Schizophrenic Delusions - A Phenomenological Approach

VOL 19, NO.
3, 1993
Schizophrenic Delusions:
A Phenomenological
Approach
propose a specificity in the
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by Pierre Bovet and Abstract
Josef Parnas themes of schizophrenic delu-
The issue of specificity of delusions. Delusions acquire a
sions in schizophrenia is still a schizophrenic quality when on-
matter of debate. The authors tological (i.e., universal) elements
analyze the delusion formation of the discourse between the
in schizophrenia from a pro- locutor and the Other dominate
totypical, phenomenological point at the expense of the worldly
of view, focusing on the sub- elements. It is emphasized that
ject's experience. This perspective delusional content and form are
links delusion formation to the dialectically related and hardly
autistic predisposition, which is distinguishable. The authors con-
considered here as the elemen- sider the delusion formation as a
tary phenotypic expression of the phenomenon of emergence, a sit-
vulnerability to schizophrenia. uation in which a new qualita-
Autism is viewed as a defective tive order arises from the reorga-
preconceptual (i.e., before lan- nization of essentially unchanged
guage) attunement to the world. elements. To consider schizo-
It impedes the individual's shar- phrenia as an emergent, particu-
ing of "common sense" with lar way of experiencing, related
others and impairs the ability to to the autistic defect, has impor-
project into the future. The de- tant consequences for research
velopment of delusions is illus- and for treatment. A dialectic ex-
trated, in part, by Klaus Con- change is needed between pro-
rad's work on the onset of totypical models generated by
paranoid schizophrenia. Delu- phenomenological inquiry and
sions are viewed as transforma- empirical, operational validation
tions of the structure of ex- of testable aspects of such
periencing. When threatened in models.
future ability to be, the autistic,
vulnerable person looks for the
clues to becoming by attributing A delusion is usually defined by a
significance to disparate elements set of formal, descriptive criteria,
of the environment, which be- which have been summarized by
come self-referential. The link Oltmanns (1988, p. 5).
established between these dispa-
rate elements is based on univer- The following list includes
sal characteristics that give the several features that have
been used to describe delu-
schizophrenic delusion a meta- sions. They might also be
physical quality. The transitivis- seen as defining characteris-
tic experience in delusions of tics, with none being consid-
control and omnipotence points ered to be either necessary or
sufficient conditions [italics
to a specific way of crossing the added].
border between "mine" and
"yours" (disturbances of the ex- a. The balance of evidence
periencing "I"). What strikes a for and against the belief is
clinician in these delusions is
that the normally tacit link be- Reprint requests should be sent to
tween the sense of being and Dr. P. Bovet, Policlinique psychiatri-
the sense of acting becomes que universitaire A, 18, av. de
quite apparent The authors also S£velin, CH-10O4 Lausanne,
Switzerland.
580 SCHIZOPHRENIA BULLETIN

such that other people con- should be accompanied by a set of case of schizophrenia, the work of
sider it completely incredible. subcriteria, which in turn should Kraepelin, Bleuler, and Schneider)
b. The belief is not shared be more precisely defined, and so influence the conceptual guidelines
by others. of polythetic operational systems
c. The belief is held by forth. In otheT words, we can only
firm conviction. The person's designate a given statement as de- with respect to specificity and
statements or behaviors are lusional within a specific context, pathogenesis. Prototypical cases
unresponsive to the presenta- encompassing the patient's and the cannot, by definition, be gener-
tion of evidence contrary to clinician's experience. alized as true or false (e.g., a
the belief.
d. The person is preoc- Moreover, delusion is a non- sparrow is more prototypical of a
cupied with (emotionally specific symptom, occurring in bird than a penguin, but all of its
committed to) the belief and many functional and organic men- own characteristics cannot be gen-
finds it difficult to avoid tal disorders (Oepen et al. 1988). eralized to the generic class of
thinking or talking about it. birds), and empirical work is nec-
e. The belief involves per- The issues of objectivity and speci-
sonal reference, rather than ficity become more problematic essary to assess the sensitivity and
unconventional religious, sci- when delusions are included in specificity of singular features that
entific, or political conviction. the diagnostic criteria of schizo- are derived from the prototype.
f. The belief is a source of phrenia. The clinical demarcation In the absence of external val-
subjective distress or inter-
feres with the person's oc- of schizophrenia lacks, so far, a idation, the diagnostic concepts of
cupational or social func- specific, independent validation cri- schizophrenia have to rely on a
tioning. terion (i.e., biological marker). This dynamic exchange between pro-
g. The person does not re- lack immediately renders any pos- totypical conceptualizations and
port subjective efforts to re- tulate about specificity of a given empirical validations based on op-
sist the belief (in contrast to clinical feature debatable. Opera-
patients with obsessional erational definitions. The variety of
ideas). tional diagnostic systems deal with behavioral phenotypes in schizo-
these difficulties by specifying a phrenia results from a long causal
This line of thinking, called "op-
number of features that should co- chain of increasingly complex in-
erationalism," is currently the most exist in a given case in order to teractions between the putative
accepted approach in psychiatry be included in a diagnostic cate- biological etiological factors and
(Stein 1991). Operational definitions gory (polythetic systems). The environment (Bleuler 1917; Ciompi
of scientific terms aim at "objec- DSM-IU-R (American Psychiatric 1988a). Single symptoms of adult
tivity" of knowledge, "in the sense Association 1987) requires that schizophrenia patients are not pri-
of being intersubjectively certifia- delusions either have to be ac- mary (in the pathogenetic sense)
ble, independently of individual companied by specified other and are only rarely diagnostically
opinion or preference" (Hempel symptoms (e.g., incoherence, hal- specific. However, some of these
1965). lucinations) or exhibit a bizarre symptoms may exhibit qualities
An operational definition of a quality (sufficient requirement). that reflect basic disturbances, that
term is conceived as a rule to Unfortunately, Flaum et al. (1991) is, the disturbances that are "mid-
the effect that the term is to did not find "bizarreness" to be way" between the underlying
apply to a particular case if the operationally reliable even among
performance of specified opera- pathophysiology and overt
tions in that case yields a cer- the members of the task force on symptomatology.
tain characteristic result, [p. 123] DSM-1V.
We hypothesize that these basic
However, delusion is difficult to Polythetic systems do not arise disturbances, which create a vul-
define operationally. Each of the out of the blue but derive from nerability to schizophrenia, relate
listed criteria, considered sepa- prototypical descriptions. "Pro- to a difficulty in the intersubjective
rately, is insufficient. For instance, totypic categories are organized constitution of the sense of a Self.
criterion b, "The belief is not around prototypical examples (the We use a phenomenological ap-
shared by others," should require best examples of the concept) with proach to explore how delusional
the psychiatrist to screen a large less prototypical examples forming transformation in paranoid schizo-
sample and would be refuted in a continuum away from these cen- phrenia reflects a particular way of
cases of folie-b-deux. To improve tral cases" (livesley 1985, p. 355). relating to the world, exhibited
operationality, each of the criteria The prototypical notions (in the premorbidly. The ideas presented
VOL. 19, NO. 3, 1993 581

below are based on a prototypical bring to mind as precisely as pos- of the world to which it is per-
approach and cannot avoid a fla- sible what the patient experiences petually directed. The word phe-
vor of generalization. Components ("presentifi cation"). nomenon does not refer to a mere
of such a prototype still have to Our approach, which may be appearance, but, being a correlate
face empirical validation. Even considered as post-Jaspersian phe- of any mental act, phenomenon
though the mechanisms we discuss nomenological psychiatry, has been possesses a certain intrinsic sense
are not applicable to all pheno- developed mainly in Germany and of truth (essence). Phenomenologi-
types summarized today as schizo- France. It is based on phenom- cal inquiry tries to unearth the
phrenia, we think that they illus- enological philosophy (Husserl meaning of the phenomenon; pri-
trate specific aspects of the 1900/1970b, 1936/1970^; Heidegger ority is given to the "evident-
ontogenic development of schizo- 1927/1962, 1975/1988; Merleau- ness" or "given-ness" of the phe-
phrenic symptomatology. Ponty 1945/1962, 1947/1964, nomenon as opposed to its pos-
1964/1968), which aims at identi- sibilities of being objectified. In
fying and describing the essential the epistemic act, which Husserl
Definitions of features of the human being in the (1913/1975) called "originally pre-
Phenomenology world. Phenomenology represents senting experience" or "lived ex-
a radical departure from the Carte- perience," the phenomenon unfolds
Phenomenology has ambiguous itself to us, and in our mutual in-
connotations, as was illustrated by sian tradition of sharp subject-
object, mind-body, affect-cognition volvement with it, we are able to
a recent debate in the Schizo- grasp the invariant essence or
phrenia Bulletin (Andreasen 1991; dualisms. "Subject and object must
structure of it by focusing on its
Rotov 1991). For the sake of clar- be conceived as two abstract 'mo-
variations against a horizon (con-
ity, we shall distinguish between ments' of a unique structure which
text or texture). The "lived ex-
three common uses of this term is presence" (Merleau-Ponty,
perience" is always embedded in
and indicate which of them is 1945/1962, e.t. p. 430).1 Phenom- intersubjectivity, that is, the tacit
used by the present authors. enological inquiry focuses on the apprehension that our individual
In Anglo-Saxon psychiatry, phe- concrete fullness of the subject- privacy is always constituted and
nomenology is synonymous with object whole as it is lived before framed by its similarity to (though
descriptive psychopathology and the conceptual split between object not identity with) other peoples'
refers to the description of symp- and subject is introduced by the privacies.
toms and signs in psychiatric ill- use of language. Phenomenology
ness. This descriptive process is considers human knowledge as a My awareness of constructing
ideally performed by an impartial, dialectic between the object and an objective truth would never
"objectifying" observer. the subject, implying intentionality provide me with anything more
of the subject: consciousness is al- than an objective truth for me,
In continental Europe, Jaspers and my greatest attempt at im-
(1923) considered phenomenology ways consciousness of something. partiality would never enable
as a branch of psychopathology Consciousness itself is a projection me to prevail over my subjec-
tivity, if I had not, underlying
concerned with the patient's inner my judgments, the primordial
world, that is, with "symptoms" 'References to the literature first certainty of being in contact
rather than "signs." This world is published in German, French, or Pol- with being itself, if before any
inaccessible to direct observation ish are quoted with the original pub- voluntary adoption of a position I
and can only be grasped through lication's date to facilitate a historical were not already situated in an
apprehension of the concepts' per-
intersubjective world. [Merleau-
the patient's report. The psycho- Ponty 1945/1962, e.t. p. 355]
pathologist, then, must faithfully spective evolution. When an English
reproduce the patient's experience, translation is available, it is indicated The context of intersubjectiviry is
preferably by quoting the patient's in the list of references. In that case,
designated by Husserl (1936/1970a)
pages in the text are those of the
spontaneous self-descriptions, be- English translation (e.t.). We have as "lived world," that is, the ex-
cause these are undistorted by slightly modified the English transla- perienced world, which is always
questioning. The observer relies in tion of Minkowski's Le Temps Vtcu. there in its concreteness and fac-
his investigation on empathy, and Quotations not published in English ticity, as the universal field of all
the goal of the investigation is to have been translated by the authors. action. What is given in our en-

counter with the world is neither was already sketched by Bleuler The overall picture emerging
the object perceived nor the per- and Jung in 1908 and explicitly from these studies is that gross
ceiving subject, but rather an ex- formulated by Minkowski 20 years behavioral abnormalities are not
perience that implies the inter- later identifiable in all preschizophrenia
twining of perceiver and perceived subjects. However, abnormalities
and the reversibility of my percep- The notion of schizophrenia, as can be shown in several be-
tion with that of another. The phe- a mental disease, can be decom- havioral domains with the pos-
nomenological maxim "to the posed into two factors, of dif- sibility "that each of the indicators
ferent order: first, the schiz-
things themselves" implies for psy- oidia, which is a constitutional involves information on one or
chopathology a task of unprej- factor, highly specific, and tem- several separate aspects of a single
udiced concern with man and porally enduring through the underlying vulnerability that is
man's modes of being-in-the-world individual life; and, second, a simply manifested more clearly in
as they are directly encountered in noxious factor, of an evolutional some sorts of behavior in one case
nature, and which has the abil-
experience. ity to determine a morbid men- and other sorts in other cases"
Historically, phenomenological tal process. This latter factor (Hartmann et al. 1984, p. 1055).
psychiatry in that philosophical has, for itself, no definite taint, We hypothesize that premorbid
it is of a more unspecific na- male aggressiveness and female in-
line of thought is considered as ture, and the clinical picture to
having been founded in Zurich which it will lead will depend troversion in school (Watt 1972,
during the 63rd Assembly of the upon the ground on which it 1978); difficulties in interpersonal
Swiss Psychiatric Association in will act. Together with schiz- relations, anxiety, neophobia, and
1922 (Schweizerischer Verein fur oidia, it will transform the latter flat affect in males (Hartmann et
into a specific morbid process, al. 1984); and defective emotional
Psychiatrie 1923). into schizophrenia. [Minkowski
It is clear that there is some 1927, pp. 50-51] rapport, eccentricity, and formal
overlap between Jaspersian and thought disorder in high-risk pre-
post-Jaspersian psychiatric phe- schizophrenia subjects (Parnas et
According to this model, schizo- al. 1982; Parnas and Jergensen
nomenology. Even though "early" phrenia occurs only among vulner-
Jaspers used concepts like "empa- 1989) are all indicators of a defec-
able individuals. There is a con- tive attunement between the indi-
thy" and "presentification/' he sensus among researchers that
was reluctant to abandon his vidual and the outer world. The
vulnerability to schizophrenia is specificity of this defective attune-
positivist perspective (Blankenburg formed early in life. Premorbid
1980). Later, Jaspers moved to an ment is hardly recognizable in any
characteristics may therefore be single behavioral disturbance;
existential philosophical position. considered as subtle clinical indica-
Readers interested in philosophical rather, the overall picture attains
tors of such vulnerability. Up to some prototypical value. This lack
phenomenology are referred to the end of the 1960s, all empirical
Hammond et al. (1991). A readily of attunement corresponds to what
studies on premorbid characteris- Minkowski calls "schizoidia." We
accessible account of phenomeno- tics were retrospective (Offord and
logical psychopathology can be shall designate this defective rap-
Cross 1969) and therefore largely port between the individual and
found in De Koning and Jenner unreliable. More recently, studies
(1982). the outer world as the autistic vul-
appeared using data collected dur- nerability (Parnas and Bovet 1991).
ing the subjects' childhood before
their first schizophrenia episode It must be emphasized that the
A Phenomenological and recoded by the investigators term "autistic" does not denote
Approach to Schizophrenic along the dimensions of their in- here a withdrawn and shut-in atti-
Vulnerability terest (Watt 1972, 1978; Hartmann tude. Autism was originally de-
et al. 1984). Prospective studies of fined by Bleuler (1911/1950) as a
Our basic assumption, which is children at risk for schizophrenia withdrawal from outer reality, ac-
shared by most clinicians and re- used clinical evaluations and other companied by the predominance of
searchers involved in the field of concurrent data sources (Parnas et the inner fantasy life. However,
schizophrenia, is to consider al. 1982; Parnas and Schulsinger both the notion of withdrawal and
schizophrenia as an epigenetic de- 1986; Pamas and Jergensen 1989; the notion of rich fantasy life are
velopmental process. Such a model Parnas and Mednick 1991). often contradicted by empirical
VOL. 19, NO. 3, 1993 583

data (Bleuler's own descriptions of proper perspective, to distinguish were transcribed as literally as
"latent schizophrenias," 1911/1950; between what is relevant and irrel- possible.
Kraepelin 1919/1921; Minkowski evant, likely and improbable,
"I have the need of support in
1927; Zilborg 1941; Dunaif and which is a more elementary ability the most trivial everyday mat-
Hoch 1955). In fact, Bleuler was than to distinguish between what ters. I cannot do it by myself
not able to provide a satisfactory is true and what is false. It is It is of course the natural evi-
symptomatological description of "knowing how to negotiate our dence, which I am lacking."
autism and therefore categorized way through a world that is not Sometimes she spoke also of
"the evidence of feeling." [What
it as a complex fundamental fixed and pregiven but that is con- does she mean by that?] "Every
symptom. tinually shaped by the types of ac- human must know how to be-
For phenomenology, autism is tions in which we engage" (Varela have, every human has a track,
not a symptom in the sense of the et al. 1991, p. 144). Common sense a way of thinking. His be-
reflects our preconceptual attune- havior, his humanity, his so-
medical model; rather, it is a phe- ciality, all these rules of the
nomenon that is recognizable in ment to the world. It reveals not game which he uses: until now,
the intersubjective space (Tatossian so much what is evident but how I have been unable to recognize
1979). It is precisely for that rea- it is evident, the constantly present it clearly. I lack foundations....
and tacit frame of experience I am precisely lacking that,
son that clinicians are sometimes what I know, I would know it
able to make a very quick diag- (Tatossian 1979; Forguson 1989). also in my encounter with other
nosis of schizophrenia in the en- The defect in common sense can people—so, evidently It was
counter with the patient. In such a manifest itself in a lack of taste exactly the same in the store
diagnostic act, the clinician imme- and feeling for what is adequate [where she had been em-
diately and preconceptually grasps and a lack of the sense for the ployed]. How people behave,
"rules of the game" of human be- now they lived correctly! It is
the sense of the clinical picture not knowledge. One cannot
(Riimke 1942; Schwartz and Wig- havior. Relatives of patients with simply see it and understand it.
gins 1987). schizophrenia often report that, in Probably, one must first with
the initial stages of schizophrenia, parents—it is probably with the
Phenomenology sees autism as a parents—one must first have a
the patient asks questions about
defective expressive-perceptual at- link with them, a link with a
the most self-evident issues, human being that one under-
tunement between the subject and
whereas the ability to solve ab- stands.... If now—just when we
the outer world. The autistic defect
stract and intellectual problems re- have to work together, I cannot
is perceivable both in the cognitive stand it for a long time; I am
mains intact. In such cases, it is
and in the affective domains be- unable. For example washing
sometimes clear that the lack of
cause the attunement to the world up: the difficulty, yes what
common sense is compensated by would be the difficulty for me,
is affected at the very elementary,
a hypertrophied devotion to logical how to say it, I do not manage
preconceptual level. Expressions
solutions (Blankenburg 1969). it in a self-evident way: it is
used by European phenomenolo- strange and disconcerting,
gists, such as "loss of vital contact The view of autism as a "global [pp. 42-14]
with reality" (Minkowski 1926, crisis of common sense" points to
1927, 1933/1970), "inconsistency of the defective core of ontic attune- These complaints illustrate
natural experience" (Binswanger ment. (The Greek word "onta" the "naked," elementary lack of
1963), "global crisis of common means reality, real being. Through- attunement to the world
sense," or "loss of natural evi- out this article, we distinguish be- (Minkowski's "autisme pauvre,"
dence" (Blankenburg 1969, 1971), tween the adjectives "ontic," refer- i.e., empty autism), which often
refer precisely to this autistic im- ring to something worldly, and becomes concealed by withdrawal
pairment of the elementary di- "ontological," referring to general or by productive psychotic symp-
alogue between the Self and the and universal possibilities for toms (Minkowski's "autisme
outer world. something to occur. Ontology is riche," i.e., rich or florid autism as
According to Blankenburg (1969), the branch of philosophy con- described by Bleuler).
the essential feature of autism is cerned with the essence of being.) An essential component of the
the "lack of common sense" Blankenburg (1971) gives the fol- attunement to the world and of
(sensus communis). Common sense lowing vignette of a young female intersubjectivity is their temporal
is the ability to see things in the patient whose self-descriptions aspect. Minkowski (1926, 1933/

1970) pointed to the temporal di- and present are meaningfully and impedes maturation processes; au-
mension in the preconceptual at- reciprocally interwoven as structur- tistic subjects cannot become ex-
tunement and in intersubjectiviry ing the referential context of hu- perienced because their experienc-
by introducing the term "lived man existence. In this sense, tem- ing is not properly incorporated.
synchronism/' which is described porality, unlike time, is not One of Minkowski's (1927, p. 100)
as follows: unidirectional from past to future patients expressed this peculiar
but is reversible, continuous, and waiting attitude in the following
The faculty of advancing harmo- finite, bound by the wholeness of way: "I have even less flexibility
niously with ambient becoming
and in the same time of letting the human existence, which is when I think about the future
us be penetrated by it and of completed by death. Temporality is than I have about the present and
feeling one with it [A] phe- only apprehended preconceptually: the past. There is a kind of'rou-
nomenon which achieves vital our sense of the Self integrates the tine affecting me which does not
contact with reality in a par-
ticularly vibrant way is sympa- sediments of our experiences, our allow me to contemplate the fu-
thy, in the etymological sense of past belongs to our present and ture. The creative ability in me
the word.... Sympathy cannot future, and our projections into the has gone. I see the future only as
be instantaneous, there is al- future influence our experience of a repetition of the past." In our
ways duration in it, and in this the past. In temporality, the future view, the difficulty of many pre-
duration there are two becom-
ings which flow side by side in is the fundamental element, be- schizophrenia subjects is a reduced
perfect harmony.... We find the cause this is the temporal dimen- ability to transcend, that is to flex-
same phenomenon of vital con- sion on which human beings pro- ibly change a perspective while
tact with reality in that feeling ject themselves. This potential to still retaining one's autonomy and
of measure and limits which sur- project into the future is a unique self-identity. In fact, a defective
rounds all of our precepts like
a living fringe, rendering them characteristic of human existence. sense of the continuity of the Self
infinitely nuanced and infinitely over time is one of the empirically
human. It is a good thing to One can distinguish between
demonstrated indicators of vul-
have rules of conduct, it is bet- two fundamentally different ap-
nerability (Hartmann et al. 1984).
ter to know how to apply proaches to the future (Heidegger
them It is intuition, and intu- 1927/1962; Minkowski 1933/1970): Our clinical experience indicates
ition alone, which lays down activity or anticipation, in which that schizophrenia patients tend to
our line of conduct and which,
in particular cases, let us depart we feel ourselves going toward act, think, and feel as if their life
from previously adopted pre- the future, and waiting, in which is congealed in an ahistorical per-
cepts. We just seek by that to we feel the future coming toward spective. The word ahistorical
be in accord, obviously through us. In waiting, the individual feels means that the dynamic interaction
feeling and not through reason, submerged, experiencing the whole between past, present, and future
with ourselves, and with life.
Without ever being able to for- of becoming, concentrated outside is deficient. The impact of the past
mulate it, we know what we himself, as a prearranged destiny. is not hierarchically structured,
have to do; and it is this that An essential component of the and events that usually fade away
makes our activity infinitely may retain a disproportionate im-
malleable, infinitely human. autistic defect is the impairment of
[Minkowski 1933/1970, e.t. the subject's self-temporalization, portance. The elements of the past
pp. 65-69] that is, a defect in "lived synchro- are often relived in a stereotyped
nism." (We do not speak here of way and do not change with cir-
"lived synchronism" expresses the disturbances of the subjective cumstances. The future has a lim-
the possibility of accord and mutu- perception of time [e.g., time ited degree of freedom and is
ality between temporalization standing still, being discontinuous, often experienced as a prearranged
("lived time") of disparate Selves. time-rushing, etc.] which may be destiny. Such a fixed outlook is
Temporality is a phenomenological observed both in schizophrenia frequently shared by the nuclear
concept and refers to the dynamic [Fischer 1929] and in epilepsy.) family of a schizophrenia patient
matrix of temporal references in The subject's potential to project and is reflected in complex repeti-
which any concrete life is lived himself into possible futures and tive patterns of attitudes and be-
(Heidegger 1927/1962; Merleau- anticipate himself is diminished. haviors that may persist across
Ponty 1945/1962; Ricoeur 1985/ Autistic subjects seem to live generations (Bovet and Schmid
1988). In temporality, future, past, mainly in the waiting mode. This 1987; Schmid and Bovet 1988).
VOL 19, NO. 3, 1993 585

Case #1. One of our schizo- vital contact with reality" (the fundamental to understanding the
phrenia patients was severely in- daily routine or the planning of onset of paranoid schizophrenia.
hibited in his everyday obligations the future career become meaning- Conrad described in detail the
by extreme difficulty in getting out less by their disconnection with onset of schizophrenia in a sample
of bed in the morning. He would their context) and at the same of 117 cases, which he collected
spend hours lying awake in his time point to the corollary of this during World War II when he
bed, anticipating the necessary ac- defective preconceptual attunement, was working as a psychiatrist in a
tivities before the beginning of the namely the impaired temporaliza- German military hospital. Conrad
day. At therapy sessions he ex- tion of the Self. distinguishes four stages in the de-
plained that his reluctance to start These three correlated aspects of velopment of delusion: (1) the ini-
the day was related to his aware- the autistic defect, that is, defective tial phase, which he calls "das
ness of the necessity of washing attunement, weak intersubjective Trema"; (2) the apophantic phase,
his hair and shaving himself after ties, and difficulties in self- in which the establishment of a
getting up. He would then think temporalization, are fundamental to delusion gradually takes place.
about thousands of his past, and our view of the development of (The Greek word apophainein
endless future, washings and shav- delusions in schizophrenia. We means "becoming visible or appar-
ings. The cumulated image of propose that the normal subject, ent." The word apophantic con-
these repetitive activities acquired veys therefore the quality of a
always immersed in intersubjec-
a quality of an insurmountable ab- revelatory experience. This phase
tivity, searches in himself for the
surdity and prevented him from represents an autoplastic reshaping
main clues to his future, whereas
getting up. of one's being-in-the-world.); (3)
the preschizophrenia subject, un-
the apocalyptic phase, in which
Case #2. A 25-year-old male framed by intersubjective ties, is the patient disintegrates; and fi-
schizotype, interviewed in the forced to look for such guiding nally (4) the consolidation phase,
course of a genetic study, reported clues in the "outer world," render- which refers to outcome.
that his marks dropped when he ing the latter potentially self-
was finishing his secondary school, referential. If such a vulnerable in-
dividual finds himself committed Case #3. Born in 1921, the pa-
when he was about 17 years old. tient had been referred [to Con-
Asked for explanation, he gave the to a situation that threatens his
autonomy beyond his capacities, rad] in 1941. He had a severe de-
following account: He would have lusion of reference. He refused to
fantasies about some specific fu- the way to escape the threat is to
reshape the context of his being- be examined, as he claimed that
ture university training, and then everyone had access to his
try to imagine himself working in in-the-world, either by an "auto-
plastic," delusional reshaping of thoughts. He was extremely sus-
a job with this education. For in- picious, misidentified people, and
stance, becoming an engineer the experience or by a temporary,
senseless "alloplastic" behavior. was in a state of excitation. He
would involve working in the con- improved slowly and was finally
struction industry. He would then Such episodes may relieve the ten-
sion, and the individual may re- able to report the development of
imagine himself endlessly and re- his illness, even though he still
peatedly calculating mechanical turn to the status quo ante or pro-
gress by an autocatalytic process was deluded.
constraints of the buildings. This
into a long-lasting schizophrenic (1) When he was 18 years old,
"eternal" and senseless image of
episode (Ciompi 1982/1988b). some months before the beginning
himself would lead him to drop
of the war, he graduated from a
this particular educational project
merchants school, but he did not
and change to another one, with
Development of Delusions get the diploma that would allow
similar result. The end conse-
in Schizophrenia him to enter the University (in
quence was that he withdrew from
Germany: "Abitur"). He was upset
the school work.
To illustrate the development of by and ambivalent to his parents'
These two cases illustrate the delusional process, we shall expectations as how to continue
Blankenburg's concept of "global rely partly on vignettes translated his career and about his future fi-
crisis of common sense" and from Klaus Conrad (1958), whose nancial dependence on them. He
Minkowski's concept of "loss of work is considered in Europe as decided to leave his parents' home

and to move to another city, as from a shared bottle, or the bottle bed and given some medication,
his father once mentioned the pos- was handed to him with a par- perhaps in order to artificially
sibility of making a business ca- ticular gaze; the atmosphere was raise his temperature.
reer without having the "Abitur." all but friendly. (9) Suddenly, a physician and
He wanted to be relieved from the (5) Suddenly, he felt that he was medics entered the room. He was
awareness of being financially supposed to play some "role" dur- carried into a car and immediately
dependent on his parents. After ing the night; perhaps his peers got the feeling that he was given
being drafted into the army, he would bind him and stamp him a new chance. It was very clear
was sent with his company to with hammer and sickle. So he that he had to pass an examina-
France in November 1940. stayed alert in his bed, watching tion in Germany for becoming an
(2) He was the oldest soldier in its immediate surroundings. Sud- officer. He did not know whether
the company and had a feeling denly, he heard some cracking in the car was bringing him to the
that a particular performance was the floor, jumped out of his bed, airport or to the hospital. The di-
expected from him. He felt under and waited in a defensive position rection to the airport implied
tension. In the camp, the soldiers near the oven. He was hyperalert going to Germany and entering
spoke of promotions. He felt very and sensitive to any noise in the the school of officers. He had to
inclined to enter the career of an neighborhood. But each time he interpret the clues under way in
officer. But because he did not was up, everything seemed appar- order to overcome the uncertainty
have his "Abitur," he just had to ently normal, and he concluded imposed upon him by the driver's
take that idea out of his mind. For that his comrades were faking confusing choice of small country
some time he dwelled on the pos- him. Once, when a guard entered roads.
sibility of entering a professional the barrack, he felt that the guard (10) He was offered a cigarette,
career as an under-officer. During was somehow "instructed." His which he knew was prepared with
that time, he was often reflecting odd behavior was noticed by the a substance which would either
about his future, and his wish of guard, and he was ordered to paralyze his will or let him have a
entering a career as an officer reg- dress himself, and to spend the glimpse of his future.
ularly came to his mind. rest of the night in the guards' (11) On the way, they bypassed
(3) After some time, he got a room. After returning to his bar- an infantry troop, which at this
peculiar feeling that "something rack, he felt a hostile atmosphere, very moment took their arms up,
was in the air"; what it was, he and even his best friend asked which meant that he had to pull
could not say, but he faced per- him, in an "innocent" way, what himself together. As they bypassed
haps a special stake. There were happened. city signs, the names of the vil-
rumors that he, and only he, was (6) Now (at the time of the psy- lages connected to his past memo-
to be promoted to corporal. No chiatric examination), he under- ries. They stopped at a railway
specific names were uttered, but it stands that all these events were crossing, where he noticed the let-
seemed nevertheless clear, that he preparatory steps to his examina- ter "N" on a sign. That meant
had to get the charge. For that tion as a candidate officer. "No," and indicated that his hopes
reason, he felt hostility and feel- (7) (...) for the future were unfounded.
ings of jealousy from his peers. (8) When he was brought to the (12) The car set in motion again,
During a break in an exercise, the medic room, an orderly spoke to and the landscape became more
haversacks were not in a strict him. He then had a feeling that friendly, and his mood improved
alignment; the sergeant told him: there was a plan to prohibit his also. They bypassed the city sign
"Put this stuff in order, it will be promotion. He thought that per- "Gradigan," and that meant that
your responsibility...," an allusion haps he would be caught in some his career was supposed to "re-
to his promotion; such allusions sort of trap and have to scandalize sume its upward direction" (gerade
were very common. himself in public. He was aware w/'eder bergan).
(4) In the following days, he did that the decision of his promotion (13) (...)
not speak to other people, because had to come from provincial au- (14) Even when brought to the
he feared their jealousy. He felt he thorities, and, in case of a scandal, hospital, he was still hopeful,
was stared at by other people. these authorities would withhold noticing that the receptionist had a
One forbade him to have a sip promotion. He was confined to green cover on his desk. He was
VOL 19, NO. 3, 1993 587

ordered to bed in a room with (18) He sensed that his thoughts For a person in a preschizo-
barred windows, which reminded were transmissible and that he phrenic state, the Trema is ex-
him of a prison. A lot of people was hypnotized. They wanted to perienced as a single modality of
were watching him, and one of- drain him of everything. Everyone future coming to the present. He
fered him a cigarette. As soon as could read his thoughts. Whatever becomes caught in a situation that
he inhaled, his vision became he was thinking, the others made he cannot evade because of his in-
wavering. "And now the true the- it clear to him that they knew his ability to transcend.
ater begins, all the other has been thoughts (Conrad 1958, pp. 8-11). In the case of the autoplastic,
the foreplay." delusional resolution of the Trema,
(15) "Of course, I did not know During the initial period (1 and the subject's awareness of the im-
that all this was a part of the ex- 2), there is a longstanding eleva- pending becomes increasingly
amination to become an officer." tion of tension while the patient thematized and self-referent (3 and
All these people were there to ob- faces an ambivalent choice of ca- 4). The preschizophrenia subject
serve him; from the conversation, reer. He cannot find out whether has a feeling of being put under
he was astonished to note that his parents would encourage or some as yet unknown test situa-
much was known of his private discourage him to take his tion, and phenomena in his field
life; allusions were made to his "Abitur." A similar ambivalence of experience (be it inner or outer)
family. concerning his future career tor- acquire a pregnant significance,
(16) He noticed that there were ments him after he is drafted into which is sometimes indicative of
some cows lowing outside the the army. This tension is ex- the future theme of the delusions.
building, and he suddenly was perienced like a pressure that nar- The individual is in a state of
convinced that he was to be exter- rows his field of experience into a "abnormal awareness of signifi-
minated, that he had to be slaugh- single expectation of something cance" 0aspers 1923). The ex-
tered like cattle. impending. What is impending is perienced situation is somehow
(17) He was brought to the doc- always either positive or negative "made" or "fabricated" (6 and 8).
tor's office. The doctor resembled and always significant for one's This turning point, that is the
his uncle, who is a cashier. This life. The impending narrows the Wahnstimmung (delusional mood),
similarity paralyzed him. The doc- individuals' experiential field and represents, according to Conrad, a
tor's voice also had the same nice leads to an increase of tension. transformation of the structure of
quality as the uncle's. He began to The increase of tension is some- experiencing and leads to the ap-
lose the feeling of the connections times called prodromal, in the ophantic (revelatory) phase in
of the situation's elements to each sense of being a signal of the which the delusional perception is
other. Things seemed to go in a coming disease, but, according to crystallized.
supernatural way. He was sure Conrad, the word prodrome is a
In the apophantic phase, the
that the doctor was made up in nosological and not a phenomeno-
connections between the elements
that way in order to test his reac- logical concept and therefore does
that form the perceptual Gestalt
tions. The doctor transcribed his not convey information about the
are transformed. Any single ele-
utterances, but in a distorting way, structure of the lived experience.
ment of a Gestalt always has a
which he protested against, but Conrad therefore introduces the
"cloud" of contextual significance
nobody cared. He had to lie on untranslatable term das Tretna,
for an individual. For example, a
the examination bed and was con- which is taken from the world of
rifle may be associated with mili-
vinced that he would now be theater. It is the word used by an
tary discipline, with the fear of
slaughtered, as there were some actor to designate his state of ten-
being shot, and with the pleasant
blood spots on the doctor's white sion, which precedes his entering
memory of a hunting party. Nor-
coat. He considered the medical the stage, when he can no longer
mally, in a total Gestalt, such sig-
examination as a simulation. Once decide to quit the challenge but
nificance of all elements of ex-
brought back to his bed, he was can only face winning or losing.
perience is in a tacit, mutual
overwhelmed by the thought that The Trema is not always tainted
equilibrium, preventing any ampli-
the cows' low signified that he by anxiety; for instance, an actor
fied univocal attribution of
would be converted into an animal or a sportsman can experience it
significance.
through hypnosis. with a joyful mood.
In the apophantic phase, how-

ever, the connections between the point (17 and 18) this coherence of One day when he was sitting in
elements of the experience are experience, this "common de- his bedroom, his gaze fell upon an
based on a single significance, the nominator," cannot even be main- open pack of his own cigarettes
one that is the same in every ele- tained. In Conrad's scheme, the lying on the table. He suddenly
ment. This common denominator apocalyptic phase is now touched realized that the cigarettes were
has a sort of ontological quality, upon. aligned in a different way than
that is, it possesses a very general Blankenburg (1965) points out when he put his cigarettes on the
or universal character. "One is that the use of some general as- table, and this signified that he
much clearer about the relatedness pect of a Gestalt in a revelatory was going to be killed. In the fol-
of things, because one can over- experience of delusional perception lowing days, he interpreted
look the factuality of things," as is not specific to schizophrenia pa- various clues in his environment
one schizophrenia patient re- tients. It is also found in normal as corroborating his original
marked (Matussek 1952, p. 308). people, especially at turning points conviction.
This patient, when successively en- of their life and in the creative en-
countering a dog, a foal, and an deavor. However, normal people Sometimes, the Trema is not re-
old lady, connected these objects are able to assimilate and tran- solved through the formation of
with each other, as a sign of a scend such an experience in a way delusions, but in an alloplastic
more profound meaning, namely that amplifies their future pos- way, when the preschizophrenia
that the whole landscape and en- sibilities for being-in-the-world. For subject transiently engages in a
vironment were rooted in nature the schizophrenia patient, however, senseless behavior. Such episodes
and were primordial in character. such experience has a quality of of senseless behavior may precede
This feeling was amplified when finitude and forces his existence the outbreak of delusions by sev-
the patient noticed the names of into a prearranged destiny. eral years.
villages in the neighborhood, "Er-
In summary, in the apophantic Case #5. One of our patients, a
ding" and "Freising," which con-
phase the subject has an expe- 50-year-old female with paranoid
tain the German words "earth"
rience comparable to the expe- schizophrenia and delusional ideas,
and "free."
rience of a revelation, in that he which she in no way enacted,
In case #3, the apophantic ex- now "understands" what was pre- lived peacefully with her mother
perience is gradually intensified. In viously only alluded to. The delu- in a small Swiss town which she
the beginning (5), the context of sional perception, which is the es- had apparently never left, helping
the situation (an isolated barrack sence of the apophantic phase as with house- and garden-keeping.
in a dark forest) is coherently ex- described above, may be reported She expressed her paranoid ideas
pressed in his experience that by the patient as an instantaneous about her sister, which she main-
cracking in the floor means that event. tained for years quietly and with-
he will somehow be tricked by his out anger. To the astonishment of
comrades. This coherence becomes Case #4. One of our schizo- her psychiatrist, she once revealed
less obvious but still discernible in phrenia patients, a 37-year-old that she could speak fluent Italian.
his subsequent experience (11). The male refugee from the formerly It turned out that in her early
allusion to the necessity of "pull- Communist part of Europe, de- twenties, when she was working
ing himself together" when ob- scribed the onset of his psychosis, as a bank clerk, she fell in love
serving soldiers taking up their which began 3 years ago, in the with an Italian, an unskilled con-
arms is coherent with the taint of following way. Immediately after struction laborer. The possibility of
rigidity and discipline inherent in Christinas 1988, a PanAm air car- an overt relationship was unthink-
the picture of soldiers. The N sign rier was terror-bombed when fly- able in this very conventional,
at the railway crossing has the ing over Lockerbie in Scotland. provincial town. One evening,
"natural quality" of a negation, This event attracted an extraordin- when leaving the bank, she stole
given the fact that in most Euro- ary interest on the part of the pa- 20,000 Swiss francs and fled to
pean languages the word "no," as tient. He spent hours listening to Naples with her lover, where they
well as many of its correlates various radio stations in order to opened and ran a pizzeria for 2
(never, nothing, negation, etc.) be- obtain more details about the acci- years. The patient was untraceable
gin with the letter N. At some dent. He felt increasingly tense. by the family and the police dur-
VOL 19, NO. 3, 1993 589

ing that period of time. She then Conrad, of course, feels uneasy overlap more or less the Anglo-
returned upon her own wish, and in designating this behavior as Saxon concepts of "depersonaliza-
the money was paid back by her "crazy," due to its positive human tion," "derealization," "loss of con-
family. Several years later she was aspect. However, this gross trans- trol," "disturbed ego-boundaries,"
diagnosed as having schizophrenia. gression of discipline, which was "passivity phenomena," and "delu-
completely incongruent with the sions of reference" (Spitzer 1988).
What is essential to her situation sergeant's former exemplary con- In our view, the concept of Ich-
after falling in love is the conflict duct appeared in its motivation— Storungen is more appropriate for
with her family and her social net- to approximate his soldiers to the the phenomenological understand-
work that the enactment of her af- culture of the enemy—as coming of delusion, because it refers
fair would provoke. A "normal" pletely "mad" in the eyes of his directly to the experiencing subject.
person would either have faced superiors. We selected two vignettes from
this conflict or made a deliberate
The shared aspect of these two Conrad (1958) as examples of de-
decision to move to Italy and in-
vignettes, at a clinical level, is the lusions that are usually considered
form the family. Instead, her act
outstanding oddity of conduct, specific to schizophrenia and that
overnight commits her to a drastic
which is transient and which is in illustrate the Ich-St6rungen in
change in her life and structures
marked contrast to the individual's schizophrenia.
her future in a limited and fixed
way by making a return difficult. habitual behavior. At a phenome-
nological level, this reshaping of Case #7. The patient reports
Conrad (1958) offers another exam- his being under the influence of
ple of a similar behavior. the context of the situation is re-
lated to the autistic defect in the some apparatus for several days.
vital contact with reality, expressed He had been in the city recently.
Case #6. H.K., 24, a sergeant, in an alloplastic fashion. Everything, along the whole way,
was in a "dreadful" state of ten- was prepared anew. All people on
For both alloplastic and auto- the streets were involved, they ex-
sion since the beginning of the at-
plastic resolution of Trema, Conrad changed signs, and in that manner
tack on France, in which he par-
(1958) emphasizes that what is led him all the way along. This
ticipated. He was an exceptional
specific for the schizophrenic must be in connection with the
soldier, much beloved by his supe- world is the transformation of the
riors and full of ideals, but apparatus, from which everything
structure of experiencing. "It is starts, a kind of wave apparatus,
"deeply" affected by several mat- imperative to disattend from what
ters. The dizziness of a victorious which can be turned on "high" or
is experienced, i.e., thematic, and "low." When it is turned on "very
advance, punctuated by critical to focus upon how, i.e., the
engagements with the enemy, was high," he is totally deprived of his
modality of experiencing, and to own will, has to perform every-
mixed up with the feelings of de- consider the latter as the essence
ception in relation to his comrades, thing that the apparatus suggests,
of the change" (p. 54). and even the smallest moves are
who could not resist the tempta-
Even though a distinction be- directly piloted and made. Turned
tion of plundering, a behavior he
tween form and content has prac- on "low" signifies that he may
despised. In a letter to his mother,
tical relevance, form and content have his own free will. During his
he once wrote that he was close
are dialectically related to each excursion in the city, he had been
to shooting himself. When his other (Muller-Suur 1954), and we
troops' advance stopped in the piloted all the way through and
shall discuss the issue of thematic was completely deprived of his
vicinity of Paris, he took his serv- below. own will. Sometimes, the influ-
ice car and, breaking the strict and
ences of the apparatus cross each
explicit orders, drove into Paris
other contradictorily, and then it is
with some privates under his com- Delusion and not exactly attuned. But otherwise
mand in order to "draw their at- "Ich-St6rungen" everything proceeds in a very pre-
tention on the cultural values of cise manner, as in a clock, even
the enemy." He was condemned One of the essential features of the smallest matters.
to 6 weeks in prison. The psy- schizophrenia is the disturbances
chosis broke out some months la- of the experiencing "I" (Ich- He wrote a letter for his wife's
ter (Conrad 1958, p. 35). Storungen). These disturbances birthday. He noticed immediately

that his style and content of writ- was looking at a magazine, with Bleuler (1911/1950) called this
ing were piloted from outside. It pictures showing wonderful specific overstepping of the me-
was not his way of arranging the weather. And at this very moment, not-me boundary "transitivism."
sentences; the formal aspect was the sun came in the room. And Then, what seems specific for
not even his own. "I still know then I looked at a picture of rain, Ich-Stcirungen in schizophrenia is
my writing." All of his movements and stormclouds arrived. I that the intransitive "to be" is ex-
when writing, everything was con- thought, I am a little God, and the perienced as transitive. This is the
stantly "piloted from a distance" weather regulates itself following shared experience in the delusions
(p. 102). me..." (p. 74). of control and omnipotence de-
scribed above. The former can be
In most textbooks of psychiatry, epitomized as "The world is I,"
Case #8. The patient reported,
as well as in the DSM-III-R, these and the latter as "I is [sic] the
at the very first examination, that
two vignettes would have two dif- world."
he had to shout "faster, faster!"
ferent designations, namely delu-
during his transportation by train The problem of description in
sion of control and delusion of
to the hospital. He had, while the area of Ich-Stcirungen is closely
omnipotence (or grandiose delu-
shouting, the overwhelming con- related to the descriptive problems
sion). These designations would be
sciousness that he could, by his of what is an "I" and thereby of
based primarily on the delusional
shouting, influence the course of self-reflection. In some acts of self-
content—the first patient feels that
the war. Some time later, still dur- reflection, one can describe oneself
his actions are steered from out-
ing his first delusional phase, he as an experiencing subject. This
side and the second claims divine
said that he felt as if he could in- kind of self-reflection is partly
abilities.
fluence in some special way the communicable to others (e.g., "I
destiny of the whole German On a more detailed descriptive am sad"). There is, however, an-
army. When he had to get out level, this distinction would proba- other sort of self-reflection pertain-
during the night to urinate, he bly also touch on certain qualita- ing to the very sense of Self as a
had the feeling that he could, in tive aspects of the experience, be- founding instance (Blankenburg
that way, let the releasing of cause in the first case the 1971), which is hardly communica-
bombs on England be executed. It "mineness" of the experience is ble on a verbal level. This latter
was very clear for him, in that absent, and the delusion would be kind of self-reflection is linked to
very moment, that his urination called a delusion of passivity, the relation between the sense of
was immediately linked with whereas in the second case the being and the sense of acting. Act-
bomb-releasing.... When asked to "mineness" is grossly inflated. ing, with its connotations of pro-
explicate his experience, he said However, such a view of the issue jecting oneself into many possible
that in the very moment when the of "mineness" does not reveal the futures, is part of the sense of an
bomber-planes fly over England essential quality of the morbid "I." Being and acting tacitly pre-
and release bombs, he is their pro- experience. suppose each other, and we are
tector and has the consciousness of tacitly aware of our own "I" and
being linked to them; he has this In both cases (delusion of om-
nipotence and delusion of con- of others' by our own and others'
ability "as a God," without willing trol) the link between I and the acting. This co-constitution of
it. He could say in his mind: now environment seems qualitatively being and acting, immersed in
I throw bombs, in the moment of changed in a characteristic way. temporalization, is normally
urination, and he has the con- It is not the direction, that is, it only vaguely grasped in any
is not the question of either I or
sciousness that, simultaneously, the environment being expe- introspection.
bombs are actually falling on Eng- rienced as the more powerful,
land. Of course, he does not know nor is it the unilaterally con- In delusions of control and om-
whether it is really the case, but cerned mineness of experiencing; nipotence, it is not the strength or
at the moment of acting (urinat- it is rather the border between weakness of the feeling of activity,
"mine" and "yours" (i.e., the nor the sense of power or impo-
ing), he has no doubts.... Some- outer world), and not the border
times he had also seen that, for only, but also the way in which tence that shows specificity to
example, the weather was exactly it is overstepped, that is specific schizophrenia. Rather, it is the
how he had wanted it to be: "I for schizophrenia. [Blankenburg "immediacy" (Unmittelbarkeit) of
1988, p. 187] the access by which the patient
VOL 19, NO. 3, 1993 591

experiences his being and acting patient's spontaneous self- schizophrenia. They seem to be, at
that qualifies such experiences as descriptions (Akiskal and Puzan- first glance, very impersonal and
typical for schizophrenia. In the tian 1979; Mellor 1982; see also do not transmit a "bizarre" mes-
delusions of control and omnipo- our exposition of Jaspers' view of sage, although they are definitely
tence, clinicians are struck by the phenomenology). unconventional. However, closer
fact that, for the schizophrenia pa- examination revealed that these
tient, to be and to act fuse with statements reflected severe tran-
each other. What actually happens Thematic of Delusions in sitivistic experiences of the patient.
is that the normally tacit link be- Schizophrenia In fact, he was a marijuana user
tween being and acting becomes and felt that his will was para-
apparent. The content of the schizophrenia lyzed. On other occasions, he felt
Such delusions are the only way patient's statements often reflects vibrations in unison with the cy-
the schizophrenia patient can ex- the distortions of the experiencing cles of nature. Consequently, the
press the "unthinkable" experience "I." Spitzer (1988) suggests that unveiling of the transitivistic
of the dissolution of the Self. This such statements should not be re- quality of his experiences, to
basic disturbance is beyond the garded as delusions but as meta- which these delusions were linked,
scope of variation of normal ex- phors used by the patient to qualified the latter as schizo-
perience (normal experience cannot describe his "undescribable" ex- phrenic. A comparable situation
vary with regard to the me-not-me perience. We propose that such can sometimes be encountered in
differentiation, which we assume is statements should be regarded as the apparently "normal" utterances
disturbed). The dissolution of the experience-congruent delusions, in of a schizophrenia patient.
Self is probably experienced by which case the content of the de-
most schizophrenia patients at the lusion apparently qualifies schizo- The patient never omitted to be-
phrenia. However, what is charac- gin the session by some, usually
onset of psychosis; for some of pertinent, remark on today's
them, this experience will recur teristic is that we face a Gestalt weather. Each time we tried to
throughout the entire course of composed of both structure (form) scratch beneath the surface of
their illness. The way in which the and content ("matter pregnant such remark, it turned out that
me-not-me boundary is over- with form"; Merleau-Ponty these meteorological utterances
were concealing some delusional
stepped in schizophrenia is, in our 1945/1962). connotations. For example, "it is
view, qualitatively different from hot today" meant "the sun's
the expansive delusions seen in Case #9. One of our schizo- heat is today too intense for me
mania and from the complaints of phrenia patients claimed that the to come close to you and shake
CIA was responsible for the drug hands with you." And, in fact,
a loss of autonomy encountered in while she uttered her "it is hot
depressive patients. A similar point problem, both in the United States today," she froze on the door-
can be made with respect to tran- and in other countries. In his step, but without giving any ex-
sitivistic phenomena of thought- opinion, the CIA was facilitating planation to her attitude. [De
insertion and thought-deprivation. the distribution of drugs in order Waelhens 1972, pp. 137-138]
Empirical studies demonstrating to weaken people's resistance and
pacify them. Another idea of this Kepinski (1974) claims that there
these first-rank symptoms of
patient was that farmers were mis- is a certain metaphysical taint to
schizophrenia (Schneider 1955/
taken in their way of cultivating the thematic of the delusions in
1959) in affective illness (Pope and
the soil. He considered that schizophrenia that helps us to dis-
Lipinski 1978) are most likely not
ploughing the soil after the harvest tinguish them from nonschizo-
sensitive enough to the complex-
ities of qualitative aspects in the was, in fact, diminishing the soil's phrenia delusions. Kepinski divides
investigated experience. Structured organic resources, because it let this metaphysical taint into three
interviews may provoke false these resources evaporate into the interrelated trends.
positive answers when applied to air, rather than letting them dis- The ontological trend, which con-
experiences that are not di- solve down into the soil. cerns the essence of Being and the
chotomously present or absent concept of existence in the cosmos.
(Koehler 1979) and that can only These statements, regarded at The main characteristic of
be properly evaluated from the the purely contentual level, would schizophrenic cosmology is its
not be considered diagnostic of fantastic and magic character....

The schizophrenic world is filled what is left is heaven or hell, values and goals) has to face this
with secret energies, rays, good which often are presented in a discontinuity, which delusions of
and evil forces or waves which secular way: ideal political sys- affiliation (e.g., parthenogenetic or
penetrate human thoughts and tem, concentration camp, life on
direct human behavior Even another planet, etc.... The cata- of grandiose affiliation) deny
though the cultural changes strophic atmosphere makes the (Schmid and Bovet 1988). In sum-
throughout history have influ- schizophrenic delusions different mary, Kepinski (1974) states
enced the thematic of the schizo- from nonschizophrenic delusions.
phrenic world, there are, nev- The fact of being spied upon, The presented metaphysical as-
ertheless, certain motifs which persecuted, poisoned, etc., ac- pects of the schizopnrenic world,
repeat themselves: a struggle of quires a universal quality; if despite variable details due to
contradictory forces, the pos- such events are possible, the cultural influences, remain the
sibility of action per distance, whole world is against the pa- same in their essential pattern.
and the pretended character of tient, the whole world has This pattern can be found in the
the perceived world. The world changed, [pp. 120-121] oldest descriptions of schizo-
is a place of struggle between phrenia. To a great extent, this
forces with moral connotation: The charismatic trend, which con- pattern allows us to identify a
good and evil, beauty and ugli- tains issues concerning the mean- given case as suffering from
ness, wisdom and stupidity.... It ing and sense of human life, its schizophrenia, [p. 122]
seems as if the patient discovers
the essence of reality—Kant's true purpose and goal ("charisma" Muller-Suur (1954) arrives at a
"Ding an sich" (noumenon). Ac- means gift). very similar conclusion, but his
cording to the patient, other
people are ignorant and only The patient is not inactive when perspective takes into account both
aware of the Kantian phe- the world is exposed to apoc- the content and the form of ex-
nomenon (appearance). The alyptic events. He is in the cen- perience. Considering content and
world becomes a caricature of tral position of that world. He
may feel immortal, immaterial, form as cocontributors, he emphas-
causal connections: there are no izes that formal aspects of experi-
independent events—one event almighty, as God or devil; the
is always dependent on another fate of the world depends upon ence often influence its content.
and interacts with the other, him The world is threatened According to the DSM-III-R,
[pp. 118-119] by annihilation, and the patient
wants to warn mankind, offer many of those examples from the
himself for the sake of human- schizophrenic world would be con-
The eschatological trend, which ity The meaning of his life sidered bizarre delusions, on the
concerns the ultimate issues reveals itself to the patient: a face of their implausible or, as Jas-
("eschatos" means ultimate), such great mission, an act of heroism, pers would have said, false con-
as the end of the world. martyrdom, [pp. 121-122]
tent. (Spitzer [1990] notes that this
The feeling of impending disas- We would also consider delu- criterion is usually referred to as
ter is not rare for a human sions of affiliation as belonging to "impossibility of content," but it is
being. It is usually connected the metaphysical type of schizo- clear from the context in Jaspers'
with depressed mood (e.g., de- phrenia delusions described by original publication that he is re-
pression in which the future is ferring to falsity.) However, what
black and one has feelings of to- Kepinski. Delusions of affiliation
tal self-insufficiency).... However, confront us with the paradox of Kepinski is denoting as the invar-
such moods never reach the continuity or discontinuity in our iant metaphysical taint of such
apocalyptic intensity of schizo- own history as a human being. utterances is, phenomenologically
phrenia. In the latter case, the Every individual, as a child of two speaking, not only reflected in the
impending disaster is preceded
by a mood of apprehension; the parents, is an original being, content, but also related to the in-
color of the world darkens, provided with unique characteris- tersubjecn've apprehension of the
everything becomes ambiguous tics both at the biological level speaker's experience. When De
and threatening. The anxiety in- and as a member of human so- Waelhens' patient says "The sun's
creases crescendo; at the climax, heat is today too intense for me to
there is an explosion: end of the ciety. Therefore, an essential dis-
world, wars, cataclysms, chaos, continuity exists in the sequence of come close to you and shake
the Last Judgment Day, separa- generations, and no individual can hands with you," it is not the
tion between devils and angels, be considered as the pure exten- pure content of the utterance that
condemned and saved, good and sion of one of his lineage. Hered- has a delusional quality, because
evil, compatriots and enemies,
living and dead, etc. Gradually, ity in its broad sense (the trans- the patient could, in fact, be hesi-
this storm calms down, and mission of both genes and cultural tant to approach the therapist
VOL 19, NO. 3, 1993 593

because of her sweating and smell- depressed person would convey qualitative order arises from the
ing. What constitutes the delu- his feeling of guilt embedded in a reorganization of essentially un-
sional quality of this meteorologi- personal statement, accompanied changed elements. Clear examples
cal statement is its place in the by paraverbal signals indicating of emergence are the appearance
context of the entire interaction guilt feelings, but without any re- of life on earth (molecular compo-
with the therapist. It is therefore course to the general concept of nents of living beings must fulfill
essential to recognize that the dis- guilt. On the other hand, a schizo- all physical laws, but the phe-
tinction between content and form phrenia patient, claiming, for in- nomena they generate in function-
(structure) is only possible to some stance, that his breathing is re- ing as living organisms depend
degree, and that every item of lan- sponsible for the famine in the on their organization) and the
guage is embedded in a total Ge- Third World, is presenting to us, origin of consciousness in human
stalt which communicates to the through this delusional amplifica- phylogeny.
Other something of the speaker's tion, the very idea of guilt. Due to The phenomenon of emergence
experience of the world. The co- a lack of common sense sharing makes sense only when the objects
constitution of form and content with others of the notion of guilt, studied are considered as systems,
generally has been neglected by the schizophrenia patient expresses that is, as unities defined by the
psychopathology (Miiller-Suur feelings in a way that points to relationships among their different
1954). the ontological essence of guilt. components.
We propose that the invariant One of Minkowski's (1927) pa- As human beings, we interact
metaphysical taint in the delusions tients expressed it very precisely: with other human beings in a way
of schizophrenia patients conveys "I feel that I can reason quite that can be described as a high-
something about the nature of the well, but only in the absolute, be- order coupled system in the
dialog between the schizophrenia cause I have lost contact with affective-cognitive and linguistic
individual's Self and the outer life." These ontological qualities of domains. Such a situation creates a
world. It informs us about the na- schizophrenic discourse may also new coherence in which, though
ture of the subject's being-in-the- be perceivable in the way the pa- the participating beings preserve
world. It is therefore not the per- tient reveals his conviction: their individual limits, a new phe-
ception per se of the outer world, Whereas a paranoid (i.e., non- nomenological domain of abilities
nor the conviction per se of the schizophrenic delusional) patient emerges, comprising consciousness
subject that qualifies these delu- would eagerly corroborate his de- and intersubjectivity (Maturana and
sional statements as schizophrenic, lusions by post hoc arguments and Varela 1988). Self-consciousness
but the disturbance of the "Self as even by presenting some "empiri- and the sense of the Self as a
a founding instance," which is cal" pseudo-evidence, a schizo- founding instance can emerge only
perceivable in both the subject's phrenia patient would have diffi- in the context of intersubjectivity
perception and conviction. The culty comprehending why any and historicity (Varela et al. 1991).
schizophrenia patient's autistic de- evidence should be needed at all The phenomenological notions of
fect impedes his ontic tie to the (Muller-Suur 1950). life-world (Husserl 1936/1970a)
world and to the Other. Conse- What we are confronted with in and of being-in-the-world (Heideg-
quently, schizophrenic utterances the schizophrenic delusional trans- ger 1927/1962) and Stern's (1985)
become characterized by two inter- formation is a phenomenon of views on the emergence of Self all
related features: first, the Other in emergence—the emergence of a point to the coconstitution of the
the dialog is not considered as an- new paradigm, the transformation Self and the interpersonal world.
other ontic being, and, second, the of the patient's being-in-the-world. The autistic defect is related to an
ontological elements of the com- impairment in this coconstitution.
munication become quite apparent
and dominating because they lack Delusion formation can be re-
ontic embodiment. What we, as Delusional Transformation as garded as the emergence of a new
listeners, are confronted with in an Instance of Emergence structure comprising the deluded
such communications is a sort of person and his transformed world.
"empty ontological matrix." The phenomenon of emergence is This new structure comprises the
familiar to all natural sciences and intentional attributions of the pa-
As an example, a normal or a denotes a situation where a new tient and their universal (ontologi-

cal) counterparts in his world. My being-in-the-world by attributing to characteristics of the observable
perception of the world is usually the elements of his experience and also point to the existence of
tripartite, comprising me, the some common intention. As we nonlinear processes in human con-
Other with whom I interact, and said before, such common inten- sciousness. To be fruitful, phe-
the objects that I perceive and that tion ("common denominator") has nomenology must keep up a di-
I know that the Other perceives necessarily ontological qualities. alectic exchange with the empirical
(or at least could perceive) in a The phenomena of emergence in approach. The current situation in
way with which I am familiar. It the cognitive domain are currently psychopathology is that, unfor-
is an everyday experience that, in studied within the framework of tunately, this dialectic hardly ex-
our interactions with the world, Prigogine's theory of "order ists. Such a dialectic should strive
we attribute some anthropo- through fluctuation" (Prigogine for a more balanced emphasis on
morphic intentions to other people, and Stengers 1984). Prigogine's reliability and on meaning (valid-
animals, and objects with which model deals with the thermo- ity). Operationalized criteria are
we are interacting (e.g., if my car dynamics of open systems, which necessary for empirical research,
"refuses" to start when I am in a are supplied with energy from mainly for reasons of reliability.
hurry). These attributions of inten- outside. A trivial example of such However, even this approach uses
tions axe always framed by our in- a system is the phase transition data saturated by subjective ex-
tersubjective ties with the Other, between the liquid and the gas- periences of the patients. The
by the fact that "we know how eous state. In such an open system quest for reliability attempts to re-
the Other knows." The extent of some of the internal fluctuations duce this subjective component. In
this framing or limitation of at- can acquire a localized new struc- phenomenological inquiry it is pre-
tribution of intentions to the world ture called nucleation (e.g., the for- cisely this component that gener-
is highly dependent on the preva- mation of droplets of conden- ates heuristic models.
lent culture. sation in a gas). Under certain From the phenomenological per-
Delusion formation begins when necessary conditions, which are co- spective, the development of delu-
such framing dissipates. The major determined by the environment sions in schizophrenia can be
problems of a predelusional, autis- and by the system, these fluctua- viewed as the emergence of a new
tic person, as described above, are tions can amplify and "inform" "order of being," intimately related
his weakened intersubjective an- the whole system. Correlations be- to the autistic vulnerability. Such a
choring and difficulties in self- tween normally independent events view has both research and clinical
evident discrimination of the may appear, letting the latter jump consequences for schizophrenia.
world's signs. According to Wig- into a new regimen of functioning, With respect to research, the issue
gins et al. (1990) the primordial into an entirely new structure. at stake is the psychopathological
certainty in the invariant, funda- Within this model, the Trema demarcation of schizophrenia. In
mental features of the Self and the phase can be viewed as a system etiological research, we are inter-
world becomes shaken in the early in a certain field of force, the ini- ested in phenotypic features that
stages of schizophrenia. tial delusional hints as nucleations, can be expected to relate as
and the apophantic phase as a closely as possible to the underly-
In the delusional transformation
new order through fluctuation. ing pathophysiology. The contem-
a disinhibition of attribution of in-
tentions occurs. In the first stage porary descriptive psychopathology
(delusional mood and other initial focuses on symptoms that seem
phases of delusional perception), fairly distant from the putative pa-
Conclusions thophysiology, and even these
the disinhibited attribution of in-
tentions to the outer world relates Phenomenology is a specific way symptoms, regarded at the purely
to the patient's defective self- of understanding human conscious- descriptive level, lose their diag-
temporalization, in the sense that ness and its world. Phenomeno- nostic specificity. The autistic vul-
he can now "read" from the logical inquiry is best fit to gener- nerability, as viewed by phenom-
world indications of his future. ate conceptual models derived enologial psychiatry, may be
The patient, in search of the from an investigation into subjec- potentially closer to the patho-
meaning of his predetermined fu- tive experience. Such models can physiology and more specific to
ture, suddenly understands his both pertain to the essential schizophrenia.
VOL. 19, NO. 3, 1993 595

With respect to clinical issues, a Blankenburg, W. AnsStze zu einer Ciompi, L. The Psyche and Schizo-
phenomenological approach has Psychopathologie des "common phrenia: The Bond Between Affect
some implications for the concep- sense." Confinia Psychiatrica, and Logic. (1982) Translated by
tualization of schizophrenia as a 12:144-163, 1969. D.L. Schneider. Cambridge, MA:
disease and for its treatment. If Blankenburg, W. Der Verlust der Harvard University Press, 1988b.
we consider the delusional state in nattirlichen SelbstverstUndlichkeit. Ein Conrad, K. Die beginnende Schizo-
schizophrenia as a special form of Beitrag zur Psychopathologie symp- phrenic Versuch einer Gestaltanalyse
existence (being-in-the-world), we tomarmer Schizophrenien. Stuttgart, des Ylahns. Stuttgart, Germany:
add a further dimension to the Germany: Enke, 1971. Thieme, 1958.
concept of schizophrenia. This new
dimension enables the clinician to Blankenburg, W. Phenomenology De Koning, A.J.J., and Jenner, F.A.,
adopt a multidisciplinary treatment and psychiatry. Journal of Phenom- eds. Phenomenology and Psychiatry.
approach. In some cases, one enological Psychology, 11:50-78, London, England: Academic Press,
would abstain from treating delu- 1980. 1982.
sions with neuroleptics, so as not Blankenburg, W. Zur Psycho- De Waelhens, A. La psychose. Essai
to interfere with the equilibrium of pathologie des Ich-Erlebens Schizo- d'interpretation analytique et existen-
the restructured being-in-the-world. phrener. In: Spitzer, M.; Uehlein, tiale. Louvain, Belgium: Nau-
Autism is not amenable to neuro- F.A.; and Oepen, G., eds. Psycho- welaerts, 1972.
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VOL 19, NO.

propose a specificity in the

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