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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


ARGUMENTATION FOR A RIGOROUS SEMANTICS OF PSYCHOPATHOLOGY TERMS

Autor: Ştefan Milea
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Six arguments are outlined that these days need rigorous circumscription of psychiatric concepts. The author also points out that this requirement is igno- red too easily. The statement is demonstrated by means of five examples: aggression, anxiety, depression, stress and hyperkinetic disorder.

Introduction:

There are at least six reasons that require the concepts with which we operate in the field of psychiatric diagnosis be clearly defined and accepted.

Firstly, scientific research has always asked for the use of a common, widely recognized language.

Secondly, as we also underlined in 2009, when summarizing the reasons why the DSM classification system of mental disorders, which is a valuable tool in administrative psychiatry, cannot substitute clinical psychiatry, we mentioned that among the special merits of the DSM was the one that it brings the psychiatric semiotics back into the foreground. Abandoned for a long time to the decision of various doctrinal guidelines, starting with DSM III (1980) [1] semiology is given the leading role in building the diagnosis. In fact, the diagnosis, this time aetiological and atheoretical, is mainly based on numerically minimum sets of symptoms assessed as sufficient and representative. However, it is obvious that the representativeness of psychopathological symptoms that is indispensable in the diagnosis requires, as a major condition, for them to be defined clearly and universally recognized by all those involved in the certification and use of diagnosis.

Thirdly, today specialists speak more and more loudly about evidence-based medicine. Nevertheless, evidence can be obtained only through studies on homogenous lots, which means that they are constituted of individuals who are rigorously similar, i.e. with the same symptoms.

Fourthly, today there is a tendency to personalize the approach to the clinical context and to the therapeutic intervention. Neither this orientation can be exploited without a rigorous delimitation of the concepts with which specialists operate with. As we shall see, at least three distinct elements here cannot be overlooked that can individualise a patient, a dia­gnostic reality or a clinical symptom, namely: the presence of a specific neuro-psycho-biologic base, some nuances of the clinical aspect and, why not, when it is possible, gene markers, too.

Fifthly, today, assimilation of new knowledge that it allows a more nuanced individualization of clinical realities is indispensable.

Sixthly, today, administrative psychiatry obliges us to operate with diagnostic and therapeutic guidelines, which are based on the general and not the particu­lar, although the latter is indispensable to an effective therapeutic conduct.

However, not infrequently, we find an attitude, comfortable at least, on how the terms are used, even the most important ones, by the experts who ought to impose their responsible point of view. In the following part we give a few examples.

1. Aggression (symptom)

Aggression is a phenomenon so general that it seems inherent to life itself, as Bernard and Trouve [2] pointed out (1977). However, as Meguire and Troisi (1999) claimed, too, although it benefits from many definitions, none of them is satisfactory because they imply many exceptions to the rule. This statement is demonstrated by the usual definitions. For example, DEX (1984) [3] speaks generally of “the condition of being aggressive, being sometimes a pathological symptom”. Popescu Neveanu (1978) [4] speaks of “destructive and violent behaviour directed at persons, objects or self ” and Sillany (1996) [5] of the “tenden­cy to attack… a bellicose character of the person.”

There are formulations that, as appropriate, disregard: inaction with the purpose of generating injury; thoughts and feelings taking the form of indifference to the suffering of the another, or sometimes of unjustified satisfaction generated by another person’s suffering and even taking pleasure in doing evil; that aggression is not a form of action but a mental trait and that has also a normal aspect that goes far beyond the scope of the abnormal; and very importantly, that aggressiveness is not attested by all the manifestations that produce harm but only by those which are the product of hostility, whether or not they end in damages.

The difficulty in offering a satisfactory definition of aggression and even in identifying it has several causes:

Firstly, this is the consequence of the complexity and diversity of aggression’s forms of expression or, as we said in 2010, of the fact that it is a complex, interactive, heterogeneous and open concept.

Secondly, aggression is more than a psychological trait; it is actually a mental structure with holistic organization and multi-systemic and interdisciplinary character. It represents a certain intrinsic and dynamic way of being of the individual, respectively, a way of reacting to external and internal stimuli, which put their stamp on all mental processes and functions. As such, we can speak about an aggressive way of thinking, speaking, perceiving, acting, or working, of enjoying or suffering and loving, and, in general, of being.

Thirdly, both aggression and concepts that support it (aggressivity, guilt, intentional discrimination, civil rights, individual freedom, normal-abnormal, etc.) are also, in turn, complex structures that are unrigorously defined (see also Milea-2010) [6]. In spite of all these, aggression interacts with many fields. We encounter them in psychology, psychopathology, psychiatry, forensic medicine, justice, sociology, ethics, ordinary language and not only. All these are instances operating with rules, values and have their own assessment tools. It is not just that some are more concessional than others are, and do not overlap entirely; it is also about the independent mobility in time of some of them and even the existence of certain di­vergent options. The law, moral norms, socio-cultural components have also their own mobility in time and space. One should also mention the subjective, motivational, religious factors as well as the moral factors of the group and of the individual, the aggressor, the victim and the sideliners who put their imprint modulating the system very actively. With good reason, every area is entitled to opt for aspects that represent it better. Let us mention that even a slap given by a parent can be assessed differently and that the victim may not be aware of the aggression and even deny or keep it secret. If only for these reasons, aggression in general and its normal and abnormal representatives are open structures, respectively with mobile limits that vary in time and space.

In this context we may consider that abnormal aggression (symptom) is a complex mental structu­re, heterogeneous, interactive and open, with holistic lay-out, characterized by the naturalness of certain feelings, fantasies, daydreams, thoughts, aspirations and hostile intentions, low frustration threshold as well as through the pleasure to witness and partici­pate in scenes, all centred around the idea of doing harm. It is what in ordinary language it means “a bad person”, a conflicting, hateful, spiteful, vindictive, cruel, sadistic one. Psychologically speaking, aggression is represented by phantasms, a low threshold of frustra­tion, a way of thinking of, aspiring at and enjoying the evil happening to someone else. It is a way to estimate the reality and finally to act and react in a manner that damage and satisfaction should be the result. It has a passive branch, the background, stable component of aggressiveness, which inhabits the subjective space, being controlled, suppressed or concealed. And an ac­tive branch, which, when it manifests itself, expresses either as an aggressive way of being or as offensive, elementary manifestations that are unexpected, dra­matic, violent, choleric, like short-circuit and blind anger that can go as far as affective crises with the narrowing of the field of consciousness and amnesia gaps. Not infrequently, events are deliberate, tactfully controlled, dispensed, processed, prepared or postponed until a favourable moment appears, or a pretext to justify “the outrages”, either the aggressors provoke the victim intentionally or they use interested intermediaries.

This definition emphasizes that:

  1. Abnormal aggression is not a simple psychological trait but a multisystem and interactive mental structure with holistic organization. It engages the person marked by pathological aggression, the target to which aggression is directed and the community, moral, socio-cultural, forensic and ethical entities which establish rules and assess the situation.
  2. Abnormal aggression is generating a great diversity of recurring events having a hostile character and representing the externalization of aggression and not aggression itself. They are called aggressions that are marked by aggressiveness. This means that they stand out by having a more or less gratuitous character, that they are the expression of a low frustration threshold, are committed maliciously, with the desire and even pleasure in doing harm. Harmful intentions, the felt pleasure, gratuitous nature or low frustration threshold make the difference between aggressions as expression of aggressiveness from those having a different meaning – negligence, inattention, mistake, fear, self-defence, material benefits etc. Moreover, the latter are aggressions only because they generated physical psychological, material or moral injury, while the former are impregnated with signs of aggression without a necessary need to be completed. This means that:
  3. Abuse, penalties of any kind, constraints and any events that, in spite of producing harm or suffering, are the expression of aggression only if they bear the mark of hostility, being inconsistently motivated, malicious, generating reactions of pleasure or are shortcircuit reactions.
  4. Suicide known to have numerous other reasons, most often is not the expression of self-aggression as it is often considered.
  5. Damages caused by patients with mental disorders (psychosis, obsessive-compulsive pathology, quantitative and qualitative disorders of consciousness, dementia, etc.) are also not always the expres­sion of aggressiveness. When aggression is present, it has a unique character because the behaviour that can result in damage or not is a symptom subordinate to the psychic condition which leaves its specific motivational, clinical, therapeutic and evolutionary mark, as appropriate, distorts and even cancels some of the defining criteria of aggression.
  6. Aggression has also a normal component – a universal phenomenon meant to satisfy vital needs or, as K. Lorentz (1969) [7] specified, one of the instincts that govern the behaviour of all species. This, instead of the commonly used formula of “aggression in the good sense of the word” would be preferable and it is what M Epuran proposed in 1967 (quoted by Popescu – Neveanu -1978 [8]), namely the term of combativeness. Among its forms of expression we mention only: ambition, perseverance, a winner’s mentality, pride, desire to set off one’s assets, to assert and impose oneself, to confront and surpass the others, to overcome difficulties and obstacles, fight with someone or for something or to respond to challenges etc. Are normal forms of aggression that need to be engaged and stimulated.
  7. The openness of aggression should also be stressed. It considers the ongoing process of both identification of new manifestations of aggression and decriminalization. We have in view the wide palette of the forms of manifestations located at the boundary between normal, abnormal or pathological where the border cursor moves as appropriate, either in one sense or in another. We shall exemplify with stubbornness, opposition, teasing, pleasure in gossiping, in seeing horror films or in criticism, jealousy, pride, irony, jokes with address etc.. At their level, approximate quantitative criteria operate that are individual, marked by subjectivity, interpret ation and are even controversial or different from one context, situation, socio-culture to another. We should also add the way in which intra-family aggressions, conflicts between parents and children, individual and collective rights and freedoms are interpreted. Surely that the delimitation describing their manifestation in excess does not help too much. There are also ambivalent contexts demonstrated practically by the phrase … “qui s’aime se taquine”; or by what the psychoanalytic concept emphasizes when it speaks of the ambivalent feeling represented by the desire to incorporate the desired object and exemplified by the widely used expression “I feel like eating you” as a way to highlight the plenitude of affection felt. From another perspective that is even more special, the sadomasochistic relationships express aggression only for outsiders. In addition, we are witnessing a process of elimination on behalf of individual rights of constraints previously imposed by social norms in the field of sexuality, family status, the use drugs, the mentally ill individuals or a child’s education.

2. Anxiety (symptom)

It is the basic component of anxiety syndrome and anxiety disorder. It has to be distinguished from its normal correspondences represented by caution, care, risk avoiding conduct and alert to unexpected or new stimuli. Speaking of normal anxiety, R Spitz (1887­1974) considers it the second organizer of the psychic life and DSM acknowledges it when since 1980 it has included a chapter entitled “Anxiety Disorders.” It is what Mihailescu (1999) [8], has emphasized in good faith and it means accepting the existence and of a normal one. It is constitutive part and expression of the defensive instinct that has an important protective function. This is because it triggers the sharpening of senses resulting in mobilization of defences, increase of efficiency and effectiveness of actions; it also protects and supports the adaptation, diversification and refinement of emotional experiences. Moreover, as Melanie Klein (1882-1960), R Spitz (1887-1974) and J. Bowlby (1907-1990) claimed in their works, it is involved in the normal development of the child. Conversely, abnormal anxiety is marked by the inability to adequately use available resources is excessive, unrealistic, unreasonable or absurdly motivated, represses curiosity, disturbs adaptation and generates negative, hesitant behaviours, defensive, unjustified and even dangerous reactions, or contributes to the genesis of other psychic disorders.

Although anxiety symptom is a psychopathological phenomenon constantly encountered in medical practice, not only in the psychiatric one, but also in everyday life, it is not defined consistently. In fact, even today, the claim of “Encyclopaedia of Psychiatry for General Practitioner (1972)” [9] that it lacks a precise definition is still valid. The definition given by Jaspers in 1913 (quoted by Pichot, 1987) [10] is classic, saying that anxiety is “a pointless fear”; this is an operational form, tempting in its simplicity, to which reference is often made. In fact, it is not adequate enough even if it is sometimes supplemented with details such as: it has apparently no object (Deley, quo­ted by Sarbu -1979) [11], or currently, we would add; irrational character, lack of external threats, embarrassing stat of expectation, undefined imminent danger, etc. This is because anxiety, even if it is a genuine negative emotional state, that seems simple at first glance, it is not limited to the aspects that have been mentioned so far. It is a complex and heterogeneous phenomenon. For Quetin and Peyrouset (1964) [12] anxiety is composed of three fundamental weaknesses of the psychic apparatus: insecurity (affective disorder), uncertainty (thought disorder) and indecision – (volitional disorder). In turn, Teodorescu (1999) [13] outlines the involvement of thought (an inter­pretative distortion), of attention (a selective hyper- vigilance) and of memory (easy access to certain life experiences). In the same vein, Predescu and Ionescu (1988) [14] state that anxiety “is more potential than actual, and sometimes more thought of than lived.” It must also be said that an anxious background is able to prevent thought from being fully rational, while the defence instinct and the memory that comes with previous experience may also make thought to be overly cautious. Moreover, thought can not only be employed in the system by anxiety but it may also, in some cases, generate anxiety by itself because it is the one that can build up a false danger to which it may assign an insurmountable character, and especially it can anticipate this danger, respectively envision it in the future.

To these we must add the presence of the pageant of somatic manifestations peculiar to states of fear: autonomic, endocrine – humoral, motor and behavioural ones, which, in the presence of anxiety, make us deal not only with mental phenomenology, but also with acts which can reach the complexity of certain absurd measures of defence. This time, too, par­ticular issues may occur that can place them in the posture of source of anxiety. As such, there are also somatoform – vegetative disorders, like, for example, renal colic, myocardial pre-infarction, pulmonary embolism, asthma, etc. that may be located, this time to the origin of a particular form of anxiety that, being special for some specialists, is called anguish. We will not find this name in German or American psychia­tric literature. In this area, opinions are very different. Some authors consider that anxiety and anguish of two synonymous terms; others refer to anguish only when presenting normal mental development or paroxysmal forms of character or of forms dominated by somatic-vegetative phenomena and psychomotor agitation, while ICD-10 speaks only of separation an­guish (F-93.0).

Returning to the definition of anxiety offered by Jaspers, it must be said that the specification of the lack of an object is not fully satisfactory, either. In fact, in many cases, it is difficult to accept the absolute lack of an “object” or that there is no identifiable external but especially internal cause. In reality, anxiety is often considering something, anything able to pose a threat. This is at least a mental representation of a threat; it is true, of something, which sometimes is outlined vaguely, that eventually, transient or stable, can take shape and a name. Furthermore, anxiety itself may ca­use perception disturbances, which may feed anxiety; or, even more important to point out, such disturbances that are present from whatever cause may, in turn, induce anxiety. They make the delimitation of anxiety from phobia (fear with object) become relative sometimes. In fact, some authors have ignored it. We exemplify with R Spitz (1887-1974) who defines the separation anxiety as the negative reaction appearing during approximately the 9th month of life at the sight of strangers or with Bowlby who, in young children, refers to anxiety as the fear of losing the main attachment figure.

Depression is another emotional disorder that accompanies and even intertwines closely with anxiety. The fact that, as a rule, anxiety is usually characterised by bustle, while depression by inhibition makes the difficulty of delimiting them seem unnatural. However, the two semiotic entities use some common constituting mental tools (i.e. thought); they stimu­late and disguise each other, which makes them often difficult to distinguish. In fact, both of phenomena have a common way of perceiving reality that includes easy identification and anticipation of hazards, amplification of their significance as well as the false feeling that they cannot be overcome. These are characteristics of the thought of both the anxious person and of the depressed one, which draw two types of disorder very close to each other. In addition, ICD-10 acknowledges the diagnosis of agitated depression (code F32.2) so as anxiety can take a stuporous aspect. In fact, it is the well-known phrase “one has petrified in terror”.

Obsessions are another category of disorders. In spite of being primarily thought, or perhaps for this very reason, obsessions are also accompanied by anxiety due to the anxious background that “colours” them, to the anxiousness produced by their presence and inability to free from them as well as from their significance especially in the case of phobic obsessions.

All these are only to underline the complexity and heterogeneity of anxiety. Direct involvement of thought, attention, memory, and activity in anxiety will make it a semiotic complex that brings it closer to the idea of syndrome, an aspect that has already been highlighted by Lazarus and Averil in 1972. Moreover, as seen above, anxiety has many sources of provenance and several generating factors; it associates and interacts with many types of psychiatric and somatic disorders in the form of: a dominant central element, similar in intensity or, on the contrary, as modest ele­ment or as obvious component or one that is difficult to distinguish. There are aspects that bestow significant peculiarities upon its various manifestations in many ways distinct. As such, anxiety may present itself as:

  1. primary manifestation having an internal, cen­tral source, which dominates the whole assembly of disorders as in panic attacks;
  2. background secondary symptom as in obsessions;
  3. accompanying manifestation as in phobias and depression;
  4. manifestation resulting from other psychiatric or somatic disorders (see anguish);
  5. combinations of the above circumstances. Thus, in anxiety, the first condition of a personalized intervention is to obtain feedback on the type of anxiety that has to be dealt with.

3. Depression (symptom)

It is the component of depression syndrome and depression disease. The definitions often prefer to use descriptive formulas. We believe that depression is a state of rigid, stable and lasting, unmotivated, poorly or aberrantly motivated despair. It differs and must be distinguished from the normal variant that is correctly called sadness or unhappiness, therefore a consequence of reasonable intensity and duration of the experience of negative affective events such as losing someone close or related drama of someone for whom we care enough. The latter is, as judiciously highlighted Pelicier (1983) [15], more mobile and disappears with the responsible cause. Incorrect delimitation is one of the causes of the wide variety of data on morbidity and depression as well as the great prevalence of the phenomenon offered mainly by the media and the statistics based on questionnaires offered to the population where the normal version is easily confused with depression symptom.

Depression was not and even more so today it is not a homogeneous reality. Alongside the well-known clinical variants, good progress made in the last 20­30 years in deciphering the pathogenic mechanisms of depressive disorder and the action of numerous preparations for its control have shown that not only the clinical frame but also its neurobiological and biochemical basis differs in many ways view, from one case to another. Current data allow depending on the dominant biologic – biochemical substrate to identify four functional models namely: the model with the predominance of the deficit of noradrenaline, the one with serotonin deficit predominance, the model with the predominance of dopamine deficit and mixed depressions. I stress, these are working models which explains remissions, relapses and eventual turn to anger. The idea was suggested by Van Praag (1975) [16] and taken over by Marinescu (1997 pp. 294-295) [17] who also points out that they have clinical features and indicative biochemical and biological markers.

Of course, in depression, the involvement of the dysfunction of other morphological and biochemical cerebral systems is demonstrated, which should be taken into account. We mean here the adrenergic, cholinergic, GABAergic or histaminergic systems and beyond. Either they join among themselves, dominating from case to case, or they join the domi­nant ones. The dominant ones, which dominate also with respect to the number of cases and as outlined above, have some clinical and laboratory features that may guide the diagnosis. Alternatively, recognizing the existence of four morphological and biochemical types of depression is of great practical importance. They allow us:

  1. to divide depression into therapeutic classes, respectively serotoninoprival, noradrenalinoprival, dopaminoprival; and mixed;
  2. to understand why cases are not always controlled satisfactorily by the treatment;
  3. to personalize the therapy taking care to mind what Marinescu (1997) [17] called therapeutic adequacy, respectively, to move from empirical symptomatic therapeutic model using a selective psychoactive preparation in accordance with the morphological and biochemical defect underlying the depressive disorder;
  4. to understand why it is necessary to exchange the antidepressant with one having a different therapeutic profile from the first one chosen arbitrarily, which proved less effective.

4. Concept of Stress

Perhaps the most complicated situation is represented by the concept of stress. Today we ignore the fact that, since 1936, Hans Selye has imposed this concept to the attention of the medical world considering it primarily a physiological reality and then a general and common psychophysiological reality. In spite of this, both in the professional language and in the ordinary one, the concept of stress has become synonymous (see also Milea 2013), especially with the idea of being either a pathogenic factor or an abnormal result thereof. Because of this, Floru (1974) considers the concept of stress is marked by exaggerations and confusions, Garmezi and Rutter (1990) see it as source of ambiguity and Drisdale (2000) a slippery term. Speaking of stress, Deley (1965) considers it an acute tension of the body forced to mobilize its defences to cope with a threatening situation, while Sillamy (1996) [5] defines stress as a state of the organism which is threatened by imbalance under the action of agents menacing its homeostasis mechanisms. We stress it: homeostasis mechanisms not the health. In other words, as Hans Selye understood it, too, it is a nonspecific response to any requests, respectively stimuli regardless of their nature, an aspect emphasized by Popescu Neveanu (1978) [4], too. The common interaction of the individuals with their environment is envisaged, which involves their adaptation, defence, learning, training or toughening means that are indispensable for normal development and competitiveness. It has not been and cannot be limited to the idea of being the cause of disease as unfortunately DEX (1998) has done when it defined stress as “a name given to any environmental factor (or combination of factors) that causes an abnormal reaction in the human body”. Here it is evident that the definition is limited to pathogenic factors and disorders generated by them. So that option is not unique because to Lafon (1973) stress is the set of reactions in consequence of (we highlight it) an aggression. As such, while at origin the stress was limited to the idea of strain on the organism, today it is understood as overstraining and even as aggression. Thus, the delimitation of notions such as eustress and distress, initiated by Selye (cited by Fischer and Riedesser-2001) is ignored.

In Selye’s option, eustress is the equivalent of physiological, respectively psychophysiological sphere, the normal component and the most important part of the domain. In turn, distress is synonymous with its abnormal, respectively accidental or secondary side. The delimitation eustress-distress has been minimized although it allows removal of many ambiguities. It is not simply the recognition of the existence of a border between the two realities. It also helps to avoid:

  1. shifting the focus to the idea of stress as just an abnormal phenomenon, therefore an undesirable one;
  2. what is already underway, that is the transforming of any request from the externai environment into an undesirable situation, the promotion of the facile, of the hyper-protective education, the confusion of the distress with the effort required for training, adapting to and overcoming obstacles but especially with the effort required in mastering the reality that surrounds us and in overcoming obstacles.

Speaking of stress in the sense that is usual today, there is always the risk of believing that everything that surrounds and strains us is distress; that any greater effort is an undesirable condition; that any discomfort is a pathological condition but especially that hyper-protection is a sanogenous solution. However, what is most annoying is that it minimalizes the promoting of resilience as a modern form of primary psycho-prophylaxis where the individual must be taught not to wait passively to be helped but to overcome obstacles by his/her own means.

5. Hyperkinetic disorder

It is the long-time privileged name which together with the (approximately synonyms) (ICD-8 -1965, Rutter et al. -1975) [18] hyperkinetic syndrome reaction (DSM II-1965) or hyperactive disorder, that is preferred in America, (Thorley-1984) [19] demonstrates the assertion that often psychiatric gives us the sight of superficies, i.e. events that conceal the point. This is because the motor disorders that have impressed the clinician for decades are actually secondary to dysfunctions at the level of attention. What is surprising here is that it continues to be promoted today, although more than 30 years have passed since DSM III (1980) [1] pointed out that the name of hyperkinetic disorder is not adequate for the disorders it has represented for a very long time. This happens even if this fact is a source of certain regrettable diagnostics errors. Even WHO adopted it in 1994 (ICD-10 Code F-90) instead of the name of childhood instability. We also find in specialty scientific journals and events in our country, even recent ones, although professional committees supervise them.

It must be said that this is not about formal aspects, respectively a different name given to pathological manifestations but about minimizing the fact that we are not faced with neurological disorders but primarily with psychopathological ones and it is not just a sim­ple excess in motion. In fact, for DEX (1984), hyperkinesia is an “exaggerated activity performed by skeletal muscles or by smooth muscles of a hollow organ” such designation is restrictive to neurological semiology. Moreover, given that at the base of each pathological manifestation there are specific disorders and that psychiatry does not deal with symptoms, syndromes, or diagnoses and even less with diagnostic codes but with their substrate, respectively the neuro-psycho-biologic dysfunctions which are at their base, it is very important to understand and know that this time, both in therapy and in research, we have to address the sphere of attention and not the one of the motor skills. In fact, speaking of ADHD, American authors have identified and unearthed attention disorder that they have valued at maximum putting it in the position of central symptom. This means to reconsider the biological basis of the field and thus to provide a new target, more valid for the therapeutic approach. In our opinion (Milea-2010) [6], the name of ADHD is not without imperfections, either. The first objection is directed to the formulation attention deficit, which we consider inadequate, because: it refers only to concentration deficit of voluntary attention. It is true that in ADHD, there is a deficit in voluntary attention span but the representative cases, namely those that are what can be called “quicksilver”, are secondary to involuntary hyperprosexia. As such, it would be more correct to speak of a dysfunction or deficiency of the attention focused on the idea of involuntary hyperprosexia and not on the deficit. Not acknowledging the involvement of involuntary hyperprosexia has the disadvantage of creating certain difficulties in the differential diagnosis, the risk of erroneous diagnoses and misleading the therapeutic approach directed to neuro-psycho-biologic foundation of attention deficit and not to the one of involuntary hyperprosexia. Rather, emphasis on presence of involuntary hyperprosexia allows one to explain easily the presence in combination of voluntary attention deficit, mental and motor hyperactivity, impulsivity as well as the answer of all of them to the same medication.

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stmilea@yahoo.com