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Background Although there is an increasing number of adults older than 60 years old (>60) suffering from psychiatric disorders, there are only few studies about elderly patients in psychiatric emergencies, and no European data. The goal of our study is to describe the population of patients > 60 consulting in the most important French emergency psychiatric centre, and to identify predictive factors of psychiatric hospitalisation. Methods Our study was monocentric and prospective, including 300 consecutive patients > 60. Results Patients > 60 consulting in psychiatric emergencies were more often females and autonomous. More than 40% had a history of at least one psychiatric hospitalisation, and 44% had consulted a psychiatrist in the 6 preceding months. 75% were taking at least 1 psychotropic drug, and 50% at least 2. The most frequent reasons for consultation were depression, anxiety, sleep disorders and suicidal thoughts. Psychiatric disorders were mainly mood disorders, neurotic, stress-related and somatoform disorders, and schizophrenia, schizotypal and delusional disorders. Organic, including symptomatic, mental disorders were diagnosed in only 10% of the total sample. 39% of elderly patients were hospitalised in psychiatry. Factors predicting hospitalisation were a history of psychiatric hospitalisation, suicidal thoughts, and a diagnosis of mood disorder or schizophrenia / schizotypal / delusional disorder. Conclusion Only psychiatric factors intervene in the decision of psychiatric hospitalisation for elderly people consulting in psychiatric emergencies. Socio-demographic characteristics, level of autonomy at home and MMSE score have no influence on the hospitalisation decision. We need more data to better understand the current and future needs of this population.

The population of older adults is growing fast, especially in Europe and Northern America. Old age is often associated with mental health comorbidities. Moreover, life expectancy of people suffering from psychiatric disorders has increased, but with age-related difficulties, such as loss of independence. This represents a challenge for public health policies, as this population requires specific care and living conditions. As a response, a convention was signed between living facilities for dependent elderly (EHPAD) and the GHU Paris Psychiatry and Neurosciences. The agreement included dedicated places in EHPAD for older patients with psychiatric disorders. The aim of the study was to describe the sociodemographic and clinical characteristics of those patients.We conducted a cross-sectional study among patients who applied for an EHPAD admission.Between 2016 and 2019, 163 patients applied for placement in an EHPAD, and 117 were admitted (72%). Applicants were 71 years old on average. Admitted patients were older than non-admitted and lived in different Parisian sectors. Among admitted patients, nine in 10 were single, divorced or widowed, and 64.3% were childless. Almost half of them were schizophrenic or had delusional disorders (46.9%), and 65.3% were considered as moderately dependent. At the time of the study, 89 patients still lived in EHPAD. Almost half of them had anxiety and depressive disorders (48.3%), 19.1% had cognitive disorders, and 42.7% manifested agitation.Our study highlighted older psychiatric patients' specificities regarding their admission status into long-term living facilities.

Resume Cet entretien est la suite et le complement de l’article « Transidentites et changement de sexe : le point de vue du sociologue, le role du psychiatre ». Les psychologues Sandrine Coussinoux, Eirini Rari et le psychiatre Thierry Gallarda y evoquent la problematique de la reassignation de sexe pour des personnes transidentitaires ainsi que le role des psychologues qui travaillent sur ce sujet au sein de l’equipe parisienne pluridisciplinaire specialisee « Dysphorie de genre et sante mentale ».

Very-late-onset psychotic symptoms (PS) are a common gateway to both neurodegenerative dementias and primary psychiatric disorders. Despite similarities in clinical expression, no consensual guidelines or a specific nosographic framework exist. The purpose of this systematic review is to establish a phenomenological classification of PS among the main neurodegenerative dementias and late psychosis. More specifically, to: 1) allow psychotic phenotypes to be considered according to aetiology; 2) help clinicians screen for psychiatric-type dementia, when appropriate; and 3) justify research into very-late-onset PS in patients with dementias at a pre-clinical cognitive stage in order to establish a nosographic framework for these PS based on the prognosis of dementia. Methods A literature review was conducted to search for very-late-onset PS (>60 years old) in reports of late-onset (known as primary) psychoses, Alzheimer-type dementia and Lewy body dementia, focusing on the phenomenological data. Results Very-late-onset schizophrenia-like psychosis appears to be a primary psychiatric diagnosis that is clinically distinct from PS, which emerges among established dementias, but remains a heterogeneous entity due to its age-based syndromic aspect. It is possible to differentiate between the more common phenotypes based on the aetiology of the dementia. Conclusion The results confirm the value of the phenomenological approach in terms of distinguishing between different aetiologies of PS among confirmed cases of dementias. Prospective longitudinal studies are required to examine the early discriminatory characteristics of PS in order to improve prognosis based on the nosographic framework thus established.

Background Although treatment-resistant and nontreatment-resistant depressed patients show structural brain anomalies relative to healthy controls, the difference in regional volumetry between these two groups remains undocumented. Methods A whole-brain voxel-based morphometry (VBM) analysis of regional volumes was performed in 125 participants’ magnetic resonance images obtained on a 1.5 Tesla scanner; 41 had treatment-resistant depression (TRD), 40 nontreatment-resistant depression (non-TRD), and 44 were healthy controls. The groups were comparable for age and gender. Bipolar/unipolar features as well as pharmacological treatment classes were taken into account as covariates. Results TRD patients had higher gray matter (GM) volume in the left and right amygdala than non-TRD patients. No difference was found between the TRD bipolar and the TRD unipolar patients, or between the non-TRD bipolar and non-TRD unipolar patients. An exploratory analysis showed that lithium-treated patients in both groups had higher GM volume in the superior and middle frontal gyri in both hemispheres. Conclusions Higher GM volume in amygdala detected in TRD patients might be seen in perspective with vulnerability to chronicity, revealed by medication resistance.

International audience; Qu’entend-on par transidentités ? Pourquoi des personnes transidentitaires veulent ou ne veulent pas changer de sexe ? Quel est le rôle du psychiatre dans le changement de sexe de personnes transidentitaires ? C’est à ces questions, aux enjeux souvent complexes, qu’Arnaud Alessandrin, sociologue, et Thierry Gallarda, psychiatre, répondent dans cet entretien.

Autobiographical memory deficits are prominent from the early stages of Alzheimer's disease (AD) and result in a loss of personal identity. Nevertheless, standardised methods of autobiographical memory stimulation for the neuropsychological rehabilitation of patients with AD remain underdeveloped. Our aim was to evaluate the impact of a new cognitive training programme for autobiographical memory (REMau) on both the episodic and semantic components of autobiographical memory performance across lifetime periods, as well as on mood. Pre/post evaluations were conducted on two groups of patients with early to moderate AD, assigned to one of two different training activities: either the REMau or a cognitive training programme focused on collective semantic memory. Statistical comparisons showed significant improvement of episodic and semantic autobiographical memory performance in the REMau group, which was more pronounced for the semantic component, as well as improved mood. By contrast, deleterious pre/post differences were observed in the other group. Most interestingly, this study showed that the REMau programme boosted autobiographical memory from the reminiscence bump period, which is considered crucial for the construction and maintenance of personal identity. We discuss the theoretical and practical implications of these results for the reduction of autobiographical memory deficits in AD.

Objective Repetitive transcranial magnetic stimulation (rTMS) over the left temporo-parietal region has been proposed as a treatment for resistant auditory verbal hallucinations (AVH), but which patients are more likely to benefit from rTMS is still unclear. This study sought to assess the effects of rTMS on AVH, with a focus on hallucination phenomenology. Method Twenty-seven patients with schizophrenia and medication-resistant AVH participated to a randomized, double-blind, placebo-controlled, add-on rTMS study. The stimulation targeted a language-perception area individually determined using functional magnetic resonance imaging and a language recognition task. AVH were assessed using the hallucination subscale of the Scale for the Assessment of Positive Symptoms (SAPS). The spatial location of AVH was assessed using the Psychotic Symptom Rating Scales. Results A significant improvement in SAPS hallucination subscale score was observed in both actively treated and placebo-treated groups with no difference between both modalities. Patients with external AVH were significantly more improved than patients with internal AVH, with both modalities. Conclusions A marked placebo effect of rTMS was observed in patients with resistant AVH. Patients with prominent external AVH may be more likely to benefit from both active and placebo interventions. Cortical effects related to non-magnetic stimulation of the auditory cortex are suggested.

A recently tested hypothesis suggests that inter-individual differences in episodic autobiographical memory (EAM) are better explained by individual identification of typical features of a gender identity than by sex. This study aimed to test this hypothesis by investigating sex and gender related differences not only in EAM but also during retrieval of more abstract self-knowledge (i.e., semantic autobiographical memory, SAM, and conceptual self, CS), and considering past and future perspectives. No sex-related differences were identified, but regardless of the sex, feminine gender identity was associated with clear differences in emotional aspects that were expressed in both episodic and more abstract forms of AM, and in the past and future perspectives, while masculine gender identity was associated with limited effects. In conclusion, our results support the hypothesis that inter-individual differences in AM are better explained by gender identity than by sex, extending this assumption to both episodic and semantic forms of AM and future thinking.

Autobiographical memory (AM) underlies the formation and temporal continuity over time of personal identity. The few studies on sex-related differences in AM suggest that men and women adopt different cognitive or emotional strategies when retrieving AMs. However, none of the previous works has taken into account the distinction between episodic autobiographical memory (EAM), consisting in the retrieval of specific events by means of mental time travel, and semantic autobiographical memory (SAM), which stores general personal events. Thus, it remains unclear whether differences in these strategies depend on the nature of the memory content to be retrieved. In the present study we employed functional MRI to examine brain activity underlying potential sex differences in EAM and SAM retrieval focusing on the differences in strategies related to the emotional aspects of memories while controlling for basic cognitive strategies. On the behavioral level, there was no significant sex difference in memory performances or subjective feature ratings of either type of AM. Activations common to men and women during AM retrieval were observed in a typical bilateral network comprising medial and lateral temporal regions, precuneus, occipital cortex as well as prefrontal cortex. Contrast analyses revealed that there was no difference between men and women in the EAM condition. In the SAM condition, women showed an increased activity, compared to men, in the dorsal anterior cingulate cortex, inferior parietal and precentral gyrus. Overall, these findings suggest that differential neural activations reflect sex-specific strategies related to emotional aspects of AMs, particularly regarding SAM. We propose that this pattern of activation during SAM retrieval reflects the cognitive cost linked to emotion regulation strategies recruited by women compared to men. These sex-related differences have interesting implications for understanding psychiatric disorders with differential sex prevalence and in which one of key features is overgenerality in AM.

Apathy and depression are the most frequent neuropsychiatric symptoms in Alzheimer's disease (AD). In a cross-sectional observational study of 734 subjects with probable mild AD, we evaluated the prevalence of apathy and depression. After the use of specific diagnostic criteria, we tested the interaction between the two syndromes and their relation with specific comorbidities, and different functional outcomes. Depression was diagnosed using the diagnostic criteria for depression in AD, and apathy with the diagnostic criteria for apathy in neuropsychiatric disorders. According to the specific diagnostic criteria, depression had a 47.9% prevalence, while apathy prevalence was 41.6%. Apathy and depression were associated in 32.4% of patients (n = 225). 9.4% (n = 65) had only apathy, 15.4% (n = 107) had only depression, and 42.9% had no apathy and no depression (n = 298). The three most frequent depressive symptoms were fatigue or loss of energy (59.4%), decreased positive affect or pleasure in response to social contacts and activities (46.2%), and psychomotor agitation or retardation (36.9%). Concerning apathy, loss of goal-directed cognition was the most frequently altered (63.6%), followed by loss of goal-directed action (60.6%) and loss of goal-directed emotion (43.8%). Patients with both apathy and depression more frequently required a resource allowance for dependency. Neurological comorbidities were more frequent in the "apathy and depression" and "depression alone" groups (p0.001). Apathy and depression overlap considerably, and this might be explained by the presence of some non-specific symptoms in both diagnostic criteria. The need for social support is higher when a patient fulfills the two diagnostic criteria.

Homicide is an extreme outcome of violence which is infrequent in older adults, with a prevalence ranging from 1% to 4%. In those cases, homicide is usually followed by suicide. Homicide appears in different psychopathology contexts: Mood disorder, alcohol disorder and psychosis disorder. An association of mild to moderate dementia with homicide has been reported. The risk factors of homicide in demented patients remain unknown. Dysexecutive syndrome could be a cause of homicide in demented patients. The reported case highlights this issue and shows that neuropsychiatric evaluation of older murderers could be useful in understanding the murder. Clinical and criminological characteristics of elderly murderers with a dementia will also be discussed.

Auditory verbal hallucinations are a cardinal symptom of schizophrenia. Bleuler and Kraepelin distinguished 2 main classes of hallucinations: hallucinations heard outside the head (outer space, or external, hallucinations) and hallucinations heard inside the head (inner space, or internal, hallucinations). This distinction has been confirmed by recent phenomenological studies that identified 3 independent dimensions in auditory hallucinations: language complexity, self-other misattribution, and spatial location. Brain imaging studies in schizophrenia patients with auditory hallucinations have already investigated language complexity and self-other misattribution, but the neural substrate of hallucination spatial location remains unknown. Magnetic resonance images of 45 right-handed patients with schizophrenia and persistent auditory hallucinations and 20 healthy right-handed subjects were acquired. Two homogeneous subgroups of patients were defined based on the hallucination spatial location: patients with only outer space hallucinations (N = 12) and patients with only inner space hallucinations (N = 15). Between-group differences were then assessed using 2 complementary brain morphometry approaches: voxel-based morphometry and sulcus-based morphometry. Convergent anatomical differences were detected between the patient subgroups in the right temporoparietal junction (rTPJ). In comparison to healthy subjects, opposite deviations in white matter volumes and sulcus displacements were found in patients with inner space hallucination and patients with outer space hallucination. The current results indicate that spatial location of auditory hallucinations is associated with the rTPJ anatomy, a key region of the “where” auditory pathway. The detected tilt in the sulcal junction suggests deviations during early brain maturation, when the superior temporal sulcus and its anterior terminal branch appear and merge.

Objectives: Cerebral abnormalities have been detected in patients with bipolar disorder (BD). In comparison to BD with a later onset, early-onset BD has been found to have a poorer outcome. However, it is yet unknown whether neuroanatomical abnormalities differ between age-at-onset subgroups of the illness. We searched for cortical folding differences between early-onset (before 25 years) and intermediate-onset (between 25 and 45 years) BD patients. Methods: Magnetic resonance images of 22 early-onset BD patients, 14 intermediate-onset BD patients, and 50 healthy participants were analyzed using a fully automated method to extract, label, and measure the sulcal area in the whole cortex. Cortical folding was assessed by computing global sulcal indices (the ratio between total sulcal area and total outer cortex area) for each hemisphere, and local sulcal indices for 12 predefined regions in both hemispheres. Results: Intermediate-onset BD patients had a significantly reduced local sulcal index in the right dorsolateral prefrontal cortex in comparison to both early-onset BD patients and healthy subjects, and lower global sulcal indices in both hemispheres in comparison to healthy subjects (p

The study evaluated the impact of a general practice-based intervention on 3021 patients in France aged 75 years and above with spontaneous memory complaints. The objective was to identify evocative signs of Alzheimer's disease through a cluster randomized controlled trial. The study involved 681 general practitioners (GPs), randomly selected and assigned to an intervention ( n = 352) or a control group ( n = 329), and 214 specialists. The intervention group participated in training sessions relating to dementia diagnosis and the use of brief neuropsychological tests suited to general practice. The control group dispensed usual general practitioner care. The primary outcome was suspicion of dementia by GPs. The secondary outcome was accurate detection of dementia by the GPs. Most patients (96%) were already followed by the GPs (mean follow-up duration 10.8 years, similar in both groups). Suspicion of dementia was two-fold higher for GPs in the intervention group (adjusted OR = 1.99, p < 0.0001). Probability of suspected dementia increased with patient age and decreased with educational level. However the positive predictive value was not significantly different between the two groups (60.9% vs. 64.4%, p = 0.41). GPs from the intervention group also had a higher probability (adjusted OR = 2.24, p = 0.01) of correctly detecting demented patients (intervention did not increase the number of diagnosed cases of dementia, but increased the number of suspected cases that were later confirmed by specialists). The study showed that information on dementia and application of simple psychometric tests could improve the precision of a GP's diagnosis without changing the efficacy of detection of dementia.

Resume Les reactions paradoxales d’agressivite sous benzodiazepines ont fait l’objet d’une litterature scientifique specifique depuis 1960. Si peu d’etudes controlees ont pu etre realisees, de nombreux cas cliniques ont ete recenses et discutes dans la litterature. Desinhibition, anxiete, comportements auto ou heteroagressifs et actes medicolegaux ont ete observes chez des patients presentant differents facteurs de vulnerabilite, sans qu’une modelisation des processus incrimines ait pu etre elaboree. Cependant, le role de la personnalite limite et de la personnalite anxieuse, l’influence du controle gabaergique sur le systeme serotoninergique ainsi que l’impact de l’alcool semblent etre autant d’hypotheses expliquant une partie de ces phenomenes paradoxaux.

Background Depression negatively affects rehabilitation and quality of life after stroke. Identifying in the acute phase patients at high risk for post-stroke depression would facilitate early detection of depressive symptoms. Methods The DEPRESS (Depression Predictors after Ischemic Stroke) study was a prospective cohort study designed to identify baseline predictors of depression occurring within six months after ischemic stroke and high-risk patients for post-stroke depression. All patients without aphasia were screened for depression by a neurologist using the Patient Health Questionnaire, and the diagnosis was confirmed by a psychiatrist with the Mini International Neuropsychiatric Interview. In severely aphasic patients, depression was diagnosed using the Aphasic Depression Rating Scale and the Visual Analog Mood Scale. Results Depression was present in 61 of 251 (24%) patients enrolled in the DEPRESS study. Female gender, prior history of depression, major physical disability, prior history of stroke, stressful life event exposure in the month preceding stroke onset, and pathologic crying were significant predictors of depression within six months after ischemic stroke. Depression was more frequent in patients with left caudate and/or lenticular nucleus lesion (OR = 2.4, 95% confidence interval, 0.97–5.91), but the difference was not significant. The presence of ≥2 predictors identified the largest proportion of depressed patients (62%) in the smallest proportion of the cohort (36%). Conclusion Female gender, prior history of depression, major physical disability, prior history of stroke, recent stressful life event exposure before stroke, and pathologic crying were significant predictors of post-stroke depression occurring within six months after stroke onset.

International audience; Self-referential processing relies mainly on the medial prefrontal cortex (MPFC) and enhances memory encoding (i.e., Self-Reference Effect, SRE) as it improves the accuracy and richness of remembering in both young and older adults. However, studies on age-related changes in the neural correlates of the SRE on the subjective (i.e., autonoetic consciousness) and the objective (i.e., source memory) qualitative features of episodic memory are lacking. In the present fMRI study, we compared the effects of a self-related (semantic autobiographical memory task) and a non self-related (general semantic memory task) encoding condition on subsequent episodic memory retrieval. We investigated encoding-related activity during each condition in two groups of 19 younger and 16 older adults. Behaviorally, the SRE improved subjective memory performance in both groups but objective memory only in young adults. At the neural level, a direct comparison between self-related and non self-related conditions revealed that SRE mainly activated the cortical midline system, especially the MPFC, in both groups. Additionally, in older adults and regardless of the condition, greater activity was found in a fronto-parietal network. Overall, correlations were noted between source memory performance and activity in the MPFC (irrespective of age) and visual areas (mediated by age). Thus, the present findings expand evidence of the role of the MPFC in self-referential processing in the context of source memory benefit in both young and older adults using incidental encoding via semantic autobiographical memory. However, our finding suggests that its role is less effective in aging.

Clinical signs and symptoms preceding the onset of dementia are sometimes acute, such as mood disorders often associated with hypochondriacal traits and cognitive slowing, sudden and serious suicide attempts, character and conduct disorders contrasting with the previous state, and psychotic disorders presenting as pathological mistrust, or ill-structured prejudice or persecution. Most forerunning symptoms reflect a progressive deterioration of cognitive functions over a long period, that have been masked by various coping strategies used by the patient with the spouse's help. Progressive cognitive deficits may develop over years before dementia can be diagnosed with confidence. Quantitative tools can help to detect dementia incipiens, such as the Folstein Mini Mental Test, the Mattis Dementia Scale, the five-word learning test, the clock drawing test, and the brief cognitive battery. The profile of early cognitive deterioration varies according to the type of dementia (Alzheimer's disease, fronto-temporal dementia, Lewy body dementia, and vascular dementia). The symptoms of dementia may be interlinked with symptoms of other disorders. Neuropsychological tests and brain imaging are needed to validate the diagnosis.

Background Beneficial effects of repetitive transcranial magnetic stimulation (rTMS) were demonstrated by many controlled studies in major depression. Moreover, this promising and non invasive therapeutic tool seems to be better tolerated than electroconvulsive therapy. Vascular depression is a subtype of late-life depression, associated with cerebrovascular disease and means a poorer response to antidepressant treatment. We employed rTMS over the left prefrontal cortex in 11 patients with late-onset resistant vascular depression. The primary purpose of this two-week open study was to examine antidepressant efficacy of rTMS in vascular depression. The secondary aim was to evaluate cognitive effects of rTMS in our sample. Methods Clinical status, as measured with the Hamilton Depression Rating Scale (HDRS), and cognitive effects, as evaluated by neuropsychological tests, were assessed at baseline and after two weeks of rTMS. Brain measurements to obtain an index of prefrontal atrophy were performed at both the motor cortex and prefrontal cortex. Results Five out of 11 resistant patients with late-onset vascular depression were responders. They showed a clinically meaningful improvement in HDRS scores, with a decrease of 11, 4 points (p

RESUME La depression constitue l’un des problemes de sante publique les plus frequents chez le sujet âge. Elle reste souvent consideree comme une consequence legitime du vieillissement, survenant en reaction a une affection medicale, lors du declin cognitif et fonctionnel ou accompagnant les pertes affectives et sociales. De nombreuses etudes recentes soulignent son faible taux de detection et de traitement, particulierement en soins primaires. Chez le sujet âge, l’episode depressif majeur presente les memes symptomes qu’aux autres âges de la vie. Neanmoins, le vieillissement peut accentuer certaines caracteristiques symptomatiques ou en attenuer d’autres. Des plaintes somatiques, une anxiete marquee, des troubles de la memoire, des elements psychotiques et des pensees recurrentes de mort peuvent masquer la tristesse ou l’anhedonie. Des facteurs existentiels et des facteurs organiques sont le plus souvent intriques dans la genese des etats depressifs du sujet âge. La contribution des lesions cerebro-vasculaires a pu etre etablie, notamment dans les depressions d’installation tardive. Comme chez l’adulte plus jeune, la prise en charge de la depression conjugue des moyens pharmacologiques et psychologiques. L’electroconvulsivo-therapie peut etre indiquee dans certaines situations. L’interet de la stimulation magnetique trans-crânienne est en cours d’evaluation.

Background: To explore clinical features of symptoms and comorbidity according to the age of onset of patients suffering from obsessive–compulsive disorder (OCD). Methods: The survey involved collecting data from both patient members of an OCD association, and a sample of 175 OCD patients seen in OCD specialty practice. All the patients (n=617) responded to a questionnaire on family and personal psychiatric OCD history, phenomenological features of OCD and comorbidity. They were classified according to OCD age at onset [group early age of onset (EO): under 15, group late age of onset (LO): older than 15]. Results: A higher percentage of patients from Group LO complained of OCD triggering by factors such as professional difficulties and childbirth (P

International audience; RésuméIntroduction Le risque de développer une maladie d’Alzheimer augmente avec l’âge. Le rôle de celle-ci comme un facteur de risque indépendant de suicide n’est pas bien compris et demeure complexe et mal élucidé. L’objectif de cet article est d’envisager une compréhension neuropsychologique de la crise suicidaire dans le cas d’une maladie d’Alzheimer débutante. Méthode Une évaluation cognitive globale (Mini-Mental State Examination, Batterie Rapide d’Évaluation Frontale) complétée de l’exploration de l’inhibition cognitive selon ses fonctions d’accès (tâche de lecture en présence de distracteurs), de suppression (Trail Making Test), et de freinage (Stroop, Hayling, Go/No-Go) a été réalisée chez une femme souffrant d’une maladie d’Alzheimer (MMSE à 21/30) avant et après réalisation d’une tentative de suicide dans un contexte de dépression. Résultats L’échelle d’Hamilton était cotée à 24/52, l’échelle de dépression de Cornell à 21/38. L’intentionnalité suicidaire était modérée avec un score à 15/25à l’échelle d’intentionnalité suicidaire de Beck. Initialement préservées, le déclin des fonctions exécutives a coïncidé avec l’émergence d’une crise suicidaire dans un contexte de dépression chez une patiente souffrant de maladie d’Alzheimer. Les fonctions de l’inhibition cognitive étaient altérées dans ses trois composantes, après ajustement des facteurs de confusion. Conclusion Une évaluation détaillée des fonctions exécutives et singulièrement de l’inhibition cognitive dans la population des patients atteints d’une maladie d’Alzheimer permettrait de détecter les personnes les plus à risque de passage à l’acte et de proposer une surveillance plus étroite dans le cadre des soins généraux de leur maladie. AbstractIntroduction The role of Alzheimer's disease as a risk factor for suicide is unclear. The aim of this study was to understand neuropsychological component of the suicidal crisis in Alzheimer's disease. Method Using an extensive neuropsychological battery, different aspects of cognitive inhibition were particularly examined: Access to relevant information (using the Reading with distraction task), suppression of no longer relevant information (Trail Making Test, Rule Shift Cards), and restraint of cognitive resources to relevant information (Stroop test, Hayling Sentence Completion test, Go/No-Go). One female Alzheimer depressed case was assessed before and after a suicide attempt. Results Ten days after the patient's suicide attempt, dementia was still moderate with a MMSE score at 21/30 but with a worsening of executive functions (FAB at 8/18) in the context of depression and suicide. The Hamilton-Depression Rating Scale was at 24 (maximal score at 52), and the Cornell Scale for Depression was at 21 (maximal score at 38). Suicidal intent was moderate with a score of 9 on the Beck Suicide Intent Scale (maximal score at 25). The patient did not present a delirium, psychotic symptoms, or anosognosia. Her episodic memory was altered as shown by her semantic performance on verbal fluency (naming 12animals in 120 seconds) and on lexical fluency (naming 8 words beginning with the letterP). Initially preserved, executive function declined during a suicidal crisis in a context of depression in Alzheimer's disease case. Neuropsychological testing confirmed a dysexecutive syndrome (FAS at 8/18), with an impairment in her conceptualization capacity (MCST) and a deficit in cognitive inhibition and its access (reading task in the presence of distractors), deletion (TMT) and restraint (Stroop, Go/No-Go, Hayling) functions. Computed tomography has shown no signs of intracranial expansive process. Conclusion Assessing predictors of suicide and means of completion in patients with dementia may help the development of interventions to reduce risk of suicide among the growing population of individuals with dementia. Because of Alzheimer's-related cognitive inhibition impairment, identification and intervention addressing the complex issues of depression, executive dysfunction and dementia may help clinicians to mitigate the risk of suicide in patients with Alzheimer's disease.

Resume Le transsexualisme designe un trouble precoce, severe et permanent de lˈidentite de genre ; la plupart des transsexuels primaires rapportent avoir initialement connu une « phase de transvestisme » au debut de leur affection. Le nombre de transvestis « a composante transsexuelle », vivant sous une apparence feminine durant des periodes de plus en plus prolongees, et finissant par requerir une procedure de changement de sexe est en augmentation. Les therapeutiques hormonochirurgicales demeurent exclusivement reservees aux transsexuels primaires, les transvestis pouvant beneficier de prises en charge psychotherapiques specialisees. Objectif et methodes – Notre etude avait pour objectif dˈevaluer les representations sexuees de transsexuels primaires et de transvestis en comparaison avec celles de sujets controles de sexe masculin, au moyen de deux indices psychometriques : planche III du test de Rorschach et score masculinite/feminite du MMPI. Notre hypothese etait que ces indices psychometriques permettraient de discriminer ces deux groupes de patients differents, pourtant susceptibles de solliciter une meme therapeutique hormonochirurgicale. Au total, 28 transsexuels M-F (transsexuels masculins sollicitant un reassignement feminin) et 15 hommes repondant aux criteres de transvestisme ont ete compares a dix controles masculins. Resultats – Lˈidentification sexuee des transsexuels primaires et des transvestis (planche III) se differencie de celle des sujets controles masculins (p Discussion – Cette etude suggere que lˈevaluation de lˈidentification sexuee au moyen dˈune seule planche du test de Rorschach ne peut constituer un indice valide pour discriminer des transsexuels primaires de transvestis demandeurs dˈune therapeutique de reassignation hormonochirurgicale. Lˈetude de la deviation au score M/F pourrait davantage aider au diagnostic differentiel entre les deux affections. Ce constat doit nous amener a reviser les procedures dˈevaluation psychometrique actuelles permettant de guider le choix therapeutique.

International audience; Age-related changes in autobiographical memory (AM) recall are characterized by a decline in episodic details, while semantic aspects are spared. This deleterious effect is supposed to be mediated by an inefficient recruitment of executive processes during AM retrieval. To date, contrasting evidence has been reported on the neural underpinning of this decline, and none of the previous studies has directly compared the episodic and semantic aspects of AM in elderly. We asked 20 young and 17 older participants to recall specific and general autobiographical events (i.e., episodic and semantic AM) elicited by personalized cues while recording their brain activity by means of fMRI. At the behavioral level, we confirmed that the richness of episodic AM retrieval is specifically impoverished in aging and that this decline is related to the reduction of executive functions. At the neural level, in both age groups, we showed the recruitment of a large network during episodic AM retrieval encompassing prefrontal, cortical midline and posterior regions, and medial temporal structures, including the hippocampus. This network was very similar, but less extended, during semantic AM retrieval. Nevertheless, a greater activity was evidenced in the dorsal anterior cingulate cortex (dACC) during episodic, compared to semantic AM retrieval in young participants, and a reversed pattern in the elderly. Moreover, activity in dACC during episodic AM retrieval was correlated with inhibition and richness of memories in both groups. Our findings shed light on the direct link between episodic AM retrieval, executive control, and their decline in aging, proposing a possible neuronal signature. They also suggest that increased activity in dACC during semantic AM retrieval in the elderly could be seen as a compensatory mechanism underpinning successful AM performance observed in aging. These results are discussed in the framework of recently proposed models of neural reorganization in aging.

International audience; Neuroimaging studies of patients with treatment-resistant depression (TRD) have reported abnormalities in frontal and temporal regions. We sought to determine whether metabolism in those regions might be related to response to repetitive transcranial magnetic stimulation (TMS) in patients with TRD. Magnetic resonance images and baseline resting-state cerebral glucose uptake index (gluMI) obtained using 18F-fluorodeoxyglucose positron emission tomography were analyzed in TRD patients who had participated in a double-blind, randomized, sham-controlled trial of prefrontal 10Hz-TMS. Among the patients randomized to active TMS, 17 responders, defined as having 50% depression score decrease, and 14 nonresponders were investigated for pre-stimulation glucose metabolism and compared with 39 healthy subjects using a voxel-based analysis. In nonresponders relative to responders, gluMI was lower in left lateral orbitofrontal cortex (OFC), and higher in left amygdala and uncinate fasciculus. OFC and amygdala gluMI negatively correlated in nonresponders, positively correlated in responders, and did not correlate in healthy subjects. Relative to healthy subjects, both responders and nonresponders displayed lower gluMI in right dorsolateral prefrontal (DLPFC), right anterior cingulate (ACC), and left ventrolateral prefrontal, cortices. Additionally, nonresponders had lower gluMI in left DLPFC, ACC, left and right insula, and higher gluMI in left amygdala and uncus. Hypometabolisms were partly explained by gray matter reductions, while hypermetabolisms were unrelated to structural changes. The findings suggest that different patterns of frontal-temporal limbic abnormalities may distinguish responders and nonresponders to prefrontal magnetic stimulation. Both preserved OFC volume and amygdala metabolism might precondition response to TMS.

It is currently unknown whether the antidepressant effect of repetitive transcranial magnetic stimulation (rTMS) depends on specific characteristics of the stimulated frontal area, such as metabolic changes. We investigated the effect of high-frequency rTMS, administered over the most hypometabolic prefrontal area in depressed patients in a two-site, double-blind, randomized placebo-controlled add-on study. Forty-eight patients with medication-resistant major depression underwent magnetic resonance imaging and [(18)F]-fluorodeoxyglucose positron emission tomography (PET) in order to determine a target area for rTMS. After randomization to PET-guided (n = 16), standard (n = 18), or sham rTMS (n = 14) conditions, the patients received 10 sessions of 10-Hz rTMS (1600 pulses/session) at 90% motor threshold. Change from baseline in Montgomery-Asberg Depression Rating Scale (MADRS) scores did not differ between PET-guided, standard and sham groups at 2-wk end-point. Exploratory comparison of left PET-guided (n = 9), right PET-guided, standard, and sham rTMS revealed significant effects. The highest improvement in MADRS scores was observed with left PET-guided (60 + or - 31%), significantly superior to sham (30 + or - 37%, p = 0.01) and right-guided (31 + or - 33%, p = 0.02) stimulation. Comparison between left PET-guided and standard rTMS (49 + or - 28%) was not significant (p = 0.12). Comparison between stimulation over dorsolateral prefrontal cortex (BA 9-46), stimulation of other areas, and sham rTMS was statistically significant. Stimulation over BA 9-46 region (n = 15) was superior to sham rTMS (p = 0.02). The results do not support the general hypothesis of increased antidepressant effects of high-frequency rTMS with prefrontal hypometabolism-related PET guidance. Nonetheless, whether metabolism and anatomy characteristics of left frontal area underneath the coil might account for an increase or speeding up of rTMS effects needs further investigation.

Clinical signs and symptoms preceding the onset of dementia are sometimes acute, such as mood disorders often associated with hypochondriacal traits and cognitive slowing, sudden and serious suicide attempts, character and conduct disorders contrasting with the previous state, and psychotic disorders presenting as pathological mistrust, or ill-structured prejudice or persecution. Most forerunning symptoms reflect a progressive deterioration of cognitive functions over a long period, that have been masked by various coping strategies used by the patient with the spouse's help. Progressive cognitive deficits may develop over years before dementia can be diagnosed with confidence. Quantitative tools can help to detect dementia incipiens, such as the Folstein Mini Mental Test, the Mattis Dementia Scale, the five-word learning test, the clock drawing test, and the brief cognitive battery. The profile of early cognitive deterioration varies according to the type of dementia (Alzheimer's disease, fronto-temporal dementia, Lewy body dementia, and vascular dementia). The symptoms of dementia may be interlinked with symptoms of other disorders. Neuropsychological tests and brain imaging are needed to validate the diagnosis.

Depressive symptoms are observed in many organic brain diseases in the elderly, particularly in stroke, degenerative or vascular dementias and Parkinson's disease. In many cases, an accurate estimation of the respective part of neurobiological abnormalities, adjustment disorders, disability and narcissistic wounds related to the disease appears very difficult for the practitioner. Specific data on the therapeutical aspects of secondary depressive disorders remains quite scarce. The efficacy of antidepressant drugs may be less important in geriatric depression with cerebral disorders or "secondary depressions" than in primary ones. Consequently, electroconvulsive-therapy may appear as an interesting therapeutical option for these patients.

Depression is one of the most common health disorders in elderly people. It is still often considered as a natural consequence of aging, arising in reaction to a medical disease, cognitive or functional decline, or a loss of social fabric. Many studies have highlighted the low rates of diagnosis and treatment of depression, especially in the primary care setting. Major depression in old age is characterized by the same core symptoms as in other periods of life. However, aging may accentuate some symptoms and alleviate others. Somatic concern, marked anxiety, poor subjective memory, psychotic ideation, and recurrent thoughts of death can mask sadness and anhedonia. Organic factors and adverse life events are often intricately linked with the pathogenesis of depressive states in the elderly. The role of cerebrovascular lesions has also been established, particularly in late-onset depressive disorders. The management of depressive disorders in older people, as in younger adults, involves pharmacological and psychological treatments. Electroconvulsive therapy can be beneficial in some cases. Transcranial magnetic stimulation is being evaluated in this setting.

Because Alzheimer’s disease (AD) tends to be underdiagnosed, there is an increasing need for accurate neuropsychological screening tools that are easy to administer by general practitioners or specialists. The aim of the present study was to validate, in French, a sensitive and specific screening battery designed to improve the discrimination between patients with AD, patients with depression and healthy elderly subjects. The Short Cognitive Evaluation Battery (SCEB) consists of 4 brief tests: temporal orientation, 5-word test, clock-drawing test and a semantic verbal fluency task. The SCEB was administered to 123 ambulatory subjects (mean age 76.4±2.3 years): 49 patients with mild AD, 27 patients with depressive symptoms and 47 healthy elderly subjects. The mean time for administration of the test was 11.2 min in the AD group, 8.2 min in the depressive group and 7.2 min in the control group (p < 0.001). Multivariate analysis showed that, compared with controls, patients with mild AD were significantly impaired for all four tests. Response operating characteristics analysis of the SCEB showed: 93.8% sensitivity and 85% specificity for discriminating AD from control patients, and 63% sensitivity and 96% specificity for discriminating AD from depressive patients. In summary, the SCEB appears to be a highly sensitive and specific tool for discriminating between patients with mild AD and healthy elderly individuals. Furthermore, in combination with clinical evaluation, the SCEB could improve the specificity of the difficult discrimination between mild AD and depression.

Entre pratique psychiatrique et pratique psychannalytique, il existe une difficulte de selectionner les malades pour effectuer les presentations cliniques dans un service universitaire.