic characterization, physical leisure activity, occurrence of daytime napping and its duration, symptoms of insomnia and use of sleep medication. A significant association was found between the practice of walking and the daytime nap of short duration. Studies indicate that a short nap can benefit the quality of sleep and health of the elderly. Therefore, promoting the practice of walking can be a nursing intervention that favors the sleep patterns of the elderly.

Laparoscopic Antireflux Surgery In Patients With Extra Esophageal Symptoms Related To Asthma.

Asthma, laryngitis and chronic cough are atypical symptoms of the gastroesophageal reflux disease. To analyze the efficacy of laparoscopic surgery in the remission of extra-esophageal symptoms in patients with gastroesophageal reflux, related to asthma. Were reviewed the medical records of 400 patients with gastroesophageal reflux disease submitted to laparoscopic Nissen fundoplication from 1994 to 2006, and identified 30 patients with extra-esophageal symptoms related to asthma. The variables considered were: gender, age, gastroesophageal symptoms (heartburn, acid reflux and dysphagia), time of reflux disease, treatment with proton pump inhibitor, use of specific medications, treatment and evolution, number of attacks and degree of esophagitis. Data were subjected to statistical analysis, comparing the pre- and post-surgical findings. The comparative analysis before surgery (T1) and six months after surgery (T2) showed a significant reduction on heartburn and reflux symptoms. Apart from that, there was a significant difference between the patients with daily crises of asthma (T1 versus T2, 45.83% to 16.67%, p=0.0002) and continuous crises (T1, 41.67% versus T2, 8.33%, p=0.0002). Laparoscopic Nissen fundoplication was effective in improving symptoms that are typical of reflux disease and clinical manifestations of asthma.

Myelodysplastic Syndrome With Synchronous Gastric Cancer: When The Symptoms Suggest Something Else.

Although myelodysplastic syndromes have a clear definition in theory, the morphologic dysplasia associated with ineffective hematopoiesis may be subtle and difficult to recognize and can commonly be mimicked by systemic conditions, such as infections, autoimmune disorders, nutritional deficiencies, toxic factors and non-hematological malignancies. However, myelodysplastic syndromes may truly coexist with other systemic diseases, which can be masked when the patient's symptoms are attributed exclusively to myelodysplastic syndromes without further investigation. To better illustrate this, we herein describe two cases associated with synchronous gastric cancers.

Bilateral Peripheral Facial Palsy And Mastoid Infiltration As Symptoms Of Relapsed Acute Myeloid Leukemia.

Although Bell's palsy (BP) is the most common cause of peripheral facial palsy (PFP), other etiologies merit investigation. A 60-year-old female patient presented with recurrent bilateral PFP. Although the patient had a history of acute myeloid leukemia (AML), she had initially been diagnosed with BP-related PFP and had been treated accordingly. When the PFP recurred, additional diagnostic tests were performed. The resulting immunohistochemical profile included CD3 positivity in a few reactive T lymphocytes; positivity for myeloperoxidase in atypical cells; and focal positivity for CD34 and proto-oncogene c-kit proteins in neoplastic cells, thus confirming the suspicion of mastoid infiltration caused by relapsed AML. In patients with neoplastic disease, a finding of PFP calls for extensive investigation in order to rule out the involvement of the temporal bone.