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Familiarity with self-disorders is an indispensable tool in diagnosing a patient suspected for developing schizophrenia. Such knowledge improves communication with the patient and may serve as a starting point for therapeutic intervention.
SPECIAL REPORT: SCHIZOPHRENIA & PSYCHOSIS
Disordered selfhood may be a core phenotypic trait of schizophrenia spectrum disorders. The reader should note that this article was written from a European phenomenological psychiatric perspective.1 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 structured interview 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.2 See: Significance for the Practicing Psychiatrist
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 involves at least the two following aspects:
1. The patient should be interviewed in a way that maximizes their spontaneous self-descriptions, which can provide concrete and manifold examples of his abnormal experiencing. This requires a non-judgmental attitude that prevents the clinician from prematurely reifying and classifying the patient’s inner lifer.
2. 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 and trained you will not be able to hear what the patient is trying to convey.
The rediscovery mentioned in the title concerns a profound dis-order of subjective life in schizophrenia. For the patient, distortions of subjective life are often their usual mode of existing in the world, and they only become accessible for the interviewer when they succeed to facilitate the patient’s self-reflection and verbalization. The following transcript from an interview with a patient gives perhaps 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 being disconnected 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.
What is the self?
Phenomenology distinguishes between the narrative self (personality) and the minimal or basic self.3 If you ask a random person on the street “who are you?” the person may respond “I am Paul Brown, 30 years old, working as an engineer,” and he may proceed with information about his life history, his characterological traits, cognitive abilities, preferences, goals, and so forth. This level of selfhood we usually call personal identity or in technical terms the narrative self.
It is a complex and continuously evolving self and self-identity that is anchored in the person’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 (eg, 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 advanced by the scholars who founded the concept of schizophrenia (ie, Kraepelin, Bleuler, Schneider, Minkowski).4 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 .4 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 person). 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.
They also complained about loss of meaning 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).5 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 schizophrenia patients. In collaboration with psychiatrists in Denmark, Norway, and Germany as well as a philosopher, we went on to develop a phenomenologically oriented psychometric instrument for a semi-structured detection and registration of self-disorders: the EASE.6
The EASE consists of five domains: alienations of cognition, disorders of basic self, disorders of embodiment, disorders of ego-boundaries, and existential changes. It contains in total 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).7
The EASE has been used in multiple and subsequent empirical studies. These studies uniformly supported our hypothesis finding a significant hyper-aggregation of self-disorders among patients with schizophrenia and schizotypal disorders compared with patients with other non-psychotic and bipolar psychosis.8 Self-disorders improve differentiation of the schizophrenia spectrum from borderline personality disorder, obsessive-compulsive disorder, and autistic spectrum disorders.9-12
Self-disorders are unrelated to neurocognitive dysfunctions and correlate weakly or moderately with positive and negative symptoms.7 They exhibit a remarkable temporal stability over 5 to 7 years and predict development of psychosis in the ultra-high-risk population.8,13,14 A recent prospective study of adolescents who were help-seeking and non-psychotic predicted a schizophrenia spectrum disorder (schizophrenia and schizotypal disorder) in early adulthood 7 years later (sensitivity of 78% and specificity of 67% at a cut-off score of 6 EASE-items).15 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 literature on self-disorders.16,17
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 following is an illustrative case of the evolution of schizophrenia.18
“Ola” 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 non-existent.
Ola reported 2 former episodes of what she called “depression” where she stayed at home with inverted day-night rhythm spending her time on the internet. 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 born as 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 and found out 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 the secret descendant and that other people could read her thoughts.
She was relieved by discovering the explanation because she had 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, 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. Ola 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.19 Our patient described a sense of “not belonging” since early childhood. Only later, this became 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.20 It refers to a sense of a fundamentally different existential position, which obviously the patient cannot easily conceptualize and verbalize and instead uses vague but comprehensive terms such as “I felt wrong.” Experience of Anderssein is quite specific to schizophrenia spectrum disorders but is practically unknown in contemporary psychiatry.
Our patient seemed to have disorders of common sense; she felt uncomfortable in the company of others and manifested a phenomenon of “involuntary self-witnessing” where she involuntarily observed herself during interaction with others. This differs from an introspective self-observation because the sense of subjectivity is doubled, so to say, and none of the “two consciousnesses” functions as a full-fledged person.
It seems that the self-disorders of this patient played a generative role in her psychopathology. A schematic phenomenological proposal of symptom evolution is outlined in the Figure. In general terms, the disorder of basic self in schizophrenia led to a self-alienation where fragments of the self become an “Other” that manifested as voices, external influences, or characteristic delusions.
Implications and conclusion
Self-disorders research 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.21 A familiarity with self-disorders enables the clinician to understand certain meaningful patterns of psychopathology and re-humanizes the patient-clinician relationship. Furthermore, such familiarity improves differential diagnosis, especially in the early stages of the illness and opens up novel psychotherapeutic approaches. Finally, a pathogenetic focus on a core phenotype may be more useful and fruitful than the study of causally distant symptoms such as delusions and hallucinations.
Dr Parnas is Professor of Psychiatry, Mental Health Centre Glostrup, Faculty of Health and Medical Sciences, University Hospital of Copenhagen; and Center for Subjectivity Research, Faculties of Humanities, University of Copenhagen, Denmark; Dr Zandersen is Clinical Psychologist and part-time lecturer, Mental Health Centre Glostrup, University Hospital of Copenhagen; and Faculties of Social Sciences, University of Copenhagen. They report no conflicts of interest concerning the subject matter of this article.
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