Automutilations chroniques: des patient/es difficiles

Patientinnen mit chronischer Selbstbeschädigung stellen eine Gruppe schwieriger Patientinnen dar, die häufig wenig zu einer psychiatrischen oder psychotherapeutischen Behandlung motiviert sind. Nach dem Versuch einer klinischen Einteilung wird auf ein psychoanalytisches Konzept zur Psychodynamik selbstverletzenden Verhaltens eingegangen. Abschließend wird das Schema der KOMEPP (Kontext orientierte Modellentwicklung bei einer Psychotherapieplanung) vorgestellt und mögliche therapeutische Probleme im Umgang mit dieser schwierigen Patientinnengruppe diskutiert.Schlüsselwörter: Chronische Selbstbeschädigung, Psychotherapie.atients with self mutilation behavior represent a group of difficult patients, who are often less motivated for psychiatric or psychotherapeutic treatment. After attempting a clinical classification we discuss a psychoanalytical, psychodynamic concept of self-mutilation behavior. Finally a new concept (KOMEPP) of a context oriented development of models for planning psychotherapy is presented and different psychotherapeutic problems dealing with this special group of patients are discussed.Keywords: Self-mutilation behavior, psychotherapy.Lorsqu’un/e patient/e se blesse volontairement, son environnement proche a de multiples réactions émotionnelles: consternation, sentiment d’impuissance, horreur et peur.Du fait que les patient/es souffrant de sérieux troubles de la personnalité représentent une proportion croissante de la clientèle des institutions, mais aussi des cabinets de psychothérapie, la question de savoir comment gérer adéquatement les évolutions chroniques dans lesquelles les patients s’automutilent gagne en importance. Avant d’accepter de traiter ce genre de patient en ambulatoire et dans le cadre d’un cabinet privé, il faut poser un diagnostic clair et définir sans équivoque le contexte du traitement.Nous traitons ci-dessous de la manière dont une psychothérapie peut être planifiée en fonction de l’élaboration d’un modèle tenant compte de son contexte. Cette approche doit permettre de préparer le traitement de patients difficiles en associant à sa planification leur environnement familial et psychosocial, ceci durant l’élaboration du modèle et le projet de psychothérapie déjà.La manière dont Herpertz et Sass (1994) proposent de définir l’automutilation chronique nous semble utile: “Par automutilation chronique manifeste, on entend toutes les blessures physiques que le/la patient/e s’inflige, exception faite de celles qui visent à entraîner la mort. Le patient comme ses proches savent que c’est celui-ci qui a causé la blessure.” Cette définition exclut les comportements qui ont des effets néfastes indirects (fumer, par ex.), ainsi que l’abus de nourriture ou de boissons nuisibles à la santé.Du point de vue clinique, on effectue une distinction entre des formes relativement peu sérieuses (coupures superficielles, petites brûlures, égratignures, morsures, coups sur la tête ou les extrémités, manipulation de plaies, brûlures causées par des substances alcalines ou acides, trichotilomanie, extraction d’ongles etc.) et d’autres formes plus graves (ablation de l’œil, castration, mutilation des mamelons, amputation d’une extrémité).De notre point de vue, il faut inclure dans cette catégorie diagnostique les comportements autodestructeurs qui provoquent des atteintes physiques: infection ou lésions dermiques artificielles, saignements, ainsi que les hypo- et hyperglycémies provoquées sciemment par des patients diabétiques, etc.Le service de traitement ambulatoire des automutilations chroniques établi dans le cadre de la Clinique universitaire de psychologie des profondeurs et de psychothérapie de l’Université de Vienne a développé un schéma, sur la base duquel une psychothérapie peut être planifiée- la “Kontextorientierte Modellentwicklung bei einer Psychotherapieplanung”, KOMEPP (Schuster et al., 1998, en préparation). L’utilisation de ce schéma permet souvent de créer les conditions rendant possible l’offre d’un traitement psychothérapeutique à ce groupe de patients difficiles.Lors du processus menant à un premier entretien on tente de définir, avec le/la patient/e, les variables qui vont favoriser le traitement. La discussion des problèmes se fait sur des bases multiprofessionnelles et multiécoles et tente de saisir les points saillants du contexte. Ceci implique que les professionnels qui se sont déjà occupés du patient (médecins, assistantes sociales, psychothérapeutes) et les personnes appartenant à son contexte social (famille, enseignants, assistants sociaux etc.) collaborent directement à l’élaboration d’un modèle de psychothérapie. Durant la phase qui précède la planification du traitement, toutes les personnes faisant partie de l’environnement du patient participent donc à la discussion, ce qui permet de préparer un modèle individuel de traitement.Une planification soigneuse de la psychothérapie permet ensuite d’appliquer ce modèle. Les patient/es souffrant de sérieux troubles de la personnalité sont souvent incapables de gérer la thérapie. Lorsque des problèmes se présentent dans leur environnement social, leur famille, avec leurs enfants, etc. ce sont souvent une assistante sociale ou un médecin qui assument cette fonction. L’unique possibilité de mener une psychothérapie avec ces patients difficiles implique fréquemment que l’on confie à une personne 'externe’ la tâche de gérer le traitement, de le coordonner et de servir de 'centre de décision’. Du point de vue de son contenu, nous considérons qu’une thérapie d’orientation psychanalytique doit viser à mettre en évidence les aspects ayant une fonction psychologique qui sont contenus dans les actes d’automutilation. Le patient qui se voyait contraint d’agir (dans un sens destructif) doit pouvoir faire l’expérience de et verbaliser ces contenus, découvrant leur signification dans le cadre d’une interaction avec le thérapeute. Initialement, il va sans doute refuser cette signification; mais en cours de thérapie, elle pourra être intégrée dans l’ensemble de sa personnalité. Du fait que les patient/es dont nous parlons souffrent souvent de graves troubles de la personnalité, les pronostics ne peuvent pas être trop optimistes - et pourtant une psychothérapie à long terme représente souvent la seule chance de traitement

Forty years of increasing suicide mortality in Poland: Undercounting amidst a hanging epidemic?

Abstract Background Suicide rate trends for Poland, one of the most populous countries in Europe, are not well documented. Moreover, the quality of the official Polish suicide statistics is unknown and requires in-depth investigation. Methods Population and mortality data disaggregated by sex, age, manner, and cause were obtained from the Polish Central Statistics Office for the period 1970-2009. Suicides and deaths categorized as ‘undetermined injury intent,’ ‘unknown causes,’ and ‘unintentional poisonings’ were analyzed to estimate the reliability and sensitivity of suicide certification in Poland over three periods covered by ICD-8, ICD-9 and ICD-10, respectively. Time trends were assessed by the Spearman test for trend. Results The official suicide rate increased by 51.3% in Poland between 1970 and 2009. There was an increasing excess suicide rate for males, culminating in a male-to-female ratio of 7:1. The dominant method, hanging, comprised 90% of all suicides by 2009. Factoring in deaths of undetermined intent only, estimated sensitivity of suicide certification was 77% overall, but lower for females than males. Not increasing linearly with age, the suicide rate peaked at ages 40-54 years. Conclusion The suicide rate is increasing in Poland, which calls for a national prevention initiative. Hangings are the predominant suicide method based on official registration. However, suicide among females appears grossly underestimated given their lower estimated sensitivity of suicide certification, greater use of “soft” suicide methods, and the very high 7:1 male-to-female rate ratio. Changes in the ICD classification system resulted in a temporary suicide data blackout in 1980-1982, and significant modifications of the death categories of senility and unknown causes, after 1997, suggest the need for data quality surveillance.</p

Forty Years Of Increasing Suicide Mortality In Poland: Undercounting Amidst A Hanging Epidemic?

BACKGROUND: Suicide rate trends for Poland, one of the most populous countries in Europe, are not well documented. Moreover, the quality of the official Polish suicide statistics is unknown and requires in-depth investigation. METHODS: Population and mortality data disaggregated by sex, age, manner, and cause were obtained from the Polish Central Statistics Office for the period 1970-2009. Suicides and deaths categorized as ‘undetermined injury intent,’ ‘unknown causes,’ and ‘unintentional poisonings’ were analyzed to estimate the reliability and sensitivity of suicide certification in Poland over three periods covered by ICD-8, ICD-9 and ICD-10, respectively. Time trends were assessed by the Spearman test for trend. RESULTS: The official suicide rate increased by 51.3% in Poland between 1970 and 2009. There was an increasing excess suicide rate for males, culminating in a male-to-female ratio of 7:1. The dominant method, hanging, comprised 90% of all suicides by 2009. Factoring in deaths of undetermined intent only, estimated sensitivity of suicide certification was 77% overall, but lower for females than males. Not increasing linearly with age, the suicide rate peaked at ages 40-54 years. CONCLUSION: The suicide rate is increasing in Poland, which calls for a national prevention initiative. Hangings are the predominant suicide method based on official registration. However, suicide among females appears grossly underestimated given their lower estimated sensitivity of suicide certification, greater use of “soft” suicide methods, and the very high 7:1 male-to-female rate ratio. Changes in the ICD classification system resulted in a temporary suicide data blackout in 1980-1982, and significant modifications of the death categories of senility and unknown causes, after 1997, suggest the need for data quality surveillance

Suicide risk after psychiatric discharge : study protocol of a naturalistic, long-term, prospective observational study

Background: Suicide risk of psychiatric patients has proven to be strongly increased in the months after discharge from a psychiatric hospital. Despite this high risk, there is a lack of systematic research on the causes of this elevated suicide risk as well as a lack of treatment and intervention for patients at high risk after discharge. The main objective of this pilot study is, firstly, to examine the factors contributing to the elevated suicide risk and, secondly, to investigate whether an additional setting of care starting at discharge may reduce suicidality. Methods: In this multi-centre pilot study, treatment as usual is complemented by an additional 18-month post-discharge setting of care for psychiatric patients at high risk for suicide. Two groups of patients differing in the amount of post-discharge personal contacts will be compared. One group of patients will be offered continuous personal contacts after discharge (months 1–6: monthly contacts; months 6–18: every 2 months) while another group of patients will receive contacts only at months 6, 12, and 18 after discharge. Data on suicidality, as well as associated with other symptoms, treatment, and significant events, will be collected. In the case of health-related severe events, the setting of care allows the patient to have the opportunity to connect with the doctor or therapist treating the patient. Discussion: The results of this study will contribute to identifying critical factors raising suicide risk after discharge and will demonstrate the potential influence on suicide prevention of a setting of care with regular personal contact after discharge

Suicide risk after psychiatric discharge: study protocol of a naturalistic, long-term, prospective observational study

Background!#!Suicide risk of psychiatric patients has proven to be strongly increased in the months after discharge from a psychiatric hospital. Despite this high risk, there is a lack of systematic research on the causes of this elevated suicide risk as well as a lack of treatment and intervention for patients at high risk after discharge. The main objective of this pilot study is, firstly, to examine the factors contributing to the elevated !##!Methods!#!In this multi-centre pilot study, treatment as usual is complemented by an additional 18-month post-discharge setting of care for psychiatric patients at high risk for suicide. Two groups of patients differing in the amount of post-discharge personal contacts will be compared. One group of patients will be offered continuous personal contacts after discharge (months 1-6: monthly contacts; months 6-18: every 2 months) while another group of patients will receive contacts only at months 6, 12, and 18 after discharge. Data on suicidality, as well as associated with other symptoms, treatment, and significant events, will be collected. In the case of health-related severe events, the setting of care allows the patient to have the opportunity to connect with the doctor or therapist treating the patient.!##!Discussion!#!The results of this study will contribute to identifying critical factors raising suicide risk after discharge and will demonstrate the potential influence on suicide prevention of a setting of care with regular personal contact after discharge.!##!Trial registration!#!ZMVI1-2517FSB135 - funded by the German Federal Ministry of Health

The gap between suicide characteristics in the print media and in the population

Background: Programmes to educate media professionals about suicide are increasingly established, but information about which suicide cases are most likely to be reported in the mass media is sparse. Methods: We applied binomial tests to compare frequencies of social characteristics of all domestic suicides in the 13 largest Austrian print media in 2005 with frequencies of suicide characteristics in the population. Additionally, each reported suicide case was linked to its respective entry in the suicide database. We performed a logistic regression analysis, with presence of an article as outcome, and sex of the suicide case, age, religious affiliation, family status, conduction of an autopsy and location of the suicide as explaining variables. Time of the year and federal state where the suicide happened was controlled for. Results: Binomial tests showed that suicides involving murder or murder attempt were over-represented in the media. Reporting on mental disorders was under-represented. In the regression analysis, the likelihood of a report was negatively associated with the age of suicide cases. Foreign citizenship was a further predictor of a suicide report. The methods of drowning, jumping, shooting and rare methods were more likely to be reported than hanging, which is the most frequent suicide method in Austria. Conclusions: Suicide characteristics in the media are not representative of the population. The identified discrepancies provide a basis for tailor-made education of mass media professionals