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).