Cognitive behavior therapy versus supportive therapy in social phobia: a randomized controlled trial.

BACKGROUND: The efficacy of cognitive behaviour therapy (CBT) in social phobia has been demonstrated in several controlled trials and meta-analyses, but no comparison of CBT with supportive therapy (ST) can be found in the literature. METHOD: The aim of the trial was to study the effectiveness of CBT versus ST carried out 'as usual'. Sixty-seven DSM-4 social phobic patients (89% generalized subtype, most with avoidant personality) were randomly allocated into two groups. Group 1 (CBT) received 8 1-hour sessions of individual cognitive therapy (CT) for 6 weeks, followed by 6 2-hour sessions of social skills training (SST) in group weekly. Group 2 received ST for 12 weeks (6 half-hour sessions), then the patients were switched to CBT. All patients agreed not to take any medication during the whole trial. In group 1, 29 patients reached week 6, 27 reached week 12, and 24 weeks 36 and 60 (endpoint). In group 2, 29 patients reached week 6, 28 reached weeks 12 and 18, 26 week 24, and 23 reached weeks 48 and 72 (endpoint). RESULTS: At week 6, after CT, group 1 was better than group 2 on the main social phobia measure. At week 12, after SST, group 1 was better than group 2 on most of the measures and demonstrated a significantly higher rate of responders. This finding was replicated after switching group 2 to CBT. Sustained improvement was observed in both groups at follow-up. Compliance with abstinence from medication increased over time. CONCLUSIONS: CBT was more effective than ST and demonstrated long-lasting effects. This may suggest that social phobia management requires more than a simple and inexpensive psychological intervention.

[Clozapine and refractory schizophrenia. Long-term prospective study of 20 patients]. / Clozapine et schizophrénies résistantes. Etude prospective à long terme chez vingt patients.

Clozapine, a dibenzodiazepine derivative, has potent antipsychotic activity. But bone marrow suppression resulting in agranulocytosis has been associated with clozapine treatment; thus its clinical development has been delayed and the administration of this drug has been restricted to treatment-resistant schizophrenic patient. This report describes an open prospective study of the effects of clozapine on symptomatology of patients who are refractory to neuroleptics. Authors prospectively followed up until 36 months, 20 DSM III-R schizophrenic patients who had failed to respond to various neuroleptics (7.7 +/- 3.0). When clozapine treatment was initiated, the mean duration of the illness was 17 +/- 10 years. Various scales were used for evaluation: total BPRS, BPRS "positive symptoms", BPRS "negative symptoms", PANSS positive and PANSS negative were realized at days 0 and 15, months 1, 2 and 3 and then every 3 months. Significative improvements in total BPRS, BPRS positive symptoms and PANSS positive were noted at day 15 (p < 0.005, p < 0.026, p < 0.02, respectively); clozapine produced significant improvement on the BPRS negative symptoms and the PANSS negative at 1 month (p < 0.03 and p < 0.008, respectively). Side effects were studied: dry mouth was more prominent in the first month after wash-out (15%), while salivation was more and more prevalent (20% within the first month; 53% beyond). There was no agranulocytosis in this cohort; 2 cases (10%) of eosinophilia occurred during the first month; 20% of the patients experienced an increase in total white blood cell count (> 12.000/mm3). Weight gain (> 5 kg) affected 32% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Prevalence of anxiety and depressive symptoms in patients with type 1 and 2 diabetes]. / Prévalences des troubles anxieux et dépressifs chez les patients diabétiques de types 1 et 2.

The authors studied data on psychiatric disorders in 34 insulin-dependent and 27 non-insulin dependent diabetic patients by comparison with 25 patients suffering from hypertension. Analysis was performed following clinical diagnosis (according to DSM III-R criteria), Hamilton Anxiety Inventory, Hopkins Symptom Check List 58 and Beck Anxiety Inventory. In all groups the two major psychiatric clinical diagnoses were anxiety disorders (respectively, 53, 59 and 60%, NS) and depressive disorders (respectively 21, 22 and 20%, NS). These disorders were more common in women. The influence of degenerative complications was studied. Insulin-dependent diabetics with objective nephropathy had significantly higher anxiety scores. In non-insulin-dependent diabetic patients, microangiopathy, diabetic foot and poor control (HbA1c > or = 10%) were also associated with depressive disorders. We conclude that diabetics present with high prevalences of anxiety and depressive disorders and we suggest specific therapeutic approaches.

[When to continue or stop Clozapine therapy?]. / Quand continuer ou arrêter un traitement par la clozapine?

The decision whether or not to stop clozapine therapy in schizophrenic patients depends on a lot of factors involving the benefit/risk ratio. Thus, authors successively analyse various data: the clinical status of the patient is the first one. The evaluation has to take into account short and long-term efficacies; the problem of the minimal duration of clozapine therapy required before concluding to ineffectiveness is still open: from 4 to 12 months; the question of efficacy of the drug according to the type of symptoms is also quite difficult. Efficacy on positive symptoms among schizophrenic patients seems most prominent; negative symptoms also improve but the reasons why are quite difficult to evaluate. It is sometimes difficult to indicate if the improvement in negative symptoms is independent of the improvement in positive symptoms; the patient's request and his feeling (including tolerability) are another decisional factor; because of the lack of dystonia and other extrapyramidal side effects, some patients are more compliant under clozapine therapy; the side effect (hematologic, cardiovascular, hepatic and central nervous systems) lead to discontinuation of clozapine treatment when severe. The most frequent ones are: sedation, EEG alteration, seizures, increase of liver enzymes, hypotension/collapse, hypersalivation, fever (> 38), ECG alteration, tachycardia, gastro-intestinal adverse effects, weight gain, and leucopenia. In the event of a white blood cell count (WBC) below 3,500/mm3, the patient should be evaluated immediately with respect to the WBC and the differential count (DC). Should the results confirm a WBC below 3,500/mm3 and/or reveal an absolute neutrophil granulocyte count of 2,000 to 1,500/mm3, the leucocytes and the granulocytes must be checked at least twice a week.(ABSTRACT TRUNCATED AT 250 WORDS)

[Drug therapies in anxiety disorders of children]. / Les thérapeutiques médicamenteuses des troubles anxieux de l'enfant.

Although childhood anxiety disorders are currently generating new interest, they continue to pose problems in everyday clinical practice. Drug treatment is far from being the only therapeutic approach but does undeniably have a place which should be clearly defined. The main drugs, dosages, indications, and adverse effects of antidepressants, benzodiazepines, antihistamines and neuroleptics which may be used in children with anxiety disorders are discussed.

[Anxiety disorders in children: incidence, comorbidity and risk factors]. / Les états anxieux de l'enfant: fréquence, comorbidité et facteurs de risque.

According to epidemiological studies, prevalence of children's anxiety disorders is about 10%. Among children who suffer from anxiety disorders, a majority also presents one or more anxiety or mood disorders. The children's sex and age are likely to influence anxiety disorders. As well as the children's personality: studies about 'temperament' indeed pointed up this notion. Low socio-economic level of family could be a risk-factor, the importance of which varies according to anxiety disorders subtypes. Current and/or history of parental anxiety disorders, presenting or not with mood disorders, increase the risk for their children to suffer from anxiety disorders.

[A new therapeutic approach tp drug-resistant schizophrenia: clozapine. Long-term prospective study in 16 patients]. / Une nouvelle approche médicamenteuse des schizophrénies résistantes: la clozapine. Etude prospective à long terme chez 16 patients.

Clozapine, a dibenzodiazepine derivative, has potent antipsychotic activity; but bone marrow suppression resulting in agranulocytosis has been associated with clozapine treatment and has restricted the administration of this drug to treatment-resistant schizophrenic patients. This report describes preliminary results of an open prospective study of the effects of clozapine on symptomatology and social function in 16 treatment-resistant schizophrenic patients. Authors prospectively followed up for 18 months 16 DSM III-R schizophrenic patients who had failed to respond to various neuroleptics (n: 7.2 +/- 2.8); when clozapine treatment was initiated, the mean duration of the illness was 14.2 (+/- 6.7) years. Total BPRS, BPRS "positive" and "negative" symptoms scores were used for evaluation. Social integration and side effects were also studied. 14 of 16 patients are still receiving clozapine; 1 out of 14 patients has a more than 60% decrease in total BPRS, 11 out of 14 have 30 to 60% decrease in total BPRS and 2 out of 14 have less than 30% decrease in total BPRS. Improvements in both total and positive symptoms BPRS scores were observed within the first month of treatment (p < 0.001); improvement in negative symptoms was noted within the third month (p < 0.02). At the end of the follow up period, 43% of patients showed marked improvement in family life and 21% found a job during the study. Beyond noteworthy improvement of clinical symptoms in these patients who presented with severe schizophrenia, clozapine also significantly reduced the use of concomitant medication. Side effects are studied but none required treatment disruption; neurological side effects were less reported than with usual neuroleptics. It is concluded that clozapine offers particular benefits for some treatment-resistant schizophrenic patients; however the increased comparative risk requires a restricted use of clozapine to selected patients.

[The role of inhibition in academic failure]. / Rôle de l'inhibition dans l'échec scolaire.

Disorders of failing academically children represent an important part of child psychiatrists' occupation. Various reasons are responsible for these disorders. But the role of inhibition seems to be major. Authors study cases of 66 children, as outpatients, who failed academically. Incidence of inhibition is about 26.9%. Authors analyse demographic data, personal and familial history of these children, age of beginning of disorders and their symptomatic aspects, and last, clinical categories in which some of these disorders can be classified. Thus early detection of inhibition disorders occurs as an absolute necessity.

[Development of anxiety syndromes in childhood. The fate of children with anxiety disorders]. / Evolution des syndromes anxieux de l'enfance. Devenir d'enfants qui ont souffert de troubles anxieux.

The authors study the course of childhood anxiety disorders and their relationship with adult psychopathology using data from children presenting anxiety disorders. The evolution of some of these disorders, such as obsessive-compulsive disorder, is well documented but the evolution of other anxiety disorders is still controversial.

[Considerations on respective roles of anxiety and depressive disorders in children]. / Considérations sur les places respectives des troubles anxieux et dépressifs chez l'enfant.

Anxiety and depression are often clinically associated in children, but are very different in term of effect and symptoms. Family studies favor the hypothesis of a common diathesis for these disorders. Parental history of major depressive and/or anxiety disorders increase the risk of mood and anxiety disorders in children. At the present time, biological studies have not determined any biochemical conclusion for these disorders. It should be noted that although imipramine is efficient in both depressive disorder and separation anxiety, this does not implicate a common physiopathologic basis.

[Anxiety disorders in children: do any risk factors exist?]. / Les troubles anxieux de l'enfant: existe-t-il des facteurs de risque?

Anxiety disorders in children are currently undergoing reclassification. On the basis of a review of the literature, the authors have attempted to point out the main evidence suggesting that a number of risk factors are associated with childhood anxiety disorders. Age and sex seem to influence the risk of anxiety disorder. The child's personality is of central importance: studies of the concept of "temperament" carried out in recent years have underscored that inhibition and introversion in early childhood are associated with an increased risk for anxiety disorders in later childhood. A low socioeconomic setting also seems to be a risk factor whose incidence varies across types of anxiety disorder. Familial risk factors have a very strong effect: children of parents with current or past anxiety disorders with or without mood disorders are at increased risk for anxiety disorders; this risk varies according to the type of disorder in the parents (for instance, the respective roles of panic attacks and avoidance behaviors remain unclear). Lastly, comorbidity is also an important factor: most children with anxiety disorders also have one or several other anomalies, usually anxiety or mood disorders.

[Is an obsessive-compulsive disorder in children an anxiety disorder?]. / Le trouble obsessionnel compulsif de l'enfant est-il un trouble anxieux?

Concerning the update reconsideration of anxiety disorders of children, should childhood obsessive-compulsive disorder be assimilated as an anxiety disorder? Authors attempted to answer to this question by taking into account various levels of consideration which lead them to position childhood obsessive-compulsive disorder in the vicinity of anxiety disorders.