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Schzphen Buendoi:10.1093/schbul/sbs190

The Author 2013. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.For permissions, please email: journals.permissions@oup.com

Editorial

K Jspes n he Geness f deusns n Schzphen

M Mj

Department o Psychiatry, University o Naples SUN, Naples, Italy

In his General Psychopathology, Karl Jaspers identifestwo stages in the genesis o delusions in schizophre-nia. The frst is a set o primary subjective experiences,which he encompasses under the rubric o delusionalatmosphere,1 building upon F.W. Hagens construct odelusional mood.2 The second is the patients work-ing through those experiences, sometimes calling or

the ull strength o an intelligent personality,1 whichleads to delusional ideas. The content o delusionsJaspers addsstrikes one as a symbol or somethingquite dierent,1 is certainly not meant literally andis quite dierently experienced rom similar contentin the case o a person we can ully understand.1 Itis certainly possible to wonder whether the patientshave ound any content adequate or their actualexperience.1

In this issue o the journal, Mishara and Fusar-Poli3propose that Kapurs model o aberrant salience4may represent a bridge between a revised version o

the dopamine hypothesis o schizophrenia

5

and Jaspersconstruct o delusional atmosphere. Abnormal striataldopamine fring would lead to an aberrant assignment osalience to neutral stimuli and consequently to the emer-gence o delusional mood.1

One could argue, though, that the overlap between theexperiences reported by Kapur in his seminal paper4 andthose described by Jaspers under the heading o delu-sional atmosphere1 is only partial. Common elementsare the patients experience that something in the worldaround them is changing, leaving them somewhat con-used and looking or an explanation4 and their eelingthat there is some overwhelming signifcance in this4

or that certain objects or persons signiy something,although initially nothing defnite.1

However, absent in Jaspers description o delusionalatmosphere is Kapurs emphasis on the increased inten-sity o perceptions (my senses were sharpened, sightsand sounds possessed a keenness that I never experi-enced beore, my senses seemed alive things seemedclearcut, my capacities or aesthetic appreciation andheightened sensory receptiveness were very keen at thistime).4 Experiences o this kind are included by Jaspers

in another section oGeneral Psychopathology (changesin intensity o perception).1 In delusional atmosphere,the intensity o perception is not modifed (percep-tion is unaltered in itsel, perception itsel remainsnormal and unchanged, sensory richness is not essen-tially changed)1 and the change in the environment isexperienced as quite subtle (there is some change which

envelops everything with a subtle, pervasive, and strangelyuncertain light).1

Furthermore, not prominent in Kapurs accounto aberrant salience, but emphasized by Jaspers in hisdescription o delusional atmosphere, is the aectivecomponent o the experiences: objects, persons, andevents appear eerie, horriying; patients eel that thereis something suspicious aoot; a distrustul, uncom-ortable, uncanny tension invades them; they suerterribly, becauseJaspers argues quoting Hagennodread is worse than that o danger unknown.1 Not sur-prisingly, the fnal outcome o delusional atmosphere is

oten represented by convictions o being persecuted,attacked, or conspired against, which might be more di-fcult to explain i the primary experience were just o anexaggerated salience o percepts.

So, there is some overlap between Kapurs descriptiono aberrant salience and Jaspers account o delusionalatmosphere, and the common elements may indeed pointto an abnormal striatal dopamine fring. But there are alsoother elements in Jaspers descriptionthe strangelyuncertain light enveloping everything, the eeling thatthere is something suspicious aoot, the distrustul,uncanny tensionthat seem to point to an abnormaldopamine fring at the level o limbic areas such as the

amygdala and the hippocampus,6,7 whose involvementin ultra high-risk states and in frst-episode schizophre-nia has been actually reported by several neuroimagingstudies.810

Obviously, Jaspers construct o delusional atmosphereremains o great relevance to psychopathological enquiryand neuroscientifc research. However, several assump-tions he makes concerning that set o experiences, orpatients working through them, have been recentlyquestioned.

Schizophrenia Bulletin Advance Access published January 11, 2013

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First, the experiences encompassed under the headingo delusional atmosphere may not be as psychologicallyirreducible and phenomenologically fnal1 as Jaspersassumes. In recent phenomenological literature, thoseexperiences are in act oten regarded as the outcome oa more remote and gradually evolving impairment othe awareness o sel and the world.11. So, rather than

representing a break in the normal lie-curve,1 they maybe rooted in a aulty developmental process.

Second, Jaspers assumption that the patient developshis delusional ideas, on the basis o primary abnormalexperiences, through cognitive processes that are essen-tially normal is quite controversial. There are indeed somemodels supporting that view,12 but several others suggestthat a deect o probabilistic reasoning (eg, a tendency tojump to conclusions) is also involved.13 It has been alsohypothesized that an impairment in predictive learningmay underlie both pathological experiences and abnormalbelies: a global ailure o anticipation may produce a

sense o unexpectedness,14 which could drive the devel-opment o delusions through establishment o predictiveassociations that, whilst maladaptive, represent attemptsto render the world more predictable.15 Also o note isthat several authors16 have built upon Jaspers view that thecontent o delusions is certainly not meant literally andis quite dierently experienced rom similar content in thecase o a person whom we can ully understand,1 arguingthat patients with schizophrenia may not express beliesat all, but use what we might call the language o belie toexpress the bizarre and disorienting nature o their experi-ence.17 Patients may state that something is true to their

experience which they know not to be true simpliciter.

17

Third, that the experiences subsumed under the head-ing o delusional atmosphere are indeed quite alien andbeyond our understanding1 has been put in question. Ithas been stated that the sense o fnding onesel in theworld shits in a range o dierent and oten subtle ways,not just in psychiatric illness but throughout the courseo everyday lie, and that less extreme maniestationso that kind o existential eeling may be not so arremoved rom everyday experience as they might seem.14Some people may be able to cope with milder orms othose experiences, not develop a delusion and never cometo the attention o mental health services.18

How common the primary experiences described byJaspers are in patients with schizophrenia, how specifcthey are or that disorder, and whether they are amenableto a systematic assessment, even i retrospective, are allissues open to research. The degree o overlap betweensuch experiences and those currently reported in ultrahigh-risk states or prodromal stages o psychosis, andassessed through standardized psychometric scales,19 alsoremains to be explored.

Finally, in the light o the above discussion, it shouldbe acknowledged that the defnition o delusion providedby the DSM-III and its successors is less straightorward

than it may seem, since several o its elementsthat delu-sions are always belies (vs metaphorical utterances),16that they are always based on an incorrect inerence(vs being based on an unimpaired inerential processapplied to anomalous experiences),1,12 and that this iner-ence always regards external reality (vs, in some cases,patients inner mental lie)20have been put in question.

refeences

1. Jaspers K. Allgemeine Psychopathologie. Berlin: Springer; 1913.English translation o the 7th edition: General Psychopathology.Baltimore: Johns Hopkins University Press; 1997.

2. Hagen FW. Studien auf dem Gebiete der rztlichenSeelenheilkunde. Erlangen: Besold; 1861.

3. Mishara A, Fusar-Poli P. The phenomenology and neurobiol-ogy o delusion ormation during psychosis onset: Jaspers,Truman symptoms, and aberrant salience. Schizophr Bull.doi:10.1093/schbul/sbs155.

4. Kapur S. Psychosis as a state o aberrant salience: a ramework

linking biology, phenomenology, and pharmacology in schizo-phrenia. Am J Psychiatry. 2003;160:1323.

5. Howes OD, Kapur S. The dopamine hypothesis o schizophre-nia: version IIIthe fnal common pathway. Schizophr Bull.2009;35:549562.

6. MacLean P. The limbic brain in relation to the psychoses. In:Black P, ed. Physiological Correlates of Emotion. New York:Academic Press, 1970:129146.

7. Pankow A, Knobel A, Voss M, Heinz A. Neurobiological cor-relates o delusion: beyond the salience attribution hypothesis.Neuropsychobiology. 2012;66:3343.

8. Witthaus H, Mendes U, Brne M, et al. Hippocampal sub-division and amygdalar volumes in patients in an at-riskmental state or schizophrenia. J Psychiatry Neurosci.

2010;35:3340.9. Watson DR, Bai F, Barrett SL, et al. Structural changes in thehippocampus and amygdala at frst episode o psychosis. BrainImaging Behav. 2012;6:4960.

10. Qiu A, Gan SC, Wang Y, Sim K. Amygdala-hippocampalshape and cortical thickness abnormalities in frst-episodeschizophrenia and mania.Psychol Med. 2012;18:10811085.

11. Wiggins O, Schwartz M, Northo G. Toward a Husserlianphenomenology o the initial stages o schizophrenia. In:Spitzer M, Maher BA (eds). Philosophy and Psychopathology.New York: Springer; 1990:2134.

12. Maher BA, Ross JS. Delusions. In: Adams H, Sutker P, eds.Comprehensive Textbook of Psychopathology. New York:Plenum Press; 1984:383409.

13. Garety PA, Hemsley DR, Wessely S. Reasoning in deludedschizophrenic and paranoid patients. Biases in perormance on aprobabilistic inerence task. J Nerv Ment Dis. 1991;179:194201.

14. Ratclie M. Delusional atmosphere and the sense o unreality.In: Stanghellini G, Fuchs T, eds. One Century of Karl JaspersGeneral Psychopathology. Oxord: Oxord University Press. Inpress.

15. Corlett PR, Taylor JR, Wang XJ, Fletcher PC, KrystalJH. Toward a neurobiology o delusions. Prog Neurobiol.2010;92:345369.

16. Berrios G. Delusions as wrong belies: a conceptual history. BrJ Psychiatry. 1991;159(Suppl. 14):613.

17. Gerrans P. Delusions as perormance ailures. CognNeuropsychiatry. 2001;6:161173.

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18. Murray GK. The emerging biology o delusions. Psychol Med.2011;41:713.

19. Parnas J, Handest P, Jansson L, Saebye D. Anomaloussubjective experience among frst-admitted schizophrenia

spectrum patients: empirical investigation. Psychopathology.2005;38:259267.

20. Spitzer M. On defning delusions. Compr Psychiatry.1990;31:377397.