Trouble bipolaire, auto-stigmatisation et restructuration cognitive : une première tentative de prise en charge - 15/12/17
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Résumé |
Les personnes souffrant de troubles psychiques subissent fréquemment une stigmatisation sociale. Elles ont également tendance à s’auto-stigmatiser, c’est-à-dire qu’elles-mêmes intègrent des attitudes négatives à l’égard de leur propre condition. Dans le domaine de la psychose, la problématique de l’auto-stigmatisation est de plus en plus considérée. En revanche, cette problématique reste sous-évaluée chez les personnes souffrant d’un trouble bipolaire. Les conséquences en sont pourtant importantes : la culpabilité, la honte, le repli sur soi et le renoncement à mener sa vie selon ses propres valeurs et croyances péjorent la qualité de vie des personnes, y compris celles qui sont euthymiques depuis plusieurs années. De plus, l’auto-stigmatisation augmente le risque de rechutes thymiques et de ré-hospitalisations. Actuellement, peu de stratégies thérapeutiques ont été évaluées et les données disponibles s’adressent essentiellement aux personnes souffrant de schizophrénie. À travers la description d’un cas clinique, nous présentons une intervention de restructuration cognitive des croyances auto-stigmatisantes, qui pourrait s’avérer une stratégie thérapeutique bénéfique pour faire face à l’auto-stigmatisation.
Le texte complet de cet article est disponible en PDF.Summary |
Self-stigmatization of people with bipolar disorder is an underestimated problem. However, it is probably equally significant for schizophrenia (Andrews et al., 2002; Sarisoy et al., 2013). For all the patients, including euthymic patients, self-stigmatization decreases thymic stability and, more globally, the quality of life (Levy et al., 2015). Indeed, it affects the evolution of bipolar disorder (more relapses, more frequent hospitalizations, more intense symptoms…) (Levy et al., 2015) and alters interpersonal relationships (Cerit et al., 2012; Hayward et al., 2002). Moreover, the frequently co-morbid social anxiety of bipolar disorder is the consequence of self-stigmatization and chronic feelings of shame and decline in self-esteem (Aydemir et al., 2011; Brohan et al., 2011). A good therapeutic alliance is insufficient to improve self-stigmatization of patients (Kondrat et al., 2010). In 1999, Holmes and River presented coping strategies for the individual management of self-stigmatization and in 2010 Larson and Corrigan empirically proposed an example of cognitive-behavioral therapy focused on self-stigmatization in a person with depression. Currently, few therapeutic strategies have been evaluated to treat self-stigma in bipolar disorder (Yanos et al., 2015). This article describes cognitive restructuring on self-stigmatization for a patient suffering from bipolar disorder. The case presented concerns a 52-year-old woman, divorced and the mother of three children. She is an Italian teacher. The patient has not taught since 2008 and has received a 100% disability pension since 2011, because of a bipolar disorder. Since the last hospitalization in 2010, the patient is euthymic. Since 2012 she has followed no treatment. However, despite this stability, this patient repeatedly referred to the “shame she feels to be bipolar”. It was postulated that self-stigmatizing thoughts are negative automatic thoughts. An intervention focused on self-stigmatization was proposed. Restructuring cognitive strategies were used. First, psychoeducation about stigmatization and self-stigmatization, and after several self-observing exercises exploring self-stigmatizing thoughts, work was carried out with the patient on cognitive distortions, which underlay her negative thoughts. Finally, for exposition, a holiday project was targeted: the patient wished to go on a trip to Egypt but refused because she felt guilty and illegitimate to take holidays. Following cognitive restructuring, she was able to go on holiday with her family, serenely. More generally, the patient evolved from the “why try?” effect (Corrigan et al., 2009) to the “And why not?”. Finally, she considered the experience of the disease as a positive social identity (Michalak et al., 2011) and she is going to do a training course to become a peer-helper. This work demonstrated the feasibility of cognitive restructuring for the management of self-stigmatization. The discussion on public stigmatization and self-stigmatization is essential: the patient can then correctly identify his self-stigmatizing thoughts and begin effective cognitive restructuring. The ability to discuss allows the establishment of a strong and deep therapeutic link. However, this is a clinical case. Only our clinical evaluation and the subjective real-life experience of improvement of the patient allow a description of the benefits of this intervention. In the future, it is important to develop clinical trials to characterize the impact of this intervention of the quality of life and the course of the disorder. Often unrecognized and little considered by therapists, the self-stigmatizing thoughts of people with bipolar disorder severely affect their quality of life and increase the risk of relapse. Identifying these beliefs and qualifying them by using cognitive restructuring seems to be a beneficial strategy to erase shame and withdrawal. Other studies will be necessary in the future to estimate more exactly the impact of this approach so that people suffering from bipolar disorder can live according to their values and faith.
Le texte complet de cet article est disponible en PDF.Mots clés : Trouble bipolaire, Thérapie cognitive, Stigmatisation, Restructuration cognitive
Keywords : Bipolar disorder, Cognitive therapy, Stigmatization, Cognitive restructuring
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Vol 27 - N° 4
P. 177-183 - novembre 2017 Retour au numéroBienvenue sur EM-consulte, la référence des professionnels de santé.
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