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Psychopathology

Psychopathology DOI: 10.1159/000351837

Subjectivity and Schizophrenia: Another Look at Incomprehensibility and Treatment Nonadherence

Josef Parnas a, b Mads Gram Henriksen a, b

a Psychiatric Center Hvidovre, and b Center 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 place over 30 years ago with the purpose of improving reliabil-ity of psychiatric diagnoses as a means to uncover their etiology [1] . There is an increasing awareness of the scar-city of truly novel, actionable etiological and therapeutic knowledge [2–4] . 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 usefulclinical 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. Parnas Center for Subjectivity Research, University of Copenhagen Njalsgade 142 DK–2300 Copenhagen (Denmark) E-Mail jpa   @   hum.ku.dk

© 2013 S. Karger AG, Basel0254–4962/13/0000–0000$38.00/0

www.karger.com/psp

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various responses to this crisis. It is usually acknowledged that the complexity of the etiological task is far greater than originally assumed. Often, it is proposed that the stagnation is partly rooted in the very nature of diagnos-tic categories, reflecting commonsensical, sociohistorical constructs rather than really existing natural entities; consequently, such diagnoses are useless for etiological research. Such categorically dismissive proposals are usu-ally formulated in a quite vague, indistinctively general-izing manner. It is instead suggested that research should focus 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 reconsiders the epistemological behaviorist dogma dominating psy-chopathology as a potential cause of the stagnation. We believe that another partly related but perhaps even more important source of the current deadlock is the vast over-simplification of the ontology and epistemology of the ‘object of psychiatry’, which has taken place in the wake of the ‘operational revolution’ [8] . It is certainly true that psychiatric diagnoses, constituted by an aggregate ofsocial, experiential, behavioral, and temporal criteria, achieve a complexity that hardly can be matched by any coherent 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 phenomenological framework, and insensitive to their qualitative diversity and heterogeneity (expressed, for example, in claims such as that auditory verbal hallucinations are shared by a mul-titude of psychiatric disorders [9] and widely prevalent among healthy people as well [10, 11] ).

Psychiatry confronts the so-called ‘hard problem of consciousness’ [12] : phenomenal consciousness has no analog in the physical domain. There is an ‘explanatory gap’ [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’ of something) and a complexity (e.g. identity, rationality, and self-experience) that are unlike a spatial ‘thing’ and therefore not straightforwardly reducible to the levels of hypothetically malfunctioning substrates. We believe that meaningful correlations between phenomenal and biological levels of the mind-brain system may only emerge if consciousness itself, its modus operandi, its dis-

tinctions, and basic structures are considered and studied as an explanandum in its own right, as philosophers of mind have recently emphasized [12, 14] . Indeed, ‘without some 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 the necessity of a comprehensive and general psychological-phenomenological framework for any psychopathologi-cal enterprise.

In the case of schizophrenia, we believe that etiological research would have a chance to fare better if the domain to be explained, the ‘explanandum’, was grasped at its fun-damental phenomenal level, which is not that of advanced psychotic 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 générateur’. The generative disorder of schizophrenia is conceived of as a basic disturbance of subjectivity or consciousness [19, 20] . It is a disorder of the ‘structure’ of consciousness which lends the diagnostic specificity and a certain syn-chronic and diachronic gestaltic coherence to the quite polymorphic 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] ; an idea already anticipated by Bleuler, Minkowski, and oth-er psychopathologists. Our claim originated from lengthy, phenomenologically oriented, clinical interviews with patients with beginning schizophrenia [24] , and since then corroborated by a series of systematic empirical studies performed on various patient and population samples [25–31] . It is important to stress here that our theory is not based on an inference to self-as-a-construct, supposed to operate as a hypothetical, explanatory latent entity. Rather, the self-disorder claim refers to a real and phenomenologically 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, followed by 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 more useful clinical and scientific terms. We will examine the so-called schizophrenic incomprehensibility (bizarre ge-stalt, bizarre delusions, and ‘crazy actions’) and treatment noncompliance.

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Schizophrenia as a Self-Disorder

The phenomenological, experiential notion of the self signifies that we live our (conscious) life in the first-per-son perspective, as a self-present, single, temporally per-sistent, bodily, and bounded entity that is the subject of experience [32] . To describe the essential or core dimen-sion of selfhood, phenomenology and cognitive science [33, 34] operate with the concept of ‘minimal’ self, i.e. a structure that necessarily must be in place in order for all experience to be subjective , i.e. to be someone’s experience (rather than existing in a free-floating state and only post hoc appropriated by the subject in the act of reflection). Phenomenology considers this basic self-awareness as experientially, but prereflectively, manifest. The minimal self refers to the first-personal articulation of experience, typically called ‘mineness’, ‘myness’, ‘for-me-ness’, or ‘ipseity’ (for a detailed elaboration, see [33, 35] ). The no-tion of a bare perspective, however, is not entirely ex-haustive of the sense of ipseity. Ipseity is also a sense of ‘I-me-myself’ that persists across the flux of time and ex-periences and across different modalities of conscious life. It is prereflectively and noninferentially present as a sub -jectum of my life. This sense of ‘I-me-myself’ is prop-ertyless and it cannot be reduced to a set of attributes. Quoting Hart [ 36 , p. 310], we may say that, ‘if intelligibil-ity is grasping properties, then the ‘‘myself’’ (…) eludes our grasp.’ Ipseity founds the so-called ‘radical self-rec-ognition’, which implies that I am always already aware of ‘I-me-myself’ and have therefore no need for self-ob-servation or self-reflection to assure myself of being my-self. Ipseity conveys the very basic, immutable core of identity, a core that is foundational for our ordinary sense of existing as a self-present, single, bodily, demar-cated, and persisting entity. Ipseity thus manifests acertain paradoxical nature. On the one hand, it may be considered as a general, universal ‘form’ of human con-sciousness. Yet, on the other hand, and notwithstanding its lack of properties, ipseity founds the most intimate, individuated (but propertyless) essence of our personal identity [36] . In that sense, we may, though obviously in a somewhat artificial way, distinguish ipseity from the more complex self, the so-called ‘narrative’ or ‘extended’ self, involving personal history, narrative-language, per-sonality structure, and patterns of relating, and involving psychological concepts such as ‘self-image’, ‘self-esteem’, ‘self-presentation’, etc. Our claim is that schizophrenia selectively involves a disturbance of ipseity, which inevi-tably has implications on the extended self. By contrast, the disorders of extended self but with ‘intact ipseity’

mark the personality disorders outside the schizophrenia spectrum disorders.

A stable sense of basic selfhood and identity goes to-gether with an automatic, unreflected immersion in the shared social world. The world is pregiven, i.e. alwaystacitly grasped as a real, taken-for-granted, self-evident background of all experiencing and all meaning [37] . One is not only self-present but also present in the midst of the world of which one is partaking. This tacit and founda-tional self-world structure – the ‘intentional arc’ [38] – is threatened or unstable in the schizophrenia spectrum dis-orders, constituting its core vulnerability [22, 23, 39, 40] . Thus, the notion of self-disorder in schizophrenia does not imply a lack of ipseity or dissolution of the intention-al arc (which perhaps may occur in the terminal stages of life-threatening catatonia). Rather, we assume that this infrastructure of conscious life is constantly challenged, unstable, and oscillating, resulting in alarming and alien-ating experiences, typically occurring already in child-hood or early adolescence.

The patients feel ephemeral, lacking core identity, pro-foundly (yet often ineffably) different from others (‘An-derssein’) and alienated from the social world. There is a diminished sense of existing as a bodily, self-present sub-ject, distortions of first-person perspective with a failing sense of ‘mineness’ of the field of awareness (e.g. ‘my thoughts have no respect for me’), spatialization of the experiential contents (e.g. thoughts being experienced as located extended objects), and deficient sense of privacy of the inner world. There is a significant lack of at-tunement and immersion in the world (‘loss of common sense’) and pervasive perplexity, i.e. inadequate prereflec-tive grasp of self-evident meanings (e.g. ‘Why is the grass green?’) and hyperreflectivity (e.g. ‘I only live in my head’, ‘I always observe myself’). Social isolation and loneliness often bear a solipsistic stamp, arising ‘from within’ rather than operating solely as a psychological defense or a sim-ple deprivative consequence of the illness.

It is important to emphasize at this point that the self-disorder (instability of ipseity/intentional arc) may throw the patient into a new ontological-existential perspective or ‘modal space’ [41] , an often solipsistic framework, no longer ruled by reliable certitudes and axioms of the ‘nat-ural attitude’ concerning space, time, causality, and self-identity. There is an altered ontological position, i.e. an altered sense of reality and existence: ‘(the) patients can-not take things to be the case in the usual way, as the sense of ‘‘is’’ and ‘‘is not’’ has changed’ [ 42 , p. 194].

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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. characteristic of 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 two levels are of course intertwined. The overall gestalt of schizophrenia, 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, certain hallucinations, and ‘crazy actions’. How can we possibly understand a person who is fully convinced that her neighbor for no apparent reason is inserting malicious thoughts into her head, a person who believes that his bodily movements are controlled by external forces, or a patient 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’ , ‘délire en acte’) may leave us baffled like in the famous case of a schizoid father, who as a Christmas gift for his dying daughter buys a coffin [45] , or the case of a skilled German sergeant who, as his troops’ advance stopped in the 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 their attention on the cultural values of the enemy’ [ 46 , 47 , p. 68]. We will address in some detail how the self-disorder approach may aid the understanding the phenomena of bizarre gestalt, bizarre delusions, and ‘crazy actions’.

The expression ‘praecox feeling’ was coined by a Dutch psychiatrist, H.C. Rümke [48] , who claimed that the di-agnosis of schizophrenia was sometimes bolstered by (more or less) ineffable intuition, probably based on a fundamental inaccessibility of the patient (for a detailed account, see [44] ). Rümke’s idea was as old as the concept of schizophrenia itself. Similar terms included ‘diagnostic par pénétration’ [19] , ‘diagnosis through intuition’ [49] or ‘atmospheric diagnosis’ [50] . Wyrsch [49] proposed that what was here at play was a perception of an existen-tial change. We perceive a transformation of the modal-ity of being (the patient’s ‘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 patient’s ‘be-ing-in-the-world’, e.g. the temporality and spatiality of being, self-identity, self-other relation, and self-world im-mersion; in other words, modifications of the structures making up ‘the intentional arc’. Such structures are, of course, not concrete perceivable ‘thing-like’ objects. Rather, they are constitutive, i.e. operating as preconcep-tual conditions of our existence [ 51 , p. 48]. The clinician may perceive such changes in a nonconceptual, prereflec-tive way; an experiential mode that may be difficult or even impossible to convert into a linguistic, proposition-al (sentence-like) format (hence the talk of ‘atmospheric feeling’).

The notion of ‘bizarre’ delusion is a product of the op-erational versions of the DSM and ICD. The creation of the category of ‘bizarre delusions’ was justified by a cur-sory reference to Kraepelin’s 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 in DSM-IV as ‘clearly implausible and not understandable and do not derive from ordinary life experiences’ [ 53 ,p. 299] and in ICD-10 (though without using the term ‘bizarre’) as ‘culturally inappropriate and completely im-possible’ [ 54 , p. 87], and epitomized by the delusions of thought insertion, thought deprivation, and delusions of control.

For Jaspers, schizophrenic delusions are primary path-ological experiences, i.e. they cannot be psychologically reduced to other experiences and they remain therefore, on his account, empathically incomprehensible [16] . On the other hand, the thematic delusional elaboration of a pathological primary experience, for example that it is the city’s mayor and the municipal council that jointly form a conspiracy to control my thoughts, would be considered as 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 would therefore claim that the primary delusional experience is not beyond comprehensibility because such an experi-ence is continuous with the preexisting disorder of ip-seity. So even though such delusional experiences violate some 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 nonphysical causality, no self-other boundaries, the reversibility of time, etc.), these delusions remain, from the perspective of self-disorders, comprehensible to some extent. Bizarre delusional 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 ipseity involves an increasing experiential distance between the sense of self and the flow of consciousness, which brings along disturbing forms of defamiliarization and self-alienation. For example, patients may come to experience their own voice, thoughts, feelings, and body or parts of it as increasingly objectified, detached and increasingly alien to the extent that their thoughts or body no longer feel as their own but rather as something anonymous (‘it thinks’ rather than ‘I think’) or even instigated or steered from the outside. From a phenomenological perspective, there is here a developmental continuity from early non-psychotic self-disorders to the fully formed first-rank symptoms. However, this ‘continuity’ is neither to be conceived along the lines of ‘physical causality’ (in the sense 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 a drink). The quasiphysical causality has at least partly (though not clearly) been proposed in the studies on the transitional sequences from the ‘basic’ to the first-rank symptoms [57, 58] . We suggest, instead, that this conti-nuity, phenomenologically speaking, is ‘eidetic’ in nature, i.e. the underlying ipseity-intentional arc disturbance prefigures or constrains the psychotic symptoms that may emerge as possible thematizations of the former, and additionally 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 experiences or aspects of them, we must realize that the content and structure 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 content expressed in the delusion.

In the case of ‘crazy actions’, we are confronted with another type of incomprehensibility. From a detached theoretical stance, the act of buying a coffin as a Christ-mas gift for a dying daughter, because that’s what she will need soon, or the act of disregarding explicit orders to enlighten comrades about the foe’s cultural values are to some 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 implicit rules of social interaction. ‘Buying the coffin’ reflects a complete lack of understanding of the daughter’s 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 the sergeant’s behavior appear as completely ‘mad’ in the eyes of his superiors. Whether or not an action should be con-sidered as ‘crazy’ depends of course on the culture and context. Thus, the ‘crazy action’ is characterized not so much by its specific content as by the way it is enacted, i.e. by its friction with the situational context or by its social or normative inappropriateness. ‘Crazy actions’ indicate a take on the world that is markedly different from that of the shared community. In our view, the eccentric orid iosyncratic behavior displayed in ‘crazy actions’ re-flects, what Blankenburg [60] termed, a ‘loss of common sense’ – an aspect of the instability of ‘the intentional arc’ [ 45 ; vide supra]. According to Blankenburg, ‘common sense’ is an attitude of being naturally and spontaneously immersed in the shared social world and at ease in it, and to experience oneself, others and the world through this attitude, which provides an implicit, prereflective grasp of what is contextually relevant and socially appropriate. Consequently, the loss of common sense, which accord-ing to Blankenburg constitutes the core of schizophrenic autism, is typically associated with a panoply of other anomalous self-experiences. By conceiving ‘crazy actions’ as expressions of a profound dislocation from common sense, we may come to understand these peculiar actions as 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 treatment of schizophrenia, i.e. the patients’ reluctance to take anti-psychotic medication continuously over a longer period of time. It is widely assumed that if we are to modify the noncompliant 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 towards positive symptoms [62, 63] . Yet, the primary cause of medication noncompliance in schizophrenia is generally considered to be poor insight into illness [53] . Empirical studies estimate that 50–80% of patients with schizophre-nia do not believe they have a mental disorder [64–66] .

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

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tologically inversely related to the severity of psychosis and delusionality) predicts treatment compliance and better clinical and functional outcome, whereas poor in-sight predicts poorer compliance and outcome [67–70] . 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 disorder’s so-cial consequences [71] ; ‘poor insight’ reflects a decrease or 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 and social 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 warding off, for example, depressive symptoms arising from awareness of having a chronic illness [73] . In contrast, the cognitive account claims that poor insight is a ‘failure of metacognition’ [74] . First, both accounts conceptualize the issue of insight into schizophrenia as a simple and straightforward problem of self-reflection: insight is just an act of critical reflection on one’s own psychological life. The ‘reflecting’ self somehow notices a problem in the ‘reflected’, ongoing subjective life, which then may be-come rationally corrected. In schizophrenia, it is said, this self-reflection fails, either due to interference from sub-conscious defense mechanisms or because of metacogni-tive dysfunctions. Second, and most importantly, both accounts implicitly assume that if these ‘problems’ (de-fense or dysfunction) were remedied, the patients would acquire insight into their medical condition, i.e. they as-sume that, following the standard medical model, there is a 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, as we 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 schizophrenia and improve medication compliance have failed [70] . This disheartening result should serve as a wakeup call: we must acknowledge that in spite of decades of research on 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, this failure results from an inadequate understanding of what poor insight into schizophrenia really is. Instead of simply continuing 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, despite multiple relapses and readmissions, still not feel ill?

We will now present a novel account of poor insight into 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 us better 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 shared social world and their own private bizarre psychotic world. Not only do patients with double bookkeeping seem 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 to collide. 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 she complained about these hallucinations, apologized for her acts of violence; but in the middle of her complaints she expressed pleasure in a pretty belt. She managed to weave 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 patient’s behavior is strikingly at odds with her delusional beliefs. Normally, we would expect someone, who firmly believes that she is about to be slain, to defend herself or to seek cover; we would certainly not expect her to ask for a piece of chocolate.

The patient manifests a stark incongruity between her beliefs and actions, which puzzles us given that we tend to perceive actions as solid confirmations of beliefs. With this 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 held with unshakable certainty. A few other examples may help illuminate our point. We may encounter schizo-phrenic patients who believe that people around them are automatons but who nonetheless interact with them (as if they were real), or patients who believe that the nurses in the ward are trying to poison them but still happily eat the food that is being served them [ 75 , p. 21]. Viewed from the clinical perspective, double bookkeeping, al-though not always as spectacular as in Bleuler’s vignettes, is a very prevalent phenomenon, perhaps characterizing the majority of psychotic patients with schizophrenia.

It is important to emphasize that the deluded patients’ often quite inconspicuous daily behavior also indicates that the patients might not literally believe what they claim to believe in their delusions, that there is ‘a coefficient of subjectivity’ to their beliefs [ 75 , p. 27]. The question is of course how are we to make sense of this paradoxical claim. From a phenomenological perspective, there is a significant difference between ordinarily held beliefs such as ‘there is an Italian restaurant around the corner’ or ‘the train is leaving at 5 p.m.’ and delusional beliefs such as ‘Judas is about to slay me down’, ‘others are automatons’, or ‘the nurses strive to poison me’. The ordinarily held beliefs reflect a mundane (wordly or ‘ontic’) orientation (‘natural attitude’), which is an aspect of immersion in a shared social world, and these beliefs belong to what is called ‘the logical space of reasons, of justifying and being able to justify what one says’ [ 76 , p. 298]. In contrast, the delusional beliefs reflect an autistic-solipsistic orienta-tion, which we suggest results from a profound loss of common sense and persistent self-disorders, both involv-ing an altered framework for experiencing. Schizophren-ic delusions, as we argued in the previous section, emerge from this altered experiential-ontological framework; therefore, the delusional beliefs formed within this frame-work do not belong to ‘space of reasons’, but rather to a uniquely private quasisolipsistic space.

In our view, many patients with schizophrenia have poor insight into their illness, i.e. they do not consider their hallucinatory or delusional experiences as patho-logical phenomena because they do not experience their initial self-disorders from which psychosis emerged as ‘symptoms’ of an illness (similar to how an intense pain in the leg might be a symptom of a fracture), but rather as intrinsic aspects of their existence and identity. For ex-ample, first-admitted schizophrenia patients who report hearing their own thoughts spoken aloud ‘internally’ (‘Gedankenlautwerden’) often get surprised and some-

times even suspicious when the psychiatrist explains that most people only have ‘silent’ thoughts. In our view, this is characteristic for many self-disorders. When interview-ing schizophrenia spectrum patients about their self-dis-orders, one quickly realizes that many of their anomalous self-experiences have been present for as long as the pa-tients can remember or that the self-disorders emerged either in childhood or early adolescence. In other words, the self-disorders are often trait-like modes of the pa-tient’s experiential life, usually preceding the onset of psy-chosis and persisting after remission. It is, therefore, a radically different situation than a reactive depression where the patient has a distinct sense of who she was and how her life used to be before the depression set in and after. In schizophrenia, this is not the case to the same extent, given that the altered experiential framework for years 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 of a ‘prepsychotic double bookkeeping’. One of our patients lived during his high school years a fundamentally altered self-world relation with a sense of diminished presence and quasisolipsistic experiences, while remaining incon-spicuously adapted to a shared social world. He thought of others as ‘souls’ that had fallen on earth from an en-compassing ‘world soul’ (to which we all return after death), like raindrops from a cloud. He accounted for his unique abilities and feelings of ‘Anderssein’ by thinking that he perhaps retained a sort of ‘capillary’ continuity with the ‘world soul’ and thereby had access to the far deeper reality levels than his fellow humans were able to achieve. Such an explicit, quasireligious, metaphysical position is not a common clinical-empirical finding, but it illustrates well the transformation of the patient’s onto-logical-existential framework. Many young, pre-onset patients try to account for their sense of ‘Anderssein’ by fantasies of being ‘time-travelers’, extraterrestrials, etc.

From the perspective of ‘prepsychotic double book-keeping’, we can easily imagine that patients may find the distinction 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 and believing 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 (or habitually) experiences (i.e. self-disorders) and what he sometimes experiences (e.g. positive symptoms) may seem very slim and perhaps irrelevant to the patient – and even 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 makes sense that many schizophrenia patients do not feel ill or do 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 insight and consequently do not comply with treatment, might be 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 patient’s self-disorders as vulnerability traits rather than on their awareness of certain positive symptoms, may effectively modify the patient’s insight into their condition and op-timize treatment compliance. One thing that does point in this direction is that while patients often are reluctant to 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 the television is sending messages specifically to you?’ or ‘Do you hear voices?’ usually are not.

Conclusion: Understanding Schizophrenia

Summarizing our central claims, we will now try to flesh 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 disorders of subjectivity in schizophrenia, able to better understand the patient who, say, is presenting bizarre delusions, ‘cra-zy actions’, or treatment noncompliance rooted in double bookkeeping?

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 belonging to the world is not a matter of having a belief-like inten-tional state with the content ‘the world exists’. Rather, it involves (…) having a sense of reality , by which I mean a grasp of the distinction between ‘real’, ‘present’ and other possibilities , without which one could not encounter any-thing as ‘there’ or, more generally as ‘real’. We generally take for granted that others share this same modal space with us and that they are able to encounter things in the same was as we do’ [ 41 , pp. 479–480; 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 is often a prerequisite of an attempt to understand the pa-tient with schizophrenia. Here, understanding means a genetic or developmental reconstruction of the patholog-ical phenomena, i.e. a reconstruction that enables the pa-tient’s mental life to appear less enigmatic. Even though most of us cannot imagine how it might feel that the pri-vacy of one’s subjectivity is compromised or that one’s field of awareness is populated by anonymous egoless thoughts, we can nonetheless understandingly grasp cer-tain consequences of these self-disorders, such as the fear of external access to one’s thoughts or increasing objecti-fication and spatialization of the field of awareness. This kind of understanding has similarities with what Ratcliffe [41] called ‘radical empathy’ and which we elsewhere have described as a ‘philosophical understanding’ [78] . Such an understanding requires that the clinician effectu-ates the phenomenological epoché (i.e. he suspends his normally taken-for-granted habitual beliefs about the world) and strives to reconstruct the altered life-world in schizophrenia; a world that often is deprived the onto-logical securities that ground a normal existence and which is infused with unpredictability and vulnerability. In a clinical context, e.g. in managing treatment noncom-pliance, epoché aims to disclose the nature and subjective significance of the patient’s ontological-existential frame-work, thereby providing a more informed and probably more efficient, departure point for addressing this clinical issue therapeutically.

Disclosure Statement

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

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