At Issue: Vulnerability to Schizophrenia and
Lack of Common Sense
by Qiovanni Stanghellini
psychotic symptoms and a persistent feature in nonremitting psychoses. Several theoretical approaches consider
impairments of social functioning to be not just an outcome of psychotic syndromes but a fundamental phenomenon of schizophrenic vulnerability. Vulnerability to
schizophrenic psychoses seems to involve a basic relational deficit (Maj 1998) that can be intuited but is difficult to define reliably. Nonoperationalized but far-reaching concepts—such as the "schizoid-syntonic" distinction
(Bleuler 1922; Kretschmer 1922; Minkowski 1927)—
focus on the attitudes of people with psychosis toward
their social environments. In this article, I will try to make
these concepts compatible with empirical testing.
Schizophrenic vulnerability will be reinterpreted in relation to the disconnection from common sense found in
many people with psychosis.
To describe situations characterized by detachment
from common sense, psychopathology adopts terms like
"perplexity" in acute conditions and "autism" in chronic
cases. People with or vulnerable to schizophrenia seem to
be especially prone to bracket common sense, especially
when compared to those with bipolar disorder (Kraus
1982). They seem to lack, or sometimes to reject, common sense categories that are normally used to typify
everyday experiences. In short, people with schizophrenia
are hypoconnected to common sense, while those with
bipolar disorder are hyperconnected. Traditional vulnerability models (Zubin and Spring 1977; Nuechterlein and
Dawson 1984; Strauss et al. 1995) have generally ignored
the issue of disconnectedness from common sense in people with schizophrenia. Little attention has been paid to
the common sense issue in schizotypal personality (Meehl
1962; Raine et al. 1995; Claridge 1997). More attention to
the patients' attitudes toward common sense is paid by
phenomenologically oriented psychopathological studies
on schizophrenic vulnerability (Parnas and Bovet 1991).
Abstract
This article explores the hypothesis that the relational
deficit in schizophrenia is not a consequence of acute
symptoms and course but instead is a fundamental
aspect of schizophrenic vulnerability. This basic relational deficit could be better understood as disconnectedness from common sense. Common sense is a tool
for adaptation whose main scope is establishing causeand-effect and motivational relationships in the physical and social realms. The common sense deficit
appears to involve a lack of intuitive attunement
(impaired capacity to accurately typify the mental
states of other persons because of the incapacity to be
involved in their mental lives) and a damaged social
knowledge network (disorders of the background of
knowledge useful for organizing everyday experiences). Three dimensions of schizophrenic vulnerability can be distinguished: the sensory, conceptualization, and attitudinal dimensions. Sensory disorders are
aberrations of self, body, and world perceptions.
Conceptualization disorders are disturbances in the
attribution of meanings and intentions. Attitudinal disorders consist of eccentricities in the individual's
structure of values and beliefs, characterized by distrust toward conventional knowledge and attunement.
This article describes the present state and possible
future directions of qualitative analyses and empirical
investigations relevant to assessing the interplay
between vulnerability dimensions and disorders of
common sense.
Keywords: Common sense, attunement, relational
deficit, schizophrenia, social knowledge, vulnerability.
Schizophrenia Bulletin, 26(4):775-787,2000.
Schizophrenia involves severe impairments in social functioning, typically in interpersonal relationships. Social
dysfunction is described in diagnostic manuals (American
Psychiatric Association 1994) as a consequence of acute
Send reprint requests to Dr. G. Stanghellini, U.O. Sperimentale di
Psichiatria, Dipartimento di Salute Mentale, Universita di Firenze, Viale
Michelangiolo 41,1—50125 Firenze, Italy; e-mail: [email protected].
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Schizophrenia Bulletin, Vol. 26, No. 4, 2000
G. Stanghellini
My thesis is that the common sense issue is crucial for
understanding schizophrenic worlds, since the crisis of
common sense is probably the main root of the schizophrenia patient's vulnerable condition, and consequently,
the origin of full-blown psychotic symptoms. The concept
of "crisis of common sense" (Blankenburg 1971) is probably the most accurate way to characterize the prodromal
changes in thought process, as well as in awareness of and
attitude toward both self and world, that are observed in
patients with psychosis. Persisting signs of withdrawal
and positive symptoms can be interpreted as reactions to
disordered emotional and cognitive attunement to the
world. The main purpose of this article is to redescribe
vulnerability to schizophrenic psychoses in the light of the
concept of common sense.
Vulnerability Revisited
In a revised vulnerability model, two main components
must be highlighted: (1) the clinical characteristics of
basic disorders of experience that occur in the prodromal
phases of schizophrenic episodes, that lead to full-blown
psychotic symptoms, and that last after remission of acute
breakdowns; and (2) the role of the patient in experiencing prepsychotic phenomena, coping with them, and constituting psychotic symptoms.
Basic Disorders of Experience. The recognition of subjective experience provides the basis for psychopathological research on psychoses (Schizophrenia Bulletin, 15[2],
1989). Basic disorders of experience in prodromal phases
of schizophrenia have been described as depersonalization
and derealization phenomena (i.e., strange changes in self
and world awareness in which patients feel as if they, the
external environment, or both are unreal). Huber and
coworkers and Chapman and coworkers were among the
first who emphasized the importance of investigating
early subjective complaints in people with schizophrenia.
Table 1 summarizes their findings.
The Role of the Person in Dealing With Basic
Disorders. The active role that the person with psychosis
can play in the shaping of psychotic syndromes has been
emphasized in phenomenological psychopathology
(Stanghellini 1997b) and is implicit in Bleuler's (1911)
distinction between primary symptoms—direct expressions of the schizophrenic illness process—and secondary
symptoms that result from psychoreactive coping strategies. Dialectic vulnerability models emphasize the active
role that patients have in interacting with their own disturbing experiences and suggest that this may be the
prime factor in the development of psychotic symptoms
and worldviews. Table 2 summarizes the main characteristics of these models.
Table 1. Basic disorders of experience
Area of Study
Chapman:
perceptive aberrations
Huber:
basic symptoms
Prepsychotic, subjective complaints (Huber 1966,1983)
Attenuated versions of schizophrenic experiences
(Chapman 1966, Chapman et al. 1978)
Subjective side of schizophrenic vulnerability
(Klosterkoetter 1988; Huber 1990)
Indicators of psychosis-proneness (Chapman et
al. 1994, 1995)
Loss of control and automatism; impairments of
perception, language, thought, memory, and motricity;
anhedonia and anxiety (Suellwold 1986)
Distortions in perceptions of one's body and
external objects (Chapman et al. 1978)
Table 2. Dialectic vulnerability models
Author
Disturbing experience
Bleuler(1911)
Minkowski(1927)
Wyrsch (1949)
Janzarik(1959)
Huber (1983)
Mundt(1985)
Strauss (1989)
Primary symptoms
Schizophrenic evolutive factor
Schizophrenic process
Irruptive dynamic
Basic symptoms
Intentionality breakdown
Illness
776
Personal reaction
+
+
+
+
+
+
+
Psychological reaction
Schizoid personality
Person's position taking
Stabilizing intentionality
Psychoreactive coping
Intentionality repair
Coping
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Schizophrenia Bulletin, Vol. 26, No. 4,2000
Two Main Shortcomings (and Possible Improvements)
of the Vulnerability Paradigm. Although perceptual disorders and coping styles represent key features of psychotic vulnerability, other phenomena should be taken
into account.
Vignette 2. Disordered attribution
C.D.B. is a 27-year-old insightful man with schizophrenia. He says that nothing is obvious to him; everything
can be uncanny. The world is complicated, difficult to
understand: "Why does this happen? What does that
mean? How to explain these facts? Why?" Facts are
not self-evident. Only explanations can give a shape to
his experiences. He feels the need for a general theory
that makes the world understandable and his actions
possible. Each theory he builds up is short-lived; it
needs to be tested every time a new fact happens. He
does not experience sensory disorders but experiences
severe disorders of the conceptualization of reality.
The role of conceptualization disorders. The basic relational deficit in psychosis involves at least two different
levels of disturbed experience: (1) depersonalization and
derealization phenomena that are mainly related to disorders of sensory experience, and (2) disorders of the conceptualization of experiences (Mundt 1991).
Whereas perceptual aberrations often involve derealization feelings (vignette 1), disorders of conceptualization
involve impairments of the symbolic representation of perceptual stimuli. In the latter, the attribution of their function
to objects, of meanings to social situations, and of motivations to other persons' behaviors are disordered (vignette 2).
A special category within conceptualization disorders is the
disorders of social cognition (Perm et al. 1997), that is, disorders of relatedness to other persons (vignette 3).
Conceptualization disorders involving impairments in
social cognition are better accounted for by theories that
focus on interpersonal awareness, such as phenomenological theories of schizophrenic vulnerability based on constructs of disordered intentionality (Mundt 1985) and crisis of common sense (Blankenburg 1971; Wiggins et al.
1990; Parnas and Bovet 1991), and by cognitive
approaches such as the theory-of-mind deficit hypothesis,
which is based on the model of child autism interpreted as
the failure to attribute mental states to other people
(Baron-Cohen et al. 1994). Blankenburg (1971) argued
that the fundamental source of relationship disturbances
occurring in people with schizophrenia is the loss of nat-
Vignette 3. Impairment in social cognition
P.S. is a 42-year-old man who has been affected by
paranoid schizophrenia since the age of 20. At the
onset of his psychosis, he was trying in various ways to
compensate for his difficulties in getting in touch with
other people. He had no secure ground to interpret the
others' intentions. He lacked the structure of the rules
of social life and systematically set about searching for
a well-grounded and natural style of behavior. For
instance, he was busy with an ethological study of the
"biological" (i.e., not artificial) foundation of others'
behaviors through a double observation of animal and
human habits. The former was done through television
documentaries, the latter via analyses of human interactions in public parks. An atrophy in his knowledge of
the "rules of the game" led him to engage in intellectual
investigations and to establish his own "know-how" for
social interactions in a reflective way.
ural evidence of commonsensical everyday reality. This is
the core of schizophrenic vulnerability. People with schizophrenia seem no longer able to typify their experiences
along common sense categories; the at-homeness that
accompanies most of us in our everyday life is not there.
The role of eccentricity. A second shortcoming of
the vulnerability paradigm is that the role of the person
with psychosis in the constitution of the syndrome is
mainly conceived as involving coping strategies to try to
compensate for feelings of derealization and strangeness.
This underestimates the individual's attitude toward ordinary perception and common sense categorizations of the
world. Persons vulnerable to schizophrenic psychoses
may hold opinions and convictions that are critical of
common sense conventions, and for this reason these people may attempt deliberately to situate themselves outside
the constraints of shared beliefs and values. This is an
active self-positioning outside of commonsensical reality,
not a passive or merely reactive response to experiences
of derealization and depersonalization.
Vignettei. Derealization feelings
F.B. is a 24-year-old man whose main psychopathological feature is disorganization. Especially at the sunset
hour, he complains of paniclike attacks of psychotic
severity. During these attacks, which he calls "feelings
of vagueness," he sees colors more brightly and hears
sounds more acutely than usual, and he undergoes
experiences of self and body transformation. He is
aware that these are pathological experiences and cannot find any suitable explanation for them. He also sees
other people as strange and unfamiliar. These experiences of derealization and depersonalization are somewhat "naked" and not otherwise conceptualized.
Although these phenomena of world and self transformation are often accompanied by experiences of reference, only sometimes do they become truly delusional,
that is, changes in the outside world or in the facial
expressions of people are usually not interpreted
according to a paranoid attributional style.
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G. Stanghellini
Traditional vulnerability models stress derealization
and depersonalization as prime causes of overt symptoms
and psychotic breakdowns, and they neglect eccentricity,
i.e., active positioning at the margins of socially shared
worldviews (vignette 4) and the refusal of social norms
(vignette 5). The structure of values and beliefs of the person who is vulnerable to schizophrenia is also of central
importance. But whether it is a passive experience of
deprivation of one's normal anchoring in the world (i.e.,
disorders of perception and conceptualization) or an
active rejection of taken-for-granted assumptions about
the world itself (i.e., eccentricity), the crucial element
involves distortions in the experience of common sense.
Vignette 4. Active self-marginalization
ment without any reflection, commonly felt by a whole
order, a whole people, a whole nation or the whole human
kind." The 18th-century Scottish philosopher T. Reid
(Reid 1997) postulated that the human mind could harmonize with common sense because of an innate "instinct."
In contrast to Vico's and Reid's praise for common sense,
modem scientists and philosophers, with few but significant exceptions, more often have a critical attitude toward
it (Koir6 1965). The major contributions to a positive
"philosophy of common sense" are given by E. Husserl
(1970) and his followers, and by L. Wittgenstein (1969),
who affirmed that common sense is a set of rules of the
game that discipline human behaviors.
Common Sense as a Tool for Adaptation. Common
sense is a kind of understanding whose purpose is not theoretical (knowing about something) but practical (doing
something). It has its roots in evolution, and its purpose is
an adaptive one, since it provides an image of reality built
up for the pragmatic aim of survival and adaptation
(Horton 1982). Locke (1688) emphasized that common
sense consists of a set of empirical cause-and-effect relationships useful for practical orientation in everyday
actions. Modern psychologists argue that the fundamental
feature of human thinking is its need to understand the
causes and motivations of behavior and everyday events
(Heider 1958). Evolutionary psychologists state that "our
literal survival depends upon a finely tuned knowledge of
the causal texture of the world" (Plotkin 1997, p. 185).
V.V. is a 22-year-old university student of the humanities. She plans to get rid of what she herself calls "heteronomia" (i.e., depending on the rules established by
others). She has recently started a course on Sumerian
language: "Since this was the first written language, I
think that in it are expressed parts of the mind that were
working by that age and are silent at present."
Exploring parts of the human mind that were active
once, and are no longer active now, could help her find
that original and eccentric view on the human condition
that she is looking for. Her personal fight against the
rules established by others results in solitude and a
highly intellectualized style of living.
Vignette 5. Hyperawareness
Common Sense and Intersubjectivity. Not only the
adjustment to and survival of individuals in their immediate environments, but also the integrity of a whole society
depend on the possession of this "primary theory" of the
world that we call common sense. Common sense has
adaptive significance for both the natural environment and
culture. It is mainly the latter aspect, (i.e., social adaptation based on an adequate degree of connectedness to
common sense) that is of relevance in psychopathology.
Social scientists and philosophers highlight the intersubjective character of common sense and its implications for
mutual understanding (Schutz 1962). The main characteristic of common sense is its self-evidence for all members
of a given community—it comprises all that the members
of a given society are disposed to take as obvious and
unproblematic (Husserl 1970).
E.B. is a 30-year-old man who says of himself "I am a
paranoid schizophrenic. That's science's verdict. So let it
be." He is very religious and shows esoteric and metaphysical interests. During one hospitalization, he was
often perplexed and found it very difficult to relate to other
people and in general to the external world. Almost every
time he perceived an object, the perception evoked in
him one concept or word, and that word was kindling an
overwhelming trend of word associations. It was like a
'Hood of words" that made him lose his grasp on the
actual situation. Therefore he could not engage in the
most simple activities and participate in conversations.
He explains that in the beginning it was a way "to exercise memory through perception. A way to enhance my
mind. I was looking at one thing and I hadto put my
strength in order to evoke another thing, and so on. I was
fixed on potentiating my brain. It all started as a voluntary
action that later turned into a passive experience."
The Social Imprinting of Common Sense. Our knowledge of the world we live in derives only in part from our
firsthand experience; to a much greater extent, it is
socially derived—handed down by reports and teachings
of others (Schutz 1962). The common sense world is an
old inheritance. We learn it as children who faithfully
What Is Common Sense?
"Common sense" is not an easy concept to define. The
18th-century Italian philosopher G.B. Vico (1744, Degnita
12) gave the following sweeping definition: "It is a judge-
778
At Issue
Schizophrenia Bulletin, Vol. 26, No. 4, 2000
accept the teachings of adults at a stage of psychological
growth that is prior to doubts and uncertainties. In short:
we are imprinted with it.
Preservation of Common Sense. The common sense
world enjoys relative stability and consistency among
individuals who belong to the same group. The remarkable stability of common sense is due to the tendency to
assimilate the unusual into the usual. As a rule, experiences that fit common sense typifications are felt as more
real than those that are idiosyncratic. If an experience
does not fit common sense schemata, it is usually not the
schemata that are called into question; rather, the new
character of the experience is ruled out and normalized.
What Is Common Sense About? Two main categories of
facts are dealt with by common sense—physical states
and psychological ones. Common sense represents a
guideline for orientation in both realms. The 18th-century
Scottish philosopher D. Hume (1739-1740) held that the
human mind's main purpose was to detect cause-andeffect relationships. Modern psychology seems to confirm
Hume's theory (Sperber et al. 1995) in arguing that everyone is a natural physicist and a natural psychologist
(Plotkin 1997). While physical causation deals with the
relationships between material objects (e.g., "If I touch
fire, then my hand will burn"), psychological causation is
concerned with interpretation of others' mental states
through the attunement with and observation of others'
behaviors (actions, facial expressions, etc.; e.g., "If she
smiles, she is happy"). This property of detecting the
intentions and motivations behind somebody's behaviors
is called "mind reading" (Baron-Cohen et al. 1994).
Social cognition (Perm et al. 1997) is especially relevant
to the issue of psychotic vulnerability, since disorders of
the capacity to attribute meanings to social situations are '
involved in psychotic syndromes. Children with autism
seem to have an incapacity to make sense of others'
behaviors (Baron-Cohen et al. 1994). In people with
schizophrenia, the ability to attribute mental states is also
impaired (Frith 1992) and delusions can be seen as the
effect of the "exclusion of casualness" (Berner 1982).
Common Sense as Social Knowledge. One may ask
whether common sense is a set of "commonplaces"
involving particular beliefs or whether it is more adequately represented as a "sense" useful for attuning with
what is "common." Is common sense a network of knowledge relevant to ordinary life situations shared by the
members of a given society? Or is it more of a psychic
function aimed at understanding current social situations
and at harmonizing with them? Or both? The construct of
common sense has two aspects. The first aspect can be
779
conceptualized as a stock of knowledge useful at the level
of everyday life. Common sense is a set of rules of inference that is the medium for organizing the everyday experiences of individuals and social groups (Flick 1998). It is
the foundation of people's expectations and of meaning
attributions (Moscovici and Hewstone 1983). This process
of inference is mainly automatic in nature—motivations
and meanings are attributed prereflectively.
Common Sense as Intuitive Attunement. Phenomenological definitions (Merleau-Ponty 1945; Husserl 1970)
emphasize the second aspect of common sense: the
importance of preconceptual perceptive attunement
between the subject and the outer world that is rooted in
intuition, corporeality, and the affective or emotional life.
Bovet and Parnas (1993, p. 583) write, "Common sense
reflects our preconceptual attunement to the world. It
reveals not so much what is evident but how it is evident,
the constantly present and tacit frame of experience . . . .
The defect in common sense can manifest itself in . . . a
lack of the sense for the 'rules of the game' of human
behavior." However, the concept of attunement is rather
vague. What sort of psychological process is involved?
What is it that a person is (or is not) attuned with?
In everyday experience, we feel familiarly related to
the environment and to current social situations. At a perceptual level, objects in the world and persons appear
familiar (i.e., as we expect them to be according to our
past experience). In social situations, the movements,
expressions, and utterances of others also appear typical
and understandable. There is a break with ordinary experience when objects or persons disagree perceptually with
expectancies (e.g., when colors are too bright or details
magnified—perceptive aberrations). But one can also
have this feeling of strangeness without any change on the
perceptual level, that is, when the meanings of objects in
the world (e.g., "What is this chair for?") and of the
actions of others (e.g., "Why is he laughing?") appear
uncanny. The attunement concept refers mainly to this
second level of experience, which involves the intuitive
attribution of meanings to objects and situations, and of
intentions to other people. Phenomenological research in
psychopathology has been mainly concerned with what
the philosopher J.R. Searle (1995) calls "social reality,"
whose main components may be considered "mental
facts" and "social facts," as opposed to brute physical
facts (e.g., "There is snow on Mt. Everest"). The concept
of intuitive attunement—reshaped within the framework
of the theory-of-mind (Baron-Cohen et al. 1994)—may
help to explain some aspects of the phenomena that happen in the social space and involve social cognition in
attributing mental states to partners. Social attunement
involves the ability to intuit (from Latin intuire, intus +
Schizophrenia Bulletin, Vol. 26, No. 4, 2000
G. Stanghellini
ire, "to go inside") what is going on in somebody else's
mind. I can attune with a given social situation when I am
able to comprehend thoughts and feelings of others by
observing their behavior and to explain others' behavior
in terms of intentional (e.g., "He is looking for an
aspirin") or nonintentional (e.g., "He has a headache")
mental facts. Social cognition is based on a fundamental
feature of the human mind, the urge to establish motivational relationships, and understanding other minds probably depends on coordinating one's own movement and
facial expressions with those of others—a capacity
already present in newborn babies (Butterworth 1999).
These different dimensions of schizophrenic vulnerability can be outlined as follows:
1.
2.
3.
Schizophrenic Vulnerability as a Disorder
of Common Sense Typification
Studies on premorbid adjustment of people with schizophrenia (Malmberg et al. 1998) and high-risk studies
(Dworkin et al. 1993; Dworkin et al. 1994; Olin et al.
1998; Hodges et al. 1999) demonstrate that early problems in interpersonal relationships are strongly associated
with schizophrenia. Boys who will develop schizophrenia show disruptive behaviors and social anxiety, and
they suffer from rejection by peers; girls are often nervous and withdrawn. Severe impairments in social competence such as social isolation, sensitivity, odd behavior,
and odd speech are common features in people with
schizotypal personality (Kendler et al. 1989). A basic
relational deficit is supposed to be a core phenomenon of
the schizophrenic condition (Maj 1998). In this section,
the global deficit involved in schizophrenic vulnerability
will be conceptualized as a disconnection from common
sense. Two main areas of this construct are at issue: common sense as social knowledge, and common sense as
intuitive attunement. Since the concept of "typification"
(Schutz 1962) includes both these aspects, I will adopt
this term to designate that feature of human thinking
through which we make sense of the world by attributing
meanings, causes, and intentions to objects, situations,
and other persons. In the case of schizophrenic vulnerability, we may speak of hypotypification. Deficits of common sense typification can be described as a deficit in the
knowledge of commonsensical beliefs or rules—what can
be termed the damaged social knowledge network
hypothesis. It is also possible that abnormalities in common sense typification are a consequence of an individual's distrust toward social knowledge and criticism
toward its conventionality. Deficits in common sense typification can also be interpreted as consequences of a lack
of intuitive attunement, or alternatively as an attitude of
distrust toward intuition (and an emphasis on rationality,
for instance).
Sensory-level disorders (perception of self, body,
and world)
Conceptualization-level disorders (attribution of
meaning and intention)
2.1 Damaged social knowledge network
2.1.1 Atrophy of social knowledge network
2.1.2 Hypertrophy of social knowledge
network
2.2 Lack of intuitive attunement
Attitudinal-level disorders (eccentric structure of
values and beliefs): distrust toward conventional
knowledge and intuitiveness
3.1 Skepticism
3.2 Hypertolerance of ambiguity
Sensory-Level Disorders. Sensory-level disorders are
aberrations in the perception of self, body, and world.
Strictly speaking, these are not disorders of common
sense. I mention this category of disorders, however,
because they are involved in the pathogenesis of schizophrenic psychoses and are presumably related to the disorders of conceptualization of reality. These disorders of
subjective experience occur very early in the course of
schizophrenia (Huber 1983) and are relevant for the
development of full-blown psychoses (Chapman et al.
1978; Klosterkoetter 1988).
Conceptualization-Level Disorders
Damaged social knowledge network. Conceptualization disorders involve impairments in the attribution of
meanings and intentions that can be related either to an
atrophy or to a hypertrophy of the background of knowl. edge useful for typifying everyday experiences.
Atrophy. In the case of atrophy, there is a lack of
available knowledge of socially shared categories to typify the actions of both others and oneself. People with
schizophrenia, relative to those with neuroses or bipolar
disorder (Cutting and Murphy 1988, 1990) are markedly
deficient in "real-world knowledge"—the majority of people with schizophrenia seem to have deficient knowledge
concerning events and behaviors in the world around
them. Those with hebephrenia especially are impaired in
their knowledge of how other people might behave in a
certain situation (see also vignette 3). According to these
findings, Cutting and Murphy argue that incompetent
social judgment is an intrinsic feature of schizophrenia
(especially of hebephrenia) and not a consequence of
environmental factors or actual illness. These findings
confirm classic phenomenological hypotheses about the
pathogenetical role of lack of common sense in schizo-
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Schizophrenia Bulletin, Vol. 26, No. 4, 2000
At Issue
phrenia, in which the pragmatic use of things is affected
(Minkowski 1927).
Hypertrophy. Disorders of conceptualization can also
be due to a hypertrophied background of knowledge-athand. The phenomenon of "automatic consciousness"
experienced by E.B. (vignette 5) is a well-known and
fundamental feature of psychotic thinking. Complex
associations are passively triggered by a single word or
perceptual detail. This stream of consciousness generates
the emergence of meanings that would usually remain
implicit in normal experience. The emergence of the
explicit from the implicit is responsible for an "expansion
of the horizon of meanings" (Schwartz et al. 1997, p.
178). An enlarged horizon of meanings may reflect a
hypertrophied network of knowledge-at-hand and a lack
of inhibition in the associations between semantically
related concepts. The phenomenon of automatic consciousness shows that disentanglement from common
sense can occur not only through a defective state (atrophy of social knowledge network), but also vice-versa
via a positive condition. Indeed, these free-association
variations may lead to a condition of hyperawareness in
which all possible meanings linked to a given situation
emerge. A hyperextended network of semantic association stored in the data base is actualized by a single experience. Relevant meanings are no longer selected from
the set of all possible meanings. There is a failure of a
purpose-at-hand device that can no longer select just
those meanings that are relevant to a given situation.
These abnormalities in the conceptualization of experience are studied according to the experimental paradigms
of cortical maps and semantic priming (Evans 1997;
Schwartz et al. 1997), which generate hypotheses of neurobiological relationships that can be empirically tested
(Spitzer et al. 1993).
Lack of intuitive attunement. Lack of intuitive
attunement can be defined as an impairment in the capacity to typify the mental states of others accurately because
of the incapacity to be involved in others' mental lives
(vignette 6).
What is "reasonableness" to M.M.? It is the capacity
to interpret reality spontaneously and the ability to take
someone else's point of view without feeling subjugated.
Reasonableness is common sense as
intuitive
attunement—the ability to be aware that others have
minds and to understand their thoughts and feelings by
being attuned to their behaviors. M.M. describes what
happens when someone lacks spontaneous reasonableness
or intuition: reality looks flat and colorless; people seem
empty and anonymous. The image of "lunar" energy
eclipsing the light of the sun neatly expresses this experience of a desolate and dehumanized world. Since everything becomes equally uninteresting ("anything goes"),
Vignette 6. Impaired intuitive attunement
M.M. is a 42-year-old woman affected by paranoid
schizophrenia. During a therapy session she asked me
and herself, "What is reasonableness? It is the light that
allows the interpretation of reality. In me it is switched
off. It is not spontaneous. One must work on it. I feel
switched off here in my forehead. Interpreting reality is
also saying: 'I don't like him!' It is a subjective interpretation of reality. Everything becomes gray, flat. Anything
goes. Indeed, nothing goes: I cannot move away from
my bed. I do feel a 'lunar' energy that is tackling the
sun and eclipses it. I experience the others as if they
were empty. The sun is missing. The perception of oneness and multiplicity is missing. When a subject gets to
know something, he becomes one with it. But subjectivity is needed in order to get to know something. In me,
it is as if subjectivity were subjugated, and I do not
know by what. I dive a lot of times into my psychologist's head because I can manage to get out from it. I
do not dive into my mother's head because I am
scared. She was a medium. I am afraid to get lost in
her head, to get caught in it."
she has no motivation to move away from her bed.
Avolition, social isolation, and apathy are consequences
of what she calls the "eclipse" of the "light that allows
interpretation of reality." She also explains how she tries
to react. If the world does not spontaneously seem significant and worthy, then one "must work on it." Reflective
forms of thinking may be useful to compensate for this
impairment of intuitiveness or common sense; indeed, a
very complicated, hyperreflexive (Sass 1992) paraphilosophical system arose soon after the onset of her psychosis. Last but not least, she alludes to a possible pathogenesis of her basic lack of intuitiveness, relating it to a
developmental context in which her mother's mind was
experienced as dangerous and scary. What she seems to
be lacking is the basic confidence, probably based on
mother-infant "affective-cognitive-conative" relatedness
(Hobson 1994), necessary to direct oneself to someone
else's mind without being afraid to lose one's subjectivity.
Experimental studies designed to assess such disorders of intuitive attunement test the ability to infer intentions behind indirect speech (Cocoran et al. 1995), to
detect characters' beliefs in short stories (Frith and
Cocoran 1996), or to attribute mental states in nonverbal
scenarios (Sarfati et al. 1997a, 19976). The theoretical
paradigm of these studies is the theory-of-mind deficit in
schizophrenia (Bebbington 1988; Frith 1992). These studies confirm that people with schizophrenia have an
impaired ability to accurately perceive the intentions of
other individuals. The failure to attribute relevant intentions to others is more severe in disorganized people with
schizophrenia than in other schizophrenic subgroups and
781
Schizophrenia Bulletin, Vol. 26, No. 4, 2000
G. Stanghellini
normal controls (Sarfati et al. 1997a, 1997b). Thought,
language, and communication disorders are especially
highly correlated with this inability. People with schizophrenia who fail to appreciate other people's mental states
do not seem to rely on what is specifically relevant to the
context, but on two competing strategies of decoding:
either they choose the prevailing meaning of an ambiguous stimulus (e.g., a word), thus relying on their background knowledge (Swiney 1984), or else they show
facilitation for word recognition by semantic categorization (Koh and Peterson 1978; Traupman 1980).
Attitudinal-Level Disorders (Eccentric Structure of
Values and Beliefs): Distrust Toward Conventional
Knowledge and Intuitiveness. The concept of attitude
refers to the individual's philosophy of life, that is, the
structure of values and beliefs that orients attitudes and
actions. Persons vulnerable to schizophrenia often have an
attitude of distrust toward conventional knowledge, as for
instance E.C. (vignette 7), who expresses his disdainful
refusal of conventional values and beliefs, or V.V.
(vignette 4), whose existential project—getting rid of heteronomia (dependence on the rules established by others)—led her to solitude, instinct suppression, and a
highly intellectualized and eccentric style of living. Their
behaviors may reflect not only the effort to compensate
for the loss of common sense, but also the deliberate
attempt to disengage from all sources of spontaneity,
instinctiveness, automatic actions, and unwitting typifications. Vignette 8 is taken from Minkowski's (1924)
description of a young man with schizophrenia who
refuses spontaneity and uses all his strength to disconnect
himself from vital contact with reality.
Cases of this kind are rare in the literature and
unusual in clinical practice. Nonetheless they illustrate the
possibility that a schizophrenic condition can evolve,
rather than from a loss of common sense, from an active
and voluntary bracketing of common sense (Stanghellini
1997a, 19976). Schizophrenia can also be generated from
within rationality itself, rather than by the loss of rational-
Vignette 8. Bracketing of common sense1
F. is now 26 years old. He was once a sensible boy, who
loved to be alone. At the age of fifteen he began feeling
the pure and romantic desire of having a girl friend. No
sensual factor was involved. But since he was very shy,
he could not fulfil his desire. This did not trouble him
very much, nonetheless he thought it was suitable at his
age to have a sentimental life and so he tried to behave
as an individual who is in love and sad. He would like to
feel melancholic, but he cannot. Therefore, in order to
be coherent ('logique') with his plan, he spared no effort
to look as if he were in love and sad, and he began to
"derange." So he decides to try not to see reality as it is.
Reality humiliates him, he does his best to deny it. But
he also defends himself from all pleasures and wants to
suppress little by little all his life. He puts forth all his
strength of imagination to deny reality. He does everything he can to disengage from reality. Now he can
dominate his own state. He becomes aware of all his
actions. When he happens to stand up mechanically, he
sits down and makes that movement again, this time
consciously. He does not want to do anything mechanically. He hates spontaneity, because it would lead him
back to his normal life.
1
Minkowski 1924 [italics added].
ity. This "mind's perverse self-apotheosis" can be seen as
the "end-point of the trajectory consciousness follows
when it separates from the body and the passions, and
from the social and practical world, and turns upon itself
(Sass 1994, p. 12; see also Sass 1992).
Skepticism. Common sense conceptualizations may
be dismantled by rational criticism. This is the case with a
skeptical attitude toward common sense because of a distrust of prereflective typification and an emphasis on
rationality. When this happens, the destruction of the
building blocks of everyday experience comes from
above, rather than from below: common sense is dismissed by means of a rational or pseudophilosophical
skepticism. The German philosopher Rosenzweig (1984)
ironically defined this paralysis of common sense as
"apoplexia philosophica"—an intellectualistic condition
(vignette 9, very similar to self-reports of persons recovered from acute catatonic schizophrenia) derived from a
distrust of common sense typification and related to
hyperreflexivity.
Cutting (1997) described this condition as related to a
shift to the left along the intelligence-intuition axis. This
issue is also addressed by Minkowski's (1927) "morbid
rationalism" and Sass's (1992) hyperreflexivity (see also
vignette 2). Whereas the latter emphasizes the schizophrenic mind's self-destruction, morbid rationalism is a
coping reaction that invades the psychic life of the individual who has lost vital contact with reality—an attempt
Vignette 7. Refusal of social norms
E.C. is a 17-year-old boy with psychosis and is showing
severe difficulties at school and in social relationships.
He withdrew to his bedroom and was aggressive with
those who tried to get in touch with him. Although he
complains of cognitive problems (perception, concentration, and memory), he nonetheless gets involved in
extensive readings about Eastern philosophies and
tries to get original insights from writing with his left
hand (he is right-handed). He himself speaks of his disdainful refusal of conventional values and beliefs, which
he identifies with his parents' teachings.
782
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Schizophrenia Bulletin, Vol. 26, No. 4, 2000
Vignette 9. Apoplexia philosophies1
ivity and the tendency to reify abstractions. It is also possible for an attitude based on the hypertolerance of ambiguity to generate the refusal of conventional common sense
typifications that do not reflect enough of the complexity
of reality and to promote the search for idiosyncratic and
esoteric cues to interpret reality itself.
"We moved to the patient's bedside. The patient had to
confine himself to his bed; he was no longer able to
perform any of the essential daily actions. He felt paralyzed. The rigidity of his stupor had taken control over
him. His hands could no longer grasp, for who was it
that gave them the right to take things? His feet could
no longer walk, for who could ensure ground for their
steps? His eyes could no longer look, for who could
prove to him that no dream was fooling them? The
same was true for his ears that could no longer listen,
for was it really worthwhile to pull something out of the
void?"
1
Conclusions
The basic assumption of this article is that the relational
deficit observed in patients with schizophrenia is not a
consequence of acute symptoms or a social or institutional
artifact but a fundamental aspect of schizophrenic vulnerability. Phenomenological psychopathology has attempted
to describe this basic relational deficit as disconnectedness from common sense. The first aim of this study was
to gather philosophical cues and empirical evidence
(mainly from developmental psychology) to stipulate a
definition of common sense. In my view, common sense
is a tool for adaptation that is generally shared by the
members of a given community, derived from a process of
social imprinting, and preserved by assimilation of the
unusual into the usual. Its main purpose is the discerning
of cause-and-effect relationships in the physical realm and
motivational ones in the social world. The latter are especially relevant in psychopathology. There is considerable
empirical evidence that the schizophrenic condition is
characterized by loss of common sense of two kinds: lack
of intuitive attunement (i.e., impairment in the capacity to
accurately typify the mental states of others because of an
incapacity to be involved in their mental lives) and a damaged network of social knowledge (i.e., of the background
knowledge useful for organizing everyday experiences).
In the proposed model of schizophrenic vulnerability, I
distinguish three dimensions: sensory disorders, conceptualization disorders, and attitudinal disorders. Although
sensory disorders (aberrations of self, body, and world
perceptions) are not common sense disorders in a strict
sense, they are tightly interconnected with common-sense
disorders. Conceptualization disorders (disturbances in
the attribution of meanings and intentions) are related
either to a damaged social knowledge network or to a lack
of intuitiveness. Conceptualization disorders include
social knowledge network disorders and disorders of intuitive attunement. Social knowledge network disorders can
involve either atrophy of the social knowledge data base
or a kind of hypertrophy because of a hyperextended network of semantic associations between the concepts
stored in the data base. Both atrophy and hypertrophy lead
to deficits in social functioning. Disorders of intuitive
attunement are manifest as a defective ability to attribute
mental states in short stories or nonverbal scenarios. This
approach to disorders of intuitive attunement relies on the
Rosenzweig 1984.
to re-establish new rules for typification when life can no
longer be lived but only thought of (Minkowski 1947).
Both pathways, active bracketing and passive loss of
common sense, would seem to be possible.
Hypertolerance of ambiguity. Hypotypification,
whose source can be traced back to the vulnerable individual's set of values and beliefs, can also originate from a
hypertolerance of ambiguity (Frenkel-Brunswik 1949). As
in the case of skepticism, this can also be a deliberate epistemological attitude, related to a concern for the complexity of reality, to a realization that facts-in-the-world, with
their infinite profiles, cannot be caught by a single conceptualization or reduced to a unidimensional form of understanding. Such an attitude of intolerance toward the
restricted horizon of common sense typifications is also
partly reflected in the case of the patient E.B. (vignette 5),
who does all he can to enhance his mind's capacity to
understand. He uses all his power to connect the perception of the meaning of one object with a trend of associated meanings. An enlarged horizon of meanings may not
simply reflect an automatic train of more or less relevant
associations. It may also reflect a deliberate attempt to
enlarge one's own mental capacity for conceptualization.
The philosophical paragon of this attitude is the "art of
memory," a mental exercise to improve memory through
the activation of fluid semantic associations (Yates 1966;
Rossi 1983). The art of memory is also an esoteric
hermeneutic instrument to break through the innermost
secrets of nature. In fact, E.B.'s mnemonics evolve toward
overt psychopathology in two ways. There is a shift from
activity to passivity: he begins with a voluntary attempt to
enlarge his mental capacities and ends up by being disconnected from common sense typifications. There is a second
shift from using the art of memory as a mnemonic device
to using it as a tool to interpret the complex symbolism of
reality. In short, a skeptical attitude toward common sense
typifications can generate a metaphysical move (asking for
the proper meaning of something), leading to hyperreflex-
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Schizophrenia Bulletin, Vol. 26, No. 4, 2000
G. Stanghellini
theory-of-mind deficit paradigm. Attitudinal disorders
(eccentric structures of values and beliefs) are characterized by distrust toward common sense (i.e., conventional
knowledge and intuitiveness). They include a skeptical
attitude toward common sense and a hypertolerance of
ambiguity, reflecting a refusal to conceptualize the world
through the simplifying views given by common sense.
Further empirical investigations are needed to verify
the basic hypothesis that disorders of common sense are
primary phenomena of schizophrenic vulnerability and not
side effects of schizophrenic symptoms and course. This
could be done in longitudinal studies, especially with highrisk subjects, by assessing conceptualization disorders
before the onset of overt schizophrenic symptoms and by
looking for their possible correlation with disorders of
social competence in people who subsequently develop
schizophrenia. The relationship between attitudinal-level
disorders and social competence should also be investigated in high-risk subjects before the onset of psychotic
symptoms. Interview-based research instruments should be
developed to assess the patterns of values and beliefs of
people at risk for schizophrenia in order to test the hypothesis that, in some cases, an eccentric attitudinal orientation
can be involved in the pathogenesis of the schizophrenic
relational deficit. Also, the interplay between the three different dimensions of schizophrenic vulnerability needs
more investigation. It is still unclear how the different
components of each dimension interact with each other
(i.e., how disorders of the social knowledge data base and
of intuitiveness are related to each other). It is also unclear
how different dimensions affect each other (i.e., how a disorder in one dimension can affect a nondisordered one, or
how a nondisordered dimension may prevent a schizophrenic breakdown when other dimensions are affected).
In the model I propose, the three dimensions are relatively
independent of each other, that is, one can be disordered
independently from the other two (vignettes 1 and 2). But
it can also happen that a disorder in one dimension may
affect another (vignette 5). It is tempting to hypothesize
that at least two dimensions must be affected to imply a
schizophrenic syndrome in the full clinical sense.
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Acknowledgments
I wish to thank Prof. M. Maj and Prof. L.A. Sass for their
helpful comments on earlier versions of this manuscript.
The Author
Giovanni Stanghellini is Psychiatrist, Florence
Department of Mental Health, Florence, Italy; Secretary,
World Psychiatric Association Clinical Psychopathology
Section and Italian Society for Psychopathology; and
Professor of Social Psychopathology, Postgraduate School
of Psychiatry, University of Florence, Florence, Italy.
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