Les courants intégratifs en psychothérapie

The field of psychotherapies integration is large, especially in the Anglo-Saxon countries where the number of publications increase enormously over the years. Research trends have shown to be interested in the efficiency of psychotherapies, as well as in the common factors of all their approaches. Thus, whilst studying these common denominators, has emerged an interest to link maybe even merge some of them. We will detail in this work the major trends in the field of psychotherapies integration.     

Les thérapies utilisant la réalité virtuelle dans les troubles phobiques

For the past 15 years, virtual reality has been increasingly used as a therapeutic tool in psychiatry. In particular, virtual reality exposure therapy (VRET) has been developed from and proposed as an alternative to standard cognitive behavioural therapy (CBT) for the treatment of phobic disorders. Using real-time computer graphics and visual displays, the patient is immersed in different computer-generated virtual environments specifically designed for different types of phobia. As imaginative or in vivo exposure therapy, VRET consists in a gradual presentation of phobic stimuli. The desensitization through VRET has been found to be efficient in different types of anxiety disorder, and in particular in phobic disorders. Moreover, it presents most of the advantages of both in vivo and imaginative exposure therapies without most of the inconveniences. Indeed, VRET can be tailored to individual progression. It takes place in the privacy of the therapist's office, ruling out all the problems of confidentiality. It can be repeated or prolonged easily, even for rare or dangerous situations. It is less time-consuming for the therapist and really more acceptable by the patients. This report presents the preliminary results of a controlled and randomised study suggesting a comparable efficacy of VRET and standard CBT for the treatment of panic disorder with agoraphobia. Moreover, new therapeutic targets are investigated, like fear of falling. As a conclusion, VRET represents an interesting alternative therapeutic method to standard CBT for the treatment of phobic disorders, but it is generally not sufficient and has to be included in a more global therapeutic project.     

Le Réseau de Recherches Fondées sur les Pratiques Psychothérapiques : comprendre pourquoi et comment une psychothérapie marche

This article presents 1) the Psychotherapy Practice-Based Research's Network, 2) the principles on which it is constructed: to contribute to answer two key questions for the practices and research: “Why and How a psychotherapy works” and to adapt methodology to clinical reality and not the reverse, 3) its innovating methodology: intensive study of psychotherapies carried out under natural conditions, with follow-up of the chronology of changes and correlation of the outcomes with the process of psychotherapy, and 4) its organization (thematic poles, groups of peers, meetings of formations and experience feedbacks, collaboration between clinicians and researchers).     

Sexualité infantile et lien d’attachement. Notes sur la refonte de la métapsychologie proposée par Laplanche

The idea of a unified model of mental life makes it necessary to take account of the role of the recent ideas issuing from attachment theory while simultaneously reconsidering Freudian metapsychology. The revisited and then revised basis of metapsychology proposed by Laplanche (1970, 1993, 2007) considers that interhuman adult-infant communication emerges from an instinctual genetic basis but that, from the very beginning, this communication is compromised by the adult's infantile unconscious. In other words, this situation of adult-infant communication or Fundamental Anthropological Situation reignites the parent's unconscious conflictuality - in his relations to his own parents - and points him back towards his own history as a child. In this way, unconscious adult sexuality infuses the care bestowed by the other involved in the attachment and puts the child's psyche “to work”, with the child thus attempting to translate the enigma of this message and forming the basis for his or her own unconscious. A case study of child psychoanalysis is presented to illustrate this model.     

Le langage et la parole dans les dysphasies : pour une approche psychanalytique

In this article, we propose to study the relevance of a psychaoanalytic reading of specific language imparement, generally called dysphasias. A concise recall of the history and evolution of this concept leads to specify the essence of the present definitions and to question the various theoritical approaches leading to the various methods of therapeutics taking in charge. Then, from the psychodynamic point of view, we present the heuristic interest of a distinction between the language and the speech considered in its dimension of power and act of language basically implying the body. Lastly, in the light of a brief case study, we propose a theoretical and clinical reflection on the place and the function of speech in specific language imparement.     

De la médiation picturale dans le traitement de la schizophrénie

With schizophrenic patients, the use of the pictorial mediation during individual session of psychotherapy makes easier the display of the transferential y counter-transferential relationship. These creations are truly a way to say what the patient is unable to express differently. The use of a media: mediator, mediation, malleable medium, constitutes a first level of symbolization. It is used as an intermediary between nonsense feelings and their elaboration through the speech. In addition, these pictorial productions throw light on the question of ideality in psychosis and on this kind of archaic transference of the narcissistic pathologies.     

Clinique des psychoses et théorisation du désarroi

The psychotic states occupy a particular position (?) within the psychoanalytical theorization. They set a major resistance against their treatment so clinical as theoretical arousing movements of profound disarray at the clinicians. The part counter-transference (?) of the process of theorization aroused by the psychotherapy of the psychotic states engenders a particular shape of elaboration, an conceptual higher bid which plays the role of “theoretical reprisals” in front of the narcissistic wound imposed by these problems. These “theoretical reprisals” represent an attempt of connection of the psychic processes in failure and fix the limits of the models of understanding. This necessary stage of the work of conceptualization can be exceeded by return on the clinical practices allowing the subjective appropriation of the theorized notions.     

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.     

La gestion des affects dans la relation thérapeutique chez le patient schizophrène

This article studies schizophrenic patient's affective conflict by non-integrated ambivalence and absence of symbolisation of affect. Through the meet with a psychotic patient, the authors show that evolution of therapeutic relation is on a par with affect-representation link and its expression in therapy. The authors differentiate processes, which are involved in affect-representation link ; ones concern on representation (in particular déscénarisation and démétaphorisation), others concern on affect, as “thinging” of affects and external deposit of affect. The term of “insulating split”, a form of psychotic insulation, is used to describe this process.     

Habituation à l’acouphène : les fondements épistémologiques de l’approche cognitivo-comportementale en question

Tinnitus is frequently a motive for consultation in audiological services, which is generally a tolerated symptom according to epidemiological studies. However clinicians must also give counselling to some distressed patients, for whom the ringing in the ear are unbearable, leading to significant emotional disorders. The clinical contrast between suffering and non-suffering tinnitus patients has suggested comparative researches in order to enlighten this minor lack of tolerance to tinnitus compared to an epidemiological normal response. Studies have supported an habituation model to tinnitus which stands that habituation is the normal state of perception of tinnitus, and inhabitation is the result of a psychiatric co-morbidity. Referring to the neurophysiological principle of a natural inhibition of the orienting reflex with repeated stimulations, the habituation model states that tinnitus is a meaningless stimulus for the perception. Several psychopathological roadblocks (related to anxiety and depression) would prevent this natural inhibition to occur, leading to individual annoyance. In this article we analysed the epistemological foundations of the habituation model framework, regarding to experimental results in the psychoacoustics of tinnitus, and the concept of habituation in its neurophysiological framework. The process of habituation to tinnitus is discussed from these experimental references and recent progress in magnetic resonance imaging (MRI) from the neuroscience of tinnitus. Clinical implications of this analysis are suggested in conclusion, opening the discussion to the opportunity of another clinical approach of patients suffering from tinnitus.     

Hypothèse idiographique concernant la médiation cognitive à partir du Rorschach « non valide » d’un patient schizophrène en phase de stabilisation symptomatique

After reflexion about “short” and “invalid” protocols in the Rorschach Comprehensive System, the author analyses a protocol of a schizophrenic patient in symptomatic stabilization. This Rorschach does not meet the criteria of validity (less than 14 answers and 3 rejections of cards) and therefore does not allow to achieve a complete structural psychopathological analysis. The hypothesis of this contribution is to achieve a phenomenological study of this protocol centered on the cognitive mediation process. The implicit approach of “false perception” suggested to the patient (“what might this be?”) seems hardly tolerable and could, in part, explain the refusal of cards and the systematic questioning of the response and finally their rejection. This “methodical doubt” is similar to the exercises of cognitive remediation based on knowledge of disorder and his associated symptoms. Finally, the analysis of the Rorschach gives us interesting information about symptomatology stabilization and residual component of the schizophrenic disorder. These observations appear to be incompatible with homeostatic hypothesis and demonstrate the usefulness of residual schizophrenia diagnosis.     

Étude de validation de la version française des échelles de codage du coping et des erreurs cognitives (CE-CAP) sur une population non clinique

This study examined the validity and reliability of the French version of two observer-rated measures developed to assess cognitive errors (cognitive errors rating system [CERS]) [6] and coping action patterns (coping action patterns rating system [CAPRS]) [22] and [24]. The CE measures 14 cognitive errors, broken down according to their valence positive or negative (see the definitions by A.T. Beck), and the CAP measures 12 coping categories, based on an comprehensive review literature, each broken down into three levels of action (affective, behavioural, cognitive). Thirty (N = 30) subjects recruited in a community sample participated in the study. They were interviewed according to a standardized clinical protocol; these interviews were transcribed and analysed with both observer-rated systems. Results showed that the inter-rater reliability of the two measures is good and that their internal validity is satisfactory, due to a non-significant canonical correlation between CAP and CE. With regard to discriminant validity, we found a non-significant canonical correlation between CAPRS and CISS, one of most widely used self-report questionnaire measuring coping. The same can be said for the correlation with a self-report questionnaire measuring symptoms (SCL-90-R). These results confirm the absence of confounds in the assessment of cognitive errors and of coping as assessed by these observer-rated scales and add an argument in favour of the French validation of the CE-CAP rating scales.     

Neurofeedback dans le trouble déficit de l’attention avec hyperactivité : de l’efficacité à la spécificité de l’effet neurophysiologique

Clinical guidelines for attention deficit/hyperactivity disorder (ADHD) recommend a multimodal treatment encompassing pharmacological medication with methylphenidate, cognitive-behavioral therapy (CBT) and family treatments. Methylphenidate is the most effective treatment, though the relatively high rate of partial responders, and the possible parental reluctance against the pharmacological treatment. Thus, it is interesting to consider new non-pharmacological therapies based, such as CBT, on the learning capacity of children to self-regulate their behavior. Neurofeedback is interesting insofar as it would allow children to acquire self-control over certain brain activity patterns to improve the regulation of their behavior in daily-life situation. Early studies on neurofeedback in ADHD are nearly 30 years old. Two training protocols were created, based on EEG abnormalities in ADHD. First training allows the modulation of EEG frequency bands: increased activity in the beta band, or decreased activity in the theta rhythm. The second allows an increase in a slow cortical potential. In both protocols, feedback of the brain activity patterns is given to children in real time as a kind of computer game, and changes that are made in the desired direction are rewarded, i.e., positively reinforced. The evidence-based level of the neurofeedback is still unclear. But, unlike other mental disorders, many studies have investigated the effect of this treatment on symptoms of ADHD. Thus, we propose to analyze the data of literature and especially recent studies. A meta-analysis and randomized controlled studies seem to confirm the efficacy and the possible place of neurofeedback in the multimodal treatment strategies of ADHD. But, if this treatment supposes to allow self-regulation of children behavior by learning the control of EEG activity, the specific mechanisms of action on brain activity remains problematic. Thus, we propose to identify methodological and neurophysiological areas for future research on this therapy involving the subject and electrophysiology in psychiatry.     

Comorbidité TDA/H (Trouble du Déficit de l’Attention avec ou sans Hyperactivité) et TSA (Troubles du Spectre autistique)

The publication of the fifth version of the DSM in May 2013 officially recognized comorbidity between Attention-Deficit Disorder with or without Hyperactivity (ADD/ADHD) and Autism Spectrum Disorders (ASD). Indeed, the DSM-IV didn’t allow concomitant diagnosis. However, there is a clinical, neuropsychological and genetic overlap between these two disorders. Thus, 30–80 % of patients with ASD fill criteria for ADD/ADHD and in 20–50 % of patients with ADD/ADHD are found the diagnostic criteria for ASD. These observations raise the question of the link between ADD/ADHD and ASD: Is ADD/ADHD a minor form of ASD? Are ASD and ADD/ADHD different manifestations from a single neurodevelopmental disorder? Finally, are they two distinct developmental disorders whose clinical expressions would approach? Recent studies seem to distinguish two types of situations: Comorbid patients with less severe symptoms of ASD do not differ qualitatively from ADD/ADHD patients alone, which argues for a continuum between ADD/ADHD and ASD. Patients with ASD symptoms predominate are qualitatively different subjects from ADD/ADHD alone, thus corresponds to the hypothesis of two distinct nosological entities. Anyway, when ADD/ADHD and ASD are associated, there are specific clinical expression of developmental pathways and prognosis. Thus, these comorbid patients suffer more frequently from other psychiatric disorders, have a poorer quality of life, poorer adaptive functioning and clinical expression is more persistent over time. The modalities of treatment of comorbid patients may associate psychoeducational, psychotherapeutic approaches and medication (methylphenidate, atomoxetine, guanfacine, risperidone, aripiprazole).     

Psychopathologie des demandeurs d’asile accueillis en République slovaque. Étude portant sur 40 requérants

Objectives

By the end of 2006, 32.9 million people in 111 countries had been placed under the protection scheme of the United Nations High Commissioner for Refugees (UNHCR). Amongst these people, more than 10 million refugees were fleeing from wars and various conflicts. Few psychological studies (more particularly francophone-based ones) were conducted on the psychological health of asylum seekers among these populations having suffered many traumatisms (war, exile, etc.). The following study was undertaken with asylum seekers in reception centres in the Slovak Republic and its aim was to assess their psychological health and, amongst other aspects, to evaluate post-traumatic stress and depressive and anxiety disorders.

Patients and methods

The following data was gathered from 40 asylum seekers who knowingly accepted to undergo a psychological examination including a clinical interview and three questionnaires of self-evaluation: the General Health Questionnaire (GHQ-12), the Post-Traumatic Stress Questionnaire (PTSQ) and the Experimental Anamnestic Questionnaire. At completion of the interview, the psychologist filled in the Depression Evaluation Scale (MADRS), the Anxiety Appreciation Scale (HAS) and the DSM-IV diagnostic criteria for post-traumatic stress disorders, major depressive episode and generalized anxiety.

Results

This study highlighted the precarious state of psychological health and the substantial psychological co-morbidity of the population seeking asylum in the Slovak Republic. The results show a prevalence rate as important as 55% of symptoms of post-traumatic stress disorders, 75% of the participants were exposed to events of a traumatic nature. The prevalence rate is as high as 65% for major depressive episodes and 62.5% for generalized anxiety.

Conclusions

The author underlined the major impact of the traumatisms these Europe-based asylum seekers have had to deal with (war traumatisms, flight, exile, etc.) in order to explain the importance of psychological health issues. Certain factors such as the isolation of individuals, not to mention the context of the asylum-seeking procedure and its restraints, become stressful events highly likely to cause psychological vulnerability. These factors represent a field to be explored in depth. The results of this study induce questions relating to the accessibility and to the adequacy of the psychological care proposed by the hosting structures. These queries fall within the framework of a larger questioning relative to potential complementary actions in the field of mental health.