Ternyata bahwa formulasi-formulasi itu menggambarkan penyakit bukan sebagai suatu keadaan yang bersifat static, tetapi melukiskan keadaan itu sebagai sesuatu yang dinamik dan yang menimbulkan kerusakan pada seluruh organisme. Adanya akibat-akibat yang bersifat merusak itu, dapat dinyatakan dengan terjadinya fungsi-fungsi yang abnormal. . . . . Over the years, the Cambridge group has claimed, however, that there is no such a thing as an independent, objective, eternal description of a ‘mental symptom’ (let alone of a ‘disease’). Seterusnya baca di https://dryuliskandar.wordpress.com/2009/09/22/psikiatri-kusumanto-yul-iskandar-35/
Empat Dasa Warsa Pendekatan Eklektik-Holistik di bidang Kedokteran Jiwa (Psikiatri) (1966-2006), dan Terapi Gangguan Skizofrenia.
R. Kusumanto Setyonegoro.,MD.,SpKJ., PhD
Guru besar (emeritus) psikiatri FKUI, Jkt
mantan Direktur Kesehatan Jiwa, Depkes RI
Yul Iskandar,MD., SpKJ., PhD
Direktur Institute for Cognitive Research.
Tulisan adalah diambil dari Disertasi Kusumanto Setyonegoro (1966), dan pendapat Yul Iskandar terhadap tesis itu, naskah ini telah dipersiapkan selama lebih kurang 10 tahun, dan baru bisa selesai tahun 2006. Naskah ini sedianya akan diterbitkan menjadi buku atas persetujuan Prof. Kusumanto pada tahun 2006, dengan judul diatas. Abstrak tulisan ini pernah dibacakan dalam kongress Indonesian Society for Psychopharmacology, Biological Psychiatry and Sleep Medicines. Tulisan ini untuk sementara diterbitkan dalam bentuk seperti ini. Tulisan ini bisa diperbanyak tanpa izin asal menyebut sumbernya.
Dari pendapat Krehl “Penyakit adalah suatu kehidupan menurut syarat lain; tidak ada hal yang dapat disebutkan “penyakit’, yang ada hanyalah “manusia sakit”.
Dari pendapat Ribbert : Yang dapat jatuh sakit ialah hanya manusia sebagai keseluruhannya, yang disebut penyakit ialah keseluruhan dari pada gangguan-gangguan yang terjadi karena jaringan badan kurang berfungsi, jadi hal ini kebanyakan berupa kelainan-kelainan dari struktur jaringan itu.
Aschoff membedakan suatu reaksi yang berhasil dijalankan oleh badan, apabila kepadanya tertuju suatu rangsang tertentu, dari suatu reaksi badan yang tak berhasil, dan berpengaruh mendalam pada kehidupan manusia, yaitu penyakit.
Ternyata bahwa formulasi-formulasi itu menggambarkan penyakit bukan sebagai suatu keadaan yang bersifat static, tetapi melukiskan keadaan itu sebagai sesuatu yang dinamik dan yang menimbulkan kerusakan pada seluruh organisme. Adanya akibat-akibat yang bersifat merusak itu, dapat dinyatakan dengan terjadinya fungsi-fungsi yang abnormal.
Oleh sebab itu, maka Herxheimer berpendapat, bahwa dalam tiap-tiap definisi tentang paham penyakit, haruslah terkandung atau tersimpul pernyataan tentang adanya bahaya tentang kelangsungan hidup.
Lenz menyatakan, bahwa penyakit adalah suatu keadaan dimana organisme telah sampai pada batas kemampuannya untuk menyesuaikan dirinya. Definisi yang dikemukakan Muck menyatakan bahwa penyakit sebetulnya bukanlah sesuatu yang lain, melainkan merupakan suatu jawaban tentang stimulus. Walaupun demikian harus pula diperhatikan bahwa tidak semua stimulus mengakibatkan jawaban (response) yang sama.
Jelas kiranya bahwa daripada penjelasan-penjelasan yang bersifat deskriptif-definitoir seperti dinyatakan diatas itu, sukar diambil kesimpulan bahwa kita akan dapat sampai pada suatu pengertian lebih mendalam tentang keadaan sakit dan penyakit dalam relasinya dengan manusia.
(Kusumanto Setyonegoro , Disertasi 1966)
Dibawah ini dikutip suatu wawancara dengan Prof. German E. Berrios yang ada relevansinya dengan topic yang sedang didiskusikan. Perbedaan antara tahun 1966 dan tahun 2006 menjadi lebih jelas dengan wawancara ini. Wawancara ini tidak diterjemahkan akan tetapi diambil dari aslinya supaya jangan ada bias semantic lagi antara bahasa Indonesia dan bahasa Inggris.
Interviewing a Colleague: Prof. Germán E. Berrios*
On psychopathology, nosology and neurobiology.
*Prof. G.E. Berrios
BA (Oxford); DPhilSci (Oxford); MD; Dr. Med. honoris causa [Heidelberg; San Marcos]; FRCPsych; FBPsS; FMedSci
Consultant Neuropsychiatrist, Head, Neuropsychiatry Services.
Reader in the Epistemology of Psychiatry, University of Cambridge.
Addenbrooke’s Hospital, Cambridge. United Kingdom
This section is aimed at discussing controversial and up-to- date topics in biological psychiatry or related disciplines by means of a short interview with an expert. Personalities of Psychiatry and related fields will share their opinions, concepts and critical points of view about our subject of interest: The Human Brain and the Human Mind. (1)
Jorge Ospina-Duque, Editor (JOD)
Dear Professor Berrios, it’s a great pleasure to have you with us in this section. Let’s start with your definition of descriptive psychopathology.
Professor German E. Berrios (GEB)
Descriptive psychopathology (DP) is the foundational discipline of psychiatry. It provides 1) a language for the capture of phenomena which, at a later stage, may be conceptualized as ‘mental symptoms’ and 2) rules for the use thereof. Capturing such phenomena is a fundamental epistemological undertaking. In relation to DP, the adjective ‘descriptive’ is something of a misnomer for DP does more than ‘setting forth in words’ the phenomena of mental disorder. Nor the language of DP does “carve nature at the joints”: instead, it ‘breaks up’ the flow of behaviour according to arbitrary rules and meanings and in a second stage selects some of the resulting fragments to elevate them to the status of ‘mental symptoms’.
In its constructionist function DP is guided by ‘social representations’ which are systems of thought involving concepts, meanings and rules which members of the same culture utilize to interpret the world. Such representations also include a model of man (i.e. a philosophical anthropology) and a model of the mind (what the mind is, what furniture does it contain, how does it connect with the body, etc.). DP is thus an interface between clinician and patient; it creates a space in which these two actors negotiate ways of configuring and naming the constitutive phenomena of mental disorder. The first is always the crucial negotiation. This is when the putative patient for the first time reports his/her inchoate experiences. When these are in a pre-linguistic state all that the patient can do is express his perplexity. Sometimes he/ she has a view of what these experiences might be. (The internet is contributing to this. Thereat, patients read about ‘symptoms’ and fit their experiences into the most likely.) This can lead to difficult negotiation between patient and his/ her clinical interlocutor because assimilating the experience with a particular configuration ‘makes’ the patient feel it in that specific way.
Once doctor and patient agree on the form and name of the experience, the latter crystallizes into a ‘stable’ and ‘typical’ symptom. Indeed, its typicality will increase as the patient is interviewed by successive clinicians. In this sense, DP produces regional and self-fulfilling narratives. Regional because they affect a specific person in a specific clinical and cultural situation. Self-fulfilling for the narrative feeds back into the individual a manner of experiencing his experiences which is self-confirmatory. The meaning of these narratives is stable and accessible only in relation to specific social representations. The latter may last for a considerable period of time and the associated narratives give the impression of being eternal and of reflecting objects in the real world. Over the years, the Cambridge group has claimed, however, that there is no such a thing as an independent, objective, eternal description of a ‘mental symptom’ (let alone of a ‘disease’).
The stability of the narratives generated by DP depends upon their social usefulness and semantic coherence. Social usefulness refers to the contribution the narrative makes to social order and control. Semantic coherence refers to the capacity of the narrative to encourage plausible colligations between concepts, beliefs, expectations, worrisome behaviours and landmarks or changes in official brain maps. Once a ‘plausible colligation’ has been achieved, it is possible to generate within it significant statistical correlations. For example, once everyone accepts the (unproven) claim that hallucinations’ are ‘perceptual disorders’ then correlations will be found between hallucinations and neuroimaging hot spots which not by chance happen to be located near regions of the brain in charge of perception! Based upon the correlations generated by such colligation, researchers claim then that their narrative alone is ‘true’. Apart from the social ‘kudos’, claiming exclusive rights to the truth entitles researchers to get more grant money and to be treated in a special way.
These feelings of exclusiveness must be resisted for there are alternative narratives (only that they are suppressed). These alternative narratives are based upon different models of man, of society, and of mind. If given a chance, they could create their own colligations and within them also generate significant correlations. For example, if a new narrative were to redefine hallucinations as a disorder of belief then correlations would soon be found between hallucinations and regions of the brain related to cognition (no longer to perception!). In other words, the epistemology of neuroimaging, about which we know very little, is pliable and self-fulfilling.
Some think that the current nosological approach is the best way to overcome the limitations of descriptive psychopathology. Please comment on this.
The claim that descriptive psychopathology (DP) has ‘limitations’ is difficult to understand. Although an artificial language, DP behaves like a natural languages and does its job in relation to its sector of reality. In the same way it makes little sense to say that Spanish, English or French (or bahasa Indonesia, YI) has ‘limitations’ as a language. Reality (in this case the reality of mental illness) is defined by what the relevant language tell us it is! All other forms of data capture, including nosology, do depend upon the gold standard of psychopathology. Neuropathology, neuroimaging, neurochemistry, etc. etc. are also technical languages but they depend upon DP to provide them with an object of inquiry. This means that none of these auxiliary disciplines can by bypass DP and get directly at the putative object of mental disorder. This does not exist independent from the language of DP.
Let us define our terms so that we can understand how epistemologically depend such disciplines are upon DP. Nosography and nosology name disciplines whose job is to configure and classify diseases, respectively. To do so, they must make use of building blocks or units of analysis. In the case of psychiatry, the latter are mental symptoms, and these DP constructs as we have seen above. More than 10 years ago the Cambridge group published a study showing that there was no basis to the vaunted reliability claims of the DSM IV nosology. The figures provided are only sustainable if it is assumed that symptom-recognition and disease-recognition constitute two cognitively independent stages, and that symptom-recognition is based exclusively on the intrinsic features of each symptom (on which, by the way DSM is silent – the glossary at the end of the book offers qualitative definitions of a limited number of symptoms). By using neural networks, we showed that symptom recognition only occurs when clues external to the definition of the mental symptom are brought into operation. There are two types of external clues: early diagnostic hypotheses and symptom-networking. To use the first clue the clinician must already have a diagnosis in mind at the time he is recognizing the symptoms. This means that there is a major cognitive contamination of the first stage by the second stage. This makes nonsense of the reliability claims (which have been the main argument to accept such a narrow and distorted nosology). The second clue concerns the fact that each mental symptom is not independent of the others and there are small clusters which tend to appear together. So, nosology is not of much use to psychiatry unless it captures its data through the grid of DP.
In summary, the nosological approach is conceptually and informationally parasitical upon DP and it is difficult to envisage a way in which it could bypass DP. I am aware of the fact that some neuroimagers hope that they will soon be able to develop high neuroimaging markers to ‘diagnose’ mental disorders which would obviate having to ascertain mental symptoms (i.e. talk to patients!) and that neuro-geneticists feel sure that soon enough they will be able to work out the ‘real phenotype’ of a mental disorder from its genotype and from these they would work out specific protein and receptor expressions and link this up with magic bullets and that would resolve the problem of psychiatry. Once again, there would not be the need to talk to patients.
All these hopes, which are non-sense reveal a misunderstanding of what a mental disorder is and how it was constituted in the first place. Of course, this is NOT to deny the organicity of mental disorders! The fact that all mental disorders have brain representation is irrelevant to the view that their boundaries and definition are determined by a social representation and hence can only be captured by DP. One corollary of this view is that the same brain ‘change’ may or may not be considered as a ‘disease’, and that the decision on whether it is or not based on brain language but on social or semantic criteria. Since both genotypes mutate and social expectations change it is difficult to see how eternal phenotypes can be established from a transient genotype.
(Yul Iskandar, dikutip dariThe worl Jounal of Biological Psychiatry, 2006)