A debate between a lacanian point of view and a freudian point of view, beyond the controversies about technique, deals with the nature of the "clinical" in the therapeutic process. The nature of unconscious fantasy is at the core of this question. From a criticism of the biological hypothesis, in the drive, the object of fantasy may be considered, not as a representation of the other but as the use of the representation of any other as characters in scenarios which are present in Psychic Reality, i.e. as hallucinatory representations of actions. (c) 2005 Elsevier SAS. Tous droits reserves.

Le statut professionnel de psychothérapeute et les procédures d'évaluation des résultats sont deux sujets actuels particulièrement impliqués dans un débat politique. Il est nécessaire de les replacer dans le champ scientifique mais la tâche demeure difficile en raison de l'ambiguïté liée à la question permanente de la relation entre normalité et pathologie. Néanmoins, nous devons conserver le concept de psychothérapie dans le domaine de la santé mentale. Nous présentons quelques propositions pour justifier cette position et préciser les exigences méthodologiques pour une politique d'évaluation correcte.

Le terme insight a connu en psychopathologie un destin singulier. À partir de ses origines allemandes et anglaises, il signifiait « perception, intuition » et c’est en ce sens qu’il a été utilisé dans la psychiatrie de langue anglaise et aussi dans l’œuvre de Freud lui-même. C’est par un faux-sens que la clinique française, particulièrement psychanalytique, lui a conféré la signification d’une perception de soi, d’un regard tourné vers l’intérieur. De ce faux-sens est née une clinique particulièrement riche dont il est fait ici une brève description.

Following a preceding study, two samples of patients, one French (N = 20) and one American (N = 29), from two affective disorders clinics, were given free word-association tests consisting of two successive presentations of the same list of stimulus words separated by a 15 minute interval. On the one hand, commonness of word responses was not affected by changes of mood, and consequently aberrancies in associative processes may be a trait of persons with bipolar affective disorders. On the other hand, repetition of responses was directly correlated with lithium concentration in plasma, which allowed a prediction of the success of lithium therapy.

Wrist motor activity was continuously recorded by a solid-state monitor in 12 patients with major depression throughout their stay in hospital; their clinical state was evaluated using three scales. During the day, activity troughs and immobility peaks occurred before noon and around 1500 hrs. Activity level progressively increased, while the duration of immobility decreased, with clinical improvement. The immobility measurement appeared to be a valuable index of depression and is more sensitive than the activity level, mainly for agitated depressed patients. Immobility episodes during the day could suggest the release of an ultradian sleep-wake rhythm in depression.

Wrist motor activity was continuously monitored in 10 major unipolar depressed inpatients. Clinical state and motor activity parameters were studied. The data obtained at the beginning of the hospitalization, before the antidepressant treatment, were compared to chose found just before discharge. Time of day effect and subtypes of depression (endogenous versus non-endogenous) were considered. Motor retardation is related to both fluctuations of activity level and high number of 15 minute immobility epochs. Immobility parameters at night and during day were a good indicator of the severity of the depressive state. The temporal pattern of activity level was related to the subtype of depression.

A previously healthy young man developed encephalopathy after a wasp sting in 1968. Neurological complications included chorea, currently of a minor degree, replaced by buccofacial dyskinesias and compulsive movements. The most disabling consequences were of psychic nature, the patient presenting an unusually marked compulsive activity of an obsessional type. The whole psychic picture however was quite different from that of the usual neurosis, since there was neither anxiety nor doubt, but a mental vacuum contrasting with almost normal intellectual and affective capacities. It was as though there was a loss of the auto-activation system of psychic life, postulated by dynamic psychologists. C.A.T. demonstrated bilateral pallidostriatal necrosis. This suggests that the striatum plays a motor and psychic role. In the field of motor control, its hypoactivity appears to determine not only chorea but dyskinesias similar to tics and compulsive movements. In the psychic field, the striatum appears to play the very general role of an auto-activation system of intellectual and affective life, its deficiency leading to mental activity of a compulsive nature. Improvement in knowledge of striatal biology should clarify not only the basic mechanisms of chorea, but those of tics and obsessions.