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.

The self, neuroscience and psychosis study: Testing a neurophenomenological model of the onset of psychosis.

AIM: Basic self disturbance is a putative core vulnerability marker of schizophrenia spectrum disorders. The primary aims of the Self, Neuroscience and Psychosis (SNAP) study are to: (1) empirically test a previously described neurophenomenological self-disturbance model of psychosis by examining the relationship between specific clinical, neurocognitive, and neurophysiological variables in UHR patients, and (2) develop a prediction model using these neurophenomenological disturbances for persistence or deterioration of UHR symptoms at 12-month follow-up. METHODS: SNAP is a longitudinal observational study. Participants include 400 UHR individuals, 100 clinical controls with no attenuated psychotic symptoms, and 50 healthy controls. All participants complete baseline clinical and neurocognitive assessments and electroencephalography. The UHR sample are followed up for a total of 24 months, with clinical assessment completed every 6 months. RESULTS: This paper presents the protocol of the SNAP study, including background rationale, aims and hypotheses, design, and assessment procedures. CONCLUSIONS: The SNAP study will test whether neurophenomenological disturbances associated with basic self-disturbance predict persistence or intensification of UHR symptomatology over a 2-year follow up period, and how specific these disturbances are to a clinical population with attenuated psychotic symptoms. This may ultimately inform clinical care and pathoaetiological models of psychosis.

Self-Disorder in Schizophrenia: A Revised View (2. Theoretical Revision-Hyperreflexivity).

A growing body of research supports the role of self-disorders as core phenotypic features of schizophrenia-spectrum conditions. Self-disorders comprise various alterations of conscious experience whose theoretical understanding continues to present a challenge. This is the second of two articles that aim to clarify the nature of self-disorders in schizophrenia by considering the currently most influential, phenomenological model of schizophrenia: the basic-self-disturbance or ipseity-disorder model (IDM). The previous paper (article 1) presented a state-of-the-art overview of this model and critically assessed its descriptive adequacy with respect to the clinical heterogeneity and variability of the alterations in self- and world-awareness characteristic of schizophrenia. This paper (article 2) proposes a theoretical revision by considering how hyperreflexivity might form the crucial common thread or generating factor that unifies the heterogeneous, and sometimes even contradictory features of schizophrenic self-disorders. We outline implications of our revised model (IDMrevised) for explanatory research, therapeutic practice, and our general understanding of the abnormalities in question.

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.

Metaphor, magic, and mental disorder: Poetics and ontology in Mexican (Purépecha) curanderismo.

This article offers an epistemological, poetic, and ontological reading of the ways of knowing regarding mental disorders that are characteristic of the traditional healers (curanderas and curanderos) of an Indigenous group in Mexico. The study is based on ethnographic interviews with traditional Purépecha (Tarascan) healers in rural Michoacan. Interviews focused on local conceptions of emotional and mental illness, especially Nervios, Susto, and Locura (nerves, fright, and madness). We discuss the conceptual structure of these Indigenous illness notions, the nature of the associated imagery and notions of the soul, as well as the general sense of meaningfulness and reality implicit in Purépecha curanderismo. The highly metaphorical modes of understanding characteristic of these healers defy analysis in purely structuralist terms. They do, however, have strong affinities with the Renaissance "episteme" or implicit framework of understanding described in The Order of Things, Michel Foucault's classic study of modes of knowing and experiences of reality in Western thought-a work profoundly influenced by Heidegger's interest in the historical and cultural constitution of what Heidegger termed "Being." After examining the individual illness concepts, we explore both the poetic and the ontological dimension (the foundational sense of reality or of Being) that they involve, with special emphasis on supernatural concerns.

Uncovering the realities of delusional experience in schizophrenia: a qualitative phenomenological study in Belgium.

BACKGROUND: Delusions in schizophrenia are commonly approached as empirical false beliefs about everyday reality. Phenomenological accounts, by contrast, have suggested that delusions are more adequately understood as pertaining to a different kind of reality experience. How this alteration of reality experience should be characterised, which dimensions of experiential life are involved, and whether delusional reality might differ from standard reality in various ways is unclear and little is known about how patients with delusions value and relate to these experiential alterations. This study aimed to investigate the nature of delusional reality experience, and its subjective apprehension, in individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis. METHODS: In this qualitative phenomenological study, we recruited individuals with lived experience of delusions and a schizophrenia-spectrum diagnosis from two psychiatric-hospital services in Belgium using homogenous sampling. Criteria for participation were having undergone at least one psychotic episode with occurring delusional symptoms, present at least 1 year before participation, on the basis of clinical notes assessed by the attending psychiatrist; a schizophrenia-spectrum diagnosis, ascertained through clinical interview by the attending psychiatrist upon admission; being aged between 18 years and 65 years; and having the capacity to give informed consent. Exclusion criteria included worries concerning capacity to consent and risk of distress caused by participation. We did phenomenologically driven semi-structured interviews with the participants to explore the nature of delusional reality experience and their subjective valuation of these experiences. We used interpretative phenomenological analysis, a qualitative method tailored to the in-depth exploration of participants' first-person perspective, to analyse their accounts. FINDINGS: Between March 2, 2020, and Sept 30, 2020, 18 adults (13 men and five women, aged 19-62 years) participated in the interview study. The findings suggest that delusions are often embedded in wide-ranging alterations of basic reality experience, involving quasi-ineffable atmospheric and ontological qualities that undermine participants' sense of the world as unambiguously real, fully present, and shared with others. We also found that delusional reality experience can differ from standard reality in various ways (ie, in a hypo-real and hyper-real form), across multiple dimensions (eg, meaningfulness, necessity and contingency, and detachment and engagement), and that participants are often implicitly or explicitly aware of the distinction between delusional and standard reality. Delusional experience can have an enduring value and meaning that is not fully captured by a strictly medical perspective. INTERPRETATION: Increased awareness and recognition of the distinctive nature of delusional reality experience, in both clinical and research settings, can improve diagnostic accuracy, explanatory models, and therapeutic support for individuals with delusions whose lived realities are not always evident from an everyday perspective. FUNDING: FWO Flanders. TRANSLATION: For the Dutch translation of the abstract see Supplementary Materials section.

The Bracketing of Presence: Dematerialization and Disembodiment in Times of Pandemic and of Social Distancing Biopolitics.

The purpose of this paper is to help us understand how and why the COVID pandemic, and its associated biopolitics of social distancing, may have affected our relationships with our own bodies and other persons, thus helping to accelerate what might be termed a bracketing of presence that was already well underway in our modern and contemporary social practices. We focus on 3 historical vectors, all rooted in specific technologies, that have profound implications at the levels of our social imaginary and prereflective ways of being: architecture, social media, and medicine. Architecture has progressively eliminated "porosity" between spaces by establishing clear borders between public and private spaces (also within the private ones), thereby contributing to our drive for social distancing. Social media have provided apparatuses that replace intercorporeal encounters with disembodied, virtual interactions mediated by images. Visual experiences that are more embodied, participatory, and "immersed" are replaced by passive forms of "seeing": the other becomes an image for me, and I for the other. The object of medicine has also recently dematerialized with the advent of the new "optical" and "digital" machines of modern medicine, which can operate remotely thanks to an increasingly powerful interface reliant on computational power and the resources of artificial intelligence, thereby dispensing with body-to-body interactions. We offer these reflections as routes to a better understanding of changes that have occurred and are occurring on the planes of both culture and individual psychological existence.

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.

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, η2partial = 0.37, and also in the combined UHR/FEP sample, F = 23.56, p < 0.001, η2partial = 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.

Anomalous Experience of Self and World: Administration of the EASE and EAWE Scales to Four Subjects with Schizophrenia.

The aim of this paper was to study anomalies of self- and world experience in schizophrenia from a phenomenological perspective through the use of the Examination of Anomalous Self-Experience (EASE) and Examination of Anomalous World Experience (EAWE) interviews. Four patients with diagnoses of schizophrenia were interviewed with both the EASE and the EAWE. A qualitative analysis of these interviews was carried out on all the data; quantitative scores were also assigned, based on the frequency and intensity of the items endorsed by the subjects. In the EASE, the subjects endorsed an average frequency of 45% of all items. In the EAWE, the subjects endorsed an average frequency of 26% of all items. Furthermore, the EAWE data indicated more heterogeneous profiles of experience than the EASE data. This heterogeneity is not surprising, given that the EAWE was designed to be a more broad-based or less targeted exploration of various changes likely to be associated with the schizophrenia spectrum (but also with certain other conditions). Our data suggest that although disturbances of world experience may always be present in schizophrenia, they may take numerous and varied forms. Because the experience of the world occurs across many different modalities, disturbances of this experience would be fundamentally less unitary, whereas the experience of the self presents a more coherent and unitary gestalt. These results show a certain overlapping between the scales while also indicating the potential value of a combined use of the two instruments. Finally, we discuss the relationship between experiential description and behavioral observation, and their potentially complementary value in exploring the first-person perspective, particularly in the case of experiences that occur at a more prereflective level.

Self and world experience in non-affective first episode of psychosis.

A disturbance of "minimal self," - of the immediate sense of mine-ness inherent in experience-is hypothesized to be the core disturbance in schizophrenia. Research with the Examination of Anomalous Self Experience (EASE) has demonstrated the selective aggregation of anomalous self-experiences in the schizophrenia spectrum. Conceptual research suggests that anomalous world experiences, including changes in the experience of space, time, and other persons, occur alongside anomalous self-experiences and are an important aspect of subjectivity in schizophrenia. The Examination of Anomalous World Experience (EAWE) is a recently published interview format designed to explore changes in world experience in schizophrenia. In the current study, 24 hospital outpatients with non-affective first-episode psychosis and 24 healthy-control participants were assessed with the EAWE and the EASE. First episode psychosis patients had total EAWE and EASE scores that were both, on average, significantly higher than the healthy-control group. EAWE and EASE scores were highly correlated, even after removing overlapping items. The distribution of EAWE items and subtypes in the first-episode psychosis sample was heterogeneous. We conclude that anomalous world experiences represent a relevant aspect of first-episode psychosis, and that they may be related to the self-disturbances thought to underlie schizophrenia spectrum disorders.

Three Dangers: Phenomenological Reflections on the Psychotherapy of Psychosis.

BACKGROUND/AIMS: This paper offers a hermeneutic-phenomenological perspective on three dangers relevant to the psychotherapy of an underserved and often poorly understood population: persons with schizophrenia and other psychotic conditions. METHODS: The discussion offered relies on analyses offered by Heidegger (on the "forgetting of the ontological difference"), Husserl (on the nature and importance of intersubjectivity), and Levinas (on appreciating the "infinitude" of human experience, versus adopting a "totalizing" attitude). RESULTS: The three dangers are: (1) that of neglecting the ontological horizon or overall framework dimension of altered experience in favor of a preoccupation with more obvious, content elements of experience (e.g., by focusing overly much on specific delusional beliefs and their apparent falsehood, rather than on how delusions may be experienced and how literally they may, or may not, be taken); (2) the danger of overemphasizing the relevance and need for direct interpersonal interaction at the expense of appreciating issues concerning the implicit, intersubjective sense of sharing (or not sharing) perspectives with other persons; and finally (3) the error of being overconfident of one's ability to grasp the patient's subjectivity. CONCLUSION: The paper explores how phenomenology's general perspective may offer a helpful alternative or supplement to some widespread attitudes and practices.

Varieties of Self Disorder: A Bio-Pheno-Social Model of Schizophrenia.

The self-disorder model offers a unifying way of conceptualizing schizophrenia's highly diverse symptoms (positive, negative, disorganized), of capturing their distinctive bizarreness, and of conceiving their longitudinal development. These symptoms are viewed as differing manifestations of an underlying disorder of ipseity or core-self: hyper-reflexivity/diminished-self-presence with accompanying disturbances of "grip" or "hold" on reality. Recent revision to this phenomenological theory, in particular distinguishing primary-vs-secondary factors, offers a bio-pheno-social model that is consistent with recent empirical findings and offers several advantages: (1) It helps account for the temporal variations of the symptoms or syndrome, including longitudinal progression, but also the shorter-term, situationally reactive, and sometimes defensive or quasi-intentional variability of symptom-expression that can occur in schizophrenia (consistent with understanding some aspects of ipseity-disturbance as dynamic and mutable, involving shifting attitudes or experiential orientations). (2) It accommodates the overlapping of some key schizophrenic symptoms with certain nonschizophrenic conditions involving dissociation (depersonalization, derealization), including depersonalization disorder and panic disorder, thereby acknowledging both shared and distinguishing symptoms. (3) It integrates recent neurocognitive and neurobiological as well as psychosocial (eg, influence of trauma and culture) findings into a coherent but multi-factorial neuropsychological account. An adequate model of schizophrenia will postulate shared disturbances of core-self experiences that nevertheless can follow several distinct pathways and occur in various forms. Such a model is preferable to uni-dimensional alternatives-whether of schizophrenia or ipseity-disturbance-given its ability to account for distinctive yet varying experiential and neurocognitive abnormalities found in research on schizophrenia, and to integrate these with recent psychosocial and neurobiological findings.