Jeu d’argent problématique et responsabilité pénale

ObjectivesIn total, 14% to 30 % of individuals with gambling disorder engage in illegal acts to finance such behavior. This clinical situation could be explained by higher gambling severity, associated substance use disorder, antisocial personality disorder and economic factors (debts, financial problems). The present work focuses, more broadly, on criminal responsibility of problematic gamblers.MethodsWe will discuss this question through different typical situations that medical experts of criminal responsibility may have to face. We will address each of the following cases: 1) isolated problematic gambling; 2) problematic gambling associated with antisocial personality disorder; 3) problematic gambling associated with a manic episode; 4) problematic gambling associated with substance use disorders; and 5) problematic gambling associated wiht dopamine agonist treatment.ResultsIsolated problematic gambling, (not associated with any psychiatric or addictive disorder): it seems consensual that individuals committing infractions in this case are criminally responsible. However, impeded ability to action control and possible sentence attenuation could be discussed in case of severe gambling disorder. Problematic gambling associated with antisocial personality disorder: if the penal offence reports solely to personality disorder, criminal responsibility would be attributed. However, if illegal or violent acting is directly linked to co-cocurrent delusional symptoms, it could be a cause of criminal non-responsibility. Problematic gambling associated with manic episode: manic episode related offence could lead to negation of criminal responsibility, while a hypomanic episode may provide grounds for sentence reduction. Problematic gambling associated with substance use disorders: in France, addiction is not considered to remove nor to impede a person's ability to understand or control his actions and is excluded from criminal non-responsibility causes. However, substance induced delusional or confusional episodes could abolish a subject's discernment or his ability to control his actions yielding to penal non-responsibility. Problematic gambling associated with dopamine agonist treatment: Criminal responsibility for dopamine agonist induced gambling related illegal acts is still controversial. Nevertheless, people committing an infraction linked to associated dementia or dopamine agonist induced mania should be considered as criminally non-responsible.ConclusionsSome clinical dimensions such as craving intensity, compulsivity, disorder's severity, volitional control might be forensic targets to assess criminal responsibility.     

De l’aliénation au double

ObjectiveTo identify the place and importance of the notion of transitivism in detecting structural features enabling a differential diagnosis between Autism and Psychosis.MethodThe study uses two paradigmatic case studies, one case reported in the psychoanalytic literature, the other study reporting cures with autistic children with heuristic value for general induction.ResultsTransitivism is found in excess in infantile psychoses and in default in autism.DiscussionStarting from the concept of alienation in the teaching of Jacques Lacan, the article posits firstly that transitivism, a concept also taken up by Henri Wallon, is the first form of relationship with others, and secondly, using two paradigmatic case studies, attempts to show that the outcome of transitivism is different between autism and psychosis.ConclusionThe notion of transitivism proves decisive for establishing structural differences between autism and psychosis, and the emergence of transitivism corresponds to a moment of crystallisation of transference in psychoanalytic cures with autistic children.     

Quelle est la responsabilité pénale de l’auteur d’une infraction commise sous l’emprise d’un état alcoolique ?

ContextExcessive consumption of alcohol is a major problem for public health in France and in particular in Pays de la Loire and Brittany. It is considered a factor encouraging criminal behaviors. There is a paradox between the alcohol consumption considered by judges as aggravating circumstances of the infraction on one hand and scientific data establishing that in certain circumstances (amount, consumption habits, background, polydrug use, …) alcohol could change the judgment and discernment of the consumer on the other hand. However, during criminal proceedings, the expert psychiatrist may be called upon to assess the degree of discernment of the perpetrator of the committed infraction under the influence of alcohol. Depending on whether the judge pronounce an intact, an altered or an abolished discernment — after having taken into account the conclusions of the expert psychiatrist — the perpetrator of the infraction will be considered as entirely or partially responsible or as irresponsible.GoalThe goal is to assess the proportion of abolition or alteration of discernment that is proposed by psychiatrists when an infraction is committed under the influence of alcohol.Patient and methodologyThe study is retrospective and multicentric. It includes the criminal appraisals relating to the liability that have been performed by psychiatrists of the Courts of Appeal of Rennes and Angers over the period from the 1^st January 2015 to the 31^st December 2016. The exclusion criteria are criminal appraisals which do not relate to criminal liability and criminal investigations for infractions that are not committed under the influence of alcohol.ResultsWe browse 529 psychiatric appraisals and 104 of them were included. Appraisals that did not correspond to evaluation of responsibility (appraisals of victim, appraisals of guardianship or curatorship, appraisals of dangerousness after sentencing), appraisals for which author of the facts did not consume alcohol or data on alcohol consumption was not available, were excluded. Seven experts psychiatrists practicing in Brittany and Pays de la Loire did contribute to the study. The statistical analysis did not brought to light an impact of alcohol consumption on the degree of discernment assessed by the experts. The existence of an alcohol-related disorder in the perpetrator was not significantly associated with an impairment of discernment. On the other hand, the presence of psychiatric comorbidity (p < 0,001) and the existence of a psychiatric care after the commission of the offense (p < 0,02) were the only data significantly associated with an impairment of discernment.ConclusionThe consumption of alcohol during a criminal offense is not retained by the experts as a factor disturbing discernment.     

Applications de la réalité virtuelle en psychiatrie légale : la perspective de l’autorégulation comme cadre théorique

IntroductionForensic psychiatry is the field whose expertise is the assessment and treatment of offending behaviours, in particular when offenses are related to mental illness. An underlying question for all etiological models concerns the manner in which an individual's behaviours are organized. Specifically, it becomes crucial to understand how certain individuals come to display maladaptive behaviours in a given environment, especially when considering issues such as offenders’ responsibility and their ability to change their behaviours.Virtual realityThanks to its ability to generate specific environments, associated with a high experimental control on generated simulations, virtual reality is gaining recognition in forensic psychiatry. Virtual reality has generated promising research data and may turn out to be a remarkable clinical tool in the near future. While research has increased, a conceptual work about its theoretical underpinnings is still lacking. However, no important benefit should be expected from the introduction of a new tool (as innovative as virtual reality) without an explicit and heuristic theoretical framework capable of clarifying its benefits in forensic psychiatry.ObjectivesOur paper introduces self-regulation perspective as the most suitable theoretical framework for virtual reality in forensic psychiatry. It will be argued that virtual reality does not solely help to increase ecological validity. However, it does allow one to grant access to an improved understanding of violent offending behaviours by probing into the underlying mechanisms involved in the self-regulation of behaviours in a dynamical environment. Illustrations are given as well as a discussion regarding perspectives in the use of virtual reality in forensic psychiatry.     

Le rapport de la schizophrénie au désir dans l’enseignement de Lacan

Objectives

In psychoanalytic research on psychosis, the tendency in Lacan's thinking, as well as among his readers and commentators, is to focus work on paranoia. However, it is here counterbalanced by a specific approach to schizophrenia. It is also against the current trend of positioning Desire in psychosis as a deficiency that we explore what might be the “desiring” economy of the schizophrenic.

De l’aliénation mentale de l’enfant et de l’adolescent à la pédopsychiatrie dans les communications à la Société Médico-Psychologique de 1852 à 1937

In 1848, the Société Médico-Psychologique was founded. Its aims is to promote the study and improvement of mental pathology. During the 19th century, François Arnaud (1858–1927), Claude-Etienne Bourdin (1815–1886), Michel Catsaras (1860–1939), Louis Delasiauve (1804–1893), Eugène Dally (1833–1887), Jules Fournet (1812–1888), Paul Garnier (1848–1905), Valentin Magnan (1835–1916), Jacques-Joseph Moreau De Tours (1805–1884), Emmanuel Régis (1855–1918), Paul Sollier (1861–1933), Edouard Toulouse (1865–1947), Auguste Voisin (1829–1898) and Jules Voisin (1844–1920) were the alienists or not, French or foreigners who succeeded at the chair of the Société Médico-Psychologique. This later presented observations of children or teenagers. The communications and discussions but also the issues raised by the alienists, neuro-psychiatrists then child psychiatrists will contribute to the reflections of members of the Société Médico-Psychologique over the course of the last century. But, they also forced us to take a more perceptive look at the child's mental health. Its communications and their authors belong to their time and to a time or even a place where they emerged. Apart from to looking into the topics pursued (deficiency, dementia praecox, epidemic encephalitis, autism, etc.) concerning the infantojuvenile psychiatry, we will carry out a work of communications contextualization focused on the child's mental health at the Société Médico-Psychologique during 170 years.     

De la contagiosité de l’électrohypersensibilité

Electro-hypersensitivity (EHS) is a phenomenon that emerged in the 1980s and which seems to attribute the occurrence of some symptoms to an exposure to electromagnetic fields (EMF). Since it has appeared, the number of cases has not stopped increasing, suggesting some kind of contagion. However, the correlation between exposure and the onset of symptoms has been tested repeatedly and has never been confirmed. The hypothesis that a psychogenic effect named the “nocebo effect” could be at work then took shape, bringing us to an awareness of our ever-increasing exposure to anxiety-inducing news about the presence of EMFs. This context of negative expectations reinforces the action of the nocebo effect (an effect which is inherently contagious) but does not, in itself, explain the path of a majority of victims in whom the onset of symptoms preceded knowledge of a possible harmful effect of EMFs. Different studies have shown that in the latter case, it could be a phenomenon of wrong attribution of symptoms. The victims, left unanswered by the medical community, will seek a cause and will be confronted with the orientation of the cognitive market towards EMF. This confrontation will be all the more unbalanced as the victim is unaware that it is subject to many cognitive biases in its way of understanding the information offered to it. Once the attribution is established, the nocebo effect can again come into play and strengthen the feeling of being a victim of EHS. Whatever the path, the victim enters a vicious circle from which it appears very complicated to escape.     

La paranoïa au travers de la procédure pénale

One clinical case. Three steps of a criminal proceeding. The opportunity to approach clinical data and legal issues through three essential questions. Pre-sentence responsibility; paranoid position at the time of trial; post-sentence dangerousness. From marginal, « simple » personality reorganization, normal psychic functioning, to characterized delusion. Is there a continuum? Some mentioned it. Are we facing distinctive psychic states? Some think there are. In front of a situation involving emotion, mood, and passion, clinicians regularly face a dead end. This case shows both legal system and psychiatry limits addressing paranoia.     

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.     

Le cycle de la honte dans l’obésité

IntroductionIn Western countries obesity is currently a major public health issue. Part of a complex system, it should not be studied alone. Yet it is often seen only as the result of qualitatively and/or quantitatively deviant dietary-intake and is seldom questioned as a symptom in the psychoanalytic sense, i.e. as a part of a package that makes sense.Objectives of the studyThe purpose of this article is to highlight the importance of shame in the psyche of obese subjects as “subjective backup”. The author questions the experience of shame in obese subjects as the cornerstone of this symptom in the psychoanalytic sense.MethodsWhile reporting a clinical case, the author notes the occurrences of shame in the discourse of the patient. The subsequent analysis is presented based on the transferential and counter-transferential relationship. To carry out this study, the author drew on a device supporting catharsis.ResultsThe author addresses successively: the complaint of obese subjects and the effect of shame, their shame as the alpha and omega of bulimic crises and lastly their body as a work of art by building a monstrosity. The author concludes with the social dimension of shame and how it is part of the symptom of body transformation in obese subjects.DiscussionIt appears that pathological shame reveals a difficulty to maintain a sense of existence. For this reason, it seems important to consider this effect and to establish a framework for the emergence of the latter in the consultations of patients with eating disorders. Under these conditions, the patient is able, on the pedestal of shame, to voice his shame of being and to support a subjectivity.     

Dangerosité psychiatrique et responsabilité pénale atténuée : à propos de la condamnation à la réclusion à perpétuité d’un schizophrène auteur d’un homicide sexuel sadique

The second paragraph of article 122-1 of the French Criminal Code provides for a reduced penalty in criminal matters (Court of Assizes) when the offender is suffering at the time the act is committed from a mental disorder that reduces his liability. This legal provision is not always respected, as shown by the sentencing to life imprisonment of a chronic psychotic patient who committed a sexual homicide (sadistic rape). The Court of Assizes found that the great dangerousness of this schizophrenic, with a multiple criminal record and who had refused his treatment, justified his conviction, while the psychiatric expertise concluded that he should benefit from a reduction on his criminal liability. The sentence was passed without the level of severity of his mental state having been verified by a new expert. The author therefore questions the “ethical” nature of this court decision which, albeit legal, is contrary to the spirit of the law. There was no appeal against the sentence.     

Le travail de l’hypocondrie chez le sujet en insuffisance rénale chronique et hémodialysé

Aim of the research

Since the interiority of the body is redefined by the experience of a chronic somatic disease and its therapies, one of the psychic approaches we propose to study is the work on hypochondria.

Verticalisation en abduction de hanches pour la prévention de l’excentration de hanche chez l’enfant paralysé cérébral

Hip eccentricity (EH) is a common musculoskeletal deformity in children with cerebral palsy (CP), with severe and multiple consequences. The risk of EH increases with young age, functional limitation, spasticity, and if the condition is quadriplegic. Prevention of EH is therefore a public health issue from an early age. The standing program with hip abduction (VAH) is commonly used for this purpose, but it is highly controversial. Based on a review of the literature and external sources, only seven clinical trials in relation to the subject were found. There is a great disparity in methodology between the articles. VAH may have an effect on EH in children with CP, both preventively and after soft tissue surgery, but the level of evidence is moderate. This device seems to be more effective if the management is more comprehensive. Younger age and less advanced CP are indications where VAH seems to be effective, especially when started early. Confirming this effect with larger numbers is necessary as well as studying the long-term effect, especially in adolescence.