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E-Mail [email protected]

Psychopathology

Psychopathology 2013;46:320329

DOI: 10.1159/000351837

Subjectivity and Schizophrenia: AnotherLook at Incomprehensibility and TreatmentNonadherence

Josef Parnasa, b Mads Gram Henriksena, b

aPsychiatric Center Hvidovre, and bCenter for Subjectivity Research, University of Copenhagen, Copenhagen, Denmark

poor insight into illness. We propose that poor insight into

schizophrenia is not simply a problem of insufficient self-

reflection due to psychological defenses or impaired meta-

cognition, but rather that it is intrinsically expressive of the

severity and nature of self-disorders. The instabilities of the

first-person perspective throw the patient into a different,

often quasisolipsistic, ontological-existential framework. We

argue that interventions seeking to optimize the patients

compliance might prove more efficient if they take the al-

terations of the patients ontological-existential framework

into account. 2013 S. Karger AG, Basel

Introduction

Contemporary psychiatry suffers from a profound

malaise, caused at least in part by the unfulfilled etiologi-cal promise of the operational revolution that took placeover 30 years ago with the purpose of improving reliabil-ity of psychiatric diagnoses as a means to uncover theiretiology [1]. There is an increasing awareness of the scar-city of truly novel, actionable etiological and therapeuticknowledge [24]. Worries are being voiced about the sta-tus and the future of our profession and about an appar-ent redundancy of academic psychiatry [5]. There are

Key Words

Schizophrenia Self Self-disorder Compliance

Incomprehensibility Insight

Abstract

Psychiatry is in a time of crisis. The absence of significant

breakthroughs to actionable etiological knowledge has left

the discipline in a state of uncertainty and worries are being

voiced about its status and future. In our view, the stagnation

can be, at least in part, ascribed to an excessive, behaviorist-

oriented, epistemological, and ontological simplification of

psychopathology. The aim of this phenomenological study

is to articulate the notion of the disordered self in schizo-

phrenia, a notion that we believe constitutes an important

step forward in grasping its essential pathogenetic struc-

tures. Through the framework of self-disorders, we analyze

two domains of the psychopathology of schizophrenia,seeking to recast their puzzling nature into more useful

clinical and scientific terms. First, we examine the so-called

schizophrenic incomprehensibility (bizarre gestalt, bizarre

delusions, and crazy actions) and argue that grasping the

altered framework for experiencing, associated with the dis-

ordered self, makes these phenomena appear comprehen-

sible to a considerable extent. Second, we explore the issue

of treatment noncompliance and provide a novel account of

Published online: July 11, 2013

Dr. J. ParnasCenter for Subjectivity Research, University of CopenhagenNjalsgade 142DK2300 Copenhagen (Denmark)E-Mail jpa @ hum.ku.dk

2013 S. Karger AG, Basel02544962/13/04650320$38.00/0

www.karger.com/psp
http://dx.doi.org/10.1159%2F000351837http://dx.doi.org/10.1159%2F000351837

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various responses to this crisis. It is usually acknowledgedthat the complexity of the etiological task is far greaterthan originally assumed. Often, it is proposed that thestagnation is partly rooted in the very nature of diagnos-tic categories, reflecting commonsensical, sociohistoricalconstructs rather than really existing natural entities;

consequently, such diagnoses are useless for etiologicalresearch. Such categorically dismissive proposals are usu-ally formulated in a quite vague, indistinctively general-izing manner. It is instead suggested that research shouldfocus elsewhere, such as domains of psychopathology(e.g. depression, reality distortion) [6], behavioral con-structs with known neural bases (e.g. in the RDoC: nega-tive and positive valence systems, arousal/regulatory sys-tems) [7] or the so-called endophenotypes.

Unfortunately, none of these responses reconsidersthe epistemological behaviorist dogma dominating psy-chopathology as a potential cause of the stagnation. We

believe that another partly related but perhaps even moreimportant source of the current deadlock is the vast over-simplification of the ontology and epistemology of theobject of psychiatry, which has taken place in the wakeof the operational revolution [8]. It is certainly true thatpsychiatric diagnoses, constituted by an aggregate ofsocial, experiential, behavioral, and temporal criteria,achieve a complexity that hardly can be matched by anycoherent neurobiological or psychosocial entity. Howev-er, it can also be argued that the components of such di-agnostic categories (symptoms and signs) have been sim-plified into banalities through commonsensical defini-tions, deprived of any overarching phenomenologicalframework, and insensitive to their qualitative diversityand heterogeneity (expressed, for example, in claims suchas that auditory verbal hallucinations are shared by a mul-titude of psychiatric disorders [9] and widely prevalentamong healthy people as well [10, 11]).

Psychiatry confronts the so-called hard problem ofconsciousness [12]: phenomenal consciousness has noanalog in the physical domain. There is an explanatorygap [13] between the levels of molecules, neurons, syn-apses and neural circuits and a sense of phenomenal

awareness. Phenomenal consciousness exhibits a particu-lar nature (a feeling of how is it like to be conscious ofsomething) and a complexity (e.g. identity, rationality,and self-experience) that are unlike a spatial thing andtherefore not straightforwardly reducible to the levels ofhypothetically malfunctioning substrates. We believethat meaningful correlations between phenomenal andbiological levels of the mind-brain system may onlyemerge if consciousness itself, its modus operandi, its dis-

tinctions, and basic structures are considered and studiedas an explanandum in its own right, as philosophers ofmind have recently emphasized [12, 14]. Indeed, withoutsome idea of what the subjective character of experi-ence is, we cannot know what is required of a physicalist[reductive] theory [15, p. 437]. Such study of subjectivity

demands an adequately tailored epistemological frame-work. It is for this reason that Jaspers [16] emphasized thenecessity of a comprehensive and general psychological-phenomenological framework for any psychopathologi-cal enterprise.

In the case of schizophrenia, we believe that etiologicalresearch would have a chance to fare better if the domainto be explained, the explanandum, was grasped at its fun-damental phenomenal level, which is not that of advancedpsychotic symptoms (e.g. expressed as positive and nega-tive PANSS scores [17]), but rather the trait-like features,coined by Bleuler and others as fundamental symptoms

and designated by Minkowski [18] as trouble gnrateur.The generative disorder of schizophrenia is conceived ofas a basic disturbance of subjectivity or consciousness [19,20]. It is a disorder of the structure of consciousnesswhich lends the diagnostic specificity and a certain syn-chronic and diachronic gestaltic coherence to the quitepolymorphic clinical picture of the illness [18, 21].

Some time ago, we proposed that the generative disor-der in schizophrenia is a disorder of the self [22, 23]; anidea already anticipated by Bleuler, Minkowski, and oth-er psychopathologists. Our claim originated from lengthy,phenomenologically oriented, clinical interviews withpatients with beginning schizophrenia [24], and sincethen corroborated by a series of systematic empiricalstudies performed on various patient and populationsamples [2531]. It is important to stress here that ourtheory is not based on an inference to self-as-a-construct,supposed to operate as a hypothetical, explanatory latententity. Rather, the self-disorder claim refers to a real andphenomenologically accessible structure of conscious-ness, which, in the case of schizophrenia spectrum disor-ders, exhibits certain characteristic anomalies.

The purpose of this article is first to briefly articulate

the notion of the self-disorder in schizophrenia, followedby an analysis of two important domains of psychopa-thology of schizophrenia; domains in which, we suggest,the notion of the disordered self might be fruitfully ap-plied in order to recast their puzzling nature into moreuseful clinical and scientific terms. We will examine theso-called schizophrenic incomprehensibility (bizarre ge-stalt, bizarre delusions, and crazy actions) and treatmentnoncompliance.

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Schizophrenic Incomprehensibility

Since the very foundation of the concept of schizo-phrenia, incomprehensibility, strangeness, and bizarre-ness have been considered its hallmark, i.e. characteristicof the illness both at a global, gestaltic level of the encoun-

ter with the patient and at a more detailed level of descrip-tion of individual symptoms and signs [43]. These twolevels are of course intertwined. The overall gestalt ofschizophrenia, e.g. its expressivity, behavior, thinking,and appearance, often radiate an air of a typical, yet un-specifiable, strangeness, which gave rise to clinical no-tions such as atmospheric diagnosis or praecox feeling[18, 44]. Many single symptoms and signs appear so con-spicuously strange that they typically are deemed far be-yond comprehensibility, e.g. bizarre delusions, certainhallucinations, and crazy actions. How can we possiblyunderstand a person who is fully convinced that her

neighbor for no apparent reason is inserting maliciousthoughts into her head, a person who believes that hisbodily movements are controlled by external forces, or apatient claiming in the office of a Copenhagen psychia-trist that he is hearing voices from New York? Also cer-tain behaviors (crazy actions, unsinnige Handlungen,dlire en acte) may leave us baffled like in the famouscase of a schizoid father, who as a Christmas gift for hisdying daughter buys a coffin [45], or the case of a skilledGerman sergeant who, as his troops advance stopped inthe vicinity of Paris in 1940, took his service vehicle and,breaking strict and explicit orders, drove with some pri-

vates under his command to Paris, in order to draw theirattention on the cultural values of the enemy [46, 47, p.68]. We will address in some detail how the self-disorderapproach may aid the understanding the phenomena ofbizarre gestalt, bizarre delusions, and crazy actions.

The expression praecox feeling was coined by a Dutchpsychiatrist, H.C. Rmke [48], who claimed that the di-agnosis of schizophrenia was sometimes bolstered by(more or less) ineffable intuition, probably based on afundamental inaccessibility of the patient (for a detailedaccount, see [44]). Rmkes idea was as old as the concept

of schizophrenia itself. Similar terms included diagnosticpar pntration [19], diagnosis through intuition [49]or atmospheric diagnosis [50]. Wyrsch [49] proposedthat what was here at play was a perception of an existen-tial change. We perceive a transformation of the modal-ity of being (the patients ontological framework, de-scribed in the previous section) into an order of its own(eigene Daseinsweise). What appears as incomprehensi-ble, though preconceptually apprehended by the clini-

cian, are alterations in the structures of the patients be-ing-in-the-world, e.g. the temporality and spatiality ofbeing, self-identity, self-other relation, and self-world im-mersion; in other words, modifications of the structuresmaking up the intentional arc. Such structures are, ofcourse, not concrete perceivable thing-like objects.

Rather, they are constitutive, i.e. operating as preconcep-tual conditions of our existence [51, p. 48]. The clinicianmay perceive such changes in a nonconceptual, prereflec-tive way; an experiential mode that may be difficult oreven impossible to convert into a linguistic, proposition-al (sentence-like) format (hence the talk of atmosphericfeeling).

The notion of bizarre delusion is a product of the op-erational versions of the DSM and ICD. The creation ofthe category of bizarre delusions was justified by a cur-sory reference to Kraepelins observation that schizo-phrenic delusions often were nonsensical and to Jaspers,

according to whom primary delusional experience is un-understandable [52]. Bizarre delusions are specified inDSM-IV as clearly implausible and not understandableand do not derive from ordinary life experiences [53,p. 299] and in ICD-10 (though without using the termbizarre) as culturally inappropriate and completely im-possible [54, p. 87], and epitomized by the delusions ofthought insertion, thought deprivation, and delusions ofcontrol.

For Jaspers, schizophrenic delusions are primary path-ological experiences, i.e. they cannot be psychologicallyreduced to other experiences and they remain therefore,on his account, empathically incomprehensible [16]. Onthe other hand, the thematic delusional elaboration of apathological primary experience, for example that it is thecitys mayor and the municipal council that jointly forma conspiracy to control my thoughts, would be consideredas a secondary delusion, a product of reflective processes,not different in kind from those involved in nonschizo-phrenic delusions (e.g. delusions of guilt due to a melan-cholic mood). In disagreement with Jaspers, we wouldtherefore claim that the primary delusional experience isnot beyond comprehensibility because such an experi-

ence is continuous with the preexisting disorder of ip-seity. So even though such delusional experiences violatesome of our normally held beliefs about reality and usu-ally also deny the very framework of these normal beliefs(by implying, for example, the existence of nonphysicalcausality, no self-other boundaries, the reversibility oftime, etc.), these delusions remain, from the perspectiveof self-disorders, comprehensible to some extent. Bizarredelusional explanations are, in our view, attempts to

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frame and thematize a multiplicity of preexisting anoma-lous self-experiences, which are manifestations of an al-ready altered subjectivity [55, 56]. The unstable ipseityinvolves an increasing experiential distance between thesense of self and the flow of consciousness, which bringsalong disturbing forms of defamiliarization and self-

alienation. For example, patients may come to experiencetheir own voice, thoughts, feelings, and body or parts ofit as increasingly objectified, detached and increasinglyalien to the extent that their thoughts or body no longerfeel as their own but rather as something anonymous (itthinks rather than I think) or even instigated or steeredfrom the outside. From a phenomenological perspective,there is here a developmental continuity from early non-psychotic self-disorders to the fully formed first-ranksymptoms. However, this continuity is neither to beconceived along the lines of physical causality (in thesense that one self-disorder or a cluster of self-disorders

causes another that causes yet another until, say, the delu-sion is formed) nor as a form of mental causation (simi-lar to how feelings of thirst might cause one to get adrink). The quasiphysical causality has at least partly(though not clearly) been proposed in the studies on thetransitional sequences from the basic to the first-ranksymptoms [57, 58]. We suggest, instead, that this conti-nuity, phenomenologically speaking, is eidetic in nature,i.e. the underlying ipseity-intentional arc disturbanceprefigures or constrains the psychotic symptoms thatmay emerge as possible thematizations of the former, andadditionally it may elicit certain automatic (e.g. nonvoli-tional hyperreflection) and compensatory responses (e.g.introspective scrutinizing to reassert a feeling of control)[59, p. 268f]. To comprehend such abnormal experiencesor aspects of them, we must realize that the content andstructure of these experiences are dialectically inter-twined, and therefore we must take into account the al-tered framework of experiencing in schizophrenia in-stead of focusing exclusively on the propositional contentexpressed in the delusion.

In the case of crazy actions, we are confronted withanother type of incomprehensibility. From a detached

theoretical stance, the act of buying a coffin as a Christ-mas gift for a dying daughter, because thats what she willneed soon, or the act of disregarding explicit orders toenlighten comrades about the foes cultural values are tosome extent meaningful and perhaps even logical. Yet,at the same time, these acts reveal a profound lack of at-tunement with the intersubjective world and the implicitrules of social interaction. Buying the coffin reflects acomplete lack of understanding of the daughters emo-

tional needs and, more generally, of what is socially ap-propriate. The cultural enlightenment of the soldiers in-

volves a severe transgression of German military disci-pline, which in this particular subculture made thesergeants behavior appear as completely mad in the eyesof his superiors. Whether or not an action should be con-

sidered as crazy depends of course on the culture andcontext. Thus, the crazy action is characterized not somuch by its specific content as by the way it is enacted, i.e.by its friction with the situational context or by its socialor normative inappropriateness. Crazy actions indicatea take on the world that is markedly different from that ofthe shared community. In our view, the eccentric oridiosyncratic behavior displayed in crazy actions re-flects, what Blankenburg [60] termed, a loss of commonsense an aspect of the instability of the intentional arc[45; vide supra]. According to Blankenburg, commonsense is an attitude of being naturally and spontaneously

immersed in the shared social world and at ease in it, andto experience oneself, others and the world through thisattitude, which provides an implicit, prereflective grasp ofwhat is contextually relevant and socially appropriate.Consequently, the loss of common sense, which accord-ing to Blankenburg constitutes the core of schizophrenicautism, is typically associated with a panoply of otheranomalous self-experiences. By conceiving crazy actionsas expressions of a profound dislocation from commonsense, we may come to understand these peculiar actionsas somehow consequential of the inner logic of an autisti-cally transformed schizophrenic world [61].

Treatment Noncompliance

We will now address a major problem in the treatmentof schizophrenia, i.e. the patients reluctance to take anti-psychotic medication continuously over a longer periodof time. It is widely assumed that if we are to modify thenoncompliant patients attitude toward taking medica-tion, we must attain a better understanding of the mecha-nisms behind that attitude. Some of the causes are side

effects of pharmacotherapy, mistrust against the clini-cian, stigma of diagnosis, and positive attitudes towardspositive symptoms [62, 63]. Yet, the primary cause ofmedication noncompliance in schizophrenia is generallyconsidered to be poor insight into illness [53]. Empiricalstudies estimate that 5080% of patients with schizophre-nia do not believe they have a mental disorder [6466].

Consistent with the general clinical impression, moststudies have found that insight into illness (typically tau-

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tologically inversely related to the severity of psychosisand delusionality) predicts treatment compliance andbetter clinical and functional outcome, whereas poor in-sight predicts poorer compliance and outcome [6770].The current medical definition of insight includes aware-ness of having a mental disorder and of its symptoms and

signs, of the need for treatment, and of the disorders so-cial consequences [71]; poor insight reflects a decreaseor lack of awareness in some or all of these domains. Re-searchers have struggled to reach a more profound un-derstanding of poor insight, typically by exploring its cor-relations with other clinical and sociodemographic vari-ables such as symptomatology, prognosis, age of onsetof the disorder, neurocognitive impairment, global andsocial functioning, clinical outcome, gender, and educa-tional level. The studies, however, have yielded conflict-ing results (for an overview, see [70, 72]) with little prag-matic utility.

Two theoretical accounts of poor insight predominate.In psychodynamic theory, poor insight is a defense mech-anism, i.e. a denial of being ill with the purpose of wardingoff, for example, depressive symptoms arising fromawareness of having a chronic illness [73]. In contrast, thecognitive account claims that poor insight is a failure ofmetacognition [74]. First, both accounts conceptualizethe issue of insight into schizophrenia as a simple andstraightforward problem of self-reflection: insight is justan act of critical reflection on ones own psychologicallife. The reflecting self somehow notices a problem in thereflected, ongoing subjective life, which then may be-come rationally corrected. In schizophrenia, it is said, thisself-reflection fails, either due to interference from sub-conscious defense mechanisms or because of metacogni-tive dysfunctions. Second, and most importantly, bothaccounts implicitly assume that if these problems (de-fense or dysfunction) were remedied, the patients wouldacquire insight into their medical condition, i.e. they as-sume that, following the standard medical model, there isa clear separation between the self and the illness (be-tween the reflecting self and the ongoing conscious life).On this account, the self essentially remains unaffected by

the illness. However, this underlying assumption is out-right false since the schizophrenia spectrum disorders, aswe have argued and empirically demonstrated, are intrin-sically trait-marked by self-disorders, i.e. a variety of spe-cific alterations of the structures of experiencing, affect-ing the very conditions of self-experience and self-reflec-tion.

A comprehensive meta-analysis examining the effica-cy of psychoeducation for schizophrenia concluded that

attempts to increase awareness of illness in schizophreniaand improve medication compliance have failed [70].This disheartening result should serve as a wakeup call:we must acknowledge that in spite of decades of researchon poor insight into schizophrenia and treatment compli-ance, focusing explicitly on increasing the patients aware-

ness of their illness, there has been no significant thera-peutic advance during the last 30 years. In our view, thisfailure results from an inadequate understanding of whatpoor insight into schizophrenia really is. Instead of simplycontinuing to correlate poor insight to new additional

variables, we propose to return to the fundamental ques-tions and raise them anew. What is poor insight in schizo-phrenia? Why do many schizophrenia patients, despitemultiple relapses and readmissions, still not feel ill?

We will now present a novel account of poor insightinto schizophrenia that is based on the self-disorders ap-proach. The guiding idea is that a phenomenon, which

Bleuler [43] termed double bookkeeping, may help usbetter understand the complexity of poor insight into ill-ness. In short, double bookkeeping refers to the predica-ment (and ability) of many patients to, so to say, simulta-neously live in two different worlds, namely the sharedsocial world and their own private bizarre psychoticworld. Not only do patients with double bookkeepingseem to experience both worlds as real, they also gener-ally seem to experience them as two separate, incommen-surable, and thus not conflicting realities, thereby typi-cally allowing them to coexist and only occasionally tocollide. Here is illustrative example from Bleuler [43, p.43]: A catatonic patient was in great fear of a hallucinat-ed Judas Iscariot who was threatening her with a sword.She cried out that the Judas be driven away, but in be-tween she begged for a piece of chocolate. Next day shecomplained about these hallucinations, apologized forher acts of violence; but in the middle of her complaintsshe expressed pleasure in a pretty belt. She managed toweave this belt into her delusions sufficiently to need re-assurance that it was not a Judas kiss.

What is enigmatic in this vignette is that the patientsbehavior is strikingly at odds with her delusional beliefs.

Normally, we would expect someone, who firmly believesthat she is about to be slain, to defend herself or to seekcover; we would certainly not expect her to ask for a pieceof chocolate.

The patient manifests a stark incongruity between herbeliefs and actions, which puzzles us given that we tendto perceive actions as solid confirmations of beliefs. Withthis patient, we are left wondering whether or not she,strictly speaking, believes what she claims to believe, and

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the situation is of course even more convoluted since de-lusional beliefs per definition are incorrigible and heldwith unshakable certainty. A few other examples mayhelp illuminate our point. We may encounter schizo-phrenic patients who believe that people around them areautomatons but who nonetheless interact with them (as

if they were real), or patients who believe that the nursesin the ward are trying to poison them but still happily eatthe food that is being served them [75, p. 21]. Viewedfrom the clinical perspective, double bookkeeping, al-though not always as spectacular as in Bleulers vignettes,is a very prevalent phenomenon, perhaps characterizingthe majority of psychotic patients with schizophrenia.

It is important to emphasize that the deluded patientsoften quite inconspicuous daily behavior also indicatesthat the patients might not literally believewhat they claimto believe in their delusions, that there is a coefficient ofsubjectivity to their beliefs [75, p. 27]. The question is of

course how are we to make sense of this paradoxicalclaim. From a phenomenological perspective, there is asignificant difference between ordinarily held beliefs suchas there is an Italian restaurant around the corner or thetrain is leaving at 5 p.m. and delusional beliefs such asJudas is about to slay me down, others are automatons,or the nurses strive to poison me. The ordinarily heldbeliefs reflect a mundane (wordly or ontic) orientation(natural attitude), which is an aspect of immersion in ashared social world, and these beliefs belong to what iscalled the logical space of reasons, of justifying and beingable to justify what one says [76, p. 298]. In contrast, thedelusional beliefs reflect an autistic-solipsistic orienta-tion, which we suggest results from a profound loss ofcommon sense and persistent self-disorders, both involv-ing an altered framework for experiencing. Schizophren-ic delusions, as we argued in the previous section, emergefrom this altered experiential-ontological framework;therefore, the delusional beliefs formed within this frame-work do not belong to space of reasons, but rather to auniquely private quasisolipsistic space.

In our view, many patients with schizophrenia havepoor insight into their illness, i.e. they do not consider

their hallucinatory or delusional experiences as patho-logical phenomena because they do not experience theirinitial self-disorders from which psychosis emerged assymptoms of an illness (similar to how an intense painin the leg might be a symptom of a fracture), but rather asintrinsic aspects of their existence and identity. For ex-ample, first-admitted schizophrenia patients who reporthearing their own thoughts spoken aloud internally(Gedankenlautwerden) often get surprised and some-

times even suspicious when the psychiatrist explains thatmost people only have silent thoughts. In our view, thisis characteristic for many self-disorders. When interview-ing schizophrenia spectrum patients about their self-dis-orders, one quickly realizes that many of their anomalousself-experiences have been present for as long as the pa-

tients can remember or that the self-disorders emergedeither in childhood or early adolescence. In other words,the self-disorders are often trait-like modes of the pa-tients experiential life, usually preceding the onset of psy-chosis and persisting after remission. It is, therefore, aradically different situation than a reactive depressionwhere the patient has a distinct sense of who she was andhow her life used to be before the depression set in andafter. In schizophrenia, this is not the case to the sameextent, given that the altered experiential framework foryears has been the rule (or norm) rather than the excep-tion, making the issue of onset dating not only a techni-

cal but also a conceptual issue [77]. We may thus speak ofa prepsychotic double bookkeeping. One of our patientslived during his high school years a fundamentally alteredself-world relation with a sense of diminished presenceand quasisolipsistic experiences, while remaining incon-spicuously adapted to a shared social world. He thoughtof others as souls that had fallen on earth from an en-compassing world soul (to which we all return afterdeath), like raindrops from a cloud. He accounted for hisunique abilities and feelings of Andersseinby thinkingthat he perhaps retained a sort of capillary continuitywith the world soul and thereby had access to the fardeeper reality levels than his fellow humans were able toachieve. Such an explicit, quasireligious, metaphysicalposition is not a common clinical-empirical finding, butit illustrates well the transformation of the patients onto-logical-existential framework. Many young, pre-onsetpatients try to account for their sense of Andersseinbyfantasies of being time-travelers, extraterrestrials, etc.

From the perspective of prepsychotic double book-keeping, we can easily imagine that patients may find thedistinction fuzzy between, on the one side, their normal(i.e. anomalous) experiences (e.g. loss of thought ipseity,

thoughts aloud, and nonpsychotic demarcation prob-lems) and, on the other side, the occasional fearing andbelieving that others can access their thoughts or that cer-tain thoughts have been planted into their mind. In oth-er words, the line between what a patient normally (orhabitually) experiences (i.e. self-disorders) and what hesometimes experiences (e.g. positive symptoms) mayseem very slim and perhaps irrelevant to the patient andeven more so if the patient does not literally believe in his

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delusional beliefs though he obviously is unable to dis-tance himself from them. From this perspective, it makessense that many schizophrenia patients do not feel ill ordo not attribute their pathological experiences to the dis-order.

On the basis of this account, we suggest that the reason

why some patients with schizophrenia have poor insightand consequently do not comply with treatment, mightbe rooted in the severity and nature of their self-disorders.The future empirical task is to answer the question wheth-er psychoeducational attempts, focusing on the patientsself-disorders as vulnerability traits rather than on theirawareness of certain positive symptoms, may effectivelymodify the patients insight into their condition and op-timize treatment compliance. One thing that does pointin this direction is that while patients often are reluctantto discuss their delusions and hallucinations, most pa-tients are quite willing to explore and discuss their self-

disorders. This is most likely because, as many of our pa-tients have expressed it, questions about anomalous self-experiences are central to their existence and identity,whereas questions such as Do you really believe that thetelevision is sending messages specifically to you? or Doyou hear voices? usually are not.

Conclusion: Understanding Schizophrenia

Summarizing our central claims, we will now try toflesh out the type of understanding the self-disorders ap-proach enables in schizophrenia with the following ques-tion. Are we, as the clinicians familiar with the disordersof subjectivity in schizophrenia, able to better understandthe patient who, say, is presenting bizarre delusions, cra-zy actions, or treatment noncompliance rooted in doublebookkeeping?

All accounts of interpersonal understanding and ratio-nality presuppose a normal framework for experiencing,i.e. a shared ontological-existential perspective, or follow-ing Ratcliffe [41], a shared modal space. The belongingto the world is not a matter of having a belief-like inten-

tional state with the content the world exists. Rather, itinvolves () having a sense of reality, by which I mean agrasp of the distinction between real, present and otherpossibilities, without which one could not encounter any-thing as there or, more generally as real. We generallytake for granted that others share this same modal spacewith us and that they are able to encounter things in thesame was as we do [41, pp. 479480; some italics added].This existential-ontological structure, as we have argued,

is destabilized and constantly threatened in schizophre-nia, and a grasp of this instability or even dislocation isoften a prerequisite of an attempt to understand the pa-tient with schizophrenia. Here, understanding means agenetic or developmental reconstruction of the patholog-ical phenomena, i.e. a reconstruction that enables the pa-

tients mental life to appear less enigmatic. Even thoughmost of us cannot imagine how it might feel that the pri-vacy of ones subjectivity is compromised or that onesfield of awareness is populated by anonymous egolessthoughts, we can nonetheless understandingly grasp cer-tain consequences of these self-disorders, such as the fearof external access to ones thoughts or increasing objecti-fication and spatialization of the field of awareness. Thiskind of understanding has similarities with what Ratcliffe[41] called radical empathy and which we elsewherehave described as a philosophical understanding [78].Such an understanding requires that the clinician effectu-

ates the phenomenological epoch (i.e. he suspends hisnormally taken-for-granted habitual beliefs about theworld) and strives to reconstruct the altered life-world inschizophrenia; a world that often is deprived the onto-logical securities that ground a normal existence andwhich is infused with unpredictability and vulnerability.In a clinical context, e.g. in managing treatment noncom-pliance, epoch aims to disclose the nature and subjectivesignificance of the patients ontological-existential frame-work, thereby providing a more informed and probablymore efficient, departure point for addressing this clinicalissue therapeutically.

Disclosure Statement

Mads Gram Henriksen is funded by a grant from the CarlsbergFoundation (2012010195).

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