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S78 I. Missmahl et al. / European Psychiatry 27 (2012) / supplement n°2 / S76-S80
the manuals were approved by the Ministry of Public Health and
are now obligatory for all psychosocial counsellors who want to
work in the Health system.
This curriculum and training methodology differs from
the WHO mental health Gap Action Programme (mhGAP).
Intervention Guide in so far as it is not so much orientated
on a diagnosis based on DSM IV or ICD10 and the associated
case management but rather puts the main emphasis on the
understanding of the symptom in a given cultural context.
Specifi c attention is given to the question how far standard
diagnostic tools developed in a Western cultural setting can
assess culturally signifi cant indicators in the local context.
Starting point of the therapy is the most pressing problem of
the patient, which is usually connected to those forms of social
distress that contribute most strongly to social isolation and
functional impairment. Already after the fi rst session the patient
should feel that he or she will be able to regain some infl uence on
their life situation. Subsequent psychotherapeutic interventions
are then resource- orientated and based on a problem solving
approach focusing on the main problem of the client; they apply
basic elements of standard therapeutic techniques including the
salutogenetic approach of Antonovsky [3].
In 2011, more PSCs have been trained for the Northern
Provinces and after their one year examination, the best ones
with the background of medical doctors will receive a skillbased
training in methodology and teaching skills and will become
National Trainers for Psychosocial Counselling. In 2012, this
program will be rolled out in all provinces of Afghanistan and
by 2014, there will be National Mental Health Trainers in all
Provinces who are able to train further PSCs for all CHCs. Careful
training can thus assure that counsellors proceed in a way that
is both culturally sensitive [1] as well as individually focused
on the needs of their clients. Moreover, psychosocial counsellors
– like medical personal in general – need to acquire basic
psychiatric knowledge. However, most manuals available for
psychiatric care are too complex and it cannot be expected that
psychosocial counsellors are really able to correctly diagnose
psychiatric illness according to ICD- 10 or DSM- 4 [16,2].
4. Learning a Basic Medical Approach to Psychopathology
An alternative approach to identifying psychopathology
is based on university experience in the training of medical
students around the world. This training also does not focus on
clear identifi cation of single disorders in ever more complex classifi
cation systems. Rather, medical student education focuses on
distinguishing between six types of psychiatric disorders: Acute
and chronic exogenous psychoses (e. g. delirium and dementia
as examples of cognitive disorders with a “brain organic”
background and the associated syndromes of drug dependence),
endogenous psychotic disorders and major affective disorders
(such as schizophrenia and bipolar as well as severe unipolar
disorder), psycho reactive / adjustment disorders (formally
classifi ed as neuroses) and personality disorders (Fig.1).
Being able to classify mental disorders at least with respect
to these broad categories helps to decide whether somatic diagnoses
is urgently required, whether certain kinds of medications
can help and how urgent psychotherapeutic and psychosocial
Exogenous psychoses
Delirium Schizophrenic Psychoses Neuroses
Dementia
Bipolar Disorders Personality Disorders
counselling may be. Furthermore, a few core symptoms can
help to systematically distinguish the most pressing acute brain
disorders (with potentially lethal outcome within a few hours,
e. g. acute deliria) from chronic neurodegenerative disorders and
from psychoses and severe affective disorders (Fig. 2).
We are aware that such broad classifi cations and a limited list
of symptoms are presenting an extreme reduction of psychiatric
complexity, however, in our own experience, knowledge of
such basic symptoms and categories can greatly help medical
students, non- psychiatric medical personal and psychosocial
counsellors to understand when and how urgently a psychiatric
specialist should be contacted. Furthermore distinguishing
between these basic categories can help to limit medication to
many patient groups and prevent e.g. use of neuroleptics outside
of “endogenous psychoses” and, more specifi cally, patients from
being wrongly classifi ed as suffering from schizophrenia.
5. Training of psychiatric specialists
Our experience in Kabul revealed that even doctors trained
in internal medicine and specializing on mental disorders within
mental health hospital require training in basic neurological
examination skills. Clinical examination, a mainstay of neurological
diagnosis until recently, when brain imaging became
available is a must in countries with limited medical resources
such as Afghanistan. Of extreme importance is also the distinction
between epilepsy and dissociative states. Therefore, the
relatively cheap and repeatedly usable EEG is a highly relevant
diagnostic tool in such settings, and doctors require training
to use this instrument: However, when we taught in Kabul
in 2009 and 2010, no EEG was available in any public mental
health institution. Finally, in our experience, medical training in
a mental health hospital involved rather profound knowledge
of DSM- 4 symptoms and syndromes, however, there was a
certain lack of practical training e. g. in applying such criteria to
individual patients and to discuss diagnostic and differentialdiagnostic
considerations. Moreover, discussion of adequate
dosage of pharmaceutical medications, particularly neuroleptics,
is strongly required and - at least in our experience – greatly
supported by basic knowledge of e.g. required neuroleptic doses
to reach therapeutic levels of dopamine- D2- receptor blockade.
The rather low dose of haloperidol (below 5 mg) required to
assess such therapeutic receptor blockade was generally not
known to psychiatric practitioners, who tended to dose much
higher even in never medicated subjects [6].
Since there is no hope to have psychiatric specialists in
the immediate future in smaller or larger regional hospitals,
interested practitioners of internal medicine or other related disciplines
require training in basic medication skills with respect
to antidepressant, neuroleptic and sedative medication and
Proofs
Endogenous psychoses Variations
Fig. 1. Pragmatic grouping of disease entities in psychiatry and psychotherapy.
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