Vers une nouvelle nosographie des troubles psychiques post-traumatiques : intérêts et limites

Abstract

BackgroundPost-traumatic stress disorder is not just about post-traumatic stress disorder! The complexity of the psychic consequences of psychological trauma often results in delayed care and/or partial compensation for the damage suffered. Providing for severe clinical presentations, the interlinking of many symptoms is sometimes confusing to such an extent that the traumatic origin of the suffering remains masked by other more apparent difficulties. However, only the precise recognition of the clinical situation as a whole picture make it possible to implement the most appropriate and most diligent care in order to improve the prognosis. ObjectivesOur objectives are to formalize a global and precise clinical analysis, useful to the clinical activity of care and expert as well as to clinical research and, more generally, to the conception that we can have of the psychic traumatism as its clinical consequences. We especially wish to specify the links and sequencing of the symptoms at the semiological level. Finally, it is a question of proposing a classification in didactic format to reach the greatest number of caregivers and clinical researchers. MethodologyFrom a socio-anthropological point of view, we address the origin and definitional modifications of “post-traumatic stress disorder” in the diagnostic and statistical classification of psychic disorders, from DSM-I to DSM-5, in order to better understand the current description and to define its limits. Then, based on our clinical experience enriched with data from international literature, we propose a precise definition of psychic trauma followed by a new nosography of post-traumatic psychic disorders, new in the sense that it appears more detailed and dynamic than all those brought to our knowledge. ResultsAfter defining the psychic trauma, the immediate clinical reaction and the chronic cardinal symptoms, we detail the mood, anxious and psychotic clinical forms of post-traumatic psychic disorders. We mention somatoform expressions, psychosomatic and somatic consequences (with implications of possible traumatic brain injury), before specifying the traumatic impact on instinctual functions, behaviors, personality organization, and coping abilities (professional and private). DiscussionLet us never forget that the vast majority of scientific research has, in the medical-psychological field, aimed at facilitating the therapeutic course. Here, closer to each patient, a classification-only approach seems insufficient. This is why we associate other semiological clinical evaluations with other perspectives such as the dimensional and psychodynamic approaches. From classificatory generalities to a singular clinical situation, from global principles referenced to stress to an approach centered on the trauma experienced by an individual, two worlds can meet on the side of subjectivity. If one of the initial objectives of the international classifications was to reduce the “diagnostic subjectivity” in psychiatry, the nosographic entities nevertheless remain changeable from one reprint to another, reflecting what we call the “societal subjectivity”. The validity of diagnoses could still increase in the future by the characterization of biomarkers, although we cannot know if the clinical approach would be truly upset. The current clinical practice is always resulting from the transmission of knowledge from one generation of practitioners to another and, in the same therapist, from a changing experience according to the patients encountered. The issues are vast and the so-called “scientific” methodology with reference to the uses of the moment could appear insufficient. Beyond a virtual psychiatry, whether it is solely administrative or neurobiological alone, our models must also be useful both for the transmission of clinical experience and for a revision of the paradigms of scientific research.