Although in internal medicine a clear distinction is made between symptom (the complaint which the patient makes) and sign (the indicator of specific disease observed or elicited on examination), in psychiatry both are contained within the speech of the patient. He complains about his unpleasant mood state, therefore identifying the symptom; he ascribes the cause of the pain in his knee to alien forces outside himself, thus revealing a sign of a psychotic illness. Because both symptoms and signs emanate from the patient's conversation, in psychiatric practice the term symptom is often used to include both. For a symptom to be used diagnostically, its occurrence must be typical of that condition and it must occur relatively frequently in the condition. Fundamental to psychiatric examination is the use of empathic understanding to explore and clarify the patient's subjective experiences. The method of empathy implies using the ability to 'feel oneself into' the situation of the other by proceeding through an organized series of questions, rephrasing and reiterating where necessary until one is quite sure of what is being described by the patient. The final stage is recounting back to the patient what you, the psychiatrist, believe the patient's experience to be, and the patient recognizing that as indeed an accurate representation of their own internal state. Empathy uses the psychiatrist's capacity, as a fellow human being, to experience for him- or herself what the patient's subjective state must feel like as it arises from a combination of external environmental and internal personal circumstances.
Identifying phenomena as specific indicators of defined psychopathology may be difficult. It may require recording much conversation of the patient for significant words and sentences to reveal material of diagnostic importance within the undifferentiated whole of ordinary speech. The psychiatrist, when in the role of psychopathologist, has to assume that all speech of the patient, all behaviour of the patient, and every nuance has meaning, at least to the patient at the time the speech or behaviour takes place; it is not just an epiphenomenon of brain functioning.
Jaspers has contrasted understanding (verstehen) with explaining (erklären); descriptive phenomenology is concerned with the former. Understanding is the perception of personal meaning of the patient's subjective experience and involves the human capacity for empathy. That is, I understand because I am able to put myself into my patient's situation and know for myself how he is feeling, I feel those feelings of misery myself. Explanation is concerned with observation from outside and working out causal connections as in scientific method. In psychopathology, the terms primary and secondary are based upon this important distinction between meaningful and causal connections. That which is primary can be reduced no further by understanding, i.e. by empathy. What is secondary emerges from the primary in a way which can be understood by putting oneself into the patient's situation at the time; that is, if I were as profoundly depressed as my patient, I could have such a bleak feeling that I believed the world had come to an end—a nihilistic secondary delusion.
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