|
Understanding Schizophrenic Delusions: One branch of the science of psychopathology tries to understand the human experience of madness -- the meanings and structural/functional requirements for psychosis. As is well known, Karl Jaspers, the German psychiatrist-philosopher, in his 1913 text General Psychopathology, formulated a descriptive psychopathology that has strongly influenced generations of psychiatrists. He believed that primary delusions were in the realm of the incomprehensible. Jaspers emphasized understanding through empathy. Schizophrenia was excluded from empathic understanding and was exported, along with the patient, to a realm which is today typified by an approach which emphasizes understanding along the lines of DSM and psychopharmacological interventions. This view of schizophrenic delusion as un-understandable minimized the crucial importance of understanding from within schizophrenic experience. Schizophrenia is treated as epiphenomenon of disclosed and yet-to-be-disclosed neurogenetic and neurobiological dysfunction. As many on this listserve know, my view is that the neurobiology and neurogenetics of the schizophrenias is largely the neurobiology of the person’s encounter with a kind of lacerating nothingness, with annihilation and disintegration of the self and the lived world of the individual. I believe the psychopathology of schizophrenia to be intimately involved with the coming-into-being of the autonomous-relational subject. What Jaspers did not consider was the possibility that incomprehensibility could be a function of one’s own resistance to engage in empathic understanding of this horrific situation. Gaetano Benedetti once speculated that much of the social antipathy towards persons with schizophrenia may very well be this resistance to identifying with the catastrophes of their lived experiences. It seems to me that there exists in our encounter with madness a depersonalized method of understanding. In my lectures to graduate students on such topics as psychopharmacology and psychopathology, I am impressed by the degree of reductionism endemic to our field, e.g., neurotransmitter levels are viewed as the ‘cause’ of complex emotional and behavioral states, i.e., viewing the brain as a kind of endocrine gland, albeit a complex one and that complex behavioral states, e.g., depression and anxiety, are reduced to molecular interactions. Giovanni Stranghellini (2004), a phenomenologically-oriented psychiatrist, noted: “Psychopathological phenomena’s rate of comprehensibility increases dramatically in function to the psychiatrist’s own personal engagement in understanding and to her knowledge of her patients’ socio-relational style and social contexts” (p. 34 in his highly recommended volume Disembodied Spirits and Deanimated Bodies: The Psychopathology of Common Sense published by Oxford University Press). Stranghellini lamented: “Psychopathology seems to have lost sight of its own centaurical nature-a discipline aimed at both understanding and care -- and so it has forsaken its own mandate: elaborating conceptual tools which would allow a rigorous comprehension of the pathological phenomena of subjectivity. Instead it has been recycled as a discipline that merely selects those symptoms which are supposed to be useful to the diagnostic procedures, and to define these symptoms operationally” (pp. 40-41). Stranghellini issues a call to return to a phenomenological grounding of psychopathology as opposed to hyper-technical algorithms. To grasp the experience of the other one must engage in empathy (as I have noted in previous postings, we are helped along in this by our God-given mirror neurons -- we empathize with the other through our bodies). Empathy attempts to understand a person’s communications and actions from the standpoint of the person’s subjective frame of reference. I must note here, in anticipation of the objection of many clinicians who hold schizophrenia to be a “brain disease”(an empty signifier as far as I am concerned), that it is not possible in nature to be a disengaged ‘objective’ observer of phenomena (Sullivan’s model of participant-observer in psychiatry and Heisenberg’s uncertainty principle in quantum physics are relevant here). Stranghellini notes: “Empathy is not only a cognitive performance, since it bridges the gap between two individuals’ experiences by establishing not only a cognitive understanding, but is based on the intuitive recognition of others’ intentions and mental states through the identification with the other’s body. This is what the philosopher Merleau-Ponty called intercorporeality” (p.42). Phenomenology is a kind of active gathering of letting the other speak for herself. In order to obtain a coherent viewpoint, we need to see from above (this is similar to Bion’s injunction to “over-stand” as opposed to “understand”), without superimposing general theories or hypothetical presuppositions. Meaningfulness is a product of this way of approaching phenomena. As Wittgenstein suggested, we should not strive merely for exactness, but rather, for a view of the whole. I would add that it is through the patient and therapist engaging in this process, that coherence and meaning are created. Stranghellini stated: “...phenomena can only be gathered by interactive (emotional) involvement, not by dispassionate observation; concepts should not be used as labels of experience, but as expressions which function in an interpersonal, indexical context; the goal of inquiry should preferably be understanding, not hypothesis testing; meaningfulness, and not simply agreement with observation, should validate psychological expression; and, finally, understanding should require a holistic approach which expands rather than constricts the realm of relevant phenomena” (p. 44). For Stranghellini and many others (myself included), what counts in delusion is not the delusion itself. Schizophrenic delusion is probably rooted in an alteration of sense of self, of self-consciousness, downstream to the condition of perplexity and foreboding that might immediately precede the delusion itself. The individual’s self-experience is constituted and colonized by the other. The other permeates through and dislocates the experience of autonomy -- in-relatedness. The psychotic person suffers an initial ‘laceration’ of self in an overwhelming experience of an encounter with one’s own helplessness and with nothingness, i.e., the perception of non-being. Barbro Sandin (1993), Swedish psychoanalyst of persons diagnosed with schizophrenia, had this to say about the contradiction at the heart of the schizophrenic dilemma: “How can we understand the schizophrenic view of the schizophrenic? To be no one. Every schizophrenic patient expresses it time again and time again, even if the personal non-being has many forms. Let us call this the schizophrenic’s [I would prefer the term the individual with psychosis] paradox. He or she who is no one, someone who is and expresses his or her being in words of non-being” (p. 23.) “When being is not to be” contained in the excellent volume The Psychotherapy of Schizophrenia: Effective Clinical approaches-Controversies, Critiques and Recommendations, edited by Gaetano Benedetti and Pier Maria Furlan in 1993 for Hogrefe & Huber Publishers). Stranghellini noted that at the origin of delusion may be an “ontological emptiness,” the perception of not having a cohesive identity, the experience of non-being. For me, the unbearable contradiction in which the psychotic individual is trapped, may be what Louis Sass has referred to as ‘self-as-all’ and ‘self-as-nothing,’ that is, the patient feels both that the world is undifferentiated from and constituted by their own mind, and paradoxically, they are at the utter mercy of the other, the world by which they are constituted, colonized and controlled by, etc. Stranghellini suggested: “Delusion is triggered as a safety net, a life preserver, upon the experience of feeling ungrounded” (p. 189). This is similar to Edward Hundert’s viewpoint that delusions may be an evolutionary development of the struggle for survival. Again Stranghellini: “Defense from this encounter with nothingness can be nothing other than perceiving or intuiting threats, destruction, annihilation of one’s mental or corporeal self, together with feeling in all this, something indecipherable, mysterious, uncontrollable, unshareable. [The schizophrenic delusional person] enriches his own existence in order to fill in an ontological emptiness; he is no longer a man who shares and lives in a structured world, but, rather, in an emptiness that he needs to fill up either with silence or with mortifying and negative conceptions of his own existence [e.g., persecutory hallucinations and delusions], together with contrasting and paradoxical rationalizations, with a phantomatic contrivance that expresses his ‘being different’ and his ‘being against,’ a being that is prey to hostile, external forces” (p.189). Stranghellini makes clear that he is referring to a sensorial experience of nothingness, not just some cognitive experience. As I suggested in my writing on auditory hallucinations, in which I bolstered my argument with current fMRI neuroimaging research as well as extensive clinical experience, the psychotic patient unconsciously enlists neural regions, including the PAC-primary auditory cortex which is activated when a person is listening to external speech, in a mode that gives it the stamp of concrete lived experience. The hyperactivation of the limbic system (e.g., amygdala, hippocampus, etc.) and the inhibition of prefrontal areas, lend support to the experience of nothingness/annihilation, hallucinations, delusions, etc., as having a sense of concrete reality. In addition, hyperactivation of right parietal regions support the confusion between internal and external realities (see the research of Chris Frith and colleagues at the Institute of Neurology , London ). Stranghellini cogently points out that we are not dealing with a metaphoric expression of the sense of nothingness. Schizophrenic delusions are understood as a very deep transformation of the self-world relationship that reflects a solipsistic position prefigured in the prodromal stages of the illness. Stranghellini proposed: “Within the schizophrenic condition, this experience of nothingness revolves around a fragile structure of the self, around profound anomalies in sensory self-consciousness and of its correlates: intersubjectivity and the significant perception of the world. The schizophrenic [again there is no such reality as a “schizophrenic” or “schizophrenic brain,” there are persons caught in an internal and social tragedy and predicament which results in their having certain psychobiological symptoms within a particular social context] one is an empty presence,’ in the most concrete and literal sense of the term. The core of the schizophrenic condition is disembodiment...[a] lack of a sensory self-consciousness...which gives rise to a perception of the self as a soulless body, or as a disembodied soul” (p.191). For many years I have been impressed by the degree of insight into mental illness evidenced by anthropologist Ernest Becker (author of The Denial of Death, which won a Pulitzer Prize, and many other texts bearing on subjects addressed by psychiatry and psychoanalysis). Becker (1973, The Denial of Death) had this to say about the conditions we call schizophrenia: “There is a type of person...for whom the burden of anxiety and fear is almost as constant as his daily breath...His feelings of magical omnipotence...are a reaction to the terror of death by a person who is totally incapable of opposing this terror with his own secure powers. We might even say that the psychotic uses blatantly, openly, and in an exaggerated way the same kinds of thought defenses that most people use wishfully, hiddenly, and in a more controlled way...In this sense the psychoses are a caricature of the life styles of all of us -- which is probably part of the reason that they make us so uncomfortable...human experience is split into two modes -- the symbolic self and the physical body -- and that these two modes of experience can be quite distinct. In some people they are so distinct as to be unintegrated, and these are the people we call schizophrenic. The hypersensitive individual reacts to his body as something strange to himself, something utterly untrustworthy...he is not securely rooted in his body...his self is not anchored intimately in his neuroanatomy...[he] is deprived precisely of this neurological-cultural security against death...He relies instead on a hypermagnification of mental processes [hyperreflexivity in the model of Louis Sass and within a more Winnicottian relationally based model, taking one’s own mind as a holding environment] to try to secure his death-transcendence [i.e., to ward off annihilation and disintegration anxieties]”(pp.217-219). Winnicott spoke of the difficulties some persons have in their psyche indwelling in their soma. Benedetti (1987) also understood the importance of the indwelling of the psyche with soma. Benedetti , based on his lifelong experience in the psychoanalysis of psychotic individuals, pointed out that the human psyche cannot observe itself without the mediation of the body and world of others. In the schizophrenic individual, the disorganization of the ego immediately appears as a transformation of the patient’s body and world which are the self-mirror of the psyche. In psychosis there is a confusion of the body with others (transitivism and appersonation) and the disintegrated ego can have impressive bodily aspects, e.g., one patient had to continuously look in the mirror to make sure she still existed, another to make sure there were no missing pieces in her face. In this model, the therapist or psychoanalyst would serve as a bridge between the psychotic individual’s psyche and soma-to help the patient safely inhabit her or his own body. Stranghellini speaks of the separation of things, images and symbols, organized by consciousness. Many of our psychotic patients have difficulties distinguishing between them. He notes: “In other words, the criterion that makes a given phenomenon a thought (and not an action or the perception of an external object) is our feeling ourselves as the thinker of this phenomenon. The attestation that makes a given action or perception a real action or perception (and not a mere thought, a figment of imagination) is one’s feeling oneself as the agent, or the perceiver, of that phenomenon. Not being able to distinguish between ‘thought, imagination and factual reality’ is, in sum, the consequence of the crisis of sensory self-consciousness” (p.196). Stranghellini summarizes his view of the different forms of schizophrenic delusions: “...the root of schizophrenic delusion is not some semantic swooning, the temporary loss of the book of shared meanings. The epicenter, which is much deeper, has its roots in a metamorphosis of the consciousness, coinciding with the crisis of sensory self-consciousness, which nullifies the confines between bodies, images and symbols. For a deanimated body, or for a disembodied spirit, the bodies of the objects out there themselves turn into images that have been [solipsistically] created by consciousness (epistemological delusion); things lose their concreteness ‘ready-to-hand’ turning into divinatory symbols (alethic delusions); symbols, the metaphors that enable us to represent the stranger aspects of our experiences, cannot be distinguished from concrete objects and from mechanisms that explain the experience (catachrestic delusions); images, which are inside a consciousness and need to be spatialized to represent themselves, turn into things or bodies (hallucinatory delusion) “ (pp.202-203). In terms of psychoanalytic psychotherapy, within this situation the therapist would not only accept such countertransference feelings as murderous rage, erotic attractions, dependency, annihilation anxieties, etc., but, as pointed out by Searles (1979), an acceptance of one’s own symbiotic dependency on the patient. It is the latter, which assists the patient in identifying with her or his therapeutic partner. The self is born out of intersubjectivity. I believe that the insight of Harold Searles, i.e., that the patient’s symptoms must become transitional phenomenon for both members of the therapeutic dyad, as part of the therapeutic symbiosis, is crucial for the patient’s establishment or recovery of being an embodied spirit or animated body. Brian Koehler PhD |