Abstract
During the first half of the twentieth century, German psychiatry came to consider ‘Ich-Störungen’, best translated as self-disorders, to be important features of schizophrenia. The present text is a translation of a chapter by the German psychiatrist Hans Gruhle, which is extraordinarily clear and emblematic for this research line. Published in 1929, it was part of a book co-written with Josef Berze, The Psychology of Schizophrenia (concerning its subjectivity). Gruhle claims that the essential core of schizophrenia is of an affective nature, a ‘mood’ manifesting itself as self-disorder, an unstable, incomplete pre-reflective self-awareness. His impact on contemporary psychiatry was probably limited due to his confrontational style, but this text has great significance for the modern revival of phenomenological research in schizophrenia.
Introduction: ‘Gruhle’s original insight’
The title of our introduction is a paraphrase of the title of a paper written by German philosopher Dieter Heinrich (1966): ‘Fichtes ursprüngliche Einsicht.’ In this very influential paper, Heinrich revives the idea of the German philosopher Johann Gottlieb Fichte (1762–1814), arguing that all intentional acts must be intrinsically self-aware or, as Sartre expressed it, all conscious acts must be pre-reflectively self-conscious (Sartre, 1956). This self-awareness is not a separate experience nor a product of an introspective reflection, but a constitutive moment of all experience. We have translated Gruhle’s text because it is emblematic of a research line in German-speaking psychiatry in the first half of the twentieth century which considered ‘Ich-Störungen’ to be an important feature of schizophrenia. It included psychiatrists and scholars such as Pick, Bleuler, Berze and Kronfeldt, and may also be said to include Kurt Schneider with his list of first-rank symptoms. These disorders were considered to be fundamental to the schizophrenia spectrum disorders by Bleuler (1911/1950) but remained unnoticed in anglophone psychiatry (with the exception of psychoanalysis and phenomenology) in the second half of the twentieth century. Although there was a mention of self-disorder in schizophrenia in the glossary of technical terms in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), it completely disappeared in subsequent editions of DSM and has only recently been revived in phenomenological psychiatry (Parnas and Handest, 2003; Sass and Parnas, 2003). Gruhle’s position is highly original: he claims that the essential core of schizophrenia is of an affective nature and it manifests itself as a self-disorder, an unstable, incomplete pre-reflective self-awareness. For several reasons we have consistently translated ‘Ich-Störungen’ as self-disorders, first because ‘I-disorders’ sounds strange in English, and second because the notion of I or Ego technically contains personal, thematic content related to the features of the person (personality; e.g. ‘he has a big ego’). Also, in compound words ‘Ich-’ is rendered as ‘self’. What becomes clear from reading Gruhle’s text is that he is addressing pre-personal, structural aspects of self and self-awareness. Contemporary cognitive science and phenomenology distinguishes between the narrative self and the minimal or core self (Zandersen and Parnas 2019a). The former refers to the personal self, which is a complex identity, evolving throughout life and heavily dependent on language, social interactions and biography, and includes characterological, temperamental and cognitive dispositions. The notion of core self refers to the first personal articulation of experience; in other words, all experience manifests itself as my experience or for me (mine-ness, for-me-ness, me-ness) involving an elusive affective sense of self-presence and self-familiarity (in the words of William James a sense of ‘warmth and intimacy’; James, 1890). This pre-reflective self-awareness of first-person perspective is considered by phenomenology as a minimal manifestation of self or subjectivity. In continental philosophy it has also been termed as a ‘sentiment of existence’ or ‘interior sentiment’ (Audi, 2017), with a very vivid description to be found in Rousseau (1796). Gruhle, who was influenced by phenomenology, maintains a similar position and claims that all mental processes are infused with a ‘self-content’ or ‘self-awareness’ which is precisely this self-presence or, as a French phenomenologist Michel Henry (1963/1973) expresses it, ‘a self-feeling of self’ or self-affection. At this point, Gruhle seems aware of the fact that it is not an experience of this or that quale but a pervasive pre-reflective dimension of selfhood. Henry, like Gruhle, considers affectivity as the essence of self-manifestation. According to Gruhle, this very basic self-presence manifests itself most clearly in intransitive affective or mood states and also in all intentionally directed mental acts such as feelings towards someone, thinking or acting. He also thinks that the essence of schizophrenic self-disorder consists of an inadequate self-saturation of mental processes leading to different forms of self-alienation. He describes rather subtle phenomena of thinking or perceiving losing their tag of mine-ness, which are not yet of psychotic intensity. A further aspect of the core self which Gruhle emphasizes as being affected in schizophrenia is the spontaneity of consciousness. We can consider spontaneity of consciousness as an aspect of the core self, a sense of freedom, mobility and self-coincidence (Frank, 1997). At any moment I can decide to think about something other than what I am thinking about right now, and this potential mobility of mental acts is always self-coinciding with an intact sense of self-presence. Gruhle exemplifies the issue of spontaneity with the use of obsessive ideas. These are, although involuntary and stressful, always automatically felt by the patient as his own. In other words, in these cases the automatic and pre-reflective self-ascription is entirely intact.
According to Gruhle, the disorder of self is a foundation of the phenomena of ‘mental automatisms’, which were thoroughly described in the French literature at the turn of the twentieth century. These automatisms include thought-insertion, thought-deprivation, thought-control, thought-broadcasting, thought-echo, varieties of hallucinations and a variety of bodily or motor influences. Kurt Schneider elevated some of these phenomena to the status of the so-called ‘first-rank symptoms’ (Schneider, 1959: 133ff.). The French psychiatrist Henry Ey called the process of the formation of these psychotic phenomena a process of alterization (Ey, 1973: 417ff.). He claims that because of weakened self-feeling of self, certain regions of our immanent life acquire a sort of autonomy and independence as uncontrollable fragments of the self.
The subtle phenomena of self-alienation are today well described in a psychometric instrument created by a group of Danish, Norwegian and German psychiatrists with input from phenomenological philosophy (Parnas et al., 2005). This instrument has been used in many recent empirical studies, which consistently show that disorders of core self significantly hyper-aggregate among patients with schizophrenia and schizotypal disorder, compared with patients with bipolar disorder, other non-schizophrenia disorders and autistic spectrum disorders (Haug et al., 2012; Nilsson et al., 2019; Nordgaard and Parnas, 2014; Rasmussen, Nordgaard and Parnas, 2019; Zandersen and Parnas, 2019b). It has to be emphasized that self-disorders at the initial stages are not yet of the psychotic quality. The patient simply reports that his feeling of existence is, for example, ephemeral or that his thoughts feel strangely anonymous, but he is retaining a reflective distance from these disturbances. It is for this reason that self-disorders are also observed in schizotypes. An intensification of self-disorders converts them into the psychotic phenomena described above as ‘mental automatisms’.
In conclusion, we can therefore say that Gruhle’s work very clearly and concisely anticipates the most recent development in psychopathological research on schizophrenia. We have naturally translated the German word ‘Stimmung’ as the English ‘mood’. However, the reader should be aware that in German, much more than in English, Stimmung has other, more complex connotations such as atmosphere or attunement. The latter term in particular seems to be applicable to Gruhle’s exposition
Brief biography
Hans Walter Gruhle (1880–1958) was born in Lübben, Germany. He studied medicine in Leipzig, Würzburg and Munich and also attended lectures in many other disciplines such as psychology, philosophy and history. He took his doctoral dissertation, entitled ‘Ergographic studies’, under Kraepelin. He continued as Professor of Psychiatry at the Heidelberg University Clinic until he was dismissed by the Nazis and, to avoid involvement in the euthanasia programme, he chose to work during the following years as an asylum superintendent. After the war, he was appointed Professor of Psychiatry in Bonn. He was known for his sharp professional criticism of many colleagues, for example Kraepelin and Bleuler, which probably caused some obstacles in his career. More biographical details are available in the excellent introduction to the translation of another text by Gruhle in this journal (Schioldann and Berrios, 2015), which also mentions many of Gruhle’s papers and books on psychiatric, psychological and social themes.
The Classic Text
The following text is a chapter of Gruhle’s section of the book Psychologie der Schizophrenie published in 1929, written with the Austrian psychiatrist, Josef Berze (1866–1958) (Berze and Gruhle, 1929). In the first section of the book, Berze introduces the concepts of ‘psychotic basic disorder’ and ‘psychotic primary symptoms’ (for an English translation of this part, see Berze, 2007). The primary symptoms are symptoms that cannot be reduced further psychologically, whereas the basic disorder of a psychosis is a single uniform disorder indicated from the totality of primary symptoms, not in itself demonstrable phenomenologically, but forming the basis for the development of symptoms. The basic disorder reflects Bleuler’s primary symptoms or, rather, the generative process whose presence Bleuler assumed produces his primary symptoms (Bleuler, 1911/1950).
In the introduction to his own section of the book, Gruhle contrasts two views held by psychiatrists on the psychology of schizophrenia: one maintains that mental manifestations only constitute chaotic epiphenomena of a brain disease, like paralysis, and the other– which Gruhle himself subscribes to – believes that they are expressive of a meaningful coherence, a meaningful core of schizophrenia. In order to extract the essentials of the manifold symptoms, one must ignore the content and focus on the ‘pure functions’ and on the internal coherence among the mental phenomena. Thus, being deluded is ‘primary’ to various delusional contents. Gruhle holds that what is most important is to obtain a psychological understanding by studying empirically the primary abnormal symptoms of will, emotion, thinking, etc. In Gruhle’s opinion, these primary symptoms – which are not further psychologically reducible – determine the schizophrenic process. He lines up five such symptom categories, dedicating a chapter to each of them: hallucinations, the basic mood, disturbances of impulse (agitation, stupor, and ambivalence), thought disorder, and delusion. The text below is devoted to the second of these (Berze and Gruhle, 1929: 86–94).
Footnotes
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.