La semaine des hopitaux : organe fonde par l'Association d'enseignement medical des hopitaux de Paris最新文献

Clinicians trained in dermatology and having submitted themselves to psychoanalysis have developed an original psychosomatic approach to skin disease at the Tarnier Hospital (Cochin-Port Royal University Hospital Center). Its mainspring is detection and management of the patient's distress. The author analyzes the conditions under which it was possible to carry out this experiment and the implications of this approach which is directed at achieving a change in the way the department is run rather than adding one more specialized appendage to the outpatient care activity.

When the general practitioner is convinced that a somatic symptom covers a psychosomatic problem, he may choose one of two strategies. The first is to minimize it on the grounds of possible subsequent change or to spare a vital compromise (duty of reservation). The second is to ignore the request in order to offer the possibility of implementing his therapeutic conviction. In this strategic choice, the doctor's authority as a "trustee" is pitted, in practice, against the inconsistent and irresolute nature of the request, and the shortcomings of the institution or socioeconomic level. Strangely enough, psychologising information may jeopardize the therapeutic commitment. The higher the cultural level, the greater the deviation, especially in depression. Observations from everyday practice in urban centers exemplify the variety of these approaches.

Everyday cases, clinical experience, and some experimental data show that emotional life has significant and varied expressions in the body: behaviours expressed somatically, "functional" visceral disorders, and even "organic" diseases. To explain these findings, various theoretical concepts have been or are currently put forward. Taking the basic hypothesis of psychosomatics, i.e. the notion of a psyche-soma functional unit, as a starting point, the author considers these main concepts under three different lightings, which are related to the methodologic conditions under which facts are studied: 1) the physiologic approach, which underscores the significance of psychophysiologic interactions, emphasizes either the results of conditioning or those of emotions, according to the case; stress is considered under this angle; 2) the psychological approach, according to the point of view, emphasizes the following notions: life event, subjective experience, personality profile, specific conflict, conversion or regression, defective mentalization; 3) the sociologic and ecologic approach focuses on the relationships between the individual and his surroundings and gives predominance to the notion of environment factors. After a few considerations on the concept of disease and the notion of etiologic multideterminism it is recalled that therapeutic effectiveness stems from the ability to take into account both bodily and psychic distress.

Although, strictly speaking, they are not psychosomatic diseases, psychologic reactions to illness are both very common and often closely related to the psychopathological setting in which genuine somatizations occur. Thus, after a review of the possible meanings of the disease and its occurrence in the patient's life history and experience, the problem of reciprocal causal relationships between moral and psychologic distress, mental distress and objectivation of a disease is considered. From this discussion an opening towards slightly different theorizations on the psyche and soma, such as those which oriental medicines have always transmitted, is proposed.

A retrospective study of the follow up in 13 patients under maintenance Dogmatil 200 mg treatment (1 to 12 years) establishes the drug's effectiveness and tolerance. The best results were obtained in plain schizophrenia, borderline states and severe neuroses.

Psychosomatic disorders are part of the pediatrician's everyday practice. However, they have only lately become a field for systematic investigations, based on diverse methods and concepts. The viewpoints supported by the authors originate in studies carried out in the pediatric department of a hospital which deals only with psychosomatics. The following points are considered successively: 1) definition and peculiarities of psychosomatic disorders in children; 2) susceptible emotional organizations, which carry a high risk of psychosomatic disease; 3) depression, which is a key mental mechanism in psychosomatic disruption. One of the main purposes of research is description of a specific semiology of childhood psychosomatic disease. Its ambition is to be both open to medical practice and acknowledged in its specificity, so as to be used in psychological disciplines, i.e., sufficiently clear but without oversimplification. Further developments can be found in "L'enfant du désordre psychosomatique" (Privat 1981) and "La psychosomatique de l'enfant" (PUF 1983).

The denomination psychosomatic should include both man in his entirety and his relationships with the surrounding world in which he originated. After a limitative review of the various body techniques, we describe three illustrative clinical cases treated by relaxation. We believe these techniques are valuable as they position the therapeutic relationship, from the outset, with respect to the "painful body" on which management focuses, and to the request for recovery. They involve the connections between the "organic body" and its functions of symbolization and confront the therapist with the notions of narcissism, erotization of the symptom and "choice of organ". They allow for a remodelling of narcissic investments which, through the approach of the various psychopathological mechanisms, enables a rebalancing of the patient as a whole and of his interpersonal relationships. They often open up perspectives for training practitioners to the study of the patient-practitioner relationship.

The notion of psychosomatic disorder will be given preference over that of disease as we believe it most important to identify the mechanism of somatization which underlies and commands the formation of polyvalent and polymorphic symptoms. The practitioner's first task is not to mistake the different mechanisms of somatization. This relies on the quality of the physical examination and the appositeness of the organic workup. It rests on demonstration of the psychosomatic connection by painstaking elicitation of the case history. The purpose is to make the patient himself aware of the psychosomatic nature of his distress and capable of an understanding attitude towards his own symptoms. It is this process that will allow the patient to turn towards a specific mechanism, rather than the clinical presentation of the symptom strictly speaking, or even the identifiable personality characteristics which in many cases are only suggestive. Similarly, it is this identification of mechanisms which will enable the practitioner to implement the appropriate therapeutic strategy.

The author analyzes data assembled during psychotherapy of a 38-year-old woman who had experienced serious obstetrical difficulties, with two deaths in utero late in each pregnancy, ascribable, at least in part, to toxemia. These difficulties are brought into connection, in particular, with the patient's subconscious conflicts and the ambivalence of her planned motherhood. During psychotherapy a new pregnancy was successfully completed: the psychotherapy plan, at first indistinguishable from the request for medical help, especially as the treatment was undertaken in a general hospital, has been nevertheless progressively extended beyond the psychosomatic symptom to aim at a greater general comfort.

The search for an organic etiology in psychiatric conditions is greatly facilitated by modern radiological techniques. The most frequent etiologies demonstrated in the department of Radiology at the Sainte Anne Hospital were tumors, dementias, vascular disease and trauma with its attendant pathology.