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Phenomenology and the reconceptualization of schizophrenia

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

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
(e.g., 1939/1970)

European sciences in crisis, blinded by

Transcendental phenomenology
, in contrast, suspends prior beliefs

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

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

ontological insecurity


(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

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

(1857-1939): Group of schizophrenias

(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

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

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

“zones of rarity”
(Kendell & Jablensky, 2003)

genotypic overlap

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

Research Questions
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)
Semi-structured narrative task

(2) Select items from the

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


Positive and Negative Syndrome Scale

; Kay, Opler, & Fizbein, 2006)

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.

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

James Edward Deeds, Jr.

Fordham University GSAS
Dissertation Research Fellowship


Allardyce, J., Gaebel, W., Zialaek, J., & van Os, J. (2007). In C. A. Tamminga, P. J. Sirovatka, D. A. Regier, & J. van Os, J.,
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.
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.),
clinical roots of the schizophrenia concepts
(pp. 83-88). Cambridge, UK: Cambridge University Press.
Binswanger, L. (1957).
. 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
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Carpenter, W. (2011, September).
Schizophrenia: The beginning, the change, the future
. Keynote Lecture at the World Congress of
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Deeds, E. (2014).
Electric Pencil Drawings Archives.
Retrieved with permission from www.electricpencildrawings.com
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British Journal of Psychiatry, 195,
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Pittsburgh, PA: Duquesne
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Heidegger, M. (2010).
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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


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
(1975, 2009)

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

Four stages

[0] Bracketing -
(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 ??

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

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

-Edmund Husserl
"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
]. 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
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
Idiosyncrasies in salience attribution

"Psychosis Susceptibility Syndrome"
George & Klijn
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
of psychosis from the patient's perspective

Generate hypotheses for later quantitative probability testing


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

-Recent focus on


(self disturbances)

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

What can phenomenology contribute to the reconceptualization of

The schizophrenia

Diagnostic debates
Turning to

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

US Census:
Statistical Manual for the Use of Institutions for the Insane
: American Medico-Psychological Association (1918)
Discourse about
"paradigm shift"

Further developed by

(e.g., 1927/2010),


(e.g., 1945/2012),

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


(e.g., 1975)

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

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

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

-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/
-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)
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The crisis of European sciences and transcendental phenomenology
(D. Carr, Trans.). Evanston, IL:
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Transforming diagnosis
[Web log post]. Retrieved November 10, 2014 from http://
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