Five reasons for teaching psychopathology

The rediscovery of psychopathology is among the top priorities for psychiatric training and practice (1). Early career psychiatrists are not satisfied with the training they receive in psychopathology. They solicit an improvement of their educational opportunities in this field, asking to couple theoretical knowledge with practical clinical skills (2).

For the past generations of residents in psychiatry, as M. Maj reminds us (3), Jaspers' General Psychopathology was a prescribed reading. The familiarity with that and other classics of psychopathology helped them to see the DSMs as synopses of available knowledge and diagnostic algorithms to be used for clinical purposes (4). This may not be the case for current residents, which involves a high risk of misunderstanding and oversimplification.

In a survey we carried out among the representatives of national associations of European early career psychiatrists (2), it emerged that trainees, perhaps more than academicians, seem to be well aware of that risk, as they complain about the quality and the quantity of training they receive in psychopathology, and ask for more hours in clinical practice under the supervision of an expert in psychopathology. National and international bodies that are responsible for education in psychiatry should seriously re-consider the importance of psychopathology in training curricula, given its role in psychiatric diagnoses, its importance in understanding and explaining mental disorders, and its capacity to re-humanize psychiatric practice.

There are no common guidelines on training in psychopathology worldwide. There is not even an agreement about the meaning and the purposes of the discipline called “psychopathology” (5). The main misunderstanding is, perhaps, that psychopathology is the name of an old-fashioned religious sect celebrating the dogma that psychiatry should be part of the medical humanities rather than a biomedical science. Actually, psychopathology is a discourse (logos) about the sufferings (pathos) that affect the human mind (psyche). It brings into focus the primary – although not unique – “object” of psychiatry: the psyche, that is, patient's abnormal experiences lived in the first-person perspective, embedded in anomalous forms of existence and structured according to unusual meaning patterns.

There are at least five reasons for psychopathology to re-become a fundamental column of psychiatric training. The first reason is the need to provide psychiatrists with a method enabling them to capture the subtle nuances of the patients' experience that constitute the essentials of the “psychiatric object” (6). The precise characterization of these nuances is, at present, the only secure basis for diagnosis and treatment, since experiential symptoms are by far more specific diagnostic indexes than any other kind of symptoms, including behavioural ones (7).

The second reason is the need to acknowledge that what patients manifest is not a series of mutually independent, isolated symptoms, but rather a certain structure of interwoven experiences, beliefs, and actions, all permeated by biographical details (8). What stands in front of the clinician is not an amorphous agglomerate of symptoms, but a person with a specific, meaningful and (to a certain extent) coherent “form of life”.

Obviously, psychopathology helps to rehumanize psychiatry, but this does not mean that it stands against science. Psychopathology, being the science of human abnormal subjectivity, is a peculiar kind of discipline characterized by an and-and agenda: it brings into a clear epistemic focus the fact that psychiatry is based on two main, complementary methodological approaches: explaining and understanding. We causally explain a phenomenon when we find, by repeated experience, that this phenomenon is regularly linked to a number of other phenomena. This allows us to formulate general rules and to establish causal connections with subpersonal causes. The third reason to teach psychopathology derives from this: it helps to causally explain a given abnormal phenomenon, or a set of abnormal phenomena, since it helps characterizing them. Any phenomenon, in order to be explained, must first of all be described in the greatest detail.

The fourth reason for teaching psychopathology is that mental symptoms do not simply have subpersonal causes, but also have a personal feel and meaning. Psychopathology is a method for grasping the personal feel and meaning of an experience or set of experiences. Understanding is not the effect of a generalized knowledge, but is achieved by sinking ourselves in a singular situation. Thus, psychopathology preserves the individuality and uniqueness of the suffering person.

Psychopathology can operate in parallel with a traditional biomedical approach, since it does not exclude seeing abnormal phenomena as symptoms caused by a dysfunction to be treated, but additionally includes the exploration of personal meanings (9). The sick person, as a self-interpreting agent, plays an active role in trying to cope with and make sense of his/her aberrant experiences. Psychopathology conceptualizes mental symptoms as the outcome of a mediation between the person and his/her abnormal phenomena (10).

The fifth reason for teaching psychopathology is that the personal background, as a pre-reflective context of meaning and significance within which and against which persons construe the significance of their abnormal phenomena, should be part and piece of a thorough psychiatric assessment.

Psychopathology, as the discipline that assesses and makes sense of abnormal human subjectivity, should be at the heart of training in psychiatry, and a key element of the shared intellectual identity of clinicians and researchers in this field (11).