Identité sexuelle et schizophrénie : l’impossible intégration du féminin. Étude clinique et projective du fonctionnement psychique de trois femmes atteintes de schizophrénie

There are very few French studies that look at schizophrenia from the angle of sexual difference. Using the clinical and projective approach offered by Rorschach and TAT tests of three female schizophrenic patients (simple, paranoid and dysthymic) aged 21, 35 and 60, this article studies stumbling blocks in the construction of the sexual identity and in particular, the organisation of the female identity. The investment of the female body, secondary sexual identifications and the identification with the maternal imago are successively examined on the basis of clinical elements drawn from the three participants’ Rorschach and TAT tests. Our study shows how failure to come to terms with anality, passivity and identification with the maternal figure leads to refusal to identify with the female identity. This refusal should be taken as a negation of the libidinal link with objects. This implies that identity and sexual identity are inextricably linked. Sexual identifications appear to be intimately linked to the constitution of solid narcissistic foundations. However, while they may not be defining for psychic functioning, these underlying elements of the female identity would appear to be present in psyches marked by psychosis.     

Étude des représentations sociales de la schizophrénie dans la population générale et dans une population de patients schizophrènes

This study aims to compare social representations of schizophrenia in a sample of schizophrenics patients and in the general population. This question is of considerable interest in clinical practice and in psychosocial intervention. On the one hand, most of the schizophrenics patients have been informed about their diagnosis. On the other hand it is well known that stigmatisation attached to the labeling of schizophrenia has major repercussions on the acceptation of the diagnosis for the patient and his family, the compliance to treatment and the quality of life. Understanding social representations of schizophrenia in a sample of schizophrenics may be useful in adapting psychoeducation techniques and preventing relapses. We have investigated these reprentations in a sample of 20 schizophrenics who were informed of their diagnosis and in a 20 matched sample in the general population. We have excluded the persons who had a previous contact with a schizophrenic. Results show that medical representations of the trouble occur in general population, which can be considered as a positive evolution of the representation of schizophrenic people who are considered as ill persons rather than just “mad”. With regard to stigmatising representations, it is surprising to note that schizophrenics and the general population share the same representations. We hypothesize that this attitude in schizophrenics may result from an internalization of the supposed stigmatisation about their illness.     

Spécificité de la psychothérapie du patient postadolescent : à partir de deux exemples cliniques

This article is about the post-adolescence issue as a key period in the identity development of the subject prior to his definitive identification as an adult. At his stage in life, the adolescence's identity crisis goes on through tensions between two polarities, resulting in a more or less adaptative type of balance, requiring sometimes the need for special care. The process of subjectivisation “subjectivation” to adolescence that concurs with the problematic of borderline case continues with the construction of an achieved adulthood. This process requests nevertheless high levels of energy, hence resorting to specific psychological processes, sometimes leading to psychopathological disorders where recourse to psychotherapeutic treatments is necessary. This will be illustrated through the case studies of two post-adolescent girls, one requiring a light treatment to face a neurotic symptomatology, the other demanding a far heavier treatment in order to fight a chronic development of a psychotic symptomatology. The results are encouraging as far as specific cares are concerned at this stage in life, especially in fighting back a schizophrenic evolution after a state of delirium. They supply us as well with a model for treating borderline case pathologies and acute psychotic states at different stages in life.     

Déficit de mémorisation d'information à contenu émotionnel chez le patient souffrant de schizophrénie

Studies in the relationship between cognition and emotion are still ongoing. This new perspective has led Andreasen, among others, to consider the disturbance of the cognition-emotion relationship in schizophrenic patients as a fundamental aspect of the illness. This aspect is central in the care of these patients, since the difficulties engendered by it have a great effect on their quality of life. This study examines the process of recalling information with an emotional content among schizophrenic patients. The participants were divided into two groups (a group of 15 schizophrenic subjects and a group of 14 comparison subjects) and were asked to listen to a story containing information with both emotional and factual content. This information was presented both explicitly and implicitly. The participants then had to provide instant and delayed recall of the information. The results underlined a marked deficit in the immediate and delayed recall of information with an emotional content for the group of schizophrenic subjects regardless of how the information was presented or how long the delay in retention was. This indicates that memory deficit among schizophrenic patients increases when they have to remember information that is emotionally charged. On the other hand, it seems necessary to develop some cohesion around the terms used (“emotional memory”, “memory of information with an emotional content”) to further this type of research.     

Conscience de soi et conscience de la maladie dans la schizophrénie : relations avec l’anxiété et la dépression

Elevated rates of suicide in schizophrenia lead us to think that a lot of patients can’t cope with such a frightening, disorganizing or apragmatic experience. In contrast, we insist about the frequency of unawareness of illness as a characteristic of the schizophrenic patient, with paradoxically litlle or no effect on suicidal behaviour. Our study tended to precise the links between awareness of illness, anxiety and depression. We also rated self-consciousness, to see if this tendency could be correlated with other variables, and confirm if possible the hypothesis that awareness of illness relies on a broader tendency for self consciousness.In our population of 46 schizophrenic or schizoaffective inpatients, we failed to show any correlation between awareness of illness, anxiety or depression. Moreover, awareness of illness is not correlated with self-consciousness. On the other hand, anxiety and depression are correlated with self-consciousness. A tendency for high self reflection is frequently observed in autistic attitudes but also when the patient is in relation with others. Some patients sometimes feels like if a an “active” and a “reflexive” self were simultaneously present when they speak to others or even when they are doing daily life activities. The consequences are a loss of spontaneity, apragmatism, anxiety and depression. Those data are discussed in regard to phenomenological studies of Bin Kimura and to mescaline experiences described by the writer H. Michaux.     

Intérêt du programme éducationnel Soleduc pour la prévention des rechutes dans la schizophrénie

Informing schizophrenic patients of their disease is supposed to enhance compliance to antipsychotic treatments and hence to reduce the number of relapses. However, it is not clear whether the provision of psychoeducation changes schizophrenic patients’ behaviour. Recently, a two-year study of 220 schizophrenic patients was designed to evaluate the impact of a psychoeducational program (Soleduc^®) on the rate of relapses (new hospitalizations). This was a multicentric French clinical trial (51 centers) of phase IV, open, controlled, randomized, consisting in two parallel groups: the Soleduc group (N = 111) and the control group (N = 109). All schizophrenic patients were treated with the same antipsychotic drug (amisulpride). The Soleduc^® program contents were presented in 21 sessions, seven were programmed at the beginning of the study, seven at six months later and seven at 12 months. Patients in the control group received usual information on the disease during a period equivalent to the Soleduc^® program. The risk of relapse was significantly reduced for patients who followed at least five modules. In conclusion, attendance of at least five out of 21 program sessions was required to see a modest but significant two-year relapse prevention in schizophrenia. Other well-designed studies are required to evaluate the medical impact of patient's education programs.     

Familles et patient souffrant de schizophrénie : questions liées à l’avancée en âge ?

The management of elderly schizophrenic patients is a medical and a political issue with regard to life expectation. There is a paucity of global research. This matter concerns patients, sanitary and social workers, family, care teams, and also decision makers and elective representatives as they all have to work together. A psychiatric patient remains a psychiatric patient throughout his/her life, he/she does not become a geriatric patient. Assuring a continuity of care, of housing, of financial autonomy and of support in a social network is indispensable. Family and care teams are of capital importance (as in all long-lasting diseases). Training in the management of care is essential. One question: can a schizophrenic patient also be an elderly person?     

L’annonce du diagnostic de schizophrénie. Analyse textuelle d’entretiens cliniques

The issue of announcing a schizophrenia diagnosis induced a great controversy among practitioners, some of whom being reluctant to inform patients. This taboo seems to be disappearing. In France, on the one hand the March 4, 2002 patients’ rights law requires doctors to inform patients of the diagnosis and of the appropriate treatment and on the other hand research has thrown light on the positive impact of announcing a schizophrenia diagnosis. Considering that qualitative patient studies should be developed to gain a better understanding of the way in which patients receive the news of their diagnosis, we have conducted semi-directive interviews recorded with 20 schizophrenic subjects who were informed of their diagnosis and gave their consent for this study. Data were processed using the Alceste Method, a computer program of discourse analysis. Results show that schizophrenic patients can experiment relief in being informed of the diagnosis and that they are active in searching for information about the disease. The therapeutic alliance appears to be heightened by announcing the diagnosis.     

Langage et schizophrénie : l’intention en question

Language disorders in schizophrenia are of crucial importance for the social relationships and the living experience of schizophrenic patients. With notions such as context, intention and theory of mind, research devoted to language in schizophrenia is moving toward effective conditions of language production in this pathology, and to more specific troubles in the schizophrenic speech. Nevertheless, the usual cognitive and experimental paradigms ignore some of the fundamental dimensions in language: intentionality and inter-subjectivity. In a previous study, we stressed the importance of the social and inter-subjective bases of language, with a particular look at Vygotski’s works on schizophrenic speech and thinking. In the present paper, we have analysed more precisely the notion of intention in schizophrenic speech, and compared its meaning relative to cognitivism and phenomenology. Concerning cognitivism, Frith’s neuropsychological model is presented here paying specific attention to the main hypothesis: a deficit in the monitoring of intention. This deficit is supposed to affect both one’s intention (as in hallucination) and the ability to infer another’s intentions. Nevertheless, our core idea is the following: the intention, as conceptualized by cognitivists, can only be thought and studied by the means of a preliminary objectification, instead of by a foundation of subjectivity as in phenomenology. This particular point leads us to reconsider speech troubles in schizophrenia in the light of the subjective and lived side of language in this pathology. More precisely we have argued that language disorders in schizophrenia could be considered in the light of concepts such as empathy, conversion of meaning, and the splitting of intentionality itself. Indeed, language and intentionality in communication, as conceptualized by Husserl, cannot be reduced to mere transmitting of information. Two components are required: intention of signification, and intention of communication itself. These two dimensions lead, in each speech act, to a conversion from one side to another, between thought and language. In schizophrenia, this splitting of intentionality and the conversion of meaning could be extremely crucial to account for the inner links between the schizophrenic patient and his own speech, as we have tried to explain. In the same way, we have argued that the theory of mind, frequently invoked in schizophrenia, is here rather considered as a part of a more important notion, namely the notion of empathy. This point, as the previous one, cannot be reduced to a mere cognitive process by first involving the body in the process of communication. We have concluded by arguing that works on schizophrenic language should not ignore the subjectivity of intentionality, as well as the importance of the body dimension in inter-subjectivity, in order to obtain useful insights into the lived world of schizophrenic patients.     

Mortalité et surmortalité dans la schizophrénie

The aim of the present communication is to present an overview on mortality in schizophrenic patients. Recent meta-analyses have confirmed high rates of mortality in schizophrenic patients and, notably, the gap observed in the last three decades between mortality in the general population and that of schizophrenic patients. In this population mortality rates due to non-natural causes, essentially suicide, are 12 times higher than that of the general population, natural causes of mortality being due to cardiovascular and respiratory diseases. Atypical antipsychotics have been incriminated in the high rate of mortality among schizophrenic patients. Prevention was focused firstly on a decrease of the risk of suicide and secondly on poor living habits (smoking, obesity). The importance of a regular follow-up of the somatic health of schizophrenic patients was discussed.     

La perspective du travail comme média thérapeutique en psychiatrie : étude psychodynamique de trois patientes schizophrènes en soins de réadaptation

Patients often solicit the psychiatry services about their future especially concerning their social integration and their job. This question is as a problem as a help for care especially when it comes from schizophrenic patients. The psychiatric response is the psychosocial rehabilitation. In a psychodynamic conception, the author studies the evolution of three schizophrenic women in treatment in a care service of rehabilitation psychosocial. The author outlines the importance of the work project as a therapeutic medium. Some important characteristics are pointed out: the signification of the “job” for each patient and his family; the familial context; the effects of the job project’s on their psychopathology, the effects on their psychical organization of the reality of job and the importance of the protection in their social rehabilitation. These elements imply a multidimensional approach for the psychologist working in a psychosocial rehabilitation care service.     

Psychose froide, relation fétichiste : réflexions à propos d’un cas

Using certain fragments in the case study of a young patient hospitalized on several occasions at our institution and who was diagnosed as suffering from a “cold” psychosis, we have studied the pertinence of this concept in the institutional management of young non-delirious psychotic patients and smokers of hashish. E. and J. Kestemberg introduced the concept of “cold psychosis”. At the clinical level, this refers to that category of patients with identity disorders and a tendency towards substance abuse. Recourse to a fetish is one of the main elements in their intrapsychic functioning. The fetishistic relation is based on Freudian concepts of fetishism, but extends beyond the field of sexual perversion and leads to a particular type of object-relation, the predominant defence mechanisms being the split at the level of the self and denial. The use of a “fetish” by these patients is a means of providing a focus to bypass delirious expression in their transactions with reality, and the fetishistic relation also has a protective role in warding off innate aggressivity which could otherwise be expressed in an uncontrolled manner. This type of relation is established very early on in the infant’s development, even before he exists as a subject in relation to his mother. Later on, the adolescent or young adult is unable to identify with the oedipean triangle, as recourse to fetishism at an intrapsychic level is reflected by a split within the self, which blocks the way to bisexuality. In these patients who are prone to vacillating narcissism, and whose capacities for identification and sense of personal identity are a vast wasteland in which all relation with another individual represents a menace of annihilation unless they have at their disposal the possibility of dealing with the delirious situation and restructuring their attitude to life, the diversity of professional care-givers and mental healthcare centers that provide the institutional framework are the triggering factor for the therapeutic process which can guide these subjects towards a possible investment in the world outside, and in the individuals who live there.     

L'image du corps en neurologie : de la cénesthésie à l'image spéculaire. Apports cliniques et théoriques de la psychanalyse

In neurology, the terms body schema and body image currently refer to two different body representations. These representations are meant to allow humans individuals to automatically adjust their bodies to space in sensorimotor activities and also have a semantic knowledge of their bodies and their body-space relationships. The term body image is also used in psychoanalysis, in a quite different maner. From the psychoanalytical point of view, body image is one of the registers of identity and the Other’s regard plays a primordial role in the subject's acquisition of this identity. The crucial role of this gaze appears in the term specular image. After reminding the reader of history and the predecessors of these terms, we consider the implications of the concept of specular image in neurology. We show that neurological pathology may have effects upon specular image, up to and including a disorganization of the structure of specular image when brain lesions affect body schema. This perspective permits to find out a coherence and a logic in some psychiatric-like symptoms of right hemispheric brain lesions.     

Schizophrenia. A comparative trial of community orientated and hospital orientated psychiatric care

Sixty-five schizophrenic patients presenting for admission were randomly allocated into two groups. Control patients received standard hospital care and after-care. Experimental patients were not admitted if this could be avoided; instead they were taken back to the community by the Community Treatment Team who provided them and their relatives with comprehensive community treatment and a 24-h crisis service. During the 12 months study period 68% of the schizophrenic patients in the experimental group were not admitted; 10% were admitted two or more times and for 5 weeks or longer. All the schizophrenic patients in the control group were admitted--two-thirds or more times and for 5 weeks or longer. It was feasible to treat most schizophrenic patients in the community. Community treatment was considered by patients and their relatives to be the more satisfactory and helpful form of treatment and achieved a superior clinical outcome.     

Reconnaissance de l’émotion faciale et schizophrénie

A broad range of deficits in interpersonal skills characterizes schizophrenia. A natural way to tackle these deficits is to explore the ability of schizophrenic patients to process stimuli that have a well-established psychosocial content: faces, for instance. Schizophrenia deficits in facial recognition and discrimination have been studied extensively and most investigators have pointed out that patients with schizophrenia perform less well than non-patients and psychiatric controls in numerous facial paradigms, including facial identity, emotion and age recognition tests. The extent of the schizophrenic deficit suggests the alteration of a processing mechanism common to all kinds of facial information and the configural information extraction process has then been regarded as a probable candidate. Nevertheless, only a few studies directly tested the hypothesis. In what follows, we draw a general schema of the schizophrenia deficit in facial processing, next we present a series of studies investigating the putative implication of configural information in the abnormal processing of facial emotion in the disease.     

Facteurs sociodémographiques et construction de l’alliance thérapeutique aux urgences psychiatriques

Therapeutic alliance is a clinical concept considering the non-specific aspects and the common factors of the therapeutic relationship. In emergency, the therapeutic alliance seems to be one of the essential elements of crisis management, as the first stage of therapeutic framework. The aim of this study was to investigate the influence of sociodemographic factors in the constitution of the therapeutic alliance between patient and psychiatrist at the emergency psychiatric unit of a university general hospital. The study concerned 140 patients, requiring during workdays an urgent psychiatric intervention. Data were collected during four months. The exclusion criteria were the acute psychotic disorders, mania, delirium and dementia, situations interfering with the understanding of the study and with the patients' informed consent. The level of therapeutic alliance was estimated by means of the French translated questionnaire of “Helping Alliance” of Luborsky, completed separately by psychiatrists and patients. The results show a relatively limited influence of socio-demographic factors on the therapeutic alliance. The patients' age is a factor influencing alliance only for the psychiatrists, with a better alliance for the less than 25-year-old patients and more than 45 years. The patients with a lower instruction level have a better type I alliance. The scores of alliance with the French-speaking psychiatrists do not differ for the immigrant patients and the native French-speaking patients. Further than the epidemiological interest, this preliminary study suggests the interest of the consideration of the emergency time, in the construction of the therapeutic alliance.     

Adhésion au traitement prescrit et traits de personnalité dans une population de patients atteints de schizophrénie

Schizophrenia is one of the most important public health problems. It is a common, tragic and devastating mental illness that typically strikes young people when they are maturing into adulthood. Among schizophrenic out-patients, 24-63% of patients are non compliant as they failed to take the correct drug in the correct dosage. Clinical experience had demonstrated the existence of several groups of patients, some who comply with the medical regimen and others who do not adhere to treatment. Some of the factors that had been linked to poor compliance included low socio-economic status, unstable lifestyle, general negative attitudes towards one’s predicament, cognitive strategies and patient’s personal and psychological characteristics. As such, several studies have shown that three personality dimensions are particularly important for understanding schizophrenia which are extraversion, neuroticism and peculiarity. The aim of this study is to search for the possible association between personality traits or cognitive strategies and compliance to treatment in a sample of adult patients with schizophrenia. Eighty-three patients were screened for suitability for inclusion into the study. Patients who fulfilled the following criteria were recruited: aged 18 and more, who received a diagnosis of schizophrenia (Axis I DSM-IV), without severe cognitive impairment, without a diagnosis of personality disorder (Axis II DSM-IV), consulting their psychiatrist for a period of one year after dismissal of their psychiatric ward and having given their written informed consent. The final study sample consisted of 50 out-patients adults, 35 males and 15 females, age 19-59 years. After inclusion, patients were divided into two groups (Compliant-C and Non Compliant-NC) on the basis of their compliance to treatment. Mean age for the two groups is, respectively, 34.59 ± 9.62 and 27.29 ± 7.93. Compliance to treatment was measured by indirect methods such as the impression of the treating psychiatrist, interviewing patients, therapeutic outcome, counting the number of tablets remaining in a patient’s supply and objective criteria such as presence to medical and staff appointments or ending the follow-up. Personality traits were measured by the Rorschach Test, scored and interpreted according to Exner’s Comprehensive System. This psychological measure was selected for its ability to differentiate state and trait personality variables and its sound validity when used in the manner for which it was designed and intended. The selected trait variables in the Rorschach are: P < a + 1, which identifies tendencies to be passive and deferential in social situations; HVI index, which indicates a cautious, distant and mistrustful orientation to people ; EB which shows a cognitive style of decision making; Lambda > 0.99 which identifies a lack of adequate openness to experience and tendencies to view one’s world with an overly narrow focus of attention; and Fr + rF, associated with narcissistic marked tendencies to overvalue personal worth. The selected defense mechanisms in the Rorschach are: the intellectualization index (2AB + Art + Ay) used to keep emotion at a distance and minimize their impact. Denial (MP > MA) defines a predilection for escapist fantasy and prevents the impact of an unpleasant reality. Patients were contacted during their hospitalization period by the medical chief of staff who described the study in details. After they had consented, participants received the Rorschach test, before leaving the hospital. The Rorschach protocols have been scored by two Senior Rorschach practitioners. On the selected variables their scoring agreement percentage was 100%. Rorschach protocols were assigned to the C and NC groups by the end of the scoring process and once the medical team had finished the inclusion into the two groups (C and NC). The two Rorschach practitioners had worked single-blind on the set of Rorschach protocols. Group differences in Rorschach variables at the end of one year of medical follow-up were examined by using the χ² test. The significance level was set at P < 0.05. Results have shown that the C and NC groups differ significantly on the basis of schizophrenia subtypes. The Paranoid type (295.30) is more frequent in the C group whether the Disorganized type (295.10) is more frequent in the NC group (χ²= 12.16, P < 0.001). Compliant schizophrenic patients use significantly, more frequently the intellectualization defense mechanism (χ² = 6.17, P < 0.012). Non compliant patients appear to have significantly more marked narcissistic traits and tendencies to overvalue personal worth (χ² = 8.79, P < 0,003). These observations support the idea that paranoid delusions, even if persecutory, do not alter pervasively the ability of maintaining genuine relationships with some others, such as the treating psychiatrist, for instance. In Disorganized type patients, the orientation to people is overall disturbed, the interest in the therapeutic alliance more superficial and fragile. Due to narcissistic traits and tendencies to overvalue personal worth, non compliant patients display a sense of grandiosity and entitlement which distort the genuine perception of personal needs and that of their psychological states. Intellectualization acts as cognitive coping strategy aiming to mute the intensity of emotions and safeguard against distress. Shifting emotional experience to a cognitive level allows the schizophrenic patient to acknowledge his needs for medical therapy even if he does not recognize himself as being ill. The research presented here comprises a 1-year prospective study designed to test some associations between personality factors and compliance to treatment. The degree to which schizophrenic patients comply with the advice of health workers depends, among other factors, on their stable personality traits and coping mechanisms. Continued study of the links between personality traits and compliance to treatment in this population as well as regular psychological assessment of these patients may identify which therapeutic approaches are best for which patients. There is increasing interest in the role of psychological mechanisms in compliance behavior formation after the onset of illness and these models may also be useful in thinking about events before onset.