[Take-home messages from the 2nd COPD 2023 Biennial of the French Society of Respiratory Diseases. Placing the patient at the center of the care pathway]

INTRODUCTION

The second COPD Biennial organized by the COPD working group of the French Society of Respiratory Diseases took place in Paris (Cochin) on 13th December 2023.

STATE OF THE ART

Major trends in 2023 were discussed; they encompassed concepts, definitions, biologics, care pathways, pulmonary rehabilitation and complex situations entailed by respiratory infections, cardiovascular comorbidities and pulmonary hypertension, and modalities of oxygen therapy and ventilation.

PERSPECTIVES

The different talks underlined major changes in COPD including the concepts of pre-COPD, etiotypes, health trajectories and new definitions of exacerbation. Recent results in biologics for COPD open the door to new pharmacological options. Assessment of current care pathways in France highlighted some causes for concern. For example, pulmonary rehabilitation is a key but insufficiently practiced element. Respiratory infections require careful assessment and treatments. Diagnosis and treatment of cardiovascular comorbidities and pulmonary hypertension are of paramount importance. As of late, oxygen therapy and ventilation modalities have evolved, and are beginning to afford more personalized options.

CONCLUSIONS

As regards COPD, a personalized approach is crucial, placing the patient at the center of the care pathway and facilitating coordination between healthcare providers.

Clinical profile of schizophrenia comorbid with obsessive-compulsive symptoms: A comparative study

OBJECTIVE

Describe and compare the clinical profile of schizophrenic patients with and without obsessive-compulsive symptoms and obsessive-compulsive disorder (OCD) patients.

METHODS

A descriptive and analytical cross-sectional study was carried out at the psychiatry department of Hassan II University Hospital in Fez over 12 months to compare three groups of patients: "schizo-obsessive" (n=32), "schizophrenia" (n=34), and "OCD" (n=46). All participants (n=112) were assessed using the mini-international neuropsychiatric interview (MINI), the Yale-Brown obsessive-compulsive scale (Y-BOCS), the Brown assessment of beliefs scale (BABS), the Hamilton anxiety rating scale (HAM-A), the Beck's depression inventory (BDI-II), the positive and negative syndrome scale (PANSS), and the clinical global impressions-severity scale (CGI-S).

RESULTS

The "schizo-obsessive" group differed from the "schizophrenia" group in: more severe psychotic symptoms (mean=64.16±17.049, P<0.001), higher anxiety (mean=8.87±5,655, P<0.001) and depression (mean=7.50±5.989, P<0.001) scores, more prevalent suicide attempts (46.9%), higher illness severity score (mean=5.13±1.157, P=0.02), and more professional disinsertion (78.1%). The "schizo-obsessive" group (mean= 14.47±3.388) had significantly poor insight (P<0.001) compared to the "OCD" group (mean= 8.35±4.542). There were similarities in the obsessive and compulsive themes between the "schizo-obsessive" and the "OCD" groups, with no significant difference of severity (P=0.26).

CONCLUSION

A careful assessment of obsessive symptomatology is essential in schizophrenia for better patient management and prognosis.

Association of mental disorders with costs of somatic admissions in France

OBJECTIVES

Mentally ill patients have worse health outcomes when they suffer from somatic conditions compared to other patients. The objective of this study was to assess the association of mental illness with hospital inpatient costs for somatic reasons.

METHODS

All adult inpatient stays for somatic reasons in acute care hospitals between 2009 and 2013 were included using French exhaustive hospital discharge databases. Total inpatient costs were calculated from the all-payer perspective and compared in patients with and without a mental disorder. Only patients who had been admitted at least once for a mental disorder (either full-time or part-time) were considered to be mentally ill in this study. Generalized linear models with and without interaction terms studied the factors associated with hospital inpatient costs.

RESULTS

17,728,424 patients corresponding to 37,458,810 admissions were included. 1,163,972 patients (6.57%) were identified as having a mental illness. A previous full-time or part-time admission for a mental disorder significantly increased hospital inpatient costs (+32.64%, 95%CI=1.3243-1.3284). Interaction terms found an increased impact of mental disorders on costs in patients with low socio-economic status, as well as in men, patients aged between 45 and 60, and patients with a cardiovascular disease or diabetes.

CONCLUSION

Mentally ill patients have higher hospital costs than non-mentally ill patients. Improving curative and preventive treatments in those patients could improve their health and decrease the burden on healthcare systems.

[Clinical and epidemiological characteristic of COVID-19 deaths in Mali]

INTRODUCTION

Mali recorded its first COVID-19's death related case on March 26, 2020. The aim of this study was to evaluate the comorbidity of COVID-19's death related cases in the Malian context.

METHOD

A cross-sectional study was conducted between March 25 and October 11, 2020. Community death information was analyzed from the patient descriptive list, and from the hospitalization registry of the treatment sites.

RESULT

Of the 3,286 COVID-19 confirmed cases, 132 died making a lethality rate of 4.00% (132/3286). Men were the most represented with 75.76% (100/132). The mean age was 63.77 ± 15.25 years. The mean time of hospital stay was 4.50 days ± 6.35. Diabetes and cardiovascular disease remain the most frequent comorbidities with death patients with 20.45% and 17.42%, respectively.

CONCLUSION

The results of this study allow to draw map of patients who died from COVID-19 as well as provide information on the comorbidities for better management of hospitalized patients.

[Comorbid major depressive disorder of anorexia nervosa in adolescence: A scoping review of treatment strategies]

OBJECTIVES

Psychiatric comorbidities are frequent in anorexia nervosa, with the highest rate of suicidal lethality among psychiatric disorders. Major depressive disorder is one of the most life-threatening comorbidities of anorexia nervosa, exacerbating the risk of suicide, aphagia, and pervasive refusal syndrome. The aim of this study is to conduct a systematic review of studies exploring strategies for the treatment of severe depression in the acute phase of anorexia nervosa in adolescence.

METHODS

We conducted a scoping review of the publications dealing with the treatment of depressive comorbidities in adolescents suffering from anorexia nervosa published between 2005 and 2019. An electronic search in Pubmed and Medline for relevant studies used the following keywords adolescent, youth, anorexia nervosa, depress*, suicide*, "melancholic depression", treat*, therapy*, care. Included studies were dealing with 10-18-year-old inpatient or outpatient adolescents presenting an anorexia nervosa complicated by a major depressive disorder.

RESULTS

Of 562 studies identified, eight were included in the final sample. Regarding psychiatric treatments, four studies concerned the prescription of antidepressants, one case-study was described a treatment by electroconvulsive therapy and another was dealt with light therapy. Finally, the two last studies evaluated the effect of nutritional treatment on psychiatric symptoms but found no significant direct association between weight gain and improvement of depressive symptoms.

DISCUSSION

There is a need to identify faster severe depressive disorders in adolescents with anorexia nervosa in order to provide, along with refeeding, a more intensive treatment of mood symptoms. A multidisciplinary and coordinated approach must be initiated at the beginning of the trouble. There is a need for more systematic studies on the therapeutic approaches of mood disorder comorbidities in adolescents suffering from anorexia nervosa.

Comorbidités de la dermatite atopique

Atopic dermatitis is associated with an increased risk of asthma (10 to 30% according to age), allergic rhinitis and conjunctivitis and food allergy. Other comorbidiies are globally lest frequent than in psoriasis. There is no increased risk of solid cancer. Smoking is a major confounding factor that has to be taken into account. Obesity and metabolic syndrome are more frequent and there is a moderately increased cardiovascular risk in severe forms of atopic dermatitis. There is a clear-cut increased risk of vitiligo and alopecia areata and a lower risk of other auto-immune diseases, including type I diabetes in children. There is a higher risk of cutaneous but not extra-cutaneous bacterial and viral infections, and increased frequency of contact dermatitis and urticaria. Severe atopic dermatitis is associated with psychiatric comorbidities, like attention disorders/hyperactivity, depression and suicidal ideas. © 2019 Elsevier Masson SAS. All rights reserved.

[Particularities of psychiatric and dermatological comorbidity among medical students in Morocco: Multicenter study]

OBJECTIVES

To evaluate the prevalence and factors associated with dermatological conditions and to study the peculiarities of comorbidity between psychiatric disorders and dermatological conditions among medical students in Morocco.

METHODS

This is a multicenter, descriptive, and analytical cross-sectional study over a period of 4 weeks during the month of February 2019.

RESULTS

Six hundred and five students from the seven faculties of medicine of Morocco were included. Dermatological conditions were present in 15.5% (94) of students, acne being the most common condition (10.7%), followed by psoriasis in 1.65% of students as well as urticaria in 1.65%. Psychiatric disorders were present in 28% (168) of the students depression being the most common disorder (10.4%), followed by anxiety disorders (7.8%), comorbidity between depression and anxiety disorder (6.94%), and psychotic disorders (2.46%). Dermatological diseases were significantly and independently associated with the presence of a psychiatric disorder (0.0000) and marital status (P=0.0103). Suicide attempts and substance use are more common among medical students who have an association between psychiatric disorder and dermatological pathology compared to students with isolated dermatological conditions or students with isolated psychiatric disorders.

CONCLUSION

Dermatological and psychiatric conditions are frequent and underestimated among medical students in Morocco. Dermatologic and psychiatric comorbidity is associated with a higher prevalence of psychoactive substance use and suicide attempts.

Somatic assessment of one hundred inpatients in a psychiatric crisis unit: A retrospective observational study

OBJECTIVES

Compared to the general population, psychiatric patients are more exposed to physical illness but have reduced access to care.

METHODS

We conducted a descriptive study in Montpellier between November 2011, 2nd and December 2012, 21st. Every Wednesday and Friday, the last two inpatients admitted in the psychiatric post-emergency unit of the University Hospital of Montpellier were assessed by a general practitioner and included in the study. This unit takes care of suicidal patients suffering from mood and/or personality disorders. The general practitioner assessed lifetime somatic history, current somatic comorbidities and medical follow-up for non-psychiatric issues.

RESULTS

One hundred patients were included. The sample consisted of 81% women with a mean age of 43 years (18-79 years). The majority of patients had a lifetime history of somatic disease (96%) and was followed by a general practitioner (99%). Six patients had no met general practitioner for at least one year. Dyslipidemia was reported in 32 patients, among those only one patient was on lipid-lowering drug (96.88%). Among patients with impaired dental condition, 29 (55.77%) had not met a dentist for at least one year. Among those with impaired near visual acuity and/or impaired distance visual acuity, 19 (65.52%) had not met an ophthalmologist for at least one year.

CONCLUSION

Although detected, somatic comorbidities seem outsourced in psychiatric patients. Greater awareness among different health professionals about the medical care of such patients could improve healthcare management and life expectancy.

Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults

Attention deficit with or without hyperactivity disorder (ADHD) is one of the most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast with many European countries, the identification and management of adult ADHD remains underdeveloped in France, and a subject of controversy. This review provides a practical update on current knowledge about ADHD in adults for French-speaking professionals who have to detect or manage adult patients with ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of the international diagnostic classification. While symptoms and impairment due to ADHD are frequently severe during childhood, they often evolve as children grow older, with frequent persistent disabilities in adulthood. In adulthood, the clinical presentation, as in childhood, involves the symptom triad of inattention, hyperactivity and impulsivity. However, differences are noted: hyperactivity is more often internalized, symptoms of inattention may be masked by anxiety symptoms or obsessive-like compensation strategies. ADHD is often diagnosed during childhood, but it is not rare for the diagnosis to be made later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively well-developed compensation factors could be two underlying reasons for the long delay until diagnosis. Other symptoms, such as emotional deregulation or executive function-related symptoms are also usually observed in adults. In addition, in adults, ADHD is often associated with other psychiatric disorders (in 80% of cases); this makes the diagnosis even more difficult. These disorders encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety disorders, and other neurodevelopmental disorders and personality disorders, especially borderline and antisocial personality disorder. Substance-use disorders are very common, either as a consequence of impulsivity and emotional dysregulation or as an attempt at self-treatment. Sleep disorders, especially restless leg syndrome and hypersomnolence, could share common pathophysiological mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for serious functional impairment, in various domains, leading to academic, social, vocational, and familial consequences. The impact on other psychiatric disorders as an aggravating factor should also be considered. The considerable disability and the poorer quality of life among adults with ADHD warrant optimal evaluation and management. The diagnostic procedure for ADHD among adults should be systematic. Once the positive diagnosis is made, the evaluation enables characterisation of the levels of severity and impairment at individual level. A full examination should also assess medical conditions associated with ADHD, to provide personalized care. In recent years, a growing number of assessment tools have been translated and validated in French providing a wide range of structured interviews and standardized self-report questionnaires for the evaluation of core and associated ADHD symptoms, comorbidities and functional impairment. The treatment of ADHD in adults is multimodal, and aims to relieve the symptoms, limit the burden of the disease, and manage comorbidities. The most relevant and validated psychological approaches are psycho-education, cognitive-behavioural therapy and "third wave therapies" with a specific focus on emotional regulation. Cognitive remediation and neurofeedback are promising strategies still under evaluation. Medications, especially psychostimulants, are effective for alleviating ADHD symptoms with a large effect size. Their safety and tolerance are satisfactory, although their long-term clinical benefit is still under discussion. In France, methylphenidate is the only stimulant available for the treatment of ADHD. Unfortunately, there is no authorization for its use among adults except in continuation after adolescence. Hence the prescription, which is subject to the regulations on narcotics, is off-label in France. This article aims to provide practical considerations for the management of ADHD and associated disorders in adults, in this particular French context.

[Undernutrition of the elderly]

Malnutrition remains a particularly important issue in elderly. Physiological ageing induces many changes but ageing cannot entirely explain a Protein-Energy Malnutrition (PEM). Nutritionnal screening is indicated once a year in community medicine or in the first 48hours in case of an acute disease or of hospitalization. The Mini Nutritional Assessment is recommended for screening and for the diagnostic of malnutrition. Possible aetiologies are large and must be investigated in order to be careful not to dismiss curable disease and to be able to take corrective actions. PEM is associated to functional decline, length of stay in hospital and to morbi-mortality. Recommendations for dietary intakes in healthy old subjects are about 30 kcal/kg/day and 1 g/kg/day of protein and are strongly enhanced in case of acute or chronic diseases. The nutritional strategy depends on spontaneous food intake, medical situation, patient profile and opinion. Appropriate nutritional care could reduce morbidity-mortality and prevent functional decline in various disease contexts.

[Comorbidity schizophrenia and diabetes mellitus in Algeria - A study of risk factors]

BACKGROUND

The combination of schizophrenia and diabetes mellitus presents a public health problem in the world. Several studies have been carried out for the analysis of this comorbidity, including prognostic factors.

OBJECTIVE

The objective of our study is to determine the risk factors associated with the comorbidity schizophrenia and diabetes mellitus.

METHODS

From a sample of 200 cases of schizophrenic patients hospitalized at the Sidi Chami psychiatric hospital of Oran in Algeria, we carried out a descriptive transversal and analytical study during the period of one year.

RESULTS

Our results are consistent with those of the different studies carried out in neighboring countries. Among the risk factors recorded in our study, we mention the age of 40 and over, divorce, dyslipidemia, high blood pressure, overweight and severe and moderate obesity, the age of schizophrenia of 30 to 40 years, the first-generation neuroleptic treatment and family history related to diabetes. While the male sex, celibacy and second-generation neuroleptics were found in the study as protective factors against the onset of diabetes mellitus in schizophrenic patients.

CONCLUSION

The factors associated with comorbidity schizophrenia and type 2 diabetes are manifold. These factors must be taken into account when introducing preventive behaviors that must be multidisciplinary in order to ensure better patient care.

Dynamic iron status after acute heart failure

BACKGROUND

Iron deficiency (ID) is common in heart failure (HF), and is associated with unfavourable clinical outcomes. Although it is recommended to screen for ID in HF, there is no clear consensus on the optimal timing of its assessment.

AIM

To analyse changes in iron status during a short-term follow-up in patients admitted for acute HF.

METHODS

Iron status (serum ferritin concentration and transferrin saturation) was determined in 110 consecutive patients (median age: 81 years) admitted to a referral centre for acute HF, at three timepoints (admission, discharge and 1 month after discharge). ID was defined according to the guidelines.

RESULTS

The prevalence rates of ID at admission, discharge and 1 month were, respectively, 75% (95% confidence interval [CI] 67-83%), 61% (95% CI: 52-70%), and 70% (95% CI: 61-79%) (P=0.008). Changes in prevalence were significant between admission and discharge (P=0.0018). Despite a similar ID prevalence at admission and 1 month (P=0.34), iron status changed in 25% of patients. Between admission and discharge, variation in C-reactive protein correlated significantly with that of ferritin (ρ=0.30; P=0.001). Advanced age, anaemia, low ferritin concentration and low creatinine clearance were associated with the persistence of ID from admission to 1 month.

CONCLUSIONS

Iron status is dynamic in patients admitted for acute HF. Although ID was as frequent at admission as at 1 month after discharge, iron status varied in 25% of patients.

[Impact of comorbidities on hemoglobin stability in patients with chronic kidney insufficiency on hemodialysis, treated with CERA in current practice: The MIRIADE study]

This national, prospective and multicenter study aimed to describe the real-life impact of comorbidities on hemoglobin stability in patients with chronic kidney disease on hemodialysis, treated with CERA in relay of an erythropoietin stimulating agent. Comorbidities were defined by the Charlson Index (adjusted on age) and hemoglobin stability as a variation of ±1g/dL after the 6-month treatment period. The 585 analyzed patients were distributed as follows according to the adjusted Charlson index: score≤3 (12% of patients), 4≤score≤5 (17%), 6≤score≤7 (31%) and score≥8 (40%). At CERA start, its median monthly dose was of 100μg for the overall population, with no changes during the treatment period and with little variation according to the comorbidity score. Patients with stable hemoglobin (56%, 67% if score≤3) were more numerous to reach the therapeutic target range between 10 and 12g/dL after 6 months (85% versus 43% if not stable hemoglobin). Patients with low C-reactive protein value (≤5mg/L ; P=0.04), no red blood cell transfusion (P=0.03), or no/low dose of intravenous iron (≤200mg ; P=0.03) were more likely to reach stable hemoglobin under CERA after 6 months. Among the 644 CERA-treated patients, 4 patients (<1%) had one serious adverse event related to treatment. A stable hemoglobin within the therapeutic target was reached in the majority of the patients after 6 months in current practice with a lower CERA dose, regardless of the comorbidities scores of patients on hemodialysis.

[Spotting the GLObalRIsk of severe outcomes in undiagnosed COPD patients (GLORI-COPD)]

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a severe chronic disease and its prevalence is increasing. Nevertheless, mortality linked to moderate and mild COPD without comorbidities is low. The aim of the study is to create and validate a questionnaire in primary care to spot patients with undiagnosed COPD who are at high risk of severe complications considering the severity of their COPD and their comorbidities.

METHODS

The development of the questionnaire has three steps. The first is the selection of the items which can be included in the questionnaire with a two-round Delphi method. The second step is a cross-sectional study to assess the link between spirometry and the selected items in the first step. The last step is the validation of the questionnaire in a prospective study in primary care.

EXPECTED RESULTS

Identifying undiagnosed COPD patients with a high global risk of complications in primary care will help to establish which patients have to be diagnosed as a priority. This is particularly useful in general practice as the patient is considered globally and not just on the basis of respiratory criteria. It should allow better selection of patients who need specialised follow up.

Facial emotion recognition in children with or without Attention Deficit/Hyperactivity Disorder: Impact of comorbidity

OBJECTIVES

This study sought to assess facial emotion recognition deficit in children with Attention Deficit/Hyperactivity Disorder (ADHD) and to test the hypothesis that it is increased by comorbid features.

METHOD

Forty children diagnosed with ADHD were compared with 40 typically developing children, all aged from 7 to 11years old, on a computerized facial emotion recognition task (based on the Pictures of Facial Affect). Data from parents' ratings of ADHD and comorbid symptoms (on the Conners' Revised Parent Rating Scale) were also collected.

RESULTS

Children with ADHD had significantly fewer correct answer scores than typically developing controls on the emotional task while they performed similarly on the control task. Recognition of sadness was especially impaired in children with ADHD. While ADHD symptoms were slightly related to facial emotion recognition deficit, oppositional symptoms were related to a decrease in the number of correct answers on sadness and surprise recognition.

CONCLUSION

Facial emotion recognition deficit in children with ADHD might be related to an impaired emotional process during childhood. Moreover, Oppositional Defiant Disorder seems to be a risk factor for difficulties in emotion recognition especially in children with ADHD.

[Dose adaptation of the drugs used for hematopoietic stem-cell transplantation in patients with comorbidity: Obesity, chronic renal disease or hepatopathy: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]

In September 2016 in Lille, France, the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) organized the 7th Allogeneic Stem Cell Transplantation Clinical Practices Harmonization Workshop Series. Our work group focused on chemotherapy drug dose adaptation for hematopoietic stem cell transplantation patients presenting a comorbidity. The purpose of this workshop was to provide recommendations on chemotherapy drug dose adaptation for patient populations receiving hematopoietic stem cell transplantation who also had the following comorbidities: obesity, chronic kidney disease and hepatopathy.

[Which psychiatric comorbidities in cannabis dependence during adolescence? Comparison of outpatients and controls]

BACKGROUND

The use of illicit substances, in particular cannabis, among French adolescents and young adults has become an important public health concern. A better understanding of the mechanisms involved in pathological substance use is nowadays critical. Psychiatric comorbidities have been previously reported in adult substance abusers but are less documented in adolescents, especially regarding cannabis dependence.

OBJECTIVES

We investigated mental health problems in adolescents and young adults, seeking treatment for their problematic cannabis use, comparatively to healthy controls, taking into account the participant's gender and age. Moreover, we explored the relationships between psychiatric diagnosis and substance use modalities.

METHODS

In total, 100 young patients (80 males - mean age 18.2 (SD=2.9; [14 to 25] years old)) with a cannabis dependence (DSM-IV-TR criteria) seeking treatment in an addiction unit, and 82 healthy control subjects (50 males - mean age 18.3 (SD=3.4; [14 to 25] years old)) with no substance misuse diagnostic other than for alcohol, participated in the study. The MINI was administered to evaluate cannabis dependence, and DSM-IV axis I comorbid diagnosis, and a semi-structured interview was used to determine psychoactive substance use.

RESULTS

Statistical analyses revealed that 79 % of the patients reported at least one other non-drug or alcohol comorbid diagnosis, versus 30.5 % in the control group (χ²=16.83; P<0.001). Logistic regression indicated that participants with a psychiatric diagnosis had an 8.6 times higher risk (P<0.001; OR 95 % CI=[4.38-16.81]) of being patients. Significant inter-group differences and OR were noted for several diagnoses: dysthymia over the previous 2years (χ²=14.06; P<0.001; OR=10.63; OR 95 % CI=[2.41-46.87]), life-time panic attack disorder (χ²=4.15; P<0.042; OR=3.59; OR 95 % CI=[0.98-13.19]), alcohol abuse (χ²=47.72; P<0.001; OR=66.27; OR 95 % CI=[8.87-495.11]) and dependence (V=0.230; P=0.001) and generalized anxiety disorder (χ²=7.46; P=0.006-OR=3.57; OR 95 % CI=[1.37-9.30]). On the whole, the females (n=20) of our clinical sample presented significantly more comorbid diagnoses than the males (n=80) (95 % versus 75 %; χ²=6.25, P=0.011). These significant gender differences were found for life-time eating disorder (V=0.352; P=0.007) and generalized anxiety disorder diagnoses (V=0.278; P=0.013). Moreover, young adult patients (19-25years old; n=35) presented, on the whole, significantly more comorbid diagnoses than adolescent patients (14-18years old; n=65) (70.8 % versus 94.3 %; χ²=7.58, P=0.006). These age inter-group differences were found for several diagnoses: alcohol dependence (6.2 % versus 20 %; V=0.211, P=0.047), dysthymia over the past 2years (13.8 % versus 34.3 %; χ²=5.73, P=0.017) and generalized anxiety disorder (12.3 % versus 40 %; χ²=10.17, P=0.001). Various associations were observed between psychiatric comorbid diagnosis and substance use indicators.

CONCLUSION

This study demonstrates that cannabis dependence in adolescents and young adults is related to great psychological distress and puts emphasis on the importance of substance use prevention as early as middle school. Moreover, the psychiatric features of adolescents and young adults need to be taken into consideration for treatment planning.

[Affective disorders and anxiety comorbidities]

Anxiety disorders are frequently associated with affective disorders and represent one of the most important comorbidity in patients with bipolar disorder. Their prevalence is high, whatever the anxiety disorder, with nevertheless higher rates for generalized anxiety disorder (18.4 to 19.9% for lifetime prevalence). Such high frequencies raise essential questions about the link between these groups of disorders, and if it is necessary to distinguish them or to consider their phenomenological overlap as resulting of common disease processes. The existence of comorbid anxiety disorder in bipolar disorder significantly worsens its evolution, inducing more severe episodes, shortening remission periods, favoring relapses and suicide as well as substance use, and reducing quality of life in comparison to bipolar patients without anxiety. The mechanisms that link the anxious symptomatology to mood dysregulation are still poorly understood, although it is likely that genetic factors play a key role, combined with other factors of vulnerability, including those involved in coping strategy to address ongoing distress. Despite the high impact of anxiety on the severity of bipolar disorder course, few randomized controlled trials examined treatments of comorbid anxiety disorders and only recent recommendations offer useful therapeutic perspectives. In this context, it seems necessary to better understand the features associated with the occurence of anxiety disorders in affective disorders, in order to better identify the mechanisms underlying such comorbidity, together with working to develop therapeutics that efficiently target them.

[Psychiatric comorbidity related to children with attention deficit hyperactivity disorder at schools in Sfax, Tunisia]

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a prevalent behavioral disorder particularly noticed among school children. It is often associated with other psychological troubles at the origin of an additional difficulty that has to be overcome.

OBJECTIVE

Our research's aim was to study the comorbidity of school-aged children diagnosed with ADHD in Sfax, Tunisia.

SUBJECTS AND METHODS

A cross-sectional descriptive study was carried out from 1st April 2008 to 1st October 2008. Five hundred and thirteen pupils aged between 6 and 12, from primary arbitrarily chosen schools from Sfax were subjected to this study. Measurements were carried out in two steps: parents and teachers of each child filled in separately Conners questionnaire, then children with a score in subscales inattention, hyperactivity impulsivity higher than 70 were selected for psychiatric interview that was intended to confirm or to invalidate the ADHD diagnosis and the possible comorbid diagnosis. The diagnoses were made according to DSM-IV-TR.

RESULTS

We have noticed that 109 pupils exhibited at least one pathological score on the Conners questionnaire. After interviewing these 109 pupils, the results have shown that 51 among them fulfilled criteria of ADHD. Prevalence of ADHD was found to be 9.94 %. About 72.54 % of children with ADHD had one or more comorbid disorder: learning disabilities (23.52 % of cases), anxiety disorder (31.37 % of cases), oppositional defiant disorder in (15.68 % of cases), mood disorder (3.92 % of cases), enuresis (13.72 % of cases) and slight mental retardation (1.95 % of cases).

CONCLUSION

We can say that this study has shown that ADHD school children's psychiatric comorbidity is similar to any other previous study.

[Autism spectrum disorder and suicidality]

INTRODUCTION

Most studies on suicide exclude subjects with autism spectrum disorders, yet there is a risk group. The purpose of this article is to present the data in the literature regarding the clinical and epidemiological characteristics of suicidality in subjects with autism spectrum disorders and to identify the factors that promote the transition to action.

METHODS

This review was carried out using the data set collected in Medline PubMed, items with "autism spectrum disorder", "pervasive developmental disorder", "Asperger's syndrome", "suicide", "suicide attempt", and "suicide behavior".

RESULTS

In all subjects from our research on PubMed, 21.3% of subjects with autism spectrum disorder reported suicidal ideation, have attempted suicide or died by suicide (115 out of 539 subjects) and 7.7% of subjects supported for suicidal thoughts or attempted suicide exhibited an autism spectrum disorder (62 out of 806 subjects), all ages combined. Suicidal ideation and morbid preoccupation are particularly common in adolescents and young adults. Suicide attempts are accompanied by a willingness for death and can lead to suicide. They are more common in high-functioning autism and Asperger subjects. The methods used are often violent and potentially lethal or fatal in two cases published. Suicide risk depends on many factors that highlight the vulnerability of these subjects, following autistic and developmental symptoms. Vulnerability complicating the diagnosis of comorbid depressive and anxiety disorders are major factors associated with suicidality. Vulnerability but also directly related to suicidality, since the origin of physical and sexual abuse and victimization by peers assigning them the role of "scapegoat" are both responsible for acting out.

CONCLUSION

Given the diversity of factors involved in the risk of suicide in this population, this does not validate "a" program of intervention, but the intervention of "customized programs". Their implementation should be as early as possible in order to treat while the brain has the greatest plasticity. The aim is to provide the necessary access to the greatest possible autonomy. Hence, including working communication skills and interaction, these subject will have independent means of protection, an essential complement to measures to protect vulnerable subjects; the vulnerability of direct and indirect suicidality. Comorbid diagnoses must take into account the specificities of these patients, their difficulties in communicating their mental state, and adapted and innovative therapeutic strategies must be offered and validated.

Developmental coordination disorders: state of art

In the literature, descriptions of children with motor coordination difficulties and clumsy movements have been discussed since the early 1900s. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), it is a marked impairment in the development of fine or global motor coordination, affecting 6% of school-age children. All these children are characterized for developmental coordination disorder (DCD) in motor learning and new motor skill acquisition, in contrast to adult apraxia which is a disorder in the execution of already learned movements. No consensus has been established about etiology of DCD. Intragroup approach through factor and cluster analysis highlights that motor impairment in DCD children varies both in severity and nature. Indeed, most studies have used screening measures of performance on some developmental milestones derived from global motor tests. A few studies have investigated different functions together with standardized assessments, such as neuromuscular tone and soft signs, qualitative and quantitative measures related to gross and fine motor coordination and the specific difficulties -academic, language, gnosic, visual motor/visual-perceptual, and attentional/executive- n order to allow a better identification of DCD subtypes with diagnostic criteria and to provide an understanding of the mechanisms and of the cerebral involvement.

["Factitious disorder and skin picking: Clinical approach". A case report]

OBJECTIVE

The number of patients requiring primary and secondary care for factitious disorder unexplained by any known medical condition is high. We report a case illustrating the clinical and psychopathological features of factitious disorder. The treatment difficulties encountered in the association of this disorder with dermatillomania are discussed.

CASE REPORT

The patient was a 22-year old girl with abrasions on the face and forearms with ingested epidermal layer of the skin. She also had multiple somatic complaints, the authenticity of which was difficult to confirm. The diagnosis of comorbid factitious disorder with dermatillomania was retained. In view of reducing self-harm acts, we prescribed a mood stabilizer associated with an anxiolytic for 6 months. The self-harming acts have regressed, while the hypochondriacal complaints remain with a tendency of overstatement.

DISCUSSION

Factitious disorder (FD) is a mental disorder occurring in patients acting intentionally similar to a physically or mentally sick person with no apparent benefits. The reported cases often show FD comorbidity with other psychiatric disorders such as substance abuse, somatoform disorders, dysthymia, borderline personality disorder and sexual disorders. Comorbidity of factitious disorder with neurotic excoriation is exceptional, and rarely described in the literature. Pathological skin picking (PSP) is a disabling disorder characterized by repetitive skin picking, which causes tissue damage. It was estimated to affect 2% of the population. PSP is currently listed as an impulse control disorder not otherwise specified, it is associated with a high rate of psychiatric comorbidity like borderline personality disorder.

CONCLUSION

The comorbidity of factitious disorder and dermatillomania makes diagnosis very difficult. The limit between the two disorders is sometimes unclear.