La clinique des troubles séquellaires du traumatisme psychique se partage en deux options : celle du trauma comme « stress » et celle du trauma comme « rencontre avec le réel de la mort ». Ces deux options induisent des méthodes thérapeutiques différentes, la première, l’emploi de techniques cognitivo-comportementales ; la seconde, le recours à des psychothérapies psychodynamiques. À la suite d’Oppenheim, Kraepelin et surtout Freud et ses élèves est apparu le concept de névrose traumatique, toujours en vigueur chez bon nombre de psychiatres français, les psychiatres militaires, en particulier. Les Anglais, puis les Américains ont préféré le recours à la notion psychophysiologique de stress qui induit une clinique différente, celle du “Post-Traumatic Stress Disorder” (PTSD). Nous choisirons l’option « névrose traumatique » tant pour la clinique que pour le traitement. Clinique : la névrose traumatique comporte deux types de symptômes et syndromes. Nous décrirons les symptômes et syndromes pathognomoniques de la névrose c’est-à-dire ceux qui sont pris dans la répétition : cauchemars, reviviscence, réactions de sursaut. Puis, nous verrons les symptômes ou syndromes associés : anxieux, dépressifs, comportementaux, troubles des conduites, maladies psychosomatiques. Le traitement psychothérapique psychodynamique comporte dans ses prémices un parcours précis du réel de l’événement traumatique (debriefing). Puis, il s’agit de traiter la névrose au point où celle-ci a favorisé l’incrustation dans l’appareil psychique de l’image traumatique qui fait retour dans la répétition. Ce type de traitement a d’autant plus de chance de réussir qu’il a été entrepris plus tôt et avec au moins au début une prise en charge intensive.

This article begins with an observation which describes perfectly the cause of traumatic stress disorder (traumatic neurosis). Raphael is a young man engaged within the paratroopers. He is eighteen years old. He was sent with his section in Kigali to repatriate European diplomats while the Hutu slaughtered the Tutsi. From the first day, walking down a city street with a comrade, they stopped by a corpse who had his head cracked open by a blow from a machete, blood and brains flowed out of the wound. Raphael continues to speak and says: “It's odd that with all this we feel nothing”. He finished his mission normally and continued his engagement. During the last six months of his presence in the army, he was sent to Sarajevo, a town also plagued by a killing spree. He supports this with difficulty and sleeps all day when he is not on a mission. His comrades call him “Groundhog”. On his return to France, he suffered from panic attacks. He was hospitalized in the military hospital where he was followed regularly by a psychiatrist. Amongst other adventures, he tells of his encounter with the corpse of a Rwandan. On the fourth day of his presence in the hospital, he is in a state of extreme anguish: “Doctor last night, everything exploded in my head. I saw the head of the corpse with his horrible wounds; he had the face of someone who has just seen the devil himself”. Raphael told us, is that the moment of terror when with his comrade he contemplates the corpse. His comment, “It's odd that with all this we feel nothing”, shows one of the advanced features of “frightened” in that brief moment (short, here, but not in all cases) breaking thought processes accompanied by the absence of any emotion. What he saw in fact in Kigali, it is not a man dead but death itself, “the real of the death”, death as annihilation. This image reappears with violence in traumatic nightmares. In fact, this scenario is that of any traumatic event: A moment of fright when the meanings have just disappeared: there are neither words nor thoughts or memories, and emotions associated with them disappear too. It can be done, but this is not always the case, that anxiety immediately follows the trauma; it is about what the subject will remember more readily than the fear that is often reconstituted in the course of psychotherapy. In an article published in 2003 about accident victims on the road, Vaiva Brunet et al. show that PTSD appears later in the evolution of the patient if there was at that moment of fright that proves totally predictive. The English translation of the German word schreck or l’effroi in French is the use of the word fright. This word is ambiguous because it refers first to fear, and, as we have said, there is no affect here. Moreover, experience shows that traumatic neurosis (or PTSD) is constituted only if the subject has a neurotic structure as if it called the embedding of the traumatic scene in the psychic apparatus. The traumatic scene takes the place of what Freud called “the lost object” object persistence of total satisfaction in the first months of life (the mother's body). This “lost object”, the object found here again, is in the neurosis which impedes the free functioning of desire, always dissatisfied or impossible. In the tradition which goes back to Selyes concept of stress, much of modern psychiatry preferred to ignore the diagnosis of “fright” to instead refer PTSD as a causal factor. And various versions of the DSM contain all the criteria A which summarizes the etiopathologeny of a stressful experience. This is not our opinion, nor psychiatrists who take seriously the psychoanalytic thoughts. Inside this vision of stress, the treatment of PTSD addresses only the symptoms. This is to have the patient placed in a position of a substitute student, grace of suggestion; the traumatic scene becomes a calm scene. In contrast, in traumatic neurosis the psychotherapist will push the patient to revise its neurotic position relative to life and to others and to transform the injury into a process of language. We conclude with the example of the treatment of a psychotherapeutic patient. Frederick is a young steward who tried to revive a passenger taken ill during the flight. As he bent down to look at her to commence CPR, she dies under his hands, next to them a young eight-year-old boy looks with amazement. He is the son of the patient. The body is wrapped in a sheet and wedged in the toilet until the end of the flight. On arrival at the destination, the cabin crew (PNC) face the wrath of the African family as if they were guilty of a murder and after by the violation of the corpse. The PNC group decides to leave for four days in the forest to recover from their emotions. It will be a horrible trip and they are worse on their return than they were to at the departure. In Paris, the doctor of the airline decides to do a debriefing and then addresses Frederick. In the course of his psychotherapy the latter refers to the fact that he has no memory of childhood. What is his last memory? He is eight years old and he sees the car of his father, his father who is leaving his family forever. How did you live afterwards? “We were all three, my mother, my daughter and me.” The slip does not escape him (he was referring to his younger sister) and leads him to reconsider that part of his childhood and adolescence. With the help of his mother, he behaved more and more like the chef of the family until his mother's remarriage when he was 16 years old. He behaved like an impostor who was usurped from the place of the father. He didn’t support the arrival of this other man, so he left his family. Two types of problems appeared: A failing sexuality, symptom always present, and risky behavior in water sports, with two traumatic episodes. In the current trauma, he understands the impact of the presence of this child seeing his mother die under his hands. And it also emphasizes the feeling of guilt that drives him. It is usual for the PNC in those cases when they must perform medical procedures when they are not doctors although generally they are in contact with the UAS. This usurpation of a place that was not his reminded him something of his personal history. Trauma disappears in the course of this reconstruction of its history, and he will continue with psychotherapy until the amendment of his impotence. The repetition syndrome disappeared from the first interviews.