Subjectivity and Schizophrenia: Another Look at Incomprehensibility and Treatment Nonadherence

Abstract

Psychiatry is in a time of crisis. The absence of significant breakthroughs to actionable etiological knowledge has left the discipline in a state of uncertainty and worries are being voiced about its status and future. In our view, the stagnation can be, at least in part, ascribed to an excessive, behaviorist-oriented, epistemological, and ontological simplification of psychopathology. The aim of this phenomenological study is to articulate the notion of the ‘disordered self' in schizophrenia, a notion that we believe constitutes an important step forward in grasping its essential pathogenetic structures. Through the framework of self-disorders, we analyze two domains of the psychopathology of schizophrenia, seeking to recast their puzzling nature into more useful clinical and scientific terms. First, we examine the so-called schizophrenic incomprehensibility (bizarre gestalt, bizarre delusions, and ‘crazy actions') and argue that grasping the altered framework for experiencing, associated with the disordered self, makes these phenomena appear comprehensible to a considerable extent. Second, we explore the issue of treatment noncompliance and provide a novel account of ‘poor insight' into illness. We propose that poor insight into schizophrenia is not simply a problem of insufficient self- reflection due to psychological defenses or impaired metacognition, but rather that it is intrinsically expressive of the severity and nature of self-disorders. The instabilities of the first-person perspective throw the patient into a different, often quasisolipsistic, ontological-existential framework. We argue that interventions seeking to optimize the patients' compliance might prove more efficient if they take the alterations of the patients' ontological-existential framework into account.

Basic Self-Disturbance in the Schizophrenia Spectrum: Taking Stock and Moving Forward

“…Although statistical power was limited, the data indicated that basic self-disturbance was particularly predictive of schizophrenia spectrum disorders. Recent work has also indicated that basic self-disturbance correlates with suicidality (more strongly than positive symptoms) [49,50,51], lack of illness insight [31,52], social dysfunction [53], longer duration of untreated psychosis [54], and childhood trauma in first episode schizophrenia, particularly in females [55]. …”

Do deficits in the magnocellular priming underlie visual derealization phenomena? Preliminary neurophysiological and self-report results in first-episode schizophrenia patients

“…Depersonalization on the other hand did not show any predictive quality (Schultze-Lutter and Ruhrmann, 2008). Finally, Parnas and Henriksen (2013) recently proposed that the effectiveness of the interventions aimed to improve the patient's compliance might be optimized "if they take the alterations of the patients' ontological-existential framework into account".…”

Clinical Manifestations of Self-disorders in Schizophrenia Spectrum Conditions

“…In other words, many characteristic, primary psychotic experiences, which traditionally have been deemed bizarre or incomprehensible, can in fact be understood to some extent within this phenomenological framework [30,31]. For example, delusions of being bugged, filmed or controlled are often merely a secondary, propositional framing of primary psychotic experiences of being 'listening to', 'watched' or 'touched' within the innermost intimacy of one's own subjectivity.…”