Disconnection of External and Internal in the Conscious Experience of Schizophrenia: Phenomenological Literary and Neuroanatomical Archaeologies of Self.

Abstract

Patients with schizophrenia demonstrate an inability to distinguish internal from external sources of some experiences. Although there are numerous models, the causes and neural substrates are largely unknown. In schizophrenia, the commonsensical overlapping oppositions of internal/external, self/other, active/passive, mind/body, voluntary/involuntary become disentangled. Due to the loss of common sense, the imprecise coincidence of these oppositions inner and self, outer and other, mind and body lose their obviousness to the patient. Once the nexus of oppositions is unraveled, the patient tries to recover order by keeping the oppositions clear and separate in delusional interpretations of reality. The patient counters with delusional schemes that artificially keep these oppositions from merging. However, this web of proximate and overlapping oppositions lost to the patient not only inform the way we describe our everyday experience but also implicitly guide our conceptual models in psychology and neuroscience. Their source is a resilient but also protective common sense. Phenomenological method brackets the oppositions of common sense to study the otherwise concealed structures of consciousness. However, when applied to schizophrenia as a disorder of consciousness, phenomenology is burdened by controversy between two approaches: the Apollonian and Dionysian. Both traditions propose that the loss of common sense (in which the paradoxes and contradictions implicit to everyday experience are "overlooked" (von Weizsaecker)) is core to schizophrenia. Experience no longer rests on what is assumed to be probable (Blankenburg), but only proceeds in staccato, what must be, or delusional certainty. The Apollonian approach (Minkowski, Sass, Cutting) claims that the destruction of common sense in schizophrenia comes from above, melting under the scrutiny of an intact but too intense "hyperreflection." The Dionysian approach (Binswanger, Blankenburg, von Weizsaecker) attributes the erosion of common sense, coming from below, to a disruption of pre-attentive, automatic processing. The patient attempts to piece together experience by means of delusions in terms of the remaining fragments. However, both traditions have not been directly studied experimentally. The Apollonian model is hard 88 AARON L. MISHARA to operationalize and remains untestable. Moreover, most experimental evidence indicates that attentional processing is not intact in schizophrenia, with pronounced deficits in sustained and selective attention and the recruitment of brain areas guided by top down processing. This suggests that many of the effects would not be due to too much concentration but its absence. Supporting the Dionysian view, the distractability and attentional capture in patients with regard to fragments of experience not relevant to current goals may be secondary to abnormal salience and disrupted mesolimbic dopamine function (Kapur, Grace), i.e. pre-attentional factors. The metaphorical association of above and below with external and internal - in terms of the inner depths of the self - is modem, and is found in German Romantic and later existentialist authors, such as Kafka. The journey into the self is associated with depth, a descent into the underworld. The metaphorical relation between depth and inner may also be found in the neuroanatomical mapping of cognitive function onto the cytoarchitectonic structure of the brain. Several contemporary prominent neuroscientists and neuropsychiatrists (Cummings and Mega, Mesulam, Pandya and Yeterian) subscribe to a not-well known evolutionary theory of the dual origin of cortical development (Sanides) in terms of more inner, deeper core structures. An amygdala-orbitofrontal division, which is more concerned with conveying information about the organism's internal milieu is distinguished form a hippocampal-cingulate division, which is more concerned with the registering of external information. U sing this division, I propose links between philosophical, literary and neuroanatomical approaches to examine the loss of the common sense relation of internal and external experience in schizophrenia. In doing so, I suggest some neural pathways that could be linked with phenomenological and neuropsychological evidence of brain dysfunction in schizophrenia.