A Disappearing Heritage

The Clinical Core of Schizophrenia

Josef Parnas


Schizophr Bull. 2011;37(6):1121-1130. 

In This Article

"Fundamental" Symptoms

European psychopathologists agreed that there was something phenomenologically distinctive and typical about schizophrenia, a "something", a characteristic "whatness." It resides in a prototypical core whose properties are not temporally fluctuating "surface" psychotic symptoms, but the features that reflect a phenomenological depth or a structure of the disorder. Here, it is important to emphasize that the core is not merely a construct but possesses phenomenological reality. It is perceivable and accessible to observation. Although it may be difficult to define verbally, it is open to ostensive definition and hence to teaching, intersubjective agreement, and analysis. The core was considered, by and large, as a trait condition. The diagnostic specificity was anchored in the prototypical Gestalt of the illness.

Bleuler (inspired by Hecker's[13] description of hebephrenia) was among the first to distinguish between the fundamental symptoms, specific to schizophrenia and specifying its spectrum extension (schizoidia, latent schizophrenia) and accessory symptoms, nonspecific state phenomena, marking a psychotic episode (hallucinations, delusions, and flamboyant catatonic features). The fundamental features—also emphasized by Kraepelin and others—were many: autism, formal thought disorder, ambivalence, affective-emotional, and affect-expressive changes, changes in the structure of the person, disorders of volition, acting and behavior, and the socalled "schizophrenic dementia" (which Bleuler did not conceived on the analogy with organic dementia[14,15]).

The fundamental symptoms overlap each other, with descriptive redundancies. We will therefore concentrate on the prime fundamental symptom, the schizophrenic autism, which contains aspects of nearly all other fundamental symptoms as well. The autism concept became, in Europe, a shorthand term for the core Gestalt of schizophrenia, or for schizophrenia, tout court.

Autism: Withdrawal to Fantasy Life

Bleuler[16] defined autism as a detachment from reality associated with rich fantasy life:

The […] schizophrenics, who have no more contact with the outside world live in a world of their own. They have encased themselves with their desires and wishes […]; they have cut themselves off as much as possible from any contact with the external world. This detachment from reality with the relative and absolute predominance of the inner life, we term autism.

He described a rich variety of clinical manifestations under the heading of autism: poor ability to enter into contact with others, withdrawal and/or inaccessibility, negativistic tendencies, indifference, rigid attitudes and behaviors, private hierarchy of values and goals, inappropriate expression and behavior, idiosyncratic logic and thinking, and a propensity to delusion formation. The description includes interrelated expressive, behavioral, subjective (cognitive, affective), and existential aspects.[17] This multitude, Bleuler and others explained, was caused by a disaggregation, dissociation (loosening of associations), "Spaltung," or discordance between and within the modes and contents of consciousness.[18] Autism manifests a discordance in the operations of consciousness. Henri Ey[19] a renowned French psychiatrist, summarized the 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 disconcerting intention of the paradoxical or the illogical. (3) Impenetrability: all schizophrenic symptoms appear to be imbued by an enigmatic tonality; there is always some opacity of the understanding in the relations between the patient and the others. (4) Detachment: loss of vital contact with reality[20] [lack of attunement, loss of the world's natural self-evidence, inability of immersion in the world, solipsism]. (5) "Destructuration" of consciousness [ie, disorder of subjectivity structure; see below]"[19] (p53) (my translation and additions in square brackets).

Bleuler's description of autism demonstrates its resilience to a medical definition. The definition of autism as a "withdrawal to fantasy life" became trivialized along the common-sense psychological and psychodynamic understanding: All can turn their back to an unpleasant or threatening reality and engage in a wishful thinking. What is overlooked in such a comparison is the fact that in 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.

Although Bleuler undoubtedly had a profound clinical intuition of the schizophrenic trait phenomena, the conceptual resources at his disposal did not permit a clear articulation of this intuition.

Autism as a Phenomenon With Subjective Dimension

The panoply of clinical features making up the concept of autism is beyond what the notion of a symptom can contain. Aware of the problem, but not of the solution, Bleuler qualified autism as a "complex" symptom. Phenomenological notions of Gestalt and prototype offer more adequate conceptualizations here: autism is not an atomic single symptom but a phenomenon or a Gestalt, a certain whole reflecting a radically altered mental life. It is perceivable in the ways in which mentality (subjectivity, consciousness) operates and manifests itself. It is this alteration that transpires through the manifold of clinical manifestations of schizophrenia.

Eugène Minkowski[20] a French psychiatrist trained by Bleuler, was the first to grasp the notion of the core of schizophrenia on an adequate theoretical level. He did not think that the core of schizophrenia could be addressed by a list-wise description of single symptoms. What was needed was a background theory on the nature of mental life, a position that he shared with Jaspers[21] and for both authors, it was phenomenology that was relevant. Minkowski proposed that a mental state (eg, a hallucination) should not be treated in isolation and as a thing because it is an aspect, a trace of the whole from which it originates. This whole is the structure of subjectivity. Every anomalous mental state contains therefore an imprint of more basic experiential and existential alterations, comprising, for example, changes in time and space experience, self-experience or alterations in the elementary relatedness to the world. It is such structural alterations that transpire phenomenally in the single symptoms, shaping them, keeping them meaningfully interconnected, and founding the specificity of the overall diagnostic Gestalt.[22] Minkowski[20] considered autism as a disorder of self (trouble de la structure intime du moi), marked by an inadequate basic prereflective 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 an ability to "resonate with the world", to empathize with others, 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 what we have to do; and it is that that makes our activity infinitely malleable and human." Manifestations of autism involve a peculiar distortion of the relationship of the person to himself, to the world, and to his fellow men. There is a decline of the dynamic, flexible, and malleable aspects of these relations, and a corresponding predominance of the fixed, static, rational, and objectified elements (one of our patients said: "I am unable to go directly to the world; for me, the world is always a matter of composition; there are no simple givens"). Autism may also transpire through the patient's acting. Autistic activity shows itself not so much through its content or purpose, but more through an inappropriate manner by which it is enacted, its friction with the situational context ("crazy actions";[23] see,[24] for several examples). A famous vignette of a "schizoid" father, who buys, as a Christmas present for his dying daughter, a coffin, illustrates this friction. The act is rational from a formal-logical point of view because, ultimately, the daughter is going to need a coffin, yet the act is nonetheless bizarre by any human standard of our culture.

Autism as "Crisis of Common Sense": Exploring Subjective Dimension

The subjective dimension of autism, addressed by Minkowski, became further articulated by a contemporary German psychiatrist, Wolfgang Blankenburg[25] who considered autism as "a crisis of common sense".

What is at stake in common sense is not a possession of a sufficient stock of explicit or implicit knowledge of the 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 and appropriate, likely, and relevant. Briefly, it refers to a nonconceptual and nonreflective indwelling in the intersubjective world, a preunderstanding of the context and background, a necessary condition for the grasp of of objects, other people, and situations. The patient finds himself in a pervasive state of ambivalence and perplexity (confusion about meaning). The loss of meaning is frequently associated with intense hyperreflectivity, ie, an excessive tendency to monitor, and thereby objectify, one's own experiences and actions.[26] Everything may become a matter of deliberation (Why is the grass green; why has the nature chosen this particular color?), relating to others is felt disfigured, requiring preparatory efforts. There is no evident way to choose among options or to be sure of one's own opinion. Blankenburg presents a case of a young female schizophrenic patient, whose monotonous complaint is the lack of naturalness, lack of 'self-evidentness' and 'self-understandability' (Selbstverständlichkeit):

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 has simply to do with living, how to behave yourself in order not to be pushed outside, outside society. But I cannot find the right word for that which is lacking in me […]. It is not knowledge, it is prior to knowledge; it is something that every child is equipped with. It is these very simple things 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 something' of which you are not even conscious. This 'something' is first of all that which makes lenience possible. It provides the first ground.

Not surprisingly, lacking this "something so small, so comic" goes hand in hand with another lack, namely a diminished sense of self, lacking inner, persistent core of the person.[27]