Clinical Psychopathology

Details: Last Updated: Sunday, 27 October 2013 20:37; Written by Paul Kugler, Ph.D.

Paul Kugler, Ph.D., Dipl. Jungian Analyst (East Aurora, New York)

The following Introduction is an excerpt from the larger work, Clinical Psychopathology.

Introduction

On a cold overcast morning in September 1971 I arrived in Zurich to begin my training as a psychoanalyst. Part of my studies involved regularly attending clinical demonstrations at the local psychiatric hospitals. Memories of those clinical sessions still inform my work as a therapist. In particular, one very gifted psychiatrist comes to mind. He would introduce the specific psychopathology to be discussed that day, and following a brief presentation of the various clinical symptoms present in the disorder, he would introduce a patient and conduct a psychiatric interview. He was not a very reflective man, nor a theoretician. He had instead the nature of an artist. He was a visual man. A man who sees. He would look again and again at the patient's symptoms, especially those he did not understand until the apparent chaos in the clinical presentation gave way to some deeper orderthe nosological picture began to emerge characterized by a particular combination of symptoms. I remember a specific remark he made about how Charcot had always asked why it was that psychiatrists see only what they have already learned to see. Charcot too was a man of seeing. He was heard to say that "the greatest satisfaction a person could have was to see something new"that is, to recognize for the first time the significance of a particular clinical presentation. It requires great observational skill to suddenly grasp the significance of a particular cluster of symptoms, a new syndrome, which while probably as old as humanity, had been overlooked up to now.

This psychiatrist taught me the importance of purely clinical observation which consists of seeing and ordering symptoms against the encroachment of theoretical psychology. This is not to say that theory is unimportant. It surely is. But presentation comes first, conclusions second. As clinicians we were developing a rigor of observation, a purification of seeing apart from constructs and interpretations. In our clinical demonstrations we were learning to carefully and precisely see what is presented, without developmental schema, criteria of normalcy, or the various axes of the DSM IV. "Krankeits Bild" it is called in German. We were learning to see the precise presentation of the illness. The presenting psychiatrist was teaching us how to clinically see in the great tradition of psychopathology going back to Kraepelin, Charcot, Janet, and Bleuler.

Clinical psychopathology is the study of the sick, the suffering, and the abnormal conditions of the human psyche. These conditions affect all of us in one form or another. Every personality may experience illusions and depressions, fixed ideas, manic flights, and sexual obsessions. We may be overcome by psychotic rage, dreadful anxiety, unending compulsions. Or suddenly our insights may become over-valued, our feelings euphoric. We have a sense of grandiosity and become haunted by paranoid spiritualisms and secret hallucinations. And as the personality ages, we may encounter loneliness, hypochondriasis, a sense of vulnerability, and those haunting remembrances as memory begins to disintegrate in senility. In psychopathology the human mind is confronted with its own darkness, the psyche witness to its own breakdown.

A Brief History of Psychopathology

Before we enter into a clinical study of psychopathology, let us first establish a historical context for the present work. Early descriptions of the symptoms of mental illness can already be found in the writings of Galen some eighteen hundred years ago. These early "clinical histories" consist primarily of superficial descriptions of the most conspicuous and overt behavior of the patient. They show a remarkable lack of subtlety and resemble the style of writing one might find today in a popular magazine. It would be many centuries before the clinical description of mental symptoms would move beyond the mundane matter-of-fact level.

The first significant progress in establishing a systematic study of psychopathology did not come until the seventeenth century. The modern clinical examination of the patientthat is, the clarification of symptoms and their detailed description began when Paolo Zacchia developed a simple but useful schema for studying the diversity of symptoms found in mental illness (Vallon and Genil-Perrin, 1912). The clinical frame of reference developed by Zacchia differentiated the patient's presentation into the traditional disturbances of overt behavior to which he added an assessment of disorders of the major psychological functionsemotions, perceptions, and memory (Ellenberger, p. 93, 1958). The inclusion of an analysis of disturbances of mental functions was a major advancement in the clinical examination of the patient. Zacchia's schema laid the foundation for today's mental status exam.

During the following century Zacchia's schema was further refined, differentiating psychological processes into three "faculties": intellect, affectivity, and will. The faculty of intellect was in turn subdivided into its various functions: perception, sensation, association, judgment, imagination, and intellection. Using this new schema the patient's clinical presentation was now differentiated according to disturbances in these mental "faculties."

Already by the beginning of the nineteenth century this new schema was being adopted by the psychiatric profession and used as a means for systematically studying mental illness. The basic assumption behind this approach was that mental symptoms reflect disturbances of one or another of these elementary mental functions. This represented a significant development from Galen's approach. Prior to the eighteenth century, psychopathologists studied only the outer behavior of the patient. Zacchia focused not only on the patient's overt behavior but also carried out a detailed observation of disturbances of the major mental functions.

The next significant development came in the nineteenth century when the detailed analysis of symptoms proceeded to its natural conclusionthe differentiation of symptom-complexes constituting specific mental diseases. While other nineteenth century investigators were busy exploring and giving names to new territories in the outer world, psychopathology was doing much the same to the world within. Esquirol, Morel, Kraepelin, Wernicke, and Bleuler were the great explorers of psychopathology during this period. Their work focused on naming, defining, and ordering the mass of psychic symptoms which had been carefully differentiated over the past century. The classification of symptoms in terms of their clinical pictures, their syndromes, led to the development by Kraepelin in the late nineteenth century of the first over-all nosological system.

The beginning of the 20th century brought a significant new contribution to the study of psychopathology. The clinical approach which had grown out of Zacchia's schema was no longer viewed as adequate for a complete appreciation of the experience of psychopathology. The mentally disturbed patient lives in a reality quite different than the clinician's. Where our usual descriptions and definitions of psychic disorders may be useful in differentiating and classifying mental illness, these definitions do not necessarily help us to understand the patient's subjective experience of the pathology. For example, since Esquirol the standard definition of a hallucination is, "A perception without a sensation." While this definition may be correct on a descriptive level, it does not help us appreciate the patient's subjective experience of perceiving images for which there are no corresponding objects. To empathically understand the subjective reality of the patient, a new approach was needed.

In his classic study of mental disorders, General Psychopathology (1913), Karl Jaspers developed a new approach which distinguished two aspects of mental illness: the objective pathology and the subjective experience. The objective pathology is the exterior manifestation of mental symptoms as viewed from the clinician's perspective, while its phenomenology deals with the person's subjective experience. The exterior manifestations are those symptoms the clinician sees in the consulting room or on the wards of the hospital. The following narrative is a description of a patient's condition from the clinician's perspective.

The patient entered the admitting office and seemed confused, disoriented, and agitated. She complained of not knowing where she was or why she was there. She grimaced and performed various stereotyped movements with her hands. She paid no attention to questions, although she talked to herself in a childish tone. She moved about constantly. At times she moaned and cried like a child, but she'd no tears.

This description of the patient's symptoms provides important information concerning the clinical presentation. The subjective phenomena, on the other hand, reveals significant additional insight into the person's state of mind, their inner experience of the pathology, but cannot be viewed and interpreted in the same fashion. The following narrative is the patient's account of the experience of entering the admitting office.

I kept asking myself "Why am I here? What is happening? Where on Earth am I?" I was completely confused and had no idea what I was doing in this place? I couldn't sit still, pacing back and forth. I didn't understand what was happening to me. Nothing seemed real anymore. I felt so helpless and confused. I couldn't stop sobbing.

The objective and subjective descriptions of psychopathology present strikingly different views. Each adds an important dimension to our overall understanding of mental illness. Where the clinician's perspective provides for the objective study of symptoms, syndromes, and disease entities, the phenomenological description of the patient's state of consciousness contributes significantly to the clinician's capacity to empathize more closely with the patient's actual experience. Jasper's methodology provided a powerful new means for developing clinical empathy, the therapeutic capacity to share the patient's perspective. The traditional approach to psychopathology located the clinician as an external observer of the symptoms, while Jasper's new approach placed the clinician in the subjective scene of the personal experience.

Jasper's General Psychopathology was the first large scale application of phenomenology to clinical psychopathology. As descriptive phenomenology became more extensively used as a methodology in the study of mental illness, the focus of clinical research increasingly became the personal experience of the patient. Blondel (1914) studied the subjective experiences of various psychotic states. Minkowski (1933) focused on the structures of consciousness (temporality, spaciality, causality, and materiality) and showed how from disturbances in these structures we can deduce the particular symptoms and mental contents experienced by the patient. Von Gebsattel (1954) and Straus (1948) analyzed the inner world of the obsessive compulsive, Binswanger (1933, 1955) studied the subjective experiences of mania and depression, while Carney Landis (1964) compiled an extraordinary collection of subjective reports documenting a whole range of psychopathological experiences.

Phenomenology also provided important advances in other aspects of psychopathology. Where the traditional methodology dating back to Zacchia causally reduced symptoms to disturbances in mental faculties, phenomenology instead viewed the symptom as an integral part of the living personality as a whole. Behind melancholy lies a depressed person, behind confusion, the confused, behind a delusion, the deluded. Studying the symptom in terms of the living personality, not simply as a disturbance in a particular mental function, achieved a greater understanding of the patient's whole being. Rather than focus on the psychiatric syndrome, attention was shifted to the psychological structure of the living personality experiencing the symptoms. Careful analysis of the lived experience of patients raised important questions regarding the classification of psychopathology based upon reducing a group of symptoms to the disturbance of a single mental function. For example, reducing all delusions to a "disturbance in judgment" or all hallucinations to a "perception without a sensation," highlights certain similarities while concealing fundamental differences.

Consider the delusion of grandeur traditionally viewed as resulting from a disturbance in judgment. When we compare the actual clinical presentation of this type of delusion in a schizophrenic to its presentation in a general paretic suffering from syphilis, we, in fact, find only a superficial similarity in the ideational and verbal expressions associated with the symptoms. Clinical examples of this kind abound. For instance, even though auditory and visual hallucinations are both classified as disturbances of perception, clinical experience demonstrates that auditory hallucinations hold quite a different place than visual hallucinations from both diagnostic and prognostic points of view. Auditory hallucinations are primary symptoms of schizophrenia, while visual hallucinations are more often present in confusional syndromes. What is it in the living personality that accounts for the difference between seeing images and hearing voices? Is the difference caused by a disturbance in perception? Is the difference related to the dissociative process found in schizophrenia and the global characteristic of states of mental confusion? Or is the difference related to the place visual and auditory phenomena occupy in the general context of the individual in relation to the world? These are important questions about the very nature and structure of psychopathology and raise serious concerns about the etiology of symptoms. The problem was not simply in the classification of symptoms in relation to mental faculties but in the overall view of mind underpinning psychopathology in general (Minkowski, 1933).

In the nineteenth and early twentieth century the mind was viewed as consisting of an aggregation of separate, distinct functions, such as imagination, perception, memory, association and so on. Today this view has been replaced by a more integrated model in which "mental functions" are approached as different aspects of one homogeneous process. Even though mental behavior is a function of the entire living personality, in studying mental disorders, it continues to be useful to approach symptoms as representing disturbances in reasonably distinguishable phases of the mental processas long as we remember that the division is, at best, artificial.

Phenomenology was particularly sensitive to the difficulties inherent in the analysis of individual symptoms apart from the living personality as a whole. Consequently, many of the later phenomenological studies abandoned the more traditional clinical descriptions and in their place presented minutely detailed philosophical analyses of subjective states of experience. While this may have avoided the underlying assumptions about discrete mental functions and developed new insights into the personal experience of the pathology, it resulted in several difficulties. First, it produced a body of clinical literature that was unreadable for the philosophically uninitiated, and therefore, inaccessible to the vast majority of clinicians. And second, the use of Jaspers' multiple perspectives was lost in favor of privileging the patient's lived experience. Where phenomenology abandoned many of the original clinical descriptions, more traditional psychiatry has moved in the opposite direction, forgoing the descriptions of personal experiences in favor of the more objective clinical accounts.

Clinical Perspectives of Observing and Experiencing

Our approach will use the current classification of psychopathology as found in most contemporary psychiatry textbooks. While classifying the symptoms in terms of disorders of mental functions, we intend "mental functions" to connote the various phases of a homogeneous mental process and use the classification as part of a pragmatic nomenclature to designate groups of mental processes sharing a common feature, not as separate and independent faculties. We will attempt to integrate many of the insights and methodological advances made by phenomenology into a format more accessible to today's mental health community. By using multiple perspectives it becomes possible to integrate contributions from both traditional psychopathology and phenomenology, thus allowing the clinician to move freely between the perspectives of observing and experiencing.

Our format will attempt to work constructively with the tension between the objective and subjective perspectives in relation to psychopathology: the need for careful clinical description and the richness of the patient's unique experience. In the following pages we will provide detailed clinical descriptions of mental symptoms, followed, wherever possible, by first person accounts of the actual lived experience. In reading the personal narratives next to the more clinical descriptions, one cannot help but be impressed by the extraordinary richness of the subjective experience. By comparison our clinical language pales. Objective descriptions are often dull, distant, and lacking in the personal subtlety so necessary for human individuality. By holding the tension between the two perspectives, a deeper clinical understanding begins to emerge, one that privileges neither the objective nor the subjective dimension. Through this approach the clinician is able to make a careful evaluation of the patient in a language and format accessible to the larger mental health community, while at the same time developing clinical empathy through a greater appreciation of the unique qualities of the person's lived experience.

The Diagnostic and Statistical Manual

An introduction to clinical psychopathology would not be complete without a few comments about the Diagnostic and Statistical Manual of the American Psychiatric Association. It first appeared in 1952 and was at the time the only official manual of mental disorders to contain a detailed description of the diagnostic categories. In the first edition of the Manual, the disorders were referred to as "reactions" throughout the classification. This reflected the influence of Adolf Meyer's view that mental disorders were a reaction of the personality to psychological, social, and biological stimuli. This has often been referred to as the psychobiological view. The psychological approach to psychiatry adopted by the DSM IV dates back to Eugene Bleuler (1857-1939) and his early study of schizophrenia: Dementia Praecox, or the Group of Schizophrenias (1911/1950). This approach followed a unitary model of mental illness positing essentially one mental disorder. The various mental reactions differed by degree, not type, and ranged from neuroses, personality disorders, and manic-depression to schizophrenia.

In the second edition of the Manual it was decided to base the classifications, instead, on the mental disorders section of the International Classification of Disease and to eliminate "reactive" from most of the diagnoses. The psychological approach had been founded by Bleuler on the principle of inferring mechanisms of causation behind the observed clinical presentation, but since the etiologies of most mental disorders were unknown, this approach had considerable limits. The DSM-II reflected a major shift in American psychiatry away from the psychological approach and a return to the earlier tradition of descriptive psychiatry inaugurated by Emil Kraepelin (1856-~926). The Kraepelinian approach to psychiatry based nosology on a classification of presenting symptoms, not inferred etiologies or psychological criteria. The DSM-III, DSM-III-R and the most recent DSM-IV all have continued to use the Kraepelinian approach, favoring description over causation in establishing psychiatric nosology.

The purpose of the Manual is in part to provide a classification of mental disorders. The Manual is designed to help the clinician determine the presence or absence of specific clinical features and then to use the criteria provided in the manual as basic guidelines for making a diagnosis. To this end the Manual focuses on diagnostic categories, such as organic brain syndromes, schizophrenia, delusional disorders, anxiety disorders, adjustment disorders, and so on. The main purpose of the Manual is to provide clear descriptions of diagnostic categories in order to enable clinicians to diagnose, communicate about, study, and treat the various mental disorders. The approach of the Manual is essentially psychiatric in orientation and its primary focus is on the establishment of a diagnosis, followed by a treatment plan, a prognosis, and where appropriate, an etiology.

Symptoms and Syndromes

The Manual differentiates mental disorders according to regularly occurring symptom-complexes. A recurrent complex of symptoms is a syndrome. While the Manual focuses on the diagnosis of psychiatric syndromes, our study of psychopathology focuses, instead, on the clinical differentiation of individual symptoms. The symptom is the smallest describable unit with which the psychopathologist works. Only after a careful clinical study of the patient accompanied by the clarification of presenting symptoms is it possible to make a differential diagnosis using the appropriate psychiatric nosology. In this way our study complements the Manual, providing the clinician with the necessary background in descriptive psychopathology to first differentiate the presenting symptoms, followed by the diagnostic formulation of a particular syndrome. Through this approach we hope to help mental health professionals develop a greater capacity to differentiate clinical symptomatology and formulate a diagnosis, while at the same time enhancing their therapeutic capacity to empathically relate to the patient's lived experience.

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