Le trouble neurologique fonctionnel : Une élaboration de l'atteinte traumatique ?

Context

Functional neurological disorders (FND) are characterized by neurological symptoms without detectable organic abnormalities. They often manifest alongside various symptoms, such as motor, sensory, swallowing, speech, and non-epileptic psychogenic seizures. These disorders are frequently associated with traumatic life events, particularly during childhood, yet their etiology remains complex and multifactorial. While FNDs are prevalent, with estimates ranging from 10 to 18% of neurology consultations, the understanding of the underlying mechanisms and the different responses to trauma within this population remains limited and warrants further exploration.

Objective

This study aims to explore the intricate links between FND and trauma, focusing on the diverse modalities of trauma processing that emerge through FND manifestations. By examining two clinical cases, the study seeks to elucidate how FND can serve as a means of processing traumatic experiences, highlighting the variability in patient responses and the impact of these processes on the chronicity and nature of FND symptoms.

Method

The study is based on a detailed examination of two female patients suffering from FND, selected from a cohort of 20 adult patients aged between 20 and 65 years. These patients were evaluated using a combination of standardized psychological assessments, in-depth clinical interview, and projective tests (Rorschach and Thematic Apperception Test). The selected cases, Assia and Héloïse, both have a history of significant trauma but display markedly different modalities of trauma processing. Assia, aged 43, presented with functional symptoms manifesting as severe muscle tension and sensations of suffocation, while Héloïse, aged 49, exhibited severe motor impairments requiring a wheelchair, along with chronic pain and respiratory issues.

Results

The findings indicate that for the first patient, FND works as a means to express the unthinkable through somatic representations, allowing her to manage and partially process her traumatic experiences. Her engagement with her internal world, albeit fragile, enables a certain level of psychological elaboration of trauma. On the other hand, for the second patient, FND allows her to avoid psychic effraction and struggle against depression. Her defensive structure, which includes rigid psychological defenses and a tendency to externalize, prevents effective processing of traumatic events. The Rorschach and TAT results further reveal the fragility of her psychic containment and the impoverishment of her associative resources, which contrasts with the first patient's more dynamic internal world. Her responses indicate a struggle with depressive positions, often marked by themes of persecution and identification with the aggressor, reflecting a complex interaction between trauma and narcissistic vulnerability.

Conclusion

The study underscores that FND can serve multiple roles in the processing of trauma, depending on the quality of pulsional management, access to depressive affects and the psychic defenses employed by the patients. For some, like Assia, FNDs appear to offer a temporary means of translating and managing overwhelming psychic content, facilitating the possibility of psychic elaboration. This process is closely linked to the patient's ability to tolerate depressive affects, which serve as a protective mechanism against intrusive excitations. For others, like Héloïse, the FNDs become entrenched as chronic conditions, where the symptoms themselves represent a failed attempt to process trauma, leading to a repetitive, closed circuit of trauma re-enactment. Héloïse's inability to integrate these experiences into a coherent narrative, coupled with her reliance on rigid defenses, exacerbates the chronicity of her condition. These findings highlight the importance of considering FND under different modalities in trauma processing. The patients’ capacity to manage pulsional energy and depressive affects significantly influences the chronicity and nature of FND, suggesting the need for tailored therapeutic approaches. Understanding the individual differences in trauma processing among FND patients, their ability to engage with their internal world, and the role of FNDs as both a defense and a potential avenue for psychic healing can guide more effective interventions that address both the psychic and somatic dimensions of these disorders.