VOL13.NO. 2,1987 The Disorder of Consciousness in Schizophrenia 241 by Roderick Anscombe Abstract The schizophrenic experience is de- scribed as an inability to sustain an intentional focus to attention. At- tention is captured by incidental de- tails in the schizophrenic patient's environment, and this gives rise to a spurious sense of significance. The patient's inability to direct a train of thought prevents full access to long-term memory so that early components of perception, which are designed to give early warning . of threat, are overly influential and unmodulated by further mental processing. These hasty ideas are given delusional conviction when they capture attention and induce a sense of significance similar to the false significance of perception. The schizophrenic patient's lack of control over his mental processes makes him passive in relation to his own thinking. It prevents him from attending to the slight promptings of his subconscious, and when these emotions and intuitions are not amplified by being brought into focus, he loses a sense of himself. There have long been reports in the literature, both from clinicians (McGhie and Chapman 1961; Chap- man 1966) and from patients them- selves (MacDonald I960), that people with schizophrenia have dif- ficulty filtering out irrelevant stimuli and controlling what they pay atten- tion to: ... the mind must have a filter which functions without our con- scious thought, sorting stimuli and allowing only those which are relevant to the situation in hand to disturb consciousness. And this filter must be working at max- imum efficiency at all times, par- ticularly when we require a high degree of concentration. What had happened to me in Toronto was a breakdown in the filter, and a hodge-podge of unrelated stim- uli were distracting me from things which should have had my undivided attention. [MacDonald 1960, p. 218] When they cannot effectively ig- nore what is unimportant, schizo- phrenics cannot choose what they will think about, and mental proc- esses that would normally be imper- ceptible and automatic intrude into awareness (Frith 1979). This has led many writers to regard a deficit in selective attention as one of the cen- tral psychological lesions in schizo- phrenia. As early promise gives way to the growing success of the attentional deficit hypothesis, there remains a gap between the computer terminol- ogy in which attentional theories are couched and the patient's experi- ence of schizophrenia. Somehow, the neat lawns of the information- processing experiment still seem a far cry from the luxuriant jungle of paranoid symptomatology. The con- cept of attention needs to be trans- lated into the language of experience if we are to use it to understand the patient in human terms. In this article, I use schizophrenic patients' own accounts of their ill- ness to illustrate a disorder of con- sciousness. The literature of first- person accounts of schizophrenia is vast (Sommer and Osmond 1983) and rich (Landis 1964; Freedman 1974), and although it needs to be approached with caution (North and Cadoret 1981; Gordon 1982), it provides important information that can be used to connect different ac- counts of the disease. I do not dis- cuss hallucinations, which have Reprint requests should be sent to Dr. R. Anscombe, North Shore Community Mental Health Center, 47 Congress St., Salem, MA 01970. by guest on March 1, 2015 http://schizophreniabulletin.oxfordjournals.org/ Downloaded from
Transcript
VOL13.NO. 2,1987 The Disorder ofConsciousness inSchizophrenia
241
by Roderick Anscombe Abstract
The schizophrenic experience is de-scribed as an inability to sustain anintentional focus to attention. At-tention is captured by incidental de-tails in the schizophrenic patient'senvironment, and this gives rise toa spurious sense of significance.The patient's inability to direct atrain of thought prevents full accessto long-term memory so that earlycomponents of perception, whichare designed to give early warning .of threat, are overly influential andunmodulated by further mentalprocessing. These hasty ideas aregiven delusional conviction whenthey capture attention and induce asense of significance similar to thefalse significance of perception.The schizophrenic patient's lack ofcontrol over his mental processesmakes him passive in relation to hisown thinking. It prevents him fromattending to the slight promptingsof his subconscious, and whenthese emotions and intuitions arenot amplified by being brought intofocus, he loses a sense of himself.
There have long been reports in theliterature, both from clinicians(McGhie and Chapman 1961; Chap-man 1966) and from patients them-selves (MacDonald I960), thatpeople with schizophrenia have dif-ficulty filtering out irrelevant stimuliand controlling what they pay atten-tion to:
... the mind must have a filterwhich functions without our con-scious thought, sorting stimuliand allowing only those which arerelevant to the situation in handto disturb consciousness. And thisfilter must be working at max-imum efficiency at all times, par-ticularly when we require a highdegree of concentration. Whathad happened to me in Torontowas a breakdown in the filter, and
a hodge-podge of unrelated stim-uli were distracting me fromthings which should have had myundivided attention. [MacDonald1960, p. 218]
When they cannot effectively ig-nore what is unimportant, schizo-phrenics cannot choose what theywill think about, and mental proc-esses that would normally be imper-ceptible and automatic intrude intoawareness (Frith 1979). This has ledmany writers to regard a deficit inselective attention as one of the cen-tral psychological lesions in schizo-phrenia.
As early promise gives way to thegrowing success of the attentionaldeficit hypothesis, there remains agap between the computer terminol-ogy in which attentional theories arecouched and the patient's experi-ence of schizophrenia. Somehow,the neat lawns of the information-processing experiment still seem afar cry from the luxuriant jungle ofparanoid symptomatology. The con-cept of attention needs to be trans-lated into the language of experienceif we are to use it to understand thepatient in human terms.
In this article, I use schizophrenicpatients' own accounts of their ill-ness to illustrate a disorder of con-sciousness. The literature of first-person accounts of schizophrenia isvast (Sommer and Osmond 1983)and rich (Landis 1964; Freedman1974), and although it needs to beapproached with caution (North andCadoret 1981; Gordon 1982), itprovides important information thatcan be used to connect different ac-counts of the disease. I do not dis-cuss hallucinations, which have
Reprint requests should be sent to Dr.R. Anscombe, North Shore CommunityMental Health Center, 47 Congress St.,Salem, MA 01970.
It is difficult to systematize schizo-phrenic experience, because ac-counts appear contradictory. Somepatients describe an animated worldfull of significance, while others de-scribe experience that is empty andnull. Some of the contradiction maybe only apparent, caused by thestrain put upon language as it isstretched to refer to experiencesbeyond its proper domain. Theusual mentalist language which weapply to ourselves was designed todescribe a particular kind of con-sciousness—consciousness in theWestern European tradition (Walsh1980). Within this tradition, the im-pression of a subjective agency, or"I," is so basic to our thinking abouthuman beings that even the gram-mar we use presupposes it. But thelanguage that supports this implicitpsychology may not be well suitedto describe schizophrenic experience(Stich 1983), and some of what ap-pears to be contradictory, and mostof what appears to be vague, mayarise from this source.
To a large extent, however, pa-tients' accounts differ because theirexperiences are different, dependingon whether they suffer more fromthe positive or from the negativesymptoms of schizophrenia. By con-vention (but see Sommers 1985), thepositive symptoms are delusions,auditory hallucinations, bizarre be-havior, and formal thought disor-der. The negative symptoms formthe defect state that Kraepelin(1913/1971) thought characteristic ofdementia praecox: blunting of affect,decreased production and povertyof content of speech, apathy, lack ofpersistence at tasks, neglect of per-sonal appearance, and a reductionin sexual interest and in interest inother people (Andreasen 1982; An-dreasen and Olsen 1982). While
negative symptoms may be presentat the beginning of the illness (lin-denmayer, Kay, and Opler 1984;Pogue-Geile and Harrow 1984), theyalso appear to be a function ofchronicity (Owens and Johnstone1980; Pfohl and Winokur 1982).These findings suggest that therewill be marked differences in the pa-tients' descriptions of their experi-ence, depending upon their initialsymptom picture and the stage oftheir illness.
In this article, I suggest that theschizophrenic's deficit in focusingattention leads to difficulty in main-taining a stable topic of thought andin following its theme without beingdiverted or petering out, and thatwhen the patient cannot direct hisattention to vague hunches and in-tuitions, he becomes disconnectedfrom his emotional origins in thesubconscious. The capturing of hisattention by incidental details in hissurroundings or memory means thathe increasingly becomes the au-dience of his mental life, rather thanits initiator, so that he becomes pas-sive and displaced. Finally, the lossof a feeling of identity—of "I" as theeffective source of mental life—im-poverishes the feeling of kinshipwith other people as humans.
Normal Attention
It is customary to divide cognitioninto two kinds of process (Kahne-man 1973; Schneider and Shiffrin1977; Shiffrin and Schneider 1977;Posner 1982). The first kind is thequick, superficial sorting of stimulibefore awareness, or the executionof stereotyped actions. An exampleis the effortless way in which theeyes sweep over a photograph tofocus upon the important feature,the figures in the landscape. This isin contrast to the slow and deliber-ate way in which a person scans
across an array of letters when hehas been instructed to pick out anygrouping that spells a word. In thefirst case, the procedure has been sopracticed that it has become auto-matic and no longer requires con-scious attention. This basicorganizing of the perceptual input isan example of what Neisser (1967)called preattentive processing. Theprinciple applies also to some ac-tions, such as the key strokes of askilled typist. These are activities,like walking and chewing gum atthe same time, that can proceed inparallel without detriment to theperformance of either.
The second kind of cognition, in-volving selective attention, is vol-untary, controlled, effortful, inten-tional, and more limited in theamount of information that it canhandle at any given moment. An ex-ample would be rehearsing some-thing one wished to remember, ordeciding whether two drawings of acomplex three-dimensional shapeare mirror-images of each other.There is a tendency to equate selec-tive attention with conscious aware-ness (Mandler 1975), and to think ofthe preattentive processes as akin toautomatic reflexes.
An example of the interplay of thetwo processes is the dichotic listen-ing paradigm. This is also known asthe "cocktail party phenomenon,"since it resembles the difficulty ofpaying attention to one conversationwithout being distracted by otherconversations close by. In a typicalexperiment, the subject, wearingheadphones, is asked to listen toone of two messages and to repeat itas it is being spoken to him. Themessage that the subject is requiredto shadow may be defined as theone presented to the left ear, or asthe message spoken in English or bya female voice (irrespective ofwhether it switches from ear to ear).
When the message to be attended tois defined by simple physical charac-teristics such as its location or voicequality, the subject can performthese shadowing tasks very effi-ciently. In these simple cases, wecan imagine attention being di-rected—like foveal centering, orpointing a directional microphone—on the basis of the characteristics ofthe message to be attended to.However, properties of the ignoredmessage also affect the ability to at-tend, and this indicates that the per-son shadows by excluding the to-be-ignored message as well as by se-lecting the to-be-attended message.To filter out the irrelevant messageselectively, the subject must firstsample and analyze it so that it canbe distinguished from the messageto be attended to (Treisman 1964). Inother words, although subjects gen-erally show little evidence of ac-quaintance with the content of theto-be-ignored message, they must"know" something about it to rejectit correctly.
Although early, automatic proc-essing is capable of determiningwhether something is of emotionalsignificance to the person beforeconsciousness (Corteen and Wood1972), and can even make this deter-mination on the basis of what aword means without the person'sconsciously reading it (Marcel andPatterson 1978), it is necessarily aquick and unelaborated perception.This early appraisal of the signifi-cance of the stimulus is somewhatmore than a report of mere salienceor a crude alert, but far less than anappreciation of its full meaning tothe person (Anscombe, in press). Itis not until the later, effortful, andusually conscious reappraisal takesplace, that the percept developsmeaning by being integrated withthe person's body of knowledge andby being placed in context.
The first (gut) reaction occurs be-fore awareness: it is a crude scan ofthe object to appraise its significanceaccording to preset notions, whichinclude expectations, aversions, ap-petitive states, prejudice, and otherfactors that color first impressions(Erderlyi 1974; Zajonc 1980). Pre-attentive analysis gives the person aquick sweep of his surroundingswithout engaging attention untilsomething important has been de-tected.
There is, however, a tradeoff be-tween the speed of the scanning andthe depth to which each item can beprocessed (Fodor 1983). Typically,preattentive processing is fast andshallow, so that it does not identifythe object it singles out beyond thecharacteristic which makes it impor-tant and brings it to notice. Suchprocessing is, both literally and met-aphorically, a cursory glance. This isconsistent with its function of draw-ing attention to a particular part ofthe visual field that preliminaryanalysis indicates may be important(Posner 1980).
In locating stimuli that may be sig-nificant, the preattentive analyzersconstitute the organism's earlywarning system, particularly forlooming and approaching objects(Bernstein 1979). To fulfill this func-tion well, it is better for them to re-spond in error than to omit callingattention to a valid threat. In fact,we could say that it is part of thepreattentive analyzers' job to be"paranoid." As Fodor puts it:
Perception is built to detect whatis right here, right now—what isavailable, for example, for eatingor being eaten by. If this is indeedits teleology, then it is under-standable that perception shouldbe performed by fast, mandatory,encapsulated . . . systems that. . .are prepared to trade false posi-tives for high gain. It is, no doubt,
important to attend to the eter-nally beautiful and to believe theeternally true. But it is more im-portant not to be eaten. [Fodor1985, p. 4]
If preliminary sampling indicatesthat the object is significant, the pre-attentive processes attract attentionto it, so that the person can focus onit with the full faculties of conscious-ness, thinking about it, watching it,trying to remember when it hasbeen seen before, whether it is asdangerous as it seems at first glance,what it tastes like, and so on. Con-sciousness is a way of accessing fur-ther associations and deepening theprocessing. It fills out the meaningof what is perceived beyond theshallow, nervous appraisal of thepreattentive analyzers and gives asecond opinion on what has beenglanced at.
To be efficient, preattentive anal-ysis must be selective in what itdraws attention to. A person cannotnotice everything. To a large extent,the kind of stimuli and features thatpreattentive analysis responds to ispreset; for example, it is particularlyresponsive to change and novelty inthe environment, alerting the per-son and orienting attention to thenew stimulus (Bernstein 1979). Frommoment to moment, the preatten-tive analyzers need to be set so thatthey can alert the person to the oc-currence of something that he hasalready established he is interestedin (Hoffman, Nelson, and Houck1983). Although this route can bebypassed, the common way wemanage to notice what we are inter-ested in is by deliberately framing itto ourselves, and by setting the pre-attentive analyzers by conscious re-hearsal. In the dichotic listeningtask, subjects are able to switch atwill from attending to a message de-fined by one characteristic ("themessage in English") to another
message defined differently ("themessage spoken by the malevoice"): they are able to set, by con-scious intent, the kind of preatten-tive analysis that is carried out, andthey are able to maintain it so thatthey continue to track the messageby its relevant characteristic ("malevoice" rather than "in English").
Attention in Schizophrenia
Recently, a pattern of deficits inschizophrenia involving selective at-tention and the linkage of attentionto preattentive processes has begunto emerge. In their review of infor-mation processing in schizophrenia,Nuechterlein and Dawson (1984)conclude that schizophrenic patientsdo poorly in experimental para-digms in which successful perform-ance depends on sustaining focusedattention in the face of boredom, fa-tigue, high information load, or dis-traction. They found some sug-gestion that automatic processesmay be impaired (e.g., Braff andSaccuzzo 1981), particularly duringperiods of active psychosis. In gen-eral, however, people at risk forschizophrenia, patients who wereacutely symptomatic, and those inrelative remission were deficient intasks requiring the active, effortful,attentional manipulation of material,such as maintaining a set (contin-uous performance task), scanningmemory (forced-choice span of ap-prehension), and active rehearsal(serial recall). Acutely symptomaticschizophrenic patients also appearto do poorly in shadowing messagesduring dichotic listening. Other re-viewers also emphasize that whilethe automatic processes of schizo-phrenic people appear almost nor-mal, their conscious, controlledcognitive processes are unusuallyvulnerable to interference (Callawayand Naghdi 1982; Gjerde 1983).
A similar picture emerges of mem-ory in schizophrenia. On the onehand, the performance of schizo-phrenic patients on tasks that relyon automatic processes do not showsignificant differences from normalcontrols. Recognition memory,which is thought not to require anactive search process, is adequate(Koh and Peterson 1978), and theencoding of conceptual categories ofitems to be remembered is not im-paired (Traupmann, Berzofsky, andKesselman 1976). Other componentprocesses of memory, although notnecessarily automatic, also appearnormal, such as the rate of scanningitems in short-term memory (re-viewed in Broga and Neufeld 1981).In long-term memory, the semanticand syntactic ordering of representa-tions also appears to be normal(Larsen and Fromholt 1976; Koh,Marusarz, and Rosen 1980; Brogaand Neufeld 1981; Lutz and Marsh1981). Recall, however, is impaired.In contrast to the previous proc-esses, recall requires the person's di-rected attention: the person mustorganize the items and actively re-hearse the list to store them in long-term memory and must then directan accurate search through associa-tions to retrieve them. Importantly,the schizophrenic patient's deficit inrecalling information can be over-come when active rehearsal inducedas part of the experimental condi-tions substitutes for the patient'sspontaneous efforts to structure theinformation (Larsen and Fromholt1976; Koh and Peterson 1978; Brogaand Neufeld 1981).
Neuropsychological studies ofschizophrenia mirror the findingsfrom information-processing experi-ments. As in the psychological stud-ies, there is some suggestion thatschizophrenics may have a deficit inthe early processing of informationat the level of stimulus registrationand channel selection, although the
results of evoked potential studiesare mixed on this question. This isovershadowed, however, by thegeneral consensus that later compo-nents, such as F30a, are abnormal(Shagass et al. 1978; Spohn and Pat-terson 1979; Baribeau-Braun, Picton,and Gosselin 1983; Brecher and Beg-leiter 1983). While the exact psycho-logical correlate of P^ remainselusive, its amplitude appears to berelated to the degree to which animportant and relatively uncommonstimulus engages the subject's atten-tional resources (Wickens et al. 1983)and makes it necessary for the sub-ject to update his model of the con-text in which the stimulus occurs(Donchin, Ritter, and McCallum1978; Pritchard 1981). The attenua-tion of PJO,, in schizophrenia sug-gests that these patients mayregister the occurrence of a stim-ulus, but have difficulty in subject-ing it to further processing thatwould assimilate the new informa-tion with their background knowl-edge.
A study by Steinhauer and Zubin(1982) helps link together the twoapproaches of information process-ing and evoked potentials. Theyfound that schizophrenic patientsshowed early evoked potentials totarget tones that they had beenasked to count, indicating that thestimuli had been initially processed.The subjects showed diminished P^,responses, however, and they didnot show the pupil dilation that usu-ally accompanies it and that hasbeen shown to be a good measure ofintentionally directed "mentaleffort" (Beatty 1982).
When a person detects a stimulusthat might be of significance tothem, a characteristic orienting re-sponse occurs. The response iscomposed of an increase in skinconductance, peripheral vaso-constriction, bradycardia, blocking
of electroencephalographic (EEG) al-pha rhythm, and a turning of thehead or eyes toward the stimulus(Lynn 1966). In view of the lack ofcorrelation between the differentmeasures of the orienting response,it seems likely that it is composed ofa number of related but distinct per-ceptual processes, including bothpreattenu've processes and the en-gagement of attention itself. Clearly,however, this is an area that bearsparticularly on the question of howthe two kinds of cognition are linkedin schizophrenia.
Measures of the orienting re-sponse, such as skin conductanceand finger pulse volume (Spohn andPatterson 1979; Bernstein et al. 1982;Dawson and Nuechterlein 1984), in-dicate that about half of the schizo-phrenic subjects do not show anautonomic response to tones orflashes of light that they have noreason to pay attention to (the corre-sponding proportion among nor-mals is about 10 percent). When thestimuli are made relevant by askingthe subjects to press a pedal whenthey occur, schizophrenic patientsinitially show autonomic responsesthat are similar to those of normalsubjects, but these habituate quicklyso that the patients again becomeunresponsive (Bernstein et al. 1985).However, one EEG indicator of theorienting response—alpha block-ing—does not show the same lack ofresponsiveness and does not habitu-ate prematurely (Fedio et al. 1961;Hein, Green, and Wilson 1962;Bernstein et al. 1981, 1985).
Normal alpha blocking contrastswith the abnormal attenuation ofP ^ in schizophrenia. If we take al-pha blocking to be an indication thatthe system is preparing to receiveinformation (Ray and Cole 1985),performing tasks such as movingthe eyes to center on the target, ac-commodating, and so on, and if we
take the autonomic changes as anindication that the organism has re-sponded to the call for attentionalprocessing capacity (Bernstein et al.1981; Beatty 1982), then the absenceof impairment in alpha blocking inthe presence of abnormal autonomicorienting is consistent with the otherresults suggesting that the schizo-phrenic patient's preattentive proc-esses are largely intact while hiscapacity to direct and sustain atten-tion is defective.
Consciousness
The elemental precision of cognitivepsychology is obtained at some cost,mainly a reduction in scope. Likethe early explorers of Africa, weknow a great deal about the coast-line of the mind—the periphery ofperception and response—but littleof the ramifications within. In con-trast to attention, which is a pre-dominantly perceptual notion basedon the metaphor of foveation, theconcept of consciousness empha-sizes the contents of awareness andthe mentation in between stimulusand response. Intentionality andchoice are intrinsic to the concept(Sartre 1956), and it meshes morenaturally with the language of sub-jective experience such as wishes,willing, intuitions, and the sense ofself.
Thematic Tracking. When the clini-cian takes a history, what he doesaloud with the patient resembleswhat he does later with his ownthoughts as he mulls the case over.He controls the interview in variousways, pacing the flow of informa-tion, asking the patient to elaborateon some aspect in greater detail, orskipping from one episode to an-other. All the time, the interviewertracks the implicit theme that gives
meaning to the events which arebeing recounted to him.
When he thinks about the inter-view to himself, the clinician is ableto switch from a narrow focus ("Didhis brother leave to join the armybefore or after his first hospitaliza-tion?") as he connects togetherpieces of information to form a con-clusion, to broader musings as hetries to open himself to possibilities("What must it have been like tohave your brother leave you unex-pectedly?"). In doing so, he moni-tors the boundaries of his thoughtso that his mind does not wanderoff the topic. He sticks to the pointby moving his attention at will fromone topic to another, actively search-ing for a pattern. I do not wish toimply that the shifting of attention isalways a conscious decision, butthat it is usually accessible to delib-eration and that it is flexible and re-sponsive to momentary changes inwhat the person is interested in. Inthis way, the clinician finds meaningin the material and, most impor-tantly, meaning that he has createdfor himself.
Access. The clinician's ability toframe what he is thinking about,and his ability to shift the focus ofhis thought in a thematic way, al-lows him self-access characterizedby a precision that his schizophrenicpatient cannot attain. The ideas wewant to think are rarely the onesthat we are immediately consciousof. Emotions, too, are not always sointense that they become obviousand pressing.
Subconscious promptings arise asvague stirrings, and they develop,given the proper attention, into in-tuitions, impulses, convictions, andhunches. They need to be amplifiedand elaborated, and fixed in theform of a verbal or pictorial image in
consciousness if they are to be sus-tained. Sometimes these ideas arememories, and we need to followthe right associations if we are tofind the recollection we are lookingfor. Each of these cases demandsthat attention be placed accurately.The precision involved in mentalmaneuvers is easily overlooked.Even those processes that appear tobe passive require an initial aim andimpetus. Beginning a fantasy, forexample, requires accuracy inlaunching ourselves on the right as-sociative "glide-path," although thisis usually so effortless that it may gounnoticed.
Gaining access to oneself may notbe a simple procedure. For example,when the clinician has a hunch thata psychotic patient might have beendepressed, he might try to remem-ber certain moments during the in-terview to see if there were objectivesigns—eyes downcast, a lack of ca-dence, delusions whose grandiositydisguised their gloominess—to sup-port this guess. It is not a randomsearch, for his attention is guided torecall certain moments. He turns theinterview over in his mind in thehope that he can reempathize withthe patient, and use this intuition asa detector to locate instants in theinterview from which he can thenproceed to more objective clinicalfeatures.
Gaining access to the sub-conscious is a little like fishing: it re-quires careful positioning of theright lure. If we are lucky, inspira-tion comes serendipitously; butmore often we must actively try toelicit ideas or feelings that we sensejust beneath the surface by directingthe right kind of thought into theright area in the hope of cuing theassociation we seek. Hunches needto be attended to so that they can beamplified and gather associations,so that they achieve a critical seman-
tic mass to allow them to be put intowords. This focusing transforms anintuitive prompting into a thought,and gives it greater definition andpersistence so that the person canmore clearly represent himself tohimself. Like casting a line, intuitingis a directed, effortful, willed proc-ess, which may be accomplished ac-curately or inaccurately, with moreor less skill and dexterity. Suchthinking is accompanied by a par-ticular cognitive sensation of atten-tional effort (Kahneman 1973),indicating to the person that thethought which emerges is some-thing he has produced himself, fromhis own mind.
In addition, the person's experi-ence of emotion and action as orig-inating in his mind, and as some-thing over which he has somecontrol, forms the basis of an analo-gous understanding of other people.To some extent, his own emotionallife is a starting point from which heextends himself empathically to oth-ers, so that he understands otherpeople as he experiences himself. Ifthe patient is not able to experiencehimself as having depth, he mayalso find it difficult to credit otherswith an emotional life.
Intent and Owned Action. For in-tentional behavior to take place, astable thought must be maintainedfrom its coming into focus as im-pulse, through deliberation, andinto action. This ensures that the ac-tion is guided toward its goal. Ac-tion that is willed in this fashionlinks the person's inner and outerworlds so that his subjectivity im-pinges on the real world. Actionthat is not intentional is reflex or au-tomatic and lacks this origin, whichgives it meaning.
Intentional actions are broughtinto being by means of active mentaloperations, and they confer upon
the thinker a sense of personalagency, in the sense that if I dosomething that I have decided to do,it is my action. Volitional mental ac-tivity also provides a subjectivesense of location for awareness: sub-jective experience is centered at thispoint as a sense of "I." Because in-tentional action originates in thisway, it carries the person's stampupon it: it is owned action.
In view of Freud's contribution toour understanding of unconsciousconflict, we should not overempha-size the consistency of the impulsespresent at the edge of conscious-ness, or exaggerate the unitary na-ture of the person. However, thepoint I wish to make is that withoutthis capacity to shape and to directthought, the person cannot give co-herance to his behavior, and re-mains at the mercy of hissurroundings or impulse. In somebasic way, the link between innerstates, via thought and intention, toeffects out there in the world provesthe person's efficacy in a crucialway: thought and will work, be-cause they produce actions.
In summary, I am suggesting thatthe clinician's experience of himselfas an agent in the world on his ownbehalf, and as a continuous "I,"comes from the way in which his ac-tions originate: he does things inten-tionally for his own reasons. Thiscapacity in turn depends on his abil-ity to carry out certain subjectivemental operations—specifically, heis able to think things through totheir conclusion, to frame a topic,and to track along a theme. His rea-sons are not always "reasonable,"but they are his, because he makesthem himself, refining them from in-tuitions that arise within him.
He stays connected to himself be-cause he can introspect sufficientlywell to prompt his subconscious andto bring vague impulses and ink-
lings to a focus leading to delibera-tion, whimsy, or action. Above all,his thinking is an active process,and he experiences his mental appa-ratus as something efficacious—hehas a self and it works. Finally, heextends this assumption to others,supposing them, too, to be agents ofa mental life that is complex andsometimes factious.
The Experience ofSchizophrenia
The Capture of Attention. Peoplewith schizophrenia find themselvesstaring at things and describe theirattention as being captured by inci-dental aspects of their surroundings.In 1913 Kraepelin (1971) noted an"irresistible attraction of the atten-tion to casual external impressions"(pp. 6-7). Minor details of color ortexture, or blemishes, attract the pa-tient's notice with a salience that isout of proportion to their true sig-nificance. At the same time, thething that the person is led to fixatehis attention upon may have nogenuine meaning to him:
I seem to be noticing colours morethan before, although I am not ar-tistically minded. The colours ofthings seem much . . . clearer andyet at the same time there issomething missing. The things Ilook at seem to be flatter as if [I]were looking just at a surface.[McGhie and Chapman 1961,p. 105]
The patient's attention may jam sothat he remains stuck for minutes onend at a single thought or percep-tion. On a psychiatric ward, for ex-ample, it is not uncommon to see apatient open the refrigerator doorand stand as if frozen in thought,his attention captured by the illumi-nated contents inside. Patients talkabout thought blocking as beinghypnotized or entranced:
If I am reading I may suddenly getbogged down at a word. It may Deany word, even a simple wordthat I know well. When this hap-pens I can't get past it. It's as iflam being hypnotized by it. It's asif I am seeing the word for thefirst time and in a different wayfrom anyone else. It's not so muchthat I absorb it, it's more like it ab-sorbing me. [McGhie and Chap-man 1961, p. 109]
Getting bogged down at a wordwould appear to be the subjectivesensation of the patient's inability toselect the attentional focus for him-self and to move it along to the nextword to be read. In the last example,the word captured attention, butthis did not result in any deepeningin meaning or associative move-ment. It appeared to be without anyfurther effect other than a sense ofstrangeness and fascination.
Normal subjects can also experi-ence this "stickiness" of attention.When they are required to reverse atask that they would normally per-form consciously but that enormousamounts of practice have enabledthem to perform automatically, theyfind that they are often unsuccessfulin resisting the allocation of their at-tention to targets that have ceased tobe relevant. In experiments byShiffrin and Schneider (1977)," . . . the subjects were uniformlystartled and even dismayed by theextreme difficulty of the reversedtask" (p. 135) when they wereasked, after a long time detectingletters among numbers on a visualdisplay, to look for numbers amongletters. The subjects had become sopracticed at the first task that theycould detect letters preattentively,and this automatic process mis-directed their attention when thetask was reversed and often over-rode their intention to look fornumbers.
The schizophrenic patient resem-bles these subjects in that his atten-tional focus becomes subservient topreattentive processes that have be-come detached from higher centers.It is as if he suffers from an ataxia ofattention, so that it drifts here andthere and is eventually snagged bysomething his gaze happens tofocus upon. Attention is captured byincidental details because an inten-tionally imposed focus is absent oroverridden, and so early routines ofperception, such as locating thetarget and centering the visual appa-ratus upon it, proceed independ-ently of what he intends. Thepatient is not able to assert his ownpurpose and to overcome the powerof such low-level processes to attractattention to what they have de-tected, and so he finds himself star-ing at something of no particularimportance.
Some of the ways in which pa-tients try to escape from the captureof their attention resemble thoseadopted by patients with a spasm offixation due to a supranudear palsyof eye movements:
. . . when these patients tried tolook towards an object theyemployed various devices bywhich to interrupt the fixation ofthe point on which their eyeswere directed: some blinked orclosed their eyes momentarily, orjerked their heads abruptly; oneman occasionally brought nishands before his eyes Nor-mally, fixation is under the controlof volition, for we can move oureyes from object to object as wewill, but when voluntary move-ment is defective the fixation re-flex becomes so dominant that theeyes may remain anchored to anobject and can move from it onlywhen the reflex is broken by inter-ruption of the retinal impulses.[Holmes 1938, p. 110]
Since the remobilization of atten-tion in schizophrenia involves morethan breaking off a visual focus,
however, the maneuvers may beless successful. When attention hasbecome stuck upon some object,
• even attempts to escape the en-trancement can lead, like a psycho-logical maze, back to the beginning,as if even this exertion of intent hasbeen subverted:
As soon as my gaze fell on a spotof any sort, a shadow or a ray oflight, I could not drag it away,caught and held fast Dy theboundless world of the infinitelysmall. To wrench myself out ofthis impasse I began to beat onthe table or on the wall with bothfists. But the efficacy of this ac-tivity soon exhausted itself. In-stead of saving me from theabsorbed perception of the spot,in turn I became lost in the auto-maticity of this substitute be-havior. [Sechehaye 1970, p. 56]
In this passage, Renee,Sechehaye's patient, describes theentrapment of attention by her ownactivity, developing into repetitiousmovement similar to that seen in therhythmic mannerisms of chronic pa-tients. With this, the capture of at-tention is complete, and as McGhieand Chapman (1961) point out, thepatient's attention is less subject tohis volition and more determinedfor him by the stimuli that impingeupon him.
Heightened Significance. In schizo-phrenia, objects seem to jump outand capture attention, but this at-traction has nothing to do with whatthe person is looking for or what hemight be interested in. We are ac-customed to our attention beingdrawn to things that are either ob-vious because their physical charac-ter makes them stand out—they areloud or noxious—or because theyare surprising or novel, or becausethey match some internal state—ahungry man noticing a hotdog
stand, for example.Much of what preattentive anal-
ysis brings to attention is by virtueof the objective, physical propertiesof the stimulus: a loud noise, abright, saturated color against a drabbackground, or sudden movementat the periphery of the visual field.Aspects of the environment are alsomade obvious. Preattentive percep-tual mechanisms are tipped off fromabove: they may be primed to bringattention quickly to certain featuresthat the person has deemed impor-tant (Posner and Snyder 1975), orthey may be enhanced by the activa-tion of the representation in mem-ory of what the person is expecting(McLean and Shulman 1978).
To find someone in a crowd, forexample, we might (preattentively)scan everyone there to pick out thepeople with green scarves, and thenlook more closely at (consciously at-tend to) those people's faces to see ifone of them is the particular personwe are looking for. The focus ongreen in a particular location (be-tween heads and shoulders) is setdeliberately and gives the detectionof green a special status in attractingattention to it once it has been lo-cated. It is as if the preattentiveprocesses are instructed by con-sciousness to bring certain things toits attention: the search is prepareddeliberately to proceed automaticallywith a green "set."
When preattentive analysis de-tects the feature that it was primedto react to, it attracts attention andthe resources of consciousness tothat location in the perceptual field(Posner 1980). This arranged con-junction of object and conscious per-ception is accompanied by a certainkind of subjective experience—oneof recognition, arousal, startle, or in-terest. Sets may be relevant only to aparticular occasion, or they may bemore enduring matters of policy.
Some features of the world, such asthe red of a brake light, your ownname, someone's eyes directed atyou, pubic hair, and so on, achievea perceptual salience because oftheir importance to the person.
To say that such features are moreobvious is simply a way of restatingthe fact that the person notices themmore quickly and easily. Since notic-ing is a function of the orienting ofattention to a feature that has beendetected by perceptual processespreceding awareness, and since fea-tures are noticed more readily ifthese processes have been activatedin advance, the quality of being ob-vious may be as much a conse-quence of the intentions of theperceiver as the physical characteris-tics of the object itself. However, itmay not always be recognized thatbeing interesting, or important, orobvious, or significant is an "endo-genous" quality, instead of some-thing "out there." At times, it mayappear to be a property of the objectrather than a contribution of the per-ceiver.
Normal subjects can be startled bythe quasi-physical "halo" about ob-jects when their preattentive ana-lyzers have been set by methodswhich they are not accustomed toand which bypass intentional prim-ing. These subjects appear to experi-ence something similar to theheightened significance that schizo-phrenic patients complain of, so thatthe subjective impression ofemphasis appears almost as a physi-cal property of the object itself. Forinstance, Neisser (1967) described atendency among subjects for famil-iar targets to "pop" out of the ex-perimental display. Kahneman(1973, p. 93) suggested that whensubjects detect an item of the kindfor which they have a set, attentionis charged with a particular inten-sity, so that the stimulus "jumps"
Kahneman to describe the reactionsof normal subjects are strikinglysimilar to the way in which schizo-phrenic patients themselves describeperception, for example, of colors:"Colours seem to be brighter now,almost as if they are luminous"(McGhie and Chapman 1961,p. 105). This is mirrored even in theterms in which theory is couched—Callaway and Naghdi (1982), for ex-ample, refer to the activation of pre-attentive analyzers in their model ofschizophrenic attentional disorder as"glow."
The jump, pop, and glow of ob-jects is the experiential equivalent ofattention being vigorously switchedto focus on these items in the sur-roundings. As Kahneman (1973)suggests, the analyzers can be setfrom above down, by instructions todraw attention to features of the en-vironment that the person has de-fined as important, by the effort ofconcentration, or by other consciousstrategies (Posner and Snyder 1975).In this way, when aspects of the en-vironment are recognized as signifi-cant, they do not generally "popout" in any remarkable way, be-cause recognition is the accustomedresult of an intentional sequence oflooking for, or noticing, and itmatches an expectation. In addition,the significance conferred by thedrawing of attention to an object hasits origin in the person, and it is notexperienced as something emanat-ing from the environment. When, inschizophrenia, this intentional com-ponent of noticing something ismissing, it is possible for the personto be confused about whether the"significance" to which their atten-tion is drawn is a quality of the ob-ject or a subjective aspect ofperception.
We are so accustomed to the con-
junction of noticing something, andfor the thing that we notice to beeither physically intense or impor-tant to us, that it is natural to inferthat if attention is drawn to some-thing, then the object is either ob-vious or interesting. But if, inschizophrenia, the person finds hisattention caught by an object whichdoes not possess the usual physicalcharacteristics that attract attention(e.g., loud, bright, sexy, noxious,and delicious-smelling), they mustconclude, if they are to make senseof their experience, either that theirperception has undergone somedrastic disturbance, or that the thingthey are staring at really does pos-sess a significance whose nature isnot immediately obvious. Thatschizophrenic patients almost al-ways choose the second—delu-sional—kind of explanation ratherthan one of the first kind is a factthat needs to be accounted for, and Iaddress this issue in the next sec-tion.
The schizophrenic patient cannotshift his attention flexibly, and hisinterest is captured, not becausesomething there is important, butbecause attention does not shift backto what he was busy with or on tosomething else. The process runsbackwards, so that things appearsignificant because they capture at-tention, and then the salience mustbe interpreted to mean something.The enhanced significance of whatthe patient fixates may be so strikingto her that the importance of whatshe is looking at overrides the factthat it lacks any particular meaning:
Every single thing "means" some-thing. This kind of symbolicthinking is exhausting I have asense that everything is morevivid and important; the incomingstimuli are almost more than I canbear. There is a connection toeverything that happens—no co-
incidences. [Brundage 1983,p. 584]
The conjunction of salience with-out the person's understanding whythe things she is paying attention toshould be important to her is nicelycaptured by Norma MacDonald:
. . . I became interested in a wideassortment of people, events,places, and ideas which normallywould make no impression onme. Not knowing mat I was ill, Imade no attempt to understandwhat was happening, but felt thatthere was some overwhelmingsignificance in all this, producedeither by God or Satan, and I feltthat I was duty-bound to ponderon each of these new interests,and the more I pondered theworse it became. The walk of astranger on the street could be a"sign to me which I must inter-pret. [MacDonald 1960, p. 218]
The significance is spurious, butpatients feel impelled to react bymaking sense of it in some way. Ifthey are playful or creative, theymay find the experience exhilarat-ing. David Zelt (1981) describes thefascination of colors, each one filledwith its own special meaning:
Ordinarily unimportant informa-tion from external reality took onnew dimensions for him. For ex-ample, colors powerfully influ-enced him. At any given momentwherever David went, colors wereused to express judgments abouthis spirituality. People used thecolors of their clothes or cars toexpress positive or negative viewsof nim. Green meant that Davidwas like Christ; white stood forhis spiritual purity; orange indi-cated he was attuned to thecosmos.... [Zelt 1981, p. 530]
Here the world presents Davidwith an excess of significance. Butnote that the colors express theideas of other people, and that David
is the passive recipient of these im-pressions: "colors powerfully influ-enced him." Whether the details arefull of significance, or alarminglyempty of meaning, they capture theattention of the person in a way thatappears to take the initiative fromhim. It is as if the world preemptshim with its own significance, or im-poses its meaninglessness uponthose patients with negative symp-toms.
The strain of keeping up with thecontinuous importance of every-thing becomes exhausting, and asthe significance of things begins tooverwhelm the patient's capacity tomake meaning, he falls behind ingiving sense to what he perceives.Delusions become careless and hap-hazard. The locus of control hasshifted, the person becomes morepassive, and what is happening ap-pears more and more to originate"out there."
Delusional Meaning. The capturingof attention, the apparent role of ex-ternal circumstances in assigningmeaning, and the "glow" of signifi-cance emitted by objects add up to aradical change in experience. It al-most makes plausible the patient'sdutches at explanatory straws—tele-pathy, thought control, radio re-ceivers, and electronic brainimplants.
Several authors (e.g., Maher 1974;Bowers 1974) have noted the height-ened significance with which appar-ently trivial details are invested inthe perception of schizophrenic pa-tients, and have suggested that de-lusions are attempts to explain thisaberration:
. . . for many paranoid patients thedelusion should be seen as the re-action of a normal, "sane" indi-vidual to abnormal but genuineperceptual experience. [Maher1974, p. 112]
The difficulty with this kind of ex-planation is that schizophrenic pa-tients come up with explanations oftheir perceptual aberrations, par-ticularly heightened significance,that are not sane. The sane explana-tion is that they have schizophrenia,or something like it. There is anadded obscurity to the explanation:since most of us have only dreamingand a small repertoire of intoxica-tions to refer to, we are quite limitedin our experience of other forms ofconsdousness, and we simply donot know how we would respond tothat degree of distortion. The con-cepts of everyday "folk psychology"do not extend that far (Churchland1981; Stich 1983), and the truth ofthe matter is that we do not knowwhat sane people do when they gomad.
Fischman (1983) has pointed outthe similarities between the phe-nomenology of schizophrenia andLSD states, noting in particular thatthey share a heightened awarenessand sense of significance. We findsimilar features in marijuana use,with a dwelling of attention upondetails which the eyes happen tolight upon and the consequent senseof significance or feeling of en-hanced appredation. But whereasschizophrenic patients are deludedin addition to their exaggeratedsense of significance, people whotake LSD are generally not: theynote the perceptual illusion withoutgetting delusional about it (Young1974). This indicates that heightenedsignificance alone is not suffident toinduce delusion, and that we re-quire more extreme pathology tojustify the transition from illusion todelusion.
The perception of significance,without the person's having a dearunderstanding of the meaning of theobject which holds this apparent fas-cination for him, constitutes a new
kind of experience. The patient hasan affective response to somethinghe notices, but his emotional reac-tion lacks the resonance of normalconviction. Much of the time, theconviction that something has per-sonal significance comes about bybacking up one's first impressionwith previous experience and back-ground knowledge. Zajonc (1980)has proposed that many emotionalreactions and preferences to whatthe person perceives—reactionswhich he may not be aware of—pre-cede the more elaborated, verbal,consdous, "rational" processing ofinformation. If he is right, then aninability to shift attention to gain ac-cess to one's accumulated workingknowledge in memory, and an in-ability to use this in putting togethera more integrated and filled-out per-cept, would result in one's beingstuck at this early stage of percep-tion.
The evidence suggests that whilethe structure of representations inthe schizophrenic patient's memoryis intact, he has difficulty remember-ing things because of a defect in thecontrolled, attentional processes thatmake for effident recall (Larsen andFromholt 1976; Koh and Peterson1978; Koh, Marusarz, and Rosen1980; Broga and Neufeld 1981; Lutzand Marsh 1981). Without easy re-course to long-term memory, andwithout being able to shift attentionfurther along to the next cognitivestages, the schizophrenic patient isat the receiving end of a volley offirst impressions—and therefore atthe mercy of a perception heavily in-fluenced by old prejudices, atti-tudes, and momentary fears andexpectations.
In particular, such truncated per-ception leaves the preattentive ana-lyzers, with their heavy emphasison the detection of threat, withoutthe checks and balances of long-
term memory. The effect may be tobombard the patient with alarmingbut very sketchy outputs withouthis being able to direct his attentionaccurately to the knowledge he hasthat would reassure him that he isencountering something quite mun-dane. This would give an affectiveintensity to ordinary objects and sit-uations, and heighten the signifi-cance of events, without theopportunity for more considered ap-praisal:
My confusion was complete. I wasterrified and the wait for some-thing bad to happen was ex-cruciating I was not"thinking"; I was just reacting,using no judgment. My emotions,inwardly, were at a fever's pitchand it seemed to me that I wasonly feeling, not thinking. [Brun-dage 1983, p. 584]
Of course, the first impressionsare the impressions of the person,but to some degree they lack thepersonal touch. They are not the re-sponses of the whole person, sinceit is a shallow response that doesnot include the contribution of otherparts of the subjecf s mind. In asense, they are resolutions passedwithout a full psychological quorum(Anscombe, in press). Also, in thesame way that a knee jerk elicited bya tap on the patellar tendon doesnot feel like a normal leg movement,or in the same way that vocalizationinduced by stimulation of the motorcortex does not feel like a voluntaryaction (Penfield 1938), delusional re-sponses to a sense of preattentivesignificance are different from nor-mal convictions because they do notcome about it the usual way (Fein-berg 1978). They are ideas that havenot passed through the customarymental channels, and they do notfeel the same.
This may go some way to explain-ing why the schizophrenic patient
chooses a delusion in his attempt tomake sense of the unusual signifi-cance that everyday objects assume,instead of attributing it to perceptualdisorder. The patient, for example,finds himself gazing at a small poolof coffee someone has spilled on thetable: there is nothing remarkableabout the blot, and yet it engageshis attention. It fascinates him. Hestrives to find the reason for this, ex-amining its outlines, looking at thepattern of vibrations across its sur-face as someone walks by, and soon, but his efforts are confounded.Firstly, the coffee spill is imbuedwith a significance that is spurious—it appears significant because he islooking at it, and not the other wayaround—but he has no way ofknowing this, given the way inwhich his perception has usuallyworked in the past.
Secondly, his capacity to gain ac-cess to his store of knowledge in anorderly way is impaired. It is diffi-cult for him to get beyond the quickfixes of first impressions, the config-urations given to perception by am-bient emotion and immediatepersonal bias. In the absence of athought-out appraisal, what comesto mind are the things that usuallycome to mind when a person sus-pends his critical faculties in artisticcreation or free association, or isotherwise careless about what he isthinking: the whimsy, the phan-tasmagoria, and the elemental fearsand appetites of fantasy. The pa-tient, unable to direct his attentionin an accurate search of memory,lacks the ability to monitor andcheck up on these productions, andin the absence of more plausible,common-sense candidates fromlong-term memory, these may seemlike more compelling solutions tothe problem of significance thanthey would otherwise be.
But these factors are still not
enough to explain why the patientshould believe that God is commu-nicating to him in the shape of thecoffee spill. Why are delusional ex-planations held so tenaciously? Andwhy, if they are the result of a mis-take, a failure of memory, can theynot be easily corrected when the pa-tient is reminded of the real state ofaffairs?
The additional factor is the com-pelling nature of delusional inspira-tion. The hunches that occur toschizophrenic patients are convinc-ing to an abnormal degree, and thedelusional conviction often seems toarise in an unaccustomed way—sud-denly and fully formed—and not ina way in which normal thoughtscome into being. Kurt Schneider(1959) referred to this as "delusionalperception." A.T. Boisen, whoworked as a chaplain at a mentalhospital after several psychoticbreakdowns of his own, describesthe intensity of delusional belief:
After a period of preoccupationand sleeplessness, ideas begin tocome as though from an outsidesource. This dynamism is a nor-mal one. It is known as the "in-spiration," or the "automatism,"and may be defined as the idea orthought process which after aperiod of incubation darts sud-denly into consciousness. In thecase of the schizophrenic . . . suchideas come surging in with pecu-liar vividness. They seem to himentirely different from anythinghe had ever thought or dreamedbefore. He assumes therefore thatthey come from a superhumanforce. He thinks God is talking tohim, or perhaps the devil is on histrail. In any case he feels himselfin the realm of the mysterious andthe uncanny. All the acceptedbases of judgment and reasoningare gone. [Quoted in Landis 1964,pp. 32-53]
Many authors, in describing theirpsychotic experiences, have strug-
gled to convey how delusional ideascome to mind in a way that seemsradically different from their usualthinking:
At the onset of panic, I was sud-denly confronted with an over-whelming conviction that I haddiscovered the secrets of the uni-verse, which were being rapidlymade plain with incredible lu-cidity. The truths discoveredseemed to be known immediatelyand directly, with absolute cer-tainty. I had no sense of doubt orthe awareness of the possibility ofdoubt. In spite of former atheismand strong antireligious senti-ments, I was suddenly convincedthat it was possible to prove ra-tionally the existence of God.[Anonymous 1955, p. 679]
What makes this sudden, delu-sional inspiration so convincing?One way of accounting for the phe-nomenon is to assume that a processoccurs during introspection that re-sembles the disordered way inwhich the schizophrenic person per-ceives the external world. The in-ability to attend in a discriminatingmanner may allow attention to focusand to dwell upon ideas in the sameway in which patients find their at-tention captured by objects. In asimilar way to which certain objectsbecome abnormally significant whenfixated by attention, certain of theperson's own thoughts may be im-bued with a significance that is outof proportion to their real impor-tance, simply because they happento capture the attentional focus.
This undue significance of athought may be seen when personsunder the influence of marijuana,LSD, or nitrous oxide try to commu-nicate their intense sense of insight:to a sober person, their revelationsoften seem incomprehensible or vac-uous. Oliver Wendell Holmes, oneof the first proponents of ether,gives an example of such an over-
valued idea induced by inhaling thedrug:
The veil of eternity was lifted. Theone great truth which underlies allhuman experience, and is the keyto all the mysteries that philoso-phy has sought in vain to solve,flashed upon me in a sudden rev-elation. Henceforth all was dear: afew words had lifted my intel-ligence to the level of the knowl-edge of the cherubim ... stag-gering to my desk, I wrote, inul-shaped, straggling characters,the all-embracing truth still glim-mering in my consciousness. Thewords were these (children maysmile; the wise will ponder): "Astrong smell of turpentine prevailsthroughout." [Holmes 1872,pp. 46-47]
Given the cognitive limitationsand liabilities of the schizophrenicpatient, there may be a scarcity ofideas that are suitable candidates forawareness. The likelihood of an in-appropriate idea capturing attentionand gaining prominence in this wayis increased if the person cannotgain access to the usual associationsin long-term memory that wouldput what they perceive into a com-mon-sense context. In addition, theproportion of unsuitable candidatesfor consideration may be increasedby the crude appraisals of the stim-ulus contributed by preattentiveanalyzers whose function is toprovide early warning of threat—whose job it is to be "paranoid."These are the thoughts that may befurther enhanced with a "glow" ofsignificance if they then capture thefocus of attention.
To summarize, a degree of inten-tional focus to perception—percep-tion sensitized by what the person isinterested in—means that the per-son imposes significance by con-centrating on what he wants tonotice. At a later stage of cognition,a normal attentional capacity en-
ables the person to give meaning towhat he perceives by guiding accessto the appropriate associations inmemory and by maintaining thetheme so that he can think aboutwhat he has seen. When the capac-ity to direct attention is impaired,dysfunction in the first componentmay make incidental features un-usually noticeable without therebeing any good reason for such sig-nificance. When this happens, theperson may confuse physical sali-ence of the object with perceptualemphasis of a set, so that signifi-cance seems to be a property of theobject itself, rather than a gratuitouseffect produced by the person's per-ceptual processes. In addition, if theperson is not able to gain access tocognitive resources to place what isseen in a more elaborated personalcontext, the percept is colored byearly, impressionistic components ofthe perceptual process—by preju-dice, bias, and ambient emotion.Delusional conviction may comeabout by an idea's assuming unduesignificance because the patient's at-tention has become stuck upon it. Ifnegative symptoms predominate asthe illness progresses, and the inten-sity of first impressions fades in ageneral waning of emotion, the ob-ject the person is looking at may beempty of meaning altogether, andthe schizophrenic person may lookout upon a world that is both signifi-cant and meaningless.
Passive Thought. For Bleuler(1911/1950), the loosening of associa-tions between the patient's ideaswas the primary symptom of schizo-phrenia from which the secondarysymptoms such as delusions andhallucinations followed. It is asymptom that is found early inschizophrenia and tends to persistthroughout the course of the illness(Pfohl and Winokur 1982), and it ap-
pears to be largely independent ofpositive and negative symptomatol-ogy (Bilder et al. 1985; Gibbons at al.1985).
The loosening of associations inthe patient's speech shows the diffi-culty he has in tracking a theme.When asked about it, patients de-scribe an unwieldy profusion ofthoughts: wrong words come out bythemselves, associations are too dis-parate to be assimilated, andthoughts become jumbled at the mo-ment of articulation. Thinking be-comes caught in a circle, or isenmeshed in subsidiary considera-tions that are beside the point, orstops. Personal, idiosyncratic topicsintermingle with the patient's dis-course and cause it to veer awayfrom the original topic (Harrow etal. 1983). Often the person starts asentence or a thought, but thinkingcurves off in a direction determinedby something else instead of accord-ing to his own purpose. He may notnotice that he has lost his goal, ex-cept to feel a vague futility at theend.
There is, as Shakow (1962) termsit, a loss of set. Holzman (1978) sug-gests that this difficulty in "cogni-tive centering" comes from a failureto inhibit irrelevant responses andresults in an inability to sustain cog-nitive control. In a similar vein,Hemsley (1975) discusses a disrup-tion in the schizophrenic patient'scentral "command signal" which se-lects the focus of attention.
Instead of tracking thematically,or being guided along a chain of as-sociations, the patient's thoughtproceeds independently. Mental ac-tivity becomes haphazard asthoughts take on a life of their own,replacing the person's intention.Ideas are not so much thought bythe patient as they instead appear tomove along a trajectory. JesseWatkins described to R.D. Laing the
feeling of words not only catchinghis attention, but of going a step fur-ther and driving his thoughts:
.. .they gave me newspapers andthings to read, but I couldn't readthem because everything that Iread had a large number of asso-ciations with it It seemed tostart off everything I read . . . andeverything that sort of caught myattention seemed to start off,bang-bang-bang, like that with anenormous number of associationsmoving off into things so that itbecame so difficult for me to dealwith that I couldn't read. [Laing1967, p. 124]
Like the capture of attention bydetails in his environment, the pa-tient loses control of the attention bywhich he directs his thoughts. Heloses track of what he was thinkingabout, and so his thinking is in-conclusive. There is a shift in thelocus of control as sensations orqualities intrinsic to the ideas them-selves determine mental activity. Asthoughts move autonomously of theperson thinking them, he becomesincreasingly passive in relation tothe activity of his own mind. Whenhe cannot chose what he wants tothink about, and when his thoughtsare determined more by his sur-roundings than by his "self,"thoughts are things that happen tohim.
Lack of Meaning. People withschizophrenia describe both anemptying of perception, and percep-tion as overflowing with signifi-cance. In both cases there is a loss ofthe person's own meaning. In amanner similar to the way in whichparticular aspects of sensation suchas colors seem to "glow" or appear"flat," sensation as a whole maytake on an enhanced or an emptymode. The differences parallel thedistinction between positive and
negative symptoms. In the case ofpatients with positive symptoms,the instability of attention permitsinappropriate associations to takethe place of a deliberate stream ofconsciousness, and attention iscalled to objects that have no realsignificance. In the case of patientswith negative symptoms, nothingmuch fills the vacuum left by delib-erate thought, and no alternative at-tracts attention in the absence of anintended focus. In the negativemode, perception renders the worlddull, and there is a flattening of per-spective and "something missing"that the patient may be at a loss toconvey further.
O'Brien (1958) described the diffi-culty in giving meaning to a stateshe perceived as being like a drybeach with waves of fresh thoughtall too seldomly washing upon it:
I passed a newsstand and saw anewspaper headline which an-nounced that a star had fallenfrom a window. The dry beachcontemplated the headline withmild surprise. How could a bigthing like a star get into a win-dow? A wave cascaded gently onthe shore and I realized suddenlythat the star was probably a Hol-lywood star. Death of a Salesman,said a movie marquee. The drybeach blinked at me marquee andspeculated vaguely that a sales-man might be a native of somecountry named Sales, probably inAsia. Then a wave brolce and I re-membered that I had read theplay and I was aware sharply ofthe name of the country in whichthe salesman was a native.[O'Brien 1958, p. 100]
This is the subjective experienceof concrete thinking. The persondoes not enter his subconscious forintuitions that would fill out the per-cept and link it to himself. It doesnot easily relate to his past by theassociations it evokes in memory, orto his future by its relevance to his
intentions. A shift has occurred: lessand less, the subject forms his ownimpressions, and more and more heis impinged upon by his environ-ment. In part this shift occurs be-cause there are fewer intuitionsabout the situation that prompt hisattention, and in part because heseems unable to shift his attention totap and amplify the inklings of emo-tional reaction that might be evoked.
Other People. If the person withschizophrenia does not experiencehimself as emotionally coherent andvital, then he may not be able toimagine others in that way. The flat-ness and lack of meaning apply alsoto the perception of people, makingit difficult to feel their humanity orto view them as sources of emo-tional warmth.
Renee, Sechehaye's patient, de-scribes perception that has beenstripped of meaning. The links andconnotations that would enliven theschoolroom scene are missing, andso the situation is stark and lacks ahuman touch:
During class, in the quiet of thework period, I heard the streetnoises—a trolley passing, peopletalking, a horse neighing, a hornsounding, each detached, immov-able, separated from its source,without meaning. Around me, theother children, heads bent overtheir work, were robots or pup-pets, moved by an invisible mech-anism. On the platform, theteacher, too, talking, gesticulat-ing, rising to write on the black-board, was a grotesquejack-in-the-box. [Sechehaye 1970, p. 24]
People's eyes are particularlypiercing. Since they are a natural fo-cal point that people fixate uponwhen they talk to one another, an-other person's gaze is a commonstarting point for the capture of at-tention and the misperception that
follows upon this. Other people arebewilderingly complex to the para-noid patient: their casual glances inhis direction arouse his suspicion,and when he scrutinizes them forfurther dues, his attention is cap-tured in a paranoid stare that exag-gerates their spurious significanceand the threat they pose to him:
A custodian's eyes attracted myattention; they were especiallylarge and piercing. He lookedvery powerful. He seemed to be"in on it,"maybe he wasgivingmedicine in some way. Then I De-gan to have the feeling that otherpeople were watching me.[Bowers 1974, p. 186]
Because of the power of otherpeople to hold the schizophrenic pa-tienf s attention, it is easy for him tobecome entangled with them. If hecannot shift his attention away fromwhat the person is saying to him,there may be times when the otherperson's train of discourse imposesitself on his attention, and that per-son may, in some eerie way, bemore effective in moving the pa-tienf s thoughts in an associative di-rection than he is himself.
Even when other people are notdevoid of meaning, they may pres-ent a dangerous ambiguity. The pa-tient may be disturbed by theunusual significance of what theyare saying without being clear aboutthe meaning of the words theyspeak:
I am good at disguising the diffi-culty I often have in picking upwhat people say, especially if I amdistracted by something Prob-lems with my normal 'facade"arise mainly when other peopleexpect me to become emotionallyinvolved with them. I find emo-tions tremendously complex, andI am quite acutely aware of themany over- and undertones ofthings people say and the way
they say them. [Anonymous 1981,p. 197]
In addition, if the patient cannotturn his attention away to ignorepeople who intrude upon him andcriticize, he is unusually defense-less. He may need to get relief byphysically leaving their presence, asstudies of families' expressed emo-tion have shown (Brown, Birley,and Wing 1972).
Relocation of the Source of Agency.Without the capacity to focus and toformulate what he wants to do, theschizophrenic risks receding as themotivating force in his own life. Hisactions are interrupted and some-times aimless as they appear to loseintent halfway through. Manschreckand colleagues (Manschreck, Maher,and Ader 1981; Manschreck et al.1981) found that even simple volun-tary movements such as shakinghands or clapping were disrupted inschizophrenic patients, and that thedisturbance of movement correlatedwith disturbed thinking. Malenka etal. (1982) found that impaired motorperformance in schizophrenic sub-jects could be related to a deficiencyin the way in which they repre-sented and monitored the move-ments they intended. White (1965)has suggested that in the absence ofa sense of efficacy which comesfrom performing an action guidedby directed effort, the schizophrenicpatient suffers a basic feeling of in-competence.
These studies suggest that the pa-tienf s thought disorder makes it dif-ficult for him to think through acourse of action. His inability to givehis own meaning to what he per-ceives because of spurious illusionsof significance interferes with his ca-pacity to formulate reasons for ac-tion. Perception empty of meaningremoves any motive to act. The
thoughts and actions that he per-forms do not have his stamp uponthem, because in some basic, experi-ential sense, it does feel as if he hasinitiated them. They are like guessesin that they are not fully informedby a purpose. This leads the personto feel that he does not work insome basic way:
Things just happen to me nowand Ihave no control over them. Idon't seem to have the same sayin things any more. At times Ican't even control what I want tothink about. I am starting to feelpretty numb about everything be-cause I am becoming an objectand objects don't have feelings.[McGhie and Chapman 1961,p. 109]
It becomes harder for the patientto be an agent on his own behalf.He cannot channel stirrings of emo-tion into consciousness in a way thatlocates and focuses this latent partof himself so that he connects withhimself. Consciousness is a methodof amplifying the hunches and han-kerings that arise as barely detect-able ideations. By directing attentionto them, we make them clearer andmore identifiable, and in the proc-ess, we bring parts of ourselves thatare subtle or imminent into view.Given the unwieldy nature ofschizophrenic consciousness, it ismuch more difficult for the patientto gain access to himself in this way.He cannot so easily direct his atten-tion, or put himself into the rightframe of mind so that he can noticeand discover further the vaguepangs and urges that arise withinhim. The direction that we imposeon our thoughts, as well as the wayin which they carry out our plans,makes mental life an intrinsicallypersonal life. But for the patient,mental activity is not instrumental inthis way, since it does not give ex-pression to an inner life. Objects
don't have feelings; only peoplewho connect with themselves do.
Some patients give up the strug-gle to assert themselves and insteadlose themselves further in rhythmicmannerisms that trap attention andfurther close down the mind. Theself hardly exists as an experiencedcontinuity that imposes its will onthought and action. For these pa-tients, the locus has shifted outsideof themselves—their attention iscaught by details, their thoughtsdrift waywardly with a life of theirown, their internal states cannot beformulated and so cannot be trans-lated into action, and the center nolonger lies within them. Their senseof self is lost, and they undergo ex-perience that hardly seems to betheir own.
The Temptation of Delusions. Inmany schizophrenic patients there isa gradual progression from delu-sions and hallucinations to a defectstate characterized by fading of theemotional coloring of experienceand a lack of personal significance inevents (Pfohl and Winokur 1982), al-though this trend may not be evi-dent during the first 5 years (Pogue-Geile and Harrow 1985).
The loss of self is a gradual proc-ess attended by vagueness. As inother processes in which the intel-lect is affected, the patient goesthrough an early stage in which it ispossible to deny the changes thatare taking place, and a later stage inwhich the failings themselves pre-vent awareness. In between is astage of alarm in which the personretains enough insight to be awareof what he is losing. As the "Influ-encing Machine" (Tausk 1919/1933)takes over more and more, the per-son is slowly vacated:
. . . the most sacred monumentthat is erected by the human
spirit, i.e., its ability to think anddecide and will to do, is torn apartby itself ... things . . . are done bysomething that seems mechanicaland frightening, because it is ableto do things and yet unable towant to or not to want to. [Meyerand Covi 1960, pp. 215-216]
The person feels himself slippingaway as his emotional responses topeople and activities fade. At thesame time his attention is attractedto people and events about him. Thesignificance that the patient hasfoisted upon him is spurious, but hemust react in some way. The per-ception of a heightened significancewithout any ready explanation for itresults in a "mental diplopia" (Pen-field and Rasmussen 1950, p. 225)which can be resolved, either bysuppressing the image of the worldas holding any significance—ineffect turning one's back on percep-tion—or by remaining connected tothe world by accepting the signifi-cance and risking delusion.
Some authors (e.g., McGhie andChapman 1961) have viewed the ap-athy of the patient with negativesymptoms as a way of counteringstimulation that he cannot regulateand that would otherwise flood him.To some extent, this "choice" mayrepresent an existential stance(McGlashan 1982). Clinical experi-ence, however, suggests that the ac-tive process lies not so much in theperson turning away from the worldas in turning toward delusion. Delu-sions hold an attraction of theirown, like a temptation. The follow-ing description is all the more re-markable for the fact that it waswritten by a medical student with adoctorate in psychology:
When someone told me later thatI was delusional, though, Iseemed to know it. But I wasreally groping to understand whatwas going on. There was a se-
quence with my delusions: firstpanic, then groping, then elationat having found out Therewere times when I was aware, ina sense, that I was acting on a de-lusion. One part of me seemed tosay, "Keep your mouth shut, youknow this is a delusion and it willpass." But the other side of mewanted the delusion, preferred tohave things this way. [Bowers1974, p. 187]
The delusional perspective offersintensity, involvement, and pur-pose—precious qualities to someonewho feels himself slipping away intonegative symptomatology. Delu-sions have a power and a vitalitywhich can counteract the creepingnumbness of the defect state:
Whaf s so "special"? Well, thetimes when colors appearbrighter, alluring almost, and myattention is drawn into theshadows, the lights, the intricatepatterns of textiles, the bold out-lines of objects around me. It's asif all things have more of an exist-ence than I do, that I've gonearound the corner of humanity towitness another world where myseeing, hearing, and touching areintensified, and everything is awonder. [McGrath 1984, p. 639]
Delusions make experience vivid.Suspicion brings drama and involve-ment into the paranoid person's life,and restores some fervor and pur-pose to him. In addition, delusionsmay provide a psychological splintthat stabilizes certain lines ofthought (albeit pathological ones)and gives a greater sense of intra-psychic connectedness. The du-rability of delusions when so muchof the rest of the patient's psyche isdisrupted attests to this possibility.For example, the way in which thecosmic delusions of some patientswithstand the otherwise fragment-ing effects of formal thought disor-der suggests that delusions may be
privileged, and the patient's endlessrepetition of his beliefs to anyonewho will listen may be an attempt topreserve this last remaining mentalconduit between himself and theworld. In this sense, delusions keepalive a certain kind of hope, andperhaps the desire to be crazy (VanPutten, Crumpton, and Yale 1976)and the need to recruit others(Searles 1965) become more under-standable when the alternative—theloss of self—is considered.
Conclusion
The capture of attention is a com-mon phenomenon. It appears in pa-tients with both positive andnegative symptoms, and it may beinduced in people who do not haveschizophrenia by the conditions of apsychological experiment, recrea-tional drug use, L-dopa (Sacks 1976),meditation, mystical states (James1902/1936), or an aesthetic experi-ence. Possibly some impending epi-sodes of schizophrenia are abortedat this benign stage. It need not leadto psychosis. Paranoia appears to re-quire more than a perceptual disor-der, and a further instability ofattention would seem necessary tobring about a state of schizophrenia.It is likely that the ataxia of attentionbecomes pathological when it in-volves a failure of the inward focus,and that one crosses the line fromperceptual illusion to delusion whenone is unable to frame and follow anintrospective theme.
The inability of the patient to im-pose his own focus on his thinkingresults in a breakdown of perceptionand cognition to a lower level of or-ganization. Following Bleuler(1911/1950), I have suggested thatsome of the symptoms of schizo-phrenia stem from a basic inabilityto direct and maintain a focus of at-
tention, both outward in perceptionand inward in introspection. In thisview, delusions are produced by theinterplay of four factors: the captureof attention by incidental details im-bues them with a spurious signifi-cance; the perceptions are notplaced in a context of backgroundknowledge; this results in the com-ing to awareness of hasty and alarm-ing appraisals by preattentive proc-esses; finally, the importance ofthese ideas is enhanced when theyin turn capture attention. Delusionsare not static phenomena, however,nor are they always held with all-or-nothing conviction (Sacks, Carpen-ter, and Strauss 1974; Hole, Rush,and Beck 1979; Kendler, Glazer, andMorgenstern 1983). Often the de-gree of conviction changes overtime, suggesting that changes in thecapacity to monitor experience bytapping background knowledge andthe power of preattentive processingto impose itself on thought may un-derlie changes in the patient's clini-cal state.
Differences in the balance of thesefactors may account for some of thechanges from a positive to a nega-tive symptomatology. Whereas pa-tients with positive symptoms findtoo many things of significance, pa-tients with negative symptoms suf-fer from a profound lack of meaningin their lives—too little matters tothem or interests them. Patientswith negative symptoms have diffi-culty in directing attention to findassociations and to amplify the intu-itive responses to what they per-ceive, but unlike paranoids, patientswith negative symptoms find littleto fill the vacuum. This is reflectedin differences found by Cornblatt etal. (1985): whereas positive symp-toms are associated with an abnor-mal lability of attention, making thepatient distractible because his at-tention is easily captured, negative
symptoms are associated with a def-icit beyond the perceptual stage ofcalling attention, by an inability toswitch attention between differentperceptual foci and memory. It isthis failure of the inward focus, I amsuggesting, that makes the world ofthe patient with negative symptomsappear "flat," meaningless, and bor-ing.
Instead of the autonomouselaboration of fragments from long-term memory under the influence ofpreattentive processing in paranoidpatients, there are no plots or hid-den signs that occupy the attentionof patients with negative symptoms.Their attention may be captured, butwhen this happens, patients withnegative symptoms seem to experi-ence little in the way of an abnormalsense of significance:
Everything seems to grip my at-tention although I am not par-ticularly interested in anythingOften the silliest little things thatare going on seem to interest me.Thar s not even true; they don'tinterest me but I find myself at-tending to them and wasting a lotof time this way. [McGhie andChapman, 1961, pp. 104-105]
It is not clear why, in the absenceof an intentional focus to thought, asubstitute topic does not engage at-tention as it does in paranoid pa-tients. Perhaps there is a generallowering of intensity of the spon-taneous processes in mental life,such as intuition and affect, so thatthere is little activation of associa-tions in long-term memory or insuf-ficient priming of preattentiveprocesses to give them "call" uponattention. These nonspecific effectsare similar to those seen in mentalretardation or as sequelae of closedhead injury, and they are consistentwith the numerous studies showingevidence of diffuse"neurological dys-
function in patients with negativesymptoms (e.g., Owens andJohnstone 1980). It remains unclearwhich comes first: whether a lack ofemotion leaves attention aimlessand without propulsion in one di-rection or another, or whether theemotional life atrophies if it is notamplified and fostered by attentionbeing directed upon it.
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The Author
Roderick Anscombe, M.D., is Medi-cal Director of the North ShoreCommunity Mental Health Centerin Salem, Massachusetts, AssistantPsychiatrist at the Beth Israel Hospi-tal in Boston, and Instructor in Psy-chiatry at Harvard Medical School.
