Examination Of Anomalous Self-Experience
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A self-disorder, also called ipseity disturbance, is a psychological phenomenon of disruption or diminishing of a person's minimal self ''–'' the fundamental sense that one's experiences are truly one's own. People with self-disorder feel that their internal experiences are actually external; for example, they may experience their own thoughts as coming from outside themselves, whether in the form of true auditory hallucinations or merely as a vague sense that their thoughts do not belong to them. There is evidence that self-disorder is characteristic of schizophrenia spectrum disorders such as
schizophrenia Schizophrenia () is a mental disorder characterized variously by hallucinations (typically, Auditory hallucination#Schizophrenia, hearing voices), delusions, thought disorder, disorganized thinking and behavior, and Reduced affect display, f ...
itself as well as
schizotypal personality disorder Schizotypal personality disorder (StPD or SPD), also known as schizotypal disorder, is a cluster A personality disorder, cluster A personality disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, dereali ...
. This is true across both psychotic and non-psychotic disorders. The presence or absence of self-disorders has been used to distinguish schizophrenia spectrum disorders from other psychotic disorders,
bipolar disorder Bipolar disorder (BD), previously known as manic depression, is a mental disorder characterized by periods of Depression (mood), depression and periods of abnormally elevated Mood (psychology), mood that each last from days to weeks, and in ...
,
borderline personality disorder Borderline personality disorder (BPD) is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, an acute fear of Abandonment (emotional), abandonment, and intense emotiona ...
, and
autism spectrum disorder Autism, also known as autism spectrum disorder (ASD), is a neurodevelopmental disorder characterized by differences or difficulties in social communication and interaction, a preference for predictability and routine, sensory processing di ...
. Detecting self-disorders may also be useful for early intervention in psychosis, since they occur in the prodrome of schizophrenia prior to the emergence of psychotic symptoms. The concept resembles the
basic symptoms of schizophrenia Basic symptoms of schizophrenia are subjective symptoms, described as experienced from a person's perspective, which show evidence of underlying psychopathology. Basic symptoms have generally been applied to the assessment of people who may be at- ...
, but the term itself was introduced in the early 2000s together with the ''Examination of Anomalous Self-Experience'' (EASE) scale, which is used to measure the presence and severity of self-disorder. The concept is associated with the theoretical approach to psychology known as
phenomenology Phenomenology may refer to: Art * Phenomenology (architecture), based on the experience of building materials and their sensory properties Philosophy * Phenomenology (Peirce), a branch of philosophy according to Charles Sanders Peirce (1839â ...
.


Minimal self

The minimal (or basic) self has been likened to a "flame that enlightens its surroundings and thereby itself." 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 extended self, which is composed of properties such as the person's identity, the person's narrative, their likes and dislikes, and other aspects that are the result of reflection on one's self. The minimal self, however, refers to the "mine-ness" or "given-ness" of experience, that the experiences are that of the person having them in that person's stream of
consciousness Consciousness, at its simplest, is awareness of a state or object, either internal to oneself or in one's external environment. However, its nature has led to millennia of analyses, explanations, and debate among philosophers, scientists, an ...
. 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. The minimal self goes hand-in-hand with immersion in the shared social world, such that " e world is always pregiven, ie, tacitly grasped as a self-evident background of all experiencing and meaning." This is the self-world structure. 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.", cited in 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 person 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 person 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 person'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. Similar phenomena can occur in other conditions, such as bipolar disorder and depersonalization derealization 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; 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. 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. The disturbance of the minimal self may manifest in people 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 people 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 person 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, as well as normal experience and first-rank symptoms. 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.


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 person. 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 person does not own their thoughts (but not to the level of psychosis), and "spatialization of experience", which is where the person 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 person that if they move, pseudo-movements of other, unrelated objects are experienced # ''Demarcation/transitivism'', which covers specific disturbances in the person's ego boundaries such as the person confusing their own thoughts, ideas, and feelings for that of their interlocutor. # ''Existential reorientation'', which refers to changes in the person's experience of the world that reflect the effect of self-disorders on the person's worldview. A large number of these items have affinities with the basic symptoms. The EASE, and pre-EASE studies attempting to assess basic self-disturbance, has been found in studies to discriminate between people 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. 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.


EASE items


Examination of Anomalous World Experience (EAWE)

The EAWE is the companion interview to the EASE that focuses on the person's experiences with the world, rather than with the self. There are 6 domains: # ''Space and objects'', which deals with the person's experience with space and physical objects, with disorders including hallucinations, distortions of spatial relationships, and experiences of seeing the same object in multiple ways at the same time (called "contamination" on the
Rorschach test The Rorschach test is a projective test, projective psychological test in which subjects' perceptions of inkblots are recorded and then analyzed using psychology, psychological interpretation, complex algorithms, or both. Some psychologists u ...
). # ''Time and events'', which deals with the person's experience with time, with disorders involving time speeding up or slowing down, time breaking up or becoming fragmented, and constant anticipation of something major about to happen. # ''Other persons'', which deals with the person's experience of other people, with disorders including disruptions of the sense of ego boundaries with other people, referential ideation based on actions or words by other people, and loss or lack of the ability to naturally understand social situations and social cues leading to attempts to compensate through increased focus or concentration. # ''Language'', which deals with reduced fluency and disruption of prose in one's native language, distortions in the person's expression which causes others to misunderstand the person, problems with concrete and abstract concepts, and distraction by individual words and phrases leading to the person having difficulty following what they are reading or listening to. # ''Atmosphere'', which deals with the person's overall feeling-state of the world, with disorders including derealization (particularly ''The Truman Show''-style derealization), objects no longer having normal meaning, hyper-awareness of things that normally stay in the background of awareness, apophanous mood, and a sense of radical changes in the very structure of the
universe The universe is all of space and time and their contents. It comprises all of existence, any fundamental interaction, physical process and physical constant, and therefore all forms of matter and energy, and the structures they form, from s ...
itself. # ''Existential orientation'', which deals with radical changes in a person's worldview, dealing with such things as rejecting society's conventions and rules, being extremely open to believing new ideas, and
grandiosity In psychology, grandiosity is a sense of superiority, uniqueness, or invulnerability that is unrealistic and not based on personal capability. It may be expressed by exaggerated beliefs regarding one's abilities, the belief that few other peopl ...
which involves the person considering others to be inferior, like insects compared to them.


EAWE items

*Indicates experience that can also occur in other primary psychotic or mood disorders outside the schizophrenia spectrum, such as delusional disorder, major depressive disorder, or bipolar disorder.


Clinical relevance

The presence of self-disorders may have predictive power for whether those with an at risk mental state will develop psychosis; the risk of
suicidal ideation Suicidal ideation, or suicidal thoughts, is the thought process of having ideas or ruminations about the possibility of dying by suicide.World Health Organization, ''ICD-11 for Mortality and Morbidity Statistics'', ver. 09/2020MB26.A Suicidal i ...
and
suicide Suicide is the act of intentionally causing one's own death. Risk factors for suicide include mental disorders, physical disorders, and substance abuse. Some suicides are impulsive acts driven by stress (such as from financial or ac ...
by people with schizophrenia, though depression would also be an important factor; predicting initial social dysfunction in people with either schizophrenic or bipolar psychosis; and whether a person will move to a schizophrenia spectrum diagnosis later. Considering the presence of self-disorders is useful when attempting to differentially diagnose disorders that can be confused with schizophrenia spectrum disorders.
Autism spectrum disorder Autism, also known as autism spectrum disorder (ASD), is a neurodevelopmental disorder characterized by differences or difficulties in social communication and interaction, a preference for predictability and routine, sensory processing di ...
and
schizotypal personality disorder Schizotypal personality disorder (StPD or SPD), also known as schizotypal disorder, is a cluster A personality disorder, cluster A personality disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, dereali ...
can appear outwardly similar but have different etiologies and require different treatment approaches. The presence of self-disorders is evidence for a diagnosis of schizotypal personality disorder over autism spectrum disorder. Likewise, in the case of first instance psychosis, self-disorders are indicative of a diagnosis of schizophrenia in favor of other psychotic disorders. The presence of self-disorders may cause reduced person insight into their illness through the alteration of the basic structures of consciousness. Self-disorders are difficult for the people experiencing them to articulate spontaneously; and are not well-known, by either the general public or professionals in the field. Because of this, people will often make vague, clichéd 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 person'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 people presenting with a vague, unelaborated picture of maladjustment, underperformance, chronic
malaise In medicine, malaise is a feeling of general discomfort, uneasiness or lack of wellbeing and often the first sign of an infection or other disease. It is considered a vague termdescribing the state of simply not feeling well. The word has exist ...
and
dysphoria Dysphoria (; ) is a profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation. In psychiatry Intense states of distress and uneas ...
, negative symptoms, or hypochondriac preoccupations." People with schizophrenia often describe their self-disorders as causing more suffering for them than psychosis. Self-disorders underlie most of the first-rank symptoms, those often termed passivity phenomena. There is a current proposal to list self-disorder as one of the symptoms of schizophrenia in the upcoming
ICD-11 The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World H ...
.


Evidence

The first systematic review of empirical studies on self-disorders based on the EASE scale was published in 2021. It found consistent support for the concept as a characteristic component of schizophrenia spectrum disorders and not other mental disorders. Another systematic review and meta-analysis from 2022 covering an aggregated sample of 810 patients found good evidence to support the existence of self-disorders as core clinical feature in schizophrenia spectrum disorders. The concept and its link to schizophrenia was likewise supported by a 2021 meta-analysis.


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 person's attempts to resolve the incoherence give rise to schizophrenia. The problems with the integration of sensory information create problems for the person 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. Sass and Borda have studied the correlates of the dimensions of self-disorders, namely ''disturbed grip'' (perplexity, difficulty "getting" stuff most people can get), ''hyperreflexivity'' (where thoughts, feelings, sensations, and objects pop up uncontrollably in the field of awareness, as well dysfunctional reflecting on matters and the self), and ''diminished self-affection'' (where the person has difficulty being "affected" by aspects of the self, experiencing those aspects 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 Multisensory integration, also known as multimodal integration, is the study of how information from the different sensory modality, sensory modalities (such as sight, sound, touch, smell, self-motion, and taste) may be integrated by the nervous sy ...
. 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, and not from the "solipsistic" concept of the self as proposed by Sass, Parnas, and others. 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 person'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 person's anomalous experiences regarding time, space, persons, language, and atmosphere; he suggests there are problems with both the self and the world in people with self-disorder, and that it may be better conceptualized as a "presence-disturbance". 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.


History

The concept of a basic self-disturbance in schizophrenia appears in all the foundational texts on the disease. The
basic symptoms of schizophrenia Basic symptoms of schizophrenia are subjective symptoms, described as experienced from a person's perspective, which show evidence of underlying psychopathology. Basic symptoms have generally been applied to the assessment of people who may be at- ...
include descriptions of self-disorders. Likewise,
Kurt Schneider Kurt Schneider (7 January 1887 – 27 October 1967) was a German psychiatrist known largely for his writing on the diagnosis and understanding of schizophrenia, as well as personality disorders then known as psychopathic personalities. ...
's first-rank symptoms, especially his concept of as well as the so-called passivity phenomena may be considered as examples of self-disorders. Similar concepts were also discussed by
Karl Jaspers Karl Theodor Jaspers (; ; 23 February 1883 – 26 February 1969) was a German-Swiss psychiatrist and philosopher who had a strong influence on modern theology, psychiatry, and philosophy. His 1913 work ''General Psychopathology'' influenced many ...
. The concept of "ontological insecurity", which resembles self-disorder, was proposed by R. D. Laing in 1960. The publication of the DSM-III (1980) lead to an increased emphasis on concrete signs and symptoms of mental disorders over the subjective experiences underlying those symptoms; in other words, it privileged a
behaviorist Behaviorism is a systematic approach to understand the behavior of humans and other animals. It assumes that behavior is either a reflex elicited by the pairing of certain antecedent stimuli in the environment, or a consequence of that indivi ...
approach to diagnosis. Because the concept of self-disorders had been difficult to operationalize, it began to be criticized as overly vague and too subjective; indeed, little systematic or empirical research was done on the concept in the 20th century. It therefore began to fall out of clinical use and soon disappeared entirely from training programs in the United States. A notable exception to this trend was the Bonn Scale for the Assessment of Basic Symptoms (BSABS), created in the 1980s to assess sub-clinical affective, cognitive and perceptual disturbances, as well as basic self-disturbance. In many studies, basic symptoms as measured by the BSABS were found to aggregate in people with schizophrenic and schizotypal disorders. In early 2000s, a group of researchers including Danish psychiatrist Josef Parnas sought to operationalize and revive the idea of schizophrenia as a disorder of the minimal self. This work resulted in the creation of the EASE, which was published in 2005. The scale was based on phenomenological interviews with first-admission people with schizophrenia spectrum disorders, to enable empirical research of self-disorders. It was also partially based on the BSABS, but more focused on items relating specifically to disturbed self-experience. The creation of the EASE resulted in an uptick in research into the topic, and the first
systematic review A systematic review is a scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from published studies on ...
of the concept was published in The Lancet Psychiatry in 2021, finding good empirical support for self-disorders as a defining characteristic of schizophrenia spectrum disorders.


See also

* Attribution (psychology) * Center for Subjectivity Research * Schizotypy


References


External links


Examination of Anomalous Self-Experience

Center for Subjectivity Research
{{Neuroscience symptoms of schizophrenia Symptoms Phenomenology Neuropsychology