Perplexity and Meaning: Toward a Phenomenological “Core” of Psychotic Experiences

Introduction

The experiences of people with psychotic disorders such as schizophrenia have long been considered “incomprehensible.”¹ However, more recently the incomprehensibility of psychosis has been brought into doubt by more phenomenologically oriented researchers who view psychosis not only as the result of aberrant neurobiology but also as a disorder of self-awareness and experience.^2,3 To propose the idea that psychosis has no biochemical or genetic bearing is extremely naive to say the least, if not outright dangerous. Nevertheless, to negate the phenomenological perspective is also counterproductive. Phenomenology may well lie at the “core” of psychotic experiences just like any other human experience; in this article, I aim to use some of the available evidence of phenomenological research in psychosis, taking into account first-person perspectives as important factors, in order to put forward this argument.

First-Person Perspectives: The Forgotten “Core” of Psychopathology

Schizophrenia Bulletin is the one of the very few academic journals that keeps its precious tradition of regularly publishing first-person accounts of psychosis. On closer inspection of these first-person perspectives, one will more often than not find striking clarity and sophistication in their writings and a curious (and perhaps unexpected) sense of actually being able to understand or even empathize with their experiences.^4,5 There is truth in these accounts beyond idiosyncratic explanations; there is a reality to the authors’ unreal worlds and that reality is a sense of a fellow human being’s immense internal turmoil. In Johnson’s account⁵ of schizophrenia, she reports a feeling of dehumanization and thus a need to be “included in the census,” yet this is not simply the result of social exclusion and stigma. As Scharfetter⁶ suggests, this sense of dehumanization may also originate from within—because the self is, in essence, devitalized and has lost all connections with the world and other people. As I have written in my own accounts,^7,8 there is a distorted sense of being—a void originating from deep within one’s own self. Psychosis may well be at least partly caused by misfiring neurons. However, it is not a sensation of misfiring neurons that the authors of first-person accounts are trying to express; nor does it follow that once one has deciphered how neurons misfire one will also automatically be able to fully understand the forefront of a tormented self-experience.

Admittedly, those who have written their own accounts are unfortunately the minority of people with psychosis. It also must be noted that these authors write about their psychoses on reflection rather than during the acute phase. Some might therefore argue that there is still no meaning in what people with an acute psychosis think or say despite being able to reflect in hindsight when they are more “clear-minded.” Studies collecting experiential data during acute psychoses are rare, but those that do exist (eg, studies connecting emotions and psychosis) have shown that such data convey meanings that are, if not evident from first glance, still far from nonsense.^9,10

Delusions: Searching for Meaning

In a fascinating theoretical investigation by Stanghellini,¹¹ psychosis is viewed as “a crisis of common sense.” Common sense has always been an interesting yet confusing concept to me as a certain perplexity has always been a part of how I experience the world and its inhabitants. When I was younger, I used to stare at the words on the pages of a book until they became so unfamiliar that they were practically incomprehensible to me even if I had learnt their meanings before. Then I would wonder, why do words mean anything anyway? They are just letters put together by some unspoken rule, they could even be random combinations. Or, what if they are not random? What is this hidden rule? The hidden rules that govern thoughts and behaviors were not transparent to me although others seemed to know them. It was puzzling, albeit not threatening or unsafe. However, in my late teens, this sense of puzzlement grew stronger and stronger. People were incomprehensible, as well as the world. I did not understand my peers, why they could have so much “fun” just by engaging in gossip or in a party. I much preferred my own company. Rules about how to deal with others were learnt and memorized instead of being intrinsically felt. What should come naturally, and without effort, became a difficult cognitive task. The actual onset of my psychosis was an insidious one, perhaps because the increase in perplexity was so gradual that even I did not notice at first. The salience of my surroundings and my own thoughts slowly heightened, each gesture from strangers in the street had become a signal and a message to me. I could not easily decode their messages and had to assign meanings to them myself regardless of whether or not there was any meaning in the first place. It was a permanent state of “there must be a meaning in what I have just observed—what is it?”, and this was when a previously confusing but harmless world turned threatening. I was no longer able to discriminate what was relevant for me to process, to find meaning. I thought I was dissolving into the world; my core self was perforated and unstable, accepting all the information permeating from the external world without filtering anything out. Where did my self end and where did the external world start? I would stretch out my hand just to see how far it could reach. This kind of perplexity and lack of “common sense” were noted by other researchers as core features of schizophrenia and related psychoses.^12,13 It may seem paradoxical^8,14; when there was heightened salience from my surroundings, I would be absorbed by the external world, but my self tended to dissociate simultaneously. Nevertheless, considering how damaged my ego boundary was, it was not surprising that the internal disintegrated while being consumed by the external.

According to Stanghellini’s account¹¹ common sense has 2 facets: one is common sense as shared social knowledge and the other as attunement to understanding others. Is there any common sense or meaning at all in even the most bizarre delusions?¹⁵ To use an analogy, people suffering from color-blindness may see the sky as gray, whereas those with normal color vision see it as blue. Can we deny the fact that the sky is gray to color-blind people only because we see it differently? We could in theory empathize that some may indeed see the sky as gray because of their color-blindness, yet we do not in general acknowledge the reality status that the sky is gray. Psychosis is like color-blindness in this regard: whatever the underlying etiology, what the individual with psychosis experiences is his reality. To him, this reality could even be more real than “consensual reality” because the majority of people take the latter for granted and thus hardly feel its “realness” in everyday life. I do not agree with the idea that psychosis is “a natural response towards an insane world”; rather, to me psychosis is an unfortunate endpoint of one’s desperate search for explanations and understanding. The psychotic individual is perpetually trapped in a cul-de-sac. In an instinctive search for meaning in the face of the confusion with which he meets the world and other, he loses insight into his own mentality. Once he regains insight, he will have to confront the cold “reality” that his reality has not been real.

However, psychosis is not something from which one can easily escape without the right kind of help from others because it questions the very nature of thinking and perception. The certainties of psychosis are protected by processes such as “delusional double-bookkeeping,” where multiple realities can coexist in a single mind. Someone who believes he is God may be content stacking shelves in a supermarket; someone who believes he is dead may be happily talking away. Or, do we actually need the word “believe” in order to describe these paradoxes? A delusion is more than a belief.¹⁶ A delusion may be linked with thought insertion where the individual does not experience the thoughts as his own; similarly, the sense of being controlled is not necessarily delusional ideation but a phenomenon, in which the individual feels he is indeed being controlled, whether he actually believes it or not. Just like the notion that reality is not changed by one’s beliefs, in this case, the sense of control is real and not amendable by a person’s subjective thoughts.

Hallucinations: The Interface Between Thought and Perception

In this section, I will use the loose term “hallucinations” to describe auditory-verbal hallucinations (or voices) only. Delusions and hallucinations do have at least 1 thing in common in that they are both intangible, the former being a thought and the latter a perception not shared by anyone else. Theories about hallucinations are manifold, the most widely accepted one being that they are brought about by deficits in source monitoring.^17,18 Phenomenological research sometimes describes hallucinations as originating from an alienated or disembodied part of the self (the source), which are experienced as external. However, the notion that only externalized hallucinations are “true” hallucinations has been challenged also by investigations into the first-person perspectives^19,20 because many individuals with a diagnosis of psychosis report voices both inside and outside their heads.

The very presence of hallucinations raises puzzling and fascinating questions about reality. My wondering about why words had meanings and why others behaved the way they did was probably an aspect of questioning everyday reality. However, my real questioning did not fully occur until the voices started, which was once again a gradual process. Even if I was aware that nobody was there with me, I thought—and it was almost a natural instinct—that someone somewhere must be transmitting the “messages” to me, which eventually evolved into delusions that there was a receiving device planted in my brain. It would seem that at least in this case this delusion was a direct result of the voices. Once again there was a paradox: I was repeatedly, desperately looking for an explanation, yet at the same time, doubts began to occupy my brain, until it finally settled on a delusion. However, I must confess that the sense of perplexity and feeling threatened by others preceded the fully formed voices by just over 2 years even though subtle (almost unnoticeable) perceptual changes were present during that period. When the voices occurred, I perceived them as omnipotent and omniscient²¹; they knew everything about me and were controlling my every move. They would tell me I was dead and I did not exist so it would not matter if I killed myself,⁷ and I was convinced by them. They were my reality. Who is to deny my reality when all I need to do is to perceive? The thoughts and voices were as self-evident as “reality” would be to any otherwise “normal” person. One could argue that without me as the perceiver the voices would not exist anymore, whereas for a “real” sound, others would still be able to hear it. However, what if there was nobody at all? Again to use the color-blindness analogy, would the sky truly become gray if everyone was color-blind? Questions and doubts like this often consume me.

To me, auditory-verbal hallucinations are the result of thought processes of which I am unaware. Although delusions and hallucinations might predict the presence of each other, neither is an essential prerequisite for the other.^22,23 Whether the hallucinations themselves are external or internal, it is the externality of self-experience that acts as a trigger. A delusion may arise as the consequence; alternatively, the intensity of thinking and distress caused by having frightening delusions may be linked to the tendency for the individual to dissociate and alienate the unwanted thoughts that then turn into voices. Sadly, the voices often exacerbate and “confirm” the original delusions. It is perhaps not about what exactly one experiences, but how one experiences. Whether it is a thought or a voice, they belong to the perceiving individual once they have been perceived. Their origin might still remain a mystery, but nobody can ignore their existence. As I wrote in my second article,⁸ even unreality can be an entity—like matter and antimatter. One can call it a vicious circle or simply an interaction effect, but the most important thing is that it is mine. The lack of first-person givenness and the concurrent reality of a hallucinatory experience form an elegant paradox, like many other paradoxes in a psychotic mind.^8,14 I am in no way suggesting that such “elegance” is something that should be nourished; however, I do not think it should always be eliminated either. Perhaps one day reality and unreality could coexist when we finally accept the both of them.

Phenomenology and Biological Psychiatry

In my first article,⁷ I mentioned how in my opinion schizophrenia is fundamentally a self-disturbance and not simply a biochemical imbalance, 2 statements that may now seem too arbitrary to hold. It was neither my intention nor my place to deny the endeavors of biological psychiatry by promoting phenomenological research. In fact, I do not envisage anyone who can effectively establish a fully valid, reliable, and convincing model of something as complex as psychosis without contributions from biological psychiatry. However, what about our understanding of psychotic experiences? What if we look beyond symptom labels and focus more on the suffering individual while investigating the question of “what was it like,” not just “how did it happen”? With continuing advancements in functional imaging and pharmacogenomics, it should be seen as a challenging inspiration and not an unrealistic “whim.”

The vast majority of clinicians and researchers hold good intentions and strong beliefs when they conduct their work, and this most definitely should not be undermined or overlooked. Nevertheless, refusal to acknowledge the hidden compatibility and synergy between phenomenology and biology can also manifest as a good intention or a strong belief. Perhaps, it is only my belief that the 2 can work together to create a much more complete picture and benefit many more people with psychosis. Yet, nothing will happen without a belief—an idea—in the first place, no matter whether the final results are certain or not. Phenomenology and biology do not, and should not, antagonize each other.

Implications for Future Research

Psychiatry, like all other branches of medicine, is about treating people’s suffering. Unlike other branches of medicine the ailment resides within the individual’s mind. To state the obvious, the mind is an abstract concept, whereas the brain is a physical organ. This is perhaps why it seems more logical to focus on the brain more than the mind as we believe that the mind is a meta-representation that cannot exist without the brain. This could very well be true, but nobody can deny the existence of the mind just like the fact that every living person has a functioning brain. As an early-stage researcher with a diagnosis of psychosis, I would encourage my colleagues to “bear the mind in mind.” Perhaps the fact that I have such a diagnosis is not even relevant in the first place; I am not suggesting this simply because I have experienced psychosis myself and I certainly do not claim to represent anyone else with the same diagnosis. In fact, all I hope for is more open-mindedness and integration within the scientific community. No matter how valid our results are, the research is not yet complete if we do not realize that what we study is the human experience that can only exist as a combined effort of mind and brain.