self, solipsism, and schizophrenic delusions

Self, Solipsism, and Schizophrenic Delusions

Josef Parnas, Louis Arnorsson Sass

Philosophy, Psychiatry, & Psychology, Volume 8, Number 2/3, June/September2001, pp. 101-120 (Article)

Published by The Johns Hopkins University PressDOI: 10.1353/ppp.2001.0014

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Parnas and Sass / SELF, SOLIPSISM, AND SCHIZOPHRENIC DELUSIONS � 101

© 2002 by The Johns Hopkins University Press

Self, Solipsism, andSchizophrenic

Delusions

ABSTRACT: We propose that typical schizophrenic delu-sions develop on the background of preexisting anom-alies of self-experience. We argue that disorders of theSelf represent the experiential core clinical phenome-na of schizophrenia, as was already suggested by thefounders of the concept of schizophrenia and elabo-rated in the phenomenological psychiatric tradition.The article provides detailed descriptions of the pre-psychotic or schizotypal anomalies of self-experience,often illustrated through clinical vignettes. We arguethat delusional transformation in the evolution ofschizophrenic psychosis reflects a global reorganiza-tion of consciousness and existential reorientation, bothof which radiate from a fundamental alteration of theSelf. We critically address the contemporary cognitiveapproaches to delusion formation, often finding theminconsistent with the clinical features of schizophreniaor implausible from a phenomenological point of view.

KEYWORDS: self-awareness, subjective experience, pre-schizophrenic prodrome, phenomenology, psychosis,cognitivism

The greatest hazard of all, losing one’s self, can occurvery quietly in the world, as if it was nothing at all.No other loss can occur so quietly; any other loss—anarm, a leg, five dollars, a wife etc.—is sure to be noticed.

—Søren Kierkegaard

1. Introduction

THE ARGUMENT OF this paper, based on em-pirical research, clinical experience, andphenomenological considerations, is that

disorders of the Self represent the psychopatho-logical core of schizophrenia. The notion of“core” refers to a basic, generative disorder(“trouble générateur”: Minkowski 1997), clini-cally detectable in the pre-illness stages and oper-ative in the formation of the schizophrenic psy-chosis as its underpinning, and lending coherenceto the various symptoms of the advanced stage(e.g., delusions). In our view, the emergence ofdelusions in schizophrenia cannot be compre-hended as an effect of a modular dysfunction inthe chain of “information-processing,” butshould, rather, be seen as an instance of a quiteprofound Self-World transformation, as a con-struction of a “delusional world” reflective of asolipsistic position inchoate in the pre-onset orprodromal stages of the illness.1 These views canbe accommodated within a framework of the so-

Josef Parnas and Louis A. Sass

102 � PPP / VOL. 8, NO. 2–3 / JUNE–SEPTEMBER 2001

called neuro-developmental hypothesis of the or-igins of schizophrenia, essentially proposing thatnoxious environmental and genetic factors, act-ing pre/post-natally and during early infancy,contribute to the vulnerability to schizophrenia(Murray and Lewis 1987; Asarnow et al. 1995;Woods 1998). The nature of this vulnerability ishypothesized here to comprise a fragile constitu-tion of selfhood.

The present paper presents in clinical detailanomalous self-experiences in the pre-onset (i.e.,prodromal) phases of schizophrenia and in theschizotypal disorders (i.e., sub-clinical, non-psy-chotic forms of schizophrenia) that are consid-ered as being crucially informative in a patho-genic sense (Meehl 1962; Parnas 1999a). To putit differently, one cannot comprehend the delu-sional transformation in schizophrenia unless thesubtler, fundamental features, predating the on-set of psychosis, are also taken into account.Well-crystallized psychotic symptoms are “state”phenomena, with marked intra- and inter-indi-vidual variations (Parnas and Bovet 1995b; Par-nas et al. 1996), reflecting fleeting mental orga-nization of a complexity quite distant from theunderlying vulnerability to the illness. Such symp-toms are therefore not the most relevant startingclues for charting the evolution of schizophrenia(Huber 1983; Klosterkötter 1988; Parnas 1999a).To use an analogy: Exclusive focus on the well-crystallized psychotic symptoms would correspond,in internal medicine, to exclusive studies of strokevictims to uncover the causes of hypertension.

2. Self and Schizophrenia:Early Descriptions

A variety of self-disorders in schizophreniahave always been recognized, at least implicitly,as essential components of its clinical picture. Anabsent reference to a Self is frequently merelyterminological, because the relevant phenomenaare addressed in other terms and/or in anothertheoretical framework.

Self-disorders were already described in detailat the turn of the nineteenth and twentieth centu-ry; French psychiatrists, especially, published nu-merous case histories of patients, who today

would have been diagnosed as suffering fromschizophrenic and schizotypal disorders and werecharacterized by profoundly altered self-experi-ence (Janet 1903; Hesnard 1909; de Clérambault1942). Eugene Bleuler (1911) considered “basicdisorder” of personality,2 including various al-terations of behavior and the schizophrenic “de-mentia” as the so-called “complex fundamental”(diagnostic) features of schizophrenia, stating thatthe illness invariably involves an affliction (“Spal-tung”) of the Self: “Ganz intakt ist dennoch das Ichnirgends” (Bleuler 1911, 58). The schizophrenicautism, another of E. Bleuler’s “fundamental”symptoms, may also be conceived of as inclusiveof self-disorders (Manfred Bleuler 1972; Parnasand Bovet 1991). Kraepelin (1896, 1913) claimedthat a disunity of consciousness (“orchestra with-out a conductor”) is the core feature of schizophre-nia. This disunity was closely linked to “a pecu-liar destruction of the psychic personality’s innerintegrity, whereby emotion and volition in par-ticular are impaired” (1913, 668, our translation).

A contemporary of Bleuler and Kraepelin, Jo-seph Berze (1914), explicitly proposed that abasic alteration of self-consciousness (“primaryinsufficiency”) was a primary disorder of schizo-phrenia. He described this “primary insufficien-cy” as a peculiar change, a diminished luminosi-ty and affectability of self-awareness. Jaspers(1923) proposed the following experiential modesin which a Self is aware of itself: (a) activity,comprising awareness of one’s existence and ac-tion, (b) unity, (c) temporal-diachronic identity,and (d) me/not me demarcation. The sense ofSelf, says Jaspers, may be affected in any of thesemodes. The vignettes that Jaspers provided toillustrate self-disorders are often suggestive ofschizophrenia, but he stopped short of pursuingthe potential theoretical significance of such dis-orders. Kurt Schneider (1959) addressed Self-disorders in his description of passivity phenom-ena, allegedly reflective of a loss of “ego-boundaries.” Scharfetter (1980, 1981) modifiedJaspers’ domains of self-experience to comprise,in a hierarchical order of increasing experientialcomplexity, vitality, activity, continuity, demar-cation, and identity. Scharfetter considered manydelusional phenomena as reflecting compensato-


ry reactions to self-disorders. Most of his clinicalexamples of altered self-experience in schizophre-nia are, however, of a clearly psychotic intensity.

Detailed descriptions of self-disturbances, fre-quently associated with the explorations of thesense and the nature of the Self, are to be foundin phenomenological psychiatry (Minkowski1927, 1997; Laing 1959; Blankenburg 1969,1971, 1986; Tatossian 1979; Kimura 1997). Themain implication from this line of work is thatalteration of the Self represents the primary dis-order of schizophrenia, conferring on it a uniqueGestalt and reflecting its pathogenetic nucleus:

La folie . . . ne consiste pas ni dans un trouble dujugement, ni de la perception, ni de la volonté, maisdans une perturbation de la structure intime du moi(Minkowski 1997, 114).

3. Recent Studies

Little empirical research offers prospective dataon self-experience in schizophrenia. One follow-back study using objective data did, however,reveal fluidity of self-demarcation, lack of a co-herent narrative-historical self-identity, and oth-er self-disturbances to be prominent features ofthe pre-schizophrenic states at school age (Hart-mann et al. 1984). None of the completed pro-spective high-risk projects or birth cohort studiescollected data relevant to self-experience.

An important contribution in this field is thework of Gerd Huber and his colleagues in Ger-many: In a series of retrospective and, more re-cently, prospective clinical studies, they identifiedsubtle cognitive, perceptual, motor, and corpore-al disturbances, designated as “basic symptoms,”many of which are specific to schizophrenia andprecede its onset (Huber et al. 1979; Huber 1983;Klosterkötter 1988; Klosterkötter et al. 1997,2001). Several of these disturbances reflect anom-alies in self-experience (e.g., varieties of deper-sonalization, disturbances of the stream of con-sciousness, and distorted bodily experiences). The“basic symptoms” are thoroughly described in aprototypical manner in the Bonn Scale for theAssessment of Basic Symptoms or BSABS (Grosset al. 1984), translated into Danish and routinelyused in our psychopathological assessments.

In a Norwegian study using naturalistic in-depth interviews with twenty first-onset schizo-phrenic patients (Møller and Husby 2000), threedomains of the pre-onset subjective change wererevealed: All patients had profound and alarm-ing changes of self-experience; nearly all patientscomplained of ineffability of their altered self-experience; and a great majority reported preoc-cupations with metaphysical, supernatural, orphilosophical issues.

Our own pilot retrospective study of the schizo-phrenic prodromes in nineteen first-onset pa-tients (Parnas et al. 1998) indicated a nearlyidentical profile of results. More recently, wehave completed systematic and detailed psycho-pathological data collection, including items per-taining to self-disorders and basic symptoms(BSABS) on 155 first-admission cases, which werediagnosed according to International Classifica-tion of Diseases (ICD-10) research criteria (WHO1992): fifty-seven suffered from schizophrenia,forty-three from schizotypal disorder, and theremaining fifty-five patients suffered from other,non-schizophrenia spectrum disorders (“TheCopenhagen Prodromal Study,” Handest andParnas, in prep.). Self-disorders were measuredwith an a priori constructed scale, summing upthe individual scores on the interview items per-taining to the anomalies of self-experience. In aseparate project, lifetime frequencies of anoma-lies of self-experience were compared betweentwenty ICD-10 patients with residual schizophre-nia and twenty remitted bipolar patients matchedfor sex and age (Parnas and Handest, submit-ted). Preliminary data analyses indicate collec-tively that self-disorders are (a) highly specific tothe schizophrenia spectrum conditions (note thatself-disorders are not a part of the ICD-10 diag-nostic criteria of schizophrenia), (b) mark thepicture of the pre-schizophrenic prodromes, and(c) occur frequently in hospitalized schizotypalconditions. Self-disorders correlate positively withthe duration of the pre-onset social dysfunction,are significantly associated with the retrospec-tive information on infantile or early childhooddevelopmental disorders, and aggregate signifi-cantly in the patients with a “positive” familyhistory of schizophrenia. Self-disorders correlate


with the “negative” and “positive” symptom-scales of the PANSS, i.e., the Positive and Nega-tive Syndrome Scale (Kay et al. 1987).

The vignettes and quoted statements stem fromour own studies and clinical work unless indicat-ed otherwise. Socio-demographic characteristicsof the subjects in the vignettes from our studiesare usually altered to preserve the subjects’ ano-nymity. Morbid self-experience is defined here asan experience in which one’s first-person experi-ential perspective or one’s status as a subject ofexperience or action are somehow distorted.

4. Anomalous Self-Experiencein the Pre-Onset Phases ofSchizophrenia and in theSchizotypal Disorder

The majority of first-admitted schizophreniaspectrum patients in our series had been treatedbefore their first psychiatric hospitalization bypracticing psychologists or psychiatrists, usuallywith a diagnosis of major depression and anattempt at treatment with antidepressant medi-cation. One reason for this lack of early correctdiagnosis is linked to the cryptic ways in whichthe patients verbalize their complaints.3 Theypresent non-specific complaints such as depres-sion, fatigue, and lack of concentration or anxi-ety. Blankenburg (1971) speaks in this context of“non-specific specificity”: a trivial (non-specific)complaint of fatigue turns out, on more closeevaluation, to be caused by a pervasive inabilityto grasp the everyday significations of the worldand a correlated perplexity (a condition highlysuggestive of schizophrenia, hence “specificity”).As observed by Berze (1914), self-disorders fre-quently reveal themselves only after an attemptto penetrate behind such surface complaints byan interviewing clinician who is familiar with thepotential manifestations of self-disorders. Thedifficulty, which the patients have in describingtheir experiences, is multi-determined. The lin-guistic resources for characterizing dimensionsof subjectivity, especially of the non-proposition-al type, are not readily available. This is doublytrue of anomalous self-experience that affects thevery condition of experience and impedes its

reportability. Adding to these difficulties is thefragility of the forms of consciousness in ques-tion, with their unstable wavering of implicit/prereflective into explicit/reflective modalities.

The varieties of anomalous self-experience de-scribed below are intimately interrelated, yet dis-tinguished for the sake of clarity of exposition.

Presence and Its Alterations

The phenomenological concept of presenceindicates that in our everyday transactions withthe world, the sense of self and the sense ofimmersion in the world are inseparable: “Subjectand object are two abstract moments of a uniquestructure which is presence” (Merleau-Ponty1945, 430, our italics).

From a phenomenological perspective, we candistinguish here two intentional moments: a cer-tain luminosity of self-presence or pre-reflectiveself-awareness (ipseity) (Henry 1963) and a cor-relative pre-reflective embeddedness in the world.4

These intentional moments deserve a closer phe-nomenological exposition, because disturbancesof presence appear to be the very earliest type ofthe prodromal experience in schizophrenia (Par-nas et al. 1998; Møller and Husby 2000).

We may speak of a pre-reflective self-aware-ness whenever we are directly, non-inferentiallyconscious of our own occurrent thoughts, per-ceptions, feelings, or pains; these appear in afirst-personal mode of givenness that immediate-ly reveals them as our own, i.e., entails a built-inself-reference. Thus if the experience is given in afirst-personal mode of presentation to me, it is(at least tacitly) given as my experience and countsas a case of primitive or basic self-awareness(Zahavi and Parnas 1998). First-personal given-ness is not something incidental to the being ofexperience, a mere varnish that the experiencecould lack without ceasing to be an experience; itis precisely its first-personal givenness that makesthe experience subjective. To be aware of oneselfis consequently not to apprehend a pure Selfapart from experience, but to be acquainted withan experience in its first-personal mode of pre-sentation, that is, from “within.” The subject ofexperience is a feature or function of its given-


ness (Zahavi 1999). Ipseity is here considered asa medium in which specific modes of experiencebecome articulated and thus equals the mostbasic form of selfhood.

Unreflected immersion in the world is phe-nomenologically considered as a pre-reflective,perceptual intentionality. Phenomenology distin-guishes between a thematic, explicit, or objecti-fying perceptual intentionality, and a non-reflec-tive, tacit sensibility, constituting our primarypresence to the world. This so-called operativeintentionality (Merleau-Ponty 1945; Husserl1972) is pre-reflectively functional without be-ing explicitly engaged in any epistemic acquisi-tion. It procures a basic texture or organization,and hence a coherence and familiarity, to thefield of experience. It is upon such texture thatexplicit intentionality configures its categorical,recognizing, or judgmental disclosures. It is inthe pre-reflective mode that habits or disposi-tions become sedimented and exercise their in-tentional role. The call for action in this mode doesnot originate from an explicit content in the mind(i.e., from a represented goal) but rather fromthe thing itself, perceived as a certain deviationfrom the optimal Gestalt and leading to a global-ly attuned response (Dreyfus and Dreyfus 1999).Operative intentionality is therefore considered asa necessary component of our non-reflexive, auto-matic attunement to the world, i.e., “commonsense” (Parnas and Bovet 1991; Parnas 2000).

The most prominent feature of altered pres-ence in the pre-onset stages of schizophrenia isan unstable sense of the groundedness, fullness,or reality of the self and a frequent, intimatelycorrelated feeling of alienation from the world.The patient feels that a profound change is af-flicting him, but he cannot verbalize and pin-point what exactly is changing, because it is nota something that can easily be expressed in prop-ositional terms. What becomes problematic is apervasive and normally tacit medium of being.The patient appears to be saying that he feelsbereft of the foundation of his existence. Thephrasings of such complaints may range from atrivial “I don’t feel myself” or “I am not myself”to “I am losing contact with myself,” “I amturning inhuman,” or “I am becoming perverse,

a monster,” etc. The patient senses an inner voidand complains of the lack of an “inner nucleus,”which seems normally constitutive of his field ofawareness and crucial to its very subsistence. Thesecomplaints may take a predominantly existentialturn: The patient does not feel being fully existingor alive, fully awake or conscious, or fully presentand affected. Altered presence may also be de-scribed as a lack of immersion or as a “phenom-enological distance” within perception and ac-tion. In a normal perceptual experience, the objectperceived is given directly, in the flesh so to say,but now it appears somehow filtered, deprivedof its fullness. Perception is not lived but is morelike a mechanical, purely receptive sensory pro-cess, unaccompanied by its affective feeling-tone.5

Case 1. Robert, a twenty-one-year-old un-skilled worker, complained that for more than ayear, he had been feeling painfully cut off fromthe world and had a feeling of some sort ofindescribable inner change, prohibiting him fromnormal life. He was troubled by a strange, perva-sive, and a very distressing feeling of not beingpresent or fully alive, of not participating in theinteractions with his surroundings. He was neverentirely involved in the world, in the sense ofengaged absorption in daily life. This experienceof disengagement, isolation, or ineffable distancefrom the world was accompanied by a tendencyto observe or monitor his inner life. He summa-rized his affliction in one exclamation: “My firstpersonal life is lost and is replaced by a thirdperson perspective” (He was not at all philo-sophically read). To exemplify his predicamentmore concretely, he said that, for instance, listen-ing to music on his stereo would give him animpression that the music somehow lacked itsnatural fullness, “as if something was wrongwith the sound itself,” and he tried to regulatethe sound parameters on his stereo equipment,to no avail, and only to finally realize that he wassomehow “internally watching” his own recep-tivity to music, his own mind receiving or regis-tering of musical tunes. He, so to speak, wit-nessed his own sensory processes rather thanliving them. It applied to most of his experiencesin that, instead of living them, he experienced his


own experiencing. He reflected on self-evidentdaily matters and had difficulties “in letting thingsand matters pass by”6 and linked it to a long-lasting attitude of “adopting multiple perspec-tives,” a tendency to regard any matter from allpossible points of view (Parnas 2000, 124–25).

We should add here that psychiatrists tend todescribe such patients as “an-hedonic” (deficientin feeling pleasure), but an-hedonia is only oneparticular aspect of this diminishment of basictonality, luminosity, or affectability of self-aware-ness accompanied by a sense of inexplicable in-ner fissure or void. (A similar description is to befound in Berze [1914].)

The incertitude of which Robert complainsreflects a sort of poly-valence (rather than am-bivalence) and seems to be linked to a moreglobal fragmentation of meaning, a loss of “nat-ural evidence” or “loss of common sense,” whichis the hallmark of the schizophrenic autism andperplexity (Parnas and Bovet 1991). Robert re-sembles Anne, a patient described in detail byBlankenburg (1971). Anne’s main and monoto-nous complaint was her inability to grasp theworld’s natural significance and appeal. Nothingwas self-evident, and Anne had a distressing dif-ficulty in the automatic understanding of peopleand situations: “It is not the question of knowl-edge; it is prior to knowledge . . . ; it is so small,so trivial; every child has it!” It is thereforeimportant to note that the lack of “natural evi-dence” or of “common sense” does not refer to adeficient stock of propositional knowledge butto a deficient ante-predicative, pre-conceptual,or immediate grasp of the world’s significations.7

The experience of meaning fragmentation is,in the case of Robert, linked to a lack of “per-spectival abridgement,” a lack of a dominantpoint of view, blocking out potential rival per-spectives and necessary for fluid attunement tothe world (Sass 1992). Such abridgement canonly be realized in the experiential medium ofreliable selfhood. Disturbances of presence andfragmentation of immediate meaning are usuallyassociated with hyper-reflexive forms of aware-ness (Case 1), discernible in the emotional life,perception, cognition, and action (see also be-

low). Hyper-reflexivity refers to forms of exag-gerated self-consciousness in which a subject takesitself as its own object (Sass 1992).

Most likely, the disturbances of presence con-stitute a foundation of the more explicit andarticulated anomalies of selfhood described inthe following sections.

Sense of Corporeality and ItsAlterations

In incipient schizophrenia, there is a variety ofdissociations of the bodily experiential modes, witha striking tendency to experience one’s body pre-dominantly as an object, i.e., there is an increas-ing experiential distance between subjectivity andcorporeality. The following vignette illustrates manyexperiential aspects of such a fissure or disjunction.

Case 2. “I am no longer myself . . . .I feelstrange, I am no longer in my body, it is someoneelse; I sense my body but it is far away, someother place. Here are my legs, my hands, I canalso feel my head, but cannot find it again. I hearmy voice when I speak, but the voice seems tooriginate from some other place.” He has diffi-culty in localizing his own person: “Am I here orthere? Am I here or behind?”

When he does something, he has a feeling ofobserving his actions as a witness without beingactively involved: “One might think that my per-son is no longer here . . . .I walk like a machine; itseems to me that it is not me who is walking,talking, or writing with this pencil. When I amwalking, I look at my legs which are movingforward; I fear to fall by not moving them cor-rectly.” When he watches himself in a mirror, heis afraid of staying there or is not sure on whichside of the mirror he actually is . . . .

His reason is intact; he knows very well thathe is himself (Hesnard 1909, 138, our transla-tion and italics)

The most frequent early change is a sense ofbeing detached, disconnected from one’s body,which feels somehow alien or not “fitting” thesubject, e.g., a patient may say that he feels “as ifhis body was too small to be inhabited,” or assomehow indefinably uncomfortable to live with.


A more clear distortion of experience consistsof the loss of bodily coherence: Bodily parts arefelt as if they were disconnected or isolated fromeach other. This feeling may take an alarmingintensity, where the psycho-corporeal unity dis-integrates, a sense of fragmentation is accompa-nied by a (pre-)psychotic panic of literal dissolu-tion (“going into pieces”).

Yet another experientially more articulateddisturbance consists of a feeling of morphologi-cal change: the body or its parts feel heavier/lighter/smaller/larger/longer/shorter, a feeling thatmay be accompanied by optical illusions involv-ing an actual visual experience of bodily change.The most known of the latter is the “mirrorphenomenon” (“signe du miroir” [Abely 1930]or “Spiegelphänomen”), in which the patient in-spects his face in the mirror because of feelings ofself-alteration: The eyes may look dead, empty,the face may seem deformed; a more subtle vari-ety of this phenomenon consists of avoiding one’smirror image because it is perceived as somehowthreatening or provoking, of having difficulty inrecognizing oneself in photographs, or of becom-ing amazed by one’s look in the photographs.

Disturbance of subjectivity may manifest itselfin motor performance. Motor or verbal acts mayoccur without or despite the patient’s intention andinterfere with his actions or speech, but are notregarded as being made by some external forces.

Case 3. A former paramedic reported thatmany years before the onset of his illness, heoccasionally found himself (for example, whendriving in an ambulance and to the driver’s sur-prise) involuntarily uttering a few words entirelyunconnected with his occurrent thoughts. Hewould then immediately continue to speak in arelevant way or express a few clichéd remarks tocover up this embarrassing episode.

Motor block (complete blockage of intendedactions) occurs as a sudden and brief sense ofparalysis during which the patient is unable tomove or speak. Another and frequent phenome-non is the deautomatization of motor action inwhich habitual performances (such as dressingor teeth brushing) suddenly require conscious

attention and a sense of mental and physicaleffort as shown in the next case.

Case 4. A female library assistant reportedthat before the onset of her illness, she wasalarmed by a frequently recurring experience inwhich replacing returned books from a trailer tothe library shelves suddenly required attention.She had to think how she was to lift her arm,grasp a book with her hand, turn herself to theshelf, and so forth.

Stream of Consciousness and ItsAlterations

A fundamental change in the stream of con-sciousness in the early phases of schizophreniaconsists of an emerging experiential gap betweenthe Self and its contents (in a similar way asdescribed above for the changed sense of corpo-reality). Mental content becomes quasi-autono-mous, bereft of its natural dimension of myness.Thoughts may appear as if from nowhere, arefelt as ego-less, decentered from the Self, andmay sometimes possess an unusual significance(Conrad 1958). They interfere with the ongoingstream of thoughts (thought interference) andmay be described by the patient through specificprivate designations such as “automatic,” “acute”thoughts, or “thought-tics,” etc. The patient stillself-ascribes his thoughts as his own; their con-tent is often neutral, but there is no sense ofongoing inner resistance or mental struggle (as inthe case of obsessions).

Patients report increasing hyperreflexive ob-jectivation of the introspective experience. Innerspeech becomes transformed from a medium ofthinking into an object-like entity with quasi-perceptual characteristics (“Gedankenlautwer-den”). Other patients may exhibit a subtler spa-tialization of inner experience. They describe theirthoughts or feelings in physical terms, as if pos-sessing an object-like spatial quality (“mythoughts are dense and encapsulated”) or locatethem spatially (“my thoughts feel mainly in theright side of the brain” or “it feels as if mythoughts were slightly behind my skull”). Onepatient reported that her “experiential point ofperspective” (presumably her experiential “I-


pole”) felt “as if” spatially “shifted some centi-metres behind” (she had a feeling as if she lookedat the world somehow “more from behind”).

Shrinking of the sense of myness strips theexperience of its lived context, inviting an intro-spective, hyper-reflexive awareness (Case 1) (Sass1992a, 2000).

Case 5. If a thought passed quickly throughhis brain without him being fully aware of it, hewas forced to direct back his attention and scru-tinize his mind to know exactly what he hadbeen thinking. In one word, he was preoccupiedby the continuity of his thinking. He feared thathe may stop thinking for a while, that theremight have been “a time when my imaginationhad been arrested . . . .” He awoke one night andasked himself, “Am I thinking? Since there isnothing which can prove that I am thinking, Icannot know whether I exist.” In this manner, heannihilated the famous aphorism of Descartes(quoted in Hesnard 1909, 179, our translation).

Hyperreflexivity may have a compensatorynature, making up for enduring perplexity and“loss of natural evidence” (Blankenburg 1971)as in Case 6, or it appears as a more primaryaffliction as in Case 7 (both below). In conse-quence, the thinking processes lose the sense ofsubjective mastery and are experienced as in-creasingly alienated.

Case 6. A thirty-four-year-old university grad-uate reported that for many years trivial mattersfrequently came to occupy his mind. For exam-ple, while reading a novel written in the firstperson and encountering a sentence like “Shesaid that he must return tomorrow,” he immedi-ately started to reflect on the reasons for usingpersonal pronouns and to finally conclude that“It has something to do with communication.”He then turned his attention to the word “com-munication” and continued to think on the ne-cessity to communicate. He could also reflectupon the fact that the air distributed itself in therooms of his apartment. He called this type ofthinking, “chopping up a sentence, taking a wordout of its flow.”

Case 7. “I bypass a window display of a shopin which there are exposed bicycles and bicycleparts; [in a wheel] all the metal spokes cross eachother in sharp angles before they reach the axle . . .the axle turns around with the spokes. No, it isnot the axle that rotates; it is the bar, a piece ofsteel. The axle does not exist; it is just a mathe-matical line, perpendicular to the plane of thewheel that is determined by the spokes, by fortystraight lines. However, this is not necessary ei-ther: Only two lines are needed to determine aflat surface. And the circumference? 2πr is theexpression for the length of the felloe, or moreprecisely, for the theoretical circumference, out-lined by this inexact circle (i.e., the felloe). Arewe able to conceive an ideal line by paying atten-tion to the lines in nature? Is Spencer’s claim thatmathematics originates from experience and in-duction correct? . . . These associations . . . wouldnot seem to me as sick if I were able to masterthem, like someone who calmly reflects on thematters that he is working with, contemplatingsome professional problems. But when I am think-ing in this way, without being able to stop it . . . Ihave no mastery over the course of these ideas . . .it seems to me as if it is not me who generatesthem . . . ” (Hesnard 1909, 146, our translationand italics).

This state of mind may intensify into a thoughtpressure (“Gedankenjagen”), in which the pa-tient is overwhelmed by a myriad of unconnect-ed thoughts going in different directions; loss ofmeaning or lack of an organizing theme is acardinal feature of this symptom, in addition tothe fact that the contents may appear affectivelyneutral (as opposed to depressive ruminations).One patient reported a feeling “as if” his con-sciousness consisted of multiple emanating sourc-es, disconnected from each other and each “pul-sating” at its own pace. A seemingly oppositeexperience is of a thought block, in whichthoughts abruptly disappear from the stream ormore gradually fade away. A variant of this phe-nomenon is a sudden and total discontinuity ofself-awareness: The patient may report that forsome seconds he loses awareness of his activity,e.g., he does not know how and why he got from


his living room to the kitchen or he finds himselfsomewhere in the city without knowing how hegot there. Less characteristic phenomena com-prise difficulties in initiating and carrying throughthe thinking process: The patient may complainof a diminished ability to generate thoughts or of ageneral slowness of cognition and inability to reachthe desired goal (disturbances in thought inten-tionality and goal-directedness). Communicationof meaning to other people may also be distorted(disturbed self-expression). The patient has anexperience of a disaccord between his cognitive-emotional state and its outward expression. Heperceives his own behavior, gestures, facial ex-pression, or language as somehow disfigured andout of control, a condition usually associatedwith hyperreflexive forms of self-awareness.

Hyperreflexivity and diminished myness areoften associated with a peculiar splitting or adoubling of the Self (“Ich-Spaltung”) into anobserving and observed ego, neither of each as-suming ipseity function (Case 1). Such experi-ence becomes especially prominent immediatelybefore the onset of a frank psychotic episode. Itmay be felt as a form of inner struggle or anoscillation between the good and the evil “parts”or between different selves (which themselvesmay be described in spatialized terms). This is, atleast initially, felt and communicated on the “asif” metaphorical level. Normal processes of re-flection and imagination also involve an ego-split, but they possess a natural flexibility andhappen in a unified field of experience in whichthe sense of myness or self-presence never callsitself into question.

Self-Demarcation and Its AlterationsInability to discriminate Self from not-Self in

schizophrenia was described as transitivism byBleuler (1911). This phenomenon attracted at-tention by numerous authors, usually in connec-tion with psychotic symptoms such as delusionsof external influence, mind reading, thoughtbroadcasting, certain hallucinations, and psychot-ic “projection” in psychoanalytic terms (loss ofego-boundaries [Fenichel 1945]), and in connec-tion with the more recent neurocognitive investi-gations (Frith 1992). Typically, in the neurocog-

nitive literature the sense of mental self-posses-sion is regarded as being generated by inferentialself-monitoring mental processes. From a phe-nomenological perspective, the “me/not-me” de-marcation (deficient in transitivistic experience)is automatically constituted in every experience;such border is just an aspect of non-reflexiveself-awareness. Inferential reflection seems to ariseonly post hoc as a consequence of a deficientsense of myness (see also section 6) as in Case 8.

Case 8. A young schizotypal patient frequentlycontemplated his “ego-boundary.” He thoughtabout “this fluid transition between me and theworld”: “It must consist of a mixture of airmolecules, sweat droplets, and tiny fragments ofskin debris.”

In the prodromal phases of schizophrenia andin schizotypal conditions, one may observe sub-tle transitivistic phenomena that are purely expe-riential, that is, unaccompanied by delusionalelaborations (i.e., a “loss of reality testing”).Case 9 is paradigmatic of such experiences.

Case 9. A young man was frequently confusedin a conversation, being unable to distinguishbetween himself and his interlocutor. He tendedto lose the sense of whose thoughts originated inwhom and felt “as if” his interlocutor somehow“invaded him,” an experience that shattered hisidentity and was intensely anxiety provoking.When walking on the street, he scrupulouslyavoided glancing at his mirror image in the win-dowpanes of the shops, because he felt uncertainon which side he actually was. He used to wear awide and tight belt to feel “more whole anddemarcated.” He was very attracted to the phi-losophy of Merleau-Ponty, whom he consideredas the only philosopher who truly had graspedthe fundamental subject-object reversibility.

SolipsismMøller and Husby observed in their study

(confirming a common clinical experience) thatyoung pre-schizophrenic patients become preoc-cupied with philosophical, supernatural, andmetaphysical themes. It seems as if for many


patients a fundamental transformation of theirworldview is taking place: “Had to define andanalyze everything I was thinking about; needednew concepts for the world and human exist-ence; absorbed by new ideas or interests, gradu-ally taking over my way of life and thinking”(Møller and Husby 2000).

Anomalies in self-experience described in thepreceding sections motivate such a quest becausethe patient is shattered in the very foundation ofhis being and self-presence. He experiences phe-nomena, which are beyond commonsensical, nat-uralistic folk metaphysics: “Reality” is increas-ingly mind-dependent; “other minds” becomemalevolent projective constructions; causalityseems non-physical; the Self-World polarity orsubject-object articulation is blurred and self-awareness endures a transformation in which theconstitutive and therefore normally tacit mentalprocesses become available for an introspectivegaze (Parnas 1999b). The term “solipsism,” de-noting here a paradoxical mixture of increasingsubjectivization of the world and self-dissolu-tion, seems to capture such a position (Sass 1994).

Case 10. A young patient reported that hehad, in brief moments, a feeling that only theobjects in his current field of vision were real, asif the rest of the world, including most familiarplaces and persons, did not really exist. Probedabout suicidal intentions, he replied: “No, I couldnever kill myself. I can’t imagine the world notbeing represented [by me].”

It is the solipsistic sentiment that inspires thepatient to suspect an existence of a hidden onto-logical domain only accessible to him. Feelingsof centrality may be prominent in such conditions:

Case 11. A former physician, when workingin the emergency room of a small provincialhospital, experienced, during fleeting moments,a feeling that he was the only true doctor in theentire world and that the fate of humanity was inhis hands. He immediately suppressed this feel-ing as entirely nonsensical.

Case 12. When I hear a dog barking or a catscreaming far away, I instantly get a feeling that

they bark and scream at me. When I listen to theradio, I get this thought that one is trying to letme understand something. I know that it is purerubbish (Gross et al. 1984, 78, our translationand italics).

Mimetic experiences may occur and are usual-ly accompanied by a feeling of centrality: Thepatient, while in motion, experiences similarmovements of inanimate objects or of people. Hemay feel, in the “as if” mode, that he is somehowforced to imitate others or that others imitate him.

Case 13. Luc, age seventeen years, reports: “Imade the same gestures as others, but ahead ofthem.” Then he corrects himself: “following them,”but this does not seem satisfactory either. Hehesitates between these two versions and ends upchoosing the one in which he precedes the others(Grivois 1995, 107, our translation and italics).

Solipsism may be a source of a quite specifictype of subtle grandiosity observable in the schizo-phrenia spectrum conditions: The patient mayregard other people as pitiable, ontologically ig-norant morons, solely chasing the material as-pects of life. In the later, more chronic stages ofthe disease, the entire ontological-epistemologi-cal framework of experience, normally revolvingaround “naïve realism” (in the Western world),is dramatically transformed (Sass 1992b; Bovetand Parnas 1993), leading to “beliefs” that, on apurely contentual basis, are classified as the so-called bizarre delusions (defined as “physicallyimpossible”; American Psychiatric Association1994).

5. Transition to Psychosis andTypicality of SchizophrenicDelusions

We have so far described the anomalies ofself-experience that occur in the initial prodrom-al phase of schizophrenia and in schizotypal con-ditions. Yet, pre-schizophrenics and schizotypalpatients frequently manifest behavioral abnor-malities in early infancy and childhood. The over-all picture emerging from prospective studies onthe childhood antecedents of schizophrenia is


that impairments are detectable in several do-mains, even though their exact significance andtime sequences are unknown. There is evidenceof: (1) during infancy and childhood, erratic, zig-zag–like neuro-motor development, dysfunctionsin perceptual, cognitive, and motor domains, anddisturbed emotionality (Fish et al. 1992; Walkeret al. 1994); (2) during school-age, aggressivity,especially in boys, and introversion, especially ingirls, disturbed emotional rapport, formal thoughtdisorder (Parnas et al. 1982; Parnas and Jørgens-en 1989; Tyrka et al. 1995), disturbed interper-sonal relations and neo-phobia (Hartmann et al.1984); and (3) from age two to fifteen, linguisticdifficulties (Crow et al. 1995). These data sug-gest collectively that future schizophrenia spec-trum individuals are not only impaired in thecognitive-affective domain but also exhibit a gen-erally unstable perceptuo-motor organization(Parnas and Bovet 1995b; Parnas et al. 1996).These multi-modal disturbances precede and maybe associated with the anomalies of self-experi-ence. They may also be observed among geneti-cally predisposed (high-risk) children, who donot necessarily develop a long-lasting psychosis:

Case 14. Maria, now in late adolescence, bornto a mother with severe schizophrenia and placedin foster family care immediately after birth (andsubsequently adopted to the family), followed upregularly in an ongoing high-risk schizophreniaproject (Parnas and Carter, in press). During theneonatal period, she exhibited severe neuro-irri-tability, with difficulties of sleeping/eating rhythm,excessive screaming, and an inability to calmdown. At six-month psychological evaluation,there was no eye contact; similarly, a severe con-tact disturbance was noted at twelve-month eval-uation. At twenty-four months, psychological test-ing was impossible to carry out because ofpronounced restlessness and attentional difficul-ties. At thirty-six months, psychological assess-ment revealed severe but transient regression onmotor- and language-developmental assessment.

In early childhood Maria exhibited severe com-pulsive phenomena and a pronounced fragilityof the sense of selfhood, e.g., when given a doll-house as a birthday present, she was afraid of“not remaining Maria any longer.” At the age of

twelve, she had a brief psychotic episode, domi-nated by delusions (not fulfilling the diagnosticcriteria of schizophrenia), and was treated suc-cessfully with a small dose of an antipsychoticdrug. Since puberty, her condition was perma-nently marked by the lack of “natural evidence”(hyper-reflexivity and a tendency to ask ques-tions concerning self-evident matters) and a fra-gility of the sense of Self (e.g., worried aboutchanging into someone else because of physicalchanges linked to puberty; yet she was cognitive-ly well aware of the absurdity of such worries).Her academic school performance is now excel-lent; she functions well among her peers, hasseveral girlfriends, and apart from certain fragil-ity of self-hood and a tendency to hyper-reflexiv-ity, she has no psychiatric symptoms.

In the psychotic phases of schizophrenia, self-disorders become thematized in the emergence ofdelusions, hallucinations, and passivity phenom-ena. The patient loses his sense of autonomy andfeels “at the mercy” of the world (“Beeinflus-sungsstimmung”). Pervasive sentiment of cen-trality and self-reference (to the point of literalresonance between inner experience and externalworld events) precedes the emergence of psy-chotic phenomena (“Anastrophé”: Conrad 1958).Many such symptoms involve fundamental alter-ations of the sense of possession and control ofone’s own thoughts, action, sensations, emotions,and bodily experience (Scharfetter 1980). Thesepsychotic experiences of self-dissolution seem toarise on the background of more primary andsubtler disturbances in presence and in otherdisorders of Self described in the preceding sec-tion. The following retrospective reconstructionof the evolution symptoms illustrates a transitionfrom a prodromal phase into a frank psychosis.

Case 15. Peter’s history of illness:

January 1985: “strange change is affecting him,”feels “self-disgust,” has “lost contact to him-self”

August 1985: increasingly preoccupied by exis-tential themes and Indian philosophy, “per-haps meditation could help,” increasingly iso-lated


January 1987: feels fundamentally transformed,“something in me has become inhuman,” “nocontact to his body,” “feels empty,” has to“find a new path in his life”

January 1988: is of the opinion that Indians aresuperior compared to other human races; theyperhaps have a mission to save our planet

September 1992: preoccupied by recurringthoughts about extraterrestrials

January 1993: is convinced that Indians are rein-carnated extraterrestrials

April 1994: feels that he is being brought hereeach day from another planet to assist Indiansin their salvatory mission; delusions of exter-nal influence

June 1994: first admission to a psychiatric wardat age twenty-four (Møller 2001; details add-ed after pers. comm.)

We notice here that the initial and ineffableself-transformation is progressively articulatedand thematized: new interests in existentialismand Buddhist philosophy reflect the emergenceof charismatic and eschatological preoccupations.In the operational psychiatric terminology, theinitial self-disturbances evolve through “odd orovervalued” ideas and culminate in the emer-gence of “bizarre delusions.”

Müller-Suur (1950, 1954) and Kepinski(1974), among others, have observed that thereis a characteristic metaphysical coloring of thecontent of delusions in schizophrenia, which helpsus to distinguish them from non-schizophrenicdelusions, a taint, in our view, closely linked tothe solipsistic position. According to the DSM-IV or ICD-10, many examples from the “schizo-phrenic world” would be considered as bizarredelusions on the face of their implausible, or asJaspers would have said, impossible content.However, that which is perceived as bizarre isnot only the content in itself, but also a form ofthe patient’s experience transparent through thecontent (Sass 1992b; Bovet and Parnas 1993).The “metaphysical taint” in schizophrenic delu-sions conveys something to us about the natureof the relatedness between the Self and the world.It is therefore not a perception per se of theworld, nor a conviction per se of the subject,which qualifies such delusional statements as

schizophrenic, but rather a Gestalt reflecting thedisturbance of the “Self as a founding instance”(Blankenburg 1988), which is perceivable bothin the subject’s perception and conviction. Whatwe are confronted with in the delusional trans-formation is, therefore, a phenomenon of emer-gence: the emergence of an entirely new existen-tial paradigm.

6. Cognitive Approaches toSchizophrenic Delusions: APhenomenological Appraisal

We will now briefly address the dominantaccounts of schizophrenic delusions, that are ar-ticulated in the “information processing” cogni-tivist framework, to provide a contrast to ourown phenomenological approach.

Current neuro-cognitive approaches to delu-sion formation broadly fall into an empiricist orrationalist tradition, a dispute mirroring the de-bates that already surfaced throughout the nine-teenth century’s French psychiatry (Rigoli 2001)and occupied a prominent position in the Ger-man psychiatric discourse until World War II(Schmidt 1940). Certain problems that confrontboth approaches include:

(1) The lack of any adequate formal definition ofdelusion (Jaspers 1923; Schmidt 1940; Spitzer1990; Parnas and Bovet 1995a). This crucial con-ceptual lacuna is frequently ignored in the face ofclinical or theoretical demands.

(2) A tendency to treat delusion as a homogenousphenomenon, when, in fact, the pathways leadingto delusion may be different in different disordersor even within the same disorder.

(3) The extreme ambiguity and obscurity of the con-cept of “belief” (Needham 1972), a concept cen-tral to both cognitive science and analytic philoso-phy of mind and obviously crucial to the topic inquestion.

(4) Reliance by both approaches on a modular theoryof mind, now largely forsaken by its major archi-tect on theoretical grounds (Fodor 2001), andwhose applicability to schizophrenia is increasing-ly questioned in the neuroscientific literature (Par-nas et al. 1996; Andreasen et al. 1998), mainlybecause neuropsychological studies of schizophre-nia fail to identify a consistently focal dysfunc-tion; rather, they demonstrate multiple and wide-


spread deficits (Mohamed et al. 1999; Parnas etal. 2001).

(5) A correlated reliance on the so-called “symptomapproach,” i.e., addressing pathogenesis of isolat-ed symptoms, rather than syndromes.

(6) A tendency to waver between phenomenologicaland sub-personal claims: Usually, if the phenome-nological account appears incoherent or inconsis-tent with clinical evidence, recourse is made tohypothetical neural mechanisms (e.g., the notionof “efferent copy”; see below).

(7) As already mentioned, studies of the advancedillness stages have limited explanatory power: Toidentify, say, a particular cognitive style amongdeluded people does not show that this particularstyle is, in fact, a necessary causal factor in theformation of delusion (instead of being, say, aconsequence).

The empiricist approach to delusions empha-sizes a peripheral deficit in the attentional orperceptual processes, leading to explanatory at-tempts in the form of delusions. Maher (1988)elegantly formulated this approach with a specif-ic focus on the logic of explanation, an approachalready proposed by Wernicke (1900) in his no-tion of “explanatory delusions” (Erklärungswahn).

Delusions are best thought of as theories—much likescientific theories—that serve the purpose of provid-ing order and meaning for empirical data obtained byobservation. Delusional theories . . . should developwhenever there is (1) a real impairment in sensoryfunctioning . . . , (2) a defect in the processes thatselect incoming information for processing (i.e. anattentional deficit), or (3) the experience of distur-bance in personal expressive behavior, such as lan-guage disturbances or motor impairment . . . . Adelusional theory, like other theories, is not readilyabandoned . . . . (This fact) merely tells us that delud-ed patients are like normal people—including scien-tists—who seem extremely resistant to giving up theirpreferred theories, even in the face of damningly neg-ative evidence (Maher 1988, 20–22, italics added).

Maher’s argument is a variant of a more gen-eral empiricist, and basically a dualist, assump-tion that human transactions with the world canbe adequately reduced to a logical processing ofatomistic sensory input:

Each of us lives within the universe—the prison—ofhis own brain. Projecting from it are millions of frag-ile sensory nerve fibers, in groups uniquely adapted tosample the energetic states of the world about us:

heat, light, force, and chemical compositions. That isall we know of it directly: all else is logical inference(Mountcastle [1975] quoted in Popper and Eccles[1981, 274], our italics).

Yet, it is doubtful whether humans are solipsisticentities whose dealings with the world only de-pend on theories that are either verified or dis-proved by sensory evidence. Even in the case ofscientists, there can be no talk about solipsism,because, either consciously or not, scientists arecommitted to a certain paradigm (Fleck 1935;Kuhn 1970). What Kuhn calls a “disciplinarymatrix,” i.e., “the entire constellation of beliefs,values, techniques, . . . shared by the members ofa given community” (Kuhn 1970, 175) consti-tutes the intersubjective horizon of scientific en-deavor. It is precisely due to such a horizon thatobservations that contradict theories are usuallyignored until serious problems arise and lead to atransformation of the entire paradigm.

However, phenomenology would also arguethat intersubjectivity is already operative at thelevel of the perceptual process itself. First, per-ception is not of atoms of sensory data; rather, itis a perception of a perceptual field, the latterbeing immersed in the “primary experiential da-tum” of the experiential (lived) world, which is a“unity of concordant total actuality, which iscontinually re-established in the course of ourexperiences” (Husserl 1962, 44). Second, themajority of objects that surround human beingspossess a reference of use, be it as tools, artifacts,or affordances. Third and most importantly, phe-nomenology emphasizes the role of intersubjec-tivity in the very nature of intentional relation tothe world. The subject is intentionally directedtoward objects whose horizonal, incomplete wayof givenness attests to their openness for othersubjects. My perceptual objects are not exhaust-ed in their appearance for me; rather, each objectalways possesses a horizon of coexisting profiles,which although being momentarily inaccessibleto me—I cannot see the front and the back of achair simultaneously—could very well be per-ceived by other subjects. Since the perceptualobject is always there for others too, whether ornot such other subjects are de facto physicallypresent, the object refers to those other subjects


and is for that reason intrinsically intersubjective(Zahavi 2001).

Therefore, the fundamental weakness in Ma-her’s theory is the absence of explicit reference tointersubjectivity in the co-constitution of percep-tion. Maher’s analogy between the creation ofscientific theory and delusion formation is alsofundamentally inadequate as far as schizophre-nia is concerned. It fails because, whereas a sci-entist is committed to his paradigm that is hisscientific community’s set of beliefs, a schizo-phrenic is weakened in his intersubjective ties.Otherwise, he would have consulted an ophthal-mologist for his perceptual aberrations insteadof proceeding to develop delusions. Moreover,schizophrenic delusions are not encapsulated orisolated islands of mental activity to fit singlydisordered perceptions, but possess a global anddiffuse quality. It is therefore impossible to com-prehend delusional transformation in schizophre-nia without explicit reference to the solipsisticpredicament of a pre-schizophrenic.

The approaches we term rationalist are thosethat ascribe schizophrenic delusion to a disorderof some central or intellective capacity, such asinferential or probabilistic reasoning, abstrac-tion, attributional style, or self-awareness.

Garety and Freeman (1999) show that schizo-phrenic patients (mostly of the paranoid type)seem to demonstrate a “jumping-to-conclusions”data-gathering bias and are especially “ready toabandon existing hypotheses and form new ones,again on the basis of little evidence” (131); bothobservations merely reflect the clinical, defini-tional aspects of being deluded.

Stone and Young (1997), citing Fodor (1989),invoke a distinction between two potentially com-peting constraints on belief formation: “observa-tional adequacy,” which refers to reliance onperceptual input, and “conservatism,” which re-fers to maintaining consistency with the body ofaccepted beliefs. Belief formation typically in-volves appeal to both factors, which exist in amutual dynamic equilibrium that is highly con-text-sensitive. Stone and Young make the com-pelling argument that explaining many delusions(presumably also in schizophrenia) may requirepostulating two necessary factors: not only an

alteration of perceptual input, but also a cogni-tive bias, namely, a disequilibrium between thetwo just-mentioned factors that allows uncon-ventional ideas to be accepted and held.

Our own approach would certainly not denythe importance of biases in reasoning. We are,however, inclined to interpret these biases in asomewhat different way. We prefer a less cogni-tivist or mentalistic interpretation that more di-rectly acknowledges the social or intersubjectivenature of human judgment and reasoning. Itwould not, then, be a matter of cognitive princi-ples or intellectual rules so much as of whatmight be termed general existential orientations:the difference between an attitude that is funda-mentally constrained by the intersubjective ma-trix, as opposed to a solipsistic or quasi-solipsis-tic orientation that relies almost exclusively onexperiences that might well be unique to oneselfand in which the automatic or pre-reflective graspof the world’s significations is impaired (Parnasand Bovet 1991; Bovet and Parnas 1993; Sass1994: re the quasi-solipsistic experiences de-scribed above). What Stone and Young (1997)characterize as the favoring of observational ad-equacy over conservatism can equally be under-stood as the manifestation of a relative indiffer-ence to the social world (Stanghellini 2000).

Another type of rationalist approach to delu-sion is Frith’s hypothesis of a deficient “meta-representational” capacity. Frith (1987, 1992)suggested that many “first rank symptoms” ofschizophrenia, involving loss of the sense of con-trol or possession of one’s own thoughts or move-ments, result from a defect in the central moni-toring of one’s own intentions that is itself theexpression of a neurologically based degradationof the “efferent-copy” signal, although he ac-knowledged that his theory did not seem able toaccount for the full range of schizophrenic symp-toms (Frith and Done 1989, 569). For example,a delusion of thought insertion is claimed to ariseupon a mismatch between the efferent copy of“the intention to think” and the actual, occur-rent thought, a mismatch supposedly detected bya “comparator” or a “self-monitoring” module.

Frith’s model seems to us problematic on phe-nomenological and theoretical grounds (see Gal-


lagher 2000, for a detailed critique). First, it isdifficult to envisage an intention to think beforethinking itself, unless the intention to think is thethinking itself, in which case we are confrontingan infinite regress. Yet, Frith speaks of a con-scious “feeling of effort” or intention to think(“willed intention”) and associates this with aconscious monitoring of efferent copy; thus hisanalysis relies, not just on a hypothetical sub-personal intention to act or think, but on theawareness of such intentions (the sub-personallevel is invoked by Campbell [1999] in a friendlyrescue operation). This awareness, or “meta-rep-resentation,” is the ability to reflect on our repre-sentations of the world and to introspect ourthoughts, but such proliferation of cognitive meta-levels is more characteristic of schizophrenia (Sass1992a) than of the normal cognition where think-ing is not preceded by intentions to think orfollowed by introspective scrutiny. On theoreti-cal grounds, it is difficult to understand how anautomatic (and therefore primitive) self-moni-toring module should possess a capacity neededto assess a potential match between a copy ver-sion of thinking and the actual thinking, becausethe assertion of identity in this case can only beachieved through a semantic, contextual evalua-tion. It is therefore not at all obvious that anotion of reflexive meta-representation makessense in relation to efferent feedback, which, infact, is a far more basic and low-level capacitythat is believed to operate throughout much ofthe animal kingdom and is perhaps present evenin the fruit fly (Currie 2000, 173).

In the 1992 monograph, Frith argues that thedeficiency of central monitoring should be un-derstood in explicitly representational terms,namely, as “an inability to represent our ownmental states, including our intentions,” that is,to “mentalize.” Frith seems to have been im-pressed by certain affinities between schizophre-nia and childhood autism and proposed thatschizophrenic individuals might suffer from anunderlying disorder similar to that characteristicof autism, namely, a deficit in “theory of mind,”in the person’s ability to be aware of the natureor perhaps even the existence of one’s own men-tal states and those of other people.

The notion of a disturbed capacity for aware-ness of mental states allowed Frith to extend hisexplanation of schizophrenic delusion beyondSchneiderian symptoms to include delusions ofreference and persecutory delusions; the latter,he argues, may often involve the patient’s at-tempt to explain his inability to ascertain themental states of others as, for example, when apatient who finds herself unable to “read” orinfer the intentions of other people, comes tobelieve that others are actually disguising theirthoughts and perhaps conspiring against the pa-tient (Cahill and Frith 1996, 384; Corcoran et al.1995; see Kinderman et al. [1998] for a critiqueand Garety and Freeman [1999, 121], concern-ing the dearth of evidence of a specific theory-of-mind deficit in paranoid patients).

Both types of phenomena to which Frith drawsour attention—a diminished sense of personalintentionality and difficulties in interpersonalunderstanding—are key features of schizophren-ic pathology, and both seem likely to play asignificant role in delusion formation and main-tenance. It is not, however, clear that Frith’s useof his overarching concept of a meta-representa-tional disturbance is either coherent or apt. Theconcept of meta-representation clearly impliessome kind of higher-level capacity for self-con-sciousness or meta-awareness, reminiscent, per-haps, of neurologist Kurt Goldstein’s notion ofthe abstract attitude or the Piagetian notion offormal operations. It is true that Frith (Frith andCorcoran 1996) does allow for the possibility ofa misuse or distortion rather than a straightfor-ward decline in meta-representation. In this way,however, the notion of incapacity for meta-rep-resentation seems to be stretched almost to thebreaking point, with disturbances of a hypothe-sized meta-representational module now seem-ing able to describe just about any kind of distur-bance of normal interpersonal cognition orunderstanding. In any case, in his actual descrip-tions, Frith often stays rather close to the deficit-construal: Thus Frith describes schizophrenics asbeing “unable to reflect (consciously) upon theirown mental activity (due to abnormalities in themechanism for meta-representation)” (Mlakar etal. 1994, 557). He writes that, since such persons


are unaware of their goals, they would be “slave[s]to every environmental influence or, on the otherhand, be prone to perseverative or stereotypedbehavior, because they would not have the in-sight to recognize that certain goals were unob-tainable or inappropriate” (Frith 1992, 151).Frith’s characterization of the schizophrenic dis-turbance of meta-representation generally sug-gests a diminishment of the highest and mostquintessentially human aspects of the psyche,including the ability to read the thoughts orintentions of others and, above all, to engage inself-conscious or introspective forms of awareness.

The concept of meta-representational deficitseems quite problematic as an explanation of thedifficulties with interpersonal cognition or un-derstanding that are prominent in schizophrenia.In contrast with childhood autism, the theory-of-mind deficit is not, in fact, found in all or nearlyall schizophrenic patients, but only in those withprominent disorders of thought and language,and even there (also unlike in childhood autism),it seems to be a state rather than a trait variable(Drury et al. 1998; Sarfati and Hardy-Bayle1999). Like infantile autists, some schizophren-ics make errors on theory-of-mind tasks; butunlike autists, schizophrenics are prone to offervarious kinds of unconventional or erroneousresponses, rather than just those that suggest afailure to mentalize (Sarfati et al. 1997, 12).Some researchers argue, in fact, that the theory-of-mind deficit that may sometimes occur in someschizophrenic individuals is actually a conse-quence of more general cognitive disturbancesinvolving attention or working memory (Druryet al. 1998; see also Davis and Pratt 1995).

In the context of childhood autism, the notionof a “theory of mind” deficit involving loss ofmeta-representational capacity has, perhaps, acertain plausibility. (However, see Gallagher[2001] for a succinct phenomenological critiqueof the cognitivist “theory of mind” approaches.)In schizophrenia, however, as we have pointedout, we are hardly faced with an absence or evendiminishment of “mentalizing” or of the capaci-ty for self-consciousness: Consider, for example,that the world of the paranoid schizophrenicmay well be bristling with complex, and oftenmalevolent, mental or intentional states, frequent-

ly experienced as being directed toward the pa-tient, and that schizophrenic persons often dem-onstrate an exaggerated and all-encompassingkind of self-consciousness (see Sass 1992a andalso cases 1, 6, and 7 above).

The incapacity-for-meta-representation viewseems very far from the clinical realities of thesepatients and is vulnerable to many of the criti-cisms that have been directed at prior attemptsto characterize schizophrenia as a kind of de-mentia or organic-like concreteness (Sass 1992).

Another problem is that certain key distur-bances of schizophrenia do not seem likely to beexplicable in these top-down terms: How, forinstance, would a disturbance of meta-represen-tation account for the deficient pre-reflective at-tunement to the world, motor awkwardness, andperceptual distortions so characteristic of thesepatients?

We would also note that schizophrenics are justas inclined to see things as persons as to see personsas things, and that they are more often hyperab-stract than hyperconcrete, which includes a prone-ness to excessive philosophizing or pseudo-phi-losophizing. It is too strong to say that thesefeatures of schizophrenia actually contradict Frith’semphasis on a meta-representational disturbance.There is, however, nothing in Frith’s theory thatseems able to give much of an account of theseprominent and distinctive aspects of the illness.

Our own view of schizophrenia as a self-dis-turbance places greater emphasis on more low-level or immediate disturbances of consciousnessthat affect both ipseity and the basic, pre-reflec-tive relatedness to the world. One of Minkows-ki’s (1927) patients expressed this predicamentvery precisely: “I feel that I can reason quite well,but only in the absolute, because I have lostcontact with life.”

8. Implications

Contrary to the classical view, schizophreniais portrayed here as a disorder of consciousness,although certainly of a different kind than pa-thologies observed in the organic delirious con-ditions. The essential phenomenological features,in the form of self-disorders, are already presentin the very first stages of the illness. Psychotic


developments seem to take place as progressiveorganizations of novel coherence patterns withvarious degrees of stability and temporal con-stancy, organizations that articulate themselvesaround the fundamental alterations of Self-Worldrelatedness (Bovet and Parnas 1993; Parnas2000).

An emphasis on the pathogenic import of self-disorders allows one to see the schizophreniaspectrum disorders as something other than acontingent agglomeration of essentially discon-nected symptoms held together by a convention.Rather, these disorders may constitute a unitarygroup, qualitatively distinct from the affectiveand organic disorders, and organized around thedisorders of the Self (Parnas 1999b; Sass andParnas, submitted). Such a unitary view is, ofcourse, not new. It was behind countless attemptsto extract a specific, unifying Gestalt from thepolymorphic picture of schizophrenia (e.g., Wyr-sch 1946), although, as aptly commented by Bleu-ler, this Gestalt is quite elusive: “The disease ischaracterized by a peculiar transformation offeeling, thinking and perceiving, found nowhereelse in this particular fashion” (Bleuler 1911).

Etiological research, if guided by phenomeno-logical concerns, should focus on the early illnessstages and even on its earlier, infantile antecedents.Developmental trajectories in infants and chil-dren at high risk for schizophrenia should be stud-ied in conjunction with studies of the normalontogenesis of Self and perception. A multidisci-plinary framework, with focus on infantile selfhood(Stern 1985; Rochat 1995), might be an appro-priate framework for such a research program.

Notes1. The notion of prodrome refers to a heralding of

imminent psychosis and involves a change from thehabitual way of experiencing and acting. The averageduration of a pre-schizophrenic prodromal phase isfour to five years (Huber et. al. 1979).

2. The expression “basic disorder of personality,”also used in the ICD-8 and 9, refers to universal,impersonal aspects of a person, i.e., the fundamentalstructure of the Self, and not to individuated, uniquepersonality features.

3. Early misdiagnosis may also be attributed to awidespread ignorance of the non-psychotic subjectiveexperience in schizophrenia.

4. The term “luminosity” indicates a fundamentalmode of self-awareness, equal to the very being oremergence of consciousness. It is different from theconcept of “clarity” (disturbed in delirious conditions);luminosity is a condition of the latter. It denotes acertain welling up of (self)-awareness, its phenomenal-ity (Henry 1963). Naturally, a sense of presence and asense of embodiment are closely inter-related, yet wehave decided to describe these two separately to im-pose a certain simplified taxonomy on the presentedmultitude of anomalous experiences.

5. Apart from this disjunction of perception, Robertis spared for perceptual anomalies, which are neverthe-less quite common at this stage (especially in the visualmodality): instability or deformation of the perceptualobject, sometimes associated with instability of per-spective (e.g., the patient feels “as if” he was lookingfrom the position of his shoulder), dissolution of Ge-stalt, physiognomization of the world, and increasingor decreasing perceptual intensity and clarity.

6. This is, incidentally, similar to a phrase used byBinswanger to describe the nature of schizophrenia asan inconsistency of natural experience: “that inabilityto ‘let things be’ in the immediate encounter withthem” (Binswanger 1963, 250).

7. The phenomenological concept of “commonsense” is similar to the notion of “background capaci-ties” proposed in the analytic tradition by John Searle(1992).

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