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Troubles thymiques délirants versus troubles schizophréniques délirants. A propos de l'étude d'une cohorte d'adolescents délirants. I. Antécédents et sémiologie

Published online by Cambridge University Press:  28 April 2020

O Halfon
Affiliation:
Fondation santé des étudiants de France, Clinique médico-psychologique, 77000 Neufmoutiers-en-Brie
E Albert
Affiliation:
Hôpital Robert-Debré, 75019Paris
MC Mouren-Siméoni
Affiliation:
Hôpital Necker-Enfants-Malades, 75015Paris, France
M Dugas
Affiliation:
Hôpital Robert-Debré, 75019Paris
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Résumé

La présence d'idées délirantes au cours d'un épisode dépressif ou maniaque majeur signe-t-elle une affection différente qui aurait ses caractéristiques cliniques évolutives et thérapeutiques propres, se traduisant en particulier par un handicap fonctionnel plus marqué au fil des années? Qu'en serait-il alors de ses rapports avec la maladie maniaco-dépressive et la schizophrénie? La réponse à ces questions apparaît complexe comme le montre l'étude de la littérature qui n'a cessé d'osciller entre une classification dichotomique et unitaire. Jusque vers les années 80, les adolescents présentant des troubles de l'humeur délirants étaient considérés, la plupart du temps, comme des schizophrènes car les troubles délirants l'emportaient sur les troubles thymiques. A partir de cette date, avec l'introduction du DSM III (1980), ces troubles appartiennent plutôt à la catégorie de la maladie maniaco-dépressive. La catégorie des troubles schizo-affectifs devient résiduelle. La schizophrénie et la maladie maniaco-dépressive font-elles partie d'un même continuum ou sont-elles des entités distinctes? La catégorie schizo-affective est-elle une catégorie d'attente, une catégorie résiduelle? Pour tenter de répondre à ces questions, nous avons constitué une cohorte d'adolescents délirants présentant ou non des troubles de l'humeur, dont l'évolution sera suivie de manière prospective sur 5 années. Le présent article est une description des antécédents familiaux, personnels et de la sémiologie délirante de l'épisode index de notre cohorte. L'évolution et la thérapeutique de ces sujets constitueront un autre travail. Cette étude a permis de constater qu'actuellement les troubles de l'humeur délirants sont mieux repérés chez l'adolescent. L'âge du début des troubles, contrairement à ce qui est couramment énoncé, est à peu près équivalent, quelle que soit la catégorie diagnostique: schizophrénie ou maladie maniaco-dépressive. Dans les antécédents familiaux, une nette prédominance des troubles de l'humeur est retrouvée quelle que soit la catégorie diagnostique. L'analyse de la sémiologie psychotique permet de noter l'importance de la non-congruence et des troubles du cours de la pensée chez les patients bipolaires et schizo-affectifs, alors que jusqu'à présent ces signes étaient considérés comme « pathognomoniques» de la schizophrénie. Au total, il apparaît très difficile de distinguer lors d'un premier épisode délirant un trouble de l'humeur délirant, en particulier maniaque, d'une schizophrénie débutante chez l'adolescent. Il n'y a pas d'éléments réellement prédictifs. La catégorie schizo-affective est peu spécifique avec soit des éléments qui la rapprochent des troubles de l'humeur (antécédents personnels), soit des symptômes qui la rapprochent de la schizophrénie (trouble du cours de la pensée). Le diagnostic différentiel entre trouble de l'humeur délirant et trouble schizophrénique délirant sera précisé en fonction de l'évolution et ceci constituera la deuxième partie de notre travail.

Summary

Summary

Does the presence of delirious ideas during a major depressive or manic episode indicate a different affection with its own specific developmental and therapeutic clinical characteristics, expressing itself in particular as a more marked functional handicap over a period or years? If so, what of its relationship with manic depressive illness and schizophrenia? The answer to these questions appears complex; indeed, literature on the subject has always varied between a dichotomic classification and a unitary one. Until around 1980, adolescents suffering from delirious affective disorders were usually considered as schizophrenics because delirious disorders appeared to be more significant than cyclothymic disorders. Since that time, with the introduction of the DSM III (1980), it has been more likely to place these disorders in the category of manic depressive illness. The category of schizoaffective disorders has become residual. Is there a continuity linking schizophrenia and manic depressive illness, or are they distinct entities? Is the category of schizoaffective disorders precursory or residual? To attempt to answer these questions, we designated a sample group of delirious adolescents, some suffering from affective disorders and some not. We followed their development prospectively over a period of 5 years, studying the diagnosis, prognosis and therapy applied to their cases. This article is a description of the personal and family history and the delirious semiology of the group's index episode. We will deal with the development and therapy of these patients elsewhere. Thanks to this study we have observed that nowadays delirious disorders are being detected more successfully in adolescent subjects. The age at which the disorders begin, contrary to what is commonly stated, is more or less the same whatever the diagnostic category: schizophrenia or manic depressive disorder. As far as family history is concerned, we have found that affective disorders predominate irrespective of diagnostic category. As far as Personal history is concerned, we noted a majority of affective disorders among unipolar, bipolar and schizoaffective patients, and a majority of schizophreniform disorders among schizophrenic patients. An analysis of psychotic semiology reveals a high occurrence of non-congruence and thought disorders in bipolar and schizoaffective patients, whereas in the past these signs were thought to be « pathognomonic » with respect to schizophrenia. In all, on the strength of personal and family history and clinical diagnosis, it seems very difficult to distinguish between a delirious affective disorder (especially a manic disorder) and the first stages of schizophrenia in an adolescent subject during an early delirious episode. There are no elements which would permit predictions to be made with certainty. The category of schizoaffective illness is not particularly specific; some diagnostic elements (for example personal history) bring it close to affective disorders, whilst some symptoms (for example thought disorders) make it appear more akin to schizophrenia. Clearly, any differential diagnosis attempting to distinguish between delirious affective disorders and delirious schizophrenic disorders must be defined with regard to the development of the individual patient; we shall discuss this in the second part of our study.

Type
Article original
Copyright
Copyright © European Psychiatric Association 1990

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