Psychopathology of schizophrenias Schizophrenia as a disorder of the self M.G. Henriksen1,2, J. Nordgaard1 1 Psychiatric Center Hvidovre, University of Copenhagen, Denmark; 2 Center for Subjectivity Research, University of Copenhagen, Denmark Summary this paper, we elicit the meaning of the phenomenological no- This paper offers an overview of a current direction of clini- tion of “disordered self” in schizophrenia spectrum disorders, cal and empirical research in schizophrenia, viz. the phenom- we offer rich clinical descriptions of self-disorders, and we pro- enologically informed approach that regards the generative vide a concise overview of results from contemporary empirical disturbance of schizophrenia as a specific disorder of the self. studies. Finally, we provide some suggestions for future research Empirical studies have recently documented that anomalous on self-disorders, their nosological and diagnostic implications, self-experiences (i.e. self-disorders) aggregate in schizophrenia and consider their potential value in psychotherapy for schizo- phrenia. spectrum disorders, but not in other mental disorders. What ap- pears to underlie this aggregation of self-disorders is an insta- Key words bility of the first-person perspective, which threatens the most basic experience of being a subject of awareness and action. In Self-disorders • Schizophrenia • Schizotypy • EASE • Phenomenology Introduction phrenia 2. Yet, the meaning of the term “self” and the na- ture of its “diminishment” vary considerably among these The neglect of the phenomenology and epistemology of approaches – some considerations on these approaches, the psychiatric object, which occurred in the wake of similarities and dissimilarities can be found elsewhere 2 3. the so-called “operational revolution” in psychiatry, has Due to the ambiguities associated with the notion of led to a vast oversimplification of psychopathological “diminished sense of self”, we first illuminate the phe- phenomena (e.g. delusions and hallucinations, but also nomenological notion of “disordered self” in the schiz- syndromes), depriving them of their phenomenological ophrenia spectrum (i.e. schizophrenia and schizotypy). 1 validity and any overarching conceptual framework . Secondly, we offer a series of typical and quite common One possible remedy to this unfortunate development clinical complaints of anomalous self-experiences (i.e. involves a return to the basic science of psychiatry, viz. self-disorders) from patients diagnosed within the schizo- psychopathology, and systematic explorations of the phrenia spectrum. Finally, we will summarise the results ways in which psychopathological phenomena manifest from contemporary empirical research and discuss their themselves in patients’ experiences and existence. Here, implications for future research and treatment in schizo- we must bear in mind that grasping mental phenomena phrenia. is not similar to grasping physical objects. To place the “disordered self” in schizophrenia into proper perspec- tive, some preliminary considerations on subjectivity and The disordered self consciousness are required. For the purpose of providing the reader with a prelimi- For a long time, the issue of subjectivity was nearly for- nary sketch of the conclusions we shall draw later, we gotten in psychiatry, but currently we are witnessing an anticipate here the central result from the empirical stud- almost global increase of interest in this particular topic. ies: collectively, these studies demonstrate that the self in Psychiatry, existential psychiatry, phenomenological schizophrenia is often fragile and unstable. psychiatry, psychoanalysis, psychosocial rehabilitation Most importantly, the “self” that is found to be disordered and dialogical psychology all seem to agree that schizo- in schizophrenia spectrum disorders in empirical stud- phrenia involves a ”diminished sense of self” – a view ies does not refer to complex aspects of selfhood such also supported by many first-person accounts of schizo- as “social identity” or “personality” (although these as- Correspondence M.G. Henriksen, Center for Subjectivity Research, University of Copenhagen, Njalsgade 140-142, 25.5.23, DK-2300 Copenhagen S, Denmark • Tel. +45 3533 5597 • E-mail: [email protected] Journal of Psychopathology 2014;20:435-441 435 M.G. Henriksen, J. Nordgaard pects certainly also may be affected), but to a very basic taneous immersion in the shared world and diminished experience of being a self. This experience signifies that sense of being present in it, alienation from the social we live our (conscious) life in the first-person perspec- world (often leading to social isolation and withdrawal), tive, as a self-present, single, temporally persistent, bod- perplexity (questioning what others consider quite ob- ily and bounded subject of experience and action 4. In vious or just take for granted, e.g. why do people say other words, it is the first-personal articulation of expe- “hello” to each other or why is the colour code in traf- rience that implicitly facilitates a sense of “mine-ness” fic signals “red-yellow-green’?) and various forms of de- or “ipseity” 5, transpiring through the flux of time and realisation. Against this backdrop, it should be evident changing modalities of consciousness (e.g. perception, that the phenomenological notion of a “disordered self” imagination, thinking), which appears to be unstable in in the schizophrenia spectrum disorders does not refer to schizophrenia. Consequently, the normally tacit, taken- a disturbance solely at the level of the subject, but rather for-granted, and pre-reflective experience of being a self to a disturbance of the tacit and foundational “self-world no longer saturates one’s experiences in the usual and structure” 7 or, differently put, of “the intentional arc” 8. unproblematic manner. It is quintessential to realise that This self-world structure appears to be fragile and unsta- this experiential notion of “self” is not a hypothetical ble in disorders in the schizophrenia spectrum, consti- construct, but a real and phenomenologically accessible tuting its core vulnerability, and resulting in a variety of structure of consciousness. I am always pre-reflectively specific self-disorders of which we provide clinical ex- aware of being myself and I have no need for self-reflec- amples below. tion or self-perception to assure myself of actually being It also merits attention that this “instability” does not myself. For example, I do not need to reflect upon who equal something like a disappearing or dissolution of the these trains of thoughts might belongs to or whose image self. Of course, patients with schizophrenia spectrum dis- I perceive in the mirror in order to know that it is me. This orders continue to be subjects of awareness and action, intimate, foundational sense of self is not really a sort of and to affirm themselves with the first-personal pronoun knowledge, but rather prior to knowledge; it arises from a (i.e. the “I”). Patients experience self-disorders within an structure of consciousness that is operative in all experi- overarching experiential-existential perspective, which ential modalities; it is simply there, given and imbuing all constitutes their being-in-the-world, and no matter how my experiences with an elusive, yet absolutely vital feel- many self-disorders they suffer from, their lives remain ing of “I-me-myself” (which we also may describe with complete forms of human existence. The notions of “in- the concept of self-presence). Following Henry, we can stability” and “dis-order” suggest, however, that the nor- say that this basic sense of self arises from the “auto-af- mally tacit and pre-reflective experience of being a sub- fectivity” of subjectivity – a feature of the very givenness ject of awareness and action no longer saturates one’s of consciousness 6. Of course, I may still question what I experiences in the usual, unproblematic way. think, why I have these thoughts or feelings and the possi- ble allurement of my body or the nature of my being (e.g. Clinical descriptions my moral values, ability to exist in accordance to these values, and the purpose of my existence), but usually the Many first-admitted patients with schizophrenia spectrum question never arises if these thoughts, feelings or this disorders complain of feeling as if they do not truly exist, body actually is mine. of lacking an inner core and of being profoundly, though In schizophrenia spectrum disorders, by contrast, this regularly ineffably, different from others (Anderssein). structure of consciousness is unstable and oscillating, re- The distinctness of the quite frequent feeling of Anders- sulting in certain characteristic anomalies of self-experi- sein seems to be a pervasive sense of being ontologically ence (e.g. a markedly diminished sense of mine-ness of different; it is a feeling of being different in which one’s one’s own thoughts, actions and body), which patients very humanity is at stake. As one of our patients put it, “I frequently report and which, in empirical studies, have looked just like every other child, but inside I was differ- consistently been found to aggregate in schizophrenia ent. It is as if I am another creature that somehow ended spectrum disorders but not in other mental disorders (see up inside a human body”. Another patient described this summary of results below). feeling in the following way: “I feel categorically differ- From a phenomenological perspective, this basic experi-