Psychiatric Center Hvidovre, University of Copenhagen, Copenhagen, Denmark.
Psychopathology. 2013;46(5):320-9. doi: 10.1159/000351837. Epub 2013 Jul 11.
Psychiatry is in a time of crisis. The absence of significant breakthroughs to actionable etiological knowledge has left the discipline in a state of uncertainty and worries are being voiced about its status and future. In our view, the stagnation can be, at least in part, ascribed to an excessive, behaviorist-oriented, epistemological, and ontological simplification of psychopathology. The aim of this phenomenological study is to articulate the notion of the 'disordered self' in schizophrenia, a notion that we believe constitutes an important step forward in grasping its essential pathogenetic structures. Through the framework of self-disorders, we analyze two domains of the psychopathology of schizophrenia, seeking to recast their puzzling nature into more useful clinical and scientific terms. First, we examine the so-called schizophrenic incomprehensibility (bizarre gestalt, bizarre delusions, and 'crazy actions') and argue that grasping the altered framework for experiencing, associated with the disordered self, makes these phenomena appear comprehensible to a considerable extent. Second, we explore the issue of treatment noncompliance and provide a novel account of 'poor insight' into illness. We propose that poor insight into schizophrenia is not simply a problem of insufficient self- reflection due to psychological defenses or impaired metacognition, but rather that it is intrinsically expressive of the severity and nature of self-disorders. The instabilities of the first-person perspective throw the patient into a different, often quasisolipsistic, ontological-existential framework. We argue that interventions seeking to optimize the patients' compliance might prove more efficient if they take the alterations of the patients' ontological-existential framework into account.
精神病学正处于危机之中。由于缺乏对可操作病因知识的重大突破，该学科处于不确定状态，人们对其地位和未来表示担忧。在我们看来，这种停滞至少可以部分归因于对精神病理学的过度、行为主义导向的、认识论和本体论的简化。本现象学研究的目的是阐明精神分裂症中“紊乱的自我”的概念，我们认为这是理解其基本发病结构的重要一步。通过自我障碍的框架，我们分析了精神分裂症的两个病理领域，试图将其令人困惑的性质重新构建为更有用的临床和科学术语。首先，我们研究了所谓的精神分裂症不可理解性（奇异的整体、奇异的妄想和“疯狂行为”），并认为，把握与紊乱的自我相关的体验改变框架，在很大程度上使这些现象变得可以理解。其次，我们探讨了治疗不依从的问题，并对疾病的“洞察力差”提供了一种新颖的解释。我们提出，精神分裂症的洞察力差不仅仅是由于心理防御或认知受损导致的自我反思不足的问题，而是本质上表达了自我障碍的严重程度和性质。第一人称视角的不稳定性使患者陷入一种不同的、常常是准孤立主义的本体论-存在论框架。我们认为，如果干预措施考虑到患者本体论-存在论框架的改变，那么试图优化患者依从性的干预措施可能会更有效。
