Disordered self in the schizophrenia spectrum: a clinical and research perspective

Schizophrenia, the very idea: On self-disorder, hyperreflexivity, and the diagnostic concept

The purpose of the present article is to consider schizophrenia-the very idea-from the perspective of phenomenological psychopathology, with special attention to the problematic nature of the diagnostic concept as well as to the prospect and challenges inherent in focusing on subjective experience. First, we address historical and philosophical topics relevant to the legitimacy of diagnostic categorization-in general and regarding "schizophrenia" in particular. William James's pragmatist approach to categorization is discussed. Then we offer a version of the well-known basic-self or ipseity-disturbance model (IDM) of schizophrenia, but in a significantly revised form (IDMrevised). The revised model better acknowledges the diverse and even seemingly contradictory nature of schizophrenic symptoms while, at the same time, interpreting these in a more unitary fashion via the key concept of hyperreflexivity-a form of exaggerated self-awareness that tends to undermine normal world-directedness and the stability of self-experience. Particular attention is paid to forms of exaggerated "self-presence" that are sometimes neglected yet imbue classically schizophrenic experiences involving subjectivism or quasi-solipsism and/or all-inclusive or ontological forms of paranoia. We focus on the distinctively paradoxical nature of schizophrenic symptomatology. In concluding we consider precursors in the work of Klaus Conrad, Kimura Bin and Henri Grivois. Finally we defend the concept of schizophrenia by considering its distinctive way of altering certain core aspects of the human condition itself.

Self-Disorder in Schizophrenia: A Revised View (1. Comprehensive Review-Dualities of Self- and World-Experience)

A growing body of research supports the role of self-disorders as core phenotypic features of schizophrenia-spectrum disorders. Self-disorders comprise various alterations of conscious experience whose theoretical understanding continues to present a challenge. The following 2 articles aim to provide further clarification of the nature of self-disorders in schizophrenia by offering a comprehensive review (article 1) and theoretical revision (article 2) of the currently most influential model of altered selfhood in schizophrenia: the basic-self-disturbance or ipseity-disorder model (IDM). This article presents a state-of-the-art overview of the current self-disturbance model and critically assesses its descriptive adequacy with respect to the clinical variability and heterogeneity of the alterations in self- and world-awareness characteristic of schizophrenia. Special attention is paid to experiences of exaggerated basic self, increased "grip" or "hold" on the world, and paradoxical combinations. The next article proposes a theoretical revision of the self-disturbance model by considering how hyperreflexivity might form the crucial common thread or generating factor that unifies the phenomenologically heterogeneous, and sometimes even contradictory features of schizophrenic self-disorders. We outline the implications of our revised model for explanatory research, therapeutic practice, and our general understanding of the abnormalities in question.

Identifying Patients with Cognitive Motor Dissociation Using Resting-state Temporal Stability

Using task-dependent neuroimaging techniques, recent studies discovered a fraction of patients with disorders of consciousness (DOC) who had no command-following behaviors but showed a clear sign of awareness as healthy controls, which was defined as cognitive motor dissociation (CMD). However, existing task-dependent approaches might fail when CMD patients have cognitive function (e.g., attention, memory) impairments, in which patients with covert awareness cannot perform a specific task accurately and are thus wrongly considered unconscious, which leads to false-negative findings. Recent studies have suggested that sustaining a stable functional organization over time, i.e., high temporal stability, is crucial for supporting consciousness. Thus, temporal stability could be a powerful tool to detect the patient's cognitive functions (e.g., consciousness), while its alteration in the DOC and its capacity for identifying CMD were unclear. The resting-state fMRI (rs-fMRI) study included 119 participants from three independent research sites. A sliding-window approach was used to investigate global and regional temporal stability, which measured how stable the brain's functional architecture was across time. The temporal stability was compared in the first dataset (36/16 DOC/controls), and then a Support Vector Machine (SVM) classifier was built to discriminate DOC from controls. Furthermore, the generalizability of the SVM classifier was tested in the second independent dataset (35/21 DOC/controls). Finally, the SVM classifier was applied to the third independent dataset, where patients underwent rs-fMRI and brain-computer interface assessment (4/7 CMD/potential non-CMD), to test its performance in identifying CMD. Our results showed that global and regional temporal stability was impaired in DOC patients, especially in regions of the cingulo-opercular task control network, default-mode network, fronto-parietal task control network, and salience network. Using temporal stability as the feature, the SVM model not only showed good performance in the first dataset (accuracy = 90%), but also good generalizability in the second dataset (accuracy = 84%). Most importantly, the SVM model generalized well in identifying CMD in the third dataset (accuracy = 91%). Our preliminary findings suggested that temporal stability could be a potential tool to assist in diagnosing CMD. Furthermore, the temporal stability investigated in this study also contributed to a deeper understanding of the neural mechanism of consciousness.

Relating self-disorders to neurocognitive and psychopathological measures in first-episode schizophrenia

AIM

The notion of a disturbed self as the core feature of schizophrenia dates back to the founding texts on the illness. Since the development of the psychometric tool for examination of anomalous self-experience (EASE), self-disorders have become accessible to empirical research. Empirical studies have shown that EASE measured self-disorders predict schizophrenia spectrum in prospective studies and consistently show a selective hyper aggregation of self-disorder in schizophrenia and schizotypal disorders. The aim of this study is to investigate the relationship between self-disorders cognitive deficits and symptoms in schizophrenia.

METHODS

Thirty-five non-acute first-episode patients with schizophrenia and 35 matched healthy controls were evaluated with EASE, cognitive deficits, and symptoms (PANSS positive, negative and general). [Correction added on 28 January 2022, after first online publication: the words, 'evaluated with' were missing and have now been added to the preceding sentence.] RESULTS: The results show that self-disorders and symptoms are correlated among patients with schizophrenia, but not with cognitive deficits. Moreover, with the exception of attentional deficits, neurocognitive impairment was not significantly higher among patients with schizophrenia compared to healthy controls.

CONCLUSIONS

We argue that this adds support to a view of schizophrenia as being characterized by specific traits of pre-reflective self-disturbance, which are related to the severity of symptoms, whereas neurocognitive impairment reflects a separate or distinct aspect of schizophrenia.

A functional neuroimaging study of self-other processing alterations in atypical developmental trajectories of psychotic-like experiences

Self-disturbances constitute a hallmark of psychosis, but it remains unclear whether these alterations are present in at-risk populations, and therefore their role in the development of psychosis has yet to be confirmed. The present study addressed this question by measuring neural correlates of self-other processing in youth belonging to three developmental trajectories of psychotic experiences. Eighty-six youths were recruited from a longitudinal cohort of over 3800 adolescents based on their trajectories of Psychotic-Like Experiences from 12 to 16 years of age. Participants underwent neuroimaging at 17 years of age (mean). A functional neuroimaging task evaluating self- and other-related trait judgments was used to measure whole-brain activation and connectivity. Youth who showed an increasing trajectory displayed hypoactivation of the dorsomedial prefrontal cortex and hypoconnectivity with the cerebellum. By contrast, youth who showed a decreasing trajectory displayed decreased activation of the superior temporal gyrus, the inferior frontal gyrus, and the middle occipital gyrus. These findings suggest that the increasing trajectory is associated with alterations that might erode distinctions between self and other, influencing the emergence of symptoms such as hallucinations. The decreasing trajectory, in comparison, was associated with hypoactivations in areas influencing attention and basic information processing more generally. These alterations might affect the trajectories’ susceptibilities to positive vs. negative symptoms, respectively.

Are Self-disorders in Schizophrenia Expressive of a Unifying Disturbance of Subjectivity: A Factor Analytic Approach

BACKGROUND AND HYPOTHESIS

The idea that a disorder of the basic self is a central feature in schizophrenia has recently been corroborated in a meta-analysis and a systematic review. Manifestations of the self-disorder can be systematically explored with the Examination of Anomalous Self-Experience (EASE). In this study, we examined the factorial structure of EASE, and diagnostic efficacy of EASE. We hypothesized that EASE will have a monofactorial structure as an instability of the basic self will result in multiple deformations of self-experience which would be meaningfully interrelated as aspects of a unifying Gestalt.

DESIGN

EASE data for 226 patients suffering from various mental disorders were analyzed under a confirmatory factor analysis framework (CFA). Area under the receiver operating characteristic curve (AUC) was calculated for the total EASE sums, and sensitivity and specificity values for prediction of schizophrenia spectrum disorders based on different cut-offs were obtained.

RESULTS

Fit indices for the CFA model: RMSEA = 0.036, SRMR = 0.100, CFI = 0.983, TLI = 0.981. The AUC value was 0.946 (95% confidence interval: 0.919-0.974). Sensitivity as well as specificity for schizophrenia spectrum disorders were high.

CONCLUSION

Our results lend support for EASE exhibiting a monofactorial structure and the notion of self-disorders as a central phenotypic feature of schizophrenia spectrum disorders.

Time in schizophrenia: a link between psychopathology, psychophysics and technology

It has been widely demonstrated that time processing is altered in patients with schizophrenia. This perspective review delves into such temporal deficit and highlights its link to low-level sensory alterations, which are often overlooked in rehabilitation protocols for psychosis. However, if temporal impairment at the sensory level is inherent to the disease, new interventions should focus on this dimension. Beyond more traditional types of intervention, here we review the most recent digital technologies for rehabilitation and the most promising ones for sensory training. The overall aim is to synthesise existing literature on time in schizophrenia linking psychopathology, psychophysics, and technology to help future developments.

Posture, gait and self‐disorders: An empirical study in individuals with schizophrenia

AIM

In schizophrenia, subjectively perceived disruptions of the sense of the Self (also referred to as "self-disorders") seem to be intimately associated with a perturbation of the implicit awareness of one's own body. Indeed, an early impairment of the motor system, including posture and gait, is now considered a marker of schizophrenia neurodevelopmental substrate and appears more pronounced in early-onset schizophrenia. Therefore, the present study was aimed at: (1) investigating a possible relationship between self-disorders, symptom dimensions and postural and gait profile in schizophrenia; (2) identifying a specific motor profile in early-onset conditions.

METHODS

A total of 43 schizophrenia outpatients and 38 healthy controls underwent an exhaustive investigation of posture and gait pattern. The positive and negative syndrome scale (PANSS), the examination of anomalous self experience scale (EASE) and the abnormal involuntary movement scale (AIMS) were administered to the schizophrenia group. Subsequently, schizophrenia patients were divided into early and adult-onset subgroups and compared with respect to their motor profile.

RESULTS

We found an association between specific postural patterns (impaired sway area), a general disruption of the gait cycle and subjective bodily experiences (concerning the loss of bodily integrity, cohesion and demarcation). Only motor parameters (increased sway area and gait cadence reduction) differentiated between early and adult-onset patients.

CONCLUSION

The results of the present study hint at a link between motor impairment and self-disturbances in schizophrenia and candidate a specific motor profile as a possible marker of early-onset forms.

Too soon to discard Kraepelin: improving diagnosis by appropriate use of neo-Kraepelinian and unitary psychosis models

There is a debate in psychiatry regarding whether it is better to use neo-Kraepelinian diagnostic categories or unitary models of psychosis in clinical practice. This article argues that clinicians should use either model as appropriate for the case in question, along with the conceptual framework used in the clinical management of psychosis without a clear biological cause. It first explores the values involved in the development of psychiatric classification systems, the purpose of classification and how we reached the current DSM/ICD and unitary models of psychosis. It then describes a diagnostic approach in which the choice of model should depend on the case in question, and offers a diagnostic protocol to guide the decision.

The experience of psychosis and recovery from consumers' perspectives: An integrative literature review

WHAT IS KNOWN ON THE SUBJECT?: Since the first decade of this century, few qualitative studies and literature reviews have reported consumers' experiences of psychosis and recovery. The findings from these studies need further exploration. WHAT DOES THE PAPER ADD TO EXISTING KNOWLEDGE?: New insights into consumers' experiences of psychosis were generated. Additionally, understanding of consumers' conceptions and experiences of recovery were reported. Consumers' insights into the enablers and barriers to recovery that they encountered were also identified. Gaps in the literature remain, particularly those related to the effects of gender and culture on consumers' experiences of and recovery from psychosis. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses' understanding of consumers' perspectives and experiences of psychosis is vital to enhancing the quality of mental health nursing when caring for people living with psychosis. To support user-based recovery, mental health nurses need to incorporate person-centred approaches and reduce their preferencing of medical understandings of recovery.

ABSTRACT

INTRODUCTION: Psychosis is a distressing disorder. Consumers' perspectives about their experiences of psychosis and recovery are essential aspects of mental health nursing.

AIMS

To review contemporary evidence related to consumers' experiences of and recovery from psychosis.

METHOD

An integrative review was the method used; six databases were systematically searched. Of the 157 articles screened, 14 met the inclusion criteria and were assessed for quality using Joanna Briggs Institute Appraisal tools. Data were compared, classified and integrated.

RESULTS

Findings revealed that consumers' experiences of psychosis included issues with self-expression and language, psychosocial problems and stigma. Also, consumers' experiences associated with their recovery were reported, and this included their perspectives on the enablers and barriers that they encountered.

DISCUSSION

Consumer's experiences of and recovery from psychosis provide an essential basis for managing and working with people experiencing psychosis. Further research identifying the potential effects of gender and culture into consumers' lived experiences is required.

IMPLICATIONS FOR PRACTICE

Exploring the experience of someone with psychosis will help nurses to understand the impacts of this condition. This understanding can guide nurses to apply recovery-oriented practices. Specific aspects of psychosis experience, including gender and culture, should inform nurses' practices towards recovery.

Prevalence and assessment of self-disorders in the schizophrenia spectrum: a systematic review and meta-analysis

Self-disorders have been proposed as the "clinical core" of the schizophrenia spectrum. This has been explored in recent studies using self-disorder assessment tools. However, there are few systematic discussions of their quality and utility. Therefore, a literature search was performed on Medline, Embase, PsychINFO, PubMed and the Web of Science. Studies using these assessment tools to explore self-disorders within schizophrenia spectrum disorders (SSDs) were included. A meta-analysis was performed on the outcomes of total self-disorder score and odds ratios of self-disorders, using Comprehensive Meta-Analysis software. Weighted pooled effect sizes in Hedge's g were calculated using a random-effects model. 15 studies were included, giving a sample of 810 participants on the schizophrenia spectrum. Self-disorders showed a greater aggregation within schizophrenia spectrum groups compared to non-schizophrenia spectrum groups, as measured with the Bonn Scale for the Assessment of Basic Symptoms (Hedge's g = 0.774, p < 0.01) and Examination of Anomalous Self-Experiences (Hedge's g = 1.604, p < 0.01). Also, self-disorders had a greater likelihood of occurring within SSDs (odds ratio = 5.435, p < 0.01). These findings help to validate self-disorders as a core clinical feature of the broad schizophrenia spectrum.

Basic self-disturbance trajectories in clinical high risk for psychosis: a one-year follow-up study

Basic self-disturbance (BSD) has been proposed as a driver of symptom development in schizophrenia spectrum disorders (SSDs). In a one-year follow-up of 32 patients (15-30 years) at putative risk for psychosis, we investigated trajectories of BSD levels from baseline to follow-up, and associations between clinical characteristics at baseline and follow-up, including follow-up levels of BSD (assessed with the EASE). Clinical high risk (CHR) for psychosis status and symptom severity were assessed with the SIPS/SOPS scales and also according to the cognitive basic symptoms high-risk criteria (COGDIS). DSM-IV diagnoses, functioning and other clinical characteristics were assessed with standard clinical instruments. Higher severity of negative symptoms and meeting COGDIS criteria at baseline were associated with higher BSD levels at follow-up. All measured at follow-up, higher BSD levels correlated with higher severity of positive, negative, disorganization and general symptoms, and with a lower level of global functioning. We found higher BSD levels at follow-up in subjects with schizotypal personality disorder (SPD) at baseline (n = 5) and in SSDs at follow-up (n = 12, including nine with SPD). Mean BSD levels decreased significantly from baseline to follow-up, but individual trajectories varied considerably. Increased BSD levels were associated with higher baseline BSD levels, non-remission of positive symptoms and functional decline. Overall, the current study indicates that subgroups in the CHR population with a higher risk of non-remission or deterioration may be identified by supplementing CHR criteria with assessment of BSD and negative symptoms.

Basic self-disturbance in schizotypy

AIM

Phenomenological researchers argue that schizophrenia spectrum disorders are primarily disorders of the basic self. To test this argument, we compared self-report and lexical measures of basic self-disturbance between schizophrenia spectrum (high-schizotypy) and non-spectrum groups (low-schizotypy).

METHODS

From an initial sample (n = 310) screened with the (SPQ), n = 39 were classified as high schizotypy (z > 1.28 on at least one SPQ factor scale) and were compared to a randomly selected low-schizotypy group (z < 1 on all three SPQ factor scales; n = 41). Participants wrote four narratives about personal and fictional experiences and completed the Ego Strength Questionnaire and a self-report version of the Schizophrenia Proneness Instrument. The written narratives were subjected to linguistic inquiry to examine pronoun usage (lexical measures).

RESULTS

The high-schizotypy group reported higher levels of basic symptoms, lower ego strength, and used third-person and personal pronouns more frequently than the low-schizotypy group. Self-report measures correlated significantly with lexical measures. Self-report and lexical measures were useful tools in predicting high schizotypy, correctly classifying 68% and 69% of schizotypy and non-schizotypy, respectively.

CONCLUSION

In line with phenomenologists' arguments, high schizotypy was associated, to some extent, with basic self-disturbance.

Borderline We-Space? The Phenomenology of the Background of Safety in Borderline Personality Disorder

Borderline personality disorder (BPD) is a severe psychiatric condition characterized by instability in identity, relationships, and affect. Individuals, with BPD typically lack a coherent sense of self, are highly sensitive to interpersonal stressors, experience intense fluctuations in mood, and frequently engage in impulsive and self-destructive behaviors. Although both empirical research and development of effective psychotherapy have evidently progressed over the past years, many aspects regarding the structure of experience and the life-world typical for persons with BPD are not yet fully understood. Somewhat surprisingly, phenomenological psychopathology has only recently started to pay more attention to the disorder. A comprehensive elaboration of the phenomenology of BPD is therefore still lacking. This article aimed to contribute to such a phenomenological understanding by focusing on what we think is an essential aspect that has yet not been sufficiently addressed: the background of safety. To clarify what this means, we depart from Sandler's [Int J Psychoan. 1960;41:352-6] psychoanalytic concept and elaborate on it phenomenologically. This leads us to argue that the development of a background of safety requires a particular embodied presence of others, which, in turn, contributes to the constitution of a safe we-space, a shared and familiar environment providing a matrix for the experience of a stable world. However, even when established, the background of safety remains in need of a continuous reconfirmation through corresponding experiences within a sufficiently reliable and controllable environment. The background of safety is vulnerable and open to (interpersonal) disruptions like trauma or neglect. In BPD, we suggest 3 aspects regarding the phenomenology of the background of the safety need to be considered: first, typically, patients with BPD did not develop a robust background of safety in infancy; second, weakening of the background of safety gives rise to symptoms and dynamics typical for BPD; third, these symptoms and dynamics further undermine the possible development of a background of safety in adult life and thus gravitate toward a petrification of the borderline condition, a "stable instability." To conclude, we examine whether this concept should be understood as a trouble générateur and, last, consider its clinical implications.

Four Core Concepts in Psychiatric Diagnosis

In the present article, we aimed at describing the diagnostic process in Psychiatry through a phenomenological perspective. We have identified 4 core concepts which may represent the joints of a phenomenologically oriented diagnosis. The "tightrope walking" attitude refers to the psychiatrist's ability to swing between 2 different and sometimes contrasting tendencies (e.g., engagement and disengagement). The "holistic experience" includes all those intuitive, nonverbal, and pre-thematic elements that emerge in the early stages of the clinical encounter as an emanation of the atmospheric quality of the intersubjective space. The "co-construction of symptoms" regards the hermeneutic process behind psychiatric symptoms, involving both the patient as a self-interpreting agent and the clinician as a translator of his/her experience. Finally, by the "evolving typification" we mean that the closer the relationship becomes with the patient, the more specific and nuanced becomes the typification behind psychiatric diagnosis. Each of these concepts will be accompanied by an extract from a clinical case deriving from one of the authors' most recent clinical experiences.

Integration and Causality in Enactive Approaches to Psychiatry

In this paper I address what has been called the integration problem in psychiatry. This problem is tied to conceptions of causality and explanatory levels in our understanding of mind. I take an interdisciplinary enactive perspective to develop a 3-fold method for exploring the dynamics of integration, based on a concept of dynamical causation and a non-hierarchical (level-free) notion of gestalt. I also consider Autism Spectrum Disorder (ASD) as a test case.

Integrating trauma, self-disturbances, cognitive biases, and personality into a model for the risk of psychosis: a longitudinal study in a non-clinical sample

The hypothesis of the psychosis continuum enables to study the mechanisms of psychosis risk not only in clinical samples but in non-clinical as well. The aim of this longitudinal study was to investigate self-disturbances (SD), a risk factor that has attracted substantial interest over the last two decades, in combination with trauma, cognitive biases and personality, and to test whether SD are associated with subclinical positive symptoms (PS) over a 12-month follow-up period. Our study was conducted in a non-clinical sample of 139 Polish young adults (81 females, age M = 25.32, SD = 4.51) who were selected for frequent experience of subclinical PS. Participants completed self-report questionnaires for the evaluation of SD (IPASE), trauma (CECA.Q), cognitive biases (DACOBS) and personality (TCI), and were interviewed for subclinical PS (CAARMS). SD and subclinical PS were re-assessed 12 months after baseline measurement. The hypothesized model for psychosis risk was tested using path analysis. The change in SD and subclinical PS over the 12-month period was investigated with non-parametric equivalent of dependent sample t-tests. The models with self-transcendence (ST) and harm avoidance (HA) as personality variables were found to be well-fitted and explained 34% of the variance in subclinical PS at follow-up. Moreover, we found a significant reduction of SD and subclinical PS after 12 months. Our study suggests that combining trauma, cognitive biases, SD and personality traits such as ST and HA into one model can enhance our understanding of appearance as well as maintenance of subclinical PS.

Double bookkeeping and schizophrenia spectrum: divided unified phenomenal consciousness

Eugen Bleuler, the founder of the concept of schizophrenia, pointed out that psychotic patients were able to live in two disjoint worlds (namely, the social, intersubjective world and the delusional world). He termed this phenomenon "double bookkeeping," but did not provide any conceptual elaboration of this phenomenon or its possible mechanisms. Double bookkeeping has been neglected in mainstream psychiatry, but it has been addressed in recent theoretical work, however mainly concerned with the issue of delusion. In this article, we present clinical material that supports the view that double bookkeeping manifests itself across various psychotic phenomena and its antecedent may be observed in premorbid (pre-onset) phases as well as in the schizotypal disorder. We try to conceptualize double bookkeeping to concretize an often atmospheric perception of paradoxicality in the encounter with the patient. A phenomenological analysis of double bookkeeping suggests an instability in the affective ("auto-affection") articulation of selfhood. We point to four main implications of our presentation: (1) diagnostic, (2) epistemological, (3) therapeutic and (4) pathogenetic research.

Affect-Logic, Embodiment, Synergetics, and the Free Energy Principle: New Approaches to the Understanding and Treatment of Schizophrenia

This theoretical paper explores the affect-logic approach to schizophrenia in light of the general complexity theories of cognition: embodied cognition, Haken's synergetics, and Friston's free energy principle. According to affect-logic, the mental apparatus is an embodied system open to its environment, driven by bioenergetic inputs of emotions. Emotions are rooted in goal-directed embodied states selected by evolutionary pressure for coping with specific situations such as fight, flight, attachment, and others. According to synergetics, nonlinear bifurcations and the emergence of new global patterns occur in open systems when control parameters reach a critical level. Applied to the emergence of psychotic states, synergetics and the proposed energetic understanding of emotions lead to the hypothesis that critical levels of emotional tension may be responsible for the transition from normal to psychotic modes of functioning in vulnerable individuals. In addition, the free energy principle through learning suggests that psychotic symptoms correspond to alternative modes of minimizing free energy, which then entails distorted perceptions of the body, self, and reality. This synthetic formulation has implications for novel therapeutic and preventive strategies in the treatment of psychoses, among these are milieu-therapeutic approaches of the Soteria type that focus on a sustained reduction of emotional tension and phenomenologically oriented methods for improving the perception of body, self, and reality.

Self-disorders and psychopathology: a systematic review

In foundational texts on schizophrenia, the mental disorder was constitutively linked to a specific disintegration of subjectivity (often termed a self-disorder). Apart from Scharfetter's work on ego-pathology, research on self-disorders generally faded into oblivion, and self-disorders were only rediscovered as notable psychopathological features of the schizophrenia spectrum nearly two decades ago. Subsequently, the Examination of Anomalous Self-Experience (EASE) scale was constructed to allow systematic assessment of non-psychotic self-disorders. This Review is the first systematic review of empirical studies on self-disorders based on the EASE or other related scales. The results consistently show that self-disorders hyper-aggregate in schizophrenia spectrum disorders but not in other mental disorders; that self-disorders are found in individuals at a clinical risk of developing psychosis; that self-disorders show a high degree of temporal stability; that self-disorders predict the later development of schizophrenia spectrum disorders; and that self-disorders correlate with the canonical dimensions of the psychopathology of schizophrenia, impaired social functioning, and suicidality. Issues with the methods of the reviewed literature are critically discussed and the role of self-disorders in clinical psychiatry and future research is outlined.

Reduced readiness potential and post-movement beta synchronization reflect self-disorders in early course schizophrenia

Disturbances of conscious awareness, or self-disorders, are a defining feature of schizophrenia. These include symptoms such as delusions of control, i.e. the belief that one's actions are controlled by an external agent. Models of self-disorders point at altered neural mechanisms of source monitoring, i.e. the ability of the brain to discriminate self-generated stimuli from those driven by the environment. However, evidence supporting this putative relationship is currently lacking. We performed electroencephalography (EEG) during self-paced, brisk right fist closures in ten (M = 9; F = 1) patients with Early-Course Schizophrenia (ECSCZ) and age and gender-matched healthy volunteers. We measured the Readiness Potential (RP), i.e. an EEG feature preceding self-generated movements, and movement-related EEG spectral changes. Self-disorders in ECSCZ were assessed with the Examination of Anomalous Self-Experience (EASE). Patients showed a markedly reduced RP and altered post-movement Event-Related Synchronization (ERS) in the beta frequency band (14-24 Hz) compared to healthy controls. Importantly, smaller RP and weaker ERS were associated with higher EASE scores in ECSCZ. Our data suggest that disturbances of neural correlates preceding and following self-initiated movements may reflect the severity of self-disorders in patients suffering from ECSCZ. These findings point towards deficits in basic mechanisms of sensorimotor integration as a substrate for self-disorders.

"Apples and pears are similar, but still different things." Bipolar disorder and schizophrenia- discrete disorders or just dimensions ?

Starting with the dichotomous view of Kraepelin, schizophrenia and bipolar disorder have traditionally been considered as separate entities. More recent, this taxonomic view of illnesses has been challenged and a continuum psychosis has been postulated based on genetic and neurobiological findings suggestive of a large overlap between disorders. In this paper we will review clinical and experimental data from genetics, morphology, phenomenology and illness progression demonstrating what makes schizophrenia and bipolar disorder different conditions, challenging the idea of the obsolescence of the categorical approach. However, perhaps it is also time to move beyond DSM and search for more refined clinical descriptions that could uncover clinical invariants matching better with molecular data. In the future, computational psychiatry employing artificial intelligence and machine learning might provide us a tool to overcome the gap between clinical descriptions (phenomenology) and neurobiology.

Basic self-disturbance in subjects at clinical high risk for psychosis: Relationship with clinical and functional outcomes at one year follow-up

Basic self-disturbance (BSD) is assumed to drive symptom development in schizophrenia spectrum disorders and in clinical high-risk (CHR) for psychosis. We investigated the relationship between BSD at baseline, assessed with the Examination of Anomalous Self-Experience (EASE), and symptoms and functional outcome after one year in 32 patients, including 26 CHR and six with non-progressive attenuated psychotic symptoms. Correlations between baseline BSD levels and positive, negative and disorganization symptoms, and global functioning level at follow-up were significant. Hierarchical regression analyses revealed that higher levels of baseline BSD predicted more severe positive symptoms and lower global functioning at follow-up, after adjusting for baseline positive symptoms and functioning. Subjects who were not in symptomatic and functional remission after one year had higher levels of BSD and negative symptoms, and lower functioning level, at baseline. Baseline BSD in participants with schizophrenia spectrum diagnoses at follow-up (9 of 12 were schizotypal personality disorder) were at the levels seen in schizotypal disorders in previous studies, but not significantly different from the other participants. Early identification and assessment of BSD may constitute a useful prognostic tool and a signal for therapeutic targets in CHR conditions. Further CHR studies investigating these relationships with larger samples are recommended.

Framing a Phenomenological Mixed Method: From Inspiration to Guidance

Despite a long history of researchers who combine phenomenology with qualitative or quantitative methods, there are only few examples of working with a phenomenological mixed method—a method where phenomenology informs both qualitative and quantitative data generation, analysis, and interpretation. Researchers have argued that in working with a phenomenological mixed method, there should be mutual constraint and enlightenment between the qualitative (first-person, subjective) and quantitative (third-person, objective) methods for studying consciousness. In this article, we discuss what a framework for phenomenological mixed methods could look like and we aim to provide guidance of how to work within such framework. We are inspired by resources coming from research in mixed methods and existing examples of phenomenological mixed-method research. We also present three cases of phenomenological mixed methods where we study complex social phenomena and discuss the process of how we conducted the studies. From both the research inspiration and our own studies, we depict the landscape of possibilities available for those interested in mixing phenomenology with qualitative and quantitative methods, as well as the challenges and common pitfalls that researchers face. To navigate in this landscape, we develop a three-fold structure, focusing on (1) the phenomenological frame, (2) the phenomenologically informed generation of qualitative and quantitative data (tier one), and (3) the phenomenologically informed analysis and interpretation of data (tier two).

Delusions beyond beliefs: a critical overview of diagnostic, aetiological, and therapeutic schizophrenia research from a clinical-phenomenological perspective

Delusions are commonly conceived as false beliefs that are held with certainty and which cannot be corrected. This conception of delusion has been influential throughout the history of psychiatry and continues to inform how delusions are approached in clinical practice and in contemporary schizophrenia research. It is reflected in the full psychosis continuum model, guides psychological and neurocognitive accounts of the formation and maintenance of delusions, and it substantially determines how delusions are approached in cognitive-behavioural treatment. In this Review, we draw on a clinical-phenomenological framework to offer an alternative account of delusion that incorporates the experiential dimension of delusion, emphasising how specific alterations to self-consciousness and reality experience underlie delusions that are considered characteristic of schizophrenia. Against that backdrop, we critically reconsider the current research areas, highlighting empirical and conceptual issues in contemporary delusion research, which appear to largely derive from an insufficient consideration of the experiential dimension of delusions. Finally, we suggest how the alternative phenomenological approach towards delusion could offer new ways to advance current research and clinical practice.

Disturbances of Shared Intentionality in Schizophrenia and Autism

Schizophrenia and autism are today considered complex spectrum disorders characterized by difficulties in social behavior. Drawing on recent advances in collective or shared intentionality studies, we present a novel theoretical approach to these social difficulties by exploring them from the angle of shared intentionality. We begin by describing two forms of shared intentionality: joint intentionality and we-intentionality. Joint intentionality crucially relies on the agents' mentalizing abilities such as mind reading and the ability to factor in (or "to be moved" by) their partner's intentions in deliberation and action planning. By contrast, we-intentionality relies on the agents' capacity to understand themselves as group members and to adopt the group's perspective. In schizophrenia spectrum disorders, we propose that joint intentionality remains unaffected, but we-intentionality may be impaired. In severe autism spectrum disorder (i.e., infantile autism), we propose that both forms of shared intentionality are impaired. We suggest that the source of the problems affecting we-intentionality in schizophrenia spectrum disorders lies primarily in trait-like, anomalous self-experiences. In severe autism spectrum disorder, we suggest that problems with mind reading, the ability to "be moved" by others' intentions, and with the capacity for perspective-taking impede both forms of shared intentionality.

Distinguishing schizophrenia spectrum from non-spectrum disorders among young patients with first episode psychosis and at high clinical risk: The role of basic self-disturbance and neurocognition

INTRODUCTION

The distinction between the schizophrenia spectrum and other types of disorders may be clinically relevant in terms of its predictive validity as suggested by studies showing schizophrenia spectrum patients have more unfavourable outcomes compared to other psychotic disorders. The present study aimed to investigate whether basic self-disturbances and neurocognitive processes that have been linked to psychosis risk have discriminative power for schizophrenia spectrum disorders in patients presenting with first episode psychosis (FEP) and at ultra-high risk for psychosis (UHR).

METHODS

38 FEP patients, 48 UHR patients, and 33 healthy controls were assessed for basic self-disturbances (using the Examination of Anomalous Self-Experience, EASE, interview), source monitoring and aberrant salience (behavioural tasks to measure neurocognitive constructs). Clinical groups were divided into patients with schizophrenia spectrum disorders and those with other non-spectrum disorders and were further compared on measures controlling for symptom severity and age.

RESULTS

Basic self-disturbances distinguished schizophrenia spectrum from non-spectrum disorders in the 'FEP only' sample, F = 19.76, p < 0.001, η²_partial = 0.37, and also in the combined UHR/FEP sample, F = 23.56, p < 0.001, η²_partial = 0.22. Additionally, some processes related to source monitoring deficits were elevated in schizophrenia spectrum disorders. In contrast, the two groups (schizophrenia spectrum vs other diagnoses) performed similarly in aberrant salience tasks. Comparable results were obtained for analyses performed with an FEP/UHR combined sample and the 'FEP only' sample.

DISCUSSION

Basic self-disturbances at the phenomenological level and source monitoring deficits on the neurocognitive level may be useful in identifying risk of schizophrenia spectrum disorders at the earliest clinical presentation.

The Self in the Spectrum: A Meta-analysis of the Evidence Linking Basic Self-Disorders and Schizophrenia

Disturbed self-experience has been reported as a characteristic feature of schizophrenia since the first formulation of its diagnostic concept; however, only in the last 2 decades an explicit notion of basic Self-disturbance, or Self-Disorders (SD), has emerged as target for a systematic research program. We conducted systematic searches in bibliographical databases to identify cross-sectional studies that explored SD across different diagnostic groups and explored diagnostic ascription within or outside schizophrenia spectrum disorders (SSD) as main outcome. Data were pooled using fixed- and random-effects meta-analysis models. Heterogeneity was assessed using stratified meta-analyses and meta-regression. Of 218 identified studies, 32 were included in the systematic review and 27 in the meta-analysis. Patients diagnosed with SSD scored higher on measures of SD than healthy controls (HC) (Hedges' g = 1.8; 95% CI = 1.5 to 2.0), individuals diagnosed with other mental illness (OMI) (1.9; 1.6 to 2.2), bipolar or affective disorders (1.8; 1.4 to 2.2), and clinical high risk for psychosis (CHR) (1.6; 0.9 to 2.4). Patients with schizotypy or schizotypal personality disorder scored higher on measures of SD than OMI (1.5; 1.3 to 1.8) and HC (1.4; 1.1 to 1.7). Patients with first-episode psychosis scored higher on measures of SD than HC (2.5; 2.1 to 2.9) and OMI (1.6; 1.2 to 2.1). Subjects at CHR scored higher on measures of SD than HC (2.0; 1.7 to 2.2) and OMI (19; 1.6 to 2.2). Overall, heterogeneity ranged from negligible to high, especially in comparisons of the target group with OMI, probably as a reflection of the immanent diagnostic heterogeneity of this group. The findings suggest that SD selectively aggregate within schizophrenia spectrum disorders as compared to other mental disorders and that they could be a central phenotypic marker of vulnerability to schizophrenia across the different shades of severity of its spectrum of disorders.

When the World Breaks Down: A 3-Stage Existential Model of Nihilism in Schizophrenia

The existential crisis of nihilism in schizophrenia has been reported since the early days of psychiatry. Taking first-person accounts concerning nihilistic experiences of both the self and the world as vantage point, we aim to develop a dynamic existential model of the pathological development of existential nihilism. Since the phenomenology of such a crisis is intrinsically subjective, we especially take the immediate and pre-reflective first-person perspective's (FPP) experience (instead of objectified symptoms and diagnoses) of schizophrenia into consideration. The hereby developed existential model consists of 3 conceptualized stages that are nested into each other, which defines what we mean by existential. At the same time, the model intrinsically converges with the phenomenological concept of the self-world structure notable inside our existential framework. Regarding the 3 individual stages, we suggest that the onset or first stage of nihilistic pathogenesis is reflected by phenomenological solipsism, that is, a general disruption of the FPP experience. Paradigmatically, this initial disruption contains the well-known crisis of common sense in schizophrenia. The following second stage of epistemological solipsism negatively affects all possible perspectives of experience, that is, the first-, second-, and third-person perspectives of subjectivity. Therefore, within the second stage, solipsism expands from a disruption of immediate and pre-reflective experience (first stage) to a disruption of reflective experience and principal knowledge (second stage), as mirrored in abnormal epistemological limitations of principal knowledge. Finally, the experience of the annihilation of healthy self-consciousness into the ultimate collapse of the individual's existence defines the third stage. The schizophrenic individual consequently loses her/his vital experience since the intentional structure of consciousness including any sense of reality breaks down. Such a descriptive-interpretative existential model of nihilism in schizophrenia may ultimately serve as input for future psychopathological investigations of nihilism in general, including, for instance, its manifestation in depression.

Mentalization and embodied selfhood in Borderline Personality Disorder

Aberrations of self-experience are considered a core feature of Borderline Personality Disorder (BPD). While prominent etiologic accounts of BPD, such as the mentalization based approach, appeal to the developmental constitution of self in early infant-caregiver environments, they often rely on a conception of self that is not explicitly articulated. Moreover, self-experience in BPD is often theorized at the level of narrative identity, thus minimizing the role of embodied experience. In this article, we present the hypothesis that disordered self and interpersonal functioning in BPD result, in part, from impairments in "embodied mentalization," that manifest foundationally as alterations in minimal embodied selfhood, i.e. the first-person experience of being an individuated embodied subject. This account of BPD, which engages early intersubjective experiences has the potential to integrate phenomenological, developmental, and symptomatic findings in BPD, and is consistent with contemporary theories of brain function.

The Indirect Effect of Trauma via Cognitive Biases and Self-Disturbances on Psychotic-Like Experiences

Although self-disturbances (SD) are considered to be a core psychopathological feature of schizophrenia spectrum disorders, there is still insufficient empirical data on the mechanisms underlying these anomalous self-experiences. The aim of the present study was to test a hypothesized model in which cognitive biases and exposure to traumatic life events are related to the frequency of SD which, in turn, contribute to the frequency of psychotic-like experiences (PLEs). Our sample consisted of 193 Polish young adults from the general population (111 females; 18-35 years of age, M = 25.36, SD = 4.69) who experience frequent PLEs. Participants were interviewed for PLEs, SD and social functioning as well as completed self-reported questionnaires and behavioral tasks that measure cognitive biases (e.g., safety behaviors, attention to threat, external attribution, jumping to conclusion, source monitoring, overperceptualization). The model was tested using path analysis with structural equation modeling. All of the hypothesized relationships were statistically significant and our model fit the data well [χ²(23) = 31.201; p = 0.118; RMSEA = 0.043 (90% CI = 0.00-0.078), CFI = 0.985, SRMR = 0.041, TLI = 0.976]. The results revealed a significant indirect effect of traumatic life events on PLEs through SD and self-reported cognitive biases. However, performance-based cognitive biases measured with three behavioral tasks were unrelated to SD and PLEs. The frequency of SD explained a substantial part (43.1%) of the variance in PLEs. Further studies with longitudinal designs and clinical samples are required to verify the predictive value of the model.

Anomalies of Imagination, Self-Disorders, and Schizophrenia Spectrum Psychopathology: A Network Analysis

BACKGROUND

Anomalies of imagination encompass disturbances of the basic experiential structure of fantasies and imagery that can be explored in a semi-structured way with the Examination of Anomalous Fantasy and Imagination (EAFI). We aimed (1) to examine the distribution of anomalies of imagination among different diagnostic groups and a group of healthy controls, and (2) to examine their relation with disorders of basic self, perceptual disturbances and canonical state psychopathology of the schizophrenia-spectrum (positive, negative and general symptoms).

METHODS

The 81 participants included patients with schizophrenia or other non-affective psychosis (N = 32), schizotypal personality disorder (N = 15) or other mental illness (N = 16) and healthy controls (N = 18). The assessment encompassed EAFI, Examination of Anomalous Self-Experience (EASE), parts of Bonn Scale for the Assessment of Basic Symptoms (BSABS) and Positive and Negative Syndrome Scale (PANSS). For network analysis, the associations of EAFI with the other psychopathological variables were tested by Pearson's correlation coefficient and graphically represented using multidimensional clustering. Comparisons between correlations in the network were tested with Steiger's test.

RESULTS

Anomalies of imagination aggregated significantly in schizophrenia-spectrum disorders compared to other mental illness and healthy controls with no difference between schizophrenia and schizotypal disorder. In the network analysis, anomalies of imagination were closely inter-connected with self-disorders. Although, the anomalies of imagination correlated moderately with perceptual disturbance and positive, negative and general state symptomatology, these dimensions aggregated separately and relatively distant in the network.

CONCLUSIONS

The results support that anomalies of imagination are highly characteristic of schizophrenia-spectrum disorders and closely related to self-disorders.

Formal Thought Disorder and Self-Disorder: An Empirical Study

Background: Formal thought disorder was constitutively linked to the original concept of schizophrenia and has since been one of central features supporting its diagnosis. Bleuler considered formal thought disorder as a fundamental symptom of schizophrenia among other fundamental symptoms, including ego disorders. The contemporary concept of self-disorder represents a more developed, nuanced, and systematic approach to disturbances of self-experience than the Bleulerian concept of ego disorders. As fundamental symptoms, on Bleuler's account, are persistently present in every case, an association between these symptoms could be expected. The purpose of this study was to examine the association between self-disorder and formal thought disorder. Methods: A sample of 94 diagnostically heterogeneous patients was examined for formal thought disorder using clinical rating and a proverb test. The proverb test was analyzed for two different aspects of formal thought disorder: literal responses and bizarre responses. The sample was comprehensively assessed for psychopathology, including self-disorder as measured with the Examination of Anomalous Self-Experience scale. Results: The patients, who provided bizarre responses, had a higher level of self-disorder, more negative symptoms, lower level of social functioning, and lower level of intelligence. Bizarre answers aggregated in patients diagnosed within the schizophrenia spectrum compared with patients outside the schizophrenia spectrum. We found moderate correlations between the two measures of formal thought disorder (clinically rated and bizarre responses) and self-disorder (0.454 [p < 0.01] and 0.328 [p < 0.01]). Literal responses did not differ between diagnostic groups and also did not correlate with bizarre responses. Specificity of bizarre responses for a diagnosis within schizophrenia spectrum was 86.89%, whereas sensitivity was 40.85%. Conclusion: The close relation between formal thought disorder and self-disorder further adds to the notion of self-disorder as a unifying psychopathological core beneath the apparently heterogeneous symptoms of schizophrenia.

The Self and Its Nature: A Psychopathological Perspective on the Risk-Reducing Effects of Environmental Green Space for Psychosis

Epidemiological studies have shown that environmental green space contributes to the reduction of psychosis incidence in the population. Clarifying the psychological and neuro-functional mechanisms underlying the risk-decreasing effects of green surroundings could help optimize preventive environmental interventions. This perspective article specifically aims to open a new window on the link between environmental green space and psychosis by considering its core psychopathological features. Psychotic disorders, such as schizophrenia, are essentially characterized by self-disturbances. The psychological structure of the self has been described as a multidimensional phenomenon that emerges from the reciprocal interaction with the environment through intrinsic and extrinsic self-processes. The intrinsic self refers to the experience of mental activity and environmental information as inherently related to one’s own person, which involves self-referential processing, self-reflection, memory, interoception, and emotional evaluation. The extrinsic self refers to sensorimotor interactions with the environment and the sense of agency, that is, the experience of being the source of one’s own actions and the multisensory consequences thereof. In psychosis, anomalous self-processing has been related to a functional fragmentation of intrinsic and extrinsic self-processes and related brain networks. Moreover, evidence from cognitive neuroscience suggests that green space could have beneficial effects on self-related processing. Based on the literature, it could be hypothesized that self-processing is involved in mediating the beneficial effects of green space for psychosis. Considering the multidimensionality of the self, it is proposed that urban green space design aimed at improving mental health ideally impacts the complexity of self-facets and thus restores the individual’s self.

Exploring schizophrenia spectrum psychopathology in borderline personality disorder

We have previously argued that the current borderline personality disorder (BPD) diagnosis is over-inclusive and clinically and conceptually impossible to distinguish from the schizophrenia spectrum disorders. This study involves 30 patients clinically diagnosed with BPD as their main diagnosis by three BPD dedicated outpatient treatment facilities in Denmark. The patients underwent a careful and time-consuming psychiatric evaluation involving several senior level clinical psychiatrists and researchers and a comprehensive battery of psychopathological scales. The study found that the vast majority of patients (67% in DSM-5 and 77% in ICD-10) in fact met the criteria for a schizophrenia spectrum disorder, i.e., schizophrenia (20%) or schizotypal (personality) disorder (SPD). The schizophrenia spectrum group scored significantly higher on the level of disorders of core self as measured by the Examination of Anomalous Self-Experiences Scale (EASE). The BPD criterion of "identity disturbance" was significantly correlated with the mean total score of EASE. These findings are discussed in the light of changes from prototypical to polythetic diagnostic systems. We argue that the original prototypes/gestalts informing the creation of BPD and SPD have gone into oblivion during the evolution of polythetic criteria.

Understanding Identity Changes in Psychosis: A Systematic Review and Narrative Synthesis

BACKGROUND AND OBJECTIVE

Experiencing psychosis can be associated with changes in how people see themselves as individuals and in relation to others (ie, changes in their identity). However, identity changes receive little attention in treatment, possibly due to a lack of clarity or consensus around what identity change means in people with psychosis. We aimed to create a conceptual framework synthesizing how identity changes are understood in the psychosis literature.

METHODS

Electronic databases were searched up to April 2020. Studies about identity changes among people with psychotic disorders were analyzed using narrative synthesis by a collaborative review team, including researchers from different disciplines, clinicians, and people who have experienced psychosis.

RESULTS

Of 10 389 studies screened, 59 were eligible. Identity changes are understood in 5 ways as (1) characteristics of psychosis, (2) consequences of altered cognitive functioning, (3) consequences of internalized stigma, (4) consequences of lost roles and relationships, and (5) reflections of personal growth. These 5 understandings are not mutually exclusive. Across a heterogeneous literature, identity changes were mostly framed in terms of loss.

CONCLUSIONS

Our conceptual framework, comprising 5 understandings, highlights the complexity of studying identity changes and suggests important implications for practice and research. For clinicians, this framework can inform new therapeutic approaches where the experience and impact of identity changes are acknowledged and addressed as part of treatment. For researchers, the conceptual framework offers a way of locating their understandings of identity changes when undertaking research in this area.

Childhood schizotypal features vs. high-functioning autism spectrum disorder: Developmental overlaps and phenomenological differences

Although autism spectrum disorder and schizophrenia have allegedly different onset timelines (e.g. in early years of life vs adolescence/early adulthood), there is nonetheless a diagnostic grey-zone along developmental stages, in which overlapping clinical features related to social impairment and oddity could impact on the differential diagnosis between childhood schizotypal features and high-functioning autism spectrum disorder. A phenomenological perspective may be helpful for the purpose of timely differential diagnosis also in developmental years.

Narcissistic Equilibrium in Paranoid Schizophrenia

Several studies have stressed the relevance of family environment in the course of schizophrenia and the perception of the pathology by both the subjects and family members. The objective of the current qualitative study consisted in the development of a grounded theory (GT) regarding narcissism and the family dynamics of subjects diagnosed with paranoid schizophrenia. Semistructured interviews were conducted with five subjects in a state psychiatric hospital in the urban catchment area of Lisbon and their respective families. A diagnosis of paranoid schizophrenia had previously been established according to DSM-IV-TR and ICD-10 criteria. The interviews were transcribed and analyzed using the GT methodology, in order to identify the latent processes. A basic social process of narcissistic equilibrium was identified as a way to protect personal and familial identity, where three main processes were found: splitting, detachment and projective identification. These processes were developed as a tentative solution for the existing narcissistic impairments in the self and/or family, occurring both in an intrapsychic dimension and on a transactional dimension within family relationships.

Real-Time Functional Magnetic Resonance Imaging Neurofeedback for the Relief of Distressing Auditory-Verbal Hallucinations: Methodological and Empirical Advances

Auditory-verbal hallucinations (AVH) are often associated with high levels of distress and disability in individuals with schizophrenia-spectrum disorders. In around 30% of individuals with distressing AVH and diagnosed with schizophrenia, traditional antipsychotic drugs have little or no effect. Thus, it is important to develop mechanistic models of AVH to inform new treatments. Recently a small number of studies have begun to explore the use of real-time functional magnetic resonance imaging neurofeedback (rtfMRI-NF) for the treatment of AVH in individuals with schizophrenia. rtfMRI-NF protocols have been developed to provide feedback about brain activation in real time to enable participants to progressively achieve voluntary control over their brain activity. We offer a conceptual review of the background and general features of neurofeedback procedures before summarizing and evaluating existing mechanistic models of AVH to identify feasible neural targets for the application of rtfMRI-NF as a potential treatment. We consider methodological issues, including the choice of localizers and practicalities in logistics when setting up neurofeedback procedures in a clinical setting. We discuss clinical considerations relating to the use of rtfMRI-NF for AVH in individuals distressed by their experiences and put forward a number of questions and recommendations about best practice. Lastly, we conclude by offering suggestions for new avenues for neurofeedback methodology and mechanistic targets in relation to the research and treatment of AVH.

Temporal dynamics of suspiciousness and hallucinations in clinical high risk and first episode psychosis

The objective of the current study is to elucidate the temporal dynamics of suspiciousness and hallucinations as they occur in daily life in the early stages of psychosis. Their prevalence and co-occurrence, as well as their temporal relation to affect and delusions, were compared between patients with a first psychotic episode (FEP) and individuals at clinical high risk for psychosis (CHRp). The Experience Sampling Method was used to investigate suspiciousness and hallucinatory experiences, delusions, and affect at semi-random moments throughout six days in 33 CHRp and 34 FEP. Overall, 91% of CHRp and 59% of FEP reported suspiciousness, and 24% and 39% reported hallucinations, respectively. Hallucinations almost always co-occurred with suspiciousness, whereas suspiciousness was often present without hallucinations. Suspicious episodes in CHRp occurred with marked increases in delusional intensity, while hallucinatory experiences were mostly absent. In FEP, a decrease of positive affect preceded suspicious episodes, while an increase of negative affect preceded hallucinatory episodes. Our results indicated the presence of a delusional mood (atmosphere) in CHRp as an experience in itself, without co-occurring or following hallucinations, thus refuting the anomalous experience hypothesis of psychosis. The co-occurrence of hallucinations, on the other hand, indicates a more severe stage of symptomatology.

A Phenomenological Paradigm for Empirical Research in Psychiatry and Psychology: Open Questions

This article seeks to clarify the way in which phenomenology is conceptualized and applied in empirical research in psychiatry and psychology, emphasizing the suitability of qualitative research. It will address the “What,” “Why,” and “How” of phenomenological interviews, providing not only preliminary answers but also a critical analysis and pointing to future directions for research. The questions it asks are: First, what makes an interview phenomenological? What are phenomenological interviews used for in empirical research in psychiatry and psychology? Second, why do we carry out phenomenological interviews with patients? Is merely contrasting phenomenological hypotheses or concepts enough to do justice to the patients’ involvement? Third, how should we conduct phenomenological interviews with patients? How can we properly perform analysis in empirical phenomenological research in psychiatry and psychology? In its conclusion, the article attempts to go a step beyond these methodological questions, highlighting the “bigger picture”: namely, the phenomenological scientific paradigm and its core philosophical claim of reality as mind-dependent.

The Self and Its Prolonged Intrinsic Neural Timescale in Schizophrenia

Schizophrenia (SCZ) can be characterized as a basic self-disorder that is featured by abnormal temporal integration on phenomenological (experience) and psychological (information processing) levels. Temporal integration on the neuronal level can be measured by the brain's intrinsic neural timescale using the autocorrelation window (ACW) and power-law exponent (PLE). Our goal was to relate intrinsic neural timescales (ACW, PLE), as a proxy of temporal integration on the neuronal level, to temporal integration related to self-disorder on psychological (Enfacement illusion task in electroencephalography) and phenomenological (Examination of Anomalous Self-Experience [EASE]) levels. SCZ participants exhibited prolonged ACW and higher PLE during the self-referential task (Enfacement illusion), but not during the non-self-referential task (auditory oddball). The degree of ACW/PLE change during task relative to rest was significantly reduced in self-referential task in SCZ. A moderation model showed that low and high ACW/PLE exerted differential impact on the relationship of self-disorder (EASE) and negative symptoms (PANSS). In sum, we demonstrate abnormal prolongation in intrinsic neural timescale during self-reference in SCZ including its relation to basic self-disorder and negative symptoms. Our results point to abnormal relation of self and temporal integration at the core of SCZ constituting a "common currency" of neuronal, psychological, and phenomenological levels.

Thinking, believing, and hallucinating self in schizophrenia

In this Personal View, we discuss the history and concept of self-disturbance in relation to the pathophysiology and subjective experience of schizophrenia in terms of three approaches: the perceptual anomalies approach of the early Heidelberg School of Psychiatry, the ipseity model, and the predictive coding framework. Despite the importance of these approaches, there has been a notable absence of efforts to compare them and consider how they might be integrated. This Personal View compares the three approaches and offers suggestions as to how they might work together, which represents a novel position. We view self-disturbances as transformations of self that form the inseparable background against which psychotic symptoms emerge. Integrating computational psychiatric approaches with those used by phenomenologists in the first two listed approaches, we argue that delusions and hallucinations are inferences produced under extraordinary conditions and are both statistically and experientially as real for patients as other mental events. Such inferences still approximate Bayes-optimality, given the personal, neurobiological, and environmental circumstances, and might be the only ones available to minimise prediction error. The added contribution we hope to make focuses on how the dialogue between neuroscience and phenomenology might improve clinical practice. We hope this Personal View will act as a timely primer and bridging point for the different approaches of computational psychiatry and phenomenological psychopathology for interested clinicians.

The relation of basic self-disturbance to self-harm, eating disorder symptomatology and other clinical features: Exploration in an early psychosis sample

BACKGROUND AND AIMS

The notion of basic self-disturbance has been proposed as a core feature of schizophrenia-spectrum disorders and as an indicator of future transition to psychosis in high-risk populations. However, the relation of this notion to many clinical characteristics has not been explored. The aim of this study was: (a) to investigate the distribution of self-disturbance and other symptoms dimensions in ultra-high risk (UHR), first-episode psychosis (FEP) and healthy control groups; and (b) to explore the association of self-disturbance with a history of self-harm, suicidal attempt, eating disorder symptomatology, school bullying victimization and sexual or physical abuse.

METHODS

Patients with UHR status (n = 38) or FEP (n = 26) and healthy controls (n = 33) were assessed with the Examination of Anomalous Self-Experience (EASE) and the Comprehensive Assessment of at Risk Mental States (CAARMS). The clinical-historical variables were assessed through medical records.

RESULTS

The FEP group scored significantly higher on the EASE than the UHR group, which scored significantly higher than the healthy control group, which had a very low score. Multivariate logistic regression analyses revealed that higher EASE score was significantly associated with a history of self-harm, disordered eating and bullying victimization (but not with suicide attempts or sexual/physical abuse) after controlling for positive, negative and depressive symptoms.

CONCLUSION

These novel findings suggest that self-disturbance may be related to a history of school bullying victimization, self-harm and eating disorder symptomatology in patients with or at-risk of psychosis. If further confirmed, these findings are potentially relevant to clinical risk assessment and therapy.