الرئيسية / الأعمال العلمية / كتب علمية / Structural-Teleological Approach to Nosology

Structural-Teleological Approach to Nosology

Chapter I: Earlier Trials

  • 1-Active-Established dimension
  • 2-Revision of the Use of the Term “Affective” in Psychiatric Practice and Research.
  • 3-Typology of Depression: a structural teleological approach
  • 4-Anxiety: Structural Orientation.
  • 5- Successive trial for typifying Schizophrenia. Biological-Evolutionary Model The schizophrenic march

  • 6- Psychotic-    Non    Psychotic Dimensions (& Six Psychoses worth considered as independent categories
  • 7-Organic-Functional Polarity A Fading Illusion…
  • Chapter II: The hypothesis: Breakthrough    the    Current Psychiatric Nosology

  • 1-Part I: Prospects and illusions
  • 2- Part II: Multi-axial  vis-a-vis multidimensional approach..
  • 3- Critical Comment on the first part (Dr Osman Abdul-Karim)
  • 4-Comment on the comment

1- Active-Established Dimension ([1])

‏The DSM III (1980) has provided psychiatry with a well defined form  to include and delineate most current disorders. Its acceptance is going much more beyond the declared criticism. It seems to drag clinicians (aggressively but secretly) away from their original task as professional artists and primary healers. For instance, according to this manual, chronicity is to be determined almost exclusively by the duration rather than by the degree of established mal-organization. Acuteness, is related also to the floridity of the apparent symptoms along with the short duration and perhaps sudden onset.‏

‏This emphasis on such overt circumscribed criteria  as well as duration as judged by  turning the hand consulting a concrete watch would make us overlook  the real underlying how  of  organization denoting activity  (regardless the duration) or established status even if it settles down in a very short time. If we have to consider the actual degree of stability or stirred up state we should use some added parameter which is previously referred to as the “active-established dimension” (Rakhawy 1979)

‏This dimension is essentially a structural concept rather than a symptomatic one. It is also related longitudinally to the concept of rhythmic biological unfolding in health and disease.   However certain behavioral clues could help to delineate its characteristics:‏

‏The more the following criteria are detectable, the more the syndrome  is considered active, even though its duration could be years:‏

‏1- Awareness of the holistic changes going on rather than “verbal recording” of some disablement or stress.‏

‏2- Fluctuation of intensity and change in quality of the presenting symptom. This looks more relevant to activity than a sudden onset rapidly followed by a stable pathological outcome.‏

‏3- Genuinity of the reaction to symptoms and abnormal phenomena. This could be declared by apprehension or active perception of some impending or actual change. It declares a “lived-in” experience existing now rather than alienated information to be spoken about.‏

‏4- Direct presentation of uncovered intrapsychic content rather than elaborate sophisticated, partially intellectualized symptom formation.‏

‏5- Disturbed sleep and dream pattern and content.‏

‏6- Associated autonomic imbalance.‏

‏To demonstrate how such dimension could be clinically and nosologically relevant I am going to point to certain examples in terms of the current nosological and symptomatic  labels.‏

‏Most Schneider’s hallucinatory symptoms are related to activity in contrast with the established hallucinatory system of a chronic paranoid state for example. The reaction to “voices arguing” is quite different from following the orders of the hallucinatory voices. Phobic reactions (particularly phobia of insanity and phobia of loss of control) are active symptoms in contrast with intellectualized obsessive phobia (from dirt or disease). ‏

‏While a variant of “cross-road crises” (Rakhawy, 1979) could be equated with the so called “active  incipient psychosis”, a borderline state patternized in some  personality disorder pattern is an established  malorganized syndrome. Not infrequently both categories (incipient psychosis and personality disorder) could be put in the same nosological basket as border line states although they are simply the opposite of each other.‏

‏A manic-depressive illness, depressive type (DMP  I) is an active major affective disorder to be contrasted with its extreme opposite i.e. The established cumulative nagging hypochondriac depression (Rakhawy, 1979).‏

‏Similarly, subacute paranoid episode is just the opposite to a chronic delusional or fantastic paranoid state. While the former is active the latter is established. Both management and prognosis differ accordingly. Schizoaffective periodical disorder could be the active contrast of the established residual or hebephrenic settlement. On the whole, distinction of schizophrenia into chemically determined illness and organically related one (Okasha, 1980) may also be related to such dimension.‏

‏The term chronic active  syndrome used by Jaspers more than fifty years ago is now becoming  in common use in other medical speciality such as: chronic active hepatitis or chronic active rheumatoid arthritis  and so on. ‏

‏To conclude, this suggested dimension could prove to be clinically  definable, biologically distinct, structurally significant and therapeutically relevant. A need to delineate the concept in operational terms as well as to give chances for training procedures for rater to assess, may be the starting point for further elaboration and research investigation.

References:‏

‏American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders  (Third Edition) Washington: The Association. ‏

‏Egyptian Psychiatric Association (1975) Diagnostic Manual of Psychiatric Disorders (DMP I) Cairo: The Association .‏

‏Okasha, A. (1980) Is schizophrenia more than one disease? Egypt. J. Psychiat. 3: 153-158.

2- Revision of the Use of the Term “Affective” in Psychiatric Practice and Research ([2]) 

(ref …… egypt etc).

‏Some fundamental disturbance of emotions  occurs in every diagnostic category in psychiatry. It could be the basic disturbance or a presenting symptom in whatever clinical picture. However, the phenomenon known as emotion is no more clear than it has ever been.  “Emotion is (still) a complex phenomenon which is only incompletely understood” (Lane, and Schwartz, 1987). The author has previously criticized the 29 definitions of emotions introduced by Blutchick, (1980) and came to the conclusion that none is sufficiently comprehensive (Rakhawy, 1984). Intolerance of this ambiguity has led the recent criteria-oriented nosological disciplines to avoid facing the real everyday challenges practitioners face in clinical practice. Using seemingly well defined operational criteria could lead to certain mixing and misinterpretations, even though if they look to fulfil consensuality. For instance, a group of disorders said to be “non-mood” psychotic disorders include, as examples, “schizophrenia, schizoaffective or delusional disorders” (DSM-III-R, 1987). ‏

‏In normal life it is still very difficult to delineate emotion, as an independent phenomenon. Only emotional expression is partly defined. This expression in terms of verbal, social or autonomic manifestations does not necessarily cover the most important component of this complex phenomenon i.e. the experiential aspect.‏

‏This misleading situation is augmented in  most Arab countries including  Egypt, since we study and possibly practice psychiatry in a foreign language. We are used to start by importing, rather than translating, a foreign word from a foreign language having some foreign definition (Rakhawy, 1987). However, a diagnostic label is not defined through consulting a dictionary or encyclopedia. A concept in psychiatry is essentially derived from feedback in clinical practice.‏

‏Let us revise how the term affective, and more specifically the term depression  has been used by the psychiatrists in actual practice over the last few decades. On one hand psychiatrists are recalling (or using) the term affective or depressive whenever they deal with a periodical, vivid, active, warm phenomenon. This may be the implicit basis of the empirical use of antidepressants in some many other syndromes not necessarily presenting with evident depression as a symptom in clinical picture.  Revision of extending empirical use of certain antidepressants allowed Hudson, J. and Pope, Jr. (1990) to gather together what they called “affective spectrum disorders”. On the other hand strictly following only circumscribed operational criteria may include opposite phenomena under the same label. Rationalizing nihilistic depression or nagging parasitic depression could lie on the extreme opposite pole opposite to confrontation dialectic depression (Rakhawy, 1979). Similarly hyper-awareness anxiety is just the opposite of hypo-awareness anxiety although both may share the same behavioural operational criteria (Rakhawy, 1981).

‏The term “affective”, as well as certain emotional labels such as depression or anxiety are more and more denatured and reduced as they‏ت‏are put in verbal test forms in order to assess this or that emotional behaviour in health and disease. Lane and Schwartz (1987) read “for the present state of our knowledge about emotions, there is no consensus…”. This perspective is best shown by researchers who consider the objective measurement of physiological arousal and/or the objective measurement of behavioural expression to be adequate measures of emotions.  Lane and Schwartz (1987) continue, “.instruments such as the Taylor ManifestAnxiety State, The Hamilton Rating Scale for depression. (…etc) specify the emotion or mood and ask the respondent to quantify the intensity or frequency of that experience on a categorical or ordinal scale. The structure of the experience in question -its degree of differentiation and integration-is thus determined by the instrument.”  Results should be always debatable and should be restricted to inform us that the respondents are telling about their understanding of the words we put, rather than about their actual affective life.‏

‏Any profound revision in a trial to assess our attitude to understand, detect or assess emotional life or emotional disorders would come to conclude that we are facing a rather inaccessible complex phenomenon,  the measurable aspect of which may prove to be the poorest  and the least significant. So, it could be better to keep the specific words of particular emotions as the appropriate label for a particular syndrome   instead of using a redundant poorly delineated term like “affective”. For instance, a term like manic depressive disorder is better preserved in preference to terms like affective disorder or mood disorder. Also studies totally or predominantly dependent on verbal response to certain emotional words and based on our arbitrary conceptualization about emotions, should not be taken directly as referring to the incidence or prevalence of this or that mood disturbances.‏

‏It may be quite reasonable and relatively objective to preserve a term like “affect” as an added dimension to whatever syndrome. Since this approach has been initiated and inspired from investigating an Arabic word, wijdan, the author proposed to introduce the word as such in English until we find the proper translation, or keep it as such.‏

‏The word wijdan  is more inclusive referring to some holistic existential tone with variable affective connotation as well as definite cognitive and volitional implications (Rakhawy,1987). This hypothesis was detailed elsewhere (Rakhawy,1990). To quote the essence of the idea the hypothesis reads “To judge a syndrome as wijdanic or non-wijdanic does not indicate directly the presence or absence of a particular affect. A Schizophrenic disorder could be wijdanic, this may be the so called schizo-affective disorder in the holistic interpretation provided earlier by the author (Rakhawy, 1982) but not necessary due to the presence of associated depression or elation. Also, we can meet sadistic dangerous paranoid states (non-wijdanic) on one side and on the other we may have warm smiling paranoid states (wijdanic). Even depressive illness could be wijdanic like in vivid periodic manic depressive illness, or non-wijdanicas in parasitic or post-schizophrenic depression of the ICD- 10 (1988)”.‏

‏To conclude the term affective seems to connote more than its reference to the presence or absence of a particular expressed mood. Hence, it is better not to be attached to a particular category or syndrome, or to be restricted to manic and depressive variants or illnesses.‏

‏If the term mood would refer to the behavioural level of symptom presentation, the term affective (or wijdanic) may be better preserved for the holistic  complex phenomenon referring to some periodic, integrative, cognito-volitional-active presentation of whatever phenomenon or syndrome. ‏

References:‏

‏American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders- (DSM- III- R)  Washington, D.C.:The association.‏

‏Blutchick R. (1980) Emotion: A Psychoevolutionary Synthesis. Harper & Row Publishers. N.Y.Hugers Town Philadelphia San Francisco London (P81-83).‏

‏Hudson, J. and Pope Jr. (1990) Affective Spectrum Disorder: Does Antidepressant Response Identify a Family of Disorders With a Common Pathophysiology Am.J. Psychiatry  147:2, 552-562‏

‏ Lane, D.R. and Schwartz, G.E. (1987) Level of Emotional Awareness and Its Application to Psychopathology.Am.J.Psychiatry 144:133,2-143.‏

‏Rakhawy, Y. T. (1979) Evolutionary Value of Tolerance of Depression, Egyptian J. of Psychiat., 2: 138-144 ‏

‏Rakhawy, Y. T. (1981) Anxiety Relation of Conceptualization to Therapy, Egyptian J. of Psychiat., 1981, 4: 6-14   ‏

‏Rakhawy, Y. T. (1982) Schizoaffective disorder: An exclusive waste basket or a specific cross-road devolutionary phase, Egypt. J.  Psychiat., 5: 192-.194‏

‏Rakhawy, Y.T. (1984) The Essence of Affect and its Evolution. Man and Evolution Journal, 18: 108-.150‏

‏Rakhawy, Y. T.(1987) Psychic phenomena and the Hazards of Translation. Egypt. J. Psychiat.,10: 9-10‏

‏Rakhawy, Y. T. (1990) Breakthrough The Current Psychiatric Nosology- Part I. The Arab Journal of Psychiatry, 1: 81-.92‏

‏Rakhawy, Y. T. (1990) Breakthrough. The Current Psychiatric Nosology- Part II. Multi-axial vis- a- vis Multidimensional Approach to Psychiatric Nosology, The Arab Journal of Psychiatry, 2 (in press).‏

World Health Organization (1988) International Classification of Diseases- 10th Edition (Dr.aft). Geneva: the Association.‏

3- Typology of Depression ([3])‏

(A structural-Teleological Management-Oriented Approach)

‏The term depression is getting to be more and more mutilated mainly through the abuse of psychiatrists. Instead of stimulating empathy, sympathy, care and responsibility it has become a conditioned stimulus inviting one to swallow this or that pill. This looks to be denaturing human beings. As much as the homo-sapiens is especially characterized by symbolic thinking, language, awareness and free choice he is particularly characterized by the ability to be depressed.‏

‏The psychiatrist, as well as the layman  has to revise the real meaning of the word before submitting to the creeping invasion of psychiatric terminology on human emotions. This warning should not be taken as anti-psychiatric protest or as denying the efficacy of drug therapy. On the contrary, it should stimulate thinking in other terms that are more representative of pathology with the aim of defining and delineating   negative aspects from positive ones of the same phenomenon.‏

‏Any clinical  artist is familiar with many types of depression other than those forced upon his mind through the current f scientific (!!) Language. An honest interviewer of drug research on depression will find himself lacking a definite profound essential dimension by which he could assess the depth and meaning of the phenomenon. This is not simply the poetic touch of the misery of our life but is mostly the profound biological meaning of depression. In DMP I (1975), there are eleven types of depression including depressive personality and reactive neurotic depression as well as psychotic types. In the DSM II there are seven, in the ICD 8 there are 8 and in the DSM III there are nine types (other than possible reduplications on various axes). All such types are mainly descriptive with little or no reference to meaning, function, goal, value and corresponding management.‏

‏ Arieti (1974) believes that by being unpleasant , depression seems to have a function in its own. Like pain, depression stimulates a change in order to be removed but it is both a psychological change and ideational change: a re-arrangement of thought and clusters of thoughts. Eventually the actions of the individual will change too, as a sequel of this cognitive re-arrangement. According to Arieti (1974)” depression is the evolutionary outcome at a human symbolic interpersonal level of biological nociceptive pain”. This extremely condensed orientation should be thoroughly analyzed with special accent put on the word “symbolic”, “interpersonal” and ” biologic”. ‏

‏On the other hand Zewar (1975) states that”…we can say that what characterizes depression is the deterioration of the ability to “become”, which results in decrease in the sense of existence i.e. in the sense of being. Early in my hypothesis on levels of mental health (Rakhawy,1972), I have suggested that one of the associates of the evolutionary crises is characterized by depression which is naturally motivating for the individual”s own growth.  Later on ( Rakhawy 1978) I started to avoid using the term depression for describing such positive feelings met with, for example, during and after a psychotherapeutic impasse in group therapy. To quote the statement”. I am inclined not to label such feelings associated with this confrontation as depression. I prefer to name them “psychic pain”, since depression has become a symbol of a specific symptom or syndrome that was too much mal-used, while psychic pain (which I mean) is characterized by: a) It evolves through a certain degree of awareness and free choice. b) It is devoid of guilt feelings. c) the individual  who suffers its impact, is  striving with his ambivalence in a trial to replace it by what is known as “tolerance of ambiguity”.‏

‏In a trial with perphenazine enanthate in the schizophrenic continuum, Rakhawy et al (1978) have considered depression as an advantageous step, rather than a side-effect during reorganization of the schizophrenic disorganization. This was interpreted in terms analogous to the same phases described by object relational theorists (Guntrip, 1965). We recommended that it would be better not to be hasty in interfering with such changes, since they may resolve into natural therapeutic improvement as a step towards recovery.‏

‏Based on  clinical experience I am going to present a tentative typology of depression with various psycho structural organizations. It is not easy to grasp the new terminology and any overlap or mixed states could be met with. For instance the defensive neurotic depression although described in dynamic terms could be a defense against another type of depression (and anxiety) i.e. the active confrontation one. If it lasts and becomes habituated it could turn into character trait or other stagnant type. The main dichotomy could also be related to the previously mentioned active-established dimension.‏

This paper has been published before such dimension become well established. According certain terminology has been altered to fit the two main categories i.e. active established which are called here stagnant and vivid biologic the diagram is added to illustrate this dichotomy with minimal alteration of the text.‏ ([4])

1- Defensive Neurotic Depression

‏This type is simply an exaggerated defence mechanism  to avoid and alleviate intolerable anxiety.  In so doing, it is just like dissociation, displacement or any other neurotic defence. The underlying psychopathological rationale is that: actualizing frustration on a fantastic level looks better than expecting it vaguely all the time. This type should not be mixed with reactive depression on one hand and mild (simple) periodic depression on the other hand. Reactive depression   is an exaggerated response to depressing environmental stimuli while mild non psychotic periodical depression is biologically determined and harmonious with dialectic pulsations. This type could only be altered by considering the underlying anxiety and manipulating it both biologically and psychologically.‏

Typology of Depression
Stagnant Vivid Biologic
Rationalizing Nihilistic Periodic unfolding
Delusional Guilty Confrontation Dialectic
Character Trait
Nagging Parasitic
Defensive Neurotic

2- Rationalizing Nihilistic depression

 This type is characterized by a serene despair. It is equivalent to the schizoid existence where psychic equilibrium is maintained by the delusion of hopelessness. Delusion of hopelessness sometimes does not necessitate actual hopelessness. It may be a disguised way declaring a tendency to rationalize a sarcastic nihilistic attitude. Management of such depression is rather dangerous if this delusion is enthusiastically, but clumsily, shakened. Not infrequently suicide occurs when hope becomes near or realistic. This type is sluggish in response to drug therapy if the patient ever accepts to take the chance of management at all.‏

3- Delusional Guilty   depression:‏

‏This type represent another form of delusions which are famous as typical symptom of depression. As a matter of fact such delusion usually replaces the vivid affect (wijdan). Delusion of guilt is commonly associated with self-reproach and unworthiness. Both look to be punitive. It is not actually so. Such intellectualized declaration seems to act as partially successful defenses that serve to replace actual despair. The result is stagnation, self-centered existence and a closed circuit pseudo-life. Suicide, if it occurs, is not a result of guilt as much as it is an acted out mechanism. ‏

‏Breaking this circle by intensive interference should be tackled as cautiously under the umbrella of  antidepressants and moderate doses of neuroleptics. If the closed circle is cut off this may liberate the entangled energy in this stagnant existence. Thus the dose of therapeutic interference including BST (Ex:ECT) should be appropriately adjusted and spaced accordingly.‏

The expression “Brain Synchronizing Therapy” has replaced the misnomers of electro-shoch and Electro Convulsive Therapy ECT).

4- Character trait habituated depression:‏

‏In this type depression becomes so fixed that it forms part of the structure of the personality itself. It looses its sharpness and becomes stereotyped. It is usually a late phenomenon since it results from both habituation and intellectualization of depression so much so that it becomes less and less genuine and very difficult to manage. It is expected after intensive interference in a group or milieu which is not available for most, if not all, such cases.‏

5- Nagging parasitic depression .‏

‏If the second type (rationalizing nihilistic) is equated with the schizoid compromise, this type is to be equated with schizophrenic existence, sometime I label it as schizophrenic personality. The individual is characterized by being sticky, nagging, clinging and ever complaining of his claimed depression. The management of such type should be taken as serious and deep as management of chronic schizophrenia considering the acted out infantile dependency all the time.‏

‏Intensive zigzag neuroleptic medication is more useful than antidepressants. Milieu management and early prolonged rehabilitation are the only way out if there is any at all.‏

6- Periodic unfolding depression :‏

‏This term, biologic, does not signify that other types are not biological, but it only stresses that this type is related basically tobiological pulsation (Rakhawy, 1987). It could be met with as simple non-psychotic presentation or may be psychotically severe. In this type the unfolding brain rhythm (systole) is not well tolerated and utilized in the synthetic growth as will be soon mentioned. As such the problem is to assimilate the pulse rather than simply to abort the unfolding. However the dose of the unfolding is usually beyond assimilation at once and hence physical (BST- Ex: ECT) or antidepressant are the first aid measures. The possibility that this could be followed up by some other measures aiming at assimilating the pulsation could alter such type into the dialectic confrontation depression (next type).‏

7- Confrontation dialectic depression :‏

‏This is the same type which I previously labelled as “psychic pain” (Rakhawy, 1987)  and that Arieti (1974) has called “the evolutionary outcome at human symbolic interpersonal level….”. It is the natural result of confronting the dichotomy of our existence and at the same time the ambiguity of our world. The result of such confrontation is to utilize the biological unfolding in a dialectic synthesis permitting expansion of awareness which corresponds to extension of neuronal associative potentialities. The latter may again correspond to lengthening and organizing the coherent memory chains (perhaps on an intracellular level through higher organization of macromolecules). The result of this process is more and more stepping along the evolutionary scale along with more and more pain. It is definitely regretful to mix such experience with the above mentioned types of depression, so much so that whenever available it is instantaneously eliminated, if possible, by the available chemical or physical weapons.‏

‏ However, this problem could not be safely solved by considering such confrontation type as a normal depression that should not be liable to mishandling by psychiatrists. First, the associated pain and the loneliness resulting from increased awareness is frequently beyond the individual’s tolerance. Second, the overwhelming psychiatric propaganda does not permit anyone to tolerate such essential pain long enough to permit unfolding. The steady diminution of manic depressive illness (Cohen 1975) with both its disastrous and possible positive aspects, is relevant to this point.‏

Closing :‏

‏We may assume that depression, in general  needs to be understood and re-channeled rather than feared and eliminated, and more recently, in the  lithium era may be prevented all together. In profound therapy, depression if lacking, it should be searched for and reactivated in the proper context. For instance, dialectic group therapy advocated by the author is said to be “.growth oriented, deliberately reactivating the mal-organized personality compromise into a dialectic synthetic confrontation” (Rakhawy 1978). Sleep deprivation therapy, in its proper application (Mahfouz, et al, 1978) tries to integrate this depression in a lengthy plan of growth therapy in a special milieu. Physical therapy, if properly applied, should aim at helping to tolerate such experience rather than to eliminate it.‏

‏If the human species is going to persist, it has no choice but to continue its evolution against all resistance forced upon it, not only by external dangers and natural calamities, but also by the products of its own mind. Abuse of chemicals and mishandling of human experiences even under scientific claims are among such dangerous products.‏

Referrences:

‏American Psychiatric Association (1968) Diagnostic and statistical Manual of Mental Disorders (DSM II) Washington : American Psychiatric Association .‏

‏American Psychiatric Association (1978)Diagnostic and Statistical Manual of Mental Disorders (DSM III)American Psychiatric Association .‏

‏Arieti, S. (1974)Interpretation of Schizophrenia   2nd edition. New York ” Basic Books , Inc. Publishers.‏

‏Cohen, R.A.(1976) In freedman, A.M. Kaplan. H.I. and Sadock. B.I.(eds) Comprehensive Text Book f Psychiatry . 2nd Vol. Baltimore : Williams & Wilkins Co.‏

‏Egyptian Psychiatric Association (1975) Diagnostic Manual of Psychiatric Disorders  (DMP I) Cairo ‏

‏Guntrip, H. (1965) Schizoid Phenomenon, Object Relations and the Self. London: The Hogarth Press.‏

‏Mahfouz, M. and Rakhawy, Y. (1978) Sleep Deprivation Therapy : a Part of an Integrated Plan in a Special Milieu. (Read at Cairo Symposium on Prevention and Treatment of Psychiatric illness

December (1978).Rakhawy,Y.(1972) The Dilemma of a Psychiatrist . Cairo Dar El-Ghadd Publisher (In Arabic).

Rakhawy,Y. (1978) Introduction to Group Psychotherapy . A search in self and life, Cairo: Dar El-Ghadd Publisher ( In Arabic‏).

Rakhawy,Y Shaheen O,  Gawad, M.S.A. and Shaalan. (1978) Perphenazine Enanthate in Schizophrenic Continuum .  Read at Cairo Symposium on Prevention and Treatment of Psychiatric illness December (1978).

World Health Organization (1977) Manual of International Statistical Classification of Diseases, Injuries and Causes of Death, Revision 9 ( ICD 9) Geneva:  World Health  Organization .‏

Zewar, M. (1975) Lecture on Psychic Depression (Cairo: Anglo-Egyptian Library (In Arabic).

4- Anxiety: Structural Orientation ([5])‏

Relation of Conceptualizationto Therapy

Introduction

‏Every word has its particular connotative history. A concept included in a symbol is the result of such history at a particular moment of evolution. Psychiatric vocabulary is the least stable, and in the view of many psychiatrists is of doubtful pragmatic value. The word boundaries in psychiatry (like ego boundaries in schizophrenia) are becoming more ill-defined, let apart the hazards of translation, thus hyper-permeable, in spite of all the efforts given by the members of national and international nosological committees. The concept of anxiety is in no way an exception.‏

‏The problem  has its direct implications on the how of practice, particularly in terms of therapeutic techniques and goals …etc. The term anxiety provides an additional source of ambiguity since it is originally a lay expression. As Davitz (1969) put it “…the use of such everyday words. adds a considerable potential for confusion in a field that hardly needs additional source of noise in the channels of professional communication”‏

‏The available disciplines, placing anxiety as a neurosis, or the mother neurosis, stress two main dimensions viz: a free-floating ill defined fear as well as the autonomic concomitants . Neither could be traced back to the Latin origin where “anxietas” means disquiet while “anger” means constriction. However neither the psychiatric connotations nor the original meaning has adequate correlation with the differential therapeutic orientation.‏

‏As a developing country as we are,  we are not (or should not be) the least   satisfied by reproducing the imported, sometimes illusive, information about the subject. We have to search before all for the useful meaning. As Kendell (1975) puts it “.it is almost meaningless to ask which is right. The appropriate question is always which is more useful or appropriate and the answer varies with the purpose in mind” I hope or believe that our purpose in mind is primarily therapy and not the least stereotyped pseudo-communication.‏

Concepts and Practice

‏A concept in psychiatry  is, or should be,  primarily derived from feedback in clinical practice.  It should be understood as a logical phenomenological approach through an evolutionary psychopathological orientation where psychopathology is neither etiology nor symptomatology but the psycho structural morbid organization along more than one axis and dimension. Both conceptualization and practice are directly influenced by the personal defenses of the psychiatrist as well as the attitudes and values imposed upon him from society as a spatio-temporo-environmental incidence.‏

‏1- Anxiety for a therapist who conceptualized health as the “anxiety free nirvana” would differ from another believing in life as a crescendo dialectic synthetic formation always in the make.‏

‏2- Understanding anxiety as a ” language for” rather than “a manifestation of “or” resulting from“: that is to  say adding teleology to determinism is apt to alter the therapist’s stand and to favour certain therapeutic procedures.‏

‏3- Interpreting the presenting “form” of  anxiety in terms of behavioral manifestation of some morbid organization (personality organization as well as neuronal and molecular) varies from interpreting it in terms of some manifestations of this or that brain amine or in terms of a mal-learning or residual fixation.‏

The Suggested Approach:‏

‏The syndrome, or symptom,  called anxiety could be conceived through multitude of aspects:

  1. i) on behavioural level as a symptom or syndrome refers to that ill-defined fear associated with autonomic manifestations.
  2. ii) on behavioural On a deeper level related to awareness, anxiety is to be considered as a phenomenon of hyper-arousal resulting from a disproportion between the scope of awareness and the intrapsychic activity. ‏

‏iii) On psychostructural level, anxiety could present in different forms according to the underlying structural formulation.‏

I- Awareness Dimension

‏The hyper-arousal awareness referred to just now is essentially relative. It refers to the discrepancy between the intrapsychic activation (with or without external objective stirring up forces) and the coping of the holistic awareness with such activation terms of. If the hyper-arousal is due to hyper-awareness more subjective symptoms and less autonomic and motor symptoms are met with. The contrary occurs in cases of hypo-awareness arousal i.e. more irritability and autonomic manifestations are met with.‏

1) Hyper-awareness anxiety

‏In general this refers to a  state of relative increased dose of awareness which could be met with in healthy growth crises, in  creative experience as well as various morbid states of handicapping hyper awareness. In this special presentation I shall not delineate the healthy from the pathological as it is, in most cases, a matter of dose and handical as manifested in the tolerance and outcome. It should be differentiated from intellectual tual insight in the morbid inner life which could be only part of the syndrome to alleviate some of the internal objective confrontation.

The overlap between subcategories of this group is much more met with, The specific term of a sub-type only refers to the dominant characteristic feature .‏

a-Existential anxiety

‏This is a recently applied term in psychiatry borrowed from philosophical vocabulary. It refers to a certain degree of awareness of on”s true self e.g.in boundary experience (K. Jaspers) or of the absurdity and meaninglessness of the world as such (J.P.Sartre). It is neither healthy or unhealthy in itself. Under appropriate conditions it should be an intermediate stage the further specification of which is related to the outcome. As such, it could be also called Cross-Roads anxiety particularly when choice and re-choice is emphasized. ‏

Cross-roads anxiety:‏

This term has been used by the author  (Rakhawy 1979) to refer to the cross roads crises declaring the peak of a growth experience where the old organization fails while the new one has not yet been sufficiently established to be put into action as a dominant or leading. When anxiety predominates such crises the suggested term is justified. In the original publication it has been cited as independent subtype but I preferred to make it as basic for most other categories in this main hyperawareness group. It is characterized by deeper reorientation in one”s self and in the reality around (usually  associated  with  or ushered by depersonalization and derealization). By definition it could take any  road (hence outcome) according to different variables (personal predisposition or  environmental factors)  Most hyperawareness types are cross roads  experiences but levels differ. While it is related to free choice in existential anxiety it is more related to  nihilism in nihilistic one. Also cosmic anxiety is cross roads one between mystical experience, regression and mania.  Psychotic awareness anxiety is also a declaration of cross roads impasse that could lead to any psychotic presentation particularly disorganization.

c-Nihilistic anxiety‏    

‏This type is usually considered as a variant of existential anxiety but with selective hyper-awareness related to the futility of life (e.g.Camus).The overdose of awareness uncovers the aimless, doubted finality of one”s existence. Depression or nihilistic schizoid withdrawal may be met with from the start or may ultimately supervene. Here the selective hyper-awareness is usually related to the limited existence span  of the individual and not infrequently projected  onto others.‏

d-Cosmic (&Mystic) anxiety:‏

‏When hyper-awareness extends beyond one”s own existence (as a mesa-cosmos) to surpass his limited personal time and space, one may be confronted with cosmic orientation (macro-cosmos) beyond his ability to assimilate such experience at once. This may continue in either way, either to establish a higher level of relatedness and harmony beyond one’s own personal existence and thus elaborates a specific growth experience or, otherwise, it may start some other morbid march towards manic detachment or still worse disorganizing outcome. As such it is a cross roads variant as well.‏

e-Internal alarm (phobic) anxiety:‏

‏This  is usually described under phobic disorders in terms of fear of insanity, fear of loss of control, or any other fear from some activated intrapsychic structures.(E.g. from being helpless once again , from some homicidal impulse or from incestuous inclinations, etc..).It is not fair to put such fears as simple phobias since they declare directly the result of hyper-awareness in what is actually present inside everybody. Such awareness could be related to uncovering (or impending uncovering) of deeper intrapsychic  reactivated ontogenetic or phylogenic structure. The so called psychotic ego is perceived as an active impending hostile monster rather than a negative inert outcome of some breakdown of the previously existing organization.‏

‏ It is claimed that such phobias are usually concomitant with depression. This is partly true but its structural interpretation still refers to hyper-awareness in one’s intrapsychic content and the depression could be the result of excessive control in a trial to compensate for such dangerous awareness.‏

f-Psychotic awareness anxiety:‏

‏In the early stages of a psychotic process, the patient is occasionally submitted to sudden uncovering of the intrapsychic content which presents directly in the overt  conscious matrix as a real overwhelming bare unusual

Awareness Dimensiom
Anxiety = Disproportion between awareness and inner psychic activity
Hyper –Awareness Anxiety Hypo-Awareness Anxiety
Existential A Agitated A.
Cross Roads A.
Nihilistic A. Dull Depressive A.
Cosmic A.
Internal Alarm A. Blind psychotic A.
Psychotic awareness A.
Creative

existence, not only  feared of, acted out or alienated. This phenomenon has been described by the author as awareness of the  psychotic or psychotic awareness (Rakhawy 1979) in contrast with psychotic insight of Arieti (1974). It is less dynamically manipulated as in case of internal alarm anxiety. It declares actual activation rather than impending one or fear of outcome. This direct perception of the seves and reality as “they are” is usually associated with real apprehension, astonishment, fluctuating perplexity, depersonalization experience and occasional suspicion. Not infrequently, ixed forms are met with declaring both hyper-arousal and hypo-awareness at a time. The outcome of such stage of instability is usually more serious than the previous ones since the dose of activation and direct uncontrolled confrontation are definitely higher than any possibility for assimilation..‏

g-Creative anxiety

‏Such type characterizes the prodromal or the preparatory stages of creative experience. Basically it could not be differentiated from existential, cosmic or even psychotic awareness. Nihilistic anxiety in the process of creation is more related to the fruitlessness of the older organization. The creative outcome either as a creative product or  creating ones”self  determines its categorization here and not elsewhere under a pathological label.  Diagnosis is made, then in most case, in retrograde.‏

1-Hypo-awareness anxiety

‏The anxiety in this variant manifests predominantly as motor and autonomic hyper-arousal.The disproportion between a restricted awareness in the face of an unduly activated intrapsychic structure is responsible for  this type. I am not going to give new examples to illustrate this type since they constitute the main bulk of anxiety syndromes as described behaviourally. However, tension anxiety, exhaustion anxiety (neurasthenia), agitation anxiety  and projected phobic anxiety  could be included here. When the psychotic awareness anxiety is associated with hypoawareness rather than hyperawareness it could be overwhelmingly disorganizing.

II-The Structural-Organization  Dimension

‏The second  dimension which could clarify   our conceptualization of anxiety particularly in relation to therapy is the how of organization of the personality structure where any outcome is simply the outer facade of such organization. This dimension is the most difficult to assess but again it is perhaps indispensable to uncover. It is directly related to the psychiatrist”s theoretical orientation about the how of organization of the personality and  of the brain.

Psycho-Structural Dimension
Anxiety as a result of different

 intrapsychic OrganizationDual Holistic O.Chaotic Dispersed O.ConfrontationA.Agitation A.Oscillatory A (Hesitancy)Blind Psychotic A.Conflict A. (Tension) 

‏Different presentations of anxiety according to the how the multi-organizations (assumed or real intrapsychic  wholes  or  persons ego states  etc..) are inter-related is tried in this section.

 ‏If the personality is still preserving certain whole organizations, mainly two outstanding (dual),  some coherent presentation could be described and grasped. On the contrary the personality could no more represent such wholes but rather an agitated chaos and in this case other types of anxiety could be met with. With the risk of reductionism two main categories are introduced: The dual holistic one and the chaotic one.‏

A– Dual Holistic Organization (type) This main category comprises the following types:‏

1-Confrontation Anxiety

‏When two main organizations (say : old- new, child-parent , social-native or right-left hemispheres… Etc.) Confront each other for dominance while both are equally strong some behavioral manifestations are presented declaring this equivalence. Depression is the main result of such structural pattern but occasionally a special form of anxiety dominates the clinical picture usually along with the depressive symptoms. Phobias which are respondent to anti-depressive therapy could be variants of this type.‏

2-Hesitancy (Oscillatory) anxiety

‏Instead of confronting each other, simultaneously reactivated structural organizations may oscillate alternating rapidly with one another presenting symptomatically as hesitancy, unsustained activity, occasionally lability and ambivalence. Such type is mainly met wit in early disorganizing psychoses sometimes called acute schizophrenia, in extremely rapid cycling manic depressive syndrome, in borderline‏

‏ personality (of DSM III) as examples. They are not called anxiety  in its final presentation as symptoms. However the stirred-up shifting disorganization worth considering as anxiety from a structural point of view.

3- Conflict (tension) anxiety:‏

‏The word conflict is usually used in psychiatry to declare the dynamic relation of any opposing forces. In this context it is indicative that one structural organization has achieved some relative dominance over the other while the latter does not yield totally, still performing its active traction and influence, although at a distance (less confronting). This assumed distance differentiates this type from confrontation anxiety. . Behaviourally this type is manifested as a symptom mainly in the form of  tension and exhaustion.‏

B-The Chaotic  Organization

‏This type is occasionally known as psychotic anxiety and less frequently as disorganization anxiety.  It could be arbitrary classified into two main variants. The chaotic dispersed, and the the blind agitated.‏

1-Chaotic Dispersed anxiety

‏One can identify here the dispersion of energy as a result of multiple organizations losing their own unity. Perhaps this is mainly manifested in schizophrenic anxiety and in the course of organic dementia (crise de perplexite of Henry Ey). It is characterized by vagueness, hesitancy, fluctuation and hyperkinetic agitation. It could be also met with in some akasthesias resulting from prolonged use of major tranquilizers. Such complication could be interpreted in terms of irregular displacement of energy through loosely associated fragments of organizations.‏

2-Blind agitated anxiety

‏ This other type is also called psychotic anxiety. It has been referred to it in relation to psychotic awareness anxiety, where the sever haphazard activation is associated with hypoawareness. The result is restricted consciousness associated with extreme emotional turmoil with its motor and autonomic accompaniments.‏

Rationale and clinical utility of the approach :‏

‏It is evident that the word anxiety here has included more than it should. This introduction did mean to replace the included symptoms under the one omnipotent over-inclusive word. It is a trial to go back to the origin of psychic disharmony and to present psychiatric phenomenon through more holistic approach. ‏

‏In practice this apparent difficult (or rather splitting approach) could be directly related to the how of management more than the definition of a psychiatric symptom by other words can do.

The  goal of therapy is to restore, once again, a functioning balance between the dose of awareness and the ability to assimilate its consequences as well as to control the surplus intrapsychic activity. This could be established first through adjusting the dose of awareness, the ability to assimilate the activated intrapsychic structure and proper timing. Such approach for identifying and understanding anxiety on one hand in relation to awareness and on the other hand from an organizational point of view could be very helpful to consider  in the therapeutic planning.Of course it needs special training and definite artistic  healing approach which is but medicine.‏

Conclusions

‏As Tyrer (1979) put it “..The recognition of anxiety in a psychiatric patient is but the first step in classification..” .  it is more logic that the same principle‏ applies to therapeutic planning. Answering the following questions may help to clarify one”s concept about a particular case and consequently the nature of possible therapy to be applied:

‏1-Is anxiety in a given person, a direct declaration of an overdose of awareness or is it a defense against impending untimely dose (of awareness) ?‏

‏2-What is the underlying morbid (not only premorbid) structural organization?‏

‏3-How is it (anxiety) presenting? Predominantly behavioral autonomic acting out with consequent perception of the bodily alterations or is it perceived more as a phenomenon related to consciousness and subjective experience?‏

‏4-What does anxiety  mean for this particular person, in this particular presentation, in this particular time at this particular stage of   evolution and in that particular society?‏

‏5-What are the resources of such  person to cope with such morbid situation? Will he be able to assimilate more of the activated structure or is he obliged to suppress whatever is intolerable and narrow more and more his scope of awareness (the same applies to the therapist depending on who is he and to what  is he after.

References

‏Arieti,S.(1974) Interpretation of Schizophrenia. New York: Basic Books.‏

‏Davitz,J.R.(1969) The Language of Emotion. New York :  Academic Press.‏

‏Ey, H.(1950) Etude Psychiatrique. Tome II, Paris: Desclee de Brouwer et Cie.‏

‏Kendell, R.E.(1975) The role of diagnosis in Psychiatry Oxford: Blackwell Scientific Publications.

‏Rakhawy, Y.(1979) A Study in Psychopathology. Cairo: Dar El Ghadd. In Arabic.

Tyrer,P.(1979) Anxiety States. In Granville-Grossman, K. (Ed) Recent Advances in Clinical Psychiatry, 3rd ed. London: Churchill and Livingstone.‏

5- Successive trials for typifying Schizophrenia

Local trials to re-classify schizophrenia through adding other dimensions, probing into deeper strata and trying to understand the quality of existence did not stop over our practice in the last few decades. Along with the introduction of our  special orientation in the “study in psychopathology” typifying schizophrenia was arranged along the structural biological march that has been described. A summary of this march seems to be a pre-requisite before introducing earlier trials. The presenting order does not signify the historical march. Trials have been rearranged to fulfil the present revision. First the trial to revise the structural- phenomenological aspect of the classical types is introduced. Special accent is put on the differentiation between disorganization and deterioration dimensions. Then comes the trial oriented by the psychopathological march described before. The schizoaffective disorder was introduced next as an example of some cross-roads arrest along that march. Then the schizophrenic spectrum was introduced as a graded scale along Schneider- Bleuler- Kraeplin continuum..‏

All such  trials are showing some precursors to the multidimensional hypothesis that is given at the outset of these collected papers. However this would replace most of these trials but is not enough to cover the longitudinal dimension.‏

Minimal changes were carries out and some boring repetition could be encountered. This may show the degree of my preoccupation by the same theme.‏

Scientific and lay uses and abusesof the termSchizophrenia.‏

‏Different  uses of the term schizophrenia do not mean that it is a meaningless or over-inclusive term. The history and current dilemma in relation to the term are indications to look in whatever possible use at whatever level of orientation and conceptualization which could stem out of different orientation about bothe denotatation and connotation of the word schizophrenia.  Starting at the behavioral level (mainly symptomatology) but extending to cover internal structure, teleology and the longitudinal march as well as the outcome, the following uses (and abuses) could be identified. The lay uses of the term are also considered.‏

‏1-The behavioral concept is the most consensual one as it deals with behavioral phenomena that are obvious to others. Thus, it refers to what is agreed upon in terms of signs and symptoms most common to Schizophrenia. Although it is usually stressed that the term schizophrenia should only be limited to this behavioural delineation the actual practice proves that this could represents some sort of false reductionism and pseudo-delineation.  However, the opposite (all the following uses) bears the danger of overinclusion.‏

‏2- The structural approach  to schizophrenia is to be related to the degree of aparting the basic levels and units of the structure of the personality as well as to the degree of its plasticity to resume order towards holism and unity. The word structure is close to  Arieti”s “psycho-structural configuration” as well as to Berne”s “Structural analysis” but is not used here as synonymous. It is mainly related to the multi-organizational relatedness of units and levels of the nervous system along with the corresponding modes of existence and possible presentations in behaviour. Structurally, schizophrenia would refer to progressive disengagement of organizations of brain levels, compartments or ego states starting from dislodgement up to its disorganization and ultimate disintegration. This could be applied to certain orientation even though the symptoms are  not yet , or not enough diagnostic of schizophrenia on behavioural level.‏

‏3-Teleologically it is assumed that schizophrenia ultimately tends to fulfil withdrawal and nihilistic relatedness. This seems to be a defence that seems to help to maintain basic organic existence regardless which mature level it spares or what reality it discards. This is frequently called psychic death (which is teleologically a temporary stage). Simultaneously schizophrenia represents a progressive regression and reactivation of primitive devolutionary activities. This includes at least functional cessation of time, of learning and relating to others (objects). In other words, the purpose of schizophrenia is to achieve some temporary human functional death which means deterioration, regression, disorganization and disintegration. In this sense however, this cessation is simultaneously serving preservation of body existence with some hidden hope to resume life in some more favourable situations i.e. when evolutionary powers within the biological human march could resume unfolding in some more appropriate circumstances.The lasting hazardous structural (and organic) deterioration is a result of malcalculation and is to be considered not as a goal per se but rather as a complication. Speaking with this special language schizophrenia, teleologically, is : a dangerous partial and chaotic hypbernation (or incubation) that is definitely unable to resume rebirth except in rare favourable circumstances. If one is able to spot and delineate such attitude as inferred from behaviour, existence or hidden language one may be justified to speak of schizophrenia as a failing goal- seeking behaviour.‏

‏4-Dynamically,  schizophrenia is presenting some sort of  absolute personification i.e. Complete abandonment of the world of objective relatedness.  In this sense it refers to the absolutenarcissistic existence or “no object existence”. Such phenomenon could be met with without special symptoms referring to schizophrenia as known at behavioural level. This means that it could include certain personality‏ ‏disorders and is more related to the term narcissistic neurosis of Freud.‏

‏5-  Biologically a person or any living being is in a continuous alternations  between two opposing powers, the harmonizing integrating forward evolutionary power  and the disrupting dysharmonious  devolutionary one towards   dis-integration. Schizophrenia, from this point of view, could be considered as a severe transient or final victory of the devolutionary power this evolutionary approach to the term is too inclusive It seems to serve as a constellation of the previously presented approaches. It is more related to the theoretical background emphasizing the holistic biological nature of schizophrenia rather than to specific behaviour, structural or dynamic organization.‏

‏ 6- The outcome oriented approach permits some retrograde use of the term schizophrenia even with those syndromes which did not show schizophrenic symptoms or criteria along a major part of their course. The term schizophrenia jumps to one’s mind when a relatively rapid deterioration is going on, threatening or expected along the course of any major (so called functional) psychiatric disorder. This is directly related to early Kraplenian tendency.‏

Biological-Evolutionary Model of Schizophrenia.‏

A structural Teleological approach

‏The Biological Evolutionary Model has adopted phenomenological methodology while integrating whatever   plausible approach into a wholistic frame work with more than one dimension. Longitudinally both the ontogenetic and the phylogenetic history are considered as active particpants. Teleologically both the meaning of symptoms and the goal of the schizophrenic language as well as of life are considered. The dynamic orientation whether in object relations terms or in the defense mechanism language are the matrix of the approach. The biological nature of the whole march lies in the core of the conceptualization and the biorhythmic pattern of dialectic growth is the essential way of reorganization and creative unfolding.Schizophrenia is considered as the most dislocating- disorganizing pathological unfolding (i.e. psychopathogeny).

‏Schizophrenia, to develop, needs certain imbalance between levels and organizations of the brain. The predisposition to such embalance is supposed to have its roots back frome some selected phylogenetic conditions which is translated in terms of genetic predisposition. The ontogenic development could be so embalancing even with negative genetic predisposition that allows equal vulnerability to progressive splitting disorganization detereoration march i.e. schizophrenia. However variable degree of embalance is met with in every growth crisis or onset of other psychoses. Rechanneling   into some positive outcome is always assumed if the crisis is properly handled in optimum circumstances.‏

The Schizophrenic March.‏

‏The term “march”is used here to stress certain longitudinal steps along the schizophrenic process. Seven phases are described.‏

Phase one:‏

The genetic predisposition phase :‏

‏The naturally existing schizoid organization of the brain may have been   reinforced at a certain stage of evolution by being dominant in certain environmental circumstances for some longer era.  This may have been perpetuated through imprinting and neural plasticity more in certain human sectors (families) through specific environmental, phylogenetic then familial circumstances. Collectively these accumulating factors constitute, through imprinting of evolutionary significant behaviour i.e. the tendency to withdraw and split apart towards disorganization then deterioration. (= the so called inheritance of schizophrenia).

‏However, while inheritance of schizophrenia depends on the ability of this level archaic level to dominate, thus to drag march of growth backwards i.e. to enhance devolution. a counter movement is almost equally cultivated. In other words one does not inherit schizophrenia, but inherits both a devolutionary organization and an equally strong or potentially stronger evolutionary one. The genetic predisposition to schizophrenia which has a possible advantageous outcome depends on the relative extent of each and of such opposing power. This assumption the offered explanation of the contradictory facts declaring that schizophrenia is a common disease (> 1/ 10.000) and is still considered as evolutionary malignant (less longevity and fertility than the normal population).‏

‏This phase could be summed up as follows:‏

‏I-The patient as a human possessing some history  definitely carrying schizophrenic roots in terms of primitive readily active schizoid (solitary) organization  that may function independently leading to disorganization and withdrawal at least as primary defence if other factors call for that.‏

‏2- The patient as a member of a particular family   carries  more than normal tendency to reactivate this primitive level. At the same time he carries more than normal tendency to counteract such devolution by the as mighty evolutionary (creative) energy.‏

‏3- The outcome of such opposing tendencies depends on other factors but always bearing the potentiality to turn to the opposite side.‏

‏4- The upbringing, and later on, therapy are among the most important factors to determine the primary  presentation and the possible reversal rechannelling.‏

Phase two:‏

The premorbid phase  is related to the effect of the recent and current environment in predisposing to schizophrenia. This is achieved through mal-nourishment or undernourishmen by appropriate biological information to whatever level of organization and to the organism as a whole. ‏

Predisposition

Genetic &

Premorbid phase

Biological under & malnutrition

Preonset

Onset of the onset

Atypical Neurosis affective disorder etc

Onset

Incipient Schiz

The march

Dislodge,ent

Incipient

Schizo-affective

Dislocation

Inter-reception

& trans-reception

Apartition

Paranoid and

Chronic undifferentitated

Progressive

Increment

& Stability of the disharomony

Hebephrenic &

Some residual.

Multi-autistic

Disintegration

Late catatonic & Disentegrated.

‏The expression “biological nourishment by meaningful  information” is specifically used in the vocabulary of this evolutionary theory to mean the significant coherent messages reaching the human being as a biological existence. This is not necessarily conscious, verbal or overtly understandable. Its source is usually, but not exclusively, a real human object. Sometimes the term is described as a meaningful information. “Meaningful” here means that   a specific information represent an organization which is co-harmonious complementary or significant to the brain organization  receiving it thus enhancing the positive growth process.‏

‏  The following modes of mal- or under- nourishment, could predispose to schizophrenia:‏

‏a) Prolonged (and/or overdose) reinforcement of the schizoid (solitary ,brain] organization) e.g. through a possessive  detached mother ‏

‏ b) Prolonged (and or overdose) of  competitive multi-channel message-feedback informations to different levels at a time e.g. double bind relation. ‏

‏ c)Excessive unprogrammed chaotic casual shifts from one level to another, e.g. erratic information. ‏

‏d)Shortened (and/or under-dose)  feeding by appropriate information to the mature object relating realistic level of organization (s).

‏The biological undernourishment or mal-nourishment  in infancy and childhood predisposes to a ready tendency to  retreat away from the realistic forward march in due time. The main possible sequence of this retreat is schizophrenia. This does not mean weakness or fragility. Retreat needs a powerful counterpower to dominate the forward (life /evolutionary) direction.‏

‏The pre-schizophrenic has a mighty  ready inner self  (or selves) but a mutilated weak self images. The two concepts are not synonymous; while the former refers to the primitive temporary dominant biologic organizations (Ego state, levels etc) the latter is partly introjected delusional (or conceptual) formulations. The discrepancy between the two should be taken as a definite variable that could predispose to schizophrenia. It enhances more and more repression, denial, intellectualization and over compensation, all of which predisposes to the possible coming break.‏

Phase three:‏

The pre-onset  phase, is presenting frequently by an atypical extraordinary fluctuating neurotic and dysphoric states but without a clear cut point of change. The pre-schizophrenic is still the ONE same person. This stage may corresponds to the so called pseudoneurotic schizophrenia or constitute a part of the prodromal symptoms. It is usually characterized by various manifestation such as vague feelings, stormy dreams, unsustained compensatory overwork, reconsideration of beliefs and attitudes, “loss” phobia and/or generalized hyper productivity including sexual excitement”.‏

‏Though the individual at this stage may look to the close relatives as the “ONE” or the “same” person,  a far acquaintance is more likely to grasp the qualitative changes.The patient frequently  grasps that he had been definitely altered, even  though no body may notice.  Phase Four: ‏

The onset phase, is the stage of clinical beginning of schizophrenia. The actual onset of the schizophrenic is almost always sudden and qualitatively delineated. Even if it is said to be insidious, by high power goal seeking examination, the moment of change may be identified even in a dream .Not infrequently the patient points to certain events or experiences in the recent past as the real starting point. This should not be considered as simple precipitation. Such experience could be referred to as antedating of the onset. In this sense it may be considered that the schizophrenic process has actually started but was still hidden behind or postponed by the neurotic-like or dysphoric disorders or symptoms.  This moment  could be labeled the “onset of the onset“. It declares the change of the cumulative progress into qualitative alteration i.e. the shift of the quantitative changes into a qualitative one. It also declares disruption of the existing conscious organization and the eruption of an “other” existence simultaneously in the same matrix of consciousness.‏

‏The onset is usually associated with certain subjective experiences which may  present as the complaint of the patient or of the relative, or could be recalled as a retrospective history later on. This is not simply memorizing something that had happened on behavioural level but forgotten. It is spotting, afterbeing uncovered, the real qualitative change that had happened on some other level of consciousness. These include: insight in the duality of existence, awareness of the normal going on apathy, the meaningless information as well as reinterpretation of events including dreams and even being partially aware of his share in choosing the disease. At other occasions, this special insight is associated also with the feeling of “as if” simulating or malingering.He may speak about being shy or guilty towards this changes “illness” being partially responsible for it. The patient also pretends, or partially tries, to go “back” but usually only to be sure that this is impossible. Perplexity, looking as if going along with some secret content, depersonalization and feelings of bodily independence (in part or as a whole) are also common associates in this stage. Transient  Scneiderian symptoms are occasionally experienced. A scene of duplication of personality in the same conscious matrix,  depersonalization, acute vibrating hesitancy and bizarre somatic  complaints are also encountered.‏

‏This onset is not very specific to schizophrenia. Certain factors make schizophrenia more liable to set in. These include positive schizophrenic family history, a premorbid schizoid personality, biological information undernourishment or mal-nourishment and neglect of the surroundings.‏

Phase Five:

The phase of progress of the schizophrenic march (in structural terms).

‏ The early stages of this phase overlaps with the previous one but are reintroduced in structural terms. Five consequent steps are usually identified.‏

‏(a) The dislodgement step: Dislodgement is the term used to describe partial disentaglemnt of organizations to present or been aware of as independent or apart. This normally occurs as a temporary phenomenon in normal developmental march as well as in dream activity. In this stage of schizophrenic march it becomes undely prolonged, threatening and alarming. The patient may declare this step as subjective feeling of apartition or phobia of impending loss of unity as just mentioned. This stage is not considered part of the schizophrenic march unless it extends to declare further separation of organizations (ego states) more and more apart to merge into:‏

‏(b) The dislocation step: This step follows  the previous one and causes more apartition of the organizations which usually present symptoms such as ambivalence, ambitendency, ambithoughts and similar signs. It seems in this step that the cathexis of energy is equally charged over the splitting/splitted organizations to which the term of “equi-valence” is given to explain all  equi- phenomena  just referred to as ambivalence, ambitendency etc….‏

‏(c)The inter-reception or trans-reception step. In this step the organizations have split completely to the extent that each perceives the other as an independent one. This first occurs within the subjective space (e.g. audible thoughts, inner voices, or becomes partially projected and re-perceived as is the case in more late first rank Schneider’s symptoms .‏

‏(d) The inter-penetration step: this refers on one hand to loose boundaries of each  organization and on the other hand to the influence and   entrance of the special contents of one organization on/into the other”s without  “permission”. When contents are projected, some other first rank Schneider’s symptoms are declared  e.g. thought withdrawal, broadcasting and insertion.‏

‏(e) The a partition of functions step:  Here, a single psychological function is divided between two organizations. Perception for example is divided between two organizations that each deals with certain aspects of the perception as is the case of delusional perception. The same if occurs in the thought sphere results in delusional misinterpretation and so on. ‏

Phase Six:

Progressive increment and stability of the disharmony phase:

This phase is characterized by the appearance of a certain degree of malignant stability when the perplexity is replaced by (intentional) helplessness, the delusional certainty replaces partly or wholly some areas of confusion and doubts, the equi-valence extends to parts of activity beyond major organizations resulting in paralysis of volition. By increasing loss of harmony the central internal cohesive powers weakens and is replaced by multiple aggregations of independent part cohesions. In this stage delusions become more stable and intellectualized, hallucinations gets pale with added fantastic details and incoherence is of poor content.Mixing between fantasy and reality with the domination of the former is also met with in this stage.‏

Phase Seven:‏

‏  Multi-Autistic disintegration phase:

By further reinforcement of disorganization each part organization (e.g. ego state) exists more or less independently (autistic) with its goal, different levels of evolution and different psychological functioning. The net result of such independent autistic multiplicity is presented in the clinical picture as bizarre chaos since all such multiple behaviours are taken as related to, and expressed by “one” person which is not the least true. The behavioural presentation of this phase is the apparent resultant of three different phenomena going on simultaneously i.e.(a)The autistic withdrawal of each organization (b)The remnants of the decathected rational realistic holistic organization and (c)  The part  presentation of part functions of many independent active organization at a time.‏

Defects in the longitudinal organization ,The loss of central ideas(s)

‏The longitudinal structural organization is related to the teleological orientation which is in turn is related to the goal or central idea or ideas. The defect in schizophrenia is to be searched for as a result of loosing some central cohesive ability and harmonizing teleology. The disruption of this basic longitudinal teleological organization of axial structure results in the inability to perform most elaborate functions as ONE goal seeking whole. The failure of the internal cohesive power is perpetuated by a defective external “message-feedback” organizing system. Further perpetuation of such vicious circle is expected the more the gaol disappears or becomes multiple opposite and equally cathected.

‏However, the  deficiency in the internal cohesive power (which is simultaneously represented by the main central idea) is partly related to the inherited intensity of fixed primitive (no object organizational level) and partly to the confusing (disorganized) messages that has been described under the terms mal-nourishment and undernourishment.‏

Consequences:‏

Formal thought disorder is to be interpreted in terms of loss of central ideas. The lack of consensuality, of sequential associations, of appropriate goal directed behavior of poor cohesive feed back are the basic factors responsible for weakening the main objective central idea. Thus new multiple part-central competitive ideas jump into the realm of consciousness simultaneously resulting in different types of formal thought disorders. The schizophrenic has his own special logic which consist of remnants of normal, reactivation of archaic logic and special innovated private logic. To him, like Arieti, the schizophrenic does not simply fail to abstract but he re-concretizes the abstracted concepts into new percepts.‏

Emotions in schizophrenia are neither lacking nor even withdrawn. They are apparently missing as the result of separation between the symbols and meanings as well as reactivation of primitive wholistic non-object related clumsy emotion. In another way they become useless as a motive for relatedness and goal seeking behaviour. Instead they become either hidden or serving primitive goals and adaptation at a lower level. ‏

‏The impairment of volition is declared by eruption of equivalent tendency simultaneously resulting in paralyzing hesitancy.This is followed by a “vessel like” negative existence ending in a nihilistic solidified and confused  existence. The autistic existence however may represent some active pathological volition maintaining withdrawal.‏

‏Since the  schizophrenic is still physically living, we can not accept that he is living with no object altogether. On the contrary if we listen to his cry we shall find that his  need for an object is over-whelming active all the time. His cry for succour is deep genuine but prejudged by an absolute conviction of uselessness”.  Simultaneously, he is relating himself to self objects with , special significance. Otherwise, he would not be able to maintain his biological life‏.

I  Schizophrenia

Differentiating Parameters

(Classical and Nonclassical Current Terms)

‏ One of the major mutilation the DSM III has inflicted in psychiatric nosology is how it handled schizophrenia. As much as he  (the DSM III) stresses the mere presence of delusions and hallucinations as synonymous with psychotic,  he puts a special accent  on Schneider”s symptoms in diagnosis of schizophrenia. Moreover, he usually speaks about Schneider”s symptoms he refers to them as bizarre.(Let aside the story of six months duration of residual and/or prodromal symptoms(.‏

‏On the contrary, the DMP I  approaches schizophrenia both as a process and an outcome. This process-oriented approach stresses disorganization as presenting, and deterioration as the very possible outcome. In the main category there is no direct reference to a single Schneider symptom and  delusions and hallucinations are put in a way to let one feels they could be subsidiary.This appears for instance in the last sentence  introducing the main category stating that ” delusions and hallucinations when present  (!!) are..Etc)

‏  Whenever one tackles the problem of typifying schizophrenia certain  basic  facts  and observations jump to his mind just as:‏

‏1-The history of the concept of dementia precox then schizophrenia is as   illuminating as perplexing.‏

‏2-If deterioration proved not to be a must in the course of some schizophrenics, this  does not mean that it is rare or even uncommon.‏

‏3-The term split usually refers to dislodgement of brain organizations or the corresponding ego states (some sort of dissociation), while the term disorganization is more relevant to structural de-association which is more fragmenting and lately disintegrating. Nevertheless both processes are mutually going along each other and the former could be the precursor of the latter.‏

‏A trial to delineate different variables that have variable weights in diagnosing  the classical types is presented here before introducing some alternative: ‏

A-Classical types could be classified  according to  :‏

‏a) the degree of disorganization    ‏

‏b) the degree of deterioration (usually, but not always, correlated with the duration)

‏c) the stage of the disease       and ‏

‏d) the ratio of : ‏

‏ i) positive / negative symptoms. ‏

‏ ii) affective / non-affective experienced  association and‏

‏iii) typical / atypical manifestations.‏

Disorganization  and deterioration has been referred to just now.‏

Table I : Classical Types of Schizophrenia

Type Simple Hebephrenic Paranoid Catatonic Schiz.Aff.
Disorg. + ++++ ++ + +
Deterioration ++ ++ + ++++
Stage Late Late Intermediate Late Early
Positive S. Few if at all III IIII II(Not overt) ++
Negative S. Plenty +++ + ++ +
Typical + +++ ++ ++
Atypical ++ + +
Affective + ++ + +++
Non-affective ++++ ++ + + +

‏”Stage”   refers to the evolution of the schizophrenic process from early (incipient) to catatonic then degenerative.The earlier stages could pass very rapidly, sub-clinical and unnoticed, like in catatonic type.‏

Positive and negative symptoms are the classical known varieties as well some further elaboration like dividing incoherence could be positive or  negative incoherence according to the associated flight of thoughts or poverty respectively.‏

Typical  refers to something like process schizophrenia and atypical to other wise‏

Affective does not refer to mere presence of affective symptoms but  essentially to the  sort of presentation and how of relating  (See before Wijdanic-Nonwijdanic dimension P)‏

‏One can notice that neither special symptoms are mentioned nor operational criteria are defined or ordered. Also no specific duration for a particular symptom or a cluster of symptoms is required as basic to diagnose schizophrenia , eventhought if they are called classical.‏

‏Some other non-classical terminology worth considering in this respect:‏

A- Some Non-Classical types:‏

1Periodical schizophrenia : is mainly related to the dimention of disorganization and not deterioration.. Most positive and disorganised schizophrenic symptoms are present during the attack but they are ready to subside without residual deficit  (See later periodical disorganization psychosis P).

‏2- Schizophrenoform psychosis is not simply related to shorter duration (e.g.less than 6 months in the DSM III) but to the presence of severe significant environmental stress along with some other neurotic or affective symptoms with better prognosis.‏

‏3-Incipient schizophrenia refers to the acutual onset (not preonset) of the psychotic process in a vulnerable patient usually in adolescence with fragile ego and possible positive family history of frank schizophrenia or severe personality disorder. It declares the intense awareness about the onset of the qualitative changes. The same signs and symptoms could usher the onset of any other psychosis e.g.affective psychosis , if they occur in the middle age with affective family history for instance.‏

‏4-Pseudoneurotic schizophrenia is usually a pre-onset phase. It refers to some definite mixed neurotic symptoms which are both atypical and resistant to management. Some lack of rapport exist as well and positive family history of classical schizophrenia or personality disorder could be met with. The term preschizophrenic states or preschizophrenic neurosis may be applied also to this syndrome.‏

‏5-Latent schizophrenia is a definite type  which uncovers its frank schizophrenic symptomatology if normal adequate stress is encountered.‏

‏6-Oligo-symptomatic schizophrenia could represent some formes frustes of latent schizophrenia. It is usually met with as residual phenomenon but could present as such from the start. Here also positive family history is helpful in diagnosis.‏

‏7-Regressive schizophrenia could overlap with oligosymptomatic, or  latent types. However the childish behaviour could be decent and adaptation at that level (e.g. play activity or free artistic expression) with no disorganization or even symptoms so long as no realistic obligation is forced upon him.  (See later regressive psychosis P ).

‏8- Sectorial schizophrenia : this newly described category by the author refers to certain cases which present with definite disorganization in one (or more) sphere or compartment while sparing almost completely the others. For instance the so called non-formal thought disorder schizophrenia is related to this group. In some schizophrenic while the motor behaviour or general appearance are unquestionably disorganised and bizarre the thought process, and content, is intact and may be superior all the time. Other times disorganization is only met with in the thought sphere in the form of formal thought disorder while none of the other disorganization manifestation is met with i.e. no incongruity, no bizarre behaviour, no facility etc.‏

‏9-Potential schizophrenia is not the least schizophrenia as a presenting clinical syndrome. The term only refers to the definite predisposition to have schizophrenia whether this is inferred from positive family history, special pointers in the early upbringing or special impoverished ego which declared definite fragility.‏

II Earlier march-oriented typifying

‏Along with introducing the structural-teleological approach  of the march of schizophrenia (1979) six clinical groups were described. In these groups, however, the traditional subtypes can be met with here or there. Such groups which are not adequately tested at large in clinical practice are presented as follows:‏

‏(1) The active biologic schizophrenias are the beginning of the split process in its early separation before the clash of the splitted portions and symptom- formation take place. It is a cross-roads situation which is failing to start a new developmental unfolding, towards macrogenic development This is replaced by psychopathogeny which  is arrested at the schizoid mode of existence  from the start. This replaces the expected marogenic unfolding of the Schizoid- Paranoid- Depressive unfolding.‏

‏This is to be considered as schizophrenia if the ambivalence, ambitendency and ambithoughts are severe enough to be handicapping associated with acute pathological hesitancy and lasting for some stable duration. This group include incipient and some periodical schizophrenias.‏

‏(2) The acute biologic devolutionary schizophrenias are characterized by acute confused and deviated unfolding from the beginning, that is associated with overt symptoms of disorganization as well as detachment. It does not simply declares the arrest of psychopathogeny and equi-cathexis of organization. It represents both the arrest and the overwhelming result of mixing and cloudedness. This stage  includes acute undifferentiated schizophrenic episodes, intermittent relapsing and acute catatonic schizophrenia.‏

(3)The schizophrenic compromise group:  includes chronic types of the paranoid, the undifferentiated and the residual schizophrenia. In all these though they show relative stability but certain symptoms of disorganization, disintegration and those of withdrawal on one had and those that defend excessive disintegration on the other are still active face to face.‏

‏(4)The regressive oligo-symptomatic type is that which can be explained trans-actionally as an active regression to the Child, partial abandonment of the Parent and disappearance of the Adult ego states. Disorganization and symptoms are thus minimal; similar to non-active regressive mania.‏

‏(5) Established deteriorated group  is that which goes well with the classic behavioral and course concept of schizophrenia. It includes deteriorated type, vegetative disintegrated and probably some of the resistant hebephrenic type.‏

‏(6) Schizophrenic Equivalents are more obvious when speaking in teleologic psychopathological terms than in clinical picture, presentation, and symptom constellations. It includes those syndromes that are some form of fulfillment of schizophrenic teleology (i.e. psychic death) through symptoms not characteristically schizophrenic e.g. personality (mostly pattern) disorder, chronic neuroses such as fixed obsessive compulsive and hypochondriacal neuroses.‏

III  Schizoaffective Disorder

Egypt. J. of Psychiat. (1982)  5: 192-194….121

An Exclusive Waste Basket or a‏‏ Specific Cross-road Devolutionary Phase

‏(A psychopathological stand point)

‏After considering schizoaffective disorder as an independent category by the DSM III (APA, 1980)  it seems logic to revise its use as a waste basket declaring our failure to diagnose neither “pure” schizophrenia nor “pure” major affective disorder in a single case.‏

‏I would like to show first what such term should not mean rather than what it can actually indicate.‏

‏1- It is not simply atypical schizophrenia where depressive symptoms or attitude seem to colour the verbal complaint of a schizophrenic patient in a nihilistic “no object” despair.‏

‏2-It is not atypical depression where declared depression lacks its genuinity, periodicity or vividness and where the apathy is acted out through nagging stickiness and occasional cruelty, a variety I have previously  called the nagging sticky parasitic depression (Rakhawy 1979).The atypical depression in the French classification (1969) is classified under schizophrenia with this label, “depression atypique” and not schizophrenia: schizo-affective depressive.‏

‏3-It  is not simple association of schizophrenic symptoms with  regressive manic-like  behavior that may be responsible for apparent pseudo-integrity at a lower level. The regressive mechanism usually hides the schizophrenic disorganization  to turn the   syndrome into either oligosymptomatic or as recently described  regressive psychosis(Rakhawy 1989).All these varieties are  not the least schizo-affective disorder .‏

‏4-Lastly, it is not simply an indication that a certain degree of emotional reactivity (particularly reactive depression) and insight, are preserved in a schizophrenic patient aware of the nature of the catastrophe he is entangled in.‏

‏Then what can a schizo-affective disorder be?‏

‏In evolutionary-rhythmic language (Rakhawy 1980) has stressed that almost all life phenomena have a  rhythmic dimension. Periodicity in health and disease is  some behavioral manifestation of such rhythmicity.The non-periodic presentation of certain psychiatric disorders (e.g. chronic neurosis, personality pattern disorder and lasting established schizophrenia) are but some lasting complications (malorganization rather than active disorganization) of failing or aborted periodicity.‏

‏Schizo-affective disorder is to be approached and conceptualized as a specific periodic pathological presentation of  certain degree of disorganization along with partially successful affective defence. This is some sort of exaggeration of periodical partial unfolding which is both aborted and handicapping. ‏

‏To delineate more , this disorder usually refers psychopathologically to:‏

‏1-A definite periodic tendency to disorganize rhythmically (the  pathological aspect of the physiological  rhythmic de-organization in dreams  or in growth crises).

‏2-Simultaneous trials are set up to be ready to prevent undue   exaggeration in this tendency. This is established either by putting more control (=depression: through repression and awareness, of intolerable psychic pain) or by undermining denying and bypassing the threatening disorganization (=mania: through dissociation, acting out, or regression).

‏As such, both schizophrenic (disorganizing and disorganized) symptoms and affective ones are not mere associations or secondary to one another. The former is declaring the degree of disorganization that succeeded to be available as behavioral symptoms while the latter represent the partial success to control further disorganization by utilizing mechanisms responsible for affective disorders.‏

‏In healthy growth crises, de-organization of the old pattern of existence (with its corresponding neuronal and molecular organizations) is an indispensable step in the way to establish reorganization at a higher level. This is usually established along with tolerance of psychic pain as well as a certain degree of adaptive regression (sometimes known as ARISE: (Adaptive Regression in the Service of the Ego). Under unfavorable conditions the de-organization becomes disorganization, the psychic pain augments to depression and the regression to mania. In other words, using evolutionary rhythmic language, schizo-affective disorder is “the genuine pathological unfolding” that represents three dimensions simultaneously:‏

‏a-Manifestations of failure of pre-existing normal organization,  ‏

‏b-Signs of partial arrest at the  disorganization stage and,

‏c-Simultaneous reactivation of   depressive  and/or manic compensatory organizations.‏

‏This reorientation may open the door for considering the schizo-affective phase of evolution of psychopathology as the mother cross-road phase of most psychiatric syndromes (especially the so called functional psychoses).

‏The possible alternative roads are not simply either schizophrenic or major affective disorders, but any other one.‏

‏The periodicity of the schizo-affective manifestations, with the least residual deficit during remissions declares the failure to pursue a deteriorated course, or otherwise a pure affective periodicity. In other words, it indicates a reactivated periodicity that seems to represent a compromise between partial integrated personality and an aborted disorganization along with a partially successful affective defenses.‏

Further elaboration ( 1989)

‏After publication of this editorial certain developments have occurred that are worth mentioning:‏

‏1-In the ICD 10 (draft 1988) the schizo-affective disorder was suggested to be included under the affective disorder but this was again undone to let it go back to the schizophrenic disorders.‏

‏2- The author has described four functional psychoses that worth considering as independent variants i.e. regressive psychosis, periodical disorganization psychosis, dissociative psychosis and obsessive compulsive psychosis .(Rakhawy , 1989). The periodical disorganization psychosis is most near to the schizo-affective disorder, even though there are no frank affective symptoms. This does not necessarily mean that periodicity per se is to be considered as an affective phenomenon although it could be wise to do so.‏

References:

‏American Psychiatric Association (1980) Diagnostic and Statistical Manual of Mental Disorders (DSM III). Washington: The Association. French Classification (1969)Unpublished document,Personal communication.

‏Rakhawy, Y.T. (1979) The evolutionary value of tolerance of depression  Egypt. J. Psychiat   2: 138-144‏

‏Rakhawy , Y.T. (1980) Selected Lectures in Psychiatry (Unpublished post graduate lectures. Faculty  of Medicine Cairo university).

‏Rakhawy,Y.T. (1989) Four more Functional Psychoses : (to be considered independently). Unpublished document

IV Along the Schizophrenic Spectrum.‏

(Dislodgement-Disorganization-‏

Deterioration Continuum)

Egypt. J. of Psychiat. Oct. 1992

{This scaling could be out of use if the mutidimensional approach is adopted}

‏The concept of schizophrenia is still as controversial as it has ever been. Neither the criteria-oriented approach nor the effort to classify into definite types and categories have succeeded to add adequate information that could answer questions like whether schizophrenia is one disease or more, (Okasha, 1980), is it exclusively a chronic disease with remittent course and exacerbations or could it be acute and reversible. (DSM III Vs. DMPI and ICD 10)The late inclusion of personality disorders-like syndromes and atypical affective disorders with schizophrenia in one category; adds to the confusion. The delineation of schizophrenia into a chemical type I syndrome and an organic type II syndrome is a step towards identifying deteriorated, relatively irreversible type from the disturbed possibly reversible one. However, this delineation did not show clearly neither the possibility of type-shifts nor the structural psychopathological differences.‏

‏Another source of confusion is the tendency to take disorganization and deterioration as synonyms. This is not the least true (Rakhawy, 1990).

 ‏Delineation of positive schizophrenic symptoms from negative ones is another dichotomy that points to some implicit differentiation between disorganization and deterioration.‏

‏The DMP I (1979) states that schizophrenia “……..  Includes a group of disorders representing (a) the evolution of a disorganizing psychotic process and      (b) the end result of this process in the form of personality deficit or deterioration. The heterogeneity of the group comes from the various presentations of different stages. The presence or absence of specific symptoms depends on the type”. Evidently, this means that certain types are more related to disorganization than deterioration (e.g. hebephrenic, paranoid and type I) others are more related to deterioration than disorganization (ICD 10) e.g. simple, catatonic and type II or non-paranoid variants.‏

‏The present hypothesis is a trial to add an independent dimension over and above the traditional typifying according to the circumscribed operational criteria. Its application depends on the holistic clinical judgement rather than gathering circumscribed symptoms. The three main types refer to three stages of the schizophrenic march.‏

‏In structural terms the three main groups refer to dislodgement-disorganization-deterioration continuum (Rakhawy 1979, El-Katheri 1990).

‏The early active type A is more related to active Schneiderian symptoms while the relatively compromized type B  is more -related to Bleuler”s concept of split and the deficit-deteriorated type C to the earlier negative Morel- Kraeplin”s concepts of dementia precox.‏

‏It is always possible to meet with mixed forms which could be referred to in capital/small letters such as Ab or Ba. Less commonly the march passes from A to C and forms like Ac or even Ca are rarely met with. Certain clinical training is essential to achieve a valid degree of consensuality among raters. The following is the suggested clinical profile of the suggested syndromes along the schizophrenic spectrum from structural stand-point.‏

‏This hypothesis, if proved practical and valid would have a direct bearing on both management and prognosis. Biological monitors and parameters are expected to differ significantly.‏

Type A Schizophrenia (Predominantly Schneiderian)

‏The patient is actually living the schizophrenic process which is directly and genuinely experienced at a certain level of awareness. Simultaneously, he is unable to tolerate the changes going on. The experience, remains peculiar, inexplicable and beyond the previous range of his normal perception. There is usually morbid, rather painful, yet genuine hyper-awarenesswith bewildering astonishment to such an extent that the individual begins to be uncertain about the nature of the experience itself.‏

‏Regardless of how detailed, defined and rich the  patient describes what he experiences, he still complains of a definite discrepancy between his verbal expression and the actual  lived phenomena. i.e., he senses a degree of inability to describe what is actually going on.(this is usually misnamed: perplexity).

‏The patient may express a fear of impending madness, loss of the self or loss of control. He might be aware of loss of his sense of self unity (wholeness or oneness,) yet he presents behaviourally as some whole person with only subjective sense of duality or multiplicity. ‏

‏The patient as a whole is rather warm, near and affectively resonant. The total psychic clinical picture is continuously stirring and changing in an unceasingly searching procession. Patterns of presentation of symptoms is obviously variable and oscillating.‏

‏Delusional elaboration is minimal and evanescent; hallucinations are vivid with minimal projection. Experienced positive symptoms predominate.‏

‏Although the patient gives enriched and distressing accounts of various deficits in volition and feelings such as inhibition of will or emptiness of feelings,  these subjectively experienced changes are not actualized into observable behavioural patterns. ‏

‏Generally, the prevailing symptoms are: a) experienced Schniederian symptoms, and b) some positive  (productive) symptoms‏

Schneider’s ===>Bleuler s====>Kmeplin ‘s Diseases
Early activeSchizophrenia

(Schneider’s )Split compromizedSchizophrenia

(Bleuler’s)Late deficit

Schizophrenia

(Kraeplin ‘s )Timing             Early in the processRather lateMuch more   lateStructure: Disoldgement  +++ Disorganization  +++ Deterioration +++Symptoms Experienced    as part CircumscribedNegative   symptoms(as a whole)

 of the whole existenceposi­tive (as a Foreign body)more (deficit) 

 

 

 

 

 

 

 

Affect:

 

 

Hallucinations:

 

 

Thought process:

Thought     posses­sion e.g.

Thought    content

e.g. delusions.

Insight

 The patient presents as a whole personaware of something new making him not that ONE.

Varying description of experience   &  symp­toms.

Affective tone rather than affective symp­toms

Hallucinations       are

usually    from within

(e.g inner voice)

Thoughts   are     just loose but rich and viv­id

Influence    or    with­drawal    are    experi­enced and reacted to.

Delusional perception,(experience)

 The patient loses hisONENESS    and acts, as a result [=> contra­dictions^ambivalence)hesitancy etc].

The same symptom is

usually described the

same way.

Affective     symptomsassociated, not colour­ing

Hallucinations    comefrom   definite figurese.g persons

Thoughts   moderately active    and    discon­nected ( +ve incoher­ence)

Influence or with­drawal are intellectu-alized (a delusion)

Delusions are fixedideas (intellectualized)The patient is no more a whole or ONE He is but fragmented rem­nants of a person (+ multiple sutistic egos)

blunting

Symptoms    are  pre­sented in chaos rather than described by pa­tients.

Incongruity, & apathy

Hallucinatory behav­ior, if any, more overt and acted out.

Poverty of thoughtsfragments widelyapart & vagueness (-ve incoherence)

The effect of in­fluence (if any) isseen more than com­plained of.

No de-

lusions,or  superficial

and fragmented not in

Insight    lost, focal

 Partial     insight  with   Insight   lost but the  casual or special

 Type B Schizophrenia (Predominantly Bleulerian)

‏The lived in  schizophrenic experiences become predominantly alienated, mainly through delusional elaboration and intellectualization. The sense of self-unity is subjectively reclaimed, at the expense of actual integrity and oneness. The split into distant contradictory organizations, presents as projected alienated symptoms. The strange and alien quality of the schizophrenic process, the puzzlement and uncertainty experienced by the patient give way to undoubted delusional elaboration or sometimes an outpouring flow of intellectualized narrated descriptions. Genuine hyper-awareness is replaced by fruitless introspection which may be partially limited and distorted through delusional elaboration. Although attempts to establish contact with the patient may be initially or apparently successful, the relating distance remains fixed. Affective colouring of the patient”s presentation is fading away. Well defined disturbances of mood may be an associated finding as circumscribed symptoms. Occasionally, the prevailing mood may be one of silly cheerful indifference or empty monotonous brooding. The total psychic clinical picture settles down from unceasing shifting procession to a rather stable and stationary stand still. Symptoms become more delineated and crystallized,fixed and consolidated. i.e., the same symptoms are likely to be described the same way at different occasions.‏

‏Volitional impairment is in the form of parabulia  (inability to decide due to cross and counter volitional impulses) rather than abulia  (lack of volition due to no decision).

‏Disturbance of affect takes the form of para-affectivity.  (ambivalence and rapid fluctuation of emotion) rather than a- affectivity. (apathy and emotional flattening).

‏The same applies to thinking paralogia. (e.g., overinclusion) rather than alogia. (poverty of thought).

‏Generally, the psychic phenomena which were predominantly subjectively experienced become more actualized into observable behavioural patterns.‏

‏The prevailing symptoms are: a) Intellectualized (rather than experienced or lived-in). Schneiderian symptoms (their absence is not infrequent). b) Positive Schizophrenic symptoms (are moderately presented. and, c) Minimal or moderate negative symptoms.‏

Type C Schizophrenia (Predominantly Kraeplinian)

‏The patient”s personality is rather shattered and destroyed he is cold aloof with almost absence of relating distance. He is quite dull and inert with diminished productivity and cessation of initiative and spontaneity. He is shut in and withdrawn, living entirely in a world of his own.‏

‏The total psychic clinical picture is stagnant and barren.  There is an almost robot-like fixity and petrification (stiffness) of attitudes and reactions. Symptoms become, monotonous, repetitive and stereotyped. They are fleeting in character, poorly worked out and presented with uncomplaining acceptance. The whole psychic functioning is invariably characterized by poverty or insufficiency. Volitional impairment is in the form of abulia, the same applies to thinking and affect (alogia and apathy) rather than parabulia, paralogia and para-affectivity.‏

‏The patient remains quite dull, experiencing neither fear, hope, wishes nor desires. Besides this emotional dullness, his expression is empty and vacant displaying no emotional depth.‏

‏Generally, the prevailing symptoms are: a) Pale positive schizophrenic symptoms. b) Moderate or marked negative symptoms. And, c) Symptoms declaring residual deficits and adaptation at a lower level.‏

References:

‏American Psychiatric Association (1986). Diagnostic and Statistical Manual of Mental disorders. (Revised 3rd ed.) DSM-III-R Washington, DC: APA.‏

‏Andreasen, N.C. (1982) Negative Vs positive Schizophrenia. Arch. Gen. Psychiatry  39, .789‏

‏Egyptian Psychiatric Association (1979) Diagnostic Manual of Psychiatric Disorders  (DMP-I). Cairo: The Association.‏

‏El-Kutheri, A. (1990) Phenomenology of Schizophrenia. (Unpublished thesis). Kasr El-Eini Faculty of Medicine Cairo University Cairo.‏

‏International Classification of Diseases 10th Extract from clinical Descriptions and Guideline at chapter V (F). Mental, Behavioural, and Developmental Disorders (Draft 1990).

‏Okasha, A., (1980) “Is Schizophrenia More than one Disease?” Egypt. J. Psychiat., Vol. 3 No .2‏

‏Rakhawy, Y. (1979) Study in Psychopathology (The secret of the Game) Cairo: Dar El-Ghad. (In Arabic).

‏Rakhawy, Y. (1990) Illustrative Lectures in Psychiatry, Kasr El-Eini Faculty of Medicine Cairo.‏

Psychotic/Non-Psychotic Dimension(& Six Psychoses worth considered as independent categories).

‏The term psychosis is  getting to be more and more ambiguous. In spite of the fact that it is more used than the term neurosis in recent nosological disciplines, it is less used than has been before. Psychiatric syndromes do not stand any more such dichotomy into either neurotic or psychotic. In the DMP I while psychotic disorders are predominantly described in behavioral descriptive terms the only category (among sixteen main categories) called neurotic is described basically in terms of predominant mechanisms i.e.dynamic language. However many categories are having labels (and adjectives) not necessarily qualifying them as being psychotic or not. For instance in the DMP I terms like illness (Manic and Depressive Illnesses, 06), or states (Paranoid states, 08) or Disorders (Psychiatric Disorders with Epilepsy, 04) Personality Disorder, 11) or without any  qualification (Schizophrenia, 07).

‏The only well delineated categorization  between what is psychotic and what is non-psychotic is met with in the two categories related to Organic Brain syndrome (i.e. 02 and 03 : Psychosis associated with Organic Brain syndrome and Non-Psychotic conditions associated with organic brain syndrome). This agrees with, and actually had been derived from both the DSM II and ICD 8.

‏Against all the expected advance in the direction of identifying more axes that would be prognostically significant and therapeutically useful, a clear cut delineation between psychotic and non-psychotic is generally lacking  in the DSM III and its revision as well as from the available drafts of the ICD -10.

‏In medicolegal practice, particularly in Egypt, being labelled as neurotic or personality disorder is a criterion to consider the accused, on the part of the judge, as “responsible” regardless the severity of his condition or the degree of handicap.‏

‏The recent trend to discard the dichotomy between organic and functional mental disorders simply on etiological basis adds to the problem. Using the term functional psychosis is, then, getting to be less exclusive and poorly inclusive. It also devaluates the added category in the DMP I known as “Other Functional Psychoses”. ‏

‏Extra effort is needed in a trial to define what is psychotic . One, then,  can describe any psychiatric syndrome as psychotic or not psychotic regardless the original label whether a disorder, a misconduct,  a state,  an illness or without any qualification. ‏

A disorder is psychotically severe if the following criteria is met with (and not the mere presence of such and such symptoms):

‏1- Severe alteration of the personality organization as a whole (this includes either disorganization or malorganization or both).

‏2-Detachment from, mutilating or replacing reality.‏

‏3-Severe lasting handicap in the domain of productive performance and social relation as a result of the psychiatric disorder.‏

‏4-Definite danger to the individual and/ or his surroundings as a result of the existing psychiatric symptoms or psychopathology.‏

‏I am not going to identify how much of this and for how long (as we expect after being habituated to the DSM III language).

‏ Certain basic consideration worth mentioning at the outset in this stage of introducing such criteria.Two main  ones are to be forwarded:‏

‏a-Psychosis is not simply, as the DSM III usually stresses over and again, related to the presence of delusions and hallucinations, particularly if  the above mentioned four criteria are evidently  lacking.‏

‏b-In the DMP I In a trial to redefine psychosis, in the section of Organic Brain syndrome he onset of psychotic transformation, ushered by mis-evaluation of perception has been stressed with the rationale that declaring the onset of psychotic process could avoid misconception met with in the DSM II and ICD 8 like labelling a schizophrenic disorder (e.g.simple type)  as non psychotic. We were then after the idea that schizophrenia could never be non-psychotic. This trial on the part of the DMP I proved to be most perplexing and least helpful. Unless this mis-evaluation proceeds to fulfil the four above mentioned criteria for delineation of what is psychotic, it is not justified to consider this early alteration as psychotic.‏

‏It seems not only  fair but also necessary  to speak about psychotic intensity of any cluster of  psychiatric symptoms resulting in a degree of handicap that fulfills the above mentioned criteria. This means that we can add a psychotic (or non-psychotic) adjective to an

y psychiatric syndrome regardless the classical label it may harbor. This has been directly reported in relation to some grave types of hysteria where the DMP I recommended to put it under psychotic categories (09). It is worth quoting the words of the DMP I, even though they are a little bit detailed.” Sometimes the hysterical reaction persists and increases to the extent that  it interferes with the patient”s mental functions as a whole. In such cases the reaction surpasses the secondary gain and definite regressive mechanisms dominate the picture resulting in actual disorganization

Psychotic <==> Non Psycotic

Not Not mere presence of delusions and /or hallucinations.(DSM-III & ICD-10 tendencies

Not necessarily bizarre

Not just opposite to neurosis.

Not necessarily irresponsible(medico-legally)Not synonymous with neurotic

Not exclusive to his-to-pathological organic etiology i.e.

Not always dynamically determined.

 ButEssentiallyDisorganization(or radical negative alteration) of the personality.Detachmentfrom (or severe mutilation or replacement of) reality.Major handicapin actual psychic performances

Minimal signs and symptoms not amounting to any of thesemajor criteria=(severe:Detachement & handicap)

of the personality, the adaptation is markedly impaired and reality is distorted and falsified and insight is almost lost. These cases acquiring such psychotic qualities may deserve to be classified under psychoses (09)”. The DMP I added that if the cause of such sever psychotic reaction is proportionate to the intensity of the reaction and the situation is directly responsible it could be labelled as chronic reactive and situational psychosis. If not, otherwise it may deserve a new category “.‏

‏It is  time to go a step further to describe any syndrome in terms of its possible  psychotic intensity. When such qualification (e.g. psychotic) recurs as part and parcel of certain presenting syndrome it may be logic to have an independent label as psychotic and to be described and diagnosed separately. This has been originally the basis on which the category “other functional psychoses 09″was put  (DMP I) to include whatever syndrome that prove to be of psychotic intensity but is still not possible to be considered  organic, schizophrenia, affective or paranoid psychosis. However the subcategories included are very poorly defined neither as exclusive nor as inclusive particularly the acute confusional psychosis. Other subcategories included under this heading are polymorphic, situational or waste basket. ‏

Psychoses worth considered as independent categories.‏

)These added categories could be only used  if the multidimensional approach is not applied).

‏ During the last three decades of my clinical practice I have been acquainted with  six, relatively delineated psychoses, which are worth introducing as independent variants different from other traditional ones (i.e. schizophrenia,paranoid and affective psychoses etc…). Of course in this short introductory note there is no place to show in any detail the rationale of their independence or to demonstrate some case reports. I found that separation of these categories has its advantage both in therapy and in medicolegal practice by all means.I hope that I can develop and demonstrate each of them in details in the near future.  The following are but the headings and the broad lines:‏

1-Dissociative psychosis:‏

‏The concept of dissociation is basic in the history of psychiatric psychopathology. Starting from physiological dissociation in sleep and dreams up to molecular dissociation in schizophrenia (disorganization) we can identify this split of the unity of the stream of consciousness into some two or more parallel, stratified or alternating levels or sub-streams. If such split occurs without lasting disorganization detaching the individual from reality relations and function it is usually described as dissociated hysteria (as a neurotic disorder) . If such dissociation lasts and severe one or more criteria of psychotic intensity mentioned above are fulfilled the term dissociative psychosis is justified. Conversion in a sense is considered as a variant of dissociation and could be dealt with on the same grounds.‏

‏Diagnosis of dissociative psychosis  is justified when the mechanism of dissociation is mainly responsible for the psychopathology without resulting in neither one of three main psychotic schizophrenia manic depressive psychosis or paranoid psychosis. Dissociative psychosis shares with schizophrenia the phenomenon of split (Bleuler”s disease) but the affect is definitely preserved and the split is rather longitudinal as well as (or more than) transverse and there is no tendency to deteriorate. ‏

‏Schneider”s symptoms could be met with and they are typically dissociative symptoms where the dissociated egos are not widely apart. They present in dissociative psychosis more asexperience than as delusions.‏

‏Structurally dissociative psychosis is more related to manic depressive illness. Dissociative mania have been described by the author (Rakhawy 1979) and confrontation between two molar organization is the basic structural psychopathology of depression. However the typical disturbed affect is lacking and periodicity is not that frequent although recurrence is not infrequent.‏

2Regressive psychosis:‏

‏In many cases of schizophrenia and less frequently certain types of mania and still much more rare of depression, when regression is allowed either spontaneously by some dependable surroundings or intentionally in a therapeutic milieu, the symptoms of original psychosis disappear at least temporarily. If this regression is not well assimilated in the service of the ego in the natural therapeutic process, the original symptoms are liable to recur once the regression is denied and reality obligations are forced upon the patient. ‏

‏This observation has attracted our attention to search for such regressive syndrome as a first hand presentation in clinical practice. I have found that certain current, relatively old labels could prove to be justifiable under this new category. Latent schizophrenia oligo-symptomatic schizophrenia, some residual states, some of the severely handicapped inadequate personality disorder and the regressive nonproductive mania are but examples.‏

‏Diagnosis of regressive psychosis is justified if the handicapping dependency has paralyzed the personality up to self harm and denial of reality. The affect is usually preserved on childish level with minimal other severe positive so called psychotic symptoms (i.e. delusions and hallucinations). In other words the main defect in this type of psychosis is the disruption of the relation to reality through absolute dependency.‏

‏ The personality looks integrated  and the affect preserved so long as regression is allowed. Once regression is denied and dependency is threatened personality disorganization or other psychotic symptoms like delusions and hallucinations would appear.This type is to be differentiated from personality disorder by the fact that the personality disorder (e.g inadequate type) is not that ready for disorganization and for production of positive psychotic presentation under normal stress when regression is over. However teleologically they could be considered one and the same.‏

3-Disorganization psychosis:‏

‏This category stems in my clinical practice from two main sources. The bouffee delirante of the french psychiatry (corresponding partly to acute undifferentiated psychosis 09.0 DMP I) and the  active schizoaffective schizophrenia (see before). Disorganization is a severe degree of multiple splits of the personality structure. It could be met with  as across roads  mother category along the march of development of different psychoses or rarely before major growth unfolding. Although disorganization could eventually lead to deterioration it is not the least synonymous or a definite precursor to deterioration. This goes with the ability of this type of psychosis to subside without lasting deficit. As such, diagnosis of of schizophrenia would be postponed if the only feature is disorganization with certain pointers to the possibility of reintegration without residue. ‏

‏To diagnose this category the basic criteria for psychotic intensity should be fulfilled particularly that related to massive disruption of personality structure. ‏

‏It was also  observed that this delineated category frequently occurs in a periodical pattern to remind us with some variants of the cycloid psychosis of Leonhart. Not infrequently they do not only remit without deficit, but some cases could achieve higher level of adaptation if properly managed. This may be related to the possibility that disorganization if temporary and periodical is more similar to physiological de-organization in dream activity. As much as dream activity is repatterning and consolidating such periodical behavioral disorganization, if proper chances are allowed is liable to permit repatterning i.e.reorganization on a higher level than if the periodical activation have acquired some definite depressive or manic defenses. However this does not mean that we are allowed to let disorganization last more than it could be assimilated or even to welcome such degree of disorganization even though if it is periodical or has a history of a similar one that subsided completely.‏

‏Structurally it is more related to active schizophrenia but management wise it is more related to affective disorder. Sometimes, the warm type of the so called disorganization anxiety mentioned before could be related to this type of psychosis.‏

‏ The main features of  periodical disorganization psychosis is the presentation with predominant disorganization, preservation of the personality warmth and relatedness. The history of a previous attack of similar nature (or of affective or paranoid periodical illness) and the positive family history of periodicity as a whole (and not only  periodical affective illness) are factors that could favour more and more this diagnosis. ‏

4Affective (periodical) paranoid psychosis:‏

‏The DMP I has included acute and subacute paranoid states with the various types of chronic paranoid states under the same category i.e.paranoid states .08 This is absolutely unfair. The two main groups (acute and subacute as one group and the chronic as the other) are completely different in dynamics, structure, management and prognosis. While the former  (acute and subacute) is produced through  uncovering of present paranoid intrapsychic organization manifesting in interpersonal paranoid modes of relating the latter (chronic) is a deliberate stablestructural transformation  based on slow process of delusion (or hallucination or fantasy) formation that becomes part and parcel of the personality structure though still presenting as symptoms both ego alien and partly ego dystonic.‏

‏The term affective is added here to refer to the preservation of affect as well as the tendency to periodicity and the partial response to BSt (ECT) and antidepressant in the same way affective disorders do. ‏

‏To diagnose such type the basic psychotic intensity is fulfilled, the delusions look to be uncovered rather than newly formed, the affect is congruent with the delusions but not necessarily secondary to them and the personality is integrated and the interpersonal relating is preserved through and in spite of the active delusions or hallucinations. Once again it could be conceptualized as a variant of cycloid psychosis of Leonhart.‏

5Impulsive Psychoses:‏

‏The short lived psychotic episodes that may occur in normals, in personality disorder patients (particularly in explosive or stormy personality), in other  psychiatric disorders are well known. It is usually met with as a challenging medico-legal psychiatric problem. However in clinical practice it should be considered here along with our trial to delineate some other psychoses. Occasionally, we have this severe attacks of disorganization, detachment from reality and not infrequently impulsive destructive acts towards oneself or others while the individual is relatively intact in between the attacks. This particular type of episode is not usually associated with amnesia, although consciousness may be altered but rather qualitatively than quantitatively.‏

(Remembering that in any active psychotic process due examination of the quality of consciousness should always reveal certain qualitative change which is usually overlooked in normal routine behavioral gathering of symptoms).

‏That these episodes are psychotic in terms of holistic personality disorganization, detachment from reality and occasional disinihibition needs no further proof. The question is:  since such episodes do not last and the patient in between is rather normal and not the least handicapped, are we justified to label such behavior as an independent psychosis or just as some severe personality trait or episodic disorder. For the sake of management, which is usually extremely  difficult, and for medicolegal purposes it  is worth the label: Impulsive psychosis.‏

‏This type of psychosis  could be partly related to dissociation psychosis. The content of the psychotic impulses may take other forms than disorganization or impulsive acting out. It could be in the form of short lived paranoid episode, ultrashort attacks of mood changes or   irrational thinking. This had made some investigators to suspect the epileptic nature of such attacks. I am not inclined to refuse such proposition provided that the epilepsy is taken in its profound nature in relation to the biorhythm and the meaningful unfolding of energy (Rakhawy, 1979).

‏Diagnosis of impulsive psychosis  is justified, then, if the personality in between the impulsive psychotic attacks is normal.Also the attacks themselves should be persistently recurrent and the contents should be psychotic acquiring the above mentioned criteria whatever shortly they could last.‏

6Obsessive compulsive psychosis :‏

‏Viewing the obsessive compulsive phenomenon to acquire, at times, definite psychotic intensity has come to my awareness through two main sources. The medicolegal challenge of assessment of volition as well as some fatal cases of anorexia nervosa where compulsion was the leading symptom.‏

‏ The main problem in the obsessive compulsive syndrome is the volitional impairment. The personality is usually intact (not the least disorganized) and the relation to reality is preserved as far as the  perception, insight  and initial judgment is concerned. In order to consider an obsessive compulsive syndrome as psychotic the impairment of volition and subsequent danger to the self or the others should be severe, rather absolute, to compensate for the lacking of the two other main criteria of psychotic intensity. However it seems not sufficient to perceive reality as it is or to judge an act as abnormal in order to guarantee a good contact with reality. It seems to me that the efferent limb of the relation to reality should be taken as important as the afferent one. This efferent relation with reality in such absolute cases of compulsion endangering not only one’s adaptation but also one’s life (and / or others”) should be considered in such cases as severe degree of impairment of relation to reality . ‏

‏To diagnose  obsessive compulsive psychosis the obsessive phenomenon should be identified in a crystal clear way and then the consequences of this ‏

‏phenomenon, particularly in relation to volitional impairment should be assessed to be psychotically intense. However the classical pattern of obsessive script formed of : idea-resistant-tension and execution then again, is usually altered in such cases reaching psychotic intensity. The resistance could be cold and the tension may become dull and diffuse (not related to the particular act or resistance).

Closing:‏

‏If we admit that the ultimate goal it is not a matter of the presence or absence of such and such symptoms together but it is  what follows after putting a particular label on some patient I believe that what have introduced in this paper would permit:‏

‏a- To add an independent adjective (or axis!!) to any syndrome regardless its history or front.‏

‏b-To minimize using schizophrenia and/or affective disorder as the alternative to the absence of one another.‏

References:

‏Rakhawy, Y. (1979) Study in Psychopathology. (The secret of the Game) Cairo: Dar El Ghad   (In Arabic).

Organic-Functional  Polarity  

A Fading Illusion

Abstract

‏ The discovery of organic basis of the so called functional disorders does not mean that they are, or could be considered as, one and the same as organic disorders. On the contrary this significant objective information about the organic nature of all psychiatric disorders on whatever level represent a new challenge asking for real search for the profound differences between the two main categories of psychiatric syndromes. ‏

‏A trial   to delineate one from the other on some more existentially significant (still biological) basis is given in this paper. It has been shown that it is not a matter of where is the brunt of the specific handicap  or deficit. What counts is the basic differences in the biological setting, the level and nature of pathology,  the existential meaning, the march of handicap and the how of organization. This would, ipso facto, influence research criteria, management and prognosis.‏

‏For  the so called organic*  disorders  the term Discomposition-Deficit  disorders is suggested  to  refer to the type of  basic pathology as well as the nature of the derangement. The term discomposition  refers more to  the dissolution of the holism of the matrix of consciousness while the term deficit  is more related to the specific handicap resulting from destruction or outfall of neurones in a particular domain  or locality.‏

‏On the other hand  the term Organizational -Goal seeking  is used here to replace the dyeing term functional.. It is intended  to emphasize the fact that such disorders are but pathological reorganization on some other level of existence (and corresponding neuronal patterning) to achieve some goal which is still pathological ‏

‏  It seems  high   time  to face  the  failure  of  the  current   nosological disciplines to show the actual basic qualitative differences between what is known (or used to be known)  as functional  psychiatric disorders and those known as  organic   psychiatric disorders.‏

‏In this context the word functional  is becoming least exclusive. All psychiatric disorders are but functional disorders. At the same time  almost all members of what is labelled functional disorders are proving to have some more or less underlying pathology (extending the word pathology to include chemical pathology (Lipowzki, 1986).The current flood of  researches giving  relevant etiologies for the functional syndromes (Trimble, 1988), particularly psychoses, seems to favour  the  other face of the illusion i.e. mixing such two main categories.‏

‏The word organic  does not, any more,  refer simply to some outfall of neurones or loss of myelin sheath. By the galloping advance of the  recent technological devices in the field of psychiatric research along with the   hierarchical ordering of somatic organizations we come to identify the organicity at multiple interrelated levels. We can identify certain   chemical pathology (particularly in relation to synaptic transmission), physical  (rather physiological) pathology ( in relation to electric activity and biorhythmic disturbances) in addition to the  well known cellular pathology  (e.g. neuronal loss and demyelination). All such phenomena are but organic alterations of brain structure that are directly or indirectly related to almost all psychiatric disorders. ‏

‏The more recent trend to classify categories according to the essential presenting behavioral syndromes (considering organic disorders as basically cognitive disorders  while other disorders are basically mood thought or personality disorders and the like) (Spitzer 1988) would throw more and more shadows that invite mixing and confusion.‏

‏ It is not a sufficient to identify of where is the brunt of the specific handicap or deficit. What counts is the basic differences in the biological setting, the level and nature of pathology,  the existential meaning, the march of handicapping and the how of organization. This would, ipso facto, influence  prognosis and management as well as research criteria. As a matter of fact the actual status of psychiatric classification needs now, more than at other time, delineate more rather than  interpenetrate  these two main categories.‏

‏ To clean out some adequate clear area in between the two main categories in the process of contrasting, one has  to omit altogether the terms functional and organic as opposing poles. Nothing that influences the psyche or appears in behavior could be other than organic some level or another.‏

‏Essentially, one has to  keep in mind the following basic facts and observations:‏

‏1-Organic cellular pathology is to be   delineated from organic chemical pathology (and to a lesser extent from: organic physical pathology  e.g. in epilepsies).

‏2-While the causal relation, is almost always  clear in Type I* disorders (Ex- organic) it is much less so  in  Type II disorders (Ex-Functional).‏

‏3-Disruption (and failure to perform) is to be distinguished from avoidance and rather  intended (at some level of existence)to refuse  or refrain  to function.

4-Secondary mechanisms on top of  Type I disorders are usually   more related to Type II (e.g.obsessions and orderliness in certain dysmnesic syndromes) (Lipowzki,1975). On the other hand late stages of some prolonged disuse and malorganization of certain variants of type II disorders is more related to type one (e.g deteriorated schizophrenics).

‏5-Teleological causality  is as relevant and differentiating (or even  more so)  as deterministic one (Rakhawy, 1979).

‏Moreover, certain  NOTs  should be emphasized in the process of  such differentiation.‏

‏1- It is not  only a matter of mere presence or absence of some organic disturbance of whatever  nature.‏

‏2-It is not  a matter of  detection of some definite cognitive deficits.‏

‏3-It is not  a matter of identifying some quantitative  consciousness disturbances.‏

‏4- It is not  a matter of disturbance of function simply with undetectable structural derangement.‏

Basic differences

‏For type I Disorders I suggest  the term Discomposition-Deficit  disorders hoping to refer to the type of pathology as well as the nature of the derangement. This would include  what has been called organic disorders.The term discomposition refers more to  the dissolution of the holism of the matrix of consciousness while the term deficit is more related to the specific handicap resulting from destruction or out-fall of neurones in a particular domain  or locality.‏

‏On the other hand  the term Organizational-Goal seeking  is used here  to emphasize the fact that such disorders are but pathological reorganization on some other level of existence (and corresponding neuronal patterning) to achieve some goal which is still pathological.The search for the meaning or the goal should go beyond, although directed by,  the overt symptoms. For instance, the apparent chaos of disturbances in schizophrenia are not without meaning although it  usually overshadows the underlying coherent  goal seeking primitive devolutionary activity‏

Type I Discomposition*-Deficit Disorders  (currently  known as organic) are to be identified by the following basic criteria:‏

‏a-Known  causally linked organic etiology is usually detectable.‏

‏b-Such pathology is mainly of cellular (frequently  microscopical) nature and  usually just precedes the appearance of symptoms and could be localized in certain cases.‏

Discomposition-Deficit D. Organizational Goal-Seeking D.
(Ex-organic Mental D.) (Ex Functional or Psychology)
a-           Known causally linked organic etiology.

b-          Pathology is mainly of cellular (frequently microscopical) nature and usually just precedes the appearance of symptoms and may be localized.

c-           Minimal (indirect, or secondary) chemical pathology could be also detected, but is not the essential derangement.

d-          Such disorders lack understandable teleology.

e-           The subsequent handicap is directly or indirectly related to the deficit or discomposition.

f-            If certain secondary mechanisms set in, they are determined basically be the original deficit but the have of reorganization could take more or less the same patter as in type II disorders.a-Cumulative (interacting, ill fined) etiological factors (with without precipitation).

b-Possible chemical pathology, with or without definite causal links.

c-Understandable teleological cause (meaning, goal, …etc).

d-Handicap related to the teleology as well the predominance of another level organization (i.e. lower, primitive regressive).

e-If this handicap is prolonged malorganization or disorganization established, possible organic cell pathology may complicate the picture due to some disuse and consequences lasting deficit.* Mixed or intermediate disorders are those disorders that have combined or contradictory qualities of either categories such as some psychiatric manifestations of epilepsyc and organic delusional syndrome.

‏c-Minimal (indirect, or secondary) chemical pathology could be also detected, but is not the essential derangement.‏

‏d-Such disorders lack coherent understandable teleology.‏

‏e-The subsequent  handicap  is directly or indirectly related to the deficit or discomposition.  ‏

‏f-If certain secondary  mechanisms set in, they are  determined basically by  the original deficit but  the how  of reorganization  could take more or less the same pattern as in  type II disorders.‏

Type II  Organizational Goal-seeking Disorders (so called functional) (Rakhawy,Y. 1981,1980,1979 and 1984).

‏This main category could be identified by the following:‏

‏a-Cumulative (interacting, ill defined) etiological factors (with or  without precipitation.

‏b-Possible chemical pathology, with or without definite causal links.‏

‏c-Understandable teleological causality  (meaning, goal,..etc).

‏d-The handicap of functioning is partly related to the teleology as well as to the predominance of another level of  organization and functioning (still  pathological i.e. lower, primitive or regressive).

‏f-If this handicap is prolonged and malorganization or disorganization is established, possible organic cellular pathology may complicate the picture due to some disuse  and consequent lasting deficit.‏

‏Such criteria for both types  are not the least  directly detectable  on quantitative behavioral  level. Never-the-less they seem to be the only valid criteria if we come to consider  the holistic biological  identity (relevant to most researches). It is also directly related to prognosis and management.‏

‏* This should not be mixed with the phenomenon of disorganization and the negative symptoms in schizophrenia. In schizophrenia the disorganization is related to the personality rather than the consciousness and the deficit is related essentially  to the pre-functioning adapted level. However, late in the course of deteriorating schizophrenia the differentiation is rather impossible.‏

Mixed Disorders:‏

‏This distinction into two main categories  does not solve the problem of certain  disorders such as the psychiatric aspect of  epilepsy or the so called organic/functional syndromes (e.g. organic delusional states  of the  DSM III).  In  case of epilepsy the pathology could be on any level (cellular, chemical or physical) while the presentation  may take a discomposition (e.g. consciousness dissolution), deficit (e.g. epileptic dementia) or organizational (e.g. epileptic paranoid state). Apart from the lasting complications of epilepsy which are  much more related to type I disorder (e.g.. epileptic dementia)  most psychiatric complications of epilepsy are more related to organizational  disorders (Type II).The differentiating criteria here are the paroxysmal nature and the  the short or  ultra- short duration.‏

‏As regards the so called organic delusional syndrome (and the like), while  the etiology is mainly chemical e.g. (intoxication) the presenting clinical picture is mainly organizational  and the teleological causality is usually lacking (or at least transient and  obscure).‏

Discomposition Versus Deficit  Disorders :‏

‏ In this preliminary introduction, I shall restrict myself to further  delineation, as an example, within the first category (Type I Disorders : deficit discomposition  disorders).

‏The common criteria of the main category (type I disorders) are to be fulfilled first. Then we are  able to distinguish two main  subtypes :‏

‏A-The discomposition disorders which mostly refer to the majority  of the syndrome  previously categorized as acute OBS (e.g. delirium, subacute delirious state). This group is mainly related to some disorder of consciousness. Other manifestations could be related to the dissolution  of the holism of the state of consciousness. ‏

‏B- The deficit disorders (representing  the bulk of organic deterioration disorders) are mainly due to some out-fall and failure of  functioning units (neurones) particularly in relation to cognitive function.The main manifestations are related to the particular loss of units responsible for particular performance as well as the interrelation between functioning units.‏

Table II: The Differences between Discomposition-Deficit Disorders
Holistic discomposition Disorder Deficit Disruption Disorder
1-The disturbance is related to (or due to) disorders of consciousness in the form of quantitative diminution (blurring), decomposition (fragmentation) and/or fluctuation.

2-Other psychic  disturbances e.g. in attention or perceplated to, the discomposition of the holistic matrix.

3-They are usually reversible unless they ,erge into deficit disorder.1-The consciousness is clear.

2-Disorders of attention and perception as well as other cognitive functions are related to the principal deficit of functioning unit (direct ability).

3-They are usually lasting a commonly irreversible.

In short the holistic discomposition  disorders are characterized by the following (Table II):

‏ 1-The disturbance is related to (or due to) disorders of consciousness in the form of quantitative diminution (blurring), decomposition (fragmentation) and/or fluctuation.(Barrier disability(

‏2-Other psychic disturbances, particularly in the attention and  perceptual fields,  are secondary to, or related to, this primary discomposition of the holistic matrix.‏

‏3- They are usually and frequently reversible  and transient  (unless it merges, later on,  into a deficit  disorder(

‏The deficit disruption  disorders are mainly characterized by :‏

‏1-The consciousness is relatively clear.‏

‏2-Disorders of attention and perception as well as other cognitive deficit are related to the primary loss or derangement of certain  functioning units (direct disability(.‏

‏3-They are usually lasting  and commonly  irreversible.‏

‏To sum up, I  hope that I have succeeded to Dr.aw the attention to the fact that the discovery of organic basis of the so called functional disorders does not mean that they are, or could be considered as, one and the same as organic disorders. On the contrary this significant objective information about the organic nature of all psychiatric disorders on whatever level  represent a new challenge asking for real search   for the profound differences between the two main categories of psychiatric syndromes.

‏I do  admit that my trial  here to delineate one from the other on some more structural  existential basis  (still  dynamically  biological)  does not appeal to most psychiatrists who are brain washed by the criteria oriented reductionism. All of us have been recently fascinated to some degree or another by the mechanical discipline introduced by the DSM III. Fortunately, by now, in a rather very short time, this apparently structured solution is proving every day that it is more and more de-naturing not only psychiatry but also human nature. If the teleological nature of some disorder is difficult to detect, this does not justify that we have to deny its existence restricting ourselves to the behavioral facade illuding ourselves that the truth is what wecould delineate mechanically and agree upon automatically  regardless who we are and how we have been cultivated as clinicians and research people  to assess, agree or disagree.          ‏

References:

‏Lipowzki, Z.J. (1980) A New Look at Organic Brain syndrome.Am. J. Psychiatry  13: 647-678‏

‏Lipowzki, Z.J. (1975) Organic Brain  Syndromes: Overview and Classifications. Psychiatric Aspects of Neurological disorders. Benson and Blumer (Eds) Grune and Stratton. New York.‏

‏Rakhawy, Y. (1979) Study in Psychopathology.(The secret of the Game) Dar El Ghad Cairo  (In Arabic)‏

‏Rakhawy, Y. (1980) Expansion of the Concepts of ” Medical Model” in Psychiatry  Egypt.J. Psychiatry  2: 159- .160‏

‏Rakhawy, Y. (1981) Brain Organization and Brain Function Egypt.J. Psychiatry  3: 151- .152‏

‏Rakhawy, Y. (1984) Active Therapy and Brain Organization Egypt.J. Psychiatry  7: 13-15‏

‏Spitzer 1988  WPA symposium in Washington,Okasha quoted him through personal communication, cited in Okasha,A 1989, The Organicity Dilemma  (Quoting.)Egyyt. J. Psychiat.,1989, 12: 3-5‏

‏Timble, M.R. (1988) Biological Psychiatry.  (ed.) WiIley Medical Publication. Chichester. New york.‏.

[1] –Egyptian J. of Psychiatry, (1983)  6: 9-11

[2] – Rakhawy ,Y.T.(1979) A study in Psychopathology.  Cairo: Dar El-Ghad. (In Arabic).‏

[3] –‏  Egyptian J. of Psychiatry, (1979) 2, 138-144

Original title : Evolutionary Value of Tolerance of Depression

[4] – Added remarks in this collection will be put within the text in a special smaller italic fonts reviving an Arabic style of writing.

[5] – ‏ Egyptian J. of Psychiat., 1981 4: 6-14 

Chapter II: The hypothesis: Breakthrough    the    Current Psychiatric Nosology

Chapter II

The hypothesis:‏ Breakthrough the Current Psychiatric Nosology[1]

Part I: Prospects and Illusions:

Introduction:‏

‏” No honest observer can claim that psychiatry as an independent science has established its definite identity. If this is true in the so-called developed countries it is expected to be even more so in the so called “developing countries (a more diplomatic term than the real underlying concept, “under developed countries. ‏

‏Since these statements have been put forward by the author (Rakhawy,1978) many happenings have occurred both in Egypt and in the Arab world. The number of psychiatrists has been doubled or tripled. More psychiatric associations have been founded. The Arab Federation of Psychiatrists have been established and three more Pan Arab congresses of Psychiatry were held. However, nothing radical has changed. We did not become more independent or less illuded. ‏

‏Revising the nosological stand as well as the theory and practice that has been reviewed one decade before  in Egypt, as an example (Rakhawy 1978 and 1979), one can state that we still have something of our own  to say. We still are able to contribute (not only to copy or reduplicate).

‏I do not intend to follow up in detail what had happened during this last decade. On the contrary I shall try to focus on   days to come. If the second part of this series (Rakhawy, 1979) has been defined as a “personal view”, this trial after ten years could be more so.‏

‏This paper is mainly  devoted to what we could possibly add  to the field of psychiatry  (perhaps as a modest example of some many other fields). However, I could not find a definite line of demarcation between what could be some sort of exploration and looking forward (prospects), and what is but wishful thinking mis-evaluating reality  (illusions). That is why I have put the subtitle prospects and illusions. I feel like preferring to put it   together as such, leaving the reader to select for himself which is which.‏

‏The present part  is devoted to revision of the present status of the current  psychiatric nosology  as matched by our actual practice. The next revisions would define proposed axes as well as revise some aspects of our  clinical practice in the light of these introduced concepts.‏

The fate of the DMP I :‏

‏Although the DMP I has been officially recommended  as the Arab reference for Psychiatric nosology (DMP I.,1979) one can hardly admit that this recommendation has been adequately put into action. This fact necessitates revision and re-orientation. The author has ended his discussion about the critical issues of the DMP I (Rakhawy, 1978) by asking few questions which after more than one decade is still waiting some more well defined answers.‏

‏The four posed questions were :‏

‏1-If our pace is that short and hesitant, is it worth having our independent national nosological discipline?

‏2-If there is what can be called, now or later, Egyptian views in psychiatry, or even, as hoped by some, Egyptian Psychiatry, would  it has its direct influence on the Egyptian nosology hoping to participate in solving the everlasting nosological problem in psychiatry ?

‏3-If we dare to put down our thinking in a different nosological discipline; how much can we expect other “developed disciplines”to listen to our neologism?

‏4- If the nosological problem in psychiatry is that perplexing, is it advisable to by-pass  it for now trying to concentrate on other problems related to the practical management of psychiatric problems from our point of view?

‏The answers, after 12 years are definitely influenced by some significant changes that have been working all through. These are not the least new. The initial retreat indicated by posing such questions, particularly the first one, was called for “..After the publication of the ICD 9 and the DSM III…etc.”(Rakhawy, 1978). Now, after more than one decade, the DSM III has occupied (rather colonized) most territories. The DSM III R soon follows !! and the DSM IV is in the make. The ICD 10 Draft 1988 is available and the next is coming soon. As such, the elective answer to the question posed in 1978 becomes obligatory in .1990‏

‏The hazards that resulted from the  overwhelming flood of the DSM III all over the world is beyond any imagination. There is no point in blaming Americans for successfully marketing their intellectual goods. What we need to investigate more is how we, all over the world, accept, so easily, such adulterated goods. This may need some real search in the psychopathology of our speciality (i.e ourselves) some way or another. This could be partly related to our long standing inferiority feelings as a result of the long lasting ill-defined etiology of our disorders as much as our increasing intolerance of ambiguity. The rush to be sheltered by the misnomer medical model  is another factor. Misnomer since it refer to more chemical than medical model. Lastly the tendency to computerize our information is tempting just as some other modern fashion to follow. If we add all these factors to the need to communicate with advanced people in developed countries by using a common verbal, written, listened to, language things become more clear and understandable. The result could not be other than sticking common well-defined labels at the expense of identifying genuine objective truth.‏

‏Our thinking  has been sectored and imprisoned in part criteria gathered together with some very weak  central  goal idea, if there is any at all. There is no place here to enumerate any of the increasing published criticism of this spreading abnormal growth (the DSM III).

‏To sum up, we can recall that the DSM III ( and the like) has sacrificed homogeneity and objectivity for the sake of pseudo-consensuality. Through this DSM III we became more related to criteria than to the illness or the ill person, as much as more related to some label than to the underlying biological phenomenon. A user of the DSM III can easily defend his diagnostic label but,if he has enough insight ,  he cannot the least deny how much this procedure has detached  from his patients and himself, i.e.from objective reality.‏

‏If this is true in other more developed, more sophisticated schools of thought (Great Britain, Scandinavian countries and lately France and other continental psychiatry) what could be the case in a country like ours? The invasion by the DSM III of Egyptian Psychiatry has its evident complications:‏

‏1-In spite of the fact that the main innovation  of the  DSM III has been the multi-axial approach, what actually happened  in our  country (and I think in many others) is that  the whole story has been reduced practically to the first axis. The most important axis, from my point of view, the fifth one, actual performance during the last year, was also overlooked in most cases.‏

‏2-The DMP I, our national classification, is ultimately overwhelmed by the giant enterprise and  is now  suffering from some sort of disuse atrophy. Apart from Kasr El-Eini school of psychiatry and to a lesser extent Mansoura University and Dar EL-Mokattum  Hospital; it is, by now, rarely used if at all remembered.‏

‏3-The DSM III (exclusively the first axis) is frequently used as a reference for research criteria as such. In spite of the fact that DSM III people do not claim that it is a research criteria discipline, most our researchers find it easier to label their sample by the current terminology of the DSM III..!!!. This is usually resorted to in order to find a collaborator or more who readily agrees upon the diagnosis and also it facilitates the illusion that we are speaking some international language. The result is that research, including biochemical investigations, are probing definitely heterogenous material.‏

‏4-A divorce has been established between the longitudinal  etiologically loaded and dynamically oriented life history on one hand and the presenting concrete criteria in the present mental state on the other hand. Nevertheless psychiatrists are still taking the history and occasionally listening to patients. When I teach my post graduate students I ask them to diagnose in terms of DSM III or  even DMP I  for the sake of passing the examination. Then I turn to reconsider the whole status including longitudinal march and structural set up for the sake of responsible management and prognosis (sometimes the latter  is said to be for the sake of GOD!!  referring to some goal seeking genuine objectivity). This situation reflects how the nosological disciplines in general and the DSM III in particular are  alienating rather than really  goal seeking.‏

‏5-Gradually, as being more and more detached from our patients we are left but with the drugs to be given symptomatically to alleviate, control and tranquilize  and neutralize  the influence of some label stuck on the patient. From the first look, one cannot find the direct link between this fragmentation tendency propagated by the DSM III and the rush to use drug therapy, but this what actually exists. I suspect that the giant pharmaceutical establishments  lie behind the whole story, a topic previously tackled by the author (Rakhawy, 1984) which is beyond the present scope.‏

‏The second  and third questions were related to  the  challenging confrontation of promising independent contribution versus  fear of nosological neologism. After more than one decade we are in the same position or rather have moderately shifted towards  following and copying. ‏

‏The fourth question  assumed from the start negative  answers to the preceding ones. After passing through what had happened during the last years it seems logic to accept such retreat. Are we also to accept the proposed shift included in the fourth question to: “..by-pass the nosological problem trying to concentrate on other problems related to the practical management of our patients”. This, of course, has never been possible, simply because such practical problems  of management are almost always related to the diagnostic label whether consciously or unconsciously.‏

‏As a matter of fact the lengthy trials of the WHO to face and compensate for the hazards of the DSM III are worth respect. The available drafts of the ICD 10 have resuscitated our agitation and made us  much more trustful and hopeful. There is no place here to enumerate how much similarity lies between our DMP I (which is mainly derived form the ICD 8 and DSM II) and the ICD 10 draft. However this does not answer the questions but it would make us face our undue ambitions in a trial   to be so independent. After more than one decade we may think of some  sort of practical retreat to recommend taking the ICD 10 as the common basis to which each nation and culture can add its own cultural remarks as special supplement.‏

‏As far as our persistence to go on as  ambitious  and independent as we believe we are, we can claim  that :we can add original ideas.‏

Revision and proposals: ‏

‏ Remembering that this is an extremely personal view I am going to gather and introduce few headings, which may represent essentially certain working hypotheses to be tested in the actual clinical practice.‏

‏1-Since the basis on which  separation of the so-called organic  disorders from the so-called functional  is getting more and more vague and illusive some other approach is suggested. The discovery of organic basis of the so-called functional disorders does not mean that they are, or could be, considered as one and the same as organic disorders. On the contrary this significant objective information about the organic nature of all psychiatric disorders on whatever level represent a new challenge asking for real search for the profound differences between the two main categories of psychiatric syndromes.‏

‏Delineating one from the other on some more existentially significant (still biological) basis look now more essential than any other time. It has been shown that it is not a matter of  locating  the brunt of the specific handicap  or pathological deficit. What counts is the basic differences in the biological setting, the level and nature of pathology,  the existential meaning, the march of handicap and the how of organization.  This would, ipso facto, influence research criteria, management and prognosis.‏

‏For  the so called organic  disorders  the term Discomposition-Deficit  disorders is suggested  to  refer to the type of  basic pathology as well as the nature of the derangement. The termdiscomposition  refers more to  the dissolution of the holism of the matrix of consciousness, while the term deficit  is more related to the specific handicap resulting from destruction or outfall of neurones in a particular domain  or locality.‏

‏On the other hand,  the term Organizational-Goal seeking  is used  to replace the dyeing term functional. It is intended  to emphasize the fact that such disorders are but pathological reorganization on some other level of existence (and corresponding neuronal patterning) to achieve some goal which is still pathological.‏

‏We can then identify a certain degree of each of the two opposing qualities in most psychiatric disorders. The so called organic could start mainly as a discomposition or deficit which is compensated for by some goal seeking organization. On the other hand, profound lasting disrupting syndromes like schizophrenia may result in a certain degree of deficit or discomposition. This may necessitate some added adjective, or axis, to each category whenever necessary.

‏2-It may be necessary to reconsider  the dichotomy  between what is acute and what is chronic. This would be based not only on the duration but essentially on the pace, stability  and degree of disruption and alienation.. This is particularly essential in relation to the so called organic disorders, where delirium and subacute delirious states have different etiology prognosis and need   immediate management. The newly suggested term discomposition  disorder  may refer implicitly to the possibility  that this discomposition disorder (in relation to what has been called organic) is but an acute (organic) disorder. Delirious states related to intoxication and/or withdrawal of drug abuse are typically related to this acute discomposition group. ‏

‏The  adjective acute used in the so called acute schizophrenic episode (of the DMP I)  should be  typically describing a state of fulminating disorganization as well as alienation leading, in good number of cases, to established disorganization and possible deficit. The most analogous medical syndrome is the acute yellow atrophy  of the liver. ‏

‏Sometimes the negative  outcome is not that manifest, and such short lived episode may be followed by something like being switched off  with no definite diagnosable psychiatric disorder as a residue short of the possibility of personality disorder later on. In other words such outcome could be schizophrenic (to be diagnosed in retrospect) as much as it could be personality disorder or any alienated form of growth cessation. ‏

‏The episodic, paroxysmal and recurrent impulsive attacks occurring along the course of epilepsy, certain short lived affective disorders and some attacks  of the explosive and stormy personality disorders tempt  being described as acute  in principle. It is better to keep the more specific adjectives (episodic, paroxysmal..etc) indicating a self limited, short lived episodes.‏

‏The term acute, as suggested here, should be differentiated on one hand from the term sudden  or immediate  and on the other hand from the term active. While sudden or immediate refers mainly to the onset, the term active lies on some other scale. Also immediate could be more  related to the cause and the short duration in the so called acute situational or reactive neurosis or psychosis (e..g. ..09.6& 10.7 in the DMP I). Here the condition is described as acute in terms of intensity and pace rather than related to discomposition or alienation.‏

‏However, a syndrome could  lie in an intermediate stage deserving terms like subacute and sub-chronic which are worth considering provided that their use does not depend only   on the duration.‏

‏3-The active-established  dimension (or axis) is not  synonymous with the  acute – chronic  one. While acute-chronic axis is related to both the duration and the floridity of symptoms, acute-established scale  is more related to biological and psychopathological reactivation of actual organizational levels. The active group present in the behavioral clinical picture as genuine experience that could last as active for any time, while established syndromes are quite consolidated with narrow awareness and limited existence.

‏In our experience the clinical use of both acute- chronic scale and active-established scale is no matter of theoretical differentiation as new attractive symbolic labels. They have their direct  radical effect on both management and prognosis and, still more essentially, prevention and re-channeling.There is more  overlap between the term chronic and established than between acute and active. If we remember once again the analogy with liver diseases we can speak about chronic active psychiatric disorders which is parallel to the term chronic active hepatitis. We have to remember that Jasper has preceded the hepatologist is so describing such chronic active syndrome in psychiatry some decades before. (Jasper, 1962)

‏ 4-The connotation of the terms psychotic and non-psychotic  worth re-considering both for clinical, therapeutic, and medicolegal assessment. We should recall here that by psychotic  we do not mean the mere presence or absence of delusions and hallucinations as both the DSM III and the ICD 10 do  in most cases. The acceptance of hallucination and to a lesser extent delusions as possible normal variants in our culture may lie behind the caution to consider their mere presence as the main criteria for diagnosing psychotic intensity. By psychotic we mean a definite degree of disorganization of the personality, detachment from reality, severe handicap in performance and/or dangerousness to the self or others  (as a result of mental derangement).

‏As such we are justified to separate the name of a syndrome as commonly used from the possibility of being psychotic or not. So we can speak about obsessive psychosis (Rakhawy,1989) and psychotic hysteria as much as we speak about non-psychotic schizophrenia or even paranoid state.   ‏

‏5-It seems that it is high time to consider the pathology as well as the psychopathology of epilepsy as etiologically relevant and phenomenologically parallel  as well as equivalent  to psychiatric disorders in general. The rationale of keeping epilepsy as an independent category in the DMP I is getting more and more poor. We have to consider de novo, from a patho-physiological point of view, how and when epilepsy could be related to the biorhythm and its distortions resulting in some paroxysmal, periodical or lasting psychiatric disorders. On the other hand the lasting sequelae and complications of epilepsy should find its place in due categories according to the presenting behavioural front.‏

‏6-Revision of the various uses of the term affective  is essential. Using the term” affective” to denote  the presence or absence of affective symptoms (depression, elation, guilt etc..) is completely different than using the same term “affective” to refer to some sort of integration of personality, periodicity, warmth and vivid presence. The latter connotation is perhaps more understandable in our culture as the word “wijdan” in Arabic denotes something more profound and comprehensive  than describing  simply a stirred up state of feelings.While it refers to sadness, anger, love and hate (according to the predisposition that follows) it could denote knowing, creating and enriching (Rakhawy 1989) As such, the word affective in our practice seems to have more over-inclusive connotations than used in other languages including current psychiatric language.‏

‏However, affective-non affective axis definitely overlaps the active-established axis, but it would prove not to be one and the same. ‏

‏Using this holistic connotation of the word wijdan (affective) as the arabic language suggests (=i.e. vivideness integrity and warmth), a smiling periodical paranoid state could be considered affective while a parasitic nagging lasting depression is not (although it is called depression). This has its consequence on management and prognoses and not less so on research.‏

‏7- Depressive syndrome should be further differentiated and detailed, perhaps as an independent category with different variants. As just mentioned, the possibility of separating an apparently paradoxical syndrome labelled non-affective (or better, non-wijdanic) depressive syndrome (!!!) away from affective group is worth considering. This is to be partly related to the atypical depression of the French classification (Pichot,1986) categorized under schizophrenia and perhaps with the post schizophrenic depression innovated by the ICD .10‏

‏8-Differentiation of mania into dissociative (productive) type and regressive (nonproductive) childish type  (Rakhawy 1979 C) may have some place until we admit the concept of regressive psychosis as an independent category (Rakhawy 1989).‏

‏9-Schizophrenia should be diagnosed essentially by two main parameters viz, the degree of disorganization and the extent of deterioration. In the current approach to schizophrenia Schneider”s symptoms are too much emphasized so far. It is rather common experience in certain normals in our culture to admit some sort of phenomena similar to Schneiderian symptoms without being psychiatry ill at all. ‏

‏In the present  revision, it is advised to identify three stages of the so called schizophrenic process, viz: early active schizophrenia (could be called Schnieder“s disease), intermediate splitschizophrenia (could be called Bleuler”s disease) and late  deficit schizophrenia (could be called  Kraeplin”s disease). In addition we may invite to consider autistic syndrome in adulthood as another variant of schizophrenic existence. When the DSM III put a condition to diagnose autistic syndrome as schizophrenic only if there is superadded delusions and /or hallucinations, it does not clarify enough where to put the autistic syndrome of adulthood if there is no delusions or hallucinations. Autism per se worth considering as a variant of schizophrenia whether it is included in some covert world of fantasy or is some sort of consolidation of extreme schizoid (or even schizophrenic)  personality like existence.‏

‏All these differentiating landmarks worth revival of the suggestion handling schizophrenia as more than one disease.‏

‏10-Much more attention should be paid to the pre-schizophrenic states. This could be especially relevant from a preventive (morally responsible) point of view. A trial to identify and diagnose the group of pre-schizophrenic, states would help to deal with this group to prevent further evolution to the full blown picture of schizophrenia, or at least to be ready to handle the consequences as early as possible. This would take in consideration atypical symptoms in some neurotic and affective disorders particularly those with family history of frank schizophrenic disease or morbid psychopathic behavior or criminality. ‏

‏However, from a nosological point of view this area should be thoroughly investigated to differentiate, for instance, between pseudo-neurotic, which is definitely pre-schizophrenic and incipient, particularly the active variant, which denotes that the process (not necessarily the schizophrenic process) has already started. This would open the file of border line states (not border line personality as the DSM misused the term ).

‏However terms like incipient psychosis  would refer to starting psychotic process as indicative for   some stand along possible psychotic outcome. It should not be taken simply as synonymous to the newly suggested term cross-road crises (Rakhawy, 1979 C)   where the outcome is not commonly psychotic and positive outcome (growth unfolding) is possible.‏

‏ If we admit to accept incipient psychosis as independent category it should be included apart from schizophrenia. However, this would be a new controversial problem since psychotic intensity, as just defined, in the so called incipient psychosis is lacking at the outset. I am not sure how much we could agree to revive using terms  like potential psychosis or potential schizophrenia.‏

‏Once again, it would be reasonably, after the failure of that rush towards absolute superficial consensuality, not to omit whatever we cannot agree upon. Interest in such potential, cross road,or borderline  area  is essentially preventive and once more related to essential medical morality  and human responsibility.‏

‏12-Paranoid states should be sharply separated into two different categories. The active vivid and periodical group (very near to the sub-category 08.0 of the DMP I labelled subacute or acute paranoid episodes) which are manageable by drugs and physical restoring rhythmic therapy (BST, still mis-named as ECT). It is also noticed that occasionally added anti-depressants may help the patient to respond readily. This is contrary to what was believed that antidepressants are rather contraindicated in paranoid states. ‏

Chronic group as a whole (delusional, hallucinatory and fantastic) is, at least structurally, but a stable personality transformation. The structural organization as well as the management of this latter group is more like that of a personality pattern disorder.The psychoactive drugs are not as effective unless this stable structure is dislodged and the whole biological constitution is reactivated.‏

‏13-The group called  other functional psychoses (09 DMP I) worth receiving more serious attention. The term functional has a weak rationale to prolong its life time. As just mentioned, the definition of psychosis should not mean the least mere presence of delusions and hallucinations. The present sub-categories should be radically revised. For instance, the sub-category called confusional psychosis proved to be either a mis-nomer or a mis-diagnosis. Other independent psychoses such as: impulsive psychosis, obsessive compulsive psychosis, regressive psychosis, dissociative psychosis, disorganization psychosis (periodical and otherwise) (Rakhawy, 1989) as well as polymorphic psychosis and cycloid psychosis are perhaps justified to find their place here. Nevertheless this category should not be the least used as a waste basket.‏

‏14-The neuroses still have their place and dignity in our practice. We found no point to go on denying their existence in recent nosological disciplines simply because they are predominantly dynamically described categories. It is not the least a weak point to base the diagnosis on dynamic interpretation to start with. ‏

‏However, apart from the reactive and situational neuroses it is hardly possible to face neurosis as an acute superimposed clinical problem. This drags us to the area of the personality disorder which agrees with the idea of grouping personality disorders and neuroses in one main category (Mayer Gross et al, 1972). In profound and lasting neuroses some consideration should be given to probe trying to detect some psychotic intensity or persistently threatening psychotic potentiality. Perhaps we may succeed to find out definite clinical behavioral landmarks to agree upon allowing separation of prolonged handicapping neurosis into some independent category nearer to either chronic psychoses or personality disorder. Management surely would differ.‏

‏Post-psychotic and late onset personality disorder are commonly met with in our clinical practice and thus worth considering as independent categories. This group is particularly increasing with the extensive use of long term narcoleptics.‏

Closing:‏

‏To conclude, it is evident that such observations and ideas arising from our very clinical practice are but an introduction that needs further elaboration and testing. In the following parts of this series of revisions I intend to introduce some relatively better delineation for the suggested axes. This would be followed by more observation about the relative utility and influence of such orientation on therapy and research activities as well as theorization.‏

References

‏American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders. (Third Edition Revised). Washington, DC : The  Association.‏

‏Egyptian Psychiatric Association (1979) Diagnostic Manual of Psychiatric Disorders   Cairo, The Association.‏

‏Jasper, K., (1962) General psychopathology English translation (From the German 7th Edition by Hoenig J. And Hamilton, M.) Britain: Manchester University Press.  (First Edition:1923).‏

‏Mayer-Gross,W.; Slater,E. and Roth, M.(1972) Clinical Psychiatry. 3rd Ed.  London : Bailliere, Tindall and Cassel.‏

‏Pichot, P.(1969) Frensh Classification (1968) Unpublished document.

‏Rakhawy, Y. (1978) Psychiatry in Egypt to-day.  Egypt. J. Psychiat., 1: 13:23‏.

‏Rakhawy,Y. (1979 A) A Study in Psychopathology, Cairo: Dar El-Ghadd. (In Arabic).

‏ Rakhawy, Y. (1979 B) Psychiatry in Egypt to-day.  Egypt. J. Psychiat., 2:19: 26‏.

‏ Rakhawy, Y. (1979 C) Psychiatry in Egypt To-day.  Egypt. J. Psychiat., 2″: 8: 12‏.

‏ Rakhawy, Y. (1984) Pharmaceutical Interpretation of Recent Psychiatric Theorization.  Man and Evolution,  5: 18-40‏.

‏Rakhawy, Y. (1989 A) Organic-Functional Polarity: A fading Illusion.  Egypt. J. Psychiat., 12:  7-.11‏

‏Rakhawy, Y. (1989 B) Basic Concepts Psychiatry : Revision and Re-orientation (An Egyptian Point of view) Cairo. Evolutionary. Psychiatric Association.‏

World Health Organization  (1988): International Classification of Diseases 10 th Edition (Draft). Geneva: The Association.‏

* * * *

[1] – Arab Journal of Psychiatry (1990) Vol. 1 No. 2 81-92.

Part II: Multiaxial vis-a-vis Multidimensional ‏

Approach to Psychiatric Nosology‏

Arab Journal of Psychiatry (1991) Vol. 2 No1.  Page 1-13‏

Abstract ‏

‏This is the second part of the trial to add some of our orientation out of  clinical practice about the current psychiatric nosology. In a trial to share in the effort to achieve the essential level of international consensuality by using a common nosological language, some sort of compromise was suggested to make use of the enormous and unique effort behind the construction of the  ICD-.10 The clinical syndromes, as described in the clinical diagnostic guidelines of the ICD-10, would occupy  the first diagnostic level. In a trial to open the gate for added dimensions for optional use, three dimensions are provided (one of which is subdivided into four subscales). The overlap is expected and notified and the difficulty in agreement is accepted. Any other possible dimension could be added whether related to cultural differences, different modes of conceptualization or special colouring of clinical experience.  ‏

‏A very preliminary trial to show the outline of each dimension is given. The rationale of the proposed multi-dimensional approach with illustrated few examples is demonstrated. The consequence on high power diagnostic delineation, management, prognosis and research is referred to with an invitation to field trials.‏

‏In the first part of this paper (Rakhawy,1990) a trial was made to introduce a rather limited overview of the current status of diagnostic inclinations in Egypt and how the DMP- I (Egyptian Psychiatric Association, 1975) failed to compete with the traditional trends as well as with the DSM- III- R (American Psychiatric Association, 1987). Passing rapidly through the DMP-I, some limited remarks and alternatives were introduced in a rather hasty but daring way. Certain axes were mentioned as an additional or alternative diagnostic aid. The paper ended by  “..I intend to introduce some relatively better delineation for the suggested axes”‏

‏When I started  collecting my previous notes and discussions I found that what I am introducing is some sort of qualifying  dimensions or scales rather than  axes. I believe that it is better to differentiate between the two at the outset. An axis,  is a main line of direction, motion, growth or extension. The word “dimension” as will be used here, is not in the sense of “one of the elements or factors making up a complete personality or entity” but rather “the range over which something extends“. The latter sense permits some sort of quantitative scaling of a particular quality.‏

‏Looking back in the DSM- III axes we may notice that the first three axes are descriptive main lines of direction i.e. real axes, while the fourth and the fifth are more related to some possible quantitative scaling i.e. dimensions. Most axes of the DSM- III are based on behavioural assessment, depending on both verbal information and part judgement, rather than on holistic clinical approach. They are lacking structural orientation, dynamic understanding, growth dialectics, teleological aspect as well as qualitative assessment of the “how” of existence which is directly related to certain basic considerations of what positive mental health could be.‏

‏It is not advised to split hairs for the sake of linguistic sophistication. I am just referring to the fact that  expanding diagnostic orientation presented in this second part is more in the direction of scaling whatever clinical entity, as much as possible, over some dimension. This could prove to be essentially practical and related to clinical judgement rather than to gathering circumscribed criteria.‏

‏It has been observed in our practice that the stand of a clinical entity on any particular site over a certain scale would make a lot of differences as regards biological variables, prognosis and management.‏

‏ In part I, the paper after discussing the fate of DMP- I, came to the conclusion that “…. After more than one decade we may think of some sort of practical retreat to recommend taking the ICD-10 (World Psychiatric Association, 1988) as the common basis to which each nation and culture can add its own cultural remarks as special supplement.”‏

‏This part II is in this direction. However certain basic remarks are to be put  clear from the very beginning:‏

‏1-The proposed dimensions are not alternative  to whatever clinical  agreed upon entity or axis .‏

‏2-They have been suggested  mainly by the author but actually put as a working variable in clinical practice, tried and  discussed by  a group of senior and junior practitioners for one hour every week  for the last nine years.‏

‏3-They are culture related in as much as we differ in conceptualization which is surely to related language as structure and to some holistic approach (rather in Gestalt way) as well as to the direct relation to a biorhythmic environment*‏

‏*Which could go parallel with our relative heightened  awareness of our biorhythmic nature in health and disease. Our psychiatric disorders look more periodic than elsewhere, remembering that we cannot afford, and we are not habituated to, maintenance or continuous psychiatric medication by neuroleptics.‏


What cultural differences should not only mean?

The incidence as prevalence of certainThey shuld not refer, simply, to:

Ill-defined as add syndrome

The presenting symptoms

The content of delusions

The traditional mades of healing

The possible autcomeCultural differences should essentially be related to:

The hoe of conceprualization of psychiatric disorders

The hierarch priorities

Tea special meaning and goal –idea

All such factors are basically bound tolanguage as structure and not simply as symbol or vehicle.

)through habits, timing and praying etc). All such factors are directly or indirectly influencing our conceptual framework in general and towards what  mental health  could be in particular. Consequently the ultimate goal of psychiatric classification and management is influenced accordingly.‏

‏ 4- Certain repetition of what has been mentioned in part I is indispensable. However the approach differs.‏

‏5- The term “level”  is going to be used for the first stage of delineating the common language from the added options. This would separate clearly between the common internationally agreed upon clinical entities and the suggested added dimensions. Level I refers to the former while level II to the latter.‏

‏6-The term “axis” is not going to be used and this means that what has been mentioned in  part I as axes is by now called dimensions.‏

‏7-All the proposed dimensions, as described here, in this introduction are to be taken simply as outlines of the suggested  trend hoping that each one will be introduced in detail, with its rationale and origin from clinical practice, later on. This surely will be dependent on the nature of  feedback, special inquiry, criticism and dialect.‏

‏8- The added dimensions should not be taken as  some fifth digit for national use (c.f. ICD- 9-CM) since they are not some added sub-diagnoses but it is rather re-classification on some other, equally basic, level. Moreover it is hoped not to be simply national. This is not the least contradicting with any other use of axes from the DSM- III or the multi-axial set of the ICD-.10 The preference is to be judged by the goal, the clinical competence and the appropriateness.‏

‏9-By using the multi-dimensional approach any specific syndrome (on level I) could acquire further qualifications on some other specific dimension. ‏

‏10- Not all introduced dimensions are new. Some  are revived (psychotic/non-psychotic) others are totally original (e.g. growing / closed circle or organizational / disruption).

Level I: Clinical Syndromes

(ICD-10 ) Clinical Diagnostic GuidelinesLevel II: Diagnostic Dimensions

Dimension I

Active <======> Established

Subscale A Acute     <===>Chronic

Subscale B Wijdanic<===>Non-wijdanic (AffectiveóNon—Affective)

Subscale C Periodic <===>Non-periodic

Subscale D Pulsating<===>Closed circle

Dimension II

Psychotic<===> Non-Psychotic

Dimension III

Organizational<===>Disruption

(Goal seeking<==>Discomposition/Deficit)

Dimension 1 Active<=—=>Established
Active Established
Stirred up condition (Biologically & structurally) Usually of short or moderate duration (Could ex­tend to years in all subgroups except acute)

Management needs active interference.Could pass to established side by neglect or pro­longed medication.

Responds favourably (or hazardously) to active chemical medication.Stable malorganized (Biologically & structurally) Usually of prolonged or lasting duration.

Management needs prolonged rehabilitation. Could turn into active by intensive therapy.

Responds poorly though apparently controlled by maintenance medication Subscales

A-Acute<================>Chronic

B-Wijdanic <=============>Non-Wijdanic

C-Periodic<===============>Non-Periodic

D-Growing (Pulsating <=>Consolidated (Closed circuit)

[With definite overlap, no dichotomy and no exclusive polarity]

LEVEL   I :  CLINICAL SYNDROMES‏

‏The glossary for ICD- 10 will appear with four different sets of guidelines (Sartorius, 1988) : firstly, clinical  diagnostic guidelines, secondly, diagnostic research criteria, thirdly, a multi-axial system and fourthly a short guide for use in general health care.  The first level we suggest here is to be occupied by one of these four guidelines. As far as our experience reveals and in order to move lightly to the next level, it suffice to use the first clinical diagnostic guide line (c.f. ICD-9) at this first level. In other words the first level would be confined to the clinical category as labelled in any approved discipline. It is better, at least in our practice in this stage of development, to follow the  first set of ICD- 10 guidelines. The first axis of the DSM- III or even the clinical syndromes as cited in the DMP- I could be taken as alternatives. If we agree world-wide on the first level (ICD- 10) and then move to some significant dimensions, we perhaps can carry‏ on better.‏

LEVEL II: DIMENSIONS‏

The First Dimension‏

Active <==> Established‏

‏The words used to introduce this level of orientation are less familiar, more holistic, and somewhat vague. Nevertheless, this dimension is to be introduced  first. It is directly related to management, research sampling and possible alteration of the outcome of any psychiatric disorder. It represents some basic orientation of the author which was previously, though partly introduced (Rakhawy, 1983) and partly tested ( Rakhawy et al. 1983). The holistic quality (rather Gestalt approach) as well as the Arabic language influence are the main characteristic colouring this dimension in general as well as almost all its subscales. ‏

‏It could be sufficient to add the qualifying term active or established (with or without grading*). It is not synonymous with acute chronic dichotomy (see later). Further subscaling adds better delineation to the stand of the syndrome. One can categorize a syndrome directly on any of its subscales without direct reference to it being active. When one labels a paranoid as periodic, it goes without saying that it is active. A trial to delineate included subscales is provided as follows.‏

Dimension I: Subscale A‏

Acute <===> Chronic ‏

‏This subscale should not be simply based on duration. It is essentially based on the pace by which instability, fulmination or disorganization sets in. Sudden severe alienation is also considered acute. It is some sort of extreme degree of activity, acted out and presenting in the behavioural sphere overtly and rapidly.‏

‏Not infrequently, consciousness is involved  and this may need further qualification by another dimension (e.g. D- III: “discomposition” in delirious mania). This involvement is more frequent in organic deleria and this should remind us of this valid differentiation  between acute and chronic OBS in DSM- I. The rationale of its abandonment In DSM- II and- III is least convincing. The analogue in internal medicine is the acute yellow atrophy of the liver as compared with liver cirrhosis. The best examples, to demonstrate how an active syndrome is not necessary acute, are: chronic active paranoid states, or prolonged incipient schizophrenia (active variant in DMP- I). The analogue of such apparent contradiction in internal medicine is: chronic active hepatitis or chronic active rheumatic fever in contrast with acute yellow atrophy or acute abdomen.‏

Dimension I: Subscale B‏

Wijdanic<=>Non-wijdanic‏

(Affective<==> Non-affective)

‏This subscale seems to be unique and rather original since it is basically derived from the Arabic word wijdan which has no exact translation to English. It does not simply ‏mean: affect, mood or emotion. It is more inclusive referring to some holistic existential tone with variable affective connotation as well as definite cognitive and volitional implications(Rakhawy, 1987). The temporary and arbitrary translation to English is affect.‏

‏To judge a syndrome as wijdanic or nonwijdanic does not indicate directly the presence or absence of a particular affect. A Schizophrenic disorder could be wijdanic, this may be the so called schizoaffective disorder in the holistic interpretation provided earlier by the author (Rakhawy, 1982) but not necessary due to the presence of associated depression or elation. Also, we can meet sadistic dangerous paranoid states (non-wijdanic) on one side and on the other we may have warm smiling paranoid states (wijdanic). Even depressive illness could be wijdanic like in vivid periodic manic depressive illness, or non-wijdanic as in parasitic or post-schizophrenic depression (ICD- 10).

D I Subscale A: Acute<=>Chronic
Acute

Sudden    Florid  Fulminating Rapid Disorganizing.

Examples

Acute Schiz. (DMP I)

Acute delirium.

Boufee Delirante (French)

Analogues:  

Acute yellow atrophy (liver)

Acute abdomen.Chronic

Creeping     Invading

Steadily   alienating/ ed

Consolidating/ ed Scarring/ ed.

Examples

Chronic Paranoid States.

Most Schizophrenias.

Dementia.

Analogues:   Liver cirrhosis.

Chronic Constrictive

pericarditis.

D I Subscale B

Wijdanic <====>Non-wijdanic

(Affective <==> Non-affective or Warm<==> Frozen)Wijdanic

Genuine  experience

Expanded awareness

Variable symptoms

Astonishment (exploring)

Warm (Rapport)

Changing distance (to Object )

Elasticity

Oneness (Personality)

Resonant expression

Meaningful words.

Partial (or heightened) insight

Periodicity   is very possibleNoil-wijdanic

Empty experience Narrow (limited) awareness

Repetitive   symptoms. Apprehension (or denial)

Coldness   (Frozen) Fixed distance (or None)

Rigidity

Parts: apart (Personality).

Empty expression Verbalism

Lost, (or useless) insight.

Lasting course or remittent

Dimension I: Subscale C‏                             

Periodic<=>Non-periodic‏

‏This subscale is very frequently related to the active side of D II, i.e. a syndrome is usually at a time active, wijdanic and periodic.‏

‏A periodic illness has usually, but not necessarily, some features of any of the active group (general, acute, affective or pulsating, etc.). Family history is usually positive, not only as regards periodical illnesses but also in relation to periodical phenomena in general (or other active variants or disorders). Remission of the single attack is almost complete or with minimal deficit. The attack is frequently self limiting and responds to active treatment, not to anti-depressants alone.‏

‏On the other hand a non-periodic illness does not  necessarily  bear too much features of many of the established group (e.g. Chronic, non-affective or closed circle). Family history is usually negative as regards periodicity, but could be positive for any established variant of disease or personality disorder. Remission, if at all, has the marks of definite residual deficit particularly in the area of warm human relation or creative existence. The course is progressive, and the response to medication may occur superficially or on the expense of vividness and growth.‏

D I Subscale C

Periodic <=====>Non PeriodicPeriodic

Shares active group in general.

Family history usually positive, for periodic phenomena in general.

Remission     is   almost complete without deficit.

Frequently self limiting.

Responds to active treatment, not only anti-depressants.Non-Periodic

Less sharing established group.

Family history may be positive for personality disorder or established disorders.

Remission,if at all, is with definite deficit.

Frequently progressive.

Response to medication: superficial or negative.

A syndrome could occasionally be persistently periodic although it lacks some or many of the criteria of being affective or even active, e.g. periodical obsessional syndrome or periodic disorganization.‏

Dimension I: Subscale D‏

Pulsating<=>Closed circle‏

‏This is a longitudinal dimension by definition. However, the more the previous grouping is related to the active side, the more growth pulsation is preserved. The term “growth pulsation” is used in biorhythmic language as adapted to human ontological development in terms of rhythmic unfolding (Rakhawy, 1979).‏

‏This subscale, pulsating / closed circle, is rarely‏ت‏used in current psychiatric practice. It is particularly related to the concept of the so called “cross-roads crisis” (Rakhawy, 1979) where growth pains and deviations present as psychiatric symptoms.‏

‏The qualification along this dimension is essential lest the psychiatric intervention should abort a possible growth unfolding. The extreme responsible optimistic view considers most predominantly active group as potentially growing in the long run.‏

‏The author has previously described, from structural growth oriented point of view, almost all personality disorders, especially post psychotic, as a relatively lasting cessation of normal growth (Rakhawy, 1979). This is directly related to this dimension.‏

‏The rationale of presenting this trial to differentiate most psychiatric disorders into active or established varieties is mainly introduced to help the psychiatrist to take an active role in the possible positive outcome of the active group. This could help him to be oriented that his role in established group is to activate them optimally to start again another cycle of growth (Rakhawy, 1984 & 1986). This is based on the general conception that most psychiatricdisorders are presentations of abnormal growth pulsations i.e. psychopathogeny.( Rakhawy, 1979) that could be, or should be, altered into normal growth pulsation macrogeny. ‏

‏It seems not enough to judge whether a syndrome is affective or periodical but what looks more essential, whenever possible, is to assess  the possible direction of the outcome. This implies a very optimistic and responsible therapeutic attitude saying that a psychiatric syndrome, though very rare, could be a stage along the ascending limb of growing.‏

DI  Subscale D

Pulsating <=======>Closed circle

Growing<===> Consolidated/abortedPulsating

The outcome of the previous crises (growth or pathological) has been favourable (higher lev­el).

Early development was satis­factory, meaningful and crea­tive.

Premorbid ego functions partic­ularly ARISE and Reality rela­tion are adequate.

Family history declares mainte­nance of growth march till older age.Closed  circle

The outcome of the previous crises (growth or periodical) has been unfavourable(lower level/ deficit).

Early development was handi­capping, poor and splitting.

Premorbid ego functions partic­ularly ARISE and Reality rela­tion are poor.

Family history declares fragili­ty, deteriorated figures, prese-nile decline or excessive number of personality disorders.

The Second Dimension‏

Psychotic<=>Non-Psychotic‏

‏This dimension is not the least new (e.g., O.B.S. in the DSM-II). Abandonment of qualifying psychiatric syndromes by the adjective “psychotic” did not solve the problem of labelling patients as mad.‏

‏However, psychotic and non- psychotic qualifications should not be merely related to the presence or absence of delusions and hallucinations as stressed in both the DSM- III and the ICD-.10 Psychosis as introduced here is mainly related to some other more serious criteria related to personality organization as well as the mode of relating to reality. Moreover non-psychotic is not synonymous with neurotic. ‏

‏Using such dimension independently from the clinical label (Level I), will allow further qualification for syndromes that are not known to be simply psychotic such as “obsessional psychosis” or “dissociation psychosis” (Rakhawy,1989).

‏ On the other hand, one is allowed to add qualifying adjective of this dimension to the syndromes usually taken as psychotic ipso facto- e.g., “Non-psychotic schizophrenia” describing simple or residual types.‏

The Third Dimension‏

Organizational<=>Disruption ‏

‏It should be admitted that this is one of the most difficult dimensions introduced in this paper. It is more related to the structural organization, meaning and teleology‏ ‏of any psychiatric disorder.‏

‏In part I it was proposed that this dimension can replace partly or wholly the organic functional

Dimension II

Psychotic <=========>Non-PsychoticPsychotic

Disorganization of the personality.
Detachment from reality (or muti­lation to reality etc.) Dangerousness to self or   to oth­ers.
Handicapping, interfering    delu­sions and hallucinations.
Lasting deterioration of function & regressive infantile dependency
Use of defensive mechanisms is either massive and chaotic ormarkedly failing.Non-Psychotic

Personality organized even though if it is badly so.

Preserved relation with reality though difficult.

Danger is mild and concealed (particularly that directed towards self)

Delusions and hallucinations are ab­sent transient or least handicapping.

Actual functioning (performance) is difficult or interrupted but still goingon.

Use of defensive mechanisms could be of exaggerated normal pattern.

dichotomy.  The present modification here in part II preserves the term organic but not functional.  Categorizing a syndrome as organic should be related to clinical entity, level I, and is predominantly related to identification of organic causal pathology. Over and above one can identify how much of the presenting symptoms are related to this organic insult and how much they are the result of a trial for reorganization.‏

‏Before going to give further illustrations and rationale I have to admit that  I am not the  least happy about this unfamiliar terms though their roots in structural language are deep and rational. However, I can hardly find better alternatives for the time being.  ‏

‏The so called functional disorders should be approached as much more meaningful, still  though pathological mode of organization. This does not exclude schizophrenia which is still understandable at deeper levels. At the same time, searching for some meaning and looking for some structural organization should also include organic brain syndromes. Like all others, this dimension is an added quality to define how much a psychiatric clinical entity is organizational (goal-seeking) and how much it is disruptive (chaotic).

‏ For instance, Organic Brain Syndrome associated with cerebral atherosclerosis could present by disruption in the form of memory deficit and difficulty in association.  At the same time the associated compensatory orderliness and obsessive symptoms are organizational and so on. Another example of the organic group may clarify matters from another angle; the organic paranoid state due to amphetamine intoxication is purely organic as regards etiology. Nevertheless, it is only partly chaotic, i.e. it is more meaningful and hence partly organizational. In other words this intoxication uncovers hidden meanings and thus presents with goal seeking organization trying to say something, even though it is provoked by some chemical toxin.

‏On the other hand the vegetative negative schizophrenia is very near to the chaotic organic deficit. This chaos surpasses the organizational teleology of schizophrenia and is a result of disuse (Arieti, 1974).

‏The right pole of this dimension (i.e.disruption or chaotic) could be further subdivided into the dissolution / deficit subscale. While dissolution is related to dissolution of the holism of consciousness, the deficit is related to actual, rather permanent, decrease in basic functions due to derangement of the functioning neuronal cells by‏ a rather direct pathological insult.‏

Dimension III
Organizational <======>Disruption

[Goal Seeking<==>Discomposition/Deficit.]Organizational

Dynamically & Teleologicallyreorganized personality but to serve patholgical goals.

Clear consciousness or qualitatively ly and phenomenologically altered levels.

May be associated with chemicalneuropathology

Deficit is mainly a result of disuseatrophyDisruption

Chaotically disorganized personality

Quantitative disturbed conscious­ness (in discomposition variety: deliriurn)

Frequently have known localized.

 pathological etiology.

Could end in lasting deficit due to permanent  derangement   of  neu­rones.

Dimension  III- Subscale

Discomposition/Deficit Subscale Holistic Discomposition Disorders:e.g. Delirium

1-The disturbance is related to (or due to) disorders of consciousness in the form of quantitative diminution (blurring), decomposition (fragmentation) and / or fluctuation.

2-       Other psychic
disturbances e.g in attention
or perception, are
secondary to, or related to,
the discomposition of the
holistic matrix

3-They are usually reversible unless they merge into deficit disorder.Deficit Disruption Disorder: e.g. Dementia

1-The   consciousness   is clear.

2- Disorders of attention and perception as well as other cognitive functions are related to the principal deficit of functioning unit (direct ability).

3- They are usually lasting a commonly irreversible.N.B. Certain psychiatric disorders of epilepsy are either holistic discomposition (acute transient psychiatric episodes) or deficit disruption (in chronic complicated sequelae) disorders.

Conclusions

‏1- The choice of the appropriate dimension is determined by the goal of the diagnosis; whether defining the prognosis, planning for management, assessing legal responsibility or submitting for a research, etc.‏

‏2- Every single dimension needs further elaboration, delineation and detailed description in order to be properly applied. Of course the validity, utility and degree of possible consensuality using such approach, need the effort of a huge number of trained workers in actual clinical practice.‏

‏3-Dimensions that need special experience and lengthy training should be preserved for senior efficient and interested psychiatrists.‏

‏4- It is hypothesized that biological (biochemical) research would prove that the introduced dimensions are qualitatively different not only as dynamic or teleological variants but also as regards the somatic and biochemical monitors and associates. Thus, it would be very essential to consider stand on the significant dimensions in the operational definition of whatever research  sample, especially  in biological researches.‏

‏5-It is not the least mandatory to use any of these dimensions in every case.‏

References:‏

‏American Psychiatric Association (1968) Diagnostic and Statistical Manual of Mental Disorders- (DSM- II) Washington DC: The Association.‏

‏American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders- (DSM- III- R). Washington, DC: The association.‏

‏Arieti, S. (1974) Interpretation of Schizophrenia. London : Grosby Lockwood Staples.‏

‏Egyptian Psychiatric Association (1975) Diagnostic Manual of Psychiatric Disorders- (DMP- I). Cairo: The Association.‏

‏Rakhawy, Y. T. (1979) A study in Psychopathology. Cairo: Dar El Gadd. (In Arabic).

‏Rakhawy, Y. T. (1982) Schizoaffective disorder: An exclusive waste basket or a specific cross-road devolutionary phase. Egypt. J.  Psychiat.,  5: 192-194‏.

‏Rakhawy, Y. T. (1983) Acitve- established dimension. Egypt. J. Psychiat.,  6: 9-.11 ‏

‏Rakhawy, Y. T. (1984) Active therapy  and  brain organization restoring. Egypt. J. Psychiat.,  7: 13-105‏.

‏Rakhawy, Y. T. (1986) Active  alternating activation- tranquilization rhythm.  Egypt. J. Psychiat., 9: 5-7.

‏Rakhawy, Y. T. (1987) Psychic phenomena and the hazards of translation. Egypt. J. Psychiat.,  10: 9-10‏

‏Rakhawy, Y. T. (1990)  Breakthrough  the current psychiatric nosology- Part I. The Arab Journal of Psychiatry,  1: 81-.92‏

‏Rakhawy, Y.T.,Amin, Y., Hamdi, E., Mahfouz, R. and Howiadi, M. (1983) Thought disorder in schizophrenia: Relation to activity and temporal dimensions- Part II. Egypt. J. Psychiat., 6: 213-238.

‏Sartorius, N. (1988) International perspectives of psychiatric classification. British Journal of Psychiatry (Suppl,2), 152: 9-14. ‏

‏World  Health Organization (1988) International Classification of Diseases- 10th Edition (Draft). Geneva: the Organization.‏

Acknowledgement

Thanks are due to all my colleagues, students and participants who have shared in the discussion and trials of the hypotheses introduced, at least weekly, over the last fifteen years. To mention some: R. Mahfouz, E. Hamdi,M. Arafa,  Yousria Amin,M. Hassseeb,M. Howaidi, R. Hatem, H. Souliman, Magdah Saleh,  A. Sobeih, M.Hafez, M. Khater, Siham Rashed, Enayat Abd El-Wahab,  Zeinab Sarhan Amani EL-Rasheedi,  M. Askar, A. Hashem, Lamis EL-Raii, M.El-Batrawy, Azza EL-Bakri, O. Arafa, E. El-Labbad, A. Abulla, H. El-Rawi, G. Salama, A. Jejibian  M.Y.Rakhawy, Fawzia Dawoud,  T.S.Gawad, Ola Shaheen, M. Riad,Z.Haleem,M. El-Nisr, M. Shaheen, Soad Moussa, Maha  Wasfi, S. Abul-Magd, A. Akram, Salwa Erfan,Noha Sabri, Nahed Khayri. ‏

Sepecial gratitude is to those who have particpated in review or research related to some of these hypotheses like Yousria Amin.  E. Hamdi,M. Hassib, Azza El- Bakri M, Howaidi and Nagat EL Nahrawi and A. Ibrahim.‏

I owe a particular debt to R. Mahfouz who has been there all  through all the time. The last modification of this  thesis into two main levels is his achievement.‏

A.Okasha has been tolerant and permissive during  his association as chief editor of the Egyptian Journal of Psychiatry where most prodroma of this approach have been published as editorials.

Comment on Rakhawy”s ‏  Break-through the current‏  Psychiatric Nosology‏

Dr. A. A. Osman‏

Arab Journal of Psychiatry (1991) Vol. 2 No1.  Page 1-13‏

‏This comment was sent to the Journal after the publication of the first part and it was published with the comment  of the author before the second part. In this collection it appears at the end  which is perhaps unfair.‏

‏.I read with interest what Dr.Rakhawy was trying to put forward in that article. However, my interest had soon changed to distress which has generated in me an urge, which I could not resist, to put down the following comments on his prospects and illusions. I have to admit that this distress and an uneasy feeling which I suffered while reading through this article was not solely due to my total disagreement with what Dr. Rakhawy has tried to suggest but was mainly due to the fact that the author was Dr. Rakhawy, one of the senior authorities in psychiatry in Arab World.‏

‏To criticize scientific work is not an easy task to do, and to  qualify to do that you have to equip yourself with enough scientific tools, which are well defined, solid, and testifiable, and not with linguistic philosophical manipulations which are so vague and difficult to understand. the objective should be one of positive contribute to improve things and should have no personal or political motivation.‏

‏Dr. Rakhawy”s prospects and illusions have come with many inconsistencies and contradictions. Most of the points, and questions which he tried to propose and raise  lacked the genuine scientific milieu and were expressed in rather ambiguous if not neologismic words. The issue of nosological difficulty is not unique to psychiatry, a branch which lacks well defined pathological or etiological factors. Such difficulty, is still encountered even in general medicine and other specialities despite their well known etiological and pathological findings. Intolerance to such difficulties and disagreements among different authorities will have devastating negative effect on the progress of scientific research. Nosology is a foundation no further planning can proceed. This reflects the importance of being built on well defined and internationally authenticated pillars. Authorities involved, like Dr.. Rakhawy, should not talk in dialect with their ultimate aim being one of establishing their own identity and independency regardless of the after effects. Dr.. Rakhawy is asking to develop our own nosological classification out of our own experience and clinical practice in our own language. The question which poses itself will be why do we need to do that. Do we need that to establish our independency and integrity and to shake off the deep seated inferiority complexes from ourselves as he is implying, or do we indeed need it to contribute positively in the world scientific reservoir. To me as far as I could infer from Dr.. Rakhawy”s paper, the former and not the latter one is the dominating motivation for his cry for help. We do not need to have our Arab Manual of Nosology to show people that we are as Dr.. Rakhawy in saying “ambitious and independent. and to add original ideas.” This last statement which, in reality, matters. But, adding original ideas not necessarily needs independent nosological discipline. Why we should not contribute by these original ideas to enrich the international nosological system rather than to keep them to ourselves. Moreover, original ideas should be pertinent on our clinical findings and experience if our patients are at all unique to breed such original phenomena or features. I could not understand why Dr.. Rakhawy sees following ICD 10 or DSM III as sort of inferiority and illusion. What difference would it make if we introduced our own nosological system which I am positive will add nothing to what is  available in these manuals. These manuals are multi-axial with broadly defined terms which are flexible enough to accommodate all cross-cultural differences in the content and nature of symptoms to facilitate better understanding to the psychiatric disorders.‏

‏One of the most negative views of psychiatry with its devastating effect is the time honoured misconception that psychiatric disorders are synonymous with socio-cultural problems. Such conception has dominated the thinking of not few psychiatrists in the past, but still now-a-days few of them, particularly those ones who are psycho-dynamically oriented, are still holding such illusion. Dr.. Rakhawy is definitely  one of them who always sees psychiatric disorders through such narrow angled lenses. No one denies the strong influence and contribution of socio – cultural factors in determining the nature and the content of the symptomatology  in psychiatry more than in physical medicine. However, it will be far less conceivable to think that all psychiatric disorders are socio – culturally dependent which necessitates introduction of individual diagnostic manuals to suit each socio – environmental. One cannot deny that the content and the nature of many symptoms in psychiatry could differ significantly from one culture to another, but, ultimately these symptoms are the manifestation of the underlying psychopathology which is relatively independent of culture. Strong unshakable conviction which persists against all logical argument and which is not keeping with socio – cultural norms, will be denoted as a delusion in Egypt as well as in America and U.K. Content of such delusions may be heavily coloured by the effect of socio – cultural factors but the forms will be the same, be it grandiose, persecutory or something else. All diagnostic manuals deal with forms and number of criteria necessary for diagnosis without involving themselves in specifying what is the content or how it started. The same applies in general medicine. Take for example, anaemia, a patient diagnosed as anaemia in U.K. will not be diagnosed as anaemia in a village in Sudan. The range of the level of Hb which matters here, but once anaemia is diagnosed in patient in Sudan it will carry the same significance attached to anaemia in U.K.. On the other hand, a deluded person is Egypt will not be different from a deluded person in U.K. even though the content of their delusions may be significantly different.‏

‏Dr.. Rakhawy enumerated five complications in consequence to the invasion of Egypt by DSM III. Although he mentioned that there is ever increasing published criticism of this malignant spread of DSM III throughout the world, he failed to mention a single reference to substantiate his claim. On the other hand, he went on criticizing the easy acceptance of the world to DSM III which he explained in terms of inferiority feeling and submissiveness which reflects the underlying psychopathology of psychiatrists working in these countries. To me, the opposite is true. Acceptance of such valid and reliable manual which has come out as a result of continuous inspiration to improve current manuals should be seen as a genuine positive gesture to encourage good scientific liason among different centres, and should not be seen otherwise. To me, to reject such effort and not to make use of it for the mere reason of being the product of foreign country is the serious sign of the underlying psychopathology which needs active treatment.‏

‏Let us now have a look to the five hazards and complications mentioned by Dr.. Rakhawy.‏

‏(1)The fact that, DSM III is not actually utilized by its five axes but has been reduced practically to the first axis. I need not go any further on this point more than asking him: – whom do you blame for that, the invasion or the clinicians who are mal-practicing it?‏

‏(2) Failure of DMP I to establish itself.Again it is unfair to attribute this failure on the part of DMP I to the invasion of DSM III.The unwillingness of Egypt psychiatrists to use DMP I & their preference to DSM III should be seen as a result of their dissatisfaction of DMP I for some inherent defect in it rather than due to availability of DSM III.‏

‏(3) In this point Dr.. Rakhawy raised two different issues. The first one is that DSM III is used as a reference for research criteria although he sees otherwise and claims that. However I have found it extremely difficult to understand how a diagnostic manual is not intended for research work. One of the prime aims of diagnostic manuals is to refine diagnoses which cannot be achieved without such strict well defined manuals to facilitate better communication between different research centres. The second point is his assertion that psychiatrists are illuded by using an international language which he claims is the cause of heterogeneous results in research in psychiatry.Such communication is supposed to give birth to a more homogeneous results and not as he said, heterogeneous material and that one of the main reasons why all people are over-concerned of developing such manuals.‏

‏(4) The fourth complication as he said is the divorce which has been established between the longitudinal course of the illness and the presenting mental state criteria which are mainly used in DSM III to label people with specific diagnosis. Most of the criteria of DSM III are indeed inferred from the history and without proper detailed history I doubt any psychiatrist can reach the diagnoses adopted by DSM III with its five axes. Moreover, we should not mix between diagnosis and etiology. DSM III is a diagnostic manual and not psychopathological manual. To diagnose we need criteria but not necessarily we have to know their causes. In general medicine for example, even after such huge expansion in modern medical technology, the time honoured diagnosis of pyrexia of unknown origin (P.U.O.) is still confidently occupying its place in almost every text book  of medicine with no one asking to drop it off because it implies only presence of fever which we do not know its nature. I think all readers will agree with me that all now well established medical illness and syndrome  had been described in terms of such criteria and were known as such long before their etiological or pathological nature been discovered. Few of the well known diseases in general medicine were described first by Arab physicians and we did not hera that European physicians outraged and rejected them for the mere reason of being described by Arabs.‏

‏Dr.. Rakhawy himself unfortunately admits that he teaches his postgraduate students (i.e.potentially psychiatrists) to use DSM III or even DMP I and the reason he forwarded for that was…” for the sake of passing the examination…” and not for the sake of responsible management and prognosis of the patients. As I have already mentioned, all these diagnostic manuals are meant for the better management of our patients and not for the sake of examinations as Dr..Rakhawy has indicated. Quite amazingly Dr.. Rakhawy concluded all nosological disciplines in general and the DSM III in particular are alienating rather than really goal seeking. I wonder on what basis he has reached such bizarre conclusion.‏

‏(5) His argument in this point is contradictory. While he began blaming DSM III for detaching clinicians from their patients he returned back to hold it responsible for labelling patients and consequently giving them drugs and strangely enough he derailed to a new channel which is not related to DSM III and that is the pharmaceutical explosion. I could not really pinpoint which of the two is he blaming. the DSM III or the pharmaceutics. To me neither of them is to be blamed. The clinicians are responsible if such mal-practice is still prevailing. Further more, DSM III neither gives any advice of how to treat these patients, nor which modality of treatment to choose. Interestingly, after such protracted argument about negative effects of diagnostic manuals in practical management of the patients, Dr.. Rakhawy has ended his discussion by stating that “…by passing the nosological problem trying to… this of course has never been possible, simply because such practical problems of management are almost always related to the diagnostic label…” I am astonished now after such long argumentative discussion of the whole issue, Dr.. Rakhawy has come so easily to give up and accept the inpracticability if not the impossibility of splitting diagnostic labels from the practical management of the patients. I need not to comment on his new proposals to improve our diagnostic manuals or skills, for one simple reason and that is all the terms and proposals he is forwarding are extremely ill defined, difficult to understand, more ambiguous, and seriously confusing. And if the whole objective is to improve the currently available diagnostic manuals, we should try to introduce more well-defined terms which are concrete and comprehensible and not amenable to linguistic manipulations and modifications which by far is the most destructive element in the scientific field. I end up ;my points of view by quoting only “..the term discomposition refers more to the dissolution of the holism of the matrix of consciousness while the term deficit is more related to the specific handicap resulting from destruction or out-fall of neurones in a particular domain or locality.” To me, this term is not only ambiguous but mind splitting. ‏

Comment on Dr. Osman”s Comment on the paper “Breakthrough the current psychiatric nosology “Part I”‏

‏It was a great pleasure (painful responsible pleasure !!)  to receive the editor”s letter including this comment on my paper “Breakthrough…”, asking me to comment in turn. To have a serious reader who can shift from interest to distress to suffering to split mind while passing through all this over-inclusive ambiguous material and then takes the pain to comment as such in detail, is something I was really lacking and in due need to face it and start a serious and trustful dialogue.‏

‏After reading Dr.. Osman”s comments many times I could hardly find anything new. This does not mean that Dr.. Osman added nothing. On the contrary he has summarized seriously and enthusiastically all the critics and challenges I have been living facing, and somewhat afraid of, over three decades. By reading Part I again and again before commenting in turn, I hoped that Dr.. Osman could do the same thing, perhaps there would be no place for either his or my comments. However we have to let readers share.‏

‏I wonder if Dr.. Osman has read in the introduction of the paper this statement  ‏

‏”..I felt like preferring to put it together (the prospects and illusions), leaving the reader to select for himself which is which”.‏

‏If he has selected all the proposed and alternative ideas as illusions, it is his right and I am accepting it before hand. But to deny the author from being equipped with enough scientific tools without showing by what scale he is judging the author”s tools or methods, seems to me far away from real objectivity.‏

‏The author, among many others, has a consistent stand towards what is objective and what is scientific (Rakhawy, 1984). I believe that other methodological contributions are to be searched for, all through his publications and supervisions before putting this judgement as such.  This could be available on request.[1]

‏  What is new in Dr.. Osman”s notice in this respect if the author has put it from the start (P 86) as such‏

‏”.. remembering that it is an extremely personal view”? ‏

‏Why did  not he  notice that the introduced proposals are‏

‏”… few headings which may represent essentially certain working hypotheses to be tested in the actual clinical practice” (same page).

‏Why did  not he ask all through his comment for further information about the possible formulation or further connotation of a new term or expression he considered ununderstandable or ambiguous? It is very serious to accept the idea that what I do not understand, what I am not familiar with, is but nonsense !!!

‏However, the delineation between what is personal and what is not, is rather impossible in general and specially so in psychiatric research and practice. I hope it has come to Dr.. Osman”s knowledge that it is by now agreed upon almost everywhere that: real objectivity does not exclude subjectivity and that honest methodological approaches now speak in terms of inter-subjectivity rather than illusions about objectivity. To start by defining and introducing personal views derived from intensive experience and practice over decades, is the right as well as the responsibility of any honest observer. There is no place here to remind my colleague or the reader of what is meant exactly by the phenomenological approach in research (Arafa,1980; Thin,1977 ).

‏ As regards political motivation, I have to admit that this is something not under full volitional control. We are motivated politically whether we know or we do not, simply because we, scientists and lay people, are part of competitive society and the computing power directing us is not always within our reach. We are so motivated not only in the way of passing our leisure time, but also as regards how do we think. I am not the least anti-psychiatric. I know very well what   hazards Lang or Cooper have been responsible for. I consider such movement in my country as some sort of immature luxury that I cannot afford.‏

‏However I should be all the time alert about the undercurrents influencing our thinking particularly  in psychiatry. When I knew that the pharmaceutical agents represent the third or the fourth political lobby in the states I started cautiously to make my own interpretations (Rakhawy 1984). After six years Farmer and McGuffin (1990) read:‏

“Unfortunately the reality is that convergence or divergence of views on classification often reflects the whim of fashion or the pressure of political persuasion. Inevitably psychiatrists, as researchers or as clinicians, need to be responsive to market forces (discharge diagnoses for hospital inpatients must conform to classification “X”, papers submitted to a certain journal will be frowned upon unless the authors use the official diagnostic scheme “Y”). In recognizing this, we must also recognize that our classifications remain but working hypotheses”.‏

‏Perhaps the direct relation is still vague, but let us put it as such: the more man is perceived  as parts apart, the more psychiatric disorders are perceived as the results of changes in chemicals, plus or minus in this or that aggregation of synapses or receptors. The only way, or for tactics, the main way to handle the situation is to give molecules of specific formulae to correct this synaptic pathology. The role of criteria oriented, theory free, diagnostic disciplines is to keep us away from the oneness of human being and to by-pass his urge to integrate along his march‏ ‏of growth.‏

‏Dr.. Osman has condemned and refused most of the introduced concepts, if not all,  simply because he considered them as some sort of “linguistic and philosophical manipulation”.‏

‏As far as language (and linguistics !) is concerned, I hope that he would have time and patience to go through the author’s paper labeled “Psychic phenomena and the hazards of translation” (Rakhawy, 1987).I have shown that language is a biological structure rather than a tool or vehicle. Reviving certain connotations of particular words, specially if these words are not belonging to one’s native language (imported), is as essential,or even more, as examining a patient labeling him by a redundant and/or an ill-defined word. If this responsibility in dealing with words is coupled with the original information acquired from clinical practice, things would change to some better level.‏

‏As regards what he called philosophical manipulation, I believe that it is a scientific honour to handle the problems of cognition and classification through this profound approach. I am afraid that he, like most other psychiatrists, is mis-conceiving what philosophy could, and should, really mean. It is high time to manage decently, but daringly the epidemic of philosophobia that most psychiatrists are suffering from. Philosophy is not solving a chess puzzle. It is not only concerned with the how of thinking or the why of living but also, and perhaps most important in the so what of our teleological march. All such questions are thrown everyday in the centre of our consciousness by our patients. If this is not part and parcel of our everyday practice and responsible worry, what else are we doing? What is really meant by  mental health? Isn”t it by definition promoting growth and participating in shared responsibility with our patients using all the time our chemical and physical tools as well as ourselves (philosophy in daily action)!‏

‏ I was very happy to receive this week a notice from the Royal College of Psychiatrists Philosophy Group Workshop including subjects like the Quantum self and Nosology Taxonomy and the Classification of functional psychosis held in October 1990.‏[2]

‏  I have just remembered, what I have never forgotten, Hippocrates saying that “what fits to philosophy fits to medicine and what fits to medicine fits to philosophy”. I remind the reader that medicine that Hippocrates meant was the art of healing as well as the responsible warm associationism towards a common goal.‏

‏Let us quote a more recent remark. In his introduction to The Born-Einstein Letters, Werner Heisenberg (1971) wrote:‏

‏”…work, of course, based consciously or subconsciously on some philosophical attitude, on a thought structure which serves as a solid foundation for further development. Most scientists are willing to accept new empirical data to recognize new results, provided they fit into their philosophical framework.”‏

‏I am selecting my quotation bearing in mind what I believe that Dr.. Osman could idealize. However  our Arabian history has settled this argument since Ibn Rushd, Ibn El – Hiethum and El – Razy as examples.‏

‏It is not clear how  Dr.. Osman, objectively, has judged what he failed to grasp  as inconsistent and contradictory. Once again, what is the genuine scientific milieu which he missed all the time? What does science and what does medical practice and clinical notes and structured follow up and profound experience could mean to him?‏

‏His comment on the ambiguous language which has amounted to actual neologism is definitely right, I do not deny. On the contrary I feel proud of it.Original ideas, particularly those exploring “other” areas are, by definition, unfamiliar. Describing new ideas  often needs to use new words.This  problem was raised by‏ت‏the author earlier (Rakhawy, 1979 B), which was quoted again in part I (Rakhawy, 1990), as such:‏

“If we dare to put down our thinking  in a different nosological discipline, how much can we expect other developed disciplines” to listen to our neologism ?”

‏ I was not sure that caution should be directed  to our colleagues, here around, first.‏

‏I think that misnomers in psychiatry are too much to be mentioned. I hope that we can dare enough to name observed phenomena as they present to our senses and consciousness as they are. This should be tried first in our language and then translated into their”s if possible. If this fails, and it, not infrequently, does, we have to keep the arabic word and go on using and testing until it finds its way as such when “they” really need it (see Wijdanic / Non-Wijdanic dimension in part II).

‏I think that Dr.. Osman would kindly let me disagree with his inference that (our) main motive is to shake off the deeply seated inferiority. I admit that we are inferior by all means at least as regards structuring, systematization and equipment. However this does not mean that we have to go on as followers all through. Even a little boy can share in a dialect with his ancestors and they would benefit more than if he goes on some uttering echolalia infinitely. I want to remind my dear colleague that they  do need our real responsible sharing  more than anything else. If we insist on limiting our role to adding some cultural fingerprints as decoration and putting some accent here and some extraordinary symptom there, we are but a burden rather than  participants.‏

‏ The relation of culture to psychiatry is not the least like the relation of culture to other branches of medicine particularly as regards special etiology or symptom content of a specific syndrome. Psychiatry is a medical profession that deals with the structural basis of existence, the goal in life and the how of re-channeling suffering and handicapped individuals to live up to their potentialities and aspirations. Cultural studies restricted to enumerating special disorders in a particular area or delineating some different delusional content of particular outcome do not add but very little to the core of psychiatric practice.I do not believe that we can do any good or bear our responsibility in participating in the ongoing march of scientific activity if we merely go on describing some culture bound syndromes as added categories to this or that code (like Latah, Amok or Koro etc).

‏What is needed for a dialect between cultures (transversely) and civilizations (longitudinally) is to uncover basic structural differences in the how of conceptualization  along the way towards complementary synthetic integration between different groups of people sharing common human interest. This lies very deeply in the structural and biological make up of different cultures and individuals. This in turn is basically bound to language as the most significant and available bio-existential structure of human beings (not simply as symbols or vehicle for communication). Language is some basic structural configuration that judges our perception to what is human  in health and disease. I believe that Arabic language is more related to the gestalt mode of conceptualization than the latin-origin languages are. (see also  in Part II what cultural differences should mean).

‏ I am sorry I could not get how Dr.. Osman had this very fixed idea that I am behind developing our own very independent diagnostic discipline. The idea of the DMP-I was inspired by our late Prof. Askar. I Have been taking some major role, with few of my colleagues, in bringing it up to light through preparing the drafts and sharing discussions with our colleagues in the scientific committee of the Egyptian Psychiatric Association over years. In that modest trial we were keen to keep  pace with both the DSM-II and ICD-8 so much so that many categories are simply identical.Quite early I (Rakhawy, 1979 B) raised the four questions that were quoted in the present paper  doubting the value of having an independent discipline. The outcome of this revision as published in part I (p 82-83) was very clear : ‏

‏”…After more than one decade we may think of some sort of practical retreat to recommend taking the ICD 10 as the common basis to which each nation and culture can add its own cultural remarks as special supplement.” (Page 86).

‏I wonder if these are my own words or Dr.. Osman”s. How came that he quotes me as rejecting absolutely following the ICD-10, in spite of  describing its available Dr.aft as having “.. resuscitated our agitation and made us much more trustful and hopeful.. (Page 86).

‏The criteria oriented diagnostic manuals, even after the introduction of the multi-axial approach, are simply providing a frozen alphabet of symptoms that at most would enable different beginners to pronounce the same words. This would never allow looking in the whole text (the patient) as we should.‏

‏Dr.. Osman massively  denied  all the hazards and Dr.aw-backs related to the DSM-III. This made me believe that Dr.. Osman is more royal than the King. I wonder if he is following the critical researches published in the last five years about the subject or not. I am giving some lengthy quotations from one single recent paper  (Anne Farmer   &  Mcguffin,1990)  since I believe that this  is the appropriate answer  Dr.. Osman can listen to in original English language:‏

‏(1)”Operational criteria rigidly impose pre-set diagnostic rules from the top down and the clinician has to decide whether an individual case fulfills these rules or not. Because of this rigidity, the operational criteria inevitably fail to assign a diagnosis to some patients, as they fail to fulfil all criteria, and who, therefore, become “not yet diagnosed”. This is dealt with by the creation of miscellaneous “rag bag” categories which inevitably become more full than a more flexible diagnostic approach encouraged the ICD – 9 clinical guidelines and the CATEGO system”.‏

‏(2)”There may be a tendency (there is certainly a temptation) among clinicians to use clinical judgement to make a diagnosis first and to fit the patient to the criteria second.This we can describe as a “Procrustean bed” error after the practice of the Greek innkeeper of legend to suit his guests to the size of a particular bed by either stretching them or cutting pieces off to fit.This post – hoc method of using operational definitions would certainly be contrary to the spirit with which Hempel suggested they be introduced into psychiatry”.‏

(3)”Most operational criteria have no inherent hierarchy in contrast with common clinical practice where implicit hierarchies are frequently  employed”.

(4)”The multi-diagnostic approach runs counter to the rules of logic, as usually applied in the classification of diseases”

(5) “The last major criticism of the use of operational criteria is that, although they can be used with good reliability (Farmer et al. 1983; McGuffin et al., 1984),without knowing the precise etiology of depression their validity remains in question”.‏

‏ However, the widespread use of anything does not imply ipso facto neither its validity nor its applicability.‏

‏  Birley  (1990) reads:‏

The widespread use of operational criteria means only that the clinicians and researchers may be  using the same criteria, not that the criteria are being used in the same way”.‏

‏Of course  there is  a  mal-manipulation; the DSM-III appears, for the first look,not to be responsible for it. But let us continue reading  Birley (1990):‏

“Any system can of course be criticized for its abuse, but this is unfair and not relevant unless the system is designed so as to lend itself easily‏ ‏to abuse”.‏

‏The DSM-III authorities do not claim that it is designated primarily to be a research tool. However, it is accepted to be so. But let us look in a single category like schizophrenia, which includes an omnibus heterogenous collection that could never represent an adequate sample for a particular research unless further specifications are mentioned. Many a time in my practice (e.g while discussing a thesis) a naive research worker looks very satisfied declaring that his diagnosis is according to the DSM-III with no further qualification. This could mean actually nothing. Moreover the multi-axial approach, if properly used, makes it rather impossible to have a matched sample fit for the so called controlled comparison.‏

‏I quite agree with Dr.. Osman that I  have gone somewhere a little bit far in criticizing the DSM-III as lacking the longitudinal dimension. However I was not referring to the fact that it does not explore the longitudinal axis including development and so on. What I am insisting upon, is to clarify the divorce between such information and the actual formulation of the case. I am not asking for sophisticated psychopathological interpretation but for further categorizing and judging the management as well as the prognosis through considering such factors which should be as essential as the diagnostic label and axes.This is the main concern of the second part of this thesis.‏

‏However, I failed to find the rationale for giving the example of (P.U.O.Pyrexia of Unknown Origin) from the internal medicine  to defend what Dr.. Osman is saying. I do not put particular emphasis on defining the etiology as a prerequisite to diagnose or manage. On the contrary, I am laying more stress on the “here and now” structural configuration of the whole personality which bears little relation to the etiological factors. Of course there is no place to go further in any detail about how to perceive and make use of psychopathology in the ” here and now” (Rakhawy, 1979 A).

‏Whether all diagnostic manuals are meant for management or not is debatable. The prime goal is consensuality whether related to management or not. What counts in management is not to label the patient just as your colleague can do (although this is very essential). In part II most dimensions are directly related to the stand for management not only to abate the disease but also to re-direct the outcome.‏

‏The quotation with which Dr.. Osman, has ended his paper made me see his face in distress and resentment reading words like dissolution, discomposition, matrix and holism without consulting even Webster”s dictionary. However, the hypothesis using these words has been a basic concept for a thesis under my supervision (Noha Sabry, 1989). Revising the current status of the organic brain syndrome and the so called functional disorders have shown that the suggested words are less ambiguous though not necessarily exclusive.‏

‏Let me end my‏ت‏comment by  hoping that Dr.. Osman could appreciate my real gratitude for his serious comments which have helped me to clarify more what I meant to say and in the same time to feel less lonely. I believe that his critical comment has been much more valuable to me than the hostile nihilistic silence or superficial undoing.‏

References:‏

‏Arafa, M. (1980) Phenomenology and the Scientific Research of Man. Man & Evolution Journal, 3,2&4 : 20-8,59-41&6-.25‏

‏Farmer A. & Mcguffin, P.(1989) The Classification of Depressions: contemporary confusion revisited.British Journal of Psychiatry, 155 : 437-.443‏

‏Birley, J.L. (1990) DSM-III : From Left to Right or From Right to Left. British Journal of Psychiatry, 157 : 116-.118‏

‏Heisenberg, W. (1971) Introduction in the Born Einstein Letters (Translated By I.Born) New York : Walker & Co.In Contemporary Issues in Schizophrenia Ed Alan Keper & Philip Smith.‏

‏Rakhawy,Y.T.(1979 A) A study in Psychopathology. Cairo: Dar El Ghad.(In Arabic(

‏Rakhawy, Y. T. (1979 B)  Psychiatry in Egypt to-day  Egypt. J. Psychiat., 2: 19-.26 ‏

‏Rakhawy, Y.T.  (1980) In Researchs on Childhood and Insanity : the observer is both the tool  as well as part and parcel of the field of research  Man and Evolution Journal,  4 : 26-45‏

‏Rakhawy, Y.T. (1980) The researcher as the research tool &field in the study of  and Childhood and Insanity.Man and Evolution Journal, 4 : 26-.45‏

‏Rakhawy, Y.T. (1984) Pharmaceutical interpretation of  recent psychiatric theorization. Man  and Evolution Journal, 5 : 18-.40‏

‏Rakhawy, Y.T. (1987) Psychic phenomena and the hazards of translation. Egypt. J. Psychiat., 10: 9-.10  (For Arabic readers, I hope Dr.. Osman is one of them, the original paper have been read in the third Pan Arab congress Held in Amman  March 1987)

يحيي‏ ‏الرخاوي‏ (1987) ‏اللغة‏ ‏العربية‏ ‏والعلوم‏ ‏النفسية‏ ‏الحديثة‏ – ‏القاهرة‏.‏

‏Rakhawy, Y. T. (1990)  Breakthrough  the current psychiatric nosology – Part I. The Arab Journal of Psychiatry,  1: 81-.92‏

‏Thin, G. (1977) Phenomenology and the Science of Behaviour. London: George Allan & Univ.‏

‏Zimmerman (1988)  Why are we rushing to publish D.S.M. IV? Archives of General Psychiatry, 45 : 1135-.1138 In Birley, J.L. (1990) DSM-III : From Left to Right or From Right to Left. British Journal of Psychiatry, 157 : 116-.118‏

[1]- Almost all my scientific worries and research have  been centered around this very topic (the nature of objectivity and the challenge of methodology in our speciality). If I am going to recommend a list, I am about to put down a  western tradition, my C.V., something I never liked or have been convinced with‏

[2] – Without mentioning further details about other conferences held simultaneously, such as : the Science of Consciousness (20th October 1990 University of London) or phenomenology, language and schizophrenia that is going to be held in March 1990 in University Psychiatric Clinic Heidelberg.‏

أضف تعليقاً

لن يتم نشر عنوان بريدك الإلكتروني. الحقول الإلزامية مشار إليها بـ *

يمكنك استخدام أكواد HTML والخصائص التالية: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>