Prolegomenon to the Clinical Prerequisite; Psychopharmacology and the Classification of Mental Disorders
(Volume 1)

Conceptual Development of Current Psychiatric Nosology

Thomas A. Ban and Antonio Torrez Ruiz

Exploration of Psychopathology

The diagnostic process in psychiatric disorders is based on the mental status examination. The purpose of this examination is the establishment of patient's "psychopathological symptom profile," primarily on the basis of "phenomenological exploration."

There are numerous difficulties encountered in the detection of psychopathological symptoms. One of the most important is that "conscious psychic life" presents itself in a "total relational context" instead of "distinct," "clearly separated" and "isolated phenomena" (Jaspers, 1962).  In Jaspers (1962) General Psychopathology both "Phenomenology" and "Performance Psychology" (or "Objective Performances of Psychic Life") are dealt within Part One under the heading "Individual Psychic Phenomena."

The difficulty is compounded by the "constant flux" of this complex clinical picture; and the simultaneous presence, and quick succession, of widely varied "phenomenological forms" of the same content. In acute psychosis, for example, the same jealous content may appear in the form of an emotional state, a hallucination and/or a delusion.

For some time, it was believed that the "individual momentary experience," which is "woven from a number of phenomena," is so complex, that it cannot be "disentangled." It is, however, increasingly recognized that psychopathological symptoms can be "separated" and "artificially isolated" from each other even within the most "complex" and "entangled individual momentary experience Furthermore, it is also increasingly acknowledged that among the "artificially isolated phenomena," those which are relevant to patient's mental ill- ness appear to be "clearer" and "sharper" than all other phenomena in patient's experience. Because of this, some consider "artificial isolation of phenomena" as one of the important methods in the exploration of psychopathological symptoms and in the diagnostic evaluation of psychiatric patients.

Ordering of Psychopathological Symptoms

The role of "psychopathology" in the diagnostic process is to render the "knowledge" obtained through the mental status examination accessible by "integration" and "systematization" for clinical-diagnostic decisions. "Ordering," or "integration" and "systematization," is an "arbitrary process," which depends on its ultimate purpose.

For diagnostic evaluation psychiatric patients are usually described in terms of "disorders of perception and thought," "disturbances of emotions and mood," and "disorders of drive and psychomotricity" (Wernicke, 1981; Nyiro, 1962). To obtain a comprehensive picture, however, this information must be supplemented with other information e.g., on "disorders of consciousness," "disturbances of attention and memory," "disorders of the experiencing of the self (ego)" as "one" in a "moment of time" ("ego-integrity"), as the "same" in the "course of time" ("ego-identity") and as "distinct from the environment" ("ego-boundaries") (Guy and Ban, 1982).

Considering that psychiatric illness represents a "dynamic totality," information on "psychopathology" must include information on "onset," "course" and "outcome"; and considering that psychiatric illness is primarily based on "pathological experiences," information on "psychopathology" must qualify the "pathological forms" and "contents," i.e., whether the experiences are "allopsychic," reflecting the outside world, or "autopsychic," reflecting one's self, or "somatopsychic," reflecting one's body (Wernicke,1899).

Integration of Psychopathological Symptoms

While the role of "general psychopathology" in the diagnostic process is the "ordering" of information relevant to diagnostic decisions, the role of "clinical psychopathology" is the "integration" of this pre-ordered information into "disease entities" of mental illness. Since psychiatric patients present their "problems" (symptoms) in terms of events, i.e., "contents," while clinical diagnosis is based on the integration of "pathological forms of experience," the crucial step in the diagnostic process is the separation "in the steady flow of contextual information the modes, or forms in which the different events are experienced."

Separation of Form from Content

In all "psychic experience” there is an "object," i.e., "an objective element in its widest sense" that is called "psychic content" and a "subject," i.e., "a mode" in which the "subject" is presented with the "object." "Perceptions," "ideas," "judgments," "feelings," "drives," "self-awareness" are all "forms" of "psychic phenomena," whereas "events" and "behaviors" are "contents." Accordingly, "hypochondriacal complaints," a "content," may appear in the "forms" of "hallucinatory voices," "compulsive ideas," "overvalued ideas" and/or "delusional ideas," and "grandiose delusions," a "content," may appear in the "forms" of "hyperthymic mood" and/or "fabulations" i.e., "memory falsifications" (Jaspers, 1962). Furthermore, in case of "delusions of being controlled," the delusions are the "content" (or "object") of the "pathological experiences," which are presented in the form of "disturbance of self-integrity" to the "subject." Because of this, "delusions of being controlled," a "content disorder of thought," is a "disturbance of ego-integrity" in so far as psychopathology is concerned.

Formal Characteristics of the Psychopathological Process

In the ultimate analysis, the "formal characteristics" of the "psycho- pathological process" must be separated from their "contents" in terms of "onset," "course" and "outcome." While the "form of onset" may be "acute," "subacute" or "insidious," the "form of the course" may be "episodic" or "continuous." Among the formal characteristics of the course "periodicity" ("irregular" or "rhythmic"), "polarity" ("unipolar" or "bipolar") and "progressiveness" ("remitting" or "deteriorating") must also be considered (Petho, 1984). "Form of outcome" ranges from "full recovery" to "clinical defect." In between are "maladjustment," "accentuated personality," "transformation of personality," "personality defect," "transient partial remission," "clinical recovery" and "residual psychopathology" (Petho et al., 1984).

Finally, in so far as cross-sectional "psychopathological symptoms" are concerned the total clinical picture may display one of three forms, i.e., "polymorphous," "monomorphous" or "amorphous" (Petho et al., 1984). In case of a "polymorphous," i.e., "multiform" or "variable" clinical picture, different symptoms and/or syndromes prevail at different times, whereas in case of a "monomorphous," i.e., "well defined," "pure," or "distinct" clinical picture, the prevalent manifestations remain unchanged during the illness, or at least within a single episode of the illness. In case of an "amorphous" clinical picture the different "psychopathological symptoms" and tendencies, do not combine into a uniform picture. They do not crystallize and define themselves but remain transient and indefinite.