Traitement comportemental des mutilations d’une adolescente présentant un trouble disruptif avec dysrégulation de l’humeur

Le présent article vise à présenter le traitement d’une adolescente de 13 ans ayant un trouble disruptif avec dysrégulation de l’humeur (TDDH) associé à des comportements parasuicidaires. Cette adolescente a bénéficié d’une thérapie comportementale proposée par notre équipe. Ce traitement s’inspire de la thérapie comportementale dialectique (TCD) utilisée à l’origine dans le trouble de personnalité borderline (TPB). Cette thérapie postule que les patients souffrant d’un TPB ont des déficits importants en termes de compétences interpersonnelles, de régulation émotionnelle et de tolérance à la détresse. Le protocole a été adapté à la singularité de la patiente. Les stratégies thérapeutiques utilisées y sont décrites : gestion des émotions, des comportements-problèmes et leurs conséquences, analyse comportementale en chaîne, choix et mise en place des solutions. Une analyse clinique de l’évolution de la patiente est proposée, de même que des pistes de réflexion.

This article describes a clinical case presenting the treatment of a 13-year-old adolescent with disruptive mood dysregulation disorder (DMDD) associated with parasuicidal behavior. This new diagnosis, its epidemiology and the future of these patients are discussed in the first part. Disruptive mood dysregulation disorder (DMDD) is characterized by the presence of frequent temper outbursts, associated with a persistent irritable mood between outbursts. The diagnosis was created to differentiate between patients who present chronic irritability and who, up until now, received a diagnosis of bipolar disorder. Its prevalence is estimated at between 1.8 and 3.3% of the population of 9–19 year olds. There is a long-term risk of depression. For the moment there are no recommendations for the treatment of these patients. The lack of treatment for this population led to extrapolating a treatment which was already validated for parasuicidal behavior in borderline personality disorder: dialectical behavioral therapy (DBT). In fact, these disorders have the dimension of emotional dysregulation in common. This dimension results from the interaction between emotional vulnerability and a disabling environment. The effect of this treatment is proven and it is currently the most comprehensive, validated treatment for emotional regulation and the decrease of suicidal and parasuicidal behavior. It is in this context that dialectical behavior therapy (DBT) was used with an adolescent in the treatment of this behavior. A clinical case was chosen principally because the patient had severe, chronic emotional difficulties leading to parasuicidal behavior involving scarification. The DBT program appeared to be suitable to adapt to this patient. Given the size of the organization, individual interviews were used, contrary to Linehan's program which envisaged group sessions. The clinical case was firstly described respecting the case history, history of the disorder and the request for treatment. The diagnosis of DMDD was detailed. A diagnosis of a condition of post-traumatic stress was rejected. The case was then conceptualized with the help of Cottraux's functional analysis. The treatment of the behavior with adaptions of DBT was then detailed. The protocol was adapted to the singularity of the patient and possibilities of the organization. The base lines were taken with the number of mutilations per week (around four at the start of treatment). The therapy started with a period of psychoeducation of emotional dysregulation. The therapeutic strategies used were described: emotion management, behavior chain analysis and analysis of the consequences of problematic behavior, solution analysis, choice and exercise of solutions and tasks to be carried out at home. The objective of emotion management was to allow the patient to identify factors which could increase their emotional vulnerability, identify their emotional system and identify a way to deal with intense emotions. Activities enabling the control of their emotions were then taught. Behavior chain analysis and analysis of the consequences of the problematic behavior enabled the patient to understand the chain of events leading to harmful behavior. Solution analysis outlined the patient's behavior management strategies so that it was no longer detrimental to their functioning. At the end of the treatment, there was no more self-harming behavior. The conclusion highlighted the results of the treatment: a clinical analysis of the situation. Finally, reflections on the suitability of this treatment for self-harming behavior in adolescents were provided.