Introducing Oloudenia: A Novel Psychopathological Framework for Ambivalence in Psychosis

“To enjoy bodily warmth, some small part of you must be cold, for there is no quality in this world that is not what it is merely by contrast.” [1]. We experience by contrast. When introducing the foundational concept of “ambivalence”, Bleuler drew an analogy between the intricate dynamics of limb movements, where opposite forces of agonist and antagonist muscles interact, and psychological phenomena [2]. Ambivalence was thus meant as the co-existence at different levels of consciousness of distinct, even contradictory mental contents [3]. More than a century later, psychosis is still considered as a dreamlike state [4] wherein incongruent possibilities co-exist simultaneously. However, while dreams purely originate from ambivalent internal productions, ambivalence during psychosis arises from the amalgamation of internal and external stimuli. This increased permeability between internal and external realities stands as an intrinsic facet of all psychotic symptoms: hallucinations, delusions and thought disorganization. For instance, auditory hallucinations entail the perception of internal thoughts as external sounds. Yet, patients may also feel that they can access others’ minds. Likewise, delusions frequently reflect a disruption in the basic sense of self [5] where self and non-self identities can be present at the same time. Hence, a patient might concurrently hold beliefs of being his/her authentic self while also identifying as someone else (eg., Jesus). As the core self becomes fragmented, the boundary between the subject and the surrounding world blurs, potentially leading to the experience of diverse mental contents that interfere with each other. The so-called “thought crowding” [6] finds its expression in a disordered speech flow, wherein seemingly distant concepts are juxtaposed in incoherent patterns. The shared link between the co-existence of irreconcilable meanings and the loss of differentiation of internal and external realities contributes to shape the very concept of psychosis. Indeed, when idiosyncratic experiences are allowed to persist within the same consciousness, the contrast defining their boundary weakens. If these experiences involve both world-related and self-related stimuli, the external can seamlessly meld with the internal and vice versa. Among the major consequences of this misattribution lies the disruption of meaning, which is the boundary between semantic categories. Referring back to the aforementioned examples of psychotic symptoms, the meanings associated with the words “internal” and “thoughts” can recombine with those of “external” and “perceptions”, encoding internal processes as perceptions (hallucinations) or external events as own thoughts (ie., reading others’ minds).

The term “World/Self Ambivalence” has been coined to describe this bidirectional confusion of information [7]. While a certain degree of World/Self Ambivalence reflects the physiological connection between the subject and the object of his experience, its dramatic increase during psychosis - see Conrad’s concept of apophenia [8] - triggers the disruption of the world/self boundaries. At its utmost level, ambivalence becomes existential: On one hand, the ego expands and invades the world, on the other it dissolves in it [9]. Typically, we become aware of such paradoxes or mental conflicts due to our ability to perceive the cognitive dissonance arising from their contrast [10]. Anks to this innate process, we instinctively conceive ourselves as unique and separate entities from the world, as excessive World/Self Ambivalence is perceived as a logically incorrect or uncomfortable state of mind. Under the extreme circumstances of psychosis, the dissonance ceases to be perceived, and each stimulus is assigned equal-or aberrantsalience. Everything can be possible, causing meaning to erode until it holds no substance. The absence of contrast generates a state of maximum entropy, accepting all the possibilities but preventing the brain from encoding information through difference [11]. I propose to define the simultaneous presence of all (olos, όλος) and nothing (ouden, ούτεν) experienced during acute psychosis with the term Oloudenia. In this condition, where ambivalence reaches its pinnacle, the individual’s identity is severely threatened by a sea of possibilities with the same valence. The internal and external realities merge into a single atmosphere of awe allowing to feel both anguish and indifference at the same time. The firsthand experiences of experts by experience further clarify the bewildering sense of fusion and perforation of the world/ self boundaries perceived during acute psychotic episodes [12]. The notion of Oloudenia itself has been eloquently elucidated during a session where a patient shared insights on a psychotic breakdown he overcame: “…to consistently see the whole and the nothingness, to immerse oneself in one thing and in another at the same time, which is, in a way, the essence of psychosis.” In conclusion, Oloudenia encapsulates two interdependent aspects that characterize the most severe stage of psychosis. Firstly, the fragmented mind (literally, schizo-phrenia) seen as a multiplicity of co-existent meanings. Secondly, the merging of those meanings into a singular, unmeaningful ambivalence where internal and external realities collide.

1. Melville H, Moby D (1892) The white whale, New York, USA.
2. Kuhn R, Cahn CH (2004) Eugen Bleuler’s concepts of psychopathology. History of psychiatry 15(3): 361-366.
3. Graubert DN, Miller JS (1957) On ambivalence. The Psychiatric Quarterly 31: 458-464.
4. Limosani I, D’Agostino A, Manzone ML, Scarone S (2011) The dreaming brain/mind, consciousness and psychosis. Consciousness and cognition 20(4): 987-992.
5. Nelson B, Fornito A, Harrison BJ, Sass LA, Yung AR, et al. (2009) A disturbed sense of self in the psychosis prodrome: Linking phenomenology and neurobiology. Neurosci Biobehav Rev 33(6): 807-817.
6. Sass L, Pienkos E (2013) Varieties of self-experience: A comparative phenomenology of melancholia, mania, and schizophrenia, Part I. Journal of Consciousness Studies 20(7-8): 103-130.
7. Damiani S, Poli LF, Brondino N, Provenzani U, Baldwin H, et al. (2020) World/self ambivalence: A shared mechanism in different subsets of psychotic experiences? Linking symptoms with resting-state fMRI. Psychiatry Research: Neuroimaging 299: 111068.
8. Conrad K (1958) The beginning of schizophrénia (Attempt at a Gestalt Analysis of Madness): Stuttgart, ed Georg. Thieme, Germany.
9. Stoliker D, Egan GF, Friston KJ, Razi A (2022) Neural mechanisms and psychology of psychedelic ego dissolution. Pharmacol Rev 74(4): 876-917.
10. Jones EH, Mills J (2019) An introduction to cognitive dissonance theory and an overview of current perspectives on the theory. American Psychological Association pp. 3-24.
11. Northoff G (2013) Unlocking the brain: Volume 1: Coding: Oxford University Press, UK.
12. Poli PF, Estradé A, Stanghellini G, Venables J, Onwumere J, et al. (2022) The lived experience of psychosis: A bottom‐up review co‐written by experts by experience and academics. World Psychiatry 21(2): 168-188.