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Phenomenology and the reconceptualization of schizophrenia

Herzog Hospital Psychiatry Div. Lecture Series, Nov. 13, 2014
by

Sarah Kamens

on 25 January 2017

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Transcript of Phenomenology and the reconceptualization of schizophrenia

What is phenomenology?
A scientific method for investigating experience and the structures of consciousness

Developed by Austrian mathematician and philosopher
Husserl
(e.g., 1939/1970)

European sciences in crisis, blinded by
naturalism
and
objectivism
.

Transcendental phenomenology
, in contrast, suspends prior beliefs


Phenomenological contributions to the study of schizophrenia
P1
=
Common clinical use
; descriptive psychopathology; signs & symptoms
P2
= Quasi-technical term
P3
= Description of mental states; Jaspers
P4
=
Scientific method
; Husserl + followers
Current debates about the schizophrenia diagnosis
Phenomenological contributions
Jaspers
(1912/1968): "
un-understandability
" (deficit in intersubective
connection / empathy)

Binswanger
(1956, 1957, 1963):
extravagant and exaggerated ideals

Laing
(1960):
ontological insecurity

Fuchs

(2005, 2007):
disturbance in time consciousness

Sass and Parnas

(2003; Sass, Parnas, & Zahavi, 2011):
ipseity disturbance
= hyperreflexivity + diminished self-affection




Sarah R. Kamens, M.A., Doctoral candidate in clinical psychology, Fordham University, New York

Yisca Baris Ginat, M.D., Psychiatry Resident, Herzog Hospital, Jerusalem


Kraeplin
(1856-1926): Dementia praecox
(early dementia)

Bleuler
(1857-1939): Group of schizophrenias

Schneider
(1887-1967): First-rank symptoms

Key figures in the history of schizophrenia:
(see Mishara & Schwartz, 2013)
(for a comprehensive review of fin-de-ciècle theories prior to Jaspers, see Mishara & Schwartz, 2013)
"But the phenomenological approach is not yet so widespread as not to require repeated efforts to promote it. One may hope that its application will further enrich our knowledge of what the psychiatric patient really experiences."

-Karl Jaspers, 1912/1968, p.1323
“I think we made very serious mistakes in the way we conceptualize schizophrenia currently."

-William Carpenter (2011), Chair of DSM-5 Psychotic Disorders Workgroup
"[T]he current world of schizophrenia likely includes multiple phenotypically overlapping syndromes and diseases [...] the unitary concept of schizophrenia may have outlived its usefulness."
-Keshavan, Nasrallah, and Tandon (2011, p.11)
"The label schizophrenia is still with us, but hopefully not for too much longer. It is a tired, old concept that has outlived much of its usefulness."
-Allen Frances (2011), Chair of DSM-IV Task Force
Response to the debates: 3 major trends
Turning to phenomenology
"If our definition of schizophrenia does not represent a 'real' construct in nature, then it will not delineate the true pathology and causal mechanisms underlying psychosis; it will obfuscate etiology."

-Allardyce, Gabel, Zielaek, & van Os, 2007
"[P]henomenology [...] is at the present moment an essential tool for any further progress in psychiatric classification [...] familarity with its basic tenets should be included in the psychiatric training curriculum."


-Parnas & Zahavi, 2002
The 'heterogeneity problem'
Within-disorder heterogeneity

2+ people, 1 disorder, 0 common sx

Polythetic criteria
- neither necessary nor sufficient for a diagnosis
(e.g., Krueger & Bezdjian, 2009)

1 person, 2+ disorders/symptoms

Comorbidity
(Boyd et al., 1994; Kessler et al., 2005)

Phenotypic/diagnostic overlap
(a.k.a. "
fuzzy boundaries"
)
(e.g., Frances, 2009b; Krueger & Markon, 2006)

No
“zones of rarity”
(Kendell & Jablensky, 2003)

High
genotypic overlap

(e.g., Regier, Narrow, Kuhl, & Kupfer, 2011).

Research Questions
Method
Status and Projected Timeline
Cross-cultural heterogeneity

Severity, prognosis, and symptoms
vary across cultures
in surprising ways
(Hopper, 2004; Jablensky, 1987; Jablensky et al., 1992)

"Cultural syndromes"
(e.g., Bar-el et al., 2000)
Interviews
(1)
Semi-structured narrative task


(2) Select items from the

Examination of Anomalous Self-Experience
(
EASE
; Parnas et al., 2005) and the
Examination of Anomalous World-Experience
(
EAWE
; in development by Sass & Pienkos)


(3)

Positive and Negative Syndrome Scale

(
PANSS
; Kay, Opler, & Fizbein, 2006)


(4)
Debriefing questions
Data Analysis
Herzog Hospital
Psychiatry Division Lecture Series
November 13, 2014

Thank you:
Pesach Lichtenberg, M.D.
Tal Shachar-Malach, M.D.
Herzog Hospital Staff

Research Mentor:

Frederick Wertz, Ph.D.

Dissertation Committee
:
Monica Rivera-Mindt, Ph.D.
Margaret Andover, Ph.D.
Rachel Annunziato, Ph.D.
Louis Sass, Ph.D.

Manhattan Psychiatric Center PI:

Jacob Kader, Psy.D.

Maimonides Medical Center PIs:

David Miller, Ph.D.

Lyra Ward, Ph.D.


Co-Investigator:
Mary Beth Morrissey, Ph.D., MPH, J.D.

Research Assistants:
Faith Forgione, B.A. Caroline Silva
Jillian Minahan, B.A. Ryan Scanlon
Ileana Driggs, B.A. Katherine Sullivan
Oren Matar, M.A. Lia Kamar

Artwork:
James Edward Deeds, Jr.
electricpencildrawings.com

Funding:
Fordham University GSAS
Dissertation Research Fellowship

References

Allardyce, J., Gaebel, W., Zialaek, J., & van Os, J. (2007). In C. A. Tamminga, P. J. Sirovatka, D. A. Regier, & J. van Os, J.,
Deconstructing
psychosis: Refining the research agenda for DSM-V
(pp. 1-10). Arlington, VA: American Psychiatric Association.
Andreasen, N. C. (2007). DSM and the death of phenomenology in America: An example of unintended consequences.
Schizophrenia
Bulletin, 33
, 108-112.
Bar-el, Y., Durst, R., Katz, G., Zislin, J., Strauss, Z., & Knobler, H. Y. (2000). Jerusalem syndrome.
Journal of mental science, 176
, 86-90.
Berrios, G. E. (1989). What is phenomenology? A review.
Journal of the Royal Society of Medicine, 82
, 425-428
Binswanger, L. (1956). Extravagance, perverseness, manneristic behaviour and schizophrenia. In J. Cutting & M. Shepherd (Eds.),
The
clinical roots of the schizophrenia concepts
(pp. 83-88). Cambridge, UK: Cambridge University Press.
Binswanger, L. (1957).
Schizophrenie
. Tuebeingen, Germany: Neske.
Binswanger, L. (1963).
Being-in the-World: Selected papers of Ludwig Binswanger
(J. Needleman, Trans.) New York, NY: Basic Books.
Boyd, J. H., Burke, J. D., Gruenberg, E., Holzer, C. E., Rae, D. S., George, L. K. ... Nestadt, G. (1984). Exclusion criteria of DSM-III: A study
of co-occurrence of hierarchy-free syndromes.
Archives of General Psychiatry, 41
¸ 983-989.
Carpenter, W. (2011, September).
Schizophrenia: The beginning, the change, the future
. Keynote Lecture at the World Congress of
Psychiatry, Buenos Aires, Argentina.
Deeds, E. (2014).
Electric Pencil Drawings Archives.
Retrieved with permission from www.electricpencildrawings.com
Frances, A. (2009). Whither DSM-V?
British Journal of Psychiatry, 195,
391-392.
Frances, A. (2011). Why psychiatrists should mind their language: Review of Richard Noll's
American Madness: The rise and fall of
dementia praecox. Culture Lab
. Retrieved 15 December, 2011 from http://www.newscientist.com/blogs/culturelab/2011/12/why-psychiatrists-should-mind-their-language.html
Fuchs, T. (2005). Delusional mood and delusional perception: A phenomenological analysis.
Psychopathology, 38
, 133–139.
Fuchs, T. (2007). The temporal structure of intentionality and its disturbance in schizophrenia.
Psychopathology, 40
, 229-235.
George, B. & Klijn, A. (2014). Psychosis susceptibility syndrome: An alternative name for schizophrenia.
The Lancet Psychiatry, 1
(2),
110-111.
Giorgi, A. (1975). An application of phenomenological method in psychology. In A. Giorgi, C. Fischer & E. Murray (Eds.),
Duquesne studies
in phenomenological psychology
(Vol. 2, pp. 317-342). Pittsburgh, PA: Duquesne University Press.
Giorgi, A. (2008). Conceming a serious misunderstanding of the essence of the phenomenological method in psychology.
Journal of
Phenomenological Psychology, 39
, l-26.
Giorgi, A. (2009).
The descriptive phenomenological method in psychology: A modified Husserlian approach.
Pittsburgh, PA: Duquesne
University Press.
Heidegger, M. (2010).
Being and time.
(J. Stambaugh, Trans.). Albany, NY: State University of New York Press. Original work published
1927

Between-disorder heterogeneity
Present study:
Reconceptualizing Psychosis: Culture and heterogeneity in the 'schizophrenia' diagnosis
Data collection sites:

Psychiatric hospital, inpatient - Jerusalem
Psychiatric hospital, inpatient - New York
Psychiatric hospital, outpatient - New York



Participants:

Min. 16 psychiatric patients with current
schizophrenia-spectrum disorder diagnoses
4 pilot-comparison participants
Purposive sampling procedure to
maximize diversity in cultural and symptom profiles
Exclusions: Brain damage, under 18



Goal: address the '
heterogeneity problem
' in schizophrenia from a phenomenological, cross-cultural perspective

& (in doing so) to demonstrate the use of phenomenology in resolving taxonomic dilemmas
Image by Edward Deeds*
Table from S. Chapman at dxrevision watch: http://dxrevisionwatch.com/?s=kappas
DSM-5 Field Trial Kappas

Phenomenological procedures
developed by
Giorgi
(1975, 2009)
and

Wertz
(1985, 2005, 2010; Wertz et al., 2011)


Four stages
:

[0] Bracketing -
epochés
(1) Open listening
(2) Demarcation / reflection on meaning units
(3) Individual Psychological Structures
(4) General Psychological Structure(s)
eidetic analysis

Among the psychological processes and experiences of diverse individuals diagnosed with schizophrenia-spectrum disorders...


(1) What are the
meaningful similarities and differences?





(2) What
general structure or structures
are found?




(3) How are these similarities, differences, and/or structure(s)
related to
regional and cultural life
?

Feb '13 May '13 Aug '13 Nov '13 Sep '14 'Dec 14 March '15 ??

Pilot
interviews
Manhattan Psychiatric
Center data collection
Data analysis
Herzog Hospital
data collection
Maimonides Medical
Center data collection
Preliminary findings
expected

zu den Sachen selbst!
(to the things themselves!)


-Edmund Husserl
1859-1938
"You know those medieval maps? [...] In the places where they didn’t know what was going on, they wrote ‘Dragons live here.' We have a dragon’s world here [in the
DSM
]. But you wouldn’t want to be without that map."
In 2010 Wired.com interview with Gary Greenberg, Ph.D.
-Allen Frances, M.D., Chair of DSM-IV Task Force
DSM-IV
DSM-5
????
Dissatisfaction after DSM-III revolution
"DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. [...] [S]ymptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better."

-Thomas Insel (2013)

In a nutshell:

No biomarkers
Diagnoses don't "cut nature at its joints"
We can't agree on what a mental disorder is

Image by Edward Deeds*
Four levels


Stick with what we have, even if imperfect

"Deconstruct" into symptoms & look for biomarkers
(e.g., NIMH's RDoC)
"The mouse may be the way to rescue the trapped elephant!"


Rename and/or reconceptualize

"Salience syndrome"

-
van Os
(2009)
Idiosyncrasies in salience attribution

"Psychosis Susceptibility Syndrome"
-
George & Klijn
(2014)
Alternative name to reduce stigma, emphasize latent periods

"Seishin Bunretsu Byo" ("mind-split-disease") now "Togo Shitcho Sho" ("integration disorder")
-

Phenomenologists have variously attempted to:

Describe the subjective
experience
of psychosis from the patient's perspective

Generate hypotheses for later quantitative probability testing

Identify
Grundstörungen

(core disturbances) that may underlie the varied symptoms of schizophrenia

-Recent focus on

Ichstörungen

(self disturbances)



Images by
Edward Deeds
Committed for life to State Hospital No.3, Nevada, MO in 1936
Diagnosis: Dementia Praecox
http://www.electricpencildrawings.com/


What can phenomenology contribute to the reconceptualization of
'schizophrenia'?

The schizophrenia
diagnosis

Diagnostic debates
Turning to
phenomenology

Phenomenology & schizophrenia
The present project
Method
Status & References
Thanks
Q&A
Psychiatric Classification Systems: A
Brief
History
1840 1899 1918 1949/52 1968 1980 1994 2013 2025

US Census:
idiocy/insanity
Kraepelinian
dichotomy
Statistical Manual for the Use of Institutions for the Insane
: American Medico-Psychological Association (1918)
ICD-6
DSM-1
DSM-II
DSM-III
"Revolution"
Discourse about
"paradigm shift"

Further developed by
Heidegger

(e.g., 1927/2010),

Merleau-Ponty

(e.g., 1945/2012),
Sartre

(e.g., 1943/1993), and

Ricœur

(e.g., 1975)

More recently systematized for social-science research by
Giorgi
(1975, 2009) and
Wertz

(1985, 2005, 2010; Wertz et al., 2011)


Key features
(Giorgi, 2008; Wertz, 2010):

Bracketing
-epoché of the natural sciences
-epoché of the natural attitude

Eidetic reduction (intuition of essences)
-reveals invariant, essential features of phenomenon
-free imaginative variation

What is phenomenology?
"Several pathophysiological models [of schizophrenia] have been proposed with differing interpretations of the illness, like the fabled six blind Indian men groping different parts of an elephant coming up with different conclusions."
-Keshavan, Nasrallah, & Tandon (2011)

Image: http://wildequus.org/2014/05/07/sufi-story-blind-men-elephant/
DSM-IV
DSM-5
????
http://www.wired.com/2010/12/ff_dsmv/all/
-Keshavan, Tandon, & Nasrallah (2011)
"Deconstructing psychosis" ... into what?

Descriptive & biological research can go hand-in-hand

Importance of methodological pluralism



Director, National Institute of Mental Health (NIMH)
from "Schizophrenia, 'just the facts'"
Japanese Society of Psychiatry and Neurology

"The first reason for the renaming was the need to remove the harmful impact [...] on the patients and their families" (Sato, 2006)
References
Greenberg, G. (2010). Inside the battle to define mental illness.
Wired
. Retrieved 11 November 2014 from http://
www.wired.com/2010/12/ff_dsmv/5/
Hopper, K. (2004) Interrogating the meaning of ‘culture’ in WHO international studies of schizophrenia. In J. H. Jenkins & R.
J. Barrett (Eds.), S
chizophrenia, culture, and subjectivity: The edge of experience
(pp. 62-86). New York, NY: Cambridge University Press.
Husserl, E. (1970).
The crisis of European sciences and transcendental phenomenology
(D. Carr, Trans.). Evanston, IL:
Northwestern University Press. (Original work published 1939)
Insel, T. (2013, April 29).
Transforming diagnosis
[Web log post]. Retrieved November 10, 2014 from http://
www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
Jablensky, A. (1987). Multicultural studies and the nature of schizophrenia: A review.
Journal of the Royal Society of
Medicine, 80
, 162-167.
Jablensky, A., Sartorius, N., Ernberg, G., Anker, M., Korten, A., Cooper, J. E., Day, R., & Bertelsen, A. (1992).
Schizophrenia: Manifestations, incidence and course in different cultures. A World Health Organization ten-country study.
Psychological Medicine Monograph Supplement, 20
, 1-97.
Jaspers, K. (1968). The phenomenological approach in psychopathology.
British Journal of Psychiatry, 114
, 1313-1323.
Original work published 1912
Kay, S. R., Opler, L. A., & Fiszbein, A. (2006).
The Positive and Negative Syndrome Scale (PANSS).
North Tonawanda, NY:
Multi-Health Systems.
Kendell, R., & Jablensky, A. (2003). Distinguishing between the validity and utility of psychiatric diagnoses.
American
Journal of Psychiatry, 160
, 4-12.
Keshavan, M. S., Nasrallah, H. A., & Tandon, R. (2011). Schizophrenia, "just the facts" 6. Moving ahead with the
schizophrenia concept: From the elephant to the mouse.
Schizophrenia Research, 127
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Kessler, R. C., McGonagle, K. A., Zhao, S., & Nelson, C. B. (1994). Lifetime and 12-month prevalence of DSM-III-R
psychiatric disorders in the United States: Results from the National Comorbidity Study.
Archives of General Psychiatry, 51
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Kessler, R. C., Berglund, P., Demler, O., Robert, J., Merikangas, K. R., & Walters, E. E. (2005). Lifetime Prevalence and
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Krueger, R. F., & Bezdjian, S. (2009). Enhancing research and treatment of mental disorders with dimensional concepts:
Toward DSM-V and ICD-11.
World Psychiatry, 8
, 3-6.

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psychopathology.
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Laing, R. D. (1960).
The divided self.
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Phenomenology of perception.
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response.
Psychopathology, 46
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Psychiatric diagnosis and classification
(pp. 137-162). Chichester, UK: John Wiley & Sons.
Parnas, J., Møller, P., Kircher, T., Thalbitzer, J., Jansson, L., Handest, P., & Zahavi, D. (2005).
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