La médicalisation de l'intuition charitable : de saint Jean de Dieu à Philippe Pinel

To shed some light on the medicalization movement that has pervaded psychiatry for more than a decade, the authors focus on the origin of our discipline in France from a historical point of view. They compare the work of Philippe Pinel, founder of French psychiatry and the work of the brothers of Saint John of God in the 18th century. These brothers began admitting the mentally ill in five of their French hospitals (Cadillac, Charenton, Château-Thierry, Pontorson and Senlis). They provided sympathetic and compassionate care derived from their Christian humanism and inspired by their founder saint John of God (1495-1550). They materialized the charitable intuition that he had had towards the insane. They gave primacy to compassion in their approach to caring. During the French revolution, as the order of Saint John of God was dissolved and dispersed Philippe Pinel was appointed “Doctor in charge of the infirmaries” at the Bicêtre hospital in Paris in 1793. Pinel, who had studied theology, subscribed to the charitable instinct but he transformed it by introducing scientific and empirical philosophic dimensions. He suggested a medical approach based on observation and analysis of large numbers of the mentally ill. As an example of this medicalization process, the authors propose a comment on one of Pinel's articles entitled “Medical Thoughts on the Monastic Life”. This view of the history of psychiatry allows a renewed understanding of our scientific and medical approach in psychiatry. On the other hand, it seems to raise some questions about the place given to subjectivist dimensions, such as empathy, in our daily caring practice.     

Les « pousseurs de métro » : à propos de huit cas de patients hospitalisés en unité pour malades difficiles

“Subway pushers” have been newspapers' highlights but also a forensic subject. Through eight case reports of offenders sent to high secure unit (unité pour malades difficiles Henri Colin), a profile of homeless psychotic man without any outpatient treatment has been found. Crimes seem unmotivated, where as delusions or hallucinations exist. Meta-analysis confirms this profile, though some alcoholic pushers have been described. Prevention of these tragic accidents rests on psychiatrists' awareness of homeless mentally ill people risk and safety subway programs.     

L'évolution du concept de mythomanie dans l'histoire de la psychiatrie

During the l9th century, morbid lying and imaginative exuberance are pointed out in several forms of the mental alienation: Intellectual monomania (Esquirol, 1819), hereditary madness (Morel, 1860), megalomania (Dagonet, 1862 and 1876), grandiose delusion (Foville, 1871) — with ideas of filiation — and over all hysterical madness (J. Falret, 1866; Lasègue, 1881). Several historical personages reincarnated (false Joan of Arc, false Louis XVII) have likely suffered from these disorders. For the first time in Germany, Delbrück isolates an autonomous form of pathological lying that he calls “pseudologia fantastica” (1891). The French alienist E. Dupré (1862-1921) describes in 1905 the mythomania and its three forms: 1) vain (fantastic boasting, criminal autoaccusation, malingering); 2) mischievous (hoax, slanderous accusation, anonymous letters); 3) perverse (swindlers, seducers, wandering mythomania). Dating from 1910, Dupré characterizes the delusions based on “imaginative” mechanisms, with grandiose ideas, either chronic (autosuggestion, confabulation), or acute (often symptomatic of delirium, dementia, amnestic or mood disorders). In 1919, he considers mythomania as the basis of hysteria, through its “constitutional” (or “temperamental”) theory of mental disorders. These conceptions are accepted by Delmas and Boll (1922), Heuyer (“délire de rêverie”, 1922), Vinchon (1926) and Dide (1935), but criticized by the pupils of Charcot (Janet), the phenomenologists (K. Schneider) and the “structuralist” school (Ey). Kraepelin's confabulatory and fantastic paraphrenias are compared with Dupré's imaginative delusions by the pupils of H. Claude (Nodet, 1937). But the intuition is separated from the imagination as an autonomous delusional mechanism (1931), whereas Delay (1942) and then Guiraud (1956) distinguish confabulation from mythomania. Since the DSM-III (1980), the word mythomania is no more retained into psychiatric classifications. The clinical entity of Dupré is divided in delusional disorders (grandiose type), facticious disorders, antisocial, narcissistic and borderline personality disorders. On the other hand, pathological lying is nowadays differentiated from malingering, delusions, Ganser's syndrome and confabulation. Its boundaries with histrionic personality disorder are not clear.     

« L'expertise » de fin d'hospitalisation d'office médicolégale (article L 3213-8 du code de la santé publique)

The “expertise” required by article L. 3213.8 of the Code of Public Health is exceptional within the statute of “compulsory hospitalization” (Police-instructed compulsory hospitalisation in France corresponds to the juridical or court-ordered hospitalisation in Anglo-Saxon law). This paper proposes a critical analysis of this “expertise” and of the ensuing situation of pathological criminals based on an extended practice of expertise and taking into consideration the recent evolution of the concept of dangerousness.     

Déjouer le jeu. Réappropriation et détournement de l'univers de jeux vidéo dans la création contemporaine

In the era of cyber culture and collective intelligence, video game establishes itself more and more nearby the artistic disciplines historically settled. Its aesthetics and its way of revisiting the real reveal a new “formal representation” and an increasing number of contemporary artists use it as an expression mean. The spatial development of video games is comparable to contemporary installations; it presents itself as a distinctive space recreated into a public or a domestic dimension. Video games, like installations, intensify the feeling of displacement or ubiquity that any kind of show may provide. The installations using video games mechanism make us pass from the idea of “esthetique relationnelle” introduced by Nicolas Bourriaud to a participative aesthetics where the spectator takes the place of the protagonist. The analyze of different works: “Vigilance 1.0” of Martin Le Chevalier, Kolkoz in “Hong Kong 2002”, “Nekropolis” of Tobias Bernstrup, and “Sam” of Palle Torsson shows some examples of reappropriation and diversion of the video games universe in contemporary art. Those examples allow us to see in a new way the world of video games. The contemporary artists appropriate this form of expression to make new plastic and participative explorations far of from the first play and entertainment finality. In these pieces the role of the spectator in the device is fundamental and it produces a total experience mobilizing at the same time: the vision, the hearing and the touch. The video game represents a post-modern form where contemporary artists may express the idea of “Gesamtkunstwerk” evoked by Richard Wagner in the second half of the XIX century with his theory of the “complete art work piece”. We are witnessing a turning point in the way of experimenting life which consists in interrogating the body into space and time in synaesthesia. Contemporary artist seem indisputably to make their own the Duchamp's words: “the viewers are the ones who make the painting”, the art of work remains unfinished until the spectator hasn't received it, the viewer turns up into an actor in a spectacular dynamics and his relation to the work of art goes beyond a simple passive contemplation.     

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.     

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.     

Plaidoyer pour les cothérapies non-intégratives

The official way of taking care of the mentally disabled is by its principles, procedures and techniques a two-fold treatment. It will appear in this paper that our preference goes to the most traditional of the two options, the combined-therapies, in other words the “multisided therapies”, also called the “focus-shifting” strategies. The issue concerning combined therapies with two or three focuses being applied to severely disabeled patients is raised. This involves simultaneously an analytic investigation as well as behavioral psychotherapy, together with medication and support. Concerning the other more popular technique - the “integrating psychotherapies” - also known as the “psychotherapeutic movement for integration”, it will be critically examined. Our aim is to show that this integrative approach in psychotherapy is an offshoot from the eclectic and pragmatic american school of thought.It is not compatible with a psychoanlytical approach even when it tries to use its clinical and theoretical contribution.     

À propos des limites de l'expertise psychiatrique pénale des victimes

In legal proceedings the expert witness testimony may be considered a medical act only if the expert conducts his clinical observations within the limits established by the medical code of ethics. This will then allow the psychiatrist to help the judge reach a more informed legal decision. The difficulty inherent in this process is for the expert to give an exact answer (“yes” or “no”) to the questions formulated in order for the judge to arrive at an accurate decision. To better understand the evidence presented, the judge may ask empirical questions that require the expert witness to give testimony going beyond the information directly gathered through clinical observations. It is the expert witness' responsibility to determine what amount of interpretation of material drawn from a clinical observation is appropriate to help the judge make a legal decision. This requires defining legal standards such as credibility, truth, and suggestibility. One must also recognize that the clinical observation of a victim is often the person's first contact with a psychiatrist.