Schizophrénie et double parricide : à propos d'une observation clinique

Parricide has always been considered as the most appalling, rarest and most unnatural crime ever. Among the adults that have committed parricide, numerous of them are mentally ill. This incredible story of a schizophrenic responsible for committing double parricide, enables us to understand the dimensions conductive to crime related to delirious and paranoid states. In more general terms, this example opens the debate on the problems posed in approaching a prognostic and prevention of psychotic's violent acts. On the 25th December, Christmas day, feeling lonely and abandoned by everyone, A. calls his parents asking them to come to his home. Scared by previous violent incidents involving their son, they decide to go there accompanied by A's uncle, and ring on the bell. A. greets them on the side-walk, and seeming already “tolerably” agitated and unsteady, he offers a meticulously wrapped present to his father, which proves to be a loaded hunting gun. Confronted by his fathers refusal to accept the present, A. opens the package and kills him father firing two gunshots in his chest, then proceeded to fire at close range on his mother, killing her by a shot her in the abdomen. The uncle, now injured in the shoulder, manages to escape. As a result of this double murder, A. is questioned by the police. As consequence of faced with his delirious account, he is hospitalised immediately. How could such a terrible tragedy occur? At the time of the act, A. is 27 years old. His schooling is marked by early difficulties and instability, as is his professional experience, which only consists of various “small” jobs. He blames these failures on his parent's frequent disputes, who finally end up in divorce. This represents a real trauma for A., on which he crystallises the entirety of his suffering, which is fuelled by his persecutive delirium based on his past and lived experiences. In the preceding five years leading up to the murder, A. had been hospitalised for psychiatric care on four occasions, all linked with violence perpetrated on his mother. These all took place in a state of delirium, with themes of persecution and interpretation. Some examples including : “My parent's made a prostitute of my sister… They used me for the psychiatric services… I mustn't be hospitalised again, they practice vivisection on their patients… My mother used to insult me… She has been transformed and manipulated by the medical services… She has the strength of the devil…” clearly show us the active and targeted persecution and suffering ; violence is used in an effort to put an end to this. However, A's patch of violence does not stop within the family group. He has been involved, on two separate occasions with the law. Firstly, after a fight, for which he has not convicted, and secondly, for grievous bodily harm along with death threats and arson. For the latter, he was convicted following a psychiatric assessment, and served 15 months imprisonment with compulsory psychiatric treatment. All these measures do not stop such a tragedy occurring, after which, in accordance to clause D 398 of the French Procedure Penal Code, A. is hospitalised immediately. In accordance with two psychiatric assessments, the judge pronounces a decision of nonsuit in applying the French Penal Code clause 122-1 alinea 1. During his hospitalisation, and despite his transfer into UMD. “Unité pour Malades Difficiles” (Psychiatric Unit accepting dangerous mentally ill patients) and even if the delirium declines, with the effects of chemotherapy, psychotherapy and institutionalisation, A. remains potentially highly dangerous. He continues to be only superficially aware of his parricidal acts, represses his delirium and actively denies his pathology. Here we can see that mental illness occupies the preponderant place in the origin and dynamic in committing violent acts. The persecutive delirium, violence and denial (symptoms of mental dissociation) give a clinical explanation to this act, which is usually reputated among the most incomprehensible. This typical case of dangerous delirious schizophrenia illustrates once again the necessity not to underestimate the extremely clear and recurring signs of danger (lived experience, delirious directive speech, the generated pain and desire to end the suffering and alleged prejudices, all bringing about aggressive action…). These negative emotions aroused by deliriums of prejudice and persecution most often risk, and we insist of this point, a provocation of pathological self-defensive attitudes and behaviour. These are defensive, avoidance reactions or escape, or, as we saw with A., aggression against “the persecutors”. This violent acts are destined to control or stop the source of persecutive feelings. Constrained hospitalisation, even at long term if necessary, with constant and regular checks of chemical and psychotherapeutic treatment are curative and preventive measures which should be compulsory to avoid this type of tragedy.     

Un cas de cristallisation de délire paranoïaque sur un élu : de l’état dangereux aux menaces et à la tentative d’homicide

Paranoid delusions based on themes of persecution and prejudice pose the question of the dangerousness of those who suffer from it, particularly when their delusions are focused on one or more perceived persecutors. The case of paranoid delusion crystallising on an elected official that is evoked in this article illustrates this recurrent clinical problem, which can sometimes generate homicide attempts or homicides motivated by reactions of self-defense and/or revenge with pathological motives.     

Réflexions sur la fréquence, l’organisation et les facteurs prédictifs des homicides psychotiques : à propos de trois observations avec mutilation corporelle

The statistically positive correlation between severe mental disorders and physical violence has now been firmly established by international studies. In Europe, about 10% of homicides are committed by psychotic patients who may re-offend. Three medicolegal observations of homicides with bodily mutilation are presented. The first concerns a 31-year-old schizophrenic man who killed a passer-by in the street when in a state of paranoid delusion with themes of homosexual rape and persecution. The crime was committed in two separate phases: first, emotional violence and then, a few hours later, operational utilitarian violence with amputation of the victim's hands. The second case concerns a 21-year-old man suffering from paranoid schizophrenia associated with an antisocial personality disorder. During the night, he assassinated two women who worked in a psychiatric unit, one of whom was decapitated while still alive. Although living freely in the community, the patient acted with premeditation and method under the influence of ideas of persecution and cosmic supernatural terror. The third case concerns a 30-year-old man who had been forcibly hospitalized in a psychiatric unit for delusional disorder of persecution with paranoiac personality disorder. During a period of weekend leave, he killed his own mother in the family home in a totally disorganized emotional moment of acting out, then cut off her leg and threw it out of the window. Six years beforehand, he had already killed a prison inmate who was sharing his cell. In the first two cases, the patients’ behavior was partially or totally organized despite delusional motives of paranoid type. In the light of these three dramas and a litterature review, the main psychopathological predictors of physical violence committed by psychotic patients are discussed: severe psychotic episode, persecutory delusional beliefs, comorbidity with substance abuse (alcohol, cannabis) and personality disorders, little or no antipsychotic treatment, and poor therapeutic compliance. In France, it appears mandatory to apply a rigorous procedure for evaluating the dangerousness of severe mental patients and violent criminals.     

Délires paranoïaques,dangerosités et homicides

“Are you threatening to kill me?”, asks the psychiatrist. “It's not a threat, it's a promise!”, replies the paranoiac patient. In just a few short words, this exchange raises the issue of a dangerous, potentially homicidal nature linked to paranoia. This mental disorder is such that it severely complicates interpersonal relationships. Its mechanisms and delusional themes often cause paranoiac individuals – male or female – to have difficult, tense, conflictual and even violent relationships both inside and outside of the family. These difficult relationships can sometimes lead to serious non-lethal attacks or, more exceptionally, single or multiple homicides that have frequent precursory warning signs. The motives for homicides committed by paranoiacs are linked to the themes of their delusions: persecution, prejudice, jealousy, filiation, erotomania, betrayal, etc. The therapeutic alliance, frequently difficult to set up and maintain, makes healthcare treatment difficult for dangerous paranoiac individuals. Ideally, this treatment is based on two key approaches: medicinal treatment and psychotherapy. When these people are not considered to be criminally responsible for the acts that they have committed they are forced to receive care.     

L'expérience du corps vécu dans la paranoïa

The concept of Paranoia is almost synonymous with a certain “interpretative” style, whether it refers to emotionally disturbed or frankly manic states. This intellectualization, which is to a large extent a result of the psychopathological matrix from which Paranoia issued has in fact limited comprehension of the latter, in particular as regards the two following aspects: on the one hand, the distinction between a “sectorial” manic state that nevertheless has a marked confiscatory effect on the person's entire existence and a “network-associated” delirium that remains compatible with a certain social integration; and on the other hand, the marginalization of the hypochondria that is frequently observed in these patients and which may include a possible accusatory component (e.g. laying the blame on the therapist and associated structures for inadequate treatment) or a “neurosis” that sometimes replaces the patient's passionate or delirious attitude for a period of time. The phenomenological concept of the “opaque body” provides a certain reply to these questions: it shows that the body plays major role in Paranoia, as it represents the constitutive limit of the “truth” the paranoid subject seeks, and it also acts as a transmitter of signals - both mimico-gestural and verbal - through which the patient attempts to circumvent such a limit. The marginal role assumed by hypochondria then alters to become one of the body's possible means of physical expression of Paranoia; it does not manifest itself as an “other” illness that sometimes replaces the former, but rather as a continuation of the paranoid state including a reversal of roles, with the patient acting as persecutor and the therapist becoming the object of persecution. Thus one could qualify as Paranoia any pathological interpretative situation characterized by the persistence of an “opaque body”; and exclude the type of situations in which the body has become transparent to the patient's intuition as it has to the hallucinations of the paranoid subject.     

Le dérapage psychotique dans le grand âge : une voie d’expression du désir

Old age, with the accompanying physical transformations and social modifications, is a period requiring a psychical reorganization. This reorganization will help the elderly to cope with everyday life. Many events put the elderly to the test. Some elderly persons will have enough strength to affront these events with a certain amount of support from a stable environment. Others will need to be helped and will ask for help. But for some elderly people this situation will be a drama, which disrupts the bio-psycho-social order and may entrain different disorders including a massive withdrawal blocking the psyche and leading to its annihilation or delirious behaviour evoking a diagnosis of psychosis with a well-known pernicious effect. The frequency of depression associated with somatic diseases is known to be high. Psychotic symptoms are essentially delusions leading toward paranoiac delirium. The main signs of these disorders are disturbances that usually require sedation. The author suggests leaving room for patient's expression and, via the psychotherapy of a 78-year-old patient, shows that human beings exist with their own transmissible history. The author then analyses the sense of the delirium trouble in order to optimize the treatment taking into account all clinical features.     

Intérêt curatif et préventif des thérapies cognitives et comportementales (TCC) dans le traitement de croyances délirantes schizophréniques criminogènes : TCC d’une conviction délirante ayant généré un double homicide à l’extérieur de la famille

Subject and problematicDelusions of persecution and prejudice are the most common delusional themes. Psychotic subjects (schizophrenics or paranoiacs) who suffer from delirium are therefore liable to defensive behavioural characteristics and mechanisms, often leading to the pathological reactions of defence and/or vengeance. These reactions come from behaviour that compels one towards avoidance or escape, sometimes even aggression towards the perceived persecutors. In such cases, violent acts are committed in an effort to control or destroy the source of perceived suffering and persecution. Several examples regularly attest this claim. Some of these pathological reactions can even give rise to unique or multiple homicides. Cognitive and behavioural therapies are a therapeutic method that can be used to treat some of these delusional beliefs.Patient and methodIn this article, we present a cognitive and behavioural therapy for this type of criminogenic delusional belief. We carried out this therapy with the dangerous schizophrenic perpetrator of a double homicide that was driven by a pathological need for vengeance. This patient was convinced for four years that his girlfriend's mother had deliberately transmitted the AIDS virus to him by making him drink a coffee, and that as a result he was going to die in terrible agony. “She contaminated me because I wanted to leave her daughter and she was not happy about this”, he thought. Following the manifestation of this mistaken conviction, the patient developed a reactive depression: a social retreat and a significant isolation, during which he constantly nourished his delusional thoughts. As a way of anticipating this “death by AIDS”, he eventually wished first to eliminate the person whom he held responsible for his contamination, then to commit suicide. In the latter stages, his thoughts came to him “as voices” which he heard repeatedly in his head: “I have AIDS! I’m going to die! I must kill her! I absolutely must kill her! There's nothing to do, I must kill her!”. As a result, using a hunting rifle he killed a couple, having mistook his target. The aim of the therapy was to induce a doubt in the delusional conviction of his contamination. This increasingly significant doubt and the gradual alleviation of the delirium were mainly researched using the socratic method of modifying belief(s). This technique enabled progressive critical analysis of the “proofs” which had lead the subject to construct and furnish his erroneous conviction while wrongly processing extra psychic or infra information. While still respecting the pathological belief of the patient, this method allowed him to find alternative and substitutional explanations for his false ideas. The reinforcement of the delusional belief by direct confrontation was thus avoided, and the patient grew to realise and understand the dysfunctional dimension of his cognition, his emotions and his behaviour. The therapeutic care carried out in a unit devoted to dangerous patients was composed of five sessions of functional analysis, followed by twelve sessions of therapy at a rate of one session a week. Between each session, the patient was required to complete some exercises.ResultDisappearance of the delusional criminogenic conviction by the end of therapy. The depressed state of mind, like his suicidal tendencies, decreased step-by-step as the conviction of having AIDS extinguished, the disappearance of the cause naturally leading to the dissipation of its effects.Discussion/conclusionAfter the failure of traditional psychiatric therapies to resolve or to ease the patient's delirium and the reactional symptomatology to this delusion, we note the success of the cognitivist approach and regret that it did not take place before the transition of this delusion into criminal acts. Obtaining this result was certainly facilitated by the relative recentness of the delusional conviction, by the total investment of the patient in psychotherapy in order to “escape death”, by his consequently increased suggestibility, and by the existence of a predominantly healthy psyche. Equally one must notice in the subject the existing disproportion between the extreme division (one single overbearing mistaken belief), or even the banality of the delusion, and his criminogenic power (two homicides preceded and followed by vague suicidal tendencies as well as significant, recurring, vindictive tendencies). Similarly, the relative ease in resolving the problem seems disproportionate compared to the emotional and psychodynamic power. Non-confrontational and progressive dissolution of the components of the delusion, with very active participation from this chemo resistant patient, formed the central and effective axis of this therapy, carried out in 1994. It seems that this psychotherapy may be the first CBT for a criminogenic delusional conviction carried out on a schizophrenic murderer. Since then, scientific literature has consistently confirmed the interest of cognitive and behavioural therapies in the treatment of some schizophrenic delusional beliefs. Whether associated with traditional strategies (hospitalisations, psychotropic chemotherapy, etc.) or with newer and complementary techniques (modules in rehabilitation of social skills, neuroleptic modules, psychoeducation, etc.), these therapies seem especially effective when they are carried out early in the genesis of delusional beliefs.     

La consultation psychologique spécialisée pour les sujets souffrant de syndromes psychotraumatiques : premiers éléments d'évaluation

There are currently a large number of results published in English concerning the question of evaluating the therapeutic care of posttraumatic stress states, in particular since their international recognition by the DSM in 1980. Overall, the studies reveal no difference in effectiveness between various recognized therapeutic methods while cognitive therapies seem to lead to even better results. Operating within the framework of emergency psycho-medical units, we have set up a consultation facility specializing in the psychological treatment of posttraumatic stress states intended for individuals who do not suffer from serious personality disorders or any major associated psychiatric problems. The technical aspects of this psychological consultation take their inspiration from the psychodynamically-based model of short term psychotherapy. This consultation is accompanied by medical and social care given by a psychiatrist who is responsible for prescribing the treatment and for relations with the social, professional and possibly also legal institutions. The aim of this study was to evaluate the effects of this specific care on the improvement of the psychotraumatic symptoms and the general health of these patients. The population consisted of 20 initial patients (mean age = 43 years) who had been the victims of a variety of traumatic events (eight physical assaults and 12 accidents). The criteria used for the evaluation of the clinical change were: (a) symptomatic criteria relating to the improvement of the posttraumatic symptoms (DSM-IV criteria); (b) criteria relating to the improvement in general mental health; (c) criteria relating to the evaluation of the change by the therapist and the patient; (d) criteria relating to the evaluation of the psychotherapy taking account of the notion of therapeutic alliance. The subjects were assessed at the end of the psychotherapy and then again three and a half months later. Both self-evaluation and external evaluation questionnaires were used (DSM-IV criteria for the posttraumatic stress state, the Steinitz and Crocq posttraumatic stress state inventory (1992), L. Crocq’s posttraumatic stress state self-evaluation scale (1990), Luborsky’s health-sickness scale, the Penn Helping Alliance Questionnaire Method (Alexander and Luborsky, 1986). The results showed that only four of the 20 subjects still exhibited a posttraumatic stress state three and a half months after the therapy. These non-improving subjects also suffered from associated pathologies (major depression and somatization), a conflictual problem that predated the trauma and numerous problems at the social level. Furthermore, in the patients who did exhibit an improvement, the “alertness state” concerning those cues that risked provoking recall of the trauma continued to be of moderate intensity. The improvement in the symptoms was accompanied by a general improvement in the mental health of the subjects who were able to reinvest in their social lives and relations. The study, therefore, shows that the subjects’ improvement is correlated with two dimensions of the helping alliance method (working alliance with therapists and feeling of having been understood and supported) and the subjects’ capability of acting independently. Finally, the speed with which psychological care is initiated following the traumatic event seems to be a determining factor for patient improvement: the earlier care is administered, the faster subjects are able to regain their balance. The proposed evaluation is subject to a certain number of limits: therapists involved in the evaluation and the brief evaluation interval (three and a half months after the psychotherapy) which does not necessarily allow us to conclude that the improvement is permanent or assess possible relapses.     

Le contingentement de la jouissance dans la paraphrénie

At 1913, in the eight edition of its Treatise, E. Kraepelin changed its own classification of chronics delirium because he wanted to insert in it the group of paraphrenias; at 1978, H. Ey, in its Treatise of hallucinations, showed that he had conserved some interest for this clinical type that he named delirious fantastic psychosis. At 1996, J.-C. Maleval introduced a progressive logic of delirium where paraphrenia appears as the end of therapeutic work of delirium. We study more precisely here the case of a paraphrene subject who had one's moment of glory at 1905 in Paris where he was the object of a hoax played by J. Romain: J.-P. Brisset was elected prince of thinkers. In this example, the evolution of paraphrenic delirium preserves the subject from the “jouissance de l'Autre”.     

Rééducation de la position assise de l’enfant paralysé cérébral infantile. Les moyens préventifs orthopédiques non chirurgicaux. Présentation d’un cas clinique

There are several sitting positions, which need a specific control of adjustment against gravity and a postural organization available to be learnt. The acquisition of sitting position is a very important step of child's functional development: this step is a very crucial point for clinicians who take care of rehabilitation of children affected by cerebral palsy because these children have abnormalities of functions against gravity and bad propioceptive informations. There are several and different pathological factors that could disturb the sitting position and it is very important to know these factors to prevent the orthopaedic problems and offer the most suitable chair for each child. For the most part, the children affected by cerebral palsy, especially if they belong to 3 or 4%, spend in sitting position 80% of their living time. If the child spends a lot of his time in a particular position, we must pay attention to the postural abnormalities and their orthopaedic outcomes. For this reason, it is very important to understand the importance of preventive treatment and clinic assessment oriented to identify the abnormalities. The educational and therapeutic strategies should be organized in an integrated and multidisciplinary way.     

Suicidal Behaviour in Mood Disorders—Who,When, and Why?

Objective:

About one-half to two-thirds of all suicides are by people who suffer from mood disorders; preventing suicides among those who suffer from them is thus central for suicide prevention. Understanding factors underlying suicide risk is necessary for rational preventive decisions.

Method:

The literature on risk factors for completed and attempted suicide among subjects with depressive and bipolar disorders (BDs) was reviewed.

Results:

Lifetime risk of completed suicide among psychiatric patients with mood disorders is likely between 5% and 6%, with BDs, and possibly somewhat higher risk than patients with major depressive disorder. Longitudinal and psychological autopsy studies indicate suicidal acts usually take place during major depressive episodes (MDEs) or mixed illness episodes. Incidence of suicide attempts is about 20- to 40-fold, compared with euthymia, during these episodes, and duration of these high-risk states is therefore an important determinant of overall risk. Substance use and cluster B personality disorders also markedly increase risk of suicidal acts during mood episodes. Other major risk factors include hopelessness and presence of impulsive–aggressive traits. Both childhood adversity and recent adverse life events are likely to increase risk of suicide attempts, and suicidal acts are predicted by poor perceived social support. Understanding suicidal thinking and decision making is necessary for advancing treatment and prevention.

Conclusion:

Among subjects with mood disorders, suicidal acts usually occur during MDEs or mixed episodes concurrent with comorbid disorders. Nevertheless, illness factors can only in part explain suicidal behaviour. Illness factors, difficulty controlling impulsive and aggressive responses, plus predisposing early exposures and life situations result in a process of suicidal thinking, planning, and acts.     

Le passage à l'acte homicide en milieu médical et carcéral

Little is known about the frequency and characteristics of the homicide of which medical staff, institutionalized patients and prisoners may be victims. To date, several categories of victims have been described: medical staff murdered during their working hours, mentally ill patients assassinated by other patients, patients killed by medical staff and prisoners murdered by other prisoners. The criminological observation of a female general practitioner assassinated by one of her occasional clients, a perverse multirecidivist psychopath, illustrates the complexity and diversity of the utilitarism and/or pathological motives encountered in such affairs. Homicidal attacks on medical staff can be classified into four categories: the first three (fortuitous crime, occasional crime and personal cause crime) have no relation with therapeutic activity; the fourth (crime for a professional cause) involves a one-off or lasting medical relationship between the aggressor and his victim. Murderers in the latter category have been reported to suffer frequently from paranoid schizophrenia or persistent delusional disorder (paranoiac delusion). Such homicides on medical staff may be impulsive unforeseeable acts, reactions to conflict, or premeditated acts of vengeance. Homicides perpetrated by medical staff on patients are of a euthanasic or “heroic” nature. In those between hospitalized mental patients or between prisoners, the aggressors are frequently violent psychopaths or delusional psychotic patients. The prevention of such dramas is difficult and raises the problem of how we should evaluate the dangerousness, the conditions of institutional life, and the financial and medical means that are made available to hospitals and prisons.     

Innocence et culpabilité pathologiques

Innocence and culpability are two realities of the experiment human at the same time paradoxical and contrary and capable of subtle intrications. After having approached the roots of these two great concepts in their historical concepts, we will be able to traverse the fields specific to each one of them. Innocence is very early in the history reported to the problems of the young children and their violent death to mean the values of a moral and spiritual nature thereafter. The culpability refers as of the Antiquity to the fault of the culprit and its crime to relate to later the transgressions of a particular group and of its rites. These considerations enable us to seize the specific fields well. Innocence is characterized especially by the style and the manner of living. The experiment of innocence is made vulnerability in direct relationship to the otherness and soustendue of intentionnality. The pathological conviction of innocence is important to include/understand, because it is marked in a context of derealisation darkening the conscience of the acts. And this conviction is in one lived of persecution. The charged act is not recognized and the subject brings it back to the other, in the more or less delirious conviction, always derealized, of its innocence. But, it is advisable to distinguish that well from the refusal. The culpability is an experiment able to invade the personalities. The sociological and psychological designs are with being differentiated well. But, it is important to distinguish well the various methods, culpability real, subjective, morbid, delirious culpability. The latter constitutes the center of pathologies melancholic persons able to take very serious forms many work show us that innocence and the culpability constitute contingent experiments     

Concept actuel de paraphrénie et lien avec les troubles thymiques

Objectives

From a clinical observation, firstly we will discuss the clinical value of such diagnosis of paraphrenia. Secondly, we will describe possible associations between paraphrenia and affective disorder.

Observation

We present the clinical observation of M. B., 42 years, hospitalized in psychiatric department against his will for behavioral troubles and delusional ideas. He previously suffered twice from depression that needed hospitalizations (in 1995 and 2010). After the last hospitalization, a treatment by escitalopram was prescribed but the patient didn’t follow this treatment. When he was rehospitalised, he showed a psychomotor excitation, a depressive mood and insomnia without fatigue. He also had systematized delusions centered on his family, with imagination and interpretation mechanisms and megalomania and persecution thematics. The patient was not desorganised. A treatment by risperidone and valproic acid was prescribed and resulted in a good regression of the different symptoms within two months.

Discussion

If we apply the international classification like the ICM 10, this patient could be diagnosed: “persistent delirium and bipolar disorder”. But if we apply other criteriae such as those of Ravidran and al., M. B. could be considered as presenting a paraphrenia. If we consider the euphoria and the psychomotor excitation as being a part of confabulatory paraphrenia, the affective disorder could be considered as a recurrent depressive disorder rather than a bipolar disorder. Thus, this clinical observation may link paraphrenia to affectives disorders and this link could be supported by four hypotheses. First, paraphrenia can be an affective disorder. Two observations support this hypothesis: the cyclic evolution and some symptoms, like the psychomotrice excitation, which are common between paraphrenia and mania. Second, paraphrenia may be considered as a kind of evolution of affectives disorders as a delusional reconstruction scarring. Nodet even described the paraphrenia post-mania and the paraphrenia post-depression. Third, patient with a paraphrenia may be more prone to develop an affective disorder and the delusional disorder mixing reality and imaginary elements may result in difficulties for the adaptation to environmental stress. Fourth, same risks factors such as genetic or epigenetic factors, emotional deprivation and/or social isolation are common to paraphrenia and affective disorder. However, paraphrenia is frequently associated with cluster A personality disorder (paranoiac and schizoid) while affective disorder are more linked to cluster B personality disorder (borderline).

Conclusion

The efficacy of a treatment combining neuroleptic and mood stabilizers and the preservation of social insertion are important and indicate a therapeutic strategy that is different from schizophrenia. Thus, the determination of a link between paraphrenia and affective disorders could allow better therapeutic strategy and better follow-up on the long run.     

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.     

Comment sortir de la sorcellerie ? D’une société orale à une expérience de médiation transculturelle dans la banlieue parisienne

The belief in witchcraft, which Africans commonly invoke as an explanation for their physical suffering and their misfortune, is an expression of persecution: “If I suffer, it is because someone close to me wishes me ill, and has cast an evil spell”. In the first part of this article, the author, who is an ethnologist with considerable experience in the field and a mediator for African families living in the suburbs of Paris - whose children have been brought before the juvenile court - explains how the Bamileke people of Cameroon manage to free themselves from their belief in the effect of witchcraft through the ritual acknowledgment of three types of debts (infinite, symbolic, reciprocal), and in reality by three types of discourse: that expressing persecution; that which expresses the so-called state of unbelief, which in fact banalises the significance of the dualistic conflict, just as making a joke out of the situation may do; and thirdly, that which expresses a normative approach to religion, through which the individuals concerned become reintegrated within the structural order. In the second part of the article, the author shows how this cycle involving three specific types of verbal expression can be used in the process of mediation to assist African families to free themselves from the belief in witchcraft that they resort to, and cling to when their children are in difficulty. As these three changing forms of verbal expression can be transposed from one cultural context to another, it is concluded that they thus have a transcultural significance.