Pub Date : 2024-04-16DOI: 10.1016/j.evopsy.2024.03.002
Objectives
This article aims to bypass the epistemological impasses produced by the contemporary development of the concept of disability – a concept formed in close relation with the societal context and with questions of human rights, more than with a nosographic and clinical problematic - and more precisely with regard to mental disability, a clinical entity whose classification history is particularly difficult, and yet at the heart of the edification of psychiatry since the 19th century. In studying this trajectory, we aim to demonstrate the interest of psychoanalysis's theoretical-clinical approach.
Method
We analyze the evolution of psychiatric and psychoanalytical conceptions of mental disability. We discuss them and identify avenues of reflection for the psychoanalytically oriented clinical and therapeutic work we do with young disabled patients and their parents.
Results
Mental disability is placed in the historical dynamic of the attempts to classify it: idiotism, idiocy, mental debility, mental or intellectual disability, etc. Its proven or strongly assumed organic etiology originally marginalized, and continues to marginalize, certain modes of clinical thinking and psychic treatments, of which the psychoanalytical approach is one.
Discussion
We discuss and differentiate between the concepts of “mental” and “psychic” and the ambiguity of their meanings. The “mentally handicapped” subject, when reduced to their neuronal aetiology, is considered from a deficit perspective, which relegates the investigation of psychic life to the background or even renders it superfluous. Following in the footsteps of D. Widlöcher, we point out that Kraepelin's thinking, which made the therapeutic indication dependent on the supposed aetiology, is now outdated. We therefore emphasize the individual differences in the relationship that develops between the young disabled person and his or her family, and in the interaction between their psyches. The effects of the birth of a disabled child on the construction of the feeling of parenthood, the bond of filiation, and parental narcissism are thus understood within the dynamics of interactions, both real and fantasized, which necessarily differ according to the subjects, parents and children. More specifically, we consider J. Laplanche's “fundamental anthropological situation” as a heuristic model for thinking about the psychic life of the child with a disability and the infantile sexuality that constitutes it, in adult-child interaction, as in everyone else. We hypothesize that the parental encounter with a child presenting a handicapping pathology is likely to send some parents back to their own “uncanniness,” that is to say, to the disturbing return of a repressed or primitive way of thinking abandoned a long time ago, coming from their own “internal foreign land.” This internal irruption is likely to lead t
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Pub Date : 2024-04-09DOI: 10.1016/j.evopsy.2024.03.003
Héloïse Haliday (Maître de conférences en psychologie clinique et psychopathologie)
Objectives
The clinician who adopts a psychoanalytic approach in a psychiatric context often regards the encounter between two individuals as an interplay of subjectivities, whose mode of being-in-the-world is shaped by their unique historical experiences. Despite some psychoanalytic authors exploring the concept of “contact”, it has often been reduced to its similarity with transference and countertransference, with little attention given to its distinctive qualities. This limits psychoanalysis in its ability to conceptualize an unmediated, preverbal encounter between two individuals. In this article, we argue that the dimension of “contact” cannot be equated with transference, and that it constitutes a vital tool for diagnosing and guiding therapy for various clinical conditions commonly encountered in psychiatry.
Method
This article is based on theoretical considerations. We first worked on the history of the concept of contact, then of Praecox Gefühl in the works of H.C. Rümke, to which we added the findings of current studies on the relevance of Praecox Gefühl in the diagnosis of schizophrenia and the study of the works of the great phenomenological psychiatrists. In so doing, we aimed to show that contact could be a tool of great use for psychiatric diagnosis, insofar that it allows for a typification of the forms of existence of different patients.
Results
H.C. Rümke's investigation of the concept of Praecox Gefühl highlights the unique mode of contact observed in schizophrenia. It is distinct from the feeling of strangeness and involves an intuitive observation of a perceived distance within the clinical relationship. Given that many psychiatric pathologies can cause patients to withdraw from the shared world, we suggest that the notion of Praecox Gefühl, beyond its original designation of the clinician's experience of schizophrenic dissociation and the particularities of the schizophrenic mode of being-in-the-world, may be applicable to other pathologies studied in psychiatric phenomenology. We propose four main forms of contact: the loss of vitality in schizophrenia, the untraceable authenticity of the hysteric, the impossible fluidity in the melancholic, and the failure of anchorage in mania. By approaching contact as a fractal form that reveals the entire mode of the subject's being-in-the-world, this typifying approach goes beyond a purely semiological or etiological reflection and can be diagnostically useful in guiding therapeutic efforts to enhance the subject's capacity to truly engage with others.
Discussion
Our paper focuses on the relationship between contact and what clinicians commonly refer to as an “encounter.” It is important to recognize that contact is not always equivalent to an encounter, and that assuming otherwise risks overlooking the possibility that certain relational modalities could act
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Pub Date : 2024-03-02DOI: 10.1016/j.evopsy.2024.01.007
Zoë Dubus (Docteure en histoire contemporaine, postdoctorante à l’Université de Saskatchewan, College of Arts, Science, Department of History, Bénéficiaire de la bourse Banting du Conseil de recherches en sciences humaines (CRSH) canadien, Chercheuse associée à l’unité PSYCOMadd de l’hôpital Paul Brousse de Paris, membre du réseau scientifique de l’Institut des humanités en médecine du CHUV de Lausanne)
Objective
In 1958, a medical team at Bonneval Hospital, headed by the famous psychiatrist Henri Ey, decided to experiment with a promising new psychotropic substance: LSD. This was one of the first research projects of its kind in France. Until then, only a Parisian team, led by Jean Delay, had published similar essays. Yet Henri Ey's team never published their results. Only an internal report was written, then lost – or destroyed during the period when studies on psychedelics were halted – by the institution where it had been filed. After months of research, an older part of this report was found in an archive.
Methods
Despite the fact that the document is not complete (in particular, the self-experiments carried out by the medical team are missing), it is a unique source for understanding the French context of psychedelic research in the 1950s–1960s. The archive presents 19 cases of female patients, aged between 17 and 59, all with a low level of education. The dose was usually 100 to 150 μg and was mainly injected. Each case report describes the patient's characteristics, medical history and, in some cases, biographical details. Next comes the course of the session (which is unique, except for one patient who receives LSD twice), sometimes minute by minute, with a few comments from the doctors and transcriptions of some of the patient's words. Each report concludes with a brief analysis by the medical team of the session and its aftermath. This article analyzes the protocol used to carry out these trials, as well as the patients’ reactions to the treatment, and compares the method used to those developed at the same time in Anglo-American countries.
Results
In a very specific way, the context of therapeutic use of psychedelics in France stands in stark contrast to the methodological developments observed in other Western countries at the same time. The concepts of set and setting, which were being developed at the time, were not adopted by the French teams, who remained within the framework of shock therapy. Patients were given no information concerning the expected effects, no support to reassure them during the experience, and their requests for contact were systematically interpreted in erotic terms. Despite their panic (which could go as far as vomiting), some were left alone. Doctors also sought to refine what they knew about reactions to LSD, and did not hesitate to test their patients to observe their behavior, for example by trying to make them believe that the injection they had received did not actually contain any substance. Under these conditions, session reports were mostly tinged with anguish and even terror. Although the team reported one case of recovery and 4 cases of “slight improvement,” the majority of patients experienced a worsening of their condition as a result of the experience.
{"title":"Henri Ey et le LSD : analyse d’un pré-rapport de 1958 sur les expériences thérapeutiques menées à Bonneval","authors":"Zoë Dubus (Docteure en histoire contemporaine, postdoctorante à l’Université de Saskatchewan, College of Arts, Science, Department of History, Bénéficiaire de la bourse Banting du Conseil de recherches en sciences humaines (CRSH) canadien, Chercheuse associée à l’unité PSYCOMadd de l’hôpital Paul Brousse de Paris, membre du réseau scientifique de l’Institut des humanités en médecine du CHUV de Lausanne)","doi":"10.1016/j.evopsy.2024.01.007","DOIUrl":"10.1016/j.evopsy.2024.01.007","url":null,"abstract":"<div><h3>Objective</h3><p>In 1958, a medical team at Bonneval Hospital, headed by the famous psychiatrist Henri Ey, decided to experiment with a promising new psychotropic substance: LSD. This was one of the first research projects of its kind in France. Until then, only a Parisian team, led by Jean Delay, had published similar essays. Yet Henri Ey's team never published their results. Only an internal report was written, then lost – or destroyed during the period when studies on psychedelics were halted – by the institution where it had been filed. After months of research, an older part of this report was found in an archive.</p></div><div><h3>Methods</h3><p>Despite the fact that the document is not complete (in particular, the self-experiments carried out by the medical team are missing), it is a unique source for understanding the French context of psychedelic research in the 1950s–1960s. The archive presents 19 cases of female patients, aged between 17 and 59, all with a low level of education. The dose was usually 100 to 150<!--> <!-->μg and was mainly injected. Each case report describes the patient's characteristics, medical history and, in some cases, biographical details. Next comes the course of the session (which is unique, except for one patient who receives LSD twice), sometimes minute by minute, with a few comments from the doctors and transcriptions of some of the patient's words. Each report concludes with a brief analysis by the medical team of the session and its aftermath. This article analyzes the protocol used to carry out these trials, as well as the patients’ reactions to the treatment, and compares the method used to those developed at the same time in Anglo-American countries.</p></div><div><h3>Results</h3><p>In a very specific way, the context of therapeutic use of psychedelics in France stands in stark contrast to the methodological developments observed in other Western countries at the same time. The concepts of set and setting, which were being developed at the time, were not adopted by the French teams, who remained within the framework of shock therapy. Patients were given no information concerning the expected effects, no support to reassure them during the experience, and their requests for contact were systematically interpreted in erotic terms. Despite their panic (which could go as far as vomiting), some were left alone. Doctors also sought to refine what they knew about reactions to LSD, and did not hesitate to test their patients to observe their behavior, for example by trying to make them believe that the injection they had received did not actually contain any substance. Under these conditions, session reports were mostly tinged with anguish and even terror. Although the team reported one case of recovery and 4 cases of “slight improvement,” the majority of patients experienced a worsening of their condition as a result of the experience.</p></div><div><h3>Discussion</h3><p>This exceptional archive gives","PeriodicalId":45007,"journal":{"name":"Evolution Psychiatrique","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2024-03-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140084008","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-20DOI: 10.1016/j.evopsy.2023.12.005
Julia Neyroud (Psychologue) , Rose-Angélique Belot (Psychologue clinicienne, Professeure des Universités, Psychologie clinique et Psychopathologie) , Pascal Roman (Professeur de Psychologie clinique, Psychopathologie et Psychanalyse)
Objectives
This article aims to study the psychic changes during maternity in primiparous women without psychic and organic disorders and to put into perspective the reorganizations during the maternity process in patients with a borderline psychic functioning.
Method
This paper is based on longitudinal data collected with the Rorschach test. Two clinical cases revealing this processual dynamic will be analyzed and discussed.
Results
The analysis of Rorschach protocols of two women with different psychic elaboration capacities reveals an experience of boundary invasions linked to the precariousness of psychic envelopes between the end of pregnancy and the beginning of postpartum, followed by a reinforcement of certain defensive mechanisms post-delivery in order to compensate for the state of disorganization linked to the processes of motherhood.
Discussion
The analysis of these data will allow us to observe modalities of psychic arrangements specific to the maternity process as well as reorganizations, close to a “symbolization catastrophe”.
Conclusion
The psychic dispositions of women during maternity allow us to detect borderline arrangements of psychic functioning during this period.
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Pub Date : 2024-02-20DOI: 10.1016/j.evopsy.2023.12.006
Jessica Tran The (Psychologue clinicienne, Maître de Conférences)
The objective of this article is to clarify the specificities of the psychoanalytic approach to trauma, based on the study of a single clinical case. Whereas contemporary discourses tend to emphasize the role of lived events in the emergence of a psychopathological picture, we aim to demonstrate how psychoanalysis operates a shift in perspective vis-à-vis deterministic and linear explanatory models. Focusing on the case of a psychotic patient in his fifties who had lost his sight following a gunshot wound, we demonstrate how psychoanalysis invites us not to place the emphasis intrinsically on a past event. Rather, it suggests looking at the singular and unpredictable response of the subject as an individual, in a diachronic perspective that takes into account the importance of temporality and hindsight. In this way, I was able to study how this patient gradually integrated the traumatic event into a singular subjective construct. In turn, this allowed me to understand the stabilizing mechanisms of this construct, through the prism of the Freudian hypothesis of delusion as an “attempt at healing”.
Method
The method I adopted is that of the single case study. This approach was chosen as it is the only one that can illustrate the singularity of the subject's response in its diachronic character. In particular, I deliberately chose the style of an analytical case study. This differs from the ideal of scientific objectivity insofar as the psychoanalytic technique is characterized by the importance given to the transferential dimension in the cure, and thus calls upon the subjectivity of the therapist. Thus, I endeavored to reconstruct the history of this patient in its diachronic unfolding, by recounting the biographical and anamnestic elements as they appeared during the clinical encounter. To support this further, I integrated elements from the archival consultation of medical records. I then studied the evolution of the patient's subjective position through the prism of Freudian and Lacanian theories on psychosis.
Results
A psychoanalytic approach made it possible to demonstrate that in this patient, his position as the object of an injury predated the occurrence of his wounding by firearm. This later event was thus initially reintegrated, by him, within the framework of the logic of the delusion of persecution that predated it. Nevertheless, the social recognition of his position as a victim may have induced in him a pacifying effect. He was able to reinterpret the event in the aftermath, based on the construct of a position of exception. In that position, he assumed the figure of the ‘seer’ who played the role of naming, leading to a significant appeasement of the persecution anxieties.
Discussion
Here I propose a discussion of the possible similarities between the position of exception constructed by this patient, and the cases of President Schreber and the writer
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Pub Date : 2024-02-14DOI: 10.1016/j.evopsy.2024.01.005
Luc Surjous (psychiatre, pédopsychiatre)
Objectives
L’Essai sur quelques problèmes concernant le normal et le pathologique, a medical thesis defended in 1943 by Georges Canguilhem (1905–1995), is certainly the best-known French text on the epistemology of medicine. Canguilhem, then a young philosopher, medical student, and member of the French Resistance, defends the self-determination of the living individual, capable of judging what is normal or pathological – categories subsequently adopted by medicine and physiology – as well as a conception of the medical practice tailored to the singular situation. His argumentation is largely based on the theories of psychiatrists, yet excludes psychopathology from its scope. It is this paradox, little studied until now, that I attempt to resolve in this article.
Methods
I have conducted an extensive study of the texts on psychology and mental care in G. Canguilhem's archives, his recently published complete works, and current academic research.
Results
I propose to return to the two problems presented at the beginning of the Essai: “that of the relationship between science and technology, and that of norms and the normal”. Canguilhem responds to the latter by proposing the concept of vital normativity, which follows on from earlier work on psychology, presented in high school courses in the 1930s and in a Traité de psychologie, never published, which already promoted a subject able to value, to commit, and thus to escape from the determinism of his environment and organism. Regarding the relationship between science and technology, which Canguilhem began to conceptualize at the very end of the 1930s, in his Essai, he proposes a path that reverses that of positivism, moving from clinical practice to science, in which the former is clarified by the latter; however, scientific psychology cannot play a role equivalent to physiology in psychological care. Indeed, Canguilhem considers psychology's claim to objectivity incompatible with the respect for subjectivity that his psychologie réflexive, on the contrary, defends. To conclude, I examine Canguilhem's few writings on psychotherapy, as well as those on psychopharmacology.
Discussion
I discuss the clinical consequences of the inability of scientific psychology to play a role in psychotherapy similar to that of physiology in medicine.
Conclusion
Canguilhem's conception of psychological care is essentially a defense of human dignity, based on a philosophical, not a scientific, theory of the individual.
ObjectivesL'Essai sur quelques problèmes concernant le normal et le pathologique（关于正常与病理的几个问题的论文）是乔治-康吉伦（Georges Canguilhem，1905-1995 年）1943 年通过答辩的医学论文，无疑是法国最著名的医学认识论著作。康吉伦当时还是一名年轻的哲学家、医科学生和法国抵抗运动成员，他为活生生的个体的自我决定权辩护，认为个体有能力判断什么是正常或病理--医学和生理学随后采用了这些分类--以及一种针对特殊情况的医疗实践概念。他的论点主要以精神病学家的理论为基础，但又将精神病理学排除在外。我对 G. Canguilhem 档案中有关心理学和精神治疗的文本、他最近出版的全集以及当前的学术研究进行了广泛的研究。结果 我建议回到《随想录》开头提出的两个问题："科学与技术的关系以及规范与正常的关系"。坎吉拉姆针对后者提出了 "生命规范性 "的概念，这一概念源于他早先的心理学研究，在 20 世纪 30 年代的高中课程和从未出版的《心理学教程》中都有介绍。关于科学与技术之间的关系，康吉雷姆在 20 世纪 30 年代末就开始将其概念化，在他的《随想录》中，他提出了一条与实证主义相反的道路，即从临床实践转向科学，前者通过后者得到澄清；然而，科学心理学在心理治疗中并不能扮演与生理学相同的角色。事实上，康吉伦认为心理学的客观性主张与他的反思心理学所捍卫的对主观性的尊重是不相容的。讨论我讨论了科学心理学无法在心理治疗中发挥类似于生理学在医学中的作用所带来的临床后果。结论康吉伦的心理治疗概念本质上是对人类尊严的捍卫，其基础是关于个人的哲学理论，而非科学理论。
{"title":"Science et soin du psychisme dans l’œuvre de Georges Canguilhem","authors":"Luc Surjous (psychiatre, pédopsychiatre)","doi":"10.1016/j.evopsy.2024.01.005","DOIUrl":"10.1016/j.evopsy.2024.01.005","url":null,"abstract":"<div><h3>Objectives</h3><p><em>L’Essai sur quelques problèmes concernant le normal et le pathologique</em>, a medical thesis defended in 1943 by Georges Canguilhem (1905–1995), is certainly the best-known French text on the epistemology of medicine. Canguilhem, then a young philosopher, medical student, and member of the French Resistance, defends the self-determination of the living individual, capable of judging what is normal or pathological – categories subsequently adopted by medicine and physiology – as well as a conception of the medical practice tailored to the singular situation. His argumentation is largely based on the theories of psychiatrists, yet excludes psychopathology from its scope. It is this paradox, little studied until now, that I attempt to resolve in this article.</p></div><div><h3>Methods</h3><p>I have conducted an extensive study of the texts on psychology and mental care in G. Canguilhem's archives, his recently published complete works, and current academic research.</p></div><div><h3>Results</h3><p>I propose to return to the two problems presented at the beginning of the <em>Essai</em>: “that of the relationship between science and technology, and that of norms and the normal”. Canguilhem responds to the latter by proposing the concept of vital normativity, which follows on from earlier work on psychology, presented in high school courses in the 1930s and in a <em>Traité de psychologie</em>, never published, which already promoted a subject able to value, to commit, and thus to escape from the determinism of his environment and organism. Regarding the relationship between science and technology, which Canguilhem began to conceptualize at the very end of the 1930s, in his <em>Essai</em>, he proposes a path that reverses that of positivism, moving from clinical practice to science, in which the former is clarified by the latter; however, scientific psychology cannot play a role equivalent to physiology in psychological care. Indeed, Canguilhem considers psychology's claim to objectivity incompatible with the respect for subjectivity that his <em>psychologie réflexive</em>, on the contrary, defends. To conclude, I examine Canguilhem's few writings on psychotherapy, as well as those on psychopharmacology.</p></div><div><h3>Discussion</h3><p>I discuss the clinical consequences of the inability of scientific psychology to play a role in psychotherapy similar to that of physiology in medicine.</p></div><div><h3>Conclusion</h3><p>Canguilhem's conception of psychological care is essentially a defense of human dignity, based on a philosophical, not a scientific, theory of the individual.</p></div>","PeriodicalId":45007,"journal":{"name":"Evolution Psychiatrique","volume":null,"pages":null},"PeriodicalIF":0.6,"publicationDate":"2024-02-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139877713","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-02-10DOI: 10.1016/j.evopsy.2024.01.004
Clémence Isaac PhD , Sarah Joanny MSc , Noomane Bouaziz PhD , Marie-Carmen Castillo (Pr) , Dominique Januel (Pr)
Objectives
Cognitive impairments represent a major issue in mental health that remains understudied in clinical practice. This article aims to provide an overview of the literature on cognitive functioning in bipolar disorders. Additionally, its purpose is to highlight potential interventions that promote recovery, particularly within the bipolar “Centers of Expertise” of the Fondation FondaMental network.
Method
We conducted a literature review to explore various aspects related to cognitive issues in bipolar disorders, such as trait-related cognitive impairments, variations throughout the course of the illness, and the assessment and treatment of these cognitive deficits.
Results
In bipolar disorders, many cognitive disorders may present themselves in different ways; the literature identifies disorders of attention, psychomotor speed, executive functions, memory, emotional and social cognition, and metacognition. These cognitive disorders are present in all phases of the disease with heterogeneity between patients. This heterogeneity does not depend on whether patients have type I or type II bipolar disorders; nor does it depend on depressive, manic, or euthymic phases, although cognitive symptomatology is more intense in the acute phases. Bipolar disorders require treatment, although some treatments can have an influence on cognition, notably antipsychotics, lithium, or more general polypharmacy. The International Society for Bipolar Disorders (ISBD) Targeting Cognition Task Force developed consensual recommendations for clinicians regarding cognitive interventions in bipolar disorders. The recommendations include an objective and subjective assessment of cognition for all patients, regardless of whether partial or complete remission is achieved. Caregivers who are not neuropsychology specialists may, after a short training period, use screening tools such as the “Screen for Cognitive Impairment in Psychiatry” (SCIP) and “Cognitive Complaints in Bipolar Disorders Rating Assessment” (COBRA), and must refer patients for a more complete evaluation if any difficulties emerge. There is also an interest in regularly assessing cognition, in connection with the possibility of neurodegeneration. Indeed, there are several theories about the development of cognitive impairments in bipolar disorders in the literature. One theory suggests that neurodevelopmental factors could influence the occurrence of these disorders. On the contrary, the “neuroprogression model” postulates that allostatic load may disrupt cognitive functioning as part of a longer term degenerative process.
Discussion
The FondaMental network Centers of Expertise provide educational programs as well as interventions adapted to several aspects of psychiatric diseases, notably cognitive impairment. Patients can be provided with a complete cognitive assessment, and then directed towards appropriate the
目的认知障碍是精神健康领域的一个重要问题，但在临床实践中仍未得到充分研究。本文旨在概述有关双相情感障碍认知功能的文献。方法我们进行了一次文献综述，以探讨与双相情感障碍中的认知问题相关的各个方面，如与特质相关的认知障碍、整个病程中的变化以及对这些认知障碍的评估和治疗。结果 在双相情感障碍中，许多认知障碍可能会以不同的方式表现出来；文献指出了注意力、精神运动速度、执行功能、记忆、情感和社会认知以及元认知等方面的障碍。这些认知障碍存在于疾病的各个阶段，患者之间存在异质性。这种异质性并不取决于患者是 I 型还是 II 型双相情感障碍，也不取决于抑郁期、躁狂期或缓解期，尽管认知症状在急性期更为强烈。双相情感障碍需要治疗，但有些治疗方法会对认知产生影响，特别是抗精神病药物、锂盐或更普遍的综合药物治疗。国际双相情感障碍协会（ISBD）认知目标工作组为临床医生制定了有关双相情感障碍认知干预的共识性建议。这些建议包括对所有患者的认知能力进行客观和主观评估，无论患者的病情是部分缓解还是完全缓解。非神经心理学专家的护理人员在经过短期培训后，可以使用 "精神病学认知功能障碍筛查"（SCIP）和 "双相情感障碍认知主诉分级评估"（COBRA）等筛查工具，如果出现任何问题，必须将患者转介到更全面的评估机构。此外，定期评估认知能力还与神经变性的可能性有关。事实上，关于双相情感障碍患者认知障碍的发展，文献中有多种理论。一种理论认为，神经发育因素可能会影响这些疾病的发生。相反，"神经退化模型 "则推测，作为长期退化过程的一部分，异位负荷可能会破坏认知功能。讨论方达精神医学网专家中心提供教育计划和干预措施，适用于精神疾病的多个方面，尤其是认知障碍。中心可为患者提供全面的认知评估，然后指导他们接受适当的治疗。例如，这些中心为躁狂症患者提供认知矫正服务，以实现个人康复为目标。认知矫正是一种社会心理康复治疗，包括通过练习来训练认知功能，目的是制定可用于日常生活的解决问题的策略。这种治疗应能提高患者的生活质量和自主能力。在世界范围内，还缺乏针对情绪障碍患者（包括躁郁症患者）的公认方案。不过，一些研究报告称，认知矫正治疗可以改善患者的认知和功能，尽管这些研究的结果不尽相同。这些研究的一些作者建议，以患者的个人和职业项目为中心，针对不同的心理过程（这些心理过程是功能改善的中介），开发个性化的综合疗法。最近，法国为包括躁郁症在内的情绪障碍患者制定了一项名为 "Eco "的生态认知矫正计划。该计划使用纸张和可操作工具进行认知矫正练习，这些工具专门用于支持将认知技能转移到人们的日常生活中。它由一个心理教育模块组成，该模块可以：发展患者的元认知知识；减少自我鄙视；增加治疗的内在动力。该计划包括三个认知训练模块（注意力、记忆力和执行功能），以及针对特定功能的子模块，练习可在指导课程中进行，也可偶尔在家中进行。模块的讲解顺序以及每个子模块的训练次数都根据每位患者的情况进行调整。练习由十个难度等级组成，让患者发现、发展并推广新的认知策略。
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Pub Date : 2024-02-06DOI: 10.1016/j.evopsy.2024.01.003
Quentin Dumoulin (Psychologue clinicien, Maître de conférences) , Pierre Bonny (Psychanalyste, psychologue clinicien, Maître de conférences)
Objectives
The aim is to examine the psychopathological and sociocultural implications of DID (Dissociative Identity Disorder), in relation to the way in which the epidemic of “multiple personalities” had dissipated by the end of the 20th century.
Method
We begin by tracing the history of dissociative disorder, reviewing the diagnostic criteria of DID (DSM-5 and ICD-11) and comparing them with those of the former MPD (Multiple Personality Disorder) in DSM-III. We then return to the concept of “dissociation” in psychiatry, highlighting some translation difficulties and its plurivocity. Finally, we conclude with a discussion of the issues involved in clinical practice with the patients concerned.
Results
The renaming of dissociative disorder (from MPD to DID) was a response to the forensic controversies of the 1990s. However, this new diagnostic label resolves neither the epistemological issues surrounding dissociation (around the neurosis/psychosis differential diagnosis), nor the question of therapeutic accompaniment. Today, DID is the subject of two opposing interpretations: the psychotraumatic model and the social-cognitive model. Although they present irreconcilable differences and conceptions of the dynamics of psychic disorders, they both emphasize many points in common with regard to DID. The possibility of the cohabitation of different consciousnesses, identities, or personalities is not called into question. Similarly, the issue of trauma is examined by proponents of both models.
Discussion
The success of the DID could thus be partly explained as a return to the initial thesis of subjective division (Freud, Lacan), incompatible with the idea of a strongly unified ego as an ideal of mental health. However, the “loop” logic inherent in the classification of psychological disorders means that DID can be seen as a way for patients to describe some of their symptoms. So, the question is not to determine the superiority of an “explanatory” model of DID, but to examine the dynamics that led the subject to be identified with this diagnosis. In the case presented here, DID is linked to the patient's psychotic experience.
Conclusion
The success of DID is contemporaneous with social questioning around questions of identity. However, the dynamics of the social bond, specific to the development of a new vocabulary, cannot eclipse a certain reality of suffering manifested through dissociative phenomena. The unconscious as an “autre scène” can shed light on the logic of these mechanisms, notably by drawing on the tools of structural diagnosis proposed by Lacanian psychoanalysis. These insights help to define the conditions under which transference-related disorders can be accepted and elaborated for the patients concerned.
方法我们首先追溯解离障碍的历史，回顾 DID（DSM-5 和 ICD-11）的诊断标准，并将其与 DSM-III 中的前 MPD（多重人格障碍）的诊断标准进行比较。然后，我们回到精神病学中的 "解离 "概念，强调一些翻译上的困难及其多元性。最后，我们讨论了相关患者在临床实践中遇到的问题。结果解离障碍的重新命名（从 MPD 到 DID）是对 20 世纪 90 年代法医争议的回应。然而，这一新的诊断标签既没有解决围绕解离症的认识论问题（围绕神经症/精神病的鉴别诊断），也没有解决伴随治疗的问题。如今，对 DID 有两种截然相反的解释：精神创伤模式和社会认知模式。尽管它们在精神障碍的动力学方面存在着不可调和的分歧和概念，但它们都强调了 DID 的许多共同点。不同意识、身份或人格共存的可能性没有受到质疑。因此，DID 的成功在一定程度上可以解释为回到了最初的主观分裂论（弗洛伊德、拉康），这与作为心理健康理想的强烈统一的自我的想法是不相容的。然而，心理障碍分类中固有的 "循环 "逻辑意味着，DID 可以被视为患者描述其某些症状的一种方式。因此，问题不在于确定 DID "解释 "模式的优越性，而在于研究导致受试者被确定为这一诊断的动力。在本文介绍的病例中，DID 与患者的精神病经历有关。然而，新词汇发展所特有的社会纽带动力，并不能掩盖通过分离现象所表现出的某种现实痛苦。作为 "另一个场景 "的无意识可以揭示这些机制的逻辑，特别是通过借鉴拉康精神分析提出的结构诊断工具。这些洞察力有助于为相关患者界定在何种条件下可以接受和阐述与移情相关的失调。
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