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Phenomenology and the reconceptualization of schizophrenia
Transcript of Phenomenology and the reconceptualization of schizophrenia
A scientific method for investigating experience and the structures of consciousness
Developed by Austrian mathematician and philosopher
European sciences in crisis, blinded by
, 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
; Husserl + followers
Current debates about the schizophrenia diagnosis
" (deficit in intersubective
connection / empathy)
(1956, 1957, 1963):
extravagant and exaggerated ideals
disturbance in time consciousness
Sass and Parnas
(2003; Sass, Parnas, & Zahavi, 2011):
= 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
(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'
2+ people, 1 disorder, 0 common sx
- 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)
(e.g., Frances, 2009b; Krueger & Markon, 2006)
“zones of rarity”
(Kendell & Jablensky, 2003)
(e.g., Regier, Narrow, Kuhl, & Kupfer, 2011).
Status and Projected Timeline
Severity, prognosis, and symptoms
vary across cultures
in surprising ways
(Hopper, 2004; Jablensky, 1987; Jablensky et al., 1992)
(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)
Psychiatry Division Lecture Series
November 13, 2014
Pesach Lichtenberg, M.D.
Tal Shachar-Malach, M.D.
Herzog Hospital Staff
Frederick Wertz, Ph.D.
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.
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.
Bar-el, Y., Durst, R., Katz, G., Zislin, J., Strauss, Z., & Knobler, H. Y. (2000). Jerusalem syndrome.
Journal of mental science, 176
Berrios, G. E. (1989). What is phenomenology? A review.
Journal of the Royal Society of Medicine, 82
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
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,
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
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Fuchs, T. (2007). The temporal structure of intentionality and its disturbance in schizophrenia.
George, B. & Klijn, A. (2014). Psychosis susceptibility syndrome: An alternative name for schizophrenia.
The Lancet Psychiatry, 1
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Phenomenological Psychology, 39
Giorgi, A. (2009).
The descriptive phenomenological method in psychology: A modified Husserlian approach.
Pittsburgh, PA: Duquesne
Heidegger, M. (2010).
Being and time.
(J. Stambaugh, Trans.). Albany, NY: State University of New York Press. Original work published
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 '
' 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
(1985, 2005, 2010; Wertz et al., 2011)
 Bracketing -
(1) Open listening
(2) Demarcation / reflection on meaning units
(3) Individual Psychological Structures
(4) General Psychological Structure(s)
Among the psychological processes and experiences of diverse individuals diagnosed with schizophrenia-spectrum disorders...
(1) What are the
meaningful similarities and differences?
general structure or structures
(3) How are these similarities, differences, and/or structure(s)
regional and cultural life
Feb '13 May '13 Aug '13 Nov '13 Sep '14 'Dec 14 March '15 ??
Center data collection
Center data collection
zu den Sachen selbst!
(to the things themselves!)
"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:
Diagnoses don't "cut nature at its joints"
We can't agree on what a mental disorder is
Image by Edward Deeds*
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
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
Committed for life to State Hospital No.3, Nevada, MO in 1936
Diagnosis: Dementia Praecox
What can phenomenology contribute to the reconceptualization of
Phenomenology & schizophrenia
The present project
Status & References
Psychiatric Classification Systems: A
1840 1899 1918 1949/52 1968 1980 1994 2013 2025
Statistical Manual for the Use of Institutions for the Insane
: American Medico-Psychological Association (1918)
Further developed by
(e.g., 1943/1993), and
More recently systematized for social-science research by
(1975, 2009) and
(1985, 2005, 2010; Wertz et al., 2011)
(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)
-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)
Greenberg, G. (2010). Inside the battle to define mental illness.
. Retrieved 11 November 2014 from http://
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J. Barrett (Eds.), S
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(pp. 62-86). New York, NY: Cambridge University Press.
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The crisis of European sciences and transcendental phenomenology
(D. Carr, Trans.). Evanston, IL:
Northwestern University Press. (Original work published 1939)
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[Web log post]. Retrieved November 10, 2014 from http://
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