Review

Psychopathology 2012;45:344–351 Received: September 30, 2011

Accepted after revision: February 9, 2012
DOI: 10.1159/000337968
Published online: July 31, 2012

Logic Structure of Clinical Judgment and

Its Relation to Medical and Psychiatric
Semiology
Carlos Rejón Altable

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Hospital Universitario de La Princesa, Madrid, España

Key Words Introduction

Clinical judgment ⴢ Clinical semiology ⴢ Psychopathology ⴢ
Clinical psychiatry ⴢ Clinical medicine Clinical judgment, as it was described by Feinstein in
a series of classic papers [1–7], consists of a sequential pro-
cess which leads from the input data of the patient’s man-
Abstract ifestation of disease to the output result of diagnostic en-
Background: The logical nature of clinical judgment has tities [4]. Of all the multifarious components proposed by
been conceptualized in different ways, but a clear connec- Feinstein, which encompass everything from the selec-
tion between the features of clinical judgment and those of tion and validation of manifestations to the construction
semiology is still lacking. Methods: The characteristics of of algorithms, I shall focus mainly on symptom identifi-
clinical judgment, medical semiology, and psychiatric semi- cation. Diagnosis begins with sign and symptom identi-
ology are described. Connections between them are drawn. fication and finishes in a putative disease, of course. But
Results: Clinical judgment is described as an abductive infer- naming some particular manifestation as a particular
ence. Abductive inferences are especially useful to balance sign or symptom is actually a ‘diagnosis’ itself [5], and the
universal and singular information. In psychiatric semiology, logic procedure which leads a clinician through symptom
due to some specific features, a careful balance between the diagnosis is the same type of logical inference found in a
information present in descriptive definitions and the infor- ‘syndrome diagnosis’, in spite of the obvious differences
mation absent from the definition but present in singular of input and output.
symptoms is needed. The main types of out-of-definition in- From now on, I shall consider clinical judgment as a
formation are reviewed. Conclusions: The implications of logical inference which leads from some empirical, par-
the results for diagnosis and research are drawn. ticular fact to some putatively suitable diagnosis. Early
Copyright © 2012 S. Karger AG, Basel contemporaneous work on the subject considered clini-
cal judgment an inductive, deductive or Bayesian infer-
ence [8–10] and even proposed for it a structure similar
to that of laboratory experiments [1]. However, it was also

© 2012 S. Karger AG, Basel Carlos Rejón Altable, MD, PhD

0254–4962/12/0456–0344$38.00/0 Hospital de Día, Hospital Universitario de La Princesa
Fax +41 61 306 12 34 C/Marqués de Ahumada 11
E-Mail [email protected] Accessible online at: ES–28028 Madrid (Spain)
www.karger.com www.karger.com/psp Tel. +34 917 131 990, ext. 50, E-Mail crejon @ hotmail.com
noted that some constraints which bound clinical judg- be understood as a compound of manifestation plus
ment did not easily fit these models [11–14]: clinical judg- name, raw material conceptualized within medical dis-
ment deals with single particulars for which some cate- course.
gory must be found (induction infers a general rule out
of several particulars and deduction needs the rule in
advance). It must balance general knowledge about dis- Peircean Characterization of Clinical Judgment
eases and its presentations with specific features of the
case. It faces ‘ill-structured problems’ where the present- Clinical Illustration 1
ing problem and the goal of reasoning process are not A 33-year-old woman entered the psychiatry ward
defined in advance. It follows a ‘known-effect-to-puta- room and exposed her complaint. She was suffering from
tive-cause’ reasoning direction, with different possibili- insomnia, which she attributed to the maintenance work
ties of interpretation of the empirical fact. Thus, a num- in her building and the heat of July in Madrid. She showed
ber of authors turned to another kind of logical inference no psychomotor disturbance or gross behavioral abnor-
called abduction [11, 13–14]. In the first part of this pa- malities. Both the staff and the trainee psychiatrists con-
per, I shall introduce a model of clinical judgment based sidered the expression of the complaint a little ‘over-emo-

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on abductive inference and then proceed to show that tional’ and her prompt denial of further symptomatology
this logical procedure is of particular significance for ‘a bit too prompt’. Her medical and psychiatric report of-
psychiatry, due to some characteristics of psychiatric se- fered no significant information. She received a prescrip-
miology. In a subsequent paper, I will employ this theo- tion and left the ward somewhat relieved. A number of
retical stance to examine some contradictions consis- questions arise: Which are the most common causes of
tently appearing in empirical work on the ‘continuity sleep disturbances in young women? Does this particular
model’ of hallucinations and delusions. disturbance show any specific pattern? Which other
In the sections dealing with clinical semiology, I shall symptoms are present or absent? Should any meaning be
draw upon some specific terminology which I must clar- accorded to the verbal and non-verbal expressive quali-
ify beforehand. It is common practice in clinical semiol- ties of her behavior? Which are the putative causes and
ogy to set apart symptoms and signs. Symptoms are con- consequences of the disorder? Is she reticent out of suspi-
sidered the subjective manifestation of disease and signs, ciousness? Is she just trying to get a benzodiazepine pre-
either spontaneous (jugular throb) or produced (Kernig’s scription?
sign), their objective counterpart. But both symptoms Schleifer and Vannatta [14] have proposed three ele-
and signs share a common relation to injury or dysfunc- ments as constituent to the epistemic core of clinical
tion. They both are caused by some anatomic or physi- judgment: first, some ‘knowledge base’, which comprises
ologic damage. Thus (the last and least in a long tradition the current body of empirical knowledge about symp-
which starts in Laënnec), I shall deal with symptoms and toms and disorders. It also includes descriptive defini-
signs as close relatives and call them signs altogether. tions of signs and symptoms, either operationalized or
Wherever distinctions are needed, I shall make them. not, demographic data concerning syndromes and perti-
But, either objective or subjective, manifestations of nent laboratory or neuroimaging results [5]. Following
disease are not (yet) signs. For something to be a sign of some science theorists, a frame theory or general theo-
something, some relation must be established between retical assumptions should be included as part of the
two elements in which element A stands for element B. knowledge base, as they are needed for any empirical data
This relation is called ‘code’, and this codification is cul- to be meaningful [15] (in clinical illustration 1, it might
turally, historically forged. There are no such things as consist of the statistically more likely causes of sleep dis-
‘natural signs’ in clinical semiology. ‘Raw’ features of dis- turbances in young women, plus the commonly co-pres-
ease should be considered ‘pre-sign’ or ‘pre-symptomatic’ ent symptoms or the incidence of major psychiatric dis-
material which becomes a sign only after the procedures orders in which insomnia is found). Second, clinical
which include them in medical discourse. Any medical judgment includes a method for hypothesis formation
sign, then, is the product of some putative biological dam- (the logic of diagnosis itself, which will be developed later;
age and some culturally achieved codification and not a it leads from this particular complaint to some general
mere relation between ‘natural features’ of the world. As disorder). And finally, it includes a reflection on the par-
stated above, a name is a label, a label is a diagnose [2]. ticular case in relation to the diagnostic possibilities
Thus, whenever I deal with medical signs, ‘sign’ should which arise from the conjunct work of the empirical/de-

Clinical Judgment Psychopathology 2012;45:344–351 345

scriptive/theoretical database and the logic of hypothesis some true kinship of ‘bedside experiments’ and labora-
formation (Is this diagnostic possibility the single most tory experiments, it may lie within the abductive infer-
likely, parsimonious and exhaustive one? Did I take into ence itself.
account all the information available?). Third, abductive inferences are kin to perceptual
The abductive logic of hypothesis formation, intro- judgments (those involved in ‘interpreting’ sense data)
duced by the American logician, philosopher and bona [16, 5.173]. Perception may be defined as psychic act, with
fide genius Charles Sanders Peirce, features three prop- a subject pole and an object pole, which picks up an ob-
erties. First, it is always rooted in a particular situation/ ject or quality among several within a spatiotemporal
symptom/case. Inference begins with a (yet) unex- frame; which is always perspectivistic and body cen-
plained/unexpected fact C (somebody complains about tered; and which allows identification (one among sev-
her mind being controlled by the government) and pro- eral other objects) and re-identification (in different
ceeds the following way: if hypothesis A (the patient suf- times) [17]. Perceptual judgments are actually consid-
fers from psychosis) were true, C would be explained/ ered by Peirce extreme cases of abductive inferences [16,
expected, so there is good reason to suspect that A is true 5.181], in which some balance is achieved between the
[16, 5.186]1. (Deductive inferences proceed just the other singular features of the object perceived and the features

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way round. Once a general hypothesis is proposed, we it must share with the rest of the members of its class. I
may anticipate some effect and confirm/discard it em- consider this connection to perceptual judgments of ut-
pirically. Inductive inferences are supposed to furnish most importance for clinical judgment, because it allows
some general rule concerning a number of putatively logical inference to balance the descriptive information
correlated particulars.) included in symptom definitions with a wealth of infor-
Second, it is ‘retroductive’. As Schleifer and Vannatta mation (contextual or expressive, for instance) which
[14] as well as Fischer [13] and Feinstein [5] state, hypoth- cannot be included in symptom definitions but which
esis in clinical judgment runs from the effect (speckles, play a crucial role in symptom eliciting. In clinical illus-
chest pain, unexplained abnormal behavior or experi- tration 1, clinicians must decide whether ‘promptness’
ence, insomnia) to putative causes (measles, angor pecto- and ‘disproportion’ deserve special attention or may be
ris, schizophrenia). In classical logic, this would be an dismissed. And, further, if they are better explained by
example of fallacious reasoning called fallacia consequen- the interview context, the insomnia itself, the reticence
tis, but this is the very feature called ‘retroduction’ by and suspiciousness of a deluded patient or just bad tem-
Peirce [16, 5.276, 6.479]. General abductive inference and per. Another non-clinical example on the abductive na-
common clinical practice is retroductive, as we always ture of perceptual judgments could consist of a ‘tree
come across some effect whose cause must be inferred naming’ exercise. In front of the same object, the lay ob-
(i.e., ‘extracted’) from the case. However, once one or sev- server would call it ‘tree’, a second, more seasoned ob-
eral hypotheses have been abducted from a single case, server ‘pine tree’, and an expert ‘Mediterranean pine
they should be tested to prove their predictive power and tree, roughly 20 years old’. The object is one and the same
their general pertinence [16, 6.470ff.] (‘If this is a psycho- for the three observers, but the balance between relevant
sis, she is likely to behave so and so, but if she has been and non-relevant information varies. The more experi-
exposed to heavy pre-electoral propaganda, maybe she is enced and skilled the observer is, the more reliable, valid,
just talking in metaphors.’ ‘If this pain is angor, then we and nuanced the judgments are.
will find either ECG/CPK abnormalities or both.’). And Fourth and last, abduction proceeds by colligating fea-
this test should proceed deductively and allow some pre- tures of facts present but as yet unattended in a new, cre-
diction going from cause to effect. ative fashion [16, 5.171, 5.581]. This synthetic-creative
Abduction, then, is common to both ‘diagnostic hy- side of logical inference explains why one and the same
pothesis’ and ‘experimental hypothesis’. Feinstein [1] series of behaviors or experiences may be considered
even conceptualized clinical judgment as a ‘bedside’ ex- ‘cyclothymia’ or ‘borderline personality disorder’ or ‘nor-
periment, formally analogous to laboratory experi- mal quick-temperedness’. The diagnostic (and semantic)
ments in spite of all the obvious differences. If there is weight accorded to a number of descriptive and non-de-
scriptive features colligated may lead to different results.
Hitherto, the similarities between the lay characteriza-
1
Peirce’s texts are quoted following academic usage with the number of tion of clinical judgment and its reconstruction as an ab-
the volume and the paragraph. ductive inference may seem instructing but of painfully

346 Psychopathology 2012;45:344–351 Rejón Altable

scholastic interest. Further deepening into the logic of ab- ceived antipsychotic medication. Eventually, the whole
ductive judgment will shed some light on the special dif- story proved true.
ficulties of symptom eliciting in psychiatry. Medical semiology is mainly characterized by the
connections drawn between two series of elements: the
observed/provoked bodily manifestations of disease
On the Mutual Aid between Clinical Judgment and (unilateral mydriasis/light arreactivity with spared ac-
Clinical Semiology commodation) and those of the subjacent injuries or dys-
functions. The link between them is considered causal
As far as mere abductive reasoning is concerned, I [18, 19], either known or (yet) unknown. I will call re-
have not yet presented any differences between medical lations between sign (remember: ‘manifestation plus
and psychiatric clinical judgment. But medical and psy- name’) and injury ‘vertical’. Medical signs also keep rela-
chiatric diagnostics are different, and the signs, symp- tions of mutual determination (I will call them ‘horizon-
toms, and syndromes abducted are different. I shall pre- tal’). The meaning of dullness in thoracic percussion
sent some differences concerning medical and psychiat- may be ‘edema’ or ‘fibrosis’ depending on the other
ric semiology and then proceed to show how they are symptoms present or absent: fever, dyspnea, cough.

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echoed in different kinds of abduction. Therefore, the meaning of any medical sign is deter-
A good introduction may be found in Feinstein [5]. mined by the subjacent injury/dysfunction which causes
Roughly put, clinical reasoning follows this path: first, manifestation and by the syndrome amidst which the
signs are identified; second, signs are referred to a do- sign is found and which reduces the polysemy of isolated
main [part of the body which is the source of the mani- signs [18].
festation (organ or system)] and to a disorder (abnormal- Psychiatric signs or symptoms have not established
ity in the structure or function of a domain); third, dis- these vertical, causal relations, although they do enter-
orders are referred to an underlying pathological process, tain horizontal syndromic relations. As I have shown
and fourth, diagnostic reasoning proceeds to pathoana- elsewhere [20], there is a good number of reasons for this
tomic entities and causal entities. lack of causal remission, but maybe the most straightfor-
Feinstein assures that psychiatry remains in the do- ward of them is the very biology of the brain. Several re-
main-disorder stage, ‘psyche’ being the domain and ma- views of the neuronal networks putatively involved in the
jor depression or schizophrenia the disorder. Feinstein’s physiopathology of the depressive disorder [21] or cogni-
view is of course debatable, and many psychiatrists tive deficit in schizophrenia [22] point to the same con-
would choose ‘brain’ as a domain and display their clusion: they are scattered over so many brain locations
knowledge of a wide array of anatomical or functional and they interact in so many ways that the very concept
findings. But the point I want to stress here is that there of correlation or remission should suffer a complete re-
is no pathway from signs to anatomic/functional/etio- furnishing to remain operative.
logic entities in psychiatry which could be considered A second key feature of psychiatric semiology is the
analogous to those of clinical medicine. In this section, relation between sign-type and sign-tokens. I will employ
I shall substantiate this peculiarity of psychiatry on the the term ‘sign-type’ as a ‘universal’ or ‘category name’
nature of its signs. synonymous to the descriptive definition of a sign: ‘hal-
lucination = perception without object’. Sign-tokens are
Clinical Illustration 2 any particular item which belongs to any category, i.e.,
‘I need help or I will kill myself.’ A 44-year-old Cauca- the particular hallucination, delusion, obsession found in
sian male entered the psychiatric ward room. He had concrete, individual, empirical patients.
come accompanied by his 70-year-old mother. He claimed According to Eco [23], type-token relationships belong
he was afraid of his mother plotting against him with her to two kinds: ratio facile (RF) and ratio difficile (RD). In
criminal colleagues. Reportedly, she was fresh out of pris- RF, every feature needed to characterize any token is in-
on and had resumed her drug dealing activities. He in- cluded in the descriptive definition of the type. In RD,
sisted his telephone was wired and that he was being fol- some extra information is needed.
lowed by the police as a suspected accomplice. He was In clinical medicine, relation between type and token
highly anxious, restless, barely slept, and ‘worst of all, no- is RF. Descriptive definitions of the sign include every
body believes me’. His mother belied her son’s story. He relevant feature of the token. In turn, these features may
was diagnosed with acute delusional disorder and re- be referred to their immediate causal processes.

Clinical Judgment Psychopathology 2012;45:344–351 347

 RD is well known by clinical psychiatrics, trainers other common symptoms, to either schizophrenia or ma-
and trainees. The difference between schizophrenic and nia; or thoracic dullness to either edema or fibrosis. The
melancholic delusion or depersonalization may be ob- absence of univocal relationship between symptom and
served and pointed out (and thus receive what is called injury allows different ways to gather disturbances in a
‘ostensive definition’), but it cannot be found in the de- coherent whole.
scriptive definition of delusion. It is also the case with In creative abductions, the rule must be found ex novo.
many other symptoms, such as true obsessions versus A quite unproblematic example could be the causal
schizophrenic and even autistic pseudo-obsessions. In weight of a random biographical event in a given clinical
this RD relation between types and tokens rests part of situation. It is very likely that similar circumstances will
the special importance of abductive reasoning in psy- be quite unique; therefore, no explanation provided will
chiatry. As causal vertical correlations are lacking, the make it into a law of general validity.
bulk of the work in clinical psychiatry does not consist Maybe less intuitive, notwithstanding its maximum
of finding signs (‘manifestation plus name’) which lead clinical importance, the process of symptom eliciting
to causal entities but in a meticulous, probing work with also consists of either hypocodified or creative abduction.
pre-symptomatic material in order to achieve consistent, As mentioned before, it is forceful for psychiatric signs to

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reliable, valid symptom labeling. In this task, the balance balance the information included in the descriptions of
between features included in a descriptive definition and the thesaurus and the information present in the case but
features excluded from it becomes crucial. In short, while absent from the descriptive definition. But these ‘not-in-
medical semiology consists of a thesaurus of signs whose definition’ characteristics of individual symptoms vary
descriptive definitions correlate with anatomical/func- from case to case. Ergo, the clinical judgment which iden-
tional damage, psychiatric semiology consists of a the- tifies some particular delusion cannot fix and codify the
saurus of signs and symptoms whose descriptive defini- rule abducted from this particular case. When some ab-
tions need to be completed in order to reach good ‘symp- normal behavior is again found, a new balance between
tom diagnosis’. the general features of the ‘sign type’ candidates and the
individual features of the empirical experience must be
achieved.
Different Signs, Different Judgments In clinical illustration 2, the patient’s speech acts and
behavior may be ‘abducted’ following different rules: Is
How are these different signs managed in clinical he delusional? And if so: mixed manic or anxious para-
judgment? Every clinical judgment is abductive, sure, but noid? Is he just afraid of his mother’s past deeds and thus
some species within the genre have been described. Um- overvaluing the chances of new criminal behavior? Is
berto Eco classified abductive judgments into three main everything just plain truth? As long as there is no ‘gold
categories: hypercodified, hypocodified, and creative standard test’ against which a hypothesis may be
(and added a subsidiary one, the meta-abductions, which checked, careful consideration of all kinds of semiotic
we will not analyze here) [24]. In hypercodified abduc- material available is crucial. This is, of course, a general
tions, there exists an inferential rule followed every time principle which affects differently the various items of
any given sign appears. The rule, then, becomes a code. the semiological psychiatric thesaurus. If we compare
Eco himself chooses medical signs as cogent examples: anterograde memory impairment (a more or less dis-
Kernig’s sign implies meningeal irritation. The rule is crete psychic function, with well-established anatomi-
well chosen if it leads from sign to damage, in other cal correlations) and hallucinations or delusions in Alz-
words, if the rule is mapped onto a causal relation. As heimer’s disease, we will get a nice, concise grasp of the
Feinstein [5] puts it, a sign ‘implies’ a damage, but a dam- differences.
age ‘causes’ a sign. The rule is valid as long as ‘causal’ and In the next paragraph, I shall advance a provisional
‘implication’ relations follow the same pathway in oppo- outline of the ‘not-in-definition’ information at work in
site directions. symptom eliciting. Of course, operationalized descrip-
In hypocodified abductions, the inferential rule must tive features play a definitive role here, too. But, for the
be selected from a number of equally pertinent options sake of space, I shall focus on non-codified material.
already known to the clinician. A common example
could be the need to ascribe a hallucination or a persecu-
tory delusion, present together with a limited number of

348 Psychopathology 2012;45:344–351 Rejón Altable

 ‘Not-in-Definition’ Material at Work: An Outline which have been bypassed, which may very well be the
core of the syndrome and whose characteristics are
Psychiatric sign-token contribution to the symptom worse understood, are modeled following other dis-
identification process consists of traits and features which eases, as is the case with analogies between poor in-
may be described but which vary between tokens. They sight and anosognosia.
‘individuate’ the symptom, then. These individuation (3) Patient’s biography and premorbid personality, which
conditions include: are classic contextual dimensions underlying concep-
– Extrinsic individuation conditions (EIC), such as time, tual dichotomies, such as ‘development versus pro-
space, and putative causal relations [25, 26]. I will pay cess’, ‘delusion versus delusion-like’.
no more attention to EIC, as they are quite straightfor- (4) The background network of meaning and knowledge
ward (‘this patient’s’ delusion, ‘which problem are we which supports any singular experience and without
talking about? The exhilaration following last cocaine which there can be nothing such as experience. It has
binge, which provoked mild paranoid ideation’). been analyzed by Husserl, Merleau-Ponty, Wittgen-
– Intensive individuation conditions (IIC), such as the stein, Waissmann or Searle (I will not enter into their
intensity, persistency, and frequency of the features in- differences here). Stanghellini [28] has fruitfully em-

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cluded in the sign-type definition and the balance be- ployed these concepts in his psychopathological anal-
tween them (as in differential diagnosis between so- ysis of common sense. Another good example could
matoform disorders and their delusional counter- be the differences between the obsessive or pseudo-
parts, based on the ‘intensity of conviction’). obsessive symptoms, seemingly all-pervading in psy-
– Contextual individuation conditions (CIC), such as: chiatric diseases. Are obsessions in obsessive-compul-
(1) Relations between the content of the utterance and the sive disorder, schizophrenia, schizotypal personality,
expressive qualities of the utterance, where expression Asperger’s syndrome, and major depressive disorders
works as a microcontext to content [27]. The utterance one and the same phenomenon? Patients with border-
‘I have never felt so sad in my life’ may change its line personality disorders often describe themselves as
meaning depending on the quality of the expression: ‘perfectionist’ or ‘obsessive’ just the same as obsessive
Irony (‘I’m really happy’); sarcasm (‘I always feel the personalities do. But what about the differences? Ob-
same, if you were a good therapist you would know’); sessive symptoms and obsessive traits in these condi-
need of care (as in histrionic personality disorders) or tions may be equaled if only a sort of ‘common mini-
plain melancholic but not anesthetic depression. Of mal verbal content’ is heeded. But the experience from
course, this does no belie the suffering of non-melan- which this content arises may be quite different: cogni-
cholic patients. But the relationship between content tive difficulties to manage changes in routines and
and expression may well isolate different phenomena familiar entourages as in Asperger’s syndrome, hyper-
which, if the content of the utterance was the only ma- reflexivity and loss of natural evidence as in schizo-
terial taken into account, would be grouped together, phrenia, misconstrued narrative identity and interior-
as it has been the unfortunate case with the final com- ized lack of external validation as in borderline per-
mon pathway of depression approach to mood disor- sonality disorders.
ders.
(2) Other symptoms present or absent, as it was advanced
above. Some behaviors and experiences may be con- ‘Not-in-Definition’ Material at Work – An Example
sidered as ‘apathy-avolition’ or ‘blunted affect’ de- (I): Evaluative Judgments and Clinical Criteria
pending partially on the co-present symptoms. Thus,
poorly known conditions may be bypassed or alto- The need of balance between definitional and ‘not-in-
gether ignored, as other, more easily recognizable definition’ material in the process of symptom identifica-
symptoms are preferred for diagnostic purposes. The tion is not only related to current operationalized glos-
risk of backlash is double: we may use hallucinations saries. It is deeply entrenched both in the basic features of
and delusions (less specific) to diagnose schizophrenia human experience, behavior, and speech and in the way
in spite of more specific but less readily identifiable psychopathology makes sense out of their derailment. I
symptoms (schizophrenic autism or hyperreflexivity have reviewed elsewhere the relations between human
or disturbances of ipseity). Thus, we face overinclusive experience and language and symptom individuation
categories. Then, these symptoms of schizophrenia [20]. But in the next two sections I shall stick to clinical

Clinical Judgment Psychopathology 2012;45:344–351 349

judgment and show how its abductive structure is needed soning styles. There is, then, good reason to set them
in order to handle the ‘not-in-definition’ material de- apart. But, in the outline of ‘out-of-definition’ material
scribed by Sadler and Fulford [29] and Stanghellini [30]. exposed above they were brought together again. Some
Sadler and Fulford [29] have discovered as many as CIC belong to clinical psychopathology, some to struc-
seven possible evaluative judgments necessarily made tural psychopathology. EIC involving causal relations be-
when applying DSM-IV-TR diagnostic criteria for per- long to clinical psychopathology, and IIC are essential to
sonality disorder. These judgments ‘nested’ in diagnostic grasp the descriptive features of descriptive psychopa-
acts are involved in determining whether a criterion is thology: if conviction is not ‘intense’ enough, then it is not
met, in other words, if token fits type. The seven judg- a convincing conviction.
ments proposed are: (1) ‘semantic-phenomenal matching’ These claims are not contradictory. Stanghellini ana-
(Does the patient’s phenomenal clinical presentation lyzes the dense, complex phenomena of abnormal human
match the criterion semantic content?); (2) ‘solicitation experience, language, and behavior. But, given the intrin-
choice’ (Which is the appropriate approach to the solicit- sic semiological characteristics of descriptive psychopa-
ing of data from the patient?); (3) ‘sociocultural context’ thology, some synthesis must be performed in order to
(Which cultural norms are relevant to a particular crite- reach full semanticity of signs and symptoms. As I have

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rion?); (4) ‘performance-context matching’ (Appraisal of shown elsewhere [20], the different species of psychopa-
the patient’s performance relevant to the sociocultural thology set apart by Stanghellini are forcefully needed to
norms in 3); (5) ‘deviance threshold’ (Is the patient’s devi- reach the minimal intelligibility of human experience,
ance from specific cultural norms substantive enough to language, and behavior encoded in the words ‘melan-
warrant meeting the criterion?); (6) threshold character- choly’ or delusion. As far as clinical judgment is con-
ization (Is the deviance threshold qualitative or quantita- cerned, I do believe abductive inference constitutes a
tive?), and (7) ‘disvalue characterization’ (Is the deviance good model of the formal mechanics needed to balance
related to the criterion ‘for the worse’?). the different approaches and scopes of clinical, descrip-
These judgments are considered normative warrant, tive or structural psychopathology and their different in-
for they involve one or more justifications for the norma- volvement in symptom eliciting.
tive elements involved in applying diagnostic criteria to
concrete patients. The series of judgments may be object-
ed to, and the ‘judgmental’ nature of some of them put Conclusions
into question. However, this paper provides a nice exam-
ple of the wealth of ‘not-in-definition’ information need- I have argued for two related theoretical issues. First,
ed to determine whether any criterion is met. that psychiatric clinical judgment is an abductive infer-
ence. Second, that abductive inference bears special sig-
nificance for psychiatric diagnosis, as it is the best way to
‘Not-in-Definition’ Material at Work – An Example (1) balance definitional and ‘not-in-definition’ informa-
(II): Clinical Judgment and the Threefold Division of tion and (2) deal with the cognitive and epistemic nature
Psychopathology of psychiatric semiology. Besides, I have outlined three
types of non-codified information, EIC, IIC, and CIC,
Stanghellini [30] has argued for a threefold division of which vary between individual signs but which are none-
psychopathology, comprising descriptive, clinical, and theless essential for symptom eliciting. Which conse-
structural psychopathology. Descriptive psychopatholo- quences are to be drawn?
gy (akin to the term ‘psychiatric semiology’ employed First and most important, descriptive definitions of
here) should provide accurate descriptions of signs and mental signs and symptoms must be ‘completed’ some
symptoms. It is considered the common language of psy- way or another during symptom eliciting. Clinicians are
chiatry, a tool which ensures communication in spite of trained to do so through repeated exposure to paradig-
theoretical differences. Clinical psychopathology choos- matic examples, although maybe in some less-explicit-
es signs and symptoms with (ideally) good reliability and than-desirable fashion. Non-clinicians psychometric in-
validity, for diagnostic purposes. And structural psycho- terviewers receive training too, but it is now commonly
pathology disentangles the many threads interwoven in admitted that supervision by experienced clinicians is a
human subjectivity. Each psychopathology fulfills differ- quality index of empirical research. But if no such control
ent roles, obeys different rules and employs different rea- is provided, as in online interviews or self-adscription

350 Psychopathology 2012;45:344–351 Rejón Altable

formularies, which information is fulfilling this role? ness, paranoia, and acute delusions? Recent empirical
And how? work seems to point in this direction [31]. Which is then
Second, the pragmatic constraints of research on hal- the cognitive structure of symptom categories? These
lucinations and delusions in non-clinical studies involve questions will be answered in a sequel paper that will
some loss of this kind of ‘out-of-definition’ descriptive draw on the theoretical model introduced here and will
information. May this lead to an over-inclusion of phe- apply it onto the extensive body of work dealing with con-
nomena? Are we grouping together phenomena with only tinuity models for hallucinations and delusions.
loose ‘family resemblance’, such as common suspicious-

References
1 Feinstein AR: Scientific methodology in 10 Suppes P: The logic of clinical judgment: 21 Meyberg H: Aplicaciones de la neuroimagen
clinical medicine I. Introduction, principles Bayesian and other approaches; in Engeld- en psiquiatría clínica. Madrid, Aula Médica
and concepts. Ann Int Med 1964; 61: 564– hardt HT, Spicker SF, Towers, B (eds): Clini- Ediciones, 2006.

Downloaded from http://karger.com/psp/article-pdf/45/6/344/3491008/000337968.pdf by guest on 12 February 2024

579. cal Judgment: A Critical Appraisal. Dor- 22 Zandio-Zorrilla M, Langarica-Eseverri E,
2 Feinstein AR: Scientific methodology in drech/Boston/London, D. Reidel Publish- García de Jalón E, Campos-Burgui MS, Per-
clinical medicine II. Classification of human ing, 1977, pp 145–160. alta Martín V, Cuesta-Zorita MJ: Alteracio-
disease by clinical behavior. Ann Int Med 11 Gatens-Robinson E: Clinical judgment and nes cognitivas en la esquizofrenia. Medicina
1964;61:757–781. the rationality of human sciences. J Med Phi- clínica Monografías (Barcelona) 2005; 6: 17–
3 Feinstein AR: Scientific methodology in los 1986;11:167–178. 26.
clinical medicine III. The evaluation of ther- 12 Greenblatt SH: Limits of knowledge and 23 Eco U: Tratado de semiótica general. Barce-
apeutic response. Ann Int Med 1964;61:944– knowledge of limits: an essay on clinical lona, Lumen, 2000.
965. judgment. J Med Philos 1980;5:22–29. 24 Eco U: Cuernos, cascos y zapatos: tres tipos
4 Feinstein AR: Scientific methodology in 13 Fischer HR: Abductive reasoning as a way of de abducción; in Eco U: Los límites de la in-
clinical medicine IV. Acquisition of clinical world making. Found Sci 2001;6:361–383. terpretación. Barcelona, Lumen, 2000, pp
data. Ann Int Med 1964;61:1162–1193. 14 Schleifer R, Vannatta J: The logic of diagnosis: 254–282.
5 Feinstein AR: An analysis of diagnostic rea- Peirce, literary narrative and the history of 25 Davidson D: Essays on Actions and Events.
soning I. The domains of clinical macrobiol- present illness. J Med Philos 2006;31:363–384. Oxford, Oxford University Press, 1980.
ogy. Yale J Biol Med 1973; 46:212–232. 15 Ramírez A: Inferencia abductiva y gener- 26 Strawson PF: Individuals: An Essay in De-
6 Feinstein AR: An analysis of diagnostic rea- ación de hipótesis. Revista de filosofía 2006; scriptive Metaphysics. London, Methuen,
soning II. The strategy of intermediate deci- 62:73–79. 1959.
sions. Yale J Biol Med 1973; 46:264–283. 16 Peirce CS: Collected Papers of Charles Sanders 27 Filkenstein D: La expresión y lo interno.
7 Feinstein AR: An analysis of diagnostic rea- Peirce, vols 1–8. Hartshorne C, Weiss P, Burks Oviedo, KRK, 2010.
soning III. The construction of clinical algo- AW (eds). Cambridge, The Belknap Press of 28 Stanghellini G: Psicopatologia del senso
rithms. Yale J Biol Med 1974; 1:5–32. Harvard University Press, 1935. commune. Milano, Raffaello Cortina Ed,
8 Pellegrino E: Anatomy of clinical judgment; 17 Gallagher S: Bodily self-awareness and ob- 2008.
in Engeldhardt HT, Spicker SF, Towers B ject-perception. Theoria et Historia Scien- 29 Sadler JZ, Fulford B: Normative warrant in
(eds): Clinical Judgment: A Critical Apprais- tiarum: International Journal for Interdisci- diagnostic criteria: the case of DSM-IV-TR
al. Dordrech/Boston/London, D. Reidel plinary Studies 2003;7:53–68. personality disorders. J Pers Disord 2006;20:
Publishing, 1977, pp 169–194. 18 Lantéri-Laura G: Recherches psychiatriques 170–180.
9 Scriven E: Clinical judgment; in Engeldhardt (III). Sur la sémiologie. Chilly-Mazarin, Edi- 30 Stanghellini G: A hermeneutic framework
HT, Spicker SF, Towers, B (eds): Clinical tons Sciences en Situation, 1994. for psychopathology. Psychopathology 2010;
Judgment: A Critical Appraisal. Dordrech/ 19 Lantéri-Laura G: La sémiologie psychi- 43:319–326.
Boston/London, D. Reidel Publishing, 1977, atrique: histoire et structure; in Fuentenebro 31 David AS: Why we need more debate on
pp 3–16. F, Huertas R, Valiente C (eds): Historia de la whether psychotic symptoms lie on a contin-
psiquiatría en Europa: Temas y tendencias. uum with normality. Psychol Med 2010; 40:
Madrid, Frenia, 2003, pp 211–229. 1959–1961.
20 Rejón Altable C: Concepción de la psicopa-
tología como lógica. Modos de configura-
ción del signo psiquiátrico. Madrid, UAM,
2009.

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