1960] REVIEWS 1595

of the evidence. Though not exhaustive, it is none the less surprisingly broad in its
range, and there is little worth-while evidence that is not mentioned. The subject is
treated sympathetically, yet with scrupulous impartiality. Readers who want a polemic
for one side or the other will be disappointed, but those who would like to see what
the evidence is when it is displayed to its best advantage will find the book well worth
reading.
It is certainly one of the best surveys that have appeared for many a year.
W. Ross ASHBY.

Die Beginnende Schizophrenie. By K. CONRAD.Georg Thieme, Stuttgart, 1958.

In this book Conrad has tried to explain the origin of and inter-connection
between the different delusional and paranoid phenomena which occur in acute
schizophrenic shifts. Before discussing his ideas it is necessary to describe the back
ground against which they have developed.
Jaspers was originally responsible for the intensive interest which the German
psychiatrist had in so-called primary delusional phenomena. He introduced Husserl's
concepts of ‘¿ understanding'
and ‘¿ explaining'
psychology into psychiatry. Briefly Husserl
believed that in psychology we have two different types of connection between events.
There are causal connections which are established on the basis of observation and
experiment. These connections form the basis of ‘¿ explaining'psychology. The other
variety of connection is the understandable connection. This arises because a psycho
logical event can arise out of another psychological event in a way which we can
understand. Thus for example we can understand why a man who is being ridiculed
becomes angry and aggressive. Such an understandable connection between two
psychological events can be called a genetic understandable connection because it
allows us to understand how one psychological event arises out of another.
Jaspers used this idea of understandable connections in his analysis of the psycho
pathology of the delusion. He divided delusions into two kinds—delusion-like ideas
and true delusions. Delusion-like ideas are delusions which arise in an understandable
way from some other well-known psychological event. Thus a depressed patient
develops delusions of guilt because he is depressed and feels useless. The true delusion
arises from a primary delusional experience which cannot be understood. The new
signification emerges in connection with some psychological event, but cannot be
derived from it. At the time when Jaspers wrote the prevalent type of psychology
was that of Wundt, which tried to dissect all phenomena into their basic elements and
basic functions. Consequently a large number of primary delusional experiences were
isolated, such as delusional perception, delusional state of consciousness, delusional
memory, delusional presentation and so on.
The older German workers who followed Jaspers described and analysed
delusional experiences in great detail. However they were influenced by the prevailing
psychology and did not attempt to explain these primary experiences. It is necessary
to consider in some detail the three most important delusional experiences, viz.
delusional mood, sudden delusional ideas (autochthonous delusions) and delusional
perception.
In delusional mood the environment appears to be changed in a strange threatening
way, but the significance of the change cannot be understood by the patient. A delusion
may crystallize out of this mood and when it does the tense, anxious, unpleasant
feeling usually disappears. A sudden delusional idea is one which arises abruptly in the
patient's mind without any preparatory thoughts. Delusional perception occurs when an
abnormal significance, usually in the sense of self-reference, is attributed to a normal
perception in the absence of any emotional or logical reason. This phenomenon
has been described and discussed more than the others and Kurt Schneider has con
sidered it to be diagnostic of schizophrenia. Conrad has pointed out the need for a
convenient designation for all these delusional experiences from which an adjective
could be derived. Since in all these experiences something is becoming manifest to the
patient Conrad suggests the word apophany, which is the Greek for the becoming
1596 REVIEWS [Oct.
manifest, as the suitable designation. The adjective apophanous can be derived from
this term so that one can talk of apophanous ideas, moods, perceptions and so on.
Matussek has examined the concept of delusional perception and attempted to
explain it in terms of Gestalt psychology. The older investigators were all agreed that
delusional perception was a disorder of thought and that perception was not altered
in this experience. Matussek pointed out that there were two different types of
delusional perception. In one the abnormal significance is dependent on a play on
words. Thus a patient heard a floorboard squeak, he looked down and saw the
linoleum. He said to himself “¿ Lino―
and immediately the thought “¿ Don'tlie―came
into his mind. This signified that he was being warned not to lie. This sort of play
on words is similar to the verbal tricks used by the obsessional ruminator when he
finds indications of his obsessional thoughts in his environment. In the other type of
delusional perception Matussek believes that there is a perceptual change which
consists of a loosening of the coherence of perception which leads to the undue
prominence of essential properties of the object. Essential properties are expressions
of the essence of the object. They are, for example, expressed in the adjective in the
following phrases—the laughing man, the sleeping village, and the threatening
mountain. If the essential properties gain undue prominence in delusional perception
they naturally have a new significance for the patient.
Conrad accepts Matussek's ideas and weaves them into a theoretical structure
which is an attempt to correlate the variegated symptomatology of the acute schizo
phrenic shift. He bases his interpretations on his experiences with a group of 107
acute schizophrenics, whom he looked after in a German military hospital in Germany
in the years 1940—1941
. He believes that five phases can be seen in a typical shift.
These are:
I . The Trema.
2. The Apophanous Phase.
3. The Apocalyptic Phase.
4. The Consolidating Phase.
5. The Residual Phase.
The word trema is German stage slang for the stage fright which occurs before
the actor makes his appearance. In the trema the patient experiences a loss of freedom
so that he feels hemmed in and unable to communicate with his environment. Senseless
actions occur and these were particularly noticeable in Conrad's patients because they
led to conflict with authority. Thus one patient held his ears when his company
commander shouted at him. Severe anxiety may occur, but depression is also common
with marked ideas of guilt and disgust with life. In other patients there was a general
feeling of suspicion, which pervaded all social contacts and led these patients to feel
that there was something else behind all their experiences. Finally, delusional mood
occurs, in fact Conrad believes it occurs in nearly all early schizophrenics but they
are often not able to describe it. The trema may last a very short time or for several
months before the apophanous phase begins. Sometimes the illness subsides without
any further development.
The apophanous phase can be divided into two. There is the apophany of external
space, that is external events acquire a new significance and there is apophany of
internal space in which psychic events not directly related to the external world
acquire a new significance. In external apophany an event acquires a special meaning
for the patient and, unlike a normal person who accidentally believes that some
external event has some connection with him, he is unable to put to himself the
alternative that the event has no significant attention for him. Delusional perception is a
common external apophanous experience. Conrad distinguishes three stages of de
lusional perception. In stage 1 the perceived object indicates to the patient that it
has some significance for him, but he cannot say to what extent. This is pure apophany.
In stage 2 the perceived object indicates to the patient that it has a significance for
him and he knows immediately the extent of this. For example, it has been put there
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to test him or observe him. These are the made or prefabricated experiences of
Schneider. The third stage occurs when the perceived object signifies something quite
definite. The essential properties have come into prominence. This is delusional
perception in the strict sense.
Misidentification of persons often occurs in the apophanous phase, so that
unknown persons are recognized as friends or acquaintances and persons well known
to the patient appear to be unknown. This can be explained by the undue prominence
of essential properties which cause the patient to misidentify acquaintances and
strangers.
All these experiences give the patient the impression that he is in the centre of a
changed world. On the other hand some of Conrad's patients had the experience of
omnipotence and knew that their actions influenced the world. Thus one patient
believed that as he urinated he caused bombs to fall on England. There is a quality of
accomplishment in this experience, since both urinating and bombing are activities in
which something is made to fall, so that they both have a common essential property
of activity. The experience of a special effect of the constituents of the world on the
patient which is best seen in delusional perception is coupled with an experience of a
reciprocal effect of the patient on objects of the world. In other words the essential
properties of the patient's own actions may become important for the world as he
experiences it. The patient may have the experience that he is in the centre of the
world, thus everything revolves round him. Conrad calls this anastrophe.
Apophany may only affect external space or internal apophany may not occur
for some time. It seems as if there is a barrier which stops the process from spreading
quickly from the sensory aspects to the representational aspects of psychic life. Once
apophany affects internal space there is a dc-differentiation of field structure. Thus
freely rising memory images lose their connection with the total field and become
delusional inspirations. In thought broadcasting the patients' thoughts become
manifest to his environment and this can be regarded as the reverse aspect of delusional
perception where a perception becomes manifest to the patient. The loosening of the
coherence of representational aspects of psychic life leads naturally to the patient
hearing his own thoughts spoken aloud, so-called Gedankenlautwerden. When all
personal indication of the thoughts is lost then hallucinatory voices occur. Bodily
hallucinations can be explained as apophany affecting bodily sensations and the
body image.
The illness may stop at the apophanous phase, but if the schizophrenic process
is very severe the loosening of coherence of perception and representation may proceed
to complete chaos. Psychic life becomes fragmented and the apocalyptic phase or
catatonia is present. The release of representations of bodily sensations and movements
leads to the motor disorder. As sense continuity is destroyed, only fragments of the
total experience can be remembered subsequently. In rare cases the apocalyptic phase
may end in death.
Usually the phase of consolidation sets in after a few weeks or months. The
apophany dies away and the patient may finally gain insight into his strange experi
ences. Finally the residual phase is reached. Here no active symptoms are present,
but the patient feels less capable than before. Often this change is much more apparent
to the patient than to his fellows. Conrad considers that every individual has his own
particular ability to direct and apply his energies or in other words has his own energy
potential. In the residual phase this potential is lower than normal.

Conrad has described seven different types of course of illness which are illustrated
in the diagram overleaf. These are:
Type I . The process does not pass beyond phase I and only abates on phase 2. It
subsides in a few weeks. The loss of energy potential is minimal.
Type 2. The process passes through phase 1, enters phase 2 and then subsides after a
few weeks. Loss of energy potential is slight.
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Phase Time

(Type 1-3')
Trema . . . . . . Hebephrenic Form

(Type 4-5)

Apophariy (Type

Catatonic Form
Apocalypse (Type 7)

Terminal

VARiETIES OF ACUTE SCHIZOPHRENIC SHIFTS

(AFTER CONRAD)

Type 3. Phases I and 2 are passed through and phase 3 is touched on. The process
then subsides.
Type 4. Phases 1 and 2 are quickly passed through without the psychosis being
recognized. A marked loss of energy potential occurs and the residual state
may make adaptation very difficult.
Type 5. Process does not pass beyond phase 1 but a severe reduction of energy
potential occurs.
Type 6. Process reaches phase 2 and it is arrested there.
Type 7. The process reaches phase 3 and is arrested in that phase. This results in a
severe loss of potential.
Conrad believes that schizophrenia is due to a disorder of the nervous system.
He has used Gestalt theory to explain the form and relationship of symptoms in acute
schizophrenic shifts.
This is the first fresh approach to the psychology of schizophrenia for many
years. It is extremely stimulating and worthy of careful consideration.
FRANK FISH.