L' « Ouverture émotionnelle » dans les Troubles de la dépendance et les Troubles de la personnalité

Emotion processing is supposed to play an important role in psychological dysfunctions in alcohol and drug dependency disorders (DD), as well as in personality disorders (PD). The model of “Emotional Openness” (“Ouverture émotionnelle”) provides a multidimensional framework to analyze problematic patterns of emotion processing. Within this framework, it is suggested that drug- and alcohol-dependent patients as well as borderline and antisocial patients show reduced a) “cognitive/conceptual representation” of affective states; b) “emotion regulation”; and c) “expression and communication of emotion”; but d) increased “awareness of body internal indicators” of affectivity; and e) appropriate psychological treatment is supposed to improve these patterns. Drug-dependent patients with PD comorbidity (in particular borderline or antisocial) are supposed to present even stronger deficits in (a) and (b). The hypotheses are tested with the 36-item DOE questionnaire (“Dimensions of Openness to Emotional experiences”, trait version; [19]), assessing six main dimensions of emotion processing as represented by the subject (French and Italian version). The instrument presents satisfying reliability coefficients (mean alphas of the scales in two recent studies (N = 251; N = 435) vary between 0.74 and 0.82) and good factorial validity (6-factor PCA solutions with varimax rotation solutions in the two samples are highly coherent; the mean of Tucker's congruence coefficients is 0.93). Results of two clinical studies are presented, comparing N = 71 patients (21 drug-dependent without personality disorder; 30 drug-dependent with borderline or antisocial personality; 20 dependent in-patients receiving psychological therapy) with normal control subjects (N = 51 matched; N = 50 reference group), including one pre-post treatment comparison. Results confirm marked deficits of DD patients concerning “conceptual representation” and “emotion regulation”, as well as a reduction of “communication/expression of emotion” but an increased “awareness of body internal indicators” of affectivity. Differences of patients with a double diagnosis correspond to effect sizes of d = -1.33 for cognitive/conceptual representation of emotions and d = -1.25 for emotion regulation; differences in emotion communication and expression are also significant but less important d = -0.44. Awareness of body internal emotion indicators is increased (d = +0.27) but does not differ significantly from the control group. As supposed, patients with a double diagnosis (DD and PD) described significantly stronger deficits in conceptual representation and emotion regulation than the patients with dependency disorder only. In the second study, a group of DD patients receiving multi-component treatment, including individual and group therapeutic intervention, according to the client-centered approach, and working on emotion processing, showed marked differences from the reference group at the beginning of the treatment (d = -0.91 for cognitive/conceptual representation, d = -0.82 for emotion regulation and d = +0.46 for awareness of bodily internal indicators). As supposed, pre-post comparisons indicate improvement with change effect sizes of d = 0.99 for conceptual representation, d = 0.97 for emotion regulation, as well as d = 0.88 for emotion communication and expression. Furthermore, the changes following treatment are highly significant and substantial, except for the awareness of internal bodily indicators, which only slightly decreased. Patients “normalize” their emotion processing following treatment, describing increased conceptual representation and emotion regulation, as well as emotion communication and expression. Results underline the importance of dysfunctional modes of emotion processing in both pathologies, and underline the validity of applying the model and the DOE instrument. They are discussed with reference to the model of alexithymia.     

Rôle des équipes de soins dans l'évaluation et la prévention de l'agressivité

Aggressiveness and violence in psychiatric wards have been common for some time. Situations that incur risks may originate at different levels such as the feeling that one is not heard, a break with one's entourage, feelings of isolation, factors related to pathology, postponing a treatment, the prohibition of smoking in the rooms... Further to the analysis of the relative situation of the patient, it is of utmost importance that the team pay attention to it's own sentiments of fear, to its divisions, to its feelings of distress and of its difficulties with some patients. On the other hand, conversations, follow-up at patient's homes and out of hospital psycho-educative groups are set up to allow patients to better manage their treatment, to detect risk situations for themselves and to detect early signs of relapse so as to forestall crisis situations and to avoid re-hospitalisation.     

Travail psychanalytique, transfert et maniement du transfert dans la cure des personnes diagnostiquées « psychose » ou « schizophrénie »

The possibility of a psychoanalytic treatment or cure in the case of a psychotic patient is the controversial subject of many discussions. We are reminding in this paper Freud's different positions about this subject, in order to show his ambivalence. We examine further the hypotheses and techniques that are proposed by several schools of psychoanalysis and we show how the technical rules of the treatment are resulting mainly of theses hypotheses concerning the etiology and the pathology. The technical rules are inducing a particular position of the analyst, which is different for each school. We assume that these postures are not excluding each other, but they are reflecting particular “moments” of the treatment, or specific “techniques” which are more or less appropriated for each category, we explicit different postures and we match they with these proposed by Freudian, Lacanian or Kleinian authors. The imaginary transference is the one described by Freud in “An Outline of Psychoanalysis”. It represents the transfer on the analyst's person of an early significant figure (imago). We argue the idea that the initial transference of a psychotic person is a transfer of “functions”, as in the R-scheme described by Lacan. The symbolic transference involves the language, i.e. the working out of a delusion. The real transference is the contrary of the neurotic process of “uncovering” the object: it is the one, which grasp the object into the discourse. We argue the idea that there is a possibility of structural mutations between psychosis and neurosis. The structure is conceived as a preferential pattern of relationship (transference) at a “m” moment.     

Une dimension de la barrière au traitement et sa fidélité chez des patients hospitalisés

The treatment barrier affects different modalities of opposition or resistance to the treatment process. It involves patients, medical or nursing teams, programs or institutions. An evaluation of the treatment barrier from the patient's view was investigated using a twenty item auto-questionnaire relative to knowledge of the care process and negative opinions relative to treatment, to psychotherapeutic relationship or to fear of dependence. This questionnaire was administered to schizophrenic patients or inpatients with affective disorders. The mean duration of the illness was over nine years. The treatment barrier was high in both groups and significantly higher for schizophrenic subjects compared to patients with affective disorders. Test-retests revealed a reliable fidelity. This study confirms the important role of multiple resistances to treatment.     

Une phénoménologie de la dépendance à l'alcool. Une expérience primordiale de la « nostrité »

The phenomenological approach to alcoholism interestingly focuses on specific dynamics of interpersonal relationships displaying the founding of the Self from a primary “us” and its original basis in the human feast. Priorities for treatment intervention recommend to involve social setting and relationships of the patients, reaching their active participation to a motivational and long term group treatment, underlying the specific therapeutic effect of world exchanges. Biopsychosocial determination of alcoholism could be primarily based on components of interpersonal relationships. Regarding social background, drinking is one of the most famous supports for the achievement of the feast, a founding marker of present time. Taking an existential point of view, the feast appears as the heart of mankind because it presents a primary “us”, a plural state which indicates the beginning and founding of the Self from the others. During the feast, we regularly have to reach our Self from the “us” while avoiding two main dangers, drunkenness, an increase in the dizziness of upright verticality, and addiction, an opposite vertical surrender to alcohol and falling into in the alcoholic relapse, both situations imply a spatial domination and the disappearance of others. Treatment programs of alcohol addicts need to integrate the necessity of reaching the existential basic trust from the support of a group to the appropriation of the community which can be defined as an original “usness”.     

Expertises pour la sécurité sociale : méthodologie et spécificités

Mental disorders represent in France for the Social Security the second post of spending in consumption of care with 11,4 billion euro, that is 10,6% of the spending, behind the diseases of the circulatory system. They stay in the rank of the pathologies justifying the allocation of a disability pension, representing 26,7% of invalids. It is to say the importance of the psychiatric expertise for the Social Security. This type of expertises is particular among the expertises in psychiatry because the objective of the expertise is to establish an arbitrage between the position of CPAM's doctor and his regular doctor. Effectively, except legal flaw, the opinion of the expert imposes upon the parts (parties). The realization of the expertise and its editorial staff are detailed in their specificities. Problem specific of the psychiatry are approached as well as the functions (offices) of the expert which are well beyond arbitrator's role towards a function of teacher and intermediary.     

Spécificité de la psychothérapie du patient postadolescent : à partir de deux exemples cliniques

This article is about the post-adolescence issue as a key period in the identity development of the subject prior to his definitive identification as an adult. At his stage in life, the adolescence's identity crisis goes on through tensions between two polarities, resulting in a more or less adaptative type of balance, requiring sometimes the need for special care. The process of subjectivisation “subjectivation” to adolescence that concurs with the problematic of borderline case continues with the construction of an achieved adulthood. This process requests nevertheless high levels of energy, hence resorting to specific psychological processes, sometimes leading to psychopathological disorders where recourse to psychotherapeutic treatments is necessary. This will be illustrated through the case studies of two post-adolescent girls, one requiring a light treatment to face a neurotic symptomatology, the other demanding a far heavier treatment in order to fight a chronic development of a psychotic symptomatology. The results are encouraging as far as specific cares are concerned at this stage in life, especially in fighting back a schizophrenic evolution after a state of delirium. They supply us as well with a model for treating borderline case pathologies and acute psychotic states at different stages in life.     

Étude de la limite dans le dispositif de la présentation du cas

A study of the limit in the case presentation setting. The pedagogic setting of clinical presentation can be considered as a limit-practice since « Leçon clinique »'s birth, as well as from the reactions it raised up than from the theoretic mouvements it inspired (Charcot, Ribot, Freud, Lacan…) The formation and transmission aim is studied and valued according to the concept of limit, which allows to show its full implications, its efficiency and its risks, and therefore, conjointly, its strength and its fragility. At the junction of the unversity and the hospital, of general and individual psychopathology, it stands today at the cross-roads of psychiatry and psychoanalysis. It embodies the history of transition from showing to verbal relation, from scopic dimension to psychoanalytic listening. The inherent violence of unconscious and instinctive strengths which work through this clinical and pedagogic act, produces a particular interference on the three protagonists - clinician, patient, audience; by this way, pass over tracks are founded, offering to the future clinicians, through a shared work, the main tools of listening and analysis of a clinical situation.     

Le surgissement de l'originaire et le « retrait hallucinatoire » dans les formes délirantes de l'éveil de coma

The clinical investigation of delirious and hallucinatory states during the awakening from a coma reveals hallucinated representations of a polymorphic nature. The diversity of their contents suggests the implication of differentiated etio-pathogenic processes. The assumption followed here, based on the conceptualizations of P. Aulagnier, is that the emergency care awakening traumatism causes a prevailing reinvestment of various operating modes, from the recovery of a “pictographic production” due to the abolition of conscience, to the fantastical scenario characterising primary education that remobilises and upsets the identity bearing layers in which the essential moments of the instinctual history were elaborated. These symptomatic constructions thus express this “in-more” generated by the psychotic processes which combine the double movement of a regression and of a “redeployment” of the traces of the Primal. This second period fulfils the paramount requirement of a primitive development of the coma awakening experience following the “postulate” of the dominance of the Primal according to which any psychic object is seen initially metabolized in a pictographic representation. The stratification noted within these dreamlike formations reveals: on the one hand modes of composition of images similar to those of the night dream; and on the other a deployment of various imagos of archaic states of the parcelled out body; and finally “psychic residues” that re-appear in the form of “parasitic” reminiscences, analysable as resurgences of psychic activities resulting from the coma phase. Thus a representation of the data of the Primal is then generated and although these data are psychic they remain forever heterogeneous and external to the Unconscious and to the I. The common clinical term which supports this analysis is “hallucinated feeling” which, according to Aulagnier, emerges sometimes within a schizophrenic patient which could be understood as equivalent to an autistic withdrawal which we suppose to be here at the heart of the deliriousness of the awakening from the coma. Thus the proposal that two etio-pathogenic logics are at work in these acute episodes: 1/ one that is initiated in a movement of decomposition of the I, due to the multiple traumatic effects of the primary affection and of the emergency care awakening process, balanced by the variations of the state of consciousness of the patient. At the time of this regression the projective mechanism, combined with other defences such as rejection or cleavage, reveals scenarios in the psychic space which mobilize images of the body and perceptive or mnemonic fragments. 2/ the other trajectory is comparable to this dynamics of the “withdrawal in the hallucination”. The re-establishment of the specific processes of the primary and secondary agencies imposes a requirement of specific psychic work consisting in metabolizing this resurgence of the pictographic representations that originate in the (quasi) nothing of the coma.     

Rétinopathie liée à l’interféron-ß 1a sous-cutané

Introduction

Interferon-α associated retinopathy is an ocular complication of hepatitis C treatment well established in the literature. But, there are far fewer reports on multiple sclerosis related interferon-ß retinopathy.

Case report

A 58-year-old male while receiving subcutaneous interferon-ß 1a 44 μg thrice a week since 2001 for multiple sclerosis developed blurred vision. Visual acuity remained stable throughout the course of surveillance. Cotton wool spots were found on fundus exam. The retinopathy disappeared without specific therapy 2 months after discontinuing interferon injections. The diagnosis of interferon-ß 1a retinopathy was retained due to the lack of any other etiology.

Conclusion

An ophthalmological examination including a fundus examination to search for a retinopathy should be undertaken when new ocular symptoms develop in a multiple sclerosis patient receiving interferon. An adverse event linked to interferon can be discussed and favored if the retinopathy resolves after interferon withdrawal.     

Psychothérapie et phénomènes de langage : une application clinique de la phénoménologie

The question is what possible interaction can be found between a personal interest in phenomenological philosophy and the practice of psychotherapy? To begin, applying a phenomenological thought process enables one to point out the distinction between the symptoms, rooted in reasoning by inference, a by-product of somatic medicine, and the phenomenon, as sensed by the psychiatrist, often without actual recognition. The intuitive grasp of phenomena requires the qualification of a sustained distancing as regards any established knowledge, which puts one in the position of being surprised by events, just as you can let yourself be surprised by children. In this way, it can be illuminating to compare the “sense of realisation” experienced through the psychotherapeutic dialogue with the account of a dream such as a child may supply. This is the kind of discourse which may witness the birth of “meaning in the making”, lack completion, which differs from the intentional meaning of acts of consciousness, such as traditionally described in phenomenology. In its manifestations, this meaning can be related to artistic significances, and particularly those, which are displayed, live during of an improvisation. Finally, applying a phenomenological method makes it possible to reveal as a true moment of crisis the moment when the continuity of discourse is interrupted, for example when experiencing boredom during an exchange. Such an interruption brings to light a fundamental feature of time and affectivity.     

Vérité et mensonge : l'évaluation de la crédibilité en psychiatrie légale et en pratique judiciaire

The issue of whether the truth or lies are being told in police and court hearings is as long-standing as justice itself and has given rise to countless forensic controversies. The focus of alienist doctors, especially in affairs of sexual assault, was on pathologic lying, mythomania, moral insanity, false self- and hetero-accusations, and the sincerity of children's testimonies. During the first half of the twentieth century, authors such as the Italian Altavilla, the Spanish Mira y Lopez and the Frenchman Gorphe devoted entire textbooks to the psychology of criminal investigations and trials, the analysis of hearings before investigators, the discrepancies between psychological truth and judicial truth and the methods for discovering lying and confabulation. Recent authors like Vrij, St-Yves and Landry have established a three-stage classification of practical and experimental procedures for detecting lying: a) observing the non-verbal and paralinguistic behaviour of the declarant ; b) analysing discourse in the search for clues to assess the credibility of the testimony ; c) technically measuring the emotion-driven physiological clues that accompany lying (polygraphy, voice analysis, electroencephalography with evoked potentials). In the absence of concrete evidence and when the accusation rests solely on the word of the presumed victim, the judge's firm conviction or reasonable certainty is the only element allowing the suspect to be judged. In such circumstances, psychological and psychiatric examinations of the personality of the accused and the « victim's » credibility will likely play a preponderant role in the ruling of the courts. In the current state of judicial practice, the psychological or psychiatric expert should in no way give his or her opinion about the reality of the matter or take the place of the judge in deciding where the judicial truth lays.     

Le rapport du sujet au langage : vers une approche des « phénomènes de style » dans la clinique des névroses

The present article questions a paradox specific to the clinical approach: how to reconcile the advantage in identifying structural indicators enabling a diagnostic to be elaborated, while also deriving the consequences of the limits of the structuralist hypothesis in order to aim at the indeterminate? Exploring the link between language, clinical structure and subjective position affords a way of highlight the structuring function of language in so far as it separates the body from its pleasure, thus simultaneously bringing out the subject. However, this link also reveals the antinomy between the universal and the singular, for which the notion of “style” constitutes an issue to be situated at the very core of the constitution of the subject and the social link. In its very prolongation, the notion of “phenomenon of style” emerges on the horizon as a possible specificity of the neurotic subject's relation to language. Indeed, J. Lacan showed us a tension at the origin of style: this both involve an effect of structural determinations, and that of a subjective choice in ethical terms. J. Lacan first explored the question of style in order to elucidate psychosis phenomena, but it also concerns, though not directly, neurosis. Through this approach, we hope to address the enigma that is constitutive of the subject in inventing its own neurosis, while simultaneously considering the traces of the movement that pushes a subject to invent words to express the unspeakable.     

Perturbations précoces de l'intersubjectivité et de l'empathie : quels liens avec les troubles externalisés de l'enfant et de l'adolescent ?

Child and adolescent behavioral disturbances including narcissistic and conduct disorders share several delays or enduring dysregulations in executive control and empathy. These neurocognitive abnormalities are rooted in the early perturbations of the infant's intersubjective relationships with his environment. How much those early impairments will result in latter disruptive disorders depends on the contribution of environmental factors. The presentation will review in an integrative manner psychoanalytic works and recent neurobiological findings.