Le trauma de l’agresseur à l’origine du trouble de stress post-traumatique. Implications psycho-légales concernant le sujet « auto-traumatisé »

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BackgroundIs it possible for an aggressor to suffer from psychic trauma after his act of violence? This question, which might appear to be provocative, nevertheless brings up a myriad of theoretical and clinical interrogations. ObjectivesWe will explore the issue of the “self-traumatized aggressor” from several points of view: anthropological, psychopathological, and psycho-legal. Material and methodsAfter an anthropological critique of the history of trauma in contemporary psychiatric nosography, we turn to a detailed clinical situation to demonstrate the way in which conscientiously taking the subject's history into account reveals itself to be crucial to the diagnosis of post-traumatic stress disorder, particularly in the forensic context. The medico-legal impacts of so doing lead less to an interrogation of the subject's penal responsibility than they do to reflections on the possibilities of a judicial reparation of psychic damage. ResultsSince Antiquity, descriptions of post-traumatic psychic disturbances have been part of the history of societies, rediscovered and then forgotten, until the turning point of the Vietnam War, which profoundly scarred American society. After the war's end, there was a gradual societal shift, as the major issue – no longer the penal question regarding killings enacted by soldiers on the front – became the problem of the nature of the therapy for, and the judicial reparation of, the damage caused by the massive amounts of psychic disorder among veterans. Under pressure from insurance companies to create precise criteria that would allow veterans to access mental health care, the existence of post-traumatic disturbances reemerged under the name “post-traumatic stress disorder” in 1980, on the occasion of the publication of the DSM-III. If the notion of traumatogenic hetero-aggressive acts informs the origins of the description of PTSD, the number of epidemiological and psychopathological studies specifically dedicated to this phenomenon remains small. We examine in detail the story of Hans, a former legionnaire examined by a forensic psychiatrist, whose report seemed destined to be banal. Ever since the “aggression,” as he called it – a fall that he experienced at age 64, “nothing serious” according to several doctors – Hans experienced shoulder pain, had trouble sleeping, became irritable, and ruminated, leading him to consult a psychiatrist. The forensic doctor assigned by the tribunal three years after Hans's fall logically wished to consult a specialist. In his letter to the latter, he expresses his incomprehension that this former legionnaire “who's certainly seen worse” found himself unable to psychologically move on after an “objectively” minor event, a simple shoulder injury. Hans's story would shine a light on another side of things, revealing an unexpected psychotraumatic dynamic. DiscussionTrauma intrinsically complicates psycho-legal analysis, inasmuch as a multiplicity of potentially traumatic confrontations and other major stress factors are part of each person's life story. Should one link a post-traumatic disorder to the event that laid the groundwork for it, or rather to the subsequent event that provoked it, or finally, after a latency period, to the elements that caused the subject to relive the initial trauma? The medical and psychological consequences of the traumatic event, even those that emerge later, are thus attributed to the event. But should one consider that a cirrhosis caused by a subject's alcoholism that is itself secondary to PTSD can be attributed to the PTSD? What about psychotic symptoms induced by psychoactive substances that were consumed as sedatives after a traumatic incident? Such situations are complex: the forensic expert will have to argue her/his comprehension of the timeline of the disorders, as well as her/his analysis of the relationship of symptoms to the initial event, on a case-by-base basis – and always with the juridical framework in mind. ConclusionsA forensic evaluation is a crucial moment for the subject. While the subject may hope for therapeutic advice from the forensic expert, it's impossible for a single professional to both carry out an evaluation and treat the subject (except in military settings, in contexts of emergency or of judicial requisition). However, according to the terms of the 1992 decree relative to victims of war and terror attacks, “the forensic expert carries out a task that indirectly contains a therapeutic dimension.” The practitioner's attitude is benevolent, as close as possible to the attitude maintained in general medical practice – and the validity of the clinical evaluation depends upon it. Let us not forget that, like Hans, certain people with psychological wounds open up for the first time in an evaluation. To underestimate the subjective impact of a trauma could lead to what Claude Barrois calls a “second trauma.” If its consequences on the symptom cannot be predicted, a successful evaluation – no matter its conclusions – can lead to relief. Putting an event into words, asserting a date of consolidation, and recognizing the damage caused by the event can often help the subject project her- or himself into the future.