Le déni comme angle d'approche psychosomatique en cardiologie et en oncologie

For patients suffering from organic disorders, denial is one of the available coping styles to face the stress of the disease. In case of coronary disease or of cancer, denial diminishes the risk of anxiety disorders and of depression, at least at short term. On condition that it does not prevent fast access to care, it also seems to be beneficial for the short term somatic evolution of the coronary patients. However, at long term, the coronary patients who deny are less compliant to medical recommendations, and their somatic prognosis worsens. Denial may also damage the compliance of cancer patients, and for instance extend the delay in medical presentation for care. Most of research works in psycho-oncology have failed to confirm results of studies pleading for a favourable effect of denial on the somatic evolution of cancer patients. The effects of the stress on the cardiovascular system are well known, and its deleterious somatic impact in case of coronary disease is well established. These scientific data are in agreement with the fact that coping mechanisms as denial, which allows the subject to avoid the confrontation with the stress, may protect him against somatic complications of the latter, at least at short term. On the contrary, there is no consensus about a possible favouring role of the stress on the cancer progression. So, the contradictory results concerning the effects of denial on the cancer evolution are in accordance with the current knowledge about the impact of the stress: just as we can not clearly support this one, we must be very careful when hypothesizing that some coping styles can be beneficial for the somatic outcome of the cancer patients. So, the coronary psychosomatic model, which among others attempts to explain the harmful effects of the stress and the protecting effects of denial, cannot be applied in oncology as it is. A psychosomatic model which is relevant in a particular field of the health can not be blindly transposed in other fields, and we must display a critical thinking to denounce the abusive generalizations sometimes at stake in psychosomatic medicine.     

Du déni de grossesse au néonaticide : hypothèses diagnostiques autour d’un cas

Neonaticide and pregnancy denial concepts have to be more precisely defined. These concepts do not give us any information about the psychical status of mothers during their acting-out. The history of court sentences, showing a wide disparity ranging from acquittal to life sentences reflects the difficulties in analysis of these concepts.This case study reports on the psychic state of a young woman at the time of her committal of neonaticide, after she had denied her pregnancy. The report discusses the hypotheses of brief psychotic trouble, dissociative trouble or acute stress state during her heteroaggressive act.     

Le déni de grossesse : étude réalisée sur 75 dossiers de découverte tardive de grossesse

The denial of pregnancy is a vague and badly defined entity with no international consensus. Yet this phenomenon is often found by health professionals, provoking much questioning on its aetiology and how to treat it. The denial of pregnancy constitutes a potentially risky situation for both mother and child.     

Déni de grossesse,infanticide et Justice

In the French law, as opposed to English law, the killing of a newborn is nowadays considered aggravated murder. No specific consideration is given to the mental state of the mother having recently given birth. This dramatic change occured in 1994 without debate about medical and psychiatric considerations. However, several cases of neonaticide, allegedly following denial of pregnancy, have provoked an intensive debate in the French society. Careful research in judiciary archives have shown that probably less than 10% of infanticides are preceded by denial of pregnancy, and a comparison with obstetrical data shows that probably less than of 1% of denial of pregnancy are followed by infanticides. In this article, we examine the different definitions of the “denial of pregnancy”, its risks and its consequences. We also examine its advantages as a defence mechanism and we recommended new terminology. We differentiate the two main mechanisms leading to a “denial of pregnancy”, respectively denial and disavowal and their specific attributes. We also discuss the benefit of a psychiatric classification of the “denial of pregnancy” to avoid a significant variability of the judgments.     

Déni,négation et dénégation : aspects psychopathologiques et cas cliniques

The word “denial” has several meanings; in psychoanalytically inspired psychopathology, it signifies a refusal to recognize sensory evidence, and it has a defensive function. Denial makes the perception of certain realities disappear from mental and unconscious life, whereas repression, while performing a similar task, integrates the intolerable reality into the unconscious. The term “negation” points to the negating of a psychic reality; it is the refusal to recognize a thought, a desire, or a feeling that is a source of intrapsychic conflict as one's own. Psychotic denial is multifactorial; it includes the existence of psychic troubles, but also the medico-legal behaviors that result from these. Neurotic denial is partial; it plays the role of a defense mechanism in that, it rejects the reality of a perception perceived as dangerous or painful for the ego. Perverse denial is characterized by the coexistence – within the same personality – of two contradictory judgments, unrelated to external reality. In order to maintain emotional stability in the face of anxieties concerning his physical or psychological soundness, the subject resorts to banalization and minimization. These mechanisms are not limited to the unconscious. The denial of an act and/or its consequences characterizes psychopathic denial; this also includes law and authority. Anosognosia is not a defense mechanism, but rather a pathological symptom, demonstrating a neuropsychological deficit or a cerebral dysfunction. “Insight” is an Anglo-Saxon term related to denial, anosognosia, and introspection, depending on the context. Two clinical examples illustrate different types of denial in different psychiatric pathologies.     

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.     

Le lithium dans la dépression unipolaire

Although poorly used as an augmentation strategy in resistant depression, the association of lithium is a good therapeutic option to consider in case of partial or insufficient response to the initial antidepressant. Various studies show significant efficacy of this treatment in combination with antidepressants: the practical aspects of implementation and monitoring are also discussed in this paper.     

Déni complet des faits : une perspective interpersonnelle

This article focuses on complete denial in a population of offenders in mandatory treatment. We present a literature review about factors associated to categorical denial, providing data about its frequency, its persistence and/or desistance. Drawing on Rogers and Dickey's model we propose to conceptualize deny as an interpersonal process.     

Innocence,déni,aveu et culpabilité. Un président d’assises face aux expertises psychiatriques

The author, through his professional experience, shares his thoughts on “psychiatric truth” supposed to inform the judge on “judicial truth”. He discusses five key issues: impartiality of the expert psychiatrist, deposing an expert, insanity defense, credibility of the accused, assessing the accused's future dangerousness.     

Le processus de désinstitutionnalisation

The policy of humanization of care given to people suffering from chronic mental disorders consists in maintaining them in their natural environment. The massive development of extrahospital structures and of alternatives to hospitalization allows a reintegration of stabilized psychotic patients. The insufficiency of psychiatric structures due to reduction of beds and that of the duration of hospitalization - for various reasons, whether ideological or economic - condemns the patients suffering from serious mental disorders to wandering and imprisonment. Any absence of social and therapeutic response to the isolation and pathology of de-institutionalized patients poses serious public health problems.     

Le concept de l’insight en psychiatrie

It was in France (particularly in the Société Médico-Psychologique 1869 to 1870) that the concept of insight into mental disorder began to appear around the middle of the 19^th century. Amongst other things, changing views concerning the nature of insanity, particularly the emergence of the notion of partial insanity, led to debates about the question of insight in patients with mental illness. Following a resurgence of interest in insight in psychiatry numerous empirical studies have sought to explore the relationship between patients’ insight and clinical variables. Results however have been variable and contradictory. Explanations for this can be found in the complexities inherent to the concept of insight. In order to tease these out, it is essential to distinguish between the concept and the phenomenon of insight and to view insight as a relational concept. Clarifying these issues around insight helps to define the ways and limits in which it is possible to capture insight empirically. In addition, it facilitates an understanding of insight as a mental state whose fluctuations are dependent on an interplay of psychological, pathological and wider sociocultural factors.     

Soigner la psychose. Le cadre de soin extrahospitalier : un objet à utiliser

The present article examines, through the evocation of a transference relationship between the author and a psychotic patient, the effects of an outcare setting based on the model of a Therapeutic Club. This structure was created during the institutional psychotherapy's era and was seen as a fundamental way of transforming the psychiatric institution. The personal decision of the patient to attend this kind of specific structure, i.e. without the interference of therapeutic injunction but with the nursing staff notifying this initiative, allows, in our opinion, to make a direct link with Winnicott's use of an object theory. This analysis puts emphasis on the dynamics articulating the inside and the outside and allowing thus to build, destroy, rebuild the outer setting towards the identification as object. The main hypothesis is that the process would help the psychotic patient towards re-entering into a libinal and progressive subjectivation by orchestrating an interaction between the patient and the object. The extra-care of the nursing staff, corollary with an internal need of reparation, leads to the emergence of a containing function. It works like a central component for the patient in the progress of self-individualization, in terms of indicator of his use of an object process.     

Effraction d’un cadre psychothérapique en milieu carcéral et décompensation psychotique

The objective of our study is to prevent pathological outcomes of the institutional abuse in a prison facility, which can trigger a psychotic breakdown of inmate patients, by enhancing a healthy communication between penitentiary staff and medical team despite the fact that they both adopt two opposite approach of inmates. In France, since 1994, public health institution took in charge medical and psychological penitentiary follow-up through Counseling and Ambulatory Care Units (UCSA). Composed of a multi-field team (psychiatrists, psychologists, medical staff), those care units have to constantly deal with security and normative issues specific to the prison facility. Usually, it is difficult to keep the psychotherapy setting safe from external “attacks” inflicted by penitentiary staff. Moreover, admitting UCSA within prison walls raises the eternal conflicting issue between two opposite logics: punishment (related to guilt) and treatment (related to illness and suffering). Whereas, UCSA staff perceives inmates as patients (to be cured), penitentiary staff perceives them as “cons” or out-laws (to be punished). The daily confrontation of such opposing logics not only affects the quality of communication between health team and penitentiary staff, but it also triggers acting-outs which put to the test the feasibility of psychotherapy in a prison setting mainly with mentally vulnerable inmate patients. Our method is based upon a case study of an inmate patient, C., who suffered a psychotic break down as a consequence to the unannounced renovation of the office dedicated to his psychotherapeutic sessions. Though, it is true that C., a former addict, had already a psychotic predisposition, his encounter with the intrusive and arbitrary authority of the penitentiary institution triggered his mental breakdown while undergoing psychotherapy. The result of our study emphasizes upon the necessity to establish a true communication between the medical team and the penitentiary staff and a mutual understanding of the value of their professional task in order to contain any conflict issues or misjudgment that may affect the progress of the most vulnerable inmate patients. Our study concludes to the importance of a complementary, cooperative, comprehensive and balanced approach of mental health problems in a prison facility through continuous training courses and discussions involving both penitentiary staff and medical teams whose roles, despite their differences, revolve around the same goal: the social and mental rehabilitation of inmates.     

Le déni de la complexité en douleur chronique : la part psychique maltraitée

Patients with chronic pain often want to obtain a diagnosis and treatments from a practitioner that supports them in their conviction of organicity in order to protect themselves against difficult and painful concerns. Therefore, it is pertinent to evoke a real collusion between the request and the numerous reductive derivatives of modern medicine, often clearly choosing denial of the complexity of variable dependants (psychological, social and environmental) when providing care services. The epistemological obstacles marking the limits of the knowledge and medical abilities redouble here the gap of the patients of another gap, making a shift of an organic conviction versus a “somato-psychic” one even more difficult. A linguistic masking through somatic diagnoses, semantic and conceptual shifts with regard to the definition of pain versus a “disease”, allowing a purely somatic access, are just as much modalities of a “failure” of subjectivity… Has an exposure of patients at risk of their conditions becoming chronic to be classified as poor treatment or as a form of iatrogenitics? Does a choice of denial of some in order to protect themselves against all ethical suffering justify the risk-taking of patients as well as a significant social cost that we also have to take into account?     

Trouble déficit de l'attention-hyperactivité de l'enfant et l'adolescent : du diagnostic à la prise en charge

What is the scientific evidence to support ADHD as a disorder? What are the risks of the use of stimulant medication? These questions are frequently discussed and often with passion. The objective of this article is to present the conclusions and recommendations relative to these questions. The International Diagnosis criteria retained are those of DSM-IV which describe three subtypes of ADHD : ADHD primarily of the inattentive type ; primarily of the hyperactive-impulsive type and a combined type. Establishing a diagnosis of ADHD requires a rigorous strategy, and it should be operated by stages: one to receive requests, one to collect information, and one to confirm the diagnosis. The use of scale is a clinical option but cannot be a substitute to clinical diagnosis. A therapeutic approach must combine several modes of intervention such as the use of stimulants and psychosocial treatment. The treatment will have to be revised regularly according to beneficial effects.     

Les thérapeutiques non médicamenteuses en psychiatrie

Resistance to psychopharmacological and psychotherapeutic therapies is a frequent difficulty clinicians are confronted to, with a frequency of 20 to 30 % concerning depression disorders. Other therapeutic approaches hence seem unavoidable to optimize treatments: structured psychotherapies such as behavioural and interpersonal therapies have shown their efficiency in anxiety and depression disorders, psychoeducational approaches help better observance in chronic pathologies. Biological and non medicinal approaches such as electroconvulsive therapy are still a therapy of reference for treating mood disorders and remain an indication for resisting schizophrenic disorders.