L'emploi d'une arme à feu dirigée contre la tête est un mode suicidaire particulièrement violent et grave. L'étude clinique de 19 patients défigurés après un tel geste, hospitalisés au CHU de Rennes, a permis de dégager certains traits psychologiques chez ces suicidants ; elle a permis également de montrer l'absence de corrélation entre l'importance du délabrement facial et l'évolution sur le plan psychiatrique. La reconstruction chirurgicale s'accompagne d'un travail psychique d'élaboration : la relation privilégiée entre le patient et le chirurgien, dont le rôle paraît assimilé à une fonction maternante, et les multiples réparations chirurgicales aident à la restauration narcissique et à l'élaboration du sentiment d'identité. Cela explique en partie la rareté des récidives suicidaires et l'amélioration psychique durant toute la période de la prise en charge somatique.

Objective. - To examine the psychopathology and the future of subjects having attempted to commit suicide with firearms with resulting face wounds and who are followed by a surgery team.

Method. - Nineteen subjects having attempted suicide (18 men and one woman) were examined by liaison-psychiatric doctors, during their surgery periods at the university hospital of Rennes, between 1994 and 2001. The clinical evaluation was completed for 15 of them by the MADRS, HAD, and SAS-SR scales.

Results. - The average age was 46.2 years. Sixteen patients suffered from chronic alcoholism; seventeen had mood disorders, and only one was a schizophrenic patient. Fourteen were first-attempters. During follow-up, two men repeated a suicide attempt: one by slashing some months after the first attempt, and the other by self-poisoning two years later. Some months after the suicide attempt, the majority of patients (13/15) had a MADRS score under the limit note of depression (<15). Two out of fifteen had a score that had raised to the HAD scale level. The adaptation to the work fell in the SAS score. The psychiatric evolution of the patients with the gravest physical damages and undergoing numerous interventions, was better than that of the patients who required fewer interventions.

Psychopathology. - The face plays an essential role in the psychic development of the child; the firearm is often considered as a typically male attribute, a phallic symbol. For us, the choice of the facial destruction by a firearm shows the desire for physical violence; the attempter wants to show the others his intense psychic suffering. The suicidal behaviour can be interpreted as the desire to stop these thoughts immediately. The subject not only wishes death, but also the disappearance of his identity, through the destruction of his face. The facial reconstruction can be considered as an act of revival, a narcissistic restoration. The surgery can be likened to a maternal function. The surgeon is invested by the patient as the one who is able to restore his life; who brings him a narcissistic valuation.

Conclusion. - This study underlines the necessity of a common work between the surgical team and the psychiatrist taking care of these patients:

- the psychiatrist will allow the patients verbalization, which initially failed, and the inscription of the suicidal act in the patient's history. He brings support to the patient, to the family and also to the surgery team;

- the surgeon in a maternal role, allows the physical and narcissistic restoration.

This double medical care restores the dimension of subject to the patient, and may explain the rarity of further attempts at suicide among these patients.