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The phenomenological dissection in psychopathology

Phenomenological psychopathology their reliable, measurable and easy-to-assess nature.

and the identity of the psychiatrist Moreover, in order to explain narrower symptomato-
logical phenotypes of a mental disorder, the concept of
Who is a psychiatrist? What is the objective and pur- endophenotype has been introduced – namely the up-
pose of psychiatry? What formation process and body of stream manifestation (neurophysiological, biochemical,
knowledge is needed to become a good clinician of the endocrinological, neuroanatomical, cognitive or behav-
psyche? What is the role of psychopathology in psychia- ioural measures) of a smaller genotype than the whole
try and what can young psychiatrists learn from it today? disease-related genotype  3. However, a simply sympto-
The purpose of this Special Issue is to try to answer these matic evaluation cannot explain or grasp the psycho-
questions by analysing the theoretical, empirical, clinical pathological phenotype  4. Indeed, from a psychopath-
and therapeutic aspects of psychopathology. ological viewpoint, mental illnesses are experiential
The nosographic revolution, triggered by the devel- anomalies of one’s own self/body, of time/space and of
opment of DSMs and ICDs, led to significant changes otherness that produce abnormal, dysfunctional cogni-
with the aim of organising the chaotic world of men- tions and/or behaviours 5. Hence, symptoms are not ac-
tal illness diagnoses and providing a scientific point of cidental to the patient, but rather the manifestation of
view to psychiatry within the medical field, which un- some implicit subjective dimension; the patient is not
til then was considered a fringe medical specialty. The a passive casualty of the illness, and on the contrary he
two main operational changes were the introduction of has an active role as a self-interpreting agent or goal-di-
a simple, descriptive and “atheoretical” approach with rected being in dealing with his abnormal experiences.
homogeneous diagnostic criteria, and the development Cognitions or behaviours are not pathological per se,
of assessment instruments that could simplify the diag- but in the light of personal history, social situation and
nostic process. The objectivism and physicalism of this cultural context - and this is particularly true in the in-
revolution were also fostered by the expanding perspec- creasingly multicultural society where we live. What the
tives of neurobiological research and treatment. What patient manifests is not a series of mutually independent
could not be foreseen at that time was that progresses symptoms, but certain meaning-structures permeated by
in neurobiology have not improved purely clinical- biographical details 6. Moreover, the concept of comor-
descriptive diagnostic systems. Moreover, the hope bidity brought about by the DSM and ICD discourages
for easy-to-use, reliable categorical diagnostic systems seeing the manifold of symptoms displayed by a patient
gradually replaced psychopathological manuals, and as a meaningful and coherent whole leading to the dis-
diagnostic criteria became the simplistic picture of the aggregation of the structural unity of the patient’s per-
mental illnesses. The entire body of psychopathological sonal existence. The mushrooming of comorbid multi-
knowledge was shelved as if it could hinder the newly- ple diagnoses undermines the conceptual basis and the
born operational revolution. credibility of current classification systems.
The early career psychiatrists of today, as sons of the Furthermore, as already mentioned, the epistemological
“DSM-ICD generation”, are training in this milieu where level has been affected in several ways. Structured inter-
psychiatry is more morbus-oriented than person-orient- views were built in order to explore those symptoms that
ed  1. This was an ideological shift that affected both are relevant to establish a specific diagnosis. Standard as-
the What (ontology) and How (epistemology) related to sessment procedures are devised in such a way that the
mental illnesses 2. The ontological level has been affect- patient’s symptomatology needs to fit pre-existing diag-
ed since the psychiatric object is supposed to be more nostic criteria, overlooking the subtle experiential differ-
subordinate to symptomatic, physical and biological pa- ences and their meaning for the patient. This approach
rameters than to subjectivity and singular human experi- makes use of a stimulus-response pattern of questions
ence. In this sense, symptomatological phenotypes have designed to elicit “relevant” answers with the risk of get-
become the main object of psychiatric study thanks to ting not the whole picture, but a “tunnel vision” of the

Journal of Psychopathology 2014;20:345-350 345

G. Stanghellini, V. Ramella Cravaro

patient’s manifold of abnormal phenomena. This type of on understanding the achievable only by sinking one-
interview weakens the intimacy of the relationship, pre- self into a singular situation. From the psychopathologi-
sumes shared meanings between the interviewer and in- cal perspective, mental illness is conceptualized as the
terviewee and gives the interviewer an excessive domi- outcome of mediation between a vulnerable self and
nant role over the patient. Furthermore, because of the the person that tries to cope with and make sense of
polysemous nature of psychiatric vocabulary, the techni- the disturbances that arise from it. Symptoms are not
cal approach to psychiatric diagnosis underestimates the only the direct outcomes of anomalous brain events,
need to clarify the subjective meaning of the terms with but are generated by the interplay between abnormal
which patients and clinicians refer to abnormal mental basic phenomena that have a neurobiological back-
phenomena (how can a word aptly express the proper ground and the patient’s coping and meaning strategies.
meaning of a mental state?). In the psychopathological In this sense, as neurophysiological, biochemical, en-
perspective, the context of the clinical encounter should docrinological, neuroanatomical, cognitive, or behav-
be one of co-presence with the aim of understanding and ioural measures (endophenotypes) could improve the
not labelling  7. This approach is also relevant to rescue understanding of mental disorders  3, phenomenal (i.e.,
abnormal marginal phenomena, not usually covered by experiential) traits and constructs (pheno-phenotypes)
standard assessment procedures, which nonetheless are could also occupy the terrain between symptoms and
part and piece of a mental picture, not to mention a dis- genetics, leaving room to subjectivity as the primary
turbed form of existence. object of inquiry  4. The method of ‘phenomenological
The aim of good psychopathological assessment is to dissection’ may prove useful on both theoretical and
reconstruct the subjective experience of a patient and clinical grounds. The pheno-phenomenological level
the lived world in which it is embedded. Its under- could be helpful to establish clear-cut syndromic cat-
lying tools are empathy and narratization. Empathy is egories that can be studied in neuroscientific terms (e.g.
the internal actualization of the other’s experience, delusion is a very heterogeneous category that must be
a special kind of immediate resonance (feeling with) split into more specific sub-categories in order to suc-
between one person and another 8. The empathic ap- cessfully look for its neurobiological correlates). In addi-
proach makes the interviewer a participant observer tion, the use of the ‘phenomenological razor’ is of great
and implies a balanced relationship with the inter- help in sorting out “psychopathological receptors” since
viewed. Narratization, rather than stimulus-response for successful therapeutic decision-making phenom-
interviews, allow the patient to communicate and ex- enological fine-grained characterization of abnormal
plain their own experiences in their own terms, to posit phenomena as targets of pharmacological treatment  is
them in the context of their personal world and history, needed  15 16 (e.g. so-called “social phobia” cannot be a
and to try to make sense of them 9 10. valid category for drug prescription as it may arise from
This is not to speak out against the neurosciences or to a suspicious attitude, or from a melancholic self-blame,
praise psychopathology, but only to give psychopathol- or in the context of an anxiety disorder).
ogy its proper place  11. Controversies between radical
advocates of the biomedical status of psychiatry and
Phenomenological psychopathology
strong supporters of its belonging to the humanities
as the core science for psychiatry
is abstract and sterile. A pathology of the psyche can
have clear biological causes, but this does not make it All these questions are developed in the first part of this
a simple natural entity. The question is that in psychi- Issue on Phenomenological psychopathology as a core
atry, more than in any other specialty, both scientific science for psychiatry.
and humanistic contributions are necessary, and psy- This sections opens with a paper on the phenomenol-
chopathology can be seen as the bridge between these ogy of atmospheres  17. The technical approach to the
two approaches  12  13. This concept was already hoped psychiatric interview is blind to essential aspects of the
for in the early 20th century by Karl Jaspers, the founder clinical encounter. It is this same objectifying inten-
of psychopathology as the basic science for psychiatry. tion that compromises the attention needed to notice
His masterpiece – General Psychopathology – first pub- the aesthetic properties of the clinical encounter and
lished 100 years ago, was the first systematic attempt to restricts linguistic contexts risking tautology. Atmos-
classify abnormal mental phenomena and became the pheres are examples of such phenomena that should
most secure basis to establish valid and reliable diag- be salvaged to allow in-depth psychopathological as-
nosis  14. As the science of abnormal subjectivity, psy- sessment. The authors of this paper clinical also expli-
chopathology relies both on explanation that allows cate the relevance of tact in sensing atmospheres and
the formulation of general rules by observing events, the role of metaphors in articulating them. They argue
experimenting and collecting numerous examples, and that by bringing aesthetics into the clinical encounter

The phenomenological dissection in psychopathology

we may achieve an understanding of the meaning of hood stems from the dialectics of selfhood and otherness
a clinical situation as felt, rather than simply assessing at the core of being a person, and that moods are one of
objective signs and symptoms. the most conspicuous epiphanies of otherness in human
The following paper touches on the relationship be- life. These dialectics become particularly evident in the
tween phenomenological psychopathology and the way our moods challenge our sense of personal identity
neurosciences  18. It starts with a discussion of Jaspers’ due to the way it complicates our relation to the norms
idea of unity and strong interdependence between soma and values.
and psyche, and then passes to subsequent and recent The second paper of this Section illustrates an exemplary
suggestions to naturalize phenomenology relating the phenomenological prototype of vulnerable structure to
subjective experience of the world to brain functions, mood disorders, and specifically to melancholia (a par-
and to phenomenologize neurosciences driving scien- ticular type of major depressive disorder characterized
tific research of the human mind with basic philosophi- by lack of vital drive, guilt and affective depersonalisa-
cal principles. tion)  22. The melancholic type of personality is a clear
The third paper is about phenomenological psychopa- example of the tight interrelation between personality
thology and causal explanation 19. The author argues that and mood disorder. This is a personality structure char-
a commonly held view – namely, that psychopathologi- acterised by tight interpersonal commitments, that is,
cal phenomenology is relevant only to description and the need for order in interpersonal relationships and the
not to explanation – is inaccurate. The phenomenologi- avoidance of guilt feelings achieved through extreme
cal approach (focusing on the subjective life of the pa- norm adaptation and identification with one’s own so-
tient) is relevant to empirical science, and this relevance cial role. The author also discusses the metamorphosis
includes causal explanation of mental disorders. It de- of this personality structure in late modern society, in
velops a deep analysis of ambiguities and controversies which the personal ethos is more guided by “I can’s”
pertaining to the notions of description, explanation, un- than by “I have’s”.
derstanding and causality (with the particular example of The following two papers investigate in great detail the
schizophrenia). Phenomenology can help to “explain” in phenomenology of mood disorders. The first describes,
several senses of that term, by showing how prima facie next to depressive symptoms per se, the life-world of
distinct symptoms may actually be mutually interdepend- persons affected by depression and mania 23. The pa-
ent (sometimes called ‘implicative’ relationship), or can rameters of this phenomenological dissection of mood
help one to grasp how one phenomenon might lead into disorders – which the reader will find in the majority of
another, or motivate it, etc. clinical papers in this Issue  – are the existential struc-
The last paper of this Section overviews the current Eu- tures of the life-worlds. The utility is to produce a sys-
ropean situation of psychopathologic training based on tematic description of subtle and often elusive changes
an online interview addressed to 41 early career psy- in the person’s subjective experience and to reconstruct
chiatrists’ who are representatives of their national as- the ontological framework within which they are gen-
sociations. Young psychiatrists recognize that psycho- erated. The experience of time, space, body, self and
pathology is a core part of the psychiatric curriculum, others, and their modifications, are the guidelines to this
although the quality and quantity of the training they dissection whose aim is to enlarge our awareness of the
received was not satisfying, and emphasize the capacity life-world people affected by mental disorders, under-
of psychopathological education to re-humanize psy- stand their behaviour and experiences, refine diagnostic
chiatric practice 20. criteria and establish homogenous categories for treat-
ment and aetiological research.
The next paper examines recent phenomenological re-
Phenomenological psychopathology search on both depressive and manic episodes 24. The
of mood disorders author argues that depression and mania cannot be
Section Two starts with the explanation of what emotions characterised by any particular mood (e.g. sadness,
are and why they are so relevant in psychiatry  21. Emo- hopelessness, guilt or euphoria, grandiosity or irrita-
tions disclose an inescapable fragility at the heart of our bility), but instead as a change in the way we “have”
identity and our vulnerability to mental illness. This paper moods. Thus, if we conceive of the affective dimension
proposes and discusses the definition of ‘emotion’ as feel- as a decrease or an increase in the degree to which one
ing motivation to move, the distinction between “affect” is situated in and attuned to the world through moods,
and “mood” according to their intentional structure, and then the particular mood one finds oneself in is sim-
the dialectics between affects and moods. The authors ply irrelevant to a diagnosis of either depression or ma-
propose a model constructed upon the theoretical as- nia. This analysis is applied to so-called “mixed states”,
sumption that the fragility characterizing human person- showing how phenomenologically oriented studies can

G. Stanghellini, V. Ramella Cravaro

help overcome the apparently paradoxical nature of this risk for progression to psychotic illness and in investigat-
psychopathological condition. ing new biological and psychological treatments to pre-
vent a transition to psychosis with the ultimate purpose of
Phenomenological psychopathology improving long term outcomes by reducing the duration
of schizophrenia of untreated illness. The “at-risk mental state” concept
as well as the two main approaches to the early psycho-
The first contribution in this Section contains a detailed sis question are analysed: the ultra high risk approach
account of the schizophrenic life-world  25. It gives a (UHR) and the basic symptoms (BS) approach, each with
panoramic view of the way schizophrenic patients live its assessing instruments. Besides these, the “anomalous
their life as embodied persons and how they understand self-experience” (ASE) concept is also analysed and a
the existence of other people. To this end, lived time, tentative integration between the UHR, BS and ASE ap-
space, body, selfhood and otherness are used as the proaches is developed. In closing, the authors describe
principal descriptors of the transformation these patients the clinical staging model and the advantages that it may
undergo. The authors propose that the phenomenon of bring in early psychosis from both clinic and research
fragmentation, which is the loss of a coherent Gestalt of standpoints.
experience, is the best candidate as the core feature of
schizophrenia spectrum disorders that runs through the
manifold of schizophrenic abnormal phenomena, also
Phenomenological psychopathology
affecting self-world related and inter esse. Fragmenta-
of the present
tion appears to be a basic feature of lived time, as well The fourth and last part is about three psychopathological
as space, body and selfhood. This suggests the crisis of conditions that, until now, have received relatively little
the synthetic function of consciousness, that is, of the attention by clinical phenomenologists compared to the
temporal unity of consciousness, may be at the basis areas of mood disorders and schizophrenia: borderline
of characteristics of “disarticulation”, distinctive of the personality disorder, eating disorders and addictions.
schizophrenic world. As is well-known, borderline personality disorder is a
The second paper in this Section widely discusses the highly variegated clinical area in which we encounter
self-disorder hypothesis of schizophrenia, a cutting- particularly difficult patients who, subject to “emotional
edge model of the psychopathology and pathogenesis of dysregulation” and tendency to impulsive action, cause
schizophrenia  26. Schizophrenia is interpreted as a dis- much distress to clinicians and health workers commit-
order of the pre-reflexive self, i.e. a pervasive perturba- ted to their treatment. The contribution of psychopa-
tion of the core sense of self that is normally implicit in thology becomes essential whenever it allows the clini-
each act of awareness. Such a core sense of self refers to cian to move from the level of the symptoms to that of
a crucial sense of self-sameness, of existing as a unified, lived experience 28. When this shift is not attempted, the
unique and embodied subject of experience that is at clinician remains trapped by the triad of stigmatisation,
one with oneself at any given moment. When this basic intractability and chronicity. To ask “What is like to be
sense of self is disturbed, the person is inclined to ex- a person with borderline personality disorder” means,
perience both a kind of exaggerated self-consciousness for example, to identify the characteristics of a perpetu-
and a concomitant fading in the tacit, pre-verbal feeling ally dysphoric mood condition that forces the subject to
of existing as a living and unified subject of awareness look for ways to quickly reduce such an uncomfortable
(diminished self-affection). This paper gives special at- state. Psychopathology allows us to shed some light on
tention to the notion of anomalous self-experience and the dynamics of dysphoric mood and the transformation
disordered-self with rich clinical descriptions, stress- of dysphoria into anger: such knowledge can also help
ing how the instability of the first-person perspective reduce the risk of an emotional mirror-involvement in
threatens the most basic experience of being a subject the clinician.
of awareness and action. Eating disorders represent another example of wide-
The third paper focuses on the pathogenesis and early de- spread contemporary conditions  29. There is general
tection of schizophrenia  27. Although the developmental agreement on considering behavioural anomalies as
nature of the disease and the subclinical prodromal phase secondary epiphenomena to a more profound psycho-
have always been recognized, clinical management con- pathological core, defined by excessive concerns about
ventionally begins only at the time of the first frank psy- body shape and weight. Body image disturbances have
chotic episode. Nevertheless, during the last 20 years, the been associated with a more profound subjective altera-
early phases of psychotic disorders have become one of tion consisting in disorders of the way patients experi-
the major clinical and research issues in psychiatric set- ence their own body and shape their personal identity.
tings because of their importance in defining markers of In a phenomenological perspective, the core dimension

The phenomenological dissection in psychopathology

of eating disorders also encompasses the subjective per- approach as an integrative future perspective for psychiatry.
ception of space and time. Several behaviours and cog- World Psychiatry 2008;7:159-60.
nitive distortion can be derived from the metamorphosis 4
Stanghellini G, Rossi R. Pheno-phenotypes: a holistic ap-
in lived body, space and time. As an example, the sub- proach to the psychopathology of schizophrenia. Current
jective perception of time in eating disorder patients ap- opinion in psychiatry. Curr Opin Psychiatry 2014;27:236-41.
pears to be connected with the temporal discontinuity 5
Parnas J, Sass LA, et al. Phenomenology and psychopathol-
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Stanghellini G. De-stigmatising manipulation: an exercise in
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The last paper examines the “being-in-the-world” of ad- 2014;20:11-4.
dicted patients  30. First of all, there is the need to dis-
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