An Empirical-Phenomenological Exploration of Anderssein (Feeling Different) in Schizophrenia: Being in-between Particular and Universal.

INTRODUCTION: In this paper, we wish to elucidate alterations of basic existential and intersubjective configurations in schizophrenia spectrum disorders (SSD) through the phenomenon of Anderssein ("feeling different"). Anderssein is an important yet neglected notion from German psychiatry, referring to a specific sense of feeling profoundly different from others occurring in SSD. Although phenomenological-psychopathological research mentions it as an aspect of the core disturbance of SSD (namely, "self-disorders"), the phenomenon has not yet been explored in empirical or theoretical detail. METHOD: We present material from a phenomenological-empirical study on the mode and onset of psychosis based on qualitative interviews with 25 patients with SSD. RESULTS: Most of the participants in our study report having felt fundamentally and often ineffably different since childhood and articulate it as a sense of existing "outside" of the shared reality. Intersubjective reality appears progressively unreal or inauthentic, and simultaneously, the patient's intimate, subjective sphere is permeated by an alien otherness. Importantly, this outside position should be understood carefully as it is often accompanied by the sense of being invaded by social rules, other people's thoughts, or emotions. Incipient psychosis is described as a gradual extension of precedent alterations of the structures of (inter)subjectivity. CONCLUSION: We conceptualize the ontological feature of Anderssein as an altered "being in-between" - that is, some sort of halting of the dynamic movement between particularity and intersubjectivity. Finally, we discuss the critical implications of these results for research into the "onset" of schizophrenia.

Double bookkeeping in schizophrenia spectrum disorder: an empirical-phenomenological study.

Double bookkeeping is a term introduced by Eugen Bleuler to describe a fundamental feature of schizophrenia where psychotic reality can exist side by side with shared reality even when these realities seem mutually exclusive. Despite increasing theoretical interest in this phenomenon over the recent years, there are no empirical studies addressing this issue. We have, therefore, conducted a phenomenologically descriptive qualitative study of 25 patients with schizophrenia in which we addressed the following issues: (1) Experience of double reality; (2) Emergence and development of two realities; (3) Truth quality of psychotic or private reality; (4) Insight into illness; (5) Communication of psychotic experiences. The most important result was that most patients felt to be in contact with another dimension of reality. Hallucinatory and delusional experience pertained to this different reality, which patients most frequently kept separated from the shared reality. This other dimension was considered by the patients as being more profound and real. The pre-psychotic and psychotic experiences were difficult to verbalize and typically described as totally different than ordinary experience. Double reality was persistent across remissions. None of the patients considered their condition as an illness analogous to a somatic disorder. Most patients described a vague sense of duality preceding the crystallization of double bookkeeping. This emergence of doubleness was associated with a fundamental alienation from oneself, the world, and others stretching back to childhood or early adolescence. We discuss the results with a special emphasis on the concept of psychosis, clinical interview, treatment, and pathogenetic research.

Auditory Verbal Hallucinations in Schizophrenia, Part II: Phenomenological Qualities and Evolution.

ABSTRACT: Hallucination is defined in the diagnostic systems as an experience resembling true perception without causal stimulus. In this second report from an in-depth phenomenological study of schizophrenia patients experiencing auditory verbal hallucinations (AVHs), we focused on the phenomenological qualities of AVHs. We found that a substantial proportion of patients could not clearly distinguish between thinking and hallucinating. The emotional tone of the voices increased in negativity. AVHs became more complex. Spatial localization was ambiguous and only 10% experienced only external hallucinations. There was an overlap with passivity phenomena in one third of the cases. The patients occasionally acted upon the content of AVHs. In the discussion section, we criticize the perceptual model of AVHs. We conclude that the definition of AVH in schizophrenia is misleading and exerts negative consequences on the clinical work and empirical research.

Disorder of Selfhood in Schizophrenia: A Symptom or a Gestalt?

INTRODUCTION: The concept of schizophrenia (SCZ) was originally associated with a disorder of formal strata of the self. During the last two decades, empirical studies have demonstrated a selective hyper-aggregation of self-disorders in the SCZ spectrum. As with other scientific research areas, the role of self-disturbances in SCZ has been up for debate in various disciplines including cognitive sciences, philosophy of mind, and psychopathology. Several philosophical papers have used the psychopathological phenomena of "thought insertion" as an alleged example of a complete loss of minimal selfhood. In the field of psychopathology, it has been claimed that self-disorders may comprise a transdiagnostic phenotype. Common to these approaches is the underlying assumption that self-disorders reflect well-delineated and isolated symptoms akin to the notion of symptom in the medical model. The aim of this paper was to argue that the clinical manifestation of self-disturbances is to be seen as aspects of a Gestalt of disturbed experiential selfhood. METHODS: Seven videotaped interviews of patients with SCZ who were emblematic of very diverse symptomatological constellations were selected and jointly watched and discussed by the authors, who reached a consensus assessment. The interviews were semi-structured and narrative in nature in order to obtain faithful self-descriptions according to the standards of phenomenologically oriented interviews. For the purpose of this article, we chose 4 videos from which excerpts were verbatim transcribed and translated from Danish into English. RESULTS: The patients describe unique combinations of various psychopathological phenomena such as diminished sense of embodied self-presence, loss of ego boundaries, diminished sense of self, alienation and objectification of the experiential processes, mirror-phenomena, and Schneiderian passivity phenomena. DISCUSSION: Through an interweaving of the four vignettes and their subsequent psychopathological discussions, we argue that the invariant commonality across the different symptomatic expressions in these patients resides in a Gestalt of pervasive disturbance of self-experience. From a phenomenological perspective, these self-disturbances target a basic structure of phenomenal consciousness, namely, the first-person givenness of experience. We conclude that self-disorders reflect a trait-instability in the most basic structures of consciousness in SCZ and that its clinical manifestations are to be seen as aspects of a particular Gestalt rather than appearing as separate and well-delineated symptoms.

Double bookkeeping and schizophrenia spectrum: divided unified phenomenal consciousness.

Eugen Bleuler, the founder of the concept of schizophrenia, pointed out that psychotic patients were able to live in two disjoint worlds (namely, the social, intersubjective world and the delusional world). He termed this phenomenon "double bookkeeping," but did not provide any conceptual elaboration of this phenomenon or its possible mechanisms. Double bookkeeping has been neglected in mainstream psychiatry, but it has been addressed in recent theoretical work, however mainly concerned with the issue of delusion. In this article, we present clinical material that supports the view that double bookkeeping manifests itself across various psychotic phenomena and its antecedent may be observed in premorbid (pre-onset) phases as well as in the schizotypal disorder. We try to conceptualize double bookkeeping to concretize an often atmospheric perception of paradoxicality in the encounter with the patient. A phenomenological analysis of double bookkeeping suggests an instability in the affective ("auto-affection") articulation of selfhood. We point to four main implications of our presentation: (1) diagnostic, (2) epistemological, (3) therapeutic and (4) pathogenetic research.

"Transition" to Schizophrenia or Fluctuations within the Same Disorder?

BACKGROUND: To prevent or delay the onset of psychotic disorders or ameliorate their course, prodromal research has strived to identify and treat individuals at risk of developing psychosis. While this approach is laudable, it is, however, not entirely unproblematic from clinical and conceptual perspectives. For example, it remains unclear how we are to understand the development from a nonpsychotic, distressing condition such as schizotypal disorder to a psychotic disorder such as schizophrenia? The current terminology on the subject implies either a nonlinear jump ("conversion") or a more linear progression ("transition") from one disorder to another. To enrich our understanding of such diagnostic shifts, we examined the psychopathological pictures of patients who "transitioned" from schizotypal disorder to schizophrenia. METHODS: From a larger study on psychopathology, we examined 40 patients who were diagnosed with schizotypal disorder at baseline. At 5-year follow-up, 30 patients maintained the diagnosis of schizotypal disorder, while 10 were re-diagnosed with schizophrenia. We examined detailed descriptions of the 10 patients who progressed to schizophrenia, comparing psychopathology and level of functioning. RESULTS: The level of functioning decreased slightly from baseline to follow-up in 9 out of 10 patients. Eight patients had previously had micro-psychotic or psychotic experiences. All patients had self-disorders at baseline, and several patients had perceptual disorders. Nine patients had formal thought disorders at baseline. The progression is illustrated by 2 cases. CONCLUSION: In this small study, we did not find any striking changes in any of the patients, neither in terms of psychopathological manifestations nor in terms of their level of functioning. Thus, rather than witnessing a genuine "conversion" or "transition" from schizotypal disorder to schizophrenia, we observed dimensional fluctuations within the same condition.

Disordered Selfhood in Schizophrenia and the Examination of Anomalous Self-Experience: Accumulated Evidence and Experience.

Disordered selfhood in schizophrenia was rediscovered at the turn of the millennium. In 2005, Psychopathology published the psychometric instrument, the Examination of Anomalous Self-Experience (EASE). In this article, we summarize the historical background of the creation of the EASE, explicate the notion of the disorder of basic or minimal self with the help of phenomenological philosophy, and provide a brief description of clinical manifestations targeted by the EASE. We also present our personal experience using and teaching the EASE and summarize the empirical evidence obtained so far. We conclude that the basic self-disorder represents a crucial phenotype of schizophrenia spectrum disorders and that this phenotype offers a potential avenue to empirical pathogenetic research and psychotherapeutic treatment.

Exploring schizophrenia spectrum psychopathology in borderline personality disorder.

We have previously argued that the current borderline personality disorder (BPD) diagnosis is over-inclusive and clinically and conceptually impossible to distinguish from the schizophrenia spectrum disorders. This study involves 30 patients clinically diagnosed with BPD as their main diagnosis by three BPD dedicated outpatient treatment facilities in Denmark. The patients underwent a careful and time-consuming psychiatric evaluation involving several senior level clinical psychiatrists and researchers and a comprehensive battery of psychopathological scales. The study found that the vast majority of patients (67% in DSM-5 and 77% in ICD-10) in fact met the criteria for a schizophrenia spectrum disorder, i.e., schizophrenia (20%) or schizotypal (personality) disorder (SPD). The schizophrenia spectrum group scored significantly higher on the level of disorders of core self as measured by the Examination of Anomalous Self-Experiences Scale (EASE). The BPD criterion of "identity disturbance" was significantly correlated with the mean total score of EASE. These findings are discussed in the light of changes from prototypical to polythetic diagnostic systems. We argue that the original prototypes/gestalts informing the creation of BPD and SPD have gone into oblivion during the evolution of polythetic criteria.

Schizophrenia-spectrum psychopathology in obsessive-compulsive disorder: an empirical study.

The differential diagnosis of obsessive-compulsive disorder (OCD) and schizophrenia-spectrum disorders can be difficult. In the current diagnostic criteria, basic concepts such as obsession and delusion overlap. This study examined lifetime schizophrenia-spectrum psychopathology, including subtle schizotypal symptomatology and subjective anomalies such as self-disorders, in a sample diagnosed with OCD in a specialized setting. The study also examined the differential diagnostic potential of the classic psychopathological notions of true obsession ('with resistance') and pseudo-obsession. The study involved 42 outpatients diagnosed with OCD at two clinics specialized in the treatment of OCD. The patients underwent semi-structured, narrative interviews assessing a comprehensive battery of psychopathological instruments. The final lifetime research-diagnosis was based on a consensus between a senior clinical psychiatrist and an experienced research clinician. The study found that 29% of the patients fulfilled criteria of schizophrenia or another non-affective psychosis as main, lifetime DSM-5 research-diagnosis. Another 33% received a research-diagnosis of schizotypal personality disorder, 10% a research-diagnosis of major depression and 29% a main research-diagnosis of OCD. Self-disorders aggregated in the schizophrenia-spectrum groups. True obsessions had a specificity of 93% and a sensitivity of 58% for a main diagnosis of OCD. In conclusion, a high proportion of clinically diagnosed OCD patients fulfilled diagnostic criteria of a schizophrenia-spectrum disorder. The conspicuous obsessive-compulsive symptomatology may have resulted in a disregard of psychotic symptoms and other psychopathology. Furthermore, the differentiation of obsessions from related psychopathological phenomena is insufficient and a conceptual and empirical effort in this domain is required in the future.

Auditory Verbal Hallucinations in Schizophrenia: Mode of Onset and Disclosure.

Recent reviews on auditory verbal hallucinations (AVHs) advocate a qualitative and interdisciplinary research that not only is limited to single descriptive features, but also involves contextual issues and co-occurring psychopathology. In this study of mainly readmitted patients with the International Classification of Diseases, Tenth Revision, diagnosis of paranoid schizophrenia and experiencing AVH, we performed a qualitative, phenomenologically oriented interview study. The focus was on the beginning of hallucinatory experiences, time to disclosure of the symptom, and the context surrounding the disclosure. We found that on average the patients experiencing AVH for 6.5 years before disclosing the symptom to a psychiatrist. Moreover, the term "voices" was typically appropriated by the patient during his contact with a psychiatric treatment facility. None of the patients considered themselves as being psychotic or severely mentally ill. The AVH in the majority of the patients was associated with other pathological subjective experiences. The significance of these findings is briefly discussed in relation to the concept of insight, diagnosis of psychosis, and early detection.

The Hoarding Phenomenon in Schizophrenia Spectrum Disorders.

The presence of hoarding behavior among patients with schizophrenia has been known for more than a century. Nevertheless, only a few studies have examined the hoarding phenomenon among patients with schizophrenia, and no studies have examined the potential motivation. Hoarding disorder became a separate diagnosis in DSM-5. Studies about hoarding disorder use primarily quantitative approaches (e.g., scales, self-administered questionnaires, and structured interviews) when assessing the patients. The main objectives of this study were to examine the meaning of hoarding for patients with schizophrenia spectrum disorders and to explore associated psychopathology which may motivate the hoarding. We have examined 13 patients diagnosed with schizophrenia spectrum disorders showing hoarding behavior. The patients underwent semistructured, narrative interviews about the following domains: the time of onset of hoarding, the meaning of hoarding and associated psychopathology, the presence of insight into hoarding, and problematic issues about discarding. The study shows that hoarding begins very early in life for these patients and can be motivated by various psychopathologies. Diminished sense of basic self and transitivistic experiences were mentioned by several patients as motivations for collecting objects. Furthermore, the difficulty with discarding reflected a huge ambivalence and ruminations. Our findings suggest that thorough and comprehensive assessments of people with hoarding symptoms are necessary to assure the correct diagnosis and to understand the patient. An increased knowledge of the patients' motivations for hoarding behavior may also be useful for the treating personnel and may prevent social adversities. We think it is questionable that in the DSM-5 hoarding is not mentioned in the description of schizophrenia but has been elevated to a separate disorder.

'The schizophrenic basic mood (self-disorder)', by Hans W Gruhle (1929).

During the first half of the twentieth century, German psychiatry came to consider 'Ich-Störungen', best translated as self-disorders, to be important features of schizophrenia. The present text is a translation of a chapter by the German psychiatrist Hans Gruhle, which is extraordinarily clear and emblematic for this research line. Published in 1929, it was part of a book co-written with Josef Berze, The Psychology of Schizophrenia (concerning its subjectivity). Gruhle claims that the essential core of schizophrenia is of an affective nature, a 'mood' manifesting itself as self-disorder, an unstable, incomplete pre-reflective self-awareness. His impact on contemporary psychiatry was probably limited due to his confrontational style, but this text has great significance for the modern revival of phenomenological research in schizophrenia.

Thought insertion and disturbed for-me-ness (minimal selfhood) in schizophrenia.

In contemporary consciousness research, we have defended a position of experiential minimalism, arguing that for-me-ness (or minimal selfhood) is a necessary, universal feature of phenomenal consciousness. The concept of for-me-ness refers to the fact that experiences are given first-personally to the subject of experience. To challenge the universality of for-me-ness, several authors have referred to the case of thought insertion as a clear counter example. In this study, we address and refute the claim that episodes of thought insertion represent examples of experiences lacking for-me-ness. We highlight certain unaddressed methodological and psychopathological problems that tend to hamper philosophical discussions of thought insertion. Although thought insertion does not involve a lack of for-me-ness, we do argue that thought insertion involves a disturbed for-me-ness. Finally, we offer a novel account of how for-me-ness is disturbed in schizophrenia spectrum disorders and we discuss how a disturbed for-me-ness may be involved in the formation of thought insertion.

Detail, dynamics and depth: useful correctives for some current research trends.

Several research trends in contemporary psychiatry would benefit from greater emphasis on detailed assessment, modelling dynamic change, and micro-level analysis. This may assist with clarifying nosological and pathoaetiological issues. We make this case by referring to three areas: psychopathology and nosology; prediction research; and 'big N' data sets.Declaration of interestNone.

Self-disorders in schizophrenia-spectrum disorders: a 5-year follow-up study.

Self-disorders have been hypothesized to be an underlying and trait-like core feature of schizophrenia-spectrum disorders and a certain degree of temporal stability of self-disorders would therefore be expected. The aim of the study was to examine the persistence of self-disorders measured by the Examination of Anomalous Self Experiences over a time span of 5 years. 48 patients with schizophrenia-spectrum disorders were thoroughly assessed for psychopathology at baseline and 5 years later. Self-disorders were assessed by the Examination of Anomalous Self Experiences. The level of self-disorders was same at the two occasions for the full Examination of Anomalous Self Disorders and for four out of the five domains. For one domain, the level of self-disorders increased slightly from baseline to follow-up. The correlations between baseline and follow-up were moderate. 9 out of the 13 most-frequently rated items at baseline showed equal frequencies at follow-up. The baseline level of self-disorders predicted global symptomatic, but not functional outcome. Self-disorders measured by the Examination of Anomalous Self Experiences show a high level of temporal persistence over 5 years and predict symptomatic outcome.

EAFI: Examination of Anomalous Fantasy and Imagination.

The Examination of Anomalous Fantasy and Imagination (EAFI) is an instrument for a semistructured, phenomenological exploration of psychopathology of imagination. The EAFI provides a conceptual-descriptive framework to address such experiences. It consists of 16 main items, sometimes divided into subtypes. We suggest that the anomalies of imagination explored by the EAFI reflect an alteration in the structure of consciousness and belong to a fundamental, generative layer of psychopathology with relevance to differential diagnostic purposes.

A Phenomenological Approach to Psychopathology of Imagination: Development of a Descriptive Instrument - Examination of Anomalous Fantasy and Imagination.

This paper serves as an introduction to the Examination of Anomalous Fantasy and Imagination (EAFI) - a novel instrument for a semistructured, phenomenological exploration of psychopathology of imagination. We present an account of the phenomenology of imagination and proceed to a presentation of the disorders of imagination that are addressed in the EAFI. Furthermore, the interrater reliability of the EAFI was examined in a diagnostically heterogeneous sample of 20 in-patients. The interrater agreement ranged from 0.6 to 1.0, with an average κ of 0.84. The internal consistency of the EAFI as measured by Cronbach's α was above 0.88. We suggest that the anomalies of imagination explored by the EAFI reflect an alteration of the structure of consciousness and belong to a fundamental, generative layer of psychopathology. These disorders may have relevance for differential diagnostic purposes, especially in first-contact, young patients.

EAWE: Examination of Anomalous World Experience.

The "EAWE: Examination of Anomalous World Experience" is a detailed semi-structured interview format whose aim is to elicit description and discussion of a person's experience of various aspects of their lived world. The instrument is grounded in the tradition of phenomenological psychopathology and aims to explore, in a qualitatively rich manner, six key dimensions of subjectivity - namely, a person's experience of: (1) Space and objects, (2) Time and events, (3) Other persons, (4) Language (whether spoken or written), (5) Atmosphere (overall sense of reality, familiarity, vitality, meaning, or relevance), and (6) Existential orientation (values, attitudes, and worldviews). The EAWE is based on and primarily directed toward experiences thought to be common in, and sometimes distinctive of, schizophrenia spectrum conditions. It can, however, also be used to investigate anomalies of world experience in other populations. After a theoretical and methodological introduction, the EAWE lists 75 specific items, often with subtypes, in its six domains, together with illustrative quotations from patients. The EAWE appears in a special issue of Psychopathology that also contains an orienting preface (where the difficulty as well as necessity of studying subjective life is acknowledged) and a brief reliability report. Also included are six ancillary or background articles, which survey phenomenologically oriented theory, research, and clinical lore relevant to the six experiential domains.

Mysticism and schizophrenia: A phenomenological exploration of the structure of consciousness in the schizophrenia spectrum disorders.

Mysticism and schizophrenia are different categories of human existence and experience. Nonetheless, they exhibit important phenomenological affinities, which, however, remain largely unaddressed. In this study, we explore structural analogies between key features of mysticism and major clinical-phenomenological aspects of the schizophrenia spectrum disorders-i.e. attitudes, the nature of experience, and the 'other', mystical or psychotic reality. Not only do these features gravitate around the issue of the basic dimensions of consciousness, they crucially seem to implicate and presuppose a specific alteration of the very structure of consciousness. This finding has bearings for the understanding of consciousness and its psychopathological distortions.

Variability in clinical diagnoses during the ICD-8 and ICD-10 era.

AIMS: To explore whether the diagnostic homogeneity in a daily, routine clinical activity changed visibly over two historical periods (the ICD-8 and the ICD-10 era) across and within five psychiatric in-patient clinics. METHODS: In this register study, we analyzed the discharge diagnoses from five university-affiliated departments of psychiatry in Denmark in two time periods: 1980-1985 (ICD-8) and 2001-2010 (ICD-10). RESULTS: The synchronic inter-departmental diagnostic differences did not decrease in the ICD-10 era compared with ICD-8 era. Nor did the diachronic stability within each department become more homogeneous. CONCLUSION: The diagnostic variability reflected by the diagnostic differences between the departments and by the diagnostic homogeneity within each department remained similar in the two historical periods with no evidence of an increased homogeneity of diagnostic habits after the introduction of the ICD-10. LIMITATIONS: There is a myriad of variables that affects the diagnostic variability over time that we were not able to control.