DSM-5, trouble de la personnalité schizotypique et nosographie psychanalytique structurale française

Abstract

ObjectivesIn this article, we present the evolution in the diagnostic criteria in the DSM-5 for schizotypal personality disorder, which is included both in personality disorders and in the new schizophrenia spectrum. The different interpretations (categorical versus fully dimensional) of experiences assimilated to psychosis raise important issues in contemporary approaches to mental health. One major aspect of the problem appears to be the development of the paradoxical notions of “healthy”, “benign” or even “happy” schizotypy. We consider the choice of favouring the dimensional approach, setting this alongside the French structural psychoanalytical nosography, and in particular the definition by Bergeret of the schizophrenic character and the notion of suppléances in Lacanian structural psychoanalytical clinical practice. MethodWe reviewed the points in common between the new DSM-5 model and the French structural psychoanalytical model, by way of a comparative study of recent English language publications in the field of schizotypy and some French psychoanalytical clinical studies. ResultsThe two formerly opposing models have drawn considerably closer, with the acceptation of a dimensional perspective in the DSM-5. The choice of a dimensional rather than a categorical approach has undeniably contributed to reducing the gap between the psychiatric classification and French psychoanalytical nosography. Insofar as the new model for personality disorders – still requiring empirical validation – focuses on personality traits and functioning (assessed not only with regard to the self, but also on interpersonal level, approached via the ability for empathy and intimacy), it relies on far more stable aspects than symptoms alone, and at the same time places them on a continuum from normal to pathological. We consider this amounts to genuine progress in the detection and understanding of psychopathology. DiscussionThe DSM-5 can no longer claim to be a-theoretical (despite the long-standing position of its authors). Moreover, the American Psychiatric Association (APA) confirms that the Big Five factorial theory was used to define the field of personality and personality traits. However, the APA forgets to mention the implicit influence of the American psychoanalytical work by Kernberg, published earlier. Indeed the new severity scale for alterations in the functioning of personality in the DSM-5, whether for self or for interpersonal relationships, presents a fair number of similarities with the conceptualisations by Kernberg concerning the degrees of alteration in self and in object relations, established by this author to distinguish levels of severity in different narcissistic pathologies. Nevertheless, we feel that the new options taken up by the APA are curiously contradictory. Although they are closer to the psychoanalytical model in the new conception proposed for personality disorders, they are in some respects surprisingly distant: the paranoia disorder has disappeared and only certain of its indicators are maintained (such as persecutory delusion) in an excessively wide schizophrenia spectrum. This misses the reality of the various levels of dissociation present in psychotic entities, already reported by psychiatric pioneers, like Bleuler and by a large number of contemporary psychoanalytical psychopathologists. These levels are not strictly organised in identical manner on the intrapsychic level, and their clinical symptomatology during decompensation does not take exactly the same form. We suggest that substantially different levels of dissociation, leading to explicitly distinct symptom profiles, provide a spectrum that it would be more legitimate to call “psychosis” rather than “schizophrenia”, whilst maintaining a distinction in the contemporary psychoanalytical model between schizophrenia, paranoid schizophrenia and paranoia. ConclusionThe authors propose a more integrative approach. This would involve symptoms, functioning dimensions and personality traits, by taking into consideration the intrapsychic mechanisms that underpin their expression, despite the difficulties in objectifying these mechanisms. The markers for these mechanisms are linked in particular to the nature of the conflicts experienced by patients, the nature of their distress and dominant defences, as well as their object investment mode and areas of conflict.