This article presents two clinical cases of probable onset of schizophrenia, characterized by the organization of a central symptom of hypochondria, signaling the subject’s non-belonging to the moment of pubertary transformation. In both cases, neuroleptics proved to be less useful than anti-depressants. This observation prompts three comments. The first is that it is necessary to respect a certain coherence between the rules of prescription and the clinical field of reference. The second is that antidepressants may be useful in this type of onset of schizophrenia with hypochondriacal symptoms. The third is that the neuroleptic treatment is interwoven with the subject’s narcissistic economy, an economy already implicated in the formation of the hypochondriacal symptom, which would explain the usefulness of antidepressants in this case.
The methodology of therapeutic trials is well-established in somatic pathologies. Is this also the case in psychiatry, and in particular, the psychiatry of the adolescent? Four key methodological points relating to the evaluation of any therapy will be examined successively: what are the therapies to be compared? Which patients are included? How do we evaluate the effectiveness of the therapies? How can we ensure that the treatment groups are comparable? In this way we will see that the evaluation of therapies in psychiatry has, in the first approximation, to do with the same methodology that is used to compare therapies in somatic medicine. Especially strong similarities can be found, for example, with approaches used for the evaluation of surgical treatments.
We will approach the question of the therapeutic effectiveness of psychotropic drugs in adolescent psychiatry from a double perspective: a meta-psychological one, using the historical works of psychiatrist-psychoanalysts, and a clinical one, using our daily practice of adolescent psychiatry. Since psychotropic drugs were introduced in psychiatry in the 1950’s, research has focused on metapsychological models of the effect of psychotropic drugs and on the place of the prescription in the transference-countertransference relation. Using clinical vignettes, we show that psychotropic medication is a tool in the relation with the adolescent, a psychotrope whose effectiveness can not be conceived of outside of the relation dynamic that is at work.
The aim of this article is to offer some thoughts about the place of the pharmacological prescription within the framework of the institutional treatment of children and adolescents who present severe psychological disorders. Far from being a simply technical approach, prescribing medication to an adolescent within an institution corresponds to the construction of a transitional space which is the fruit of the encounter between the adolescent and the staff. The action of the psychotropic drugs must be inscribed in the overall psychical economy of the subject, taking into account the relationship between medication and the question of dependence and the inevitable issues of mastery and control that this engenders in adolescence, which are amplified by the institutional setting. Lastly, it is important to emphasize that this problematic must not be seen as confined to the specific institution which receives the adolescent, but applies more widely to the different institutions and referents which deal with the adolescent in the perspective of a multi-focus treatment among institutions and a longitudinal and parallel conception of treatment.
If there one really complex subject in psychiatry, it is the prescription of medication and the analysis of its objective and subjective effects, particularly in the adolescent, for whom the use of psychotropic drugs is relatively recent, even though it has quickly expanded. The model of institutional treatment developed here rests on the theory proposed by experienced practicians: the institutional therapeutic setting is metaphorized as a transitional space. The medication is therefore conceived of as one of the concrete objects which will allow for mediation of the bond and the establishment of a common, malleable object within the transference relation with the young patient. We discuss the possible pitfalls of the prescription and try to highlight its subjective and intersubjective aspects. If the medication must allow for the containment of intra-psychical drive activity that is too overwhelming for the adolescent, it should nevertheless not be used as a tool to obtain mastery or control over him. A « well-tempered » use of psychotropic drugs would enable one to work usefully with the patient on his inner conflicts, within the institution.
Psychiatric epidemiology raises a number of problems : the necessary operationalization of what is a mental disorder ; the conceptualization of what constitutes a risk factor, etc. These problems are not entirely solvable, but are nevertheless not enough to hamper the collection and interpretation of results, some of which are presented in this article.
Adolescence is a key period in the development of brain circuits that underlie the regulation of affects and behavior. Research on neuroimaging allows for a better understanding of the courses of normal and pathological brain development in adolescence. Thus, modifications of normal development seem to be implicated in the physiopathology of disorders like schizophrenia and various forms of depression.
The avatar may be treated as a double of the self or as a companion, a guide whom one follows or a slave to whom one gives orders. But in any case, its owner is invited to engage here in three complementary forms of symbolization: sensory-motor, imaged, and verbal.
Thus it can embody a fragment of oneself, a person one has known, admired or feared, even someone that one has imagined on the basis of stories one has heard or a family legend. This exploration can enable the construction of a potential space or, on the contrary, foster disavowal. Asking a player to speak of the choice and the history of his avatar is an essential moment of psychotherapy.
Video games and educational computerprograms prove to be excellent supports for the clinical observation of behavior and of the man-machine relation. Children and video games inspire us to ask new questions about the transitional space they create. The virtual world is able to reveal how the subject interacts with his environment. What results from this are new hypotheses about the quality of perceptions and the apprehension of the object in the construction of the Ego and its emotional future.
In the past twenty years, video games have become firmly entrenched in our culture. Adolescents find in them spaces in which adolescent issues can be played out and re-played. Psychotherapists have started using them within the framework of therapeutic mediations. This paper reports the construction of a therapeutic arrangement: video game group therapy. This is conceived of as a working apparatus allowing for the stimulation and reception of affects and thoughts. This type of mediation is particularly interesting in the treatment of children and adolescents whose total inhibition initially compromises the therapeutic project. The notion of « ludo-landscape» characterizes a part of the psychical work which is summoned up by the video game. The case of Julien illustrates the work that was carried out.
Adolescence, 2009, T. 27, n°3, pp. 699-709.
Revue semestrielle de psychanalyse, psychopathologie et sciences humaines, indexée AERES au listing PsycINFO publiée avec le concours du Centre National du Livre et de l’Université de Paris Diderot Paris 7