Embodiment and schizophrenia
Authors: GIOVANNI STANGHELLINI
Journal: World Psychiatry (2009)

Since the beginning of the 20th century, phenomenology has developed a distinction between lived body (Leib) and physical body (Koerper), or body-subject and body-object. The first is the body experienced from within, my own direct experience of my body in the first-person perspective, myself as a spatiotemporal embodied agent in the world. The second is the body thematically investigated from without, as for example by natural sciences as anatomy and physiology, a third person perspective. Phenomenology conceives of the lived body as the center of three main dimensions of experience: a) the experience of my self, and especially of the most primitive form of self-awareness; b) object-experience and meaning-bestowing; c) the experience of other people, i.e. intersubjectivity. I experience myself as the perspectival origin of my experiences (i.e., perceptions or emotions), actions and thoughts. This primordial access to myself, or primitive form of egocentricity, must be distinguished from any explicit and thematic form of I-awareness, since it is tacit and implicit, although experientially present. This primitive experience of myself does not arise in reflection, i.e. from a split between an experienced and an experiencing self, but is a pre-reflexive phenomenon. It is also immediate, since it is an evidence not inferentially and criterially given. This form of primitive self-awareness is not a conceptual or linguistic representation of oneself, but a primordial contact with oneself or self-affection in which who feels and who is felt are just one thing 1. Last but not least, it must be also distinguished from a kind of object-awareness, since it is does not arise from an objectifying or observational perception of oneself. Henry uses the term ipseity to express this basic or minimal form of self-awareness 1. Thus, ipseity is the implicit, pre-reflexive, immediate, non-conceptual, non-objectifying and non-observational sense of existing as a subject of awareness. It is prior to, and a condition of, all other experience. Two basic and closely related aspects of minimal self-awareness are self-ownership and self-agency 2. Self-ownership is the pre-reflexive sense that I am the one who is undergoing an experience. Self-agency is the pre-reflexive sense that I am the one who is initiating an action. The immediate awareness of the subjectivity of my experience or action involves that these are in some sense owned and generated by myself. These are the basic components of the experienced differentiation between self and non-self, my self and the object I perceive, and my representation of that object and the object itself. Merleau-Ponty 3 emphasized that this basic form of self-experience is rooted in one's bodily experience and its situatedness amongst worldly objects and other people. Ipseity, to Merleau-Ponty, is indiscernible from "inhabiting" one's own world, i.e. being engaged and feeling attuned to one's own environment. It is the lived body that provides this engagement and attunement. Being conscious — says Merleau-Ponty 3 — is dwelling in (être-à) the world through one's own lived body. There is good empirical evidence in developmental psychology that newborn infants are already equipped with this minimal form of self-awareness that is embodied and attuned to the world; for instance, Rochat 4 argues that children, long before they have developed a conceptual image of themselves, have a proprioceptive and ecological sense of their bodily self. The power of organizing experience is grounded in motility and perception. Husserl 5 showed that a modification in one's lived body implies a modification in the perception of the external world. To Husserl, the shape of material things, just as they stand in front of me in an intuitive way, depends on my configuration, on the configuration of myself as an experiencing embodied subject. By means of the integrity of kinaesthesia — the sense of the position and movement of voluntary muscles — my own body is the constant reference of my orientation in the perceptive field. The perceived object gives itself through the integration of a series of prospective appearances. The lived body is not only the perspectival origin of my perceptions and the locus of their integration, it is the means by which I own the world, insomuch as it structures and organizes the chances of participating in the field of experience. The living body perceives worldly objects as parts of a situation in which it is engaged, of a project to which it is committed, so that its actions are responses to situations rather than reactions to stimuli. The body — as Merleau-Ponty would put it — seeks understanding from the objects with which it interacts; the lived body is silently at work whatever I do. I understand my environment as I inhabit it, and the meaningful organization of the field of experience is possible because the active and receptive potentials of my own body are constantly projected into it 6. Knowledge is enacted 7 or action-specific, and perception is always tangled up with specific possibilities of action 8. Perception is constantly geared up to tracing possibilities for action; these possibilities for action are what we call "meaning", since the meaning of an object is how we put it at use. As Heidegger 9 put it, the basic kind of knowledge I have of objects I encounter in the world is not a kind of mere theoretical cognition, but rather a kind of concern which manipulates things and "puts them to use". Objects appear to my embodied self as something "in-order-to", as "equipment", "ready to hand", for manipulating reality and so for cutting, sewing, writing, etc. I literally grasp the meaning of one thing, since this meaning is exactly the specific "manipulability" (Handlichkeit) of one thing. Merleau-Ponty places the lived body also at the center of the problem of intersubjectivity, setting the stage for the understanding of intersubjectivity as intercorporeality, i.e. the immediate, pre-reflexive perceptual linkage between my own and the other's body through which I recognize another being as an alter ego and make sense of his actions. From the angle of intercorporeality, intersubjectivity is a communion of flesh and not a relationship between separate persons. Intercorporeality means the transfer of the corporeal schema, the primary bond of perception by which I recognize others as being similar to myself. This phenomenon is the phenomenal basis of syncretic sociability, i.e., of pathic identification with the other; in a word, of intersubjectivity 10. Intercorporeality is never fully evident, but it is the bearing support of all interaction connected with behaviour, already active and present ahead of any explicit communication. The perceptive bond between myself and another person is based on my possibility to identify with the other person's body by means of a primary perceptive tie. Developmental psychologists support the hypothesis that proprioception is involved in understanding other persons through body-to-body attunement 11. Scientific evidence from neuroimaging also seems to corroborate this view: mirror neurons are a set of visuo-motor neurons in the pre-motor cortex of primates that are supposed to be the neurophysiological substratum for intersubjectivity as intercorporeality. Mirror neurons fire both when a given action is performed by the self and when, performed by another individual, it is simply observed, and as such they are involved in action understanding: meaning is assigned to an observed action by matching it on the same neuronal circuits that may generate it 12–13. Cenesthesia is the word by which psychopathologists, and sometimes philosophers, talk of the internal perception of one's own body, whereas cenesthopathy refers to abnormal bodily sensations. Both are quite neglected subjects in mainstream contemporary psychopathology, but they have represented a fundamental topic in French and German 19th and early 20th century psychiatry. The historian Starobinski 14 speaks of an "imperialism of cenesthesia" in the last century. It was Reil in 1794 who coined this term, indicating "the means by which the soul is informed of the state of its body". Cenesthesia (deriving from Greek koiné aesthesis, common sensation) is defined as the global experience in which all the single bodily sensations are synthesized, the crossroads of all sensibility on which consciousness is grounded, including the feeling of existing, of being a self and of being separated from the external world. Affections of cenesthesia are, especially to French early 20th century psychopathologists, the origin of psychoses. For instance, Dide and Guiraud 15 thought that hebephrenia is characterized by the specific impairment of those cellular nervous systems presiding to the cenesthetic and kynesthetic synthesis and to instinctual vital activity. Athymormia — the global disorder of instinct (hormé) — is considered "the spring of delusions" since delusions are supposed to be disorders of the "primordial psychic activity", complicated and masked by the intellectual and affective superstructures of human thinking 16. In a quite different vein, Huber 17 defined as the fourth subtype of schizophrenia — next to paranoid, catatonic and simplex-hebephrenic forms — a clinical syndrome called cenesthetic schizophrenia, characterized by abnormal bodily sensations. These are disorders of the lived body, painful and uncanny, that occur abruptly, and often migrate from one organ or bodily zone to another. Typical examples are feelings of extraneousness, or numbness, or non-existence of parts of one's own body, sensations of paralysis, heaviness, abnormal lightness, of shrinking or enlargement, of movement or traction, etc. These abnormal bodily sensations may lead to psychotic symptoms, such as hypochondriac delusions and more typically delusions of being controlled. Sass 18 remarked that these bodily sensations are not abnormal per se, but remarkably similar to those reported by normal subjects adopting a detached introspective stance toward their bodies. Schizophrenic cenesthopathies are normal bodily sensations that are always present, even though we do not usually attend to them; what is abnormal is the way schizophrenic persons attend to them — they are abnormal since they are "lived in the perfectly abnormal condition of hyperreflexive awareness and diminished self-affection" 17. The final result is an experience of increasing distance between subjectivity and bodily experience. Others remarked that schizophrenic cenesthopathies are typically quasi-ineffable. Huber 17 observed that a key feature of schizophrenic bodily disesthesias is that they challenge the ordinary capacity for linguistic representation: in our language, the expressive possibilities and adequate categories concerning these peculiar bodily sensations are completely lacking. The issue of the relations between abnormal bodily sensations and language has a long tradition. Blondel 19, a forerunner in this field, postulated that cenesthopathies occur when the mind is not able to categorize bodily sensations, i.e. to express them through the impersonal system of socialized discourse. Ey 20 remarked that bodily hallucinations crop up when the subject cannot express linguistically a bodily sensation. To Ey, the expression of bodily sensations always needs a metaphor. Hallucinating, in the field of this peculiar sense, is perceiving one's own body completely or partially as an object or a living entity outside oneself, i.e., as an object transformed by the very impossibility of metaphorical expression. The essential feature of schizophrenic existence is its being disembodied. This is the feature that unifies the varied dimensions of schizophrenic existence. The disembodiment of the self, of the self-object relation and of interpersonal relationships all lead back to a kind of world in which the schizophrenic person lives and behaves like a soulless body or a disembodied spirit 21–22. The crisis of ipseity is the clearest expression of the shape schizophrenic life assumes as a deanimated body (i.e., a body deprived of the possibility of living personal experiences — perceptions, thoughts, emotions — as its own) and also as a disembodied spirit (i.e., as a sort of abstract entity which contemplates its own existence from outside — a third-person perspective view, or a view from nowhere). As a deanimated body, the schizophrenic person experiences a specific feeling of loss of presence. In the lightest cases, he feels detached from himself and his actions and experiences. The seam between mind and body seems to have been torn apart. In the severest cases, he describes himself as empty, hollow: "There's nothing inside my body; it's just a frame", "Inside my chest nothing's there, just a big hole" 23. The hollowness manifests itself, in movements, as a lack of contact between the various parts of the body: "When I move I seem to lose something, like my whole body is leaving me. The spinal column or something goes invisibly through the flesh" 23. Organs lose their mass, and with this, their ability to have a reciprocal bond that acts as a force to tie them together. This state is marked by a total mechanization of the body: "I'm blessed with a bladder-emptier that I can turn on and off, and an anal expeller". They feel like mechanical replicas of living organisms: "I'm a psycho-machine" — says a patient of Kimura 24. These experiences and expressions must be taken literally and not metaphorically. A second way people with schizophrenia experience their own body is that of disembodied spirit or incorporeal, purely theoretical awareness. They live as mere spectators of their own perceptions, actions, and thoughts: "The world is an illusion because it's seen through a brain"; "If the mind is empty it functions like a plotter or a camera". This radical dualism between a subject who's thinking and an object that is conceived of in its pure and simple extensive externalness — pure consciousness and pure materialness — is the fundamental phenomenon of schizophrenic anomalies of embodied self-awareness. The global crisis of embodiment involves anomalies of self-object relations and meaning-bestowing. If my body-based involvement in the world is switched off, my grasp onto the world will fade away too. Objects in the world will not immediately relate to my body as existentially relative utensils. They become non-utilizable and appear devoid of practical meanings. There is a loss of ready-to-hand meanings to be attached to things in the world, which paradigmatically occurs in pre-delusional perplexity. Here the expression "ready-to-hand" must be taken literally, not metaphorically: since things cannot be grasped, they appear as devoid of their ordinary meaning, i.e. the way one usually puts them to use 25. New meanings may emerge (as in delusional perceptions) that are not practical meanings in the ordinary sense, i.e. geared up with survival and drive-based ordinary life; rather, they are geared up with idiosyncratic concerns that arise from a background of ontological incompleteness and abnormal constitution of intersubjectivity. The quest for personal identity and one's place in the world and metaphysical concerns typically provide a new and peculiar kind of enactment in schizophrenic disembodied self-world relationship. For instance, a patient described by K. Schneider 26 may take a dog lifting its leg in front of him as "a true revelation". What comes into view in delusional perceptions is a perceptive detail that speaks to the person and in so doing discloses a new understanding of the world or a new identity that is deeper and more personal 27. An emblematic example of metaphysical enactment is the following: a schizophrenic person says that, when he seats at the theatre, he is not focused on what happens on the stage, since he cannot help thinking of what's going on backstage, what "makes the scene possible". An unusual perspective unto the world takes place and new meanings (the quest for what is real vs. unreal) emerge 28. A further feature of disembodiment is the inclination to abstraction of schizophrenic cognition: words escape the situation to which they are referred and the meaning they take on according to the context in which they are used. Words too become disembodied and de-situated and acquire an existence of their own. They themselves may get an object-like existence, undistinguishable from "real" objects (these too disembodied and thus more similar to concepts and representations than to material objects). Words are no longer used to share a world, but to create an alternative one, or a world on its own. Therefore, words and objects may become interchangeable: paradigmatically, metaphors become flesh-and-blood things; the catachresis (concrete expression) of metaphors flings open the door to delusions. In the relations between the disorders of embodied self-awareness and intersubjectivity-intercorporeality, we can recognize a circular relationship. The defective structuring of selfhood, particularly through the phenomena of somato-psychic depersonalization (bodily perception disorders) and auto-psychic depersonalization (detachment from one's own emotions and thoughts), can become an obstacle to the intercorporeal attunement between the self and the other persons. Schizophrenic autism may derive from the incapacity to enter into emotional attunement with others and recognizes as primum movens a different quality of bodily performance. Schizophrenic autism reflects the fundamental constitutional fragility of selfhood, that is its fundamental incompleteness, which results in problematic relations, meetings and confrontations with the other. Detachment from the social world appears to derive from the lack of this fundamental structure, of this ontological setting, necessary and indeed crucial to be a self and thus to take part in the self/other-from-self dialectic of social relations. Looking at it from the opposite angle, that is, from the interpersonal dimension of the ontogenesis of consciousness, a disorder in early relationships can heavily damage the maturing process of full corporeal self-awareness. The attunement crisis conveys this third-person perspective to the interpersonal world. This social world loses its characteristic as a network of relationships among bodies moved by emotions, and turns into a cool, incomprehensible game, from which the schizophrenic person feels excluded, and whose meaning is sought through the discovery of abstract algorithms, the elaboration of impersonal rules.