The psychiatric approach to mental disorders
Both psychiatry and psychotherapy concern themselves and deal with disturbances in human psychic functioning. They regard them, however, from different standpoints, employing different approaches, forming different concept groups, and using different terminology. They also set different objectives for diagnostics and treatment, as well as having a slightly different notion of what is norm and what is pathology, and they rely on different concepts of mind functioning.
Psychiatry, being a field of medicine, relies on biology and natural science. Medical science traditionally applies the nosological approach that regards pathological processes of the human organism, including those of the mind, as diseases with their own etiology, pathogenesis, course, and outcome. Introduced into psychiatry by E. Krepelin, the a nosological approach was typical of the German school of psychiatry, and today it still defines many clinicians’ mentality directly or implicitly. It is interesting that, in spite of replacing the term “disease” with that of “disorder” in the International Classification of Diseases-10 (ICD-10) in the field of psychiatry, “The ICD-10 classification of mental and behavioral disorders” still remains an integral part of ICD as a whole, meaning that it functions within a medical paradigm characterized by nosological and biological approaches. Psychiatry, as well as medical science generally, predominately uses biological treatment, be it drugs or, for instance, electroconvulsive therapy (ECT). In a typical psychiatric diagnostic process, a patient’s integral pattern of behavior and experience is broken into separate elements as it is successively measured against standard classification schemes (based on psychopathology), like holding up pre-cut stencils to a large picture. Everything that does not fit these classification schemes (certain types of behavior, emotions, and experience, which are not defined in those schemes) is discarded as insignificant. In psychiatry, the process of diagnosis aims to single out those components of a patient’s entire behavior and experience pattern that can and should be treated by medicines, by ECT, or by other means of biological therapy. Obviously, this does not provide the psychiatrist with a comprehensive and thorough understanding of the patient’s experience of his existence in the world in the context of his unique life situation. However, considering psychiatric diagnosis objectives, such comprehensive and thorough understanding is not required. Dealing as it does with assessing mental processes and with describing their state, psychiatry cannot entirely do without psychology in its conceptual bases. Obviously, however, this psychological conceptual framework should be well suited for achieving the aims and goals of psychiatric diagnostics.
Traditionally, psychiatry as a whole and psychopathology as one of its branches are based on functional psychology, the foundations of which were laid at the end of the 19th to the beginning of the 20th centuries. Consciousness, perception, intellect, thought, emotions, and the will are regarded by functional psychology as separate independent functions comprising human mentality, like cinder blocks. Clinical psychology, employing psychological tests to carry out experimental psychological examination for the purpose of psychiatric diagnostics, is to a large extent adapted to the same functional psychology framework. Even projective drawing tests based on the psychodynamic model are in practice frequently interpreted in psychiatric clinics within the narrow framework of the aforementioned functional psychology. This makes clinical psychology highly suitable for its key task in a psychiatric clinic: helping with psychiatric diagnostics. In this regard, the psychiatric model can be viewed in juxtaposition not so much with the psychological model in general (because clinical psychology, as has been mentioned above, is integrated into the psychiatric medical model) as with the psychotherapeutic model in particular, along with its associated psychological concepts. What psychiatry considers “norm” is the absence of delusions, hallucinations, memory and intellect disorders, the absence of psychogenic functional physiological and vegetative disorders, dissociative disorders, pronounced emotional and mood disorders, as well as motivational, will, and thought disorders that could result in obvious non-adaptive behavior, intense suffering, distorted perception of reality, and inability to work and to build even superficial social ties. In a nutshell, what psychiatry regards as “norm” is actually the absence of mental disorders that fall into corresponding classification frameworks. That is, in psychiatry, norm means lack of certain elements (whereas in psychotherapy, norm implies the presence of certain elements).
Psychiatric treatment aims at patients’ achieving, as close as possible, the state of “norm”, as it is defined by psychiatry.
The psychiatric medical model more willingly recognizes the role of psychotrauma, the part played by an individual’s maladaptive responses to stressful life circumstances in causing a mental disorder, affecting its development and its clinical picture, mostly when it identifies such a disorder as non-psychotic. The above mentioned model, however, disregards those factors in cases of psychotic mental disorders, such as schizophrenia or bipolar disorder. To conclude that there has actually been psychotrauma or stressful life circumstances, psychiatrists rely on their patients’ conscious opinions, which they receive in the process of a structured conversation (interview) carried out for diagnostic purposes. It is clear, therefore, that information obtained or not obtained in the course of such a conversation (interview) will depend on a number of factors: Firstly, on the angle from which psychiatrists choose to regard their patients (that of the medical psychiatric model); secondly, on the goal and objective of such conversation (those of psychiatric diagnostics); thirdly, even on the fact that the conversation in question (the interview) is structured (for during unstructured conversation about their “problem,” patients may let such information “slip out” that they would not otherwise say to psychiatrists, along with corresponding questions). In practice, psychiatrists, albeit only to a certain extent, tend to rely on their subjective opinion based on their own life experience in identifying or not identifying their patients’ traumas or stressful life circumstances. It often happens that psychiatrists themselves haven’t fully undergone their personal psychotherapy, which may hinder separating their patients’ problems from their own. In identifying (or not identifying) their patients’ stressful life circumstances, psychiatrists may also depend on opinions of their patients’ relatives, who are likely to be involved in the patients’ neurotic problems, as well as to be in highly complicated pathological, from the psychological point of view, relations with them (which the medical model ignores as well). In recognizing patients’ traumas and stressful life circumstances, the psychiatric medical model likewise disregards the role of psychological defense mechanisms in mental disorders, mechanisms that break mental links between psychological factors triggering these disorders, simultaneously activating intrapersonal conflicts and clinical symptoms. The concept of psychological defense mechanisms explains why during a diagnostic interview psychiatrists cannot identify psychotraumatic circumstances provoking a mental disorder, not only in cases of psychoses, but also in cases of non-psychotic disorders (e.g. very often in cases of panic or generalized anxiety disorders).