Los trastornos de la conducta alimentaria son trastornos psiquiátricos incapacitantes, que aparecen con mayor frecuencia durante la adolescencia y tienen un impacto directo en el desarrollo del adolescente y en su posterior estado de salud. Estos trastornos se entrelazan con factores etiológicos multifactoriales, tanto genéticos como psicológicos y socioculturales, que deben tenerse en cuenta en su totalidad. Estos trastornos frecuentes son responsables de numerosas complicaciones médicas que requieren una atención multidisciplinaria pediátrica, psiquiátrica infantojuvenil y psicoterapéutica. La atención debe estar perfectamente coordinada entre estas distintas especialidades para que sea lo más adecuada y personalizada posible. Debe tener en cuenta el aspecto ponderal según las características personales del paciente y los recursos familiares. Los trastornos de la conducta alimentaria suelen requerir tratamiento a largo plazo, ya que tienden a cronificarse. En este artículo se identifican los principales diagnósticos incluidos en los trastornos de la conducta alimentaria, a saber, la anorexia nerviosa, la bulimia y la hiperfagia bulímica, tal como se describen en la quinta edición del Manual diagnóstico y estadístico de los trastornos mentales (DSM-5). Después se detallan las comorbilidades médicas, incluidas las psiquiátricas, asociadas a estos trastornos, su epidemiología, su trayectoria evolutiva, sus factores etiopatogénicos y, por último, su tratamiento multidisciplinario.

BACKGROUND:In child and adolescent psychiatry, many patients are placed in welfare institutions or foster care.OBJECTIVE:It is important to study their progress in the long term and to examine the psychological and social care arrangements as well as their impacts.POPULATION AND METHODS:This qualitative study designed to identify potential prognostic factors relating to the outcome of children placed in a welfare center or foster care before the age of 4 years was based on the analysis of 34 case histories of children placed in a welfare center or foster care in Angers. These records involved 129 cases collected for the "Saint Ex" study, a quantitative case study conducted from 1994 to 2001 designed to assess the outcome of children placed in a welfare center or foster care in Angers before the age of 4. The population sampling was purposive and was based on eight subgroups defined by three clinical criteria: Parent-Infant Relationship Global Scale assessment (PIR-GAS) at T1 (admission into welfare center or foster care), the status of a "infant at risk" at T1, and GAF (Global Assessment of Functioning) at T2 (exit from the welfare center or foster care).RESULTS:The study population included 11 girls and 23 boys. Factors contributing to adverse progression included problems with interactions at a very early age, failure to listen or respond to a child's request regarding his or her placement, long delays between establishing facts and implementing social measures, discontinuity and/or inconsistency regarding the placement arrangements, and sexual abuse. On the other hand, factors contributing to positive progress included the diagnosis and adapted treatment of a mental disorder in the case of one or both parents, early placement in a foster family, considering the child's requests regarding the placement, responsiveness of social services, and psychological or psychiatric follow-up.CONCLUSION:The analysis of these 34 cases sheds light on several prognostic elements, with the combination of all these factors as the background. Care based on prevention seems essential to protect early interactions and shorten the time that children are exposed to danger.

Suicide is the leading cause of maternal mortality in high-resource countries. The onset of suicidal ideation is a major risk factor for suicide attempts. Suicidality has a major impact on the mother-baby relationship and on child development. The main objective of the study was to identify factors associated with the occurrence of perinatal suicidal ideation in women requiring hospitalization. The secondary objectives of the study were to describe the socio-demographic and clinical characteristics of this specific population, to specify the follow-up procedures at hospital discharge and to develop a semi-directed interview framework for psychiatric evaluation of perinatal patients admitted to a psychiatric hospital in order to better identify those at risk of suicide and improve overall management, particularly in terms of referral to existing perinatal care services.Descriptive and retrospective study carried out at the Specialized Hospital Center of women hospitalized in the perinatal period between 2014 and 2019. The inclusion criteria were: inpatient pregnant or postpartum within one year of delivery, 16 to 43 years. A keyword search was performed to retrieve the computerized records. All records matching the inclusion criteria were included. We studied the occurrence of suicidal ideation according to the main known clinical and socio-demographic risk factors.The sample included 25 pregnant patients and 57 post-partum patients. The presence of a psychiatric history increased the risk of suicidal ideation by 4.38 (P<0.03). The association between the occurrence of a stressful life event and the risk of suicidal ideation onset was close to significant (P<0.10). One third of the patients had been admitted for a reason related to suicidality. Less than one-third of the patients had been referred to existing perinatal services.Suicidality in the perinatal period has a major impact on the dyad as well as on the whole family. The search for suicidal ideas must be systematic during psychiatric interviews, a fortiori when a psychiatric history has been authenticated. Every patient hospitalized in adult psychiatry should be referred to specialized outpatient perinatal psychiatry services. Prevention involves raising awareness and training of all health professionals, networking, but also informing the general public.

Objectives. - Suicide is the leading cause of maternal mortality in high-resource countries. The onset of suicidal ideation is a major risk factor for suicide attempts. Suicidality has a major impact on the mother-baby relationship and on child development. The main objective of the study was to identify factors associated with the occurrence of perinatal suicidal ideation in women requiring hospitalization. The secondary objectives of the study were to describe the socio-demographic and clinical characteristics of this specific population, to specify the follow-up procedures at hospital discharge and to develop a semi-directed interview framework for psychiatric evaluation of perinatal patients admitted to a psychiatric hospital in order to better identify those at risk of suicide and improve overall management, particularly in terms of referral to existing perinatal care services. Methods. - Descriptive and retrospective study carried out at the Specialized Hospital Center of women hospitalized in the perinatal period between 2014 and 2019. The inclusion criteria were: inpatient pregnant or postpartum within one year of delivery, 16 to 43 years. A keyword search was performed to retrieve the computerized records. All records matching the inclusion criteria were included. We studied the occurrence of suicidal ideation according to the main known clinical and socio-demographic risk factors. Results. - The sample included 25 pregnant patients and 57 post-partum patients. The presence of a psychiatric history increased the risk of suicidal ideation by 4.38 (P< 0.03). The association between the occurrence of a stressful life event and the risk of suicidal ideation onset was close to significant (P< 0.10). One third of the patients had been admitted for a reason related to suicidality. Less than one-third of the patients had been referred to existing perinatal services. Conclusions. - Suicidality in the perinatal period has a major impact on the dyad as well as on the whole family. The search for suicidal ideas must be systematic during psychiatric interviews, a fortiori when a psychiatric history has been authenticated. Every patient hospitalized in adult psychiatry should be referred to specialized outpatient perinatal psychiatry services. Prevention involves raising awareness and training of all health professionals, networking, but also informing the general public. (C) 2021 L'Encephale, Paris.

L’obésité, définie par un excès de masse grasse, représente un problème majeur de santé publique. Sa prévalence a fortement augmenté à l’échelle mondiale depuis la seconde moitié du XXe siècle, à tel point que l’on parle « d’épidémie » d’obésité ou encore de « globésité ». Au vu des résultats souvent insuffisamment probants des mesures physiques et nutritionnelles, l’indication de chirurgie bariatrique peut être posée dès l’adolescence pour des cas d’obésité sévère, après échec d’autres stratégies thérapeutiques. L’indication de cette chirurgie pour les patients mineurs est encadrée en France par les recommandations de la Haute Autorité de Santé publiées en 2016. Elle a pu montrer pour cette population son efficacité à court terme sur la réduction de l’Indice de Masse Corporelle, le traitement des comorbidités et une amélioration de la qualité de vie. Cependant la réussite à la chirurgie n’est pas systématique et des données de l’évolution à plus long terme de ces adolescents sont requises pour appréhender au mieux cette chirurgie. Il est primordial de repérer et renforcer des éléments de motivation interne et de capacités d’adaptation du jeune, afin d’affiner la demande et d’améliorer l’efficacité de la chirurgie. Elle s’intègre dans une prise en charge pluridisciplinaire indispensable.

De la creation experimentale de quelques Centres de Ressources Autisme (CRA) en 1999 a un deploiement territorial par region apres la circulaire ministerielle du 8 mars 2005, la volonte nationale, mais aussi celle des acteurs de terrain, a toujours ete celle d’ameliorer la connaissance et la prise en charge des personnes avec autisme. Les missions des CRA sont nombreuses (accueil, information, orientation, formation, recherche, reseau, appui au diagnostic) et se declinent differemment selon les temps de vie. Les modalites d’interventions des CRA varient selon les regions, les territoires et les specificites des equipes. Chaque antenne du CRA des Pays de la Loire intervient sur l’ensemble des missions et a tous les âges de la vie. Au sein de la population presentant un trouble du spectre autistique (TSA), les problematiques necessitant l’intervention du CRA different. Avant 3 ans, notre CRA est un acteur important dans l’animation des reseaux de diagnostics et d’accompagnement (ex: aide au deploiement des SESSAD tres precoces). De l’enfance a l’adolescence, le CRA intervient a differents niveaux : en appui des equipes (sanitaires, medico-sociales, scolaires, etc.) pour les situations complexes afin de favoriser la transmissions de competences et en proposant des formations aux aidants familiaux et aux professionnels. A partir de l’adolescence, les modifications physiologiques et psychologiques, l’augmentation des exigences sociales, la limite des capacites d’adaptation des jeunes avec TSA (diagnostiques ou non) mais aussi les perspectives de la vie d’adulte amenent a de nouveaux types de sollicitations du CRA (ex : interventions dans les colleges-lycees ou structures specialisees, aide a l’orientation vers les structures adultes, participation a un premier diagnostic de TSA dans les situations complexes, soutien des familles et partenaires, etc.). En ce qui concerne la population adulte, l’experience des acteurs du diagnostic et de l’accompagnement est plus recente et les interpellations de notre CRA sont plus nombreuses (ex : bilan fonctionnel en structures en cas de comportement probleme, aide a la construction de projets favorisant l’inclusion dans le milieu professionnel). La declinaison de nos missions evolue donc pour cette population (ex : formation des internes et psychiatres sur les specificites des TSA chez l’adulte, rencontre des structures d’insertion professionnelle).

Background: The results of medical treatment of severe obesity in the adolescent population (balanced diet and physical activity) are often unsatisfactory, and bariatric surgery is questioned. The psychological determinants for requesting bariatric surgery in these adolescents are unclear. The objective of this study was to report the psychiatric and psychological aspects as well as the determinants of the medical decision for surgery in a cohort of obese adolescents requesting bariatric surgery by laparoscopic adjustable gastric banding. Methods: Thirty-five adolescents (12.3-17.7 years of age), were recruited from January 2007 to December 2012. Semistructured interviews were conducted. Results: Fifty-four percent of the adolescents had a psychiatric history and 85% had psychiatric comorbidities. In adolescents undergoing surgery, excess weight loss was 46% after 1 year and 51% after 2 years. For patients not receiving surgery, excess weight loss was 0.43% after 1 year (P = 0.001). Compliance with medical treatment was the only significant element contributing to the decision to perform surgery. Results in terms of satisfaction and perception 1 and 2 years after surgery were encouraging. Conclusion: Bariatric surgery is feasible in young patients and produces good results in terms of excess weight loss. We argue that compliance with medical treatment is probably one of the most important elements for making the decision to perform bariatric surgery and in excess weight loss after surgery. We probably need to focus on the compliance of young patients and evaluate how this can be improved. (C) 2018 Elsevier Masson SAS. All rights reserved.

Organic mental disorders are different and further revealed by increasingly advanced research. They are nevertheless misunderstood, without consensus, and raise clinical, diagnostic, and therapeutic questions. These disorders require effective collaboration between practitioners such as pediatricians and child psychiatrists. The subject should not disappear behind the complexity related to the clinical expression of these symptoms. Based on three cases of autoimmune encephalitis, we offer a reflection on the management and assessment of these diseases by a multidisciplinary team with the intention of providing optimal management. The aim of this paper is to override an initial divide posed by a particular clinical presentation. We would like to shed light on the place and legitimacy of child psychiatrists and their clinical expertise. This does not exclude the need for care of the symptoms, considering each subject and her experience. Follow-up is necessary because of the possible, often traumatic, functional and psychological consequences. Finally, the presence of each professional should be specified when the psychiatric symptoms appear to be the result of an organic disease in order to better support the subject in his suffering body.

En France, les hommes ayant des relations sexuelles avec des hommes (HSH) étaient « ajournés de façon permanente » du don du sang. Cette mesure résultait du fait que selon des données de recherche scientifiques, les HSH ont un risque plus élevé d’être infecté notamment par le virus de l’immunodeficience humaine. Cet « ajournement permanent » fait l’objet de nombreux débats en tant que critère de discrimination. L’éthique peut-elle constituer une base à la ré interrogation des conditions d’accès des HSH au don du sang ? Il semble qu’en effet, l’éthique peut et doit de fait être reconvoquée dans les réflexions. Les critères de sélection des donneurs doivent être régulièrement réexaminés en fonction des risques émergents. L’exclusion doit être aménagée, questionnée à nouveau, en n’oubliant pas la réalité et en n’enfermant pas la transfusion sanguine dans une dynamique sécuritaire inadaptée à la réalité du risque. Aussi, il apparaît capital de garder à l’esprit le cadre du débat, qui dépasse largement celui du don du sang pour concerner davantage celui d’une recherche légitime d’égalité et de justice au sein d’une société. Le débat doit tenir compte de ces éléments de réalité, sans pour autant s’en laisser fasciner au risque de fournir une réponse non ajustée à la problématique initiale. L’éthique nous semble convoquée dans ces débats, car elle indique des axes de réflexion ou des voies de problématisation. Loin de fermer, de clore le débat, elle ouvre celui-ci vers de nouveaux aspects et participe de l’avancée des idées, constituant donc un acteur principal.

In France, men who have sex with men (MSM) were "permanently deferred" of blood donation. This measure reflected the fact that according to scientific research data, MSM have a higher risk to be infected notably by the human immunodeficiency virus. This "permanent postponement" was the subject of much debate as discrimination criterion. Can ethics be the basis for the reexamination of conditions of access of MSM to blood donation? It seems that ethics can and should in fact be reconvened in the reflections. The donor selection criteria should be regularly reviewed in the light of emerging risks. The exclusion must be reexamined, questioned again, remembering the reality and not enclosing blood transfusion in a secure dynamic unsuited to the reality of the risk. Also, it appears capital to keep the debate in mind, far exceeding that of blood donation to involve more that a legitimate search for equality and justice in a society. The debate must take account of these elements of reality, without leave to fascinate at the risk of providing an unadjusted answer to the original problem. Ethics seems to invite us in these discussions as they show the axes of reflection or problematization channels. Far from closing the debate, it opens the latter to new areas and participates in the advance of ideas, thus constituting a main actor. (C) 2016 Published by Elsevier Masson SAS.

Aim. The purpose of this study was to determine the institutional trajectory and future of young children in child welfare.Materials and methods. A catamnestic study - based on data from the child welfare office in Maine and Loire, France, from 1994 to 2001 - was conducted by a child psychiatrist and a psychologist. Medical, judicial, and educational data (development, health, pathways in child protection services) were collected and analyzed regarding the status of these children 15 years later, adding information gathered by interviewing the child welfare and foster family consultant.Results. We included 128 children admitted to the child welfare office before 4 years of age. Admission to the child welfare system suffers from care delays (a mean of 13.1 months between the first child protection referral and placement) with an average entry age of 17 months and frequent cases of child a. buse (e.g., seven Silverman syndrome cases). The physical and mental health status of these children was poor (poorly monitored pregnancies, prematurity, low birth weight). More than one third of the children had growth failure at admission, with catch-up in half of the cases. The average length of stay in the child welfare system was 13.2 +/- 4.6 years. At the end of the follow-up, there were specific measures to safeguard vulnerable adults: "young adult" (24 cases), "major protection" (eight cases) and "disabled living allowance" (nine cases). One hundred and sixteen children suffered from psychiatric disorders at entry and 98 at the end. The general functioning of children as assessed by the Children's Global Assessment Scale (CGAS) showed a statistically significant improvement. One out of two young adults showed problems integrating socially with chaotic pathways: many foster placements, unsuccessful return to the family, and academic failures.Conclusion. The clinical situations of children in the child welfare office and their long-term progression confirm the importance of this public health problem. Although the measures can greatly improve their physical and psychological recovery, with evidence of thriving, this remains limited: only a few of these children are well integrated socially and academically. (C) 2015 Elsevier Masson SAS. All rights reserved.

Les troubles des conduites alimentaires (TCA) chez l’adolescent sont des pathologies d’origine psychique dont les retentissements sont à la fois somatiques et psychologiques, témoignant ainsi des intrications étroites entre psyché et soma. Ces affections sont particulièrement complexes car au carrefour de la psychologie individuelle et des interactions familiales, du corps dans ses aspects les plus biologiques et de l’image du corps, sans oublier bien sûr les influences sociales et culturelles. Les classifications internationales sont régulièrement actualisées, témoignant ainsi d’une étiopathogénie polyfactorielle complexe et discutée. Les troubles des conduites alimentaires relèvent en effet de facteurs génétiques et psychologiques individuels, en étroite relation avec des facteurs environnementaux familiaux et socioculturels. D’un point de vue psychodynamique, ces troubles des conduites alimentaires s’intègrent aujourd’hui parmi les conduites d’addiction ou de dépendance. Au fil du temps, il faut noter une plus grande considération pour les troubles des conduites alimentaires, particulièrement chez l’adolescent, ce qui a favorisé une meilleure sensibilisation des professionnels ainsi qu’un décloisonnement salutaire des pratiques. En effet, s’est développée une véritable clinique de l’adolescent prenant en compte un sujet en proie à de profondes transformations physiques, psychologiques, sociales. Ainsi, les prises en charge des TCA à l’adolescence s’articulent aujourd’hui entre somaticiens (pédiatres, médecins généralistes) et (pédo)psychiatres, de manière coordonnée. Elles sont toujours longues (sur plusieurs années). Les soins portent simultanément sur la conduite symptomatique et sur l’ensemble de la personnalité du jeune, tout en prenant en compte le contexte familial. Dans un premier temps, on reprendra les définitions, les terminologies et les classifications actuelles des troubles des conduites alimentaires. Dans un souci didactique, les troubles des conduites alimentaires typiques tels que l’anorexie mentale et la boulimie nerveuse seront traités, puis certains troubles atypiques, telle l’hyperphagie boulimique (ou binge eating disorder [BED]), récemment individualisée comme entité à part entière (DSM 5), seront abordés. L’obésité, problème majeur de santé publique à l’adolescence, est aussi abordée et discutée, en partant de l’hypothèse d’une possible origine psychoaffective chez certains adolescents obèses, souffrant de BED. Puis, l’épidémiologie, la symptomatologie clinique, l’étiopathogénie seront décrites. Enfin, on reprendra ce qu’il en est de l’évolution, du pronostic et des modalités de prise en charge de ces troubles.

Le but de cette étude était de connaître la trajectoire institutionnelle et le devenir de jeunes enfants admis dans une structure d’aide sociale à l’enfance (ASE). Une étude catamnestique des dossiers archivés de 1994 à 2001 a été menée par un pédopsychiatre et une psychologue clinicienne. Elle a porté sur l’évolution clinique des enfants admis avant l’âge de 4 ans au village Saint-Exupéry, foyer de l’enfance du département du Maine-et-Loire. Les données administratives médicales, judiciaires et éducatives (développement, santé physique, situation familiale, parcours à l’ASE) ont été recueillies et analysées à l’aune de leur évolution au sein de la structure. Le recueil a été fait en respectant l’ordre chronologique d’admission afin d’obtenir un recul optimal, tout en complétant par l’interview de référents ASE et des familles d’accueil les informations recueillies sur dossier. Cent vingt-huit enfants ont été inclus. Les délais avant placement avaient été longs (13,1 mois en moyenne après la première alerte) pour un et l’âge moyen d’admission était de 17 mois. La situation sanitaire, physique et psychique des enfants à l’admission était mauvaise : grossesses mal suivies, troubles psychiatriques fréquents, cas de maltraitance avérée dont 7 cas de syndrome de Silverman. tiers des enfants présentait un retard de croissance à l’admission qui a récupéré dans la moitié des cas. La durée moyenne du parcours au sein du dispositif ASE avait été de 13,2–4,6 années. À échéance, 24 mesures « jeune majeur », 8 mesures de protection des majeurs et 9 mesures allocation adulte handicapé (AAH) avaient été prises. Des troubles psychiatriques avaient été notés chez 116 enfants à l’entrée et chez 98 à la sortie du dispositif. Une progression significative du fonctionnement social et scolaire de l’enfant (évalué par l’échelle CGAS pour Children's Global Assessment Scale) a été notée. À l’issue du suivi, un adulte jeune sur deux présentait des difficultés d’insertion sociale, avec parcours chaotique dans de nombreuses familles d’accueil, échecs de restitution et échecs scolaires. La situation clinique des enfants pris en charge à l’ASE et son évolution à long terme confirment les hypothèses de départ sur le retard de prise en charge de ces enfants provenant, dans leur grande majorité, de familles connues et suivies par les services sociaux. Si le placement a permis une amélioration de l’état physique et psychique de ces enfants, avec notamment une récupération staturo-pondérale, nous avons noté à l’issue de cette prise en charge la persistance de troubles psychiques graves nécessitant des mesures de protection sociale ou d’AAH pour un adulte jeune sur cinq. The purpose of this study was to determine the institutional trajectory and future of young children in child welfare. A catamnestic study – based on data from the child welfare office in Maine and Loire, France, from 1994 to 2001 – was conducted by a child psychiatrist and a psychologist. Medical, judicial, and educational data (development, health, pathways in child protection services) were collected and analyzed regarding the status of these children 15 years later, adding information gathered by interviewing the child welfare and foster family consultant. We included 128 children admitted to the child welfare office before 4 years of age. Admission to the child welfare system suffers from care delays (a mean of 13.1 months between the first child protection referral and placement) with an average entry age of 17 months and frequent cases of child abuse (e.g., seven Silverman syndrome cases). The physical and mental health status of these children was poor (poorly monitored pregnancies, prematurity, low birth weight). More than one third of the children had growth failure at admission, with catch-up in half of the cases. The average length of stay in the child welfare system was 13.2 ± 4.6 years. At the end of the follow-up, there were specific measures to safeguard vulnerable adults: “young adult” (24 cases), “major protection” (eight cases) and “disabled living allowance” (nine cases). One hundred and sixteen children suffered from psychiatric disorders at entry and 98 at the end. The general functioning of children as assessed by the Children's Global Assessment Scale (CGAS) showed a statistically significant improvement. One out of two young adults showed problems integrating socially with chaotic pathways: many foster placements, unsuccessful return to the family, and academic failures. The clinical situations of children in the child welfare office and their long-term progression confirm the importance of this public health problem. Although the measures can greatly improve their physical and psychological recovery, with evidence of thriving, this remains limited: only a few of these children are well integrated socially and academically.

Obesity is considered as an epidemic affecting adults, children and adolescents. An obese child become often an obese adult and early obesity is associated with increased mortality in adulthood. Medical treatments of obesity are often disappointing. Also, bariatric surgery is required for several years as a treatment of choice in adults, and more recently in adolescents. Since 2009, the pediatric team of the University Hospital of Angers offers an innovative multidisciplinary support in addition to conventional medical, the 'obesity network', and offers the possibility of surgery for adolescents under specific indications. The authors studied retrospectively thirty-five case of severly obese adolescents followed at the University Hospital of Angers for which bariatric surgery was considered. The objective was to determine for each folder lighting elements on the clinic and specific psychopathology of these adolescents. A first observation concerns the common paternal absence in the study cohort. It is also found long delays between parental perception of an overweight problem and the first specialist consultation. This last observation is significantly related to the presence of a paternal overweight. Weight loss is also significantly higher in the group of patients operated on the group of non-operated patients. Finally, we argued necessary psychotherapy support of these patients in their care.

Los trastornos de las conductas alimentarias (TCA) en el adolescente son patologías de origen psíquico con repercusiones somáticas y psicológicas, lo cual demuestra las íntimas intrincaciones entre psique y soma. Estas afecciones son particularmente complejas, ya que se encuentran en la intersección de la psicología individual y de las interacciones familiares, del cuerpo en sus aspectos puramente biológicos y de la imagen del cuerpo, sin olvidar, por supuesto, las influencias sociales y culturales. La actualización regular de las clasificaciones internacionales es la expresión de una etiopatogenia multifactorial compleja y controvertida. Los trastornos de las conductas alimentarias dependen, efectivamente, de factores genéticos y psicológicos individuales, en estrecha relación con factores medioambientales familiares y socioculturales. Desde un punto de vista psicodinámico, los trastornos de las conductas alimentarias forman parte de las conductas de adicción o de dependencia. Una mayor consideración actual por los trastornos de las conductas alimentarias, particularmente en el adolescente, ha favorecido una sensibilización de los profesionales y una saludable liberalización de las prácticas. De hecho, se ha desarrollado una verdadera atención clínica del adolescente, que tiene en cuenta a una persona sometida a profundas transformaciones físicas, psicológicas y sociales. Así, la atención médica de los TCA en el adolescente se articula entre clínicos (pediatras, médicos generales) y paidopsiquiatras de forma coordinada y siempre prolongada (varios años). Los cuidados se dirigen simultáneamente a la conducta sintomática y al conjunto de la personalidad, sin olvidar el contexto familiar. En este artículo, primero se han de considerar las definiciones, la terminología y las clasificaciones actuales de los trastornos de las conductas alimentarias. Con un interés didáctico, se tratarán los trastornos típicos de las conductas alimentarias, como la anorexia y la bulimia nerviosa y, después, algunos trastornos atípicos como la hiperfagia bulímica (BED, binge eating disorder), recientemente reconocida como una entidad específica (DSM 5). También se estudia la obesidad, un problema importante de salud pública en la adolescencia, partiendo de la hipótesis de un posible origen psicoafectivo en algunos adolescentes obesos que padecen BED. Después se describirán la epidemiología, las manifestaciones clínicas y la etiopatogenia. Por último, se tratarán aspectos relacionados con la evolución, el pronóstico y las modalidades terapéuticas de estos trastornos.

L’obésité, définie par un excès de masse grasse, représente un problème majeur de santé publique. Sa prévalence a fortement augmenté à l’échelle mondiale depuis la seconde moitié du XXe siècle, à tel point que l’on parle « d’épidémie » d’obésité ou encore de « globésité ». Au vu des résultats souvent insuffisamment probants des mesures physiques et nutritionnelles, l’indication de chirurgie bariatrique peut être posée dès l’adolescence pour des cas d’obésité sévère, après échec d’autres stratégies thérapeutiques. L’indication de cette chirurgie pour les patients mineurs est encadrée en France par les recommandations de la Haute Autorité de Santé publiées en 2016. Elle a pu montrer pour cette population son efficacité à court terme sur la réduction de l’Indice de Masse Corporelle, le traitement des comorbidités et une amélioration de la qualité de vie. Cependant la réussite à la chirurgie n’est pas systématique et des données de l’évolution à plus long terme de ces adolescents sont requises pour appréhender au mieux cette chirurgie. Il est primordial de repérer et renforcer des éléments de motivation interne et de capacités d’adaptation du jeune, afin d’affiner la demande et d’améliorer l’efficacité de la chirurgie. Elle s’intègre dans une prise en charge pluridisciplinaire indispensable.The prevalence of severe and morbid obesity in children and adolescents is sharply increasing. Severe obesity is defined by a body mass index > 120% of BMI IOTF-30 cut off and morbid obesity by a BMI > 140% of BMI IOTF-30 cut off. It concerns 5 to 10% of French obese adolescents. This condition is simple to diagnose but complex to manage. Somatic complications can be found in about half of these patients, and psychiatric symptoms such as depression and anxiety are common. These comorbidities have a real impact on the quality of life of these patients. In case of severe obesity, bariatric surgery can be indicated for adolescents once other therapeutic strategies have failed. It is an effective option when lifestyle interventions – such as nutritional, physical and behavioural care – turn out to be inefficient. The three techniques used are gastric banding, gastric bypass and sleeve gastrectomy. It has shown short-term effeciency in adolescents with severe and morbid obesity regarding weight loss, treatment of comorbidities and improvement of quality of life. However, success in surgery is not systematic and side effects can occur. Sometimes, patients require another surgery. Also, obesity in adolescence is associated with a context of psychological vulnerability. It seems wise to identify and reinforce elements of internal motivation and adaptive capacities of the young person in order to refine the demand and improve the efficiency of surgery. When a psychiatric disorder is identified, it is essential to take it into account and propose a fitting psychiatric care. Medical care has to be performed in specialized multidisciplinary centers. Multidisciplinary follow-up must be standardized and continued even into adulthood. Data regarding middle-term and long-term evolution are sparse, thus it is primordial to pursue this follow-up in order to improve knowledge of the clinical evolution of these patients and to maintain a sustainable efficacy. It is also essential to identify the factors that could be responsible of failure of bariatric surgery so that effectiveness can be improved. French recommendations regarding bariatric surgery indications and specialized multidisciplinary care have been published by the French National Health Authority (Haute Autorité de Santé) in 2016.

Objectives. - From manic-depressive psychosis to bipolar spectrum, today's psychiatry allows us to observe a widening of bipolar criteria. This article aims at studying this evolution, its consequences with a critical look and the psychopathology of mood changes and morbid euphoria.Methods. - All of our considerations refer to current data on bipolar disorders (review with Medline and Science Direct) compared with studies from classical psychiatrists (Kraepelin, Ey) and various authors inspired by psychoanalysis (Freud, Racamier) and phenomenology (Binswanger, Tellenbach, Tatossian).Results. - Many contemporary authors encourage clinicians to detect bipolar disorders from symptoms, early signs and attenuated or atypical expressions. The concept of a widened spectrum is supposed to be closer to clinical reality and it would be an opportunity to diagnose this disease and its deleterious consequences better and thus to set up an appropriate therapy at an early stage. Other authors, on the other hand, deplore a dilution of bipolar disorders together with harmful diagnostic inflation around a concept that has become too heterogeneous to be effective, that subjugates or interferes with other pathologic entities in an excessive manner and abandoning a psychopathological approach. In this view, we shall analyze the nosographic shifts of bipolar disorders throughout the history of psychiatry, from manic-depressive psychosis to bipolar disorder and spectrum. We shall then scrutinize the autonomy and limitations related to bipolar disorders as opposed to normality, confusing clinical presentations and other major mental diseases: Psychosis, depression, pathological personality, anxiety, impulse-control, attention deficit-hyperactivity, addiction and psycho-organic disorders. This work shall first introduce a discussion on the concept of bipolar disorders for children, and then through the case of some historical figures. Then we will deal with the contemporary social factors that are currently furthering the extension of this diagnosis. Last, this article sheds a light on psychopathological specificities of mania - the cornerstone in bipolar disorders - mood changes and morbid euphoria.Conclusion. We think that classic psychiatry, phenomenology and psychoanalysis would act as a guiding light through this debate and could help the clinician in this daily practice. Mood variations require a careful clinical observation and a rigorous set of interpretation, before being specified too excessively or hastily as a symptom of a real bipolarity. (C) 2013 Elsevier Masson SAS. All rights reserved.