Fenomenología de la intersubjetividad en la enfermedad bipolar y en la esquizofrenia

• Autores: Otto Dörr Zegers
• Localización: Salud mental, ISSN 0185-3325, Vol. 34, Nº. 6, 2011, págs. 507-515
• Idioma: español
• Títulos paralelos:
  • Phenomenology of intersubjectivity and its importance for the understanding of schizophrenia and mood disorders
• Enlaces
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• Dialnet Métricas: 1 Cita
• Resumen
  • español

    I. Introducción y observaciones clínicas Uno de los rasgos centrales de la esquizofrenia es la alteración a nivel de la relación interpersonal. El autismo de Bleuler y la dificultad de contacto de Minkowski son dos ejemplos de la trascendencia de esta perturbación. Pero también otros síntomas de la esquizofrenia pueden ser vistos desde la misma perspectiva. Así, en el síndrome paranoídeo el otro se torna tan poderoso que puede perseguir, asediar e invadir la intimidad del paciente. También las alucinaciones auditivas pueden ser concebidas como una peculiar perturbación de la relación con un otro anónimo.

    Walter von Baeyer definió las características de este encuentro interpersonal deformado de los esquizofrénicos, el que se caracterizaría por la falta de reciprocidad, la anonimización y la mediatización. En el delirio de amor, por ejemplo, el paciente no puede defenderse de las voces amorosas o de las alucinaciones cenestésicas vinculadas a la esfera sexual. Por otra parte ese tú invasor, que en un comienzo tiene un nombre, va perdiendo su individualidad para hacerse colectivo. Por último, ese contacto con el otro alucinado se mediatiza, a través de aparatos como radios o televisores.

    En la depresión también observamos una profunda alteración de la esfera interpersonal. Se podrían distinguir dos formas de depresión: las delirantes y las no delirantes. En la primera la sintomatología está comandada por el delirio (de culpa, ruina o enfermedad) y en las segundas por los síntomas corporales, la experiencia del «no poder» y la alteración de los ritmos biológicos. Y sin embargo y desde la perspectiva del encuentro, ambas tienen en común el progresivo desinterés en el otro y su reemplazo por el tema predominante: el cuerpo en un caso, el delirio en el otro.

    En la manía lo más llamativo es la euforia, la hiperactividad, el pensamiento ideofugal y el insomnio, sin embargo, aquí también hay una profunda alteración de la interpersonalidad, p. ej., una pérdida de la distancia social hasta el extremo de la irrespetuosidad.

    II. «Apresentación», temporalidad inmanente e intencionalidad en la constitución de la intersubjetividad según Husserl En este capítulo se intenta explicar la teoría de la apresentación de Husserl y su rol en la constitución de la intersubjetividad.

    III. Intersubjetividad y psicosis maníaca Remitámonos al ejemplo de Binswanger de la paciente maníaca que ingresa a una iglesia donde se desarrolla un servicio religioso e interrumpe al organista para que le dé clases. El organista está presente para sí como el fluir de contenidos de conciencia, las sensaciones provenientes de su cuerpo, entre otras las de sus dedos tocando el órgano. Estas presentaciones están acompañadas de la «apresentación» de que él es un organista que ha sido contratado para tocar en el servicio religioso y esa misma «apresentación» la comparte con la comunidad que asiste a la iglesia. La paciente, en cambio, no comparte esta «apresentación»; ella no es capaz de «apresentar» que se trata de un concierto en el marco de un servicio religioso.

    IV. Intersubjetividad y psicosis depresiva El fluir de mi vida interna es, por cierto, inseparable de la temporalidad originaria, con respecto a la cual el tiempo objetivo es sólo un derivado. Y esa temporalidad se da como el permanente entrelazamiento de tres instancias que Husserl llama retentio (pasado), protentio (futuro) y presentatio (presente). En la depresión psicótica o delirante la alteración de la interpersonalidad no se encuentra en el fracaso de la «apresentación», como en la manía, sino en la alteración de la temporalidad y su rol en la constitución de la intersubjetividad. El auto-reproche significa una invasión del pasado (la retentio) por el futuro (la protentio), mientras en las ideas deliroides (una posibilidad, que yo me arruine, p. ej., es vivida como ya ocurrida) sucede a la inversa: el pasado invade al futuro.

    V. Intersubjetividad y esquizofrenia El concepto más fundamental de la fenomenología es el de intencionalidad, que apunta al hecho que todo fenómeno psíquico se caracteriza por estar referido a otra cosa que sí mismo. A través de la intencionalidad y por medio de los procesos de percepción/apercepción o de presentación/apresentación, el Yo constituye el objeto en su totalidad y con ello, el mundo común o koinos kosmos. En la esquizofrenia, en cambio, habría un debilitamiento de la intencionalidad, con las siguientes consecuencias:

    1. De los objetos surgen múltiples significados.

    2. El debilitamiento del arco intencional lleva a la laxitud de las asociaciones.

    3. Se produce una «inversión de la intencionalidad» y el otro se transforma en perseguidor, porque la intencionalidad del paciente está debilitada y no es capaz de contrarrestar la intencionalidad del otro.

    4. Este debilitamiento explica también la improductividad de la vida de estos pacientes, porque la intencionalidad ha fallado en la constitución del otro y del mundo.

  • English

    I. Introduction and clinical observations One of the central features of the group of diseases we call schizophrenia is the alteration at the level of interpersonal relationships. Autism, considered by Bleuler (1911) as one of the primary symptoms of the disease, and contact difficulty, described by Minkowski (1927), are two examples of how far this disturbance reaches. But other symptoms of schizophrenia can also be seen from the same perspective. Thus, in the paranoid syndrome the other becomes so powerful that he can persecute, harass and invade the patient's intimacy. Auditory hallucinations can also be conceived of as a peculiar disturbance of the relationship with an anonymous other. As we showed in a previous work, something similar occurs in instances of coenesthetic schizophrenia. Thus, one patient, suffering from this form of the disease, said in his diary, "My failure is to love very much myself. I have not found yet the way toward the you". And later on he writes: "The world arrives directly to me, there is no distance between the world and me. And that is valid both for persons and for things... It can even happen that in the worst states I consider myself for moments like the other, whom I am looking at".

    Walter von Baeyer (1955) defined the characteristics of this deformed interpersonal encounter of schizophrenics, although based on paranoid patients: lack of reciprocity, anonymization and mediatization. In the delusion of being loved, for example, the patient cannot defend himself from loving voices or from coenesthesic hallucinations related to the sexual sphere. On the other hand, that invading you, who in the beginning has a name, gradually loses his individuality and becomes collective. Finally, contact with the hallucinated other is mediated through devices such as radios or television sets.

    In the case of depression, even though the complaints of the patients predominantly refer to the feeling of oneself and to bodily changes, we also observe a deep alteration of the interpersonal sphere. Two different forms of depression can be distinguished: delusional and not delusional. In the first form, the symptomatology is commanded by delusion (of guilt, ruin or disease) and in the second, by corporal symptoms, the experience of "not being able to" and the alteration of biological rhythms. And additionally, from the perspective of the encounter, both forms of depression have something in common: the progressive disinterestedness in the other and its replacement by the prevailing subject: the body in one case, delusion in the other.

    In mania, what first draws attention is euphoria, hyperactivity, flight of ideas and insomnia; however, a deep alteration of interpersonality is also apparent. Thus, it is common to observe that these patients treat the other with excessive confidence and a loss of social distance up to the extreme of disrespectfulness.

    II. "Apresentation", immanent temporality and intentionality in the constitution of Intersubjectivity according to Husserl How precisely are these three elements of intersubjectivity –apresentation, temporality and intentionality– altered in manic, depressive and schizophrenic psychoses? Each section in the report that follows will begin with an introduction explaining Husserl's understanding of these concepts. As the theory of "apresentation" is more complex and less known, a more detailed exposition of this concept will be offered.

    III. Intersubjectivity and manic psychosis Let us recall Binswanger's example of a manic patient who has abandoned the clinic, goes into a church where a religious service is being held, and interrupts the organist's playing to ask him for lessons. For the layman, the attitude of the patient appears to be inappropriate and incomprehensible. A psychiatrist may speak here of facilitation and of loss of natural inhibitions. But neither of these two interpretations accounts for what is really occurring. Somatic medicine has a theory of the organism as a framework within which it can “measure” deviations with respect to the norm; psychiatry is not able to do this because its basic science is not sufficiently developed. In our opinion, that place must be occupied, following Binswanger, by phenomenology of intentional consciousness.

    The organist is present for himself as the flowing of conscious contents; the sensations coming from his body; and among others the ones of his fingers playing the organ. These presentations are accompanied by the "apresentation" that he is an organist who has been hired to play in the religious service and he shares that same "apresentation" with the community assisting the church. The patient, on the contrary, does not share this "apresentation". For her the organist is certainly present, playing, but she is not capable of "apresenting" that it is a concert in the framework of a religious service. From Husserl's theory, explained above, it is inferred that if one fails in the constitution of the alter Ego, the constitution of oneself –of one's own Ego– also fails. Binswanger's patient is unable to "apresentitatively" understand the sense of the organist (in his context), because she can not experience herself "apresentatively" as an Ego.

    IV. Intersubjectivity and depressive psychosis The flowing of my internal life is, certainly, inseparable from originary or primordial temporality, with respect to which objective time or the time of the clock is only a derivate. And that originary temporality is given as the permanent interspersing of three instances, called by Husserl retentio (past), protentio (future) and presentatio (present). To understand the important role played by these temporal instances both in the constitution of one's own I (Ego) and of the other (alter Ego) we need only to think that every person who is talking at a given moment (presentation) could not say what he is saying without knowing exactly what he already said, that is, without retaining the past (retentio) and what he is going to say, in other words, without anticipating the future (protentio). And this is not only valid in the case of a speech or a lecture, but in any conversation, however simple it may be.

    Now, in psychotic or delusional depression the alteration of interpersonality is not found in the failure of the "apresentation", as in mania, because we know how attached to the norms and respectful personalities prone to depression are (Tellenbach, 1961, 1983; Krauss 1977; von Zerssen, 1982), so they would never ignore the sense of the situational context in the relationship with another. Hence, what fails in the relationship of the depressive with the other? First, it is the very confinement in the body and it's inaccessibility. But there are two other very characteristic phenomena which also could be interpreted from the perspective of intersubjectivity: self–reproaches and depressive delusional ideas. When a depressive patient reproaches himself, for example, "if I had not sold the house, then I would have not be ruined.", what he is doing is putting in the past, immovable by definition, some empty possibilities. In other words, the retentio (the past) is invaded by the protentio (the future), with which one does not arrive at any actualization in the presentatio (the present). And in depressive delusions, situations that could be possible in the future, for example, becoming guilty of something, financially ruined, or seriously ill, are lived as if they had already happened, that is, as past: protentio or anticipation is invaded by retentio (Binswanger, 1960).