The core Gestalt of schizophrenia

• DOI: 10.1016/j.wpsyc.2012.05.002
• Publication Date: 2012-06-19T12:58:00Z
• Authors: JOSEF PARNAS
• Keywords: 03 medical and health sciences; 0302 clinical medicine; 3. Good health

The recent debate in World Psychiatry on prototypes versus operational criteria 1 invites a prototypical reassessment of the clinical-phenomenological presentation schizophrenia, especially light developments phenomenological psychopathology 2. Although schizophrenia has been intensively studied for more than century, with bewildering accumulation empirical data, we have still only very partial understanding its diagnostic boundaries 3 and pathogenetic mechanisms 4,5. This epistemic resistance motivates variety responses: e.g., shortcutting phenotype-related problems by studying easily graspable proxy variables; attempts to convert into dementia-like neurocognitive disease; proposals further simplification psychopathological diversity (e.g., notion "unitary psychosis"); or elimination altogether. It seems unlikely, however, that strategic evasion defiant phenotype silencing epistemological associated this defiance will somehow lead an ultimate scientific enlightenment. One additional timely response is reexamine clinical nature highlighting distinctiveness theoretical difficulties current nosological representations. Perhaps, are related disappearance reifying permutations. issues at stake so-called "problem description" psychiatry, which particular version mind-body issue. question how address phenomena consciousness: distinctions relevant adequate here, what "mental object" (symptom sign), first-, second-, third-person perspectives, kind methodology needed addressing these phenomenal realms 6. Since advent behaviorism operationalism, topic consciousness vanished from academic discourse, become rediscovered last 20 years philosophy mind, cognitive sciences neurosciences. Consciousness (subjectivity) forefront today's debate, constituting perhaps most important challenge 7. Unfortunately, largely eluded mainstream psychiatry. Yet, concepts mental illness general, particular, founded abnormalities experience, belief expression, i.e. consciousness. Historically viewed, crystallized itself as end-achievement successive descriptions These may be seen — retrospect reiterative quest characteristic phenotypic pattern, prototype Gestalt. search clearly transpires famous passage Dutch psychiatrist, Rümke, claiming certain hallucinations delusions but if they exhibit schizophrenic taint; tautological claim, Rümke himself qualified "a absurdity", yet absurdity "familiar every experienced clinician" 8. Gestalt refers salient unity intrinsic organization diverse features, based reciprocal part-whole interactions. In framework, psychiatric symptoms signs cannot considered mutually independent, atomic features individuated (i.e., identified symptom) "in themselves", independently their experiential context. A smile such predefined inappropriate silly. silliness emerges flow expressivity communication. contrast somatic medicine, where possess clear referring function "extensionality" chronic coughing → suspicion lung disease), through meaning "intensionality" "avoiding others" changes significance when arising, respectively, due paranoid attitude, melancholic sense self-reference, fear external access one's own thinking). identification pre-operational psychiatry was not cross-sectional, momentary, or, metaphorically speaking, "two-dimensional" summation independent ("symptom counting"), linked recognition, necessarily imbuing diagnosis dimension "depth", contextual interrelations between single qualities, developmental temporal aspects. Two, interdependent, belong schizophrenia: a) aspect, i.e., typically does arise abruptly, ex nihilo, nearly always preceded premorbid trajectory, b) belongs spectrum conditions, varying intensity qualitative profiles, nonetheless share trait-phenotypic commonalities. Both aspects contingent, facts constitutive involving essential trait dimension. articulation development concept recognition typicality, "whatness" core properties temporally fluctuating state (psychotic symptoms), reflecting structure. To phrase it differently: validity manifestations core. There were many grasp describe list-wise enumeration signs. Bleuler others distinguished fundamental symptoms, specifying (schizoidia, latent schizotypal disorders) accessory phenomena, indexing psychotic episode (hallucinations, delusions, flamboyant catatonic features). former described level expression behavior, mainly "signs": withdrawal, inaccessibility, inadequate strange affectivity, emotional- affect-expressive changes, formal thought disorder, ambivalence, structure person, disorders volition, acting behavior Many overlap closer inspection. More importantly, predominantly expressive ("objective") sign character usually anomalies experience (symptoms). Thus, rather functioning self-subsistent, signs, "fundamental features" larger wholes, jointly constituted manifests contextually pregnantly interpersonal communicative-symbolic space. We witness here reciprocity Gestalt: infuse concrete rootedness, whereas wholeness confers significance. many, often metaphoric, designations underlying Gestalt, "disunity consciousness", "discordance", "intra-psychic ataxia", "autism", "loss vital contact reality", "global crisis common sense", "cognitive dysmetria", etc. referent modular psychological dysfunction delimited, fleeting, pathological content, alteration (subjectivity, mentality). phrased ICD-8 "the disturbance personality [i.e., self], [which] involves basic functions, those give normal person his feeling individuality, uniqueness, self-direction" (my additions square brackets). phenomenological, experiential, self signifies live our (conscious) life first perspective, self-present, single, persistent, embodied, bounded entity, who subject experiences. stable selfhood identity goes together automatic, un-reflected immersion shared (social) world. world pre-given, tacitly grasped real, taken-for-granted, self-evident background all experiencing 9. Recent studies confirm classic observations foundational self-world subjectivity unstable failing vulnerability 2,10. results alarming alienating experiences, already occurring childhood early adolescence. structural marks extension disorders: occurs schizotypy 11,12,13,14,15 pre-onset 16,17. patients feel ephemeral, lacking identity, profoundly (often ineffably) different alienated social diminished existing embodied subject, self-present present world, distortions perspective anonymization deficient "mineness" field awareness ("my thoughts no respect me"), spatialization contents being spatially located extended objects) privacy inner significant lack attunement pervasive perplexity, pre-reflective ("why grass green?") hyper-reflectivity ("I my head", "I observe myself"). Social isolation loneliness solipsistic, arising "from within", solely defense simple deprivative consequence illness. disorder translates altered existential patterns, e.g. solipsistic grandiosity, bizarre attitudes actions, "double book-keeping", mannerist behaviors, searching new metaphysical adherence sectarian political religious groups). What diagnostically confronting condition marked fundamentally changed manifest across domains: affect, motivation, mood, cognition, willing action. illness' polymorphic picture themselves, others, merely experience. possesses generative status, making less enigmatic, because endowed static (synchronic) coherence symptomatic elements. passivity phases appear thematic elaborations primary 18. An unintended remake systems decline competence scholarship 19, coupled reification categories explosion phenomenon comorbidity. Schizophrenia became reshaped psychosis hallucinations, depleted affective features. diagnoses disorganized (more broadly, non-paranoid schizophrenia) rarity, yielding space other, alternative (typically, checklist-derived) diagnoses, borderline phobia, obsessive-compulsive attention-deficit/hyperactivity 20. other way forward reviving prioritizing teaching psychopathology, including peer-shared assessments accompanied interdisciplinary discussions. reinvigorated investigation today urgently achieve progress therapeutic research improvements practice, includes intervention. sophistication necessary fruitful match technological possibilities offered rapidly advancing neuroscience.