Exploring a lay Gestalt of schizophrenia? A Danish background population’s explanations on why and how first-episode schizophrenia patients’ narratives were intuitively sensed as contextually inappropriate

Table 1 shows the lay experts’ explanations cited directly of why or how the patients narratives were contextually inappropriate. The numbers in parentheses show how many evaluators used a particular explanation – for example, 31 evaluators concurrently evaluated the patient narratives as inappropriate, because they were “short”.

The explanations can be grouped into three subgroups: affective explanations concerning how the patient felt or how the evaluators felt reading the narrative; formal explanations concerning pauses, fluency, and brevity; and explanations concerning understanding, interpretation, and meaning as well as aesthetics, provisorily placed side by side, because meaning may be regarded as, basically, aesthetic.

Under formal explanations, lack of fluency and pauses are probably two sides of the same coin; “pauses” as the positive or neutral explanation and “lack of fluency” as the negative explanation for the same phenomenon of silence. Both are common in spoken language, but violate written language norms (all narratives were transcribed verbatim and printed as such to the evaluators). Consequently, spokenness characteristics may “naturally” have elicited contextual inappropriateness evaluations

The explanations “notches”, “stops”, and “dots” seem to comment upon some perceived strangeness of such phenomena in the narratives, whereas the lay evaluators use of the term “pauses” probably recognize the conventional notation in the narratives (verbatim “…” and “uhm”).

Under affective explanations, the evaluators seem to mark a distance from the patients interpreted as “uncertain” and themselves experience the reading as “annoying”, “confusing” and “disturbing”, but this may be due to the evaluators’ knowledge of their role as evaluators.

Thus, this study says nothing about self-other biases, e.g. evaluation of the oneself more positively than evaluations of a generalized other.

Sensitivity to formal and affective explanations have previously been found in a qualitative study of one class (9); in the present study the lay experts add to this inappropriateness evaluation sense or meaning. But what is meant by meaning and related explanations?

Occasionally, the explanations are supported by more than one explanation per narrative, presumably related enumerations or even sentence formed explanations with additional information elaborating further on this explanation, hereby, in various ways, constituting “explanations of explanations”.

If we take a closer look at the explanation sheets and ask what the lay experts meant by referring to no “meaning”, lack of “understanding”, different “interpretation” and “strange” or “mystic” patient narratives, each time these explanations occurred, this additional information appears rather ambiguous. The following analysis, reports all additional information about, what the evaluators meant by referring to these explanations of explanations. This method is transparent in the sense that all added explanations of explanations are presented below.

Lack of “meaning” is related to “brevity” as Narrative I is “too short, gives no meaning if you have not seen the pictures” and Narrative J is “short, gives no meaning” (evaluator 51). In addition, meaning is related to fictive elements as it “gives no meaning to me, that the animals talk” in Narrative A (evaluator 57). This explanation refers to the fictive or imaginary use of direct speech, which strictly speaking is not used in the wordless elicitation material. Finally, lack of orientation is found disturbing in Narrative I; “no proper meaning, because the boy suddenly gets a baby frog home with him, while the narrator had not introduced it beforehand” (evaluator 146).

Evaluator 70 do not give additional explanation (“difficult to find an understanding and meaning” in Narrative F).

Lack of “understanding” is primarily related to “pauses”. Evaluator 70 had “difficulty in finding an understanding maybe because of the pauses and “ehh”” in narrative A, and in the same manner narrative J was “difficult to read and understand because of “ehh, okay”. Similarly, evaluator 133 comments on Narrative F by “many notches…does not understand the story”. Additionally, evaluator 123 explains that “incorrect language made me not understand the story”, in Narrative A evaluator 149 distinguishes his own understanding from the patient’s understanding in narrative J “lack of understanding in relation to my own story”, and evaluator 83 explains that the narrator F “does not understand the experiment” (an explanation probably provoked by many initial questions about how to narrate, see below).

Narrative I, J and F (and occasionally Narrative A) are continually mentioned as lacking in meaning or understanding, which are related to formal aspects of “brevity” and “pauses”, respectively.

“Interpretation” is often related to the lay expert’s own interpretation. Evaluator 68 states that the patient “does not know how the story should be interpreted” (Narrative F), implying that evaluator 68 does know this, evaluator 103 states that “I don’t interpret the same way” (Narrative C), and evaluator 149 states that Narrative F is “very disturbing and imprecise in relation to my own interpretation” just as Narrative J is “lacking and incomprehensible in relation to my own interpretation”.

Finally, six evaluators find narrative I, J, C and F “strange” or “mystic”. Three evaluators explain that Narrative F “starts strangely” (evaluator 30), has a “mystic start” (evaluator 99), or that the narrator initially “destroys everything, is uncertain, disruptive and much like ‘then this happened and then this happened’” (evaluator 19). In addition, some evaluators explain that narrative I is “strange to read after the long stories” (evaluator 15), that Narrative J is “short, imprecise, strange” (evaluator 19), that Narrative C has “many strange pauses and details and a strange ending” (evaluator 26) and that Narrative F has “short paragraphs, which do not give meaning in relation to the events, strange details, which do not fit the story telling style” (evaluator 26). Finally, Narrative C “ends strangely, as if the frog does not come home” (evaluator 150, similar to evaluator 26 mentioned above).

To summarize, Narratives F, I, J and C were in particular found “strange” and “mystic”, and these four narratives were most frequently evaluated as inappropriate by the larger group of 157 high school students (respectively; 92%, 72%, 72% and 59%, 9).

Finally, if we take a closer look at when these narratives are inappropriate, it is especially at the beginning - that is, the story elicited from the first picture (Picture 1) and at the end - that is, the story elicited from the final picture (Picture 24), as indicated in italics in the previous paragraph.

Table 2 presents the full narration elicited from Picture 1 in Narratives I and J as well as the full narration elicited from Picture 24 in Narrative C, however, due to the lack of space only the initial narration elicited from Picture 1 in Narrative F is presented below (the patient’s questions continued). Comments in parentheses are the researchers answers to the patients questions (in Narratives I and J).

These beginnings and this end share a particular characteristic. They are meta commentaries at an experimental level (italics in Table 2) as opposed to just “doing it” – that is, telling the story a level “inside” the narrative world. Narratives F and J apparently question the rules of the narrative game and in Narrative C the story as depicted on the pictures takes its course independently of the narrator, who disagrees about this unhappy ending. Only if the pictures are somehow distant from the narrator, does the narrator have reasons to excuse her narrative potentially with “so it did not end quite happily”. In a similar vein, a patient’s indignant reactions toward the lack of ownership of her or his thoughts seem only relevant if a phenomenological distance is actually present – for example, “my thoughts have no respect for me” (18, p. 1301). This distance is described as coexisting and only occasionally to collide.

But what about Narrative C? The conjunction “selvom” (even if) in Danish introduces a reason that is left out or cancelled (19, p. 1548), as if the narrator cancels her own narrative. The narrator apparently reports events according to what is presented on the pictures (the boy leaves with a frog), “even” if it has a family, and the depressive magnitude of this is illustrated with the addition “and a lot of siblings and a mother and a father”. Finally, the patient explicitly uses the first person pronoun to announce her negative reaction to the story “and I think, it was there (with the family) it would preferably be. So it didn’t end very happily”; now, also, contrary to the traditional happy ending. Negations notoriously presuppose a counter-view, thus, saying “I’m not coming tomorrow” presuppose that somebody thinks or might think the opposite or that something else was expected (20). In Narrative C, the narrator’s story collides with the narrative expectations of the standard happy ending. In sum, the pictures seem to take their independent course regardless of both the narrator and the narrative tradition.

These beginnings and this end may be considered “strange” by the lay experts, because the default position of the authorial authority is radically destroyed by questions in Narratives F and J, and because the narrator’s authorial lead in Narrative C collides with both the narrative tradition and the pictured events. Or generally because the patients have a certain distance toward their own narratives or merely describe events by “enumeration” – e.g., “then this happened and then this happened”.

A final remark; formal thought disorders, as measured by, for example, the Thought Disorder Index, are traditionally mediated by and measured as language deviations. The evaluators in the present study may obviously have taken into account, e.g., what they consider as inappropriate distance toward the (narrative) task, needless excessive qualification etc.

In classic texts, something “Ünverständliches” may be experienced by both patient and psychiatrist (22, p. 30) or be “incompréhensible” for the psychiatrist, but swiftly transformed into guiding life principles for the patient – that is, indicating some “meaning” dictating nothing less than life (23, p. 149) or “beyond our comprehension”, but nevertheless potentially indicative of the patient’s “failed attempts toward communication” (24, p. 339).

Despite differences, some agreement prevails. Even if the “incomprehensible” by definition is not understandable, it may still be shared with the listener as a “shared alienation, a feeling evoked by accurate intuitions of what the patient is actually going through” (25, p. 241). Patients may not communicate any precise meaning – given the “unexpected swerves and cryptic references” and “puzzlements that can erode the very framework of human understanding” (ibid., p. 175) – but on the other hand the patient may prompt an “accurate intuition” of what he or she is “actually” going through

The definition of “empathy” in many dictionaries is “understanding” or sharing of feelings”. From a diachronic perspective of schizophrenia, potentially suggestive of a certain taxonomy of understanding and (a later possibility of only) sharing.

In sum, the strange or incomprehensible is intimately correlated with accuracy of diagnostic specificity.

In the present study, the lay experts actually describe the patient narratives as “strange” and “mystic” (Table 1), and exemplified in the narratives, this strangeness refers to various questions about the narrative task or critical comments on their own narrative manifesting a certain distance (Table 2). Also, explanations such as “only description of pictures”, “mechanical”, “superficial”, “not emphatic enough”, and “enumeration” (Table 1), for example, “then this happened and then this happened”, seem to refer to a somehow distant narrator. Such distance may provoke the traditional habit of mediating the narrative with meaning as far as it is told by somebody, unlike world events which just “happen”

Or unlike experimenting-behavioristic narratives – with feigned objectivity.

Consequently, an inappropriate distance manifests, according to the lay experts, both in meta commentaries on an experimental level as well as on the story level “inside” the narrative world, i.e., as a pervasive inappropriateness, which so to speak, does not care about level. Pervasiveness defines the subtle Gestalt of schizophrenia (4). Inspired by Minkowski’s description of loss of vital contact with reality, the lay experts may to some extent actually share the patients’ potential inability to “resonate” with their own narrative and henceforth the lay experts’ ability to “empathize” and be “affected” by the narratives, may also be weakened (4, p. 1123). Or as some lay experts explain, the narratives are “boring”, “tiresome”, “indifference” affects the reader and another evaluator is simply “not caught” (Table 1). Nearly all explanations concerning aesthetics negate its presence with “only”, “not”, and “no” (Table 1) suggesting that something else was expected – e.g., fantasy, meaning, depth, and empathy.

Berze suggested that the basic disturbance in schizophrenia was a “primary insufficiency” of various degrees; in mild forms patients’ reactions appear “strained” and purposeful activity, attention, direction, comprehension, and capacity to think clearly was described as diminished or weakened (26, p. 52)

On complications; see below.

In general, the lay experts in the present study seem not to have their expectations met, given that negations penetrate nearly all explanations, in particular, formal aspects (e.g. “not fluent”, “not going as a story ought to”) and aspects related to meaning and aesthetics (e.g., “gives no meaning”, “does not understand”, “not clear what he wants to say”, “I do not interpret the same way”, “lack of understanding”, “does not know how the story should be interpreted” (Table 1). Whether pauses are suggestive of “strained” efforts of purposeful, goal-directed storytelling, is not quite clear since pauses as a spoken language characteristic may “naturally” elicit inappropriateness evaluations of written texts. Explanations like “not going as a story ought to” seem, however, to signal expectation of a certain willful intentionality or creative power. And some formal explanations potentially thematize a basic lack of objectively observable reactivity or affectability stimulated by the elicitation material, “eliciting” only “minimalistic”, “short”, and “not detailed” narratives. Finally, conceptual clarity, luminosity, and “comprehension” are potentially thematized in inappropriateness explanations like “no meaning”, “difficult to follow”, “not clear”.

The lay experts’ evaluations appear somehow in line with Berze’s third-person descriptions; the narratives appear as not sufficient, being too short (a formal aspect) and too emptied of meaning (an aspect related to sense), or, in sum, “too short, gives no meaning” and “short, gives no meaning”. As seen here, “brevity” is not necessarily associated with something (affective aspects like “uncertainty”), but also with nothing or no meaning.

Lack of meaning or understanding is at the center of Sass’ introduction to the listener’s “precox feeling” (25, pp. 174–175). In conclusion, “brevity” may give rise to “no meaning”, which may obligatorily be incomprehensible or even “strange”, “mystic”, or “bizarre”.

Schizophrenia is often associated with disturbed reality testing and thinking, conceptualizations that may neglect the fact that affective abnormalities may be among the most central features, in particular because they are intimately related with alternations of personhood, self-experiences, and changes of the self (27, p. 1). Central to the initial “Grundstimmung” in schizophrenia is an inner insecurity, doubt, and skeptical disunity (“Zerrisseheit”) that may later “convert” to its opposite (22, pp. 30, 32, 33). According to Störring, “perplexity” (“Ratlosigkeit”) is to some extent pathognomonic for schizophrenia and based on “the experience of being unable to maintain a consistent grasp of reality” (28, p. 81). Recently, the loss of the “implicit non-conceptual grip of the ‘rules of the game’” as a “pre-understanding of the context and background” are associated with “ambivalence and perplexity (confusion about meaning)” (4, p. 1123). Loss of meaning and perplexity are considered core features and particularly crucial for early identification and psychotherapy (29).

Several empirical studies suggest that “uncertainty”, “insecurity”, and other descriptors of affect as well as “strangeness” and descriptors related to meaning are continually found in initial stages of schizophrenia and in first-episode patients.

Møller and Husby (30) studied the initial prodrome retrospectively in 19 first-episode schizophrenia patients and found continuous descriptions of “strangeness”, frequently, of the usually most familiar (“stranger to myself”) as well as doubts about being “good enough”, a “growing uncertainty”, “uncertain gender identity”, experiences of being socially more “insecure”, “afraid to talk”, and an impossibility to “relax” (ibid., pp. 227–228).

Henriksen et al. (29) reported, in a qualitative single-case study of one introspective patient with schizophrenia, that pre-psychotic feelings of being “uncertain and anxious in any activity or project” were present around first episode and that the patieent “doubted his identity” accompanied by feelings of “strangeness” of the usually most familiar expressed in questions like “Who am I?”, “Who are my parents?” (p. 362). The patient ascribes a primary role to feelings, which preceded the cognitive delusional elaboration: “first of all, there was anxiety. The story I build upon it (the delusion) was not so important” (ibid., p. 363).

Conrad (31) examined 107 soldiers admitted to a military hospital during World War II with a first episode of schizophrenia and thematized with “das Trema” an increased “bodenaffektivität”, usually of anxiety and “insecurity”, but in delusion formation a sense of “uncertainty” was related to a sense of absolute “certainty” and to having no doubt that something was happening – that is, an “insecurity”, frequently about trivial, everyday events as well as absolute certainty that something was wrong. “Die Wahnstimmung” is, for example, described by a patient in the following manner:

In delusion formation, an initial “uncertainty” is apparently replaced by a forced closure of meaning concretized and elaborated cognitively as a secondary psychotic work. As formulated elsewhere, the “pathic” or affective aspect is prominent as compared to the “gnostic” or cognitive aspect and “In the face of the disturbing uncertainty, the patient searches for solutions or answers” to their problems or questions (32, p. 79).

Petersen (14) found epistemic expressions as well as questions, indicating uncertainty or need for certainty or precision in the potential initial prodrome, first-episode schizophrenia, and younger patients with several admissions manifested by adverbs (e.g., “maybe”, “presumably”, “apparently”), epistemic use of modal verb (e.g., “can be”, “it might be the case”), negated reflection or consciousness verbs (e.g., “I don’t know”, “I think”, “I guess”, “I assume”), and questions like “Is it good enough?”, “What happens here?”, “Are you allowed to give the boy a name?”, “Do you have to give the story a title?”, “Should I tell you what I see or what I experience?”. If patients were asked, sincerely, accurately, and as precisely as possible to relate what they saw in a wordless picture story, these epistemic expressions would be highly appropriate. The patients, however, were asked to “tell a story” from the wordless picture story and in this context these “facts in fiction” seem less appropriate, as appropriateness obviously changes according to context.

Parnas and Sass (33, p. 438) reported an “incertitude” (i.e., polyvalence) in first episode patients with schizophrenia closely bound up with perplexity and a “strange” feeling of not being “really present” associated with a “mechanical” perceptual experience at a phenomenological “observing” distance. This distance is potentially responsible for less serious memory problems given a lack of involvement.

In the present study, the patients’ questions about the narrative game invites an answer even if other narratives already exist as part of our culture – that is, they could implicitly have instructed about a narrative norm or tradition. Questions are usually paradigmatic examples of doubt and uncertainty; you may ask if something is not known (34), but also if you are in doubt and already know the answer. In the last situation, questions may avoid taking the dominant role and in contrast induce the listener to act – for example, as in help-seeking questions (35, p. 110). In the present study, Narrator F asked several information seeking questions and potentially also avoided to speak for himself by questioning the researcher instead (the narrative task implying a monologue was replaced by a dialogue in Narrative F, see Table 2). In addition, epistemic expressions manifesting (both) uncertainty and certainty appear throughout the directly cited patient utterances in Conrad’s contribution on first episode schizophrenia (exemplified above with “weiss…nicht”, “bedeuten”…“natürlich”)

A discussion on the use of epistemic expressions is found in Petersen (15).

Whereas the phenomenological studies are based on patients’ subjective rapports, the explanations in Table 1 are first and foremost evaluations of patients by others. And we may add, subjective life or not! The present study is, in other words, well aware that discrepancy may exist between objective signs observable from third-person perspective and subjective complaints reported by the patients in first-person accounts. Already in 1929, Berze (22) described patients, who from an objective observers point of view seemed “indifferent”, and on the other hand were “jovially” in “resonance” with surroundings as well as “moved” by intellectual considerations. Thus, patient narratives evaluated as inappropriate by the lay experts because the patient is apparently “unconcentrated”, “unfocused”, and “indifferent”, to the contrary, may imply a significant amount of concentration toward another context than that of the narrative, namely the psychotic. For example, the narratives were occasionally told in staccato with pauses of “total” silence, which additionally was so abrupt that taken together these patients seemed both highly attentive toward inner experience (total silence seemed to correspond to total attention) as well as maybe simply being interrupted by these experiences and therefore narrating in an abrupt manner. In a psychotic context in particular, silence may “communicate” in the company of a listener or reader who fills the gap of pauses with interpretations, including various projected content

Projected contents, however, not open an endless variety of “only” individual projections; human’s capacity for imaginative and interpretive empathy tends to reduce the apparent uniqueness of projective contents (36, p. 69). Also in the present study, the various wording of the patients’ world is relatively uniform or grouped around basic formal or affective aspects or aspects related to meaning and interpretation.

In this context, the naïve idea that the word denotes some reality “out there” or “in” the patient, seem especially important and we probably need to move well beyond any naïve referentialism of the word cited directly and consider the direct citations as evidence in language of a preferentialism, or as it were, a dis-preferentialism for the patient narratives, which is a preliminary description of how an early vulnerability trait may be described from the third-person perspective of common people.

In sum, the more cognitively related explanations of inappropriateness (e.g., “unfocused”, “unconcentrated”) should not necessarily be taken at face value, whereas the affective evaluations seem to correspond to several empirical studies on first-episode schizophrenia.