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Article history:
Received 22 July 2014
Received in revised form
24 August 2014
Accepted 11 September 2014
Available online 16 October 2014
It is a current trend in psychiatry to discard the Kraepelinian dichotomy schizophrenia vs. manicdepressive illness and use the overinclusive label psychosis to broadly indicate the whole spectrum of
severe mental disorders. In this paper we show that the characteristics of psychotic symptoms vary
across different diagnostic categories. We compare delusions in schizophrenia and major depression and
demonstrate how these phenomena radically differ under these two psychopathological conditions.
The identication of specic types of delusions is principally achieved through the differential
description of subjective experiences. We will use two general domains to differentiate schizophrenic
and depressive delusions, namely the intrinsic and extrinsic features of these phenomena. Intrinsic
features are the form and content of delusions, extrinsic ones include the background from which
delusions arise, that is, changes in the eld of experience, background feelings, ontological framework of
experience, and existential orientation. This kind of systematic exploration of the patients experience
may provide a useful integration to the standard symptom-based approach and can be used to establish
a differential typology of the clinical manifestation of psychosis based on the fundamental alterations of
the structures of subjectivity characterizing each mental disorder, particularly with respect to the
Kraepelinian dichotomy schizophrenic vs. manic-depressive illness.
& 2014 Elsevier B.V. All rights reserved.
Keywords:
Classication
Delusion
Major depression
Phenomenology
Psychosis
Schizophrenia
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intrinsic features of delusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.
Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.
Content. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Extrinsic features of delusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.
Preparatory eld of experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.
Background feelings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.1.
Schizophrenia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.2.
Major depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Since time immemorial delusion has been taken as, the basic characteristic of madness. To be mad was to be deluded and indeed what constitutes a delusion is one of the
basic problems of psychopathology (Jaspers 1997, p.93).
n
Corresponding author at: "G. d'Annunzio" University, Via dei vestimi 31, 66100 Chieti Scalo, Italy.
http://dx.doi.org/10.1016/j.jad.2014.09.027
0165-0327/& 2014 Elsevier B.V. All rights reserved.
172
3.3.
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1. Introduction
It is a current trend in psychiatry to discard the Kraepelinian
dichotomy schizophrenia vs. manic-depressive illness and use the
overinclusive label psychosis to broadly indicate the whole
spectrum of severe mental disorders. Yet, it is often unclear
what is actually meant by psychosis (Parnas, 2013). Although at
a nave-intuitive level the notion of psychosis might seem unambiguous and clear-cut, the very concept of psychosis remains
unaddressed in contemporary diagnostic manuals, which only
vaguely dene psychosis as poor reality testing World Health
Organization (1992) or rather circularly identify psychosis with the
presence of its putative semiologic markers. In DSM 5 the term
psychotic is used to refer to the presence of a variegated set of
symptoms, so called primary symptoms of psychosis, including
delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Mental disorders that
present the primary symptoms of psychosis are admittedly heterogeneous (American Psychiatric Association, 2013) since they
include schizophrenia, depression, mania, substance/medicationinduced psychotic disorders, etc. DSM 5 suggests that the severity
of symptoms can predict important aspects of the illness, such
as the degree of cognitive or neurobiological decits (), may
help with treatment planning, prognostic decision making,
and research on pathophysiological mechanisms (American
Psychiatric Association, 2013).
A purely quantitative criterion (severity of symptoms) may be
insufcient to characterize psychotic symptoms as they actually
occur in the manifold of severe psychopathological disorders.
There is a need of a qualitative characterization of psychotic
symptoms addressing the alterations of human subjectivity (e.g.,
self-awareness, relatedness to the world, and relatedness to
others) in which psychotic experiences are embedded. These
alterations appear relevant for a differential typology of the clinical
manifestation of psychosis, particularly with respect to the Kraepelinian dichotomy schizophrenic vs. manic-depressive illness.
The purpose of this paper is therefore to discuss whether the
characteristics of psychotic symptoms are identical or vary across
these two diagnostic categories. We will compare delusions in
schizophrenia and major depression and show how these phenomena radically differ under these two psychopathological
conditions. The identication of specic types of delusions is
principally achieved through the phenomenological razor (Rossi
Monti and Stanghellini, 1996), i.e., the differential description of
Table 1.
Table 2.
173
174
175
Table 3.
3.3.1. Schizophrenia
Schizophrenic delusions are not the effect of wrong reasoning,
rather they arise from a breakdown of the patient's total awareness of reality. What is changed is not an opinion about reality, but
the very structure of the global perspective on the world: the
patient's existential-ontological framework of experience (Parnas,
2004, 2011, 2012; for a detailed analysis see Stanghellini and
Rosfort, 2013; patients quotes from unpublished database). In the
following, we will conne our description to the most salient
features of this transformation.
3.3.2. Time
A typical feature of lived time in persons with schizophrenia is
temporal fragmentation, e.g., patients may experience a collection of disarticulated snapshots rather than as a coherent series of
actions and events (Things are glittering like a mirage). Another
key feature is captured by the concept of ante festum (Kimura,
1992, 1994), e.g., patients feel that something is about to happen
to them or in the external world (I have a premonition of what is
going to happen to me). These and similar anomalies in lived
temporality are widely described in phenomenological literature
(Minkowski, 1933; Binswanger, 1960; Pringuey, 1997; Fuchs, 2013;
Sass and Pienkos, 2013b).
3.3.3. Body
Most characteristic are ongoing bodily feelings of disintegration/violation and thingness/mechanization. These include
experiences of dynamization of bodily boundaries (Areas of body
where forces enter), bodily construction (Mouth was where hair
should be), body appearance (Face changing), and externalization (Vagina half outside). Other typical phenomena are morbid
objectivization and devitalization (Felt programmed like a robot)
(Cutting, 1997; de Haan and Fuchs, 2010; Stanghellini, 2008b;
Stanghellini et al., 2012; Stanghellini and Rosfort, 2013;
Stanghellini et al., 2014b, in press).
3.3.4. Space
One key feature of lived space in schizophrenia is its growing
homogeneous, two-dimensional, losing its perspectival quality
(Sechehaye, 1951; Conrad, 1958; Matussek, 1987; Sass and
Pienkos, 2013c, 2013d). Another typical feature is itemization
(Stanghellini and Rosfort, 2013): as with time experience, the
fragmentation of space Gestalt reduces the ensemble of a living
situation to a mere collection of itemized details (I am overwhelmed by too much detail too much detail in objects).
3.3.5. Self
Schizophrenia has been interpreted as a disorder of the prereexive self, i.e. a pervasive perturbation of the core sense of self
(ipseity) that is normally implicit in each act of awareness (Parnas,
2011, 2012; Parnas et al., 2005; Parnas and Sass, 2001; Sass and
176
4. Existential orientation
The existential orientation is a person's philosophy of life, his
world-view, that is, the values that regulate meaning-bestowing
and the signicant actions of the person. Grasping the values of a
person is a key to understanding her way of interpreting her
experience and representing herself. In general, it is a key to
understanding her form of life or being in the world, that is, the
pragmatic motive and the system of relevance that determine
the meaning structure of the world she lives in.
4.1. Schizophrenia
Many authors (Kretschmer, 1925; Berze and Gruhle., 1929;
Minkowski, 1927; Binswanger, 1960; Blankenburg, 1971) highlight
eccentricity as the core of the existential orientation of persons
with schizophrenia. The schizophrenic value system conveys an
overall crisis of common sense. The outcome of this can be
designated as antagonomia and idionomia. Antagonomia reects
the choice to take an eccentric stand in the face of commonly
shared assumptions and the here and now other. Idionomia
reects the feeling of the radical uniqueness and exceptionality
of one's being with respect to common sense and the other human
beings. This sentiment of radical exceptionality is felt as a gift,
177
Table 4.
Conict of interest
None of the authors or their immediate family members have a potential
conict of interest in the work presented here.
Acknowledgment
The research and writing of this paper was solely done by the authors.
5. Conclusions
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