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A Disappearing Heritage: The Clinical Core of Schizophrenia

Josef Parnas*,1,2

1Psychiatric Center Hvidovre , University of Copenhagen, Njalsgade 142, 5-floor, Copenhagen, 2300 Denmark; 2DanishNational ResearchFoundations Center for Subjectivity Research, University of Copenhagen, Njalsgade 142, 5-floor, Copenhagen, 2300 Denmark

*To whom correspondence should be addressed; tel: 45-26740246, fax: 45-3532 8681, e-mail: [email protected]

This article traces the fundamental descriptive features ofschizophrenia described in the European continental litera-ture form Kraepelin and Bleuler, culminating with the crea-tion of the International Classification of Diseases (ICD)-8

(1974).Therewasaconsensusamongtheresearchersthatthespecificityandtypicalityofschizophreniawasanchoredtoitsfundamentalclinicalcore(withtraitstatus)andnottopos-itive psychotic features, which were considered as state,accessory phenomena. The clinical core of schizophreniawas,inadilutedform,constitutiveofthespectrumconditions(schizoidia and latentschizophrenia). The fundamentalfeatures are manifest across all domains of consciousness:subjective experience, expression, cognition, affectivity, be-havior, and willing. Yet, the specificity of the core was onlygraspable at a more comprehensive Gestalt-level, variouslydesignated(eg,discordance,autism, Spaltung),and notonthe level of single features. In other words, the phenomeno-

logical specificity was seen as being expressive of a funda-mental structural or formal change of the patientsmentality (consciousness, subjectivity). This overall changetranspires through the single symptoms and signs, lendingthem a characteristic phenomenological pattern. This con-cept of schizophrenia bears little resemblance to the currentoperational definitions. The Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition, and ICD-10seem to diagnose a subset of patients with chronic paranoid-hallucinatory variant of schizophrenia.

Key words: schizophrenia/clinical core/Bleuler

Introduction

The purpose of this contribution is to make a panoptic at-tempt to describe how schizophrenia was conceptualized inthe continental European psychiatry and described sinceBleuler and Kraepelin and as recently as in the 8th and9th editions of the International Classification of Diseases(ICD) ie, in practical clinical use in Europe at least until theintroduction of the ICD-101 in 1992.

The knowledge of the core features has gradually fadedaway in the operational permutations of the schizophre-nia concept. This notion becomes increasingly alien toclinicians. This is partly due to a reification of diagnostic

categories, associated with a general decline of psycho-pathological competence.2

A centenary of the publication of Bleulers DementiaPraecox or the Group of Schizophrenias is a pretextforthisreflection.Thereadershouldnotexpectahistoricalexegesis of Bleulers ideas. Rather, the goal will be to tracethe evolution of the concept of the clinical core of schizo-phrenia into its common continental articulation in ICD-8,3 beforethecreationofDiagnosticandStatistical Manualof Mental Disorders, Third Edition, (DSM-III).4

Thepreoperationalnotionofschizophreniamaybecon-sidered as a zenith of psychopathologic research, creatingconditions for the first major scientific accomplishments,

eg, the foundational Scandinavian epidemiological stud-ies,5 the US-DK Adoption studies,6 the US-DK high-risk studies,7 longitudinal patient follow-up studies,8,9

and the WHOs International Pilot Studies of Schizophre-nia.10 The modifications of the concept of schizophreniathat happened in the DSM-III-DSM-IV-TR4,11 and theICD-10 entail obvious and importantclinicaland researchconsequences.

What is Schizophrenia?

This trivial question hides certain important epistemolog-

ical issues, intimately linked to the question of a clinicalcore. The DSM-IV-TR11 defines schizophrenia in thefollowing way:

The essential features of schizophrenia are a mixture of char-

acteristic ( . ) positive and negative [symptoms] that havebeen present for a significant portion of time ( . ), associ-ated with marked social and occupational dysfunction. Thedisturbance is not better accounted for by .

Maj12 criticized this definition for not offering any gen-eral account of what schizophrenia is but rather of what it

Schizophrenia Bulletin vol. 37 no. 6 pp. 11211130, 2011doi:10.1093/schbul/sbr081Advance Access publication on June 19, 2011

The Authors 2011. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.This is an Open Accessarticle distributed undert he terms of the Creative Commons Attribution Non-Commercial License(http://creativecommons.org/licenses/

by-nc/2.5), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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is not (nonorganic, nonaffective, etc.). The definitiondoes not consider negative or positive symptoms (or theircombinations) as specific to schizophrenia. Moreover,Maj claimed that operational criteria are only useful toa clinician who is already familiar with what schizophre-nia is. The issue addressed by Maj is that of whatness(quiddity). It refers to the properties that a particular cat-

egory (eg, a patient) shares with others of its kind. What(quid) is it? simply asks for a general description throughsome essential or prototypical commonality.

Asking such question does not presuppose a commit-ment to realism about natural kinds. It is a questionprompted by clinical experience and based on the as-sumption that schizophrenia displays a characteristiccore Gestalt, conferring a certain typicality or prototypi-cality on its concrete clinical manifestations. It is not thequestion of a pathognomonic symptom but rather ofa characteristic Gestalt.

The question of the core dominated the psychiatric de-

bate since the beginning of the 20th century.

Fundamental Symptoms

European psychopathologistsagreed thatthere was some-thing phenomenologically distinctive and typical aboutschizophrenia, a something, a characteristic what-ness. It resides in a prototypical core whose propertiesare not temporally fluctuating surface psychotic symp-toms, but the features that reflect a phenomenologicaldepth or a structure of the disorder. Here, it is importanttoemphasize that thecore isnot merely a constructbutpos-sesses phenomenological reality. It is perceivable and ac-cessible to observation. Although it may be difficult todefine verbally, it is open to ostensive definition and henceto teaching, intersubjective agreement, and analysis. Thecore was considered, by and large, as a trait condition.ThediagnosticspecificitywasanchoredintheprototypicalGestalt of the illness.

Bleuler (inspiredby Heckers13 description of hebephre-nia) was among the first to distinguish between the funda-mental symptoms, specificto schizophreniaandspecifyingits spectrum extension (schizoidia, latent schizophrenia)and accessory symptoms, nonspecific state phenomena,marking a psychotic episode (hallucinations, delusions,

and flamboyant catatonic features).The fundamental fea-turesalso emphasized by Kraepelin and othersweremany: autism, formal thought disorder, ambivalence, af-fective-emotional, and affect-expressive changes, changesin the structure of the person, disorders of volition, actingand behavior, and the socalled schizophrenic dementia(which Bleuler did not conceived on the analogy with or-ganic dementia 14,15).

The fundamental symptoms overlap each other, withdescriptive redundancies. We will therefore concentrateon the prime fundamental symptom, the schizophrenicautism, which contains aspects of nearly all other funda-

mental symptoms as well. The autism concept became, inEurope, a shorthand term for the core Gestalt of schizo-phrenia, or for schizophrenia, tout court.

Autism: Withdrawal to Fantasy Life

Bleuler16 defined autism as a detachment from reality as-

sociated with rich fantasy life:

The [. . .] schizophrenics, who have no more contact with theoutside world live in a worldof theirown.They have encasedthemselves with their desires and wishes [. . .]; they have cutthemselves off as much as possible from any contact with the

external world. This detachment from reality with the rela-tive and absolute predominance of the inner life, we termautism.

He described a rich variety of clinical manifestationsunder the heading of autism: poor ability to enter intocontact with others, withdrawal and/or inaccessibility,negativistic tendencies, indifference, rigid attitudes and

behaviors, private hierarchy of values and goals, inappro-priate expression and behavior, idiosyncratic logic andthinking, and a propensity to delusion formation. The de-scription includes interrelated expressive, behavioral,subjective (cognitive, affective), and existential aspects.17

This multitude, Bleuler and others explained, was causedby a disaggregation, dissociation (loosening of associa-tions), Spaltung, or discordance between and withinthe modes and contents of consciousness.18 Autism man-ifests a discordance in the operations of consciousness.Henri Ey19 a renowned French psychiatrist, summarizedthe clinical expressions of the discordance in 5 general

dimensions:(1) Ambivalence: a division of all states or operations of the

mind into contradictory tendencies: desire/fear-repulsion;willing/not willing; affirmation/negation. (2) Bizarreness:impression of a strangeness that seems to reflect a disconcert-ing intention of the paradoxical or the illogical. (3) Impen-etrability: all schizophrenic symptoms appear to be imbuedby an enigmatic tonality; there is always some opacity of theunderstanding in the relations between the patient and the

others. (4) Detachment: loss of vital contact with reality 20

[lack of attunement, loss of the worlds natural self-evidence,inability of immersion in the world, solipsism]. (5) Destruc-

turation of consciousness [ie, disorder of subjectivity struc-

ture; see below]

19(p53)

(my translation and additions insquare brackets).

Bleulers description of autism demonstrates its resil-ience to a medical definition. The definition of autism asa withdrawal to fantasy life became trivialized alongthe common-sense psychological and psychodynamicunderstanding: All can turn their back to an unpleasantor threatening reality and engage in a wishful thinking.What is overlooked in such a comparison is the fact thatin schizophrenia, a confinement to interiority (inner life)is not primarily due to a voluntary choice to withdraw,but is more like an affliction or existential destiny.

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Although Bleuler undoubtedly had a profound clinicalintuition of the schizophrenic trait phenomena, the con-ceptual resources at his disposal did not permit a cleararticulation of this intuition.

Autism As a Phenomenon with Subjective Dimension

The panoply of clinical features making up the concept ofautism is beyond what the notion of a symptom can con-tain. Awareof theproblem,but notof thesolution, Bleulerqualified autism as a complex symptom. Phenomeno-logical notions of Gestalt and prototype offer more ade-quate conceptualizations here: autism is not an atomicsingle symptom but a phenomenon or a Gestalt, a certainwhole reflecting a radicallyalteredmental life. It is perceiv-able in the ways in which mentality (subjectivity, con-sciousness) operates and manifests itself. It is thisalteration that transpires through the manifold of clinicalmanifestations of schizophrenia.

Eugene Minkowski20

a French psychiatrist trained byBleuler, was the first to grasp the notion of the core ofschizophrenia on an adequate theoretical level. He didnot think that the core of schizophrenia could beaddressed by a list-wise description of single symptoms.What was needed was a background theory on the natureof mental life, a position that he shared with Jaspers21 andfor both authors, it was phenomenology that was rele-vant. Minkowski proposed that a mental state (eg, a hal-lucination) should not be treated in isolation and asa thing because it is an aspect, a trace of the wholefrom which it originates. This whole is the structure ofsubjectivity. Every anomalous mental state containstherefore an imprint of more basic experiential andexistential alterations, comprising, for example, changesin time and space experience, self-experience or altera-tions in the elementary relatedness to the world. It issuch structural alterations that transpire phenomenallyin the single symptoms, shaping them, keeping themmeaningfully interconnected, and founding the specific-ity of the overall diagnostic Gestalt.22 Minkowski20 con-sidered autism as a disorder of self (trouble de la structureintime du moi), marked by an inadequate basic prereflec-tive attunement between the person and his world, ie,a lack of immersion in the world, lack of vital contact

with reality. Minkowski defined the vital contact as anability to resonate with the world, to empathize withothers, an ability to become affected, and to act suitably,as a prereflective immersion in the intersubjective world:Without being ever able to formulate it, we know whatwe have to do; and it is that that makes our activityinfinitely malleable and human. Manifestations of autisminvolve a peculiar distortion of the relationship of theperson to himself, to the world, and to his fellow men.There is a decline of the dynamic, flexible, and malleableaspects of these relations, and a corresponding pre-dominance of the fixed, static, rational, and objectified

elements (one of our patients said: I am unable to godirectly to the world; for me, the world is always a matterof composition; there are no simple givens). Autism mayalso transpire through the patients acting. Autistic activityshows itself not so much through its content or purpose,but more through an inappropriate manner by which itis enacted, its friction with the situational context (crazy

actions23; see24, for several examples). A famous vignetteof a schizoid father, who buys, as a Christmas present forhis dying daughter, a coffin, illustrates this friction. The actis rational from a formal-logical point of view because,ultimately, the daughter is going to need a coffin, yetthe act is nonetheless bizarre by any human standard ofour culture.

Autism as Crisis of Common Sense: ExploringSubjective Dimension

The subjective dimension of autism, addressed by Min-

kowski, became further articulated by a contemporaryGerman psychiatrist, Wolfgang Blankenburg25 who con-sidered autism as a crisis of common sense.

What is at stake in common sense is not a possessionof a sufficient stock of explicit or implicit knowledge ofthe world that can be expressed in sentence-like terms: eg,I know that one says hello to greet the others. Rather,it is the ability to see things in the appropriate perspective,an implicit nonconceptual grip of the rules of the game,a sense of proportion, a taste for what is adequate andappropriate, likely, and relevant. Briefly, it refers toa nonconceptual and nonreflective indwelling in the inter-

subjective world, a preunderstanding of the context andbackground, a necessary condition for the grasp of ofobjects, other people, and situations. The patient findshimself in a pervasive state of ambivalence and perplexity(confusion about meaning). The loss of meaning is fre-quently associated with intense hyperreflectivity, ie, anexcessive tendency to monitor, and thereby objectify,ones own experiences and actions.26 Everything may be-come a matter of deliberation (Why is the grass green;why has the nature chosen this particular color?), relatingto others is felt disfigured, requiring preparatory efforts.There is no evident way to choose among options or to besure of ones own opinion. Blankenburg presents a case

of a young female schizophrenic patient, whose monot-onous complaint is the lack of naturalness, lack of self-evidentness and self-understandability (Selbstverstand-lichkeit):

What is it that I really lack? Something so small, so comic,but so unique and important that you cannot live without it

[. . .]. What I lack really is the natural evidence [. . .]. It hassimply to do with living, how to behave yourself in order notto be pushed outside, outside society. But I cannot find the

right word for that which is lacking in me [. . .]. It is notknowledge, it is prior to knowledge; it is something that ev-ery child is equipped with. It is these very simple things

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a human being has the need for, to carry on life, how to act,

to be with other people, to know the rules of the game. [. . .]Another patient writes to his friend: For your happiness,your lenience and your security, you can thank a somethingof which you are not even conscious. This something is first

of all that whichmakes lenience possible. It provides the firstground.

Not surprisingly, lacking this something so small, socomic goes hand in hand with another lack, namely a di-minished sense of self, lacking inner, persistent core of theperson.27

The Structure of Subjectivity: Self in Schizophrenia

A brief articulation of the structure of subjectivity or con-sciousness is now needed to grasp the notion of the dis-orders of the self in the core Gestalt of schizophrenia. Theconcept of self can be addressed at different levels of re-ality and abstraction. Here, we are concerned with its ba-sic universal experiential aspects.28 This ordinary

phenomenological notion of the self means that we liveour conscious life in the first person perspective, asa self-present, single, temporally persistent, embodied,and bounded (demarcated) entity, who is the subject ofhis experiences.29 That these basic structural aspects ofself-hood may become altered or even shattered in schizo-phrenia was noted already at the very conception of thenotion the illness. Bleuler16 considered self-disorders asbelonging to the complex fundamental symptoms (af-fecting the person). He wrote that the patients ego tendsto undergo the most manifold alterations, eg, splittingand loss of the directedness of thinking. A very intelli-

gent person needs hours of strenuous effort to find herown ego for a few brief moments; patients cannot catchup with themselves or they have lost their individualself16 (p143). Gruhle30 talked about the disordered self-hood as reflecting a specific existential tonality of beingin schizophrenia. Kraepelin31 considered loss of innerunity of consciousness and devastation of the will (or-chestra without a conductor) as the core features definingschizophrenia. Both notions imply a devastation of theself because it is the self that imposes a sense of unity onthe multitude of mental contents. Right now, while I amtyping this text into my notebook, the unity of my ongo-ing visual, tactile, auditory, etc. experiences is broughtabout through their shared feature or character of beingmy experiences. They are all given to me as their subject,making them inherent in one (my) field of awareness.28

Kurt Schneider noted that:

(C)ertain disturbances of self-experience show the greatestdegree of schizophrenic specificity. Here we refer to those

disturbances of first-personal-givenness(Ich-heit) or mine-ness (Meinhaftigkeit) which consist of ones own acts andstates not being experienced as ones own, 32(p58).

The issue of disorders of self was widely addressed inpsychopathological literature,19,27,30,33,34 both at a clini-

cal and a theoretical level. The view of autism, as a man-ifestation of the fundamental changes of subjectivitycame to mark the final articulation of European viewon the whatness of schizophrenia. Thus, the ICD-8/9 Glossary35 defines the clinical core of schizophreniaas a change in the patients structure of subjectivity: itis the fundamental disturbance of personality (self),(which) involves its most basic functions, those thatgive the normal person his feeling of individuality,uniqueness, and self-direction (p27; here, personalityin its most basic functions refers to the structure ofthe person or the self).

More recently, 2 Scandinavian studies have indepen-dently rediscovered the disorders of self-experiencein the schizophrenia spectrum conditions, a researchinspired by extensive semistructured interviews withyoung first-admitted patients with beginning schizo-phrenia. The patients typically complained of feelingephemeral, not really existing, lacking a basic identity

core, feeling profoundly different from others, andnot fully belonging to the shared world. This workwas systematically replicated on 151 first admissioncases followed up for 5 years3638 and on a large, diag-nostically stratified sample at genetic risk for schizo-phrenia.39

It is important to emphasize that we are dealing herewith the anomalies of experience and not with delusionsor hallucinations. Self-disorders occur both in schizo-phrenia and schizotypal disorders. They comprise a per-vasively diminished or insecure sense of existing as anembodied self-present subject, various distortions of first

person perspective, eg, with anonymization of the field ofawareness or deficient mineness (my thoughts haveno respect for me), various alienations in the streamof cognition, spatialization of mental contents, eg,thoughts being experienced as located extended objects(my thoughts always press from behind mainly here,on the left), feelings of disembodiment, inadequateego-demarcation, and, very importantly, lack of attune-ment to and inability of immersion in the world (I onlylive in my head). Isolation seems here to be more solip-sistic, growing from within, ie, constitutive, rather thanoperating only as a defensive withdrawal. Bleulerian re-treat to the inner world is more adequately seen as a con-stitution of a different, ie, private world.

The inability to project oneself forth in the world ( . . ), thetendency to disperse oneself in the flux of subjectivity, the

disproportion between the inside and the outside of ex-istence, constitute a constant infrastructure of consciousness( . ) in schizophrenia.40(p167)

Self-disorders are persisting and often pervasive (trait)phenomena, whose onset usually dates to early adoles-cence or even childhood. The schizophrenia spectrumpatients may also experience a variety of anomalies inall perceptual modalities.41

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The Ill-Famed Praecox-Feeling

We will briefly address here the notion of PraecoxGefuhl, now antiquated and out of use, but nonethelessimportant for an understanding of the attempts to cap-ture the clinical core of schizophrenia. The expressionpraecox feeling was coined by a Dutch psychiatrist,

Rumke42

who claimed that the diagnosis of schizophre-nia was sometimes bolstered by a (more or less) ineffableintuition, probably based on a fundamental inaccessibil-ity of the patient. Rumkes idea was almost as old as theconcept of schizophrenia itself, and it was widely de-scribed in schizophrenia research. Similar terms includeddiagnostic par penetration,20 diagnosis through intu-ition, 43 or atmospheric diagnosis.44 The term intu-ition refers in phenomenology to a direct apprehensionof an object or state of affairs, an apprehension that is notmediated by reflection. Muller-Suur45 emphasized thatthe original intuition of incomprehensibility could be

strengthened by a more reflective diagnostic apprehen-sion: the incomprehensibility in schizophrenia is notsomething vague but something definitely incompre-hensible. No matter how well we come to know thepatients psychopathology and personal history, we re-main confronted with a residuum of definite incompre-hensibility. Wyrsch43 suggested that what was here atplay was a perception of an existential change. We per-ceive a transformation of the modality of being into anorder of its own (eine Daseinsweise). What is incompre-hensible, but nonconceptually grasped by a clinician, arealtered basic structures of the being-in-the-world, eg,the temporality and spatiality of being, the self, and basic

self-world relatedness. These structures are not concrete,perceivable objects, like symptoms or signs; they are con-stitutive, ie, functioning as preconceptual conditions ofour existence.46(p48) The clinicians may perceive suchchanges in a nonconceptual mode, a type of experiencethat is difficult to convey in a linguistic propositional(sentence-like) format.

The validity of the intuitive diagnosis by an experiencedclinician was documented in a spectacular way by Gottes-man and Shields47 in their seminal Maudsley schizophre-nia twin study. The study showed concordance ratesamong MZ- and DZ-co-twins of the schizophrenic pro-

bands to be around 50% and 10%, respectively. They in-vited an outsider, a renowned Swedish expert on theschizophrenia spectrum conditions (schizoidia), professorEssen-Moller, to blindly diagnose the vignettes of theirsample, asking for a binary classification: within or outsidethe schizophrenia spectrum?. Essen-Mollers schizophre-nia spectrum cases demonstrated MZ a concordancerate of approximately 90%, without inflating the corre-sponding DZ concordance. Gottesman and Shields con-cluded that it was the most successful attempt ofvalidation of the schizophrenia spectrum concept.However, Essen-Moller was not able to explicate his

diagnostic performance in a descriptive, symptom-listmanner. His performance was, most likely, an instanceof Gestaltor pattern-recognition, executed by anextremely skilled and knowledgeable clinician.

The concept of praecox feeling gradually lost its theo-retical and phenomenological baggage, and became triv-ialized into a notion of instant or first 3 minutes

diagnosis. Eventually, it lost all clinical significancewith the introduction of the operational criteria for diag-nosis. In a theoretical debate preceding the formation ofthe DSM-III, the praecox-feeling was considered asemblem of psychiatrys subjectivism, incompatible withits scientific aspirations. The term also served as ammu-nition for antipsychiatrists who pointed out the arbitrar-iness and the excessive power of psychiatric labeling.

There are certain misunderstandings, which, in my view,obscure a potential epistemological import of the notion ofpraecox feeling. The intuition arises mainly passively; itcannot be instigated at will. It needs not to be restricted

to the first minutes of the encounter with the patient,but may arise at any moment throughout the interview.It may arise seemingly unprovoked or provoked by a singlegesture, a facial expression, or something uttered by thepatient, a something that changes the entire apprehensionof the patient because it changes the significance of the per-ceived Gestalt. In such cases it resembles the experience ofaspect dawning (like, when looking at an ambiguous fig-ure, eg, a duckrabbit, you start to see the rabbit and then,your way of viewing somehow changes, and now, sud-denly, you see the duck.48 (193c)) There is a change inthe perception of the entire Gestalt despite no or minimalchanges at the sensory level.

In an ordinary diagnostic situation, there is no extraintuition on the top of a Gestalt-recognition supportedby the symptom/sign-based information. The passivelyexperienced intuitive diagnostic hunch was never sup-posed to be applied as an autonomous classificatory ar-biter in a random population of patients. Rather, it wasbelieved to sometimes help the clinician in distinguishingbetween schizophrenia and other types of psychosis(schizophrenia vs pseudoschizophrenia [The Anglo-phone concept of a schizophrenia like psychosis [eg,in epilepsy], ie, a psychosis with hallucinations and delu-sions, was certainly not schizophrenia-like in the Eu-

ropean perspective, where the specificity ofschizophrenia was dependent on the clinical core fea-tures, rather than on the positive psychotic symptoms.]).It is obvious that praecox-feeling, for several reasons,cannot belong to the diagnostic tools in clinical psychia-try. That does not cancel its clinical reality or its concep-tual/epistemological import for schizophrenia research.

Gestalt, Prototype, and Symptom

Throughout the text, the notion of Gestalt has been reoc-curring. This epistemological issue is in the need of

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a further articulation because its understanding is essen-tial in addressing the clinical core features of schizophre-nia, ie, the defining features that constitute itswhatness. 49 When the preDSM-III psychopatholo-gists emphasized this or that feature as being very char-acteristic of schizophrenia, they did not use the concept ofa symptom/sign as it is being used today in the opera-

tional approach. This latter approach envisages thesymptoms and signs as being (ideally) third persondata, namely as reified (thing-like), mutually independent(atomic) entities, devoid of meaning and therefore appro-priate for context-independent definitions and unprob-lematic assessments. It is as if the symptom/sign andits causal substrate were assumed to exhibit the same de-scriptive nature: both are spatio-temporally delimitedobjects, ie, things. In this paradigm, the symptoms andsigns have no intrinsic sense or meaning. They are almostentirely referring, ie, pointing to the underlying abnor-malities of anatomo-physiological substrate. This scheme

of symptoms = causalreferents is automatically acti-vated in the mind of a physician confronting a medical-somatic illness. Yet the psychiatrist, who confronts hispsychiatric object, finds himself in a situation withoutanalog in the somatic medicine.21 The psychiatrist doesnot confront a leg, an abdomen, not a thing, but a person,ie, broadly speaking, another embodied consciousness.What the patient manifests is not isolated symptoms/signs with referring functions but rather certain wholesof mutually implicative, interpenetrating experiences,feelings, beliefs, expressions, and actions, all permeatedby biographical detail. The psychiatric typificationsand reflections start from these meaning-wholes. The lat-ter are not constituted by the referential symptom func-tion but by their meaning. We do not (with fewexceptions) know causal referents in any diagnosticallyrelevant sense. From a phenomenological point ofview, a diagnostic encounter is a second person situation,a process through which we evaluate expressions in con-

junction with experiences. We extract, represent, and in-dividuate from the flow of the patients subjective lifecertain repeatable (invariant) constellations of experienceand expression, certain meaningful wholes. A psychiatricsymptom or sign only emerges as an individuated entity(as this or that symptom) in the context of other, simul-

taneous, preceding, and succeeding experiences. A smileas such cannot be predefined as silly; the silliness ofa smile can only emerge in the context of the flow ofexpressions relative to a particular discourse.

These are the epistemological constraints behind thefact that all descriptions of the phenomenological speci-ficity of schizophrenia were invariably located at a moreencompassing level than the notion of a single, context-independent symptom or sign (eg, the concepts of autism,lack of vital contact with reality, disunity of conscious-ness, etc.). Indeed, the very idea of a context-independentphenomenological feature would probably never cross

the mind of a preDSM-III psychopathologist. Imaginea case of social phobia, caused by fear of physical con-tact with other people, a proximity being experienced asengulfing and annihilating. We would probably not con-sider this phobia as an isolated behavioral dysfunctionbut rather as being indicative of a larger whole of insecureidentity and self-demarcation, with avoidant coping be-

havior ensuing by implication. Consider, as another ex-ample, mumbling speech. In itself it is perhapscharacteristic of 5% of population. Yet, in a specific di-agnostic context, eg, if associated with mannerist allure,inappropriate affect, and vagueness of thought, itacquires a psychopathological significance.

The notion of Gestalt helps here to express the whole-ness of the clinical picture that constrains the particular-ity of its component features and accounts for theepistemic nature of the diagnostic encounter. Gestalt ele-ments are always present in the clinical diagnostic pro-cess, and so are the typification processes, ie,

progressive differential diagnostic approximations thatultimately result in the allocation of the investigated en-tity into a particular class. A Gestalt is a salient unity ororganization of phenomenal aspects. This unity emergesfrom the relations between component features (part-part-whole relations) but cannot be reduced to their sim-ple aggregate (whole is more than the sum of its parts).The Gestalts aspects are interdependent in a mutuallyconstitutive and implicative manner22 and the whole ofGestalt codetermines the nature and specificity of its par-ticular aspects, while, at the same time, the whole receivesfrom the single aspects its concrete clinical rootedness. AGestalt cuts across the dichotomies of inner and outer,form and content, universal and particular. The sa-lience of eg, interpersonal encounter does not normallyemerge in piecemeal-disconnected allusions to thepatients inner life on the one hand, in addition to inde-pendently salient fragments of his visible expressions, onthe other hand. Rather, the person articulates himselfthrough certain wholes, jointly constituted by his experi-ence, belief, and expression (inner and outer). What hesays (content) is always molded by the how (form) ofhis way of thinking and experiencing. A Gestalt instan-tiates a certain generality of type (eg, this patient is typicalof a category X), but this typicality is always modified,

because it is necessarily embodied in a particular, con-crete individual, thus deforming the ideal clarity oftype (universal and particular). The Gestalt alwaysexpresses a certain likeness to its prototype. Typifica-tions may be shared by other psychiatrists and assessedfor the interrater reliability. The gestaltic nature ofmental object does not preclude that the formal diag-nosis may follow a list of prespecified criteria, becausenothing a priori forbids constructing a list of criteriawith reflect the diagnostic Gestalt (It takes 2 years ofresidency with a weekly 23 hours of psychopathologyteaching [concepts, live interviews followed by

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Table 1. Clinical Core Features of Schizophrenia: Descriptive Levels

Signs SymptomsGestaltDesignations

Structure ofSubjectivity

Existentialorientation

Various disordersof all modalities ofexpression/bizarreness

Inadequate (parathymia)or diminished affectivemodulation

Paramimia (disorganizedfacial expression)

Parakinetic and stereotypicfacial (eg, paraocular)and other movements

Peculiar stiff posture withlumbar hyperextension,forward cervical bent,and lack of arm swing(Gebundenheit)

Shifting, capricious, orshallow emotions/moods

Staring or elusive orvigilant gaze

Excessive parallelism of ocular axes

Radical impenetrability/noemotional reciprocity/rigidity

Indifference

Varieties of formal thoughtdisorder, especiallyvagueness, derailment,metonymy

Stilted, manneristappearance/behavior/speech

Eccentricity/Antagonomia/Negativism

Mirror-phenomenon-observable

Detachment, Withdrawal,Social isolation/social anxiety

Inappropriate behavior(crazy actions)

Perplexity

Ambivalence/poly-valence

Sense of loss of meaning;emptiness, nonbeing(depression)

Hyper-reflectivity

Self-disorders: diminishedself-presence, disturbed firstperson perspective,disembodiment, spatializationof mental life, disorders ofthe stream ofthoughts (blocking, pressure,perceptualization), porousego-boundaries, lack ofbasic sense of identity, senseof unclarity or opaqueness ofconsciousness, anhedonia,devitalization,solipsism/grandiosity,etc.

Mirror-phenomenon-assubjective experience

Ontological insecurity andanxiety, fear of existence,

fear of dissolution

Disorders of attention andperception (esp. visualand auditory)

Anomalous bodilysensations

Discordance

Spaltung

Disunity ofconsciousness

Intrapsychicataxia

Autism

Unstable firstperson perspective

Diminishedself-presence

Hyper-reflexivity

Diminishedimmersion inthe world

Changes intemporality

Changes in

embodiment

Changes inintersubjectivity

Inaction

Crazy projects

Altered existentialorientation:(new) interestin philosophy,mysticism,adherence toa religious ora politicalsect, or otheralternativecommunity etc.

Clinicians

nonconceptualperception ofan alteredexistentialmode

The table attempts to provide an extended but not exhaustive summary of descriptions of the clinical core of schizophrenia. The first 2columns from the left list the single features, first as signs and then as symptoms, which are frequently described as trait-typical ofschizophrenia and its spectrum conditions. The third column indicates the frequently utilized terms or labels for the perceived coreGestalt. The last 2 columns indicate the overarching Gestalt, first articulated as disorders of the structure of subjectivity (such as self-world relation or temporality), and the last column refers to certain global changes, perceivable at the level of the patients existence.The question of specificity or whatness of schizophrenia was answerable with a reference to these larger Gestalts.

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Acknowledgments

The authors have declared that there are no conflicts ofinterest in relation to the subject of this study.

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