Diagnostic Reasoning in Psychiatry: Acknowledging an Explicit Role for Intersubjective Knowing

Four Core Concepts in Psychiatric Diagnosis

“…In other words, it requires what dual-process theories [81,82] describe as the two interrelated systems of human cognition, the intuitive and the analytic system [83]. The clinician needs to exert his/her intuitive system in order to grasp the contextual features (i.e., the Gestalt) of the clinical encounter, in order to generate the hypotheses (i.e., the ideal-type) that feed into the analytic approach and need to be tested by a hypothetico-deductive methodology [1].…”

“…They both point at a somatic disease, meant as a natural entity, with its causes, course, and prognosis. Diagnostic reasoning in somatic Medicine may be compared to completing a puzzle [1], by matching the information obtained from the patient with the evidence deriving from physical examination, laboratory investigations, and diagnostic imaging.…”

“…Conversely, in Psychiatry, symptoms and signs both involve a subjective component, since behavioral signs are meant as expressive, in so far as they point at a meaningful complex of emotional, cognitive, and bodily phenomena [2]. In recent years, several theoretical models have been developed to describe diagnostic thinking and clinical decision-making in Psychiatry [1,[3][4][5][6]. With few exceptions [1,4], most of them tend to reproduce a modified version of the medical model, where diagnosis is conceived as an individual, cognitive process aimed at categorizing the patient's problem according to some predefined diagnostic criteria.…”

“…In recent years, several theoretical models have been developed to describe diagnostic thinking and clinical decision-making in Psychiatry [1,[3][4][5][6]. With few exceptions [1,4], most of them tend to reproduce a modified version of the medical model, where diagnosis is conceived as an individual, cognitive process aimed at categorizing the patient's problem according to some predefined diagnostic criteria.…”

“…Our assumption is that the inherently ambiguous nature of the psychiatric object, suspended between empirical difficulties and problems of meaning [7,8], requires a "disciplined spontaneity" [9] to the clinician, a sort of epistemological and methodological turn, characterized by being more sensitive to the role played by subjectivity (of both the patient and the clinician) than to the objective approach of Medicine, more prone to understanding than to verifying and more person-centered than morbus-oriented [10]. For that purpose, we have identified 4 core concepts derived from the phenomenological literature, which we synthetically named (1) the "tightrope walking" attitude, (2) the "holistic experience," (3) the "co-construction of symptoms," and (4) the "evolving typification." Each of these concepts will be accompanied by an extract from a clinical case deriving from one of the author's most recent clinical experiences.…”