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Diagnostics – Classification and Systematics in Psychiatry and Medicine

Othmar Maeser

Diagnostics –

Classification and Systematics in Psychiatry and Medicine

Dedicated to Karl Jaspers

Thanks for making this English edition possible go in particular to the developers of the translation tool DeepL Pro (www.deepl.com). I have made only minor changes to the machine translation of the German edition and slightly expanded the text in some places to make it more understandable. Further thanks go to Erik Kinting, the lector of the German edition, who also helped me with the publication of this book in English and did the typesetting of the book. I owe him the reference to the tredition publishing house and I am confident that the tredition team will succeed in presenting the book on the English book market as well. Last but not least, I would like to thank my wife Lucretia Maeser-Trevisani, JSD, who once again actively supported me.

Thanks for the german Edition April 2, 2019

I would like to express special thanks to the pathologist Walter Widder, MD, under whose assistance individual sections in the 2nd chapter were written. I would also like to express my special thanks to my editor Erik Kinting for his accuracy, flexibility and friendliness – thanks to his talent and knowledge, the revision and supervision succeeded in the best possible way.

Last but not least, I thank my wife Lucretia Maeser-Trevisani, JSD, without whose support and suggestions I would never have started this book.

Note on usage:

In the text, intensive reference is made to various quotations.

Superscript numbers and letters with numerals refer to the respective citation, which can be read in greater detail in the Appendix-Citations (see page 809 ff.).

Small superscript letters refer to footnotes.

Foreword

In this book the basic principles of diagnostics, classification and systematics in psychiatry and medicine are shown. This is possible with the help of the philosophy of Immanuel Kant. Through a passage in the Critique of Pure Reason, the great difference in knowledge and thus in diagnostics can be shown.

From the basis of knowledge the degree of knowledge and thus the different diagnostics, classification and systematics in psychiatry in comparison to medicine results. In addition, it becomes clear from the different basis of knowledge how psychiatry developed as an independent discipline out of the former medicine, how it came to the separation of psychiatry from medicine and how conventional medicine in the sense of today's university medicine came into being. This split was finally followed by the striving for the restoration of wholeness and it becomes clear how individual methods of complementary medicine as part of alternative medicine and later psychosomatics as so-called holistic medicine developed.

Of course, the knowledge and content of the medical science cannot be treated in this book, but very well the fundamentals, the structure and thus the inner construction of the knowledge. And with the help of the philosophy of Immanuel Kant questions can be answered, with which especially psychiatry as a science has been concerned since its beginning, but to which it could not find proof and answers by scientific studies. For example, it can be clarified whether certain mental disorders can be determined in a generally valid way, or whether psychiatric diagnoses can be validated by biological findings and thus reliably determined. This also applies to open questions in a sub-area of medicine, such as whether health disorders and diseases that are recorded by symptom complexes can be determined in a generally valid way in the future and whether the causes of these health disorders (e.g., in migraine) can be identified and determined in the future.

The book is structured in such a way that, after the introduction, the basic principles of diagnostics are shown in detail with the help of Immanuel Kant's philosophy and then applied to medical science. Because diagnostics in a broader sense is concerned with the concepts of understanding, explaining, evidence, validity, reliability, causality, norm, health, disease, proof, probability, theory and the concept of science, these topics are also treated in short chapters based on the philosophy of Immanuel Kant. Thus, the different classification, systematics and finally the different structure of medicine in comparison to psychiatry can be shown in a further step.

The second part of the book deals with the consequences of the basis of knowledge on practice and science under individual headings.

The book intends to draw the reader's attention to the various foundations of knowledge and to show what consequences are associated with them. Accordingly, the book is aimed primarily at physicians, but also at others interested in the foundations and degree of knowledge in the various fields of healing and of medical science and provides the basis for methodological reflection on the extent to which knowledge can be acquired in the individual fields.

Starting from the Critique of Pure Reason by Immanuel Kant, the basis of knowledge and thus the basis of diagnostics, classification and systematics is shown. The respective degree of knowledge results from the basis of knowledge. It is shown that the characteristics of health disorders, both physical and mental, determine the degree of knowledge.

The psychiatrist and philosopher Karl Jaspers recognized the basis of knowledge in psychiatry by studying the philosophy of Immanuel Kant, this is presented by means of quotations from his book General Psychopathology as well as from Immanuel Kant's Critique of Pure Reason. Endnotes are used to refer to citations that can be read in the appendix, so that those interested can see for themselves the connections presented here. The book is designed in such a way that the reader can use the references to get to the specific sections and to the citations in the appendix. This makes it possible to follow the connections for oneself.

Because the main arguments arise from a few fundamental insights, repetitions in the text are unavoidable. This is helpful for those who are not more familiar with the Critique of Pure Reason and General Psychopathology. The meaning of the terms used there is explained in various contexts, resulting in a deeper understanding of the terms used by Kant and Jaspers.

The fundamental differences in knowledge are pointed out and thereby it becomes clear that part of our knowledge is created by facts – on the level of objects – and other by ideas, namely by the comparison of ideas – on the level of ideas – by the concepts of ideas. This is additionally illustrated by numerous illustrations, which make the subject a bit more tangible.

Othmar Maeser, Feldkirch April 2019 (German edition) Translation into English September 2021

Contents in brief

(detailed table of contents at the beginning of each chapter)

First part

Diagnostics, classification and systematics in medicine

Introduction to diagnostics

Diagnostics

Content Diagnostics – Part A: The basic

Content Diagnostics – Part B: The core of diagnostics illuminated in detail

Content Diagnostics – Part C: Consequences as a result of the basis of knowledge

Diagnostics of health disorders and diseases at a glance

Diagnostics in medicine

Diagnostics in psychiatry

On diagnostics in alternative medicine (complementary medicine) and psychosomatics

Understanding and explaining in psychiatry and medicine

Evidence in psychiatry and medicine

Validity and Reliability in Psychiatry and Medicine

10 Causality and Cause in Psychiatry and Medicine

11 On the Concept of Norm and Normality in Psychiatry and Medicine

12 On the concepts of health and disease in psychiatry and medicine

13 On the Concept of Proof in Psychiatry and Medicine

14 On the Concept of Probability in Medicine and Psychiatry

15 On the concept of theory in psychiatry and medicine

16 On the concept of science in psychiatry and medicine

17 Classification of health disorders and diseases at a glance

18 Classification in medicine

19 Classification in psychiatry

20 Systematics of health disorders and diseases at a glance

21 Systematics in medicine

22 Systematics in psychiatry

23 Structure of medicine and psychiatry

Second part

Basis of knowledge – Consequences for the practice and science of medicine

24 Systematic study has led to new thinking in medicine

25 Consequences for the practice and science of psychiatry as a result of the basis of knowledge

26 Consequences for the practice and science of medicine as a result of the basis of knowledge

27 Consequences for practice and science of alternative medicine, complementary medicine and psychosomatics as a result of the basis of knowledge

28 Review of systematics in medical science

Appendix – Quotes

First part

Diagnostics, classification and systematics in medicine

From the basis of knowledge results the diagnostics, classification and systematics of medical science. This is presented in the first part with the help of the philosophy of Immanuel Kant.

Introduction to diagnostics

1.1 Diagnostics – introductory definition

1.2 Diagnostics of health disorders and diseases

1.3 In the Occident, medical science is primarily divided into medicine and psychiatry

1.3.1 Emergence of holistic medicine

1.4 Karl Jaspers recognized the basis of knowledge in psychiatry based on the philosophy of Immanuel Kant

1.5 On the emergence and development of medicine as a science

1.6 On the emergence and development of psychiatry as an independent discipline and as a science

Summary

Literature

 

1.1 Diagnostics – introductory definition

Diagnostics is the procedure that leads to the determination of the diagnosis. Thus, diagnostics is concerned with the recognition of facts or phenomena and this process is called diagnosing, insofar at the end of this process the diagnosis is determined, by which the facts or phenomena are recognized and named.

1.2 Diagnostics of health disorders and diseases

In medicine, diagnostics is concerned with the detection of health disorders and diseases.

Since time immemorial, people have been confronted with the occurrence of health disorders, which were first studied more thoroughly in the Occident in ancient times. After the decline of advanced civilizations, after the Middle Ages, in the period of the Renaissance, there was a new upsurge and the emergence of science in the sense of today's university. As shown in the book, this gave rise to the systematic study of man and health disorders. During this period, significant discoveries were made in various fields. For example, by combining two lenses, the function of the telescope and that of the microscope were discovered. This opened up completely new possibilities to explore and study the macrocosm as well as the microcosm. At that time, anatomy made significant progress, histology developed (as a result of the microscope) and more and more macroscopic and microscopic features of the body and thus also those of diseases were discovered and diagnostic units were described.

Following the example of the classification of entities in botany – the Swedish naturalist Carl von Linné should be mentioned here – physicians developed the first systematic classifications of diseases (e.g. Nosologie methodica, François Boissier de Lacroix). With regard to the psyche, the French physician Philippe

Pinel had for the first time undertaken a systematic classification of insanityP1 (following the method of classification in natural history), and the first beginnings of psychiatry as an empirical science thus emerged. In this sense, the classification of the different health disorders – both on the level of the body and on the level of the psyche – led to systematic diagnostics and classification, and thus systematics developed in these areas of knowledge.

Thus, in the Occident, the medicine of that time gave rise to today's orthodox medicine (conventional medicine) in the sense of university medicine (which deals with the systematic research of physical diseases, their therapy and prevention) and also the systematics of mental diseases.

As will be shown in the following, the difference in characteristics results in the different internal structure and thus the different structure of medicine (orthodox medicine) compared to psychiatry.

The systematic study of the body thus led to the separation of the psyche (soul) and thus to the emergence of psychiatry, and because of the division of the wholeness of the human being, various methods of complementary medicine were subsequently developed, which will be discussed in more detail below.

Certain health disorders are recognized on the basis of physical characteristics, others on the basis of symptoms and non-objectifiable phenomena (φαινόμενον fainómenon, Greek: that which appears, the appearing, the appearance). With the help of Immanuel Kant's philosophy, it can be shown that some of the diseases and health disorders are captured by factual findings and therefore by factual entities (Chapter 2.7.3), but others are captured by the clinical phenomena and therefore by systematic entities (Chapter 2.7.4).

1.3 In the Occident, medical science is primarily divided into medicine and psychiatry

Until the time of the Enlightenment, the term psychiatry did not yet exist. It was only when physicians began to systematically observe and study certain mental abnormalities that mental illnesses were increasingly recognized as such and described as independent disease entities.

On this way psychiatry, the doctrine in which doctors (Greek: iatros – doctor) deal with the diseases of the psyche (soul in the psychological sense), developed. Thus, because the human being as a whole was divided into body and psyche (soul) for the purpose of systematic study, today's orthodox medicine and psychiatry emerged from the former medicine (Fig. 1.2).

Accordingly, in the Occident, medicine in the sense of orthodox medicine (university medicine) on the one hand and psychiatry on the other hand emerged from the division of the former medicine. Psychiatry is concerned with the pathological disorders of the psyche and orthodox medicine with the pathological disorders of the body.

This splitting led to the loss of wholeness, which in turn led to the striving for the restoration of unity, and thus various methods of complementary medicine have emerged along this path, as well as psychosomatics, which is why these methods see themselves as holistic medicine (Fig. 1.3).

With the help of the philosophy of Immanuel Kant, it can be shown that these alternative methods are concepts (Chapter 2.24), through which certain relationships are mentally grasped, understood, and explained in an alternative way in medical science. In other cultures, other ways of understanding and explaining health disorders have emerged (Traditional Chinese Medicine, Ayurveda in India, and others in different cultures around the world). In Chapter 6, the epistemological foundations of these alternative disciplines of medicine are also cursorily demonstrated with the help of Immanuel Kant's philosophy.

Fig. 1.1: Systematic study of man led to the splitting of wholeness

The systematic study of man led to the splitting of wholeness into body and psyche.

Fig. 1.2: The systematic study of man caused the division of the former medicine

The systematic study of man in the period from the Renaissance onwards caused the division of the former medicine into university medicine (orthodox or physical medicine) and psychiatry.

1.3.1 Emergence of holistic medicine

It can be said that due to the separation of psychiatry from the former medicine, a deficiency had arisen in a certain respect, insofar as in orthodox medicine the body is systematically examined and studied anatomically, histologically, biologically, physiologically, biochemically, by imaging and according to other physical criteria and methods, without, however, taking into account the experience and thus the psychological events. This deficiency caused the striving for a holistic medicine, because it was noticed that the restriction to the only physical or physical study does not do justice to the human being, and on this basis various methods of complementary medicine or alternative medicine as well as psychosomatics developed. These areas of medicine complement conventional medicine and thus the therapeutic spectrum for practice, insofar as holistic ways of understanding and explaining certain relationships have been created and alternative treatment methods have emerged from them.

Fig. 1.3: Lack of wholeness was noticed

The lack of wholeness was noticed and was the reason for the emergence of alternative/complementary methods. The alternative medicine, complementary medicine and psychosomatics emerged and understand themselves as so-called holistic medicine.

1.4 Karl Jaspers recognized the basis of knowledge in psychiatry based on the philosophy of Immanuel Kant

The psychiatrist and philosopher Karl Jaspers, on the basis of the philosophy of Immanuel Kant, recognized the difference in knowledge in psychiatry in comparison to medicine and described it to his book General Psychopathology, when he writes concerning the difference between a genus and a type: I capture the cognizable object of knowledge in genera to which it belongs, I encircle the object of the idea in types. And in another place: If I cannot recognize the ”whole as an idea” straightforwardly, I approach it – in Kant's words – through the "schema" of the idea. And in yet another place: Schemata are designed types, false if I treat them as realities or as theories of an underlying, true as a methodological aids that are limitlessly correctable and transformable (Karl Jaspers, p. 468)J1.

Finally, Jaspers recommends the study of Kant's theory of ideas in the Critique of Pure Reason and Critique of Judgment in the original (Karl Jaspers, p. 468)J1.

The author followed this recommendation more than three decades ago, during his training as a general practitioner and then during his training as a specialist in psychiatry and neurology. In the Critique of Pure Reason were found the passages from which the connections presented here are derived. Initial results of these studies led in 1994 – at the end of residency training – to the publication of the article An investigation of cognition in psychiatry, in reference to Immanuel Kant in Fundamenta Psychiatrica (Othmar Mäser, Vol. 8,1994). While the response to this article was initially low, after the publication of the same on the Internet in 2008, lively interest in this topic was shown. This motivated the author to publish several papers at international psychiatric congresses and to give lectures on the topic: Diagnostics in Psychiatry and Forensic Psychiatry.

Now, as it were, as a summary, extract and further development of these publications, the result concerning diagnostics, classification and systematics as well as related subject areas can be presented on the basis of the philosophy of Immanuel Kant. The book therefore sees itself partly as a supplement to the General Psychopathology of Karl Jaspers, insofar as the application of Kant's philosophy succeeds in placing the methodological awareness achieved by Jaspers in a new space (Karl Jaspers, General Psychopathology, preface to the 7th edition). Thereby, with the help of the Critique of Pure Reason, the great difference between objective and subjective knowledge can be shown and the consequences to which this leads in practice and science can be illustrated.

Whereas in medicine many health disorders can be determined on the basis of objects par excellence (objects absolutely),1 thus on the basis of objects/facts, thus objectively certain with respect to belonging to generaJ1 and therefore on the basis of factual units (Chapter 2.7.3), this is fundamentally not possible in psychiatry and here knowledge can only be determined on the basis of objects in the idea1 or on the basis of the concepts1of ideas through the schemata of ideas1,J1 with respect to defined typesJ1. Thus, for instance, the different mental phenomena and thus also the different psychological symptom complexes of the different mental disorders can be recognized only through the concepts1of ideas, which appear as systematic units1 (Chapter 2.7.4) in the consciousness of the recognizing person.

Therefore, these diagnostic units are recognized by belonging to (defined) typesJ1 (Karl Jaspers, p. 468).

Thus, based on the philosophy of Immanuel Kant, it can be shown that the normal psychological phenomena – and likewise the pathological psychopathological phenomena – are recognized under the guidance of ideasJ1 through the schemata of ideas1,J1. Therefore, psychological and likewise psychiatric knowledge is fundamentally subjective knowledge. In medicine, too, part of the acquired knowledge is only subjectively valid, which will be shown in detail in chapters 2 and 4. Yet these diagnostic units are systematic units throughout,1,3 because they are recognized by ideas1 or by the (diagnostic) schemata1of (diagnostic) ideas (Chapter 2).

While in a subfield of medicine certain diagnostic units are recognized as systematic units1 by noticing the coherence of the sensually perceptible, for instance the microscopically perceptible characteristic bodily features (e.g. in histopathology the entities of the histopathological images, more on this in 4.4.2), in psychiatry all diagnostic units are systematic units,1 which here, however, can only be determined by pure synthesis11. Namely, these are diagnostic units that are recognized by the (pure) synthesis of psychological phenomena. Thereby, the physicians working in psychiatry have recognized on the level of their ideas through the concepts of ideas1 certain mentally delimited units – precisely the different psychopathological phenomena and also the typical or the characteristic psychological symptom complexes of the different mental disorders – through pure synthesis,11 thus through their understanding and their (pure) reason6 on the basis of their clinical experience. In the words of Karl Jaspers one can say, they recognized these typesJ1 as a result of their thinking viewJ1 and under the guidance of ideasJ1 on the basis of their clinical experience and thus described these diagnostic units by the (diagnostic) schemes of (diagnostic) ideas1,11,J1 and defined them on this way.

These conceptions developed by physicians, according to advancing clinical experience and testing of the defined psychiatric categories, were further developed over time. In the process, empiricism showed that these projected units9 (Chapter 2.32) have generally proven themselves sufficiently in practice and science,6 although there is no touchstone of experience6 for them, respectively, they cannot be tested biologically (physically). These empirically developed concepts (Chapter 2.24) are thus useful and thus purposeful unities5 (Chapter 2.31) in the sense of Immanuel Kant, with the help of which one as a psychiatrist (without knowledge of the cause of the respective mental disorder) can subjectively validly determine the characteristic psychological symptom complex on the basis of the scheme of the idea1,J1 – within the defined psychiatric classification. Thereby – from the epistemological point of view – the psychiatric categories (on the level of ideas) form a mental grid, in order to thereby subjectively validly determine the different psychological symptom complexes by these systematic units1,3 in the diagnostics.

Thereby, however, as said, it is not possible to physically determine such a conceived unity. This means that it is not possible to determine such a unit, which is only problematically grounded3, biologically, because the diagnostic unit is always the systematic unit1,3 of the idea, which refers to an only imagined object of knowledge. Accordingly, a psychiatric idea – like a psychological idea7 is a transcendental idea8 in the sense of Immanuel Kant.

The aim of the book is to help the reader gain a detailed understanding of these interrelationships so that the consequences arising for practice and science can be recognized, considered and taken into account.

At this point, I would like to point out once again the paramount importance of the first quotation from the Critique of Pure Reason, which I call the root quotation1 (see Appendix). One can say that in this passage Immanuel Kant succeeded in putting into words the root of human cognition and knowledge. From this root results the further, which is pointed out here in relation to the diagnostics, the classification and the systematics in the medical science, because both the diagnostics and the classification and the systematics emerge epistemologically from this root (see Kant, quotation 1, in the appendix).

In other words, because the terms1of such a defined system are systematic units1,3 (of ideas) they mutually limit each other by their definitions – and they are therefore dialectical to each other (Chapter 2.15.5.1 and 2.15.5.2). This fact has the unavoidable consequence that the same or similar things occur repeatedly in different passages of this book. However, these repetitions seem to be useful insofar as they contribute to a deepening of the understanding of the terms used by Kant and Jaspers and thus lead to a better understanding of the connections.

1.5 On the emergence and development of medicine as a science

Medicine as a science emerged when people began to systematically observe and study health disorders in order to find the best possible therapy for the specific case. In this way, already in ancient times, physicians recognized certain health disorders and discovered and described different disease entities as a result of their empirical observation – in nature.

In the course of time, more and more characteristics were found on the level of the body by which certain health disorders could be described and determined in diagnostics. In the case of other health disorders, on the other hand, it was assumed that there were natural disease entities – in the sense of underlying natural units (Chapter 2.36 and 2.36.1) – that produced certain clinical manifestations in the form of characteristic symptom complexes.

However, in relation to these health disorders, it was usually not possible to find a factual cause as a result of which the clinical appearance arises.

Only in the course of time, with the progress of science and the methods and equipment developed as a result of advancing technology (e.g. invention of the microscope) and the knowledge gained in this way, was it possible to trace individual pathological abnormalities back to an identifiable physical cause and thus to determine these health disorders generally on this basis. For example, the symptom complex phthisis (consumption) could in many cases be traced back to the infection and multiplication of the tubercle bacillus in the body. Thus, after the discovery and visualization of the tubercle bacillus in the microscope by Robert Koch, it had become possible to diagnose this health disorder as tuberculosis in a generally valid way, which had not been possible before under the diagnostic unit phthisis. Thus, the term tuberculosis as a factual diagnosis (Chapter 2.7.3.1) could replace the phenomenological diagnosis (Chapter 2.7.4.2) phthisis.

In this sense, in the course of time it had become possible in medicine to replace various phenomenological-diagnostic units by the factual or by the etiological diagnosis after the discovery of the factual cause.

In addition, however, there were and still are many disease states in medicine that cannot be traced back to a physical/factual cause in the sense of a conditio sine qua non (Latin, literally: condition without which not) a(Chapter 2.50) and determined on this basis in a generally valid manner in diagnostics. For example, to this day, it is not possible to state and determine a factual cause of the health disorder called migraine. This health disorder can still only be recognized phenomenologically, i.e. only on the basis of the clinical appearance, thus only on the basis of the more or less typical symptom complex, and therefore only subjectively validly determined in diagnostics.

This shows that the disease units in medicine are divided, on the one hand, into the objectively determinable natural disease units, which can be generally validly determined on the basis of physical objective findings as factual diagnoses (Chapter 2.7.3), and, on the other hand, there are health disorders that can be subjectively validly determined only by their clinical appearance and therefore only as systematic units (Chapter 2.7.4) (of ideas). These include, for example, tension headaches and other primary forms of headache in which no physical cause can be identified, in addition to the migraine mentioned above. Furthermore, this type of health disorder includes the diagnostic units vegetative dystonia, dyspepsia, fibromyalgia, somatoform pain disorder and other pain syndromes that can only be subjectively validly determined by the respective characteristic symptom complex.

Finally, there are clinical entities in medicine for which one can establish physical findings (e.g., multiple sclerosis), but whose symptom complex cannot, as a rule, be traced back to an object and determined in a generally valid way on this basis. This has the consequence that such a health disorder can likewise only be recognized by the (diagnostic) scheme of the (diagnostic) idea1. This will be discussed in various places in this book.

Thus, while a part of the health disorders in medicine can be traced back to an objective finding and thereby the respective diagnosis can be determined in a generally valid way, this is not possible with other health disorders. These can be recognized only by the clinical phenomena (clinical appearance) on the basis of an idea1 (by the systematic unity of the idea, mediated by the (diagnostic) scheme of the (diagnostic) idea1).

Because in such a case the diagnostic unity – as explained in more detail in Chapter 2 – is only recognizable on the level of ideas by the concept of the idea1 and thus only subjectively validly determinable, such knowledge is always limited knowledge.

Thus, in medical science, depending on the basis of knowledge, some health disorders can be determined objectively valid and thus generally valid on the basis of facts and can be studied systematically with the methods of statistics in science on the basis of objective evidence (Chapter 8.1.1), whereas this is not possible for other health disorders and no such reliable knowledge can be obtained in this respect on the basis of subjective evidence (Chapter 8.1.1). Thus, the difference in the basis of knowledge leads to diagnostic units of different epistemic value or to knowledge of different degrees. This difference in knowledge and degree of knowledge gives rise to consequences for practice and science.

1.6 On the emergence and development of psychiatry as an independent discipline and as a science

Psychiatry emerged as an independent discipline and as a science just over 200 years ago. At that time, physicians had begun to systematically observe pathological mental abnormalities. This was the beginning of the professional study of mental illnesses and thus the diagnostics and classification of the various pathological mental phenomena.

Until then, many mental abnormalities had not been recognized and acknowledged as pathological conditions, but had been dismissed as the result of moral aberrations or obsessions. Therefore, in many cases the madnesses were cured by moral chastisements in the penitentiary (prison) and partly by exorcism.

In Europe, it was not until the time of the Enlightenment that certain mental abnormalities began to be recognized and acknowledged as diseases, apart from melancholy, which had already been understood as a disease (melan chole – black bile) since antiquity (on the basis of the doctrine of the humors) and had been recognized in isolated cases (Schott/Tölle, Geschichte der Psychiatrie, p. 328).

The French physician Philippe Pinel (1745-1826) who was the first to systematically study insanity or mania and to free these mentally ill people from the penitentiary became famous. Philippe Pinel described the first psychological symptom complexes, on the basis of which these mentally ill people could be determined according to the different clinical manifestations by the spirit of observation, the aphoristic language, and the method of classificationP1. He had thus created a first phenomenological order by which the mentally ill could be recorded and classified in diagnostics according to a system.

In his textbook Pathology and Therapy of Mental Diseases (1845), the German internist and neurologist Wilhelm Griesinger (1817-1868) described the first comprehensive nosology and thus a psychiatric theory of disease in the German-speaking world. Griesinger distinguished three main groups: mental depression states, mental exaltation states and mental weakness states (Wilhelm Griesinger, p. 211 ff.).

While in medicine at that time it was already possible to diagnose many health disorders on the basis of physical findings and thus on the basis of physical facts, in psychiatry this was not possible. Mental illnesses, as Griesinger aptly writes, are currently recognizable only on the basis of mental abnormality (psychic anomaly)G1 and thus only psychologically – or, in today's terminology, only psychopathologically based. However, Wilhelm Griesinger was confident that in the future it would be possible to diagnose mental diseases on the basis of the anatomical changes of the brainG1 (Griesinger 1871, p. 211), because physicians working in psychiatry recognized that certain mental diseases occur in connection with physical abnormalities.

Similar to Wilhelm Griesinger, Emil Kraepelin (1856-1926) later believed that certain mental illnesses could be determined in a generally valid way. Emil Kraepelin was convinced that in certain mental illnesses, lawful relationships between the physical and mental eventsKr1 would be found (Kraepelin 1899, pp. 6-7), on the basis of which these mental illnesses could be determined in a generally valid manner (Kraepelin 1899, p. 19). In general, Emil Kraepelin assumed that psychiatry would develop into a powerful branch of medical science on the basis of scientific understandingKr3 (Kraepelin 1899, p. 2).

In this sense, Eugen Bleuler (1857-1939) still believed that at least the concept of the disease unit schizophrenia – which he had derived from the disease unit dementia praecox – would be resolvedB1 in the future (Bleuler 1911).

Emil Kraepelin was thus convinced that in the future it would be possible in psychiatry – as in medicine – to trace certain mental illnesses back to a biological cause and to determine them generally on this basis. Henceforth, many other experts in psychiatry were also confident that natural disease units in the sense of physically determinable natural units (Chapter 2.36) would be found on the basis of which certain disorders of the psyche could be determined objectively and thus universally.

In contrast, Karl Jaspers writes from the 4th edition of his book General Psychopathology that (in psychiatry) the idea of the unity of disease in any single case can never be realizedJ2 (Karl Jaspers 1973, p. 476). Jaspers had come to this realization after he had once again deepened his own basic knowledge by studying the writings of Immanuel Kant, and elsewhere he refers to the doctrine of ideas of I. Kant in the Critique of Judgment and Critique of Pure Reason (Karl Jaspers from the 4th ed. 1946 in the footnote, p. 468).

Karl Jaspers writes in the fourth part of his General Psychopathology: Even if I cannot staightforwardly recognize the “whole as an idea”, I approach it – in Kant's words – through the "scheme" of the ideaJ1 (Karl Jaspers, p. 468). As is well known, even after the publication of the 4th edition of Jaspers' General Psychopathology, most experts continued to follow the view of E. Kraepelin, who was confident that psychiatry would develop into a powerful branch of medical scienceKr3 or that certain mental diseases could be determined biologically in the future.

Until today the results of research and science, especially of neuroscience, show that still no single psychic phenomenon, therefore also no single mental disorder and therefore also no corresponding psychiatric diagnosis can be determined biologically or physiologically founded. It is still possible to recognize and determine all psychic phenomena and therefore also all mental disorders only psychologicallyG1 or only psychopathologically based in diagnostics.

With the help of the General Psychopathology of Karl Jaspers and the philosophy of Immanuel Kant it can be shown – through the Critique of Pure Reason – why this is so. A single psychic phenomenon respectively a psychopathological phenomenon can only be recognized by the concept1of the idea. Thus, the entire psychological symptom complex of the mental disorder and thus the associated psychiatric diagnosis can only be recognized as the systematic unity1 (Chapter 2.7.4) (of the idea), which appears as the concept1of the idea in the consciousness of the recognizing professional when he mentally grasps the characteristic features of the mental disorder through the schema1,J1 of the idea.

Thus, as Karl Jaspers recognized, one can recognize the psychic phenomena and thus the mental disorder by the schema1,J1 of the idea only approximately and determine it in psychiatric diagnostics (Karl Jaspers, p. 468).

Whereas in medicine in many cases the health disorder can be determined on the basis of physical facts and thus factual units (Chapter 2.7.3) and thus objectively valid and generally applicable in relation to membership of a genusJ1(Genus), it should turn out that in psychiatry a mental disorder can still be recognized and determined in diagnostics only on the basis of the mental abnormality (psychic anomaly)G1 and thus only psychologically or psychopathologically justified in relation to a defined typeJ1(Typus).

The expectations of Wilhelm Griesinger that mental illnesses could be recognized in the future by anatomical changes of the brainG1 (W. Griesinger 1871, p. 211) respectively on the basis of lawful relations between the physical and mental eventsKr1 (E. Kraepelin, Vol. I, pp. 6-7) and determined in diagnostics, should not be fulfilled. In the 2nd Chapter it is shown in detail why this is basically not possible.

It can be said already at this point that in psychiatry the diagnostic units can be recognized only at the level of ideas by the concepts of ideas in relation to defined typesJ1 and therefore can be determined only subjectively valid, whereas in medicine many diagnostic units can be diagnosed at the level of the body and therefore at the level of objects substantiated by facts, according to the different genera and therefore can be determined generally valid.

Summary

This chapter explains the concept of diagnostics and shows how the systematic study of the human being in the Occident led to the division of the former medicine into today's university medicine (orthodox medicine) and psychiatry. As a result of this division, methods of alternative medicine/complementary medicine and later psychosomatics also emerged, in an effort to form a holistic medicine that seeks to overcome the division into the body and the soul (psyche).

It becomes clear that the university medicine systematically records the health disorders of the body, whereas psychiatry systematically records those of the psyche and it was realized by the psychiatrist and philosopher Karl Jaspers on the basis of the philosophy of Immanuel Kant that in psychiatry the mental disorders are diagnosed by the schemes of ideas in terms of types, whereas other disorders of health (in medicine) are diagnosed in terms of genera.

 

Literature

Bleuler, Eugen: Dementia praecox oder Gruppe der Schizophrenien (1911), Nachdruck: Arts & Boewe, Nijmegen

Griesinger, Wilhelm: Die Pathologie und Therapie der psychischen Krankheiten (3rd ed. 1871), Nachdruck: Arts & Boewe, Nijmegen

Jaspers, Karl: Allgemeine Psychopathologie (1973), 9. unveränderte Auflage, Springer, Berlin

Jütte, Robert: Geschichte der alternativen Medizin, Beck, 1996

Kant, Immanuel: gesammelte Werke in 12 Bänden (complete works in 12 volumes), Vol. I-XII, paperback edition edited by Wilhelm Weischedel (1974), Suhrkamp

Kraepelin, Emil: Psychiatrie – Ein Lehrbuch für Studierende und Aerzte (1899),

6. Auflage, Nachdruck: Arts & Boewe, Nijemegen

Mäser, O. (Othmar): Eine Untersuchung über das Erkennen in der Psychiatrie in Bezug auf Immanuel Kant, Fundamenta Psychiatrica, 1994; Bd. 8, S. 65-73,

F. K. Schattauer Verlagsgesellschaft mbH

Pinel, Philippe: Philosophisch-medizinische Abhandlung über Geistesverirrungen oder Manie, aus dem Französischen übersetzt und mit Anmerkungen versehen von M. Wagner, Wien, Carl Schaumburg und Compagnie, 1901

Schott, Heinz, Tölle, Rainer: Geschichte der Psychiatrie – Krankheitslehren, Irrwege, Behandlungsformen, C. H. Beck, 2006

P1 refers to the Pinel citation in the Appendix Citations (page 856 ff.) – see also box with reference to page IV.

a More on the concept of conditio sine qua non in chapter 10 on the question of causality.

2 Diagnostics

This chapter contains the core of the book. The 2nd chapter Diagnostics is divided into parts A, B and C because of its large size. In these three parts, the root of knowledge is analyzed on the basis of the root citation1 and the consequences resulting from the basis of knowledge are shown and explained in detail. In particular, the Transcendental Deduction and its application to diagnostics in healing are explained, therefore most of the references of the book refer to the sections of this chapter.

Because this chapter has been kept largely abstract, it is possible to simply skim this chapter briefly at first, and then return to the individual sections later, via references from other chapters.

Content Diagnostics – Part A: The basic

2.1 Diagnostics is based on recognizing

20.1.1 Introduction to recognition

2.2 Diagnostics (definition)

2.3 Immanuel Kant recognized the great difference between the objects of knowledge

2.3.1 A diagnostic unit is either a factual unit or a systematic unit

20.3.1.1 In medical science, a diagnosis is recognized either by a factual unit or by a systematic unit

2.3.2 The difference in evidence results from the basis of knowledge

2.3.2.1 Apparent Evidence can be proven by Facts

2.3.2.2 Evidence that is plausible can be proven by arguments

2.4 Recognition moves either on the level of objects or on the level of ideas

2.4.1 Objects of cognition recognized at the level of objects

2.4.1.1 The object of cognition is recognized by an object

2.4.1.2 The object of cognition is recognized by the idea or by the schema of the idea – occurrence of problems in diagnostics

2.4.1.3 Objects of cognition that can be recognized by physical features but cannot be determined in a generally valid way – problems in physical diagnostics

2.4.1.4 When making a diagnosis, it is not always possible to unambiguously identify the physically tangible object of knowledge – rationally staged approach to diagnostics

2.4.1.5 Diagnostic borderline case

2.4.1.6 Plausibility – as a criterion in the diagnostic causality chain

2.4.2 Objects of cognition recognized at the level of ideas

2.4.2.1 Diagnoses that can be objectified secondarily

2.4.2.2 Diagnoses that cannot be objectified

2.4.2.3 Plausibility decides in case of different argumentation

2.4.2.4 What can be objectified in diagnostics?

2.5 In diagnostics, the degree of knowledge results from the features

2.6 Diagnostics is based on units (entities)

2.7 What is a diagnosis? (Definition)

2.7.1 In medical science, there are different diagnoses

2.7.2 A diagnostic unity is a factual unity or a systematic unity

2.7.3 Factual unity (factual diagnosis) – (definition)

2.7.3.1 The factual diagnosis in the narrower sense is recognized by the object

2.7.3.2 The factual diagnosis in the broader sense is recognized by the scheme of the idea

2.7.3.3 A factual diagnosis in the narrower sense is always recognized by belonging to a genus

2.7.3.4 A factual diagnosis in the broader sense is usually recognized by membership of a genus, but in borderline cases in relation to a type

2.7.3.5 Factual diagnosis in the narrower sense versus factual diagnosis in the broader sense

2.7.4 Systematic unity (definition)

2.7.4.1 A systematic unity is recognized in relation to a (defined) type

2.7.4.2 A phenomenological unity (phenomenological diagnosis) is recognized through the systematic unity

2.7.4.3 A phenomenological diagnosis is recognized in relation to the (defined) type

2.7.5 A type is not an independent diagnostic unity

2.7.5.1 A type is recognized dialectically in a defined system

2.7.5.2 A type is rationally recognized in psychiatric diagnostics

2.7.5.3 There are phenomenological diagnoses in a narrower and in a broader sense

2.7.5.4 A phenomenological diagnosis in the narrower sense is a syndromal diagnosis

2.7.5.5 The term syndrome should be avoided if the medical diagnosis is determined by medical facts

2.7.5.6 A functional diagnosis which is not physically verifiable is a phenomenological diagnosis in the narrower sense

2.7.5.7 A phenomenological diagnosis in the broader sense is further defined by physical characteristics

2.7.5.8 Phenomenological diagnosis in a broader sense versus factual diagnosis in a broader sense

 

2.1 Diagnostics is based on recognizing

Diagnostics is based on recognizing and strives to gain knowledge about the facts.

2.1.1 Introduction to recognition

In one of his early writings, Immanuel Kant describes how a hiker is walking in a mountain landscape in search of an inn and sees something from a distance that could possibly be the outline of a house. Because the hiker thinks that this contour could be the outline of a house, the imagination and thus the idea of a house arises in his consciousness. As he gets closer, the hiker notices a wispy plume of smoke rising from the top of the contour, and the closer he gets to the object, the more convinced he becomes that it is indeed a house, or that this is a house.

This example shows clearly how, when recognizing and thus diagnosing an initially unclear object, the recognizing person first develops a conception (idea) on the level of ideas, which in this example can ultimately be verified on the level of objects. Thus, in the consciousness of the recognizing person a conception (idea) develops, what it could be about, which in this example can actually be verified by the approach of the hiker – in the physical reality – by the sensual perceptions and the reflections. Thus, in this case, the imagination or the idea1 could be verified on the level of the objects and thus the initial diagnosis of suspicion could be verified, the objectification of the diagnosis of suspicion was thus possible in this case.

In many cases, this is also how a physician first arrives at an idea and thus at his or her idea of what might be involved in a given case when assessing a medical circumstance – for example, when assessing an injury. For example, when examining a patient who has suffered a back injury, the physician develops the idea and thus the suspected diagnosis that it could be a bony vertebral injury. If a vertebral fracture is indeed present, the physician can verify this idea of his, i.e. the tentative diagnosis, at the level of objects – thus at the level of facts – by means of the X-ray examination and thus objectify his findings in the given case.

It can be seen that in this case the cognition and thus the diagnosis can be determined in a generally valid way by the object or by the objective X-ray finding, because in relation to this object of cognition (the fracture or the sensually perceptible X-ray image) all judgments agree with each other.2

While in this sense in medical science in certain cases a tracing back of the idea1 (conception) to an object (objective finding) and thus objectification is possible, there are other cases in which this is not possible because the diagnosis is based, for example, on a symptom complex which cannot be traced back to an object and therefore cannot be verified in a generally valid way.

Elsewhere it is shown that such a cognition is based on an idea1 that has arisen empirically – i.e. on the basis of experience – but cannot be traced back to an object or to an objective finding. Immanuel Kant calls such an idea a mere idea3 (Chapter 2.17), which is discussed in detail elsewhere.

For example, if a patient reports recurrent unilateral headache, nausea, vomiting, and sensitivity to light, the physician usually cannot attribute this symptom complex to an object and thus cannot generally determine the diagnosis at the level of objects by an objective finding. As will be shown, in this case, as a consequence of the clinical phenomena (clinical apparence), the physician develops the idea that there is an underlying entity, in the sense of a unit of nature4 (Chapter 2.36), namely, the unit migraine, which causes this characteristic symptom complex. In this context, however, the physician cannot attribute this idea1of his, which arises in his consciousness as a result of the complaints described, to a factual unit (Chapter 2.7.3) and thus not to a factual cause; rather, it is the systematic unity1 (Chapter 2.7.4) (of the idea) that arises in the examiner's consciousness as a result of recognizing the characteristics of the health disorder under the concept1of the idea.

As it turns out, this idea or the concept of the idea is a concept (Chapter 2.24) through which the symptom complex is mentally grasped. In this case, then, the features of the clinical appearance are grasped by the idea, and because this is an idea that cannot be physically verified, it is a mere idea (Chapter 2.17) in the sense of Immanuel Kant. One can also say that in this case the symptom complex is recognized through the concept of the idea, which then appears as the systematic unity1,3 (Chapter 2.15.4) (of the idea) in the consciousness of the recognizing person when this person mentally grasps the characteristic features of the symptom complex through the schema1 (Chapter 2.15.2 and 2.15.3) of the idea1.

Thus, in this case, the recognizing person, namely the physician concerned with it, cannot just recognize the “whole as an idea”J1 (Karl Jaspers), as Jaspers recognized with regard to the mental phenomena on the basis of the philosophy of Immanuel Kant and pointed out in his book General PsychopathologyJ1, but in such a case the diagnostic unity and thus the concept of the idea is mentally grasped by an only problematically grounded3 unity, thus by a concept, and it can be subjectively validly determined the diagnosis on this way. The psychiatrist Eugen Bleuler, for example, believed that there is a natural unit of disease that produces the characteristic psychological symptom complex he described, which he called schizophrenia. As will be shown below, such a diagnostic unit-because it is a phenomenological unit recognized by the systematic unit1 (Chapter 2.7.4) (of the idea)-cannot be traced back to an object or to an objective finding and, on this basis, determined in a generally valid way.

Immanuel Kant shows in the Critique of Pure Reason that a part of our knowledge in this sense, although it arises on the basis of experience (thus empirically) and is usually sufficiently proven6 (in practice), cannot be verified at the touchstone of experience6. Thus, these empirically established units, which are the systematic units1,3 (of ideas) cannot be empirically physically (physical, physiologically, chemically, biochemically, biologically, imagingly, etc.) verified, precisely because they are based on an only problematically grounded3 unity.

In this sense, these systematic units are nothing else than concepts derived from experience, through which the respective clinical phenomena – arranged according to a system and thus – can be systematically grasped.

And as one can also easily see it is not possible to trace such an idea derived from experience back to an object or an objective finding and on this basis to determine it in a generally valid way, with which it is a question of a mere idea in the sense of Immanuel Kant, i.e. of empirical knowledge, which has come into being as the result of the sensory perceptions and the internal operations of our minds (internal Operations of our Minds)L1 in the sense of John Locke (1632-1704) (John Locke, Book II, Chapter I, p. 54). One can also say, in the words of David Hume (1711-1776), that this cognition arose as a complex idea (complex idea)H1 in the consciousness of the cognizing person, because he or she mentally conceived the state of affairs through the concept of the idea (David Hume, Book I, Part I, Section I, pp. 1-2). One thus recognizes that in such a case the concept1of the idea1 arises on the basis of the sense perceptions and through the rational considerations of the cognizing subject. But one can also say that this diagnostic entity has arisen on the basis of the understanding and the (pure) reason6of this person and therefore this cognition and thus this diagnosis has no direct relation to an object respectively to an objective finding.

So, while certain cognitions and thus certain diagnoses in this sense can be recognized objectively validly on the level of objects and thus on the level of facts and therefore can be determined generally validly, this is not possible with other cognitions, because these can only be recognized subjectively validly on the level of ideas with the help of the schemata1 of the ideas1 and therefore can only be determined subjectively validly, which will be discussed later.

At this point it should be noted that at the time of Immanuel Kant (1724-1804) the term psychiatry did not yet exist. It was only coined later by the physician and city physicist Johann Christian Reil (1759-1813). At the time of Immanuel

Kant, however, the term psychology did exist. In his writing: Kritik der reinen Vernunft (Critique of Pure Reason), Kant showed that psychological ideas8 just like cosmological and theological ideas – are transcendental ideas8.

This is relevant for medical science, because certain diagnostic ideas – like the ideas in theology and in cosmology – are transcendental ideas and such an idea refers to an object of knowledge which is only problematically grounded, i.e. to a transcendent or a transcendental object of knowledge. Because in medicine many a diagnostic unit refers to a transcendent or a transcendental object of knowledge, in such a case it is not possible to check these ideas physically (physical, physiologically, chemically, biochemically, biologically, imagingly etc.). Therefore, in the Critique of Pure Reason, the treatise on the transcendental ideas – and thus the treatise on the psychological ideas in the section Transcendental Dialectics: Of the Final Intention of Natural Dialectics is of fundamental importance for diagnostics in certain areas (Immanuel Kant, Collected Works in 12 Volumes, Vol. IV, p. 582 ff.).

Philosophically, one can say that in this book the transcendental deduction is applied to the diagnostics in psychiatry (psychology) and also to a part of medicine. Namely, with respect to this part of medicine, it can be shown through the philosophy of Immanuel Kant why certain diagnoses in medicine and all diagnoses in psychiatry cannot be objectified, precisely because these diagnoses are based on mere ideas (Chapter 2.17) or transcendental ideas. In this circumstance we find the deeper reason why research and science/neuroscience – especially in psychiatry and biological psychiatry – have been trying in vain for a long time to determine or validate certain findings physically (biologically).

2.2 Diagnostics (definition)

Diagnostics is the procedure that leads to the recognition of the diagnosis. In this process, the object of knowledge is more or less concretely recognized and determined by the diagnosis.

Thus, diagnostics is the method that leads to the recognition of the diagnosis in a field of knowledge and, accordingly, records the same or similar diagnostic units in a class or in a category. A distinction must be made between a diagnostic unit that is recognizable and determinable at the level of objects, usually in relation to a genus (Genus) (Chapter 2.27), and a diagnostic unit that is recognizable and determinable at the level of ideas, in relation to a defined type (Typus) (Chapter 2.28). Accordingly, the great difference1 between an object of cognition given to my reason1 as an object par excellence (object absolutely)1 or only as an object in the idea1 should be noted.

2.3 Immanuel Kant recognized the great difference between the objects of knowledge

Immanuel Kant writes:

It is a big difference whether something is given to my reason, as an object par excellence (object absolutely) or only as an object in the idea.

In the first case (Fig. 2.1a), my concepts go towards determining the object; in the second, it is really only a scheme, to which no object is directly added, not even hypothetically, but which only serves to present other objects, by means of the relation to this idea, according to their systematic unity, thus indirectly to us.1 (Fig. 2.1b).

Since far-reaching consequences result from the great difference between the objects of knowledge, this passage from the Critique of Pure Reason can be called a root quotation.

2.3.1 A diagnostic unit is either a factual unit or a systematic unit

A diagnostic unit is a factual unit if the object of knowledge is given as an object par excellence (object absolutely),1 thus as an object or as an object of knowledge determinable by facts. Or the diagnostic unit is a systematic unity1 if it is given only as an object in the idea1. In this case, the diagnostic unity is determined by mentally apprehending the features of the idea through the schema of the idea. Thus, in this case, the diagnostic unity is recognized by the concept1of the idea, which appears as the systematic unity1 (of the idea) in consciousness, if the features of the idea are mentally apprehended by the schema1 of the idea.

Fig. 2.1a/b: The big difference between objects of cognition

a) The object of knowledge is recognized on the level of objects as object par excellence (object absolutely) by the factual unity.

b) The object of cognition is recognized on the level of ideas only as an object in the idea.

In the second case (Figure b), then, the object of cognition is given only as an object in the idea, which appears as the concept of the idea as the systematic unity of the idea in one's consciousness, if one mentally grasps the features of the idea through the scheme of the idea.

In the former case, the object of cognition – and thus the diagnosis – can usually be determined objectively valid, i.e. generally valid. In the second case, the object of knowledge – and thus the diagnosis – can be recognized and determined only subjectively valid, because the recognition depends on one's own mental analysis and synthesis. One can also say: In this case the cognition and thus the diagnosis depends on the mental analysis and synthesis of the cognizing subject2 and is therefore only subjectively valid.

Viewed differently, one can say: As a consequence of the difference in the basis of knowledge, there are diagnoses that are based on an object or on facts and, on the other hand, diagnoses that are based on ideas1. Here, a diagnosis based on facts is usually recognized and determined by an experiential judgment19 with respect to the membership of a genus (Genus) (Chapter 2.27), whereas a diagnosis determined by the defined type (Typus) (Chapter 2.28) is recognized and determined by a perceptual judgment19.

Conclusion 2a: Difference of the objects of knowledge

Immanuel Kant recognized the great difference of the objects of knowledge. Certain objects of knowledge are given as object par excellence (object absolutely) and thus actually as object or fact.

Other objects of cognition are given only as a concept of the idea and thus only as an object in the idea, which appears as a systematic unity of the idea in consciousness.

Conclusion 2b: The object of knowledge is recognized by the scheme of the idea

If the object of cognition is given only as an object in the idea, the concept of the idea appears as a systematic unity of the idea in consciousness when the features of the idea are mentally grasped by the schema of the idea.

2.3.1.1 In medical science, a diagnosis is recognized either by a factual unit or by a systematic unit

In medical science, a diagnosis is recognized either by a factual unity (Chapter 2.7.3), because one can recognize and determine the health disorder by factual features, or one recognizes it as a physician by the systematic unity1 (Chapter 2.7.4) of the idea1, which appears as the concept1of the idea in one's consciousness when the features of the idea are apprehended by the schema1of the idea1.