Dis-sociality: the phenomenological approach to social dysfunction in schizophrenia

After more than a century since its introduction in psychiatric nosography, schizophrenia still hides its face. We lack the comfort of a 'strong' paradigm capable of explaining the reasons for the many different schizophrenic phenotypes and of pulling these different strands together into one unified model. Psychopathological research obstinately oriented towards compiling a systematic description has failed to achieve its purpose, as witnessed by the free-fall of the first rank symptoms and more generally by the absence of pathognomonic symptoms of schizophrenia (1-3). Maj (4) proposes a recovery of the broad psychopathological organisers of the continental tradition, such as autism, advancing the hypothesis that the basic phenomenon of schizophrenic pictures lies in a disturbance of social relationships. Indeed, it is amply documented that schizophrenic pictures have varying, but generally quite pronounced, levels of social dysfunction. The de-structuring of social life (Criterion B) is a basic diagnostic characteristic of the schizophrenic syndrome (5,6). While for other psychiatric disorders the impairment of social life is a direct consequence of the clinical symptoms, in the case of schizophrenia it "does not appear to be a direct result of any single feature" (5,6). Since it is not possible to find the pathognomonic character of schizophrenia in the clinical patterns (Criterion A), it is legitimate to ask if the basic psychopathological character of schizophrenia might not lie right there in Criterion B (7,8). What gives the character of schizophrenia to certain psychotic pictures is a particular form of impairment of social life.

In what does the specificity of social dysfunction in schizophrenia consist? Social dysfunction has been considered as a direct outcome of the disease process, a phenomenon of de-socialisation due to a negative or hostile environmental reaction, or a consequence of a non-effective psychological strategy operated by ill persons. In deficit models, the impairment of social functioning is a consequence of the disease (9-13). It is possible to distinguish the process of disease from its individual and social consequences. The deficit model expresses a clear direct line between cause and effect, according to which the phenomena of illness produce over time a deficit in social functioning. In stigma models, social dysfunction is seen as an artefact, a consequence of environmental stigma phenomena. Stigma acts as primum movens and the phenomena of de-socialisation are a consequence (14). Nonetheless, a substantial literature emphasises that social dysfunction precedes the appearance of clinical signs, thus being a premise, not a consequence (15-20). In coping models, social dysfunction derives from particular ways of coping with the disease process and with situations of social interactions (21,22). Social competence would act as a factor modulating the course of the psychosis. Unfortunately, it is an extremely complex matter to establish if the disturbance of social competence is a direct expression of schizotropic vulnerability or a modulating factor of it. Besides, either we admit that the processes of coping with social situations are aspecific, or we find a qualitative peculiarity in the social coping of schizophrenic patients.

IS SOCIAL DYSFUNCTION THE BASIC DISORDER IN SCHIZOPHRENIA?

Social dysfunction has also been considered a specific and autonomous psychopathological dimension in the course of schizophrenia (23,24). It seems, moreover, to contribute to define the disease, its course and its outcome (25). Is all this enough to confirm the peculiar nature of social dysfunction in the course of schizophrenia? If this is the case, social dysfunction appears to be a trait that, albeit in a quantitatively variable manner, is present in patients even before the onset of overt symptoms and is reflected in the organisation of the person and in his/her manner of living. The concept of autism (7,26-30) expresses this disturbance of participation in social life and reflects the disturbance of social competence, or dis-sociality. It is preferable to speak of dissociality in reference to the basic disturbance of social relations indigenous to schizophrenia because on the one hand the term underscores the qualitative alteration of social competence, and on the other it goes beyond the strictly behavioural-functionalist perspective inherent in the term social dysfunction. Dis-sociality is not limited to aspects of deficit, such as behaviour inappropriate to the circumstances, lack of affective contact, detachment from social life. It is also reflected in phenomena like the tendency to rumination not oriented towards reality, rigid and non-adaptive adherence to idiosyncratic ideas, the emergence of a deviant hierarchy of values, aims, and ambitions (27-29). All this clearly expresses a disturbance of participation in social life. Rigorously defining dissociality can help us to define the meaning organiser (the fundamental phenomenon for the understanding) of schizophrenic pictures.

MODELS OF SOCIAL COMPETENCE

What is the primary ability that makes social life possible? Different schools have suggested different explicative models (Table 1) (5).

Behaviourism/functionalism. This is the shadow-paradigm of a great number of socio-psychiatric approaches. In this model (32-35), social competence lies in the ability to adopt the necessary behavioural procedures in order to satisfy one's needs and achieve one's goals. A disturbance in the implementation of social skills is supposed to be a ready consequence of the disease process. Several psychiatric disorders involve an impairment of social skills; differences are situated on a quantitative rather than qualitative level. Social competence defined by the behaviourist/ functionalist model enhances the behavioural aspects of an individual in social interaction situations. It allows rather easy and repeatable measurements, but it does not enable us to reach the patient's subjective experience and to distinguish those disturbances of social competence that are related to schizophrenia from those related to other psychiatric disorders.

Structural functionalism. This theory (36) has been adopted in psychiatry as the 'disability model' (13,37). In this model, the most important phenomenon is social adjustment, i.e. the participation in social life in an adequate manner, by behaving exactly as others expect one to behave. To be normal means to be in accordance with socially established norms. There are some behavioural patterns that are generally judged as adequate - i.e. organised systems of participation of an individual in a social system, called 'social roles'. Disability is defined by deviance from the rules and expectations of one's own social context; the landmark is given by individuals' functioning in that particular social-cultural context. The assessment of disability is based on the observation of the inability to satisfy social demands and to perform social roles appropriately. Disability is considered as a consequence of the disease, with different levels of depth and expressiveness. This model also allows repeatable evaluations, but like the previous one it is not able to differentiate dis-sociality belonging to schizophrenia. In addition to this, it flattens out the social dimension of each individual as the ability to adopt the rules of a context, placing the subjective world of meaning and values in the background.

Cognitivism. Cognitivism is the dominant approach to empirical research on vulnerability and therapeutic interventions in schizophrenia (38,39). Social competence is here described as social cognition (39-41), i.e. the ability to understand, predict and correctly respond to thoughts, feelings and behaviours of others in diverse and often unrehearsed social contexts. Social cognition is based on three types of cognitive patterns, called 'social patterns' (41): a) person patterns, b) role patterns, and c) event patterns or scripts (39-41). Person patterns are based on prototypical personal features or on specific representations of individuals. Role patterns have already been described in the paragraph about structural functionalism. Event patterns are coherent sequences of events expected by the individual, linked together by time and by their cause. Social competence lies in the ability to develop social patterns in a correct way and to use them in an effective manner. This is a necessary premise for the social cognition process. The arguments of the social cognition model are an effective explanation of social competence, in order to bypass behavioural reductionism and normative reductionism. Social cognition processes, in any case, are not the fundamental phenomenon of social competence. As a matter of fact, they assume and do not explain one's own mental ability to understand the manifestations of the mind of other individuals.

Symbolic interactionism. The social world is given by interaction processes between persons, mediated and made possible by shared symbols (42). Individuals act according to the meanings that objects and events have for them, and this meaning derives from social interactions. Each person experiences herself not through direct information but only indirectly, with the help of the ability to adopt the other's point of view. The typical feature of the adult self is the ability to adopt the whole community's point of view - the so-called 'generalised other'. This is the way single persons participate in the social community. The set of knowledge shared by the entire social community is called 'social knowledge'. This forms a sort of network of shared symbols, representing a fundamental premise to the communication process. Social competence lies in the ability to interact with others using this common symbols network. The concept of 'adopting the others' point of view' introduces, though not explicitly, the fundamental phenomenon of intersubjectivity. These concepts have influenced the psychosocial (43) and phenomenological (44) approaches to the understanding of psychoses.

Psychoanalysis. Social competence lies in the emotional ability to maintain stable interpersonal relationships (45-47). Its disturbances may be attributed to structural conflicts/defaults of the individual mind, such as pathological ways of developing object relationships. A fundamental role is attributed to the ways in which the early stage of the mother/child relationship is enacted (48). Disturbances in social competence appear as qualitatively different in different psychiatric disorders, in relation to the different pathological ways in which object relationships, attachment patterns and defence mechanisms are enacted. These concepts assume the fundamental phenomenon of primordial intersubjectivity, widely discussed in the phenomenological approach.

THE PHENOMENOLOGICAL PERSPECTIVE

In the phenomenological perspective, the social world is a product of the individual mind; i.e. the social dimension lies in the very mind of each individual. Facts, events, and objects of the world (and in general every social fact) are not considered realities that are independent from the individuals' mental activity, but as phenomena - i.e. contents related to intentional minds (the individuals' mental activities). Phenomenology has defended the inescapable subjective peculiarity of sociality, adopting as its landmark the subjective dimension of social action and the forms of symbolic mediation operated by the mind during the process of interaction between individuals. The social world is the world made of meanings understood and shared by every individual. The constant reference to the subjective dimension does not appear only as a fundamental epistemological argument or as a methodological procedure, but throughout this model it also adopts a full ethical choice feature (49-52). Recent trends in phenomenology have questioned to validity of early phenomenological attempts to develop a theory of experience of the other based on the analysis of isolated individuals (53). Recently, this solipsistic perspective has been abandoned. This has fundamental consequences. The nature of knowledge (the meaning and explanations that each of us gives to his/her own experience) becomes necessarily conventional and deriving from society. This is where one can clearly trace social constructivism features (49). The phenomenon of intersubjectivity is considered as a primordial event, rather than a category that must be attained starting from the solus ipse. As a consequence, social phenomenology abandons the naïve belief that reality is ontology. We experience objects and events as 'real' because we share their meanings with the others. The social world is the world of meanings shared by individuals who are part of it. According to phenomenology, on the one hand it is wrong to adopt a model of social interactions that bypasses the analysis of subjectivity during the process of the constitution of meanings (as behaviourism and functionalism do). On the other, it is also wrong to separate the individual mind from social phenomena as we analyse the process through which we attribute the meanings of objects and events. The analysis of subjectivity as a social phenomenon is the epistemological basis for the clarification of the impairments of intersubjectivity in schizophrenia.

THE WORLD OF SHARED MEANINGS

The social world is not established by a prescriptive order, that is a set of rules accepted by everyone. Instead, the social world is established by an interpretative order valid for every individual belonging to a specific cultural context. Every person receives and participates in this interpretative order spontaneously, intuitively and in an ante-predicative (i.e. un-reflected) manner. This interpretative order in everyday life is not a matter for reflection because it is given and taken for granted by every person (52). This interpretative order valid for everyone is called common sense (54). Common sense is not only the set of knowledgeable facts available to everyone; it is the set of interpretative procedures or 'account practices' (50) shared in a tacit and undiscussed manner by everyone belonging to the same cultural context. The social world presents itself as a building, made of arbitrary and conventional meanings, built on the edge of the great abyss of the doubt that reality is not how it is usually represented. Common sense itself covers, conceals and prevents access to this abyss of doubt. The interpretative procedures that establish common sense make it possible to experience the different phenomena of the world as solid realities whose meaning is taken for granted. The interpretative order of common sense has a moral and emotional value: each form of deviance brings bewilderment, disapproval, embarrassment. Common sense is the constitutive element of the perception of reality, and as such, it is the true pillar of normal mental life. The boundaries of the perception of reality begin from, and are traced by, the evidence of common sense. Common sense is based on the primordial phenomenon called intersubjectivity. Intersubjectivity is not just communication with others; it is the very condition that makes communication possible. The cornerstone of intersubjectivity is 'social attunement' (19,55,56), i.e. the ability to make emotional contact and establish mutual relationships; perceive the existence of others and their mental structure as similar to one's own; understand intuitively the mental manifestations of other persons; communicate with others using the shared meaning structures.

CONCLUSIONS

Social dysfunction is considered by DSM-IV as a diagnostic feature of schizophrenic disorders, but its definition lacks validity: Which theoretical paradigm lies behind DSM-IV's definition of social dysfunction? What is the relationship between social dysfunction and clinical symptoms in schizophrenia? Is social dysfunction a salient factor in the pathogenesis or should it be atheoretically considered as a state of overt schizophrenia useful for diagnostic procedures? Last but not least, are there specific landmarks of schizophrenics' social dysfunction? In this paper, we argued that the fundamental and characteristic element of schizophrenia lies in a specific kind of disorganisation of the basic structures of social life. We called this specific phenomenon 'dis-sociality' - the qualitative disturbance of spontaneous and intuitive participation in social life. We would rather use the term dissociality since the term 'social dysfunction' leads to a strictly behavioural-functionalist way of seeing things. Dis-sociality consists in a disorder of primordial intersubjectivity and common sense - i.e. the pillars of a normal mental life - which undergo severe perturbations in the early stages of schizophrenia. Primordial intersubjectivity is the very condition that makes communication possible. Its cornerstone is social attunement, that is the affectiveconative- cognitive human ability to perceive the existence of others as similar to one's own, make emotional contact with them and intuitively access their mental life. The sharing of meanings and of social scripts, the understanding of rules and the adoption of adequate behavioural procedures all depend on the pre-existence of a valid social attunement. Social attunement affords the constitution of common sense. Common sense is the interpretative order valid for every individual belonging to a specific cultural context that makes possible the existence of a socially shared world. Every person receives and participates in this interpretative order spontaneously. Common sense is a set of knowledgeable facts available to everyone (social knowledge) and a set of interpretative procedures (account practices) shared in a tacit understanding by everyone belonging to the same cultural context. Common sense prevents the access to the abyss of doubt. Is this very abyss of perplexities, that in normals is concealed by common sense, the landmark of early precursors of schizophrenic experiences? Are deviant behaviours in pre-schizophrenics the epiphenomena of the disorders of primordial intersubjectivity and common sense? Are also the disorders of social adjustment, cognition and knowledge the consequences of those more basic disorders pointed out by phenomenological analyses? Can schizophrenic dissociality be distinguished from social dysfunction in general according to phenomenological criteria? Our answers to these questions is 'yes'. But, of course, we still need a great deal of work to define the dis-sociality of schizophrenics, this primordial disorder of conceptualisation of the world and its relationships with idiosyncratic ways to get in touch with the others.

Table 1.

What is social competence?

Model	Ability	Conceptualisation
Behaviourism/functionalism	Social skills	Ability to adopt the necessary and adequate behavioural procedures
		in order to satisfy one’s needs and achieve one’s goals
Structural functionalism	Social adjustment	Ability to internalise the rules of a specific socio-cultural
		environment, and use them as a guideline to one’s own behaviour
Cognitivism	Social cognition (social schema)	Ability to understand, predict and correctly respond to thoughts,
		feelings and behaviours of others
Symbolic interactionism	Social knowledge	Ability to use and share the symbolic means of communication
Psychoanalysis	Object-relationship attachment	Emotional ability to maintain interpersonal relations