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Psychopathology as the basic science of psychiatry

Article  in  The British journal of psychiatry: the journal of mental science · September 2014
DOI: 10.1192/bjp.bp.113.138974 · Source: PubMed

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 PSYCHOPATHOLOGY

AS THE BASIC SCIENCE OF PSYCHIATRY

Giovanni Stanghellini, MD and Dr. Phil. h.c.

University “G. d’Annunzio” – Chieti (Italy) and
University “Diego Portales” – Santiago (Chile)
Matthew R. Broome, MRCPsych PhD
University of Oxford, UK
Oxford Health NHS Foundation Trust, UK

Abstract: Psychopathology, as established one century ago by Jaspers, is the discipline that
provides psychiatrists with basic knowledge about the abnormal phenomena that affect the human
mind and with a valid and reliable method to appraise them. As such, it should be the basic
educational pre-requisite in the curriculum for mental health professionals and a key element of the
shared intellectual identity of clinicians and researchers in this field.

Keywords: Jaspers, psychiatric curriculum, phenomenology, psychopathology, subjectivity.

Introduction

2013 is the centennial of the birth of psychopathology as a discipline in its own right (1, 2). In this
paper, we cannot offer a comprehensive outline and defence of psychopathology, but clarify its
purpose and method. Psychiatry's domain of investigation is that of mental disorders, and at present,
such disorders are defined by changes in behaviour and experience. Psychopathology, as the
discipline that assesses and makes sense of abnormal human subjectivity, should be at the heart of
psychiatry.

In contemporary usage, the term ‘psychopathology’ is employed in a number of different ways.   A

common way to use it is to conflate psychopathology with symptomatology - the study of isolated
symptoms in view of their clinical, i.e., diagnostic and aetiological, significance. Assessing
symptoms allows the identification of specific diagnostic entities that in turn enable prediction of
natural history and response to treatment. Psychopathology is also about that, but not just about
that. Whereas symptomatology is strictly disease or illness oriented, psychopathology is also person
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oriented since it attempts to describe the special modes of a patient’s experience and his relationship
to himself and to the world. Biomedical science was built on the transformation of complaint into
symptom. This allowed medical science to see in a complaint – e.g. exhaustion – the effect of a
cause situated in the human body – e.g. a biochemical imbalance. This may overshadow the fact
that a complaint, next to a cause has a meaning, expressing a question, or desire. A person may not
seek elimination of her complaint, but rather fulfilment of her desire to see the doctor fail and
herself triumphantly to become an incurable patient. Biomedical science – and all its indubitable
authority and success – is built on (at least) partial exclusion of the subjectivity of the patient and
the meaning their symptoms hold for them. A psychopathological approach does not exclude seeing
abnormal phenomena as symptoms caused by a dysfunction to be cured, but additionally includes
the exploration of personal meanings next to the hunt for causes. Psychopathology focuses on the
experiencing subject. The person of the patient is an active partner in the diagnostic process,
capable of interpreting her own complaints. Symptoms are conceptualized as the outcome of a
mediation between a vulnerable self and the sick person trying to cope and make sense of her
complaints (3).  

A second sense of psychopathology is when used as a synonym to nosography. The latter outlines
provisional and conventional characteristics of a syndrome (i.e., a combination of symptoms
empirically and statistically aggregated) and thereby serves the goal of a clinical diagnosis.
Psychopathology is not merely about diagnosis. To psychopathology what matters most is that the
"chaos of phenomena" should stand out in an evident way and in multiple connections.
Psychopathology promotes radical attention to the person’s whole field of experience, rather than a
restricted focus on symptoms selected according to their putative diagnostic relevance. The existing
classifications of mental illnesses are merely provisional diagnostic conventions. Since no
extraclinical (e.g., biological) indexes of putative nosological discontinuities are available (4), our
taxonomy is necessarily based on exclusively psychopathologically defined syndromes. Hence psy-
chopathology has become the main method of linking symptoms and diagnosis, but if
psychopathology is conflated with nosography, only those symptoms that are supposed to have
diagnostic value are investigated, in a sort of nosography-focused twilight state where we wear
clinical blinkers structured by contemporary classificatory systems. The dominant focus on
diagnosis disregards the attention to real people’s experiences. As a consequence, clinical utility is
confined to ad hoc bits of information useful for clinical decision-making. This blinkering to only
view the phenomena relevant to diagnosis excludes the scrutiny of the manifold manifestations of
what is really there in the patients’ experience, the essential prerequisite to understand the worlds
they live in, and closes us off to the discovery of new psychopathological knowledge.

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Phenomenological psychopathology

The basic purpose of psychopathology is to empower psychiatrists with a systematic knowledge of

the patients’ experiences, with the capacity to investigate and classify them, and to use valid and
reliable terminology when reporting abnormal mental phenomena. These issues are addressed by
phenomenological psychopathology (PP). PP is ‘open’ to an unusual extent, in that it reveals
aspects of experience that other approaches tend to overwrite or eclipse with their strong theoretical
and ontological claims. In this sense, PP can be conceived of as psychopathologia prima - but not in
the sense of being theory-free. PP has its own theoretical presuppositions, in terms of method, that
inform the clinician’s engagement with the patient and her way of assessing phenomena, but not in
prejudging the content that may be discovered.

For PP, the features of a pathological condition emerge in their peculiar feel, meaning and value for
the persons affected by them. PP also assumes that the primary object of psychiatry is the patient’s
subjectivity, thus putting all its efforts to focus on the patients’ states of mind as they are
experienced and narrated by them. Expressions and behaviours are considered important, but less
specific than personal experiences. The form, i.e. the mode in which content is given to
consciousness (e.g., verbal-acoustic hallucination) is considered more important than the content
itself (the precise theme, e.g., the verbal hallucination being persecuting). To PP a symptom is the
expression of a profound modification of the human subjectivity and its form (more than its
content) reveals the underlying characteristic of this type of global change in the patient’s basic
structures of subjectivity (5). The form of a symptom, as it emerges from careful
psychopathological analysis, is potentially more informative than “surface” clinical features (6) in
order to describe a given phenotype, establish reliable diagnosis and understand a patient’s ‘life-
world’. A life-world is the ‘province of reality’ inhabited by a given person, having its own
‘meaning-structure’ and a ‘style of subjective experience’ determined by a ‘pragmatic motive’ (7).
Although the majority of people are situated in a shared life-world, there are several others life-
worlds – e.g., fantasy worlds, the dream world, and what we may call here ‘psychopathological
worlds’.

PP is not one of numerous approaches aiming at conceptualizing mental disorders or illuminating

their aetio-pathogenesis – as it is the case with psychoanalysis or the cognitive sciences. It is prior
to any causal accounts addressing subpersonal mechanisms. PP is at the end of continuum where
theoretical assumptions are minimised and the structures and contents of the patient's experience are
prioritised. Psychoanalytic or cognitive psychopathologies, in contrast, start with a theoretical
model that explains mental pathology and as such sit towards the opposite end of the continuum.

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Although they may address the issue of the subjectivity of a patient, their main focus is on the aetio-
pathogenesis of mental disorders, whether it be a pathophysiology using models from information
processing, or the dynamic Freudian unconscious. These accounts risk taking for granted the
possession of a rigorous knowledge of the patient’s abnormal mental phenomena – i.e., the basic
endeavour of psychopathology. For instance, psychoanalytic psychopathology in describing a
neurotic symptom assumes that it is produced by an unconscious mechanism of defence. Its main
focus is on the process producing a symptom. It seems that psychoanalytically oriented clinicians
cannot refrain from asking ‘Why?’ before having answered to the question ‘How?’. The same
applies to another kind of extra-conscious explanatory accounts – namely sub-personal biological
mechanisms. Thus, PP must be clearly demarcated from explanatory psychopathologies.

In order to causally explain a phenomenon, it must be first clearly demarcated from similar
phenomena. Such delineation should then be followed by a grouping of similar cases. This
approach paves the way to scientific explanatory psychopathology, which acknowledges the
genuine fine grain of experience, and allows subpersonal mechanisms that may explain the
similarities and difference between these phenomena to be examined. At least part of the spurious
results in neuroscience research is perhaps the effect of insufficient knowledge in psychopathology.
Significant correlations between abnormal phenomena and biological findings are more likely to be
found if clear-cut demarcations between abnormal phenomena have previously been delineated. For
example, progress in the cognitive neuroscience of verbal-acoustic hallucinations is dependent upon
prior psychopathological work (8). Basic psychopathological knowledge is a prerequisite for
research in explanatory psychopathologies and it can give new impulse to epistemologically sound
biological psychiatry. In order to dig into the abyss of the sick mind, one needs first to have a
precise map of its surface. The psychopathologist’s skill lies in having this map in mind when
interviewing patients, but also being aware of the limitations of this map, and being able to note
new phenomena and relate these to others, based upon their characteristics.

Conclusions

Qualifying psychopathology – as it stems from its original foundation - as ‘phenomenological’ is

misleading if one views ‘phenomenology’ as just another ‘adjective’ since it implies listing it next
to other sub-disciplines (like psychoanalytic or cognitive psychopathologies) that must presuppose
core psychopathological knowledge in order to achieve their explanatory ambitions.
Psychopathology is ‘phenomenological’ not in the sense that it embraces a given philosophical
approach; rather it is methodologically so. Although the emphasis on subjectivity and form may
look like a theoretical commitment, that commitment is the product of a stance that seeks to respect

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 the phenomenon rather than impose upon it. PP aspires to respect the phenomenon rather than to
market a specific, inflexible theory.

Word count (text, without title, abstract, keywords and references): 1539.

Declaration of interest: nil

References

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8. McCarthy-Jones S, Krueger J, Larøi F, Broome M, Fernyhough C. Stop, look, listen: The need for
philosophical phenomenological perspectives on auditory verbal hallucinations. Frontiers in Human
Neuroscience, 9,7: 127.

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