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Methodological problems of psychiatry
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1.)6-1 J, 1,]. NII~YI~,i~I l r l l , l l l i O l l 0 d tilt, t,ollll|)oriltiOil of tilt" l!syei~i~lirie t~.OsltiI N .tal,s ( o f. Ih/~ . . tllliV().rsilil's . ill l{i'liillg('l/, ~X;lllJliZ, ~ l i i l l s l t , r, ]l(_liltbtll"g lill(:l \V('s.| l~e.rllil ili +~. hqtlq" Io tills joilrlll;lt l i } ) o l i l p s ) , c h i a l r y ili (~;Ol'llliltl-.~p{~l~ilti~ CI)lli~i Iril:'s/'" T h i s e o l h l } ) ( l l ' l i l i o i l ~wigii~al¢-d f r o m lh,:, l)rOlt|onls l?ll¢2Oillilt)n.,d dill-ill{( (:liliil:lll l<'.slhig~ Of l).S)'(+hopharnlacologie drugs," Ill l h e lilOlllllilYlO, lll(~ ~{VO p~),eliititri(" nltivor.,171L)" tloSl)ihlls ~lf Switz~.,riand a n d .ill(, Psyc:hhitri¢" Uni~,'t'Itsil¥ iliiSl)illlls (if %/iOllllll hlivl~ llo('(liill~ ~iNNO(;ili{.(~l xVilll flit." (;('l'lll~ili g r o l l i t . ~T I l e n(,t,d tt)r illli~l'li'i'(?d it..~slivlt~ l r i e l l t o d s ro~l'lli-od lit i n t e l i s i i i o d StlldiO$ lit i l i o proliit~ili.,; Ill c rto(~tiltll'Illlitlliit illill SI~ItiSl:i('s, ]Dlltk t¢) tills, tht" Jlll('l'('st ot: tiit~ ~1"Oll i) sliit'ted t r o i l l .l)!il'~; d r i i ~ le.~iilil( 1o t4('ne.ral i l l o l h ( i d o l o g i ~ a l prot)li.'ilis (if l)SXrc~hll.ltrio re.~l.~;Ir(~ll. Ill o i ' d i - r . f o t*it('ililal~, till' tlliil](",r~;titildirig of lhos(~ prol.~ic'~ns we, w i s h to tlisc~lss ( 1 ) 'their hi,~t¢iri(,al .r~)ots, to, .~onit; CIlITUIII (,'()II¢'(.'|){N. l l l l ( l ( 3 ) difHculi it-s ilt lilt-" till, ¢)f thi'st'. ¢.'oilt~o|)ty; (ill i h e 1);Isis (:if li t*~w t-
l'~>'c'iliatry itl (;erman-sp**akilJg~ ¢'ot~l~lries is c|lar~tolt~rized |>y its leltclelJ(~y t o w a r d sys!enis of ('hlssi[]eation/* i~i~l~t), years ago Kraept:l/n b(~gan to evoh'{" ih~, svsl~.m which is still mo~t bro.,itlly used, t,speeially in the.- form of S(.tu.~/th.r's tr/adic systonl, whiclt izlc:lud¢,s lhe gro~H~s of symptonl:ttic; psyc}~ose,s, i'liC|l)~t~iiltll,N l)S),etaos(.,~ ;lil(t l~sy(~tlore:lctive (lisorders. *~ "Fllis syslt'lll, ix 1lasted oil (,al'oi-ltl (.'~lSt~ s l i l d i l , s lltid Oil |)|l/,ilOlil(~ii()logllj arid Iogi¢~al-defiilitory illtll|),NiN of il~dividua! l)-s)'t~liOl);ll|loltlgi(.~li] i)tlu[IOlllt.~ll~l. "l'ii(~.'il' ln¢,iiiods r~*pc'~il(~ll)- (tOlltirill(,(t thi., li;lsi(: t)lllliltlx,; o f the SyStl'rtl, b i l l l h l ' i r nlort- dilii:l-t, l i t l l l l o : l sllt),~I'()Ili)N Chan~,'d ~{tlit(,~ t)t'tl'l:l. Kril('t)t:]iii t l i l i i s t ' I f rel-l¢'iltt,dly cilalig~'d lii.s .sy'st¢.'itl ill tilt, llilit.'. (,(iilioil.,; o|' Ills t{Jxli)ook w l i i C i l :il)tie.;lred })~.'tw(~(,~l 1883 lili(l J$):~7. !I(~ ;irri'¢(~d :it i|lt~ fii]|ovcillg~ t:Oiit'tllsi/)ll: " ' { V i t ] l i l i t~t:l'l~illi l i r l i i t ; l t i o l t s ali~watiltils ill ¢iii1" di~tgll,osii(y t.:llissiiri(~:ition i.i( I)ill" t)iilil~liis w i l l pri)vidt~ i I t t ' o r t l i l i t i o l i ~-ls Ill wii(~'ilil~r ill- lit_)t ~,x.-t; It;ivy: itlr(~;ld)" aehit-t'(-d ~i lil(;)l~y (,x~iet c'ollla('t; xvit|i i't,iilll),. "':~'~ l,~rlioltolili iri¢,d 1() tIv(.~i'~.,Olilt ~ t h i s iili(.~l?rlilili[)' l : n l p i r i o l i i l ) ; }))+ iitirodtlc-ilil~ s)'.,;ll~.liiillit:'d(icUtll~.'lll~llioll io ps),('lli;llry.:-': !1~' xvrotl, Ihe si~ili|ic~illl poilil.s oJ[ it liX)'~:ilialri¢: (:list" h i s t o r y OlliO V(II'iIiIIN ()ili'ds, w h i c h lll'ovidt, d l i i n i w i t l t a lx, litlivt, l)* r a p i d x l i r x l , v ql~ ill|lit), p ; i l i ( ' l l t s ;|lid w i l i c i i n i a d o spi,t.ia] lhiding.s r e a d i l y awailill)It,, tit }li.s Olillii()ll, ()lily s l t i r i l l g (11 Illl, ('lliii't' t']/liiC;ll Oll.~,('l'V~'lli()ll lll~tll)l'i;ll ill ii ilSiilll¢' illl'ltl p r o v i d e d ll real t i u s s i l ) i i i t y to t'vlihl~ill, s c h ? l l i t i < : a l l y tilt- d a l l y t)i).st~l'ViiliitllS (if gl,ii(-l'ltlililis ()[' l)ii).,,;i(,i{lllg illsl(~;td of ,';('l'liild i}lt~llt |)(;riililli('.ltl|%' tlisitlili(.iir ilt tilt. iiill('('t'NNi|,)](" ()(!t';lll Ill filed ('|is(, hisl(wit.s. T h i s lii~'liil)(l, h o w / " f i l m t/t,. l',sl/('/tilitrit" , t l d ,%i'l'ttroIoi'.if-,~t'~:11. I!. lli-:i,~ll'lii:,,~, |'illi', i), "I'. l)il. ~Xlli~ ii. lill,l,ll's. ]'lilt. l). :1". |)It..tll:li : [ ll~.rliti l~.& Nii.lsl#ait,l,llc+" :J0-.'t,%>
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over, was n o t g e n e r a l l y a c c e p t e d . A p p a r e n t l y the a m o t m t of w o r k r e q u i r e d ~or it was excessive. T i m e was p r o b a b l y not y e t r i p e for the r e a l i z a t i o n t h a t p s y c h i a t r i c d o c u m e } a t a t i o n is a n t m a v o i d a b l e n e c e s s i t y . At t h a t time, t h e c o m p l e x i t y of p s y c h i a t r i c c o n d i t i o n s was i n c r e a s i n g l y reco g n i z e d . M e t h o d o l o g i c a l c o n c e p t s , such as K r e t s c h m e r ' s " m u l t i ~ d i m e n s i o n a l d i a g n o s i s " a n d B i r n b a u r n ' s " s t r u e t t m f l a n a l y s i s , " o f f e r e d to take s u c h comple.xitics i n t o c o n s i d e r a t i o n b u t c o u l d i n i t i a l l y o n l y be u t i l i z e d i n t u i t i v e l y . ';,:':' At first this " ' a n a l y t i c - u n d e r s t a n d i n g " m e t h o d s h o w e d its v a l u e in c l e a r - c u t eases a n d S e e m e d n o t to r e q u i r e d o c u m e n t a t i o n . L a t e r . S c h n e i d e r d e f i n e d psychopath(~logical p h e n o m e n a v e r y eareflflly. His p r e c i s e a n d r e a d i l y u n d e r s t a n d a t . q e defi n i t i o n s g u i d e t h e d i a g n o s t i c process of the clinical s t a t e of s c h i z o p h r e n i a t)cc a t , s o o f the f r t x l u e n c y a n d conjm~etion of s y m p t o m s , e'tlled " s y m p t o m s ~If the first o r d e r " ( S y m p t o m v elwtel~ l{an.ge.v).:' 1-towever, t h e <)perational a n d st~ltistical b e g i n n i n g c o n t a i n e d in this a p p r o a c h R)r a classification of c o m p l e x psyc h i a t r i c c o n d i t i o n s c o u l d n o t f u r t h e r e v o l v e b e c a u s e of t h e lack of suital)lt" methods. 1[ In t h e meantime:, t h e s e f r a m e w o r k s of t h o u g h t h a v e e v o l v e d on tile basis o[ c l i n i c a l o b s e r v a t i o n s , a n d a d e q u a t e m e t h o d s f o r t h e i r e r n p i r i e a l t e s t i n g haw.' also d e v e l o p e d . VVithin tim last f e w y e a r s t h e c o n c e p t of n o s o l o g i c a l e n t i t y its a disease, u n i t d e f i n e d by t h e s a m e etiology', s a m e s y m p t o m s , a n d satile c o u r s e has b e e n p r o g r e s s i v e l y d i s p r o v e d . It b e c o m e s i n c r e a s i n g l y Obvious t h a t p s y c h o p a t h o l o g i c a l s y m p t e m s a r e nonspecific. -'7 l;'ro,n tim s a m e ps~,chopathoh)gical s y m p t o m s o n e can n e i t h e r a s s u m e t h e s a m e e t i o l o g y n o r tile s a m e p r o g n o s i s in e v e r y case. T h e d i a g n o s t i c s i g n i f i c a n c e of a s y m p t o m results o n l y f r o m its context--i.e., the s i m u l t a l l e o u s p r e s e n c e of o t h e r s y m p t o m s a n d t h e i r sequ(zntial d e v e l o p m e n t . F . x a m i n a t i o n o f t h e c o n n e c t i o n b e t w e e n t h e p r e s e n t i n g syml)t o n m t o l o g y a n d its e t i o l o g y ( " v e r t i c a l , " n o s o l o g i c a l h y p o t h e s i s ) .is n o w •.-'-eompanied l)y e x a m i n a t i o n s p e r t a i n i n g to c e r t a i n c o m b i n a t i o n s of c h a r a c t e r istics w i t h i n t h e p s y c h o p a t h o l o g i c a l s y m p t o m - c o m p l e x e s ( " h o r i z o n t a l . " synd r o m a l h y p o t h e s i s ) . T h i s s h i f t of t h e focus of e x a m i n a t i o n n o w m a k e s o u r d a t a m o r e verifial)le, sinc-e m e t h o d s for tile t e s t i n g of tile "'horizontal" h y p o tlmsis are c u r r e n t l y at a m o r e a d v a n c e d s t a g e t h a n t h o s e l)y w h i c h it is p o s s i b l e to v e r i f y or falsify " v e r t i c a l " hypotheses.:' In iilm w i t h t h e s e d e v e l o p m e n t s , t h e c o n c e p t of n u m e r o u s f a c t o r s l~eing responsil>le for the e t i o l o g y of p s y d l i a t r i c d i s o r d e r s (miiltivondiiiolmlc Gencsc) has g a i ~ , d i n c r e a s i n g i m l ) o r t a n c e . No l o n g e r does o n e ask o n l y for tile c a u s e of t h e disease, h u t o n e asks p r e d o m i n a n t l y for Ill,.- co~Hitions o f t h e clinical sytldroHu:. ''''':-z" T h i s slfift is prolmlfly dlu: c-hi~'tlv to t h e f a c t t h a t t'xami~mtiol~ ~m dn c t i o l o a i c a n d l m t h o g e n e t i c level t'nc{)tHitt'rs e'¢('~l znore oxtensiv(' m e t h o d o l o g i c ; t l difFielHti~,s t h a n e x a m i n a t i o n s c>~ a elinical-desc,ril)tive h'vcl, Most of all, l m w c v c r , it was the irnmenst, a m o u ~ t of clinical observatiomls ot i n d i v i t h u d lmtiel~ts w h i c h h a v e c o n f i r m e d tilt, p r a c t i c a l axed t i m o r c t i c a l imlmrl a n c e of t h e multi f a c t o r (.o,~cept "l'hlas, still withizi the n o s o l o g i c a l conCel:~t, t l o t f , :X.rnold a n d l l o l t J n a n of V i m m a h a v e w o r k e d o u t at m o d e l tff tim %nultifaettw ~,tiology of schizop h r e n i a . "'~ A c c o r d i n g to tiffs ;t h e r e d i t a r y , specific ,,nz.vmp ab~Jormality din'clops
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into a p s y c h o s i s d u e to the most va~ried e n d o c r i n e , 4 e g e t a t i v e allot psychod y n a m i c f a c t o r s . I n d i v i d u a l , specific r e a c t i o n s are addecr to the s y m p t o m s a n d the course of the psychosis. Z u t t listed a numbe!7 of hereditaD,, d y n a m i c a n d s o m a t i c c o n d i t i o n s a n d the ide~i of p a r a n o i d a t t i t u d e shifts d e v e l o p i n g f r o m crises e x p e r i e n c e d d u r i n g life as "'nosologieal hypotheses.":'" In b r o a d l y t:msexl, e p i d e m i o l o g i e a l l y o r i e n t a t e d field studies K i s k e r a n d his co-workers h a v e e x a m i n e d the various social a n d b i o g r a p h i c a l r e q u i r e m e n t s for s e l H z o p h r e n i e m a n i t e s t a t m n s . . \Ve a t t e m p t e d to e x p l a i n the, o c c u r r e n c e of p s y c h i c sideeffects of t h e p s y e h o p h a r m a e o l o g i e a l d r u g s on the basis of t h e c o m p l e x interactions of a i m m b e r of r e q u i r e m e n t s , w h i c h a r e d e t e r m i n e d b y the d r u g , t h e b a s i c disease a n d the i n d i v i d u a l disposition ("sYnch'ome-genetie t r i a d " ) . ~=~'.e'','-~': l t e r e a g a i n we f o u n d it q u i t e v a h m b ] e t o l e a v e t h e n a r r o w nosologieal concept."; T h u s , b y c o m p a r i n g e n t i r e l y different dise, ases w e w e r e a b l e to o b t a i n findings that Support the old hyt~othesis that tim a c t u a l psyclaotic s y m p t o m s are not o n l y d e t e r m i n e d b y the t y p e of disease, b u t are also c o n s i d e r a b l y inltueneed, b y the intensity, the acuity, the d u r a t i o n a n d o t h e r Imn-nosologieaI criteria of the disease course. T h e s e diffe.rent s y n d r o m e - g e n e t i c " i n f l u e n c e factors" f r e c l u e n t ] y asstmle a profile suitablt:- for e x a m i n a t i o n o n l y d u r i n g the course of the diseast'. T h u s ( ; r i e s i n g e r a l r e a d y a s s u m e d t h a t the various clinical forms of l u n a c y arc a c t u a l l y o n l y i n d i v i d u a l s e g m e n t s of the u n i f o r m c o u r s e of the p s y c h i c disorder, as in m e n t a l c o n d i t i o n s the s y n d r o m e s rnolanclaolia, m a n i a , craziness, eonf~lsion, a n d s t u p i d i t y q u i t e f r e q u e n t l y sueeeecl o n e a n o t l m r ill an o r d e r l y m a n n e r . " S p e e h t felt that dilfc:renees in the i n t e n s i t y of t h e disease-prochmirlg taetors w e r e r e s p o n s i h l e for the chalage of the s y n d r o m e s d u r i n g the, course of the d i s e a s e . " Later, it was esp{eeially Biissow w h o d e s c r i b e d the c o n t i n u o u s s e q u e n c e o | "'encloge,.mus" a n d "'exogenous" p r e s e n t i n g s y n d r o n m s d u r i n g lhe course of l~s.vehosis a s s o c i a t e d w i t h pc'rnieious a n e m i a . '~ C o n r a d p r e s e n t e d a n a n a l o g ( m s s y n d r o m ( t s e q u e n c e in the beginvJing of sel~izot)hrenia. ~'-' By u s i n g g e n e r a l p a r a l y s i s of the i n s a n e as a n exanq~le, Zeh rec,~'ntl~" e x p l a i n e d that various p. ~,chop,dhologlcal svndromt'.s do not lmvp to r e p r e s e n t varitms forms of the paralysis, b,tt m a y also b e a eross-seetiona/ e x p r e s s i o n o f at ,uore or less p r o t r a c t e d c o n t i n u o u s a l t e r a t i o n of p s y c h i c ttmcetmns," ' ' T h e s e e x a m p l e s e m p h a s i z e t h e m e t h o d o l o g i c a l valut- of o|)servations of the course of disease. ( T h e similar-apl~eav-illg eovit't*pls of "'lnnif{~rnl l~syc'.hosis"" (Einiteitp.~'t.lchosc) that are c u r r e n t l y a d v o c a t e d in ( ; e r m a n y , p r e d o m i n a u t l y b v R e n n e r t as tlwe "'nni~oersal etiology of eJlclo,~enolls psyt.hoses'" or b y J a n z a r i k as tim " ' d y n a m i c base-eonstella!iolv of e n d o g e m m s l)syehoses'" cavmt~t b e consid~.red here.:"'."") O n l y l h r d e v e l o l m , e n t a n d rt.missi
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¢.riteria of s y n d r o m e - g e n e t i c factors--e.g., type a n d d y n a m i c s of disease-producing a n d d i s e a s e - s u p p o r t i n g influenees, on one hand, a nd " p r e c o n c e i v e d structures, ':~:~ on the other h a n d - - b e c o m e m a n i f e s t only in t h e disease course profiles, vchich are f 0 n n e d by" l i n k i n g the s y m p t o m s a n d s y n d r o m e s w h i c h occur in t e m p o r a l sequeneeY a T h e s e e m p i r i c a l l y f o u n d e d concepts h a v e m e t h o d o l o g i c a l consequences, T h e y d e m a n d the use of m e t h o d s that c a n deal w i t h the n e w l y recognized complexities. T hese m e t h o d s are a v a i l a b l e b u t they c a nnot yet be used for an objective study of such concepts. ()he significant p r e r e q u i s i t e for such a study' has b e e n fulfilled only i n c o m p l e t e l y : It is c u n ' e n t l y imtmssible to r e p r o d u c e the p s y c h o p a t h o l o g i c a l states w i t h o u t distortion a n d to describe t h e m in s u d l a m a n n e r that the statistical m e t h o d s can be used s e n s i b l y a nd their results intm-preted clearly. III Accurate r e p r o d u c t i o n of comple x p s y c h o p a t h o l o g i c a l p h e n o n m n a is hind e r e d b y psychological a n d organizational difficulties.'-':" Ah'e a dy the framew o r k of the r e p r o d u c t i o n process m a k e s this obvious. Tile nonspecifity o/ lxvychopathological symptoms d e m a n d s that e-vet3" p s y c h o p a t h o l o g i c i t e m s h o u l d b e registered i n d e p e n d e n t l y of all other items. T h e multi/actor etiology of p s y e h i a t r i c disorders makes u n i f o r m a n d extensive r e ~ s t r a t i o n necessmT, even of items that b e l o n g to different categories. T h e time-dependent variability of m a n y characteristics ean only be registered b y systematic, synchronous, r e p e a t e d e x a m i n a t i o n s that h a v e a time r e l a t i o n s h i p to one a n o t h e r d u r i n g tile course of the disease. At first, the psychoiogieal d i ~ c u l t i e s s h o u l d be outlined. \Vithin the stated eoneept the characteristics of the p s y c h o p a t h o l o g i c a l m a n i f e s t a t i o n s a n d the characteristics of their possible pr e r e quisite s are r e pr oduc e d. F r o m observation, recognition a n d e x a m i n a t i o n of tim items until their correct d o c u m e n t a tion, this process is ex-posed to n u m e r o u s a n d p r e d o m i n a n t l y u n c o n t r o l l a b l e factors w h i c h m a y distort its accuracy. 1. T h e observation a n d description of an ite m is not a p h o t o g r a p h i c process. T h e p h y s i c i a n w h o obser~-es a n d describes the s y m p t o m s is not an opticalm e c h a n i c a l apparatus, but a h u m a n b e i n g w h o enters an inte r pe r sona l relat i o n sh i p w i th a n o t h e r h u m a n being. This r e la tionship develops in the context of a certain e x t e n m l situation an d d e p e n d s not only on the m e n t a l a t t i t u d e of the patient, b u t also on the m e n t a l a t t i t u d e of the physician. 2. T h e p a t i e n t tells the p h y s i c i a n about alterations in his r na nne r of experie n c i n g h i m s e l f a n d his w o r l d or expresses t h e m by his behavior; these are the s y m p t o m s of his illness. VVhether the " s y m p t o m " can be confided to the p h y s i c i a n d e p e n d s u p o n t h e intensity of the s y m p t o m s and tile i m p o r t a n c e of its emotional m e a n i n g to the patient. Retx)rting of s y m p t o m s even d e p e n d s on the a b i l ity of tile p a t i e n t to describe the "'symptoms." T h e subjective imp o r t a n c e of the s y m p t o m s is influenced by, concepts that the patient has about his disease, b y his hopes a n d / e a r s . 3. In histories o b t a i n e d b y otlmr persons, s y m p t o m s m a y be distorted by the relationship rff the history given t o the patient,
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4. A d d i t i o n a l clistortimi o c c u r s d u r i n g t h e r e l a t i o n s h i p l~etxx'eel~ tilt. p a t i e n t a n d tim physician. T h e p a t i e n t e x p r e s s e s h i m s e l f in medic~tl t e r m s a n d sl.a.t(?s d i a g n o s e s in o r d e r to i m p r e s s t h e p h y s i c i a n , to p i n him d o w n . or l)ecatls(, he lhinks a c c o r d i n g to the p o p u l a r c o n c e p t i o n s of the u n e n l i g h t e n e d l a y m a n . 5 . T h e p h y s i c i a n also distorts the p r o c e s s of o b s e r v a t i o n a n d d e s c r i p t i o n . C l e a r - c u t i t e m s c o n t r a s t m o r e s h a r p l y f r o m the b a c k ~ x m l l d s of n o r m a l pheTumlena. F'or this r e a s o n t h e y t e n d to influence the p h y s i c i a n m o r e t h a n other, less ob-,ious items, tile limits of w h i e h b o r d e r onto n o r m a l , T h e r e l a t i v e v a l u e t h a t the e m o t i o n a l e x p e r i e n c e a n d t h o u g h t processes ot t h e p h y s i c i a n at-',ach t¢~ t h e s y m p t o m s c a u s e a n additiorml distortion of the s y m p t o m s . T r a n s f e r e n c e s affect a c c u r a t e r e p r o d u c t i o n . ] l , i f n e r p o i n t e d o u t the pressur<:: t h a t the m o r e o b v i o u s exerts on t h e r e c o g n i t i o n process, w h i c h ¢lep(mds on the e m o t i o n a l i n t e n s i t y of the " i n n e r p i c t u r e s , " t h e ".a. .t.t.i. t. u. d e . - G e r h a r d t a n d Ziolko s t a t e d : " D e s i r e d c o n t e n t s a r e m o r e q u i c k l y r e c o g n i z e d a n d m o d i f i e d a s desired, r e j e c t e d cxmtents a r e only i n c o m p l e t e l y recog'nized or a r e not recogllized at all. "'~7 E v e n m o r e i m p o r t a n t , a s t h e y a r e less a v o i d a b l e , a r e distorlions d u e to limitations of t h e o b s e r v a t i o n field, the o b s e r v a t i o n i n t e n s i t y a n d the o b s e r v a t i o n a c c u r a c y . This is d u e to the fact t h a t t h e p h y s i c i a n is not only u n a b l e to f o r g e t his nosologic~il s y s t e m d u r i n g the o b s e r v a t i o n , b u t lit, actlially" m a k e s a i m e d use of it. This is e s p e c i a l l y t r u e if the p h y s i c i a n ' s t i m o is limited. T h e next step in t h e r e p r o d u c t i o n p r o c e s s is tile d e s c r i p t i o n of the ol~served s y m p t o m s , D e s c r i p t i o n is l i m i t e d lLv terms. T e r m s d e f o r m the p h e n o m e n a w h i c h t h e y d e s c r i b e b e c a u s e t h e y d e l i n e a t e mid s e p a r a t e thein from their xdtal context. This is t r u e for a n y specialist's t e r m i n o l o g y a n d Ls also at p r o b l e m ill p s y c h i a t r y . This terrninolog 3- h a s d e v e l o p e d f r o m the special n a t u r e of the p h c n o m e r m w h i c h h a v e to be d e s c r i b e d . D u r i n g t h e historical developme.,at of thcst: t e r m i n o l o g i e s , t h e t e c h n i c a l t e r m has f r e q u e n t l y b e c o m e d e t a c h e d frtm'~ t h e i t e m w h i c h ,,','as o r i g i n a l l y d e f i n e d b y it. It has a s s u m e d its ow:t lift: a n d h a s n a r r o w e d , e x t e n d e d o r c h a n g e d its m e a n i n g . A c c o r d i n g to t h e position of t h e p h y s i c i a n in this p r o c e s s of t h e d e v e l o p m e n t of SlX~.eial m e d i c a l ttrrminolog3 .', t h e r a n g e of associations a n d m e a n i n g s of the i n d i v i d u a l t e r m s will v a r y f r o m p h y s i c i a n to p t w s i e i a n . ':~ A n a d d i t i o n a l ditfleulty results f r o m the. f a c t t h a t the p a t i e n t ' s a c t u a l exp e r i e n c e is b y n o m e a n s a n artificial o b s e r v a t i o n trait, the "'sylnptoln.'" O11 t]li~ c o n t r a r y , h e ex-perienees a l t e r a t i o n s of his body', his s t a t e of w e l l - b e i n g , a n d his e n v i r o n m e n t . F o r this r e a s o n t h e p h y s i c i a n f r e q u e n t l y rt:eognizes c o m plexes w h i c h h e c a n o n l y d e s c r i b e "'holistically,'" in the s e n s e of "'Gestalt" c h a r acteristic,-s, a n d t h e i m p o r t a n c e of w h i c h h e c a n only d e t e r m i n e f r o m t h e i r r e l a t i o n s h i I) to o t h e r items. T h e p h y s i c i a l b a t t e m p t s to s u b d i v i d e ana l y t i c a l l y the. o b s e r v e d e m o t i o n a l exl~.rience a n d b e h a v i o r c o m p l e x e s " izJto s y m p t o m s b y t r a n s f e r r i n g t h e m into p s y c h o p a t h o l o g i c a l terms, F r e q , u m t l y , h¢~wcver, he is not a w a r e as to w h a t extent h e a l r e a d y i n c o r p o r a t e s evalt_ations into this process. At this point, t h e real diagnostic. 1)roct-ss, t h e e v a h m t i o n of the syTnptoms anti t h e i r g r o u p i n g to a r r i v e at a diagnosis, lmgins. T h e i m p o r t a n c e of a s,vml~tom m a n i f e s t s itself from its relatitnJs I o r)tht,r i¢~'rns of the" ~l~servetl syml)torla
p a t t e r n . T h e i m p o r t a n c e of the item is d e / c r m i ~ m d t)y c o m p a r i ~ g it w i t h s i m i l a r s y m p t o m p a t t e r n s b a s e d (m (~xperienee. ~Ve a r r i v e at tlmse s y m p t o m p a t t e r n s t~y c()ntinIH)l~sly c:Oml)aring classical o|)serx-ations w i t h o u r own. C e r tain items b e c o m e m o r e ol)vio~s b e c a u s e of t h e i r s e v e r i i y ; t!r'e(tuenc Y, or c h a r a c teristic c o m t f i n a t i ( m of s y m p t o m s , a n d these a r e rei:crrcd to as so-called l e a d i n g s y m p t o m s , T h e y aehicv(~ t h e s e p r o p e r t i e s ( 1 ) on t h e basis of (:lear-cut c a s e s t h a t h a v e p r e v i o u s l y b e e n o b s e r v e d a n d ( 2 ) (m the basis of g e n e r a l i z a t i o n from e x p e r i e n c e w i t h m a n y p a t i e n t s . "lThiF ir~(l.icales t h a t t h e d i a g n o s t i c process is also sld)ject to a c c i d e n t a l a n d si~bj¢,ctive factors at s e v e r a l points. T h u s , Siml)ly the l e a r n i n g of c o m p a r i s o n p a t t e r n s m a y ]cad to e r r o n e o u s d i a g n o s e s . l-l,ifner anti his c o - w o r k e r s liavc{ m a d e a special s t u d y of t h e significant influen('(:~ w h i c h t h e diagmoslic a t t i t u d e a n d the p e r s o n a l i t y of tim hea<| of t h e d e p a r t m e n t has on tilt', dietgnos(-s ma(h, ~ b y his co-xvorkers, a~ L e a r n i n g is ioth ing cl.se l)u t c h a n g i n g experi(,z me in to e x p e e t a t i o n , u, E x p e c t a t i o n s, h o w e vet, arc" at p r e l i m i n a r y s t e p t o w a r d p r e j n d i e e s . T h e y m a y s h o w t h e i r effect t)y i m p l y i n g tile p r o l ) a b i l i t y that, a f t e r o b s e r v i n g the l e a d i n g s y m p t o m , c(-rlain other s y m p t o m s a r e s i m t d t a n e o u s l y p r e s e n t . In a d d i t i o n to this, it t)('('onu.,'s n e c e s s a r y to classify tim d i s e a s e process ;rod to a r r i v e a t a dia~_,nosis. Tl~e ] a l t e r i n c l u d e s nosologie, p a t h o g e n e t i c a n d etiologic coneel)tS. These.-, tlmn m a k e mmh t herape~ltle, l)rognostie a n d o t h e r deeisi(ms possil)le w h i c h a r e decisive for m e d i c a l lnanagetl~ellt. It is n o t i n f r e q u e n t t h a t tim p h y s i c i a n limits his i n t e r v i e w just to. el)rain the d i a g n o s t i e a J l y r e l e v a n t items, T h e importnn(:(., of t h e s e items, h o w e v e r , h e e v a l u a t e s c o n t i n u o u s l y on tlu~ ha,;is of t h e al)ove-d(:seril)ed coral)arisen, e v e n w h i l e m a k i n g his O|)servation.s. T h e irJ(livi(]ua] stc'ps of the diagqmstic proc'css thus do not strictly follow one a n o t h e r , b u t r a t h e r 1)lined into ()~m a n o t h e r a n d tlH,s also affect o n e a n o t h e r . T h e s e mm~erous sources o|: e r r o r d e t e r m i n e d t)y sul)jectivity a n d c o i n c i d e n c e m a k e it al)s()Iut¢,ly rJeeessarv to g a i n control o~' t h e r e t ) r o d u c t i v e a n d the d i a g n o s t i c process.-'::-": T h e in(livi(hml ~leps of t h e s e p r o c e s s e s m u s t b e e x a m i n e d e x p e r i m e n t a l l y , "1.'he e x t e n t a n d the dire(.'tion of d i s t o r t i n g i n l h m n e e s n m s t 1)e diseovcr('d. T h e s e mmlvses 1)e,:ome l)ossil)le b y m e t h o d s of e x p e r i m e n t a l l)syehoto
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S n c h st~.reo.tyt)iiL~ o t ll)e i n t e r v i e w dcerea.~,..~ I h(: pa I ie))t's m o t i v a t i o n f o r u n d i s l o r t e d repot'! i)Ltr, of his .~yml:)loms ev(,n l._)(?for(' a t'ailur~, of a t . c u r a t e r e p r o d u c t i o n t)v th(r physit,ia~. O n the,, l)nxis of t)l))- obs(,rva•lions w i t h the L o r r scale, we, c a n c o n f i r m this d a n g e r , w h i c h h a s l>ee~t deso:tilted by A ~ e r l m c h a n d Ewing,:" An a d d i t i o n a l m~d s t i l l u n s o l v e d l ) r o b h : t n r e s u l t s tt'~m~ t h e fact t h a t nt-m,, ¢)t' t h e scales is e x c h l s i v c q y a "'dc'scriplive-scah,.'" hut ratt~er is " a n t.vahmtiv~rseah,~.'" R a t i n g so'ale's c a n n o t p r o d n c e a p u r e rel~rodt|Ction of t h e p s y c l m l m t h o l o g i c a l r e n l i l y sinc-t, s u c h a r e p r o d u c t i o n inct~rpor;ttes ¢'valuations, w l | i c h r e s u l t f r o m the. inat:c,essil)h, i n d i v i d u a l i t i e s of t h e i n t e r p e r s o n a l e x a m i ~ m f i o n siltuatio~, w h i c h a r e a h v a y s u n i q u e . I t is iic~ssible to d e c r e a s e this d a n g e r ( 1 ) if t h e old f l m d a m t , ~ t a l r u l e ot: p s y c h i a t r i c i n t e r v i t , w to explort- e n t i r e l y evt,~" p s y c h t l p a t l mlogic-;~t, pl:,enomenon is a d h t - r t ' d It), ;n~d ( ~ ) if t h e itt-ms ~t t h e so'ale a r c defn~ed c o m p h . t e l y , ch,arly, e x p l i c i t l y a n d ~ p e r a / i o n a l l y . Sine~ ~- evt~ry i n s t r u intuit c a n t-~rod~cc, b e l i e r .results b y sc'nsible ;n~d c;|ref|~l ~lst:, t h e r a t i n g scal~,.,, aIll~t'ar to ~s :~s ~m essc, n t i a l a i d for psychiatric, rt,st,aruh if ! h e y a r e c r i t i e a l i y u s e d a n d signific,ant!y ' f u r t h e r i m p r t ) v e d . I l a t i n g scales ~ot o n l y p e r m i t a n a n a l y s i s of tht~ d a t a - g a t h ~ r i ~ g !)ro,.:ess as tht.~ b a s i s o f d o c u m e n t a t i o n , b u t t h e y als0 f o r m a s i g n i f i c a n t p r e r e q u i s i t e i o r s t a t i s t i c a l a n a l y s e s . A d e q ~ m t e o b j e t ~ i v e a n a l y s i s ot: c(~mplex p s y c h o p a t h o l o g i c a l c o n d i t i o n s is p o s s i b l e o n l y w i t h s t a t i s t i c a l m t , t]mds.:'.'.'".-'",";-':','" S t a t i s t i c s p e r s o ~:to n o t t ) r o d n c e n e w d i s c o v e r i e s . S t a t i s t i c a l r e s u l t s h a v e t~ 1)t' intt-rprt.tcd. F o r this p~lrpose s u b t l e kI~owledgt, of c l i ~ i c a l r e a l i t y is e s s e n l i a l , lnteri~rt:,tat i o n takes p l a c e b y s t a t i s t i c a l a n a l y s i s of h y l ) ~ t h c s e s , w h i c h a r e f o r m e d f r o m c l i n i c a l e x p e r i e n c e s t h a t h a v e b~,en acctnm~at~'d b y ch~ar-c~t i n d i v i d u a l o b s e r v a tions a n d ex'perienc, es, =:~'.:* As a resul! of this. t h e ¢mtlook for the- m~dtilud¢- of l i v i n g c l i n i c a l r e a l i t y m u s t not l)t, n a r r o w e d ¢h)wn l)v f o r m s a n d st~,r¢-t~tyl)eS, tntt ; n n s t t)e c ~ n t i n u o n s l y e d u c a t e d . T h i s " c l i n i c a l vi,-w'" m e a n s G e , v t a l t u : a h r l u , h . m i m e . xx'l~ost, v;~lut, for seie~tific r¢'ct)gnition h a s I~et,n s t r e s s e d e s p e c i a l l y b y I,orc'nz. :''~ T h u s , g~,nt~ine adva'~.ct, c a n n o t b e t.xt~t,¢:tt.d fr~,~ an "t'itl|t,r-or ~ a s p e c t . b u t o n l y f r o m ;m "'a.s well as" aspt,cl ~)f ¢lelailp(l, l~lasti(-, indi,cid~ml dt's~'ripti(m ~,f the cli~lic~! i m p r e s s i o n in a |'rt't, m a n n e r o~ t l~(, (';lit' rc(.t~r<| ;lilt] .~im)HJ~n~_,ot~,s d~cmn~,ntatit~! ae¢:or(li~g 1o tl~e fixed grtiltpittM ¢~|" ilt,rlt~ (~lt it rali~ru, .se;t,t-. :.~°',': If p s y c h i a t r i c r t , s e a r c h ix cu~rrietl o!~! a c c u r d i n g to tht'st, lmsie m~tl,~clo](~gicM t~ri~cil)les, o r g a n i z a t i o ~ m l c ( m s - , ~ l n t , ~ t , t , s ;~is¢~ ~ ' ~ s ~ ' . 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d i n a l section, m u s t be r e f e r r a l ) l e to one a n o t h e r . ~.~~ T h e special m e d i c a l termin o l o g y m u s t Mso n e c e s s a r i l y b e c o m e m o r e u n i f o r m , a n d t h e i r t e r m s m u s t beC()I¥I(~ HI(ire, c l e a r - c u t .
T h e s a m e p r o M e m s exist if s e v e r a l ]mspitals c.ooperate. ~a In this case a c c o r d ing to c u r r e n t l y availabh~ e x p e r i e n c e s , it is also possible in this c a s e to realize a mfi form, e x t e n s i v e a n d c o m p l e t e doc~m~entation" a c c o r d i n g to a m i n i m u m . o u t line of i t e m s , w h i c h is b i n d i n g fi~r all e x a m i n e r s . In this r e g a r d , uniform r e g i s t r a tion m e a n s t h a t all e x a m i n e r s d o c u m e n t the o b s e r v e d i t e m s a c c o r d i n g to t h e s a m e criteria. T h e use of a glossa D" w h i c h c l e a r l y defines all t e r m s u s e d is a p r e r e q u i s i t e to this. T h e extent of the r e g i s t r a t i o n proeess refers to ( I ) as m a n y c h a r a c t e r i s t i c s as pr~ssible in the i n d i v i d u a l p a t i e n t , ( 2 ) t h e m o s t ext e n d e d o b s e r v a t i o n p e r i o d possible for t h e i n d i v i d u a l p a t i e n t , a n d ( 3 ) as mm~y p a t i e n t s as possible. E s p e c i a l l y this extention of time a n d s p a e e is e a p a l)le of h a v i n g c o n s i d e r a b l e effects on p s y c h i a t r y . T h e r e g i s t r a t i o n of life-long d i s e a s e processes, as h a s b e e n s u g g e s t e d b y \ V e i t b r e e h t , u s u a l l y b y f a r exc~'e(ls the r e s i d e n c y period, w h i c h only lasts a f e w years, a n d for this r e a s o n , this m e t h o d c a n only he r e a l i z e d b v o b j e c t i v e d o c u m e n t a t i o n . ~~ Spatial e x p a n s i o n b e y o n d t h e i n d i v i d u a l hospitals will e l i m i n a t e the confusion of t e r m i n o l o g y a m o n g p s y c h i a t r i s t s . \Ve h a v e b e e n e n c o u r a g e d to t h e s e p r e dictions b y o u r o b s e r v a t i o n s on t w o interelinieal s t u d y teams, in w h i d l w e p a r ticipated, t t e e e n t l v t h e grou I) of C, e r m a n , Swiss a n d A u s t r i a n p s y e h i a l r i s t s w a s a b l e to a c h i e v e a g r e e m e ~ t on a u n f f o n n list of p s y e h o p a t h l o g i e a l c h a r a c t e r isties, t I n t r o d u c t o r y discussions, w h i c h t o o k p l a c e o v e r a p e r i o d of years, m a d e it possible f o r fellow p h y s i c i a n s of d i f f e r e n t s d m o l s to a r r i v e at a u n i f o r m l a n g u a g e a n d , e v e n m o r e , i m p o r t a n t , to find m u t u a l u n d e r s t a n d i n g . A q u e s t i o n n a i r e for e p i l e p t i c c o n d i t i o n s t h a t w a s w o r k e d ollt b y lx*diatricians, p s y chiatrists a n d n e u r o l o g i s t s o v e r a t w o - y e a r p e r i o d could b e u n d e r s t o o d a n d a c c e p t e d a l m o s t w i t h o u t c o m m e n t a r y b y six o t h e r p e d i a t r i c clinics. ~a Flege, l a n d t-Iaase a n d h n r n i e h a n d }fig" c o - w o r k e r s c o n s t i t u t e p h a r m a e o t h e r a p e u t i e s t u d y t e a m s of this s a m e sort in Cermany.'".'-~- ~'' A g r o u p u n d e r t h e d i r e c t i o n of M e y e r is s p e c i a l i z i n g on the p r o b l e m s of d i a g n o s i s s c h e m e s . ''~,-~s D u r i n g t h e ¢xourse of s u c h t e a m efforts the c o n t e n t , extent a n d d e l i n e a t i o n of the t e r m s is t h o r o u g h l y d i s c u s s e d ; thus t h e g l o s s a r y of definitions, w h i c h are as open~tional as possible, c a n b e u n i f o r m l y u s e d b y all e x a m i n e r s . F u r t h e r m o r e , a g r e e m e n t is o b t a i n e d on at m i n i m u m of i t e m s w h i c h s h o u l d b e r e g i s t e r e d completely. "lqfis m i n i m u m o u t l i n e s h o u l d be s m a l l if the d~mum e n t a l i o n d i s c i p l i n e is poor. I t does not h a v e to e x c e e d b e y o n d a e e r t a i n extent, if a special p r o b l e m is e x a m i n e d . D i s c u s s i o n has s u g g e s t e d t h a t it m a y be g o o d to e x p a n d t h e s e m i n i n m m outlines, w h i c h are, l i m i t e d to p a r t i a l questions. In aeeor(1 w i t h the e m p i r i c a l r e q u i r e m e n t s their e x t e n t will at first increase, but it ma-y p e r h a p s b,.- possil)lc. once a g a i n 1o r e d u c e it in the next d e v e l o p m c ' n t a l step 1)y m e a n s of statistical o p e r a t i o n s . "Iqm ot,tlines m u s t h a v e cor|neetillg p~ints for, as an e x a m p l e , ne~lroradiologie, sterologie, electroellcephalographic., sociologic, p s y e h c × l y n a m i c spt.eial outlines, w h i c h a r e f a e u l t a t i v e l y usaMe. If d o c a m w n t a t i o n c o n t i n u e s to b~. p e r f o r m e d at r e g u l a r intervals a c c o r d i n g to the sam~: outline, thtr1~ this u~ellang, ing cxmrdinate s y s t e m p r o v i d e s a h.ss distorted l)i(./l~rc of the Collrst. of
?~ll'71"lt()l)ifjLO(;lCAI+
PtlOI:tI.,ENIS ()t "+ t'SY('I I1A,'I'ltY
40]-
the disease ,than the u s u a l course notes in t i m case r(:'cord, w h i d l > froin an interval p o i n t of v i e w as w e l l a s f r o l n il v o l t l r l l e p o i n t of view, lllay 1)O ()x(?t'e(l-
i n g l y in-eg'ular. ::+ IV T h e i m l m r t a n e e of d o c u m e n t a t i o n t e c h n i q u e s a n d modc'.rn slatisticaI mothods as a n e s s e n t i a l a i d to ps.vchiatrie r e s e a r c h has t:mcn~ +;nereasingly r e c o g n i z e d by Oerrnali psychiatry during the last f e w years." Major difl3eulties result from the application of these techniques, but w o r k i n g on these ditReulties is, in itself, capable of elevating our m e t h o d o l o g i c a l k n o w l e d g e to a n e w level and o f stimulating our psychiatric diagnostic acumen. It is our opinion that these m e t h o d s w i l i ' s h o w their effects on diagnostic practice, on the use of electronic computers, on the ;l_:,tsie data o f psychiatric research, on the formation of psychiatric c o n c e p t s , and on psyei~iairic langliage :is w e l l as on psydliatrie didactics. REFERENCES 1. Arl.~sf, J,, 11. B a t t e g a y , I3. Bente, F. C o r n u , P. D i c ~ , M,-P. E n g e l n m i e r , ]l. He.iniaim, K. t l e i n r i c h , H . H i p p i u s , \V. P¢mldin,wr, 1L S c h m i d l i n , \V. S c h m i t t a n d P, x.Veis: O b c r d a s ge.ineinsain(: Vor/e.ehen e i n e r
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iVortentwickhmg der psyehiatrisehen Systematik, Zsehr. Neurol. Psychiat, ,t8:370-377, 1919, 36. Lorenz, K.: (;estaltwahrnehmung als Quelle wissenschaftlicher Erkenntnis. Zschr. exp, angew. Psychol. 6:118165, 1959. 37. Martini, P.: 0"her Kast,Jstik und Statistik in der .Xledizin. Klin. \Vsehr. ! 961, I-5.
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47. \Veifl~recht, I1, J.: Zm" Frage der Spezifitiit psydmloIzischer Symplome. Fortschr, Neurol, Psyehiat. 25:,11-56, 1957, 48. Weitbreeht, tl. J.: End0gene phasische Psyclmsen Symptombilder und Verlfiufe. F'ortsehr. Neurol. I>sychiat. 29: 129-144, 1961. 49. Zeh, W.: Progressive Pamlyse, Verlaufsund Korrelatiortsst ndien. In: W . Scheid, H. J. Weitbrecht and H. H. XVieck (Eds.) Sammlung I'sychiatrischer und Neurologischer Einzeldarstelhtngen, S. 199. Thieme Verlag, Stuttgart, 1964. 50. Zutt, J.: Das SchizophrenieproMem. Nosol0gische Hypothesen. Klin. \Vschr. 1956, 670-684.
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1.)6-1 J, 1,]. NII~YI~,i~I l r l l , l l l i O l l 0 d tilt, t,ollll|)oriltiOil of tilt" l!syei~i~lirie t~.OsltiI N .tal,s ( o f. Ih/~ . . tllliV().rsilil's . ill l{i'liillg('l/, ~X;lllJliZ, ~ l i i l l s l t , r, ]l(_liltbtll"g lill(:l \V('s.| l~e.rllil ili +~. hqtlq" Io tills joilrlll;lt l i } ) o l i l p s ) , c h i a l r y ili (~;Ol'llliltl-.~p{~l~ilti~ CI)lli~i Iril:'s/'" T h i s e o l h l } ) ( l l ' l i l i o i l ~wigii~al¢-d f r o m lh,:, l)rOlt|onls l?ll¢2Oillilt)n.,d dill-ill{( (:liliil:lll l<'.slhig~ Of l).S)'(+hopharnlacologie drugs," Ill l h e lilOlllllilYlO, lll(~ ~{VO p~),eliititri(" nltivor.,171L)" tloSl)ihlls ~lf Switz~.,riand a n d .ill(, Psyc:hhitri¢" Uni~,'t'Itsil¥ iliiSl)illlls (if %/iOllllll hlivl~ llo('(liill~ ~iNNO(;ili{.(~l xVilll flit." (;('l'lll~ili g r o l l i t . ~T I l e n(,t,d tt)r illli~l'li'i'(?d it..~slivlt~ l r i e l l t o d s ro~l'lli-od lit i n t e l i s i i i o d StlldiO$ lit i l i o proliit~ili.,; Ill c rto(~tiltll'Illlitlliit illill SI~ItiSl:i('s, ]Dlltk t¢) tills, tht" Jlll('l'('st ot: tiit~ ~1"Oll i) sliit'ted t r o i l l .l)!il'~; d r i i ~ le.~iilil( 1o t4('ne.ral i l l o l h ( i d o l o g i ~ a l prot)li.'ilis (if l)SXrc~hll.ltrio re.~l.~;Ir(~ll. Ill o i ' d i - r . f o t*it('ililal~, till' tlliil](",r~;titildirig of lhos(~ prol.~ic'~ns we, w i s h to tlisc~lss ( 1 ) 'their hi,~t¢iri(,al .r~)ots, to, .~onit; CIlITUIII (,'()II¢'(.'|){N. l l l l ( l ( 3 ) difHculi it-s ilt lilt-" till, ¢)f thi'st'. ¢.'oilt~o|)ty; (ill i h e 1);Isis (:if li t*~w t-
l'~>'c'iliatry itl (;erman-sp**akilJg~ ¢'ot~l~lries is c|lar~tolt~rized |>y its leltclelJ(~y t o w a r d sys!enis of ('hlssi[]eation/* i~i~l~t), years ago Kraept:l/n b(~gan to evoh'{" ih~, svsl~.m which is still mo~t bro.,itlly used, t,speeially in the.- form of S(.tu.~/th.r's tr/adic systonl, whiclt izlc:lud¢,s lhe gro~H~s of symptonl:ttic; psyc}~ose,s, i'liC|l)~t~iiltll,N l)S),etaos(.,~ ;lil(t l~sy(~tlore:lctive (lisorders. *~ "Fllis syslt'lll, ix 1lasted oil (,al'oi-ltl (.'~lSt~ s l i l d i l , s lltid Oil |)|l/,ilOlil(~ii()logllj arid Iogi¢~al-defiilitory illtll|),NiN of il~dividua! l)-s)'t~liOl);ll|loltlgi(.~li] i)tlu[IOlllt.~ll~l. "l'ii(~.'il' ln¢,iiiods r~*pc'~il(~ll)- (tOlltirill(,(t thi., li;lsi(: t)lllliltlx,; o f the SyStl'rtl, b i l l l h l ' i r nlort- dilii:l-t, l i t l l l l o : l sllt),~I'()Ili)N Chan~,'d ~{tlit(,~ t)t'tl'l:l. Kril('t)t:]iii t l i l i i s t ' I f rel-l¢'iltt,dly cilalig~'d lii.s .sy'st¢.'itl ill tilt, llilit.'. (,(iilioil.,; o|' Ills t{Jxli)ook w l i i C i l :il)tie.;lred })~.'tw(~(,~l 1883 lili(l J$):~7. !I(~ ;irri'¢(~d :it i|lt~ fii]|ovcillg~ t:Oiit'tllsi/)ll: " ' { V i t ] l i l i t~t:l'l~illi l i r l i i t ; l t i o l t s ali~watiltils ill ¢iii1" di~tgll,osii(y t.:llissiiri(~:ition i.i( I)ill" t)iilil~liis w i l l pri)vidt~ i I t t ' o r t l i l i t i o l i ~-ls Ill wii(~'ilil~r ill- lit_)t ~,x.-t; It;ivy: itlr(~;ld)" aehit-t'(-d ~i lil(;)l~y (,x~iet c'ollla('t; xvit|i i't,iilll),. "':~'~ l,~rlioltolili iri¢,d 1() tIv(.~i'~.,Olilt ~ t h i s iili(.~l?rlilili[)' l : n l p i r i o l i i l ) ; }))+ iitirodtlc-ilil~ s)'.,;ll~.liiillit:'d(icUtll~.'lll~llioll io ps),('lli;llry.:-': !1~' xvrotl, Ihe si~ili|ic~illl poilil.s oJ[ it liX)'~:ilialri¢: (:list" h i s t o r y OlliO V(II'iIiIIN ()ili'ds, w h i c h lll'ovidt, d l i i n i w i t l t a lx, litlivt, l)* r a p i d x l i r x l , v ql~ ill|lit), p ; i l i ( ' l l t s ;|lid w i l i c i i n i a d o spi,t.ia] lhiding.s r e a d i l y awailill)It,, tit }li.s Olillii()ll, ()lily s l t i r i l l g (11 Illl, ('lliii't' t']/liiC;ll Oll.~,('l'V~'lli()ll lll~tll)l'i;ll ill ii ilSiilll¢' illl'ltl p r o v i d e d ll real t i u s s i l ) i i i t y to t'vlihl~ill, s c h ? l l i t i < : a l l y tilt- d a l l y t)i).st~l'ViiliitllS (if gl,ii(-l'ltlililis ()[' l)ii).,,;i(,i{lllg illsl(~;td of ,';('l'liild i}lt~llt |)(;riililli('.ltl|%' tlisitlili(.iir ilt tilt. iiill('('t'NNi|,)](" ()(!t';lll Ill filed ('|is(, hisl(wit.s. T h i s lii~'liil)(l, h o w / " f i l m t/t,. l',sl/('/tilitrit" , t l d ,%i'l'ttroIoi'.if-
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over, was n o t g e n e r a l l y a c c e p t e d . A p p a r e n t l y the a m o t m t of w o r k r e q u i r e d ~or it was excessive. T i m e was p r o b a b l y not y e t r i p e for the r e a l i z a t i o n t h a t p s y c h i a t r i c d o c u m e } a t a t i o n is a n t m a v o i d a b l e n e c e s s i t y . At t h a t time, t h e c o m p l e x i t y of p s y c h i a t r i c c o n d i t i o n s was i n c r e a s i n g l y reco g n i z e d . M e t h o d o l o g i c a l c o n c e p t s , such as K r e t s c h m e r ' s " m u l t i ~ d i m e n s i o n a l d i a g n o s i s " a n d B i r n b a u r n ' s " s t r u e t t m f l a n a l y s i s , " o f f e r e d to take s u c h comple.xitics i n t o c o n s i d e r a t i o n b u t c o u l d i n i t i a l l y o n l y be u t i l i z e d i n t u i t i v e l y . ';,:':' At first this " ' a n a l y t i c - u n d e r s t a n d i n g " m e t h o d s h o w e d its v a l u e in c l e a r - c u t eases a n d S e e m e d n o t to r e q u i r e d o c u m e n t a t i o n . L a t e r . S c h n e i d e r d e f i n e d psychopath(~logical p h e n o m e n a v e r y eareflflly. His p r e c i s e a n d r e a d i l y u n d e r s t a n d a t . q e defi n i t i o n s g u i d e t h e d i a g n o s t i c process of the clinical s t a t e of s c h i z o p h r e n i a t)cc a t , s o o f the f r t x l u e n c y a n d conjm~etion of s y m p t o m s , e'tlled " s y m p t o m s ~If the first o r d e r " ( S y m p t o m v elwtel~ l{an.ge.v).:' 1-towever, t h e <)perational a n d st~ltistical b e g i n n i n g c o n t a i n e d in this a p p r o a c h R)r a classification of c o m p l e x psyc h i a t r i c c o n d i t i o n s c o u l d n o t f u r t h e r e v o l v e b e c a u s e of t h e lack of suital)lt" methods. 1[ In t h e meantime:, t h e s e f r a m e w o r k s of t h o u g h t h a v e e v o l v e d on tile basis o[ c l i n i c a l o b s e r v a t i o n s , a n d a d e q u a t e m e t h o d s f o r t h e i r e r n p i r i e a l t e s t i n g haw.' also d e v e l o p e d . VVithin tim last f e w y e a r s t h e c o n c e p t of n o s o l o g i c a l e n t i t y its a disease, u n i t d e f i n e d by t h e s a m e etiology', s a m e s y m p t o m s , a n d satile c o u r s e has b e e n p r o g r e s s i v e l y d i s p r o v e d . It b e c o m e s i n c r e a s i n g l y Obvious t h a t p s y c h o p a t h o l o g i c a l s y m p t e m s a r e nonspecific. -'7 l;'ro,n tim s a m e ps~,chopathoh)gical s y m p t o m s o n e can n e i t h e r a s s u m e t h e s a m e e t i o l o g y n o r tile s a m e p r o g n o s i s in e v e r y case. T h e d i a g n o s t i c s i g n i f i c a n c e of a s y m p t o m results o n l y f r o m its context--i.e., the s i m u l t a l l e o u s p r e s e n c e of o t h e r s y m p t o m s a n d t h e i r sequ(zntial d e v e l o p m e n t . F . x a m i n a t i o n o f t h e c o n n e c t i o n b e t w e e n t h e p r e s e n t i n g syml)t o n m t o l o g y a n d its e t i o l o g y ( " v e r t i c a l , " n o s o l o g i c a l h y p o t h e s i s ) .is n o w •.-'-eompanied l)y e x a m i n a t i o n s p e r t a i n i n g to c e r t a i n c o m b i n a t i o n s of c h a r a c t e r istics w i t h i n t h e p s y c h o p a t h o l o g i c a l s y m p t o m - c o m p l e x e s ( " h o r i z o n t a l . " synd r o m a l h y p o t h e s i s ) . T h i s s h i f t of t h e focus of e x a m i n a t i o n n o w m a k e s o u r d a t a m o r e verifial)le, sinc-e m e t h o d s for tile t e s t i n g of tile "'horizontal" h y p o tlmsis are c u r r e n t l y at a m o r e a d v a n c e d s t a g e t h a n t h o s e l)y w h i c h it is p o s s i b l e to v e r i f y or falsify " v e r t i c a l " hypotheses.:' In iilm w i t h t h e s e d e v e l o p m e n t s , t h e c o n c e p t of n u m e r o u s f a c t o r s l~eing responsil>le for the e t i o l o g y of p s y d l i a t r i c d i s o r d e r s (miiltivondiiiolmlc Gencsc) has g a i ~ , d i n c r e a s i n g i m l ) o r t a n c e . No l o n g e r does o n e ask o n l y for tile c a u s e of t h e disease, h u t o n e asks p r e d o m i n a n t l y for Ill,.- co~Hitions o f t h e clinical sytldroHu:. ''''':-z" T h i s slfift is prolmlfly dlu: c-hi~'tlv to t h e f a c t t h a t t'xami~mtiol~ ~m dn c t i o l o a i c a n d l m t h o g e n e t i c level t'nc{)tHitt'rs e'¢('~l znore oxtensiv(' m e t h o d o l o g i c ; t l difFielHti~,s t h a n e x a m i n a t i o n s c>~ a elinical-desc,ril)tive h'vcl, Most of all, l m w c v c r , it was the irnmenst, a m o u ~ t of clinical observatiomls ot i n d i v i t h u d lmtiel~ts w h i c h h a v e c o n f i r m e d tilt, p r a c t i c a l axed t i m o r c t i c a l imlmrl a n c e of t h e multi f a c t o r (.o,~cept "l'hlas, still withizi the n o s o l o g i c a l conCel:~t, t l o t f , :X.rnold a n d l l o l t J n a n of V i m m a h a v e w o r k e d o u t at m o d e l tff tim %nultifaettw ~,tiology of schizop h r e n i a . "'~ A c c o r d i n g to tiffs ;t h e r e d i t a r y , specific ,,nz.vmp ab~Jormality din'clops
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into a p s y c h o s i s d u e to the most va~ried e n d o c r i n e , 4 e g e t a t i v e allot psychod y n a m i c f a c t o r s . I n d i v i d u a l , specific r e a c t i o n s are addecr to the s y m p t o m s a n d the course of the psychosis. Z u t t listed a numbe!7 of hereditaD,, d y n a m i c a n d s o m a t i c c o n d i t i o n s a n d the ide~i of p a r a n o i d a t t i t u d e shifts d e v e l o p i n g f r o m crises e x p e r i e n c e d d u r i n g life as "'nosologieal hypotheses.":'" In b r o a d l y t:msexl, e p i d e m i o l o g i e a l l y o r i e n t a t e d field studies K i s k e r a n d his co-workers h a v e e x a m i n e d the various social a n d b i o g r a p h i c a l r e q u i r e m e n t s for s e l H z o p h r e n i e m a n i t e s t a t m n s . . \Ve a t t e m p t e d to e x p l a i n the, o c c u r r e n c e of p s y c h i c sideeffects of t h e p s y e h o p h a r m a e o l o g i e a l d r u g s on the basis of t h e c o m p l e x interactions of a i m m b e r of r e q u i r e m e n t s , w h i c h a r e d e t e r m i n e d b y the d r u g , t h e b a s i c disease a n d the i n d i v i d u a l disposition ("sYnch'ome-genetie t r i a d " ) . ~=~'.e'','-~': l t e r e a g a i n we f o u n d it q u i t e v a h m b ] e t o l e a v e t h e n a r r o w nosologieal concept."; T h u s , b y c o m p a r i n g e n t i r e l y different dise, ases w e w e r e a b l e to o b t a i n findings that Support the old hyt~othesis that tim a c t u a l psyclaotic s y m p t o m s are not o n l y d e t e r m i n e d b y the t y p e of disease, b u t are also c o n s i d e r a b l y inltueneed, b y the intensity, the acuity, the d u r a t i o n a n d o t h e r Imn-nosologieaI criteria of the disease course. T h e s e diffe.rent s y n d r o m e - g e n e t i c " i n f l u e n c e factors" f r e c l u e n t ] y asstmle a profile suitablt:- for e x a m i n a t i o n o n l y d u r i n g the course of the diseast'. T h u s ( ; r i e s i n g e r a l r e a d y a s s u m e d t h a t the various clinical forms of l u n a c y arc a c t u a l l y o n l y i n d i v i d u a l s e g m e n t s of the u n i f o r m c o u r s e of the p s y c h i c disorder, as in m e n t a l c o n d i t i o n s the s y n d r o m e s rnolanclaolia, m a n i a , craziness, eonf~lsion, a n d s t u p i d i t y q u i t e f r e q u e n t l y sueeeecl o n e a n o t l m r ill an o r d e r l y m a n n e r . " S p e e h t felt that dilfc:renees in the i n t e n s i t y of t h e disease-prochmirlg taetors w e r e r e s p o n s i h l e for the chalage of the s y n d r o m e s d u r i n g the, course of the d i s e a s e . " Later, it was esp{eeially Biissow w h o d e s c r i b e d the c o n t i n u o u s s e q u e n c e o | "'encloge,.mus" a n d "'exogenous" p r e s e n t i n g s y n d r o n m s d u r i n g lhe course of l~s.vehosis a s s o c i a t e d w i t h pc'rnieious a n e m i a . '~ C o n r a d p r e s e n t e d a n a n a l o g ( m s s y n d r o m ( t s e q u e n c e in the beginvJing of sel~izot)hrenia. ~'-' By u s i n g g e n e r a l p a r a l y s i s of the i n s a n e as a n exanq~le, Zeh rec,~'ntl~" e x p l a i n e d that various p. ~,chop,dhologlcal svndromt'.s do not lmvp to r e p r e s e n t varitms forms of the paralysis, b,tt m a y also b e a eross-seetiona/ e x p r e s s i o n o f at ,uore or less p r o t r a c t e d c o n t i n u o u s a l t e r a t i o n of p s y c h i c ttmcetmns," ' ' T h e s e e x a m p l e s e m p h a s i z e t h e m e t h o d o l o g i c a l valut- of o|)servations of the course of disease. ( T h e similar-apl~eav-illg eovit't*pls of "'lnnif{~rnl l~syc'.hosis"" (Einiteitp.~'t.lchosc) that are c u r r e n t l y a d v o c a t e d in ( ; e r m a n y , p r e d o m i n a u t l y b v R e n n e r t as tlwe "'nni~oersal etiology of eJlclo,~enolls psyt.hoses'" or b y J a n z a r i k as tim " ' d y n a m i c base-eonstella!iolv of e n d o g e m m s l)syehoses'" cavmt~t b e consid~.red here.:"'."") O n l y l h r d e v e l o l m , e n t a n d rt.missi
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¢.riteria of s y n d r o m e - g e n e t i c factors--e.g., type a n d d y n a m i c s of disease-producing a n d d i s e a s e - s u p p o r t i n g influenees, on one hand, a nd " p r e c o n c e i v e d structures, ':~:~ on the other h a n d - - b e c o m e m a n i f e s t only in t h e disease course profiles, vchich are f 0 n n e d by" l i n k i n g the s y m p t o m s a n d s y n d r o m e s w h i c h occur in t e m p o r a l sequeneeY a T h e s e e m p i r i c a l l y f o u n d e d concepts h a v e m e t h o d o l o g i c a l consequences, T h e y d e m a n d the use of m e t h o d s that c a n deal w i t h the n e w l y recognized complexities. T hese m e t h o d s are a v a i l a b l e b u t they c a nnot yet be used for an objective study of such concepts. ()he significant p r e r e q u i s i t e for such a study' has b e e n fulfilled only i n c o m p l e t e l y : It is c u n ' e n t l y imtmssible to r e p r o d u c e the p s y c h o p a t h o l o g i c a l states w i t h o u t distortion a n d to describe t h e m in s u d l a m a n n e r that the statistical m e t h o d s can be used s e n s i b l y a nd their results intm-preted clearly. III Accurate r e p r o d u c t i o n of comple x p s y c h o p a t h o l o g i c a l p h e n o n m n a is hind e r e d b y psychological a n d organizational difficulties.'-':" Ah'e a dy the framew o r k of the r e p r o d u c t i o n process m a k e s this obvious. Tile nonspecifity o/ lxvychopathological symptoms d e m a n d s that e-vet3" p s y c h o p a t h o l o g i c i t e m s h o u l d b e registered i n d e p e n d e n t l y of all other items. T h e multi/actor etiology of p s y e h i a t r i c disorders makes u n i f o r m a n d extensive r e ~ s t r a t i o n necessmT, even of items that b e l o n g to different categories. T h e time-dependent variability of m a n y characteristics ean only be registered b y systematic, synchronous, r e p e a t e d e x a m i n a t i o n s that h a v e a time r e l a t i o n s h i p to one a n o t h e r d u r i n g tile course of the disease. At first, the psychoiogieal d i ~ c u l t i e s s h o u l d be outlined. \Vithin the stated eoneept the characteristics of the p s y c h o p a t h o l o g i c a l m a n i f e s t a t i o n s a n d the characteristics of their possible pr e r e quisite s are r e pr oduc e d. F r o m observation, recognition a n d e x a m i n a t i o n of tim items until their correct d o c u m e n t a tion, this process is ex-posed to n u m e r o u s a n d p r e d o m i n a n t l y u n c o n t r o l l a b l e factors w h i c h m a y distort its accuracy. 1. T h e observation a n d description of an ite m is not a p h o t o g r a p h i c process. T h e p h y s i c i a n w h o obser~-es a n d describes the s y m p t o m s is not an opticalm e c h a n i c a l apparatus, but a h u m a n b e i n g w h o enters an inte r pe r sona l relat i o n sh i p w i th a n o t h e r h u m a n being. This r e la tionship develops in the context of a certain e x t e n m l situation an d d e p e n d s not only on the m e n t a l a t t i t u d e of the patient, b u t also on the m e n t a l a t t i t u d e of the physician. 2. T h e p a t i e n t tells the p h y s i c i a n about alterations in his r na nne r of experie n c i n g h i m s e l f a n d his w o r l d or expresses t h e m by his behavior; these are the s y m p t o m s of his illness. VVhether the " s y m p t o m " can be confided to the p h y s i c i a n d e p e n d s u p o n t h e intensity of the s y m p t o m s and tile i m p o r t a n c e of its emotional m e a n i n g to the patient. Retx)rting of s y m p t o m s even d e p e n d s on the a b i l ity of tile p a t i e n t to describe the "'symptoms." T h e subjective imp o r t a n c e of the s y m p t o m s is influenced by, concepts that the patient has about his disease, b y his hopes a n d / e a r s . 3. In histories o b t a i n e d b y otlmr persons, s y m p t o m s m a y be distorted by the relationship rff the history given t o the patient,
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4. A d d i t i o n a l clistortimi o c c u r s d u r i n g t h e r e l a t i o n s h i p l~etxx'eel~ tilt. p a t i e n t a n d tim physician. T h e p a t i e n t e x p r e s s e s h i m s e l f in medic~tl t e r m s a n d sl.a.t(?s d i a g n o s e s in o r d e r to i m p r e s s t h e p h y s i c i a n , to p i n him d o w n . or l)ecatls(, he lhinks a c c o r d i n g to the p o p u l a r c o n c e p t i o n s of the u n e n l i g h t e n e d l a y m a n . 5 . T h e p h y s i c i a n also distorts the p r o c e s s of o b s e r v a t i o n a n d d e s c r i p t i o n . C l e a r - c u t i t e m s c o n t r a s t m o r e s h a r p l y f r o m the b a c k ~ x m l l d s of n o r m a l pheTumlena. F'or this r e a s o n t h e y t e n d to influence the p h y s i c i a n m o r e t h a n other, less ob-,ious items, tile limits of w h i e h b o r d e r onto n o r m a l , T h e r e l a t i v e v a l u e t h a t the e m o t i o n a l e x p e r i e n c e a n d t h o u g h t processes ot t h e p h y s i c i a n at-',ach t¢~ t h e s y m p t o m s c a u s e a n additiorml distortion of the s y m p t o m s . T r a n s f e r e n c e s affect a c c u r a t e r e p r o d u c t i o n . ] l , i f n e r p o i n t e d o u t the pressur<:: t h a t the m o r e o b v i o u s exerts on t h e r e c o g n i t i o n process, w h i c h ¢lep(mds on the e m o t i o n a l i n t e n s i t y of the " i n n e r p i c t u r e s , " t h e ".a. .t.t.i. t. u. d e . - G e r h a r d t a n d Ziolko s t a t e d : " D e s i r e d c o n t e n t s a r e m o r e q u i c k l y r e c o g n i z e d a n d m o d i f i e d a s desired, r e j e c t e d cxmtents a r e only i n c o m p l e t e l y recog'nized or a r e not recogllized at all. "'~7 E v e n m o r e i m p o r t a n t , a s t h e y a r e less a v o i d a b l e , a r e distorlions d u e to limitations of t h e o b s e r v a t i o n field, the o b s e r v a t i o n i n t e n s i t y a n d the o b s e r v a t i o n a c c u r a c y . This is d u e to the fact t h a t t h e p h y s i c i a n is not only u n a b l e to f o r g e t his nosologic~il s y s t e m d u r i n g the o b s e r v a t i o n , b u t lit, actlially" m a k e s a i m e d use of it. This is e s p e c i a l l y t r u e if the p h y s i c i a n ' s t i m o is limited. T h e next step in t h e r e p r o d u c t i o n p r o c e s s is tile d e s c r i p t i o n of the ol~served s y m p t o m s , D e s c r i p t i o n is l i m i t e d lLv terms. T e r m s d e f o r m the p h e n o m e n a w h i c h t h e y d e s c r i b e b e c a u s e t h e y d e l i n e a t e mid s e p a r a t e thein from their xdtal context. This is t r u e for a n y specialist's t e r m i n o l o g y a n d Ls also at p r o b l e m ill p s y c h i a t r y . This terrninolog 3- h a s d e v e l o p e d f r o m the special n a t u r e of the p h c n o m e r m w h i c h h a v e to be d e s c r i b e d . D u r i n g t h e historical developme.,at of thcst: t e r m i n o l o g i e s , t h e t e c h n i c a l t e r m has f r e q u e n t l y b e c o m e d e t a c h e d frtm'~ t h e i t e m w h i c h ,,','as o r i g i n a l l y d e f i n e d b y it. It has a s s u m e d its ow:t lift: a n d h a s n a r r o w e d , e x t e n d e d o r c h a n g e d its m e a n i n g . A c c o r d i n g to t h e position of t h e p h y s i c i a n in this p r o c e s s of t h e d e v e l o p m e n t of SlX~.eial m e d i c a l ttrrminolog3 .', t h e r a n g e of associations a n d m e a n i n g s of the i n d i v i d u a l t e r m s will v a r y f r o m p h y s i c i a n to p t w s i e i a n . ':~ A n a d d i t i o n a l ditfleulty results f r o m the. f a c t t h a t the p a t i e n t ' s a c t u a l exp e r i e n c e is b y n o m e a n s a n artificial o b s e r v a t i o n trait, the "'sylnptoln.'" O11 t]li~ c o n t r a r y , h e ex-perienees a l t e r a t i o n s of his body', his s t a t e of w e l l - b e i n g , a n d his e n v i r o n m e n t . F o r this r e a s o n t h e p h y s i c i a n f r e q u e n t l y rt:eognizes c o m plexes w h i c h h e c a n o n l y d e s c r i b e "'holistically,'" in the s e n s e of "'Gestalt" c h a r acteristic,-s, a n d t h e i m p o r t a n c e of w h i c h h e c a n only d e t e r m i n e f r o m t h e i r r e l a t i o n s h i I) to o t h e r items. T h e p h y s i c i a l b a t t e m p t s to s u b d i v i d e ana l y t i c a l l y the. o b s e r v e d e m o t i o n a l exl~.rience a n d b e h a v i o r c o m p l e x e s " izJto s y m p t o m s b y t r a n s f e r r i n g t h e m into p s y c h o p a t h o l o g i c a l terms, F r e q , u m t l y , h¢~wcver, he is not a w a r e as to w h a t extent h e a l r e a d y i n c o r p o r a t e s evalt_ations into this process. At this point, t h e real diagnostic. 1)roct-ss, t h e e v a h m t i o n of the syTnptoms anti t h e i r g r o u p i n g to a r r i v e at a diagnosis, lmgins. T h e i m p o r t a n c e of a s,vml~tom m a n i f e s t s itself from its relatitnJs I o r)tht,r i¢~'rns of the" ~l~servetl syml)torla
p a t t e r n . T h e i m p o r t a n c e of the item is d e / c r m i ~ m d t)y c o m p a r i ~ g it w i t h s i m i l a r s y m p t o m p a t t e r n s b a s e d (m (~xperienee. ~Ve a r r i v e at tlmse s y m p t o m p a t t e r n s t~y c()ntinIH)l~sly c:Oml)aring classical o|)serx-ations w i t h o u r own. C e r tain items b e c o m e m o r e ol)vio~s b e c a u s e of t h e i r s e v e r i i y ; t!r'e(tuenc Y, or c h a r a c teristic c o m t f i n a t i ( m of s y m p t o m s , a n d these a r e rei:crrcd to as so-called l e a d i n g s y m p t o m s , T h e y aehicv(~ t h e s e p r o p e r t i e s ( 1 ) on t h e basis of (:lear-cut c a s e s t h a t h a v e p r e v i o u s l y b e e n o b s e r v e d a n d ( 2 ) (m the basis of g e n e r a l i z a t i o n from e x p e r i e n c e w i t h m a n y p a t i e n t s . "lThiF ir~(l.icales t h a t t h e d i a g n o s t i c process is also sld)ject to a c c i d e n t a l a n d si~bj¢,ctive factors at s e v e r a l points. T h u s , Siml)ly the l e a r n i n g of c o m p a r i s o n p a t t e r n s m a y ]cad to e r r o n e o u s d i a g n o s e s . l-l,ifner anti his c o - w o r k e r s liavc{ m a d e a special s t u d y of t h e significant influen('(:~ w h i c h t h e diagmoslic a t t i t u d e a n d the p e r s o n a l i t y of tim hea<| of t h e d e p a r t m e n t has on tilt', dietgnos(-s ma(h, ~ b y his co-xvorkers, a~ L e a r n i n g is ioth ing cl.se l)u t c h a n g i n g experi(,z me in to e x p e e t a t i o n , u, E x p e c t a t i o n s, h o w e vet, arc" at p r e l i m i n a r y s t e p t o w a r d p r e j n d i e e s . T h e y m a y s h o w t h e i r effect t)y i m p l y i n g tile p r o l ) a b i l i t y that, a f t e r o b s e r v i n g the l e a d i n g s y m p t o m , c(-rlain other s y m p t o m s a r e s i m t d t a n e o u s l y p r e s e n t . In a d d i t i o n to this, it t)('('onu.,'s n e c e s s a r y to classify tim d i s e a s e process ;rod to a r r i v e a t a dia~_,nosis. Tl~e ] a l t e r i n c l u d e s nosologie, p a t h o g e n e t i c a n d etiologic coneel)tS. These.-, tlmn m a k e mmh t herape~ltle, l)rognostie a n d o t h e r deeisi(ms possil)le w h i c h a r e decisive for m e d i c a l lnanagetl~ellt. It is n o t i n f r e q u e n t t h a t tim p h y s i c i a n limits his i n t e r v i e w just to. el)rain the d i a g n o s t i e a J l y r e l e v a n t items, T h e importnn(:(., of t h e s e items, h o w e v e r , h e e v a l u a t e s c o n t i n u o u s l y on tlu~ ha,;is of t h e al)ove-d(:seril)ed coral)arisen, e v e n w h i l e m a k i n g his O|)servation.s. T h e irJ(livi(]ua] stc'ps of the diagqmstic proc'css thus do not strictly follow one a n o t h e r , b u t r a t h e r 1)lined into ()~m a n o t h e r a n d tlH,s also affect o n e a n o t h e r . T h e s e mm~erous sources o|: e r r o r d e t e r m i n e d t)y sul)jectivity a n d c o i n c i d e n c e m a k e it al)s()Iut¢,ly rJeeessarv to g a i n control o~' t h e r e t ) r o d u c t i v e a n d the d i a g n o s t i c process.-'::-": T h e in(livi(hml ~leps of t h e s e p r o c e s s e s m u s t b e e x a m i n e d e x p e r i m e n t a l l y , "1.'he e x t e n t a n d the dire(.'tion of d i s t o r t i n g i n l h m n e e s n m s t 1)e diseovcr('d. T h e s e mmlvses 1)e,:ome l)ossil)le b y m e t h o d s of e x p e r i m e n t a l l)syehoto
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S n c h st~.reo.tyt)iiL~ o t ll)e i n t e r v i e w dcerea.~,..~ I h(: pa I ie))t's m o t i v a t i o n f o r u n d i s l o r t e d repot'! i)Ltr, of his .~yml:)loms ev(,n l._)(?for(' a t'ailur~, of a t . c u r a t e r e p r o d u c t i o n t)v th(r physit,ia~. O n the,, l)nxis of t)l))- obs(,rva•lions w i t h the L o r r scale, we, c a n c o n f i r m this d a n g e r , w h i c h h a s l>ee~t deso:tilted by A ~ e r l m c h a n d Ewing,:" An a d d i t i o n a l m~d s t i l l u n s o l v e d l ) r o b h : t n r e s u l t s tt'~m~ t h e fact t h a t nt-m,, ¢)t' t h e scales is e x c h l s i v c q y a "'dc'scriplive-scah,.'" hut ratt~er is " a n t.vahmtiv~rseah,~.'" R a t i n g so'ale's c a n n o t p r o d n c e a p u r e rel~rodt|Ction of t h e p s y c l m l m t h o l o g i c a l r e n l i l y sinc-t, s u c h a r e p r o d u c t i o n inct~rpor;ttes ¢'valuations, w l | i c h r e s u l t f r o m the. inat:c,essil)h, i n d i v i d u a l i t i e s of t h e i n t e r p e r s o n a l e x a m i ~ m f i o n siltuatio~, w h i c h a r e a h v a y s u n i q u e . I t is iic~ssible to d e c r e a s e this d a n g e r ( 1 ) if t h e old f l m d a m t , ~ t a l r u l e ot: p s y c h i a t r i c i n t e r v i t , w to explort- e n t i r e l y evt,~" p s y c h t l p a t l mlogic-;~t, pl:,enomenon is a d h t - r t ' d It), ;n~d ( ~ ) if t h e itt-ms ~t t h e so'ale a r c defn~ed c o m p h . t e l y , ch,arly, e x p l i c i t l y a n d ~ p e r a / i o n a l l y . Sine~ ~- evt~ry i n s t r u intuit c a n t-~rod~cc, b e l i e r .results b y sc'nsible ;n~d c;|ref|~l ~lst:, t h e r a t i n g scal~,.,, aIll~t'ar to ~s :~s ~m essc, n t i a l a i d for psychiatric, rt,st,aruh if ! h e y a r e c r i t i e a l i y u s e d a n d signific,ant!y ' f u r t h e r i m p r t ) v e d . I l a t i n g scales ~ot o n l y p e r m i t a n a n a l y s i s of tht~ d a t a - g a t h ~ r i ~ g !)ro,.:ess as tht.~ b a s i s o f d o c u m e n t a t i o n , b u t t h e y als0 f o r m a s i g n i f i c a n t p r e r e q u i s i t e i o r s t a t i s t i c a l a n a l y s e s . A d e q ~ m t e o b j e t ~ i v e a n a l y s i s ot: c(~mplex p s y c h o p a t h o l o g i c a l c o n d i t i o n s is p o s s i b l e o n l y w i t h s t a t i s t i c a l m t , t]mds.:'.'.'".-'",";-':','" S t a t i s t i c s p e r s o ~:to n o t t ) r o d n c e n e w d i s c o v e r i e s . S t a t i s t i c a l r e s u l t s h a v e t~ 1)t' intt-rprt.tcd. F o r this p~lrpose s u b t l e kI~owledgt, of c l i ~ i c a l r e a l i t y is e s s e n l i a l , lnteri~rt:,tat i o n takes p l a c e b y s t a t i s t i c a l a n a l y s i s of h y l ) ~ t h c s e s , w h i c h a r e f o r m e d f r o m c l i n i c a l e x p e r i e n c e s t h a t h a v e b~,en acctnm~at~'d b y ch~ar-c~t i n d i v i d u a l o b s e r v a tions a n d ex'perienc, es, =:~'.:* As a resul! of this. t h e ¢mtlook for the- m~dtilud¢- of l i v i n g c l i n i c a l r e a l i t y m u s t not l)t, n a r r o w e d ¢h)wn l)v f o r m s a n d st~,r¢-t~tyl)eS, tntt ; n n s t t)e c ~ n t i n u o n s l y e d u c a t e d . T h i s " c l i n i c a l vi,-w'" m e a n s G e , v t a l t u : a h r l u , h . m i m e . xx'l~ost, v;~lut, for seie~tific r¢'ct)gnition h a s I~et,n s t r e s s e d e s p e c i a l l y b y I,orc'nz. :''~ T h u s , g~,nt~ine adva'~.ct, c a n n o t b e t.xt~t,¢:tt.d fr~,~ an "t'itl|t,r-or ~ a s p e c t . b u t o n l y f r o m ;m "'a.s well as" aspt,cl ~)f ¢lelailp(l, l~lasti(-, indi,cid~ml dt's~'ripti(m ~,f the cli~lic~! i m p r e s s i o n in a |'rt't, m a n n e r o~ t l~(, (';lit' rc(.t~r<| ;lilt] .~im)HJ~n~_,ot~,s d~cmn~,ntatit~! ae¢:or(li~g 1o tl~e fixed grtiltpittM ¢~|" ilt,rlt~ (~lt it rali~ru, .se;t,t-. :.~°',': If p s y c h i a t r i c r t , s e a r c h ix cu~rrietl o!~! a c c u r d i n g to tht'st, lmsie m~tl,~clo](~gicM t~ri~cil)les, o r g a n i z a t i o ~ m l c ( m s - , ~ l n t , ~ t , t , s ;~is¢~ ~ ' ~ s ~ ' . 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d i n a l section, m u s t be r e f e r r a l ) l e to one a n o t h e r . ~.~~ T h e special m e d i c a l termin o l o g y m u s t Mso n e c e s s a r i l y b e c o m e m o r e u n i f o r m , a n d t h e i r t e r m s m u s t beC()I¥I(~ HI(ire, c l e a r - c u t .
T h e s a m e p r o M e m s exist if s e v e r a l ]mspitals c.ooperate. ~a In this case a c c o r d ing to c u r r e n t l y availabh~ e x p e r i e n c e s , it is also possible in this c a s e to realize a mfi form, e x t e n s i v e a n d c o m p l e t e doc~m~entation" a c c o r d i n g to a m i n i m u m . o u t line of i t e m s , w h i c h is b i n d i n g fi~r all e x a m i n e r s . In this r e g a r d , uniform r e g i s t r a tion m e a n s t h a t all e x a m i n e r s d o c u m e n t the o b s e r v e d i t e m s a c c o r d i n g to t h e s a m e criteria. T h e use of a glossa D" w h i c h c l e a r l y defines all t e r m s u s e d is a p r e r e q u i s i t e to this. T h e extent of the r e g i s t r a t i o n proeess refers to ( I ) as m a n y c h a r a c t e r i s t i c s as pr~ssible in the i n d i v i d u a l p a t i e n t , ( 2 ) t h e m o s t ext e n d e d o b s e r v a t i o n p e r i o d possible for t h e i n d i v i d u a l p a t i e n t , a n d ( 3 ) as mm~y p a t i e n t s as possible. E s p e c i a l l y this extention of time a n d s p a e e is e a p a l)le of h a v i n g c o n s i d e r a b l e effects on p s y c h i a t r y . T h e r e g i s t r a t i o n of life-long d i s e a s e processes, as h a s b e e n s u g g e s t e d b y \ V e i t b r e e h t , u s u a l l y b y f a r exc~'e(ls the r e s i d e n c y period, w h i c h only lasts a f e w years, a n d for this r e a s o n , this m e t h o d c a n only he r e a l i z e d b v o b j e c t i v e d o c u m e n t a t i o n . ~~ Spatial e x p a n s i o n b e y o n d t h e i n d i v i d u a l hospitals will e l i m i n a t e the confusion of t e r m i n o l o g y a m o n g p s y c h i a t r i s t s . \Ve h a v e b e e n e n c o u r a g e d to t h e s e p r e dictions b y o u r o b s e r v a t i o n s on t w o interelinieal s t u d y teams, in w h i d l w e p a r ticipated, t t e e e n t l v t h e grou I) of C, e r m a n , Swiss a n d A u s t r i a n p s y e h i a l r i s t s w a s a b l e to a c h i e v e a g r e e m e ~ t on a u n f f o n n list of p s y e h o p a t h l o g i e a l c h a r a c t e r isties, t I n t r o d u c t o r y discussions, w h i c h t o o k p l a c e o v e r a p e r i o d of years, m a d e it possible f o r fellow p h y s i c i a n s of d i f f e r e n t s d m o l s to a r r i v e at a u n i f o r m l a n g u a g e a n d , e v e n m o r e , i m p o r t a n t , to find m u t u a l u n d e r s t a n d i n g . A q u e s t i o n n a i r e for e p i l e p t i c c o n d i t i o n s t h a t w a s w o r k e d ollt b y lx*diatricians, p s y chiatrists a n d n e u r o l o g i s t s o v e r a t w o - y e a r p e r i o d could b e u n d e r s t o o d a n d a c c e p t e d a l m o s t w i t h o u t c o m m e n t a r y b y six o t h e r p e d i a t r i c clinics. ~a Flege, l a n d t-Iaase a n d h n r n i e h a n d }fig" c o - w o r k e r s c o n s t i t u t e p h a r m a e o t h e r a p e u t i e s t u d y t e a m s of this s a m e sort in Cermany.'".'-~- ~'' A g r o u p u n d e r t h e d i r e c t i o n of M e y e r is s p e c i a l i z i n g on the p r o b l e m s of d i a g n o s i s s c h e m e s . ''~,-~s D u r i n g t h e ¢xourse of s u c h t e a m efforts the c o n t e n t , extent a n d d e l i n e a t i o n of the t e r m s is t h o r o u g h l y d i s c u s s e d ; thus t h e g l o s s a r y of definitions, w h i c h are as open~tional as possible, c a n b e u n i f o r m l y u s e d b y all e x a m i n e r s . F u r t h e r m o r e , a g r e e m e n t is o b t a i n e d on at m i n i m u m of i t e m s w h i c h s h o u l d b e r e g i s t e r e d completely. "lqfis m i n i m u m o u t l i n e s h o u l d be s m a l l if the d~mum e n t a l i o n d i s c i p l i n e is poor. I t does not h a v e to e x c e e d b e y o n d a e e r t a i n extent, if a special p r o b l e m is e x a m i n e d . D i s c u s s i o n has s u g g e s t e d t h a t it m a y be g o o d to e x p a n d t h e s e m i n i n m m outlines, w h i c h are, l i m i t e d to p a r t i a l questions. In aeeor(1 w i t h the e m p i r i c a l r e q u i r e m e n t s their e x t e n t will at first increase, but it ma-y p e r h a p s b,.- possil)lc. once a g a i n 1o r e d u c e it in the next d e v e l o p m c ' n t a l step 1)y m e a n s of statistical o p e r a t i o n s . "Iqm ot,tlines m u s t h a v e cor|neetillg p~ints for, as an e x a m p l e , ne~lroradiologie, sterologie, electroellcephalographic., sociologic, p s y e h c × l y n a m i c spt.eial outlines, w h i c h a r e f a e u l t a t i v e l y usaMe. If d o c a m w n t a t i o n c o n t i n u e s to b~. p e r f o r m e d at r e g u l a r intervals a c c o r d i n g to the sam~: outline, thtr1~ this u~ellang, ing cxmrdinate s y s t e m p r o v i d e s a h.ss distorted l)i(./l~rc of the Collrst. of
?~ll'71"lt()l)ifjLO(;lCAI+
PtlOI:tI.,ENIS ()t "+ t'SY('I I1A,'I'ltY
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the disease ,than the u s u a l course notes in t i m case r(:'cord, w h i d l > froin an interval p o i n t of v i e w as w e l l a s f r o l n il v o l t l r l l e p o i n t of view, lllay 1)O ()x(?t'e(l-
i n g l y in-eg'ular. ::+ IV T h e i m l m r t a n e e of d o c u m e n t a t i o n t e c h n i q u e s a n d modc'.rn slatisticaI mothods as a n e s s e n t i a l a i d to ps.vchiatrie r e s e a r c h has t:mcn~ +;nereasingly r e c o g n i z e d by Oerrnali psychiatry during the last f e w years." Major difl3eulties result from the application of these techniques, but w o r k i n g on these ditReulties is, in itself, capable of elevating our m e t h o d o l o g i c a l k n o w l e d g e to a n e w level and o f stimulating our psychiatric diagnostic acumen. It is our opinion that these m e t h o d s w i l i ' s h o w their effects on diagnostic practice, on the use of electronic computers, on the ;l_:,tsie data o f psychiatric research, on the formation of psychiatric c o n c e p t s , and on psyei~iairic langliage :is w e l l as on psydliatrie didactics. REFERENCES 1. Arl.~sf, J,, 11. B a t t e g a y , I3. Bente, F. C o r n u , P. D i c ~ , M,-P. E n g e l n m i e r , ]l. He.iniaim, K. t l e i n r i c h , H . H i p p i u s , \V. P¢mldin,wr, 1L S c h m i d l i n , \V. S c h m i t t a n d P, x.Veis: O b c r d a s ge.ineinsain(: Vor/e.ehen e i n e r
3, Anerl)ach, -%. H., a n d J. H . E w i n g : Si)IIIO liniitations of p s y c h i a t r i c ruling scales: T h e clinician's v i e w p o i n t . Coil|pP. P s y c h | a t , 5 : 9 3 - 1 0 0 , 196,1. 4, ltenlc-, I)., ~ l . - l ' . E n g e l n l e i e r , K. H e i l i rich. f t . l t i t l p h i s , aiid ~l!ir. S c h m i t t : Zllr i)okutllielilaiJOll II ltx,|i l
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