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Psychopathology as the basic science of psychiatry

  • Giovanni Stanghellini (a1) and Matthew R. Broome (a2)

Summary

We argue that psychopathology, as the discipline that assesses and makes sense of abnormal human subjectivity, should be at the heart of psychiatry. It should be a basic educational prerequisite in the curriculum for mental health professionals and a key element of the shared intellectual identity of clinicians and researchers in this field.

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Copyright

Corresponding author

Giovanni Stanghellini, ‘G. d'Annunzio’ University, Via dei Vestini 31 – 66100 Chieti Scalo, Italy. Email: giostan@libero.it

Footnotes

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Declaration of interest

None.

Footnotes

References

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1 Jaspers, K. General Psychopathology. Johns Hopkins University Press, 1997.
2 Stanghellini, G, Fuchs, T (eds) One Century of Karl Jaspers' General Psychopathology. Oxford University Press, 2013.
3 Stanghellini, G, Fulford, KWM, Bolton, D. Person-centered psychopathology of schizophrenia. Building on Karl Jaspers' understanding of the patient's attitude towards his illness. Schizophr Bull 2013; 39: 287–94.
4 Maj, M. Mental disorders as ‘brain diseases’ and Jaspers' legacy. World Psychiatry 2013; 12: 13.
5 Gallagher, S, Zahavi, D. The Phenomenological Mind. An Introduction to Philosophy of Mind and Cognitive Science. Routledge, 2008.
6 Parnas, J. The core Gestalt of schizophrenia. World Psychiatry 2012; 11: 67–9.
7 Kendler, KS. Introduction: Why does psychiatry need philosophy? In Kendler, KS, Parnas, J (eds) Philosophical Issues in Psychiatry; Explanation, Phenomenology, and Nosology. Johns Hopkins University Press, 2008.
8 Broome, MR, Harland, R, Owen, GS, Stringaris, A. The Maudsley Reader in Phenomenological Psychiatry. Cambridge University Press, 2013.

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Psychopathology as the basic science of psychiatry

  • Giovanni Stanghellini (a1) and Matthew R. Broome (a2)
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eLetters

Psychopathology: the new epoche attitude (Response to G Stanghellini and MR Broome's "Psychopathology as the basic science of psychiatry").

Michel Cermolacce, MD, PhD
07 November 2014

Psychopathology must stand for what it ever has been: the basic science for all psychiatric knowledge. So do Stanghellini and Broome (1) claim in their editorial referring to Jaspers' phenomenological approach. Yet we here wish to carry on the debate further than a Jasperian approach which is likely to be caught up in the natural vs human sciences opposition. The core issue may therefore be phrased as follows: is psychopathology meant to bridge the gap between explanation and comprehension, providing some shared language between causal and understanding theories -points (a) to (d) in the referred article-, or is it mainly intended, in order to cure and stand as close as possible to thepatient's subjective experience -points (e) and (f)-, to push back the limits of psychological understanding?

This method was borrowed from Husserl's followers viewing his epoche as a clue to getting away from folk psychology leading to a more existential perspective. It consists of provisionally setting aside all wetake for granted (causal theories, cliches, the existence of the world even) in order to examine what is left (2). Such method may require some intense effort since, as soon as it is held aside, the daily-life world backlashes as though we were bound to it with some elastic band. Bracketing the world allows us to realise how it builds itself up.

Using such method for psychiatry shows the psychiatric world in the making and allows us to rebuild more significant connections (3). We learnabout the way we interact, whether instrumentally or communicatively, and the way any psychiatric fact -from symptom to treatment- may be meaningfulto the subject experiencing it. Psychopathology provides the basis for some insight into the subjects' relationship to their own worlds, which will always retain some mystery that no taxonomy will clear away.

Training young practitioners into psychopathology is now again a priority. Psychopathology is not priorily learnt from books but experienced in the encounter with the phenomenon highlighting, within the significance and production of symptoms, the mutual function of the subject experiencing them and the subject whom they are addressing (4). Inthe clinical field of psychiatry, this effortful va-et-vient between first-, second-, and third-perspective is what we call the epoche attitude.

References

1. Stanghellini G, Broome MR. Psychopathology as the basic science ofpsychiatry. Br J Psychiatry 2014; 205: 169-70.

2. Naudin J, Azorin JM, Stanghellini G, Bezzubova E, Kraus A, D?rr O,Schwartz MA. An international perspective on the history and philosophy ofpsychiatry: the present-day influence of Jaspers and Husserl. Curr Opin Psychiatry 1998; 9: 390-4.

3. Mishara A, Parnas J, Naudin J. Forging the links between phenomenology, cognitive neuroscience, and psychopathology : the emergenceof a new discipline. Curr Opin Psychiatry 1999; 11: 567-573.

4. Norgaard J, Sass L, Parnas J. The psychiatric interview: validity,structure and subjectivity. Eur Arch Psychiatry Clin Neurosci 2013; 263: 353-64.

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Conflict of interest: None declared

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Psychopathology as the art and science of psychiatry

Smitha Ramadas, Associate Professor
07 November 2014

Sir,

This is in response to the editorial "Psychopathology as the basic science of Psychiatry"1, emphasizing psychopathology as the central tenetof psychiatry. Beyond the narrow confines of making a nosographical diagnosis, psychopathology is important in understanding the unique pathological subjective experiences.

With the burgeoning of neurobiological research, little emphasis is given to psychopathology ,which is the heart and soul of psychiatry. Priebe et al2 in their editorial has also cautioned against the excessive use of the neurobiological paradigm and noted that no path breaking discoveries have been made in psychiatry in the past 30 years. To quote Osler, Medicine is both a science of probabilities and art of uncertainties. The subjective aspects of illnesses should never be ignored in a specialty like psychiatry.

In this context we have an interesting case which highlights the relevance of psychopathology, beyond the realms of nosography.

A 49 year old unemployed male with basic primary education presented with suspicions that wife was poisoning his food, refusal to take food from home, hearing voices, keeping his ears closed with hands, probably to reduce the voices, poor personal, social and occupational functioning, since 22 years with worsening of symptoms for the past 3 years. There was exacerbation of symptoms since one week, following discontinuation of medicines. On examination, he was relatively mute and withdrawn. Cognitive functioning was grossly intact . The patient was diagnosed as schizophrenia according to ICD -10.3 The illness was continuous in course with poor drug adherence leading to exacerbations on and off.

He was found to be drinking his own urine during the course of the hospital stay. Patient remained guarded, and did not elaborate upon this. The patient refused to eat or drink anything other than his urine for somedays, but he took medications. We instructed the wife to remove all the mugs and buckets from the toilet just before he entered, to prevent him from collecting and drinking urine. He was then found drinking urine collected in his cupped hands. He had the same symptom during the previousexacerbations also. Patient was treated with Olanzapine 20 mg for about 3 weeks. As there was inadequate response, oral Trifluoperazine was startedand dose increased to 15 mg / day. As his sleep continued to be disturbed,Quetiapine, 100 mg was also added.

Gradually the intensity and severity of urine drinking decreased, simultaneously with improvement in psychotic symptoms.On follow up, the psychotic symptoms improved .His urine drinking also completely stopped. But he remained guarded about it .There was significant negative symptoms.

In the literature, urine drinking is reported as fetishistic or paraphilic behavior. But here it is a manifestation of his psychotic process. Though we could not elicit the patient's perspective( subjective experience ) of ingesting his own egesta, perhaps that reflects the extreme autistic withdrawal, accentuated during exacerbations.This case report highlights that psychopathology cuts across diagnostic boundaries, (from psychosis to paraphilia) and is unique in each individual.

References 1.Stanghellini G, Broome MR. Psychopathology as the basic science of psychiatry. Br J Psychiatry 2014 ; 205:169-1702.Priebe S, Burns T, Craig TK. The future of academic psychiatry may be social. Br J Psychiatry 2013;202(5):319-2

3.World Health Organization (1992) Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD--10). Geneva: WHO.

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Conflict of interest: None declared

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RE: Psychopathology as the basic science of psychiatry

How I welcome the paper by Stanghellini G. And Broome M., "Psychopathology as the basic science of psychiatry". To many of us rearedin the atmosphere of strict 'phenomenology', there now appears to be scantattention to the basic precepts of psychiatric diagnosis. I have always taught that diagnosis in psychiatry is a three-stage process: observation both objective and subjective, identification of psychopathological phenomena, and with other external information such as family history and collateral from relatives etc, diagnosis, using one of the two standard diagnostic languages. Through serving on Mental Health Tribunals, I note that this attention to psychopathology is often lacking, even by the Responsible Clinician/ consultant. An example is the misunderstood and over-used term 'paranoid', so that any expressed resentment, complaint or mistrust from the patient, often understandable in context, attracts this label, which then allows the side into 'schizophrenia', via the diagnosis of 'schizoaffective disorder'. This 'diagnosis' is very rarely according to ICD or DSM criteria, which of course requires diagnostic criteria of both Bipolar and Schizophrenic Disorder. Usually 'paranoid' alone does for the schizophrenic component and true diagnostic criteria are lacking.

It now appears rare for many psychiatrists to identify psychotic depressive phenomena, such as depressive delusions. The patient who is distressed in their delusional belief that they have killed their family, is simply termed 'paranoid' and thus 'schizoaffective'. The consequence isthe under-diagnosis of Bipolar Disorder, and the failure in the mind of the psychiatrist to construe the case accordingly. Thus the patient who isapparently recovered and symptom-free, continues to be detained, because of the belief that the medication is suppressing symptoms of schizoaffective disorder. The alternative explanation, that the affective episode has ended and the patient is euthymic, leads to prognosis, based on the previous history and the choice of prophylactic mood stabiliser. Treating every disturbed patient as if they lay on the untestable 'psychotic spectrum', leads to the mistreatment of Bipolar Disorder by depot neuroleptics, with the serious consequence of persisting disability and the high risk of suicide.

Many will say that that the choice of diagnostic label is merely a social process, but these in general are not psychiatrists, who should understand that their unbiased examination of the mental state of the patient in the clinic and on the ward - phenomenology - using a systematised process, well-based on over a century of observations - psychopathology - is unique to the psychiatrist and has demonstrably produced improvement in treatment and laid the basis for research.

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Conflict of interest: None declared

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Phenomenological psychopathology and the problem of other minds: the case of schizophrenia

Matthew M Nour, Core Psychiatry Trainee Doctor
19 September 2014

Stanghellini and Broome argue that a focus on phenomenological psychopathology is necessary for an epistemologically sound biological psychiatry (1). In a similar vein, Bleuler and other early psychiatrists postulated that the essence of disorders like schizophrenia was not the presence of individual symptoms, but a fundamental alteration in the structure of subjective experience itself, resulting in autism, disorders of volition and behaviour, and alterations in the attitude of the patient towards themselves and the world (2). If so, should psychiatrists despair that the core psychopathological dysfunction in schizophrenia is objectively inaccessible?

The traditional problem of other minds states that we have no direct access to the mental state of other people, and must extract this information from their actions. This problem can be generalised as the problem of inferring the nature of hidden causes that lie behind observable phenomena. To solve this, brains must contain models that capture the causal structure of the world (3).

During development, the infant brain increases its aptitude for generating fine motor movement by optimising an internal model that predicts how sensory information will change as a consequence of self-generated movements. The task of 'decoding' the hidden mental states of others during social interaction may be achieved by 'inverting' these models. This inversion would generate a recognition model that could theoretically infer 'hidden' mental states from observation of another person's action (4,5). But the inversion is not mathematically trivial.

Biologically plausible implementations of this inversion converge on the notion that an intuitive understanding of another person's mental state is founded on a neural architecture that is able to identify the mental state from our own personal repertoire that best predicts the actions of the other person. In other words, these models rely on the 'similarity of brains across people' (4). Promising hierarchical predictive-coding solutions to the inversion problem capture the hierarchyof goals that underpin human action, and are equivalent to empirical Bayesian inference (4,5).

How does this tie back to the discussion of phenomenological psychopathology and schizophrenia? For the recognition models mentioned here, understanding the intentions of another person is only possible whenthe person being observed has a mental structure that shares key qualitative similarities with mental states within the observer's personalrepertoire. This assumption, according to the early psychiatrists, is violated in of schizophrenia (2).

If patients with schizophrenia have a first-person experience of the world that is fundamentally different from others, their mental landscape would be impenetrable to the assessing clinician. Moreover, a patient experiencing the world in a fundamentally different way to those around her would be denied the gift of intuitive mind-reading that is enjoyed by most people. In the extreme this could lead to autism, social withdrawal and a preoccupation with inner fantasy life.

In the tradition of phenomenological psychopathology, the models discussed here refocus attention on the lived experience of the patient, and shed new light on the alienation that patients may feel in their day-to-day experience of a world populated by others who they struggle to intuitively understand.

References1. Stanghellini G, Broome MR. Psychopathology as the basic science of psychiatry. Br. J. Psychiatry 2014;205(3):169-170. 2. Parnas J. The core Gestalt of schizophrenia. World Psychiatry 2012;11(2):67-9.3. Clark A. Whatever next? Predictive brains, situated agents, and the future of cognitive science. Behav. Brain Sci. 2013;36(3):181-204. 4. Wolpert DM, Doya K, Kawato M. A unifying computational framework for motor control and social interaction. Philos. Trans. R. Soc. Lond. B. Biol. Sci. 2003;358(1431):593-602. 5. Kilner JM, Friston KJ, Frith CD. Predictive coding: an account of the mirror neuron system. Cogn. Process. 2007;8(3):159-66.

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Conflict of interest: None declared

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What we observe in not nature herself, but nature exposed to our method of questioning

Saad F. Ghalib, consultant old age psychiatrist
09 September 2014

The authors are correct to describe psychopathology as the ''exploration of meaning''! But isn't that what Freud tried to do and ended up conflating two entirely different concepts, that of meaning and causality? Freud's phenomenology was probably more in line with Martin Heidegger', were the emphasis is on existence over consciousness. Husserl,on the other hand, relies on the description of phenomena as they are given to consciousness. I suppose they are all phenomenologists in their own way! All different approaches should be treated on an equal footing. There are no ''inflexible theories'', and certainly no golden gate to subjectivity. Instead, there are specific theories each of which is capable of glimpsing one aspect of the phenomenon being studied but never capable of encompassing the whole, the reason being that dealing with subjectivity is a complex affair. So, is a complex system any different from a complicated one?

The difference between complicated and complex systems is one of typerather than degree. In complicated systems, reductionism rules and causality can potentially be elucidated. On the other hand, complex systems can only be understood holistically, as they are inherently relational and highly interconnected. Furthermore, in a complex system, efforts to ascertain causality are by and large unsuccessful. Structural analysis can be applied to complicated systems. However, functional analysis is required to understand complexity.

Historically, complicated systems are relatively easier to study as they can be decoupled from their environment. This can usually be achievedby finding a way of ignoring external influences on the system. Curiously,it's the way we ask questions that will inevitably determine the way we isolate the system from its environment. Replicability, another pillar of science, is easier to obtain in complicated systems once we have mastered the techniques of blocking outside interference/noise. However, the same cannot be true when it comes to complex systems, the likes of mental health or the mind, primarily because complex systems are adaptive (they learn) therefore they undergo continues change. Moreover, there are intricate positive and negative feedback mechanisms to and from the environment which makes replicability almost impossible to achieve.

Contrary to common wisdom, the brain with all its intricate workings can still be represented as a complicated system, from neurones and synapsis to receptors and neurotransmitters down to the level of genes andDNA. The mind, on the other hand, is a complex system that can never be studied in isolation from its world of local customs, culture, language, intentionality and so forth. It is for those reasons that we are yet to succeed in having subjective experiences experimentally reduced to that ofchemicals and genes.

As mental health professionals, it's entirely our choice, when listening to patients' experiences, as to how much probing we are preparedto do in order to uncover the underlying subjective experience. However the manner in which we question the system will inevitably influence the answers we obtain. Different settings come with different sets of questions (descriptive, psychodynamic, or behavioural), and it is in each and every setting that we glimpse a different aspect of patient's experience but never all aspects at the same time.

It is prudent to keep in mind that in complicated systems we can determine outcomes or fix the problem once enough information is available. However, we can only 'intervene' or 'enable' complex systems. We may not able to fix our patients, but can certainly enable them. The mind, mental health, ecosystems, the immune system, and the stock market, all share the characteristics of complex adaptive systems. Therefore, we should not be surprised when patient's experience changes in a way that wedid not foresee, it's all very complex!N.B1. The title of this letter is a quote by Werner Heisenberg.2. The literature on complex versus complicated systems is vast; you just need to google it.3. Italics as quoted by the authors in the editorial.

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Conflict of interest: None declared

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