Encephale
-
The autonomic nervous system sends messages through the sympathetic and parasympathetic nervous system. The sympathetic nervous system innervates the cardioaccelerating center of the heart, the lungs (increased ventilatory rhythm and dilatation of the bronchi) and the non-striated muscles (artery contraction). It releases adrenaline and noradrenaline. As opposed to the sympathetic nervous system, it innervates the cardiomoderator center of the heart, the lungs (slower ventilatory rhythm and contraction of the bronchi) and the non-striated muscles (artery dilatation). It uses acetylcholine (ACh) as its neurotransmitter. Sympathetic and parasympathetic divisions function antagonistically to preserve a dynamic modulation of vital functions. These systems act on the heart respectively through the stellar ganglion and the vagus nerve. The interaction of these messages towards the sinoauricular node is responsible for normal cardiac variability, which can be measured by monitoring heart rate variability (HRV). Heart rate is primarily controlled by vagal activity. Sensorial data coming from the heart are fed back to the central nervous system. HRV is an indicator of both how the central nervous system regulates the autonomic nervous system, and of how peripheral neurons feed information back to the central level. HRV measures are derived by estimating the variation among a set of temporally ordered interbeat intervals. The state of perfect symmetry, which, in medical parlance, is called respiratory sinus arrhythmia (RSA), can be described as a state of cardiac coherence. Obtaining a series of interbeat intervals requires a continuous measure of heart rate, typically electrocardiography (ECG). Commercially available software is then used to define the interbeat intervals within an ECG recording. ⋯ The autonomic nervous system is highly adaptable and allows the organism to maintain its balance when experiencing strain or stress. Conversely, a lack of flexibility and a rigid system can lead to somatic and psychological pathologies. Several studies have shown a link between reduced HRV in postmyocardial infarction patients and increased risk for adverse cardiovascular events, including ventricular arrhythmias and sudden death. Recently, studies indicate that patients with depression and anxiety disorders exhibit abnormally low HRV compared with non-psychiatric controls. Reduced HRV seems indicate decreased cardiac vagal tone and elevated sympathetic activity in anxious and depressive patients and would reflect deficit in flexibility of emotional physiological mechanisms. A few studies have also revealed that biofeedback using respiratory control, relaxation and meditation techniques can increase HRV. For now, there is insufficient data to determine if paced respiration or subjective relaxation is necessary or sufficient for the efficacy of HRV biofeedback. Although the literature is modest, this review suggests that the use of biofeedback with relaxation and meditation approaches may result in increased HRV and parasympathetic activity. Limitations of the review literature have also been considered to identify areas for future research.
-
Many studies have stressed the importance of neurocognitive deficits in schizophrenia that represent a core feature of the pathology. Cognitive dysfunctions are present in 80% of schizophrenic patients, including deficits in attention, memory, speed processing and executive functioning, with well-known functional consequences on daily life, social functioning and rehabilitation outcome. Recent studies have stressed that cognitive deficits, rather than the positive or negative symptoms of schizophrenia, predict poor performance in basic activities of daily living. If it is possible to reduce psychotic symptoms and to prevent relapses with antipsychotic medication, it is not yet possible to have the same convincing impact on cognitive or functional impairments. Cognitive remediation is a new psychological treatment which has proved its efficacy in reducing cognitive deficits. A growing literature on cognitive rehabilitation suggests possibilities that in schizophrenia, specific techniques are able to enhance an individual's cognitive functioning. ⋯ Indeed, learning potential could represent a good cognitive predictor and indicator for rehabilitation in schizophrenia for clinicians and should be used in cognitive assessment practice. However, the individuals most likely to benefit from cognitive remediation, and whether changes in cognitive function translate into functional improvements, are as yet unclear.
-
The International Association for the Study of Pain (IAPS), in 1986, defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage". Thus, the few studies on this phenomenon conducted on schizophrenic patients did not result in a firm consensus; certain studies showed that such patients seemed to have a higher threshold against pain (hypoalgesia) than healthy subjects, whilst other studies showed that the threshold is the same, but the absence of expressing the pain would be due to the pathology itself (non-expression of the pain, denial). Insensitivity to pain would be the consequence of a complex reaction between a biological sensorial abnormality and the psychopathology of schizophrenia itself (including the affective processes). Hence, various hypotheses referring to biological, psychological and sociological mechanisms have been proposed. ⋯ THE REALITY: Schizophrenic patients have a sensitivity to pain which is identical to that of healthy subjects. The apparent analgesia would be the result of a denial "attitude", a different manner of expressing pain in relation with the non-verbal communication difficulties, and not an alteration in the brain functions nor a biological anomaly. Diverse methodological biases arise from the studies of pain in patients with schizophrenia.
-
To establish the social, clinical, and forensic differences between murderers suffering from a major mental disorder and murderers without any psychiatric disorder and, in particular, to compare their respective records of psychiatric symptoms and their respective relationship with their victims. ⋯ The main difference between murderers with a major mental disorder and murderers without any mental disorder is the psychopathology of the morbid process which underlies the homicide. Impairment of judgment at the time of the crime should be taken into account. As a clinician, we should focus our attention on general risk factors of violence and homicide (male, young, underprivileged class, abuse of alcohol) and on more specific factors (mental disorder co-morbidities...). To these factors should be added the dynamic characteristics of the meeting of the protagonists.
-
Practice Guideline
[Drawing up guidelines for the attendance of physical health of patients with severe mental illness].
Having a mental illness has been and remains even now, a strong barrier to effective medical care. Most mental illness, such as schizophrenia, bipolar disorder, and depression are associated with undue medical morbidity and mortality. It represents a major health problem, with a 15 to 30 year shorter lifetime compared with the general population. ⋯ Patients on antipsychotic drugs should undergo regular testing of blood sugar, lipid profile, as well as body weight, waist circumference and blood pressure, with recommended time intervals between measures. Clinicians should track the effects of treatment on physical and biological parameters, and should facilitate access to appropriate medical care. In order to prevent or limit possible side effects, information must be given to the patient and his family on the cardiovascular and metabolic risks. The cost-effectiveness of implementing these recommendations is considerable: the costs of laboratory tests and additional equipment costs (such as scales, tape measures, and blood pressure devices) are modest. The issue of responsibility for monitoring for metabolic abnormalities is much debated. However, with the prescription of antipsychotic drugs comes the responsibility for monitoring potential drug-induced metabolic abnormalities. The onset of metabolic disorders will imply specific treatments. A coordinated action of psychiatrists, general practitioners, endocrinologists, cardiologists, nurses, dieticians, and of the family is certainly a key determinant to ensure the optimal care of these patients.