www.crossingdialogues.com/journal.htm ORIGINAL ARTICLE Crossing Dialogues Association Searching for the lost meaning PAOLA GAETANO The Roman Circle of Psychopathology, Rome, Italy Not only defi ning the nature of schizophrenia, but even defi ning schizophrenia as a diagnostic entity is still a challenge for psychiatry. The current diagnostic systems and the related approach to psychopathology are of little aid to this purpose, and have inadvertently resulted in an impoverished clinical practice. There is substantial meaning underlying schizophrenic symptoms that would appear bizarre and senseless from the viewpoint of a purely descriptive method. Psychiatry needs to devise an approach that embraces the complexity of the different perspectives of explanation and understanding of mental illness, examining the interplay of each element in the subjective experience. Symptoms such as delusion and hallucinations cannot merely be conceptualized as false judgment or lacking of external object, respectively, as they refl ect the fact that patients try to make sense of their different, globally altered experience of the self, of others and of the world. This line of reasoning builds on previous work in the phenomenological tradition postulating a disturbance in sensorimotor processes, which bond human beings with one another while remaining imperceptible to consciousness. This suggestion is consistent with a large body of research highlighting impairment in sensory processing in schizophrenia. Other authors underscored the importance of subtle alterations of functions other than sensorimotor processes, such as experiential anomalies of affectivity, cognition-perception and body-motor experience, alterations of self-awareness, and disturbances in reciprocal attunement leading to disconnection from a common register of meanings and loss of common sense. Heidegger refers to a human being as Being intrinsically selfrevelatory in the unity of physis and logos. He refers to the lived experience of being constantly in the everyday situation as being located, "thrown" into the world. The existence is always 'in the world', 'near the things' and 'with the others' for everybody, in the ways of 'attunement', 'understanding' and 'discourse', that are always together, in the unity of the Dasein. This conception of human existence may help understand the subjective experience of a schizophrenic patient and increase diagnostic accuracy and treatment adequacy. Keywords: schizophrenia, phenomenology, delusions, hallucinations, subjective experience DIAL PHIL MENT NEURO SCI 2011; 4(2): 27-30 27 In his enlightening paper, Kraus drives attention to the substantial meaning that underlies symptoms that would appear bizarre and senseless from the viewpoint of a purely descriptive approach to psychopathology (Kraus 2010). His work is deeply rooted in the classical European tradition of phenomenology that focuses on how phenomena present themselves in consciousness. Consistently with the notion that the signs and symptoms of schizophrenia reveal a global alteration of the basic structure of human experience advanced by other contemporary psychopathologists, his main point is that hallucinations and delusions have substantive rather than metaphoric value, and thus may provide a way to understand patients' experience. Indeed, despite more than a Century of clinical research, defi ning the nature of schizophrenia continues to be a challenge for psychiatrists. Even the simpler act of defi ning schizophrenia as diagnostic entity and tracing its nosological boundaries is proving a diffi cult task. The current diagnostic systems and the related approach to psychopathology are of little aid to this purpose. American psychiatry has produced a Diagnostic and Statistical Manual of Mental Disorders that, although it helped increase diagnostic reliability and communication between clinicians, it also had the unintended consequence of leading to substantial changes in the nature and practice of the fi eld. Its apparent simplicity and clarity often led to abuse, due to an uncritical acceptance of the Manual, as the ultimate authority on psychopathology and diagnosis. The widespread reliance on the Manual alone as an authoritative source in the fi eld of psychopathology has inadvertently resulted in an impoverished clinical practice, where diagnoses are Dialogues in Philosophy, Mental and Neuro Sciences DIAL PHIL MENT NEURO SCI 2011; 4(2): 27-30 Gaetano based on simple lists of signs and symptoms that fi t together as entities existing in neutral space without any particular mood or subjectivity. Andreasen (2007) has expressed concern about the fact that DSM often forms the basis for psychiatric teaching and examination of residents, so that the classical school in psychopathology is now largely ignored, and the study of phenomenology and nosology is seen as irrelevant. Although the DSM was never intended to provide a comprehensive description of mental disorders, nor to reduce them to a checklist, it has actually had a dehumanizing impact on the practice of psychiatry, discouraging clinicians from considering history and knowing the patient as an individual. It created a common nomenclature that is at least partly wrong, and a series of standardised diagnoses that, despite their improved reliability, in many instances are of limited usefulness for research purposes because of lack of validity. Psychiatry needs to fi nd an approach that embraces the complexity of the different perspectives of explanation and understanding of mental illness, examining the interplay of each element in the subjective experience. A biopsychosocial approach that does not take into account the fi rst-person method can be reduced to a "vanilla" in which, as stated by Ghaemi (2003), "all perspectives deserve a seat at the table". Instead, we should be able to capture the "vital connection" that is generated between the various factors under certain conditions. As Husserl points out: "while the natural scientist is thus interested in the objective and is involved in his activity, the subjective-relative is on the other hand still functioning for him, not as something irrelevant that must be passed through but as that which ultimately grounds the theoretical-logical ontic validity for all objective verifi cation, i.e., as the source of self-evidence, the source of verifi cation" (Husserl, 1934-37, Ed. 1970, p.126). While the Anglophone literature often characterises phenomenology as a descriptive rather than an explanatory enterprise, fortunately we have recently witnessed a renewed interest in European phenomenology. As Andreasen states: "Fortunately, the Europeans still have a proud tradition of clinical research and descriptive psychopathology. Someday, in the 21st century, after the human genome and the human brain have been mapped, someone may need to organize a reverse Marshall plan so that the Europeans can save American science by helping us fi gure out who really has schizophrenia or what schizophrenia really is" (Andreasen 2007, p.112) In this proud tradition, Kraus (2010) raises the fundamental question of the meaning of phenomena in schizophrenia, discussing the socalled technical delusions and hallucinations. Delusion, he says, cannot be conceptualized as false cognition or judgment, or hallucination as lacking of external object. The way these patients experience their self and the world is comparable to the experience of being infl uenced and explored by technological processes. Thus, these symptoms refl ect the fact that the patients try to make sense of their different, globally altered experience of the self, of others and of the world. Kraus's line of reasoning builds on previous work in the phenomenological tradition. Some contemporary psychopathologists (Grivois 1995; Raballo et al. 2006) identifi ed the phenomenon of self-centrality as a qualitative modifi cation of the psychotic experience that can be found in the prodromic phase and at the beginning of psychosis or in the post-psychotic phase. They point out that the emergence of abnormal meaning occurs generally in a sense of self-centrality, of "being placed in the centre". The normal sensorimotor processes, which bond human beings with one another while remaining imperceptible to consciousness, are disturbed. According to Conrad (1958), the ability to freely change reference systems is the foundation of interpersonal attunement. Normally, people are able to see themselves from "the outside", "from above", "from a bird's eye view", and to relate their own world to the general world of others. In the Trema phase, the schizophrenic has lost this possibility of transcendence and his consciousness is permeated with a state of alarm that evolves into Apophany or Anastrophe. Grivois (1995) reviews the normal sensorimotor processes which bond human beings with one another while remaining imperceptible to consciousness and the disturbance of which may be the basis of psychosis. In the course of incipient psychosis, patients are affected both in their personal experience and in their public position; they feel dispossessed of their own selves to the benefi t of other individuals. They may also feel 28 www.crossingdialogues.com/journal.htm that they have power over others by assisting or hindering them in their gestures. This gestural perplexity can grow into a feeling of personal annihilation. Yet, nobody helps patients to recognise the implicit knowledge based on the interpersonal mechanism of coordination, and its relevance to the comprehension of meanings within intersubjectivity. The feeling of "centrality" is a constant element in such clinical situations and imposes interpretation. Consistently with these observations, a large body of research suggests that sensory processing in schizophrenia is impaired (Javitt 2009). Defi cits in sensory processing in schizophrenia are well documented in the auditory system, where integrity of sensory function can be assessed using well-defi ned event-related potentials. One of these, mismatch negativity, i.e., response to stimuli that deviate from a predictable sequence, occupies the interface between sensory/perceptual and cognitive processing, and is commonly generated independently from attention. Defi cits in mismatch negativity generation to attributes such as stimulus pitch or duration deviance have consistently been reported in schizophrenia. In the visual system, framing functions are impaired. Patients also show reduced sensitivity to stimulus features (e.g., weight) but normal ability to retain representations once they are formed. Impaired 2-point discrimination and elevated pain thresholds are also well documented. Also, an experiment designed to assess mirror neuron activation with a transcranial magnetic stimulation revealed a reduction in motor facilitation during action observation in schizophrenia, refl ecting a possible dysfunction within the mirror neuron system (Enticott et al. 2008). Other authors highlighted the central importance of subtle alterations of functions other than sensorimotor processes. Klosterkötter's transitional phenomena target non-psychotic experiential anomalies of affectivity, cognition-perception and body-motor experience (Klosterkötter et al. 2001). These symptoms predict subsequent development of schizophrenia with remarkable accuracy. Basic symptoms are described as alterations of subjective experience which denote the beginning of psychosis. Guided by phenomenological considerations, Sass and Parnas (2003) proposed that alterations of self-awareness constitute the phenotypic core of schizophrenia-spectrum disorders. They observed self-anomalies as unstable fi rst-person perspective, disturbed sense of ownership and agency, fl uidity of the basic sense of identity. Sass and Parnas argued that schizophrenia is an ipseity disturbance with two complementary components: hyperrefl exivity and reduction of self-affection. Diminished intensity or vitality of one's own subjective selfpresence should be related to an exaggerated self-consciousness. These complementary distortions lead to a loss of salience or stability in which objects stand out in an organized fi eld of awareness. Ipseity (mine-ness) refers to the experiential sense of recognising oneself as the centre around which things are placed, of being a living body which tends toward oneself in ones eternal openness to the world and to the others. Ipseity is a motion that maintains traces of past experience but at the same time transcends itself toward a new destination, giving a new sense to a past event (Costa 2009). In this perspective, Sass and Parnas probably underplay the notion that there is no experience of self without experience of others. Establishing a spontaneous contact with others and the ability to communicate through a common symbolic register are essential elements in human existence. As Stanghellini and Ballerini (2004) point out, common sense is the required condition for the possibility of social life. Inter-corporeality is never fully evident, but it supports all interactions connected with behaviour and sensations already active and present ahead of any explicit communication. The attunement disorder has its roots in the non-constitution of that common way of organizing experience in its primary perceptive moment, linked to the body's basic coenaesthesic experience. The sense of Self is deprived of the certainty of what is one's own, and the person is unable to cope with social confrontation as a face-to-face relationship with others. The ipseity crisis is refl ected in a deprivation of a living personal experience in one's body (soulless body) and in a contemplation of one's own existence from a third person perspective (disembodied spirit). Although it is not possible to establish a pathogenetic priority among the phenomena described above, the opportunity of reciprocal attunement is the constitutional fi eld of common 29 DIAL PHIL MENT NEURO SCI 2011; 4(2): 27-30 Gaetano sense, and it is probably the primum movens toward the establishment of a common register of meanings. It should be emphasised that language is not only a system of signs, not just a result of judging or a way to communicate inner states. It is primarily a way through which the world can appear, and the appearance of meanings is language. Meaning is the possibility of action indicated by the thing, revealed by an action or by a word. In this sense, semantics and logic of schizophrenic delusions disclose the fragmentation of the coherent totality of meanings of the intersubjective world. In order to shed more light on the meaning of the apparently bizarre "technological" positive psychotic symptoms, Kraus revisits the fundamental structures of Dasein (Heidegger, 1963) and the existential a prioris. Passing over the difference between Kant's and Heidegger's conception of the a priori, what is very helpful for overcoming the antinomies of the literature in this fi eld is to consider the essence of a human being. Heidegger refers to a human being not as a subject opposed to an object, but as Being intrinsically self-revelatory in the unity of physis and logos. The term Da-sein means "being there/here" or "being situated". Heidegger refers to the lived experience of being constantly in the everyday situation as being located, "thrown" into the world. Being-there is considered being always: In-a-world (In-Sein), that is historical and intersubjective; Near-things (Bei-Sein) that are ready-to-hand; and With-others (Mit-Sein), which includes the recognition of the presence of others. The existence is always "in", "near" and "with" for everybody, in the ways of "attunement", "understanding" and "discourse". Each man is always in a mood; his emotions and feelings reveal the value of things for him, offering them to his reasoning. Each man is capable of understanding his own possibilities in the context and to project himself in making his choices and, fi nally, to express himself in a language, thinking or talking with others. The human world is a coherent totality of meanings. The understanding of the totality of references allows us to understand the single entity. For each person, comprehension has to do with the memory of what they can do, not of past events. Attunement, understanding and discourse are always together, in the unity of the Da-sein. This conception of human existence helps us to understand the subjective experience of a schizophrenic patient, to identify the early transformations in the psychotic consciousness, and hopefully to increase diagnostic accuracy and treatment adequacy through increased understanding. 30 Corresponding Author: Dr. Paola Gaetano Centre of Cognitive Therapy Via degli Scipioni, 245 00192 Rome, Italy Tel. +39 0645439124 email: paolagaetano@gmail.com Copyright © 2011 by Ass. Crossing Dialogues, Italy REFERENCES Andreasen NC. DSM and the death of phenomenology in America: an example of unintended consequences. Schizophr Bull 2007;33: 108-112. Conrad K. Die beginnende Schizophrenie. Versuch einer Gestaltanalyse des Wahns. Thieme, Stuttgart, 1958. Costa V. I modi del sentire. Un percorso nella tradizione fenomenologica. Quodlibet, Macerata, 2009. Enticott PG, Hoy KE, Herring SE, Johnston PJ, Daskalakis ZJ, Fitzgerald PB. Reduced motor facilitation during action observation in schizophrenia: a mirror neuron defi cit? Schizophr Res. 2008; 102:116-121. Ghaemi SN. The concepts of psychiatry: a pluralistic approach to the mind and mental illness. Johns Hopkins University Press, Baltimore, 2003. Grivois L. Le fou et le mouvement du monde. Éditions Grasset et Fasquelle, Paris, 1995. Heidegger M. Sein und Zeit. Niemeyer, Tübingen, 1963. Husserl E. (1934-37) Crisis of European Sciences and Transcendental Phenomenology. Northwestern University Press, Chicago, 1970. Javitt DC. Sensory processing in schizophrenia: neither simple nor intact. Schizophr Bull 2009;35:1059-1064. Klosterkötter J, Hellmich M, Steinmeyer EM, SchultzeLutter F. Diagnosing schizophrenia in the initial prodromal phase. Arch Gen Psychiatry 2001;58:158-164. Kraus A. Existential a prioris and the phenomenology of schizophrenia. Dial Phil Ment Neuro Sci 2010; 3: 1-7. Raballo A, Lundgren E, Leuci E, Fontò S, Maggini C. Self-centrality, psychosis and schizotaxia: a conceptual review. Acta Biomed 2006;77:33-39. Sass L, Parnas J. Self, consciousness, and schizophrenia. Schizophr Bull 2003;29:427-444. Stanghellini G, Ballerini M. Autism: disembodied existence. PP&P 2004;11:259-268.