Schizophrenic autism: clinical phenomenology and pathogenetic implications

Abstract

The purpose of this contribution is to address, from a phenomenologically informed empirical perspective, the essential clinical features of the schizophrenia spectrum disorders and to suggest their potential import for pathogenetic research and clinical praxis. The very concept and the phenotypic boundaries of schizophrenia are still unclear and continue to stir up intense controversies (for a comprehensive debate, see 1). Recent worldwide attempts to establish programs for early detection and therapeutic intervention in schizophrenia have inadvertently revealed an embarrassing lacuna in the contemporary operationalist psychopathology, i.e., a lack of descriptions of subtle pathology that might be useful for early, prodromal diagnosis (2). This state of affairs is, to a non-trivial extent, caused by a dramatic simplification of psychopathology that has taken place over the last decades, now echoed by raising concerns expressed in the editorials of major journals (3-6). The operational diagnostic criteria specify in detail what schizophrenia is not (e.g. not an affective or organic disorder) rather than affording the psychiatrist with a solid conceptual-clinical grip of what it is (3). Yet, a crucial and primary component of the diagnostic validity is exactly to offer a certain conceptualization or typification of what a given disorder is in the first place (7), an aspect that is conspicuously absent in the contemporary nosological debates. All classic psychopathologists agreed that, diagnostically speaking, a certain characteristic Gestalt, irreducible to single symptoms or signs, distinguished the schizophrenia spectrum from other disorders. The terms used in this context were 'diagnosis through intuition' (8), 'atmospheric diagnosis' (9), 'Praecox Gefühl' (10), and 'diagnostic par pénétration' (11). All these terms converge in pointing to an intersubjective nature of this Gestalt. The concept of autism, introduced by Bleuler in 1911 (12), was the first thorough attempt to capture the clinical essence of schizophrenia and therefore played an important role in its definitions until the advent of the operational criteria. It will serve us as a departure in addressing the phenomenology of the trait features of the schizophrenia spectrum disorders.