| | Phenomenology of anomalous self-experience in early schizophrenia☆☆☆★Abstract Disorders of self-experience were emphasized in classic literature and in phenomenological psychiatry as essential clinical features of the schizophrenia spectrum disorders, but are neglected in the contemporary psychopathology due to epistemologically motivated distrust of studying anomalies of subjectivity. Based on our own and other empirical studies, we present here detailed clinical phenomenological descriptions of nonpsychotic anomalies of self-experience that may be observable in the prodromal phases of schizophrenia and in the schizotypal disorders. Anomalies of self-experience are grouped according the experiential domain that appears to be affected and are illustrated by short vignettes or verbatim quotes from the patients. It is suggested that disorders of the self deserve further systematic empirical investigations, also from an etiological perspective. Self-disorders may turn out to be potentially useful as a psychopathological organizer of the schizophrenia spectrum disorders. Psychopathological emphasis on these disorders may also help to integrate the search for the neurodevelopmental mechanisms in schizophrenia with developmental-psychological research on the ontogenesis of the self. Copyright 2003, Elsevier Science (USA). All rights reserved.
The greatest hazard of all, losing one's self, can occur very quietly in the world, as it was nothing at all. No other loss can occur so quietly; any other loss—an arm, a leg, five dollars, a wife etc.—is sure to be noticed.
Søren Kirkegaard
Psychopathology of subjective experience is today systematically neglected, partly because of reliability concerns and partly due to the prevailing behavioristic epistemological paradigm.1 This neglect is particularly perceptible in the domain of schizophrenia. An instructive example here is a construal of the so-called negative symptoms of schizophrenia as purely behavioral deficits.2 Yet, this construal does not exhaust these symptoms' diagnostic significance as the fundamental trait features of schizophrenia,3 nor does it cohere with the patient's perspective, often populated by quite “positive” anomalies of subjective experience that cannot be faithfully described in pure deficit terms.4 This serious and embarrassing psychopathological lacuna is becoming glaringly apparent thanks to the recent emphasis on early diagnostic detection and therapeutic intervention in schizophrenia.5 These attempts have demonstrated that operational psychiatry is short of descriptions of subtle anomalies of subjective experience that might be clinically useful for identifying individuals at risk of imminent psychosis. Behaviorally defined prodromal features of schizophrenia are for that purpose prohibitively common in the general population6 and “behavioral deviations alone, without exploring subjective experience, lack the specificity necessary to predict future schizophrenia”7 (p. 962). For that reason, nearly all early therapeutic programs target already psychotic cases, albeit in their early stages.8
The aim of this paper is to present in clinical detail (assisted by vignettes or verbatim statements) phenomenological manifestations of anomalous self-experience that are detectable in the prodromal phases of schizophrenia and in the schizotypal conditions, a presentation that does not exhaust the scope of anomalous experience in the schizophrenia spectrum disorders (e.g., perceptual aberrations will not be addressed here). Apart from its potential theoretical significance, this task is of obvious pragmatic importance9: familiarity with subtle, nonpsychotic anomalies of subjective experience is obviously crucial for early differential diagnosis.
Morbid self-experience is defined here as a pervasive or frequently recurrent experience in which one's first-person experiential perspective or one's status as a subject of experience or action is somehow distorted. Anomalous experience described here is of not-yet psychotic intensity, i.e., we are not dealing with delusional elaborations, hallucinatory phenomena, or experiences of passivity already thematized by explanatory efforts. The patient is able to keep a distance to his altered experience, a distance frequently expressed through the conditional “as if”statements, e.g., “it feels as if my body does not belong to me.”
Self and psychopathology  Addressing the issue of experiential self-disorders quickly confronts rather principal obstacles and ambiguities. The term depersonalization, coined in 1899,11 is retained in the contemporary psychiatric vocabulary, but with quite confused usage12, 13 (p. 296). Despite a lack of convincing empirical justification, the DSM-IV14 and the ICD-1015 contain depersonalization as a separate disorder. The notion of a self is deleted from the terminology of DSM-IV and ICD-10. It is rarely used in psychiatric literature, and usually in a colloquial or psychoanalytic sense. Cognitive science, cognitive psychology, and most of the analytic philosophy of mind try to undermine the reality of the self through various theoretical moves: (1) the self is seen as a construct, a view that is saturated by specific metaphysical (representational-computational) views on the nature of mind1; (2) the self is a folk-psychological illusion16 or (3) a narrative fiction17; or (4) the self is an illusion generated by a linguistically improper use of the reflexive pronoun.18 None of these options is useful to a psychiatrist, engaged in describing mental states of his patients. In accordance with our descriptive phenomenological orientation, a realist approach is adopted here: the self is not merely a construct or a fiction, but possesses a mental reality of its own.19, 20, 21, 22 Phenomenologically speaking, one can address the self on three hierarchically organized or founded, but intertwined, levels. On the most basic, foundational level, the notion of self equals the first personal givenness of experience.21 It is an implicit, pre-reflective egocentricity determining the very manifestation of experience. Thus, an experience is never a free-floating event, to which a sense of being its subject is somehow subsequently added, i.e., experience and self are not separate entities. Rather, the first personal perspective is a way in which the experience articulates itself.23, 24 This form of self-awareness will be addressed in more detail below. At a more explicit or articulated, reflective level, self-awareness is a consciousness of an “I” as the invariant subject pole of the manifold of experience and action. On the most sophisticated or complex level, one may speak of a person or social self, a self-referential structure that comprises distinctive, individuated characteristics, style, habits, and historical narrative. Psychological concepts such as “self-esteem” or “self-image” only make sense on this level of selfhood. Self and schizophrenia: Early descriptions Self-disorders in schizophrenia have always been recognized as essential components of its clinical picture. An absent reference to a self is frequently merely terminological, because the relevant phenomena are addressed in other terms or in another theoretical framework. Self-disorders were already described in detail at the turn of the 19th/20th century. Especially French psychiatrists published numerous case histories of patients, characterized by profoundly altered self-experience and who today would be diagnosed as suffering from schizophrenia spectrum disorders.25, 26, 27 Eugene Bleuler28 considered “basic disorder”of personality as a so-called complex fundamental feature of schizophrenia, stating that the illness invariably involves an affliction of the self (“Ich-Spaltung”): “Ganz intakt ist dennoch das Ich nirgends”28 (p. 58). The schizophrenic autism, another of Bleuler's fundamental symptoms, may also be considered to encompass self-disorders.29, 30 Kraepelin31, 32 claimed that a disunity of consciousness (“orchestra without a conductor”) was the core feature of schizophrenia. An Austrian contemporary of Bleuler and Kraepelin, Joseph Berze33 proposed that subtle alteration of self-consciousness was the primary disorder in schizophrenia, specifically detectable in the incipient cases. He described this alteration as a peculiar change, a diminished luminosity and affectability of self-awareness and offered rich clinical material to illustrate these phenomena. Jaspers34 provided a commonsensical list of the experiential modes in which a self is aware of itself: (a) activity, comprising awareness of one's existence and action, (b) unity, (c) identity over time, and (d) me/not me demarcation. The sense of self, says Jaspers, may be affected in any of these modes. The vignettes on self-disorders presented by Jaspers are often suggestive of the schizophrenia spectrum conditions, yet he offered no account of theoretical or clinical significance of self-disorders. Kurt Schneider35 alluded to a “loss of ego-boundaries” in his description of passivity phenomena. Scharfetter36 modified Jaspers' taxonomy to comprise, in an order of allegedly increasing complexity: vitality, activity, continuity, demarcation, and identity. He considered many delusional phenomena as compensatory reactions to self-disorders. Most of his examples of altered self-experience in schizophrenia are, however, of a clearly psychotic intensity. Detailed descriptions of self-disturbances, frequently associated with the explorations of the sense and the nature of the self, are to be found in phenomenological psychiatry.37, 38, 39, 40, 41, 42, 43, 44 The main message from this line of work is that self-alteration represents the primary disorder of schizophrenia, conferring on it a unique Gestalt and reflecting its pathogenetic nucleus:
La folie (…) ne consiste pas ni dans un trouble du jugement, ni de la perception, ni de la volonté, mais dans une perturbation de la structure intime du moi38 (p. 114). Recent studies There is no research that offers prospective premorbid information on altered self-experience in schizophrenia: none of the completed high-risk or birth cohort studies collected data relevant to the alterations of self-experience. One follow-back study using objective information did, however, reveal fluidity of self-demarcation, lack of a coherent narrative-historical self-identity, and other self-disturbances to be prominent features of the pre-schizophrenic states at school age.45 An important and unique contribution in the field is the work of Gerd Huber and Joachim Klosterkötter and their colleagues in Germany: in a series of retrospective and, more recently, prospective clinical studies, they identified subtle (nonpsychotic) affective, cognitive, perceptual, motor, and bodily disturbances, designated as “basic symptoms,” many of which are specific to schizophrenia and may precede its onset.10, 46, 47, 48, 49 Several of these disturbances reflect anomalies in self-experience (e.g., varieties of depersonalization, disturbances of consciousness and action, distorted bodily experiences). The basic symptoms are thoroughly described in the Bonn Scale for the Assessment of Basic Symptoms (BSABS),50 translated into several languages, including Danish, and available in a preliminary English translation from the German research group.49 In a Norwegian study with naturalistic in-depth interviews with 20 first-onset schizophrenic patients,51 three domains of pre-onset subjective change were revealed: all patients had alarming anomalies of self-experience; nearly all patients complained of ineffability of their experiences; and a great majority reported preoccupations with metaphysical, supernatural, or philosophical issues. Our pilot study of 19 first-onset patients with schizophrenia52 demonstrated very similar prodromal profiles. In another project, lifetime prevalence of the BSABS-defined anomalies of subjective experience was compared between patients with residual schizophrenia and psychotic bipolar illness in remission (DSM-IV): of all experiential anomalies, the disorders of self-experience were the most significant discriminators between the groups.53 More recently, we have completed detailed, in-depth psychiatric interviews performed by one of us (P.H.), including the BSABS, on 155 first-admission cases and diagnosed according to the ICD-10 research criteria: 57 suffered from schizophrenia spectrum psychosis, 43 from schizotypal disorder, and the remaining 55 patients from other, nonschizophrenia spectrum disorders (The Copenhagen Prodromal Study).54 Self-disorders were analyzed using an ordinal a priori scale, of high internal consistency, summing up the interview items that pertained to most of the clinical features described below. The data from our studies collectively indicate that self-disorders are specific to the schizophrenia spectrum conditions (note that self-disorders are not a part of the ICD-10 or DSM-IV diagnostic criteria of schizophrenia) and mark the prodromes of schizophrenia. Self-disorders correlate both with the negative and the positive symptom scales of the Positive and Negative Syndrome Scale (PANSS).55 Clinical descriptions of self-experience in early schizophrenia and schizotypal disorders The vast majority of the first admitted schizophrenia spectrum patients in our series had been, prior to their first psychiatric hospitalization, in contact with practicing psychologists or psychiatrists. They were typically diagnosed as suffering from a major affective disorder and were treated with antidepressants. One reason for this initial misdiagnosis is linked to the cryptic ways in which the patients verbalize their complaints; it may also be attributed to a widespread ignorance among clinicians of the nonpsychotic subjective experience in schizophrenia. The patients usually present nonspecific complaints such as depression, fatigue, or lack of concentration. Blankenburg41 speaks in this particular context of a “nonspecific specificity”: a trivial (nonspecific) complaint of fatigue may turn out, on a close evaluation, to be associated with a pervasive inability to grasp everyday significations of the world (a condition highly suggestive of schizophrenia, hence “specificity”). As quite explicitly pointed out by Berze,33 self-disorders usually reveal themselves only after an attempt to penetrate behind such surface complaints by an interviewing clinician who is aware of potential manifestations of self-disorders. The difficulty, which the patients confront in reporting their experiences, is multi-determined. The linguistic resources for expressing dimensions of subjective experience, especially of the nonpropositional type, are not readily available. This is especially true of anomalous self-experience, because it affects the very condition of experience and its reportability. Adding to these difficulties is the fragility of the forms of consciousness in question, with their unstable wavering of implicit-pre-reflective into explicit-reflective modalities. The varieties of anomalous self-experience described in the following sections are intimately interrelated, yet classified according the phenomenological domain that appears to be affected. The vignettes or quotes are from the patients investigated in our research studies, unless it is indicated otherwise. Sociodemographic characteristics of the patients are sometimes altered in order to preserve their anonymity. Presence and its alterations The phenomenological concept of presence signifies that in our everyday transactions with the world, the sense of self and the sense of immersion in the world are inseparable: “Subject and object are two abstract moments of a unique structure which is presence”56 (p. 430; our italics). We are normally self-aware through our absorption in the world of objects. We reside actively among the things and in this absorption our self-awareness operates at a pre-reflective or tacit level. From a phenomenological perspective, we can distinguish here two aspects: a pre-reflective self-awareness (ipseity; Latin: ipse = self, itself) and a correlative pre-reflective embededness in the world. These experiential moments (i.e., non-independent parts) deserve a more detailed exposition, because disturbances of presence appear to be the earliest and most fundamental type of the prodromal experience in schizophrenia.51, 52 We may speak of a pre-reflective self-awareness whenever we are directly, non-inferentially, or non-reflectively conscious of our own occurrent thoughts, perceptions, feelings, or pains; these appear always in a first-personal mode of presentation that immediately reveals them as our own, i.e., it entails a built-in self-reference. To put it differently, when the experience is given in a first-personal mode of presentation to me, it is, at least tacitly, given as my experience and counts as a case of primitive or basic self-awareness, i.e., ipseity.21 First-personal givenness is not a mere varnish that the experience could lack without ceasing to be an experience; it is precisely its first-personal givenness that makes the experience subjective. Consequently, to be aware of oneself is not to apprehend a pure self apart from experience, but to be acquainted with an experience in its first-personal mode of presentation, that is, from “within.” The subject of experience is a feature or function of its presentation.21, 22 Unreflected immersion in the world is considered by phenomenology as a mode of intentionality, i.e., a mode of consciousness' object-directedness. Phenomenology distinguishes between a thematic, explicit, or objectifying intentionality (e.g., when I am aware of this chair to the left from me), and a nonreflective, tacit sensibility, constituting our primary presence to the world. This so-called “operative intentionality”56, 57 is pre-reflectively functional without being engaged in any explicit epistemic acquisition. It procures a background texture or organization to the field of experience. It is upon such texture that explicit intentionality configures its perceptual (e.g., seeing this particular chair) or judgmental disclosures. It is in the pre-reflective mode that habits or dispositions become acquired. Operative intentionality may therefore be considered as a condition of the nonreflexive, automatic attunement to the world, i.e., “common sense.”30, 58 The most prominent feature of altered presence in the pre-onset stages of schizophrenia is disturbed ipseity, a disturbance in which the sense of the self no longer saturates the experience. For instance, the sense of myness of experience may become subtly affected: one patient reported that his feeling of his experience as his own experience only “appeared a split-second delayed.” The patient complains of unstable fullness or reality of his self-awareness. He feels that a profound change is afflicting him, yet he cannot pinpoint what exactly is changing because it is not a something that can be easily expressed in propositional terms. The phrasings of such complaints may range from a quite trivial “I don't feel myself” or “I am not myself” to “I am losing contact with myself,” “I am turning inhuman,” or “I am becoming a monster.”51 The patient may sense a sort of “inner void” or “a lack of inner nucleus,” which is normally constitutive of his field of awareness and crucial to its very subsistence. Some of these complaints point to the alterations of self-consciousness, as if the luminosity of consciousness was somehow disturbed or diminished (the term “luminosity” refers to the very manifestation, welling-up or phenomenality of self-awareness23). The patient does not feel being fully awake or conscious: “I have no consciousness,” “My consciousness is not as whole as it should be,” “I am simply unconscious,” “I am half awake,” “I have no self-consciousness,” “My I-feeling is diminished,” “My I is disappearing for me,” “My feeling of consciousness is fragmented,” “It is a continuous universal blocking”33 (pp. 126-129). This alteration of self-consciousness is frequently associated with diminished affectability or reactivity of the self. Case 1 I have lost all form of desire. I have no contact to myself. I feel like a zombie; I am unable to feel pleasure; everything appears indifferent. I am not a part of this world; I have a strange ghostly feeling as if I was from another planet. I am almost nonexistent. Psychiatrists describe such patients as anhedonic, yet a diminished capacity for feeling pleasure is only an aspect of a more profound alteration of self-awareness. The intentional aspect of altered presence is usually described as lack of immersion in the world, a lack of presence or a sense of imposed detachment from the world. It may also manifest itself as a “phenomenological distance” within perception and action. In a normal perceptual experience, the object perceived is given directly, in the flesh so to say, but now it appears somehow filtered and deprived of fullness. Perception is not lived but is more like a mechanical, receptive, sensory process, unaccompanied by its affective feeling-tone. Case 2 Robert, a 21-year-old unskilled worker, complained that for more than a year, he had been feeling painfully cut off from the world and had a feeling of some sort of indescribable inner change, prohibiting him from normal life. He was troubled by a strange, pervasive and a very distressing feeling of not being really present, or fully alive, of not participating in the interactions with his surroundings. This experience of disengagement, isolation, or ineffable distance from the world was accompanied by a tendency to monitor his inner life. He summarized his affliction in one exclamation: “my first personal life is lost and is replaced by a third-person perspective” (He was not at all philosophically read). In order to exemplify his predicament more concretely, he said, for instance, that listening to music on his stereo would give him an impression that the musical tune somehow lacked its natural fullness; “as if something was wrong with the sound itself,” and he tried to regulate the sound parameters on his stereo equipment, to no avail and only to finally realize that he was somehow “internally watching” his own receptivity to music, his own mind receiving or registering of musical tunes. He so to speak witnessed his own sensory processes rather than living them. It applied to most of his experiences that, instead of living them, he experienced his own experiencing. He reflected on self-evident daily matters and had difficulties “in letting things and matters pass by” and linked it to a long-lasting attitude of “adopting multiple perspectives,” a tendency to regard any matter from all possible points of view58 (pp. 124-125). Robert's incertitude reflects a sort of polyvalence (rather than ambivalence), linked to global fragmentation of meaning, a loss of “natural evidence” or “loss of common sense,” which is the hallmark of the schizophrenic autism and perplexity.30, 59 Robert resembles Anne, a patient described in detail by Blankenburg.41 Anne's main and monotonous complaint was her inability to grasp the world's natural significance and appeal. Nothing was self-evident for Anne, who had a distressing difficulty in the automatic understanding of people and situations: “it is not the question of knowledge; it is prior to knowledge (…); it is so small, so trivial; every child has it!!”41 Case 3 Maria, 24, reported that since the age of 16, she was insecure and avoided others. She didn't understand the others' “rules of the game,” felt always being “outside the company,” did not have “a sense of situation” and could not understand the interactions between people, nothing came spontaneously, out of itself. “I cannot read the others; they are always a mystery!!” Lack of “natural evidence” should not be seen as a deficiency in the stock of explicit, thematic knowledge, but as being indicative of a deficient pre-reflective and direct grasp of the world's significations, a deficient “pre-reflective attunement.”30 Such fragmentation of meaning may also be described as a lack of” perspectival abridgement,60 a lack of dominant point of view or a dominant frame of reference, which normally blocks out potential rival perspectives, and which only can be realized through a medium of intact selfhood (case 2). The disturbances of presence exert profound reverberations on the sense of personal identity: unstable ipseity and lack of common sense create a vacuum at the very core of one's subjectivity. This vacuum deprives the patient of reliable dispositional attitudes that normally imbue cognition and emotion with a sense of typicality and familiar direction. These identity disturbances are different in kind from the disturbances seen in the non-schizophrenia spectrum personality disorders (e.g., borderline or narcissistic patients). In the latter case, the identity disorder operates on the level of social self (self-image), with the sense of ipseity and pre-reflective immersion remaining intact. The disturbances of presence seem to constitute a foundation of the more explicit and articulated anomalies of selfhood to described in the following sections. Phenomena such as sense of identity over time or demarcation presuppose ipseity in order to arise at all.21 For example, if a memory of a past event is to contribute to my sense of identity over time (a claim widely held in cognitive science), it can only do this job in so far as the past event is being remembered as having taken place in my field of awareness, as something which was originally experienced from my first-person perspective. Sense of corporeality and its alterations Conscious experience is usually never purely cognitive or spiritual but is closely intertwined with our bodily existence and experience (embodiment, incarnation). Embodiment is a fundamental condition of selfhood (see Depraz61 for a recent comprehensive account). It is a prerequisite of the constitution of objective space, populated by mind-independent objects—a view shared by phenomenology56 and contemporary analytic philosophy of mind.62, 63 The body has ambiguous experiential status: at the one extreme it is a “lived body” (“Leib”; “chair”), i.e., subjective, animated body, identical with the self; at the other extreme it is experienced as a physical, spatially extended object or thing (“Körper”; “corps”).57 Incessant oscillation or interplay of gradations61 between these experiential bodily modes constitute a tacit foundation of all experiencing. In the incipient schizophrenia a variety of dissociations of the bodily experiential modes may be observed, with a striking tendency to experience one's body predominantly as an object: there is an increasing experiential distance between subjectivity and corporeality (“disembodiment”). The following vignette dramatically illustrates such a fissure or disjunction: Case 4 “I am no longer myself (…) I feel strange, I am no longer in my body, it is someone else; I sense my body but it is far away, some other place. Here are my legs, my hands, I can also feel my head, but cannot find it again. I hear my voice when I speak, but the voice seems to originate from some other place.” He has difficulty in localizing his own person: “Am I here or there? Am I here or behind?” When he does something, he has a feeling of observing his actions as a witness, without being actively involved: “One might think that my person is no longer here (…) I walk like a machine; it seems to me that it is not me who is walking, talking, or writing with this pencil. When I am walking, I look at my legs which are moving forward; I fear to fall by not moving them correctly.” When he watches himself in a mirror, he is afraid of staying there or is not sure on which side of the mirror he actually is (…) His reason is intact; he knows very well that he is himself26 (p. 138, our translation). A common early change is a sense of being detached, disconnected from one's body, which feels somehow alien or not “fitting” the subject. For example, the patient may say that he feels “as if his body was too small to be inhabited” or as somehow, indefinably, uncomfortable to live with. A more clear distortion of experience consists of a loss of bodily coherence: bodily parts are felt as if disconnected from each other. This experience may take an alarming intensity, where the psycho-corporeal unity disintegrates, a sense of fragmentation accompanied by a (pre)-psychotic panic of literal dissolution (“going into pieces”). Another, experientially articulated, disturbance consists of a feeling of morphological change: the body or its parts feel heavier/lighter/smaller/larger/longer/shorter. One patient reported that he frequently had a feeling that his body became very small, yet at the same time was filling up the entire room: “I feel a simultaneous implosion and explosion”. Such feelings may be accompanied by optical illusions of actual experience of bodily change. The most famous of the latter is the “mirror phenomenon” (“signe du miroir,”64 “Spiegelphänomen”50), where the patient inspects his face in a mirror because of feelings of self-alteration: the eyes may look dead, empty, or the face seems deformed. A subtler variety of this phenomenon consists of avoiding one's mirror image (which is perceived as threatening or provoking). Certain identity disturbances, such as a peculiar sentiment of being much younger or older than one's chronological age are probably linked to the distortions of bodily self-awareness: “I have a strange, almost physical feeling, as if I was a little girl,” reported a 23-year-old female patient. Disturbances of subjectivity may be manifest in motor performance. Motor or verbal acts may occur without or despite the patient's will and interfere with his actions or speech but are not yet regarded as being imposed by some external agency. Case 5 A former paramedic reported that many years prior to the onset of his illness he occasionally experienced (e.g., when driving in an ambulance and to a drivers surprise) that he would involuntarily utter a few words, entirely unconnected with his train of thoughts. He immediately continued to speak in a relevant way or made some cliché remarks in order to cover up for this embarrassing episode. Motor block (blockage of intended actions) occurs as a sudden and brief sense of paralysis where the patient is unable to move or speak. Another, and frequent phenomenon is desautomatization of motor action in which habitual motor performance (e.g., dressing, teeth brushing) requires conscious attention and sense of effort: Case 6 A female library assistant reported that prior to the onset of her illness she was alarmed by a frequently recurring experience that replacing the returned books from a trailer on the library shelves suddenly required attention: She had to think how she was to lift her arm, grasp a book with her hand, turn herself to the shelf, etc. Stream of consciousness and its alterations The stream of consciousness (also designated as “stream of thoughts”) is a sense of consciousness as a temporal flux.65, 66, 67 This flux oscillates between introspectible “static” moments of explicit cognitive-emotional activity and vaguely articulated tendencies of transitions into new directions (“fringes of consciousness”65). Even though the stream (especially of thoughts) may be quite saccadic, self-awareness remains uninterrupted as the same flow. In a given temporal moment of the stream, its constituent contents (e.g., thoughts, images, sensations) are co-conscious, i.e., united in an experiential whole.68 The self permeates this whole as its first personal perspective: there is no distance between my thoughts and myself. Apart from certain reflective acts, my thinking is at a “zero point of orientation.”43, 57 Consciousness is essentially nonspatial in the physical sense of space, although certain perceptual contents are experienced with spatial dimensions. Consciousness is never experienced as a thing with specific location or with spatial characteristics; its introspective contents are transparent or immediately given in a nonspatial way (i.e., the contents are not like physical objects lending themselves to a description in perspectival spatial terms). A fundamental change of the stream of consciousness in the early phases of schizophrenia consists of an increasing experiential fissure between the self and its contents (as it was the case for the sense of embodiment). Mental contents become quasi-autonomous, bereft of their natural ipseity dimension. Thoughts may appear as if from nowhere, are felt somehow ego-less, decentred or at a distance from the self. They may interfere with the ongoing stream of thoughts (thought interference), and are often described by the patient through specific private designations such as “automatic,” “acute” thoughts, “thought-tics,” etc. The patient still self-ascribes his thoughts as his own, their content is often quite neutral and there is no sense of ongoing inner resistance or mental struggle (as in the case of obsession). The patients frequently report hyper-reflexive form of introspective experience. Hyper-reflexivity refers to forms of exaggerated self-consciousness in which a subject takes itself as its own object,60 a phenomenon that is closely associated with ipseity disturbance and loss of meaning. Case 7 If a thought passed quickly through his brain (…), he was forced to direct back his attention and scrutinize his mind in order to know exactly what he had been thinking. In one word he is preoccupied by the continuity of his thinking. He fears that he may stop thinking for a while, that there might have been “a time when my imagination had been arrested” (…) He wakes up one night and asks himself: “Am I thinking? Since there is nothing that can prove that I am thinking, I cannot know whether I exist.” In this manner he annihilated the famous aphorism of Descartes…26 (p. 179, our translation). Intense hyper-reflexivity tends to objectify the introspective experience: the content of experience is less lived and appears more like an inspected object (see case 2). For example, the inner speech becomes transformed from a medium of thinking into an object-like entity with quasi-perceptual characteristics (“Gedankenlautwerden”). Many patients exhibit a subtler spatialization of inner experience. They describe their thoughts or experiences in physical terms, as if possessing object-like spatial quality (“dense and encapsulated thoughts”) or locate them spatially (“my thoughts feel mainly in the right side of the brain”; “it feels as if my thoughts were slightly behind my skull”). One patient reported an experience as if she looked at the world somehow much “far from behind”; her “point of perspective” was felt “as if displaced some centimetres behind.” Case 8 A patient reported frequently occurring “surrealistic experiences,” by which he meant episodes where “the next thought arrives before the first one is finished” and a feeling that the “thoughts are layered one upon another.” He felt sometimes as if his thoughts “originated in three distinct strata of the brain.” Hyper-reflexivity may sometimes possess a compensatory role, making up for perplexity41 (see case 9) or it appears as a more primary affliction (case 10). In all circumstances, the thinking processes lose their sense of subjective mastery and are experienced as increasingly alienated. Case 9 A 34-year-old university graduate reported that for many years trivial matters frequently came to occupy his mind. For example, while reading a novel written in the first person, and encountering a sentence like “she said that he must return tomorrow” he immediately started to reflect on the reasons for using the personal pronouns, to finally conclude that “it has something to do with communication.” He then turned his attention to the word “communication” and continued to think on the necessity to communicate, etc. He could also reflect upon the fact that the air distributed itself in the rooms of his apartment. Case 10 “I bypass a window display of a shop in which there are exposed bicycles and bicycle parts; [in a wheel] all the spokes cross each other in sharp angles before they reach the axel,…the axel turns around with the spokes. No, it is not the axel that rotates; it is the bar, a piece of steel. The axel does not exist; it is just a mathematical line, perpendicular to the plane of the wheel that is determined by the spokes, by 40 straight lines. But this is not necessary either: only two lines are needed to determine a flat surface. And the circumference? 2πr is the expression for the length of the felloe, or more precisely, for the theoretical circumference, outlined by this inexact circle (i.e., the felloe). Are we able to conceive an ideal line by paying attention to the lines in nature? Is Spencer's claim that mathematics originates from experience and induction correct? (…) These associations…would not seem to me as sick if I were able to master them, like someone who calmly reflects on the matters that he is working with, contemplating some professional problems. But when I am thinking in this way, without being able to stop it…I have no mastery over the course of these ideas…it seems to me as if it is not me who generates them…”26 (p.146, our translation and italics). This state may intensify into a thought pressure (“Gedankenjagen”), where the patient is overwhelmed by a myriad of unconnected thoughts going in different directions; loss of meaning or lack of an organizing theme is the cardinal feature of this symptom; moreover, the contents are frequently affectively neutral (as opposed to, e.g., depressive ruminations). One patient reported a feeling “as if” his consciousness consisted of multiple emanating sources, disconnected from each other and each “pulsating” at its own pace. A seemingly opposite experience is of a thought block, where thoughts abruptly disappear or gradually fade away. A variant of this phenomenon is a sudden and total discontinuity of self-awareness: the patient may report that for some seconds he loses awareness of his activity, e.g., he does not know how he got from his living room to the kitchen or finds himself somewhere in the city without knowing how he got there. Less characteristic phenomena comprise difficulties in initiating and carrying through the thinking processes: the patient complains of diminished ability to generate thoughts or of general slowness of cognition and inability to reach its desired goal (disturbances in thought intentionality and goal-directedness). Communication of meaning to others may be distorted (disturbed self-expression). The patient experiences a mismatch between his cognitive-emotional state and its outward expression, perceiving his own behavior, gestures, facial expressions, or speech as somehow disfigured and out of control, a condition usually associated with hyper-reflexivity. Hyper-reflexivity and diminished ipseity often lead to a peculiar and pervasive splitting or a doubling of the self (“Ich-Spaltung”) into an observing and observed ego, none providing a reliable sense of ipseity (case 2). This experience may intensify prior to a frank psychotic episode: it may articulate itself as an inner struggle or oscillation between the good and the evil “parts” or between different selves. Although the normal processes of reflection and imagination also involve experiential ego-split, they nevertheless happen in a unified field of experience, in which the sense of ipseity never questions itself. Self-demarcation and its alterations Inability to discriminate self from not-self was described as transitivism by Bleuler.28 This phenomenon attracted attention of numerous authors, typically in connection with the Schneiderian symptoms such as delusions of external influence and thought broadcasting. Weak “ego boundaries” were also an important topic for psychoanalysis and inherent in the concept of “psychotic projection.”69 In the neurocognitive investigations of the Schneiderian symptoms,70, 71 the sense of ownership of experience and the sense of agency are believed to be generated by inferential self-monitoring mental processes (but see a critique by Gallagher72). From a phenomenological perspective however, the “me/not-me” demarcation is a constitutive moment of the experience itself; in other words, the sense of myness of experience is just an aspect of the nonreflexive self-awareness (ipseity). Inferential reflection seems to arise only post hoc, as a consequence of a deficient sense of myness: Case 11 A young schizotypal patient frequently contemplated his own “ego-boundary.” He thought about “this fluid transition between me and the world”: “it must consist of a mixture of air molecules, sweat droplets and tiny fragments of skin debris.” In the prodromal phases of schizophrenia and in the schizotypal conditions, one may observe subtle transitivistic phenomena that are purely experiential, i.e., unaccompanied by delusional elaborations. The following case is paradigmatic of such experiences: Case 12 A young man was frequently confused in a conversation, being unable to distinguish between himself and his interlocutor. He tended to lose the sense of whose thoughts originated in whom, and felt “as if” his interlocutor somehow “invaded him,” an experience that shattered his identity and was intensely anxiety provoking. When walking on the street, he scrupulously avoided glancing at his mirror image in the windowpanes of the shops, because he felt uncertain on which side he actually was. He used to wear a wide and tight belt in order to feel “more whole and demarcated.” He was very much attracted by the philosophy of Merleau-Ponty, whom he considered as the only philosopher who truly had grasped the fundamental subject-object reversibility. Solipsism and existential reorientation Møller and Husby observed, confirming a common clinical experience, that young pre-schizophrenic patients become excessively preoccupied with philosophical, supernatural, and metaphysical themes: “Had to define and analyze everything; needed new concepts for the world and human existence; absorbed by new ideas or interests, gradually taking over my way of life and thinking.”51 This search for a transcendent meaning (i.e., metaphysical quest) is of course not restricted to schizophrenia but is a distinctive and pervasive characteristic of all human thought. It is fuelled by a paradox or a discordance intrinsic to the human self-relation, what Dieter Henrich, a contemporary German philosopher, designates as the “basic relation”73: on the one hand, we experience ourselves as spiritual, unique, and autonomous free beings; on the other hand, we are also self-aware as finite, causally determined entities, belonging to the world order of natural objects.
The origins of transcending thinking arise out of the following states of affairs (…): the unintelligible self-relation due to which self-consciousness exists; the (…) opposition of reality and self-consciousness (…); and the unintelligibility of finite individuality in the world order. Taken together, they constitute what can be experienced as the darkness that inheres in the basic relation. That darkness calls for a [metaphysical] thinking in which these states of affairs can be comprehended (…) with a clarity that is not available in the basic relation itself”73 (p. 126; our italics). Anomalies of experience so far described, involving subjectivization of the world, disembodiment, and instability of the self, shatter the experiential equilibrium normally characteristic of the “basic relation” and intensify the metaphysical quest, thereby leading to the existential reorientations described by Møller and Husby. The patient's altered ways of experiencing transcend commonsensical, everyday metaphysics: “reality” seems somehow mind-dependent, physical causality loses its regulatory ontological role, “other minds” are either enigmatic entities or become malevolent constructions, the subject-object distinction is blurred and the normally tacit mental processes are available for introspective gaze9 (see case 2). The term “solipsism*,” denoting here a paradoxical blend of subjectivization of the world and of others and of self-dissolution, seems to capture such a position adequately.60, 74 It is a position motivated by a profoundly altered self-experience (cases 13 through 16) and cognitively elaborated into a nexus of interests and beliefs pointing to a new existential orientation. Case 13 A young patient reported that he had, in brief moments, a feeling that only the objects in his current field of vision were real, as if the rest of the world, including most familiar places and persons, did not really exist. Probed about suicidal intentions, he replied: “No, I could never kill myself. I can't imagine the world not being represented [by me].” Feelings of centrality may be prominent in such conditions. Case 14 A former physician, when working in the emergency room of a provincial hospital, experienced, during fleeting moments, a feeling that he was the only true doctor in the entire world and the fate of humanity was in his hands. He quickly suppressed such feelings as entirely nonsensical. Case 15 When I hear a dog barking or a cat screaming far away, I instantly get a feeling that they bark and scream at me. When I listen to the radio, I get this thought that one is trying to let me understand something. I know that it is pure rubbish50 (p. 78, our translation and italics). Mimetic experiences may rarely occur, usually as an aspect of feelings of centrality: the patient, while in motion, experiences similar movements of inanimate objects or of other people. He may feel, in the “as if” mode, that he is somehow bound to imitate others or that others imitate him. Case 16 Luc, 17 years old, reports: “I made the same gestures as others, but ahead of them.” Then he corrects himself: “following them,” but this does not seem satisfactory either. He hesitates between these two versions, and ends up choosing the one in which he precedes the others75 (p. 107, our translation and italics). Solipsistic position often entails a sentiment of having a unique access to the deeper and more essential layers of reality, inaccessible to other people. It may therefore become a source of a quite distinctive type of grandiosity: the patient considers other people as pitiable, ontologically ignorant morons, solely chasing superficial and material aspects of existence. Case 17 Thomas, 22 years old and a highly gifted and successful student of mathematics, hospitalized with a pre-psychotic panic, reported that he felt to be quite different from other people since his very early childhood. He never had intimate friends, yet was very popular in the primary school because of a gift for inventing imaginary games. At the interview he mentioned that he always believed in the existence of a “world-soul.” All humans were, metaphorically speaking, like water drops fallen on earth, and so irreversibly separated from this soul. He, however, still felt in touch with the “world-soul,” like a droplet yet hanging in a tiny manner to its original source. Asked about magical abilities, he responded that “ability” was a wrong word to use; rather, he felt “as if” he somehow contained the entire universe within his own consciousness. He was perfectly aware of the impossibility of its being true in the ordinary causal sense. He felt superior to others and was always amazed by a profound banality of ordinary human strivings and interests. Transition to psychosis In the transition to psychosis, anomalies of subjective experience become thematized in the emergent delusions, hallucinations, or passivity experiences,10, 33, 36, 76 a process sometimes called as “psychotic re-personalization.”77 The following reconstruction of the illness evolution illustrates a transition from a prodromal phase into a frank psychosis. Case 18 Peter's history of illness: January 1985: “strange change is affecting him,” feels “self-disgust,” has “lost contact to himself.” August 1985: increasingly preoccupied by existential themes and Indian philosophy, “perhaps meditation could help.” Increasingly isolated. January 1987: feels fundamentally transformed, “something in me has become inhuman,” “no contact to his body,” “feels empty,” has to “find a new path in his life.” January 1988: is of the opinion that Indians are superior compared to other human races; they perhaps have a mission to save our planet. September 1992: preoccupied by recurring thoughts about extraterrestrials. January 1993: convinced that Indians are reincarnated extraterrestrials. April 1994: feels that he is being brought here each day from another planet in order to assist Indians in their salvatory mission. June 1994: first admission to a psychiatric ward, 24 years old78 (details added upon personal communication). The initial ineffable self-transformation is being progressively infused with content, reflected by new interests in the Buddhist thought and motivated by charismatic and eschatological concerns. In the operational terminology, self-disturbances evolve through “odd or overvalued ideas” and culminate in the emergence of “bizarre delusions.” Many classic psychopathologists interested in the diagnostic specificity of delusions34, 79, 80 have observed that there is a characteristic metaphysical coloring of the content of delusions that is specific to schizophrenia. This taint, in our view, is closely linked to the solipsistic position described above. Many such delusions would be considered as being bizarre on the face of their implausible or impossible content. Yet, what is being perceived as bizarre in this kind of delusions is not only the content as such, but also an altered way of the patient's experiencing, transparent through this content.81 The “metaphysical taint” indicates something about the nature of the experienced self-relation; that is to say, it points to a disturbance of the “self as a founding instance.”42 Conclusions and implications We have tried to provide descriptions of the anomalies of self-experience that are detectable in the schizophrenia spectrum disorders; descriptions that do not conform to the pre-formed operational checklists, and that neither can be found in the standard contemporary texts on schizophrenia. We have alluded in the introduction to a systematic neglect of subjective experience in psychiatry. Recently, other voices have deplored a decline of clinical finesse and skill in psychiatry.3, 82 Yet, a necessity of studying subjective experience will not go away just because it is difficult. A faithful description of experience is the first step in any taxonomic project or in any effort to correlate pathological experience to its biological substrate. This prerequisite, articulated in psychopathology by Karl Jaspers in 1923,34 has been more recently expressed by the philosopher Thomas Nagel83 in the context of consciousness research: “a necessary requirement for any coherent reductionism is that the entity to be reduced is properly understood” (p. 437). Exploring subjective experience requires appropriate phenomenological methodology, integrated in systematic empirical designs.84, 85 When practicing this approach we have been struck by two quite typical reactions from the interviewed patients: one of relief, when the patient realizes that his strange world of experience is not entirely unique or private since it seems familiar to the psychiatrist, and second, of amazement, that previously encountered mental health professionals never had asked him questions about his inner life. The incipient stage of schizophrenia is portrayed here as a disorder of consciousness, although certainly of a different kind than pathologies observed in organic delirious conditions. Profound alterations of the self mark this stage and are also observed in the schizotypal conditions, perhaps indicative in the latter case of a future risk for a psychotic progression. The described phenomena appear to point to the core phenomenological aspects of schizophrenia and therefore deserve further systematic empirical investigations, also from a pathogenetic perspective. Potential demonstration of pathogenetic significance of self-disorders may significantly alter our perspective on schizophrenia: first, it may help integrating the search for neurodevelopmental factors in schizophrenia with the developmental-psychological studies on the ontogenesis of the self86 (pp. 28-80). Second, the schizophrenia spectrum disorders need not to be conventionally defined as an aggregation of essentially disconnected symptoms, but may rather constitute a disorder essentially linked to anomalies of self-experience. Solipsism and the existential enactments of anomalous self-experience impose certain limitations upon the medical model view of schizophrenia. In the medical model, the symptoms of the illness and the self of the patient can usually be neatly separated. 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Cambridge, MA: Harvard University Press; 2001;. Cognitive Research Unit, Department of Psychiatry, Hvidore Hospital, University of Copenhagen, Copenhagen, Denmark; and the Danish National Research Foundations Centre for Subjectivity Research, Copenhagen, Denmark ☆ Supported by a grant from the University of Copenhagen (P.H.) and a grant from the Research Council of the Copenhagen Hospital Corporation (J.P.). ☆☆ Address reprint requests to Josef Parnas, M.D., Dr. Med. Sci., Cognitive Research Unit, University Department of Psychiatry, Hvidovre Hospital, Brøndbyøstervej 160, 2605 Brøndby, Denmark. ★ 0010-440X/03/4402-0004$30.00/0 PII: S0010-440X(03)00037-3 doi:10.1053/comp.2003.50017 © 2003 Published by Elsevier Inc. | |
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