Schizophrenia

Historical reference marks

As of -2000, the Papyrus Ebers in the Book of the hearts list its Symptoms. The Greek literature of civilizations and Roman refer there without indicating how they were treated.

Historically, the psychiatrist Emil Kraepelin is the first to make the distinction between the Dementia praecox described 50 years before him by Bénédict Augustin Morel, and the other forms of madness. It is then famous schizophrenia by the psychiatrist Eugen Bleuler when it became obvious that the designation of Kraeplin is not an adequate description of the disease.

It is in 1898 that Emil Kraepelin, speaking about dementia praecox, finds three variations:

the Hébéphrénie ( hébé = adolescence, phrên = thought ): qualify an intense disintegration of the personality;
the Catatonie: the most serious form;
the paranoid form : the least serious form, resting on Hallucination S.

In 1911, Eugene Bleuler uses the term of schizophrenia, and proposes five symptoms:

the disorder of the association of the ideas;
the disorder of the Affectivity;
the loss of contact with reality;
the Autism (in the direction of the autistic fold);
the dissociative Syndrome.

=== Epidemiology ===

Schizophrenias touch 1% of the world population, without notable variations of a country, culture or one time to another. Heredity is a factor which increases the risk as the genetic luggage increases. Thus, the incipient child sees his risk increasing: 5% if it has a relative of the second degree (uncle, aunt, cousin, cousin) which suffers from schizophrenia; 10% if it has a relative of the first degree (father, mother, brother, sister); 10% if it has a different twin who suffers from schizophrenia; 40% if he is child of two schizophrenic parents; 50% if it has an identical twin who suffers from schizophrenia.

According to certain studies with large scales, they would be more widespread in the big cities. These diseases, which generally appear at old subjects from 15 to 35 years, thus represent an main issue of public health.

Some generally accepted ideas

The schizophrenia term, introduced initially by Bleuler, means literally: “ spirit cut ”. Associated with the frequent representation in the Anglo-Saxon cinema characters presenting of the multiple personalities, this etymology supports a rather widespread confusion in the general public between schizophrenia and dissociative Trouble with multiple personalities.

In addition, part of press general practitioner has taken practice to associate schizophrenias and behaviors dangerous or Hétéroagressif S. Actually, although it happens indeed that schizophrenic patients have dangerous drivings, that remains relatively rare. The rate of acts of violence is not higher within the schizophrenic population than within the total population. Lastly, the affection is a factor of vulnerability in oneself and it thus exposes the schizophrenes to social violence: the statistics show that the latter have an life expectancy less raised than that of the total population.

Diagnosis

The diagnosis of a schizophrenia rests on the observation by the psychiatrist of indirect signs primarily related to dissociation, and thus their setting in prospect with the lived psychic one brought back by the patient. This diagnosis can possibly be supplemented by tests neuropsychological S. It does not exist biological screening test or of medical imagery making it possible to emit a positive diagnosis of schizophrenia. The realization of in particular somatic complementary assessments is essential, in particular at the beginning of pathology, in order to pose the diagnosis, but also during the evolution of the disease.

Catégoriel diagnosis

The diagnostic criteria used can be those of international classifications: DSM and international Classification of the diseases CIM-10. In this case the diagnosis rests on the collection of a list of clinical symptoms which must be joined together so that a person is " qualifiée" of schizophrene; all depends at the same time on the presence and of the duration of some sign S or Symptôme S.Y also intervenes of the subjective elements in a given relational context, thus the bizarrery " interprète" in a relational context where the felt subjective one of the clinician intervenes.

The estimate of the symptoms of schizophrenias as of the other mental affections is always to put in prospect with the social context, family and cultural of the subject. Indeed certain bizarreries, or speeches can for example know a social variability.

Thus, it is banal for the clinicians that references to phenomena which can seem delirious in France can testify to a depression for a subject strongly registered in the Maghrébine culture (of the fact for example of the use of the dialectical Arabic impoverished on the semantic level compared to the language classical Arabic in the chapter of descriptions of the states of heart, as by the influence of Mektoub which can move the culpability apart from the individual sphere).

In DSM-IV, these criteria are:

A) Symptoms caractéristiques' :

These symptoms can be present in an isolated or associated way, and an evolution of more than six months of symptomatology makes it possible to propose a diagnosis which in addition requires to eliminate a organicity. The turbid cognitifs' are often the primary symptoms which appear at the schizophrene. They are called also symptoms heralding. These are the disorders which involve the difficulties of socialization at a person reached.

Turbid of attention, of concentration, misses tolerance with the effort: The schizophrene takes time to answer the questions, to react to the situations asking for a prompt response. It is not able any more to follow its courses, to concentrate on a film.
Turbid of memory: The schizophrene forgets to make tasks of the daily life (to make its duties, to go to its go), has difficulty in tell what it reads, to remember what the others say or to follow a conversation. Its autobiographical memory is affected: he forgets several moments of his personal history. Its working memory functions with difficulty: the weather is unable to be several tasks at the same time by remembering where it is returned in each one of them.
Turbid of the executive functions: The executive functions are essential with any directed, autonomous and adapted behavior, like preparing a meal. The schizophrene has difficulty in conceptualize the gestures necessary to the realization of a task, to anticipate the consequences; it misses planning, of organization of the sequences of actions to achieve a goal and also misses flexibility, of understanding, checking, self-criticism.

Whereas they are presented in first, these symptoms heralding will persist longer than the acute symptoms.

The acute symptoms (positive) usually appear at the beginning of the adulthood, between 17 and 23 years at the men and between 21 and 27 years among women. They are known as “positive” because they are demonstrations which are added to the normal mental functions. It is their presence which is abnormal.

Hallucinations: They are disturbances of generally auditive perceptions (the schizophrene hears a voice which makes comments or utters insults, threats), but sometimes also visual, olfactive or tactile.
Be delirious: They are error of judgments logical. The schizophrene thinks that the person who looks it in the bus or who crosses it in the street is there for the espionner; he feels supervised, persecuted, in danger or believes that television sends messages to him; it is convinced to have the capacity to influence the events in the world, which it is controlled by a force or which one can read in his thoughts, etc
incoherent Langage: The schizophrene known as of the sentences without continuation or incomprehensible and invents words.
odd Intrigues: The schizophrene closes the blinds of the house by fear to be a spy; it collects empty water bottles; he walks naked in the street, etc

The overdrawn symptoms (negative) are observed by a lack or an absence of spontaneous behaviors, awaited.

Insulation, social withdrawal: The schizophrene loses pleasure with his activities of leisures. He forsakes his friends, withdraws himself in his room, becomes even irritable if one tries to approach it. He cuts little by little reality.
Alogie or difficulty of conversation: The schizophrene does not find any more his words, gives answers short and evasive and does not succeed in any more communicating its ideas or its emotions.
Apathy, loss of energy: The schizophrene spends his days in front of the TV without really being able to follow what occurs there, it neglects his hygiene or his personal appearance and misses persistence or of interest to begin or complete routine tasks (studies, work, household). This attitude gives an impression of unconcern, negligence, lack of will and idleness.
Reduction in the expression of emotions: The face of the schizophrene becomes inexpressive, his vocal inflections decrease (he always speaks on the same tone), its movements are less spontaneous, its gestures, less conclusive.

social B) Dysfonctions or of professional occupation:

So for a significant length of time since the beginning of the disorders, one of the fields related to the social relations like the community activity, the interpersonal relationships or hygiene, is definitely reduced compared to the former situation.

C) Duration:

the continuous signs of the disorder persist for at least six months: this period must include at least a month of symptoms (or less in the event of successful treatment) corresponding to the criteria of the type has .

One can start to count, for example, five sub-types of schizophrenia:

standard catatonic (with rare or put out of order movements);
standard hebephrenic (where the autistic fold prevails);
standard paranoid (where the hallucinations and/or is delirious it more or less badly structured prevail);
standard dysthymic (with major disorders of mood);
standard heboidophrenic (pseudo psychopathic).

Dimensional model

One can think, as recently Richard Bentall in his book Madness explained: psychosis and human natural , appeared in 2003, that schizophrenia is only one limiting spectrum of the experiment and behavior, and that all those which live in company can have some experiences in their life of them. That is known like the continuous model of the psychosis .

Clinical presentation

Schizophrenias are characterized clinically by psychic dissociation and the presence, in variable proportion, of Symptôme S known as “ positive ” and “ negative ”. This classification was introduced by Andreassen into the Années 1980. The positive symptoms, thus named because being added to the experiment of reality and the usual behaviors, include/understand the semiological elements common to the states acute psychotics: delirious ideas and Hallucination S, as well as the cognitive disorders gathered under the term of disorganization or disorders of the course of the thought. The negative symptoms are thus named because they reflect the decline of the normal functions and result in a deterioration of the complex cognitive functions of integration: deterioration of the mnemic functions, difficulties of concentration, poverty of the spontaneous language, the driving behavior: abulia, amimy, apragmatism, but also of social or emotional operation: deterioration of the life of relation, abrasement of the affects and motivation (Athymhormie). Because of the great number of possible different combinations between these symptoms, thus leading to varied clinical forms, some schizophrenia as a syndrome, clinical translation of multiple pathologies regard and not like a single pathology.

The psychiatrist Kurt Schneider tried to index the particular forms of the symptoms psychotics which could produce the Psychose S. They are called symptoms of first rank and include/understand the impression to be controlled by an external force, not to be a Master of his thought more, flight of the thought, the echo and comments of the thought, impression that the thought is transmitted to other people, the perception of voice commenting on the thoughts or the actions of the subject, or to have conversations with other voices hallucinated all in all what concerns the mental automatism of G.G of Clérambault.

Differential diagnosis

One can note that several of the positive symptoms or psychotics can intervene in many disorders and not only in schizophrenias. Schizophrenias are different from the other chronic psychoses by the associative relaxation, the diffluence of the psychic processes and the relaxation of the thought, is delirious it itself often fuzzy and is badly organized.

To pose the diagnosis, it is important to seek the manifestations of dissociation. Not to confuse with the term of dissociation introduced by Anglo-Saxon classifications to try to remove hysteria because description " objective" of this last installation problem.

It is also advisable to eliminate from the organic causes for example: In particular toxic (for example: chronic intoxication with the cannabis and its amotivationnelles consequences…), the epilepsy, the presence of a Tumor with the brain, the disorders endocriniens thyroid, just as of other physical affections which cause symptoms apparently similar to those of schizophrenia, the such Hypoglycémie and the Maladie of Wilson. It also should be established clearly that of a bipolar Trouble or of any other psychosis or irrational syndrome it is not a question. Lastly, some personality disorder can be misleading for the laymen or at the beginning of evolution.

Early diagnosis

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Forms of schizophrenia

One can also distinguish several even intricate rather polymorphic forms coarsely from them:

simple schizophrenia. The negative symptoms are in the foreground: impoverishment of the socio-professional relations, tendency to insulation and the autistic fold in an interior world. There is little or not delirious symptoms. This form evolves slowly but very often to a more and more marked deficit.
the paranoid schizophrenia. It is the most frequent form of schizophrenia. Is delirious and the hallucinations dominate the clinical picture and the subject generally answers the antipsychotic treatments.
the hebephrenic schizophrenia. The dissociation of the psychic unit of the subject is prevalent. It is the form most resistant to the therapeutic ones. This form of schizophrenia touches mainly the teenagers.
the catatonic schizophrenia. The patient is like fixed physically and preserves the attitudes that one imposes to him, like a wax headstock. He is locked up in a dumbness or always repeats the same sentences. Currently, this form is treated and been thus seldom final.
the dysthymic schizophrenia (schizo-emotional). The acute accesses have the characteristic to be accompanied by depressive symptoms, with suicidal risk, or contrary to symptoms maniacs. These forms answer at least partly the treatments by lithium.
pseudonevrotic schizophrenia. It associates symptoms of schizophrenia and important symptoms of neurosis (hysterical, phobic, anxious or obsessional).
the pseudo-psychopathic or “heboidophrenic” schizophrenia. This state is regarded as a disorder in pre-schizophrenic matter where the teenager has important behaviors of opposition towards his entourage in the presence of disorder of the thought, delirious phases and impulsiveness. It then coexists of the passages to the act very violent one and the dissociative symptoms like a great emotional coldness.

According to the DSM-IV-TR, schizophrenia is divided into 5 types:

Standard paranoid: See catatonic Ci-high
Standard: See Standard Ci-high
disorganized: The disorganized speech, the behaviors disorganized and the abraded or inappropriate affect take all the place of the clinical picture. Great family incidence with an unfavorable forecast.
Standard undifferentiated: The key symptoms of schizophrenia are present and the general criteria are reached without returning in a particular type (paranoid, catatonie, disorganized).
Standard residual: The absence of active positive symptoms (hallucination, is delirious, behavior and disorganized speech) is characteristic as well as the presence of certain attenuated elements (strange beliefs) or of negative symptoms (apathy, social insulation, loss of pleasure and interest, etc).

Bio-psycho-social model etiologic

It is about a multifactorielle pathology leading to a disorder of a neuropsychiatric nature (deterioration of cerebral and relational operation). It is estimated that it is a mixture of genetic predispositions (tendency family or individual attached to the genome) and environmental predispositions (emotional environment, history and personal trajectory, hygiene of life, marital status, environment or stressing recurring situation), an event significant for the subject and possibly endogenous or of alleviating appearance will constitute a particularly acute kind of Stress and then will play part of release generating the crisis.

One thinks that the first phases of development of the individual are determining, in particular during the fetal stage and at the time of the interaction early with the mother (it is a restrictive interpretation of the latter point which could strongly lead to a speech culpabilisator with regard to the families). One will note, for memory, the place of the Dopamine in the cerebral circuit mesolimbic. The role of the Dopamine in this disease was proposed starting from the observation of the improvement of the delirious symptoms and of dissociation with the use of the Neuroleptique S at the time of their discovery, this wheel intervenes but is only one aspect of a very complex conjunction of factors. Thus the plan neurochimic well of others Neuromédiateur S exploits of the role in schizophrenia such as for example the Sérotonine. Each time a new lighting is related to one of them its implication in the psychic life is greedily explored by the researchers in all the fields of psychopathology, of course.

Genetic factors and environmental

Genetics

Statistically, it is observed that at the men the disease is clinically declared during the end of adolescence, whereas for the women that is sometimes later, that the oldest sons or single are statistically more affected. None of these arguments pleads in favor of a genetic cause.

It is noted however that the inheritance of an individual gives predispositions to this disease: on identical twin, in the case of a schizophrenic person, her twin has 40% of risk to be it too. In the same way, the probability of being reached is higher in the event of attack of a case in the same family.

Certain genes were identified as marker of risk, like NRG1 or DTNBP1 .

Environmental

Certain environmental factors contribute to the release of the disease in particular in the first weeks of the development. This point of view insists on the fact that it is not the order in which the symptoms appear, order very difficult to prove, but the result which can be compared: Without interference of cannabis, the person has 4x less risk to find victim of schizophrenia.

These studies are supplemented by other studies which establish a possible relation between schizophrenia and cannabis, without defining the symptom psychotic as a preliminary but enumerates of them the symptoms for then connecting them to schizophrenia, which can constitute a form of skew. In addition, one belongs to other contradictory studies. It is thus mentioned that the use of the cannabis being in great increase since the Années 1980, if a true correlation existed with schizophrenia, one should have seen the same curve of increase in the diagnoses.

At all events, at present of research, according to the Inserm the use of cannabis thus seems one of the very many factors of causality (neither necessary, nor sufficient) which accompanies occurred by schizophrenia without affecting the favorable evolution of way of it, quite to the contrary these products worsen certain symptoms. Taking into consideration study analyzed by the experts, it appears nevertheless that all the people exposed to the cannabis will not become schizophrenic.

Neurobiology

Early anomalies neuro-développementales

One also considers that processes related to the early development of the nervous system are important, in particular during the pregnancy. For example, of the women who were pregnant during the severe famine of 1944 in the Netherlands presented an increased risk for their child to develop the disease later. In the same way, of the studies compared Finnoises mothers having learned death from their husband with the Guerre of Winter of 1939-1940, whereas they were pregnant, with mothers having learned death from their husband after the pregnancy. These studies showed in the first case a strongly increased risk for the child to develop the disease, which suggests that even a psychological traumatism in the mother can have a harmful effect. Moreover, there exist now clear indications that a antenatal exposure to viral or bacterial infections increases the risk of appearance of schizophrenia, confirming the existence of a bond between a pathology développementale and is likely it to develop the disease.

Certain researchers suggest that it is an interaction between environmental factors at the time of childhood and the neurobiologic risk factors which determines the probability of developing schizophrenia with a later age. It is considered that the neurological development of the child is sensitive to elements characteristic of a disturbed social framework such as the trauma, the Violence, the lack of heat in the personal contacts or the hostility. Each one of these elements was identified as risk factor. Research suggested that the favorable or unfavourable effects of the environment of the child interact with the genetic determinants and the development processes of the nervous system, with long-term consequences for the operation of the Cerveau. This combination of factors would play a part in the vulnerability with the psychosis which appears later at the adulthood.

Dopaminergique model

The schizophrenic disorders are frequently attached to a dysfunction of the mesolimbic dopaminergique way. This theory, known under the name of " dopaminergique assumption of the schizophrénie" , is based on the fact that the majority of the substances with antipsychotic properties have an action on the system of the Dopamine. It is the fortuitous discovery of a class of drugs, the Phénothiazines, which is at the origin of this discovery. The antipsychotic drugs or Neuroleptiques acting inter alia on the dopaminergique system were the subject of later developments and remain a treatment running of first indication.

However, this theory is currently regarded as too simplifying and incomplete, in particular owing to the fact that new drugs (atypical antipsychotic ), like the Clozapine, are as effective as the older drugs (or antipsychotic typical), the Halopéridol. However this new class of molecules also has effects on the system of the Sérotonine, and could be one blocking a little less effective receivers with the dopamine. According to the psychiatrist David Healey, pharmaceutical companies would have encouraged too simple biological theories to promote the treatments of biological nature which they propose.

Role of Glutamate and receivers NMDA

The interest also went on another neuro-transmitter, the Glutamate, and on the decreased function of a particular type of receiver to glutamate, the Récepteur NMDA. This theory originates in the observation of abnormally low levels of receivers of the type NMDA in the brain of examined schizophrenic patients post-mortem, and the discovery that substances blocking this receiver, like the Phencyclidine or the Kétamine, can mimer at the healthy subject of the symptoms and the disorders Cognitif S associated with the disease. L'" assumption glutamatergique" schizophrenia becomes currently increasingly popular, in particular because of two observations: on the one hand the system glutamatergic can act on the dopaminergique system, and on the other hand a reduced glutamatergic function could be associated with a low performance level with tests which require the operation of the hippocampus and the frontal Lobe, which one knows that they are implied in schizophrenia. This theory is also supported by clinical trials showing that molecules which are Co-agonistes of the complex associated with receiver NMDA are effective to reduce the schizophrenic symptoms. Thus, the Amino-acid D-serine, glycine and D-cyclosérine facilitate the function of receiver NMDA thanks to their action on the site Co-agoniste receiving the Glycine. Several clinical trials controlled by placebo, and aiming at increasing the concentration of glycine in the brain, showed a reduction mainly negative symptoms.

Neurophysiological data and cerebral imagery

With the recent development of the techniques of medical imagery, much of work are devoted to differences of structure or function in certain cerebral areas among schizophrenes.

It was believed a long time that the brain of the schizophrenes was of primarily normal appearance. The first indications of differences structural came of discovered from a widening from the cerebral ventricles among patients whose negative symptoms were particularly marked. However, this result hardly proves usable at the individual level because of great variability observed between the patients. A bond between ventricular widening and an exposure to the antipsychotic drugs was suggested.

More recent studies showed that there exist many differences in the cerebral structure according to whether the people present or not a diagnosis of schizophrenia. However, like in the case of the former studies, the majority of these differences are detectable only when one compares groups and not individuals.

Studies implementing neuropsychological tests combined with techniques of cerebral imagery like the Imagery by functional magnetic resonance (IRMf) or the tomography by emission of positons (Mtoe) sought to highlight functional differences in cerebral activity among patients. They showed that these differences more frequently occur on the level of the frontal lobes, of the hippocampus and the temporal lobes. These differences are strongly related to the cognitive deficits frequently associated with schizophrenia, in particular in the field of the memory, the attention, the solution to problem, the executive functions and social cognition.

Electroencephalographic recordings (EEG) schizophrenic people at the time of tasks to dominant perceptive showed an absence of activity in the waveband gamma (high frequencies), who would indicate a weak integration of critical neuronal circuits of the brain. The patients presenting of the intense Hallucinations, the illusory beliefs and a disorganization of the thought also had the synchronization moreover low frequency. The drugs taken by these people did not allow a return of the rate/rhythm towards the frequency band gamma. It is possible that deteriorations of the band gamma and the Working memory are related to deteriorations of the inhibiting interneurones producing acid gamma-aminobutyrique (GABA). One observed in the schizophrenic Cortex préfrontal dorsolatéral of patients a deterioration of a particular subclass of interneurones GABAergiques characterized by the presence of the protein parvalbumine.

Comorbidities

Comorbidities, or association of other pathologies, are frequent in schizophrenias: Intoxication, abuse and dependence with the substances, anxious, turbid disorders of mood, Suicide, social handicap, iatrogénie. All in all, the schizophrenic patients live 10 to 12 years less on average than the life expectancy in the general population.

Treatment and to become schizophrenes

Médicamentaux treatment

The Neuroleptique S typical and atypical, recently called for primarily commercial reasons Antipsychotique S are the principal drugs used in the treatment of schizophrenias or the close disorders. They do not cure the disease, they contribute to look after it, and some symptoms attenuate some. They present side effects of which some are corrected by treatments known as " correcteurs". One can associate them with the other psychotropic ones (anxiolytic, hypnotic, antidepressants). The medicamentous treatments are only one generally essential but never sufficient aspect in complex care. The treatment is a long and difficult process. A second generation of antipsychotic was developed, they are antagonists to the dopamine and serotonin (S.D.A.) having more targeted action (less side effects). At the méso-limbic level, they block the D2 receivers (with dopamine, there is thus a reduction in the positive syndromes. At the méso-cortical level, they block the production of serotonin, which starts the production of dopamine (defective on this level), the symptoms negative disappear.

in first intention

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Nerve sedative S;

forms resistant to the treatment of first intention

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Assumptions of responsibility psychotherapeutic and educational

Psychoanalytical psychotherapies of the psychoses and schizophrenias

Following Eugene Bleuler, Carl Gustav Jung his pupil and temporary fellow traveller of the psychoanalysis opened the way of the psychotherapeutic treatment of schizophrenia. Victor Tausk, and, later, Paul-Claude Racamier, Gisela Pankow, Harold Searles, Marguerite Sechehaye and its famous “Newspaper of a schizophrene”, Christian Müller, Solomon Resnik, Herbert Rosenfeld, Wilfred Bion and Frieda Fromm-Reichmann was interested as well in the treatments as the psychoanalytical theory of schizophrenias. Considered refractory with the Transfert, according to the psychoanalysts schizophrenias appeared accessible to an authentic psychoanalytical work, whether it is within an institutional framework or an arranged setting.

However, the report/ratio INSERM: " Psychotherapy: Three approaches évaluées" (2004), (object of criticisms, inter alia, of Perron and coll on the site of the Psychoanalytical Company of Paris; the answers of Cottraux to these criticisms were published on the site of the AFFORTHECC) reports that two méta-analyzes gathering the work carried out on schizophrenic patients stabilized and followed into ambulatory show little or not effect of psychodynamic psychotherapy or psychoanalysis; and that a study which concerns in-patients (in acute phase) does not highlight of additional effect of the psychodynamic therapy on the medicamentous treatment.

cognitive therapy of the delirious ideas

August 1st A psychotherapist cannot make a schizophrene more cognitive, and even if it arrives there that does not last a long time (less than one day) because the loss of cognitivity is very specific to the schizophrenes, moreover the schizophrenic people are unstable, they do not manage to take initiatives, if they have problems, they notice them unconsciously (they feel problems but of it are not conscious of their concretization) then they do not even imagine that they can solve them and that their state can improve. They cannot thus solve and face their daily and long-term problems (future professional life) and surmount them. In particular, one finds a difficulty of fixing his attention, a deterioration of certain mechanisms of memory, an incapacity to project oneself in the future or to perceive the intentions of the other. All this is harmful with the good development of the schizophrene. There is thus no effective cognitive therapy but only the drugs are it.

cognitive remediation

The cognitive remediation is a technique which is connected with the occupational therapeutic methods. It is employed more and more in the treatment of schizophrenia, in complement of the association of the Neuroleptique S and the Psychothérapie. The use of the cognitive remediation in the treatment of schizophrenia is justified by the effectiveness only partial of the other treatments employed. The symptoms negative, the disorganization, the disorders attentionnels and mnemic and certain positive symptoms frequently resist these treatments. Moreover, disorders attentionnels, mnemic and executive often persist, even when the positive and negative symptoms were amended under the effect of the nerve sedative treatment. However these disorders are at the origin of a Handicap residual, awkward for the patient who suffers from it. In practice, all the forms of cognitive remediation employed aim at acting on deteriorated processes, so as to make the patients more efficient in the realization of certain tasks. This intervention can be realized in two manners: either while acting directly on the processes in question, or while trying to develop alternative competences. The objective is to allow about being able to deal more effectively with the artificial situations elementary, which will be able to have an impact on its capacity to face the concrete situations of its daily life.

magnetic Stimulation transcranienne repetitive

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psychosocial rehabilitation

The Anglo-Saxon literature generally uses the term of “rehabilitation” to refer to the process making it possible an individual to find a function or to mitigate a deficit. The French term of “readjustment” is the translation and is appropriate thus to indicate this process of drive of skills so that the person suffering from a mental disease collaborates in methods of training in order to develop her capacities, assuming her responsibilities in the life and functioning in a as active and autonomous way as possible in the company. Sometimes a French-speaking literature uses in this same direction the Anglicism “rehabilitation”, by reserve to perhaps accept the connotation behaviorale training attached to the activities of readjustment. However, the dictionary the Petit Robert specifies well that the rehabilitation rather refers “to restore in its rights in the public regard, in the consideration of others” what is in fact the objective sought by the process of the readjustment: with a work of readjustment, one can aspire to the rehabilitation and the re-establishment.

Anthony and Liberman worked out, starting from concepts initially introduced in physical health, a conceptual model of the psychiatric readjustment. They divide into four levels the impact of a serious mental disease as well as the interventions to be implemented:

• Pathology (Pathology): Anomaly or anatomical lesion at the cerebral level caused by a process or agent etiologic. For example an infection, a cerebral tumor or a neurodégénératif process. The investigations of laboratory and in imagery are here of setting.

• Deficit (Impairment): Loss or anomaly of a structure or operation of the brain caused by a subjacent pathology which leads to the deterioration of cerebral operation and the demonstration of symptoms such as be delirious, cognitive hallucinations and disorders. The diagnostic evaluation and of the interventions like the hospitalization, the pharmacothérapie and the therapy cognitivocomportementale are indicated.

• Disability (Disability): Incapacity in the achievement of an activity considered normal for an human being. For example, a deficit on the level of the social abilities caused by the negative symptoms of schizophrenia. When the facets pathology and deficit connected to the acute phase of the disease are stabilized, the psychiatric readjustment and its technologies come into play. It should be mentioned that the readjustment can (and must) begin even if deficits (or symptoms) persist, in so far as they are taken into account in the development of a plan of intervention • Handicap: Disadvantage resulting from a disability which limits the possibility of assuming a role considered as normal for an individual (according to its age, its culture, etc). For example, unemployment, the itinérance. The installation of social programs will support the most complete possible rehabilitation of the person in her various roles

Role of the cultural and social factors in the evolution

A recent study

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