E16. Josef Parnas #2 – The Phenomenology of Schizophrenia

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Today we speak again with Professor Josef Parnas, Professor of Psychiatry at the University of Copenhagen and a co-founder and Senior Researcher at the Danish National Research Foundation: Center for Subjectivity Research.

For some 40 years, Professor Parnas has worked as a clinician and conducted research into the schizophrenia spectrum with an emphasis on the phenomenology of schizophrenia. In our first conversation we discussed the implications of taking the phenomenology of schizophrenia seriously, and covered topics such as importance of clinical experience, and adequacy of current systems to classify psychopathology.

But after the interview I realised that we didn’t really discuss the phenomenology of schizophrenia itself and felt that I had missed an opportunity to learn from someone with so much experience. So in this episode, I ask of a lot of basic questions to better understand what schizophrenia is and what life is like for those with it.

Show Notes

1:20 – On the prototypical case of schizophrenia. 

26:15 – On psychosis and it’s relationship to schizophrenia

32:10 – On psychosis in schizophrenia vs. psychosis in other conditions. 

38:00 – What catalyses psychotic episodes?

44:30 – Is psychosis itself adaptive?

49:00 – On the marked difference in quality of life outcomes between different cultures.

55:00 – On the link between Autism and Schizophrenia

1:20 – On the prototypical case of schizophrenia. 

One interesting point about schizophrenia is that it can be difficult to date its onset. Although onset of flamboyant psychotic symptoms and diagnosis with schizophrenia typically occurs somewhere around the early 20s, and there is often a prior history of contact with psychological/psychiatric services and differences in behaviour and the person’s experience that occur well before diagnosis. These differences and difficulties are related to being a subject in the world. For example, even as a, say 11 or 13 year old, the person would often feel profoundly different and cut-off from others, even if they don’t display conspicuous behavioural differences. Interestingly people with schizophrenia may find it difficult to verbalise in what sense they are profoundly and fundamentally different. This feeling of a lack of naturalness in and attunement to the world is reflected in the person being perceived as peculiar or eccentric, and sometimes leads to a interest in metaphysical or philosophical issues. 

The onset of psychosis itself, is linked to an increasing sense of self-alienation. For example, the patient starts to experience their thoughts as being ‘at a distance from themselves’ and eventually as not belonging to themselves. This may lead to a sense of revelation that they are in contact with another dimension of reality that is not accessible to other people (and such a sense is often experienced by those with schizotypal traits without psychosis). Other schizophrenic symptoms such as the sense of have thoughts inserted into their head, and of one’s thoughts/actions being controlled (ie. passivity phenomena) is also related to this increasing sense of self-alienation. Delusions are also related to the growing sense of self-alienation, and are often developed while the person realises that something is happening, but doesn’t understand what is happening. 

For most patients, schizophrenia is a fluctuating condition (with or without medication). Only a minority of people deteriorate into a chronic debilitated state.  

26:15 – On psychosis and it’s relationship to schizophrenia

Psychosis is nearly impossible to define satisfactorily. People may have the auditory hallucinations characteristic of psychosis, but should not be considered psychotic if they recognise them as such and are able to function in the world. Only when such private experiences are taken to be the objective, shared world and are then acted upon is there a clear case of psychosis. And indeed, many people who are discharged as non-psychotic will continue to have unusual experiences but are able to separate their own experiences from those of the socially shared reality. 

32:10 – On psychosis in schizophrenia vs. psychosis in other conditions. 

The experience of psychosis itself is similar between its occurrence in schizophrenia and in other conditions. However, you might say that before psychosis, the experience of the person with schizophrenia is closer to the psychotic state than that of non-schizophrenic people. 

38:00 – What catalyses psychotic episodes?

Drug abuse can precipitate schizophrenia, but often there are questions about the direction of causality. Self-medication through dug abuse is common amongst people with schizophrenia. Additionally trauma, emotional deprivation (as was more common in the foster homes of past generations) or the loss of another person on whom the person is in some way dependent, is often a catalyst. 

44:30 – Is psychosis itself adaptive?

I asked this question after coming across this paper: https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00237/full

In contrast, Josef doesn’t consider there to be any real adaptiveness to psychosis itself. 

49:00 – On the marked difference in quality of life outcomes between different cultures.

Research almost 30 years ago by the WHO suggested that people in less developed countries had a better prognosis than people in more developed countries. However, such studies are extremely complicated. But the social environment is certainly important for life outcomes for those with schizophrenia. People with schizophrenia will do better in more tolerant social environment than a rigid and hostile one. So we could expect a more productivity-focused social environment to lead to worse outcomes for people with schizophrenia. 

55:00 – On the link between Autism and Schizophrenia

Josef does not think there is a link between the two conditions. This is not surprising given Josef’s emphasis on anomalous self-experiences – a recent paper has pointed to very different self-experiences in ASD and schizophrenia (https://academic.oup.com/schizophreniabulletin/article/46/1/121/5485220). He is also sceptical about the dramatic increase in prevalence of ASD in recent years, mentioning the work of Ian Hacking (for example, https://www.lrb.co.uk/the-paper/v28/n16/ian-hacking/making-up-people)

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