Another distinction made by psychiatrists is between 'form' and 'content' of the symptom. A person believes that neighbors are plotting to harm or kill him. He may have some reasons for this, as there were some disputes between them and his family over boundary of the plot or something else. But of all the family, only this person believes that there is a plot against him. The other family members might say "It is true that we are not on good terms with them. But that was because our father had a case against them in the court over the boundary. Now that is over, but we are not very cordial to them. Our children play and talk with each other. We do not see any reason why they should conspire to harm or kill us. They are ordinary people without such malicious intent". Now what can the psychiatrist do. He looks at the form and the content.
Content is explainable (explaining and understandability are term used in phenomenological psychology) from the antecedent event of previous conflict. It means that you can reasonably explain the circumstances and the logic behind the belief. But the form (the false unshakable belief, which is not shared by his family members - that is a delusion) is not understandable (understandability is the ability to empathize with him based on the person's situation). Why does he believe so, when even his father (who filed the case) does not believe so ? This is how the belief is labelled as a delusion. Presence of a delusion is conclusive proof of a psychotic illness. Now this is done by looking at other parameters. The person may get one of the psychotic diagnosis - Delusions (paranoid)psychosis, paranoid schizophrenia, or mood disorder (either mania or depression) with psychotic features.
There are two aspects in analyzing any symptom. The Dynamic psychology, which explains the content of the symptom - Why this person is showing this particular symptom now ?. This is based on psychological theories - psychoanalysis or others.
The other is the phenomenological school. The task of Phenomenology is to describe any phenomena that is manifesting in a person's mind by making him to describe it in as much detail and accuracy as possible. This helps to explain the belief baesd on cause and effect logic. Ability to understand and empathize will help to form the therapeutic alliance. In the case of delusions, explanation may be possible based on antecedents, but the form, that is, how a man could be convinced of a patenlty false ideas is not understandable.
Freud and psychoanalysts stressed on the dynamic line of thinking. Emil Kraepelin (the father of psychiatric classification) stressed on accurate description and labelling of the symptom. It was Karl Jaspers (psychiatrist who later turned a philosopher) who highlighted the importance of the use of Phenomenology (a branch of existential philosophy) in Psychiatry.
The dynamic approaches were very popular as everybody wanted an explanation for the errant behavior. But this approach met with only limited success as a therapeutic tool. Later most of the underlying psychological theories used to explain behaviors fell into the category of pseudoscience, as empirical evidence for support was lacking. The current classification systems (both DSM - IV TR and ICD - 10) give more emphasis to accurate descriptions of symptoms. This is why their manuals become a list of symptoms. Used sensibly, this helps to increase objective agreement between different clinicians seeing the same patient. But superficial approaches can do more harm than good.
One more issue is the role of insight. A person with a delusion does not have the insight that his belief is false, or that it does not hold up on objective scrutiny. This is why Esquirol (is it not him ?) remarked "Delusions are the hallmark of insanity". Hence presence of a delusion merits the diagnosis of psychosis (Insight is lost in psychosis, contrary to neurosis). So Sashi's fond hope that a person with a delusion will voluntarily seek treatment does not happen usually. On the contrary they turn hostile to anybody who attempts to correct their belief. Yesterday I Happened to see a lady send by the CJM court Thalassey, who was abusing even the accompanying police constables alleging that they are also a party to the big conspiracy against her.
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1 week ago
9 comments:
Excellent! Thank you for making it clear for us.
What will you call an irrational belief with an insight and when the patient becomes unable to act against this belief? What about irrational beliefs that makes a man paranoid?
Befor answering Ajeesh's query, I need to add that I forgot to mention one important thing. Real medical and neurological disorders can present with psychiatric symptoms including delusions. Hence these have to be ruled out before before treatment is started by appropriate investigations.
There can be many types of irrational beliefs that fall short of being a full fledged delusion. Most of these come under a category called 'over valued ideas'. These beliefs have fairly good convition, may be shared by the community to some extent. Belifs that certain foods are hot/cold to the body, beliefs about certain diets or about the mailicious intent of others etc are shared by many with varying degrees of convition. These do not lead to adverse consequences like delusion. Though passionatly held, the person may not 'act out' based on the belief. He may metion these ideas during discussions, but will not insist that others believe this. Such a situation occurs in personality disorders like paranoid personalities. They are mistrustful of others, always see 'evidence' of the malicious intent of others and appear guarded when others try to become close to them. Occaddionally, especially during stress (for example when he goes to wotk in the Gulf countries or changes job or residence), he may breakdown and show frank delusional thinking and a psychotic episode.
Another situation with partial insight is when a psychotic patient gains partial insight into the morbid nature of his belief during treatment. He may continue in this state for some time and finally become fully cured. He may relapse again especially during times of stress.
Insight (and in fact many psyological attributes, or even belief in God) is better understaood from a dimensional perspective than a categorical one. In categorical view, a symptom or belief is either present or absent. In a dimensional perspective it is viewd on a continuum from Nil to 100%. people may fluctuate between 40 - 60% to 60 - 40% depending on situational (alone or in company, type of the company etc ) and endogenous (mood state for example) factors. This is the case with paranoid personalities and people with other eccentric notions. But in Psychosis, there is a clear, qualitative break into a world of irrational thinking, which cannot be corrected by logic or arguements.
I hope you have read my belated replies to your comments on my previous posts.
hi, thanks to harish for the detailed explanation. I think classifications of mental ilnesses are absolutely necessary, more as a social safeguard than a scientific imperative., as i understbnd the treatment is personalised and does not depend on the classification, except in a broad sort of way., different schools of thought having thehr own adherents.( if wrong please correct me ). It seems ajeesh thinks the criteria syrtem is wrong. I dont think there is anything to be alarmed about, as there is no coercion involved in placing anybody under any classification, nor is anybody declared mentally ill just because he happens to satisfy some criteria. The classification kicks in only when the doctor is consulted by the patient, which indicates he is ill anyway, and all that remains is to categorise that illness. A more scientific classification is desirable but not available. Thank you
The drug ‘Tianeptine’ works in the opposite way of an SSRI but it produces antidepressant and anxiolytic effects like an SSRI and can be used in Major Depression, Panic attacks and a spectrum of other anxiety disorders. So what is the fundamental property that gives its efficacy to an SSRI? Is it the increased availability of serotonin in the synaptic cleft? Tianeptine is an SSRE that leads to a decreased availability of serotonin in the synaptic cleft. So the serotonin hypothesis seems to be in trouble. I have read that there are other advantages like neuroprotection, receptor down regulation, anti inflammatory effects etc… associated with the use of an SSRI. The drugs like mirtazapine or bupropion also have antidepressant effects. Do these drugs play any common role in its positive effects like neurogenesis or something like that?
Thank you.
Hi Sashi,
I said a psychiatrist’s observation and judgment is more important than simple classification according to DSM or ICD. It should not be used like laboratory examination results to identify the disease. It should be supportive evidence to a psychiatrist’s own findings. We know many people who can be classified into a disorder but function in daily life better than others who are classified as ‘normal’. I have only a limited knowledge about DSM or ICD but I hope it may be useful to add one more dimension into the diagnostic criteria. ‘A perfectly normal person’ is only a concept. Everybody behaves irrational in some fields of their interaction to life. A person may be insane, irrational, normal or very good in different instances or different aspects of life. We can construct a ratio in terms of total quality of life. A mentally ill person’s extra abilities like artistic or conversational skills may outweigh his disabilities caused by mental/brain disorder so the person can lead a better life than others without any mental illness. It is my humble opinion that usually people who stand out of the crowd are less normal than the others. Psychiatrists usually try to analyze the abnormal part of a patient, compare it with the DSM and prescribe the necessary drugs. All psychiatrists do not act this way but there are many of them around us. A person with Ophidiophobia (pathologically afraid of snakes, not able to watch it on TV or the very word ‘snake’ makes them irritated) living in a modern city doesn’t need treatment as there are no or less chances of encountering a snake in a city. But the same person needs treatment if he is living in a village area where there are many snakes around or he is supposed to work in a zoo. This is really a simple example of contextual importance but it is really complex in real cases of mental/brain disorders. I used the word ‘pseudoscience’ in a figurative way, it just expressed how much dissatisfied I am. It is more accurate to say that it is in its infancy as a science. Diagnosing mental disorders requires the skills of a psychiatrist but that is not in the case of diabetes or hypertension where we have more objective methods. Now, diagnosing mental disorders is both art and science at the same time.
There should be a comparison of both positive and negative deviations from the ‘normal’.
Thank you.
hi, i was saying the same thing. The criteria is important to avoid subjectivity in the examiner itself. For example, an atheist psybhiatrist would look at a believer patient in a particular way and a believer psychiatrist would look at an atheist patient in a totally different way. An impersonal criteria system would, or should unburden the psychiatrist of his personal prejudices, thats what i meant that it is is a social safeguard. It would be ton foolish to submit ourselves to the untrammelled opinions of a psychiatrist who doesnt need to adhere to any criteria. Not all psychiatrists are dr harish. Thank you.
Well said ! Ajeesh and Sashi. The analogy of snake phobia is most apt. I really enjoyed the discussions.
Hai, Sir
very good informative discussion on an interesting topic
dear sashi..
I feel the scope of subjectivity in medical practice is/was maximum in psychiatry which deals with "human mind" which itself is difficult to define & a matter of never ending debates.
The Best test or criteria should have 100% sensitivity and 100%specificity,which is practically impossible in majority of the clinical situations.
In psychiatry,a criertia which is more sensitive but less specific will be very painful/and less acceptable to the general public for obvious reasons.......
and is afraid of the changing classifications and theories in psychiatry.
Evidence based medicine(and general public)is hopeful that gradually more and more doctors/psychiatrists will become less averse to the guidelines and International classifications!
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