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The goal of this activity is to update readers about the putative link between personality disorder and dangerousness.

1. Understand 3 cardinal elements contributing to legal definitions of dangerousness (namely, danger to self or others, inability to care for self, and, potentially, the need for treatment), and describe the empirical link between Cluster B personality disorders and violence.

2. Identify 3 limitations inherent in using risk assessment tools to verify the link between personality disorder and dangerousness (namely, categorical DSM classifications, the influence of social norms, and the redundancy of definitions that include aggression).

This accredited continuing education (CE) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Physicians’ Education Resource®, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Driven by a mandate to protect the public, many Western jurisdictions call upon psychiatrists, particularly

, to evaluate dangerousness in individuals with mental disorders. Such evaluations occur for civil and criminal proceedings, bail and parole determinations, and hospital and emergency department discharges.

 While risk assessment has become a relatively uncontested part of criminal proceedings in places like the United States and the United Kingdom (UK), the influence of expert testimony on civil commitment, guardianship, sentencing or release, and the attendant civil liberties require a careful look at the accuracy and reliability of expert assessments,

 especially among the prevalent but commonly misunderstood personality disorders.

This article examines the empirical literature on the link between 

 and dangerousness, the limitations inherent in using risk assessment tools to verify the link, and the ethical issues surrounding the assessment.

The DSM-5 defines personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in early adolescence or early adulthood, is stable over time and leads to distress or impairment.”

This definition attests to the pervasive, persistent, and problematic nature of the disorder, not just how the individual is currently presenting. DSM-5 recognizes 10 types of personality disorder (apart from personality disorder not otherwise specified).

 These are classified into 3 well-known clusters: Cluster A (paranoid, schizoid, schizotypal); Cluster B (antisocial, borderline, histrionic, narcissistic); and Cluster C (avoidant, dependent, obsessive-compulsive).

Five major epidemiological studies in the United States showed overall prevalence rates of around 10% for any personality disorder.

 The comprehensive National Comorbidity Study Replication reported a past-year prevalence of 9.1% for any personality disorder among adults 18 years and older.

 The most common personality disorder was the avoidant type (5.2%), followed by schizoid (4.9%), schizotypal (3.3%), obsessive-compulsive (2.4%), paranoid (2.3%), borderline (1.6), antisocial (1.0%), and dependent (0.6%). The study recorded no cases of histrionic or narcissistic personality disorders. Although the National Epidemiologic Survey on Alcohol and Related Conditions did not report an overall prevalence rate for personality disorders, it did identify higher rates for histrionic (1.8%)

In contrast, European studies report lower prevalence rates. For instance, the British household survey of more than 8000 respondents found a prevalence rate of 4.4% in the general population, with higher rates being reported in men, the unemployed, those who were separated or divorced, and those living in urban areas.

Notwithstanding variations in prevalence, personality disorders, particularly antisocial personality disorder (AsPD), exact a substantial health and economic burden, affecting health service utilization, unemployment, criminality, suicidality, and 

 AsPD has particularly strong effects on violence.

One challenge to linking personality disorder to dangerousness is that no universally accepted definition exists, although some commentators distinguish clinical and legal dangerousness.

 regarded it as “a propensity to cause serious physical injury or lasting psychological harm.”

 More recent definitions are mainly legal, so they vary across jurisdictions. A notable exception intended to assess and treat individuals with Dangerous and Severe Personality Disorder (DSPD) is the UK’s DSPD Program, launched in 2001 in 2 high-security prisons and 2 high-security forensic hospitals. An individual was classified as having DSPD if they showed evidence of both dangerousness (defined as a high risk of harm to others) and severe personality disorder, as well as a functional link between the 2. Severe personality disorder was operationalized as high scores (25 or above) on the well-established Psychopathy Checklist–Revised, in conjunction with at least 1 personality disorder other than antisocial, or 2 or more personality disorders.

 The program was a costly one that catered to the needs of only a few hundred individuals with DSPD who were detained in maximum security. There was little or no provision for those living in the community. It was eventually ended in favor of a new community-based strategy for managing personality-disordered offenders. The new strategy adopted a whole-systems approach across the criminal justice and health systems, recognizing the various stages of an offender’s journey from sentence through community reintegration.

Legal definitions tend to be prescriptive. For example, in the United States, the evolution of dangerousness is most clearly seen in statutes on civil commitment, where dangerousness ultimately replaced illness as a standard for hospitalizing individuals against their will.

 Often traced back to the passage in the District of Columbia of the influential Ervin Act of 1964 (an early piece of influential legislation named for US Senator Sam Ervin of Watergate fame), dangerousness usually required an imminent threat, generally interpreted as physical harm to oneself or others. A right to treatment based in the US Constitution’s due process clause never materialized. Many states instead followed the District’s commitment model, emphasizing the specific link between mental illness and danger. The US Supreme Court ultimately underscored the risk of harm, adding the inability to care for oneself and intimating that treatment may be required as well.

Under the UK’s Criminal Justice Act 2003, an offender is classified as dangerous “if the court is of the opinion that there is significant risk to members of the public of serious harm occasioned by the commission by him of further specified offenses.”

 A “specified offence” is a violent, sexual, or terrorism offense, and “serious harm” means “death or serious personal injury, whether physical or psychological.”

A consideration common to most legal definitions is that dangerousness is a relatively stable attribute of the individual,

 although scientific evidence shows that human behavior is influenced by a complex interplay of individual and environmental factors.

This is a conflict that calls for a comprehensive clinical assessment for any individual facing a concern for 

, including a review of protective factors.

Current approaches to assessment of dangerousness rely on violence (including sexual) risk assessment tools, which fall into 3 broad categories (

): unstructured clinical, actuarial, and structured professional judgment. While the unstructured clinical approach performs better than chance in predicting future violence, it has been criticized for lacking reliability and validity.

Actuarial approaches rely heavily on static (unchangeable) risk factors (ie, sex, prior offenses, age at release) and provide probabilistic estimates of the risk of future violence within a specified time period.

 Actuarial approaches have been criticized for leaving no room for clinical discretion and for relying on factors that are not amenable to change.

 Additionally, their accuracy in predicting rare events has been contested because they rely on information derived from group data to assess risk for an individual.

Structured professional judgment approaches rely on a constellation of actuarial and dynamic (changeable) risk factors that have been empirically associated with future violence. While they help bridge the gap between clinical and actuarial approaches, structured judgments are resource intensive and their predictive value is often less than robust.

While each approach has its advocates and critics, none is wholly satisfactory.

 A problem common to actuarial and structured professional judgment is the difficulty inherent in predicting a behavior with a low base rate. To illustrate the point, Singh et al reported significant variations in actual rates of violence in individuals identified as high risk by structured instruments, likely due to failure to account for local base rates for violence.

 Although collateral information about violence rates in the geographic area may be useful, the issue of how to obtain and incorporate this information into risk assessments is yet to be determined.

Another problem is the variability in predictive accuracy of these tools. In 74 samples totalling 24,847 individuals, for example, Fazel et al assessed the predictive validity of the 9 most commonly used tools assessing the risk of violence, sexual, and criminal behavior (

 The authors reported that although violence risk-assessment tools performed better than those designed to predict sexual and general offending, they had a median predictive value of only 41% with a corresponding median number needed to detain of 2 (range, 2-4). The evidence did not support the use of these tools as sole determinants of decisions related to detention, sentencing, and release.

Similarly, Buchanan and Lesse reported on the sensitivity and specificity of actuarial and structured tools used to predict future violence among adults in the community.

 They reported a mean sensitivity of 0.52 (essentially a coin toss) and mean specificity of 0.68; the corresponding number needed-to-treat for these tools was 6. These are hardly encouraging numbers for assessments that carry significant dangers of detention, 

, particularly Cluster B, and violence is well-documented.

 For example, the British Household Survey found that individuals with a Cluster B personality disorder were 10 times more likely than those without to have a criminal conviction, whereas individuals with a Cluster A or C personality disorder were no more violent than the general population.

 Indeed, Yu et al reported an odds ratio of violence of 12.8 for those with AsPD compared with the general population.

, the mechanisms which mediate the link remain poorly understood. Any analysis must begin with the distinction between risk and causal factors. A risk factor is one that consistently predicts an outcome, while causality requires that certain criteria are actually met. These criteria are (1) covariance between the predictor and outcome (a measure of how much 2 factors vary together); (2) temporal precedence (ie, the predictor preceding the outcome); (3) exclusion of other plausible explanations; and (4) a logical connection between the predictor and outcome.

In applying these criteria to the relationship between personality disorder and violence, Duggan and Howard found no unequivocal evidence to support a causal relationship, emphasizing the need to specify an understandable mechanism by which the disorder causes violence.

 They suggested that other variables like comorbidity with both DSM-IV Axis I and II may mediate the relationship.

However, a major obstacle to research and analysis is the problem inherent in the assessment and diagnosis of personality disorder itself. Current psychiatric classification systems like the DSM-5 are categorical and heavily influenced by prevailing social norms, whereas personality traits are dimensional in nature.

 This means that categorical measures of personality disorder are of limited validity, and that diagnosis may vary from one assessment method to another.

 This distinction between approaches (whether conditions fit neatly into a category or along a spectrum) continues to confound diagnosis because conditions overlap and differ in their range of impairment and severity. The DSM itself in 2013 described dimensionality as an emerging model, encouraged further research, and included dimensional approaches alongside the traditional categorical approach.

Another obstacle is the issue of circularity or redundancy.

 This arises because the diagnostic criteria for some Cluster B personality disorders include attributes that are already associated with criminality, namely 

, anger outbursts, hostility, impulsivity, and callousness. The relationship between personality and violence is further confounded by comorbidity. Individuals with personality disorder typically present with more than 1 personality disorder, as well as other common disorders such as 

 Similarly, personality disorders, particularly cluster B, are highly prevalent among individuals with substance use disorders, with an overall prevalence rate of 56.5% reported among patients treated for addictions.

 These may all contribute to violence risk and further confound the link between personality disorder and violence.

A commonly reported comorbidity in forensic populations is the co-occurrence of antisocial and borderline personality disorders, alongside psychopathy. This has been linked to a wide range of antisocial outcomes, including both the severity and versatility of violent offending, as well as substance misuse.

A persistent conundrum is the mechanism through which personality disorder, including personality comorbidity, is linked to violence. It has been suggested that factors linking personality disorder to violence may include emotional dysregulation, deficits in self-regulation, early-onset alcohol abuse (18 years or younger), and impulsivity.

 Influential factors can be protective as well, since some have been associated with desistence from crime. These include employment, marriage, association with prosocial peers, developing prosocial values and behaviors, and others.

Beyond matters of scientific uncertainty, the ethics of working where psychiatry and the law overlap is bound to give rise to tensions between safety and liberty, and between the individual and the community. Denying one’s liberty on the grounds of a clinical opinion (diagnosis) couched in legal language (dangerousness) goes well beyond definitional uncertainties. Practitioners must be explicit about their inferences and opinions because the patient’s best interest matters to both law and psychiatry.

 At the same time, the community’s safety is a time-honored consideration as well. Balancing these influences is neither a medical nor legal exercise alone.

The traditional ethics question posed to psychiatrists assessing violence risk is this: Do they serve medicine or the law? Newer perspectives on forensic agency take views that advocate more clearly for the dignity of individuals and the professionalism of practitioners when pitting vulnerable patients against large social systems.

 It is important to remember that patients require support and advocacy when facing assessments that threaten their freedom, including appropriate informed consent and robust warnings on the limits of 

Risk assessment itself is bound to raise ethical issues. As neither a medical nor psychological concept, it is not yet an exact science. There is disagreement about ethical values and what constitutes a risk to the community. There may be differences between professionals like judges and physicians, between professionals taking an actuarial or structured approach, and between plaintiffs and defendants. These are the tensions of an evolving science that incorporates medical, legal, and psychological concepts all at once (

). Sadly, the community retains unrealistic expectations that psychiatrists can protect society with accurate assessments of rare events like physical or sexual violence.

Although the link between some personality disorders and violence is well documented, much still remains to be learned about the factors that mediate the link. Indeed, some of these factors may be outside the sphere of medicine. The limitations are therefore manifold.

First, current measures of personality disorder are of limited validity and are heavily influenced by prevailing social norms.

Second, dangerousness is neither a medical nor psychological concept. It is primarily legal and varies across jurisdictions.

Third, current assessment tools are far from perfect. Certainly, the current evidence suggests that their use as sole determinants of dangerousness is fraught with difficulty.

Fourth, professional ethics require acknowledging the uncertainty of scientific methods, methods that enter a social forum like the courts where nonmedical standards of morality and culpability apply.

Finally, a determination of dangerousness carries a heavy stigma for the individual concerned, alongside the potential denial of liberty.

Ultimately, risk assessments are more appropriately conducted as part of a broader clinical process aimed at developing risk management plans for high-risk groups.

 For individual assessments, they require robust informed consent, warnings on the limits of confidentiality, and a strong understanding of low base-rate phenomena and the jurisdiction’s definition.

 is an associate professor in forensic psychiatry at Queen’s University, Kingston, Ontario, Canada. He is also the regional psychiatry lead for the Ontario Region of Correctional Service Canada.

is director of medical affairs at Saint Elizabeths Hospital in Washington, DC, and professor of psychiatry and behavioral sciences at The George Washington University School of Medicine and Health Sciences.

Reversal of fortune: the resurgence of individual risk assessment in criminal justice. 

Dangerous offenders, indeterminate sentencing, and the rehabilitation revolution.

Predicting the risk of future dangerousness. 

4. Duggan C, Howard R. The ‘functional link’ between personality disorder and violence: a critical appraisal. In: McMurran M, Howard R, eds. 

Personality, Personality Disorder and Violence: An Evidence-Based Approach.

5. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.

Personality disorders: a nation-based perspective on prevalence.

7. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. 

DSM-IV personality disorders in the National Comorbidity Survey Replication.

8. Grant BF, Stinson FS, Dawson DA, et al. 

Co-occurrence of 12-month alcohol and drug use disorders and personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions.

9. Stinson FS, Dawson DA, Goldstein RB, et al. 

Prevalence, correlates, disability, and comorbidity of DSM-IV narcissistic personality disorder: results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions.

Violence and psychiatric morbidity in the national household population of Britain: public health implications.

Personality disorders over time: precursors, course and outcome.

Dangerous severe personality disorder—bad tidings from the UK.

13. Her Majesty’s Stationary Office. Report on the Committee of Mentally Abnormal Offenders. 1975. CMND 6244. London HMSO.

14. Hare RD. The Hare Psychopathy Checklist – Revised. 2nd ed. Multi-Health Systems; 2003.

15. Howard R, Khalifa N, Duggan C, Lumsden J. 

Are patients deemed ‘dangerous and severely personality disordered’ different from other personality disordered patients detained in forensic settings?

A joint offender personality disorder pathway strategy: an outline summary. 

18. Civil Commitment and the Mental Health Continuum: Historical Trends and Principles for Law and Practice. Substance Abuse and Mental Health Services Administration; 2019. Accessed August 9, 2021. 

https://www.samhsa.gov/sites/default/files/civil-commitment-continuum-of-care.pdf

19. O’Connor v Donaldson, 422 US 563 (US 1975).

20. Parliament of the United Kingdom. Criminal Justice Act 2003. Section 337(1), Act No. 44 of 2003.

Moving on from old dichotomies: beyond nature-nurture towards a lifeline perspective.

22. Litwack TR, Schlesinger LB. Dangerousness risk assessments: research, legal and clinical considerations. In: Hess AK, Weiner IB, eds. 

Comparative efficiency of informal (subjective, impressionistic) and formal (mechanical, algorithmic) prediction procedures: the clinical-statistical controversy.

A prevention-based paradigm for violence risk assessment: clinical and research applications.

25. Singh JP, Fazel S, Gueorguieva R, Buchanan A. 

Rates of violence in patients classified as high risk by structured risk assessment instruments.

Use of risk assessment instruments to predict violence and antisocial behaviour in 73 samples involving 24 827 people: systematic review and meta-analysis.

Detention of people with dangerous severe personality disorders: a systematic review.

Personality disorders, violence, and antisocial behavior: a systematic review and meta-regression analysis.

29. Chang Z, Larsson H, Lichtenstein P, Fazel S. 

Psychiatric disorders and violent reoffending: a national cohort study of convicted prisoners in Sweden.

Violence and psychiatric morbidity in a national household population—a report from the British Household Survey.

In this CME, the link between personality disorders and violence is explored. Much still remains to be learned about the factors that mediate the link.

Personality Disorder and Dangerousness

There are 13 million adults with borderline personality disorder (BPD) in the United States and, of that number, 1.5 million are adolescents, Carl Fleisher, MD, told attendees of the 2021 Annual 

 World CME Conference. To best support them, there are 3 things you need to do, added Fleisher, assistant clinical professor of psychiatry at University of California Los Angeles Health.

To kick off the discussion, Fleisher shared the case example of “Hannah,” a 16 year old girl who presents wondering if she has BPD after Googling her experience. Specifically, she has rapid mood swings, feels numb more often than sad, and cuts herself superficially several times a week. She has 1 friend and spends all of her time with that friend in fear the friend will desert her. She is interested in boys, but she avoids them. Hannah does not voice her needs to parents, teachers, or friend; instead, she goes along with whatever they want or like.

The first thing to do, therefore, is to make the diagnosis, Fleischer said. To do so, there are 9 criteria to consider, and sometimes it feels like they are all over the map. As such, the patient might not see the connections, so it is important to help draw them for patients. One way to do that, he explained, is to use a model of interpersonal hypersensitivity. Since we all want and need to be in relationships, and we are hypersensitive, we may have a fear of abandonment. From there, you can talk about the other symptoms.

 for rapid assessment of patients. It helps patients think things through, he explained. It also provides an opportunity for further discussion, as the clinician may have a different perspective than the patient does on a particular item.

Most patients are relieved when they finally receive a diagnosis, Fleischer said. He shared the following patient perspective: “It explained a lot of things and I felt an enormous sense of relief that there was an explanation for the way I was.”

The second thing is to refer to helpful resources, including psychoeducation, support, and treatment strategies, Fleisher said. He recommended a number of resources both for patients and their clinicians: the National Education Alliance for Borderline Personality Disorder, Mentalizing Initiative, the Anne Freud National Centre for Children and Families, and McLean’s Borderline Personality Disorder center.

In terms of treatments, there are 4 evidence-based psychotherapy modalities, Fleisher said. They include dialectical behavioral therapy, transference-focused psychotherapy, mentalizing-based therapy, and good psychiatric management, which is not an orientation but more of framework for clinicians. “It is also possible also that a plain old talk therapy is an adequate treatment for borderline personality disorder, especially if you have nothing else,” he told attendees.

It is also important to consider psychoeducation and family support, Fleischer added. He shared the results of a study looking at the impact of 6 weeks of psychoeducation on patients. The investigators found that symptoms reduced greatly—by about half—and stayed low for 2 months after the intervention protocol.

 Similarly, since caregivers and family members are under a lot of stress and strain, it is important to broaden the treatment lens and provide support to them, too.

Unfortunately, Fleischer noted there are no medications approved by the US Food and Drug Administration to specifically treat BPD. Likewise, there is no medication that is uniformly helpful. Too often, patients find themselves on multiple medications, he said, and polypharmacy poses a significant danger because of adverse effects, like weight gain associated with antipsychotics.

“We can do a whole hour-long talk on just medication for BPD, but the short of it would be: If you're going to use medication to treat one of the comorbid illnesses that BPD presents with, as opposed to this BPD itself, then you can try that,” Fleisher told attendees. “But if we're going to try to treat the symptoms of BPD itself like lability, paranoia, that sort of thing, then it may be that we want to consider a brief trial of medication to get people through a crisis.” After using the medications in a way that is helpful, it is important to consider taking it away, because we do not expect them to be helpful in the long-term and do not want to cause a problem of polypharmacy, he added.

The third thing to do is to monitor the effectiveness of the treatment, Fleischer said. Start with baseline measurements on the areas you and the patient want to address, be it self-harm, work performance, risky behaviors, and quality of life and relationships.

With these 3 things in mind, Fleisher concluded, clinicians can best support their patients with BPD. As he told attendees, “Borderline personality disorder is worth treating, and people with BPD are very rewarding to work with.”

1. Lester R, Prescott L, McCormack M, Sampson M; North West Boroughs Healthcare, NHS Foundation Trust. 

Service users' experiences of receiving a diagnosis of borderline personality disorder: A systematic review.

2. Ridolfi ME, Rossi R, Occhialini G, Gunderson JG. 

A Clinical Trial of a Psychoeducation Group Intervention for Patients With Borderline Personality Disorder

 2019;81(1):19m12753. Published 2019 Dec 31.

These 3 essential steps best support patients with borderline personality disorder, according to Carl Fleisher, MD. 

Borderline Personality Disorder: 3 Things You Need To Do for Patients

Disordered selfhood may be a core phenotypic trait of schizophrenia spectrum disorders. This article is written from a European 

 In Anglophone psychiatry, phenomenology refers to a simple layman description of signs and symptoms, the latter preferably in their behavioral aspects. The symptom is viewed as a well-defined, quasi-objective entity liable to unproblematic quantification. For example, using the 

 presupposes the conception of a symptom as a pre-existing ripe fruit only waiting for a push from a pre-formed question in order to come into full view.

The term phenomenology used here is different from American usage. It refers to a faithful exploration, description, and conceptualization of the patient’s contents and structures of subjective life and modes of existence (eg, not only the content of the delusion but its mode of emergence and articulation and ways of experiencing the delusion).

Such an approach should minimally include:

Interviewing the patient in a way that maximizes their spontaneous self-descriptions, which can provide concrete and manifold examples of their abnormal experiences. This requires a non-judgmental attitude that prevents the clinician from prematurely reifying and classifying the patient’s inner life.

Such an interview, however, also requires that the clinician is knowledgeable, possessing a rich conceptual repertoire. An old dictum says, “perception without concept is blind.” In other words, if you are not well-read or trained, you will not be able to hear what the patient is trying to convey to you.

The rediscovery mentioned in the title concerns a profound dis-order of subjective life in schizophrenia. Distortions of subjective life for the patient is often their usual mode of existing in the world, and they only become accessible for the interviewer when they successfully facilitate the patient’s self-reflection and verbalization. The following patient perspective provides a clear idea what is at stake:

This dissolved self . . . It is a truly dissolved self. I feel that I am everywhere and nowhere at the same time. It is like a dream in which I am not present. It is like a sea where you can see fishes and plants and there is a current of water. It is in such a way that I feel that I am present. Not as a fish or a plant but as a current of water. My life feels like a manuscript written by someone else. I am open to the idea that my childhood was not my own. That my childhood is somebody else’s and that I have taken it over in some way. If you said to me that what I am telling you actually is about my friend instead of me, then I would be open to this suggestion. That my ideas stem from a movie or from another person.

This very metaphorical and evocative narrative conveys that the patient seems to lack a stable and substantial sense of self as an anchor and a vantage point. Normally our sense of self permeates our thinking, perceiving, and feeling. This patient experiences a disconnection from her thinking, speaking, and remembering, involving a global alienation toward herself. Although such rich descriptions are not very frequent, most of the patients are able to verbalize similar experiences in a more restricted vocabulary.

 between the narrative self (personality) and the minimal or basic self.

 If you ask a random individual on the street “who are you?” the person may respond “I am Paul Brown, 30 years old, working as an engineer.” He may proceed with information about his life history, his characterological traits, 

, preferences and goals, and the like. This level of selfhood we usually call personal identity or, in technical terms, the narrative self.

This level of selfhood is a complex and continuously evolving self and self-identity that is anchored in the individual’s biography and heavily dependent on language and memory. It is a narrative that contributes to create a self-coherence for ourselves and others. However, Paul Brown will certainly not tell us that he is experiencing everything in the first-person perspective; yet the first-person perspective is the condition for all these complex personality features to emerge.

This is the level of the so-called “minimal” or “basic” self, which implies that all my experiences (perceiving, thinking, remembering) articulate themselves as my experiences. When I am thinking about something, I do not ask myself who is doing the thinking. But this dimension of me (me-ness or mine-ness) is simply a tacit, automatic, and pre-reflective dimension of all my mental life. This elementary sense of selfhood also implies a sense of self-coincidence (I am always at one with myself) and affectively felt self-presence and self-persistence.

This basic self is the most intimate nucleus around which more complex features of the narrative self-coalesce. We believe that the central disorder of schizophrenia and schizotypal disorder consists in the instability of the basic self, leading to varieties of self-alienation, basic identity problems, and a whole area of cognitive and other disturbances.

By the end of the 1990s, we proposed that the fundamental phenotypic feature of the schizophrenia spectrum was an instability in the very basic experiential structures of consciousness (ie, self-disorders), an idea originally 

 by the scholars who founded the concept of schizophrenia (eg, Kraepelin, Bleuler, Schneider, Minkowski).

 Our hypothesis was based on empirical research in US-Denmark high-risk studies and genetic linkage studies and on clinical experience with patients with first-onset schizophrenia.

 During this research, we noticed that the patients with beginning schizophrenia consistently complained of alarming disturbances gravitating around their very sense of being a self (eg, describing an unstable sense of being a self-present, unified, and persistent subject). The patients complained of lacking a core, lacking a kind of substantiality that could function as an anchoring point for their perspective, feelings of being ephemeral, not really present either in themselves or in the world, and experiencing an increasing alienation in the form of a distance between their own sense of being a subject and their thoughts and perceptions.

 and of naturalness and obviousness of the surrounding world and social relations, “other people seem to have some knowledge that I am completely lacking” (ie, in phenomenological terms, disorders of common sense).

 It is not a question of understanding complex cognitive tasks but simply of a lack of attunement and resonance, a failure to grasp proportions, relevance, and significance.

These disorders typically begin in childhood or adolescence and entail a sense of being different from others in a very fundamental way, affecting one’s experience of one’s inner life, the world, and social relations. We believed that a systematic description of self-disorders would rekindle interest in the inner life of patients with schizophrenia. In collaboration with a philosopher and psychiatrists in Denmark, Norway, and Germany, we developed a phenomenologically oriented psychometric instrument for a semi-structured detection and registration of self-disorders, the EASE.

The EASE consists of 5 domains: alienations of cognition, disorders of basic self, disorders of embodiment, disorders of ego-boundaries, and existential changes (

). It contains 57 items, sometimes divided into subtypes. There are also rules of scoring and a manual that introduces certain theoretical issues and provides a practical guide to conducting the interview. The EASE exhibits high interrater reliabilities among trained interviewers (with Kappa around .80) and a high internal consistency (with the Cronbach alpha close to .90).

The EASE has been used in multiple and subsequent empirical studies. These studies uniformly supported our hypothesis, finding a significant hyperaggregation of self-disorders among patients with schizophrenia and schizotypal disorders compared with patients with bipolar psychosis or no psychosis.

 Self-disorders improve differentiation of the schizophrenia spectrum from 

 and correlate weakly or moderately with positive and negative symptoms.

 They exhibit a remarkable temporal stability over 5 to 7 years and predict development of psychosis in the ultra-high-risk population.

 A recent prospective study of adolescents who were help-seeking and nonpsychotic predicted a schizophrenia spectrum disorder (schizophrenia and schizotypal disorder) in early adulthood 7 years later (sensitivity of 78% and specificity of 67% at a cutoff score of 6 EASE-items).

 It is important to realize that self-disorders as a trait feature are equally characteristic of schizotypal disorder and schizophrenic psychosis. There is also an emerging neuroscientific 

The empirical research is consistent with the hypothesis that self-disorders constitute the core phenotype of schizophrenia. One could perhaps consider this statement as a banality or a tautology since the very original concept of schizophrenia was constitutively associated with the clinical evidence of self-disintegration. The Case Vignette illustrates case of the evolution of schizophrenia.

“Olga” is a 31-year-old, single, never married woman. She works in a hospital laboratory as a biochemist. She has always been isolated and felt uncomfortable in the company of others. She always enjoyed being alone and engaged herself in “analyses” (ie, trying to think through important existential questions). She can often become so self-absorbed that she feels disembodied or even nonexistent.

Olga reported 2 former episodes of what she calls “depression” where she stayed at home spending her time on the internet and an inverted day-night rhythm. She was admitted to a psychiatric ward because she was disturbed by thoughts about being switched at birth with another infant. Asked about her name and age, she replied that she could not answer, because she did not know who she was at birth and, therefore, did not know her “true identity.” The substitution became clear to her 8 months ago during a period of restlessness and global feelings of insecurity when she read some old family letters. The style of the letters and some variation in handwriting made it clear to her that the letters signaled the hidden message about her substitution as an infant. She then searched online to find her biological roots; she “discovered” that she was a secret descendant of a Jewish, mystical family known from 200 BC. She had the impression that strangers in the street knew that she was this secret descendant, and she was concerned other people could read her thoughts.

On some levels, Olga was relieved with her finding, because she always felt that something “didn’t add up.” She always felt that she was “weird” or “just wrong,” and she had a tendency to observe herself when talking to other people as if there was an “extra consciousness” about how she should say things and how her face and hands looked. She felt that people never addressed her true self: “When people talk to me, they talk to the other child, and not the real me. That is because I’m substituted with the other child . . . Communication [with other people] goes awry from the beginning because I don’t have my real identity and I’m being judged as a wrong person. . . . There is no connection between who I am and who the other child is, they do not know who I am and I do not know it either. I couldn’t explain that before. All my life, it was just a question mark: Why do I not belong?”

The disorder of basic self and identity is evident in this case, and, it is clearly delusional. Olga developed what is called a primary delusion or a delusional perception. This delusion is not simply a false belief about matters in the empirical world but rather reflects an altered structure of the self (a lack of basic identity) that becomes infused with delusional content.

 Our patient describes a sense of not belonging since early childhood. Later this becomes thematized as a (delusional) idea of being substituted as an infant; moreover, it is a delusion that seems to involve some sort of psychological resolution. Thus, the sense of being different from others precedes finding out what is different.

In German psychiatry this phenomenon has been known as Anderssein.

 It refers to a sense of a fundamentally different existential position that the patient cannot easily conceptualize and verbalize, but uses vague but comprehensive phrases like “I felt wrong.” Experience of Anderssein is quite specific to schizophrenia spectrum disorders but is practically unknown in contemporary psychiatry.

Our patient seems to have disorders of common sense; she feels uncomfortable in the company of others and manifests a phenomenon of “involuntary self-witnessing” where she involuntarily observes herself during interaction with others. This differs from an introspective self-observation because the sense of subjectivity is doubled, so to say, and neither of the 2 consciousnesses functions as a full-fledged subject.

It seems that the self-disorders of this patient play a generative role in her psychopathology. A schematic phenomenological proposal of symptom evolution is outlined in the 

. In general terms, the disorder of basic self in schizophrenia leads to a self-alienation where fragments of the self become another that manifest as voices, external influences, or characteristic delusions.

 has important theoretical and therapeutic consequences. Schizophrenia spectrum is not seen as a contingent mixture and meaningless collection of positive and negative symptoms but as an expression of profound structural changes of subjective life that often cause suffering, other pathological phenomena, and varieties of dysfunctions.

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