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One hundred years ago, Karl Jaspers published his ‘Allgemeine Psychopathologie’ [1], a book, which in its seventh edition from 1959, provided the most comprehensive analysis of psychiatry's theoretical foundations, concepts, and methods needed to investigate consciousness, particularities of psychiatric interviewing, classificatory principles, and many other issues, deemed relevant for clinical psychiatry. Today's psychiatry is very far from Jaspers’ emphasis on adequate concepts and methods for exploring the patient's perspective and his correlated insistence on the interdisciplinary nature of psychiatric enterprise, bordering not only biology but also psychology, sociology, philosophy, and other disciplines.

Since the late 1960s, psychiatry, conforming itself to the scientific ideals of behaviorism, underwent a radical remake, the so-called operational revolution. The operational revolution resulted in criteria-based diagnostic categories and ‘operational definitions’ of such criteria. The body of the then-accumulated clinical knowledge and sophisticated descriptions was simplified and shortened into diagnostic manuals, available to lay public because written in lay-language and free of theoretical burden. These manuals became the main teaching source for psychiatrists, a situation that progressively has led to a ‘death’ of psychiatric description and tended to dehumanize the clinical encounter [2]. The structured diagnostic interviews and checklists have emerged as adequate methodology to cut through the complexities of subjectivity and communication. The structured interviews, modelled upon the behaviorist stimulus–response paradigm, consist of preformulated questions (paraphrasing the corresponding diagnostic criteria), presented in a fixed, predetermined order. They are believed to eventuate in a faithful and valid reproduction of the patient's inner world and point of view. At the heydays of operationalism, it was widely predicted that enhanced reliability would lead to rapid breakthroughs in the etiological knowledge, ‘carving nature at its joints’ [3].

Unfortunately, a ‘gaping disconnect’ is today widely recognized between the impressive progress in genetics and neurosciences and ‘its almost complete failure’ to elucidate the causes and guide the diagnosis and treatment of psychiatric disorders [4]. Psychiatry increasingly worries about its own status as a clinical profession [5], partly due to vigorous attacks from a reborn antipsychiatry, this time originating from within the academia. The research stagnation has generated diverse criticisms of psychiatric classifications, together with proposals to focus elsewhere, for example, on domains of psychopathology (e.g. depression, reality distortion), proxy-variables (e.g. endo-phenotypes), or behavioral constructs with known neural bases (e.g. the RDoC: negative/positive valence systems, arousal/regulatory systems) (see [6]).

We suggest a somewhat different approach to psychiatry's current impasse [7]. A cardinal problem, in our view, is that our very conception of psychiatry's object of study has been vastly oversimplified, and that this oversimplification has been reinforced by reliance on methodologies that are unable, because unsuited, to capture the distinctions in experience and expression that constitute the essentials of the ‘psychiatric object’. It is worthwhile to recall that the ‘operational’ criteria are not, in fact, operational in their original sense of specifying action rules, linking psychiatric concepts with their counterparts in reality (operations, as in: ‘X is harder than Y because X can make a scratch on Y, but not vice versa’). What the adjective ‘operational’ actually amounts to, despite its air of scientific precision, is no more than simplified, lay-language, common-sense descriptions of symptoms and signs, which are, moreover, occasionally phenomenologically incorrect [8].

A general account of consciousness, its form of being, its structure, its aspects or phenomena (symptoms, signs, existential patterns), and a discussion of how to adequately address and translate the patient's experience, lived in the first person perspective, into a third-person, sharable-objective format for use in diagnosis and treatment, can nowhere be found in the today's literature [7]. This is in a stark contrast with contemporary neuroscience, cognitive science, developmental psychology, and philosophy of mind, where the topics of consciousness and subjectivity are at the forefront of the debate and are seen as a major, perhaps the most important, scientific, and theoretical challenge.

Psychiatry continues to assume that ‘symptoms and signs’ should be treated as being close to third-person data: publicly accessible, mutually independent entities, thing-like in nature, devoid of meaning, and suitable for context-independent definitions and measurements. The symptom is viewed on analogy to a ripe fruit, existing in the patient's consciousness and only waiting for an adequate push by a preformed question of the structured interview to come out into a full view. However, we face here a theoretical and methodological singularity of psychiatry [1]. What the patient manifests is not a series of mutually independent, isolated symptoms/signs, partly individuated by their reference to an underlying anatomo-physiological substrate (e.g. like: sneezing→rhinitis) but rather certain meaning gestalts of interwoven experiences, feelings, expressions, beliefs, and actions, all permeated by biographical detail. Patients vary in their intellectual capacities, their mastery of language and metaphor, their motivation, their impulse and ability to dissimulate, to entertain a ‘double book-keeping’, etc. A symptom needs not to exist as a fully articulated, introspectible ‘mental object’ but may sometimes entail changes in the structure (form) of consciousness, it may exhibit a quasi-habitual, prereflective quality, and its reporting often involves recollection, imagination, and reflection. To adequately ask a relevant question at a right moment requires a prior grasp of the conversational and situational context [7]. All these (and many other) reasons make the foundations of the structured interview something of an epistemological mystery. Recent research has demonstrated a poor diagnostic performance of a fully structured interview (performed by a for-the-purpose trained non-clinician) in a sample of 100 consecutive, first admissions [9]. Even the police, although unlikely concerned with epistemological problems, has discovered that open-ended, conversational, listening-oriented witness interrogation-techniques, allowing for spontaneity, recollection, and reflection on the part of the witness, are a better way to elicit valid information than a fixed series of closed questions [7].

However, abandoning an operationalist illusion of simplicity does not imply an automatic regression to subjectivism and unreliability, reminiscent of the era of psychoanalytic domination. Psychopathology, as any other scientific endeavor, requires a scholarly effort, that is, an investment in study, training, peer-discussion, and supervision. Only such effort can restore the validity of descriptive concepts and rehumanize the clinical praxis while assuring empirical rigor and reliability [7].

References

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  2. References
  • 1
    Japers K. Allgemeine Psychopathologie. Springer, Berlin (English transl. J. Hoenig, MW Hamilton) General psychopathology, 7th edn. Chicago: The University of Chicago Press, 1963.
  • 2
    Andreasen NC. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull 2007;33:108112.
  • 3
    Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 1970;126:983987.
  • 4
    Frances AJ, Widiger T. Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Annu Rev Clin Psychol 2012;8:109130.
  • 5
    Katsching H. Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry 2010;9:2128.
  • 6
    Kendler KS, Parnas J. Philosophical issues in psychiatry II: nosology. Oxford: Oxford University Press, 2012.
  • 7
    Nordgaard J, Sass LA, Parnas J. The psychiatric interview: validity, structure, and subjectivity. Eur Arch Psychiatry Clin Neurosci 2012. doi: 10.1007/s00406-012-0366-z
  • 8
    Parnas J, Sass LA. Varieties of ‘phenomenology’: on description, understanding and explanation in psychiatry. In: Kendler KS, Parnas J, eds. Philosophical issues in psychiatry explanation, phenomenology, and nosology. Oxford: Oxford University Press, 2008:239277.
  • 9
    Nordgaard J, Revsbech R, Saebye D, Parnas J. Assessing the diagnostic validity of a structured psychiatric interview in a first-admission hospital sample. World Psychiatry 2012;11:181185.