Un trouble de l’humeur non dépressif, non maniaque et non schizophrénique : à propos d’un cas. Conception clinique, nosographique et physiopathologique

RésuméNous rapportons ici le cas d’une femme âgée de 60 ans présentant un trouble « thymique » difficilement catégorisable, et qui est l’occasion d’une réflexion théorique et physiopathologique sur certains aspects de la classification des troubles de l’humeur. Ce trouble est caractérisé par un émoussement thymique, un anidéisme, un apragmatisme important, des déficits sensitifs divers, et un affaiblissement partiel des émotions et des instincts. Les différents examens complémentaires sont sans particularité, notamment l’imagerie cérébrale. Le tableau résiste aux antidépresseurs, et seule la sismothérapie permet une levée de l’ensemble de la symptomatologie. Par le passé, Mme F. a connu huit épisodes identiques. Si le cas de Mme F. ne répond pas au diagnostic de syndrome dépressif, il nous semble en revanche pouvoir être rapproché de certaines descriptions de la littérature médicale du xixe siècle. Cela nous amène à envisager l’existence d’un trouble thymique différent de la manie, de la dépression, voire de l’hébéphrénie telle que la conçoit Delay, et qui serait essentiellement caractérisé par une abolition de l’humeur.

ObjectivesHere we report the case of an atypical mood trouble with a functional appearance. This case is an opportunity for a critical approach of mood troubles.PatientMme F. is a 60-year-old woman, pensioner after a full, active, working life. The family describes her as a dynamic and organised person without passiveness and suggestibility. The patient has not particular previous medical problem and has been taking only postmenopausal hormone replacement therapy. From the age of 23 until she was 56 years, Mme F. has had eight episodes identical with the actual phenomenom. All were resistant to high and repeated doses of different antidepressants: Clomipramine 200 mg per day during 9 weeks, iproniazide 150 mg per day during 6 weeks, paroxetine 50 mg per day during 7 weeks and fluoxetine 60 mg per day during 6 weeks. Only electroconvulsivotherapy had strongly improved the situation. Only one of these episodes had coincided with potential trigger event (a divorce). At present episode, the situation is characterised by a blunted mood, an anideism, an apragmatism, and a weakening of emotions and instincts. There are various sensitive deficits too: Hemiesthesia of the left part of the body, anosmia, agueusia and deafening for the left ear. There is no sadness or delirium. The beginning is sudden without an evident cause. The results of all paraclinical exams (specially cerebral imaging) are normal. Like the other episodes, the trouble resists to the antidepressant, and she comes out of this state completely only with electroconvulsivotherapy.ResultsThe case of Mme F. corresponds imperfectly to the diagnosis of major depressive episode, but a parallel can be made with “psychic akinesia”, “athyhormia” or “loss of self-psychic-activation” despite the lake of lesionnal cause. It can be closely identified to the “melancholia with stupor”, which was rapported, by Griesinger, a German psychiatrist of the middle of 19th century.ConclusionsOur report could be an argument for the existence of a mood trouble characterised by an “abolition of mood”. Clinically, therapeutically and physiopathologicaly, this “hypothymia” could be the opposite of the booth “hyperthymias” (mania and depression). The relevance of this observation needs to be confirmed by other cases like this.