Basic self-disturbance in schizophrenia.
Various anomalies of subjective experience have been described in schizophrenia spectrum conditions which collectively point towards an instability or disturbance of basic selfhood, captured in the IDM. Although intimately interrelated, these anomalies have been organized into the categories of disturbed stream of consciousness, sense of presence, corporeality, self-demarcation, and existential reorientation (Parnas, 2003; Parnas, Møller, et al., 2005). They have been comprehensively catalogued in the Examination of Anomalous Self-Experience (EASE) instrument (Parnas, Møller, et al., 2005), which is a semi-structured interview designed to elicit and measure aspects of basic self-disturbance. Brief descriptions of the anomalous subjective experiences are provided below.
Categories of anomalous self experience in schizophrenia
Stream of consciousness
A “gap” emerges in experience between the self and mental or cognitive content. The implicit sense of “mineness” of mental content is disrupted, as if thoughts were taking on an almost autonomous and anonymous identity and were no longer a lived aspect of subjectivity. A person may describe thoughts as having a physical, object-like, or acoustic quality, or as being disturbed in their normal flow, such as being pressured or appearing to be blocked. These experiences may evolve into frank psychotic symptoms, such as thought insertion, thought withdrawal, and thought broadcasting.
Presence
Normal human experience consists of being absorbed in activity among a world of (animate and inanimate) objects. As described above, this absorption provides us with a sense of “inhabiting” our self in a pre-reflective, tacit, or automatic fashion. This is referred to as self-presence or self-affection. As described above, our experiences appear to us in a first-person mode of presentation – that is, we automatically or pre-reflectively experience them as our experience. This sense of “mineness” constitutes a basic form of self-awareness. Disturbed presence is often evident in the schizophrenia spectrum, with a characteristic sense that the self no longer “saturates experience” (Parnas & Handest, 2003, p. 125) but instead stands alienated from itself. Patients may describe various forms of depersonalization or derealization, a sense of inner void, and a reduced ability to be affected or influenced by events or other people.
Corporeality
A disjunction between one’s subjectivity and bodily experience is often present in schizophrenia spectrum conditions, particularly during the pre-onset or prodromal phase. This is represented in many of the bodily basic symptoms, such as cenesthesias and impaired bodily sensations (Klosterkötter, Hellmich, Steinmeyer, & Schultze-Lutter, 2001). The transformation in the experience of the “lived body” (Merleau-Ponty, 1964) is characterized by an experiential gap or distance emerging between the sense of self and bodily experience. That is, rather than automatically “inhabiting” one’s body and experiencing it as a “background” feature, as in normal experience, aspects of physical experience can come to seem object- or thing-like in schizophrenia spectrum conditions. For example, parts of the body can appear to the person to have changed in some way (e.g., “my hand is thinner, longer”) or to appear strange, alien or lifeless (to use an example from the EASE: “It is as if his body was alien. He knows that it is his body, but it feels ‘as if it did not hang together’, it feels ‘as if his head was just fixed to the body’.”)
Self-demarcation
A diminution or permeability of self–other/self–world boundaries (“transitivism”) is often apparent in schizophrenia spectrum conditions. This can be represented in a variety of subtle phenomena. Examples include confusion of boundaries between self and others (e.g., losing sense of whether thoughts, feelings, etc., originated in oneself or another person or whether a reflected image is of oneself or another person), a sense of passivity in relation to the world and others (being “at the mercy of the world,” lacking agency), or experiencing the physical presence and contact of others as threatening to one’s existence in some way.
Existential reorientation
A common finding in studies of the early psychotic phase has been of a developing preoccupation with philosophical, supernatural, and metaphysical themes (Møller & Husby, 2000; Yung & McGorry, 1996). The rupture in “normal” self-experience motivates such a preoccupation. The person is attempting to explain, justify, or perhaps just to explore their anomalous experience. Feelings of centrality or solipsism may come to the fore. Examples include: the person may describe fleeting feelings that the only things existing in the world are those that are in his visual field, and that people and objects that he cannot see do not exist. The person may also be extremely occupied by thoughts about living up to impossible ideals of thought or behavior, and may search world religions for ultimate metaphysical answers.
It is important to note that the IDM view of the schizophrenia spectrum posits a Gestalt or structural shift in self-world experience (Parnas, 2012; Parnas & Sass, 2011; Sass & Parnas, 2003). Accordingly, the notion of “core” disturbance is often invoked (Parnas, 2012). This is consistent with psychotic symptomatology not being restricted to any particular modality of consciousness (i.e., it can appear as a disruption of cognitive functioning or sensory perception, etc.), and indeed can manifest as disturbance of different senses (e.g., auditory versus visual hallucinations, etc.), as well as being consistent with the variable expression of its single features (i.e., why one symptom might recede and another become more prominent; Parnas, 2011; Sass & Parnas, 2007). An instability in basic selfhood can have a reverberating effect through the different modalities of conscious experience (Sass & Parnas, 2003). In this sense, the basic self might be thought of as the center of experiential gravity, so that when this central organizing dynamic is disturbed, the various modalities of consciousness are thrown off-kilter, resulting in the aberrations of experience in psychotic symptoms. This formulation stands in contrast to the “single symptom” approach often advocated in the cognitive-behavioral tradition (Bentall, 2003; Spaulding, Sullivan, & Poland, 2003), sometimes referred to as an atomistic or “zoom in” approach (Murphy, 2013; Skodlar, Henriksen, Sass, Nelson, & Parnas, 2013).
The IDM describes instability of the basic self as consisting of two complementary aspects: hyperreflexivity and diminished self-affection (or self-presence; Sass, 1992; Sass & Parnas, 2003). Hyperreflexivity is a form of exaggerated self-consciousness and heightened awareness of aspects of one’s experience. This style of awareness objectifies aspects of oneself that are normally tacit (e.g., awareness of the act of breathing or sensations while walking), thereby forcing them to be experienced as if they were external objects. Hyperreflexivity is a concept that includes hyperreflectivity (or “reflective hyperreflexivity,” an exaggerated intellectual or reflective process) but is not limited to this: it also refers to acts of awareness that are not intellectual in nature, and that may occur involuntarily, as in the case of kinaesthetic experiences “popping” into awareness; these latter, which are probably more basic in a pathogenic sense, are termed “operative hyperreflexivity” (Sass & Parnas, 2007).
Diminished self-affection or self-presence refers to a weakened sense of existing as a vital subject of awareness, a diminished “saturation” of experience with implicit self-awareness. Hyperreflexivity and diminished self-affection are considered to be complementary, mutually implicating aspects of self-disturbance: “Whereas the notion of hyper-reflexivity emphasizes the way in which something normally tacit becomes focal and explicit, the notion of diminished self-affection emphasises a complementary aspect of this very same process – the fact that what once was tacit is no longer being inhabited as a medium of taken-for-granted selfhood” (Sass & Parnas, 2003, p. 430). The complementary distortions of hyperreflexivity and diminished self-affection are necessarily accompanied by certain alterations of a person’s “grip” or “hold” on the conceptual or perceptual field of awareness. This refers to the sharpness or stability with which figures or meanings emerge against a background context. For example, there may be an unusual salience of particular features of the perceptual world (e.g., a striking prominence of the visual image of the chair in front of me) or of particular thoughts (e.g., a preoccupation with the meaning of a blue umbrella). This can often lead to the sense of perplexity commonly seen in schizophrenia. An important feature of basic self-experience is what Heidegger captured in the concept of “mattering,” i.e., the self as a point of orientation directed by needs, desires, and purposes and the resulting pattern of meanings that make for a coherent and significant world (Nelson & Sass, 2009). A diminished vitality of subjectivity (diminished self-affection or self-presence) implies a weakening of these needs, desires and purposes, and therefore of the structuring and organizing influence they have on the cognitive and perceptual domains (i.e., disturbed “grip” or “hold”).
Finally, as has been more or less implicit in the description above, it is important to note that being self-present and present in the world of others and objects (the self-world structure) exist as two sides of the same coin (Henriksen & Parnas, 2014). Accordingly, basic self-disturbance involves diminished attunement to others and immersion in the world, inadequate spontaneous grasp of self-evident meanings (perplexity, diminished “common sense”), and hyperreflectivity.
Empirical studies
The IDM of schizophrenia has gained substantial empirical support. Two in-depth qualitative studies revealed alterations of basic self-experience to be a central feature of the prodromal phase of schizophrenia spectrum disorders (Møller & Husby, 2000; Parnas et al., 1998). In subsequent studies, a Danish research group found that basic self-disturbance: (1) is specific to schizophrenia spectrum conditions compared to remitted psychotic bipolar patients and a mixed group of first-admitted patients, (2) is characteristic of pre-schizophrenic prodromes, and (3) frequently occurs in hospitalized schizotypal conditions (Handest, 2003; Handest & Parnas, 2005; Nordgaard & Parnas, 2014; Parnas, 2003; Parnas, Handest, Saebye, & Jansson, 2003). Also, they found that: (4) self-disturbance correlated positively with the duration of pre-onset social dysfunction and aggregated significantly in patients with a positive family history of schizophrenia, and (5) self-disturbance correlated both with negative and positive psychotic symptom scales in schizophrenia patients. Five-year follow-up data of 155 first-admission cases indicated that basic self-disturbance (but not PANSS-scored positive and negative symptoms) was a strong predictor of a future schizophrenia spectrum diagnosis in those who presented with non-psychotic conditions (Parnas, Raballo, Handest, Vollmer-Larsen, & Saebye, 2011).
Genetic linkage data has indicated a similar pattern of findings. Raballo and Parnas (2011) analyzed data from 218 unaffected members of 6 extended families of schizophrenia patients (i.e., individuals at high genetic risk). Basic self-disturbance was incrementally present in groupings of family members with no mental illness, no mental illness but with schizotypal traits, personality disorders other than schizotypal personality disorder (the majority of whom had comorbid schizotypal traits), and schizotypal personality disorder, independent of sociodemographics, negative symptoms, and formal thought disorder. Similar findings were evident when this data set was analysed according to schizophrenia spectrum conditions, with basic self-disturbance being characteristic of schizophrenia spectrum conditions and levels of basic self-disturbance increasing with diagnostic severity (no mental illness, mental illness not in the schizophrenia spectrum, schizotypal personality disorder, schizophrenia; Raballo, Saebye, & Parnas, 2011).
A somewhat different approach was adopted in two quasi-empirical studies that compared self-disturbances in schizophrenia (as defined in the EASE; Sass, Pienkos, Nelson, & Medford, 2013) with self-anomalies found in two non-schizophrenic conditions: depersonalization disorder (which involves loss of self-presence) and intense introspection (which involves reflective or largely volitional forms of hyperreflexivity; Sass, Pienkos, & Nelson, 2013). Whereas some EASE items did appear to be fairly common in these latter conditions, the most severe indications of a fundamental disturbance of ipseity seemed to occur only in the schizophrenia spectrum.
Other work provides further evidence that basic self-disturbance is a central feature of the pre-onset phase of psychotic disorders, particularly of schizophrenia spectrum disorders. In a follow-back study using objective data, Hartmann et al. (1984) found that fluidity of self-demarcation, lack of a coherent narrative–historical self-identity, and other self-disturbances were prominent features of pre-schizophrenic states at school age. “Basic symptoms,” some of which reflect basic self-disturbance (e.g., varieties of depersonalization, disturbances of the stream of consciousness, distorted bodily experiences), have consistently been identified early in the pre-onset phase (Klosterkötter et al., 2001). Davidsen (2009) found that, although there was a difference in the kind and number of single features, disorders of self-experience were evident in all subjects in a clinical high-risk sample (N = 11), i.e., those with sub-threshold positive psychotic symptoms. In another clinical high-risk study, Nelson, Thompson, & Yung (2012) found that basic self-disturbance, assessed using the EASE, predicted onset of fully fledged psychotic disorder over a 1.5-year follow-up period. Although statistical power was limited, the data indicated that basic self-disturbance was particularly predictive of schizophrenia spectrum disorders. Recent work has also indicated that basic self-disturbance correlates with suicidality (more strongly than positive symptoms; Haug, Melle, et al., 2012; Skodlar & Parnas, 2010; Skodlar, Tomori, & Parnas, 2008), lack of insight (Henriksen & Parnas, 2014; Parnas & Henriksen, 2013), and social dysfunction (Haug et al., 2014) in schizophrenia spectrum disorders.
In sum, empirical findings indicate that basic self-disturbance distinguishes schizophrenia spectrum conditions from other psychoses (Nelson, Thompson, & Yung, 2013; Parnas et al., 2003), characterizes the schizophrenia prodrome in retrospective studies (Møller & Husby, 2000; Parnas & Handest, 2003; Parnas, Handest, et al., 2005; Parnas et al., 1998), is present in non-psychotic family members of schizophrenia spectrum patients (Raballo & Parnas, 2011; Raballo, Saebye, & Parnas, 2011), predicts onset of schizophrenia spectrum disorders in those who present with non-psychotic conditions (Parnas et al., 2011), is prominent in “ultra high-risk” (UHR) patients (Davidsen, 2009; Nelson et al., 2012), and predicts future onset of psychotic disorder in UHR patients, particularly schizophrenia spectrum cases (Nelson et al., 2012). These findings are strong indicators that the construct may be considered a phenotypic trait marker of schizophrenic vulnerability and may therefore be useful in early identification and diagnosis.
Neurocognitive correlates
Recent work has started to address the neurocognitive and neurobiological processes related to basic self-disturbance. A study by a Norwegian group (Haug, Oie, et al., 2012) examined basic self-disturbance (using the EASE instrument) and neurocognitive variables in a group of patients in the early phase of schizophrenia. The neurocognitive variables included measures of psychomotor speed, working memory, and executive and memory functions. Few associations were found between basic self-disturbance and neurocognitive impairment, with impaired verbal memory emerging as the single correlate. We have recently argued that the lack of association between neurocognitive measures and basic self-disturbance in this study may have been due to the fact that the particular neurocognitive measures used were standard, reasonably broad measures (Nelson, Whitford, Lavoie, & Sass, 2014a, 2014b). It may be that the neurocognitive disturbances underpinning basic self-disturbance are more specific and subtle, requiring different tests. The “traditional” neurocognitive measures used in psychosis research were, after all, devised for assessing acquired brain injury and intellectual disability (Keefe, Kraus, & Krishnan, 2011) and therefore may not be sufficiently sensitive to detect specific deficits in schizophrenia. We proposed that two streams of neurocognitive research in psychosis show particular affinity with the IDM. Broadly speaking, they consist of (1) source monitoring deficits, and (2) aberrant salience. These will be addressed briefly in turn.
Various neurocognitive models of schizophrenia are based on the idea that psychotic symptoms emerge from a difficulty distinguishing between the origins of endogenous (i.e., internally or self-generated) and exogenous (i.e., externally or other-generated) stimuli. These “source monitoring” deficits, as they are known, are believed to arise from failures in the neural mechanisms involved in distinguishing endogenous from exogenous stimuli, namely corollary discharges (i.e., a copy of a motor command that is directed to sensory brain areas to inform them of an impending movement). Although the models differ in detail, a common tenet is that positive psychotic symptoms result from the predictions we make and the extent to which these predictions are fulfilled. This has been dubbed the comparator model (Frith, 2012) as the predicted outcomes are compared with the actual outcomes. A key difference between self- and other-generated stimuli is that the former are predictable and controllable whereas the latter are not. When stimuli are predictable (i.e., self-generated) they are “dampened” in perception. When these self-generated stimuli are not effectively “dampened,” they might be experienced as if they were external in origin (Feinberg, 1978). A range of studies have yielded data consistent with the view that in schizophrenia there is some form of disconnection between a (self-generated) motor act and the sensory consequences of that act (see Nelson, Whitford, et al., 2014b for review). We have argued that various aspects of the IDM, particularly diminished ownership of experience, self–other boundary confusion, and hyperreflexivity, are congruent with the types of disturbances one would expect from source monitoring deficits (see Nelson, Whitford, et al., 2014b for full discussion).
A considerable amount of research indicates the presence of attention and memory disturbances in schizophrenia. A major theme in these findings is the failed suppression of attention to irrelevant or familiar information or stimuli in the environment, leading to aberrant salience of objects and associations (Hemsley, 2005a, 2005b; Kapur, Mizrahi, & Li, 2005) – or, to reverse the terminology, excessive attention to information that is irrelevant or highly familiar. A number of neurocognitive models and experimental paradigms have yielded findings consistent with this view, including Keefe and colleagues’ memory-prediction model of cortical function (Keefe & Kraus, 2009; Keefe et al., 2011; Kraus, Keefe, & Krishnan, 2009); the salience dysregulation model based on dopamine system abnormalities (Gray, Feldon, Rawlins, Hemsley, & Smith, 1991; Hemsley, 1992; Kapur, 2003); mismatch negativity reduction findings (Todd, Michie, Schall, Ward, & Catts, 2012); the latent inhibition theory (Gray, 1998; Gray, Hemsley, & Gray, 1992; Lubow & Gewirtz, 1995); and Corlett’s model of ketamine as a pharmacological model of psychosis (Corlett et al., 2006; Corlett, Honey, & Fletcher, 2007). We have argued that this line of neurocognitive research, broadly referred to as “aberrant salience” research, is congruent with important aspects of the IDM, including hyperreflexivity, disturbed “grip” or “hold” on the perceptual and conceptual field, and disturbances of intuitive social understanding (“common sense”; Nelson, Whitford, et al., 2014a).
Developmental pathways
Little is known about the etiological pathways leading to disturbance or instability in the basic sense of self. This is perhaps not surprising given that the development or formation of the normal or non-pathological experience of the basic self is not well understood (Gallagher, 2011). However, there are some promising avenues of enquiry that should be the focus of future research. If the neurocognitive constructs (aberrant salience and source monitoring deficits) described above do indeed prove to have a role in basic self-disturbance, then tracing the development of these disturbances may inform our understanding of basic self-disturbance. Another area of research from developmental psychology, “intermodal integration,” otherwise referred to as “multisensory integration” (Gamma et al., 2014; Parnas, Bovet, & Innocenti, 1996; Postmes et al., 2014), may also be of relevance. Intermodal integration refers to the integration of perceptual experience across modalities (vision, touch, hearing, proprioception), as well as the integration or linking of perception with motility. Intermodal integration occurs from birth onwards and much research in developmental psychology indicates that it is critical to the development of self/non-self discrimination and, by implication, a basic sense of self (Bahrick & Watson, 1985; Damasio, 2012; Parnas et al., 1996; Rochat, 2001; Rochat & Striano, 2002).
If early intermodal integration contributes to the development of the basic sense of self (and associated components of self–other differentiation, motor awareness, and social cognition), then some form of disruption of this process may contribute to basic self-disturbance, and therefore to vulnerability to schizophrenia spectrum disorders. Testing this etiological model obviously requires challenging longitudinal work. However, some consistent data have already emerged. Gamma and colleagues (2014) report data from the New England Family Study, which consisted of over 17,000 pregnant women recruited between 1959 and 1966. They ascertained a “high-risk” sample of infants of parents with schizophrenia (n = 58) and compared data from this sample with infants of parents with affective psychoses (n =128) and healthy controls (n = 174). Infants were assessed with a range of measures at eight months of age. Early intermodal integration measures were grouped into three domains characterizing different aspects of infant development: sense of one’s own body, object awareness, and social interactions. Results indicated that body and object-related early intermodal integration abnormalities were significantly increased for infants of parents with schizophrenia compared with control infants. These abnormalities were not detected in infants of parents with affective psychoses. However, early intermodal integration abnormalities in relation to social interactions were significantly increased both in infants of parents with schizophrenia and affective psychoses. These data support the notion of dysfunction in intermodal integration as a risk marker for vulnerability to schizophrenia. Similar intermodal integration deficits have been observed in infants at risk of autism (Guiraud et al., 2012). Future work needs to investigate how this early dysfunction evolves over the developmental trajectory, how it relates to other neurodevelopmental dysfunctions in young people at risk for psychosis, and if it predicts the anomalies of subjective experience associated with basic self-disturbance and onset of psychotic symptoms. Genetic high-risk and clinical high-risk populations provide ideal groups in which to investigate these questions.
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