The Significance of Intuition for the Diagnosis of Schizophrenia

Alfred Kraus1

The current classification and diagnosis in psychiatry, as presented in the diagnostic manuals of DSM-IV and ICD-10, are based on operational criteria

1Department of Psychiatry, University of Heidelberg, Vosstrasse 4, 69115 Heidelberg, Germany and specific rules for use (so-called algorithms). To a large extent intuition is excluded from the diagnostic process. What is lost with the exclusion of intuition? Can we afford this loss [1]?

The intuition of the schizophrenic element is mainly identified with the praecox-feeling. Minkowski's [2] ''diagnostique par penetration'' and Tellenbach's [3] ''atmospheric diagnosis'' are also intuitive approaches to the essence of the schizophrenic element. After Rümke [4] described the praecox-feeling referring to dementia praecox, Wyrsch [5] further analysed this intuitive recognition of the schizophrenic person. He recognized that it is based neither only on signs such as facial or gestural expressions or a bad emotional contact, nor only on an impairment of understanding other people's motives. According to Wyrsch, the praecox-feeling has nothing to do with symptoms or other single features, but rather with a certain modality of being (''Eine Daseinsweise''), a certain way of ''being in the world and taking part in it''. What Wyrsch explicitly asserted, that this intuitive recognition is no ''guessing and presuming'' but ''really recognition'', is decisive in this context. Also according to Müller-Suur [6] the intuitive perception of the schizophrenic element is not the perception of something vague, but of a ''definite incomprehensibility'' (''ein bestimmtes Unverstandliches''). It is in our opinion a relatively definite changed form of being-in-the-world (''In-der-Welt-sein'') with an order of its own. What is incomprehensible, but intuitively perceived as something well defined, are certain basic structures of our being which have changed, as for instance the temporality and spatiality of being, the being with others, etc. — in short the ontolog-ical status of the person. Because these structures are not concrete, but are constituting objectivity (Gegenstandlichkeit), they are called prepredicative structures.

We want to show this first with the hallucinations of schizophrenic patients. The schizophrenic patient does not experience hallucination as a normal perception: (a) his hallucination is like an event on another stage, not in the world, but in front of it [7], that means not participating in the field of normal perception; (b) the person concerned is at the mercy of this perception not only because the hallucinated voice is coming from everywhere, but also because his body scheme [8] has changed (the perceived voice reaches the centre of the person, while the activity of the ego is blocked, and it is really impossible to objectify it); (c) schizophrenic hallucination is like a revelation, stirring up the whole being of the person. The intuitive diagnosis of hallucination is not made because this kind of perception has no real object, as the operational definition of the ''Arbeitsgemeinschaft fur Methodik und dokumentation in der Psychiatrie'' (AMDP) says, but because the quality of this kind of perception is, as we have shown, different and cannot be compared with normal perception. Therefore,

Steffens and Graham [9] recently proposed not to conceive schizophrenic hallucination as a perceptive disturbance at all, but as a disturbance of active self-consciousness.

Delusion is another example showing the significance of intuition in the diagnostics of schizophrenia, intuition here also recognizing a change of prepredicative structures. As to DSM-IV, delusions are erroneous beliefs. The difference between delusion and strongly held ideas is seen only in the degree of conviction with which the belief is held, despite clear contradictory evidence. But can superstitious and fanatical people not also keep up erroneous beliefs with a similar strong opposition against contradictory evidence? What really enables us to diagnose a delusion is not only the assessment of lack of insight, abnormality of certainty and incorrectibility [10] in connection with a wrong judgement of reality, not statements of the patient about facts, but his totally different kind of relationship to reality and to others. What the intuition of delusion recognizes, is not an alteration of cognitive function, but a change of the personality of the patient and his relationship to the world, as Jaspers already stated [10]. The whole ontological status of the patient has changed. Thus, it is this intuitively grasped, changed self of the patient and his changed relationship to the world which gives his abnormal certainty or lack of insight a special quality, and makes it a real criterion of delusion.

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