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.

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.‏

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