European Archives of Psychiatry and Clinical Neuroscience

https://doi.org/10.1007/s00406-023-01609-7

ORIGINAL PAPER

Double bookkeeping in schizophrenia spectrum disorder:

an empirical‑phenomenological study
Helene Stephensen1,2 · Annick Urfer‑Parnas3,4 · Josef Parnas1,2,4

Received: 8 January 2023 / Accepted: 4 April 2023

© The Author(s) 2023

Abstract
Double bookkeeping is a term introduced by Eugen Bleuler to describe a fundamental feature of schizophrenia where psy-
chotic reality can exist side by side with shared reality even when these realities seem mutually exclusive. Despite increas-
ing theoretical interest in this phenomenon over the recent years, there are no empirical studies addressing this issue. We
have, therefore, conducted a phenomenologically descriptive qualitative study of 25 patients with schizophrenia in which
we addressed the following issues: (1) Experience of double reality; (2) Emergence and development of two realities; (3)
Truth quality of psychotic or private reality; (4) Insight into illness; (5) Communication of psychotic experiences. The most
important result was that most patients felt to be in contact with another dimension of reality. Hallucinatory and delusional
experience pertained to this different reality, which patients most frequently kept separated from the shared reality. This
other dimension was considered by the patients as being more profound and real. The pre-psychotic and psychotic experi-
ences were difficult to verbalize and typically described as totally different than ordinary experience. Double reality was
persistent across remissions. None of the patients considered their condition as an illness analogous to a somatic disorder.
Most patients described a vague sense of duality preceding the crystallization of double bookkeeping. This emergence of
doubleness was associated with a fundamental alienation from oneself, the world, and others stretching back to childhood or
early adolescence. We discuss the results with a special emphasis on the concept of psychosis, clinical interview, treatment,
and pathogenetic research.

Keywords Schizophrenia · Double bookkeeping · Psychosis · Insight · Reality · Phenomenology

Introduction [1]. One of our hospitalized patients, who believed that CIA
had surrounded the hospital in order to kill him, nonethe-
Double bookkeeping is an important yet neglected feature of less unconcerned left the hospital to buy ice-cream nearby.
schizophrenia spectrum disorder. The term was first intro- Professor Elyn Saks offers an articulate illustration of this
duced by Eugen Bleuler in 1911 to capture the character- double reality from a first-personal perspective:
istic, although paradoxical phenomenon of schizophrenia
[M]y life truly began to operate as though it were being
where psychotic reality can exist side by side with shared
lived on two trains, their tracks side by side. On one
reality even when these realities seem mutually exclusive
track, the train held the things of the ‘real world’—my
academic schedule and responsibilities, my books, my
* Helene Stephensen connection to my family (. . .). On the other track:
[email protected]
the increasingly confusing and even frightening inner
1
Center for Subjectivity Research, University of Copenhagen, workings of my mind. The struggle was to keep the
Karen Blixens Plads 8, 2300 Copenhagen S, Denmark trains parallel on their tracks, and not have them sud-
2
Mental Health Centre Glostrup, University Hospital denly and violently collide with each other. [2]
of Copenhagen, 2605 Brøndby, Denmark
In recent years, double bookkeeping has gained increas-
3
Mental Health Centre Amager, University Hospital ing attention in phenomenological and theoretical literature
of Copenhagen, 1610 Copenhagen V, Denmark
on the nature of delusions [3–8]. However, these studies
4
Faculty of Health and Medical Sciences, University
of Copenhagen, 2200 Copenhagen N, Denmark

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 European Archives of Psychiatry and Clinical Neuroscience

mainly deal theoretically with the phenomenon and ques- Table 1  Sociodemographic data
tion whether it is adequate to view delusions as beliefs at all.
Gender (n) Male 8
We recently published a paper on double bookkeeping
Female 17
based on long-lasting research, clinical experience with
Other 0
schizophrenia, and literature studies [9]. We claimed that
Age (years) Mean (SD) 30.7 (11.3)
the phenomenon comprehends a more global transformation
Median (range) 26 (18–54)
of the experience of reality and phenomenal consciousness,
Education Primary school 8
which appears to be specific for the schizophrenia spectrum
High school 7
disorders. Rather than merely concerning delusions, double
Completing high school 5
bookkeeping seems to be characteristic of most psychotic
University 1
symptoms in schizophrenia and to manifest itself before
Completing university 4
the onset of overt psychosis in more subtle changes of the
Occupational status Disability pension 7
structure of subjectivity. The formation of a psychotic world
Unemployed 3
seems to be associated with an alteration of the way of being
Sick leave 7
in the world where the patient feels profoundly estranged
Actively studying or employed 8
from the world, others, and herself. The idea is that the
original articulation of psychosis in schizophrenia consists
in the emergence of an alarming openness to another pres-
ence within the patient’s most intimate subjective life. This Methods
is accompanied by a sense of breakthrough to some kind of
“other” layer of reality varying from an inner life of quasi- Sample
solipsistic character (i.e., a sense to be the only existing
consciousness) to contact with other-worldly dimensions. The patients were recruited from psychiatric services of the
Patients often describe their psychotic reality as more true Capital Region of Denmark: Psychiatric Center Glostrup,
and profound than the socially accepted reality. To grasp this Psychiatric Center Copenhagen, and Psychiatric Center
different layer of reality, we used the notion “ontological,” Amager. All these services are affiliated with University of
which refers to the nature of being as such, e.g., the struc- Copenhagen. The inclusion criteria comprised the diagnoses
tures of spatiality, temporality, or language. Importantly, this of schizophrenia spectrum (i.e., schizophrenia, other non-
is a realm we do not ordinarily notice in our everyday lives, affective psychosis, and schizotypal disorder). The patients
engaged in daily life activities, which is the so-called realm were required to be able to tolerate lengthy interviews,
of the “ontic.”1 The idea is that psychotic experience by its because the study targeted detailed qualitative aspects of
ontological dimension touches upon different structures of experience. The exclusion criteria comprised organic brain
meaning. disorder, IQ < 70, clinically dominating alcohol or substance
Since there are no systematic empirical studies on the abuse, acute/agitated condition, forensic status, or exposure
issue of double bookkeeping, we decided to undertake a to coercive interventions. The patients were contacted by
phenomenological-qualitative interview study of a group of their primary care staff and informed about the study.
patients with schizophrenia. In this report, we address the In total 33 patients were contacted and 8 declined leav-
following issues. ing the sample at 25 persons (8 males, 17 females, mean
age 30.7 years; see Table 1). The reasons for decline com-
(1) Experience of double reality prised logistic problems, or lack of energy to use the time
(2) Emergence and development of two realities for the study (especially among outpatients who did not wish
(3) Truth quality of psychotic or private reality to make an extra trip to the outpatient clinic). One patient
(4) Insight into illness was excluded because of an overlooked forensic status. The
(5) Communication of psychotic experiences inclusion diagnosis was the diagnosis made by the treating
clinicians. However, all hospital charts were reviewed by the
A closer comprehension of double bookkeeping may have senior investigators (AUP, JP) in order to assure the fulfil-
a significant import for the understanding of the nature of ment of the ICD-10 criteria. Upon this review 24 patients
psychosis, its management and treatment as well as concep- fulfilled the ICD-10 research criteria for schizophrenia and
tual issues in research on schizophrenia. 1 patient for schizotypal disorder.
Eight patients were recruited during hospital admission,
whereas the remainder was recruited from outpatient clin-
1
The terms ontic and ontological are technical philosophical notions, ics (n = 17). Six of these patients were recruited from an
which we will not discuss in detail in this paper [10].

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European Archives of Psychiatry and Clinical Neuroscience

outpatient clinic for patients who had lived several years Experience of double reality
with schizophrenia, whereas 11 patients were recruited from
an outpatient clinic for young patients with recent onset of Most patients (n = 24) described a sense of existing in two
psychosis. realities. One reality being our shared, everyday world
and the other reality being the world of private sometimes
psychotic experience. In one case, it was not possible to
The interview ascertain the information needed for the assessment of the
patient’s experience.
The interviewer (HS) is a philosophy PhD-fellow with four We found varieties of the experience of double realities
years of clinical experience as an employee at a psychiatric that can overall be divided into two groups. The majority of
hospital where she had training in psychiatric interviews and patients (n = 18) described the psychotic reality as an insight
the use of the Examination of Anomalous Self-Experience or contact to a more true layer of reality (see
(EASE) interview [11]. AUP and JP are both senior consult- “Double reality: the second reality as an expression
ants in psychiatry with clinical and research experience in of another dimension”). The remaining patients (n = 6),
the domain of schizophrenia. AUP participated in the major- although living in two realities did not ascribe any form
ity of the interviews. of special insight or transcendent connection linked to the
For this study, we prepared an interview guide according private reality (see “Double reality: the second reality as a
to phenomenological interview principles [12]. The inter- private, quasi-solipsistic domain”). The two groups should
views lasted between 1 and 4 hours and were sometimes not be seen as two sharply separated categories, but rather
split into two or more sessions. The interviews were semi- as representing different ends of a dimension.
structured and conversational giving the patients ample
possibility to describe their experiences. The structured
element in the interview consisted in the obligation to cover Double reality: the second reality as an expression
the first four domains of the study outlined in the introduc- of another dimension
tion. We used 15 items from the EASE interview focusing
on the subject’s existential position, sense of basic self, and Patients described existing in two disjoint realities, namely
relation to the world and others (domain 1, 2, 4, and 5). We the reality of the shared world and the reality of psychotic
excluded domain 3 because of time concern. Domains 1, experience (i.e., hallucinations and delusions). The psy-
2, and 4 are most specific to schizophrenia spectrum [13]. chotic world was described as something behind or beyond
Domain 5 targeted existential issues and thus overlaps with the appearing, physical world often with terms like “mysti-
the entire interview. cal,” “supernatural,” “quasi-religious,” or the like. Hallu-
cinations or delusions were considered as insight into or
Data analysis messages from a different dimension or parallel world.
Case 8: “I’ve always lived in two parallel worlds..
All interviews were audiotaped and subsequently tran- Meaning that I live in the world everybody else does,
scribed. The data analysis consisted in obtaining a consen- where we know that the table is a table, and then in my
sus about the four target domains (top-down approach) fol- own world, where I have visions and hear voices. But
lowing the principles of qualitative, thematic analysis [14]. my sense of reality is intact. I know that you can’t see
The fifth domain related to the difficulties of verbalizing and hear what I can see. I can easily keep them apart.”
psychotic experience, which emerged during the analysis Case 27: “There is this common reality, that we share,
(bottom-up). and then I can tap into this other reality. It is some
The patients participated on the condition of informed, sort of understanding of how everything in the world
written consent and the study was approved by the Data is connected […] In the other world, I think there are
Protection Agency (P-2020-4), University of Copenhagen some supernatural beings controlling the world and
(514-0045/19-4000), and the ethics committee of University deciding how things are happening. Somewhat God-
of Copenhagen. like. And I think everything is set up for me.”
Case 11: “I thought I was an alien from a faraway
planet (…) I believe that there are several dimensions
and that they are so close to each other that it is dif-
Results
ficult to see the difference (…) I can feel a little differ-
ence, something strange, and then I think: ‘I wonder
We present the results divided into target sections of the
if I just entered another dimension?’ You can never be
interview.

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 European Archives of Psychiatry and Clinical Neuroscience

totally sure because the worlds look like each other. of double realties: self-fragmentation”).2 The patients with
It’s not like the sky is suddenly pink.” recent onset of schizophrenia remembered more vividly the
beginning of these experiences than patients in later stages
Double reality: the second reality as a private, of psychosis. Concerning the development and course of two
quasi‑solipsistic domain realities over time, most patients described that the sense of
two realities remained constant across the intensity of the
Some patients experienced double reality in the sense of illness (see “The course of double reality”).
feeling divided between their private world and the shared,
external world (n = 6; the only patient with schizotypal dis- The emergence of double realities: feelings of being
order belonged to this group). They described their inner different and derealization
world with a quasi-solipsistic quality, i.e., a transient sense
of being the center of the universe or that their experiential All patients described feeling profoundly alienated from the
field was the only truly existing reality. They felt to exist or shared world in the sense of being fundamentally different
being locked inside their own heads. This inner world felt to from others (“Anderssein”), experiencing the shared world
exist side by side with the shared world in a disjoint manner as unreal or somehow artificial (i.e., derealization), and a
rather than being in dynamic contact with it. The patients did radical feeling of not truly belonging to the shared reality.
not report explicit feelings of contact or insight into another The patients reported a profound sense of solitude and an
dimension of reality. unbridgeable distance from other people. Many patients
associated this sense of being “outside” the shared world
Case 20: “I live inside my own head (…) I know what
with feelings of being in a different world than others and a
is real and what is not real, but sometimes I get a little
beginning sense of contact to this other world.
confused (…) It can be difficult controlling to [return
to the real world], because sometimes I don’t know Case 18: The patient, 18 years old, described the sense
where I am (…) It’s not like I imagine that I’m in of two realities as emerging gradually over the course
another dimension or that I exist in another physical of many years, and it became explicit and persistent
world. It’s more something that goes on in my head.” 1 year ago. She always had the sense to fundamen-
Case 16: “It is as if I live between two worlds. There is tally exist “outside” the world and that other people
my own, little world and then there is the surrounding were not authentic: “When you watch a movie, and the
world. And I need to juggle between what I focus on cameras act as someone’s eyes, that is how I feel. You
and where I am present […] I spent most of the day see everything that goes on around you, but it doesn’t
being inside my own head rather than being in the real feel like you are present (…) It is like a film that just
world. It takes a lot of time and energy to exist on two runs while you sit and watch, and you cannot really
tracks at the same time.” be part of it, but you can also not, not be part of it,
Case 21: “It feels like I have to fight my way out of a because obviously you are there (…) your body and
daydream and all the time remind myself to be pre- your surroundings are unreal, but your head is the
sent or to try to focus on something present, to become only thing that exists and is really real, and then there
less out of tune [with everyone else] (…) Sometimes it is somewhere else, a place.” One day, out of the blue,
keeps running in the background, even if I’m for exam- the following thought emerged in the form of a voice:
ple in the middle of eating dinner [with my family]. It’s “They are in one world, and I am in another.” This
like a movie that keeps running on the inside.” voice is not experienced as the patient’s own voice, but
feels like “contact” to another dimension.
Case 13: “It’s just a feeling that it is difficult to fit in
Emergence and development of two realities with other people.. I don’t really know how to explain
it but it’s just like there is something that kind of stands
Most patients experienced a sense of double realities since out.”
childhood or early adolescence. It was often difficult for the Case 28: “All that is visible of the iceberg is every-
patients to determine an exact time of emergence since it felt thing that you can observe.. as for example that one
to be a habitual part of their experiential life. They associ- becomes psychotic and think that there is a lizard in
ated the emergence of double realities with feelings of a the room (…) or get paranoid. But actually, I feel more
fundamental estrangement from the shared world (see “The
emergence of double realities: feelings of being different and
derealization”), and their sense of self (see “The emergence 2
This division should be seen as a pedagogical move because in
most cases these two experiential domains seemed to be interdepend-
ent.

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European Archives of Psychiatry and Clinical Neuroscience

sick in what happens in the iceberg below the surface usually not enact their psychotic experiences in the shared
of the water. This means a completely, concrete differ- reality. However, occasionally and typically in acute psy-
ent way of perceiving the world than all other human chotic exacerbations, the two realities collided and became
beings (...) It is much more frightening to fundamen- confused with each other. In the phases leading to hospi-
tally feel that one is from another planet [than being talization, the psychotic or inner world typically became
in a psychotic state] (…) I feel profoundly emotionally increasingly invasive and out of control. Many patients,
distanced from other people because I feel that I have while in their psychotic condition, were acutely aware of
access to a different level of consciousness than oth- what was going on around them but had a difficulty in com-
ers.” municating this awareness. Importantly, during the remis-
sion, the significance of psychotic experiences remained
The emergence of double realties: intact.
self‑fragmentation
Case 27: A 29-year-old patient reported a “persis-
tent feeling of another world” during the last 7 years.
All participants reported self-alienating experiences pivot-
Previously, she experienced vague signs of this other
ing around a fragile sense of their most intimate sense of
world (e.g., she felt that other people were manipulat-
existing as a subject, e.g., feelings of not truly existing, not
ing or controlling her and that things were staged).
being fully present, or an experiential distance to their own
This other world was always there, also when she felt
thoughts, feelings, or actions. In relation to the emergence of
to “not exist in it.”
double realities, patients typically mentioned self-alteriza-
Case 15: The patient described that even when she felt
tion (i.e., a pronounced, anonymous otherness in the middle
that her psychotic experience was not true, the sense
of subjective life) and simultaneous introspection (i.e., invol-
or significance of these experiences was neverthe-
untary self-monitoring disturbing the patient to fully engage
less preserved: “It was a strong feeling. I think it can
in various activities such as social interaction or watching
maybe be defined as a delusion, maybe you can call
television). These experiences were associated with a sense
it that (…) Now, I can see that it makes no sense that
of division of the patient’s own subjectivity between differ-
my frontal lopes are made of starlight, but I still have
ent realities or parts.
a feeling deep inside, believing that this is the case.”
Case 25: The patient feels divided between himself as
an “individual” and himself as “a person in society.”
He often questions “who is the true me?” He observes Truth quality of psychotic or private reality
himself instead of being engaged in situations: “I
become almost out of myself. I can observe myself The truth quality of psychotic (see “Truth quality of psycho-
existing (…) when I heard the squealing train tracks, sis”) or private (see “Truth quality of private world”) reality
I also heard the sound itself (…) and I became con- was typically described as a different kind of truth than that
scious that it felt like there was more in it than there pertaining to the shared world.
maybe was (…) I felt there was a deep, inner voice
that could observe (…) There is something rational, Truth quality of psychosis
observing from the inside, simultaneously as there is
the very thing that I experience or do.” Most participants were able to distinguish their psychotic
Case 26: The patient relates double bookkeeping to experience from daily life experience. Patients were aware
a sense of being “two persons.” “It feels like there is of their hallucinations or delusions as private rather than
something inside your own self that you cannot relate intersubjectively valid. This awareness would not make
to in your head (…) something that you cannot relate patients question the truth of psychotic experiences in the
to, which is yourself. (…) Sometimes I am so much sense of their importance, relevance, or meaningfulness. On
inside my head that I am without a body.” the contrary, patients often described psychotic experience
in terms of being more “real” than the “real reality” and as
The course of double reality something involving a deeper level of truth, transcending
common sense knowledge. It was not possible to doubt the
Most patients described a persisting sense of double reality certainty of these experiences. Typically, patients reported
with fluctuating salience of one of the two. They mentioned that the meaning involved in psychosis came from the out-
the periods where they felt mostly at ease as when there was side with a revelatory character, arising suddenly in the
a balance between the two. This implied that they could middle of the intimate or affective sphere of their subjec-
keep these two realities separated. In these periods they did tivity. The meaning did not always have a specific content

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 European Archives of Psychiatry and Clinical Neuroscience

and was often enigmatic and puzzling for the patients them- the sole creator of this universe and at the same time, a pas-
selves. Although the meaning was vague, the patients knew sive spectator. Furthermore, it was difficult or impossible to
undoubtedly that it uniquely had something to do with them. keep up with the inner and shared reality at the same time.
Psychotic experience was described with a quality of being
Case 21: “When I say I don’t doubt what is real [and
alien or unfamiliar compared to ordinary perception, think-
what is daydream], then it depends on what you mean
ing, or imagination, resembling perceptual experience with-
by real. Because it has some sort of quality for me,
out in fact being like it (e.g., “seeing without seeing”).
when I daydream. But it doesn’t have a quality like
Case 26: “[The parallel universe] has a very differ- the table. (…) I think [the daydream world] has an
ent quality because it is not something that melts into emotional reality - not an objective [reality]. It can
my daily life. (…) Psychotic experiences are extremely feel true. (…) I think this is why it can be difficult to
alien. It’s like if you are walking to your kitchen, open change between the two worlds, because if you are in
the door, and then it’s a different kitchen (…) It is phys- one emotional reality, then you somehow have to twist
ically impossible things happening (…) When I’m in a and turn to join the rhythm everyone else is in.”
psychotic state I can in fact differentiate it from what it Case 13: The patient feels divided between a private,
should be from a logical perspective. But when you are phantasy world and a public world. “What I make up
in the situation, it is extremely difficult to think logi- in my own head has nothing to do with the public, real
cally because you see it, hear it, or feel it, and it is very world […] it is what I think and feel that are easily
difficult to contradict something that you can see.” accessible to others. My phantasy world is closed.”
Case 24: Pt: “I used to think that I’m [the center of the
universe]. It doesn’t sound good to say, but I thought
that I was Jesus or that I was chosen to do something
great.” Insight into illness
I: “Where do you know it from?”
Pt: “I don’t know. It is a truth like ‘gravity exists.’ I None of the patients accounted for their symptoms of schizo-
just know.” phrenia as being comparable to an illness in the ordinary
Case 25: The patient reported a hallucinatory experi- sense of the term. Eighteen patients considered their psy-
ence of seeing a woman. “It wasn’t like I physically chotic symptoms as signs from another dimension, parallel,
saw something change, but it was more like a mixture, or supernatural world, or insight into a more true level of
dream-like, but more visual somehow. I looked up and reality. The remainder, although not considering psychotic
saw a woman figure standing at the top of a staircase symptoms as signals from another dimension, nonetheless
(…) If I close my eyes and move my arm, I can sense considered their schizophrenia as an integral part of their
how my arm is moving without seeing it. It feels like person. All patients except one found their “illness” to con-
that.. It felt like it exceeded consciousness (…) It is like tain positive aspects, whereof most patients mentioned crea-
seeing without really seeing (…) It is there, but in the tivity. Several patients feared that antipsychotic medication
back of my head, inside the mind, not in my [physical] would rob them of their creativity and flatten out their rich
eyes.” inner life.
Case 13: “I think there is a part of me that always will
Truth quality of private world be schizophrenic, whereas somatic diseases most of the
time will pass and be over with.”
Most patients described their inner world with a different Case 10: “Well, I don’t really know. ‘Schizophrenia?’
truth quality than other aspects of their inner life and ordi- I’ve read some explanations and models of explanation
nary perceptual experience. This inner world was populated of it. Both the official psychiatric diagnoses and explana-
by daydreams and fantasies that, however, differed from tions and it doesn’t really explain anything. So of course,
normal imagination by acquiring a certain autonomy, and I have turned to the alternative (…) There are the psy-
spatial characteristics. This had some type of affective and chotic symptoms, and what is that? To see things that are
immediate truth value, sometimes more true than the shared seemingly not there, which other people do not see or
reality. The private fantasy world felt closed off from the experience. Well, I have done that for 17 years now (…)
shared world in a radical manner as something uniquely The mystical and the supernatural. It just exists. (…) I
involving the patient and without any dynamic interplay with actually think that both the voices and the visions origi-
the shared world. In contrast, other parts of the patients’ nate from the astral dimension. It just makes sense to
inner life were often described as too open, accessible, or think about it in that way because I can’t explain it in any
transparent for others (i.e., transitivism). They felt to be both other possible sense. (…) Anxiety, depressed thoughts,

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European Archives of Psychiatry and Clinical Neuroscience

and pain, and those kinds of things are something one double in double bookkeeping: beyond the question of real-
could consider illness.” ity; (2) insight into illness; (3) the emergence of double reali-
Case 3: The patient has multiple psychotic symptoms. ties: self-fragmentation and Anderssein; (4) communicating
The constant theme in his thinking is the idea that he is psychotic experiences. This overlap is unavoidable, because
Jesus: “Now that I feel better, I know that [the idea that double bookkeeping is not an isolated symptom but expres-
I’m Jesus] is a part of my illness—a delusion. But it sive of a specific change in the structure of subjectivity.
created a whole atmosphere so I cannot help that other
people still think that I’m Jesus.” Asked what he thinks Methods and limitations
about his schizophrenia diagnosis, he replied: “it seems
quite true. All that with the split personality” I: “How A key methodological challenge is that double bookkeeping
so?” Pt: “When I’m happy, then I’m happy Jesus, when is a phenomenon that pervades multiple aspects of expe-
I’m sad, then I’m failed Jesus. And sometimes I’m just rience, cognition, and behavior. Thus, the study involved
myself, when I’m on medication.” in-depth, narrative interviews, and a subsequent time-con-
Case 24: “When I feel bad, I think it is an illness (…) suming analysis involving the three authors. Given these
and then it’s nice to be able to say it is an illness because difficulties, the sample size appears reasonable for a qualita-
then it’s something beyond myself, but mostly it is dif- tive study of this type. We cannot be certain that the selected
ficult to call it ‘illness’ because it is me, and it’s not like patients are representative of schizophrenia in an epidemio-
putting plaster on your leg (…) it’s the very way my mind logical sense, but we believe that our mixture of patients
functions (…) if you call it illness you will think of it as with recent onset of psychosis and advanced patients is
an enemy or something that you need to get rid of.” comparable to patients with schizophrenia in general. It is
important to note that none of the patients was in acute psy-
Communication of psychotic experiences chosis or a severe exacerbation of their illness.

Most participants explicitly described difficulties in verbaliz- The double in double bookkeeping:
ing their psychotic experience. Typically, they only disclosed beyond the question of reality
their experiences to others after many years.
From a phenomenological perspective, double bookkeeping
Case 27: A 29-year-old patient experienced psychotic
is not simply a reflection of holding conflicting attitudes,
symptoms for nine years but only disclosed these during
beliefs, or perceptions. Rather, the delusional and shared
her second contact with psychiatry one year ago. In her
reality can exist side by side without conflicting because
first encounter with psychiatry eight years ago, she did
these realities are incommensurable [5, 9, 15]. Jaspers
not feel listened to. “I [was angry about] only seeing
termed the apparent incongruence between action and the
[the psychiatrist] one time and it was a questionnaire
content of a delusion as “inconsequential attitude” [16, 17].
(…) There was no conversation about how I was doing,
The participants in our study did typically not experience
my life circumstances, etc. (…) I really needed to talk to
any contradiction in the sense of incompatibility. Rather,
someone and she [the psychiatrist] didn’t want to. She
they experienced the two realities as separate domains that
just wanted to diagnose me and get it done.”
are rarely confused. This means that the two realities are not
Case 25: “It [hallucinatory experience] felt as if it
simply different but that they cannot be judged by the same
exceeded consciousness, like it ‘bubbled over.’ You can
standard. As most participants reported, psychotic experi-
no longer describe it, because it is so.. it was so.. it was
ence has a completely different quality than ordinary experi-
so.. so wild and it was so beyond, it was so beyond (…)
ence (e.g., the mode of givenness is characterized by hyper-
It’s extremely difficult to describe (…) like a pure sensing
proximity, because it happens in the midst of the subject).
without logical thought.”
This is in line with the findings in recent phenomenological-
Case 26: “I don’t really know how to formulate it [psy-
empirical studies [18–21].
chotic experiences], the only word I can think of is
Now, the question is what this other realm of reality more
“supernatural,” but it’s not really that. It’s very alien.”
precisely means? For a minority of patients, the other reality
consists of an enclosure in a purely immanent, subjective life
that is often solipsistically tainted and cut off from a dynamic
Discussion
exchange with the shared, social environment. The majority
of patients reported an access to a dimension of reality hid-
In the following, we will first address the methods and lim-
den for others. Psychotic experience is distinguished from
itations of the study and then discuss the significance of
ordinary experience as it seems to be also concerned with a
our results separated into the overlapping sections: (1) the
realm beyond the sensory. A patient described it as a truth

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 European Archives of Psychiatry and Clinical Neuroscience

“behind all appearance.” Others compared it to mystical- It makes no sense for the patients to speak of their psychotic
like, other-worldly, or divine experience (see also [22]). experience as true or false by empirical or mundane stand-
Importantly, these experiences are imbued with a sense of ards and it is not possible to prove (logically or empirically)
absolute certainty (as apodictic truths), which precedes any that a given delusion or hallucination is incorrect. The idea
specific content of delusional or hallucinatory experience is that psychosis does not primarily concern the sphere of
[23]. In other words, the affective moment of experience reason (judgment or perception), but rather an alteration of
precedes its cognitive elaboration. A patient described a the structure of subjectivity in its basic, pre-cognitive rela-
paranoid fear as a feeling that anteceded a specific content tion to the shared world.
of that fear: “It was like the fear was already there from the
inside and then it found its target.” This sense of certainty is
different from everyday perception. Phenomenologically, the Insight into illness
latter is imbued with doubt, or more precisely the possibility
to be corrected by interaction with one’s surroundings [24]. Our results, especially the tendency of persistence of psy-
The affective certainty of psychotic experiences is associated chotic reality between so-called “relapses” is consistent with
with another important feature, namely that these are pro- the findings of Jones & Shattell [27]. Thus, the notion of
foundly singular and subjective. Patients describe the experi- “a psychotic episode” is often not valid for the course of
ences as something uniquely concerning them. In sum, psy- schizophrenia. Briefly put, double bookkeeping begins to
chotic experience transcends the sensory and shared reality emerge early in life and may become a persistent condition.
and does not seem to be integrated or “woven into the fabric As we have already mentioned, the patients do typically not
of the intersubjective world” [15]. It is crucial to emphasize consider their psychotic experiences as an expression of ill-
that this does not mean that psychotic experience is simply ness, but rather as constant companions that they need to
“outside” the shared reality in the sense of being completely keep apart from their interactions in the social world. The
unrelated to it. Rather, psychosis concerns a different onto- participants were likely to consider depression, anxiety, lack
logical layer of reality, namely the very meaning or nature of energy, and initiative as signs of illness. This finding is
of reality. As one of our patients explained, she often strug- consistent with studies showing that first-contact with treat-
gled to grasp what people were saying because she started ment facilities is motivated by these so-called non-specific
to think about the very meaning and truth of language. We symptoms, rather than complaints about psychosis [28]. As
can paraphrase Müller-Suur’s observation that the altera- already noted, the patients do not consider their experiences
tion of experience in schizophrenia concerns the “horizon of as pathological but as phenomena testifying to their access
meaning” (“Sinnhorizont”) [25]. The same empirical object to another domain or level of reality. In mainstream psychia-
can be regarded upon different horizons of meaning, e.g., try, the insight into illness is defined as an awareness of the
as something pragmatically useful, as something created, a illness, its symptoms and signs, risk factors, consequences,
sacred item, or an exemplar of materiality of the world. In and the need of treatment. This medical definition implies
a similar vein, Blankenburg pointed to an alteration of con- an experiential distance between the self and symptoms. In
textual framework of experience, rather than to a change in the case of schizophrenia, the patients have no possibility
the content of experience [26]. When patients question the for such an experiential distance, because psychotic phe-
context or validity of reality, it is different from question- nomena originate in the intimacy of their own selfhood and,
ing if something is real or not in the standard sense of the therefore, carry with them an apodictic certainty. This is the
term. The latter often leading to misunderstandings between case notwithstanding the fact that psychosis often inflicts a
patients and clinicians. The phenomenological point is that severe suffering. As Mørck expressed it in her first-person
when we perceive something, we also implicitly and tacitly account of living with schizophrenia: “I am 46 years old
perceive a whole network of significance and a familiarity today, and I do not believe in the word ‘recovery’ […]. I
within a given intersubjective framework. Briefly put, the coexist with schizophrenia, and it is as big a part of my
other layer of reality involved in psychosis may pertain to identity, as part of me dealing with the outer world” [29]. In
the axioms or structure of reality (ontological level). The sum, when participants do not regard their psychotic symp-
two realities involved in double bookkeeping can thus be toms as illness it does not seem to reflect poor insight, but
incommensurable, although they concern one and the same rather to reflect double bookkeeping. Many patients have a
reality. In the face of this, many patients described a senti- double-awareness as it is well illustrated by the philosopher
ment of being split or divided. It could, therefore, perhaps be Wouter Kusters accounting for his first-personal experience
more precise to speak of a rupture within reality rather than of psychosis:
double reality. Rather than being two separate perceptions or
For me, that was beyond strange. I knew exactly what
beliefs, double bookkeeping is expressive of a specific “uni-
a psychosis was–I was right in the middle of one–and
fied divided consciousness” as we phrased it elsewhere [9].

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European Archives of Psychiatry and Clinical Neuroscience

yet I couldn’t pull myself out. The psychosis presented coloring of the world. The majority of our patients described
itself to me as an inescapable truth and reality. [30] this progressive self-alienation and alienation from others
and the world as beginning already in childhood or early
The emergence of double realities: adolescence and apparently functioning as a precursor of
self‑fragmentation and anderssein the crystallization of double bookkeeping. Briefly put, we
see elements of double bookkeeping before the development
Double bookkeeping is not a contingent feature of schizo- of frank psychosis. Psychotic experience takes place within
phrenia, but rather an expression of its core Gestalt. Our the intimacy of the patient’s subjectivity and simultaneously
patients described some sort of transformation of their exis- feels exterior, which gives rise to the sense of a rupture
tential position (basic relation to self, world, and others), within reality. It is important to emphasize that the idea that
including a feeling of being fundamentally different from the ‘other reality’ originates in the middle of subjectivity
others (Anderssein). This alteration of the self-world-relation does not exclude a developmental or intersubjective aspect
can be either emphasized on the side of the subject or in of psychosis [37, 38]. In many cases, patients described
its relation to the surrounding world and others [31, 32]. their psychotic experiences as something giving the patient
On the purely subjective level, there is a self-fragmentation a meaningful subjective position in the universe (see also
(self-alterization), which consists of the parts of the subject [39]). Furthermore, patients described their private or psy-
acquiring an alien otherness: “It feels like there is something chotic world as a place where they felt at a safe distance from
inside your own self that you cannot relate to in your head.” the unpredictability and ever-changing character of shared
These alien fragments constitute the kernels upon which the reality. It is important to note that the emergence of double
other reality progressively articulates itself and eventually realities should not simply be understood as a coping strat-
becomes the stage for the psychotic phenomena. Phenom- egy. Rather, it is a “phenomenological compensation,” i.e.,
enologically, we can describe this as a fragile sense of basic not as a willed or intentional act on the part of the patient,
self or first-person perspective. The first-person perspective but rather as an automatic re-organization of consciousness
implies that all my experiences are given to me as my own, as a way to remain in contact with reality or preserving a
as my experiences [33]. I do not need to ask myself if it is sense of existing as a subject [40].
me who is now looking at my computer screen. In other
words, all experience involves a tacit self-affection (“auto- Communicating psychotic experiences
affection”) [9]. My experiences are self-saturated, shot
through by a dimension of a tacit affective self-presence. It is crucial to discuss the difficulty for the patients to ver-
However, this basic self is not an undifferentiated homoge- balize these subtle phenomena and for the clinician to help
neity but is a dynamic structure of diverging and coalescing patients to report them. First, it requires of the clinician to be
affective moments. Subjectivity is open to the world and is attuned to the patient in a specific way, i.e., to let the patients
always given to itself in this relatedness, affected by some- unfold their self-descriptions without judgmental interrup-
thing other than itself and thus involving a structural, poten- tions and premature categorizing. The latter requires a broad
tial alterity. It seems that in schizophrenia, the moments of knowledge of psychopathological phenomena that are not
alterity become unintegrated or congealed, leading to the yet converted into categorical symptoms [16]. Surprisingly,
formation of intrusive, alien otherness, i.e., self-alterization studies show that even trained psychiatrists are not always
or self-fragmentation [34]. Thus, this change of subjectivity capable to facilitate self-descriptions of the patients. On the
is highly correlated with an altered relation to the world and contrary, even when patients actively tried to talk about their
others.3 The basic vulnerability of schizophrenia implies a psychotic symptoms, the psychiatrists avoided further explo-
breach in the dynamic with the shared reality. Minkowski ration [41, 42]. Secondly, it is difficult for most persons to
described this alteration as a “loss of vital contact with real- respond to questions of how they experience reality, how
ity” [35] and Blankenburg designated it as a “crisis of com- their thoughts feel like, and so forth. Most participants men-
mon sense” [36]. It is an alteration of pre-reflective and pre- tioned explicitly the difficulties of finding the right words for
conceptual grasp of intersubjectively and contextually valid the psychotic experience. A patient articulates that the other
meanings resulting in an enigmatic and often threatening reality is “some sort of understanding of how everything
in the world is connected.” Thus, rather than involving a
specific content, it involves a change in the very mode of
3
In terms of the EASE scale, the patients typically reported dimin- experiencing and meaning. In other words, communicating
ished sense of basic self, distorted first-person perspective, and loss this experience is difficult, because it concerns a realm out-
of thought ipseity, as well as a sense of I-split. Furthermore, patients side of ordinary experience, language, and rules of logic.
reported derealization, hyperreflectivity, loss of common sense/per-
plexity/lack of natural evidence, transitivism, and solipsistic-like The patients often use metaphors, which may be sometimes
experiences. shifted into a private use of words. We have not found any

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 European Archives of Psychiatry and Clinical Neuroscience

psychiatric studies that are explicitly concerned with the of psychosis requires a more refined psychopathological
relation between pre-verbal experience and its expression exploration and description than the commonsense notion of
in language. However, already in 1914, a French psycho- “falsity.” Moreover, the phenomenon of double bookkeeping
pathologist emphasized that in psychosis a central problem questions the view of schizophrenia as a series of relapses
consists in the patients having experiences, which cannot be and remissions of psychosis. Perhaps, it would be more
framed in an intersubjective discourse [43]. appropriate to speak of exacerbations, because the change
of subjectivity appears to have a tendency to persist. With
respect to treatment and psychotherapy, it is most impor-
Conclusion and implications tant to help the patient negotiate a balance between the two
realities and prevent the exacerbations where the psychotic
The literature on double bookkeeping portrays it as paradox- world overwhelms the patient and translates into severe suf-
ical since patients appear to hold self-contradictory beliefs fering or maladaptive behaviors [44]. Finally, with respect to
as in the prototypical example of the patient who gladly con- pathogenetic research, it is perhaps more important to focus
sumes poisoned food. This self-contradiction made Bleuler on the phenomena of subjectivity rather than studying neu-
question whether the patients regarded their delusions as real roscientific correlates of multifarious psychotic symptoms.
or not, which to this day is a frequent concern of clinicians. More specifically, we believe that pathogenetic research can
However, this question of reality when it comes to psychosis take advantage of a more refined psychopathology.
seems to be misguided. If you ask the patients whether they
Funding Open access funding provided by Royal Danish Library. This
think their psychotic experience is real or not it is nonsensi- research did not receive any specific grant from funding agencies in the
cal from the patients’ perspective. It would be like asking public, commercial, or not-for-profit sectors.
someone with a toothache whether they believe the pain is
real or not. Therefore, we argue that psychosis is not a ques- Declarations
tion of real or not, but rather a question of reorganization
Conflict of interest On behalf of all authors, the corresponding author
of subjectivity and the meaning of reality. Consequently, states that there is no conflict of interest.
we believe that the primary disturbance is located on the
level of experience and affectivity rather than on the level Ethical standards This study was approved by the ethics committee of
of cognition. University of Copenhagen and has been performed in accordance with
the ethical standards laid down in the 1964 Declaration of Helsinki
We believe that double bookkeeping is an integral dimen- and its later amendments. Informed consent was obtained from all the
sion of the schizophrenia Gestalt, involving alterations of individual participants prior to their inclusion in the study.
selfhood and intersubjectivity. It is thus specific for the
schizophrenia spectrum disorders. The awareness of this Open Access This article is licensed under a Creative Commons Attri-
phenomenon is crucial in the interaction with patients with bution 4.0 International License, which permits use, sharing, adapta-
schizophrenia. The symptomatic picture of schizophrenia tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
cannot be regarded on analogy with somatic illness where provide a link to the Creative Commons licence, and indicate if changes
symptoms and signs are often well-delimited objective enti- were made. The images or other third party material in this article are
ties with referential function pointing to underlying pathol- included in the article's Creative Commons licence, unless indicated
ogy of the substrate. In schizophrenia, the psychotic phe- otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
nomena have no referential function but are a configuration permitted by statutory regulation or exceeds the permitted use, you will
of altered structure of the subject’s being-in-the-world. We need to obtain permission directly from the copyright holder. To view a
would like to emphasize that our qualification of the inad- copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
equacy of the medical model is not motivated by any roman-
tic version of schizophrenia but by a concern for adequate
treatment and research. The phenomenon of double book-
keeping has consequences for the nature of clinical exami- References
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