Schizophrenic Delusions: A Phenomenologic al Approach

VOL 19, NO. 3, 1993 Schizophrenic Delusions:A PhenomenologicalApproach

by Pierre Bovet andJosef Parnas

Abstract

The issue of specificity of delu-sions in schizophrenia is still amatter of debate. The authorsanalyze the delusion formationin schizophrenia from a pro-totypical, phenomenological pointof view, focusing on the sub-ject's experience. This perspectivelinks delusion formation to theautistic predisposition, which isconsidered here as the elemen-tary phenotypic expression of thevulnerability to schizophrenia.Autism is viewed as a defectivepreconceptual (i.e., before lan-guage) attunement to the world.It impedes the individual's shar-ing of "common sense" withothers and impairs the ability toproject into the future. The de-velopment of delusions is illus-trated, in part, by Klaus Con-rad's work on the onset ofparanoid schizophrenia. Delu-sions are viewed as transforma-tions of the structure of ex-periencing. When threatened infuture ability to be, the autistic,vulnerable person looks for theclues to becoming by attributingsignificance to disparate elementsof the environment, which be-come self-referential. The linkestablished between these dispa-rate elements is based on univer-sal characteristics that give theschizophrenic delusion a meta-physical quality. The transitivis-tic experience in delusions ofcontrol and omnipotence pointsto a specific way of crossing theborder between "mine" and"yours" (disturbances of the ex-periencing "I"). What strikes aclinician in these delusions isthat the normally tacit link be-tween the sense of being andthe sense of acting becomesquite apparent The authors also

propose a specificity in thethemes of schizophrenic delu-sions. Delusions acquire aschizophrenic quality when on-tological (i.e., universal) elementsof the discourse between thelocutor and the Other dominateat the expense of the worldlyelements. It is emphasized thatdelusional content and form aredialectically related and hardlydistinguishable. The authors con-sider the delusion formation as aphenomenon of emergence, a sit-uation in which a new qualita-tive order arises from the reorga-nization of essentially unchangedelements. To consider schizo-phrenia as an emergent, particu-lar way of experiencing, relatedto the autistic defect, has impor-tant consequences for researchand for treatment. A dialectic ex-change is needed between pro-totypical models generated byphenomenological inquiry andempirical, operational validationof testable aspects of suchmodels.

A delusion is usually defined by aset of formal, descriptive criteria,which have been summarized byOltmanns (1988, p. 5).

The following list includesseveral features that havebeen used to describe delu-sions. They might also beseen as defining characteris-tics, with none being consid-ered to be either necessary orsufficient conditions [italicsadded].

a. The balance of evidencefor and against the belief is

Reprint requests should be sent toDr. P. Bovet, Policlinique psychiatri-que universitaire A, 18, av. deS£velin, CH-10O4 Lausanne,Switzerland.

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580 SCHIZOPHRENIA BULLETIN

such that other people con-sider it completely incredible.

b. The belief is not sharedby others.

c. The belief is held byfirm conviction. The person'sstatements or behaviors areunresponsive to the presenta-tion of evidence contrary tothe belief.

d. The person is preoc-cupied with (emotionallycommitted to) the belief andfinds it difficult to avoidthinking or talking about it.

e. The belief involves per-sonal reference, rather thanunconventional religious, sci-entific, or political conviction.

f. The belief is a source ofsubjective distress or inter-feres with the person's oc-cupational or social func-tioning.

g. The person does not re-port subjective efforts to re-sist the belief (in contrast topatients with obsessionalideas).

This line of thinking, called "op-erationalism," is currently the mostaccepted approach in psychiatry(Stein 1991). Operational definitionsof scientific terms aim at "objec-tivity" of knowledge, "in the senseof being intersubjectively certifia-ble, independently of individualopinion or preference" (Hempel1965).

An operational definition of aterm is conceived as a rule tothe effect that the term is toapply to a particular case if theperformance of specified opera-tions in that case yields a cer-tain characteristic result, [p. 123]

However, delusion is difficult todefine operationally. Each of thelisted criteria, considered sepa-rately, is insufficient. For instance,criterion b, "The belief is notshared by others," should requirethe psychiatrist to screen a largesample and would be refuted incases of folie-b-deux. To improveoperationality, each of the criteria

should be accompanied by a set ofsubcriteria, which in turn shouldbe more precisely defined, and soforth. In otheT words, we can onlydesignate a given statement as de-lusional within a specific context,encompassing the patient's and theclinician's experience.

Moreover, delusion is a non-specific symptom, occurring inmany functional and organic men-tal disorders (Oepen et al. 1988).The issues of objectivity and speci-ficity become more problematicwhen delusions are included inthe diagnostic criteria of schizo-phrenia. The clinical demarcationof schizophrenia lacks, so far, aspecific, independent validation cri-terion (i.e., biological marker). Thislack immediately renders any pos-tulate about specificity of a givenclinical feature debatable. Opera-tional diagnostic systems deal withthese difficulties by specifying anumber of features that should co-exist in a given case in order tobe included in a diagnostic cate-gory (polythetic systems). TheDSM-IU-R (American PsychiatricAssociation 1987) requires thatdelusions either have to be ac-companied by specified othersymptoms (e.g., incoherence, hal-lucinations) or exhibit a bizarrequality (sufficient requirement).Unfortunately, Flaum et al. (1991)did not find "bizarreness" to beoperationally reliable even amongthe members of the task force onDSM-1V.

Polythetic systems do not ariseout of the blue but derive fromprototypical descriptions. "Pro-totypic categories are organizedaround prototypical examples (thebest examples of the concept) withless prototypical examples forminga continuum away from these cen-tral cases" (livesley 1985, p. 355).The prototypical notions (in the

case of schizophrenia, the work ofKraepelin, Bleuler, and Schneider)influence the conceptual guidelinesof polythetic operational systemswith respect to specificity andpathogenesis. Prototypical casescannot, by definition, be gener-alized as true or false (e.g., asparrow is more prototypical of abird than a penguin, but all of itsown characteristics cannot be gen-eralized to the generic class ofbirds), and empirical work is nec-essary to assess the sensitivity andspecificity of singular features thatare derived from the prototype.

In the absence of external val-idation, the diagnostic concepts ofschizophrenia have to rely on adynamic exchange between pro-totypical conceptualizations andempirical validations based on op-erational definitions. The variety ofbehavioral phenotypes in schizo-phrenia results from a long causalchain of increasingly complex in-teractions between the putativebiological etiological factors andenvironment (Bleuler 1917; Ciompi1988a). Single symptoms of adultschizophrenia patients are not pri-mary (in the pathogenetic sense)and are only rarely diagnosticallyspecific. However, some of thesesymptoms may exhibit qualitiesthat reflect basic disturbances, thatis, the disturbances that are "mid-way" between the underlyingpathophysiology and overtsymptomatology.

We hypothesize that these basicdisturbances, which create a vul-nerability to schizophrenia, relateto a difficulty in the intersubjectiveconstitution of the sense of a Self.We use a phenomenological ap-proach to explore how delusionaltransformation in paranoid schizo-phrenia reflects a particular way ofrelating to the world, exhibitedpremorbidly. The ideas presented



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below are based on a prototypicalapproach and cannot avoid a fla-vor of generalization. Componentsof such a prototype still have toface empirical validation. Eventhough the mechanisms we discussare not applicable to all pheno-types summarized today as schizo-phrenia, we think that they illus-trate specific aspects of theontogenic development of schizo-phrenic symptomatology.

Definitions ofPhenomenology

Phenomenology has ambiguousconnotations, as was illustrated bya recent debate in the Schizo-phrenia Bulletin (Andreasen 1991;Rotov 1991). For the sake of clar-ity, we shall distinguish betweenthree common uses of this termand indicate which of them isused by the present authors.

In Anglo-Saxon psychiatry, phe-nomenology is synonymous withdescriptive psychopathology andrefers to the description of symp-toms and signs in psychiatric ill-ness. This descriptive process isideally performed by an impartial,"objectifying" observer.

In continental Europe, Jaspers(1923) considered phenomenologyas a branch of psychopathologyconcerned with the patient's innerworld, that is, with "symptoms"rather than "signs." This world isinaccessible to direct observationand can only be grasped throughthe patient's report. The psycho-pathologist, then, must faithfullyreproduce the patient's experience,preferably by quoting the patient'sspontaneous self-descriptions, be-cause these are undistorted byquestioning. The observer relies inhis investigation on empathy, andthe goal of the investigation is to

bring to mind as precisely as pos-sible what the patient experiences("presentifi cation").

Our approach, which may beconsidered as post-Jaspersian phe-nomenological psychiatry, has beendeveloped mainly in Germany andFrance. It is based on phenom-enological philosophy (Husserl1900/1970b, 1936/1970^; Heidegger1927/1962, 1975/1988; Merleau-Ponty 1945/1962, 1947/1964,1964/1968), which aims at identi-fying and describing the essentialfeatures of the human being in theworld. Phenomenology representsa radical departure from the Carte-sian tradition of sharp subject-object, mind-body, affect-cognitiondualisms. "Subject and object mustbe conceived as two abstract 'mo-ments' of a unique structure whichis presence" (Merleau-Ponty,1945/1962, e.t. p. 430).1 Phenom-enological inquiry focuses on theconcrete fullness of the subject-object whole as it is lived beforethe conceptual split between objectand subject is introduced by theuse of language. Phenomenologyconsiders human knowledge as adialectic between the object andthe subject, implying intentionalityof the subject: consciousness is al-ways consciousness of something.Consciousness itself is a projection

'References to the literature firstpublished in German, French, or Pol-ish are quoted with the original pub-lication's date to facilitate a historicalapprehension of the concepts' per-spective evolution. When an Englishtranslation is available, it is indicatedin the list of references. In that case,pages in the text are those of theEnglish translation (e.t.). We haveslightly modified the English transla-tion of Minkowski's Le Temps Vtcu.Quotations not published in Englishhave been translated by the authors.

of the world to which it is per-petually directed. The word phe-nomenon does not refer to a mereappearance, but, being a correlateof any mental act, phenomenonpossesses a certain intrinsic senseof truth (essence). Phenomenologi-cal inquiry tries to unearth themeaning of the phenomenon; pri-ority is given to the "evident-ness" or "given-ness" of the phe-nomenon as opposed to its pos-sibilities of being objectified. Inthe epistemic act, which Husserl(1913/1975) called "originally pre-senting experience" or "lived ex-perience," the phenomenon unfoldsitself to us, and in our mutual in-volvement with it, we are able tograsp the invariant essence orstructure of it by focusing on itsvariations against a horizon (con-text or texture). The "lived ex-perience" is always embedded inintersubjectivity, that is, the tacitapprehension that our individualprivacy is always constituted andframed by its similarity to (thoughnot identity with) other peoples'privacies.

My awareness of constructingan objective truth would neverprovide me with anything morethan an objective truth for me,and my greatest attempt at im-partiality would never enableme to prevail over my subjec-tivity, if I had not, underlyingmy judgments, the primordialcertainty of being in contactwith being itself, if before anyvoluntary adoption of a position Iwere not already situated in anintersubjective world. [Merleau-Ponty 1945/1962, e.t. p. 355]

The context of intersubjectiviry isdesignated by Husserl (1936/1970a)as "lived world," that is, the ex-perienced world, which is alwaysthere in its concreteness and fac-ticity, as the universal field of allaction. What is given in our en-



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counter with the world is neitherthe object perceived nor the per-ceiving subject, but rather an ex-perience that implies the inter-twining of perceiver and perceivedand the reversibility of my percep-tion with that of another. The phe-nomenological maxim "to thethings themselves" implies for psy-chopathology a task of unprej-udiced concern with man andman's modes of being-in-the-worldas they are directly encountered inexperience.

Historically, phenomenologicalpsychiatry in that philosophicalline of thought is considered ashaving been founded in Zurichduring the 63rd Assembly of theSwiss Psychiatric Association in1922 (Schweizerischer Verein furPsychiatrie 1923).

It is clear that there is someoverlap between Jaspersian andpost-Jaspersian psychiatric phe-nomenology. Even though "early"Jaspers used concepts like "empa-thy" and "presentification/' hewas reluctant to abandon hispositivist perspective (Blankenburg1980). Later, Jaspers moved to anexistential philosophical position.Readers interested in philosophicalphenomenology are referred toHammond et al. (1991). A readilyaccessible account of phenomeno-logical psychopathology can befound in De Koning and Jenner(1982).

A PhenomenologicalApproach to SchizophrenicVulnerability

Our basic assumption, which isshared by most clinicians and re-searchers involved in the field ofschizophrenia, is to considerschizophrenia as an epigenetic de-velopmental process. Such a model

was already sketched by Bleulerand Jung in 1908 and explicitlyformulated by Minkowski 20 yearslater

The notion of schizophrenia, asa mental disease, can be decom-posed into two factors, of dif-ferent order: first, the schiz-oidia, which is a constitutionalfactor, highly specific, and tem-porally enduring through theindividual life; and, second, anoxious factor, of an evolutionalnature, and which has the abil-ity to determine a morbid men-tal process. This latter factorhas, for itself, no definite taint,it is of a more unspecific na-ture, and the clinical picture towhich it will lead will dependupon the ground on which itwill act. Together with schiz-oidia, it will transform the latterinto a specific morbid process,into schizophrenia. [Minkowski1927, pp. 50-51]

According to this model, schizo-phrenia occurs only among vulner-able individuals. There is a con-sensus among researchers thatvulnerability to schizophrenia isformed early in life. Premorbidcharacteristics may therefore beconsidered as subtle clinical indica-tors of such vulnerability. Up tothe end of the 1960s, all empiricalstudies on premorbid characteris-tics were retrospective (Offord andCross 1969) and therefore largelyunreliable. More recently, studiesappeared using data collected dur-ing the subjects' childhood beforetheir first schizophrenia episodeand recoded by the investigatorsalong the dimensions of their in-terest (Watt 1972, 1978; Hartmannet al. 1984). Prospective studies ofchildren at risk for schizophreniaused clinical evaluations and otherconcurrent data sources (Parnas etal. 1982; Parnas and Schulsinger1986; Pamas and Jergensen 1989;Parnas and Mednick 1991).

The overall picture emergingfrom these studies is that grossbehavioral abnormalities are notidentifiable in all preschizophreniasubjects. However, abnormalitiescan be shown in several be-havioral domains with the pos-sibility "that each of the indicatorsinvolves information on one orseveral separate aspects of a singleunderlying vulnerability that issimply manifested more clearly insome sorts of behavior in one caseand other sorts in other cases"(Hartmann et al. 1984, p. 1055).We hypothesize that premorbidmale aggressiveness and female in-troversion in school (Watt 1972,1978); difficulties in interpersonalrelations, anxiety, neophobia, andflat affect in males (Hartmann etal. 1984); and defective emotionalrapport, eccentricity, and formalthought disorder in high-risk pre-schizophrenia subjects (Parnas etal. 1982; Parnas and Jergensen1989) are all indicators of a defec-tive attunement between the indi-vidual and the outer world. Thespecificity of this defective attune-ment is hardly recognizable in anysingle behavioral disturbance;rather, the overall picture attainssome prototypical value. This lackof attunement corresponds to whatMinkowski calls "schizoidia." Weshall designate this defective rap-port between the individual andthe outer world as the autistic vul-nerability (Parnas and Bovet 1991).

It must be emphasized that theterm "autistic" does not denotehere a withdrawn and shut-in atti-tude. Autism was originally de-fined by Bleuler (1911/1950) as awithdrawal from outer reality, ac-companied by the predominance ofthe inner fantasy life. However,both the notion of withdrawal andthe notion of rich fantasy life areoften contradicted by empirical



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data (Bleuler's own descriptions of"latent schizophrenias," 1911/1950;Kraepelin 1919/1921; Minkowski1927; Zilborg 1941; Dunaif andHoch 1955). In fact, Bleuler wasnot able to provide a satisfactorysymptomatological description ofautism and therefore categorizedit as a complex fundamentalsymptom.

For phenomenology, autism isnot a symptom in the sense of themedical model; rather, it is a phe-nomenon that is recognizable inthe intersubjective space (Tatossian1979). It is precisely for that rea-son that clinicians are sometimesable to make a very quick diag-nosis of schizophrenia in the en-counter with the patient. In such adiagnostic act, the clinician imme-diately and preconceptually graspsthe sense of the clinical picture(Riimke 1942; Schwartz and Wig-gins 1987).

Phenomenology sees autism as adefective expressive-perceptual at-tunement between the subject andthe outer world. The autistic defectis perceivable both in the cognitiveand in the affective domains be-cause the attunement to the worldis affected at the very elementary,preconceptual level. Expressionsused by European phenomenolo-gists, such as "loss of vital contactwith reality" (Minkowski 1926,1927, 1933/1970), "inconsistency ofnatural experience" (Binswanger1963), "global crisis of commonsense," or "loss of natural evi-dence" (Blankenburg 1969, 1971),refer precisely to this autistic im-pairment of the elementary di-alogue between the Self and theouter world.

According to Blankenburg (1969),the essential feature of autism isthe "lack of common sense"(sensus communis). Common senseis the ability to see things in the

proper perspective, to distinguishbetween what is relevant and irrel-evant, likely and improbable,which is a more elementary abilitythan to distinguish between whatis true and what is false. It is"knowing how to negotiate ourway through a world that is notfixed and pregiven but that is con-tinually shaped by the types of ac-tions in which we engage" (Varelaet al. 1991, p. 144). Common sensereflects our preconceptual attune-ment to the world. It reveals notso much what is evident but howit is evident, the constantly presentand tacit frame of experience(Tatossian 1979; Forguson 1989).The defect in common sense canmanifest itself in a lack of tasteand feeling for what is adequateand a lack of the sense for the"rules of the game" of human be-havior. Relatives of patients withschizophrenia often report that, inthe initial stages of schizophrenia,the patient asks questions aboutthe most self-evident issues,whereas the ability to solve ab-stract and intellectual problems re-mains intact. In such cases, it issometimes clear that the lack ofcommon sense is compensated bya hypertrophied devotion to logicalsolutions (Blankenburg 1969).

The view of autism as a "globalcrisis of common sense" points tothe defective core of ontic attune-ment. (The Greek word "onta"means reality, real being. Through-out this article, we distinguish be-tween the adjectives "ontic," refer-ring to something worldly, and"ontological," referring to generaland universal possibilities forsomething to occur. Ontology isthe branch of philosophy con-cerned with the essence of being.)

Blankenburg (1971) gives the fol-lowing vignette of a young femalepatient whose self-descriptions

were transcribed as literally aspossible.

"I have the need of support inthe most trivial everyday mat-ters. I cannot do it by myselfIt is of course the natural evi-dence, which I am lacking."Sometimes she spoke also of"the evidence of feeling." [Whatdoes she mean by that?] "Everyhuman must know how to be-have, every human has a track,a way of thinking. His be-havior, his humanity, his so-ciality, all these rules of thegame which he uses: until now,I have been unable to recognizeit clearly. I lack foundations....I am precisely lacking that,what I know, I would know italso in my encounter with otherpeople—so, evidently It wasexactly the same in the store[where she had been em-ployed]. How people behave,now they lived correctly! It isnot knowledge. One cannotsimply see it and understand it.Probably, one must first withparents—it is probably with theparents—one must first have alink with them, a link with ahuman being that one under-stands.... If now—just when wehave to work together, I cannotstand it for a long time; I amunable. For example washingup: the difficulty, yes whatwould be the difficulty for me,how to say it, I do not manageit in a self-evident way: it isstrange and disconcerting,[pp. 42-14]

These complaints illustratethe "naked," elementary lack ofattunement to the world(Minkowski's "autisme pauvre,"i.e., empty autism), which oftenbecomes concealed by withdrawalor by productive psychotic symp-toms (Minkowski's "autismeriche," i.e., rich or florid autism asdescribed by Bleuler).

An essential component of theattunement to the world and ofintersubjectivity is their temporalaspect. Minkowski (1926, 1933/



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1970) pointed to the temporal di-mension in the preconceptual at-tunement and in intersubjectiviryby introducing the term "livedsynchronism/' which is describedas follows:

The faculty of advancing harmo-niously with ambient becomingand in the same time of lettingus be penetrated by it and offeeling one with it [A] phe-nomenon which achieves vitalcontact with reality in a par-ticularly vibrant way is sympa-thy, in the etymological sense ofthe word.... Sympathy cannotbe instantaneous, there is al-ways duration in it, and in thisduration there are two becom-ings which flow side by side inperfect harmony.... We find thesame phenomenon of vital con-tact with reality in that feelingof measure and limits which sur-rounds all of our precepts likea living fringe, rendering theminfinitely nuanced and infinitelyhuman. It is a good thing tohave rules of conduct, it is bet-ter to know how to applythem It is intuition, and intu-ition alone, which lays downour line of conduct and which,in particular cases, let us departfrom previously adopted pre-cepts. We just seek by that tobe in accord, obviously throughfeeling and not through reason,with ourselves, and with life.Without ever being able to for-mulate it, we know what wehave to do; and it is this thatmakes our activity infinitelymalleable, infinitely human.[Minkowski 1933/1970, e.t.pp. 65-69]

"lived synchronism" expressesthe possibility of accord and mutu-ality between temporalization("lived time") of disparate Selves.Temporality is a phenomenologicalconcept and refers to the dynamicmatrix of temporal references inwhich any concrete life is lived(Heidegger 1927/1962; Merleau-Ponty 1945/1962; Ricoeur 1985/1988). In temporality, future, past,

and present are meaningfully andreciprocally interwoven as structur-ing the referential context of hu-man existence. In this sense, tem-porality, unlike time, is notunidirectional from past to futurebut is reversible, continuous, andfinite, bound by the wholeness ofthe human existence, which iscompleted by death. Temporality isonly apprehended preconceptually:our sense of the Self integrates thesediments of our experiences, ourpast belongs to our present andfuture, and our projections into thefuture influence our experience ofthe past. In temporality, the futureis the fundamental element, be-cause this is the temporal dimen-sion on which human beings pro-ject themselves. This potential toproject into the future is a uniquecharacteristic of human existence.

One can distinguish betweentwo fundamentally different ap-proaches to the future (Heidegger1927/1962; Minkowski 1933/1970):activity or anticipation, in whichwe feel ourselves going towardthe future, and waiting, in whichwe feel the future coming towardus. In waiting, the individual feelssubmerged, experiencing the wholeof becoming, concentrated outsidehimself, as a prearranged destiny.

An essential component of theautistic defect is the impairment ofthe subject's self-temporalization,that is, a defect in "lived synchro-nism." (We do not speak here ofthe disturbances of the subjectiveperception of time [e.g., timestanding still, being discontinuous,time-rushing, etc.] which may beobserved both in schizophrenia[Fischer 1929] and in epilepsy.)The subject's potential to projecthimself into possible futures andanticipate himself is diminished.Autistic subjects seem to livemainly in the waiting mode. This

impedes maturation processes; au-tistic subjects cannot become ex-perienced because their experienc-ing is not properly incorporated.One of Minkowski's (1927, p. 100)patients expressed this peculiarwaiting attitude in the followingway: "I have even less flexibilitywhen I think about the futurethan I have about the present andthe past. There is a kind of'rou-tine affecting me which does notallow me to contemplate the fu-ture. The creative ability in mehas gone. I see the future only asa repetition of the past." In ourview, the difficulty of many pre-schizophrenia subjects is a reducedability to transcend, that is to flex-ibly change a perspective whilestill retaining one's autonomy andself-identity. In fact, a defectivesense of the continuity of the Selfover time is one of the empiricallydemonstrated indicators of vul-nerability (Hartmann et al. 1984).

Our clinical experience indicatesthat schizophrenia patients tend toact, think, and feel as if their lifeis congealed in an ahistorical per-spective. The word ahistoricalmeans that the dynamic interactionbetween past, present, and futureis deficient. The impact of the pastis not hierarchically structured,and events that usually fade awaymay retain a disproportionate im-portance. The elements of the pastare often relived in a stereotypedway and do not change with cir-cumstances. The future has a lim-ited degree of freedom and isoften experienced as a prearrangeddestiny. Such a fixed outlook isfrequently shared by the nuclearfamily of a schizophrenia patientand is reflected in complex repeti-tive patterns of attitudes and be-haviors that may persist acrossgenerations (Bovet and Schmid1987; Schmid and Bovet 1988).



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Case #1. One of our schizo-phrenia patients was severely in-hibited in his everyday obligationsby extreme difficulty in getting outof bed in the morning. He wouldspend hours lying awake in hisbed, anticipating the necessary ac-tivities before the beginning of theday. At therapy sessions he ex-plained that his reluctance to startthe day was related to his aware-ness of the necessity of washinghis hair and shaving himself aftergetting up. He would then thinkabout thousands of his past, andendless future, washings and shav-ings. The cumulated image ofthese repetitive activities acquireda quality of an insurmountable ab-surdity and prevented him fromgetting up.

Case #2. A 25-year-old maleschizotype, interviewed in thecourse of a genetic study, reportedthat his marks dropped when hewas finishing his secondary school,when he was about 17 years old.Asked for explanation, he gave thefollowing account: He would havefantasies about some specific fu-ture university training, and thentry to imagine himself working ina job with this education. For in-stance, becoming an engineerwould involve working in the con-struction industry. He would thenimagine himself endlessly and re-peatedly calculating mechanicalconstraints of the buildings. This"eternal" and senseless image ofhimself would lead him to dropthis particular educational projectand change to another one, withsimilar result. The end conse-quence was that he withdrew fromthe school work.

These two cases illustrateBlankenburg's concept of "globalcrisis of common sense" andMinkowski's concept of "loss of

vital contact with reality" (thedaily routine or the planning ofthe future career become meaning-less by their disconnection withtheir context) and at the sametime point to the corollary of thisdefective preconceptual attunement,namely the impaired temporaliza-tion of the Self.

These three correlated aspects ofthe autistic defect, that is, defectiveattunement, weak intersubjectiveties, and difficulties in self-temporalization, are fundamental toour view of the development ofdelusions in schizophrenia. Wepropose that the normal subject,always immersed in intersubjec-tivity, searches in himself for themain clues to his future, whereasthe preschizophrenia subject, un-framed by intersubjective ties, isforced to look for such guidingclues in the "outer world," render-ing the latter potentially self-referential. If such a vulnerable in-dividual finds himself committedto a situation that threatens hisautonomy beyond his capacities,the way to escape the threat is toreshape the context of his being-in-the-world, either by an "auto-plastic," delusional reshaping ofthe experience or by a temporary,senseless "alloplastic" behavior.Such episodes may relieve the ten-sion, and the individual may re-turn to the status quo ante or pro-gress by an autocatalytic processinto a long-lasting schizophrenicepisode (Ciompi 1982/1988b).

Development of Delusionsin Schizophrenia

To illustrate the development ofthe delusional process, we shallrely partly on vignettes translatedfrom Klaus Conrad (1958), whosework is considered in Europe as

fundamental to understanding theonset of paranoid schizophrenia.Conrad described in detail theonset of schizophrenia in a sampleof 117 cases, which he collectedduring World War II when hewas working as a psychiatrist in aGerman military hospital. Conraddistinguishes four stages in the de-velopment of delusion: (1) the ini-tial phase, which he calls "dasTrema"; (2) the apophantic phase,in which the establishment of adelusion gradually takes place.(The Greek word apophaineinmeans "becoming visible or appar-ent." The word apophantic con-veys therefore the quality of arevelatory experience. This phaserepresents an autoplastic reshapingof one's being-in-the-world.); (3)the apocalyptic phase, in whichthe patient disintegrates; and fi-nally (4) the consolidation phase,which refers to outcome.

Case #3. Born in 1921, the pa-tient had been referred [to Con-rad] in 1941. He had a severe de-lusion of reference. He refused tobe examined, as he claimed thateveryone had access to histhoughts. He was extremely sus-picious, misidentified people, andwas in a state of excitation. Heimproved slowly and was finallyable to report the development ofhis illness, even though he stillwas deluded.

(1) When he was 18 years old,some months before the beginningof the war, he graduated from amerchants school, but he did notget the diploma that would allowhim to enter the University (inGermany: "Abitur"). He was upsetby and ambivalent to his parents'expectations as how to continuehis career and about his future fi-nancial dependence on them. Hedecided to leave his parents' home



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and to move to another city, ashis father once mentioned the pos-sibility of making a business ca-reer without having the "Abitur."He wanted to be relieved from theawareness of being financiallydependent on his parents. Afterbeing drafted into the army, hewas sent with his company toFrance in November 1940.

(2) He was the oldest soldier inthe company and had a feelingthat a particular performance wasexpected from him. He felt undertension. In the camp, the soldiersspoke of promotions. He felt veryinclined to enter the career of anofficer. But because he did nothave his "Abitur," he just had totake that idea out of his mind. Forsome time he dwelled on the pos-sibility of entering a professionalcareer as an under-officer. Duringthat time, he was often reflectingabout his future, and his wish ofentering a career as an officer reg-ularly came to his mind.

(3) After some time, he got apeculiar feeling that "somethingwas in the air"; what it was, hecould not say, but he faced per-haps a special stake. There wererumors that he, and only he, wasto be promoted to corporal. Nospecific names were uttered, but itseemed nevertheless clear, that hehad to get the charge. For thatreason, he felt hostility and feel-ings of jealousy from his peers.During a break in an exercise, thehaversacks were not in a strictalignment; the sergeant told him:"Put this stuff in order, it will beyour responsibility...," an allusionto his promotion; such allusionswere very common.

(4) In the following days, he didnot speak to other people, becausehe feared their jealousy. He felt hewas stared at by other people.One forbade him to have a sip

from a shared bottle, or the bottlewas handed to him with a par-ticular gaze; the atmosphere wasall but friendly.

(5) Suddenly, he felt that he wassupposed to play some "role" dur-ing the night; perhaps his peerswould bind him and stamp himwith hammer and sickle. So hestayed alert in his bed, watchingits immediate surroundings. Sud-denly, he heard some cracking inthe floor, jumped out of his bed,and waited in a defensive positionnear the oven. He was hyperalertand sensitive to any noise in theneighborhood. But each time hewas up, everything seemed appar-ently normal, and he concludedthat his comrades were fakinghim. Once, when a guard enteredthe barrack, he felt that the guardwas somehow "instructed." Hisodd behavior was noticed by theguard, and he was ordered todress himself, and to spend therest of the night in the guards'room. After returning to his bar-rack, he felt a hostile atmosphere,and even his best friend askedhim, in an "innocent" way, whathappened.

(6) Now (at the time of the psy-chiatric examination), he under-stands that all these events werepreparatory steps to his examina-tion as a candidate officer.

(7) (...)(8) When he was brought to the

medic room, an orderly spoke tohim. He then had a feeling thatthere was a plan to prohibit hispromotion. He thought that per-haps he would be caught in somesort of trap and have to scandalizehimself in public. He was awarethat the decision of his promotionhad to come from provincial au-thorities, and, in case of a scandal,these authorities would withholdpromotion. He was confined to

bed and given some medication,perhaps in order to artificiallyraise his temperature.

(9) Suddenly, a physician andmedics entered the room. He wascarried into a car and immediatelygot the feeling that he was givena new chance. It was very clearthat he had to pass an examina-tion in Germany for becoming anofficer. He did not know whetherthe car was bringing him to theairport or to the hospital. The di-rection to the airport impliedgoing to Germany and enteringthe school of officers. He had tointerpret the clues under way inorder to overcome the uncertaintyimposed upon him by the driver'sconfusing choice of small countryroads.

(10) He was offered a cigarette,which he knew was prepared witha substance which would eitherparalyze his will or let him have aglimpse of his future.

(11) On the way, they bypassedan infantry troop, which at thisvery moment took their arms up,which meant that he had to pullhimself together. As they bypassedcity signs, the names of the vil-lages connected to his past memo-ries. They stopped at a railwaycrossing, where he noticed the let-ter "N" on a sign. That meant"No," and indicated that his hopesfor the future were unfounded.

(12) The car set in motion again,and the landscape became morefriendly, and his mood improvedalso. They bypassed the city sign"Gradigan," and that meant thathis career was supposed to "re-sume its upward direction" (geradew/'eder bergan).

(13) (...)(14) Even when brought to the

hospital, he was still hopeful,noticing that the receptionist had agreen cover on his desk. He was



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ordered to bed in a room withbarred windows, which remindedhim of a prison. A lot of peoplewere watching him, and one of-fered him a cigarette. As soon ashe inhaled, his vision becamewavering. "And now the true the-ater begins, all the other has beenthe foreplay."

(15) "Of course, I did not knowthat all this was a part of the ex-amination to become an officer."All these people were there to ob-serve him; from the conversation,he was astonished to note thatmuch was known of his privatelife; allusions were made to hisfamily.

(16) He noticed that there weresome cows lowing outside thebuilding, and he suddenly wasconvinced that he was to be exter-minated, that he had to be slaugh-tered like cattle.

(17) He was brought to the doc-tor's office. The doctor resembledhis uncle, who is a cashier. Thissimilarity paralyzed him. The doc-tor's voice also had the same nicequality as the uncle's. He began tolose the feeling of the connectionsof the situation's elements to eachother. Things seemed to go in asupernatural way. He was surethat the doctor was made up inthat way in order to test his reac-tions. The doctor transcribed hisutterances, but in a distorting way,which he protested against, butnobody cared. He had to lie onthe examination bed and was con-vinced that he would now beslaughtered, as there were someblood spots on the doctor's whitecoat. He considered the medicalexamination as a simulation. Oncebrought back to his bed, he wasoverwhelmed by the thought thatthe cows' low signified that hewould be converted into an animalthrough hypnosis.

(18) He sensed that his thoughtswere transmissible and that hewas hypnotized. They wanted todrain him of everything. Everyonecould read his thoughts. Whateverhe was thinking, the others madeit clear to him that they knew histhoughts (Conrad 1958, pp. 8-11).

During the initial period (1 and2), there is a longstanding eleva-tion of tension while the patientfaces an ambivalent choice of ca-reer. He cannot find out whetherhis parents would encourage ordiscourage him to take his"Abitur." A similar ambivalenceconcerning his future career tor-ments him after he is drafted intothe army. This tension is ex-perienced like a pressure that nar-rows his field of experience into asingle expectation of somethingimpending. What is impending isalways either positive or negativeand always significant for one'slife. The impending narrows theindividuals' experiential field andleads to an increase of tension.The increase of tension is some-times called prodromal, in thesense of being a signal of thecoming disease, but, according toConrad, the word prodrome is anosological and not a phenomeno-logical concept and therefore doesnot convey information about thestructure of the lived experience.Conrad therefore introduces theuntranslatable term das Tretna,which is taken from the world oftheater. It is the word used by anactor to designate his state of ten-sion, which precedes his enteringthe stage, when he can no longerdecide to quit the challenge butcan only face winning or losing.The Trema is not always taintedby anxiety; for instance, an actoror a sportsman can experience itwith a joyful mood.

For a person in a preschizo-phrenic state, the Trema is ex-perienced as a single modality offuture coming to the present. Hebecomes caught in a situation thathe cannot evade because of his in-ability to transcend.

In the case of the autoplastic,delusional resolution of the Trema,the subject's awareness of the im-pending becomes increasinglythematized and self-referent (3 and4). The preschizophrenia subjecthas a feeling of being put undersome as yet unknown test situa-tion, and phenomena in his fieldof experience (be it inner or outer)acquire a pregnant significance,which is sometimes indicative ofthe future theme of the delusions.The individual is in a state of"abnormal awareness of signifi-cance" 0aspers 1923). The ex-perienced situation is somehow"made" or "fabricated" (6 and 8).

This turning point, that is theWahnstimmung (delusional mood),represents, according to Conrad, atransformation of the structure ofexperiencing and leads to the ap-ophantic (revelatory) phase inwhich the delusional perception iscrystallized.

In the apophantic phase, theconnections between the elementsthat form the perceptual Gestaltare transformed. Any single ele-ment of a Gestalt always has a"cloud" of contextual significancefor an individual. For example, arifle may be associated with mili-tary discipline, with the fear ofbeing shot, and with the pleasantmemory of a hunting party. Nor-mally, in a total Gestalt, such sig-nificance of all elements of ex-perience is in a tacit, mutualequilibrium, preventing any ampli-fied univocal attribution ofsignificance.

In the apophantic phase, how-



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ever, the connections between theelements of the experience arebased on a single significance, theone that is the same in every ele-ment. This common denominatorhas a sort of ontological quality,that is, it possesses a very generalor universal character. "One ismuch clearer about the relatednessof things, because one can over-look the factuality of things," asone schizophrenia patient re-marked (Matussek 1952, p. 308).This patient, when successively en-countering a dog, a foal, and anold lady, connected these objectswith each other, as a sign of amore profound meaning, namelythat the whole landscape and en-vironment were rooted in natureand were primordial in character.This feeling was amplified whenthe patient noticed the names ofvillages in the neighborhood, "Er-ding" and "Freising," which con-tain the German words "earth"and "free."

In case #3, the apophantic ex-perience is gradually intensified. Inthe beginning (5), the context ofthe situation (an isolated barrackin a dark forest) is coherently ex-pressed in his experience thatcracking in the floor means thathe will somehow be tricked by hiscomrades. This coherence becomesless obvious but still discernible inhis subsequent experience (11). Theallusion to the necessity of "pull-ing himself together" when ob-serving soldiers taking up theirarms is coherent with the taint ofrigidity and discipline inherent inthe picture of soldiers. The N signat the railway crossing has the"natural quality" of a negation,given the fact that in most Euro-pean languages the word "no," aswell as many of its correlates(never, nothing, negation, etc.) be-gin with the letter N. At some

point (17 and 18) this coherence ofexperience, this "common de-nominator," cannot even be main-tained. In Conrad's scheme, theapocalyptic phase is now touchedupon.

Blankenburg (1965) points outthat the use of some general as-pect of a Gestalt in a revelatoryexperience of delusional perceptionis not specific to schizophrenia pa-tients. It is also found in normalpeople, especially at turning pointsof their life and in the creative en-deavor. However, normal peopleare able to assimilate and tran-scend such an experience in a waythat amplifies their future pos-sibilities for being-in-the-world. Forthe schizophrenia patient, however,such experience has a quality offinitude and forces his existenceinto a prearranged destiny.

In summary, in the apophanticphase the subject has an expe-rience comparable to the expe-rience of a revelation, in that henow "understands" what was pre-viously only alluded to. The delu-sional perception, which is the es-sence of the apophantic phase asdescribed above, may be reportedby the patient as an instantaneousevent.

Case #4. One of our schizo-phrenia patients, a 37-year-oldmale refugee from the formerlyCommunist part of Europe, de-scribed the onset of his psychosis,which began 3 years ago, in thefollowing way. Immediately afterChristinas 1988, a PanAm air car-rier was terror-bombed when fly-ing over Lockerbie in Scotland.This event attracted an extraordin-ary interest on the part of the pa-tient. He spent hours listening tovarious radio stations in order toobtain more details about the acci-dent. He felt increasingly tense.

One day when he was sitting inhis bedroom, his gaze fell upon anopen pack of his own cigaretteslying on the table. He suddenlyrealized that the cigarettes werealigned in a different way thanwhen he put his cigarettes on thetable, and this signified that hewas going to be killed. In the fol-lowing days, he interpretedvarious clues in his environmentas corroborating his originalconviction.

Sometimes, the Trema is not re-solved through the formation ofdelusions, but in an alloplasticway, when the preschizophreniasubject transiently engages in asenseless behavior. Such episodesof senseless behavior may precedethe outbreak of delusions by sev-eral years.

Case #5. One of our patients, a50-year-old female with paranoidschizophrenia and delusional ideas,which she in no way enacted,lived peacefully with her motherin a small Swiss town which shehad apparently never left, helpingwith house- and garden-keeping.She expressed her paranoid ideasabout her sister, which she main-tained for years quietly and with-out anger. To the astonishment ofher psychiatrist, she once revealedthat she could speak fluent Italian.It turned out that in her earlytwenties, when she was workingas a bank clerk, she fell in lovewith an Italian, an unskilled con-struction laborer. The possibility ofan overt relationship was unthink-able in this very conventional,provincial town. One evening,when leaving the bank, she stole20,000 Swiss francs and fled toNaples with her lover, where theyopened and ran a pizzeria for 2years. The patient was untraceableby the family and the police dur-



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ing that period of time. She thenreturned upon her own wish, andthe money was paid back by herfamily. Several years later she wasdiagnosed as having schizophrenia.

What is essential to her situationafter falling in love is the conflictwith her family and her social net-work that the enactment of her af-fair would provoke. A "normal"person would either have facedthis conflict or made a deliberatedecision to move to Italy and in-form the family. Instead, her actovernight commits her to a drasticchange in her life and structuresher future in a limited and fixedway by making a return difficult.Conrad (1958) offers another exam-ple of a similar behavior.

Case #6. H.K., 24, a sergeant,was in a "dreadful" state of ten-sion since the beginning of the at-tack on France, in which he par-ticipated. He was an exceptionalsoldier, much beloved by his supe-riors and full of ideals, but"deeply" affected by several mat-ters. The dizziness of a victoriousadvance, punctuated by criticalengagements with the enemy, wasmixed up with the feelings of de-ception in relation to his comrades,who could not resist the tempta-tion of plundering, a behavior hedespised. In a letter to his mother,he once wrote that he was closeto shooting himself. When histroops' advance stopped in thevicinity of Paris, he took his serv-ice car and, breaking the strict andexplicit orders, drove into Pariswith some privates under his com-mand in order to "draw their at-tention on the cultural values ofthe enemy." He was condemnedto 6 weeks in prison. The psy-chosis broke out some months la-ter (Conrad 1958, p. 35).

Conrad, of course, feels uneasyin designating this behavior as"crazy," due to its positive humanaspect. However, this gross trans-gression of discipline, which wascompletely incongruent with thesergeant's former exemplary con-duct appeared in its motivation—to approximate his soldiers to theculture of the enemy—as com-pletely "mad" in the eyes of hissuperiors.

The shared aspect of these twovignettes, at a clinical level, is theoutstanding oddity of conduct,which is transient and which is inmarked contrast to the individual'shabitual behavior. At a phenome-nological level, this reshaping ofthe context of the situation is re-lated to the autistic defect in thevital contact with reality, expressedin an alloplastic fashion.

For both alloplastic and auto-plastic resolution of Trema, Conrad(1958) emphasizes that what isspecific for the schizophrenicworld is the transformation of thestructure of experiencing. "It isimperative to disattend from whatis experienced, i.e., thematic, andto focus upon how, i.e., themodality of experiencing, and toconsider the latter as the essenceof the change" (p. 54).

Even though a distinction be-tween form and content has prac-tical relevance, form and contentare dialectically related to eachother (Muller-Suur 1954), and weshall discuss the issue of thematicbelow.

Delusion and"Ich-St6rungen"

One of the essential features ofschizophrenia is the disturbancesof the experiencing "I" (Ich-Storungen). These disturbances

overlap more or less the Anglo-Saxon concepts of "depersonaliza-tion," "derealization," "loss of con-trol," "disturbed ego-boundaries,""passivity phenomena," and "delu-sions of reference" (Spitzer 1988).In our view, the concept of Ich-Storungen is more appropriate forthe phenomenological understand-ing of delusion, because it refersdirectly to the experiencing subject.

We selected two vignettes fromConrad (1958) as examples of de-lusions that are usually consideredspecific to schizophrenia and thatillustrate the Ich-St6rungen inschizophrenia.

Case #7. The patient reportshis being under the influence ofsome apparatus for several days.He had been in the city recently.Everything, along the whole way,was prepared anew. All people onthe streets were involved, they ex-changed signs, and in that mannerled him all the way along. Thismust be in connection with theapparatus, from which everythingstarts, a kind of wave apparatus,which can be turned on "high" or"low." When it is turned on "veryhigh," he is totally deprived of hisown will, has to perform every-thing that the apparatus suggests,and even the smallest moves aredirectly piloted and made. Turnedon "low" signifies that he mayhave his own free will. During hisexcursion in the city, he had beenpiloted all the way through andwas completely deprived of hisown will. Sometimes, the influ-ences of the apparatus cross eachother contradictorily, and then it isnot exactly attuned. But otherwiseeverything proceeds in a very pre-cise manner, as in a clock, eventhe smallest matters.

He wrote a letter for his wife'sbirthday. He noticed immediately



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that his style and content of writ-ing were piloted from outside. Itwas not his way of arranging thesentences; the formal aspect wasnot even his own. "I still knowmy writing." All of his movementswhen writing, everything was con-stantly "piloted from a distance"(p. 102).

Case #8. The patient reported,at the very first examination, thathe had to shout "faster, faster!"during his transportation by trainto the hospital. He had, whileshouting, the overwhelming con-sciousness that he could, by hisshouting, influence the course ofthe war. Some time later, still dur-ing his first delusional phase, hesaid that he felt as if he could in-fluence in some special way thedestiny of the whole Germanarmy. When he had to get outduring the night to urinate, hehad the feeling that he could, inthat way, let the releasing ofbombs on England be executed. Itwas very clear for him, in thatvery moment, that his urinationwas immediately linked withbomb-releasing.... When asked toexplicate his experience, he saidthat in the very moment when thebomber-planes fly over Englandand release bombs, he is their pro-tector and has the consciousness ofbeing linked to them; he has thisability "as a God," without willingit. He could say in his mind: nowI throw bombs, in the moment ofurination, and he has the con-sciousness that, simultaneously,bombs are actually falling on Eng-land. Of course, he does not knowwhether it is really the case, butat the moment of acting (urinat-ing), he has no doubts.... Some-times he had also seen that, forexample, the weather was exactlyhow he had wanted it to be: "I

was looking at a magazine, withpictures showing wonderfulweather. And at this very moment,the sun came in the room. Andthen I looked at a picture of rain,and stormclouds arrived. Ithought, I am a little God, and theweather regulates itself followingme..." (p. 74).

In most textbooks of psychiatry,as well as in the DSM-III-R, thesetwo vignettes would have two dif-ferent designations, namely delu-sion of control and delusion ofomnipotence (or grandiose delu-sion). These designations would bebased primarily on the delusionalcontent—the first patient feels thathis actions are steered from out-side and the second claims divineabilities.

On a more detailed descriptivelevel, this distinction would proba-bly also touch on certain qualita-tive aspects of the experience, be-cause in the first case the"mineness" of the experience isabsent, and the delusion would becalled a delusion of passivity,whereas in the second case the"mineness" is grossly inflated.However, such a view of the issueof "mineness" does not reveal theessential quality of the morbidexperience.

In both cases (delusion of om-nipotence and delusion of con-trol) the link between I and theenvironment seems qualitativelychanged in a characteristic way.It is not the direction, that is, itis not the question of either I orthe environment being expe-rienced as the more powerful,nor is it the unilaterally con-cerned mineness of experiencing;it is rather the border between"mine" and "yours" (i.e., theouter world), and not the borderonly, but also the way in whichit is overstepped, that is specificfor schizophrenia. [Blankenburg1988, p. 187]

Bleuler (1911/1950) called thisspecific overstepping of the me-not-me boundary "transitivism."

Then, what seems specific forIch-Stcirungen in schizophrenia isthat the intransitive "to be" is ex-perienced as transitive. This is theshared experience in the delusionsof control and omnipotence de-scribed above. The former can beepitomized as "The world is I,"and the latter as "I is [sic] theworld."

The problem of description inthe area of Ich-Stcirungen is closelyrelated to the descriptive problemsof what is an "I" and thereby ofself-reflection. In some acts of self-reflection, one can describe oneselfas an experiencing subject. Thiskind of self-reflection is partlycommunicable to others (e.g., "Iam sad"). There is, however, an-other sort of self-reflection pertain-ing to the very sense of Self as afounding instance (Blankenburg1971), which is hardly communica-ble on a verbal level. This latterkind of self-reflection is linked tothe relation between the sense ofbeing and the sense of acting. Act-ing, with its connotations of pro-jecting oneself into many possiblefutures, is part of the sense of an"I." Being and acting tacitly pre-suppose each other, and we aretacitly aware of our own "I" andof others' by our own and others'acting. This co-constitution ofbeing and acting, immersed intemporalization, is normallyonly vaguely grasped in anyintrospection.

In delusions of control and om-nipotence, it is not the strength orweakness of the feeling of activity,nor the sense of power or impo-tence that shows specificity toschizophrenia. Rather, it is the"immediacy" (Unmittelbarkeit) ofthe access by which the patient



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experiences his being and actingthat qualifies such experiences astypical for schizophrenia. In thedelusions of control and omnipo-tence, clinicians are struck by thefact that, for the schizophrenia pa-tient, to be and to act fuse witheach other. What actually happensis that the normally tacit link be-tween being and acting becomesapparent.

Such delusions are the only waythe schizophrenia patient can ex-press the "unthinkable" experienceof the dissolution of the Self. Thisbasic disturbance is beyond thescope of variation of normal ex-perience (normal experience cannotvary with regard to the me-not-medifferentiation, which we assume isdisturbed). The dissolution of theSelf is probably experienced bymost schizophrenia patients at theonset of psychosis; for some ofthem, this experience will recurthroughout the entire course oftheir illness. The way in which theme-not-me boundary is over-stepped in schizophrenia is, in ourview, qualitatively different fromthe expansive delusions seen inmania and from the complaints ofa loss of autonomy encountered indepressive patients. A similar pointcan be made with respect to tran-sitivistic phenomena of thought-insertion and thought-deprivation.Empirical studies demonstratingthese first-rank symptoms ofschizophrenia (Schneider 1955/1959) in affective illness (Pope andLipinski 1978) are most likely notsensitive enough to the complex-ities of qualitative aspects in theinvestigated experience. Structuredinterviews may provoke falsepositive answers when applied toexperiences that are not di-chotomously present or absent(Koehler 1979) and that can onlybe properly evaluated from the

patient's spontaneous self-descriptions (Akiskal and Puzan-tian 1979; Mellor 1982; see alsoour exposition of Jaspers' view ofphenomenology).

Thematic of Delusions inSchizophrenia

The content of the schizophreniapatient's statements often reflectsthe distortions of the experiencing"I." Spitzer (1988) suggests thatsuch statements should not be re-garded as delusions but as meta-phors used by the patient todescribe his "undescribable" ex-perience. We propose that suchstatements should be regarded asexperience-congruent delusions, inwhich case the content of the de-lusion apparently qualifies schizo-phrenia. However, what is charac-teristic is that we face a Gestaltcomposed of both structure (form)and content ("matter pregnantwith form"; Merleau-Ponty1945/1962).

Case #9. One of our schizo-phrenia patients claimed that theCIA was responsible for the drugproblem, both in the United Statesand in other countries. In hisopinion, the CIA was facilitatingthe distribution of drugs in orderto weaken people's resistance andpacify them. Another idea of thispatient was that farmers were mis-taken in their way of cultivatingthe soil. He considered thatploughing the soil after the harvestwas, in fact, diminishing the soil'sorganic resources, because it letthese resources evaporate into theair, rather than letting them dis-solve down into the soil.

These statements, regarded atthe purely contentual level, wouldnot be considered diagnostic of

schizophrenia. They seem to be, atfirst glance, very impersonal anddo not transmit a "bizarre" mes-sage, although they are definitelyunconventional. However, closerexamination revealed that thesestatements reflected severe tran-sitivistic experiences of the patient.In fact, he was a marijuana userand felt that his will was para-lyzed. On other occasions, he feltvibrations in unison with the cy-cles of nature. Consequently, theunveiling of the transitivisticquality of his experiences, towhich these delusions were linked,qualified the latter as schizo-phrenic. A comparable situationcan sometimes be encountered inthe apparently "normal" utterancesof a schizophrenia patient.

The patient never omitted to be-gin the session by some, usuallypertinent, remark on today'sweather. Each time we tried toscratch beneath the surface ofsuch remark, it turned out thatthese meteorological utteranceswere concealing some delusionalconnotations. For example, "it ishot today" meant "the sun'sheat is today too intense for meto come close to you and shakehands with you." And, in fact,while she uttered her "it is hottoday," she froze on the door-step, but without giving any ex-planation to her attitude. [DeWaelhens 1972, pp. 137-138]

Kepinski (1974) claims that thereis a certain metaphysical taint tothe thematic of the delusions inschizophrenia that helps us to dis-tinguish them from nonschizo-phrenia delusions. Kepinski dividesthis metaphysical taint into threeinterrelated trends.

The ontological trend, which con-cerns the essence of Being and theconcept of existence in the cosmos.

The main characteristic ofschizophrenic cosmology is itsfantastic and magic character....



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The schizophrenic world is filledwith secret energies, rays, goodand evil forces or waves whichpenetrate human thoughts anddirect human behavior Eventhough the cultural changesthroughout history have influ-enced the thematic of the schizo-phrenic world, there are, nev-ertheless, certain motifs whichrepeat themselves: a struggle ofcontradictory forces, the pos-sibility of action per distance,and the pretended character ofthe perceived world. The worldis a place of struggle betweenforces with moral connotation:good and evil, beauty and ugli-ness, wisdom and stupidity.... Itseems as if the patient discoversthe essence of reality—Kant's"Ding an sich" (noumenon). Ac-cording to the patient, otherpeople are ignorant and onlyaware of the Kantian phe-nomenon (appearance). Theworld becomes a caricature ofcausal connections: there are noindependent events—one eventis always dependent on anotherand interacts with the other,[pp. 118-119]

The eschatological trend, whichconcerns the ultimate issues("eschatos" means ultimate), suchas the end of the world.

The feeling of impending disas-ter is not rare for a humanbeing. It is usually connectedwith depressed mood (e.g., de-pression in which the future isblack and one has feelings of to-tal self -insufficiency).... However,such moods never reach theapocalyptic intensity of schizo-phrenia. In the latter case, theimpending disaster is precededby a mood of apprehension; thecolor of the world darkens,everything becomes ambiguousand threatening. The anxiety in-creases crescendo; at the climax,there is an explosion: end of theworld, wars, cataclysms, chaos,the Last Judgment Day, separa-tion between devils and angels,condemned and saved, good andevil, compatriots and enemies,living and dead, etc. Gradually,this storm calms down, and

what is left is heaven or hell,which often are presented in asecular way: ideal political sys-tem, concentration camp, life onanother planet, etc.... The cata-strophic atmosphere makes theschizophrenic delusions differentfrom nonschizophrenic delusions.The fact of being spied upon,persecuted, poisoned, etc., ac-quires a universal quality; ifsuch events are possible, thewhole world is against the pa-tient, the whole world haschanged, [pp. 120-121]

The charismatic trend, which con-tains issues concerning the mean-ing and sense of human life, itstrue purpose and goal ("charisma"means gift).

The patient is not inactive whenthe world is exposed to apoc-alyptic events. He is in the cen-tral position of that world. Hemay feel immortal, immaterial,almighty, as God or devil; thefate of the world depends uponhim The world is threatenedby annihilation, and the patientwants to warn mankind, offerhimself for the sake of human-ity The meaning of his lifereveals itself to the patient: agreat mission, an act of heroism,martyrdom, [pp. 121-122]

We would also consider delu-sions of affiliation as belonging tothe metaphysical type of schizo-phrenia delusions described byKepinski. Delusions of affiliationconfront us with the paradox ofcontinuity or discontinuity in ourown history as a human being.Every individual, as a child of twoparents, is an original being,provided with unique characteris-tics both at the biological leveland as a member of human so-ciety. Therefore, an essential dis-continuity exists in the sequence ofgenerations, and no individual canbe considered as the pure exten-sion of one of his lineage. Hered-ity in its broad sense (the trans-mission of both genes and cultural

values and goals) has to face thisdiscontinuity, which delusions ofaffiliation (e.g., parthenogenetic orof grandiose affiliation) deny(Schmid and Bovet 1988). In sum-mary, Kepinski (1974) states

The presented metaphysical as-pects of the schizopnrenic world,despite variable details due tocultural influences, remain thesame in their essential pattern.This pattern can be found in theoldest descriptions of schizo-phrenia. To a great extent, thispattern allows us to identify agiven case as suffering fromschizophrenia, [p. 122]

Muller-Suur (1954) arrives at avery similar conclusion, but hisperspective takes into account boththe content and the form of ex-perience. Considering content andform as cocontributors, he emphas-izes that formal aspects of experi-ence often influence its content.

According to the DSM-III-R,many of those examples from theschizophrenic world would be con-sidered bizarre delusions, on theface of their implausible or, as Jas-pers would have said, false con-tent. (Spitzer [1990] notes that thiscriterion is usually referred to as"impossibility of content," but it isclear from the context in Jaspers'original publication that he is re-ferring to falsity.) However, whatKepinski is denoting as the invar-iant metaphysical taint of suchutterances is, phenomenologicallyspeaking, not only reflected in thecontent, but also related to the in-tersubjecn've apprehension of thespeaker's experience. When DeWaelhens' patient says "The sun'sheat is today too intense for me tocome close to you and shakehands with you," it is not thepure content of the utterance thathas a delusional quality, becausethe patient could, in fact, be hesi-tant to approach the therapist



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because of her sweating and smell-ing. What constitutes the delu-sional quality of this meteorologi-cal statement is its place in thecontext of the entire interactionwith the therapist. It is thereforeessential to recognize that the dis-tinction between content and form(structure) is only possible to somedegree, and that every item of lan-guage is embedded in a total Ge-stalt which communicates to theOther something of the speaker'sexperience of the world. The co-constitution of form and contentgenerally has been neglected bypsychopathology (Miiller-Suur1954).

We propose that the invariantmetaphysical taint in the delusionsof schizophrenia patients conveyssomething about the nature of thedialog between the schizophreniaindividual's Self and the outerworld. It informs us about the na-ture of the subject's being-in-the-world. It is therefore not the per-ception per se of the outer world,nor the conviction per se of thesubject that qualifies these delu-sional statements as schizophrenic,but the disturbance of the "Self asa founding instance," which isperceivable in both the subject'sperception and conviction. Theschizophrenia patient's autistic de-fect impedes his ontic tie to theworld and to the Other. Conse-quently, schizophrenic utterancesbecome characterized by two inter-related features: first, the Other inthe dialog is not considered as an-other ontic being, and, second, theontological elements of the com-munication become quite apparentand dominating because they lackontic embodiment. What we, aslisteners, are confronted with insuch communications is a sort of"empty ontological matrix."

As an example, a normal or a

depressed person would conveyhis feeling of guilt embedded in apersonal statement, accompaniedby paraverbal signals indicatingguilt feelings, but without any re-course to the general concept ofguilt. On the other hand, a schizo-phrenia patient, claiming, for in-stance, that his breathing is re-sponsible for the famine in theThird World, is presenting to us,through this delusional amplifica-tion, the very idea of guilt. Due toa lack of common sense sharingwith others of the notion of guilt,the schizophrenia patient expressesfeelings in a way that points tothe ontological essence of guilt.

One of Minkowski's (1927) pa-tients expressed it very precisely:"I feel that I can reason quitewell, but only in the absolute, be-cause I have lost contact withlife." These ontological qualities ofschizophrenic discourse may alsobe perceivable in the way the pa-tient reveals his conviction:Whereas a paranoid (i.e., non-schizophrenic delusional) patientwould eagerly corroborate his de-lusions by post hoc arguments andeven by presenting some "empiri-cal" pseudo-evidence, a schizo-phrenia patient would have diffi-culty comprehending why anyevidence should be needed at all(Muller-Suur 1950).

What we are confronted with inthe schizophrenic delusional trans-formation is a phenomenon ofemergence—the emergence of anew paradigm, the transformationof the patient's being-in-the-world.

Delusional Transformation asan Instance of Emergence

The phenomenon of emergence isfamiliar to all natural sciences anddenotes a situation where a new

qualitative order arises from thereorganization of essentially un-changed elements. Clear examplesof emergence are the appearanceof life on earth (molecular compo-nents of living beings must fulfillall physical laws, but the phe-nomena they generate in function-ing as living organisms dependon their organization) and theorigin of consciousness in humanphylogeny.

The phenomenon of emergencemakes sense only when the objectsstudied are considered as systems,that is, as unities defined by therelationships among their differentcomponents.

As human beings, we interactwith other human beings in a waythat can be described as a high-order coupled system in theaffective-cognitive and linguisticdomains. Such a situation creates anew coherence in which, thoughthe participating beings preservetheir individual limits, a new phe-nomenological domain of abilitiesemerges, comprising consciousnessand intersubjectivity (Maturana andVarela 1988). Self-consciousnessand the sense of the Self as afounding instance can emerge onlyin the context of intersubjectivityand historicity (Varela et al. 1991).The phenomenological notions oflife-world (Husserl 1936/1970a)and of being-in-the-world (Heideg-ger 1927/1962) and Stern's (1985)views on the emergence of Self allpoint to the coconstitution of theSelf and the interpersonal world.The autistic defect is related to animpairment in this coconstitution.

Delusion formation can be re-garded as the emergence of a newstructure comprising the deludedperson and his transformed world.This new structure comprises theintentional attributions of the pa-tient and their universal (ontologi-



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cal) counterparts in his world. Myperception of the world is usuallytripartite, comprising me, theOther with whom I interact, andthe objects that I perceive and thatI know that the Other perceives(or at least could perceive) in away with which I am familiar. Itis an everyday experience that, inour interactions with the world,we attribute some anthropo-morphic intentions to other people,animals, and objects with whichwe are interacting (e.g., if my car"refuses" to start when I am in ahurry). These attributions of inten-tions axe always framed by our in-tersubjective ties with the Other,by the fact that "we know howthe Other knows." The extent ofthis framing or limitation of at-tribution of intentions to the worldis highly dependent on the preva-lent culture.

Delusion formation begins whensuch framing dissipates. The majorproblems of a predelusional, autis-tic person, as described above, arehis weakened intersubjective an-choring and difficulties in self-evident discrimination of theworld's signs. According to Wig-gins et al. (1990) the primordialcertainty in the invariant, funda-mental features of the Self and theworld becomes shaken in the earlystages of schizophrenia.

In the delusional transformationa disinhibition of attribution of in-tentions occurs. In the first stage(delusional mood and other initialphases of delusional perception),the disinhibited attribution of in-tentions to the outer world relatesto the patient's defective self-temporalization, in the sense thathe can now "read" from theworld indications of his future.The patient, in search of themeaning of his predetermined fu-ture, suddenly understands his

being-in-the-world by attributing tothe elements of his experiencesome common intention. As wesaid before, such common inten-tion ("common denominator") hasnecessarily ontological qualities.

The phenomena of emergence inthe cognitive domain are currentlystudied within the framework ofPrigogine's theory of "orderthrough fluctuation" (Prigogineand Stengers 1984). Prigogine'smodel deals with the thermo-dynamics of open systems, whichare supplied with energy fromoutside. A trivial example of sucha system is the phase transitionbetween the liquid and the gas-eous state. In such an open systemsome of the internal fluctuationscan acquire a localized new struc-ture called nucleation (e.g., the for-mation of droplets of conden-sation in a gas). Under certainnecessary conditions, which are co-determined by the environmentand by the system, these fluctua-tions can amplify and "inform"the whole system. Correlations be-tween normally independent eventsmay appear, letting the latter jumpinto a new regimen of functioning,into an entirely new structure.Within this model, the Tremaphase can be viewed as a systemin a certain field of force, the ini-tial delusional hints as nucleations,and the apophantic phase as anew order through fluctuation.

Conclusions

Phenomenology is a specific wayof understanding human conscious-ness and its world. Phenomeno-logical inquiry is best fit to gener-ate conceptual models derivedfrom an investigation into subjec-tive experience. Such models canboth pertain to the essential

characteristics of the observableand also point to the existence ofnonlinear processes in human con-sciousness. To be fruitful, phe-nomenology must keep up a di-alectic exchange with the empiricalapproach. The current situation inpsychopathology is that, unfor-tunately, this dialectic hardly ex-ists. Such a dialectic should strivefor a more balanced emphasis onreliability and on meaning (valid-ity). Operationalized criteria arenecessary for empirical research,mainly for reasons of reliability.However, even this approach usesdata saturated by subjective ex-periences of the patients. Thequest for reliability attempts to re-duce this subjective component. Inphenomenological inquiry it is pre-cisely this component that gener-ates heuristic models.

From the phenomenological per-spective, the development of delu-sions in schizophrenia can beviewed as the emergence of a new"order of being," intimately relatedto the autistic vulnerability. Such aview has both research and clinicalconsequences for schizophrenia.With respect to research, the issueat stake is the psychopathologicaldemarcation of schizophrenia. Inetiological research, we are inter-ested in phenotypic features thatcan be expected to relate asclosely as possible to the underly-ing pathophysiology. The contem-porary descriptive psychopathologyfocuses on symptoms that seemfairly distant from the putative pa-thophysiology, and even thesesymptoms, regarded at the purelydescriptive level, lose their diag-nostic specificity. The autistic vul-nerability, as viewed by phenom-enologial psychiatry, may bepotentially closer to the patho-physiology and more specific toschizophrenia.



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With respect to clinical issues, aphenomenological approach hassome implications for the concep-tualization of schizophrenia as adisease and for its treatment. Ifwe consider the delusional state inschizophrenia as a special form ofexistence (being-in-the-world), weadd a further dimension to theconcept of schizophrenia. This newdimension enables the clinician toadopt a multidisciplinary treatmentapproach. In some cases, onewould abstain from treating delu-sions with neuroleptics, so as notto interfere with the equilibrium ofthe restructured being-in-the-world.Autism is not amenable to neuro-leptic treatment, but can perhapsbe modified if the therapist,through his or her personal in-volvement, amplifies the schizo-phrenia patient's intersubjectiveties.

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The Authors

Pierre Bovet, M.D., Dr. Med., isConsultant, University Departmentof Adult Psychiatry, University ofLausanne, Switzerland; JosefPamas, M.D., Dr. Med., is Associ-ate Professor of Psychiatry atCopenhagen University, and Medi-cal Director at the University De-partment of Psychiatry at Copen-hagen Municipal Hospital,Hvidovre, Denmark.



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