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Psychology in Russia: State of the Art Volume 7, Issue 3, 2014
Lomonosov Moscow State University
CLINICAL PSYCHOLOGY
contribution to postnonclassical psychopathology
Joaquim Quintino-Aires
Institute Vegotsky of Lisbon, Lisbon, Portugal Corresponding author. E-mail: quintino.aires@gmail.com
Any psychological paradigm needs a psychopathological system that helps professionals to describe and explain the behavioral expressions that deviate from "normal" (whether this term is used with the semantic property of statistical or ideal adaptations). In this work, I seek to present the system that I have been developing since 1998 among the psychologists at the Instituto Vegotsky de Lisboa (Vygotsky Institute of Lisbon), Portugal, to understand psychopathology with regard to the vygotskian approach. It was conceived and designed according to the work of Rita Mendes Leal and her contribution to socio-emotional development theory, AR Luria's systemic and dynamic theory of the human brain, the theory of Activity (dyatel'nost) of AN Leont'ev, and the psychopathological German school of E Kraepelin, presented and disseminated in Portugal in the early twentieth century by Professor Sobral Cid. It is intended to be a proposal to colleagues who are interested in postnonclassical psychology and a request for arguments. Keywords: psychopathology, development, vygotsky, Luria, postnonclassic, syndromic analysis
Introduction — why a new contribution?
I remember the time, as a psychology student at the University of Lisbon in the 1980s, several of my professors of Psychiatry told me that it would not be possible to understand psychopathology or to prepare to be a psychiatrist without a good understanding of psychology. Recent advances in molecular biology and biochemistry, including the old discovery of chlorpromazine in the 1950s, have been met with enthusiasm by professionals in psychiatry and even in clinical psychology. Because of this, in last the 20 years, the psychopathological training in academic and professional settings has forgotten psychology.
ISSN 2074-6857 (Print) / ISSN 2307-2202 (Online) © Lomonosov Moscow State University, 2014 © Russian Psychological Society, 2014 doi: 10.11621/pir.2014.0304 http://psychologyinrussia.com
"... the patient attitude to a situation and to himself should become an Object of study [of psychopathology]" (B.V. Zeigarnik, 1971, p. 29).
In recent years, I returned to university as a student dedicated part of my time to the study of health sciences (molecular biology and medical biochemistry). Soon, I realized that the enthusiasm for molecular biology, which is popular in many areas of health sciences, in the case of the study of mind and behavior is an illusion (Quintino-Aires, 2014).
On the other hand, and in parallel with paths not touched for years, the epis-temology of psychology has advanced remarkably. The disclosure of the historical cultural psychology of L.S. Vygotsky, beyond the borders of the former Soviet Union, generated an interest within an extraordinarily heuristic paradigm and accelerated research. Classical psychology was quickly surpassed by nonclassical psychology, which was used to build postnonclassical psychology (Zinchenko & Pervichko, 2013).
Today, I believe that just as it would not be possible for a doctor to work without knowing physiology and molecular biology nor a surgeon to work without knowing human anatomy, it also does not seem possible that someone working in psychopa-thology, whether as a psychiatrist or a clinical psychologist, could work without a conceptualization of the mental and behavior functioning of their clients that goes beyond the description of symptoms and grouping them into extremely artificial categories to be verified after spending enough time with each client because, in reality, the categories are further apart than the natural history of the disease.
Psychopathology is redeemed by concepts such as syndromic analysis, primary and secondary symptoms, minus and plus symptoms, and the understanding of these concepts according to the fascinating reasoning that postnonclassical psychology presented to us as a continuation of the works of Vygotsky, and it seems that is it is mandatory to overcome confusion in the science of mental health.
Just observing the difficulties of the adaptation of some humans to simple different behaviors is an extremely reducing form. The recent financial crisis that arose in the United States of America and crossed the Atlantic and settled in Europe has shown in a very clear way that the differences in the skills of adaptation of human beings are beyond simple individual differences.
Any psychological paradigm needs a psychopathological system that helps professionals describe and explain the behavioral expressions that deviate from "normal" (whether this term is used with the semantic property of statistical or ideal adaptation). In this work, I seek to present the system that I have been developing since 1998 among the psychologists at the Instituto Vegotsky de Lisboa (Vygotsky Institute of Lisbon), Portugal, to understand psychopathology with regards to the vygotskian approach. It was conceived and designed according to the work of Rita Mendes Leal and her contribution to socio-emotional development theory, A.R. Luria's systemic and dynamic theory of the human brain, the theory of Activity (dyatel'nost) of A.N. Leont'ev, and the psychopathological German school of E. Kraepelin, presented and disseminated in Portugal in the early twentieth century by Professor Sobral Cid*.
Portuguese psychiatrist and politician (1877-1941). As a university professor, he created the Portuguese school of clinical psychology, which was based on psychiatric semiology, the definition of psychological concepts, and on a humanized clinical practice that values the relationship between doctor and patient without losing the sense of medical psychiatry and its biological basis.
*
The integration of these scientists is made separately. First, the paradigm of the Cultural History theory is synthesized in the thesis of Lev Vygotsky. In this grouping, the work of L.S. Vygotsky, A.R. Luria, A.N. Leont'ev and R.M. Leal fit naturally. The integration of Rita Mendes Leal in this group is due to due to the understanding that I reached in 1989, when I began my studies of Vygotsky and Luria, when I was her student and after I was as a psychologist supervising the Relational Dialogical Psychotherapy Society. Later, I realized that my understanding had been previously suggested by the examiners of her doctoral thesis, defended at the University of London in 1975, specifically by Professor Tony Bufery, from the Institute of Psychiatry. After 1999, it was stated and written by her.
The second group includes the psychopathological school of E. Kraepelin and Sobral Cid. I conducted the integration of this school in a Cultural History paradigm with the study of texts by B.V. Zeigarnik, and, particularly, texts by the Czech psychologist Eva Syristova. I separate these two groups because they are epistemo-logically distinct. However, conceptual bridges build something new, overcominges the boundary that separates them, and allowing communication between professionals from different approaches. This destruction of the border is possible due to syndromic analysis.
The psychological paradigm of Emil Kraepelin and Sobral Cid is still rooted in the Cartesian philosophy (which makes sense for two authors of the late nineteenth century and early twentieth century*). The psychological paradigm of Vygotsky in the philosophy of Spinoza is monistic (the body and mind are two categories of the same substance**).
Vygotsky's thesis in relation to the human brain and higher nervous functions (Vygotsky, 1930) was later demonstrated experimentally both in psychology and in neurosciences and and is the core of what is understood to be the vygotskian paradigm***. Introducing fundamental concepts, such the Law of Double development, the Zone of Proximal Development, and the discussion on Signal, Meaning and Sense (Vygotsky, 1934), the psychological paradigm of Vygotsky presents an understanding of psychology that is compatible with the XXI century; whichit is as an independent science that supports the discussion of Biology (thesis), Sociology and Anthropology (the law of double development) and Linguistics (with the introduction of the categories Sign, Meaning and Sense).
Psychopathology I — The classical approach
Working in Clinical Psychology suggests having a system that allows the performance of psychopathological diagnoses, in which it is possible to have a general orientation of the prognosisto and to design a plan of care and treatment. Primitive psychiatric classifications were necessarily symptomatic because the authors, with all of the value of their pioneering, were ignorant of the true causes and underlying
* Cartesian philosophy, in my opinion, is only overcome in the psychological sciences by Vygotsky and Luria in studying the structure and origin of higher neurological functions.
** RM Leal monistic understanding comes from a philosopher of the fourth century, St. Augustine.
*** Although often poorly framed, they are sufficiently documented, so I will not concern myself here in their presentation.
the disease processes of mental illness, seeing themselves forced to rank them according to the similarity or difference to the clinical symptoms offered them (Sobral Cid, 1924).
However, as all other artificial classifications, as noted by Sobral Cid, symptomatic classifications have the drawback of being included in the same group (...) [pathologies], "that, despite their apparent similarities outside, have intrinsic characteristics that clearly separate them (...), and different species disperse clinical syndromes that — notwithstanding their diversity — only express different modalities, or successive stages, of the evolution of the same morbid process "(Sobral Cid, 1924, p. 76).
Sobral Cid criticized the theory of degeneracy that was adopted by Morel. Because of the misleading connotation attributed to the idea of heredity, "in which sense is woefully confused with biological heredity itself, which is the tendency to repeat the progeny of characters ancestors, and so-called morbid heredity, that is, the set of disturbing influences during the ontogenic development that are incidentally introduced by the parent and pathological conditions that might damage the germ reaching the nervous system in the developing fetus and in the immature brain's children in the early years of child life "(Sobral Cid, 1924, p. 84). Morbid heredity, in the language that we use in our team, has been discussed in the "theory of the mold of form." By this, I mean that those with whom we interact continuously and significantly in some sense work in behavioral and psychological terms to "mold" our "forma". We come to present behavioral characteristics and similar structures, even when we dpreviously criticized them. As Vygotsky wrote, "The social and class lines are formed in man from internalized systems, which are nothing more than systems and social relations between persons transferred to the personality" (Vygotsky, 1930, p. 133). Basically, this "theory of the mold of form" is no more than the Vygotsky's Law of Double Development.
The misconception presented in Sobral Cid's first critique is better understood and accepted after the work of Vygotsky and Luria. This is especially true after they indicated that consciousness and higher neurological functions were objects of psychology.
In the second critique, Sobral Cid refers to evolutionary nature in mental pathology. "The evolutionary law of a specific morbid process is one of its most essential characters and surely has more taxonomic value than the cause, which is not always specific, or that its symptomatic form, which is often accidental" (Sobral Cid, 1924, p. 89). He adds, "In addition, under the practical point of view, a purely etiological or symptomatic classification does not enable the clinician to deduce from the nosographic item the prognosis of each case" (Sobral Cid, 1924, p. 89). The evolutionary law seems to me to be an old alert to the genetic analysis of clinical psychological phenomena (Zinchenko & Pervichko, 2013).
Sobral Cid notes the fact that Valentin Magnan*, despite having assumed the evolutionary nature of a mental illness, constituted nosographic specific groups
French psychiatrist (1835-1916). Even today, it is known for its importance in the history of French psychiatry in the second half of the nineteenth century and especially for expanding the concept of degeneration that was introduced in psychiatry by Bénédict Augustin Morel (1809-1873). Magnan's degeneration theory was influenced by biological theories of evolution and heredity ("Considerations générales sur la folie des héréditaires ou Dégénérés" published in 1887).
*
and givengave them clinical individuality. This choice was quite different from that made by Karl Kahlbaum* (1863), who introduced the evolutionary criterion in his classification (which, curiously, he called Gruppierung and not Klassifikation), which helps us transitions between psychology and psychopathology and psychopathology and psychology, as is proposed here.
The evolutionary law was patiently studied and demonstrated by Emil Kraepe-lin (1899). That is why Sobral Cid wrote that if Magnan (French School) had the greatest number of alienated people, Kraepelin (German school) had observed their patients for a prolonged period of time and with a greater esprit de suite. This enabled Kraepelin to realize that what was indicated as different frames corresponded to different phases of the disease (leastways, in the case of their studies on psychosis). As is known, this method led him to classify only two forms of psychosis: schizophrenia, in 1893 (he called it dementia praecox), and the manic-depressive psychosis, manic-melancholic, as it is best known, in 1899.
Psychopathology II — Beyond the classical approach
In the psychopathological system proposed here, I allocate the two critiques Professor Sobral Cid defended in 1924, which are also still the most commonly used systems today (the ICD-10-R and the DSM-IV). The diagnosis is not of the symptoms but of the pathognomonic vector (primary symptom).
Also presented in this natural classification submitted here, and in contrast to the artificial classifications, variants do not have the value of nosographical species per se but only represent evolutionary forms of the same species.
In turn, the various nosographical species are not completely independent of each other. In 1884, Hunghlings Jackson** offered a very new neurological theory of the "evolution and dissolution" of the central nervous system. This theory, which received little attention at the time but is now perfectly integrated in neuroscience, explains the physiological function and the organization of the CNS into three levels that undergo a process of evolution during development but that can also undergo a process of dissolution.
The first level, or the lower level, corresponds to the medulla and the brain stem and has a primarily fixed and organized functioning level, is less complex, and is more resistant to pathology. The upper level, corresponding anatomically to the association areas (parieto-temporo-occipital and prefrontal), is still less organized, more complex, and particularly susceptible to pathology. The intermediate level, with an intermediate level of operation, corresponds to the cortical sensory and motor areas, the subcortical nucleus and gray matter.
Jackson's theory would suggest a lower level with a function such as a "single piece" that is scheduled biologically, i.e. by genetic information, and an upper level with a run type "contraption" that is artificially programmed, i.e., by a relationship with other humans, and is mediated by historical and cultural instrumentalities, as we may say today. This thought was skillfully introduced by Luria in 1966and was and was more recently discussed by Homskaya (2003), and it can also be under-
* German psychiatrist (1828-1899).
** English neurologist (1835-1911).
stood based on Ivan Pavlov's (1924) work on generalized reflexes (in the species) and specific reflexes (in the individual). It is not completely foreign to the cronoge-netic principle of location (Anokhin, 1973).
In the neurological theory of the "evolution and dissolution" of the CNS, Jackson also included the principle of the duality of the symptom, whereby the pathological functioning shows the extent of the commitment, or rather, what the patient has not acquired or lost (minus or negative symptoms), but also the extent of the evolution, or what the patient has acquired and endures (plus or positive symptoms). In other words, basically what we understand today to be adaptation and compensatory potential (Zinchenko & Pervichko, 2013).
Following the theory of H. Jackson, I would like to share the words of the Czech psychotherapist Eva Syristova: "The unconscious emotional eruptions, the thought and the dissociated behavior do not have the character of a child or archaic psyche. Psychosis cannot be reduced to these regressive forms because it has its own origi-nalityand and is an evolutionary or historical neologism" (Syristova, 1971, p. 51).
She also wrote: "The symptoms of mental illness simultaneously express the fact that the individual is unable to resolve and consciously master a particular life situation and satisfy their needs in a real way" (Syristova 1971, p. 49). She adds, "this positive conception of mental illness as a defense mechanism, even as a spontaneous effort to heal is the fundamental approach of dynamic psychopathology" (Syristova, 1971, p. 49).
Cristina Canavarro (1998), from the University of Coimbra, showed that mental health is a function not only of relations with former caregivers, as we can infer from the work of S. Freud, but also of the relationships with friends in childhood and adolescence (second heroes or caregivers) and love partnerships in adulthood (a third hero or caregiver). In this context, we extract from the term "pathogenic parent", in Eva Syristova's terms, and the concept of the "pathogenic caregiver".
Psychopathology is not the result of a predetermination of the genome or the condemnation suffered at some point in a bad relationship in childhood; rather, it is formulated and reformulated within relationships mediated by culture, as indicated by the hypothesis of the changeability of personality structures by Rita Men-des Leal (1975; 1997; 2007), a hypothesis that I prefer to call a theory, as it has over forty years of intense experimental demonstration, received several awards from the scientific community, and has about twenty years of clinical verification by myself and the clinical group that I work with.
According to what I have presented here, there is a clear need for a new psycho-pathological system that allows us to hear and think about each client in consultation within the psychological postnonclassic paradigm. A psychopathological system that considers that, as written by Zeigarnik evoking Vygotsky, "the psychological processes arise in the joint activity of humans and their mutual communication ... [and for which] the action principle is split between two people, and converts depending on the personal conduct of the individual" (Zeigarnik, 1971, p. 110). A psychopathological system in which, "The pathological material allows the establishment of the laws of modification of human motivational sphere, which result in a change of views, interests and personality values" (Zeigarnik, 1971, p. 156).
Continuing from Zeigarnik: "The views, the acts and the person's reactions are not an immediate response to external irritants and instead depend on attitudes,
motives and needs. These attitudes will be formed throughout life, under the influence of education and teaching (broad sense); once formed, they themselves determine the actions and acts of healthy or sick people. The attitudes of the person are related to the structure of personality, needs and the emotional and volitional characteristics. Although the latter are considered by psychology as processes, they, in essence, form part of the personality structure" (Zeigarnik, 1971, p. 29).
"We can speak of a pathological personality change when under the influence of the disease, which diminishes the person's interests, whether making their needs narrower; when it remains indifferent to things that troubled him/her before; when their actions have no purpose, the actions are not controlled; when the person ceases to regulate their behavior, they may not adequately value their capabilities; and when it changes his/her attitudes towards him/herself and the world that surrounds him/her. This changed attitude is indicative of personality change" (Zeigarnik, 1971, p. 29). In this sequence, followed by B.V. Zeiganik stating that "the very attitude of the patient relative to a situation and for him/herself must become the object of study (of psychopathology)" (Zeigarnik, 1971, p. 29).
With these assumptions, it seemed to make sense to look at the suggestion of Mary Rita Mendes Leal (1988), of a Genetic Affectology theory, which was presented in seven 'steps' of socio-emotional development,to and to use this rationale as a research tool in psychopathology in an attempt to propose a natural classification system based in vectors (the main activities — D. Elkhonin, 1978 — in the healthy development) and not pathognomonic symptoms, approaching a postnonclassic version of psychology.
Psychopathology III — From the theory of development to a psychopathological system
I first presented this proposal of a psychopathological system at a training course on Clinical Psychology and Psychotherapy at the Intituto Vegotsky de Lisboa (Lisbon Vygotsky Institute) in September 1998. At that time, the proposal was only a logical and accessible system for clinical psychologists in postgraduate training. However, at this time, several colleagues, based on their own clinical work, contributed important critiques and arguments that sustain this proposal.
As Rita Mendes Leal (2006) wrote, "life is linked from the beginning until its end, a pattern of attendance and contact relationship with an "object" that responds and establishes a meeting with the world beyond it and which transcends the relationship" (Leal, 2006, p. 10). This pattern of relationship works as the "broth" within which the mental apparatus is structured because an organism (a human) operates according to the laws of biology until the construction of a human being (a person), which operates under the laws of psychology.
This route is not predeterminedand is and is based only on a condition of biological heredity (genomic). Rather, this route unfolds according to the "relational format", living with others lends to the relationship, and also according to the cultural instrumentalities created in cultural history — in terms of things, activities and standards that are also embodied in the idiom that serves speech.
It is clear, therefore, that this route is not fixed/rigid or mandatory. As Vygotsky wrote, the development of mental apparatus does not occur in the same way that
a plant grows. When the gardener sows the seed in the earth, we know in advance what will be born at the end of a given time,; for example, a red rose or a blue lily. At the birth of a human being, we only know that he comes with "the capacity for human relationships and for appropriating culture." Therefore, we can only make predictions about how the anatomy and physiology of his brain will develop and how he will relate to himself and with others and the world. We can only make these predictions ifwith respect to the adults of their culture.
Throughout life, a human goes through different stages of social and emotional growth, each one different from others, even if each stage contains the characteristics of the preceding ones. The change to the next stage ("step", as Rita Mendes Leal called it) requires an intercourse social pattern with a caregiver, which "lends the relationship" like a human "veteran". The pattern of relationship that characterizes the operation at each step realizes the personality style (stage) of that human. This offers us the opportunity to perceive different typical structures of personality at each step and the possibility of identifying each vector operation at each personality structure. In practice, the vector is the essence of operating at a specific step.
Throughout the development of the human psyche, each stage corresponds to a psychological age, with a normal operation (in terms of a real standard, that also could be statistics) corresponding to a chronological age with its historical, cultural and social demands. The interruption of this movement (development) by the triangle commitment of the Self (I) — Other (Caregiver) — Object (historical-cultural instrumentalities) leads to a personality that in a relational-historical context is assessed as pathological (less adaptive). According to the evolutionary law referred to above, the vector that identifies the personality structure is the "pathognomonic vector", which identifies psychopathology.
Thus, the "Steps of Genetic Affectology", by Maria Rita Mendes Leal, serve as the "grammar", morphology and syntax of personality that allow us to listen/read with sense the phonemes produced by the patient, which are then the symptoms expressed in actions and speech.
Psychopathology IV — A proposal for a system
We therefore deduce a psychopathological system from natural sequencing, in what is currently observed as an usual development in Western society, which is possible from the pathognomonic vector by predicting symptoms without being dependent on only one them for diagnosis; inferring a therapeutic attitude; and developing a prognosis. Obviously, in the space of an article it is not easy to synthesize and clarify a new proposal for a possible future psychopathological system. In another work, a book, I presented the various relational formats that we have identified. Following the Marxist proposal from the most complex to understand to the simplest (we cannot understand human from ape, but we can probably learn something about apes from studying the human), in that book I focused on the types of romantic love relationships between adults to address different personality structures that suffer because they have not adapted (Quintino-Aires, 2009). Unlike the traditional route from childhood to adolescence to adulthood, here I chose to start with the adult romantic relationship in order toto understand adolescents' friendships and the affection between the child and their parents.
Psychosis
The vector pathognomonic of psychosis is the difficulty of entering into a relationship. It develops in personality structures in which the vector operation occurs as an analogy with the first and second steps described in the Genetic Affectology. This vector corresponds to two different psychopathologies: autistic psychosis and affective psychosis.
Autistic psychosis has as reference the vector of the first step of personality: the orientation to contingency analysis. It is understood that autistic psychosis features an operation in which the initiatives are dramatically reduced due to the absence of previous contingency to his/her previous initiatives but aredo not completely disappear. Thus, discomfort is organized in the physical and social presence of another human, which is needed (biologically) to successfully enter into a satisfactory relationship. This type of operation is recognized in autistic and Asperger children and in schizophrenic adults. The difference that we observed between autistic and Asperger children or a schizophrenic adult corresponds to a different brain structure, according to the principle of the heterochonous anlage of components of a functional system by Anokhin (1974) and Vygotsky's thesis of systemic and dynamic organization, as documented experimentally by Luria (1966; 1973) and, more recently, by many others, including F. Ostrosky-Solis (2004) using the modern methods of neuroimaging.
affective psychosis manifests during the second step of personality development, which has an attention circular reaction vector of operation. The affective psychotic person already has the ability to be contingent on the initiative of another person, and this novelty becomes the main activity (Elkhonin, 1978). However, another one is more a Phantom (French psychoanalytic school) than real, so it is functionally unavailable. This operation is recognized in hyperactive children and in adults with manic depression, or according to the terminology suggested by Sobral Cid, the manic-melancholic. H. Jackson's neurological theory and the principle of "equal simplicity", a dynamic theory of localizations by N. Bernstein (1967), allow us to understand the nature of the motor symptoms in hyperactive children and its ideational character in manic-melancholic adults. Hyperactivity in children requires the availability of intermediation by brain regions (the frontal motor region), while the manic-melancholic operation requires the availability of (prefrontal) upper regions that are only available after 12-13 years of age. However, both forms have the same pathognomonic vector.
To understand the vector (personality structure) that is discussed here, I suggest reading the biography of the Portuguese singer Amalia Rodrigues, written by Pavao dos Santos (2005), recently reissued.
Psychopathy
The pathognomonic vector of psychopathy is the feeling of injustice resulting from an encounter with the "self-other-object (thing, person, or event)" that does not function as a vehicle of consensual meaning. It develops from the structure of the third step of personality, Genetic Affectology.
Psychopathy is the evolution of the third step, and the vector is joint naming and referencing. The inability of the psychopath to name the act of another, which
sometimes does not coincide with its own (the self), is the injustice of another, an operation that we can recognize in the defiant-oppositional child (omnipotent child) and in adult psychopaths. The unavailability of shared mutual consensus meanings in vygotskian terminology hinders the understanding of the Act (dyatel'nost; Tätigkeit; "action" in the terminology of Rita Leal) of the other, leading to interpreting it as injustice.
In the training of clinical psychologists at the Vygotsky Institute of Lisbon, we propose as activity for understanding how this works as a personality structure and psychopathology in which each element of the group of trainees evokes the most intense experience of injustice that he/she has committed. Following the proposed group dynamic, which is always accompanied by the trainer, descriptions that demonstrate the difficulty of the meaning of being unfair to another arise, and behaviors (thankfully only verbalized fantasy) that match the psychopathic symptoms also arise.
Clinical practice often shows two evolutionary moments in psychopathy. An earlier moment, characterized by passivity resulting from the perception of "pow-erlessness" to restore justice, and a more evolved moment, characterized by the activity to repair injustice that resembles a moral guardian. We call the first form passive psychopath, and the second active psychopathy, and the second arein-cludes serial killers, who are commonly associated with psychopathy.
The identification of a pathognomonic vector, corresponding to a vector operation, leads me to consider psychopathy as a nosographic species, a clinical entity,to and to reject terms such as border-line. We have performed some discussion on this issue at the Vegotsky Institute of Lisbon, and the term psychopathy has a negative connotation in our culture, and that the vector operation and the pathognomonic vector — restoring justice — are well presented in stereotypes and substantial cultural and social figures. For example, the classic college student of Coimbra University, who several years after he entered university continues without graduating and who every summer in his hometown engages, seduces and impregnates some poor girl who works as a servant in his house without worrying about what will happen to her and the child after, and in the opinion of everyone in the small village, he is an admired play-boy. Alternatively, in another case, in some religious priests and nuns, who advocate that truth is different from practice acted, realizing a pre-symbolic function, and separated the "active role" and "knowledge function" (in the terminology of A.N. Leont'ev and B.V. Zeigarnik). It it is reminiscent of the famous phrase by E. Kraepelin: "with the Bible in hand and a stone in her lap."
Neurosis
Neurosis has a pathognomonic vector, the need to control, which begins with the need to control the attention of the Other, and then, by a process of generalization, becomes the need to control things, people and events. It develops in personality structures during the fourth, fifth and sixth steps of Genetic Affectology, thus appearing in three different psychopathologies: anxious-phobic, hysterical and obsessive-compulsive neuroses.
The phobic anxiety neurosis is an evolution of the fourth step, which has as a vector of operation of the pre-symbolic elaboration of losses and meets again
with a caregiver, as discussed by Rita Mendes Leal. This neurosis is experienced as a figure of unreliable appearance and has to be "controlled" so that it can suddenly disappear. Thus, the personality with this vector operation systematically searches for the physical presence of another, affecting the activity of exploration and enjoyment of the world during this presence, even if illusory. These individuals can serve as caregivers because sometimes it is "just" a child or a voice on the phone requiredthat can allow them to enjoy a bit of sun on the esplanade.
In phobic anxiety neurosis, the pathognomonic vector is accompanied by an inhibitory strategy that reduces anxiety (commonly understood as the problem to solve), a condition shown in studies of neurophysiology in rats that were trapped without the possibility of escaping from a potential aggressor to reduce the brain's electrical activity recorded on EEG, corresponding to fainting or even to a coma. Thus, we hear the phobic-anxiousness that neurotics refer to upon non-entry into elevators or airplanes, not because they fear that they might fall, but to avoid the situation of wanting to go out and not being able to; not passing the bridge on the "25th April"* for fear of shooting up by himself; not going to a bank or a government agency because of the waiting context is intolerable; and not entering a motorway because no one can prevent a traffic jam and the consequent impossibility of getting out if desired. That is, individuals avoid events that take place outside of their own control because they does not appear in their consciousness to be masters who address the confusing world full of thean unforeseen need, such a single that ensures a stable relationship with the world of external and internal objects.
A rather evolved form in the pathology of phobic-anxious neurosis is called Post-Traumatic Stress Syndrome, with which I had the opportunity to work with in the years I worked at the Military Hospital in Lisbon. When placed in a situation where it is impossible to have control over the events in which a person is involved (in war it is impossible to predict when the enemy attacks or who will be hit by the bullet), the phobic-anxious personalities rapidly develop pathology and express the symptoms we all know.
The interaction of the events with separation between the "active role" and the "knowledge function", using the terminology of A.N. Leont'ev and B.V. Zeigarnik, denounces a symbolic operation where the social meaning of events have not yet turned in to the personal sense** of the same events. In other words, where the nonappropriation of the personal sense of the event prevents the discernment of control for himself and his life, it becomes a Principal Activity in the terminology of Elkhonin.
Hysteric neurosis is an evolution of the fifth step, which has as operating vector, the differentiation of its live relative to their parents (self live meaning).
The person embodied the narrative of their parents and presents it to other peers, sometimes combined with dissatisfaction of the consensual meanings. Finding themselves bereft of the dream to be the world's center to "others", the person embodies the narrative of adults in terms of social meaning, but not in the personal sense, which results in immature acts.
* Bridge in Lisbon, similar to Bridge of San Francisco, USA.
** Here, we distinguish "social meaning" and "personal sense", when what someone says or advocates (social meaning) is different from how she acts (Personal sense).
As also happens with a child, in this step, the person is dependent in many ways on the emotional charges that transcend him/her. Involvement with thea face to face scenario with adults (the dramatization has already been addressed many times) presents (the incorporation of character) what is observed, and they copy the adults who they grew up with (their values and their talking). Throughout this process, it is possible to distance his/herself enough to "discover" and evaluate their ancient heroes (even though peers comment on these heroes ...) and to perceive them (ancient heroes, parents) as imperfect people. Often, this is a painful process but provides the freedom to own a personal search of consistency.
In hysterical neurosis, the pathognomonic vector is accompanied by a strategy of theatricality, which reduces the anxiety produced by the main activity (Elk-honin) dictated by the vector of operation. Stuck between the proposal of the adult character and the condition of being younger than they are the frequent sexuality and sensuality contents (some type of crisis typical of the Zone of Proximal Development). These are not experienced in life but are phantasmatically tested without the experience that dramatization permits without compromise, while holding the other's attention. I recall here the words of Professor Manuel de Matos: ... "The hysterical woman induces, induces, induces; but when a man opened to her, she runs away". This makes us think that the adult character created too much anxiety when approaching real life. What can be dramatized and neutralized (because it is the main activity), dictated by the vector operation, could not be tried. Once again, this reveals the separation between the "active role" and the "knowledge function".
The obsessive-compulsive neurosis is an evolution of the sixth step, while the vector operation is the discovery of pleasurable partnership outside the family (attachment with peers). As a result of the evaluation and disappointment of his oldest, and having distanced himself enough to assess parents among peers, he increases the perception of belonging to the group and seeking mates who speak the same language and have the same customs, thus solidifying social rules. They are still without a symbolic force of personal sense, which is not an appropriation by itself but is a new embedding narrative. No further incorporation of the narratives of the parents, but the narratives of couples, with the problem that they are plural (a group of peers) and present relative diversity, which causes anxiety (we cannot please Greeks and Trojans ...).
In obsessive-compulsive neurosis, the pathognomonic vector is accompanied by a rationalization strategy to reduce anxiety. Obsessive-compulsive neurosis works for the acceptance and attention from all others within the social norms, which he takes as personal, but are not personal in a sense.
In the training of clinical psychologists at the Vegotsky Institute of Lisbon, a dynamic is proposed by the trainer in which each student must imagine a dinner at the home of someone important from another culture. With the help of trainers, trainees are directed to enhance the admiration of the owners of the house where the dinner takes place. The absence of cutlery (suggested by the trainer) creates a situation in which control is lost. Even without knowing the psychopathological system under study, the responses of learners to solve the situation reveal exactly one of the three typical strategies to reduce anxiety in neurosis: inhibition, theatricality, or rationalization.
Depression
Depression has as a pathognomonic vector of hopelessness resulting from the simultaneous presence of a desire that the world could be otherwise and the certainty that it is not possible. Depression is an evolution of the seventh step, the vector operation of which is creating personal meanings (self live sense). Again, as a test plan, testing approaches/creates separations with older persons and with peers (because they also disappointing), alternating between being a caregiver and being cared for. A new format of dialogical relationship begins to occur, rehearsing the experience of romantic love and passion. The test of reality is operationalized and raises awareness that the intention of the other, any other, can not only be different from his/her own but even feigned and deceitful. The world is seen in its real hue, and this finding causes woe and the hopelessness prevails.
This is the least common psychopathology and has been observed in only a few cases over the last two decades. In one case, I worked with a thirty-two-year-old woman who was brought to my practice after wandering between the bed during the night and the living room sofa during the day for the past year. The change of location was caused by her mother, who tells her: "It is day, get up" or "It's late, go to bed to sleep." During the four years of therapy, the main activity (or theme) was just one aspect of her life that she could not give up but was one that she had absolute conviction of not being possible: her homosexuality!
This is the reason why the depressed individual does not cry: because he/she knows that there is nothing to change while the desire does not disappear or change. Is thus tied to the drawing of something in the future that is unable to be resolved in the present.
Table 1. Summary of the proposed psychopathological system
step Personality Vector Pathognomonic Vector Psychopathology in children Psychopathology in Adults
1 Contingence orientation Difficult to connect with others/uncomfortable Autism and other infant psychosis Schizophrenia
2 Attention circular reaction Difficult to connect with others/grief Hyperactivity Maniac- Depressive Psychosis
3 Joint naming Omnipotence Defiant-Opposer Psychopath
4 Loss and meet again Control/Inhibition Phobic Anxious Neurosis Phobic Anxious Neurosis
5 Self live meanings (from family) Control/theatrical Hysteric Neurosis Hysteric Neurosis
6 Attachment with peers Control/Rationalization Obsessive Compulsive Neurosis Obsessive Compulsive Neurosis
7 Self live sense (from friends) Despair Depression Depression
Conclusion
This work is a proposal. It is not a finished theory, as no proposal yet exists in this field of science. It reflects a desire that psychopathology return to the field of psychology, in this case, a postnonclassical approach in psychology. Moreover, it is also intended to be a contribution to psychiatry, as a medical science, as it enters into the twenty-first century, such as other medical specialties. This work implies overcoming classifications based on lists of symptoms. Naturally, therefore, it is also a request for argument.
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Original manuscript received July 11, 2014 Revised manuscript accepted September 3, 2014 First published online September 30, 2014
