Le traitement du trouble délirant et ses aspects cognitifs

Cet article fait état de la phénoménologie cognitive du trouble délirant (TD) et examine les modèles cognitifs actuels. Des études de cas ont mis à jour des résultats forts prometteurs concernant l'utilisation de la thérapie cognitivo-comportementale (TCC) pour traiter le TD, même si cette dernière n'en est qu'à ses débuts dans ce domaine. Bien que les étapes de la TCC pour traiter le TD soient très similaires à ceux de la TCC pour les autres troubles psychotiques, son approche comporte des différences considérables. Toutefois, il est primordial de combiner plusieurs stratégies afin de pouvoir modifier les inférences propres au TD. L'évaluation clinique des délires ainsi que l'application de la TCC comme traitement seront illustrées par deux études de cas comportant des diagnostics de TD à thème prédominant de persécution. Les cas ont requis des périodes de temps différentes lors des diverses étapes de la TCC, suggérant l'importance de poursuivre la TCC au besoin.Cognitive aspects and treatment of delusional disorders This article reviews the cognitive phenomenology of delusional disorders (DD) and examines the current cognitive models. Some case studies have shown considerable promise concerning the utilisation of cognitive behavioral therapy (CBT) for the treatment of DD, even if this approach is in its infancy. Although the stages of CBT to treat DD are very similar to that of other psychotic disorders, there are also considerable differences. However, it is essential to combine several strategies in order to modify inferences specific to DD. The clinical evaluation of delusions as well as the application of CBT as a treatment is illustrated in two cases with a diagnosis of DD with persecutory subtype. The cases required different time periods for different stages of CBT and highlight the importance of tailoring CBT according to need.El tratamiento del trastorno delirante y sus aspectos cognitivos Este artículo tiene en cuenta la fenomenología cognitiva del trastorno delirante (TD) y examina los modelos congnitivos actuales. Investigaciones recientes han puesto al día resultados prometedores referente a la utilisación de la terapia cognitiva-comportamiento (TCC) para tratar el TD, aunque esta última esté empesando en este campo. Aunque las etapas de la TCC para tratar el TD sean similares a los de la TCC para otros trastornos psicóticos, su aproximación comporte diferencias considerables. Sin embargo es primordial combinar varias estrategias para modifiar las inferencias propias al TD. La evaluación clínica de los delirios asi que la aplicación de la TCC como tratamiento son ilustrados por dos estudios de casos incluyendo diagnósticos de TD con tema predominante de persecusión. Los casos han requerido periodas de tiempo diferentes durante las varias etapas de la TCC, sugeriendo la importancia de seguir con la TCC si es preciso

Der inferenzbasierte Ansatz bei Zwangsstörungen

Obwohl die kognitive Verhaltenstherapie, häufig in der Form der Exposition und Reaktionsverhinderung, das in der Behandlung der Zwangsstörung am weitesten verbreitete Behandlungsverfahren darstellt, profitieren Betroffene mit bestimmten Subtypen der Zwangserkrankung (z.B. überwertigen Ideen oder ich-syntonen Zwangsgedanken) davon nur unzureichend oder gar nicht. Aufgrund der begrenzten Erfolge von auf verhaltenstherapeutischen oder kognitiv-verhaltenstherapeutischen Modellen basierenden Verfahren hat sich die Forschung vermehrt ausschließlich kognitiven Theorien und Behandlungsmodellen zugewandt. Der inferenzbasierte Ansatz zur Behandlung der Zwangsstörung geht davon aus, dass zwangstypische Kognitionen und Bewertungen von vorausgehenden Zweifeln und Inferenzen herrühren. Dieser Ansatz konzentriert sich auf die fehlerhaften Denkprozesse, die dem zwanghaften Zweifeln zugrunde liegen, welches Zwangsverhalten auslöst. Die vorliegende Arbeit fasst den gegenwärtigen Stand des inferenzbasierten Modells und die es stützenden empirischen Befunde zusammen

L’utilisation clinique des benzodiazépines pour le traitement de l’anxiété : Où en sommes-nous?

Cet article vise à faire le point sur l'utilisation clinique des benzodiazépines (BZD) pour le traitement de l'anxiété. Une synthèse de la littérature sur les différents aspects potentiellement problématiques associés à leur utilisation à long terme pour la gestion de l'anxiété ainsi que des solutions alternatives sont présentées. La recherche a été effectuée à l'aide des banques de données Medline et Psychlitt consultées de 1980 à 2001. Des articles pertinents mais antérieurs à ces dates, localisés par l'entremise de la section référence des articles révisés, ont également été consultés. Conclusion : les risques et bénéfices de l'utilisation à long terme des BZD pour le traitement de l'anxiété ne sont toujours pas clairement établis. Néanmoins, malgré des recommandations d'une utilisation à court terme seulement, une proportion importante de patients les utilisent encore sur une base continue. Il serait utile d'évaluer la façon dont certaines ressources alternatives sont présentées aux patients et, s'il y a lieu, comment les rendre plus accessibles et attrayantes pour les patients anxieux.Clinical use of Benzodiazepines for anxiety problems: Where do we stand? This article presents an overview of the clinical use of Benzodiazepines (BZD) for anxiety problems. It presents a synthesis of the literature on potentially problematic aspects associated with long-term use and presents alternatives to BZD use in the management of anxiety. Medline searches from 1980 to 2001 were conducted. Relevant articles anterior to these dates, located through reference sections of more recent articles, were also reviewed. Conclusions: Risks and benefits of these drugs for the long-term management of anxiety problems are still not clearly established. Nevertheless, despite recommendations that BZDs should be used on a short-term basis only, an important proportion of patients continue using them on a long-term basis. It would be useful to assess how alternative anxiety management strategies are presented to patients and, if relevant, how to make them more accessible and appealing to anxious patients.Utilisación clínica de benzodiazepines para el tratamiento de la ansiedad: ¿Donde estamos? Este artículo apunta sobre la utilisación de los benzodiazepines (BZD) para el tratamiento de la ansiedad. Estan presentadas una síntesis de la literatura sobre los varios aspectos potentialmente problemáticos asociados a su utilisación al largo tiempo para la gestión de la ansiedad asi que soluciones alternativas. La investigación ha sido efectuada con la ayuda de los bancos de datos Medline y Psychlitt consultados de 1980 a 2001. Articulos pertinentes pero anteriores a esas fechas, localisados por la sección de referencia de los articulos revisados tambien han sido consultados. Conclusión: los riesgos y beneficios de una utilisación a largo plazo de los BZD para el tratamiento de la ansiedad no son claramente establecidos. Sin embargo, a pesar de recomendaciones de una utilisacón a corto plazo solamente, una proporción importante de patientes les utilisan todavia sobre una base continua. Sería útil evaluar la manera que estan presentados ciertos recursos alternativos a los patientes y, si procede, como hacerlos más accesibles y atractivos para los patientes con ansiedad.A utilização clínica dos benzodiazepínicos para o tratamento da ansiedade: progressos O objetivo deste artigo é situar a utilização clínica dos benzodiazepínicos (BZD) no tratamento da ansiedade. São apresentados resumos de artigos que tratam dos diferentes aspectos duvidosos associados à sua utilização a longo prazo no controle da ansiedade, e soluções alternativas. A pesquisa foi realizada com a ajuda dos bancos de dados Medline e Psychlitt consultados de 1980 a 2001. Também foram consultados artigos pertinentes, anteriores a estas datas, localizados através da seção "referência dos artigos revisados". Conclusão: os riscos e benefícios da utilização a longo prazo dos BZD para o tratamento da ansiedade ainda não foram determinados claramente. Entretanto, apesar das recomendações de uma utilização somente a curto prazo, um grande número de pacientes ainda os utilizam regularmente. Deve-se ressaltar a importância de avaliar a maneira como alguns recursos alternativos são apresentados aos pacientes e, quando for o caso, como torná-los mais acessíveis e atraentes aos pacientes que sofrem de ansiedade

The effect of talking about psychological trauma with a significant other on heart rate reactivity in individuals with posttraumatic stress disorder

Individuals with posttraumatic stress disorder (PTSD) commonly make efforts to avoid trauma-oriented conversations with their significant others, which may interfere with the natural recovery process. Trauma-oriented conversations can be experienced as physiologically arousing, depending on the intensity of PTSD symptoms and perceptions of social support. In the current investigation, changes in heart rate responses to a trauma-oriented social interaction with a significant other were assessed. Perceived supportive and unsupportive or negative social interactions were examined as moderators of the association between heart rate changes to this context and intensity of PTSD symptoms. A total of 46 individuals with PTSD completed diagnostic interviews and self-report measures of symptoms and perceived supportive and negative social interactions during a trauma-oriented social interaction with a significant other. Heart rate was continuously measured during this interaction. Results showed that engagement in a trauma-oriented social interaction was predictive of elevations in heart rate that positively correlated with intensity of PTSD symptoms. The moderation hypothesis was partially supported. In addition, perceived negative social interactions positively correlated with elevations in heart rate. These findings can inform social intervention efforts for individuals with PTSD

The buffering power of overt socially supportive and unsupportive behaviors from the significant other on posttraumatic stress disorder individuals’ emotional state

Social support is one of the three strongest predictors of posttraumatic stress disorder (PTSD). In the present study, we aimed to assess the buffering power of overt socially supportive and unsupportive behaviors from the significant other, in a group with PTSD and a comparison group. Design and methods: A total of 46 individuals with PTSD and 42 individuals with obsessive-compulsive disorder (OCD) or panic disorder (PD) completed diagnostic interviews and an anxiety-oriented social interaction with a significant other. Heart rate of participants was continuously measured during this interaction and overt social behaviors from the significant other were recorded on videotape and coded using a validated system. Results: Changes in heart rate in PTSD participants correlated negatively with changes in overt socially supportive behaviors from their significant other (r from −.36 to −.50, p  .05). No such statistically significant association emerged in the group with OCD or PD (r from .01 to −.27, p > .05). Conclusions: This study sustain the buffering power of overt supportive behaviors from the significant other on heart rate changes in PTSD

Is context a crucial factor in distinguishing between intrusions and obsessions in patients with obsessive-compulsive disorder?

Objective Some cognitive models of obsessive‐compulsive disorder (OCD) posit that intrusions exist on a continuum with obsessions; others consider that they may be unrelated phenomena that differ in the context where they occur. We aimed to examine and compare, at two different moments, the context of the occurrence of intrusions and obsessions. Method Sixty‐eight patients with OCD completed an interview appraising their most upsetting obsession and intrusion. Results At their onset, the obsessions/intrusions were associated with experiencing negative emotional states and life events, and they were more likely to appear in 'inappropriate' contexts. The context of the obsessions/intrusions differed the last time they were experienced. Autogenous obsessions/intrusions occurred more frequently in contexts with an indirect link. Conclusions The context distinguishes between intrusions and obsessions, not when they emerge, but when the obsession is already established. The results support that there is a continuum or progression from intrusions to obsessions

How do social interactions with a significant other affect PTSD symptoms? An empirical investigation with a clinical sample

Social support and coping are both related to posttraumatic stress disorder (PTSD) symptoms, but the mechanisms underlying their relationships remain unclear. This study explores these relationships by examining the perceived frequency of supportive and countersupportive interactions with a significant other in PTSD patients. Ninety-six participants with PTSD were recruited and completed questionnaires assessing social interactions, ways of coping, and PTSD symptoms. Associations of social interactions (r2 = 4.1%–7.9%, p < .05) and coping (r2 = 15.9%– 16.5%, p < .001) with symptoms were independent, and suggested a direct association between social interactions and PTSD. Countersupportive interactions were more associated to symptoms than supportive interactions. Our findings suggest the development of psychotherapies that integrate social support interventions

Spanish version of the Inferential Confusion Questionnaire-Expanded Version: Further support for the role of inferential confusion in obsessive-compulsive symptoms

Objective Some cognitive models of obsessive‐compulsive disorder (OCD) posit that intrusions exist on a continuum with obsessions; others consider that they may be unrelated phenomena that differ in the context where they occur. We aimed to examine and compare, at two different moments, the context of the occurrence of intrusions and obsessions. Method Sixty‐eight patients with OCD completed an interview appraising their most upsetting obsession and intrusion. Results At their onset, the obsessions/intrusions were associated with experiencing negative emotional states and life events, and they were more likely to appear in 'inappropriate' contexts. The context of the obsessions/intrusions differed the last time they were experienced. Autogenous obsessions/intrusions occurred more frequently in contexts with an indirect link. Conclusions The context distinguishes between intrusions and obsessions, not when they emerge, but when the obsession is already established. The results support that there is a continuum or progression from intrusions to obsessions

Treating delusional disorder : a comparison of cognitive-behavioural therapy and attention placebo control

Objective: Cognitive-behavioural therapy (CBT) has proved effective in treating delusions, both in schizophrenia and delusional disorder (DD). Clinical trials of DD have mostly compared CBT with either treatment as usual, no treatment, or a wait-list control. This current study aimed to assess patients with DD who received CBT, compared with an attention placebo control (APC) group. Method: Twenty-four individuals with DD were randomly allocated into either CBT or APC groups for a 24-week treatment period. Patients were diagnosed on the basis of structured clinical interviews for mental disorders and the Maudsley Assessment of Delusion Schedule (MADS). Results: Completers in both groups (n = 11 for CBT; n = 6 for APC) showed clinical improvement on the MADS dimensions of Strength of Conviction, Insight, Preoccupation, Systematization, Affect Relating to Belief, Belief Maintenance Factors, and Idiosyncrasy of Belief. Conclusion: When compared with APC, CBT produced more impact on the MADS dimensions for Affect Relating to Belief, Strength of Conviction, and Positive Actions on Beliefs