The intersubjectivity of delusions
Authors: Thomas Fuchs
Journal: World Psychiatry (2015)

Sass and Byrom 1 convincingly argue for the need to systematically investigate the lived or subjective experience of schizophrenic delusions. Moreover, they connect phenomenological accounts of delusion formation with current neurocognitive models of salience dysregulation and prediction error. I fully subscribe to this approach, yet I want to draw the reader's attention to an additional dimension of delusions which may be elucidated by a phenomenological and enactive approach. To begin with, traditional notions such as incomprehensibility (Jaspers), decontextualization (Matussek) or apophany (Conrad), but also more recent concepts presented by Sass and Byrom such as ipseity disorder, hyperreflexivity or schizophrenic solipsism, may convey the impression that schizophrenic delusion is a rather individual or subjective phenomenon, implying a withdrawal from sociality into a dream-like inner world. Similarly, the neurocognitive models of prediction error signalling or of hypersalience attempt to explain delusions by reference to basal cognitive dysfunctions that lend abnormal significance or strangeness to normally irrelevant "environmental cues". What threatens to be overlooked in both cases is that schizophrenic delusions are essentially intersubjective phenomena, both in form and content. First, Sass and Byrom rightly question the standard account of delusions as "mistaken beliefs" about objective facts in the world. Bizarre delusions aside, in most cases the psychiatrist will hardly be able to empirically falsify the patient's delusional claims – but this won't even be necessary. Delusions typically manifest themselves in an intersubjective situation, namely as a peculiar inability or refusal of the patient to adequately take the other's perspective into account, to understand his doubts, to try to make himself adequately understood, etc.. In other words, delusions appear primarily as a specific disturbance or breakdown of communication: the mutual comparison and alignment of perspectives fails. Nevertheless, regarding content, schizophrenic delusions notoriously show a pervasive reference to others by whom the patient feels observed, spied at, persecuted or manipulated. Even though the others often remain hidden, act covertly or in a roundabout way, the patient nevertheless has the impression of being in the centre of their gazes, intentions and actions. Conrad's trema or "stage fright" in beginning psychosis as well as his notion of anastrophe ("everything turns around me") point to the self-centrality of the schizophrenic person, experienced as if being on a clandestine stage, in the midst of a mysterious play that he tries in vain to decipher (P. Weir's Truman Show is a movie which patients often mention in order to describe their experience). Similarly, the hypersalience of environmental cues in most cases refers to social situations and significances (meaningful gazes, "telling" gestures, strange people walking by, etc.), resulting in an experienced threat from evil intentions of others rather than from the natural world. Thus it seems that an adequate analysis of the phenomenon of delusion has to take its intersubjective dimension into account 2. Our experience of the world is not a solitary achievement, but is based on a continuous intersubjective co-creation of meaning. We live in a shared life-world because we continuously create and "enact" it through our coordinated activities and "participatory sense-making" 3. This implies circular processes of mutual understanding, negotiation of intentions, alignment of perspectives and reciprocal correction of perceptions – processes that take place in every interaction and communication with others. An essential presupposition for these processes is the capacity of shared intentionality or perspective taking – that means, to transcend one's primary, egocentric perspective and to grasp others' intentions and point of view. This suspends the primary self-centrality that is ultimately rooted in the subjective or lived body. Intersubjectivity in its full sense is thus based on the ability to oscillate between an ego-centric, embodied perspective on the one hand, and an allo-centric or decentred perspective on the other, without thereby losing one's bodily centre of self-awareness. This decisive step of human cognitive development may also be summarized as reaching the excentric position, a term coined by German philosopher H. Plessner 4 to denote a third or higher-level stance from which the integration of the ego- and allo-centric point of view is possible. Thus, intersubjectivity implies a continuous co-construction of meaning through mutual interaction and perspective taking. However, if there are constraining boundary conditions to these circular processes, then the co-construction of meaning will be disturbed and mutual understanding will fail. Such is the case, for example, when one of the partners is deaf, or does not understand the other's language or cultural background. It is well known that these are typical conditions which in vulnerable persons may lead to suspicion, paranoid ideation and finally to delusions of persecution – termed "paranoia of the hard-of-hearing" 5 or "paranoia of immigrants" 6-8. In these cases, adequate understanding of verbal utterances is compromised, leading to a disturbance of the circles of social interaction and perception. With some modifications, this description applies to schizophrenic delusions as well. In the prodromal stages of the psychosis, the alienation of perception and the resulting loss of familiar significances particularly extend to the social sphere. The faces, the gazes and the behaviour of others become highly ambiguous, and the interactive circles with others are fundamentally disturbed. In the delusional mood arising from this ambiguity, the basic trust in others breaks down 9, 10. The co-constitution of a shared world fails and is replaced by the new, idiosyncratic coherence of the delusion. But this does not at all mean that the others are no longer important. On the contrary, now the patient feels being observed by gazes from the background, being spied at from out of anonymous cars, or secretly tested in well-prepared situations. In other words, he takes others' presumed perspectives even excessively (this has been termed "overmentalization", e.g. 11), but in a way that all these perspectives seem to be directed centripetally towards himself in a threatening way. Delusions may thus be described as a loss of the excentric position. Deluded patients are able to take the (supposed) perspective of others; what they lack, however, is the independent position from which they could compare and integrate their own and another's point of view, and from which they could also relativize or question their feeling of centrality and reference (being observed, spied at, persecuted, etc.); this independent or "third" position is the excentric position. Thus, delusions result from the failure of co-constituting the world through mutually taking and aligning one's perspectives. "Double book-keeping" is a possible consequence: the patient's own and the others' point of view are only juxtaposed instead of being integrated. Another result is the exclusion of chance 12. Chance or coincidence normally allows us to neutralize irrelevant elements of a situation by attributing them to a mere contingency, not to another's intention: "this was not meant for me" or "not aimed at me". For the schizophrenic patient, however, the situation is reversed: it is precisely the normally irrelevant and accidental background elements that adopt a meaningful, sinister and threatening character. The deluded person does no longer acknowledge the possibility of chance, and thus refuses to treat the shared situation as an open one. Everything revolves around him. In sum, delusions may not be sufficiently described as individual false beliefs. Rather, they correspond to an intersubjective situation bereft of the basic trust that could help to restore a consensual understanding of the situation and to co-constitute a shared, commonsensical reality. No matter what their neurobiological presuppositions and neurocognitive components are – no doubt that these are of crucial importance – delusions are not just products of individual brains. Their basis is not a faulty representation of the world, but a failure of enacting a shared world through interaction with others.