Hyperactivité chez l'enfant : réflexions sur les mécanismes psychopathologiques sous-jacents

Requests for consultations in child psychiatry for cases of hyperactivity with or without attention deficit disorder (ADHD) have increased markedly in the last few years. Hyperactivity is presently the most frequently occurring psychopathological disorder in young children. This change could be linked to the mediatisation of this disorder and to a lowering of the threshold of tolerance to behavior disorders and externalized conduct in a 'hyper-controlled' society. We could also question the subjective character of this poorly defined clinical entity about which there is no strict consensus. Thus, early detection of troubles which would allow us to diagnose hyperactivity before the age of four also beg the question of comorbid diagnoses (oppositional behavior or aggressiveness) and above all questions the interactive system in which the young child is developing. The Anglo-Saxon approach tends to consider hyperactivity as a complete syndromic entity (this is encouraged by the diagnostic criteria - essentially behavioral - of the DSM IV), favoring an organic approach (due to the importance of genetic inheritability). The European approach, the minority approach, does not dissociate the problem from its environmental context and pays more attention to affective problems, to the structuring of the personality and to inter-family relations. This second approach will be developed by the authors, giving preference to two stages, on the one hand (1) that of the process of separation - individuation, symbolization and socialization, and on the other hand, (2) that of the establishment of the process of secondary narcissism, of the role of psychic instances which are the ego ideal, the ideal ego and the superego. They will also consider (3) societal evolution and the functioning of the family, shedding light on the maternal or paternal role in the genesis of problems of hyperactivity. These clinical considerations lead the authors to suggest a distinction between two types of clinical hyperactivity which they will discuss based on their practices and on the literature: 1)“Hyperactivity with early behavioral problems, due mainly to the problematics of separation” and 2) “Attention problems with hyperactivity, anxiety, difficulties at school, due mainly to narcissistic problems.” These two types can be said to correspond in some way to the categorical forms of ADD and ADHD (according to the criteria of the DSM IV): 1) Attention-Deficit/Hyperactivity Disorder Predominantly Hyperactive-Impulsive Type and 2) Attention-Deficit/Hyperactivity Disorder Predominantly Inattentive Type. They are also akin to the findings of various authors who have attempted to reveal the particularities of anxious hyperactive subjects as compared to non-anxious hyperactive subjects, or of behavioral hyperactivity as compared to cognitive hyperactivity. Several principles of therapeutic treatment will be referred to for each clinical type.     

De l'effraction traumatique au processus de création, narcissisme et sublimation

The original link which exists between sublimation and narcissism is a link which may sometimes be dangerous. The purpose of this study is to show, based on the paintings of Nicolas de Staël, the nature of certain traumatic events which are or were experienced as obvious breakings. In that it is inextricably linked to the issue of the body, narcissism is, right from the beginning, involved and in tune with the sublimatory activity which is considered by Freud to be also at the outset. The painting portrays the surface of the self and affects the integrity of a precarious self which is the true narcissic subject. A good example is the life of Nicolas de Staël which was troubled, violent and traumatic at the beginning. So long as painting helps him live, the fine link between narcissism and sublimation continues to be sufficiently solid so as to maintain a cohesion between the psyche and the soma. However, if the melancholic object appears so as to return to the reality of the space of the painting, the sublimatory process may remain unable to preserve the subject which Ferenczi refers to as the « self-tear process ».     

Psychose froide, relation fétichiste : réflexions à propos d’un cas

Using certain fragments in the case study of a young patient hospitalized on several occasions at our institution and who was diagnosed as suffering from a “cold” psychosis, we have studied the pertinence of this concept in the institutional management of young non-delirious psychotic patients and smokers of hashish. E. and J. Kestemberg introduced the concept of “cold psychosis”. At the clinical level, this refers to that category of patients with identity disorders and a tendency towards substance abuse. Recourse to a fetish is one of the main elements in their intrapsychic functioning. The fetishistic relation is based on Freudian concepts of fetishism, but extends beyond the field of sexual perversion and leads to a particular type of object-relation, the predominant defence mechanisms being the split at the level of the self and denial. The use of a “fetish” by these patients is a means of providing a focus to bypass delirious expression in their transactions with reality, and the fetishistic relation also has a protective role in warding off innate aggressivity which could otherwise be expressed in an uncontrolled manner. This type of relation is established very early on in the infant’s development, even before he exists as a subject in relation to his mother. Later on, the adolescent or young adult is unable to identify with the oedipean triangle, as recourse to fetishism at an intrapsychic level is reflected by a split within the self, which blocks the way to bisexuality. In these patients who are prone to vacillating narcissism, and whose capacities for identification and sense of personal identity are a vast wasteland in which all relation with another individual represents a menace of annihilation unless they have at their disposal the possibility of dealing with the delirious situation and restructuring their attitude to life, the diversity of professional care-givers and mental healthcare centers that provide the institutional framework are the triggering factor for the therapeutic process which can guide these subjects towards a possible investment in the world outside, and in the individuals who live there.     

Anorexie mentale et problématique familiale

The etiological factors associated with the syndrome of anorexia nervosa are heterogenous. This pathology which is connected with adolescence and the effect of the onset of puberty has in particular been associated with narcissistic disorders (notably the concept of negative narcissism), leading to behavioral disorders. Although some studies have examined the role of the parents’ personality in the etiology of this disorder, only few studies have focused on certain specificities of family dynamics. The functioning of the family group can thus lead to an intergenerational lack of differentiation, and an intense interactivity that is fostered by an incestual bond. On the basis of a case study in which a multifocal treatment approach was adopted, we have analyzed how traumatisms, the suppression of mourning and loss at the parental level can be responsible for the development of an intergenerational lack of differentiation. This results in an impossibility to integrate the sexual element during adolescence: sexuality is viewed as a threat by the anorexic subject. The trauma associated with puberty is intensified by a particularly stimulating and exciting reality, i.e. that of a continuing state of narcissistic seduction. It is therefore necessary to determine what prevented the initial expression of mourning and loss which could have instigated a first separation with the primary object. From this viewpoint, a multifocal approach is advocated so that the symptoms of the young adolescent and their relation to family history can be more widely investigated and understood.     

La mythomanie : ludisme bipolaire et protestation identitaire

Mythomania (Dupré, 1905) and pathological lying are imaginative fabrications resorting to deceit, imposture and lying as well as to play and delusion. Whether it be an acute or a long-duration identification to a newly formed or imaginary person, this can be understood either as self entertainment, as a hypo-manic equivalent, or as an identity replacement to restore one's self-esteem and narcissism. Some clinical examples are given to illustrate these psychopathological perspectives.     

E. Weiss et G. Perec, ou la nécessité psychique de l’écriture autofictionnelle

This article is a comparative analysis of two autofictions: The Trial by Fire (Die Feuerprobe) by Ernst Weiss and W by Georges Perec. Both writers, who are well-versed in psychoanalysis, decide to search for their unconscious by writing autofiction. To Weiss and Perec, only this process will allow them to access the memory that has stored traumatic events occulted by childhood amnesia. The writers share a phantasmic — yet, anonymous — agreement with their attentive reader. In both texts, the analyst reader observes the figure of an inner witness who writes in order to capture a child lost in the writer's unconcious. This infantile part is psychotic, as it is caused by an early-childhood trauma, possibly the father's death, and it focuses on primary narcissism. It also involves an anal bunker that is supposed to serve as a protective barrier against any traumatic memory surge. The mental state of the child threatens the psychogenic integrity of the two writers. A clinical reading of the two works unveils the secret of autofictional writing: the inner witness, identified with Freud, becomes the mother/father analyst for the lost child. Thus, under the protective fantasy of self-procreating, a psychical rapport with the child has been recreated. As the inner witness brings back the father's law into the rules of language, the primitive scene is extirpated from amnesia and opens up to desire, even if only during the writing process. Thus, autofictional writing saves a precarious and borderline psychical equilibrium.     

Individualized prediction of trait narcissism from whole‐brain resting‐state functional connectivity

Narcissism is one of the most fundamental personality traits in which individuals in general population exhibit a large heterogeneity. Despite a surge of interest in examining behavioral characteristics of narcissism in the past decades, the neurobiological substrates underlying narcissism remain poorly understood. Here, we addressed this issue by applying a machine learning approach to decode trait narcissism from whole‐brain resting‐state functional connectivity (RSFC). Resting‐state functional MRI (fMRI) data were acquired for a large sample comprising 155 healthy adults, each of whom was assessed for trait narcissism. Using a linear prediction model, we examined the relationship between whole‐brain RSFC and trait narcissism. We demonstrated that the machine‐learning model was able to decode individual trait narcissism from RSFC across multiple neural systems, including functional connectivity between and within limbic and prefrontal systems as well as their connectivity with other networks. Key nodes that contributed to the prediction model included the amygdala, prefrontal and anterior cingulate regions that have been linked to trait narcissism. These findings remained robust using different validation procedures. Our findings thus demonstrate that RSFC among multiple neural systems predicts trait narcissism at the individual level.     

Passion et pratique sportive

Clinical psychiatrists should approach links between passion and the practice of sport by several angles. Indeed there is no linearity between the practice of sport and the emotional system supporting it. In this presentation, the author will try to take a psychological approach to various aspects from the relation to risk, to addiction, via the implications of narcissism and of the ideal.     

Séquelles délirantes d’une psychose puerpérale ancienne, un climat d’inquiétante étrangeté : observation clinique

Mr and Mrs P., recently settled in the area, are experiencing difficulties. Mr P. suffering from depression has to be admitted to the hospital. Mrs P., who suffered for years from bipolar trouble, is sent to the outpatients department for medical supervision of her lithium treatment. Discussions with her and the reading of a text she wrote years before bring back a delirious experience, which happened 20 years ago involving the disturbing strangeness of a world of goats. This looking back into the past becomes the starting point of an intense pictorial productivity on which the psychotherapy will be based… An eight months effort which will succeed in obtaining the normalization of family life and a better adaptability to reality.     

Les thérapies médiatisées, médiations artistiques. Musicothérapie

The music therapy is one among the four specialties of the arts therapies. It is known since ancient times and in every culture. Its professionalization is recent, in France as on the international level. This article presents a short history, basic theories, principal methods, what it is for, and how are its effects evaluated. The reader will find the debate on the place given to art in the therapies, and precisions on the new trainings (Master degree professional and research).     

La mélancolie : de la psychiatrie à la métaphysique

The concept of melancholy covers a conjunction of very diverse revelations, which include phenomenons of philosophical or spiritual nature. We will study this problem, questioning in what melancholy refers to the difficulties of metaphysical nature, maybe to understand a little better the mental pathology. We will refer ourselves to the notion of totality, which answer to the intuition as a primary phenomenon in the relation which the other, maybe like an actualised expression of the ideal-ego, a totality of which the reasoning has to pass by; like the language has to exclude an object, which has to be repaired maybe in the field of art. We will see how the artist, the philosopher and the religious, also anybody concerned by the psychical suffering, follow different ways. They are all concerned by the desire of an unreachable absolute of which each theory is just a reflect despite their hegemonical temptations. That will be the matter of a thought about the intuition considered as a primary movement of the relation to the other, a movement, which precedes its creative organisation.     

La psychanalyse entre athéisme freudien et ouverture à l’écoute de l’évènement intérieur du sujet

The question left open by Freud in his 35 new conference is perhaps more interesting today than before World War II: how psychoanalysis is going to take place in the conflict between religious and scientific world conceptions. To start to answer, we shall return to the question of Freud's identification with “the man Moses”, we shall also take into account his words: “I am an infidel Jew”, and we shall examine his attitude towards religious beliefs and mysticism. In the end, we will be able to understand why his view on spiritual life can enlarge our conception of psychic personality.     

Une nouvelle prise en charge de la sphère oro-faciale des enfants paralysés cérébraux par un jeu interactif en 3D

Rehabilitation of facial praxia in children affected by cerebral palsy is an important goal, although its efficiency remains hard to evaluate. We have listed difficulties encountered by a child during a session of classical rehabilitation, and we propose a novel technique of rehabilitation based on the use of an interactive avatar. In addition to the game-like use of this interactive tool, motions captures that will be recorded during work sessions will also be usable to get metric measurements of the buccofacial movements of children with cerebral palsy. For each child, we will be able to define their own characteristics, which will probably reflect the great heterogeneity of clinical aspects and movements developed by these children. This study will require that each patient will be his own control to evaluate the efficiency of this new protocol.     

Analyse phénoménologique de la notion d'événement et ses implications pour la psychopathologie

If, contrary to most facts whose meaning is context dependant, an event is understood as having a meaning that is not context dependant, precisely because this event reshapes completely the context, one can understand that such an event may induce the collapse of all basis of interpretation, or in other words the collapse of the world as the horizon of intelligibility, as the horizon of possibilities from which can be constructed the meaning. One can also understand in which sense the world we deal with, when such an event occurs, is the world that arises with and through this event. This phenomenological understanding of the event sheds a new light on aspects of empirical research in psychopathology in which the event plays a central role. We will consider the case of “reaction pathologies”, as well as epidemiological research on life events in psychopathology. Finally, we will come back to the hypothesis, proposed by philosophers, of a loss of the ability in psychotic states to remain open to the event, and in general to the unforeseen..     

Les pathologies neurovisuelles chez les enfants cérébrolésés

Cerebral visual impairment is one of the main causes of child visual impairment in developed countries. The pattern of the brain damage is dependent on the stage on brain development at insult, the severity and the duration of the insult. Brain pathology caused by an insult during the first and second trimester will cause cerebral malformations. Between 24 and 34 weeks, brain damage is referred to as periventricular leucomalacia, subcortical damage affecting particularly visual pathways. After 34 weeks, hypoxic-ischaemic injury leads to cortical lesions in chronic injury and subcortical nuclei lesions in acute hypoxia. Visual dysfunction is caracterized by fixation troubles, subnormal acuity, visual fields defects, difficulty with perceiving depth, cognitive defects (dysgnosia [pictures, objects], prosopagnosia, visuospatial disorders, clumsiness to identify an element within a crowded scene and to bring about visually guided movement, difficulty with movement perception), ocular motility disorders (tonic gaze deviation, strabismus, nystagmus).     

Intérêt d'une approche multidisciplinaire en psycho-oncologie des personnes âgées

Old age is not an illness. However the incidence of cancer increases with age. The care of elderly persons with cancer has its own “technical” specificities that will lead to decide whether to apply or not, to adjust or not, cancer treatments in the most individual way possible. This implies a global and pluri-disciplinary approach of the elderly cancer patient. Among the actors of care, psycho-oncologists will have to explore the vast and little-known world of the behaviour of elderly cancer patients, their repercussions on the illness and the results of the treatments on the quality of life of the patients. That is what the “onco-more or less psychologist” expects from the “psycho-more or less oncologist”…     

Le concept d'originaire en psychanalyse

Advent of psychic life in infant faces researchers with the challenging question of primal object that is primal conditions of this emergence. Freud's answers consist mainly in “archaeological” models and hypothesis of phylogenetic inheritance. These hypothesis have been often examined critically. In this article, we propose a reality-based “primal device”. According authors' hypothesis mother and infant are structurally and mutually involved in a “primal gap” which demands regulation. For mother, regulation is carried out by primary maternal preoccupation and prohibition of incest. For infant, regulation is carried out by inner physiological and instinctive patterns, perceptive and interactional skills, and primary narcissism. So are defined setting and experiences resulting in construction of primary object which represents in authors' opinion the beginning of psychic life.     

La confusion des sexes : un écueil et une chance pour la clinique

This article has an objective: relieve the « natural evidences » concerning sex in 2006. These « natural evidences » will be twice criticized: first, opposing scientific data, which give them a new complexity; second, examining throughout several level of observation. Decomposing and complexing sex category, it should be possible to show that many certitudes are indeed, not strongly established. While taking account of the new men and women constitutions, and the many opportunity of combining them, this article would like to show a contemporary psychiatry must not ignore or — it would be the same — deny them in categorizing this kind of subjectivity in a pathological section, with perversions, as if they have to be excluded of our reflection because of escaping from a model seeing the world only as heterosexuality and dichotomy. It will be time, then, to ask what could replace the classical representations on which our clinical argumentation relies.     

Le Réseau santé mentale Yvelines-Sud : « une expérience pilote »

The aim of this communication is to present the process and current status of an experiment concerning the establishment of a general mental health network, initiated in 1999, in the residential area of Yvelines-Sud (600,000 inhabitants). The author will summarise the methodological principles underlying the functioning and development of this network, while also describing its mode of organization ; he will also highlight two types of concrete interventions, already being practiced in the area. 1. specialist consultation and joint follow-up procedures ; 2. the set-up of the liaison team operating in the field of socialwork and medicine. The general objective is to improve joint health care procedures involving the various partners in the field of mental health.     

Phénoménologie non intentionnelle et psychopathologie

The relations between phenomenology and psychopathology must be examined in an evolutionary perspective. Two distinct periods clearly stand out this way: a founding period and a contemporary period. The former period encompasses the works of E. Husserl, M. Heidegger and L. Binswanger. As for the contemporary period, it is characterized by a close connection and a convergence between the works of many phenomenologist psychiatrists and philosophers. This presentation will focus on the contemporary period and will aim at bringing to the fore a new trend in the relations between phenomenology and psychopathology, characterized by a closer, and thus more complex, reciprocity. Indeed, contemporary phenomenology takes into account and integrates the understanding of psychotic phenomena as far as to transform the sense of philosophy; it looks as if there were a break with the intentional phenomenology. According to Husserl, the consciousness is always consciousness of something, intentionality is a property of directedness towards an object. Not only do psychotic phenomena question the organisation of thinking, but also the constituent forms of experience, rooted in non intentional grounds. Three philosophers, Henri Maldiney, Marc Richir and Michel Henry, have renewed the non intentional approach of phenomenology. Recentering itself on the enigma of madness, philosophy makes it possible for psychiatry to reconsider mental illnesses which used to be dealt with only in terms of deficiencies. The reference to H. Maldiney will shed light on the human phenomenon seen at the crossing of the catastrophe and of the crisis. The issue of philosophical anthropology is then posed on the background, which is questioned and destabilized by the psychotic experience seen as an agonistic moment of derealisation and depersonalisation. The schizophrenic existence evades any constituent foundation of subjectivity and intentionality. The presentation of M. Richir's meditations will then lead us to redefine philosophy as a radical phenomenological epoche confronted with the abyss of the psychotic epoche. M. Richir re-enacts the Husserlian tradition, and in particular, the idea of genetic phenomenology, dealing with passive syntheses in which the body-of-flesh and the non intentional tonality come before the emergence of the consciousness. The last reference will be the work of M. Henry bases on philosophy of life and non intentional phenomenology; an opposed direction to Husserl will be taken by singling out pathos as an auto-affection of life. Pathos becomes the essential form of affect as condition for the actual existence, independent of intentionality. According to M. Henry, life never appears in the exteriority of the world, life's pure manifestation appears in its invisible interiority. The end-point of this phenomenology is the primitive suffering, thus the phenomenology of life concerns the qualitative aspects of psychopathological experiences bounded to a radical passivity. From the issue of psychosis, contemporary non intentional phenomenology carries out the theoretical, therapeutic and ethical consequences in the field of psychiatric research and practice.