FR :

Le craving, ce désir intense de consommer, est un symptôme central de la toxicomanie. Jusqu’au début des années 2000, peu d’outils existaient afin d’étudier le phénomène de manière plus concrète pour mieux le définir, le comprendre et approfondir les fondements neurobiologiques qui le sous-tendent. Avec les avancées technologiques des dernières années (IRM fonctionnelle, PET Scan), puis l’arrivée du DSM-V et son inclusion comme critère diagnostique des troubles liés à l’utilisation de substances, le craving est devenu un symptôme central en toxicomanie. Sa définition a évolué et est de plus en plus précise à plusieurs égards. Nous avons une meilleure compréhension des voies neurobiologiques impliquées dans le phénomène ainsi qu’une meilleure compréhension des facteurs capables de le déclencher. Finalement, plusieurs travaux ont évoqué le rôle du craving dans la rechute lors de l’abstinence, et quelques traitements pharmacologiques se sont démontrés efficaces afin d’atténuer ce symptôme et éviter la rechute. Le craving s’avère ainsi une cible de choix afin de trouver de nouvelles avenues thérapeutiques pour briser le cycle de la dépendance.

EN :

Objective: Observed by physicians and often reported by patients, craving is a core symptom of addiction, although not well defined nor understood completely. In the last several years, functional imaging as well as the measurement of different biological substrates of addiction have greatly evolved, allowing for a better understanding of the underlying neurobiological pathways of craving. Furthermore, with the development of the DSM-V and its inclusion as a diagnostic criterion for substance use disorders, craving has gained a whole new level of interest. Hence, the general objective of this article is to examine findings of studies that have led to a better understanding of craving and its implications. First, we address the definition of craving and its epidemiology in individuals with substance use disorders. We then summarize the results of the research conducted on the neurobiological substrates of craving. Finally, we present the role of craving in the cycle of addiction and its potential as a therapeutic target for pharmacological and non-pharmacological interventions.

Methods: Narrative review of the literature.

Results: The definition of craving has greatly evolved throughout the years, and it is commonly described as an abnormal desire or need to take a drug. While its conscious aspect is well known, whereas it is expressed subjectively, it is growingly also defined as an unconscious phenomenon illustrated by a physiologic activation that is not perfectly correlated with subjective measures. Available data on craving have also demonstrated the presence of this symptom in all three phases of the addiction cycle, including early and prolonged abstinence, long after the acute physical withdrawal syndrome. Three factors have been identified as potent craving inducers: the drug itself, drug related cues and stress. PET scan studies and fMRI studies confirmed the implication of dopaminergic pathways in craving, and have more recently shed light on the contribution of other neurotransmission systems, such as GABA, norepinephrine as well as the endocannabinoid and opioid systems, but their roles are not yet fully understood. Furthermore, craving-related activations of specific areas of the brain involved in learned habits and behavior as well as memory have been demonstrated by various studies; in contrast, regions associated with regulation and control of emotion have been demonstrated to be hypoactive during craving episodes. Finally, several studies have demonstrated that craving is a valid predictive indicator of relapse, making it an interesting target for pharmacological and non-pharmacological treatment. Several anti-craving medications have been shown to decrease craving, including varenicline for tobacco and naltrexone for alcohol dependence. Studies examining the efficacy of other anti-craving medications for other substances are growing in numbers.

Conclusions: Available data on craving support its role as a core symptom of addiction and allow for a better understanding of the underlying neurobiological substrates. Studies tend to show that it is a valid indicator of relapse during early and prolonged abstinence. Further research is needed to truly understand the complexity of the neurobiological substrates involved in craving as well as to develop new anti-craving interventions to facilitate long-term abstinence in individuals with substance use disorders.

FR :

Cet article propose d’explorer les différentes formes de contrainte qui s’exercent dans le champ de l’intervention auprès des toxicomanes. Nous proposons dans un premier temps de définir l’intervention thérapeutique en insistant sur le fait que toute intervention implique nécessairement l’exercice d’un pouvoir ; d’où l’importance d’étudier le caractère contraignant de l’intervention en toxicomanie. Nous proposons ensuite de distinguer les différents niveaux de contrainte qui peuvent s’exercer sur les personnes manifestant des problèmes de dépendance dans un contexte de soins thérapeutiques. Trois formes de contrainte seront tour à tour exposées, soit la contrainte judiciaire, la contrainte institutionnelle et la contrainte relationnelle. Le caractère coercitif de l’intervention thérapeutique auprès de cette clientèle se manifeste alors par une combinaison variable de ces trois niveaux de contrainte. Ultimement, cet article vise à établir des repères nous permettant de mieux réfléchir aux enjeux éthiques et cliniques qui sont liés au caractère contraignant de la prise en charge thérapeutique des toxicomanes.

EN :

Objectives: This article is exploring different forms of constraint that are exerted in the field of drug addiction treatment. The objective of this article is to establish benchmarks and to stimulate reflection about the ethical and clinical implications of those constraints in the field of drug addiction treatment.

Methods: This article is presenting a critical review of different forms of constraint that can be exerted in Canada in regard to the treatment of drug addiction. In the first section of the article, a definition of therapeutic intervention is proposed, that includes the dimension of power, which justifies the importance of considering the coercive aspects of treatment. The second section, which represents the core section of the paper, is devoted to the presentation of different levels of constraint that can be distinguished in regard to drug addicts who are under treatment.

Results: Three levels of constraint are exposed: judicial constraint, institutional constraint and relational constraint. The coercive aspect of treatment can then be recognized as a combination of all tree levels of constraint. Judicial constraint refers to any form of constraint in which the court or the judge is imposing or recommending treatment. This particular level of constraint can take different forms, such as therapeutic remands, conditions of a probation order, conditions of a conditional sentence of imprisonment, and coercive treatment such as the ones provided through drug courts. Institutional constraint refers to any form of constraint exerted within any institutional setting, such as correctional facilities and programs offered in community. Correctional facilities being limited by their own specific mission, it might have a major impact on the way the objectives of treatment are defined. Those limitations can then be considered as a form of constraint, in which drug users don’t have much space to express their personal needs. Finally, relational constraint refers to any form of constraint in which the drug addict might be coerced to treatment under the pressure of people from the immediate environment, such as members of family, friends or employers. Even if this form of constraint is not as obvious as the ones exerted by court and correctional facilities, it has to be considered by practitioners who are evaluating the motivation of drug addicts under treatment.

Conclusion: Considering the diversity of constraints that are exerted on drug addicts who are under treatment, it appears that we should be always aware of the ethical and clinical challenges facing practitioners every day. The recognition of those constraints can also help to understand how important it is to consider the institutional and social context in which treatment is being provided.

FR :

La consommation et la dépendance aux drogues furent longtemps considérées comme un problème typiquement masculin. Néanmoins, bien que l’abus et la dépendance à l’alcool, au cannabis et à la nicotine soient encore plus répandus chez les hommes, les différences de genre en ce qui concerne les stimulants et les opiacés ont largement disparu. Il semblerait également que les motivations pour commencer à consommer, l’escalade vers la dépendance et les taux de cessation diffèrent chez les hommes et les femmes. Les raisons qui expliquent ces différences sont multiples et complexes. Nous allons examiner ici les données des études épidémiologiques et cliniques concernant la consommation de diverses drogues chez des hommes et chez des femmes en contexte des facteurs socioculturels, psychologiques et neurobiologiques.

EN :

Drug use and drug addiction have been traditionally considered to be a male problem, however the gender gap has been decreasing over the past few decades. Thus, while the prevalence of alcohol, cannabis and nicotine dependence is still overall greater among men than among women, sex/gender differences in the abuse of stimulants and opiates seem to have disappeared. Moreover, women appear to be more prone to develop drug dependence, suffer more severe physical and psychological consequences of drug abuse, and have more difficulties quitting the habit. Numerous psychological, socio-cultural and biological factors have been implicated in these changing statistics. For example, while a large proportion of men initiate drug use to induce feelings of elation, energy or focus, women frequently start taking drugs to alleviate pre-existing mental health problems, including high levels of stress, feelings of alienation, depression, anxiety, or post-traumatic stress disorder. This maladaptive self-medication strategy often results in a faster transition to a habitual drug use and eventually a more severe dependence. In addition, the socio-cultural norms (particularly in the Western society) have changed dramatically over the past few decades. Thus, while there is still a more severe stigma and prejudice against women who use drugs (especially if they are pregnant of have children), overall there is much greater acceptance of women’s drug use than it was several decades ago. Moreover, women have much greater access to various drugs of abuse than they used to have. Finally, over the past couple of decades new research started emerging pointing to some neurobiological factors that could also contribute to sex differences in drug addiction. Thus, there is now evidence that dopamine system, which for decades has been strongly implicated in drug reinforcement, is sexually dimorphic. The number of dopaminergic neurons, the density of the dopaminergic terminals, as well as responsiveness of the dopaminergic system to drugs of abuse, has been shown to differ between males and females and it has been shown to be modulated by sex steroid hormones, especially estrogen. For example, female rats exhibit greater motivation to self-administer cocaine than male rats and their motivation is the highest during elevated levels of estrogen. All these psychological, socio-cultural and biological factors that contribute to sex/gender difference in drug use and drug dependence, should be considered while evaluating and treating individuals with drug addiction problem.

FR :

L’objectif de cet article est d’évaluer la qualité des évidences produites par les 25 méta-analyses publiées dans le domaine de la comorbidité entre la psychose et la toxicomanie. L’évidence suggère que le cannabis serait un facteur de risque dans le développement de la psychose. Cette relation est toutefois faible, et ses implications demeurent équivoques. La prévalence de la consommation de tabac, d’alcool et de cannabis est élevée dans la psychose, mais elle semble surestimée, puisqu’inférée à partir d’études cliniques et non pas populationnelles. La toxicomanie est associée à une exacerbation des symptômes positifs et dépressifs de la schizophrénie, mais cette observation est basée sur des études transversales, et non pas longitudinales. Une forte association existe entre la toxicomanie et la violence dans la psychose, mais celle-ci n’est pas pondérée en fonction de divers facteurs confondants. Les effets de la toxicomanie sur la cognition dans la schizophrénie sont hétérogènes. Le bupropion et la varénicline augmentent les taux de cessation tabagique dans la schizophrénie, mais cette observation est basée sur un petit nombre d’études. Enfin, les traitements intégrés ne semblent pas supérieurs aux traitements habituels offerts à cette population comorbide. Le champ de la comorbidité demeure certainement un immense défi pour la médecine fondée sur les évidences.

EN :

Objectives The comorbidity between psychosis and substance use has attracted wide attention over the years, and a vast literature is now available for meta-analytic treatment. In the field, a majority of authors assume that cannabis smoking is a risk factor for psychosis, that substance abuse is highly prevalent in schizophrenia, that substance abuse worsens the prognosis of schizophrenia, and that integrated treatments have greater efficacy than treatment-as-usual for this complex population. The objective of the current article is to review the meta-analyses that have been published in the comorbidity field in order to determine if the above-mentioned assumptions are substantiated by evidence or not. Methods A search of the literature was performed using PubMed, PsycINFO and EMBASE. The literature search retrieved a total of 25 systematic quantitative reviews, addressing the following issues: etiology, age at onset, prevalence rates, cognition, treatment, as well as psychiatric, neurologic and functional outcomes. Results Evidence shows that the prevalence of tobacco smoking, cannabis smoking and alcohol use is elevated in psychosis. However, this prevalence is likely to be over-estimated since studies have been performed in clinical settings rather than the general population. Reliable evidence also suggests that cannabis smoking is a risk factor for psychosis outcomes. However, the association is rather small and it remains difficult to draw an unequivocal public health message from this literature. In the same vein, evidence suggests that cannabis smoking is associated with an earlier age at onset of psychosis. However, this observation is derived from cross-sectional studies, not longitudinal ones; thus, no undisputable claims on causality can be made from them. On clinical grounds, some evidence also suggests that substance use is associated with self-harm, increased positive and depressive symptoms in psychosis patients, but this evidence is derived from cross-sectional studies, not longitudinal ones. Cocaine may exacerbate antipsychotic-induced extrapyramidal symptoms in schizophrenia, but this observation is based on a small number of studies. In the case of violence, the aggregation of studies involving very large samples of patients has shown a strong association with substance abuse in psychosis patients. However, this association is based on statistics that are not adjusted for potential confounds, and the role of cluster-B personality disorders in the substance abuse-violence association has yet to be determined from an evidence-based perspective. The effects of psychoactive substances on cognition in psychosis patients are inconsistent and contradictory. In terms of treatment, evidence shows that bupropion and varenicline increase tobacco smoking cessation rates in psychosis. However, this observation is based on a small number of studies. Finally, there is no evidence that integrated psychosocial interventions are superior to treatment as usual in this population. This lack of efficacy may due to a real lack of efficacy or to methodological problems making the comparison of intervention studies difficult. Discussion The evidence supporting the main assumptions of the comorbidity field is not as strong as it may seem. Moreover, important gaps in our understanding of the psychosis-addiction comorbidity remain. Due to lack of interest or lack of data, no meta-analysis has been performed, in the dual-diagnosis population, on injectable antipsychotics, subjective reasons for use, treatment compliance, medical comorbidities, the social context of use, the neurobiological links between substance use and psychosis, as well as the comparative efficacy of nicotine replacement therapy.

FR :

Introduction Les troubles de la personnalité appartenant au groupe B du DSM-V, notamment les troubles de la personnalité limite et antisociale, sont associés à des taux élevés de problèmes liés à l’utilisation d’une substance. Les mécanismes qui pourraient expliquer cette relation demeurent cependant mal compris. Le craving a par ailleurs récemment été reconnu comme étant une composante majeure des troubles liés à l’utilisation d’une substance. Le but de cet article est donc d’effectuer une recension des écrits afin d’explorer la possibilité que le craving explique en partie cette comorbidité fréquente chez les personnes atteintes de troubles de la personnalité limite ou antisociale.

Méthode Revue critique de la littérature.

Résultats Un nombre limité d’études suggèrent une association positive entre la présence de troubles de la personnalité et le craving. Par ailleurs, les personnes atteintes de ces troubles répondent différemment aux médicaments qui réduisent ce symptôme, lorsque comparées à des sujets normaux. Alors qu’un nombre réduit d’études ont porté directement sur le craving et les troubles de la personnalité, plusieurs ont exploré l’association entre certains traits de tempérament et le craving. La corrélation entre l’impulsivité, les affects négatifs et le craving pourrait potentiellement expliquer la prévalence élevée et la sévérité des troubles liés à l’usage de substances chez les personnes atteintes d’un trouble de la personnalité limite ou antisociale.

Conclusion Ces résultats suggèrent que certains traits de personnalité seraient liés au craving et pourraient servir de cibles intéressantes pour prévenir, évaluer et gérer les troubles comorbides liés à l’utilisation de substances.

EN :

Background Cluster-B personality disorders (DSM-V), particularly borderline and antisocial personality disorders, are associated with high rates of substance use disorder. However, the mechanisms underlying this relationship have yet to be fully understood. Craving has recently been identified as an important component of substance use disorder. The purpose of this article is therefore to review the current literature and explore whether craving could be implicated as an underlying mechanism of comorbid substance use disorder in antisocial and borderline personality disorders.

Method Critical review of the literature.

Results Emerging evidence indicates that there is in fact an association between craving and personality disorders. Patients afflicted with the latter, incidentally, respond differently to anti-craving medication when compared to normal subjects. While a limited number of studies have directly assessed craving in patients with personality disorders, a growing number have looked at the association between craving and specific personality traits. The correlation between impulsivity, negative affect and craving seems like a plausible explanation for the high prevalence and severity of substance use disorder in subjects with antisocial or borderline personality disorders.

Conclusion These findings suggest that specific personality traits are related to craving and could represent promising targets for the prevention, assessment and management of comorbid substance use disorders.

FR :

Épidémiologie Au cours des 10 à 15 dernières années, le Canada est devenu le deuxième plus grand consommateur d’opioïdes de prescription (OP), principalement pour le traitement de la douleur. Cette augmentation a été plus marquée chez les 55 ans et plus. Même si personne ne conteste le droit des patients à recevoir des traitements adéquats pour la douleur, il n’en demeure pas moins que cette disponibilité accrue a entraîné son lot de problèmes : augmentation des visites à l’urgence et des décès liés aux opioïdes ainsi que du trouble lié à l’utilisation (TLU) des opioïdes, trouble qui est d’ailleurs associé à une prévalence accrue, de l’ordre de 40 %, de divers problèmes psychiatriques, dont les troubles dépressifs majeurs.

Neuroscience De nouvelles connaissances issues des neurosciences nous permettent de mieux comprendre la réaction du cerveau lors de l’exposition à ces substances et le caractère chronique du TLU des opioïdes. Quoique historiquement perçu comme une faiblesse de caractère ou un vice, le TLU des opioïdes est maintenant reconnu comme une condition chronique résultant d’une interaction complexe entre une substance, des facteurs d’environnement et un génotype individuel. Malheureusement, ces évidences scientifiques ne sont pas encore largement appliquées à la clinique et la majorité des médecins n’ont pas les habiletés nécessaires pour diagnostiquer et traiter le TLU des opioïdes.

Guides de pratique clinique Des recommandations et guides de pratique peuvent nous aider à identifier les personnes plus vulnérables à un mésusage, et à mieux encadrer la prescription et la gestion de la médication. Il ne s’agit pas de se désintéresser de ces patients et de les abandonner à leur sort mais plutôt de leur offrir des soins inspirés des meilleures pratiques et appuyés sur des évidences scientifiques de qualité.

EN :

Epidemiology Canada now has the second highest number of opioid prescriptions per capita in the world. The rate of prescriptions has increased over the last decade, most notably in adults over 55 years of age. A recognition of the importance of treating pain has influenced this increase, but higher rates of opioid prescribing have produced undesirable outcomes including the misuse of medication as well as an increased number of deaths and emergency department visits attributable to opioids. Diverse psychiatric disorders, such as major depression, now also occur in 40% of those with an opioid use disorder (OUD).

Neuroscience We now understand that addictive behaviors are caused by both environmental and genetic factors. Although OUD has historically been perceived as a weakness of character, it is now clear that it is a chronic disease, which results from a complex interaction between a substance, such as opioid, environmental factors, and an individual’s genotype. Unfortunately, this evidence has yet to be successfully translated into clinical practice and most physicians are unable to diagnose and manage OUD patients appropriately.

Clinical guidelines Many clinical guidelines for the management of chronic, non-cancer pain are available. All guidelines identify the need to assess the patient appropriately and screen for factors associated with misuse before prescribing opioids. Guidelines generally acknowledge that patients should not be denied appropriate pain management, but that some patients will require close supervision and frequent follow-up to prevent the misuse of prescription opioids.

FR :

La méthamphétamine (MA) fait beaucoup couler d’encre dans les médias, par sa popularité grandissante ainsi que par ses effets psychotropes et néfastes. S’agit-il d’un stimulant comme un autre, ou la méthamphétamine entraîne-t-elle des difficultés spécifiques chez ses utilisateurs ? Cet article se veut une brève revue de la documentation scientifique décrivant les raisons de sa popularité ainsi que les problèmes physiques, dentaires, psychiatriques, cognitifs et judiciaires qui y sont associés. Les profils d’utilisateurs ainsi que les traitements proposés à ce jour seront également présentés. En somme, nous tenterons d’illustrer la complexité des troubles rencontrés chez l’utilisateur de MA, les similitudes avec les utilisateurs de stimulants, ainsi que les limites des traitements actuels pour répondre aux besoins liés à cette complexité.

EN :

Methamphetamine (MA) has recently become very popular in the media, due in part to its increasing popularity as well as its psychotropic effects and the negative consequences of its use. Is it a stimulant like any other, or does methamphetamine use lead to specific difficulties in its users? The aim of this article is to provide a brief review of the literature by explaining some of the reasons for its popularity in Canada as well as the physical, dental, psychiatric, cognitive and legal problems associated with its use. MA’s popularity: Regarding its popularity, MA has benefitted from multiple factors, namely its low cost for users and manufacturers, its quick and intense psychotropic effects (increased energy, sexual arousal, rapid thinking, sleeplessness, lack of appetite), its easy access, as well as its various methods of ingestion (nasal, oral, injection). MA abuse also results in a multitude of negative effects, both physical and mental. MA’s physical effects: In terms of negative physical effects, cardiac problems, skin infections, sexually transmitted (and injection-related) diseases as well as meth mouth are described. MA’s mental effects: In terms of mental consequences, two recently published Canadian studies revealing high rates of depression symptoms and of sustained psychotic symptoms in a subgroup of MA users are presented. Studies reporting various cognitive deficits in MA user are also reviewed, including reports of high prevalence of childhood attention deficit and hyperactivity disorder diagnoses among adult MA users. Furthermore, MA abusers are documented as having been highly exposed to trauma in their lives, with many presenting with post-traumatic stress disorder criteria. This manuscript also explores the reasons behind the forensic profiles of individuals using MA, particularly the increased tendency toward violent acts, the high incarceration rates of the homeless users and the high percentage of individuals diagnosed with antisocial personality disorder reported in studies. In terms of user profiles, various methods of ingestion, frequency of use as well as combination with other drugs are described, with a special focus on the frequent polysubstance abuse found in MA users and the reality of bingers. Treatment: This manuscript describes specific treatments designed for stimulant users such as MA abusers, namely the MATRIX program, as well as modifications piloted for those with comorbid depression. Pharmacological treatments, as well as antioxidant supplements, are also discussed although they have not yielded positive results with humans to date. Overall, our goal in this manuscript is to highlight the complexity of the difficulties faced by MA users as well as the limited ability of currently available treatments to address the multiple needs associated with this complexity.

FR :

À ce jour, il n’existe aucun consensus quant aux critères diagnostiques d’une dépendance à Internet (Hinic, 2011 ; Tonioni et al., 2012 ; Weinstein et Lejoyeux, 2010). Pourtant, des personnes s’autodéclarent cyberdépendantes et réclament des soins dans les centres de réadaptation en dépendance (CRD) au Québec. Ces admissions ont amené l’Agence de la santé et des services sociaux de Montréal à demander la réalisation d’une étude descriptive sur la cyberdépendance.

Objectifs : Décrire les caractéristiques sociodémographiques des cyberdépendants en traitement dans les CRD ; et 2) Documenter leurs problématiques associées telles les problèmes de consommation d’alcool, de drogues, pratiques de jeux, estime de soi, symptômes de dépression et d’anxiété.

Méthode : L’étude a été menée dans huit CRD au Québec. Un échantillon de convenance de 57 personnes a été recruté sur une période de 24 mois de 2010 à 2012. Pour participer à cette étude, il fallait être âgé d’au moins 18 ans, s’identifier comme étant cyberdépendant, demander de l’aide pour un problème de cyberdépendance dans un CRD public. L’Internet addiction test (IAT) (Young, 1998), dans sa version française validée (Khazaal et al., 2008), a servi à évaluer la gravité des habitudes d’utilisation d’Internet. Les problèmes associés ont été évalués à l’aide des questionnaires suivants : l’inventaire d’anxiété de Beck (Beck, Epstein, Brown et Steer, 1988) ; l’inventaire de dépression de Beck (Bourque et Beaudette, 1982) ; le DÉBA-Alcool/Drogues/Jeu (Tremblay et Blanchette-Martin, 2009) et le questionnaire de l’échelle d’estime de soi (Rosenberg, 1965).

Résultats. Cinquante-sept personnes ont accepté de participer à l’étude. La très grande majorité des participants était des hommes (88 %), âgés en moyenne de 30 ans, vivant chez leurs parents et ayant un faible revenu. Ils consultaient à la suite des recommandations de leurs proches et rapportaient de nombreuses conséquences reliées à leur utilisation d’Internet. Ils passaient en moyenne 65 heures par semaine sur Internet et rapportaient avoir plusieurs applications problématiques. Les applications problématiques les plus fréquemment rapportées étaient les jeux de rôles multijoueurs (57,8 %), les sites de divertissement streaming (35,1 %) et les bavardoirs communément appelés chat rooms (29,8 %). À l’échelle d’estime de soi, 66,6 % des participants présentaient une estime de soi très faible, ou faible, alors que 21,1 % rapportaient une estime supérieure à la moyenne. L’inventaire de dépression de Beck a évalué que 3,5 % (n = 2) de l’échantillon atteignait le seuil clinique tandis que 7,5 %, (n = 4) vivait de l’anxiété atteignant le seuil clinique. Presque la moitié (45,6 %) prenait une médication psychotrope pour un problème de santé mentale et 33,3 % présentait un problème de santé physique chronique.

Conclusion : Cette étude a permis de mettre en lumière les caractéristiques d’un groupe encore méconnu dans la population, soit les personnes cyberdépendantes. Ces cyberdépendants vivent des conséquences significatives à la suite de la perte de contrôle de l’utilisation d’Internet. Par ailleurs, à leur admission en traitement, bien que la détresse psychologique subjective ne soit pas toujours élevée, les participants présentent un tableau clinique complexe où la comorbidité est la règle plutôt que l’exception. Il nous semble que les données actuelles comportent suffisamment de similarités avec les autres troubles addictifs pour permettre aux cliniciens de travailler en prenant assise sur leur expérience avec d’autres dépendances.

EN :

To date, there is no consensus on the diagnostic criteria for Internet addiction (Hinic, 2011; Tonioni & coll., 2012; Weinstein & Lejoyeux, 2010). Nonetheless, some people consider themselves cyberdependent and request treatment services in the addiction rehabilitation centers (ARC) of the province of Quebec. These admissions have led the Health and Social Services Agency of Montreal to ask for the realization of a descriptive study on Internet addiction.

Objectives: 1) Describe the socio-demographical characteristics of cyberdependent individuals receiving treatment in the ARC; 2) Document their associated problems, such as problems related to alcohol and drug abuse, gambling, self-esteem, and symptoms of depression and anxiety.

Methodology: The study was conducted in eight ARC’s of the province of Quebec. A convenience sample of 57 people was recruited over a period of 24 months, from 2010 to 2012. To participate in this study, individuals had to be 18 years or older, identify themselves as cyberdependent, and request help for an Internet addiction problem in a public ARC. The Internet Addiction Test (Young, 1998), in its validated French version (Khazaal & coll., 2008), was used to assess the severity of Internet use habits. The associated problems were assessed using the following questionnaires: the Beck Anxiety Inventory (Beck, Epstein, Brown & Steer, 1988); the Beck Depression Inventory, in its validated French version (Bourque & Beaudette, 1982); the DÉBA-Alcool/Drogues/Jeu (Dépistage-évaluation du besoin d’aide), an instrument used to screen and assess the need for help in problems related to alcohol, drugs, and gambling (Tremblay & Blanchette-Martin, 2009), and the Rosenberg’s Self-Esteem Scale (Rosenberg, 1965).

Results: Fifty-seven people agreed to participate in the study. A large majority of these cyberdependent individuals were male (88%), the mean age was 30 years old, had low incomes and were living with their parents. They consulted following the pressure of their entourage and reported many consequences due to their Internet addiction problem.They spent, on average, 65.8 hours per week on the Internet and reported having several problematic applications. Amongst these problematic applications, the most frequently reported were the role playing game (MMORPG) (57.8%), the streaming on entertainment sites (35.1%), and the chat rooms (29.8%). Regarding the self-esteem scale, 66.6% of participants presented a very low or low self-esteem, while 21.1% presented an above average self-esteem. According to Beck Depression and Anxiety Inventories, 3.5% (n=2) of the sample reached the clinical threshold for depression, while 7.5% (n=4) reached it for anxiety. Almost half (45.6%) of the participants were taking psychotropic medication for a mental health problem, and 33.3% had a chronic physical health problem.

Conclusion: This study highlights the characteristics of a still unknown group in the population, that of cyberdependent people. Individuals having an Internet addiction problem live significant consequences due to the loss of control on their Internet use. In addition, when they are admitted into treatment, even if the subjective psychological distress is not always high, participants present a complex clinical profile, where comorbidity is the rule rather than the exception. We believe that the current data show enough similarities with other addictive disorders, to allow clinicians to work taking into consideration their experience with other addictive behaviours.

FR :

La présente étude est une revue critique de la documentation scientifique sur les effets du bruit sur la santé mentale. Cette étude a été réalisée sur la base de la recherche de mots-clés, de l’impact factor des revues, du nombre de fois que l’article a été cité. Hinari a servi de base des données. L’analyse et la sélection des articles scientifiques nous ont permis de les regrouper en trois catégories d’études. Les études fondamentales ont dosé les taux des hormones de stress dans le plasma, les urines et la salive. Les études expérimentales ont exposé les sujets humains à la pollution sonore pour évaluer les déficits de leurs mémoire, attention et performance. Les études épidémiologiques ont évalué les déficits cognitifs chez les élèves étudiant dans des milieux bruyants et l’état de santé mentale des individus habitant aux alentours des aéroports, voies ferrées et des autoroutes. Les études fondamentales et expérimentales ont abouti à un consensus scientifique sur les effets négatifs du bruit tandis que les résultats des études épidémiologiques ne permettent pas de tirer des conclusions solides, des études ultérieures s’avèrent donc nécessaires.

EN :

Any human activity generates noise. It is considered as a risk factor for people’s health. The present review of literature has assessed the impact of noise on mental health; it is summarized into four points: objective, methods, results and conclusion. Objective: The main objective of this study is to expose the actual knowledge state of noise effects on mental health after overview and critical analysis of literature to identify the acquired and shortcomings, to reflect on research direction in terms of noise pollution in the future. Methods: The literature review was conducted based on: research of keys words in articles published, research of the number of quotations of articles in Journal Citation Reports (JCR), published in web of science, research of impact factor of journals. One hundred articles were selected, after analyzing contents, items were classified into: fundamental studies (25%), experimental studies (50%), and epidemiological studies (25%). Results: The fundamental studies have verified the hypothesis according to which noise generates stress. Researchers have dosed hormones of stress in plasma, urine and saliva in individuals exposed to noise of different decibels. The results found were unanimous: The rates of stress hormones found, were significantly high in three liquids. This means that noise causes stress. For experimental studies, researchers have experienced the role of noise on memory, attention and performance. Human subjects were exposed to different decibels to assess level of disruption to their memory, attention, and performance. The results revealed that noise disturbs memory, distracts attention and decreases performance. Experimental studies are the most abundant and constitute 50% of the current literature review.

The epidemiological studies have evaluated the intellectual performance of students in schools located in noisy environments and residents in areas surrounding airports, railways and highways. Results have revealed that students in schools located in noisy environments have presented cognitive impairment. Conclusion: This review of literature on noise effects on mental health lead to the following conclusion. It seems to exist a consensus in fundamental and experimental studies on the detrimental effect of noise but results from epidemiological are not convincing and require further studies.

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Contexte La schizophrénie est un trouble allant de pair avec un manque d’autocritique par rapport aux délires et aux hallucinations. En contrepartie, on en sait beaucoup moins en ce qui concerne la conscience des patients par rapport à leurs déficits cognitifs, qui sont des symptômes clés de ce trouble psychiatrique. Afin de faire la synthèse de l’état de la connaissance à ce sujet, nous avons effectué une méta-analyse de 22 études comprenant 1609 patients. Les analyses ont révélé que les patients rapportent davantage de plaintes subjectives que les sujets sains. La corrélation entre la cognition subjective et objective s’est avérée faible toutefois. Les études utilisant la Scale to Investigate Cognition in Schizophrenia ont produit des corrélations plus fortes que celles utilisant d’autres échelles de plaintes subjectives. La relation entre la cognition subjective et les symptômes dépressifs s’est avérée comparable à la relation entre la cognition subjective et la cognition objective. Enfin, une relation faible a été observée entre la cognition subjective et l’autocritique par rapport aux symptômes positifs. Les résultats de la présente méta-analyse montrent que les patients atteints de la schizophrénie se plaignent de déficits cognitifs, mais qu’ils n’ont pas une représentation claire de la nature de ceux-ci, ce qui confirme l’existence de déficits méta-cognitifs dans la schizophrénie.

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Background Schizophrenia is well-known to be associated with a lack of insight into symptoms. Comparatively, little is known on insight into neurocognitive deficits in schizophrenia, despite the fact that these dysfunctions are undoubtedly core features of the disorder. Recently, growing interest has been paid to subjective cognition, and thus far, results have been heterogeneous. The objectives of current meta-analysis were to determine the magnitude of subjective complaints in schizophrenia; to examine the association between subjective cognitive complaints and objective cognition, as well psychiatric symptoms and insight into illness. The meta-analysis also sought to determine if results are influenced by the choice of the scale used to measure subjective cognition. Methods A search was performed with PubMed, PsycInfo and EMBASE, using the following key words: schizophrenia OR psychosis AND cognition OR memory OR attention OR “executive functions” AND insight OR “subjective cognition” OR awareness. Studies involving patients with schizophrenia-spectrum disorders and measuring subjective cognition with a validated self-report scale were included. Studies using scales measuring insight into thinking processes (e.g. Beck Cognitive Insight Scale) were excluded. Statistical analyses were performed with the Comprehensive Meta-Analysis-2 software. Cognitive scores were grouped into 6 cognitive domains (as recommended by the MATRICS group): attention, problems solving, speed of processing, verbal memory, visual memory and working memory. The difference in cognitive complaints between schizophrenia patients and healthy controls was examined using Cohen’s d. The associations between subjective cognition and objective cognition, psychiatric symptoms and insight into illness were examined using Pearson’s correlation coefficients. Results Twenty-two studies were retrieved, including a total of 1609 patients and 294 controls. Patients reported increased subjective cognitive complaints, compared to controls (moderate effect size). A weak association was observed between subjective and objective (global) cognition. The association was larger in studies using the Subjective Scale To Investigate Cognition in Schizophrenia (SSTICS), compared to studies using other scales. The largest association was observed between subjective complaints and problem solving. The association between subjective complaints and depressive symptoms was in the same range as the association between subjective complaints (measured with the SSTICS) and objective cognition. No association was found between subjective complaints and positive / negative symptoms. Finally, a weak association was found between subjective complaints and insight into illness. Discussion Taken together, these results suggest that schizophrenia patients report significant subjective cognitive complaints. However, patients have a poor understanding of these deficits, since subjective complaints are as strongly associated with depressive symptoms as they are associated with objective cognitive deficits. Schizophrenia patients may be more aware of their problem solving deficits. However, this observation is based on a limited number of studies and will need to be replicated in future studies. Our results also show that insight into neurocognitive deficits is largely independent from insight into illness. Finally, the results of the current meta-analysis may have methodological implications, since they suggest that the SSTICS produces stronger associations between subjective and objective cognition than other scales. In the future, greater attention will need to be paid to the domains of subjective complaints, as well as to subjective cognitive complaints in other psychiatric disorders.

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Cet article fournit un survol de la logique de l’intervention précoce pour psychose, de ses fondements théoriques et de la littérature essentielle sur le concept. L’intervention précoce repose sur l’hypothèse de la période critique, qui vient accentuer l’importance des premiers stades de la maladie, et sur les résultats d’études dans le domaine, qui suggère que la durée d’une psychose non traitée en influence le pronostic. L’intervention précoce facilite l’accès à un traitement spécialisé adapté à la phase de la maladie par un processus de recommandations médicales plus ouvert, des délais rapides et l’éducation du public et des praticiens sur la psychose. L’intervention précoce, qui dure généralement deux ans à partir du dépistage, comprend une prise en charge intensive et des médicaments antipsychotiques à faible dose. L’accent est mis sur le fonctionnement social, l’intervention familiale, l’attention précoce aux troubles connexes ainsi qu’une alliance thérapeutique entre le jeune et sa famille. Selon les données scientifiques disponibles, une telle intervention donne de meilleurs résultats que les soins typiquement offerts. Les critiques du concept visent la qualité des études en sa faveur, sa mise en oeuvre, la répartition des ressources en intervention précoce et son utilité pour les personnes présentant un risque élevé de psychose. En termes de disponibilité et d’élaboration de politiques en intervention précoce, le Royaume-Uni détient une avance certaine, alors que le Canada se situe au milieu, et les États-Unis au bas de l’échelle. Au Québec, les résultats varient et d’autres études et investissements sont nécessaires. Récemment, le concept d’intervention précoce a servi d’exemple à des mesures plus importantes visant la transformation des soins de santé mentale des jeunes, ce qui constitue une toute nouvelle percée au Canada.

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Objectives: This paper seeks to provide an overview of the motives, rationale, theoretical underpinnings and foundational literature of the early intervention movement for psychoses. It also seeks to review the current status of the field, highlight its significant developments and identify its emergent trends.

Methods: This paper begins by contextualizing the burden of psychosis. It then traces the origins of the early intervention movement and surveys the seminal literature that established and shapes the field. It describes the movement’s characteristic elements, types, approaches, strengths, criticisms and trajectories in select Western nations. It closes with a presentation of how the early intervention movement is informing broader endeavours to transform youth mental health.

Results: We find that the early intervention movement is predicated on the critical period hypothesis that emphasizes the significance of the early stages of the illness; and on findings that the duration of untreated psychosis influences prognoses. Early intervention redresses this situation by facilitating access to specialized, phase-specific treatment. Access is enhanced through open referral, fast response times, and public and practitioner education. Ideally, the intervention, provided for the first two years after detection, features intensive case management; low-dose antipsychotic medication; an emphasis on social functioning; family intervention; early attention to comorbid concerns; and due regard for the needs and priorities of youth and their families. Evidence suggests that specialized early intervention yields better outcomes than routine care. The cost-effectiveness of such services has not yet been definitely investigated. Criticisms of early intervention pertain to the quality of evidence for, the manner of implementation of, the allocation of resources to early intervention and its utility for persons at high risk for developing psychosis. We also identify advocacy within the field for extending early intervention to the first five years of the course of psychosis.

Conclusion: We conclude that the status of the early intervention movement (in terms of availability and policy) in Western public healthcare systems can be resolved into a spectrum. The United Kingdom is shown to be the leader while Canada appears at the middle of the spectrum (with the United States bringing up the rear). In the Quebec context, the picture is found to be mixed and recommendations for further research and investment are made. Finally, an examination is undertaken of how the early intervention for psychosis movement has provided the impetus for and dovetails into the larger effort to transform youth mental healthcare in general, a development that is in its nascent stages in Canada.

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Cet article revoit la documentation scientifique portant sur le transfert tel qu’il s’exprime chez les personnes atteintes du trouble dissociatif de l’identité (TDI). Puisque des traumatismes importants sont omniprésents dans l’histoire des personnes souffrant du TDI, les aspects post-traumatiques du transfert propres à ce trouble sont présentés. Les relations transférentielles typiques et les aspects dissociatifs du transfert chez le TDI y sont aussi exposés. De plus, le transfert est abordé sous l’angle de l’attachement désorganisé, élément essentiel à l’étiologie du TDI selon plusieurs écrits scientifiques. Une vignette clinique présente de manière plus concrète ces éléments.

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A literature review about transference in the treatment of dissociative identity disorder (DID) is presented. Common transference reactions resulting from serious traumas are explored, considering that those kind of trauma are higly present in the pathways of DID patients. Post traumatic transference aspects specific to DID are also presented. In addition, common transference patterns and dissociative aspects of transference in the treatment of DID are explained. Transference is also discussed in relationship to the possible impact of disorganized attachment, which is a main component in the development of DID. The clinical implications of this proposition will be discussed and supported by a case example.

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La population hospitalisée en psychiatrie apparaît davantage exposée à des événements traumatiques que la population française en général, avec plus particulièrement des agressions à caractère sexuel. Notre objectif principal est de décrire la population hospitalisée en psychiatrie et en particulier l’histoire traumatique des patients, les comorbidités associées (psychiatriques et addictologiques) ainsi que le niveau socioéconomique. Cette étude descriptive, transversale et rétrospective a été réalisée au Centre de crise du Centre Hospitalo-Universitaire de Martinique de février à juillet 2013. Un questionnaire socioéconomique, le Mini International Neuropsychiatric Interview 5.0, le Trauma History Questionnaire et le questionnaire Impact Events Scale-Revised (IES-R) ont été réalisés de façon aléatoire auprès de 49 des 143 patients admis sur cette période (soit 34,3 %). Dans notre échantillon, une moyenne de 6,5 types différents d’événements traumatiques a été établie (écart-type = 4,2) : 38,8 % des patients rapportent un traumatisme à la suite d’une catastrophe naturelle, et 38,8 % déclarent au moins une agression sexuelle. Parmi les 25 patients souffrant de syndrome de stress post-traumatique, 66,7 % ont subi une agression sexuelle dans l’enfance, avant l’âge de 10 ans (P = 0,01), et dans l’adolescence, entre 10 et 18 ans (P = 0,01). Ces résultats soulignent l’importance d’interroger systématiquement le profil traumatique, c’est-à-dire l’association entre les événements traumatiques et leur retentissement clinique.

EN :

The population hospitalised in psychiatry seems more exposed to traumatic events than the French general population, with particularly more sexual aggressions. The aim of this study is to describe the population hospitalised in psychiatry and more precisely the traumatic history of these patients, their comorbidities (mental diseases and addictions), and socio economical level. This descriptive, cross sectional and retrospective study took place in the Crisis Center in the University Hospital in Martinique (French West Indies), from February to July 2013. A socio-demographic information, the Mini International Neuropsychiatric Interview 5.0, the Trauma History Questionnaire and the Impact Events Scale-Revised were realised with 49 of the 143 patients admitted during this period (34.3%). In this population, we found a mean of 6.5 (standart-deviation=4.2) different types of traumatic event, with 38.8% patients reporting a natural disaster, and 38.8% declaring at least one sexual aggression. In the 25 patients suffering from post-traumatic stress disorder, 66.7% underwent a sexual aggression, significatively during childhood (before 10 years old, P=0.01), and during adolescence (between 10 to 18 years old, P=0.01). These results underline the importance of a systematic screening of the traumatic profile: the characteristics of the traumatic events and its clinical impact.