Tentatives suicidaires de l’hystérique : quels enjeux en milieu psychiatrique ?

Abstract

ObjectivesSuicide attempts, when they are repeated, challenge psychiatric care, particularly in the case of hysterical patients. Nursing staff often report their difficulty dealing with the suffering involved, either misinterpreting or misunderstanding it. This raises the issue of the clinical approaches, which are mainly based in strictly behavioural criteria. It is possible to wonder whether the prevailing definition of Histrionic Personality Disorder in the DSM-IV and partially reiterated in the DSM-5 has not had a part in the development of this misunderstanding. The history of suicidal phenomena and hysteria recalls the importance of the discovery of the subconscious, since this is what enabled the accusation of intentional simulation of distress to be lifted from the hysterical subject. MethodTwo cases are described here, drawn from interviews in a larger study in an open psychiatric ward. Interviews and clinical observations were conducted in a psychoanalytical approach. This specific approach was intended to challenge the behavioral postulates of the DSM-IV concerning hysteria, the terminological construction and the etymology of “histrionic personality disorder”, and its moral implications. ResultsFollowing this clinical study, it appeared that the suffering among suicidal hysterical patients diagnosed as “histrionic” proved to be genuine, and rarely simulated, while the diagnosis of Histrionic Personality Disorder entails the suggestion that these patients intentionally simulate the distress of other patients. DiscussionThe work by Charcot, Freud or Janet, beyond their differences in doctrine, jointly provides an approach to hysteria that differs from the widely accepted Histrionic Personality Disorder promoted by the DSM. ConclusionThe increasing numbers of suicides among hysterical patients in psychiatric facilities appears to relate to incorrect diagnosis of forms of distress that are socially unacceptable. Many subjects are wrongly identified as having Histrionic Personality Disorder, while those that are genuinely concerned are confronted with complete misunderstanding of their distress. The treatment of suicidal hysteria in psychiatric care thus appears ill suited. The psychiatric hospital, as the perfect stage for indifference towards this illness, could indeed encourage subjects to enhance their demonstrations of distress.