Acta Psychiatr Scand 2013: 127: 434435 All rights reserved DOI: 10.1111/acps.

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2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
ACTA PSYCHIATRICA SCANDINAVICA

Editorial

A haunting that never stops: psychiatrys problem of description

One hundred years ago, Karl Jaspers published his Allgemeine Psychopathologie (1), a book, which in its seventh edition from 1959, provided the most comprehensive analysis of psychiatrys theoretical foundations, concepts, and methods needed to investigate consciousness, particularities of psychiatric interviewing, classicatory principles, and many other issues, deemed relevant for clinical psychiatry. Todays psychiatry is very far from Jaspers emphasis on adequate concepts and methods for exploring the patients perspective and his correlated insistence on the interdisciplinary nature of psychiatric enterprise, bordering not only biology but also psychology, sociology, philosophy, and other disciplines. Since the late 1960s, psychiatry, conforming itself to the scientic ideals of behaviorism, underwent a radical remake, the so-called operational revolution. The operational revolution resulted in criteria-based diagnostic categories and operational denitions of such criteria. The body of the then-accumulated clinical knowledge and sophisticated descriptions was simplied and shortened into diagnostic manuals, available to lay public because written in lay-language and free of theoretical burden. These manuals became the main teaching source for psychiatrists, a situation that progressively has led to a death of psychiatric description and tended to dehumanize the clinical encounter (2). The structured diagnostic interviews and checklists have emerged as adequate methodology to cut through the complexities of subjectivity and communication. The structured interviews, modelled upon the behaviorist stimulusresponse paradigm, consist of preformulated questions (paraphrasing the corresponding diagnostic criteria), presented in a xed, predetermined order. They are believed to eventuate in a faithful and valid reproduction of the patients inner world and point of view. At the heydays of operationalism, it was widely predicted that enhanced reliability would lead to rapid breakthroughs in the etiological knowledge, carving nature at its joints (3). Unfortunately, a gaping disconnect is today widely recognized between the impressive progress 434 in genetics and neurosciences and its almost complete failure to elucidate the causes and guide the diagnosis and treatment of psychiatric disorders (4). Psychiatry increasingly worries about its own status as a clinical profession (5), partly due to vigorous attacks from a reborn antipsychiatry, this time originating from within the academia. The research stagnation has generated diverse criticisms of psychiatric classications, together with proposals to focus elsewhere, for example, on domains of psychopathology (e.g. depression, reality distortion), proxy-variables (e.g. endo-phenotypes), or behavioral constructs with known neural bases (e.g. the RDoC: negative/positive valence systems, arousal/regulatory systems) (see 6). We suggest a somewhat dierent approach to psychiatrys current impasse (7). A cardinal problem, in our view, is that our very conception of psychiatrys object of study has been vastly oversimplied, and that this oversimplication has been reinforced by reliance on methodologies that are unable, because unsuited, to capture the distinctions in experience and expression that constitute the essentials of the psychiatric object. It is worthwhile to recall that the operational criteria are not, in fact, operational in their original sense of specifying action rules, linking psychiatric concepts with their counterparts in reality (operations, as in: X is harder than Y because X can make a scratch on Y, but not vice versa). What the adjective operational actually amounts to, despite its air of scientic precision, is no more than simplied, lay-language, common-sense descriptions of symptoms and signs, which are, moreover, occasionally phenomenologically incorrect (8). A general account of consciousness, its form of being, its structure, its aspects or phenomena (symptoms, signs, existential patterns), and a discussion of how to adequately address and translate the patients experience, lived in the rst person perspective, into a third-person, sharable-objective format for use in diagnosis and treatment, can nowhere be found in the todays literature (7). This is in a stark contrast with contemporary neuroscience, cognitive science, developmental psychology,

Editorial and philosophy of mind, where the topics of consciousness and subjectivity are at the forefront of the debate and are seen as a major, perhaps the most important, scientic, and theoretical challenge. Psychiatry continues to assume that symptoms and signs should be treated as being close to thirdperson data: publicly accessible, mutually independent entities, thing-like in nature, devoid of meaning, and suitable for context-independent denitions and measurements. The symptom is viewed on analogy to a ripe fruit, existing in the patients consciousness and only waiting for an adequate push by a preformed question of the structured interview to come out into a full view. However, we face here a theoretical and methodological singularity of psychiatry (1). What the patient manifests is not a series of mutually independent, isolated symptoms/signs, partly individuated by their reference to an underlying anatomophysiological substrate (e.g. like: sneezingrhinitis) but rather certain meaning gestalts of interwoven experiences, feelings, expressions, beliefs, and actions, all permeated by biographical detail. Patients vary in their intellectual capacities, their mastery of language and metaphor, their motivation, their impulse and ability to dissimulate, to entertain a double book-keeping, etc. A symptom needs not to exist as a fully articulated, introspectible mental object but may sometimes entail changes in the structure (form) of consciousness, it may exhibit a quasi-habitual, prereective quality, and its reporting often involves recollection, imagination, and reection. To adequately ask a relevant question at a right moment requires a prior grasp of the conversational and situational context (7). All these (and many other) reasons make the foundations of the structured interview something of an epistemological mystery. Recent research has demonstrated a poor diagnostic performance of a fully structured interview (performed by a for-thepurpose trained non-clinician) in a sample of 100 consecutive, rst admissions (9). Even the police, although unlikely concerned with epistemological problems, has discovered that open-ended, conversational, listening-oriented witness interrogationtechniques, allowing for spontaneity, recollection, and reection on the part of the witness, are a better way to elicit valid information than a xed series of closed questions (7). However, abandoning an operationalist illusion of simplicity does not imply an automatic regression to subjectivism and unreliability, reminiscent of the era of psychoanalytic domination. Psychopathology, as any other scientic endeavor, requires a scholarly eort, that is, an investment in study, training, peer-discussion, and supervision. Only such eort can restore the validity of descriptive concepts and rehumanize the clinical praxis while assuring empirical rigor and reliability (7).
Acta Psychiatrica Scandinavica Julie Nordgaard1 and Josef Parnas1,2 Invited Guest Editors 1 Psychiatric Center Hvidovre, University of Copenhagen, Broendby, Denmark, and 2 Center for Subjectivity Research, University of Copenhagen, Copenhagen S, Denmark
E-mail: jpa@hum.ku.dk

References
1. Japers K. Allgemeine Psychopathologie. Springer, Berlin (English transl. J. Hoenig, MW Hamilton) General psychopathology, 7th edn. Chicago: The University of Chicago Press, 1963. 2. Andreasen NC. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull 2007;33:108112. 3. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry 1970;126:983987. 4. Frances AJ, Widiger T. Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Annu Rev Clin Psychol 2012;8:109130. 5. Katsching H. Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry 2010;9:2128. 6. Kendler KS, Parnas J. Philosophical issues in psychiatry II: nosology. Oxford: Oxford University Press, 2012. 7. Nordgaard J, Sass LA, Parnas J. The psychiatric interview: validity, structure, and subjectivity. Eur Arch Psychiatry Clin Neurosci 2012. doi: 10.1007/s00406-012-0366-z 8. Parnas J, Sass LA. Varieties of phenomenology: on description, understanding and explanation in psychiatry. In: Kendler KS, Parnas J, eds. Philosophical issues in psychiatry explanation, phenomenology, and nosology. Oxford: Oxford University Press, 2008:239277. 9. Nordgaard J, Revsbech R, Saebye D, Parnas J. Assessing the diagnostic validity of a structured psychiatric interview in a rst-admission hospital sample. World Psychiatry 2012;11:181185.

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