Violences, homicides et délires de persécution

Persecution and prejudice are the most common themes of delirium. Psychotic subjects (paranoiacs or schizophrenics) who suffer from delirium are therefore liable to defensive behavioural characteristics and mechanisms. These characteristics include behaviour of avoidance or escape and even aggression towards the persecutor/s. In such cases, violent acts are committed in an effort to control or destroy the source of suffering and persecution. Several examples regularly attest this claim. In complement to classical therapeutic methods, certain new cognitive and behaviourist psychotherapies of chronic psychoses, appear to be promising therapeutic and preventive vectors, which reduce or resolve the different intensity of criminal urges caused by certain delirium of persecution and prejudices. Delirium of prejudice and persecution, whether isolated or associated with other themes of delirium, are a risk factor for emotional changes, which can engender self or heteroaggressive acts (once or multiple), carried out by subjects who suffer from them. The interruption of treatment of these psychotic processes, when they exist, is a possible factor for maintaining or increasing these troubles and sometimes of the dangers associated with them. Therefore, to avoid subjects committing dangerous acts, constant and regular checks of psychotherapeutic and psychotropic treatment, with constrained hospitalisation if necessary, are curative and preventive measures, should be systematic.     

Une tentative de réponse partielle à l’échappée psychotique

Confrontation with a psychotic episodes invariably remains a particular and demanding task. Most often, once the effect of surprise or even the feeling of anxiety or uneasiness is over, the therapist is tempted to react by providing a unifying and reassuring response to deal with the expression of a psychotic episode, which takes the form of outburst or loss of control, and to propose a reconstructive context. Thus at the institutional level, this approach psychosis leads the therapist to respond to the fragmentation by its apparent opposite, that is to say by developing a structural approach based on a stable unity. However, although this approach seems at first sight to be called for, and although its capacity to contain the psychotic episode may have a certain pertinence it often remains superficial, and above all it does not take into account the psychotic response itself. In fact, from this viewpoint imaginary control takes over the place of symbolization.We have put forward the hypothesis of another form of treatment response, i.e. that is incomplete and partial, which takes into account the irreducible nature of the psychotic condition, and which considers the very expression of the psychosis as an attempt at symbolization. From the frequent perplexity that is encountered at the onset of the psychosis to a full comprehension of the paranoid individual, the forms of psychic construction in psychotic individuals are varied, mobile, and finally are always specific to the subject as far as their actual presentation is concerned. They can be considered as “solutions” which the subject expresses according to the given moment in his psychosis, and may provide support for the treatment response that has been proposed. The attentive presence of the therapist and the treatment team, and an approach that is based on non-intentionality is essential.     

Les psychoses brèves

In current classifications one may apply the concept of brief psychosis to clinical pictures dominated by the presence of psychotic symptoms but whose characteristics, mainly their duration, allow, at least in the short term, to rule out diagnoses of more typical psychoses. In DSM-IV these pictures are referred to, as brief “psychotic disorder” and “schizophreniform disorder” whereas they are subsumed under the category of “acute and transient psychotic disorder” in the ICD-10. The history of brief psychoses, which can be traced back to the concept of Bouffée Délirante of French authors is marked by the multiplicity of names these entities received depending on the perspective they were addressed from. For instance, one can mention in Germany the works of Jaspers on “reactive psychoses”, those of Mayer Gross on the “oneroïd states” as well as the “atypical psychoses” and “cycloïd psychoses” of Kleist, whereas the concepts of “schizoaffective psychosis” and “psychogenic psychoses” were influential in the Scandinavian countries. Current entities differ according to the duration of psychotic symptoms and/or the color of the clinical picture. If DSM-IV classification is mainly based on duration criteria, ICD-10 takes more into account the qualitative aspect of clinical symptomatology, especially the presence or absence of the polymorphous and fluctuating syndrome characteristic of the French “Bouffée délirante”. In this respect, empirical criteria have been proposed in France to separate the “Bouffée délirante” from other psychotic disorders. It is still difficult to assess the long term prognosis of brief psychoses due to a lot of methodological shortcomings, i.e. variability in diagnostic criteria used, number of patients included in follow-up studies, presence or absence of a comparative group, differences in treatments received, lack of compliance monitoring, duration of follow-up. However, quick onset of symptoms (<4 weeks), confusion during the episode, good premorbid functioning and lack of blunted or flat affect seem to be good pronostic factors. Etiology of brief psychoses is a complex matter, involving endogenous, psychogenic as well as social and cultural factors. The first two factors can be better understood within the framework of vulnerability models. Biological diathesis, personality factors (of both temperamental and character origin), involving vulnerability as well as resilience, are deemed to be intertwined with stress in the outbreak of psychotic episodes. The question as to whether the vulnerabilities involved in brief psychoses are or not the same as those predisposing to affective and schizophrenic disorders is still unanswered: brief psychotic disorder, schizophreniform disorder and “Bouffée délirante” may differ in this respect. The role of social and cultural factors is evidenced by the increase in prevalence observed in the context of immigration and acculturation processes. According to Guiness this prevalence may be explained by a phenomenon of “cultural transition” which on the one hand requires new adaptation strategies, especially as regards the way people have to express their mental suffering, and on the other hand increases sources of stress. A modern approach to the treatment of brief psychoses may rely upon pharmacotherapy as well as psycho- and sociotherapy. Antipsychotics, particularly those of second generation, are still the cornerstone of biological treatment. However in some cases, taking into account individual and family history as well as the characteristics of clinical picture, one can preferentially use mood stabilizers or antidepressants. A few cases may require psychotherapy as first line treatment, suggesting a close relationship to dissociative disorder.     

Introduction au concept de réalité chez Lacan

During more than 20 years, J. Lacan did not cease to explain and to determine with precision the concept of reality. The “psychical reality”, described by S. Freud, is according to Lacan the most important concerning this question of reality. Lacan demonstrates that subjective reality is structurated by the language, by the first symbolic and significant relations. The construction of reality depends on “lost object”, therefore Lacan identified finally reality and phantasm. This conception can be precious and useful for clinicians particularly in the orientation of the treatment concerning psychotic patients. Besides, this psychoanalytic approach concerning reality is also a fundamental ethic question.     

Pour une distinction de la machine à influencer et de l’objet autistique

While research on autism continues to progress, it is interesting to return to a particular point of view on the conception of Mahler and Elkisch's pathology, including the controversial assumption which was to consider some autistic constructions as preliminary to the development of the ‘Influencing Machine’. Consideration of the cas princeps of Tausk, in association with the more detailed Haslam, Porter and Williams, allows a demonstration of the function of these machines within the mental processes of the subjects presented. This subjective work engages the subjects to find the cause of bodily manifestations and hallucinations while delirious. The response is to blame ‘Influencing Machines’ considered by the subject as driven by an autonomous dynamic system linked to a participating elementary phenomena of psychosis. Gradually the conclusion is reached that there is a machine and this signifies the systematization of psychotic delirium as a result of mental automatism. Different to this, the autistic machine is the result of knowledge that comes from an elaboration trying to compensate for the absence of the symbolic function. While the friends of the psychotic are subject to the same punishment as him, the autistic person is the only one driven by the machines he imagines. Their functioning in connections come to affect the enigma of the body, libidinal function and distinction with the Other. It is a question of created machines, controlled by the autistic person, unlike the delusions of machines by the psychotic subject, where the initiation and execution come from the Other, and which therefore exert an influence on the subject.     

L'adolescent malade : quelle guérison pour le corps ?

The legitimacy of therapeutic mediations has long been asserted in care centres. Yet non verbal, body-oriented mediations appear to have retained a singular status, particularly in those psychiatric institutions concerned with the adolescent and the young adult. Traditional ergotherapy has adapted to the new mediators of the young (video games, multimedia, cinema, etc.). At the same time it has made a step in the direction of occupations which involve the physical body more explicitly - when any such association had usually been excluded from therapeutic mediations that privileged the verbal expression as the principal tool to restart the symbolisation process. We have set out to investigate the part such body-oriented mediations play, and whether they are a superior mean in dealing with patients resistant to other forms of assistance. We have concerned ourselves with the indoor climbing activities which take place in the out patient “care and study” department of the hospital (Clinique Dupré). We reason that the learning and safety aspects of indoor climbing permit to re-enact regressive phenomena associated to the repetition of early experiences of distress. Climbing as a mediation opens the therapeutic doors by allowing the physical resurrection of those early experiences which had yet to be symbolised.     

Le signe du miroir : reflets cliniques et théoriques

Paul Abely (1927-1930) and then Delmas (1929) described in three articles published in French what came to be called the miiror sign. Sadly psychiatry sold out to'management and “stastical gibberish” so that essential clinical discoveries fell by the wayside… In this article - the sythesis of a longer piece of research - we try to show that the mirror sign is the clinical and theoretical validation of the mirror phase (or stage) as theorised by H. Wallon, J. Lacan and others. We have called upon the history of art to show that the mirror sign is the key to understanding what seperates neurosis from psychosis. G. Rodenbach and his “freind from the mirror” will accompany us and explain the very experience of “the mirror sign…”.     

Rausch aus psychiatrischer Sicht – Strukturelemente und Differentialdiagnose

Intoxication is the monotone reaction of the CNS to consumed psychoactive substances. Intoxication-like conditions may also occur without taking drugs. We then use the term “ecstasy”. Intoxication can follow typical or atypical course. The main symptoms are disturbances of consciousness and orientation and additionally changes of mood, affect, drive and initiative, train of thought and self-control. The diagnosis of intoxication differs from the diagnosis of psychosis because the latter continues its own course, occurs in the absence of psychoactive substances in the organism and always lasts longer than an intoxication.