Some Aspects of the Schizophrenic Formal Disturbance of Thought

by Erwin Levy

[first published in: Psychiatry, 6 (1943), pp 55-69;
German translation 1997 by Gerhard Stemberger in Gestalt Theory, 19 (1), S. 27-50:
"Einige Aspekte der schizophrenen formalen Denkstörung"]

(2nd part)

"When will you buy your new tires?"

"Sorry, I am unessential."

A few months prior to this writing this would have sounded completely incoherent and senseless. However, experienced as determined by the present situation of the tire rationing system the answer fits the question perfectly: "I cannot buy any tires because my driving has been declared unessential."

In the case of the patient, the doctor's question had not been asked at random but had occurred within, and had been determined by, a clearly structured field situation. The doctor had asked the patient why he shivered, a question which clearly fitted in with his role. He himself had suggested an answer which would have fitted in with the concrete situation since the window happened to be open. However, the patient's answer not only did not fit the question, it also fitted nowhere into the field situation. It was flung into it like a foreign body, seemingly arbitrarily, piecemeal, without any functional determination by anything in the field as the doctor experienced it.

The solution of the enigma came some weeks later. It was learned that the patient had written a good deal of poetry which dealt with problems of paramount importance to him. In a discussion of these it developed that for many years he had been a lonely timid sad fellow without any way of articulating his inner trends, but with an intense desire to do so. He had wanted a full rich happy life, but had actually had just the opposite. All his needs and hopes had remained hidden, no one knew of them. This difficulty became so disturbing that he had gone to the library to look at the psychological literature, and there he found a formulation for his problem: he was an introvert and should be an extrovert. Here then was the psychological situation which had determined his 'answer.'

To the doctor this situation was entirely new and unexpected. For the patient it had existed for several years and had become increasingly urgent. He had become more and more preoccupied with it, and finally, in the illness, devoted all his time to its solution. Everything, every moment in his life was centered around it.

For the sake of clarity the 'real' hospital situation is called S1, and the patient's psychological situation S2. In relation to S2, S1 was external and peripheral. For the patient, the demands made of him by S1, the 'reality,' were just annoying, essentially constituting a disturbing intrusion into S2. At the beginning of the physical examination he had responded to the S1 requirements and had let himself be annoyed. But when the disturbance became too strong the S2 forces dealt with it abruptly and sharply, and the patient resumed his preoccupation with his problern. His sarcastic grin indicated that he knew quite well that the doctor could not know anything of this problem and of the second situation, and would be unable to understand the 'answer.'

There are two possible ways of understanding this answer. One could assume that the patient wanted to improve the doctor's question in the direction of what should be most essential in the doctor-patient situation: "Don't ask me why I shiver. lt does not matter. Tell me rather whether an introvert can ever be an extrovert. This is my central problem." The other possibility is that he wanted to reduce all S1 interference to a minimum so that he would not be disturbed in his preoccupation with S2.

The doctor's question may be called q. The doctor asks it as a fitting part of, and functionally determined by S1. [6] The patient experiences it essentially in its functional relation to his S2, where it has the totally different psychological quality of a disturbance. [7] One sees that psychologically the two are unequal. lt is therefore not permissible simply to assume the validity of q = q. The piecemeal identity of the isolated question is not what matters functionally. It has to be seen in its field dynamics. It is also clear that the fitting answer to the question in its S1 meaning is by no means necessarily identical with a fitting answer to it in its S2 meaning. Within the framework of S2 the patient's answer and behavior are understandable; not so within S1. The innocent doctor, not knowing at this time of the existence of S2 naturally experienced the answer within S1, and was baffled. To him it appeared 'irrelevant.'

This type of case must be clearly differentiated from another type, illustrated by the following example. A mother asks her child, "Did you brush your teeth?" The child answers, "I want to go to the movies." The question arises out of the mother's situation with regard to the care of the child. The answer arises out of the child's preoccupation with the Saturday afternoon serial picture. But in this case both S1 and S2 are parts of a common situation in which both live. Question and answer are mutually understandable at once, although they do not fit each other directly. In the case of the patient S1 and S2 were not part of any encompassing common situation.

The following paragraph deals with apparently good and simple cases which may, however, be shown to be cases of schizophrenic thinking if analyzed carefully.

"How are you?"

"Fine. I want to go home."

This answer was given regularly by another patient on morning rounds. It deals with the same topic as the question, the patient's health. It continues the question's direction. It seems a good answer. There are three possible ways of understanding it. It could be sound, simple, sincere. The patient might not have realized that he was ill, and, subjectively might have felt well enough. Or, it could be a normal lie. Knowing that he was not well he might have wanted to leave, just as a patient with a physical disorder might want to leave a hospital prematurely.

In this particular case a third possibility seemed to exist. The patient was a young, acutely ill, paranoid schizophrenic, He stated that prior to his hospitalization he had been unjustly fired from his job, that he had been singled out and persecuted by his foreman. [8] Subsequently he felt that people watched him in the street and followed him. It fitted perfectly into his paranoid picture of the world that in the hospital he found himself in a place with locked doors, confined, deprived of his freedom, unable to make decisions. This was his S2. The thing to do was, of course, to get out. He knew that the people in charge of the place claimed that it was a hospital, and that he was a mentally ill man who needed doctors. He had been told that he could not be discharged as long as he was sick. He was far from certain that all this was true; it could be pretense on their part. They probably fooled him for some hidden reason. However, theirs was the power, and he had to play their game. In order to get out he had to convince them that he was well. This seemed to be the reason for the answer. One sees that the answer is only apparently simple. lt is simple only as long as one looks at it without realization of its meaning in S2. The simplicity is deceptive. The question is not simply q but fq(S1), the answer not simply a, but fa(S2). [9] The two are logically and psychologically not an innocent good whole, but conceal a cunning bit of trickery. Such instances are usually overlooked in the textbook chapters and investigations dealing with the formal disturbance of thought because the usual approaches do not take into account the fact that they are field determined.

Echolalia and echopraxia, two other very puzzling forms of psychotic speech and behavior, may sometimes be similarly understood. A patient who was a very nice and friendly young furrier suffering from an acute paranoid episode, was convinced that he was being persecuted by his union. He was hallucinated, and very busy listening to the names which his enemies called him. He was constantly preoccupied with his psychotic experiences, and repeated attempts to talk to him were very difficult because of his marked echolalia. On one occasion when his physician had taken him into his office and with a friendly smile asked, "How do you do?" the patient with an equally friendly grin had vigorously nodded his head and eagerly answered, "How do you do?" The doctor now said, "Good morning." The patient repeated, "Good morning." The doctor put his finger to his nose. The patient, nodding and smiling did the same. And this went on. It was, however, noticeable that when the doctor asked no questions and let him alone the patient watched him out of the corner of his eye, and yet at the same time seemed again intensely preoccupied with his psychotic experiences. This observation gave the clue to a possible understanding of what was going on.

The doctor was really forcing the patient into a very complicated situation. On the one hand the patient had to attend to the dangerous events in S2 which demanded constant concentration and alertness. On the other hand there was the friendly doctor trying to get the patient into a nice social situation within S1. [10] Now to the patient, and with regard to his S2, the hospital situation was something peripheral, implying a neutral routine which, most of the time, he could follow more or less passively and automatically. But when it demanded more of his attention it constituted an interference in his concentrated functioning within S2. This was also true of the doctor's attempt to draw him into a conversation. But since he was peripherally aware that the doctor was a well-meaning fellow, and since he himself was exceedingly friendly and good-natured, it did not occur to him just to give the doctor the cold shoulder.

This was a dilemma. He had to satisfy the requirements of both S1 and S2 although the two situations seemed to be mutually exclusive. Under the pressure of these two conflicting situational needs he hit upon a way out. While he could not rid himself of the urging S2 forces to meet adequately the S1 requirements, he could at least enter into a peripheral halfautomatic social relationship with the doctor by repeating whatever the latter did and said, while still being able to be preoccupied with S2. While this was not very adequate and certainly strange it served to indicate his good will towards the doctor. In this case, echolalia and echopraxia were in all probability determined as the resultant of the clashing requirements of two heterogeneous simultaneous situations.

Echolalia was recently observed in a case of presenile dementia with moderate brain atrophy as shown by air studies. As far as could be observed, the dynamics here were somewhat different. In this case there was no S2. The difficulty was created by the organic handicap. This patient also felt the need to respond to the questioning physician, and to establish some sort of relationship; apparently he very much wanted to do so. But he was too dull, too slow, too much handicapped to grasp and respond quickly and adequately. In this case prolonged handshaking and repetition of the questions or greetings were the best possible way, a stop-gap. At least he did not have to stand mute while he felt the need to respond somehow. Echolalia saved the social situation.

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[6] q = fq(S1) (read q = function q of S1). [-> back to text]

[7] q = fq(S2). It follows that fq(S1) # fq(S2). [-> back to text]

[8] Actually he had been dismissed because of a general slow-down of business.
[-> back to text]

[9] Read a = function a of S2. [-> back to text]

[10] The patient's delusions had not spread to the hospital environment. [-> back to text]

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