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OUP Copyright Chapter 16 The self in schizophrenia: Jaspers, Schneider, and beyond Thomas Fuchs Introduction The concept of self-disorders has always played a major role for the psychopathology of the psychoses. In his General Psychopathology , Jaspers distinguished what he called ego-consciousness ( Ich-Bewusstsein ) from object-consciousness and characterized it by the sense of activity, unity, identity, and ego-demarcation. On this basis, Kurt Schneider later coined the term ‘ Ich-Stoerungen ’ (ego-disorders) for the experience of one’s thoughts, actions, feelings, or bodily sensations being infl uenced or manipulated by others. However, neither the term ‘self-disorder’ nor ‘ego-disorder’ appears in the tenth revision of the International Classifi cation of Diseases (ICD-10) or the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), although these symptoms are attributed major importance for a valid diagnosis of schizophrenia. Instead, thought insertion, thought withdrawal, made actions or feelings are regarded as bizarre delusions, commonly referred to as delusions of infl uence, control, or passivity.1 It has often been criticized by continental psychopathologists that this conception of ego-disorders as delusions misses their core disturbance which consists not in a cognitive distortion of reality but in a more fundamental alteration of self-awareness and demarcation of self from the environment (Kraus 2010; Spitzer 1988). Only secondarily do these altera- tions of self-experience give rise to corresponding delusional convictions. The concept of ego-disorders therefore characterizes a group of core schizophrenic symptoms which may not be ranged on the same level as, for example, simple delusions of persecution. Moreover, the term ‘ego-disorder’ may serve as a mediating term which connects the core syndrome of acute schizophrenia with a more basic symptom level, namely the level of prodromal or basic self-disorders which have been investigated by Huber (1983, 1995), Klosterkoetter (1988, 1992), and more recently by Parnas and his group (Parnas et al. 2005a, 2005b; Raballo et al. 2012). The study of the transition from prodromal to acute psychotic symptoms, for example, from alienated thoughts to thoughts aloud and full-blown thought insertions, is of particular importance for understanding the nature and the course of schizophrenia as leading from basic self-disturbances on a pre-refl exive level to disorders of 1 There is no consistent English translation of ‘Ich-Stoerung’. I use the term ‘ego-disorder’ instead of ‘I-disorder’ (Spitzer 1988) which seems a bit awkward in the English language. However, there is no reference implied to the psychoanalytic ‘ego psychology’ and its theory of psychosis (e.g. Federn 1953).OUP Copyright 16_Stanghellini_C16.indd 245 6/1/2013 7:30:08 AM 246 THEOUP SELF IN SCHIZOPHRENIA: JASPERS, Copyright SCHNEIDER, AND BEYOND ego-demarcation. The term ‘ego-disorder’ seems better suited to express this transition. On the other hand, Jaspers and Schneider themselves have contributed to impeding the inves- tigation of transitional phenomena, since they conceived of ego-disorders as all-or-nothing symptoms for the sake of clear-cut nosological distinctions. In this chapter I will give a short historical introduction into the problem of self-disorders. Then I will analyse the connection of ego-disorders with more basic disorders of self-awareness. I will argue that full-blown delusions of alien control are based on a disturbance of the intentionality of thinking, feeling, and acting. This disturbance of intentionality, for its part, may be traced back to a lack of pre-refl exive self-awareness as it has been proposed by more recent phenomenological approaches to schizophrenia. Finally, I look at the intersubjective disturbances that arise as a consequence of self-disorders which, as I will argue, are always disorders of self-with-others at the same time. A short history of self-disorders The phenomena of self-alienation and self-disorders gained particular attention for the fi rst time in German and French psychopathology around 1900. Stoerring (1900) and Pick (1909) had already emphasized the disturbance of the sense of activity or agency ( Aktivitaetsgefuehl ) in psychotic patients: ‘They lack the sense of agency, the sense of striv- ing in thinking and acting’. Oesterreich (1907) saw the core of self-consciousness in the affects and attributed the alienation of reality to a loss of self-affection. Dugas and Moutier (1911) introduced the notion of depersonalization to denote the disturbance of an integra- tive mental process which they thought ‘personalizes’ mental acts and endows them with a sense of mineness: ‘Personalization is the act of a psychical synthesis, of appropriation or attribution of states to the self’ (Dugas and Moutier 1911: 13). Later, Berze (1914: 130) attributed depersonalization to a ‘dynamic insuffi ciency of single intentions’: ‘Since the ego may be regarded as a product of the fusion or integration of the … single intentions, the weakness of the power of consciousness must manifest itself in a decrease of personality or ego-consciousness’. Drawing on these approaches in the fi rst edition of his General Psychopathology (1913), Jaspers characterized ‘personal consciousness’ (which he termed ‘ego-consciousness’ later on) by four formal features: 1. ego-consciousness in contrast to the external world and to others 2. sense of activity 3. sense of identity over time 4. sense of unity or of being one and the same person. Among these features, the sense of activity was crucial for Jaspers, since through it percep- tions, sensations, thoughts, feelings, and actions are ‘personalized’. The experience of one’s mental acts as not being one’s own, as alien or automatic was termed ‘depersonalization’ by Jaspers. Later editions of General Psychopathology were increasingly infl uenced by Kurt Schneider. Jaspers now put the sense of activity in the fi rst place and further divided it into: 1 . Existenz- or Daseinsbewusstsein (awareness of existence or of being-there), whose disturbance meant a self-alienation in different degrees. OUP Copyright 16_Stanghellini_C16.indd 246 6/1/2013 7:30:08 AM OUP CopyrightA SHORT HISTORY OF SELF-DISORDERS 247 2 . Vollzugsbewusstsein (awareness of agency), whose disturbance was now equivalent to experiencing one’s thoughts or actions as being made, controlled or withdrawn from outside. In his Clinical Psychopathology which fi rst appeared in 1950, Kurt Schneider, for his part, referred to Jaspers’ criteria and stated, somewhat simplifying, that in clinical practice only the sense of activity may actually be disturbed (Schneider 1959). However, since the notion of activity could hardly be attributed to feelings and spontaneous thoughts, he substituted the sense of activity by the term ‘mineness’ ( Meinhaftigkeit ). Disturbances of mineness became now equivalent to the major schizophrenic self-disorders or experiences of alien control. In the last edition from 1967, Schneider subsumed thought insertion, thought withdrawal, thought broadcasting, and all phenomena of ‘made’ feelings, sensations, and actions under the term ‘ego-disorders’, characterizing them as an abnormal permeability of the boundary between ego and environment. By this, he implicitly referred to the fi rst of Jaspers’ original criteria, namely ego-consciousness in contrast to the external world and to others. This permeability became the hallmark of ego-disorders which in Schneider’s sys- tem assumed the status of fi rst-rank symptoms for the diagnosis of schizophrenia. It cannot be denied that Jaspers’ and Schneider’s emphasis on the concept of ego-consciousness and its disorders marked a crucial progress in the psychopathology and nosology of schizophrenia. On the other hand, the concept also showed a number of remarkable fl aws: 1. First, the term ‘depersonalization’ taken by Jaspers from Dugas and Moutier remained too unspecifi c. It took a long time until it was removed from the fi eld of schizophrenic ego-disorders and fi nally came to denote a separate diagnostic entity, namely neurotic depersonalization disorder (ICD-10 F.48.1). 2. The notions of ‘sense of existence’ ( Daseinsbewusstsein ), ‘sense of activity’ ( Vollzugsbewusstsein ), ‘mineness’, and ‘ego-demarcation’ were neither clearly distinguished nor philosophically grounded terms. It remained inconclusive whether or not Daseinsbewusstsein only referred to feelings and bodily sensations and Vollzugsbewusstsein only to thoughts and actions, all the more since neither Jaspers nor Schneider came to grips with the question which mental acts and states should be regarded as activities and which not. 3. The possibility of transitional phenomena leading from basic disorders of Daseinsbewusstsein to disorders of Vollzugsbewusstsein , or from lower to higher levels of self-awareness disappeared, for the already mentioned reason of clear-cut nosological distinctions. The level of basic self-awareness in schizophrenia had previously come into view, namely in the monograph of the Viennese psychiatrist Joseph Berze, referred to earlier (Die primaere Insuffi zienz der psychischen Aktivitaet, 1914). He regarded the primary disorder in schizophrenia as a diminished state of awareness or mental activity which he called hypophrenia. Kronfeld (1922) and Minkowski (1927) also developed concepts of the schizophrenic core disturbance as a loss of basic mental activity, or of vital contact to reality. But it was not

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