Understanding / Psychosis

Abstract

“Understanding” in Jaspers’ sense is the essential concept for defining psychosis, although its relationship is paradoxical, that is, psychosis is defined by un-understandability or inability to understand. Un-understandability means the inability of empathizing with the patient’s mind and implies the existence of a pathological process in the patient’s brain. The pivotal concept which makes psychotic patients be judged as irresponsible in forensic cases is disturbed self-understanding or un-understandability of their own intentions. It is suggested that self-disorder representing psychosis might be based on disturbed self-understanding.

1. Introduction

“Understanding psychosis” is in itself a contradictory remark, because psychosis is defined as an “un-understandable” entity. As is well-known, “understanding” in classic psychopathology has a special meaning which differentiates psychosis from neurosis defined as psychogenic symptoms. As neurotic symptoms like anxiety or phobia are “understandable”, that is, imaginable and relivable on the basis of normal mental life, they can be thought of as quantitative extremes of normal mental activities, and therefore can be treated psychologically. In contrast, psychotic symptoms like hallucinations or delusions are qualitatively different from normal mental activities and cannot be imagined as their quantitative extremes. This qualitative difference should be considered as a marker of the existence of pathological processes in the patient’s brain.

While nowadays various neurotic disorders which had been considered as psychogenic have turned to be thought to have some neural basis, psychotic symptoms still remain a special group of symptoms, which indicate difficulty for purely psychological treatments. Therefore, “understanding” still remains an important clinical methodology, although it is entirely subjective and fairly ambiguous. This chapter reviews and examines the implications and possibilities of the concept of “understanding” for clarifying what is psychosis.

2. Understanding and Jaspers

The concept of understanding in the specialized sense is introduced in psychiatry by Karl Theodor Jaspers (1883–1969), who was a German psychiatrist and later an existential philosopher, but it is not he who invented it. This methodological concept was introduced in order to distinguish the method of history from that of natural sciences by German historian Johann Gustav Bernhard Droysen (1808–1884). Then German philosopher Wilhelm Christian Ludwig Dilthey (1833–1911) adapted it from history to psychology. Dilthey endeavored to establish a methodological basis of human sciences (Geisteswissenschaften in German) and proposed understanding (Verstehen) as the distinct and essential methodology of them, opposed to explanation (Erklären) characteristic of natural sciences. Understanding is a subjective method based on empathy and imagination, contrasted with that explanation is an objective method based on some theory or logical interpretation.

Because psychiatry is not a pure natural science like other disciplines of medicine, but an interdisciplinary field comprising natural, human and social sciences, it was reasonable that Jaspers adopted understanding as a principal method of psychiatry, besides causal explanation. In the monumental textbook “General Psychopathology (Allgemeine Psychopathologie)” [1, 2] (abbreviated as GP in the following), he urged psychiatrists to consider the difference between psychical symptoms and somatic symptoms, that is, the former is subjective and the latter is basically objective. Causal explanation can only be applied to objective phenomena and so-called “psychological explanation” should exactly be called understanding as far as it is purely subjective.

At the time Jaspers published the first edition of GP in 1913, he was facing and had to oppose the then propagating influence of psychoanalysis. He pointed out the methodological weakness of psychoanalysis in various ways and characterized it as “pseudo-understanding” or “as-if-understanding (Als-ob-Verstehen)” in which plausible but fictitious interpretation is mistaken for understanding (GP, pp. 306–7).

It is important to note that Jaspers also emphasized the limitation of understanding. He writes, it is not that the psyche can only be understood and cannot be causally explained, but it can also be explained. While explanation has no limits, as it continues to widen the range in proportion to the progress of neuroscience, “with understanding there are limits everywhere” (GP, p. 305), as it is only based on our innate ability of empathy and imagination. Also, he writes, “Understanding by itself does not lead to any causal explanation except in indirect fashion when it happens to come up against the un-understandable” (GP, p. 305). In other words, understanding indicates the existence of a pathological process in the human psyche not by its ability but by its inability. This is the seemingly paradoxical feature that makes the concept of understanding look somewhat confusing, but also makes it unreplaceable by any other concepts.

3. Psychosis as the un-understandable

There are common misunderstandings of Jaspers’ characterization of psychotic disorders as the “un-understandable”. Some clinicians take un-understandability for disorder of communication often seen in chronic cases of schizophrenia. As such cases often show thought disorder in which logical and verbal rules appear disrupted, resulting in difficulty of communication with others, the expression “schizophrenia is un-understandable” might often be misunderstood as describing such a situation. However, the right meaning of “schizophrenia is un-understandable” is that psychic phenomena characteristic of schizophrenia cannot be imagined and relived by healthy people. “Understanding” of Jaspers’ meaning is not at all related to logical or verbal thinking.

Another misunderstanding of the un-understandability of psychosis is that it is taken for indicating the impossibility of scientific elucidation of psychosis or schizophrenia. Whereas Jaspers was critical about the premature adoption of the biological explanation of psychotic disorders, accusing such attempts as “brain mythologies” (GP, p. 18), he did not deny the possibility of the future success of such scientific research for the cause of psychosis in the brain. In fact, his characterization of psychosis as the un-understandable implies the necessity of biological research, because when understanding faces limitations, he writes, “each limitation is a fresh stimulus to formulate the problem of cause anew” (GP, p. 305). Jaspers believed that schizophrenia should have some biological cause, which is gradually appearing as un-understandable symptoms and eventually bringing the person into a sterile deficient state.

Psychosis in the meaning of Japers is not confined to schizophrenia. It includes mood disorders, although in the classical definition of the cyclic appearing of severe affective symptoms. While the diagnostic criteria of mood disorders have been significantly broadened since his era, resulting in the inclusion of people without any psychotic nature, Jaspers’ definition of mood disorder was much narrower, confined to severe depression (melancholy) and bipolar disorders (manic depressive illness). He characterized it as psychosis, not because of the existence of hallucinations or delusions like modern operational diagnostic systems, but because of un-understandability in the same meaning as schizophrenia.

What is, however, the sameness between schizophrenia and severe mood disorder, if it is not the existence of hallucinations or delusions which are un-understandable symptoms? It might be said that those two have disorders in reality testing in common from the behavioral viewpoint. While, from Jaspers’ viewpoint of understanding, because the experience of mood disorders is fairly understandable on the basis of normal affective life, it seems to differ from schizophrenic experience that is un-understandable. Un-understandability of mood disorders exists not in the mood itself, but in its manner of appearance. That is, affective symptoms in mood disorders appear cyclically with a certain period like automatic machinery, almost not at all related to incidents in mental life. Patients feel sad or cheerful for a certain duration without any incidents that are understandable by others to induce those affects. This is the meaning of un-understandability of mood disorders.

The two major types of psychosis, schizophrenia and mood disorders are thus defined as the “un-understandable”. Then another question might arise: why there are only two types in psychosis? The author’s answer is based on Kraepelin’s principle of dichotomy, that is, disease process without regard to pathogenesis could only be classified into two forms, chronic-progressive and acute-recurrent. In addition, the chronic-progressive process implies gradual diffusion and the acute-recurrent process does localized irritation. Therefore psychosis also should be classified almost necessarily into two corresponding forms, chronic-diffuse and acute-local, whose actualizations are schizophrenia and mood disorders respectively. Thus the “un-understandable” manifests itself as gradually permeative in schizophrenia, whereas in mood disorders it does as mechanically cyclic.

4. Psychosis, responsibility, and self-understanding

One reason, and the most important one from the sociocultural viewpoint, why the psychopathological distinction between psychosis and various psychogenic states should be defined is that it matters forensic judgments on responsibility for illegal acts. A person afflicted with the severe psychotic disorder would not be punished because of a lack of responsibility for illegal acts, which are supposed to have been executed by lack of reason resulting from the disorder.

Here it is to be clarified what is lack of reason because the meaning of the word “reason” is quite ambiguous. Concretely, it can be classified into three categories. The first is the insufficiency of the ability for distinguishing right from wrong, which is represented by people with intellectual disabilities or dementia virtually equated with children. The second is acute confusion with impairment of consciousness, which can be induced by intoxication by alcohol or other psychotropic substances, and also by epileptic disorders. In principle, memories of the behavior are disturbed in these cases. The third category is the most complicated cases, namely, people with schizophrenia or delusional disorders, who are with sufficient ability for telling right and wrong, and without any impairment of consciousness.

Then, what is the reason why people with schizophrenia or delusional disorders are thought “without reason”? It is because their delusions are, although often wrong in content, never correctable by any factual evidence or sincere persuasion. In other words, the patients lack the ability of “reality testing”, as they take their delusions as more real than the reality shared by others intersubjectively.

However, an important question remains: what is the difference between the delusions of the patients and queer thoughts held by, for example, religious minorities? Is it that whereas a psychotic delusion is held only by a patient, a religious belief is held by, however small it is, a collective? However, this question is ultimately insoluble, because there is always a possibility of the existence of co-believers of the thought, especially in the contemporary setting in which queer religious and other kinds of thoughts are scattered and pervading through the internet without forming any physical collective.

It is, therefore, necessary to define the essential deficit of the patients with psychotic delusions, which justifies the lack of responsibility, without being based on the content of the belief. The concept of understanding is here again useful as shown in the following.

Let us think about a typical legal case of a person with schizophrenia. He committed a kind of crime, for example, violence against a woman. He accepts that it is a fact that he executed brute force on her, but he does not accept that it was directed by his intention. He does not mean that it was an accident or a mistake, and he has a clear memory about the violence he employed. What he insists is that whereas the violence was executed by his body, it was directed by another person’s intention, that is, the agent of his body was not himself at that time. It is a quite irrational statement, which describes an un-understandable experience that we, the psychically healthy, cannot relive or imagine.

The reason why delusional patients should be thought irresponsible is, however, not the fact itself that their experience during the criminal acts is un-understandable by the healthy people. If it was the reason, it would be in effect the same situation as the queer thoughts held by the minorities. The true reason is the fact that the patient himself cannot understand his own intention. Our voluntary acts are based on our intentions and the connection between our intentions and our acts is always understandable without any verification, which is the basic fact for the responsibility. In the psyche of people with schizophrenia, however, the connection is broken and becomes un-understandable, so that the agent of his acts is lost and found in another, often undesired horrible person. Therefore the patient was himself horrified when he executed the violence. In this way, the un-understandability of the insistence of people with psychotic disorders stems from the un-understandability of their own intentions, so to speak, a disorder of self-understanding.

5. Self-understanding as the basis of self-disorder

Disorder of self-understanding has much broader significance than that has within the range of forensic psychiatry. With regard to general psychopathology of schizophrenia or psychosis, it could be thought to constitute the basis of various “bizarre” hallucinations and delusions, generally called ego disorder (Ich-Störung) or self-disorder, for example, verbal hallucinations criticizing or commenting on the patient, passivity phenomena and delusion of observation. Although Jaspers characterized schizophrenia as the un-understandable and therefore incomprehensible, it seems rather consistently comprehensible from the viewpoint of self-disorder, as once Kurt Schneider (1887–1967) and lately phenomenological psychopathologists have maintained [3, 4, 5].

Whereas the self is what should be the most understandable for us, because it is the very basis of the understandability of the world which we live in, nevertheless, it becomes un-understandable for the patients with schizophrenia. When the self is un-understandable, all the percepts coming in from the outside or even from inside the body become mysterious and alienated, resulting in the entire world being opaque and un-understandable. Furthermore, they cannot effectively respond to and resist the situation, because their own intention also becomes alienated, remaining their bodies impotent and paralyzed. Thus various bizarre and un-understandable complaints and disorganized behaviors that the patients show are to be comprehended as manifestations of the predicament into which they are being fallen and their desperate striving against it.

6. Summary

Modern operational diagnostic system like DSM-5 lacks the essential concept for defining psychosis [6]. Understanding and un-understandability are, although somewhat confusing because of the paradoxical feature, and too ambiguous from the viewpoint of operationalization, still necessary concepts for psychiatrists to make clinical practice effectively. Also, there seems to be a need for the development of the concept of self-understanding, based on that of understanding, for deeper comprehension and more sensible treatments of psychotic patients.