Autism in Schizophrenia Revisited

Josef Parnas and Pierre Bovet

The concept of autism is reviewed in its historical evolution. It is suggested that the Bleulerian
insistence on the withdrawal component in autism contributed to the decline of its use in adult
psychiatry. Phenomenology offers another approach to grasping the nature of autism as a
relational (subject-outer world) phenomenon. European phenomenological psychiatry in the
field of schizophrenia is introduced and its attempts to reveal the essence of autism are
presented. Autism is here considered as a “loss of vital contact with reality” (Minkowski),
“inconsistency of natural experience” (Binswanger), or “the global crisis of common sense”
(Blankenburg). It is proposed that autism represents dysfunctional perceptual/expressive
attunement to the outer world. The usefulness of this concept is briefly examined in relation to
the diagnosis and etiopathogenesis of schizophrenia.
Copyright 0 1991 by W.B. Saunders Company

I N THE FIRST HALF of this century, autism was considered as a cardinal

component of the definition of schizophrenia, but has been deleted from the
major diagnostic systems because of its lack of precise definition, and hence of
reliability. As an example, in the DSM-III-R,’ the only criterion that is remotely
connected to the concept of autism is “flat and/or inappropriate affect.”
Even esteemed clinicians who used this concept in the beginning of this century
had difficulties in defining it, because it does not fit to the classical medical model
operating with symptoms and signs. The founders of the concept of schizophrenia
were all able to recognize this phenomenon, and to attach a paramount
importance to it, but differed widely in their descriptive attempts. Grasping that
concept was assisted by other epistemological approaches in science than the pure
empiricism. For that reason, phenomenological psychiatrists arrived at a better
formulation, and therefore at a better clinical utility, even though they also named
it by various terms.
It is our intention to present the historical evolution of that concept, and to
evaluate its usefulness in the diagnostic demarcation of schizophrenia, and its
potential importance for the pathogenetic model of the disease.

EVOLUTION OF THE CONCEPT OF AUTISM

The term was introduced by Bleuler in 1911, and defined as a detachment from
outer reality, accompanied by the predominance of the inner fantasy life.
“The most severe schizophrenics, who have no more contact with the outside world, live in a
world of their own. They have encased themselves with their desires and wishes (which they

Fram the Psykolagisk Institut, Kommunehospitalet, Copenhagen, Denmark; University Department of

Psychiatry, Hvidovre University Hospital, Hvidovre, Denmark Social Science Research Institute, University
of Southern California, Los Angeles, CA; and the Clinique psychiatrique universitaire de Cery, University
Department ofAdult Psychiatry, Lausanne, Switzerland.
Address reprint requests to Josef Parnas, M.D., Psykologisk Institut, Kommunehospitalet, 1399
Copenhagen K Denmark.
Copyright 8 1991 by FEB. Saunders Company
0010-440X/91/3201-0010$03.00/0

Comprehensive Psychiatry, Vol. 32, No. 1 (January/February), 1991: pp 7-21

 PARNAS AND BOVET

consider fulfilled) or occupy themselves with the trials and tribulations of their persecutory ideas;
they have cut themselves off as much as possible from any contact with the external world.
This detachment from reality with the relative and absolute predominance of the inner life. we
term autism.“’ (et. p. 63).*

Bleuler was influenced by psychoanalysis and by associationist psychology, which

is reflected in his theory of symptom formation in schizophrenia.
The primary disturbance that makes autistic withdrawal possible was consid-
ered by Bleuler to be the loosening of associations. Thus, in the pathogenetic
sense, autism was considered as a secondary symptom, in line with delusions. On
the other hand, autism was considered as one of the fundamental (pathogno-
manic) symptoms of schizophrenia. According to Bleuler, fundamental symptoms
could be divided into “simple” (disturbances of associations and affectivity, and
ambivalence), and “complex” (autism, disturbances of attention, will, and
personality, the schizophrenic dementia, and disturbances in acting and behav-
ing). These symptoms have been simplified into so-called four “A’s by epigones of
Bleuler, even though the latter would probably have disagreed with that
reduction.3
It is important to recognize the Bleulerian distinction between primary/
secondary (pathogenetic) division of symptoms and fundamental/accessory (refer-
ing to diagnostic specificity) division of symptoms. These divisions are different,
but usually confused with each other. Autism is, according to Bleuler, a
fundamental but a secondary symptom.
Bleuler described a variety of clinical manifestations under the name of autism.
It comprised poor ability of the patient to enter into contact with other people,
withdrawal and inaccessibility (in extreme cases in the form of mute and
negativistic behavior), emotional indifference, rigid attitudes and behavior,
deranged hierarchy of values, goals, and ambitions, inappropriate behavior, and
formally idiosyncratic thinking. Autism was also considered as promoting delu-
sional ideation. This enumeration of symptoms and signs illustrates the difficulty
in defining autism, mainly because neither of these manifestations is in itself
sufficient nor necessary to make the diagnosis of autism. This is perhaps the
reason why Bleuler considered autism as a “complex” fundamental symptom. For
Bleuler, autism was a direct consequence of the primitive splitting in schizophre-
nia [Spaltung], the latter facilitating shutting off the external world and promoting
an inner aconflictual, wishfulfilling fantasy life. From the very introduction of his
term, Bleuler’ related autism to Freud’s concept of autoerotism,4 the difference
between which he just considered as semantic. He also referred to P. Janet’s
concept of “perte du sens de la rt?alitk,“5with whom Bleuler, however, disagreed
because, according to Bleuler, loss of reality function in schizophrenia occurred
only selectively, when outer reality contradicted the patient’s own affective needs
and wishes [Komplexe].

*References to literature first published in German or French are quoted with the original
publication’s date, in order to facilitate historical apprehension of the concept of autism. When an
English translation is available, it is indicated in the list of references. In that case, pages in the text are
the ones of the English translation (e.f.). Quotations that have not been published in English have been
translated by the present authors.
AUTISM IN SCHIZOPHRENIA 9

Later, Bleuler expanded his concept of autism by including in it all kinds of

irrational thinking:

“The thinking of schizophrenics-which is much like that of dreams-is insufficiently known,

but I am tempted to say that it has its laws of its own, the deviations of which from the usual laws of
thinking explain most schizophrenic thought-disorders, especially delusions. We find the same
mechanisms in dreams, in the daydreams of normals and hysterics, in mythology, in superstition,
as well as in other deviations of thought from reality. There are essentially only quantitative
differences between the dream of the youngster who plays general on his hobby-horse, the poet
whose poem abstracts his unhappy love or transforms it into a happy one, the twilight state of
hysteric, and the hallucinations of the schizophrenic in which his most impossible wishes appear
fulfilled. All these are but points along the same scale.“” (e.~ pp. 401-402).

Clearly, this conceptualization indicates that Bleuler did not consider autism as
specific to schizophrenia. He even used this term to denounce some forms of
traditional medical thinking,6 which provoked a turmoil in the scientific commu-
nity and, as a byproduct, made psychiatrists feel unsecure about the clinical utility
of the concept of autism. Consequently, Bleuler attempted to attenuate the
psychopathological connotation of the title of his controversial book by (unsuccess-
fully) creating the new term of “dereistic thinking.“7
Even though Bleuler was influenced by Freud and Jung, the term of “autism”
was not in use among psychoanalysts until the post-war analysts became interested
in psychoanalytic psychotherapy of schizophrenia. Basically, autism in psychoan-
alysis is used to denote either a very early, objectless developmental stage of the
infant, or as a defense position due to narcissistic failure and weak ego-
boundaries. In this latter sense, autism in schizophrenia is viewed as withdrawal,
avoidance of object relationships which prevents potential injuries to a fragile
narcissism. In clinical psychiatry, Manfred Bleuler’ considers autism in a similar
way, but in contrast to his father, he views autism as a both fundamental and
primary symptom of schizophrenia. More recently, a term of “aphanisis” was
introduced’ to denote autistic stimulus barrier protecting the individual from the
influx of aversive stimuli. Similar line of thought can be discerned in the learning
theory of schizophrenia which considers the disease as a product of a learning
process in which an autonomically hypersensitive person cumulatively diminishes
his anxiety by deviating attention to nonrelevant issues:

“The thought disorder consists of a set of conditioned avoidance responses which help the
schizophrenic to control his autonomic hyperresponsivity. The avoidant responses (associates or
thoughts) are learned on those occasions when the pre-schizophrenic escapes from some
arousal-producing stimulus by switching to a thought which interrupts this arousal stimulus.“‘0
(P. 86).

As illustrated, the concept of autism in adult psychiatry reduced to withdrawal or

avoidance reaction became too vague and insufficient, both for psychoanalysis
(which uses better formulations) and for clinical psychiatry (where the diagnostic
utility of this concept is doubtful).
However, the term autism was revived and retained since 1943 by child
psychiatry,“” where it denotes a specific syndrome of infantile psychosis with
extreme isolation, stereotypies, and inhibited language development.
10 PARNAS AND BOVET

PHENOMENOLOGY: A BRIEF OVERVIEW

The term “phenomenology” is so frequently used in different meanings that it
seems necessary first to clarify them and to indicate which of them is used by the
present authors.
In Anglo-Saxon psychiatry, the word phenomenology is equal to descriptive
psychopathology and refers to the description of symptoms and signs in psychiatric
illness. In European psychiatry, another meaning has been introduced through
the work of K. Jaspers.13 Jaspers considered psychopathology as consisting of
phenomenology, psychology of expression [Ausdruckspsychologie] and psychol-
ogy of performance [Leistungspsychologie]. This corresponds roughly to the
Anglo-Saxon distinction between symptoms and signs, where the former are the
subject for phenomenology. Jaspers considered phenomenology as the only way of
getting access to the inner world of the patient. Since this world is inaccessible to
direct observation, and its grasping is only possible through the patient’s report,
the task of the psychopathologist requires as faithful reproduction of the patient’s
experience as possible, preferably by the quotation of the patient’s spontaneous
self-descriptions [Selbstschilderungen], because these are undistorted by question-
ing. In this process, the psychopathologist is an active participant. Jaspers uses the
concept of “presentification” [Vergegenwtirtigung], which indicates some sort of
imaginative variation on the part of the psychiatrist. Jasperian concept of
phenomenology overlaps to some degree the third and original use of this word,
namelyphilosophicalphenomenology, as introduced by E. Husserl’4.t
Philosophical phenomenology is an epistemological attempt to overcome
difficulties inherent in both empiricism and intellectualism.

“The empiricist argument states, in essence, that the way things are is the way things are and
that human attempts to understand the way things are must take their measure from the reality
that transcends us and exists in itself independently of us. The rejoinder, emanating from the
intellectualist camp, is that all cognition of the way things are is mediated by the finite structures
of human subjectivity: we cannot measure the validity of our cognition from the way things are in
themselves, because we only have access to the way things are for us.“15(p. 87).

The phenomenological epistemology occupies a meta-position versus those two

theories. It posits the possibility of human knowledge as a dialectic between the
object and the subject, implying intentionality, and a priori abilities of the subject.
Thk a priori component is a prelinguistic and prepredicative perception indicating a
primordial unity of subject and object. In phenomenoIogica1 terminoIogy, the word
“phenomenon” is a correlate of any conscious act. And conscious act is always
intentional: to be conscious implies to be conscious of something. Every mental
act has therefore the intrinsic property of “object directedness” [Gegenstandlich-
keit].14

“One cannot . . conceive any perceived thing without someone to perceive it. But the fact
remains that the thing presents itself to the person who perceives it as a thing in itself, and thus
poses the problem of a genuine in-itself-for-u.s.“‘~ (e.r. p. 322).

tThe term “phenomenology” can be traced to Kant, who distinguished between noumenon
(thing-in-itself), and phenomenon (appearance), and to Hegel.
AUTISM IN SCHIZOPHRENIA 11

Consequently, the phenomenon has the ontological primacy, because it exists

both in itself and for us. The phenomenal world is the real world and is equated
with the perceptual world. Perception becomes the touchstone of the real.
However, perception is not an atomistic process as viewed by pure empiricism, but
follows rules of the contextual experience of Gestalt.
Phenomenological epistemology posits that it is possible to obtain a prescien-
tific knowledge of the object, by the act of contextual perception and adoctrinal
reflection on the part of the subject. Husserl” spoke of “originally presenting
intuitive experience” [origin& gebende Anschauung]. He claimed that such
“lived-experience” [Erlebnis] is “presented” or “given” and that no intellectual
judgement is yet involved. He called such experience as “pure” or “pre-
predicative.” In this process, the phenomenon unfolds itself to us in different
manners, and in our mutual involvement with it, we have to point to it in various
ways. We are then able to progressively grasp the essence or structure of the
phenomenon, by focusing upon its variations against a horizon, context, or
texture. Husserl introduced the concept of “lived world” [Lebenswelt] to denote
the primary intersubjective horizon:

“The world is pregiven to us, the waking, always somehow practically interested subjects, not
occasionally but always and necessarily as the universal field of all actual and possible praxis, as a
horizon. To live is always to live-in-certainty-of-the-world.“’8 (et. p. 142).

According to Merleau-Ponty,

“One can say that we perceive the things themselves, that we are the world that thinks itself--or
that the world is at the heart of our flesh.“19 (e.t. p. 136).

This very obscure formulation attempts to overcome the difficulties created by the
use of language, by which the terms “subject” and “object” deal with the
experience:

“We speak of the perceiving subject and the objects perceived. However, to speak in this
manner is already to have abstracted from perceptual experience. What is given in experience
after all is neither a subject for-itself nor an object in-itself, but rather a perception. The fallacy
inherent in abstraction and analysis lies in our tendency to reify the abstract terms: we speak of
such second-order abstractions as subject and object as though they were given in first-order
experience. Such is our legacy from Descartes that our language is shot through with locutions
which tacitly reify (or realize into first-order existence) the abstractions which should properly be
used for second-order reflection upon experience.“” (p. 48).

Naturally, philosophical phenomenology is as diversified as any other philosoph-

ical trend, but we believe that the concepts introduced above correspond to
philosophical phenomenology as applied to psychiatry. For a detailed account of
the role of phenomenology in psychiatry and psychology, see Spiegelberg,” and
for its application in psychology, see Shapiro.”

THE CONCEPT OF AUTISM IN PHENOMENOLOGICAL PSYCHIATRY

In phenomenological psychiatry, autism is considered as a phenomenon, and as
such, it reveals a totality which it contains, even though it is only one of the facets
of this totality. In this sense, autism indicates an existential change, or its correlate
in the form of communicative experience.
12 PARNAS AND BOVET

“The sick individual, following a classical, descriptive diagnosis, is ‘carrier of the symptom,’ and
the descriptive diagnosing attributes to the individual, as an exclusive property, the characteristics
which it isolates, independently of the present relation with the observer. The word “schizophrenic”
has here the meaning of ‘a predicative characterization of the (assumed) schizophrenic process.’
But its meaning is completely different in the ‘phenomenological diagnosis,’ in which it does not
qualify a pathological process, but Being as globally met by the observer, and as he is met.
Understanding of autism as a phenomenon leads to a shift of emphasis from the schizophrenic
individual to the impression he makes on someone else.“** (p. 42).

Many classic clinicians were aware of such diagnostic process of autism, even
though they were not explicitly influenced by phenomenology, and named it in
different ways. Expressions like “diagnosis through intuition” (Wyrsch),Z” “atmo-
spheric diagnosis” (Tellenbach),24 “Praecox Geftihl” (Rtimke),” “Diagnostic par
penetration” (Minkowski)” occurred regularly in the psychiatric literature.
Riimke postulated that a skilled clinician is able to diagnose schizophrenia very
quickly in the encounter with the patient, and he named this diagnostic feeling on
the part of the psychiatrist as “praecox feeling” [praecox Geftihl]. He was unable
to verbalize the essence of this feeling, but proposed that it had something to do
with the inability to empathize with the patient’s personality as a whole. In his
discussion of the diagnostic value of Kraepelinian fundamental symptoms, he
writes:

“If the symptoms are taken in the literary sense . . ., these criteria are totally insufficient. But
when we add to each of these symptoms the words ‘a very definite,’ it is clear what Kraepelin
meant. It is, however, impossible so far to describe this ‘very definite’ character. Properly
speaking, these words ‘a very definite’ ought to be replaced by ‘a schizophrenic.’ To do so would
seem to be a scientific absurdity. And yet this is not the case, for every examiner with great
experience of genuine schizophrenia knows very precisely what this word ‘schizophrenic’ refers
to.“*’ (et. p. 304).

Tellenbach24 coined the expression of “atmospheric diagnosis,” which refers to a

recognition of a disharmony between specific atmospheres of the patient and the
participant observer.
It is quite likely that these affective-cognitive processes taking place in the
participant observer are linked to the prelinguistic perception described by
phenomenological philosophy. It is precisely for this reason that these processes
are elusive and resistant to any simple verbal description. Nonetheless, this feeling
has a diagnostic validity, as is illustrated by Gottesman and Shield? in their
famous schizophrenia study of Maudsley twin series. They obtained concordance
rates for schizophrenia at approximately 50% for MZ twins, and 10% for DZ
twins. They invited a Swedish psychiatrist, E. Essen-Moller, an internationally
known schizophrenia researcher, with special interest in the concept of schizoidia
and autism,29 to blindly diagnose the twin sample.

“Our summaries could not of course provide the data Essen-Moller preferred for assessing
characterological defects such as facial tonicity and emotional accessibility.“28 (p. 219).

Asked to expand his schizophrenia concept to include “personality traits that

might have a genetic relationship to schizophrenia,” all MZ co-twins of typical
schizophrenics, according to Essen-Miiller’s judgement, when not themselves
affected, revealed characterological abnormalities of the schizoid type.
AUTISM IN SCHIZOPHRENIA 13

“Up to now, Essen-Moller’s clinical assessments represent the most successful attempt ever
made to identify the schizotype or spectrum disorders.“” (p. 220).

This was achieved without inflating corresponding concordance rates for DZ

twins. However, Essen-Miiller was not able to verbalize or explicate what single
symptom or sign made him to allocate his diagnosis.
E. Minkowski, a French psychiatrist and a pupil of Bleuler, considered autism
as the essential feature of schizophrenia.

“Expressions like ‘discordance’ (Chaslin), ‘intrapsychic ataxia’ (Stransky), ‘intrapsychic dyshar-

mony’ (Urstein), ‘loss of inner unity’ (Kraepelin), ‘dissociation’ (Claude and Levy-Valensi),
‘schizophrenia’ (Bleuler) point to the idea that it is not this or that function which is disturbed, but
much more their cohesion, their harmonious interplay, in its globality. To make use of an image,
the essential disorder does not alter one or many faculties, whatever be their order in the
hierarchy of functions, but resides between them, in the ‘interstitial space.’ “XI(p. 12).

Minkowski was influenced by phenomenology and the vitalistic philosophy of

H. Bergson, and therefore departed from classical psychological and medical
model. He considered the essential feature of autism to consist of a “loss of the
vital contact with reality” [perte du contact vital avec la realitC].30*31
He defined the
vital contact in the following way:

“What we have in mind is the faculty of advancing harmoniously with the ambient becoming, in
penetrating it and in feeling one with it. We employ here the term ‘lived synchronism.’ Elements
of the vital contact with reality comprise ‘penetration, ’ ‘contemplation,’ and ‘sympathy.’ It is
because of the penetration that there is no place for the subject/object opposition. There is more
of an equivalence between the two, for if I absorb myself in that I contemplate, the thing
contemplated becomes animated, becomes as alive as I, penetrates to the depth of my being,
becomes the source of my inspiration. . . . Vital contact with reality gives us measure and limits of
our percepts, rendering them infinitely human and nuanced. It is good to have rules of conduct. It
is better to know how to apply them. . . Without being ever able to formulate it, we know what we
have to do; and it is that that makes our activity infinitely malleable and human.“26 (e.t. pp. 66-69).

The phenomenological version of the concept of “vital contact with reality” is

illustrated by Husserl:

“This means that within vitally flowing intentionality in which the life of an ego-subject consists,
every other ego is already intentionally implied in advance by way of empathy and empathy-
horizon.“‘* (e.t. p. 255).

Minkowski disagreed with Bleuler on several points. First, he did not consider
“thepredominance of the innerfantay 1ife”as the necessary component of autism. In
fact, he claimed that a typical schizophrenic was characterized by the poverty of
affective-cognitive processes. For such cases he introduced the concept of
“autisme pauvre, “31 i.e., autism characterized by “poverty.” On that point, he
incidentally agreed with Kraepelin, who also criticized Bleuler’s definition of
autism:

“But I very much doubt if it (i.e. autism), as Bleuler thinks, is caused by the withdrawal of the
patient to his own phantasies. . . Stubborn inactivity is often shown by patients, in whom there
can be no thought of special imaginings in which they could lose themselves, and it is lacking in
numerable other delusional diseases (e.g. general paresis), in which the patients dream
themselves into a world of imaginings.“‘j (e.t. p. 51).
14 PARNAS AND BOVET

Minkowski claimed that florid Bleulerian autism [autisme riche] occurred only
when a patient was equipped with an autism-independent propensity towards
affective-cognitive expressivity. Also, he did not consider autism as a withdrawal, but
as a loss of the vital contact with reality In this sense, autism can be viewed as a defect
rather than as a defense mechanism. This defect is discernible not only in the
patient’s expressivity or communication, but also in the activity and attitudes of
the patient. Minkowski coined the term “autistic activity.” What is characteristic
for the autistic activity is not its content, but the way this content is enacted. This
aspect of autistic activity is characterized by its inappropriateness, its friction with
the context of the situation, and its lack of relevant consequences. He mentions as
an example a schizoid father who buys, as a Christmas present for his dying
daughter, a coffin. This act is by objective standards quite rational and logical,
because the coffin is something which the daughter is going to need. At the same
time, this act reveals its total lack of attunement to the daughter’s emotional
needs, and is inappropriate and bizarre by any human standard. It follows from
Minkowski’s conception of autism that loss of the vital contact with reality, that is
lack of attunement with the environment, is discernible both in extraverted and
introverted behavior. This is in contrast with the predominance of a withdrawal
element contained in the Bleulen’an definition, which has led many psychiatrists to
confuse autism with introversion, mutism, or negativism. Last but not least,
Minkowski considered autism as a both primary and fundamental disorder of
schizophrenia, upon which other psychopathological features could be compre-
hended (generating disorder) [trouble gen&ateur].26
L. Binswanger,34235in his existential phenomenology [Daseinsanalyse], arrives at
a similar notion of the schizophrenic way of being as Minkowski, but primarily
from an anthropological (in the European sense of this word) analysis of the
schizophrenic existence.

“The basic concept used in understanding what is called the schizophrenic existential pattern
proves to be the notion of a breakdown in the consistency of natural experience-its inconsis-
tency. Inconsistency implies precisely that inability to ‘let things be’ in the immediate encounter
with them, in other words, to reside serenely among things.“” (p. 250).

The notion of natural experience and natural evidence has been elaborated by
W. Blankenburg.36-3s Natural experience is only possible because it rests on an
anonymous and silent mass of evidences that always and already are present, and
which constitute what has been called the “axioms of everyday life” (Straus).39
Such a formulation refers also to what phenomenology describes as a pre-
linguistic and pre-predicative perceptual ability and attunement (“the allusive
logic of the perceived world”16 e.t. p. 37). On the part of the human being, this
natural experience is given due to the presence of a “common sense” [sensus
comrnunis] (Blankenburg).% According to Blankenburg, common sense is the
ability to see things in the right perspective, provides knowledge of the “rules of
the game” for the human behavior, provides a sense and taste for that which is
adequate and proper, and knowledge of the Other even before his recognition.
Common sense enables us to distinguish between what is relevant and irrelevant,
likely and improbable, which is a more elementary ability than to distinguish
between what is true or false. In short, it is the ability to sense the exact weight of
things.
AUTISM IN SCHIZOPHRENIA 15

“It is a logic, not the one of the logicians, but a ‘logic of the world’ [Weltlogik], a ‘natural logic.’
What common sense brings is not whnt is evident, but how it is evident, the ever present and ever
forgotten frame of experience: the most trivial but also the most basic thing, because it forms the
ground of human Presence and Praxis in everyday life, brings historical continuity to the Self, and
constitutes the stream of intersubjectivity.“‘* (pp. 58-59).

Common sense is therefore not a conglomerate of objective knowledge, but

reveals its value as an attitude-a natural attitude-from which humans see and
experience the world. Blankenbulg claims that the essence of autism consists of a
“@obal crisis of common sense. ” He presents following vignettes to illustrate his
point:

“A young patient complains: ‘What is it I really lack? Something so small, but so unique and
important that you cannot live without it. I have the need of support in the most trivial everyday
matters; what I lack really is the natural evidence [Selbstverstandlichkeit]. Every human should
know how to behave and conduct himself. I did not have the requisite premises. There are so many
things which are alien for me. It has simply to do with living, how to behave yourself in order not to
be pushed outside, outside society. But I cannot find the right word for that which is lacking in
me-that is the way I feel it. It is not knowledge; it is something that every child is equipped with.
It is these very simple things a human being has the need for, to carry on life, . . how to act, to be
with other people, to know rules of the game . . . Such a thing as washing for instance, I do not
manage it in a self-evident way. . . . I have to force myself. . that is the case with all the world. I
cannot find a rest in myself, as if I did not have any point of view nor any attitude [Haltung]. I do
not have any solid attitude towards things. Other people see only the relevant questions, natural
problems which do not affect them personally. That is the reason why they can be more relaxed
and more natural. I do not know how I am going to live with this defect.’ Another patient writes to
his friend: ‘I do not know whether you are happy, let us assume that. Whom do you have to thank
for this-let us say-unburdened easiness [Unbeschwertsein]? For your happiness, your easiness
and your security, you can thank ‘a something’ of which you are not even conscious. This
‘something’ is first of all that which makes easiness possible. It provides the first ground’.“3”

Such reports are of course not very frequent. We encounter them in the
complaints of young incipient hebephrenics who still have retained an ability for
self-reflection. This defect in the preintentional attunement makes the preschizo-
phrenic vulnerable to the demands of the outer world, and may result in a
withdrawal from object relations. According to Blankenburg, the lack of natural
evidence facilitates construction of subjective evidences, which leads to the
productive paranoid psychosis. What is typical for such paranoid psychosis is its
universal and stereotyped way of being, which is resilient to any factual
experience.
In the discussion of differences between schizophrenics and depressives,
Blankenburg3’ states that for depressives, the sense for [das Geftihl fur] what they
lack, as evidenced by their guilt or insufficiency feelings, is still present, and
perhaps even intensified as compared to normals, whereas for schizophrenics or
schizoids this sense of experiencing a lack of empathy [das Geftihl fur das Erleben
eines Mange1 an Mitgeftihl] is at least partially lost.
The global crisis of common sense or lack of natural evidence constitutes the autistic
nucleus and leads to the schizophrenic perplexity [Rastlosigkeit14’ or “hyper-
reflexion” [Reflexionskrampf141 where the patient has a feeling that the environ-
ment has lost its elementary meaning and reference. In this sense, the schizo-
phrenic has lost a worldly paradigm for his reflections and activities, and is
compelled to address, for other people, quite elementary and self-evident issues.
16 PARNAS AND BOVET

The global crisis of common sense is well illustrated in the work of K. Conrad,“’
who observed that in the initial stage of schizophrenia [das Trema], judgements,
emotions and behavior are often inappropriate to their social context. Such a
heralding of schizophrenia by isolated, bizarre statements or behaviors was in
classical psychiatry called “paragnomen.”
As illustrated, these three concepts of autism in phenomenological psychiatry,
i.e., “loss of vital contact with reality” (Minkowski), “inconsistency of natural
experience” (Binswanger), and “global crisis of common sense” (Blankenburg),
overlap each other considerably.
These descriptions indicate that autism comprises both affective and cognitive
components. This may imply that the primary dialogue between the Self and the
outer world [Mitweltbezogenheit] is an intertwining of affect, cognition and will,
which become semantically separated by the application of language.
The diagnostic value of autistic tendencies for milder forms of schizophrenia or
schizoid personality was noted by all classic schizophrenia researchers. Already
Kahlbaum4’ spoke about “heboid states” (heboidophrenias), which he noted
occurred frequently among relatives of hebephrenics, and which were character-
ized by subtle formal thought disorder, and disturbances in social feelings, tact,
and conduct. Later, expressions like simple form of Dementia praecox,43 latent
schizophrenia,’ or schizoid personality44 were introduced to describe behavioral
features which were identifiable in preschizophrenics, relatives of schizophrenics,
and attenuated forms of schizophrenia. These observations were in our time
confirmed by the adoption studies in schizophrenia45,46 and premorbid study of
schizophrenics and schizotypes.47-4y Basically, all these studies indicate that
peculiar expressivity is the hallmark of the schizophrenic phenotype. In the
DSM-III-R’ definition of schizotypal personality, there are at least four criteria
that are connected to the concept of autism: excentricity, restricted and/or
inappropriate rapport, odd communication, and social isolation. It is interesting
to note that the interviewer in the Danish-American adoption studies was always
employing the concept of autism in his diagnostic work (Jacobsen, personal
communication).

A HYPOTHETICAL VIEW ON THE NATURE OF AUTISM

As it was stated in the phenomenological definition of autism, this phenomenon
reveals itself in a relational process between the autistic person and the outer
world. Autism is therefore not a classical symptom in itsel’ but a phenomenon
in-itselffor-us. In this sense, it is not an inherent characteristic of an isolated
symptom carrier, but refers to a global defective cognitive/affective attunement
between the schizophrenic subject and his environment.
Philosophical phenomenology refers to the issue of primary attunement with
the introduction of the concept of tacit-cogito by Merleau-Ponty.‘6 Tacit-cogito can
be defined as a preverbal, unnoticed cognition, which is primarily bound to
perception and corporeality. It is the foundation of incarnate consciousness
because it links the transcendent (outer) world with the immanent (inner)
consciousness formalized by Descartes (self-reflection). Tacit-cogito can be
understood as a latent corporeal reflexivity, which experiences the world but does
not thematize it. It is tacit-cogito that constitutes the world and oneself as familiar
AUTISM IN SCHIZOPHRENIA 17

figures, trustworthy and known even before experienced. In phenomenological

sense, perception and expression are different names of the same link between the
subject and the outer world.

“All perception, and all action which presupposes it, in short, every human use of the body, is
already primordial expression. This means that perception is . , the primary operation which first
constitutes signs as signs. Perception makes what is expressed dwell in signs, not through some
previous convention, but through the eloquence of their very arrangement and configuration.“‘”
(et. p. 78).

According to phenomenology, apprehension of a phenomenon requires dif-

ferent pointings to the same object, using various and interrelated perceptual
modalities:
“As perceptively active I experience all nature, including my own living body, which is thus
reflexively related to itself. That becomes possible because I can perceive one hand by the means
of the other, an eye by the means of a hand, and so forth-a procedure in which the functioning
organ must become an object, and the object the functioning organ.“” (e.?. p. 44). “Since the same
body sees and touches, visible and tangible belong to the same worlds. . . . Every movement of my
eyes--even more, every displacement of my body-has its place in the same universe that I
itemize and explore with them, as, conversely, every vision takes place somewhere in the tactile
space. There is double and crossed situating of the visible and the tangible, and of the tangible in
the visible; the two maps are complete, and yet they do not merge into one. The two parts are total
parts and yet are not superposable.“” (e.r. p. 134).

Recently Stern, a psychiatrist interested in developmental psychology, explor-

ing the ways by which the elementary sense of Self emerges during infancy,
attributes the constitution of affective sharing and attunement (“the acts and
processes that let other people know that you are feeling something very like what
they are feeling”) to cross-modal abilities to recognize the same phenomenon.5’
“Attunements have the following characteristics, which make them ideal for accomplishing the
intersubjective sharing of affect: 1. They give the impression that a kind of imitation has occurred.
There is no faithful rendering of the infant’s overt behavior, but some form of matching is going
on. 2. The matching is largely cross-modal. That is, the channel or modality of expression used by
the mother to match the infant’s behavior is different from the channel or modality used by the
infant. . . . 3. What is being matched is not the other person’s behavior per se, but rather some
aspect of the behavior that reflects the person’s feeling state. The ultimate reference for the match
appears to be the feeling state (inferred or directly apprehended), not the external behavioral
event. Thus the match appears to occur between the expressions of inner state. These expressions
can differ in mode or form, but they are to some extent interchangeable as manifestations of a
single, recognizable internal sate. We appear to be dealing with behavior as expression rather
than as sign or symbol, and the vehicles of transfer are metaphor and analogue.“” (pp. 141-142).

One can therefore consider autism as a defect in the elementay perceptual1

expressive anchoring of the subject in the outer world, in what Merleau-Ponty
describes as “tacit-cogito” and Stern as “attunement.” Affective and cognitive
elements are intertwined in autism, and form a “total Gestalt.” This Gestalt
becomes split into different components by our descriptive and experimental
efforts, which variously focus on affective or cognitive features.

AUTISM IN AN ETIOPATHOGENIC MODEL OF SCHIZOPHRENIA

The concept of autism can be related to two recent, complementary models of
the development of frank schizophrenic symptoms.
18 PARNAS AND BOVET

Meeh15’,53suggests that schizophrenia is monogenetically determined. What is

inherited in schizophrenia is an elementary neurointegrative deficit, which he
called schizotaxia. A schizotaxic individual, in most cases, will develop some
schizotypal features, one of which is the autistic tendency.53 Polygenic influences
and environmental factors can decompensate such an individual and lead to a
schizophrenic episode.
IUosterk6tter,54 in continuation of Conrad’s original work,41 presented observa-
tions illustrating symptom development in paranoid schizophrenia. His interpreta-
tion of his data is in accordance with the hypothesis of Maher,” who considers a
delusion in a schizophrenic as an explanatory effort to account for an aberrant
perceptual experience. Klosterkotter describes the following development of
schizophrenic delusions and hallucinations: their initial stage [Ausgangserfahr-
ung], to which a schizophrenic can also return during his remission, consists of the
so-called ‘basic symptoms.‘8,56,57 These are elementary intrusions in perception,
cognition, volition, affectivity, expressivity, and motor/bodily activity. Progres-
sively, the patient passes into an intermediate stage of “as if’ experience
[Zwischenphanomene]. For instance, certain intrusive thoughts, though still
recognized as his own, are experienced as if they were somehow alien and
imposed. The third stage is the crystallization of a delusion or hallucination
[Endphanomene] as a final concretization [Konkretisierung] of those initially
elementary disturbances.
What is not evident is why this transition from the basic symptoms to delusions
and hallucinations takes place and whether the postulated neurointegrative
deficit by itself is involved in this transition. In other words, it is a question
whether schizotaxia in itself impairs reality testing in addition to its being the
primary source of basic symptoms. One of the possibilities is that it is precisely the
preexistent autistic defect, which facilitates such a transition. In this sense, autistic
tendencies can be regarded as primary and fundamental, in that they constitute
the first and elementary phenotypic level of expression of schizotaxia, intertwined
with the “basic symptoms.” In this paradigm, a schizotype is the individual who
only rarely transgresses this phenotypic level, whereas a schizophrenic, due to
other genetic and environmental factors, undergoes the full transition. In this
process, autism and environment are caught in a positive feedback loop (Fig 1).

CONCLUSION AND PERSPECTIVES

The concept of autism has been developed by skilled clinicians interested in
grasping the psychopathological essence of schizophrenic and schizotypal disor-
ders. In this sense, the concept of autism was of decisive importance in the original
demarcation of schizophrenia and schizophrenia spectrum disorders. However,
when autism is conceptualized according to the classical objectivistic descriptive model
of medicine, itprogressively disintegrates, because it defies any simple and operational
formulation in this model. Nevertheless, it seems quite likely that recognition of
autism as a phenomenon plays a fundamental role in clinical diagnosing of
schizophrenia and schizotypy.
We believe that this concept is worthwhile to reassimilate into theorizing about
the pathogenesis of schizophrenia, and about psychopathology of schizophrenia.
Consequently, it might be profitable for psychiatric research to revive and reapply
AUTISM IN SCHIZOPHRENIA 19

Molecular level

.___________________------------ __________________
(pre-phenomenal level)

I. khizolaxia
(prephenomenal,
Neurwintegrative deficit physiological
,~ r,,
”

Fig 1. Tentative model Delusions and hallucinations

of the etiopathogenesis of
schizophrenia (see text).

this concept to empirical studies with the assistance of skilled schizophrenia

clinicians. The latter may be unable to verbalize or operationalize their perfor-
mance, but they can help to delineate the object of the study in a way which may be
fruitful to our biological or other empirical attempts. If psychiatry remains
one-sidedly stuck with the use of structured interviews solely compatible to
pre-existing operational criteria, it will cut itself off from the major variable,
namely psychopathology. Psychopathology is still the important correlate of our
empirical effort.

REFERENCES
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 3,
revised). Washington, DC, APA, 1987
2. Bleuler E: Dementia Praecox oder Gruppe der Schizophrenien, in Aschaffenburg G (ed):
Handbuch der Psychiatric. Leipzig, Germany, Deuticke, 1911. Translation by Zinkin J, Lewis NDC:
Dementia Praecox or the Group of Schizophrenias. New York, NY, International University Press,
1950
3. Landmark J: A manual for the assessment of schizophrenia. Acta Psychiatr Stand Suppl65,1982
4. Freud S: Drei Abhandlungen zur Sexualtheorie. Wien, Austria, Deuticke, 1905
5. Janet P: Les Obsessions et la Psychasthenic. Paris, France, Alcan, 1903
6. Bleuler E: Das autistisch-undisziplinierte Denken in der Medizin und seine Ueberwindung.
Berlin, Germany, Springer, 1919. Translation by Rapaport D, in Rapaport D (ed): Organization and
Pathology of Thought. New York, NY, Columbia University, 1951, pp 399-437
7. Stromgren E: Autism. Eur J Psychiatry 1:45-54,1987
8. Bleuler M: Die schizophrenen Geistesstorungen im Lichte langjahriger Kranken- und Familienge-
schichten. Stuttgart, Germany, Thieme, 1972. Translation by Clemens SM: The Schizophrenic
Disorders. Long-term Patient and Family Studies. New Haven, CT, Yale University, 1978
9. McGlashan TH: Aphanisis: The syndrome of pseudo-depression in chronic schizophrenia.
Schizophr Bull 8:118-134,1982
10. Mednick SA, Schulsinger F: Factors related to breakdown in children at high risk for
schizophrenia, in Roff M, Ricks DF (eds): Life History Research in Psychopathology. Minneapolis,
MN, University of Minnesota, 1970, pp 51-93
11. Kanner L: Autistic disturbances of affective contact. Nets Child 2:217-250,1943
20 PARNAS AND BOVET

12. Asperger H: Die “At&t&hen Psychopathen” im Kindesalter. Arch Psychiatr Nervenkrank

117:76-136, 1944
13. Jaspers K: Allgemeine Psychopathologic (ed 3). Berlin, Germany, Springer, 1923
14. Husserl E: Logische Untersuchungen. Halle, Germany, Niemeyer, 1900. Translation by Findlay
JN: Logical Investigations. London, England, Routledge & Kegan Paul, 1970
15. Dillon MC: Merleau-Ponty’s Ontology. Bloomington, IN, Indiana University, 1988
16. Merleau-Ponty M: Phenomdnologie de la Perception. Paris, France, Gallimard, 1945. Transla-
tion by Smith C: Phenomenology of Perception. London, England, Routledge & Kegan Paul, 1962
17. Husserl E: Entwurf einer “Vorrede” zu den logischen Untersuchungen. Halle, Germany,
Niemeyer, 1913. Translation by Bossert PJ, Peters CH: Introduction to Logical Investigations. The
Hague, Netherlands, Nijhoff, 1975
18. Husserl E: Cartesianische Meditationen. The Hague, Netherlands, Nijhoff (Husserliana I), ed.
Strasser S, 1931. Translation by Cairns D: Cartesian Meditations. The Hague, Netherlands, Nijhoff,
1973
19. Merleau-Ponty M: Le visible et I’invisible. Paris, France, Gallimard, 1964. Translation by Lingis
A: The Visible and the Invisible. Evanston, IL, Northwestern University, 1968
20. Spiegelberg H: Phenomenology in Psychology and Psychiatry. A Historical Introduction.
Evanston, IL, Northwestern University, 1972
21. Shapiro KJ: Bodily Reflective Modes. A Phenomenological Method for Psychology. Durham,
NC, Duke University, 1985
22. Tatossian A: Phenomdnologie des Psychoses. Paris, France, Masson, 1979
23. Wyrsch J: Ueber die Intuition bei der Erkennung des Schizophrenen. Schweiz Med Wochenschr
46:1173-1176,1946
24. Tellenbach H: Geschmack und Atmosphare. Medier menschlichen Elementarkontaktes.
Salzburg, Austria, Miiller, 1968
25. Riimke HC: Das Kernsymptom der Schizophrenic und das “Praecox Gefilhl.” Zentralbl
Gesamte Neurol Psychiatr 102:168-169, 1942
26. Minkowski E: Le Temps V&u. Etudes Phenomenologiques et Psychopathologiques. Paris,
France, Coll de I’Evolution Psychiatrique, 1933. Translation by Metzel N: Lived Time. Phenomenolog-
ical and Psychopathological Studies. Evanston, IL, Northwestern University, 1970
27. Riimke HC: Die klinische Differenzierung innerhalb der Gruppe der Schizophrenien, in
Rtimke HC: Eine bliihende Psychiatric in Gefahr. Ausgewlhlte Vortrlge und Aufsltze. von Baeyer W
(ed.) Berlin, Germany, Springer, 1959, pp 203-211. Translation by Stoll WA: The clinical differentia-
tion within the group of schizophrenias, in Stoll WA (ed): Proceedings of the Second International
Congress for Psychiatry. Zurich, Switzerland, Fiissli, 1959, pp 302-310
28. Gottesman II, Shields J: Schizophrenia and Genetics: A Twin Study Vantage Point. San Diego,
CA, Academic, 1972
29. Essen-Moller E: The concept of schizoidia. Psychiatr Neurol 112:258-271,1947
30. Minkowski E: La Notion de Perte de Contact Vital avec la Rtalite et ses Applications en
Psychopathologic. Paris, France, Jouve & Cie, 1926
31. Minkowski E: La Schizophrenic. Psychopathologic des Schizoi’des et des Schizophrtnes. Paris,
France, Payot, 1927
32. Husserl E: Die Krisis der europaischen Wissenschaften und die transzendentale Phanomenol-
ogie (1936). The Hague, Netherlands, Nijhoff (Husserliana VI), ed. Biemel W, 1954. Translation
by Carr D: The Crisis of European Sciences and Transcendental Philosophy. Evanston, IL,
Northwestern University, 1970
33. Kraepelin E: Dementia Praecox und Paraphrenie. Leipzig, Germany, Barth, 1919. Translation
by Barclay RM, Robertson GM: Dementia Praecox and Paraphrenia. Edinburgh, Scotland, Living-
stone, 1919.
34. Binswanger L: Drei Formen missghickten Daseins: Verstiegenheit, Verschrobenheit, Manieri-
ertheit. Tubingen, Germany, Niemeyer, 1956
35. Binswanger L: Being-in-the-World: Selected Papers. Ed and translated by Needleman J. New
York, NY, Basic Books, 1963
36. Blankenburg W: Ansltze zu einer Psychopathologic des “common sense.” Confinia Psychiatr
12:144-163, 1969
37. Blankenburg W: Der Verlust der nattirlichen Selbstverstandlichkeit. Ein Beitrag zur Psycho-
pathologie symptomarmer Schizophrenien. Stuttgart, Germany, Enke, 1971
AUTISM IN SCHIZOPHRENIA 21

38. Blankenburg W: Autismus, in Muller C (ed): Lexicon der Psychiatric. Gesammelte Abhandlun-
gen der gebriuchlisten psychiatrischen Begriffe (ed 2). Berlin, Germany, Springer, 1986, pp 83-89
39. Straus E: Die Aesthesiologie und ihre Bedeutung fur das Verstandnis der Halluzinationen, in
Straus E: Psychologie der menschlichen Welt. Gesammelte Schriften. Berlin, Germany, Springer,
1949, pp 236-269. Translation by the editors: Aesthesiology and Hallucinations, in May R, Angel E,
Ellenberger HF (eds): Existence. New York, NY, Basic Books, 1958, pp 139-169
40. Starring GE: Wesen und Bedeutung des Symptoms der Rastlosigkeit bei psychischen Erkrankun-
gen. Leipzig, Germany, Thieme, 1939
41. Conrad K: Die beginnende Schizophrenic. Versuch einer Gestaltanalyse des Wahns. Stuttgart,
Germany, Thieme, 1958
42. Kahlbaum KL: Ueber Heboidophrenie. Allgem Zschr Psychiatr 46:461-480,189O
43. Diem 0: Die einfach demente Form der Dementia praecox (Dementia simplex). Arch Psychiatr
Nervenkrank 37:11-187,1903
44. Kretschmer E: Korperbau und Charakter. Untersuchungen zum Konstitutionsproblem und zur
Lehre von den Temperamenten. Berlin, Germany, Springer, 1921. Translation by Sprott WJH:
Physique and Character; an Investigation of the Nature of Constitution and of the Theory of
Temperament. London, England, Kegan Paul, 1925
45. Kety SS, Rosenthal D, Wender PH, et al: The biological and adoptive families of adopted
individuals who later became schizophrenic: Prevalence of mental illness and other characteristics, in
Wynne LC, Cromwell RL, Matthysse S (eds): The Nature of Schizophrenia. New York, NY, Wiley,
1978, pp 25-37
46. Gunderson JG, Siever LJ, Spaulding E: The search for a schizotype. Arch Gen Psychiatry
40:15-22, 1983
47. Parnas J, Schulsinger F, Schulsinger H, et al: Behavioral precursors of the schizophrenia
spectrum. Arch Gen Psychiatry 39:658-664, 1982
48. Parnas J, Schulsinger H: Continuity of formal thought disorder from childhood to adulthood in a
high risk sample. Acta Psychiatr Stand 74:246-251, 1986
49. Parnas J, Jorgensen A: Pre-morbid psychopathology in schizophrenia spectrum. Br J Psychiatry
155:623-627,1989
50. Merleau-Ponty M: La Prose du Monde. Paris, France, Gallimard, 1969. Translation by O’Neill
J: The Prose of the World. Evanston, IL, Northwestern University, 1973
51. Stern DN: The Interpersonal World of the Infant. A View From Psychoanalysis and
Developmental Psychology. New York, NY, Basic Books, 1985
52. Meehl PE: Schizotaxia, schizotypy, schizophrenia. Am Psycho1 17:827-838, 1962
53. Meehl PE: Schizotaxia revisited. Arch Gen Psychiatry 46:935-944,1989
54. Klosterkotter J: Basissymptome und Endphinomene der Schizophrenic. Heidelberg, Germany,
Springer, 1988
55. Maher BA: Anomalous experience and delusional thinking: The logic of explanations, in
Oltmanns TF, Maher BA (eds): Delusional Beliefs. New York, NY, Wiley, 1988, pp 15-33
56. Ciompi L, Miiller C: Lebensweg und Alter der Schizophrenen. Eine katamnestische Langzeit-
studie bis ins Senium. Berlin, Germany, Springer, 1976
57. Huber G, Gross G, Schuttler R: Schizophrenic. Verlaufs- und sozialpsychiatrische Langzeitunter-
suchung an den 1945-1959 in Bonn hospitalisierten schizophrenen Kranken. Berlin, Germany,
Springer, 1979