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Longand Hull
Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
https://doi.org/10.1186/s13010-023-00142-8
REVIEW
Conceptualizing alessparanoid
schizophrenia
James Long1* and Rachel Hull2
Abstract
Schizophrenia stands as one of the most studied and storied disorders in the history of clinical psychology; however,
it remains a nexus of conflicting and competing conceptualizations. Patients endure great stigma, poor treatment
outcomes, and condemnatory prognosis. Current conceptualizations suffer from unstable categorical borders, hetero-
geneity in presentation, outcome and etiology, and holes in etiological models. Taken in aggregate, research and clini-
cal experience indicate that the class of psychopathologies oriented toward schizophrenia are best understood
as spectra of phenomenological, cognitive, and behavioral modalities. These apparently taxonomic expressions are
rooted in normal human personality traits as described in both psychodynamic and Five Factor personality models,
and more accurately represent explicable distress reactions to biopsychosocial stress and trauma. Current categori-
cal approaches are internally hampered by axiomatic bias and systemic inertia rooted in the foundational history
of psychological inquiry; however, when such axioms are schematically decentralized, convergent cross-disciplinary
evidence outlines a more robust explanatory construct. By reconceptualizing these disorders under a dimensional
and cybernetic model, the aforementioned issues of instability and inaccuracy may be resolved, while simultane-
ously opening avenues for both early detection and intervention, as well as for more targeted and effective treatment
approaches.
Keywords Schizophrenia, Schizophrenia spectrum disorders, Schizotypy, Schizoid, Psychosis
Background
Schizophrenia is one of the oldest and most studied men-
tal disorders within the history of psychological science.
Mental and medical health practices consistently fall
short for patients diagnosed with schizophrenia spec-
trum conditions. Treatment plans are predominantly
stereotyped, heavily reliant on second-generation antip-
sychotics [1–4], and rarely include validated psychoso-
cial or psychotherapeutic interventions [5–7], Verdoux
et al., 2010). is pattern persists despite widespread
agreement on heterogenous presentation and treatment
outcome [3, 8–11], moreover, a tremendous amount of
the variability in prognosis, etiology, and even the effec-
tiveness of pharmacotherapy is accounted for by factors
overlooked in diagnosis and/or outcomes monitoring
[10, 12–14]. is poses an ethical issue in that, to the
extent that the goal of the mental health field is to allevi-
ate human suffering and to promote human flourishing,
past and present approaches miss the mark. is also
implies that the currently accepted conceptualization(s)
of schizophrenia spectrum disorders is at least partially
flawed. Finally, this treatment failure incurs a heavy social
and economic cost. e US domestic economic cost of
schizophrenia is staggering, estimated at US$60 billion
per annum [15], moreover, accounting for indirect costs,
this is likely a conservative estimate.
Open Access
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Philosophy, Ethics, and
Humanities in Medicine
*Correspondence:
James Long
LongJ2@chc.edu
1 Department of Psychology, Chestnut Hill College, 7113 Valley Avenue,
Philadelphia, PA 19128, USA
2 Chestnut Hill College Department of Professional Psychology, 9601
Germantown Avenue, Philadelphia, PA 19118, USA
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Page 2 of 19
Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
e reasons for this systemic deficiency are as diverse
as the schizotypy spectrum itself, ranging from founda-
tional flaws in the current diagnostic model of mental
health to constraints inherent in the contemporary men-
tal health system. e increase in biologization of the
field [16] has encouraged efforts to identify neural corre-
lates in line with a disease model, while the preponder-
ance of evidence indicates that schizotypy, in all of its
manifestations, is profoundly moderated by environment.
Such emphasis on materialism has not mitigated stigma
or improved treatment outcomes and likely contributes
to the current and historical plight of the population [5].
Accounting for the schizotypal population as a whole, it
may be appropriate to conceptualize schizophrenia as
“the story of the way that poverty, violence, and being
on the wrong side of power drive us mad” ([17], p.197),
or perhaps more succinctly, “bad things happen and can
drive you crazy” ([3], p. 145).
Housing the etiological locus solidly within the realm
of environment and not genetics is consistent with the
Hearing Voices Movement (HVM; [18], which seeks to
reframe psychosis symptoms within culture and con-
text, and refrain from treatment of those experiences
as a “biogenetic disease state,” [18], p. 134) which is not
supported by recent data. While the model and per-
spective proposed in this paper aspire towards a new
operational explanation, the body of research necessary
and sufficient for such a definition is either nascent or
theoretical,nonetheless, there exists precedent for de-
stigmatizing and de-pathologizing psychosis (the symp-
tom) and schizotypy (the syndrome).
e heterogeneity of presentation and treatment
outcome has lead other researchers to argue that the
construct of schizophrenia as a whole needs to be recon-
ceptualized [3, 18–22]. Inasmuch as disagreement may
be attributed to the unknowns inherent in any scientific
dispute, the issues around schizophrenia are more pro-
nounced. is is likely due to numerous factors. e fore-
most being that all issues involving psychosis lie contrary
to the unspoken morality of post-enlightenment socie-
ties, the overarching dogma of which describes a world
which is ultimately without contradiction, and which
can only be truly understood through the mechanisms of
reason. e second unspoken assumption is that such an
understanding is unquestionably good. Given the ubiq-
uity of instrumental rationality as final arbiter of value,
the ability to participate in consensus reality becomes
a measure of one’s human worth, and one’s divergence
from said explanatory consensus is an index of one’s ill-
ness. is cultural and methodological axiom thus doubly
binds the schizotype, as their phenomenological position
is simultaneously given an unspoken moral dimension
while providing tools for study and care predisposed to
pathologize and dispense with said position as inherently
aberrant and symptomatic.
e present article will begin with rationale explicat-
ing the historical, philosophical, and conceptual difficul-
ties precipitating myopic approaches to treatment and
research within the population. Secondly, it will survey
relevant evidence from various disciplines which provide
converging evidence toward a more comprehensive view
of schizotypy and its manifestations with psychotic fea-
tures. Finally, the present authors propose a more thor-
ough conceptualization of the schizotypal spectrum,
along with a framework to reconceptualize schizotypal
diagnoses as identifiable patterns within a dimensional
paradigm incorporating both “healthy” and “patho-
logical” members. Finally, clinical implications will be
discussed.
Ultimately, it will be argued that a properly developed
cybernetic model, rooted in trauma-informed personal-
ity theory, best captures the nature and breadth of this
human experience. It is the present authors’ hope that
with such a reconceptualization, self-stigma in those with
schizophrenia will mitigate as well, as self-stigma in indi-
viduals on the schizotypal spectrum has been recognized
as a “second illness” [23], as cited in [3, 24–29].
Historical andphilosophical precedents
Underlying axioms andparadigmatic blind spots
Although there is room to debate many of his specific
points and inferences, Foucault (1965) addressed many
of the genealogical ideas that underlie current mental
health practice. Salient are the social and moral implica-
tions of mental illness in a post-enlightenment age. Rea-
son and empiricism were held up as the means by which
humanity would extract itself from the arbitrary and
oppressive moral and social systems that characterized
the preceding epochs. However, as no human or soci-
ety can exist without an orienting value system (ought
from is) [30], this revolution merely altered the param-
eters. Moral punishment became reserved for “healthy”
individuals with deviant behavior, while those whose
behavior was determined to be medical in origin were to
be cured (i.e. brought back to reason and regulated pas-
sions). However, in both cases it was deviance from the
collectively understood “good” which was targeted. In
the former case, deviant behavior was punished or cor-
rected through learning, while in the latter psychologi-
cal deviance imbued society with a moral duty to treat or
cure. Much of our current approach to treatment, such
as cognitive-behavioral theory, is predicated on this idea,
that it is irrational thoughts that cause distress, based on
the underlying assumption that showing the person that
their thinking is irrational is itself a kind of cure for their
experience.
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
In a recent review of 30 consecutive court-mandated
medication hearings, 29 were approved without a jury,
most in cases where serious neurological damage had
been caused by medications and at higher doses than
would be recommended. All cases of treatment had
entirely discounted options such as psychotherapy,
despite defendant and family protest, demonstrating that
the line between moral capability, medical impairment,
and societal responsibility is still quite blurry [5].
e presenting issues involving psychosis are inher-
ently aberrant against the axioms of the age, giving their
expression a numinous quality absent from comparable
symptomology. While a “healthy” person can empathize
with a depressive or obsessional person (seeing their
experience as merely an extreme version of their own),
the hallucinations, delusions, disorganized thoughts, and
behaviors of psychosis are deeply unsettling. Such a per-
son may be pitied or sympathized with, but how can one
empathize with a person who is not participating in con-
sensus reality, let alone take their perspective seriously?
e rational-empirical model Foucault was dissect-
ing had more comprehensive effects as well, establishing
the parameters by which reality was defined. Truth was
to be determined through careful observation, data col-
lection, and objective analysis of results. One could sub-
sequently remove the confounds of arbitrary values and
subjectivity and determine what was and was not “real.”
is idea has been one of the most important and useful
tools in human history, and its benefits cannot be over-
stated; however, as with any idea, it rests upon axioms
and results in outcomes with predictable constraints.
As much of the unspoken paradigm scaffolding within
scientific models can be traced back to the ideas of ration-
alism and empiricism, and to the extent this paper aims
to address axiomatic flaws in those models, it is worth
exploring the concepts. Broadly speaking, the rational-
ists argued that knowledge was attained through logic
and reason and that human understanding was founded
on innate ideas. In contrast, the empiricists argued that
humans were tabula rasa, and that knowledge was gained
exclusively through sensory experience. Responding to
both, Kant [31] outlined his synthetic a priori proposi-
tions on reason and its recognition of necessary cog-
nitive structures preceding sensory modification. He
argued that the only way in which a human being could
have knowledge in a functionally infinite sea of data was
through categorization. at we contained an innate
scaffolding which predisposed us to select and judge our
sensory data, and that without such we could not pos-
sibly perceive the world in any meaningful way at all.
Moreover, as we were goal-oriented creatures, this was
an inherently value-laden conceptualization. While this
perspective was revolutionary in overall enlightenment
thinking, its ultimately phenomenological approach to
reality has had little impact on the scientific endeavor to
understand that very rationality.
What has been retained is something of the desire
which drove Kant’s deductive exploration; namely to
arrive at a surety of knowledge without call to a divine
authority. His endeavors into synthetic a priori knowl-
edge assumed and ultimately sought to prove that foun-
dational sure knowledge could be found and worked
upwards from to arrive at universal and objective truth.
e distillation of this is the reductionism which subtly
underlies scientific inquiry to this day; the belief that the
best way to understand a complex system is to break it
into its smallest constituent units and then extrapolate
upwards. From this we may identify the roots of the
atomism and materialism which will be discussed further
in this paper.
Equally important to these methodological axioms
however is the subtle implications of a unitary truth
when applied to the psyche and its inquires (i.e. that a
single correct perspective is attainable and thus devia-
tion therefrom is an error to be corrected). rough this
lineage one has dispensed with subjectivity (the valu-
ing ‘ought’ and its many constraints) in favor of objec-
tive proxies as a means of study and have thus over time,
often with a sense of moral duty, come to see subjectiv-
ity as (at best) epiphenomenal. is trend has likely rein-
forced, if not outright caused, the current preference
for biological interventions for subjective experiences
while viewing aberrant subjectivities as a problem to be
solved. e more strictly empirical approach can likely
be attributed to the structural disconnect between verifi-
able data and subjective experience endemic to objective
and materialistic approach to science; however, this inat-
tention has created potential blind-spots in investigative
assumptions.
Congruent models andfractal patterns
While Kant arrived at his categorical phenomenologi-
cal conclusions from deduction and intuition, Jean Pia-
get [32] outlined a nearly identical process by observing
the developmental construction of schemata in young
children. In highlighting the evolution of children’s
reports and understandings of reality, Piaget stands as
a kind of naturalist of the same process proposed by
Kant, in which a rather simple set of structures give
rise over time to the operations of intelligence. In both
Kant’s concept of understanding and Piaget’s concept
of a schema (in a total sense), a person can only con-
ceive of realities congruent with the structure of their
framework,that is, they have a subjective perspective.
Where Piaget’s observations stand out is in his detail-
ing of the process by which these structures update and
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
organize themselves across time (e.g. the famous cog-
nitive revolution children experience when developing
a theory of mind). In light of contemporary evolution-
ary, genetic, and personality research though, the full
scope of potential schematic diversity remains an open
question. at is, to what degree do we converge upon
a universal perception of reality and to what degree are
we perceiving and conceptualizing differently?
Regardless, the implication of the symptom-focused
taxonomy of the DSM or ICD is that subjective diver-
sity is either irrelevant or non-existent and thus our sci-
entific study of the mind cannot account for it. Given
that our schemata expand and evolve through assimila-
tion and accommodation, and that they are the medium
through which we construct our reality, the means by
which that dynamic equilibrium is affected by biologi-
cal predisposition and the specific nature of events
experienced during this process must be accounted
for if psychology is to succeed as a scientific pursuit.
Understanding the forces which led to and maintain
such an equilibrated structure carries implications for
psychological models of cognition and perception as
well as for clinical treatment.
Symmetrical to Piaget’s schemata, Kuhn’s [33]
description of the paradigmatic nature of scientific dis-
covery demonstrates this process at the level of con-
sensus reality and may also indicate the core problem
with current models of schizophrenia-spectrum disor-
ders. Much in the same way a developing child in Pia-
get’s model works pragmatically within a ‘good enough’
schema until sufficient development and anomalous
information induces a reorganizational (and thus per-
ceptual) classification, Kuhn noted that scientific
paradigms (collective schemata of interpretation and
behavior) progress until sufficient anomalous data
induces a reorganization of core assumptions, such that
previous evidence and anomalous evidence remain, are
accounted for, and explained. Much as two individuals
with incompatible schemata would find mutual under-
standing impossible without accommodation on one or
both ends, the current paradigms informing much of
psychological research (e.g. objectivism, materialism,
etc.) cannot account for the symptomatic manifesta-
tions of the schizotypal spectrum other than as patho-
logical deviation, and thus remain obtusely focused.
Instead, models must account for the biological and
environmental impacts on schematic development as
a necessary component in any defensible definition of
mental health. Currently, models such as the Five-Fac-
tor Model of personality (FFM); [34] offer avenues to
begin exploring and discussing this scientifically, how-
ever their implications have yet to meaningfully propa-
gate throughout the psychological field.
Outcomes andlimitations ofunexamined axioms
In a discussion on the theoretical challenges facing psy-
chology today, Slife (as cited in Lambert, 2004) identified
numerous constraints on theory and its practical applica-
tion. Objectivism essentially posits that the logic inher-
ent in the methods and techniques of science and clinical
practice can be relatively free of systematic biases and
values. is is achieved through the use of logical rea-
soning (rationalism) and unbiased observation of phe-
nomena (empiricism). is permits a certain unbiased
standard of proof that can be verified and agreed upon
without appeal to arbitrary authority or preconceived
assumptions; however, it also leads to limitations. It
bounds what can be studied (and thus proven) to those
things which can be observed and replicated. In psychol-
ogy, this translates to examining the psyche by proxy. As
one can have no direct observation of experience, various
behaviors are examined instead with the assumption that
these act as indicators of internal states and dynamics.
Where behaviors cannot be determined, states are opera-
tionalized; anxiety becomes the nexus of racing thoughts,
restlessness, distractibility, etc. What cannot be captured
is the valence, meaning, and experience of anxiety, or the
idiosyncratic relationships an individual’s anxiety has
with their own history, conceptual framework, and day-
to-day experience.
For example, within a psychodynamic framework, a
clinician would find it important to determine whether
a patient’s depression was anaclitic or introjective, thus
accounting for the inner subjectivity underlying the over-
all state. However, most strictly empirical research and
certainly most pharmacological research must measure
itself by symptom reduction within the DSM criteria of
depression, which does not account for personality style.
In this way, the methods by which research is conducted
systemically deem irrelevant domains of human experi-
ence and psychological evolution, becoming blind to
them.
A second axiom is materialism, which posits that
psychological experiences will eventually be shown
to have observable and biological bases. All psychol-
ogy is simultaneously biology. As with objectivism,
this assumption is predominantly benign or benefi-
cial; however, it too creates complications. One is the
implicit causal direction; that the core problem is
contained within, and thus solvable and explicable
through, biology. Indeed, materialism is tightly wedded
to objectivism as it is often far easier to study physical
systems than social or psychological ones. is belief
underlies much of the faith in and reliance on pharma-
ceuticals as “cures” for psychological disorders. Once
a biological correlation is identified, it is treated as
the cause despite our knowledge that the relationship
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
is more complicated; moreover, the entire DSM/ICD
classification systems assume biologic etiology. is
causal direction also promotes an aura of preeminence
to biological markers over holistic biopsychosocial
assessment. For example, if research finds that seroto-
nin differences act as a biomarker of depression, it is
assumed that such differences causally precede the psy-
chological state and so become the target of treatment,
despite evidence that such neurotransmitters are them-
selves greatly influenced by environment and cognitive
framing [35, 36].
Finally, the axiom of atomism assumes that the quali-
ties of people are contained within the individual, and
so treatment should focus on individual cognition,
biology, and behavior. As can be seen, atomism dove-
tails seamlessly with reductionism (the individual is the
indivisible member of the collective), materialism (the
biological operations of others do not influence those
around them), objectivism (it is easiest to observe the
components of an individual rather than the network
of influences between them and their environment over
time) and implicit morality (the locus of choice and thus
moral human agency exists within the individual). ese
assumptions, while almost certainly a necessary heuris-
tic, can lead researchers and practitioners to underesti-
mate or ignore the impact of relationship factors or social
context.
ese and other axioms inform many more areas of
human life than the field of psychology, and in many of
them (e.g. particle physics), they may operate more or
less perfectly. Inasmuch as psychology is to be the study
of the psyche, however, it must at some point include the
study of human subjectivity; moreover, it is the experi-
ence of suffering that we aim to alleviate, not its proxies.
is is decidedly difficult within a framework that goes
to great lengths to remove all subjectivity before even
beginning its search.
Furthermore, whatever it is one means by the psyche,
it is a dynamic and multi-level phenomenon. It is shaped
by the past through memories and biological altera-
tions (processes which continue to change throughout
the lifetime); simultaneously, how a person conceives of
the future continuously alters behaviors, cognitions, and
relationships (which in turn recontextualizes memories
and alters biology). Each of these is further informed by
the idiosyncratic relationships a person has (as well as
how he conceives of them) and the environment in which
he lives (physical and social). It is in fact this entire set of
inter-penetrating and interlocking systems which deter-
mine how any particular experience manifests. Within
the framework above, those elements which are most
difficult to operationalize or which lie perpendicular
to accepted rigor are granted a reality significantly less
substantial than those which are considered more “evi-
dence-based,” and thus most often lay unaccounted for in
final etiology and nosology.
e DSM’s taxonomy, as well as its preeminence in
mental health practice, is the distillation of this process.
It testifies to the strengths this approach has brought to
the field, and simultaneously contains its weaknesses. As
has been noted by clinicians throughout its development
and subsequent iterations, the DSM’s approach dispenses
with, misinterprets, or lies contrary to the bulk of histori-
cal and contemporary clinical wisdom [37–40].
Without an explicit definition or discussion of mental
health, the DSM implies that the removal or reduction
in stated symptoms is the goal (empiricism and reduc-
tionism). is creates the following three issues: (1)
While symptom relief may be desired, no other medi-
cal professional would equate symptom reduction with
a cure. (2) e DSM can offer no discussion or guidance
on important qualia within those symptoms (e.g. recall
objectivism—is the depressive experience fundamentally
anaclitic or introjective). (3) e DSM offers no insight
on the depth of, interactions between, or potential func-
tions of experiences as outlined. One may contend that
none of these was meant to be the function of the DSM,
which was instead intended to be one tool in an arse-
nal the clinician would bring to bear. However, whether
due to the constraints of time and energy, the demands
of insurance companies, the limitations of training, the
(above-outlined) biased nature of research, the fact that
the DSM is subservient to the ICD, or any combination
of these factors, it is often the case that the DSM is used
in exactly this manner. In 2013, the National Institute
of Mental Health (NIMH) ceased funding DSM-based
research citing the model’s overall “lack of validity” (Insel,
as cited in [41], p. 522).
e weight of evidence accrued even within this frame-
work calls its assumptions into question. It has been
noted, for example, that in clinical settings, depression
is usually paired with anxiety and somatic symptoms,
while also manifesting in highly variable ways (aggres-
sion, risk-taking behaviors, etc.) [39]. Simple diagnosis
is insufficient for treatment planning [42] and ultimately
leads to stereotyped and imprecise responses; moreover,
if disorders were, in fact, distinct categories, one should
expect them to have distinct boundaries with matched
biological correlations. However, antidepressant medica-
tions are used to treat anxiety and other mood disorders,
and antipsychotic agents are prescribed for bipolar disor-
der and various severe personality disorders. Symmetri-
cally on the treatment side, cognitive-behavioral therapy
(developed to address internalizing disorders) has since
expanded to encompass nearly every class of mental
disorder [43], despite major methodological flaws in the
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
research that supports CBT [44]. Moreover, longitudi-
nal and epidemiological evidence indicates that etiology,
prognosis, and even pharmaceutical effectiveness depend
on psychosocial factors disregarded in the current tax-
onomy. For example, in patients with schizotypy and psy-
chosis, treatment and pharmacological outcomes depend
much more on factors such as childhood trauma, social
factors, and neurocognition [3, 11, 45].
While the full impact of this dynamic stretches
throughout the whole of psychology, select points are
particularly relevant. In striving toward the objectiv-
ity so highly valued under our society’s ruling metanar-
rative, psychological practice and research has adopted,
almost axiomatically, a “disease” model of psychological
suffering; we document symptoms and attempt to place
them into distinct categories which would have distinct
biological/behavioral underpinnings which can be dis-
cretely addressed. us, the experience of a disorder and
its treatment can be generalized and divided into discrete
components. It also implies that, as the symptom expres-
sor, the problem lies within the individual and so must be
addressed at that level. As was outlined through under-
lying Enlightenment philosophies earlier, these assump-
tions are natural outcomes; that the moral locus lies
within the individual’s own rationality (their claim to full
personhood) and so remains unquestioned within most
research models. As Higgs [18] purported, “the advance-
ment of neoliberal values and policies likewise favors nat-
uralizing inequality through the lens of biology, locating
the suffering caused by social problems within individual
bodies, which are perceived as self-contained and (ide-
ally) fully independent” (p. 138).
Given that such a model is conducive to research, con-
forms well to the needs of insurance and pharmaceutical
companies, and carries the implied authority of decades
of acceptance, the situation is self-reinforcing. Moreover,
the taxonomic model implies a baseline human expe-
rience, deviation from which constitutes the nature of
psychopathology. Given biologization and atomism, the
problem is seen as localized within the person, and treat-
ment focuses on the adjustment of biological systems
and the resolution of irrational thoughts and behaviors.
In so doing, the complexity of human psychology and
the entirety of subjectivity is done away with; a seri-
ous issue given that the psyche is defined by and expe-
rienced through subjectivity. Indeed, “a grisly tradition
of ‘biologizing social facts’ exists within psychiatry”
[18], p. 137–138). is divides much of psychology as a
body of knowledge from the bulk of clinical wisdom and
makes the training, expansion, and transmission of this
understanding difficult at best. It limits the field’s under-
standing of human psychology and our ability to address
individuals’ actual experiences. For example, in addition
to the model’s inability to discuss characterological dif-
ferences or dynamic interactions between disorders and
psyche, it has nothing to say about the positive side of
human experience as a necessary component of health.
Finally, while this complex is problematic for any psy-
chological disorder, it becomes more so the more deeply
and/or longitudinally it exists within the client, and the
further from placidity, conformity, and rationality it takes
her. A person experiencing an anxiety attack has a prob-
lem, a person with borderline personality disorder needs
extensive management, and a person with schizophrenia
is beyond the pale.
Philosophical summary andsubsequent steps
e broad philosophical assumptions which form the
basis for the rational-empirical model informing current
scientific inquiry have given primacy to objectivity as the
measure of truth as a matter of course. In so doing, it has
ultimately directed research and our collective under-
standing of psychology into a taxonomic and symptom-
based structure which will naturally prioritize biological
causation and atomistic approaches to treatment. Simul-
taneously, the same axioms which dictate our current
scientific paradigm contain implicit moral assumptions
which reflexively pathologize experiences, perspectives,
and expressions which are deemed “irrational,” regard-
less of whether they are themselves the source of distress.
is interaction has led to an overall approach to psycho-
logical research and treatment which stigmatizes patients
(particularly those on the schizotypal spectrum) while
concurrently falling short in developing effective treat-
ments and models due to inherent methodological flaws;
despite clear evidence that current taxonomies are unsta-
ble and that the assumed biological mechanisms underly-
ing them do not align with their framework. Moreover,
given the shared genealogy of both these processes, they
are self-reinforcing and inherently perpetuated through
the systems and approaches they generated. Without a
revolution within the paradigm (systemic schema), psy-
chology as a whole will struggle to fully grasp its subject
matter (the psyche). Much as in Piagetian models, it is
the failure of schemata to account for experience through
assimilation that sparks accommodation. Current evi-
dence from within our paradigm indicates a similar pro-
cess needs to occur to progress. us, developing a full
conceptualization of schizotypy requires an act of decen-
tralization and a re-examination of the current body of
evidence as a whole if the field is to mature.
In contrast to categorical approaches, current evidence
suggests that adopting a cybernetic model better captures
the complexity of the phenomena, the etiology of patho-
logical development, and ultimately offers insight into the
phenomenological bases of and treatment approaches for
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
the schizotypal population. Briefly, cybernetic models
seek to map the behavior of complex self-regulating sys-
tems. e mathematician Norbert Wiener defined cyber-
netics as the study of “control and communication in the
animal and the machine.” [46] and noted its applicabil-
ity to biological systems, computer systems, and broad
organizational structures such as governments. What
must be understood is that within a cybernetic model,
a number of interlocking processes exist within a net-
work of mutually influential relationships. Such systems
are reactive and attempt to reach equilibrium through
alterations in one or more of their domains. In the case of
small disturbances, a cybernetic system may merely make
a minor adjustment in one domain to achieve homeosta-
sis; however, in cases where a sufficiently large disrup-
tion occurs, the system as a whole may reorganize into an
entirely novel point of balance. In such systems, feedback
loops between systems are conceptualized; accounting
for how over time relatively minor interactions can rein-
force and strengthen each other sufficiently to cause such
a restructuring. It should be noted the conceptual reso-
nance such a framework has with Piagetian schemata,
Kuhnian paradigms, and many psychodynamic concep-
tualizations of personality development.
With this in mind, the following sections will begin
outlining relevant insights gained across a number of
disciplines outlining the qualities of the proposed schi-
zotypal population and suggesting the important factors
contributing to the development of experiences such as
schizophrenia.
The Schizotypal spectrum withincategorical models
While schizophrenia spectrum disorders have been rec-
ognized categories of pathology for many decades, the
debate about whether there is an underlying genotype
or phenotype which preceded each disorder is ongoing.
Indeed, there are larger limitations in the assessment
of schizophrenia spectrum syndromes than any assess-
ment’s individual construct validity. ese are under-
standable, due to the disorder’s complex etiology and
overall institutional focus on diagnosis as a starting point.
Given the vast number of contributing factors both pre-
ceding and subsequent to formal diagnosis, capturing
the most salient dimensions of any particular patient’s
experience requires a long list of assessments and exten-
sive clinical interviewing. at is, if there were a healthy
population out of which schizophrenia spectrum disor-
ders arise, one cannot know their characteristics except
perhaps through post-hoc inference as assessments cap-
ture only symptoms of the most extreme pole of disor-
ders. Currently, there is no comprehensive assessment
covering all or even most of the domains noted through
clinical research and experience. As such, developing
an informed treatment plan would demand a complex
exploratory phase and numerous specific follow-up
assessments to achieve reliable effectiveness; however,
given the stereotyped nature of current schizophre-
nia treatment [1–4], such a comprehensive assessment
would likely be too unwieldy for clinical use, or so broad
as to merely perpetuate the problem.
Despite this, the schizotypal spectrum exists implicitly
as an entire chapter in the DSM (though syndromes are
arbitrarily demarcated) in the temporal evolution from
brief psychotic disorder through to formal schizophrenia.
In contrast, the autism spectrum exists as a single F-code
with level of impairment handwritten in (Levels 1–3). At
the present moment, the field appears to be quite con-
fused as to how to understand the schizophrenia spec-
trum. is factor remarkably complicates assessment.
Despite diagnostic confusion, known empirical correlates
exist with MMPI3 and Rorschach, for example; however,
such correlates exist for personality traits [47], Mondal &
Kumar, 2021), which may be helpful in diagnosing shizoid
PD and schizotypal PD, but less helpful for a brief psy-
chotic episode all the way through to formal schizophre-
nia. One’s transient state greatly impacts presentation, a
second complicating factor of assessment. irdly, scales
on the MMPI such as Scale 8 (entitled “Schizophrenia”
on the MMPI2) and Restructured Clinical Scale 8 (RC8;
entitled “Bizarre Ideation”) on the MMPI3 do a fine job
gathering data on positive symptoms, as does the Achen-
bach System of Empirically Based Assessment’s “ought
Problems” subscale [48], however, negative symptoms are
easier to overlook and possess a more abstract develop-
mental quality. is is decidedly problematic given the
evidence that it is negative symptoms which most influ-
ence the etiology and the treatment of schizophrenia
spectrum disorders [49–51].
Toward issues around diagnosis the problem is even
more obtuse. As the current diagnostic model requires
the presentation of 2 or more serious symptoms such
as hallucinations or delusions for a significant period
of time and persistence of disturbance for six months
[8], clinicians are caught in an orientation of triage,
approaching the problem after the fact. While the DSM-
5TR does imply a manner of progression from brief psy-
chotic disorder to schizophreniform disorder and finally
schizophrenia, this interpretation also focuses on the
presentation of the most extreme symptoms, creates an
observational perspective (altering diagnoses as various
milestones are reached), and ultimately fails to properly
account for the broad heterogeneity of patient presenta-
tion and differential reactions to treatment [52, 53].
It is an essential theoretical assumption that underlies
the current paper that these categories more accurately
represent extreme presentations along a spectrum
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Page 8 of 19
Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
of “schizotypy”; essentially, a spectrum which mani-
fests diversity in presentation. Similar models already
exist within psychology [54], as does the overall diag-
nostic mindset (e.g. identifying and treating those on
the autism spectrum). It is believed that the spectrum
framework better accounts for the heterogeneity of
presentation and treatment outcome within the popula-
tion with implications for more accurate prognosis and
effective treatment. is also normalizes and contextu-
alizes the variability and range of symptom expression.
Said normalization carries not only ethical implica-
tions but also suggests dimensions of treatment that
offer increased dignity and resilience to those currently
experiencing the spectrum’s most distressing pres-
entations while simultaneously opening avenues for
pre-morbid interventions to prevent many otherwise
healthy schizotypal individuals from experiencing said
distress and its accompanying stigma. Indeed, “because
the incontrovertibly psychotic diagnosis of schizophre-
nia fits people at the disturbed end of the schizoid con-
tinuum, and because the behavior of schizoid people
can be unconventional, eccentric, or even bizarre, non-
schizoid others tend to pathologize those with schizoid
dynamics” [55], p. 196). Schizotypes find themselves in
a double-bind: those with poor insight often have poor
outcomes, and those who possess high insight are fre-
quently besieged with depression, low self-esteem, and
suicidality [56]. us, developing a comprehensive and
destigmatizing model is an essential element in treating
the population.
e presence or absence of psychosis is not an appro-
priate criterion measure of a distinct schizophrenia
spectrum condition, nor is it deviant or divergent.
Approximately 7% of the general population will have a
psychotic experience within their lifetime. Of those 80%
will be transitory, with only 7% going on to develop a
psychotic disorder [21]. Psychotic experiences are also
transdiagnostic and thus may be inappropriately con-
ceptualized as unique to schizophrenia. “It is only when
high levels of schizotypy are combined with other aetio-
logical risk factors that an individual may be considered
at risk for schizophrenia and other psychotic disorders.
According to this perspective, unless high schizotypy is
combined with other risk factors, it is considered neutral
in regards to psychopathology” [57], as cited in [20].
e overall focus on psychosis (and, its “irrational”
positive symptoms) is an axiomatic bias. However, there
is empirical and clinical evidence that a population exists
which is predisposed to psychotic experience and more
likely to do so for much longer periods of time. If true,
two questions must be answered. Firstly, what are the
qualities which define this population and how do these
qualities relate to psychotic experiences? Secondly, what
factors (internally and externally) select some members
for pathological expression?
Dimensional models
Spectra ofphenomenology
ere is significant evidence supporting a dimensional
reframing of psychological disorders [3, 39, 40]. During
DSM–5 field trials, 40% of diagnoses did not meet cutoff
for acceptable interrater reliability (IRR). Operational-
ized dimensionally, the same disorders achieved excellent
IRR [39]. A dimension, in this context, is a psychological
continuum stretching from the average range to extreme
expression. It is the individual’s degree along a dimen-
sion and his specific dimensional interactions that ulti-
mately lead to the higher order complexes addressed in
psychotherapy.
e Hierarchical Taxonomy of Psychopathology
(HiTOP) model, for example, describes ascending lev-
els of complexity beginning with dimensions and ris-
ing through components, traits, syndromes, subfactors,
spectra, and super-spectra. In such a conceptualization,
an individual traditionally diagnosed as having depres-
sion, anxiety, and an attentional disorder is understood
instead as having an interlocking network of specific and
interacting anxiety, avoidant, and/or internalizing dimen-
sions. Ultimately, a dimensional framework addresses
many of the problems within categorical models, includ-
ing heterogenous presentation, comorbidity, diagnostic
instability, and unstable boundaries with normal psy-
chological functioning, all while having a much stronger
empirical basis [39, 40].
In research on schizotypy and psychoticism, strong evi-
dence exists that individuals manifesting these disorders
instead represent a small cross-section of a more diverse
psychological phenotype within the general population.
As was noted, clinically significant psychotic experi-
ences are not uncommon in the general population [21].
In a six-year general population study, it was found that
subclinical positive psychotic experiences themselves
were insufficient to predict transition into clinical disor-
der; alternatively, it was the presence and persistence of
environmental factors such as childhood trauma, devel-
opmental problems and ethnic minority status, as wellas
severity of secondary distress due to these experiences
that best predicted a disorder status [3, 48]. Most individ-
uals with psychotic experiences also carry an additional
diagnosis (most often a mood disorder), and the presence
of such a disorder is highly predictive of poor progno-
sis [21]. is is consistent with epidemiological research
indicating that the negative symptom dimension (such as
poor emotional expression and avolition) is a strong pre-
dictor of outcome measures, including the need for treat-
ment at all [58].
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
As any phenomenology is reactive to its environment,
it can be understood how stressful and traumatic experi-
ences can begin altering patterns of cognition and behav-
ior along such dimensional lines. While the more extreme
presentations along the schizotypal spectrum (catatonia,
flat affect, delusional thinking, etc.) may appear entirely
unique, they are not inconsistent with trauma research.
ose suffering traumatic or sufficiently stressful expe-
riences often display magical thinking, irrational nar-
ratives, affectively-driven reactions incongruous with
present reality, and behavioral tendencies towards with-
drawal, explosive externalization, and somatic behavior
[59, 60]. Moreover, such experiences also create neuro-
logical and biological changes quite consistent with those
in schizophrenia [61–63]. us conceived, even the most
extreme presentations within the spectrum can be rooted
in explicable and often even beneficial human behaviors
and predilections, merely pushed beyond their capacity
for stress.
Given the above, there is reason to believe that much of
the current conceptualization of schizotypal individuals
suffers from a kind of survivorship bias. at is, research
is conducted and models are created based on those indi-
viduals already in sufficient distress to seek help, and in
attempting to reverse-engineer an etiology, the most
unusual symptoms are given priority. However, while the
presence of positive symptoms such as hallucinations or
delusions can certainly be distressing on their own, evi-
dence suggests that these symptoms are acute responses
to internal suffering and environmental stressors and
rarely, if ever, rise to the level of clinical significance
outside of prolonged and unresolved stress [48, 64–66].
From a dimensional perspective, any psychopathology is
understood as a dynamic interaction of symptoms influ-
encing each other over time. us, in the earliest stages
of an “illness,” symptoms are diffuse. Specific syndromes
manifest only after prolonged influence and interaction.
e specific expressed disorder depends on the nature
of the stressors, the developmental stage in which they
appeared, and their duration [48, 66]. Equally or more
important is the individual’s idiosyncratic response style
based on differentiation of dynamics between mental
states [48].
To reframe the problem in terms of the overall philo-
sophical blind spots outlined earlier: In trying to under-
stand the nature of schizophrenia so late in its etiology,
those elements which seem most alien to our implicit
beliefs about mental health are accepted as descriptive
of and central to “the problem.” Consequently, we ignore
those elements driving the observed symptoms, and sub-
sequent treatment becomes mere management of those
symptoms most distressing to norms and caretakers.
is may be necessary when a schizotypal individual’s
perceptions and thought patterns create distress, iso-
lation, or additional issues; however, it is insufficient to
claim that merely subduing these expressions is equiva-
lent to successful treatment, if the underlying sources of
stress, maladaptive defenses, and/or relational/attach-
ment experiences remain.
Personality organization andclinical
understandings
In her discussion about schizoid personality structure,
McWilliams [55] limned its key traits from a psychody-
namic perspective: (1) schizotypes are easily overstimu-
lated and report the experience of their own and others’
affect as overwhelming (p. 198), (2) often perceive the
world as threatening to damage or distort their individ-
uality and security; “A deep ambivalence about attach-
ment pervades their subjective life. ey crave closeness
yet feel the constant threat of engulfment by others; they
seek distance to reassure themselves of their safety and
separateness yet may complain of alienation and loneli-
ness” (p. 201). (3) As favoring the defense of withdrawal
(e.g. into fantasy or physical isolation) while often lacking
many of the more common defenses (though projection,
introjection, idealization, devaluation and intellectualiza-
tion are not unheard of); “Under stress, schizoid individ-
uals may withdraw from their own affect as well as from
external stimulation, appearing blunted, flat, or inap-
propriate, often despite showing evidence of heightened
attunement to affective messages coming from other” (p.
200). (4) they often speak and act in eccentric and non-
conforming ways and may have a natural reliance on
metaphor, symbolism, and creative expression when con-
veying thoughts and experiences; “Even when they see
some expediency in fitting in, they tend to feel awkward
and even fraudulent making social chitchat or participat-
ing in communal forms, regarding them as essentially
contrived and artificial” (p. 204).
Applied under a dimensional framework (not incon-
gruous with psychodynamic concepts such as defense
mechanisms) the above qualities lead to a probability field
of likely dynamics. For example, a person who instinctu-
ally withdraws when distressed, and receives little inter-
nal reinforcement for casual social interaction, is less
likely to develop robust interpersonal skills while being
simultaneously forced to understand and manage their
powerful affect without guidance or community. If such
a person also speaks and acts in an eccentric or unusual
way, while maintaining sensitivity to others’ reactions, it
is likely they will develop an “othered” conception of self.
It is straightforward enough to see a potential for self-
reinforcing patterns of pain, expression, social failure,
withdrawal, and isolation. If this combines with a pen-
chant for imagistic/symbolic thinking/representation, an
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
entirely separate phenomenological language could begin
to develop.
Germane to the larger point is that none of these com-
ponents are pathological in and of themselves. Indeed,
McWilliams argued that most schizoid-organized
individuals are quite functional, some even highly so.
Although they may be stigmatized and misunderstood
(even, and perhaps especially, within the mental health
field) due to an unexamined normativity bias [67], an
effective clinician should explore both the valid content
within their unusual expressions as well as the charac-
terological strengths rather than assuming them to be
meaningless, aberrant, or dangerous. In fact, she noted
that working with such a client may be quite pleasant
as they are often well in tune with their own internal
dynamics and how those influence their own experiences
and broader environment.
Personality research andparallels
A third conceptually parallel line of inquiry has been
conducted within the frameworks of Five Factor Model
of personality theory (FFM) which offers to blend the
phenomenological depth of psychodynamic understand-
ing with the scientific rigor of empirical inquiry along
dimensional lines. While debates about the structure,
components, evolution, and even the ontological nature
of human personality are nearly endless, FFM is notable
for several reasons. From a broadly conceptual stand-
point, FFM stands out in that its development was nearly
atheoretical; that is, rather than being reverse-engineered
from an existing psychological or culturally instantiated
models of human nature, it was instead derived in a bot-
tom-up fashion based on factor-analysis of patterns with
linguistic representations. is lends a certain assurance
that the model contains fewer a priori assumptions than
many of the other popular models espoused. Further-
more, from a more purely empirical perspective, FFM has
shown remarkable performance in research settings.
While the initial model was developed through a lexi-
cal analysis of English, subsequent studies have been per-
formed utilizing numerous other languages (e.g. Filipino,
German, Czech, Dutch, Korean, Hebrew, etc.), which
have reasonably confirmed the same five dimensional
structure [68–71]. Cross-cultural multivariate behavioral
genetic analysis demonstrated that the phenotypic struc-
ture of the FFM reflected a universal genetic and environ-
mental structure [72]. Longitudinal studies have shown
temporal stability across lifetime as well as the dimen-
sions’ antecedent impact on later psychopathology [73,
74], and FFM research indicates that dimensions such
as neuroticism and extraversion are central elements
underlying the vast majority of currently designated dis-
orders [75, 76]. is level of construct validity is lacking
in current DSM-based personality disorders [77], and as
was noted earlier in this paper, is an issue with current
disorder constructs categorically.
As with any living model, there are varying ways of
dividing and organizing the personality dimensions
depending on the area of inquiry. For example, some
models explore a construct directly labeled psychoticism,
while others do not. Given the modular and hierarchical
nature of the model though, it largely avoids the decoher-
ence this diversity might otherwise imply. At core, FFM
postulates that personality is composed of an individual’s
position along five continuous dimensions: extraversion
(sociability or positive affectivity), agreeableness (com-
passion or cooperation), conscientiousness (diligence or
constraint), neuroticism (emotional instability or nega-
tive affectivity), and openness (intellect or unconvention-
ality). Depending on the level of analysis, each dimension
can be meaningfully decomposed into sub-elements (e.g.
conscientiousness may be broken into component parts
of orderliness and industriousness) [78] which can then
be differentiated further into even more specific facets,
behaviors, and tendencies. It is worth noting that it is at
this level where the chirality between FFM and dimen-
sional models such as HiTOP comes into focus; they do
not neatly superimpose when reflected over each other;
FFM being a bottom-up model beginning with founda-
tional tendencies and investigating upwards and out-
wards, most other dimensional models may be viewed as
top-down, beginning with a psychopathological state and
deconstructing it into it constituent elements and ante-
cedents. In the latter case, explorations of experiences
such as hallucinations tend to cease at the point where
hallucination-like experiences do. If (as this paper postu-
lates) such higher-order expressions are emergent prop-
erties of entirely benign faculties, then such top-down
explorations will have little insight into this non-patho-
logical domain. Where FFM shows the greatest potential
as a framework is in its potential for providing phenom-
enologically causal explanations for behavior rooted in
“normal” personality structures while offering broad ave-
nues for research into biological instantiation.
e schizotypal spectrum has been a robust area of
interest within FFM research for a number of years. Most
consistently, schizotypal individuals score highly on trait
neuroticism and low on trait extraversion [79–81]. is
is unsurprising in light of previously mentioned clinical
profiles and the generally accepted symptoms within cur-
rent taxonomies, as negative affectivity is found to load
onto the former, while detachment loads onto the latter
[82]. Additionally, research has indicated that low agreea-
bleness is a factor in positive symptoms [81] and perhaps
in manifestations overall [83] and some research has
implicated low conscientiousness compared to “healthy”
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
controls [52]. Most contemporary factor research high-
lights specific subcomponents of each dimension (e.g.
the level of trust vs. mistrust within trait agreeableness is
often indicated as accounting for much of the variability).
However, given the high number and variability of these,
a full overview is unwieldy.
Of particular interest within FFM schizotypy research
is trait openness. While studies into the personality com-
ponents of psychopathologies have consistently found
meaningful contributions for the first four traits, the data
around openness is much more variable. is has led to
some speculation that trait openness is functionally dis-
sociable from psychological disorders [84, 85],however,
it is consistently found to be one of the best personality
markers for those on the schizotypal spectrum [86, 87].
In parallel, it has been shown to carry greater variance
with PID-5 Psychoticism [86].
e construct of openness provides perhaps the best
theoretical basis within FFM for understanding the
positive symptoms associated with schizotypy (e.g. hal-
lucinations, delusions, disordered thoughts/behaviors,
etc.). Broadly speaking, openness encompasses intel-
ligence and creativity, or one’s interest in ideas and
one’s interest in aesthetics [86]. It may be meaningfully
differentiated into subcomponents such as openness
to fantasy, aesthetics, feelings, actions, ideas, and val-
ues, and it is tied to scores on measures such as diver-
gent thinking and fantasy-proneness [34, 85]. ere is
an obvious conceptual link between these facets and
many of the positive symptoms of interest; however,
much of the research looking to tie the trait to spe-
cific symptoms has delivered conflicting results [86].
Some of the conflicting findings may be accounted for
by the complex nature of the trait. For example, it has
been demonstrated that while interest in aesthetics
meaningfully predicts variance in positive symptoms,
interest in ideas/intelligence has a negative correla-
tion with the same [86, 88]. is finding is supported
in neural modeling research demonstrating that psy-
choticism, openness, and their shared variance were
positively related to coherence in the default network
(simulation of experience rather than attention to sen-
sory input) and negatively related to coherence in the
frontoparietal cortical network (voluntary control of
attention), which have each been tied to psychosis and
trait intelligence respectively [88]. Further research has
shown that the positive dimension is better captured by
measuring the “maladaptive” poles of the traits (i.e. the
extreme high and low ends of expression) [83, 87, 89,
90]. Within a cybernetic model, this predictive extreme
is precisely what would be expected as such extremity
would require equally extreme adaptation to achieve
equilibrium. Moreover, with the context of the trauma
work cited earlier, one would expect that highly stress-
ful experiences would themselves push the natural
pathways of behavior into radical adaptation.
Schizotypal individuals obtain higher scores in diver-
gent thinking [91], a trait linked to openness as well as
creative performance generally [9, 87, 92]. Fractional
anisotropy measurements of white matter integrity have
shown “an apparent overlap in specific white matter
architecture underlying the normal variance of divergent
thinking, openness, and psychotic-spectrum traits, con-
sistent with the idea of a continuum” [92]. As well, trait
openness and creative achievement show a negative cor-
relation with latent inhibition (cognitive shielding from
information previously coded as irrelevant), indicating a
higher psychological permeability [89], consistent with
the noted sensitivity and eccentricity of schizoid individ-
uals within psychodynamic understandings.
FFM research generally finds openness to ideas and
openness to aesthetics to be distinct factors. ere is evi-
dence for opposing influences between the two factors
and positive psychotic symptoms, and correlational data
indicates a relationship between the aesthetic/fantasy-
prone dimension and schizophrenia spectrum disorders;
therefore, a discussion of the psychological concept of
aesthetics is relevant.
While a full interrogation of the science of aesthetics is
beyond the scope of this paper, contemporary literature
highlights some salient points about component experi-
ence. Firstly, that aesthetic appreciation derives neither
from simple perception nor from straightforward com-
plexity, but instead arises as a higher-order experience
comprised of an evaluative dimension (sensory‐motor),
a phenomenological/affective dimension (emotion‐valua-
tion), and semantic (meaning‐knowledge) and their neu-
ral correlates [93, 94]. Secondly, the appreciation arises
from the diversity of sources of information that come
into play, and the diversity of ways in which this informa-
tion can be used, combined, and associated [95]. irdly,
the aesthetic response can be reflexive and momentary,
or manifest in long-lasting mood shifts [95]. Notably, this
higher-order and emergent experience goes some way
toward accounting for some of the difficulty in measur-
ing motivational patterns in openness [36, 96], which
often seek to measure the value of merely novel informa-
tion without context. As well, to the extent that schizo-
typal-spectrum experiences load onto openness and are
dopaminergic, it dove-tails cleanly with dopamine mod-
els understanding the phenomenological function of the
neurotransmitter as coding emotional salience [97, 98].
As currently the dopamine hypothesis is one of the lead-
ing biological explanations for schizophrenia-spectrum
disorders, this begins to offer a more intuitive under-
standing of such findings.
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Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
Comprehensively, this evidence indicates that the aes-
thetic dimension of openness implicated in schizotypal
research is driven by an experience of derived or con-
structed meaning in complex stimuli. at is, recognizing
and associating patterns (across sensory, affective, and
cognitive levels) and deriving meaning. is is impor-
tant as it begins to provide a phenomenological outline
with potential neural mechanisms for many of the seem-
ingly more inexplicable traits associated with the spec-
trum such as delusional thinking, disordered speech,
and magical thinking in scientific research, as well as the
noted predilection for symbolic and metaphorical under-
standing and high affective sensitivity in psychodynamic
conceptualizations.
Contemporary approaches
Schizophrenia and related disorders occupy a unique
place within the social consciousness. While contem-
porary discourse around mental health has demystified
and destigmatized many disorders, experience of psy-
chosis is rarely included in this trend. Even within the
mental health field, individuals experiencing psychotic
symptoms are differentially received. Clinicians across
disciplines stigmatize patients with schizotypal spec-
trum syndromes more than patients with other diagno-
ses [99–101]. “Schizophrenia is one of the most serious
and frightening of all mental illnesses. No other disorder
arouses as much anxiety in the general public, the media,
and doctors” [102], p. 91).
De-stigmatising psychosis as a symptom both separate
from schizophrenia proper and “mad” in it’s own right
is a hallmark of the Hearing Voices Movement (HVM),
which began in the late 1980’s [18, 103]. “Some disabil-
ity scholars further emphasize the role of ‘madness as
testimony’: as Clementine Morrigan explains, so-called
symptoms occurring in the wake of trauma may in fact
be ‘acts of resistance to violence,’ a means of sounding an
alarm that something is very wrong” [18], p. 138).
More research is needed to establish an evidence-base
for Hearing Voices Groups (HVGs); however, such psy-
chosocial interventions hold promise, particularly since
isolation is often a hallmark of both schizotypy and psy-
chosis. Such group therapies approach treating the voices
(auditory hallucinations) as non-pathological and not
necessarily a sign that one is mentally ill. Participants
in HVGs have reported a sense of higher self-esteem
and social competence [104, 105], while those who have
learned to form more positive and active relationships
with their voices have reported a less negative and some-
times supportive and beneficial relationship with said
voices [106–108] Groups are growing, international, and
are usually led by a “voice hearer” and a clinical practi-
tioner. ough CBT interventions appear to be the most
promising in terms of change mechanisms, more rand-
omized clinical trials are needed [103]. Another psycho-
social intervention that may hold promise is the concept
of the Phone Pal (Into de Costa, 2020) to combat isola-
tion in those experiencing psychosis. Marriage and
family therapy is also effective for treating first-episode
psychosis and reducing relapse rates [109].
Read and Dillon [3] utilized a grounded theory
approach to collect qualitative data related to identifying
effective psychosocial interventions. Researchers found
that in cases of first-episode psychosis after which the
patient desired to talk about and explore the experience,
assisting the patient in such a discussion was therapeu-
tic. ough it may be theoretically “simple,” perhaps it is
in the process of relating to a caring and authentic other
that one may find and share one’s own voice and begin to
consolidate experiences. Such understanding embodies
insight, which then results in a patient who “integrates”
rather than “seals over” the psychotic experience. “Seal-
ing over is the tendency to dismiss the experience as hav-
ing little personal relevance, whereas ‘integration’ reflects
a curiosity about the experience and its personal signifi-
cance” [3], p. 180).
Within the Open Dialogue (OD) approach, patients
within the population required the use of neuroleptics
less frequently and for shorter periods [19]. While more
an approach to care than a specific intervention, the hall-
mark of OD is shared decision- and meaning-making
processes, aiming to guarantee both continuity of care
and an immediate need-adapted and social network-ori-
ented response. Research into interfamily therapy (which
seeks to generate a conversation where experiences can
be shared, and emotions can be expressed safely) has
indicated lower relapse rates, with fewer psychiatric
admissions and of shorter duration among patients dur-
ing the year of participation [109], while a meta-analysis
of 14 studies showed that family intervention in first psy-
chotic episodes led to a 58% reduction in relapse rates,
shorter duration of hospitalizations, less severe psychotic
symptoms and improved functionality up to 24months
after the intervention [110].
In accounting for trauma within psychosis treatment,
post-traumatic growth (PTG) was found to be elicited
through narrative interaction with themes of meaning
in life, coping self-efficacy and core beliefs; mediating
the relationship between total PANSS scores and PTG.
Notably, emotional experience was noted as the least fre-
quent facilitator of PTG, casting doubt on the symptom
-focused approaches of current treatment [111]. Con-
sistent with this, individuals experiencing psychosis who
engaged in poetry as a form of therapy and expression
reported greater experiences of integration and accept-
ance, and overall higher senses of meaning and efficacy,
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Page 13 of 19
Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
through the practice. It was postulated that such carni-
valesque spaces (in which the alternative, transgressive or
idiosyncratic are explorable and celebrated) directly sup-
ported the wellbeing of the participants [112].
Taken in aggregate, the successes and implications
of these approaches lends strong support to the over-
all premise of the proposed conceptualization. Namely,
that the targeted eccentricities of schizotypal individuals
are not themselves the issue within the population, but
instead it is underlying stress and distress which drives
the formation of states such as schizophrenia; and thus
must themselves be the target of effective intervention.
Moreover, that in reconnecting such individuals with
others, providing a voice to meaningfully express their
experiences, utilizing their sense of creativity and diver-
gent thinking, and engaging their inner representational
dynamic, the suffering experienced by schizotypal indi-
viduals can be mitigated without stigma or permanent
pharmaceutical interventions.
“A good metaphor for psychotherapy of psychosis
could be that it is a form of prayer: striving to bring
order out of chaos, helping patients recover confi-
dence in their humanness, seeking something of a
resurrection, returning the patient to emotional life
from a position of deadness” [3], p. 245).
Clinical implications
Taken as converging lines of evidence, the aforemen-
tioned paradigm allows for a reconceptualization of the
psychopathology currently understood as schizophrenia
and its related disorders as emergent properties of a par-
ticular spectrum of psychological predispositions under
stress. Although a dimensional model, it does not adhere
to any currently proposed but instead seeks to harmonize
the evidence collected across multiple lines of inquiry.
With this in mind, we propose a cybernetic model, which
accounts not only for the strengths of dimensional tem-
plates but provides a means for elucidating the nature
of development within and amongst those dimensions
over time; offering means of understanding the emergent
properties manifested in extreme poles or interactions.
Models such as HiTOP are understood as arriving at their
traits and dimensions from a predominantly “top-down”
approach, working backwards from observed disorders
to identify their constituent parts. Models such as FFM
are oriented from a predominantly “bottom-up” per-
spective, and so can better capture what may be meant
by normal personality. In so doing, it is proposed that
informed clinicians would better understand how a per-
son’s natural interest in aesthetics might predispose them
to proto-psychotic equilibrated states (thus aiding prog-
nosis and early intervention) while also indicating how
one might utilize this trait in strength-based treatment.
As FFM already contains frameworks for understanding
its dimensions as motivational frames, the component
forces driving the homeostatic tendencies within the psy-
che (which give rise to the defense mechanisms and idi-
osyncratic feedback loops schizotypal syndromes would
likely display) are explicable. While such a view certainly
helps to normalize what might otherwise be seen as inex-
plicable psychosis, it also offers avenues for more robust
and bespoke treatment and early identification of at-risk
individuals.
At very early ages these individuals would likely have
the heritable biological predispositions toward a specific
general profile of FFM personality traits; namely some
combination of high openness, low extraversion, high
neuroticism, and low agreeableness. Probable attributes
include high sensitivity to their external environment [55,
113] and relatively socially reserved disposition [55, 114].
Attachment theory research has shown how fundamen-
tal habits of behavior within mother-infant dyads create
characteristic patterns that reinforce over time (Bowlby,
as cited in [115]. Natural inclinations toward introversion
and cognitive abstraction are likely to become reinforced
by the overall social environment. Additionally, it is feasi-
ble that such individuals would be differentially rewarded
for information-seeking, complex and conceptual pat-
tern identification, and social interaction. As the indi-
vidual developed his natural inclinations combined with
idiosyncratic environmental patterns, disposition would
tend toward the broad personality profiles described in
psychodynamic literature,namely introverted, outwardly
eccentric, metaphorically and fantasy-oriented, affec-
tively and behaviorally sensitive, and favoring withdrawal
when psychologically threatened. ey would likely show
heightened divergent thinking, be creatively or intellectu-
ally motivated, display less regard for social expectations,
and show lower levels of trust in others overall.
Where the risk develops is in how these factors can
interact under highly stressful and traumatic experi-
ences. A natural tendency to withdraw rather than
express leaves a person, particularly a developing child,
far more vulnerable to further psychological damage [65,
116]. Childhood trauma victims often develop magical
or illogical narratives to conceptualize their experiences
while maintaining identity integrity and basic trust. Chil-
dren who do not externalize distress are far less likely to
receive direct help or more mature interpretations from
adults in their lives, and thus those beliefs are less likely
to be revised. Introverted and eccentric children are pre-
disposed to fewer and less frequent social interactions,
yielding a slower growth curve in social competence,
thus widening the gap and reinforcing natural tendencies
to withdraw. Higher natural neuroticism creates a more
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Page 14 of 19
Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
sensitive threat-detection response, which coupled with
natural distrust, high sensitivity to affect and behavior,
divergent thinking, and high internal motivation toward
complex pattern resolution, creates a network of feed-
back loops favoring loose, complex, affectively potent
interpretive frameworks built on an internal lexicon to
some degree tangential to consensus social understand-
ings. As initially small and disparate behaviors and cogni-
tive tools become habit, they begin to interact and create
more complex syndromes based on the individuals’ nat-
ural tendencies, their specific environment, and their
own phenomenological choices. e specific complexes
will be in some ways unique; however, they will follow
relatively predictable patterns. Based on the severity and
specific combination of these, an individual is then ulti-
mately given a categorical diagnosis of schizophrenia,
schizoaffective, etc.
What is principal under this view is that while the traits
underlying the more unique features of schizotypal psy-
chosis are involved in the etiology of the disorder, none
of them are themselves inherently pathological. Instead,
they act as “paths of least resistance,” and in some cases,
socio-behavioral risk factors when faced with highly
stressful or traumatic experiences. In many ways, the
symptoms of delusions, hallucinations, and disordered
speech/behavior, etc., would then represent the individ-
ual’s greatest psychological strengths pushed well out-
side of their functional equilibrium and ultimately forced
into self-reinforcing feedback loops. However, as it is
trauma and emotional pain acting as fuel for these spe-
cific symptoms, it is here where treatment ought to focus.
Certainly, the presence of psychotic symptoms would
necessitate approaches specific to their management and
interpretation; however, overall approaches would be
formulated much more heavily along trauma recovery
lines (i.e. establishing safety, building authentic relation-
ships, reconnecting with the social environment, etc.).
Indeed, it is likely that robust and prolonged treatment
would need to engage constructively with the individual’s
natural areas of strength as part of its process as they will
represent that individual’s highest yield sources of posi-
tive affect, self-esteem, social recognition, etc. For exam-
ple, to gain the benefits of greater social engagement, the
schizotypal individual must be given the skills to utilize
their naturally metaphorical style of communication
effectively (rather than pushing them to conform to more
traditional social expectations) for the interaction to feel
authentic and the sense of connection to be meaningful.
Within a cybernetic model of the human psyche, the
state of equilibrium is itself endlessly complex; inasmuch
as it requires achieving physiological needs, fulfilling
interpersonal needs, maintaining needs around iden-
tity and meaning, the solutions to which (in each case)
impact one’s ability to do each of the others and more.
is is further complicated by the fact that humans are
dynamic and goal-oriented creatures, and so this state is
itself a moving target constantly informed by experiences
and shifting patterns of response. For conceptual pur-
poses only, the specifics will be subsumed into the word
equilibrium for now; however, by utilizing this lens, clear
bridges can be made between the domains of clinical psy-
chodynamics, personality theory, and biological research.
What is frequently discussed under names of defense
mechanisms, cognitive distortions, and behavioral pat-
terns, etc., are understood as solutions and corrective
measures to achieve this equilibrated state, the specif-
ics of which are shaped by the natural inclinations of the
individual (e.g. low extraversion) and their idiosyncratic
experiences.
For example, an abused child may develop a narra-
tive of nearly magical self-blame, as their ability to solve
the problem of their suffering is nearly zero; however,
they must find a logical explanation for their experi-
ences to manage their anxiety, confusion, loss, and pain.
Less extreme, a socially anxious person may simply stop
engaging with people at all to keep anxiety tolerable. Each
person’s specific needs will vary based on their makeup
(this is roughly what is called “personality” in FFM), and
thus there will be characteristic strategies, obstacles, and
areas of flourishing individuals will construct along the
way. However, as psyches are permeable structures by any
measure, that natural equilibrium point can be moved
over a lifetime. Each adaptation creates new forces of its
own and must be accounted for by the others, thus neces-
sitating new adaptations. A stressor of sufficient dura-
tion or intensity may demand such extreme adjustment
that the settling point itself is (more or less) permanently
moved. Within the dimensional models such as HiTOP,
this is roughly the process by which dimensions impact
each other and combine to ultimately create symptoms
and syndromes.
In the case of schizotypy, we can highlight some ten-
dencies. Naturally high levels of emotional salience beget
heightened need for affect management; as they are likely
also to score high in neuroticism, much of this height-
ened affect is likely to be anxiety-related. Tendencies
toward introversion mean fewer opportunities to express
internal states or experience other’s internal states. Dif-
ferential motivation and reward systems create interest
toward complex and abstract constructs (ideas, aesthet-
ics, literature, etc.) and favors the individual toward inner
worldbuilding over outer worldbuilding. During stress-
ful experiences, natural tendencies to withdraw, to use
imagination and abstract problem-solving skills, etc. are
favored and likely to become habitual parts of identity.
As is with any human trait or capacity, these bring their
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Page 15 of 19
Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
own sets of challenges and advantages; however, they are
themselves neither pathological nor particularly unusual.
Nonetheless, under extreme or prolonged stress, his nat-
ural tendencies can put the schizotypal person at height-
ened risk. Tendencies to withdraw mean that they are
less likely to receive aid from others, and so prolonged
isolated suffering is more likely. Heightened emotional
salience means that the likelihood of an emotional over-
load is increased. Natural strengths in divergent think-
ing, coupled with tendencies toward abstraction, pattern
recognition, and problem solving are likely to leave an
individual anxiously searching their environment for
explanations for and solutions to their unbearable feel-
ings while receiving very little input from others.
Over time and based on the nature of the psyche-
environment interaction, the entire structure of psychic
equilibrium can begin moving in profound ways as the
individual attempts to use the tools available and the con-
ceptions to which they have experiential access, to navi-
gate the world and manage their own phenomenology.
us, natural abilities like divergent thinking, or tenden-
cies such as withdrawal into fantasy, begin to themselves
become overly stressed and utilized and may themselves
become sources of stress as the person moves through
life. However, while observing such a mind well into
this process (e.g. unequivocal schizophrenia), though its
entire makeup may appear fundamentally illogical, it is in
fact a complex psychological adaptation to challenges and
suffering in life. at is, constructs such as schizophrenia
are unstable, heterogenous, and contentious because they
are emergent properties within a complex and self-cor-
recting system. While certainly accounting for etiology,
heterogeneity, as well as currently clinically unaccounted
for though empirically verified biopsychosocial factors,
this frame also opens up approaches to treatment that
account for differential motivational patterns (as estab-
lished in FFM research), which indicate potentially effec-
tive strength-based modalities for the population.
Conclusion
e various models, perspectives, and orientations dis-
cussed so far represent a wide cross-section of interest
into the phenomenon of psychosis and schizophrenia
spectrum disorders, as well as personality and psy-
chological research. It is the stance of this paper that
these and others represent converging lines of evidence
for a schizotypal population naturally occurring within
the larger human population overall. Furthermore,
this population would span the range from “normal”
and “high-functioning” individuals to those experienc-
ing major and prolonged schizophrenic episodes. is
schizotypal population would thus be best conceptu-
alized as a cohort “at-risk” of schizotypal psychosis;
depending on the number of relevant traits held, their
overall intensity, their interactions with each other,
and interactions with the environment. e disor-
ders referred to as schizophrenia, schizoaffective,
STPD, etc., represent relatively stable emergent states
of consciousness appearing as a result of stressful and
traumatic experiences within an otherwise healthy pop-
ulation. While their specific presentations may be par-
ticularly disorienting and extreme within foundational
rationalistic frameworks, they are, in fact, extensions
of natural human adaptations under prolonged and/or
extreme duress.
Under the proposed conceptualization, a dimensional
model similar to HiTOP views the higher-order symp-
toms accounted for in the DSM as phenomena emergent
from specific combinations of more general and mutu-
ally influencing sub-traits and behaviors. Rooted in FFM
research, this model can be extended beyond simple
decomposition of maladaptive traits and defense mecha-
nisms and thus understand how such extreme outcomes
arise out of “normal” human personality features while
accounting for heritable and biological substrate noted
throughout the literature. Functionally, the model recon-
ceptualizes the biological and phenomenological devel-
opment of more extreme schizotypal presentations as a
cybernetic system, in which the ongoing interactions of
multiple elements attempting equilibrium to experiences
of trauma and stress (whether acute, periodic, or ongo-
ing) arrive at explicable resting states. us, disorders
such as schizophrenia can be understood as emergent
properties of more fundamental systemic interactions
rather than discrete disorders in and of themselves. Such
a model would account for the clinically significant dis-
tinction between those experiencing psychotic episodes
and those diagnosed with a schizophrenia-spectrum dis-
order, as well as the apparent contradiction between the
heterogeneity of presentation and the phenotypic resem-
blance of said disorders.
To the extent that the above is true, this allows not
only for a more accurate and tailored understanding of
etiology, but also suggests means of risk factor detection
early in life and a theoretically sound strengths-based
approach to treatment accounting for the underlying
affective and characterological engines behind currently
targeted symptoms. In so doing, the heterogeneity of
traditionally taxonomic disorders is accounted for while
offering conceptual bridges between biological, cogni-
tive-behavioral, and psychodynamic understandings of
the population and outlining explanatory frameworks
for differences between brief psychotic episodes, ongoing
and degenerative schizotypal-spectrum disorders, and
those cases of total or periodic remission attested to in
more culturally diverse literature.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 16 of 19
Longand Hull Philosophy, Ethics, and Humanities in Medicine (2023) 18:14
It is the hope of the authors that the proposed under-
standing of schizotypy as a spectrum rooted in natural
and even beneficial psychological functions, and with
explicable trauma-driven manifestations, will assist
not only in furthering the field’s knowledge of human
functioning and treatment of psychosis, but also begin
to remove the stigma and aversion which have grown
around the concepts. Grounded assessments for early
detection will offer incremental validity to a genuinely
biopsychosocial approach to research, treatment, and
ongoing patient management.
Acknowledgements
Not applicable.
Authors’ contributions
JL was responsible for the original ideas of the paper, the new conceptual
model, and the identification and elucidation of the philosophical and histori-
cal precedents. RH contributed to each of JL’s ideas by adding more explana-
tion or attempting to clarify concepts to readers. RH performed most of the
editing of the paper. All authors read and approved the final manuscript.
Authors’ information
JL is a philosopher and scientist, whose research interests include schizo-
phrenia spectrum conditions and psychoanalytic theory. RH is a licensed
psychologist.
Funding
Not applicable.
Availability of data and materials
Not applicable.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 3 April 2023 Accepted: 11 October 2023
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