Phenom Cogn Sci

DOI 10.1007/s11097-015-9429-8

The phenomenology of hypo- and hyperreality

in psychopathology

Zeno Van Duppen1

# Springer Science+Business Media Dordrecht 2015

Abstract Contemporary perspectives on delusions offer valuable neuropsychiatric,

psychoanalytic, and philosophical explanations of the formation and persistence of delusional
phenomena. However, two problems arise. Firstly, these different perspectives offer us an
explanation Bfrom the outside^. They pay little attention to the actual personal experiences, and
implicitly assume their incomprehensibility. This implicates a questionable validity. Secondly,
these perspectives fail to account for two complex phenomena that are inherent to certain
delusions, namely double book-keeping and the primary delusional experience. The purpose of
this article is to address both problems, by offering an understanding Bfrom the inside^. Our
phenomenological approach is a form of Bradical empathy^, and crosses the Jaspersian limits of
understanding. It compares delusional experiences with variations of reality experience in
everyday life, and makes use of the structure of imagination. Six factors influencing the
experience of reality are discussed and illustrated by clinical and non-clinical examples. These
factors are: continuity (1), materiality and resistance (2), multiplicity of sensations and
perceptions (3), intensity (4), the sense of authorship (5), and the complex role of
intersubjectivity (6). I suggest that experiences of hypo- and hyperreality are not restricted to
pathology, but have their place in everyday life as well. Delusional phenomena can be better
understood by investigating the interplay of these six factors.

With this framework, the two complex phenomena consequently prove to be better
understandable to us. Our approach remains within the phenomenal experience and might
thereby contribute to the validity of psychopathology.

Keywords Delusion . Reality. Schizophrenia . Radical empathy. Double book-keeping .

Hallucination . Imagination

* Zeno Van Duppen

zeno.vanduppen@telenet.be

Section for Phenomenological Psychiatry and Psychotherapy, Clinic for General Psychiatry -

Center for Psychosocial Medicine, University Hospital Heidelberg, Voss-straße 4, 69115

Heidelberg, Germany

Z. Van Duppen

1 Introduction

Delusions are mental symptoms that can be present in different mental disorders, including
schizophrenia, affective disorders such as the bipolar disorders, dementia’s and other organic
illnesses. The presence of a delusion is a particularly important diagnostic criterion for
schizophrenia (American Psychiatric Assocation 2013).

Delusions are often defined as erroneous beliefs that are firmly sustained despite what almost
everyone else believes and despite incontrovertible and obvious proof to the contrary (American
Psychiatric Assocation 2013).
A rich debate has emerged on the explanatory mechanism for the formation and persistence of
delusions. A key part of this debate is whether we should conceive of a delusion as a false belief
resulting from a bottom-up, top-down, or two-factor mechanism (Bortolotti 2010, 2011).
According to the first account a faulty perception without any dysfunction on the cognitive level
can lead to a delusion (Maher 1974; Bayne and Pacherie 2004). The second account argues that
the error is to be found at the higher order of cognition rather than on the level of experience and
perception (Campbell

2001). The third account claims that both perception and cognition will have to be defective in
order for a delusion to be formed (Davies et al. 2002; Coltheart et al.

2011). Some of these accounts are found in neuropsychiatric research. One example of these is
the controversial (Kendler and Schaffner 2011; Kendler 2014), but prominent dopamine
hypothesis as advocated in its most recent form by Kapur

(2003, 2004), which provides a bottom-up approach to the formation of delusions and other
psychotic experiences.

A traditionally strong source for the explanation of delusions and their formations is found in
psychoanalysis. Here, the content of the delusion plays a central role in the explanation of its
formation. Delusions have thus been described as attempts to relive feelings, fantasies, and
experiences from the past, to fulfill unconscious wishes and desires, or as attempts at personal
healing (Karon 2003). Notorious among these was the claim that certain delusions are
expressions of repressed homosexuality (Spitzer 1989, 71).

Two problems arise from the previous perspectives on delusions. Firstly, they only offer us an
explanation Bfrom the outside^, as Karl Jaspers would say (Jaspers 1948, 24).

Secondly, these perspectives fail to account for two complex phenomena that are inherent to
certain delusions, namely double book-keeping and the primary delusional experience.

The purpose of this article is to address both problems, by offering an understanding Bfrom the
inside^ that can account for the two complex phenomena. After articulating the exact nature of
these two problems for psychopathology (Section 2), we compare delusional experiences with
variations of reality experience in everyday life, and use the structure of imagination as a
paradigmatic example (Section 3). After this comparison, six factors will be discussed that
contribute to the experience of reality and of hypo- or hyperreality (Section 4). We will show
how the phenomenology of non-clinical hypo- and hyperreality experiences can help us to better
understand delusional phenomena (Section 5). By method and goal, our approach is an attempt at
radical empathy (Ratcliffe 2012). By making the phenomena of double book-keeping and of the
primary delusional experience more understandable, this article tries to cross the delusional
incomprehensibility. Both for the phenomenology of delusions and for the validity of
psychopathology, this could be valuable step.

The phenomenology of hypo- and hyperreality in psychopathology 2 Two problems

2.1 Problem 1: explanation in psychopathology

Jaspers famously introduced the distinction between explaining (BErklären^) and understanding
(BVerstehen^) into psychopathology (Jaspers 1948, 1968). This was inspired by Wilhelm
Dilthey (Jaspers 1948, 250) and his earlier distinction of BNaturwissenschaft^ and
BGeisteswissenschaft^ (Jaspers 1948, 642). Although both explaining and understanding have
their role to play in psychopathology, and although both offer scientific evidence, they should be
strictly kept apart (Jaspers 1948, 24).

Explanation is required for acknowledging causality and objective connections. It implies a

perspective from the outside and makes use of empirical methods. The earlier named dopamine
hypothesis would be a form of explanation, according to Jaspers’

distinction. Understanding, on the contrary, is defined as a perception (BAnschaung^) or a

representation (BVergegenwärtigung^) of the psychic phenomena from the inside (Jaspers 1948,
23–24). Within understanding, Jaspers distinguished two forms. First, there is a direct empathic
grasping of the patient’s psychic state and conscious phenomena, which he called static
understanding. Based on the verbal and non-verbal expressions and the behavior of someone, I
am able to immediately grasp his or her psychic state, for example sadness. Jaspers’
phenomenology is essentially static understanding. Secondly, there is a form of understanding
from the inside how mental states emerge from each other, and how they are meaningfully
connected, which he called genetic understanding (Henriksen 2013, 110). I understand, for
example, how someone’s anger follows from frustration.

The limits of static understanding, and thus of phenomenology, are reached when dealing with
what is not conscious (Jaspers 1948, 16), and with the somatic (Jaspers 1948, 48). But it also
refers to particular experiences that the clinician cannot understand through empathy (Jaspers
1948, 486). In those cases, the gap between the clinician and the patient is supposed to be just
too wide, and the former cannot participate in the reality of the latter (Sass 2013, 98–99). Jaspers
considered certain psychotic phenomena, and particularly the primary delusional experience as
prototypes of incomprehensibility (Jaspers 1948, 82, 483–486).

Although he did not conceive incomprehensibility as an a priori for every clinical encounter with
delusional patients, his claim is often understood in this way (Henriksen 2013; Spitzer 1989, 30).
He did indeed remark that schizophrenic life in general, and not only certain delusional
phenomena, is in essence incomprehensible to us (Jaspers 1948, 486).

Jaspers concludes that, in these cases, understanding falls short, and explanation is needed
(Jaspers 1948, 253). The perspectives described above, namely the analytical debate, the
neuropsychiatric approach of the dopamine hypothesis, and the psychoanalytic theories de facto
follow Jaspers on the limits of understanding and the need for explanation. The problem of
explanation in psychopathology concerns the validity of the explanations, or in other words, the
relation of explanans to explanandum. How do we know that our hypotheses and theories have
anything to do with the patient’s experiences when we presume the incomprehensibility of these
experiences? The assumption of incomprehensibility implies that we may lose the actual
phenomenal experience of the patient out of sight.

Z. Van Duppen
It can be argued that explanation and understanding are not as distinct as Jaspers would claim
(Fuchs 2014, 82–83). If we accept this hermeneutical critique, then we could see how certain
explanations can actually support our attempt to understand the patient’s experiences. Kendler
and Campbell (2014) have recently called this Bexplanation-aided understanding^. A patient
described us how suddenly the color of passing cars seemed to signify something important to
her, and their number plates entailed unclear personal messages. Kendler and Campbell claim
that clinicians are better able to understand this by means of an explanation from the outside, in
this case by a neuropsychiatric hypothesis. In agreement with this text, they do remark that
explanation-aided understanding will be fruitless, if there is no underlying mental state, no
identifiable subjective experience to identify. In other words, one cannot neglect the subjective
experience of psychopathological phenomena. Thus, in order to safeguard the validity of
psychopathology, phenomenology, as the study of these subjective experiences, turns out to be
indispensable.

2.2 Problem 2: two incomprehensible phenomena

Besides the question of validity in explanation from the outside, we are confronted with another
problem. Certain phenomena associated with, or even central to delusions do not fit the available
definitions and explanations. The first example is the so-called double book-keeping. The second
is the primary delusional experience. Double book-keeping is a notorious concept that has been
described by different psychopathologists.

At the end of the Nineteenth century, Emil Kraepelin described a patient who believed to be the
Brex totius mundi^, but who would still work in the hospital’s garden. And another one of his
patients believed to be BGod himself^, but continued to carry around firewood (Kraepelin 1904,
260). After redefining Kreapelin’s Bdementia praecox^ into Bthe spectrum of the
schizophrenia’s^, Eugen Bleuler (1955) also dealt with double book-keeping in various ways. In
the most extreme example he described a patient who had murdered his wife and child. During
and after the murder, he knew that these were his wife and child, but at the same time he also
knew that they were devils (Bleuler

1955, 340). According to Bleuler, although some patients might be aware of the incorrectness of
their delusion, they will hold on to it. Double book-keeping, thus, involves a paradoxical double
orientation to the reality of the delusion and to normal reality. It is not only an intellectual stance
of delusional persons, but it is manifested in the inadequacy of their behavior. BThe emperor and
the pope help working on the fields; the queen of heaven irons the patients’ shirts and besmears
herself and the table with saliva^ (Bleuler 1955, 344).

Louis Sass has revived interest into this phenomenon, and he described the paradoxical co-
existence of delusional convictions with irony and distance towards these same convictions (Sass
1994, 21). BThe metaphor of double book-keeping implies the existence of two distinct realms
that, like an accountant’s two ledgers, are kept strictly apart^ (Sass 2013, 135).

Let us recall that the DSM-definition of delusions refers to erroneous beliefs that are firmly
sustained, but falls short of describing the inconsistency, irony, and ambivalence of double book-
keeping (American Psychiatric Assocation 2013). The phenomenon is
The phenomenology of hypo- and hyperreality in psychopathology particularly challenging for
certain analytical views, and especially for those claims that delusions are indeed some form of
beliefs (Bortolotti 2010). The paradoxical and inconsistent behavior seems to contradict this
view. Kapur’s neuropsychiatric approach neglects this phenomenon in total (Kapur 2003).
Jaspers himself pointed out three characteristic features of delusions, namely absolute certainty,
incorrigibility, and lack of correspondence with reality (Jaspers 1948, 80). They remain present
in clinical views on delusions, particularly in the distinction between delusional-like ideas and
real delusions (Spitzer 1989). This definition of the delusion does no justice to the complex
phenomenon that we have just described.

The second example that illustrates the fact that delusions are difficult to grasp through
definition, explanation, and empathic understanding, is the primary delusional experience. This
is the origin of the incomprehensibility of the real delusion, according to Jaspers (Jaspers 1948,
80). He claims that we can neither empathically grasp this experience, nor do we understand
genetically where it emerges from originally. Both chronologically and ontologically, this
experience precedes the further elaboration or crystallization (depending on whether one
conceives of this as an active or passive process) of the delusional world (Kusters 2014, 605).
The patient notices a sudden change, which perplexes her, but she cannot explain: BSomething is
happening, please tell me what it is^ (Jaspers 1948, 82). This moment is often called uncanny, or
in the German original Bunheimlich^ (Jaspers 1948, 73, 346).

Jaspers further explains that the varieties of primary delusional experiences present themselves in
two main forms. In the first, the patient experiences this uncanny feeling, where the atmosphere
seems to be changed in a particular way. Jaspers also called this the delusional mood
(BWahnstimmung^). The patient searches for answers and clarifi-cation, because this experience
is incomparable to any other previous experience.

Although we saw earlier that patients are certain of the content of their delusions, in this first
form it is rather uncertainty and doubt that characterize the experience. Even more, there seems
to be no content yet to be certain about (Jaspers 1948, 82).1

The second main form of the primary delusional experiences contrasts with the first, as both the
content and the certainty of the content seem to be given right away (Jaspers

1948, 83). The patient does not experience uncertainty or doubt, and he or she does not search
for answers, as they seem clear from the beginning. Klaus Conrad (1958, 88) called this the
‘apophany’ and it can be compared to the religious experience of a revelation (Henriksen and
Parnas 2014, 545). Jaspers noted that it is possible that this second form emerges from the first,
but that this is not a necessity. In other words, the second main form of primary delusional
experiences can be both the chronological consequence of the first, and an independent
experience at the origin of a real and possibly elaborated delusion (Jaspers 1948, 83).

1 The primary delusional experience is discussed differently by other authors. Hemmo Müller-
Suur (1950)

characterized the experience by the Bcertain uncertainty^, while Klaus Conrad (1958, 83–87)
described the delusional mood as part of the Btrema^, preceding the apophantic phase of the
delusion proper.

Z. Van Duppen

The first form of the primary delusional experience poses a problem for the definition and
explanation of delusions from the outside. The idea of delusions as false beliefs seems to
contradict with the uncertainty and doubt that, according to Jaspers, precedes possible further
elaborated delusions. The doxastic accounts seem to neglect this experience, and so, neglect the
original experience in which a delusion might be embedded (Ratcliffe 2013, 231). At first sight,
the neuropsychiatric approach that we have taken as an example in this text, namely the
dopamine hypothesis, might seem to be better able to account for the primary delusional
experience (Kendler and Campbell

2014). According to this hypothesis, this experience is the consequence of dysregulation, and
specifically of aberrant salience of dopamine (Kapur 2003; Kendler and Campbell 2014). Its
implicit assumption remains, however, that we can only grasp these experiences by explanation
from the outside, and thus this approach stays true to Jaspers’ limit of understanding and the
related problem of validity.

3 A different approach to incomprehensibility

These two phenomena stand out as perplexing in the clinical encounter. Can there be another
way to account for them, not by constructing hypotheses from the outside, but by paying close
attention to the actual experiences themselves? In other words, could we increase the validity of
our psychopathology of delusions by crossing Jaspers’ limits of phenomenology and
understanding?

Some phenomenological accounts of schizophrenia have indeed claimed that the understanding
of delusional persons does not stop at this point of incomprehensibility, but may B…go a long
way toward rendering delusional experience comprehensible in some psychological,
phenomenological, and empathic way^ (Sass and Pienkos 2013,

644). It is arguably the main task of phenomenological psychopathology to describe and

understand these pathological experiences. A different form of understanding may therefore be
required, what Ratcliffe (2012, 2013) has called Bradical empathy^.2

Radical empathy involves suspending the world that we Boften take for granted as a backdrop of
interpretation^ (Ratcliffe 2012, 491). It Bdirects attention towards the ordinarily presupposed
world^ and it B… involves incorporating such a stance into an engagement with others’
experiences^ (Ratcliffe 2012, 478). The phenomenological stance Bcan be integrated into our
attempts to engage with the experiences of others^

(Ratcliffe 2012, 483). The experiences of others can certainly differ from ours, but this difference
implies a challenge rather than impossibility (Ratcliffe 2012, 474, 491).

Double book-keeping and the primary delusional experience are such phenomenological
challenges, as we seem to be incapable of spontaneous empathic understanding of them. An
attempt at understanding these may indeed have therapeutic significance, by 2 Stanghellini’s
(2013) ‘second order empathy’, and Henriksen’s (2013) notion of ‘philosophical understanding’

are similar attempts to extend our understanding of schizophrenic phenomena.

The phenomenology of hypo- and hyperreality in psychopathology searching a reconnection

with others, who have lost connection to the shared world (Ratcliffe 2012, 474).

To reach the particular phenomenological stance that grounds radical empathy, we first have to
reflect on the components we take for granted in our own natural attitude.

This reflection will show to improve the understanding of the supposed incomprehensible
experiences. In other words, we use the examination of first-person experience, our experience,
to study the second-person experience, the experience of the delusional patient we attempt to
understand. Our assumption is that understanding can be extend-ed, by recognizing what is
similar in what seems alien.

Importantly, phenomenology, as we will outline here, could prove to be valuable for the validity
of the definitions and explanations from the outside. Attention for the first-person perspective,
for what-it-is-like to have delusions, should indeed be the guiding tool in our psychopathology
(Parnas et al. 2013). This does not mean that phenomenology is empathy, be it radical or not.
Rather, phenomenology Bcan facilitate a distinctive kind of empathy^ (Ratcliffe 2012, 473).

In an attempt to answer the problems of double book-keeping and the primary delusional
experience, we compare the phenomenology of delusional experiences with variations of reality
experience in everyday life. Thus, we do not only pay attention to the pathological experiences
of reality, but also to what seems self-evident in our own natural experience of reality.

In everyday life, our experiences are seldom clearly categorized into the groups of reality or
unreality. We seem to experience different degrees of reality, sometimes even simultaneously.
Think about the other realities we discover when reading a book, watching a play, or playing a
videogame. These different realities sometimes even contradict each other (Gallagher 2009, 254;
Schütz 1945). A paradigmatic example of the variation in reality experience concerns
imagination. The phenomenological structure of imagination as described by Eugen Fink (1966,
21, 28–29) is shown in Fig. 1.

Fig. 1 A person (P) in our shared reality (R1) imagines a second reality (R2) in which this person
(P) acts or perceives an object (O). Note: The simplified structure might not be adequate to
describe every form of imagination. It may be adequate for when I imagine being in a theater and
watching a play, but not when I imagine the play itself. In this latter case, the person (P) is not
explicitly present or thematized in the imagined reality (R2). One could argue that still, this
person is implicitly present, as the one who perceives the play, or better, who quasi-perceives it.
This will be discussed in more detail in Section 4, specifically when arguing for factor 5. Our
approach is motivated by the ‘Philosophy of Madness’ of the Dutch philosopher Wouter Kusters,
who experienced two episodes of psychosis and wrote about these experiences. This text
explicitly refers to the experiences and descriptions of Kusters concerning hypo- and hyperreality
(Kusters 2014, 59–77). This approach also has certain parallels to the work of Aggernaes (1972)
on the quality of reality in hallucinations.

A recent adaption of his work can be found in Farkas (2014)

Z. Van Duppen

Thus, one person (P) has the experience of two realities (R1 and R2) with intentional acts in both
realities and with objects in both realities (objects in R1

and O in R2).

It seems obvious that there are clear differences between the imagined reality (R2), and
perceptual reality (R1). When I imagine what I will do tonight, I do not mistake my imagination
for perceptual reality, where I am working in my office. The imagined plans for tonight depend
on my own imaginative activity, while perceptual reality is predominantly constituted passively
(Husserl 2001). Another difference concerns the different temporality of the two worlds: in our
imaginations, we are not bound to the continuous time experience, but we can jump from one
moment to the other, back and forward (Fink 1966, 32, 46). In this paradigmatic example, we
can thus distinguish clearly between the different realities (R1 and R2).

The schema above, with its distinction between the different realities, allows us to discuss those
cases where a second reality is manifest, delusional or not. One of the significant differences
between delusional and imaginative reality should, however, be emphasized: the imaginative
reality is characterized by Bontic neutrality^ (Fink 1966,

46–47; Husserl 1983, 260, 2005, 691). When imagining an activity, for example, being a
professional football player and scoring an important goal, the real existence of this sportive
activity is set aside: it is neutralized. Whether the imagined content is actually true or false, you
do not ascribe reality to it, but remain neutral.

In a delusion however, this neutrality seems to be lacking: the delusional world (R2) is real,
sometimes even more real than the shared reality (R1). Both worlds (R1 and R2) can actually be
experienced with different degrees of reality. Contrary to the simple distinction of reality in
imagination, double book-keeping, irony and ambivalence (Bleuler 1955, 338; Minkowski 1966,
97) suggest that a clear cut experience of reality in either R1 or R2 is missing. Can they be real at
the same moment? How can the patient who is certain to be Bthe queen of heaven at the same
time iron the other patients’ shirts and besmear herself and the table with saliva^ (Bleuler 1955,
344)?

4 Six factors of hypo- and hyperreality

With the paradigmatic structure of imagination in mind, we will now discuss the factors that
influence the variations of reality experience. These variations will, from now on, be specified
into either hypo- or hyperreality. But what is actually meant by these terms? Hyporeality
involves the feeling of a certain degree of unrealness to the experiences one has. This can
concern both everyday and pathological experiences, and it is not problematic per se. We can
recall experiences of hyporeality, when in emotional shock after a sudden break up of a
relationship, or after receiving news about the loss of a beloved. It just does not seem real. If we
fantasize, of course, we experience the fantasy as a hyporeality, or even more, as an unreality.
Interestingly, contemplating on the nature of our reality experience, we may distance ourselves
from our natural reality experience, and our experience might become less real. In the clinical
spectrum, such experiences are, for example, present as derealization in certain depressions, or in
cases of severe anxiety and panic attacks. Delusional experiences, as we will discuss in detail
further on, can also consist of hyporeality experiences. Hyperreality, on the other hand, concerns
those experiences that seem to

The phenomenology of hypo- and hyperreality in psychopathology have a higher degree of

reality. They seem more real than other experiences (Kusters

2014, 61). Crossing the gaze of another person that one feels strongly for —whether it is because
of love or hate— can be a hyperreal experience. The intensity of the experience might make it
stand out as more real in comparison to other experience that lack this intensity. It might be
experienced as so real, that it strongly dominates one’s thoughts and behavior. Clinically, we can
find examples in different delusional disorders, such as the erotomanic or the jealous type, where
a particular delusional content might be hyperreal. And as we will see, we encounter hyperreality
in the primary delusional experiences.

The discussion of the six factors clarifies which factors can lead a person further into believing
and being certain of the delusional reality (R2), or on the other hand, which (therapeutic) factors
can increase the tendency towards the shared world (R1). The factors are, however, not
constituents of reality, but they rather describe what is in the experience itself that might
influence its realness. Experiences of reality are often made up of a combination of these factors,
while some other factors may be absent. In this analysis, each factor is illustrated with examples
of clinical and non-clinical origin. These phenomena are indeed B… not so far removed from
everyday experience as they might seem^ (Ratcliffe 2013, 236). Afterwards, we will have a new
perspective on the two complex phenomena of double book-keeping and the primary delusion
experience.

4.1 Continuity

The first factor is continuity. Seeing a boat float on a river is much more real than a sudden
visual hallucination of a demonic face that pops up behind a window. However, were this
hallucination to accompany you for quite some time, the demon would become much more real
than the first time you saw it. Non-clinically, we are able to recognize a dream to be unreal
because of the clear discontinuity between life while awake and while dreaming, and because of
the lack of continuity of experiences during the dream state itself. Although you might see
parallels, symbols, or elements out of your everyday life, you recognize them to be unreal. Thus,
continuity works in a twofold way: experiences that are bound together with other experiences
are more real, and real experiences present themselves gradually to us (Kusters 2014, 67).

Continuity as a factor of reality is not restricted to the experiential level, but plays a role on a
biographical or Bnarrative^ (Zahavi 2010, 5) level as well. Discontinuities on this level appear
when moving out of the parental house, or after breakups of long lasting relationships with the
related emotional disclosure and social exposure. This biographical discontinuity is known to be
a factor in the first outbreak of psychosis (Fuchs 2010, 566).

Thus, also in this sense, discontinuity seems related to disturbances of reality experience.

4.2 Materiality and resistance

The second factor is materiality. When asked what reality is, we would immediately and
somewhat naively point to the world of objects around us (Kusters 2014, 64). The chair you are
sitting on is real, the wall you are facing is real, your arms are real.

Something material might seem more real than something that lacks this materiality. A book
might seem more real than the story in it, my writing more real than my thoughts.

Z. Van Duppen

With Jaspers (1948, 79) and Schütz (1945, 546) we can specify that what is real about
materiality, is its resistance. I can act on something, I can grab something. The degree of reality
depends on the resistance I discover when performing the action. The earth is real, because I can
stand and walk on it.

The closer I am to objects of my actions and the less reflected I am about them, the more
resistance and realness I discover. My thoughts, on the other hand, are less real because they lack
this materialistic resistance. But then again, they do have a peculiar resistance, because I cannot
shape them exactly how I want without discovering some kind of resistance. Interestingly, the
phenomenon of hyperreflectivity, that has been described in phenomenological psychopathology
as one of the experiential core features of schizophrenia (Sass and Parnas 2003), illustrates this
negatively. A predominant reflective and distanced attitude disturbs the hold or grip on
perceptual reality (De Haan and Fuchs 2010).

The resistance of reality can dissolve our imaginative worlds. BReality is not only what fills our
imagination, but also that which may destroy it^, Wolfgang Blankenburg

(1991, 10) wrote, capturing the multiple roles that resistance can take in experience.

Reality imposes itself on our imagination with little resistance from the latter. A remarkable
literary example of this can be discovered in a novel by the Austrian writer Stefan Zweig, ‘Der
Widerstand der Wirklichkeit’ (2009). In this novel Zweig describes the resistance of reality on
the narrative level. Two former lovers finally meet again after almost ten years. Not only the
world had changed, but they themselves had changed, and their hopes, imaginations, and
memories vanished, when confronted with the resistance of reality.

4.3 Multiplicity of sensations and perceptions

With Husserl (2001, 95, 107) in mind, we could say that a variety of and a concordance
(Einstimmigkeit) among the different senses leads to the experience of something being real. The
fact that I see, feel and even hear (e.g., when dropping my fork, moving my plate,…) the table I
am eating on makes it more real than the food I assume to be around when I only recognize the
smell of it. Seeing, touching, and tasting the food makes it much more real than only smelling it.
In a hallucination, a person might hear a voice, but he or she does not see, smell, or feel the
person talking to her. This might make the hallucination less real than the voice of a real
person.3 Minkowski (1995, 388) noticed a different quality in the reality of certain
hallucinations, and this lack of multiple sensational modalities might be one of the reasons why.4

3 This does not mean that in everyday experience, we always perceive with all sensational
modalities at once.

There are certainly times when we only hear, only see, or only feel someone or something that
we nevertheless hold to be real. We could indeed speak of Bperceptual faith^ (Merleau-Ponty
2005). See factor 6 and the discussion on the interplay of these factors for further elaboration.

4 Another reason for the hyporeality of certain hallucinations could be the disfunctioning of
Victor Von Weizsäcker’s BGestaltkreis^ (1950) that continuously couples actions and
perceptions. This ‘Gestaltkreis’ is thus more than the sum of a variety of perceptions and the
possibility of acting on a materiality that offers resistance. This is not counted as one of the
factors, as we try to stick to the phenomenal experience itself without imposing too much theory
to it.

The phenomenology of hypo- and hyperreality in psychopathology A patient strives to gain

reality by attempting to make use of different senses: BAll objects appear so new and unknown,
that I pronounce the names of the things I see. I touch them, to convince myself of their realness.
I stamp on the ground, but still I cannot experience the feeling of reality^ (Jaspers 1948, 54).

4.4 Intensity and affection

The quality of reality might be lower in a certain hallucination and delusion, what we call
hyporeality (Kusters 2014, 76–78). But they may be hyperreal as well. What makes this
experience more real than others? The intensity of an experience could be another factor
influencing the dominance of either of the realities (R1 or R2). As we saw earlier, crossing the
gaze of another person that one feels strongly for can be an intense and hyperreal experience.
One can even feel physically affected. The gaze of the other may be enough to renounce all the
doubts that one might have had.

The delusional experience, on its turn, may be so intense, and the person can feel so affected, or
even overwhelmed, that she becomes immune to other experiences or arguments that deny or
contradict this first intense experience. The experiential horizon of the patient seems to constrict
itself to the delusional reality. Thus, the intensity makes the delusional world more powerful than
any perception, as Kraepelin (1904, 178) rightly remarked. As a perfect illustration of this a
patient said about his own first psychosis: BThe truths I found, presented themselves
immediately and directly with absolute certainty.^ (Kaplan 1964, 94).

4.5 Independency and the sense of authorship

The phenomenological structure of imagination and multiple realities allows us to argue that
another factor might lead to a change in reality experience. Namely, when the intentional
(imaginative) act that constitutes the delusional reality (R2), is not recognized as an activity of
the person (P). As we saw earlier, Fink and Husserl noticed that imagination is characterized by
ontic neutrality, implying that the person who imagines is actually somehow aware of doing so.
Imagination, according to Husserl (2005, 656), involves an as-if- or quasi-perception. When I
imagine the Panthéon, to take Sartre’s example (Sartre 2004, 88), I do imagine a structure with a
color, a location and a shape, but I do not perceive it. I cannot count the columns, which I could
do if I perceived it. I quasi-perceive it, I perceive it Bas-if^ it were in my visual field.

The Bas-if^ of the delusional reality might be lost (Fuchs 2013, 252), and it may become a
perceptual reality, rather than the consequence of an imaginative act. This incapacity of the
person to recognize that he or she is the active creator of the imaginative world seems to
correspond to the descriptions of a disturbance of the sense of agency, as phenomenological
psychopathologists have described in schizophrenia.

Jaspers (1948, 102, 484) did so at the beginning of the 20th century, and recently this sense of
agency has been studied more intensively (Gallagher 2000). In this context, we can understand it
as a sense of authorship (Wegner and Wheatley 1999; Zahavi 2005, 6) concerning one’s own
imagination.

Z. Van Duppen

A remarkable pathological example of a disturbance in sensed authorship was recently described

by Rosen Rasmussen and Parnas (2014). A young schizophrenic woman reported that she had
seen a movie inside her head of a planned visit to the cinema. BLater that day, she decided not to
go to the cinema after all because the phantasy had left an unpleasant feeling that it probably
would not turn out nicely.

Although, she knew ‘deep down’ that it was all just a phantasy, ‘it felt like being there

[in the cinema] in person’^ (Rosen Rasmussen and Parnas 2014, 4). In agreement with the fifth
factor, they write that the pre-reflective self-awareness of the intentional act, what we refer to as
the sense of authorship, is weakened. If the person does not acknowledge (although implicitly)
that he or she is the creator of this imaginative or delusional world, it gains independence and
reality.

A more common loss or weakening of the sense of authorship can occur in everyday life. We
occasionally confabulate memories of events that did not really take place, or not the way we
remember them. To a lesser degree, this is an example of a non-clinical failure to recognize one’s
own imaginative act.

4.6 Intersubjectivity

Let us now look at the last factor, concerning the complex role of intersubjectivity. In the natural
attitude, certain things will be unquestioned, undoubted and never made explicit — although
they might even be fundaments of our knowledge and experiences (Wittgenstein 1988, §88,
§341, §342; Henriksen 2013, 112–115; Kusters 2014, 62).

Some of these things may lose their self-evidence when made explicit, and may even lose their
realness. In this way normal reality (R1) is actually filled with unrealities —

but unrealities that we set aside using certain rules. However, the reality of this normal world is
highly dependent on the fact that we share it with others, with many, and that whole institutions
of certainty are built on this sharing. We could imagine cultures where the reality of things
differs from ours, and a certain element that we hold for plain imagination or primitive magic
might be very real to someone in such culture.

Science, and religion, with its institutions, its rituals and its morality, are obvious examples of
how intersubjectivity influences our experiences of reality.

While language and culture play a fundamental role in determining how a person actively and
intentionally shapes reality — as in the example of science and religion — we could assume that
other aspects of intersubjectivity might be at work on the ‘non-propositional, pre-reflective and
pre-intentional’ (Varga 2012, 104) level of passive reality experience.

On this lower level we can describe first of all the need for more than one perspective on the
world in order to experience it as real. You do not only need multiple perspectives through the
movement of your eyes and body, but especially the possible perspectives of others on the
objects and on the world (Blankenburg 1991, 16–27).

Paraphrasing Husserl (1973, 110), Gallagher writes that B… intersubjectivity is transcendental,

in the sense that it is a condition of possibility for us to experience anything like a coherent and
meaningful world, and specifically to experience it as real and objective^ (Gallagher 2014, 2). In
other words, the sharing of the world is a necessary condition for Bperceptual faith^ (Merleau-
Ponty 2005, 305), for a stable experience of the reality of your perception. In the earlier
mentioned example of dreaming, it is not only the discontinuity that allows you to recognize the
unreality of the dream after you have woken up, but also the absence of other perspectives
(Schütz 1945, 563).

The phenomenology of hypo- and hyperreality in psychopathology Secondly, recall how,

according to Wittgenstein (1988, §88, §341, §342), certain things in normal reality (R1) are
unquestioned, undoubted and never made explicit.

These things constitute what Rhodes and Gipps (2008, 299–302) have called the Bbackground^.
It concerns Bour direct, pre-reflective and practical grasp of the world^

(Rhodes and Gipps 2008, 298). These bedrock certainties emerge from our everyday experience
of the world, which is not an isolated experience, because we share our engagement in the world
with others (Zahavi 2001). The famous mirror mechanisms of motor activity seem to emphasize
this intersubjective condition of our practical engagement in the world on the level of neural
processes (Gallese 2010).

Intersubjectivity, thus, has a two-fold effect on our reality experiences. First, on the higher order
level of language and rules, the presence of others forms the community in which we agree
mostly implicitly on what is real and what is not. Secondly, the presence of others as agents in
the world is a condition for the experience of the reality of this world. The fact that I am engaged
in this world makes my experiences intersubjective, as all my activities and engagements are
shared. This is what has been referred to as Benactive intersubjectivity^ (Fuchs and De Jaegher
2009). Building on this practical engagement, I integrate the bedrock certainties of my
community. Intersubjectivity thus constitutes a form of basic trust in my own subjective
experiences of the world.

Returning to psychopathology, we can now bring Spitzer’s definition of a schizophrenic delusion

to mind: it has the form of a statement about one’s most personal mental states, but its content
concerns the intersubjectively accessible world (Spitzer 1989, 115).

This definition indicates that intersubjectivity as such seems to be disturbed in this form of
delusion, as the patient does not recognize what is private and what is shared, what is self and
what is other. Kusters (2014, 551) remarks that the psychotic self essentially loses connection
and attunement with others and their stable reality. This is exactly what Minkowski (1927, 5,
236, 250) defined as the Bloss of vital contact with reality^.

Disturbances of intersubjectivity, like in schizophrenia (Fuchs 2010, 564; Sass 1994), urge the
constitution of a new, idiosyncratic reality (Schwartz et al. 2005; Fuchs 2015). A delusional
reality, however, without the characteristics of self-evidence and attunement to others. When
imagining, on the contrary, I am aware that my imagination is private.

Others do not have the same access to and power over my imaginative world.

5 Understanding the two phenomena

We are now better able to understand the two complex phenomena that challenge the
explanations from the outside. First of all, double book-keeping, the related ambivalence, and
possible distanced attitude of delusional patients towards their own convictions and beliefs
becomes clearer in the light of these six factors. Let us take a closer look at the following
example, where some of the factors interplay to form the paradoxical co-existence of supposed
excluding realities. A patient experiences a frightening influence of the internet on his own
thoughts (Stompe et al. 2003). This experience may be so intense (factor 4) that it seems
hyperreal, and the factors that contradict the reality of this experience are neglected, such as the
discontinuity (factor 1) and the lack of multiple sensational modalities (factor 3). However,
confronted with family or caregivers who try to reassure the patient, his original experiences of
being influenced may start to seem doubtful and less real. The lack of intersubjective

Z. Van Duppen
confirmation (factor 6) of his experiences may in a way neutralize their realness.

However, if these experiences remain, they gain continuity (factor 1) and become more real.
Furthermore, the patient may not recognize his own imagination at work, what we referred to as
the sense of authorship, but instead experiences what happens to him passively (factor 5). The
patient may learn that others do not believe him and categorize his experiences as phantasms or
as psychopathology. He may thus talk about these experiences with distance and irony, somehow
acknowledging that these are private experiences that are only real to him, but real nonetheless.

Both main forms of the primary delusional experience, as Jaspers described, can be better
understood with use of these factors as well. The patient, who suddenly discovered that the
colors of passing cars seemed to signify something important to her, and for whom the number
plates carried unclear messages, was markedly affected by these hyperreal insights (factor 4).
The discovery of being at the center of all these symbols was perplexing, and it shook her with
an unknown intensity. But when confronted with the disbelief of her husband (factor 6), and later
on, during psychoeducation, with the health care workers explaining her that it was the
consequence of her own neurotrans-mitter dysregulation (factor 5), rather than an independent
reality, she turned doubtful on her previous insights.

To take another example, consider the person who felt touched by the light of God in a moment
of heavenly clarity. The clear content and answers she receives may arise with an overwhelming
intensity and affection, becoming hyperreal. In this case this dominates the factors that would
contradict it, such as its discontinuity (factor 1), its lack of resistance and materiality (factor 2),
and the lack of intersubjective confirmation (factor 6). There are examples enough of similar
experiences that are intersubjectively embedded, for example in a religious context. In these
cases, the intersubjective confirmation may allow and support such experiences to function in a
meaningful way, without being considered pathological (Hunt 2000). With the interplay of these
factors in mind, both the doubt and uncertainty that characterizes the first main form, and also
the immediate certainty of the second main group become more accessible and understandable.

6 Discussion

6.1 Answers

The purpose of this article was to address two problems concerning the understanding and
explanation of delusions. Firstly, we aimed at developing an understanding from the inside that
could increase the validity of different psychopathological accounts of delusions. In order to do
so, we compared the phenomenology of delusional experiences with variations of reality
experience in everyday life. To clarify these different reality experiences, we used the structure
of imagination as a paradigmatic example.

This structure made it possible to articulate the paradoxical co-existence of multiple realities (R1
and R2), in both clinical and non-clinical context. The key difference between imagination and
delusion involves ontic neutrality.

Six factors were discussed and illustrated by clinical and non-clinical examples. This way, it
became clear that experiences of hypo- and hyperreality are not restricted to pathology, but have
their place in everyday experiences as well. This suggests that
The phenomenology of hypo- and hyperreality in psychopathology pathological phenomena of
hypo- and hyperreality can be understood by investigating the interplay of the six factors in
specific situations. This method remains within the phenomenal experience and can thus be
called an understanding from the inside.

The factors should not be considered constituents of a metaphysical effort to describe what
reality is as such. Rather — and within the limits of phenomenology

— these factors describe what is in the experience itself that might determine its realness.
Neither one of the factors is a necessary condition for reality experience, but every one of them
can influence the degree of reality experienced. Experiences of reality are often made up of a
combination of these factors, while some other factors may be absent. The list of factors is not
considered to be exhaustive.

The second aim of this article was to provide an understanding of the two complex phenomena
that seem to escape our rationality and our empathic understanding, namely double book-keeping
and the primary delusional reality. The phenomenology of non-clinical hypo- and hyperreality
shows how pathological reality experiences, including these two phenomena, are influenced by
the same factors as normal everyday experiences. In this approach, delusional reality, in all of its
complexity, could be better understood as the result of a specific interplay and a particular
dominance of certain factors over others. This contributes to the elaboration and persistence of
the delusional reality, and sustains phenomena like double book-keeping and the associated irony
and distance. Our understanding of these phenomena has increased, as we now recognize
similarities to our own experiences, in what is commonly assumed to be incomprehensible.

6.2 Limitations

There are four limitations to our approach that we would like to address. The first concerns
double book-keeping. It has taken up a central role in our argumentation, but one could argue
that it is only a marginal phenomenon with an unknown prevalence. Even more, one could deny
that double book-keeping is a delusional phenomenon in the first place, as it does not match the
definition of a false belief, or of Jaspers’ three criteria of incorrigibility, absolute certainty, and
incorrectness. This would, however, turn the problem around. We are not trying to fit the
phenomena to the definitions and descriptions, but we take the given phenomena as starting
point, even if they appear marginal. Their stable presence throughout the historical descriptions
of delusions, and the puzzling impression they leave the clinician with are extra indicators that it
is a phenomenon not to neglect.

The second limitation concerns our claim of attempting radical empathy (Ratcliffe

2012). Does this article really offer a radical and innovating stance to the delusional experience?
Or is it a hermeneutical modification of Jaspers’ distinction between understanding and
explaining, comparable to the earlier mentioned Bexplanation-aided understanding^ of Kendler
and Campbell (2014)? The difference is that our approach did remain within phenomenology,
and thus, does not necessitate explanation from the outside, such as neuropsychiatric hypotheses.
Basing ourselves on the seemingly self-evident reality experience of everyday life, we could use
our own familiar experiences to connect to the alien and incomprehensible. Explanation-aided
understanding has the same goal as our approach, but the method has proven to be different.
Nevertheless, we should keep in mind that our attempt at radical empathy is based on the
artificial distinction and separation of factors of reality experience, with the risk of reification.

Z. Van Duppen

This does little justice to the ontology of what we conveniently name reality. Arguably, this is an
artifact typical for phenomenological investigations.

The third limitation concerns the role of hypo- and hyperreality for delusions. It can be asked
what the relation between delusions and the experiences of hypo- and hyperreality exactly
consists of. Firstly, we know now that these experiences of hypo- and hyperreality are not
restricted to pathology, but are present in everyday life as well. They are, in other words, not
specific for delusions or psychopathology. Secondly, we have only focused on two problematic
delusional phenomena. These two phenomena certainly proved to involve different hypo- and
hyperreality experiences. It is an intriguing question whether every (schizophrenic) delusion
involves such experiences. It could be correct to distinguish different degrees of reality
experiences in different delusions, from a full-blown loss of the as-if, and of ontic neutrality, to
phenomena like double book-keeping. At this point, we cannot make unambiguous claims about
whether or not experiences of hypo-and hyperreality are decisive in the formation and
persistence of delusions. This would indeed still be within the scope of understanding, albeit
genetic, and not static understanding or phenomenology. In this article, the focus was rather on
the latter, by elucidating the factors themselves, rather than investigating their causal
connections.

The last limitation questions our claim on validity. Validity in the context of psychopathology
mostly refers to the correspondence of a definition or concept to a specific natural kind or disease
entity that is supposed to exists behind the symptoms and syndromes of psychiatry, for example
a particular disease process (Kendell and Jablensky 2003). This is not what we are after here. We
have proposed that attention for what-it-is-like of a pathological experience should guide us in
phenomenological psychopathology (Parnas et al. 2013). Validity, in this sense, means that the
first-person experiences of the patient correlate to our descriptions. This phenomenological
validity can consequently support the hypotheses and theories Bfrom the outside^, as Jaspers
(1948, 1968) argued. The discussion of the six factors did not teach us what causes one of them
to dominate, or what determines their interplay, nor did it clarify why a certain dominance or
specific interplay is called pathological in the first place.

Our task here was to restrict ourselves to the description of the phenomenal experience itself. We
now have the possibility to search for explanations, and to investigate empirical correlations of
these phenomenal experiences. Complementary to explanation-aided understanding, we can call
this understanding-aided explanation. While Kendler and Campbell (2014, 5) Bare suggesting
that neuroscience advances translated in neuropsychological models will expand the range of the
understandable beyond that of careful history taking^, we would analogously suggest that radical
empathy based on non-clinical phenomenology can expand the range of the understandable in
psychopathology.

7 Conclusion
The aim of this article was to address two problems concerning the understanding and
explanation of delusions, namely the questionable validity of the common psychopathological
explanations from the outside, and the two complex phenomena of double book-keeping and the
primary delusional experience that seem to escape our rationalization and empathic
understanding. I developed a form of radical

The phenomenology of hypo- and hyperreality in psychopathology empathy that allowed a better
understanding of these phenomena from the inside.

By using the structure of imagination as a paradigmatic example, I could articulate the

paradoxical co-existence of multiple realities (R1 and R2), in both clinical and non-clinical
context. Six factors were discussed and illustrated by clinical and non-clinical examples. These
factors include continuity (1), materiality and resistance (2), multiplicity of sensations and
perceptions (3), and intensity (4). With the sense of authorship (5) we suggested how a
disturbance of the sense of agency on the level of creation might increase the independency and
thus realness of the delusional reality. Lastly we discussed the complex role of intersubjectivity
(6) on both the level of language and rules, as on a more basic level of passivity with reference to
perceptual faith and shared engagement in the world.

It became clear that experiences of hypo- and hyperreality are not restricted to pathology, but
have their place in everyday experiences as well. This suggests that pathological phenomena of
hypo- and hyperreality can be understood by investigating the interplay of the six factors in
specific situations. The two complex phenomena of double book-keeping and the primary
delusional experience proved to be better understandable to us. This method remains within the
phenomenal experience and can thus be called an understanding from the inside.

Our approach requires openness to particular experiences of others, which are commonly
claimed to be incomprehensible. By questioning our own self-evident experiences and by
recognizing the similarities between pathological and everyday experiences, we allow to be
affected by these experiences, rather than just categorize them as alien. It is rightly demonstrated
that such an attitude is indeed phenomenological, as it minimizes assumptions on the nature of
delusional phenomena. Both for the phenomenology of delusions, as for the validity of
psychopathology, this could be a valuable step to take. As Ratcliffe (2012) has argued, it can
have therapeutic consequences, to attempt to reconnect with others, by understanding the
incomprehensible.

Acknowledgments

I would like to thank the anonymous reviewers, Michela Summa, Samuel Thoma, Lars Siersbaek
Nilsson, Wouter Kusters, Steve Velleman, Mike Finn, and Thomas Fuchs for their helpful
suggestions for this article.

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Document Outline
The phenomenology of hypo- and hyperreality in psychopathology
Abstract
Introduction
Two problems
Problem 1: explanation in psychopathology
Problem 2: two incomprehensible phenomena
A different approach to incomprehensibility
Six factors of hypo- and hyperreality
Continuity
Materiality and resistance
Multiplicity of sensations and perceptions
Intensity and affection
Independency and the sense of authorship
Intersubjectivity
Understanding the two phenomena
Discussion
Answers
Limitations
Conclusion
References