� Deux m�ta-analyse=
s:
suicide est la 2 nde � cause de mortalit�
=
div>
� Complications de
l�amaigrissement: 46% - 54%
� Suicide: 27% - 3=
2%
� Etudes longitudi=
nales
de suivi de patientes hospitalis�es
� 0-5,3% de suicid=
e
� Etudes de suivis=
de
patientes ambulatoires
� 2,4%-4,8% de
suicide
� Au total, 2,5% d=
es
patients AN d�c�dent de suicide
� 5,6% par d�cade&=
#13;
� Taux de mortalit�
standardis�s de suicide chez les femmes:
32 dans l�AN, 0 dans la BN (d�pression 28, alcool 18, SZ 8)
� X 8 / population=
� g�n�rale
Franco & Keel Clinical Psychology review 2006
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Introduction
Keel et al Arch Gen Psychiatry 2003, Franco & Keel Clin=
ical
Psychology review 2006
Le suicide dans la Boulimie
� La mortalit� est
sup�rieure dans l�AN / la BN
� Mortalit� suicidair=
e:
� 1,8%-2,9% dans AN=
13;
� 0 dans BN
�
=
span>
� Le
risque de suicide abouti est �lev� dans l�anorexie mentale, faible dans la boulimie
=
span>
�
�
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Introduction
Viesselman & Roig J Clin Psychiatry 1995, Herzog et al
JAACAP 1999, Bulik et al Acta Psychiatr Scand 1999,
Corcos et al =
Acta
Psychiatr Scand 2002,
=
Les
tentatives de suicide dans des populations mixtes d�AN et =
de
BN
� Bulik et al 1999 (n =3D 280 patientes ambulatoires=
)
� AN 27%, BN 31%,
d�prim�es 36%
� Intention suicid=
aire:
AN =3D MDD > BN
� Viesselman & Roig (1995) (n =3D 95 hospitalis�=
es)
� AN 23%, 19% bing=
e, 20%
binge + purge
� Herzog et al (1999) (n =3D 246 ambulatoires)
<=
/span>
� AN-R 12%,
AN-BingePurging 14%, BN 9%
� Corcos et al (20=
02)
(295 boulimiques ambulatoires multicentriques
francophones)
� 28% quel que soi=
t le
sous-type (BN-P, BN-NP, AN-BP)
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Introduction
TS dans les TCA - une
� grande � �tude fran�aise
� 1000 patientes TCA
cons�cutives
� 36% TS
Fedorowicz et al Int J Eeat Disord 2007
<=
span
style=3D'mso-special-format:lastCR;display:none'>
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Introduction
TS dans les TCA - une
� grande � �tude fran�aise
Fedorowicz et al Int J Eeat Disord 2007
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Introduction
TS dans l�anorexie mentale
� 432 AN r�seau NIH=
13;
� 17% TS
(intentionnelle)
� AN-R 7%, AN-Purging 26%, AN-binge 29%=
, AN+BN
21%
� Facteurs de risque:=
� Apr�s contr�le pour=
la
d�pression:
� S�v�rit� du TCA
=
;
� Abus de substances,
Panique, PSTD,
� Cluster B, Impulsiv=
it�
Bulik et al Psychosom Medicine 2008
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Introduction
Corr�lats des TS
� Comorbidit�
psychiatrique
� Abus de substances&=
#13;
� Abus sexuels
=
span>
� Personnalit� =
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Introduction
L=
es
comorbidit�s psychiatriques
sont tr�s fr�quentes dans le TCA
� =
D�pression,
dysthymie: 50-75%
� =
Trouble
bipolaire: 6-13%
� =
TOC:
25% dans AN
� =
Phobie
sociale
� Abus
de substances: 20% dans AN (surtout purging), 1/3 des BN
=
span>
� =
Troubles
de la personnalit�: > 50%
� =
Abus
sexuels: 20-50%
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Introduction
Des
caract�ristiques du TCA ?
� Risque de TS plus � lev � lorsque existent des comportements de � purge � (vomissements, laxatifs)
� Chez AN
� Et chez BN
� S�v�rit� des purge&=
#13;
� Utilisation de
laxatifs
� S�v�rit� du TCA
=
;
�
Favaro & Santonastaso Int J Eat Disord 1996, Acta Psych=
iatr
Scand 1997, Milos et al Gen Hospit Psychiatry 2004
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Introduction
La maltraitance infantile
� Les abus sexuels sont un corr�lat
suicidaire robuste dans les TCA
� AN
� Et BN
=
div>
� Pourrait d�finir un sous-groupe de BN
avec des comportements auto-destructeurs impulsifs marqu�s
<=
span
style=3D'mso-special-format:lastCR;display:none'>
Favaro & Santonastaso Acta Psychiatr Scand 1997, Wonder=
lich
et al Int J Eat Disord 2001,
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Introduction
Troubles et traits de personnalit� =
div>
� =
Personnalit�
du groupe B
� =
Dimension
� impulsive �
� =
Dimension
anxieuse
Bulik et al Acta Psychiatr Scand 1999, Milos et al Gen Hosp=
it
Psychiatry 2004
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Introduction
Quels pr�dicteurs de TS ?
� Etude longitudinale sur 9 ans, �valua=
tion
/ 6 mois, de 250 patientes, TS: 22% AN, 11% BN
Franko et al Psycho Med 2004
<=
span
style=3D'mso-special-format:lastCR;display:none'>
<=
span
style=3D'mso-special-format:lastCR;display:none'>
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Introduction
Pourquoi AN suicide - BN TS ?
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Introduction
Processus
=
div>
Suicidaire
Vuln�rabilit�
(traits)
Evaluation suicidaire dans les TCA
� Ant�c�dents de tentative de =
span>=
suicide
� Ant�c�dents familiaux de =
conduites suicidai=
res
� Impulsivit� agressivit�
=
span>
� Tendance au pessimisme
� Abus dans l�enfance
S�v�rit� du TCA
Binge / purge
Comorbidit�s
psychiatriques
(d�pression, substances)
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Introduction
Conclusion
� =
Le
risque suicidaire est bien r�el dans les TCA
� =
Evaluer
le risque et la l�talit� du processus suicidaire
� =
Rechercher
activement les abus de substances
� =
Rechercher
activement l�histoire de maltraitance infantile
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Cliquez pour modifier les styles du texte du masque
Deuxi�me niveau
Troisi�me niveau
Quatri�me niveau
Cinqui�me niveau
El objetivo para Europa de la Organizaci�n Mundial de la Sa=
lud es
una disminuci�n para 2020 de al menos un terci=
o de
la mortalidad por suicidio. C�mo se puede lograr este
objetivo tan ambicioso
Durante la primera parte de la exposici�n pretender� introd=
ucir
un modelo vulnerabilidad estres de las conduct=
as
suicidas que se basa en datos a la vez cl�nicos y
biol�gicos resultantes de 30 a�os de investigaci�n.
Este modelo permiti� seguir probando hip�tesis benefici�ndo=
se
ahora de las herramientas modernas de investig=
aci�n
en neurociencias.
Veremos que podr�a aportar la investigaci�n neurocientifica=
en
relaci�n a una mejor comprensi�n de la
fisiopatolog�a de las conductas suicidas.
Daremos algunos elementos ilustrativos de nuestro planteami=
ento
de investigaci�n en este �mbito que nos conduc=
e de
la gen�tica a las im�genes cerebrales y en busca de
endofenotipos.
Les TCA re=
pr�sent�
par AN et BN surviennent chez 1-5% des adolescentes et femmes adultes.
=
;
L�AN est
caract�ris�e par le refus de maintenir un poids normal, la perception anor=
male
de son poids, et l�amenorrh�e.
La BN est =
d�fini�e
par la survenue de crise de boulimie suivies de comportements
compensatoires.
Dans les d=
eux cas
l�auto-�valuation est gouvern�e par la perception de son poids et de sa
silhouette.
Parmi les
diff�rences entre ces troubles: la perception de son corps est plus pertur=
b�e
dans l�AN, et plus r�aliste dans la BN. Le v�cu des sympt�mes est � gosyntonique dans l � AN, tandis que les BN souffrent des binge et
purge.
Les tb sont associ � s � des comorbidit � s thymiuqes et anxieuses fr � quentes. Dans la BN=
il
y a plus d � abus de substances et de tb de perso du groupe B.
On retrouve plus les AN en hospit et les BN en cs.
Les ttt m � dic et TCC sont plus efficaces dans les BN.
=
Enfin, ces=
tb sont
diff�rents pour la mortalit�, les taux dans l�AN �tant les plus �lev�s de =
tous
les tb psy, alors que la mortalit� des BN est faible. On pourrait en d�dui=
re
que la mortalit� est cosn�qcutive � l�amaigrissement, constant dans l�AN et
absent/faible dans la BN. En fait la mortalit� de l�AN est surtout
indirecte.
Les patients souffrant d�un trouble bipolaire constit=
uent
la population � plus haut risque de conduites
suicidaires (suicides aboutis et tentatives de suicide).
Compte tenu de l�importance du ph�nom�ne suicidaire d=
ans
notre pays (plus de 10000 d�c�s annuels),
consid�r� d�sormais comme une priorit� de sant� publique, et de la pr�valence du trouble bipolaire (d�au moins =
1%),
la prise en compte du risque suicidaire et
l�instauration de mesures de pr�vention dans cette population sont � envisager pour infl�chir ces chiffres, illustr=
ant
la magnitude de ce fl�au.
Les SMR: t=
aux de
mortalit� li�s au suicide dans un groupe diagnostique donn� en comparaison=
�
la pop g�n�rale d�age et de sexe comparable
Dans les �=
tudes de
suivi qui portent sur des dur�es pouvant aller jusqu�� plus de 20 ans, =
3;
Dans 3 �tu=
des de
suivi d�adolescentes suivis jusqu�� 15 ans, les r�sultats sont identiques.=
Etudes de =
suivis
d�AN de cs sur parfois 20 ans: taux pas inf�rieur � ceux des patientes sui=
vis
apr�s hospit
Tr�s peu de d�c�s sont rapport�s dans les
�tudes de patientes souffrant de BN
Qq �tudes ont port� � la fois sur des pat=
ientes
AN et sur des BN,suivis pdt pr�s de 10 ans, en sp�cifiant les donn�es li�es aux suicides, ce qui permet de comparer =
le
risque de suicide dans chacun des deux
TCA.
Dans les �tudes, non seulement la mortali=
t� est
sup�rieure dans l�AN / BN, mais il n�y a pas de mortalit� suicidaire dans la BN!
Dans les �tudes transversales portant sur=
des
populations de patientes souffrant d�AN et de patientes souffrant de BN
Les taux de TS sur la vie sont souvent
comparables entre AN et BN, la seule �tude longitudinale
retrouve plus de TS chez les AN (Franko)
Deux autres �tudes, qui portent sur des
effectifs plus importants (350), retrouvent plus d�histoire de TS chez les BN (moins de 20%) que ch=
ez les
AN (moins de 10%)
Il serait possible que chez les AN, les t=
aux de
TS soit plus �lev� chez les AN binge, comparables
au BN, les AN restrictives ayant les taux les plus faibles.
1009 patie=
nts TCA
admis dans un service parisien
Ils n�ont =
gard�
que les hommes: 968 femmes TCA exactement
La fr�quen=
ce des
TS est �lev�e: 36%
Les fdr et=
de
protection retrouv�s dans cette �tude sont le diagnostic de TCA (plus fort
pour la BN et plus de proximit� de AB-B/P avec la BN qu�avec l�AN-R)
<=
/div>
Ceci confi=
rme
l�id�e d�un risque de TS associ� avec l�existence de binge/purge, plus qu�=
avec
le Dg
et�
=
div>
Parmi les
dimensions de l�EDI, est associ�e l�insatisfaction avec son apparence
Le type de=
TCA
�tant fortement associ� au risque de TS, les auteurs ont �tudi� les fdr da=
ns
chaque cat�gorie
On retrouve
toujours la d�pression et sa s�v�rit�, et la s�v�rit� du TCA, notamment de=
la
boulimie et �galement les plus forts facteurs pour chacun des trois
diagnostics: les substances!!!
Ces donn�e=
s vont
dans le sens d�un sous-groupe multi-impulsif au sein des TCA avec impulsiv=
it�,
substances et suicidalit�
Dans cette=
�tude ,
l�illustration que les TS sont fr�quentes, s�v�res et intentionnelles.
=
;
Ainsi, >=
;2/3
n�cessitent des soins m�dicaux, 3/4 voulaient mourir, et > 1/2 avaient =
une
intention suicidaire nette avec d�sir de mort.
Ceci confi=
rme les
donn�es pr�c�dentes de l�intention plus �lev�e chez AN et d�prim�es / BN, =
et
indique le besoin d� �valuation de l�intention et la l�talit� suicida=
ire
en routine dans les TCA.
Ces donn�e=
s sur
les corr�lats indiquent �galement l�existence des deux facteurs impulsivit=
� et
anxi�t� dans le risque suicidaire.
Les diffic=
ult�s
m�thodologiques (taille n�cesaire) expliquent l�absence de donn�es sur les
corr�lats du suicide abouti dans les TCA.
Les donn�es
disponibles concernent les TS � partir des �tudes transversales
Ces comorb=
idit�s
tr�s fr�quentes sont d�autant plus importantes � rechercher qu�elles
augmentent le risque de TS
(sont plus
fr�quentes chez les sujets TCA avec TS)
Les abus de
substances sont un facteur de risque suicidaire important et tr�s fr�quemm=
ent
retrouv�es chez les BN, moins chez les AN (surtout AN-P)
Dans cette=
�tude
la s�v�rit� du TCA est un fdr uniquement dans la BN, tandis que la psychop=
atho
g�n�rale est un fdr dans l�AN.
Sur le pla=
n de
l�EDI, ce sont les variables de personnalit� et des relations interpersonn=
elles
qui sont associ�es au risque de TS: sentiment d�inefficacit�, de manque de
confiance dans les relations � autrui
Met l�acce=
nt sur
l�importance d��valuer la personnalit � dans les TCA pour � valuer le risque de TS
On peut noter � galement que la prise en charge est un fdr. Ceci =
peut
refl � ter un biais de s � lection dans cette � tude vers des patientes plus s � v � res. Ceci indique par
ailleurs la n � cessit � d �� valuer le risque suicidaire r � guli � rement, y compris
lorsque les patientes sont en traitement.
Si les TS =
semblent
fr�quentes autant chez les AN que chez les BN, les suicides aboutis sont
clairement plus fr�quents chez les AN
Comment pe=
ut on
comprendre cette diff�rence?
Le but de =
la CS
diff�re: la s�v�rit� de l�AN, sa chronicit�, l�alt�ration de la qualit� de
vie, les complications m�dicales font que le d�sir de mort est important. =
Chez
les BN, la CS est plus sous-tendue par la r�gulation des affects,
l�impulsivit�.
Ceci a des
implications th�rapeutiques sp�cifiques dans chaque cas: dans l�AN am�lior=
er
la qualit� de vie, et aider � trouver un sens � son existence, dans la BN
am�liorer la r�gulation des affects et de l�impulsivit�.
J Mann in 1990 proposed a heuristic model of suic=
idal
behaviour taking into a=
ccount
these epidemiological facts.
The idea was that among patients suffering from
psychiatric disorders or
presenting environmental stresses, only those who are carrying a specific vulnerability would realise
suicidal behaviour.
Importantly, the demonstration of an association
between a serotonergic
dysfunction and the history of suicidal behaviour independently of the psychiatric diagnoses, gave a
substantial weight to t=
his
hypothesis, suggesting that the dysfunction of the serotonin system may represent a vulnerability fa=
ctor
at the biological level=
.
A large amount of data have accumulated to involve
several factors in the
vulnerability to SB, at the clinical level : these include the personal and family history of SB,
personality traits rela=
ted to
impulsive aggression and hopelessness and childhood abuse.
Se souveni=
r que le
suicide est une cause importante de mortalit� dans l�AN
Et qu�une
anorexique sur 5 et une boulimique sur 3 fait des TS
Il est �ga=
lement
important d��valuer le risque suicidaire en pr�sence d�abus de substances,=
de
maltraitance infantile
Les TCA so=
nt �
haut risque de CS, probablement parce qu�ils portent de nombreux facteurs =
de
risque suicidaire
------=_NextPart_01C8F312.54B5F170
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------=_NextPart_01C8F312.54B5F170
Content-Location: file:///C:/B0C330E5/TCA-et-suicide_fichiers/script.js
Content-Transfer-Encoding: quoted-printable
Content-Type: application/javascript; charset="windows-1252"
function LoadSld()
{
var sld=3DGetObj("SlideObj")
if( !g_supportsPPTHTML ) {
sld.style.visibility=3D"visible"
return
}
if( MakeNotesVis() ) return
runAnimations =3D _InitAnimations();
if( IsWin("PPTSld") )
parent.SldUpdated(GetSldId())
g_origSz=3DparseInt(SlideObj.style.fontSize)
g_origH=3Dsld.style.posHeight
g_origW=3Dsld.style.posWidth
g_scaleHyperlinks=3D(document.all.tags("AREA").length>0)
if( g_scaleHyperlinks )
InitHLinkArray()
if( g_scaleInFrame||(IsWin("PPTSld") && parent.IsFullScrMode() ) )
document.body.scroll=3D"no"
_RSW()
if( IsWin("PPTSld") && parent.IsFullScrMode() )
FullScrInit();
=09
MakeSldVis();
ChkAutoAdv()
if( runAnimations )
{
if( document.all("NSPlay") )
document.all("NSPlay").autoStart =3D false;
if( sld.filters && sld.filters.revealtrans )
setTimeout( "document.body.start()", sld.filters.revealtrans.duration * =
1000 );
else
document.body.start();
}
}
function MakeSldVis()
{
var fTrans=3Dg_showAnimation && SldHasTrans()
if( fTrans )
{
if( g_bgSound ) {
idx=3Dg_bgSound.indexOf(",");
pptSound.src=3Dg_bgSound.substr( 0, idx );
pptSound.loop=3D -(parseInt(g_bgSound.substr(idx+1)));
}
SlideObj.filters.revealtrans.Apply()
}
SlideObj.style.visibility=3D"visible"
if( fTrans )
SlideObj.filters.revealtrans.Play()
}
function MakeNotesVis()
{
if( !IsNts() ) return false
SlideObj.style.display=3D"none"
nObj =3D document.all.item("NotesObj")
parent.SetHasNts(0)
if( nObj ) {
nObj.style.display=3D""
parent.SetHasNts(1)
}
return 1
}
function ChkAutoAdv()
{
if(SldHasTrans())
SlideObj.onfilterchange=3DAutoAdv
else
AutoAdv()
}
function AutoAdv()
{
if(!IsWin("PPTSld") || !gUseSldTimings )return
var sld=3DGetCurSld()
if( (sld.mAdvDelay>0) && !parent.IsFramesMode() )
setTimeout("parent.GoToNextSld()",sld.mAdvDelay)
}
function GetObj(id)
{
if(g_supportsPPTHTML) return document.all(id);
else return document.getElementById(id);
}
function SldHasTrans() { return SlideObj.style.filter !=3D ""; }
function GetSldId() { return sId=3Dlocation.href.substring(location.href.la=
stIndexOf('/')+1) }
function HideMenu() { if( frames["PPTSld"] && PPTSld.document.all.item("ctx=
tmenu") && PPTSld.ctxtmenu.style.display!=3D"none" ) { PPTSld.ctxtmenu.styl=
e.display=3D'none'; return true } return false }
function IsWin( name ) { return window.name =3D=3D name }
function IsNts() { return IsWin("PPTNts") }
function IsSldOrNts() { return( IsWin("PPTSld")||IsWin("PPTNts") ) }
function SupportsPPTAnimation() { return( navigator.platform =3D=3D "Win32"=
&& navigator.appVersion.indexOf("Windows")>0 ) }
function SupportsPPTHTML()
{
var appVer=3Dnavigator.appVersion, msie=3DappVer.indexOf("MSIE "), ver=3D0
if( msie >=3D 0 )
ver=3DparseFloat( appVer.substring( msie+5, appVer.indexOf(";",msie) ) )
else
ver=3DparseInt(appVer)
return( ver >=3D 4 && msie >=3D 0 )
}
function _RSW()
{
if( !g_supportsPPTHTML || IsNts() ||
( !g_scaleInFrame && (!IsWin("PPTSld") || !parent.IsFullScrMode()) ) )
return
var padding=3D0;
if( IsWin("PPTSld") && parent.IsFramesMode() ) padding=3D6
cltWidth=3Ddocument.body.clientWidth-padding
cltHeight=3Ddocument.body.clientHeight-padding
factor=3D(1.0*cltWidth)/g_origW
if( cltHeight < g_origH*factor )
factor=3D(1.0*cltHeight)/g_origH
newSize =3D g_origSz * factor
if( newSize < 1 ) newSize=3D1
s=3DSlideObj.style
s.fontSize=3DnewSize+"px"
s.posWidth=3Dg_origW*factor
s.posHeight=3Dg_origH*factor
s.posLeft=3D(cltWidth-s.posWidth+padding)/2
s.posTop=3D(cltHeight-s.posHeight+padding)/2
if( g_scaleHyperlinks )
ScaleHyperlinks( factor )
}
function _InitAnimations()
{
animRuntimeInstalled =3D ''+document.body.localTime !=3D 'undefined';
isFullScreen =3D (window.name =3D=3D "PPTSld") && !parent.IsFramesMode();
g_animUseRuntime =3D g_showAnimation && animRuntimeInstalled && !(isFullSc=
reen && parent.IsSldVisited());
if( g_animUseRuntime ) {
collSeq =3D document.all.tags("seq");
if( collSeq !=3D null ) {
for(ii=3D0;ii
numSlds )
gSldJumpIdx =3D numSlds;
if ( gSldJumpIdx >=3D 0 ) {
if ( gSldJumpIdx =3D=3D 0 )
gSldJumpIdx =3D 1;
var jumpTo =3D parseInt(gSldJumpIdx);
gSldJump =3D 0; gSldJumpIdx =3D "";
win.GoToSld( parent.GetSldList().mList[jumpTo-1].mSldHref )
}
}
}
function _KDH()
{
if( event.keyCode =3D=3D 8 ) {
event.returnValue =3D 0;
parent.GoToPrevSld();
}
}
function DocumentOnClick()
{
if( IsNts() || parent.HideMenu() ) return;
if( ( g_allowAdvOnClick && (window.name=3D=3D"PPTSld") && !parent.IsFrames=
Mode() ) ||
(event && event.keyCode=3D=3D32) ) {
if( g_animUseRuntime && g_animMainSequence && g_animMainSequence.cangonex=
t )
return;
parent.GoToNextSld();
}
}
var g_supportsPPTHTML =3D SupportsPPTHTML(), g_scaleInFrame =3D 1, gId=3D""=
, g_bgSound=3D"",
g_scaleHyperlinks =3D false, g_allowAdvOnClick =3D 1, g_showInBrowser =
=3D 0, gLoopCont =3D 0, gUseSldTimings =3D 0;
var g_showAnimation =3D g_supportsPPTHTML && SupportsPPTAnimation() && ( (w=
indow.name=3D=3D"PPTSld" && !parent.IsFramesMode()) || g_showInBrowser );va=
r g_animManager =3D null;
var g_animUseRuntime =3D false;
var g_animItemsToHide, g_animInteractiveItems, g_animSlideTime;
var g_animMainSequence =3D null;
var ENDSHOW_MESG=3D"Fin du diaporama, cliquez pour quitter.", SCREEN_MODE=
=3D"Frames", gIsEndShow=3D0, NUM_VIS_SLDS=3D23, SCRIPT_HREF=3D"script.js", =
FULLSCR_HREF=3D"fullscreen.htm";
var gCurSld =3D gPrevSld =3D 1, g_offset =3D 0, gNtsOpen =3D gHasNts =3D gO=
tlTxtExp =3D 0, gHasNarration =3D 0, gOtlOpen =3D true
window.gPPTHTML=3DSupportsPPTHTML()
var gMainDoc=3Dnew Array(new hrefList("slide0116.htm",1,55521,1),new hrefLi=
st("slide0304.htm",1,73653,1),new hrefList("slide0289.htm",1,-1,1),new href=
List("slide0290.htm",0,-1,1),new hrefList("slide0292.htm",1,-1,1),new hrefL=
ist("slide0293.htm",1,-1,1),new hrefList("slide0294.htm",1,-1,1),new hrefLi=
st("slide0295.htm",0,-1,1),new hrefList("slide0296.htm",0,-1,1),new hrefLis=
t("slide0297.htm",1,-1,1),new hrefList("slide0011.htm",1,-1,1),new hrefList=
("slide0305.htm",1,-1,1),new hrefList("slide0306.htm",1,-1,1),new hrefList(=
"slide0307.htm",1,-1,1),new hrefList("slide0312.htm",1,-1,1),new hrefList("=
slide0313.htm",1,-1,1),new hrefList("slide0311.htm",1,-1,1),new hrefList("s=
lide0308.htm",1,-1,1),new hrefList("slide0288.htm",1,-1,1),new hrefList("sl=
ide0299.htm",1,-1,1),new hrefList("slide0302.htm",1,-1,1),new hrefList("sli=
de0301.htm",1,-1,1),new hrefList("slide0309.htm",1,-1,1),new hrefList("slid=
e0303.htm",1,-1,1),new hrefList("slide0314.htm",1,85534,1),new hrefList("sl=
ide0310.htm",1,-1,1));
function FullScrInit()
{
g_allowAdvOnClick =3D GetCurSld().mAdvOnClk
document.body.style.backgroundColor=3D"black"
document.oncontextmenu=3Dparent._CM;
document.onkeydown =3D _KDH;
document.ondragstart=3DCancel
document.onselectstart=3DCancel
self.focus()
}
function Redirect( frmId )
{
var str=3Ddocument.location.hash,idx=3Dstr.indexOf('#'), sId=3DGetSldId()
if(idx>=3D0) str=3Dstr.substr(1);
if( window.name !=3D frmId && ( sId !=3D str) ) {
obj =3D GetObj("Main-File")
window.location.href=3Dobj.href+"#"+sId
return 1
}
return 0
}
var MHTMLPrefix =3D CalculateMHTMLPrefix();
function CalculateMHTMLPrefix()
{
if ( document.location.protocol =3D=3D 'mhtml:') {
href=3Dnew String(document.location.href)
Start=3Dhref.indexOf('!')+1
End=3Dhref.lastIndexOf('/')+1
if (End < Start)
return href.substring(0, Start)
else
return href.substring(0, End)
}
return '';
}
function GetTags(base,tag)
{
if(g_supportsPPTHTML) return base.all.tags(tag);
else return base.getElementsByTagName(tag);
}
function UpdNtsPane(){ if(frames["PPTNts"]) PPTNts.location.replace( MHTMLP=
refix+GetHrefObj( gCurSld ).mNtsHref ) }
function UpdNavPane( sldIndex ){ if(gNavLoaded) PPTNav.UpdNav() }
function UpdOtNavPane(){ if(gOtlNavLoaded) PPTOtlNav.UpdOtlNav() }
function UpdOtlPane(){ if(gOtlLoaded) PPTOtl.UpdOtl() }
function SetHasNts( fVal )
{
if( gHasNts !=3D fVal ) {
gHasNts=3DfVal
UpdNavPane()
}
}
function ToggleOtlText()
{
gOtlTxtExp=3D!gOtlTxtExp
UpdOtlPane()
}
function ClearMedia()
{
if (PPTSld.pptSound) PPTSld.pptSound.loop =3D 0;
}
function FullScreen()
{
if ( PPTSld.g_animUseRuntime )
PPTSld.document.body.pause();
ClearMedia();
var href =3D ( document.location.protocol =3D=3D 'mhtml:') ? FULLSCR_HREF =
: FULLSCR_HREF+"#"+GetHrefObj(gCurSld).mSldHref;
if(PPTNav.event.ctrlKey) {
var w =3D (window.screen.availWidth * 1.0) / 2.0
var h =3D w * (PPTSld.g_origH * 1.0) / PPTSld.g_origW
win =3D window.open( MHTMLPrefix+href,null,"toolbar=3D0,resizable=3D1,top=
=3D0,left=3D0," + "width=3D"+ w + ",height=3D" + h );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
else
{
win =3D window.open( MHTMLPrefix+href,null,"fullscreen=3Dyes" );
if( win.document.body && PPTSld.g_animUseRuntime )
win.document.body.PPTSldFrameset=3Dwindow;
}
}
function ToggleVNarration()
{
rObj=3DPPTSld.document.all("NSPlay")
if( rObj && !PPTSld.g_animUseRuntime ) {
if( (rObj.playState =3D=3D 1)||(rObj.playState =3D=3D 0) )
rObj.Play()
else if( rObj.playState =3D=3D 2 )
rObj.Pause()
else
return;
}
else if( PPTSld.g_animUseRuntime )
{
narObj =3D PPTSld.document.all("narrationID")
if( narObj )
narObj.togglePause()
}
}
function GetCurSldNum()
{
obj=3DGetHrefObj(gCurSld)
if( obj.mOrigVis =3D=3D 1 )
return obj.mSldIdx
else
return gCurSld
}
function GetNumSlds()
{
if( GetHrefObj(gCurSld).mOrigVis =3D=3D 1 )
return GetSldList().mNumVisSlds;
else
return GetSldList().mList.length
}
function GetSldNum( href )
{
for(ii=3D0; ii 1 )
PopSldList();
else if( !IsFramesMode() ) {
if( gLoopCont )
GoToFirst()
else
EndShow()
}
}
function GoToPrevSld()
{
ii=3DgCurSld-1
if( ii > 0 ) {
obj=3DGetHrefObj(ii)
while ( obj && ( obj.mVis =3D=3D 0 ) && ( ii>0 ) )
obj=3DGetHrefObj(--ii)
if( ii =3D=3D 0 ) ii=3D1
GoToSldNum(ii)
}
}
function GoToFirst(){ GoToSld( GetHrefObj(1).mSldHref ) }
function GoToLast()
{
ii=3DGetSldList().mList.length
if( ii !=3D gCurSld )
GoToSld( GetHrefObj(ii).mSldHref )
}
function GoToSldNum( num )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
obj =3D GetHrefObj( num )
obj.mVis=3D1
gPrevSld=3DgCurSld
gCurSld =3D num;
PPTSld.location.replace(MHTMLPrefix+obj.mSldHref)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function GoToSld( href )
{
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
GetHrefObj( GetSldNum(href) ).mVis=3D1
PPTSld.location.replace(MHTMLPrefix+href)
}
function SldUpdated( id )
{
if( id =3D=3D GetHrefObj(gCurSld).mSldHref ) return
gPrevSld=3DgCurSld
gCurSld=3DGetSldNum(id)
if( IsFramesMode() ) {
UpdNavPane(); UpdOtlPane(); UpdNtsPane()
}
}
function PrevSldViewed(){ GoToSld( GetHrefObj(gPrevSld).mSldHref ) }
function HasPrevSld() { return ( gIsEndShow || ( gCurSld !=3D 1 && GetHrefO=
bj( gCurSld-1 ).mVis =3D=3D 1 )||( GetCurSldNum() > 1 ) ) }
function HasNextSld() { return (GetCurSldNum() !=3D GetNumSlds()) }
function CloseWindow() {
if( HideMenu() ) return;
var event =3D PPTSld.event;
if( !IsFramesMode() && event && (event.keyCode=3D=3D27 || event.keyCode=3D=
=3D32 || event.type=3D=3D"click" ) )
window.close( self );
CatchNumKeys( self, event );
}
function Unload() { gIsEndShow=3D0; }
function SetupEndShow() {
gIsEndShow=3D1;
PPTSld.document.body.scroll=3D"no";
PPTSld.document.onkeypress=3DCloseWindow;
PPTSld.document.onclick=3DCloseWindow;
PPTSld.document.oncontextmenu=3D_CM;
}
function EndShow()
{
if( IsFramesMode() ) return
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
doc=3DPPTSld.document
var dir =3D doc.body.dir
if( dir !=3D "rtl" ) dir =3D "ltr";
doc.open()
doc.writeln('' + ENDSHOW_MESG + '
=
body>')
doc.close()
}
function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue }
function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited }
function hrefList( sldHref, visible, advDelay, advClk )
{
this.mSldHref=3D this.mNtsHref =3D sldHref
this.mOrigVis=3D this.mVis =3D visible
this.mVisited=3D false
this.mAdvDelay=3D advDelay
this.mAdvOnClk=3D advClk
}
function SldList(arr,curSld,fEnd)
{
this.mCurSld =3D curSld;
this.mList =3D new Array();
var idx =3D 1;
for(ii=3D0;ii 0) {
PushSldList(sldList,fEnd);
gCurSld =3D 1;
}
else
if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue
}
function PushSldList(arr,fEnd) {
var ii =3D gSldStack.length;
gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd);
GoToSld( gSldStack[ii].mList[0].mSldHref );
}
function PopSldList() {
if (gSldStack[gSldStack.length-1].fEndShow)
EndShow()
else {
gCurSld =3D gSldStack[gSldStack.length-1].mCurSld;
gSldStack[gSldStack.length-1] =3D null;
gSldStack.length--;
var sldList =3D gSldStack[gSldStack.length-1];
GoToSld( sldList.mList[gCurSld - 1].mSldHref );
}
}
var custShowList=3Dnew Array();
function ImgBtn( oId,bId,w,action )
{
var t=3Dthis
t.Perform =3D _IBP
t.SetActive =3D _IBSetA
t.SetInactive=3D _IBSetI
t.SetPressed =3D _IBSetP
t.SetDisabled=3D _IBSetD
t.Enabled =3D _IBSetE
t.ChangeIcon =3D null
t.UserAction =3D action
t.ChgState =3D _IBUI
t.mObjId =3D oId
t.mBorderId=3D bId
t.mWidth =3D w
t.mIsOn =3D t.mCurState =3D 0
}
function _IBSetA()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 )
obj.style.posTop=3D0
}
}
function _IBSetI()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 )
obj.style.posTop=3D0
}
}
function _IBSetP()
{
if( this.mIsOn ) {
obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 )
obj.style.posLeft+=3D1; obj.style.posTop+=3D1
}
}
function _IBSetD()
{
obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 )
obj.style.posTop=3D0
}
function _IBSetE( state )
{
var t=3Dthis
GetObj( t.mBorderId ).style.visibility=3D"visible"
if( state !=3D t.mIsOn ) {
t.mIsOn=3Dstate
if( state )
t.SetInactive()
else
t.SetDisabled()
}
}
function _IBP()
{
var t=3Dthis
if( t.mIsOn ) {
if( t.UserAction !=3D null )
t.UserAction()
if( t.ChangeIcon ) {
obj=3DGetObj(t.mObjId)
if( t.ChangeIcon() )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth
else
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth
}
t.SetActive()
}
}
function _IBUI( clr1,clr2,nextState )
{
var t=3Dthis
SetBorder( GetObj( t.mBorderId ),clr1,clr2 )
obj=3DGetObj( t.mObjId )
obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj=
.style.posTop
t.mCurState=3DnextState
return obj
}
function TxtBtn( oId,oeId,action,chkState )
{
var t=3Dthis
t.Perform =3D _TBP
t.SetActive =3D _TBSetA
t.SetInactive=3D _TBSetI
t.SetPressed =3D _TBSetP
t.SetDisabled=3D _TBSetD
t.SetEnabled =3D _TBSetE
t.GetState =3D chkState
t.UserAction =3D action
t.ChgState =3D _TBUI
t.mObjId =3D oId
t.m_elementsId=3D oeId
t.mIsOn =3D 1
}
function _TBSetA()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gHiliteClr,gShadowClr,0,0 )
}
function _TBSetI()
{
var t=3Dthis
if( t.mIsOn && !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
}
function _TBSetP()
{
if( this.mIsOn )
this.ChgState( gShadowClr,gHiliteClr,1,1 )
}
function _TBSetD()
{
this.ChgState( gFaceClr,gFaceClr,0,0 )
this.mIsOn =3D 0
}
function _TBSetE()
{
var t=3Dthis
if( !t.GetState() )
t.ChgState( gFaceClr,gFaceClr,0,0 )
else
t.ChgState( gShadowClr,gHiliteClr,1,1 )
t.mIsOn =3D 1
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Introduction
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Re=
marques
1
Pr Philippe COURTET
Service de Psychologie M�dicale
& Psychiatrie
CHU Montpellier
2
3
Diagnostics: difficiles
D�tection: tardive
Pronostic: m�diocre
mortalit� de 5-20%
chronicit� des troubles dans 25% des cas
Complications m�taboliques et s�quelles psychosociales
Traitement: � am�liorer �
4
Boulimie
Fr�n�sies alimentaires, pulsions irr�pressibles
d�finit le � binge eating �
quantit� de nourriture > normale
�pisodes s�par�s ≠ grignotage
sentiment de perte de contr�le
am�liore l�humeur dysphorique, suivi de malaise
fr�quence minimale de survenue (2/sem , ≥ 3 mois)
Vomissements provoqu�s & abus de laxatifs
Peur morbide de devenir gros
2 sous types: purging / non purging
Anorexie Mentale
Comportement : perte de poids marqu�e (> 15%, IMC <17.5)
Psychopathologie : peur morbide de grossir
importance capitale du poids et de la forme qui gouverne sa percept=
ion
de soi
d�ni des cons�quences de la perte de poids
Dysfonctionnement endocrinien : amenorrh�e
2 sous types: Restrictif / Anorexie boulimie
5
6
7
8
Suicide abouti
Risque x 50 dans l�AN
2nde cause de mortalit� de l�AN
Risque plus faible dans la BN
Tentatives de suicide
20% des patientes AN
35% des patientes BN
9
Deux m�ta-analyses: suicide est la 2nde cause de mortalit=
�
Complications de l�amaigrissement: 46% - 54%
Suicide: 27% - 32%
Etudes longitudinales de suivi de patientes hospitalis�es
Etudes de suivis de patientes ambulatoires
Au total, 2,5% des patients AN d�c�dent de suicide
5,6% par d�cade
Taux de mortalit� standardis�s de suicide chez les femmes: 32 dans
l�AN, 0 dans la BN (d�pression 28, alcool 18, SZ 8)
X 8 / population� g�n�rale<=
/li>
10
La mortalit� est sup�rieure dans l�AN / la BN
Mortalit� suicidaire:
1,8%-2,9% dans AN
0 dans BN
Le risque de suicide abouti est �lev� dans l�anorexie mentale, faible
dans la boulimie
11
Bulik et al 1999 (n =3D 280 patientes ambulatoires)
AN 27%, BN 31%, d�prim�es 36%
Intention suicidaire: AN =3D MDD > BN
Viesselman & Roig (1995) (n =3D 95 hospitalis�es)
AN 23%, 19% binge, 20% binge + purge
Herzog et al (1999) (n =3D 246 ambulatoires)
AN-R 12%, AN-BingePurging 14%, BN 9%
Corcos et al (2002) (295 boulimiques ambulatoires multicentriques
francophones)
28% quel que soit le sous-type (BN-P, BN-NP, AN-BP)
12
1000 patientes TCA cons�cutives
36% TS
13
14
432 AN r�seau NIH
17% TS (intentionnelle)
AN-R 7%, AN-Purging 26%, AN-binge 29%, AN+BN 21%
Facteurs de risque:
Apr�s contr�le pour la d�pression:
S�v�rit� du TCA
Abus de substances, Panique, PSTD,
Cluster B, Impulsivit�
15
Comorbidit� psychiatrique
Abus de substances
Abus sexuels
Personnalit�
16
D�pression, dysthymie: 50-75%
Trouble bipolaire: 6-13%
TOC: 25% dans AN
Phobie sociale
Abus de substances: 20% dans AN (surtout purging), 1/3 des BN
Troubles de la personnalit�: > 50%
Abus sexuels: 20-50%
17
Risque de TS plus �lev� lorsque existent des comportements de � =
;purge �
(vomissements, laxatifs)
S�v�rit� des purge
Utilisation de laxatifs
S�v�rit� du TCA
18
Les abus sexuels sont un corr�lat suicidaire robuste dans les TCA
Pourrait d�finir un sous-groupe de BN avec des comportements
auto-destructeurs impulsifs marqu�s
19
Personnalit� du groupe B
Dimension � impulsive �
Dimension anxieuse
20
Etude longitudinale sur 9 ans, �valuation / 6 mois, de 250 patientes,
TS: 22% AN, 11% BN
21
22
Ant�c�dents de tentative de suicide
Ant�c�dents familiaux de conduites suicidaires
Impulsivit� agressivit�
Tendance au pessimisme
Abus dans l�enfance
23
Le risque suicidaire est bien r�el dans les TCA
Evaluer le risque et la l�talit� du processus suicidaire
Rechercher activement les abus de substances
Rechercher activement l�histoire de maltraitance infantile
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