Values in Persons With Schizophrenia

Abstract

This is an explorative study on the values of persons with schizophrenia based on transcripts of individual therapy sessions conducted for 40 persons with chart diagnoses of schizophrenia or schizotypal disorder. Values are action-guiding attitudes that subject human activities to be worthy of praise or blame. The schizophrenic value system conveys an overall crisis of common sense. The outcome of this has been designated as antagonomia and idionomia. Antagonomia reflects the choice to take an eccentric stand in the face of commonly shared assumptions and the here and now “other.” Idionomia reflects 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,” often in view of an eschatological mission or a vocation to a superior, novel, metaphysical understanding of the world. The aim of this study is neither establishing new diagnostic criteria nor suggesting that values play an etio-pathogenetical role in the development of schizophrenia but improving our understanding of the “meaning” of schizophrenic experiences and beliefs, and by doing so reducing stigmatization, and enhancing the specificity and validity of “psychotic symptoms” (especially bizarre delusions) and of “social and occupational dysfunction” through a detailed description of the anthropological and existential matrix they arise from.

Introduction

There is an axiological dimension in schizophrenia. The purpose of this article is to illustrate it—to describe the structure of schizophrenic people's values, the principles that make up the pivot of their morality and meaningful actions, and their “philosophy of life.” This axiological dimension is a component of human suffering that descriptive psychopathology (and even more so, clinical psychiatry) has often disregarded. A recent issue of this Journal¹ has focused on the attitude of healthy people toward persons with schizophrenia, but the value system of persons with schizophrenia remains unfocused. The neglect of the value system of persons suffering from schizophrenia contributes to seeing them merely as people who bear pathological experiences and beliefs; this may have a stigmatizing effect on them and contribute to judge some of these people's actions as meaningless and incomprehensible.

Values are attitudes that function to regulate our actions. Although they do not coincide with symptoms described in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, text revision's (DSM-IV-TR's)² criteria A and B, values are part of the “background” and the “surrounding” of schizophrenic symptoms as usually described and assessed. Mainstream descriptive psychopathology chiefly focuses on signs and symptoms that are supposed to be relevant for diagnosis. A consequence of this “tunnel vision” is that much of the “life-world” persons with schizophrenia live in remains out of view. As recently stated by Andreasen, “we need to go beyond simply doing DSM checklists of current symptoms when we evaluate our patients.”³ On the whole, the way persons affected by schizophrenia inhabit their worlds is hardly researched. Not only are these “fringe” phenomena underresearched and underdescribed, they are also undertaught in educational programs and underinvestigated in clinical interviews. Values are part of this submerged continent.

Descriptions of values in persons with schizophrenia can be found in classic descriptive clinical psychiatry, eg, Kretschmer,⁴ and in the area of phenomenological and anthropological psychiatry, including the works by Berze and Gruhle,⁵ Minkowski,⁶ Binswanger,⁷ and Blankenburg.^8,9

Our aim is neither establishing new diagnostic criteria nor suggesting that values play an etiological or pathogenetical role in the development of schizophrenia. Rather, our aim is to improve our understanding of the life-world persons with schizophrenia live in, and by doing so reducing stigmatization, and enhancing the specificity and validity of “psychotic symptoms” (criterion A) and of “social and occupational dysfunction” (criterion B) in DSM-IV.² We do this through a detailed description of the anthropological and existential matrix criteria A and criteria B features arise from.

What Are Values?

Values are action-guiding attitudes that subject human activities to be worthy of praise or blame.^10–12 Although values are articulated in concepts, they are concepts of a special kind because they are originally given in feelings, not in reason.^13–14 This means that the conceptualization of values by a person is experientially preceded by her perception of what is valuable (or not) in the realm of her emotional experience. Values are inseparably tied to emotional experience; they are not logical abstractions existing per se somewhere in the mind of a person (neither are they properties inherent to things). The connection of values and emotions is of the essence. In experiencing values, we experience the priority of feeling (the emotional, prereflexive experience of preferring) over reasoning and thinking (reckoning) and over willingness (intentionally choosing). Feeling values is then essential to the person's acts because it (although almost implicitly) orientates actions. Because values tend to form a structure, they imbue emotions with a hierarchical order. They impress their order to the “chaos” of a person's emotions. Values are also rooted in a given modality of being in the world or ontological constitution, ie, a given type of a person's relatedness to one's own self, others, and reality. Because of that, values entail metaphysical assumptions and worldviews that involve notions about the good, the important, the true, and the real.¹² This is especially relevant in the case of people with schizophrenia, whose being in the world involves fragility of the tacit dimension of self-coherence that is at the base both of subjectivity and intersubjectivity, a pervasive experience of self as absent or missing to the subject and of the world and the others as unreal and made-up.

Schematically,¹⁵

• i. Values are beliefs but not cold beliefs: they are not logical abstractions but are originally given in feelings and inextricably tied to emotions.

• ii. Values are motivational feelings: they refer to desirable/undesirable goals that person strives to attain or avoid.

• iii. Values are general attitudes that transcend particular actions and situations. This distinguishes values from norms which refer to specific situations or actions.

• iv. Values serve as (often implicit and prereflexive) criteria for emotive preferring (more than reflexive or rational choosing): they guide the evaluation of actions, people (including the self), and events.

• v. Values form a structure that is rooted in the person's ontological constitution: they form a rather coherent order and as such they suffuse and organize the person's emotions.

As we will see, persons with schizophrenia are worried with the status of reality of those phenomena which for us are "facts," ie, they mainly have ontological concerns (what is reality and what is “really” real). Their values often prove to be coherent with these metaphysical concerns.

Values in Persons With Schizophrenia: the Legacy of 20th Century Psychiatry

Kretschmer: Moral and Emotional Idiocy

It was Kretschmer⁴ who led the way to a naturalistic description of the connections between the unsociability of schizoid and schizophrenic persons, their abnormal mix of emotions, and their structure of values. Among schizoid and schizophrenic people, there are “quiet enthusiasts” who, in their flight from humanity, extravagantly pour out all the sensitive tenderness of which they are capable over the beautiful still objects of nature or the dead contents of a collection of books. Others, the “sulky eccentrics,” are prophets or inventors who brood “in a locked, ill-ventilated dungeon”^4(p160) over their own metaphysical trains of thoughts. Other schizoid or schizophrenic persons cultivate an aristocratic etiquette and impersonal formalities in their need for distance and their “wish that things were otherwise and better.”^4(p161) Many of these people indulge in endless self-analyses concerning psychological and ethical questions; their worldview often develops out of a sharp metaphysical antithesis between “I” and “the external world.” Their cramping reflections concern objectivity, rectitude, fidelity, nobility, and purity.

Kretschmer thus reconstructs the system of values that subtends and to certain extent motivates the autistic behaviors. Their “disinclination for human society”—he says—“is seldom mere unfeeling dullness, it usually has a clear admixture of displeasure, of active turning away, of a defensive or more offensive character.”^4(p158) Autistic behaviors (unsociability and eclectic or superficial sociability) and values (concerns for objectivity, rectitude, etc) emerge out and are the protection and compensation of a peculiar mix of hypersensitivity and of lack of affective resonance.

Minkowski: Being in Contradiction With Life

Minkowski⁶ followed Kretschmer's footsteps in emphasizing the connections between values, emotions, and alienation in persons with schizophrenia. He describes a 32-year-old teacher. He is isolated from the external world and from other human beings; his vital contact with reality is broken down. He is extremely interested in philosophical problems but avoids reading philosophy books that may “disturb” his own reflections and “deform” his own thinking. He isolates himself from the world, he says, in order to find in himself the spring of his philosophical thoughts. Minkowski designates this “antithetical attitude”: every force coming from without the self is feared as an attack to one's own individuality. People who have an antithetical attitude feel vulnerable to the influx coming from the external world and claim their independence as the most important value. The teacher builds his philosophy of life according to his antithetical attitude: one has to decide to be alone, he holds, in order to avoid all perturbations coming from the external world and detach himself from all materiality and decide according to “impersonal principles.”

His ideas are not attuned to reality; his impersonal speculations are in contradiction with life. He judges all actions according to abstract and rational dichotomies. This is called by Minkowski morbid rationalism, an intellectualistic attitude that consists in governing one's own life only according to abstract principles and renouncing the extrarational feelings of harmony with oneself and the outer world.

Striving for or Faithfulness to One's Own Eccentricity?

The German psychiatrists Berze and Gruhle⁵ claimed that the eccentricity (Verschrobenheit) (Blankenburg¹⁶ translates Verschrobenheit with “queerness” that according to the Oxford Concise Dictionary perhaps originates from German quer, meaning oblique or thwart. We have chosen to translate it with “eccentricity.” Another option would be “bizarreness”) of people with schizophrenia is not an isolated feature but the core of a global and deliberate attitude: “The schizophrenic wants to be against, the schizophrenic is always […] if not anti-social—at least anti-traditionalist, anti-conventionalist.”^5(p151) The oppositional behavior of persons with schizophrenia is not a “defect,” rather the effect of a “diverse will.”^5(p118)

The eccentricity of persons with schizophrenia is the outcome of a difference that has been chosen. According to Berze and Gruhle, the value system of schizophrenic persons is centered on a deliberate epistemological and ethical attitude consisting in the disdainful refusal of taken-for-grantedness that is of conventional meanings, values, and beliefs. Persons with schizophrenia are purposely oriented toward being against the ordinary mode of existence.

Binswanger⁷ rejected Berze and Gruhle's idea that schizophrenic eccentricity is based on a choice. People with schizophrenia are not eccentric because they try to be different. Their weird behavior is not simply the consequence of an antagonistic lifestyle choice. Binswanger holds that persons with schizophrenia do not strive for being against as such; rather, they strive to be faithful to their own eccentricity, to their own being so. The eccentricity of persons with schizophrenia is a matter of ontology, it is a given, not a lifestyle choice. They are eccentric; therefore, they feel and look different. Not schizophrenic eccentricity itself but the schizophrenic persons' being faithful to their own eccentricity is a matter of choice. What they value most is being loyal to their being and principles as their own. Their eccentricity is the consequence of both—a priori peculiarity and deliberate fidelity to it.

Blankenburg⁹ speaks of a “pseudovoluntary choice” of alienation.^9(p192) People with schizophrenia to a certain degree seem to flirt with their psychosis.^9(p195) Their preference for eccentricity apparently contributes to their alienation. One of the most important tasks of anthropological psychiatry, says Blankenburg, is to approach the question—are persons with schizophrenia striving for eccentricity or are they striving to be faithful to it? The question needs to be approached with a subtle empiricism, characteristic of good clinical phenomenology, rather than with ideological prejudices.

The Value System of Persons With Schizophrenia and the Breakdown of Common Sense

Common sense functions as the fundamental bond that links each individual to the social world; it is the genuine milestone and condition to the possibility of social life.¹⁷ Schizophrenia involves a profound alteration to common sense, ie, to the symbolic register of socially shared meanings^8–9 and of prereflexive I-you attunement.¹⁸ Both the feeling of perplexity, ie, the depths of doubt that occurs during the initial phases of schizophrenia, and the deviated behavior during the premorbid period can be seen as an expression of a crisis of participation in common sense.¹⁹ The loss of the reassuring participation in socially shared interpretative procedures leads to the inability to understand the meaning of the objects that occupy one's own cultural context, the sets of regulations required by social situations; all this takes on a totally different value for people suffering from schizophrenia, compared with healthy people.^15,20

Common sense is a framework that disposes a person toward certain values and a context that serves to structure such values. Eccentric values in persons with schizophrenia are one aspect of an overall crisis of common sense; the outcome of this has been designated as antagonomia²¹ and idionomia.²² Antagonomia reflects the choice to distance oneself from common sense rules and take an eccentric stand in the face of commonly shared assumptions and the here and now “other.” Idionomia reflects the sentiment of the radical uniqueness and exceptionality of one's own internal law (nomos) with respect to common sense or the other human beings. This may go together with an appreciation of one's own radical exceptionality, that is felt as a “gift,” often in view of an eschatological mission or a vocation to a superior, novel, metaphysical understanding of the world. All this will be analyzed in depth in the following sections.

We assume here that antagonomia and idionomia in persons with schizophrenia form a structure that is rooted in the person's ontological constitution. The problem, in this vein, is 2-fold: (1) we need to make the values of persons with schizophrenia the object of a more subtle empirical analysis and (2) we need to see what is the connection between values and the essential character of the ontological constitution (ie, their eccentricity) of persons with schizophrenia.

Methods and Cautionary Remarks

What Is Clinical Phenomenology?

The overall framework is provided by the phenomenological approach in psychopathology. As recently stated by Kendler,²³ “psychiatry is irrevocably grounded in mental, first-person experiences.” To introduce the method adopted here, we will first answer to the following questions²⁴: (1) what is the focus of study of clinical phenomenology? and (2) what does clinical phenomenology look for?

• (a) Phenomenology is the science of the subjective, and clinical phenomenology is the science of abnormal subjectivity. Its basic concerns are what is it like to be in a certain mental state? and what is the personal meaning of that certain state? The first question explores the experiential level, the feeling of an experience. Experiences do not only have an information content, they also have a certain feel, ie, the subjective quality or the what-it-is-like of an experience.²⁵ Each psychopathological experience is also accompanied by a personal meaning or value that the patient attributes to it, ie, each patient may take a certain position with respect to his abnormal experiences.

• (b) Clinical phenomenology looks for the meaningful organization of the other's experiences, expressions, and behaviors, pointing to the narrative understanding of the other. Narratives are synthesizing schemes of comprehension, conferring a unitary meaningfulness to prima facie heterogeneous phenomena.²⁶ Narratives have to make sense and to be internally coherent. Clinical narratives must be distinguished from medical history because the latter mainly focuses on the impact of the illness on the biological body and its functions, whereas the former enables the interviewer to grasp what the disorder is like for that particular patient, her unique biographical situation, and the values inherent in that situation.²⁷ Narratives must also be distinguished from diagnostic categories because the latter fix a priori systems of meanings which obscure personally structured meanings and may force researchers and clinicians to stretch the patient's subjective experiences and beliefs to fit the diagnostic criteria.

Internal coherence is an essential requirement for narratives.²⁸ Narrative coherence, sometimes referred to as “thick description,”²⁹ is the final aim of this feel- and meaning-oriented approach. Through a cycle of interpretations, it aspires at forcing the tacit, implicit, and opaque to the surface of awareness³⁰ and collect a range of indicators that point to multiple facets of a potentially significant construct.³¹

Methodology

The theoretical framework of our inquiry is clinical phenomenology, its empirical method is grounded theory,³² a qualitative research method entailing (1) detailed, systematic, but flexible interrogation of initially unstructured phenomena selected for its close relationship to the problem under investigation, (2) maximum flexibility in generating new categories from the phenomena promoting dense conceptual development, and (3) 2-way dialectical process between phenomena and the clinician's conceptualizations. The basic epistemological requirements are summed up in figure 1.³³

Fig. 1.

Quality Checklist for a Qualitative Study.

The aim of our study is assessing the value system of persons with schizophrenia. We adopted a qualitative methodology because this is an explorative study, and our focus has been permanently on subjective experiences and explicit self-reports. To our knowledge, no structured interviews are at present available in this field. We have assumed that the detailed analysis of subjectivity is the cornerstone of psychiatric research,³ and it is “particularly valuable to hypothesis development.”³⁴ Values have been evaluated via sentences spoken by patients and faithfully reported in the clinical files. The sentences reported here are exemplifications of the values of persons with schizophrenia, as they were made explicit during therapeutic interviews—not research interviews. All the interviewed patients are or have been in long-term treatment with one of the 2 authors. Each subject included in this study was interviewed at least 10 times. In the course of interviews, persons were encouraged to narrate, conceptualize, and elaborate on the principles that influence their choices and actions. Extensive notes were taken during each interview. Phenomena were gathered from interview transcripts and from diaries or personal notes provided from patients or their relatives. Transcript analysis was done by highlighting, cutting, and pasting when similar themes occurred in interviews.³¹ Elaborations of these materials and coconstruction of meaningful narratives were seen as part of the treatment as well as of the inquiry. We assume that a long-term therapeutic setting enhances trust and dialogue as basic prerequisites for an in-depth exploration of values, ie, beliefs that are originally given in feelings and inextricably tied to emotions. This is a potential limitation of this kind of inquiry because it may imply a selection bias excluding noncompliant patients.

Phenomena were tentatively grouped together according to constant comparison and active theoretical sampling.³⁵ Constant comparison is an analytical task of sifting and comparing the elements gathered during interviews according to their similarities in order to generate the basic theoretical property of a given group of phenomena. Theoretical sampling is the active sampling of new relevant cases as the analysis proceeds in order to deepen the interviewer's emergent understanding and not only to generalize hypotheses.

We started from individual narratives in order to capture a core theoretical feature of a certain type of phenomenon, ie, a feature that may help to make sense of the other manifestations of a certain type of existence. (Efforts have been made to incorporate into our general interpretation data that apparently were in contradiction with the majority of findings.) Of course, the complexity of the value system of people with schizophrenia cannot be reduced simplistically to the image depicted here—nor to any other more or less stereotyped vision. There is much more than this in “real” persons with schizophrenia, and this account has been read as the description of a kind of “ideal type” that always remains in tension with more divergent ways of living, and with “normal” aspects of humans' lived world.

A common critique of studies like this one is that they may have the effect of reifying and essentializing what is schizophrenic in a way not warranted by any large-scale empirical evidence. The aim of this study is not defining a statistically significant phenomenon that is present in persons diagnosed as affected by schizophrenia; rather, the purpose is to shed light on the meaning of a certain type of phenomenon.

Another potential critique to our method is that in the way any person acts there is a lot more than just what can be made explicit in affirmations. Perhaps what is more important is a person's ethos—what he does more than what he says. However, the statements reported here have never been in obvious conflict with these peoples' actual behaviors.

Last but not least, a potential limitation of our study, that is based on a narrative approach, is that it may imply a selection bias excluding patients noncompliant to a dialogical approach, eg, negativistic or withdrawn patients. Also, patients with high linguistic competence may be overrepresented. The final picture may not be representative enough of the actual state of severe “negative” or “disorganized” patients.

Clinical Sample

This article is based on a review of transcripts of individual therapy sessions we have conducted for 40 persons with chart diagnoses of schizophrenia or schizotypal disorder according to DSM-IV criteria. Only a small number of our patients (N = 7) were uninterested in talking about their values and personal beliefs, or could give scanty information, or explicitly declined to report about them; their clinical and sociodemographical characteristics were similar to those of respondents. All respondent patients, on whom these observations were based, (N = 33) were adults treated in an outpatient clinic of a medical center under voluntary and routine conditions. All patients gave their consent to contribute to our research on the values of severe psychopathological disorders. Twenty-seven patients suffer from full-blown schizophrenia (undifferentiated = 5; disorganized = 8; paranoid = 14) and 6 fulfill criteria for schizotypal personality disorder. The majority of patients were male (males = 20; females = 13), 22 to 60 years of age (mean = 35.6; SD = 11.7), and all were prescribed psychiatric medications. Nonschizophrenic psychoses (affective psychoses, delusional disorders, and psychoorganic or drug-induced psychoses) were accurately excluded. We also excluded all patients with mental retardation, drug addiction, severe cognitive impairments, and patients with schizophrenia, residual type. Mean duration of illness is 14.3 (SD = 11.1). The average educational level is 11.8 years of education (SD = 2.7). None of the patients were homeless or lack adequate economical support. None of them was currently married. All patients with schizophrenia still lived in parental families, were engaged in daily rehabilitation programs, and (except one) were unemployed; all schizotypals were employed.

Results

In our interviews, the schizophrenic value system emerges as an overall crisis of common sense. There are 5 features to this.

Ego-Syntonic Feelings of Radical Uniqueness and Exceptionality

Persons with schizophrenia feel “detached from (commonly shared) reality” and “away from home”; they claim to be “radically different from all other people” and “exceptional” (see table 1). Their sentiment of exceptionality is apparently rooted in strange sensations (eg, “I feel strange energies,” “[I feel] perhaps an alien or an evil creature”), experiences of disconnection from commonly shared reality (eg, “In my head there is the time zone of California,” “I would be away from home in any part of the world”), and quasi-solipsistic feelings of being the creator of one's own reality (eg, “I live from the reality I am able to build,” “I don't perceive anymore what I feel, but what I imagine”). These strange unusual phenomena are not felt as merely disturbing or alienating but are ego-syntonically embedded in the person's narrative identity as a gift or a privilege (“This does not happen to everyone!,” “It's a privilege”). They are the source of extremely relevant questions, inquiry, and speculations; these feelings of radical exceptionality are frequently integrated in the value system of persons with schizophrenia and may be meaningfully connected to their characteristic metaphysical concerns (“I am a psychoparanoid detached from reality. One of these days someone should explain to me what reality really is”), as is addressed in the next feature.

Table 1.

Ego-Syntonic Feelings of Radical Uniqueness and Exceptionality

1. When I met my girl-friend, in the beginning I was moved by her. You see, she was a student away from home [“fuori sede,” in Italian] … Well, I would be “away from home” in any part of the world.

2. I've always thought to be radically different from all other people, perhaps an alien or an evil creature. It depended by all my strange thoughts that surprised me.

3. I am a psychoparanoid detached from reality One of these days someone should explain to me what reality really is.

4. I wake up very early in the morning and in the afternoon I go to sleep. In my head there is the time zone of California.

5. I am very sensible. I feel strange energies. This does not happen to everyone.

6. I have been chosen for the experiment. It's a privilege.

7. I live from the reality I am able to build.

8. I don't perceive anymore what I feel, but what I imagine.

Metaphysical Concerns, Including Ontological, Anthropological, and Semantic Concerns

Persons with schizophrenia are not satisfied with what appears in immediate experience and are concerned with metaphysical questions (see table 2). These questions are chiefly ontological. Ontology (from on ont- being + logos) is the theory of being, the discourse about things that constitute reality and especially about their “being,” ie, their existence (vs nonexistence) and their true meaning (vs ordinary meaning). Ontology, as a branch of philosophy, deals with a series of conceptual dichotomies like appearance/actuality, necessity/contingency, permanence/transience, singularity/universality, substance/accident, identity/diversity, etc. It is essentially concerned with questions like what really exists, in contrast with what only seems to exist? What does exist independently and unconditionally, in contrast to what exists dependently and conditionally? and what does permanently exist, in contrast to what only temporarily exists? Persons with schizophrenia are especially explicitly concerned with the first question (eg, “I must test the reality of reality”). The following sentence epitomizes the ontological attitude: “My attitude towards life can be summed up as follows: It is as if we were all at theater. But, whereas, all the others are focused on what happens on the stage I cannot help thinking of what's going on backstage, what makes the scene possible.” They observe everyday, pragmatic reality from without (eg, “I am like an emperor in a pyramid. I am not involved in the world, merely observing it from outside to understand its secret workings,” “I am a detached onlooker”), engaged in understanding its workings either being skeptical about the face value of phenomena (eg, “It is not enough for me to take things as the others do”) or feeling unable to unreflectively grasp their meaning (eg, “The others know the rules; I have to study them”). Many persons with schizophrenia report that they feel like anthropologists, as if they were coming from another planet (eg, “I am like an anthropologist,” “I am an anthroponaut lost at sea”). Human actions and interactions are their focus of concern and research (eg, “I like to get walking around. I am fascinated by observing other people in everyday activity and seeing how it functions”). Also, persons with schizophrenia may be unsatisfied with ordinary semantics for articulating their own way of experiencing the world (eg, “I don't understand why this has to be called a table, and if the sun's out we have to say it's a nice day”) and look for alternative means of expression (eg, “I will use my left hand for writing in order to activate a new part of my brain”).

Table 2.

Metaphysical Concerns (Including Ontological, Anthropological, and Semantic Concerns)

1. I am like an emperor in his pyramid. I am not involved in the world, merely observing it from outside to understand its secret workings.

2. The others know the rules; I have to study them.

3. I am a detached onlooker.

4. I am like an anthropologist.

5. I am an anthroponaut lost at sea.

6. I like to get walking around. I am fascinated by observing other people in everyday activity and seeing how it functions.

7. My attitude towards life can be summed up as follows: It is as if we were all at theatre. But whereas all the others are focused on what happens on the stage I cannot help thinking of what's going on backstage, what makes the scene possible.

8. I must test the reality of reality.

9. I come up against something, in the street, anywhere, and suddenly I don't see “him”, but instead I see in him, then I see from him … I live trembly vital unique saturated exploding-over-its-banks … energy that implodes in a single dot and the thinking galaxy expands out … black hole and white hole … blind whirlpool and light … maybe you'd just say, call them a wren, a rock, a cat, a cloud, a blade of grass … my psyche finds hospitality there, becomes a part of it, is it.

10. It is not enough for me to take things as the others do. They are happy with that. I need endless explanations of all that happens. “Why does that happen?” “What does that mean?” “How to explain it?”.

11. I don't understand why this has to be called a table, and if the sun's out we have to say it's a nice day.

12. I will use the left head for writing in order to activate a new part of my brain.

Charismatic Concerns

The sentiment of radical uniqueness and exceptionality of persons with schizophrenia may entail their feeling gifted (charisma originally means gift, although in ordinary language it has the connotation of “emotionally compelling” or “attractive”) with superior spiritual powers (eg, “I have this spiritual level,” “I have the invention in my head”) (see table 3). They feel chosen for an important eschatological (eschatos means “ultimate”) task (eg, “I was chosen for this. Something extremely important”) and committed to use their privilege to save mankind from the Evil (eg, “I was given this task from God: the fight between good and evil,” “I have a mission, I should look for the Devil”), to build a better and more authentic world (eg, “To build a more liveable and fraternal world,” “I walk downtown in Florence watching the most important monuments meanwhile I dictate how to improve them”), or a deeper understanding of reality (eg, “I was given some powers from God to penetrate the deep sense of reality”), or of other people (eg, “I made my senses more sensible to feel the Holy Spirit of people”). Thus, the sufferings, detachment from reality, desertification of the world, and uncanny sensations of persons with schizophrenia get the character of a charisma (eg, “Through suffering from God I will have the power over the Planet. This will happen as soon as all people will disappear from the world. It will be a desert planet, I will be able to pass from one temporal dimension to another, I will meet only replicas of myself”). There is an in-order-to quality of a commitment or a value, ie, of a set of motivational feelings, rooted in the person's ontological constitution, that serve as the criterion for preferring and acting in a given way.

Table 3.

Charismatic Concerns

1. Doctor, I have a mission to accomplish. First of all, to build my country, Somalia, then together with my brother to build a more liveable and fraternal world. I realized that there is a new culture in the world, tomorrow's world, that of brotherhood.

2. Through suffering, from God I will have the power over the Planet. This will happen as soon as all people will disappear from the word. It will be a desert planet, I will be able to pass from one temporal dimension to another, I will meet only replicas of myself.

3. I feel some energies, and this does not happen to everybody. I have this spiritual level. I have this privilege, I was given this task from God: the fight between Good and Evil, till the defeat of Evil.

4. I have the invention in my head. Mine is not an illness, it is an experiment. I was chosen for this. Something extremely important.

5. I made my senses more sensible in order to feel the holy spirit of people.

6. I walk around downtown in Florence watching the most important monuments, meanwhile I dictate how to improve them.

7. I suffered from acute mysticism. I knew that I was given some powers from God to penetrate the deep sense of reality.

Refusal of Interpersonal Bonds

Next to these feelings of detachment from commonly shared reality and from other people, we find the deliberate choice to distance oneself from the here and now “other” (see table 4). Being disconnected and the refusal of intimate interpersonal connections often coexist (eg, “I cannot reach them but I also don't want to reach them,” “I am not able to take part in the world as the others and I don't like it”). Interpersonal bonds are rejected (eg, “Interpersonal bonds have no reason to exist”) and one's own tendency to identify with the others is especially feared (eg, “I reject my tendency towards identifying myself with what the others say,” “ What I detest more than anything else is being persuaded by others”). The contact with other human beings may be felt as a dangerous source of loss of identity (eg, “I'm getting to be more humane. Will it ruin my brain? All this humanity is upsetting my own special framework. It's polluting me”) or original thought (eg, “I would like to be clear-headed to have intuitions. And for this I would like not to be too domesticated”). Detachment and feeling different from others are acknowledged as positive values (eg, “I feel all right on my own,” “I've always liked being different very much”).

Table 4.

Refusal of Interpersonal Bonds

1. What I detest more than anything else is being persuaded by others.

2. I reject my tendency towards identifying myself with what the others say.

3. Interpersonal bonds have no reason to exist.

4. I'm changed. I'm getting to be more humane. Will it ruin my brain? All this humanity is upsetting my own special framework. It's polluting me.

5. I cannot reach them [other people], but also I don't want to reach them.

6. I used to put on a mask: at school, at work in order to do things like the others do, like my mother wanted. I am not able to take part to the world as the others do and I don't like it.

7. I feel all right on my own. I know the goals of people of my age, but I am old fashioned, I do not have the initiative for them, I do not belong to them.

8. I would like to be clear-headed to have intuitions. And for this I would like not too be too much domesticated.

Refusal of Common Sense Knowledge and Semantics

The last feature of the value system of persons with schizophrenia is their choice to distance themselves from common sense rules and take an eccentric stand in the face of conventional meanings, values, beliefs, and ordinary ways to convey them—all this epitomized in the sentence “My aversion to common sense is stronger than my instinct to survive” (see table 5). Essential features of the value system of persons with schizophrenia are a disdainful refusal of the ordinary way of being and the taken-for-granted understanding of reality (eg, “Man is merely a heap of memories in a standard hardware,” “The brain is a believalogical imbecile”), a skeptical attitude toward conventional knowledge (eg, “Mathematics, geometry, art, and justice, are the improper certainties of human beings,” “Objectivity is the involution of subjectivity”), a praise of disconnectedness and an attempt at bracketing common sense to get a deeper understanding of reality (eg, “Revelation is a subjective vision of the human condition disconnected from the “common” idea to be or to belong to the human condition,” “Madness is necessary to human intelligence to get to the higher levels”). Sometimes, this rejection of common sense and “objective” knowledge is part of a more general clash between oneself as a “different” and unique person and the other human beings that are felt as a dangerous source of loss of individuality (eg, “Civilisation is objectivity made common by the incompatibility of subjectivities,” “By being by myself I am able to understand that nothing has a sense”). Common sense, the tacit codex that implicitly allows human beings to understand each other, is at the same time lacking and rejected (eg, “I admitted the physiological abjuration of common sense, in the moment in which I could admit the desperate effort to understand the tacit codex that is implicit in human actions”). A skeptical attitude also involves conventional semantics. Its main characteristics are criticizing the usual object-meaning pairing allowed for by common sense and the attempt to devise better tools to express one's own often idiosyncratic experiences (eg, “It's time to change this objective handwriting into a subjective one” [written on a diary where the handwriting goes on with an idiosyncratic alphabet]).

Table 5.

Refusal of Common Sense Knowledge and Semantics

1. The brain is a believalogical imbecile [he means here everybody's brain. ‘Believalogical’ is the translation of credilogiche that also in Italian is a neologism].

2. Man is merely a heap of memories in a standard hardware.

3. People buy a ticket to get on a train—that is the rule. But this rule is for them, not for me.

4. Civilisation is objectivity made common by the incompatibility of subjectivities.

5. Revelation is a subjective vision of the human condition disconnected from the “common” idea to be or to belong to an objective human condition.

6. Mathematics, geometry, art, justice, etc. are the improper certainties of human beings – improper since they are objective. Objectivity is the involution of subjectivity [‘objectivity’ here means common-sense knowledge].

7. My aversion to common sense is stronger than my instinct to survive. That's why I say that being against common sense is both a gift and a punishment at the same time.

8. I admitted the physiological abjuration of common sense, in the moment in which I could admit the desperate effort to understand the tacit codex that is implicit in human actions.

9. Madness is necessary to human intelligence to get to the higher levels.

10. [Ironically] By being by myself I'm able to understand that nothing has any sense. That's why I'm everybody's friend; because that's how I can see that everything has a sense.

11. It's time to change this objective handwriting into a subjective one [written on a diary where the writing goes on with an idiosyncratic alphabet].

Discussion

This study represents a still primitive, explorative attempt at making the value system of persons with schizophrenia perspicuous; this attempt is, above all, based on the patients' personal accounts. In our interviews, persons with schizophrenia convey an appreciation and often an exaltation of their own feelings of radical uniqueness and exceptionality. Sometimes, all this is claimed as the result of a free choice, the effect of a “diverse will” (as assumed by Berze and Gruhle⁵); other times it is felt as a destiny, an ontological necessity, and not a lifestyle choice. Their claim to be “radically different from all other people” (category 1) is seemingly rooted in a profound metamorphosis of self-awareness. Parts of the self are objectified, spatialized, ie, felt as existing in an outer space. For instance, thoughts may be experienced as existing somewhere outside the limits of what defines the self, and persons may feel thrown away from their natural seat and can only contemplate themselves from the outside or from a third-person perspective.³⁶ In this state, there is a loss of prereflexive, immediate self-awareness, including the feeling of agency (the sense that it is I the source of this thought or movement) and of ownership or myness (the sense that it is I who am experiencing this thought, emotion, or movement as my own). The sentiment of exceptionality is grounded in anomalous sensations, feelings of disconnectedness from commonly shared reality, and solipsistic experiences.³⁷ Values are embedded in a context—a world—that is quite different from common sense world. We suggest that (as Binswanger⁷ has predicted), this feeling of ontological eccentricity (transformation of self-world relationship) is the core value in persons with schizophrenia. This core value or Ur-value is not an articulate concept, rather an evaluative attitude that arises from a special kind of self-world transformation. It is basically a given, not a choice, and the source of the characteristic charismatic and metaphysical concerns in persons with schizophrenia.

The remaining 4 sets of phenomena are tentatively grouped together according to their similarities and theoretical affinities. Through this method, 2 basic theoretical properties were generated: idionomia and antagonomia. Idionomia includes metaphysical concerns (category 2) and charismatic concerns (category 3). These phenomenal dimensions form together a coherent structure whose basic feature is the sentiment of the radical uniqueness and exceptionality (idios) of one's own nomos or internal law with respect to common sense or the other human beings. Idionomia is originally given in this sentiment and tied up with emotions like “exaltation” and “fascination.” Persons with schizophrenia may feel their ontological eccentricity as the supernatural sign of their vocation to an eschatological mission or to a deeper understanding of the world. These are 2 different ways to react to this feeling of ontological eccentricity: a metaphysical trend (the concern to discover the essence of reality of which other people are ignorant) and a charismatic trend (the concern to use one's own gift to save mankind).³⁸ Both display that one's own radical exceptionality is positively appreciated and taken as the grounds of an eschatological mission to accomplish. Persons with schizophrenia are captivated by the perplexing metaphysical complexity of existence; their value system reflects this “exalted fascination”⁷ for “what is going on in the backstage” and their being disconnected to what appears in immediate experience. Spellbound to ultimate questions and never-ending ontological and anthropological inquiries, persons with schizophrenia lose the “vital” contact with here and now reality. Morbid rationalism⁶ precisely captures the deliberate epistemological option at work in idionomia, which is an intellectualistic attitude that disparages all skill to shape knowledge in a contextually relevant manner. Also, the concept of “hyperreflexivity”³⁹—ie, a kind of exaggerated self-consciousness, ie, a tendency to direct focal, objectifying attention toward processes and phenomena that would normally be “inhabited” and thus would not pop-up in explicit awareness—nicely portrays the nonintentional, passive side of idionomia.

The most characteristic psychotic symptoms of schizophrenia, ie, delusions, typically involve idionomia in that they focus on the metaphysical status of reality (and not merely on ontic or empirical-pragmatic issues, like being attacked or conspired against as in persecutory delusions that are not specific to schizophrenia). Typical schizophrenic delusions have as their theme the “being” of the world and its components (including one's own self or parts of it), ie, their existence (vs nonexistence) and their true meaning (vs ordinary meaning),⁴⁰ and the relationship of knower and known.⁴¹ These typically schizophrenic delusions are deemed “bizarre”² because they involve the phenomena that “the person's culture would regard as totally implausible”^2(p821) and that “do not derive from ordinary life experiences.”^2(p299) Idionomia may shed a new light on the bizarreness of bizarre delusions by showing how they arise from a different sort of “being,” a radical breakdown of common sense experiences and understanding of the world (the feeling of ontological uniqueness and exceptionality) and from a coherent set of emotions and values (metaphysical and charismatic concerns) that give rise to the search for a new meaning and a new order of the world itself. In the light of idionomia, bizarreness (including the bizarreness of schizotypal personality disorder, eg, “odd” beliefs and unusual perceptual experiences) is not simply an incomprehensible deviation from standard behavioral patterns or standard ways of cognition, but the expression of the exalted fascination arising from a radically different kind of being in the world. (A limitation to this study is that we have chosen to include both people with schizophrenia and with schizotypal disorder. Further research is needed to show differences in idionomia/antagonomia in schizophrenic and schizotypal disorders. Our clinical impression is that people with schizotypal disorder are more antagonomic and schizophrenic people more idionomic.).

Antagonomia reflects the choice to distance oneself from common sense rules and take an eccentric stand in the face of commonly shared assumptions and the here and now “other.” In life without psychosis, the understanding of the other is based on a precognitive, intuitive experience, a direct perception of the others' emotional life (so-called primordial intersubjectivity), and on the implicit sharing of a common horizon of meanings (so-called common sense), rather than calculated inferences of others' mental states.¹⁹ Primordial intersubjectivity is the very condition that makes communication possible. Its cornerstone is social attunement, ie, the affective-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 behavioral procedures all depend on the preexistence 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 and pragmatic engagement in it. Every person receives and participates in this interpretative order spontaneously. This implicit sharing is disordered in people with schizophrenia, but it is also rejected. As foreseen by Kretschmer,⁴ schizophrenic “disinclination for human society” is seldom mere unfeeling dullness, but it typically involves an “active turning away, of a defensive or more offensive character.” Conventional (common sense) knowledge, immediate (empathic) relationships, and emotional attunement are evaluated as dangerous sources of loss of individuation. As shown by Minkowski,⁶ persons with schizophrenia display an antithetical attitude: they feel vulnerable to the influx coming from the external world and claim their independence as the most important value.

Antagonomia concept builds on and extends Minkowski's and Kretschmer's ideas: persons with schizophrenia exhibit a general distrust toward emotional attunement with other people (feature 4) and are skeptical toward conventional knowledge and socially shared values and express an explicit repugnance to common ways of thinking, called “objectivity” or “common sense,” and an attempt at bracketing it (feature 5). This explicit repugnance toward the prereflexive, spontaneous foundations of sociality is apparently in contrast to the authentic interest in the others' way of life that appears in the attempt at reflexively building the “algorithms” of social life. They are not disinterested in “real” people; on the contrary, they often do their best to meaningfully connect with them. The social world in schizophrenia thus loses its characteristic as a network of relationships among embodied selves moved by emotions and turns into a cool, incomprehensible game, from which the person feels excluded, and whose meaning is sought through the discovery of abstract algorithms and the elaboration of impersonal rules.⁴² The attunement crisis and antagonomia together leave the person with only the third-person perspective from which to characterize and understand the interpersonal world.

Schizophrenic social and occupational dysfunction is considered as a core diagnostic feature of schizophrenic disorders: “Schizophrenia involves dysfunction in one or more major areas of functioning (eg, interpersonal relations, work or education, or self-care).”^2(p302) Here, heterogeneous domains like interpersonal and occupational dysfunctions and impairments of self-care are mixed up. This seems to be the result of a strictly functionalistic approach that merely evaluates the outcomes of dysfunctional behaviors (eg, isolation, unemployment, hygienic problems) and not their meanings or reasons (eg, abnormal experiences or beliefs motivating these behaviors). The validity and specificity of this definition of social and occupational dysfunction can be improved in the light of antagonomia. In this vein, it consists in a disarray of primordial intersubjectivity and common sense which undergo severe perturbations being both disordered and rejected in persons with schizophrenia.