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Thursday, 23.11.2017

Carlos R. Hojaij: A Psychopathological Marker For Biological Psychiatry:
The Point of No Return and the “Something New" *

 

             It is always a goal for any clinical investigator to identify a symptom or a cluster of symptoms for the definition of a disease. The "target symptom," the "essential symptom," the "primary symptom," the "nuclear symptom," etc., have been some of the expressions given to the phenomenon that would produce the clue for the correct diagnosis.  Sometimes this task can be carried out properly, for example, the sign of jaundice for hepatitis, a Blumberg signal for peritonitis, or even a Veraguth signal for endogenous depression.

             Many have tried to identify a clear sign or symptom for schizophrenia. Modern classifications base the diagnosis of schizophrenia on Schneider’s first rank symptoms. But even considering the whole clinical picture, a first rank symptom is not a safe indication for the diagnosis of schizophrenia. On the other hand, until now, no somatic marker has been identified to definitely support the diagnosis of schizophrenia. As is well known, in terms of this enigmatic disease we continue in a confusional state, like walking in a fog, changing direction according to the strongest immediate propagated data, and very often coming back to the same point. Of course, we are also touching important elements which will one day complete the final picture. However, it requires hard work to proceed having just a more or less strong impression. Genetic or other biological methods are expected to help make more reliable diagnoses or sub-classifications in the near future. However, until such time arrives, we should try to resolve the issues with the current tools.  It is always necessary to repeat that, also in biological psychiatry, psychopathology is the first and essential tool.

             Ninety years ago, Karl Jaspers coined a simple expression to represent the change in personality occurring in the schizophrenic patient: "something new." Jaspers called this phenomenon the result of a "psychic process."  "Psychic process" is a concept based only on psychological elements and presents some similarity with the organic process (cerebral process). Jaspers’ definition for "psychic process" is: changes in the psychic life, the personality becoming diverse from the anterior one and in an irreversible mode. 

             The great psychopathologist used to say that a major problem is the recognition of the relation between the 'psychic process" and the subjacent "cerebral process," which he called "direct parallel process."  Nowadays, research is very much focused on the "cerebral process" (from molecular biology to genetics, neurophysiology, neuropathology, etc.), completely ignoring the "direct parallel process," or in another language, what makes (and how) the "disable" brain promoting the "psychic symptoms." Under that perspective, schizophrenia (the psychopathological features) would be nothing more than the consequence of the "direct parallel process."

             I would like to draw your attention to part of that intricate problem. I would like to highlight the "something new." Many times it is relatively  comfortable  for the psychiatrist to recognize a personality changed by schizophrenia; however, we are rarely able to identify the moment of that change. As an example, we could say that the so-called late-onset schizophrenia means only that we were not able to identify the correct moment of the transformation in the personality, possibly happening at a younger age. It is reasonable to assume that the recognition of  this moment will give an indication for more precise research in terms of which stage of brain development is implicated in the disease, as well as the genetic process involved in that phase of  life (the "genetic clock"). "Something new" represents the result of a crucial transformation in the personality at a certain point in life, and according to its characteristics and sequence as a "psychic process," it can be recognized as happening at the "point of no return." Therefore, evolving from Jaspers, we should try to establish this "point of no return" and then investigate the "cerebral process" at that stage.

             How can we reach the "point of no return"?  When a person comes to a psychiatrist, the schizophrenic process has already started sometime previously. It has also been recognized that the family or other persons close to the patient are only able to identify the process after a period of time. The most favorable situation for the psychiatrist would be the observation of the sequence of the initial phase (so diverse in its presentation). One way to reach the "point of no return" is through the patient’s consciousness. How is the consciousness of a schizophrenic? At that point, the focus is not the disease itself, but the way the patient presents himself in terms of consciousness, the way the patient perceives himself, the others and the world. Stimulating self-descriptions promote a critical self-consciousness that becomes broader and deeper as the time goes.

             The studies of "Comprehension" by Wilhelm Dilthey give a theoretical reference to analyzing the schizophrenic consciousness. "Comprehension" means an intuitive  (immediate) knowledge, a natural disposition of human being. "Comprehension" is a psychological apprehension considering the connections of life events.  "Comprehension" means knowledge with a meaning referred specifically to a person in a situation, including a teleological sense. How is the capability of comprehension in the schizophrenic? It is definitely changed. The psychological apprehension is almost completely replaced by causal relationships; the teleological sense is replaced by an analysis of the concrete appearance. Consequently, the patient lacks empathy and the acts lack intentionality. The patient conducts himself moved by causal laws.

             In making the patient look at his consciousness, this will give him a chance to realize that he is someone that has structurally changed in his personality; then, he is able to detect the ‘point of no return’ to the previous way of being; he is able to perceive himself as a person who is no longer capable to spontaneously practice the transposition mechanism, it means, to be in the other’s place and feel and think like the other, and to participate. The schizophrenic is able to realize that life is no moving according to the immediacy of sensations, without taking into consideration the continuous spiraled movement of life and the intentionality of the events. He becomes reduced to the concrete appearance of life.

             The "something new" is the manifestation of the disturbance of comprehension we find in the schizophrenic. The "something new" refers to the irreversible change in the personality that occurs in the "point of no return" and can be self-identified. The longitudinal (biographic) perspective brings opportunity to research the patient’s consciousness.

             The phenomenological psychopathological study of the schizophrenic’s consciousness appears to give opportunity to reach what can be a nuclear phenomenon in schizophrenia: the peculiar disturbance in the capability of comprehension. If we are dedicated to exploring the schizophrenic consciousness through the consciousness of the patient, we are able to identify the ‘point of rupture’ in the vital curve and explore the changes in the capability of comprehension. In this sense, the irreversible change in the capability of comprehension could be understood as a  psychopathological marker for schizophrenia,  and a significant indicator of the crucial moment of the beginning of the schizophrenic process.

 

* Based on an editorial published in The World Journal of Biological Psychiatry, 4:1, 2-3, 2003.

 

 June 29, 2017