The dynamic paradigm of illness in psychopathology
Authors: Giovanni Stanghellini
Journal: World Psychiatry (2024)

Medical thought oscillates between two representations of illness. According to the first, illness enters or leaves the organism as through a door, by either adding something that should not be there, or removing something that should be there. Infection is the paradigm of illness as a pathogenic addition; haemorrhage is the paradigm of illness as a pathogenic removal of something which is needed. This representation of illness, called "ontological"1, is to some extent reassuring: what the organism has lost can be restored, and what has entered can be removed. A different representation of illness is called "dynamic"1. According to this view, illness is not an accident that arrives from outside and upsets the state of equilibrium of an otherwise healthy organism. Humans are intrinsically vulnerable beings who fall ill when they respond incongruously to what they perceive as a threat for the unstable and vulnerable equilibrium characterizing their condition. This threat must not necessarily be an objective noxious entity; it is enough that it is subjectively experienced as such. Are there good arguments to support the dynamic paradigm? Contemporary research in clinical phenomenology appeals to the notion of "position-taking" to provide a framework for the investigation of the person's attempts at healing as a fundamental component of the dialectics of symptom formation2. Psychotic symptoms, for instance, are understood as the expression of the person's efforts at making sense of "strange" self- and world-experiences. These basic uncanny experiences and the patient's resources to cope with them face one another. The manifestation and course of the illness can be understood as emerging from the person's efforts at fighting against or adapting to the existential challenges associated with the onset of the above uncanny self- and world-experiences3. This approach has the potential to address oft-neglected troubling experiences without threatening the person's epistemic agency. The recognition of psychopathological conditions from the viewpoint of a dynamic representation of illness is the gateway to a radical extension of our human perspective on mental disorders and in general on humana condicio. It helps thinking of the vulnerability to mental disorders as an intrinsic property of being human. Persons affected by mental symptoms may be closer than ourselves to the core of the human condition4. From this viewpoint, any research on psychopathological symptoms becomes an exploration of their meanings and an attempt to answer the question "What does it mean to be human?". Our research in psychopathology can become a means to investigate the core of human existence. This dynamic representation of mental symptoms can be integrated into a new medical, anthropological, technological and socio-political understanding of psychopathology. Should we assume that uncanny self- and world-experiences are common to all, or at least most, human beings? The point is not whether an extrinsic stressful event facilitates the emergence of these experiences – this should be considered a fact. The question is whether these experiences emerge from a vulnerability intrinsic to the human condition. From this perspective, what comes from outside is at most the occasion for the unleashing of pathology, but not its cause. Is there any evidence that occasional experiences of unreality of self, body and world are common to most human beings? We could tentatively refer to two kinds of "evidence": one derived from psychopathological research, and another that could be called "cultural". Regarding the former, epidemiological surveys document that transient depersonalization/derealization experiences occur rather frequently in the general population5, and are common among adolescents without a psychiatric diagnosis6. These findings may be taken to suggest that feeling unreal, cut-off from the world; detached from oneself, one's thoughts and one's memories; seeing oneself from without, feeling like an "automaton", notwithstanding their color of "strangeness", are "quasi-physiological" experiences. Coming to the "cultural" evidence, it is a common argument in the philosophical, anthropological and spiritual literature that what characterizes the human condition is its being "a work of indefinite nature"7. "Nothing has received more universal confirmation than the proof that the universe is a creation of chaos, life an epiphenomenon, and man an accident"8. To protect ourselves from the anxiety that comes with the awareness of being so intrinsically vulnerable, we seek refuge in our social identity and common-sense beliefs. But these defensive "housings" are precarious; they do not provide a secure shelter. The acute awareness of our vulnerability typically arises during limit-situations which may take place in everyday life9. These are situations in which the "housing" of everydayness and common-sense assumptions is jeopardized. Our basic trust breaks down. During these limit-situations, we experience human basic "anxieties", e.g., unavoidability of guilt, inescapability of freedom, fragility of our body, loneliness of our existence, vertigo of unreality, meaninglessness. These feelings may unsettle some individuals, breaking them out of their common-sense beliefs, identifications and social bonds. States of depersonalization and derealization may emerge, together with an overall condition of bewilderment, from which psychopathological symptoms or growth opportunities may arise. From an ethical perspective, only if we consider such experiences, and the existential questions accompanying them, as an integral part of the human condition, we can manage them with due respect and not merely undertake to eliminate them as one would eliminate something inhuman. Care, in this dynamic view, involves supporting the person in his/her search for meanings. The clinician, as an expert in human limit-situations, is like a guide who helps the patient to find a new equilibrium with his/her existential conundrums. The therapeutic intervention is not aimed to eradicate these conundrums, which are radically human in nature, but to help the patient acknowledge the existential meaning of his/her uncanny feelings, achieving awareness of his/her own "housings" and specific "limit-situations", and taking responsibility for his/her choices. This vision can also help update our perception of recovery: no longer the elimination of symptoms, or of the pathogenic noxa, but the achievement of a new and more effective dynamic balance in a person's vulnerable condition, modulating the intensity of troubling experiences, and making them less pervasive in order to facilitate the deciphering of their existential meanings. This conception is certainly optimistic, but has the merit to promote a more balanced therapeutic perspective. The notion that patients are passively subdued by an illness can contribute to establish asymmetric relations, limiting our possibility of exchange with the other's perspective, mutilating our understanding of his/her world, and locking us into the dead-end of our limited sectoral perspective. On the contrary, a dynamic view can help establish a more balanced helping relationship, centred on the support given by the clinician to the patient's own efforts at self-healing based on self-understanding.