Self-disorder

Schizophrenia

Self-portrait of a person with schizophrenia, representing that individual's perception of the distorted experience of reality in the disorder
Classification and external resources
Pronunciation /ˌskɪtsəˈfriːniə, ˌskɪdz-, -oʊ-, -ˈfrɛniə/[1]
Specialty Psychiatry
ICD-10 F20
ICD-9-CM 295
OMIM 181500
DiseasesDB 11890
MedlinePlus 000928
eMedicine med/2072 emerg/520
MeSH F03.700.750
This article is about the mental phenomenon associated with schizophrenia. For the mental disorders of self and personality in general, see personality disorder.

A self-disorder, also called ipseity disturbance, is a psychological phenomenon of disruption or diminishing of a person's sense of minimal (or basic) self. The sense of minimal self refers to the very basic sense of having experiences that are one's own; it has no properties, unlike the more extended sense of self, the narrative self, which is characterized by the person's reflections on themselves as a person, things they like, their identity, and other aspects that are the result of reflection on one's self. Disturbances in the sense of minimal self, as measured by the Examination of Anomalous Self-Experience (EASE),[2] aggregate in the schizophrenia spectrum disorders, to include schizotypal personality disorder, and distinguish them from other conditions such as psychotic bipolar disorder and borderline personality disorder.[3]

Minimal self

The minimal self has been likened to a "flame that enlightens its surroundings and thereby itself." Unlike the extended self, which is composed of properties such as the person's identity, the person's narrative, and other aspects that can be gleaned from reflection, the minimal self has no properties, but refers to the "mine-ness" "given-ness" of experience, that the experiences are that of the person having them in that person's stream of consciousness. These experiences that are part of the minimal self are normally "tacit" and implied, requiring no reflection on the part of the person experiencing to know that the experience is theirs. The minimal self cannot be further elaborated and normally one cannot grasp it upon reflection.[3] The minimal self goes hand-in-hand with immersion in the shared social world, such that "[t]he world is always pregiven, ie, tacitly grasped as a self-evident background of all experiencing and meaning." This is the self-world structure.[4]

De Warren gives an example of the minimal self combined with immersion in the shared social world: "When looking at this tree in my backyard, my consciousness is directed toward the tree and not toward my own act of perception. I am, however, aware of myself as perceiving this tree, yet this self-awareness (or self-consciousness) is not itself thematic."[5] The focus is normally on the tree itself, not on the person's own act of seeing the tree: to know that one is seeing the tree does not require an act of reflection.

Disturbance

In the schizophrenia spectrum disorders, the minimal self and the self-world structure are "constantly challenged, unstable, and oscillating," causing anomalous self-experiences known as self-disorders. These involve the patient feeling as if they lack an identity, as if they are not really existing, that the sense of their experiences being their own (the "mine-ness" of their experiential world) is failing or diminishing, as if their inner experiences are no longer private, and that they don't really understand the world. These experiences lead to the patient engaging in hyper-reflectivity, or abnormally prolonged and intense self-reflection, to attempt to gain a grasp on these experiences, but such intense reflection may further exacerbate the self-disorders. Self-disorders tend to be chronic, becoming incorporated into the patient's way of being and affecting "how" they experience the world and not necessarily "what" they experience. This instability of the minimal self may provoke the onset of psychosis.[4][6]

Similar phenomena can occur in other conditions, such as bipolar disorder and depersonalization disorder, but Sass's (2014) review of the literature comparing accounts of self-experience in various mental disorders shows that serious self-other confusion and "severe erosion of minimal self-experience" only occur in schizophrenia;[7] as an example of the latter, Sass cites the autobiographical account of Elyn Saks, who has schizophrenia, of her experience of "disorganization" in which she felt that thoughts, perceptions, sensations, and even the passage of time became incoherent, and that she had no longer "the solid center from which one experiences reality", which occurred when she was 7 or 8 years old.[8] This disturbance tends to fluctuate over time based on emotions and motivation, accounting for the phenomenon of dialipsis in schizophrenia, where neurocognitive performance tends to be inconsistent over time.[7]

The disturbance of the minimal self may manifest in patients in various ways, including as a tendency to inspect one's thoughts in order to know what they are thinking, like a person seeing an image, reading a message, or listening closely to someone talking (audible thoughts; or in German: Gedankenlautwerden). In normal thought, the "signifier" (the images or inner speech representing the thought) and the "meaning" are combined into the "expression", so that the person "inhabits" their thinking, or that both the signifier and the meaning implicitly come to mind together; the person does not need to reflect on their thoughts to understand what they are thinking. In patients with self-disorder, however, it is frequently the case that many thoughts are experienced as more like external objects that are not implicitly comprehended. The patient must turn their focus toward the thoughts to understand their thoughts because of that lack of implicit comprehension, a split of the signifier and the meaning from each other, where the signifier emerges automatically in the field of awareness but the meaning does not. This is an example of the failing "mine-ness" of the experiential field as the minimal self recedes from its own thoughts, which are consigned to an outer space. This is present chronically, both during and outside of psychosis, and may represent a middle point between normal inner speech and auditory hallucinations.[9]

They may also experience uncontrolled multiple trains of thought with different themes simultaneously coursing through one's head interfering with concentration (thought pressure) or often feel they must attend to things with their full attention in order to get done what most people can do without giving it much thought (hyper-reflectivity), which can lead to fatigue.[3][2]

Examination of Anomalous Self-Experience (EASE)

The EASE is a semi-structured interview that attempts to capture the extent of the mainly non-psychotic self-disorders experienced by the patient. It is divided into 5 broad sections: Cognition and stream of consciousness, which covers disturbances in the flow of thoughts and experiences, and includes such self-disorders as "thought pressure", an experienced chaos of unrelated thoughts, "loss of thought ipseity", a sense as if the patient does not own their thoughts (but not to the level of psychosis), and "spatialization of experience", which is where the patient experiences their thoughts as if they occurred within a space; self-awareness and presence, which deals with dissociative experiences of the self and world as well as a tendency toward intense reflection, in addition to a declining understanding of how to interact with others and the world called "perplexity" or "lack of natural evidence"; bodily experiences, which deals with alienating experiences of the body as well as with "mimetic experiences", the sense of a patient that if they move, pseudo-movements of other, unrelated objects are experienced; demarcation/transitivism, which covers specific disturbances in the patient's ego boundaries such as the patient confusing their own thoughts, ideas, and feelings for that of their interlocutor; and existential reorientation, which refers to changes in the patient's experience of the world that reflect the effect of self-disorders on the patient's worldview.[2]

The EASE, and pre-EASE studies attempting to assess basic self-disturbance, has been found in studies to discriminate between patients on the schizophrenia spectrum, and those with psychotic bipolar disorder or borderline personality disorder. The EASE has been found to have good reliability, meaning that when 2 clinicians do the assessment, they draw roughly the same conclusions.[3] The items on the EASE were compared against the accounted experiences of depersonalization disorder, finding many affinities, but also differences, reflecting namely the failing sense of "mine-ness" of the experiential world and a tendency to confuse the self with the world, others, or both.[10]

Clinical relevance

The presence of self-disorders may have predictive power for whether those with an at risk mental state will develop psychosis;[11][12] the risk of suicidal ideation and suicide by patients with schizophrenia, though depression would also be an important factor;[13] predicting initial social dysfunction in patients with either schizophrenic or bipolar psychosis;[14] and whether a patient will move to a schizophrenia spectrum diagnosis later.[15]

The presence of self-disorders may cause reduced patient insight into their illness through the alteration of the basic structures of consciousness.[4][3]

Self-disorders are difficult for the patients experiencing them to articulate spontaneously;[2][16] and are not well-known, by either the general public or professionals in the field. Because of this, patients will often make vague, cliched complaints that mimic the symptoms of other mental disorders, symptoms such as "fatigue" or "concentration difficulties". Were a knowledgeable clinician to probe deeper, however, the underlying self-disorders may be assessed and help clarify the nature of the patient's illness. In their review, Parnas, et al. (2014) say, "The psychiatrist’s acquaintance with the phenomenon of 'non-specific specificity' is, in our view, extremely important in the context of early diagnostic assessment, especially of patients presenting with a vague, unelaborated picture of maladjustment, underperformance, chronic malaise and dysphoria, negative symptoms, or hypochondriac preoccupations." Patients with schizophrenia often describe their self-disorders as causing more suffering for them than psychosis.[3]

Future directions and controversy

In a 2014 review, Postmes, et al., suggested that self-disorders and psychosis may arise from attempts to compensate for perceptual incoherence and proposed a hypothesis for how the interaction among these phenomena and the patient's attempts to cope give rise to schizophrenia. The problems with the integration of sensory information create problems for the patient in keeping a grip on the world, and since the self-world interaction is fundamentally linked to the basic sense of self, the latter is also disrupted as a result.[17] Sass and Borda have studied the correlates of the dimensions of self-disorders, namely disturbed grip (perplexity, difficulty "getting" stuff that most people can get), hyperreflexivity (where thoughts, feelings, sensations, and objects pop up uncontrollably in the field of awareness), and diminished self-affection (where the person has difficulty getting "affected" by aspects of the self, experiencing aspects of the self as if they existed in an outer space), and have proposed how both primary and secondary factors may arise from dysfunctions in perceptual organization and multisensory integration. [18][19]

In a 2013 review, Mishara, et al., criticized the concept of the minimal self as an explanation for self-disorder, saying that it is unfalsifiable, and that self-disorder arises primarily from difficulty integrating different aspects of the self as well as having difficulty distinguishing self and other, as proposed by Lysaker and Lysaker: Ichstörung or ego disorder, as they say, in schizophrenia arises from disturbed relationships not from the "solipsistic" concept of the self as proposed by Sass, Parnas, and others.[20] In his review, Sass agrees that the focus of research into self-disorder has focused too much on the self, and mentions attempts to look at disturbances in the patient's relationship with other people and the world, with work being done to create an Examination of Anomalous World Experience, which will look at the patient's anomalous experiences regarding time, space, persons, language, and atmosphere; he suggests there are problems with both the self and the world in patients with self-disorder, and that it may be better conceptualized as a "presence-disturbance".[7] Parnas acknowledges the Lysaker model, but says that it is not incompatible with the concept of the minimal self, as they deal with different levels of self-hood.[3]

History of the concept

The concept of a basic self-disturbance in schizophrenia appears in all the foundational texts on the disease. However, the concept was difficult to operationalize and was criticized for being vague and too subjective; little systematic or empirical research was done on the concept in the 20th century. The publication of the DSM-III (1980) had unintended consequences, however, and led, in many instances, to focusing only on the signs and symptoms listed as criteria and generally ignoring the other signs and symptoms that can appear with each disorder; it privileged a behaviorist approach to diagnosis. The concept of this self-disturbance soon disappeared from training programs in the United States.[3][21]

The Bonn Scale for the Assessment of Basic Symptoms was created to assess sub-clinical affective, cognitive and perceptual disturbances, as well as basic self-disturbance, in patients, and in many studies basic symptoms were found to aggregate in patients with schizophrenic and schizotypal disorders. Basic symptoms are subjective and difficult for the patient to describe spontaneously, but the patient will try to adapt and cope with them: functioning becomes impaired when patients reach their adaptive capacity. In the period leading up to the first episode of schizophrenia, uncharacteristic basic symptoms first appear and are followed by the onset of more characteristic basic symptoms and, finally, psychosis.[16]

To revive the concept of basic self-disturbance and to overcome the previous problems of a lack of a concrete definition of it, a group of researchers developed the EASE, based on phenomenological interviews with first-admission patients with schizophrenia spectrum disorders, to enable empirical research of self-disorders.[2][3]

See also

References

  1. ↑ Jones, Daniel (2003) [1917], Peter Roach, James Hartmann and Jane Setter, eds., English Pronouncing Dictionary, Cambridge: Cambridge University Press, ISBN 3-12-539683-2
  2. 1 2 3 4 5 Josef Parnas, Paul Moller, Tilo Kircher, Jorgen Thalbitzer, Lennart Jansson, Peter Handest & Dan Zahavi (September 2005). "EASE: Examination of Anomalous Self-Experience". Psychopathology 38 (5): 236–258. doi:10.1159/000088441. PMID 16179811.
  3. 1 2 3 4 5 6 7 8 9 Josef Parnas & Mads Gram Henriksen (September 2014). "Disordered self in the schizophrenia spectrum: a clinical and research perspective". Harvard Review of Psychiatry 22 (5): 251–265. doi:10.1097/HRP.0000000000000040. PMID 25126763.
  4. 1 2 3 Mads G. Henriksen & Josef Parnas (May 2014). "Self-disorders and schizophrenia: a phenomenological reappraisal of poor insight and noncompliance". Schizophrenia Bulletin 40 (3): 542–547. doi:10.1093/schbul/sbt087. PMID 23798710.
  5. ↑ De Warren, N. Husserl and the Promise of Time. New York: Cambridge University Press., cited in Brice Martin, Marc Wittmann, Nicolas Franck, Michel Cermolacce, Fabrice Berna & Anne Giersch (2014). "Temporal structure of consciousness and minimal self in schizophrenia". Frontiers in Psychology 5: 1175. doi:10.3389/fpsyg.2014.01175. PMID 25400597.
  6. ↑ Louis A. Sass & Josef Parnas (2003). "Schizophrenia, consciousness, and the self". Schizophrenia Bulletin 29 (3): 427–444. PMID 14609238.
  7. 1 2 3 Sass, Louis A. (2014). "Self-disturbance and schizophrenia: Structure, specificity, pathogenesis (Current issues, New directions)". Schizophrenia Research 152 (1): 5–11. doi:10.1016/j.schres.2013.05.017. ISSN 0920-9964. PMID 23773296.
  8. ↑ Saks, Elyn (2007). The center cannot hold : my journey through madness. New York: Hyperion. ISBN 1-4013-0944-5.
  9. ↑ Kendler, K.S.; Parnas, J. (2012). Philosophical Issues in Psychiatry II: Nosology. International Perspectives in Philosophy & Psychiatry. OUP Oxford. p. 242-243. ISBN 978-0-19-964220-5. Retrieved 2016-04-12.
  10. ↑ Louis Sass, Elizabeth Pienkos, Barnaby Nelson & Nick Medford (June 2013). "Anomalous self-experience in depersonalization and schizophrenia: a comparative investigation". Consciousness and Cognition 22 (2): 430–441. doi:10.1016/j.concog.2013.01.009. PMID 23454432.
  11. ↑ Andrea Raballo, Elena Pappagallo, Alice Dell' Erba, Nella Lo Cascio, Martina Patane', Eva Gebhardt, Tommaso Boldrini, Laura Terzariol, Massimiliano Angelone, Alberto Trisolini, Paolo Girardi & Paolo Fiori Nastro (January 2016). "Self-Disorders and Clinical High Risk for Psychosis: An Empirical Study in Help-Seeking Youth Attending Community Mental Health Facilities". Schizophrenia Bulletin. doi:10.1093/schbul/sbv223. PMID 26757754.
  12. ↑ Barnaby Nelson, Andrew Thompson & Alison R. Yung (November 2012). "Basic self-disturbance predicts psychosis onset in the ultra high risk for psychosis "prodromal" population". Schizophrenia Bulletin 38 (6): 1277–1287. doi:10.1093/schbul/sbs007. PMID 22349924.
  13. ↑ Elisabeth Haug, Ingrid Melle, Ole A. Andreassen, Andrea Raballo, Unni Bratlien, Merete Oie, Lars Lien & Paul Moller (July 2012). "The association between anomalous self-experience and suicidality in first-episode schizophrenia seems mediated by depression". Comprehensive Psychiatry 53 (5): 456–460. doi:10.1016/j.comppsych.2011.07.005. PMID 21871617.
  14. ↑ Elisabeth Haug, Merete Oie, Ole A. Andreassen, Unni Bratlien, Andrea Raballo, Barnaby Nelson, Paul Moller & Ingrid Melle (April 2014). "Anomalous self-experiences contribute independently to social dysfunction in the early phases of schizophrenia and psychotic bipolar disorder". Comprehensive Psychiatry 55 (3): 475–482. doi:10.1016/j.comppsych.2013.11.010. PMID 24378241.
  15. ↑ Josef Parnas, John Carter & Julie Nordgaard (February 2016). "Premorbid self-disorders and lifetime diagnosis in the schizophrenia spectrum: a prospective high-risk study". Early Intervention in Psychiatry 10 (1): 45–53. doi:10.1111/eip.12140. PMID 24725282.
  16. 1 2 Frauke Schultze-Lutter (January 2009). "Subjective symptoms of schizophrenia in research and the clinic: the basic symptom concept". Schizophrenia Bulletin 35 (1): 5–8. doi:10.1093/schbul/sbn139. PMID 19074497.
  17. ↑ Postmes, L.; Sno, H.N.; Goedhart, S.; van der Stel, J.; Heering, H.D.; de Haan, L. (2014). "Schizophrenia as a self-disorder due to perceptual incoherence". Schizophrenia Research 152 (1): 41–50. doi:10.1016/j.schres.2013.07.027. ISSN 0920-9964. PMID 23973319.
  18. ↑ Borda, Juan P.; Sass, Louis A. (2015). "Phenomenology and neurobiology of self disorder in schizophrenia: Primary factors". Schizophrenia Research 169 (1-3): 464–473. doi:10.1016/j.schres.2015.09.024. ISSN 0920-9964. PMID 26516103.
  19. ↑ Sass, Louis A.; Borda, Juan P. (2015). "Phenomenology and neurobiology of self disorder in schizophrenia: Secondary factors". Schizophrenia Research 169 (1-3): 474–482. doi:10.1016/j.schres.2015.09.025. ISSN 0920-9964. PMID 26603059.
  20. ↑ Mishara, A. L.; Lysaker, P. H.; Schwartz, M. A. (2013). "Self-disturbances in Schizophrenia: History, Phenomenology, and Relevant Findings From Research on Metacognition". Schizophrenia Bulletin 40 (1): 5–12. doi:10.1093/schbul/sbt169. ISSN 0586-7614. PMID 24319117.
  21. ↑ Nancy C. Andreasen (January 2007). "DSM and the death of phenomenology in america: an example of unintended consequences". Schizophrenia Bulletin 33 (1): 108–112. doi:10.1093/schbul/sbl054. PMID 17158191.

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