Céline BALZANI

L'objectif de cette thèses est double. Le premier objectif est de fournir une définition élargie de la conscience, qui puisse être viable dans une perspective médicale, et être enrichie à la fois par les données actuelles des neurosciences, par les courants de pensée philosophiques, et par le débat conceptuel entre ces disciplines. Dans un cadre neurophysiologique, cette définition devra nécessairement intégrer le concept de vigilance, puisque l'éveil apparaît comme un des éléments principaux de mise en disposition de la conscience. Ce propos permettra de préciser en quoi vigilance et conscience ne sont pas strictement corrélés. Le deuxième objectif de cette thèse est d'étudier certaines dégradations pathologiques de la conscience, afin qu'elles puissent mettre en évidence les facteurs physiopathologiques qui mettent en péril son maintien. Nous choisirons dans un premier temps de détailler la dégradation quantitative de la conscience représentées par la catégorie nos...

L’apprentissage et la pratique de la medecine posent des questions qui ne relevent pas uniquement du savoir medical biopsychosocial et de la pratique reglee sur ce savoir. Ces questions impliquent en effet le vecu subjectif et des experiences du patient comme du medecin [1]. Du cote du patient, on peut notamment soulever les questions importantes du sentiment de bonne sante, comme de l’acceptation et de l’engagement dans les therapeutiques ne correspondant pas forcement a ses representations et pouvant n’etre pas comprises voire s’averer angoissantes [2]. Du cote du medecin, on peut soulever les questions de l’apprentissage du diagnostic, de l’evaluation du pronostic et de la decision therapeutique, mais egalement de la conduite pratique des therapeutiques et de l’accompagnement du patient [3].

Explicitation interview, as a help of verbalization of the action by the subject himself, has been developped by P. Vermersch, who laid the theorical and practical guidelines. In this article, we offer to consider the potential contributions of this method to medical practice, especially psychiatry, but also in first-person approaches in neurosciences. We take side for phenomenological perspective, which gives primacy to the experience of the subject. Initially, we question the medical experience, through the importance of subjectivity in clinical practice. In a second time, we detail the methodology for conducting the explicitation interview and to guarantee its quality. Finally, we consider the epistemological and philosophical aspects inherent in the practice of this interview and the questions it raises about the structure of our

Le biofeedback (ou therapie par retrocontrole biologique) est un procede psychophysiologique d’enregistrement informant en temps reel sur le niveau de fonctionnement d’un systeme physiologique donne. Il permet de developper diverses strategies d’ajustement perceptivo-cognitives, affectives et comportementales. Il augmente le sentiment de controle percu du patient par la boucle psychophysiologique retroactive que cette technique met en place. Ce sentiment de controle percu est une variable importante en psychologie de la sante, qui s’integre dans le necessaire developpement de la prescription de therapeutiques non medicamenteuses validees dans le contexte des maladies chroniques et dans le modele integratif de la maladie et de la sante. Nous proposons ici une synthese des niveaux de preuve d’efficacite du biofeedback, dans les differents domaines de la medecine.

La loi du 5 juillet 2011, apres un large debat, a reforme les conditions des soins psychiatriques sans consentement. Le praticien non psychiatre est souvent celui qui initie la procedure. En etablissant les certificats medicaux prevus par la loi, il engage sa responsabilite. Cet article vise a apporter le plus clairement possible quelques reperes dans les nouvelles modalites legales et a repondre aux questions les plus couramment soulevees lors de la redaction des certificats.

Event related potentials (ERP’s) constitute a large research field in psychiatry, based on neurophysiology. In this short review, we present the ERP’s theorical framework, the different recording methods, and the signification of these ERP’s; P50 with gating, P300, N400, P600 and contingent negative variation. We emphasize the ERP’s chronometry, the reaction times, and late positive components. At last, we propose cognitive neurophysiological profile based on the variables obtained in the various ERP’s.

Mild traumatic brain injury (MTBI) constitutes a public health problem with major socioeconomic consequences (Maas, Stocchetti, & Bullock, 2008). The notion of post-concussion syndrome (PCS) following MTBI is now a well-described (Borg et al., 2004) and extensively discussed concept (Rees, 2003; Wood, 2007). However, current standard imaging (mainly MRI) techniques rarely reveal abnormalities, and the consequences of diffuse axonal damage are difficult to document. For these reasons, PCS is often considered to be either psychogenic in origin (Whittaker, Kemp, & House, 2007)ora fallacious pretext for financial compensation. However, it is clear that new MR imaging methods such as MRI diffusion anisotropy (Belanger, Vanderploeg, Curtiss, & Warden, 2007; Maller et al., 2010) and magnetic resonance spectroscopy (MRS; Garnett et al., 2000; Govindaraju et al., 2004) can reveal structural and metabolic white matter abnormalities in connection with post-concussion symptoms, including depression (Maller et al., 2010). A significant proportion (5-7%) of patients with MTBI present a later cognitive decline (Hammond et al., 2004). Recent studies conducted on 2525 U.S. soldiers exposed to blasts and who suffered MTBI clearly reveal the neurological correlates of PCS and indicate that PCS is closely associated with loss of consciousness during the trauma (Hoge et al., 2008). The link between cognitive deficits related to PCS and impairment of brain connectivity, particularly in frontal regions, has been recently demonstrated (Sponheim et al., 2011).Apart from a few music-related pathologies (congenital amusia, musicogenic epileptic seizures), few studies have reported abnorCeline malities of listening to or producing music in neurological and psychiatric pathologies (Vion-Dury & Besson, 2010). However, throughout human history, billions of human beings have created and listened to sound patterns and sequences that do not carry any denotative meaning (Sacks, 2008). In this respect, Andrade and Bhattacharya (2003) proposed that the brain is tuned to music. Although many studies emphasize the value of music therapy in patients with various neurological and psychiatric diseases, the scientific literature exploring changes in the quality of music listening is sparse. Sacks presented many clinical examples related to this issue (Sacks, 2008), but only a few examples of any given pathology are available to the best of our knowledge.The current study stems from a clinical observation: during individual interviews prior to neurophysiological assessment of PCS following an MTBI, several patients reported an experience of time disruption, with alterations of their capacity to evaluate durations and the feeling of being disoriented in time. This led us to question them about changes in their music listening habits because music can be regarded as an "art of time" (Emery, 2000); thus, its appreciation requires precise processing of temporal structures at different time scales (Accaoui, 2001). Following the question "Has your way of listening to music changed since your brain trauma?", patients remained silent for several seconds. Then, they reported being aware that their music listening habits had changed. However, they were unable to accurately describe this modification. This recurrent clinical observation gave rise to this study, the aim of which was to assess musicrelated changes in patients suffering from MTBI, by combining both objective and subjective data experienced in the "firstperson," according to the neurophenomenological approach (Vion-Dury, 2007; Vion-Dury et al., 2011) and by analyzing if these music-related changes are correlated to any abnormality in imaging, neuropsychological, or neurophysiologic evaluation.MethodSubjectsThis study took place during a global assessment of the PCS diagnosis in MTBI patients, as organized by the Groupe d'Etudes des Professionnels Alpes-Mediterranee sur les Traumatismes Crâniens (GREPAM-TC), from October 2008 to June 2009 (Soriat-Barriere, Tcherniack, & Vion-Dury, 2011). …

Apres une presentation rapide de la philosophie phenomenologique et de son cadre applicatif a la psychiatrie, cet article fait une revue des quelques textes en francais sur la phenomenologie des processus dementiels, apres avoir tente de comprendre pourquoi les demences ont ete « oubliees » par la psychiatrie phenomenologique. Les deux auteurs etudies sont Minkowski, qui insiste sur le fait que la demence est une maladie de la temporalite, et Tatossian qui considere que la demence est un trouble de la conscience de soi (self-awareness) et de l’auto-organisation du comportement. Tatossian suggere aussi que la demence frontale est la demence prototypique et la demence d’Alzheimer un cas particulier de demence avec troubles de la memoire.

Dans le second volet de cette etude, plus particulierement consacre a la maladie d’Alzheimer, nous aborderons la phenomenologie de cette demence dans une premiere perspective, husserlienne. Dans la maladie d’Alzheimer, du fait de la disparition de conscience de soi (« self awareness »), et de la perte de la fonction superieure de synthese, la conscience pre-reflexive est mise a nu, et l’« awareness » separee de son « self ». La perte de la spatialite et de la temporalite ramene le patient dans une decouverte continuelle du chaos primordial. Dans une perspective heideggerienne, nous proposons ensuite que la maladie d’Alzheimer se presente phenomenologiquement comme un double estompement : estompement de l’etre-le-plus-propre et estompement de l’etre au monde. Enfin la disparition du langage nous amene a penser, suivant Heidegger, la disparition de la maison de l’etre.

Event related potentials (ERP’s) constitute a large research field in psychiatry, based on neurophysiology. In this short review, we present the ERP’s theorical framework, the different recording methods, and the signification of these ERP’s; P50 with gating, P300, N400, P600 and contingent negative variation. We emphasize the ERP’s chronometry, the reaction times, and late positive components. At last, we propose cognitive neurophysiological profile based on the variables obtained in the various ERP’s.

Epidemiological studies of major depressive episodes (MDE) highlighted the frequent association of symptoms or signs of mania or hypomania with depressive syndrome. Beyond the strict definition of DSM-IV, epidemiological recognition of a subset of MDE characterized by the presence of symptoms or signs of the opposite polarity is clinically important because it is associated with pejorative prognosis and therapeutic response compared to the subgroup of "typical MDE". The development of DSM-5 took into account the epidemiological data. DSM-5 opted for a more dimensional perspective in implementing the concept of "mixed features" from an "episode" to a "specification" of mood disorder. As outlined in the DSM-5: "Mixed features associated with a major depressive episode have been found to be a significant risk factor for the development of bipolar I and II disorder. As a result, it is clinically useful to note the presence of this specifier for treatment planning and monitoring of response to therapeutic". However, the mixed features are sometimes difficult to identify, and neurophysiological biomarkers would be useful to make a more specific diagnosis. Two neurophysiological models make it possible to better understand MDE with mixed features : i) the emotional regulation model that highlights a tendency to hyper-reactive and unstable emotion response, and ii) the vigilance regulation model that highlights, through EEG recording, a tendency to unstable vigilance. Further research is required to better understand relationships between these two models. These models provide the opportunity of a neurophysiological framework to better understand the mixed features associated with MDE and to identify potential neurophysiological biomarkers to guide therapeutic strategies.

La surveillance électroencéphalographique (EEG) des séances d’électroconvulsivothérapie (ECT) est indispensable mais nécessite une connaissance minimale de la neurophysiologie et de la lecture de l’EléctroEncéphaloGramme (EEG) par le psychiatre. La lecture de l’EEG pendant les ECT nécessite un œil formé à la reconnaissance sur le tracé EEG de certaine forme spécifique, associée à l’utilisation d’un vocabulaire de description rigoureux. Ce poster a pour objectif de fournir une méthode illustrée de lecture de l’EEG pendant les ECT. Premièrement, les artefacts du signal EEG doivent être reconnus pour ne pas les confondre avec des activités épileptiformes. Deuxièmement, le déroulement de la crise doit être reconnu et décrit en phase : pré-critique, critiques (précritique, recrutante, tonique et clonique) et post-critique. Troisièmement, la qualification de la crise doit être posée par l’utilisation des termes de crise épileptique adéquate, optimale et prolongée. Cette démarche de lecture EEG pendant la séance ECT permet de détecter une crise épileptique prolongée afin de diminuer le risque à court terme d’état de mal épileptique post-ECT et à moyen terme le risque de mauvaise tolérance cognitive de la cure ECT. Elle permet également d’adapter de manière optimale les paramètres de stimulation à la prochaine séance d’ECT afin de maximiser l’efficacité des ECT. La lecture de l’EEG pendant les ECT ne résume pas l’entièreté de la conduite des cures ECT en psychiatrie. Cependant elle reste une démarche indispensable à l’aide à la prise de décision et souligne la place centrale que peut prendre la neurophysiologie clinique dans une stratégie thérapeutique psychiatrique.

ABSTRACT Conventional electroencephalogram (EEG) is an essential non-invasive technique to determine the physiological and functional brain status. EEG is worthy of interest (i) for the diagnosis of neurological diseases in psychiatric syndromes and (ii) for the monitoring of possible iatrogenic effects of some psychiatric treatments: electroconvulsive therapy (ECT), antipsychotics (particularly clozapine), lithium and tricyclic antidepressants. The purpose of this article is to provide a basic knowledge to psychiatrists about the EEG signal and its origin, the special techniques used in psychiatry and EEG vocabulary description, in order to precise the best prescriptions of it and to understand the reports in their daily clinical practice. The relevance of the conclusion of an EEG requires an electro-clinical confrontation that involves a good knowledge of psychiatry by neurophysiologists and a good knowledge of EEG by psychiatrists. This complementary approach associated with an easy EEG accessibility in psychiatry allows this examination to keep an essential place for quality of health care of patients with mental disorders.

ABSTRACT Explicitation interview, as a help of verbalization of the action by the subject himself, has been developped by P. Vermersch, who laid the theorical and practical guidelines. In this article, we offer to consider the potential contributions of this method to medical practice, especially psychiatry, but also in first-person approaches in neurosciences. We take side for phenomenological perspective, which gives primacy to the experience of the subject. Initially, we question the medical experience, through the importance of subjectivity in clinical practice. In a second time, we detail the methodology for conducting the explicitation interview and to guarantee its quality. Finally, we consider the epistemological and philosophical aspects inherent in the practice of this interview and the questions it raises about the structure of our consciousness.