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Operationalized diagnostic systems did some good to psychiatry. We remember the whimsical and idiosyncratic ways psychiatric diagnoses were given – or rejected, by the so-called anti-psychiatrists – in the 1970s and early 1980s. DSM and ICD contributed to clean this profoundly unscientific and irrational attitude towards systematic assessment and diagnosing. What could not be foreseen at that time was that generations of psychiatrists since then confused operationalized diagnostic manuals with handbooks of psychiatry and psychopathology, and diagnostic criteria with the whole picture of the illnesses. As a nefarious consequence, a magnificent thesaurus of psychopathological knowledge, including in-depth, fine-grained descriptions of mental abnormal phenomena and syndromes has simply been removed from psychiatric educational programmes.

What is psychopathology?

One century after the first edition of Karl Jaspers’ General Psychopathology [1] – the most comprehensive analysis of psychiatry's methodological foundations and clinical concepts [2] – today's psychiatry is far from Jaspers’ emphasis on adequate concepts and methods for exploring the patient's perspective [3]. Psychopathology is a discourse (logos) about the sufferings (pathos) that affect the human mind (psyche). Our very conception of the object of psychiatry, that is the patient's abnormal experiences lived in the first-person perspective and embedded in anomalous forms of consciousness and existential patterns, has been vastly oversimplified by current assessment procedures. This oversimplification has been reinforced by reliance on methodologies (e.g. behaviourism or the emphasis on reliability rather than validity) that are unable to capture the subtle distinctions in experience that constitute the essentials of the ‘psychiatric object’ (e.g. [4]), and to acknowledge that what the patient manifests is not a series of mutually independent, isolated symptoms, but rather certain meaning-structures of interwoven experiences, beliefs, and actions, all permeated by biographical details [3].

Mental illnesses are mental

Disclaiming the subtleties of subjectivity and the unity of the person are two steps in the wrong direction because mental illnesses are first of all mental. Mental pathology is completely on view only at ‘the personal level of analysis’ [5, 6]. Mental illnesses are anomalies in the constitution and the experience of one's own self/body, of time/space and otherness which produce abnormal, dysfunctional cognitions and sometimes disturbing behaviours, including social behaviour. Behaviours, as well as cognitions, are not pathological per se; rather, their being signs and symptoms of a mental illness emerges within a given form of consciousness, a personal history, a cultural context and a given social situation. Mental illnesses qua illnesses are manifest at this level. What we can learn from psychopathology is that for establishing whether a given conduct (e.g. an anomaly in eating behaviour) is pathological or not, and for attributing it to a given mental syndrome, we need to trace it back to the deep changes in experience which produced it [e.g. an abnormal experience of one's body and identity[7]]. Also, what really matters for psychiatric care is not diagnosing a given conduct as pathological, rather trying to grasp its subjective and personal correlates to make it understandable in the light of its peculiar feel, meaning and value for the persons who displayed it.

Can we conclude that the ‘technical approach’ embodied by operationalized diagnostic systems – as opposed to the person-centred approach promoted by Psychopathology – have contributed to dehumanize psychiatric practice? There are at least two reasons to think so.

The clinical encounter is dehumanized

To the technical approach, the scientific status of psychiatry is founded on reliable diagnosis. The effectiveness of the diagnostic process relies on two domains: diagnostic criteria and the interview method. Operational diagnostic criteria are instrumental in achieving high reliability in the domain of the diagnostic schema, primarily because of their reduction of criterion variance. Structured interview methods help to improve the reliability of diagnostic assignment by reducing information variance. These two domains are coupled in such a way that structured interviews are designed to explore only those symptoms that are relevant to establish a diagnosis according to the diagnostic criteria themselves. The main goal is discovering whether a patient with a given set of signs/symptoms ‘meets criteria’. Accordingly, interviewing is seen as a technique that should conform to the technical-rational paradigm of natural sciences in which psychiatry as a branch of bio-medicine is positioned and the clinical encounter is thus conceived as a stimulus–response pattern.

As a consequence, a true dialogue between interviewer and interviewee is discouraged, the interviewer ‘knows’ a priori what is relevant to assess, the interview is conceived as a heavily asymmetric process in which the patients has the ‘pieces’ of the puzzle and the clinician the ‘whole picture’ of the patient's illness, ‘procrustean errors’ (to stretch and trim the patient's symptomatology to fit criteria) and ‘tunnel vision’ (avoiding the assessment of phenomena not included in standardized interviews) are implied, shared meanings between interviewer and interviewee are assumed and not investigated, personal narratives are avoided. Also, the uncoupling between diagnostic and therapeutic procedures is encouraged [8].

The patient qua person is dehumanized

With each successive revision of the operationalized diagnostic systems psychiatric comorbidity – the co-occurrence of clinically independent conditions – has become more prevalent. The DSM-IV/ICD-10 approach to diagnostic comorbidity has several advantages as it aims to ensure that all clinically important aspects of the patient's symptomatology are addressed and to maximize the communication of diagnostic information [9]. However, the proliferation of comorbid diagnoses in psychiatry [10] – strains credibility on the conceptual basis of the current classification system [11].

The mushrooming of monster-comorbid multiple diagnoses has several epistemological and ethical troubling implications. The most important is that it discourages seeing the manifold of phenomena displayed by a patient as a meaningful whole. Psychopathology sees the symptoms of a syndrome as having a meaningful coherence and aims to understand a given world of experiences and actions grasping the underlying characteristic modification that keeps the symptoms meaningfully interconnected. Focusing on morbus rather than on person, comorbidity disaggregates the structural unity of the patient's personal existence, her way of being in the world. It dismisses key psychopathological concepts like ‘development’ or ‘reaction’ [1] and related forms of understanding which try to grasp the continuity linking a given personality structure and Axis I symptoms. All this may encourage eclectically combined treatments through which the unity of the person gets irredeemably lost.

References

  1. Top of page
  2. References
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    Japers K. Allgemeine Psychopathologie. Springer, Berlin. (English transl. J. Hoenig, MW Hamilton) General psychopathology, 7th edn. Chicago: The University of Chicago Press, 1963.
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    Stanghellini G, Fuchs T. One century of Karl Jaspers’ General Psychopathology. Oxford/New York: Oxford University Press, 2013.
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    Nordengaard J, Parnas J. A haunting that never stops: psychiatry's problem of description. Acta Psychiatr Scand 2013;127:434435.
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    Stanghellini G, Langer A, Ambrosini A, Cangas AJ. Quality of hallucinatory experiences: differences between a clinical and a non-clinical sample. World Psychiatry 2012;11:110113.
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    Hornsby J. Personal and sub-personal: a defence of Dennet's early distinction. Philos Explor 2000;2:624.
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    Gabbani C, Stanghellini G. What kind of objectivity do we need for psychiatry? A commentary to Oulis’ ontological commitments in psychiatric taxonomy. Psychopathology 2008;41:203204.
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    Stanghellini G, Castellini G, Brogna P, Faravelli C, Ricca V. Identity and Eating Disorders (IDEA): a questionnaire evaluating identity and embodiment in eating disorder patients. Psychopathology 2012;45:147158.
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    Stanghellini G. Philosophical resources for the psychiatric interview. In Fulford KWM, Davis M, Gipps R., Graham G, Sadler JZ, Stanghellini G, Thornton T, eds. Oxford handbook of philosophy and psychiatry. Oxford/New York: Oxford University Press, 2013.
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    Pincus HA, Tew JD, First MB. Psychiatric comorbidity: is more less? World Psychiatry 2004;3:1823.
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    Wittchen HU. What is comorbidity – fact or artefact? Br J Psychiatry 1996;168(Suppl. 30):78
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    Jablensky A. The syndrome – an antidote to spurious comorbidity? World Psychiatry 2004;3:2425