LETTER TO THE EDITOR

Five reasons for teaching psychopathology

The rediscovery of psychopathology is among the top pri-orities for psychiatric training and practice (1). Early careerpsychiatrists are not satisfied with the training they receivein psychopathology. They solicit an improvement of theireducational opportunities in this field, asking to couple the-oretical knowledge with practical clinical skills (2).

For the past generations of residents in psychiatry, as M.Maj reminds us (3), Jaspers General Psychopathology was aprescribed reading. The familiarity with that and other clas-sics of psychopathology helped them to see the DSMs assynopses of available knowledge and diagnostic algorithmsto be used for clinical purposes (4). This may not be the casefor current residents, which involves a high risk of misun-derstanding and oversimplification.

In a survey we carried out among the representatives ofnational associations of European early career psychiatrists(2), it emerged that trainees, perhaps more than academi-cians, seem to be well aware of that risk, as they complainabout the quality and the quantity of training they receive inpsychopathology, and ask for more hours in clinical prac-tice under the supervision of an expert in psychopathology.National and international bodies that are responsible foreducation in psychiatry should seriously re-consider theimportance of psychopathology in training curricula, givenits role in psychiatric diagnoses, its importance in under-standing and explaining mental disorders, and its capacityto re-humanize psychiatric practice.

There are no common guidelines on training in psycho-pathology worldwide. There is not even an agreementabout the meaning and the purposes of the discipline calledpsychopathology (5). The main misunderstanding is, per-haps, that psychopathology is the name of an old-fashionedreligious sect celebrating the dogma that psychiatry shouldbe part of the medical humanities rather than a biomedicalscience. Actually, psychopathology is a discourse (logos)about the sufferings (pathos) that affect the human mind(psyche). It brings into focus the primary although notunique object of psychiatry: the psyche, that is, patientsabnormal experiences lived in the first-person perspective,embedded in anomalous forms of existence and structuredaccording to unusual meaning patterns.

There are at least five reasons for psychopathology to re-become a fundamental column of psychiatric training. Thefirst reason is the need to provide psychiatrists with amethodenabling them to capture the subtle nuances of the patientsexperience that constitute the essentials of the psychiatricobject (6). The precise characterization of these nuances is,at present, the only secure basis for diagnosis and treatment,since experiential symptoms are by farmore specific diagnos-tic indexes than any other kind of symptoms, includingbehavioural ones (7).

The second reason is the need to acknowledge that whatpatients manifest is not a series of mutually independent, iso-lated symptoms, but rather a certain structure of interwovenexperiences, beliefs, and actions, all permeated by biographi-cal details (8). What stands in front of the clinician is not anamorphous agglomerate of symptoms, but a person with aspecific, meaningful and (to a certain extent) coherent formof life.

Obviously, psychopathology helps to rehumanize psychi-atry, but this does not mean that it stands against science.Psychopathology, being the science of human abnormal sub-jectivity, is a peculiar kind of discipline characterized by anand-and agenda: it brings into a clear epistemic focus thefact that psychiatry is based on two main, complementarymethodological approaches: explaining and understanding.We causally explain a phenomenonwhen we find, by repeat-ed experience, that this phenomenon is regularly linked to anumber of other phenomena. This allows us to formulategeneral rules and to establish causal connections with sub-personal causes. The third reason to teach psychopathologyderives from this: it helps to causally explain a given abnor-mal phenomenon, or a set of abnormal phenomena, since ithelps characterizing them. Any phenomenon, in order to beexplained, must first of all be described in the greatest detail.

The fourth reason for teaching psychopathology is thatmental symptoms do not simply have subpersonal causes,but also have a personal feel and meaning. Psychopathologyis a method for grasping the personal feel and meaning ofan experience or set of experiences. Understanding is notthe effect of a generalized knowledge, but is achieved bysinking ourselves in a singular situation. Thus, psychopa-thology preserves the individuality and uniqueness of thesuffering person.

Psychopathology can operate in parallel with a tradi-tional biomedical approach, since it does not exclude see-ing abnormal phenomena as symptoms caused by a dys-function to be treated, but additionally includes the explo-ration of personal meanings (9). The sick person, as a self-interpreting agent, plays an active role in trying to copewith and make sense of his/her aberrant experiences.Psychopathology conceptualizes mental symptoms as theoutcome of a mediation between the person and his/herabnormal phenomena (10).

The fifth reason for teaching psychopathology is thatthe personal background, as a pre-reflective context ofmeaning and significance within which and against whichpersons construe the significance of their abnormal phe-nomena, should be part and piece of a thorough psychiat-ric assessment.

Psychopathology, as the discipline that assesses andmakes sense of abnormal human subjectivity, should be at

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the heart of training in psychiatry, and a key element ofthe shared intellectual identity of clinicians and research-ers in this field (11).

Giovanni Stanghellini1, Andrea Fiorillo21Department of Psychological, Humanistic and

Territorial Studies, G. dAnnunzio University, Chieti,Italy and Diego Portales University, Santiago, Chile;

2Department of Psychiatry, University of Naples SUN,Naples, Italy

References

1. Fiorillo A, Malik A, Luciano M et al. Challenges for trainees inpsychiatry and early career psychiatrists. Int Rev Psychiatry 2013;25:431-7.

2. Fiorillo A, Sampogna G, Del Vecchio V et al. Is psychopathologystill the basic science of psychiatric education? Results from aEuropean survey. Acad Psychiatry (in press).

3. Maj M. Introduction: The relevance of Karl Jaspers General Psy-chopathology to current psychiatric debate. In: Stanghellini G,

Fuchs T (eds). One century of Karl Jaspers General Psychopa-thology. Oxford: Oxford University Press, 2013:xxiv-viii.

4. Frances A. The past, present and future of psychiatric diagnosis.World Psychiatry 2013;12:111-2.

5. Stanghellini G. The meanings of psychopathology. Curr Opin Psy-chiatry 2009;22:559-64.

6. Parnas J. The Breivik case and "condition psychiatrica". WorldPsychiatry 2013;12:22-3.

7. Stanghellini G, Raballo A. Differential typology of delusions inmajor depression and schizophrenia. A critique to the unitaryconcept of psychosis. J Affect Disord (in press).

8. Stanghellini G, Fulford KWM, Bolton D. Person-centered psy-chopathology of schizophrenia. Building on Karl Jaspers under-standing of the patients attitude towards his illness. SchizophrBull 2013;39:287-94.

9. Fulford KW, Bortolotti L, Broome M. Taking the long view: anemerging framework for translational psychiatric science. WorldPsychiatry 2014;13:110-7.

10. Stanghellini G. Psychopathology: re-humanizing psychiatry. ActaPsychiatr Scand 2013;127:436-7.

11. Stanghellini G, Broome MR. Psychopathology as the basic sci-ence of psychiatry. Br J Psychiatry 2014;205:169-70.

DOI 10.1002/wps.20200

108 World Psychiatry 14:1 - February 2015