One of the most curious features of the history of psychopathology is the attitude Karl Jaspers adopted toward schizophrenia and, in particular, toward delusion —a key symptom that he considered to occur, in its “true” or “primary” form, only in this particular illness. Schizophrenia, aptly termed the “sacred symbol” and “sublime object of psychiatry” (Szasz 1976; Woods 2011), has been the major preoccupation of psychopathologists over the course of the last century; phenomenologists have been particularly fascinated, devoting great effort to exploring the subjective lives of people with this diagnosis. Jaspers’ magnum opus, the General Psychopathology (a work of genius whose first version was published in 1913), is typically seen as the inaugural monument of this crucial movement of modern psychiatry and clinical psychology.¹ It is curious, then, that in this very book, Jaspers declares schizophrenia to be essentially closed to the very possibility of empathy, thus setting it outside the domain of possible or legitimate phenomenological inquiry, on the other side of “a gulf which defies description” (Jaspers 1963, p. 447). Though well aware of the many attempts to offer psychological explanations of the strange symptoms and demeanor of such individuals, Jaspers was skeptical that one could do more than register an essential mysteriousness: “We call the behavior crazy or silly,” he wrote, “but all these words simply imply in the end that there is a common element of ‘the ununderstandable’” (p. 581).

Jaspers believed that schizophrenia was, essentially, a brain-based illness, and that the neural abnormality in question (which was and remains unknown) altered the coordinates of schizophrenic experience in so fundamental a way as to place it beyond the empathic or imaginative capacity of normal persons. This meant that schizophrenia could not on principle be “understood” but only “explained” through causal analysis of a neurobiological sort.

We need not assume that Jaspers believed persons with schizophrenia to be entirely opaque to us: he surely knew that they are “simply human” as well as “otherwise” (in the famous phrasing of Harry Stack Sullivan 1953, p. 32), sharing many of the perceptions and concerns of normal individuals. But there is, he thought, a central kernel that lies beyond all empathy or psychological comprehension; this kernel is the core of the illness, the very thing that makes them schizophrenic. Although Jaspers was not the first to describe the strangeness of schizophrenia, his formulation crystallized the notion of an essential bizarreness that has been prominent in psychiatry ever since—whether conceived as an inability to make sense out of the schizophrenia patient’s action or speech, to imagine what she might be going through, or simply to feel a minimal sense of emotional attunement (Rümke 1990).

The issue of empathy and related questions about psychological comprehension or explanation constitute an obscure and highly contested domain in the psychopathological literature, both classic and contemporary. A few contemporary philosophers, relying on a particular interpretation of the philosopher Ludwig Wittgenstein (e.g., Read 2001; Thornton 2004), would indeed place schizophrenia beyond the pale of the comprehensible. There are many psychiatrists whose adoption (often unthinking) of a pure-deficit model and neurobiological reductionism places them in a similar camp. But many subsequent psychopathologists who have thought about these issues (Henriksen in press; Sass 2003, 2004a) are disinclined to accept the radical nature of Jaspers’ distinction, or his view about schizophrenia in particular.

The issue of the understandability or comprehensibility of delusions is not unitary, as has been noted (Conrad 1958). One might speak, for example, of the comprehensibility of the content of the delusion , the course of its development, its putative triggering experience, or even of overall ontological status. And as already indicated, one might distinguish between modes of comprehension: some more empathic and involving imaginative reliving or “simulation” of the experience at issue, others involving more distanced and intellectualized analysis.

But whatever one’s view on these questions, several things seem fairly clear and uncontentious: there are certain experiences that, if not unique, are at least highly distinctive of schizophrenia; these experiences tend to have a quality of the bizarre; and this bizarreness is often apparent in their delusions (Cermolacce et al. 2010). In this spirit, we need not take Jaspers’ account of schizophrenic incomprehensibility literally, but may look to it as a guide to what may be, at the same time, most difficult (yet not impossible) to understand yet most crucial for grasping the distinctive nature of this key disorder.

The features of schizophrenia that Jaspers considers so difficult and distinctive fall into two broad domains . The first involves loss or diminishment of what seems the most basic sense of existing as a self or first-person perspective: “though he exists,” wrote Jaspers, the schizophrenic individual “is no longer able to feel he exists. Descartes’ ‘cogito ergo sum’ (I think therefore I am) may still be superficially cogitated but it is no longer a valid experience’ (Jaspers 1963, p. 122). This has been operationalized at both the psychotic and sub-psychotic levels—in Schneider’s “First Rank Symptoms” (Mellor 1970) and the Examination of Anomalous Self-Experience or EASE (Parnas et al. 2005). The second domain is perhaps even more difficult to operationalize. It pertains to what might be termed the “phenomenality” or “worldhood” of the experiential world and its objects, and is particularly bound up with the classic issue of the nature of schizophrenic delusion .

In General Psychopathology, Jaspers describes two modes of worldly experience that are, in his view, associated with the “true” or “primary” delusions found in schizophrenia. One involves experiential mutations of the perceived world that typically proceed, and lay the foundations for, the subsequent development of delusions . Objects and events become abnormally salient or “just so,” taking on intensified significance. This has been termed the predelusional state, delusional mood, or Wahnstimmung (Berrios 1996, pp. 115–125; Fuchs 2005; Sass & Pienkos in press). The second pertains especially to the patient’s attitude or belief in the reality of her delusional objects or world. This is the topic of the present chapter.

Standard approaches to delusion generally define it as a form of “mistaken belief,” as in the current DSM IV-R definition of delusion as “a false personal belief based on incorrect inference about external reality and firmly sustained in spite of what almost everyone else believes and in spite of what constitutes incontrovertible proof or evidence to the contrary” (American Psychiatric Association 2000, p. 821). Most definitions of “belief” (what analytic philosophers call the “doxastic” attitude) imply commitment to the actuality of a particular state of affairs in the external or inter-subjective world and imply, in concert with this, a promise of action (where appropriate) with regard to this state of affairs and an implicit acceptance of at least the potential relevance of evidence either in favor or against the truth value of the belief in question .

But as Jaspers pointed out, the “true delusions” of schizophrenic patients do not seem to fulfill these criteria (see also Berrios 1996, p. 112–115). Such patients will frequently demonstrate a degree or kind of certitude, and their delusions a sort of “incorrigibility” (p. 105), that goes beyond any possibility of doubt. “Well, that is how it is; I have no doubts about it,” says the patient. “I know it is so” (Jaspers 1963, p. 97). Yet at the same time the patient does not, at least in the typical case, act on what he (seemingly) so confidently asserts, as if the belief, or pseudo-belief, pertained to some other realm. Eugen Bleuler (1911/1950, pp. 378, 127–130), coiner of the term “schizophrenia,” described a kind of “double orientation,” “double registration,” or “double bookkeeping”—the phenomenon whereby the patient who seems to be convinced of her delusion nevertheless acts or reacts as if the delusion were either untrue or irrelevant. Thus the savior of humanity worries about not getting his grounds pass; the creator of the universe does not balk at lining up at the cafeteria. A schizophrenia patient may experience others or even himself as dying, but then as coming back to life again and again (Tatossian 1997). Bleuler remarks as well on a quality of emotional experience or expression, the “striking … indifference of patients toward their own delusional ideas and strivings,” giving the example of a patient who complains “in peculiar tones” that his children are being killed but does not manifest an appropriate emotional reaction (p. 369) .

From these facts—the combination of absolute incorrigibility with inconsequentiality, together with a seeming lack of normal emotional response²—one might well conclude, with Jaspers, that the patient’s overall experience of the world must be not simply mistaken but somehow altered or transformed in some overall way. “Reality for [the patient] does not always carry the same meaning as that of normal reality,” wrote Jaspers (1963, p. 105). The patient’s “world has changed … a changed knowledge of reality so rules and pervades it that any correction would mean a collapse of Being itself, in so far as it is for him his actual awareness of existence.” Speaking of “the incorrigibility of delusion,” Jaspers writes:

So far, however, we have not succeeded in defining what this is. … we simply give a name to something which we can neither see nor comprehend. And yet it is precisely this problem that gives us no peace. … This constitutes what is called ‘being unhinged or mad … ’. (Jaspers 1963, p. 411)

Here, it seems, we are concerned not just with alterations in the quality of objects, events, or bodily sensations, such as the “uncanny particularity” and “phantom concreteness” characteristic of the delusional mood (Sass 1994), but with challenges to (what Husserl called) the “natural attitude” itself—namely, to the very sense of encountering an objective or shared world and thus to its ontological status in the full sense of that term. We are dealing here with the ontological dimension that, as Heidegger teaches us, is so easily forgotten or ignored in what he termed the “forgetting of the ontological difference” (Sass 1992). Although this may be the most crucial aspect of delusion in schizophrenia, it is perhaps the most difficult to characterize or to comprehend .

The ontological dimension, it seems, is not only a fact of the delusional world; it can also come to be its theme—expressed in the content of the delusion itself. Thus Jaspers (p. 107) mentions the prominence and the problem of “metaphysical delusions,” noting that “patients may display their delusions in some supra-natural mode and such experiences cannot be adjudged true or untrue, correct or false.” Schizophrenic delusions in particular tend to involve encompassing issues of a philosophical or religious nature. These include metaphysical, epistemological, or eschatological themes that are typically suppressed by common-sense assumptions and the exigencies of practical life. Typically, the metaphysical delusions do not make reference merely to some empirical or “ontic” fact occurring within the normal framework of the “natural attitude,” but concern some more encompassing (ontological) sense or grasp of the entire universe, self, or self-world relationship. Jaspers mentions delusions expressing both “the shattering of the self” and “the end of the world” (p. 10). To treat such delusions as mere errors or falsehoods hardly does them justice. It is in fact uncomfortably reminiscent of attempts to reduce religious or mythic intuition to a crass conception of magical belief, and may involve similar forms of condescension and over-simplification (see Wittgenstein 1979).³

The challenge of understanding “true delusion” is exacerbated by the fact that there is no single delusional alternative to the lived-world of the natural attitude, but a gamut of ways in which things or the world may be “derealized”—that is, may lack or otherwise deviate from the normal experience of objective and intersubjective reality. Each of these ways is itself both strange and ambiguous; and these latter, disconcerting qualities are compounded by the fact that the experiential modalities may, at times, slip and slide one into the other. The overall feel of the world of the delusional patient has been aptly described as “peculiarly insubstantial, evanescent, and hovering” (Schmidt 1987, p. 115), and as having the “conceptual halo of the fantastic” (Ey 1996, p. 214) .

One statement from a person with schizophrenia, “Sophie” (whom I will quote extensively below), will serve as a first example: “I often feel that certain people physically enter my brain through my ear canals and then proceed to rearrange various parts of my brain—albeit not in a truly literal way” (email to author, 2010–11).⁴ Sophie’s reference to experiencing a physical event that was nevertheless not literal suggests the potential complexity of delusional or so-called delusional experiences, as well as the difficulty of knowing how to capture such experiences in standard words and categories. Patients themselves often complain of the ineffability of their delusional or pre-delusional experiences (Møller and Husby 2000), and may sometimes despair of the very possibility of communication (Aviv 2010, p. 41). “There are no words,” says a patient named Chloe, referring to the delusional state, “It’s like trying to explain what a bark sounds like to someone who’s never heard of a dog.”

Sophie herself used the term “derealization,” and states that, based on her own past experience and careful reflection, this is the universal and defining feature of psychotic or delusional experience: “the single most pervasive, enduring, and destabilizing ‘world-disturbance’ in schizophrenia.” But what, precisely, is derealization, and how does it manifest in schizophrenic delusion?

In a recent report, one patient with schizophrenia is described as trying to explain to herself why people seemed to her to be “so phony and lifeless and small, as if they could be manipulated in her fingers” (Aviv 2010, p. 46). In order to explain this experience, she considered various possibilities: Were the people only drawings? Were they marionettes, robots, or automatons? Were they “agents of an omniscient godhead”? Eventually she settled on the idea of paper figurines, though this never really satisfied her: it only seemed “to border on reasonable.”

Sophie explains, however, that derealization—at least for her—can take many forms and is not restricted to experiences involving obvious forms of diminished intensity or vitality; it may also involve “increases in metaphysical dynamism, universal animism, emotional resonance, human and/or divine purposiveness”—these too “have clearly and unambiguously led me to feel that the world is profoundly unreal.”

To make my point a little clearer (perhaps), let me emphasize that the feeling of unreality I get when I perceive others as transformed into paper maché chess pieces …, is absolutely no different from (the same feeling of derealization I get) when I perceive them as gods, manifestations (faces) of a single god, mental projections, one dimensional stage trappings, physical instantiations of my thoughts, phony or fake, superhumanly powerful, changed in size and/or shape, etc. The common factor is not a loss of dynamism or vitality, but simply radical change. Faced with people who no longer feel anything like ‘normal’ people—the people one has lived with one’s whole life—for any reason, the logical conclusion is that they are simply not real.

It seems clear enough that the “radical change” to which Sophie refers—whereby things seem “simply not real”—involves a loss of the standard reality with which one is most familiar and feels most at ease. Sophie speaks in fact of not feeling “at home.” The hovering strangeness and ambiguity that tends to transfix and unhinge the patient is clearly ontological in nature. But does it necessarily involve a loss of the sense of things possessing the objectivity implied by Husserl’s notion of the “natural attitude”—that is, the quality of existing “out there” in the world, independent of the mind that experiences them? Might it even be described, in fact, as a subjectivized or even solipsistic reality—as a realm felt to exist only for, or even perhaps to be created by, the patient or person who witnesses it?

The answer to this question must, as we shall see, be both yes and no. Though indispensable, such words as “subjective” and “objective,” “unreal” and “real,” or “internal” and “external,” are hardly adequate and can even be misleading in discussing delusional experience; they presuppose something like normal experience or the common-sense world-view; and as we shall see, this is precisely what is obliterated or at least suspended in delusion .⁵

Let us first look at some of the more extreme and clear-cut forms of derealization. Later we shall consider forms that are more ambiguous, and more likely to confuse both patient and theorist .

The present chapter is qualitative and exploratory. It relies heavily on analogical comparisons and on reports from a schizophrenia patient of unusual articulateness (Sophie) with whom the author is in dialogue. The reader is hereby warned that, as we proceed, some early claims will seem to be revised or even reversed. As we uncover the diversity and complexity in the phenomena at hand, some threads of the argument may even seem to come unraveled, then to intertwine in unexpected ways. But this is as it should and must be: Jaspers was right to stress the difficulty of understanding schizophrenic delusion, and, perhaps, not entirely wrong to insist on some irreducible element of the incomprehensible.

A particularly clear description of a delusional world is offered by Daniel Paul Schreber, perhaps the most famous psychotic or schizophrenic patient in the history of psychiatry (analyzed in Sass 1994) . In his Memoirs of My Nervous Illness, more accurately translated as Great Thoughts of a Mental Patient (Denkwürdigkeiten eines Nervenkranken), Schreber (1988) describes an elaborate delusional world consisting of “souls” and “gods” and of “nerves” and “rays” that span the cosmos, connect him with God, and, often, monitor or control his thoughts and actions. He speaks of losing his stomach and having it reappear repeatedly, and of foreign beings who inhabit his consciousness and control his thoughts. A key delusion is of being transformed into a woman. He sometimes experienced the actual people around him as being mere “fleeting-improvised men” who had been set down by God to fool him (M 43n). These delusions have often been taken as clear instances of poor reality-testing—as, for example, when in a legal brief, the superintendent of the asylum wrote of Schreber, “What objectively seen appears as delusions and hallucinations is to him (a) unassailable truth and (b) adequate motive for action” (M 301) .

Schreber clearly took these delusional realities very seriously indeed (he describes his revelations as bringing him “infinitely closer to the truth than human beings who have not received divine revelation”; M 41); and is confident of their truth value. But he does not seem to have ascribed to them the kind of reality-status or ontological weight of something objectively real, or in which he could be said fully to believe—at least in the standard sense of that term. In a legal document Schreber himself rejects the superintendent’s characterization:

I have to confirm the first part (a) of [the superintendent’s] statement, namely that my so-called delusional system is unshakeable certainty, with the same decisive ‘yes’ as I have to counter the second part (b), namely that my delusions are adequate motive for action, with the strongest possible ‘no.’ I could even say with Jesus Christ: ‘My Kingdom is not of this world,’ my so-called delusions are concerned solely with God and the beyond, they can therefore never in any way influence my behavior in any worldly matter…. (M 301)

The non-literal nature of Schreber’s delusion is apparent in his account of being transformed into a woman. As he explains in the memoir, this event occurred when he stood before a mirror looking at himself while stripped to the waist and wearing feminine jewelry. As Schreber stared at his own torso, he would feel the approach of “the rays,” which constitute an important center of consciousness in his delusional world, and then “my breast gives the impression [Eindruck] of a pretty well-developed female bosom” (M 207) Attentive reading of Schreber’s description makes it clear the he is not describing an actual anatomical change, but something more like a way of seeing or construing an unchanged physical reality. (“Naturally hairs remain… on my chest…; my nipples also remain small as in the male sex.”) Indeed, he even describes it as an illusion [Illusion in German]. Thus he speaks of getting “the undoubted impression of a female trunk—especially when the illusion [Illusion] is strengthened by some feminine adornments” (M, 207). Elsewhere in his Memoir, Schreber describes what he calls “picturing” (Zeichnung) or “representing,” which may occur in a more passive or a more active manner and which involves “use of the human imagination for the purpose of producing pictures [Bilder]” (M 180–181). Typically Schreber does not make claims about the external or interpersonally shared world, claims that could be supported or refuted by evidence independent of the experience itself. His delusional beliefs are often described in a way that gives them a coefficient of subjectivity—as when he says not “I am a scoffer at God” or “I am given to voluptuous excesses,” but I am “represented” [dargestellt] as one of these things (M, 120).

Schreber was also acutely aware of the difficulty of conveying the precise nature of his experiences and the likelihood of being misunderstood by his readers: “Again it is extremely difficult to describe such changes in words because matters are dealt with which lack all analogies in human experience and which I appreciated directly only in part with my mind’s eye [mit meinem geistigen Auge]” (M 109, 117, 124, 137, 181f, 227). “To make myself at least somewhat comprehensible I shall have to speak much in images and similes, which may at times perhaps be only approximately correct” (M 41). In accord with this recognition, Schreber peppered his original text with such phrases as “in part,” “on the other hand,” “so to speak,” “up to a point,” and “in a way”—all of which imply a certain non-literal and self-aware quality that is apparent in the original German.⁶

We see, then, that the delusions of at least this classic case lack the kind of straightforward objective or inter-subjective referentiality that would seem to be implied by the standard “poor reality testing” formula, with its use of such terms as “false,” “incorrect,” and “absurd.” What is suggested, rather, is something akin to Bleuler’s double book-keeping, where the patient experiences the delusional reality as existing in a different ontological domain from that of everyday reality. In an email to the present author, Sophie states this explicitly: “I often feel that many of my aberrant pseudo-perceptions feel the way they do because I am actually perceiving them taking place in a parallel reality that only partially overlaps with this one.” She continues:

For instance I can feel absolutely certain that space and time (and hence physical reality) no longer or never did exist, and yet understand that in order to get to a psychiatry appointment I have to walk down the street, get on the train, and so on (in other words, physically navigate or move through the “objective” world). Or I can feel certain, even as I am talking to my psychiatrist, that I killed him five minutes earlier (fully aware that he is sitting a few feet from me talking). The strangeness is that both “beliefs” exists simultaneously and seem in no way to impinge on one another (nor have I ever figured out any way of consciously reconciling them)—which is not to say that the very simultaneity isn’t rather deeply disturbing (it is, and it often drives me to self-consciously engage with and elaborate on the delusional in order to escape this painful contradiction).

Speaking also of a friend with schizophrenia, Sophie says:

“John” described to me in detail a time when he walked to the store to buy some groceries (in spite of, in his own words, feeling “absolutely convinced” that aliens were gunning the streets) and yet was conscious of the strange absence of expectable negative affect (fear or anxiety). (Likewise he confirmed that he was quite aware that others would not be affected by the alien bullets and was thus utterly unsurprised to see them walking around unfazed.) [He proceeds to tell a number of related stories from the half-decade he spent homeless …]

The standard “natural attitude,” in normal life, involves the sense that the objects one perceives are intersubjectively present—that is, present to the gaze of awareness of other persons who are separate from and similar to oneself. But as we have seen with both Schreber and Sophie, the derealization of the delusional realm can imply a certain subjectivization, a sense that the realities in question are true for me (in “my mind’s eye”), as immediate experiential realities rather than as entities existing somehow “out there” and directly accessible to other consciousnesses—or, at least, to other consciousnesses in the actual world (more on this point below). Two analogies are worth exploring in order to clarify the distinct nature of the universe or experiential stance in question. (Some disanalogies—and another analogy—will come later.)

Various phenomenologists (Blankenburg 1971, Tatossian) have pointed out the affinity between this kind of delusional stance and the fundamental nature of phenomenological “bracketing” or the phenomenological “reduction” itself, which are the key methodological moves of Husserlian phenomenology. In phenomenological bracketing, one sets aside the objectivist claims of the “natural attitude” in order to isolate an immanent realm of pure experiencing, a realm from which doubt can presumably be expunged and within which “apodictic” or absolute certitude can be achieved. Another close affinity (but not, as we shall discuss later, an identity) is with the experiential stance or modality of imagination.