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Thérapie des schémas chez la personne âgée déprimée - 06/04/13

Doi : 10.1016/j.jtcc.2012.10.002 
Sophie Kindynis a, , Margaux René b
a Service universitaire de psychiatrie de l’adulte et du sujet âgé, hôpital Corentin-Celton, 4, parvis Corentin-Celton, 92133 Issy-les-Moulineaux, France 
b Université Paris Ouest Nanterre-La-Défense, 200, avenue de la République, 92001 Nanterre Cedex, France 

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Résumé

La fréquence des troubles dépressifs chez les personnes âgées, associée à l’accroissement de la durée de vie, augmente la nécessité de leur proposer une aide psychothérapeutique adaptée. La validité reconnue des thérapies comportementales et cognitives (TCC) pour cette population, nécessite des adaptations à ses besoins spécifiques. Parmi les particularités cognitives, les schémas dépressifs typiques enrichissent nos connaissances et nos pratiques thérapeutiques. Cet article a pour objectif de présenter une synthèse de travaux sur l’adaptation de la TCC aux spécificités de la personne âgée, en y soulignant l’intérêt de la thérapie centrée sur les schémas ainsi que l’intérêt de la modalité groupale.

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Summary

The frequency of depressive disorders and the higher risk of suicide (Harwood et al., 2001 [13]) in older adults increase the need for appropriate psychotherapeutic help. Cognitive behavioral therapy (CBT) is effective in treating older adults (Laidlaw et al., 2003 [3], Steuer et al., 1984 [7], Stanley et al., 1996 [8], Koder et al., 1996 [9]), individually or in a group (Laidlaw et al., 2003 [3], Engels and Verney [10]), provided that it is adapted to suit their specific needs. The specific depressive schemas approach which, up until now, has been little researched, is a very interesting modification.

Characteristics of depression in older adults

The first aspect is the difficulty in diagnosis with an underrated frequency (Helmer et al., 2004 [14]), especially in those above 80s (Frémont, 2004 [15]): the acceleration of somatic comorbidities complexifies depression and its diagnosis (Alexpoulos, 2005 [18]). Specific depressive themes have been identified (THompson, 1996 [20] Laidlaw et al., 2004 [21]), notably relating to loss and transition. The associated cognitions may activate latent dysfunctional schemas and promote depression. Tison and Hautekeete, 2001, 2005 and 2007, [23, 24, 25] confirmed the hypothesis of the presence of two dysfunctional cognitions in the depressed older adult: the trivialization of depressive symptoms and the inability to changed due to aging. They showed the activation of these automatic thoughts towards the age of 60, as well as the effectiveness of cognitive restructuring specifically targeting these two cognitions. Interest in Young’s model of aging (1990 and 2005 [26, 27]) in early maladaptive schemas (EMS), risk factors of depression, was confirmed by Antoine et al. (2007 and 2008 [29, 30, 31]): typical depressive schemas are activated due to the specific conditions of aging. He validated the Cognitive Inventory of Subjective Distress (CISD) which assesses seven schemas: four which are similar to early maladaptive schemas (fear of loss of control, dependency, vulnerability, abandonment) and three specific to the older adult (loss of individuality, refusal of help and disengagement).

Adapting CBT to these characteristics

Greater flexibility of the framework is recommended and the usual approaches must be overcome (Evens, 2007 [19]). The potential loss of certain abilities leads to the need to reformulate and summarize more often. Faced with frequent somatic and anxiety disorders, it is necessary to set realistic treatment goals, while targeting the dysfunctional cognitions is likely to lead to behavioral limitations. Psychoeducation must be intensified, emphasizing in particular the joint role of medication and psychotherapy, and the importance of patient involvement. Discussion on pyschoeducative topics improves the therapeutic alliance by reducing the passive attitude of the patient towards treatment. Functional analysis focuses on the exploration of cognitions relating to problem areas of aging. Along with typical depressive schemas, attention is also paid to personality schemas that translate into chronic difficulties likely to reinforce depression. The therapeutic tasks take into account the physical limitations which sometimes lead to focusing on primarily cognitive work (Evans, 2007 [19]). If the cognitive tasks are difficult, particularly for very elderly patients, an integrative approach is more favorable (Bizzini, 2000 [34]), centering on life retrospection, accessing personal values and schemas (Beck et al., 1979 [11], Raskind, 1992 [35]).

Schema therapy and group therapy: therapeutic interest and proposals

Hospitalization is conducive to psychotherapy (Stanley et al., 2003 [40]), consisting of group sessions and individual interviews. The comportmental tasks associated with cognitive work stimulate the patient is involvement in activities and interpersonal exchanges. Sharing in a group on topics of despair and suicide can reduce feelings of shame and isolation. Group therapy is effective in the long term for the elderly (Krishna et al., 2011 [41]). It favors decentration (Bizzini and Favre, 1999 [42]) by cognitive restructuring facilitated by peer proposals, increasing social links. Early maladaptive schemas underlie personality disorders. The frequency of personality disorders in older adults, combined with difficulty in diagnosis (Widiger and Seidlitz, 2002 [44]), emphasizes the importance of studying their characteristics. This allows us to define modifications that are likely to increase the effectiveness of the treatment. The validation study of CISD (Antoine et al., 2008 [31]) is unique, which justifies further studies on larger samples, to gain better understanding of the links between schemas and psychopathological symptoms. Knowledge regarding the effectiveness of CBT in older adults is restricted to relatively young subjects (between 60 and 80 years old), while the very old population continues to grow. Although somatic modifications accelerate and the risk of suicide is increased (Harwood et al., 2001 [13]) in this population, it seems paradoxical that psychotherapy is rarely offered even when there is a diagnosis of depression.

Conclusion

In the treatment of depressive disorders in the older adult, psychotherapy, particularly group therapy, targeting schemas promotes change by helping develop more positive attitudes which lead to better commitment to activities, relationships and the future. Improvement observed in the patient’s condition is obviously related to the psychiatric treatment as a whole, where medication and hospital environment play a major role. It would seem desirable to involve older adults in psychotherapy, adapting it to their particular needs.

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Mots clés : Dépression, Détresse, Personne âgée, Schéma, Thérapie comportementale et cognitive, Thérapie de groupe, Traits de personnalité

Keywords : Cognitive behavior therapy, Depression, Distress, Elder persons, Group psychotherapy, Personality traits, Schema


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Vol 23 - N° 1

P. 31-38 - mars 2013 Retour au numéro
Article précédent Article précédent
  • Estime de soi et bien-être émotionnel des élèves en difficulté scolaire : une étude en vie quotidienne
  • Reda Salamon, Mathilde M. Husky, Joel D. Swendsen
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  • Bien gérer son temps, C. Mirabel-Sarron, N. Chidiac. Odile Jacob, Paris (2012). 272 pp.
  • Jacques Van Rillaer

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