Abstract
Eugen Bleuler, the founder of the concept of schizophrenia, pointed out that psychotic patients were able to live in two disjoint worlds (namely, the social, intersubjective world and the delusional world). He termed this phenomenon “double bookkeeping,” but did not provide any conceptual elaboration of this phenomenon or its possible mechanisms. Double bookkeeping has been neglected in mainstream psychiatry, but it has been addressed in recent theoretical work, however mainly concerned with the issue of delusion. In this article, we present clinical material that supports the view that double bookkeeping manifests itself across various psychotic phenomena and its antecedent may be observed in premorbid (pre-onset) phases as well as in the schizotypal disorder. We try to conceptualize double bookkeeping to concretize an often atmospheric perception of paradoxicality in the encounter with the patient. A phenomenological analysis of double bookkeeping suggests an instability in the affective (“auto-affection”) articulation of selfhood. We point to four main implications of our presentation: (1) diagnostic, (2) epistemological, (3) therapeutic and (4) pathogenetic research.
Highlights
Clinical observations of the phenomenon of double bookkeeping, not conceptualized with this term, can already be found in the works of Philippe Pinel [1] and JeanÉtienne Esquirol [2]
The notion of double bookkeeping was coined by Eugen Bleuler in his monograph on schizophrenia [3] and his subsequent textbook of psychiatry [4] referring to the patients’ ability to separate their delusional world from the everyday socially shared world
We need to emphasize that in these clinical examples we do not merely encounter a psychotic patient, who by necessity finds himself in our common world
Summary
Clinical observations of the phenomenon of double bookkeeping, not conceptualized with this term, can already be found in the works of Philippe Pinel [1] and JeanÉtienne Esquirol [2]. Sass proposed that delusions in schizophrenia rather than being concerned with the mundane (ontic) issues focus on the very (ontological) horizons of human existence [24] He emphasizes that the patient lives in a double reality with his delusional conviction forming a part of the reality with a “subjectivized” quality that is unconnected to the intersubjective world [5]. Insight is defined following the medical model and refers to when the patient is aware of suffering from diabetes and its symptoms and long-term risks We think that this approach to insight is not entirely adequate in the case of schizophrenia [39]. The experience of penetration into another ontological realm may be followed by cognitive and metaphysical elaboration of this experience with a formation of various delusional explanations, which the French psychiatrist Henry Ey termed “psychotic work” (travail psychotique) [18]
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