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INFLUENCING AND BEING INFLUENCED
THE OTHER SIDE OF 'BIZARRE DELUSIONS'
I. ANALYSIS OF THE CONCEPT
"Psychopathology", 26, 159-164, 1993
Mario Rossi Monti and Giovanni Stanghellini
Mental Health Services. Florence. Italy.
Abstract.
The psychopathological validity of the current concept 'bizarre delusion' is questioned. A review
of literature reveals that the traditional category 'ego disorders' - though preferable than 'bizarre
delusion' - is also biased, taking into account mainly 'passivity experiences' of the kind of
Gemacht, eclipsing experiences of active influence on external reality. Although anecdotal
records of activity experiences in schizophrenic psychoses are reported since Kraepelin, any
general systematization is lacking.
Introduction
The term 'bizarre delusion' has gained a wide diffusion in the last years,
but no adequate conceptual focusing has corresponded to it. Indeed, a
closer inspection reveals the ambiguity and imprecision of such notion.
On one side, we can doubt that the psychopathological phenomena to
which it addresses (i.e. ego disorders, Jaspers 1965) could be classified
under the label 'delusion'. On the other side, the attribute 'bizarre',
referring to the content of an experience, is methodologically alien to
psychopathological reasoning, not being engaged with the description of
modal and formal qualities of a phenomenon. Moreover, 'bizarreness' is
semantically overinclusive, being in natural language a synonym to
'strange', 'eccentric' and 'grotesque', suggestive more of a moral criticism
than of a descriptive attitude.
Clinical Psychopathology has always attributed great importance to ego
disorders (disorders of the experience of the self, Ichstoerungen), tracing
them back to the criterion of the impairment of myness (Meinhaftigkeit) as
their common psychopathological organizer and pointing out a strong
connection with schizophrenic syndromes on the nosographical level
(Schneider, 1971). The disorders of the experience of the self have often
been identified with passivity experiences, through the common
denominator of the disturbance of the awareness of self-activity and
therefore methonimically merged with the psychopathology of Gemacht.
Our impression is that even such very sophisticated conceptual frame, by
far more sensible than the notion of 'bizarre delusion', may allow to grasp
only a pars pro toto of a wider and more articulated variety of phenomena.
A revision of psychotic symptoms in endogenous syndromes shows that
considering only the passive side of ego disorders may eclipse what a
phenomenological analysis indicates as its possible complement: the
experiences of activity.
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On the bizarreness of 'bizarre delusions'
A recent contribution (Flaum et al., 1991) on the reliability of 'bizarre
delusion' desolately concludes that such operational criterion - traditionally
a cornerstone of the diagnosis of schizophrenia - is highly untrustable for
clinical diagnosis. Paradoxically, the original intention was to
operationalize the ancient concept of Gemacht according to angloamerican pragmatic tradition. Indeed, while continental tradition is mostly
concerned with definitions as adequate as possible to the definiendum,
anglo-american psychiatry is more interested in the criterion of 'reliability',
that is in the intersubjective comprehension of a concept. This is probably
the reason why one might think it useful to shift attention from the modal
aspects of an experience to its thematic contents, blinded with the illusion
that on this ground a wider diagnostic agreement may subsist.
In this direction, Kendler (1983) - examining the dimensions of delusional
experience - defines 'bizarreness' as 'the degree to which the delusional
belief departs from culturally determined consensual reality'. DSM-III-R
(APA, 1987) lists 'bizarre delusions' among the characteristic symptoms of
schizophrenic disorder. In the Glossary, 'Bizarre delusions' appear under
the category 'Disorders of thought content' and are defined as 'a false
belief whose content is patently absurd relatively to the subject's cultural
world', a typical example being the case of the experience of somatic
influence. Such categorisation is questionable since it adopts a prepsychopathological definition of 'delusion' as a false belief out of keeping
with the patient's cultural background. An evident incoherence in DSM-IIIR is adding a specific paragraph for 'Delusions of influence', which
therefore appear twice in the Glossary, as a subgroup of 'Bizarre
delusions' and as a specific item, here defined not anymore according to
its contents, but to the fundamental property of the loss of myness. Such
coexistence of incoherent criteria - based on the content or on the
modality of the experience - remains unexplained.
Other diagnostic systems too follow DSM adopting 'bizarre delusion' as a
general category inclusive of thought broadcast, insertion and withdrawal
and of the delusion of being controlled, such as the RDC (Spitzer et al.,
1978) and the Flexible System for the Diagnosis of Schizophrenia
(Carpenter et al., 1973). The RDC recommend not to include within
bizarre delusions those false beliefs 'which are the elaboration of common
implausible ideas or subcultural belief, such as communicating with God,
the Devil, ghosts, or ancestors, or being under the influence of curses,
spells, voodoo, or hypnosis', adopting a purely contenutistic and
dimensional diagnostic rule.
Such oversimplifications seems unacceptable if we have in mind the
conclusions of the IPSS (WHO, 1973), stating the ubiquitous diffusion of
Ichstoerungen and their independence from cultural milieu. As Jablenski
and Sartorius (1988) summarize: 'Patients in different cultures feel alike
that their innermost thoughts are being stopped, taken away, read by
some alien agency or broadcast at large. Considering the variety of social
norms, believes, attitudes, and techniques for coping with stress, the
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similarity of the subjective experience of the core schizophrenic symptoms
is quite striking'. Indeed, Leff's (1988) distinction between the 'form' and
'content' of a delusion of control is here effective. While the form of such
symptom is unvarying, being represented by the experience that one's
own will is substituted by an alien agency, the content of such experience
- to which the attribute 'bizarre' refers - may vary according to the cultural
background, being expressed by technological means of control (such as
electricity or laser) or by spiritual forces.
Is Gemacht a kind of delusion?
One must not forget Jaspers' (1965) teaching, according to which
delusions are expressed in judgements and beliefs, but originate on the
ground of experience. Recently M. Spitzer (1990) reaffirmed such
traditional point of view: 'one should rather refer to these phenomena - he
wrote regarding ego disorders - as disorders of experience'. From this
stand-point, he also stressed an internal contradiction in DSM-IIIR, which
formerly defines 'delusions' as beliefs concerning external reality and later
applies the same category to phenomena concerning the subject's mental
space; Spitzer argues that if one holds that a delusion regards the
external world, then 'the patients' statement about changes in their
experience of their own mental activity cannot be called delusion'.
All this introduces further problems concerning the endiadys 'bizarre
delusion'.
Actually,
considering
ego
disorders
merely
and
unproblematically as 'delusions' may shift the attention: (i) from the field of
the symptoms of experience to that of expression and consequently
privilege a diagnosis based on this second criterion, and (ii) from the
ground of the 'experiences' of passivity to that of 'delusions' of passivity
(Fish, 1967), the latter representing a secondary and superimposed
explanation of the first. Furthermore, if one applies the notion 'bizarreness'
as a quantitative measure, the road to a diagnostic anarchism is spread
open.
In a Bleulerian (Bleuler, 1911) view, the disturbance of thought control
(thought alienation) is considered as a secondary elaboration of the
primary symptom 'alogia'. Indeed, on the pathogenetical ground Bleuler
attributes the role of primary symptom to the blocking of associations,
which the patient subsequently explains ascribing it to an external
influencing agent. On the nosographical level, the primary symptom
thought blocking 'is of fundamental importance - Bleuler writes - for the
symptomatology and the recognition of schizophrenia'; he also affirms that
if the secondary symptom thought withdrawal is present, then 'the
diagnosis of schizophrenia can be made with sufficient certainty. At least,
till today we have found no exception'.
This perspective becomes especially fertile in the context of Basicsymptoms paradigm, and particularly in Klosterkoetter's 'Serial
connections' theory (1988). Coherently with this model, thought insertion,
withdrawal and broadcast are interpreted as secondary elaboration of so
called 'first stage' basic disorders, such as obsessive thoughts and
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impulses which the subject experiences as irritating and uncontrollable.
From this first stage, the symptom-transition evolves through a second
stage characterized by the phenomenon of autopsychic depersonalization
and in the next stages it passes from the 'as if' modality to complete
experiences of thought and impulses made from the outside. Analogue
sequences can be described from basic-symptoms such as
cenesthopaties to the experiences of will and body being influenced.
In such pathogenetical key, the pathway between two hypothetical poles
is described, the first pole being the patient's immediate experience ('first
level' Basic-symptom) and the second one viewed as the final
phenomenon resulting from a psychological elaboration ('coping') of the
first. Naturally, the symptom 'delusion' appears only when the patient
moves away from the primary experience and approaches to the pole of a
final pseudo-explicative construct, which can also reproduce a situation
analogous to that hypercomplicated psychopathological object named by
Tausk (1919) 'influencing machine'. At this regard, Fish (1967)
distinguished between 'experiences of passivity', in which the patient
merely asserts to be unable to give any kind of explanation for what he is
feeling, and 'delusions of passivity' for the secondary explanation of the
feeling of foreign control.
As classical psychopathological Authors (such as Mayer-Gross, 1955, or
Wyrsch, 1949) pointed out, as long as the patient moves from the ground
of cenesthopathies to that of the 'influencing machine', we assist in
parallel to the shift from experiencing one's own body as the structure or
the field of initial and evaluative psychotic phenomena - characterizing
acute poussées in a sort of somatic Wahnstimmung - to the body as a
theme of psychotic symptomatology, for instance in hypondriac or in
somatic influence delusional beliefs occurring in stabilized paranoid
syndromes . From this point of view, we could even say that talking tout
court of 'bizarre delusions' implicitly means moving the focus towards a
chronic picture of psychosis. Identifying 'experiences of passivity' and
'delusions of passivity' is equal to conceiving all the phenomena belonging
to the Gemacht-family as something which is not the consequence of a
morbid experience, but as something which is generated d'emblée, as an
Athena that according to Greek mythology was born already weaponed
from Zeus' head.
Influencing and being influenced: anecdotal literature
While the clinical records concerning passivity experiences of influence
are systematized in a veritable corpus of knowledge centred on
psychopathological organizers such as the loss of myness or the
impairment of the sense of ego activity (Blankenburg, in Mueller, 1973),
the literature about activity experiences is merely anecdotal. Schneider
(1971) devotes fundamental pages of Clinical Psychopathology to the
analysis of passivity experiences, 'having the highest schizophrenic
specificity'. He icastically writes that 'we admit a surely schizophrenic
disorder only if it is told that they are others who are withdrawing one's
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thoughts, steeling them'. In German-speaking psychopathology - since
Jaspers (1965) and till AMDP (1981) - the essential element is the
Erlebnis of passivity, 'thoughts flying towards me', as a patient of Jaspers
told. Koehler (1979) sketched one of the most complete account of such
view. What he called 'passivity continuum' is a purely descriptive
juxtaposition of psychopathological symptoms of increasing severeness.
Its first step (experience of influence) is defined as that condition in which
the patient feels that his own thoughts, impulses, etc. are controlled or
imposed upon him by some external agency and its final step (experience
of alienation) is the situation in which the patient is aware that thoughts,
impulses, etc. are not his own in the sense that they are coming from an
outside source. In Koehler's systematization we may find three levels of
dimensional psychopathological organizers: (i) the transition from a diffuse
Stimmung to the focusing of a specific pathological experience, (ii) the
progressive dissolution of the ego-world boundary along the
symptomatological continuum, (iii) the progressive impairment, till its total
loss, of the sense of Meinhaftigkeit. As we know, Schneider adopted this
last criterion for sharply distinguishing between obsessive and
schizophrenic experiences (Ballerini and Stanghellini, 1989).
Koehler's profound and detailed analysis of Schneiderian first-rank
symptoms, exclusively dealing with passivity experience in the area of ego
disorders, contributed to eclipse those phenomena that we suggested to
consider as the 'other side of bizarre delusion' and we propose to name
experiences of activity within psychotic ego disorders, the following being
a very authoratative example, concerning schizophrenia psychopathology:
'Still more characteristic of the disease which is here discussed seems to
be the feeling of one's thoughts being influenced which often occurs (...).
On the other hand, the patient sometimes knows the thoughts of other
people (...). He can also think for others, he passes on the thoughts,
carries on conversations, dialogues with his companions, with the people
in other houses' (Kraepelin, 1919).
As we have already pointed out, while the first part of Kraepelin's
observation has found a precise theoretical organization in the frame of
clinical psychopathology, of the second we mostly find anecdotical clues.
Another of these is Binswanger's Case Aline (1965), which - though
centered on passivity experiences - also reports: 'But I also hear (...) the
people that I look at, I make them have my own thoughts (...). I can also
read in men's souls without mistaking'. Weitbrecht (1968) too refers,
without any comment, the following clinical fragment of a schizophrenic
patient: 'sometimes the patient also experiences an equivalent magic
omnipotence, so that he himself can influence other people and even the
cosmos in a supernatural way'.
Conclusion
We might catalog many other similar records in literature, but all of them
lack a comprehensive enquadrement within the psychopathology of
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schizophrenia, and more generally of endogenous psychoses. The
concept 'bizarre delusion' must be improved in two directions: firstly,
distinguishing between the experiential level of ego disorder and the
pseudo-explicative delusional belief concerning such experiences;
secondly, focusing clinical enquiry not only on the passive, but also on the
active side of ego disorders.
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