Caractérisation de la manie dans la cohorte nationale de 1 090 patients de l’étude « EPIMAN-II-Mille » : fréquence des sous-types cliniques, début et errances diagnostiques

Background. - Based on the data of a prior epidemio-clinical study, EPIMAN, in which 104 subjects hospitalized for acute mania were included, a new multi-site study was initiated with the objective to replicate the obtained data from EPIMAN and to thrive them through a more complete assessment of psychotic and anxious features associated with mania.Method. - “EPIMAN-II-Mille” is a national collaborative study, which involved training 317 French psychiatrists working in different sites representative of France. The study already succeeded in including 1 090 cases hospitalized for acute mania belonging to primary bipolar disorder (DSM-IV criteria). At inclusion, the psychometric assessment was made by using Mania Rating Scale (MRS) and the Beigel-Murphy Scale (MSRS), a checklist of depressive symptoms (McElroy et al. as modified by Akiskal et al.) and MADRS for intensity of depression, the SAPS of Andreasen for psychotic features, and the multiple visual analog scales of bipolarity (Ahearn and Carroll) for self-rating. An agenda for mood stability was filled out three times daily during the first week of hospitalization, separately by nursing staff and patients. After acute mania abated the full self-rated version of affective temperament (Hantouche et al.), was filled out by patients, and the anxious comorbidity explored by searching for DSM-IV criteria for all anxiety disorders and by using the AMDP-AT scale (Bobon).Results. - They confirmed the high rate of psychotic mania (33,4 % with MCP, mood-congruent psychotic features, and 16,5 % with MIP, mood-incongruent psychotic features) and mixed depressive mania (30 %). These clinical sub-types of mania were characterized by high frequency of diagnostic errors, toward schizophrenia for MIP, and toward anxiety and personality disorders for mixed mania. Female over-representation was observed in both mixed and MIP mania sub-groups (respectively 65 % and 67 %). Psychotic mania (MCP + MIP) seemed to be prevalent in younger patients, not married, presenting a substance abuse (other than alcohol). Mixed depressive mania (as defined by the presence of two or more depressive symptoms) was characterized by a mixed polarity of first episodes (22 % versus 7 % in pure mania), especially by higher rate of recurrence (7,5 versus 6,8 episodes), and suicide attempts (46,4 % versus 29,1 %), and more consumption of antidepressants and anxiolytics during the last six months prior to admission. Certain overlapping similarities were observed between psychotic and missed sub-types of mania. Beside female over-representation, MIP sub-group showed higher score on MADRS (when compared to non psychotic mania) and mixed sub-group presented higher rate of MIP (21,8 % versus 14,2 % in pure euphoric mania) and augmented scores on delusions (9,4 versus 7,7) and hallucination (2,7 versus 1,8) items of the SAPS.Conclusion. - The first data deriving from this largest study ever conducted suggested that acute mania belongs to a rich phenotype spectrum, in which psychotic and / or mixed forms are not easily recognized, and adequate treatments initiated with long delays. A correct appraisal of the different sub-types of acute mania seems to be warranted in clinical practice.     

Le burnout dans la profession enseignante

Teachers have been claimed to have more mental health problems than other professions. However this has not been formally established. Reviewing a worldwide literature no study except one where the comparison group was inadequate, show an increase either in psychological distress or psychiatric morbidity. A recent French study (1999/2000) conducted at MGEN in a national French representative sample (6650 persons, 3856 teachers) confirms this result except for the ageist women teachers who were suffering more from depression than the non teacher equivalent age strata. On the other hand teachers considered themselves as stressed but this is hard to compare to others profession and no one study was describing adequate control group if any; at any rate feeling of stress does not constitute a disease. Turning out to burnout the authors tackle the issue by presenting the burn out as initially described by Maslach on nurses and look at the possibilities to apply it to teachers. They underline the dimensions of burnout as three dimensional: emotional exhaustion, depersonalisation and low personal accomplishment. Although close to anxious and depressive symptoms the burn out person will attribute them exclusively at the working situation; in addition the burnout has been described in the helping professions in which reaching an ideal was considered as an important motivation which was not reached; consequently the person becomes distant to the patients and treats them as object loosing interest in his job. This could be explained trough psychoanalytical and sociological perspectives as well and the authors considered that this concept could be applied to the teaching profession. They quoted a study using the Maslach inventory adapted to teachers by replacing “patients” by “students”. To test some of the hypotheses, the data from the MGEN survey concerning the motivations to choice the profession: ideal versus material motivations, the feeling to have completed this ideal and some reported difficulties to perform diverse teachers tasks were analysed. More women that men declared having chosen the profession to complete an ideal (44.3 versus 35,5%) and this motivation helps the teacher to feel in agreement with his ideal when teaching; however it increases the sense of moral responsibility toward their scholars and decreases the fear to teach and be impotent toward the scholars. Psychological distress scores are lower in those who chose to teach by ideal at the beginning of the career then this effect disappears. To feel in accordance with this ideal is linked to low distress score. Finally on the group who reports between 6 and 10 years of experience, those who have chosen by ideal and feel not be able to reach their ideal have the highest distress score and those able to reach their ideal the lowest distress score indicating an interaction between motivation and ideal completion toward distress. An empirically built theory is then described which shows a pathway to burnout for teachers: they want to provide to scholars knowledge and moral values and put efforts to obtain results; when they is no results after continuous efforts and adaptation the teacher enters a negative circle where he becomes less and less efficient which in turn accentuates the absence of results to end up with the constitution of a burnout syndrome. They conclude that teachers and the caring professions have very much in common: some of them came in by ideal and found the day to day work quite hard with few results and became more distant and cynical toward their patients or scholars; since teachers do not seem to present higher mental health problems than others professions their distance may be effective as a defence mechanism. Concerning mental health and relationships between vocation type choice for this profession, they felt distance to professional ideal and mental health in relation to career duration. They conclude that burnout may be considered as a relatively efficient defence mechanism again stress which may prevent mental health disorders.     

De la psychomotricité et de la place du corps dans l'hyperactivité

Based on his experience of the clinical expression of hyperactivity, the author's clinical approach of the hyperactive child leads him to analyse the place of the body in the psychomotor experience of the child. The author tries to articulate the relationship between the moving body and the mind's work and to enunciate hypotheses on the participation of the body in the precarious balance of the hyperactive subject.     

Cruellisation du corps dans les troubles de la fonction alimentaire

Body in eating function disorders is the subject of a self-control conservative paradox. To survive, this body is subjected to instinctual movement, which goes beyond masochistic conduct. The body crualisation involved refers to self-cruelty auto-eroticism, as opposed to sadistic dimension often highlighted. Supported with patient's clinical, this article attempts to describe the dangerous process hidden in these behaviour. It consists to question this cruelness body and teratogenic notion.     

Implication du stress oxydant dans la physiopathologie de la schizophrénie : revue de la literature

Background

Schizophrenia is a devastating psychiatric disorder with a broad range of behavioural and biologic manifestations. There are several clinical characteristics of the illness that have been consistently associated with poor premorbid adjustment, long duration of psychosis prior to treatment and prominent negative symptoms. The etiopathogenic mechanisms of lack of insight in patients with schizophrenia are to date unknown, although several hypotheses have been suggested. A point of convergence for the theoretical models occurs with regard to the neuronal membrane. Neuronal membrane contains a high proportion of polyunsaturated fatty acid and is the site for oxidative stress. Oxidative stress is a state when there is unbalance between the generation of reactive oxygen species and antioxidant defence capacity of the body. It is closely associated with a number of diseases including Parkinson's disease, Alzheimer-type dementia and Huntington's chorea. Accumulating evidence points to many interrelated mechanisms that increase production of reactive oxygen or decrease antioxidant protection in schizophrenic patients.

Objectives

This review aims to summarize the perturbations in antioxidant protection systems during schizophrenia, their interrelationships with the characteristic clinics and therapeutics and the implications of these observations in the pathophysiology of schizophrenia are discussed.

Literature findings

In schizophrenia there is evidence for deregulation of free radical metabolism, as detected by abnormal activity of critical antioxidant enzymes (superoxide dismutase, glutathione peroxidase and catalase). Many studies conclude in the decrease in the activity of key antioxidant enzymes in schizophrenia. A few studies have examined levels of non enzymatic antioxidants such as plasma antioxidant proteins (albumin, bilirubine, uric acid) and trace elements. How showed decreased levels in schizophrenic patients. Others studies have provided evidence of oxidative membrane damage by examining levels of lipid peroxidation products. Such abnormalities have been associated with certain clinical symptoms and therapeutic features. Negative symptoms have been associated with low levels of GSH-Px. Positive symptoms have been positively correlated with SOD activity. Plasma TAS was significantly lower in drug-free and haloperidol treated patients with schizophrenia. A low erythrocyte SOD activity has been found in never-treated patients, but with haloperidol treatment, SOD activity increased.

Discussion

These results demonstrate altered membrane dynamics and antioxidant enzyme activity in schizophrenia. Membrane dysfunction can be secondary to free a radical-mediated pathology, and may contribute to specific aspects of the schizophrenia symptomatology. Membrane defects can significantly alter a broad range of membrane functions and presumably modify behavior through multiple downstream biological effects. Phospholipid metabolism in the brain may be perturbed in schizophrenia, with reduced amounts of phosphatidylcholins and phosphatidylethanolamine in post-mortem brain tissue from schizophrenic patients, and large amounts of lipofuscin-like materiel in the oligodendrocytes. The existence of these products within cell membranes results in an unstable membrane structure, altered membrane fluidity and permeability and impaired signal transduction. Recent findings suggest that multiple neurotransmitter systems may be faulty. CNS cells are more vulnerable to the toxic effects of free radicals because they have a high rate of catecholamine oxidative metabolic activity. Neurotransmitters, like glutamate, can induce the same metabolic processes that increase free radical production and can lead to impaired dopamine-glutamate balance. These results question the role of this imbalance in the biochemical basis evoked in the etipathogenic mechanisms of schizophrenia, as well as the role of antioxidants in the therapeutic strategy and their implication in preventive and early intervention approaches in populations at risk for schizophrenia.     

Exercice de la psychiatrie dans le monde du travail

Sectorization has been set up to allow the practice of psychiatry closer to people by opening community mental health centers in most cities. Since this advent, the sociology of cities has changed and this response to mental health issues is no longer fully appropriate. Time is accelerating and the waiting list for an appointment has extended. In addition, the “village” has disappeared; families are often single parents because of divorces. The main socializing area is now the company. Also, in these work environments, many human tragedies such as suicides are increasing. These tragedies are not always directly related to the company's issues and internal functioning's. Psychiatrists have a duty to invest the social fields more. This new area of expertise in psychiatry is called upon most often as a preventive measure when faced with potential psychological vulnerabilities. It implies risk assessment of psychosocial origins, accompaniment of a social transition, maintaining human capital, psychological support following difficult and/or brutal events (such as suicides, accidents, etc.). Often, this type of exercise requires adjustment of our practices (ethics, limits of intervention). In these new fields, the objective is to take care of people in order to avoid the appearance of psychiatric disorders (adjustment disorders, etc.) that are not easily absorbed by the current health institutions. Hence these potential disorders may lead to the exclusion of individuals due to their inability to work.     

Les troubles de la personnalité dans le DSM-5

This presentation summarizes the revision process in preparing DSM-5 for personality disorders. The preliminary steps were The Research Agenda for DSM-5 published by D Kupfer et al. in 2002 and the APA/NIH Conference on Dimensional Models of Personality Disorders (Arlington, 12.01.2004) published in 2006 by T Widiger et al. DSM-IV categories showed excessive comorbidities and within- diagnosis heterogeneity, temporal instability and poor convergent and discriminant validity. The workgroup on personality and personality disorders chaired by Andrew Skodol has been working since 2007. The initial recommendations were published online on February 10, 2010. A major reconceptualization of personality disorders has been proposed by the workgroup with five severity levels of personality functioning based on degrees of impairment in core self and interpersonal capacities. A reduction in the number of categories (5) was expected to reduce the comorbidities and the replacement of some behavioral criteria by traits in 6 broad domains was expected to result in a better coverage and temporal stability. This new model did not receive a real approval from the American Psychiatric Association. The final decisions consist in the removal of the multiaxial perspective and the maintenance of DSM-IV personality disorders categories and criteria in DSM-5 Section II. The alternative hybrid model was placed in Section III with five domains and 25 trait facets. More validation studies are needed for the Personality Inventory for DSM-5 (PID-5) from R. Krueger (stability of factorial structure in psychiatric samples and concurrent validity with the new version of NEO PI-R (NEO 3).     

Approche exploratoire du discours autour de la suspension dans le cadre du body art

This semantic analysis led by a discourse analysis software (Tropes) proposes a reflection concerning a speech about body art's practice: suspension. It is an exploratory research presenting an analysis of a text written by a young man practicing the suspension. The purpose being to focus on the speech concerned the act of suspension.     

L’« hyperdatation » et sa fonction défensive dans la psychose

The question of time in psychoses has been studied more often as lived time (perceived) than as discursive time (abstract). The specificity of lived time in psychosis can disturb the modes of “intrigue setting” (‘mise en intrigue’ according to Ricœur seems to translate lived time into a narrative process), particularly as concerns lack of dating or excess of dating. In this paper, the authors study the phenomenon they have named “hyperdating” and its defensive function in psychosis. “Hyperdating” would be a function of overdating, illustrating the distance between the patient who “hyperdates” and the affective charge he feels. “Hyperdating” would then consist in a radical lack of the dating function. The purpose of dating would not be to tag events temporally in order to organize the narrative chronologically, but to proceed to evacuate the meaning out of the event by designating only its date. In fact, we suppose that the affect would be shifted onto this date, and thus disconnected with the representation of the event for which there are representational deficiencies and probably a very intensive original affective load. Dating is a vehicle of chronology, and is the manifestation of a faculty for the narrative of self to become an autobiography as temporal experience. We suppose that in psychosis, this process is inefficient. In fact, there is either a lack of dating of narrative events, or a “hyperdating” which overloads narrative with temporal pseudo-indicators, in particular through quasi-sacred dates. “Hyperdating” would therefore be a defensive psychic process against the traumatic load connected to the remembrance of the event, transferring the central characteristics to the date itself, which would then be exterior to any meaningful chronology. The authors propose to define this “hyperdating” phenomenon, and to investigate its psychic function. The methodology is qualitative, and based on two clinical cases, one of schizophrenia, the other of mania.

A single case of schizophrenia

We think that in schizophrenia the “hyperdating” phenomenon could be underlain by a schism between affect and representation. This is an isolating process which fits into a psychotic dissociation, recalling the break characterising schizophrenic temporality. The speech is centred on a time-based accuracy to the detriment of experience narration and its affective expression. It then seems that “hyperdating” enables the person to avoid the huge traumatic load related to the factual content in order to shift the affective load on the dating itself.

A single case of mania

Here “hyderdating” would be the expression of a game with dates in an omnipotent process. This game appears as a mosaic, a disjointed and blurred control attempt lacking a linear temporal trajectory. In mania, a cumulated series of dates does not ensure either temporal links or any necessary “temporalisation” for “intrigue setting”. Time is one of the forms of “discontinuity and hopping” frozen in instantaneity. “Hyperdating” reveals a need to control the temporal flux which can only fail and it is, under a chronological appearance, an expression of a temporality frozen on the return of the same. The lack of temporal succession and of alternatives to “temporalisation” of events by means of a date which freezes them and removes their affective dimension can only render the reflexive capture of an identity through a biographic narrative problematic.

Conclusion

Thus, other than the discrepancies related to the specificity of the “hyperdating” process in the psychic economy of psychotic patients, there would be some similarities concerning “hyperdatation” in psychoses such as abortive attempts of intrigue restoration, deadlock of the chronological function of dating, but also freezing of temporalisation on a number. These illustrate the schism or the instantaneity, devoid of any temporal flux and therefore of any link with “withholding” (apprehension of what has just occurred) and with “protention” (intuition of the immediate future), which characterise time experience according to Husserl. The limits of our study are rooted in the difficulty of identifying this phenomenon as it seems to occur less often than those concerning forgetting or lack of dating. Furthermore the links between “hyperdating” and the affect management process as well as the differences of those links within the different types of psychosis will need to be investigated more thoroughly. That is why the prospects of this study could be the following ones: interrogating the links between “hyperdating” and memory in psychoses. (Is the “hyperdating” phenomenon a failed attempt to recover memories, and/or an attempt to shape raw mnesic traces?); further investigations of the psychotic temporality issue; therapeutic contributions in the management of time and affects could be based on these previous points as far as it seems that it is only through the flexibility of such a defence that the patient will reach the affects and integrate them in an intersubjective relationship with the therapist.     

La fonction cicatrisante du délire dans la schizophrénie

Psychoanalytic epistemology considers psychosis to be linked to the resurgence of traumatic experiences that have not been assimilated by subjectivity. The hallucinatory return of this primitive agony faces the psychotic subject with a driving encroachment that attacks his body and disintegrates its unitary organisation. Considering this reliving of traumatic experiences, the authors will present schizophrenic delusion less as a pathological result than as a subjective response that aims to treat the psychic over tension, which fractures the subject's body identity. Based on several clinical studies, this article will question the healing effect of delusion in schizophrenia. It is therefore concerned with investigating the different functions of delusion and identifying their incidence on the subject's body image. Using the different clinical examples cited, the authors will then attempt to develop certain therapeutic applications, which contribute to a possible reduction of the body disintegration phenomena in schizophrenia.     

Avis critique sur la place du lithium dans les recommandations professionnelles sur la prise en charge du trouble bipolaire

Objectives

In the last few decades, from the discovery of lithium, an increasing number of drugs have been approved for the treatment of bipolar disorders. Guidelines have been established to help clinicians make a relevant choice of medication in specific clinical circumstances. The aim of this article is to review the place of lithium in the recent guidelines for the treatment of bipolar disorder.

Materials and methods

We reviewed the recently published guidelines in English and in French for the management of bipolar disorder. Electronic library and Web-based searches were performed using recognized tools (MEDLINE, PubMED and EMBASE) to identify guidelines that have been published since 2006. In addition, other sources of information known to us, such as national agency reports, were searched.

Results

Since 2006, seven sets of guidelines have been established or updated by official scientific societies. The different guidelines are in agreement on the choice of lithium to be used as a first-line treatment for mania. The efficacy of lithium in combination with second-generation antipsychotic in the management of manic episodes has made these associations first-line choices in some guidelines. However, choosing a combination from the outset for the management of mania will depend on whether the Task Force that developed the guidelines gives priority to efficacy or tolerance and not on the guidelines methodology, which is used. For the treatment of bipolar depressive episode, the only drug recommended in monotherapy as first-line treatment by all guidelines is quetiapine. The place of lithium in this indication is controversial and only some guidelines recommend lithium in monotherapy as first-line strategy. The recommendation grade of lithium depends on how the results of the studies are interpreted by the Task Force elaborating the guideline. Guidelines disagree on the first-line treatment choice in mixed state. Some guidelines make no distinction between treatments of classic mania and that of mixed state. The other guidelines consider lithium to be less efficacious in this indication. For the long-term treatment, all guidelines take into consideration the predominant mood polarity of the patient. Lithium is considered to have an important role in preventive strategies for bipolar disorder whatever the predominant mood polarity. However, it is perceived as a more effective treatment in the prevention of manic episodes than depressive episodes.

Conclusions

Lithium remains a gold standard treatment in the recently published practice guidelines. The main differences between the guidelines on its use are related to methodological discrepancies and interpretation of the scientific data by the Task Force that developed the guidelines.     

Syndrome de Cotard et fuite des idées

From a case of anxious melancholia including delusions of negation: organs, death and language, we would like to demonstrate, on one hand, the specific nature of Cotard's syndrome manic depressive psychosis. On the other hand, it concerns the study of body somatic and overvalued signifiers. We consider the logical relationships between Cotard's syndrome and the flight of ideas, as a manic symptom “par excellence”. According to this case, we consider language related to melancholia, with no holes always fleeing to the same point, as an organised sort of flight of ideas. What we call confused flight of ideas, an expansive and auto-destructive flight could be comprehended as the reverse of melancholic language which may underly somatic symptoms. This methodology allow us to define criteria for the diagnosis for melancholia as related to metonymies and the foreclosure of the Name-of-the-Father. In other words, this study allows us to theorise foreclosure as a partial process.     

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.     

Relations paradoxales entre l’internalisation et l’externalisation en psychopathologie de l’enfant : exemples de l’hyperactivité et de la dépression avec idées suicidaires

Introduction

The difference between internalising disorders (anxious and depressive disorders) and externalising disorders (conduct disorder and oppositional defiant disorder) is largely accepted by clinicians and researchers. Although hyperactivity may seem linked with the externalising disorders, recent empirical research suggested it could be often comorbid with depression, and recent theoretical research suggested it could be, at least partially, founded on psychodynamic mechanisms intended to master separation anxiety. These works suggest that the internalising dimension of hyperactivity may have been underestimated in empirical research. The purpose of this paper is to assess the level of internalisation in hyperactivity.

Method

Twenty five hyperactive children were compared with children presenting anxious disorders (N = 22), depressive disorder without suicidal ideation (N = 28), with suicidal ideation (N = 20), and academic learning disorders (N = 23). All diagnoses were made according to the ICD-10 criteria, which are very similar to the DSM criteria for anxious, depressive, and academic learning disorders, but are more stringent regarding hyperkinetic disorder than the DSM criteria for attention-deficit/hyperactivity disorder. Internalisation and externalisation were assessed by the Child Behavior Checklist (completed by one of their parents), and the presence of suicidal ideation was assessed on the basis of the Children Depression Inventory item 9.

Results

Hyperactive children exhibit more internalisation problems than those with learning disorder, but less than those with anxious and depressive disorders. Unexpectedly, depressive children with suicidal ideation presented high levels of delinquent and aggressive behaviour, equal or superior to those of the hyperactive children.

Discussion

These findings bring partial support to the psychodynamic view of hyperactivity. But they also underscore the unexpectedly high rate of externalising symptoms among depressive-suicidal children, whose pathology is theoretically regarded as a typically internalising disorder. In conclusion, these results suggest the relationship between externalisation and internalisation could be more complex than is generally assumed, and support the possibility of simultaneous presence of high levels of externalisation and internalisation in some disorders.     

De l'état dépressif à l'état de triomphe du moi

Although melancholy has been the focus of a large number of studies, this has not been the case for mania and even less for the passage from melancholy to mania, more particularly the passage from a depressive state to a self-triumphant state, the latter expression being used by Freud to characterize states of self-induced excitement or elation. On the basis of the specific pathological model of the passage from melancholy to mania, the present study has therefore attempted to determine the underlying metapsychological processes for what are commonly termed cyclic disorders or changes of mood, the dynamics of which is connected with the types of interaction between the various elements within the psychic system. The theoretical approach that has been adopted is essentially psychoanalytical, and in parallel to Freud’s analysis of this state, we are already able to delineate the context in which cyclic disorders occur: it consists of an “interior theatre”, and on its stage the self in its relation to the ideal self which continues to play the same role as it had previously assumed in its relation to the exterior object, i.e. before it had incorporated the exterior object and allowed it to take its place. The self thus finds itself in the position of the object confronted with its ideal self, and the omnipotence of the latter henceforth determines the course of their relations.Melancholy and mania are thus related to the same “complex” and their metapsychological difference lies in the fate of the introjected object: if in the case of melancholy the object has taken over the role assumed by the self, what has become of the self in the manic state? In the present study, the hypothesis proposed is that of committing an intrapsychic act, an indefinitely perpetrated crime, i.e. the act of murdering the object constructed on the basis of a working model of mourning which requires that the mourner “strikes a fatal blow” for a second time in order to actively confirm the subject’s own satisfaction at remaining alive. However, the state of manic exhaltation, just like the state of melancholic depression, is linked to the conflict between the self and its ideal self and to the law of an alter ego that is always as cruel toward a mythical lost object which remains a cause of irrepressible nostalgia.