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Journal of Affective Disorders 171 (2015) 171178

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Journal of Affective Disorders


journal homepage: www.elsevier.com/locate/jad

Review

Differential typology of delusions in major depression


and schizophrenia. A critique to the unitary concept of psychosis$
Giovanni Stanghellini a,b,n, Andrea Raballo c
a

G. dAnnunzio University, Chieti, Italy


D. Portales University, Santiago, Chile
c
Department of Mental Health and Pathological Addiction, AUSL Reggio Emilia Reggio Emilia, Italy
b

art ic l e i nf o

a b s t r a c t

Article history:
Received 22 July 2014
Received in revised form
24 August 2014
Accepted 11 September 2014
Available online 16 October 2014

It is a current trend in psychiatry to discard the Kraepelinian dichotomy schizophrenia vs. manicdepressive illness and use the overinclusive label psychosis to broadly indicate the whole spectrum of
severe mental disorders. In this paper we show that the characteristics of psychotic symptoms vary
across different diagnostic categories. We compare delusions in schizophrenia and major depression and
demonstrate how these phenomena radically differ under these two psychopathological conditions.
The identication of specic types of delusions is principally achieved through the differential
description of subjective experiences. We will use two general domains to differentiate schizophrenic
and depressive delusions, namely the intrinsic and extrinsic features of these phenomena. Intrinsic
features are the form and content of delusions, extrinsic ones include the background from which
delusions arise, that is, changes in the eld of experience, background feelings, ontological framework of
experience, and existential orientation. This kind of systematic exploration of the patients experience
may provide a useful integration to the standard symptom-based approach and can be used to establish
a differential typology of the clinical manifestation of psychosis based on the fundamental alterations of
the structures of subjectivity characterizing each mental disorder, particularly with respect to the
Kraepelinian dichotomy schizophrenic vs. manic-depressive illness.
& 2014 Elsevier B.V. All rights reserved.

Keywords:
Classication
Delusion
Major depression
Phenomenology
Psychosis
Schizophrenia

Contents
1.
2.

3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intrinsic features of delusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.
Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.
Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Extrinsic features of delusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
Preparatory eld of experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.
Background feelings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Since time immemorial delusion has been taken as, the basic characteristic of madness. To be mad was to be deluded and indeed what constitutes a delusion is one of the
basic problems of psychopathology (Jaspers 1997, p.93).
n
Corresponding author at: "G. d'Annunzio" University, Via dei vestimi 31, 66100 Chieti Scalo, Italy.

http://dx.doi.org/10.1016/j.jad.2014.09.027
0165-0327/& 2014 Elsevier B.V. All rights reserved.

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G. Stanghellini, A. Raballo / Journal of Affective Disorders 171 (2015) 171178

3.3.

Ontological framework of experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


3.3.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.2.
Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.3.
Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.4.
Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.5.
Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.6.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.7.
Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.8.
Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.9.
Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3.10. Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Existential orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.
Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Role of funding source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conict of interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction
It is a current trend in psychiatry to discard the Kraepelinian
dichotomy schizophrenia vs. manic-depressive illness and use the
overinclusive label psychosis to broadly indicate the whole
spectrum of severe mental disorders. Yet, it is often unclear
what is actually meant by psychosis (Parnas, 2013). Although at
a nave-intuitive level the notion of psychosis might seem unambiguous and clear-cut, the very concept of psychosis remains
unaddressed in contemporary diagnostic manuals, which only
vaguely dene psychosis as poor reality testing World Health
Organization (1992) or rather circularly identify psychosis with the
presence of its putative semiologic markers. In DSM 5 the term
psychotic is used to refer to the presence of a variegated set of
symptoms, so called primary symptoms of psychosis, including
delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Mental disorders that
present the primary symptoms of psychosis are admittedly heterogeneous (American Psychiatric Association, 2013) since they
include schizophrenia, depression, mania, substance/medicationinduced psychotic disorders, etc. DSM 5 suggests that the severity
of symptoms can predict important aspects of the illness, such
as the degree of cognitive or neurobiological decits (), may
help with treatment planning, prognostic decision making,
and research on pathophysiological mechanisms (American
Psychiatric Association, 2013).
A purely quantitative criterion (severity of symptoms) may be
insufcient to characterize psychotic symptoms as they actually
occur in the manifold of severe psychopathological disorders.
There is a need of a qualitative characterization of psychotic
symptoms addressing the alterations of human subjectivity (e.g.,
self-awareness, relatedness to the world, and relatedness to
others) in which psychotic experiences are embedded. These
alterations appear relevant for a differential typology of the clinical
manifestation of psychosis, particularly with respect to the Kraepelinian dichotomy schizophrenic vs. manic-depressive illness.
The purpose of this paper is therefore to discuss whether the
characteristics of psychotic symptoms are identical or vary across
these two diagnostic categories. We will compare delusions in
schizophrenia and major depression and show how these phenomena radically differ under these two psychopathological
conditions. The identication of specic types of delusions is
principally achieved through the phenomenological razor (Rossi
Monti and Stanghellini, 1996), i.e., the differential description of

subjective experiences. We will use two general domains to


differentiate schizophrenic and depressive delusions, namely
the intrinsic and extrinsic features of these phenomena. Intrinsic
features are the form and content of delusions, extrinsic ones
include the background from which delusions arise, that is,
changes in the eld of experience, background feelings, ontological framework of experience, and existential orientation
Table 1.

2. Intrinsic features of delusions


2.1. Form
The form-content distinction in psychopathology dates back to
Jaspers. The form of a symptom is the way a given content is
presented to consciousness (Jaspers, 1997) and the relationship
that a given content has with the subject of experience. For the
most part, form is more diagnosis specic, whereas content
appears more incidental, idiosyncratic and individual. The same
content can appear in a diverse range of phenomenological forms.
For instance, a patient may have a long standing preoccupation
with illness presented in the form of an over-valued idea, or in the
form of the persistent intrusive thought even though he resists the
intrusion and knows it to be false (the form of a compulsive idea),

Table 1.

G. Stanghellini, A. Raballo / Journal of Affective Disorders 171 (2015) 171178

or the sudden and compelling idea of being ill (the form of a


primary delusional intuition). All have the same content, hypochondriasis, but they are present in consciousness in different
forms (Walker, 2013).
2.1.1. Schizophrenia
Revelation is the form of experience that characterizes schizophrenic delusions (Kraus, 1977). The person is struck with a
something that opens up a new meaning, a new identity and a
new understanding of the world that is deeper and more personal.
Typically, this new awareness comes in the way of a sudden
disclosure (Stanghellini and Ballerini, 1992) or as a kind of esthetic
experience (Parnas, 2013): [f]rom the second he saw it captured
him, subduing him with its charm, from which he could not
unhook himself (Blankenburg, 1965). Revelation follows upon a
phase of incertitude and tension: a new world is coming, one's
own life is on the point of undergoing a radical change. Revelation
is the dawn of a new reality (Stanghellini and Rosfort, 2013). This
essential feature of schizophrenic delusions is captured by several
authors using quasi-equivalent terms. Jaspers (1997) speaks of
primary delusions: the delusional content in primary delusions
presents itself to consciousness in an immediate way (Unmittelbar), that is, not mediated by reection or inference. This feature is
also encapsulated by Conrads (1958) concept of apophany, the
manifestation of a meaningfulness that is normally hidden.
Schizophrenic delusions are alethic delusions (Stanghellini,
2008a, 2008b) in the sense that a content that is new for the
deluded person is unveiled (a-letheia in Greek means un-veiling).
2.1.2. Major depression
Delusions in psychotic depression are characterized by the
form of conrmation. Depressive delusion is structured as the
validation of a belief that the person already has about herself, and
of a judgment about herself that is already implicit in her value
system (Kraus, 1983). Delusions of guilt in psychotic depressives
are the corroboration of a pre-existing identity, rather than the
disclosure of a new one. Tellenbach (1961) speaks of the original
coherence of guilt in existence. This characteristic retrospective
feature of depressive guilt delusions was already known by

Table 2.

173

Kraepelin (1908) and Binswanger (1960). One patient described


by Tellenbach (1961) did not only feel guilty about her recent
transgression, but was tortured by the constant subliminal presence of the sins of the youth. Another patient is convinced to be
a sinner who has lived all her life wrongly (our italics). Another
one says: On this occasion (brooding over a new guilt) just about
every guilt I have known came to my mind.
2.2. Content
2.2.1. Schizophrenia
Schizophrenic delusions typically reect a fundamentally
altered existential-ontological structure of subjectivity. Being
embedded in an overall change in one's sense of reality, delusions
in persons with schizophrenia are ontological in content as they
express the concern for what is real and for the true meaning of
existence, rather than common-sense views about these. They
include metaphysical, eschatological and charismatic contents
(Kepinski, 1974; Parnas and Sass, 2011). Metaphysical contents
articulate the concern to discover the essence of reality of which
other people are ignorant. Eschatological delusions express the
anxiety for the imminent end of the world. Charismatic delusions
are about the concern to use one's own gift to save the world/
mankind. Metaphysical as well as charismatic contents are encapsulated in this quote from Schrebers (1988) Memoirs of my nervous
illness: The miraculously created insects () are actually newly
created beings; whether they are of more or less molesting kind is
directly dependent on whether God's attitude to me is friendly
or not.
2.2.2. Major depression
Delusions in psychotic depression deal with worldly affairs in
which the patient is engaged and where he seeks the evidence
supporting his claims (Parnas, 2013). They mainly express our
ontic, everyday concerns (Stanghellini, 2008a, 2008b, Sass and
Pienkos, 2013a, 2013b) about the consequences of losing one's
prerogatives (rather than achieving new ones), that is, moral,
physical and nancial integrity. The following is an example of
the depressives' anxieties exquisitely attuned to the anxieties of all

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G. Stanghellini, A. Raballo / Journal of Affective Disorders 171 (2015) 171178

other human beings, to be contrasted to the kind of ontological


concerns characterizing people with schizophrenia: Nothing
works in the house; nothing to wear no clothes; all plants in
the house are dead; clothes and ties are placed in house by others
(Cutting, 1997). Delusions of guilt articulate the concern to have
lost one's moral integrity, that is, one's commitment to be there for
the others. Delusions of illness express the concern to have lost
one's physical integrity, the worry not to be autonomous and to be
a burden for the others. Finally, delusions of ruin are about the
concern to have lost one's nancial integrity, thus the worry to get
the others involved in one's bankruptcy (Schneider, 1950) Table 2.

3. Extrinsic features of delusions


3.1. Preparatory eld of experience
This is the transformation of the cognitive framework within
which delusional experiences take place. It entails changes in the
meaningfulness of reality and signicance of one's own existence.
3.1.1. Schizophrenia
The prodromal stage of schizophrenic delusions is a state
whereby reality becomes suspended between meaninglessness
and imminent revelation of a new meaningfulness: Something is
going on. Please tell me what is going on! (Jaspers, 1997). Such
pre-delusional suspension involves some sort of ineffable change
which rests upon a global quasi-perceptual transformation of the
feeling of realness. Conrad (1958) named this pre-delusional
prodrome das Trema a kind of atmosphere where everything
feels strange, ominous, uncannily transformed. Reality is undergoing some inexplicable, ineffable, ungraspable change. The world
is pervaded by a kind of latent meaningfulness: it has lost its
habitual familiarity, and has not yet acquired a new kind of
signicance. Understanding reality and acting upon it has an
achievement character. Nothing is evident and natural anymore.
A characteristic feature of Trema is a fracturing and disintegration
of previous meaning patterns, which is experienced by the patient
as an uncanny sense of strangeness (Roberts, 1992). What is
essential to Trema is a breakdown of Gestalt perception during
which the neutrality of the background gets lost (Cutting, 1989).
The patient is not struck by what people do or say but what they
do not do or say (Berner, 1991). These patients' sense of disentanglement from a commonly shared reality is followed by the
experience of revelation that characterizes full-blown schizophrenic delusions.
3.1.2. Major depression
Prodromes of psychotic depression, especially of those forms
entailing delusions of guilt, are characterized a situation of selfcontradiction that leads to a progressive loss of capability for
action preliminary to delusional sinfulness. What is at stake here is
not the meaning of reality in an ontological sense, rather the
signicance of one's own existence in an ethical sense. These
phenomena are condensed in Tellenbachs (1961) account the
depressed-psychotic initial situation termed Verzweiung, a word
that literally means disunion. Its core is not just helplessness, or
hopelessness, rather it is a situation of self-contradiction, a
movement backward and forward, an alternation, so that a denite
decision is no longer possible. Mental rumination, unnished
duties, ptites fautes, unpardonable missteps (Binswanger, 1960)
going round and round in the patient's head are characteristic
manifestations especially in prodromal major depression: She was
also inclined to take literally the slightest remarks of others ()
What another person might dismiss with a wave of hand would
never leave her (Tellenbach, 1961). The patient's capability for

perspective planning of action is affected: what normally comes


about in the style of succession, in depressive prodromes appears
in the necessity of simultaneity. Since one cannot do everything at
the same time, the patient remains trapped in inactivity.
The depressed person is unable to establish her agenda according
to an order of priorities, hence she feels pushed simultaneously to
incompatible or totally exorbitant objectives. This leads to a paniclike paralysis of action that paves the way to feeling totally
desynchronized, i.e. uncoupled in the temporal relation with one's
rigid demands on oneself of duty and orderliness as well as in the
temporal relation with the surrounding world (Fuchs, 2001). This
feeling in debt to oneself and the others, to the sensibility of the
depressed person, is already guilt (debet is already culpa,
Tellenbach, 1961), as in guilt the patients holds fast to the
omissions of the past (Fuchs, 2013)
3.2. Background feelings
Background feelings offer an angle to describe the affectiveemotional matrix from which the cognitive changes that characterize the preparatory eld of delusions may arise. Background
feelings, sometimes named existential feelings, provide the
existential orientation that operates as the pre-reexive background to experience and thoughts (Ratcliffe, 2008). They are
ways of nding oneself in the world, e.g., one can feel familiar or
unfamiliar in a given situation, participant in the world or a
detached observer, the world may feel real or unreal, etc. These
orientations are deeply rooted in bodily feelings.
3.2.1. Schizophrenia
Advocates of dynamic Schizophreniatheories (Bleuler, 1950;
Jaspers, 1997; Berze and Gruhle., 1929; Minkowski, 1927; Berner,
1991), argue that the matrix from which delusions in schizophrenic persons arise is a kind of altered mood state whose principal
character is the crisis of the quality of familiarity (Bekanntheitsqualitt) (Callieri et al., 1999). [E]xtraneousness from the world
and from himself, the premonition of something awkward, the
tone of mystery: this is the opposite of the taken-for-granted, it is
the uncanny (Callieri, 1982). Space is anonymous, time momentary, the other person is never apperceived as a socius, and
language is not univocally determined. Storring (1939) dened
this state perplexity (Ratlosigkeit) and explains it as a disturbance
of the lived body's motility. Most characteristic is the paralysis of
the body as the instrument for the discovery and the organization
of experience (Storring (1939)). Perplexity is a mood wherein the
patient's empathic capacity is declining, he is gradually becoming
detached from external reality, and undergoes feelings of strangeness (Berrios, 1996), coloring the world with alien qualities. What
is most characteristic, and contributes to distinguish schizophrenic
from depressive background feelings, is that in the former case the
kind of derealisation they bring about bewilder and unsettle the
patient, but at the same time characteristically promote a powerful
drive to a new understanding of what is being experienced.
3.2.2. Major depression
Patients complain for being affected in their very capacity of
feeling and undergo an exacerbated and painful experience of loss
of emotional grasp and resonance (Binswanger, 1960; Schulte, 1961;
Tellenbach, 1961; Berrios, 1988). It is a special kind of depersonalization characterized by the feeling of the loss of feelings or Nichttraurig-sein-Koennen (not-to-be-able-to-be-sad) (Schulte, 1961), a
degradation of the power for having moods at all Fernandez (in
press). Someone who can still be sad is not truly melancholic
(Schulte, 1961). A paradoxical feature of this experience is that this
profound indifference is experienced as a source of suffering. These

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175

Table 3.

patients' overall attitude towards this phenomenon is characterized


by self-accusing, self-reprimanding, and a sense of guilt. Rarely does
the melancholic limit herself to merely acknowledging her loss of
the capacity of feeling, rather her whole experience is permeated by
ethical worries. Impaired emotional resonance aggregates with
delusions of guilt (Stanghellini and Raballo, 2007). No drive for a
new understanding is present. Rather, these patients tend to deny
retrospectively the authenticity of their own sentiments for the
others (Kraus, 1994) Table 3.

3.3. Ontological framework of experience


Although the majority of people are situated within a shared
ontological framework, there are several other frameworks of
experience for example, fantasy worlds, dream world, and
psychopathological worlds Schutz and Luckmann, 1973. The
ontological framework of experience is the everyday world in
which one lives, eats, works, loves, suffers, gets sick and dies.
Abnormal mental phenomena are the expression of a modication
of the ontological framework within which experience is generated. The overall change in the ontological framework of experience transpires through the single symptoms, but the specicity of
the core is only graspable at a more comprehensive structural level
(Parnas, 2004; Stanghellini and Rosfort, 2013; Stanghellini and
Rossi, 2014). The experience of time, space, body, self and others,
and their modications, are indexes of the patient's basic structures of subjectivity within which each single abnormal experience is situated (Stanghellini et al., 2014a, 2014b, in press).

3.3.1. Schizophrenia
Schizophrenic delusions are not the effect of wrong reasoning,
rather they arise from a breakdown of the patient's total awareness of reality. What is changed is not an opinion about reality, but
the very structure of the global perspective on the world: the
patient's existential-ontological framework of experience (Parnas,
2004, 2011, 2012; for a detailed analysis see Stanghellini and
Rosfort, 2013; patients quotes from unpublished database). In the
following, we will conne our description to the most salient
features of this transformation.

3.3.2. Time
A typical feature of lived time in persons with schizophrenia is
temporal fragmentation, e.g., patients may experience a collection of disarticulated snapshots rather than as a coherent series of
actions and events (Things are glittering like a mirage). Another
key feature is captured by the concept of ante festum (Kimura,
1992, 1994), e.g., patients feel that something is about to happen
to them or in the external world (I have a premonition of what is
going to happen to me). These and similar anomalies in lived
temporality are widely described in phenomenological literature
(Minkowski, 1933; Binswanger, 1960; Pringuey, 1997; Fuchs, 2013;
Sass and Pienkos, 2013b).
3.3.3. Body
Most characteristic are ongoing bodily feelings of disintegration/violation and thingness/mechanization. These include
experiences of dynamization of bodily boundaries (Areas of body
where forces enter), bodily construction (Mouth was where hair
should be), body appearance (Face changing), and externalization (Vagina half outside). Other typical phenomena are morbid
objectivization and devitalization (Felt programmed like a robot)
(Cutting, 1997; de Haan and Fuchs, 2010; Stanghellini, 2008b;
Stanghellini et al., 2012; Stanghellini and Rosfort, 2013;
Stanghellini et al., 2014b, in press).
3.3.4. Space
One key feature of lived space in schizophrenia is its growing
homogeneous, two-dimensional, losing its perspectival quality
(Sechehaye, 1951; Conrad, 1958; Matussek, 1987; Sass and
Pienkos, 2013c, 2013d). Another typical feature is itemization
(Stanghellini and Rosfort, 2013): as with time experience, the
fragmentation of space Gestalt reduces the ensemble of a living
situation to a mere collection of itemized details (I am overwhelmed by too much detail too much detail in objects).
3.3.5. Self
Schizophrenia has been interpreted as a disorder of the prereexive self, i.e. a pervasive perturbation of the core sense of self
(ipseity) that is normally implicit in each act of awareness (Parnas,
2011, 2012; Parnas et al., 2005; Parnas and Sass, 2001; Sass and

176

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Parnas, 2003). Such core sense of self refers to a crucial sense of


self-sameness, of existing as a unied, unique and embodied
subject of experience that is at one with oneself at any given
moment. When this basic sense of self is disturbed, the person is
inclined to experience both a kind of exaggerated selfconsciousness (hyper-reexivity) (Sass, 1994) and a concomitant
fading in the tacit, pre-verbal feeling of existing as a living and
unied subject of awareness (diminished self-affection). These
changes in the basic structures of consciousness are accompanied
by an alteration of the very structure of the eld of awareness, that
leads to an emergent, particular way of experiencing which is
infused by:
a) A change in the focus or salience with which objects and
meanings emerge from the background context;
b) An altered conceptual grip or hold on the world;
c) A mutual amplication of the growing dissolution of the sense
of existing as a subject with a more pronounced, disturbing and
alienating self-scrutiny;
d) An increasing objectication and externalization of normally
tacit inner phenomena, with a morbid objectication of ones
own psychic life;
At the extreme of such progression the person might lose the
naturally pre-given sense of coinciding with his own thoughts,
sensations and actions and may feel that she is under the inuence
of some alien force or entity (e.g. Schneiderian rst-rank symptoms).
3.3.6. Major depression
Depressive delusions are the way in which the depressive
patient, overwhelmed by the impact of the past, experiences her
body and is forced to read her history. The living body is
experientially reduced to an inanimate corpse. History is experienced in its absolute irrevocability, the past as an unpardonable
guilt, the future as inevitable catastrophe, and the present as
irreparable ruin.
3.3.7. Time
Major depression has been interpreted as a pathology of
becoming (Straus, 1960, 1966; von Gebsattel, 1954; Minkowski,
1933; Binswanger, 1960) or as a kind a desynchronization between
personal and objective time (Fuchs, 2001). With a standstill of
becoming, the future is a repetition of the past (Kraus, 1977).
In major depression there is a dis-articulation in lived time, but of
a different kind as compared to schizophrenic temporal fragmentation. What prevails is an experience of timelessness where past,
present and future are merged together (All is timeless, There is
no break in time. There is no day and no night. All is joined into
one). Present and future are merely a repetition of the past (There
is in me a kind of routine which does not permit me to envisage
the future).
3.3.8. Body
Major depressives have experiences of body failure (Body not
working), or collapse (Body rotted), or of slowing of bodily
functions (Bowel blocked). They do not include violation of selfboundaries or externalization of parts of one's bodily self as with
schizophrenia patients. Although they may include feelings of
body collapse these do not coincide with schizophrenic experiences of disintegration of bodily construction, since typically in
former the body implodes into itself and in the latter the body
falls apart.
Although these experiences express bodily devitalization, this
is not the same qualitative experience of mechanization that is
expressed by persons with schizophrenia. In major depression,

indeed, the deadening of one's embodied self nds expression in


feeling heavy, oppressive, suffocated (Head congested), imploded
into oneself (Stomach fallen down), and, nally, it takes the
aspect of a cadaver Drr (1997).
3.3.9. Space
The physiognomy of space in major depression reects the
sense of constriction that we nd in time and body experience
(Everything in world is too small, dining room seemed very
congested not enough places for patients). The shrinking of
space expresses the depressive's anguish (Everything closing in
around me all this blackness; Everything black, all in darkness;
my at looked all black). Also, exterminate extension may reect
the feeling that things in the world out there are out of reach and
inaccessible (Space seemed an eternity) (Straus, 1958).
3.3.10. Self
Major depression does not entail disorders of the pre-reexive
self as it is the case with schizophrenia. It implies a different kind of
depersonalization involving the process through which we form the
representation of our identity, that is, the narrative self. The narrative
self is the concept one constructs of oneself. One's own narrative
identity arises from the interplay between I-ams and I-cans. I-cans
are what one is not, one's own possibilities. Depressives insist on a
nite and un-chosen perspective of stable characteristics that they
consider their own, and with which they over-identify and experiences other possibilities merely as a source of alienation or nullication (Kraus, 1977, 1991, 1996) This intolerance to other possibilities
and the avoidance of the dialectic between I-ams and I-cans
immanent in the constitution of one's narrative self leads to an
identication with partial, external and reied identities, such as
role-identity, i.e. external/socially appreciated representations of
identity (Mundt et al., 1996; Stanghellini and Bertelli, 2006). Depressives internalize role-identities and through this internalization they
acquire a stable, although inexible, self identity (Mundt et al., 1997).
Their identity is based on a reied, sclerotic self-representation. It
implies an over-simplied categorization of oneself and of the others,
who appear in the light of their social roles, rather than in that of
their ego-identity (Stanghellini and Mundt, 1997; Stanghellini and
Bertelli, 2000, 2006).

4. Existential orientation
The existential orientation is a person's philosophy of life, his
world-view, that is, the values that regulate meaning-bestowing
and the signicant actions of the person. Grasping the values of a
person is a key to understanding her way of interpreting her
experience and representing herself. In general, it is a key to
understanding her form of life or being in the world, that is, the
pragmatic motive and the system of relevance that determine
the meaning structure of the world she lives in.
4.1. Schizophrenia
Many authors (Kretschmer, 1925; Berze and Gruhle., 1929;
Minkowski, 1927; Binswanger, 1960; Blankenburg, 1971) highlight
eccentricity as the core of the existential orientation of persons
with schizophrenia. The schizophrenic value system conveys an
overall crisis of common sense. The outcome of this can be
designated as antagonomia and idionomia. Antagonomia reects
the choice to take an eccentric stand in the face of commonly
shared assumptions and the here and now other. Idionomia
reects the feeling of the radical uniqueness and exceptionality
of one's being with respect to common sense and the other human
beings. This sentiment of radical exceptionality is felt as a gift,

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177

Table 4.

often in view of an eschatological mission or a vocation to a


superior, novel, metaphysical understanding of the world
(Stanghellini and Ballerini, 2007, 2011; Stanghellini et al., 2014b,
in press).

4.2. Major depression


Depressives are basically centric persons: hyper-connected to
common sense and overidentied with social norms (Minkowski,
1927; Kretschmer, 1925; Tellenbach, 1961; Kraus, 1977). Their style
of behavior is impressive for its over-normality, extreme social
adjustment and conformism (Stanghellini and Mundt, 1997; von
Zerssen, 2002). Their existential orientation can be condensed in
the following features:
a) Orderliness: the need for meticulous organization of ones
own life-world and the xation on harmony in interpersonal
relationships.
b) Conscientiousness: the commitment to prevent guiltattributions and guilt-feelings.
c) Hypernomia/heteronomia: exaggerated norm adaptation and
external norm receptiveness.
d) Intolerance of ambiguity: the emotional and cognitive incapacity to perceive opposite characteristics concerning the same
object or person (Stanghellini et al., 2006) Table 4.

of delusions, and the background from which delusions arise, that


is, changes in the eld of experience, background feelings, ontological framework of experience, and existential orientation. The
aim of this comprehensive assessment is delineating the manifold
phenomena experienced by patients in all of their concrete and
distinctive features, so that the features of a pathological condition
emerge, while preserving their peculiar feel, meaning, and value
for the patient. This kind of systematic exploration of anomalies in
the patients' experience may provide a useful integration to the
standard symptom-based approach and can be used to establish a
differential typology of the clinical manifestation of psychosis
based on the fundamental alterations of the structures of subjectivity characterizing each mental disorder, and particularly with
respect to the Kraepelinian dichotomy schizophrenic vs. manicdepressive illness.

Role of funding source


No funding source contributed or had any inuence on the study design,
preparation and submission.

Conict of interest
None of the authors or their immediate family members have a potential
conict of interest in the work presented here.

Acknowledgment
The research and writing of this paper was solely done by the authors.

5. Conclusions
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