Les Troubles Dépressifs Persistants (TDP) sont fréquents et invalidants et leur prise en charge thérapeutique est confrontée à un taux élevé d’échec ou de rémission partielle : on estime que la moitié des patients ne répondent pas aux interventions thérapeutiques habituelles. La théorie de l’attachement souligne l’effet des représentations insécures des relations dans l’apparition et le maintien des TDP. Cette revue de littérature présente les liens entre TDP et attachement insécure, en particulier l’attachement ambivalent, et note le caractère protecteur de la sécurité d’attachement sur le développement ultérieur de TDP. Intégrer l’attachement dans la compréhension des TDP met en évidence la nécessité de mener des études expérimentales sur les approches thérapeutiques qui reposent sur ce concept.Le texte complet de cet article est disponible en PDF.
Persistent depressive disorders (PDD) are frequent and disabling and their therapeutic management remains poorly defined. Attachment theory highlights the effect of insecure representations of relationships in the development and maintenance of PDD. The aim of this literature review is to identify the main findings regarding the place of attachment in persistent depressive disorders (PDD) to show the interest of this framework as an explanatory model of PDD and to determine the usefulness of taking attachment into consideration in the therapeutic intervention for the treatment of PDD. The current treatment of PDD faces a high rate of either failure or partial remission. Almost half of depressed patients do not achieve remission or develop chronic residual symptoms. Although there is a specific therapy built for PDD (CBASP), there is currently no psychotherapy that has been sufficiently scientifically verified to be recommended for PDD. Interpersonal difficulties seem to play a major role in the maintenance of a depressive state: the difficulty in establishing a therapeutic relationship would explain why patients with PDD often show a poor therapeutic response to traditional psychotherapies, including cognitive behavioural therapy (CBT). In addition, some characteristics that make treatment difficult may be a consequence of childhood maltreatment, in particular emotional abuse, and neglect, that are risk factors for early depression with a chronic course. Furthermore, insecure attachment is a major risk factor of severity or persistence of psychopathological disorders. Conversely, secure attachment reduces the risk of developing these symptoms. Empirical research has shown links between insecure attachment and specific psychological disorders. Insecure attachment is associated with internalizing disorders, including depression, in childhood and in adulthood. Insecure attachment is clearly associated with depressive symptoms. This relationship is mediated by several variables such as self-esteem, disrupted social and relational skills depressive cognitions and early maladaptive schemas. Taken together, these findings suggest that attachment is an important risk factor in the development of psychopathology, in particular depressive disorders. Therefore, Bosmans suggests that the integration of attachment into psychotherapies would enhance their effectiveness. Attachment should therefore be considered as an important target of clinical intervention to treat the symptoms of PDD and there seems to be a need to develop this therapeutic approach to determine the extent to which a treatment protocol can focus specifically on attachment for chronically depressed patients. Studies of attachment psychotherapies consider attachment style both as a predictor of treatment outcome and as an indicator of therapeutic orientation. The patient's attachment representations and behaviours can influence the therapeutic process and the relationship with the therapist, which means identifying them to use specific strategies: therapeutic techniques relevant to one attachment style may be problematic for another. These considerations show the need for research that considers the relationship between PDD symptoms and patients’ attachment styles at the beginning of therapy to verify which attachment patterns are related to this specific pathology and to determine the influence of patients’ attachment patterns on the therapeutic process. Finally, innovative therapies such as Integrated Attachment Therapy, that consider attachment as the foundation of the therapeutic process, are being developed and form a new care offer that seems promising for the treatment of PDD.Le texte complet de cet article est disponible en PDF.
Mots clés : Affection de longue durée, Attachement, Dépression, Prise en charge, Revue de la littérature
Keywords : Attachment, Depression, Literature review, Long-term disorder, Therapeutic management