Psychiatrie et psychanalyse : le divorce est-il consommé ? À propos des « troubles bipolaires »

RésuméObjectifsDans les suites de la publication des actes du colloque « Le bipolaire » et la psychanalyse, organisé par l’Espace analytique en mars 2012 à Paris, les auteurs proposent une analyse des raisons qui peuvent être à l’origine d’incompréhensions et de malentendus entre psychiatres et psychanalystes.MéthodeSont tour à tour évalués le flou du concept de « trouble bipolaire », la tendance au sur-diagnostic pouvant induire des attitudes thérapeutiques inappropriées pour les uns et l’oubli de la polysémie des mots « manie », « dépression » à l’origine de contre-sens sémantiques et prétention thérapeutique excessive à certains égards pour les autres.RésultatsÀ la lumière de l’itinéraire intellectuel de Freud, les auteurs proposent d’ouvrir une réflexion sur la connaissance actuelle de la maladie bipolaire dont la physiopathologie cérébrale est aujourd’hui beaucoup mieux appréhendée.DiscussionEn recourant à la fonction « méta », les auteurs en appellent à une redécouverte des propositions de Jean Delay (la psychophysiologie) et d’Henri Ey (l’organodynanisme).ConclusionEnfin, ils plaident pour une juste place des thérapies analytiques chez les patients souffrant d’une maladie bipolaire stabilisée d’un point de vue psychiatrique.

BackgroundFollowing the publication of the proceedings from the conference on bipolar disorders and psychoanalysis organized in March 2012 in Paris, the authors propose deepening the discussion regarding the diagnosis and treatment of bipolar disorders given recent advances in the scientific understanding of this disease and its etiology. It could be argued that the term “bipolar” has become a source of confusion for the medical community and the general public alike. As Jean Delay emphasized, mood is by nature bipolar and is “a fundamental affective disposition, rich with all the emotional and instinctual aspects, which gives each of our moods a pleasant or unpleasant tone, oscillating between the two extremes of pleasure and pain.” While the pathophysiology of the bipolar disorder is now much better known and understood, the “extended bipolar spectrum” as a nosological concept may be ill-defined in that certain personality disorders or neurotic problems may be mis-diagnosed within this spectrum. In many cases, this may inhibit further medical exploration as well as lead to inappropriate therapeutic management. Moreover, this is a troublesome development in that the bipolar disorder has seen a significant diagnostic inflation over the past 20 years, most noticeably in the United States but as well as in Europe. Within the context of modern science and current medical understanding, the authors reflect on the role of psychoanalysis as a potential therapeutic treatment for this disorder?MethodThe authors go on to explain that within the intellectual itinerary of Freud, and then later with Melanie Klein, psychoanalytical concepts emerged using the term “manic” within the meaning of manic defences, and “depressive” for the depressive position to explain certain intra-psychic dynamics (object relations) in the early developmental stages. However, given the development of similar historical terminology by Baillarger, Kraepelin and subsequent psychiatry for use in medical disorders, the words “manic” and “depressive” have inevitably led to further confusion. Freud wrote in “Introduction to Psychoanalysis” that psychoanalysis is to psychiatry “what anatomy is to histology: One examines the external forms of the organs, while the other examines the tissue and the cells in which these bodies are made.” Nonetheless, we should not forget that Freud himself, in his unfinished book “Outline of Psychoanalysis”, admits that there are organic and biological aspects to consider above and beyond the purely psychological components, and that advances in science would no doubt bring new biological understanding that psychoanalysis cannot ignore. On the one hand, Freud assigns a common root for the manic and depressive states, linking them closely to the action of the superego and the passing of the Oedipal stage of development. Melanie Klein, on the other hand, attributes the psychogenesis of the manic-depressive states to an earlier stage of psychological development of the child, during the first year of life when “the oscillation between the depressive position and the manic position is an essential part of normal development”. For Klein, the manic defense is an attempt to repair internalized objects with regards to their potential loss, while both the depressive and manic defensive positions are not polarities of the same phenomenon. Thus, the authors suggest that there should be a clear differentiation between manic defenses, which are found in children and healthy adults in response to anxiety or depression – and the manic state, in the psychiatric sense.ResultsNevertheless, the authors argue that the “age of science” has not sounded the death knell of metaphysics. Similarly, the current boom in neuroscience does not erase the interest of metapsychology for the understanding of mental functioning. Rather, the authors propose that recent advances in neuroscience that shed new light on the pathophysiology of mental disorders (such as bipolar disorder) may invite us to develop a “meta-psychophysiology,” a discipline that integrates the study of mental states, biological dimensions, and psychopathological aspects. In this respect, the rapprochement between Freud metaphysics and metapsychology may still be fruitful today as metaphysics is indeed the branch of philosophy that investigates the causes and origins. Thus, this tends to suggest that the divorce between psychiatry and psychoanalysis is not so pronounced. Rather, the medical diagnosis, the treatment strategy, and the therapeutic alliance should indeed balance this accumulated insight from these various disciplines. And, in order to overcome further semantic confusion and to reduce the trend in over-diagnosis, the authors propose a strategy that would better “segment” the bipolar type 1 disorder – for which the pathophysiological hypotheses are the strongest and the therapeutic management more specific – from the more attenuated type 2 forms which have more diverse and varied etiologies.ConclusionFinally, the authors propose that today, as did Freud suggested during his time, that the advances in neuroscience could facilitate a “re-think”, or paradigm shift, with regard to this specific pathology. It is now firmly established that psychosocial therapies associated with appropriate drug strategies significantly reduce the risk of relapse and the need for hospitalization for patients with bipolar disorders.