La relation entre traumatisme psychique et trouble psychotique est un enjeu de la recherche clinique depuis une trentaine d’années. L’actualisation des critères diagnostiques du Trouble Stress Post-Traumatique (TSPT) dans la cinquième édition du Diagnostic and Statistical Manual of Mental disorders (DSM5) a réaffirmé la considération du psychotraumatisme comme événement externe à l’individu et objectivable. Pour autant, la détresse d’un patient suite à une décompensation psychotique transparaît dans les entretiens médicaux en pratique clinique et le champ lexical du trauma se retrouve employé dans les observations sémiologiques. Ces éléments ont conduit à la description d’un TSPT post-psychotique (TSPT-PP), questionnant l’identification du vécu subjectif du patient face à l’expérience de sa psychose.

Afin de mieux appréhender les enjeux et limites d’une potentialité traumatique subjective de l’épisode psychotique, cette revue de la littérature propose de faire l’état des connaissances actuelles autour du TSPT-PP.

Après un intérêt premier pour les dimensions épidémiologiques de ce trouble, nous abordons les éléments sémiologiques observables au décours d’un épisode psychotique interrogeant une clinique post-traumatique. Nous développons l’intrication psychopathologique du TSPT et de la psychose au travers de l’application d’un modèle cognitif du TSPT. Après une brève analyse critique des études exploitées et du concept même de TSPT-PP, son impact pronostique et thérapeutique est discuté.

Le TSPT-PP questionne la notion de subjectivité dans l’expérience traumatique. Ce trouble, bien que non consensuel, est actuellement sous-estimé alors que la littérature permet de documenter des données cliniques et psychopathologiques pour sa prise en charge.

The update of the Post-Traumatic Stress Disorder (PTSD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5) emphasizes the definition of psychological traumatism as an objective and external event. Nevertheless, the scientific debate about the criteriology of PTSD, its clinical pertinence for application and the role of subjective dimension appears still open. Although the relation between psychotrauma and psychosis has been well examined, in the way of trauma as a risk factor for the development of schizophrenia, the potential traumatism represented by the psychotic experience seems to be less known.

This paper aims to provide a state of the art about the PTSD in reaction to psychosis, defined as PTSD post psychosis (PTSD-PP), particularly in epidemiological and psychopathological terms.

We performed a bibliographic research on Pubmed using the keywords “post-traumatic stress disorder”, “psychological trauma”, “schizophrenia review”, “psychosis”, “first episode psychosis”« », “recovery schizophrenia”, with a first screening on titles and abstracts. An acute psychotic episode referred to a decompensation of any pathology of the DSM5-schizophrenia spectrum or other psychotic disorders or to a mood disorder with psychotic features. The articles exclusively interested in the traumatic impact of hospitalizations and treatment conditions were excluded.

The literature noted that PTSD-PP affected about a quarter to a third of the psychotic patients interrogated during the recovery of an acute psychotic episode. The analytic epidemiology showed that the main validated risk factors for PTSD were also relevant in the development of PTSD-PP, including past traumatic history, childhood trauma and feeling of helplessness during the traumatic event. Criticizing the methodological heterogeneity through studies, the observational approach brought out the lack of clinical pertinence of the DSM5A criteria defining the traumatic event for PTSD. This criteriology failed to consider the subjective dimension of the threat to psychological integrity generated by a psychotrauma. Historical case studies presented a complete post-traumatic symptomatology in reaction to psychosis, suggesting that the supposed psychotic residual symptoms after acute phase could referr to actual traumatic reactions. The PTSD-PP process observed in descriptive research and patients’ interviews appeared congruent with the cognitive model of PTSD elaborated by Ehlers and Clark. Indeed, psychotic patients developed negative appraisals about themselves, others and the world because of the occurrence and the content of their psychotic symptoms. Shame, fear of recurrence, intolerance to uncertainty and perception of losing control of one's mind were demonstrated as significantly related to PTSD-PP. A perception of current threat then settled, leading to adaptation strategies, possibly psychotic themselves, to avoid intrusions and others indices about their past psychotic episode. Thus, reliving syndrome, avoidance, emotional numbing could simulate a new psychotic exacerbation to an outer-observer.

A psychotic experience could be traumatic for patients and lead to complete PTSD. Although it appears as a non-consensual clinical entity, from a likely epistemological slip of the definition of “psychotrauma”, the consideration of potential PTSD-PP presents an undoubted clinical relevance. Indeed, it could help practioners to precise the semiological analysis of patients recovering from an acute psychotic episode; to impact the prognosis of psychosis, thinking about impairment on the quality of life and the affective and suicidal comorbidities; and to modify the therapeutic approach in the recovery of schizophrenia. In addition, the literature about psychotic recovery seems particularly related to the concept of “post-traumatic growth” (PTG). The inscription of a psychotic episode in a traumatic frame requires a clinical approach as close as possible to the subjectivity of the patient experience, beyond the evaluation of psychotic symptoms and its remission. The question of trauma-focused therapies applied to PTSD-PP opens the field for future research.