The case study has a glorious past in medical education and an uncertain future, being unjustly blurred by the agglomerations of cases that make up the meta-analysis, by virtue of a superior position in the so often evoked pyramid of evidence based medicine.
Psychiatry is part of this trend. From the classic case studies of Freud (Dora, little Hans, Rattenman, Wolfsmann, President Schreber) to the DSM IV TR Casebook we find a somewhat transnosographic descriptive typology and even for this reason with perennial value, especially by kneading the pulpit semiological aspects of the cases.
In a completely undeserved way, psychiatrists are constantly increasing the ranks of the unhappy intellectual world. The destiny of Cinderella of their profession is reflected day by day and year by year on their own life, on their own destiny. Perhaps one of the sources of this unhappiness is the special difficulty of defining the notions with which it operates, a difficulty speculated maliciously by "opponents". Among other peculiarities of the field there is that of adversity: see the phenomenon marked by philosophical and ideological accents of anti-psychiatry.
If we resemble psychiatry with an unknown country, then semiology should be the language of this country, a foreign language that must be learned if we want to understand what is happening in such a country. A difficult undertaking, not least because, we must admit, psychiatric language has a number of inconsistencies, inconsistencies and even inadvertences.
The cornerstone of any case is the psychiatric examination. Psychiatric examination essentially means dialogue between doctor and patient. This dialogue (freer or tighter), in a semiotic perspective, remains, in fact, a transmission of information from a sender (patient) to a receiver (psychiatrist). The peculiarity of this interrelation is the fluidity of the vehicle carrying the information, the word. The difficulty of this interrelation consists in the fact that it involves at least 3 encoding / decoding operations:
1. primary coding: what the patient feels in what he says, in other words, the transformation of a certain feeling into a verbal communication, that is, into a sentence;
2. the decoding by the psychiatrist of this communication, ie the translation of the sentence from the patient's language into the psychiatrist's language;
3. secondary coding: transforming the sentence into a semiological notion.
We will notice that 66% of this effort belongs to the psychiatrist. It is true that he can increase the patient's effort through guided questions, through returns, that is, through feedback. To stay in Wienian terminology, we will note that the primary coding operation involves a predominantly intuitive, black-box mechanism ("Dionysian" thinking, "right hemisphere" thinking), while the secondary coding operation involves an analytical mechanism, of white-box type (“apollinic” thinking, “left hemisphere” thinking).
During the clinical interview, a young patient tells us, "My soul is in everything around me." In the process of secondary coding, the psychiatrist must identify the optimal variant of discrimination between the various meanings of this sentence: marker of noetic and / or perceptual productivity? depersonalization - derealization? Or, simply, metaphorical language? Two factors will influence his decision: a prospective, analytical factor, in which directed, dissecting, “feedback” questions are essential; and a retrospective, synthetic factor, practically superimposable to the notion of “clinical context”.
Each encoding / decoding operation is burdened with a certain risk of error. This risk is difficult to assess. We believe it is necessary to emphasize one more aspect. We showed above the importance of an active attitude of the psychiatrist (through guided questions) during the clinical interview. Unfortunately, there is also a risk of error, specific to psychiatry. It is probable that through this very active intervention the psychiatrist will produce "artifacts", to distort the expression of his patient's feelings. We could talk here about a certain psychiatric correspondent of Heisenberg's principle of indeterminacy, probably more accentuated in the psychometric version of the diagnosis.
We could complicate this discussion by evoking the situation, not even rare, of the clinical examination performed, in a certain temporal succession, by two psychiatrists. Secondary coding operations support an increase in the risk of error (if it is important to corroborate the two interviews), and the measure of this risk can be given by what has been called fidelity between evaluators (inter raters), structural parameter of any test, as well as sensitivity or specificity.
But not to complicate things, I evoked this situation. Any encoding / decoding operation can be assimilated, in the end, to a translation effort.
In this paper the effort mainly belongs to the authors.
Simona Trifu is a primary psychiatrist, associate professor at the Faculty of Psychology and Educational Sciences, University of Bucharest (where she teaches Psychopathology and Psychiatry to students and master students), doctor of psychology, doctor of medicine, direct member of IPA (International Psychoanalytical Association), senior clinical psychologist (CoPsi accredited supervisor) and senior psychotherapist in psychoanalytic psychotherapy of children and adolescents (CoPsi accredited supervisor).
Camelia Petcu is the Head of the Department at the Psychiatric Clinical Hospital „Prof. Dr. Alex. Obregia ”, doctor in Medical Sciences, assistant professor at the Department of Psychiatry of UMF“ Carol Davila ”, psychoanalyst within SRP (Romanian Society of Psychoanalysis), direct member of IPA (International Psychoanalytical Association) and independent psychotherapist in psychoanalytic psychotherapy (within ARP - Romanian Association of Psychoanalytic Psychotherapy and FROPP - Romanian-Dutch Foundation of Psychoanalytic Psychotherapy).
The paper "Clinical cases of psychiatry. Complex psychodynamic and psychological explanations" has two parts: Case studies from a psychotherapeutic perspective and Case studies from a psychiatric perspective. These approaches are preceded by a chapter devoted to the mental disorder experienced or observed by children, a chapter as original as it is disturbing.
We would be unfair if we did not properly appreciate the group of students in psychology and medicine, as well as the resident doctors who contributed to the book. Their offering is, to the despair of some of my confreres who will read the preface, unrepeatable! Because, in essence, it is about their youth that brings courage, enthusiasm, a certain ingenuity, but also vision. I don't know why Esenin haunts me: "I don't regret it, I don't mourn, I don't shout / Everything passes like a shattered flower / Withered from my cold autumn / I will never be young again."
One of the fundamental merits of the book is that it is he reads easily, like a (good) novel, as he invites to a new reading.
,, Beautiful book, honor to whom he wrote you! ”
Assoc. Prof. Dr. Radu Mihailescu
Bucharest, December 5, 2010