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Psychopathology

Psychopathology 2013;46:320329 DOI: 10.1159/000351837


Published online: July 11, 2013

Subjectivity and Schizophrenia: Another Look at Incomprehensibility and Treatment Nonadherence


Josef Parnas a, b Mads Gram Henriksen a, b
a

Psychiatric Center Hvidovre, and b Center for Subjectivity Research, University of Copenhagen, Copenhagen, Denmark

Key Words Schizophrenia Self Self-disorder Compliance Incomprehensibility Insight

Abstract Psychiatry is in a time of crisis. The absence of significant breakthroughs to actionable etiological knowledge has left the discipline in a state of uncertainty and worries are being voiced about its status and future. In our view, the stagnation can be, at least in part, ascribed to an excessive, behavioristoriented, epistemological, and ontological simplification of psychopathology. The aim of this phenomenological study is to articulate the notion of the disordered self in schizophrenia, a notion that we believe constitutes an important step forward in grasping its essential pathogenetic structures. Through the framework of self-disorders, we analyze two domains of the psychopathology of schizophrenia, seeking to recast their puzzling nature into more useful clinical and scientific terms. First, we examine the so-called schizophrenic incomprehensibility (bizarre gestalt, bizarre delusions, and crazy actions) and argue that grasping the altered framework for experiencing, associated with the disordered self, makes these phenomena appear comprehensible to a considerable extent. Second, we explore the issue of treatment noncompliance and provide a novel account of

poor insight into illness. We propose that poor insight into schizophrenia is not simply a problem of insufficient selfreflection due to psychological defenses or impaired metacognition, but rather that it is intrinsically expressive of the severity and nature of self-disorders. The instabilities of the first-person perspective throw the patient into a different, often quasisolipsistic, ontological-existential framework. We argue that interventions seeking to optimize the patients compliance might prove more efficient if they take the alterations of the patients ontological-existential framework into account. 2013 S. Karger AG, Basel

Introduction

Contemporary psychiatry suffers from a profound malaise, caused at least in part by the unfulfilled etiological promise of the operational revolution that took place over 30 years ago with the purpose of improving reliability of psychiatric diagnoses as a means to uncover their etiology [1]. There is an increasing awareness of the scarcity of truly novel, actionable etiological and therapeutic knowledge [24]. Worries are being voiced about the status and the future of our profession and about an apparent redundancy of academic psychiatry [5]. There are
Dr. J. Parnas Center for Subjectivity Research, University of Copenhagen Njalsgade 142 DK2300 Copenhagen (Denmark) E-Mail jpa@hum.ku.dk
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2013 S. Karger AG, Basel 02544962/13/04650320$38.00/0 E-Mail karger@karger.com www.karger.com/psp

various responses to this crisis. It is usually acknowledged that the complexity of the etiological task is far greater than originally assumed. Often, it is proposed that the stagnation is partly rooted in the very nature of diagnostic categories, reflecting commonsensical, sociohistorical constructs rather than really existing natural entities; consequently, such diagnoses are useless for etiological research. Such categorically dismissive proposals are usually formulated in a quite vague, indistinctively generalizing manner. It is instead suggested that research should focus elsewhere, such as domains of psychopathology (e.g. depression, reality distortion) [6], behavioral constructs with known neural bases (e.g. in the RDoC: negative and positive valence systems, arousal/regulatory systems) [7] or the so-called endophenotypes. Unfortunately, none of these responses reconsiders the epistemological behaviorist dogma dominating psychopathology as a potential cause of the stagnation. We believe that another partly related but perhaps even more important source of the current deadlock is the vast oversimplification of the ontology and epistemology of the object of psychiatry, which has taken place in the wake of the operational revolution [8]. It is certainly true that psychiatric diagnoses, constituted by an aggregate of social, experiential, behavioral, and temporal criteria, achieve a complexity that hardly can be matched by any coherent neurobiological or psychosocial entity. However, it can also be argued that the components of such diagnostic categories (symptoms and signs) have been simplified into banalities through commonsensical definitions, deprived of any overarching phenomenological framework, and insensitive to their qualitative diversity and heterogeneity (expressed, for example, in claims such as that auditory verbal hallucinations are shared by a multitude of psychiatric disorders [9] and widely prevalent among healthy people as well [10, 11]). Psychiatry confronts the so-called hard problem of consciousness [12]: phenomenal consciousness has no analog in the physical domain. There is an explanatory gap [13] between the levels of molecules, neurons, synapses and neural circuits and a sense of phenomenal awareness. Phenomenal consciousness exhibits a particular nature (a feeling of how is it like to be conscious of something) and a complexity (e.g. identity, rationality, and self-experience) that are unlike a spatial thing and therefore not straightforwardly reducible to the levels of hypothetically malfunctioning substrates. We believe that meaningful correlations between phenomenal and biological levels of the mind-brain system may only emerge if consciousness itself, its modus operandi, its disSubjectivity and Schizophrenia

tinctions, and basic structures are considered and studied as an explanandum in its own right, as philosophers of mind have recently emphasized [12, 14]. Indeed, without some idea of what the subjective character of experience is, we cannot know what is required of a physicalist [reductive] theory [15, p. 437]. Such study of subjectivity demands an adequately tailored epistemological framework. It is for this reason that Jaspers [16] emphasized the necessity of a comprehensive and general psychologicalphenomenological framework for any psychopathological enterprise. In the case of schizophrenia, we believe that etiological research would have a chance to fare better if the domain to be explained, the explanandum, was grasped at its fundamental phenomenal level, which is not that of advanced psychotic symptoms (e.g. expressed as positive and negative PANSS scores [17]), but rather the trait-like features, coined by Bleuler and others as fundamental symptoms and designated by Minkowski [18] as trouble gnrateur. The generative disorder of schizophrenia is conceived of as a basic disturbance of subjectivity or consciousness [19, 20]. It is a disorder of the structure of consciousness which lends the diagnostic specificity and a certain synchronic and diachronic gestaltic coherence to the quite polymorphic clinical picture of the illness [18, 21]. Some time ago, we proposed that the generative disorder in schizophrenia is a disorder of the self [22, 23]; an idea already anticipated by Bleuler, Minkowski, and other psychopathologists. Our claim originated from lengthy, phenomenologically oriented, clinical interviews with patients with beginning schizophrenia [24], and since then corroborated by a series of systematic empirical studies performed on various patient and population samples [2531]. It is important to stress here that our theory is not based on an inference to self-as-a-construct, supposed to operate as a hypothetical, explanatory latent entity. Rather, the self-disorder claim refers to a real and phenomenologically accessible structure of consciousness, which, in the case of schizophrenia spectrum disorders, exhibits certain characteristic anomalies. The purpose of this article is first to briefly articulate the notion of the self-disorder in schizophrenia, followed by an analysis of two important domains of psychopathology of schizophrenia; domains in which, we suggest, the notion of the disordered self might be fruitfully applied in order to recast their puzzling nature into more useful clinical and scientific terms. We will examine the so-called schizophrenic incomprehensibility (bizarre gestalt, bizarre delusions, and crazy actions) and treatment noncompliance.
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Schizophrenia as a Self-Disorder

The phenomenological, experiential notion of the self signifies that we live our (conscious) life in the first-person perspective, as a self-present, single, temporally persistent, bodily, and bounded entity that is the subject of experience [32]. To describe the essential or core dimension of selfhood, phenomenology and cognitive science [33, 34] operate with the concept of minimal self, i.e. a structure that necessarily must be in place in order for all experience to be subjective, i.e. to be someones experience (rather than existing in a free-floating state and only post hoc appropriated by the subject in the act of reflection). Phenomenology considers this basic self-awareness as experientially, but prereflectively, manifest. The minimal self refers to the first-personal articulation of experience, typically called mineness, myness, for-me-ness, or ipseity (for a detailed elaboration, see [33, 35]). The notion of a bare perspective, however, is not entirely exhaustive of the sense of ipseity. Ipseity is also a sense of I-me-myself that persists across the flux of time and experiences and across different modalities of conscious life. It is prereflectively and noninferentially present as a sub-jectum of my life. This sense of I-me-myself is propertyless and it cannot be reduced to a set of attributes. Quoting Hart [36, p. 310], we may say that, if intelligibility is grasping properties, then the myself () eludes our grasp. Ipseity founds the so-called radical self-recognition, which implies that I am always already aware of I-me-myself and have therefore no need for self-observation or self-reflection to assure myself of being myself. Ipseity conveys the very basic, immutable core of identity, a core that is foundational for our ordinary sense of existing as a self-present, single, bodily, demarcated, and persisting entity. Ipseity thus manifests a certain paradoxical nature. On the one hand, it may be considered as a general, universal form of human consciousness. Yet, on the other hand, and notwithstanding its lack of properties, ipseity founds the most intimate, individuated (but propertyless) essence of our personal identity [36]. In that sense, we may, though obviously in a somewhat artificial way, distinguish ipseity from the more complex self, the so-called narrative or extended self, involving personal history, narrative-language, personality structure, and patterns of relating, and involving psychological concepts such as self-image, self-esteem, self-presentation, etc. Our claim is that schizophrenia selectively involves a disturbance of ipseity, which inevitably has implications on the extended self. By contrast, the disorders of extended self but with intact ipseity
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Psychopathology 2013;46:320329 DOI: 10.1159/000351837

mark the personality disorders outside the schizophrenia spectrum disorders. A stable sense of basic selfhood and identity goes together with an automatic, unreflected immersion in the shared social world. The world is pregiven, i.e. always tacitly grasped as a real, taken-for-granted, self-evident background of all experiencing and all meaning [37]. One is not only self-present but also present in the midst of the world of which one is partaking. This tacit and foundational self-world structure the intentional arc [38] is threatened or unstable in the schizophrenia spectrum disorders, constituting its core vulnerability [22, 23, 39, 40]. Thus, the notion of self-disorder in schizophrenia does not imply a lack of ipseity or dissolution of the intentional arc (which perhaps may occur in the terminal stages of life-threatening catatonia). Rather, we assume that this infrastructure of conscious life is constantly challenged, unstable, and oscillating, resulting in alarming and alienating experiences, typically occurring already in childhood or early adolescence. The patients feel ephemeral, lacking core identity, profoundly (yet often ineffably) different from others (Anderssein) and alienated from the social world. There is a diminished sense of existing as a bodily, self-present subject, distortions of first-person perspective with a failing sense of mineness of the field of awareness (e.g. my thoughts have no respect for me), spatialization of the experiential contents (e.g. thoughts being experienced as located extended objects), and deficient sense of privacy of the inner world. There is a significant lack of attunement and immersion in the world (loss of common sense) and pervasive perplexity, i.e. inadequate prereflective grasp of self-evident meanings (e.g. Why is the grass green?) and hyperreflectivity (e.g. I only live in my head, I always observe myself). Social isolation and loneliness often bear a solipsistic stamp, arising from within rather than operating solely as a psychological defense or a simple deprivative consequence of the illness. It is important to emphasize at this point that the selfdisorder (instability of ipseity/intentional arc) may throw the patient into a new ontological-existential perspective or modal space [41], an often solipsistic framework, no longer ruled by reliable certitudes and axioms of the natural attitude concerning space, time, causality, and selfidentity. There is an altered ontological position, i.e. an altered sense of reality and existence: (the) patients cannot take things to be the case in the usual way, as the sense of is and is not has changed [42, p. 194].

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Schizophrenic Incomprehensibility

Since the very foundation of the concept of schizophrenia, incomprehensibility, strangeness, and bizarreness have been considered its hallmark, i.e. characteristic of the illness both at a global, gestaltic level of the encounter with the patient and at a more detailed level of description of individual symptoms and signs [43]. These two levels are of course intertwined. The overall gestalt of schizophrenia, e.g. its expressivity, behavior, thinking, and appearance, often radiate an air of a typical, yet unspecifiable, strangeness, which gave rise to clinical notions such as atmospheric diagnosis or praecox feeling [18, 44]. Many single symptoms and signs appear so conspicuously strange that they typically are deemed far beyond comprehensibility, e.g. bizarre delusions, certain hallucinations, and crazy actions. How can we possibly understand a person who is fully convinced that her neighbor for no apparent reason is inserting malicious thoughts into her head, a person who believes that his bodily movements are controlled by external forces, or a patient claiming in the office of a Copenhagen psychiatrist that he is hearing voices from New York? Also certain behaviors (crazy actions, unsinnige Handlungen, dlire en acte) may leave us baffled like in the famous case of a schizoid father, who as a Christmas gift for his dying daughter buys a coffin [45], or the case of a skilled German sergeant who, as his troops advance stopped in the vicinity of Paris in 1940, took his service vehicle and, breaking strict and explicit orders, drove with some privates under his command to Paris, in order to draw their attention on the cultural values of the enemy [46, 47, p. 68]. We will address in some detail how the self-disorder approach may aid the understanding the phenomena of bizarre gestalt, bizarre delusions, and crazy actions. The expression praecox feeling was coined by a Dutch psychiatrist, H.C. Rmke [48], who claimed that the diagnosis of schizophrenia was sometimes bolstered by (more or less) ineffable intuition, probably based on a fundamental inaccessibility of the patient (for a detailed account, see [44]). Rmkes idea was as old as the concept of schizophrenia itself. Similar terms included diagnostic par pntration [19], diagnosis through intuition [49] or atmospheric diagnosis [50]. Wyrsch [49] proposed that what was here at play was a perception of an existential change. We perceive a transformation of the modality of being (the patients ontological framework, described in the previous section) into an order of its own (eigene Daseinsweise). What appears as incomprehensible, though preconceptually apprehended by the cliniSubjectivity and Schizophrenia

cian, are alterations in the structures of the patients being-in-the-world, e.g. the temporality and spatiality of being, self-identity, self-other relation, and self-world immersion; in other words, modifications of the structures making up the intentional arc. Such structures are, of course, not concrete perceivable thing-like objects. Rather, they are constitutive, i.e. operating as preconceptual conditions of our existence [51, p. 48]. The clinician may perceive such changes in a nonconceptual, prereflective way; an experiential mode that may be difficult or even impossible to convert into a linguistic, propositional (sentence-like) format (hence the talk of atmospheric feeling). The notion of bizarre delusion is a product of the operational versions of the DSM and ICD. The creation of the category of bizarre delusions was justified by a cursory reference to Kraepelins observation that schizophrenic delusions often were nonsensical and to Jaspers, according to whom primary delusional experience is ununderstandable [52]. Bizarre delusions are specified in DSM-IV as clearly implausible and not understandable and do not derive from ordinary life experiences [53, p. 299] and in ICD-10 (though without using the term bizarre) as culturally inappropriate and completely impossible [54, p. 87], and epitomized by the delusions of thought insertion, thought deprivation, and delusions of control. For Jaspers, schizophrenic delusions are primary pathological experiences, i.e. they cannot be psychologically reduced to other experiences and they remain therefore, on his account, empathically incomprehensible [16]. On the other hand, the thematic delusional elaboration of a pathological primary experience, for example that it is the citys mayor and the municipal council that jointly form a conspiracy to control my thoughts, would be considered as a secondary delusion, a product of reflective processes, not different in kind from those involved in nonschizophrenic delusions (e.g. delusions of guilt due to a melancholic mood). In disagreement with Jaspers, we would therefore claim that the primary delusional experience is not beyond comprehensibility because such an experience is continuous with the preexisting disorder of ipseity. So even though such delusional experiences violate some of our normally held beliefs about reality and usually also deny the very framework of these normal beliefs (by implying, for example, the existence of nonphysical causality, no self-other boundaries, the reversibility of time, etc.), these delusions remain, from the perspective of self-disorders, comprehensible to some extent. Bizarre delusional explanations are, in our view, attempts to
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frame and thematize a multiplicity of preexisting anomalous self-experiences, which are manifestations of an already altered subjectivity [55, 56]. The unstable ipseity involves an increasing experiential distance between the sense of self and the flow of consciousness, which brings along disturbing forms of defamiliarization and selfalienation. For example, patients may come to experience their own voice, thoughts, feelings, and body or parts of it as increasingly objectified, detached and increasingly alien to the extent that their thoughts or body no longer feel as their own but rather as something anonymous (it thinks rather than I think) or even instigated or steered from the outside. From a phenomenological perspective, there is here a developmental continuity from early nonpsychotic self-disorders to the fully formed first-rank symptoms. However, this continuity is neither to be conceived along the lines of physical causality (in the sense that one self-disorder or a cluster of self-disorders causes another that causes yet another until, say, the delusion is formed) nor as a form of mental causation (similar to how feelings of thirst might cause one to get a drink). The quasiphysical causality has at least partly (though not clearly) been proposed in the studies on the transitional sequences from the basic to the first-rank symptoms [57, 58]. We suggest, instead, that this continuity, phenomenologically speaking, is eidetic in nature, i.e. the underlying ipseity-intentional arc disturbance prefigures or constrains the psychotic symptoms that may emerge as possible thematizations of the former, and additionally it may elicit certain automatic (e.g. nonvolitional hyperreflection) and compensatory responses (e.g. introspective scrutinizing to reassert a feeling of control) [59, p. 268f]. To comprehend such abnormal experiences or aspects of them, we must realize that the content and structure of these experiences are dialectically intertwined, and therefore we must take into account the altered framework of experiencing in schizophrenia instead of focusing exclusively on the propositional content expressed in the delusion. In the case of crazy actions, we are confronted with another type of incomprehensibility. From a detached theoretical stance, the act of buying a coffin as a Christmas gift for a dying daughter, because thats what she will need soon, or the act of disregarding explicit orders to enlighten comrades about the foes cultural values are to some extent meaningful and perhaps even logical. Yet, at the same time, these acts reveal a profound lack of attunement with the intersubjective world and the implicit rules of social interaction. Buying the coffin reflects a complete lack of understanding of the daughters emo324
Psychopathology 2013;46:320329 DOI: 10.1159/000351837

tional needs and, more generally, of what is socially appropriate. The cultural enlightenment of the soldiers involves a severe transgression of German military discipline, which in this particular subculture made the sergeants behavior appear as completely mad in the eyes of his superiors. Whether or not an action should be considered as crazy depends of course on the culture and context. Thus, the crazy action is characterized not so much by its specific content as by the way it is enacted, i.e. by its friction with the situational context or by its social or normative inappropriateness. Crazy actions indicate a take on the world that is markedly different from that of the shared community. In our view, the eccentric or idiosyncratic behavior displayed in crazy actions reflects, what Blankenburg [60] termed, a loss of common sense an aspect of the instability of the intentional arc [45; vide supra]. According to Blankenburg, common sense is an attitude of being naturally and spontaneously immersed in the shared social world and at ease in it, and to experience oneself, others and the world through this attitude, which provides an implicit, prereflective grasp of what is contextually relevant and socially appropriate. Consequently, the loss of common sense, which according to Blankenburg constitutes the core of schizophrenic autism, is typically associated with a panoply of other anomalous self-experiences. By conceiving crazy actions as expressions of a profound dislocation from common sense, we may come to understand these peculiar actions as somehow consequential of the inner logic of an autistically transformed schizophrenic world [61].

Treatment Noncompliance

We will now address a major problem in the treatment of schizophrenia, i.e. the patients reluctance to take antipsychotic medication continuously over a longer period of time. It is widely assumed that if we are to modify the noncompliant patients attitude toward taking medication, we must attain a better understanding of the mechanisms behind that attitude. Some of the causes are side effects of pharmacotherapy, mistrust against the clinician, stigma of diagnosis, and positive attitudes towards positive symptoms [62, 63]. Yet, the primary cause of medication noncompliance in schizophrenia is generally considered to be poor insight into illness [53]. Empirical studies estimate that 5080% of patients with schizophrenia do not believe they have a mental disorder [6466]. Consistent with the general clinical impression, most studies have found that insight into illness (typically tauParnas /Henriksen

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tologically inversely related to the severity of psychosis and delusionality) predicts treatment compliance and better clinical and functional outcome, whereas poor insight predicts poorer compliance and outcome [6770]. The current medical definition of insight includes awareness of having a mental disorder and of its symptoms and signs, of the need for treatment, and of the disorders social consequences [71]; poor insight reflects a decrease or lack of awareness in some or all of these domains. Researchers have struggled to reach a more profound understanding of poor insight, typically by exploring its correlations with other clinical and sociodemographic variables such as symptomatology, prognosis, age of onset of the disorder, neurocognitive impairment, global and social functioning, clinical outcome, gender, and educational level. The studies, however, have yielded conflicting results (for an overview, see [70, 72]) with little pragmatic utility. Two theoretical accounts of poor insight predominate. In psychodynamic theory, poor insight is a defense mechanism, i.e. a denial of being ill with the purpose of warding off, for example, depressive symptoms arising from awareness of having a chronic illness [73]. In contrast, the cognitive account claims that poor insight is a failure of metacognition [74]. First, both accounts conceptualize the issue of insight into schizophrenia as a simple and straightforward problem of self-reflection: insight is just an act of critical reflection on ones own psychological life. The reflecting self somehow notices a problem in the reflected, ongoing subjective life, which then may become rationally corrected. In schizophrenia, it is said, this self-reflection fails, either due to interference from subconscious defense mechanisms or because of metacognitive dysfunctions. Second, and most importantly, both accounts implicitly assume that if these problems (defense or dysfunction) were remedied, the patients would acquire insight into their medical condition, i.e. they assume that, following the standard medical model, there is a clear separation between the self and the illness (between the reflecting self and the ongoing conscious life). On this account, the self essentially remains unaffected by the illness. However, this underlying assumption is outright false since the schizophrenia spectrum disorders, as we have argued and empirically demonstrated, are intrinsically trait-marked by self-disorders, i.e. a variety of specific alterations of the structures of experiencing, affecting the very conditions of self-experience and self-reflection. A comprehensive meta-analysis examining the efficacy of psychoeducation for schizophrenia concluded that
Subjectivity and Schizophrenia

attempts to increase awareness of illness in schizophrenia and improve medication compliance have failed [70]. This disheartening result should serve as a wakeup call: we must acknowledge that in spite of decades of research on poor insight into schizophrenia and treatment compliance, focusing explicitly on increasing the patients awareness of their illness, there has been no significant therapeutic advance during the last 30 years. In our view, this failure results from an inadequate understanding of what poor insight into schizophrenia really is. Instead of simply continuing to correlate poor insight to new additional variables, we propose to return to the fundamental questions and raise them anew. What is poor insight in schizophrenia? Why do many schizophrenia patients, despite multiple relapses and readmissions, still not feel ill? We will now present a novel account of poor insight into schizophrenia that is based on the self-disorders approach. The guiding idea is that a phenomenon, which Bleuler [43] termed double bookkeeping, may help us better understand the complexity of poor insight into illness. In short, double bookkeeping refers to the predicament (and ability) of many patients to, so to say, simultaneously live in two different worlds, namely the shared social world and their own private bizarre psychotic world. Not only do patients with double bookkeeping seem to experience both worlds as real, they also generally seem to experience them as two separate, incommensurable, and thus not conflicting realities, thereby typically allowing them to coexist and only occasionally to collide. Here is illustrative example from Bleuler [43, p. 43]: A catatonic patient was in great fear of a hallucinated Judas Iscariot who was threatening her with a sword. She cried out that the Judas be driven away, but in between she begged for a piece of chocolate. Next day she complained about these hallucinations, apologized for her acts of violence; but in the middle of her complaints she expressed pleasure in a pretty belt. She managed to weave this belt into her delusions sufficiently to need reassurance that it was not a Judas kiss. What is enigmatic in this vignette is that the patients behavior is strikingly at odds with her delusional beliefs. Normally, we would expect someone, who firmly believes that she is about to be slain, to defend herself or to seek cover; we would certainly not expect her to ask for a piece of chocolate. The patient manifests a stark incongruity between her beliefs and actions, which puzzles us given that we tend to perceive actions as solid confirmations of beliefs. With this patient, we are left wondering whether or not she, strictly speaking, believes what she claims to believe, and
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the situation is of course even more convoluted since delusional beliefs per definition are incorrigible and held with unshakable certainty. A few other examples may help illuminate our point. We may encounter schizophrenic patients who believe that people around them are automatons but who nonetheless interact with them (as if they were real), or patients who believe that the nurses in the ward are trying to poison them but still happily eat the food that is being served them [75, p. 21]. Viewed from the clinical perspective, double bookkeeping, although not always as spectacular as in Bleulers vignettes, is a very prevalent phenomenon, perhaps characterizing the majority of psychotic patients with schizophrenia. It is important to emphasize that the deluded patients often quite inconspicuous daily behavior also indicates that the patients might not literally believe what they claim to believe in their delusions, that there is a coefficient of subjectivity to their beliefs [75, p. 27]. The question is of course how are we to make sense of this paradoxical claim. From a phenomenological perspective, there is a significant difference between ordinarily held beliefs such as there is an Italian restaurant around the corner or the train is leaving at 5 p.m. and delusional beliefs such as Judas is about to slay me down, others are automatons, or the nurses strive to poison me. The ordinarily held beliefs reflect a mundane (wordly or ontic) orientation (natural attitude), which is an aspect of immersion in a shared social world, and these beliefs belong to what is called the logical space of reasons, of justifying and being able to justify what one says [76, p. 298]. In contrast, the delusional beliefs reflect an autistic-solipsistic orientation, which we suggest results from a profound loss of common sense and persistent self-disorders, both involving an altered framework for experiencing. Schizophrenic delusions, as we argued in the previous section, emerge from this altered experiential-ontological framework; therefore, the delusional beliefs formed within this framework do not belong to space of reasons, but rather to a uniquely private quasisolipsistic space. In our view, many patients with schizophrenia have poor insight into their illness, i.e. they do not consider their hallucinatory or delusional experiences as pathological phenomena because they do not experience their initial self-disorders from which psychosis emerged as symptoms of an illness (similar to how an intense pain in the leg might be a symptom of a fracture), but rather as intrinsic aspects of their existence and identity. For example, first-admitted schizophrenia patients who report hearing their own thoughts spoken aloud internally (Gedankenlautwerden) often get surprised and some326
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times even suspicious when the psychiatrist explains that most people only have silent thoughts. In our view, this is characteristic for many self-disorders. When interviewing schizophrenia spectrum patients about their self-disorders, one quickly realizes that many of their anomalous self-experiences have been present for as long as the patients can remember or that the self-disorders emerged either in childhood or early adolescence. In other words, the self-disorders are often trait-like modes of the patients experiential life, usually preceding the onset of psychosis and persisting after remission. It is, therefore, a radically different situation than a reactive depression where the patient has a distinct sense of who she was and how her life used to be before the depression set in and after. In schizophrenia, this is not the case to the same extent, given that the altered experiential framework for years has been the rule (or norm) rather than the exception, making the issue of onset dating not only a technical but also a conceptual issue [77]. We may thus speak of a prepsychotic double bookkeeping. One of our patients lived during his high school years a fundamentally altered self-world relation with a sense of diminished presence and quasisolipsistic experiences, while remaining inconspicuously adapted to a shared social world. He thought of others as souls that had fallen on earth from an encompassing world soul (to which we all return after death), like raindrops from a cloud. He accounted for his unique abilities and feelings of Anderssein by thinking that he perhaps retained a sort of capillary continuity with the world soul and thereby had access to the far deeper reality levels than his fellow humans were able to achieve. Such an explicit, quasireligious, metaphysical position is not a common clinical-empirical finding, but it illustrates well the transformation of the patients ontological-existential framework. Many young, pre-onset patients try to account for their sense of Anderssein by fantasies of being time-travelers, extraterrestrials, etc. From the perspective of prepsychotic double bookkeeping, we can easily imagine that patients may find the distinction fuzzy between, on the one side, their normal (i.e. anomalous) experiences (e.g. loss of thought ipseity, thoughts aloud, and nonpsychotic demarcation problems) and, on the other side, the occasional fearing and believing that others can access their thoughts or that certain thoughts have been planted into their mind. In other words, the line between what a patient normally (or habitually) experiences (i.e. self-disorders) and what he sometimes experiences (e.g. positive symptoms) may seem very slim and perhaps irrelevant to the patient and even more so if the patient does not literally believe in his
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delusional beliefs though he obviously is unable to distance himself from them. From this perspective, it makes sense that many schizophrenia patients do not feel ill or do not attribute their pathological experiences to the disorder. On the basis of this account, we suggest that the reason why some patients with schizophrenia have poor insight and consequently do not comply with treatment, might be rooted in the severity and nature of their self-disorders. The future empirical task is to answer the question whether psychoeducational attempts, focusing on the patients self-disorders as vulnerability traits rather than on their awareness of certain positive symptoms, may effectively modify the patients insight into their condition and optimize treatment compliance. One thing that does point in this direction is that while patients often are reluctant to discuss their delusions and hallucinations, most patients are quite willing to explore and discuss their selfdisorders. This is most likely because, as many of our patients have expressed it, questions about anomalous selfexperiences are central to their existence and identity, whereas questions such as Do you really believe that the television is sending messages specifically to you? or Do you hear voices? usually are not.

Conclusion: Understanding Schizophrenia

Summarizing our central claims, we will now try to flesh out the type of understanding the self-disorders approach enables in schizophrenia with the following question. Are we, as the clinicians familiar with the disorders of subjectivity in schizophrenia, able to better understand the patient who, say, is presenting bizarre delusions, crazy actions, or treatment noncompliance rooted in double bookkeeping? All accounts of interpersonal understanding and rationality presuppose a normal framework for experiencing, i.e. a shared ontological-existential perspective, or following Ratcliffe [41], a shared modal space. The belonging to the world is not a matter of having a belief-like intentional state with the content the world exists. Rather, it involves () having a sense of reality, by which I mean a grasp of the distinction between real, present and other possibilities, without which one could not encounter anything as there or, more generally as real. We generally take for granted that others share this same modal space with us and that they are able to encounter things in the same was as we do [41, pp. 479480; some italics added]. This existential-ontological structure, as we have argued,
Subjectivity and Schizophrenia

is destabilized and constantly threatened in schizophrenia, and a grasp of this instability or even dislocation is often a prerequisite of an attempt to understand the patient with schizophrenia. Here, understanding means a genetic or developmental reconstruction of the pathological phenomena, i.e. a reconstruction that enables the patients mental life to appear less enigmatic. Even though most of us cannot imagine how it might feel that the privacy of ones subjectivity is compromised or that ones field of awareness is populated by anonymous egoless thoughts, we can nonetheless understandingly grasp certain consequences of these self-disorders, such as the fear of external access to ones thoughts or increasing objectification and spatialization of the field of awareness. This kind of understanding has similarities with what Ratcliffe [41] called radical empathy and which we elsewhere have described as a philosophical understanding [78]. Such an understanding requires that the clinician effectuates the phenomenological epoch (i.e. he suspends his normally taken-for-granted habitual beliefs about the world) and strives to reconstruct the altered life-world in schizophrenia; a world that often is deprived the ontological securities that ground a normal existence and which is infused with unpredictability and vulnerability. In a clinical context, e.g. in managing treatment noncompliance, epoch aims to disclose the nature and subjective significance of the patients ontological-existential framework, thereby providing a more informed and probably more efficient, departure point for addressing this clinical issue therapeutically.

Disclosure Statement
Mads Gram Henriksen is funded by a grant from the Carlsberg Foundation (2012010195).

References

1 Klerman GL: The evolution of a scientific nosology; in Shershow JC (ed): Schizophrenia: Science and Practice. Cambridge, Harvard University Press, 1978, pp 99121. 2 Katschnig H: Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry 2010;9:2128. 3 Hyman SE: Psychiatric drug discovery: revolution stalled. Sci Transl Med 2012;4:15. 4 Frances AJ, Widiger T: Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Annu Rev Clin Psychol 2012;8:109130.
Downloaded by: Fudan University Library 61.129.42.14 - 9/23/2013 4:01:05 PM

Psychopathology 2013;46:320329 DOI: 10.1159/000351837

327

5 Kleinman A: Rebalancing academic psychiatry: why it needs to happen and soon. Br J Psychiatry 2012;201:421422. 6 Carpenter WT: Deconstructung and reconstructing illness syndromes associated with psychosis. World Psychiatry 2007;6:9296. 7 Cuthbert BN, Insel TR: Toward new approaches to psychotic disorders: the NIMH Research Domain Criteria project. Schizophr Bull 2010;36:10611062. 8 Parnas J, Sass LA, Zahavi D: Rediscovering psychopathology: the epistemology and phenomenology of the psychiatric object. Schizophr Bull 2013;39:270277. 9 Lari F, Sommer IE, Blom JD, Fernyhough C, Ffytche DH, Hugdahl K, Johns LC, McCarthy-Jones S, Preti A, Raballo A, Slotema CW, Stephane M, Waters F: The characteristic features of auditory verbal hallucinations in clinical and nonclinical groups: state-of-the-art overview and future directions. Schizophr Bull 2012;38:724733. 10 Posey TB, Losch ME: Auditory hallucinations of hearing voices in 375 normal subjects. Imagin Cogn Pers 1983; 3: 99113. 11 Barrett TR, Etheridge E: Verbal hallucinations in normals, I: people who hear voices. Appl Cogn Psychol 1992;6:379387. 12 Chalmers DJ: The Conscious Mind. In Search of a Theory of Conscious Experience. Oxford, Oxford University Press, 1996. 13 Levine J: Materialism and qualia: the explanatory gap. Pac Philos Quart 1983;64:354361. 14 Chalmers DJ: The Character of Consciousness. Oxford, Oxford University Press, 2010. 15 Nagel T: What it is like to be a bat? Phil Review 1974;83:435450. 16 Jaspers K: General psychopathology. London, John Hopkins University Press, 1963. 17 Kay SR, Fiszbein A, Opler LA: The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987; 13: 261 276. 18 Minkowski E: La Schizophrnie. Psychopathologie des Schizodes et des Schizophrnes. Paris, Payot, 1927. 19 Parnas J: The core gestalt of schizophrenia. World Psychiatry 2012;11:6869. 20 Minkowski E: The notion of generating disorder and the structural analysis of mental disorders; in Broome MR, Harland R, Owen GS, Stringaris A (eds): The Maudsley Reader in Phenomenological Psychiatry. Cambridge, Cambridge University Press, 2012, pp 102 116. 21 Henriksen MG, Parnas J: Clinical manifestations of self-disorders and the gestalt of schizophrenia. Schizophr Bull 2012; 38: 657 660. 22 Parnas J, Handest P: Phenomenology of anomalous self-experience in early schizophrenia. Compr Psychiatry 2003;44:121134. 23 Sass LA, Parnas J: Schizophrenia, consciousness, and the self. Schizophr Bull 2003; 29: 427444.

24 Parnas J, Jansson L, Sass LA, Handest P: Selfexperience in the prodromal phases of schizophrenia: a pilot study of first admissions. Neurol Psychiatry Brain Res 1998;6:97106. 25 Parnas J, Handest P, Saebye D, Jansson L: Anomalies of subjective experience in schizophrenia and psychotic bipolar illness. Acta Psychiat Scand 2003;108:126133. 26 Parnas J, Handest P, Jansson L, Saebye D: Anomalous subjective experience among first-admitted schizophrenia spectrum patients: empirical investigation. Psychopathology 2005;38:259267. 27 Raballo A, Saebye D, Parnas J: Looking at the schizophrenia spectrum through the prism of self-disorders: an empirical study. Schizophr Bull 2011;37:344351. 28 Raballo A, Parnas J: The silent side of the spectrum: schizotypi and the schizotaxic self. Schizophr Bull 2011;37:10171026. 29 Raballo A, Parnas J: Examination of anomalous self-experience: initial study of the structure of self-disorders in schizophrenia spectrum. J Nerv Ment Dis 2012;200:577583. 30 Haug E, Lien L, Raballo A, Bratlien L, Oie M, Andreasen OA, Melle I, Mller P: Selective aggregation of self-disorders in first-treatment DSM-IV schizophrenia spectrum disorders. J Nerv Ment Dis 2012;200:632636. 31 Nelson B, Thompson A, Yung AR: Basic selfdisturbance predicts psychosis onset in the ultra high risk for psychosis prodromal population. Schizophr Bull 2012;38:12771287. 32 Albahari M: Analytical Buddhism: the twotiered illusion of self. Basingstoke, Palgrave Macmillan, 2006. 33 Zahavi D: Subjectivity and Selfhood. Cambridge, MIT Press, 2005. 34 Gallagher S, Zahavi D: The Phenomenological Mind: An Introduction to Philosophy of Mind and Cognitive Science. London, Routledge, 2008. 35 Parnas J, Sass LA: The Structure of Self-consciousness in Schizophrenia; in Gallagher S (ed): The Oxford Handbook of the Self. Oxford, Oxford University Press, 2011, pp 521 546. 36 Hart JG: Who One Is. Book 1. Meontology of the I: A Transcendental Phenomenology. Berlin, Springer, 2009. 37 Heidegger M: Being and Time. Oxford, Blackwell, 2007. 38 Merleau-Ponty M: The phenomenology of perception. London, Routledge, 2002. 39 Fuchs T: Corporealized and disembodied minds. A phenomenological view of the body in melancholia and schizophrenia. Philos Psychiatr Psychol 2005;12:95107. 40 Sass LA, Parnas J, Zahavi D: Phenomenological psychopathology and schizophrenia: contemporary approaches and misunderstandings. Philos Psychiatr Psychol 2011;18:123. 41 Ratcliffe M: Phenomenology as a form of empathy. Inquiry 2012;55:473495. 42 Ratcliffe M: Feelings of Being. Phenomenology, Psychiatry and the Sense of Reality. New York, Oxford University Press, 2008.

43 Bleuler E: Dementia Praecox or the Group of Schizophrenias. New York, International University Press, 1950. 44 Parnas J: A disappearing heritage: the clinical core of schizophrenia. Schizophr Bull 2011; 37:11211130. 45 Parnas J, Bovet P: Autism in schizophrenia revisited. Compr Psychiatry 1991;3:721. 46 Bovet P, Parnas J: Schizophrenic delusions: a phenomenological approach. Schizophr Bull 1993;19:579597. 47 Conrad K: Die beginnende Schizophrenie. Versuch einer Gestaltanalyse des Wahns. Bonn, Edition Das Narrenschiff im Psychiatrie-Verlag, 2002. 48 Rmke HC: Das Kernsymptom der Schizophrenie und das Praecox-Gefhl. Zentralbl Gesamte Neurol Psychiatr 1942;102:168169. 49 Wyrsch J: ber die Intuition bei der Erkennung der Schizophrenen. Schweizerische Med Wochenschrift 1946;46:11731176. 50 Tellenbach H: Geschmack und Atmosphre. Salzburg, Mller, 1968. 51 Krauss A: The significance of intuition for the diagnosis of schizophrenia; in Maj M, Sartorius N (eds): Schizophrenia. Chichester, John Wiley & Sons, 1999, pp 4749. 52 Spitzer RL, Fisrt MB, Kendler KS, Stein DJ: The reliability of three definitions of bizarre delusions. Am J Psychiatry 1993; 150: 880 884. 53 APA: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-IV, text revision. Arlington, APA, 2007. 54 WHO: The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Description and Diagnostic Guidelines. Geneva, WHO, 1992. 55 Cermolacce M, Sass LA, Parnas J: What is bizarre in bizarre delusions? A critical review. Schizophr Bull 2010;36:667679. 56 kodlar B, Henriksen MG, Sass LA, Nelson B, Parnas J: Cognitive-behavioral therapy for schizophrenia: a critical evaluation of its theoretical framework from a clinical-phenomenological perspective. Psychopathology 2013;46:249265. 57 Klosterktter J: Basissymptome und Endphnomene der Schizophrenie. Eine empirische Untersuchung der psychopathologischen bergangsreihen zwischen defizitren und produktiven Schizophreniesymptomen. Berlin, Springer, 1999. 58 Klosterktter J: The meaning of basic symptoms for the genesis of the schizophrenic nuclear syndrome. Jpn J Psychiatry Neurol 1992; 46:609630. 59 Parnas J, Sass LA: Varieties of phenomenology. On description, understanding, and explanation in psychiatry; in Kendler KS, Parnas J (eds): Philosophical Issues in Psychiatry. Explanation, Phenomenology, and Nosology. Baltimore, Johns Hopkins, 2008, pp 239285.

328

Psychopathology 2013;46:320329 DOI: 10.1159/000351837

Parnas /Henriksen

Downloaded by: Fudan University Library 61.129.42.14 - 9/23/2013 4:01:05 PM

60 Blankenburg W: Der Verlust der natrlichen Selbstverstndlichkeit. Ein Beitrag zur Psychopathologie symptomarmer Schizophrenien. Stuttgart, Enke, 1971. 61 Parnas J, Bovet P, Zahavi D: Schizophrenic autism: clinical phenomenology and pathogenetic implications. World Psychiatry 2002; 1: 131136. 62 Lambert M, Conus P, Eide P, Mass R, Karow A, Moritz S, Golks D, Naber D: Impact of present and past anitpsychotic side effects on attitude toward typical antipsychotic treatment and adherence. Eur Psychiatry 2004;19: 415422. 63 Moritz S, Favrod J, Andreou C, Morrison AP, Bohn F, Veckenstedt R, Tonn P, Karow A: Beyond the usual suspects: positive attitudes towards positive symptoms is associated with medication noncompliance in psychosis. Schizophr Bull 2013;39:917922. 64 Amador XF, Gorman JM: Psychopathologic domains and insight in schizophrenia. Psychiatr Clins North Am 1998;21:2742. 65 Keshavan MS, Rabinowitz J, DeSmedt G, Harvey PD, Schooler N: Correlates of insight in first episode psychosis. Schizophr Res 2004; 70:187194.

66 Dickerson FB, Boronow JJ, Ringel N, Parente F: Lack of insight among outpatients with schizophrenia. Psychiatr Serv 1997; 48: 195 199. 67 Amador XF, Flaum M, Andreasen NC, Strauss DH, Yale SA, Clark SC, Gorman JM: Awareness of illness in schizophrenia and schizoaffective and mood disorders. Arch Gen Psychiatry 1994;51:826836. 68 Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV: Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J Clin Psychiatry 2002;63:892 909. 69 Buckley PF, Wirshing DA, Bhushan P, Pierre JM, Resnick SA, Wirshing WC: Lack of insight in schizophrenia: impact on treatment. CNS Drugs 2007;21:129141. 70 Lincoln TM, Lllmann E, Rief W: Correlates and long-term consequences of poor insight in patients with schizophrenia. A systematic review. Schizophr Bull 2007;33:13241342. 71 Amador XF, David AS: Insight and Psychosis. New York, Oxford University Press, 1998. 72 Mingrone C, Rocca P, Castagna F, Montemagni C, Sigaudo M, Scalese M, Rocca G, Bogetto F: Insight in stable schizophrenia: relations with psychopathology and cognition. Compr Psychiatry 2013;54:484492.

73 Moore O, Cassidy E, Carr A, Callaghan EO: Unawareness of illness and its relationship with depression and self-deception in schizophrenia. Eur Psychiatry 1999;14:264269. 74 David AS, Bedford N, Wiffen B, Gilleen J: Failures of metacognition and lack of insight in neuropsychiatric disorders. Philos Trans R Soc B 2012;367:13791390. 75 Sass LA: Paradoxes of Delusion: Wittgenstein, Schreber, and the Schizophrenic Mind. Ithaca, Cornell, 1994. 76 Sellars W: Empiricism and the Philosophy of Mind; in Feigl H, Scriven M (eds): Minnesota Studies in the Philosophy of Science, vol 1: The Foundations of Science and the Concepts of Psychology and Psychoanalysis. Minneapolis, University of Minnesota Press, 1956, pp 253329. 77 Parnas J: Clinical detection of schizophreniaprone individuals. Critical appraisal. Br J Psychiatry 2005;187:111112. 78 Henriksen MG: On incomprehensibility in schizophrenia. Phenom Cogn Sci 203; 12: 105129.

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Psychopathology 2013;46:320329 DOI: 10.1159/000351837

329

Downloaded by: Fudan University Library 61.129.42.14 - 9/23/2013 4:01:05 PM