Le diagnostic du trouble de personnalité limite (TPL) à l’adolescence est sujet de controverse chez certains chercheurs et cliniciens. Pour plusieurs, les symptômes présentés chez les jeunes ayant un TPL ressemblent au fonctionnement normal à l’adolescence. Le diagnostic est alors retardé à l’âge adulte, décalant la mise en place d’un traitement. L’objectif de cette recension systématique de la littérature est d’examiner les symptômes permettant la différenciation d’une population adolescente avec un TPL de celles ayant un autre diagnostic ou non psychiatrisée. En tout, 17 études sur les 4 789 titres initialement identifiés rencontrent les critères d’inclusion et sont analysées. Cette recension systématique considère plusieurs symptômes diversifiés : troubles internalisés et externalisés, suicide, erreurs de mentalisation, schémas mésadaptés et diagnostics comorbides. Plusieurs symptômes distinguant de façon statistiquement significative les adolescents avec un TPL ont pu être observés en les comparant à trois groupes contrôles : les adolescents non psychiatrisés, ceux avec un autre trouble de personnalité et ceux ayant un autre diagnostic. Finalement, un patron de symptômes a pu également être observé entre les adolescents suicidaires ayant un TPL et ceux sans ce diagnostic. / The diagnosis of borderline personality disorder (BPD) in adolescence is controversial among some researchers and clinicians. For many, the symptoms presented in young people with BPD resemble normal functioning in adolescence. The diagnosis is then delayed in adulthood, postponing the treatment. The aim of this systematic review of the literature is to investigate the symptoms that can differentiate an adolescent population with BPD from one with another diagnosis and/or without any psychiatric issues. In all, 17 studies out of the 4,789 titles initially identified met the inclusion criteria and were analyzed. This systematic review considers diverse symptoms: internalized and externalized disorders, suicide, mentalization errors, maladaptive schemas and comorbid diagnoses. Several symptoms significantly differentiated adolescents with BPD from three control groups teenagers: non-psychiatric, with another personality disorder and with another diagnosis. Finally, a pattern of symptoms could also be observed between suicidal adolescents with BPD and suicidal youth without it.

Individuals with substance abuse or mental illness/neuropsychiatric disorderssuffer a higher risk of developing comorbidity. Due to the complexity of comorbidity individuals may often need multiple support from both social services and health care. Previous studies have shown that the relationship is a crucial aspect of the recovery process between the social worker and the client. It needs to be based on mutual trust, user participation and clarity. Social workers had to balance between individuals right over their own life situations and the responsibility to decide on compulsory care when the person opposes help and exposes their life to serious injury. The study aimed to investigate how socialworkers described the experience of responding to and support individuals living with comorbidity. The method chosen was semi-structured interviews with six social workers from four municipalities in Skåne. The findings showed attempts to contemplate different challenges of individuals. There were noted difficulties when investigating a person due to their mental health. Furthermore, their experiences were described as motivating and humane work. Their experience described the role of a social worker as a representative between a zero tolerance society and to start working with the client where they were. In addition, it was noted as important to familiarize oneself with aspects that the substance abuse contributed to. The insights into why individuals resorted to substance use opened up discussions about alternative solutions that did not include addiction. The reflections that emerged were adaptations of how meetings were designed and how the individuals were made involved, through the help of different strategies to examine the individual’s wishes.

Previous research describes co-morbid substance use disorders and eating disorders as a complex issue. Research on collaboration between Swedish addiction treatment facilities and Swedish eating disorder care is scarce. The aim of this Bachelor thesis is to analyze and understand how professionals in addiction care and professionals in eating disorder care experience collaboration regarding people with comorbid substance use disorders and eating disorders. The approach of this study is hermeneutic. The bio-psycho-social model and Collaboration Theory are used for data analysis. The data consists of nine semi-structured interviews with professionals working in either regional eating disorder care or municipal addiction care or in an independent addiction treatment facility. The informants work in different Swedish municipalities and regions having varying occupations. Some work in social services, others in medical care. Our results show varying experiences of collaboration among the informants. Some informants think collaboration works well whilst others see room for improvement. Poor collaboration is described by some informants as due to organizational prestige or bureaucracy. Some informants emphasize that referrals between different care units lead to long wait times for the patients/clients during which nobody takes responsibility for the patient, whose health may worsen. The professionals use different strategies, treatments, and methods to treat and recognize comorbidity and to collaborate with other care units. Joint care planning, reaching a consensus and having a holistic viewpoint are methods that the informants use. The informants have different views on which disorder that precedes the other, and also on which treatment is best suited for this type of comorbidity. Several professionals believe that the addiction should be treated primarily. According to the professionals, prerequisites for collaboration are: established contact with other collaborative parties, the knowledge and accessibility of other professionals, patient consent and motivation. An exchange of knowledge at an organisational level is requested, regarding subjects such as collaboration and comorbidity. / Tidigare forskning visar att samsjuklighet i form av missbruk och ätstörning är ett komplext problem. Forskning om samverkan mellan missbruksvård och ätstörningsvård i Sverige är dock ett relativt outforskat område. Denna intervjustudie syftar till att analysera och förstå hur professionella inom missbruksvården och professionella inom ätstörningsvården upplever samverkan gällande personer med samsjuklighet: missbruk och ätstörning. Studien antar en hermeneutisk ansats, det biopsykosociala perspektivet samt samverkansteori används för att analysera empirin. Empirin består av nio semistrukturerade intervjuer med professionella inom regional ätstörningsvård, kommunal missbruksvård och ett fristående behandlingshem. Informanterna arbetar i olika kommuner och regioner samt har olika yrkesbakgrund inom bland annat socialtjänst eller hälso- och sjukvård. I studien framgår de professionellas samverkanupplevelse, arbets- och behandlingssätt av personer med samsjuklighet i form av missbruk och ätstörning. Därtill framgår vilka förutsättningar som enligt informanterna bör ligga till grund för att upprätta samverkan kring klientgruppen. Resultaten visar att de professionellas erfarenheter och upplevelse av samverkan varierar. Att samverkan fungerar väl respektive om samverkan behöver förbättras lyfts fram. Dålig samverkan på grund av prestige eller i form av en byråkratisk klyfta mellan kommun och region identifieras av några informanter. Vissa informanter framhåller att remisskickande mellan vårdenheter leder till långa väntetider, där klienten eller patienten ”bollas runt”. Under väntetiden kan den vårdsökande fara illa. De professionella använder olika arbetssätt och strategier för behandling, för att fånga upp samsjuklighet och för att inleda samverkan. Gemensam vårdplan, samsyn och helhetssyn är några arbetssätt de professionella utgår ifrån. Informanterna har olika syn på vilket sjukdomstillstånd som föregår det andra och ser även olika på vilken behandling som lämpar sig bäst för denna typ av samsjuklighet: flera anser att missbruket bör behandlas först. Upplevda förutsättningar för samverkan är upprättade kontakter med annan samverkanspart, professionellas kunskap, tillgänglighet samt patientens samtycke, initiativtagande och motivation. Organisatorisk kunskapsöverföring om samverkan och samsjuklighet efterfrågas.

Bipolar disorders (BD) are characterized by symptoms of grandiosity, decreased need for sleep, pressure to keep talking, flight of ideas, distractibility, increased goal-directed activities, psychomotor agitation, and excessive involvement in pleasurable activities. Those with a bipolar disorder have a high degree of psychiatric comorbidity including substance use disorders, and they also experience increased mortality. Despite the widespread recognition of BD as an important psychiatric condition, available population-based estimates for BD prevalence differs across data sources. Cannabis is one of the most widely-used illicit substances. Evidence supports it as a risk factor for psychotic symptoms and disorders. Because populations with psychotic disorders and populations with bipolar disorder share genetic characteristics, cannabis may increase risk for bipolar disorders through the same pathways as it does with psychotic disorders. Limited and conflicting evidence regarding the association of cannabis use and bipolar disorder is currently available. This dissertation investigates cannabis use as a risk factor for incident manic symptoms and bipolar disorders in a large nationally representative longitudinal cohort. The first aim of this dissertation is to evaluate the implications for manic, hypomanic and major depressive episode prevalence estimates arising from the different approaches to assessing DSM-IV criterion between two national surveys. Differences in the assessment of impairment strongly influence manic or hypomanic classification within the NESARC. Compared to multiple imputation estimates (19.7% [95% CI: 19.3-20.1]) which treat depressed mood and anhedonia as separate symptoms, symptom assessment in the NESARC substantially underestimates major depressive episode prevalence (16.9% [95% CI: 16.1-17.6]). The second research objective examined self-reported cannabis use as a risk factor for incident manic symptoms, bipolar spectrum disorders (including manic and hypomanic episodes) and SCID-based recalibrated BD I and II. Cannabis use risk was assessed in the population as a whole and in sub-populations defined by age, substance abuse/dependence status, and family history. Among those reporting no lifetime major depressive or manic symptoms at baseline, self-reported past-year cannabis use was associated with increased odds of an incident week of extremely elevated or irritable mood accompanied by at least two manic episode criterion B symptoms (adj. OR 1.69, 95% CI: 1.08-2.65, p=.02) over the three year follow-up period. Among adults (ages 26 to 45) >=1 reported use(s) of cannabis per week was associated with incident manic or hypomanic episodes (adjusted OR 2.52, 95% CI: 1.32-4.80, p=.006). Among those endorsing no major depressive symptoms, substance abuse/dependence, or anti-social traits in their first degree relatives, past year cannabis use is associated with increased risk for incident bipolar spectrum disorders (adjusted OR 2.27, 95% CI: 1.01-5.10, p=.05) and CIDI recalibrated BD I and II (adjusted OR 5.49, 95% CI: 1.38-21.9, p=.02). Past year cannabis use risk for DSM-IV manic or hypomanic episodes among those aged 26 to 45 is concentrated in those with a baseline history of a substance use disorder (adj. OR 2.00, 95% CI: 1.10-3.66, p=.02) as compared to those with no such history (adj. OR 1.87, 95% CI: 0.49-7.21, p=.36). The third research objective of this dissertation was a sensitivity analysis using externally-predicted categorized exposures and continuous cannabis use propensities. The sensitivity analysis found evidence of exposure misclassification. Exposures defined by external propensity scores had improved cross-sectional association with bipolar spectrum disorders compared to reported use when both were compared to an external standard. No significant risk estimates were found for categorized predicted cannabis use among groups that were previously found to have significant risk from reported exposure. However, among adults 18 to 45 years of age with no manic or major depressive symptoms at baseline, past year cannabis use propensity (as a log transformed continuous measure) was associated with incident manic or hypomanic episodes (adj. OR 1.49, 95% CI: 1.10-2.03, p=.01). Elevated risk for high cannabis use propensity (>=1 use/week in the past year) was also found in this same group (adj. OR 1.33, 95% CI: 1.03-1.72, p=.03). Among those with no reported history of depression, substance abuse/dependence, or anti-social traits among their first-degree relatives, propensity for past year cannabis use (adj. OR 1.61, 95% CI: 1.11-2.32, p=.01) and propensity for >=1 use/week of cannabis in the past year (adj. OR 1.38, 95% CI: 1.03-1.85, p=.03) were associated with incident manic or hypomanic episodes. Among those without a substance use history at baseline, propensity for past year cannabis use (adj. OR 1.63, 95% CI: 1.33-1.55, p=1 use/week of cannabis in the past year (adj. OR 1.54, 95% CI: 1.26-1.88, p The findings of the first aim support the conclusion that the AUDADIS substantially under-estimated lifetime major depressive episode prevalence compared to an imputed estimate that treated anhedonia and depressed mood as separate and concurrent MDE symptoms. The operationalization of impairment for manic disorders in both the AUDADIS and CIDI strongly influences case identification, with the CIDI having suppressed manic and hypomanic prevalence estimates. Evidence was found supporting the conclusion that self-reported cannabis use is a significant risk factor for incident bipolar spectrum outcomes within subpopulations in a nationally representative cohort. A sensitivity analysis finds evidence that supports the conclusion that increasing cannabis use propensity is associated with increased risk of bipolar spectrum outcomes within population subgroups, with the greatest increased risk among those with the lowest innate risk. Under-reporting of illicit substance use is a major limitation in this dissertation; further study is needed with improved exposure measures.

This work deals with the issue of dual diagnosis, namely patients with schizophrenic disease who are addicted to drugs and their view of the anxiety process. Theoretical background research is devoted to schizophrenic disease, addictive disorders and specifics in the treatment of patients with dual diagnosis. The aim of this research was to find out how users of addictive substances with a schizophrenic circuit disorder evaluate and experience the process of their anxiety. To create the above goal, I set the main research question, concretized by three sub- questions: (1) How do drug users with schizophrenic disorders assess and experience the process of their anxiety? (1.1.) "How do drug users with schizophrenic disorders have insight into their difficulties in treatment?" (1.2.) "How the level of these difficulties changed before the end of treatment"? (1.3.) "What aspects of recovery do these patients consider important?" The research set was selected by methods of improbable purpose. The research group finally consisted of four patients, i.e. hospitalized in the Psychiatric Hospital X. Sources of data for the case study in this case are medical documentation of patients (anamnestic data, records of group and individual therapies) and semi-structured interviews. The obtained data fixed by audio...

Denna studie syftade till att undersöka hur socialsekreterare inom socialtjänsten uppfattar sina nuvarande förutsättningar för att samverka vid samsjuklighet i form av missbruk och psykisk ohälsa, samt vilka förutsättningar förslagen från regeringens samsjuklighetsutredning, kan ha för att åstadkomma bättre hjälp till målgruppen. En kvalitativ forskningsdesign med semistrukturerade intervjuer användes och fem socialsekreterare deltog. Resultatet indikerade att samverkan brister, främst på grund av strikt uppdelning mellan socialtjänst och hälso- och sjukvård. Möjligheter till samverkan var främst beroende av individuella faktorer. Socialsekreterarna ställde sig positiva till samsjuklighetsutredningens förslag, men var skeptiska till huruvida de kommer att verkställas. Analysen visade att socialtjänst och psykiatri kan anses ha skilda ansvarsområden, kunskapsbaser och regelverk. Uppsatsens diskussion underströk att socialsekreterarnas uttalanden liknade det som tidigare forskning framlagt, det vill säga att samsyn och samordnat arbete behövs vid samsjuklighet. Implementerande av samsjuklighetsutredningens förslag skulle kunna bidra till större förutsättningar för samverkan. / This study aimed to investigate how social workers in social services perceive their current conditions for collaboration in case of comorbidity in the form of substance abuse and mental illness, and what conditions the proposals from the recent comorbidity-investigation by the government may have, to provide better help to the target group. A qualitative study with semi-structured interviews was used and five social workers participated. The results indicated that there is a lack of collaboration, mainly due to a strict division between social services and health- and medical care. Opportunities for collaboration were mainly individual factors. The social workers were positive to the comorbidity inquiry´s proposals but were sceptical about whether they will be implemented. The analysis showed that social services and psychiatry can be considered to have different areas of responsibility, knowledge base and regulations. The thesis discussion underlined that the statements of the social secretaries were similar to those presented by previous research, which is that consensus and coordinated work are needed in case of comorbidity. An implementation of the comorbidity inquiry´s proposal could contribute to greater conditions for collaboration.

This report presents an overview of the results of the US National Comorbidity Survey (NCS) (Kessler et al., 1994) and future directions based on these results. The NCS is a survey that was mandated by the US Congress to study the comorbidity of substance use disorders and nonsubstance psychiatric disorders in the general population of the US. (...)

Der Beitrag diskutiert kritische theoretische und praktische Aspekte der Komorbidität auf der Grundlage von klinischen und epidemiologischen Befunden zur Komorbidität. Angststörungen weisen statistisch hochsignifikante Assoziationen untereinander sowie mit affektiven, psychotischen Störungen, Eβstörungen sowie Substanzstörungen und Persönlichkeitsstörungen auf. Sie gehen zumeist eindeutig den komorbiden Störungen voraus, so daβ Angststörungen als Risikofaktoren für viele andere Formen psychischer Störungen angesehen werden können. Die möglicherweise kausalen pathogenetischen Mechanismen sind jedoch nach wie vor umstritten und sind offensichtlich vielfältig. Der Beitrag diskutiert vor diesem Hintergrund besonders die möglicherweise kritische Bedeutung von Panikattacken als zentraler «Vulnerabilitätsmarker» nicht nur für die Entwicklung von Angststörungen, sondern auch für affektive Erkrankungen. Hier konnte z.B. nachgewiesen werden, daβ initiale Panikattacken nicht nur die Wahrscheinlichkeit für Rückfälle sekundärer Depressionen erhöhen, sondern auch signifikant die Häufigkeit und Länge depressiver Phasen beeinflussen. Die Vielzahl differenzierter Befunde legt nahe, Komorbidität bei der Eingangs- und Verlaufsdiagnostik ebenso wie bei der Indikationsstellung umfassender zu berücksichtigen.

Background: It is commonly assumed that there are clear lines of demarcation between anxiety and depressive disorders on the one hand and psychosis on the other. Recent evidence, however, suggests that this principle may be in need of updating. Methods: Depressive and/or anxiety disorders, with no previous history of psychotic disorder, were examined for the presence of psychotic symptoms in a representative community sample of adolescents and young adults (Early Developmental Stages of Psychopathology study; n=3021). Associations and consequences of psychotic symptomatology in the course of these disorders were examined in terms of demographic distribution, illness severity, onset of service use, and risk factors. Results: Around 27% of those with disorders of anxiety and depression displayed one or more psychotic symptoms, vs 14% in those without these disorders (OR 2.23, 95% CI 1.89–2.66, P < .001). Presence as compared with nonpresence of psychotic symptomatology was associated with younger age (P < .0001), male sex (P < .0058), and poorer illness course (P < .0002). In addition, there was greater persistence of schizotypal (P < .0001) and negative symptoms (P < .0170), more observable illness behavior (P < .0001), greater likelihood of service use (P < .0069), as well as more evidence of familial liability for mental illness (P < .0100), exposure to trauma (P < .0150), recent and more distant life events (P < .0006–.0244), cannabis use (P < .0009), and any drug use (P < .0008). Conclusion: Copresence of psychotic symptomatology in disorders of anxiety and depression is common and a functionally and etiologically highly relevant feature, reinforcing the view that psychopathology is represented by a network or overlapping and reciprocally impacting dimensional liabilities.

Studiens syfte var att undersöka yrkesverksamma socionomers upplevelser av samverkan mellan socialtjänsten och hälso- och sjukvården avseende klienter med samsjuklighet. Dessutom undersöktes vilka faktorer som försvårar och underlättar samverkan samt framtida förutsättningar för fungerande samverkan. En kvalitativ metod med semistrukturerade intervjuer har använts för att samla in det empiriska materialet. Sex yrkesverksamma socionomer intervjuades. Samtliga respondenter arbetade i samma kommun och inom samma verksamhet. Det empiriska materialet analyserades utifrån fyra organisationsteoretiska begrepp: integration, organisatoriska fält, institutionella logiker samt verksamhetsdomän. Resultatet indikerade att respondenterna upplevde samverkan mellan socialtjänsten och hälsooch sjukvården som bristfällig. Otydlig ansvarsfördelning, bristande resurser samt skilda arbetssätt mellan de två aktörerna var de faktorer som främst låg till grund för den upplevda bristande samverkan. Vidare framkom det att samverkansmodeller samt intresse och engagemang från sjukvården främjar samverkan mellan aktörerna. Avseende framtida förutsättningar för samverkan ansåg respondenterna att insatser behöver utformas efter klienternas behov och att en omorganisering av verksamheterna är nödvändig. Resultatanalysen visade att socialtjänsten och hälso- och sjukvården arbetar inom samma verksamhetsområde och organisatoriska fält, men att de har sina egna institutionella logiker samt konkurrerande domänanspråk. Analysen visade även att det finns en domän som ingen av parterna direkt tar ansvar för, vilket är behandling av den psykiska sjukdomen hos samsjukliga klienter. Vidare visade analysen att det finns en avsaknad av horisontell styrning mellan parterna för att uppnå samverkan. / This study aimed to investigate the experiences of social workers of the collaboration between social services and healthcare regarding clients with co-morbidity. We also investigated which factors hinder and facilitate cooperation, as well as future conditions for functioning cooperation. A qualitative method with semi-structured interviews was used to collect our empirical material, where six social workers were interviewed. The data was analyzed based on four organizational theoretical concepts. The result indicates that the collaboration between social services and healthcare was deficient, mainly due to factors such as unclear divisions of responsibilities, lack of resources, and different working methods between the two organizations. Furthermore, it emerged that collaboration models as well as interest and commitment from healthcare promote collaboration between the organizations. There were two factors regarding future conditions for collaboration, which were a need for contributions to be designed according to the client’s needs and a reorganization of the organizations. Our analyses showed that social services and healthcare operate within the same organizational field, but that they have their own institutional logics and competing domain claims, which can make cooperation difficult. The analysis also showed that there’s a domain neither party directly takes responsibility for, which is the treatment of mental illness in co-morbid clients. Furthermore, the result showed that there is a lack of horizontal control between the organizations to achieve cooperation.