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Abstract
Since its beginnings psychiatry controversely debated about the appropriate concept of illness, about nosology and the diagnostic terms and procedures based upon it. This paper discusses the approaches introduced by Emil Kraepelin (1856–1926), Karl Jaspers (1883–1969) and Arthur Kronfeld (1886–1941). Whereas Kraepelin postulated the existence of «natural entities» with regard to mental illness, Jaspers acknowledged the heuristic value of the term «disease entity», but declared it a «regulative idea» in a Kantian sense, i.e. an appropriate and useful, albeit never fully achievable aim. Kronfeld, in a way situated «between» Kraepelin and Jaspers, defended the notion of disease entities. However, he spoke clearly against primarily anchoring these entities in neighbouring scientific fields like neurobiology or social sciences. Psychiatry should stay (or become) «autological», in the first place using the psychological perspective. In full respect for neighbouring approaches as scientific fields in their own right, he rejected their premature transfer to mental phenomena as «heterological», i.e. as unduly narrowing down the scope of psychiatry. These issues, up to debate 100 years ago, still are of utmost relevance for psychiatry in the 21st century, a field struggling with its rather fragile scientific identity.
Disclosure statement
No potential conflict of interest was reported by the author.
Notes
1 This in no way implies that other scientific perspectives are less important for psychiatry, e.g. neurosciences, social sciences, or descriptive psychopathology. However, they necessarily depend on the above mentioned «core» to be fully effective for the psychiatric field.
2 This description refers to high-income countries, whereas in other parts of the world there are much more fundamental problems, such as a drastic lack of all resources or even the complete absence of psychiatric care.
3 The most radical position is represented by «eliminative materialism» (Churchland, Citation1986) that rejected outright the existence of anything but material, in our context: of neurobiological, phenomena, thus regarding the notions of subjectivity or personal autonomy as illusionary. Romero et al. (Citation2022) recently published a comprehensive overview of the different varieties of materialism.
4 This can also be seen on a linguistic level, for example regarding the translation of the German term «Krankheit» into one of the English terms «disease», «illness» or «disorder».
5 However, «to stumble» may well have positive connotations: An impressive example is the «Stumbling Stones-Project» initiated by the artist Gunter Demnig in 1992. It commemorates individual victims of National Socialist tyranny in over 20 European countries, including Switzerland, with small memorial plaques visibly and tangibly set into public ground and labelled with information on a single person (www.stolpersteine.eu).
6 In the German language, the term «Psychiatrie» itself was introduced by the physician Johann Christian Reil (1759–1813) in 1808 (his spelling being «Psychiaterie»).
7 «To reify» or, in substantive form, «reification» refer to the Latin «res» for «thing» or «object».
8 At the beginning of the 20th century, a scientific controversy had developed between Alfred Erich Hoche and Emil Kraepelin on this very issue. In some respects, it anticipated the present debate about «denosologisation» and «transdiagnostics» which will be addressed later in this paper. Hoche had criticised Kraepelin’s strong, in today’s terms: «reifying», concept of illness as scientifically premature. He called for psychiatric research to stay at the syndrome level at least for the time being (Hoche, Citation1912).
9 In the present context, the focus is on Kraepelin’s concept of psychiatry as a medical science and its consequences for nosology in particular. Other essential aspects of his work, such as its social and political connotations and the role of degeneration theory, cannot be addressed here. They are, however, regularly the subject of controversial debates in the literature (Becker & Hoff, Citation2024; Hoff Citation2008).
10 All quotes in German were translated by the present author.
11 The terms ‘somaticists’ and ‘psychicists’ are often used imprecisely or completely misunderstood. As the following quote in the text shows, Kraepelin also took a simplifying view. The ‘somaticists’, e.g. Maximilian Jacobi (1775–1858), did not defend a strict materialism. Rather, they saw the psychic realm, the ‘soul’, as something divine that could not fall ill. Therefore, supposed ‘mental’ illnesses always had to have a physical cause. The ‘psychicists’, on the other hand, e.g. Johann Christian August Heinroth (1773–1843), recognised the existence of mental illness sui generis, i.e. as an illness of the ‘soul’. It is obvious that the two schools pursued markedly different therapeutic strategies.
12 As, for example, brought forward by Karl Bonhoeffer (1868–1957) and Alfred Erich Hoche (1865–1943) (Bonhoeffer, Citation1910; Hoche, Citation1912).
13 In the German language the term «Irresein», literally translated as «being mad», was a terminus technicus in medicine at the time, whereas today «irre» or, substantivised, «der/die Irre» are usually perceived as discriminatory and insulting expressions.
14 According to Vorländer (Citation1928), Kant originally regarded the line of thought in his «Critique of Practical Reason» (Kant, Citation1788) as a mere supplement, better: as a clarification, of questions already addressed in the «Critique of Pure Reason» (1781). However, he obviously refrained from fully integrating it into the revised 2nd edition of the «Critique of Pure Reason» (1787) and published his second critique as a separate volume.
15 This is exactly what «reification» of mental illness is all about.
16 The German term «Seele» used by Jaspers was translated as «psyche» because the literal translation «soul» is much more ambiguous.
17 The paragraph layout in this quote was added by PH for the sake of readability.
18 Nelson, as founder, and Kronfeld were among the driving forces behind a creative, if short-lived interprofessional working group that attempted to build on the philosophy of Jakob Friedrich Fries (1773–1843) at the beginning of the 20th century. Fries had explicitly understood his philosophical system as a further development of Kant’s thinking. However, critics argued that he had inadmissibly linked Kant’s transcendental philosophy with the empirical-psychological level (“psychologism”). This complex controversy, stimulating as it is for today’s debate, is analysed in detail in the cited work by Herrmann and Schwitzer (Citation2024).
19 Kronfeld’s term in German is «Eigencharaktere», which is not easy to translate. In my view, «intrinsic elements» comes closest to what he had in mind.
20 The «Marburg School» of Neo-Kantianism focussed strongly on scientific theory and mathematical-logical topics. Its main representative was Hermann Cohen (1842–1918). Leonard Nelson was much closer to this movement than to the competing «Southwestern German School» centred around Wilhelm Windelband (1848–1915) and Heinrich Rickert (1863–1936). They systematically emphasised the importance of values for the process of creating scientific knowledge.
21 In this context, Kronfeld often spoke of «laws» («Gesetze») or «regularities» («Gesetzmässigkeiten») of the psyche, as in the following quote on the psychiatric concept of illness. Moreover, he did recognise - in a complex sense that cannot be discussed further here - a «causality of the psyche» (cf. Hoff, Citation2023, pp. 83 ff.).
22 This addresses the risk of unnecessarily restricting a comprehensive person-centred scientific approach to mental phenomena by placing too much emphasis on «laws» and «regularities». This applies regardless of whether a mental illness is present or not. It is noteworthy that in his writings published from around 1925 (until his emigration), Kronfeld increasingly focussed on the psychotherapeutic perspective, especially on person-centred aspects such as the patient’s autonomy and «empowerment» («Stärkung») and addressed methodologically strict Neo-Kantianism less prominently. However, this should not be understood as a fundamental rejection of Neo-Kantianism as presented by the above mentioned Fries-Nelson-school. Rather, it impressively demonstrates Kronfeld’s decades-long struggle to reconcile the scientific approach aimed at generalisable knowledge on the one hand and consistent psychotherapeutic person-centredness on the other. For him, both approaches were indispensable for scientific psychiatry.
23 Anglo-Saxon literature aptly refers to this as «close reading» (Greenham, Citation2019).
24 However, the changeover from ICD-10 to ICD-11 in psychiatric care practice will require a transition period of several years.