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Schizophrenia Bulletin, Vol. 29, No. 3, 2003 Sass and Parnas
point of our phenomenological analysis will be to reveal view, schizophrenia is a disorder involving subtle but per-
the superficiality of this tripartite distinction and to pre- vasive and persistent aspects of subjective experience;
vent it from obscuring underlying affinities and forms of hence any adequate conceptualization of its nature or
interdependence among these domains. boundaries requires—among other things—the adoption
Our second purpose is to draw attention to clinical of a phenomenological approach (Sass 1992a; Parnas and
manifestations of self-disorders that may be detectable at Zahavi 2002).
prodromal and even premorbid phases of the illness and We argue that, although the major symptoms and
that may reflect or constitute generative disorders at the signs of schizophrenia are heterogeneous in many
core of the illness. This is a task of obvious significance respects, they can nevertheless be understood in a fairly
given recent recognition of the importance of early diag- unified way. Schizophrenia, we propose, is a self-disorder
nostic detection and therapeutic intervention in schizo- or, more specifically, an ipseity disturbance in which one
phrenia (McGlashan and Johannessen 1996; Yung and finds certain characteristic distortions of the act of aware-
McGorry 1996; McGorry and Jackson 1999) and the ness. Ipseity refers to the experiential sense of being a vital
unavailability of clinically useful and accurate predictors and self-coinciding subject of experience or first person
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Schizophrenia, Consciousness, and the Self Schizophrenia Bulletin, Vol. 29, No. 3, 2003
IPSEITY =
The experiential sense of being a vital and self-identical subject
of experience or first person perspective on the world
spatiotemporal objects of the natural world, as "things" tal feature of consciousness is its object-directedness or
amenable to the same descriptive approach used in intentionality, the fact that consciousness is always a con-
describing a stone or a waterfall. Karl Jaspers (1963) pro- sciousness of something—that is, it has an intrinsically
posed a more restrictive use of the term phenomenology as self-transcending nature (in this specific philosophical
a study of inner experience. Our use of this term refers to sense, "intentionality" does not mean volition): one does
an endeavor inspired by phenomenological philosophy, a not merely love, fear, see, or judge; one loves, fears, sees,
tradition specifically aiming at grasping the essential or judges something. Thus consciousness is not a self-
structures of human experience and existence, both normal enclosed Cartesian theater cut off from the world but is
and abnormal (see Parnas and Zahavi 2002 for a compre- intrinsically directed toward and embedded in the world.
hensive account of phenomenology in psychiatry; see Sass Phenomenology distinguishes between a thematic,
and Parnas, in press; Sass 1992b; Petitot et al. 1999; explicit, or reflective intentionality (e.g., when I look at
Sokolowski 2000). this chair to the left from me) and a more basic, nonreflec-
Phenomenology calls attention to the fact that it is tive or tacit sensibility—called "operative intentionality"
possible to investigate consciousness in several ways. One (Merleau-Ponty 1962, p. xviii)—that constitutes our pri-
may consider it not only as an empirical object endowed mary presence to the world. Operative or prereflective
with mental properties, as a causally determined object in intentionality is the mode in which habits and dispositions
the world, but also as the subject of intentional directed- come to be sedimented; it furnishes the background tex-
ness to the world—that is, as the subject for the world or, ture or organization of the field of experience and thus
to paraphrase Wittgenstein (1922), the limit of the world. serves as a necessary foundation for more explicit or voli-
The term phenomenon refers to that which shows itself, tional acts of judgment, perception, and the like.
which manifests itself as an appearance; and conscious- A phenomenological analysis typically focuses less on
ness is a condition of such manifestation. Consciousness the contents than on the form of awareness (Jaspers 1963,
does not create the world but is the enabling or constitutive p. 59; Parnas and Zahavi 2002). This includes the mode of
dimension, the "place" in which the world is allowed to presentation of an appearing object—for example, the
reveal and articulate itself. If anything ever appears at all, experienced differences between an imagined house and a
it always appears in the medium of consciousness. Viewed perceived house, which Husserl (phenomenology's
as the constitutive dimension of appearing, consciousness founder) referred to as noematic aspects; and the subjective
is not considered as a container filled with separable, sub- processes or structures that make these appearings possi-
stantial, "thing-like" components in causal interaction. It ble, which are known as the noetic aspects. ("Noesis"
is, rather, a meaningful and dynamic network of intertwin- refers to the act of consciousness and "noema" to its inten-
ing acts, themes, motivations, and so on, largely connected tional correlate, viz. the object and world of which we are
by relations of mutual implication, and grounded in inter- aware [Bemet et al. 1993; Sokolowski 2000, p. 59f].) The
subjective frameworks and bodily propensities and expec- noetic structures of interest include the various modes of
tations that are gradually built up over time. A fundamen- intentionality (e.g., perceiving vs. remembering vs. fanta-
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Schizophrenia Bulletin, Vol. 29, No. 3, 2003 Sass and Pamas
sizing) as well as certain structures of ongoing self-aware- the correlative sense of the existence of the world), which
ness and embodiment whose distortion we consider funda- is more basic than the sense of continuity over time or any
mental in schizophrenia. sense of social identity. (Note that dissociative identity
In our everyday transactions with the world, the sense disorder patients, who lack continuity of self, generally
of self and the sense of immersion in the world are insepa- have little or no disturbance in their moment-to-moment
rable; we are self-aware through our practical absorption ipseity.)
in the world of objects. "Subject and object are two The forms of awareness inherent in the act or arc of
abstract moments of a unique structure which is presence," awareness are illuminated by the philosopher Michael
writes Merleau-Ponty (1962, p. 430). From a phenomeno- Polanyi's (1964, 1967; Grene 1968) notion of a continuum
logical standpoint, we can distinguish two interdependent stretching between the object of awareness—which is
aspects of the intentional act: a prereflective embedded- known in a focal or explicit way—and that which exists in
ness in the world along with a tacit or prereflective self- the "tacit dimension"—that is, that which is experienced
awareness or ipseity. We may speak of a prereflective self- in what Polanyi terms a more subsidiary, implicit, or tacit
awareness whenever we are directly, noninferentially, or manner. We have tacit awareness of the perceptual back-
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Schizophrenia, Consciousness, and the Self Schizophrenia Bulletin, Vol. 29, No. 3, 2003
symptoms reflect, respectively, an excess and a lack, with their illness and that, at times, many patients will simulta-
the deprivative a preceding each function that is suppos- neously manifest symptoms from two or even all three of
edly lacking (anergia, avolition, etc.). The concept of neg- the syndromes (Andreasen 1985; Liddle 1987, p. 150;
ative symptomatology is often said to be perfectly atheo- Maurer and Haefner 1991). Given these well-established
retical, merely a behavioral description. Actually, facts, it is now generally accepted that the positive, nega-
however, the overt behavioral lack at issue is often taken tive, and disorganization syndromes do not represent dis-
to indicate an underlying and fundamental diminishment tinct types of schizophrenia. It is often assumed, however,
of an "inferred function one normally expects to be pre- that they do reflect "discrete pathological processes occur-
sent" (Sommers 1985, p. 368; Dworkin et al. 1998, p. ring within a single disease" (Liddle 1987, p. 150). Cahill
393)—namely, a paucity of psychological activity or sub- and Frith (1996) state, for instance, that their modular,
jective life, and in particular of the higher mental symptom-oriented model implies that "persons experienc-
processes involving self-awareness, reasoning, abstrac- ing 'negative' symptoms could not also experience 'posi-
tion, complex emotional response, or volition (e.g., Cahill tive' symptoms" (p. 392). We shall argue that it may gen-
and Frith 1996; see also DSM-N regarding "diminution or erally be more appropriate to think of positive, negative,
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Schizophrenia Bulletin, Vol. 29, No. 3, 2003 Sass and Pamas
(Frith, 1994, p. 154). (For criticisms of the metarepresen- 1998, on the relevance of these cognitive abnormalities for
tation notion, see Campbell 1999; Currie 2000; Gallagher a disrupted sense of self). Because the latter category of
2000; Parnas and Sass 2001.) input includes kinesthetic sensations and other self-
In our view, these manifestations of external influence directed experience, this lack of habituation or disattend-
and diminished self-possession are open to a kind of psy- ing could provide the source of the hyperreflexive sensa-
chological comprehension. But, far from involving dimin- tions (automatic or "operative" forms of hyperreflexivity)
ished capacity for self-conscious awareness, the ipseity that soon come to attract more volitional forms of atten-
disturbance is actually associated with an exaggerated tion ("reflective" hyperreflexivity [Merleau-Ponty 1962, p.
self-consciousness that is rooted in diminished self-affec- xviii; Sass 2000]). It is interesting that this progressive
tion and hyperreflexive distortion of the normal structure process—from mild to extreme estrangement—seems to
of awareness. To understand how exaggerated self-con- be potentiated by the adopting of a passive, observational
sciousness could be associated with diminished self-affec- stance and that many schizophrenia patients are able, at
tion and disturbed ipseity, it is useful to recall Polanyi's times, to minimize such symptoms by throwing them-
account of the role of tacitness in the act of awareness. As selves into some kind of habitual and unthinking activity
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Schizophrenia, Consciousness, and the Self Schizophrenia Bulletin, Vol. 29, No. 3, 2003
usually serves as the tacit medium of thinking itself. These negative symptoms in schizophrenia are not, in fact,
peculiarities include omission of explicit causal and logi- straightforward deficit states but involve the presence of
cal connections, a tendency to presuppose rather than positive aberrations of various kinds.
assert, and absence of explicit markers of identity of Recent findings show, for instance, that whereas sub-
speaker, listener, time, or place (Vygotsky 1962; Sokolov jective and objective reports of negative symptoms are
1972; Sass 1992a, p. 194). The specific content of the highly correlated in cases of depression, they may not be
audioverbal hallucinations is also relevant. Among the correlated in schizophrenia (Selten et al. 1998, 2000a).
most characteristic auditory hallucinations in schizophre- There is no correlation, for example, between the level of
nia are a voice describing the patient's ongoing behavior distress associated with negative symptoms and their
or experience, and two or more voices discussing the observed severity (Selten et al. 2000fc). Also, whereas
patient in the third person. Whereas thoughts aloud, depressive patients report a quantitative decline in energy,
thought echo, and thought broadcasting appear to involve mental intensity, and the ability to think efficiently, schizo-
an externalization of a more basic level of thinking, these phrenia patients typically report a qualitative alteration of
characteristic auditory hallucinations are emblematic of thought and perception that is far more difficult to describe
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Schizophrenia Bulletin, Vol. 29, No. 3, 2003 Sass and Parnas
classic of European phenomenological psychiatry: Wolf- "perplexity" (RatWsigkeii) described in classic German
gang Blankenburg's The Loss of Natural Self-Evidence: A psychopathology (Stoning 1939). "Perplexity" refers to a
Contribution to the Study of Symptom-Poor Schizophren- self-aware, anguishing, and (to the patient) perfectly inex-
ics (Der Verlust der Natilrlichen Selbstverstdndlichkeit, plicable sense of being unable to maintain a consistent
1971, French translation 1991; also 2001; see also Sass grasp on reality or to cope with normal situational
2000, 2001). In Blankenburg's view, the central defect or demands. To understand this symptom, it is important to
abnormality in schizophrenia in general appears in its recognize that, when the tacit dimension becomes explicit,
purest and most easily discernable form in patients with it can no longer perform the grounding, orienting, in effect
the negative syndrome. This distinctive but subtle abnor- constituting function that only what remains in the back-
mality is best described as "loss of natural self-evi- ground can play. Whereas normal people have a natural
dence"—that is, loss of the usual common-sense orienta- relationship to what Anne calls their "manner of thinking"
tion to reality, of the unquestioned sense of obviousness, or "framework," she herself feels at an enormous distance
and of the unproblematic background quality that nor- from any such thing: "In my case, everything is just an
mally enables a person to take for granted so many aspects object of thought" (Blankenburg 1971/1991, pp. 79; 127).
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Schizophrenia, Consciousness, and the Self Schizophrenia Bulletin, Vol. 29, No. 3, 2003
not normally be attended to in any direct or sustained fash- attention—including tangentiality and derailment, incoher-
ion and that are no longer serving as a medium of self- ence and pressure of speech, poverty of content of speech,
affection (Klosterkotter 1992). They reflect a correlation, and distractibility. We believe that each of these signs sug-
found also in Kim et al's (1994, p. 432) study of a chronic gests abnormalities of cognitive focus that are consistent
schizophrenia group, between "loss of smoothness" of with our discussion of hyperreflexivity and diminished
action and thought and a "disturbed sense of self." Other self-affection. There seems to be a loss of the ability to be
"basic symptoms" involve abnormalities of the core sense directed toward or committed to a particular focal topic or
of the self as a thinking, feeling, or willing being. To think goal, along with a concomitant awareness, distracting and
clearly may begin to seem difficult; thoughts seem to dis- disruptive, of issues, dimensions, and processes that would
appear, come to a halt, or appear as objects of introspec- usually be presupposed. There is indeed disorganization,
tive awareness. Emotions can seem unnatural, absent, but of a kind that can be described more precisely and dis-
unsatisfying, or somehow inappropriate or out of kilter. tinguished from forms of disorganization more characteris-
Although experiences akin to the basic symptoms rarely tic of other psychopathological groups, such as patients
occur in healthy persons or in neurotic or character disor- with mania (Holzman et al. 1986). Especially common in
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Schizophrenia Bulletin, Vol. 29, No. 3, 2003 Sass and Parnas
aphasias, for they particularly affect what linguists call the Under these conditions, marked also by a "primary"
pragmatic dimension of speech (Schwartz 1982; Sass decline of "thought initiative" and "thought energy," "the
1992a, chap. 6), especially the subtle and shifting relation- intended goal of action is not sufficiently effective in elic-
ships between what can be asserted and what would nor- iting the single steps to achievement of the goal, without
mally be presupposed—that is, between what emerges as increased concentration," which leads to a loss of the auto-
the shared focus at a given moment of a conversation and maticity of action and cognition (Huber 1986, p. 1140).
what normally serves as the taken-for-granted back- Certain memory impairments characteristic of schizophre-
ground. nia can also be understood in light of this diminished self-
Most attempts to explain these disorganization symp- affection, for they appear to involve a failure to "involve
toms have assumed they are rooted in purely cognitive and the self at encoding" (Danion et al. 1999, p. 644).
often rather modular dysfunctions, such as particular kinds The relevance of both hyperreflexivity and dimin-
of associational disturbance, failure of attention or work- ished ipseity for understanding the disorganization symp-
ing memory, or an incapacity for the planning or monitor- toms is nicely illustrated in some passages in which
ing of discourse or thought (Hoffman et al. 1982; Gold- Antonin Artaud (1976) describes his own thinking as a
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Schizophrenia, Consciousness, and the Self Schizophrenia Bulletin, Vol. 29, No. 3, 2003
reactivity and spontaneous directedness (self-affection) and alarming changes of experience of the self; nearly all
that gives bias, direction, and a kind of organization to patients complained of the near-ineffability of their self-
one's thinking. Thus Artaud writes of the "essential illumi- alteration; and the great majority reported preoccupation
nation" and the "very substance of what is called the soul" with metaphysical, supernatural, or philosophical issues.
(Artaud 1976, p. 169; 1965, p. 20) and states that in the Our own pilot study of 19 first onset patients (Parnas et al.
absence of what he calls this "phosphorescent point," there 1998) indicates a nearly identical profile of results.
was "a kind of constant leakage of the normal level of Recently, lifetime B SABS-measured prevalences of
reality" (p. 82). Under these conditions of diminished self- anomalies of subjective experience were compared
affection, no charged purpose or idea, no "criterion" (p. between 21 DSM-FV patients with residual schizophrenia
169), emerged to compel his attention or around which his and 23 remitted psychotic bipolar patients (Parnas et al.
mind could organize itself. "My incorrigible inability to 2003). Schizophrenia patients scored higher on the ratio-
concentrate upon an object," he explains, "derives from nal subscales targeting perplexity, subjectively experi-
the very substance of what is called the soul and that is the enced cognitive disorders, perceptual disorders, and self-
emanation of our nervous force which coagulates around disorders. Yet in a multivariate logistic regression model
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Schizophrenia Bulletin, Vol. 29, No. 3, 2003 Sass and Parnas
inside me turned inhuman" or "I am becoming a mon- From a phenomenological perspective, we see distor-
ster." Prodromal patients usually feel detached from the tions of the intentional act as well as of the field of experi-
standard cornerstones of identity. They may complain of ence. Robert has lost the normally tacit and prereflective
being "occupied by, and scrutinizing, my own inner "myness" of experience that is a condition and medium of
world," of "excessive brooding [and] analyzing and spontaneous, absorbed intentionality; instead there is a
defining myself and my thoughts," of feeling "like a sense of "phenomenological distance" within both percep-
spectator to my own life," of "painful distance to self," tion and action. The perceived object appears somehow
or of having "thoughts . . . so numerous that I didn't filtered, deprived of its fullness of presence—largely, we
manage talking to people" (M0ller and Husby 2000, pp. would argue, because the sensory process lacks the tonal-
221-223, 228). The patient may sense a sort of "inner ity of auto-affection. Perception now seems a mechanical,
void" or "lack of inner nucleus" (Parnas and Handest purely receptive sensory process, unaccompanied by its
2003). One patient reported that his feeling of his expe- normal feeling-tone and deformed by now-intrusive
rience as his own experience only "appeared a split-sec- processes of knowing—an aspect of hyperreflexivity.
ond delayed." Some of these complaints indicate that the Robert, in fact, seems to experience a general transforma-
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Schizophrenia, Consciousness, and the Self Schizophrenia Bulletin, Vol. 29, No. 3, 2003
opposed to manic flight of ideas, and profound ontological Angyal, A. Disturbances of thinking in schizophrenia. In:
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