Florence Thibaut is a psychiatrist and endocrinologist, currently professor of psychiatry at the University Hospital Cochin-Tarnier of Paris-Descartes University (France). Her research interests are varied and include addiction, schizophrenia genetics, and paraphilia. An investigator in many clinical and pharmaceutical studies, she is also past-president of both the French Association for Biological Psychiatry (AFPB) and the World Federation of Societies of Biological Psychiatry (WFSBP). She is president-elect of the International Association for Women’s Mental Health (IAWMH) and, since 2015, a member of the WHO expert panel on pharmacodependence. Professor Thibaut is author of 250 academic papers and has published five books and 70 books chapters.

In an interview with ECNP, she shared some insights into her career choices as well as her ongoing research work.

You completed your medical training and then went on to obtain a PhD in Parkinson’s disease research. Where did you go from there?
Initially, I was an endocrinologist and psychiatrist. During my internship I also became interested in neurology. That is why I got involved in basic research in both neurology and psychiatry for the PhD. At that time, in the 1980s there was very little basic research going on in psychiatry in France.

I then used my expertise in endocrinology and neurology in psychiatry. Psychiatric disorders are complex and multifactorial – much like, for example, diabetes. Diabetes is a multifactorial, complex disease in which medication is very important, and this was all being developed in endocrinology at that time. So that helped me a lot in psychiatry.

You then went on to develop a number of research interests. Could you describe how these came about?
There is a link between my work in endocrinology and my research on sex offenders. My boss in endocrinology was in charge of research on male sexual hormones. There was the link between testosterone and sex offences. That is why I was, very early on, involved in work on sex offenders.

Concerning genetics, I was working with neurologists and endocrinologists during an internship, and they were conducting the first genetic studies in diabetes and dementia. That was the reason I became interested in genetics. Then, with the same kind of model, we tried to find genes involved in schizophrenia.

Why were you interested in schizophrenia?
Schizophrenia is related to dopamine, and I was interested in dopamine because of Parkinson’s disease. I have all these different interests because of my internship between endocrinology, neurology, and psychiatry. When I moved to Paris, my university hospital asked me to switch to addiction, which is why my focus is more on addictive disorders now.

You recently published an issue of Dialogues on Clinical Neuroscience focused on addiction.¹ You say in your editorial, “Surprisingly, DSM-5 no longer separates abuse from dependence.” Could you explain this point – is it so surprising?
They decided to no longer differentiate between abuse and dependence. Yes, but personally I think that dependence is still a very useful concept for clinicians. There is a continuum between people that don’t drink at all and people that drink too much and are dependent. In my opinion, dependence has not disappeared. It forms the most severe part of this continuum. Clinically, it has a lot of significance. Therapeutic options still rely on the concept of dependence, and withdrawal remains a key component before or during treatment.

Aside from pharmacologic treatments of addiction, how challenging is the psychological treatment aspect, i.e. engaging patients with themselves and developing their self-awareness and decision-making abilities?
You are improving their decision-making with regard to stopping alcohol or drugs. This has to come from the patient themselves, and cannot be enforced by the clinician. Brief intervention (BI) is a patient-centred form of counselling that uses brief versions of cognitive behavioural therapies and motivational interviewing, or some combination of both. The principle of BI is to motivate the patient to change his or her behaviour by pointing out discrepancies between his or her current behaviour and his or her goals, without giving the impression that the clinician is responsible for that change or that the clinician has imposed it on the patient.

You have also lately published on the importance of considering the impact of gender in research.² Certainly, a decade ago, animal model research was predominantly conducted in males. How much has changed?
A little bit has changed. Howard et al.³ recently analysed 728 papers published in JAMA Psychiatry and the British Journal of Psychiatry between 2012 and 2015. Among them, 16% stratified analyses by sex, but no studies reported a calculation powered for the analysis of its primary outcome by sex.

A Spanish member of the European Parliament, Beatriz Becerra Basterrechea, asked the parliament to be very forceful against the European Medicines Agency (EMA) and other medicines agencies, to impose upon them and pharmaceutical companies the requirement to conduct some studies in females, or at least to take gender into account in the statistical analysis of every drug appearing on the market from now on. Recently, and interestingly, the European Parliament urged the EMA to draw up separate guidelines for women as a specific population in clinical trials. The FDA in the US officially took some decisions in this way too. But we should follow up on this issue, because it ought to change.

Paraphilia is another of your research interests. Would you say that the lack of clinical research in this area motivates you especially?
The reasons for the lack of clinical research are the following. In the past, unfortunately, psychiatrists were not very interested in it. I don’t know exactly why. For example, in France, for a very long time there were only two of us interested in it. More recently, young psychiatrists have become interested – but only very recently.

The second reason is that each time I try to find grants to work in this field it is very, very difficult. We are trying to set up a cohort of sex offenders in Europe, but there are no grants in the European Commission. I have also tried another way of finding money, through the field of sexual violence and women, but also here there are no grants.

This is not a topic of interest in Europe. In addition, there are no pharmaceutical companies interested in it, although in fact 10 % of the population have been a victim of rape. A recent report concludes that, in 2012-13, the cost of child sexual abuse in the UK was 4.37 billion euros (including social, physical and mental consequences, as well as legal system expenses).⁴ This makes it a huge topic of interest. But it remains hidden.

A 2014 paper you co-authored on paraphilia pharmacologic treatment describes the treatment process.⁵ Could you describe how challenging it is to build trust between a physician and a patient, given the difficulty that many experience in coming forward for treatment at all?
With respect to serial rapists and severe paedophiliac patients, anti-androgen treatment (if used) takes one month for testosterone to decrease and two to three months to get maximal clinical efficacy. Patients will have gradually lessening sexual cravings, which means that they become more able to think and to talk about it. They then realise that sex offending is very bad for their victims. Usually when they realise this, they become depressed. Then it takes six months to one year for them to recover, and to be able to reorganise their lives.

To establish trust between the psychiatrist and a paraphiliac patient may take as long as three to five years. In fact, in severe cases, treatment may be lifelong, much like antipsychotics in severe forms of schizophrenia.

Could you summarise what the most pressing needs are in this field?
In co-operation with the World Federation of Societies of Biological Psychiatry, we have established guidelines concerning the types of sex offenders, and the types of treatment that could be required for different levels of severity of sex offending and paraphilia.⁶

There are also some research studies being conducted with neuroimaging and genetics, trying to understand why these individuals are sex offenders, why they are paedophiles or exhibitionists or rapists. Rapists are more difficult to understand, because this is a very heterogeneous group. But if you don’t know the ‘why’, you cannot find the right treatment.

In 2017, Florence Thibaut was a chair and a speaker at one of the sessions S.18 (Behavioural addictions: diagnosis, co-morbidity and neurobiology) in the 30th ECNP Congress.

In this video, she talks about what ECNP Congress means to the scientific community. She also talks about her work in the field of schizophrenia for several years and her advice to junior scientists. She is a member of the Scientific Advisory Panel of ECNP.