Micromania is more common for bipolar NOS

Christian Scharfetter-General Psychopathology _ an Introduction _ 26 Tables-Thieme (2010)

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Thieme

General Psychopathology An introduction Christian Scharfetter 6th, revised edition 16 figures 26 tables

Georg Thieme Verlag Stuttgart  New York

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Bibliographic information from the German National Library The German National Library lists this publication in the German National Bibliography; detailed bibliographic data are available on the Internet at http://dnb.d-nb.de. 1st edition 1976 2nd edition 1985 3rd edition 1991 4th edition 1996 5th edition 2002 1st Spanish edition 1978 1st English edition 1980 2nd Spanish edition 1990 1st Italian edition 1992 1st Portuguese edition 1997 1st Bulgarian edition 2000 2nd Italian edition 2004 2nd Portuguese edition 2005 Prof. em. Dr. med. Christian Scharfetter Psychiatric University Clinic Zurich Lengstrasse 31 PO Box 19 31 8032 Zurich SWITZERLAND

© 2010 Georg Thieme Verlag KG Rüdigerstraße 14 70469 Stuttgart Germany Phone: + 49 / (0) 711/8931 - 0 Our homepage: www.thieme.de Printed in Italy Drawings: Barbara Gay, Stuttgart Cover design: Thieme Publishing Group Cover photo: Prof. Hans H. Stassen, Zurich Typesetting: stm media + druckhaus köthen, Köthen typesetting from: Adobe InDesign CS4 Printing: LEGO s.pa.A, in Lavis (TN) - Italy ISBN 978-3-13-531506-5

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All the sick I learn from and all those who care for them

V.



VII

Preface

This introduction to general psychopathology resulted from dealing with patients, students and graduates - with them therapeutically and researching at the same time, with them in class and conversation. What has proven itself to me has been recorded - from the work of many psychiatrists and in my own perception. The general psychopathology of Jaspers remains important for the methodological reflection (1st edition 1913, further development until 1942, then only reprinted). In Freud's work, the passion of wanting to understand continues and the danger of getting lost becomes clear in monoidistic interpretations. The phenomenologists trained clairaudience for the matter and pointed out ways of hermeneutics. The clinicians reported from their personal knowledge. The empirically experimental-statistically oriented researchers reveal the value and limit of counting and measuring in humans. This is the state of my understanding. Since understanding is always its own, personal, it is already said that it is by no means possible to achieve agreement with others in everything. Transcultural psychiatry, modern consciousness research (using drugs, meditation, sensory deprivation and flooding, etc.), religious phenomenology, transpersonal psychology, ethnology, epidemiology including gender comparison, sociology (and certainly also antipsychiatry) contributed to the reflection on abnormality, illness and therapy in psychiatry at. The cultural, social and situational relativity of the various concepts of norms and abnormalities became clear; the inevitability of norms for our zeitgeist- and person-dependent view of man and what is appropriate for him as an individual, as a group, as humanity. Therefore norms are to be unfolded (made explicit) in reflection from the implicitness, which often means lack of reflection. The dimensions of different disease concepts, combined with causal attributions, reflect the world and human image (e.g. dualists with dominance of morphology and physiology as the “biological basis” of the mental). Illness (sickness) refers pre-scientifically (i.e. before operationalization and measurement) to suffering and infirmity (dysfunction, impairment), initially without any determinations about the cause (s) and conditions (magic, ghosts, soul robbery, Psychotrauma, physical disorder, brain disease, interpersonal, interpersonal or intra-psychological conflict).

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Preface

Disease in the narrower sense ("Morbus" model, "disease") means in medicine a presented unit (hypothetical concept) of: 1. Appearance (syndrome constellation) in cross-section and longitudinal section 2. Identifiable cause (morphological, physiological, psychological, social, cultural) and constellation of conditions (etiology) 3. Development (pathogenesis), course from the beginning to the end 4. Therapy responsiveness (pharmacological, psycho-, sociotherapeutic) Such clearly delimited and recorded diseases, nosological categories, exist in psychiatry Not. Symptoms and syndromes can rarely be related to a clear, empirically ascertainable cause and pathogenesis. The clinical picture and the course - and the presumed influences on it (physical, i.e. physical, especially brain diseases, psychological, i.e. intra-, interpersonal, social, cultural) are too diverse (polymorphic). Psychiatry of the 20th and 21st centuries (represented in the WHO, World Health Organization, and the APA, American Psychiatric Association, which have developed the two most important diagnostic manuals, ICD = International Classification of Diseases of the WHO, DSM = Diagnostic and Statistical Manual of Mental Disorders of the APA) is limited to the pragmatic (but vague) concept of "disorder": disturbed in experiencing oneself (and one's world) and in coping well (hence dysfunctionality) with life. Diagnostic units (as configured in ICD and DSM) are designed to be etiology-independent. They do not present any nosological categories ("morbus"). Similar state-course-shapes (e.g. depressive disorder) can have different causes. Similar (presumed) causal constellations can produce different clinical manifestations (depending on personality, situation, biography, culture, etc.). The influence of the worldview and view of man, and indeed the personality of researchers, clinicians, therapists on what is observed, on the conclusions drawn from them, on research priorities and on therapeutic action (a range of therapies versus needs-based, diverse therapies) must be kept current. The basic concern of general psychopathology is: 1. Basically, to capture, describe and name humanly possible modes of experience and behavior in an intersubjectively and interculturally communicable manner. We need an order of what can be described, careful description and use of terms. Describing and understanding interpretation should not be mixed up if possible. The words of the psychopathological terminology, even of the psychology on which it is based, often make it difficult to understand the



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sen, what they refer to (NB: not what they essentially grasp!). Hallucination is not recorded with “false perception without an objective source of stimulus”. What is the wealth of facets in perceiving between sensory perception, feeling, graceful sensing, intuition, differentiating apprehension, classification, giving meaning, relating to "seeing" - far beyond the traditional occidental constructive separation of cognition and affect. The process of constructing a clinical picture is to be interpreted in gestalt psychological terms: facts and (internalized or specified in the question inventory) search patterns of the examiner are determined by his personality, motivation, the interactive situation of the survey and not just by a presumed "objective" perception selection. Psychopathological phenomena are figures whose genesis is determined by the tendency towards conciseness and meaning given by the examiner / therapist. The breakdown of the form “clinical picture” into symptoms as “smallest” units of description, into subjective experiences (symptoms), objective signs (English signs) is a secondary process. The patient as a symptom carrier or producer is not a social isolate - he grows, falls ill, heals or becomes chronic in the communicative space (intra-family, extra-family, social, institutional). And this is determined by the examiner / therapist: reflected and explicitly intentional or unreflected-implicit, wholesome or unwholesome. The elementary practice-related psychopathology (presented here) will continue to focus on "disorders" of experience and behavior that can be at least approximately intersubjectively ascertained and described. What of this kind of "pathology" (which infirmity, i.e. illness justifies) lies beyond the patient's self-disposal, or how far the patient's autonomy (Blankenburg 1985) can even partially assert himself in "dealing with, in the use of" symptoms, depends not only on the patient and on the main cause of his symptoms (think of psycho-organic disorders, for example). How much a patient surrenders to experiences or behaviors out of fear, out of lustful or tormented relief from the depressions of life, out of no longer being able or willing, out of self-abandonment, which he may initially even playfully use, the victim of which he then becomes, that can and should be there as a question of "responsible, partially responsible, not responsible" for patients and for our opinion of them, even outside of forensic assessment. In doing so, we keep in mind the difficulty of substantiating such an assessment with arguments and of reaching a consensus among the supervisors (possibly an important task for supervision).

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Asking such questions means thinking beyond the concept of disease, as this implies that the patient is not responsible for his or her disorder. It means remaining open to the ethological perspective on the concept of illness: how far the patient himself gets into a dysfunctional state through his basic attitude and lifestyle and, if necessary, gets stuck in it. Such considerations are implicit in therapy and rehabilitation and determine the authoritarian-custodial expert management and management of the patient or educational, psychoeducational, psychotherapeutic accompaniment that also thinks about personal responsibility. 2. To show your topography as phenomena of the deviation from functions of the mean day-wake consciousness and as a reaction to it. The phenomena, experiences, experiences of extra-everyday consciousness (of sub- and super-consciousness) and the functionally related behaviors are precisely for this reason that psychopathologists, psychiatrists, clinical psychologists must take careful note of them (if possible also in self-awareness) an inappropriate pathologization of the extraordinary ("abnormal") can be avoided (with all the negative consequences). Experiences of special states of wakefulness require their integration into everyday life. This is their place of probation. Just as the general pathologization of such experiences is wrong, so too does the euphemistic reinterpretation of psychopathological manifestations lead to religious-spiritual-transpersonal crises with denial of the disease value of severe, i.e. H. misleading crises leading to dysfunction. 3. The theory of symptoms and the syndromatics derived therefrom is a science that requires action: It should allow constructs (“illness”) to be created that can be the subject of (causal, multiconditional, systemic) etiology research and therapy. The subject area of ​​psychopathology is the dysfunction leading (in this sense "pathological"), mostly painful experience and behavior of the conscious person. Psychopathology deals with appearances (phenomena) in the field of the mental (as opposed to the material of morphology and physiology), the psyche. It remains undetermined what the mental is essentially, •• whether it is uniform (one soul, many souls, one personality, several sub-personalities, subselves, uniform waking consciousness), •• whether it serves as a substrate of subjectivity (actually a pleonasm , because the words substrate, hypostasis, usia, subjectum mean something that is hypothetically underlying or underlying),



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•• what its limits are; "The limits of the soul cannot be measured" (He-

•• •• ••

raklit); every demarcation is fuzzy, it is done by “setting” different conceptions in cultural and personal perception (e.g. shamanic models versus models of the Enlightenment based on the rational waking consciousness), what the relationship between cognitive and emotional functional areas is, what ideas about the I / Be suitable yourself. In today's understanding, the mental includes the conscious and the unconscious. This distinction has a long tradition, which was developed in various concepts long before Freud. The waking consciousness is understood as a function of dealing with reality necessary for survival, like mountains protruding from an immeasurable sea of ​​the unconscious. The transitions from clear self-reflective waking consciousness through media-atmospheric states of consciousness (appearance, intuition, meditation, trance, ecstasy), especially fluctuations in "discrete states of mind" (Tart 1969), preconscious and semi-conscious, subliminal, dream-like (oneiroide) “States of mind” down to the unconscious per se (processes in cells, organs) are to be assumed as flowing, sliding.

The perspectives on “the unconscious” are worked out in a variety of ways (Buchholz and Gödde 2005/6). According to this, the ideas about the dynamics and contents of the unconscious are also very different - between worship as the quasi-divine, numinous primordial ground of every psychic manifestation (Jung's concept of the unconscious that takes shape in archetypes; e.g. God is a projection of the archetype God) and Freud's unconscious, which has been reinterpreted more or less as a dump of what is forbidden, denied, repressed, split off by the superego and which also carries out this discharge. This comparison of the weighting of the unconscious illuminates the ideas that are dependent on the person, the zeitgeist and the culture. The unconscious becomes the projection site for the authors' personality. Narcissus is reflected in the pond. What they thought they were discovering was presented as the result of research, “medical” experience, empiricism, science, even truth, in the linguistic clothing that psychogrammatically characterizes the author: the physicalist imagery of Freud's monoidistic interpretations, the animistic-parapsychological- magical psycho-myth by Jung. On the other hand, the task of psychopathology remains to study the modes of experience and behavior that lead to suffering and failure (dysfunction). Only after observation and description (which always contain interpretations) can the interpretation be worked out and transparently justified using conscious and unconscious motives and strategies (autotherapeutic efforts and defense mechanisms).

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Preface

Psychopathology studies the broad spectrum of what is now vaguely called “disorder”, be it episodic, phased, crisis-ridden, continuous, clearly reactive to stressful life events or from unknown “unconscious” events as a result of recognizable cerebral or general physical illnesses or due to hereditary (genetic, inherited) factors. Psychopathology does not draw any sharp lines between personality-independent disorders and the types of character that lead to suffering and functional impairment, the so-called personality disorders. Axis-I of the DSM (syndromes) must always be supplemented by axis-II (the personality of the symptom carrier, his life story, the situation). In doing so, the personality should not be pathologized (no hunting of "disorders"). The text has been revised again for the 6th edition. In keeping with the character of an introduction, the concise style should be retained. In terms of content, there was hardly anything new. The choice of language reflects a certain adherence to tradition (“endogenous”, “neurotic”), but also a gap to today's “disorder catalogs”.The bibliography has been greatly shortened, since readers of the introduction rarely look up the works and can easily access current literature through the Internet. The work reflects my decades of work as a clinician in the Burghölzli Psychiatric University Clinic, which was shaped by father (Eugen) and son (Manfred) Bleuler, as well as the efforts to find literature (mainly German and English). The numerous case studies are (with very few exceptions mentioned) my own observations - they show my perspective on the patient population, my interest in a broad psycho-neuro-biology: life (bios) produces the living, ensouled organism with the wonderful organ of the brain . This enables the mental, psychological phenomenon of life. This creates through social culture. From all three areas of somatic, mental, and cultural man constellates in health and illness. I am aware that the introduction has grown over time, is timed, ephemeral - and may be useful until it can be replaced by better designs. For the new edition I had the proven help of Mrs. P. Wiersma. I would like to thank Thieme-Verlag for the suggestions and help with the design.

Zurich, 2010

Christian Scharfetter

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Table of Contents

1 On general psychopathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Task, aim and attitude of the psychopathologist. . . . . . . . . . . . . . . . . . . . . . . . . Task of general psychopathology. . . . . . . . . . . . . . . . . . . . . . . . . . . Psychopathological insight brings people closer. . . . . . . . . . . . . . . . Psychopathology as experiential theory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Descriptive psychopathology as the basis of "psychodynamics". . . . . . . . Interactional, social and cultural aspect. . . . . . . . . . . . . . . . . . . . . . . . . Personalities in Psychiatry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . To the problem of normal, healthy, abnormal, sick. . . . . . . . . . . . . . . . . . . . . . Normal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Healthy sick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Symptom and syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychopathological symptoms - not simply pathological. . . . . . . . . . . . From symptoms to the syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Access to symptoms / syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Theories of the origin of symptoms / syndromes. . . . . . . . . . . . . . . . . . Classification of symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Concept and meaning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic process - a cognitive process. . . . . . . . . . . . . . . . . . . . . . . . Diagnosis - assignment in nosology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnosis - therapeutic instruction. . . . . . . . . . . . . . . . . . . . . . . Philosophical remark. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .



2 awareness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Day-wake consciousness, over-, under-consciousness and the place of psychopathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Typology of special waking states of consciousness. . . . . . . . . . . . . . . . . . . . . . Consciousness - delimitation of terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functional areas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Being awake (vigilance). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clarity of consciousness (brightness, lucidity). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology of consciousness - disorders of consciousness - disorders of vigilance and clarity of consciousness. . . . . . . . . . . . . . . . . . . . . . Predominantly quantitative lowering of consciousness - impaired consciousness and unconsciousness. . . . . . . . . . . . . . . . . . . . . . . . . .

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1 1 1 2 2 3 4 5 7 7 12 23 23 24 26 28 31 32 32 32 39 40 41

51 56 57 59 60 61

63 63

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Table of Contents

Qualitative disorders of consciousness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Raising and broadening awareness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

3 I-consciousness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 dimensions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Ego vitality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 I-activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Ego consistency and coherence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Ego demarcation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 I identity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Self-image (self-concept, personality image). . . . . . . . . . . . . . . . . . . . . . . . . 76 I-strength. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Constituents / determinants / development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 I experience and body feeling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 I / self experience and culture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Depersonalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Disturbance of the basic dimensions of self-awareness. . . . . . . . . . . . . . . . . 86 Disturbances of ego vitality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Disorders of ego activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 Disturbances of ego consistency and coherence. . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Disorders of ego demarcation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Disorders of the ego identity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Disorders of self-image (self-concept). . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Disorders of the strength of the ego. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 False and True Self. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 narcissism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 references to research approaches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

4 Awareness of experience and awareness of reality. . . . . . . . . . . . . . 108 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . In special circumstances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Changes in consciousness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108 108 110 110 110 110 111



XV

Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Disturbances of the ego-consciousness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Advice on therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

5 orientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Orientation in time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Orientation in town. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Orientation about oneself (autopsychic orientation). . . . . . . 116 Situational Orientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Uncertainty and fluctuations in orientation. . . . . . . . . . . . . . . . . . . . . . . . . 117 Failure of orientation: disorientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Wrong orientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Delusional misorientation and “double bookkeeping”. . . . . . . . . . . . . . . 119 Occurrence of disorientation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 6 Experience of Time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Experience of time in the narrower sense. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Time knowledge, time estimation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acceleration (time-lapse experience). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Slowing down (time stretching experience) up to a standstill. . . . . . . . . . . . Temporal loss of reality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disturbance of the time categories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

121 121 121 121 122 122 122 123 123 123 124

7 memory and recollection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology of the mnestic functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General (diffuse) memory disorders (hypomnesias, amnesias, dysmnesias). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

126 126 127 128 128 129

XVI

Table of Contents

Circumscribed amnesias and hypomnesias. . . . . . . . . . . . . . . . . . . . . . . . . . . 130 hypermnesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 phantom memories (paramnesia). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131

8 attention and concentration. . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attention Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inattention and difficulty concentrating. . . . . . . . . . . . . . . . . . . . . . . . Narrowing of attention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fluctuations in attention and concentration. . . . . . . . . . . . . . Occurrence of attention and concentration disorders. . . . . . . . . . Attention and hallucinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

133 133 134 134 134 134 135 135 135 136

9 Thinking, language, speaking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fundamentals and determinants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological and physiological basics. . . . . . . . . . . . . . . . . . . . . . . . Socio-cultural determinants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Formal thinking disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thought disorders in connection with ego experience disorders. . . . . . . . . . . . Speech disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disturbances in speech. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incomprehensibility of the language. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137 137 138 138 138 138 139 140 146 148 149 151

10 intelligence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical: structure and function of the brain. . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychological and social effects on the development of the brain and its function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology (intelligence disorders). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intelligence defects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychosocial intellectual deficiency training. . . . . . . . . . . . . . . . . . . . . . . . .

154 154 155 155 155 155 156 156 159

XVII

Intelligence disorders with a disturbed relationship to reality. . . . . . . . . . . . . . . . . . . Intelligence disorders with sensory defects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Intelligence disorders with reduced vigilance. . . . . . . . . . . . . . . . . . . . . . . Intelligence disorder for affective reasons. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160 161 161 161

11 affectivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Affectivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Affect, emotion, feeling, mood. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Neurophysiological basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Central nervesystem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Autonomous nervous system (vegetative). . . . . . . . . . . . . . . . . . . . . . . . . . . . . Endocrine system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification of feelings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Feelings of state (sensitivities, moods). . . . . . . . . . . . . . . . . . . . Feeling good about the other. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Affectivity pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual terms for the psychopathology of affectivity. . . . . . . . . . . . . . . . . . . . . Individual affect syndromes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Superpersonal affect reactions (primitive reactions). . . . . . . . . . . . . . . . . . Permanent post-traumatic moods. . . . . . . . . . . . . . . . . . . . . . . . .

163 163 163 164 164 165 165 165 165 166 166 167 167 172 183 183

12 perception. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fundamentals, components and determinants. . . . . . . . . . . . . . . . . . . . . . . . . . Sense organs and brain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . General psychological processes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personal, social, situational influences on perception. . . . . . . . . . . . Relationship of perception to reality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Relationship between perception and mood. . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Failure of a perceptual function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Perception abnormalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hallucinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

184 184 184 184 185 186 187 187 188 189 189 191 195

13 view. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

XVIII Table of Contents Requirements and Determinants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occurrence of comprehension disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

209 210 210 210

14 delusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 delusional mood, delusional idea, delusional thinking, delusional perception, delusional work, delusional system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 character of madness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 delusional reality and reality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 delusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Experience-independent certainty of meaning. . . . . . . . . . . . . . . . . . . . . . . . 225 Distance from and resistance to general experience and group conviction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Inability to change point of view. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 Isolation and Alienation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227 Conditions of the origin of madness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228 Delusion as becoming certain of what is affectively given. . . . . . . . . . . . . . . . . . . . . . 230 Delusion "certain" based on the situation in life history. . . . . . . . . . . . . . . . . . . . . . . 231 Delusions in response to certain sensory situations and hallucinogens. . 237 Delusion with changed self-experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239 etymology of madness and madness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 madness (-witz, see dementia). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 delusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242 Paranoid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Delusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 delirium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 Winning in madness - final point of view. . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 occurrences of madness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Experimental Situations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Delusion as an experience-reactive development. . . . . . . . . . . . . . . . . . . . . . . . . 246 Delusion in Affective Psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Schizophrenic madness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Delusion in physically based psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . 248 Course of the madness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 delusions in affect psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 delusions in physically based psychoses. . . . . . . . . . . . . . . . . . . . . . . . . . 250 delusions in special situations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 delusions in schizophrenics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 delusional developments that are responsive to life history and experience. . . . . . . . . . . . . . . 251



XIX

Effects of madness on the environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distancing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acceptance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rollover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Participation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Madness from a transcultural point of view. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cultural influence on the tendency towards delusion. . . . . . . . . . . . . . . . . . . . Cultural influence on the delusional content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culture and delusional formation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Culture and course of madness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypotheses to delusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Psychoanalysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analytical psychology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Individual psychology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Paleopsychology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gestalt psychology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cybernetics, filter disturbance, overload of impressions. . . . . . . . . . . . . . . . . . . Neurophysiology: reduction of sensory input. . . . . . . . . . . . . . . . . . . Multi-dimensional view. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Existential Analysis, Existential Analysis and Existential Analysis. . . . . . . . . . . . . . . . . . . . Anthropological Psychiatry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

251 252 252 252 252 253 253 254 254 254 255 255 256 256 256 257 258 259 259 259 260

15 Drive (basic activity). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomical and physiological basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Formal descriptive psychopathology of drive. . . . . . . . . . . . . . . . . . . . . . . Drive reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Drive increase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occurrence of the drive anomalies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Characteristic peculiarities of the drive level. . . . . . . . . . Acquired drive disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

261 261 262 262 262 262 263 263 263 263

16 motor skills. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Motor skills pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Motorized templates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

266 266 266 267 268 268 269

XX

Table of Contents Tic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tourette syndrome (maladie des tics). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypokinesis, akinesis, stupor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hyperkinesis, catatonic excitation, raptus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Grimaces, grimacing, paramimy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postural persistence (catalepsy), postural stereotype. . . . . . . . . . . . . . . . . . . . Negativism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Motor stereotypes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Echopraxia (imitation of posture and movement). . . . . . . . . . . . . . . . . . . . . . . Bizarre and inadequate behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

269 270 270 272 273 273 273 274 275 276

17 aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Central nervous representatives of aggression. . . . . . . . . . . . . . . . . . . . . . . . . . 279 exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Pathology of Foreign Aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Increase in aggressiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Aggression and Mental Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Reduction or inhibition of aggressiveness. . . . . . . . . . . . . . . . . . . . . . . 283 Causes, Motives, Reasons for Aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 self-aggression (autoaggression). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Suicide and Parasuicide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 self-harm (automutilation). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

18 compulsions and phobias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Constraints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification of constraints. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Occurrence of compulsions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phobias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Types of phobias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

293 293 293 294 295 297 297 297

19 impulse actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Poriomania (dromomania, fugue). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . "Collectionism". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pyromania. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

299 299 299 302 302

XXI



Kleptomania (addiction to stealing). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302 Dipsomania. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302

20 need-instinct-will. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overview and classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Overview of needs and needs-satisfying actions. . . . Clinical-practical classification of the drives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fundamentals and determinants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anatomical representative offices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hormones and metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sensory afference and interpersonal-social situation. . . . . . . . . . . . . . . . Learning processes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hunger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Thirst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Need for sleep and activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hazard protection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Motivation and will. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

303 303 304 304 304 305 305 305 305 306 306 306 307 308 309 309 309

21 sexuality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The question of the norm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Note on autosexuality and homosexuality. . . . . . . . . . . . . . . . . . . . . . Abnormal sexual object. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abnormal sexual practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rejection of one's own biological gender. . . . . . . . . . . . . . . . . . . . . . Drive strength abnormalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Erectile dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

311 311 312 312 314 315 318 320 325 326 328 329 329

Literature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330 lexicons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346

Subject index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347



1

1 On general psychopathology

Task, goal and attitude of the psychopathologist "You can only see well with the heart" (St. Exupéry)

The task of general psychopathology Psychiatry wants to help the patient - for whatever reason. Unfortunately, it cannot be said that she can always successfully realize this good will by doing right - even if she does some good deed. We still know too little how the many different existential needs that concern psychiatrists and clinical psychologists come about - and how we can turn these needs around, how we can best alleviate, heal, even prevent. The better we explain and learn to understand, the sooner it should succeed. This presupposes that we record as precisely as possible the experience and behavior of people whom we describe as sick in their biographical, sociocultural context. Psychiatry requires idiographic-casuistic1 settling in and nomothetic2 research into regular relationships. We should get involved in an emotional and empathic resonance, even endure affective consternation and shock - and at the same time learn to take note of and process in an intellectually rational manner.The subject of psychiatry is always a whole person in his developmental history. Wholeness is a strived for ideal. For a holistic image of man as possible (Scharfetter 1989), the somatic-physiological, psychological and social areas as well as the transcendent, spiritual extension of consciousness must be taken into account. We will only be able to get news of such a whole life form if we take people seriously and are careful with them. Then we can come to an understanding with one another about the sick person. Both are the task of psychopathology. Learning to do so is part of the basic training of anyone dealing with psychiatric patients. It should guide us in dealing with 1 2

I. E. completely turned towards the individual. I. E. according to rules, looking for something that is more than individual.

2

1 On general psychopathology

Teaching to hear, experience and describe the patient as a starting point for the diagnostic considerations that lead to the therapeutic instructions and for any research. Psychopathology, descriptively supplemented by functional (Scharfetter 1995), is an indispensable but not the only basis for psychiatric-psychotherapeutic tasks. Psychopathology points to the unspecificity of the relationship between symptom / syndrome and hypostatized etiology. It shows that symptoms, viewed in and of themselves, are not exactly signs of illness and that they are at most typical, but not specific for certain disease categories. Psychopathology therefore does not provide any categorical nosological systems of disease units in the sense of morbus (unit of appearance, course, outcome, cause in the somatic sense). For the construction of the disease one needs criteria other than psychopathological (e.g. heredity, physiology, morphology).

Psychopathological Insight Brings Closer to Humans Psychopathological symptoms are signs whose meanings, as with everything we come across, should be understood. That is the goal. It cannot be said that this always succeeds in individual cases. The first thing to do is see the signs and describe them. Describing and naming means, correctly understood, no fixation of the experience and behavior of a person. Descriptive psychopathology has often been accused (unfortunately not always wrongly) of seeking and fixing only the pathological. This is a wrong path, because psychopathological skills should bring us closer to the whole person and should not only show their abnormal experience and behavior, but also let us experience what is still healthy about them, so that we know what we are doing therapeutically with and what can work. If we deal in this way with people who cannot cope with life, the psychiatric examination is not a “demolition ceremony” (Garfinkel 1956). Then “the choice of syntax and vocabulary” does not have to be a negative “political act” (Laing 1967, p. 54). - We have long been made aware of the “seduction of language” (Nietzsche) (Wittgenstein).

Psychopathology as experiential theory The patient does not "have" symptoms, but experiences certain experiences and therefore behaves in a way that can be described and deviates from the group norm.



Task, aim and attitude of the psychopathologist

3

Nothing of his doing is absolutely nonsensical. This is not a scientific statement, but a commitment to psychopathology as an experiential theory and a way to therapy. Only in this attitude can we do justice to the sick person. Even “crazy” behavior can still be plausibly classified as useful for therapeutic action in an explanatory derivation and a functional interpretation (based on what experiences does the patient behave in the manner described?) Is a task that has never been completed.

Descriptive psychopathology as the basis of “psychodynamics” Descriptive psychopathology is not static psychiatry. Especially those who have learned to observe and describe carefully and self-critically will clearly recognize that psychopathology is something that is constantly moving, nothing rigid, that there is no opposition between descriptive psychopathology and so-called "psychodynamics", but that a clean descriptive psychopathology is the basis for becoming - is history that does not get lost in speculation. "Psychodynamics" interprets psychological phenomena as reactions to "unconscious" events that are viewed as "real". In any case, such a derivation is an interpretation (“hermeneutics of suspicion”) in the sense of a certain concept of the psyche with conscious and unconscious parts. Freud's psychoanalysis derived symptoms, ie the “visible”, from invisible, unconscious processes: repression, denial, displacement, reversal (inversion, e.g. hate instead of love), outward projection, division (dissociation). Freud dwelt little on the "visible" symptoms, but "found" his own ideas of unconscious processes confirmed everywhere. Therefore, he did not cultivate a careful phenomenology, but held his monoidistic interpretations (that is his self-insight, see letters to Fliess) for the truth (letter 1917 to Ferenczi). So his teaching could never become science. An impressive example is his interpretation of the symptoms and also the origin of the delusional disease by Schreber, whom he did not know, but whose text he interpreted to confirm his doctrine - in suggestive and powerfully good writing. Here psychodynamics becomes an aetiological interpretation, that is, an explanation of psychogenesis. Jung, at that time still an adept of Freud, followed the “master” in his writings “On the Psychogenesis of Mental Illnesses”. The term “complex” (ball), which comes from association psychology (Herbart 1824), became a lantern for “depth psychology” in the darkroom of the unconscious, which Freud filled with his obsession with sexuality, which Jung later became vitalistic (libido as life energy)

4

1 On general psychopathology

mantisch (Schelling, Jean Paul, Schopenhauer, Carus, von Hartmann) expanded to the collective unconscious - an "over-inclusive concept" with which "everything" between heaven and hell, God and the devil could be deduced. Insights into psychodynamics can be found long before Freud in the literature on the psychodynamics of delusional psychoses (Ideler), later in Schopenhauer and also Nietzsche. Such “unmasking psychology” can contribute to authenticity by showing masking masks, but easily seduces the interpreter into repetitive autistic self-confirmation of their own doctrine (the grandiosity: “actually” it is...). Your own early experience (e.g. with Margret Mahler's mother), your own character, becomes a model that is generalized as the “research result”. The “Textbook of Psychodynamics” by Mentzos (2008) gives an overview of the teaching model of this psychoanalyst with helpful didactic schemes. The categorizing consideration also has the communicative content of the describable symptom in its meaning. This makes it a prerequisite for researching an individual in his or her life history (“situation”) and d. H. always community-dependent becoming. Psychodynamic diagnostics (working group OPD 1998) can also be operationalized in line with today's requirements.

Interactional, social and cultural aspect It becomes clear to the psychopathologist that the experience and behavior of a person are in manifold, lively interrelationships. People are always to be seen in their social context, never in isolation. Therefore every right psychiatry is social psychiatry. A personality can only develop in a community (socialization process), this applies to the healthy as well as to the sick. Personality development and social evolution can no more be separated than physical and mental development, because both belong together in a living person. The inheritance that has been brought with us, as difficult as it is to grasp, should not be disregarded - and thus also the behavioral patterns characteristic of the homo species. Experience and behavior of a person change depending on the environment, i. H. also depending on how the conversation with him succeeds or fails, how the conversation leader understands how to unlock the patient and lead him to insight. Conversation, being able to listen and right understanding is an art, so it is never finished. If the conversation is successful, many so-called psychopathological symptoms recede - and they come back as soon as the person concerned is left alone or in an unhealthy, i.e. H. especially



Task, aim and attitude of the psychopathologist

5

has to live in an isolated, hopelessly ambiguous - or critically derogatory, exploitative, oppressive environment. Therefore one should never look at a sick person in isolation. So the question does not mean: does “schizophrenia” exist, but rather: in what environment, under what conditions a person experiences and behaves in the way that one agrees to call schizophrenic. The patient's ability to see things depends not only on his state of consciousness and his intellectual aptitude for self-reflection, but also changes with his social origin and affiliation, with his schooling, with his social and cultural background. Hardly anyone can completely free themselves from the world view of their own cultural group and their “school”. This also applies to the psychopathologist himself. Transcultural psychiatry has made the cultural relativity of human experience and behavior clear to us and has shown the impossibility of looking at people from the perspective of generally applicable norms. What is normal in one situation and in one culture may be abnormal in another.3 On the other hand, intercultural comparative psychiatry also shows that people all over the world are similarly describable even without obvious gross abuse beyond the normal group and general human level Suffer wise and / or infirm ("dysfunctional"), i.e. get sick.

Personalities in psychiatry Psychopathology must not avoid the critical consideration of themselves, their implied cognitive patterns, their potentially dangerous and unreflected values ​​(what is abnormal and what is sick), their dependence on the spirit of the times and their cultural ties. Yes, it must also reflect on the people working in this profession, their psychodynamics, motivation, character type, their pathology, their dangers. There are no generally accepted criteria for eligibility for the occupation - and admission criteria are generally not considered at all. The (psychoanalytically oriented) Menninger Clinic has developed selection procedures for training candidates. The candidates were examined by a selection committee in one (or more) interview (s) and with tests (Rorschach, TAT, association test). In follow-up examinations, personality traits and success were related to one another. It turned out to be very difficult to do a good pre-employment medical exam. The free interview by an experienced psychiatrist, 3

Killing is normal in war, not in peace - in our culture. In headhunting cultures, certain killing is normal, in other cultures the killing of the elderly and unwanted children.

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Supplemented by individual references from tests, it still seemed the most productive method. It is less about signs of grosser pathology (neuroses, perversions, psychopathies, psychoses) than about the recording of personality traits in the wide range of the non-pathological. The personal integrity, authenticity and façade nature, opportunism, seriousness, honesty, etc. were best “felt” in free conversation. Controlled and rather over-controlled behavior turned out to be more beneficial than impulsiveness and clumsy extraversion. Particularly important (but also difficult to grasp) is “emotional appropriateness”. Emotional warmth is better when it is silent and felt indirectly than when it is presented verbally or through facial expressions. The question of motivation is particularly difficult to shed light on: a real desire to help out of love and out of the ability to identify (without succumbing or acting) against pseudo-altruism out of guilt or as a reaction to hostility and sadomasochism, out of the striving for dominance. Demonstrated self-confidence is not a good sign (arrogance). Curiosity as a thirst for knowledge should be free from sexual occupation (voyeurism). Genuine desire to research is cheap. A high verbal IQ in HAWIE (over 119) is desirable. Objectivity and status identity vis-à-vis authorities, paraprofessionals and dependent persons are further important variables. Particularly good (global) criteria resulted from probation in practical work in the field of psychiatry (for details see Holt and Luborski 1958).

The psychodynamics of the therapist was reflected on in various ways, including the psychopathology of the health professions (Martin 1981, Ford 1983. For the personality of psychiatrists compared to surgeons, see Gärtner et al. 1985). Reference is made to early personal or someone else's experience of illness, in which the power figure of the diagnostician and healer impressed. The fear of illness and death can lead to the formation of reactions (fight against it). Depending on the interpreter's psychodynamic fantasy, much can be assumed into the unconscious of the therapist: drainage of sublimated aggressiveness, overcoming feelings of helplessness towards the father in identifying with the role of the powerful doctor, compensation for insufficient care by the mother in turnaround (giving others therapeutic care) , Defense against inadequacy, helplessness, powerlessness in narcissistic omnipotence (counteraphobic reaction), narcissistic need to be admired, reversal of denied hatred and pain into altruism. Guggenbuehl (1983) popularized the power problem, Schmiedbauer (1977, 1983) popularized the narcissistic components in the “helper syndrome”, and added psychosocial aspects to it in 1983. The psychopathology of the helpers is characterized by a high rate of affect disorders (depression), suicide, addiction, obsessive-compulsive personalities with poor social skills, marital conflicts (Martin 1981, Ford 1983, p. 205), whereby, like the limping Greek doctor god Hephaistos and show some essential characteristics of the medicine man, which (recognized but mastered) own vulnerability experience can also be fruitful as a preparation for samaritarian action.



To the problem of normal, healthy, abnormal, sick

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In particular, attention must be paid to the danger of misconduct on the part of therapists in the context of transgressions: Bringing private-personal information into professional action, sexual abuse of clients (possibly disguised and charged as "therapy").

On the problem of normal, healthy, abnormal, sick These terms are by no means clearly defined. This is why the problem must be clearly demonstrated (Fig. 1.1). The judgmental (socially discriminatory) use of these terms is the main misfortune.

Normal norms (Latin norm: measure, guideline, rule, regulation) are inevitable and inevitable in our dealing with the world, for our integration into a community and for the existence of society. The inevitability of the norms is also evident from the fact that even being sick, including mentally ill, is standardized with regard to the mode of behavior and social recognition as "sick". There are norms, even if vague, of abnormality in the sense of mental disorder (madness, insanity). Those who follow this pattern are allowed to take on the institutionalized role of the sick (Murphy 1976).

Fig. 1.1 Abnormality and disease.

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Norms serve to create and maintain social structures. They are necessary for the survival of the members of society (protection from killing or expulsion) and the species itself. They bring advantages for the individual and the society, which are bought with certain restrictions: Norms bring the individual protection, security, security, the society structure, framework, orientation, boundaries, guidelines for behavior, behavior, values. Our own and other people's behavior is regulated, prescribed, and therefore calculable, assessable and predictable. Your own behavior is embedded in the social context, is communicable, understood and accepted. Standards save you having to make a new adjustment every time. On the other hand, an individualistically oriented person (who experiences his society more as a not-I than as a group-I) can experience a certain restriction, even outside determination of his behavior. Norms can also suppress or intolerantly reject personally designed and unusual modes of existence and life experiences - provided that society does not again provide special functional norms for this. Norms secure the existence of the society, but can also lead to a lack of adaptation through rigidity and endanger a society (culture) for its downfall. Seeing norms (“recognizing” norms) and setting norms is part of coping with life and the world.When asked about the origin of the norms, a distinction must be made between the history of the development of the individual and collective norms “knowledge” and the motive for setting norms. The sources of norm certainty (internalized norm patterns) are perception, direct learning and the mediation of norms through language (linguistic definition of terms). In the socialization process of personality development, the norms are acquired (through punishment, disapproval, reward, promises) and internalized: identification with the norm-setter (society). The way in which a person deals with the given norms (defense, keeping clear, protest, internal and external withdrawal, voluntary acceptance) reflects his or her autonomy and maturity. The norms are constituted in a society or are set by those in power. The need for security is to be assumed as the motive for setting standards. This probably also means that norms are not only protected by worldly measures (laws, courts, police), but also by otherworldly, religious "measures": They are recognized as an order set by God (e.g. Moses as the bearer of Yahweh's tablets of the law ) and secured by threat of “divine punishment” (condemnation to hell). The norm term most commonly used in psychiatry is that of the average norm (this is also called statistical norm): normal in the sense of the



To the problem of normal, healthy, abnormal, sick

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Globally, the average norm is the behavior that the majority of people of a certain gender and certain age groups within a certain socio-cultural area are suitable in certain situations. Normal is special what they have in common with regard to a certain aspect of behavior. This underlines the social and cultural relativity of the concept of norms. Average norm means the must, should, can and may behavior accepted within a culture in consideration of a defined situation. Customs and manners contain norms of behavior as prescriptions for when (as a reaction to what) and how to behave. Such behavior is recognized within a culture with regard to the common triggers and the behavioral patterns that are then set in motion, indeed prescribed, and thus legitimized and possibly also institutionalized (Devereux 1974). The measure of "normal" in the sense of the average norm is always at hand for laypeople and "experts" as an internalized pattern for many assessments of other people (from individual symptoms, e.g. of a certain affect, to complex behaviors in the relationship area and overall lifestyle) . The dependency of the “normal” figure on one's own, the involvement of the psychodynamics and psychopathology of the expert himself (p. 5) in the process of forming the norm pattern mostly remains unreflected. There is hardly a standard that is practical and useful for measuring (or more precise assessment) and binding for all people of all cultures. The average norm is different for people of different cultures, social classes, religions and situations. Qualitative and quantitative statements about normality and abnormality of general validity remain so general that they are useless. Therefore global statements about normal / abnormal make little sense. A differentiation of norm determinations has to take into account, besides the civilizational-cultural, also subcultural background, that there are clan, family, person, role and situation norms, that these are also different depending on the role functional area. Within a couple relationship, but depending on the emotional closeness, in families, towards individual family members, in extra-family private areas (e.g. sports club), at work, in relation to peers, subordinates, superiors, different norms apply in each case. Each of these areas has its own must, should, may, and may norms. The behavior of a person is updated in the social space and is thus co-determined by the counterpart. So the social space also determines the normality / abnormality of behavior. It is even more difficult to specify norms for the privacy of a person, which perhaps manifests itself in phantasies and dreams, for the “chambers” of various subjects that may be kept hidden, partial aspects of personality. Too little attention is paid to the fact that we can hardly specify norms that are valid for humanity in a meaningful way, even within our own

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