A Disappearing Heritage

The Clinical Core of Schizophrenia

Josef Parnas


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

In This Article

Gestalt, Prototype, and Symptom

Throughout the text, the notion of Gestalt has been reoccurring. This epistemological issue is in the need of a further articulation because its understanding is essential in addressing the clinical core features of schizophrenia, ie, the defining features that constitute its "whatness".[49] When the preDSM-III psychopathologists emphasized this or that feature as being very characteristic of schizophrenia, they did not use the concept of a symptom/sign as it is being used today in the operational approach. This latter approach envisages the symptoms and signs as being (ideally) third person data, namely as reified (thing-like), mutually independent (atomic) entities, devoid of meaning and therefore appropriate for context-independent definitions and unproblematic assessments. It is as if the symptom/sign and its causal substrate were assumed to exhibit the same descriptive nature: both are spatio-temporally delimited objects, ie, things. In this paradigm, the symptoms and signs have no intrinsic sense or meaning. They are almost entirely referring, ie, pointing to the underlying abnormalities of anatomo-physiological substrate. This scheme of "symptoms = causal−referents" is automatically activated in the mind of a physician confronting a medical-somatic illness. Yet the psychiatrist, who confronts his "psychiatric object", finds himself in a situation without analog in the somatic medicine.[21] The psychiatrist does not 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 wholes of mutually implicative, interpenetrating experiences, feelings, beliefs, expressions, and actions, all permeated by biographical detail. The psychiatric typifications and reflections start from these meaning-wholes. The latter are not constituted by the referential symptom function but by their meaning. We do not (with few exceptions) know causal referents in any diagnostically relevant sense. From a phenomenological point of view, a diagnostic encounter is a second person situation, a process through which we evaluate expressions in conjunction with experiences. We extract, represent, and individuate from the flow of the patient's subjective life certain repeatable (invariant) constellations of experience and expression, certain meaningful wholes. A psychiatric symptom or sign only emerges as an individuated entity (as this or that symptom) in the context of other, simultaneous, preceding, and succeeding experiences. A smile as such cannot be predefined as silly; the silliness of a smile can only emerge in the context of the flow of expressions relative to a particular discourse.

These are the epistemological constraints behind the fact that all descriptions of the phenomenological specificity of schizophrenia were invariably located at a more encompassing 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 consciousness, etc.). Indeed, the very idea of a context-independent phenomenological feature would probably never cross the mind of a preDSM-III psychopathologist. Imagine a case of "social phobia", caused by fear of physical contact with other people, a proximity being experienced as engulfing and annihilating. We would probably not consider this "phobia" as an isolated behavioral dysfunction but rather as being indicative of a larger whole of insecure identity and self-demarcation, with avoidant coping behavior ensuing by implication. Consider, as another example, "mumbling speech". In itself it is perhaps characteristic of 5% of population. Yet, in a specific diagnostic context, eg, if associated with mannerist allure, inappropriate affect, and vagueness of thought, it acquires a psychopathological significance.

The notion of Gestalt helps here to express the wholeness of the clinical picture that constrains the particularity of its component features and accounts for the epistemic nature of the diagnostic encounter. Gestalt elements are always present in the clinical diagnostic process, and so are the typification processes, ie, progressive differential diagnostic approximations that ultimately result in the allocation of the investigated entity into a particular class. A Gestalt is a salient unity or organization of phenomenal aspects. This unity emerges from the relations between component features (part-part-whole relations) but cannot be reduced to their simple aggregate (whole is more than the sum of its parts). The Gestalt's aspects are interdependent in a mutually constitutive and implicative manner[22] and the whole of Gestalt codetermines the nature and specificity of its particular aspects, while, at the same time, the whole receives from the single aspects its concrete clinical rootedness. A Gestalt cuts across the dichotomies of "inner and outer," "form and content," "universal and particular." The salience of eg, interpersonal encounter does not normally emerge in piecemeal-disconnected allusions to the patient's inner life on the one hand, in addition to independently salient fragments of his visible expressions, on the other hand. Rather, the person articulates himself through certain wholes, jointly constituted by his experience, belief, and expression (inner and outer). "What" he says (content) is always molded by the "how" (form) of his way of thinking and experiencing. A Gestalt instantiates a certain generality of type (eg, this patient is typical of a category X), but this typicality is always modified, because it is necessarily embodied in a particular, concrete individual, thus deforming the ideal clarity of type (universal and particular). The Gestalt always expresses a certain likeness to its prototype. Typifications may be shared by other psychiatrists and assessed for the interrater reliability. The gestaltic nature of "mental object" does not preclude that the formal diagnosis may follow a list of prespecified criteria, because nothing a priori forbids constructing a list of criteria with reflect the diagnostic Gestalt (It takes 2 years of residency with a weekly 2–3 hours of psychopathology teaching [concepts, live interviews followed by diagnostic and interview-technical discussion] to produce a reliable and competent "prototypical" clinician). Recently, a more gestaltic approach has been proposed for the DSM-V.[50]