Psychopathology, Nosology and Neurobiology

Akan tetapi jelas pula kiranya, bahwa dalam ilmu psikiatri kita tidak berhubungan dengan suatu keadaan gangguan seperti sakit pilek dan batuk-batuk saja. Kita berjumpa dengan keadaan-keadaan yang biasanya dinyatakan dengan nama-nama seperti psikosis, neurosis, psikopatia, hysteria, dan lain-lain sebagainya yang kita mengetahui jauh lebih mengenai inti hidup manusia yang bersangkutan.
First of all, they cannot be defined in abstract or be given ‘operational definitions’. That is one of the myths of medicine. They can only be defined within specific epistemic frames which must include a theory of disease, of cause, of colligation, of convergence, of semantic sign, and of measurement. For example, before the 17th century the difference between disease and syndrome is meaningless simply because then the Aristotelian concept of four causes was still the rule and syndromes could not escape having causes as well, so they were just diseases. Seterusnya di:
https://dryuliskandar.wordpress.com/2009/09/23/psikiatri-kusumanto-yul-iskandar-36/

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
dan
Yul Iskandar,MD., SpKJ., PhD
Direktur Institute for Cognitive Research.

Catatan.
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.

Semua pernyataan itu memberikan kesan kuat, bahwa apa yang disebutnya “penyakit” itu dapat dianggap “terlepas” dari diri manusia itu, walaupun dapat diakui bahwa memang ada penyakit-penyakit yang demikian sifatnya, seperti antara lain penyakit pilek dan batuk-batuk.
Akan tetapi jelas pula kiranya, bahwa dalam ilmu psikiatri kita tidak berhubungan dengan suatu keadaan gangguan seperti sakit pilek dan batuk-batuk saja. Kita berjumpa dengan keadaan-keadaan yang biasanya dinyatakan dengan nama-nama seperti psikosis, neurosis, psikopatia, hysteria, dan lain-lain sebagainya yang kita mengetahui jauh lebih mengenai inti hidup manusia yang bersangkutan. Oleh sebab itu, maka sekali lagi kita yakin bahwa deskripsi dan definisi semata-mata akan sukar memberikan pendalaman materi yang lebih serius ke dalam paham dan konsep keadaan sakit dan penyakit ini.
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. (2)

JOD
Continuing with the debate on nosology and psychopathology, there is a tendency to favour studying syndromes instead of symptoms. This is due in part to the assumption that this is a more profitable strategy to elucidate the neurobiological basis of psychiatric disorders. What is your opinion?
GEB
Much is still made of the distinction between disease, syndrome, sign and symptom. I have always wondered why. Indeed, the history of these four terms shows that there never was a time when differences between them were very clear. First of all, they cannot be defined in abstract or be given ‘operational definitions’. That is one of the myths of medicine. They can only be defined within specific epistemic frames which must include a theory of disease, of cause, of colligation, of convergence, of semantic sign, and of measurement. For example, before the 17th century the difference between disease and syndrome is meaningless simply because then the Aristotelian concept of four causes was still the rule and syndromes could not escape having causes as well, so they were just diseases. After the 1650s, the Aristotelian definition of cause was abandoned and hence it became possible to understand what a disease without a cause is. It is this orphan concept which became known as a ‘syndrome’ and simply meant ‘symptoms running together’.
The same historical stringencies are valid for the distinction between sign and symptom which is totally based on a ‘theory of linguistic sign’ developed only at the end of the 18th century. Early in the 19th century the separation was still very fluid and if anything signs were considered as semantically inferior to symptoms. After the positivistic reaction of the 19th century, however, medics started to brag about getting information directly from the body, about by passing the subjectivity of the patient, and about signs being epistemically stronger and more objective than symptoms. It was little realized that they were still dependent upon the subjectivity of the clinician! At any rate, this issue is a bit irrelevant to psychiatry as in our discipline we do not have real signs; we just have symptoms.
Now, for the last 30 years I have been advocating that there is more epistemic gain in concentrating on the study of mental symptoms than of mental disorders. I believe that many of our current ‘diseases’ (e.g. schizophrenia, Alzheimer’s disease , Parkinson’s disease , obsessive compulsive disorder, etc. etc.) are high level constructs which are breaking down in front of our very eyes. In practice, it is already the case that most researchers are actually working with symptoms even if they claim that they are investigating diseases. For example, most fMRI research in ‘schizophrenia’, ‘OCD’ or ‘Alzheimer’s disease’, although may collect cases on the basis of standard diagnostic criteria, attempts to identify changes related to a symptom or at most 2 or 3 symptoms of the relevant disease. There is no such a thing as the neuroimaging of schizophrenia in toto or of all first rank Schneiderian symptoms!
Researching into mental symptoms brings us nearer to neurobiology and to social representations. Symptoms behave like fractals. As you examine them in detail they open up. One old teacher of mine, professor Max Hamilton, used to say that the symptoms of today are the syndromes or diseases of tomorrow. This because symptoms are semantically self-contained and may prove to be composite of sub-phenomena sharing related brain addresses, genetics, etc. etc. I have always wondered, and I have had some debates in my time about this, about the possible relationship of ‘delusional perception’, apathy, stereotypical behaviour and memory disturbance in schizophrenia. How are these phenomena in fact colligated?
(Yul Iskandar, dikutip dariThe worl Jounal of Biological Psychiatry, 2006)

Oleh sebab itu, maka akan ditempuh suatu jalan lain dari pada suatu cara pendekatan (approach) yang hanya deskriptif-deskriptif saja. Walaupun demikian, ada beberapa patokan tertentu yang bermanfaaat yang dapat diambil dari pada deskriptif-deskriptif itu.
Pertama : ada semacam “kata sepakat” diantara para ahli yang dikutip pernyataan-pernyataannya diatas, bahwa keadaan dan penyakit itu dapat timbul hanya dalam prinsip “terjadi suatu ancaman terhadapa kelangsungan hidup organisme”.
Kedua : ada semacam “fakta”, bahwa pada tiap-tiap keadaan ancaman hidup, dalam organisme itu terjadi semacam “mobilisasi dari pada segala potensi organisme” itu, baik yang bertujuan menghancurkan serbuan stimulus yang telah berhasil memasuki organisme dan kemudian menimbulkan keadaan ancaman tadi, maupun usaha yang bertujuan menyesuaikan diri secara lebih baik terhadap ancaman itu.
Ketiga : adanya peristiwa bahwa terjadi suatu “kegoncangan dalam keseimbangan organisasi yang semula”, yang senantiasa hendak dikoreksi oleh organisme itu atau dengan tujuan untuk mengembalikan keseimbangan semula, atau dengan mencapai keseimbangan lain yang baru.
Keempat : ada hal lain yang harus diperhatikan secara khusus yaitu dalam hal neoplasmata baik yang bersifat ganas atau pun tidak. Dalam situasi demikian itu seringkali diperoleh kesan, bahwa malignitas hanyalah berhasil menimbulkan reaksi defensif total, seperti halnya dalam penyakit typhus abdominalis itu, jika proses penumbuhan neoplasma itu mulai berada dalam keadaan yang kritik.

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. (3)
JOD
You have argued that psychopathology and neurobiological research are in a state of “mismatch” at various levels. What is the nature of this “mismatch”? How to improve the informative value of psychopathology for neurobiological research in psychiatry?
GEB
What I mean is this. In each historical period, the language of DP adapts itself to the dominant contemporary narratives, whether biological or social. Adapting means matching the level of description to the power of resolution of the research technology available. During the 19th century, when DP was first constructed, the forms of madness available were the result of an interaction between certain brain pathologies and ongoing social representations. In practice, the level of analysis of the research technology available at the time was determined by the resolution power of light microscopy and the corresponding contrasts created by available reagents and stains. DP simply matched both levels of need.
After 150 years, there have been many changes. First of all, the phenotypes of certain diseases have changed, their social perception has evolved, and the research techniques available have a much finer resolution power. DP should have kept up and recalibrated itself . Unfortunately, a rather stupid essentialist view still prevails that all symptoms have already been described, that DP is some sort of eternal language, and that reliability would be enhanced if DP was made into a close system. This has led to a reduction of research on DP, and that it gradually went out of calibration.
This is the cause of the mismatch. A research drive is now required to re-calibrate DP and increase its resolution power to so that the validity of correlations between symptom and brain is restored.
JOD
Teaching psychopathology is a difficult task. How to improve training in psychopathology during the residence?
GEB
The skills of listening to patients and of describing and identifying symptoms are rapidly disappearing. The use of ‘diagnostic’ criteria and structured interviews is killing the inquisitive capacities of young psychiatrists. Guidelines telling them that for fixed diagnosis X they must prescribe medication M discourage clinicians from emphasizing newness or variation. The rites and fashions of modern research’ do not help either: Journal editors look upon single case studies and in general DP papers with disdain. If a researcher submits a paper reporting a new symptom referees ask where these patients diagnosed according to DSM IV? ICD-10?
I feel pessimistic about these trends. In practice, it will all depend on what American psychiatry will do in the future as they exercise a marked control upon world psychiatry. If tomorrow they were to say: “We have decided no longer to pursue nosological research but to investigate symptoms” the entire world will sheepishly follow. Such decision of course would not be based on science, imagination or intelligence. It would result from the big medical insurance conglomerates and the pharmaceutical industry believing that there is more money to be made in targeting symptoms. I am not exaggerating in saying that the APA will decided whether knowledge about symptoms and the clinical skills to recognize them will stay or go.
(Yul Iskandar, dikutip dariThe worl Jounal of Biological Psychiatry, 2006)

Hal yang lain lagi, dan yang patut pula diperhatiakan ialah penderita dalam keadaan inanitio. Gambaran ini khususnya bagi Indonesia sangat terkenal, dan dahulu seringkali diperllihatkan oleh golongan romusha pada jaman pendudukan Jepang. Mereka itu memperlihatkan keadaan kurang makan yang ekstrem dan yang telah berlangsung sejak lama. Mereka itu seolah-olah tidak dapat berekasi lagi terhadap keadaan sakitnya.

Mereka dapat disebut tidakberaktivitas , malahan jelas-jelas sangat pasif sekali juga dalam dimensi-dimensi fisiologik. Hal yang demikian itu disebabkan karena organisma sebetulnya sangat sedikit lagi alasan-alasannya untuk mengadakan mobilisasi total yang bertujuan defensif atau agresif.

Jadi baik dalam keadaan tumor maligna maupun dalam keadaan defisiensi gizi yang ekstrem, organisme yang bersangkutan itu seolah-olah terpaksa tinggal diam, dan pasif dalam pertahannya. Organisme sudah terpaksa menyerah kalah, justtru karena kekurangan alasan atau pacuan untuk perjuangan terhadap serbuan atau hal-hal lain yang mengancam kelangsungan hidup secara akut.
Oleh karena itu pada tempatnya kiranyauntuk bertanya apakah penderita yang mengalami tumor ganas dan penderita yang mengelami defisiensi gizi secara extrem memperlihatkan keadaan sakit atau penyakit.
(Kusumanto Setyonegoro , Disertasi 1966)

5 Tanggapan to “Psychopathology, Nosology and Neurobiology”

  1. Just a Theory » the Psychiatry of Torture: Waterboarding is Worse … « Grumpy Ant Says:

    […] Psikiatri Kusumanto-Yul Iskandar (36) « Dryuliskandar's Weblog […]

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  3. Bill Bartmann Says:

    Hey, I read a lot of blogs on a daily basis and for the most part, people lack substance but, I just wanted to make a quick comment to say GREAT blog!…..I”ll be checking in on a regularly now….Keep up the good work!🙂

  4. dryuliskandar Says:

    Rupanya yang menyenangi tulisan Psikiatri Kusumanto – Yul Iskandar pada umumnya orang barat. Bagaimana komentar psikiater Indonesia.

  5. acai berry trials Says:

    Sympathy constitutes friendship but in love there is a sort of antipathy, or opposing passion. Each strives to be the other, and both together make up one whole.

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