PSYCHODYNAMIC BASES of MENTAL DISORDERS

1
PSYCHODYNAMIC BASES of MENTAL DISORDERS

• M. BOTBOL
• Psychiatrist
• Médical Director of Clinique Dupré (Sceaux ,
  France)

2
What dimensions constitute the Psychological
Basis of Mental Disorders ?

• Experience of illness the Phenomenologic
  dimension
• Psychological functionning and organisation the
  Structural dimension

3

• Meaning of the symptoms for the patient and the
  professional, the place it takes in the patients
  personnal history the Metaphoric or Symbolic
  dimension
• The Etiologic dimension

4

• Structural dimension, Symbolic dimension and
  Etiologic dimension can clearly be considered as
  Psychodynamic variables
• The Phenomenologic dimension is not.
  Nevertheless, to take it into account is a
  crucial first step to allow the empathy necessary
  to adress the three other dimensions

5
These dimensions are neglected by current
Classificatory System

• The subjective dimensions are neglected by the
  current Classificatory Systems (C. Berganza
  Yokohama 2002)
• Leaving us with half a science (J.Strauss NY
  2003)

6
But are essential for clinical purposes

• Essential for both patients and therapists in
  clinical settings (Philips, NY 2003)
• With some evidences that some of these
  characteristics are good predictors of the
  disorders outcome in some populations (
  Janardhan Reddy and al 1993)

7
They should then be taken into account

• They should then be taken into account if we want
  to improve the clinical usefulness of the
  International Classificatory System,
• ie assesment of individual clinical
  configuration, elaboration of multifocal type of
  treatment, relevant follow up evaluations etc

8
In spite of epistemologic obstacles

• Conflict between ideal of objectivity and
  subjective nature of the psychodynamic
  dimensions
• Conflict between singularity of individual
  experience meaning and history and classificatory
  needs
• Conflict between classification struggle for
  homogeneity and stability and clinical
  heterogeneity (subjective diversity)

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• The challenge is then to find how these
  psychodynamic basis can be integrated in a
  classificatory system in spite of these
  epistemologic obstacles
• How to take them into account so that beyond
  singularity of individual experience meaning and
  history, some relevant types could be constructed
  to respond to classificatory needs

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Tentative paths to challenge these stake

• An appendix classification for psychodynamic
  structural classification in a set of appendix
  classification reflecting heterogeneity of
  psychiatric disorders and heterogeneity of
  classifications purposes (ie Family of
  international classification ICD-ICF)
• Each appendix should not be atheoretical, but
  explicitly referred to a specific interpretative
  system of meanings
• But should however remain compatible with
  standardized assesment of psychological domains

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Responding to the need to bridge the gap with
natural or traditional clinical approach

• Not based on tight criteria sets (Phillips NY
  2003)
• But on a prototypal or ideal type approach
  grounded on a rather intuitive and mixed
  cognitive process

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The psychodynamic appendix

• Should then refer to psychodynamic structural
  categories Neurosis, Psychosis, Border Line,
  Reactional States
• And should be completed by the narrative and
  idiographic formulations on which they are based
• Refered to prototypic clinical vignettes

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This appendix should then include references to

• Defence mechanisms, object relation, core
  conflictual theme, structure of psychic
  organisation
• Interactional style
• Modes of attachment

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Globaly, how to face such a multicomplex
diversity ?

• Elicit some relevant specific field to integrate
  them in the classificatory system, each one
  beeing assessed by a specific validated
  instrument ?
• Include, as appendix, global classifications
  constructed from each of the main psychological
  approach point of view. (ie French Classification
  of Child and Adolescent Mental Disorders)?

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To give room to psychodynamic variables to truly
inform a valid psychiatric nosology, we will have
to chose between these two options, keeping in
mind that our aim is to take into account what is
neglected by the current classificatory
systemAn holistic approach of the persons
subjectivity