Introduction to psychiatry and psychopathology
During the period of MBBS training psychiatry as a discipline is many times an enigma primarily due to limited exposure to the branch. Having chosen a career in psychiatry, a resident may enter the field with different perspectives and ideas about the branch, many times not knowing what to expect. This article gives a brief introduction to psychiatry and different concepts that a new trainee should get oriented to when starting residency, to understand the discipline of psychiatry.
Literally the term psychiatry means treating (iatry) the soul (psyche – greek word for butterfly which represents the human soul). Professor Johann Christian Reil of University of Halle in Germany is credited with introducing the term ‘psychiatry’ in 1808. In his treatise (Rhapsodies on the application of psychic treatment methods to mental disturbances) he argued for psychiatry as a specialty of medicine and that only the very best physicians would have the skills to become psychiatrists! He stressed that the psyche (mind) and the soma (body) were not inseparable and diseases are an interaction of mental chemical and physical causes. Psychiatry is that branch of medicine that deals with study, diagnosis, treatment and prevention of mental disorders.
One may come across many terms such as ‘psyche’ ‘mind’ ‘mental’ being used in relation to study of psychiatry and used interchangeably. The question of what constitutes the mind has been of intense debate with concepts ranging from philosophy to neurobiology used to describe it. The essential debate has been on the concept of dualism (mind as an entity is independent of physical existence) and physicalism (mind is a result of the brain and its activity).
For the purpose of studying psychiatry as a branch of medicine; mind can be understood as an integrative response of the brain to all internal and external stimuli in the form of awareness (consciousness), thoughts (cognition), emotions (affect) and motor response (behavior). This triad of cognition, affect and behavior forms the core basis of evaluation and diagnosis in psychiatry. To understand this concept let’s take an example.
Consider a student who is waiting for the result to be announced. He is probably thinking “what if I fail?” [Cognition], he is feeling anxious [affect] and probably fidgeting and pacing around the room [behavior]. The moment he gets to know his result that he has passed the brain processes this new information received and produces an appropriate response. He is now thinking “My hardwork has paid off” [cognition], he is feeling happy [affect] and probably jumping with joy [behavior].
Concepts in psychiatry
Being a branch of medicine, how are approaches and techniques in psychiatry different from that in medicine? Probably the most important difference in psychiatry is the lack of any test to quantitatively measure cognition, affect and behavior. These are either subjective experiences (cognition and emotion) or observable phenomenon (behavior). Hence in the field of psychiatry the classical approach of using clinical skills in diagnosis probably is still most important and relevant. Understanding the subjective experience of the patient to assess variations in cognition, affect and behavior is the equivalent of a good physical examination. To do this a resident must learn essential skills of empathy and active listening.
Empathy: Is the art of understanding the subjective experience of another individual by precise, insightful, persistent and knowledgeable questioning. Quite literally it is stepping into the shoes of the other person to understand their experiences
Phenomenology: As described by Jaspers is the ‘study of subjective experience.’ Involves eliciting and giving a precise description of what the patient has been experiencing. It is synonymous with signs and symptoms in clinical medicine.
Psychopathology: it is the systematic study of abnormal experience, cognition and behavior. It involves process of empathic listening and accurate description of behavior. The process followed is one of descriptive psychopathology where in no attempt is made to define the cause of a particular experience.
To give an example, Mr X is a patient of schizophrenia experiencing auditory hallucinations. Hallucinations cannot be measured it can only be subjectively experienced by the patient. To understand and elicit this experience the psychiatrist has to establish a rapport with the patient. The patient has to gain confidence that the doctor will be able to understand his experience otherwise he will not share it with him. To do this the psychiatrist uses his clinical skills of interviewing techniques and empathic listening and elicits that Mr X has been able to hear voices of 2 individuals who are male about 30-40 years old. They speak with a husky voice and he doesn’t recognize them. They come from a distance of about 100 meters and he believes them to be true. This accurate description of Mr. X’s experience is phenomenology. Any psychiatrist who reads this description will be able to label this phenomenon as a hallucination. This is descriptive psychopathology.
Disease concepts in psychiatry
To understand pathological states in psychiatry two concepts are followed. The continuity view describes psychopathology as quantitative variation of normal mental functions. The discontinuity view considers psychopathology as qualitative aberrations from normal mental functions.
Let’s see the previous example of exam results and let’s assume that the student failed. It would be expected that the student is emotionally upset about it. But however if this students experiences a sad mood throughout the day, has lost interest in all activities, feels a lack of energy continuously for 2 weeks this would be a quantitative variation. In addition if the students starts experiencing suicidal thoughts this would be a qualitative aberration. An additional criterion for pathological state would be if the student has not been attending his classes, not interacting with friends. This is termed as dysfunction. This is an essential criterion for psychiatric diagnosis and which is why the term ‘disorder’ is used to describe psychiatric conditions (see definition below).
Health: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Syndrome: A group of set signs and symptoms that occur together and characterize a disease or medical condition.
Disorder: Clinically recognizable set of symptoms and behavior associated with distress and interference in personal functions.
Disability: A restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being
Etiology of psychiatric disorders
As discussed above mind is a function of integrative brain responses to external and internal stimuli. The mind does not work in isolation and is constantly influenced by the environment it lives in. Hence any aberration of the mind and its processes would also be a result of interaction of the complex internal and external environment it is exposed to. The etiology of disease in psychiatry is understood by the concept of biopsychosocial model. Disorders are a result of interaction of biological, psychological and social factors. The biological factors could be genetic, neurochemical, neuropathological etc. Psychological factors could be related to cognitive and psychodynamic and social factors could be related to stressors in the environment. This biopsychosocial model is the essence of all psychiatric evaluation, diagnosis and management.
For eg: schizophrenia is a classic example of biopsychosocial causative model. This disorder is known to be associated with neurodevelopmental aberrations, hyperdopaminergic state in the mesolimbic cortex (biological). Psychological attribution biases and neurocognitive deficits are known to be associated with psychopathology such as delusions. Social stressor are usually the triggering factors for the onset of psychosis and play a role in maintaining symptoms and relapses.
Objectivity in psychiatry:
The very nature of clinical psychiatry; that is the focus on subjective experience of individuals, descriptive psychopathology and dependence on good clinical interview skills to elicit symptomatology, makes this discipline prone to an element of subjectivity. Methods of making diagnosis, definitions of various psychiatric disorders has always been a matter of debate. One of the earliest people to systematically record clinical descriptions was Emil Kraepelin who observed two distinct patterns of mental illnesses and called them Dementia praecox and manic depressive insanity. Subsequent descriptions by Bleuler who coined the term schizophrenia; and others has led to various concepts and viewpoints on what actually constitutes schizophrenia! Around the same time evolution of psychological theories in Europe and Americas tried to delve into psychological origins and probable etiologies of mental disorders shifting the focus from clinical methods.
The seminal study that brought to light this issue was by Kendell (1971) on Diagnostic criterion of American and British psychiatrists. Videotaped diagnostic interviews of eight patients were shown to psychiatrists in USA and UK. The study found gross differences in diagnosis made with American concept of schizophrenia being much broader than the British concept. Further criticism of diagnostic procedures came from the famous Rosenhan experiment (on being sane in insane places). 8 volunteers who feigned auditory hallucinations got admitted to psychiatric centers. 7 of them received a diagnosis of schizophrenia on discharge. These studies highlighted the need for international consensus on diagnosis for better communication and research.
Diagnostic and classificatory systems are an attempt to define disorders and bring about uniformity in diagnosis. The international classification of diseases (ICD) by WHO and diagnostic and statistical manual (DSM) by APA are two of the most widely used systems. ICD-6 that came after World War II was the first version that included mental disorders. Many of the principles of diagnosis that we follow today were introduced in the DSM-III (1980) and ICD- 9. The current versions are ICD-10 and DSM-V.
The ICD classificatory system follows certain principles which are essential knowledge.
- Atheoretical nature of classificatory system: Causation and etiology of disorders are not considered while making diagnosis. Pragmatic clinical approach is followed based on whether a particular symptom is present or not. For eg in the previous example where the student failed his exam; if he is experiencing major and minor criteria for atleast 2 weeks a diagnosis of depressive disorder is to be made irrespective of whether it is in context of failure in exams or not. Such contextual factors are to be recorded separately.
- Hierarchical system: The ICD follows a hierarchical arrangement of diagnosis called as Fould’s hierarchy. Which means that if a patient fulfills criteria for two disorders, the diagnosis which is lower in the order is subsumed under the one higher to it. In ICD diagnosis are arranged in hierarchy as Organic, substance use disorders, Schizophrenia, Mood disorders and so on. If a patient fulfills criteria for Schizophrenia as well mania, the diagnosis made will be schizophrenia because it being higher in the hierarchy; mania gets subsumed under it. We don’t make a diagnosis of Schizophrenia with Mania which is absurd! Though there can be certain exceptions to this.
- Multiaxial diagnosis: This is an essential feature of the DSM which differentiates psychiatric disorders (called as Axis I disorder) from personality disorders and intellectual disabilities (called as Axis II disorder). Axis III defines medical conditions and Axis IV defines contextual factors contributing to the illness.
Structured clinical interviews:
To further reduce subjectivity of clinical interviews, structured clinical interviews based on diagnostic classificatory systems have been developed. These define set questions to be asked in a precise manner to elicit each symptoms. They are primarily yes or no questions and diagnosis can be derived based on answers to these questions. The interview based on DSM are SCID (structured clinical interview for DSM disorders) and MINI (Mini international neuropsychiatric interview). The interview based on ICD is called as SCAN (Schedules for clinical assessments in neuropsychiatry). These are important for research and are of lesser clinical utility.
Rating scales are a semi structured method of objectively assessing symptoms of a particular disorder to obtain a quantitative measure. These scales generally have a set of questions with a guide to interpret and score responses. These may be observer rated by the psychiatrist or self-rated by the patient. These are again important for research studies. Clinically a measure of symptoms may help quantify severity of a disorder and serial assessments can help in assessing treatment response.
Psychiatry is probably one branch of medicine that still retains its ‘human touch’. Understanding and application of the principles of clinical methodology makes the practice of psychiatry and enjoyable and enriching experience. In the words of Dr Nancy Andreasen, former editor of American journal of psychiatry and pioneer of neuroimaging research in psychiatry:
- “I think most of us became psychiatrists because we are interested in what makes human beings tick.”
- “We chose psychiatry because we want to understand the human mind and spirit as well as the human brain.”
- “We are interested in people and we like to work with them as individual people.”
- “Every person whom we encounter is a new adventure, a new voyage of discovery, a new life story, a new person”
- “This is what makes psychiatry challenging, intellectually rich, complex, and even enjoyable
- Fundamental Concepts of Descriptive Psychopathology in SIMS’s Symptoms of the Mind Textbook of Descriptive Psychopathology.
- Kendell R et al. Diagnostic criteria of American and British psychiatrists. Arch Gen Psychiatry. 1971:25;123-130.
- Kendell RE. The concept of disease and its implications for psychiatry. British Journal of Psychiatry. 1975:127;305–15.
- Rosenhan DL. Being sane in insane places. Science. 1973: 179; 250-258.
– Dr Rishikesh V Behere