RESUMEN
OBJECTIVES: In total, 14% to 30 % of individuals with gambling disorder engage in illegal acts to finance such behavior. This clinical situation could be explained by higher gambling severity, associated substance use disorder, antisocial personality disorder and economic factors (debts, financial problems). The present work focuses, more broadly, on criminal responsibility of problematic gamblers. METHODS: We will discuss this question through different typical situations that medical experts of criminal responsibility may have to face. We will address each of the following cases: 1) isolated problematic gambling; 2) problematic gambling associated with antisocial personality disorder; 3) problematic gambling associated with a manic episode; 4) problematic gambling associated with substance use disorders; and 5) problematic gambling associated wiht dopamine agonist treatment. RESULTS: Isolated problematic gambling, (not associated with any psychiatric or addictive disorder): it seems consensual that individuals committing infractions in this case are criminally responsible. However, impeded ability to action control and possible sentence attenuation could be discussed in case of severe gambling disorder. Problematic gambling associated with antisocial personality disorder: if the penal offence reports solely to personality disorder, criminal responsibility would be attributed. However, if illegal or violent acting is directly linked to co-cocurrent delusional symptoms, it could be a cause of criminal non-responsibility. Problematic gambling associated with manic episode: manic episode related offence could lead to negation of criminal responsibility, while a hypomanic episode may provide grounds for sentence reduction. Problematic gambling associated with substance use disorders: in France, addiction is not considered to remove nor to impede a person's ability to understand or control his actions and is excluded from criminal non-responsibility causes. However, substance induced delusional or confusional episodes could abolish a subject's discernment or his ability to control his actions yielding to penal non-responsibility. Problematic gambling associated with dopamine agonist treatment: Criminal responsibility for dopamine agonist induced gambling related illegal acts is still controversial. Nevertheless, people committing an infraction linked to associated dementia or dopamine agonist induced mania should be considered as criminally non-responsible. CONCLUSIONS: Some clinical dimensions such as craving intensity, compulsivity, disorder's severity, volitional control might be forensic targets to assess criminal responsibility.
Asunto(s)
Conducta Adictiva , Criminales , Juego de Azar , Humanos , Trastornos de la Personalidad , Conducta SocialRESUMEN
THEORETICAL BACKGROUND: The borderline personality disorder is a complex psychiatric disorder that represents a high number of patients in a psychiatric adult service. Even if some therapies have shown to be effective in the therapeutic care of the borderline personality disorder they only target certain symptoms (e.g. anxiety, sadness, self-mutilation). The aim of this paper is to introduce a therapeutic model little known in France: the mentalization based therapy (MBT) developed in 2004 by Bateman and Fonagy. This therapeutic model apprehends the borderline personality disorder in all its complexity and is based on two main concepts: Bowlby's attachment theory and the concept of mentalization. The MBT is based on the hypothesis that a deficit of mentalization leads to the development of borderline disorder. The capacity of mentalization, also known as reflexive function, is acquired in infancy through interpersonal relationships, in particular those of attachment, and is the ability to understand the mental state (emotions, needs, thoughts, etc.) of oneself and others which underlies explicit behaviour. This reflexive capacity is of a better quality when the person has a secure attachment style. Indeed, borderline patients have, mainly, a deficit of mentalization capacity associated with an insecure attachment style. Thus, the main objective of the Bateman and Fonagy approach is to develop and reinforce the mentalization capacity through a therapeutic relationship as a secure base, a group therapy and the concept of insight. THERAPY STRUCTURE AND TECHNIQUES: Classically, MBT is structured over a period of 18 months divided into 3 distinct phases distributed in two therapeutic axes: group and individual therapy. The initial phase aims to engage the patient in the therapy by evaluating attachment style, mentalization's ability, interpersonal functioning; providing psychoeducation about borderline disorder and establishing a therapeutic contract. To evaluate attachment style, the authors strongly recommend the use of the Relationship Scales Questionnaire. During the second phase, which includes individual and group therapy, the aim is to stimulate the capacity of mentalization through different techniques according to the patient's attachment style. These include therapeutic relationship, empathy, affect clarification and elaboration, positive and negative reinforcement. The final phase serves to review the patient's improvement and to prepare him progressively for the end of the therapy which can be experienced as an abandonment. CLINICAL TRIALS OF MBT AND DEVELOPMENTS: Effectiveness of MBT in treating borderline disorder has been shown in several studies with short and long term benefits. It can be adapted for other personality disorders and specific populations such as adolescents. CONCLUSION: This article introduces the key concepts and aims of mentalization based treatment. The therapy is briefly described in its different phases and the various techniques are discussed. Clinical trials have shown that MBT is effective in treating borderline disorder in adolescent and adult populations. Despite the effectiveness of this therapy, it is difficult to set up and requires substantial resources. Interpersonal therapy based on attachment provides a therapeutic model focused on problematic areas which can offer an alternative therapy and reduce the fields of investigations.
Asunto(s)
Trastorno de Personalidad Limítrofe/terapia , Psicoterapia/métodos , Teoría de la Mente , Adolescente , Adulto , Trastorno de Personalidad Limítrofe/psicología , Emociones , Empatía , Femenino , Francia , Humanos , Relaciones Interpersonales , Masculino , Modelos Psicológicos , Apego a Objetos , Escalas de Valoración Psiquiátrica , Psicoterapia de Grupo , Refuerzo en Psicología , Resultado del TratamientoRESUMEN
OBJECTIVE: A review of the consequences of maternal depression on fetal and infant development and the risk and benefits of SSRI use. METHOD: We have reviewed the literature published on PubMed between January 1980 and February 2009 using the following keywords: SSRI, depression, pregnancy, abnormality, teratogenic effect. RESULTS: Pregnancies complicated by the onset or recurrence of a major depressive disorder constitute a complex medical situation. The management of such situations is based on the principle of avoiding, as far as possible, the exposure of the developing foetus to both the maternal illness and the potential teratogenic effects of psychotropic drugs. Epidemiological studies show that maternal depression is a very frequent disease: 10 to 16% of pregnant women fulfill major depressive disorder diagnostic criteria and 15% suffer from postpartum depression. The consequences of such exposure on fetal and infant development are so harmful that a pharmacological treatment is highly recommended. Nowadays, the information available on the safety of SSRI use in pregnancy is abundant and these molecules are probably the most studied drugs in pregnant women. Their beneficial effects largely prevail over their potential fetal/neonatal risks and it is unlikely that any marked teratogenic effect occurs, with the possible exception of an increased risk for cardiovascular defects after maternal use of paroxetine. However, transient neonatal symptoms are common after SSRI use in late pregnancy. These include transient autonomic, gastrointestinal, somatic, and clinical respiratory manifestations in the immediate neonatal period. CONCLUSION: Treatment of maternal depression during pregnancy and immediate neonatal period is uniformly recommended despite the potential side effects on the fetus and newborn. With a possible exception for paroxetine, maternal treatment with SSRIs during pregnancy is not associated with significantly increased risks of congenital defects.