Experiential Psychopathology - Dr John Howells

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I - Experiential Psychopathology

Indicators

The man in the street, like a family or society, aspires to happiness, a state of psychic and physical harmony, which has its own indicators.  Some of the indicators of harmonious psychic functioning are:  loving, relating, co-operating, enjoyable sexuality, balanced self regard, security, self-confidence, responsible attainable goals, well-being, productiveness within capacity, hopefulness, creativeness (the capacity for self-improvement).  These are associated with physical well-being, e.g. beneficial sleep, sound digestion and elimination, ample appetite, co-ordinated muscle action, sexual satisfaction, clear skin, etc.

In pathology, the psychic noci-vectors strike the psyche of the organism, which responds by deploying its coping mechanisms, and damage to the psyche may or may not occur.  This process displays itself by indicators.

An indicator can be any part of the whole process – psychic noci-vector, damage, or coping mechanism.  Taking the analogy of a car with dirt in the petrol makes this clear.  The dirt in the pipe, i.e. the noci-vector, may cause an irregular movement of the car, the lack of petrol leads to defective combustion and hence loss of power, i.e. damage to its functioning, and the need to press hard on the accelerator to produce more petrol is an attempt to cope.  The indicators, irregular motion, loss of power and excessive use of the accelerator, are all due to different parts of the whole process.  All are useful indicators of the trouble and together give the experienced motorist a clue to the nature of the disorder.  Similarly a piece of shrapnel causing a body wound has a number of indicators – the hardness is due to the noxious vector, the shrapnel, the loss of sensations is due to a cut nerve, and the warmth around the wound is due to the body’s inflammatory coping device.  The indicators are not the process itself, they are the parts that can be assessed.  They warn the individual of pathology.  To a trained observer they may demonstrate the nature of the pathology.  Hence the need for a careful examination to identify as many indicators as possible and reach an accurate elucidation, diagnosis, of the pathology.

The organism subjected to the process, or an observer, notices a change in functioning, something different happens from the accustomed – pain, or anguish, or anxiety, or a rash, etc.  The change that can be detected by the organism itself is termed a symptom.  The change in the organism that can be detected by an observer is termed a sign.  Damage to the psyche tends to lead to fundamental changes – grief, depression, withdrawal, guilt, anger, fears, etc.  These changes in the self may be so obvious as not to escape the attention of the person.  They may be very obvious also to the observer and so constitute signs.  An indicator is the part of the process which is noticed – it is not more significant than the rest of the process and is not the whole of it.  Indicators – signs and symptoms – are produced by the whole process and therefore all these factors which determine the choice of psychic noci-vectors, damage, or coping, determine the indicator.

The psychic noci-vector, as it influences the place and mode of attack, the damage done, and the responding coping devices, is a factor in determining the nature of the indicator.

The family’s influence on choice of coping devices is great and hence it may also determine the indicator.  Given a certain constellation of factors operating, conflict can be resolved only in certain definite ways.  A particular form of coping and hence a particular indicator, is inevitable in given circumstances.  This leads to diverse and sometimes extreme as well as fanciful ways of coping.  No other way of coping is possible.

These coping devices, and hence indicators, can be passed on from one generation to the next.  A grandparent copes with is social inferiority by fastidiousness in dress; his son adopts the same coping device – and so does the grandson.  In the preceding family men meet attach with aggression, the men of the presenting family adopt the same device, which is also found in the succeeding family.  Thus familial communication may be confused with genetically induced traits.  Faced with the same psychic noci-vector as on previous occasions, the same coping devices are quickly employed and therefore the same indicators are seen.  Repetition leads to a stereotyped process and hence to stereotyped indicators.

The psychic pathological process sometimes follows a general pattern, more or less common to many families.  In that case, common indicators will be apparent.  At other times, the process is special and unique to a family and thus the indicators are unusual.

The indicators of psychic pathology can be either psychic or somatic.  Thus an examination of psychic and somatic functioning is required to make a complete assessment of the indicators.  Any bodily system can be involved in the pathological process.  Indicators of dysfunction in the soma are termed psychosomatic disorders – they are many and diverse.  It is rare for careful examination not to expose some psychosomatic disorders when the organism has been subjected to psychic harmful agents.  The psychosomatic disorder must be differentiated from the hysterical.  The first is an automatic pathological response, e.g. abdominal pain due to bowel spasm at the thought of going to school where one is bullied by a classmate.  The hysterical response is a simulated attitude because the need to simulate is great, e.g. the child simulates abdominal pain, which has no related bowel spasm, so as to avoid going to school.  The term “hysterical” denotes a special attitude – one of simulation.  But many attitudes are adopted without simulation and are not hysterical – the real situation is that a need exists to hold firmly on to an attitude.  For example, a child refuses to eat – he cannot do otherwise while caught in a deadlock with father who state, “Just eat and I will not be cross”.  The child states “If you stop being cross, I will eat” – and thus cannot eat until father changes his attitude.

As in the field of organic pathology, a particular indicator may be shared by a number of different psychopathological processes.  Inability to eat, for example, may arise from severe depression, from a reaction to grief (Queen Mary Stuart’s dog “pined away” and refused to eat after her beheading) from a conflict with the family when food is an issue, from concentration of interest elsewhere arising from severe anxiety and the need to be alert, or from gastric pain produced by acute anxiety.  The same is true of organic pathology – dyspnoea (shortness of breath) may be seen in anaemia, in carcinoma of the lung, in pneumonia, and in cardiac failure.

When attempts are made to remove an indicator, the attempt may be successful, but the indicator is usually immediately replaced by another – the substitution of indicators.  The process has not changed, but the therapy has produced an additional factor that pushes the process in another direction.  This is very conspicuous in families when the presenting pathological member is given much assistance; he is soon replaced by another family member who has become sick.

Indicators of pathology must be differentiated from bad habits.  Many attitudes are not the result of psychic noci-vectors, but are wrong attitudes inculcated in a non-stressful situation.  To exploit others may be a way of life arising from that person’s values, or it might be a coping mechanism indicating a pathological process.  The first is of interest to sociologists, the second a matter for clinicians.  This confusion leads to non-clinical procedures being advocated for clinical disorders and to armies of well-meaning citizens attempting a clinical role.

When the organism is fearful enough about its health, it will take one of its indicators as an excuse for seeking help.  It may notice only this one conspicuous indicator.  It may regard only that particular one as a sign of danger.  It may feel it will lead to attention.  This indicator is termed “the complaint”, or the presenting symptom.  It is crucial to appreciate that the presenting symptom is not the whole process, nor is it more significant than the rest of the indicators.  There must be a global assessment to lead to adequate diagnosis.  The importance of indicators is that they warn, they lead to seeking professional help, and, taken collectively, they often point the nature of the pathology to the clinician trained in reading the indicators and in systematic examination that allows of a total appraisal, leading to a discernment, diagnosis.

Indicators are not the psychopathological process and attempts to treat the indicators as if they were the process are futile.  This can limit the usefulness of behaviour therapy.  Similarly, a sign of a stressful process such as a rash, perhaps due to a hurtful marital situation, may be helped by an ointment but leaves untouched the process itself; it can only relieve any secondary stress caused by the rash.  The process itself must be treated for effective therapy.  The psychic noxious agents causing the process must stop operating or the coping devices must be strengthened, and the psychic damage must be repaired.

Indicators of morbid processes as they present in the individual, family and society will be briefly outlined.

Indicators in the Individual

Like the family and society, the individual reacts as a somato-psychic organism.  Thus there are somatic as well as psychic indicators, signs and symptoms, and it is rare for this not to be the case.  The somatic indicators are usually multiple and in the nature of the so-called “psychosomatic disorders”.  The choice of psychosomatic responses depends on a number of factors – previous trauma involving a particular organ with a reawakening of memory in relation  to it; the organic mechanisms of reaction to stress may be overstimulated, with damage to a weak organ; cultural suggestion, e.g. blushing in western society in an index of shame.  The selection of the site where damage develops is probably determined centrally by the brain, as the lesions do not follow a segmental distribution, which would be the case in local damage to the central nervous system.

It is usual to subdivide emotional disorder in the individual into certain clinical categories – anxiety states, obsessional states, hysterical states, etc.  This practice has grave weaknesses.  It pays attention to the presenting symptoms, often elevates them to the status of a disease, and limits the description of the process.  The process is all-important and cannot be covered by one or many labels.  Each process is made up of such a combination of circumstances as to be unique.

Either psychic or somatic symptoms may be the first to be noticed and constitute the presenting symptom.  Age influences the indicators.  Hostility may be manifested in an infant by temper tantrums; in a child, by lying; in an adolescent, by rebellion; and in an adult, by criminality.  A person is bound by the strength and range of his endowment at a given period of development.  There may be resurgence of psychonosis, and hence indicators, at nodal points in development, e.g. school entrance, puberty, marriage, childbirth, menopause, retirement, etc.

Sex gender may influence indicators, e.g. a woman tends to develop signs in the reproductive system.  Gastric and duodenal ulceration is commoner in men.

Examples of indicators from 25 patients are:

Vaginismus

Bouts of drinking

Indigestion

Nightmares

Screaming fits

Moodiness

Ill temper

Tremors

Irritations of skin

Epigastric pains or discomfort

Headaches

Fainting attacks

Chest pains

Numbness in the body

Violent behaviour to wife

Shyness

Fear of crowds

Cancer phobia and other phobias

Backache

Pumping in stomach

Worry

Bad temper

Giddiness

Wanting to run away

Nose bleeds

Globus hystericus

Lack of concentration

Forced pregnancy

Insomnia

Inability to go to work

Pains in the abdomen

Diarrhoea

Inability to go to school

Fearfulness

Muscular pains

Migraine

Dyspareunia

Belching

“Run down”

Frigidity

Palpitations

Cramps in the hand

Crying fits

Sweats

“Pins and needles”

Bed wetting

Loss of weight

Shortness of breath

Dyspepsia

Asthma

Loss of hair

Attacks of panic

Bouts of fever

Failing an exam

Frequent ill health, coughs, colds

Dysmenorrhoea

Colitis

Loss of appetite

“Bad heart”

Drug addiction

Depression

   

As can be seen, the above can be divided conveniently into somatic and psychic indicators.  In no patient did one group, psychic or somatic, exist alone.  Depression of varying degrees is a very common symptom.  This was also found to be so in an investigation of symptomatology shown by patients of Dr. John Hall, Shakespeare’s son-in-law, 300 years ago.

Indicators in the Family

The family too reacts as a whole, with both its psyche and its soma.  Rarely is a disturbed family without signs of somatic disorders and indeed this may be its most conspicuous feature – and its reason for seeking help.  The total range of symptomatology in a family may be great.  Indicators arise from the clashing attitudes within the family or between the family and its psychic environment.

Indicators can arise anywhere in the fabric of the family – in its individuals, in its external and internal communication system, in its physical structure (even to proneness to a streptococcal infection), and in its general characteristics.  Careful examination will usually reveal that indicators appear in all its dimensions, especially if the disturbance is severe.  However, a family group may not manifest dysfunction equally throughout its system.  One aspect of it may show disproportionate dysfunction due to the “set” of emotional events at a particular time.

Indicators are strikingly apparent in problem families, because emotionally sick families carry a high degree of psychopathogenicity.  In one family, consisting of mother and two children, the following were seen:

Dimension of the Individuals:

Mother — Aggression; rage; despair; depression; panic; lying; stealing; accident-proneness; excessive smoking; alcoholism; attacks of vomiting; fainting attacks; gastric ulcer; enuresis; shaking fits.

Child 1  — Tension; tearfulness; fear of the dark; nighmares; enuresis; lying.

Child 2  — Irritability; depression; enuresis; lack of confidence.

Dimension of Internal Communication:

Mother/Children  — Overprotectiveness; rejection; hostility;  depreciation; neglect; disparagement.

Dimension of General Psychic Properties

Two illegitimate children; low morality; shared symptom of enuresis; no aims or purpose; conflict.

Dimension of External Communication:

Isolation; truanting from school; exploitation of welfare agencies; quarrels with neighbours; poor school performance; mother unemployable.

Dimension of Physical Properties:

Poor diet; squalor; debts.

The choice of indicators is a reflection of family dysfunctioning.  The individual’s choice is dictated by his life experience in the family, e.g. an angry family evokes anger in a child.  The choice of expression in a relationship is similarly determined, e.g. physical hostility may be taboo and verbal hostility alone possible.  The material changes in the family can take place only within the limits set by its condition.  Group manifestations are a family expression, e.g. sulking may be an expression of hostility in a particular family.  The community interaction may determine the indicators, e.g. that fear be controlled by obsessional ritual or that sexual taboos be imposed.  Again, gastric ulceration is a common indicator in Western civilisation, but not in primitive communities.  No only do present events dictate choice of indicators, but so do events from the past.  Every indicator has to be understood as a manifestation of past or present family dysfunction, or as a resultant of both.

It is fundamental to the doctrine of family psychiatry that psychopathology must always be thought of as an expression of dysfunction in a whole family group.  A family can show manifestations, indicators, or dysfunction at any point in its system.  Thus indicators appear in the five dimensions.  Almost invariably they appear in all, although this may escape notice except on the closes examination.  But the family group will not show manifestations of dysfunction to the same extent through all its aspects, e.g. the second child may show more manifestations than the first, or a girl more than a boy, or the family’s external relations may be more disturbed than its physical conditions.

In the dimension of the individuals, each family member usually shows symptomatology.  Naturally, this will not be exposed if examination concentrates on one person alone and overlooks the remainder of the family.  But each individual does not show psychopathology of the same kind, nor to the same degree.

In the dimension of internal communication, each relationship will usually show disharmony.  Naturally, this will not be seen unless each relationship is examined.  In practice, the mother/child relationship often comes under far greater scrutiny than the father/child relationship; the marital relationship also receives a fair degree of attention, but not always from the psychiatric service.  Each relationship will not show psychopathology of the same kind, nor to the same degree.

A disturbed relationship may give rise to any indicator in the physical or psychic fields, in both individuals of the partnership, e.g. an obsession in the wife and a rash in the husband.  Sometimes the symptomatology is shared by both partners, e.g. impotence in both (a psychosomatic reaction); joint depression, suicide of folie à deux (affective changes), or overt quarrelling.  Furthermore, some indicators tend to be associated with a particular relationship, e.g. a mal-relationship between husband and wife is often responsible for premature ejaculation, dyspareunia, impotence and frigidity. 

Hence, too, family patterns may dictate choice of indicators, e.g. in some families open quarrelling is forbidden and its members sulk instead.  Cultural pressure may also influence choice of indicators, e.g. sexual taboos increase the incidence of sexual disharmony.

That a particular relationship comes to the attention of a referral agency may be fortuitous.  Quarrels between husband and wife may evoke the attention of friends; the faulty relationship between mother and infant may be picked up by the regular surveillance of a community “mother and baby” clinic; the relationship most under stress may come to attention , e.g. a marriage, due to the intervention of a third party.  That indicators of faulty relationships come to attention rather than individual indicators is equally fortuitous.

Symptomatology in the general psychic dimension manifests itself in a pattern common to the whole family.  Families may be prone to particular types of physical disability, e.g. accident proneness, stomach disorders, or speech disturbances.  They manifest affective changes as a group, e.g. panic may be the group reaction to stress.  The family’s pattern of behaviour is shared by all its members, e.g. exploitation of neighbours.  Choice of family group symptomatology may be influenced by cultural pressure; e.g. the culture may dictate that fear be controlled by obsessional ritual.

That group disharmony rather than individual or relationship disharmony comes to the attention of a referral agency is again fortuitous.  Usually this is less likely to happen, as few agencies ascertain whole family patters of dysfunction.  It is not inconceivable, however, that in time many more agencies will function as family agencies, e.g. in a number of countries the personal doctor operates more and more as a family physician.

Family dysfunction frequently manifests itself in the dimension of physical properties, e.g. poverty despite an adequate income; sloth resulting from apathy and disinterest; low income due to lack of application; loss of employment as a reaction to family emotional crises.  Yet again it is fortuitous that adverse material circumstances are the manifestations that arouse attention in referral agencies, rather than individual, internal communication, or general disharmony.  Most often these manifestations come to the attention of social agencies.  But selection factors operate, as an agency may have a special function, e.g. a housing agency may ascertain sloth but overlook employment failure, or an agency may serve lower income groups only and overlook child neglect in a higher income group.

In the dimension of external communication, signs of dysfunction may arise at the three points of contact: individual-community interaction, e.g. stealing outside the home by a child; partnership-community interaction, e.g. parents’ refusal to send a child to school; or family group-community interaction, e.g. quarrelling with the neighbours.  The community influences the family by informal and formal means.  Enforcement of the latter is entrusted to agencies with statutory powers, e.g. police, courts, health inspectors, child-care agencies, etc, and these, in addition to enforcement functions, may accept responsibility for ascertainment of dysfunction.  Usually agencies with statutory powers are likely to observe signs of dysfunction in this dimension of family-community interaction.

Indicators in Society

Society, too, reacts as a somato-psychic entity with psychic and somatic indicators.  Not only may there be high incidence of psychosomatic disorders, but also signs of psychic disruption, like social unrest, low morale, apathy, strife, war, corruption and fragmented incohesive public action.  The indicators may follow a common pattern through a large population, e.g. the panic reactions common in the Middle Ages.  Mass suggestion can affect the choice of indicators, e.g. the increase in drug addiction in adolescents forced by massive propaganda to display their adulthood in this fashion. 

There may be an interplay of family and social factors in indicator production, e.g. alcoholism may be the accepted expression in a given population, but only those in disturbed families manifest it to a severe degree.

Some indicators are termed “social” problems, e.g. high divorce rate, high suicide rate, alcoholism, drug addiction, promiscuity, child neglect, etc.  Some of these are “social” only in the sense that a large number of people are involved, like tuberculosis 50 years ago.  Like tuberculosis, however, the eradication of these problems involves not only large scale preventive action, but also curative procedures at individual and family level.  The preventive actions must be devised and guided by knowledge acquired through curative procedures.

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