[Transient high-intensity T2 signal in the splenium of the corpus callosum in a non-epileptic patient]. / Hypersignal T2 transitoire du splenium du corps calleux chez une patiente non épileptique.

Transient splenial lesions of the corpus callosum have been mainly reported in epileptic patients. We report the case of a non-epileptic woman with bipolar affective disorder treated by oxcarbazepine which was withdrawn because of a mild hyponatremia (128 mmol/l). A confusional state followed withdrawal and the electroencephalogram was free of spike or sharp waves. Brain MRI showed a single splenial lesion of the corpus callosum revealed by a high intensity T2 signal on FLAIR and diffusion sequences. Because of a major depressive episode, twelve sessions of electroconvulsive therapy were performed and yielded clinical improvement. A second brain MRI performed 5 weeks later was normal. The relevances of this cases are the non-epileptic status of the patient, the drug incriminated (oxcarbazepine), and the normalisation of brain MRI despite electroconvulsive therapy. Different mechanisms of this brain MRI abnormality are discussed including the sudden withdraw of oxcarbazepine. Prognosis of transient splenial lesions of the corpus callosum is good. Clinicians should search for recent metabolic disorders and therapeutic modifications.

Clinical evolution after self-induced or accidental traumatism: a controlled study of the extent and the specificity of suicidal catharsis.

BACKGROUND: The cathartic effect has been related to the short-term decrease of depressive symptomatology following the suicide attempt. This study aimed to clarify the extent of this clinical improvement to non self-induced traumas and other suicidal dimensions. METHODS: Twenty-six recent suicide attempters were compared with 21 control subjects admitted to the surgical ward after an accident-induced trauma. They completed several assessments the day after the admission and one week after discharge: Hamilton and Carroll Depression scales, Barratt Impulsivity Scale, Hopelessness scale, State-Trait Anxiety Inventory, MMPI (abbreviated version), Global Assessment Scale. RESULTS: Depression, anxiety-state, two sub-scales of the MMPI (Hysteria, Depression) and general functioning improved significantly in the suicide attempters group. Measures of impulsivity and hopelessness remained stable during the follow-up. LIMITATIONS: These results cannot not be generalized to all suicide attempters and we did not take account of the lethality and severity of the suicidal method used. CONCLUSION: Our study supports the specific role of deliberate self-aggression in the cathartic effect and the trait value of both impulsivity and hopelessness.

The detection of intentional contingencies in simple animations in patients with delusions of persecution.

BACKGROUND: It has been proposed that delusions of persecution are caused by the tendency to over-attribute malevolent intentions to other people's actions. One aspect of intention attribution is detecting contingencies between an agent's actions and intentions. Here, we used simplified stimuli to test the hypothesis that patients with persecutory delusions over-attribute contingency to agents' movements. METHOD: Short animations were presented to three groups of subjects: (1) schizophrenic patients; (2) patients with affective disorders; and (3) normal control subjects. Patients were divided on the basis of the presence or absence of delusions of persecution. Participants watched four types of film featuring two shapes. In half the films one shape's movement was contingent on the other shape. Contingency was either 'intentional': one shape moved when it 'saw' another shape; or 'mechanical': one shape was launched by the other shape. Subjects were asked to rate the strength of the relationship between the movement of the shapes. RESULTS: Normal control subjects and patients without delusions of persecution rated the relationship between the movement of the shapes as stronger in both mechanical and intentional contingent conditions than in non-contingent conditions. In contrast, there was no significant difference between the ratings of patients with delusions of persecution for the conditions in which movement was animate. Patients with delusions of persecution perceived contingency when there was none in the animate non-contingent condition. CONCLUSIONS: The results suggest that delusions of persecution may be associated with the over-attribution of contingency to the actions of agents.

[Formal thought disorders: French translation of the Thought, Language and Communication assessment scale]. / Troubles formels de la pensée: traduction française de l'échelle d'évaluation de la pensée, du langage et de la communication.

This article proposes a french translation of Andreasen's Thought, Language and Communication (TLC) scale (Andreasen, 1979). This scale is widely used in current literature and remains a reference due to the fact that it has made it possible to establish a consensus with regard to formal thought disorders and has contributed to the operationalisation of the concept of dissociation. This scale consists of 18 items. Each item is clearly defined through the use of clinical examples, rated from 0 to 4 as a function of the intensity of the disorder (absent, slight, medium, severe, extreme). The interview conditions are also stated: free interview of minimum 10 minutes followed by a more structured interview. Some items of the TLC are taken directly from the SANS and SAPS. Their translation has been taken over from french translations already validated by Lecrubier and Boyer (1987). The others were translated within the department and have been verified by a native English speaker. The entirely of the translation has been verified by Andreasen. The metrological qualities of this french translation have been studied in a population of 107 schizophrenic patients who fulfilled all the DSM IV criteria: 73 males and 34 females, mean age 33.4 9 years, in or outpatients, all under neuroleptic treatment and all evaluated by an experienced clinician. Thirty one patients have been filmed to assess the interjudge reliability. The results indicate a high level of interjudge consistency (interclass correlation coefficient 0.96). The global score was 17 9.4. In the factorial analysis before rotation we observe a main factor that makes it possible to calculate a global score. The results of factor analysis of the TLC variables after rotation yield five factors that have an eigen value greater than 1. These five factors explain 66% of the variance. All items have a weight greater than 0.45. The first factor includes Poverty of content speech, Tangentiality, Derailment, Incoherence, Illogical thinking, Loss of goal and Perseveration. It reflects thinking disorganisation. The second factor includes Pressure of speech, Circumstantiality, Self reference and Poverty of speech (negative weight). This factor reflects verbal production. The third factor is composed of Clanging, Neologisms, Word approximation and Echolalia. This factor reflects verbal structure. The fourth factor is only composed of Stilted speech and the fifth one composed of Distractible speech and Blocking. These data have been compared to those reported in the literature: Andreasen in 1979 (113 patients: 32 suffering from manic disorder, 36 from depressive disorder and 45 schizophrenic disorder) and in 1986 (194 subjects: 94 controls, 25 suffering from manic disorder, 25 schizoaffective disorder and 50 schizophrenic patients), Harvey in 1992 (115 schizophrenic patients) and Peralta in 1992 (142 schizophrenic patients). Response levels for each item of the TLC french translation were very close to those found in the english versions. Differences in scores can be explained by clinical differences between populations studied. Factorial analyses also correspond well to such versions. In particular, after rotation, the three factorial subscores found representative of disorganisation, verbal production and verbal structure respectively are closed to those proposed by the english versions. In conclusion, the translation of Andreasen's Thought, Language and Communication (TLC) scale (Andreasen 1979) that we propose here therefore appears to exhibit metrological qualities sufficiently close to those reported in literature to permit its generalised use in France.

[Natural evolution of paranoid schizophrenia treated consecutively with 4 different neuroleptics]. / Evolution naturelle d'une schizophrénie paranoïde traitée successivement par 4 neuroleptiques distincts.

Ms M is a young female patient (born 1968) with paranoid schizophrenia. The first acute psychotic episode, which involved marked delirium, was treated with an atypical antipsychotic agent. During the next year, renewed hospitalisation and treatment with two other antipsychotics resulted only in partial improvement, and troublesome adverse effects were noted. Amelioration of all symptoms, both psychotic and debilitating, was finally obtained through prescription of a third atypical antipsychotic with which the patient was highly satisfied. We examine the value of first-line treatment of schizophrenia with atypical antipsychotics as of the first acute episodes of acute delirium in the light of current data in the literature.

Can verbalization remedy the theory of mind deficit in schizophrenia?

Several studies provide convincing evidence of a specific deficit in the theory of mind (ToM) in some patients with schizophrenia. This ToM deficit consists of an inability to attribute relevant mental states to others, and studies suggest it has to be regarded as functional and remediable through the use of reinforced context processing. To investigate this, the present study compares the performances of 25 schizophrenics and 25 matched controls in a task exploring ToM before and after the introduction of verbal material into the task, initially conceived as nonverbal. All the controls and half of the schizophrenic subjects who did not initially perform at the best level remediated with verbalization, while 9 of the schizophrenics exhibited no remediation. These poor performers are characterized by a longer duration of illness. The cognitive plasticity and the characteristics of patients who do/do not remediate are discussed in the light of findings obtained with the Wisconsin Card Sorting Test. The clinical implication of these results is important since they suggest that some patients would benefit from cognitive rehabilitation in terms of their ability to attribute relevant mental states to others.

[Deficit of the theory-of-mind in schizophrenia: clinical concept and review of experimental arguments]. / Déficit en théorie de l'esprit dans la schizophrénie: relecture clinique et revue des arguments expérimentaux.

OBJECTIVE: This article synthesizes and discusses the clinical and experimental arguments for applying the concept of a theory-of-mind deficit to schizophrenia. METHOD: The term "theory of mind" is defined. A review of literature on the hypothesis of a theory-of-mind deficit in schizophrenia is then presented. Clinical and experimental arguments are discussed. The article concludes with a summary of the issue. RESULTS: The hypothesis of a theory-of-mind deficit in schizophrenia is convincing, particularly considering the most recent experimental evidence. This cognitive deficit explains the presence of schizophrenia symptoms such as delusions of influence and reference, problems in social adaptation, and signs of disorganized communication. Consideration is given to the roles played by situational ambiguity, the individual's intellectual level, and type of treatment. CONCLUSION: The hypothesis of a theory-of-mind deficit has only recently been applied in schizophrenia research; it may have a strong impact on clinical practice. If its role in the onset of symptoms is to be better understood, explanatory models and experimental paradigms must be further refined.

A PET investigation of the attribution of intentions with a nonverbal task.

Several authors have demonstrated that theory of mind is associated with a cerebral pattern of activity involving the medial prefrontal cortex. This study was designed to determine the cerebral regions activated during attribution of intention to others, a task which requires theory-of-mind skills. Eight healthy subjects performed three nonverbal tasks using comic strips while PET scanning was performed. One condition required subjects to attribute intentions to the characters of the comic strips. The other two conditions involved only physical logic and knowledge about objects' properties: one condition involved characters, whereas the other only represented objects. The comparison of the attribution of intention condition with the physical logic with characters condition was associated with rCBF increases in the right middle and medial prefrontal cortex including Brodmann's area (BA) 9, the right inferior prefrontal cortex (BA 47), the right inferior temporal gyrus (BA 20), the left superior temporal gyrus (BA 38), the left cerebellum, the bilateral anterior cingulate, and the middle temporal gyri (BA 21). The comparison of the physical logic with characters condition and the physical logic without characters condition showed the activation of the lingual gyri (BA 17, 18, 19), the fusiform gyri (BA 37), the middle (BA 21) and superior (BA 22, 38) temporal gyri on both sides, and the posterior cingulate. These data suggest that attribution of intentions to others is associated with a complex cerebral activity involving the right medial prefrontal cortex when a nonverbal task is used. The laterality of this function is discussed.

How do people with schizophrenia explain the behaviour of others? A study of theory of mind and its relationship to thought and speech disorganization in schizophrenia.

BACKGROUND: This paper examines the attribution of mental states to others in schizophrenia and its links with thought and speech disorganization. METHODS: Two groups of schizophrenic subjects (15 with and 10 without thought and speech disorganization) were compared with 10 manic subjects and 15 normal controls on their pattern of answers to 14 theory of mind comic strips. RESULTS: Schizophrenic subjects with disorganization and a more severe general psychopathology exhibited more unadaptated interpretations of others' mental states than those without disorganization or the manic or normal controls. Their explanation of other people's behaviour tended to be influenced by the frequency of their actions rather than their mental states. CONCLUSIONS: The disorganization pattern in schizophrenia may be associated with a specific deficit of the cognitive ability referred to as theory of mind, and this deficit could be a state rather than a trait variable. Patients with thought and speech disorders may be more likely to understanding other people's mental states in unambiguous and common situations.

Investigating theory of mind in schizophrenia: influence of verbalization in disorganized and non-disorganized patients.

The ability to attribute intentions to others was studied in 13 disorganized and 13 non-disorganized schizophrenic patients, 13 depressed and 13 normal controls. Subjects were asked to complete 28 comic strips requiring theory of mind skills by choosing one out of three answer cards. The answer cards were simple pictures in a first condition and short sentences in a second condition. This study, which used the cognitive neuropsychological approach, underlies the existence of a link between disorganization patterns in schizophrenia and a deficit in the attribution of intentions to others, independently of the pictorial or verbal form of the mode of answering. In addition, results show that the non-disorganized schizophrenic group, depressed and normal controls perform similarly in both pictorial/verbal conditions. The influence of the absence/presence of verbal material on a task investigating theory of mind in schizophrenia is discussed.

[New antipsychotics in the treatment of schizophrenia. A European survey]. / Utilisation des nouveaux antipsychotiques dans le traitement de la schizophrénie. Une enquête européenne.

Atypical antipsychotics (clozapine, risperidone, olanzapine, quetiapine, sertindole) make up a much larger proportion of the prescriptions for antipsychotic medications in the United States than in Europe. It is certain that these atypical neuroleptics are not all available throughout Europe; nonetheless the size of the disparity reveals certain tendencies in the different nations. In an attempt to identify the reasons for the lesser usage of the new antipsychotics in Europe, a telephone survey was conducted with 686 psychiatrists in 9 countries. This opinion survey was intended to identify, using open-ended questions and multiple choice, the reasons for which practitioners have or have not used the new antipsychotics; their perceived advantages and disadvantages in comparison with typical antipsychotics; and the hindrances in prescribing them. The results revealed that the new antipsychotics have a positive image with psychiatrists: whereas they estimate the proportion of their patients using the new antipsychotics to be at 50% (an amount larger than the objective European amounts), more than 80% of psychiatrists say they would be ready to use them more frequently if certain problems were overcome. Significant obstacles related to the product are the cost and the lack of a depot formulation; two hindrances with respect to the patient are the difficulty in using them in an emergency situation, and the fear of destabilizing a patient who is well-controlled with a classical treatment. The discussion re-addresses these points, using literature relevant to the products and the patients. The European data, which are often homogeneous, are discussed as a whole, with the exception of certain characteristics that are specific to an individual country. French psychiatrists, notably, serve as an exception, because they describe themselves as being more restrained in their prescriptions because of the lack of a depot formulation rather than because of the cost of the product.

Syntactic and semantic processing in schizophrenic patients evaluated by lexical-decision tasks.

Two lexical-decision tasks with 500-ms stimulus-onset asynchrony were conducted with 34 schizophrenic patients. This group consisted of 24 schizophrenic patients with thought disorder (TD) and 10 schizophrenic patients without thought disorder (NTD), 14 psychiatric controls (depressive illness), 20 hospitalized controls, and 20 normal controls. One lexical-decision task with semantic relations (related vs. unrelated, Experiment 1) and 1 task with syntactic relations (congruent vs. incongruent; Experiment 2) were used to evaluate processing of different lexical information. In Experiment 1, although all control groups and NTD schizophrenic patients showed semantic priming, TD schizophrenic patients did not. In Experiment 2, all groups showed a significant syntactic effect. These findings provide evidence for an abnormality in semantic processing and the preservation of syntactic processing in TD schizophrenic patients, thus suggesting a deficit in the processing of semantic information under certain conditions when compared with normal syntactic processing.

Attribution of intentions to others in people with schizophrenia: a non-verbal exploration with comic strips.

Several clinical and experimental data suggest that some people with schizophrenia have an impaired ability to attribute relevant mental states to other people. We tested this notion in 24 schizophrenic patients and two control groups, who performed a task devised to test understanding of the intentions of nonverbal comic strip characters. Only the schizophrenic subjects with thought and speech disorganization had specific difficulties attributing mental states to others. The findings support cognitive models which postulate a link between planning process disorders and a deficit in mentalizing skills. The hypothesis that the more frequent an action is in everyday life, the more easily it is understood by schizophrenic subjects, is discussed.

Rating scale for the assessment of communication disorders in schizophrenics.

Taking up the Bleulerian view of a clinical description based on a pathogenic model, we propose a rating scale for the assessment of communication disorders in schizophrenic patients. The scale consists of clinical items that could be the direct expression of the three hypotheses of cognitive dysfunction which have been postulated to explain communication dysfunction in these patients. We assessed the frequency of the 16 items in the scale in a total of 80 subjects (43 schizophrenic subjects, ten manic subjects, 17 depressive subjects and ten normal control subjects). The results of this study showed that this item schedule was specific to schizophrenic patients and, in particular, could statistically significantly discriminate schizophrenic patients from psychotic patients with affective disorder. The methodological qualities of the scale were explored and proved accurate, except for the reliability which is too low for some items and the item-to-total correlation which is too low for one item of the scale.

Attribution of mental States to others by schizophrenic patients.

The purpose of this paper is to validate experimentally the hypothesis that postulates a distorted attribution of mental states to others in schizophrenics. Twelve subjects with a diagnosis of schizophrenia were compared with a normal and a clinical control group. Subjects were asked to read a comic strip (with no verbal material) and to choose one of the two answer cards which seemed the most logical to complete the sequence based on the supposed mental state of the character. The results of this study confirm the principal hypothesis that schizophrenics with thought and language disorders have an impaired ability to attribute intentions and false beliefs as they figure in this experiment. Although the theory of mind deficit was specific to schizophrenia for the attribution of false beliefs, no difference was found between the schizophrenic group and the depressed group for the attribution of intentions. Schizophrenics' choice is based specifically on a socially familiar experience rather than the context of the story.

[Meta-process paraphrenia in manic-depressive disorder]. / Une paraphrénie méta-processus d'une maladie maniaco-dépressive.

A typical case report exemplifies existing links between paraphrenia and affective disorders. Kraepelin noted similarities between paraphrenia and manic-depressive illness, particularly between mania and paraphrenia confabulans. Thereafter, the German school has insisted on similarities of symptoms and course of the two entities. The French school, on the contrary, has insisted on the instrumental role of affective disorder in the development of paraphrenia: paraphrenia is considered as a potential evolution of primary psychotic disorders. If cases of post-schizophrenic paraphrenia have been reported, the development of paraphrenia on a background of bipolar disorder seems rarer. Such a case is presented and discussed, supporting the concept and its mechanisms as illustrated by French psychiatrists.

[Calcium antagonists and lithium in preventive treatment of manic-depressive disorder]. / Inhibiteurs calciques et lithium dans le traitement prophylactique de la maladie maniaco-dépressive.

Recent advances in knowledge about calcium's role as an intracellular regulator allow to broaden understanding of possible pathophysiologic mechanisms in affective disorders. An hypothesis emerge that bipolar illness arise from disorders in calcium-regulated functions. Given this hypothesis, some authors propose to describe the common profiles of action of the different mood-stabilizers: all the neural mechanisms that are hypothesized to explain various psychopharmacological treatments of bipolar illness involve functions that are critically controlled by calcium. Moreover, in every instance, a known action of lithium on calcium-dependent processes could account for lithium's prophylactic results. Similarities exist between the action of lithium and calcium antagonists like verapamil and nimodipine. From these considerations the hypothesis emerge that calcium antagonists could be an alternative pharmacological agent in the maintenance treatment of bipolar illness. Calcium antagonists have been found useful in this indication by a number of investigators. Given the safety and relative lack of side effects of calcium channel blocking agents, their potential efficacy in mood disorders, it is concluded that calcium antagonists may be an alternative choice in prophylactic treatment for bipolar illness, especially in patients who cannot be treated with lithium or carbamazepine. There is evidence for using verapamil at 240 to 320 mg a day, in 2 to 4 times. Some studies suggest that the association of lithium with calcium antagonist resulted more effective than lithium alone or calcium antagonist alone in the reduction of episodes of affective disorders. However, concomitant administration of a calcium channel antagonist and lithium present adverse interactions (lithium toxicity, cardiovascular accidents), probably because of synergistic toxic effects. Therefore, authors advise care in monitoring patients receiving the combination of these medications.