A little bit about pathological diagnosis
Before we begin to consider specific methods of pathological diagnostics, let’s understand a little what it is and why it is necessary. In general, pathopsychological diagnostics is a set of methods and techniques that help a specialist to identify certain violations of human mental activity.
In a psychiatric hospital, diagnosis is divided into two stages: one by a psychiatrist and the other by a medical psychologist. Ideally, the results should coincide, which, in turn, is supposed to provide greater objectivity in making the diagnosis and developing treatment strategies.
In fact, everything is not so bright, and often either the psychiatrist copied the decision of the medical psychologist, or the latter asks him what to write in the conclusion, but not about the sad realities of domestic psychiatry, and consider the situation as it should be.
A psychiatrist in his work uses clinical conversation (this is the official method in medicine), on the basis of which he makes a diagnosis using ICD-10. What the ICD’s trick is that it has quite clear and precise criteria for attributing the set of phenomena that we can observe in a patient’s behavior to a certain nosological unit. It’s very simple: if N signs from M are performed, the diagnosis fits. If not, look for another one.
We (medical psychologists) use not only clinical conversation, but also other methods: structured interviews, personal questionnaires, projective tests, etc. We are narrower professionals than psychiatrists.
On the one hand, this allows us to see more details in the patient’s mental life, but on the other hand, it does not allow us to make diagnoses (because we have much worse training in the context of somatic phenomena).
Instead of making diagnoses, we’re detecting symptom complexes.
A pathological symptom complex is a relatively specific pattern (in a certain way organized complex, structured set) of internally related, related in origin (pathogenesis) and mechanisms of development of psychological phenomena (symptoms) – signs of behavioral disorders.
These are the signs of emotional response and cognitive activity that carry information about the level (depth), volume (severity) of mental impairment and some of its nosological characteristics.
Or like this:
As in psychiatry, in pathology, syndrome is understood as a pathogenetically conditioned commonality of symptoms, signs of psychiatric disorders, which are internally intertwined and interrelated.
This is the greater diagnostic significance of syndromes compared to symptoms. In the diagnostic thinking of a doctor, the correct qualification of the syndrome is an approach to determining the nosological affiliation of the disease.
Each of the pathological syndromes includes a number of symptoms. The combination of symptoms is a syndrome (symptom complex). Syndrome is a syndrome caused by general pathogenesis and a stable combination of interrelated positive and negative symptoms.
That is, in simple terms, the symptom complex is a set of interrelated and mutually conditioned distortions in the work of the psyche that develops and exists as a whole.
The space of symptom complexes is not linearly reflected in the space of ICD-10 diagnoses. For example, schizophrenic symptoms may be observed in people diagnosed with schizophrenia, schizotypic disorder, schizoaffective disorder.
The isolation of the symptom complex is useful, first, to control the underlying diagnosis (if the psychiatrist gives the patient schizophrenia and the pathologist sees the patient as having an affective-endogenous symptom complex, then one of them is wrong. It is necessary to double-check, use other diagnostic methods, and generally understand).
Secondly, the very choice of symptom complex is already an interpretation. In the process of collecting raw data, we have at our disposal a large number of parameters (both qualitative and quantitative) for which we can monitor the dynamics of treatment.
Imagine: a chronic schizophrenic enters a hospital with a diagnosis of F.20. He leaves the hospital with the same diagnosis. But does this mean that nothing has changed?
If the hospital is working normally (which is not always the case), it certainly does not mean that the “before” condition can be characterized by a productive symptomatology (delusions, hallucinations) and the “after” condition can be characterized by good compensation and social adaptation.
And, here, in order to assess quantitatively and qualitatively these changes, a second pathological study is carried out. And within the same diagnosis, the patient will receive two different pathological conclusions.
Thus, the results of pathological diagnostics are useful throughout the whole period of treatment (and even after its completion – during screening): first, they are used to check and clarify the diagnosis, then they are used as one of the components of the basis for prescribing drugs and non-medicinal therapy (psychotherapy, occupational therapy, art therapy, etc.), and then – to assess the success (or failure) of treatment.
Now that we have made up our minds as to why pathopsychological diagnostics are being carried out, let us consider the subject of the study in more detail.
One of the main stages of pathological diagnostics is the study of personal features of the patient. First of all, we define a personal radical (i.e., we make a characterological classification of a person).
There are quite a few definitions of character, starting with the classical Freudian explanation of personality on the basis of fixations and ending with the modern developments of ego-psychologists focusing on protection.
In my clinical work, I use the following empirically derived definition: characterological type (or personal radical) is a stable interrelated and interdependent set of methods of human response, as well as methods of internal organization of mental processes.
There are many types of character traits: schizoidal, hysteroidal, obsessive-compulsive, narcissistic, depressive, and others. Do not be misled by the apparent similarity of these names with terms and diagnoses and ICDs.
For example, a schizoid does not necessarily have schizophrenia or even schizoid disorder, and a depressed person is not necessarily depressed. Moreover, everyone can be categorized as a characterological type, and this type of depression is likely to have a “bad name” for the layperson.
The relationship between character type and mental disorders is complex and non-linear. Not only may a schizoid not have schizophrenia, but it may also have obsessive-compulsive disorder or depression. Or a combination of both.
It can be said that (greatly simplifying!) those signs that normally make up a person’s character trait, the basis of his or her individuality, become more acute and hypertrophied in illness. Thus, for example, fancy, imaginative and rich speech of schizophrenia degenerates into schizophasia. But the “roots”, “rudiments” of this schizophasia can be traced back to the schizoid speech.
So, we classify our patients by type of character. This allows, firstly, a more effective approach to them (for example, to the schizoid should be approached from the standpoint of intellectual and logical reasoning, and the hysteroid just give a sense of understanding and human warmth).
Second, knowing the patient’s type of characterization, we can more effectively select strategies for psychotherapeutic and psychocorrection interventions. Third, we can better predict patient behavior (e.g., understanding that the hysteroid is likely to exaggerate the severity of its symptoms).
The examples in this paragraph are intentionally exaggerated to show what the contrasts are. Please do not take it as a guide to action.