Professional Documents
Culture Documents
Schizophrenia Bulletin
doi:10.1093/schbul/sbp144
he notices. Everyone has been instructed and knows with a transformed ‘‘physiognomic’’ quality (ie, a sense of
exactly what to do. potential revelation/threat accompanied by affective ten-
Due to his failure to follow orders, which is ‘‘another sion due presumably to underlying neurobiological
test,’’ the staff sergeant transports him by car to the psy- changes). Nevertheless, the subject (like the anosognosic
chiatric hospital. Everything along the road, eg, piles of neurological patient) does not attribute the changes to
stone, construction sites, sheep crossings, is arranged to his/her own state but externalizes them to some, yet to
test whether he notices. While looking out the window, be understood process in the world.
the staff sergeant observes whether he correctly notes all The delusions appear suddenly as an ‘‘aha experience’’
of this. Later he thinks, ‘‘There must be some kind of pe- (‘‘Aha-Erlebnis’’ or ‘‘revelation’’) concerning what had
culiar effect emanating from me. Other people are under been perplexing during delusional mood and often bring
my influence as if under a spell.’’ That is, the persons who relief. Conrad7 describes this as a reflexive turning back
experience his gaze, ie, his looking at them, exhibit a dis- on the self in which the universe is experienced as ‘‘revolv-
torted facial expression or bodily behavior, indicating the ing’’ around the self as middle point (ie, ‘‘anastrophe,’’ see
Stage Term
Note: Conrad’s later stages apocalyptic-catatonic, consolidation (or partial remission), and residual defect state are not presented here.
meaning that a stranger, or unfamiliar person, is perceived Conrad challenged the prevailing European ‘‘classical’’
as known (‘‘misplaced familiarity’’).13 Conrad describes a view (K. Jaspers, H. Gruhle, and K. Schneider) that de-
patient with incipient schizophrenia who is placed tempo- lusional interpretations of perception are two tiered, ie,
rarily in a guardhouse before transport. Being a former car- an abnormal meaning attaches to an otherwise intact per-
penter, the patient finds that the door, windows, ception without understandable reason or cause.6 He
floorboards, and bed frame in the cell have a ‘‘familiar’’ proposed that the delusion arises rather from an ‘‘already
quality. He sees all at once that he himself is the carpenter transformed Gestalt perception’’ wherein the affective
of these objects. They look so familiar. They were removed and expressive ‘‘holistic’’ properties of the Gestalt be-
from his old workshop. The windowsill has scratches on it, come exaggerated. He noted, eg, that the attention of
which he made as a child and has been removed from his both healthy individuals and deluded subjects are cap-
childhood home. Everything revolves about the patient tured more by a percept’s expressive qualities when the
(anastrophe). The familiar expressive quality of his objective or material properties of the percept are atten-
own workmanship emerges from each object he encoun- uated. For example, during a night walk, I see a tree trunk
ters in the cell and spreads (with monotonous repetition) as a crouching robber.7 Here, the attenuated perceptual
to his entire perceptual field (misplaced familiarity of de- structure contributes to the Gestalt’s prevailing expres-
lusional misidentification). sive-physiognomic quality. The physiognomic similari-
ties (between the attenuated perception of the tree
trunk and a robber) become more striking (or salient)
Background for Conrad’s Concept of Delusions in Early
than normally. In cases of delusional misidentification,
Schizophrenia
the structural–material Gestalt properties recede and
In his drive toward integration, Conrad bases his phenom- the patient relies on their physiognomic-expressive qual-
enologic study of beginning schizophrenia on the Gestalt ities. Thus, the delusional misidentification of persons or
psychological concept of holistic properties,14 his phenom- objects—as the case of the former carpenter’s misidenti-
enological approach of treating patients as peers or collab- fication of the wooden objects in his cell—is embedded or
orators in the clinical interview,15 and his own observations ‘‘given’’ in the delusional perception. The patient per-
of anomalous conscious experiences, including the intro- ceives a detail in a stranger’s face, eg, a scar or crooked
spective study of his own hypnagogic hallucinations tooth that represents an ‘‘expressive quality,’’ eg, ‘‘rug-
when falling asleep.16,17 (For review of the historical influ- ged.’’ However, it is not the actual scar or tooth in the
ences in Conrad’s work, see references.18) encountered person but its ‘‘ruggedness’’ that allows
3
A. L. Mishara
the patient to delusionally misidentify the new person other hand, remains attached to the earlier arrested phase
with some prior person who was also experienced as rug- of meaning. This marks a stable and sometimes relatively
ged, as being the same person. In delusional mood, the permanent loss of the capacity to shift frame of reference
physiognomic similarity between beings, and not their (ie, the ability to test reality) as ‘‘the subject is unable to
‘‘objective’’ structural or material Gestalt properties, shift back from the previously passive–receptive attitude
allows for their identification in the delusional perception. to a critical attitude.’’15 In the progression to an ever
Conrad recognized a similarity between delusional more articulated, or finalized Gestalt, the healthy subject
mood and what the dreamer normally experiences during is ultimately able to ‘‘detach emotionally’’ and experien-
sleep. The objective material Gestalt is suspended and ces a sense of completeness or closure. However, like
both healthy and psychotic individuals rely on the phys- the dreamer, the delusional patient is unable to detach
iognomic-expressive qualities of the truncated object per- from the incomplete perceptual meaning or pre-Gestalt
ception. This process of impoverishing the perceptual (Vorgestalt).7,16,17 Interestingly, and in conformity with
field, which can occur naturally, is induced by an exper- Conrad’s observations, patients with a history of perse-
concepts and viewpoints that are, at best, only remotely 12. Weizsäcker, V. von. Der Gestaltkreis. Theorie der Einheit von
related to the original work (for reviews of the debate Wahrnnehmen und Bewegen 4. Aufl. Stuttgart, Germany:
Georg Thieme Verlag; 1950.
concerning the interpretation of Conrad, see referen-
13. Motjabai R. Misidentification phenomena in German psy-
ces18,27–29). A large (n = 267) retrospective study2 of Con- chiatry: A historical review and comparison with the French/
rad’s stage model, including both men and women with English approach. Hist Psychiatry. 1997;7:137–158.
a greater age span than Conrad’s more homogenous male 14. Metzger W. Psychologie. Dresden, Germany: Steinkoppf; 1975.
military sample, found support especially for his first 15. Ploog DW. Autobiographical sketch. Hist Psychiatry.
stage, delusional mood (Trema), and to some extent, 2002;13:358–360.
for the next stage, apophanic psychosis. Conrad’s work 16. Conrad K. Das Unbewusste als phänomenologisehes Prob-
remains timely for current researchers and clinicians lem. Fortschr Neurol Psychiatr. 1957;25:56–73.
due to his thoroughgoing commitment to respectful, col- 17. Conrad K. Das Problem der Vorgestaltung. In: Schmoll gen.
laborative study with patients concerning their subjective Eisenwerth JA, ed. Das Unvollendete als Kuenstlerische Form.
Bern: Eisenwerth; 1959:35–45.
experiences of prodromal and beginning schizophrenia
18. Mishara AL. The ‘unconscious’ in paranoid delusional psy-