À propos de l’expérience de la torture

The large influx of asylum seekers confronts public mental health services with the suffering resulting from extreme political violence. Among these patients, survivors of torture present a unique clinical profile of which clinicians should be made aware. While certain researchers have proposed useful concepts, the statements of witnesses and the writings of clinicians constitute the point of articulation between theory and practice. In this article, we will attempt to understand the ways in which torture results in psychosis (“a laboratory of psychosis”), notably through the specific and ambiguous role of the imaginary. A specific focus will be dedicated to the processes of humiliation, which illuminate a dialectic between the body and the mind, between the physical wounds and the long-lasting injuries inflicted on the soul; torture causing, intentionally, the possibility of a rupture between the ego and the ideal of the self. Finally, the article will critically examine the role of the therapist; so that clinicians will be able find a favorable resolution to the pathogenic conflicts involved.     

Médiations thérapeutiques et processus de symbolisation : de l’expérience sensible à la modélisation

Aim

Therapeutic mediations are frequently used in mental health services. However, only a small number of studies are designed to assess their effectiveness and try to analyze their effects. In this paper we propose a summary of the research in this area in order to develop a general theory of therapeutic mediation from a psychoanalytic point of view. This topic is also discussed from the viewpoint of the qualitative analysis of the processes involved and the modeling of psychotherapies.

Étude qualitative de l’expérience de la formation en hypnose clinique pour les professionnels de santé

ObjectiveTraining in clinical hypnosis leads to important transformations in healthcare professionals, in their professional practices as well as in their personal lives. The objective of this study was to explore how health professionals experience the transformations that result from such a training.MethodSemi-structured interviews with health professionals from France and Europe were conducted. The qualitative method used was Interpretative Phenomenological Analysis. Purposive sampling required to include participants from different professions, experience and regions of origin. They had already completed training in clinical hypnosis at different teaching institutions.ResultsTen participants were included. The analysis showed four meta-themes of experience. First, it revealed participants’ motivations for training in clinical hypnosis as one's desire to improve one's practice, leading to extraordinary discoveries, at a particular timing in their life. Second, participants described that hypnosis sometimes set the ground for a relationship verging on the more “intimate”, therefore requiring greater caution so as not to disrupt the patient/healthcare professional relationship. Third, some participants experienced unforeseen personal fulfilment, better self-regulation of emotions and improved quality of life as well as greater comfort at the workplace. Finally, this study shed light on two limitations of training in clinical hypnosis as it can sometimes generate stress for the participants and/or result in bring about potential harmful effects: one of the risks being that the trainer might cross some ethical lines.DiscussionThe level of personal change experienced by the participants is similar to some changes induced by personal psychotherapy. For several participants, issues of power and vulnerability in the relationship using hypnosis were associated with a feeling of instability during the training. In hypnosis, the management of an asymmetrical relationship involves a two-way risk: vulnerability of the hypnotized person to the all-powerful relationship of their therapist as well as destabilization of therapists by the reduction of power asymmetry during hypnotic work with their patients.     

Tolérance à la détresse et expérience de la douleur chronique

IntroductionChronic pain is a highly prevalent condition that is associated with distressing somatic and emotional experiences. Consequently, an individual's distress tolerance, the perceived capacity to tolerate negative psychological and physical states, may influence their pain experience. This effect could be explained in part by a reduction in the catastrophic interpretation of pain which is associated with increased pain intensity and interference in everyday activities.AimsThe first aim of this study was to explore the association between the components of the 5-factor model of distress tolerance and (1) pain intensity and (2) pain interference in everyday activities. The secondary aim was to assess the potential mediating effect of pain catastrophizing in the eventual association between components of distress tolerance and (1) pain intensity or (2) pain interference in everyday activities.MethodThis is a cross-sectional study of adult (18 years or older) university students and staff with chronic pain (3 months). They were invited to complete the online questionnaire through an email invitation. Pain intensity and interference in everyday functioning were assessed with the corresponding subscales of the Brief Pain Inventory. The following instruments were used to assess the components of the 5-factor model of distress tolerance: Ambiguity Tolerance Scale (tolerance to ambiguity), Intolerance to Uncertainty Scale (reversed score: tolerance to uncertainty), Discomfort Intolerance Scale (reversed score: discomfort tolerance), Distress Tolerance Scale (tolerance to negative emotions), Frustration Discomfort Scale (tolerance to frustration). Participants also completed the Pain Catastrophizing Scale.ResultsEighty participants were recruited (57 % women, mean age = 33.09; standard deviation = 12,87). Tolerance to negative emotions was the only component of distress tolerance that was associated with pain (ß = ?0.04; 95% CI): ?0.07–?0.01; t (78) = ?3.06, p < 0.01) or pain interference in everyday functioning (ß = ?0.07; 95% CI: ?0.10–?0.03; t (78) = ?3.97, p < 0.01), independently of the others. Combined with age, these factors explained 16.2 % of the variance in pain intensity and 19.4 % of the variance in pain interference. Pain catastrophizing partially mediated the association between tolerance to negative emotions and pain interference in everyday functioning, but it was not involved in the association between tolerance to negative emotions and pain intensity.ConclusionTolerance to negative emotions appears to be the most relevant aspect of distress tolerance in the context of chronic pain and is a potential clinical target that is independent and complementary from pain catastrophizing.     

Prise en charge de la crampe de l’écrivain : 14 ans d’expérience de la toxine botulique

IntroductionWriter's cramp is a focal dystonia; treatment remains disappointing. We report our 14-year experience with a population of 119 patients aged between 18 and 85 years (average age 43 years).MethodsTreatment was based on botulinum toxin injections (Dysport^®) and physiotherapy. Patients were reviewed every four to six months with clinical and video evaluation by three different observers and subjective analysis of the treatment efficiency by the patient (score of 1 to 3). The post-injection deficit, if present, was also quantified.ResultsIn the group treated with toxin and physiotherapy, cramps improved (score 2 and 3) in 61.6% of patients; a majority of patients (n = 14) reported they were moderately satisfied (score 2). In the group treated with toxin alone, 37.9% of patients were improved (score 2 and 3) with a majority (n = 18) very satisfied reporting normal writing (score 3). Age was not a predictor of therapeutic response. Good results were obtained with injections of the flexor carpi radialis followed by flexor digitorum profundus II and III and the flexor pollicis longus. Seventy-one per cent of injections caused moderate muscle weakness, minimally disabling compared to the benefit of injections. Twenty-seven patients were followed for more than two years and three patients, who had achieved score 3 with excellent response, were followed for 14 years with very efficient repeated injections. If the injections were not effective the first time, we re-assessed the situation and adjusted the injections; we considered that toxin treatment was unsuccessful after three injections without benefit.ConclusionThe choice treatment for writer's cramp remains well-targeted injections of botulinum toxin. Physiotherapy is useful when the toxin injections are ineffective in completely improving writing. This requires close cooperation between the injector, the physiotherapist and the patient.     

Accompagner les professionnels de santé dans la révélation de l’erreur : de la révélation à soi à la révélation à l’autre

Error disclosure is now an ethical and professional obligation for health professionals and seeks to improve quality and safety in healthcare. Literature has highlighted the numerous benefits of error disclosure and several authors have described the options for handling this situation. However, it is not quite that simple to be honest and open and follow a protocol that instructs professionals to explain, support and apologise in situations where they are subject to criticism. While the many personal, institutional and social factors that hinder open disclosure have been identified, little attention has been paid to the obstacles associated with the psychological impact of disclosure, thereby limiting the debate on how professionals might be supported in their efforts to cope with error disclosure. The psychological impact of error on professionals is a well-established fact. Physicians are “second victims” likely to be emotionally affected by medical error. Emotional distress, anger, isolation, fear, guilt and shame can be intense, suggesting that, far from being an isolated act in professional practice, a medical error is a life event that modifies the psychological balance of a professional. Studies in the humanities have shown how work shapes individuals’ identities. The choice to heal and care for is indicative of the ideals related to professionals’ life histories, cultures, family models and representations of health and disease. Work and, more specifically, recognition at work from their peers, patients and relatives enables health professionals to support their ideals and establish a coherent identity, and to belong to a workgroup. The error foreshadows a rupture which plunges the professional and the team in a state of vulnerability that rules out the professional's or the team's possibility to be part of a process of disclosing the error. In these conditions, a policy of security of care also involves a guarantee of the caregiver's and the team's psychological security. The term psychological security was developed by the psychoanalysis who emphasised the individual's need to evolve in a “sufficiently good” protective environment that allows him/her to contain his/her emotions, while giving the individual the possibility to express and discuss them. This space implies a relation of trust between individuals. Trust refers to the idea that the individual can trust someone, it is based on the capacity to create relations. It is only through trust that the professional will be able to open him/herself to others and construct a space where the errors and the doubts that he/she has in the context of work are shared. But if trust is essential, it is also dangerous because it implies accepting the risk of being dependent on those considered as trustworthy and the risk that they will not live up to the professional's expectations. As a consequence, the professional will only have trust when he/she has evaluated the possibility of cooperation and more precisely, as stated by Hardin, a cooperation in which the professional's interests are “encapsulated interests”, in other words the interests of others. Therefore, this cooperation depends on each member of the team seeing his/her interests as being partially those of the others. Cooperation within a service reveals the relations of trust between the professionals and shows the relations of dependence that each one maintains with the others for the good administration of care. Thus the creation of relations of cooperation between the team members proves to be an important indicator to determine the professional's possibility to adhere to a process of disclosing the error. This approach shows that professionals must address multiple rather than single disclosures: to the self, and to others (colleagues, hierarchy, patients and families) who will mobilise specific knowledge, emotions and psychological defences. To avoid cases where disclosure takes on dimensions as tragic as the actual errors committed, it is important to pay attention to the psychic state of healthcare professionals by offering a space of free expression that enables them to better understand their feelings and gain a sense of support in order to restore their ideals and professional identities. Finally, it's important to emphasize that disclosure also depends on the preservation or restoration of the relations of cooperation within the team. Disclosure cannot be prescribed, it must emerge within a workgroup who allows the error to be thought over, communicated and shared. In this context, disclosure becomes a group rule that is known to all. A health professional who feels sufficiently supported might, in turn, support a patient and/or his/her relatives and engage in meaningful disclosure.     

Hypothèse physiopathologique de l’excentration de hanche dans la paralysie cérébrale à partir d’une expérience de terrain

Scoliosis, hip subluxation and hip dislocation in non-ambulant children with CP are important considerations for clinicians. In this paper, we propose a pathophysiological hypothesis to explain the process of hip dislocation based on the following chain of events: hip dislocation associated with progressive pelvic dissymmetry, lumbar spine hyperlordosis, and finally lumbar scoliosis with convexity contralateral to the dislocated hip. Our hypothesis is the psoas and ilio-psoas muscles are primarily responsible for these changes. First, the ilio-psoas muscle shortens. Second, the coapted hip becomes the center of rotation for the movements in all three planes of space. Third, the process of subluxation with pelvic dissymmetry begins and becomes irreversible. Fourth, the psoas on the dislocated side further shortens, and, because of its insertion point on the femur pulls on the lumbar spine. The psoas thus tilts the spinal column and accentuates the lordosis. Despite bone maturation, this aggressive form of scoliosis continues to progress.     

Le trouble dissociatif de l’identité : les mythes à l’épreuve des recherches scientifiques

Dissociative Identity Disorder (DID) has long been the subject of controversy in scientific literature and in clinical practice. This article identifies the main beliefs of clinicians and compares them to the scientific studies on this subject by presenting the main research of DID specialists and the opponents of this disorder. It results the following from this review of the literature: (1) DID is a different disorder from schizophrenia; (2) it exists independently of any iatrogenic influence of the therapist or of the media; (3) these patients are not particularly prone to suggestibility or fantasy; (4) DID appears outside of any hypnotherapeutic treatment; (5) it is the most severe of the traumatic disorders; (6) amnesia of childhood trauma is a proven phenomenon; (7) the extent of extreme physical and sexual abuse of children, sometimes infants, by individuals or organized groups, is known to police and judicial authorities.     

Sensibilisation à l’addictologie et collaboration avec les personnels hospitaliers. L’expérience d’une équipe de liaison

ObjectivesAddictology needs the involvement of primary care professionals, but reality is far from this will. To resolve this problem, liaison-teams have been created in the hospitals two decades ago. Training and support of caregivers is their first mission, although not obvious because they are called usually to cure the most complex addict patients. Our aim is to describe what kind of relationship they build, when they are called to meet a patient, to improve the hospital caregivers’ implication in addictology care.Materials and methodsThis study is based on the practice of a liaison-team working in a universitary hospital, including emergency, medicine, surgery and obstetrical units, and called for every kind of addictions, except tobacco when used alone.ResultsAn attention is first devoted to caregivers, who can be in difficulty because of partial or false representations of addiction and its care, or because of their personal experience of addiction. The team has to meet them regularly, to take time to think together. It promotes an interdisciplinary approach, which gives every kind of profession a position in the care of addiction. It stands back their request, to understand where their difficulties are and give an adequate answer. Second, in front of patients with whom the relation is complex, the liaison-team has to boost the self confidence of the caregivers in their ability to care for them: some simple tools and technics can be given, and new others can be built together when necessary. It pays attention to the articulation between hospital acute treatment and long-term follow-up. Third the liaison-team works in a dynamics of network, which promotes cooperation rather than separation and split.ConclusionsThis study invites for more research on the link between addictologic network and primary care providers, and the way to develop it.     

Cigarette électronique chez les patients fumeurs présentant une pathologie psychotique. Revue de la littérature

ObjectivesThis systematic literature review focused on patients suffering from schizophrenia (SZ), psychotic disorders or mental illness (MI) including SZ. It was interested in data on prevalence of electronic cigarette (EC) use, patient perceptions and expectations, as well as caregivers’ attitudes towards the EC and its benefit in helping to stop or reduce smoking.MethodThe research was carried out on Medline for the period 2000–2020. Cross-sectional, case-control, prospective, randomized controlled studies and preliminary studies were included in this review.ResultsEC is widely used by MI patients with current and lifetime use from 7.4% to 28.6%. More specifically, patients with SZ and schizoaffective disorders observe current and lifetime use from 7% to 36%, respectively. Many reasons are given by patients for its use including the possibility of using it in places where smoking is prohibited, its lower toxicity compared to cigarettes for oneself and those around, its lower cost, and the help provided to reduce consumption.ConclusionEC is used by smokers with MI; several studies confirm the possibility for these smokers to reduce tobacco consumption through EC and without disturbing their mental state. However, its value in helping to quit smoking remains uncertain.     

L’activité physique chez les patients atteints de schizophrénie : de la neurobiologie aux bénéfices cliniques

Schizophrenia is a severe chronic mental disorder that mainly manifests by positive symptoms, negative symptoms, disorganized behavior and thought and cognitive impairments. Taken together, these symptoms have substantial impact on quality of life, well-being and functional outcome. Patients with schizophrenia have dramatically higher levels of cardiovascular and metabolic morbidity than the general population due to poor physical fitness and to sedentary lifestyle. They have a reduced life expectancy, and an excess mortality being two or three times more than that in the general population. Moreover, despite major therapeutic advances in the overall management of these patients, some symptomatic dimensions, and more specifically the negative and cognitive ones, remain to be resistant to the usual pharmacological approaches. Moreover, antipsychotics can also reinforce the global cardiovascular risk due to side effects and low neurometabolic tolerance. The benefits of physical activity on health are now well described in the general population and in many medical diseases. More recently, physical activity has also found its place as an adjuvant therapy in severe mental illnesses, particularly in schizophrenia. In the literature physical activity programs, in addition to pharmacological treatments, appear to be feasible in patients and improve both physical and mental health as well as functional outcome. Clinical benefits of physical activity would be underpinned by biological and cerebral mechanisms, which remain unclear. In this review, we propose to present a state of the art and to present an update of the interests of physical activity in the management of patients with schizophrenia. We emphasize the clinical benefits of physical activity regarding the different symptomatic dimensions and its impact specifically on cognitive deficits. Finally, we describe the various underlying pathophysiological mechanisms in particular in the neurobiological, cerebral and physiological fields. We then discuss the barriers, facilitators and motivating factors towards physical activity to enhance health promotion initiatives, to optimize resource allocation when delivering physical activity programs in clinical practice, and to maximize physical activity participation. Physical activity appears to be an original and novel adjunctive therapeutic approach in the management of patients with schizophrenia and would both reduce schizophrenic symptoms and act like pro-cognitive therapy, improve quality of life and long-term functioning in daily life and reduce cardiovascular comorbidities. However, efforts are still needed to increase the motivating factors and adherence towards physical activity participation for people with schizophrenia.     

L’enfant autiste et son parent face à l’échec de l’intersubjectivité : une clinique de la narrativité

Aim

This article examines the failure of the processes enabling access to intersubjectivity and to primary subjectivation in the treatment of small children presenting autism, and the consequences thereof in the development of parenting exercised by the mothers and fathers of such children. The psychotherapeutic processes implemented via narrative and testimonial functions during consultations appear necessary to relaunch narrative identity and the capacity for parental reverie.