Enseignements de l’approche organo-dynamique de l’acouphène

Objective

In this article, we make a critical analysis of the Traité des Hallucinations by the French psychiatrist Henri Ey (1900–1977) and his organo-dynamic theory, that is focused on the functional pathology in contrast to the delirious hallucination. The analysis is dedicated in particular to the phenomenology of tinnitus (i.e. ringing in the ear[s]) that is currently labelled a “phantom auditory perception” by contemporary neurosciences.

Method

The analysis was conducted from a thorough reading of the psychiatric work of Henri Ey, mainly his important “Traité des Hallucinations” (2006), “Études psychiatriques” (2006) and “Neurologie et Psychiatrie” (1998). Following his warning regarding a pathological reality (hallucination) that cannot be seized “by draft and outlines”, in this report we address the understanding of the patient's discourse beyond its convergence with the experimental facts.

Results

Because he wanted to include in the pathogeny of his treatise the “most elementary one” – e.g. tinnitus in the auditory sense – Henri Ey felt in the conception he did not support himself, that is to compare hallucination to a “kind of” perception. Having distinguished the delirious from the functional hallucinations (that correlate with sensory deprivation), he could not avoid reifying them within the sensory deficit, leading again to the concept of perception. This remark can be applied to the contemporary neurophysiological model of the “phantom auditory perception”, which also casts the patient's discourse on a frame with its relativity and proportions that belong to the field of perception (“elementary” vs. “complex” phenomena).

Discussion

The paradox of drafting functional hallucination as an elementary perception supports a new perspective on suffering from tinnitus, that is not restricted to an understanding of the convergence between the subjective discourse and a sensory deficit. Beyond a reification of the subjective indication arising inside the body (i.e. tinnitus), the study of the individual enunciation of the suffering appears on the horizon of the organo-dynamic theory. A psychodynamic approach of this new issue on tinnitus has been supported by the author and a colleague.

Conclusions

Whilst today the magnetic resonance imaging seems to nullify the intersubjective reality, by showing visual correlates of this intangible phenomenon, Henri Ey allows us to recognize a surprisingly modern requirement: a psychotherapeutic listening to tinnitus patients has to be iconoclastic. If the aim is to set-up an individual dialogue with the tinnitus sufferer, the clinician must remove in his mind the images he created about it.     

Pronostic de l’état de mal chez l’adulte

Most investigations on prognosis of status epilepticus (SE) have focused on mortality, and suggest that outcome basically depends on the etiological and biological background. However, some recent studies also suggest that SE itself could be an independent predictor of death. Conversely, very little work has been published concerning the impact of SE on cognition. As compared with a first brief epileptic seizure, an incident SE episode seems to increase the risk of developing epilepsy.     

Traitement de l’information faciale dans l’autisme

One of the core deficits of autistic pathology is disturbances in reciprocal social interactions. As faces are essential components of social interactions, many studies have explored face processing in autism. The present paper reviews behavioural and neuroimaging studies on neutral and emotional face processing. After hypothesis of deficit of face processing in autism, recent data suggest atypical perceptual processing of faces. Indeed, individuals with autism pay less attention to eyes’ region than typically developing persons and present a local bias, contrasting with configural processing of faces in non-autistic individuals. Furthermore, people with autism do not display automatic process typically induced in persons without autism by perception of emotional faces. Peculiarities of processing are also observed at the neurobiological level. Persons with autism do not activate the same brain regions than typically developing participants during facial information processing and do not exhibit the same pattern of evoked cerebral responses. However, to date, there is no data converging to the dysfunction of a specific cerebral area in autistic pathology. Recent hypothesis suggest alteration of cerebral connectivity instead of one neural structure. These peculiarities of processing are discussed in terms of social experience and expertise in face processing.     

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.     

Développement cérébral en psychiatrie de l’enfant et de l’adolescent. Approche par l’imagerie

Modifications in cerebral development have either been demonstrated or their presence is probable in a number of psychiatric disorders which arise during childhood or adolescence. Their detection depends on new methods of image analysis; examples are presented in this article. These methodological innovations permit the quantification of anatomical or functional imaging data, not only in patient groups, but also on an individual basis. This new technology could concern diagnostic aid, psychopathological information, therapeutic evaluation, and sometimes detecting a disorder. The implementation of this type of research depends on the organization of clinico-methodological networks for setting up the relevant databases.     

Le sommeil de l’analyste

The state of “nodding off” which the psychoanalyst may experience during therapy is a phenomenon that requires further investigation into its nature, causes, and effects. Even if it occurs only sporadically and is a physiological necessity, it nevertheless has a certain effect and can present certain advantages. This introduction of resistance in the form of sleep can sometimes provide an opportunity in the development of sensorimotor functions for the patient to verbalize his experience, and in any case this phenomenon should not be taken lightly. Recourse to current knowledge regarding sleep can improve our understanding of this phenomenon, and we should be prepared to take the risk of examining psychoanalysis on the basis of a non-analytical approach, i.e. primarily psychobiological and cognitive. This also permits a link to be made between the psychoanalyst’s therapeutic activity and the contextual phenomena which influence cerebral activity and its level of vigilance which is expressed by specific types of verbalization. The pertinence of this risk-taking should also be examined, and a distinction made between physiologically necessary somnolence and other causes. It appears that in the present context, the induction of a state of somnolence is caused by the narcissistic characteristics of a transferential relation that is in the process of development; that is to say, the “positive aspects’’ of narcissism, which are an integral part of psychic growth. However, we should also bear in mind that these narcissistic characteristics can also be expressed in the form of resistance.     

Les destins de l’inceste

The clinic of patients, victims of incest in childhood, invites us to question the fate of such psychical trauma and working-through issues offered by psychoanalytical treatments. Differentiation and articulation between the registers of the act and the factual reality, and those of fantasies and psychical reality, are at the heart of the psychoanalytical approach of incest. But, despite the theoretical contributions of Ferenczi on early trauma and because of a misunderstanding of the “abandonment of Neurotica” by Freud, psychoanalysis, until recently, has been accused of ignoring the specific sexual trauma by favouring only the psychical reality. A reassessment of this theory precedes a reflection on various figures of incest worked through in psychoanalytic literature: if the father-daughter incest is considered relatively often, mother-child incest, which is more rare in its genital forms, is nevertheless common on the form of perverted care, and is just as psychologically harmful. The difficulties of counter-transference work under intense transference reactivation show that the psychotherapist is attacked in his mental capacity to contain and associate. The particular destructiveness of incest trauma lies in its attack of the œdipal organization and its structuring value.     

Place de l’électroencéphalogramme dans l’état de mal épileptique

Recordings of the electroencephalogram (EEG) play a major role in the management of patients with status epilepticus (SE). The EEG contributes to the diagnosis of SE, can be used to identify differential and syndromic diagnoses, and sometimes provides the etiologic diagnosis. EEG is helpful in monitoring therapeutic management and is an essential component of the follow up. The interpretation of the EEG in a patient with refractory SE is difficult, requiring clinical experience in this domain. We discuss the different modalities of EEG recording and their indications in emergency situations.     

Enjeux actuels de l’évaluation psychologique dans la clinique de l’enfant et de l’adolescent : vers une approche intégrée de la psychopathologie

This article will discuss different theoretical approaches and methods of data collection in view of the psychological assessment of children and adolescents. There are generally two different approaches; one being the single case study using a subjective method and the second consisting of clinical interviews and psychological tests using the objective method. In our opinion, psychological assessments should rely on two main axes. The first should be based on an updated knowledge of psychopathology, integrating new models and scientific findings with the methodology of Evidence Based Medicine (EBM). The second axis should be concerned with the psychological assessment combining subjective and objective methods. For example, the use of standardized tools such as scales or projective tests is essential to understand the interaction between multiple clinical variables influencing child psychopathology as well as to understand family and social interactions. The diversity of risk factors (e.g. family, personality, social, biological factors, etc.), implicated in mental illness shows the multi-dimensional aspects of psychopathology. Different theoretical approaches have been developed to study psycho-pathological mechanisms (neuro-psychology, psychoanalysis, biological psychiatry approaches, etc.). Therefore an integrative approach of psychopathology using different models and factors is needed to understand psychiatric disorders. A thorough psychological assessment is essential to the comprehension of mental illness in children and adolescents and is the first step to tailor treatments to individual needs. In order to answer these objectives, psychological assessments must be multi-modal, multi-disciplinary and multi-source: - Multi-disciplinary: For a better clinical assessment, psychologists and psychiatrists will need information from other professionals such as speech therapists, psychomotor therapists, neurologists… - Multi-modal: This aspect is crucial in clinical assessment. It characterizes all tools that clinicians will use in their assessment practice: Psychological tests, clinical interviews or clinical scales. - Multi-source: A comprehensive assessment of child and adolescent psychopathology includes assessments of different informants and sources (family, teachers…). These different approaches will be discussed in the perspective of the actual stakes of psychological assessment in children and adolescents. Developing integrative assessment approaches seems to be a promising field for the future in mental health services, allowing the tailoring of specific therapeutics for each child.     

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.     

Critique de l’utilisation de l’enseignement de Jacques Lacan dans l’abord psychanalytique des troubles psychotiques ou d’une question postliminaire à tout traitement possible de la psychose

Lacan has left a teaching, mainly in his “seminars”, which is often synthesized, simplified and reduced to a simple explanatory theory, principally regarding psychotic process. Such a simplifying view can become a discriminatory, iatrogenic conception of the psychotic person and of the psychotherapeutic (or psychoanalytical) treatment. In the first part of this paper, the author tries to show that Lacan’s teaching was principally a transmission of the psychoanalysis itself, in different ways, as half-sayings, ambiguity, poetry and style, topology, mathems… Lacan passed himself on as a possibility of analytical opening, like in a cure. He does not generate a rational discourse, but he proposed several different theories as simple “vectors”. In the second part, the author puts some concepts as “Name of Father foreclosure”, “borromean knot” and “object a” into a political (within the psychoanalytical community) and historical context. If those items of Lacan’s teaching are diverted from their primal function of “vectors” and are considered as explanatory theories, then they lose their pertinence and can lead to a stigmatizing conception and to possibly iatrogenic attitudes in the treatment. That will be examined further.     

Défaillance de la relation à l’objet primaire et altération de l’enveloppe psychique chez l’adolescente obèse

This article is offering a discussion on the links between developmental obesity, constitution of the psychic life and of its envelopes but also about the first object relationship. A clinical presentation of a teenager will allow a better understanding of how the mothers of these teenagers can be in suffering and so, since the birth of their child. These in-secure precocious relations for the baby are both going to inscribe in the body as well as the psyche by an alteration of the psychological envelope translating a defect of contain. A better comprehension of the stakes and the genesis of the developmental obesity is the crucial question of today according to the pressure coming from the high sphere of health authorities. Public and political authorities ask for health care establishments of the “compulsory” losses of weight. But the loss of weight cannot be obtained without psychological care in parallel. Certain obese girls cannot psychically separate their family circle influence from their polyphagic symptom. Indeed, the return at home is often followed by a weighty resumption. The fragility of their psychological containing, the psychological and corporal failures linked to a dysfunction of the first object relation do not facilitate this work of separation as well as the process of autonomy and of individuation. Then, the sustainable loss of weight at the obese teenager cannot happen if it is not accompanied in parallel with a work of psychological care among the relationship with the first object, the constitution of her corporeal and psychological envelope.     

Psychothérapies cognitivo-comportementales de l’hypocondrie

This paper reviews the cognitive-behavioural strategies of psychotherapy applied to hypochondria. Cognitive mechanisms of hypochondria are the tendency to amplify body manifestations (pain, fatigue…) and to interpret them in a catastrophic manner. The persistence of anxiety is due to a confirmatory bias, which increases the importance given to information congruent with anxiety. The exposure-response prevention model is an important technique in the treatment of hypochondria. This model has been validated in patients presenting obsessive compulsive disorders. Patients are invited to confront ideas or thoughts that induce fear. This confrontation is repeated or prolonged in order to induce the extinction of anxiety. Another cognitive approach is the step-by-step cognitive “modelling”. During the first step the patient assesses his stress-inducing thoughts concerning his health, he also has to assess the frequency of inadequate medical treatments. During the next step, the therapist helps the patient correct automatic thoughts and false beliefs concerning his illness. The last step is a phase of consolidation. The therapist identifies factors triggering anxiety and excessive medical care. All these behavioural cognitive therapies can be performed in individual or in-group processes. Therapies proposed to patients presenting generalized anxiety disorders can be adapted to hypochondriacs. Lastly, hypochondria can be understood and treated as a form of addiction to medicine characterised by a craving for medical care, for biological exams and for different forms of medication. According to this conception, the treatment can be conducted as a form of detoxification: patients identify the frequency of their pathological behaviour and find strategies to reduce and/or control them.     

Les théories de l’hypnose

Two major theoretical frameworks are proposed in the explanation of hypnosis and the mechanisms governing its idiosyncratic phenomenona: the psychosocial theory and the neo-dissociation theory. These two major paradigms conflicted with each other in the sixties and polarised on each other, the former emphasised the role of social influence in the hypnotic process, and the latter emphasised the cognitive mechanisms of the idiosyncratic response. The role of hypnosis in the production of hypnotic phenomena is disclaimed by those who hold the psychosocial perspective. If they were to recognise a psychic modulation, they would consider it to be artificially produced by the subject as a strategy inherent to taking on a role within the context of the administering of the suggestions, as well as by the motivation and expectations of the subjects. This interpretation leads them to deny that hypnosis can achieve an idiosyncratic response, and equally its existence. On the other hand, those adhering to the neodissociation perspective consider hypnosis to be at the origin of the hypnotic response and originating from a psychic dissociation inducing an involuntary response. If the existence of a dissociation mechanism is supported by certain experimental data, as proposed by those adhering to the neo-dissociation theory, it nonetheless remains hypothetical. On the other hand, given that psychic duality is found only in very good hypnotic subjects, it must be questioned if it is necessary for the achievement of all hypnotic phenomena or for only a category of very difficult items that call upon a special capacity. The two major theoretical models answer the question of the determinants of the hypnotic response only imperfectly. The question put forth precociously by hypnosis regarding the conscious or unconscious establishment of mental processes leading to the production of an action (which is in fact that of the links between consciousness and the cognitive unconsciousness), cannot be determined without an interdisciplinary approach, notably with the support of the neurosciences.     

Impact de l’adversité familiale durant l’enfance sur le développement de la personnalité psychopathique

Psychopathy is a multiple components diagnostic at the intersection of different perspectives: Psychiatry, social science, law, and criminology. Its etiology remains fuzzy given his different components. Here, we report on the base of a retrospective study that aimed at assessing the extent to which an experience of adversity during childhood is predictive of the onset of psychopathy in adulthood. Results are indicative that four adversity-related factors are indeed significantly predictive of several subscores of the Psychopathy Checklist Revised (PCL-R), despite a lack of predictive association with the total score. This suggests that the family environment plays a role in the onset of psychopathy, but also highlights the etiological complexity that characterizes the psychopathy.     

Influence de l’insight sur l’efficacité de l’entretien motivationnel dans la prévention des rechutes chez des patients alcoolo-dépendants

Motivational interventions are effective in the treatment of alcoholism, especially in the early stages of the Prochaska and DiClemente model of change. In 62 alcohol dependent patients without cognitive disorders, in addition to treatment as usual, motivational interviewing effectiveness on relapse prevention was linked with the level of insight. We have retrieved a moderate effectiveness on relapse prevention in patients with poor insight and a significant adjunctive effectiveness in patients with good insight.