Abstract
Jaspers’ nosology is indebted to Immanuel Kant’s theory of knowledge. He drew the distinction of form and content from the Transcendental Analytic of Kant’s Critique of Pure Reason. The distinction is universal to all knowledge, including psychopathology. Individual experience is constituted by a form or category of the Understanding to give a determinate or knowable object classified into the generic type of a real disease entity. The application of form and content is limited by the boundaries of experience. Beyond this boundary are wholes whose conception requires Ideas of reason drawn from the Transcendental Dialectic. Wholes are regulated by Ideas of reason to give an object or schema of the Idea collected into ideal types of an ideal typical disease entity. Jaspers drew ideal types from Max Weber’s social theory. He anticipated that, as knowledge advanced, ideal typical disease entities would become real disease entities. By 1920, this had been the destiny of general paralysis as knowledge of its neuropathology, serology and microbiology emerged. As he presented the final edition of General Psychopathology in 1946, Jaspers was anticipating the transition of schizophrenia from ideal typical to real disease entity. Almost 70 years later, with knowledge of its aetiology still unclear, schizophrenia remains marooned as an ideal typical disease entity – still awaiting that crucial advance!
Keywords
Kant’s theory of knowledge
Kant has a hierarchical theory of knowledge: ‘just as the Understanding (Verstand) unifies the manifold in the object by means of concepts, so reason (Vernunft) unifies the manifold of concepts by means of Ideas’ (A644, B672). 1 Forms of the Understanding 2 constitute knowledge; but knowledge is constrained by the limits of experience (Walker, 1993, 2013). Beyond this limit, Ideas of reason regulate the search for knowledge: ‘transcendental Ideas never allow of any constitutive employment … (but), they have an excellent, and indeed indispensably necessary, regulative employment’ (A644, B672). Forms of the Understanding employed beyond the limits of experience is metaphysics – a ‘logic of illusion’ (A293, B349).
Metaphysics held an unending, though ambivalent, fascination for Kant. One task for Critique of Pure Reason was that metaphysics be ‘set upon the secure path of a science’ (Bxxiii). He found this to be impossible and his considered view of metaphysics is illustrated by the following three vignettes. He describes metaphysics as ‘building a tower which should reach to the heavens’. Although we have ‘the Idea within ourselves’, there are major problems with the ‘materials’ and the ‘plan’, we have insufficient material and can only construct a ‘dwelling-house’; and there is ‘a babel of tongues’ regarding the plan with each worker building ‘according to his own design’. The result is unfinished and competing towers (A707, B735). In the second vignette, Kant sees metaphysics as a lover to whom we feel fated so that: ‘we shall always return to metaphysics as to a beloved one with whom we have quarrelled’ (A850, B878). In the third vignette, from Dreams of a Spirit Seer (Träume eines Geistersehers), 1766, Kant is uncharacteristically crude and taps into his lifelong hypochondriasis, in later life concerned with gastric maladies. The ‘spirit seer’ is the mystic and visionary, Emmanuel Swedenborg. Kant is scathing about Swedenborg’s fantastic visions. Goerwitz, Kant’s prudish translator, offers ‘a free rendering of the German, the outspokenness of which is hardly bearable in English’. His sanitized conclusion is that: ‘visions and holy inspirations are simply caused by a disordered stomach’ (Kant, 1766/1900: 84). He kindly offers us the German original; my literal translation follows:
Wenn ein hypochondrischer Wind in den Eingeweiden tobt, so kommt es darauf an, welche Richtung er nimmt, geht er abwaerts, so wind daraus ein F…, steight er aber aufwaerts, so ist es eine Escheinung oder eine heilige Eingebung. When a hypochondriacal wind rages in the bowels, the end result depends upon which direction it takes; should it go down the result is a fart (ein Furz); should it go up the result is an apparition or a heavenly vision.
The three images illustrate Kant’s ambivalent view of metaphysics. Metaphysics is a tower we cannot complete, a lover with whom we cannot live but to whom we constantly return, and wind going the wrong way – a ‘fart’.
As constitutive knowledge, metaphysics is forever unfinished and competing; but as regulative Ideas of reason, metaphysics is very much alive: ‘though we cannot know these objects as things in themselves, we must yet be in a position to think them as things in themselves’ (Bxxvi). A regulative Idea ‘goes far beyond what experience or observation can verify … (and) serves to mark out the path towards systematic unity’ (A668, B696). The Idea is ‘an heuristic, not an ostensive concept’ (A671, B699).
Kants Ideenlehre (Kant’s Theory Of Ideas)
This forms the appendix to Psychologie der Weltanschauungen (The Psychology of World Views) (Jaspers, 1919). ‘Kant’s teaching on Ideas … is one of the most profound and illuminating insights in philosophy’ (Jaspers 1946/1963: 560n).
3
Jaspers reiterates Kant’s theory of knowledge: ‘knowledge springs from the combination of three faculties: sensibility, Understanding and reason … knowledge reaches only as far as experience reaches, that is, only to the extent that concepts can be fully realized in intuition’ (Jaspers, 1919: 465). Beyond this limit, forms of the Understanding no longer apply; we must look to Ideas of reason:
All objectivity consists of form and matter; each is impossible without the other. All our knowledge begins with intuition based on sensibility, becomes a concept because of Understanding and ends with Ideas because of reason. (p. 465) Ideas have no intuition of their own; they relate to the Understanding and only through the Understanding to intuition. (p. 467)
If we mistake Ideas of reason for forms of the Understanding, we become ‘entangled in paralogisms or logical fallacies … antinomies … or we employ fallacious arguments which draw conclusions about the existence of an object from the nature of a concept’ (pp. 465–6). An example is the ontological argument in which God’s existence is inferred from the concept ‘God’; this is the negative, constitutive meaning of Ideas of reason. But Ideas of reason feed back into experience as heuristic models directing the search for knowledge; this is the positive, regulative meaning of Ideas of reason.
Table 1 spells out the differences between the constitutive employment of forms of the Understanding as they apply to experience, and the regulative employment of Ideas of reason as they extend beyond experience and regulate the search for knowledge. Forms of the Understanding offer ‘precise, definite knowledge’, but such knowledge is a ‘chaos’ or ‘mere aggregate’; it is knowledge but not yet science. Ideas of reason offer ‘systematic unity’ (Jaspers, 1919: 466). For Kant, it is ‘systematic unity’ which ‘raises ordinary knowledge to the rank of science’ (A832, B860). In his monograph Kant, Jaspers again spells out the nature and function of regulative Ideas (Jaspers, 1957/1962: 282; my bullet points):
Ideas give us the rules by which our knowledge advances; they do not give us the object of the Idea;
Ideas are regulative principles by which knowledge progresses; they are not constitutive principles by means of which an object is constructed;
the immanent employment of Ideas is essential to the systematic nature of scientific knowledge; the transcendental employment of Ideas is an illusion;
the schema is not fulfilled in intuition; the schema can only be fulfilled in the systematic progress of knowledge;
Ideas do not encounter an intuition which belongs to them; instead they encounter the Understanding which gives form to intuition by means of its categories;
in shaping content, categories cannot make the Idea into an object except as an analogy; such an incorrect use of the Ideas is indispensable to our thinking about objects; it is correct if we take it in this analogical sense, but, it is incorrect if we want to use Ideas to gain knowledge of objects.
(Jaspers, 1919: 468–9; I have broken up the passage)
Forms of the Understanding constitute knowledge; Ideas of reason regulate the search for knowledge.
The individual and the whole
There is tension between individual aspects of psychic life and psychic life as a whole. The Understanding is concerned with ‘the individual … conditioned … finite’; reason is concerned with ‘the whole … unconditioned … infinite’ (Jaspers, 1919: 465). Scientific research is concerned with individual phenomena from which it attempts to derive laws and causal theories. Only individual phenomena become objects of knowledge: ‘the whole cannot be known as an object; it is merely a means towards knowledge of the individual … the whole remains an Idea’ (Jaspers, 1946/1963: 28–9). The individual, conditioned and finite are constituted by forms or categories of the Understanding; the whole, unconditioned and infinite are regulated by Ideas of reason:
Ideas cannot be given in intuition because they refer to the whole while intuition is always only of the individual; Ideas refer to the unconditioned while all intuition is concerned only with the conditioned [in experience]; Ideas refer to the infinite while the content of our intuition is necessarily finite. (Jaspers, 1919: 465)
In General Psychopathology, Jaspers returns to the Kantian distinction between the individual we can know and the whole we cannot know:
Kant grasps and demonstrates brilliantly. When I want to grasp the whole, whether this be the world or the individual person, the object eludes me, because what I have in mind is not something particular, enclosed and finite but an Idea. What I get to know is never the world but only something in the world. The world itself is not an object but an Idea. If I mistakenly try to make statements about the world as an object, then I find myself enmeshed in insoluble antinomies. I may expand my knowledge in all directions in the world but the world itself I can never know. It is no different when it comes to man. He is as comprehensive as the world. He may become an object for me, but I can never know him as a whole. I know him only in particular ways and from particular points of view. (Jaspers, 1946/1963: 560)
Von der Wahrheit makes the same point: ‘everything we can know is in the world but we can never know the world. The world as a whole cannot become an object for us … The world is merely an Idea’ (Jaspers, 1947: 48).
Jaspers distinguishes ‘empirical wholes’ and the ‘encompassing whole’. Empirical wholes denote ‘psychic life as a whole’ (Jaspers, 1946/1963: 555). The encompassing (Umgreifende) is the central concept of Jaspers’ later philosophy: ‘the encompassing is either being that everything is … or it is being that we ourselves are’ (Jaspers, 1947: 47). The encompassing that we are denotes ‘human being as a whole’ (Jaspers, 1946/1963: 747). Empirical wholes are topics for science; the encompassing is the topic of philosophy. Jaspers sees three possibilities for the Idea of empirical whole: as disease entity in the science of nosology, body-psyche unity in the science of eidology, the whole course of a life in the science of biography. ‘All three approaches relate to the essence of what it is to be human … [but] at any time, just one of the three tends to stand in the foreground of our interest’ (Jaspers, 1946/1963: 557). Kraepelin stressed nosology; Kretschmer eidology; Jaspers takes them in turn.
The individual and the empirical whole are in a state of creative tension. Exclusive emphasis on individual elements leads to ‘a mosaic or kaleidoscope of dead fragments in which the colouring given to intuition by the whole is missing’. Exclusive emphasis on the whole takes the whole to be essential at the expense of lacking a ‘clear definition of concepts’ and an ‘exact analysis’. ‘Successful knowledge demands constant to-ing and fro-ing between elements and the whole.’ (pp. 555–6).
We cannot grasp the ‘whole’ as such. We are always thrown back on to the analysis of individual facts … We can never possess the whole. The nature of the whole must always remain an open question. The whole is always the Idea of the infinite. We cannot give an exhaustive meaning to the whole. The only way in which we can think of the whole is as the schema of an Idea … We are making a mistake if we try to make the whole into a fixed and definable object. (p. 555)
The individual, conditioned and finite are constituted by the forms of the Understanding; the whole, unconditioned and infinite are regulated by Ideas of reason:
individual → form of the Understanding
whole → Idea of reason
Determinate object and object of the Idea
Drawing on Kant’s theory of knowledge, Jaspers distinguishes the ‘determinate object’ (erkennbare Gegenstandsein) – literally, ‘knowable object’ – and the ‘object of the Idea’ (Gegenstand der Idee). The determinate object is the product of a content of intuition or experience and a form of the Understanding; the result is an object we can know. Both Kant and Jaspers refer to the ‘object of the Idea’ while acknowledging that Ideas cannot have an object. Both refer to the attempt to give the Idea an object as ‘hypostasis’ (Hypostasierung). Hypostasis is ‘the fundamental error: the transformation of Ideas into entities’ (Jaspers, 1919: 469; 1946/1963: 652). Both prefer ‘schema of the Idea’ although both continue to write of ‘object of the Idea’ (A674, B702; Jaspers, 1919: 469; 1946/1963: 560; 1957/1962: 282). For Jaspers: ‘Ideas find their rightful place as schemata which Kant characterizes in various ways as having an heuristic function or as having an existence “as if” they were objects’ (Jaspers, 1919: 469). He goes on:
If I cannot know the whole as an Idea, I can get closer to it, in Kant’s words, through the schema of the Idea. Schemata are types I sketch out. They are false if I treat them as reality or as theories of what underlies this reality, but they are true as a methodological aid that can be endlessly changed and corrected. (Jaspers, 1946/1963: 560)
For Kant, Ideas are an ‘heuristic fiction’, but they are more than a ‘mere fiction of the brain’ (A771, B799; A314, B371). Jaspers (1919: 481; 1957/1962: 283) finds three ‘meanings’ of Ideas of reason:
Methodological meaning: the Idea is ‘a schematic figure … an heuristic fiction’.
Subjective or psychological meaning: the Idea is ‘a force, a germ, a process in the mind of the scientist pointing him towards knowledge’.
Objective or metaphysical meaning: the Idea offers ‘systematic unity … a consonance with nature’.
Jaspers gives the example of a ‘vertebrate’. We do not ask: is the Idea of a vertebrate true or false? We ask: is the schema useful? Does it clarify the meaning of our terminology? Does it help us classify the animal kingdom? Does it correspond to something real? Does the Idea offer systematic unity? Is the Idea consonant with nature? The Idea is a fiction; it has a ‘methodological or technical meaning’, an ‘as if’ quality; it is a model or methodological tool. The three meanings are distinct but intimately related (Jaspers, 1919: 480–1; 1957/1962: 283).
The Idea offers an idealized picture; it is a model or template with an heuristic function but no realization in experience. If we treat the Idea as having an object we claim to know – the constitutive use of Ideas – the result is illegitimate. In contrast, in the regulative use of Ideas, an object has an ‘as if’ character; it makes no claim to knowledge, but it has a necessary heuristic function in the search for knowledge. The Idea ‘goes far beyond what experience or observation can verify; and though not itself determining anything, yet serves to mark out the path towards systematic unity’ (A668, B696). The Idea is an heuristic, not an ostensive concept; there can be no true object of the Idea, merely a schema of the Idea. In his Philosophie, Jaspers spells out the role of Ideas in the advancement of knowledge:
Ideas cannot be verified directly. Instead, their verification is indirect in terms of their fertility in advancing our knowledge. Such advances are expressed as schemata and principles in the shape of provisional classifications at every step in our knowledge. We are aware of them as metaphors and images behind which they are concealed; they have no representation in the world … They can never become an object in the world. They spur on and set the limits to our knowledge of world orientation although they are not in themselves an element of that knowledge. (Jaspers, 1932/1969, Vol 1: 141)
Based on forms of the Understanding, the determinate object is ‘fulfilled in intuition … precisely defined … given … definite … provides us with an individual object of experience … results in objectivity’. It is classified within a generic type. In contrast, the ‘object’ of an Idea of reason is ‘not fulfilled in intuition … extends beyond every conceivable boundary … is set us as a task … is indefinite … provides us with a unity of experience … points toward totality’ (Jaspers, 1919: 468–9; 1946/1963: 560). The determinate object relates to the individual; the object of the Idea relates to the whole.
As examples of Ideas, Kant gives ‘pure earth, pure water, pure air’ (A646, B674). These have not proved to be of enduring fertility. In contrast, his Ideas of nature versus nurture and evolution have been of enduring fertility (Kant rejected evolution). Jaspers gives the Ideas of a totality of all the senses and the Periodic Table (Jaspers, 1932/1969, Vol. 1: 141). His first example has no consonance with nature, but the Periodic Table remains an important model. The Idea is a model or schematic figure against which to compare real earth, vertebrates and chemical elements to assess the extent to which the real object conforms to the pure construct.
Schizophrenia has an identical status to vertebrates and the Periodic Table. Schizophrenia is not a determinate or knowable object; it is the schema of an Idea. We should not ask: is the Idea ‘schizophrenia’ true? Does it exist? Instead, we should challenge its utility as an Idea, its ability to clarify our terminology, to better comprehend the clinical data, its fertility as the germ of future knowledge, its fruitfulness in creating systematic unity. Schizophrenia is an heuristic, not an ostensive concept; it might or might not have a correlate in reality.
Forms of the Understanding constitute determinate objects from individual experience; Ideas of reason regulate wholes by means of schemata of an Idea:
individual → form of the Understanding → determinate or knowable object
whole → Idea of reason → object of the Idea
Generic type and ideal type
For Kant, the determinate object has a real existence in a real or generic type; the schema of the Idea has an ideal existence; it is an ‘ideal being’ which lacks any ‘determinate concept’ – it is the mere ‘analoga’ of a real object. What this ideal being offers is ‘empirical’ or ‘systematic unity’ which can ‘serve as a rule for the empirical employment of reason’ (A674–5, B702–3). In both structure and function Kant’s Idea as ‘ideal being’ is identical to Max Weber’s ideal type. Jaspers carries over Weber’s ideal types into his psychopathology (Jaspers, 1946/1963: 561n). For Weber (1904/1949: 90), ‘it is the task of historical research to establish for any individual case how near or how far reality is from this ideal construct’. The main account of the ideal type is in his 1904 paper on ‘Objectivity’ in Social Science:
An ideal type is formed through the one-sided accentuation of one or several points of view … views which are diffuse and discrete, more here, less there and sometimes absent … a unified thought construct (einheitliche Gedankenbild). In its conceptually pure form, this thought construct cannot be found empirically anywhere in reality. It is a utopia. It is the task of historical research to establish for any individual case how near or how far reality is from this ideal construct. (Weber, 1904/1949: 90)
In all editions of General Psychopathology, Jaspers makes the distinction between the real or generic type (Gattung) and the (ideal) type (Typus). In the first three editions, he writes: ‘keeping the concepts of illness group (Krankheitsgattung) and illness type (Krankheitstypus) separate is of considerable methodological importance’ (Jaspers, 1913: 268; 1920: 335; 1923: 372). In the fourth edition, this has subtly changed to: ‘the clear distinction of the generic type from the type is both essential and enlightening’ (Jaspers, 1946/1963: 560); see Table 2. Only in the fourth edition does Jaspers specifically link the determinate object with the generic type and the object or schema of the Idea with the ideal type by prefacing the distinction with: ‘I classify the determinate object into the generic type to which it belongs. I collect the object of the Idea into a typology’ (Jaspers, 1946/1963: 560). In this way, he links the generic type/ideal type distinction with Kant’s theory of knowledge – the generic type with the determinate object and forms of the Understanding; the ideal type with the object of the Idea and regulative Ideas of reason. ‘Ideas’ are peppered through Weber’s ‘Objectivity’ paper. He makes the same equation of Ideas and ideal types: ‘they run side by side and show a constant tendency to blur into one another (nebeneinander herlaufen und die stete Neigung zeigen, ineinander überzugehen)’ (Weber, 1904/1949: 99). Ideas and ideal types are two sides of the same coin.
(Jaspers, 1913: 268; 1920: 335; 1923: 372; 1946/1963: 560–1. Note that all editions are identical except that the first italicized sentences are present only in the 4th edition, and the final italicized sentence is omitted from the 4th edition.)
For the determinate object classified within a generic type, Jaspers gives general paralysis. A case either belongs or does not belong; a patient either has general paralysis or he does not. General paralysis has a clear definition like diabetes or coronary artery disease, and subsuming a case within the generic type offers a definitive diagnosis. There are real boundaries between one generic type and another, e.g. between general paralysis and other brain diseases. Generic types are defined by their pathology or aetiology: general paralysis by its specific histology (Nissl and Alzheimer), syphilitic aetiology (Wasserman), and the presence of the spirochaete, treponema pallidum, in brain tissue (Noguchi). Generic types create a classification. Each generic type has ‘its own symptomatology, course, cause and bodily findings such that no transitional states exist between them’ (Jaspers, 1946/ 1963: 564).
Turning to types, Jaspers asks ‘how do we arrive at types?’ He distinguishes average types and ideal types. An average type requires a large number of instances from which we establish the mean, but for an ideal type, ‘the experience of one or two individuals is sufficient’. This is because ideal types arise from the whole: ‘from pre-existing assumptions, I develop the causal or psychologically understandable consequences of a whole; this development is on the occasion of, not as a result of, experience’. For the object of the Idea collected into an ideal type Jaspers gives hysterical personality. The ideal type offers ‘a template against which we assess individual cases’ (Jaspers, 1946/1963: 560–1). It is a fictitious construct against which the individual case is measured, not a classification. Different cases will fit the construct impeccably, closely, moderately, barely or not at all. The type itself may be precisely defined, but boundaries between different types are fluid. There may be elements of several personality types; any individual may need to be assessed against several ideal types to exhaust all the possibilities.
In the first edition of Allgemeine Psychopathologie, Jaspers follows Weber closely: ideal types are unified thought constructs (Einheitsbildungen) … They are constructed on the basis of a small number of presuppositions given to us a priori … It is of the very essence of the ideal type that, in the first instance, it is of no empirical significance. It is merely a template against which we assess the individual case. (Jaspers, 1913: 270)
Again following Weber, ideal types are based on Evidenz. In the fourth edition, Jaspers expands on this: ‘the Evidenz for genetic understanding is something ultimate … All understanding psychology is built up from such experiences of Evidenz’ (Jaspers, 1946/1963: 303). Evidenz forms my ‘initial assumptions’, my intuitive grasp of understandable connectedness, of the way in which one psychic event links to another:
ideal types arise when, by starting out from these initial assumptions, I develop all their implications into a causally constructed and psychologically understandable type … The ideal type is not like a generic type; rather it is a template against which real cases can be assessed. (Jaspers, 1946/1963: 561)
For Weber, ‘the course [of human action] can be made directly understandable with an Evidenz which requires no proof’ (Weber, 1904/1949: 87). Evidenz lies at the root of Weber’s and Jaspers’ ideal type methodology; Evidenz is ‘the inner intuitability of the events of consciousness’ (p. 266, n.74).
Weber constructed a wide range of ideal types, the most notable being the ideal types of Protestant ethic and spirit of capitalism. He used these ideal types to show that the Protestant ethic of ascetic Calvinism – ideas of predestination of the soul to paradise or eternal torment on the basis of God’s arbitrary decision, independent of the beliefs or actions of the individual – was the seed-bed for the development of capitalism.
Jaspers instances ideal types of hysterical, hypochondriacal and self-insecure or sensitive personality, mania, depression, melancholia, catatonia and paranoia. Ideal types of personality have a ‘central trait’ (Grundzug) from which ‘all further features can be understandably deduced’. ‘Hysterical personalities see the need to appear to themselves and to others as more than they are and to experience more than they are capable of experiencing’; hypochondriacal personalities have ‘the fear of being ill, and the wish to be ill’; self-insecure, sensitive personalities have ‘a state of heightened sensitivity based on a reflective awareness of their own insufficiency’ (Jaspers, 1946/1963: 443–5). Jaspers elaborates the details beginning from these central traits. No patient needs to conform exactly to any one ideal type; several ideal types may be necessary to exhaust all the possibilities.
Turning to the affective disorders, Jaspers constructs ideal types of ‘pure mania’ and ‘pure depression’: ‘the symptom complexes of pure mania and depression seem to possess an unusually ‘natural’ character because of the way the individual features fit understandably together’. The task is to assess the degree to which each case fits the ideal type because ‘many cases do not correspond fully to the ideal type construct’. Jaspers calls such cases ‘mixed states’. The key question is: ‘what features are in fact present and how we should regard them?’ (Jaspers, 1946/1963: 596–7).
The determinate object is classified into a generic type; the object or schema of the Idea is collected into an ideal type.
individual → form of the Understanding → determinate or knowable object → generic type
whole → Idea of reason → object of the Idea → ideal type
Real disease entity and ideal typical disease entity
The nature of the disease entity is the crucial question such that Jaspers can write: ‘the central question is: what is this “something” of which these are the symptoms?’ (Jaspers, 1946/1963: 563). As he prepared the first edition of Allgemeine Psychopathologie (1913), discussion was raging over whether this “something” was a unitary psychosis (Einheitspsychose) within which all presentations could be subsumed, or whether there was a series of natural disease entities (natürliche Krankheitseinheiten). The problem for the thesis of a unitary psychosis is the diversity and multiplicity of presentations; the problem for the thesis of discrete natural disease entities is the transitional forms between disease entities. The result is a Kantian-style antinomy. An antinomy is a form of presentation in which compelling but contradictory statements are offered side by side; on the face of it, both cannot be true. Antinomic propositions extend beyond any possibility of experience. As determinate objects at the level of the Understanding, the propositions are compelling but contradictory; as objects of an Idea at the level of reason, they are complementary. Kant presented four antinomies, as shown in Table 3.
Kant’s and Jaspers’ antimonies.
(aA426–52, B454–80; b Jaspers, 1946/1963: 564; my précis in both cases)
The Prolegomena (Kant, 1783), a précis of Critique of Pure Reason to clarify various misunderstandings, is Kant’s most accessible account of the antinomies. He writes: ‘the concepts we connect are mere Ideas which can by no means be given in experience’ (Kant, 1783/1997: 94). Of the first two antinomies, he continues ‘it is not possible to have experience of either an infinite space or infinitely flowing time, or of the bounding of the world by an empty space or an earlier, empty time; these are only Ideas’ (p. 96). As forms of knowledge, antinomies are false, but as Ideas of reason – as heuristic models – both can claim to be true. At the level of the Understanding, antinomies are contradictory, but, at the level of reason, they compliment each other in the search for knowledge.
The solution to Jaspers’ antinomy of unitary psychosis versus natural disease entities is the same as the solution to Kant’s antinomies. As determinate objects of knowledge at the level of the Understanding, unitary psychosis and natural disease entities are contradictory; they cannot co-exist but, as objects or schemata of an Idea at the level of reason, they are complementary in that both can serve in the search for knowledge. As in the quotation above: ‘the concepts … are mere Ideas which can by no means be given in experience’. At the level of the Understanding, there is neither unitary psychosis nor natural disease entities but, at the level of Ideas of reason, they are complementary; both are false as determinate objects but true as objects or schemata of an Idea. Neither constitute knowledge; however, both regulate the search for knowledge. In all editions of General Psychopathology, Jaspers spells out the conclusion of his antinomy:
The question we met at the beginning: are there only states and variants of a unitary psychosis or is there a series of disease entities which we can define? We can now answer this question: neither is true. The latter view is correct to the extent that the Idea of the disease entity is a fruitful point of orientation for research in psychiatry. The former view is correct to the extent that there are actually no real disease entities within the science of psychiatry. (Jaspers, 1913: 265; 1920: 331; 1923: 368; 1946/1963: 570)
Psychiatry has traditionally looked for disease entities on the model of physical diseases defined by their pathology. Jaspers offers a definition:
Genuine, natural disease entities are those disease entities which have the same cause, the same basic psychological form, the same development and course, the same outcome and the same brain findings – that is, they are disease entities for which the total picture is in agreement. (Jaspers, 1946/1963: 566)
Apart from specific brain diseases, the search for real disease entities in psychiatry has met with a unique lack of success. As Jaspers wrote, wild claims are made for the efficacy of brain anatomical research but results were disappointing. His conclusion is that: ‘such anatomical constructions have become completely fantastic (e.g. Meynert and Wernicke). They can correctly be described as ‘brain mythologies’ (Jaspers, 1946/1963: 18).
Having stressed Ideas leading on to ideal types of disease entities, Jaspers turns to Kahlbaum and Kraepelin, and the prospects and problems of real disease entities founded on the ‘total picture’, i.e. on the whole presentation and course of the illness. It was their aim to make definitive diagnoses from just such a total picture. For Jaspers, a total picture of all individual connections is impossible: ‘no real disease entity has been found by this approach. Science knows of no disease entity which satisfies the demands placed by this concept of a disease entity’ (Jaspers, 1946/1963: 567). In regard to schizophrenia and manic depressive illness, because ‘the causes and brain pathology are almost totally unknown, their definition emphasises differences in psychological form and clinical course (recovery or not)’. It was Kahlbaum and Kraepelin’s hope that diagnoses made from the whole presentation and course of the psychosis would lead on to knowledge of aetiology. But, Jaspers concludes: ‘the hope that characteristic groups found through the clinical observation of psychic phenomena, course and outcome would later be confirmed by brain pathology has not been fulfilled’. Kahlbaum and Kraepelin’s attempt to use the whole presentation and course of the psychosis in a ‘quest for real disease entities’ had been frustrated (Jaspers, 1946/1963: 568–9). Seventy years later, the same urges and the same frustrations remain.
For Jaspers, any emphasis on the ‘whole’ must entail Ideas of reason and ideal types. Kahlbaum and Kraepelin were seeking real disease entities; but, in truth, they were employing Ideas and creating ideal typical disease entities not real disease entities. In Jaspers’ view: ‘to have grasped Ideas was Kahlbaum’s contribution; to have brought them to fruition was Kraepelin’s’ (p. 570). But, was Kraepelin schooled in Kantian Ideas? He made no claims to be a philosopher. In his youth he joined a philosophical society headed by the philosopher, Richard Avenarius (Kraepelin, 1983/1987: 3). Avenarius was crudely positivist in the tradition of the physicist/philosopher, Ernst Mach. For Mach, the subject matter of science is sense experience alone, with abstract theory merely shorthand for sense experience. Avenarius’ most notable work was his two-volume, Kritik der reinen Erfahrung (Critique of Pure Experience), published in 1888 and 1890. It is difficult not to conclude that this was a parody of Kant’s Critique of Pure Reason, with sense experience replacing Kantian reason. It is unlikely that Kraepelin would have learned of Kantian Ideas from Avenarius. But, for Jaspers, Kraepelin as a systematizer, as opposed to a clinician merely listing symptoms, ‘makes use of ideal types instinctively but without being any the less objective’ (Jaspers, 1946/1963: 560).
Jaspers has three objections to attempts to employ the total picture for diagnosis. First: ‘we can only make a diagnosis from the total picture if we already have knowledge of the definition of the illness to be diagnosed; no clearly defined illnesses emerge from the total picture, only types which vary from case to case’. Second, ‘the same outcome is no proof of the same illness; the most diverse of brain diseases result in the same state of dementia’. Third, the total picture extends beyond the limits of experience and has ‘no end point’, and, as such, it entails Ideas of reason, not forms of the Understanding. The problem of employing the total picture is that: ‘the Idea of the disease entity can never be realized in any individual case’; the gain is that: ‘the Idea can indicate profitable paths for research and a valid orientation for individual empirical studies’ (Jaspers, 1946/1963: 569).
Jaspers concludes that the search for real disease entities has been a failure. General paralysis was the paradigm case, but its successful definition in the early years of the twentieth century gave little cause for hope because: ‘general paralysis is defined purely in terms of its neurology, brain histology and aetiology’ (p. 567). A diagnosis of general paralysis is compatible with any psychiatric presentation. Clinically, only the severity of mental deterioration marks it out from other brain syndromes. The diagnosis of general paralysis created problems. Prior to Wasserman’s serological test, Kraepelin estimated that 30% of his patients suffered from general paralysis; Wasserman’s test showed the true figure to be 8%. Jaspers applauds Kraepelin’s honesty in this (p. 568n). But, as he notes, if we struggle to diagnose clinically a disorder whose pathology we know, what hope is there for disorders of whose pathology we have no idea?
When Jaspers concludes that there can be ‘no disease entities apart from those based on purely neurological processes’, he means no ‘real’ disease entities (p. xxviii). In much of psychiatry, real disease entities based on determinate objects and classified into generic types are an impossibility. The only possibility is disease entities based on the object or schema of the Idea represented in ideal types, as regulative Ideas of reason, not constitutive forms of the Understanding. In all editions of Allgemeine Psychopathologie, the significance of Kantian Ideas for psychiatric diagnosis is as follows (Jaspers, 1913: 263–4; 1920: 328–9; 1923: 365–6; 1946/1963: 569–70; my bullet points):
the Idea of the disease entity can never be realized in any individual case …
the true reality of the Idea of the disease entity is an Idea in Kant’s sense …
the Idea of the disease entity is not a task which can be achieved but it does offer the most fruitful point of orientation …
error begins to creep in when, instead of the Idea as illumination, we take the Idea to be an achievement or when we take the concept of the disease entity to be a finished description as is the case with dementia praecox and manic depressive illness …
if the reader tries to grasp such a disease entity clearly and definitively then it just slips through his fingers.
From here, ‘research followed two distinct paths both of which begin from the Idea of the disease entity’. The first path was into brain research, the hope being that Ideas and ideal types of disorder would be replaced by definitive brain findings. General paralysis as the paradigm case threw up two problems. The first problem is that ‘brain research proceeds without reference to the clinic and without taking anything from psychopathology’. Only once brain changes have been found can ‘research pose the question to psychopathology of what psychic changes result from these brain processes’. The unfortunate answer in general paralysis is that brain pathology is compatible with any psychiatric symptom. The second problem is that the successful description of brain pathology means that ‘brain processes are taken to be the very essence of individual psychic illness’, the consequence being that ‘the concept of the disease entity shifts out of the domain of psychopathology into the realm of neurology’ (Jaspers, 1946/1963: 570–1). Such a development seemed imminent in schizophrenia but further away in manic depressive illness.
The second path, again beginning from the Idea of the disease entity, is the more careful definition of ideal types. Jaspers again commends Kraepelin even though his use of ideal types was instinctive, rather than explicit. Kraepelin began with the ‘whole clinical picture’, the task being to ‘give conceptual form to the original structure of the experience’. Jaspers concedes that Kraepelin could be ‘side-tracked into an endless mosaic of symptoms … [but] it was Kraepelin who dared to construct a typology and who doggedly pursued it’ (p. 572). Jaspers’ conclusion is that such a diagnostic schema will be based on Ideas and ideal types; but, ‘a classification based on Ideas can never be of more than provisional value’ (p. 506).
individual → form of the Understanding → determinate or knowable object → generic type → real disease entity, e.g. general paralysis
whole → Idea of reason → object of the Idea → ideal type → ideal typical disease entity, e.g. schizophrenia
A diagnostic schema
Jaspers asks: ‘what do we diagnose?’ He answers that we present symptoms, connections, syndromes and causal relationships ‘until the Idea of the disease entity gives to diagnosis its own special meaning, albeit a meaning which cannot be fulfilled’ (Jaspers, 1946/1963: 604). A diagnostic schema must serve three purposes (p. 604; my bullet points):
first, we want to see what knowledge can be achieved through use of the Idea of a disease entity as a total picture of those psychic illnesses which present to us;
second, all descriptions within psychiatry must be grounded in a classification of the psychoses; we have no way of ordering the data without such a schema;
third, we need a classification as a means to the statistical treatment of the major illnesses we encounter.
Jaspers makes stringent demands of a diagnostic schema (pp. 604–5; my bullet points):
the schema must be organized in such a way that any case is classified in just one place and every case is given a place;
the classification must be reliable so that different observers arrive at the same classification;
such a schema would only be possible if all psychic illness were divisible into generic types which are mutually exclusive and jointly exhaustive;
the schema must realize the Idea of the disease entity.
Jaspers acknowledges that such a diagnostic schema is only achievable if ‘we are prepared to forgo something at the outset. We must abandon the Idea of the disease entity in order to give preference to one of the following points of view: cause, psychological structure, anatomical findings, course and outcome’ (p. 605). This is a climb-down by Jaspers who has already admitted that: ‘the basic forms of psychological structure, theories of cause or aetiology and brain findings have not led to an acceptable concept of disease entity within which the psychoses can be subsumed’ (p. 566). The upshot is: ‘we set limits to the facts where no limits really exist; and, for this reason, the classification cannot be of more than provisional value’. Having dismissed a ‘natural system’ as an impossibility, the result will be a compromise: ‘a fiction which serves its purpose if it is the most appropriate classification for its time’ (p. 605).
Jaspers’ schema has three Groups which ‘are essentially different in that they lack a single overriding viewpoint from which a systematic classification could emerge; the viewpoint changes with each of the Groups’. Jaspers concedes that: ‘because, in no case, can the Idea of the disease entity be fulfilled, we must instead adopt a particular viewpoint that we find decisive’ (p. 610). Inevitably, the schema contains logical and material inconsistencies. The concept of illness differs in each Group, drawing on different aspects of Kant’s theory of knowledge; see Table 4. The result is a system of classification which is provisional and strained, and which, of necessity, allows for different possibilities. The whole exercise may be fruitless, but we have no alternative but to continue in the attempt to diagnose and classify.
Outline of a diagnostic schema (Jaspers, 1946/1963: 605–6).
Group 1 is composed of real disease entities classified in generic types drawing on Kant’s theory of form; these are ‘known somatic processes’ such that ‘the urge for real disease entities is satisfied by this Group’ (p. 606). Diagnosis is based on somatic factors. Exact diagnosis is possible; the illness is either general paralysis or it is not; there are no transitional states between disease and health. ‘Real diagnosis is possible and necessary only in Group 1. … in terms of generic disease groups to which cases either belong or not’ (p. 611). ‘The Kahlbaum-Kraepelinian Idea of a disease entity has been reduced to brain processes and somatic events and, with the concept of the Idea no longer in use, a single biological process with a definite cause is sufficient for us to conceive of a disease entity’ (p. 606). The possibility of real disease entities implies a major step toward a scientific nosology.
Group 2 contains three disease entities collected into ideal types drawing on Kant’s theory of Ideas – epilepsy, schizophrenia and manic depressive illness. In the 1940s, the majority of the inmates of mental institutions belonged to this Group, and epilepsy was still considered a functional psychosis. Group 2 disorders have three things in common: first and most important, ‘our conception begins from the Idea of a disease entity, thus offering an insight into psychological and biological reality as a whole’. In this, Group 2 disorders are ‘unlike Group 1. disease entities which are based on clear somatic phenomena’ (p. 607). Two further features distinguish Group 2: disorders are endogeneous rather than exogeneous psychoses, and the neuroanatomical findings which would demonstrate what is essential are lacking.
Group 2 diagnoses are based on psychological or clinical factors. In most cases, diagnosis is clear; there is a sharp boundary between disease and health, but the boundary between different illnesses is blurred. The illnesses of Group 2 are ‘unique in the whole of pathology’ because they differ from both the ‘organic, somatic illnesses’ of Group 1 and the ‘human variations’ of Group 3. They are ‘both somatic and psychic at the same time’. Jaspers contrasts ‘a process of crude organic destruction’ such as general paralysis in Group 1 with the more subtle changes of schizophrenia in Group 2: ‘in schizophrenia, the clockwork is not smashed to pieces as it is in general paralysis; instead, it is transformed in a strange and frightening way but the clock keeps ticking’ (pp. 607–8).
Group 3 emphasizes the myriad of human variation: ‘diagnosis shows the least agreement having lost itself in individual facts, mechanisms, states, characters, etc.’ (p. 609). ‘Cases are conceived as types and, depending on the point of view, many different types can occur together within the same case’ (p. 611). In Group 3, there is neither a clear boundary between illness and health, nor between the different types.
Diagnostic priority
The meaning of diagnosis varies in the three Groups so that ‘diagnosis can be definitive only in Group 1’. Only Group 1 offers ‘decisive knowledge … an exact conception’. Groups 2 and 3 ‘merely allow us the space to formulate further questions starting out from particular points of view’. In all branches of medicine, the hope is that the symptoms will come together into a single diagnosis. Where this is not the case, then the question is which symptoms have priority and which symptoms, such as neurotic symptoms in organic illnesses and schizophrenia, are secondary or accidental. Jaspers notes that: ‘phenomena which occur in Groups 2. and 3. also appear in Group 1. In such cases, these symptoms are either a reflection of the underlying process or they are of no importance’. The rule is that: ‘Group 1. always has diagnostic priority over Group 2., and Group 2. over Group 3.’ (Jaspers, 1946/1963: 611–12). Jaspers fills out his hierarchical model as follows:
We can illuminate the position using a model: the symptoms lie in levels, one on top of the other. At the top are neurotic symptoms (of psychasthenia or hysteria), then come manic depressive symptoms, then the process symptoms (of schizophrenia) and finally organic symptoms (both psychic and physical). The diagnosis is decided by the lowest level that can be achieved in the investigation of any individual case. (p. 612)
The effect of this is that ‘what, at first, appeared to be hysteria might prove to be multiple sclerosis, neurasthenia might prove to be general paralysis and depression might prove to be a schizophrenic process’ (p. 612).
There is a further difference. In Group 1, ‘diagnosis is just one moment taken from a whole life … just one individual fact within the comprehensive whole of a personality’ (p. 612). Evidence of brain dysfunction is sufficient to make the diagnosis. Diagnosis is at the level of the form of the Understanding, determinate object and generic type. In Group 2, diagnosis relates to the whole at the level of the object of the Idea and ideal type. Group 1 has priority, and it is Jaspers’ aim to convert the Ideas and ideal types of Group 2 into the conceptual forms and generic types of Group 1. In general paresis, we have enjoyed real success in converting heuristic Ideas into definitive knowledge, less success with schizophrenia and manic depressive illness, and little or no success with neuroses and personality disorders.
The career of a disease entity
Kantian Ideas are central to Jaspers’ concept of diagnosis. In their constitutive use to create metaphysical knowledge, Ideas are a ‘logic of illusion’ (A293, B349); but, in their regulative use in the search for scientific knowledge, they are ‘indispensably necessary’ (Bxxvi). Following Weber, Ideas become ideal types: ‘I collect the object of the Idea into a typology’ (Jaspers, 1946/1963: 560).
Diagnosis of Group 2 disorders is based on the whole clinical presentation, and ‘any attempt to contract this whole to a single phenomenon, whether somatic or psychological, will invalidate our conception of the whole’. Wholes cannot be determinate objects of knowledge becoming generic types; they are objects of an Idea becoming ideal types, so that: ‘investigation of these illnesses stays close to the Idea of a disease entity’ (p. 607). In contrast, Group 1 disease entities have been successfully reduced to empirically valid generic types and real disease entities; they are ‘generic disease entities to which a case belongs or not’ (p. 611).
In Group 2, research ‘starts out from the whole psychological-biological reality … Research in this area has remained close to the Idea of a disease entity’ (p. 607). The position of Group 2 is that: ‘we hope for generic disease groups but, because we know nothing definite about their cause or nature, we have to make do with types’ (p. 611). Little has changed; schizophrenia still remains in Group 2: a regulative Idea and ideal type, not a generic type and real disease entity because:
the Idea of schizophrenia can never be realized in any individual case …
the true reality of the Idea of schizophrenia is an Idea in Kant’s sense …
the Idea of schizophrenia is not a task which can be achieved but it does offer the most fruitful point of orientation …
error begins to creep in when, instead of the Idea as illumination, we take the Idea to be an achievement or when we take the concept of schizophrenia to be a finished description …
if the reader tries to grasp schizophrenia clearly and definitively then it just slips through his fingers. (adapted from pp. 569–70; original already cited)
In Kant’s terms, schizophrenia is ‘a mere Idea, a focus imaginarius’; it is a focus for empirical investigation, not a determinate object of knowledge. The concept serves to bring ‘the greatest possible unity combined with the greatest possible extension’ to the search for definitive knowledge (A644, B672).
Of Group 2 ideal typical disease entities, Jaspers concludes: ‘it is a reasonable assumption that many of these psychoses will prove to have a somatic basis which, one day, we will know’ (Jaspers, 1946/1963: 607). His aim was that Group 2 disorders are promoted as real disease entities into Group 1. He correctly inferred that the promotion of epilepsy was about to occur; and he thought schizophrenia’s promotion was imminent because ‘few psychiatrists are in any real doubt that cases within the realm of schizophrenia are somatic or brain illnesses’. This was despite conceding that: ‘in schizophrenia, claims of brain findings have frequently been made but such findings are non-specific and unconfirmed’ (p. 608). He thought the promotion of manic depressive illness would be delayed.
He considered heredity an essential causal factor of Group 2 disease entities: ‘but how heredity can fashion such a tangled diversity is not at all clear’. He goes on with commendable prescience: ‘we do not know what it is that is inherited, an individual gene or a combination of genes’ (p. 608).
Conclusion
The debt of Jaspers’ concept of disease entities to Kant’s theory of knowledge is evident. Forms of the Understanding constitute determinate objects of knowledge classified into generic typologies to become real disease entities of Group 1. In contrast, wholes are regulated by Ideas of reason as objects or schemata of an Idea collected into ideal types to become ideal typical disease entities of Group 2. Group 3 is a disparate collection of neuroses, abnormal reactions and personality abnormalities. Table 5 summarizes the differences.
Jaspers’ three groups of disorder.
It is a salutory exercise to examine what has happened to Group 2 disorders in the 70 years since the fourth edition of Allgemeine Psychopathologie. Epilepsy is no longer a Group 2 disorder and has moved out of psychiatry altogether. Despite Jaspers’ optimism, schizophrenia remains at the level of regulative Ideas/ideal types (as does manic depressive illness). Its aetiology remains poorly understood. Neuroimaging offers pointers but is far from definitive. Heredity is a definite causal factor but the molecular genetics is indefinite. The pharmacological treatment is well researched, but biochemical abnormalities are proving elusive. There is a fairly sharp boundary between disease and health, but the interface between different psychoses remains problematic, and diagnosis remains based on psychological factors. For Jaspers, the ultimate aim was to promote the disorders of Group 2 into Group 1; to convert schemata of Ideas into empirically valid conceptual forms, ideal types into generic types, and ideal typical disease entities into real disease entities. There has been a wholly disappointing degree of progress; Group 2 disorders remain marooned at the level of heuristic Ideas and ideal types.