Psychose post-traumatique: contribution à une théorisation dynamique du traumatisme aigu post-immédiat: Post-traumatic psychosis: the contribution of an acute post-immediate trauma to a dynamic theorization

Abstract

In his recent publication (2004), in which he favors the psycho-dynamic approach, M. Bertrand underlines the importance of traumatic matter at the heart of new clinical, methodological and epistemological challenges of psychopathology.Our contribution ("post-traumatic psychosis") comes within that prospect in reference to the semiology of traumas generated by extreme situations, such as the tsunami in South Asia (December 2004), the terrorist attacks in Madrid (March 2004) or the hostage taking in North Ossetia (September 2004). Four principle sets of themes lead us to suggest a traumatic psychosis when the person shows symptoms of a neurotic psychic structure: 1. There's no traumatic representation or psychic inscription of the event. Sideration (and its stupor-like confusion symptoms) or panic flight (together with hallucinations or acute delirious fits) often illustrate this first clinical aspect. 2. According to the psychodynamic frame of reference, psychic processes tend to ignore the pleasure/displeasure principle. They are governed by the "invasion" of affects of pain and compulsion to repeat. 3. The models of neurosis and psychic conflict are not efficient in the management of the "quota of affect" and the drive influence. 4. It would be necessary to add, from a psychopathological point of view, the appearance of temporary fits of mental confusion, self-destructive and autolysis behavior.The frame of reference of a DSM IV type "descriptive" psychopathology (ie acute Stress Disorder) seems to de inadequate to convey the implemented post traumatic stakes. If trying to soothe the symptoms is undeniably important, psychic disorganizations that generate a semiology that is essentially present in the symptomatology of the psychoses cannot be ignored. A first clinical approach makes it possible to specify the argumentation of our proposal: "a post-traumatic psychosis". It is supported by five main syndromic classes: 1) the symptoms are often more or less temporary delirious fits (delirious ideas or perceptions of a persecutory, cenesthetic or hypochondriac nature), mental confusion (oneiroid state, anxiety and stupor), phases of depersonalization and derealization, severe death pangs, serious physical disorders, divides close to schizophrenic-type dual personalities; 2) the adhesiveness marks the impossibility for the victims to keep away from a trauma. The objects are bound, persecuting and adhesive; 3) traumatic temporality imposes a factual and current omnipresence of the trauma. It destroys the temporal projections of the patient as well as an anamnesic reconstruction; 4) the "traumatic body" is not that of hysterical neurosis conversions. The somatic semiology marks operational-type functioning (P. Marty); 5) traumatic compliance doesn't work on the level of facilitations that lead to the formation of symptoms. The identity structure appears disorganized by the dismantling of the primary psychic envelopments.A second theoretical approach makes it possible to promote this immediate psychotic-type post-traumatic psychopathology. Four considerations of fundamental psychopathology support our contribution: 1) Pictogramic inscription. The severe traumatism does not produce the polarity required for the process of "self-fathering" described by P. Aulagnier in connecting with original processes. Traumatic adhesiveness does not separate the victim from the trauma. It splits the necessary mediation spaces and distance for the emergence of representation processes. 2) Pain affect. The pain affect generated recalls the first experiences of the newborn, primitive agony and anaclitical collapse; the "narcissistic contract" is broken and the patient lives without a secure base or a sufficiently good and supporting psychic container (D.W. Winnicott). 3) Anxiety status. The anxiety is not of neurotic nature but truly annihilating. It is often similar to anxieties caused by disasters, psychoses due melancholy (H. Ey) or more "archaic" anxieties that have been observed in hebephrenic pathologies. 4) Body dismantling. The trauma results in "mute somatizations that cannot be symbolized" (M. Bertrand). They appear in sensory outward signs such as dermatosis, pruritus, diarrhea, hemorrhagic periods or persistent headaches for example. These two clinical and theoretical aspects of the severe forms of trauma confirm the unconscious traumatolytic aim of the victim's psychological destruction. The semiological forms most impervious to therapeutic processes seem to be, in reference to hostage-takings or terrorists acts, those where the patient was conformed with a trauma "that was not carried out" like mock hangings or executions. Suicidal dimension seems to be the ultimate recourse so as not to sink into insanity and to keep a subjective position when faced with barbarian figures.