...... Rfrentiel de ...........................

Psychiatrie

Psychiatrie de ladulte. Psychiatrie de lenfant et de ladolescent. Addictologie

..........................................................

Conception graphique et couverture :

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Tous droits rservs, 2014

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Dpt lgal : 2e semestre 2014

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Collge national des universitaires en psychiatrie

Association pour lenseignement de la smiologie psychiatrique

...... Rfrentiel de ...........................

Psychiatrie

Psychiatrie de ladulte. Psychiatrie de lenfant et de ladolescent. Addictologie

..........................................................

Collection /2FLHO(&1}
3UHVVHVXQLYHUVLWDLUHV)UDQRLV5DEHODLV
2014

Sommaire
Table des auteurs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

Prface du CNUP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



Prface du Collge enseignant de psychiatrie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



Gnralits
Item 59&RQQDWUHOHVEDVHVGHVFODVVLFDWLRQV
GHVWURXEOHVPHQWDX[GHOHQIDQWODSHUVRQQHJH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

Item 58 Connatre les facteurs de risque, prvention,

GSLVWDJHGHVWURXEOHVSV\FKLTXHVGHOHQIDQWODSHUVRQQHJH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29

Item 01/DUHODWLRQPGHFLQPDODGH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 60'FULUHORUJDQLVDWLRQGHORUHGHVRLQVHQSV\FKLDWULH
GHOHQIDQWODSHUVRQQHJH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

49

Situations durgence
Item 346 Agitation et dlire aigus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 347&ULVHGDQJRLVVHDLJXHWDWWDTXHGHSDQLTXH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 3485LVTXHHWFRQGXLWHVXLFLGDLUHVFKH]OHQIDQW
ODGROHVFHQWHWODGXOWHLGHQWLFDWLRQHWSULVHHQFKDUJH. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Situations risque spcifiques

Item 57 Sujets en situation de prcarit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 677URXEOHVSV\FKLTXHVGHODJURVVHVVHHWGXSRVWSDUWXP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 687URXEOHVSV\FKLTXHVGXVXMHWJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 141 Deuil normal et pathologique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Les Troubles psychiatriques tous les ges

Troubles psychotiques
Item 617URXEOHVFKL]RSKUQLTXHGHODGROHVFHQWHWGHODGXOWH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 637URXEOHGOLUDQWSHUVLVWDQW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Troubles de lhumeur
Item 64A7URXEOHGSUHVVLIGHODGROHVFHQWHWGHODGXOWH

.................................................

 

Item 627URXEOHELSRODLUHGHODGROHVFHQWHWGHODGXOWH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Troubles anxieux
Item 64B7URXEOHDQ[LHX[JQUDOLV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Item 64C7URXEOHSDQLTXH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 64D7URXEOHSKRELTXH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 64E7URXEOHREVHVVLRQQHOFRPSXOVLI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 64FWDWGHVWUHVVSRVWWUDXPDWLTXH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 64G7URXEOHGHODGDSWDWLRQ

...............................................................................

261

Autres troubles
Item 64H/HVWURXEOHVGHSHUVRQQDOLW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Item 707URXEOHVVRPDWRIRUPHVWRXVOHVJHV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 566H[XDOLWQRUPDOHHWVHVWURXEOHV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Item 1087URXEOHVGXVRPPHLOGHOHQIDQWHWGHODGXOWH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299

Les Troubles psychiatriques spcifiques de lenfant et ladolescent

Item 53'YHORSSHPHQWSV\FKRPRWHXUGXQRXUULVVRQHWGHOHQIDQW
aspects normaux et pathologiques
(sommeil, alimentation, contrles sphinctriens,
SV\FKRPRWULFLWODQJDJHLQWHOOLJHQFH
/LQVWDOODWLRQSUFRFHGHODUHODWLRQSDUHQWVHQIDQWHWVRQLPSRUWDQFH
7URXEOHVGHODSSUHQWLVVDJH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Item 657URXEOHVHQYDKLVVDQWVGXGYHORSSHPHQW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Item 667URXEOHVGXFRPSRUWHPHQWGHODGROHVFHQW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 697URXEOHVGHVFRQGXLWHVDOLPHQWDLUHVFKH]ODGROHVFHQWHWODGXOWH

...........................

 

Les Addictions
Item 73$GGLFWLRQDXWDEDF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 74$GGLFWLRQODOFRRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 75$GGLFWLRQDX[PGLFDPHQWVSV\FKRWURSHVEHQ]RGLD]SLQHVHWDSSDUHQWV . . . . . . . . . . . . .  
Item 76$GGLFWLRQDXFDQQDELVODFRFDQHDX[DPSKWDPLQHV
DX[RSLDFVDX[GURJXHVGHV\QWKVH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 77 Addictions comportementales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Les Thrapeutiques
Item 116RLQVSV\FKLDWULTXHVVDQVFRQVHQWHPHQW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 71'LUHQWVW\SHVGHWHFKQLTXHVSV\FKRWKUDSHXWLTXHV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 723UHVFULSWLRQHWVXUYHLOODQFHGHVSV\FKRWURSHV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 117/HKDQGLFDSSV\FKLTXH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Item 135 Douleur en sant mentale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Table
des auteurs de louvrage

Coordination gnrale de louvrage :

Dr Ali Amad
3r Vincent Camus
Dr3LHUUH$OH[LV*HRUR\
3r3LHUUH7KRPDV
Coordination gnrale AESP :
Dr Cllia Quiles
Dr-HDQ$UWKXU0LFRXODXG)UDQFKL
Coordination thmatique :
Dr3LHUUH$OH[LV*HRUR\
WURXEOHVGHOKXPHXU
Drs Cllia Quiles & Ali Amad
WURXEOHVSV\FKRWLTXHV
Dr7KRPDV)RYHW
WURXEOHVDQ[LHX[
Dr)DULG%HQ]HURXN
WURXEOHVDGGLFWLIV
Dr1RUD0LOOLH]SGRSV\FKLDWULH
Dr-HDQ$UWKXU0LFRXODXG)UDQFKL
LWHPVJQUDX[

Table des auteurs

12

Membres de lAESP rdacteurs :

Dr Ali Amad
Dr Sara Bahadori
Dr-HDQ0DULH%DWDLO
Dr5P\%DWLRQ
Dr)DULG%HQ]HURXN
Dr)DELHQQH&\Srien
Dr Marie Laure Daniel
Dr Thomas Desmidt
Dr Aude Doudard
Dr2OLYLHU*D\
Dr3LHUUH$OH[LV*HRUR\
Dr*XLOODXPH)RQG
Dr7KRPDV)RYHW
Dr6\OYDLQ,FHWD
Dr5JLV/RSH]
Dr-DVPLQD0DOOHW
Dr)ORUHQFH0HVRQD
Dr-HDQ$UWKXU0LFRXODXG)UDQFKL
Dr1RUD0LOOLH]
Dr)ORULDQ1DXGHW
Dr$HVD3DUHQWL
Dr%DSWLVWH3LJQRQ
Dr Cllia Quiles
Dr(OLVH5LTXLQ
Dr Ludovic Samalin
Dr'ERUDK6HEEDQH
Dr6DUDK7HEHND
Dr Antoine Yrondi
Membres du CNUP relecteurs :
3r&KULVWRSKH$UEXV
3r+HQUL-HDQ$XELQ
3r0DUF$XULDFRPEH
3r-HDQ0DUF%DOH\WH
3r)UDQN%HOOLYLHU
3r$PLQH%HQ\DPLQD
3r*LOOHV%HUWVFK\
3r Bernard Bonin
3r)UGULTXH%RQQHW%ULOKDXOW
3r7KLHUU\%RXJHURO
3r Vincent Camus
3r David Cohen
3r(PPDQHOOH&RUUXEOH

3r2OLYLHU&RWWHQFLQ
3r3KLOLSSH&RXUWHW
3r Anne Danion
3r&DUROLQH'XEHUWUHW
3r3KLOLSSH'XYHUJHU
Dr%UXQR(WDLQ
3r1LFRODV)UDQFN
3r1LFRODV*HRUJLH
3r3rLVFLOOH*LUDUGLQ
3r3KLOLSS*RUZRRG
3r-HDQ0DUF*XLOHW
3r(PPDQXHO+DHQ
3r0DULH&KULVWLQH+DUG\%D\O
3r1HPDWROODK-DDIDUL
3r,VDEHOOH-DOOHQTXHV
3r/RXLV-HKHO
3r0DULH2GLOH.UHEV
3r&KULVWRSKH/DQRQ
3r0LFKHO/HMR\HX[
3r)UGHULF/LPRVLQ
3r3LHUUH0LFKHO/ORUFD
3r&DWKHULQH0DVVRXEUH
3r Bruno Millet
3r0DULH5RVH0RUR
3r&KULVWLQH3DVVHULHX[
3r$QWRLQH3HOLVVROR
3r'LDQH3XUSHU2XDNLO
3r Laurent Schmitt
3r5D\PXQG6FKZDQQ
3r0DULR6SHUHQ]D
3r)ORUHQFH7KLEDXW
3r3LHUUH7KRPDV
3r*XLOODXPH9DLYD
3r Vincent Vandel
3r+OQH9HUGRX[
3r3LHUUH9LGDLOKHW
3r Michel Walter

prface

du Collge national des universitaires

de psychiatrie (CNUP)

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prface
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Prface

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1.1.2. Les

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Commentaires sur la notion de trouble psychiatrique

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2.3.2.La
26

spcification

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comorbidits

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*

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59

Notions dpidmiologie
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27

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les hpitaux.

Rfrences pour approfondir

+DUG\%D\O 0& +DUG\ 3 &RUUXEOH ( 3DVVHULHX[ & Enseignement de la psychiatrie 
Doin.
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Shea S. C., La conduite de lentretien psychiatrique : Lart de la comprhension  (OVHYLHU
Masson.

item 58

Connatre
les facteurs de risque,
prvention, dpistage
des troubles psychiques
de lenfant la personne ge
I. Introduction
II. /HVIDFWHXUVGHULVTXHGHVWURXEOHVSV\FKLDWULTXHV
III. 3UYHQWLRQHWGSLVWDJHGHVWURXEOHVSV\FKLDWULTXHV

Objectifs pdagogiques
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prvention et la prise en charge.

58

58

Gnralits

1.

Introduction

1.1.

Sant mentale et troubles psychiques

/DVDQWPHQWDOHFI,WHPHVWGQLHSDUO2UJDQLVDWLRQPRQGLDOHGHODVDQW206FRPPH
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par ailleurs quatre faits principaux :
*

/ DVDQWPHQWDOHIDLWSDUWLHLQWJUDQWHGHODVDQWHQHHWLOQ\DSDVGHVDQWVDQVVDQW
mentale.

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/ D VDQW PHQWDOH HVW GWHUPLQH SDU GHV IDFWHXUV VRFLRFRQRPLTXHV ELRORJLTXHV HW
environnementaux.

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cit pour la promouvoir, la protger et la recouvrer.

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30

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1.2.

1.3.

Quelques donnes pidmiologiques

*

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(
12 millions de personnes.

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DSUVOHFDQFHUHWOHVPDODGLHVFDUGLRYDVFXODLUHV(OOHVVRQWELHQVRXYHQWVRXUFHVGHKDQGLFDS
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/ HVWURXEOHVSV\FKLDWULTXHVUHSUVHQWHQWODreFDXVHGLQYDOLGLWHWVRQWDVVRFLVXQHPRUWD
lit leve. Les rpercussions socioconomiques qui en dcoulent en font un enjeu majeur de
ODVDQWSXEOLTXH

Vulnrabilit, risque et prvention

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Facteurs de risque, prvention, dpistage des troubles psychiques

58

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2.

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Les facteurs de risque

des troubles psychiatriques
Les diffrents niveaux de risque
/HVGWHUPLQDQWVGHODVDQWPHQWDOHHWGRQFGHVWURXEOHVPHQWDX[VRQWPXOWLSOHVHWUHJURXSHQW
des facteurs :
*

Sociaux et environnementaux,

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Biologiques.

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Sociaux et environnementaux :
*

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Capacits cognitives et niveau intellectuel.

31

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Gnralits

Biologiques :

2.2.

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Les spcificits selon les priodes de la vie

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grandes tapes du dveloppement.

2.2.1. La

priode antnatale (cf. Items 67 et 53)

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*

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2.2.2.Lenfance
*

et ladolescence (cf. Item 66)

Sociaux et environnementaux :
 /HVWURXEOHVSV\FKLDWULTXHVFKH]OHVSDUHQWV

32

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*

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*

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2.2.4.Le

sujet g (cf. Item 68)

Dclin cognitif, maladie chronique, dpendance.

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Maltraitance, ngligence.

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Facteurs de risque, prvention, dpistage des troubles psychiques

58

neuroscience et recherche
Facteurs de risques : lexemple de la schizophrnie

* Les facteurs de risque environnementaux :

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3DUPLFHVIDFWHXUVRQUHWURXYHdes facteurs sociodmographiques : le sexe (tre un homme augmente le risque de forme
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et le statut socioconomique peu lev
Des facteurs de stress psychologiques jouent galement un rle majeur : un stress maternel pendant la grossesse, la
maltraitance infantile.
Les facteurs environnementaux sont galement biologiquesHWSHXYHQWLQWHUYHQLUGHIDRQSUFRFHSDUH[LQIHFWLRQV
FRPSOLFDWLRQVREVWWULFDOHVVXUOHGYHORSSHPHQWGHOLQGLYLGXRXSOXVWDUGOJHDGXOWHSDUH[OHFDQQDELV
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VFKL]RSKUQLTXHHWLOVVLQWJUHQWGDQVGHVPRGOHVGHYXOQUDELOLWLQWJUDWLIVELRSV\FKRVRFLDX[FI,WHP
* Les facteurs de risque gntiques :
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YDULDQWVGHJQHVFRGDQWSRXUFHUWDLQHVSURWLQHVGXQHXURGYHORSSHPHQWFUEUDOHWSRXUOHVV\VWPHVGHQHXURP
GLDWHXUV(QFOLQLTXHFHULVTXHJQWLTXHHVWDSSURFKSDUODUHFKHUFKHGDQWFGHQWVIDPLOLDX[
* Les interactions gne environnement :
&RPPHODSOXSDUWGXWHPSVOHQVHPEOHGHODSRSXODWLRQJQUDOHHVWH[SRVHFHVIDFWHXUVHQYLURQQHPHQWDX[HWTXH
VHXOHXQHIDLEOHSURSRUWLRQGHVXMHWVYXOQUDEOHVJQWLTXHPHQWYDGYHORSSHUXQWURXEOHHQSUVHQFHGHFHUWDLQV
IDFWHXUVFHVWOLQWHUDFWLRQHQWUHFHUWDLQVIDFWHXUVHQYLURQQHPHQWDX[HWFHUWDLQVIDFWHXUVGHYXOQUDELOLWJQWLTXH
TXL YD WUH UHVSRQVDEOH GH OD VXUYHQXH GX WURXEOH 3DU H[HPSOH OHV DSSDUHQWV GH SDWLHQWV VRXUDQWV GH VFKL]R
SKUQLHVRQWGHSDUWOHXUYXOQUDELOLWJQWLTXHSOXVVHQVLEOHVDX[IDFWHXUVHQYLURQQHPHQWDX[SDUH[HHWVGX
FDQQDELVTXHOHVQRQDSSDUHQWV

33

3.

3.1.

Prvention et dpistage
des troubles psychiatriques
Les diffrents types de prvention de lOMS
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/206GLVWLQJXHWURLVW\SHVGHSUYHQWLRQ
*

La prvention primaire :

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6RQW SDU FRQVTXHQW SULV HQ FRPSWH  FH VWDGH GH OD SUYHQWLRQ OHV FRQGXLWHV LQGLYLGXHOOHV 
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DFWLRQVJQUDOHVGHVDQWSXEOLTXH
*

La prvention secondaire :

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OHVDFWHVGHVWLQVDJLUDXWRXWGEXWGHODSSDULWLRQGXWURXEOHRXGHODSDWKRORJLHDQGHVRS
SRVHUVRQYROXWLRQRXHQFRUHIDLUHGLVSDUDWUHOHVIDFWHXUVGHULVTXH&HWWHSUYHQWLRQLQFOXW
galement tous les actes de diagnostic et de prise en charge prcoces.

58

Gnralits

La prvention tertiaire :

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des rcidives dans une population et de rduire les complications, invalidits ou rechutes cons
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une meilleure optimisation thrapeutique.

3.2.

Prvention primaire (population gnrale)

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pour en savoir plus : en pratique

34

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3.3.

Prvention secondaire ( lchelle de lindividu)

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3.3.1. Stade

prinatal et petite enfance (cf. Item 53)

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58

3.3.2. Enfance
*

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3.3.3. Adultes
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3.3.4.Personnes

3.4.

ges (cf. Item 68)

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caractriss.

Prvention tertiaire
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Diminuer les rechutes et les hospitalisations via une meilleure optimisation thrapeutique
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35

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Gnralits

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Points clefs

36

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une meilleure radaptation socioprofessionnelle et une optimisation des traitements.

Rfrences pour approfondir

The Cost of Mental Disorder in France . &KHYUHXO et al (XU 1HXURSV\FKRSKDUPDFRO 
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item 01

La relation
mdecin-malade

01

I. /DUHODWLRQPGHFLQPDODGH
II. La position du mdecin
III. La position du patient
IV. Applications

Objectifs pdagogiques
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* La communication avec le patient et son entourage.
* /DQQRQFHGXQHPDODGLHJUDYHRXOWDOHRXGXQGRPPDJHDVVRFLDX[VRLQV
* La formation du patient.
* La personnalisation de la prise en charge mdicale.
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communication interprofessionnelle.
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(cf. Item 

01

Gnralits

1.

La relation mdecin-malade
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*

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&
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soignants.

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&
pouvoir suppos. Le mdecin est alors en position de domination potentielle.

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La relation consensuelle implique du patient une acceptation des soins et une coopration.
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La relation cooprative implique du patient comme dans la relation prcdente une accepta
tion et une coopration au geste mdical, mais il doit tre convaincu. Le mdecin doit faire
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38

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compte galement des reprsentations et des actions du patient concernant sa sant et la maladie
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le patient comme par le mdecin pour la prise en charge de sa maladie chronique.
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La relation mdecin-malade

01

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*

la position du mdecin,

puis la position du malade,

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Activit passivit

Consensuel

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Participatif

Patient

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Demande
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Accord du patient
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Mdecin

Actif

Actif avec
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patient

Le patient
suit le mdecin

Compromis
rciproque
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Tableau 1. Les dirents types de relation mdecin-malade.

39

Histoire de la psychiatrie
Le transfert et le contre-transfert

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la situation de soins.
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/HSHQGDQWGXWUDQVIHUWHVWOHFRQWUHWUDQVIHUWTXLGVLJQHOHVPRXYHPHQWVDHFWLIVGXVRLJQDQWHQYHUVOHSDWLHQWHWHQ
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rit des motions ressenties par le soignant.
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une dcision prise trop rapidement, etc.
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01

Gnralits

2.

La position du mdecin

2.1.

Les reprsentations du savoir mdical

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Le mdecin apprend un savoir :
*

smiologique,

nosographique,

et thrapeutique,

DQ
*

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SRQGDXVDYRLUELRPGLFDO
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UHODWLRQVDYHFOHVPGHFLQV/HPGHFLQGRLWGRQFWHQLUFRPSWHODIRLV

40

GHVHVSURSUHVUHSUVHQWDWLRQVFRQFHUQDQWODPDODGLHVDWKRULHVDYDQWH

HWGHVUHSUVHQWDWLRQVHWYDOHXUVGXSDWLHQWVDWKRULHSURIDQHDX[FRXUVGHVHQWUHWLHQV

'HVWHFKQLTXHVVSFLTXHVSHUPHWWHQWDORUVGHPHQHUOHQWUHWLHQHFDFHPHQW

2.2.

Les techniques dentretien

2.2.1. Valider

les ressentis

9DOLGHUOHVUHVVHQWLVGXSDWLHQWHVWFDSLWDOODQQRQFHGXQGLDJQRVWLFRXGHODQFHVVLWGXQWUDL
WHPHQWSRXYDQWWUHYFXFRPPHXQHVLWXDWLRQGHVWUHVVHWDYRLUXQWUVIRUWLPSDFWPRWLRQQHO
(QSUDWLTXHYDOLGHUOHVUHVVHQWLVGXSDWLHQWSDVVHSDUODUHIRUPXODWLRQTXLUHQYRLHHQPLURLUDX
SDWLHQWVHVSURSUHVUHVVHQWLVHWOXLVLJQLHTXLODWHQWHQGXHWTXLOQHVWSDVVHXO(OOHLPSOLTXH
GXPGHFLQGHOHPSDWKLH
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WKLHHOOHSHUPHWGHIDLUHEDLVVHUOHVWUHVVORUVGXQHVLWXDWLRQGLFLOHGDQVXQHQWUHWLHQHWHOOHHVW
HQVRLWRXMRXUVYUDLHVLQRXVWLRQVODSODFHGHQRVSDWLHQWVSDUGQLWLRQQRXVUHVVHQWLULRQV
ODPPHFKRVHFDUQRXVDXULRQVJDOHPHQWOHXUVYFXVHWOHXUVUHSUVHQWDWLRQVWKRULHSURIDQH

La relation mdecin-malade

2.2.2.Dpister

01

la rsistance

8QOPHQWLPSRUWDQWDXTXHOOHPGHFLQVHUDDWWHQWLIVHUDODSSDULWLRQGXQHUVLVWDQFHTXLSHXW
QDWUHDXVHLQGHODUHODWLRQPGHFLQPDODGH/RUVTXHOHPGHFLQYHXWDPHQHUOHSDWLHQWFKDQJHU
TXHOTXHFKRVHGDQVVRQVW\OHGHYLHVRQDOLPHQWDWLRQVDFRQVRPPDWLRQGHWDEDFVRQDFWLYLW
SK\VLTXHODSULVHGXQWUDLWHPHQWDORUVTXHOHSDWLHQWQHOHFRQVLGUHSDVHQFRUHFRPPHQFHV
saire, la divergence des reprsentations et valeurs (en lien avec la confrontation des thories
VDYDQWHVHWSURIDQHVGHODPDODGLHHWGHODVDQWFUXQHGLYHUJHQFHTXLSHXWSRWHQWLHOOHPHQW
DERXWLUXQFKHFWKUDSHXWLTXH/HSDWLHQWQDSSOLTXHUDSDVOHVUHFRPPDQGDWLRQVGXPGHFLQ
et ventuellement ne viendra plus le consulter, car il ne se sera pas senti compris.
/DUVLVWDQFHQHVWSDVXQVLJQHGHPDXYDLVHYRORQWGXSDWLHQWPDLVXQHUDFWLRQQDWXUHOOHXQ
FKDQJHPHQWTXLVLPSRVHGDQVVDYLHOHWURXEOHRXODPDODGLH
/DSUHPLUHWDSHHVWGRQFGH[SORUHUDYHFOHSDWLHQWVHVUHSUVHQWDWLRQVHWVHVYDOHXUVHWGH
montrer que ce qui compte vraiment pour lui dans sa vie, est pris en compte par le mdecin.

2.2.3.Insister

sur le sentiment de libert

8QOPHQWLPSRUWDQWSRXUFKDTXHLQWHUORFXWHXUHVWOHVHQWLPHQWGHOLEHUW/HPGHFLQSHXWGRQF
WRXWPRPHQWXWLOLVHUOHmPDLVYRXVWHVOLEUHGH}GHSUHQGUHXQWUDLWHPHQWGHFKRLVLUGDUUWHU
GHIXPHU&HWWHVLPSOHDPRUFHDXJPHQWHVHQVLEOHPHQWODSUREDELOLWGXFKDQJHPHQWPDLVQH
GRLWSDVWUHXQPR\HQSRXUOHPGHFLQGDEDQGRQQHUWRXWHSRVVLELOLWGHFKDQJHPHQWDYHFOH
SDWLHQW'RQFWRXWHQLQVLVWDQWVXUOHVHQWLPHQWGHOLEHUWXQHGHVWHFKQLTXHVLVVXHVGHVHQWUH
WLHQVPRWLYDWLRQQHOVSRXUSHUPHWWUHDXSDWLHQWGDUJXPHQWHUOLEUHPHQWHQIDYHXUGXFKDQJHPHQW
HVWGHSUHQGUHOHSDWLHQWFRQWUHSLHGHWGHVHIDLUHOHGIHQVHXUGXmPDXYDLV}FRPSRUWHPHQW
/H SDWLHQW QH GRLW MDPDLV VRUWLU GXQ HQWUHWLHQ DYHF OH VHQWLPHQW GDYRLU W YDLQFX RX DEDLVV
*UFHFHWWHWHFKQLTXHJDOHPHQWDSSHOHWHFKQLTXHGHmODYRFDWGXGLDEOH}HQWKUDSLHFRJQL
WLYHOHSDWLHQWVHVHQWLUDYDOLGGDQVVHVUHVVHQWLVHWVHVGLFXOWVTXLWWHUXQmFRPSRUWHPHQW
SUREOPH}HWVHUDPLHX[GLVSRVDPRUFHUOHFKDQJHPHQW
5HSUHUHWH[SOLTXHUOHVWDSHVGXFKDQJHPHQWSHXWJDOHPHQWVDYUHUQFHVVDLUHFI,WHPV
HW3RXUFKDQJHUXQFRPSRUWHPHQWOHVLQGLYLGXVYRQWGHYRLUPRGLHUOHXUVFRPSRU
WHPHQWVHQSDVVDQWSDUXQHVULHGWDSHVGFULWHVGDQVOHPRGOHGXFKDQJHPHQWGYHORSSSDU
3URFKDVNDHW'L&OHPHQWH/HVSULQFLSDX[VWDGHVGHFKDQJHPHQWVRQW
*

/ DSUFRQWHPSODWLRQOLQGLYLGXQDSDVHQFRUHHQYLVDJGHFKDQJHUVRQFRPSRUWHPHQWTXL
SUVHQWHVXLYDQWVRQSRLQWGHYXHPRLQVGLQFRQYQLHQWVTXHGDYDQWDJHV

La contemplation : le patient pense que les inconvnients sont aussi importants que les
avantages.

La dtermination : le patient pense que les inconvnients sont plus importants que les avan
tages et envisage la ncessit du changement.

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comportement.

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SRVVLELOLW

/ DUHFKXWHOHSDWLHQWDEDQGRQQHOHFKDQJHPHQWUDOLVPDLVSHXWUHFRPPHQFHUOHF\FOHGHV
6 tapes.

41

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Contemplation

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GHODSUREOPDWLTXH

Maintien
Dcision
Action

Figure 1. Les six tapes pour changer un comportement problme .

En pratique
Autres techniques pour viter la rsistance
42

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VHMXVWLHU7RXWHVOHVSKUDVHVGHYURQWFRPPHQFHUSDUmMH}RXmPH}HWQRQFHUXQHPRWLRQVLQFUHGHVRUWHQH
SDVJQUHUGHUVLVWDQFHHWGHVHQWLPHQWGDJUHVVLRQFKH]OLQWHUORFXWHXU'HODPPHIDRQOHVPRWVmWRXMRXUV}HW
m-DPDLV}VRQWSURVFULUHGXODQJDJHFRXUDQWFDULOVUHQIRUFHQWOHVHQWLPHQWGLPSXLVVDQFHHWVRQWODPDUTXHGXQH
GLVWRUVLRQFRJQLWLYHVRXYHQWDVVRFLHGHVSHQVHVDXWRPDWLTXHVQJDWLYHV

En pratique
Autres techniques pour renforcer le sentiment de libert

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DJHRXSLHGGDQVODSRUWHTXLFRQVLVWHGHPDQGHUXQSHWLWFKDQJHPHQWSRXYDQWHQVXLWHFRQGXLUHXQFKDQJHPHQW
SOXVLPSRUWDQW'HODPPHIDRQOHPGHFLQSRXUUDSURSRVHUXQSDWLHQWUWLFHQWOLGHGHSUHQGUHXQWUDLWHPHQW
GHVVD\HUOHWUDLWHPHQWSHQGDQWTXHOTXHVMRXUVHWGHODUUWHUHQFDVGHHWLQGVLUDEOH/DSOXSDUWGHVSDWLHQWVREVHU
YHURQWDLQVLOHXUWUDLWHPHQWDSUVHQDYRLUWHVWOHVHHWVEQTXHVRXHQWRXWFDVODEVHQFHGHHWVLQGVLUDEOHV
/HSHQGDQWGXSLHGGDQVODSRUWHHVWODSRUWHDXQH]RXSURSRVHUTXHOTXHFKRVHGLQWHQDEOHSRXUOHSDWLHQWXQHSV\FKR
WKUDSLHEDVHVXUODPGLWDWLRQGHX[KHXUHVSDUMRXUSDUH[HPSOHSRXUHQVXLWHSURSRVHUXQHSULVHHQFKDUJHGHPDQ
GDQWPRLQVGLQYHVWLVVHPHQWHQWHPSVRXHQQHUJLH

La relation mdecin-malade

01

En pratique
Comprendre pourquoi un patient peut persvrer dans une stratgie dchec apparent

/HHWGHJHOGFULWODSHUVYUDWLRQGXQLQGLYLGXGDQVXQHVWUDWJLHGFKHFHQVHGLVDQWTXLODWURSLQYHVWLRXTXLO
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YDLVFKDQJHU}$LQVLXQLQGLYLGXSHXWSHUVLVWHUSOXVLHXUVDQQHVGDQVXQFRPSRUWHPHQWOHFRQGXLVDQWPDQLIHVWH
PHQWOFKHF&HVWFHSKQRPQHTXLSHXWVLOOXVWUHUFKH]FHUWDLQVSDWLHQWVUHVWDQWDYHFXQFRQMRLQWPDOWUDLWDQWSDU
H[HPSOH,OVDJLWGXQSKQRPQHGmDXWRPDQLSXODWLRQ}VHORQOHVWKRULHVGHODSV\FKRORJLHVRFLDOHGYHORSSH
GDQVOHVDQQHVHQ)UDQFH

En pratique
Les schmas prcoces inadapts

/DUVLVWDQFHHQWUHOHPDODGHHWOHPGHFLQSHXWSURYHQLUJDOHPHQWGHVFKPDVSUFRFHVLQDGDSWVHQUIUHQFH
ODWKUDSLHGHVVFKPDVGH-HUH\(<RXQJTXLSHXYHQWFRQFHUQHUDXVVLELHQOHPGHFLQTXHOHSDWLHQW8QVFKPD
SUFRFHHVWXQDSSUHQWLVVDJHIDLWWWGDQVOHQIDQFHTXLVHVWULJLGLDXFRXUVGHODYLHGHOLQGLYLGXHQSDUWLFXOLHUVLO
DWVRXPLVGHIDRQSURORQJHODGYHUVLWHWTXHOHVFKPDDSSULVDWUHQIRUF
&HUWDLQV VFKPDV SHXYHQW WUH EQTXHV 'H QRPEUHX[ WXGLDQWV HQ PGHFLQH RQW DSSULV OH VFKPD mH[LJHQFH
OHYH}GDQVOHXUHQIDQFHHWOHXUDGROHVFHQFHTXLOHXUDJDOHPHQWSHUPLVGHUXVVLUOHFRQFRXUVGHPGHFLQH0DLV
DORUVTXXQLQGLYLGXGYHORSSHJQUDOHPHQWXQHSDQRSOLHGHVFKPDVVRXSOHVOXLSHUPHWWDQWGHVDGDSWHUDX[GL
UHQWHVVLWXDWLRQVVRFLDOHVDHFWLYHVSURIHVVLRQQHOOHVHWFFHUWDLQVLQGLYLGXVSHXYHQWWUHSULVRQQLHUVGHVFKPDV
DFTXLV SUFRFHPHQW GDQV OHQIDQFH HW TXL YRQW PHQHU  GHV FRQGXLWHV G\VIRQFWLRQQHOOHV  OJH DGXOWH /DQQRQFH
GXQHPDODGLHHVWXQHVRXUFHLPSRUWDQWHGHVWUHVVTXLYDSRXVVHUOHSDWLHQWGDQVOHUHWUDQFKHPHQWGHPFDQLVPHV
GLWVmDUFKDTXHV}TXLSHXYHQWGPDVTXHUXQVFKPDSUFRFHLQDGDSW/XQGHVVFKPDVIUTXHPPHQWUHQFRQWUV
HVWOHVFKPDDEDQGRQQLTXH>ODSHXUGWUHDEDQGRQQHRXUHMHWH@TXHORQUHWURXYHSRXVVVRQH[WUPHGDQVOH
WURXEOHERUGHUOLQH/HVFKPDmPDQFHDEXV}VWLSXODQWTXHWRXWWUDQJHUHVWDSULRULXQHQQHPLSRXUUDFRQGXLUH
VRQH[WUPHGHVWUDLWVGHSHUVRQQDOLWSDUDQRDTXHHWF/HPGHFLQSHXWGRQFH[SORUHUODELRJUDSKLHGXVXMHWHW
HQSDUWLFXOLHUVRQHQIDQFHHWVRQDGROHVFHQFHSRXUVHUHSUVHQWHUOHVVFKPDVGHVRQSDWLHQWHWOLQYLWHUHQSUHQGUH
FRQVFLHQFHSRXUOHVDVVRXSOLUHWOXLSHUPHWWUHGDYDQFHUVHUHLQHPHQWGDQVOHFKDQJHPHQW

3.

La position du patient

3.1.

Les reprsentations du savoir profane

6XLYDQWOHSRLQWGHYXHGXSDWLHQWXQHPDODGLHQHVWSDVVLPSOHPHQWmXQHSDWKRORJLHRUJDQLTXH
VRXVMDFHQWH} /D PDODGLH YLHQW IDLUH UXSWLRQ GDQV VD VDQW FI ,WHP  6HORQ OD GQLWLRQ
GHO206GHODVDQWHVWmXQWDWFRPSOHWGHELHQWUHSK\VLTXHPHQWDOHWVRFLDOHWSDV
VLPSOHPHQWODEVHQFHGHPDODGLHRXGHKDQGLFDS}0DLVODGQLWLRQUYLVHGHDYDQFHTXH
ODVDQWHVWmOHQVHPEOHGHVUHVVRXUFHVVRFLDOHVSHUVRQQHOOHVHWSK\VLTXHVSHUPHWWDQWOLQGL
YLGXGHUDOLVHUVHVDVSLUDWLRQVHWGHVDWLVIDLUHVHVEHVRLQV}
&HWWHGQLWLRQHVWHQOLHQ
*

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PDLVJDOHPHQWDYHFOHFRQFHSWGHmWUDQVDFWLRQ}GQLSDUODSV\FKRORJLHGHODVDQW

43

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VRFLDOHHWODSULVHHQFKDUJHYDFRQVLVWHUUHGRQQHUDXSDWLHQWOHQVHPEOHGHVUHVVRXUFHVQFHV
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*

 HVUHSUVHQWDWLRQVGXSDWLHQWFRQFHUQDQWVDVDQWHWODPDODGLHWKRULHSURIDQHTXLGWHU

G
minent les comportements que le patient peut mettre en place, et

GHVSURFHVVXVGHWUDQVDFWLRQTXHOHSDWLHQWPHWHQSODFHIDFHODPDODGLH

Les reprsentations concernant la maladie peuvent concerner :

*

OHVFDXVHVmTXRLHVWGXHPDPDODGLH"}

OHVHQVGHFHOOHFLm3RXUTXRLFHWWHPDODGLHFKH]PRLGDQVPRQKLVWRLUHSHUVRQQHOOH"}

/HVUHSUVHQWDWLRQVGHODVDQWHWGHODPDODGLHVRQWSDUIRLVSHXVXSHUSRVDEOHVDX[mUHSUVHQ
WDWLRQVPGLFDOHVRFLHOOHV}WKRULHVDYDQWHHWVRQWGSHQGDQWHVGHPXOWLSOHVIDFWHXUVOLV
ODSHUVRQQHmPDODGH}FI,WHP
*

culture,

milieu social,

personnalit,

histoire personnelle.

/HVSURFHVVXVGHWUDQVDFWLRQVRQWOHVHRUWVFRJQLWLIVPRWLRQQHOVHWFRPSRUWHPHQWDX[GSOR\V
SDUXQLQGLYLGXSRXUVDMXVWHUDX[VLWXDWLRQVGHVWUHVVWHOOHTXHOHVWODPDODGLH,OVGWHUPLQHQWOHV
VWUDWJLHVGDMXVWHPHQWTXHOHSDWLHQWSHXWPHWWUHHQSODFHSRXUVDGDSWHUODPDODGLH

44

3.2.

Les processus de transaction

/HHWVXUOHVUSRQVHVGXQLQGLYLGXGXQHVLWXDWLRQGHVWUHVVFRPPHODPDODGLHVHGURXOHGH
IDRQVTXHQWLHOOHVHORQGHX[SKDVHVXQHSKDVHGYDOXDWLRQSULPDLUHHWVHFRQGDLUHHWODER
UDWLRQGXQHRXSOXVLHXUVVWUDWJLHVGDMXVWHPHQWRXFRSLQJ

3.2.1. Phase

dvaluation

,OH[LVWHGHX[SKDVHVGYDOXDWLRQ
*

/ DSUHPLUHSKDVHGYDOXDWLRQRXYDOXDWLRQSULPDLUHFRUUHVSRQGDXmVWUHVVSHUX}SDU

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XOWULHXUGXSDWLHQWTXXQHPHVXUHREMHFWLYHGHODVLWXDWLRQGHVWUHVV

/ DGHX[LPHSKDVHGYDOXDWLRQRXYDOXDWLRQVHFRQGDLUHFRUUHVSRQGDXmFRQWUOHSHUX}

HWDXmVRXWLHQVRFLDOSHUX}SDUOHVXMHWSRXUIDLUHIDFHODVLWXDWLRQGHVWUHVV/HFRQWUOH
SHUXFRUUHVSRQGOLQYHQWDLUHGHVHVUHVVRXUFHVSHUVRQQHOOHVHWGHVDFDSDFLWFRQWUOHU
ODVLWXDWLRQHWOHVRXWLHQVRFLDOSHUXFRUUHVSRQGOLQYHQWDLUHGHVDLGHVSURWHFWLRQVHWYDOR
ULVDWLRQVUHODWLRQQHOOHVHWVRFLDOHVGLVSRQLEOHVSRXUOXL8QmFRQWUOHSHUX}HWXQmVRXWLHQ
VRFLDOSHUX}VRQWGHVSUGLFWHXUVSRVLWLIVGHOWDWGHVDQWXOWULHXUHQUGXLVDQWOLPSDFW
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QFHVVDLUHVGDQVODSULVHHQFKDUJHGHODPDODGLH8QVHQWLPHQWGHSHUWHGHFRQWUOHRXGDE
VHQFHGHVRXWLHQVRFLDOVDYUHGRQFGOWUH

&HVSKDVHVGYDOXDWLRQVRQWLQXHQFHVSDUGHVIDFWHXUVELRSV\FKRVRFLDX[HWSDUODWKRULH
SURIDQH GX SDWLHQW FI ,WHP  3DUPL OHV IDFWHXUV GWHUPLQDQWV RQ UHWURXYH TXH OHV LQGLYLGXV
SRVVGDQW FHUWDLQV WUDLWV GH SHUVRQQDOLW DVVRFLV  XQH UDFWLYLW SV\FKRSK\VLRORJLTXH DX
VWUHVVHWDX[PRWLRQVLPSRUWDQWHSUVHQWHURQWSOXWWXQVWUHVVSHUXOHY/HVLQGLYLGXVSRVV
GDQW FHUWDLQV WUDLWV GH SHUVRQQDOLW DVVRFLV  OD FUR\DQFH JQUDOLVH TXH OHV YQHPHQWV GH
VDYLHGSHQGHQWGHIDFWHXUVH[WHUQHVQRQPDWULVDEOHVRQSDUOHGHmOLHXGHFRQWUOHH[WHUQH}

La relation mdecin-malade

01

SUVHQWHURQW SOXWW XQ m FRQWUOH SHUX } IDLEOH DORUV TX OLQYHUVH OHV LQGLYLGXV SRVVGDQW
FHUWDLQV WUDLWV DVVRFLV  OD FUR\DQFH JQUDOLVH TXH OHV YQHPHQWV GH VD YLH GSHQGHQW GH
IDFWHXUVLQWHUQHVHQOLHQDYHFGHVDSWLWXGHVSHUVRQQHOOHVmOLHX[GHFRQWUOHLQWHUQH}SUVHQWH
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VLRQQHOOHVHWVRFLDOHVSHXVRXWHQDQWHVVHURQWSOXWWUHOLHVXQmVRXWLHQVRFLDOSHUX}IDLEOH

3.2.2.Phase

dajustement

/DSKDVHGDMXVWHPHQWRXGHFRSLQJHVWOHQVHPEOHGHVSURFHVVXVWUDQVDFWLRQQHOVTXXQLQGLYLGX
LQWHUSRVHHQWUHOXLHWODVLWXDWLRQVWUHVVDQWHDQGHUGXLUHVRQLPSDFW(OOHHVWGWHUPLQHQRWDP
PHQWSDUODSKDVHGYDOXDWLRQSUFGHQWH
*

 LOHSDWLHQWSHQVHTXLOSHXWFKDQJHUTXHOTXHFKRVHVDVLWXDWLRQGHPDODGLHLODGRSWHUDGHV
6
mVWUDWJLHVFHQWUHVVXUOHSUREOPH}

 LOHSDWLHQWSHQVHTXLOQHSHXWSDVJUDQGFKRVHIDFHVDVLWXDWLRQGHPDODGLHLODGRSWHUDGHV
6
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VXUOPRWLRQ}

5HVVRXUFHV
personnelles

5HVVRXUFHV
sociales

3HUFHSWLRQHWYDOXDWLRQ
des vnements de vie :
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Stratgies
de coping

Issues
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45

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Figure 2. Les processus de transaction, adapt de Bruchon-Schweitzer et Boujut, cf. Rfrences pour
approfondir .

4.

Applications
4XHOOHTXHVRLWODVLWXDWLRQOLQIRUPDWLRQWUDQVPLVHGRLWWUHOR\DOHFODLUHDSSURSULHDGDSWH
la situation et comprise par le patient. Le patient peut souhaiter que ses proches soient prsents
ORUVGHODWUDQVPLVVLRQGLQIRUPDWLRQVHWFHODGRLWWUHDFFHSW
&KH]OHVHQIDQWVOLQIRUPDWLRQHVWWUDQVPLVHDX[SDUHQWVPDLVJDOHPHQWOHQIDQW&KH]OHVDGROHV
FHQWVHQSDUWLFXOLHULOQHIDXWSDVRXEOLHUGHSURSRVHUXQPRPHQWGFKDQJHVHXOVDQVOHVSDUHQWV

4.1.

Lannonce dune maladie grave ou svre

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IDRQVXLYDQWH
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3
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avec les proches si le patient le souhaite.

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item 60

Dcrire lorganisation
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I. Pour comprendre
II. Contexte pidmiologique
III. Ore de soins en psychiatrie adulte
IV. Ore de soins en pdospychiatrie
V. Ore de soins spcifiques

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centres de soins

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tablissements publics de sant mentale

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la dsinstitutionalisation,

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'
VRLQVSV\FKLDWULTXHJQUDOLVWHHWGHSUR[LPLWQLYHDX,HW,,SRXYDQWVDSSX\HUVXUOHGYH
ORSSHPHQWGXQHRUHGHVRLQVLQQRYDQWVKDXWHPHQWVSFLDOLVVQLYHDX,,,

Lordonnance du 4 septembre 2003 :

'QLW OHV territoires de sant  TXL GHYLHQQHQW OFKHORQ GH UIUHQFH SRXU ORUJDQLVDWLRQ GH
ORUHGHVRLQVSV\FKLDWULTXHHWQRQSV\FKLDWULTXH&HWWHYROXWLRQLPSOLTXHXQHVROLGDULWHWXQH
FRPSOPHQWDULWHQWUHOHVGLUHQWVWDEOLVVHPHQWVGXWHUULWRLUHHWVRXWLHQOHSULQFLSHGHOLQWHU
VHFWRULDOLWSRXUFHUWDLQVVRLQVVSFLTXHV
La loi HPST (hpital, patients, sant et territoires) de 2009 :
3RUWHODFUDWLRQGHV$56DJHQFHUJLRQDOHGHVDQWFKDUJHVGHGQLUGHQRXYHDX[WHUULWRLUHV
GHVDQWSHUWLQHQWVSRXUOXWWHUFRQWUHOHVLQJDOLWVGHVDQW/HVFRPSWHQFHVGHV$56VRQWODU
JLHVODSODQLFDWLRQGHORUHPGLFRVRFLDOH
La loi du 5 juillet 2011 :
/HUOHGHV$56HVWFRQIRUWQRWDPPHQWGDQVODFRRUGLQDWLRQGHVVRLQVHQWUHOHVWDEOLVVHPHQWV
de sant.

3.2.

Modalits de prise en charge en psychiatrie

7URLVJUDQGVPRGHVGHSULVHHQFKDUJHHQSV\FKLDWULHDGXOWHVRQWFODVVLTXHPHQWGLVWLQJXV
*

DPEXODWRLUH

KRVSLWDOLVDWLRQFRPSOWH

VRLQVVTXHQWLHOVKRVSLWDOLVDWLRQGHMRXURXGHQXLW&$773

/DSV\FKLDWULHHVWODVHXOHGLVFLSOLQHPGLFDOHGLVSRVDQWGXGURLWGHVRLJQHUVDQVOHFRQVHQWHPHQW
GHODSHUVRQQHFI,WHP/HVGLUHQWVW\SHVGHVRLQVVDQVFRQVHQWHPHQWHQKRVSLWDOLVDWLRQ
FRPSOWHRXDPEXODWRLUHVRQWOHSOXVVRXYHQWGOLYUVSDUOHVVHUYLFHVGHSV\FKLDWULHSXEOLTXH
PDLVFHUWDLQVWDEOLVVHPHQWVSULYVSHXYHQWJDOHPHQWDVVXUHUFHW\SHGHVRLQV

53

60

Gnralits

3.2.1. Lambulatoire
'QLWOHQVHPEOHGHVSULVHVHQFKDUJHTXLQHIRQWSDVLQWHUYHQLUGKRVSLWDOLVDWLRQ,OVRUJDQLVH
selon diverses modalits :
*

Consultations ambulatoiresOHVFHQWUHVPGLFRSV\FKRORJLTXHV&03VRQWOHVVWUXFWXUHVSLYRW

GXVHFWHXUHQDPRQWHWHQDYDOGHOKRVSLWDOLVDWLRQLOVSHUPHWWHQWXQHFRRUGLQDWLRQGXSDUFRXUV
GHVRLQVSV\FKLDWULTXHV/HVVRLQV\VRQWGLVSHQVVJUDWXLWHPHQWSRXUHQIDFLOLWHUODFFV

/HV&03UHJURXSHQWGHVFRPSWHQFHVPXOWLSOHVDXVHLQGTXLSHVPXOWLGLVFLSOLQDLUHVPGHFLQV
SV\FKRORJXHVWUDYDLOOHXUVVRFLDX[HUJRWKUDSHXWHVVRFLRWKUDSHXWHVTXLDVVXUHQWXQHRUH
GLYHUVLHGHVRLQVSDUH[HPSOH
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 O KRVSLWDOLVDWLRQ  GRPLFLOH +$' SHUPHW GRULU GHV VRLQV m LQWHQVLIV } DX GRPLFLOH GX
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 O DFFXHLOHQDSSDUWHPHQWWKUDSHXWLTXHODVRUWLHGHOKSLWDOHWSHQGDQWXQHGXUHOLPLWH
SHUPHW GH GYHORSSHU OHV KDELOHWV GH OD YLH TXRWLGLHQQH HW GH UHVWDXUHU ODXWRQRPLH GX
patient. Il ncessite le passage quotidien de personnels soignants.
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La psychiatrie de liaisonUSRQGDX[EHVRLQVGLQWHUYHQWLRQVHQXQLWVGKRVSLWDOLVDWLRQQRQ
SV\FKLDWULTXH0&26RXYHQWRUJDQLVHVHORQXQGLVSRVLWLILQWHUVHFWRULHOHOOHSHXWJDOHPHQW
WUHRUJDQLVHSRXUUHQGUHGHVDYLVGDQVOHVVHUYLFHVGDFFXHLOGXUJHQFHVGHVKSLWDX[JQ
UDX[RXGDQVGHVVWUXFWXUHVPGLFRVRFLDOHVRXGHV(+3$'

3.2.2.Lhospitalisation
*
54

Lhospitalisation temps plein (90 % du temps complet) FRUUHVSRQGOKRVSLWDOLVDWLRQmWUDGL

WLRQQHOOH}DXVHLQGHOKSLWDOKSHQGDQWODSKDVHDLJXGHODPDODGLH

(OOHLQVWDXUHXQHUXSWXUHDYHFOHPLOLHXVRFLDOHWIDPLOLDO
/HVXQLWVGKRVSLWDOLVDWLRQSHXYHQWWUHORFDOLVHVDXVHLQGHV&+6FHQWUHKRVSLWDOLHUVSFLD
OLV&+*FHQWUHKRVSLWDOLHUJQUDORX&+5FHQWUHKRVSLWDOLHUUJLRQDO
GHORUHGKRVSLWDOLVDWLRQHVWGDQVOHVHFWHXUSULY
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Les centres de postcure VRQW GHV XQLWV GH PR\HQ VMRXU GH WUDQVLWLRQ HQWUH OKSLWDO HW OH
UHWRXUDXGRPLFLOHSHQGDQWODSKDVHDLJXGHODPDODGLH

'HVVRLQVLQWHQVLIVGHUKDELOLWDWLRQSHXYHQW\WUHGOLYUVHQUIUHQFHDX[SULQFLSHVGHODSV\FKR
WKUDSLHLQVWLWXWLRQQHOOHRXGHODUKDELOLWDWLRQSDUOHWUDYDLO/HVVRLQVYLVHQWOLPLWHUOHKDQGLFDS
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*

Le centre daccueil et de crise durgence (CAC) ou U72LOVDJLWGHVWUXFWXUHVKRVSLWDOLUHVGDF

FXHLOGHVSDWLHQWVHQVLWXDWLRQGHFULVHVRXYHQWDGRVVHVDXVHUYLFHVGDFFXHLOGXUJHQFHGHV
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OLPLWHUOHVKRVSLWDOLVDWLRQVHQVHUYLFHGHSV\FKLDWULHSDUWLUGHVGLVSRVLWLIVGXUJHQFHV

3.2.3. Les

soins squentiels

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WDOGHQXLW
*

Lhpital de jour (HDJ)LOVGLVSHQVHQWGHVVRLQVSRO\YDOHQWVHWLQWHQVLIVGXUDQWODMRXUQHXQ

RXSOXVLHXUVMRXUVSDUVHPDLQH,ODSRXUREMHFWLIGYLWHUODFKURQLFLVDWLRQHWGHSUSDUHUOD
rinsertion dans le milieu de vie.

Lhpital de nuitLOVSHUPHWWHQWXQHSULVHHQFKDUJHWKUDSHXWLTXHGHQGHMRXUQHHWXQH
VXUYHLOODQFHPGLFDOHGHQXLWYRLUHHQQGHVHPDLQH

Lorganisation de lore de soins en psychiatrie

3.3.

60

Les centres daccueil thrapeutique temps partiel (CATTP) : ils dispensent des activits thra
SHXWLTXHVHWRFFXSDWLRQQHOOHV,OVIDYRULVHQWODUHFRQVWUXFWLRQGHODXWRQRPLHHWODUDGDSWD
tion sociale.

Professionnels du dispositif de soins psychiatriques

/HVVRLQVSV\FKLDWULTXHVVRQWGOLYUVSDUXQHTXLSHPXOWLGLVFLSOLQDLUHTXLUHJURXSHGHVFRPS
tences diverses :
*

/HSHUVRQQHOPGLFDOSV\FKLDWUHV

/ H SHUVRQQHO QRQ PGLFDO FDGUHV LQUPLHUV DLGHVRLJQDQWV SV\FKRORJXHV DVVLVWDQWV

VRFLDX[SHUVRQQHOGHUGXFDWLRQSV\FKRPRWULFLHQRUWKRSKRQLVWHHUJRWKUDSHXWHSHUVRQ
QHOGXFDWLIDQLPDWHXUGXFDWHXUVHFUWDLUHVPGLFDOHVDJHQWVGHVHUYLFHVKRVSLWDOLHUV

Les quipes multidisciplinaires travaillent en troit partenariat avec :

*

Les autres professionnels de sant :

 les mdecins gnralistes : ils reprsentent le premier recours lors de la demande initiale
de soins et parfois galement le dernier interlocuteur accept par des patients en rupture
de soins avec le secteur,
 la mdecine spcialise.

/ HVSDUWHQDLUHVVRFLDX[HWPGLFDX[VRFLDX[LPSOLTXVGDQVOHVGLUHQWVEHVRLQVGDFFRP
SDJQHPHQWGHVSDWLHQWVKEHUJHPHQWIR\HUVRFFXSDWLRQQHOVIR\HUGDFFXHLOPGLFDOLVV
PDLVRQV GDFFXHLO VSFLDOLV DFFRPSDJQHPHQW GDQV OD FLW 6$96 RX 6$06$+ WUDYDLO
SURWJ(6$7

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Les maires dans le cadre des conseils locaux de sant mentale.

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 8
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4.

Offre de soins en pdopsychiatrie

4.1.

Le secteur de pdopsychiatrie

4.1.1. Objectifs
&RPPHSRXUODSV\FKLDWULHDGXOWHOHEXWHVWGLQVWDOOHUODSUYHQWLRQHWODFRQWLQXLWGHVVRLQV
dans la communaut pour les enfants et adolescents.
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*

 ULRULWGRQQHDX[OLHQVHQWUHOHQIDQWHWVRQPLOLHXIDPLOLDOHWVRFLDOYLWHUOHVVSDUDWLRQV
S
et les ruptures,

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VRFLDX[DVVRFLDWLRQVGHSDUHQWV

55

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Gnralits

4.1.2. Historique

et volution actuelle

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&HVWODSSOLFDWLRQGHODFLUFXODLUHGHPDUVDSUVFHOOHGHTXLPHWYULWDEOHPHQWHQSODFH
OHVHFWHXUGHSGRSV\FKLDWULH

4.2.

Modalits de prise en charge en pdopsychiatrie

2Q QRWH OHV PPHV TXHQ SV\FKLDWULH DGXOWH PDLV OHV UHFRXUV GDQV FKDFXQH GHV VWUXFWXUHV
GLUHQW

4.2.1. Lambulatoire
*

/ HFHQWUHPGLFRSV\FKRORJLTXH&03UHVWHODVWUXFWXUHSLYRWGXVHFWHXUHQSGRSV\FKLDWULH

HWUHSUVHQWHODSUHPLUHVWUXFWXUHXWLOLVHHQSGRSV\FKLDWULH

/DSGRSV\FKLDWULHGHOLDLVRQVXUWRXWDX[XUJHQFHVHQSGLDWULHHWHQPDWHUQLW

/KRVSLWDOLVDWLRQGRPLFLOH

/DFFXHLOIDPLOLDOWKUDSHXWLTXH

4.2.2.Lhospitalisation

56

/KRVSLWDOLVDWLRQWHPSVSOHLQUHSUVHQWHXQHVWUXFWXUHGHGHUQLHUUHFRXUV

Les centres de postcure.

&HQWUHGHFULVHHWFHQWUHGDFFXHLOSHUPDQHQW&$3UDUH

4.2.3.Les

4.3.

soins squentiels

+SLWDOGHMRXU+'-HVWODGHX[LPHVWUXFWXUHODSOXVXWLOLVHHQSGRSV\FKLDWULH

&HQWUHGDFWLYLWWHPSVSDUWLHO&$773VWUXFWXUHWUVXWLOLVHDXVVL

+SLWDOGHQXLWSOXWWUDUH

Professionnels du dispositif de soins pdopsychiatriques

/TXLSH GH VHFWHXU GH SGRSV\FKLDWULH HVW DXVVL PXOWLGLVFLSOLQDLUH /HV PPHV SURIHVVLRQQHOV
FRPSRVHQWXQHTXLSHGHVHFWHXUHQSV\FKLDWULHDGXOWHHWHQSGRSV\FKLDWULH
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SV\FKRPRWULFLHQVRUWKRSKRQLVWHVHWOHVSXULFXOWULFHV
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*

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PHQW30,$6(

Lorganisation de lore de soins en psychiatrie

4.4.

60

Lieux de prise en charge hors secteur

(structures mdico-sociales)
,OH[LVWHGHX[LQVWLWXWLRQVGHVRLQVDPEXODWRLUHV
*

Centre Mdico-psycho-pdagogiques (CMPP)

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QDLUHFRPPHGDQVOHV&03
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*

Centre daction mdico-social prcoce (CAMSP)

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de coordination.
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5.

Offre de soins spcifiques

5.1.

Psychiatrie durgence
(OOHHVWRUJDQLVHHQPDMRULWSDUOHVKSLWDX[JQUDX[DVVXUDQWXQ6$8
'DQVFHUWDLQVWHUULWRLUHVGDXWUHVUSRQVHVRQWSXWUHPLVHVHQSODFHTXLSHVPRELOHVSHUPD
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WOSKRQLTXHGSODFHPHQWGRPLFLOH

5.2.

Psychiatrie de liaison
/HVTXLSHVGHSV\FKLDWULHGHOLDLVRQVRQWPXOWLGLVFLSOLQDLUHVSV\FKLDWUHVSV\FKRORJXHVHWLQU
PLHUVHWLQWHUYLHQQHQWGDQVOHVVHUYLFHVGH0&2SRXUDVVXUHUOHVVRLQVHQVDQWPHQWDOH

5.3.

Addictologie
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Le dispositif est souvent intersectoriel.

5.4.

Psychiatrie de la personne ge
Il existe un grande transversalit et coordination des intervenants. Le dispositif est souvent
intersectoriel.

57

60

Gnralits

2QGLVWLQJXHWURLVW\SHVGHSULVHHQFKDUJH

5.5.

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+
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2QGLVWLQJXH

5.6.

58

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'
SV\FKLDWULTXHV

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carcrale uniquement.

Consultations de recours
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SDWLHQWVTXLQHVHPEOHQWSDVEQFLHUGHVVRLQVDVVXUVSDUOHXUPGHFLQJQUDOLVWHRXGDQV
OH FDV GH GRXWHV GLDJQRVWLTXHVSDWKRORJLHV FRPSOH[HVQFHVVLW GYDOXDWLRQ GH VRLQV VSFL
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Des consultations spcialises sont apparues depuis quelques annes : soins partags avec les
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de soins innovants dans leur territoire.
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QHOVFRQFHUQVSDUOHGLDJQRVWLFHWOYDOXDWLRQGHVWURXEOHVGXVSHFWUHDXWLVWLTXHQRWDPPHQW
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XQ&+8

Lorganisation de lore de soins en psychiatrie

60

Rsum

Mdicosocial
Structures plus ou
moins spcialises
Hbergement
EHPAD
FAM
MAS
IME
Foyers
Maisons relais
Lieux de vie...

Psychiatres

Secteur
Hospitalisation
complte
Hospitalisation
TP
De jour
De nuit

Psychiatrie
Secteur public
Intersecteur
Units
spcifiques
Prcarit
Grontologie
Addictologie

AS
secteur
Associatif du
sanitaire
Appartements
collectifs

Ambulatoire
CMP
CATTP

Griatrie
Urgences
Addictologie
Urologie
Mdecin gnraliste

Psychiatrie
Secteur priv

Foyers de jour, atelier

SAMSAH / SAVS

Psychiatrie librale
Cliniques prives

[Travail protg, ESAT]

Systme de ressources
Tutelle / curatelle
MDPH

Sanitaire hors
psychiatrie

Social
Familles

Associations
GEM
Familles
Usagers

Social droit commun

Hbergement CHRS / autres
CCAS
AS (CG)
Cap emploi
Scu, CMU
Associatif prcarit, Croix rouge...

Figure 1. Organisation de lore de soins en psychiatrie et en sant mentale, DRESS 2014.

Logement non spcialis

Logement secteur priv
Bailleurs sociaux

Travail non spcialis

ANPE
Entreprise

59

60

Gnralits

Caractristiques
socio-dmographiques

Environnement de lindividu
Qualit de vie sociale,
conomique, affective

Individu
Facteur culturel

Perception/dmarche

Stigmatisation

Perception du trouble
Perception besoin de soin
Recherche soin sant
(mentale)

Systme de sant
Assurance sociale

Recours
mdecin gnraliste
(rfrent)

Offre publique et prive,

de ville et en
tablissement de sant
Offre mdico-sociale
Niveau de remboursement

Mdecin rfre (ou non)

soins spcialiss
en sant mentale

Mdecin rfrent
Tarification

Non recours
des professionnels
de sant

Traitements
pharmacologiques

Soins spcialiss en psychiatrie et sant mentale

Soins non spcialiss

en psychiatrie et sant mentale
Urgences, Services MCO

Caractristiques
cliniques
Symptme, svrit,
comorbidit, anciennet
et chronicit des troubles

Offre,
disponibilit des services
et des professionnels

60

Genre, ge, statut marital, PCS,

niveau scolaire,
lieu de vie, isolement

tablissements
de sant publics

tablissements
de sant privs

Professionnels
de sant de ville :
psychiatres,
psychologues

Temps complet, temps partiel, ambulatoire

Figure 2. Le recours aux soins en psychiatrie, DRESS 2014.

Lorganisation de lore de soins en psychiatrie

60

Points clefs
Le secteur :
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* &03 VWUXFWXUHSLYRWGXVHFWHXU
* coordination et continuit des soins,
* insertion et maintien du patient dans la communaut.
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Multidisciplinarit.
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Soins de recours pour les situations complexes ou ncessitant un avis spcialis.

Rfrences pour approfondir

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61

partie 2

Situations
durgence

item 346

Agitation
et dlire aigus

346

I. Agitation
II. Dlire aigu

Objectifs pdagogiques
* Diagnostiquer une agitation et un dlire aigu.
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HQFKDUJHSUKRVSLWDOLUHHWKRVSLWDOLUHSRVRORJLHV

346 Situations durgence

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WLTXHPHQWDVVRFLV/DGPDUFKHGLDJQRVWLTXHHWWKUDSHXWLTXHGSHQGUDGHODSUVHQFHGXQ
VHXORXGHVGHX[V\QGURPHV/DJLWDWLRQHWOHVLGHVGOLUDQWHVQRQWSDVGHVSFLFLWGLDJQRV
WLTXHHWSHXYHQWVHUHQFRQWUHUGDQVGHQRPEUHX[WURXEOHV8QHFDXVHQRQSV\FKLDWULTXHGRLWWUH
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GOLUDQWHVGDSSDULWLRQUFHQWH

1.

Agitation
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PDLVGHVRQHQWRXUDJHTXLIDLWDORUVVRXYHQWDSSHOGHVVHUYLFHVGXUJHQFH&HWWHGHPDQGHSHXW
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2.1.1. Dfinition

dune ide dlirante

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2.1.2. Caractrisation

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2.1.3. Symptmes

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VRXYHQWXQHDJLWDWLRQSV\FKRPRWULFH&HSHQGDQWRQSHXWDXFRQWUDLUHREVHUYHUXQHLQKLELWLRQ
SRXYDQWDOOHUMXVTXODVLGUDWLRQ0PHVLHOOHUHVWHH[FHSWLRQQHOOHODSULQFLSDOHFRPSOLFDWLRQ
HVWOHSDVVDJHODFWHDXWRDJUHVVLI

79

347 Situations durgence

6\PSWPHVphysiques

5HVSLUDWRLUHV
Cardiovasculaires
Neurovgtatifs
Digestifs

6\PSWPHVpsychiques

Cognitions catastrophistes
mSHXUGHPRXULU}mSHXUGHGHYHQLUIRX}

6\PSWPHVcomportementaux

$JLWDWLRQSV\FKRPRWULFH
Sidration

Tableau 1. Smiologie de lattaque de panique.

4.

Le trouble psychiatrique

4.1.

Diagnostic positif
/H GLDJQRVWLF GH O$3 HVW XQ GLDJQRVWLF clinique /LQWHUURJDWRLUH GH OHQWRXUDJH SHXW WUH WUV
informatif.

80

DSM-IV-R
Critres de lattaque de panique

8QHSULRGHELHQGOLPLWHGHFUDLQWHRXGHPDODLVHLQWHQVHGDQVODTXHOOHDXPLQLPXPTXDWUHGHVV\PSWPHVVXLYDQWV
VRQWVXUYHQXVGHIDRQEUXWDOHHWRQWDWWHLQWOHXUDFPHQPRLQVGHGL[PLQXWHV
1. 3DOSLWDWLRQVEDWWHPHQWVGHFXURXDFFOUDWLRQGXU\WKPHFDUGLDTXH
2. Transpiration.
7UHPEOHPHQWVRXVHFRXVVHVPXVFXODLUHV
4. 6HQVDWLRQVGHmVRXHFRXS}RXLPSUHVVLRQGWRXHPHQW
6HQVDWLRQGWUDQJOHPHQW
6. Douleur ou gne thoracique.
 1DXVHRXJQHDEGRPLQDOH
6HQVDWLRQGHYHUWLJHGLQVWDELOLWGHWWHYLGHRXLPSUHVVLRQGYDQRXLVVHPHQW
9. 'UDOLVDWLRQVHQWLPHQWGLUUDOLWRXGSHUVRQQDOLVDWLRQWUHGWDFKGHVRL
10. 3HXUGHSHUGUHOHFRQWUOHRXGHGHYHQLUIRX
11. 3HXUGHPRXULU
12. 3DUHVWKVLHVVHQVDWLRQVGHQJRXUGLVVHPHQWRXGHSLFRWHPHQWV
)ULVVRQVRXERXHVGHFKDOHXU

Crise dangoisse aigu et attaque de panique

347

Ce qui change dans le DSM-5

/HVFULWUHVSULQFLSDX[GHO$3QRQWSDVVXELGHPRGLFDWLRQVPDMHXUHVGDQVOH'60&HSHQGDQWFHWWHFODVVLFDWLRQ
SURSRVHGHGLUHQFLHUGHX[W\SHVG$3mDWWHQGXHV}HWmQRQDWWHQGXHV}/HV$3mLQDWWHQGXHV}FRUUHVSRQGHQW
DX[$3mQRQSUYLVLEOHV}VXUYHQDQWVDQVIDFWHXUGFOHQFKDQWHWVHUDLHQWGRQFSOXVVSFLTXHVGXWURXEOHSDQLTXH
/HV$3mDWWHQGXHV}VHUDLHQWTXDQWHOOHVOHV$3SOXVSUYLVLEOHVHWUDFWLRQQHOOHVSDUH[HPSOHH[SRVLWLRQEUXWDOH
DXVWLPXOXVSKRERJQHGDQVODSKRELHVSFLTXH
/$3DSSDUDWJDOHPHQWGDQVOH'60FRPPHVSFLFDWHXUSRXUWRXWHVOHVSDWKRORJLHVGHODFODVVLFDWLRQSXLVTXHOOH
SHXWFRPSOLTXHUERQQRPEUHGHQWUHHOOHV

4.2.

Diagnostics diffrentiels
,OVDJLWHVVHQWLHOOHPHQWGHSDWKRORJLHVmdicales gnrales et toxiquesTXLOIDXWLPSUDWLYHPHQW
OLPLQHUDYDQWGHSRVHUOHGLDJQRVWLFG$3

4.2.1. Pathologies

mdicales non psychiatriques

&RPSWHWHQXGHVV\PSWPHVSK\VLTXHVDXSUHPLHUSODQGDQVO$3LOIDXWOLPLQHUXQHWLRORJLH
PGLFDOHQRQSV\FKLDWULTXH/HVSULQFLSDOHVSDWKRORJLHVOLPLQHUVRQW
*

des pathologies cardiovasculaires DQJRU LQIDUFWXV GX P\RFDUGH SRXVVH GLQVXVDQFH

FDUGLDTXHK\SHUWHQVLRQDUWULHOOHWURXEOHVGXU\WKPHHWF

GHVSDWKRORJLHVGHOappareil respiratoireDVWKPHHPEROLHSXOPRQDLUHHWF

des pathologies neurologiquesSLOHSVLHQRWDPPHQWOHVFULVHVSDUWLHOOHVWHPSRUDOHVFULVHV

PLJUDLQHXVHVDFFLGHQWVLVFKPLTXHVWUDQVLWRLUHVHWF

des pathologies endocriniennes K\SRJO\FPLH SKRFKURPRF\WRPH K\SHUWK\URGLH

V\QGURPHGH&XVKLQJK\SRSDUDWK\URGLHHWF

&HVSDWKRORJLHVGRLYHQWWUHUHFKHUFKHVDXPR\HQGXQH[DPHQclinique complet, appareil par

DSSDUHLOFRPSOWVLEHVRLQSDUGHVH[DPHQVSDUDFOLQLTXHVRULHQWVSDUOH[DPHQSK\VLTXH&HW
H[DPHQFOLQLTXHGRLWVHRUFHUGHQHSDVUHQIRUFHUOHSDWLHQWGDQVVDFRQYLFWLRQGDYRLUXQHSDWKR
logie mdicale gnrale.

4.2.2.Causes

toxiques

La prise de toxiquesDOFRROFDQQDELVFRFDQHHFVWDV\HWFGRLWWUHUHFKHUFKH,OVDJLWLFLSOXV

GXQOPHQWGFOHQFKHXUSDUWLFXOLHUGHO$3TXHGXQYULWDEOHGLDJQRVWLFGLUHQWLHOFHUWDLQHV
VXEVWDQFHVSRXYDQWJQUHUGHYULWDEOHV$3
Les causes iatrognes doivent galement tre voques, certains traitements pouvant favoriser
OHV$3HQFDVGHVXUGRVDJHFRUWLFRGHVKRUPRQHVWK\URGLHQQHVHWF
8QFRQWH[WHGHsevrageVHUDDXVVLUHFKHUFKDOFRROEHQ]RGLD]SLQHVHWF

4.3.

Notions de physio/psychopathologie
/D SK\VLRSDWKRORJLH GH OD FULVH GDQJRLVVH DLJX UHVWH PDO FRQQXH &HUWDLQHV PDQLIHVWDWLRQV
SK\VLTXHVSRXUUDLHQWWUHOLHVOK\SRFDSQLHVHFRQGDLUHOK\SHUYHQWLODWLRQVHQVDWLRQVYHUWL
JLQHXVHVSDUHVWKVLHVHWF

81

347 Situations durgence

'LUHQWV IDFWHXUV VRQW LPSOLTXV GDQV O$3 GHV IDFWHXUV ELRORJLTXHV DYHF G\VIRQFWLRQQH
PHQWGDQVODUJXODWLRQGHFHUWDLQVQHXURWUDQVPHWWHXUVFHUWDLQHVVXEVWDQFHVFRPPHODFKRO
F\VWRNLQLQHRXOHODFWDWHGHVRGLXPVRQWFDSDEOHVGHSURYRTXHUGHYULWDEOHV$3GHVIDFWHXUV
SV\FKRORJLTXHV DXWRUHQIRUFHPHQW GHV FRJQLWLRQV FDWDVWURSKLVWHV SDU OD VXUYHQXH GHV V\PS
WPHV SK\VLTXHV HW HQYLURQQHPHQWDX[ LQTXLWXGH GH OHQWRXUDJH UHQIRUDQW OHV FRJQLWLRQV
FDWDVWURSKLVWHV

5.

Le pronostic et lvolution

5.1.

Crise dangoisse aigu isole

8QSLVRGHG$3SHXWGHPHXUHUXQLTXH,OVDJLWDORUVOHSOXVVRXYHQWGXQH$3UDFWLRQQHOOHXQH
situation de stress.

5.2.

Crise dangoisse dans le cadre dune pathologie psychiatrique

/DWWDTXHGHSDQLTXHSHXWVLQVFULUHGDQVOHFDGUHGXQHSDWKRORJLHSV\FKLDWULTXH

5.2.1. Le
82

trouble panique

,OVHGQLWSDU
*

la rptition GHV $3 TXL VXUYLHQQHQW DX PRLQV HQ GEXW GYROXWLRQ GX WURXEOH GH PDQLUH
LPSUYLVLEOHHWVDQVIDFWHXUGFOHQFKDQWFI,WHP&

OHGYHORSSHPHQWGXQHanxit anticipatoire.

5.2.2.Autres

pathologies psychiatriques

/$3SHXWJDOHPHQWVXUYHQLUGDQVOHFDGUHGDXWUHVSDWKRORJLHVSV\FKLDWULTXHV
*

 RQIURQWDWLRQ  XQH VLWXDWLRQ SKRERJQH SKRELH VRFLDOH RX YRFDWULFH GXQ WUDXPDWLVPH
&
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  ODFP GH UXPLQDWLRQV DQ[LHXVHV RX GSUHVVLYHV WURXEOH DQ[LW JQUDOLVH SLVRGH

GSUHVVLIFDUDFWULV

Crise dangoisse aigu et attaque de panique

347

Symptomatologie AP
(cf. tableau 1)

Causes mdicales
gnrales
et toxiques

Examen physique
+/- paraclinique

Comorbidits
psychiatriques
OUI

Prise en charge
de ltiologie mdicale
non psychiatrique

NON

Prise en charge des comorbidits

(pisode dpressif caractris,
autres troubles anxieux, etc.)

Rptition des AP

NON

OUI

AP isole

Trouble panique

Information et rgles
hygino-dittiques

Prise en charge du
trouble panique
(cf. Item 64)

Figure 1. Orientation devant une AP.

6.

La prise en charge psychiatrique

6.1.

Prise en charge en urgence

'HYDQWXQH$3XQFHUWDLQQRPEUHGHPHVXUHVSKDUPDFRORJLTXHVHWQRQSKDUPDFRORJLTXHVVLP
SRVHQW2XWUHFHVPHVXUHVHWGDQVOHFRQWH[WHGHOXUJHQFHLOIDXWDXVVLLPSUDWLYHPHQWOLPLQHU
une urgence mdicale gnrale ou une prise de toxique3RXUODSULVHHQFKDUJHFIWDEOHDX

6.1.1. Mesures

non pharmacologiques

Les mesures de prise en charge non pharmacologiques sont primordiales :

*

Mise en condition LQVWDOODWLRQDXFDOPHVXSSUHVVLRQGHVOPHQWVDQ[LRJQHVLVROHPHQW

attitude empathique.

83

347 Situations durgence

*

RassuranceGXSDWLHQWLQIRUPHUVXUODEVHQFHGHGDQJHUGHPRUWVXUOHFDUDFWUHVSRQWDQ
PHQWUVROXWLIGHODWWDTXHGHSDQLTXH,OVDJLWLFLGHUHFRQQDWUHODVRXUDQFHVXEMHFWLYHGX
SDWLHQW/HVV\PSWPHVVRQWUHOVHWSDUWLFXOLUHPHQWGVDJUDEOHVPDLVSDVJUDYHVGDQVOH
VHQVGXQGDQJHUGHPRUW

Mesures de contrle respiratoireSHUPHWWHQWGHUHIRFDOLVHUODWWHQWLRQGXSDWLHQWHWGHOLPLWHU

OK\SHUYHQWLODWLRQ

6.1.2. Mesures

pharmacologiques

8Q WUDLWHPHQW SKDUPDFRORJLTXH anxiolytique doit aussi tre utilis, notamment si la crise se
prolonge.
/HWUDLWHPHQWGHUIUHQFHHVWODSUHVFULSWLRQGXQHbenzodiazpine par voie oraleFI,WHP
([HPSOHV
*

$OSUD]RODP;DQD[PJSHURVHQXQHSULVHUHQRXYHOHUVLQFHVVDLUH

/RUD]HSDP7HPHVWDPJSHURVHQXQHSULVHUHQRXYHOHUVLQFHVVDLUH

'LD]SDP9DOLXPPJSHURVHQXQHSULVHUHQRXYHOHUVLQFHVVDLUH

La voie parentrale ne prsente aucun avantage en terme de pharmacocintique et peut, au

contraire renforcer les cognitions catastrophistes du patient : la voie per os doit donc tre
privilgie.
,OVDJLWGXQWUDLWHPHQWSRQFWXHOSRXUODFULVHGDQVOHFRQWH[WHGHOXUJHQFH&HOXLFLQHGRLWSDV
tre reconduit au long cours.

84

6.1.3. Surveillance
/HFDFLWHWODWROUDQFHGXWUDLWHPHQWGRLYHQWWUHYDOXHV

6.1.4.Orientation

du patient

(QUJOHJQUDOHLOQ\DSDVGLQGLFDWLRQXQHSULVHHQFKDUJHHQKRVSLWDOLVDWLRQSRXUXQH$3
isole.
OLPLQHUXQHFDXVHmdicale gnrale ou toxique
Mesures non pharmacologiques

Mise en condition : isolement au calme

5DVVXUDQFH
Contrle respiratoire

Mesures pharmacologiques

7UDLWHPHQWDQ[LRO\WLTXHW\SHEHQ]RGLD]SLQH
par voie orale.
3DUH[HPSOHORUD]HSDPPJSHURV
HQXQHSULVHUHQRXYHOHUVLQFHVVDLUH

6XUYHLOODQFHGHOHFDFLWHWGHODWROUDQFHGXWUDLWHPHQW
Tableau 2. Prise en charge en urgence dune AP.

&HSHQGDQW OYDOXDWLRQ FOLQLTXH ULJRXUHXVH GRLW SHUPHWWUH GH UHSUHU OHV FRPRUELGLWV SV\FKLD
WULTXHV8QHKRVSLWDOLVDWLRQSRXUUDWUHHQYLVDJHHQFDVGHFRPRUELGLWVORXUGHVSLVRGHGSUHV
VLIFDUDFWULVGLQWHQVLWVYUHSDUH[HPSOHHQSDUWLFXOLHUVLOH[LVWHXQrisque suicidaire important.

Crise dangoisse aigu et attaque de panique

6.2.

347

Prise en charge distance

/DSULVHHQFKDUJHGLVWDQFHGHOSLVRGHDLJXGSHQGGXFRQWH[WHGDQVOHTXHOVLQVFULWO$3

6.2.1. Attaque

de panique isole

/LQIRUPDWLRQHWOGXFDWLRQWKUDSHXWLTXHVRQWIRQGDPHQWDOHVDYHFGHX[REMHFWLIV
*

$SSUHQGUHDXSDWLHQWUHFRQQDWUHXQHFULVHGDQJRLVVHDLJXHQFDVGHUFLGLYH

 UYHQLUXQHYHQWXHOOHUFLGLYHJUFHGHVUJOHVK\JLQRGLWWLTXHVVLPSOHVGLPLQXWLRQ
3
GHVFRQVRPPDWLRQVGHSV\FKRVWLPXODQWVUJOHVK\JLQRGLWWLTXHVGHVRPPHLOHWF

6.2.2.Attaque

de panique
dans le cadre dune pathologie psychiatrique

/DFULVHGDQJRLVVHDLJXSHXWVLQVFULUHGDQVOHFDGUHGXQHSDWKRORJLHSV\FKLDWULTXH'DQVFH
FDVODSULVHHQFKDUJHGHODSDWKRORJLHSV\FKLDWULTXHVRXVMDFHQWHHVWLQGLVSHQVDEOH
(QFDVGHUSWLWLRQGHVDWWDTXHVGHSDQLTXHXQHSULVHHQFKDUJHVSFLTXHGXWURXEOHSDQLTXH
GRLWWUHPLVHHQSODFHFI,WHP&

Rsum
85
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SHXWVXUYHQLUVRLWGHPDQLUHLVROHVRLWGDQVOHFDGUHGXQHSDWKRORJLHSV\FKLDWULTXHHQSDUWL
FXOLHUOHWURXEOHSDQLTXH,OVDJLWGXQWDEOHDXFOLQLTXHIUTXHQWFDUDFWULVSDUW\SHVGHV\PS
WPHVSK\VLTXHVUHVSLUDWRLUHVFDUGLRYDVFXODLUHVQHXURYJWDWLIVGLJHVWLIVHWFSV\FKLTXHV
FRJQLWLRQVFDWDVWURSKLVWHVSHXUGHPRXULUGHGHYHQLUIRXFRPSRUWHPHQWDX[GHODJLWDWLRQ
ODVLGUDWLRQ/HVFDXVHVPGLFDOHVJQUDOHVHWWR[LTXHVGRLYHQWLPSUDWLYHPHQWWUHOLPLQHV
SDU XQ H[DPHQ SK\VLTXH ULJRXUHX[ FRPSOW YHQWXHOOHPHQW SDU GHV H[DPHQV SDUDFOLQLTXHV
/DSULVHHQFKDUJHHQXUJHQFHGHO$3UHSRVHVXUGHVPHVXUHVQRQSKDUPDFRORJLTXHVPLVHHQ
FRQGLWLRQUDVVXUDQFHFRQWUOHUHVSLUDWRLUHHWSKDUPDFRORJLTXHWUDLWHPHQWDQ[LRO\WLTXHW\SH
EHQ]RGLD]SLQHSDUYRLHRUDOH

Points clefs
* /$3FRUUHVSRQGXQSLVRGHGDQ[LWSDUR[\VWLTXHELHQGOLPLWGDQVOHWHPSV
* /$3SHXWVXUYHQLUGHPDQLUHLVROHRXGDQVOHFDGUHGXQHSDWKRORJLHSV\FKLDWULTXHWURXEOHSDQLTXHQRWDPPHQW
* /$3 VH PDQLIHVWH  W\SHVGH V\PSWPHV SK\VLTXHV UHVSLUDWRLUHV FDUGLRYDVFXODLUHV QHXURYJWDWLIV GLJHV
WLIVHWFSV\FKLTXHVFRJQLWLRQVFDWDVWURSKLVWHVSHXUGHPRXULUGHGHYHQLUIRXFRPSRUWHPHQWDX[GHODJLWDWLRQ
ODVLGUDWLRQ
* /HVFDXVHVPGLFDOHVJQUDOHVHWWR[LTXHVGRLYHQWWUHOLPLQHVSDUXQH[DPHQSK\VLTXHULJRXUHX[FRPSOWYHQ
tuellement par des examens paracliniques.
* /DSULVHHQFKDUJHHQXUJHQFHGHO$3UHSRVHVXUGHVPHVXUHVQRQSKDUPDFRORJLTXHVPLVHHQFRQGLWLRQUDVVXUDQFH
FRQWUOHUHVSLUDWRLUHHWSKDUPDFRORJLTXHWUDLWHPHQWDQ[LRO\WLTXHW\SHEHQ]RGLD]SLQHSDUYRLHRUDOH

347 Situations durgence

Rfrences pour approfondir
*XHO-'5RXLOORQ)Manuel de psychiatrie. 2eGLWLRQ,VV\OHV0RXOLQHDX[(OVHYLHU0DVVRQ
S,6%1

86

item 348

Risque et conduite
suicidaires chez lenfant,
ladolescent et ladulte :

348

identification et prise en charge

$,'(17,),(5/(5,648(68,&,'$,5(
&+(=/(1)$17/$'2/(6&(17
(7/$'8/7(

%35,1&,3(6'(35(9(17,21
(7'(35,6((1&+$5*(

I. Introduction

,, 3ULQFLSHVde prise en charge

II. 5
 HSUHUODFULVHVXLFLGDLUH
HQIRQFWLRQGXWHUUDLQHWGHOJH

,,, 3DUWLFXODULWV
OLHVDXWHUUDLQHWOJH

, 3ULQFLSHVde prvention

III. YDOXHUODFULVHVXLFLGDLUH

Objectifs pdagogiques
* 'WHFWHUOHVVLWXDWLRQVULVTXHVXLFLGDLUHFKH]OHQIDQWFKH]ODGROHVFHQW
HWFKH]ODGXOWH
* Argumenter les principes de la prvention et de la prise en charge.

348 Situations durgence

Identifier le risque suicidaire chez lenfant ladolescent et ladulte

1.

Introduction

1.1.

Dfinitions
Les conduites suicidaires comprennent :
*

OHVVXLFLGHV

OHVWHQWDWLYHVGHVXLFLGH

OHVLGHVGHVXLFLGH

les quivalents suicidaires.

Le suicideHVWODFWHGOLEUGHQQLUDYHFVDSURSUHYLHHQWUDQDQWOHGFVGHOLQGLYLGX3RXU
'XUNKHLPLOVDJLWGHmODQGHODYLHUVXOWDQWGLUHFWHPHQWRXLQGLUHFWHPHQWGXQDFWHSRVLWLIRX
QJDWLIGHODYLFWLPHHOOHPPHTXLVDLWTXHOOHYDVHWXHU}
/HVXLFLGHVWOLQGLYLGXTXLVHVWGRQQODPRUWYRORQWDLUHPHQW

88

Attention
4XDQGXQHSHUVRQQHGFGHSDUVXLFLGHRQSDUOHGHVXLFLGHmDERXWL}HWSDVGHVXLFLGHmUXVVL}

La tentative de suicideFRUUHVSRQGWRXWDFWHGOLEUYLVDQWDFFRPSOLUXQJHVWHGHYLROHQFHVXU
VDSURSUHSHUVRQQHSKOERWRPLHSUFLSLWDWLRQSHQGDLVRQDUPHIHXLQWR[LFDWLRQDXJD]RX
LQJUHUXQHVXEVWDQFHWR[LTXHRXGHVPGLFDPHQWVXQHGRVHVXSULHXUHODGRVHUHFRQQXH
FRPPHWKUDSHXWLTXH&HWDFWHGRLWWUHLQKDELWXHOOHVFRQGXLWHVDGGLFWLYHVDOFRROGURJXHV
VRQWGRQFH[FOXHVDLQVLTXHOHVDXWRPXWLODWLRQVUSWHVHWOHVUHIXVGHVDOLPHQWHU
Le suicidant HVWOLQGLYLGXVXUYLYDQWVDWHQWDWLYHGHVXLFLGH
Les ides suicidaires FRUUHVSRQGHQWODSHQVHGHVHGRQQHUODPRUWOODERUDWLRQFRQVFLHQWH
GXQGVLUGHPRUWTXLOVRLWDFWLIRXSDVVLI4XDQGFHVLGHVVRQWH[SULPHVRQSDUOHGHPHQDFHV
suicidaires.
Le suicidaire HVWOLQGLYLGXD\DQWGHVLGHVVXLFLGDLUHVHWRXH[SULPDQWYHUEDOHPHQWRXFRPSRUWH
mentalement des menaces suicidaires.
Les quivalents suicidaires VRQWGHVFRQGXLWHVULVTXHPHWWDQWHQMHXODYLHGXVXMHWVDQVTXLO
en ait rellement conscience. Cependant, il ne faut pas forcment, comme pour certains gestes
DXWRDJUHVVLIVVFDULFDWLRQVOHVFRQVLGUHUFRPPHGHVWHQWDWLYHVGHVXLFLGH

1.2.

La crise suicidaire
La crise suicidaire HVW XQH FULVH SV\FKLTXH GDQV XQ FRQWH[WH GH YXOQUDELOLW DYHF OH[SUHVVLRQ
GLGHVHWGLQWHQWLRQVVXLFLGDLUHV

Risque et conduite suicidaires chez lenfant, ladolescent et ladulte

348

/HULVTXHPDMHXUHVWODWHQWDWLYHGHVXLFLGHHWVRQDERXWLVVHPHQWOHGFVSDUVXLFLGH,OVDJLW

GXQPRPHQWGRQQDYHFXQGEXWHWXQHQGDQVODYLHGXQLQGLYLGXRVHVUHVVRXUFHVDGDS
WDWLYHVVRQWSXLVHVOLQGLYLGXGRQWOHVPFDQLVPHGDMXVWHPHQWFI,WHPVRQWGSDVVHVVH
VHQWGDQVXQHLPSDVVHHWOHVLGHVVXLFLGDLUHVYRQWHQVDXJPHQWDQWDYHFOFKHFGHVGLUHQWHV
alternatives HQYLVDJHV /H VXLFLGH YD SURJUHVVLYHPHQW DSSDUDWUH  OLQGLYLGX FRPPH OXQLTXH
VROXWLRQSHUPHWWDQWGHVRUWLUGHOWDWGHFULVHGDQVOHTXHOLOVHWURXYH&HWWHFULVHHVWrversible et
temporaireHWOHVXLFLGHHVWXQHGHVVRUWLHVSRVVLEOHVGHFHWWHFULVHTXLHQIDLWWRXWHVDJUDYLW/D
JXUHVXLYDQWHLOOXVWUHFHFRQFHSW

Alternative 1

chec
GHODOWHUQDWLYH
chec
GHODOWHUQDWLYH

Alternative 2

Alternative 2

Alternative 3

Alternative 3

Alternative 3

Alternative 4

Alternative 4

Alternative 4

Alternative 4

Suicide

Suicide

Suicide

Suicide

chec
GHODOWHUQDWLYH
chec
GHODOWHUQDWLYH
Suicide

Figure 1. Prsentation schmatique de la crise suicidaire : les ides de suicide se font de plus en plus
prsentes au fur et mesure de lvolution de la crise suicidaire.

Cliniquement, la crise suicidaire peut se manifester initialement par :

*

GHVV\PSWPHVQRQVSFLTXHVGXUHJLVWUHGSUHVVLIRXDQ[LHX[

XQHDSSWHQFHDOFRROLTXHHWWDEDJLTXH

XQUHWUDLWSDUUDSSRUWDX[PDUTXHVGDHFWLRQHWDXFRQWDFWSK\VLTXH

DLQVLTXXQLVROHPHQW

3XLVFHWWHFULVHSHXWVHPDQLIHVWHUSDUFHUWDLQHVLGHVHWFRPSRUWHPHQWVSURFFXSDQWV
*

XQVHQWLPHQWGHGVHVSRLU

XQHVRXUDQFHSV\FKLTXHLQWHQVH

XQHUGXFWLRQGXVHQVGHVYDOHXUV

XQF\QLVPH

XQJRWSRXUOHPRUELGH

HWXQHUHFKHUFKHVRXGDLQHGDUPHVIHX

$XFRXUVGHOYROXWLRQXQHDFFDOPLHTXLSHXWIDLUHFUDLQGUHXQV\QGURPHGH5LQJHOYRTXSOXV
ORLQHWXQFRPSRUWHPHQWGHGSDUWVRQWGHVVLJQHVGHWUVKDXWULVTXH

89

348 Situations durgence

1.3.

pidmiologie

pour en savoir plus

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* /DPRUWDOLWHVWYDOXHSDUWLUGHVFHUWLFDWVGHGFV&SL'FPDLVOHVXLFLGHQ\HVWSDVWRXMRXUVUHFRQQXFRPPH
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sentinelle.

Concernant les idations suicidaires :

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avoir eu des ides suicidaires.

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tentative de suicide.

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*

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Risque et conduite suicidaires chez lenfant, ladolescent et ladulte

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FKH]OHVKRPPHVGHDQVRXSOXV

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XQWURXEOHPHQWDODXPRPHQWGXGFV$LQVLOHFKLUHGHODPRUWDOLWSDUVXLFLGHHVWLOVRXYHQW
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(
les 4 minutes.

348

Attention
Les facteurs de risques sont prsents en dtail dans la partie valuation du risque suicidaire.

2.

Reprer la crise suicidaire

en fonction du terrain et de lge
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2.1.

Lexpression GLGDWLRQVVXLFLGDLUHVRXGLQWHQWLRQVXLFLGDLUH

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Le contexte de vulnrabilit.

La crise suicidaire chez lenfant et ladolescent

2.1.1. La

crise suicidaire chez lenfant

Les enfants expriment rarement des ides et des intentions suicidaires.

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PHQWVIDPLOLDX[OHQWUHDXFROOJHXQFRQWH[WHGHPDOWUDLWDQFH

91

348 Situations durgence

2.1.2. La

crise suicidaire chez ladolescent

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2.2.

La crise suicidaire chez ladulte et lg

2.2.1. La

crise suicidaire chez ladulte

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2.3.

La crise suicidaire chez un patient

atteint dune pathologie psychiatrique
Les patients peuvent facilement exprimer des ides suicidaires ou, au contraire, les dissimuler.
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marquer une augmentation du risque :

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3.

valuer la crise suicidaire

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patient sur ses ides de suicide. Cette attitude, loin de renforcer le risque suicidaire, ne peut que
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3.1.

valuation du risque
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Familiaux :
 Antcdents suicidaires familiaux.
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vnements de vie :
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93

348 Situations durgence

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amis sont autant de facteurs protecteurs.

3.2.

valuation de lurgence
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valuation de la dangerosit
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Risque et conduite suicidaires chez lenfant, ladolescent et ladulte

348

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Urgence faible

Urgence moyenne

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Bonne alliance thrapeutique

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de communication

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directement ou indirectement
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sion ou au contraire
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le suicide

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suicidaire prcis

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intention claire

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qui viennent

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fragile

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motif, agit ou anxieux

95

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changes interpersonnels. Ces signes ne sont pas rassurants et cachent un envahissement fantasmatique par des
idations suicidaires.

348 Situations durgence

Principes de prvention et de prise en charge

1.

Principes de prvention

Application
la
suicidologie

Prvention primaire

Prvention secondaire

(OOHFRQFHUQHOHVVXMHWVTXLQHVRQWSDV
en crise suicidaire mais qui prsentent

Dpistage prcoce de la crise

suicidaire pour arrter le proces
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des facteurs de risques. La suppression

des facteurs de risque et des facteurs
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tant est dtect, une hospitalisa
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tertiaire

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charge des
suicidants
est dtaille
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96

2.

Principes de prise en charge

2.1.

Abord du patient
Lentretien doit se faire dans un endroit calme, en toute confidentialit et en face face. Il a pour
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ses motions.
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Risque et conduite suicidaires chez lenfant, ladolescent et ladulte

348

2QSHXWreprer des soutiens possibles dans lentourageGMDXFRXUDQWRXQRQHWSURSRVHUDX

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La participation du patient aux soins doit tre value.
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2.2.

8QHFULVHVXLFLGDLUHGDQVXQFRQWH[WHGHFULVHSV\FKRVRFLDOH

8QHFULVHVXLFLGDLUHHQUDSSRUWDYHFXQWURXEOHPHQWDO

Conduite tenir en urgence

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WHQWDWLYHGHVXLFLGHRXORUVGXQHLQWR[LFDWLRQDOFRROLTXHRXORUVGXQHDWWDTXHGHSDQLTXHHWF
/DFFXHLOGRLWVHIDLUHDXFDOPHGDQVXQER[HQHVVD\DQWGHJDUGHUDXWRXUGXSDWLHQWOHVPPHV
LQWHUORFXWHXUVHWGRLWFRQWULEXHUVFXULVHUOHSDWLHQW
$SUVstabilisation du patient PR\HQVGHUDQLPDWLRQDGDSWVXQDYLVSV\FKLDWULTXHHWRXXQH
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Devant un risque suicidaire imminent.

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/HEXWGHOHQWUHWLHQSV\FKLDWULTXHHVWGHUDOLVHUOYDOXDWLRQGHODSV\FKRSDWKRORJLHGHODFULVH
suicidaire mais aussi la dcision de la prise en charge :
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WUHERUQHGDQVOHWHPSV

2.2.1. Indications

de lhospitalisation

/hospitalisation VLPSRVHHQFDVGHQLYHDXGurgence leve.

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/hospitalisation a les objectifs suivants :
*

3URWJHUODSHUVRQQHHQlimitant le risque de passage lacte suicidaire.

Faciliter la rsolution de la crise DOWHUQDWLYHV HQ PHWWDQW HQ SODFH XQH SV\FKRWKUDSLH GH
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Mettre en place un suivi ultrieur en ambulatoire.

Mettre en place un traitement psychiatriqueDGDSWODSDWKRORJLHHQFDXVH

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DDLUHVHWUHWUDLWGHVREMHWVGDQJHUHX[HWDVVXUHUXQHsurveillance rapproche FKDPEUHSUV
GHOLQUPHULH

97

348 Situations durgence

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DOWHUQDWLYHVSRVVLEOHVDXSURMHWGHVXLFLGH/HQWUHWLHQGRLWVDWWDFKHUYDORULVHUOHVOPHQWVSRVLWLIVGHODYLHGX
patient, de sa personnalit.
'HODPPHPDQLUHTXHFHVRLWHQKRVSLWDOLVDWLRQRXHQDPEXODWRLUHLOIDXGUDWUDLWHUXQWURXEOHSV\FKLDWULTXHFRPPH
par exemple un pisode dpressif caractris.
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mDQWLVXLFLGH}

2.3.

Suivi ambulatoire et organisation de la post-crise

En cas de prise en charge ambulatoire :

98

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Lentourage doit tre proche et disponible &ODLUHPHQW LO IDXW LGHQWLHU OHV UHVVRXUFHV DFFHV
VLEOHVGDQVOHQWRXUDJHHWVDVVXUHUTXHOOHVVRQWVXVDQWHVSRXUVRXWHQLUOHSDWLHQW

La continuit des soins GRLWWUHHQYLVDJHWRUJDQLVHGVOHGEXWGHODSULVHHQFKDUJHGHFULVH

Les modalits proposes seront adaptes au stade volutif de la crise, au moment de la prise en
FKDUJHDXFRQWH[WHGDQVOHTXHOHOOHVLQVFULWHWDX[SURIHVVLRQQHOVRXLQWHUYHQDQWVVROOLFLWV
La prise en charge doit tenir compte du contexte familial et des entretiens familiaux peuvent tre
proposs.
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SV\FKLDWULTXHHQKRVSLWDOLVDWLRQRXHQDPEXODWRLUH
8QHpsychothrapieSHXWWUHLQGLTXHSRXUWUDLWHUOHVIDFWHXUVSV\FKRSDWKRORJLTXHVGHYXOQUD
ELOLWRXHQGLPLQXHUOHVHHWVFULWLTXHV
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/assistant(e) social(e) MRXHDXVVLXQUOHLPSRUWDQWHQFDVGHFULVHSV\FKRVRFLDOH
'XUDQWOanne qui suit le dbut de la crise, le risque de rcidive important fait recommander la plus
grande vigilance.

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Risque et conduite suicidaires chez lenfant, ladolescent et ladulte

3.

348

Particularits lies au terrain et lge

(QSOXVGHVOPHQWVSUFGHPPHQWGFULWVLOH[LVWHFHUWDLQHVSDUWLFXODULWVOLHVDXWHUUDLQ
prendre en compte.

3.1.

La crise suicidaire chez lenfant et ladolescent

3.1.1. La

crise suicidaire chez lenfant

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*

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, OIDXWVLJQDOHUDXPGHFLQVFRODLUHTXLIHUDOHOLHQDYHFOHPGHFLQJQUDOLVWHHWRXOHPGHFLQ
spcialiste.

(QFDVGHcrise suicidaire avre, une hospitalisation est ncessaire pendant quelques jours pour
dbuter une prise en charge mdico-pdopsychiatrique adapte.

3.1.2. La

crise suicidaire chez ladolescent

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OPHQWVVXLYDQWVJXLGHQWODFRQGXLWHWHQLU
*

, OIDXWFUHUXQFOLPDWGHPSDWKLHDYHFOHMHXQHTXLYDSHUPHWWUHVRQDFFRPSDJQHPHQWYHUVOHV
SURIHVVLRQQHOVGHOWDEOLVVHPHQWPGHFLQLQUPLUHSV\FKRORJXHRXDVVLVWDQWHVFRODLUH
la famille et le mdecin traitant.

Il faut avoir recours aux rseaux spcialiss existants.

(QFDVGHcrise suicidaire avre et en particulier en cas de tentative de suicide, la prise en charge

hospitalire est favorise. Le suivi ambulatoire sera mettre en place ds la sortie(QFDVGHQRQ
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3.2.

La crise suicidaire chez ladulte et lg

3.2.1. La

crise suicidaire chez ladulte

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99

348 Situations durgence

3.2.2.

La crise suicidaire chez lg

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SK\VLTXHHWRXXQHPDOWUDLWDQFH

(QFDVGHFULVHVXLFLGDLUHDYUHODSULVHHQFKDUJHGRLWSDUWLFXOLUHPHQWYHLOOHUrechercher des
moyens de mort violente et les enlever du domicile.

3.3.

La crise suicidaire chez un patient

atteint dune pathologie psychiatrique
/RUVTXXQHFULVHVXLFLGDLUHHVWGSLVWHFKH]XQSDWLHQWGMVXLYLHQSV\FKLDWULHOHVOPHQWV
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*

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(QFDVGHFULVHVXLFLGDLUHDYUHODSULVHHQFKDUJHVDSSXLHJQUDOHPHQWVXUOhospitalisation.
100

Rsum
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Points clefs
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partie 3

Les situations
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item 57

Sujets en situation
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particularits.
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situation de prcarit.

57

57

Les situations risque spcifiques

1.

Origine et dfinition
du concept de prcarit
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contre ces personnes.
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deviennent des lieux de soins, plus que de refuge.
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populations.

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GRQWOHVFRQWRXUVVRQWVRXYHQWGLFLOHVDSSUKHQGHU

104

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4,9 millions de personnes.

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item 67

Troubles psychiques
de la grossesse
et du post-partum
I. Introduction
II. Les facteurs de risques
III. *URVVHVVHFKH]XQHIHPPHSUVHQWDQWGHVWURXEOHVSV\FKLDWULTXHV
IV. /HVWURXEOHVSV\FKLTXHVSHQGDQWODJURVVHVVH
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67

67

Les situations risque spcifiques

1.

Introduction
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2.1.

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Facteurs gyncologiques et obsttricaux

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Troubles psychiques de la grossesse et du post-partum

3.

3.1.

67

Grossesse chez une femme

prsentant des troubles psychiatriques
Troubles bipolaires, dpressif rcurrent, schizophrnie
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3.2.

Addictions
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vers une proposition de suivi spcialis.
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3.3.

Prcautions demploi des psychotropes

au cours de la grossesse
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posologie.

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la grossesse.

115

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Les situations risque spcifiques

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3.3.1. Les

anxiolytiques

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documents et seront utiliss prfrentiellement.
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thymorgulateurs :

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pour en savoir plus : en pratique

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Troubles psychiques de la grossesse et du post-partum

4.

4.1.

67

Les troubles psychiques

pendant la grossesse
Nauses et vomissements gravidiques
Les femmes prsentent au cours du premier trimestre de grossesse des nauses et des vomisse
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4.2.

Troubles anxieux

4.2.1. pidmiologie
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frquents au premier et dernier trimestre de grossesse.

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psychiatrique

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117

67

Les situations risque spcifiques

4.3.

Troubles de lhumeur

4.3.1. pidmiologie
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4.3.2.Smiologie

psychiatrique

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118

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Dni de grossesse

4.4.1. pidmiologie
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4.4.2.Smiologie

psychiatrique

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4.4.3.Pronostic/volution
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Troubles psychiques de la grossesse et du post-partum

5.

67

Troubles psychiques du post-partum

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5.1.1. pidmiologie

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des accouches.

5.1.2. Date

de survenue en post-partum :

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5.1.4. Prise

en charge

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5.2.

Troubles anxieux
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Les situations risque spcifiques

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5.3.

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Troubles psychotiques vieillis et tardifs

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2.2.2.Smiologie
2.2.2.1.La schizophrnie vieillie
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Troubles psychiques du sujet g

2.2.4.Diagnostics

68

diffrentiels

2.2.4.1.Troubles de lhumeur avec symptmes psychotiques

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2.2.4.2.Symptmes psycho-comportementaux de la dmence

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leur prvalence.

2.2.4.3.Troubles psychotiques dorigine mdicale non psychiatrique

et induits par une substance

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2.2.5.Prise

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rance satisfaisant.
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135

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Les situations risque spcifiques

2.3.

Symptmes psychiatriques des pathologies

neurodgnratives et crbrovasculaires

2.3.1. pidmiologie
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perscution et de jalousie. Secondairement, se sont installs des altrations mnsiques et apha
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hallucinations.

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2.3.2. Smiologie
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errone gnralement en lien avec les altrations mnsiques et qui prennent une forme dlirante.
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Troubles psychiques du sujet g

68

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141 Les situations risque spcifiques

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OHVGDQVOHQIDQFH
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ses sentiments et ses inquitudes et les rponses devraient tre simples et claires.

148

1.3.2. Le

deuil chez la personne ge

/HYLHLOOLVVHPHQWH[SRVHXQHIUDJLOLWPGLFDOHQRQSV\FKLDWULTXHFRJQLWLYHHWVRFLDOHTXLVRQW
autant de facteurs risquant de ralentir et compliquer le processus du deuil. Le processus de rorga
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de plus en plus frquents avec le vieillissement, ce qui, selon les personnes, peut les fragiliser
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TXHORQDYDQFHHQJHHQSDUWLFXOLHUFKH]OHVKRPPHVFI,WHPVHW

2.

Les complications possibles du deuil

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IDRQVDWLVIDLVDQWH3RXUXQFHUWDLQQRPEUHGHSHUVRQQHVQDQPRLQVOHGHXLOVHFRPSOLTXHGH
WURXEOHVGXFRPSRUWHPHQWPRWLRQQHOVFRJQLWLIVHWOLPLWHOHIRQFWLRQQHPHQWVRFLDO

Deuil normal et pathologique

141

2QSDUOHGHGHXLOSDWKRORJLTXHRXFRPSOLTXORUVTXHOHSURFHVVXVQYROXHSDVYHUVODSKDVHGH

URUJDQLVDWLRQHWTXLOVWDJQHSHQGDQWDXPRLQVPRLVFKH]ODGXOWHRXPRLVFKH]OHQIDQW2Q
SDUOHGHGHXLOSDWKRORJLTXHJDOHPHQWORUVTXHGHVWURXEOHVSV\FKLTXHVQRWDPPHQWXQSLVRGH
dpressif caractris, surviennent pendant la priode du deuil.

2.1.

Le deuil compliqu persistant

(Persistent Complex Bereavement Disorder)
/HWURXEOHGXGHXLOFRPSOLTXSHUVLVWDQWDWSURSRVGDQVOH'60SRXUFDUDFWULVHUOHGHXLO
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pratique clinique.
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WLIVGLVSURSRUWLRQQVSRXUVDFXOWXUHHWUHVSRQVDEOHVGXQHLQFDSDFLWIRQFWLRQQHOOHLPSRUWDQWH
SUDWLTXHPHQWWRXVOHVMRXUVHWSHQGDQWXQHGXUHVXSULHXUHPRLVPRLVSRXUOHVHQIDQWV
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pour en savoir plus

Les critres symptomatiques du deuil persistant compliqu selon le DSM-5
(traduction personnelle des auteurs)

* $XPRLQVV\PSWPHSDUPLOHVVXLYDQWV
 une nostalgie persistance concernant le dfunt,
 XQHWULVWHVVHHWXQHVRXUDQFHLQWHQVHHQUDFWLRQODPRUW
 des ruminations concernant le dfunt,
 des ruminations concernant les circonstances de la mort.
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*
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 GHODFROUHRXGHODPHUWXPHIDFHODSHUWH
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 des ides de mort pour rejoindre le dfunt,
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 XQVHQWLPHQWTXHODYLHHVWYLGHGHVHQVVDQVOHGIXQWRXODFUR\DQFHTXLOHVWLPSRVVLEOHGHFRQWLQXHUYLYUH
sans le dfunt,
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 XQUHIXVRXXQHUWLFHQFHLQYHVWLUGHVQRXYHDX[REMHFWLIVHWSODQLHUOHIXWXUGHSXLVODSHUWH

149

141 Les situations risque spcifiques

2.2.

Le risque dpisode dpressif caractris

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ULV/HVWXGHVSLGPLRORJLTXHVPRQWUHQWTXHQYLURQXQWLHUVGHVVXMHWVYHXIVPDQLIHVWHQWXQ
SLVRGHGSUHVVLIFDUDFWULVGDQVOHPRLVTXLVXLWODPRUWGXFRQMRLQWHQYLURQXQTXDUWPRLV
HWHWDQV1DQPRLQVHWPPHVLODSOXSDUWGHVSHUVRQQHVHQGHXLOOHVPDQLIHVWHXQH
WULVWHVVHLQWHQVHXQHPLQRULWGHQWUHHOOHVSUVHQWHOHVFULWUHVGXQSLVRGHGSUHVVLIFDUDFW
ULV3UVGHGHVSHUVRQQHVHQGHXLOOHVGFODUHQWUHVVHQWLUXQHVRXUDQFHLQWHQVHGDQVOHV
PRLVTXLVXLYHQWODSHUWHGXSURFKHPDLVVHXOHPHQWUHPSOLVVHQWOHVFULWUHVGHGSLVRGH
dpressif caractris.
Dans un pisode dpressif caractris comme au cours du deuil, on retrouve une tristesse de
OKXPHXUHWXQUHSOLVRFLDOPDLVFHUWDLQVOPHQWVFOLQLTXHVSHUPHWWHQWGHGLVWLQJXHUXQSLVRGH
GSUHVVLIFDUDFWULVGXSURFHVVXVQRUPDOGXGHXLOFIWDEOHDX'DQVOHGHXLOOHVSHUVRQQHV
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GHODUHODWLRQDYHFOHGIXQW/DWULVWHVVHVHPDQLIHVWHSDUDFFVGFOHQFKVSDUOHVRXYHQLUGX
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longs. Dans un pisode dpressif caractris au contraire, les motions ngatives sont persis
WDQWHVTXDVLSHUPDQHQWHVHWOHVPRWLRQVSRVLWLYHVVRQWSUDWLTXHPHQWDEVHQWHV

150

Sur le plan clinique, un pisode dpressif caractris qui survient dans un contexte de deuil est
VLPLODLUHXQSLVRGHTXLVXUYLHQWHQGHKRUVGXQGHXLO/HSURQRVWLFJDOHPHQWHVWVLPLODLUH
TXHFHVRLWODGXUHGHOSLVRGHOHVFRPRUELGLWVHWODUSRQVHDX[WUDLWHPHQWV&RPPHSRXUXQ
SLVRGHGSUHVVLIFDUDFWULVHQJQUDOHOHVDQWFGHQWVIDPLOLDX[HWSHUVRQQHOVGHWURXEOHV
SV\FKLDWULTXHVWURXEOHVGHOKXPHXUHQSDUWLFXOLHUVRQWGHVIDFWHXUVGWHUPLQDQWGXULVTXHGSL
VRGHGSUHVVLIFDUDFWULVDXFRXUVGXGHXLOFI,WHP

Deuil normal

pisode dpressif caractris

/DHFWSUGRPLQDQWHVWXQVHQWLPHQWGHYLGHHWGH
perte.

/DHFWSUGRPLQDQWHVWXQHKXPHXUGSUHVVLYH
SHUVLVWDQWHHWXQHLQFDSDFLWDQWLFLSHUGHVPRPHQWV
de joie ou de plaisir.

Les ractions motionnelles vives se produisent par

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WHQGDQFHGLPLQXHUHQLQWHQVLWDYHFOHWHPSV

/KXPHXUGSUHVVLYHHVWTXDVLFRQVWDQWHHWSDV
dclenche uniquement par les souvenirs du dfunt.

/DVRXUDQFHGXGHXLOHVWDXVVLDFFRPSDJQHSDUGHV
SULRGHVGDHFWVSRVLWLIV

La tristesse et les motions ngatives sont persistantes.

/HGHXLOFRPSRUWHJQUDOHPHQWXQHWHQGDQFHOD
rumination des souvenirs du dfunt.

8QSLVRGHGSUHVVLIFDUDFWULVFRPSRUWHJQUDOH
PHQWXQHWHQGDQFHDX[SHQVHVSHVVLPLVWHVHW
ODXWRGSUFLDWLRQ

/HVWLPHGHVRLHVWJQUDOHPHQWSUVHUYH

/HVWLPHGHVRLHVWIDLEOHDYHFGHVVHQWLPHQWVGLQXWLOLW
et de dgot de soi.

Lorsque des ides de suicide sont prsentes, elles

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dfunt.

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XQVHQWLPHQWGLQXWLOLWGHQHSDVPULWHUGHYLYUHRX
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dpressif caractris.

Tableau 1. Principaux critres cliniques permettant de distinguer le deuil normal dun pisode dpressif majeur.

Deuil normal et pathologique

2.3.

141

Le risque de suicide
Le risque de suicide est fortement augment dans le deuil, notamment dans les quelques jours qui
VXLYHQWOHGFVSDUIRLVDYHFOLQWHQWLRQmGDOOHUUHMRLQGUHOHGIXQW},OHVWPXOWLSOLSDUSOXVGH
FKH]OHVKRPPHVHWSDUFKH]OHVIHPPHVGDQVODre semaine du deuil.

2.4.

Les autres tableaux psychiatriques du deuil compliqu

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*

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(637

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cause non naturelle et violente comme un homicide ou un suicide.

3.

Laccompagnement de la personne en deuil

151

3.1.

La question de la mdicalisation du deuil

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YDOXDWLRQVHWSULVHVHQFKDUJHSUVHQWHVFLGHVVRXV

3.2.

La consultation mdicale de la personne endeuille

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*

Accompagner la personne par une coute empathique.

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 [SOLTXHUHQTXRLOHGHXLOLPSDFWHOHIRQFWLRQQHPHQWELRSV\FKRVRFLDOTXHFHODGXUHXQFHUWDLQ
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tudes favorisantes.

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antcdents personnels et familiaux.

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141 Les situations risque spcifiques

3.3.

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(
spcialise si ncessaire.

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Surveillance du deuil normal

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3.4.
152

Accompagnement dans les situations risque

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*

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Deuil normal et pathologique

3.5.

141

Prise en charge des complications du deuil

3.5.1. Le

deuil compliqu persistant

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restent envahies par des penses et des souvenirs du dfunt. Dans ce cas, les antidpresseurs
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lution du processus.

3.5.2.Lpisode

dpressif caractris
et les complications psychiatriques du deuil

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clinicien devrait tre le mme dans les 2 cas.
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*

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dpresseur devraient tre discuts.

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153

141 Les situations risque spcifiques

Points clefs
* /HGHXLOQRUPDOHVWXQSURFHVVXVTXLUSRQGXQHFHUWDLQHG\QDPLTXHTXLOFRQYLHQWGHFRQQDWUHTXLSHXWSDUIRLV
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* /HGHXLOSDWKRORJLTXHFRUUHVSRQGVRLWODSHUVLVWDQFHSHQGDQWSOXVGHPRLVRXPRLVSRXUOHVHQIDQWVGHV\PS
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* /RUVTXXQWURXEOHSV\FKLDWULTXHHVWLGHQWLDXGFRXUVGXQGHXLOLOFRQYLHQWGHOHSUHQGUHHQFKDUJHGHODPPH
PDQLUHTXHVLOWDLWVXUYHQXGDQVXQDXWUHFRQWH[WH

Rfrences pour approfondir

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 VVRFLDWLRQ$PHULFDQ3V\FKLDWULFDiagnostic and Statistical Manual of Mental Disorders,
$
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mSHUVLVWHQWFRPSOH[EHUHDYHPHQWGLVRUGHU}SHWVXUOHm0DMRUGHSUHVVLYHGLVRUGHU}S

154

partie quatre

Les troubles
psychiatriques
tous les ges

Troubles psychotiques
item 61

Trouble schizophrnique
de ladolescent
et de ladulte
I. Introduction
II. Contexte pidmiologique
III. 6PLRORJLHSV\FKLDWULTXH
IV. /HWURXEOHSV\FKLDWULTXH
V. /HSURQRVWLFHWOYROXWLRQ
VI. /DSULVHHQFKDUJHSV\FKLDWULTXH

Objectifs pdagogiques
* 'LDJQRVWLTXHUXQWURXEOHVFKL]RSKUQLTXH
* $UJXPHQWHUODWWLWXGHWKUDSHXWLTXHHWSODQLHUOHVXLYLWRXVOHVVWDGHVGH
la maladie.

61

61

Les troubles psychiatriques tous les ges

1.

Introduction
/DVFKL]RSKUQLHGFULWHDXGEXWGX xxeVLFOHHVWXQHPDODGLHIUTXHQWHHWJUDYH&HWWHPDODGLH
HVWDFWXHOOHPHQWFODVVHSDUO206SDUPLOHVGL[PDODGLHVTXLHQWUDQHQWOHSOXVGLQYDOLGLWHQ
SDUWLFXOLHU FKH] OHV VXMHWV MHXQHV (OOH IDLW SDUWLH GHV WURXEOHV SV\FKRWLTXHV FKURQLTXHV TXL VH
caractrisent par une perte de contact avec la ralit.
/D SK\VLRSDWKRORJLH GH OD VFKL]RSKUQLH QHVW SDV HQWLUHPHQW OXFLGH PDLV UVXOWH GH OLQ
WHUDFWLRQ HQWUH GHV IDFWHXUV GH YXOQUDELOLW JQWLTXHV HW GHV IDFWHXUV HQYLURQQHPHQWDX[
/K\SRWKVHGXQWURXEOHGXQHXURGYHORSSHPHQWSRVWXODQWTXHODVFKL]RSKUQLHHVWODFRQV
TXHQFHGDQRPDOLHVGXQHXURGYHORSSHPHQWGEXWDQWGHVDQQHVDYDQWOHGEXWGHODPDODGLH
HVWDXMRXUGKXLSUYDOHQWH

2.

Contexte pidmiologique
/D SUYDOHQFH GH OD VFKL]RSKUQLH HVW GHQYLURQ  6RQ LQFLGHQFH D W PHVXUH 
QRXYHDX[ FDV SRXU   SHUVRQQHV HQWUH  HW  /D IUTXHQFH GH OD VFKL]RSKU
QLHDORQJWHPSVWFRQVLGUHFRPPHLQYDULDEOHVHORQOHVOLHX[HWOHVSRSXODWLRQVPDLVFHWWH
IUTXHQFHGSHQGHQIDLWGHOH[SRVLWLRQFHUWDLQVIDFWHXUVHQYLURQQHPHQWDX[FRPPHODFRQVRP
PDWLRQGHFDQQDELVODPLJUDWLRQRXHQFRUHOXUEDQLVDWLRQ
/DPDODGLHGEXWHFODVVLTXHPHQWFKH]OHJUDQGDGROHVFHQWRXODGXOWHMHXQHHQWUHHWDQV
PDLVLOH[LVWHGHVIRUPHVUDUHVWUVSUFRFHVSUSXEHUWDLUHVRXWDUGLYHVDSUVDQV/JH
GH GEXW HVW JQUDOHPHQW SOXV WDUGLI FKH] OD IHPPH SDU UDSSRUW  OKRPPH GHQYLURQ  DQV
/PHUJHQFH GHV V\PSWPHV VFKL]RSKUQLTXHV HVW JQUDOHPHQW SUFGH SDU GHV DOWUDWLRQV
FRJQLWLYHVHWGHVV\PSWPHVSURGURPLTXHVQRQVSFLTXHVSHXYHQWWUHSUVHQWVDQVDYDQW
OPHUJHQFHGXWURXEOH&KH]FHUWDLQVSDWLHQWVODVFKL]RSKUQLHDSSDUDWDSUVXQSDUFRXUVGH
GLFXOWVGDSSUHQWLVVDJHHWGHGYHORSSHPHQW/HVH[UDWLRHVWDVVH]TXLOLEUPPHVLOH[LVWH
XQHOJUHSUGRPLQDQFHFKH]OHVKRPPHV[

158

Les principaux facteurs de risques sont de nature gntique (variants hrits ou mutation
GHQRYR SOXV UDUHPHQW REVWWULFDOH GLFXOWV SULQDWDOHV RX HQYLURQQHPHQWDOH FDQQDELV
PLJUDWLRQXUEDQLVDWLRQ

3.

Smiologie psychiatrique

3.1.

Syndrome positif

3.1.1. Ides

dlirantes

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ODEOHLQDFFHVVLEOHDXUDLVRQQHPHQWRXODFRQWHVWDWLRQSDUOHVIDLWV,OVDJLWGXQHmYLGHQFH
LQWHUQH}SRXYDQWWUHSODXVLEOHRXLQYUDLVHPEODEOHPDLVTXLQHVWJQUDOHPHQWSDVSDUWDJH
SDU OH JURXSH VRFLRFXOWXUHO GX VXMHW 'DQV OD VFKL]RSKUQLH OD SUYDOHQFH GHV LGHV GOLUDQWHV
HVWHVWLPHSOXVGH2QGFULWOHVLGHVGOLUDQWHVSDUUDSSRUWOHXUWKPHPFDQLVPHHW
structure ou organisation.

Trouble schizophrnique de ladolescent et de ladulte

61

3.1.1.1.Thmes
/HWKPHGHOLGHGOLUDQWHFRUUHVSRQGDXVXMHWSULQFLSDOVXUOHTXHOSRUWHFHWWHLGH/HVWKPD
WLTXHVSHXYHQWYDULHUOLQQLWUHXQLTXHVRXPXOWLSOHVVDVVRFLHUHQWUHHOOHVGHIDRQSOXVRX
PRLQVORJLTXH'DQVODVFKL]RSKUQLHOHVWKPHVVRQWPXOWLSOHVHWKWURJQHVYRLUOHVH[HPSOHV
GDQVOHWDEOHDXWKPHGHSHUVFXWLRQPJDORPDQLDTXHP\VWLTXHGHOLDWLRQOHVXMHWWDQW
SHUVXDGGDYRLUGLOOXVWUHVDVFHQGDQWVVRPDWLTXHURWRPDQLDTXHFI,WHPGLQXHQFHGH
rfrence.

Nom du thme

Dfinition

Exemple

Perscution

Ide dlirante dans laquelle

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harcel, tromp, perscut
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des mdicaments dans mon pain
pour que je me taise et que
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communiste qui est
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Ide dlirante qui implique

de la part du sujet
un sentiment exagr
de son importance,
de son pouvoir, de son savoir,
de son identit
ou de ses relations privilgies
avec Dieu ou une autre
SHUVRQQHFOEUH

9RXVYRXOH]PHIDLUHXQHSULVH
de sang pour le revendre.
Mais je suis votre directeur
et votre roi, je refuse
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Ide dlirante dont

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un rle spcial sur Terre.

Grandeur/mgalomaniaque

Mystique

Somatique

De rfrence

Ide dlirante dans laquelle le

WKPHFHQWUDOWRXFKH
au fonctionnement
du corps.

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le sujet pense que certains
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laquelle le sujet est lui mme la
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qui sont en fait
des camras microscopiques
qui enregistrent tout.

Le prsentateur du journal
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lieu hier.

Tableau 1. 7KPHVGOLUDQWVOHVSOXVIUTXHPPHQWUHWURXYVGDQVODVFKL]RSKUQLH

159

61

Les troubles psychiatriques tous les ges

3.1.1.2.Mcanismes
/HPFDQLVPHGHOLGHGOLUDQWHFRUUHVSRQGDXSURFHVVXVSDUOHTXHOOLGHGOLUDQWHVWDEOLWHW
VHFRQVWUXLW,OVDJLWGXPRGHGODERUDWLRQHWGRUJDQLVDWLRQGHOLGHGOLUDQWH,OH[LVWHW\SHV
GHPFDQLVPHORULJLQHGHVLGHVGOLUDQWHVOHVPFDQLVPHVLQWHUSUWDWLIKDOOXFLQDWRLUHLQWXL
WLIHWLPDJLQDWLIFI7DEOHDX
Type de mcanisme dlirant

Dfinition

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PLQMHFWHUTXHOTXHFKRVHSRXUPH
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Hallucinatoire

Construction
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dcompos allong par terre
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Alors je suis triste.

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ni raisonnement logique
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un rle central.

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mieux pour les moteurs.

Interprtatif

160

Tableau 2. 3ULQFLSDX[PFDQLVPHVGOLUDQWVUHWURXYVGDQVODVFKL]RSKUQLH

3.1.1.3.Systmatisation
/HGHJUGHV\VWPDWLVDWLRQYDOXHORUJDQLVDWLRQHWODFRKUHQFHGHVLGHVGOLUDQWHV8QHLGH
GOLUDQWH HVW FRQVLGUH SHX V\VWPDWLVH ORUVTXH ORUJDQLVDWLRQ HVW RXH YDJXH HW SHX FRK
UHQWH'DQVODVFKL]RSKUQLHRQUHWURXYHGDQVODPDMRULWGHVFDVGHVLGHVGOLUDQWHVQRQV\VW
PDWLVHVRXHVVDQVORJLTXHLQFRKUHQWHVFRQWUDLUHPHQWDXWURXEOHGOLUDQWSHUVLVWDQWGHW\SH
SHUVFXWLRQDXFRXUVGXTXHOOHVLGHVGOLUDQWHVVRQWJQUDOHPHQWV\VWPDWLVHVHWRODFRK
UHQFHGRQQHXQHFHUWDLQHORJLTXHODSURGXFWLRQGOLUDQWH

3.1.1.4.Adhsion
/DGKVLRQ DX[ LGHV GOLUDQWHV FRUUHVSRQG DX GHJU GH FRQYLFWLRQ DWWDFK  FHV LGHV HVW
YDULDEOHPDLVSHXWWUHOHYH/RUVTXHODFRQYLFWLRQHVWLQEUDQODEOHLQDFFHVVLEOHDXUDLVRQQH
PHQWHWDX[FULWLTXHVODGKVLRQHVWGLWHmWRWDOH}/RUVTXHODGKVLRQHVWSDUWLHOOHOHSDWLHQWHVW
en mesure de critiquer ses propres ides dlirantes.

Trouble schizophrnique de ladolescent et de ladulte

61

3.1.2. Hallucinations
/KDOOXFLQDWLRQ HVW GQLH FRPPH XQH perception sans objet 'DQV OD VFKL]RSKUQLH  GHV
SDWLHQWVSUVHQWHQWGHVKDOOXFLQDWLRQVQRWDPPHQWHQSKDVHDLJX

3.1.2.1.Psychosensorielles
,OVDJLWGKDOOXFLQDWLRQVUHOHYDQWGHPDQLIHVWDWLRQVVHQVRULHOOHV'DQVODVFKL]RSKUQLHWRXVOHV
sens peuvent tre touchs.
Les hallucinations les plus frquentes sont les hallucinations auditives SUVHQWHV FKH] HQYLURQ
GHVSDWLHQWV,OSHXWVDJLUGHVRQVVLPSOHVVRQQHULHPORGLHPDLVOHSOXVVRXYHQWLOVDJLW
GH YRL[ QHWWHPHQW ORFDOLVHV GDQV OHVSDFH RQ SDUOH DORUV dhallucinations acoustico-verbales.
(OOHV SHXYHQW FRQYHUVHU HQWUH HOOHV HW VDGUHVVHU DX VXMHW  OD WURLVLPH SHUVRQQH ,O VDJLW HQ
JQUDO GH SKUDVHV FRXUWHV DYHF XQH FRQQRWDWLRQ QJDWLYH 'HV DWWLWXGHV GFRXWH OD PLVH HQ
SODFHGHPR\HQVGHSURWHFWLRQFRXWHUGHODPXVLTXHVHFRQFHQWUHUVXUXQHWFKHVHERXFKHUOHV
RUHLOOHVGHVUSRQVHVEUYHVRXHQDSDUWXQHVROLORTXLHXQHGLVWUDFWLELOLWSHQGDQWOHQWUHWLHQ
VRQWYRFDWHXUVGKDOOXFLQDWLRQVDXGLWLYHVGRQWOHVXMHWQHSDUOHSDVWRXMRXUVVSRQWDQPHQW
Les hallucinations visuelles WRXFKHQW TXDQW  HOOHV  GHV SDWLHQWV DWWHLQWV GH VFKL]RSKU
QLH(OOHVSHXYHQWWUHOPHQWDLUHVOXPLUHVWFKHVFRORUHVSKRVSKQHVRPEUHVDPPHV
DVKVSDUIRLVIRUPHVJRPWULTXHVRXSOXVFRPSOH[HVREMHWVJXUHVVFQHVHWFVRXVIRUPH
GHVFQHVYLVXHOOHVFRPPHXQHPHVRUWDQWGXQFRUSVGXQSKQL[YRODQWGDQVOHFLHORXGH
IDRQSOXVDQJRLVVDQWHGHVGPRQVHWGHVPRUWVVRUWDQWGXVRO
Les hallucinations tactiles VHQV GX WRXFKHU VXSHUFLHO VRQW SUVHQWHV FKH] HQYLURQ  GHV
SDWLHQWVVRXUDQWGHVFKL]RSKUQLH/HVSDWLHQWVSHXYHQWVHQWLUGHVFRXSVGHYHQWVXUOHYLVDJH
GHVVHQVDWLRQVGHEUOXUHVGHSLTUHVOHFRUSVGXQLQGLYLGXFWGHX[RXFURLHQWWRXFKHU
GHVREMHWVGHVDQLPDX[&HVKDOOXFLQDWLRQVSHXYHQWWUHUDSSRUWHVGHVFRQWDFWVPDQXHOV
GHVSKQRPQHVGOHFWULVDWLRQRXODVHQVDWLRQGWUHFRXYHUWGHSDUDVLWHV/HVVXMHWVWRXFKHQW
SDUIRLVOHXUVKDOOXFLQDWLRQVSRXUWHQWHUGHOHVOLPLQHUVHOLEUHUGHOLHQVFUDVHUOHVSDUDVLWHV
/HV KDOOXFLQDWLRQV WRXFKDQW OHV DXWUHV VHQV VRQW PRLQV IUTXHQWHV 3DUPL HOOHV OHV hallucinations gustativesPRGLFDWLRQGXJRWGHVDOLPHQWVSDUH[HPSOHOHVhallucinations olfactives qui
SRUWHQWOHSOXVVRXYHQWVXUGHVPDXYDLVHVRGHXUVSURYHQDQWGXSDWLHQWOXLPPH/HVhallucinations cnesthsiques LQWUHVVHQW OD VHQVLELOLW LQWHUQH ,O SHXW VDJLU GLPSUHVVLRQV GH WUDQVIRU
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3.1.2.2.Intrapsychiques
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OLWHOOHVVRQWSHUXHVFRPPHGHVSKQRPQHVLQWUDSV\FKLTXHVWUDQJHUVDXVXMHW/DSHQVH
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/HVXMHWVRXUDQWGHFHW\SHGKDOOXFLQDWLRQVSHXWHQWHQGUHVHVSHQVHVFRPPHVLHOOHVYHQDLHQW
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Les troubles psychiatriques tous les ges

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Notion dhistoire : lautomatisme mental de Cleramblaut

Le syndrome dautomatisme mental

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VRQWUSWHVKDXWHYRL[

Le syndrome dinfluence

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commandent ou donnent des ordres au patient.

3.2.

Syndrome ngatif
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SV\FKLTXH

3.2.1. Au
162

niveau affectif : lmoussement des affects

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tre prsente.

3.2.2.Au

niveau cognitif : la pauvret du discours, ou alogie

/DSDXYUHWGXGLVFRXUVVHPDQLIHVWHSDUGHVGLFXOWVFRQYHUVHUDYHFGHVUSRQVHVEUYHV
vasives et parfois interrompues.

3.2.3. Au

niveau comportemental :
lavolition, lapragmatisme et le retrait social

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Trouble schizophrnique de ladolescent et de ladulte

3.3.

61

Syndrome de dsorganisation
/HV\QGURPHGHGVRUJDQLVDWLRQFRUUHVSRQGODSHUWHGHOXQLWSV\FKLTXHHQWUHLGHVDHFWLYLW
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les motions et les comportements.

Dsorganisation ou dissociation ?
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3.3.1. Cognitif
3.3.1.1.Altrations du cours de la pense
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OH GLVFRXUV HVW KHUPWLTXH HW OD SHQVH LPSQWUDEOH 2Q UHWURXYH JDOHPHQW OH[LVWHQFH GH
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3.3.1.2.Altrations du systme logique ou illogisme

La pense du patient dsorganis ne repose pas sur des lments de logique communment
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Les prodromes de la schizophrnie

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6.2.

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6.2.2.Objectifs

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6.2.4.Mise

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6.2.6.Dure

du traitement

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surveillance mdicale : il faut maintenir le suivi au long terme au moins 12 mois, les rechutes
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6.2.7. Surveillance

et tolrance

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lactinmie augmente avec la dure du traitement.

174

Avant le
traitement

1er mois

3e mois

Une fois
par trimestre

Poids et IMC

Primtre
abdominal

Glycmie jeun

Bilan lipidique

Tension
artrielle

Une fois
par an

Une fois tous

les 5 ans

+
+
+
+

Tableau 4. Surveillance clinique et paraclinique dun patient trait par antipsychotiques.

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6.3.

Traitement psychopharmacologique
des comorbidits thymiques
Les antidpresseurs peuvent tre prescrits lors des pisodes dpressifs, en association avec le
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Trouble schizophrnique de ladolescent et de ladulte

6.4.

61

Place de llectro-convulsivo-thrapie ou sismothrapie

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Pour en savoir plus

La stimulation magntique transcrnienne

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SHXWHQVXLWHIDFLOHPHQWSQWUHUOHVWLVVXVGHVXUIDFHYLVHWKUDSHXWLTXHODU706HVWGOLYUHGHPDQLUHUSWH
sous la forme de sessions quotidiennes pendant plusieurs jours, voire semaines. La rTMS est devenue une alternative
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6.5.

Rhabilitation psycho sociale

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6.5.1. Psychoducation
/DSV\FKRGXFDWLRQYLVHWUDQVPHWWUHDXSDWLHQWHWYHQWXHOOHPHQWVDIDPLOOHXQFHUWDLQQLYHDX
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W PRQWU TXH OD SV\FKRGXFDWLRQ DPOLRUH OHV FRPSWHQFHV GHV SDWLHQWV  IDLUH IDFH  OHXUV
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montr un impact sur la diminution des rechutes et rhospitalisations du patient.

175

61

Les troubles psychiatriques tous les ges

6.5.2.Psychothrapie

cognitivo-comportementales

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VTXHQFHGHVRLQVFRPSRUWDQWXQHTXLQ]DLQHGHVDQFHVGXQHGHPLKHXUHXQHKHXUH

6.5.3. Remdiation

cognitive (cf. Item 117)

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6.5.4.Entranement

aux habilets sociales

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WLRQHWGHVFRPSWHQFHVVRFLDOHV/REMHFWLIGHFHWWHIRUPHGHWKUDSLHGHJURXSHHVWGHGYHORS
per ces capacits par des exercices portant sur des situations de la vie quotidienne.
176

6.5.5. Rhabilitation

et cadre de soin

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GHVSURJUVLPSRUWDQWVSHXYHQWWUHDWWHQGXV

Rsum
/DVFKL]RSKUQLHHVWXQHPDODGLHIUTXHQWHSUYDOHQFHGHQYLURQHWJUDYH&HWWHPDODGLH
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Trouble schizophrnique de ladolescent et de ladulte

61

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Points clefs
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motionnel et comportemental.
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*
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Rfrences pour approfondir

-'DOU\ 7 G$PDWR 0 6DRXG HW &ROOHFWLI Pathologies schizophrniques, Mdecine Sciences
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177

Troubles psychotiques
item 63

Trouble dlirant
persistant
I. Introduction
II. Contexte pidmiologique
III. 6PLRORJLHSV\FKLDWULTXH
IV. /HWURXEOHSV\FKLDWULTXH
V. /DSULVHHQFKDUJHSV\FKLDWULTXH

Objectifs pdagogiques
* 'LDJQRVWLTXHUXQWURXEOHGOLUDQWSHUVLVWDQW
* $UJXPHQWHUODWWLWXGHWKUDSHXWLTXHHWSODQLHUOHVXLYLWRXVOHVVWDGHVGH
la maladie.

63

63

Les troubles psychiatriques tous les ges

1.

Introduction
/DSOXSDUWGHVWURXEOHVGOLUDQWVFKURQLTXHVQRQVFKL]RSKUQLTXHVRQWWGFULWVHQ(XURSHDX
GEXWGXxxeVLFOHHWUHJURXSDLHQWFODVVLTXHPHQWODSV\FKRVHSDUDQRDTXHODSV\FKRVHKDOOX
FLQDWRLUH FKURQLTXH OD SDUDSKUQLH HW OHV SV\FKRVHV SDVVLRQQHOOHV $XMRXUGKXL OHV GOLUHV
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QRPHQFODWXUHVLQWHUQDWLRQDOHVHWVRQWUHJURXSVVRXVOHODEHOmWURXEOHVGOLUDQWVSHUVLVWDQWV}

Histoire de la psychiatrie
/FROHSV\FKLDWULTXHIUDQDLVHUHFRQQDWWURLVW\SHVGHGOLUHVSHUVLVWDQWVQRQVFKL]RSKUQLTXHVGLUHQFLVVHORQOHXU
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VSHFWUHVFKL]RSKUQLTXHHWQHVRQWSDVWUDLWHVGDQVFHWLWHP

2.
180

Contexte pidmiologique
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/HWURXEOHGOLUDQWSHXWWUHVRXVYDOXFDUFHVSDWLHQWVUHFKHUFKHQWUDUHPHQWXQHDLGHSV\FKLD
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GEXWHVWGHQYLURQGHDQV

3.

Smiologie psychiatrique

3.1.

Rappel sur les ides dlirantes

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VDJLWGXQHmYLGHQFHLQWHUQH}SRXYDQWWUHSODXVLEOHQRQEL]DUUHPDLVTXLQHVWJQUDOH
ment pas partage par le groupe socioculturel du sujet.

Trouble dlirant persistant

3.2.

63

Caractrisation des ides dlirantes

dans les troubles dlirants chroniques

3.2.1. Thmes
/HVWKPHVOHVSOXVIUTXHPPHQWUHWURXYVVRQWODSHUVFXWLRQODJUDQGHXUPJDORPDQLHOUR
tomanie, la jalousie, et le dlire somatique.

3.2.2.Mcanismes
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Q\DSDVGHPFDQLVPHKDOOXFLQDWRLUHGDQVOHVWURXEOHVGOLUDQWVSHUVLVWDQWVFRQWUDLUHPHQWOD
VFKL]RSKUQLH

3.2.3. Systmatisation
/HV LGHV GOLUDQWHV SHUVLVWDQWHV VRQW V\VWPDWLVHV SDU RSSRVLWLRQ  OD VFKL]RSKUQLH R
OHV LGHV GOLUDQWHV VRQW QRQ V\VWPDWLVHV PDUTXHV SDU OLOORJLVPH HW OLQFRKUHQFH (OOHV
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QLHROHVLGHVGOLUDQWHVVRQWSRO\PRUSKHV

pour en savoir plus

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URWRPDQLHMDORXVLHGOLUHVGHUHYHQGLFDWLRQHWQRQSDVODWRWDOLWGHVGRPDLQHVGHODYLHGXVXMHWSDUXQHH[WHQVLRQ
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3.2.4.Adhsion
/HVXMHWDGKUHWRWDOHPHQWVHVFUR\DQFHVGOLUDQWHV

3.2.5.Participation

affective/retentissement

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GDQVOHVWURXEOHVGOLUDQWVGHSHUVFXWLRQODMDORXVLHHWOURWRPDQLH

181

63

Les troubles psychiatriques tous les ges

4.

Le trouble psychiatrique

4.1.

Diagnostics positifs

4.1.1. Pour

poser le diagnostic de trouble dlirant

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4.1.2. Les

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des formes cliniques distinctes :
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avec caractristiques mlancoliques,

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avec caractristiques mixtes,

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avec catatonie,

avec dtresse anxieuse,

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moins 2 mois conscutifs.

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6.1.

Prise en charge psychiatrique

dun pisode dpressif caractris
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Trouble dpressif de ladolescent et de ladulte

64A

Points clefs
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conscutives :
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&$EVHQFHGHFDXVHVPGLFDOHVQRQSV\FKLDWULTXHVRXDEVHQFHGHFDXVHVWR[LTXHV
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* 6RQLQWHQVLWSHXWWUHOJUHPRGUHRXVYUH
* /HVGLUHQWHVIRUPHVFOLQLTXHVGHOSLVRGHGSUHVVLIFDUDFWULVVRQW
 avec caractristiques mlancoliques,
 DYHFFDUDFWULVWLTXHVSV\FKRWLTXHVFRQJUXHQWHVRXQRQOKXPHXU
 avec caractristiques mixtes,
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 avec dtresse anxieuse,
 avec catatonie,
 DYHFGEXWGXUDQWOHSULSDUWXP
* /HWURXEOHGSUHVVLIFDUDFWULVSHXWVHSUVHQWHUVRXVGLUHQWHVIRUPHVYROXWLYHV
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 WURXEOHGSUHVVLISHUVLVWDQWDQFLHQQHPHQWWURXEOHG\VWK\PLTXH
 WURXEOHG\VSKRULTXHSUPHQVWUXHO
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*
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* Les complications sont principalement reprsentes par le risque de suicide, de dsinsertion socioprofessionnelle, de
UFXUUHQFHVGSUHVVLYHVHWGHFRPRUELGLWVSV\FKLDWULTXHVHWQRQSV\FKLDWULTXHV
re
* 3RXUOHVIRUPHVPRGUHVVYUHVOHWUDLWHPHQWPGLFDPHQWHX[HVWWRXMRXUVQFHVVDLUHDQWLGSUHVVHXU inten
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suicidaire.
* /(&7HVWLQGLTXGDQVOHVIRUPHVOHVSOXVVYUHVGSLVRGHGSUHVVLIHWRXHQFDVGHUVLVWDQFHRXGHFRQWUHLQGLFD
tion au traitement mdicamenteux.
* 7RXMRXUVDVVRFLHXQHSV\FKRWKUDSLHGHVRXWLHQXQHSV\FKRWKUDSLHVWUXFWXUH

Rfrences pour approfondir

Haute Autorit de Sant. ALD noTrouble dpressifs rcurrents ou persistants de ladulte. 2009.
Haute Autorit de Sant. pisode dpressif caractris de ladulte : prise en charge en premier
recours. 2014.
*XHO-'5RXLOORQ)Manuel de Psychiatrie. 2eGLWLRQ(OVHYLHU0DVVRQ

199

Troubles de lhumeur
item 62

Trouble bipolaire
de ladolescent
ladulte
I. Introduction
II. Contexte pidmiologique
III. 6PLRORJLHSV\FKLDWULTXH
IV. /HWURXEOHELSRODLUH
V. /HSURQRVWLFHWOYROXWLRQ
VI. /DSULVHHQFKDUJHSV\FKLDWULTXH

Objectifs pdagogiques
* 'LDJQRVWLTXHUXQWURXEOHELSRODLUH
* $UJXPHQWHUODWWLWXGHWKUDSHXWLTXHHWSODQLHUOHVXLYLWRXVOHVVWDGHVGH
la maladie.

62

62

Les troubles psychiatriques tous les ges

1.

Introduction
/HWURXEOHELSRODLUHHVWXQHPDODGLHSV\FKLDWULTXHVYUHFKURQLTXHHWIUTXHQWH&HWWHPDODGLH
HVWGFULWHGHSXLVO$QWLTXLWHWVHFDUDFWULVHSDUGHVchangements pathologiques de lhumeur et
de lnergie qui peuvent tre augmentes (la manie) ou diminues (la dpression)(QGHKRUVGHFHV
SLVRGHVPDQLDTXHVRXGSUHVVLIVLOHVWPDLQWHQDQWELHQFRQQXTXHOHVVXMHWVDWWHLQWVSUVHQWHQW
JDOHPHQWGHVWURXEOHVDXFRXUVGHVSKDVHVGHVWDELOLWGHOKXPHXUDYHFGHVDOWUDWLRQVSHUVLV
WDQWHVQRWDPPHQWGHVIRQFWLRQVFRJQLWLYHVGXVRPPHLOGHVU\WKPHVFLUFDGLHQVGHVV\VWPHV
LPPXQRLQDPPDWRLUHPWDEROLTXHVQHXURGYHORSSHPHQWDOHVHWQHXURSK\VLRORJLTXHV
Le trouble bipolaire est dorigine multifactorielle, mlant des facteurs de risque gntiques et
environnementaux.

Histoire de la psychiatrie
/HVSUHPLUHVGHVFULSWLRQVGHODPODQFROLHHWGHODPDQLHVRQWDSSDUXHVGDQVO$QWLTXLWHWFHVW$UWHGH&DSSDGRFH
TXLIXWOHSUHPLHUXWLOLVHUOHPRWmPDQLH}DXiieVLFOHDY-&/LGHTXHODPODQFROLHHWODPDQLHSRXYDLHQWWUH
OLHVXQHVHXOHHWPPHPDODGLHDWDWWULEXHVLPXOWDQPHQWHQ-XOHV%DLOODUJHUGFULYDQWmODIROLHGRXEOH
IRUPH}HW-HDQ3LHUUH)DOUHWGFULYDQWTXDQWOXLmODIROLHFLUFXODLUH}3XLV(PLO.UDHSHOLQHQUHFRQQDWXQH
SUGLVSRVLWLRQFRQVWLWXWLRQQHOOHHWKUGLWDLUHGHODPDODGLHTXLODSSHODDORUVOHVmSV\FKRVHVPDQLDFRGSUHVVLYHV}
LQGLYLGXDOLVHVGHVmGPHQFHVSUFRFHV}DSSHOHVPDLQWHQDQWmVFKL]RSKUQLH}3XLVGDQVOHVDQQHVOHV
DXWHXUV LQWHUQDWLRQDX[ VSDUHQW HQ GHX[ HQWLWV GLVWLQFWHV OHV WURXEOHV XQLSRODLUHV FDUDFWULVV SDU GHV SLVRGHV
GSUHVVLIVUFXUUHQWVHWOHVWURXEOHVELSRODLUHV

202
Les classifications nosographiques actuelles (CIM et DSM par exemple) ont toutes adopt maintenant lentit nosographique trouble bipolaire et reconnaissent un spectre de sous-types de la
maladie dfinissant ainsi les troubles bipolaires . Les deux grands sous-types identifier pour
lECN sont le trouble bipolaire de type I (alternance dpisodes maniaques et dpisodes dpressifs
caractriss) et le trouble bipolaire de type II (alternance dpisodes hypomaniaques et dpisodes
dpressifs caractriss).
$FWXHOOHPHQW LO QH[LVWH SDV GRXWLO GYDOXDWLRQ SDUDFOLQLTXH SRXU OH GLDJQRVWLF GHV WURXEOHV
ELSRODLUHV FHVW GRQF XQ diagnostic clinique 3OXV SUFLVPHQW OH GLDJQRVWLF GHV SLVRGHV HVW
cliniqueOHGLDJQRVWLFGHODPDODGLHRXGHVHVVRXVW\SHVHVWvolutif.

2.

Contexte pidmiologique
Il est classiquement reconnu que 1 4 % de la population gnrale est atteinte des formes
W\SLTXHVGXWURXEOHELSRODLUHVRXVW\SHV,RX,,1DQPRLQVVLORQFRQVLGUHOHmVSHFWUH}GHOD
PDODGLHUHJURXSDQWGHVHQWLWVPRLQVVYUHVHWRXW\SLTXHVODSUYDOHQFHGHODPDODGLHSHXW
DOOHUMXVTXGHODSRSXODWLRQJQUDOH
Lge de dbut du trouble bipolaire se fait classiquement entre 15 et 25 ans MXVWHDSUVODSXEHUW
/H VH[UDWLR HVW DXWRXU GH  /D PRLWL GHV VXMHWV DWWHLQWV GEXWHQW OHXU PDODGLH DYDQW  DQV
(QYLURQGHVVXMHWVSUVHQWDQWXQSUHPLHUSLVRGHPDQLDTXHRQWXQDQWFGDQWGSLVRGH
GSUHVVLIPDMHXU2QGLWTXHFHVWXQHPDODGLHFKURQLTXHFDUSOXVGHGHVSHUVRQQHVD\DQW
FRQQXXQSLVRGHPDQLDTXHSUVHQWHURQWGDXWUHVSLVRGHVGHWURXEOHVGHOKXPHXUFHMRXU
OH UHWDUG GLDJQRVWLF HVW XQ YULWDEOH SUREOPH GH VDQW SXEOLTXH HW HVW GHQYLURQ  DQV 8QH

Trouble bipolaire de ladolescent et de ladulte

62

SHUVRQQH GEXWDQW VRQ WURXEOH YHUV  DQV SHUG HQ PR\HQQH  DQQHV GH YLH  DQQHV HQ
ERQQHVDQWHWDQQHVGDFWLYLWSURIHVVLRQQHOOHSelon lOMS, le trouble bipolaire fait partie
des dix maladies les plus invalidantes et coteuses au plan mondial.

3.

Smiologie psychiatrique

3.1.

Syndrome maniaque
/H V\QGURPH PDQLDTXH HVW FDUDFWULV SDU OD SHUVLVWDQFH GDQV OH WHPSV GXQH DXJPHQWDWLRQ
SDWKRORJLTXHGHOKXPHXUHWGHOQHUJLH
/LQVWDOODWLRQ SHXW WUH EUXWDOH RX SURJUHVVLYH DYHF RX VDQV IDFWHXU GFOHQFKDQW H[WHUQH /HV
WURXEOHVGXVRPPHLOLQVRPQLHVRQWVRXYHQWSURGURPLTXHVGXQQRXYHOSLVRGH
2QSHXWFRPSDUHUOHVXMHWHQWDWPDQLDTXHXQHSLOHQXFODLUHFKH]TXLWRXWYDWURSYLWH&HVW
XQHXUJHQFHPGLFDOHGLDJQRVWLTXHHWWKUDSHXWLTXHPPHVLOHVXMHWJQUDOHPHQWUVLVWHHW
QHUHVVHQWSDVOHEHVRLQGWUHWUDLW
/HVV\PSWPHVGXV\QGURPHPDQLDTXHSHXYHQWWUHGLYLVVHQJUDQGHVFRPSRVDQWHV
OHVSHUWXUEDWLRQVGHODHFWLYLWKXPHXUSV\FKRORJLHHWPRWLRQV
ODFFOUDWLRQSV\FKRPRWULFH
OHV VLJQHV DVVRFLV VRPPHLO HW U\WKPHV IRQFWLRQV FRJQLWLYHV DOLPHQWDWLRQ OLELGR
UHWHQWLVVHPHQWV

* Perturbations de lhumeur :
 Gaie SDUIRLVGFULWHFRPPHOHYHH[SDQVLYHH[DOWH
 / D MRLH HW OD JDLW SHXYHQW WUH UHPSODFH SDU XQH LUULWDELOLW DWWHQWLRQ OH YFX
VXEMHFWLIQHVWSDVWRXMRXUVDJUDEOHSRXUOHVXMHW

Perturbation
de laffectivit

* Psychologie maniaque (vision du monde) :

 $XJPHQWDWLRQ GH OHVWLPH GH VRL LGHV GH JUDQGHXUV VHQWLPHQW GH WRXWH
puissance, mgalomanie.
 /XGLVPHFRQWDFWIDPLOLHUGVLQKLELWLRQ
* Perturbations des motions :
 /DELOLWPRWLRQQHOOHPRWLRQVYHUVDWLOHV
 +\SHUUDFWLYLW RX K\SHUHVWKVLH UDFWLYLW H[FHVVLYH GH OKXPHXU DX[ VWLPXOL
PRWLRQQHOVH[WHUQHV
 +\SHUV\QWRQLHSDUWLFLSDWLRQVSRQWDQHHWDGKVLRQWUVUDSLGHODPELDQFHDHF
WLYHGXPRPHQW

Acclration
psychomotrice

* Acclration psychique :
 $JLWDWLRQSV\FKLTXH
 7DFK\SV\FKLHDFFOUDWLRQGHVLGHV
 3HQVHGLXHQWHIXLWHVGHVLGHVLPSUHVVLRQTXHOHVLGHVIXVHQW
 &RTVOQHFKDQJHPHQWUDSLGHGXQHLGHODXWUHVDQVOLHQDSSDUHQW
 -HX[GHPRWVDVVRFLDWLRQVSDUDVVRQDQFHV

203

62

Les troubles psychiatriques tous les ges

Acclration
psychomotrice

* Acclration motrice :
 $JLWDWLRQPRWULFHK\SHUDFWLYLWPRWULFH
 $XJPHQWDWLRQGHVDFWLYLWVEXWGLULJSURIHVVLRQQHOOHVVRFLDOHVRXVH[XHOOHV
 /RJRUUKHDXJPHQWDWLRQGXWHPSVGHSDUROH
 7DFK\SKPLHDXJPHQWDWLRQGHODYLWHVVHGHSDUROH
 +\SHUPLPLHDXJPHQWDWLRQGHVPLPLHV
* Perturbations du sommeil et des rythmes circadiens :
 Insomnie partielle ou totale.
 5GXFWLRQGXEHVRLQGHVRPPHLO
 $EVHQFHGHVHQVDWLRQGHIDWLJXH
 +\SHUVWKQLH
* Perturbations des fonctions cognitives :
 $QRVRJQRVLHSDUWLHOOHRXWRWDOHDEVHQFHGHFRQVFLHQFHGXWURXEOH
 +\SHUYLJLODQFHK\SHUUDFWLYLW
 'LVWUDFWLELOLWWURXEOHVGHODWWHQWLRQHWGHODFRQFHQWUDWLRQ
 +\SHUPQVLH

Signes associs

* Perturbations des conduites alimentaires :

 $QRUH[LHRXDXFRQWUDLUHK\SHUSKDJLH
 $PDLJULVVHPHQWPPHHQFDVGHSULVHVDOLPHQWDLUHVDXJPHQWHV
 3RVVLEOHGVK\GUDWDWLRQ
* Augmentation de la libidoK\SHUVH[XDOLWFRPSRUWHPHQWVVH[XHOVSRVVLEOHPHQW
risque.
* Retentissement fonctionnel VRFLDOHWSURIHVVLRQQHOPDMHXU
* Achats pathologiques/dpenses inconsidres.

204

* Comportements risque, recherche de sensation fortes, prise de toxiques, conduites

VH[XHOOHVULVTXHYLWHVVH
* Possibles actes mdico-lgauxSUYHQLU

3.2.

Syndrome hypomaniaque
/H V\QGURPH K\SRPDQLDTXH HVW JDOHPHQW FDUDFWULV SDU OD SHUVLVWDQFH GDQV OH WHPSV GXQH
DXJPHQWDWLRQSDWKRORJLTXHGHOKXPHXUHWGHOQHUJLH0DLVODV\PSWRPDWRORJLHHWOHUHWHQWLVVH
PHQWIRQFWLRQQHOVRQWPRLQVLPSRUWDQWVTXHORUVGXQDFFVPDQLDTXH
Bien que le tableau clinique soit moins svre que pour lpisode maniaque, le sujet prsente une
rupture totale avec ltat antrieur VRXYHQW FRQVWDW SDU OHQWRXUDJH et manifeste comme pour
lpisode maniaque des perturbations pathologiques de laffectivit (humeur et motions), une
acclration psycho-motrice et des signes associs (sommeil et rythmes, fonctions cognitives,
alimentation, libido, retentissements).
&HVSHUWXUEDWLRQVGRLYHQWWUHSUVHQWHVWRXVOHVMRXUVSHQGDQWDXPRLQVMRXUV&HFULWUHGH
GXUH SHXW JDOHPHQW IDLUH OD GLUHQFH DYHF XQ SLVRGH PDQLDTXH GRQW OD GXUH GRLW WUH ! 
MRXUV
&RQWUDLUHPHQWOSLVRGHPDQLDTXHOSLVRGHK\SRPDQLDTXHQHQFHVVLWHVRXYHQWSDVGKRVSL
WDOLVDWLRQHQPLOLHXGHVRLQVVSFLDOLVV1DQPRLQVXQSLVRGHK\SRPDQLDTXHGRLWJDOHPHQW
tre rapidement prise en charge avec adaptation thrapeutique.

Trouble bipolaire de ladolescent et de ladulte

3.3.

62

Syndrome dpressif
Cf. Item 64.

3.4.

Spcifications dcrivant les caractristiques

du syndrome (pisode) actuel

3.4.1. Caractristique

psychotique

8QSLVRGHPDQLDTXHRXGSUHVVLIFDUDFWULVSHXWVDFFRPSDJQHUGLGHVGOLUDQWHV
$WWHQWLRQ ORUV GXQ WDW PDQLDTXH ODXJPHQWDWLRQ GH OKXPHXU HW GH OQHUJLH VH WUDGXLW SDU
XQHDXJPHQWDWLRQGHOHVWLPHGHVRLDYHFGHVLGHVPJDORPDQLDTXHVTXLVRQWmSVHXGRGOL
UDQWHV},OIDXGUDGLUHQFLHUFHVLGHVGHJUDQGHXUGXQYULWDEOHV\QGURPHGOLUDQWSRXUSRUWHU
OHGLDJQRVWLFGSLVRGHPDQLDTXHDYHFFDUDFWULVWLTXHSV\FKRWLTXHTXLHVWFRPSRV
*

 H PFDQLVPHV GOLUDQWV LPDJLQDWLI HWRX LQWXLWLI HWRX KDOOXFLQDWRLUH HW PRLQV VRXYHQW
'
interprtatif.

/ HVWKPHVVRQWVRXYHQWPJDORPDQLDTXHVP\VWLTXHVSURSKWLTXHVDYHFRXVDQVV\QGURPH
GLQXHQFHHWSRVVLEOHPHQWURWRPDQLDTXHVGHSHUVFXWLRQGHUHYHQGLFDWLRQHWF

,OVVRQWV\VWPDWLVVPDLVSHXRUJDQLVV

/DGKVLRQRXFULWLTXHGHVLGHVGOLUDQWHVHVWYDULDEOH

2QVSFLHUDVLFHVLGHVGOLUDQWHVVRQWFRQJUXHQWHVRXQRQOKXPHXU
*

La caractristique psychotique sera congruente lhumeur GDQV OH FDV R OH FRQWHQX GHV
LGHVGOLUDQWHVHVWFRQVLVWDQWDYHFOHVWKPHVW\SLTXHVGHOSLVRGHGHOKXPHXUHQFRXUV
3DUH[HPSOHOHVLGHVPDQLDTXHVGHJUDQGHXUSUHQQHQWXQHYULWDEOHRUJDQLVDWLRQGOLUDQWH
PJDORPDQLDTXHGLQYXOQUDELOLWRXGHVWKPHVGOLUDQWVGHUXLQHGHFXOSDELOLWDXFRXUV
GXQSLVRGHGSUHVVLI

 OOHV VHURQW non congruentes VL OH FRQWHQX GHV LGHV GOLUDQWHV QHVW SDV HQ OLHQ DYHF OHV
(
WKPHVGHOSLVRGHGHOKXPHXU

3.4.2.Caractristique

mixte

'HVV\PSWPHVGSUHVVLIVSHXYHQWDSSDUDWUHDXFRXUVGXQSLVRGHPDQLDTXHHWGXUHUTXHOTXHV
PRPHQWVKHXUHVRXSOXVUDUHPHQWGHVMRXUV2QSDUOHDORUVGSLVRGHPDQLDTXHRXK\SRPD
niaque de caractristique mixte.
5FLSURTXHPHQWGHVV\PSWPHVPDQLDTXHVSHXYHQWDSSDUDWUHDXFRXUVGXQSLVRGHGSUHVVLI
2QSDUOHDORUVGSLVRGHGSUHVVLIGHFDUDFWULVWLTXHPL[WH
,ODEVROXPHQWLQGLVSHQVDEOHGLGHQWLHUFHWWHFDUDFWULVWLTXHFDUHOOHVDVVRFLHXQULVTXHWUV
augment de suicide.

3.4.3.Caractristique

anxieuse

'HVV\PSWPHVDQ[LHX[SHXYHQWDFFRPSDJQHUXQSLVRGHPDQLDTXHK\SRPDQLDTXHRXGSUHV
VLI,OVSHXYHQWVHPDQLIHVWHUFKH]OHVXMHWSDUODVHQVDWLRQGWUHWHQGXGWUHQHUYRXLPSD
WLHQWGHPDQLUHLQKDELWXHOOHGHSUVHQWHUGHVGLFXOWVGHFRQFHQWUDWLRQFDXVHGLQTXLWXGHV
ODSHXUTXHTXHOTXHFKRVHGHWHUULEOHSXLVVHDUULYHUHWOLPSUHVVLRQTXHOHVXMHWSHXWSHUGUHOH
FRQWUOHGHOXLPPH

205

62

Les troubles psychiatriques tous les ges

&HWWH FDUDFWULVWLTXH DQ[LHXVH GHV SLVRGHV GRLW WUH LGHQWLH FDU HOOH VDVVRFLH  XQ ULVTXH
DXJPHQWGHVXLFLGHGHGXUHSOXVORQJXHGXWURXEOHHWGHQRQUSRQVHWKUDSHXWLTXH

3.4.4.Caractristique

de dbut en pri-partum

&HWWHFDUDFWULVWLTXHHVWSRUWHORUVTXHOSLVRGHGHOKXPHXURXVHVV\PSWPHVVHPDQLIHVWHQW
au cours de la grossesse et jusqu 4 semaines aprs laccouchement (post-partum).

3.4.5.Caractristique

catatonique

,OVDJLWGXQsyndrome trans-nosographiqueTXLSHXWDSSDUDWUHDXFRXUVGXQSLVRGHGHOKX
meur et qui peut se manifester par :
*

une immobilit motrice se manifestant par une catalepsie FRPSUHQDQW XQH H[LELOLW FLUHXVH
FDWDWRQLTXHRXXQHstupeur catatonique,

une activit motrice excessive non influence par les stimuli extrieurs et apparemment strile
RQSDUOHJDOHPHQWGHFDWDWRQLHDJLWHORUVTXHSUVHQW

une ngativisme extrmeUVLVWDQFHLPPRWLYHHWPDLQWLHQGXQHSRVLWLRQULJLGHRXmutisme,

des mouvements volontaires particuliers et positions catatoniques PDLQWLHQ GXQH SRVLWLRQ

LQDSSURSULHRXEL]DUUHmouvements strotyps, manirismes ou grimaces,

une cholalie ou chopraxieUSWLWLRQGHPRWVRXGHJHVWHV

3.4.6.Caractristique mlancolique (si pisode dpressif caractris)

Cette caractristique se manifeste par une perte complte de la capacit ressentir du plaisir
FI,WHPWURXEOHGSUHVVLI

206

3.4.7. Caractristique

atypique (si pisode dpressif caractris)

&HWWHFDUDFWULVWLTXHVHPDQLIHVWHSDUXQHUDFWLYLWGHOKXPHXUHWSRVVLEOHPHQWXQHDXJPHQWD
WLRQGXSRLGVRXGHODSSWLWXQHK\SHUVRPQLHGHVLPSUHVVLRQVGHSHVDQWHXUORXUGHXUGXQRX
SOXVLHXUVPHPEUHVHWXQHVHQVLELOLWDX[UHMHWVLQWHUSHUVRQQHOV

3.5.

Spcifications dcrivant lvolution des pisodes rcurrents

3.5.1. Caractre

saisonnier

&H FDUDFWUH SHXW WUH port quelque soit la polarit de lpisode PDQLDTXH K\SRPDQLDTXH RX
GSUHVVLIHWGRLWVHPDQLIHVWHUSDU
*

une relation temporelle rgulire HQWUHODVXUYHQXHGHVSLVRGHVPDQLDTXHVK\SRPDQLDTXHV

RXGSUHVVLIVHWXQHSULRGHSDUWLFXOLUHGHODQQHHJHQDXWRPQHRXHQKLYHUHWQRQOL
des facteurs de stress environnementaux videmment en lien avec la priode (anniversaires
WUDXPDWLTXHVHWF

des rmissions compltes RXXQYLUHPHQWGXQSLVRGHGSUHVVLIFDUDFWULVYHUVXQSLVRGH

PDQLDTXHRXK\SRPDQLDTXHRXLQYHUVHPHQWVXUYLHQQHQWDXVVLDXFRXUVGXQHSULRGHSDUWL
FXOLUHGHODQQH

au moins 2 pisodes saisonniers PDQLDTXHV K\SRPDQLDTXHV RX GSUHVVLIV aux cours des
2 dernires annes HWHQODEVHQFHGSLVRGHVQRQVDLVRQQLHUVDXFRXUVGHODPPHSULRGH

une vie entire du sujet marque par nettement plus dpisodes maniaques, hypomaniaques ou
dpressifs saisonniers que non saisonniers.

Trouble bipolaire de ladolescent et de ladulte

3.5.2.Cycles

62

rapides

&HWWHVSFLFDWLRQHVWDVVRFLHDYHFXQSURQRVWLFSOXVVYUHHWXQHUVLVWDQFHWKUDSHXWLTXH
SOXVOHYH(OOHHVWGQLHSDUODSUVHQFH sur les 12 derniers mois dau moins 4 pisodes de lhumeur WRXWHSRODULWFRQIRQGXHPDQLDTXHVK\SRPDQLDTXHVRXGSUHVVLIV

4.

Le trouble bipolaire
Troubles de lhumeur
Diagnostic diffrentiel psychiatrique :

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GXQHDHFWLRQ
mdicale gnrale

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 WURXEOHXQLSRODLUH
7+$'$
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7URXEOHGHSHUVRQQDOLW
SHUVRQQDOLWWDWOLPLWH
6FKL]RSKUQLH
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7URXEOHREVHVVLRQQHOFRPSXOVLI
7URXEOHDQ[LHX[

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induit par
XQHVXEVWDQFH

Troubles bipolaires

207

6LSUVHQFHGXQSLVRGH
PDQLDTXHRXK\SRPDQLDTXH
DFWXHORXSDVV

pisode actuel dpressif

5HFKHUFKHU

pisode actuel maniaque

5HFKHUFKHU

&DUDFWULVWLTXHSV\FKRWLTXH

Caractristique mixte

&DUDFWULVWLTXHSV\FKRWLTXH

Caractristique anxieuse

Caractristique mixte

&DUDFWULVWLTXHGXSRVWSDUWXP

Caractristique anxieuse

Caractristique catatonique

&DUDFWULVWLTXHGXSRVWSDUWXP

Caractristique mlancolique

&DUDFWULVWLTXHDW\SLTXH

Caractristique catatonique

volution des pisodes rcurrents

5HFKHUFKHU
*

&DUDFWUHVDLVRQQLHU

&\FOHVUDSLGHV

Figure 1. Arbre dcisionnel rsumant la stratgie diagnostic devant des troubles de lhumeur.

62

Les troubles psychiatriques tous les ges

4.1.

Diagnostics positifs

4.1.1. valuations

raliser lors du bilan initial

Lors du bilan initial, il faut effectuer un :

208

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5
OHVSLVRGHVSDVVVHWV\PSWPHVSUVHQWVHQWUHOHVSLVRGHV

5HFKHUFKHGDQWFGHQWVGHV\PSWPHVK\SRPDQLDTXHV\FRPSULVVRXVDQWLGSUHVVHXU

 HFXHLOGHVDQWFGHQWVIDPLOLDX[SV\FKLDWULTXHVHWDGGLFWRORJLTXHVHQSDUWLFXOLHUGHWURXEOH
5
GHOKXPHXUHWGHWHQWDWLYHVGHVXLFLGHV

 HFXHLOGHVDQWFGHQWVSHUVRQQHOVGHUSRQVHDX[WUDLWHPHQWVFKH]OHVVXMHWVWUDLWVSRXU
5
WURXEOHVGHOKXPHXU

5HFKHUFKHUGYHQWXHOVIDFWHXUVGFOHQFKDQWGHVSLVRGHVDQWULHXUV

6DLGHUGHODSUVHQFHGXQWLHUVORUVTXHOHSDWLHQWHVWGDFFRUGHWHQVDSUVHQFH

 YDOXDWLRQ GH ODHFWLYLW GH OQHUJLH GX IRQFWLRQQHPHQW SV\FKRPRWHXU HW UHFKHUFKH GH

signes associs.

YDOXHUOHIRQFWLRQQHPHQWIDPLOLDOVRFLDOHWSURIHVVLRQQHO

5HFKHUFKHUV\VWPDWLTXHPHQWODSUVHQFHGLGHVVXLFLGDLUHV

5HFKHUFKHUV\VWPDWLTXHPHQWOHVFRPRUELGLWVDVVRFLHV

4.1.2.

Poser le diagnostic dpisode maniaque

Pour poser le diagnostic dpisode maniaque dans le cadre du trouble bipolaire, il faut :
*

8QHVPLRORJLHWHOOHTXHGFULWHSUFGHPPHQW

 QH YROXWLRQ GHSXLV SOXV GH XQH VHPDLQH RX WRXW DXWUH GXUH VL XQH KRVSLWDOLVDWLRQ HVW
8
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8
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GRPPDJHDEOHVSRXUOHVXMHWRXSRXUDXWUXLRXELHQLOH[LVWHGHVFDUDFWULVWLTXHVSV\FKRWLTXHV

/ DEVHQFHGHGLDJQRVWLFGLUHQWLHOHHWVSK\VLRORJLTXHVGLUHFWVGXQHVXEVWDQFHRXGXQH
DHFWLRQPGLFDOHJQUDOH

Trouble bipolaire de ladolescent et de ladulte

62

DSM-5
pisode maniaque
$8QHSULRGHQHWWHPHQWGOLPLWHGXUDQWODTXHOOHOKXPHXUHVWOHYHH[SDQVLYHRXLUULWDEOHGHIDRQDQRUPDOHHW
SHUVLVWDQWHHWXQHDXJPHQWDWLRQGHOQHUJLHRXGHODFWLYLWRULHQWHYHUVXQEXWGHPDQLUHDQRUPDOHHWSHUVLVWDQWH
pendant au moins une semaine et prsent la plupart du temps, presque tous les jours (ou toute autre dure si une
KRVSLWDOLVDWLRQHVWQFHVVDLUH
%$XFRXUVGHFHWWHSULRGHGHSHUWXUEDWLRQGHOKXPHXUHWGDXJPHQWDWLRQGHOQHUJLHRXGHODFWLYLWRXSOXVGHV
V\PSWPHVVXLYDQWVVLOKXPHXUHVWVHXOHPHQWLUULWDEOHRQWSHUVLVWDYHFXQHLQWHQVLWVXVDQWHHWUHSUVHQWHQW
XQFKDQJHPHQWPDUTXGHVFRQGXLWHVKDELWXHOOHV
1. DXJPHQWDWLRQGHOHVWLPHGHVRLRXLGHVGHJUDQGHXU
2. UGXFWLRQGXEHVRLQGHVRPPHLOSDUH[OHVXMHWVHVHQWUHSRVDSUVKHXUHVGHVRPPHLO
 SOXVJUDQGHFRPPXQLFDELOLWTXHGKDELWXGHRXGVLUGHSDUOHUFRQVWDPPHQW
4. IXLWHGHVLGHVRXVHQVDWLRQVVXEMHFWLYHVTXHOHVSHQVHVGOHQW
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LQVLJQLDQWVUDSSRUWHRXREVHUYH
6. DXJPHQWDWLRQGHODFWLYLWRULHQWHYHUVXQEXWVRFLDOSURIHVVLRQQHOVFRODLUHRXVH[XHORXDJLWDWLRQSV\FKR
PRWULFHLHDFWLYLWQRQRULHQWHYHUVXQEXWRXVDQVEXW
 HQJDJHPHQWH[FHVVLIGDQVGHVDFWLYLWVDJUDEOHVPDLVSRWHQWLHOOHYGHFRQVTXHQFHVGRPPDJHDEOHV
&/HVSHUWXUEDWLRQVGHOKXPHXUVRQWVXVDPPHQWVYUHVSRXUHQWUDQHUXQHDOWUDWLRQPDUTXHGXIRQFWLRQQHPHQW
ou des activits sociales ou professionnelles, ou ncessiter une hospitalisation pour prvenir un danger pour soi ou
OHVDXWUHVRXVLOH[LVWHGHVFDUDFWULVWLTXHVSV\FKRWLTXHV
'/SLVRGHQHGRLWSDVWUHDWWULEXDEOHDX[HHWVSK\VLRORJLTXHVGLUHFWVGXQHVXEVWDQFHRXGXQHDHFWLRQPGL
cale gnrale.

/XWLOLVDWLRQ GFKHOOHV RX GH TXHVWLRQQDLUHVSHXWDLGHUDXGSLVWDJHWHOTXHOH0RRG'LVRUGHU

4XHVWLRQQDLUH mTXHVWLRQQDLUHGHVWURXEOHVGHOKXPHXU}0'4

4.1.3. Les

diffrentes formes cliniques

Type IVXUYHQXHGXQRXSOXVLHXUVSLVRGHVPDQLDTXHVRXPL[WHV/HGLDJQRVWLFSHXWWUH

SRVPPHHQODEVHQFHGHWURXEOHGSUHVVLI,OSHXW\DYRLUGHVSLVRGHVK\SRPDQLDTXHV
6DQVFDXVHPGLFDOHQRQSV\FKLDWULTXHLDWURJQLTXHRXWR[LTXH

Type IIVXUYHQXHGXQRXSOXVLHXUVSLVRGHVK\SRPDQLDTXHVHWXQRXSOXVLHXUVSLVRGHV

GSUHVVLIVPDMHXUV6DQVFDXVHPGLFDOHQRQSV\FKLDWULTXHLDWURJQLTXHRXWR[LTXH

Virage maniaque ou hypomaniaque sous antidpresseur (aussi appel Type III)VXUYHQXHGXQ

RXSOXVLHXUVSLVRGHVPDQLDTXHVRXK\SRPDQLDTXHVXQLTXHPHQWVRXVDQWLGSUHVVHXU

,OH[LVWHGDXWUHVVRXVW\SHVVLQWJUDQWGDQVOHVSHFWUHGLWmODUJL}GHVWURXEOHVELSRODLUHV&HV
DXWUHVVRXVW\SHVVRQWGDYDQWDJHODDLUHGHVVSFLDOLVWHV

4.2.

Diagnostics diffrentiels
&RPPH SRXU WRXWH SDWKRORJLH SV\FKLDWULTXH D IRUWLRUL DLJX XQH DHFWLRQ PGLFDOH JQUDOH
GHYUDWUHOLPLQHODLGH
*

Bilan clinique complet GWDLOOHUGHPDQLUHKLUDUFKLTXHVHORQODSUVHQWDWLRQFOLQLTXH2Q

UHFKHUFKHUDHQSDUWLFXOLHUGHVVLJQHVGHK\SRWK\URGLHRXK\SHUWK\URGLHDFFLGHQWVYDVFX
ODLUHVFUEUDX[HWWURXEOHVQHXURORJLTXHVGHW\SHGPHQFHVXUWRXWVLSDWLHQWVGHSOXVGH
DQVDYHFGHVWURXEOHVELSRODLUHVGDSSDULWLRQUHWDUGHSDWKRORJLHYDVFXODLUHRXWXPRUDOH
IURQWDOHTXLSHXWPLPHUFHUWDLQVWURXEOHVGHOKXPHXU

209

62

Les troubles psychiatriques tous les ges

Bilan para-clinique :

Bilan sanguin

*O\FPLHFDSLOODLUHYRLUHYHLQHXVH
Ionogramme, calcmie.
Bilan urinaire : ure, cratinmie.
1)6SODTXHWWHV&53
TSH86.
Bilan hpatique.
*D]GXVDQJ

Bilan urinaire

7R[LTXHVXULQDLUHVFDQQDELVFRFDQHRSLDFVDPSKWDPLQHV

Imagerie

Autres examens
complmentaires

&UEUDOHVFDQQHUFUEUDOHQXUJHQFH
((*
(&*ELODQSUWKUDSHXWLTXHGHVDQWLSV\FKRWLTXHV
6HORQSRLQWVGDSSHOVFOLQLTXHV

Les diagnostics diffrentiels lis des affections mdicales gnrales, pouvant induire des symptmes de troubles de lhumeur, sont :

210

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1
de dmence.

(QGRFULQLHQQHVWURXEOHVWK\URGLHQVPDODGLHGH&XVKLQJ

0WDEROLTXHVK\SRJO\FPLHWURXEOHVLRQLTXHVHWF

,DWURJQLTXHVPGLFDPHQWHXVHVFRUWLFRGHVDQWLGSUHVVHXUVLQWHUIURQDOSKDHWF

7 R[LTXH VXEVWDQFHV SV\FKRDFWLYHV DOFRRO FDQQDELV DPSKWDPLQHV HW FRFDQH KDOOXFLQR

JQHV&HVWOHGLDJQRVWLFGLUHQWLHOOHSOXVIUTXHQW

Les diagnostics diffrentiels psychiatriques du trouble bipolaire sont :

*

7URXEOHGSUHVVLIUFXUUHQW WURXEOHXQLSRODLUHFI,WHP

7URXEOHGHSHUVRQQDOLWSHUVRQQDOLWWDWOLPLWHFI,WHP

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6FKL]RSKUQLHFI,WHP

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7URXEOHGOLUDQWSHUVLVWDQWFI,WHP

&HVGLDJQRVWLFVGLUHQWLHOVSV\FKLDWULTXHVGHSDUOHXUSRVVLEOHVXSHUSRVLWLRQV\PSWRPDWLTXH
FRQWULEXHQWOHUUDQFHGLDJQRVWLTXHGXWURXEOHELSRODLUH

Important
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WURXEOHELSRODLUHHWGYLWHUDLQVLOHUHWDUGGLDJQRVWLFHWWKUDSHXWLTXH

Trouble bipolaire de ladolescent et de ladulte

4.3.

62

Comorbidits psychiatriques et non psychiaytriques

'H SDUW OHXU IUTXHQFH HW OHXU LPSDFW FHV FRPRUELGLWV SV\FKLDWULTXHV GX WURXEOH ELSRODLUH
GHYURQW V\VWPDWLTXHPHQW WUH UHFKHUFKHVLOV SHXYHQW SDUIRLV VH FRQIRQGUH DYHF OHV V\PS
WPHVGXWURXEOHELSRODLUHV
*

Addictions : environ 40 % 60 % vie entire. (Q SDUWLFXOLHU ODOFRRO  OH FDQQDELV
FRFDLQHHWSV\FKRVWLPXODQWVVGDWLIV

Troubles anxieux : environ 40 % vie entire. (Q SDUWLFXOLHU OH WURXEOH SDQLTXH  OHV
SKRELHVVRFLDOHVOHVSKRELHVVLPSOHV

TDAH : environ 30 % selon les tudes.

Trouble de personnalit : environ 30 % selon les tudes VXUWRXWSHUVRQQDOLWWDWOLPLWHRXGLWH

mERUGHUOLQH}

Troubles des conduites alimentaires : YLHHQWLUH

Trouble obsessionnel compulsif :YLHHQWLUH

* Comorbidits non psychiatriquesV\QGURPHPWDEROLTXHULVTXHFDUGLRYDVFXODLUHV\QGURPH

GDSQH REVWUXFWLYH GX VRPPHLO SDWKRORJLHV HQGRFULQLHQQHV PDODGLHV LQDPPDWRLUHV FKUR
QLTXHVSDWKRORJLHVWXPRUDOHVPDODGLHVQHXURGJQUDWLYHV

4.4.

Notions de physio/psychopathologie
/WLRSDWKRJQLHH[DFWHGHVWURXEOHVELSRODLUHVQHVWSDVFRQQXHPDLVODSDUWLFLSDWLRQGHIDFWHXUV
JQWLTXHVHWHQYLURQQHPHQWDX[HVWELHQGPRQWUH
211

Neuroscience et recherche
/DSUVHQFHGXQDSSDUHQWGHSUHPLHUGHJUDWWHLQWGHWURXEOHELSRODLUHHQWUDQHXQHDXJPHQWDWLRQSDUGXULVTXH
GHGYHORSSHUODPDODGLHSRXUXQVXMHW/KULWDELOLWGHODPDODGLHFHVWGLUHODSDUWGH[SUHVVLRQFOLQLTXHOLHDX[
JQHVHVWGH,OH[LVWHSDUDLOOHXUVXQQRPEUHLPSRUWDQWGHIDFWHXUVGHULVTXHHQYLURQQHPHQWDX[GRQWOHV
WUDXPDWLVPHVGDQVOHQIDQFHVH[XHOVDHFWLIVRXPRWLRQQHOVHWOHVVWUHVVHQYLURQQHPHQWDX[SOXVWDUGLIVDLJXVRX
USWV
3OXVLHXUVELRPDUTXHXUVGHVXVFHSWLELOLWHWGWDWGHODPDODGLHRQWWPLVHHQYLGHQFHHQJQWLTXHHQQHXURLPDJH
ULHHQQHXURFRJQLWLRQHQVRPPHLOHQELRORJLHGHVU\WKPHVFLUFDGLHQVHQLPPXQRLQDPPDWLRQHQQHXURSK\VLROR
JLHHQELRFKLPLHHWF
/HVUHFKHUFKHVVFLHQWLTXHVDFWXHOOHVWHQWHQWGHWUDQVIUHUOXWLOLVDWLRQGHFHVELRPDUTXHXUVHQFOLQLTXHDQGDPOLRUHU
le dpistage et les prises en charge des patients.

5.

Le pronostic et lvolution
Le pronostic de la maladie en est sa prise en charge prcoce et adapte.
%LHQ WUDLWV OHV VXMHWV DWWHLQWV GH WURXEOH ELSRODLUH SHXYHQW SUVHQWHU XQH UPLVVLRQ V\PSWR
matique et fonctionnelle avec une excellente insertion familiale, professionnelle et sociale.
1DQPRLQVFHUWDLQVVXMHWVSHXYHQWSUVHQWHUGHVV\PSWPHVUVLGXHOVHQGHKRUVGHVSLVRGHV
GHOKXPHXUGRQWOLPSDFWSHXWWUHWUVLPSRUWDQWHQSDUWLFXOLHUVXUOHSODQIRQFWLRQQHO

62

Les troubles psychiatriques tous les ges

Si le trouble bipolaire nest pas correctement pris en charge, il peut se compliquer :

*

volution plus svreGHVWURXEOHVDYHFODSSDULWLRQ

 de cycles rapides,
 de troubles psychiatriques associs DGGLFWLRQVODOFRROHWDX[VXEVWDQFHVSV\FKRDFWLYHV
LOOLFLWHVWURXEOHVDQ[LHX[HWF
 de pathologies mdicales non psychiatriques associes : maladies cardiovasculaires,
GLDEWHHWF

suicideGHVSDWLHQWVD\DQWXQWURXEOHELSRODLUHGFGHQWSDUVXLFLGH

actes mdicolgauxOLVODGVLQKLELWLRQSV\FKRFRPSRUWHPHQWDOH

dsinsertion IDPLOLDOH  IRLV SOXV GH GLYRUFHV FKH] OHV VXMHWV DWWHLQWV GH WURXEOH ELSRODLUH
professionnelle et sociale.

6.

La prise en charge psychiatrique

6.1.

Stratgies de prvention
Certains antcdents du patient doivent faire penser au diagnostic de trouble bipolaire :

212

6.2.

/DSUVHQFHGDQWFGHQWVGHSLVRGHVGSUHVVLIVUFXUUHQWVRXSOXV

/ DQRWLRQGK\SRPDQLHPPHEUYHTXLSDVVHVRXYHQWLQDSHUXHQRQUDSSRUWHVSRQWDQ
PHQWSDUOHSDWLHQW

8QSLVRGHDW\SLTXHGFOHQFKSDUXQDQWLGSUHVVHXU

/HGEXWGXQSLVRGHPDQLDTXHGSUHVVLIRXSV\FKRWLTXHGXUDQWOHSRVWSDUWXP

8QGEXWGHVSLVRGHVGSUHVVLIVUFXUUHQWVDYDQWOJHGHDQV

/ DSUVHQFHGDQWFGHQWVIDPLOLDX[GHWURXEOHVELSRODLUHVGHWURXEOHVGSUHVVLIVUFXUUHQWV
GDGGLFWLRQVRXGHVXLFLGH

Des antcdents personnels de tentative de suicide.

 QDQWFGHQWGHUSRQVHDW\SLTXHXQWUDLWHPHQWDQWLGSUHVVHXUQRQUSRQVHWKUDSHX
8
WLTXH DJJUDYDWLRQ GHV V\PSWPHV DSSDULWLRQ GXQH DJLWDWLRQ DSSDULWLRQ GH V\PSWPHV
GK\SRPDQLH

Prise en charge en phase aigu

Un pisode maniaque est une urgence mdicale !
La prise en charge aigu dun pisode maniaque comporte :
*

Hospitalisation en urgence en psychiatrie en milieu ferm.

$GPLVVLRQHQVRLQVSV\FKLDWULTXHVVXUGHPDQGHGXQWLHUV$63'7RX6'7

5K\GUDWDWLRQ

5HFKHUFKHV\VWPDWLTXHGHSULVHGHWR[LTXH

(OLPLQHUXQHFDXVHPGLFDOHQRQSV\FKLDWULTXH

5HFKHUFKHV\VWPDWLTXHGHFRQWDJH067

Chimiothrapie par thymorgulateur (appel aussi stabilisateur de lhumeur) le plus prcocement

et au long cours FDUFXUDWLIGHOSLVRGHDLJXTXHOTXHVRLWVDSRODULWSUYHQWLIGHVUFLGLYHV
HWDPOLRUHOHSURQRVWLFGHODPDODGLHHWOHVSUDQFHGHYLHGXSDWLHQW

Trouble bipolaire de ladolescent et de ladulte

62

/HVWK\PRUJXODWHXUVFLGHVVRXVRQWWRXVO$00HQre intention :
Lithium (traitement de rfrence) :
TERALITHE 400 mg LP  &3 HQ SRVRORJLH LQLWLDOH DYHF contrle de la lithmie 12 heures de la prise
JQUDOHPHQWOHPDWLQKHXUHVquilibre entre 0,8 et 1,2 mEq/L.
Le Lithium est le seul thymorgulateur efficace dans la prvention du suicide et sera donc privilgier chez
un patient suicidaire et/ou avec antcdent de tentative de suicide.
* /HVFKPDGLQWURGXFWLRQGXOLWKLXPSHXWWUHOHVXLYDQWSRXUDGXOWHGHSRLGVHWWDLOOHGDQVODPR\HQQH
 &3GH7(5$/,7+(/3SHQGDQWMRXUV
 SXLV&3VSHQGDQWMRXUVHWGRVDJHKHXUHVGHODOLWKPLH
* 6L/LWKPLHP(T/DXJPHQWDWLRQGH&3HWGRVDJHMRXUV
* 6L/LWKPLHHQWUHHWP(T/DXJPHQWDWLRQGH&3HWGRVDJHMRXUV
 XDQG/LWKPLHHVWGDQVODIRXUFKHWWHWKUDSHXWLTXHHWP(T/VXUWURLVSUOYHPHQWVKHEGR
* 4
PDGDLUHVVXFFHVVLIV/LWKPLHWRXVOHVTXLQ]HMRXUVSHQGDQWGHX[PRLVSXLVWRXVOHVPRLVSHQGDQW
un an puis tous les 6 mois.
Bilan pr-thrapeutique du Lithium :
* 1)6SODTXHWWHV
* ,RQRJUDPPHVDQJXLQ&UDWLQLQPLHFODLUDQFHGHODFUDWLQLQHSURWLQXULHJO\FRVXULH
* Bilan hpatique.
* %LODQWK\URGLHQ76+
* (&*
* ((*VLDQWFGHQWVGHFRPLWLDOLW
* +&*IHPPHHQJHGHSURFUHU
Surveillance par bilans rnal et thyrodien annuel.

Anticonvulsivant
Anticonvulsivant type Divalproate de sodium (DEPAKOTE) PJMRXUHQSRVRORJLHLQLWLDOHHQRXSULVHV
* %LODQSUWKUDSHXWLTXHGX9DOSURDWH
 1)6SODTXHWWHV
 Bilan hpatique.
 +&*IHPPHHQJHGHSURFUHU
* 6XUYHLOODQFHSDUELODQV1)6SODTXHWWHVHWKSDWLTXHUJXOLHUVSHQGDQWOLQLWLDWLRQSXLVWRXVOHVPRLV

Antipsychotique
Antipsychotique atypique (2e gnration) 2ODQ]DSLQH =\SUH[D 5LVSULGRQH 5LVSHUGDO $ULSLSUD]ROH
$ELOLI\4XHWLDSLQH;HURTXHO
* Exemple4XHWLDSLQHPJMRXUHQSULVH
 YHF(&*PHVXUHGX47FRUULJSUDODEOHVHORQIRUPXOHGH%D]HWW,0&SRLGVHWWRXUGHWDLOOHVXUYHLO
* $
OHUJO\FPLHELODQOLSLGLTXHELODQKSDWLTXH

TousOHVDXWUHVWK\PRUJXODWHXUVVRQWHQe intention !

, OHVWSRVVLEOHGHPHWWUHXQHFRPELQDLVRQWKUDSHXWLTXH/LWKLXPRX9DOSURDWHDQWLSV\FKR
WLTXHDW\SLTXHGHPEOHSRXUOHVFDVGSLVRGHVPDQLDTXHVVYUHV

213

62

Les troubles psychiatriques tous les ges

7UDLWHPHQWV\PSWRPDWLTXHVGDWLISRVVLEOH
 %HQ]RGLD]SLQHVGHW\SH'LD]HSDPPJ[MRXU9DOLXPRX/RUD]HSDP7HPHVWD
 PJ[MRXUEXWDQ[LRO\WLTXHHWVGDWLISHURV

 6
 LQRQ YRLH ,0 DYHF SDU H[HPSOH 'LD]HSDP  PJ 9DOLXP RX &ORUD]SDWH GLSRWDVVLTXH
PJ7UDQ[HQH
 (7281HXUROHSWLTXHVGDWLIW\SH/R[DSLQH/R[DSDFPJ,0

 QGHUQLHUUHFRXUVLVROHPHQWHWFRQWHQWLRQGHVPHPEUHVSRXUSURWHFWLRQGXVXMHWHWDSUV
(
VGDWLRQFKLPLTXHVLWURXEOHVGXFRPSRUWHPHQWVPDMHXUVDYHFULVTXHDXWRRXKWURDJUHV
sif lev.

Prvention et surveillance du risque suicidaire et du risque htro-agressif.

Sauvegarde de justiceVLGSHQVHVRXDFKDWVH[FHVVLIVSRXUSURWHFWLRQGHVELHQVHQXUJHQFH

FXUDWHOOHHWWXWHOOHSUHQQHQWGXWHPSVHWQHVHIRQWSDVHQXUJHQFH

ALD 30, 100 %DYHFH[RQUDWLRQGXWLFNHWPRGUDWHXU

Information des proches.

6XLYLDXORQJFRXUVHQDPEXODWRLUHSUYRLUHWOLDLVRQDYHFOHPGHFLQWUDLWDQW

Surveillance efficacit et tolrance du traitement, de manire clinique et paraclinique :

 ([DPHQFOLQLTXHDJLWDWLRQV\PSWPHVPDQLDTXHVVRPPHLO
 6
 XUYHLOODQFHGHODWROUDQFHGHVWUDLWHPHQWVVGDWLRQWURSSURIRQGHK\SRWHQVLRQRUWKRV
WDWLTXHFRQVWLSDWLRQG\VNLQHVLHDLJXDNDWKLVLHV\QGURPHH[WUDS\UDPLGDO
 &RQVWDQWHV)&3$GHERXWFRXFK)57HPSUDWXUH
 (&*%LODQOLSLGLTXHSRLGVWRXUGHWDLOOH*O\FPLHHWLRQRJUDPPHVDQJXLQ

214

De manire plus gnrale dans le trouble bipolaire, une hospitalisation se justifie en cas de :

6.3.

7 URXEOHVGXFRPSRUWHPHQWPDMHXUVTXLSHXYHQWHQJHQGUHUGHVFRQVTXHQFHVGOWUHVSRXU
OHSDWLHQWHWSRXUOHQWRXUDJHHWOHVVRLJQDQWV

5LVTXHVXLFLGDLUHOHY

) RUPH VYUH HWRX UVLVWDQWH DX WUDLWHPHQW QFHVVLWDQW XQH UYDOXDWLRQ GLDJQRVWLTXH HW
thrapeutique.

&RPRUELGLWVFRPSOH[HV

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Prise en charge au long cours

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Sur le plan chimiothrapeutique :

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6.4.

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attentionnels,

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Points clefs

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Troubles anxieux

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item 64b

Trouble anxieux
gnralis
I. Introduction
II. Contexte pidmiologique
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64B

Les troubles psychiatriques tous les ges

1.

Introduction
Le trouble anxieux gnralis 7$* HVW XQ WURXEOH DQ[LHX[ PDUTX SDU XQH V\PSWRPDWRORJLH
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2.

Contexte pidmiologique
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3.

Smiologie psychiatrique

3.1.

Anxit et soucis excessifs

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doivent tre continus, prsents tous les jours ou presque.

3.2.

Symptmes fonctionnels chroniques

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Trouble anxieux gnralis

4.

Le trouble psychiatrique

4.1.

Diagnostic positif

64B

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Ce qui change dans le DSM-5

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4.2.

Diagnostics diffrentiels

4.2.1. Pathologies

mdicales non psychiatriques

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Les troubles psychiatriques tous les ges

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4.2.2.Prises

de toxiques

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4.2.3.Pathologies

psychiatriques

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4.3.
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Comorbidits psychiatriques
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4.4.

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Notions de physio/psychopathologie
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5.

Le pronostic et lvolution

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volution
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6.

La prise en charge psychiatrique

/H 7$* HVW XQ WURXEOH FKURQLTXH TXL QFHVVLWH GRQF XQ traitement de fond, au long cours, avec
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psychothrapeutiques et ventuellement psychopharmacologiques.

6.1.

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Les troubles psychiatriques tous les ges

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Psychothrapie
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6.3.

Traitement psychopharmacologique

6.3.1. Traitement

psychopharmacologique de fond

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6.3.2.Traitement

psychopharmacologique ponctuel
en cas de manifestations anxieuses intenses et invalidantes

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Trouble anxieux gnralis

6.4.

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Prise en charge des comorbidits et complications

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6.5.

Lhospitalisation en psychiatrie
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Rsum
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Rfrences pour approfondir

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Troubles anxieux

64C

item 64c

Trouble panique
I. Introduction
II. Contexte pidmiologique
III. 6PLRORJLHSV\FKLDWULTXH
IV. /HWURXEOHSV\FKLDWULTXH
V. /HSURQRVWLFHWOYROXWLRQ
VI. /DSULVHHQFKDUJHSV\FKLDWULTXH

Objectifs pdagogiques
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* $UJXPHQWHUODWWLWXGHWKUDSHXWLTXHHWSODQLHUOHVXLYLDX[GLUHQWVJHVHW
WRXVOHVVWDGHVGHFHVGLUHQWVWURXEOHV

64C

Les troubles psychiatriques tous les ges

1.

Introduction
/HWURXEOHSDQLTXH73HVWXQWURXEOHDQ[LHX[FDUDFWULVSDUODrptition des attaques de panique
$3HWSDUODSHXUGHOHXUVXUYHQXH

2.

Contexte pidmiologique
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Il est plus frquent en population fminine.
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GEXWVSOXVSUFRFHVODGROHVFHQFHHWVSRUDGLTXHPHQWWRXWJHGHODYLH

3.

Smiologie psychiatrique

3.1.

La rptition des attaques de panique

La rptition des attaques de panique HVWODFDUDFWULVWLTXHSULQFLSDOHGX73/HSOXVVRXYHQWFHV
$3VRQWVSRQWDQHVHWLPSUYLVLEOHVSDVGHIDFWHXUGFOHQFKDQWLGHQWLDXPRLQVDXGEXWGH
OYROXWLRQGXWURXEOH

228

6HFRQGDLUHPHQWOHVFULVHVYRQWWUHGHPRLQVHQPRLQVVSRQWDQHVHWWUHOLHVXQHDQ[LW
anticipatoireVRXYHQWDVVRFLHODFRQIURQWDWLRQGHVVLWXDWLRQVUHGRXWHVGDQVOHFDGUHGXQH
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3.2.

Lanxit anticipatoire
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YRLU VH UHSURGXLUH OHV $3 GH PDQLUH LQRSLQH SXLVTXHOOHV SHXYHQW VXUYHQLU HHFWLYHPHQW GH
PDQLUH LPSUYLVLEOH 2Q SDUOH GH OD mSHXU GDYRLU SHXU} 6H GYHORSSHQW DORUV GHV SURFFX
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IRXTXLSHXYHQWPRGLHUOHFRPSRUWHPHQWGXSDWLHQWHWDERXWLUGHVFRPSOLFDWLRQVLVROHPHQW
VRFLDOFKDQJHPHQWGHVKDELWXGHVGHYLHHWF)LQDOHPHQWXQPFDQLVPHGHFRQGLWLRQQHPHQW
LQWHUQHVHPHWHQSODFHWRXVOHVV\PSWPHVGXQH$3SRWHQWLHOOHHWGEXWDQWHFRPPHGHVSDOSL
tations ou des sensations vertigineuses, deviennent angoissants et peuvent dclencher relle
PHQWXQHFULVHFRPSOWH

Trouble panique

3.3.

64C

Lagoraphobie
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OHVTXHOOHVLOQHSRXUUDLWIDFLOHPHQWVFKDSSHURXGDQVOHVTXHOOHVLOQHSRXUUDLWWUHVHFRXUXHQ
FDVG$3HVSDFHVGFRXYHUWVPDJDVLQVOHVGDWWHQWHIRXOHVOLHX[SXEOLFVHQGURLWVFORVHWF
/H SDWLHQW QLW SDU YLWHU FHV VLWXDWLRQV FH TXL SHXW UHVWUHLQGUH FRQVLGUDEOHPHQW VRQ DXWRQR
PLH/agoraphobieQHGVLJQHGRQFSDVVHXOHPHQWODSHXUGHODmSODFHSXEOLTXH}DJRUDHWGHV
JUDQGVHVSDFHVPDLVODSHXUGHWRXWHVOHVVLWXDWLRQVDVVRFLHVDXULVTXHG$3
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VDQV73HWGHVIRUPHVGH73VDQVDJRUDSKRELH

4.

Le trouble psychiatrique

4.1.

Diagnostic positif

DSM-IV-R
Critres du trouble panique sans agoraphobie

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1. Attaques de panique rcurrentes et inattendues.
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 &UDLQWHSHUVLVWDQWHGDYRLUGDXWUHVDWWDTXHVGHSDQLTXH
 3URFFXSDWLRQVSURSRVGHVLPSOLFDWLRQVSRVVLEOHVGHODWWDTXHRXELHQGHVHVFRQVTXHQFHV
 Changement de comportement important en relation avec les attaques.
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cale gnrale.
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cale gnrale.
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229

64C

Les troubles psychiatriques tous les ges

Ce qui change dans le DSM-5

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4.2.

Les diffrentes formes cliniques

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GHV IRUPHV GH VYULW GLUHQWH QRWDPPHQW HQ IRQFWLRQ GX QRPEUH G$3 TXL SHXW YDULHU GH
TXHOTXHVXQHVSDUDQSOXVLHXUVSDUMRXU

4.3.

Diagnostics diffrentiels

4.3.1. Pathologies

mdicales non psychiatriques

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* 'HV SDWKRORJLHV FDUGLRYDVFXODLUHV DQJRU K\SHUWHQVLRQ DUWULHOOH LQIDUFWXV WURXEOHV GX
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* Des pathologies neurologiques : pilepsie, sclrose en plaque, crises migraineuses, accidents

ischmiques transitoires, etc.

230

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* 'HVSDWKRORJLHVHQGRFULQLHQQHVK\SRJO\FPLHGLDEWHG\VWK\URGLHSKRFKURPRF\WRPH
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4.3.2.Prises

de toxiques

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4.3.3. Pathologies

psychiatriques

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ELHQFRPSOLTXHUXQ73FRQVWLWX

4.4.

Comorbidits psychiatriques
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*

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Trouble panique

64C

* /HV WURXEOHV GH OD SHUVRQQDOLW GLWV mDQ[LHX[} SHUVRQQDOLW GSHQGDQWH HW
SHUVRQQDOLWYLWDQWH

4.5.

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Notions de physio/psychopathologie
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YULWDEOHmFHUFOHYLFLHX[}VLQVWDOOHDORUV

5.

Le pronostic et lvolution

5.1.

Complications
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accompagn, limitation des dplacements par crainte des transports en communs, des lieux
SXEOLFVGHOORLJQHPHQWGXGRPLFLOHHWF

5.2.

volution
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PDLVODQ[LWDQWLFLSDWRLUHHWVXUWRXWODJRUDSKRELHSHUVLVWHQWVRXYHQWSHQGDQWGHVDQQHV

6.

La prise en charge psychiatrique

/H73HVWXQWURXEOHFKURQLTXHTXLQFHVVLWHGRQFXQtraitement de fond, au long cours. Le traite
PHQWDVVRFLHGHVPR\HQVpsychopharmacologiques, psychothrapeutiques et une psychoducation/REMHFWLISULQFLSDOHVWOHFRQWUOHGHV$3

231

64C

Les troubles psychiatriques tous les ges

6.1.

Psycho ducation
La psychoducationHVWFHQWUDOHGDQVODSULVHHQFKDUJHGX73FDULOVDJLWVRXYHQWGXQHSDWKR
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6.2.

$UUWGHVH[FLWDQWVFDIWDEDFDOFRROHWDXWUHVWR[LTXHV

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Techniques de relaxation.

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Psychothrapie
Les thrapies cognitivo-comportementales7&&GRLYHQWWUHSULYLOJLHVD\DQWODUJHPHQWPRQWU
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232

6.3.

Traitement psychopharmacologique

6.3.1. Traitement

psychopharmacologique de fond

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ment important.
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Contexte pidmiologique
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236

3.

Smiologie psychiatrique

3.1.

Phobies spcifiques

3.1.1. Description

clinique

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Phobie sociale

3.2.1. Description

clinique

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 vitements multiples des situations sociales qui entranent une altration de la qualit de
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3.2.2.Formes

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4.

Diagnostic des troubles phobiques

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64D Les troubles psychiatriques tous les ges

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6.

La prise en charge psychiatrique

6.1.

Psychothrapie
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H[SRVLWLRQVHWGRQFOHWUDYDLOSV\FKRWKUDSHXWLTXH

241

64D Les troubles psychiatriques tous les ges

Rsum
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fessionnelle du sujet.

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Points clefs
242

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et de conduites dvitements.
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/YROXWLRQHVWOHSOXVVRXYHQWchroniquePPHVLOLQWHQVLWGHVV\PSWPHVSHXWDYRLUWHQGDQFHGLPLQXHUDYHFOHV
annes.
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autre trouble anxieux.
La prise en charge repose sur les thrapies comportementales et cognitives.
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sociale invalidante.

Rfrences pour approfondir

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Troubles anxieux

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item 64e

Trouble obsessionnel
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I. Introduction
II. Contexte pidmiologique
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IV. 'LDJQRVWLFGHVWURXEOHVSKRELTXHV
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64E Les troubles psychiatriques tous les ges

1.

Introduction
/H WURXEOH REVHVVLRQQHO FRPSXOVLI 72& HVW OXQH GHV SDWKRORJLHV SV\FKLDWULTXHV OHV SOXV
frquentes et les plus invalidantes ,O DVVRFLH GH IDRQ YDULDEOH  W\SHV GH V\PSWPHV VSFL
TXHVGHVobsessions et des compulsions.

pour en savoir plus : histoire de la psychatrie

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244

2.

Contexte pidmiologique
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HQYLURQXQWLHUVGVOHQIDQFH/HVH[UDWLRHVWGH

3.

Smiologie psychiatrique

3.1.

Les obsessions
Les obsessions sont caractrises par lirruption de penses, de reprsentations en dsaccord
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3.2.

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Lvitement
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Thmatiques
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245

64E Les troubles psychiatriques tous les ges

Nom du thme

Caractristiques

Contamination
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mentaux.

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Tableau 1. Grandes thmatiques du TOC.

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4.

Le trouble psychiatrique

4.1.

Diagnostic positif

4.1.1. Pour

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cliniques

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4.2.

Diagnostics diffrentiels

4.2.1. Pathologies

mdicales non psychiatriques

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4.2.2.Pathologies

psychiatriques

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247

64E Les troubles psychiatriques tous les ges

4.3.

OHVWURXEOHVDQ[LHX[WURXEOHDQ[LHX[JQUDOLVSKRELHVSFLTXHQRWDPPHQW

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les mouvements anormaux : tics (mouvements ou vocalisations rptitives involontaires qui

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Comorbidits psychiatriques
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4.4.

Notions de physio/psychopathologie
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eux extrmement mal connus.

248

pour en savoir plus : neuroscience et recherche

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Trouble obsessionnel compulsif

5.

Le pronostic et lvolution

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Complications

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5.2.

volution
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isolement social, etc.
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OJHGHGEXW

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ODSUVHQFHRXQRQGXQSLVRGHGSUHVVLIFDUDFWULVDVVRFL

6.

La prise en charge psychiatrique

6.1.

6.1. Psychoducation
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249

64E Les troubles psychiatriques tous les ges

6.2.

Traitement psychopharmacologique

6.2.1. Traitement

psychopharmacologique de fond

Les antidpresseurs inhibiteurs slectifs de la recapture de la srotonine ,656RQWXQHHFDFLW

GPRQWUHGDQVOHV72&&HWWHHFDFLWQFHVVLWHGHVposologies leves VRXYHQWOHGRXEOHGH
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de maintenir le traitement au moins 12 semaines DYDQWGHFRQFOXUHXQFKHF3RXUYLWHUXQH
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SXLVGHGLPLQXHUODGRVHSURJUHVVLYHPHQWDQGDWWHLQGUHODGRVHPLQLPDOHHFDFH

pour en savoir plus : en pratique

250

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6.2.2.Traitement

psychopharmacologique ponctuel en cas de

manifestations anxieuses intenses et invalidantes

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rituels. Leur utilisation doit rester ponctuelle.

6.3.

Psychothrapie
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6.4.

Lhospitalisation en psychiatrie
/KRVSLWDOLVDWLRQQHVWHQYLVDJHUTXHQFDVGHULVTXHVXLFLGDLUHPDMHXUQRWDPPHQWHQFDVGSL
sode dpressif caractris associ.

pour en savoir plus

La stimulation crbrale profonde dans les TOC rsistants

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KDXWHIUTXHQFHFHMRXUSOXVGXQHFHQWDLQHGHSDWLHQWVGDQVOHPRQGHRQWEQFLGHFHQRXYHDXWUDLWHPHQW

Rsum
Le TOC est une pathologie frquente et encore largement sous-diagnostique/HWURXEOHGEXWH
JQUDOHPHQWGDQVOenfance RXDXGEXWGHOJHadulteDYDQWDQV/HGLDJQRVWLFUHSRVHVXU
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valente aux thrapies cognitives et comportementales. Ces deux traitements doivent tre associs
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Points clefs
* /H72&HVWXQHSDWKRORJLHfrquenteGEXWDQWGDQVOHQIDQFHRXFKH]Oadulte jeune.
* /HGLDJQRVWLFUHSRVHVXUODSUVHQFHGobsessions RXHWGHcompulsionsGXQLPSDFWIRQFWLRQQHOGHVWURXEOHVHWGH
OOLPLQDWLRQGDXWUHVSKQRPQHVPHQWDX[RXFRPSRUWHPHQWDX[UDWWDFKHUGDXWUHVSDWKRORJLHVSV\FKLDWULTXHV
* Les comorbiditsVRQWIUTXHQWHVHQSDUWLFXOLHUOpisode dpressif caractris.
* /HV7&&EDVHVHQSDUWLFXOLHUVXUODWHFKQLTXHGH[SRVLWLRQDYHFSUYHQWLRQGHODUSRQVHHWOHVantidpresseurs inhibiteurs slectifs de la recapture de la srotonine RQWXQHHFDFLWVLPLODLUH
* /HWUDLWHPHQWSDU,656GRLWWUHHHFWXdose forte et sur une dure dau moins 12 semaines.
* Il est ncessaire de maintenir un traitement de consolidation pendant au moins 1 2 ans DSUVOREWHQWLRQGHODUSRQVH

251

64E Les troubles psychiatriques tous les ges

Rfrences pour approfondir
Troubles obsessionnels compulsifs (TOC) rsistants : prise en charge et place de la neurochirurgie
fonctionnelle+$6
&ODLU$+7U\ERX9+DQWRXFKH( 0DOOHW/Comprendre et traiter les troubles obsessionnels compulsifs [nouvelles approches]3DULV'XQRG
0LOOHW%-DDIDUL1Traitement du trouble obsessionnel-compulsif.5HY3UDW-DQ
Sauteraud A. Comprendre et soigner les troubles obsessionnels compulsifs.2GLOH-DFRE

252

Troubles anxieux

64F

item 64f

tat de stress
post-traumatique
I. Introduction
II. Contexte pidmiologique
III. 6PLRORJLHSV\FKLDWULTXH
IV. /HWURXEOHSV\FKLDWULTXH
V. /HSURQRVWLFHWOYROXWLRQ
VI. /DSULVHHQFKDUJHSV\FKLDWULTXH

Objectifs pdagogiques
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HWWRXVOHVVWDGHVGHFHVGLUHQWVWURXEOHV

64F Les troubles psychiatriques tous les ges

1.

Introduction
/WDWGHVWUHVVSRVWWUDXPDWLTXH(637FRUUHVSRQGODVXUYHQXHGHV\PSWPHVFDUDFWULVWLTXHV
ODVXLWHGHOexposition directe et personnelle un traumatisme. Ce traumatismeHVWGQLFRPPH
XQ YQHPHQW DX FRXUV GXTXHO OH VXMHW RX GDXWUHV SHUVRQQHV RQW SX WUH PHQDFV GH PRUW
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DVVRFLXQvcu dimpuissance FKH]OHVXMHW

pour en savoir plus

Histoire de la psychatrie

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DYHF+2SSHQKHLPHQSRXUGFULUHOHVV\PSWPHVSUVHQWVSDUFHUWDLQHVYLFWLPHVGHFDWDVWURSKHIHUURYLDLUH
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254

2.

Contexte pidmiologique
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importante au sein des populations plus exposes aux traumatismes comme par exemple, celles
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VXMHWVH[SRVVXQWUDXPDWLVPHUHWURXYHQWXQULVTXHGHGYHORSSHUOHWURXEOHGHQYLURQ
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GHGWHQWLRQPLOLWDLUHGHJQRFLGHHWGLQWHUQHPHQWHWKQLTXHRXSROLWLTXH
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3.

Smiologie psychiatrique

3.1.

Syndrome de rptition
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intense peuvent prendre la forme de :

tat de stress post-traumatique

3.2.

reviviscences ou flashbacks lors desquels le sujet agit ou ressent les mmes motions que lors
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cauchemars.

64F

Conduites dvitement
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SHXYHQWDYRLUGLYHUVWKPHVSRXUTXRLHVWFHTXHOYQHPHQWHVWDUULYDXVXMHWTXHVWFHTXLO
DXUDLWIDOOXIDLUHSRXUOHPSFKHURXFRPPHQWOHVXMHWSRXUUDLWVHYHQJHU

3.3.

Hyper activation neuro-vgtative

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une hypervigilanceODPHQDFH

des ractions de sursautH[DJUHV

une irritabilit RXGHVDFFVGHFROUH

des difficults de concentration 

des troubles du sommeil GLFXOWGHQGRUPLVVHPHQWRXVRPPHLOLQWHUURPSX

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GHFHUWDLQVOPHQWVVLJQLFDWLIVGXWUDXPDWLVPH

4.

Le trouble psychiatrique

4.1.

Diagnostic positif

4.1.1. Pour

poser le diagnostic dtat de stress post-traumatique

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RX GDXWUHV SHUVRQQHV VRQW PRUWHV RX RQW ULVTX GH PRXULU RX GWUH JUDYHPHQW EOHVVHV RX
menaces dans leur intgrit (par exemple un attentat, une exprience de guerre, une prise
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255

64F Les troubles psychiatriques tous les ges

DSM-IV
Critres du trouble tat de stress post-traumatique

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Rfrences pour approfondir

Post-Traumatic Stress Disorder. The Management of PTSD in Adults and Children in Primary and
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Psycho-traumatologie : valuation, clinique, traitement. -(+(/ / /23(= * FROOHFWLRQ
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de cette raction au stress se situe dans laltration du fonctionnement psycho-social.

3.2.

Types de symptmes
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*

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GLDJQRVWLFGHFHWURXEOHTXLVHUDUHWHQX

4.

Le trouble psychiatrique

4.1.

Diagnostic positif
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64G Les troubles psychiatriques tous les ges

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4.3.

Les diffrentes formes cliniques

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niques prdominantes.

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Les TA avec anxit HQWUDQHQW GHV V\PSWPHV DQ[LHX[ LQYDOLGDQWV DWWDTXHV GH SDQLTXH
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caractris.

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Diagnostics diffrentiels

4.3.1. Raction

adapte au stress

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4.3.2.Pathologies

mdicales non psychiatriques

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4.3.3. Pathologies

psychiatriques

Le TA fait partie des troubles lis aux traumatismes et au stress, tout comme ltat de stress aigu
ou de stress post traumatique FI,WHP)&HSHQGDQWOH7$VHGLVWLQJXHFODLUHPHQWGHFHWWH
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intensit.

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tat de stress
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pisode dpressif
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Figure 1. Diagnostics direntiels du TA.

4.4.

Les comorbidits psychiatriques

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4.5.

Notions de physio/psychopathologie
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un dni et une sidration. Secondairement, les capacits dadaptation du patient vont se mettre
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individuels.
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265

64G Les troubles psychiatriques tous les ges

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5.

Le pronostic et lvolution

5.1.

Complications
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eux qui feront une tentative de suicide au cours du TA.
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266

5.2.

volution
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aucune complication ni squelle. Cependant, il peut parfois se chroniciser ou se compliquer de
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volution

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Tableau 1. Particularits selon lge.

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6.

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La prise en charge psychiatrique

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6.1.

Psychothrapie
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6.2.

Traitement psychopharmacologique
267
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Lhospitalisation en psychiatrie
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les manifestations cliniques prdominantes.
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268

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* La principale complication est la tentative de suicide.
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Rfrences pour approfondir

Manuel de psychiatrie. *XHO-'5RXLOORQ)VRXVODGLUHFWLRQGH3DULVGLWLRQV0DVVRQ
Adolescence et psychopathologie. 0DUFHOOL ' %UDFRQQLHU $ &ROOHFWLRQ mOHV JHV GH OD YLH}
3DULVGLWLRQV0DVVRQ 6e dition, 2004.

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Les troubles
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IV. /DSULVHHQFKDUJHGHVWURXEOHVGHSHUVRQQDOLW
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VI. /HVDVSHFWVVSFLTXHVGHFKDTXHWURXEOHGHSHUVRQQDOLW

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dpressifs, anxieux et addictifs essentiellement.

270

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internationales le Manuel statistique et diagnostique de lassociation amricaine de psychiatrie '60 HW OD Classification internationale des maladies de lOrganisation mondiale de la
sant &,0'DQVOHQFDGUVXLYDQWJXUHQWOHVFULWUHVJQUDX[GHGLDJQRVWLFGXQWURXEOH
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DSM-IV
Critres gnraux dun trouble de personnalit
A. 0RGDOLWGXUDEOHGHOH[SULHQFHYFXHHWGHVFRQGXLWHVTXLGYLHQRWDEOHPHQWGHFHTXLHVWDWWHQGXGDQVODFXOWXUH
GHOLQGLYLGX&HWWHGYLDWLRQHVWPDQLIHVWHGDQVDXPRLQVGHX[GHVGRPDLQHVVXLYDQWV
1. /DFRJQLWLRQFHVWGLUHODSHUFHSWLRQHWODYLVLRQGHVRLPPHGDXWUXLHWGHVYQHPHQWV
2. /DHFWLYLWFHVWGLUHODGLYHUVLWOLQWHQVLWODODELOLWHWODGTXDWLRQGHODUSRQVHPRWLRQQHOOH
Le fonctionnement interpersonnel.
4. Le contrle des impulsions.
B. &HVPRGDOLWVGXUDEOHVVRQWULJLGHVHWHQYDKLVVHQWGHVVLWXDWLRQVSHUVRQQHOOHVHWVRFLDOHVWUVGLYHUVHV
C. &H PRGH GXUDEOH HQWUDQH XQH VRXUDQFH FOLQLTXHPHQW VLJQLFDWLYH RX XQH DOWUDWLRQ GX IRQFWLRQQHPHQW VRFLDO
SURIHVVLRQQHORXGDQVGDXWUHVGRPDLQHVLPSRUWDQWV
D. &HPRGHHVWVWDEOHHWSURORQJHWVHVSUHPLUHVPDQLIHVWDWLRQVVRQWGFHODEOHVDXSOXVWDUGODGROHVFHQFHRXDX
GEXWGHOJHDGXOWH
(&HWDEOHDXQHVWSDVPLHX[H[SOLTXSDUOHVPDQLIHVWDWLRQVRXOHVFRQVTXHQFHVGXQDXWUHWURXEOHPHQWDO
) &HPRGHGXUDEOHQHVWSDVGDX[HHWVSK\VLRORJLTXHVGLUHFWVGXQHVXEVWDQFHSDUH[XQHGURJXHGRQQDQWOLHX
DEXVRXXQPGLFDPHQWRXGXQHDHFWLRQPGLFDOHJQUDOHSDUH[XQWUDXPDWLVPHFUQLHQ

6XUODEDVHGDQDO\VHVVWDWLVWLTXHVOHVGLUHQWHVSHUVRQQDOLWVSDWKRORJLTXHVRQWWUHJURX
SHVHQIDPLOOHVRXmclusters}FIWDEOHDX
*

Le cluster ATXLUHJURXSHOHVSHUVRQQDOLWVSDUDQRDTXHVFKL]RGHHWVFKL]RW\SLTXHFRUUHV
pond aux personnalits psychotiques.

Le cluster B TXL UHJURXSH OHV SHUVRQQDOLWV DQWLVRFLDOH ERUGHUOLQH KLVWULRQLTXH HW QDUFLV
VLTXHVHFDUDFWULVHSDUOK\SHUPRWLYLWHWOHVFRPSRUWHPHQWVimpulsifs.

Le cluster C TXLUHJURXSHOHVSHUVRQQDOLWVYLWDQWHGSHQGDQWHHWREVHVVLRQQHOOHFRPSXOVLYH
correspond aux personnalits anxieuses.
Cluster

Caractristique principale

Troubles de personnalit

3V\FKRWLTXH

3HUVRQQDOLWSDUDQRDTXH
3HUVRQQDOLWVFKL]RGH
3HUVRQQDOLWVFKL]RW\SLTXH

PRWLRQQHOOH

3HUVRQQDOLWDQWLVRFLDOH
3HUVRQQDOLWERUGHUOLQH
3HUVRQQDOLWKLVWULRQLTXH
3HUVRQQDOLWQDUFLVVLTXH

Anxieuse

3HUVRQQDOLWYLWDQWH
3HUVRQQDOLWGSHQGDQWH
3HUVRQQDOLWREVHVVLRQQHOOHFRPSXOVLYH

Tableau 1. Les 3 clusters dfinis par le DSM et les 10 troubles des personnalits.

271

64H Les troubles psychiatriques tous les ges

2.

pidmiologie
des troubles de personnalit
/HVWURXEOHVGHODSHUVRQQDOLWFRQFHUQHQWHQYLURQ10 % de la population gnrale. Chacun des
WURXEOHVGHSHUVRQQDOLWFRQFHUQHHQWUHHWGHODSRSXODWLRQJQUDOH/HWURXEOHGHSHUVRQ
QDOLWERUGHUOLQHHVWOHSOXVIUTXHQW
/HVWURXEOHVGHSHUVRQQDOLWQHVRQWSDVH[FOXVLIVOHVXQVGHVDXWUHVHWEHDXFRXSGHSDWLHQWVVH
UHWURXYHQWHQVLWXDWLRQGHFRPRUELGLWV$LQVLHQYLURQGHVWURXEOHVGHODSHUVRQQDOLWVRQW
HQHHWFRPRUELGHV

En pratique
ge et diagnostic de trouble de personnalit

/HGLDJQRVWLFGHWURXEOHGHSHUVRQQDOLWVHIDLWJQUDOHPHQWDSUVDQV7RXWHIRLVTXDQGOHVWUDLWVVRQWSUVHQWV
SHQGDQWSOXVGHDQRQSHXWHQIDLUHOHGLDJQRVWLFDYDQWDQV

3.
272

Les comorbidits psychiatriques

des troubles de personnalit
&KDTXH WURXEOH GH SHUVRQQDOLW SUGLVSRVH  GH QRPEUHXVHV FRPRUELGLWV SV\FKLDWULTXHV DX
premier rang desquels les addictions, les troubles anxieux et les troubles de lhumeur. Les traits
GHSHUVRQQDOLWSHXYHQWDORUVWUHVRLWDFFHQWXVVRLWDEUDVVSDUXQHSDWKRORJLHSV\FKLDWULTXH
DVVRFLH'HSOXVOHVWURXEOHVPHQWDX[RQWXQSURQRVWLFSOXVSMRUDWLIORUVTXLOVVRQWDVVRFLV
XQWURXEOHGHODSHUVRQQDOLW
Le risque suicidaire HVWPDMHXUFKH]OHVSDWLHQWVSUVHQWDQWGHVWURXEOHVGHODSHUVRQQDOLWHQ
SDUWLFXOLHUORUVTXLOH[LVWHGDXWUHVWURXEOHVSV\FKLDWULTXHVDVVRFLV

4.

La prise en charge
des troubles de personnalit
/DSULVHHQFKDUJHGHVWURXEOHVGHSHUVRQQDOLWSHXWWUHFRPSOH[H/HWUDLWHPHQWUHSRVHUDDX
moins autant sur celui des pathologies associes WUDLWHPHQWVELRORJLTXHVHWSV\FKRWKUDSLTXHV
TXH VXU OH WUDLWHPHQW GH OD SHUVRQQDOLW SDWKRORJLTXH 3RXU FH GHUQLHU OD psychothrapie est
FHQWUDOH/HW\SHGHSV\FKRWKUDSLHGSHQGUDGXWURXEOHGHSHUVRQQDOLWDLQVLTXHGHVFDUDFWULV
tiques individuelles du patient.

Les troubles de personnalit

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Lvolution des troubles de personnalit

/HV WURXEOHV GH OD SHUVRQQDOLW RQW XQ LPSDFW PDUTX VXU OD qualit de vie des patients et leur
insertion socioprofessionnelle/HXUYROXWLRQGSHQGODUJHPHQWGHFHOOHGHVFRPRUELGLWV(OOH
SHXWWUHVWDEOHDXFRXUVGXWHPSVSHXWVDJJUDYHURXDXFRQWUDLUHVDPOLRUHUDYHFOJH

6.

6.1.

Les aspects spcifiques

de chaque trouble de personnalit
Le trouble de personnalit paranoaque
/HWURXEOHGHSHUVRQQDOLWSDUDQRDTXHHVWFDUDFWULVHSDUXQHmfianceJQUDOLVHOJDUG
GDXWUXLGRQWWRXWHVOHVLQWHQWLRQVVRQWSHUXHVFRPPHPDOYHLOODQWHVXQHhypertrophie du moi,
une altration du jugement et une rigidit,OPRQWUHWUVpeu dmotions.
/HWURXEOHGHSHUVRQQDOLWSDUDQRDTXHQHGRLWSDVWUHFRQIRQGXDYHFOHWURXEOHGOLUDQWFKUR
QLTXHGHSHUVFXWLRQODVFKL]RSKUQLHRXGDXWUHVWURXEOHVSV\FKRWLTXHVFDUFHVGHUQLHUVVRQW
PDUTXVSDUGHVV\PSWPHVSV\FKRWLTXHVSHUVLVWDQWV,OGRLWJDOHPHQWWUHGLVWLQJXGHVV\PS
WPHVTXLDFFRPSDJQHQWOXVDJHFKURQLTXHGXQHVXEVWDQFHSV\FKRDFWLYHFDQQDELV
/HVDXWUHVWURXEOHVGHSHUVRQQDOLWGXFOXVWHU$SUVHQWHQWGHVWUDLWVHQFRPPXQDYHFODSHUVRQ
QDOLWSDUDQRDTXH&HWWHGHUQLUHVHGLVWLQJXHGHODSHUVRQQDOLWVFKL]RW\SLTXHSDUODEVHQFHGH
GLVWRUVLRQVFRJQLWLYHVRXGH[FHQWULFLWPPHVLHOOHVSDUWDJHQWOHVLGHVGHPDQFH
/H SOXV VRXYHQW OYROXWLRQ FOLQLTXH HVW XFWXDQWH $YHF OJH ODFFHQWXDWLRQ GHV WUDLWV SDUD
QRDTXHV HVW OD UJOH PPH VL FHUWDLQV YROXHQW IDYRUDEOHPHQW /DSSDULWLRQ GXQ trouble dlirant chronique de perscution SHXWFODVVLTXHPHQWFRPSOLTXHUOYROXWLRQDYHFXQHLQDWLRQGHV
LQWHUSUWDWLRQVHWODFRQVWUXFWLRQGXQGOLUHTXLVDFFHQWXHDXOGXWHPSV

6.2.

Le trouble de personnalit schizode

/HWURXEOHGHSHUVRQQDOLWVFKL]RGHVHFDUDFWULVHSDUXQHWHQGDQFHODVROLWXGHXQHabsence
dintrt SRXUDXWUXLHWOHVUHODWLRQVVRFLDOHVDLQVLTXXQHractivit motionnelle peu marque.
/HV LQGLYLGXV SUVHQWDQW XQH SHUVRQQDOLW VFKL]RGH WLUHQW peu de plaisir la participation aux
activits sociales.
/RUV GH FHUWDLQV YQHPHQWV GH YLH LOV SHXYHQW SUVHQWHU GHV pisodes psychotiques trs
brefs TXHOTXHV KHXUHV DX SOXV DYHF QRWDPPHQW GHV LGHV GOLUDQWHV GH SHUVFXWLRQ RX GHV
hallucinations.
/HGLDJQRVWLFGHSHUVRQQDOLWVFKL]RGHHVWSRVTXDQGOHVV\PSWPHVQHVXUYLHQQHQWSDVH[FOX
VLYHPHQWSHQGDQWOYROXWLRQGXQWURXEOHSV\FKRWLTXHGXQWURXEOHHQYDKLVVDQWGXGYHORSSH
PHQWRXGXQHSDWKRORJLHQHXURORJLTXH
/H WURXEOH GH SHUVRQQDOLW VFKL]RGH SHXWWUH FRQIRQGX DYHF GDXWUHV WURXEOHV SV\FKRWLTXHV
VFKL]RSKUQLH WURXEOH GH OKXPHXU GOLUDQW ORUV GSLVRGHV SV\FKRWLTXHV WUV EUHIV ,O VHQ
GLVWLQJXHSDUOHFDUDFWUHWUDQVLWRLUHGHVOPHQWVSV\FKRWLTXHV

273

64H Les troubles psychiatriques tous les ges

/HVIRUPHVOJUHVGHWURXEOHGXVSHFWUHDXWLVWLTXHRXGHV\QGURPHG$VSHUJHUSHXYHQWJDOH
PHQW SUWHU  FRQIXVLRQ 'DQV FHV WURXEOHV OHV SHUWXUEDWLRQV GHV LQWHUDFWLRQV VRFLDOHV VRQW
HQFRUHSOXVVYUHVHWVDFFRPSDJQHQWGHFRPSRUWHPHQWVVWURW\SV
,OGRLWJDOHPHQWWUHGLVWLQJXGHVV\PSWPHVTXLDFFRPSDJQHQWOXVDJHFKURQLTXHGXQHVXEV
WDQFHSV\FKRDFWLYHFDQQDELV
/HVDXWUHVWURXEOHVGHSHUVRQQDOLWGXFOXVWHU$SUVHQWHQWGHVWUDLWVHQFRPPXQDYHFODSHUVRQ
QDOLW VFKL]RGH &HWWH GHUQLUH VH GLVWLQJXH GH OD SHUVRQQDOLW VFKL]RW\SLTXH SDU ODEVHQFH
GH GLVWRUVLRQV FRJQLWLYHV RX GH[FHQWULFLW HW GH OD SHUVRQQDOLW SDUDQRDTXH SDU ODEVHQFH GH
PDQFHRXGK\SHUWURSKLHGXPRLHWGHWURXEOHVGXMXJHPHQW

6.3.

Le trouble de personnalit schizotypique

/HWURXEOHGHSHUVRQQDOLWVFKL]RW\SLTXHHVWFDUDFWULVSDUGHVcomptences sociales altres,
une vie psychique relativement riche PDUTXH SDU GHV FKDPSV GLQWUW SDUWLFXOLHUV HW mRULJL
QDX[} VFLHQFH FWLRQ VRWULVPH VXSHUVWLWLRQ SKQRPQHV SDUDQRUPDX[ RX PDJLTXHV SDU
H[HPSOHTXLOHVIDLWLGHQWLHUFHVSHUVRQQDOLWVGHmbizarres }SDUDXWUXL
2Q UHWURXYH VRXYHQW GDQV OHQIDQFH RX ODGROHVFHQFH XQH WHQGDQFH  OD VROLWXGH GHV UHODWLRQV
sociales pauvres ou des manifestations anxieuses en situations sociales. Leur discours est
SDUIRLVRXGLJUHVVLIRXYDJXH,OVQRQWSDVRXSHXGDPLVHWXQIDLEOHLQWUWSRXUOHVUHODWLRQV
VHQWLPHQWDOHVHWRXVH[XHOOHV/HXUVaffects sont pauvres HWGLFLOHPHQWDFFHVVLEOHV
/RUVGHFHUWDLQVYQHPHQWVGHYLHLOVSHXYHQWSUVHQWHUXQHsymptomatologie psychotique de
manire transitoire, qui est souvent une aggravation des distorsions cognitives prexistantes, de
GXUHWURSEUYHSRXUYRTXHUXQWURXEOHSV\FKRWLTXH

274

/HWURXEOHGHSHUVRQQDOLWVFKL]RW\SLTXHGRLWWUHGLVWLQJXGXWURXEOHSV\FKRWLTXHGHODVFKL
]RSKUQLHRXGXWURXEOHGHOKXPHXUDYHFFDUDFWULVWLTXHVSV\FKRWLTXHV,OGRLWJDOHPHQWWUH
GLVWLQJX GHV V\PSWPHV TXL DFFRPSDJQHQW OXVDJH FKURQLTXH GXQH VXEVWDQFH SV\FKRDFWLYH
FDQQDELVSDUH[HPSOH
/HVDXWUHVWURXEOHVGHSHUVRQQDOLWGXFOXVWHU$SUVHQWHQWGHVWUDLWVHQFRPPXQDYHFODSHUVRQ
QDOLWVFKL]RW\SLTXH&HWWHGHUQLUHSHXWWUHGLUHQFLHSDUODSUVHQFHGHGLVWRUVLRQVFRJQL
tives et une excentricit marque.
/H WURXEOH GH OD SHUVRQQDOLW VFKL]RGH HVW VRXYHQW DVVRFL DX WURXEOH GH OD SHUVRQQDOLW
VFKL]RW\SLTXH
/YROXWLRQGXWURXEOHGHSHUVRQQDOLWVFKL]RW\SLTXHHVWOHSOXVVRXYHQWstable8QHIDLEOHSURSRU
tion voluera vers une schizophrnieRXXQDXWUHWURXEOHSV\FKRWLTXH

6.4.

Le trouble de personnalit antisociale

/H WURXEOH GH SHUVRQQDOLW DQWLVRFLDOH HVW JDOHPHQW SDUIRLV QRPP psychopathie, sociopathie
ou personnalit dyssociale &H WURXEOH GH SHUVRQQDOLW VH FDUDFWULVH SDU XQH LPSXOVLYLW XQH
WHQGDQFH DX SDVVDJH  ODFWH XQH DEVHQFH GH FXOSDELOLW XQH LQFDSDFLW  VH FRQIRUPHU DX[
normes sociales, un mpris et des transgressions rptes GHVGURLWVGDXWUXLXQHWHQGDQFHOD
manipulationGDXWUXLSRXUHQREWHQLUGHVEQFHVVRXYHQWLPPGLDWV
/DELRJUDSKLHGHFHVSDWLHQWVHVWPDUTXHSDUlinstabilit et est souvent maille de contacts
DYHFODSROLFHHWODMXVWLFHYRLUHGHFRQGDPQDWLRQV2QUHWURXYHGDQVOHQIDQFHGHVFRPSRUWH
ments transgressifs rpts comme des agressions, des destructions ou des vols, le tout faisant
porter un diagnostic de trouble des conduites avant lge de 15 ans. Ces comportements se perp
WXHQWOJHDGXOWH

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/HV SDWLHQWV VRXUDQW GXQ WURXEOH GH SHUVRQQDOLW DQWLVRFLDOH SUVHQWHQW XQ ULVTXH DFFUX GH
dcs prmatur par mort violente ou par suicideSDUUDSSRUWODSRSXODWLRQJQUDOH/HVcomorbidits addictives et dpressivesIUTXHQWHVVRQWJDOHPHQWSDUWLHOOHPHQWUHVSRQVDEOHVGXQH
diminution de leur esprance de vie.
/HWURXEOHGHSHUVRQQDOLWDQWLVRFLDOHSUVHQWHSDUGQLWLRQXQHYROXWLRQFKURQLTXHPDLVRQ
note souvent une diminution de limpulsivit avec lge, et la survenue frquente de troubles
dpressifs SDUIRLVVYUHVDXPLOLHXGHODYLH

6.5.

Le trouble de personnalit borderline ou tat-limite

/HWURXEOHGHSHUVRQQDOLWERUGHUOLQHHVWFDUDFWULVSDUJUDQGHVIDPLOOHVGHV\PSWPHV
*

/ HVV\PSWPHVDHFWLIVPDUTXVSDUXQHLQVWDELOLWPRWLRQQHOOHXQVHQWLPHQWHQYDKLVVDQW
GHYLGHXQHWHQGDQFHOKXPHXUGSUHVVLYH

Des distorsions cognitives pouvant aller de sentiments de dralisation ou de dpersonna

OLVDWLRQ MXVTX GDXWKHQWLTXHV V\PSWPHV SV\FKRWLTXHV VXUYHQDQW QRWDPPHQW GDQV OHV
priodes de stress avec des hallucinations et des ides de perscution.

 HV WURXEOHV GX FRPSRUWHPHQW OLV  OLPSXOVLYLW DXWRPXWLODWLRQ FRQGXLWHV  ULVTXH HW
'
WHQWDWLYHV GH VXLFLGH USWHV /LPSXOVLYLW WDQW VRXYHQW SUFLSLWH SDU GHV PHQDFHV GH
sparation relles ou vcues comme telles.

 QHLQVWDELOLWLQWHUSHUVRQQHOOHPDMHXUHPDUTXHSDUGHVUHODWLRQVLQWHQVHVHWLQVWDEOHVDOWHU
8
QDQWHQWUHOHVGHX[H[WUPHVGHOLGDOLVDWLRQHWGXUHMHW&HVSDWLHQWVRQWHQHHWXQHpeur
intense dtre abandonnsHWIRQWGRQFGHVHRUWVHUQVSRXUYLWHUOHVDEDQGRQV

8Qantcdent de violence SK\VLTXHHQSDUWLFXOLHUVH[XHOOHRXSV\FKLTXHGHngligence dans

lenfance HVWXQIDFWHXUGHULVTXHGHWURXEOHGHSHUVRQQDOLWERUGHUOLQH
/HWURXEOHGHSHUVRQQDOLWERUGHUOLQHHVWPDUTXSDUGHIUTXHQWHVFRPRUELGLWVGRQWOHVSULQFL
pales sont les abus de substance, les troubles de lhumeur ELSRODLUHVHWXQLSRODLUHVOHVtroubles
anxieux et les troubles du comportement alimentaire. Le risque suicidaire est lev dans les
WURXEOHV GH OD SHUVRQQDOLW ERUGHUOLQH 8 10 % GHV VXMHWV DWWHLQWV GH WURXEOH GH SHUVRQQDOLW
ERUGHUOLQHGFGHQWSDUsuicide/HXUELRJUDSKLHHVWPDUTXHSDUXQHLQVWDELOLWPDLVOHXUDGDS
WDWLRQVRFLDOHSHXWWUHQDQPRLQVUHODWLYHPHQWERQQH

6.6.

Le trouble de personnalit histrionique

/H WURXEOH GH SHUVRQQDOLW KLVWULRQLTXH DQFLHQQHPHQW DSSHOH K\VWULTXH HVW XQH SHUVRQQDOLW
qui se caractrise par une labilit motionnelle, une qute affective excessive, une
hyperexpressivit GHVDHFWVXQthtralisme et une suggestibilit(OOHHVWSDUIRLVDVVRFLH
une dpendance affective.
'XQHIDRQLQFRQVFLHQWHOHXUTXWHDHFWLYHOHVFRQGXLWWHQWHUGDWWLUHUODWWHQWLRQHWGREWHQLU
GHV FRPSOLPHQWV YLD OHXU DSSDUHQFH SK\VLTXH HW XQH DWWLWXGH SDUIRLV SURYRFDQWH HW VGXFWULFH
inappropries.
/HVFRPRUELGLWVOHVSOXVIUTXHQWHVVRQWOHVtroubles de lhumeur, les troubles anxieux, les addictions et les autres troubles de la personnalit. Les tentatives de suicide sont frquentes et souvent
LQWJUHVGDQVODGLPHQVLRQGHTXWHDHFWLYH&HSHQGDQWOHULVTXHGHVXLFLGHHVWJDOHPHQW
OHYGDQVFHWURXEOHGHODSHUVRQQDOLW,OIDXWVDYRLUTXHFHVSDWLHQWVVXVFLWHQWVRXYHQWOHUHMHW
GHODSDUWGHVVRLJQDQWVTXLOHVFRQVLGUHQWVRXYHQWPDLVWRUWFRPPHGHVmIDX[PDODGHV}

275

64H Les troubles psychiatriques tous les ges

6.7.

Le trouble de personnalit narcissique

/HVSDWLHQWVTXLVRXUHQWGXQWURXEOHGHSHUVRQQDOLWQDUFLVVLTXHRQWXQVHQVgrandiose de leur
propre importanceVXUHVWLPDQWOHXUVFDSDFLWVHWD\DQWXQHYRORQWGHSXLVVDQFHHWGHVXFFV
illimit. Se jugeant suprieurs, spciaux ou uniquesLOVVDWWHQGHQWWUHUHFRQQXVDGPLUVHW
WUDLWVDYHFUHVSHFWHWWROUHQWPDOODFULWLTXHLautre est dvaloris et sous-estim. Ces patients
PDQTXHQWGHPSDWKLHHWVRQWUHODWLYHPHQWLQVHQVLEOHVDX[EHVRLQVHWDX[VHQWLPHQWVGDXWUXL
,OVSHXYHQWDLQVLWUHSHUXVFRPPHprtentieux, arrogants et mprisants. Cependant, leur estime
GHX[PPHVGDSSDUHQFHOHYHHVWHQUDOLWWUVIUDJLOH
/HVFRPRUELGLWVSV\FKLDWULTXHVDVVRFLHVFHVWURXEOHVGHODSHUVRQQDOLWVRQWSULQFLSDOHPHQW
des troubles de lhumeur et des addictions. Le risque disolement social est important.

6.8.

Le trouble de la personnalit vitante

/HWURXEOHGHODSHUVRQQDOLWYLWDQWHVHFDUDFWULVHSDUXQHinhibition relationnelle et sociale, une
msestime de soi et une sensibilit exacerbe au jugement ngatif dautrui.
'HV FRQGXLWHV Gvitement de situations ncessitant des contacts sociaux importants ou les
H[SRVDQWDX[UHJDUGVGDXWUXLVRQWIUTXHQWHV
/D SHUVRQQDOLW YLWDQWH GRLW WUH GLVWLQJXH GH OD SKRELH VRFLDOH JQUDOLVH V\PSWPHV
SKRELTXHVHWGHODSHUVRQQDOLWVFKL]RGH
6HVSULQFLSDOHVFRPRUELGLWVVRQWOHVtroubles anxieux, addictifs et dpressifs.
$YHFOJHFHWURXEOHGHSHUVRQQDOLWWHQGsattnuer.

276

6.9.

Le trouble de la personnalit dpendante

/D WURXEOH GH OD SHUVRQQDOLW GSHQGDQWH VH FDUDFWULVH SDU XQ besoin excessif dtre pris en
charge SDUDXWUXL/HVLQGLYLGXVSUVHQWDQWXQHSHUVRQQDOLWGSHQGDQWHRQWWHQGDQFHVHdvaloriser, ne se sentent pas capables GDVVXPHUOHXUVSURSUHVUHVSRQVDELOLWVHWVROOLFLWHQWOH[FV
XQWLHUVSRXUTXLOGFLGHOHXUSODFH
&HVSDWLHQWVSURXYHQWOHEHVRLQGHVDVVXUHUGXVRXWLHQGHODSHUVRQQHGRQWLOVGSHQGHQWDLQVL
LOVQRVHQWSDVVDUPHURXH[SULPHUXQGVDFFRUG/HXUVrelations sociales sont souvent dsquilibres HWOLPLWHVTXHOTXHVUDUHVSHUVRQQHV
/HVSULQFLSDOHVFRPRUELGLWVSV\FKLDWULTXHVVRQWOHV troubles anxieux, addictifs et dpressifs. La
VXUPRUWDOLWSDUVXLFLGHHVWIDLEOH

6.10.

Le trouble de la personnalit obsessionnelle-compulsive

/HWURXEOHGHODSHUVRQQDOLWREVHVVLRQQHOOHFRPSXOVLYHVHFDUDFWULVHSDUXQHmticulosit, un
VRXFLGXGWDLOGHORUGUHXQHrigidit, un perfectionnismeXQHWHQGDQFHODprocrastination et
une prudence excessive. Ses patients sont souvent consciencieux et scrupuleux.
Ils ont des valeurs morales ou thiques contraignantes. Leurs relations sont formelles. Ils expri
ment leurs motions avec contrle et peu de spontanit.
/DSHUVRQQDOLWREVHVVLRQQHOOHFRPSXOVLYHQHGRLWSDVWUHFRQIRQGXHDYHFXQWURXEOHREVHV
VLRQQHOFRPSXOVLIHOOHQHFRPSRUWHHQHHWSDVGREVHVVLRQVHWGHFRPSXOVLRQV

Les troubles de personnalit

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Ces patients prsentent un risque accru de troubles anxieux WURXEOHDQ[LWJQUDOLVHWURXEOH

REVHVVLRQQHO FRPSXOVLI WURXEOHV SKRELTXHV GH WURXEOHV GH lhumeur et, dans une moindre
PHVXUHGHWURXEOHVDGGLFWLIV/HULVTXHVXLFLGDLUHHVWUHODWLYHPHQWIDLEOH
/HWURXEOHGHODSHUVRQQDOLWREVHVVLRQQHOOHFRPSXOVLYHDSOXWWWHQGDQFHVDJJUDYHUDYHFOH
temps.

Rsum
/DSHUVRQQDOLWGVLJQHFHTXLO\DGHVWDEOHHWXQLTXHGDQVOHIRQFWLRQQHPHQWGXQLQGLYLGX(OOH
DVVRFLH WHPSUDPHQW DVSHFWV ELRORJLTXHV mLQQV} HW OH FDUDFWUH GLPHQVLRQV GWHUPLQHV
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dite pathologique est compose de traits rigides qui induisent une altration du fonctionnement
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64H Les troubles psychiatriques tous les ges

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Troubles somatoformes
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II. Contexte pidmiologique
III. Smiologie
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70

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1.

Introduction
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4.1.

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Diagnostics positifs

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mdicales psychiatriques

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mdicales non psychiatriques

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Comorbidits

4.3.1. Pathologies

mdicales psychiatriques

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Les troubles psychiatriques tous les ges

1.

Le comportement sexuel normal

La sant sexuelle est un tat de bien-tre physique, mental et social dans le domaine de la sexualit.
Elle requiert une approche positive et respectueuse de la sexualit et des relations sexuelles, ainsi
que la possibilit davoir des expriences sexuelles qui soient sources de plaisir et sans risque,
libre de toute coercition, discrimination ou violence.
206
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292

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vagin.

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GHQRUPDOLWGHODFFRPSOLVVHPHQWGHODFWHVH[XHOHWGLGHQWLWGHUOHFRPSRUWHPHQWDOSHXYHQW
varier selon les cultures et les poques.
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YLWVH[XHOOHGXIDLWGXGFLWHQVWURJQHVRXHQWHVWRVWURQH8QWUDLWHPHQWVXEVWLWXWLIKRUPR
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Sexualit normale et ses troubles

2.

Conduite tenir devant un trouble sexuel

2.1.

Entretien

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2.2.

Examen clinique
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 perte de pilosit,
 phimosis,
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293

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Tout au long de cet examen il convient de garder une attitude empathique et de rester neutre.

2.3.

Bilan paraclinique
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comporter :

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Les troubles des conduites sexuelles

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3.1.
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Les dysfonctions sexuelles

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expriences sexuelles antrieures traumatisantes comme un viol ou des violences sexuelles,
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 un cancer,

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 une hmochromatose,
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RXORPERDRUWLTXH

3.1.1. Troubles

du dsir sexuel
(diminution ou absence des fantasmes et du dsir)

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3.1.2. Troubles

de lexcitation

Chez lhomme
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3.1.3. Troubles

de lorgasme (incluant ljaculation prcoce)

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3.1.4. Troubles

sexuels avec douleurs

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Les troubles psychiatriques tous les ges

3.2.

Le vaginisme est un spasme involontaire et persistant des muscles du prine et de ceux qui
entourent le tiers externe du vagin, empchant toute pntration. Il est souvent primaire et
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Les dviances sexuelles

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socioprofessionnel.
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* OH[KLELWLRQQLVPH
* le ftichisme,
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* le transvestisme,
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Sexualit normale et ses troubles

3.3.

56

Lhypersexualit
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/K\SHUVH[XDOLWSHXWJDOHPHQWWUHVHFRQGDLUH
* XQHGVLQKLELWLRQGRULJLQHSV\FKLDWULTXH
 pisode maniaque,
 conduite addictive.
* une tiologie neurologique :
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 dmence.
*

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pour en savoir plus

Transsexualisme

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GHOLGHQWLWGHJHQUHPDVFXOLQIPLQLQ,OVHFDUDFWULVHSDUODFRQYLFWLRQSURIRQGHHWGXUDEOHFKH]XQVXMHWQRUPD
OHPHQWFRQVWLWXGDSSDUWHQLUDXVH[HRSSRVFHOXLGHVRQDQDWRPLH,OVDFFRPSDJQHGXQVHQWLPHQWGLQFRQIRUWHW
GLQDGTXDWLRQTXDQWVRQVH[HGFODUDYHFXQGVLULQWHQVHGWUHGEDUUDVVGHVHVFDUDFWULVWLTXHVVH[XHOOHV
FRXSOFHOXLGDFTXULUODSSDUHQFHFRUSRUHOOHGXVH[HRSSRVHWGWUHFRQVLGUSDUDXWUXLFRPPHIDLVDQWSDUWLHGX
VH[HRSSRV,OHVWUDUH
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les femmes ou les deux sexes.

Rsum
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que les conduites sexuelles sont marques par des contraintes ducatives, morales et sociales
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 phase de dsir sexuel associ aux fantasmes,
 SKDVHGH[FLWDWLRQ
 phase en plateau,
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 phase de rsolution.

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297

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Les troubles psychiatriques tous les ges

Points clefs
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Dviances sexuelles :
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item 108

Troubles du sommeil de
lenfant et de ladulte
I. Introduction
II. Insomnie
III. La somnolence diurne excessive
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Objectifs pdagogiques
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108

108 Les troubles psychiatriques tous les ges

1.

Introduction
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variations interindividuelles en fonction :

1.1.

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du sexe,

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Rgulation veille-sommeil
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Le processus homostasique, accumulatif augmente tout au long de la veille et diminue pendant

le sommeil.
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nuit

jour

nuit

jour

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300

6h

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Processus homostasique (S)

6h

18 h

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4 h du matin. Le dclenchement du sommeil et sa fin sont dtermins par linteraction des deux processus.

Troubles du sommeil de lenfant et de ladulte

108

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1.2.

Mthodes dexploration du sommeil

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enregistrement vido concomitant.

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permettent le diagnostic de pathologies du sommeil.
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1.3.

agenda de sommeil,

actimtrie,

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7HVWVGHPDLQWLHQGHOYHLO

Caractristiques du sommeil normal

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VLYHPHQWGXVRPPHLOWRWDO

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Les tats de sommeil lent lger, sommeil lent profond et sommeil paradoxal alternent tout au long
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lent, dont la profondeur augmente progressivement, puis se termine par du sommeil paradoxal.
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GHVF\FOHVGHVRPPHLOSHXWWUHYLVXDOLVHDXPR\HQGHOK\SQRJUDPPH

301

108 Les troubles psychiatriques tous les ges

Figure 2. Lhypnogramme est une reprsentation graphique de la succession des dirents stades de vigilance au cours de la nuit qui dfinit des cycles de sommeil. Lenregistrement dbute peu aprs 22 h et se
termine vers 8 h. Noter la prdominance du sommeil lent profond en dbut de nuit et celle du sommeil
paradoxal en fin de nuit. V : Veille ; SP : Sommeil paradoxal ; N1 : Stade 1 sommeil lent lger ; N2 : Stade 2
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302

2.

Insomnie

2.1.

Donnes pidmiologiques
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2.2.

Diagnostic positif

2.2.1. Dfinition
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2.2.2.valuation

108

clinique

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valuer la svrit, le retentissement, et ses caractristiques peuvent orienter le diagnostic tio
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2.2.3.Examens

complmentaires

Le recueil des informations cliniques peut tre complt par un agenda de sommeil sur quelques
semaines. Le patient indique chaque jour ses heures de lever, coucher, le temps estim pass
GRUPLUOHVKRUDLUHVGHVHVUYHLOVQRFWXUQHVODTXDOLWGXUYHLOOHPDWLQHWGHODYLJLODQFHOD
journe.
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associes.

303

108 Les troubles psychiatriques tous les ges

2.3.

Diagnostic diffrentiel
/H GLDJQRVWLF GLQVRPQLH QH SRVH HQ JQUDO SDV GH GLFXOWV &HSHQGDQW OLQVRPQLH
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DORUVXQFRXFKHUWDUGLIDVVRFLXQOHYHUWDUGLI

2.4.

Formes cliniques
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lien avec un facteur dclenchant rcent vident,

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2.4.1. Insomnies

primaires

2.4.1.1.Insomnie psychophysiologique

304

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SK\VLRORJLTXH(OOHUHSRVHVXUODWKUDSLHFRJQLWLYHHWFRPSRUWHPHQWDOHGHOLQVRPQLH7&&
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Sur le versant comportemental :

 restriction du temps pass au lit,
 viction de la sieste,
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SURSHQVLRQDXVRPPHLO

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vis du sommeil.
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2.4.1.2.Insomnie paradoxale
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GXQH UGXFWLRQ LPSRUWDQWH GH OD TXDQWLW GH OHXU VRPPHLO HQ GSLW GH ODEVHQFH GH SHUWXUED
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SUHPLUHLQWHQWLRQ

Troubles du sommeil de lenfant et de ladulte

108

2.4.1.3.Insomnie primaire idiopathique

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2.4.2.Insomnies

secondaires

2.4.2.1.Insomnies dorigine psychiatrique

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particulier :
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prcoce,

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diurne.

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des rveils nocturnes multiples.

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V\QGURPHGK\SHUYLJLODQFHDVVRFLHGHVFDXFKHPDUVV\QGURPHGHUHYLYLVFHQFH

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FODLUHPHQWLGHQWLGHUHFKXWHHWRXGHUFLGLYHGHFHGHUQLHU
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EOHV SV\FKLDWULTXHV DVVRFL 'DQV XQ SUHPLHU WHPSV OH WUDLWHPHQW GX WURXEOH SV\FKLDWULTXH
VRXVMDFHQWGRLWWUHFRQGXLW/DSHUVLVWDQFHGHOLQVRPQLHPDOJUXQHSULVHHQFKDUJHHFDFH
GHV DXWUHV V\PSWPHV SV\FKLDWULTXHV MXVWLH DORUV XQ WUDLWHPHQW VSFLTXH /HV PHVXUHV QRQ
mdicamenteuses doivent alors tre privilgies.

2.4.2.2.Insomnies dorigine iatrogne

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 certains antidpresseurs stimulants.

Sevrage de mdicaments :
 SV\FKRWURSHVHQSDUWLFXOLHUVK\SQRWLTXHV
 DQWDOJLTXHVRSLRGHV

Consommation excessive de :
 cafine,
 VWXSDQWVVWLPXODQWVFRFDQHDPSKWDPLQHV

,QWR[LFDWLRQWK\OLTXHHWVRQVHYUDJH

2.4.2.3.Insomnies dorigine mdicale non psychiatrique

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DWWHLQWHYDVFXODLUHWXPRUDOHLQDPPDWRLUHRXHQGRFULQLHQQHVK\SHUWK\URGLHVRQWIUTXHP
PHQWDVVRFLHVXQHLQVRPQLH'HVV\PSWPHVWHOVTXHODG\VSQHODSROODNLXULHSHXYHQWWUH

305

108 Les troubles psychiatriques tous les ges

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2.4.3.Le

syndrome des jambes sans repos

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2.4.3.1.Diagnostic positif
/HGLDJQRVWLFHVWFOLQLTXHHWGQLSDUODSUVHQFHGHFULWUHV

306

 HQVDWLRQVGVDJUDEOHVDXQLYHDXGHVMDPEHVUHVSRQVDEOHVGXQEHVRLQLUUSUHVVLEOHGHOHV
6
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/HVV\PSWPHVVRQWVRXODJVSDUOHPRXYHPHQW

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'DQVGHVFDVOH6-65HVWDVVRFLGHVPRXYHPHQWVSULRGLTXHVGHVPHPEUHV,OVDJLWGH
H[LRQVSULRGLTXHVGHVRUWHLOVGXSLHGGXJHQRXRXGHODKDQFKHGXUDQWTXHOTXHVVHFRQGHV
&HVFRQWUDFWLRQVVLHOOHVVRQWQRPEUHXVHVVRQWUHVSRQVDEOHVGXQHLPSRUWDQWHIUDJPHQWDWLRQ
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UDOLVLOQHUYOHDXFXQHDQRPDOLH

2.4.3.2.Diagnostic diffrentiel
/H6-65GRLWWUHGLVWLQJX
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 H OLQVXVDQFH YHLQHXVH FKURQLTXH VHQVDWLRQV GH MDPEHV ORXUGHV VXUYHQDQW ORUV GH OD
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 HVQHXURSDWKLHVVHQVDWLRQVGVDJUDEOHVQRQDVVRFLHVXQEHVRLQGHERXJHUOHVMDPEHV
'
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'
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2.4.3.3.Formes cliniques
2QGLVWLQJXH
*

/H6-65LGLRSDWKLTXHDIRUWHFRPSRVDQWHIDPLOLDOH

Les formes secondaires :

 carence martiale,
 LQVXVDQFHUQDOHVYUH
 PDODGLHGH3DUNLQVRQ
 GRULJLQHLDWURJQHDQWLGSUHVVHXUVQHXUROHSWLTXHVHWDQWLSV\FKRWLTXHV

Troubles du sommeil de lenfant et de ladulte

108

2.4.3.4.Traitement
/H WUDLWHPHQW WLRORJLTXH HVW  SULYLOJLHU HQ SUHPLUH LQWHQWLRQ GDQV OHV IRUPHV VHFRQGDLUHV
FRUUHFWLRQGXQHFDUHQFHPDUWLDOHDGDSWDWLRQGHWUDLWHPHQWV
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Les traitements de 2eOLJQHUHSRVHQWVXUOHVGULYVRSLRGHVHWFHUWDLQVDQWLSLOHSWLTXHV

2.5.

Dmarche diagnostique

307

Figure 3. Dmarche diagnostique de linsomnie.

108 Les troubles psychiatriques tous les ges

2.6.

La prescription dhypnotiques
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TXHOTXHVMRXUVRXVHPDLQHVHWGDQVODVHXOHLQGLFDWLRQGHOLQVRPQLHGDMXVWHPHQW
/HVPROFXOHVK\SQRWLTXHVDJLVVHQWSDUDJRQLVPHVXUOHVUFHSWHXUV*$%$$HWDSSDUWLHQQHQW
deux classes thrapeutiques :
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/HVEHQ]RGLD]SLQHVK\SQRWLTXHVH[/RUPWD]SDP1RFWDPLGHp/RSUD]RODP+DYODQHp

/ HV PROFXOHV m=} RX K\SQRWLTXHV  GHPLYLH FRXUWH =ROSLGHP6WLOQR[p

=RSLFORQH,PRYDQHp

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*

De dpendance :
 W ROUDQFHSHUWHGHFDFLWPR\HQWHUPHDX[PPHVGRVHVRXQFHVVLWGDXJPHQWHUOHV
GRVHVSRXUPDLQWHQLUOHFDFLW
 V\QGURPHGHVHYUDJH

'HHWVVHFRQGDLUHV
 somnolence diurne rsiduelle,
 WURXEOHVPQVLTXHV
 FRQIXVLRQVXUWRXWFKH]OHVXMHWJ
 risque de chute,
 H
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/HFKRL[GHOK\SQRWLTXHGRLWSRUWHUVXUGHVPROFXOHVGHPLYLHFRXUWHVDQVPWDEROLWHVDFWLIV
GHSUIUHQFHOHVPROFXOHVm=}SRXUXQHSUHVFULSWLRQOLPLWHVHPDLQHV

308

(Q IRQFWLRQ GX FRQWH[WH FOLQLTXH FHUWDLQV DQWLGSUHVVHXUV  SURSULWV VGDWLYHV

0LUWD]DSLQH1RUVHWpFHUWDLQVDQWLKLVWDPLQLTXHV+\GUR[\]LQH$WDUD[pGHSUHPLUHJQUD
WLRQRXODPODWRQLQHSHXYHQWWUHXQHDOWHUQDWLYHDX[K\SQRWLTXHVFRQYHQWLRQQHOV

2.7.

Linsomnie de lenfant
/LQVRPQLHGXMHXQHHQIDQWUHSRVHVXUODSODLQWHGHVSDUHQWVGXQHLQVXVDQFHGHVRPPHLO(OOH
FRUUHVSRQGXQWURXEOHGHOLQVWDOODWLRQHWGXPDLQWLHQGXVRPPHLOQRFWXUQH(OOHVHWUDGXLWSDU
GHV GLFXOWV GHQGRUPLVVHPHQW DYHF RSSRVLWLRQ DX FRXFKHU RX SOHXUV GHV YHLOV QRFWXUQHV
VRXYHQWPXOWLSOHVRXSOXVUDUHPHQWSDUXQHQXLWFRXUWH
(QODEVHQFHGWLRORJLHPGLFDOHQRQSV\FKLDWULTXHODSULVHHQFKDUJHUHSRVHHVVHQWLHOOHPHQW
VXUGHVPHVXUHVFRPSRUWHPHQWDOHVHWSDUIRLVXQHSULVHHQFKDUJHSV\FKRORJLTXHGHOHQIDQWHW
de ses parents.

2.7.1. Difficults

dendormissement et veils nocturnes

&KH]OHQIDQWGHPRLQVGHDQVOHWURXEOHOHSOXVIUTXHQWHVWXQFRQGLWLRQQHPHQWDQRUPDO
OHQGRUPLVVHPHQW OHQIDQW QH VHVW MDPDLV HQGRUPL VHXO RX QH VDLW SOXV VHQGRUPLU VHXO ,O HVW
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8QHLQVRPQLHFKH]OHQIDQWSHXWWUHIDYRULVHSDUXQHDEVHQFHRXXQHLQFRKUHQFHGHVURXWLQHV
GHFRXFKHUSURSRVHVOHQIDQWXQPDQTXHGHIHUPHWGHVSDUHQWVTXLVHODLVVHQWGERUGHUSDU
OHVPXOWLSOHVGHPDQGHVGHOHQIDQWSRXUYLWHUGWUHPLVDXOLW

Troubles du sommeil de lenfant et de ladulte

2.7.2. Troubles

108

de linstallation du rythme jour/nuit

/DSHXUTXXQHQIDQWQDLWSDVDVVH]GRUPLOHVFRQVHLOVVRXYHQWGRQQVGHQHMDPDLVUYHLOOHUXQ
HQIDQWTXLGRUWIRQWTXHWUVVRXYHQWOHVGLFXOWVGHQGRUPLVVHPHQWVRXOHVYHLOVQRFWXUQHVVH
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et lever tardifs. &HVOHYHUVWDUGLIVPPHVLOVQHVXUYLHQQHQWTXHIRLVSDUVHPDLQHOHZHHNHQG
peuvent entraner tous les jours un dcalage des siestes et surtout du sommeil nocturne.

2.7.3. Les

insomnies symptomatiques

2.7.3.1.Dmarche diagnostique
8QHLQVRPQLHV\PSWRPDWLTXHGRLWWUHYRTXHGHYDQW
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 UHWDUGVWDWXURSRQGUDO
 VXUSRLGVREVLW
 anomalies neurologiques,
 GYHORSSHPHQWSV\FKRPRWHXUDQRUPDO

2.7.3.2.Formes cliniques
,OIDXGUDSHQVHUUHFKHUFKHUHWWUDLWHUOHVDHFWLRQVVXLYDQWHV
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U\WKPHFLUFDGLHQHWRXGHVDQRPDOLHVGHODVWUXFWXUHGXVRPPHLORXGHVDSQHVGXVRPPHLO

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intolrance aux protines du lait de vache.

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 autisme,
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309

108 Les troubles psychiatriques tous les ges

3.

La somnolence diurne excessive

3.1.

Donnes pidmiologiques
/D VRPQROHQFH GLXUQH H[FHVVLYH 6'( VH GQLW SDU XQ EHVRLQ H[FHVVLI GH GRUPLU GXUDQW OD
journe.
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XQHVRPQROHQFHVYUH
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WUHUHVSRQVDEOH/D6'(UHYWGHFHIDLWGHVLPSOLFDWLRQVPGLFROJDOHV(QHHWODVRPQROHQFH
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SHUPLVGHFRQGXLUHDUUWGXGFHPEUH

3.2.

Diagnostic positif

3.2.1. valuation

310

clinique

/YDOXDWLRQGXQHSODLQWHGH6'(HVWHQSUHPLHUOLHXFOLQLTXH(OOHDSRXUREMHFWLIVGHQYDOXHU
la svrit, le retentissement, et ses caractristiques peuvent orienter le diagnostic tiologique.
(OOHQHSHXWWUHYDOXHVDQVFRQQDLVVDQFHGHODTXDOLWHWODTXDQWLWGXVRPPHLOGHQXLWGX
FRQWH[WHFOLQLTXHDQWFGHQWVPGLFDX[QRQSV\FKLDWULTXHVSV\FKLDWULTXHVIDFWHXUVLDWURJQHV
HWWR[LTXHV
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*

/HVFLUFRQVWDQFHVLQLWLDOHVHWPRGDOLWGHOLQVWDOODWLRQGHODVRPQROHQFH

Les horaires de survenue de la somnolence :

 FRQWLQXHRXXFWXDQWH
 variations circadiennes.

&DUDFWULVHUOHVDFFVGHVRPPHLOGLXUQHV
 QRPEUHGDFFVSDUMRXU
 dure,
 FDUDFWUHUDIUDFKLVVDQWRXQRQ
 FLUFRQVWDQFHVGHVXUYHQXHLQDFWLYLWDFWLYLW
 FDUDFWUHLUUSUHVVLEOH
 SUVHQFHGXQHDFWLYLWRQLULTXHDVVRFLH

La qualit du rveil le matin, sensation de sommeil de nuit rparateur ou inertie du sommeil.

Le retentissement fonctionnel de la somnolence :

 KDQGLFDSSHUXSDUOHSDWLHQW
 ULVTXHDFFLGHQWRJQH

/LQWHQVLW GH OD VRPQROHQFH SHXW WUH YDOXH DX PR\HQ GRXWLOV FOLQLTXHV VLPSOHV FRPPH
OFKHOOHGHVRPQROHQFHG(SZRUWKTXLHVWDXWRTXHVWLRQQDLUHTXLSHXWWUHIDFLOHPHQWFRPSOW
ODFRQVXOWDWLRQ8QVFRUHVXSULHXULQGLTXHXQHVRPQROHQFHGLXUQHH[FHVVLYHFHOOHFL
HVWVYUHDXGHOGH

Troubles du sommeil de lenfant et de ladulte

108

chelle de somnolence dEpworth

Instructions :SRXUUSRQGUHXWLOLVH]OFKHOOHVXLYDQWHHQHQWRXUDQWOHFKLUHOHSOXVDSSURSULSRXUFKDTXHVLWXDWLRQ





QHVRPQROHUDLWMDPDLV
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Actuellement

)DLEOHFKDQFHGH
VHQGRUPLU

&KDQFHPR\HQQHGH
VHQGRUPLU

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Score
Ne somnolerait jamais

Situations

Assis en train de lire

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roulant pendant 1 h

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WDQWDVVLVHQSDUODQWDYHFTXHOTXXQ

$VVLVDXFDOPHDSUVXQUHSDVVDQVDOFRRO

'DQVXQHYRLWXUHLPPRELOLVHGHSXLVTXHOTXHVPLQXWHV

3.2.2.Mesures

311

objectives de la somnolence

'HX[ H[DPHQV YDOLGV SHUPHWWHQW GYDOXHU GH IDRQ REMHFWLYH OD SODLQWH GH VRPQROHQFH ,OV
GRLYHQWWUHV\VWPDWLTXHPHQWSUFGVGXQHQUHJLVWUHPHQWSRO\VRPQRJUDSKLTXH
*

/ HV WHVWV LWUDWLIV GH ODWHQFH GHQGRUPLVVHPHQW 7,/( PHVXUHQW OD SURSHQVLRQ GX VXMHW
 VHQGRUPLU OD MRXUQH /HV 7,/( VRQW XWLOLVV SRXU SRVHU OH GLDJQRVWLF GH VRPQROHQFH
/HVXMHWHVWLQYLWUHSULVHVKKKKHWKVDOORQJHUGDQVOHOLWHWQHSDV
UVLVWHUDXVRPPHLO/DODWHQFHGHQGRUPLVVHPHQWHVWPHVXUHSRXUFKDTXHWHVW/HWHVWHVW
LQWHUURPSXDXERXWGHPLQXWHVVLOHVXMHWQHVHVWSDVHQGRUPLRXPLQXWHVDSUVVRQ
HQGRUPLVVHPHQW8QHODWHQFHGHQGRUPLVVHPHQWPR\HQQHLQIULHXUHPLQXWHVVLJQHXQH
somnolence pathologique.

108 Les troubles psychiatriques tous les ges

*

3.3.

/ HVWHVWVGHPDLQWLHQGHOYHLO70(PHVXUHQWODFDSDFLWGXVXMHWUHVWHUYHLOOGXUDQWOD

MRXUQH/HV70(VRQWXWLOLVVSRXUYDOXHUOHFDFLWGXWUDLWHPHQWGHODVRPQROHQFH/H70(
DGHSOXVXQHYDOHXUPGLFROJDOHDUUWGXGFHPEUH/HVXMHWLQVWDOOGDQVXQ
IDXWHXLOHQVHPLSQRPEUHHVWLQYLWUVLVWHUDXVRPPHLOORUVGHVHVVLRQV/DODWHQFHGHQ
GRUPLVVHPHQWHVWPHVXUHFKDTXHVHVVLRQLQWHUURPSXHPLQXWHVVLOHVXMHWQHVHVWSDV
HQGRUPL8QHODWHQFHGHQGRUPLVVHPHQWPR\HQQHLQIULHXUHPLQXWHVHVWSDWKRORJLTXH.

Diagnostic diffrentiel :
'HX[V\PSWPHVVRQWGLVWLQJXHUGHODVRPQROHQFH
*

La fatigue :
 VHQVDWLRQGDDLEOLVVHPHQWSK\VLTXHRXSV\FKLTXH
 VXUYHQDQWOHSOXVVRXYHQWODVXLWHGHRUWVTXLHQLPSRVHODUUW
 UYHUVLEOHDXPRLQVSDUWLHOOHPHQWDYHFODPLVHDXUHSRV

La clinophilie :
 rester allong la journe tout en tant veill,
 V\PSWPHIUTXHPPHQWREVHUYGDQVOHVWURXEOHVGHOKXPHXU

3.4.

312

Formes cliniques
/D6'(HVWPXOWLIDFWRULHOOHSRXYDQWWUHODFRQVTXHQFHGHSHUWXUEDWLRQVGXVRPPHLOGHQXLWHQ
SDUWLFXOLHUOH6$6HQOLHQDYHFGHVIDFWHXUVWR[LTXHVWUHVHFRQGDLUHGHVSDWKRORJLHVSV\FKLD
WULTXHVRXQRQRXWUHOHV\PSWPHSULQFLSDOGHVK\SHUVRPQLHVFHQWUDOHV

3.4.1. Le

syndrome dapnes du sommeil

/H V\QGURPH GDSQHV GX VRPPHLO 6$6 HVW XQH SDWKRORJLH IUTXHQWH WRXFKDQW  GH OD
population gnrale.

3.4.1.1.Aspects cliniques :
,OHVWSOXVIUTXHQWFKH]OKRPPHFKH]OHVVXMHWVHQVXUSRLGVHWVRXUDQWGREVLW&KH]FHV
sujets, le diagnostic de SAS doit tre voqu devant :
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'HVV\PSWPHVGLXUQHV
 6'(
 VRPPHLOSHUXFRPPHQRQUSDUDWHXU
 cphales matinales,
 WURXEOHVFRJQLWLIV
 WURXEOHVGHODOLELGR
 LUULWDELOLW

Des manifestations nocturnes :

 URQHPHQWSDUIRLVSDXVHVUHVSLUDWRLUHVREVHUYHVSDUOHQWRXUDJH
 SRO\XULHQRFWXUQHSOXVGHPLFWLRQVSDUQXLW
 K\SHUVDOLYDWLRQ
 VXHXUVQRFWXUQHVSDXVHVUHVSLUDWRLUHVFRQVWDWHVSDUOHQWRXUDJHVHQVDWLRQGWRXHPHQW

/HVFRPSOLFDWLRQVGHFHV\QGURPHVRQWGRUGUHFDUGLRYDVFXODLUHVHWPWDEROLTXHVK\SHUWHQVLRQ
DUWULHOOHPDQLIHVWDWLRQVLVFKPLTXHVFDUGLDTXHVRXFUEUDOHV

Troubles du sommeil de lenfant et de ladulte

108

3.4.1.2.Diagnostic
/DVXVSLFLRQGLDJQRVWLTXHGRLWWUHFRQUPHSDUHQUHJLVWUHPHQWQRFWXUQHSRO\JUDSKLHYHQWLOD
WRLUHRXSRO\VRPQRJUDSKLH&HWHQUHJLVWUHPHQWPHWHQYLGHQFHGHQRPEUHX[DUUWVUHVSLUDWRLUHV
*

$SQHVLQWHUUXSWLRQFRPSOWHGHODUHVSLUDWLRQGHSOXVGHVHFRQGHV

 \SRSQHV GLPLQXWLRQ SDUWLHOOH GH OD UHVSLUDWLRQ GH SOXV GH  VHFRQGHV DVVRFLV  XQH
+
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8Q LQGH[ GDSQHK\SRSQHV ,$+ VXSULHXU RX JDO   SDU KHXUH GH VRPPHLO FRQUPH OH
GLDJQRVWLF/LQWHQVLWGX6$6VHGQLWSDUO,$+
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/JUH,$+HQWUHHWK

0RGUH,$+HQWUHK

6YUH,$+VXSULHXUK

/H SOXV VRXYHQW OH PFDQLVPH HVW REVWUXFWLI GQLVVDQW OH V\QGURPH GDSQHVK\SRSQHV
REVWUXFWLIGXVRPPHLOSDUIRLVLOHVWFHQWUDOSDUG\VIRQFWLRQQHPHQWGHODFRPPDQGHYHQWLODWRLUH

3.4.1.3.Traitement
/RUVTXHOH6$6HVWVYUHOHWUDLWHPHQWGHUIUHQFHHVWODYHQWLODWLRQHQSUHVVLRQSRVLWLYHFRQWL
QXHDSSOLTXHDXPR\HQGXQPDVTXH
/LQGLFDWLRQGXQWUDLWHPHQWSRXUXQ6$6OJHUPRGUGRLWWUHSRVHHQIRQFWLRQGXFRQWH[WH
FOLQLTXHUHWHQWLVVHPHQWIRQFWLRQQHOIDFWHXUVGHULVTXHFDUGLRYDVFXODLUHHWXQHDOWHUQDWLYHOD
pression positive continue doit tre privilgie :
*

3ULVHHQFKDUJHGXQYHQWXHOVXUSRLGV

 UWKVHGDYDQFHPDQGLEXODLUHSURWKVHPDQGLEXODLUHSRUWHODQXLWLQGXLVDQWXQHSURSXO
2
VLRQHQDYDQWGHODPDQGLEXOHSHUPHWWDQWGHOLEUHUOHVYRLHVDULHQQHVVXSULHXUHV

 ULVHHQFKDUJHFKLUXUJLFDOH25/FKLUXUJLHGXYRLOHGXSDODLVGHVDP\JGDOHVGHVSLOLHUVHWGH
3
ODSDURLSRVWULHXUHGXSKDU\Q[GRQWODEDODQFHEQFHULVTXHGRLWWUHSHVH

,O IDXW \ DVVRFLHU GHV PHVXUHV K\JLQRGLWWLTXHV HW XQH GXFDWLRQ WKUDSHXWLTXH GX SDWLHQW
SRXUIDYRULVHUOREVHUYDQFHHWXQHSULVHHQFKDUJHGHVFRPRUELGLWVFDUGLRYDVFXODLUHVHWPWD
EROLTXHV(QQXQV\QGURPHGDSQHVGXVRPPHLOQRQWUDLWHVWXQHFRQWUHLQGLFDWLRQODSUHV
FULSWLRQGHEHQ]RGLD]SLQHV

3.4.2.Le

syndrome dinsuffisance de sommeil

2Q ODSSHOOH JDOHPHQW SULYDWLRQ FKURQLTXH GH VRPPHLO /H VXMHW QH GRUW SDV DXVVL ORQJWHPSV
TXLOOHGHYUDLWSRXUPDLQWHQLUXQQLYHDXGYHLOQRUPDO/DVRPQROHQFHHVWYRORQWLHUVSOXVIRUWHHQ
GHX[LPHSDUWLHGHMRXUQH/HV\QGURPHGLQVXVDQFHGHVRPPHLOVDFFRPSDJQHSDUDLOOHXUVGH
signes fonctionnels divers, notamment cognitifs.
/LQWHUURJDWRLUHHVWOHSOXVVRXYHQWVXVDQWSRXUUHWHQLUOHGLDJQRVWLFHQSUFLVDQWOHVKRUDLUHV
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ou les vacances.

3.4.3.Les

hypersomnies secondaires

3.4.3.1.Hypersomnie dorigine physiologique

/D 6'( HVW IUTXHQWH DX FRXUV GH OD JURVVHVVH VH PDQLIHVWDQW SULQFLSDOHPHQW ORUV GX SUHPLHU
trimestre.

313

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3.4.3.2.Hypersomnie dorigine iatrogne ou toxique
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 EHQ]RGLD]SLQHVHWDSSDUHQWV
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 antidpresseurs.

Antipileptiques.

Antihistaminiques.

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*

Lors de leur prise :

 FDQQDELV
 alcool,
 RSLRGHV

Lors de leur sevrage :

 FRFDQH
 amphtamines,
 cafine.

314

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3.4.3.3.Hypersomnie dorigine psychiatrique

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3.4.3.4.Hypersomnie dorigine mdicale non psychiatrique

(OOHVVRQWSULQFLSDOHPHQWGRULJLQHQHXURORJLTXH
*

7UDXPDWLVPHFUQLHQ

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0DODGLHGH3DUNLQVRQLGLRSDWKLTXH

Maladie de Steinert.

Sclrose en plaque.

6\QGURPHSRVWPRQRQXFORVHLQIHFWLHXVH

/H WUDLWHPHQW HVW WLRORJLTXH ORUVTXLO HVW SRVVLEOH VLQRQ V\PSWRPDWLTXH DYHF XQ WUDLWHPHQW
VWLPXODQWGHOYHLO

Troubles du sommeil de lenfant et de ladulte

3.4.4.Les

108

hypersomnies centrales

3.4.4.1.Narcolepsie-cataplexie
/DQDUFROHSVLHHVWXQHPDODGLHUDUHGRQWODSUYDOHQFHHVWHVWLPH/LQFLGHQFHGHOD
QDUFROHSVLHVXLWXQHFRXUEHELPRGDOHDYHFXQSLFDQVHWXQVHFRQGDQV/HVIRUPHVIDPL
OLDOHVGHQDUFROHSVLHVRQWUDUHV(OOHUHVWHODUJHPHQWVRXVGLDJQRVWLTXH
/D FDXVH GH OD QDUFROHSVLHFDWDSOH[LH UHVWH LQFRQQXH GRULJLQH YUDLVHPEODEOHPHQW PXOWLIDFWR
ULHOOHLPSOLTXDQWGHVIDFWHXUVJQWLTXHVHWGHVIDFWHXUVHQYLURQQHPHQWDX[6XUOHSODQSK\VLRSD
WKRORJLTXHODQDUFROHSVLHFRUUHVSRQGODSHUWHGHIRQFWLRQGHVQHXURQHVRUH[LQHK\SRFUWLQH
XQQHXURWUDQVPHWWHXUVFUWSDUXQHSHWLWHSRSXODWLRQQHXURQHVGHODSDUWLHGRUVRODWUDOHGH
OK\SRWKDODPXV8QPFDQLVPHQHXURGJQUDWLIDXWRLPPXQHVWIRUWHPHQWVXVSHFW
Le diagnostic de narcolepsie doit tre voqu devant :
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/DWWUDGHV\PSWRPDWLTXHTXLDVVRFLH
 X
 QH6'(VYUHFDUDFWULVHSDUGHVDFFVGHVRPPHLOGLXUQHVPXOWLSOHVHWFRXUWVLQFRHU
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 G
 HVFDWDSOH[LHVDEROLWLRQVEUYHHWEUXWDOHGXWRQXVPXVFXODLUHJQUDOLVHVRXSDUWLHOOHV
sans altration de la conscience, dclenches par une motion le plus souvent positive
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8
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/DSUVHQFHGHVRPPHLOSDUDGR[DOVXUDXPRLQVGHV7,/(

/HW\SDJH+/$SHXWWUHLQIRUPDWLI/DSUVHQFHGH+/$'4% HVWUHWURXYGDQVSUWGH
GHVVXMHWVVRXUDQWGHQDUFROHSVLHFDWDSOH[LHPDLVVHUHWURXYHDXVVLGDQVGHODSRSXODWLRQ
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WLRQ'4% H[LJHODSUVHQFHGHFULWUHVFOLQLTXHVLQFRQWHVWDEOHVSRXUUHWHQLUOHGLDJQRVWLF
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UDFKLGLHQTXLUYOHXQWDX[EDVYRLUHHRQGU
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/H WUDLWHPHQW GH OD QDUFROHSVLHFDWDSOH[LH HVW V\PSWRPDWLTXH ,O FLEOH OHV GHX[ V\PSWPHV OHV
plus invalidants de la maladie :
*

Traitement de la somnolence :
 amnagement de siestes,
 WUDLWHPHQWVWLPXODQWGHOYHLO0RGDQLO0RGLRGDOp0WK\OSKQLGDWH5LWDOLQHp

7 UDLWHPHQWGHVFDWDSOH[LHVDQWLGSUHVVHXUVLQKLELWHXUVGHODUHFDSWXUHGHODVURWRQLQHHWGH
ODQRUDGUQDOLQH9HQODID[LQH(H[RUpHWOHVRGLXPR[\EDWH;\UHPp

315

108 Les troubles psychiatriques tous les ges

3DUDLOOHXUVXQHSULVHHQFKDUJHGXVXUSRLGVHVWLQGLVSHQVDEOHWRXWFRPPHGHVDPQDJHPHQWV
sur le plan professionnel ou scolaire.

3.4.4.2.Hypersomnie idiopathique
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ODQFHQRUPDOH/HVRPPHLOGHQXLWHVWWUVVRXYHQWSURORQJVXSULHXUKHXUHVHWGH[FHO
OHQWHTXDOLW/HUYHLOUHVWHFHSHQGDQWWUVGLFLOHGQLVVDQWOLQHUWLHGXUYHLOSRXYDQWDOOHU
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3.4.4.3.Syndrome de Kleine-Levin
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VRXYHQWGHVH[HPDVFXOLQ,OHVWFDUDFWULVSDUODVXUYHQXHGHSOXVLHXUVDFFVGXUDQWTXHOTXHV
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KHXUHVMRXUSOXVRXPRLQVDVVRFLH

316

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Troubles du sommeil de lenfant et de ladulte

3.5.

108

Dmarche diagnostique

317

Figure 4. Dmarche diagnostique de la somnolence diurne excessive.

3.6.

Aspects mdico-lgaux
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108 Les troubles psychiatriques tous les ges

/HVFRQGXFWHXUVGRWVGHSHUPLVGHW\SHOJHUYRLWXUHPRWRUHOYHQWGXQH[DPHQFOLQLTXHHW
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/ DUHSULVHSHXWDYRLUOLHXPRLVDSUVOYDOXDWLRQGHOHFDFLWWKUDSHXWLTXHSUHVVLRQSRVL
WLYHFRQWLQXHFKLUXUJLHSURWKVHWUDLWHPHQWVWLPXODQWGHOYHLO&HWWHUHSULVHVHUDSURSRVH
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une somnolence malgr le traitement.

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VLWHQWGHSDVVHUXQWHVWGHPDLQWLHQGHOYHLO70(SRXUFRQUPHUOHFDFLWWKUDSHXWLTXHHWOD
SRVVLEOHUHSULVHGHODFRQGXLWHDYHF

3.7.

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/ D UHSULVH SHXW DYRLU OLHX  PRLV DSUV OYDOXDWLRQ GH OHFDFLW WKUDSHXWLTXH SUHVVLRQ
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malgr le traitement.

La somnolence chez lenfant

3.7.1. Caractristiques

de la somnolence chez lenfant

/D VRPQROHQFH FKH] OHQIDQW HVW VRXYHQW DFFRPSDJQH GDXWUHV V\PSWPHV GRQW FHUWDLQV
peuvent tre au premier plan :
318

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3.7.2. Principales

causes de somnolence chez lenfant

3.7.2.1.Insuffisance de sommeil
8QHK\JLQHGHVRPPHLOLQVXVDQWHGHVWURXEOHVFRPSRUWHPHQWDX[HQWUDQDQWUHWDUGOHQGRU
PLVVHPHQWHWRXYHLOVQRFWXUQHVSURORQJVVRQWODSUHPLUHFDXVHGHVRPQROHQFHFKH]OHQIDQW

3.7.2.2.Syndrome dapnes du sommeil de lenfant

/H6$6QHVWSDVUDUHFKH]OHQIDQW,OGRLWV\VWPDWLTXHPHQWWUHYRTXGHYDQWOHVV\PSWPHV
suivants :
*

5RQHPHQW

(QGRUPLVVHPHQWVHQFODVVH

,UULWDELOLW

7URXEOHVGHVDSSUHQWLVVDJHV

'LFXOWVGDWWHQWLRQ

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FULWUHVREMHFWLIVSHUPHWWDQWGHUHWHQLUXQ6$6FKH]OHQIDQWVRQWSOXVVWULFWVTXHFKH]ODGXOWH
!K/H6$6FKH]OHQIDQWHVWOHSOXVVRXYHQWREVWUXFWLIODSUHPLUHFDXVHHVWOK\SHUWURSKLH

Troubles du sommeil de lenfant et de ladulte

108

DP\JGDOLHQQHUYHUVLEOHDSUVWUDLWHPHQWFKLUXUJLFDO8Q6$6FHQWUDOSOXVUDUHGRLWIDLUHUHFKHU
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3.7.2.3.Narcolepsie-cataplexie de lenfant
/HV IRUPHV SGLDWULTXHV GH QDUFROHSVLHFDWDSOH[LH VRQW IUTXHQWHV /HV FDWDSOH[LHV UHYWHQW
SDUIRLVGHVFDUDFWULVWLTXHVDW\SLTXHVSRXYDQWUHQGUHGLFLOHOYRFDWLRQGXGLDJQRVWLF
/HGLDJQRVWLFSRVLWLIHWODSULVHHQFKDUJHVRQWLGHQWLTXHVFHOOHGHVDGXOWHV

3.7.2.4.Parasomnies
'HV SDUDVRPQLHV VYUHV HW LQYDOLGDQWHV SHXYHQW WUH VRXUFH GH VRPQROHQFH FKH] OHQIDQW HQ
SDUWLFXOLHUOHVSDUDVRPQLHVGXVRPPHLOOHQWSURIRQGHWOHVU\WKPLHVGXVRPPHLO

3.7.2.5.Autres troubles neurologiques

2QSHXWUHWHQLU

4.

/HV\QGURPHGH:LOOL3UDGHU

/DPDODGLHGH1LHPDQ3LFNW\SH&

La maladie de Steinert.

Les parasomnies de ladulte et de lenfant

/HV SDUDVRPQLHV UHJURXSHQW XQ HQVHPEOH KWURJQH GH PDQLIHVWDWLRQV FRPSRUWHPHQWDOHV RX
SV\FKLTXHV VXUYHQDQW DX FRXUV GX VRPPHLO (OOHV VRQW SDUWLFXOLUHPHQW IUTXHQWHV FKH] OHQIDQW
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PDUVHQUDSSRUWDYHFOHVRPPHLOSDUDGR[DOGDXWUHVSDUDVRPQLHVQHOHVRQWSDVFRPPHOQXUVLH

4.1.

Lagitation nocturne

4.1.1. Les

parasomnies du sommeil lent profond

/HV SDUDVRPQLHV GX VRPPHLO OHQW SURIRQG 6/3 FRPSRUWHQW OH VRPQDPEXOLVPH OHV WHUUHXUV
QRFWXUQHVDLQVLTXHOHVYHLOVFRQIXVLRQQHOV&HVSDUDVRPQLHVUHOYHQWGDQRPDOLHVGHODWUDQVL
tion entre le sommeil lent profond et la veille. Ces parasomnies surviennent le plus souvent dans
OHSUHPLHUWLHUVGHODQXLWHWVRQWDFFRPSDJQHGXQHDPQVLHSDUWLHOOHRXFRPSOWHGHVSLVRGHV
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'DQV OH VRPQDPEXOLVPH OHV PDQLIHVWDWLRQV PRWULFHV VRQW DX SUHPLHU SODQ /H[SUHVVLRQ
FRPSRUWHPHQWDOHHVWHQJQUDOVLPSOHOHVXMHWVDVVRLWRXVHOYHHWPDUFKHGDQVVDFKDPEUH
/HV\HX[VRQWRXYHUWVOHUHJDUGHVWYLGHOHVJHVWHVVRQWOHQWVVRXYHQWPDODGURLWVHWUHOHYDQW
GDXWRPDWLVPHV
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(QQOHVYHLOVFRQIXVLRQQHOVVHGLVWLQJXHQWSDUODIDLEOHFRPSRVDQWHPRWULFHHWQHXURYJWDWLYH
DXFRXUVGHOSLVRGH/HVDFFVVRQWYRORQWLHUVORQJVMXVTXSOXVLHXUVGL]DLQHVGHPLQXWHV,OV

319

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comportements instinctuels, sexuels ou alimentaires peuvent survenir.
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en particulier de la somnolence.
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Les crises sont dclenches ou leur frquence aggrave par :
*

La privation de sommeil.

Le stress, les motions fortes.

/DYUH

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4.1.2.Le

trouble du comportement en sommeil paradoxal

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VXUHV SRXU OH SDWLHQW OXLPPH RX VRQ SDUWHQDLUH /H GLDJQRVWLF HVW FOLQLTXH HW SRO\VRPQRJUD
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/HWURXEOHGXFRPSRUWHPHQWHQVRPPHLOSDUDGR[DOFRQFHUQHSULQFLSDOHPHQWOHVXMHWJGHVH[H
PDVFXOLQ7UVVRXYHQWOHWURXEOHDFFRPSDJQHRXSUFGHGHSOXVLHXUVDQQHVGHVSDWKRORJLHV
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320

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posologie.

4.1.3. Autres

causes dagitation nocturne

/SLOHSVLHIURQWDOHQRFWXUQHSHXWSRVHUXQSUREOPHGLDJQRVWLTXHDYHFOHVSDUDVRPQLHV&HWWH
IRUPHH[FOXVLYHPHQWQRFWXUQHGSLOHSVLHGRLWWUHYRTXHGHYDQW
*

/HFDUDFWUHVWURW\SGHVFULVHV

De multiples crises par nuit.

'HVPRXYHPHQWVG\VWRQLTXHVG\VNLQWLTXHV

/HSUREOPHGLDJQRVWLTXHUVLGHGDQVOHIDLWTXHO((*GHVXUIDFHHVWVRXYHQWQRUPDO
/HWURXEOHGLVVRFLDWLIQRFWXUQHUHVWHXQGLDJQRVWLFGOLPLQDWLRQLOFRUUHVSRQGGHVPDQLIHVWD
WLRQVGLVVRFLDWLYHVGH[SUHVVLRQHVVHQWLHOOHPHQWQRFWXUQH

4.2.

Autres parasomnies

4.2.1. Cauchemars
/HFDXFKHPDUFRUUHVSRQGXQHDFWLYLWRQLULTXHGHFRQWHQXGVDJUDEOHTXLUYHLOOHOHVXMHW2Q
GLVWLQJXHOHVFDXFKHPDUVGLWVLGLRSDWKLTXHVGHFHX[VXUYHQDQWGDQVOHFDGUHGHOWDWGHVWUHVV
SRVWWUDXPDWLTXH'DQVFHFDVLOVVLQWJUHQWDXV\QGURPHGHUHYLYLVFHQFH

Troubles du sommeil de lenfant et de ladulte

108

/HFDXFKHPDUFKH]OHQIDQWVHGLVWLQJXHGHODWHUUHXUQRFWXUQHSULQFLSDOHPHQWSDUODEVHQFHGDP
QVLHHWGHWURXEOHVGXFRPSRUWHPHQW/HVFDXFKHPDUVVXUYLHQQHQWOHSOXVVRXYHQWHQVRPPHLO
SDUDGR[DOGRQFPDMRULWDLUHPHQWHQQGHQXLW

4.2.2.Rythmies

du sommeil

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tiellement sur des mesures comportementales.

4.2.3.Enursie

nocturne

Ce sont des mictions involontaires la nuit.

3RXUHQVDYRLUSOXVYRLUFRXUVGXURORJLHHWGHSGLDWULH

Rsum
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OHQFHRXGHSKQRPQHVLQGVLUDEOHVVXUYHQDQWDXFRXUVGXVRPPHLOTXHORQDSSHOOHOHVSDUD
VRPQLHV /H SUDWLFLHQ GRLW HQ FRQQDWUH OHV PRGDOLWV GH[SORUDWLRQ FOLQLTXHV HW SDUDFOLQLTXHV
DQGHQGQLUODVYULWODFKURQLFLWHWOHXUWLRORJLHHQYXHGXQHSULVHHQFKDUJHDGDSWH
/LQVRPQLHHVWXQHSODLQWHGLQVDWLVIDFWLRQGHODTXDQWLWRXGHODTXDOLWGXVRPPHLO(OOHSHXW
WUHSULPDLUHVHFRQGDLUHGHVSDWKRORJLHVPGLFDOHVGRQWOHV\QGURPHGHVMDPEHVVDQVUHSRV
RXGHVFDXVHVSV\FKLDWULTXHV/HSOXVVRXYHQWXQHLQVRPQLHFKURQLTXHQHGRLWSDVIDLUHOREMHW
GXQHSUHVFULSWLRQGK\SQRWLTXHVOHWUDLWHPHQWGHOWLRORJLHVRXVMDFHQWHRXXQHWKUDSLHFRJQL
WLYHHWFRPSRUWHPHQWDOHVRQWOHVWUDLWHPHQWVGHSUHPLUHLQWHQWLRQ/DVRPQROHQFHGLXUQHH[FHV
VLYHHVWXQSUREOPHGHVDQWSXEOLTXHUHVSRQVDEOHGXQKDQGLFDSLPSRUWDQWHWGDFFLGHQWVGHOD
FLUFXODWLRQ(OOHHVWGQLHSDUXQEHVRLQH[FHVVLIGHGRUPLUODMRXUQH(OOHSHXWWUHVHFRQGDLUH
 XQH DHFWLRQ SV\FKLDWULTXH RX PGLFDOH (OOH GRLW IDLUH VXVSHFWHU XQ V\QGURPH GDSQHV GX
VRPPHLO/DVRPQROHQFHSHXWWUHSULPDLUHRQSDUOHGDQVFHFDVGK\SHUVRPQLHFHQWUDOHGRQWOD
SULQFLSDOHFDXVHHVWODQDUFROHSVLHFDWDSOH[LH'HSXLVODUUWGXGFHPEUHOHVVXMHWV
DWWHLQWVGXQHSDWKRORJLHUHVSRQVDEOHGHVRPQROHQFHGRLYHQWWUHYDOXVDQQXHOOHPHQWDYHFXQ
ELODQVSFLDOLVHWSRXUOHJURXSHmORXUG}SDVVHUGHVWHVWVGHPDLQWLHQGYHLOSRXUOREWHQWLRQ
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WLTXHVSV\FKLDWULTXHVQHXURGYHORSSHPHQWDOHV

321

108 Les troubles psychiatriques tous les ges

Points clefs
* Insomnie
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 /DSUHVFULSWLRQGK\SQRWLTXHQHVWSDVUHFRPPDQGHHQSUHPLUHLQWHQWLRQGDQVOHWUDLWHPHQWGHOLQVRPQLH
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 /DSUVHQFHGXQV\QGURPHGHVMDPEHVVDQVUHSRVGRLWV\VWPDWLTXHPHQWWUHUHFKHUFKHGHYDQWXQHSODLQWH
GLQVRPQLHFKURQLTXHFKH]ODGXOWH
* Somnolence diurne excessive
 8QV\QGURPHGDSQHVGXVRPPHLOGRLWV\VWPDWLTXHPHQWWUHYRTXGHYDQWXQHSODLQWHGHVRPQROHQFH
GLXUQHH[FHVVLYHHWGHURQHPHQWTXHFHVRLWFKH]ODGXOWHPDLVDXVVLFKH]OHQIDQW
 8QHVRPQROHQFHVYUHFKH]OHVXMHWMHXQHGRLWIDLUHYRTXHUXQHK\SHUVRPQLHFHQWUDOHQDUFROHSVLHK\SHU
VRPQLHLGLRSDWKLTXH

Rfrence pour approfondir

Les troubles du sommeil, Billiard M., Dauvilliers Y., ditions Masson, 2011.

322

partie 5

Les troubles
psychiatriques
spcifiques
de lenfant et
ladolescent

item 53

Dveloppement
psychomoteur
du nourrisson
et de lenfant :

53

aspects normaux et pathologiques

(sommeil, alimentation, contrles
sphinctriens, psychomotricit,
langage, intelligence).
Linstallation prcoce de la
relation parents-enfant et
son importance. Troubles de
lapprentissage (cf. Item 118)
I. Introduction
II. YDOXDWLRQGXGYHORSSHPHQWSV\FKRPRWHXUHWLQWHOOHFWXHO
III. 'YHORSSHPHQWSV\FKRPRWHXUGHODQDLVVDQFHDQV
IV. 5HWDUGGXGYHORSSHPHQWSV\FKRPRWHXU
V. 7URXEOHVGXVRPPHLOFKH]OHQIDQW
VI. 7URXEOHVGHVDSSUHQWLVVDJHV

Objectifs pdagogiques
* 'LDJQRVWLTXHUXQHDQRPDOLHGXGYHORSSHPHQWVRPDWLTXHSV\FKRPRWHXU
LQWHOOHFWXHOHWDHFWLI
* 5HSUHUSUFRFHPHQWOHVG\VIRQFWLRQQHPHQWVUHODWLRQQHOVHWOHVWURXEOHVGH
ODSSUHQWLVVDJH
* $UJXPHQWHUODWWLWXGHWKUDSHXWLTXHHWSODQLHUOHVXLYLGDQVOHVVLWXDWLRQV
courantes.

53

Les troubles psychiatriques spcifiques de lenfant et ladolescent

1.

Introduction
/YDOXDWLRQ GX GYHORSSHPHQW SV\FKRPRWHXU DSSDUWLHQW DX[ EDVHV GH OH[DPHQ GXQ HQIDQW
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HWSV\FKLTXHFHVGHX[FRPSRVDQWHVWDQWLQWLPHPHQWOLHVOXQHODXWUH
/HGYHORSSHPHQWSV\FKRPRWHXUHVWODUVXOWDQWHGLQWHUDFWLRQVHQWUHODPDWXUDWLRQGXV\VWPH
QHUYHX[OHVH[SULHQFHVVHQVRULHOOHVOHVFKDQJHVDYHFOHQYLURQQHPHQWHWGRQFOLODHFWHW
au social.
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* la loi de diffrenciation ODFWLYLW PRWULFH WDQW LQLWLDOHPHQW UH[H GRQF QRQ PDWULVH
JOREDOHHWLPSUFLVHHWGHYHQDQWYRORQWDLUHGRQFPDWULVHORFDOLVHSUFLVH
* la loi de variabilit FKDTXH HQIDQW YROXDQW  VRQ SURSUH U\WKPH DYHF XQH DOWHUQDQFH GH
SKDVHVGDFTXLVLWLRQVHWGHSKDVHVGHSODWHDX
*

la loi de successionHOOHPPHGLYLVHHQVRXVORLV
 la loi de dveloppement cphalo-caudale, les acquisitions motrices se droulant du haut
YHUVOHEDVGXFRUSV
 et la loi de dveloppement proximo-distale, les acquisitions motrices se droulant du centre
vers la priphrie du corps.

6LOHQYLURQQHPHQWHVWVXVDPPHQWVWDEOHVFXULVDQWHWVWLPXODQWFHODSHUPHWOHQIDQWGDYRLU
FRQDQFHHQOXLHWHQVHVFDSDFLWVDLQVLTXHGHVHGYHORSSHU6LOHQYLURQQHPHQWSUVHQWHGHV
FDUDFWULVWLTXHVLQYHUVHVFHODDWHQGDQFHIUHLQHUFHGYHORSSHPHQW/HQWRXUDJHGHOHQIDQWVH
GRLWGRQFGWUHDWWHQWLIVHVEHVRLQVDOLPHQWDLUHVGHVRPPHLOGDXWRQRPLHGHSURWHFWLRQHW
G\SURSRVHUXQHUSRQVHDGDSWH

326

2.

2.1.

valuation du dveloppement
psychomoteur et intellectuel
Observation
5HJDUGHUOHQIDQWGDQVOHVEUDVGHVHVSDUHQWVRXHQWUDLQGHMRXHUcomportement en lien avec
ODXWUH UHFKHUFKH GDWWHQWLRQ MHX[ FKRLVLV SDU OHQIDQW HQ IRQFWLRQ GH VRQ JH MHX GX mIDLUH
VHPEODQW}H[SORUDWLRQGHOHQYLURQQHPHQWSDUOHQIDQW

2.2.

Anamnnse
*

0RWLIGHFRQVXOWDWLRQHWSHUVRQQHORULJLQHGHODGHPDQGH

$QWFGHQWVIDPLOLDX[JQRJUDPPH

$QWFGHQWVSHUVRQQHOV\FRPSULVDYDQWHWSHQGDQWODJURVVHVVH

+LVWRLUHGXGYHORSSHPHQWGHOHQIDQW

Dveloppement psychomoteur du nourrisson et de lenfant

2.3.

53

Examen clinique
([DPLQHU SK\VLTXHPHQW FHVW UDOLVHU OHV courbes (PMZ) : SRLGV WDLOOH SULPWUH FUQLHQ 
FKDTXHYLVLWHTXHOTXHQVRLWOHPRWLISXLVIDLUHXQH[DPHQFOLQLTXHFRPSOHW

2.4.

Mthodes dvaluation

2.4.1. chelles

de dveloppement psychomoteur

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PRWHXUVLQWHOOHFWXHOVODQJDJLHUVVRFLRSV\FKRORJLTXHV
/FKHOOHGH*HVHOOHVWLPHXQGYHORSSHPHQWSV\FKRPRWHXUDOODQWGHPRLVDQV
/FKHOOHGH'HQYHUTXDQWHOOHSHUPHWXQHHVWLPDWLRQGHPRLVDQV

2.4.2.Tests

valuant le quotient dveloppement

et le quotient intellectuel

&HVWHVWVVRQWUDOLVVSDUGHVSURIHVVLRQQHOVSV\FKRORJXHVRXQHXURSV\FKRORJXHV
/HWHVWGH%UXQHW/H]LQHHVWLPHOHquotient dveloppement GXQVXMHW,OYDOXHODPRWULFLWJOREDOH
ODPRWULFLWQHOHODQJDJHODFRJQLWLRQODVRFLDELOLWMXVTXOJHGHGHX[DQVHWGHPL
327

Le quotient intellectuel PHVXUHOLQWHOOLJHQFHGXQLQGLYLGXHQYDOXDQWVHVFRPSWHQFHVFRJQL

WLYHVHWVHVFRPSRUWHPHQWVDXFRXUVGHGLUHQWHVSUHXYHV/HVWFKHVUDOLVHVGXUDQWOHWHVW
SHUPHWWHQWGREWHQLUXQ4,YHUEDOHWXQ4,SHUIRUPDQFH/HVWHVWVOHVSOXVXWLOLVVVRQWOHVchelles
de Wechsler :
*

OD:336,5GHDQV

OD:,6&,9GHDQV

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QI

2.5.

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retard
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normal

normal
fort

suprieur

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suprieur

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53

Les troubles psychiatriques spcifiques de lenfant et ladolescent

3.

3.1.

Dveloppement psychomoteur
de la naissance 6 ans
Rythme veille-sommeil
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WXUHSDUGHVU\WKPHV/XQGHVSOXVLPSRUWDQWVHVWOHU\WKPHYHLOOHVRPPHLO&HOXLFLYDFRQQDWUH
GHQRPEUHX[FKDQJHPHQWVHQWUHODQDLVVDQFHHWOJHDGXOWH
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DVWKQLH RX XQH VRPQROHQFH GLXUQH H[FHVVLYH ,O IDXW SRXYRLU \ SHQVHU GHYDQW GHV WURXEOHV GH
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328

3.2.

Naissance

5\WKPHVXOWUDGLHQVGHKHXUHV
YHLOFDOPHYHLODJLW

1 mois

'EXWGHODSULRGLFLWMRXUQXLW
/RQJVPRPHQWVGYHLOKK

3 mois

0HLOOHXUHV\QFKURQLVDWLRQMRXUQXLW
$OORQJHPHQWGHODSULRGHGHVRPPHLOQRFWXUQHMXVTXKHXUHVQXLW

6 mois

KHXUHVGHVRPPHLOSDUSULRGHGHKHXUHVUSDUWLHVHQVLHVWHV
et une longue priode de sommeil nocturne.

12 mois

2 siestes par jour.

18 mois

8QHVLHVWHODSUVPLGL

2 ans

KHXUHVGHVRPPHLOSDUSULRGHGHKHXUHV

4 ans

Disparition progressive de la sieste.

12 heures de sommeil par priode de 24 heures.

6 ans

7HPSVGHVRPPHLOQRFWXUQHLQIULHXUKHXUHV

Alimentation
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SULQFLSDOHPHQWGHVWLQHVODOLPHQWDWLRQ
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DOLPHQWDLUHQHGEXWHTXHQWUHHWPRLVGHYLH
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ODUHODWLRQPUHEE3RXUOHQRXUULVVRQLOVSHUPHWWHQWGHmYULHU}ODUSRQVHDGTXDWHGH
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WHQGUHVVHWLVVDQWOHVOLHQVSDUHQWHQIDQW

Dveloppement psychomoteur du nourrisson et de lenfant

53

 QRXYHDX LO HVW LPSRUWDQW GH VRXWHQLU OHV SDUHQWV GDQV ODOLPHQWDWLRQ GH OHXU HQIDQW GRQW OD
FRPSOH[LW SHXW FRQGXLUH  XQ VHQWLPHQW GFKHF GH IUXVWUDWLRQ  JQUHU HW FULVWDOOLVHU GH OD
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WLRQSDUHQWHQIDQWHWSRXUOHQIDQWVXUVRQUDSSRUWODQRXUULWXUH

3.3.

Dveloppement moteur et dveloppement de la prhension

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XQHORLGHGLUHQFLDWLRQ/HVFRPSWHQFHVPRWULFHVVDFTXLUHQWGDQVXQRUGUHSUR[LPRGLVWDO
HWORQFRPSUHQGGRQFTXLOIDXWGDERUGDYRLUDFTXLVODWHQXHGHODWWHDYDQWGWUHHQPHVXUHGH
VDVVHRLU
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GDQVVDSRVWXUHSDUXQHK\SRWRQLHGXFKHIHWGXWURQFHWXQHK\SHUWRQLHHQH[LRQGHVPHPEUHV
*UFH  OD PDWXUDWLRQ GX V\VWPH QHUYHX[ FHQWUDO HW SULSKULTXH OK\SR HW OK\SHUWRQLH VH
FRUULJHQW OH QRXUULVVRQ HVW SOXV OLEUH GDQV VHV PRXYHPHQWV D XQH PHLOOHXUH PDWULVH GH VRQ
FRUSV&HVFKDQJHPHQWVLPSDFWHQWVXUVRQHQYLURQQHPHQWTXLOSHXWDORUVPLHX[H[SORUHUPLHX[
FRQWUOHU,OJDJQHDLQVLHQDXWRQRPLH/HVUSRQVHVGHOHQYLURQQHPHQWYRQWOHXUWRXUUHQIRUFHU
les acquis et encourager le dveloppement de nouvelles capacits.

3.3.1. Dveloppement

moteur

Naissance

Marche automatique }

1 mois

0RXYHPHQWVDV\PWULTXHVLQFRRUGRQQVHQGFXELWXVGRUVDO

3 mois

Tient la tte droite, petits mouvements salutatoires.

4 mois

6HUHWRXUQHGDQVVRQOLW$OORQJVXUOHGRVOHVPRXYHPHQWVGHVHVPHPEUHVVRQW
V\PWULTXHV$OORQJVXUOHYHQWUHLOVDSSXLHVXUOHVFRXGHV
UHGUHVVHODWWHHWOHWRUVHDQGHUHJDUGHUDXWRXUGHOXL

6 mois

Tient assis avec un appui dorsal, position de trpied.

9 mois

Tient assis sans appui. Se dplace en rampant.

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12 mois

Tient debout seul0DUFKHWHQXSDUOHVPDLQVFRPPHQFHPDUFKHUVHXO

18 mois

Marche seul6DVVLHGWRXWVHXOVXUXQHFKDLVHEDVVH

2 ans

Court, monte et descend les escaliers, sans alterner les pieds.

3 ans

7LHQWHQTXLOLEUHVXUXQSLHGTXHOTXHVVHFRQGHV0RQWHHWGHVFHQGOHVHVFDOLHUVHQ
DOWHUQDQWOHVSLHGV5RXOHWULF\FOH

4 ans

6DXWHFORFKHSLHG

6 ans

6DXWHSLHGVMRLQWVVDXWHODFRUGH

329

53

Les troubles psychiatriques spcifiques de lenfant et ladolescent

3.3.2. Dveloppement
Naissance

Grasping reflex.

3 mois

3UKHQVLRQDXFRQWDFW

4 mois

Tente de saisir un hochet, retire une serviette pose sur sa tte.

6 mois

Passe les jouets dune main lautre.

9 mois

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15 mois

&DSDEOHGHPDQJHUVHXOHQIHUPDQWOHSRLQJDXWRXUGHODFXLOOUH

2 ans

Prise digitale acquiseWLHQWELHQVRQFUD\RQSRXUGHVVLQHU

5 ans

Lace ses chaussures.

6 ans

&RXGDYHFXQHJURVVHDLJXLOOHHQURXOHXQODXWRXUGXQHERELQH

3.3.3. Contrle

330

de la prhension

sphinctrien

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FRQWUOHUVHVVSKLQFWHUVYVLFDOHWDQDO/DSURSUHWSHXWVDFTXULUSDUWLUGHOJHGHPRLV
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3.3.4.Dveloppement

sensoriel

Laudition
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GLVWLQFWLRQHQWUHXQHYRL[HWXQVLPSOHEUXLW
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(QFDVGHWURXEOHGHODXGLWLRQOHEEEDELOOHSHXQHUDJLWSDVODSSHOGHVRQSUQRPSUVHQWH
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Lolfaction
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ORSSHPHQWGHODWWDFKHPHQWHQWUHOXLHWVDPUH
Le got
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/D GLYHUVLFDWLRQ DOLPHQWDLUH  SDUWLU GH    PRLV IDYRULVH OH GYHORSSHPHQW GHV SDSLOOHV
gustatives.

Dveloppement psychomoteur du nourrisson et de lenfant

53

La vision
 OD QDLVVDQFH ODFXLW YLVXHOOH HVW GH  OD SHUFHSWLRQ QHWWH VH VLWXH DX[ DOHQWRXUV GH  
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SDUOHVYLVDJHVKXPDLQVOHV[HHWOHXUVRXULW
6D YLVLRQ VDQH HW VH GYHORSSH SURJUHVVLYHPHQW MXVTX  PRLV R ODFXLW YLVXHOOH HVW GH
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Le toucher
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'MSUVHQWLQXWHURLOSHUPHWDXIWXVGHQWUHUHQFRQWDFWDYHFVDPUH/HFRQWDFWVHSURORQ
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&HVHQVHVWJDOHPHQWLQGLVSHQVDEOHSRXUSHUPHWWUHOHQIDQWGHGFRXYULUVRQFRUSVVHVVHQVD
WLRQVVHVOLPLWHVHWGHGYHORSSHUOHVHQWLPHQWGXQLWGHVRL

3.3.5. Dveloppement

de lintelligence

4 mois

5HJDUGHOREMHWSODFGDQVVDPDLQ

9 mois

1RWLRQGRXWLO

12 mois

0HWOHFXEHGDQVODWDVVH

15 mois

0HWFXEHVGDQVODWDVVH7RXUGHFXEHV

18 mois

7RXUGHFXEHV&RQQDWSDUWLHVGHVRQFRUSV$VVRFLHGHVIRUPHV
6LQWUHVVHDX[OLYUHVGLPDJHV&RPSUHQGOHVRUGUHVVLPSOHV,PLWHOHVDGXOWHV

2 ans

7RXUGHFXEHV'VLJQHSDUWLHVGHVRQFRUSV5HFRSLHXQURQG

3 ans

,PLWHXQHPDLVRQDYHFGHVFXEHV5HFRSLHXQHFURL[
&RQQDWmKDXW}mEDV}mSHWLW}mJUDQG}

4 ans

3RVHGHVTXHVWLRQVVXUODVLJQLFDWLRQGHVPRWVHWGHVFKRVHV
5HFRSLHXQSRQWGHVVLQHXQERQKRPPHDYHFSDUWLHVHQSOXVGHODWWH
&RPSDUHODORQJXHXUGHGHX[OLJQHVHWFRPSWHTXDWUHSLFHV

6 ans

5HFRSLHXQFDUUHWXQWULDQJOHQRPPHFRXOHXUVFRPSDUHGHX[SRLGV
connat les jours de la semaine.

3.3.7. Dveloppement

du langage

/HGYHORSSHPHQWGXODQJDJHQFHVVLWHGDYRLUXQV\VWPHDXGLWLIIRQFWLRQQHO
&RPPHSRXUOHVDXWUHVGRPDLQHVGXGYHORSSHPHQWSV\FKRPRWHXUOHGYHORSSHPHQWGXODQJDJH
HVWSURJUHVVLIHWVHFRPSOH[LHDXOGHVRQYROXWLRQ

331

53

Les troubles psychiatriques spcifiques de lenfant et ladolescent

3 mois

m5RXFRXOH}SURQRQFHGHVYR\HOOHV

4 mois

5LWEUX\DPPHQW

6 mois

3RXVVHGHVSHWLWVFULVDLJXV

10 mois

Langage bi-syllabique mPDPD}mSDSD}

12 mois

3URQRQFHGHX[DXWUHVPRWV

15 mois

3URQRQFHPRWV

18 mois

Non}GL]DLQHGHPRWVH[SORVLRQGXYRFDEXODLUHSHXWQRPPHU12 dessins.

2 ans

Mots-phrases }QRPPH dessins.

3 ans

3KUDVHVFRPSOWHVmJe}GRQQHVRQSUQRP

4 ans

Raconte une histoire.

6 ans

$FFGHDXlangage critSHXWDSSUHQGUHOLUHHWOFULWXUHOLH

3.3.8.Dveloppement

332

psychologique, sociabilit

/HGYHORSSHPHQWSV\FKRORJLTXHGHOHQIDQWHVWJXLGSDUXQHFRPSRVDQWHJQWLTXHLQQHHW
LQXHQFSDUOHVUHODWLRQVDYHFOHQYLURQQHPHQWHWOHVH[SULHQFHVTXLHQGFRXOHQW&RPPHOH
GYHORSSHPHQWPRWHXUGRQWLOGSHQGHQSDUWLHLOGSHQGGHODPDWXUDWLRQFUEUDOH
Naissance

Regarde dans les yeux OHVYLVDJHVTXLVHSUVHQWHQWOXL

5HFRQQDWORGHXUHWODYRL[PDWHUQHOOHV

1 mois

)L[HVRQHQWRXUDJHHVWDWWHQWLIDX[EUXLWV

3 mois

Sourire social. 5HJDUGHVHVPDLQV

4 mois

-RXHDYHFVHVPDLQV

6 mois

-RXHDYHFVHVSLHGVOHVPHWHQERXFKH7HQGOHVEUDVSRXUWUHSRUW

9 mois

FKDQJHOHVMRXHWVMRXHDYHFVHVSDUHQWV

12 mois

&RRSUHORUVTXRQOKDELOOH

15 mois

'VLJQHFHTXLOGVLUHSDUGHVVRQVHWGHVJHVWHVpointage, jette les jouets.

18 mois

'EXWGHODSURSUHWGLXUQH-RXHDYHFGHVMRXHWVDYHFIRUPHKXPDLQH
WUDQVSRUWHHPEUDVVHKDELOOHEHUFHODSRXSH

2 ans

Propre le jour.

3 ans

Propre le jour et la nuit, mange seul correctement.

0HWVHVFKDXVVXUHVGIDLWVHVERXWRQV

4 ans

Va seul aux toilettes, joue avec plusieurs enfants.

6 ans

Connat son adresse.

Dveloppement psychomoteur du nourrisson et de lenfant

4.

Retard du dveloppement psychomoteur

4.1.

Gnralits

53

4XHODFDXVHGXQUHWDUGSV\FKRPRWHXUVRLWSV\FKLDWULTXHRXQRQVDUHFRQQDLVVDQFHHWFHOOHGX
GLDJQRVWLFWLRORJLTXHVHGRLYHQWGWUHSUFRFHVDQGHSURSRVHUGHVVRLQVDGDSWVOHQIDQWHW
GHFRUULJHUDXWDQWTXHSRVVLEOHFHUHWDUG

4.2.

Dmarche diagnostique

4.2.1. Anamnse
Antcdents familiaux et personnels
/DUHFKHUFKHGHVDQWFGHQWVHVWIRQGDPHQWDOHGDQVODGPDUFKHGLDJQRVWLTXHGXQUHWDUGGH
GYHORSSHPHQWSV\FKRPRWHXU(OOHVHGRLWGWUHV\VWPDWLTXH
/D UDOLVDWLRQ GXQ arbre gnalogique permet de montrer clairement des informations impor
WDQWHVWHOOHVTXHODFRQVDQJXLQLWRXOHQRPEUHGLQGLYLGXVPDODGHV
/HVSULQFLSDX[OPHQWVUHFKHUFKHUVRQW
*

&RQVDQJXLQLWHQWUHOHVSDUHQWVGHOHQIDQW

Maladies gntiques ou chromosomiques.

SLOHSVLH

5HWDUGPHQWDO

$XWUHVPDODGLHVQHXURORJLTXHVRXSV\FKLDWULTXHV

Concernant les antcdents personnels, il est utile de les organiser chronologiquement :

*

$YDQWODFRQFHSWLRQSDUH[HPSOHJURVVHVVHREWHQXHSDUIFRQGDWLRQLQYLWUR

 HQGDQW OD JURVVHVVH SDU H[HPSOH UHWDUG GH FURLVVDQFH LQWUDXWULQ DQRPDOLHV FKRJUD
3
SKLTXHV SHUFHSWLRQ GHV PRXYHPHQWV IWDX[ SHUWXUEDWLRQV WHQVLRQQHOOHV FKH] OD PUH
GLDEWHJHVWDWLRQQHOLQIHFWLRQVSULVHVGHPGLFDPHQWVHWWR[LTXHVFI,WHP

 QSHUSDUWXPDQRPDOLHVGXU\WKPHFDUGLDTXHIWDOGLFXOWVORUVGHODFFRXFKHPHQWFVD
(
ULHQQHHWPRWLI

ODQDLVVDQFHVFRUHG$SJDUSDUWLFXODULWVOH[DPHQFOLQLTXH

Depuis la naissance.

Date du dbut des troubles

'DWHUPPHDSSUR[LPDWLYHPHQWOHGEXWGHVWURXEOHVSHUPHWGRULHQWHUOHFDGUHQRVRJUDSKLTXH
'EXWGHVWURXEOHVGDWDQWGHODJURVVHVVH
*

Anomalies gntiques ou chromosomiques.

6XLWHXQHLQIHFWLRQPDWHUQRIWDOH

3ULVHGHPGLFDPHQWVRXGHWR[LTXHVGXUDQWODJURVVHVVH

'EXWGHVWURXEOHVHQSULRGHQRQDWDOHDEVHQFHGDQWFGHQWVGHIDXVVHFRXFKHJURVVHVVH
sans particularits :
*

6TXHOOHVQHXURORJLTXHVGXQHK\SR[LH

0DODGLHQHXURPWDEROLTXH

333

53

Les troubles psychiatriques spcifiques de lenfant et ladolescent

'EXWGHVWURXEOHVGDQVOHVVHPDLQHVRXPRLVVXLYDQWODQDLVVDQFHVDQVLQIHFWLRQFRQFRPLWDQWH
QLSULVHGHWR[LTXHVPGLFDPHQWV
*

Anomalies gntiques ou chromosomiques.

6XLWHXQHLQIHFWLRQPDWHUQRIWDOH

0DODGLHQHXURPWDEROLTXH

'EXWGHVWURXEOHVDSUVXQLQWHUYDOOHOLEUH
*

0DODGLHQHXURPWDEROLTXH

Carences alimentaires.

&DUHQFHVDHFWLYHVPDOWUDLWDQFH

Modalits volutives des troubles

7RXW FRPPH OH GEXW GHV WURXEOHV OHXU PRGDOLW YROXWLYH SHUPHW GRULHQWHU YHUV XQ FDGUH
nosographique.
'HV WURXEOHV  GEXW EUXWDO YRTXHQW XQH GFRPSHQVDWLRQ GXQH PDODGLH GM SUVHQWH PDLV
MXVTXHOFRPSHQVH
8Q GEXW LQVLGLHX[ SHXW HQWUHU GDQV OH FDGUH GXQH PDODGLH QHXURGYHORSSHPHQWDOH GRULJLQH
gntique, chromosomique ou multifactorielle.
8QHUJUHVVLRQGHVDFTXLVLWLRQVFKH]XQHQIDQWVWDQWSDUDLOOHXUVGYHORSSGHIDRQVDWLVIDL
VDQWHMXVTXHORULHQWHYHUVXQWURXEOHGVLQWJUDWLIGHOHQIDQFHSDUH[HPSOHV\QGURPHGH5HWW
8QHUJUHVVLRQRXXQHDFFHQWXDWLRQGHVWURXEOHVHQIRQFWLRQGHOHQYLURQQHPHQWGRLWWUHUHFKHU
FKHSDUWLFXOLUHPHQWGDQVOHVFDVGHVXVSLFLRQGHFDUHQFHVDHFWLYHVPDOWUDLWDQFHV
334

4.2.2.Examen

clinique complet

2EVHUYDWLRQ
* Analyser et raliser des courbes ODUHFKHUFKHGXQHDQRPDOLHGHODYLWHVVHGHFURLVVDQFHGH
SRLGVGHWDLOOHHWVXUWRXWGHSULPWUHFUQLHQPMZ
* ComportementVHXODYHFVHVSDUHQWVYHQWXHOOHPHQWVHVIUUHVHWVXUVDYHFGHVMHX[HW
jouets.
([DPHQDSSDUHLOSDUDSSDUHLOODUHFKHUFKH
*

'OPHQWVdysmorphiques.

'HGFLWVVHQVRULHOV

'HGFLWVQHXURORJLTXHV

 DQRPDOLHVFXWDQHVDQJLRPHSODQGDQVOHWHUULWRLUHGXeQHUIIDFLDOHQFDVGHV\QGURPHGH
'
6WXUJH:HEHUWFKHVDFKURPLTXHVGDQVODVFOURVHWXEUHXVHGH%RXUQHYLOOH

'XQHKSDWRVSOQRPJDOLHPDODGLHGHVXUFKDUJH

4.2.3.Retard

de dveloppement homogne

/HUHWDUGGHGYHORSSHPHQWSV\FKRPRWHXUHVWFRQVLGUFRPPHKRPRJQHVLODWWHLQWVLPXOWDQ
PHQWHWDYHFODPPHSURIRQGHXUVHVGLUHQWHVFRPSRVDQWHVGHWHOOHVRUWHTXHOJHmGYHORS
SHPHQWDO}GHOHQIDQWHVWLQIULHXUOJHUHORXFRUULJGHOHQIDQW
Encphalopathie fixe
'DQVFHFDVOHQFSKDORSDWKLHQYROXHSDV/HEERXOHQIDQWDXQUHWDUGPDLVSHXWSRWHQWLHO
OHPHQWIDLUHGHVSURJUV
/HV\QGURPHGHO;IUDJLOHOHV\QGURPHGH7XUQHUVRQWSDUH[HPSOHGRULJLQHFKURPRVRPLTXH

Dveloppement psychomoteur du nourrisson et de lenfant

53

/DQR[LHSULQDWDOHRXODPQLQJLWHVRQWGHVH[HPSOHVGHFDXVHDFTXLVH
Encphalopathie volutive
'DQV FH FDV OHQFSKDORSDWKLH YROXH HW VDJJUDYH SDU GJQUHVFHQFH RX DFFXPXODWLRQ GXQ
WR[LTXHDXQLYHDXFUEUDO/HGYHORSSHPHQWGHOHQIDQWVHUDOHQWLWVWDJQHYRLUHUJUHVVH
&HVWOHFDVSDUH[HPSOHGHVPDODGLHVQHXURPWDEROLTXHV

4.2.4.Retard

de dveloppement inhomogne

OLQYHUVHGXUHWDUGGHGYHORSSHPHQWKRPRJQHXQGYHORSSHPHQWSV\FKRPRWHXUHVWFRQVLGU
FRPPHWDQWLQKRPRJQHORUVTXHVHVFRPSRVDQWHVVRQWGLUHPPHQWDWWHLQWHV&HUWDLQVHQIDQWV
SUVHQWHQWXQUHWDUGGHGYHORSSHPHQWXQLTXHPHQWPRWHXURXLQWHOOHFWXHORXSV\FKRORJLTXH
Retard du dveloppement moteur isol
&HVWOHFDVGHVP\RSDWKLHVSDUH[HPSOHODP\RSDWKLHGH'XFKHQQHGHVSDUDO\VLHVFUEUDOHV
des neuropathies.
Troubles du langage
8QHDQRPDOLHGXGYHORSSHPHQWGXODQJDJHGRLWIDLUHUHFKHUFKHUHQSUHPLHUOLHXXQHVXUGLW
8QUHWDUGGHODQJDJHSHXWJDOHPHQWIDLUHYRTXHUXQWURXEOHGXVSHFWUHDXWLVWLTXH&I,WHP
,OVXUYLHQWJDOHPHQWHQFDVGHGIDXWGHVWLPXODWLRQPDMHXUGHODSDUWGHOHQYLURQQHPHQW
/HPXWLVPHSV\FKRJQHHVWUDUHHWSOXWWVHFRQGDLUHXQWUDXPDWLVPHSV\FKLTXH

4.2.5.Syndrome

autistique

&I,WHP

4.2.6.Bilan

paraclinique

/H ELODQ SDUDFOLQLTXH HVW DGDSW  OD FOLQLTXH GRQF DX[ OPHQWV VXVFLWV GDQV OD GPDUFKH
diagnostique.
(QFRUHXQHIRLVLOHVWLPSRUWDQWGHV\VWPDWLVHUVDGPDUFKHSRXUQHULHQRXEOLHU
*

5HFKHUFKHGHPDODGLHFKURPRVRPLTXHcaryotype haute rsolution.

5HFKHUFKHGDQRPDOLHJQWLTXH

* 5HFKHUFKH GH PDODGLH PWDEROLTXH GRVDJH GHV PDUTXHXUV DSSURSULV GDQV OH VDQJOHV
XULQHVOH/&5
*

5HFKHUFKHGDQRPDOLHPRUSKRORJLTXH
 IRM crbrale.
 5DGLRJUDSKLHV
 )RQGGLO

4.3.

Prise en charge
/DSULVHHQFKDUJHGRLWWUHODSOXVSUFRFHHWODSOXVFRPSOWHSRVVLEOH(OOHFRQFHUQHOHQIDQW
mais galement ses parents, sa famille.

335

53

Les troubles psychiatriques spcifiques de lenfant et ladolescent

4.3.1. Mdicale
*

6RLQVDGDSWVODSDWKRORJLH

6RLQVDPEXODWRLUHVKRVSLWDOLHUV

4.3.2.Psychologique/pdopsychiatrique
*

6RLQVDPEXODWRLUHVHQFHQWUHPGLFRSV\FKRORJLTXHRXFHQWUHPGLFRSV\FKRSGDJRJLTXH
FHQWUHGDFWLYLWWKUDSHXWLTXHWHPSVSDUWLHO

Soins hospitaliers, hospitalisation en temps plein de secteur ou hospitalisation de jour.

3ULVHHQFKDUJHSV\FKRORJLTXHGHVSDUHQWVGHODIUDWULH

4.3.3. Sociale
*

5HFRQQDLVVDQFH0'3+$/'SULVHHQFKDUJH

Scolaire :
 Auxiliaire de vie scolaire.
 6FRODULWDGDSWH,7(36(66$'
 3URMHWGDFFXHLOLQGLYLGXDOLV

5.
336

Troubles du sommeil chez lenfant

&I,WHP

6.

Troubles des apprentissages

6.1.

Gnralits
3RXUSOXVGHSUFLVLRQVFI&ROOJHGHVHQVHLJQDQWVGHSGLDWULH

6.2.

Trouble dficit de lattention avec ou sans hyperactivit

et ses consquences (cf. Item 66)

6.2.1. pidmiologie
*

7RXFKHUDLWGHVHQIDQWVHQJHVFRODLUH

JDURQVDWWHLQWVSRXUXQHOOH

&RPRUELGLWV IUTXHQWHV WURXEOH RSSRVLWLRQQHO DYHF SURYRFDWLRQ WURXEOH GH OKXPHXU

mG\V}G\VFDOFXOLHG\VRUWKRJUDSKLHG\VOH[LH

Dveloppement psychomoteur du nourrisson et de lenfant

6.2.2.Consquences

53

sur les apprentissages

%LHQYLGHPPHQWODSUVHQFHGXQWURXEOHGHODWWHQWLRQDYHFRXVDQVK\SHUDFWLYLWUHWHQWLWVXU
les apprentissages.
/LQDWWHQWLRQUHQGGLFLOHOHPDLQWLHQGXQHWFKHTXHFHVRLWOFRXWHGXQHOHRQODUDOLVDWLRQ
GXQH[HUFLFHOFROHRXORUVGHVGHYRLUV/HWHPSVGHWUDYDLOQFHVVDLUHSRXUODUDOLVDWLRQGXQ
exercice est donc allong, la mmorisation est galement impacte. Ces enfants sont frquem
PHQWHQVLWXDWLRQGFKHFVFRODLUHVLODSULVHHQFKDUJHTXLOHXUHVWSURSRVHHVWLQH[LVWDQWHRX
LQDGDSWH FH TXL SHXW IDYRULVHU OD VXUYHQXH GH FRPRUELGLWV FRPPH OH WURXEOH RSSRVLWLRQQHO
DYHFSURYRFDWLRQRXXQWURXEOHGHOKXPHXU

6.2.3.Prise

en charge

/DSULVHHQFKDUJHGRLWWUHODSOXVSUFRFHSRVVLEOHDQGHOLPLWHUODVRXUDQFHSV\FKLTXHGH
OHQIDQWHWGHVRQHQWRXUDJHDLQVLTXHOHVFRQVTXHQFHVVXUOHVDSSUHQWLVVDJHV
/DSULVHHQFKDUJHGHOHQIDQWHVWindividualise et globale.
Mdicamenteuse
8QWUDLWHPHQWSDUPWK\OSKQLGDWHHVWSURSRVORUVTXHOHQIDQWSUVHQWHXQ7'$+svreFHVW
GLUH HQWUDYDQW VHV DSSUHQWLVVDJHV VRFLDX[ HW VFRODLUHV HWRX TXLO SUVHQWH XQH VRXUDQFH
SV\FKLTXHLPSRUWDQWHGXIDLWGX7'$+
Psychothrapeutique
8QH WKUDSLH FRJQLWLYRFRPSRUWHPHQWDOH SHXW DLGHU OHQIDQW  DGRSWHU XQ FRPSRUWHPHQW SOXV
DGDSWPHWWUHHQSODFHGHVVWUDWJLHVSOXVHFDFHVGDQVOHVDSSUHQWLVVDJHVVFRODLUHVUHQIRUFHU
positivement ses acquis et ses comptences.
8QH SV\FKRWKUDSLH GH VRXWLHQ SHXW DLGHU OHQIDQW  JDUGHU XQH HVWLPH HW XQH FRQDQFH HQ
OXLPPHVDWLVIDLVDQWH
8QHSULVHHQFKDUJHHQJURXSHSHXWWUHSURSRVHJDOHPHQW
Scolaire
*

3URMHWSGDJRJLTXHDGDSW

Auxiliaire de vie scolaire.

Familiale
Mise en place de techniques ducatives adaptes.
Sociale
'HPDQGHVDXSUVGHOD0'3+
*

AVS.

ALD.

337

53

Les troubles psychiatriques spcifiques de lenfant et ladolescent

Rsum
%DVHGHWRXWH[DPHQGHOHQIDQWYDOXHUOYROXWLRQSK\VLTXHJOREDOHHWSV\FKLTXH
JUDQGHORLVSRXUOHGYHORSSHPHQWGLUHQFLDWLRQYDULDELOLWVXFFHVVLRQ
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*

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OLQWHUURJDWRLUHHWOH[DPHQSK\VLTXH

IDLUHOHVFRXUEHVGHFURLVVDQFHFRPSOWHUOHFDUQHWGHVDQW

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R
SHUVRQQHOIDLUHXQHDQDPQVHGWDLOOHGRQWXQDUEUHJQDORJLTXHGDWHUHWUHJDUGHUOHV
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 WLOLVHUOHVFKHOOHVGHGYHORSSHPHQWOHVTXRWLHQWVGHGYHORSSHPHQWHWOHVTXRWLHQWVGLQ
X
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338

Points clefs
* YDOXDWLRQJOREDOHSUFRFHUSWH
* 0RWULFLW JOREDOH HW QH VSKLQFWHUV DOLPHQWDWLRQ VRPPHLO ODQJDJH LQWHOOLJHQFH REVHUYDWLRQ GX FRPSRUWHPHQW
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* 6\QGURPHDXWLVWLTXH
* 3ULVHHQFKDUJHSUFRFHLQGLYLGXDOLVHHWJOREDOH

item 65

Troubles envahissants
du dveloppement
I. Introduction
II. Smiologie
III. YDOXDWLRQGLDJQRVWLTXH
IV. 3ULVHHQFKDUJH
V. /HSURQRVWLFHWOYROXWLRQ

Objectifs pdagogiques
* ,GHQWLHUOHVWURXEOHVHQYDKLVVDQWVGXGYHORSSHPHQWHWOHVSULQFLSHVGHOD
prise en charge.
* 6DYRLUGLDJQRVWLTXHUXQV\QGURPHDXWLVWLTXHDUJXPHQWHUODWWLWXGHWKUD
SHXWLTXHHWSODQLHUOHVXLYL

65

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

1.

Introduction

1.1.

Historique
/HV SUHPLUHV UIUHQFHV  GHV FRPSRUWHPHQWV DXWLVWLTXHV GDWHQW GX GEXW GX xxeVLFOH 
OSRTXH OHV WURXEOHV TXH QRXV QRPPRQV DXMRXUGKXL DXWLVPH RX WURXEOHV GX VSHFWUH DXWLV
WLTXH WDLHQW FRQVLGUV FRPPH GHV IRUPHV LQIDQWLOHV GH VFKL]RSKUQLH &H QHVW TXH GDQV OHV
DQQHVTXH/R.DQQHUSV\FKLDWUHDPULFDLQGRULJLQHDOOHPDQGHHW+DQV$VSHUJHUJDOH
PHQW SV\FKLDWUH DUPHQW FKDFXQ GH OHXU FW TXH FHUWDLQV SDWLHQWV QH VRQW GH IDLW SDV GHV
VFKL]RSKUQHVPDLVTXLOVVRXUHQWGXQHPDODGLHSDUW.DQQHUGFULWGHVHQIDQWVSUVHQWDQW
GHVFRPSRUWHPHQWVmDXWLVWHV}HWUSWVQHSDUODQWSDVHWQHFRPPXQLTXDQWSDV,ODSSHOOHFH
WDEOHDXFOLQLTXHDXWLVPHLQIDQWLOH+DQV$VSHUJHUTXDQWOXLHPSORLHOHPPHWHUPHSRXUOHV
SDWLHQWVTXLODGFULWHWTXLRQWXQHLQWHOOLJHQFHSULRULQRUPDOHPDLVGHVSDUWLFXODULWVGDQV
OD FRPPXQLFDWLRQ ,O SDUOH OXL GH mSV\FKRSDWKLH DXWLVWLTXH} &HV GHX[ GHVFULSWLRQV GHYLHQ
GURQWOHVGHX[IRUPHVGDXWLVPHGLWVmW\SLTXHV}ODXWLVPHLQIDQWLOHHWOHV\QGURPHG$VSHUJHU
WRXWHVOHVDXWUHVIRUPHVLQWHUPGLDLUHVWDQWTXDOLHVGmDXWLVPHVDW\SLTXHV}
'DQV OHV DQQHV  /RUQD :LQJ XQH SV\FKLDWUH GYHORSSHPHQWDOLVWH PRGOLVH OD WULDGH
DXWLVWLTXH FI LQIUD (OOH SUHQG HQ FRPSWH OKWURJQLW GHV SUVHQWDWLRQV HW SDUOH GV ORUV
de continuum autistique FHWWH QRWLRQ GH FRQWLQXXP GHYLHQGUD OH spectre autistique puis dans
les annes 1990 le trouble envahissant du dveloppement 7(' TXL FRPSUHQG OHV WURXEOHV GX
VSHFWUH DXWLVWLTXH HW OHV 7(' QRQ VSFLV $XMRXUGKXL OH WHUPH WURXEOH GX VSHFWUH DXWLVWLTXH
76$WHQGVXSSODQWHUODSSHOODWLRQ7('

340

1.2.

Terminologies et prvalences
/HVWURXEOHVHQYDKLVVDQWVGXGYHORSSHPHQW7('GVLJQHQWGHVDQRPDOLHVGXGYHORSSHPHQW
TXLDSSDUDLVVHQWGDQVOHQIDQFHHWTXLDOWUHQWOHGYHORSSHPHQWKDUPRQLHX[GHVIRQFWLRQVFRJQL
WLYHVLQWHUYHQQDQWGDQVODFRPPXQLFDWLRQHWODVRFLDOLVDWLRQ,OVDJLWGXQHFDWJRULHDVVH]ODUJH
FRPPXQHDX'60,9HWOD&,0TXLFRPSUHQGODXWLVPHLQIDQWLOHOHV\QGURPHG$VSHUJHUOHV
IRUPHVLQWHUPGLDLUHVDSSHOHVDXWLVPHDW\SLTXHHWOHVWURXEOHVHQYDKLVVDQWVGXGYHORSSHPHQW
QRQVSFLVPDLVJDOHPHQWGHVWURXEOHVGLWVGVLQWJUDWLIVFRPPHOHV\QGURPHGH5HWW'DQV
ODYHUVLRQUYLVHOH'60H[FOXWOHVWURXEOHVGVLQWJUDWLIVHWOHV\QGURPHGH5HWWDX[TXHOVRQ
FRQQDWXQHRULJLQHQHXURORJLTXHHWTXLGHYLHQQHQWGHVGLDJQRVWLFVPGLFDX[QRQSV\FKLDWULTXHV
/H7('SHXWWUHDVVRFLRXQRQXQUHWDUGPHQWDO
6DSUYDOHQFHWDLWHQSRXUOHVSRSXODWLRQVGHPRLQVGHDQVHQIDQWVSRXUGRQW
DYHFUHWDUGVPHQWDX[
/HVWURXEOHVGXVSHFWUHDXWLVWLTXH76$VRQWXQVRXVJURXSHGH7('
8QWURXEOHGXVSHFWUHDXWLVWLTXHSHXWVDFFRPSDJQHURXQRQGHUHWDUGPHQWDO
/DSUYDOHQFHGHV76$HVWGLFLOHYDOXHUHWHQFRQVWDQWPRXYHPHQWGXIDLWGHOYROXWLRQGHOD
QRVRJUDSKLHHWGHVFRQQDLVVDQFHVVFLHQWLTXHV(QODSUYDOHQFHGHVGLUHQWHVIRUPHV
cliniques se rpartissait comme suit :
*

DXWLVPHLQIDQWLOHSRXUDYHFGHUHWDUGPHQWDODVVRFL

V\QGURPHG$VSHUJHUSRXU

DXWUHVIRUPHVLQWHUPGLDLUHVSRXUHQIDQWVGHPRLQVGHDQV

Troubles envahissants du dveloppement

2.

Smiologie

2.1.

La triade diagnostique des troubles du spectre autistique (TSA)

65

/DXWLVPHHWOHVWURXEOHVGXVSHFWUHDXWLVWLTXH76$VRQWFDUDFWULVVSDUXQHSHUWXUEDWLRQGDQV

les trois domaines suivants :
*

Anomalie des interactions sociales rciproques UFLSURFLWVRFLDOH

Anomalies de la communicationYHUEDOHHWQRQYHUEDOH

Intrts restreints et comportement strotyps.

&HVDQRPDOLHVGRLYHQWH[LVWHUDYDQWOJHGHDQVHWSUVHQWHUXQFDUDFWUHHQYDKLVVDQWFHVW
GLUHSHUWXUEHUIRUWHPHQWOHIRQFWLRQQHPHQWGHOLQGLYLGX

2.1.1. Anomalies

de la communication et de la rciprocit sociale

2.1.1.1.La rciprocit sociale

&HVWORULJLQHXQWHUPHGHSV\FKRORJLHVRFLDOH,OGFULWOHVSURFHVVXVSDUOHVTXHOVGHX[LQGL
YLGXVLQWHUDJLVVHQWHWOHVVWUDWJLHVGHFRPPXQLFDWLRQTXLOVPHWWHQWHQXYUHSRXUHQWUHWHQLU
leurs changes.
/DUFLSURFLWVRFLDOHIDLWSDUWLHGHVFRPSWHQFHVVRFLDOHVHWFRQVLVWHVDYRLUUHSUHUOHVLQGLFHV
YHUEDX[HWQRQYHUEDX[TXLUHQVHLJQHQWVXUOHVLQWHQWLRQVGHODXWUHVDYRLULQWHUSUWHUFRUUHFWH
PHQWFHVLQGLFHVDSSRUWHUXQHUSRQVHDSSURSULHHWDYRLUHQYLHGLQWHUDJLUHWGFKDQJHUDYHF
cet autre individu.
/DUFLSURFLWVRFLDOHIDLWDSSHOGHVcomptences cognitives :
*

 QHapptence la socialisationTXLHVWODSUHPLUHFRQGLWLRQSRXUTXLO\DLWXQPDLQWLHQGH
8
la relation sociale.

/ attention conjointe RXDWWHQWLRQSDUWDJHSHUPHWGDWWLUHUODWWHQWLRQGHOLQWHUORFXWHXUVXU

XQREMHWH[WULHXUODLGHGFKDQJHVGHUHJDUGVHWLQYHUVHPHQWGHFRPSUHQGUHORUVTXHOLQWHU
ORFXWHXUYHXWDWWLUHUODWWHQWLRQVXUTXHOTXHFKRVH/DWWHQWLRQFRQMRLQWHVHPDQLIHVWHWUVWW
chez le nourrisson SDUOaccroche du regard, les sourires rponse, les expressions du visage en
USRQVHXQHLQWHUDFWLRQDYHFODGXOWHSXLVSOXVWDUGSDUOHVJD]RXLOOLVOLPLWDWLRQOHVPDQL
IHVWDWLRQVPRWULFHVGHOenthousiasme lorsquon sadresse lui. Chez le petit enfant il se mani
IHVWHSDUOXVDJHVSRQWDQGHgestes instrumentaux : faire oui ou non de la tte, dire coucou}
ou au revoir }DYHFODPDLQOHYHUOHVEUDVSRXUUFODPHUOHSRUWDJH8QJHVWHLQVWUXPHQWDO
WUVLPSRUWDQWHVWOHpointagePRQWUHUGXGRLJW,OHVWHPEOPDWLTXHGHODWWHQWLRQFRQMRLQWH
HWDSSDUDWWUVWW,OH[LVWHGHX[W\SHVGHSRLQWDJHORUVTXXQHQIDQWPRQWUHXQREMHWSRXU
TXRQ OH OXL GRQQH RX XQ OLHX R LO YHXW VH UHQGUH RQ SDUOH GH pointage instrumental (avant
6 mois/RUVTXHOHSRLQWDJHVDVVRFLHOH[SUHVVLRQGXQHPRWLRQSRXUODSDUWDJHUFRPPH
XQHQIDQWTXLPRQWUHDYHFHQWKRXVLDVPHXQFKLHQRXXQFDPLRQGHSRPSLHURQSDUOHGHSRLQ
tage protodclaratif. Le pointage protodclaratifTXHORQDSSHOOHDXVVLSRLQWDJHFRPPXQLFDWLI
doit apparatre avant 14 mois.

Le partage du plaisir, par des changes de regard et par la prsence de mimiques expressives
HWOHVRXULUHUSRQVHDGDSWODFLUFRQVWDQFHRXXQcri de surprise peuvent faire cho avec
ODWWHQWLRQFRQMRLQWHHWVRQWGHVVLJQHVGHUFLSURFLWVRFLDOHTXLOIDXWFKHUFKHU

La reconnaissance des motions ou (empathie cognitive &HVW OD FDSDFLW  GFRGHU OHV
PRWLRQVSULPDLUHVHWFRPSOH[HVGHOLQWHUORFXWHXUSDUWLUGHVHVH[SUHVVLRQVIDFLDOHVGHV
indices dans la tonalit de sa voix ou de sa posture corporelle.

341

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

La thorie de lespritFHWWHFRPSWHQFHSHUPHWXQLQGLYLGXGDWWULEXHUXQWDWPHQWDOLQWHQ

WLRQFUR\DQFHFRQQDLVVDQFHXQHDXWUHSHUVRQQHHWGHFRQFHYRLUTXHFHWWDWPHQWDOSHXW
WUHGLUHQWGXVLHQ/DWKRULHGHOHVSULWSHUPHWGHSODQLHUSOXVHFDFHPHQWOHVLQWHUDF
tions sociales.

4XDQGLO\DGHVDQRPDOLHVGDWWHQWLRQFRQMRLQWHRQGFULWDORUVXQQRXUULVVRQWURSFDOPHSRXYDQW
UHVWHUVHXOGHVKHXUHVJD]RXLOODQWSHXRXSDV3OXVWDUGRQGFULUDXQHQIDQWVRXYHQWVULHX[HW
LPSQWUDEOHRXDORUVDYHFXQHVHXOHPLPLTXHHQWRXWHVFLUFRQVWDQFHVSOXWWVROLWDLUHLQGL
UHQWDX[DXWUHVHQIDQWVRXOHVREVHUYDQWGHORLQVDQVFKHUFKHULQWHUDJLUDYHFHX[
/HV DQRPDOLHV GH OHPSDWKLH HW GH OD WKRULH GH OHVSULW HQWUDQHQW FKH] OHV DXWLVWHV XQ dfaut
dajustement et une maladresse socialeFHVWGLUHXQHGLFXOWXWLOLVHUGHVFRGHVHWFRQYHQ
WLRQVVRFLDOHVGHIDRQDGDSWHHWSHUWLQHQWH

2.1.1.2.Troubles du langage verbal et non verbal

Anomalie de lapparition du langage :
*

RetardGDSSDULWLRQGXODQJDJHTXLSHXWDOOHUMXVTXOabsence GHODQJDJHYHUEDOH

/DSSDULWLRQWDUGLYHGXQODQJDJHGHPEOHFRPSOH[HHVWFODVVLTXHPHQWGFULWHPDLVFHQHVWSDV
XQHFRQVWDQWHHWVRQDEVHQFHQOLPLQHSDVXQWURXEOHGXVSHFWUHDXWLVWLTXH
$QRPDOLHVGHOaspect gnral du langage :

342

 QHprosodie anormaleJXLQGHRXPRQRFRUGHRXEL]DUUHDYHFGHVSDXVHVLQKDELWXHOOHVGDQV
8
ODSKUDVHXQSKUDVPFDQLTXHRXPRGXOGHPDQLUHLQKDELWXHOOHXQSHXFRPPHVLOLQGL
YLGXDYDLWXQDFFHQWGXQHODQJXHWUDQJUH

 QHtonalit de voix inhabituelle ou dont les modulations ne sont pas adaptes au sens de la
8
phrase.

Anomalies du contenu :
*

 LOHODQJDJHHVWWUVSHXGYHORSSRQSHXWREVHUYHUGHVYRFDOLVHVGHVFULVGHVFKRODOLHV
6
des strotypies verbales, FHVWGLUHGHVUSWLWLRQVGHERXWGHSKUDVHVVDQVLQWHQWLRQGHQ
partager le sens.

 Qlangage idiosyncrasique SHXWVHUYOHUODSSDULWLRQGXODQJDJH&HODFRQVLVWHLQYHQWHU

8
XQQRPRWSRXUGVLJQHUXQREMHWHWGHOXWLOLVHUGHIDRQVWDEOH&HQRPRWDXQUDSSRUWDYHF
OHVSUHPLHUVFRQWH[WHVRXOREMHWDGXWUHGVLJQHWQDSDVGHUDSSRUWQLDYHFVDIRQFWLRQRX
VDIRUPHFHQHVWSDVXQRQRPDWRSHQLXQHGIRUPDWLRQGXPRWLQLWLDODVVLPLODEOHDXmSDUO
EE},OVDJLWGXQHDQRPDOLH

/ inversion pronominale HVW OXQH GHV DQRPDOLHV OHV SOXV FDUDFWULVWLTXHV /LQGLYLGX DWWHLQW
UHPSODFHOHmMH}SDUmWX}RXmLO}RXHQFRUHVRQSUQRPSDUH[HPSOHODTXHVWLRQWXYHX[
XQYHUUHGHDXLOYDUSRQGUHmQRQ78QHYHX[SDVXQYHUUHGHDX}RXLOGHPDQGHUDVSRQWD
QPHQWm%DUQDEYHXWXQYHUUHGHDX}/LQYHUVLRQSURQRPLQDOHSHXWDSSDUDWUHFKH]OHQIDQW
VDQVWURXEOHPDLVLOGLVSDUDWWUVUDSLGHPHQWDYHFODFTXLVLWLRQGXSURQRPSHUVRQQHOmMH}

 XDQGOHODQJDJHHVWSOXVODERULOH[LVWHOHQFRUHGHVDQRPDOLHV/Hchoix des mots peuvent

4
tre atypiquesRQSHXWREVHUYHUXQSDUOHUW\SDYHFXQODQJDJHTXLSHXWDSSDUDWUHFRPPH
JXLQGRXLQDGDSWOJHSRXUOHVHQIDQWVRQSDUOHGHODQJDJHDGXOWRPRUSKHRXGVXHW
GXQHDXWUHSRTXH2QSHXWDXVVLREVHUYHUXQlangage strotyp QHSDVFRQIRQGUHDYHF
GHVVWURW\SLHVYHUEDOHVTXLHVWOHWHUPHTXLGFULWXQODQJDJHGVXHWRXGXQHDXWUHSRTXH
DYHF GHV H[SUHVVLRQV HW GHV ORFXWLRQV FRPSOH[HV TXL UHYLHQQHQW FRPPH mHHFWLYHPHQW}
mFHVWGLUH}GHIDRQLQDGDSWH

Anomalies de la comprhension :
2Q QRWH FKH] FHV SDWLHQWV GHV DQRPDOLHV FDUDFWULVWLTXHV GH OD FRPSUKHQVLRQ TXL UHQGHQW OD
FRPPXQLFDWLRQHQFRUHSOXVGLFLOH,OVDJLWGXQdficit daccs limplicite&HVWODFFVWRXW
FHTXLHVWVRXVHQWHQGXHWQRQOLWWUDOHWGRQWODFRQYHUVDWLRQRUGLQDLUHHVWOLWWUDOHPHQWWUXH

Troubles envahissants du dveloppement

 Q accs limit aux informations et au sens contenus dans la tonalit de la voix ou dans le
8
phras.

 QHnon-comprhension des informations contenues dans les expressions faciales et corpo

8
relles qui accompagnent le discours.

Des troubles de la pragmatique du langage TXL UHVWUHLJQHQW ODFFV DX VHFRQG GHJU DX
ODQJDJHLPDJHWOLPSOLFLWH/XQHGHVPDQLIHVWDWLRQVOHVSOXVFODVVLTXHVHVWOLQFRPSUKHQ
VLRQGHVSURYHUEHVHWGHVH[SUHVVLRQVTXLVRQWSULVHVDXSLHGGHODOHWWUHHWGRQWODSHUVRQQH
DWWHLQWHQHFRPSUHQGSDVOHVHQVLPDJ/DEVHQFHGHSUDJPDWLVPHGXODQJDJHSHXWVDYUHU
WUVLQYDOLGDQW

2.1.2. Intrts

65

restreints et comportements strotyps

Les strotypies VRQWGHVPRXYHPHQWVUSWLWLIVGXWURQFGHODWWHGXEXVWHRXGHVPHPEUHV

VXSULHXUV EDODQFHPHQWV GX WURQF RX GH OD WWH EDWWHPHQWV RX HQURXOHPHQW GHV PDLQV GHV
IURWWHPHQWVGHVJHQRX[SRLJQHWVPDLQVHWF3DUIRLVOHVVWURW\SLHVSHXYHQWRFFDVLRQQHUGHV
OVLRQVJUDYHVORUVTXHOHSDWLHQWVHPRUGRXVHIUDSSHRQSDUOHDORUVGautomutilation. Les stro
W\SLHVSHXYHQWWUHXQPR\HQGHOXWWHUFRQWUHODQ[LWH[SULPHUXQVHQWLPHQWLQWHQVHFRPPHOD
IUXVWUDWLRQRXODFROUHPDLVDXVVLODVDWLVIDFWLRQLQWHQVHRXHQFRUHXQPR\HQGHVHVWLPXOHU
/D PDUFKH VXU OD SRLQWH GHV SLHGV SHXW WUH FRPSWH SDUPL OHV VWURW\SLHV PDLV HOOH SHXW
JDOHPHQWVLJQHUGHVWURXEOHVGHODSRVWXUHFILQIUD
Les autostimulations FRPPHUHJDUGHUXQHFHOOHVHFRXHGHYDQWVRLIDLUHWRXUQHUXQHURXHHWORE
server, secouer la tte, consistent jouer avec le systme sensoriel et le stimuler. Les stimu
lations peuvent tre :
*

VisuellesMRXHUDYHFXQHFHOOHXQHVRXUFHOXPLQHXVHGHVREMHWVFRORUV

AuditiveSRVHUOHVPDLQVVXUOHVRUHLOOHVSRXUFRXWHUOHVYDULDWLRQVGHVEUXLWVDPELDQWVMRXHU
DYHFXQEWRQGHSOXLHIURWWHUWDSHUXQHVXUIDFHHWFRXWHUHWF

TactilesVHSDOSHUVHIURWWHUFDUHVVHURXIURWWHUXQREMHWODWH[WXUHSDUWLFXOLUH

Olfactif VHQWLUUHQLHU

Vestibulaire DYHFGHVEDODQFHPHQWVRXHQWRXUQDQW

Les intrts restreints VRQWXQHQVHPEOHUHVWUHLQWGDFWLYLWVSHXODERUVFDUDFWUHHQYDKLV

VDQWVHWVDQVEXWGHVRFLDOLVDWLRQ2QQRWHGDQVOHVLQWUWVUHVWUHLQWVOHVDXWRVWLPXODWLRQVOHIDLW
GHUDQJHUHWGHPSLOHUGHIDRQFRPSXOVLYH
3DUIRLV OHV LQWUWV UHVWUHLQWV VRQW SOXV ODERUV PDLV FRQFHUQDQW XQ GRPDLQH UHVWUHLQW HW VRQW
WUV HQYDKLVVDQWV RFFXSDQW WRXW OH FKDPS SV\FKLTXH GH OLQGLYLGX TXL HQ D XQH FRQQDLVVDQFH
HQF\FORSGLTXHRQSDUOHDORUVGLQWUWVSFLTXH
Les intrts spcifiques VRQWWUVYDULVGXQLQGLYLGXODXWUHFRPPHOHVGUDSHDX[OHVS\OQHV
OHV WUDLQV OHV G\QDVWLHV J\SWLHQQHV OHV GLQRVDXUHV ODVWURQRPLH WHO RX WHO W\SH GH PXVLTXH
FODVVLTXHRXFRQWHPSRUDLQHHWFPDLVSRXUXQPPHLQGLYLGXLOVQHFKDQJHQWTXHWUVSHX,OV
VRQWGLUHQFLHUGXQHPDURWWHRXGXQKREE\SDUOHXUFDUDFWUHHQYDKLVVDQWPRQROLWKLTXHHW
ODEVHQFHGHSDUWDJHGXSODLVLU2QREVHUYHDXVVLOLPSRVVLELOLWVDGDSWHUVRQLQWHUORFXWHXU
TXDQGFHGHUQLHUQHVWSDVLQWUHVVCe qui compte ce sont donc le caractre strotyp (rptitif)
des patterns et le caractre restreint et envahissant.

2.2.

Les formes cliniques

/DXWLVPHHVWXQWURXEOHDX[SUVHQWDWLRQVWUVKWURJQHVHWTXLSHXWWUHDVVRFLXQUHWDUG
PHQWDOFHTXLHQPRGLHODIRUPHFIFLGHVVRXV/HVIRUPHVFOLQLTXHVSHXYHQWDOOHUGHODSUVHQ
WDWLRQFODVVLTXHGHOLQGLYLGXVDQVDXFXQFRQWDFWYLVXHORXYHUEDODYHFGHVVWURW\SLHVMXVTXDX[
IRUPHVIUXVWHVDYHFXQODQJDJHSULRULQRUPDOHWIRQFWLRQQHOHWPDLVGHVGLFXOWVPDMHXUHVGH

343

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

VRFLDOLVDWLRQ/HGLDJQRVWLFSRXUFHVSDWLHQWVHVWSRVSDUIRLVWUVWDUGOJHDGXOWHDSUVGH
ORQJXHVSULRGHVGLVROHPHQWHWGHUUDQFHGLDJQRVWLTXH
3RXUGFULUHOHVGLUHQWHVIRUPHVFOLQLTXHVLOIDXWWHQLUFRPSWHGHGHX[D[HVYDOXHUOHVFDSD
FLWVGHFRPPXQLFDWLRQHWGHUFLSURFLWVRFLDOHGHOLQGLYLGXSXLVOHPHWWUHHQSHUVSHFWLYHDYHF
OJHGYHORSSHPHQWDOSRXUVDYRLUGDQVFKDTXHGLPHQVLRQVLOVDJLWGXQWURXEOHVSFLTXHRX
GXQHDQRPDOLHTXLHVWIRQFWLRQGXUHWDUG
(Q UDOLW OHV IRUPHV LQWHUPGLDLUHV VRQW OHV SOXV IUTXHQWHV LO H[LVWH GRQF XQH PXOWLWXGH GH
SUVHQWDWLRQVFOLQLTXHV(QYRLFLOHVSOXVFODVVLTXHV
*

/ autisme de Kanner ou autisme infantile HVW OD IRUPH GFULWH SDU /R .DQQHU GDQV OHV
DQQHV,OVDJLWGXWDEOHDXFODVVLTXHGHV\QGURPHDXWLVWLTXHVYUHDYHFDWWHLQWHPDMHXU
GHODFRPPXQLFDWLRQHWGHODUHODWLRQLQWHUSHUVRQQHOOHOH[LVWHQFHGHVWURW\SLHVLPSRUWDQWHV
HWHQYDKLVVDQWHVDVVRFLHVXQUHWDUGJOREDOGHVDFTXLVLWLRQV

Le syndrome dAsperger est la forme dcrite par Hans Asperger qui dcrit un enfant maladroit,
TXL SUVHQWH GHV GLFXOWV  VH VRFLDOLVHU PDLV WUV LQWHOOLJHQW TXL VH SUVHQWH FRPPH XQ
mSHWLW SURIHVVHXU} 'DQV OHV FULWUHV GLDJQRVWLTXHV GH FH V\QGURPH RQ UHWURXYH OHV DOWUD
WLRQVGHODUFLSURFLWVRFLDOHGHVWURXEOHVGHODFRPPXQLFDWLRQYHUEDOHHWQRQYHUEDOHHWGHV
LQWUWVVSFLTXHVFRPPHGDQVWRXVOHV76$VDQVUHWDUGGHODQJDJHQLGHUHWDUGFRJQLWLI
RQUHWURXYHHQRXWUHXQHPDODGUHVVHHWGHVWURXEOHVSUD[LTXHV/HODQJDJHHVWODERUYRLUH
PPHWUVULFKHLOH[LVWHGHVDQRPDOLHVGHODSURVRGLHHWGHODJHVWXHOOH'DQVOHVQRXYHOOHV
FODVVLFDWLRQVYHQLULOHVWFODVVGDQVOHV76$VDQVUHWDUG

/ autisme Hight Functionning RXDXWLVPHGHKDXWQLYHDXFRPPHOHV\QGURPHG$VSHUJHU

GFULWXQWDEOHDXDVVRFLDQWODWULDGHGMYRTXHHWXQQLYHDXFRJQLWLIQRUPDORXOHY&H
WDEOHDXVHGLVWLQJXHGXSUFGHQWSDUXQUHWDUGGHODQJDJHHWXQHDWWHLQWHSOXVLPSRUWDQWHGH
ODFRPPXQLFDWLRQYHUEDOH'DQVOHVQRXYHOOHVQRPHQFODWXUHVQRUGDPULFDLQHVFHWDEOHDXIDLW
galement partie des TSA sans retard.

344

2.3.

Comorbidits frquentes
*

Les retards globaux de dveloppement ou retard mental. Le retard mental peut aggraver les
manifestations autistiques et rendre la prise en charge complique. Quand elles sont conco
PLWDQWHVLOHVWGLFLOHGHGWHUPLQHUOHUOHSURSUHGHFKDFXQGHVWURXEOHVGHVHQIDQWV
prsentant un autisme infantile prsentent galement un retard de dveloppement.

Les symptmes obsessionnels compulsifs et les tics chroniques3UVHQWVGDQVGHVFDV

LQGSHQGDPPHQWGHOH[LVWHQFHGHWRXWHDXWUHFRPRUELGLWFRPPHOHUHWDUGRXOSLOHSVLHRQ
UHWURXYHSOXVYRORQWLHUVFHVV\PSWPHVDVVRFLVGHVWURXEOHVDQ[LHX[

Les troubles anxieuxeFRPRUELGLWODSOXVIUTXHQWH2QUHWURXYHGDQVOHVWURXEOHVDQ[LHX[

GHVSKRELHVVSFLTXHVFKH]GHVSDWLHQWVXQHSKRELHRXXQHDQ[LWVRFLDOHGDQV
GHVFDVHWXQHDQ[LWJQUDOLVHGDQV

Les symptmes anxio dpressifs3UVHQWVGDQVGHVFDVHWSHXYHQWVH[SOLTXHUSDUOHV

GLFXOWVJQUHVSDUOHKDQGLFDSVRFLDO

/hyperactivit et des symptmes de dficit attentionnel3HXYHQWVHUHWURXYHUDVVRFLVXQ

WDEOHDXGDXWLVPH

Les troubles du langage(QSULQFLSHOH[LVWHQFHGXQWURXEOHQHXURGYHORSSHPHQWDOH[FOXW

SDUGQLWLRQOHGLDJQRVWLFGHG\VSKDVLH&HSHQGDQWLOSHXWH[LVWHUXQHDXWKHQWLTXHDWWHLQWH
VSFLTXH GX ODQJDJH DYHF SRXU RULJLQH GHV DQRPDOLHV GH OD SHUFHSWLRQ RX GH OHQFRGDJH
LQGSHQGDPPHQWGHVWURXEOHVGHODFRPPXQLFDWLRQHWGHUFLSURFLWVRFLDOHTXHOOHVSHXYHQW
nanmoins aggraver.

Les anomalies du dveloppement psychomoteur G\VSUD[LHG\VJUDSKLHSUREOPHGHSRVWXUH

GHWRQXVPXVFXODLUHHWGHODWUDOLVDWLRQDLQVLTXHGHV troubles neurovisuels. Il convient de les
GSLVWHUGHYDQWGHVGLFXOWVGDSSUHQWLVVDJHRXXQHPDOKDELOHW

Troubles envahissants du dveloppement

65

/ pilepsie HVWXQHFRPRUELGLWIUTXHQWHHWJUDYHTXLOIDXWVDYRLUGSLVWHUHWWUDLWHU(QYLURQV
GHVSHUVRQQHVDYHF7('SUVHQWHQWXQHSLOHSVLH&HULVTXHHVWHQFRUHSOXVOHY
FKH]OHVSHUVRQQHVSUVHQWDQWXQUHWDUGPHQWDODVVRFL

pour en savoir plus

Neuroscience et recherche. De ltiologie aux hypothses physiopathologiques

/WLRORJLHGHVWURXEOHVGXVSHFWUHDXWLVWLTXHQHVWSDVOXFLGH-XVTXHGDQVOHVDQQHVOHVK\SRWKVHVFRQFHU
QDQW OD mIURLGHXU} GH OHQYLURQQHPHQW DHFWLI WDLHQW SUSRQGUDQWHV &HSHQGDQW OHV GLUHQWHV GFRXYHUWHV GH
ODUHFKHUFKHRQWPLVHQH[HUJXHGHIDRQIRUPHOOHOHUOHLPSRUWDQWGHVIDFWHXUVJQWLTXHVGVOHVDQQHV
/LPSRUWDQFHGHFHUOHUHVWHVXMHWUHODWLYHFRQWURYHUVHHWOHVWDX[GKULWDELOLWVHORQOHVWXGHVHWOHVGLUHQWHV
PWKRGRORJLHVSHXWYDULHUHQWUHHWPDLVFHVGRQQHVRQWRXYHUWODYRLHWRXWXQFKDPSGHUHFKHUFKH/HV
WXGHVGHJQWLTXHPROFXODLUHGHELRORJLHFHOOXODLUHGH[SORUDWLRQIRQFWLRQQHOOHHWGLPDJHULHRQWHQVXLWHRULHQW
YHUVSOXVLHXUVK\SRWKVHVSRVVLEOHV

Les anomalies gntiques transmission mendlienne

'HVPLFURGOWLRQVHWGHVPXWDWLRQVSRQFWXHOOHVRQWWGPRQWUHVGDQVOHVIRUPHVIDPLOLDOHVGDXWLVPH0DLVTXLO
VDJLVVHGHQRPXWDWLRQVRXGDQRPDOLHVWUDQVPLVHVOHQVHPEOHGHFHVPXWDWLRQVQH[SOLTXHTXXQTXDUWHQYLURQ
des cas.
(QIDLW les facteurs gntiques additifsFHVWGLUHXQHDFFXPXODWLRQGHSHWLWHVPXWDWLRQVDYHFGHVIRQFWLRQVGL
UHQWHVVHPEOHQWH[SOLTXHUOHPLHX[OH[SUHVVLRQGXWURXEOH

Interaction gne-environnement

/HVWXGHVGSLGPLRORJLHHWGHJQWLTXHGPRQWUHQWTXHGHODYDULDQFHSKQRW\SLTXHHVWOLHGHVFDXVHV
JQWLTXHVLOH[LVWHGRQFGHVIDFWHXUVHQYLURQQHPHQWDX[TXLLQWHUYLHQQHQWGDQVOH[SUHVVLRQGXWURXEOH/HVIDFWHXUV
JQWLTXHVHWHQYLURQQHPHQWDX[SHXYHQWWRXWIDLWLQWHUDJLUHQWUHHX[FHVWOHGRPDLQHUFHQWGHOSLJQWLTXH
PRGLFDWLRQGHODUJXODWLRQGHVJQHVVDQVPRGLFDWLRQGHODVTXHQFHG$'1

Les tudes dimagerie et les anomalies structurelles du cerveau

'HVDQRPDOLHVPRUSKRORJLTXHVRQWWPLVHVHQYLGHQFHVSDUOHVSUHPLUHVWXGHVGLPDJHULH,OVDJLWGHGLUHQFHV
GXYROXPHJOREDOHWGHFHUWDLQHV]RQHVFRPPHOHJ\UXVIXVLIRUPHRXODP\JGDOHGHVGLUHQFHVGDQVOSDLVVHXU
GXFRUWH[HWGHODVXEVWDQFHEODQFKH/LPDJHULHIRQFWLRQQHOOHDPLVHQYLGHQFHGHVDW\SLFLWVGDQVODFWLYDWLRQGHV
UVHDX[HQWUHOHFRUWH[SUIURQWDOODP\JGDOHOHVDLUHVWHPSRUDOHVHWOHJ\UXVIXVLIRUPH/WXGHGHVWUDMHFWRLUHVGH
EUHDTXDQWHOOHREMHFWLYGHVDQRPDOLHVGHFRQQH[LRQDXVHLQGHODVXEVWDQFHEODQFKHGDQVOHVUJLRQVLPSOLTXHV
entre autres dans la fonction sociale.

Les anomalies de la synapse

'HVGRQQHVLVVXHVGHVWXGHVGHELRORJLHPROFXODLUHVRQWSRLQWGHVDQRPDOLHVGHVFDVFDGHVSURWLTXHVLPSOLTXHV
GDQVODFRQVWLWXWLRQODVWDELOLVDWLRQHWODSODVWLFLWGHODV\QDSVH'HWHOOHVDQRPDOLHVRQWXQLPSDFWGLUHFWVXUOHV
UVHDX[GHFRQQH[LRQODUFKLWHFWXUHHWODIRQFWLRQGHFRQGXFWLRQ

Les anomalies de la perception sensorielle et de lintgration

* La perception auditiveRQQRWHFKH]OHVSDWLHQWVSUVHQWDQWXQ76$XQHK\SHUVHQVLELOLWFHUWDLQVEUXLWVSDUIRLV
QVRXLQDXGLEOHSRXUOHVDXWUHVFHWWHK\SHUVHQVLELOLWSHXWPPHVDYUHUGRXORXUHXVHDXSRLQWGHGFOHQFKHUGHV
FRPSRUWHPHQWVGDXWRPXWLODWLRQ'DXWUHVSDWLHQWVGFULYHQWXQHLQFDSDFLWDWWQXHUOHEUXLWDPELDQWHWQHSDV
SRXYRLUIRFDOLVHUODWWHQWLRQVXUXQHEUXLWFLEOHGDQVXQHQYLURQQHPHQWEUX\DQW/K\SHUVHQVLELOLWSHXWJDOHPHQW
GRQQHUOLHXGHVDXWRVWLPXODWLRQVDXGLWLYHV
* Le toucher XQHGVDJUDEOHK\SHUVHQVLELOLWDXWRXFKHUSLFULWLTXHHVWFODVVLTXHPHQWGFULWHDXQLYHDXGHODWWHHW
du tronc. Ce qui, en pratique, peut compliquer les gestes du quotidien comme supporter un vtement, se faire couper
OHVFKHYHX[RXVHFRLHUFRQWUDULRXQHUVLVWDQFHODGRXOHXUDWGFULWHFKH]FHUWDLQVDXWLVWHV
* La perception visuelleOHVFRPSRUWHPHQWVYLVXHOVDW\SLTXHVSUVHQWVGDQVOHV76$VRQWQRPEUHX[YLWHPHQW
GXUHJDUGK\SHU[LWGXUHJDUGDXWRVWLPXODQWVDYHFGHVVRXUFHVOXPLQHXVHVRXGHVIRUPHVJRPWULTXHV
K\SHUVHQVLELOLWFHUWDLQHVOXPLUHV/DUHFKHUFKHHVWGDQVFHGRPDLQHSOXVIRXUQLHPDLVOHVGRQQHVVRQW
WUVGLVSDUDWHVHWSDUIRLVFRQWUDGLFWRLUHV,OVHSRXUUDLWDXQDOTXHOHVDQRPDOLHVVRLHQWDXQLYHDXGHOintgration
de linformation visuelle.
3DUDOOOHPHQW DX[ DQRPDOLHV VHQVRULHOOHV OHV GRQQHV WHQGHQW  GFULUH FKH] FHV SDWLHQWV XQ GFLW GX WUDLWHPHQW
PXOWLVHQVRULHO

345

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

3.

valuation diagnostique

3.1.

Diagnostics positifs
/HGLDJQRVWLFUHSRVHWRXWGDERUGVXUXQHREVHUYDWLRQFOLQLTXHHWVXUOYDOXDWLRQGHODTXDOLW
GHODFRPPXQLFDWLRQHWGHODVRFLDOLVDWLRQGHOH[LVWHQFHGHVWURW\SLHVRXGLQWUWVUHVWUHLQWV
HW OD PLVH HQ SHUVSHFWLYH DYHF XQ QLYHDX GYHORSSHPHQWDO &HSHQGDQW OHV RXWLOV GYDOXDWLRQ
SHUPHWWHQWGHFRQUPHUOHGLDJQRVWLFGDQVOHVFDVOHVSOXVW\SLTXHVHWDSSRUWHUXQFODLUDJHGDQV
OHVVLWXDWLRQVRXOHGLDJQRVWLFVHPEOHPRLQVYLGHQW
Les chelles les plus couramment utilises sont :
*

ADI-R 'LDJQRVWLF ,QWHUYLHZ5HYLVHG TXHVWLRQQDLUH VRXV IRUPH GHQWUHWLHQ VWUXFWXU TXL
SRUWHVXUOHVPRGDOLWVUHODWLRQQHOOHVHWFRPSRUWHPHQWDOHVGDQVOHQIDQFH,OGRLWVHIDLUHDYHF
OHVSHUVRQQHVTXLOYHQWRXRQWOHYOHQIDQWHWTXLOHFWRLHQWTXRWLGLHQQHPHQW

ADOS ($XWLVP'LDJQRVWLF2EVHUYDWLRQ6FKHGXOHHQWUHWLHQVHPLVWUXFWXUTXLVHSDVVHDYHF

OHSDWLHQWHWTXLFRQVLVWHOXLIDLUHUDOLVHUXQFHUWDLQQRPEUHGHWFKHVFRQVWUXFWLRQGHVFULS
WLRQQDUUDWLRQMHX[IDLUHVHPEODQWHWREVHUYHUODTXDOLWGHVUSRQVHVHWGHVLQWHUDFWLRQV
sociales rciproques.

PEP-R3V\FKR(GXFDWLRQDO 3UROH5HYLVHG HW CARS&KLOGKRRG $XWLVP 5DWLQJ 6FDOH FH
VRQWGHVHQWUHYXHVVHPLVWUXFWXUHVDGDSWHVDX[WRXWSHWLWVHWTXLYDOXHQWGHVGLUHQWV
domaines qui peuvent tre atteints (relations sociales, adaptation au changement, communi
FDWLRQYHUEDOHHWQRQYHUEDOHXWLOLVDWLRQGXFRUSVGHODXWUHXWLOLVDWLRQGHVREMHWVLQYHVWLVVH
ments sensoriels et des domaines plus gnraux comme imitation, rponses motionnelles,
SHXUHWDQ[LWQLYHDXGDFWLYLW

/ FKHOOHGHVinelandFKHOOHGYDOXDWLRQGXFRPSRUWHPHQWVRFLRDGDSWDWLIHVWXQTXHVWLRQ
QDLUHDGPLQLVWUDX[SDUHQWVTXLYDOXHOHGYHORSSHPHQWGHOHQIDQWVXUGHVDSWLWXGHVHWGHV
FRPSWHQFHVTXLSHXYHQWWUHDWWHLQWHVGDQVOHV76$PDLVHOOHQHVWSDVVSFLTXHODXWLVPH

346

3.2.

Comment liminer les diagnostics diffrentiels

8QHDWWHLQWHVHQVRULHOOHWURXEOHGHODYLVLRQGHODXGLWLRQGRLWWUHOLPLQHV\VWPDWLTXHPHQW
DYDQWGHSRVHUXQGLDJQRVWLFGH7('RXGH76$
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DW\SLTXHGHVDQRPDOLHVPRUSKRORJLTXHVXQHUJUHVVLRQGHVFRPSWHQFHVFRJQLWLYHV,OFRQYLHQW
DORUVGHFRPSOWHUSDUGHVELODQVUHFKHUFKDQWGHVPDODGLHVPWDEROLTXHVQHXURGJQUDWLYHV
XQH FDXVH WR[LTXH 8QH FRQVXOWDWLRQ JQWLTXH SHXW FRPSOWHU OH ELODQ GHYDQW GHV DW\SLFLWV
morphologiques.
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UFLSURFLW VRFLDOH HW XQ ERQ QLYHDX GH FRPPXQLFDWLRQ QRQ YHUEDOH RX GXQH SHUWH GH FRQWDFW
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WLRQGHWURXEOHGHODVRFLDOLVDWLRQHVWWDUGLYH

3.3.

Diagnostics diffrentiels
/HFDUDFWUHSDUWLHORXWUVDW\SLTXHGHODV\PSWRPDWRORJLHOH[LVWHQFHGXQHUJUHVVLRQFRJQLWLYH
PDOJUXQHUGXFDWLRQELHQFRQGXLWHXQHPRUSKRORJLHDW\SLTXHGRLYHQWHQWUDQHUODUHFKHUFKH
GXQHFDXVHPGLFDOHQRQSV\FKLDWULTXH

Troubles envahissants du dveloppement

3.3.1. Pendant

65

lenfance

La surdit congnitale ou dans la petite enfance peut voquer un TSA. Cependant, la communication
QRQ YHUEDOH HVW SUVHQWH OH FRQWDFW YLVXHO HVW SUVHQW LO IDLW SUHXYH GH UFLSURFLW VRFLDOH HW GH
SDUWDJHGXSODLVLU6LODVXUGLWHVWFXUDEOHOHODQJDJHRUDOSHXWDORUVVHGYHORSSHUGHIDRQH[SOR
VLYHGHPPHVLXQODQJDJHVLJQHVWPLVHQSODFHHQFDVGHVXUGLWLQFXUDEOH
Le retard mental simpleOJHSUVFRODLUHSHXWSDUIRLVVDFFRPSDJQHUGHV\PSWPHVTXLUHVVHP
EOHQWODXWLVPHFRPPHOHVVWURW\SLHVRXOHVMHX[USWLWLIVPDLVTXLVRQWGXVOJHGYHO
RSSHPHQWDO/HVV\PSWPHVGLVSDUDLVVHQWGHPDQLUHVSRQWDQHRXODIDYHXUGHVWLPXODWLRQV
Les troubles spcifiques du langage SHXYHQW JDOHPHQW WUH FRQIRQGXV DYHF ODXWLVPH VXUWRXW
VLOV VDVVRFLHQW  GHV V\PSWPHV DQ[LRGSUHVVLIV HW  XQ UHWUDLW VRFLDO &HV HQIDQWV IHURQW
SUHXYHGXQHUFLSURFLWVRFLDOHFRQWUDLUHPHQWDX76$
Certains enfants prsentant un trouble oppositionnel svre ou des comportements explosifs
DVVRFLV  XQH PRWLRQQDOLW QJDWLYH SHXYHQW SUVHQWHU XQ FHUWDLQ LVROHPHQW VRFLDO HW IDLUH
voquer le diagnostic de TSA.
, OH[LVWHJDOHPHQWGHQRPEUHX[syndromes gntiques, neurologiques et maladies neurodgnrativesDVVRFLVGHVV\PSWPHVDXWLVWLTXHVSDUPLOHVTXHOOHVOHV\QGURPHGDOFRROLVPHIWDOOH
V\QGURPHGH3DUGHU:LOOLOHV\QGURPHGH'LJHRUJHOHV\QGURPHGHO;IUDJLOHRXGHVPDODGLHV
PWDEROLTXHVWHOOHVTXHOHVPDODGLHVPLWRFKRQGULDOHVRXOHVPDODGLHVO\VRVRPDOHV
 QQOHVcarences graves de stimulationHWGHVRLQSHQGDQWOHVSUHPLUHVDQQHVGHODYLHSHXYHQW
(
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WUHSHUPDQHQWHVUSWHVLPSRUWDQWHVHWGXUHUXQFHUWDLQWHPSV&HVRQWGHVWDEOHDX[FODV
VLTXHPHQWGFULWVGDQVOHVRUSKHOLQDWVGHFHUWDLQVSD\VHQJUDQGHGLFXOWFRQRPLTXH'DQV
FHW\SHGHFDVXQHSULVHHQFKDUJHDGDSWHDX[WURXEOHVGHODVRFLDOLVDWLRQSHXWGFOHQFKHUGDQV
XQHFHUWDLQHPHVXUHOPHUJHQFHGDFTXLVLWLRQVHWDPOLRUHUODV\PSWRPDWRORJLH

3.3.2.

lge adulte

Certains troubles de la personnalit DYHFTXWHDHFWLYHRXEHVRLQGHUHFRQQDLVVDQFHFHUWDLQHV

traits schizotypiquesSHXYHQWYRTXHUXQV\QGURPHG$VSHUJHURXXQ76$VXUWRXWVLOH[LVWHXQ
ERQQLYHDXFRJQLWLIHWRXTXHOTXHVWUDLWVREVHVVLRQQHOV
Il en va de mme pour les patients prsentant un TDAH associ une maladresse sociale et une
anxit.
'DQVFHVFDVODTXDOLWVXEMHFWLYHGHOLQWHUDFWLRQODUFLSURFLWVRFLDOHODEVHQFHGHULJLGLW
ODFFV  OLPSOLFLWH HW OH ODQJDJH QRQ YHUEDO SHXYHQW RULHQWHU YHUV XQ GLDJQRVWLF GLUHQWLHO
/HVHQWUHWLHQVVWUXFWXUVFIFLGHVVRXVGHPPHTXHODFKURQRORJLHGHVVLJQHVGFULWVHWOHV
OPHQWVVXUODSHWLWHHQIDQFHSHXYHQWDSSRUWHUXQHDLGHVXEVWDQWLHOOH

347

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

4.

Prise en charge
/DSULVHHQFKDUJHGHVSDWLHQWVSUVHQWDQWXQ7('RXXQ76$GRLWLGDOHPHQWWUH

4.1.

la plus prcoceSRVVLEOH

adapte DX[GLFXOWVHWDX[VSFLFLWVGHFKDTXHSDWLHQW

multidisciplinaire et coordonne

intensive et continue.

Les thrapies valides

4.1.1. Les

prises en charges comportementales intensives

Les deux exemples les plus connus de ces prises en charge sont :

348

/DPWKRGH$%$$SSOLHG%HKDYLRU$QDO\VLV$QDO\VHDSSOLTXHGXFRPSRUWHPHQW

/ D PWKRGH 7($&+ 7UHDWPHQW DQG (GXFDWLRQ RI $XWLVWLF DQG UHODWHG &RPPXQLFDWLRQ
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FDSVGHFRPPXQLFDWLRQDSSDUHQWV

&HVRQWGHVSURJUDPPHVVWUXFWXUVFRGLVHWLQWHQVLIVGHKHXUHVSDUVHPDLQHQFHVVL
WDQWXQLQWHUYHQDQWSDUHQIDQW(OOHVVRQWEDVHVVXUOHVWKRULHVGHODSSUHQWLVVDJHHWXWLOLVHQWOD
stimulation, la rptition et le renforcement positif, pour favoriser un apprentissage des compor
WHPHQWVXWLOHVODFRPPXQLFDWLRQHWDGDSWVVRFLDOHPHQW
/HVUHQIRUDWHXUVSHXYHQWWUHPDWULHOVERQVSRLQWVERQERQVJRPPHWWHVHWFHWUHODWLRQQHOV
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&HVSURJUDPPHVVRQWVSFLTXHPHQWDGDSWVDX[76$HWDX[7(',OVSUHQQHQWGRQFHQFRPSWH
OHVSDUWLFXODULWVFRJQLWLYHVHWOHVPRGDOLWVSDUWLFXOLUHVGHFRPPXQLFDWLRQGHFHVSDWLHQWV
,OVQFHVVLWHQWXQHFROODERUDWLRQWURLWHHQWUHSDUHQWVRXDLGDQWVQDWXUHOVHWLQWHUYHQDQWVOHV
SDUHQWVVRQWGRQFIRUPVODPWKRGH

4.1.2. Les

thrapies dveloppementales

,OVDJLWJDOHPHQWGHPWKRGHVLQWHQVLYHVMXVTXKHXUHVSDUVHPDLQHTXLRQWSRXUEDVHOHV

WKRULHVGHODSSUHQWLVVDJH(OOHVVRQWDGDSWHVDXVWDGHGHGYHORSSHPHQWGHOHQIDQW
%LHQTXHFRGLHVFHVPWKRGHVVRQWPRLQVVWUXFWXUHVTXHOHVPWKRGHVSUFGHPPHQWFLWHV
/DXVVLODVWLPXODWLRQHVWODEDVHPDLVHOOHHVWDPHQHDYHFOHMHX/LQWHUYHQDQWQLPSRVHSDVOHV
VTXHQFHVPDLVWHQWHGHVXVFLWHUODPRWLYDWLRQGHOHQIDQWHQFRQWLQXSRXULQLWLHUGHVFKDQJHV
rciproques et favoriser la communication.
/HV PWKRGHV OHV SOXV FRQQXHV ODERUHV GHSXLV OHV DQQHV  VRQW OD )ORRUWLPH OD 'HQYHU
0RGHOOHVL6RQULVH/D5HODWLRQVKLS'YHORSSHPHQW,QWHUYHQWLRQHWOD7KUDSLHGFKDQJHHW
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Troubles envahissants du dveloppement

4.1.3. Prises

65

en charges axes sur le langage et la communication

4.1.3.1.Pour les patients sans langage

ou avec des troubles importants du langage oral

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VDJLWGHODQJDJHVDOWHUQDWLIVYLVXHOVOHVSOXVFRQQXVVRQWOH3(&6HWOH0$.$721
/DPWKRGH3(&6HVWEDVHVXUOXWLOLVDWLRQGLPDJHVHWGHSLFWRJUDPPHVHWFRQVLVWHSRXUOHQ
IDQWDGUHVVHUXQHGHPDQGHH[SOLFLWHHQGRQQDQWVRQLQWHUORFXWHXUOLPDJHGHFHTXLOGVLUH
&HWWHPWKRGHSHUPHWGWDEOLUXQHEDVHIDFLOHPDQLHUSRXUXQHFRPPXQLFDWLRQLQVWUXPHQWDOH
UFODPHUXQREMHWH[SULPHUXQEHVRLQ/HVLPDJHVIDFLOHVIDLUHVRQWUDQJHVGDQVXQFDKLHU
GHFRPPXQLFDWLRQTXLVHUWGHVXSSRUWOFKDQJH/HVSLFWRJUDPPHVVRQWSOXVV\PEROLTXHVPDLV
restent explicites, elles permettent nanmoins de faire des phrases plus complexes.
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les signes ou les pictogrammes pour les lments importants. Les signes sont issues de la langue
des signes mais avec la grammaire commune. Cette mthode a pour particularit de permettre un
langage complexe.

4.1.3.2.Lorsquil existe un bon niveau de langage verbal

/HVSURJUDPPHVGHQWUDQHPHQWDX[KDELOHWVVRFLDOHVHWRXGDUPDWLRQGHVRLVHSUVHQWHQW
VRXVIRUPHGHWKUDSLHGHJURXSHVWUXFWXUVHWDGDSWVFKDTXHWUDQFKHGJH
La rducation orthophonique permet de travailler la pragmatique du langage.
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sociales sont destins aux patients prsentant une maladresse sociale, une anxit sociale inva
OLGDQWHHWGHVVWUDWJLHVGYLWHPHQW.

4.1.4. Traitement

des comorbidits et des symptmes envahissants

/D JXLGDQFH HW OHV WKUDSLHV LQGLYLGXHOOHV GLQVSLUDWLRQ FRJQLWLYH HW FRPSRUWHPHQWDOH SHXYHQW
WUHSURSRVVSRXUDPOLRUHUOHVV\PSWPHVREVHVVLRQQHOVODULJLGLWFRJQLWLYHHWOLQWROUDQFH
au changement.
/HVV\PSWPHVDQ[LHX[HWSKRELTXHVSHXYHQWDXVVLEQFLHUGXQHSULVHHQFKDUJHLQGLYLGXHOOH
/DSV\FKRPRWULFLWHWOHUJRWKUDSLHSHXYHQWSDUODUGXFDWLRQRXODPLVHHQSODFHGHVWUDWJLHV
DOWHUQDWLYHVUGXLUHODJQHOLHODPDOKDELOHWHWGLPLQXHUOHVWURXEOHVGHWRQXVRXGHSRVWXUH

4.2.

La prise en charge mdicamenteuse

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/HV WUDLWHPHQWV PGLFDPHQWHX[ VRQW H[FOXVLYHPHQW V\PSWRPDWLTXHV &HV WUDLWHPHQWV GRLYHQW
SHUPHWWUHGHIDFLOLWHUODUDOLVDWLRQGHVWUDLWHPHQWVGXFDWLIVHWGRSWLPLVHUOHXUVHHWV
/HV WUDLWHPHQWV PGLFDPHQWHX[ VXLYDQWV RQW IDLW SUHXYH GHFDFLW HW OREMHW GH UHFRPPDQGD
tions. Leur prescription doit tre rserve au spcialiste.
*

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SDWLHQWVVRXUDQWGH76$SRXUREWHQLUXQU\WKPHSURFKHGHODSRSXODWLRQJQUDOH

/ HV DQWLSV\FKRWLTXHV VRQW XWLOLVV HQ FDV GK\SHUDFWLYLW HW GDJUHVVLYLW LPSRUWDQWH HQ
SUVHQFHGDXWRPXWLODWLRQVJUDYHVORUVTXDXFXQDXWUHUHFRXUVQHVWHFDFHWDQWGRQQOH

349

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

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PRLQVGHG\VNLQVLHVWDUGLYHVTXHOHVDXWUHVPROFXOHVGHUIUHQFH

4.3.

/ HVDQWLGSUHVVHXUVLQKLELWHXUVGHODUHFDSWXUHGHODVURWRQLQHSHXYHQWDYRLUXQHXWLOLWSRXU
OD SULVH HQ FKDUJH GXQ SLVRGH GSUHVVLI FKH] OHV SDWLHQWV DXWLVWHV RX GDQV OH FDGUH GH OD
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comportementale.

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OHWURXEOHGFLWDWWHQWLRQQHOK\SHUDFWLYLW&HWWHPROFXOHHVWLQGLTXHORUVTXHOHGLDJQRVWLF
GH7'$+HVWDVVRFLDX[76$LOIDXWFHSHQGDQWPDQLHUFHWWHSUHVFULSWLRQDYHFSUXGHQFHHW
SHVHUVRLJQHXVHPHQWOHUDWLREQFHULVTXHGXIDLWGHVHHWVVHFRQGDLUHVFRPSRUWHPHQWDX[
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Prise en charge axe sur lenvironnement

4.3.1. Guidance

350

destine aux parents et aidants

Des programmes de guidance parentale GHVWLQVDX[SDUHQWVHWSURFKHVGHVSHUVRQQHVVRXUDQW

GH7('RXGH76$RQWWYDOXVGDQVOHVSD\VDQJORVD[RQVHWVHPEOHQWDYRLUXQLPSDFWVXUOD
TXDOLWGHYLH'HVSURJUDPPHVDQDORJXHVVRQWHQFRXUVGYDOXDWLRQHQ)UDQFH&HVSURJUDPPHV
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communication adapte.

4.3.2.Amnagements

en milieu scolaire

Depuis la loi de 2005, les enfants en situation de handicap doivent pouvoir tre accueillis en
PLOLHXVFRODLUHFKDTXHIRLVTXHFHVWSRVVLEOH
Le projet personnalis de scolarisation (PPS SUFLVH OHV DPQDJHPHQWV SUDWLTXHV TXL GRLYHQW
permettre une scolarisation en milieu ordinaire.
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interactions avec ses pairs.
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VSFLTXHV3RXUOFROHSULPDLUHLOVDJLWGHVFODVVHVSRXUOLQFOXVLRQVFRODLUHCLISHWSRXUOH
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SHXYHQWDFFGHUFHVFODVVHV

4.3.3. Amnagements

du milieu professionnel

/HVDGXOWHVSUVHQWDQWXQ76$DYHFXQQLYHDXGHFRPPXQLFDWLRQVXVDQWSHXYHQWWUDYDLOOHUHQ
PLOLHXRUGLQDLUHRXEQFLHUGHPSORLSURWJV'HVDPQDJHPHQWVGXSRVWHHWGHVKRUDLUHVGH
travail doivent tre mis en place. Il faut pour cela les adresser au mdecin du travail. Il existe des
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Troubles envahissants du dveloppement

4.4.

65

Les structures ddies la prise en charge de lautisme

4.4.1. Les

centre de ressource autisme ou CRA

/HV &5$ VRQW GHV FHQWUHV GH FRQVXOWDWLRQ GYDOXDWLRQ HW GRULHQWDWLRQ VSFLDOHPHQW GGLV 
FH WURXEOH /HXUV PLVVLRQV VRQW GLQIRUPHU GH FRRUGRQQHU OHV VRLQV GDFFRPSDJQHU GDQV OHV
GPDUFKHVGHPHWWUHHQXYUHGHVDFWLRQVGHGSLVWDJHVHWGHVRXWLHQGHIRUPHUHWGLQIRUPHU
IDPLOOHVHWSURIHVVLRQQHOVGHGRQQHUGHVFRQVHLOVGDFFRPSOLUXQHH[SHUWLVH

4.4.2.Les

structures mdico-ducatives

/ HV6(66$'$XWLVPHVHUYLFHGGXFDWLRQHWGHVRLQVGRPLFLOHUDOLVDQWXQHSULVHHQFKDUJH
multidisciplinaire et intgre (dans le milieu scolaire, au domicile, et dans les locaux de la
VWUXFWXUH

/ HV LQVWLWXWV PGLFR GXFDWLIV ,0( LQVWLWXWV PGLFRSGDJRJLTXHV ,03 LQVWLWXWV PGLFR
GXFDWLIVHWSURIHVVLRQQHOV,0352

&HV VWUXFWXUHV LQLWLDOHPHQW GGLHV DX GFLW LQWHOOHFWXHO RQW SRXU PLVVLRQ LFL GH GRQQHU XQH
ducation gnrale et pratique adapte au handicap, de prendre en charge une scolarit adapte
DX UHWDUG FRJQLWLI GH GYHORSSHU ODXWRQRPLH 3RXU OHV ,0352 XQH IRUPDWLRQ SURIHVVLRQQHOOH
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KDQGLFDSHV0'3+HVWQFHVVDLUH

4.4.3.

Les structures de soin sans caractre ducatif

Hpitaux de jour : centres de soin intgrs au dispositif de secteur qui accueillent les patients
HQ MRXUQH /HV VRLQV \ VRQW RUJDQLVV VRXV IRUPH GDWHOLHUV HW GDFWLYLWV TXL VRQW FKRLVLV
GDQVOHFDGUHGXSURMHWWKUDSHXWLTXHGXSDWLHQW,OVGLVSRVHQWGTXLSHVSOXULGLVFLSOLQDLUHVGH
SV\FKLDWUHVSV\FKRORJXHVSV\FKRPRWULFLHQVHWRUWKRSKRQLVWHVPDLVOHXUIRQFWLRQQHPHQWHVW
WUVKWURJQHHQWHUPHVGHPWKRGHHWGHIRQFWLRQQHPHQWDXTXRWLGLHQ

Les centres mdico psychologiques (CMP), centre mdico psycho pdagogiques (CMPP) et
centre daction mdico-sociale prcoce (CAMSP) : centres de soins de proximit, intgrs
GDQVOHGLVSRVLWLIGHVHFWHXU&RPPHOHVKSLWDX[GHMRXULOVGLVSRVHQWGTXLSHVSOXULGLVFL
SOLQDLUHVGHSV\FKLDWUHVSV\FKRORJXHVSV\FKRPRWULFLHQVHWRUWKRSKRQLVWHV&HVVWUXFWXUHV
SHXYHQW SURSRVHU GHV SULVHV HQ FKDUJHV HW GHV UGXFDWLRQV PRLQV LQWHQVLYHV FHSHQGDQW
HOOHVSHXYHQWFRRUGRQQHUOHVSULVHVHQFKDUJHVDFFRPSDJQHUODPLVHHQSODFHHWORXYHUWXUH
GHVGURLWVHWDXEHVRLQRULHQWHUYHUVXQHVWUXFWXUHSOXVDGDSWH(OOHVSHXYHQWJDOHPHQWWUH
HQOLHQDYHFOFROHHWDSSRUWHUXQHJXLGDQFHDX[SDUHQWV

4.4.4.Les

lieux de vie

Les foyers daccueil mdicalis VRQWGHVOLHX[GHYLHRORQWLHQWFRPSWHGXW\SHGHKDQGLFDSGH

OLQGLYLGXHWRGHVDPQDJHPHQWVVRQWIDLWVHQFHVHQV8QHTXLSHSOXULGLVFLSOLQDLUHGHSURIHV
VLRQQHOVGHODVDQWSHXYHQWLQWHUYHQLUDLQVLOHVIR\HUVGDFFXHLOPGLFDOLVSHXYHQWJDOHPHQW
DYRLUYRFDWLRQDFFRPSDJQHUYHUVSOXVGDXWRQRPLHHQUHQIRUDQWOHVDSSUHQWLVVDJHVTXLVRQW
utiles pour grer le quotidien.
Les foyers de vie VRQWGHVWLQVXQHSRSXODWLRQKWURFOLWHSUVHQWDQWXQKDQGLFDSTXLOLPLWHODX
WRQRPLHHWTXLQHSHXWWUHKEHUJHGDQVXQFDGUHIDPLOLDO&HVVWUXFWXUHVQRQWSDVGHYRFDWLRQ
de soin.

351

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

4.5.

Stratgie thrapeutique

4.5.1. Pour

les formes peu svres

Avec :
*

 UREOPH GH H[LELOLW GLFXOWV GRUJDQLVDWLRQ RX GH SODQLFDWLRQ TXL HVW XQ IUHLQ 
3
ODXWRQRPLH

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Stratgies :
* 6RXWLHQHWJXLGDQFHLQGLYLGXHOOH7&&JURXSHGHQWUDQHPHQWDX[KDELOHWVVRFLDOHVJXLGDQFH
GHOHQWRXUDJHDLGHOLQVHUWLRQSURIHVVLRQQHOOH
*

$XEHVRLQUHFRQQDLVVDQFHGXKDQGLFDSOD0'3+SULVHHQFKDUJHGHVVRLQV

4.5.2.Pour

les formes relativement svres

ncessitant un soutien substantiel

Avec :
*

'LFXOWVPDUTXHVGDQVODFRPPXQLFDWLRQYHUEDOHHWQRQYHUEDOH

Activits manifestement restreinte tranges ou rptitives.

'LFXOWQRWDEOHFKDQJHUGDFWLYLWRXGHFHQWUHGLQWUWSHUVYUDWLRQV

Stratgies :
352

* 3ULVHHQFKDUJHLQWHQVLYHVPXOWLPRGDOHVDLGHODFRPPXQLFDWLRQDPQDJHPHQWGXTXRWL
GLHQDLGHODXWRQRPLHGDQVODVRFLDOLVDWLRQ$FFRPSDJQHPHQWODPDLVRQHWVXUOHOLHXGRFFX
SDWLRQFROHWUDYDLOHWF
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SRXUXQHDOORFDWLRQVSFLTXHHWGHVDPQDJHPHQWVGXWUDYDLO

4.5.3. Pour

les formes trs svres ncessitant une aide

importante et un soutien renforc

Avec :
*

7 URXEOHV VYUHV GH OD FRPPXQLFDWLRQ YRLUH GHV SDWLHQWV VDQV ODQJDJH RX TXL QH SHXYHQW
H[SULPHUTXHOHXUVEHVRLQVSUHPLHUV

&RPSRUWHPHQWVWUVLQKDELWXHOVHWUSWLWLIV

Stratgies :
* 3ULVHHQFKDUJHWUVLQWHQVLYHDLGHDXODQJDJHDLGHODXWRQRPLHGDQVOHVJHVWHVTXRWLGLHQV
RXSRXUOHVEHVRLQVGHEDVHYRLUHOLHXGHYLHDGDSWSRXUUSRQGUHDX[EHVRLQVVSFLTXHV
* 5HFRQQDLVVDQFH GX KDQGLFDS RXYHUWXUH GH GURLWV SRXU XQH DOORFDWLRQ VSFLTXH YRLUH DX
EHVRLQGXQHDOORFDWLRQFRPSOPHQWDLUHSRXUOHVDLGDQWV

Troubles envahissants du dveloppement

4.6.

65

Prvention et dpistage prcoce

4.6.1. Prvention

primaire

/RUVTXH OH GLDJQRVWLF GH WURXEOH HVW SRV HW TXLO H[LVWH XQH DWWHLQWH JQWLTXH FRQQXH XQH
consultation de conseil gntique peut tre propose.

4.6.2. Prvention

secondaire

,OH[LVWHGHVSURJUDPPHVGHVWLQVGSLVWHUOHSOXVSUFRFHPHQWSRVVLEOHOHV7('FKH]OHVWUV
MHXQHVHQIDQWVULVTXH
*

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4XLSUVHQWHQWGHVDW\SLFLWVGXFRPSRUWHPHQWODFUFKHRXDXMDUGLQGHQIDQW

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HWXQHSULVHHQFKDUJHDGDSWH&HVVWUDWJLHVVRQWHQFRXUVGYDOXDWLRQ

4.7.

Les dispositions administratives

/HVWURXEOHVGXVSHFWUHDXWLVWLTXHVHWOHVWURXEOHVHQYDKLVVDQWGXGYHORSSHPHQWSHXYHQWGRQQHU
OLHXXQHSULVHHQFKDUJHGXKDQGLFDSOD0'3+0DLVRQGSDUWHPHQWDOHGHVSHUVRQQHVKDQGL
FDSHVHWFHTXHOTXHVRLWOJHGXSDWLHQWRXOJHGXGLDJQRVWLFOHVVRLQVHWOHKDQGLFDSSHXYHQW
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2QSHXWJDOHPHQWGHPDQGHUXQHDOORFDWLRQORQJXHGXUHSULVHHQFKDUJHm}DXWLWUH
GDHFWLRQSV\FKLDWULTXHGHORQJXHGXUH

5.

Le pronostic et lvolution

5.1.

La morbidit/mortalit
/DPRUELPRUWDOLWFKH]OHVSDWLHQWVDYHFXQ76$HVWSOXVOHYHTXHQSRSXODWLRQJQUDOH2Q
QRWHXQHVXUPRUWDOLWGXHDX[FRQYXOVLRQVHWDXWUHWURXEOHVQHXURORJLTXHVDX[FDXVHVFDUGLR
YDVFXODLUHVHWDX[DFFLGHQWV8QHVXUPRUWDOLWGRULJLQHUHVSLUDWRLUHHVWGFULWHFKH]OHVSDWLHQWV
avec retard mental.
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*

GHVFRPRUELGLWVPGLFDOHVQRQSV\FKLDWULTXHVSDVVHVLQDSHUXHV

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8QHPRLQGUHVHQVLELOLWODGRXOHXU

353

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

5.2.

 XQYLWHPHQWGXFRQWH[WHGHODFRQVXOWDWLRQORUVTXHOHSDWLHQWHVWDVVH]DXWRQRPHSRXUWUH

OLQLWLDWLYHGXIDLWGHODWWHQWHGXFDUDFWUHLQKDELWXHOGHOYQHPHQWHWFHWGHODQJRLVVH
que la situation peut gnrer.

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 X[UXSWXUHVGXSURMHWGHVRLQVDQWULHXUTXLSHXYHQWWUHOLHVDX[VHXLOVGJHXQGP
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  XQ GIDXW GH GSLVWDJH V\VWPDWLTXH HQWUH DXWUHV GHV FRPRUELGLWV VSFLTXHV FRPPH

OSLOHSVLH

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Devenir social des patients

/HV IRUPHV SOXV OJUHV VDQV UHWDUG FRPPH OH V\QGURPH G$VSHUJHU HW OHV IRUPHV FOLQLTXHV
VHPEODEOHV ORLQ GH FHUWDLQV SRUWUDLWV PGLDWLTXHV OHV SDWLHQWV SUVHQWDQW XQ 76$ VRXUHQW
VRXYHQWGLVROHPHQWVRFLDO,OVSHXYHQWRFFXSHUGHVHPSORLVVRXVTXDOLVGXIDLWGHOHXUSUVHQ
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FRPPHOHVKSLWDX[SV\FKLDWULTXHVRXOHVPDLVRQVGDFFXHLOVSFLDOLVVPDLVTXLQHVRQWSDV
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5.3.
354

Facteurs de bon et mauvais pronostic

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FRPSWHQFHVVRFLDOHVODEVHQFHGHUHWDUGPHQWDOHWXQERQQLYHDXYHUEDO(QSUDWLTXHXQHSULVH
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VRFLDOLVDWLRQIRQWODGLUHQFH

Rsum
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WURXEOHVGHODFRPPXQLFDWLRQUFLSURTXHHWGHVLQWUWVUHVWUHLQWVHWGHVSDWWHUQVFRPSRUWHPHQ
WDX[USWLWLIV/HVIRUPHVFOLQLTXHVVRQWWUVKWURJQHVFHTXLSHXWRFFDVLRQQHUGHVUHWDUGV
diagnostics et un retard de la prise en charge.
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du dveloppement.
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ces patients.

Troubles envahissants du dveloppement

65

Points clefs
*
*
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Triade diagnostique.
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Rfrences pour approfondir

Articles scientifiques
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poche.
A History of Autism: Conversations with the Pioneers. $GDP)HLQVWHLQG:LOH\%ODFNZHOO

Annexe 1
Critres DSM-5 Trouble du spectre autistique

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355

65

Les troubles psychiatriques spcifiques de lenfant et ladolescent

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Critres DSM-IV trouble envahissant du dveloppement : trouble autistique

356

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et connatre les principes de la prvention et de la prise en charge.

66

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Les troubles psychiatriques spcifiques de lenfant et ladolescent

1.

1.1.

Replacer les choses dans le contexte,

pour mieux comprendre
Quid de ladolescence normale ?
Caractristiques comportementales et psychosociales
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1.2.

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VDQWGHODSRSXODWLRQFDUWTXLQHVWSOXVXQUHWDUGPDLVXQHDQRPDOLHFRQVWLWXHUHVSRQVDEOH
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OHQIDQWODGROHVFHQW
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compliqu de distinguer les limites et de faire un diagnostic.

Troubles du comportement de ladolescent

66

/H7'$+HVWFRQVLGUFRPPHXQWURXEOHQHXURGYHORSSHPHQWDOWDQGLVTXHOH723HWOH7&VRQW
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aux autres.

1.3.

Petit dtour par les classifications

des troubles du comportement
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FKLDWUHV OD FODVVLFDWLRQ GH O206 Classification internationale des maladies &,0 FHOOH GHV
86$ Diagnostic and Statistical Manual of Mental Disorder '60 HW OD IUDQDLVH Classification
franaise des troubles mentaux de lenfant et de ladolescent, CFTMEA/D&,0HWOH'60VRQWOHV
plus utiliss.
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OHWURXEOHH[SORVLILQWHUPLWWHQWODSHUVRQQDOLWDQWLVRFLDOHODS\URPDQLHODNOHSWRPDQLH

2.

Contexte pidmiologique
des troubles du comportement
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PDQLHODGGLFWLRQDX[MHX[OHPXWLVPHOHVWURXEOHVGHODWWDFKHPHQWOHVWLFVDYHFOHV\QGURPH
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$SUVFHSUHPLHUSRLQWVXUOSLGPLRORJLHGHFHVWURXEOHVQRXVYHUURQVGHSOXVSUVODVPLROR
gie de chacun.

2.1.

Le trouble oppositionnel avec provocation TOP

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359

66

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lentes, ou au contraire trop rigoureuses et rigides,

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2.3.

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3.

Smiologie des troubles du comportement

3.1.

Lhyperactivit
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rement, et cette agitation est rapporte par toutes les personnes qui le ctoient. Il a galement le
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3.2.

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prise de risques sans notion du danger.

Limpulsivit
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361

66

Les troubles psychiatriques spcifiques de lenfant et ladolescent

3.3.

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prise de risques.

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de rgulation motionnelle.
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comportementales.
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mentale.
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OHPSDWKLHHVWXQHYDULDEOHKULWDEOHHWQRQLQXHQFHSDUOHQYLURQQHPHQWGRQFGRULJLQHmJQWLTXHHWELRORJLTXH}
SUHQDQWSDUWGDQVOHWHPSUDPHQWSURSUHGHOHQIDQWSOXVTXHQYLURQQHPHQWDOH

Les hypothses neurobiologiques et neurodveloppementales pour le TDA/H

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petite enfance.

369

66

Les troubles psychiatriques spcifiques de lenfant et ladolescent

7.

La prise en charge psychiatrique

La prise en charge suit cet enchanement :
1. SRVHUOHGLDJQRVWLFFDUWHUOHVGLDJQRVWLFVGLUHQWLHOV
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7.1.

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370

7.2.

Lhospitalisation en pdopsychiatrie
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7.3.

La psycho ducation au trouble

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Troubles du comportement de ladolescent

7.4.

66

Prise en charge scolaire : les amnagements scolaires en

milieu ordinaire, ou les structures psycho-pdagogiques
quand la scolarit en tablissement gnral nest pas/plus
possible (les ITEP)
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parents :
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Prise en charge socioducative possible

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7.6.

Prise en charge plus spcifique pour le TDAH

7.6.1. Traitement

pharmacologique

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371

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Les troubles psychiatriques spcifiques de lenfant et ladolescent

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7.6.2. Traitement

psychothrapeutique enfant et parents

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pour en savoir plus

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7.6.3. Accompagnements

7.7.

pdagogiques proposer

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Prise en charge plus spcifique du TOP et/ou du TC

7.7.1.

Traitements psychothrapeutiques possibles,

enfant et parents
*

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de gestion des crises clastiques de leur enfant, de discipline positive, de communication
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pour en savoir plus

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373

66

Les troubles psychiatriques spcifiques de lenfant et ladolescent

7.7.2. Aide

socioducatives familiales
pour les parents denfants atteint de TC et TOP

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7.7.3.

Accompagnements pdagogiques proposer

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coopratif et moins acadmique.
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374

7.7.4. Traitements

pharmacologiques

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66

Les troubles psychiatriques spcifiques de lenfant et ladolescent

Annexe 1 : Frise de lvolution

Enfance

TDA/H

Adolescence

ge adulte

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Troubles du comportement de ladolescent

66

Annexe 2 : modle hybride de Barkley (1997)

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item 69

Troubles des conduites

alimentaires chez
ladolescent et ladulte

69

I. Introduction
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conduites alimentaires.
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et leur prise en charge en aigu.

69

Les troubles psychiatriques spcifiques de lenfant et ladolescent

1.

Introduction
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Troubles des conduites alimentaires chez ladolescent et ladulte

2.2.

69

Smiologie psychiatrique
Critre DSM-IV

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plusieurs fois par jour.

381

69

Les troubles psychiatriques spcifiques de lenfant et ladolescent

Autres stratgies
de contrle du poids

* Vomissements provoqus : la plus frquente des stratgies de contrle. Les

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prescription mdicale.
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isotoniques.

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382

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Troubles des conduites alimentaires chez ladolescent et ladulte

Formes spcifiques

2.3.

69

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de famille de malade, groupe de soutien

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pidmiologie
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3.2.

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3.5.6. Aspect

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Les troubles psychiatriques spcifiques de lenfant et ladolescent

4.

4.1.

Hyperphagie boulimique
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4.4.1. Diagnostics

69

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69

Les troubles psychiatriques spcifiques de lenfant et ladolescent

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partie six

Les addictions

item 73

Addiction au tabac
I. Introduction
II. SLGPLRORJLH
III. Stratgies de prvention
IV. Complications PGLFDOHVQRQSV\FKLDWULTXHV
V. &RPRUELGLWVPGLFDOHVSV\FKLDWULTXHV
VI. Notions GHSK\VLRSV\FKRSDWKRORJLH
VII. La prise en charge

Objectifs pdagogiques
* 5HSUHUGLDJQRVWLTXHUYDOXHUOHUHWHQWLVVHPHQWGXQHDGGLFWLRQDXWDEDF
* Indications et principes du sevrage thrapeutique.
* $UJXPHQWHUODWWLWXGHWKUDSHXWLTXHHWSODQLHUOHVXLYLGXSDWLHQW

73

73 Les addictions
1.

Introduction
(Q)UDQFHHWGDQVOHPRQGHOHVDGGLFWLRQVUHSUVHQWHQWXQSUREOPHPDMHXUGHVDQWSXEOLTXH
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(QPGHFLQHODQRWLRQGaddiction est privilgie pour permettre une approche centre sur les
FRQVTXHQFHVSRXUOLQGLYLGXGHVFRQVRPPDWLRQV'HSOXVODGLVWLQFWLRQHQWUHVXEVWDQFHVOLFLWHV
HWLOOLFLWHVGHYLHQWVHFRQGDLUHGHPPHTXHODQRWLRQGDGGLFWLRQFRPSRUWHPHQWDOHHWGDGGLFWLRQ
DX[VXEVWDQFHVSV\FKRDFWLYHV
LaddictionVHGQLHSDUOLPSRVVLELOLWUSWHGHFRQWUOHUXQFRPSRUWHPHQWHQWUDQDQWODSRXU
VXLWHGHFHFRPSRUWHPHQWHQGSLWGHVHVFRQVTXHQFHVQJDWLYHVSK\VLTXHVSV\FKLTXHVIDPL
OLDOHVSURIHVVLRQQHOOHVVRFLDOHV
,O H[LVWH GHV DGGLFWLRQV FRPSRUWHPHQWDOHV MHX DFKDWV QRXUULWXUH VH[H LQWHUQHW  HW GHV
DGGLFWLRQVDX[VXEVWDQFHVSV\FKRDFWLYHVDOFRROWDEDFGURJXHVTXLVHGFOLQHQWGHOXVDJH
 OD GSHQGDQFH VHORQ OHV FODVVLFDWLRQV FODVVLFDWLRQ LQWHUQDWLRQDOH GHV PDODGLHV &,0 HW
'LDJQRVWLFDQG6WDWLVWLFDO0DQXDORI0HQWDO'LVRUGHUV'60
2Q GLVWLQJXH WURLV JUDQGV W\SHV GH FRPSRUWHPHQW GDQV OD FRQVRPPDWLRQ GH VXEVWDQFHV
SV\FKRDFWLYHV
*

OHQRQXVDJH

OXVDJHVLPSOH

le msusage.

406

Non-usage

$EVHQFHGHFRQVRPPDWLRQSULPDLUHRXVHFRQGDLUH

Usage simple

&RQVRPPDWLRQXVXHOOHGXQSURGXLWRXUDOLVDWLRQGXQFRPSRUWHPHQWVDQVTXLO
QHSUVHQWHGHFDUDFWUHSDWKRORJLTXH0RGXODEOHHQIRQFWLRQ
GHOHQYLURQQHPHQWGHVEHVRLQVRXGHVHQYLHVGHVHHWVQJDWLIV
GHODGLVSRQLELOLWGXSURGXLW

Msusage

7RXWHFRQGXLWHGHFRQVRPPDWLRQGXQHRXSOXVLHXUVVXEVWDQFHVSV\FKRDFWLYHV
FDUDFWULVHSDUOH[LVWHQFHGHULVTXHVHWRXGHGRPPDJHVHWRXGHGSHQGDQFH

Parmi le msusage, dans la CIM, on distingue :

Lusage risqueTXLHVWGQLSDUXQHFRQVRPPDWLRQGHVXEVWDQFHSHQGDQWPRLVHQWUDQDQWDX
PRLQVXQHGHVFRQVTXHQFHVSV\FKRVRFLDOHVVXLYDQWHV
*

,QFDSDFLWUHPSOLUOHVREOLJDWLRQVPDMHXUHVPDLVRQWUDYDLOFROH

3ULVHGHULVTXHVH[FRQGXLWHHQWDWGLYUHVVH

7UDQVJUHVVLRQGHODORLSUREOPHVMXGLFLDLUHV

* 3RXUVXLWHGHODFRQVRPPDWLRQPDOJUGHVSUREOPHVLQWHUSHUVRQQHOVRXVRFLDX[H[GLVSXWHV
EDJDUUHV
Lusage nocifTXLVHFDUDFWULVHSDUODFRQVRPPDWLRQUSWHLQGXLVDQWGHVGRPPDJHVSK\VLTXHV
SV\FKRDHFWLIVRXVRFLDX[SRXUOHVXMHWOXLPPHRXSRXUVRQHQYLURQQHPHQWSURFKHRXORLJQ
VDQVDWWHLQGUHOHVHXLOGHODGSHQGDQFHSK\VLTXHRXSV\FKLTXHHWGRQWOHFDUDFWUHSDWKRORJLTXH
HVWGQLODIRLVSDUODUSWLWLRQGHODFRQVRPPDWLRQHWOHFRQVWDWGHVGRPPDJHVLQGXLWV
Lusage avec dpendanceTXLVHFDUDFWULVHSDUOLPSRVVLELOLWGHVDEVWHQLUGHFRQVRPPHU(OOH
DVVRFLHXQHGSHQGDQFHSK\VLTXHTXLVHWUDGXLWSDUXQSKQRPQHGHWROUDQFHLOIDXWDXJPHQWHU
OHVGRVHVSRXUREWHQLUOHVPPHVHHWVHWXQV\QGURPHGHVHYUDJHVLJQHVGHPDQTXHSK\VLTXHV

Addiction au tabac

73

HWSV\FKLTXHVHWSDUXQHGSHQGDQFHSV\FKLTXHHQFRUHDSSHOmFUDYLQJ}TXLVHWUDGXLWSDUOH

EHVRLQLUUSUHVVLEOHGHFRQVRPPHU

Les critres dabus de substance selon le DSM-IV-TR sont :

0RGH GXWLOLVDWLRQ LQDGTXDW GXQH VXEVWDQFH FRQGXLVDQW  XQH SUVHQFH GDX PRLQV XQH GHV
PDQLIHVWDWLRQVVXLYDQWHVDXFRXUVGXQHSULRGHGHPRLV
 8WLOLVDWLRQ USWH GXQH VXEVWDQFH FRQGXLVDQW  OLQFDSDFLW GH UHPSOLU GHV REOLJDWLRQV
PDMHXUHVDXWUDYDLOOFROHRXODPDLVRQ
 8WLOLVDWLRQ USWH GXQH VXEVWDQFH GDQV GHV VLWXDWLRQV R FHOD SHXW WUH SK\VLTXHPHQW
dangereux.
3UREOPHVMXGLFLDLUHVUSWVOLVOXWLOLVDWLRQGXQHVXEVWDQFH
8WLOLVDWLRQGHODVXEVWDQFHPDOJUGHVSUREOPHVLQWHUSHUVRQQHOVRXVRFLDX[SHUVLVWDQWV
RXUFXUUHQWVFDXVVRXH[DFHUEVSDUOHVHHWVGHODVXEVWDQFH

Les critres de dpendance sont dfinis dans le DSM-IV-TR comme suit :

0RGH GXWLOLVDWLRQ LQDSSURSUL GXQH VXEVWDQFH HQWUDQDQW XQH GWUHVVH RX XQ G\VIRQFWLRQQH
PHQWFOLQLTXHPHQWVLJQLFDWLIFRPPHHQWPRLJQHQWtrois (ou plus) des manifestations suivantes,
VXUYHQDQWQLPSRUWHTXHOPRPHQWVXUODPPHSULRGHGHPRLV
TolranceGQLHSDUOXQHRXODXWUHGHVPDQLIHVWDWLRQVVXLYDQWHV
D%HVRLQGHTXDQWLWVQHWWHPHQWPDMRUHVGHODVXEVWDQFHSRXUREWHQLUXQHLQWR[LFDWLRQRXOHHWGVLU
E(HWQHWWHPHQWGLPLQXHQFDVGXVDJHFRQWLQXGHODPPHTXDQWLWGHVXEVWDQFH
&RPPHHQWPRLJQHOXQHRXODXWUHGHVPDQLIHVWDWLRQVVXLYDQWHV
a. Syndrome de sevrageFDUDFWULVWLTXHGHODVXEVWDQFH
E/DPPHVXEVWDQFHRXXQHVXEVWDQFHDSSDUHQWHHVWSULVHGDQVOHEXWGHVRXODJHURXGYLWHU
OHVV\PSWPHVGHVHYUDJH
6XEVWDQFHVRXYHQWSULVHHQquantit suprieure ou sur un laps de temps plus long que ce que la
personne avait envisag
Dsir persistantRXHRUWVLQIUXFWXHX[SRXUUGXLUHRXFRQWUOHUOXWLOLVDWLRQGHODVXEVWDQFH
Temps considrable pass IDLUHOHQFHVVDLUHSRXUVHSURFXUHUODVXEVWDQFHODFRQVRPPHURX
UFXSUHUGHVHVHHWV
'LPSRUWDQWHVDFWLYLWVVRFLDOHVRFFXSDWLRQQHOOHVRXGHORLVLUVVRQWabandonnes ou rduites en
UDLVRQGHOXWLOLVDWLRQGHODVXEVWDQFH
3RXUVXLWHGHOXWLOLVDWLRQGHOD substance malgr la connaissance de lexistence dun problme physique
ou psychologiqueSHUVLVWDQWRXUFXUUHQWGWHUPLQRXH[DFHUESDUODVXEVWDQFH

La dpendance ne se dfinit donc ni par rapport un seuil ou une frquence de consommation, ni

par lexistence de dommages induits.

407

73 Les addictions
DSM-5
Dfinition des troubles lis lusage dune substance selon leur gravit

408

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TXHPHQWVLJQLFDWLYHFDUDFWULVSDUODSUVHQFHGHGHX[RXSOXVGHVPDQLIHVWDWLRQVVXLYDQWHVXQPRPHQWTXHO
FRQTXHGXQHSULRGHFRQWLQXHGHPRLV
* &RQVRPPDWLRQGHVXEVWDQFHHQTXDQWLWSOXVLPSRUWDQWHRXSHQGDQWXQHSULRGHSOXVORQJXHTXHSUYX
* 'VLUSHUVLVWDQWRXHRUWVLQIUXFWXHX[SRXUDUUWHUGLPLQXHURXFRQWUOHUOXWLOLVDWLRQGHVXEVWDQFH
* 7HPSVFRQVLGUDEOHSDVVGHVDFWLYLWVQFHVVDLUHVSRXUVHSURFXUHUXQHVXEVWDQFHODFRQVRPPHURXUFXSUHU
GHVHVHHWV
* (QYLHVLPSULHXVHVRXREVGDQWHVGHFRQVRPPHUXQHVXEVWDQFHFUDYLQJ
* ,QFDSDFLW  UHPSOLU GHV REOLJDWLRQV PDMHXUHV DX WUDYDLO  OFROH RX  OD PDLVRQ OLH  OXWLOLVDWLRQ USWH GH
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EVSDUVHVHHWV
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* ,PSRUWDQWHVDFWLYLWVVRFLDOHVRFFXSDWLRQQHOOHVRXGHORLVLUVUGXLWHVRXDEDQGRQQHVFDXVHGHOXWLOLVDWLRQGH
VXEVWDQFH
* 8WLOLVDWLRQGHODVXEVWDQFHSRXUVXLYLHPDOJUODFRQQDLVVDQFHGHOH[LVWHQFHGXQSUREOPHSK\VLTXHRXSV\FKROR
JLTXHSHUVLVWDQWRXUFXUUHQWGWHUPLQRXH[DFHUESDUFHWWHVXEVWDQFH
* 7ROUDQFHGQLHSDUOXQGHVV\PSWPHVVXLYDQWV
 %HVRLQGHTXDQWLWVQRWDEOHPHQWSOXVIRUWHVSRXUREWHQLUXQHLQWR[LFDWLRQRXOHHWGVLU
 (HWQRWDEOHPHQWGLPLQXHQFDVGXWLOLVDWLRQFRQWLQXHGXQHPPHTXDQWLW
* 6\QGURPHGHVHYUDJHFDUDFWULVSDUOXQHRXODXWUHGHVPDQLIHVWDWLRQVVXLYDQWHV
 6\QGURPHGHVHYUDJHFDUDFWULVGHFKDTXHVXEVWDQFH
 /DVXEVWDQFHRXVRQTXLYDOHQWHVWSULVHSRXUVRXODJHURXYLWHUOHVV\PSWPHVGHVHYUDJH
Prsence de 2 3 critresWURXEOHOJHU
Prsence de 4 5 critresWURXEOHPRGU
Prsence de 6 critres ou plusWURXEOHVYUH

2.

pidmiologie
/HWDEDFSUVHQWHOHSRWHQWLHODGGLFWLIOHSOXVIRUWSDUPLOHQVHPEOHGHVVXEVWDQFHVSV\FKRDFWLYHV
GHYDQWOKURQHODFRFDQHHWODOFRRO
/JHPR\HQORUVGHODSUHPLUHFLJDUHWWHHVWVWDEOHDX[DOHQWRXUVGHDQV/DSUYDOHQFHGHV
IXPHXUVDDXJPHQWGDQVODSRSXODWLRQJHGHDQVSDVVDQWGHHQ
GHVKRPPHVHWGHVIHPPHVHQHWGHVIXPHXUVUJXOLHUVSUVHQWHQWGHV
signes de dpendance.
/H WDEDJLVPH DFWLI HVW UHVSRQVDEOH GDQV OH PRQGH GXQ GFV VXU GL[ SOXV GH  PLOOLRQV GH
SHUVRQQHV SDU DQ (Q )UDQFH OH WDEDJLVPH DFWLI HVW OD SUHPLUH FDXVH GH GFV YLWDEOH DYHF
GFVSUPDWXUVFKDTXHDQQH
/DGXUHGXWDEDJLVPHHVWOHIDFWHXUGHULVTXHOHSOXVLPSRUWDQWGHFRPSOLFDWLRQVOLHVDXWDEDF

Addiction au tabac

3.

73

Stratgies de prvention
7RXVOHVSURIHVVLRQQHOVGHVDQWGHYUDLHQWVLPSOLTXHUGDQVODSUYHQWLRQGHOLQWR[LFDWLRQWDED
JLTXHGVOJHVFRODLUHHWGDQVODLGHODUUWGXWDEDF
/HVVWUDWJLHVGHOXWWHFRQWUHOHWDEDJLVPHGRQWGLVSRVHQWOHVSRXYRLUVSXEOLFVVRQWPXOWLSOHVHW
peuvent comprendre :
* 8QH modification de lenvironnement de lindividu SUL[ GX WDEDF DFFHVVLELOLW GX WDEDF
UJOHPHQWDWLRQGHVRQXVDJHUJOHPHQWDWLRQGHVDSURPRWLRQSXEOLFLWRUHGHVRLQHWSUYHQ
WLRQFRQVXOWDWLRQVGHVHYUDJHGLVSRVLWLI7DEDF,QIR6HUYLFHSDWFKVQLFRWLQLTXHVDFFHVVLEOHVHW
UHPERXUVDEOHVLQWHUGLFWLRQGHIXPHUGDQVOHVOLHX[XVDJHFROOHFWLI
* 8QHinvitation de lindividu changer son comportement : information, communication, duca
tion pour la sant via des campagnes mdiatiques, des documents, des actions de terrain.
*

4.

Des mobilisations collectivesDGDSWDWLRQVRUJDQLVDWLRQQHOOHVHQJDJHPHQWPLOLWDQWOREE\LQJ

Complications mdicales non psychiatriques

Noplasiques
/HWDEDJLVPHHVWUHVSRQVDEOH
GHGHOHQVHPEOH
GHVFDQFHUV

&DQFHUEURQFKRSXOPRQDLUHVGHVGFVSDUFDQFHUV
EURQFKRSXOPRQDLUHV
&DQFHUSLGHUPRGHGHOVRSKDJH
Cancer de la vessie
&DQFHUVRURSKDU\QJV
&DQFHUGXODU\Q[
Cancer du pancras
Cancer du rein

Pulmonaires

%URQFKRSQHXPRSDWKLHFKURQLTXHREVWUXFWLYHGHVIXPHXUV
(PSK\VPH
Bronchite chronique
,QVXVDQFHUHVSLUDWRLUHFKURQLTXH

Cardiovasculaires
/HWDEDJLVPHUHSUVHQWHOD
SUHPLUHFDXVHGHPRUWDOLW
FDUGLRYDVFXODLUHYLWDEOHHWOH
premier facteur de risque
cardiovasculaire de la femme
QRQPQRSDXVH

,QVXVDQFHFRURQDULHQQHIXPHUPXOWLSOLHSDU3OHULVTXHGLQIDUFWXV
GXP\RFDUGH
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+7$FDUGLRSDWKLHK\SHUWHQVLYH
$QYULVPHGHODRUWHDEGRPLQDOH
$FFLGHQWYDVFXODLUHFUEUDO

Dermatologiques

$XJPHQWDWLRQGHODVYULWGHODFQ
Acclration du vieillissement cutan
Coloration des ongles
Scheresse cutane

409

73 Les addictions

5.

Autres

&RORUDWLRQVEUXQHVRXQRLUHVGHVGHQWV
3DURGRQWLH
Dchaussement des dents
3RO\JOREXOLHSRO\QXFORVH
Diminution de la fcondit
Accouchement prmatur
5HWDUGGHFURLVVDQFHLQWUDXWULQ
0RUWIWDOHLQXWHUR*(8IDXVVHFRXFKH

Tabagisme passif

Multiplication du risque de cardiopathies ischmiques et de cancer

EURQFKRSXOPRQDLUHSDU
Coronaropathie
2WLWHDVWKPHFKH]OHQIDQWEURQFKLWH

Comorbidits mdicales psychiatriques

/HOLHQHVWWDEOLHQWUHOHVWURXEOHVDQ[LRGSUHVVLIVHWOHWDEDJLVPH
/HULVTXHGDSSDULWLRQGXQpisode dpressif caractris HVWDXJPHQWSHQGDQWOHVVL[PRLVDSUV
DUUWGXWDEDF/HVIXPHXUVTXLSUVHQWHQWXQWURXEOHGSUHVVLILQGXLWSDUOHVHYUDJHRQWSOXVGH
GLFXOWVVDUUWHUGHIXPHU,OHVWDXVVLQFHVVDLUHGHUHSUHUODQ[LWHWODGSUHVVLRQYHQ
WXHOOHVDFWXHOOHVHWVXUODYLHHQWLUHDYDQWOHVHYUDJHWDEDJLTXH
/HVWURXEOHVDQ[LRGSUHVVLIVLQGXLWVSDUOHVHYUDJHGXUHQWHQJQUDOTXHOTXHVVHPDLQHVHWQH
QFHVVLWHQWHQJQUDOSDVGHSULVHHQFKDUJHSKDUPDFRORJLTXHVSFLTXH8QVRXWLHQGDQVOH
FDGUHGHODFRQVXOWDWLRQHVWQDQPRLQVQFHVVDLUH6LOHVWURXEOHVSHUVLVWHQWLOHVWXWLOHGHQYLVD
JHUXQHSULVHHQFKDUJHVSFLTXH

410

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OLQYHUVHEHDXFRXSGHSDWLHQWVDWWHLQWVGHWURXEOHVSV\FKLDWULTXHVIXPHQWSXLVTXRQUHWURXYH
GHIXPHXUVFKH]OHVSDWLHQWVDWWHLQWVGHVFKL]RSKUQLHHWHQYLURQGHIXPHXUVFKH]OHV
SDWLHQWVDWWHLQWVGHWURXEOHVELSRODLUHVGHOKXPHXU

6.

Notions de physio/psychopathologie
8QHFLJDUHWWHFRQWLHQWHQYLURQVXEVWDQFHVGRQWXQHTXDUDQWDLQHHVWFDQFULJQH
La nicotine agit sur le circuit dopaminergique de la rcompense et induit la dpendance. Lorsque
le patient fume, il existe un pic rapide de la concentration plasmatique de nicotine, se traduisant
SDUXQHHWmDVK}
Le goudron, agent cancrigne, HVW UHVSRQVDEOH GH PRGLFDWLRQV GHV FHOOXOHV SLWKOLDOHV &HV
FHOOXOHVSHXYHQWWUHUHPSODFHVSHXSHXSDUGHVFHOOXOHVVDLQHVDSUVXQDUUWSUFRFHGXWDEDF
Le monoxyde de carbone (CO)HVWXQHFDXVHGHWURXEOHVFDUGLRYDVFXODLUHV
Les radicaux libres GH OD IXPH VWLPXOHQW OD GJUDGDWLRQ GH OD SDURL DOYRODLUH HW LQKLEHQW OHV
HQ]\PHVUHVSRQVDEOHVGHVDSURWHFWLRQ

Addiction au tabac

73

Les signes de sevrage apparaissent rapidement aprs arrt brutal ou diminution significative de la
quantit fume : KXPHXUGSUHVVLYHLUULWDELOLWIUXVWUDWLRQFROUHLQVRPQLHDQ[LWGLFXOWV
GHFRQFHQWUDWLRQDXJPHQWDWLRQGHODSSWLWSULVHGHSRLGVFUDYLQJ

7.

La prise en charge
La consommation de tabac est value en Paquets-Anne (PA) : nombre de paquets par jour multipli par le nombre dannes dintoxication tabagique.
Larrt du tabac rduit la mortalit lie aux maladies cardiovasculaires et au cancer broncho-pulmonaire particulirement.
Les facteurs les plus prdictifs darrt du tabac sont un bon niveau socioconomique, une faible
consommation de tabac, labsence dentourage fumeur, une faible consommation dalcool, un
ge de dbut de tabagisme tardif, une dure de tabagisme brve, un long dlai entre lveil et la
premire cigarette, une forte motivation larrt.
Lobjectif de la prise en charge est lobtention de labstinence.

7.1.

Dpistage
7RXV OHV SDWLHQWV GHYUDLHQW IDLUH OREMHW GH PDQLUH V\VWPDWLTXH GXQH YDOXDWLRQ GH OHXU
FRQVRPPDWLRQGHWDEDFHWIDLUHOREMHWGXQVXLYLGHFHOOHFL
/HGSLVWDJHGEXWHHQSRVDQWDXSDWLHQWODTXHVWLRQ fumez-vous ? puis en suivant un algo
ULWKPHGFLVLRQQHOSRXYDQWGERXFKHUVXUODPLVHHQSODFHGXQWUDLWHPHQWGDLGHODUUWGXWDEDF
6L OH SDWLHQW VRXKDLWH DUUWHU LO GHYUD EQFLHU GXQ WHPSV GYDOXDWLRQ GHV FUR\DQFHV HW GHV
DWWHQWHVTXLODYLVYLVGXWDEDJLVPHHWGHVRQDUUW,OGHYUDJDOHPHQWEQFLHUGXQHYDOXD
tion de sa dpendance.

7.2.

Modalit de sevrage

7.2.1. valuation

de la dpendance

Le test de FagerstmHQTXHVWLRQVVHUDXWLOLVPPHVLODTXDOLWSV\FKRPWULTXHGHFHWRXWLOHVW
PDXYDLVH/HUHFRXUVDX[PDUTXHXUVELRORJLTXHVWDX[GHPRQR[\GHGHFDUERQH&2GDQVODLU
H[SLUWDX[XULQDLUHVHWSODVPDWLTXHVGHFRWLQLQHQHVWSDVLQGLVSHQVDEOH
&HSHQGDQW OD PHVXUH GX WDX[ GH &2 GDQV ODLU H[SLU UHWH OD FRQVRPPDWLRQ WDEDJLTXH GHV
KHXUHVSUFGHQWHV&HWWHPHVXUHHVWVLPSOHHHFWXHU(OOHSHXWWUHXWLOLVHSRXUYULHUODEV
WLQHQFHFKH]XQSDWLHQWTXLXWLOLVHGHVVXEVWLWXWVQLFRWLQLTXHHWSRXUPRWLYHUOHVSDWLHQWVIXPHXUV
VDUUWHURXSRXUUHQIRUFHUODEVWLQHQFH
&KH]OHVSDWLHQWVGSHQGDQWVLOHVWUHFRPPDQGGHSURSRVHUXQWUDLWHPHQWPGLFDPHQWHX[TXL
VRXODJHUDOHVV\PSWPHVGHVHYUDJHUGXLUDOHFUDYLQJHWSUYLHQGUDOHVUHFKXWHV
FHWWHYDOXDWLRQGHODGSHQGDQFHLOIDXW\DVVRFLHUOYDOXDWLRQGHVFRPRUELGLWVDQ[LHXVHVHW
GSUHVVLYHVDLQVLTXHOYDOXDWLRQGHVFRDGGLFWLRQV

411

73 Les addictions
7.2.2. Les

psychothrapies

/DSV\FKRWKUDSLHHVWlessentiel de la prise en charge du patient, en association aux traitements

QLFRWLQLTXHVGHVXEVWLWXWLRQ716/HSDWLHQWSHXWEQFLHU
*

'HQWUHWLHQVPRWLYDWLRQQHOVDQGHVXVFLWHURXGHUHQIRUFHUODPRWLYDWLRQDXFKDQJHPHQW

'XQHSV\FKRWKUDSLHGHVRXWLHQ

* 'XQHWKUDSLHFRJQLWLYRFRPSRUWHPHQWDOH7&&DQGDJLUVXUODPRWLYDWLRQDXFKDQJHPHQW

et sur la dpendance comportementale.
* 'XQ DFFRPSDJQHPHQW WOSKRQLTXH OLJQH 7DEDF ,QIR 6HUYLFH  PLVH HQ SODFH SDU OH
PLQLVWUHFKDUJGHOD6DQWHWO,QSHV
,OHVWUHFRPPDQGGDLGHUOHSDWLHQWDQWLFLSHUOHVULVTXHVGHUHFKXWHHQUHSUDQWWRXWHSHQVH
SRXYDQWFRQGXLUHODSULVHGXQHFLJDUHWWHHWOHVVLWXDWLRQVLQFLWDQWKDELWXHOOHPHQWOHSDWLHQW
fumer.

7.2.3. Les

traitements mdicamenteux de premire intention

/HV716DXJPHQWHQWMXVTXOHVFKDQFHVGDEVWLQHQFHPRLV,OVSHUPHWWHQWXQDSSRUW
TXRWLGLHQGHQLFRWLQHVRXVXQHIRUPHGLUHQWHGXWDEDFHQYLWDQWODWR[LFLWGHVFLJDUHWWHV,OV
QHVRQWSOHLQHPHQWHFDFHVTXHVLOVVRQWSUHVFULWVVXVDPPHQWORQJWHPSVXQGRVDJHDGDSW
DXSDWLHQWHWTXHOHVPRGHVGXWLOLVDWLRQHWOHVHHWVLQGVLUDEOHVYHQWXHOVVRQWELHQH[SOLTXV
DXSDWLHQW&RPPHWRXWHVXEVWLWXWLRQLOVSHXYHQWWUHPDLQWHQXVSOXVLHXUVDQQHVVHORQODGSHQ
dance du patient.
Ils existent sous plusieurs formes :
412

* )RUPHVWUDQVGHUPLTXHVWLPEUHVRXSDWFKV : permettent une administration de nicotine sur

24 h ou sur 16 h.
*

)RUPHVRUDOHV
 *RPPHV  PFKHU  OH WDX[ PD[LPDO GH QLFRWLQPLH VREVHUYH    PLQXWHV DSUV OH
GEXWGHODPDVWLFDWLRQ
 &RPSULPVVXFHUSDVWLOOHVVXFHUFRPSULPVVXEOLQJXDX[
 ,QKDOHXUVDSSRUWHQWFKDTXHERXHXQGL[LPHGHODQLFRWLQHOLEUHSDUXQHERXH
GHFLJDUHWWHODGPLQLVWUDWLRQGHQLFRWLQHVDMRXWHODSULVHHQFRPSWHGHODVSHFWJHVWXHO
 6SUD\VEXFFDX[

Lors du traitement, les formes orales peuvent tre associes aux patchs. Les traitements par
WLPEUHV VXSULHXUV   VHPDLQHV QH VHPEOHQW SDV SOXV HFDFHV TXH OHV WUDLWHPHQWV GH GXUH
infrieure.
/HV HHWV LQGVLUDEOHV VRQW PRGUV UJUHVVHQW VSRQWDQPHQW HW UDSLGHPHQW DSUV UHWUDLW
GX GLVSRVLWLI HW GSHQGHQW GHV IRUPHV FSKDOHV G\VJXHXVLH KRTXHWV QDXVHV G\VSHSVLH
GRXOHXUVHWSDUHVWKVLHDXQLYHDXGHVWLVVXVPRXVGHODFDYLWEXFFDOHVWRPDWLWHK\SHUVFUWLRQ
VDOLYDLUHEUOXUHGHVOYUHVVFKHUHVVHGHODERXFKHHWRXGHODJRUJH

Addiction au tabac

7.2.4.Les

73

traitements mdicamenteux de dernire intention

Ils ne montrent pas de supriorit defficacit en comparaison aux TNS.

Varnicline (Champix)
Agoniste partiel des rcepteurs nicotiniques.
,ODLGHVRXODJHUOHVV\PSWPHVGHPDQTXHHWSHUPHWGHUGXLUHOHVHHWVGHSODLVLUOLVDXWDEDJLVPH
/HWUDLWHPHQWGXUHVHPDLQHV3RXUOHVSDWLHQWVTXLRQWUXVVLDUUWHUGHIXPHUODQGHV
12 semaines de traitement, on peut envisager une cure de traitement de 12 semaines supplmentaires.

Contre-indications
$OOHUJLHVJURVVHVVHHWDOODLWHPHQWLQVXVDQFHUQDOHVYUH

Effets indsirables
7URXEOHVGXVRPPHLOQDXVHFRQVWLSDWLRQFSKDOHVSLVRGHGSUHVVLIFDUDFWULVFRPSRUWHPHQWV
suicidaires, hostilit, agitation.

Bupropion (Zyban)
,QKLELWHXUGHODUHFDSWXUHGHODQRUDGUQDOLQHHWGHODGRSDPLQH
,OGLPLQXHOHVV\PSWPHVGXVHYUDJH
/HWUDLWHPHQWGXUHGHVHPDLQHV
Contre-indications
,QVXVDQFHKSDWLTXHVYUHWXPHXUFUEUDOHEQLJQHRXPDOLJQHSLOHSVLHSUH[LVWDQWHPPH
WUDLWHWURXEOHELSRODLUHDQRUH[LHERXOLPLHDFWXHOOHRXDQFLHQQHWRXWWUDLWHPHQWDEDLVVDQWOHVHXLO
SLOSWRJQHVHYUDJHGHODOFRROGHPRLQVGHPRLVRXGHEHQ]RGLD]SLQHVDVVRFLDWLRQDX[,0$2
Effets indsirables
%RXFKHVFKHQDXVHVUDFWLRQVFXWDQHVRXDOOHUJLTXHVLQVRPQLHDQJRLVVHYHUWLJHVFSKDOHV
SLVRGHGSUHVVLIFDUDFWULVFRPSRUWHPHQWVVXLFLGDLUHVFRQYXOVLRQVK\SHUWHQVLRQDUWULHOOHDQJRU
HWRXLQIDUFWXVGXP\RFDUGH

7.2.5. Les

cigarettes lectroniques

/HVFLJDUHWWHVOHFWURQLTXHVGLXVHQWGHODQLFRWLQHGDQVOHVYRLHVUHVSLUDWRLUHV
,O VDJLW GH GLVSRVLWLIV  EDWWHULH TXL GLVSHQVHQW XQ PODQJH GH SURS\OQHJO\FRO HW GH QLFRWLQH
SURSXOV VRXV IRUPH GH YDSHXU HW LQKDO SDU OXWLOLVDWHXU ce jour, aucun effet indsirable ou
cas dintoxication en lien avec la prsence des solvants dans les cigarettes lectroniques na t
rapport (ANSM, 2011)>/DJO\FULQHXWLOLVHFRPPHFRPSOPHQWDXSURS\OQHJO\FROQHGHYUDLW
SDVSURGXLUHGHJD]WR[LTXHDFUROLQHPRLQVGDWWHLQGUHXQHWHPSUDWXUHGHFKDXDJHGDX
PRLQVr&$160@
(QHQ)UDQFHDXFXQW\SHGHFLJDUHWWHOHFWURQLTXHQHGLVSRVHGXQHDXWRULVDWLRQGHPLVH
VXUOHPDUFK3DUDLOOHXUVOHVFLJDUHWWHVOHFWURQLTXHVQHSHXYHQWWUHYHQGXHVHQSKDUPDFLHFDU
HOOHVQHJXUHQWSDVVXUODOLVWHGHVSURGXLWVGRQWODGOLYUDQFH\HVWDXWRULVH

413

73 Les addictions
7.2.6. Prise

en charge long terme

3HUPHWXQHWHQWDWLYHGHPDLQWLHQGHODEVWLQHQFHHWXQHDGDSWDWLRQGXWUDLWHPHQWPGLFDPHQWHX[
XQH VXUYHLOODQFH GH OWDW SV\FKLTXH GH OD FRQVRPPDWLRQ GDXWUHV VXEVWDQFHV SV\FKRDFWLYHV
,OHVWFRQVHLOOGHSURSRVHUXQVXLYLGDXPRLQVVL[PRLV

Test de Fagerstrm
1 - Le matin, combien de temps aprs tre rveill(e) fumez-vous votre premire cigarette ?
D'DQVOHVPLQXWHV

EPLQXWHV

FPLQXWHV

G3OXVGHPLQXWHV

2 - Trouvez-vous difficile de vous abstenir de fumer dans les endroits o cest interdit ?
D2XL

E1RQ

3 - quelle cigarette renonceriez-vous le plus difficilement ?
DODSUHPLUHGHODMRXUQH

EXQHDXWUH


414

4 - Combien de cigarettes fumez-vous par jour, en moyenne ?

DRXPRLQV

E

F

GRXSOXV

5 - Fumez-vous intervalles plus rapprochs durant les premires heures de la matine
que durant le reste de la journe ?
D2XL

E1RQ

6 - Fumez-vous lorsque vous tes malade au point de devoir rester au lit
presque toute la journe ?
D2XL

E1RQ

Interprtation
(QWUHHW

Pas de dpendance

(QWUHHW

Dpendance faible

(QWUHHW

Dpendance moyenne

(QWUHHW

Dpendance forte ou trs forte

Addiction au tabac

73

Rsum
(Q)UDQFHOHWDEDJLVPHDFWLIHVWODSUHPLUHFDXVHGHGFVYLWDEOHDYHFGFVSUPDWX
rs chaque anne.
/DGXUHGXWDEDJLVPHHVWOHIDFWHXUGHULVTXHOHSOXVLPSRUWDQWGHFRPSOLFDWLRQVOLHVDXWDEDF
7RXVOHVSURIHVVLRQQHOVGHVDQWGHYUDLHQWVLPSOLTXHUGDQVODSUYHQWLRQGHOLQWR[LFDWLRQWDED
JLTXHGVOJHVFRODLUHHWGDQVODLGHODUUWGXWDEDF
La nicotine induit la dpendance.
/HV FRPSOLFDWLRQV PGLFDOHV QRQ SV\FKLDWULTXHV VRQW QRPEUHXVHV OH OLHQ HVW WDEOL HQWUH OHV
WURXEOHVDQ[LRGSUHVVLIVHWOHWDEDJLVPH
/REMHFWLIGHODSULVHHQFKDUJHHVWOREWHQWLRQGHODEVWLQHQFH
/HWHVWGH)DJHUVWPSHUPHWGYDOXHUODGSHQGDQFH
/DSV\FKRWKUDSLHHVWOHVVHQWLHOGHODSULVHHQFKDUJHGXSDWLHQWHQDVVRFLDWLRQDX[WUDLWHPHQWV
QLFRWLQLTXHVGHVXEVWLWXWLRQ716
/HV716DXJPHQWHQWMXVTXOHVFKDQFHVGDEVWLQHQFHPRLVHWH[LVWHQWVRXVSOXVLHXUV
formes.
/HVWUDLWHPHQWVPGLFDPHQWHX[GHGHUQLUHLQWHQWLRQYDUQLFOLQHEXSURSLRQQHPRQWUHQWSDV
GHVXSULRULWGHFDFLWHQFRPSDUDLVRQDX[716

415

Points clefs
/HVDGGLFWLRQVUHSUVHQWHQWXQSUREOPHPDMHXUGHVDQWSXEOLTXH
/DGSHQGDQFHQHVHGQLWQLSDUUDSSRUWXQVHXLORXXQHIUTXHQFHGHFRQVRPPDWLRQQLSDUOH[LVWHQFHGHGRPPDJHV
LQGXLWVPDLVSDUODSHUWHGHODOLEHUWGHVDEVWHQLU
/HWDEDFSUVHQWHOHSRWHQWLHODGGLFWLIOHSOXVIRUW
/JHPR\HQORUVGHODSUHPLUHFLJDUHWWHHVWGHDQV
GHVGFVSDUFDQFHUVEURQFKRSXOPRQDLUHVVRQWOLVDXWDEDJLVPH
La nicotine induit la dpendance.
/HV PR\HQV GH SULVH HQ FKDUJH DVVRFLHQW OHV SV\FKRWKUDSLHV OHV WUDLWHPHQWV PGLFDPHQWHX[ GH SUHPLUH HW GH
GHUQLUHLQWHQWLRQ
/DSULVHHQFKDUJHORQJWHUPHSHUPHWXQPDLQWLHQGHODEVWLQHQFHXQHDGDSWDWLRQGXWUDLWHPHQWPGLFDPHQWHX[HWXQH
VXUYHLOODQFHUJXOLUHGXSDWLHQW

Rfrences pour approfondir

,QVWLWXWQDWLRQDOGHSUYHQWLRQHWGGXFDWLRQSRXUODVDQWwww.inpes.sante.fr
5HFRPPDQGDWLRQGHERQQHSUDWLTXH$UUWGHODFRQVRPPDWLRQGHWDEDFGXGSLVWDJHLQGLYLGXHO
DXPDLQWLHQGHODEVWLQHQFHHQSUHPLHUUHFRXUVwww.has-sante.fr

item 74

Addiction lalcool
I. Introduction
II. SLGPLRORJLH
III. 6PLRORJLHSV\FKLDWULTXH
IV. /HWURXEOHSV\FKLDWULTXH
V. &RPRUELGLWVPGLFDOHVSV\FKLDWULTXHV
VI. 1RWLRQVGHSK\VLRSDWKRORJLH
VII./DSULVHHQFKDUJHSV\FKLDWULTXH

Objectifs pdagogiques
* 5HSUHUGLDJQRVWLTXHUYDOXHUOHUHWHQWLVVHPHQWGXQHDGGLFWLRQODOFRRO
* ([SOLTXHUOHVLQGLFDWLRQVHWSULQFLSHVGXVHYUDJHWKUDSHXWLTXH
* $UJXPHQWHUODWWLWXGHWKUDSHXWLTXHHWSODQLHUOHVXLYLGXSDWLHQW

74

74

Les addictions

1.

Introduction
/DOFRRORGSHQGDQFH SDWKRORJLH FRPSOH[H HW KWURJQH SRVH XQ SUREOPH PDMHXU GH VDQW
SXEOLTXH
/HV DSSURFKHV FOLQLTXHV DFWXHOOHV GH OD GSHQGDQFH  ODOFRRO VRQW LVVXHV GHV GHVFULSWLRQV GH
(GZDUGVHWGH*URVVHQTXLRQWSURSRVVHSWFDUDFWULVWLTXHVGXV\QGURPHGHGSHQGDQFH
 ODOFRRO [DWLRQ SURJUHVVLYH GHV PRGDOLWV GH FRQVRPPDWLRQ GH ODOFRRO SUPLQHQFH GHV
FRPSRUWHPHQWV GH UHFKHUFKH GH ODOFRRO DXJPHQWDWLRQ GH OD WROUDQFH YLWHPHQW GX VHYUDJH
VHQWLPHQWVXEMHFWLIGXQHFRPSXOVLRQERLUHV\PSWPHVGHVHYUDJHUFXUUHQWVULQVWDOODWLRQ
DX GFRXUV GH ODEVWLQHQFH HW GH FHOOHV GX JURXSH GH[SHUWV GH O2UJDQLVDWLRQ 0RQGLDOH GH OD
6DQW206HQTXLDSURSRVGHUHPSODFHUOHWHUPHmDOFRROLVPH}SDUFHOXLGHmV\QGURPH
GHGSHQGDQFHDOFRROLTXH}
5DGRXFR7KRPDVHWal.HQHW6FKXFNLWHQGLVWLQJXHQWGDQVXQHSHUVSHFWLYHSLGPLR
ORJLTXHHWFOLQLTXHGHX[IRUPHVGDOFRROLVPHODOFRROLVPHSULPDLUHHWODOFRROLVPHVHFRQGDLUH
Lalcoolisme primaireTXLUHSUVHQWHUDLWGHVIRUPHVGDOFRROLVPHUHJURXSHOHVIRUPHVR
ODOFRROLVPHHVWOHSUHPLHUWURXEOHLQVWDOOFKH]OHVXMHW
Lalcoolisme secondaire TXL UHSUVHQWHUDLW  GHV IRUPHV GDOFRROLVPH VH GQLW SDU XQH
FRQGXLWHDOFRROLTXHVHFRQGDLUHXQWURXEOHSV\FKLDWULTXHRXXQWURXEOHGHODSHUVRQQDOLW
&HWWHFODVVLFDWLRQDGHVFRQVTXHQFHVVXUODSULVHHQFKDUJHWKUDSHXWLTXHGHVSDWLHQWV
'DQVOHFDGUHGXQDOFRROLVPHSULPDLUHODSULVHHQFKDUJHHVWFHQWUHVXUODFRQGXLWHDOFRROLTXH
'DQV OH FDGUH GXQ DOFRROLVPH VHFRQGDLUH OD SULVH HQ FKDUJH HVW GRXEOH D[H VXU OD FRQGXLWH
DOFRROLTXHHWVXUOHWURXEOHDQWULHXUODOFRROLVDWLRQTXLDIDYRULVHWDFRQWULEXDXPDLQWLHQGH
la conduite alcoolique.

418

*UFH  FHV WUDYDX[ OHV FODVVLFDWLRQV LQWHUQDWLRQDOHV '60,975 HW &,0 GLVWLQJXHQW OH
V\QGURPHGHGSHQGDQFHODOFRROGHODEXV'60,975RXGHOXVDJHQRFLIGDOFRRO&,0
FI,WHPm,QWURGXFWLRQ}

2.

pidmiologie
/DOFRROHVWODVXEVWDQFHSV\FKRDFWLYHODSOXVFRQVRPPHHQSRSXODWLRQJQUDOHDGXOWHHWODSOXV
FRQVRPPHOJHGHDQV
/DFRQVRPPDWLRQGDOFRROSXUHVWGHOLWUHVGDOFRROSXUSDUKDELWDQWHWSDUDQHQHOOH
WDLWHVWLPHHQ
/DSUHPLUHLYUHVVHDOLHXHQPR\HQQHOJHGHDQV
2QHVWLPHPLOOLRQVOHQRPEUHGHSHUVRQQHVTXLHQFRQVRPPHQWDXPRLQVUHSULVHVSDU
VHPDLQHHWPLOOLRQVOHQRPEUHGHSHUVRQQHVTXLHQFRQVRPPHQWWRXVOHVMRXUV
/HQRPEUHGHFRQVRPPDWHXUVULVTXHHVWGHPLOOLRQV
6XUOHVDQVVRQWFRQVLGUVFRPPHD\DQWRXD\DQWHXXQXVDJHSUREOPDWLTXHGDOFRRO
/DSUYDOHQFHGHODOFRRORGSHQGDQFHHVWHVWLPH3 % de la population gnrale. La prdo
PLQDQFHPDVFXOLQHHVWQHWWH/HVSRO\GSHQGDQFHVGDXWUHVVXEVWDQFHVSV\FKRDFWLYHVVRQW
frquentes.
$X QLYHDX PRQGLDO ODOFRRO HVW OH e IDFWHXU GH ULVTXH GH PRUELGLW DSUV OK\SHUWHQVLRQ HW OH
WDEDF

Addiction lalcool

74

/HVSUDQFHGHYLHHVWUGXLWHGHDQVFKH]OHVSDWLHQWVGSHQGDQWVODOFRRO
(Q )UDQFH ODOFRRORGSHQGDQFH HVW OD GHX[LPH FDXVH GH GFV YLWDEOH DSUV OH WDEDF
GFVVRQWGLUHFWHPHQWOLVODFRQVRPPDWLRQGDOFRRO
La dpendance est le fait de la rencontre entre une personne, un produit et un environnement.
/HV GWHUPLQDQWV LQGLYLGXHOV FRPSUHQQHQW GHV IDFWHXUV SV\FKRORJLTXHV GH SHUVRQQDOLW HW
gntiques.
/HV FDUDFWULVWLTXHV OLHV DX SURGXLW VRQW VHV SRWHQWLDOLWV WR[LFRPDQRJQHV VHV FDSDFLWV 
LQGXLUHXQHGSHQGDQFHOHVTXDQWLWVFRQVRPPHVOHVGXUHVHWOHVPRGHVGHFRQVRPPDWLRQ
/HVGWHUPLQDQWVHQYLURQQHPHQWDX[VRQWOHVIDFWHXUVGH[SRVLWLRQXQSURGXLWPDLVVXUWRXWOH
moment socioculturel.
La dpendance est une conduite dalcoolisation caractrise par la perte de la matrise de la
consommation. Elle ne se dfinit donc ni par rapport un seuil ou une frquence de consommation,
ni par lexistence de dommages induits.

3.

Smiologie psychiatrique

3.1.

Intoxication alcoolique aigu

/LQWR[LFDWLRQDOFRROLTXHDLJXLYUHVVHFRQVWLWXHXQPVXVDJHGDOFRROWPRLJQHGHODQHXUR
WR[LFLW GH OWKDQRO HW UHSUVHQWH XQH urgence mdicale FDU HOOH SHXW DVVRFLHU GHV WURXEOHV GX
comportement et des complications mdicales ou chirurgicales.
(OOHSHXWHQWUDQHUHQWUHDXWUHVGHVSHUWXUEDWLRQVGHODFRQVFLHQFHGHVIDFXOWVFRJQLWLYHVGH
ODSHUFHSWLRQGXMXJHPHQWGHODHFWRXGXFRPSRUWHPHQW
/HGLDJQRVWLFHVWOHSOXVVRXYHQWEDVVXUGHVOPHQWVGHODQDPQVHHWGHOH[DPHQFOLQLTXH
2QGLVWLQJXHlivresse simple, les ivresses pathologiques et les ivresses compliques.
Livresse simpleVHFDUDFWULVHSDUODSUVHQFHGXQHKDOHLQHFDUDFWULVWLTXHQROLTXHGHOLQ
MHFWLRQ GHV FRQMRQFWLYHV GXQH ORJRUUKH GXQH GVKLQLELWLRQ GXQ FRPSRUWHPHQW SRXYDQW
WUHDJUHVVLIGXQHG\VDUWKULHGXQHLQFRRUGLQDWLRQPRWULFHGXQWHPSVGHUDFWLRQDOORQJGH
WURXEOHVGHOTXLOLEUH
Les ivresses pathologiques peuvent tre :
* Excito-motriceDYHFGHVGHJUVGLYHUVLPSXOVLYLWHWSRVVLELOLWGHFULVHVFODVWLTXHVDYHF
DXWRHWRXKWURDJUHVVLYLW
* Dlirante DYHF SUVHQFH GLGH GOLUDQWH GH SHUVFXWLRQ GH MDORXVLH RX GH JUDQGHXU HWRX
GKDOOXFLQDWLRQV
*

Dpressive ou hypomaniaque.

ConvulsivanteDYHFFULVHFRQYXOVLYHFKH]XQVXMHWSUGLVSRV

Les ivresses sont dites compliquesORUVTXHOOHVVRQWDVVRFLHVXQWUDXPDWLVPHFUQLHQGHV

SRO\WUDXPDWLVPHVYRLUHGDXWUHVLQWR[LFDWLRQV
Le coma alcoolique (souvent lorsque lalcoolmie est suprieure 3 g/l) peut associer :
* 'HVVLJQHVQHXURORJLTXHVFRPDFDOPHK\SRWRQLTXHVDQVVLJQHVQHXURORJLTXHVGHORFDOLVD
WLRQP\GULDVHELODWUDOHHWV\PWULTXH
*

'HVVLJQHVUHVSLUDWRLUHVGSUHVVLRQUHVSLUDWRLUHDYHFULVTXHGDQR[LH

419

74

Les addictions

'HVVLJQHVFLUFXODWRLUHVK\SRWHQVLRQDUWULHOOHEUDG\FDUGLHFROODSVXVFDUGLRYDVFXODLUH

8QHK\SRWKHUPLH

'DQVFHFRQWH[WHGHFRPDDOFRROLTXHLOIDXGUDUHFKHUFKHUXQHK\SRJO\FPLHXQHDFLGRFWRVHHW
XQHK\SRQDWUPLHFDUFHVWURXEOHVSHXYHQWHQJDJHUOHSURQRVWLFYLWDO

3.2.

Intoxication alcoolique chronique et complications

/HVVLJQHVFOLQLTXHVGLPSUJQDWLRQFKURQLTXHVRQWQRQVSFLTXHVPDLVSHXYHQWFRQVWLWXHUGHV
VLJQHVGDOHUWHYDULFRVLWVIDFLDOHVLQMHFWLRQFRQMRQFWLYDOHWUPXODWLRQVGHVH[WUPLWVK\SHU
VXGDWLRQSDURWLGRPJDOLHWDFK\FDUGLHK\SHUWHQVLRQDUWULHOOHV\VWROLTXHKSDWRPJDOLHSRO\
QYULWHLUULWDELOLW

&RPSOLFDWLRQVGXQHLQWR[LFDWLRQDOFRROLTXHFKURQLTXHOLVWHQRQH[KDXVWLYH
Encphalopathies
Encphalopathie de Gayet-Wernicke
'XHOHSOXVVRXYHQWXQHFDUHQFHHQYLWDPLQH%(OOHSHXWDVVRFLHU
XQV\QGURPHFRQIXVLRQQHOGHVVLJQHVRFXORPRWHXUVXQV\QGURPH
FUEHOOHX[VWDWLTXHHWXQHK\SHUWRQLHRSSRVLWLRQQHOOH
Encphalopathie hpatique
7DEOHDXGHFRQIXVLRQPHQWDOHDVVRFLHXQDVWUL[LV
Encphalopathie pellagreuse
'XHXQHFDUHQFHHQYLWDPLQH33

420

Le syndrome de Korsakoff
&RQVTXHQFHGXQHHQFSKDORSDWKLHGH*D\HW:HUQLFNH,ODVVRFLH
XQHDPQVLHDQWURJUDGHGHVIDXVVHVUHFRQQDLVVDQFHVGHVIDEXOD
WLRQVXQHDQRVRJQRVLHHWXQHGVRULHQWDWLRQWHPSRURVSDWLDOH
Neurologiques

Encphalopathie de Marchiafava-Bignami
Lpilepsie
Le plus souvent gnralise
Polyneuropathies sensitivo-motrices
$VVRFLDWLRQGHFUDPSHVQRFWXUQHVGHGRXOHXUVSUHVVLRQGHV
PROOHWVGXQHK\SRHVWKVLHHWGXQHDUH[LHDFKLOOHQQH
Neuropathie optique
Myopathies
Atrophie crbelleuse

Hpatogastro-entrologiques

+SDWLWHDOFRROLTXHDLJX
Statose hpatique
Cirrhose hpatique
3DQFUDWLWHDLJXSDQFUDWLWHFKURQLTXH

Addiction lalcool

Cardiovasculaires

4.

74

HTA
7URXEOHVGXU\WKPH
&DUGLRP\RSDWKLHV

Rhumatologiques

Ncrose de la tte fmorale

Traumatiques

7UDXPDWLVPHVFUQLHQV
+PDWRPHVFUEUDX[
+PRUUDJLHVFUEUDOHVRXPQLQJHV

Carcinologiques

&DQFHUSLGHUPRGHGHOVRSKDJH
Cancer du pancras

Hmatologiques

3DUWR[LFLWGLUHFWHOLHVOKSDWRSDWKLHDOFRROLTXHRXDX[FDUHQFHV
nutritionnelles
/HXFRSQLHWKURPERSQLHDQPLH

Endocrinologiques

+\SRJO\FPLHV

Obsttricales

6\QGURPHGDOFRROLVDWLRQIWDOULVTXHGDFFRXFKHUGHQRXUULVVRQVVRXI
IUDQWGXQHG\VPRUSKLHHWGXQUHWDUGPHQWDO

Le trouble psychiatrique
421

4.1.

Diagnostics positifs
3RXUUDSSHO lusageFRUUHVSRQGWRXWHFRQGXLWHGDOFRROLVDWLRQQHSRVDQWSDVGHSUREOPHSRXU
DXWDQWTXHODFRQVRPPDWLRQUHVWHPRGUHFHVWGLUHLQIULHXUHRXJDOHDX[VHXLOVGQLVSDU
ORUJDQLVDWLRQPRQGLDOHSRXUODVDQW206HWSULVHHQGHKRUVGHWRXWHVLWXDWLRQULVTXHRXGH
risque individuel particulier.
Les seuils dfinis par lOMS sont les suivants :
*

-DPDLVSOXVGHYHUUHVSDURFFDVLRQSRXUOXVDJHSRQFWXHO

3DVSOXVGHYHUUHVSDUVHPDLQHSRXUOXVDJHUJXOLHUFKH]OKRPPHYHUUHVMRXUHQPR\HQQH

3DVSOXVGHYHUUHVSDUVHPDLQHSRXUOXVDJHUJXOLHUFKH]ODIHPPHYHUUHVMRXUHQPR\HQQH

6DEVWHQLUDXPRLQVXQMRXUSDUVHPDLQHGHWRXWHFRQVRPPDWLRQGDOFRRO

/XQLWGHPHVXUHHVWOHverre standard qui correspond un verre contenant 10 grammes dalcool pur.

([HPSOHV: une bire de 33 cl (5 %) = un ballon de vin de 100 ml (12 %) = un verre de spiritueux de
30 ml (40 %) = 10 grammes dalcool pur.

4.1.1. Diagnostic

dabus dalcool (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

4.1.2. Diagnostic

de dpendance lalcool (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

74

Les addictions

4.1.3. Diagnostic

de syndrome de sevrage de lalcool

DSM-IV-TR
Critres diagnostiques
A.$UUWRXUGXFWLRQGXQHXWLOLVDWLRQGDOFRROTXLDWPDVVLYHHWSURORQJH
B.$XPRLQVGHX[GHVPDQLIHVWDWLRQVVXLYDQWHVVHGYHORSSHQWGHTXHOTXHVKHXUHVTXHOTXHVMRXUVDSUVOHFULWUHA :
 +\SHUDFWLYLWQHXURYJWDWLYH
 $XJPHQWDWLRQGXWUHPEOHPHQWGHVPDLQV
 Insomnie
 Nauses ou vomissements
 Hallucinations ou illusions transitoires visuelles, tactiles ou auditives
 $JLWDWLRQSV\FKRPRWULFH
 Anxit
 &ULVHFRQYXOVLYHGHW\SHmJUDQGPDO}
C./HVV\PSWPHVGXFULWUH%FDXVHQWXQHVRXUDQFHFOLQLTXHPHQWVLJQLFDWLYHRXXQHDOWUDWLRQGXIRQFWLRQQHPHQW
VRFLDOSURIHVVLRQQHORXGDQVGDXWUHVGRPDLQHVLPSRUWDQWV
D./HVV\PSWPHVQHVRQWSDVGXVXQHDHFWLRQPGLFDOHJQUDOHHWQHVRQWSDVPLHX[H[SOLTXVSDUXQDXWUHWURXEOH
mental.

Des accidents de sevrage peuvent survenir et justifient une hospitalisation :

Le dlirium tremens (DT)

422

/HVVLJQHVGHGEXWGRLYHQWWUHGSLVWVVLJQHVGHVHYUDJHVXHXUVWUHPEOHPHQWGDWWLWXGH

GHVPDLQVGHODERXFKHGHODODQJXHFDXFKHPDUVLQVRPQLHLUULWDELOLWDQ[LW
En labsence de traitementLO\DXUDODPDQLIHVWDWLRQGXQV\QGURPHFRQIXVLRQQHODYHF
*

Agitation.

3URSRVLQFRKUHQWV

Dlire onirique avec vcu dlirant intense.

,QYHUVLRQGXU\WKPHQ\FWKPUDO

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* 6FQHVGDJUHVVLRQTXLSHXYHQWWUHODFDXVHGDJUHVVLYLWHWGHUDFWLRQVGHIUD\HXUFKH]OH
patient.
/HV VLJQHV SK\VLTXHV DVVRFLHQW YUH VXHXUV SURIXVHV GVK\GUDWDWLRQ PRGLFDWLRQ GH OD
WHQVLRQWDFK\FDUGLHWURXEOHVGXU\WKPH'HVFULVHVGSLOHSVLHXQWDWGHPDOSHXYHQWVXUYHQLU
et constitueront des signes de gravit.

Les crises convulsives

(OOHVVRQWFDUDFWULVHVSDUOHXUGEXWSUFRFHGDQVOHVKHXUHVVXLYDQWODGLPLQXWLRQRXODUUW
GHODOFRRO,OVDJLWOHSOXVVRXYHQWGHFULVHVJQUDOLVHVWRQLFRFORQLTXHV
/HVDXWUHVFDXVHVGHFULVHVFRQYXOVLYHVOLPLQHUSHXYHQWWUH
*

8QHK\SRJO\FPLH

8QHK\SRQDWUPLH

8QHFDXVHLQIHFWLHXVHLQIHFWLRQFUEUDOHRXPQLQJH

8QHLQWR[LFDWLRQPGLFDPHQWHXVH

8QDFFLGHQWYDVFXODLUHFUEUDOLVFKPLTXHRXKPRUUDJLTXH

Addiction lalcool

5.

74

Comorbidits mdicales psychiatriques

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&HVWURXEOHVSHXYHQWWUHSULPDLUHVDYDQWOLQVWDOODWLRQGXFRPSRUWHPHQWULVTXHHWGHODGSHQ
GDQFHRXVHFRQGDLUHV/DQDPQVHDLQVLTXHOHVHYUDJHSRXUURQWSHUPHWWUHGHSUFLVHUOHFDUDF
WUHGHFHVWURXEOHV
/HWURXEOHELSRODLUHHVWIRLVSOXVIUTXHQWFKH]OHVSDWLHQWVDOFRRORGSHQGDQWVSDUUDSSRUWOD
population gnrale.
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DEXVLYHGDOFRRO
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YLQJWIRLVSOXVGDEXVGDXWUHVVXEVWDQFHVFKH]OHVSHUVRQQHVGSHQGDQWHVODOFRROTXHGDQVOD
population gnrale.
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XQHDXWUHVXEVWDQFHFDQQDELVFRFDQHHWOKURQH

6.

Notions de physiopathologie
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DJLWVRQWQRPEUHX[0DOJUODVLPSOLFLWFKLPLTXHGHFHWWHPROFXOHHOOHH[HUFHGHVHHWVHWGHV
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OLQWHVWLQJUOH/DGLVWULEXWLRQHVWUDSLGHSRXUWRXVOHVRUJDQHVWUVYDVFXODULVVHWOOLPLQDWLRQ
VHIDLWSRXUSDUYRLHPWDEROLTXHOHUHVWHGHOWKDQROWDQWOLPLQVRXVIRUPHLQFKDQ
ge par les poumons.
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GHVUFHSWHXUVHWGRQFHQPRGLDQWOHXUDQLW/HVGLUHQWVV\VWPHVGHQHXURWUDQVPLVVLRQ
SHUWXUEV VRQW OHV V\VWPHV FKROLQHUJLTXH VURWRQLQHUJLTXH GRSDPLQHUJLTXH *$%$HUJLTXH
celui des acides amins excitateurs et des neuropeptides.
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WLRQHWGHGFLVLRQHQDJLVVDQWVXUOHV\VWPHGHUFRPSHQVH/DUULYHGXQVLJQDODQQRQDQWXQH
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ODLUHWHJPHQWDOHYHQWUDOHTXLOLEUHQWGHODGRSDPLQHYHUVOHQR\DXDFFXPEHQVHWYHUVOHFRUWH[
prfrontal.

423

74

Les addictions

7.

La prise en charge psychiatrique

7.1.

Stratgies de prvention
(Q )UDQFH OHV FDPSDJQHV JRXYHUQHPHQWDOHV GH SUYHQWLRQ QDSSDUDLVVHQW TX OD Q GHV
annes 1960.
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/HUHSUDJHGHVFRQVRPPDWHXUVH[FHVVLIVRXULVTXHHVWGRQFWUVLPSRUWDQWPPHVLOHVSDWLHQWV
QHFRQVXOWHQWSDVSRXUFHSUREOPH,OGHYUDLWWUHHHFWXFKH]WRXVOHVSDWLHQWVUJXOLUHPHQW
SDUXQHDQDPQVHSRUWDQWVXUODTXDQWLWHWODIUTXHQFHPR\HQQHKHEGRPDGDLUHGHODFRQVRP
PDWLRQGDOFRROODFRQVRPPDWLRQGFODUHGDOFRROCDAQRPEUHGRFFDVLRQVSDUVHPDLQHHW
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Des questionnaires de dpistage peuvent aider les praticiens comme le questionnaire AUDIT
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7URS$OFRRO
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7UDQVIHUULQ&'7@QRQWSDVGXWLOLWHQUHSUDJHGHURXWLQHFKH]GHVSHUVRQQHVDV\PSWRPDWLTXHV

424

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Questionnaire AUDIT
1. Quelle est la frquence de votre consommation dalcool ?
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IRLVSDUPRLV

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Au moins 4 fois par semaine
4
2. Combien de verres contenant de lalcool consommez-vous un jour typique o vous buvez ?
RX

RX

RX

10 ou plus
4
3. Avec quelle frquence buvez-vous six verres ou davantage lors dune occasion particulire ?
-DPDLV

0RLQVGXQHIRLVSDUPRLV

8QHIRLVSDUPRLV

8QHIRLVSDUVHPDLQH

Tous les jours ou presque
4

Addiction lalcool

74

4. Au cours de lanne coule, combien de fois avez-vous constat que vous ntiez plus capable de vous arrter de
boire une fois que vous aviez commenc ?
-DPDLV

0RLQVGXQHIRLVSDUPRLV

8QHIRLVSDUPRLV

8QHIRLVSDUVHPDLQH

Tous les jours ou presque
4
5. Au cours de lanne coule, combien de fois votre consommation dalcool vous a-t-elle empch de faire ce qui tait
normalement attendu de vous ?
-DPDLV

0RLQVGXQHIRLVSDUPRLV

8QHIRLVSDUPRLV

8QHIRLVSDUVHPDLQH

Tous les jours ou presque
4
6. Au cours de lanne coule, combien de fois avez-vous eu besoin dun premier verre pour pouvoir dmarrer aprs
avoir beaucoup bu la veille ?
-DPDLV

0RLQVGXQHIRLVSDUPRLV

8QHIRLVSDUPRLV

8QHIRLVSDUVHPDLQH

Tous les jours ou presque
4
7. Au cours de lanne coule, combien de fois avez-vous eu un sentiment de culpabilit ou des remords aprs avoir
bu ?
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Tous les jours ou presque
4
8. Au cours de lanne coule, combien de fois avez-vous t incapable de vous rappeler ce qui stait pass la soire
prcdente parce que vous aviez bu ?
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Tous les jours ou presque
4
9. Avez-vous t bless ou quelquun dautre a-t-il t bless parce que vous aviez bu ?
Non
0
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10. Un parent, un ami, un mdecin ou un autre soignant sest-il inquit de votre consommation dalcool
ou a-t-il suggr que vous la rduisiez ?
Non
0
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2XLDXFRXUVGHODQQH


Interprtation
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425

74

Les addictions

Questionnaire DETA
DETA = Diminuer Entourage Trop Alcool
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Interprtation
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XVDJHQRFLIRXDOFRRORGSHQGDQFH

7.2.

Prise en charge de livresse aigu

et des complications de sevrage

7.2.1. Prise

426

en charge de livresse aigu

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FDWLRQDYHFGDXWUHVVXEVWDQFHVGHVKPDWRPHVLQWUDFUQLHQVRXGHVKPRUUDJLHVPQLQJHV
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UDQLPDWLRQSHXWVDYUHUQFHVVDLUH

7.2.2. Prise

en charge des complications de sevrage

Le DT :
*

Hospitalisation en ranimation, examen clinique complet.

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5K\GUDWDWLRQLQWUDYHLQHXVHHWFRUUHFWLRQGHVWURXEOHVK\GUROHFWURO\WLTXHV

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Les crises convulsives :

*

Le traitement reste celui du sevrage.

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Addiction lalcool

7.3.

74

Modalit de sevrage
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VWUXFWXUHVGKRVSLWDOLVDWLRQOHVVWUXFWXUHVGHSRVWFXUHHWOHVVWUXFWXUHVGHVRLQVGHVXLWHKSL
WDX[GHMRXU
/HVHYUDJHGHODOFRROSHXWWUHUDOLVen ambulatoire ou lors dune hospitalisation.
/H VHYUDJH DPEXODWRLUH HVW UDOLV OH SOXV VRXYHQW VRXV OD VXUYHLOODQFH PGLFDOH GX PGHFLQ
traitant.
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DFTXULUOHVPR\HQVGHPDLQWHQLUVRQDEVWLQHQFHGDQVGHERQQHVFRQGLWLRQVHWYROXHUYHUV
XQHPHLOOHXUHTXDOLWGHYLH(OOHVSURSRVHQWGHVSURJUDPPHVWKUDSHXWLTXHVDOODQWGHTXHOTXHV
VHPDLQHVMXVTXTXHOTXHVPRLV
Les quipes sont pluridisciplinaires et sont composes de mdecins alcoologues, mdecins
SV\FKLDWUHVLQUPLHUVDVVLVWDQWVVRFLDX[SV\FKRORJXHVGLWWLFLHQVHUJRWKUDSHXWHVDQLPD
teurs, ducateurs, secrtaires.
Le sevrage comprend :
*

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* 8QH VGDWLRQ SDU EHQ]RGLD]SLQHV GLD]SDP RX R[D]SDP MXVTX GLVSDULWLRQ GHV V\PS
tmes de sevrage et avec dcroissance progressive.
*

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Avant un sevrage et durant la prise en charge, les motivations et les objectifs du patient sont
valus lors dentretiens motivationnels.

7.4.

Prise en charge au long cours

7.4.1. Les

traitements mdicamenteux

'HV WUDLWHPHQWV PGLFDPHQWHX[ SHXYHQW DLGHU DX PDLQWLHQ GH ODEVWLQHQFH ODFDPSURVDWH OD
QDOWU[RQHOHGLVXOUDPHWOHEDFORIQH
Lacamprosate permet de normaliser la drgulation du glutamate mdie par le NMDA. Ce mca
QLVPHGDFWLRQSHUPHWGHUGXLUHOHFUDYLQJmQJDWLI}OLDXVWUHVV
La naltrexoneHVWXQDQWDJRQLVWHRSLRGHTXLGLPLQXHOHVHHWVGHUFRPSHQVHGHODFRQVRPPD
WLRQGDOFRRO
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GH OD FRQFHQWUDWLRQ HQ DFWDOGK\GH ,O SURYRTXH DLQVL XQ HHW DQWDEXVH ERXHV GH FKDOHXU
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OHPDLQWLHQGHODEVWLQHQFHHWODUGXFWLRQGXWDX[GHUHFKXWH&HWWHPROFXOHIDLWDFWXHOOHPHQW
OREMHWGXQHUHFRPPDQGDWLRQWHPSRUDLUHGXWLOLVDWLRQ578

427

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Les addictions

7.4.2.Mesures

associes

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SUFDULW/DSULVHHQFKDUJHHVWPGLFRSV\FKRVRFLDOH
La motivationGXSDWLHQWHVWXQOPHQWFHQWUDOGXVXFFVGXWUDLWHPHQW
2Q D UHFRXUV  OD PLVH HQ SODFH GH psychothrapies LQGLYLGXHOOH W\SH 7&& GH JURXSH SRXU
SHUPHWWUH DX SDWLHQW GXWLOLVHU GHV VWUDWJLHV FRJQLWLYHV HW GHV DSWLWXGHV FRPSRUWHPHQWDOHV
FRQWULEXDQWIDYRULVHUOHVXFFVGHODSULVHHQFKDUJH
/LQFOXVLRQODSULVHHQFKDUJHGHPHPEUHVGHODfamille peut tre un lment supplmentaire
GDQVODLGHDSSRUWHDXSDWLHQW
8QH prise en charge sociale est mise en place.
Le patient peut tre orient vers les associations danciens buveurs $OFRROLTXHV DQRQ\PHV
9LHOLEUH

Rsum
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428

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simple, les ivresses pathologiques et les ivresses compliques.
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La prise en charge au long cours est pluridisciplinaire.

Addiction lalcool

74

Points clefs
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La dpendance est le fait de la rencontre entre une personne, un produit et un environnement.
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*
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Rfrences pour approfondir

www.sfalcoologie.asso.fr
ZZZKDVVDQWHIU
/HMR\HX[0Addictologie.(OVHYLHU+HDOWK6FLHQFHV
&RUFRV0)ODPHQW0 -HDPPHW3Les conduites de dpendance : dimensions psychopathologiques communes.0DVVRQ
5R\HU&ROODUG+/De lusage et de labus des boissons fermentes et distilles.$*X\RW

429

item 75

Addiction aux mdicaments

psychotropes
(benzodiazpines et apparents)
I. Introduction
II. SLGPLRORJLH
III. 'QLWLRQV
IV. /HWURXEOHSV\FKLDWULTXH
V. 1RWLRQVGHSK\VLRSV\FKRSDWKRORJLH
VI. /DSULVHHQFKDUJHSV\FKLDWULTXH

Objectifs pdagogiques
* 5HSUHUGLDJQRVWLTXHUYDOXHUOHUHWHQWLVVHPHQWGXQHDGGLFWLRQ
DX[PGLFDPHQWVSV\FKRWURSHVEHQ]RGLD]SLQHVHWDSSDUHQWV
* Indications et principes du sevrage thrapeutique.
* $UJXPHQWHUODWWLWXGHWKUDSHXWLTXHHWSODQLHUOHVXLYLGXSDWLHQW

75

75

Les addictions

1.

Introduction
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)UDQFHHWHQ(XURSH(QVHORQFHUWDLQHVGRQQHVHXURSHQQHVOD)UDQFHWDLWOHGHX[LPH
SD\VHXURSHQFRQVRPPDWHXUVGDQ[LRO\WLTXHVGHUULUHOH3RUWXJDOHWGK\SQRWLTXHVGHUULUH
OD6XGH
,OV VRQW XWLOLVV  YLVH DQ[LRO\WLTXH VGDWLYH HW K\SQRWLTXH PDLV JDOHPHQW P\RUHOD[DQWH HW
anticonvulsivante.
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RSSRVDEOHV&HVGHUQLUHVQRQFHQWOHIDLWTXLOQ\DSDVOLHXGDVVRFLHUGHX[DQ[LRO\WLTXHVGDQV
OHWUDLWHPHQWGHODQ[LWTXLOQ\DSDVOLHXGDVVRFLHUGHX[K\SQRWLTXHVTXLOQ\DSDVOLHXGH
SUHVFULUH FHV WUDLWHPHQWV VDQV WHQLU FRPSWH GHV GXUHV GH SUHVFULSWLRQV PD[LPDOHV UJOHPHQ
WDLUHVTXLVRQWGHVHPDLQHVSRXUOHVDQ[LRO\WLTXHVHWGHVHPDLQHVSRXUOHVK\SQR
WLTXHV3DUDLOOHXUVLOQ\DSDVOLHXGHSUHVFULUHXQDQ[LRO\WLTXHRXXQK\SQRWLTXHVDQVGEXWHU
ODSRVRORJLHODSOXVIDLEOHHWVDQVUHFKHUFKHUODSRVRORJLHPLQLPDOHHFDFH

2.

pidmiologie
,O\DHQEHQ]RGLD]SLQHVRXDSSDUHQWVFRPPHUFLDOLVHVHQ)UDQFH(QGH
ODSRSXODWLRQIUDQDLVHDFRQVRPPDXPRLQVXQHIRLVXQHEHQ]RGLD]SLQHRXDSSDUHQWV
GHVFRQVRPPDWHXUVGHEHQ]RGLD]SLQHVRXDSSDUHQWVVRQWGHVIHPPHV

432

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GHVVXMHWVWUDLWVSDUFHW\SHGHWUDLWHPHQWOHVWSRXUXQHGXUHVXSULHXUHGHX[DQV

3.

Dfinitions

3.1.

Usage risque
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WLRQGHODYLJLODQFHODG\VDUWKULHHWODWD[LHDXJPHQWDQWOHULVTXHGHFKXWH
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ULVTXHHWH[SRVHDX[ULVTXHVGHGSHQGDQFHDX[FRQVTXHQFHVSK\VLTXHVHWRXSV\FKLTXHVHW
une mortalit plus leve.

3.2.

Usage nocif
/XVDJHSHXWVDYUHUQRFLIHQFDVGHWURXEOHVPRWHXUVRXGHWURXEOHVGHODYLJLODQFHDVVRFLV
/HVFRQWUHLQGLFDWLRQVDEVROXHVVRQWOHVLQVXVDQFHVUHVSLUDWRLUHVWDQWDLJXVTXHFKURQLTXHV
/HVFRQWUHLQGLFDWLRQVUHODWLYHVVRQWODP\DVWKQLHOHV\QGURPHGDSQHGXVRPPHLO

Addiction aux mdicaments psychotropes

75

/HV EHQ]RGLD]SLQHV HW OHV DSSDUHQWV VRQW  YLWHU GXUDQW OD JURVVHVVH HW ODOODLWHPHQW 6L OD
SUHVFULSWLRQVDYUHLPSUDWLYHLOHVWSUIUDEOHGHIUDFWLRQQHUOHVSULVHVHWGHVHOLPLWHUGHV
IDLEOHVGRVHV,OHVWSUIUDEOHGYLWHUODSULVHORUVGXSUHPLHUWULPHVWUH

3.3.

Abus
,O \ D DEXV GH EHQ]RGLD]SLQHV RX GDSSDUHQWV ORUVTXLO \ D GWRXUQHPHQW GH OLQGLFDWLRQ
thrapeutique.
,OVDJLWGHFRQVRPPDWLRQVUSWHVDYHFGRPPDJHVSK\VLTXHVSV\FKRaHFWLIVRXVRFLDX[SRXU
le sujet ou son environnement.

4.

Le trouble psychiatrique

4.1.

Diagnostics positifs

4.1.1. Diagnostic dabus

(critres DSM-IV-TR)

aux benzodiazpines

&I,WHPm,QWURGXFWLRQ}

4.1.2. Diagnostic de dpendance

(critres DSM-IV-TR)

433

aux benzodiazpines

&I,WHPm,QWURGXFWLRQ}

4.1.3. Diagnostic

de syndrome de sevrage des benzodiazpines

(critres DSM-IV-TR)
7RXWFRQVRPPDWHXUORQJWHUPHGHEHQ]RGLD]SLQHVHVWH[SRVHQFDVGDUUWEUXWDODFFLGHQWHO
RXQRQRXEOLKRVSLWDOLVDWLRQHWFXQULVTXHGHV\QGURPHGHVHYUDJH
/DUUWGHVEHQ]RGLD]SLQHVSHXWHQWUDQHUXQUHERQGXQV\QGURPHGHVHYUDJHRXXQHUHFKXWH
6HYUDJH HHW UHERQG HW UHFKXWH SDUWDJHQW XQ JUDQG QRPEUH GH V\PSWPHV TXL SHXYHQW WUH
VRXUFHVGHUUHXUVGHGLDJQRVWLFDORUVTXHOHXUVSULVHVHQFKDUJHGLUHQW
/HVIDFWHXUVVXLYDQWVVRQWDVVRFLVODVYULWGXV\QGURPHGHVHYUDJH
*

La rapidit de diminution de la posologie.

/DFRQVRPPDWLRQGXQHSRVRORJLHOHYHGHEHQ]RGLD]SLQHV

/DGHPLYLHFRXUWHGOLPLQDWLRQGXPGLFDPHQW

/H[LVWHQFHGXQHDQ[LWLPSRUWDQWHDXGEXWGHODUUW

/H[LVWHQFHGXQWURXEOHGSUHVVLIFDUDFWULVDVVRFL

/DVXUFRQVRPPDWLRQUJXOLUHGDOFRRORXGXQHDXWUHVXEVWDQFHSV\FKRDFWLYH

75

Les addictions

Dfinition

Symptmes
Signes gnraux
frquents :
anxit, insomnie,
cphales.

6\QGURPHGH
sevrage.

4.1.4. Donnes

Apparition de signes
QRXYHDX[GXVODUUWRX
la diminution de la prise.

6LJQHVSOXVVSFLTXHV
confusion, hallucination.
3OXVUDUHPHQW
WURXEOHVGHYLJLODQFH
convulsions,
incoordination motrice,
coma.

Dlai dapparition
et dvolution

$SSDULWLRQSRVVLEOH
pendant la rduction
de posologie pouvant
GXUHUMXVTXTXHOTXHV
MRXUVDSUVODGHUQLUH
prise.
Attnuation
progressive.

du DSM-5

/D FLQTXLPH GLWLRQ GX PDQXHO GLDJQRVWLTXH HW VWDWLVWLTXH GHV WURXEOHV PHQWDX[ '60
FRPELQHHQXQVHXOGLDJQRVWLFGHWURXEOHGXWLOLVDWLRQGHVXEVWDQFHOHVGLDJQRVWLFVGDEXVGH
VXEVWDQFHHWGHGSHQGDQFHXQHVXEVWDQFHGX'60,975&I,WHPm,QWURGXFWLRQ}

434

4.2.

Comorbidits / complications mdicales non psychiatriques

2Q UHWURXYH HQ SUHPLHU OLHX OH ULVTXH GH FKXWH HW VHV FRQVTXHQFHV 3DU DLOOHXUV LO H[LVWH GHV
UHWHQWLVVHPHQWVFRJQLWLIVOLVODFRQVRPPDWLRQSURORQJHGHEHQ]RGLD]SLQHV
&HVFRPRUELGLWVVRQWPDMRUHVFKH]OHVSHUVRQQHVJHV

4.3.

Comorbidits mdicales psychiatriques

/HVFRPRUELGLWVPGLFDOHVSV\FKLDWULTXHVDVVRFLHVDX[DGGLFWLRQVDX[EHQ]RGLD]SLQHVVRQW

5.

pisode dpressif caractris.

$GGLFWLRQVDVVRFLHVDOFRRORXDXWUHVVXEVWDQFHVSV\FKRDFWLYHV

Addictions sans produits.

7URXEOHVDQ[LHX[WURXEOHSDQLTXHWURXEOHREVHVVLRQQHOFRPSXOVLIWURXEOHDQ[LHX[JQUDOLV

Notions de physio/psychopathologie
/HV DGGLFWLRQV PHWWHQW HQ MHX XQ V\VWPH FRPSOH[H GH OD UFRPSHQVH mOLNLQJZDQWLQJOHDU
QLQJ}GRQWOHQHXURWUDQVPHWWHXUSULQFLSDOHVWODGRSDPLQH,OVDJLWGXFLUFXLWPVRFRUWLFROLP
ELTXH/HV\VWPHGHUFRPSHQVHPHWHQMHXODLUHWHJPHQWDOHYHQWUDOHHWOHQR\DXDFFXPEHQV/H
V\VWPHGDXWRFRQWUOHFRUUHVSRQGDXFRUWH[SUIURQWDOHWOHV\VWPHGDSSUHQWLVVDJHPHWHQMHX
ODP\JGDOHHWOKLSSRFDPSH

Addiction aux mdicaments psychotropes

75

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OD YRLH GRSDPLQHUJLTXH (OOHV DJLVVHQW VXU OD GVLQKLELWLRQ GHV QHXURQHV  GRSDPLQH  OLQV
WDU GH OKURQH RX GX FDQQDELV /HXU DFWLRQ GRSDPLQHUJLTXH HVW FRQQH  ODLUH WHJPHQWDOH
YHQWUDOH$79HWVDSSXLHVXUOHVUFHSWHXUV*$%$$GHW\SH 1, les mmes qui sont impliqus
GDQVOHHWK\SQRWLTXH

6.

La prise en charge psychiatrique

6.1.

Stratgies de prvention
/D SUYHQWLRQ GHV DEXV HW GSHQGDQFHV DX[ EHQ]RGLD]SLQHV RX DSSDUHQWV FRPPHQFH SDU
ODPOLRUDWLRQGHOLQIRUPDWLRQGHVSURIHVVLRQQHOVGHVDQWHWGHVSDWLHQWV
Concernant les professionnels de sant, la prvention passe par une formation mdicale initiale
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WLRQHWGHGOLYUDQFHGHVGLUHQWHVVSFLDOLWVH[&ORQD]SDP5LYRWULO
(OOHFRQVLVWHHQOODERUDWLRQHWHQODSXEOLFDWLRQGHUHFRPPDQGDWLRQVHWGHPLVHVDXSRLQW
3DUDOOOHPHQWLOH[LVWHXQHQFDGUHPHQWGHODSUHVFULSWLRQHWGHODGOLYUDQFHSOXVUDSSURFK
&HUWDLQHV PRGLFDWLRQV JDOQLTXHV RQW W DSSRUWHV SRXU OLPLWHU OD VRXPLVVLRQ FKLPLTXH
H[)OXQLWUD]SDP 5RK\SQRO 'H PPH OD WDLOOH GHV FRQGLWLRQQHPHQWV D W UGXLWH SRXU
OLPLWHUOHVDEXV
(QQGHVDOWHUQDWLYHVWHOOHVTXHOHVSULVHVHQFKDUJHSV\FKRWKUDSHXWLTXHVGRLYHQWWUHSULVHV
en compte.
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SLQHVHWGRLWFHWLWUHWUHSUYHQX
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GLD]SLQHVHWGHODYLWHVVHGHGFURLVVDQFHGHODSRVRORJLH

6.2.

Modalit de sevrage

6.2.1. Lieu
/HVHYUDJHHQDPEXODWRLUHUHVWHODVLWXDWLRQODSOXVIUTXHQWH
Le sevrage en milieu hospitalier peut se voir dans deux situations :
* /DSUHPLUHHVWOKRVSLWDOLVDWLRQSURJUDPPHVSFLTXHPHQWSRXUUDOLVHUOHVHYUDJH&HWWH
situation doit rester exceptionnelle.
* /DGHX[LPHHVWODUUWGHVEHQ]RGLD]SLQHVUDOLVDXFRXUVGXQHKRVSLWDOLVDWLRQSRXUXQ
autre motif.

6.2.2.Quand

/LGDO UHVWH GH SUYRLU ODUUW GXQH EHQ]RGLD]SLQH GV VRQ LQWURGXFWLRQ HW GH VLQWHUURJHU 
FKDTXHUHQRXYHOOHPHQWGRUGRQQDQFHVXUODSHUVLVWDQFHGHOLQGLFDWLRQHWVXUOYHQWXHOOHWRO
rance thrapeutique, voire une dpendance.

435

75

Les addictions

6.2.3.Comment

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,OH[LVWHGHVULVTXHVGHV\QGURPHGHVHYUDJHSOXVVYUHGFKHFODUUWHWGHUHSULVHGXWUDLWH
PHQWSOXVIUTXHQWFKH]OHVSDWLHQWVSUHQDQWGHVSRVRORJLHVOHYHVHWGHSXLVORQJWHPSV
/DSULVHFRQFRPLWDQWHGHSOXVLHXUVSV\FKRWURSHVUHQGODUUWGHVEHQ]RGLD]SLQHVSOXVGLFLOHV
/D FRQVRPPDWLRQ GH EHQ]RGLD]SLQHV  YLVH DQ[LRO\WLTXH RX OD FRQVRPPDWLRQ GDOFRRO DYDQW
ODUUWDXJPHQWHQWOHULVTXHGHUHSULVHGHEHQ]RGLD]SLQH
8QHLQVRPQLHVYUHXQHGWUHVVHSV\FKRORJLTXHVRQWGHVIDFWHXUVGHULVTXHVGHUHFKXWH
Le sevrage en ambulatoire reste la situation la plus frquente.
/HVPRGDOLWVGDUUWVRQWOHVVXLYDQWHV,OGRLWVHIDLUHGHPDQLUHSURJUHVVLYH,OHVWFRQGXLWVXU
VHPDLQHVYRLUHSOXVSOXVLHXUVPRLVSRXUOHVXWLOLVDWLRQVORQJXHVRXSRXUOHVSRVRORJLHV
leves.
/DGLPLQXWLRQLQLWLDOHHVWGHORUGUHGHGHODSRVRORJLHODSUHPLUHVHPDLQHORUVTXHORQVH
EDVHVXUXQHGXUHGDUUWFRPSULVHHQWUHHWVHPDLQHV
'HVFRQVXOWDWLRQVUJXOLUHVSRUWDQWVSFLTXHPHQWVXUODUUWGHVEHQ]RGLD]SLQHVHWDSSDUHQ
WVGRLYHQWDYRLUOLHX3RXUH[HPSOHODSUHPLUHFRQVXOWDWLRQDOLHXXQHVHPDLQHDSUVODSUHPLUH
GFURLVVDQFHSXLVWRXWHVOHVGHX[TXDWUHVHPDLQHVVLODGFURLVVDQFHHVWELHQVXSSRUWH3RXU
OHVSDWLHQWVULVTXHXQVXLYLUHQIRUFGRLWWUHPLVHQSODFH
Au cours de ces consultations, il est ncessaire :

436

'HVVD\HUGHUHSUHUOHVV\PSWPHVOLVODUUWGXWUDLWHPHQWRXGHVV\PSWPHVQRXYHDX[

'YDOXHUODGKVLRQDXSURWRFROHGDUUW

* 'HUHFKHUFKHUXQHDXJPHQWDWLRQGHVFRQVRPPDWLRQVDVVRFLHVDOFRROWDEDFRXDXWUHVVXEV
WDQFHVSV\FKRDFWLYHV
* De titrer la rduction de posologie : demander au patient de ramener les comprims non
utiliss.
*

'HUDOLVHUXQUHQIRUFHPHQWSRVLWLIYLVYLVGHODGLPLQXWLRQGHSRVRORJLH

De laisser le patient poser des questions.

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GDQVOHVWURLVVHSWMRXUVTXLVXLYHQWODGHUQLUHSULVHGHWUDLWHPHQWDQGYDOXHUOHVV\PSWPHV
OLVODUUWGXWUDLWHPHQWHWGHGRQQHUXQHLQIRUPDWLRQFODLUHVXUOHVUHERQGVGLQVRPQLHHWRX
GDQ[LWSRVVLEOHV,OHVWUHFRPPDQGGHSURSRVHUDXSDWLHQWGHUDPHQHUOHVERLWHVGHEHQ]RGLD
]SLQHVQRQXWLOLVHVVRQSKDUPDFLHQ
8QVXLYLHQFRQVXOWDWLRQUJXOLHUGRLWWUHSURSRVHQSDUWLFXOLHUORUVGHVSUHPLHUVPRLVVXLYDQWV
ODUUW
Le sevrage en milieu hospitalier peut se voir dans deux situations :
* /DSUHPLUHHVWOKRVSLWDOLVDWLRQSURJUDPPHVSFLTXHPHQWSRXUUDOLVHUOHVHYUDJH&HWWH
VLWXDWLRQGRLWUHVWHUH[FHSWLRQQHOOH(OOHFRQFHUQHOHVSDWLHQWVD\DQWXQRXSOXVLHXUVIDFWHXUVGH
ULVTXHVGFKHFVRXMXVWLDQWXQHSULVHHQFKDUJHVSFLDOLVH
* /DGHX[LPHHVWODUUWGHVEHQ]RGLD]SLQHVUDOLVDXFRXUVGXQHKRVSLWDOLVDWLRQSRXUXQ
autre motif. Dans ce cas, la dcision doit se faire en concertation avec le mdecin traitant et en
DFFRUGDYHFOHSDWLHQW3DUDLOOHXUVOHSKDUPDFLHQKDELWXHOGXSDWLHQWHVWLQIRUPGHODGPDUFKH
entreprise.
/DUUWGRLWWRXMRXUVVHUDOLVHUGHPDQLUHSURJUHVVLYHPDLVLOSHXWVHIDLUHGHPDQLUHSOXVUDSLGH
TXHQDPEXODWRLUHHQYLURQGHX[VHPDLQHV

Addiction aux mdicaments psychotropes

75

Le taux de rduction de la posologie varie en fonction des capacits du patient et du risque de

V\QGURPHGHVHYUDJHGHHWUHERQGHWFORUVGHODUUW
%LHQTXHOREMHFWLIVRLWODUUWFRPSOHWGHODFRQVRPPDWLRQGHEHQ]RGLD]SLQHVOREWHQWLRQGXQH
GLPLQXWLRQGHODSRVRORJLHGRLWGMWUHFRQVLGUHFRPPHXQUVXOWDWIDYRUDEOH/DUGXFWLRQGH
ODSRVRORJLHVHUDLWGDLOOHXUVXQIDFWHXUSURQRVWLTXHIDYRUDEOHODUUWGHODFRQVRPPDWLRQORUV
GXQHWHQWDWLYHGDUUWXOWULHXUH
,OQ\DSDVGDUJXPHQWSRXUSURSRVHUXQWUDLWHPHQWPGLFDPHQWHX[VXEVWLWXWLIORUVGHODUUWGHV
EHQ]RGLD]SLQHV /DFFHQW GRLW WUH PLV VXU OHV PHVXUHV GDFFRPSDJQHPHQW QRQ PGLFDPHQ
teuses, aussi prolonges que ncessaire.
6LODVWUDWJLHGDUUWFKRXHLOHVWUHFRPPDQGGHQFRXUDJHUOHSDWLHQWUHFRPPHQFHUXOWULHX
UHPHQWDSUVYDOXDWLRQGHVUDLVRQVGHOFKHF

6.3.

Psycho-ducation
/DSV\FKRGXFDWLRQGXSDWLHQWHVWSULPRUGLDOH(OOHMRXHXQUOHLPSRUWDQWGDQVODSUYHQWLRQ
des rechutes.

6.4.

Psychothrapie
/HVWKUDSLHVFRJQLWLYHVHWFRPSRUWHPHQWDOHV7&&DVVRFLHVODUUWSURJUHVVLIGHVEHQ]RGLD
]SLQHVRQWPRQWUOHXULQWUWSRXUODUUWRXODGLPLQXWLRQGHODFRQVRPPDWLRQGHEHQ]RGLD]
SLQHVPDLVHOOHVSRVHQWOHSUREOPHGHOHXUDFFHVVLELOLW
437

75

Les addictions

Rsum
/D)UDQFHHVWOHGHX[LPHSD\VHXURSHQVHQFHTXLFRQFHUQHODFRQVRPPDWLRQGK\SQRWLTXHVHW
GDQ[LRO\WLTXHV
La majorit des consommateurs sont des femmes.
,OVDJLWGXQSUREOPHGHVDQWSXEOLTXH
,OH[LVWHGHVFRPRUELGLWVWHOOHVTXHOHWURXEOHGSUHVVLIFDUDFWULVHWOHVWURXEOHVDQ[LHX[
/HV FRPSOLFDWLRQV SULQFLSDOHV VRQW OHV WURXEOHV PQVLTXHV HW OH ULVTXH GH FKXWH HW VHV
consquences.
/HVEHQ]RGLD]SLQHVHWDSSDUHQWVLQGXLVHQWXQHDGGLFWLRQHQPHWWDQWHQMHXOHV\VWPHGHOD
rcompense, en stimulant les voies dopaminergiques.
/DSULVHHQFKDUJHGXQHDGGLFWLRQDX[EHQ]RGLD]SLQHVHWDSSDUHQWVHVWUDOLVHODPDMRULWGX
WHPSVHQDPEXODWRLUH
(OOHQFHVVLWHXQHGFURLVVDQFHSURJUHVVLYHGHVSRVRORJLHV
,OQH[LVWHSDVGHWUDLWHPHQWVXEVWLWXWLI

Points clefs
438

* /HVDGGLFWLRQVUHSUVHQWHQWXQSUREOPHPDMHXUGHVDQWSXEOLTXH
* /D GSHQGDQFH QH VH GQLW QL SDU UDSSRUW  XQ VHXLO RX XQH IUTXHQFH GH FRQVRPPDWLRQ QL SDU OH[LVWHQFH GH
GRPPDJHVLQGXLWVPDLVSDUODSHUWHGHODOLEHUWGHVDEVWHQLU
* /HVEHQ]RGLD]SLQHVHWOHVDSSDUHQWVDX[EHQ]RGLD]SLQHVSUVHQWHQWXQSRWHQWLHODGGLFWLIWUVPDUTX
*  GH OD SRSXODWLRQ IUDQDLVH D FRQVRPP DX PRLQV XQH IRLV GHV EHQ]RGLD]SLQHV HW GHV DSSDUHQWV DX[
EHQ]RGLD]SLQHV
* VRQWGHVIHPPHV
* /HVHYUDJHVHIDLWHQDPEXODWRLUHOHSOXVIUTXHPPHQW
* La dcroissance doit tre progressive.
* ,OH[LVWHXQULVTXHGHV\QGURPHGHVHYUDJHODUUWEUXWDO
* ,OQH[LVWHSDVGHWUDLWHPHQWVXEVWLWXWLI

Rfrences pour approfondir

HAS : Modalits darrt des benzodiazpines et mdicaments apparents chez la personne ge.
5DSSRUWGH[SHUWLVHtat des lieux de la consommation de benzodiazpines en France-DQYLHU
Afssaps.
Mdicaments psychotropes consommations et dpendances. Synthse et recommandations.
([SHUWLVHFROOHFWLYHd. Inserm 2012.
&ORRV-0et al. Addiction aux benzodiazpines : prvalence, diagnostic et traitement(0&SV\FKLD
trie, 2011.

76

item 76

Addiction

au cannabis, la cocane,
aux amphtamines, aux opiacs,
aux drogues de synthse
$&$11$%,6

&23,$&6

I. Introduction

I. Introduction

II. Contexte pidmiologique

II. Contexte pidmiologique

III. 6PLRORJLHSV\FKLDWULTXH

,,, 6PLRORJLHSV\FKLDWULTXH

IV. 7URXEOHSV\FKLDWULTXH

,9 7URXEOHSV\FKLDWULTXH

V. Complications

V. Complications

VI. 3ULVHHQFKDUJH

9,3ULVHHQFKDUJH

%&2&$1(

''52*8(6'(6<17+6(

I. Introduction

I. Introduction

II. Contexte pidmiologique

II. Contexte pidmiologique

,,, 6PLRORJLHSV\FKLDWULTXH

,,, 6PLRORJLHSV\FKLDWULTXH

,9 7URXEOHSV\FKLDWULTXH

,9 7URXEOHSV\FKLDWULTXH

V. Complications

V. Complications

9,3ULVHHQFKDUJH

9,3ULVHHQFKDUJH

Objectifs pdagogiques
* 5HSUHUGLDJQRVWLTXHUYDOXHUOHUHWHQWLVVHPHQWGXQHDGGLFWLRQ
DXFDQQDELVODFRFDQHDX[DPSKWDPLQHVDX[RSLDFV
DX[GURJXHVGHV\QWKVH
* Connatre les principes de prise en charge (sevrage thrapeutique,
SUYHQWLRQGHODUHFKXWHUGXFWLRQGHVULVTXHV
* &RQQDWUHOHVWUDLWHPHQWVGHVXEVWLWXWLRQDX[RSLDFV
* 3ODQLHUOHVXLYLGXSDWLHQW

76

Les addictions

Cannabis

1.

Introduction
/H SULQFLSH DFWLI HVW OH WWUDK\GURFDQQDELQRO 7+& ,O DJLW VXU OHV UFHSWHXUV FDQQDELQRGHV
HQ SRWHQWLDOLVDQW OD OLEUDWLRQ GH GRSDPLQH /H FDQQDELV VH FRQVRPPH SDU RUGUH FURLVVDQW GH
SULQFLSHDFWLIVRXVIRUPHGKHUEHPDUXDQDGHUVLQHKDVFKLVKHWGKXLOH

2.

Contexte pidmiologique
,O VDJLW GXQ SUREOPH GH VDQW SXEOLTXH  PLOOLRQ GH VXMHWV VRQW FRQVRPPDWHXUV UJXOLHUV
HQ)UDQFHVRLWHQYLURQPLOOLRQVGHSHUVRQQHVDQVHQRQWIDLWOH[SULHQFHDX
PRLQVXQHIRLVGDQVOHXUYLHVRLWHQYLURQ
/DFRQVRPPDWLRQHVWVXUWRXWPDVFXOLQHTXHOOHTXHVRLWODWUDQFKHGJHDQVSOXVGH
GHVMHXQHVGHDQVGFODUHQWDYRLUIXPGXFDQQDELVDXFRXUVGHOHXUYLHHWSOXVGXQVXUFLQT
GFODUHDYRLUFRQVRPPGXFDQQDELVDXFRXUVGXGHUQLHUPRLV

440

3.

Smiologie psychiatrique

3.1.

Syndrome dintoxication aigu (ou ivresse cannabique )

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ODWROUDQFHHWODVHQVLELOLWDX[HHWVGHODVXEVWDQFH/HVHHWVGXFDQQDELVSHXYHQWSDUIRLV
SHUVLVWHURXUDSSDUDWUHSHQGDQWKHXUHV
/LQWR[LFDWLRQFRPPHQFHHQJQUDOSDUXQHVHQVDWLRQGHELHQWUHVXLYLHSDUGHVV\PSWPHVTXL
incluent une euphorie avec rires inappropris et ides de grandeur, une sdation, une lthargie,
XQH DOWUDWLRQ GX MXJHPHQW GHV GLVWRUVLRQV GHV SHUFHSWLRQV VHQVRULHOOHV KDOOXFLQDWLRQV XQH
DOWUDWLRQ GHV SHUIRUPDQFHV PRWULFHV GLFXOWV GH FRRUGLQDWLRQ PRWULFH HW OD VHQVDWLRQ TXH
OHWHPSVSDVVHOHQWHPHQW/HWURXEOHVDFFRPSDJQHSDUIRLVGXQHDQ[LWTXLSHXWWUHVYUH
SRXYDQWDOOHUMXVTXODGSHUVRQQDOLVDWLRQGUDOLVDWLRQGXQHG\VSKRULHRXGXQUHWUDLWVRFLDO
/HVSHUIRUPDQFHVFRJQLWLYHVVRQWDOWUHVQRWDPPHQWODPPRLUHFRXUWWHUPHGHVGLFXOWV
UDOLVHUGHVWFKHVLQWHOOHFWXHOOHVFRPSOH[HV/DOWUDWLRQGHOHQVHPEOHGHVSHUIRUPDQFHVSHXW
SHUVLVWHUMXVTXKHXUHVDSUVOXVDJH
$X QLYHDX SK\VLRORJLTXH QRQ SV\FKLDWULTXH OLQWR[LFDWLRQ DLJX DX FDQQDELV SURYRTXH XQH
WDFK\FDUGLHXQHK\SRWHQVLRQXQHGLPLQXWLRQGHODVDOLYDWLRQXQHG\VSQHXQHDXJPHQWDWLRQ

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

76

GHODSSWLWXQHK\SHUKPLHFRQMRQFWLYDOH\HX[URXJHVDYHFP\RVLV'HVFSKDOHVQDXVHV

YRPLVVHPHQWVSHXYHQWDFFRPSDJQHUOHWDEOHDXFOLQLTXH

3.2.

Syndrome de sevrage
8QV\QGURPHGHVHYUDJHSHXWDSSDUDWUHHQYLURQKHXUHVDSUVODGHUQLUHFRQVRPPDWLRQHWLO\
DXUDLWXQSLFODe heure. Les manifestations cliniques associent une agitation, une anxit, une
G\VSKRULHXQHLQVRPQLHXQHDQRUH[LHGHVWUHPEOHPHQWVGHVH[WUPLWVGLVWDOHVGHVPHPEUHV
VXSULHXUVVXHXUVGLDUUKH/HQVHPEOHGHFHVV\PSWPHVGLVSDUDWHQVHPDLQHVHQYLURQ

3.3.

Syndrome dintoxication chronique

/LQWR[LFDWLRQFKURQLTXHGHFDQQDELVHVWUHVSRQVDEOHGXQV\QGURPHDPRWLYDWLRQQHODVVRFLDQW
altrations des performances cognitives avec un impact sur la mmoire et les capacits
DWWHQWLRQQHOOHV XQH LQGLUHQFH DHFWLYH XQ UWUFLVVHPHQW GH OD YLH UHODWLRQQHOOH PDLV
JDOHPHQWXQHDOWUDWLRQGHVSHUIRUPDQFHVDXQLYHDXVFRODLUHSURIHVVLRQQHOVRFLDOIDYRULVDQW
RXDPSOLDQWODGVLQVHUWLRQODPDUJLQDOLVDWLRQ

4.

Complications

4.1.

Complications psychiatriques

4.1.1. Trouble

psychotique bref

8QWURXEOHSV\FKRWLTXHEUHISHXWDSSDUDWUHGHPDQLUHFRQFRPLWDQWHOLQWR[LFDWLRQDLJXPDLV
SHXW JDOHPHQW DSSDUDWUH GDQV OH PRLV TXL VXLW ODUUW GH OLQWR[LFDWLRQ /D V\PSWRPDWRORJLH
FOLQLTXHUHMRLQWFHOOHGXWURXEOHSV\FKRWLTXHEUHIFI,WHP/DV\PSWRPDWRORJLHHVWUVROXWLYH
ODUUWGHOLQWR[LFDWLRQRXVRXVWUDLWHPHQWSDUQHXUROHSWLTXHV

4.1.2. Schizophrnie
/H FDQQDELV SHXW GXQH SDUW SUFLSLWHU OHQWUH GDQV OD PDODGLH FKH] OHV VXMHWV YXOQUDEOHV
GDXWUHSDUWDOWUHUOYROXWLRQGHODSDWKRORJLHSDUPLFHX[TXLORQWGMGYHORSSH

4.1.3. Troubles

anxieux

/LQWR[LFDWLRQDXFDQQDELVSHXWLQGXLUHXQYULWDEOHWURXEOHDQ[LHX[FI,WHP

441

76

Les addictions

4.2.

Complications non psychiatriques

Consquences pulmonaires :
*

$FWLYLWEURQFKRGLODWDWULFHLPPGLDWHHWWUDQVLWRLUH

Bronchite chronique.

&DQFHUEURQFKRSXOPRQDLUH

Consquences cardiovasculaires :
*

$XJPHQWDWLRQGXGELWFDUGLDTXHHWFUEUDOK\SRWHQVLRQDUWULHOOH

Vasodilatation priphrique.

%UDG\FDUGLH

&DVGDUWULRSDWKLHW\SHPDODGLHGH%XHUJHU

Consquences tumorales :
*

&DQFHUVGHVYRLHVDURGLJHVWLYHVVXSULHXUHVFKH]OHVIXPHXUVGHFDQQDELVHWWDEDF

&DQFHUVEURQFKRSXOPRQDLUHVFKH]OHVIXPHXUVH[FOXVLIVGHFDQQDELV

Consquences visuelles :

442

3KRWRVHQVLELOLW

+\SHUKPLHFRQMRQFWLYDOH

0\GULDVHLQFRQVWDQWH

5.

Trouble psychiatrique

5.1.

Troubles lis lutilisation de cannabis

5.1.1. Diagnostic

dabus (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

5.1.2. Diagnostic

de dpendance (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

5.2.

76

Troubles induits par le cannabis

5.2.1. Intoxication

au cannabis

DSM-IV-TR
Critres diagnostiques de lintoxication au cannabis
$8WLOLVDWLRQUFHQWHGHFDQQDELV
% &KDQJHPHQWV FRPSRUWHPHQWDX[ RX SV\FKRORJLTXHV LQDGDSWV FOLQLTXHPHQW VLJQLFDWLIV S H[ DOWUDWLRQ GH OD
FRRUGLQDWLRQPRWULFHHXSKRULHDQ[LWVHQVDWLRQGHUDOHQWLVVHPHQWGXWHPSVDOWUDWLRQGXMXJHPHQWUHWUDLWVRFLDO
TXLVHVRQWGYHORSSVSHQGDQWRXSHXDSUVOXWLOLVDWLRQGHFDQQDELV
&$XPRLQVGHX[GHVVLJQHVVXLYDQWVVHGYHORSSDQWFODQVOHVGHX[KHXUHVVXLYDQWOXWLOLVDWLRQGHFDQQDELV
* conjonctives injectes,
* DXJPHQWDWLRQGHODSSWLW
* VFKHUHVVHGHODERXFKH
* WDFK\FDUGLH
'/HVV\PSWPHVQHVRQWSDVGXVXQHDHFWLRQPGLFDOHJQUDOHHWQHVRQWSDVPLHX[H[SOLTXVSDUXQDXWUHWURXEOH
mental.
Spcifier VL$YHFSHUWXUEDWLRQGHVSHUFHSWLRQV
&HWWHVSFLFDWLRQSHXWWUHQRWHTXDQGOHVXMHWSUVHQWHGHVKDOOXFLQDWLRQVVDQVDOWUDWLRQGHODSSUFLDWLRQGHOD
ralit.

443

5.2.2.Syndrome

confusionnel par intoxication au cannabis

DSM-IV-TR
Critres diagnostiques dun syndrome confusionnel induit par le cannabis
$3HUWXUEDWLRQGHODFRQVFLHQFHFHVWGLUHEDLVVHGXQHSULVHGHFRQVFLHQFHFODLUHGHOHQYLURQQHPHQWDYHFGLPLQX
WLRQGHODFDSDFLWPRELOLVHUIRFDOLVHUVRXWHQLURXGSODFHUODWWHQWLRQ
% 0RGLFDWLRQ GX IRQFWLRQQHPHQW FRJQLWLI WHOOH TXXQ GFLW GH OD PPRLUH XQH GVRULHQWDWLRQ XQH SHUWXUEDWLRQ
GXODQJDJHRXELHQVXUYHQXHGXQHSHUWXUEDWLRQGHVSHUFHSWLRQVTXLQHVWSDVPLHX[H[SOLTXHSDUXQHGPHQFH
SUH[LVWDQWHVWDELOLVHRXHQYROXWLRQ
&/DSHUWXUEDWLRQVLQVWDOOHHQXQWHPSVFRXUWKDELWXHOOHPHQWTXHOTXHVKHXUHVRXTXHOTXHVMRXUVHWWHQGDYRLUXQH
YROXWLRQXFWXDQWHWRXWDXORQJGHODMRXUQH
'0LVHHQYLGHQFHGDSUVOKLVWRLUHGHODPDODGLHOH[DPHQSK\VLTXHRXOHVH[DPHQVFRPSOPHQWDLUHVTXHODSHUWXU
EDWLRQHVWGXHXQHLQWR[LFDWLRQDXFDQQDELVRXXQVHYUDJHFHIDFWHXUWDQWMXJOLWLRORJLTXHPHQWDXV\QGURPH
confusionnel.

76

Les addictions

5.2.3. Trouble

psychotique bref induit par le cannabis

(avec ides dlirantes et/ou hallucinations) (Cf. Item 61)

5.2.4.Trouble

anxieux induit par le cannabis (Cf. Item 64)

6.

Prise en charge

6.1.

Prvention
Le principe de la prvention repose sur la prise en charge de la personne, ce quel que soit la
VXEVWDQFH/DSUYHQWLRQVLQWUHVVHOKLVWRLUHGHFKDFXQSUHQGHQFRPSWHVRQHQYLURQQHPHQW
HWVHIRQGHVXUODTXDOLWGHODUHODWLRQHQWUHODFWHXUGHSUYHQWLRQHWOHFRQVRPPDWHXU
&HWWHFRQFHSWLRQSHUPHWGYLWHUWRXWGLVFRXUVPRUDOLVDWHXUTXLSDUWLFLSHUDLWODVWLJPDWLVDWLRQHW
OH[FOXVLRQGHVFRQVRPPDWHXUV
/HVSULQFLSDX[REMHFWLIVGHODSUYHQWLRQVRQWdviter la premire consommation de substances
psychoactives ou la retarder HW DJLU VXU OHV FRQVRPPDWLRQV SUFRFHV SUYHQWLRQ SULPDLUH
dviter le passage une dpendanceSUYHQWLRQVHFRQGDLUHde prvenir les risques et rduire
les dommages lis la consommation SUYHQWLRQWHUWLDLUH

444

6.2.

Prise en charge gnrale

/D SULVH HQ FKDUJH GXQ SDWLHQW VRXUDQW GDEXV RX GH GSHQGDQFH DX FDQQDELV VH GFOLQH 
plusieurs niveaux :
* 3ULVHHQFKDUJHJOREDOHXQVXLYLSOXULGLVFLSOLQDLUHGRLWWUHSURSRVDXSDWLHQWDYHFYDOXD
WLRQSV\FKLDWULTXHPGLFDOHJQUDOHHWVRFLDOH/DSULVHHQFKDUJHDXORQJFRXUVQFHVVLWHOHQ
JDJHPHQW GX SDWLHQW GDQV XQH GPDUFKH GH VRLQV FRQWUDW GH VRLQV HOOH QH VH IDLW MDPDLV HQ
XUJHQFH/DVWUDWJLHGDLGHDXVHYUDJHGRLWWUHDGDSWHDXVWDGHGHFKDQJHPHQWGXSDWLHQW
* 3ULVHHQFKDUJHSV\FKRWKUDSHXWLTXHSOXVLHXUVWHFKQLTXHVVRQWXWLOLVHVGRQWOHVWKUDSLHV
FRJQLWLYHV HW FRPSRUWHPHQWDOHV FRPSUHQDQW QRWDPPHQW OHQWUHWLHQ PRWLYDWLRQQHO HW OHV WHFK
niques de prvention de la rechute.
* 3ULVHHQFKDUJHDGGLFWRORJLTXHOHELODQGHODGSHQGDQFHHVWODSUHPLUHWDSHGHODSULVHHQ
FKDUJHKLVWRLUHSDUFRXUVGHVRLQVDQWULHXUVFRGSHQGDQFHV
* 3ULVH HQ FKDUJH GHV FRPRUELGLWV LO HVW QFHVVDLUH GH UHFKHUFKHU HW SUHQGUH HQ FKDUJH
V\VWPDWLTXHPHQWOHVFRPSOLFDWLRQVHWFRPRUELGLWVSV\FKLDWULTXHVWURXEOHDQ[LHX[HWWURXEOH
GHOKXPHXUHWOHVYHQWXHOOHVFRDGGLFWLRQV

6.3.

Traitement de lintoxication aigu

/H WUDLWHPHQW GH OLQWR[LFDWLRQ DLJX DX FDQQDELV HVW V\PSWRPDWLTXH SUHVFULSWLRQ GH
EHQ]RGLD]SLQHV HQ FDV GDQJRLVVH PDMHXUH GDJLWDWLRQ RX GH FRQYXOVLRQV QHXUROHSWLTXHV
VGDWLIVHQFDVGHV\PSWPHVSV\FKRWLTXHV

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

6.4.

76

Traitement du syndrome de sevrage

/HWUDLWHPHQWGXV\QGURPHGHVHYUDJHHVWJDOHPHQWV\PSWRPDWLTXHDVVRFLDQWDQ[LRO\WLTXHV
DQWLPWLTXHVDQWDOJLTXHV

Rsum
/HSULQFLSHDFWLIHVWOHWWUDK\GURFDQQDELQRO7+&TXLDJLWVXUOHVUFHSWHXUVFDQQDELQRGHVHQ
SRWHQWLDOLVDQWODOLEUDWLRQGHGRSDPLQH
/DEXVHWODGSHQGDQFHDXFDQQDELVFRQVWLWXHQWXQSUREOPHGHVDQWSXEOLTXH
PLOOLRQGHVXMHWVVRQWFRQVRPPDWHXUVUJXOLHUVHQ)UDQFHVRLWHQYLURQ
/LQWR[LFDWLRQDLJXDVVRFLHXQHVHQVDWLRQGHELHQWUHVXLYLHGXQHHXSKRULHDYHFULUHVLQDSSUR
pris et ides de grandeur, une sdation, une lthargie, une altration du jugement, des distor
VLRQVGHVSHUFHSWLRQVVHQVRULHOOHVKDOOXFLQDWLRQVXQHDOWUDWLRQGHVSHUIRUPDQFHVPRWULFHV
/LQWR[LFDWLRQFKURQLTXHHVWUHVSRQVDEOHGXQV\QGURPHDPRWLYDWLRQQHODVVRFLXQHDOWUDWLRQ
des performances cognitives.
8QWURXEOHSV\FKRWLTXHEUHISHXWDSSDUDWUHGHPDQLUHFRQFRPLWDQWHOLQWR[LFDWLRQDLJXPDLV
SHXWJDOHPHQWDSSDUDWUHGDQVOHPRLVTXLVXLWODUUWGHOLQWR[LFDWLRQ
/HFDQQDELVSHXWGXQHSDUWSUFLSLWHUOHQWUHGDQVODPDODGLHVFKL]RSKUQLTXHFKH]OHVVXMHWV
YXOQUDEOHVGDXWUHSDUWDOWUHUOYROXWLRQGHODSDWKRORJLHSDUPLFHX[TXLORQWGMGYHORSSH
/DSUHPLUHWDSHGHODSULVHHQFKDUJHUHSRVHVXUODSUYHQWLRQ/DSULVHHQFKDUJHGHOLQWR[L
FDWLRQDLJXHWFKURQLTXHHVWV\PSWRPDWLTXH/DSULVHHQFKDUJHGHODGSHQGDQFHHVWSV\FKLD
trique, mdicale gnrale et sociale.
/DSULVHHQFKDUJHDXORQJFRXUVQFHVVLWHOHQJDJHPHQWGXSDWLHQWGDQVXQHGPDUFKHGHVRLQV
/DSV\FKRWKUDSLHFRJQLWLYRFRPSRUWHPHQWDOHDPRQWUVRQHFDFLW

Points clefs
/HSULQFLSHDFWLIHVWOHWWUDK\GURFDQQDELQRO7+&
/DEXVHWODGSHQGDQFHDXFDQQDELVFRQVWLWXHQWXQSUREOPHGHVDQWSXEOLTXH
2QGLVWLQJXH
 /HVWURXEOHVOLVOXWLOLVDWLRQGHFDQQDELVLQWR[LFDWLRQDLJXFKURQLTXHHWV\QGURPHGHVHYUDJH
 /HVWURXEOHVLQGXLWVSDUODVXEVWDQFHWURXEOHSV\FKRWLTXHWURXEOHDQ[LHX[V\QGURPHFRQIXVLRQQHO
/HWUDLWHPHQWUHSRVHVXUODSUYHQWLRQODSULVHHQFKDUJHSV\FKLDWULTXHPGLFDOHJQUDOHHWVRFLDOH
/HWUDLWHPHQWGHOLQWR[LFDWLRQHWGXVHYUDJHHVWV\PSWRPDWLTXH

445

76

Les addictions

Cocane

1.

Introduction
/DFRFDQHHVWH[WUDLWHGHVIHXLOOHVGXFRFDFXOWLYHVHQ$PULTXHGX6XGHQ,QGRQVLHGDQV
O(VWGHO$IULTXHHWHQ$IJKDQLVWDQ
/DFRFDQHVHSUVHQWHVRXV
* une forme chlorhydrateSRXGUHEODQFKHREWHQXHSDUWLUGHODIHXLOOHGHFRFDFRQVRPPHSDU
YRLHLQWUDQDVDOHVQLRXSDUYRLHLQWUDYHLQHXVHLQMHFWLRQ
* une forme base FDLOORX[ JDOHWWHV REWHQXH DSUV DGMRQFWLRQ GH ELFDUERQDWH GH VRXGH RX
GDPPRQLDTXHDXFKORUK\GUDWHGHFRFDQHDQGWUHLQKDOHIXPH
/DFRFDQHEDVHSUDODEOHPHQWEDVHHVWDSSHOHcrackHWFHOOHEDVHSDUOHVXVDJHUVHX[PPHV
est appele free base.

2.

Contexte pidmiologique
/DFRFDQHHVWODVXEVWDQFHVWLPXODQWHLOOLFLWHODSOXVFRXUDPPHQWXWLOLVHHQ(XURSH/JHPR\HQ
GHODSUHPLUHFRQVRPPDWLRQHVWGHDQV/JHPR\HQOHQWUHHQWUDLWHPHQWHVWGHDQV(Q
PR\HQQHOHVKRPPHVVRQWWURLVTXDWUHIRLVSOXVFRQVRPPDWHXUVTXHOHVIHPPHV

446

3.

Smiologie psychiatrique

3.1.

Syndrome dintoxication aigu la cocane

/HGEXWGHVHHWVHWOHVHHWVUHVVHQWLVGSHQGHQWGHODYRLHGDGPLQLVWUDWLRQGHVLQGLYLGXVHW
de la dose consomme.
$SUVXQEUHImDVK}RXmUXVK}GHSODLVLURQREVHUYHGLUHQWVHHWVVWLPXODQWV
*

(XSKRULHGXUHTXHOTXHVPLQXWHV

6HQVDWLRQGHELHQWUHDXJPHQWDWLRQGHOQHUJLH

Ides de grandeur.

7DFK\SV\FKLH

'VLQKLELWLRQ

+\SHUYLJLODQFH

Augmentation de la concentration.

Anorexie.

YHLOVHQVRULHO

$XJPHQWDWLRQGHOLQWUWHWGHOH[FLWDWLRQVH[XHOOH

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

Insomnie.

7DFK\FDUGLHK\SHUWHQVLRQDUWULHOOHP\GULDVHSOHXUFXWDQH

76

ODVXLWHGHODSKDVHGHXSKRULHVXFFGHXQHSKDVHWUDQVLWRLUHTXHOTXHVPLQXWHVTXHOTXHV
KHXUHVGHmGHVFHQWH}FDUDFWULVHSDUXQHG\VSKRULHXQHDVWKQLHXQHLUULWDELOLWXQHSHUWH
GHOHVWLPHGHVRLXQHDQ[LW
/HVXVDJHUVWHQWHQWVRXYHQWGHJUHUFHWWHSKDVHSDUODFRQVRPPDWLRQGDXWUHVSV\FKRWURSHV
SRXYDQWWUHORULJLQHGHV\QGURPHVGHGSHQGDQFHVHFRQGDLUH

3.2.

Syndrome de sevrage de la cocane

/HVV\PSWPHVDSSDUDLVVHQWTXHOTXHVMRXUVDSUVODUUWGHODFRFDQHHWSHXYHQWGXUHUSOXVLHXUV
semaines.
/HV FRQVRPPDWHXUV SHXYHQW JUHU FH V\QGURPH GH VHYUDJH DYHF GH ODOFRRO GX FDQQDELV GHV
RSLDFVRXGHVPGLFDPHQWVSV\FKRWURSHVEHQ]RGLD]SLQHVK\SQRWLTXHVTXLSHXYHQWWUH
ORULJLQHGHV\QGURPHVGHGSHQGDQFHVHFRQGDLUH

4.

Trouble psychiatrique

4.1.

Troubles lis lutilisation de cocane

4.1.1. Diagnostic

dabus (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

4.1.2. Diagnostic

de dpendance (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

447

76

Les addictions

4.2.

Troubles induits par la cocane

4.2.1. Intoxication

par la cocane

DSM-IV-TR
Critres diagnostiques de lintoxication par la cocane

448

$8WLOLVDWLRQUFHQWHGHFRFDQH
%&KDQJHPHQWVFRPSRUWHPHQWDX[RXSV\FKRORJLTXHVLQDGDSWVFOLQLTXHPHQWVLJQLFDWLIVSDUH[HPSOHHXSKRULHRX
PRXVVHPHQWDHFWLIFKDQJHPHQWGHODVRFLDELOLWK\SHUYLJLODQFHVHQVLWLYLWLQWHUSHUVRQQHOOHDQ[LWWHQVLRQ
RXFROUHFRPSRUWHPHQWVVWURW\SVDOWUDWLRQGXMXJHPHQWRXDOWUDWLRQGXIRQFWLRQQHPHQWVRFLDORXSURIHV
VLRQQHOTXLVHVRQWGYHORSSVSHQGDQWRXSHXDSUVOXWLOLVDWLRQGHFRFDQH
&$XPRLQVGHX[GHVVLJQHVVXLYDQWVVHGYHORSSDQWSHQGDQWRXSHXDSUVOXWLOLVDWLRQGHFRFDQH
* WDFK\FDUGLHRXEUDG\FDUGLH
* dilatation pupillaire,
* augmentation ou diminution de la pression artrielle,
* transpiration ou frissons,
* nauses ou vomissements,
* perte de poids avre,
* DJLWDWLRQRXUDOHQWLVVHPHQWSV\FKRPRWHXU
* IDLEOHVVHPXVFXODLUHGSUHVVLRQUHVSLUDWRLUHGRXOHXUWKRUDFLTXHRXDU\WKPLHVFDUGLDTXHV
* FRQIXVLRQFULVHVFRQYXOVLYHVG\VNLQVLHVG\VWRQLHVRXFRPD
'/HVV\PSWPHVQHVRQWSDVGXVXQHDHFWLRQPGLFDOHJQUDOHHWQHVRQWSDVPLHX[H[SOLTXVSDUXQDXWUH
WURXEOHPHQWDO
Spcifier si $YHFSHUWXUEDWLRQVGHVSHUFHSWLRQV

4.2.2.

Sevrage de la cocane

DSM-IV-TR
Critres diagnostiques dun sevrage de la cocane
$$UUWRXUGXFWLRQGXQHXWLOLVDWLRQGHFRFDQHTXLDWPDVVLYHHWSURORQJH
%+XPHXUG\VSKRULTXHDYHFDXPRLQVGHX[GHVFKDQJHPHQWVSK\VLRORJLTXHVVXLYDQWVTXLVHGYHORSSHQWGHTXHOTXHV
KHXUHVTXHOTXHVMRXUVDSUVOHFULWUH$
* fatigue,
* rves intenses et dplaisants,
* LQVRPQLHRXK\SHUVRPQLH
* DXJPHQWDWLRQGHODSSWLW
* DJLWDWLRQRXUDOHQWLVVHPHQWSV\FKRPRWHXU
&/HVV\PSWPHVGX&ULWUH%FDXVHQWXQHVRXUDQFHFOLQLTXHPHQWVLJQLFDWLYHRXXQHDOWUDWLRQGXIRQFWLRQQHPHQW
VRFLDOSURIHVVLRQQHORXGDQVGDXWUHVGRPDLQHVLPSRUWDQWV
'/HVV\PSWPHVQHVRQWSDVGXVXQHDHFWLRQPGLFDOHJQUDOHHWQHVRQWSDVPLHX[H[SOLTXVSDUXQDXWUHWURXEOH
mental.

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

5.

Complications

5.1.

Complications psychiatriques

76

SLVRGHHWWURXEOHGSUHVVLIFDUDFWULV
Tentatives de suicide.
SLVRGHVGOLUDQWVDLJXV
Attaques de panique.

5.2.

Complications non psychiatriques

Cardiovasculaires

6\QGURPHFRURQDULHQDLJX
7URXEOHVGXU\WKPHFDUGLDTXH
'\VIRQFWLRQYHQWULFXODLUHJDXFKH
Dissection aortique
7KURPERVHVDUWULHOOHVHWYHLQHXVHV

Neurologiques

$FFLGHQWYDVFXODLUHFUEUDOLVFKPLTXHRXKPRUUDJLTXH
Crises convulsives

Pulmonaires

Bronchospasme
3QHXPRWKRUD[
Hmorragies
6\QGURPHUHVSLUDWRLUHDLJXVXLWHOLQKDODWLRQGHFUDFNRXIUHHEDVHFUDFNOXQJ

Infectieuses

,QIHFWLRQVYLUDOHV9,+9+%9+&
,QIHFWLRQVEDFWULHQQHVDEFVORFDX[HQGRFDUGLWHVSQHXPRSDWKLHV
EDFWULPLHV
,QIHFWLRQVVH[XHOOHPHQWWUDQVPLVVLEOHV

6.

Prise en charge

6.1.

Prvention
&I&DQQDELVm3UYHQWLRQ}

6.2.

Prise en charge gnrale

'HPDQLUHJQUDOHODSULVHHQFKDUJHGRLWVDGDSWHUODVLWXDWLRQFOLQLTXHGXSDWLHQWHWUSRQGUH
VHVEHVRLQVHWVHVDWWHQWHV
La prise en charge individuelle est la plus utilise et la plus adapte. Nanmoins, les prises en
FKDUJHHQJURXSHSRXUUDLHQWSHUPHWWUHXQUHQIRUFHPHQWGHODGKVLRQDX[VRLQV

449

76

Les addictions

6.3.

Traitement de lintoxication aigu en cocane

/HWUDLWHPHQWGHOLQWR[LFDWLRQDLJXHVWOHWUDLWHPHQWGHVV\PSWPHVLQGXLWVSDUODFRQVRPPDWLRQ
GHFRFDQH,OQH[LVWHDXFXQDQWLGRWHVSFLTXHGXVXUGRVDJHRYHUGRVHHQFRFDQH

6.4.

Traitement du syndrome de sevrage de la cocane

/HWUDLWHPHQWGXVHYUDJHHVWJDOHPHQWV\PSWRPDWLTXH

6.5.

Traitement de la dpendance
$XFXQPGLFDPHQWQDGDXWRULVDWLRQGHPLVHVXUOHPDUFK$00HQ)UDQFHGDQVOHWUDLWHPHQW
GHODGSHQGDQFH3OXVLHXUVHVVDLVFOLQLTXHVVRQWHQFRXUVGODERUDWLRQSRXUWHVWHUOHFDFLWGH
FHUWDLQVPGLFDPHQWVGDQVODSULVHHQFKDUJHGHODGSHQGDQFHODFRFDQH
/D SULVH HQ FKDUJH DVVRFLH XQ WUDYDLO DXWRXU GH ODOOLDQFH WKUDSHXWLTXH XQ DFFRPSDJQHPHQW
PGLFDOHWSV\FKRVRFLDODLQVLTXHODPLVHHQSODFHGXQHSV\FKRWKUDSLH

Rsum
450

/DFRFDQHHVWODVXEVWDQFHVWLPXODQWHLOOLFLWHODSOXVXWLOLVHHQ(XURSH
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Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

76

Amphtamines

1.

Introduction
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2.

Contexte pidmiologique
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Indonsie.
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PWKDPSKWDPLQHHQYLURQGHWRQQHVHWOHVVDLVLHVGHFVWDV\HQYLURQGHWRQQHV
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Lamphtamine et lecstasy restent les stimulants de synthse les plus couramment consomms
en Europe.

3.

Smiologie psychiatrique
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3.1.

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Cardiovasculaires

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Syndrome de sevrage
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semaines, surtout lorsque la consommation se fait par voie intraveineuse ou par inhalation.

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76

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pisode dpressif caractris.

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4.

Trouble psychiatrique

4.1.

Troubles lis lutilisation des amphtamines

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dabus (critres DSM-IV-TR)

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de dpendance (critres DSM-IV-TR)

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Troubles induits par les amphtamines

4.2.1. Intoxication

aux amphtamines

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Les addictions

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4.2.2.

Sevrage des amphtamines

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mental.

5.

Complications

5.1.

Complications psychiatriques
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Complications non psychiatriques

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Prise en charge

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Prvention
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6.2.

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en place.

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Prise en charge du syndrome de sevrage

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6.4.

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mthamphtamine et aux amphtamines est la thrapie cognitive et comportementale. Cette
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Les addictions

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patients dpendants.

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76

Opiacs

1.

Introduction
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VRXYHQWOREMHWGXQXVDJHGWRXUQ(OOHHVWHQJQUDOLQMHFWHELHQTXHOOHSXLVVHWUHIXPH
RXVQLHTXDQGHOOHHVWWUVSXUH

2.

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3.

Smiologie psychiatrique

3.1.

Syndrome dintoxication aigu aux opiacs

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Les addictions

3.2.

Syndrome de sevrage aux opiacs

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* 'HVVLJQHVSV\FKLDWULTXHVDQ[LWTXLSHXWWUHPDMHXUHDYHFDWWDTXHVGHSDQLTXHLUULWDEL
OLWVHQVDWLRQGHPDQTXHHQYLHGHFRQVRPPHU FUDYLQJLQVRPQLHDYHFDJLWDWLRQ
*

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3RXU OHV VXMHWV GSHQGDQWV  GHV SURGXLWV  FRXUWH GXUH GDFWLRQ FRPPH OKURQH OHV
V\PSWPHVGHVHYUDJHVXUYLHQQHQWKHXUHVDSUVODGHUQLUHGRVH/HVV\PSWPHVSHXYHQW
QDSSDUDWUH TXDSUV    MRXUV GDQV OH FDV GH SURGXLWV  GHPLYLH SOXV ORQJXH FRPPH OD
0WKDGRQHFKORUK\GUDWH/HVV\PSWPHVDLJXVGXVHYUDJHSDVVHQWSDUXQSLFDSUVMRXUV
SXLV GLVSDUDLVVHQW SURJUHVVLYHPHQW HQ    MRXUV $Q[LW G\VSKRULH DQKGRQLH LQVRPQLH
SHXYHQWSHUVLVWHUGDQVOHVVHPDLQHVHWPRLVTXLVXLYHQWODUUW

458

4.

Trouble psychiatrique

4.1.

Troubles lis lutilisation dopiacs

4.1.1. Diagnostic

dabus (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

4.1.2. Diagnostic

de dpendance (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

4.2.

76

Troubles induits par les opiacs

4.2.1. Intoxication

aux opiacs

DSM-IV-TR
Critres diagnostiques dintoxication aux opiacs
$8WLOLVDWLRQUFHQWHGXQRSLDF
% &KDQJHPHQWV FRPSRUWHPHQWDX[ RX SV\FKRORJLTXHV LQDGDSWV FOLQLTXHPHQW VLJQLFDWLIV H[ HXSKRULH LQLWLDOH
VXLYLHSDUGHODSDWKLHG\VSKRULHDJLWDWLRQRXUDOHQWLVVHPHQWPRWHXUDOWUDWLRQGXMXJHPHQWRXDOWUDWLRQGXIRQF
WLRQQHPHQWVRFLDORXSURIHVVLRQQHOTXLVHVRQWGYHORSSVSHQGDQWRXSHXDSUVOXWLOLVDWLRQGXQRSLDF
&&RQVWULFWLRQSXSLOODLUHRXGLODWDWLRQSXSLOODLUHGXHODQR[LHHQFDVGHVXUGRVHJUDYHHWDXPRLQVXQGHVVLJQHV
VXLYDQWVVHGYHORSSDQWSHQGDQWRXSHXDSUVOXWLOLVDWLRQGRSLDFV
* somnolence ou corna,
* GLVFRXUVEUHGRXLOODQW
* DOWUDWLRQGHODWWHQWLRQRXGHODPPRLUH
'/HVV\PSWPHVQHVRQWSDVGXVXQHDHFWLRQPGLFDOHJQUDOHHWQHVRQWSDVPLHX[H[SOLTXVSDUXQDXWUHWURXEOH
mental.

4.2.2.

Sevrage des opiacs

DSM-IV-TR
Critres diagnostiques de sevrage des opiacs
$/XQHRXODXWUHGHVFLUFRQVWDQFHVVXLYDQWHV
* DUUWRXUGXFWLRQGXQHXWLOLVDWLRQGRSLDFVTXLDWPDVVLYHHWSURORQJHDXPRLQVSOXVLHXUVVHPDLQHV
* DGPLQLVWUDWLRQGXQDQWDJRQLVWHRSLDFDSUVXQHSULRGHGXWLOLVDWLRQGRSLDFV
%$XPRLQVWURLVGHVPDQLIHVWDWLRQVVXLYDQWHVVHGYHORSSDQWGHTXHOTXHVPLQXWHVTXHOTXHVMRXUVDSUVOHFULWUH$
* KXPHXUG\VSKRULTXH
* nauses ou vomissements,
* douleurs musculaires,
* larmoiement ou rhinorrhe,
* dilatation pupillaire, pilorection, ou transpiration,
* diarrhe,
* ELOOHPHQW
* YUH
* insomnie.
&/HVV\PSWPHVGXFULWUH%FDXVHQWXQHVRXUDQFHFOLQLTXHPHQWVLJQLFDWLYHRXXQHDOWUDWLRQGXIRQFWLRQQHPHQW
VRFLDOSURIHVVLRQQHORXFODQVGDXWUHVGRPDLQHVLPSRUWDQWV
'/HVV\PSWPHVQHVRQWSDVGXVXQHDHFWLRQPGLFDOHJQUDOHHWQHVRQWSDVPLHX[H[SOLTXVSDUXQDXWUHWURXEOH
mental.

459

76

Les addictions

5.

Complications

5.1.

Complications psychiatriques
Les sujets qui prsentent une dpendance aux opiacs ont un risque particulier de dvelopper
GHV SLVRGHV GSUHVVLIV &KH] OHV VXMHWV D\DQW XQH GSHQGDQFH DX[ RSLDFV OH WURXEOH GH OD
personnalit antisociale ainsi que le stress posttraumatique sont retrouvs plus frquemment.

5.2.

Complications non psychiatriques

5.2.1. Opiacs

consomms par voie intraveineuse

(QUDSSRUWDYHFOHVLQMHFWLRQVLQWUDYHLQHXVHVVRQWUHWURXYHV
*

Des veines sclroses.

'HVPDUTXHVGLQMHFWLRQVXUODSDUWLHLQIULHXUHGHVPHPEUHVVXSULHXUV

* /HV YHLQHV SHXYHQW GHYHQLU WHOOHPHQW VFOURVHV TXH GHV GPHV SULSKULTXHV VH
dveloppent.
*
460

OH[WUPHOHVVXMHWVVHPHWWHQWXWLOLVHUGHVYHLQHVGHVMDPEHVGXFRXRXGHVORPEHV

* /RUVTXHOHVYHLQHVVRQWLQXWLOLVDEOHVOHVVXMHWVSHXYHQWDYRLUUHFRXUVGHVLQMHFWLRQVGLUHFWH
PHQWGDQVOHWLVVXVRXVFXWDQFHTXLFRQGXLWGHVFHOOXOLWHVGHVDEFVHWGHVFLFDWULFHVGDSSD
rence circulaire tmoignant de lsions cutanes guries.
*

'HVLQIHFWLRQVSHXYHQWVXUYHQLUGDQVGDXWUHVRUJDQHV
 (QGRFDUGLWHEDFWULHQQH
 Hpatite A, B et C.

* 9LUXVGHOLPPXQRGFLHQFHKXPDLQH9,+'HVWDX[GLQIHFWLRQSDUOH9,+DOODQWMXVTX

RQWWVLJQDOVFKH]OHVVXMHWVGSHQGDQWVGHOKURQHGDQVFHUWDLQHVUJLRQVGHVWDWV8QLV
*

7XEHUFXORVH

5.2.2.Opiacs

consomms par voie nasale

/HVSHUVRQQHVTXLSUHQQHQWGHOKURQHRXGDXWUHVRSLDFVSDUYRLHQDVDOHVQLHUGYHORSSHQW

VRXYHQWXQHLUULWDWLRQGHODPXTXHXVHQDVDOHTXHOTXHIRLVDFFRPSDJQHGXQHSHUIRUDWLRQGHOD
cloison.

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

6.

Prise en charge

6.1.

Prvention

76

&I&DQQDELVm3UYHQWLRQ}

6.2.

Prise en charge gnrale

/D SULVH HQ FKDUJH GXQ SDWLHQW VRXUDQW GDEXV RX GH GSHQGDQFH DX FDQQDELV VH GFOLQH 
plusieurs niveaux :
* 3ULVHHQFKDUJHJOREDOHXQVXLYLSOXULGLVFLSOLQDLUHGRLWWUHSURSRVDXSDWLHQWDYHFYDOXD
WLRQSV\FKLDWULTXHPGLFDOHJQUDOHHWVRFLDOH/DSULVHHQFKDUJHDXORQJFRXUVQFHVVLWHOHQ
JDJHPHQW GX SDWLHQW GDQV XQH GPDUFKH GH VRLQV FRQWUDW GH VRLQV HOOH QH VH IDLW MDPDLV HQ
XUJHQFH/DVWUDWJLHGDLGHDXVHYUDJHGRLWWUHDGDSWHDXVWDGHGHFKDQJHPHQWGXSDWLHQW
* 3ULVHHQFKDUJHSV\FKRWKUDSHXWLTXHSOXVLHXUVWHFKQLTXHVVRQWXWLOLVHVGRQWOHVWKUDSLHV
FRJQLWLYHV HW FRPSRUWHPHQWDOHV FRPSUHQDQW QRWDPPHQW OHQWUHWLHQ PRWLYDWLRQQHO HW OHV WHFK
niques de prvention de la rechute.
* 3ULVHHQFKDUJHDGGLFWRORJLTXHOHELODQGHODGSHQGDQFHHVWODSUHPLUHWDSHGHODSULVHHQ
FKDUJHKLVWRLUHSDUFRXUVGHVRLQVDQWULHXUVFRGSHQGDQFHV
* 3ULVHHQFKDUJHGHVFRPRUELGLWVLOHVWQFHVVDLUHGHUHFKHUFKHUHWSUHQGUHHQFKDUJHV\VW
PDWLTXHPHQW OHV FRPSOLFDWLRQV HW FRPRUELGLWV SV\FKLDWULTXHV WURXEOH DQ[LHX[ HW WURXEOH GH
OKXPHXUHWOHVYHQWXHOOHVFRDGGLFWLRQV

6.3.

Traitement de lintoxication aigu aux opiacs

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VXUYHLOODQFHUJXOLUHIUTXHQFHUHVSLUDWRLUHIUTXHQFHFDUGLDTXHFRQVFLHQFH6D2
7UDLWHPHQW VSFLTXH SDU XQ DQWDJRQLVWH GHV UFHSWHXUV PRUSKLQLTXHV 1DOR[RQH 1DUFDQp
 PJ HQ ,9' WRXWHV OHV  PLQXWHV MXVTX UHSULVH GX U\WKPH UHVSLUDWRLUH PD[LPXP
PJK
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HWGHVV\PSWPHVDVVRFLV
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DPSRXOHGH*HQ,9'VLK\SRJO\FPLHSULVHFRQFRPLWDQWHGDOFRRODQWLELRWKUDSLHSUREDEL
OLVWHVXUSRLQWGDSSHOYUH
%LODQLQIHFWLHX[SDUIRLVORULJLQHGXVXUGRVDJHFKRFDUGLRJUDSKLHUDGLRJUDSKLHWKRUDFLTXH
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9DFFLQDWLRQDQWLWWDQLTXHDXGFRXUVSUYRLU

6.4.

Traitement du syndrome de sevrage

/HWUDLWHPHQWGXV\QGURPHGHVHYUDJHHVWV\PSWRPDWLTXHDGDSWDX[V\PSWPHVSUVHQWVSDU
OHSDWLHQWVLJQHVJQUDX[QHXURYJWDWLIVRXSV\FKLDWULTXHV

461

76

Les addictions

6.5.

Traitement de la dpendance
/HVRSLDFVVRQWOHVVHXOHVVXEVWDQFHVSRXUOHVTXHOOHVXQWUDLWHPHQWGHVXEVWLWXWLRQSHXWWUH
SURSRV SHQGDQW SOXVLHXUV PRLV RX DQQHV OD 0WKDGRQH FKORUK\GUDWH RX OD %XSUQRUSKLQH
6XEXWH[p
Tableau rsumant les modalits de prescription dun traitement de substitution aux opiacs.

Indication

)RUPH

Mthadone chlorhydrate

Buprnorphine (Subutex)

Agoniste des rcepteurs aux opiacs

Agoniste partiel
aux rcepteurs des opiacs

7UDLWHPHQWVXEVWLWXWLIGHVSKDUPDFR
dpendances majeures aux opiacs

7UDLWHPHQWVXEVWLWXWLIGHVSKDUPDFR
dpendances majeures aux opiacs,

GDQVOHFDGUHGXQHSULVHHQFKDUJH
PGLFDOHVRFLDOHHWSV\FKRORJLTXH

GDQVOHFDGUHGXQHSULVHHQFKDUJHPGLFDOH
VRFLDOHHWSV\FKRORJLTXH

6LURSRXPJSDUGRVH
*OXOHVRXPJSDUJOXOH

&RPSULPVVXEOLQJXDX[
RXPJSDUFRPSULP

Modalits
de prescription
Sirop
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sant ou en centre de soins spcialis.
5HODLVDVVXUHQPGHFLQHGHYLOOH

462

3UHVFULSWHXU

Glule
3UHVFULSWLRQLQLWLDOHVHPHVWULHOOH
UVHUYHDX[PGHFLQVH[HUDQWHQ
FHQWUHGHVRLQVGDFFRPSDJQHPHQWHW
GHSUYHQWLRQHQDGGLFWRORJLH&6$3$
ou services spcialiss
dans les soins aux toxicomanes.
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VLURSFKH]GHVSDWLHQWVWUDLWV
GHSXLVDXPRLQVDQHWVWDELOLVV
Initiation uniquement
sous la forme sirop.

3RVRORJLHV
initiation du
traitement

3UHPLUHGRVHTXRWLGLHQQH
GHPJVHORQOHQLYHDX
GHGSHQGDQFHSK\VLTXHHWDGPLQLVWUH
DXPRLQVKHXUHVDSUV
ODGHUQLUHSULVHGRSLDFV
3RVRORJLHGHQWUHWLHQREWHQXH
par augmentation de 10 mg par semaine
+DELWXHOOHPHQWHQWUHHWPJMRXU

3RVRORJLHV
Doses suprieures parfois ncessaires.
Traitement administr en une prise
unique quotidienne.

Tout mdecin.

PJM
$XPRLQVKHXUHVDSUVODGHUQLUHSULVH
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des premiers signes de manque
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patient et ajuste en augmentant
progressivement les doses
MXVTXODGRVHPLQLPDOHHFDFH
3RVRORJLHPR\HQQHGHQWUHWLHQPJMRXU
$XJPHQWDWLRQMXVTXPJMRXU
SRVRORJLHPD[SDUIRLVQFHVVDLUH

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

3UHVFULSWLRQ
scurise

2XL

2XL

Nom, posologie et dure

du traitement crits en toutes lettres.

Nom, posologie et dure

du traitement crits en toutes lettres.

0HQWLRQREOLJDWRLUHGXQRP
du pharmacien sur la prescription.

0HQWLRQREOLJDWRLUHGXQRP
du pharmacien sur la prescription.

Dure de la
prescription

Dure maximale de prescription :

14 jours.

Dure maximale de prescription :

28 jours.

Dlivrance

Dlivrance fractionne par priodes

de 7 jours sauf mention expresse
du prescripteur :
mGOLYUDQFHHQXQHVHXOHIRLV}

Dlivrance fractionne par priodes

de 7 jours sauf mention expresse
du prescripteur :
mGOLYUDQFHHQXQHVHXOHIRLV}

Modalits de
rdaction

76

Rsum
Les opiacs ont plusieurs actions : analgsique, anesthsique, antidiarrhique ou antitussive.
/KURQHHVWOXQHGHVGURJXHVGHFHWWHFODVVH,OH[LVWHFRQVRPPDWHXUVUJXOLHUVGK
URQHHQ)UDQFH
/LQWR[LFDWLRQDLJXDX[RSLDFVVHGURXOHHQWURLVSKDVHV
*

6HQVDWLRQGHELHQWUHLQWHQVHHWLPPGLDWGXUDQWPRLQVGHPLQXWHVHQJQUDO

6RPQROHQFHDSDWKLHSHQGDQWK

$Q[LWHWWURXEOHVFRJQLWLIVWURXEOHVPQVLTXHVWURXEOHVGHODWWHQWLRQ

6XU OH SODQ PGLFDOH QRQ SV\FKLDWULTXH OLQWR[LFDWLRQ DLJX DX[ RSLDFV SHXW HQWUDQHU XQH
dpression respiratoire.
/HV\QGURPHGHVHYUDJHDVVRFLHGHVVLJQHVJQUDX[GHVVLJQHVQHXURYJWDWLIVHWGHVVLJQHV
SV\FKLDWULTXHV
Les complications en rapport avec les injections intraveineuses peuvent tre une altration du
FDSLWDO YHLQHX[ LQIHFWLRQ HQGRFDUGLWH 9+% 9+& 9,+ OD FRQVRPPDWLRQ SDU YRLH QDVDOH SHXW
provoquer une perforation de la cloison nasale.
/HWUDLWHPHQWGHOLQWR[LFDWLRQDLJXHVWXQHXUJHQFHHWVHIDLWHQUDQLPDWLRQ(OOHUHSRVHVXUXQ
WUDLWHPHQWVSFLTXHSDUXQDQWDJRQLVWHGHVUFHSWHXUVPRUSKLQLTXHV
* 1DOR[RQH1DUFDQpXQWUDLWHPHQWV\PSWRPDWLTXHGHODGSUHVVLRQUHVSLUDWRLUHHWGHVV\PS
tmes associs.
/HWUDLWHPHQWGXV\QGURPHGHVHYUDJHHVWV\PSWRPDWLTXH
/HVRSLDFVVRQWOHVVHXOHVVXEVWDQFHVSRXUOHVTXHOOHVXQWUDLWHPHQWGHVXEVWLWXWLRQSHXWWUH
SURSRV SHQGDQW SOXVLHXUV PRLV RX DQQHV OD 0WKDGRQH FKORUK\GUDWH RX OD %XSUQRUSKLQH
6XEXWH[p

463

76

Les addictions

Points clefs
/KURQHHVWOXQHGHVGURJXHVGHODFODVVHGHVRSLDFV
/LQWR[LFDWLRQDLJXDVVRFLHVHQVDWLRQGHELHQWUHSXLVVRPQROHQFHSXLVDQ[LWHWWURXEOHVFRJQLWLIV
2QGLVWLQJXH
* /HVWURXEOHVOLVOXWLOLVDWLRQDX[RSLDFVLQWR[LFDWLRQDLJXHWV\QGURPHGHVHYUDJH
* /HV WURXEOHV LQGXLWV SDU OHV RSLDFV WURXEOH SV\FKRWLTXH WURXEOH DQ[LHX[ V\QGURPH FRQIXVLRQQHO G\VIRQFWLRQ
VH[XHOOHWURXEOHGXVRPPHLO
/HWUDLWHPHQWGHOLQWR[LFDWLRQDLJXHVWXQHXUJHQFHVHIDLWHQUDQLPDWLRQHWUHSRVHVXUXQWUDLWHPHQWVSFLTXHSDUXQ
DQWDJRQLVWHGHVUFHSWHXUVPRUSKLQLTXHV1DOR[RQH1DUFDQp
/HWUDLWHPHQWGXV\QGURPHGHVHYUDJHHVWV\PSWRPDWLTXH
/HVRSLDFVVRQWOHVVHXOHVVXEVWDQFHVSRXUOHVTXHOOHVXQWUDLWHPHQWGHVXEVWLWXWLRQSHXWWUHSURSRVSHQGDQWSOXVLHXUV
PRLVRXDQQHVOD0WKDGRQHFKORUK\GUDWHRXOD%XSUQRUSKLQH6XEXWH[p

464

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

76

Drogues de synthse

1.

Introduction
/H QRPEUH GHV QRXYHOOHV GURJXHV GH V\QWKVH QRXYHDX[ SURGXLWV GH V\QWKVH DXJPHQWH
UJXOLUHPHQWVXUOHPDUFKPRQGLDOHWHXURSHQ&HVGURJXHVGHV\QWKVHVRQWHQFRUHDSSHOHV
mGHVLJQHUGUXJVSDUW\GUXJVFOXEGUXJVOHJDOKLJKV}
3RXU VXUYHLOOHU ODSSDULWLRQ GH FHV QRXYHDX[ SURGXLWV O8QLRQ HXURSHQQH D PLV HQ SODFH XQ
V\VWPHGDOHUWHSUFRFH8QJUDQGQRPEUHGHSURGXLWVFRQWLHQWGHVPODQJHVGHVXEVWDQFHV
UHQGDQWOHVDQDO\VHVGLFLOHVVXUOHVUSHUFXVVLRQVFRXUWPR\HQHWORQJWHUPHVGHFHVSURGXLWV
FKH]OHVFRQVRPPDWHXUV
1RXVQHFLWHURQVGDQVFHWWHVHFWLRQTXHOHVKDOOXFLQRJQHVOHGLWK\ODPLGHGDFLGHO\VHUJLTXH
/6'HWOHVFKDPSLJQRQVKDOOXFLQRJQHVOHJDPPDK\GUR[\EXW\UDWHRX*+%**+MXVHWOD
NWDPLQH..HWVSFLDO.9LWDPLQH.
/H /6' HVW SURGXLW VRXV IRUPH GH FULVWDX[ GDQV GHV ODERUDWRLUHV FODQGHVWLQV &HV FULVWDX[
VRQW WUDQVIRUPV HQ OLTXLGH DYDQW GWUH FRXOV &H OLTXLGH HVW LQRGRUH LQFRORUH HW D XQ JRW
OJUHPHQWDPHU
/H *+% VH SUVHQWH VRXV IRUPH GH SRXGUH GH FDSVXOHV RX GH OLTXLGH LQFRORUH HW LQRGRUH ,O D
SDUIRLVXQJRWVDOHWVDYRQQHX[TXLGLVSDUDWORUVTXLOHVWPODQJXQHERLVVRQ
/DNWDPLQHVHUHWURXYHVRXVIRUPHGHSRXGUHGHOLTXLGHHWSOXVUDUHPHQWHQFRPSULPVRXHQ
capsules.

2.

Contexte pidmiologique
(Q(XURSHFKH]OHVMHXQHVDGXOWHVJVGHDQVOHVHVWLPDWLRQVGHODSUYDOHQFHDXFRXUV
GHODYLHGHODFRQVRPPDWLRQGH/6'RVFLOOHQWHQWUHHW
/HVHVWLPDWLRQVGHODSUYDOHQFHGHODFRQVRPPDWLRQGHFKDPSLJQRQVKDOOXFLQRJQHVDXFRXUV
GHODYLHFKH]FHVMHXQHVDGXOWHVVRQWFRPSULVHVHQWUHHW
/DSUYDOHQFHGHODFRQVRPPDWLRQGH*+%HWGHNWDPLQHGDQVOHVSRSXODWLRQVDGXOWHHWVFRODLUH
HVWQHWWHPHQWLQIULHXUHFHOOHGHOHFVWDV\

465

76

Les addictions

3.

3.1.

466

3.2.

Smiologie psychiatrique
Syndrome dintoxication aigu
aux nouvelles drogues de synthse

Hallucinognes

Hallucinations
Distorsions perceptuelles
Agitation
0\GULDVH
1\VWDJPXV
+\SHUWKHUPLH
7DFK\FDUGLH
HTA
7DFK\SQH

GHB
(HWGRVHGSHQGDQW
$EVRUSWLRQRUDOHUDSLGH
(HWVDXERXWGHPLQXWHV
'XUHGHKK

Dpression du SNC
Sdation
Confusion
Ataxie
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'VLQKLELWLRQ
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%UDG\FDUGLH
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%UDG\SQH
Apne
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Ktamine
'XUHGHK

Dpression respiratoire modre et transitoire

5HWDUGSURORQJGXUYHLO
Coma
Attaques de panique

Syndrome de sevrage des nouvelles drogues de synthse

Hallucinognes

([KDOOXFLQDWLRQVJRPWULTXHV
)DXVVHVSHUFHSWLRQVGHPRXYHPHQWODSULSKULHGXFKDPSYLVXHO
)ODVKVGHFRXOHXUV

GHB
KHXUHVDSUVOD
GHUQLUHSULVH
3LFDXFRXUV
GHVSUHPLUHVKHXUHV
'XUHMXVTXMRXUV

Agitation
Hallucinations surtout auditives et visuelles
7URXEOHSV\FKRWLTXHEUHI
7URXEOHGSUHVVLIFDUDFWULV
Anxit
Insomnie
Confusion
Trmor
7DFK\FDUGLH
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Ktamine
3DVGHV\QGURPHGHVHYUDJH
VSFLTXHGFULW

Anxit
7UHPEOHPHQWV
3DOSLWDWLRQV

Addiction au cannabis, cocane, amphtamines, opiacs, drogues de synthse

4.

Trouble psychiatrique

4.1.

Troubles lis lutilisation dhallucinognes

4.1.1. Diagnostic

76

dabus (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

4.1.2. Diagnostic

de dpendance (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

4.2.

Troubles lis lutilisation de GHB (troubles lis

lutilisation dune substance autre ou inconnue)

4.2.1. Diagnostic

dabus (critres DSM-IV-TR)

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4.2.2.Diagnostic

de dpendance (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

4.3.

Troubles lis lutilisation de ktamine (troubles lis la

phencyclidine ou aux substances similaires)

4.3.1. Diagnostic

dabus (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

4.3.2.Diagnostic

de dpendance (critres DSM-IV-TR)

&I,WHPm,QWURGXFWLRQ}

467

76

Les addictions

4.4.

Troubles induits par les hallucinognes

4.4.1. Intoxication

aux hallucinognes

DSM-IV-TR
Critres diagnostiques dintoxication aux hallucinognes
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4.5.

Troubles induits par le GHB

4.5.1. Intoxication

au GHB

DSM-IV-TR
Critres diagnostiques dintoxication au GHB
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4.5.2.Sevrage

76

en GHB

DSM-IV-TR
Critres diagnostiques de sevrage en GHB
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4.6.

Troubles induits par la ktamine

4.6.1. Intoxication

la ktamine

DSM-IV-TR
Critres diagnostiques dintoxication la ktamine
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Les addictions

5.

Complications

5.1.

Complications psychiatriques
Attaques de panique.
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5.2.

Complications non psychiatriques

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6.

Prise en charge

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6.2.

Traitement de lintoxication aigu

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6.3.

Traitement du syndrome de sevrage

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6.4.

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Traitement de la dpendance
Hallucinognes
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GHB
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Ktamine
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gnrales de prise en charge.

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capsules.
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Les addictions

Points clefs
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rales de prise en charge.

Rfrences pour approfondir

2EVHUYDWRLUHHXURSHQGHVGURJXHVHWGHVWR[LFRPDQLHV5DSSRUWDQQXHO tat du phnomne de
la drogue en Europe, 2012.
5DSSRUWHXURSHQVXUOHVGURJXHVTendances et volutions
La Revue du Praticien, vol. 64, mars 2014, Addiction au cannabis, la cocane, aux amphtamines,
aux opiacs, aux drogues de synthse 'U /DXUHQW .DULOD 'U 5LP =DUPGLQL 3U 2OLYLHU &RWWHQFLQ
3U0LFKHO/HMR\HX[

Opiacs

Drogues de synthse

Trouble du sommeil

Dysfonctions sexuelles

Cocane

Troubles anxieux

Trouble de lhumeur

Cannabis

Trouble psychotique

Syndrome confusionnel
par intoxication

Amphtamines

Sevrage

Tableau inspir du DSM-IV

rsumant les troubles induits par les substances

Intoxication

472

item 77

Addictions
comportementales

77

I. Introduction
II. 'QLWLRQGXWURXEOHDGGLFWLI
III. 3K\VLRSDWKRORJLHGHODGGLFWLRQFRPSRUWHPHQWDOH
IV. Le jeu pathologique
V. Addictions sexuelles
VI. Les achats compulsifs
VII.Addiction aux jeux vido sur internet
VIII.$GGLFWLRQOH[HUFLFHSK\VLTXH

Objectifs pdagogiques
* Diagnostiquer, valuer le retentissement des principales addictions
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SK\VLTXHHWOHVSULQFLSHVGHOHXUSULVHHQFKDUJH

77

Les addictions

1.

Introduction
Les addictions comportementales, ou addictions sans drogue, ont rcemment rejoint le champ
GHV DGGLFWLRQV DYHF SURGXLWV HW RQW FRQQX XQ UHJDLQ GLQWUW FHV GHUQLUHV DQQHV DYHF
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WOSKRQHSRUWDEOHDX[VULHVWOYLVHVDX[UVHDX[VRFLDX[DX[LQIRUPDWLRQVHQFRQWLQXDX[
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2.

Dfinition du trouble addictif

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*

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Les addictions comportementales traites dans ce chapitre seront :

474

3.

le jeu pathologique,

les addictions sexuelles,

les achats compulsifs,

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ODGGLFWLRQOH[HUFLFHSK\VLTXH

Physiopathologie
de laddiction comportementale
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dopaminergique de la rcompense.
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Addictions comportementales

4.

Le jeu pathologique

4.1.

Dfinition

77

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sociofamilial.

4.2.

pidmiologie
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Clinique :
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suicidaire.

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4.3.

Diagnostic positif
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4.4.

Comorbidits mdicales psychiatriques

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Les addictions

4.5.

Diagnostics diffrentiels
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VHORQOWDWWK\PLTXH

4.6.

Traitement
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Les thrapeutiques actuellement dcrites sont :
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*

Les thrapies de groupe, thrapies de couple ou familiale, groupes de soutien par des pairs.

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TXHVWURXEOHGSUHVVLIFDUDFWULVWURXEOHREVHVVLRQQHOFRPSXOVLIHVWLQGLTXH
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476

5.

Addictions sexuelles

5.1.

Dfinition pidmiologie
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*

une frquence excessive, croissante et non contrle,

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'DXWUHVDXWHXUVSDUOHQWSOXWWGK\SHUVH[XDOLWRXGHFRPSRUWHPHQWVH[XHOFRPSXOVLI
/D SUYDOHQFH HVW HVWLPH HQWUH  HW  DX[ 86$ ,O VDJLW GXQ WURXEOH DHFWDQW XQH JUDQGH
PDMRULW GKRPPHV +) HW GEXWDQW HQ JQUDO  ODGROHVFHQFH 2Q QRWHUD JDOHPHQW OD
IUTXHQFHLPSRUWDQWHGDEXVVH[XHOVGDQVOHQIDQFHFKH]OHVSDWLHQWV

5.2.

Diagnostic positif
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ORFFDVLRQGXQSLVRGHGSUHVVLIFDUDFWULVGXQHWHQWDWLYHGHVXLFLGHGHPDODGLHVVH[XHOOHPHQW
WUDQVPLVVLEOHV /HV UHODWLRQV HQWUH DGGLFWLRQ VH[XHOOH HW GOLQTXDQFH VH[XHOOH VRQW PDO FRQQXHV
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Addictions comportementales

77

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DXWHXUVOHVmDGGLFWVVH[XHOV}SUVHQWHQWDXPRLQVGHX[GHVFDUDFWULVWLTXHVVXLYDQWHV

5.3.

la drague compulsive avec partenaires multiples,

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les rapports amoureux compulsifs multiples,

les rapports sexuels compulsifs insatisfaisants,

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Comorbidits mdicales psychiatriques

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GDXWUHVDGGLFWLRQVFRPSRUWHPHQWDOHV
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5.4.

Diagnostics diffrentiels
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une pilepsie,

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5.5.

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477

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6.

Les achats compulsifs

6.1.

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6.2.

des penses envahissantes concernant les achats,

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6.3.

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478

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6.4.

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Addictions comportementales

6.5.

6.6.

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7.5.

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8.

Addiction lexercice physique

8.1.

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77

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8.5.

Diagnostics diffrentiels
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familiales des pathologies addictives,
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les groupes de soutien par les pairs,

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Addictions comportementales

77

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 toujours avec le consentement du patient.

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Rfrences pour approfondir

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partie sept

Les
thrapeutiques

item 11

Soins psychiatriques
sans consentement
I. Introduction
II. Soins sans consentement selon la loi de juillet 2011
III. Hospitalisation par ordonnance de placement provisoire

Objectifs pdagogiques
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11

11

Les thrapeutiques

1.

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1.1.

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gence, que les dcisions soient prises par le seul corps mdical.
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1.1. Les grandes nouveauts de la rforme de 2011

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11

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2.2.3.ASPPI

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2.3.

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2.5.1. Droulement

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la demande de la CDSP

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2.6.4.

la demande dune tierce personne

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2.6.5. Pour

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avoir lieu dans le respect des droits de la dfense.
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2.7.

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2.7.2. Situations
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dirresponsabilit pnale (dites 122-1 )

Modalits dinstauration

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de police est immdiatement avis de cette dcision. Le rgime de cette hospitalisation est celui
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mois sur le maintien de la mesure.
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juge peut toutefois statuer immdiatement.

pour en savoir plus

Habilitation pour les expertises prvues par la loi du 5 juillet 2011
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en charge de la personne malade.
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Leve de la mesure

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2.8.

Droits des patients

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2.8.2. Les

voies de recours

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nouvelle dcision, le patient doit tre inform de sa situation juridique, de ses droits, des voies de
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2.8.3. Des

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de se livrer aux activits religieuses ou philosophiques de son choix.

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inform par le procureur de la mise sous sauvegarde.

2.9.

Informations de tierces personnes

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pour en savoir plus

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3.

3.1.

Hospitalisation
par ordonnance de placement provisoire
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et statuer.

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Diffrents types
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1.

Introduction

1.1.

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Psychothrapies individuelles

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SHXWWUHWXGLH&HWWHWKUDSLHSURSRVHGHGFULUHSUYRLUHWFRQWUOHUOHFRPSRUWHPHQWGQL
FRPPHXQHUSRQVHXQVWLPXOL

2.2.1.2.

La thorie cognitive = thorie du traitement de linformation

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GRQQHQWOLHXGHVSHQVHVDXWRPDWLTXHVTXLHOOHVPPHJXLGHQWOHVFRPSRUWHPHQWV
&HWWHWKUDSLHSURSRVHGLGHQWLHUFHVVFKPDVSRXUPLHX[OHVJUHU

2.2.2.Objectifs
/HV7&&VRQWGHVSV\FKRWKUDSLHVYHUEDOHVGRQWOHEXWHVWGHIDLUHDFTXULUDXSDWLHQWGHVFRPS
WHQFHVSV\FKRORJLTXHVDQGHODLGHUPLHX[IDLUHIDFHVHVSUREOPHV

Dirents types de techniques psychothrapeutiques

2.2.3.

71

Modalits pratiques

2.2.3.1. Thorie comportementale :

*

'VHQVLELOLVDWLRQSDUFRQIURQWDWLRQHQLPDJLQDWLRQDXVWLPXOXVDQ[LRJQH

* ([SRVLWLRQSDUFRQIURQWDWLRQLQYLYRJUDGXHDXVWLPXOXVDQ[LRJQHDYHFmPRGHOLQJ}SDUWL

FLSDWLIOHWKUDSHXWHPRQWUHGHQRXYHDX[FRPSRUWHPHQWV
*

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$UPDWLRQGHVRL

Dveloppement des comptences sociales.

Apprentissage de la gestion des motions.

2.2.3.2. Thorie cognitive :

*

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* 7KUDSLH UDWLRQQHOOH G(OOLV HW PWKRGH GH %HFN WXGH GHV VFKPDV GH SHQVH
mHUURQV}FRPPH OH IDLW GH VXUJQUDOLVHU GDYRLU XQH SHQVH GLFKRWRPLTXH RX GH WLUHU GHV
FRQFOXVLRQVDUELWUDLUHVGXQIDLWHWGYHORSSHPHQWGHVFKPDVFRJQLWLIVSOXVDGDSWV

2.2.4.Indications
72&SKRELHVWURXEOHVDQ[LHX[VWUHVVSRVWWUDXPDWLTXHWURXEOHGSUHVVLIFDUDFWULVSUYHQ
WLRQ GX VXLFLGH 7&$ WURXEOHV GX VRPPHLO WURXEOH GH SHUVRQQDOLW ERUGHUOLQH GSHQGDQFH
VFKL]RSKUQLH
511

2.3.

Psychothrapie analytique
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LO\DSOXVGXQVLFOHSDU)UHXG

2.3.1. Principes

thoriques

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UHOLVG\QDPLTXHPHQWDX[SURFHVVXVFRQVFLHQWV
,OVDJLWGHODWKRULHWRSLTXHGH)UHXGTXLGLVWLQJXHLQVWDQFHVSV\FKLTXHV
*

OHDLQFRQVFLHQWVLJHGHVSXOVLRQVHWGHVGVLUVUHIRXOV

* OH0RLFRQVFLHQWDXFRQWDFWGHODUDOLWFRQWUOHODFFVODSHUFHSWLRQHWODFWLRQLQVWDQFH
PGLDWULFHHQWUHOHDHWOH6XUPRL
* OH 6XUPRL mFRQVFLHQFH PRUDOH} IRUPH SDU OLQWULRULVDWLRQ GHV LQWHUGLWV SDUHQWDX[ HW
sociaux.
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WHQVLRQFRPPHODIDLPOHVRPPHLOODQJRLVVHHQWUHFHVGLUHQWHVLQVWDQFHVHVWORULJLQHGH
FRQLWVLQWUDSV\FKLTXHVGRQWOHV\PSWPHGXSDWLHQWHVWOH[SUHVVLRQ/LQGLYLGXOXWWHFRQWUHFHV
FRQLWVSDUGHVPFDQLVPHVGHGIHQVHLQFRQVFLHQWVUHIRXOHPHQWFOLYDJHSURMHFWLRQDQQXOD
WLRQGQLGSODFHPHQWSDVVDJHODFWH

71

Les thrapeutiques

2.3.2.Objectifs
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SUWFRPPHODWHQWDWLYHGHUVROXWLRQGXQFRQLWLQWUDSV\FKLTXHHWODWUDQVLWLRQYHUVODJXULVRQ
/HVEXWVVRQWODPLVHMRXUSURJUHVVLYHHWODSULVHGHFRQVFLHQFHGOPHQWVLQFRQVFLHQWVHWGH
VHV SURFHVVXV SV\FKLTXHV ,O VHQ VXLW ODPQDJHPHQW SURJUHVVLI GHV PFDQLVPHV GH GIHQVH
GOWUHVSRXUOHSDWLHQW(OOHWHQGPRGLHUODVWUXFWXUHGHSHUVRQQDOLW

2.3.3. Modalits

pratiques

Cure analytique :
* /H SDWLHQW HVW DOORQJ VXU XQ GLYDQ /H SV\FKDQDO\VWH HQ GHKRUV GH VRQ FKDPS GH YLVLRQ
DGRSWHXQHDWWLWXGHGHmQHXWUDOLWDHFWLYH}HWDQDO\VHOHVUVLVWDQFHVGXSDWLHQWHWODUHODWLRQ
de transfert.
* /HVDVVRFLDWLRQVOLEUHVOHSDWLHQWH[SULPHVHVSHQVHVVDQVOHVRUGRQQHURXOHVKLUDUFKLVHU
mFRPPHDYLHQW}
* Le transfert : mouvements motionnels du patient vers le thrapeute rptant des attitudes
DFTXLVHVGDQVOHQIDQFH
* /HFRQWUHWUDQVIHUWHQVHPEOHGHVPRWLRQVHWDHFWVLQGXLWVFKH]OHWKUDSHXWHSDUOHWUDQV
fert du patient.
* /LQWHUSUWDWLRQ LQWHUYHQWLRQ GH ODQDO\VWH HQ YXH GFODLUHU ORULJLQH GHV V\PSWPHV 8QH
importance est donne aux rves et au retour des souvenirs infantiles.
Psychothrapie dinspiration analytique (PIP) :
*

512

&RUUHVSRQGXQHmFXUHW\SHDPQDJH}SDWLHQWHWWKUDSHXWHDVVLVIDFHIDFH

* 7KUDSLHSOXVGLUHFWHPHQWRULHQWHYHUVOHVRLQFHQWUHOHVFKDQJHVVXUOHPDWULHOSV\FKLTXH
OHSOXVVLJQLFDWLIPDLVWHQGVXSSULPHUOHVV\PSWPHV

2.3.4.Indications
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VRPDWRIRUPHV WURXEOHV GH SHUVRQQDOLW KLVWULRQLTXH HW QDUFLVVLTXH VXUWRXW WURXEOHV GH
ODGDSWDWLRQHWWDWGHVWUHVVSRVWWUDXPDWLTXHV
'DQV WRXV OHV FDV OH SDWLHQW GRLW WUH GHPDQGHXU PRWLY DYHF XQ ERQ LQVLJKW FRQVFLHQFH GX
WURXEOHHWGHVUHSUVHQWDWLRQVSV\FKLTXHVDGDSWHVFHOOHGHODSV\FKDQDO\VH
/HVFRQWUHLQGLFDWLRQVVRQWOHVWURXEOHVSV\FKRWLTXHVVYUHVRXGFRPSHQVV

2.4.

Autres
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VRXYHQWGHOHXUVDXWHXUV
* /HVSV\FKRWKUDSLHVLQWHUSHUVRQQHOOHVVHIRFDOLVHQWVXUOHVFRQLWVLQWHUKXPDLQVOHVGFLWV
GHFRPPXQLFDWLRQOHVWUDQVLWLRQVGDQVOHVUOHVGHODYLHOHVSURFHVVXVGDWWDFKHPHQWHWGHSHUWH
* /HVWKUDSLHVGULYDQWGHV7&&RXDJLVVDQWVXUOHVFRJQLWLRQV7&& YDJXH WKUDSLH$&7
7KUDSLHGDFFHSWDWLRQHWGHQJDJHPHQW3URJUDPPDWLRQQHXUROLQJXLVWLTXH31/UHPGLDWLRQ
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JUDPPDWLRQSDUOHVPRXYHPHQWVRFXODLUHV
e

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WKUDSLHDQDO\VHWUDQVDFWLRQQHOOHSV\FKRWKUDSLHVLQWJUDWLYHVWKUDSLHV5RGJHULHQQHV
* /HVWKUDSLHVFRUSRUHOOHVHWPGLDWLRQPGLDWLRQFRUSRUHOOHPGLDWLRQDUWLVWLTXHUHOD[D
WLRQELRIHHGEDFNVRSKURORJLHK\SQRVH

Dirents types de techniques psychothrapeutiques

3.

Psychothrapies de groupe et collectives

3.1.

Thrapie systmique familiale (ou de couple)

3.1.1. Principes

71

thoriques

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XQV\VWPHG\QDPLTXHROHVPHPEUHVVRQWHQSHUSWXHOOHLQWHUDFWLRQ/HVV\PSWPHVGXQGHV
VXMHWVGXV\VWPHOHmSDWLHQWGVLJQ}VRQWLQFOXVGDQVFHWWHG\QDPLTXHHWQDSSDUWLHQQHQWSDV
TXDXSDWLHQW,OVUHODWHQWXQG\VIRQFWLRQQHPHQWFRPPXQLFDWLRQQHORXLQWHUUHODWLRQQHOGXV\VWPH

3.1.2. Objectifs
/DV\VWPLTXHWXGLHFHTXLIRQGHODIDPLOOHVHVUJOHVVHVP\WKHVVHVWUDQVDFWLRQVVRQTXL
OLEUHHWVDH[LELOLWIDFHDXFKDQJHPHQW(OOHYLVHODUGXFWLRQGHVV\PSWPHVFKH]OHSDWLHQW
GVLJQHQSUHQDQWHQFKDUJHOHQVHPEOHGXV\VWPHGDQVOHTXHOLOYROXHODIDPLOOH

3.1.3. Modalits
*

pratiques

Alliance thrapeutique.

* $OLDWLRQMRLQLQJOHWKUDSHXWHVLPSUJQHGHODFXOWXUHIDPLOLDOHSRXUHQFOHQFKHUOHSURFHV

sus thrapeutique.
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VLJQLFDWLRQV
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PRGLHmOHVWLTXHWWHV}DWWULEXDQWFKDFXQXQUOHJ
* *QRJUDPPHIDPLOLDOVXSSRUWFULWSRXUUHSUVHQWHUOHVUHODWLRQVHQWUHOHVGLUHQWVPHPEUHV
GHODIDPLOOHHWFRQQDWUHOHVSRVLWLRQVGHFKDFXQSDUUDSSRUWOKLVWRLUHGHODIDPLOOHHWFHOOHGHV
gnrations passes.
*

3UHVFULSWLRQGHWFKHV

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*  PLQLPD XQ WKUDSHXWH HW XQ REVHUYDWHXU TXL UHSUH OHV PRXYHPHQWV HW OHV VTXHQFHV GH
OHQWUHWLHQ
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re
* deux salles spares par un miroir sans tain : dans une 1 VDOOHODIDPLOOHHWOHWKUDSHXWH
nde
dans une 2 VDOOHOHFRWKUDSHXWH

3.1.4. Indications
/HVWURXEOHVSV\FKLDWULTXHVHQOLHQDYHFGHVIDFWHXUVGHULVTXHVHWGHPDLQWLHQHQUDSSRUWDYHF
des facteurs de stress relis aux interactions familiales.
7&$DQRUH[LHHWDXWUHVDGGLFWLRQVVFKL]RSKUQLHDXWLVPH7'$+WURXEOHVGHVFRQGXLWHV

513

71

Les thrapeutiques

3.2.

Autres
*

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3V\FKRWKUDSLHPUHEE

* 3V\FKRWKUDSLHGHJURXSHSV\FKRGUDPHSV\FKRGUDPHDQDO\WLTXHSV\FKRGUDPHGH0RUHQR
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*

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Rsum
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*

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3V\FKRWKUDSLHDQDO\WLTXH

7KUDSLHV\VWPLTXHIDPLOLDOH

Points clefs
514

3V\FKRWKUDSLH
Alliance thrapeutique.
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GLVWDQFHGHOSLVRGHDLJX
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* FKRL[DGDSWODSDWKRORJLHHWDXGVLUGXSDWLHQWHQODEVHQFHGHFRQWUHLQGLFDWLRQ

Rfrences pour approfondir

Schmitt L., Premiers pas en psychothrapie, petit manuel du thrapeute(OVHYLHU0DVVRQGLWHXU
2010
([SHUWLVHFROOHFWLYHGHO,16(50Psychothrapie, trois approches values

item 72

Prescription
et surveillance
des psychotropes
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I. 'QLWLRQ

I. Introduction

II. &ODVVLFDWLRQJQUDOHGH'HOD\
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I. Introduction
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I. Introduction

72

I. Introduction

,, 3UHVFULUHun traitement

antidpresseur

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Objectifs pdagogiques
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SV\FKRWURSHV

72

Les thrapeutiques

Introduction

1.

Dfinition
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ODFWLYLWPHQWDOHVDQVSUMXJHUGXW\SHGHFHWWHPRGLFDWLRQ}GQLWLRQGH'HOD\HW'HQLNHU

2.

Classification gnrale
de Delay et Deniker
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2.1.
516

Psycholeptiques
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Ils comprennent :

2.2.

/HVK\SQRWLTXHV

/HVWUDQTXLOOLVDQWVRXDQ[LRO\WLTXHV

/HVQHXUROHSWLTXHVRXDQWLSV\FKRWLTXHV

Psychoanaleptiques
,OVFRUUHVSRQGHQWDX[mH[FLWDWHXUV}GHODFWLYLWGXV\VWPHQHUYHX[
Ils comprennent :

2.3.

/HVQRRDQDOHSWLTXHVRXSV\FKRVWLPXODQWV

/HVWK\PRDQDOHSWLTXHVRXDQWLGSUHVVHXUV

Psychoisoleptiques
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Ils comprennent :
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Les sels de lithium.

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Prescription et surveillance des psychotropes

2.4.

72

Psychodysleptiques
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Psycholeptiques

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Humeur et autres fonctions

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517
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Humeur

Antidpresseurs

Psychoanaleptiques

Figure 1. Classification des dirents psychotropes usage thrapeutique FRPPH WRXWHV OHV FODVVLFD
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72

Les thrapeutiques

Antipsychotiques

1.

Introduction

1.1.

Rationnel

1.1.1.

Dfinition
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518

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Dans les annes 1990, une nouvelle gnration de molcules a t dveloppe. Ces molcules
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GFULWVSDU'HOD\HW'HQLNHUHWVRQWDSSHOHVDQWLSV\FKRWLTXHVGHVHFRQGHJQUDWLRQRX antipsychotiques atypiques.

1.1.2. La

thorie dopaminergique de la schizophrnie

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*

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 ODSURYRFDWLRQGLGHVGOLUDQWHVDLJXVSDUOHVDPSKWDPLQHVDXJPHQWDQWODVFUWLRQGH
GRSDPLQHHWGHQRUDGUQDOLQH

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 XQH K\SHUGRSDPLQHUJLH VRXV FRUWLFDOH UHVSRQVDEOH GHV KDOOXFLQDWLRQV HW GHV LGHV GOL
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V\QGURPHQJDWLI

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1.1.3. Les

72

voies dopaminergiques

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*

La voie mso-limbique :
 LPSOLTXHGHVQHXURQHVVLWXVGDQVOHWURQFFUEUDODXQLYHDXGHODLUHWHJPHQWDOHYHQWUDOH
TXL SURMHWWHQW YHUV GHV VWUXFWXUHV OLPELTXHV FRPPH OH QR\DX DFFXPEHQV ODP\JGDOH HW
OKLSSRFDPSH
 MRXHXQUOHGDQVODPPRLUHOHVDSSUHQWLVVDJHVGDQVOHUHQIRUFHPHQWSRVLWLIGHVFRPSRU
tements apportant du plaisir, dans la rgulation de la vie motionnelle et dans le contrle de
la motivation.

La voie mso-corticale :
 LPSOLTXHGHVQHXURQHVVLWXVGDQVOHWURQFFUEUDODXQLYHDXGHODLUHWHJPHQWDOHYHQWUDOH
TXLSURMHWWHQWYHUVOHFRUWH[SUIURQWDORUELWRIURQWDOHWFLQJXODLUHDQWULHXU
 IDYRULVH OH IRQFWLRQQHPHQW GX OREH SUIURQWDO IRQFWLRQV H[FXWLYHV GRQW OD SODQLFDWLRQ
GHVDFWLRQV
 joue un rle dans certaines activits mnsiques, certains processus attentionnels.

La voie nigro-strie :
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FDXGHWSXWDPHQ
 MRXHXQUOHGDQVOHFRQWUOHGHODPRWULFLW

La voie tubro-infundibulaire :
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 -RXHXQUOHGDQVODVFUWLRQKRUPRQDOHQRWDPPHQWHQLQKLEDQWODVFUWLRQGHSURODFWLQH

Figure 2. Les 4 principales voies

dopaminergiques ( partir dune coupe
sagittale de Patrick J. Lynch, medical
illustrator ; C. Carl Jae, MD, cardiologist.
http://creativecommons.org/licenses/
by/2.5/)
YRLHPVRFRUWLFDOH
YRLHPVROLPELTXH
YRLHQLJURVWULH
YRLHWXEURLQIXQGLEXODLUH

519

72

Les thrapeutiques

1.1.4. La

synapse dopaminergique

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*

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La rpartition de ces rcepteurs varie en fonction de la voie dopaminergique implique.

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1.2.

Principales caractristiques pharmacodynamiques

1.2.1. Principes

communs

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520

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potentialits :
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Antihistaminique provoquant la sdation et la prise de poids.

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1.2.2. Action

antisrotoninergique 5HT2

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Prescription et surveillance des psychotropes

72

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De la diminution de prolactinmie.

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1.2.3. Agonisme

partiel D2

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1.3.

Principales caractristiques pharmacocintiques

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durant plusieurs semaines.
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521

72

Les thrapeutiques

Mtabolisme :
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per os.
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limination :
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2.

Prescrire un traitement antipsychotique

2.1.

Diffrentes options thrapeutiques

2.1.1. Classifications
522

des antipsychotiques

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classe chimique ont certaines proprits en commun :
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la fois une action sdative, une action rductrice sur les hallucinations et le dlire ou une action
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Prescription et surveillance des psychotropes

72

(HWVYJWDWLIV
dominants

Action sdative
Classification

Exemples

Neuroleptiques
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523

72

Les thrapeutiques

2.1.2. Principaux

antipsychotiques utiliss
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classiques

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2.1.3. Rgles

de prescription

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Prescription et surveillance des psychotropes

72

Au moment du traitement extrahospitalier :

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La monothrapie est privilgie.

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2.2.1. Indications
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Autres indications moins classiques :

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 protocoles antimtiques lors des chimiothrapies.

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525

72

Les thrapeutiques

2.2.2.Contre-indications
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2.2.3.Interactions

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Prescription et surveillance des psychotropes

2.3.

72

Bilan prthrapeutique
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risque cardiovasculaires.
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Anxiolytiques

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Les thrapeutiques

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Les thrapeutiques

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3.

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3.1.

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3.2.

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en ce qui concerne la conduite
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si confusion

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551
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Benzodiazpines

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une prescription ultrieure de
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Actes automatiques amnsiques :

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GHVFRQVTXHQFHVPGLFROJDOHV

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ODVXUYHQXHGXQV\QGURPHGHVHYUDJH
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des antcdents de dpendance, une
escalade des doses et un traitement
prolong en sont les principaux facteurs
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associe une ractivation anxieuse, une
tension musculaire, une insomnie, des
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72

Les thrapeutiques

Classe chimique

Effets indsirables

Prise en charge

Azapirones

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traitement

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V\PSWRPDWLTXH

Sdation :
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altration de la vigilance

Information du patient,
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ODFRQGXLWHDXWRPRELOH

3RWHQWLDOLVHSDUODOFRRO

Adaptation des doses

Antihistaminique H1

bloqueurs

Nombreux : voir cours de cardiologie

Autres anxiolytiques
non benzodiazpiniques

5DUHVHWEQLQVHQGHKRUVGH
ODOOHUJLH

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FOLQLTXHODUHFKHUFKHGXQUHWHQWLVVHPHQWVXUXQHDHFWLRQQRQSV\FKLDWULTXHGMSUVHQWH
3RXUWRXVUDFWLRQVDOOHUJLTXHVSRVVLEOHV

552

Prescription et surveillance des psychotropes

72

Hypnotiques

1.

Introduction
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RXGXPRLQVXQWDWSURFKHGXVRPPHLOSK\VLRORJLTXH&HVPROFXOHVVRQWSURFKHVGHVDQ[LRO\W
LTXHVDYHFSURSULWVFOLQLTXHVVGDWLYHVSOXVPDUTXHV/DFODVVHGHVK\SQRWLTXHVVHFRQVWLWXH
GHGLUHQWHVFODVVHVFKLPLTXHV
*

/HVEHQ]RGLD]SLQHV

/HVK\SQRWLTXHVQRQEHQ]RGLD]SLQLTXHV
 OHVDSSDUHQWVEHQ]RGLD]SLQLTXHVQHVRQWDJRQLVWHVTXHGXQVRXVW\SHGXUFHSWHXUDX[
EHQ]RGLD]SLQHV
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GLQWHUDFWLRQVPGLFDPHQWHXVHV

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SRQGDQWH&HVWODFWLYLWFOLQLTXHHWODSRODULWVGDWLYHGXQHPROFXOHGRQQHTXLYDSHUPHWWUH
GHGLUHQFLHUSDUH[HPSOHXQHEHQ]RGLD]SLQHK\SQRWLTXHGXQHEHQ]RGLD]SLQHDQ[LRO\WLTXH

2.

Prescrire un traitement hypnotique

2.1.

Diffrentes options thrapeutiques

Classe chimique

Molcules
7ULD]RODP
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/RUPWD]SDP
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Aspects pratiques

Diminution de la latence
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3ULYLOJLHQWOHVVWDGHVGH
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dtriment des stades de
sommeil lent et profond et de
sommeil paradoxal
La prescription du
XQLWUD]SDPHVWOLPLWH
14 jours avec dispensation
IUDFWLRQQHWRXVOHVMRXUVFDU
LOHVWSDUWLFXOLUHPHQWDGGLFWLI

553

72

Les thrapeutiques

Classe chimique

Molcules

=ROSLGHP

=RSLFORQH

$OLPPD]LQH

$VVRFLDWLRQVGK\SQRWLTXHV

554

2.2.

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Antihistaminique H1 et
$QWLSV\FKRWLTXHVSRODULW
sdative

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anticholinergiques

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molcules associes

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inconvnients

Indications et contre-indications
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*

Insomnies transitoires.

Insomnies ractionnelles.

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IDQWGHPRLQVGHDQVGDQVOLQVXVDQFHUHVSLUDWRLUHVYUHGDQVOLQVXVDQFHKSDWLTXHHW
UQDOHGDQVODP\DVWKQLHHQFDVGLQWROUDQFHJQWLTXHDXJDODFWRVHHWHQFDVGK\SHUVHQVLEL
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celles vues pour chaque classe.
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2.3.

Bilan prthrapeutique et prescription

linterrogatoire :
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5HFKHUFKHGHFRPRUELGLWVSV\FKLDWULTXHVHWOHVFRQGXLWHVDGGLFWLYHV

linterrogatoire, lexamen clinique, voire avec des examens paracliniques :

*

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Prescription et surveillance des psychotropes

72

* 5HFKHUFKH HW WUDLWHPHQW GHV DHFWLRQV QRQ SV\FKLDWULTXHV FDUGLRORJLTXHV XURORJLTXHV

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* 8QWUDLWHPHQWGHPLYLHFRXUWHVHUDFKRLVLSRXUXQHLQVRPQLHGHQGRUPLVVHPHQWDLQVLTXH
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de nuit.
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3.

Surveiller un traitement hypnotique

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Surveiller lefficacit
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3.2.

Surveiller la tolrance : effets indsirables

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ERXFKHOHPDWLQ]RSLFORQHDVVH]IUTXHQWXQHDPQVLHDQWURJUDGHXQHVRPQROHQFHGLXUQH
UVLGXHOOH]RSLFORQHHVVHQWLHOOHPHQWGHVWURXEOHVGLJHVWLIVEDQDOVGHVKDOOXFLQDWLRQVK\SQD
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V\QGURPHFRQIXVLRQQHO,OVSHXYHQWWRXVOHVGHX[FRPPHOHVEHQ]RGLD]SLQHVHQWUDQHUXQH
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555

72

Les thrapeutiques

Thymorgulateurs

1.

Introduction

1.1.

Rationnel
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RXGSUHVVLI,OVUHSUVHQWHQWXQHFODVVHSKDUPDFRORJLTXHDVVH]UHVWUHLQWHTXLFRPSUHQG
*

Les sels de lithium.

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Attention,SOXVLHXUVDQWLSV\FKRWLTXHVDW\SLTXHVDULSLSUD]ROHRODQ]DSLQHULVSHULGRQHTXLHWLDSLQH
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*

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* 7UDLWHPHQWFXUDWLIGHOSLVRGHPDQLDTXHPRGUVYUHHWSUYHQWLIGHVUHFKXWHVPDQLDTXHV
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* 7UDLWHPHQWFXUDWLIGHOSLVRGHPDQLDTXHPRGUVYUHHWSUYHQWLIGHVUHFKXWHVGXWURXEOH
ELSRODLUHFKH]OHVSDWLHQWV\D\DQWUSRQGXDXSUDODEOHRODQ]DSLQH

556

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tant les indications, ils sont dcrits dans la section leur tant ddi.

1.2.

Principales caractristiques pharmacodynamiques

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Prescription et surveillance des psychotropes

1.3.

72

Principales caractristiques pharmacocintiques

Traitements

Thymorgulateurs
anticonvulsivants

Lithium
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Administration per os
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est peu lev
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dans le lait maternel
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2.

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2.1.

Indication et contre-indications

2.1.1. Indications
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Traitement prventif de la rechute.

557

72

Les thrapeutiques

Classe

Sels de lithiums

Molcules

Sels de lithium

Traitement
curatif de
lpisode
maniaque

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curatif de
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prventif
de la
rechute

Aspects
pratiques

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Indications moins classiques :

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Prescription et surveillance des psychotropes

2.1.2. Contre-indications
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Contreindications
absolues

et interactions mdicamenteuses

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Carbamazpine

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modre (clairance de la
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cardiopathie congnitale
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risque, supplmenter en
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interactions
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72

Diminution de la lithmie :
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au lithium :
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Halopridol
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Millepertuis
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559

72

Les thrapeutiques

2.2.

Bilan prthrapeutique et rgles de prescription

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prthrapeutique
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Bilan clinique

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2.2.2.

Rgles de prescription

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*

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* 6RXVFRQWUOHGHODOLWKLPLHSRXUOHVVHOVGHOLWKLXPKDSUVODGHUQLUHSULVHWRXVOHV
MRXUV MXVTX REWHQWLRQ GXQH OLWKLPLH HFDFH VWDEOH 3XLV WRXV OHV  MRXUV SHQGDQW GHX[
PRLVSXLVWRXVOHVPRLVSHQGDQWXQDQSXLVWRXVOHVPRLV
* 6RXVFRQWUOHGHOD1)6SODTXHWWHVGXELODQKSDWLTXHXQHIRLVSDUVHPDLQHOHSUHPLHUPRLV
SRXUODFDUEDPD]SLQH
* 6RXV FRQWUOH GX ELODQ KSDWLTXH UJXOLHU SHQGDQW OHV VL[ SUHPLHUV PRLV GX WUDLWHPHQW SDU
valpromide et valproate.
*

GXFDWLRQSRXUODVDQWGXSDWLHQW

&RQWUDFHSWLRQHFDFHFKH]OHVIHPPHVHQJHGHSURFUHU

Au moment du traitement dentretien ;

*

Surveillance adapte au traitement choisi.

Prescription et surveillance des psychotropes

3.

Surveiller un traitement thymorgulateur

3.1.

Surveiller lefficacit

72

&KH]XQSDWLHQWELSRODLUHOHFDFLWVXUOHQRPEUHGSLVRGHVWK\PLTXHVHWOHXULQWHQVLWSHXW
WUHYLVXDOLVHGDQVOLGDOVXUXQGLDJUDPPHGHOKXPHXUPDLVUDUHPHQWIDLWHQSUDWLTXH

3.2.

Surveiller la tolrance : effets indsirables

Traitement

Lithium

Carbamazpine

Valpromide

Valproate

Neuropsychiques :
7UHPEOHPHQWV
IUTXHQWV
Asthnie
3DVVLYLW
7URXEOHVFRJQLWLIV
(mmoire et
FRQFHQWUDWLRQ

Neuropsychiques :
Confusion
Somnolence
Vertige
Ataxie
Cphales

Neuropsychiques :
Confusion
Somnolence
+\SRWRQLH

Neuropsychiques :
Confusion

Endocriniens :
3ULVHGHSRLGV
+\SRWK\URGLH
*RLWUH

Effets indsirables

Rnaux :
6\QGURPHSRO\XUR
SRO\GLSVLTXH
6\QGURPH
nphrotique
*ORPUXORQSKULWH
H[WUDPHPEUDQHXVH
Nphropathie
WXEXORLQWHUVWLWLHOOH
Digestifs :
Nause
*RWPWDOOLTXH
Diarrhe
*DVWUDOJLH

Hpatiques :
Hpatite
mdicamenteuse
Hmatologiques :
&\WRSQLHVGLYHUVHV
YRLUHSDQF\WRSQLH

Hpatiques :
Hpatite
mdicamenteuse
Hmatologiques :
+\SREULQRJQPLH
&\WRSQLHV

Hpatiques :
Hpatite
mdicamenteuse
Digestifs :
7URXEOHVGXWUDQVLW

Dermatologique :
5DVKFXWDQ
6\QGURPHGH/\HOO
Neurovgtatifs :
(HWVODWUDX[
anticholinergiques
Constipation
6FKHUHVVHEXFFDOH
7URXEOHGH
ODFFRPPRGDWLRQ
Mtaboliques :
+\SRQDWUPLH

Cardiovasculaires :
7URXEOHVGHOD
conduction
7URXEOHVGHOD
repolarisation
0\RFDUGLWHV
Hmatologiques :
+\SHUOHXFRF\WRVH
DYHFO\PSKRSQLH
Dermatologiques :
Acn
3VRULDVLV
Alopcie
5DVKFXWDQ
3UXULW
Surveillance
mettre en place

Clinique
Lithmie
Bilans rnal et
WK\URGLHQDQQXHO

&RQWUOHVUJXOLHUV1)6SODTXHWWHV
ELODQKSDWLTXHFRPSOHWGRQWOH73
'RVDJHSRVVLEOHVLGRXWHVXUODREVHUYDQFH

561

72

Les thrapeutiques

psychostimulants

1.

Introduction
/HVSV\FKRVWLPXODQWVXWLOLVVHQWKUDSHXWLTXHVRQWGHVSV\FKRWURSHVSV\FKRDQDOHSWLTXHVTXL
comprennent :
*

/HVDPSKWDPLQHVHWOHVGULYVDPSKWDPLQLTXHVFRPPHOHPWK\OSKQLGDWH

/DGUDQLO

/HPRGDQLOOHPWDEROLWHDFWLIGHODGUDQLO

/HVEDVHV[DQWKLTXHVFDILQHWKREURPLQHWKRSK\OOLQH

/H PWK\OSKQLGDWH HW OH PRGDQLO VRQW OHV GHX[ VXEVWDQFHV GH FHWWH FODVVH  FRQQDWUH SRXU
OL(&1
/HVSV\FKRVWLPXODQWVSDUWDJHQWOHVSURSULWVVXLYDQWHV

562

Stimulation de la vigilance.

$FFOUDWLRQGHVSURFHVVXVGLGDWLRQ

$XJPHQWDWLRQGHOLQWHQVLWGHVSHUFHSWLRQVVHQVRULHOOHV

* 6DQVDFWLRQVSFLTXHVXUOKXPHXUGSULPHFRPPHSRXUOHVDQWLGSUHVVHXUVTXLVRQWDXVVL
SV\FKRDQDOHSWLTXHV

Traitement

Mthylphnidate

Modafinil

Principales caractristiques
pharmacodynamiques

Augmentation de la concen
WUDWLRQLQWUDV\QDSWLTXHGH
dopamine et de noradrnaline,
notamment au niveau de la
formation rticule et au niveau
du cortex

3V\FKRVWLPXODQWQRQ
DPSKWDPLQLTXHDYHFXQHHW
1 adrnergique au niveau
FUEUDO

Bonne rsorption digestive

,PSRUWDQWHHWGHSUHPLHU
passage hpatique
Principales caractristiques
pharmacocintiques

3RXUFHQWDJHGHOLDLVRQ

%LRGLVSRQLELOLWGH

0WDEROLVPHKSDWLTXHSDUOHV
F\WRFKURPHV

Liaison protique peu leve

,QGXFWHXUHQ]\PDWLTXH

0WDEROLVPHKSDWLTXH

OLPLQDWLRQUQDOH

OLPLQDWLRQUQDOH

Prescription et surveillance des psychotropes

2.

72

Prescrire et surveiller
un traitement psychostimulant
Traitement

Mthylphnidate

Modafinil

Indications

7URXEOHGHODWWHQWLRQ
DYHFK\SHUDFWLYLWGHOHQIDQW
DSUVDQV

7UDLWHPHQWGHODQDUFROHSVLHHFDFH
VXUOHVDFFVGHVRPPHLOGLXUQHHWQRQ
sur la cataplexie qui doit tre traite
SDUXQLPLSUDPLQLTXH

Traitement alternatif de la narcolepsie

HQFDVGFKHFGXPRGDQLO

7UDLWHPHQWGHOK\SHUVRPQLH
idiopathique

Absolues :
+\SHUVHQVLELOLWDXPWK\OSKQLGDWH
RXWRXWDXWUHFRQVWLWXDQWGXSURGXLW
0DQLIHVWDWLRQVGDQJRLVVHSLVRGH
dpressif caractris
0DQLIHVWDWLRQVSV\FKRWLTXHV

Contre-indications

+\SHUWK\URGLH

Absolues :

$U\WKPLHFDUGLDTXH

+\SHUVHQVLELOLW

$HFWLRQVFDUGLRYDVFXODLUHVVYUHV

Allaitement

$QJRUVYUH

Relatives :

*ODXFRPH
Antcdents personnels
HWRXIDPLOLDX[GHWLFVPRWHXUV
6\QGURPHGH*LOOHVGHOD7RXUHWWH

*URVVHVVH
Amnagement posologique sur terrains
ULVTXHH[LQVXVDQWUQDO

(QIDQWVGHPRLQVGHVL[DQV
7UDLWHPHQWSDU,0$2QRQVOHFWLIV
Traitement par vasoconstricteurs
Relatives :
*URVVHVVH
Interactions
mdicamenteuses
principales

,0$2
$QWLGSUHVVHXUVWULF\FOLTXHV
Anesthsiques volatils
Agents vasopresseurs
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mdecins hospitaliers (pdiatres,
SGRSV\FKLDWUHVSV\FKLDWUHV
QHXURORJXHV
3UHVFULSWLRQUYDOXHHWUHQRXYHOH
chaque anne par le spcialiste
hospitalier

Principes de
prescription

,QDFWLYDWLRQSDUOH0RGDQLO
GHVFRQWUDFHSWLIVRUDX[
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mdecins hospitaliers (neurologues,
pneumologues, mdecins des centres
GXVRPPHLO

3UHVFULSWLRQOLPLWHMRXUV
VWXSDQW

3UHVFULSWLRQUYDOXHHWUHQRXYHOH
chaque anne par le spcialiste
hospitalier

5HQRXYHOOHPHQWGRUGRQQDQFH
PHQVXHOSRVVLEOHSDUWRXWPGHFLQ

2UGRQQDQFHGHPGLFDPHQW
GH[FHSWLRQ

Si cela se discute, en gnral, on ne

prescrit pas le traitement durant les
vacances scolaires et parfois mme on
QHOHSUHVFULWSDVOHZHHNHQG

%LODQFDUGLRYDVFXODLUHDYHF(&*DYDQW
traitement

&KH]OHVVSRUWLIVSUYHQLUTXLOVDJLW
GXQSURGXLWGRSDQW

&KH]OHVVSRUWLIVSUYHQLUTXLOVDJLW
GXQSURGXLWGRSDQW

563

72

Les thrapeutiques

Traitement

Mthylphnidate

Modafinil

Neurologiques et psychiques :
Cphales
Nervosit
Insomnie
3KDUPDFRSV\FKRVHWUVUDUH

Neurologiques et psychiques :
Cphales
Nervosit
Insomnie
Confusion
'\VNLQVLHV
7URXEOHVYLVXHOV

Digestifs :
1DXVHVGRXOHXUVDEGRPLQDOHV
DQRUH[LHSDVVDJUHVDXGEXWGX
traitement

Principaux effets
indsirables

Digestifs :
Nauses
Anorexie
6FKHUHVVHEXFFDOH

Cardiovasculaires :
7DFK\FDUGLH
3DOSLWDWLRQV
+\SHUWHQVLRQDUWULHOOH

Cardiovasculaires :
7DFK\FDUGLH
3DOSLWDWLRQV
+\SHUWHQVLRQDUWULHOOH
+\SRWHQVLRQDUWULHOOH
SRVVLEOHDXVVL

Musculo-squelettique :
3RVVLEOHUDOHQWLVVHPHQW
VWDWXURSRQGUDO
Crampes
Arthralgies
Hmatologique :
&\WRSQLHV
Allergiques :
5DFWLRQDQDSK\ODFWLTXH

Musculo-squelettique :
0\DOJLHV
Hmatologiques et allergiques :
(RVLQRSKLOLH
8UWLFDLUHYRLUHRHGHPHGH4XLQFNH

564
Clinique
Surveillance

5HFKHUFKHGHVLJQHVGHVXUGRVDJHHWGXQHPDXYDLVHWROUDQFH
+7$FRXUEHGHFURLVVDQFHSRXUOHPWK\OSKQLGDWH
1)VGHYDQWWRXWHVXVSLFLRQGDWWHLQWHKPDWRORJLTXH

Rsum
/HV SV\FKRWURSHV VRQW WUV ODUJHPHQW SUHVFULWV HW RQW W  ORULJLQH GXQH YULWDEOH UYROXWLRQ
dans le traitement et la comprhension des pathologies mentales. Les grandes familles de
SV\FKRWURSHVVRQWOHVDQWLSV\FKRWLTXHVOHVDQWLGSUHVVHXUVOHVDQ[LRO\WLTXHVOHVK\SQRWLTXHV
OHV WK\PRUJXODWHXUV HW OHV SV\FKRVWLPXODQWV 3RXU FKDTXH IDPLOOH OHV EDVHV SKDUPDFRFLQ
WLTXHVOHVSULQFLSDX[PFDQLVPHVSKDUPDFRG\QDPLTXHVOHVUJOHVGHSUHVFULSWLRQHWOHVPRGD
OLWVGHVXUYHLOODQFHVRQWFRQQDWUH

Prescription et surveillance des psychotropes

72

Points clefs
1/ Concernant les antipsychotiques :

* /HELODQSUWKUDSHXWLTXHHWOHVXLYLUHSRVHQWVXUOHVOPHQWVVXLYDQWVH[DPHQFOLQLTXHELRORJLHVWDQGDUGELODQ
KSDWLTXH(&*47F+&*FKH]OHVIHPPHVHWELODQPWDEROLTXH((*DQWFGHQWSLOHSWLTXHRXFOR]DSLQH
3URODFWLQH
* ([HPSOHGDQWLSV\FKRWLTXHVGDWLI&\DPPD]LQH
* ([HPSOHGDQWLSV\FKRWLTXHDQWLSURGXFWLI2ODQ]DSLQH
* /LQGLFDWLRQSULQFLSDOHFRUUHVSRQGDX[WURXEOHVSV\FKRWLTXHV
* 2QOHVXWLOLVHDXVVLGDQVOHVWURXEOHVGHOKXPHXU
* Il faut privilgier la monothrapie.
* /HVHHWVLQGVLUDEOHVVRQWOHVVXLYDQWVV\QGURPHPWDEROLTXHV\QGURPHSDUNLQVRQLHQG\VWRQLHVG\VNLQVLHV
K\SHUSURODFWLQPLHV\QGURPHPDOLQGHVQHXUROHSWLTXHVHHWVDQWLFKROLQHUJLTXHVHHWVDGUQRO\WLTXHVQHXWUR
SQLHSRXUODFOR]DSLQH1)6UJXOLUHVDOOHUJLH

2/ Concernant les antidpresseurs :

* /HELODQSUWKUDSHXWLTXHHVWFOLQLTXHGHV+&*VRQWIDLWVFKH]OHVIHPPHVHW
 SRXUOHV,656HW,561$ SDVGHELODQSDUDFOLQLTXH
 SRXUOHVLPLSUDPLQLTXHV (&*ELODQRSKWDOPRORJLTXHELODQUQDOELODQKSDWLTXH((*
(QSUHPLUHLQWHQWLRQQHSDVSUHVFULUHGLPLSUDPLQLTXHRXG,0$2SUIUHUOHV,656,561$RXOHVmDXWUHVDQWLG
*
SUHVVHXUV}
 H[HPSOHG,656(VFLWDORSUDP
 H[HPSOHG,561$'XOR[HWLQH
 H[HPSOHGLPLSUDPLQLTXH,PLSUDPLQH
* /RUVGHODUUWLOIDXWIDLUHXQHGLPLQXWLRQSURJUHVVLYHGHVGRVHV
* /HVHHWVLQGVLUDEOHVGHV,656VRQWOHYHGLQKLELWLRQYLUDJHPDQLDTXHHHWVGLJHVWLIVWUHPEOHPHQWVLUULWDEL
OLWFSKDOHVV\QGURPHVURWRQLQHUJLTXHVXUGRVDJHK\SRQDWUPLHVXMHWJK\SHUWHQVLRQ
* /HV HHWV LQGVLUDEOHV GHV LPLSUDPLQLTXHV VRQW OHYH GLQKLELWLRQ  YLUDJH PDQLDTXH  HHWV DQWLFKROLQHUJLTXHV
JODXFRPHSDUIHUPHWXUHGHODQJOHHHWVDGUQRO\WLTXHVHHWVDQWLKLVWDPLQLTXHVWUHPEOHPHQWVG\VDUWKULH
SLOHSVLHGRVHOHYHHHWVQHXURYJWDWLIVWURXEOHGHODFRQGXFWLRQHWGHODUHSRODULVDWLRQDOOHUJLH

3/ Concernant les anxiolytiques et hypnotiques

* /HELODQSUWKUDSHXWLTXHHVWFOLQLTXHHWSDUDFOLQLTXHHQFDVGHSRLQWGDSSHO
* /HVFKHIVGHOHGHFHVFODVVHVVRQWOHVEHQ]RGLD]SLQHV*$%$HUJLTXHVHWDSSDUHQWV
 H[HPSOHGHEHQ]RGLD]SLQHDQ[LRO\WLTXH2[D]SDP
 H[HPSOHGDSSDUHQWK\SQRWLTXH=RSLFORQH
* /HVHHWVUHFKHUFKVVRQWODQ[LRO\VHOLQGXFWLRQGXVRPPHLORXOHHWP\RUHOD[DQW
* Il existe un risque de surconsommation, de tolrance et de dpendance.
* /HVFRQWUHLQGLFDWLRQVDEVROXHVVRQWOHVVXLYDQWHVK\SHUVHQVLELOLWLQVXVDQFHUHVSLUDWRLUHVYUHLQVXVDQFH
KSDWLTXHVYUHV\QGURPHGHVDSQHVGXVRPPHLOP\DVWKQLHDQWFGHQWGHUDFWLRQSDUDGR[DOH
* /HV HHWV LQGVLUDEOHV VRQW OHV VXLYDQWV VGDWLRQ SRWHQWLDOLVH SDU ODOFRRO  WURXEOHV FRJQLWLIV  FRQIXVLRQ 
WURXEOHV GX FRPSRUWHPHQW IDYRULVV SDU ODOFRRO HHW GVLQKLELWHXU UDFWLRQV SDUDGR[DOHV  DFWHV DXWRPDWLTXHV
DPQVLTXHVSKDUPDFRGSHQGDQFH
* /DSUHVFULSWLRQGHVK\SQRWLTXHVHWGHVDQ[LRO\WLTXHVGRLWWUHUJXOLUHPHQWUYDOXHQHGRLWSDVWUHDUUWHEUXWD
OHPHQWDSUVXQWUDLWHPHQWGDWDQWGHSOXVLHXUVVHPDLQHV
* ,OQ\DSDVOLHXGDQVOHWUDLWHPHQWGHODQ[LWGDVVRFLHUGHX[DQ[LRO\WLTXHV
* ,OQ\DSDVOLHXGDVVRFLHUGHX[K\SQRWLTXHV
* 'XUHVGHSUHVFULSWLRQPD[LPDOHVUJOHPHQWDLUHVGHVHPDLQHVSRXUOHVDQ[LRO\WLTXHVHWGHVHPDLQHVSRXU
OHVK\SQRWLTXHV

565

72

Les thrapeutiques

4/ Concernant les thymorgulateurs

* /HELODQSUWKUDSHXWLTXHUHSRVHVXUOH[DPHQFOLQLTXHGHV+&*FKH]OHVIHPPHVHVW
 SRXUOHOLWKLXP1)6SODTXHWWHVLRQRJUDPPHVDQJFUDWLQLQPLHSURWLQXULHJO\FRVXULHELODQKSDWLTXH
ELODQWK\URGLHQDXPRLQVXQH76+(&*((*VLDQWFGHQWSLOHSWLTXH
 SRXUOHVDQWLFRQYXOVLYDQWV1)6SODTXHWWHVELODQKSDWLTXH
* Les sels de lithium restent le traitement de rfrence.
* ([HPSOHGDQWLFRQYXOVLYDQWGLYDOSURDWHGHVRGLXP
* ([HPSOHGDQWLSV\FKRWLTXHXWLOLVFRPPHWK\PRUJXODWHXURODQ]DSLQH
* /HVFRQWUHLQGLFDWLRQVDEVROXHVGXOLWKLXPVRQWOHVVXLYDQWHVLQVXVDQFHUQDOHGSOWLRQK\GURVRGHK\SRQD
WUPLHUJLPHVDQVVHORXSHXVDOFRURQDURSDWKLHVYUHDVVRFLDWLRQDX[VDOLGLXUWLTXHVLQVXVDQFHFDUGLDTXH
LQVWDEOHDOODLWHPHQW
* /DVXUYHLOODQFHGHODOLWKPLHHVWLQFRQWRXUQDEOHORUVGXQHSUHVFULSWLRQGHOLWKLXP

5/ Concernant les psychostimulants (mthylphnidate en particulier) :

* La prescription initiale est faite par un mdecin hospitalier puis rvalue et renouvele chaque anne par un spcia
liste hospitalier.
* /DSUHVFULSWLRQHVWOLPLWHMRXUVVWXSDQWOHUHQRXYHOOHPHQWPHQVXHOSHXWWUHIDLWSDUWRXWPGHFLQ

566

item 117

Le handicap psychique
I. Introduction
II. &RQWH[WHSLGPLRORJLTXHLPSDFWGXKDQGLFDSSV\FKLTXH
III. 3ULVHHQFKDUJHGXKDQGLFDS

Objectifs pdagogiques
* YDOXHUOHKDQGLFDSSV\FKLTXHGHODGXOWH$QDO\VHUOHVLPSOLFDWLRQV
GXKDQGLFDSHQPDWLUHGRULHQWDWLRQSURIHVVLRQQHOOH
et son retentissement social.
* $UJXPHQWHUOHVSULQFLSHVGXWLOLVDWLRQHWGHSUHVFULSWLRQGHVSULQFLSDOHV
techniques de remdiation cognitive.

117

117

Les thrapeutiques

1.

Introduction

1.1.

Dfinition OMS du handicap

Constitue un handicap, au sens de la prsente loi, toute limitation dactivits ou restriction de participation la vie en socit subie dans son environnement par une personne en raison dune altration substantielle, durable ou dfinitive dune ou plusieurs fonctions physiques, sensorielles,
mentales, cognitives ou psychiques, dun polyhandicap ou dun trouble de sant invalidant.
Loi noGXDUWLFOH
/DQRWLRQGHKDQGLFDSWLHQWFRPSWHGHODVLWXDWLRQVRFLDOHGXVXMHWHWGHODSHUFHSWLRQTXLOHQD
/HKDQGLFDSQHVWSDVXQWDWPDLVHVWIRQFWLRQGXQFRQWH[WHGRQQFHTXLUHYLHQWSDUOHUSOXWW
GHmVLWXDWLRQGHKDQGLFDS}GRULJLQHSK\VLTXHVHQVRULHOOHPHQWDOHFRJQLWLYHRXSV\FKLTXH/D
GQLWLRQGXKDQGLFDSDGRSWHSDUODORLWRXWHQLQWURGXLVDQWODQRWLRQGHQYLURQQHPHQWUHVWH
FHSHQGDQW XQ PRGOH GH W\SH LQGLYLGXHO DWWULEXDQW OD FDXVH GX KDQGLFDS DX[ m DOWUDWLRQV GH
IRQFWLRQ}FHVWGLUHDX[GFLHQFHV/HOJLVODWHXUDHQRXWUHSUFLVHQGDQVODGQLWLRQ
GX KDQGLFDS TXH OHV DOWUDWLRQV GHV IRQFWLRQV SV\FKLTXHV VRQW ELHQ GHV VRXUFHV GH KDQGLFDS
&HVWFHWWHSUFLVLRQTXLIDLWVRXYHQWGLUHTXHODORLGHDmUHFRQQX}OHKDQGLFDSSV\FKLTXH

1.2.
568

Diffrence entre handicap mental et handicap psychique

,OHVWLPSRUWDQWGHGLUHQFLHUOHVGHX[QRWLRQVIRQGDPHQWDOHPHQWGLUHQWHVGHhandicap mental
et de handicap psychique FIWDEOHDX
/HKDQGLFDSPHQWDORXmVLWXDWLRQGHKDQGLFDSGRULJLQHPHQWDOH}HVWUHOLXQGFLWFRJQLWLI
JOREDOHQWUDQDQWXQHHFLHQFHLQWHOOHFWXHOOHGLPLQXHVRXYHQWVWDEOH
/H KDQGLFDS SV\FKLTXH RX mVLWXDWLRQ GH KDQGLFDS GRULJLQH SV\FKLTXH} HVW UHOL  XQ GFLW
FRJQLWLIVSFLTXHRXGHVELDLVFRJQLWLIVvoluant par poussesSHUWXUEDQWORUJDQLVDWLRQGHV
DFWLYLWVHWGHVUHODWLRQVVRFLDOHV/HKDQGLFDSSV\FKLTXHHVWGRQFVHFRQGDLUHXQWURXEOHPHQWDO
V\QRQ\PHGHWURXEOHSV\FKLDWULTXH'XQHFHUWDLQHPDQLUHLOVDJLWSOXVGXQHGFLHQFHGDQV
OD SRVVLELOLW GXWLOLVHU VHV FDSDFLWV FRJQLWLYHV TXH GXQH DOWUDWLRQ GH FHV FDSDFLWV HQ HOOH
PPHFRQWUDLUHPHQWDXKDQGLFDSPHQWDO
Situation de handicap dorigine mentale

Situation de handicap dorigine

psychique

Apparition

'VODQDLVVDQFH

ODGROHVFHQFHRXOJHDGXOWH

volution

6WDEOHGFLHQFHGXUDEOH

YROXWLYH

Retentissement

6RLQVPGLFDX[KDELWXHOOHPHQWSHX
frquenWVFHUWDLQVWDQWGHQDWXUH
GLPLQXHUOLPSDFWGXKDQGLFDS

6RLQVPGLFDX[LQGLVSHQVDEOHV
SHUPHWWDQWGHVWDELOLVHUOHWURXEOH
PHQWDOHWGHGLPLQXHUOLPSDFWGX
handicap

Tableau 1. Comparaison des principales caractristiques des situations de handicap dorigine mentale et
psychique.

Le handicap psychique

1.3.

117

Le modle OMS du handicap

/H PRGOH GX KDQGLFDS GH O206 GLVWLQJXH WURLV QLYHDX[ ,O postule que chaque niveau de
FRPSOH[LWLQIULHXUDGHVUSHUFXVVLRQVVXUOHQLYHDXVXSULHXU'HSOXVLOH[LVWHGHVERXFOHV
GHUWURDFWLRQTXLVLJQLHQWTXHODVWLPXODWLRQGHVQLYHDX[VXSULHXUVDGHVHHWVHQUHWRXUVXU
OHVQLYHDX[LQIULHXUV(QQFHPRGOHLGHQWLHGHX[FDWJRULHVGHIDFWHXUVVXVFHSWLEOHVGLQ
XHQFHUODFDVFDGHGHFRQVTXHQFHVPHQDQWGHVGFLHQFHVDX[UHVWULFWLRQVGHSDUWLFLSDWLRQ
les facteurs personnels et les facteurs environnementaux. Ces facteurs peuvent constituer des
REVWDFOHVRXGHVIDFLOLWDWHXUVGHODSDUWLFLSDWLRQODYLHVRFLDOH
/HVIDFWHXUVSHUVRQQHOVFRPSUHQQHQWWRXVOHVOPHQWVFRQVWLWXWLIVGXQLQGLYLGXDYHFHQSDUWLFX
lier les conceptions iVVXHVGHODSV\FKRORJLHGHODVDQWOHVWUHVVSHUXOHVRXWLHQVRFLDOSHUX
OHFRQWUOHSHUXHWOHVVWUDWJLHVGDGDSWDWLRQ
/HVIDFWHXUVHQYLURQQHPHQWDX[GVLJQHQWWRXVOHVOPHQWVGXFRQWH[WHGHYLHGHOLQGLYLGXHW
QRWDPPHQW OD SUVHQFH GDLGDQWV SURIHVVLRQQHOV HWRX QDWXUHOV ODGDSWDWLRQ GX PLOLHX GH YLH
DX[ GLFXOWV HW ODFFHVVLELOLW GH OHQYLURQQHPHQW PDLV JDOHPHQW OH WUDLWHPHQW SKDUPDFROR
JLTXHHWOHVDLGHVQDQFLUHV

Problme de sant
(maladie/trouble)

'FLHQFHV
Fonctions
et structures corporelles

Limitations
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5HVWULFWLRQ
de participation

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Tableau 2. Classification Internationale du Fonctionnement, du Handicap et de la Sant (CIF, OMS, 2001).

1.3.1. Dficience
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Les thrapeutiques

1.3.2. Limitation

dactivit

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dienne, ou encore les comptences sociales et professionnelles.
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1.3.3. Restriction

de participation

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constitue pas une restriction de participation si le sujet ne vit pas dans un contexte personnel,
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quotidienne.
570

1.3.4. valuation

du handicap

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2.

Contexte pidmiologique :
impact du handicap psychique
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Le handicap psychique

3.1.

Prise en charge du handicap

Principes gnraux de la prise en charge
du handicap psychique

Dficiences

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6\PSWPHVSV\FKLDWLTXHV

Psychotropes, ECT, rTMS

Thrapie cognitivocomportementale

Limitations
dactivits

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plus ou moins complexes

Remdiation
cognitive

Restriction
de participation

Activits de la vie quotidienne

et lieux de vie
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Radaptation
psychosociale

Rhabilitation psychosociale

3.

117

+/- sauvegarde de justice / tutelle / curatelle

Figure 1. Schma synthtisant les dirents axes de la prise en charge du handicap psychique selon le
modle OMS.

3.2.

Prise en charge des dficiences et limitations dactivit :

la remdiation cognitive
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*

soit par un entranement des processus altrs,

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neurologiques :
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la mmoire,

les fonctions excutives.

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571

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572

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de rduire les rpercussions de ces altrations. Ce dernier point ncessite que le patient se soit
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t dveloppes pour communiquer les connaissances actuelles sur la maladie et le traitement de
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si je me pose des questions sur la vitesse de ma lecture, mes capacits de comprhension, alors
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Le handicap psychique

3.3.

117

Prise en charge des restrictions de participation

(cf. Item 115)
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tations dans trois domaines en fonction du niveau de restriction de participation (svrit du
KDQGLFDSYDOXSDUOH*(9$
*

le logement,

OHWUDYDLORXDLGHVQDQFLUHV

le rseau social.

3.3.1. Lieu

de vie

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quotidienne sous la forme :
*

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cologique.

3.3.2. Emploi

et aides financires

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*

soit en entreprise adapte,

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*

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573

117

Les thrapeutiques

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des activits du patient avec notamment des ducateurs spcialiss et des ergothrapeutes. Il
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3.3.3. Rseau

social

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permet de travailler 4 domaines de comptences sociales : grer son argent, grer son temps,
favoriser ses capacits de communication et loisirs, et amliorer sa prsentation (avec ducation
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3.4.
574

Prise en charge judiciaire

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Le handicap psychique

117

Points clefs
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son environnement par une personne.
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cognitive.
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cognitives.
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Rfrences pour approfondir

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item 135

Douleur en sant mentale

135

I. Introduction
II. 'QLWLRQV
III. %DVHVQHXURSK\VLRORJLTXHVHWSV\FKRORJLTXHVGHODGRXOHXU
IV. 'RXOHXUHWWURXEOHVSV\FKLDWULTXHV
V. 3ULVHHQFKDUJH

Objectifs pdagogiques
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SDWLHQWSV\FKLDWULTXHHWODSHUVRQQHDWWHLQWHGHWURXEOHVHQYDKLVVDQWVGX
dveloppement.
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HWOHVGLPHQVLRQVSV\FKRORJLTXHVHQOLHQDYHFODSODLQWHGRXORXUHXVH

135

Les thrapeutiques

1.

Introduction
Les liens entre sant mentale et douleur sont rciproques : la douleur associe un versant
SV\FKLTXH GHV SDWKRORJLHV SV\FKLDWULTXHV RQW OD GRXOHXU FRPPH V\PSWPH RX PRGLHQW OD
IDRQGRQWODGRXOHXUHVWUHVVHQWLHRXH[SULPH
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VXUOHVSHUVRQQHVYXOQUDEOHV&KH]OHVSDWLHQWVVRXUDQWGHWURXEOHVSV\FKLDWULTXHVDXVVLOD
douleur doit tre :

2.

reconnue,

value,

soigne.

Dfinitions
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composantes :

578

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GH PDQLIHVWDWLRQV DQ[LHXVHVWDFK\FDUGLH VXHXUV LQTXLWXGH TXL DFFURLVVHQW OD VHQVDWLRQ
douloureuse.
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FRPSDJQHIUTXHPPHQWGHV\PSWPHVGSUHVVLIVODVVLWXGHSHUWHGHVSRLUHWGHVLQWUWVWULV
WHVVHUHSOLHWDQ[LHX[

3.

Bases neurophysiologiques
et psychologiques de la douleur
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JLTXHVHWFXOWXUHOVPRGOHELRSV\FKRVRFLDO

3.1.

Les douleurs par excs de nociception

(OOHVUVXOWHQWGHODVWLPXODWLRQSDUXQHOVLRQXQHLQDPPDWLRQGHVWHUPLQDLVRQVQHXURQDOHV
OLEUHVDP\OLQLTXHVVLWXHVGDQVOHVWLVVXVFXWDQVPXVFXODLUHVDUWLFXODLUHVHWOHVSDURLVGHV
YLVFUHV/HerQHXURQHEUHV$GHOWDHWEUHV&WUDQVPHWOLQIRUPDWLRQQRFLFHSWLYHMXVTXDX[
FRUQHVSRVWULHXUHVGHODPRHOOH/LQIRUPDWLRQGRXORXUHXVHHVWHQVXLWHWUDQVPLVHSDUXQHmFKDQH
QHXURQDOH}YLDOHWURQFFUEUDOHWOHWKDODPXVYHUVOHFRUWH[VRPDWRVHQVRULHOHWOHVVWUXFWXUHV

Douleur en sant mentale

135

FRUWLFDOHVLPSOLTXHVGDQVOHWUDLWHPHQWGHVLQIRUPDWLRQVPRWLRQQHOOHVFRPPHODP\JGDOHHW
FRJQLWLYHVFRPPHOHFRUWH[FLQJXODLUHOLQVXODOHFRUWH[SUIURQWDORXOKLSSRFDPSH

3.2.

Les douleurs neuropathiques (ou neurognes)

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DPSXWDWLRQ(OOHVSHXYHQWSHUVLVWHUORQJWHPSVDSUVODGLVSDULWLRQGHODFDXVHLQLWLDOH

3.3.

Les douleurs dysfonctionnelles

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mJDWHFRQWURO}
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WLUTXHSHXRXSDVODGRXOHXU$WWHQGUHODGRXOHXUHQDXJPHQWHOHUHVVHQWLHWLPSXWHUXQWUDL
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3.4.

Les douleurs psychognes

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,O H[LVWH WRXMRXUV XQH SDUW SV\FKRORJLTXH  OD GRXOHXU 2Q D SDUO GH GRXOHXU sine materia, de
GSUHVVLRQPDVTXHGHSHUVRQQDOLWSUGLVSRVHODGRXOHXUTXDQGFHWWHSDUWWDLWPDMRULWDLUH
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*

anxit,

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ODSHUFHSWLRQHWOH[SUHVVLRQGRXORXUHXVH

135

Les thrapeutiques

4.

Douleur et troubles psychiatriques

4.1.

pisode dpressif caractris

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partags.
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*

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le sexe fminin,

OJHDYDQF

Les tudes ont, elles, plutt montr un seuil de douleur augment aux stimulations lectriques et
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580

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SV\FKRORJLTXHVRQH[SUHVVLRQUHVVHPEOHVRXYHQWFHOOHGHODGRXOHXUSK\VLTXH

4.2.

Troubles bipolaires
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FKH]OHVSDWLHQWVSUVHQWDQWXQWURXEOHELSRODLUHGHVSDWLHQWV6HORQFHUWDLQVODSUVHQFH
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ELSRODULW
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maniaque.
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ELSRODLUHTXHGHVSDWLHQWVVRXUDQWGXQHSRO\DUWKULWHUKXPDWRGH

4.3.

Troubles anxieux.
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PHQWFI,WHPODQ[LWSHXWUGXLUHODFDSDFLWGHFRQWUOHGHODGRXOHXUUHQIRUFHUXQFRPSRU
WHPHQWLQDGDSWHWIDYRULVHUODFKURQLFLVDWLRQVRXOLJQDQWOLPSRUWDQFHGHVDSULVHHQFKDUJH

Douleur en sant mentale

135

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4.4.

Schizophrnie et trouble dlirant chronique

/HV SODLQWHV GRXORXUHXVHV VRQW FODVVLTXHPHQW SHX H[SULPHV SDU OHV SDWLHQWV VRXUDQW GH
VFKL]RSKUQLHHQSDUWLFXOLHUORUVTXHOHVV\PSWPHVQJDWLIVVRQWDXGHYDQWGXWDEOHDXFOLQLTXH
HOOHVSHXYHQWDXVVLWUHH[SULPHVGHIDRQLQKDELWXHOOHRXEL]DUUHGXIDLWGHODGVRUJDQLVDWLRQ
de la pense.
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IDLW XQH QJOLJHQFH IUTXHQWH GH OD SDUW GHV SDWLHQWV HW GHV PGHFLQV SRXU GHV SDWKRORJLHV
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GDQVOHVWURXEOHVGOLUDQWVFKURQLTXHVFI,WHP

4.5.

Troubles du spectre autistique

et troubles envahissants du dveloppement
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PRLQV OD GRXOHXU TXH OHV DXWUHV HQIDQWV /DXWLVPH HVW SDU FRQWUH FDUDFWULV SDU GHV WURXEOHV
FRPSRUWHPHQWDX[ HW GH FRPPXQLFDWLRQV FDSDEOHV GH PRGLHU OH[SUHVVLRQ GRXORXUHXVH DYHF
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un processus douloureux.

4.6.

Troubles somatoformes
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GHPDQLIHVWDWLRQVVRPDWLTXHVGSRXUYXHVGHVXEVWUDWOVLRQQHOFI,WHP/HVV\PSWPHVQH
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XQ JURXSH KWURJQH R OHV V\PSWPHV GRXORXUHX[ SHXYHQW WUH DX SUHPLHU SODQ /HV FRQV
quences sont :
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FURLWSDVODUDOLWGHVDGRXOHXU
*

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* XQ ULVTXH LDWURJQH PXOWLSOLFDWLRQ GHV H[DPHQV FRPSOPHQWDLUHV WKUDSLHV PXOWLSOHV HW
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581

135

Les thrapeutiques

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WLTXH}ROHVV\PSWPHVVRPDWLTXHVGRQWODGRXOHXUSRXUURQWWUHDVVRFLVXQHSDWKRORJLH
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OWDWGHVDQWHQJQUDOHWHQWUDQHUXQHVRXUDQFHHWRXXQHDOWUDWLRQVLJQLFDWLYHVGHODYLH
TXRWLGLHQQHSURIHVVLRQQHOOHVRFLDOHIDPLOLDOH8QHFRPRUELGLWHVWIUTXHQWHDYHFOHVWURXEOHV
GSUHVVLIVHWDQ[LHX[6LOH[LVWHXQHDQ[LWH[FHVVLYHFRQFHUQDQWODVDQWPDLVTXHOHVV\PS
WPHVVRPDWLTXHVFRPPHODGRXOHXUVRQWDEVHQWVRXPRGUVVHUDSOXWWSRUWOHGLDJQRVWLF
GHmFUDLQWHH[FHVVLYHGDYRLUXQHPDODGLH}

4.7.

Troubles de personnalit
/HVGRXOHXUVVRQWSOXVIUTXHPPHQWUHQFRQWUHVFKH]OHVSHUVRQQHVDYHFXQWURXEOHGHODSHUVRQ
QDOLWTXLYDLQXHQFHUODIDRQGRQWODGRXOHXUHVWUHVVHQWLHHWH[SULPH
* Personnalit histrionique : ODGRXOHXUHVWH[SULPHGHIDRQWKWUDOHLPSUFLVHGDQVVDORFD
OLVDWLRQIXJDFHPRELOHGUDPDWLVH
* Personnalit obsessionnelle : la douleur est prcise, dtaille, avec une expression motion
QHOOHUHVWUHLQWH/DWWLWXGHHVWULJLGHSDUIRLVDJUHVVLYHGHIDRQODWHQWH
*

Personnalit dpendante : attitude passive, en demande constante de rassurance.

* Personnalit narcissique : ODGRXOHXUHVWSHUXHFRPPHSOXVJUDYHTXHFHOOHGHVDXWUHVDYHF

une attitude parfois hautaine et peu empathique.
* Personnalit borderline : forte coloration motionnelle avec mode relationnel oscillant entre
dvalorisation et idalisation.
* Personnalit paranoaque :SODLQWHVRXYHQWYDJXHHWYLWDQWHSDUIRLVEL]DUUHLQWHUSUWDWLYHHW
PDQWH

582

4.8.

Dmence
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VRXYHQW FRPSRUWHPHQWDOHV DJLWDWLRQ DJUHVVLYLW WURXEOHV GX VRPPHLO SURVWUDWLRQ UHIXV GH
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GRVHVGDQWDOJLTXHVGDQVFHWWHSRSXODWLRQIUDJLOHULVTXHGHWURXEOHVFRJQLWLIVHWGHFRQIXVLRQ

4.9.

Troubles addictifs
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VXEVWDQFHHXSKRULVDQWHSHXWSHUPHWWUHSRXUXQWHPSVGHWURXYHUGXSODLVLUHWXQUHIXJHIDFH
ODVRXUDQFH

Douleur en sant mentale

135

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Il faut :
*

prciser la douleur,

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Rfrences pour approfondir

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6HUUD(La douleur est-elle un problme de sant mentale ?, Sant Mentale

587