Le DSM-5 introduit de nombreux changements importants dans la classification et le diagnostic des Troubles de l’Humeur et des Troubles anxieux : nouvelle métastructure avec classement des Troubles de l’humeur dans deux Chapitres distincts : C (Troubles bipolaires) et D (Troubles dépressifs), classement des Troubles anxieux dans trois Chapitres distincts : E (Troubles anxieux), F (Troubles obsessionnels-compulsifs et troubles apparentés) et G (Troubles liés à des traumatismes ou à des facteurs de stress) ; introduction de nouveaux troubles ; suppression, reformulation ou rajout de critères et de formes cliniques. Ces changements et les raisons qui les ont motivés seront discutés.

Background.- Up to a recent past, psychiatrists and other mental health professionals in French speaking countries have relied on concepts that had their origin in traditional French nosology. Aims.- To review the current status of traditional French nosology and the position of psychiatrists and other mental health professionals in French speaking countries on the Tenth Revision of the International Classification of Diseases (ICD-10) and the Text Revision of the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Method.- Literature review available up to August 2011. Results.- There has been a dramatic change in diagnostic practices among psychiatrists and other mental health professionals in French speaking countries during the past two decades. Up to the nineties, most French speaking psychiatrists relied on the French Classification of Mental Disorders, i.e. a classification that departed to a large extent from the International Classification of Diseases as well as from other national classifications. In 1994, the traditional French Classification was officially abandoned in favour of the ICD-10. At the same time, there has been an increasing reliance on the Diagnostic and Statistical Manual (from DSM-III to DSM-IV-TR), especially in research settings. Conclusions.- After having relied for more than a century on specific French concepts as well as on a national French classification of mental disorders, psychiatrists and other mental health professionals in French speaking countries have progressively but totally adopted international ways of classifying mental disorders as currently represented in ICD-10 and DSM-IV-TR. (C) 2011 Elsevier Masson SAS. All rights reserved.

Background.- The categorical model adopted in ICD-10 and DSM-IV-TR for the classification and diagnosis of PDs has been criticized for a number of reasons.Aims.- To review the scientific basis of the categorical model and to examine alternate ways for classifying and diagnosing disorders of personality.Method.- Literature review available up to August 2011.Results.- The quality of the psychometric properties of the categorical model (i.e. interrater reliability, stability over time, discriminant validity, sensitivity and overall coverage) has generally been found poor. Various alternative models, including dimensional, hybrid dimensional-categorical and severity models, are currently being examined by the workgroups in charge of drafting proposals for ICD-11 and DSM-5.Conclusion.- The categorical model for classifying personality pathology will be discarded in ICD-11 and DSM-5 in favour of a hybrid dimensional-categorical model and/or a model based on severity. (C) 2011 Elsevier Masson SAS. All rights reserved.

L’état de stress post-traumatique (ESPT) est un trouble fréquent, invalidant et souvent chronique qui est associé à un coût social et personnel important. Diverses approches thérapeutiques ont fait l’objet d’études témoins et randomisées : les approches médicamenteuses, psychothérapeutiques (essentiellement cognitivocomportementales) et combinant médicaments et psychothérapie. Cet article se limite à passer en revue les données empiriques sur les traitements de l’ESPT par des antidépresseurs (inhibiteurs sélectifs de la recapture de sérotonine, inhibiteurs de la recapture de la noradrénaline et de la sérotonine, inhibiteurs sélectifs des récepteurs alpha-2 sérotoninergiques, tricycliques, inhibiteurs de la monoamine-oxydase) et suggère quelques recommandations à partir des données disponibles dans la littérature scientifique. La recherche complète des données sur PubMed/Medline révèle une multitude de rapports de cas et d’études ouvertes. Nous avons décidé de limiter notre revue de la littérature aux études témoins randomisées en double insu concernant le traitement par antidépresseurs de l’ESPT. Il ressort de cette revue que la plupart des antidépresseurs ont une action positive sur certains symptômes de l’ESPT, mais que leur efficacité à court terme n’est que partielle et qu’il persiste des inconnues sur leur efficacité à long terme. Les données actuelles basées sur les résultats des études témoins randomisées en double insu suggèrent que les traitements médicamenteux de première ligne en monothérapie dans l’ESPT sont les inhibiteurs sélectifs de la recapture de sérotonine. D’autres options potentielles incluent des monothérapies avec les inhibiteurs de la recapture de la noradrénaline et de la sérotonine, les inhibiteurs sélectifs des récepteurs alpha-2 sérotoninergiques, les antidépresseurs tricycliques, les inhibiteurs de la monoamine-oxydase, ainsi que l’ajout d’autres traitements médicamenteux dans les cas des ESPT résistants. Il semble exister un certain consensus sur le fait que le traitement devrait être poursuivi pendant une durée prolongée, dépassant très largement la durée de trois mois habituellement utilisée dans les essais témoins et randomisés. Dans les cas des ESPT chroniques avec des symptômes résiduels, un traitement d’au moins 12 mois paraît indiqué.

The object of this paper is to specify the role of anxiety disorders taken as a group or separately (including panic disorder, social phobia, specific phobia, obsessive-compulsive disorder, generalized anxiety disorder and post-traumatic stress disorder) as potential causal risk factors for depression and alcohol use disorders. Several studies have consistently suggested that some anxiety disorders are primary to other mental disorders in a majority of co-morbid cases and could increase the risk of their onset. We performed a computerized search (Pubmed) on recent published studies on this subject. We focused on recent prospective studies. Several findings have confirmed that the number and severity of some primary anxiety disorders may significantly increase the risk of subsequent mental disorders (such as depression and alcohol use disorders). However, the authors are not unanimous on this subject. A precise determination of whether various anxiety disorders could constitute causal risk factors for subsequent mental disorders would permit a better understanding of disease aetiology, improve the efficiency of diagnosis and would allow development of effective interventions. (c) 2006 Elsevier SAS. Tous droits reserves.

OBJECTIVE:This is a naturalistic study comparing the outcomes of all emergency psychiatric interventions in the Hospital Center of Luxembourg during two periods of six months each, before and after the introduction of a crisis intervention program. The aim of the study was to investigate the clinical and economic impact of crisis intervention on psychiatric emergency admissions. METHODS:All subjects admitted to the emergency psychiatric unit during the two study periods were considered for participation. Data were collected retrospectively and comparisons were made between patients before (September 1, 2001 to February 28, 2002) and after (September 1, 2002 to February 28, 2003) crisis intervention programs were established. RESULTS:A comparison between the two patient groups demonstrated a significant decrease in the rate of voluntary hospitalizations after crisis intervention, and a significant increase in the number of patients with subsequent outpatient consultations. The cost increase due to ambulatory follow-ups was widely compensated for by the cost decrease due to hospitalization avoidance. CONCLUSIONS:These preliminary findings suggest that crisis intervention leads to a shift from hospitalization to outpatient psychotherapeutic management in emergency psychiatric services, which has a significant economic impact.

Objective: This retrospective study aimed to evaluate the impact of introducing crisis intervention patterns in the emergency unit of a general hospital on the number of admissions and outpatient follow-ups for patients with major depressive disorder. Method: The study included all patients with major depressive disorder (DSM-IV criteria) who visited the psychiatric emergency unit in a general hospital during two 8-month periods: before (425 patients) and after (436 patients) crisis interventions were introduced. Results: After crisis interventions were introduced, the voluntary admission rate decreased significantly (from 17.9% to 12.4%), while the number of outpatient follow-ups increased (from 82.1% to 86.2%). Borderline personality disorder was associated with a significant reduction of the admission rate (27.8% against 38.2%), while the admission rate for patients with depressive disorder with psychotic features did not decline after crisis interventions. Crisis interventions were more effective on women. Conclusions: These outcomes suggest the relevance of crisis intervention in psychiatric emergency settings to improve the management of patients with major depressive disorder. Crisis intervention fosters outpatient multimodal follow-up rather than admission in a psychiatric setting.

Ce cas décrit l’évolution vers un trouble psychotique déficitaire d’un patient de 38 ans, sans antécédents psychiatriques, après une ischémie cérébrale au niveau mésencéphalo-thalamique bilatéralement, à prédominance gauche. Les symptômes psychotiques positifs initiaux (délire, hallucinations acoustico-verbales) ont laissé progressivement la place à des symptômes négatifs, qui sont devenus prédominants après quelques mois. Le diagnostic retenu après un suivi psychiatrique de 14 mois a été : trouble psychotique avec idées délirantes, dû à une ischémie cérébrale (DSM IV). L’intérêt du développement d’une échelle spécifique pour des troubles psychotiques survenus après une ischémie cérébrale est suscité à partir des descriptions cliniques isolées, d’autant plus qu’une échelle spécifique pour des troubles dépressifs post-ischémiques a déjà été développée. La nécessité d’un examen psychiatrique et des réévaluations systématiques dans le décours des ischémies cérébrales thalamiques nous semble importante à retenir, tant au niveau du diagnostic différentiel qu’au niveau d’une prise en charge psychiatrique précoce, plus efficace.

The interest of a review concerning possible links between bipolar disorders and beta-thalassemia comes from two clinical observations. Several cases have been described in the literature suggesting a possible link between bipolar disorder and heterozygous beta-thalassemia (minor type), a monogenic hemoglobinopathy. As such, clinical observations encourage the pursuit of research for a vulnerability gene for bipolar disorders at the level of the short arm of chromosome 11, near the gene coding for the beta-globin chain, involved in beta-thalassemia. These data are in agreement with the identification on the short arm of chromosome 11 of a gene coding for a D4-dopaminergic receptor and of another gene coding for tyrosine-hydroxylase. Genetic research would support the hypothesis of the implication of catecholaminergic systems in the pathogeny of bipolar disorders, by studying the links existing between the gene coding for tyrosine-hydroxylase and the gene of vulnerability for bipolar disorders. Taking into account the important methodological difficulties, especially related to the clinical heterogeneity of bipolar disorders, linkage techniques performed starting from clinical observations associating bipolar disorders to a known monogenic disease, warrant future studies. (C) 2003 Elsevier SAS. Tous droits reserves.

A 38-year old male patient with no history of psychiatric illness developed a progressive psychotic disorder after bilateral (predominantly left) mesencephalo-thalamic cerebral ischaemia. The reason of the emergency hospitalization was the sudden onset of a confusional state, culminating in a fluctuating comatose status. The neurological examination found mild right hemiparesia, praxic disorders and reactive left mydriasis with paresia of the downward vertical stare, leading to the hospitalisation in the neurology department for suspicion of a cerebral vascular ischaemic accident. The psychiatric symptoms started with acoustic-verbal hallucinations, poorly structured paranoid delusions, progressively developed over two weeks, followed by behavioural disorders with psychomotor agitation and heteroaggressivity. The patient was transferred to the psychiatric department, because of the heteroaggressive risk and lack of morbid consciousness, in spite of recovering from the confusional status. An intensive psychiatric management was proposed, combining a psychotherapeutic approach with 4 mg of risperidone and adjustable doses of benzodiazepine according to the psychomotor agitation. During the next days, there was a net recovery of the behavioural disorders, in spite of the persistence of the ideas of persecution. All the neurological symptoms also decreased. An anomaly of the polygon of Willis was found on a cerebral arteriography (the posterior cerebral arteries had a foetal origin, dependent on carotidal axes and not on the vertebro-basilar system). The main emboligen risk factor was the presence of a permeable foramen ovale, discovered during a transoesophageal echography. The patient underwent a surgical correction of the permeable foramen ovale. The psychiatric hospitalization for three months was continued by ambulatory follow-up. The initial positive symptoms (delusions, acoustic-verbal hallucinations) progressively diminished while negative symptoms became predominant after few months. One year after the first hospitalization the patient presented a second psychotic decompensation, with delusions of persecution, jealousy and behavioural disorders with heteroaggressivity, that required an emergency psychiatric hospitalization. The wife of the patient decided to divorce, because she was "frightened by the threats of death" from her husband. A neurological assessment during the second hospitalization in psychiatry did not find new ischaemic lesions after the cardiac surgery for the permeable foramen ovale, nor relevant changes in cerebral perfusion. The final diagnosis after the psychiatric follow-up of 14 months was: psychotic disorder with delusional ideas, due to cerebral ischaemia (DSM IV). There are relatively few data in the literature regarding persistent psychotic disorders in the context of ischaemic mesencephalo-thalamic lesions. However, several authors support the hypothesis of a possible disconnection of the thalamic nuclei, the frontal lobes and limbic system as a risk factor or a triggering factor for psychotic disorders in cerebral ischaemia. Observations concerning the occurrence of psychotic disorders following cerebral--especially localised--ischaemia may help to better understand the neuro-physiological mechanisms triggering or accompanying the psychiatric symptomatology. The role of functional cerebral imagery in the detection of possible structural lesions related to clinical observations must be emphasised. The slow progression (over a year) to psychotic disorder with predominantly negative symptoms emphasized the importance for long-term prospective studies. Isolated clinical observations arouse the interest for a specific scale for psychotic disorders occurring after cerebral ischaemia, similar to existing specific scale for post-ischaemic depressive disorders. The necessity of systematic psychiatric examination and re-evaluations in thalamic cerebral ischaemia is to be highlighted, both for the differential diagnosis and for the early psychiatric care.

This article tries to highlight the place of cerebral neuroimagery in the study of post-traumatic stress disorders. After a brief historical introduction, the report intends to look through the main findings of cerebral neurorimagery in post-traumatic stress disorders, both at the anatomical and at the functional level. The hopes and the limits of cerebral neuroimagery will be discussed, while thought on future studies are considered. In conclusion, the cerebral neuroimagery, at this time constantly in progress, offers new approaches of a better understanding of post-traumatic stress disorders pathophysiology, facilitating the pharmacological development of more specific and may be more efficient drugs. (C) 2003 Editions scientifiques et medicales Elsevier SAS. Tous droits reserves.

The aim of this study was to investigate the impact of crisis intervention in psychiatric emergencies on the number of hospitalizations and the number of outpatient consultations during follow-up. We compared the number of psychiatric interventions and the number of hospitalizations before and after the introduction of the concept of crisis intervention in a psychiatric emergency unit - currently in development, at the Luxembourg Hospital Center. Data were retrospectively collected to compare patients examined in the psychiatric emergency unit during four months, from 01/09 to 31/12/2001, with patients that were able to benefit from a crisis intervention from 01/09 to 31/12/2002. The results show a statistically significant decrease (p = 0.025) of voluntary hospitalizations and found to be significant increase (p = 0.005) of the number of patients with more than five outpatient consultations, after the introduction of crisis interventions. The decrease in the rate of hospitalizations was most important for patients presenting an underlying personality disorder (p < 0.001). Crisis intervention was more efficient in women. This finding may be due to methodological difficulties, and should be confirmed by additional studies. The results of the study are in agreement with other studies and emphasize the importance of crisis interventions in psychiatry for improving the management of patients examined in emergency settings, especially patients with a personality disorder. (C) 2003 Editions scientifiques et medicales Elsevier SAS. Tous droits reserves.

Clinical assessment instruments are useful tools for accurate diagnosis and differential diagnosis of mental disorders. After an introduction on the criteria used in current psychiatric classifications, the authors outline the rationale underlying the development of these instruments and describe the major instruments that have been developed over the past 20 years. These are: 1) diagnostic checklists, 2) semi-structured interviews for Axis-I disorders, 3) semi-structured interviews for personality disorders, 4) fully structured interviews, 5) diagnostic screening questionnaires, and 6) interviews for the assessment of disablement. Special emphasis is given to their clinical and psychometric characteristics and tables illustrate sample items of these instruments. The authors conclude with a discussion on reliability and validity issues and present criteria to guide the clinician or researcher in the choice of the best instrument.