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
Prerequisite of Psychiatric Diagnosis
If the prerequisites of "psychiatric nosology" are fulfilled, psychiatric illness, like any other medical illness is the result of a disease process that becomes manifest in the "case history" of patients.
In "sui generis" psychiatric disorders the "case history" is independent of, and superimposed on, "personality development," which is intrinsically linked with the "life history" of the patient. In contradistinction to the "life history," or "biography," which is expressed by a chain of events, or "contents," the "case history" is expressed in the different "forms" of "pathological experiences" during the different developmental stages of the "dynamic totality" of psychiatric illness.
It is a commonly held view that psychiatric disorders are behavioral disorders. However, psychiatry differs from behavioral medicine, because psychiatric disorders are based on pathological (forms of) experiences--which are stronger than, and override physiological real experiences--and not on abnormal behavior. This is the case even if the abnormal behavior is the most prevalent feature of the clinical picture.
Life History vs Case History
Personality development or "life history" has its primary source in a specific "Anlage or disposition" which "grows, evolves and absorbs in a continuous sequence of the changes brought about by respective age epochs." This particular "disposition is in constant interaction with the milieu," it "gains its specific shape through its human destiny" and it "reacts to experiences in a constant way according to its own nature" (Jaspers, 1962).
In the "case history,” a "disease process" intervenes and becomes super-imposed on "life history" disrupting "personality development" (Petho, 1984). While in the original formulation a "process" implied only a "disease process" with lasting changes, today the concept of "process" is extended to include "disease processes" which are "phasic," i.e., transient, and do not affect the "life history," i.e., "personality development" of the patient between episodes.
Neuropathological Process vs Psychopathological Process
Depending on the nature of the morphological substrate involved, the "case history" is based on a "psychopathological" or on a "neuropathological process." In case of the former, i.e., "sui generis" psychiatric disorders, the "case history" is characterized by increasing differentiation of psychopathological features, whereas in case of the latter, i.e., somatically determined (organic) psychiatric disorders, the "case history" is characterized by gradual dedifferentiation – dementia -- of the clinical picture.
It has been noted that in chronic brain disease, where the actual chain of events lies in the cerebral substrate, the psychopathological manifestations are largely a haphazard sequence of symptoms (Jaspers, 1962). One possible reason for this is that they are dependent on "neuropathological changes" in the absence of a "psychopathological process" (Hoenig, 1985).
Psychopathological Process and Psychopathological Symptoms.
The morphological substrate of the "psychopathological process" is reflected in psychopathological symptoms. Each psychopathological symptom is a concept based on pathological mental (psychic) experiences (phenomena); and each psychopathological symptom has a content, which is derived from past experiences, and a form, which is characteristic of the illness.
The importance of psychopathological symptoms in psychiatric diagnosis cannot be overemphasized because it is the relative frequency of "pathological forms of experience," with consideration to the "form of onset," "course" and "outcome" of these experiences, that provides (primarily) for the clinical diagnosis.