[The crisis of the operational diagnostic approach in psychiatry]

Phenomenology of Obsessive-Compulsive Disorder: A Methodologically Structured Overview

A methodological order is derived from the concept of phenomena and stages of understanding are developed according to Karl Jaspers. The three levels of descriptive, genetic and hermeneutic understanding are applied to the study of obsessive-compulsive disorder. Descriptive understanding essentially reveals a sense of incompleteness and depersonalization that underlies the experience of the nonsense of obsessive thoughts and that obsessive-compulsive symptoms do not come to an end. Genetic understanding shows particularly by reference to the trigger situation that sensitivity, undifferentiated affects, affective hyperarousal and traumatization are important aspects in the development and maintenance of the obsessive-compulsive disorder. Hermeneutic understanding brings to light the fear of death in obsessive-compulsive disorder as its anthropological dimension. The aim of this methodologically structured overview is to focus on the experience of the obsessive-compulsive patient, to keep curiosity and interest alive, so that both research and relationship to the patient is stimulated.

[Syndromal versus nosological diagnosis]

Against the background of the current preparation of ICD-11 and DSM-5, there is a discussion whether syndromal approaches should replace the traditional nosological diagnosis in psychiatry. From a historical point of view the syndromal approach results from a reaction to the nosological model of Emil Kraepelin. Later the syndromal diagnostic approach became more important because it enabled a quantitative-dimensional assessment and analysis of psychopathological data using modern statistical procedures. However, attempts to ascribe the traditional nosological categories to psychopathological syndromes using multivariate statistical methods have failed. The syndromal approach allows a differentiated recording of the cross-sectional symptomatology; however, a plurality of different syndromes might be registered without considering meaningful principles of classification and longitudinal aspects. The syndromal approach should be complemented by a nosological classification based mainly on the psychopathological course due to the absence of consistent neurobiological findings.

[Deconstructing schizophrenia. Dimensional models or division into subtypes?]

Against the background of the arrangements of ICD-11 and DSM-V, future approaches in order to diagnose schizophrenic psychoses are currently being discussed. In this context, the current concepts of schizophrenia are questioned because attempts at neurobiological validation and validation based on family and follow-up studies have not succeeded. Therefore, dimensional diagnostic models or a division into subtypes are suggested. Both of these proposals would imply a deconstruction of the current concept of schizophrenia. A historical review shows that the psychopathological roots of the current discussion can be traced back to Kurt Schneider's nominalistic concept of schizophrenia which is based upon the so-called first-rank symptoms. In contrast, the psychopathological foundation of dimensional concepts and a division into several subtypes date from contributions of Klaus Conrad and Karl Leonhard. A triaxial diagnostic system with the axes of syndromes, course types and aetiology could provide a bridge between the different approaches.

[Gottfried Benn and schizoidism]

Based on increasing criticism concerning operational diagnostics in psychiatry, the concept of schizoid personality disorder in ICD and DSM is discussed critically. In a case study regarding the poet and doctor Gottfried Benn, the limitation of manualized, context-independent diagnostic systems is shown. In contrast Ernst Kretschmer's concept of schizoidism seems suitable to describe a schizoid character in his ambiguity.