Peut-on compter sur le care pour soigner le cure en psychiatrie ? À propos des troubles thymiques dans la clinique du jeune adulte

Abstract

What can we find in the diagnostic of bipolar disorders that interests the international psychiatry at the end of the 20th century? Nosography is simplified in response to the search of increasingly accurate neuropharmaceutical targets and to strengthen the efficiency of chemical therapies. Nevertheless, while it is essential to pursue the improvement of antidepressant treatments, should one still accept to lose any semantic reference to depression and mood disorders under the label of bipolarity? In the DSM-III (1980), “depressive disorders” had been assimilated to “bipolar disorders”, and the classical syndromic opposition between “endogenous” and “exogenous” depressions, treasured by the French psychiatry, seems to have disappeared in benefit of a split between “major depressive disorder” (isolated or recurrent) and “minor depression” (chronical or dysthymic). In the DSM-5 (2013), there is a distinction between “disruptive disorder with mood dysregulation” and “persistent depressive disorder”, which, in turn, includes major depression, characterized and chronic, as well as the dysthymic disorder, both of them differentiated previously in the DSM-IV (1994) and IV TR (2000). In this context, melancholia is reduced to its least expression in a sub-category of “major depression”, which can, in turn, present “melancholic” or “dysthymic features”. From this evolution of the DSM, could we infer that international psychiatry is gradually coming back from its excess of technical atomization of the human being and the reduction of psyche to an organic body? Is contemporary psychiatry distancing itself from the contemporary questions raised by the need to integrate subjectivity and intersubjectivity in care practices and scientific research? At the end, could melancholia possibly be the only clinical-theoretical model making sense and preserving some internal consistency? Would this concept transcend time, places and disciplines, in clinical medical practice as well as in human and social sciences, in literature and arts alike? Some considerations on the evolution of the categorisation of depression in psychiatry will introduce the clinical vignette of a patient with a “bipolar disorder” label. This diagnostic – (im)posed after acting-out during a hospitalization – had the effect of breaking down the therapeutic binomial between the psychiatrist and the psychoanalyst – in place for ten years – on the hypothesis of a border-line diagnostic close to psychosis. This was a traumatic disorganization, marked by thymic movements of despair and elation that became overwhelming for the therapeutic trio itself. On the patient side, it became possible to redynamise the cotherapeutic process – although at a high price – due to a massive regression needing a radical reorganization of the frame of treatment and a reorientation of the initial diagnostic towards melancholia. The shared experience of an authentic “manic-depressive” relationship – helping and saddened – between the therapeutic staff, as well as the implementation of a setting of institutional packing, both facilitated the yield of incestual and psychotizing maternal imagos incorporated in early childhood. These were embolized in the patient's body as well as in the staff, and were masked by the excitation discharged through the suicide attempts. Time has come to relativize classical biomedical approaches centered on the “cure” versus socioethical approaches based on “taking care” of the person, which is being valued by the care movement at an international level (Glatignol, 2013). In other words, it is a matter of getting back to a medicine “funded on values” (values-based medicine VBM) and the subjective experiences (individual and collective alike) versus the limits of medicine exclusively based on evidence (Evidence-based medicine EBM) and objective facts.