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Philosophy, Psychiatry, & Psychology 8.2/3 (2001) 219-224
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Pathogenesis, Common Sense, and the Cultural Framework:
Commentary on Stanghellini
Louis A. Sass
It is a pleasure to comment on Giovanni Stanghellini's vivid and comprehensive article, "Psychopathology of Common Sense," in which he presents a synopsis, interpretation, and extension of a number of key ideas from the tradition of phenomenological psychiatry. In the article, Stanghellini offers a way of classifying a wide range of schizophrenic abnormalities while also drawing our attention to two often neglected aspects of schizophrenia: the role of the patient's intentions and attitudes and the foundational importance of the social or interpersonal grounding of human experience and knowing. An especially valuable feature is the inclusion of extensive case vignettes to illustrate the more abstract points and help one see their application in clinical and therapeutic contexts.
I am broadly in agreement with the perspective on schizophrenic psychopathology offered here. I do wish, however, to point out what seems to me to be one exaggeration or perhaps inconsistency in Stanghellini's argument. In addition, I will question some aspects of his characterization of previous work on the phenomenology of schizophrenia, including my own. Finally, I will mention evidence from cultural anthropology that is consistent with Stanghellini's argument and consider questions that his interesting portrayal of schizophrenia might raise concerning the relationship between this condition and the social or cultural order.
Stanghellini clearly wants to argue for the central importance of intersubjectivity; there seems, however, to be some inconsistency in the precise status he attributes to it in this paper. In the first pages of the introduction, Stanghellini states that he sees the interpersonal or intersubjective dimension as having a primordial or causally primary status: " . . . I argue that the crisis of common sense is in fact a consequence of a more fundamental disturbance of intersubjectivity," he writes, "i.e., that the primary disturbance is not in the attunement between subject and object, but in the attunement between subject and subject (or self-other attunement)" (p. 201). ". . . the direction of causality seems to go from interpersonal difficulties to the schizophrenic syndrome as a whole" (p. 202). He describes one's sense of presence and of reality as "products of intersubjectivity" (p. 203).
Later, however, Stanghellini appears to adopt a more agnostic standpoint. Thus he notes at one [End Page 219] point that certain "disorders of basic cognition"—what he calls "sensory level disorders"—could play a primary role by "interfer[ing] with the perception of external and especially social reality" (p. 208). Somewhat later, he mentions the possibility that a disorder of the perception of "one's own bodily sensations, may be involved in the pathogenesis of defective attunement (i.e., inter-corporeality) and of a deficit in social functioning" (p. 215). In the latter passage, Stanghellini acknowledges that the causal relationships between disorders of ipseity, disorders of attunement, and antagonomia, in fact, are not currently understood and therefore require further empirical investigation. 1 I am not sure how far Stanghellini intends to go in emphasizing the primacy of intersubjectivity. In these later passages, he appears to be backing away from the strong claims with which he begins. Actually, I think he is wise to do so; for although Stanghellini does an excellent job of arguing for the prominence of the interpersonal dimension, I do not think he has presented any real evidence or argument that would demonstrate that it has the pathogenetically primary role.
The whole question of the relationship and relative primacy, among different aspects, features, or processes characteristic of a particular form of mental disorder is, it seems to me, a vexed and obscure issue in the field of psychopathology in general. I have not found any work of phenomenological psychopathology that offers a succinct and clear synopsis of these issues. In a recent article (Sass and Parnas, submitted), Josef Parnas and I have had to address, albeit briefly, the forms of phenomenological explanation relevant to psychopathology (a future article will treat this issue in more detail). There we distinguish relations of...