Hector Warnes' Comments

Carlos R. Hojaij: Schizophrenia, the Psychiatric Sacred Illness


            I am most impressed by Dr. Hojaij’s excellent overview of the psychopathology, phenomenology and intriguing aspects of "the sacred" disease which, unlike other medical illnesses, has a world-wide distribution, albeit varying in prevalence and manifestations due to pathoplastic factors.

            Henry Ey (1950) in his Études psychiatriques has a chapter on Coenesthopathies (proprioceptive and enteroceptive abnormal sensations).  

            On page 4, Hojaij uses the phrase "somatic experiences of passiveness" in reference to Schneider’s first-rank symptoms, in spite of the fact that these experiences, e.g., the experience that one is invaded, controlled or influenced by outside or inside forces, are usually referred to as "ideas of passivity."  Influential publications on this subject are Gaëtan de Clérambault’s (1920) monograph, Automatisme mental et scission du moi and Tausk’s (1933) paper, "On the origin of the ‘influencing machine' in schizophrenia" (Tausk and Feigenbaum1992).

            On page 4, when quoting Eugen Bleuler's (1911) definition of schizophrenia stating: "We designate 'dementia praecox' or 'schizophrenia' a group of psychosis determined by an evolution sometimes chronic, sometimes defined by intermittent attacks, that can be interrupted or recede at any time, but that do not permit a complete restitutio ad integrum...," it would be helpful to clarify that the term restitutio ad integrum probably refers to Tim Crow´s type I schizophrenia (cited by the author) or to G. Langfeldt’s “acute schizophrenia” (“schizophreniform reaction”), since these clinical presentations often recover without residual symptoms unlike Crow’s type II schjzophrenia.  

            On page 4 also, on the basis of Bleuler’s criteria, Dr. Hojaij distinguishes the symptomatology of schizophrenic in-patients from that of outpatients and notes that "in most of the inpatients ...hallucinations, delusional ideas, confusion, stupor, mania, melancholic fluctuations and catatonic symptoms" (accessory symptoms) are present.  He also refers to delusional depression and/or melancholia atónita and emphasizes the presence of a major affective component in some schizophrenic patients. He points out that in long term follow up studies in some of these cases the diagnosis must be changed to Bipolar Disorder or to Periodic Catatonia.

            On Page 5 Hojaij wrote that Binswanger (1972) considered “eccentricity” an important clue “for the apprehension of schizophrenia." In my opinion, the term “eccentricity,” which means de-centered (outside the center of Self), is too vague.  A better word would be ”bizarre.”  Ludwig Binswanger (1956) has written a classic on this topic cited by Dr. Hojaij.

            On page 6, Hojaij writes: "The transposition capability of [patients] is damaged [in schizophrenia]; in other words, the patient is not able to put himself in the place of another person and then feel, think, live as if he was the other; the capacity for loving is lost." "The loss of capacity of loving" is not limited to schizophrenia and has so many ramifications that it would be better  to use another phrase like the author does when he refers to "blunting of affect" (apathy) part of the "four A’s (autism, ambivalence, association and affect disturbances) described by Eugen Bleuler (1950) as the “fundamental symptoms” of schizophrenia. Since “transposition capability” could mean the ability ‘transitivism’ or the ability to have empathy (Einfühlung) or to relate to another human being (Mitgefühl).  Schizophrenic (and also autistic) patients are frequently lacking “empathy”. 

            I am not sure that Hojaij’s translation of the term “hebephrenia”, also on Page 6, is correct.  Hebe is a Greek word meaning "rather puberus" (as well as the name of the goddess of youth and spring). The word "silly" could be used, but is not technical and is rather offensive, the German words “dumm” or “blöd” might be better.

            On page 9, Dr. Hojaij cites the Bonn Schedule for the Assessment of Basic Symptoms and laments that it has not been widely accepted elsewhere. It would be an asset if the scale is included at the end of the paper.

            On Page 11, Hojaij presents Klaus Conrad’s classification of the “beginning of the schizophrenia process,” listed below  with some corrections:

1. Trema - delusional mood (Wahnstimmung).

2. Apophany -Aha Erlebnis -  Delusion of revelation

3. Anastrophe - delusions of passivity and of reference

4. Apocalyptic delusions (Weltuntergang)

5. Residual defect


            Hojaij’s´translation of Geisteskrankheit (Page 14) as a disease of the spirit is literally correct, but in most translations Geisteskrankheit  refers to Mental Disorders.

            I wonder why Dr. Hojaij did not tackle the issue of premorbid personality in schizophrenia?

            Finally, I would like to cite three outstanding studies on the long term follow up of schizophrenia which have shed light on the outcome of this mysterious illness: Manfred Bleuler’s, (1978); Zubin, Magaziner and Steinhauer’s (1983) and Hogarty et. al.’s (1994).

            Karl Jaspers (1997) emphasized the difference between the psychodynamic and the deterministic approach in schizophrenia research influenced by Wilhelm Dilthey’s distinction  between Understanding (meaningful connections) and Explaining (Erklären or causal connections). Jaspers writes: “We sink ourselves into the understanding the psychic situation and understanding psychopathology genetically (in the sense of historically) by empathy how one psychic event emerges (or connects) with another. When we find by repeated experiences that a number of phenomena are regularly linked together,  on this basis we explain it causally” (determinism).

            I enjoyed very much the emphasis that Dr. Hojaij places on psychopathology, a discipline that was in the center of interest in European psychiatry in the mid-20th century.



Binswanger L. Drei Formen Missglückten Daseins: Verstiegenheit, Verschrobenheit Manirierheit. 1st edition. Tübingen : Max Niemeyer; 1956.

Binswanger L. Tres formas de existencia frustrada. (Translated from the German to Spanish by E. Albizu).  Buenos Aires: Amorrortu; 1972.


Bleuler E: Dementia Praecox and the Group of Schizophrenias. (Translated from German to the English by J. Zinkin). New York:  International Universities Press; 1950.

Bleuler, M. The Schizophrenic disorder: Long-term Patient and Family studies (Translated from German to English by S. M. Clemens). New Haven: Yale University Press: 1978.

de Clerambault G.C.  L’Automatisme Mental. Paris: Téraplix; 1970.

Ey H Études Psychiatriques. Paris: Desclée de Brouwer; 1948, 1954. 

Hogarty JD, Baldesarini R, Tohen JM,  Waternaux C, Oepen G.  One hundred years of schizophrenia: a meta-analysis of the outcome literature . Am J Psychiatry 1994; 151: 1409-16.

Langfeldt G. The prognosis of schizophrenia and the factors influencing the course of the disease. Acta Psychiatrica et Neurologica   (Kjo Bemhavn) 1937; 13: 228.

Jaspers, K. General Psychopathology (Translated from German into English by J. Hoenig and MW. Hamilton), Baltimore:  John Hopkins University Press; 1997.


Tausk V.  On the origin of the influencing machine in schizophrenia. Psychoanalytic Quarterly 1933; 2: 519-56.


Tausk V, Feigenbaum D.  On the origin of the "influencing machine" in schizophrenia J Psychother Pract Res 1992; 1: 184–206.


Zubin J, Magaziner J, Steinhauer SR. The metamorphosis of schizophrenia: from chronicity to vulnerability. Psychological Medicine 1983; 13: 551-71.



October 12, 2017