Thought Disorder, Subjectivity, and the Self

Introduction

Thought disorder, a.k.a. “formal thought disorder,” has historically been treated as a key feature of severe mental illness, and closely linked with the paradigmatic form of “madness”: schizophrenia. In recent decades formal “thought disorder”—understood as disturbance in the organization and expression of thought—has increasingly come to be viewed in behavioral terms. Operationalist demands^1,2 have led many to reduce thinking largely to overt linguistic expression or so-called “disorganized speech,” defined as difficult to comprehend.^3(p88),4 Demands for high inter-rater reliability (potentially at expense of validity) have encouraged simple formulations—which can preclude forms of subtle pattern recognition required for grasping styles of thinking and speaking.

Under these circumstances, it is not surprising that “formal thought disorder” has been homogenized: viewed as a single, unidimensional phenomenon not distinctive of any particular disorder but present cross-diagnostically at different degrees of severity.⁵ Thought disorder now seems, in fact, to be a grossly neglected concept, and many younger psychiatrists are, unfortunately, not familiar with the concept.⁶ These trends are at odds, however, with what is widely regarded as the best research on thought disorder in psychosis: Holzman et al’s investigations using the TDI: Thought Disorder Index, which does show distinctive signatures of schizophrenic-vs-schizoaffective-vs-manic patients, albeit with fuzzy boundaries.⁵

It should be noted that “formal thought disorder” encompasses heterogeneous phenomena—highly overlapping with disorders of speech or language—that are only sporadically present in some persons bearing diagnoses of severe mental illness. These phenomena include (following Andreasen^1,4): poverty of speech (laconic speech); poverty of content of speech (empty speech, sometimes sounding “pseudo-philosophical”); pressure of speech; distractible speech; tangentiality; derailment (loose associations, flight of ideas); incoherence (word salad); illogicality; clanging; neologisms; word approximations; circumstantiality; loss of goal; perseveration; echolalia; blocking (interrupted train of speech or thought); stilted speech (overly formal, pompous, distant, overpolite); self-reference, and paraphasias (mispronuncation or erroneous word-choice) (see also Kuperberg^7,8). Tendencies toward hyper-concreteness, hyper-abstractness, and vagueness are often described.⁵

It is widely acknowledged that these phenomena are less characteristic of paranoid than of disorganized (previously: “hebephrenic”) schizophrenia, and virtually absent in pure paranoid psychosis (delusional disorder); some are prominent in schizotypal personality, schizoaffective psychosis, and mania. Various psychological processes may be implicated. These include, most famously, Bleuler’s “loosening of the associations” (often interacting with various affective needs, diminishments, and anomalies), which facilitates “mere fragments” and “aimless erratic thinking” in which “habitual well-worn pathways of association have lost their cohesiveness.”^{9(p352–355)}

Also implicated are other lapses of attentional, conceptual, executive, or memory processes—as well as preferred speech styles and interpersonal attitudes or maneuvers (both conscious and unconscious) including social withdrawal and contrarian defiance. Beyond the shared label “thought disorder,” it is not obvious how much the members of this congeries actually share. “Thought disorder” itself may well be a loose family-resemblance concept.

Phenomenological psychopathology offers a clear alternative to the operationalist trends, given its holistic approach and interest in subtle experiential phenomena, and its concern with what may be a distinctively schizophrenic/schizotypal pattern of abnormalities. The perspectives of classic phenomenologists from early and mid-20th century (especially Minkowski, Blankenburg, Nagai, Kimura, and Conrad^10–14) are highly relevant. Typically, however, they did not take thought disorder per se as a specific target of analysis, perhaps because their perspective conflicts with overly modular assumptions inherent in treating “thought” as a separate domain.

There is, in any case, considerable work, largely prior to the operationalist surge but often empirical, that offers insight into thought disorder. Though not specifically phenomenological in orientation, various studies of thought and language in schizophrenia (see, eg, Kasanin, Weiner, and Ey^15–17)—especially by Polyakov, Angyal, Rapaport, and Holzman’s group—have offered a more nuanced portrait that reflects the subjective dimension of these varied phenomena. Several fairly recent phenomenological studies^18–23 offer a conceptual integration of these perspectives, attempting to capture what may be distinctive of schizophrenic “thought disorder” (associated with the syndrome’s “clinical core”^24,25). Given schizophrenia’s dominance in past research and current phenomenological theorizing, we focus here on schizophrenia-spectrum, albeit with consideration of certain contrast cases, notably mania.

Our purpose is to offer some clinical and theoretical insight that might allow for better “comprehension” in 2 interrelated senses central to phenomenology²⁶: (1) empathic grasp; (2) synthetic understanding. We consider whether thought disorder in schizophrenia (or schizophrenia-spectrum) may best be conceived not in terms of straightforward cognitive deficit or defect, but as involving qualitative alterations involving forms of disruptive self-awareness as well as altered sense of self-presence and vital engagement with the world. Such a view, which considers affective/emotional, corporeal, and intersubjective dimensions of experience, accords with the current cognitive-science emphasis on “embodied,” “embedded,” and “affective” aspects of experience.²⁷ It is at odds with the implicit “Cartesianism” in mainstream psychiatry, which approaches “thought disorder” as an essentially cognitive issue. The conceptualizations on which we rely are associated with the ipseity- or basic-self-disturbance model, a prominent model in phenomenological psychopathology of schizophrenia^28,29 (Some rather different approaches to “thought disorder” are presented in this journal issue: in the review by Hart and Lewine,⁵ and in commentaries that emphasize the importance of “adopting statistical and mathematical approaches to linguistics and semantics so as to enable precise operationalization and measurement”³¹ or psycholinguistic and computational sciences in service of “quantifying an individual’s ‘symbolic representations’”.³²).

Self-Disturbance Model

The ipseity-disturbance model of schizophrenia, formulated by Sass and Parnas,^22,30 postulates a disturbance of basic self involving 3 interlocking aspects.

• 1. Hyperreflexivity refers to an exaggerated self-consciousness, a coming-to-focal-or-explicit-awareness of phenomena that would normally remain in the implicit background of experience, where they would normally be “inhabited” or experienced (tacitly) as part of oneself, but that now come to be experienced as having an alien quality (eg, kinesthetic and proprioceptive bodily sensations, verbalizations inherent in inner speech or thought).
• 2. Diminished self-presence (a.k.a. diminished self-affection) refers to decline in the experienced sense of being a subject of awareness or agent of action, of existing, we might say, in the first-person perspective—together with associated decline of experiential “penetration”^10(p305): ie, a weakening of the felt sense of the reality, force, or significance of whatever one experiences (the lived-world), or of the very actuality or fullness of the act of experiencing itself.
• 3. Disturbed grip or hold on the cognitive-perceptual world refers to disturbances of spatio-temporal structuring of the experiential field, and of the clarity of such crucial experiential distinctions as perceived-vs-remembered-vs-imagined. It is assumed that such disturbances of grip or hold are grounded in abnormalities of the embodied, vital, experiencing self, which normally serves as an orienting background for experience of the world.

None of the 3 aspects should be understood in entirely defect or deficit terms; both can have aspects of both “affliction” and “act”^19(chp2),33—the latter implying defensive and even some quasi-intentional sources (Certain changes in thinking, perception, and mood that are reminiscent of schizophrenia have been shown to occur, even in normal subjects, in conjunction with willful withdrawal into an introspective stance.^34,35). Each aspect of the ipseity-disturbance hypothesis has significant precursors in theorists from the phenomenological tradition.³⁶

The 3 aspects are intimately interlinked, and should perhaps be understood more as aspects of a single whole than as separate but interacting processes. Consider, eg, the relationship between anomalous experience of self and of world. Forms of ipseity-disturbance involving hyperreflexivity and diminished self-presence would imply, perhaps in a sense constitute, a certain fragmentation, disorganization, and fading in the field of awareness—disturbances of “grip.” This is because distracting and normally irrelevant forms of self-experience (emerging kinesthetic sensations; inner speech), together with a diminished sense of being a vital witnessing presence (normally grounded in the lived-body) would undermine the coherence, equilibrium, affordance-quality, or sheer presence (experiential “penetration”^{10(p301–306)}) of one’s thinking, speaking, or perception of the world. Normal self-presence, with its balance of tacit and explicit, would seem a necessary condition for the experience of appetite, vital energy, and point of orientation—all crucial for allocating significance and associated salience. Vital self-presence normally grounds human motivation and organizes our experiential world in accord with needs and wishes, thereby giving objects their “affordances.” With weakening of this vital self-presence, and of the orientation and sense of reality it anchors, one’s entire framework for assigning salience is likely to be disrupted—for then there can be less sense of goal-directedness, or associated differentiation of means from goal, less reason for certain objects to occupy the focus of awareness while others recede, less reason for attention to wend outward toward the world rather than inward toward hyperreflexive awareness of one’s own body or processes of thinking.^22(p436)

Here we follow Sass’s¹⁹ discussion of 3 crucial characteristics of schizophrenic “thinking,” offering, in each case, an account of both its subjective dimension and its relationship to the ipseity-disorder model. The tendencies to be discussed (which are derived from qualitative and theoretical analysis) seem quite distinctive of schizophrenia: they do not, eg, reflect euphoria, depression, emotional dysregulation, fear, or concreteness. They are not characteristic of manic flight of ideas (which may explain why manic thought disorder is easier for normal listeners to follow), nor of the slowed associations of depression, hyper-emotionality of borderline personality, wary reactivity of paranoia, or stimulus-bound concreteness of organic dementia. They are also radically at odds with the images of infantile or instinct-dominated consciousness postulated in psychoanalysis and developmental psychology (see Hart & Lewine this issue re Piaget, Vygotsky, ego-psychology; Sass prologue^5,19).

Idiosyncrasy

One characteristic feature of schizophrenic thinking might be termed its sheer idiosyncrasy or even bizarreness. Older authors spoke of “knight’s-move thinking,” metaphorically describing the absence of a straightforward, anticipatable flow of thoughts or words. The associations can often seem not just inappropriate but somehow beyond the pale, suggesting more than mere failure of attentional screening.^37(p179) The Russian psychologist Polyakov interpreted this as involving disturbed “probability prognosis”,^{19(chp4,p127)} which can be associated with an “anything goes” attitude³⁸: a failure to anticipate events, interpret the world, or channel one’s thinking in accord with what is likely, practical, or conventional.

This tendency may be associated, on the phenomenological plane, with a diminished sense of a normal, practically oriented purposefulness (reflecting hyperreflexivity and diminished self-presence), and, neurobiologically, with failure to suppress “default-mode-network” and with salience dysregulation.^33,38,39 This is generally disadvantageous, and conducive to a “perplexity” that may be distinctive of schizophrenia.⁴⁰ Such abnormalities imply a form of estrangement⁴¹ that can, however, sometimes be conducive to superior cognitive or perceptual functioning, with schizophrenia patients sometimes more logical or more accurate on some cognitive or perceptual tasks—though clearly not in the most practical settings relevant to everyday life or reflected in most IQ test items.^{9(p353),42–44} Certainly there is little support for von Domarus’s and Arieti’s once-popular notion of “paralogic,” “predicate thinking,” or “paleologic,” which assert that persons with schizophrenia rely on an erroneous logic or form of reasoning whereby phenomena are equated based on sharing a single feature or predicate.^15,45

Further insight into the “what it is like” to experience this perplexity may be gleaned from Blankenburg’s classic phenomenological monograph on “loss of natural self-evidence,”¹¹ which describes the inner sense of lacking spontaneous attunement to the obvious, socially shared, common-sensical import of situations. This is often accompanied by a sense of alienation or quasi-surrealist detachment, sometimes with hyper-reflective awareness of assumptions or practices that, for others, tend to be simply presupposed—all conducive to the “perplexity” or bafflement (Ratlosigkeit), typically schizophrenic, that Störring characterized as involving “detach[ment] from the world of perception [and a] strange turning in upon one’s self.”^40(p80)

Many forms of thought disorder that Holzman et al, using the TDI, found common in schizophrenia (as opposed to mania) smack of these tendencies. These include responses they characterize as “confused and fluid, and usually peppered with many idiosyncratic and peculiar words and phrases” (involving “fluid thinking, interpenetrations of one idea by another, unstable verbal referents, and overly concise and contracted communications,” sometimes with neologisms)—all this contrasting with the manic propensity for “loosely tied together ideas that are excessively and immoderately combined and elaborated,” yet not typically difficult to follow, with “combinatory thinking and irrelevant intrusions,” and often having a “playful, breezy, and mirthful quality.”^{46(p360,368,369)} Schizoaffective psychosis represents an intermediary case (though we should probably be thinking here more in terms of Weberian ideal-types than of either sharp categories with distinct essences or of pure differences of degree). The typically schizophrenic anomalies may sometimes reflect not only affliction-like abnormalities, but also willful or quasi-willful rejection of conventional thought or language or the intersubjective contract of normal conversation^23,47—as, eg, with patients whose apparent verbal “thought disorder” suggests indifference to the needs of the listener in favor of the inwardness of their own “inner speech”.^19(chp6) But beyond sheer eccentricity, there may be some pathways that these deviances typically follow—as suggested below.

Instability

A second feature is captured by the Rorschach concepts of “fluidity” and “contamination.” These refer to diminished tendency to maintain stable rooting within a coherent perspective on objects or the world, but instead to drift from one perspective to another or even to merge perspectives in a manner akin to photographic double exposure. Instead of incongruous combinations—a bat with human hands, a woman riding a submarine—the person sees a submarine dissolving into a woman or perhaps a bat-hand, in which the same part of an inkblot is both a bat and a human hand. Whereas fluidity and contamination are highly distinctive of schizophrenia, unrealistic or illogical combinations are common also in patients with mania, hypomania, or borderline personality.^{19(chp4),46,48}

Andras Angyal described distinctly schizophrenic instability as involving not merely unusual “relationships” among objects or items, but a fluidity or confusion of “system-connections”—by which he meant a drifting among or fusion of frameworks of interpretation (As synonyms, Angyal used “semantic stratum,” “realm,” “frame of reference,” “context,” and “universe of discourse”.^49(p119f)). This contrasts with the less disruptive and confusing tendency—common in mania and borderline personality—to allow unrealistic associations of objects or items. Similarly, Rapaport and Schafer described loss of “solidity and coherence” and difficulty deciding “the level of discourse in which to move”^{50(p475),51(p655)}—leading to dramatic shifts that are “almost distinctively schizophrenic,” as if one’s whole point of orientation or “relation to internal and external reality [were] altered from one response to the next”.^{19(chp4,p130),52(p107)}

In schizophrenia the modes can be associated with hyperawareness of dilemmas of perspectival choice,¹⁵ including of the arbitrariness of any standpoint, and sometimes with a disconcerting sense of absurdity or epistemological vertigo. There are revealing parallels with the modernist relativism that Nietzsche described as “fragmentation and fraying of all foundations, their dissolution into an ever flowing and dispersing becoming,” and, more generally, with the “languages of inwardness” characteristic of the 20th century literary avant-garde.^{19(chp6,p141)}

This meta-awareness, a form of hyperreflexivity, can be associated with a lack of any sense of strong purpose or direction deriving from diminished sense of vital self-presence in the world, not infrequently associated with feelings of disembodiment.⁵³ Whereas manic rapid-shifting of attention typically reflects the tempting pull of changing external stimuli from the periphery or “margin” of awareness (in persons showing “increase in goal-directed activity”,^3(p124)) schizophrenic drifting suggests a weakening of what phenomenological philosopher Gurwitsch, in The Field of Consciousness, terms the “thematic field,”²¹ thereby reflecting the diminished sense of purpose and orientation attendant upon a lack of self-presence (see also Bleuler re lack of “goal” or “purpose,” as a result of which “every sort of looseness may appear”^9(pp15,356)).

Disturbances-of-Distance

The third and final feature of schizophrenic thinking is best captured by Rapaport, Gill, and Schafer’s notion of “disturbances-of-distance.”^{50(pp226,427–430,440–447)} This refers to the tendency to deviate from standard modes of perception and thought, which operate at a medium level of abstraction, grounded in shared practical reality, either by being “too close” or “too far” from the stimulus object (In related formulations, studies have found schizophrenic categorizing to be “underinclusive” but also “overinclusive”.⁵). Disturbances-of-distance can involve a hyper-realistic emphasis on bare sensory surfaces or material particulars (eg, describing the literal look of ink on a Rorschach card) or else a seemingly antithetical preoccupation with highly abstract or “symbolic” notions (eg, the concept of “contrast” suggested by a Rorschach blot’s black ink against white ground^{19(chp5,p167)}). Unlike the deficiencies of perspectivism and abstraction in organic dementia,¹⁵ thinking in schizophrenia may oscillate paradoxically from hyper-literal to hyper-abstract or hyper-schematic.

One might argue that a distinctive feature of much schizophrenic thinking is that its idiosyncratic drifting sheds the normal “ballast” and purposive directedness of practical, common-sense concerns, and shifts instead toward forms of hyperreflexive awareness, whether of sensory building blocks or of conceptual framework-assumptions not normally in one’s focus of awareness.^19(chp5) Some examples of so-called “poverty of content” of speech—another common feature of “thought disorder” in schizophrenia, classically described as “pseudo-philosophical”—can actually involve attempts by the patient to reflect on highly general presuppositions that are normally ignored in the flow of practical living but emerge in more withdrawn, hyperreflexive states. Similar disturbances-of-distance (relevant here to language) may occur when a schizophrenia patient becomes hyperconscious of the look or sound of an isolated word, yet can also experience an uncontrolled semantic proliferation when potential meanings of that word, liberated from any disambiguating context, emerge in a confusing symbolic flow^{19(chp6),54(p761)} (see Dwyer et al reeffects of “diminishment of overall context or higher-order meaning”⁵⁵). Interestingly, this may lead to thought blocking—a sudden halting of speech or thinking that can sometimes derive from excess rather than deficit of associations.²⁰

Conclusion

The concept of “thought disorder” encompasses a gamut of distinct phenomena whose commonality is not obvious. The phenomenological approach offers a complex account of the patient’s subjective perspective associated with these diverse phenomena, acknowledging tendencies hardly mentioned in the mainstream literature on schizophrenia or thought disorder: not only characteristic experiences of perplexity, incapacity, and confusion, but also alienation, self-consciousness, relativism, and a sense of the absurd. Phenomenology also attempts to think holistically about thinking by considering internal relationships with more encompassing aspects of existence implicit in notions of distorted ipseity or basic-self experience.

As indicated, the ipseity-disturbance hypothesis of phenomenological psychopathology^22,29 offers a complex yet somewhat unifying model: sensitive to the variegated nature of schizophrenia-spectrum phenomena while also appreciating certain pervasive tendencies. This includes appreciating (1) forms of hyper-self-consciousness (hyperreflexivity) that are not captured by deficit models; (2) disruptions of cognition that can result from diminishment of vital self-presence, a largely affective dimension often linked with altered corporeal experience; and (3) the contributing role of defensive or even quasi-willful processes.³³ We have argued that this phenomenological account is consistent with the somewhat distinctive portrait of schizophrenia (especially as opposed to mania) offered in the most “highly sensitive” and “methodologically rigorous”⁵ empirical investigations of thought disorder—by Holzman and colleagues.⁴⁶