ࡱ > l n k s @ 0 bjbjFF 0 , , H H H H H H H \ D D D 8 | t \ 4
( @ @ @ @ @ @ 4 6 6 6 6 6 6 $ = R Z i H @ @ @ @ @ Z H H @ @ @ X H @ H @ 4 @ 4 H H @
dw D N < 0 O O \ \ H H H H O H @ @ @ @ @ @ @ Z Z \ \ $ X \ \
WHY SHOULD CHILD PSYCHIATRISTS BE INTERESTED IN RARE DISEASES?
Olivier Bonnot, Raffaella Lucanto, David Cohen
Rare diseases have a prevalence of nearly 2% in the general population (source HYPERLINK "http://www.orphanet.org" www.orphanet.org). To be considered rare, an individual disease should have a prevalence of less than 1 in 2,000 people. Of note, most of these diseases affect only a few people, sometimes less than a dozen cases in France [in how many? 100,000? 1,000,000]. Caring for these patients is a major issue in the public health system. Patients almost always face the so called medical wandering, a term that describes the need for the patient to typically attend various centres and medical professionals as diagnosis and treatment typically require a multidisciplinary approach. Difficulties may increase when psychiatric symptoms, especially behavioural impairment, occur. Thus, medical practitioners who are qualified in their area of expertise may not be familiar with rare disease. Psychiatrists are not comfortable with heavy somatic pathology and paediatric and genetics professionals are equally uncomfortable with psychiatric symptoms. One answer to this health care issue has been provided by the French government with the 2004-2008 Rare Disease Program Certification. More than 250 medical units have been certified in various domains of rare disease, primarily genetic anomalies. Many rare diseases include nervous system tropism, with consequences for neurodevelopment and association with psychiatric symptoms. A majority of rare diseases are associated with mental retardation, which requires specific education and learning programs.
Our topic in this short paper is not the unspecific psychological consequences for patients and their families when a severe disease is diagnosed. Rather, we are interested in instrumental impairments, learning disabilities, behavioural symptoms, and psychiatric diseases indirectly or directly associated with many rare genetic diseases. Three examples below illustrate why psychiatrists should be interested in rare disease.
Tuberous sclerosis
Tuberous sclerosis (TSC) is a heterogeneous genetic disorder with an estimated incidence rate of 1 in 8,000 to 1 in 30,000 births per year. Two genes are involved in approximately 50% of the reported cases: TSC1 (chromosome 9q34) and TSC2(chromosome 16p13). Beyond the classical somatic symptoms, mental retardation (MR) and seizures are frequent (40% and 60% of the patients, respectively). The severe (as opposed to mild) psychiatric phenotype typically includes severe MR, seizures, language disorders, and Kanner-type autism ADDIN EN.CITE Cohen2005494917Cohen, D.Pichard, N.Tordjman, S.Baumann, C.Burglen, L.Excoffier, E.Lazar, G.Mazet, P.Pinquier, C.Verloes, A.Heron, D.Service de Psychiatrie de l'Enfant et de l'Adolescent, Groupe Hospitalier Pitie-Salpetriere, Paris. david.cohen@psl.ap-hop-paris.frSpecific genetic disorders and autism: clinical contribution towards their identificationJ Autism Dev DisordJ Autism Dev DisordJournal of autism and developmental disorders103-16351Autistic Disorder/diagnosis/epidemiology/*geneticsCausalityChildChromosome Aberrations/statistics & numerical dataComorbidityGenetic CounselingGenetic Diseases, Inborn/diagnosis/epidemiology/*geneticsGenetic Predisposition to Disease/geneticsHumansPhenotypeSyndrome2005Feb15796126http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15796126 [1]. Language abilities are impaired in the majority of individuals with TSC, although there is a wide range in the severity of this impairment. The mild phenotype of TSC is typically associated with normal early development, learning disabilities (e.g., dyscalculia), motor coordination impairments, attention deficit, and visual-spatial deficits ADDIN EN.CITE de Vries20074417de Vries, P. J.Hunt, A.Bolton, P. F.Developmental Psychiatry Section, University of Cambridge, Douglas House, 18b Trumpington Road, Cambridge, CB2 2AH, UK. pd215@hermes.cam.ac.ukThe psychopathologies of children and adolescents with tuberous sclerosis complex (TSC): a postal survey of UK familiesEur Child Adolesc PsychiatryEuropean child & adolescent psychiatryEur Child Adolesc PsychiatryEuropean child & adolescent psychiatryEur Child Adolesc PsychiatryEuropean child & adolescent psychiatry16-241612007Feb1018-8827 (Print)17268883http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=17268883 internal-pdf://deVries 2007-1517930240/deVries 2007.pdfeng[2]. Although attention-deficit hyperactivity disorder (ADHD) is reported in more than 50% of individuals with TSC ADDIN EN.CITE Gillberg1994373717Gillberg, I. C.Gillberg, C.Ahlsen, G.Department of Child and Adolescent Psychiatry, University of Goteborg, Sweden.Autistic behaviour and attention deficits in tuberous sclerosis: a population-based studyDev Med Child NeurolDevelopmental medicine and child neurologyDev Med Child NeurolDevelopmental medicine and child neurologyDev Med Child NeurolDevelopmental medicine and child neurology50-6361AdolescentAttention Deficit Disorder with Hyperactivity/diagnosis/*etiologyAutistic Disorder/*complications/diagnosisChildFemaleHumansIntelligence TestsMalePopulation SurveillancePrevalenceReproducibility of ResultsSweden/epidemiologyTuberous Sclerosis/*complications/epidemiology1994Jan0012-1622 (Print)8132114http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8132114 engde Vries1999383817de Vries, PJBolton, PFNeuropsychychological attention deficits in children with tuberous sclerosis, abstractMolecular PsychiatryMolecular Psychiatrys514(Suppl)1999[3, 4], attentional difficulties are frequently observed in individuals with TSC without a diagnosis of ADHD. However, few reports on neuropsychological profiles and psychiatric symptoms in TSC have been published. Increased knowledge in this field could be useful for patients and caregivers by providing a functional diagnosis. This functional diagnosis would include psychiatric, cognitive, language, logic, psychomotor, and visuospatial assessments, which are essential to helping and caring for patients.
Catatonia
Catatonia is a rare and severe psychiatric syndrome. In contrast to their adult counterparts, where bipolar disorder are the first diagnose, [what is the most common diagnosis in adults?], schizophrenia is the most frequently associated diagnosis in the child and adolescent population ADDIN EN.CITE Lahutte2008541THESE 2007.enlEndNote54117<style face="normal" font="default" size="100%">Multidisciplinary approach of organic catatonia in children and adolescents may improve treatment decision making</style>[5]. Catatonia is often misdiagnosed when symptoms are not motor (echolaly, mutism, refusal to eat, acrocyanosis, verbigeration, social withdrawal...) [could you give a couple of examples of non-motor symptoms?] ADDIN EN.CITE Bonnot2007452THESE 2007.enlEndNote45217<style face="normal" font="default" size="100%">Are Patients with Schizophrenia Insensitive to Pain? A Reconsideration of the Question</style>[6]. When encountered in a child and adolescent clinic, the syndrome must lead to specific investigations because it can be caused by a physical illness, usually a neurological, infectious, intoxication or genetic condition. Given that there is likely a bias in reporting organic cases, an estimation of the proportion of organic conditions in catatonic youth is 15-20% ADDIN EN.CITE Lahutte2008541THESE 2007.enlEndNote54117<style face="normal" font="default" size="100%">Multidisciplinary approach of organic catatonia in children and adolescents may improve treatment decision making</style>[5]. The importance for clinical practice resides in the potential availability of an effective treatment for the underlying illness (e.g., plasmatic changes in catatonia associated with lupus erythematosus ADDIN EN.CITE Perisse2003544THESE 2007.enlEndNote54417<style face="normal" font="default" size="100%">Case study: effectiveness of plasma exchange in an adolescent with systemic lupus erythematosus and catatonia</style>[7], D-Penicillamine in Wilson disease). The syndrome is rare but severe and can potentially be lethal. The stakes are large not only for reducing psychiatric symptoms but also for changing the course of metabolic or neurological diseases. Apart from a thorough clinical history, systemic and neurologic examination, there are investigations that may assist clinicians in making a diagnosis. These are summarised in the Figure.
EMBED Diapositive Microsoft PowerPoint
Figure 1
Catatonia in children and adolescents: a multimodal framework for evaluation and treatment (PDD = pervasive developmental disorder; NLP = neuroleptic drug; SCZ = schizophrenia; ECT = electro-convulsive therapy) (from Lahutte et al., 2008)
Cerebrotendinous xanthomatosis
Cerebrotendinous Xanthomatosis (CTX) is an autosomal recessive disease of biliary acid synthesis. It is caused by mutations in the gene CYP27A1, localized in the long arm of chromosome 2 and coding for the mitochondrial enzyme sterol 27 hydroxylase. The metabolic block causes a progressive storage of cholesterol that is deposited in many tissues including the brain and tendons ADDIN EN.CITE Moghadasian20023 X a n t h o m a t o s e F o l l o w - u p O B 5 o c t 2 0 0 8 . e n l < / d a t a b a s e > < s o u r c e - a p p n a m e = " E n d N o t e " v e r s i o n = " 8 . 0 " > E n d N o t e < / s o u r c e - a p p > < r e c - n u mber>317<style face="normal" font="default" size="100%">Cerebrotendinous xanthomatosis: a rare disease with diverse manifestations</style>[8]. CTX is associated with non-specific psychiatric symptoms and physical signs including tendinous xanthomas, cataract, diarrhea and neurological signs. Acute psychotic episodes have been described but most psychiatric symptoms occur during childhood or adolescence and are non-specific ADDIN EN.CITE Berginer19882 X a n t h o m a t o s e F o l l o w - u p O B 5 o c t 2 0 0 8 . e n l < / d a t a b a s e > < s o u r c e - a p p n a m e = " E n d N o t e " v e r s i o n = " 8 . 0 " > E n d N o t e < / s o u r c e - a p p > < r e c - n u m b e r > 2 < / r e c - n u m b e r > < r e f - t y p e n a m e = " J o u r n a l A r t i c l e " > 1 7 < /ref-type><style face="normal" font="default" size="100%">Psychiatric disorders in patients with cerebrotendinous xanthomatosis</style>Estrov20006 X a n t h o m a t o s e F o l l o w - u p O B 5 o c t 2 0 0 8 . e n l < / d a t a b a s e > < s o u r c e - a p p n a m e = " E n d N o t e " v e r s i o n = " 8 . 0 " > E n d N o t e < / s o u rce-app>617<style face="normal" font="default" size="100%">Psychiatric symptoms of inherited metabolic disease</style>[9, 10]. Given the cumulative effect of cholesterol accumulation, the course of symptoms parallels diagnostic delay. As an example, we describe two siblings with an early psychiatric presentation of CTX with ADHD and oppositional defiant disorder (ODD) followed by regression to mild intellectual disability and major behavioral impairments. In both cases, treatment with chenodeoxycholic acid improved externalizing symptoms and led to the partial recovery of cognitive impairments. The reported cases suggest that the presence of gradual cognitive deterioration after normal early development, learning disability, externalizing disorder and diarrhea in children should lead to the investigation of metabolic disorder. Knowledge of specific signs and symptoms of treatable neurometabolic diseases is crucial.
The French government has certified one center for psychiatric symptoms in rare disease. In all the other centers (250) there are few psychiatrists or psychologists. However, functional diagnoses, in addition to the etiological diagnosis, could be useful for patients. The above examples show (i) the importance of a functional diagnoses in guiding professionals in caring for these patients and planning an integrative treatment; (ii) the need that professionals be aware that psychiatric and cognitive signs are associated with rare diseases (sometimes treatable) and that improvement in psychiatric and cognitive symptoms (often the first symptoms observed) is greater when diagnosed and treated early; and (iii) the importance of knowing about severe forms of psychiatric disease, such as catatonia, that have specific symptomatic treatments (e.g., lorazepam) and a high prevalence of comorbid organic conditions (up to 20%).
References
ADDIN EN.REFLIST 1. Cohen D, Pichard N, Tordjman S et al. Specific genetic disorders and autism: clinical contribution towards their identification. Journal of Autism and Developmental Disorders 2005;35:103-116.
2. de Vries PJ, Hunt A, Bolton PF. The psychopathologies of children and adolescents with tuberous sclerosis complex (TSC): a postal survey of UK families. European Child & Adolescent Psychiatry 2007;16:16-24.
3. Gillberg IC, Gillberg C, Ahlsen G. Autistic behaviour and attention deficits in tuberous sclerosis: a population-based study. Developmental Medicine and Child Neurology 1994;36:50-56.
4. de Vries P, Bolton P. Neuropsychychological attention deficits in children with tuberous sclerosis, abstract. Molecular Psychiatry 1999;4:s51.
5. Lahutte B, Cornic F, Bonnot O et al. Multidisciplinary approach of organic catatonia in children and adolescents may improve treatment decision making. Progress in Neuropsychopharmacology and Biological Psychiatry 2008;32:1393-1398.
6. Bonnot O, Anderson GM, Cohen D et al. Are patients with schizophrenia insensitive to pain? A reconsideration of the question. Clinical Journal of Pain 2009; 25(3):244-52.
7. Perisse D, Amoura Z, Cohen D et al. Case study: effectiveness of plasma exchange in an adolescent with systemic lupus erythematosus and catatonia. Journal of the American Acadamy of Child and Adolescent Psychiatry 2003;42:497-499.
8. Moghadasian MH, Salen G, Frohlich JJ et al. Cerebrotendinous xanthomatosis: a rare disease with diverse manifestations. Archives of Neurology 2002;59:527-529.
= ? @ o p q v w ! " H T U V Y ` i j ̿vg hQD h* 0J CJ mH sH 'j hQD h* CJ UmH sH !j hQD h* CJ UmH sH h* CJ mH sH hQD h* CJ mH sH hi h* CJ mH sH h|Q h* CJ mH
sH
ho6 h* CJ mH
sH
hn h* CJ mH sH hQD h* 5CJ mH sH h* 5CJ mH sH ( @ o p = > Q U- `- _ _ _ ` ` ` ` ) * ͓ $ dh `a$ gd* dh ]gd* gd* @& gd* d gd* dh gd*
$ dh a$ gd* dh gd* l j
*
4
<
J
M
N
O
]
n
9 A J ] _ 6 9 E H P _ d z
#
$
n
w
ʼ hDg h* CJ mH sH h* B*CJ mH ph sH !h|Q h* B*CJ mH ph sH *hd\ h* CJ mH sH h* CJ mH sH hQD h* CJ mH sH E
- T U \ d n $ - ( * < = > Q c j [ _ + - K L d e $j hQD h* 5CJ UmH sH hQD h* 5CJ mH sH h* 5CJ mH sH hDg h* 5CJ mH sH hDg h* CJ mH sH hDg h* CJ mH sH h* CJ mH sH hQD h* CJ mH sH :e f k $ 7 9 : S [ i o ! ! ! ! ! ! G! J! |! }! ~! ! T+ U+ [+ \+ v+ + + + + + + ", ), -, 6, ~, , , , , , , , , - - - 7- :- B- ϶h* 5CJ mH sH hQD h* 5CJ mH sH $j hQD h* 5CJ UmH sH h* 5CJ PJ mH sH hQD h* 5CJ PJ mH sH HB- E- F- J- U- ^- _- `- k- - - - - . . *. +. ?. B. V. W. Z. ^. ~. . . . ; ; ; ; ; ; ;
< < ˾ufZfufuZ h* CJ PJ mH sH h h* CJ PJ mH sH %j h h* CJ PJ UmH sH !hDg h* B*CJ mH ph sH *hd\ h* CJ mH sH h h* CJ mH sH h* CJ mH sH hDg h* CJ mH sH hDg h* CJ mH sH hDg h* 5CJ mH sH hQD h* 5CJ mH sH h* 5CJ mH sH # < `< a< < < < < < A A A A B B $B ,B \B cB dB B B B B B B B ;C ^ N^ _^ m^ n^ z^ ^ ^ ^ ^ ^ /_ >_ C_ W_ _ _ _ _ _ _ _ _ _ _ Żzrf j h* U^J _H j h* U jJ
h* CJ UVaJ h h* mH sH j h* Uh* mH sH h* CJ mH sH h h* CJ mH sH h* CJ mH sH h h* CJ mH sH %j h h* CJ PJ UmH sH h* CJ PJ mH sH h h* CJ PJ mH sH %_ _ $` ` ` ` ` ` ` ` ` ` ` ` a ja ka ra sa ua wa ̬̾tf[Mf@6@6@6 h* CJ mH sH hQD h* CJ mH sH hG) h* CJ \mH sH h* CJ \mH sH hQD h* CJ \mH sH hQD h* 5CJ \mH sH h* 5CJ \mH sH hQD h* 5CJ mH sH hQD h* CJ mH sH #h h* CJ H*^J _H mH sH h* CJ ^J _H mH sH h h* CJ ^J _H mH sH &h h* 5CJ \^J _H mH sH h h* ^J _H mH sH wa b b $b &b Wb Xb Yb ^b q q q q q q !q "q q q q q #r $r %r *r s ɍ ͍ C D S s $ 1 p t } ~ ď ͏ ǻ֬ǻ֬ hQD h* CJ PJ mH sH h* CJ PJ mH sH h h* CJ PJ mH sH %j hQD h* CJ PJ UmH sH h* CJ mH sH hQD h* CJ mH sH D * . @ D K X ΐ ϐ А ؐ 5 N S W e g z { | ~ ؑ ޑ
+ H I U ^ d w ג ؒ L M N ʓ ͓ Γ ϓ ړ hi h* 5CJ mH sH hi h* CJ mH sH hQD h* CJ mH sH h* CJ mH sH hQD h* CJ mH sH J͓ Γ ϓ ړ > Ж j T 4 5 6 | gd* ^`gd* dh gd* dh gd* l ړ ۓ ܓ } ~ 7 { 6 : ; Җ o v ݗ A E G P V i j " ) - 4 7 O Q { ә ۙ ʲh u h* PJ !h u h* B*PJ mH ph sH *hu h* PJ mH sH h* PJ mH sH h h* PJ mH sH h* CJ mH sH hQD h* CJ mH sH !j hQD h* CJ UmH sH < 9. Berginer VM, Foster NL, Sadowsky M et al. Psychiatric disorders in patients with cerebrotendinous xanthomatosis. American Journal of Psychiatry 1988;145:354-357.
10. Estrov Y, Scaglia F, Bodamer OA. Psychiatric symptoms of inherited metabolic disease. Journal of Inherited Metabolic Disiases 2000;23:2-6.
Olivier Bonnot MD, PhD, Raffaella Lucanto PsyD , David Cohen MD, PhD
Centre for Rare Disease with Psychiatric Symptoms ( HYPERLINK "http://crepsymar.apahp.fr" http://crepsymar.aphp.fr); Department for Child and Adolescent Psychiatry, University Hospital Pitie Salpetriere/Assistance Publique-Hpitaux de Paris; 47 boulevard de lhpital, 75013 Paris, France.
E-Mail HYPERLINK "mailto:olivier.bonnot@psl.aphp.fr" olivier.bonnot@psl.aphp.fr
Article IACAPAP Journal, 2009. PAGE 4/ NUMPAGES 4
% + v | ~ ! & 3 5 6 7 E F M ` a e f h q t { | Ⱥvii h|Q h* CJ mH
sH
*hu h* 6CJ mH
sH
h* 6CJ mH
sH
hn h* 6CJ mH
sH
*hu h* 6CJ mH sH h* 6CJ mH sH h+ h* 6CJ mH sH !j hQD h* CJ UmH sH h+ h* PJ mH sH h* PJ mH sH h h* PJ mH sH U & ع ٹ ٺ ں ۺ p q w x y z { | ĵĨąĨzrnrnrnrnd^dSd^d^ hi 0J mH nH u
h* 0J j h* 0J Uh* j h* Uhi h* mHsH hi h* 0J CJ mHsH 'jP/ hQD h* CJ UmH sH hi h* CJ mHsH h|Q h* 0J CJ mH
sH
!j hQD h* CJ UmH sH 'j. hQD h* CJ UmH sH h|Q h* CJ mH
sH
h* CJ mH
sH
gd*
hi h* mHsH h*
h* 0J h* 0J mH nH uj h* 0J U . :p* |. A!n"M#$% D y K w w w . o r p h a n e t . o r g y K 2 h t t p : / / w w w . o r p h a n e t . o r g / - D d
9B z
s * A ? ? c "$ ` " - ד^PL ,
@=, ד^PLx tE `4 I x] |TEҤN $t 019$pF%d!(E숨.
+, Hq <uQt`u9qpq^W;0v~WU^}W}U",#<ۃ6#|j!lf34IihZ|v9A?J tkPCV g<C+ 1!| 4wxC&C8N3ߟ9IK>Tᘒ ֮:A4Q
(|
2wE A3#|GAhPm4q.b2TSށ5^pvmld=h# FۻMJOjߋFӤm&n(5>LtAlFFQH{;7LJ6 =Ie3>L=L,5P^j"9Y_;1m|=eSч[谷P/w>{ӼP`\.)
n wZ^8.,+ GBz"'KHS# 6RGrl vlIu/o<c3
|@ k*'d!ē,E C0< x1b] Ѽϵ<Zrtz `gkŗNLvEėMXs)c4{sS1F\"#6u!3F+!oC> >Q+[a q| o wѴyQ9M|APoyM[y>4
iV/f 1c FH/dq E"]dՔk6]DgX}y:4pl,?ٸ8㵱c0|c| ǡ mbp+
z2 >1 8o u5_5r9\4\: B'7F㏧־K>cOn,cc؞>x?wf#).uON Fq)=w
or*UƬԻMY{Ygz<0T}3=6G2b1ݱlC'; qU>tD߯eQרIofz
~ 4I4Ǡ'*Q DK
~Yg3Ly(<ď|#:c Ϣ䂇 %ܦjlJW|ALf\ٶ# wC$: m\1(Q,
3"~|e S ̆ [!l 76GI 1VvD>c#)ƃ3D MVpTq G|Vؼ6]r@cA+P
qc3UAv$gɔO `GJ@m<'Z/ F}sWXr65ɛgJ.>0 cPUcf^Z6rWy ^xӡ :
:Fъ]mST^c(9E&Nju_;.s2ʇCFy>lSH ,% V`6le(C؍3LXO7i>,҈s>$Pv BJ(D DklӳT[9ۣܽb,͏ 8
vAphW* {(?8]pXX?q7kgeFRCeZʡӴW''[089PZIb)vb)WP$_ J K6$pvBlewh Xc9b*v~Dwb Ae6f3 D/Weqapy:uB#(R 5WQtͱr|t$q5gqE;+Z_\jՍtm jv djXWH} a[ s2%Fc.VqZQnRX6:D: ~PY#S!ʈGƷl
rEFbMϲ k#QZ.j7[+fQD-ahUcXrDBۖmK mˠhjk6,Ѧ5QOm<-}۶ъmk9E&ԀұmVR0m[Al
u~$?6ضPNǗm[Zm ж 5mPZٚc(vLv=\d_́S#K~pDk2 g%TGmYX 'ggw
sz_ŋ
9ߴl"ټ&a-ڰ mX A}mVKh. N]N&&eh
6X
z.x>RU
|UX}Ebz(ڪ3Gj2Fh2)ڪ,2&1ڨ_^[c2ewE[QVKؙK:k1LT|[Ub0mUڪتc`%hj5ڪ mU k3 [z @6!*̳8{=yf|d
f h] oh`OaFQGwJ%)mSگwį*)
~UI_uI=jqk²PmRIX6_;;r\`%y.72z64M
&e "_
ym oaV<ߢ
! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b d e f g h i j m p r q u v w x y z { | } ~ R o o t E n t r y F `8xo @
D a t a
c ?0 W o r d D o c u m e n t 0 O b j e c t P o o l @7p`8x _ 1 2 5 8 1 3 6 2 5 6 dO ) @7pp O l e
C o m p O b j { O b j I n f o
! " # $ % & (
dO )! Diapositive Microsoft PowerPoint MSPresentation PowerPoint.Slide.8 9q
_( SEC S E C Oh +'0
X ` x
Diapositive 4 o SEC SEC O C X N A M E
c o n t e n t s P i c t u r e s C u r r e n t U s e r ) S u m m a r y I n f o r m a t i o n (
P o w e r P o i n t D o c u m e n t ( t 8( D o c u m e n t S u m m a r y I n f o r m a t i o n 8
1 T a b l e O 3 C Microsoft PowerPoint P @ 0n @ odч@ h0 N ՜. +,0
d Affichage l'cran Samsung Electronics 8( # A
Arial Times Modle par dfau ( = ` / 0 D A r i a l yC l T 0 l z[ 0d D T i m e s yC l T 0 l z[ 0d @ .
@ n ? " d d @ @@ `` 0 * 0 @ ʚ; ʚ; g 4 D d D d z[ 0 p p p @ 8 0 _ _ _ P P T 1 0
p p ?
% O
= X
/ ` 33 ` S f 3 f ` 33 g ` f ` www 3 PP ` ZX db mo ` \ ғ 3 y` Ӣ ` 3f 3f f ` 3f 3 FK f ` hk] www f ܹ ` ff >>\ `Y{ ff ` R>& - {p _/ ̴ > ? " d d @ , | ? " d d @ " @ ` n ? " d d @ @@ `` P R @ ` ` p > > (
6 dC `} C
[ ' Cliquez pour modifier le style du titre (
( :
0 C ` C
v Cliquez pour modifier les styles du texte du masque
Deuxime niveau
Troisime niveau
Quatrime niveau
Cinquime niveau 4
w
0 C ^ ` C
> *
0 C ^ C
@ *
0 tC ^ ` C
@ * H
0 h ? 33 8 0 _ _ _ P P T 1 0 . -Z˔# " M o d l e p a r d f a u t &
0 0 6 (
0 y P
y
R *
0 y y
T *
d
c $ ?
y :
0 y
0 y
v Cliquez pour modifier les styles du texte du masque
Deuxime niveau
Troisime niveau
Quatrime niveau
Cinquime niveau 4
w
6 y _ P y
R *
6 "y _ y
T *
H
0 h ? 33 8 0 _ _ _ P P T 1 0 . ч@ * " (
-
0 /y @
O Hospitalize in a psychiatric setting
Manage malignant catatonia when necessary N P P 2
0 X8y
1 Diagnose catatonia with appropriate rating scales 8 2 1
6 >y ' S
b Determine associated
psychiatric condition:
Acute onset?
Mood symptoms?
Hallucinations?
Delusion? c * 9 c
6 Dy
S
Z Determine complete
psychiatric history:
PDD?
Learning disability?
Stressor?
Family style? [ & 5 [
6 4Ky S
M Address possible
organic condition:
Neurological?
Metabolic?
Toxic?
Genetic? N " , N 2
0 |Py
E
b Select appropriate treatment
0 Ty s ' f
= Related to associated
psychiatric condition:
e.g. NLP for SCZ > + >
0 Ry M
q Symptomatic
e.g. Sedative drugs "
0 t]y Y
H Related to associated
organic condition:
e.g. Plasma exchanges
for lupus I ' " I
0 by ]
7 ECT
< fy I $
?
IF RESISTANCE X B
0 D Ԕ @ @ X B
@
0 D Ԕ @gw X B
0 D Ԕ @cF X B
0 D Ԕ @@ @ X B
0 D Ԕ S m m
X B
0 D Ԕ F m m X B
@
0 D Ԕ
-s X B
0 D Ԕ
X B
0 D Ԕ S Zc
X B
@
0 D Ԕ S SFc
X B
0 D Ԕ m m R B
s * D Ԕ
m m I X B
0 D Ԕ f
=
< dmy
xo
% Monitor risk of
malignant catatonia ! 8 & 0
$ b P H
0 h ? 33 8 0 _ _ _ P P T 1 0 .
0 @ ( (
^
S
y
c $ sy
0 y
H
0 h ? 33 8 0 _ _ _ P P T 1 0 . -Zii r P
% ?
' 0 t Diapositive 4 Polices utilises Modle de conception Titres des diapositives Oh +'0 $ 0
L X
d p x 8 Why should psychiatrists be interested in rare diseases CHU de Toulouse Normal.d"UOy Qh x
/=X 'dV c1ޏ؞~-F2w|U!==gGB\~8'_]7ȖX_~&0/.[fm- rrX h.?MO6Al,~>~l,}b`;a .`q=DzGu+U S-j!tmK'kUSm>s$~qD{1 sq'~xbEs;o7 y gyëMVӧ"c=o8!5߽8fAK1k6]O O i;7}R%<%Z&-OCSb@˥ naҮg(ߟ_C ) 8P tQ G_rsL֖1?/ : h^+`2|m{CcrVN><(/
YVQY 3B%QQw 5ctOc$ztqe}Lwå4uKmn +Oc
EE4߹Ъ [O2e(?Nfk"2ػ'.^5t> > >l# ;7ُ }7@8.!קSWD-Ԣ~Kt=Rֽ2fi$:xxQDףOۄdwsI4֣xpgHgd~0̹K0\9hy}_r 3 Ҋ<1拼>qG-d y Kŏ';e)ї5Egp?=DW03D H~
xWyg T~<@; 9swg.cٽ3_ lE#?(УwC^%T#v@2RMw]x"RX[R ųX֛D Ɇ~5 kڻgE~ooKpʷۄuۧ=TX³/}(ߊ>7ܷctzqtuua.,Ƈ 5{buaGN#]*Hyx(O>.|/|^^zm
^c.- VV,k4isܤʓ9Gw = !4|`~2eJ_ rW |% _ٺr0a]Wjgq 3&!= VL̹) ؟xIsb߇xk 67THQof>h 9 G؞Sp 1G1v vFR@Iqykת2>j[0_zٲn*WLX Q>$5d/MVk^b(;ƥo`8l
"1&'g|H+GzZ ? |:5iUX7B&<xNU{ZavR=xշ }_ qO:
.׳ Eo)db;`uQĪ$8VӺV{+buiD=XM ?l3*c5Ehq7<v5ԧ&L9~Ajp'&tU'>' "e } U^j V/s2jQQ{ry0}OޭU_i/tw 2|>F Vv+b캽 otV9V?y b5{VyY,ajULu|[*c`7EGՌn~~:U
$~ ft~:R+gWWUa'g%TﯪiLtw)x};9a
o.{A>
cϾLV q'a_]}b YE+gν 8̚Pp3Տ vD 1F&T'<ٓ鄄xτa9C o]z V tE `4 9 x] pT>&< GB!,$*(c`bluh;*>(8-tSh;>j[>LkE ݛdlV2s??~xZ<:AWGvA3Li\Esm*10
R."(1|i
yd8Otb5AK֮
g ?w{$*UE l F@] Xna|B܀7u Ȇ/R+Fd>ֹ[osPh'__Xlo2(wZnyl@ %_f_c
"9QS LzQ;ˣ[jCcRqXju890>B+ `}
!FKNn!S8@xμ*cKV̫M:/Bu`''Ī`fFذ+ ײ%l+ٰ|70 lUX63 L6ΖjVM/_=V']3 $ך5L nG1R2Ϥ\sZF3#σI)|i0|1OQ3=x aty5![0ls^ Zo-^~*í6^3[Z.=+[\|hk: &QW%jNNX+++Hzc
1.xi"kfhP p Φ8 L~璼H(\
S,o?c" vń0
Z3 ;P.IA2kl)䄆JI9N:_ÞpC7۬7,\{ iyϗ >RᕜjDVJJ_K?|=0
!ĝ>%S~`?N~$K=ȿME8%؎ŸOH;V+r 4U*CxS8L^LB[>KП&QIB%ӡ0N J1} 0qAl>BE- ճ\;;@3g ;9^N-}&?y1l
F2k[G>&6l)
m1k}Дro,8韖m,J
-m|*y[_~lL*}Ķ;mԿm<|W>_Y4cG@<}L=2qL68x% dQ e[8pq>g<+|Mt\Q8 7I֪}JEYIWF(*J< **;R#28W48q+/ v#/ܿx-S|X#?5*;Wɮ9c B,= &yAڅGZh_9. Cz^TڧXj+f_qGj"owR)x+|dj'c8%^ȡtnY\>p9 )p:ˇeB9l >_GqmS_Xh}nmNqD+%꿃&x;ڍ{hK~+ XgL@;#: 2T
뫂+J/JSN8 Y1#?n$삃wի[Zj[ѺVk YWY,%+Z[fY+on[sU*uA\.T\;'Y-ׯZv9$h3m[߲-Aq͚%[ez _k^g
y:ؾH ~ӫT+L^Փ'AxR̖e+VLyYݲfmG
Y]
yy=!ޒNQ81^I+SCScg7/L.F ϩ=vvp]>
IWS vWߏ$Q:3W[gg
coE|B\- 4KAf3Ӈ@eG81>RYwJ
9Ek/䇻4}zv$ 9x;Ho\ߏ$Q:7[HO?GWZOV4=YrD$̛ax t;tAY _n ̿jpәm'4P`@~ 90 s,|p3l
)y
9}&DX9XGRjva M'YGP }jE'0iH'I+?
W~\
'+S< g<_xZ#σ/NfMtTY04
Rj'Y< YȣwyGD 3sh!= E&N|,ԤP yJ`3 5 n?lGPՋ{^5ͨ ^ NJs `G̚) 4(.,7%7Y@ ֝o!Js0@2 a@yKW:G *@ g$ yHV~|Jݏ(
!oz$3E⺳zZ,`F|*h6@@ aO>ܟ! xXh0@,}*_iQ Ф $|>{K{ ~GKGQfƃPEՊg!zZVu?t)N| }j?Kl'C8}? *5o=ީנp]XhuΨK骵$HB U!@t9 }>N{ k}Nn v}YKdUq' yRD %_QNR ´x崜F4\NF}m0@[ [
)yTAS*p:jJ_~v~=\E
u?'Wir«aI2VhN) ]]@/P pQekoJ07=h'n-SYUF'l6`\q$K_bNoK?˵ /_6>< P1
Kv5GOA D y K y K 4 h t t p : / / c r e p s y m a r . a p a h p . f r D y K o l i v i e r . b o n n o t @ p s l . a p h p . f r y K D m a i l t o : o l i v i e r . b o n n o t @ p s l . a p h p . f r S u m m a r y I n f o r m a t i o n ( D o c u m e n t S u m m a r y I n f o r m a t i o n 8 C o m p O b j ' j ot AP-HP 3 Microsoft Word 10.0 @ G @ .J@ Oa qy ՜. +,D ՜. +,p , h p
CHU de Toulouse I <
8 Why should psychiatrists be interested in rare diseases Titre 8 @ _PID_HLINKS A L U g ' " m a i l t o : o l i v i e r . b o n n o t @ p s l . a p h p . f r W $ h t t p : / / c r e p s y m a r . a p a h p . f r X C h t t p : / / w w w . o r p h a n e t . o r g /
F Document Microsoft Word
MSWo @ @ @ tv N o r m a l CJ _HaJ mH sH tH : A@ : P o l i c e p a r d f a u t V i V T a b l e a u N o r m a l 4
l 4 a 2 k 2 A u c u n e l i s t e 6 @ 6 tv E n - t t e
p# 4 )@ 4 tv N u m r o d e p a g e B U@ B tv L i e n h y p e r t e x t e >*B*ph ^ C@ "^ tv R e t r a i t c o r p s d e t e x t e $7$ 8$ a$
5CJ \ @ o p = > Q U% `% W W W X X X X c d e p G Ԉ f R 1 . 0 0 x 0 x 0 x 0 x 0 x 0 x 0 0 0 x 0 x 0 x 0 x 0 x 0 P 0 x 0 x 0 x 0 x 0 x 0 0 0 0 x 0 x 0 0 x 0 0 0 x 0 x 0 x 0 0 0 0 0 x 0 x 0 0 @0 0 @0 0 @00 o@00 o@ 0 @ 0 @ 0 x @ 0 0 |o > Q U% `% W @0 X @0 @0 @0 @0 X j
e B- < vQ _ wa ړ M P Q R S T U V W X Z ^ _ a ͓ N Y ` O d
| T# [# ~& 3 3 4 9 9 Z; H H uI U U W W W WZ g g #h p ; d } 5 f XQQQQQQQ:QQQXXw ~ ! H n p q Q
W
^# i# 4 4 4 4 .4 :4 <4 I4 gI tI U U TX _X X X X X X X X X X X Y Y %Y ,Y Y Y ]g fg gg pg 9 A M R $ ) 1 5 ; ڈ ߈ i p t z
$
y ) * 7 5 ; ? F J Q ۍ ; e } . 5 6 e g @ n p q d e : A \ ] Ɉ ψ ^ d C K Ҋ # + V - . 5 6 e g 3 3 3 3 3 3 3 3 3 3 3 3 3 pW W e * i @ y d e f R @ d d r d d d [ \ i j u v ` @ ` d ` @ ` t ` @ ` ` @ ` p@ U n k n o w n G z T i m e s N e w R o m a n 5 S y m b o l 3& z A r i a l G5
h M S M i n c h o -3 f g 5& z a T a h o m a " 1 {&& qy I qy I $ 4 < < : 2q HX ? tv 7 W h y s h o u l d p s y c h i a t r i s t s b e i n t e r e s t e d i n r a r e d i s e a s e s C H U d e T o u l o u s e A P - H P rdDoc Word.Document.8 9q