Si certains connaissent l'existence clinique et structurale d'une psychose particulière : « la psychose hystérique », d'autres préfèrent maintenir une séparation entre névrose et psychose. Confrontés à la clinique, l'expression d'une symptomatologie délirante (aiguë ou chronique) révélée sur une structure de personnalité névrotique décompensée a conduit les auteurs à s'interroger sur la notion conceptuelle de « délire hystérique » d'une part, et celle de névrose d'autre part, avec sa disparition dans les classifications des manuels de psychiatrie.

Opinions differ as to the involvement of psychotic phenomena in neurosis. Some authors acknowledge the clinical and structural existence of a particular type of psychosis, the “hysterical psychosis”, whereas others prefer to maintain the barrier between neurosis and psychosis. The concept of “hysterical delusion” has a delicate position and brings us face to face with the problems associated with the acquisition and communication of nosological criteria constructed solidly enough to avoid the personal influence of each clinician, especially when therapeutic stakes are involved. Our reflection, therefore, centered on an unstable nosographical concept by pointing to the ambiguity of the cases of “atypical psychosis”. Our objective is not to define a new psychiatric clinical entity, far from it; this was determined in clinical situations by the presence of an acute or chronic delusional state in patients with neurotic disorder. Thus, the issue of delusion in hysterical patients led us to question the concept of neurosis and its disappearance from the classifications of psychiatry textbooks. The definition of and the meaning given to the term “delusion” are ambiguous. According to authors such as Ey and Follin, the oneiric state is a state of delirium, that is to say of distraction whose dynamic structure itself does not imply the constitution of delusion, of the experience of a dereal world [8,10]. After reviving the old concept of hysterical madness to characterize the oneiric pathology, Maleval for his part proposes the notion of crepuscular hysteria. He prefers to avoid the word “delusion” since it lacks rigor and leads to misuse of language: he proposes using the word “delirium” [26]. The definition of delusion as proposed by the psychiatric discourse in textbooks is as follows (A. Porot): “intellectual construct not in accordance with reality and about which the patient has unshakeable conviction” [29]. The definition of delusional ideas according to the diagnostic and statistical manual (DSM) is organized around three notions: false judgment, unshakeable conviction, and deviance from a cultural standard. According to Maleval, the very notion of delusional idea hinders any possible definition of delusion, “there is no such thing as delusional ideation per se, but only delusional individuals”. A more interesting approach to delusion can only be attained by leaving behind a reference to reality, which is a construct peculiar to each individual [24]. The concept of delusion refers to several phenomena at the same time, one of which is a rather passive experience of the imaginary, as in dreams, and the other a sytematic set of ideas often heterogeneous to the reality of the observer, which actively integrates into the relationships binding the patient with those close to him/her. Indeed, according to Ey, Delusion with a capital D would correspond with “systematized idealizations”, and delirium with “the experiences of an unleashed imaginary”, and according to Lacan, delusion would be the consequence of the forclusion of the Name of the Father, and delirium “the fantasmatic projections centered around a return of the repressed imaginary”. That is, that the individual calls the Name of the Father when she wants to be a woman, or he to be a man. Psychotic decompensation then signals the effects of forclusion [8,17]. All the work of the psychoanalytic school concerning delusion as established autism, and particularly Nacht and Racamier’s report, emphasize its value as a defense mechanism, whereas in acute onereic delirious episodes it would be a breach of defenses. Two entities are in conflict and complement each other; on one side psychoanalysis addresses more especially the function of delusion, and on the other psychiatry still focuses on the descriptive aspect. When the patient is in a period of delusional process, evaluation of the underlying personality is not always easy. From our point of view, the diagnostic approach conditions the therapeutic modalities. The structural aspect takes on in this case its full importance. The problem of distinguishing, on purely semiological clinical data, the presenting acute delirious episode of a psychotic process from a reactional and emotional episode is referred to in all psychiatry treatises. That is why Follin wonders if such oneiric states should not be considered as such, that is to say inherent in the very nature of the pathological structure. But the autonomy of this entity is still a controversial issue [10]. Some questioning in relation to the female patient’s fascination for a sexed position is often observed at the beginning of the acute delirious episode. This situation sometimes occurs in the context of an overt appeal from an outsider, but it often arises from a sexual “fantasization” on the occasion of an encounter with a person embodying her ideal. In all cases it would be the time of reactivation of a repressed desire, resulting in calling into question a precarious balance by generating a sort of deep wound due to a choice that the patient has to make. A review of the literature enabled us to establish that the term “hysterical psychosis” has several meanings in the writings of the various authors who recognize it. In their “studies of hysteria”, Freud and Breuer use it to describe sometimes the acute phase of a major attack, and sometimes oneiric states. Follin associates it with acute delirious episodes. Others present it as a borderline state. Agreement on the vocabulary used to designate psychotic-like disorders in hysterical patients seems important. This vocabulary is not loaded with the same signifiers according to the times and according to the theories it refers to. Indeed, it would appear that the psychiatric and psychoanalytic descriptions agree with or complete each other, but that the controversy is about theory. Thus, according to the approach to mental disease and the nosology used—whether theoretical, clinical, or economic—the concept of hysterical madness may be obscured or highlighted. This semantic shift, though confusing, confirms that there is some degree of conceptual insufficiency when it comes to discussing certain types of psychotic-like episodes, which are not schizophrenic in nature: because the nosology and concepts are vague, we are in turn referred from issues related to psychosis to issues related to neurosis [30]. We have preferred the term “hysterical delusion” to that of “hysterical psychosis”, as the latter is nonsensical because it associates two conflicting entities. The very definition of delusion is also ambiguous, and this led Maleval to use the term delirium for delusion and illusion for hallucination in hysterics. But the current psychiatric discourse does not distinguish between delusion and delirium, resulting in the lumping together of the two terms. The symptom “Delusion” appears to become specific to psychosis. A clinical differential was established only in 1955 when the concept of forclusion of the Name of the Father was introduced by Lacan. The structure is associated with the Father metaphor, a novel conceptualization of the Oedipus complex. Psychosis then refers to a modality of psychic functioning, albeit different from neurotic repression. Currently, whether one refers to international classifications or to analytic concepts, “schizophrenic psychosis” may encompass “structural hysteria”. Thus, the symptom will not signify the structure by its mere presence, but only by its connection with a possible signified.