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Formes cliniques des dépressions post-traumatiques - 02/10/15

Doi : 10.1016/j.encep.2014.07.005 
Y. Auxéméry
 Service médical de psychologie clinique appliquée à l’aéronautique, hôpital d’instruction des Armées Percy, 101, avenue Henri-Barbusse, BP406, 92141 Clamart, France 

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Résumé

Grâce à notre activité clinique confrontée aux données critiques de la littérature internationale, nous définissons différents cadres cliniques et étiopathogéniques de dépressions post-traumatiques afin de mieux diriger leurs prises en charge thérapeutiques. Après quelques rappels épidémiologiques suivis de la discussion des entités nosographiques contemporaines dépressives et post-traumatiques, nous définissons les concepts de dépression post-traumatique sans et avec caractéristiques psychotiques, de dépression masquée par les doléances somatiques issues des blessures physiques concomitantes au trauma psychique (blessures parfois commotionnelles cérébrales) et de dépression intégrant un deuil différemment qualifiable de traumatique ou de post-traumatique.

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Summary

Introduction

As a result of determinants specific to the psychopathological structure of the psychological trauma, psycho-traumatised patients very rarely solicit the health care system directly with a request for treatment centred on their trauma. The medical profession is consulted for non-specific symptoms and complications, which are mainly somatoform, addictions and depressive disorders. After a few epidemiological reminders followed by a discussion concerning contemporary depressive and post-traumatic nosographic features, we define, through our clinical experience collated with the data in the literature, different clinical and etiopathogenic contexts of post-traumatic depression in order to control their therapeutic treatment.

Clinical findings

Burnout post-traumatic depression in response to re-experiencing is the most common: it is a reactive psycho-physiological burnout in response to the emotional distress re-experienced during flashbacks, insomnia, a constant feeling of insecurity and the deleterious consequences of this symptomatology in terms of social adaptation. A common genetic predisposition affecting serotoninergic regulation seems to be a vulnerability marker of both depressive and psychotraumatic symptoms. In this case, SSRI will be effective on sadness. In addition, these antidepressants have been widely prescribed for the first-line treatment of depressive and psychotraumatic symptoms. However, this pharmacological class is often insufficient in relieving autonomic hyperactivity such as re-experiencing which are mediated more by noradrenergic hyperactivity. SNRI such as venlafaxine can be used as a first-line treatment. Post-traumatic depression with psychotic features congruent with mood is dominated by a feeling of incurability; the subject blames himself and feels guilty about the traumatic event and its consequences. Symptoms of denial of identity are sometimes observed: confined by an intense depersonalization, the psycho-traumatised subject evokes that he is “no longer himself” and that his mind “is disconnected”. Confronted with the psychological emptiness of the traumatic scene, the psycho-traumatised subject remains devoid of thought as if their mind has left him. In addition to antidepressant therapy, an atypical antipsychotic drug must be prescribed to relieve the melancholic symptoms as well as the concomitant psychotraumatic symptoms. Post-traumatic depression masked by peripheral physical injuries is the result of accidents combining psychological and physical impairment. The physical pain resulting from the accident regularly recalls the drama in the same way as traumatic re-experiencing. Depression masked by this somatic suffering is difficult to diagnose, but the repeated somatic complaints at the forefront of the request for treatment, the breakdown of self-esteem as well as the level of subjective strain due to pain and dysesthesia are all indications. The psychotherapy will focus on the symbolic reconstruction of the organs that have been damaged or destroyed, with the aim of healing the extensive narcissistic impairment. Post-concussive depression is diagnosed following a head trauma, however severe. It is sometimes assigned to neurological lesions and at other times recognised as the expression of a purely psychological reaction. Antidepressant therapy, or possibly trial therapy, is often indicated. The terms traumatic grief and post-traumatic grief are often used synonymously in publications: a conceptual opposition must however been recalled. If the traumatic grief is the result of the loss of an object that holds much psychological importance for the individual, the subject has not however been traumatised by this event and is not suffering and will not suffer from re-experiencing. The therapy will include methods used in the psychotherapeutic treatment of grief; antidepressants are often insufficient. Differently, post-traumatic grief takes shape when the loss of another is concomitant with the confrontation with the reality of the death witnessed in a moment of peri-traumatic dissociation. This grief is often observed following the discovery of the body of a close friend or family member who has committed suicide, or when part of a family has been decimated by an accident whilst the survivors watch their close relations die pending the arrival of the emergency services, or when a military comrade is wounded in combat in front of his partner. The mourning process cannot really begin until the flashbacks cease.

Conclusions

Clinical depression or even melancholia, possibly masked by somatic or post-concussive complaints, is often the initial mode of contact with the health care system for the psycho-traumatised subject. The different clinical and etiopathogenic contexts of post-traumatic depression that we have developed in this work use specific therapies which need to be clarified by further research based on this nosography.

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Mots clés : Traumatisme psychique, Dépression traumatique, Dépression post-traumatique, Dépression masquée, Syndrome post-commotionnel, Deuil traumatique, Deuil post-traumatique, Psychopathologie, Psychopharmacologie

Keywords : Psychic trauma, Traumatic depression, Posttraumatic depression, Post-concussive syndrome, Traumatic grief, Posttraumatic grief, Psychopathology, Psychopharmacology


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© 2014  L’Encéphale, Paris. Publié par Elsevier Masson SAS. Tous droits réservés.
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Vol 41 - N° 4

P. 346-354 - septembre 2015 Retour au numéro
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