Self-experience in the early phases of schizophrenia: 5-year follow-up of the Copenhagen Prodromal Study

Pseudoneurotic Symptoms in the Schizophrenia Spectrum: A Longitudinal Study of Their Relation to Psychopathology and Clinical Outcomes

BACKGROUND AND HYPOTHESIS

Nonpsychotic symptoms (depression, anxiety, obsessions, etc.) are frequent in schizophrenia-spectrum disorders and are usually conceptualized as comorbidity or transdiagnostic symptoms. However, in twentieth century foundational psychopathological literature, many nonpsychotic symptoms with specific phenomenology (here termed pseudoneurotic symptoms) were considered relatively typical of schizophrenia. In this prospective study, we investigated potential associations of pseudoneurotic symptoms with diagnostic status, functional outcome as well as psychopathological dimensions of schizophrenia.

STUDY DESIGN

First-admitted patients (N = 121) diagnosed with non-affective psychosis, schizotypal disorder, or other mental illness were examined at initial hospitalization and 5 years later with a comprehensive assessment of psychopathology. Informed by the literature, we constructed scales targeting pseudoneurotic symptoms and other, more general, nonpsychotic symptoms.

STUDY RESULTS

Pseudoneurotic symptoms aggregated in schizophrenia-spectrum groups compared to other mental illnesses and occurred at similar levels at baseline and follow-up. They longitudinally predicted poorer social and occupational functioning in schizophrenia-spectrum patients over a 5-year-period but not transition to schizophrenia-spectrum disorders from other mental illnesses. Finally, the level of pseudoneurotic symptoms correlated with disorder of basic self at both assessments and with positive and negative symptoms at follow-up. The scale targeting general nonpsychotic symptoms did not show this pattern of associations.

CONCLUSIONS

The study supports that a group of nonpsychotic symptoms, ie, pseudoneurotic symptoms, are associated with schizophrenia-spectrum disorders and linked with temporally stable psychopathology, particularly disorder of the basic self. Their prospective association with social and occupational functioning needs replication.

Interplay between childhood trauma, bodily self-disturbances, and clinical phenomena in schizophrenia spectrum disorders: A network analysis

BACKGROUND

Bodily self-disturbances have long been considered central to schizophrenia. Exposure to childhood trauma has been linked to the development of both psychosis and bodily self-disturbances, yet little work has examined the role of bodily self-disturbances in the relationship between childhood trauma and schizophrenia symptomatology. This study uses network analysis to bridge this gap.

METHODS

Networks were constructed to examine relationships between schizophrenia symptoms (Positive and Negative Symptom Scale; PANSS), bodily self-disturbances (Perceptual Aberration Scale; PAS), and self-reported exposure to childhood trauma (Childhood Trauma Questionnaire, Short-Form; CTQ-SF) in 152 people with a schizophrenia-spectrum disorder. Shortest path and bridge analyses were conducted to assess the role of bodily self-disturbances in linking childhood trauma to schizophrenia symptomatology. Three networks were constructed: 1) PAS, childhood trauma, and PANSS sub-scale composites (positive, negative, general); 2) PAS, childhood trauma, and positive symptoms, 3) PAS, childhood trauma, and distress symptoms.

RESULTS

Shortest path analysis revealed that bodily self-disturbances were on the shortest path between childhood trauma and positive and general symptoms (Network 1), between trauma and hallucinations (Network 2), and between trauma and depression (Network 3). Bodily self-disturbances were also found to serve as a bridge between childhood trauma and positive symptoms of schizophrenia, particularly delusions and hallucinations.

CONCLUSIONS

Using a novel, data-driven approach, we showed that bodily self-disturbances play a key role in linking childhood trauma to positive and co-morbid affective symptoms of schizophrenia. Threat experiences (i.e., abuse) specifically relate to bodily self-disturbances and psychotic symptoms.

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.

Network Structure of Childhood Trauma, Bodily Disturbances, and Schizotypy in Schizophrenia and Nonclinical Controls

Background and Hypothesis

Exposure to childhood trauma has been linked to the development of psychosis and bodily self-disturbances, 2 hallmarks of schizophrenia (SZ). Prior work demonstrated that bodily disturbances serve as a bridge between childhood trauma and SZ symptomatology, but the diagnostic specificity of these connections remains unknown. This study uses network analysis to bridge this gap by comparing the interplays between childhood trauma, bodily self-disturbances, and schizotypy in clinical and general populations.

Study Design

Networks were constructed to examine the relationships between schizotypy (Schizotypal Personality Questionnaire; SPQ), bodily self-disturbances (Perceptual Aberration Scale; PAS), and childhood trauma (Childhood Trauma Questionnaire, CTQ) in 152 people with SZ and 162 healthy comparison participants (HC). The Fused Graphical Lasso was used to jointly estimate the networks in the 2 groups and the structure and strength of the networks were compared. Node centrality and shortest paths between CTQ, PAS, and schizotypy were examined.

Study Results

When comparing SZ and HC, the network of bodily self-disturbances, childhood trauma, and schizotypy were similarly structured, but the network was significantly stronger in SZ than HC. In both groups, bodily self-disturbances were on one of the shortest paths between childhood trauma to schizotypal experiences.

Conclusions

Our findings revealed reliable associations between childhood trauma, bodily self-disturbance, and schizotypy, with bodily disturbances acting as a bridge from childhood trauma to schizotypy. The elevated strength of the SZ network indicates a more highly interconnected, and therefore reactive network in which exposure to childhood trauma can more easily activate bodily disturbances and schizotypy.

Treatment of schizotypal disorder: a protocol for a systematic review of the evidence and recommendations for clinical practice

INTRODUCTION

Schizotypal disorder is associated with a high level of disability at an individual level and high societal costs. However, clinical recommendations for the treatment of schizotypal disorder are scarce and based on limited evidence. This review aims to synthesise the current evidence on treatment for schizotypal disorder making recommendations for clinical practice.

METHODS AND ANALYSIS

This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic literature search will be performed in PsychArticles, Embase, Medline and Cochrane Central Register of Controlled Trials. Additionally, we will search for relevant articles manually. Inclusion criteria are published studies including individuals diagnosed with schizotypal personality disorder according to Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria, or schizotypal disorder according to International Classification of Diseases (ICD) criteria. We will include interventional studies comprising any pharmacological and non-pharmacological treatment trials for patients with schizotypal disorder, and all relevant outcome measures will be reported. Risk of bias will be assessed by Cochrane risk-of-bias tools. Data will be synthesised using narrative or thematic analysis and, if suitable, through meta-analysis.

ETHICS AND DISSEMINATION

No original data will be collected as part of this study and ethics approval is, therefore, not applicable. The results will be disseminated through peer-reviewed publication and presented at international scientific meetings. We will aim at submitting the final paper for publication within 4 months of completion of analyses. Furthermore, this systematic review will inform clinicians and researchers on the current state of evidence on treatment for schizotypal disorder. Findings may guide proposals for further research and potentially guide recommendations for clinical practice using the Grading of Recommendations Assessment, Development and Evaluation.

PROSPERO REGISTRATION NUMBER

CRD42022375001.

Differential Expression of Anomalous Self-Experiences in Spontaneous Speech in Clinical High-Risk and Early-Course Psychosis Quantified by Natural Language Processing

BACKGROUND

Basic self-disturbance, or anomalous self-experiences (ASEs), is a core feature of the schizophrenia spectrum. We propose a novel method of natural language processing to quantify ASEs in spoken language by direct comparison to an inventory of self-disturbance, the Inventory of Psychotic-Like Anomalous Self-Experiences (IPASE). We hypothesized that there would be increased similarity in open-ended speech to the IPASE items in individuals with early-course psychosis (PSY) compared with healthy individuals, with clinical high-risk (CHR) individuals intermediate in similarity.

METHODS

Open-ended interviews were obtained from 170 healthy control participants, 167 CHR participants, and 89 PSY participants. We calculated the semantic similarity between IPASE items and "I" sentences from transcribed speech samples using S-BERT (Sentence Bidirectional Encoder Representation from Text). Kolmogorov-Smirnov tests were used to compare distributions across groups. A nonnegative matrix factorization of cosine similarity was performed to rank IPASE items.

RESULTS

Spoken language of CHR individuals had the greatest semantic similarity to IPASE items when compared to both healthy control (s = 0.44, p < 10-14) and PSY (s = 0.36, p < 10-6) individuals, while IPASE scores were higher among PSY than CHR group participants. In addition, the nonnegative matrix factorization approach produced a data-driven domain that differentiated the CHR group from the others.

CONCLUSIONS

We found that open-ended interviews elicited language with increased semantic similarity to the IPASE by participants in the CHR group compared with patients with psychosis. This demonstrates the utility of these methods for differentiating patients from healthy control participants. This complementary approach has the capacity to scale to large studies investigating phenomenological features of schizophrenia and potentially other clinical populations.

Developing and validating the Japanese version of the Referential Thinking Scale: A cross-sectional study

It has been shown that ideas of reference in the context of paranoia (IoR-P) and schizophrenia spectrum disorders (IoR-S) are caused by different psychological constructs. Although it is well known that both IoR-P and IoR-S are frequently evoked during the same period of life, how they interact with each other is unknown. The purpose of the present study was to develop the Japanese version of the Referential Thinking Scale (J-REF) to assess IoR-S, examine its validity and reliability, and explore the predictors of IoR-P and IoR-S. In this study, several subgroups of Japanese individuals in their 20s were included in the analysis. The J-REF had high internal consistency, high test-retest reliability, good convergent, and discriminant validity. Two hierarchical regression analyses showed that public self-consciousness predicted the manifestation of IoR-P, while the dimensions of schizotypy predicted that of IoR-S. Moreover, social anxiety and negative moods could cause IoR-P and IoR-S. This study directly showed the existence of two different types of ideas of reference in terms of their predictors. It is also significant in that it first examined referential thinking using the REF scale in the context of Asia and showed that there may not be much difference in the frequency of ideas of reference from other cultures. Future research directions are also discussed.

Phenomenology as a resource for translational research in mental health: methodological trends, challenges and new directions

This editorial reflects on current methodological trends in translational research in mental health. It aims to build a bridge between two fields that are frequently siloed off from each other: interventional research and phenomenologically informed research. Recent years have witnessed a revival of phenomenological approaches in mental health, often - but not only - as a means of connecting the subjective character of experience with neurobiological explanatory accounts of illness. Rich phenomenological knowledge accrued in schizophrenia, and wider psychosis research, has opened up new opportunities for improving prediction, early detection, diagnosis, prognostic stratification, treatment and ethics of care. Novel qualitative studies of delusions and hallucinations have challenged longstanding assumptions about their nature and meaning, uncovering highly complex subjective dimensions that are not adequately captured by quantitative methodologies. Interdisciplinary and participatory research efforts, informed by phenomenological insights, have prompted revisions of pre-established narratives of mental disorder dominated by a dysfunction framework and by researcher-centric outcome measures. Despite these recent advances, there has been relatively little effort to integrate and translate phenomenological insights across applied clinical research, with the goal of producing more meaningful, patient-valued results. It is our contention that phenomenological psychopathology - as the basic science of psychiatry - represents an important methodology for advancing evidence-based practices in mental health, and ultimately improving real-world outcomes. Setting this project into motion requires a greater emphasis on subjectivity and the structures of experience, more attention to the quality and patient-centredness of outcome measures, and the identification of treatment targets that matter most to patients.

Perceptual Functioning

Perceptual disorders are not part of the diagnosis criteria for schizophrenia. Yet, a considerable amount of work has been conducted, especially on visual perception abnormalities, and there is little doubt that visual perception is altered in patients. There are several reasons why such perturbations are of interest in this pathology. They are observed during the prodromal phase of psychosis, they are related to the pathophysiology (clinical disorganization, disorders of the sense of self), and they are associated with neuronal connectivity disorders. Perturbations occur at different levels of processing and likely affect how patients interact and adapt to their surroundings. The literature has become very large, and here we try to summarize different models that have guided the exploration of perception in patients. We also illustrate several lines of research by showing how perception has been investigated and by discussing the interpretation of the results. In addition to discussing domains such as contrast sensitivity, masking, and visual grouping, we develop more recent fields like processing at the level of the retina, and the timing of perception.

Taking subjectivity seriously: towards a unification of phenomenology, psychiatry, and neuroscience

Nearly all psychiatric diseases involve alterations in subjective, lived experience. The scientific study of the biological basis of mental illness has generally focused on objective measures and observable behaviors, limiting the potential for our understanding of brain mechanisms of disease states and possible treatments. However, applying methods designed principally to interpret objective behavioral measures to the measurement and extrapolation of subjective states presents a number of challenges. In order to help bridge this gap, we draw on the tradition of phenomenology, a philosophical movement concerned with elucidating the structure of lived experience, which emerged in the early 20th century and influenced philosophy of mind, cognitive science, and psychiatry. A number of early phenomenologically-oriented psychiatrists made influential contributions to the field, but this approach retreated to the background as psychiatry moved towards more operationalized disease classifications. Recently, clinical-phenomenological research and viewpoints have re-emerged in the field. We argue that the potential for phenomenological research and methods to generate productive hypotheses about the neurobiological basis of psychiatric diseases has thus far been underappreciated. Using specific examples drawing on the subjective experience of mania and psychosis, we demonstrate that phenomenologically-oriented clinical studies can generate novel and fruitful propositions for neuroscientific investigation. Additionally, we outline a proposal for more rigorously integrating phenomenological investigations of subjective experience with the methods of modern neuroscience research, advocating a cross-species approach with a key role for human subjects research. Collaborative interaction between phenomenology, psychiatry, and neuroscience has the potential to move these fields towards a unified understanding of the biological basis of mental illness.

Pseudoneurotic symptoms in the schizophrenia spectrum: An empirical study

BACKGROUND

Nonpsychotic symptoms (depression, anxiety, obsessions etc.) are frequent in schizophrenia-spectrum disorders. Twentieth century foundational psychopathological literature claimed that certain nonpsychotic symptoms (here termed pseudoneurotic symptoms) are relatively closely linked with the schizophrenia-spectrum, despite descriptive overlap with symptoms of other diagnoses. In this study, we investigated the association of pseudoneurotic and other nonpsychotic symptoms with the schizophrenia-spectrum as well as a hypothesis about an association of pseudoneurotic symptoms with disorder of basic self.

METHODS

The sample (N = 226) comprised patients with non-affective psychosis (N = 119), schizotypal personality disorder (N = 51) and other mental illness (N = 56), who were examined with a comprehensive assessment of lifetime psychopathology. Informed by the literature, we constructed scales targeting pseudoneurotic symptoms and other, more general, nonpsychotic symptoms.

RESULTS

Pseudoneurotic symptoms aggregated significantly in schizophrenia-spectrum disorders with an Area under the receiver operating characteristic curve of 0.84 (SE 0.03) for classifying patients with schizophrenia-spectrum disorders versus other mental illness. Patients with non-affective psychosis scored slightly, but significantly, higher on the scale targeting general nonpsychotic symptomatology than the other groups. In multiple regression analysis, pseudoneurotic symptoms were predicted by general nonpsychotic symptoms, disorders of basic self, and negative symptoms but not positive symptoms.

CONCLUSION

The study supports that certain neurotic-like symptoms with specific descriptive features (pseudoneurotic symptoms) are associated with schizophrenia-spectrum disorders. It suggests that pseudoneurotic symptoms are linked with temporally stable schizophrenia psychopathology (disorder of basic self and negative symptoms).

The stress-vulnerability model on the path to schizophrenia: Interaction between BDNF methylation and schizotypy on the resting-state brain network

The interplay between schizophrenia liability and environmental influences has been considered to be responsible for the development of schizophrenia. Recent neuroimaging studies have linked aberrant functional connectivity (FC) between the default-mode network (DMN) and the frontoparietal network (FPN) in the resting-state to the underlying neural mechanism of schizophrenia. By using schizotypy as the proxy for genetic-based liability to schizophrenia and methylation of brain-derived neurotrophic factor (BDNF) to represent environmental exposure, this study investigated the impact of the interaction between vulnerability and the environment on the neurobiological substrates of schizophrenia. Participants in this study included 101 healthy adults (HC) and 46 individuals with ultra-high risk for psychosis (UHR). All participants were tested at resting-state by functional magnetic resonance imaging, and group-independent component analysis was used to identify the DMN and the FPN. The Perceptual Aberration Scale (PAS) was used to evaluate the schizotypy level. The methylation status of BDNF was measured by pyrosequencing. For moderation analysis, the final sample consisted of 83 HC and 32 UHR individuals. UHR individuals showed reduced DMN-FPN network FC compared to healthy controls. PAS scores significantly moderated the relationship between the percentage of BDNF methylation and DMN-FPN network FC. The strength of the positive relationship between BDNF methylation and the network FC was reduced when the schizotypy level increased. These findings support the moderating role of schizotypy on the neurobiological mechanism of schizophrenia in conjunction with epigenetic changes.

Induced feelings of external influence during instructed imaginations in healthy subjects

The psychopathological phenomenon of delusions of influence comprises variable disturbances of the self-environment-border leading to the feeling of external influence on thoughts, feelings, impulses or behaviors. Delusions of influence are a hallmark in psychotic illness, but nevertheless, attenuated forms can also appear in healthy individuals. Here we present a newly developed paradigm to induce and assess feelings of external influence during instructed imaginations in healthy individuals. In the current study, we asked 60 healthy individuals to visually imagine different objects. To induce feelings of external influence, we applied one of three different physical setups (low-amplitude transcranial direct current stimulation, eye contact, or skin-to-skin hand touch), and informed the participants whether or not an external influence was attempted during the respective trial. The physical setup (setup vs. no setup, Z = -3.847, p < 0.001, r = 0.497) as well as the information given to the participants (confirmation vs. negation, Z = -5.218, p < 0.001, r = 0.674) alone were able to modulate the feeling of external influence in all three interventions. The impact of information (whether influence was attempted or not attempted) significantly exceeded the impact of the physical setup on the ratings of experienced external influence (Z = -2.394, p = 0.016, r = 0.310). Moreover, the response latency correlated with the estimated feeling of external influence (r _S = 0.392, p = 0.002). Additional analyses addressed the influence of the emotional content of imagined objects and examined the intensity and emotional valence of the imaginations. Further supplemental analyses correlated external influence estimation of the participants with other psychopathological measures (trait markers for supernatural beliefs, proneness to hallucinations, and delusions and attributional style). In conclusion, this study endorses a quantitative model of psychopathological characteristics, in this case feelings of external influence that can be induced by external cues.

Relating self-disorders to neurocognitive and psychopathological measures in first-episode schizophrenia

AIM

The notion of a disturbed self as the core feature of schizophrenia dates back to the founding texts on the illness. Since the development of the psychometric tool for examination of anomalous self-experience (EASE), self-disorders have become accessible to empirical research. Empirical studies have shown that EASE measured self-disorders predict schizophrenia spectrum in prospective studies and consistently show a selective hyper aggregation of self-disorder in schizophrenia and schizotypal disorders. The aim of this study is to investigate the relationship between self-disorders cognitive deficits and symptoms in schizophrenia.

METHODS

Thirty-five non-acute first-episode patients with schizophrenia and 35 matched healthy controls were evaluated with EASE, cognitive deficits, and symptoms (PANSS positive, negative and general). [Correction added on 28 January 2022, after first online publication: the words, 'evaluated with' were missing and have now been added to the preceding sentence.] RESULTS: The results show that self-disorders and symptoms are correlated among patients with schizophrenia, but not with cognitive deficits. Moreover, with the exception of attentional deficits, neurocognitive impairment was not significantly higher among patients with schizophrenia compared to healthy controls.

CONCLUSIONS

We argue that this adds support to a view of schizophrenia as being characterized by specific traits of pre-reflective self-disturbance, which are related to the severity of symptoms, whereas neurocognitive impairment reflects a separate or distinct aspect of schizophrenia.

A functional neuroimaging study of self-other processing alterations in atypical developmental trajectories of psychotic-like experiences

Self-disturbances constitute a hallmark of psychosis, but it remains unclear whether these alterations are present in at-risk populations, and therefore their role in the development of psychosis has yet to be confirmed. The present study addressed this question by measuring neural correlates of self-other processing in youth belonging to three developmental trajectories of psychotic experiences. Eighty-six youths were recruited from a longitudinal cohort of over 3800 adolescents based on their trajectories of Psychotic-Like Experiences from 12 to 16 years of age. Participants underwent neuroimaging at 17 years of age (mean). A functional neuroimaging task evaluating self- and other-related trait judgments was used to measure whole-brain activation and connectivity. Youth who showed an increasing trajectory displayed hypoactivation of the dorsomedial prefrontal cortex and hypoconnectivity with the cerebellum. By contrast, youth who showed a decreasing trajectory displayed decreased activation of the superior temporal gyrus, the inferior frontal gyrus, and the middle occipital gyrus. These findings suggest that the increasing trajectory is associated with alterations that might erode distinctions between self and other, influencing the emergence of symptoms such as hallucinations. The decreasing trajectory, in comparison, was associated with hypoactivations in areas influencing attention and basic information processing more generally. These alterations might affect the trajectories’ susceptibilities to positive vs. negative symptoms, respectively.

The lived experience of psychosis: a bottom-up review co-written by experts by experience and academics

Psychosis is the most ineffable experience of mental disorder. We provide here the first co-written bottom-up review of the lived experience of psychosis, whereby experts by experience primarily selected the subjective themes, that were subsequently enriched by phenomenologically-informed perspectives. First-person accounts within and outside the medical field were screened and discussed in collaborative workshops involving numerous individuals with lived experience of psychosis as well as family members and carers, representing a global network of organizations. The material was complemented by semantic analyses and shared across all collaborators in a cloud-based system. The early phases of psychosis (i.e., premorbid and prodromal stages) were found to be characterized by core existential themes including loss of common sense, perplexity and lack of immersion in the world with compromised vital contact with reality, heightened salience and a feeling that something important is about to happen, perturbation of the sense of self, and need to hide the tumultuous inner experiences. The first episode stage was found to be denoted by some transitory relief associated with the onset of delusions, intense self-referentiality and permeated self-world boundaries, tumultuous internal noise, and dissolution of the sense of self with social withdrawal. Core lived experiences of the later stages (i.e., relapsing and chronic) involved grieving personal losses, feeling split, and struggling to accept the constant inner chaos, the new self, the diagnosis and an uncertain future. The experience of receiving psychiatric treatments, such as inpatient and outpatient care, social interventions, psychological treatments and medications, included both positive and negative aspects, and was determined by the hope of achieving recovery, understood as an enduring journey of reconstructing the sense of personhood and re-establishing the lost bonds with others towards meaningful goals. These findings can inform clinical practice, research and education. Psychosis is one of the most painful and upsetting existential experiences, so dizzyingly alien to our usual patterns of life and so unspeakably enigmatic and human.

What is obsession? Differentiating obsessive-compulsive disorder and the schizophrenia spectrum

Obsessive-compulsive symptoms are frequent in schizophrenia-spectrum disorders and often cause differential diagnostic challenges, especially in first-contact patients. Drawing upon phenomenology of cognition, we critically review classic and contemporary psychopathological notions of obsessive-compulsive phenomena and discuss their relevance for differential diagnosis between obsessive-compulsive disorder (OCD) and schizophrenia-spectrum disorders. The classic psychopathological literature defines true obsession as intrusions with intact resistance and insight and regards these features as essential to the diagnosis of OCD. In schizophrenia, the classic literature describes pseudo-obsessive-compulsive phenomena characterized by lack of resistance and an affinity with other symptoms such as thought disorder and catatonia. By contrast, the notions of obsession and compulsion are broader and conceptually vague in current diagnostic systems and research instruments. Here, these phenomena overlap with delusions as well as various subjective and behavioral anomalies, which we discuss in detail. Furthermore, we examine a link between obsessive-compulsive phenomena and disturbances of basic structures of experience in schizophrenia-spectrum disorders addressed in contemporary psychopathological research. We suggest that these experiential alterations have relevance for differential diagnosis and early detection in this complex symptom domain.

Prevalence and assessment of self-disorders in the schizophrenia spectrum: a systematic review and meta-analysis

Self-disorders have been proposed as the "clinical core" of the schizophrenia spectrum. This has been explored in recent studies using self-disorder assessment tools. However, there are few systematic discussions of their quality and utility. Therefore, a literature search was performed on Medline, Embase, PsychINFO, PubMed and the Web of Science. Studies using these assessment tools to explore self-disorders within schizophrenia spectrum disorders (SSDs) were included. A meta-analysis was performed on the outcomes of total self-disorder score and odds ratios of self-disorders, using Comprehensive Meta-Analysis software. Weighted pooled effect sizes in Hedge's g were calculated using a random-effects model. 15 studies were included, giving a sample of 810 participants on the schizophrenia spectrum. Self-disorders showed a greater aggregation within schizophrenia spectrum groups compared to non-schizophrenia spectrum groups, as measured with the Bonn Scale for the Assessment of Basic Symptoms (Hedge's g = 0.774, p < 0.01) and Examination of Anomalous Self-Experiences (Hedge's g = 1.604, p < 0.01). Also, self-disorders had a greater likelihood of occurring within SSDs (odds ratio = 5.435, p < 0.01). These findings help to validate self-disorders as a core clinical feature of the broad schizophrenia spectrum.

Basic self-disturbance trajectories in clinical high risk for psychosis: a one-year follow-up study

Basic self-disturbance (BSD) has been proposed as a driver of symptom development in schizophrenia spectrum disorders (SSDs). In a one-year follow-up of 32 patients (15-30 years) at putative risk for psychosis, we investigated trajectories of BSD levels from baseline to follow-up, and associations between clinical characteristics at baseline and follow-up, including follow-up levels of BSD (assessed with the EASE). Clinical high risk (CHR) for psychosis status and symptom severity were assessed with the SIPS/SOPS scales and also according to the cognitive basic symptoms high-risk criteria (COGDIS). DSM-IV diagnoses, functioning and other clinical characteristics were assessed with standard clinical instruments. Higher severity of negative symptoms and meeting COGDIS criteria at baseline were associated with higher BSD levels at follow-up. All measured at follow-up, higher BSD levels correlated with higher severity of positive, negative, disorganization and general symptoms, and with a lower level of global functioning. We found higher BSD levels at follow-up in subjects with schizotypal personality disorder (SPD) at baseline (n = 5) and in SSDs at follow-up (n = 12, including nine with SPD). Mean BSD levels decreased significantly from baseline to follow-up, but individual trajectories varied considerably. Increased BSD levels were associated with higher baseline BSD levels, non-remission of positive symptoms and functional decline. Overall, the current study indicates that subgroups in the CHR population with a higher risk of non-remission or deterioration may be identified by supplementing CHR criteria with assessment of BSD and negative symptoms.

Comparisons between self-reported and interview-verified psychotic-like experiences in adolescents

AIM

The 15-item positive subscale of the Community Assessment of Psychic Experiences (CAPE-P15) has been widely used for measuring self-reported psychotic-like experiences (PLEs). However, its validity has not been well established. This study aimed to explore the consistency of self-reported PLEs (PLEs-S) and interview-verified PLEs (PLEs-I) based on the same items of the CAPE-P15.

METHODS

A total of 1255 college students completed the CAPE-P15 for measuring lifetime and current PLEs. Half of the students with high-risk scores and 5% of the rest were interviewed through telephone. Telephone interviews were based on the items of the CAPE-P15 using the symptom criteria for attenuated positive symptom syndrome.

RESULTS

When considering the presence of PLEs only, all κ values and correspondence rates (CRs) fell below the thresholds. However, there was adequate consistency for lifetime PLEs when associated distress was also considered in self-report (κ = .432, CR = 90.0%). Among three factors, only bizarre experiences (BEs) showed adequate diagnostic accuracy in detecting lifetime PLEs when combined with distress. Cut-off points of 1.30 (sensitivity of 89.2% and specificity of 92.3%) and 1.57 (sensitivity of 79.2% and specificity of 73.8%) for frequency scores were found to best identify genuine PLEs during lifetime and in the past month, respectively.

CONCLUSIONS

Although the validity of the CAPE-P15 for genuine PLEs is unsatisfactory, the scale showed much better diagnostic accuracy when combined with associated distress, especially for detecting lifetime PLEs. Self-report items on BEs may be more sensitive and specific when identifying PLEs in late adolescence.

Disembodied Language in Early-Onset Schizophrenia

A recent view on schizophrenia phenomenology underlines the impaired relations between the mind and the body. An aberrant feeling of ipseity may be the real source of suffering of the patients from psychosis and impacts general symptomatology. The disturbed connection between thinking processes and environmental stimuli may lead to language disembodiment. In the study, we aimed to experimentally test the presence of disembodied language and investigate its association with symptoms of psychosis in adolescents diagnosed with early-onset schizophrenia spectrum disorders. Assessment of language embodiment was conducted using the Zabór Verbal Task (ZVT) with concurrent linguistic and clinical assessment using the Thought, Language, and Communication Scale (TLCS) and Positive and Negative Symptoms Scale (PANSS). The study group of patients (n = 31) aged 11-18 years, with the diagnosis of schizophrenia spectrum according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and the International Classification of Diseases (ICD-10) criteria, was compared with a sex- and age-matched healthy control sample (n = 31). Patients with psychosis made more errors in ZVT than healthy controls (p = 0.01) and this parameter did not improve after 6-8 weeks of standard treatment (p = 0.55). A higher number of errors in ZVT were associated with the presence of auditory hallucinations (odds ratio [OR] 1.14; 95% CI 1.02-1.26). ZVT errors coincided with perception disorders, alternatively to the TLCS scores where we observed association with abnormal beliefs. The results of these preliminary studies indicate the value of the phenomenological approach in the diagnosis of schizophrenia spectrum and suggest a potential involvement of language disembodiment in symptomatology.

Anomalous self-experiences (ASE) in relation to clinical high risk for psychosis (CHRP), childhood trauma and general psychopathology among adolescent and young adult help seekers

BACKGROUND

Anomalous self-experiences (ASE) are suggested as a phenotypic core feature of schizophrenia spectrum disorders and present in at risk samples as well. In our study, we investigated the relation between ASE and clinical high risk state for psychosis (CHRP) against the background of further influencing factors like childhood trauma and general psychopathology.

METHODS

126 help-seeking adolescents were included. CHR-P patients were identified using the Structured Interview for Psychosis-Risk Syndromes (SIPS). ASE were assessed with the Inventory of Psychotic-like Anomalous Self-Experiences (IPASE). Childhood trauma, depression and anxiety were assessed with well-established questionnaires (CTQ; PHQ-9; GAD-7).

RESULTS

CHR-P subgroup (n = 50, 39.7%) show significantly higher scores in IPASE total (t (81.07) = -5.150, p = .000) and CTQ total (t (85.95) = -2.75, p = .007) in comparison with the non CHR-P subgroup. Logistic regression analysis confirmed that IPASE total could predict CHR-P status (OR 1.03, 95% CI 1.01-1.04, p = .000). Furthermore, CTQ total and IPASE total show moderate to strong positive correlation (r = 0.44, p < .001) as well as CTQ total with both IPASE subdomains Cognition (r = 0.404, p < .001) and Self- Awareness (r = 0.443, p < .001).

CONCLUSION

The CHR-P subgroup shows significantly more ASE than the non CHR-P subgroup. Further, ASE predicted CHR-P status. Our results indicated that ASE could play a considerable role in the identification of high risk for developing schizophrenia spectrum disorder and could complement CHR-P testing. Importantly, it seems that ASE may be related to exposure to childhood trauma.

Self-disorders and psychopathology: a systematic review

In foundational texts on schizophrenia, the mental disorder was constitutively linked to a specific disintegration of subjectivity (often termed a self-disorder). Apart from Scharfetter's work on ego-pathology, research on self-disorders generally faded into oblivion, and self-disorders were only rediscovered as notable psychopathological features of the schizophrenia spectrum nearly two decades ago. Subsequently, the Examination of Anomalous Self-Experience (EASE) scale was constructed to allow systematic assessment of non-psychotic self-disorders. This Review is the first systematic review of empirical studies on self-disorders based on the EASE or other related scales. The results consistently show that self-disorders hyper-aggregate in schizophrenia spectrum disorders but not in other mental disorders; that self-disorders are found in individuals at a clinical risk of developing psychosis; that self-disorders show a high degree of temporal stability; that self-disorders predict the later development of schizophrenia spectrum disorders; and that self-disorders correlate with the canonical dimensions of the psychopathology of schizophrenia, impaired social functioning, and suicidality. Issues with the methods of the reviewed literature are critically discussed and the role of self-disorders in clinical psychiatry and future research is outlined.

Basic self-disturbance in subjects at clinical high risk for psychosis: Relationship with clinical and functional outcomes at one year follow-up

Basic self-disturbance (BSD) is assumed to drive symptom development in schizophrenia spectrum disorders and in clinical high-risk (CHR) for psychosis. We investigated the relationship between BSD at baseline, assessed with the Examination of Anomalous Self-Experience (EASE), and symptoms and functional outcome after one year in 32 patients, including 26 CHR and six with non-progressive attenuated psychotic symptoms. Correlations between baseline BSD levels and positive, negative and disorganization symptoms, and global functioning level at follow-up were significant. Hierarchical regression analyses revealed that higher levels of baseline BSD predicted more severe positive symptoms and lower global functioning at follow-up, after adjusting for baseline positive symptoms and functioning. Subjects who were not in symptomatic and functional remission after one year had higher levels of BSD and negative symptoms, and lower functioning level, at baseline. Baseline BSD in participants with schizophrenia spectrum diagnoses at follow-up (9 of 12 were schizotypal personality disorder) were at the levels seen in schizotypal disorders in previous studies, but not significantly different from the other participants. Early identification and assessment of BSD may constitute a useful prognostic tool and a signal for therapeutic targets in CHR conditions. Further CHR studies investigating these relationships with larger samples are recommended.

The Self in the Spectrum: A Meta-analysis of the Evidence Linking Basic Self-Disorders and Schizophrenia

Disturbed self-experience has been reported as a characteristic feature of schizophrenia since the first formulation of its diagnostic concept; however, only in the last 2 decades an explicit notion of basic Self-disturbance, or Self-Disorders (SD), has emerged as target for a systematic research program. We conducted systematic searches in bibliographical databases to identify cross-sectional studies that explored SD across different diagnostic groups and explored diagnostic ascription within or outside schizophrenia spectrum disorders (SSD) as main outcome. Data were pooled using fixed- and random-effects meta-analysis models. Heterogeneity was assessed using stratified meta-analyses and meta-regression. Of 218 identified studies, 32 were included in the systematic review and 27 in the meta-analysis. Patients diagnosed with SSD scored higher on measures of SD than healthy controls (HC) (Hedges' g = 1.8; 95% CI = 1.5 to 2.0), individuals diagnosed with other mental illness (OMI) (1.9; 1.6 to 2.2), bipolar or affective disorders (1.8; 1.4 to 2.2), and clinical high risk for psychosis (CHR) (1.6; 0.9 to 2.4). Patients with schizotypy or schizotypal personality disorder scored higher on measures of SD than OMI (1.5; 1.3 to 1.8) and HC (1.4; 1.1 to 1.7). Patients with first-episode psychosis scored higher on measures of SD than HC (2.5; 2.1 to 2.9) and OMI (1.6; 1.2 to 2.1). Subjects at CHR scored higher on measures of SD than HC (2.0; 1.7 to 2.2) and OMI (19; 1.6 to 2.2). Overall, heterogeneity ranged from negligible to high, especially in comparisons of the target group with OMI, probably as a reflection of the immanent diagnostic heterogeneity of this group. The findings suggest that SD selectively aggregate within schizophrenia spectrum disorders as compared to other mental disorders and that they could be a central phenotypic marker of vulnerability to schizophrenia across the different shades of severity of its spectrum of disorders.

"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.

Anomalies of Imagination, Self-Disorders, and Schizophrenia Spectrum Psychopathology: A Network Analysis

BACKGROUND

Anomalies of imagination encompass disturbances of the basic experiential structure of fantasies and imagery that can be explored in a semi-structured way with the Examination of Anomalous Fantasy and Imagination (EAFI). We aimed (1) to examine the distribution of anomalies of imagination among different diagnostic groups and a group of healthy controls, and (2) to examine their relation with disorders of basic self, perceptual disturbances and canonical state psychopathology of the schizophrenia-spectrum (positive, negative and general symptoms).

METHODS

The 81 participants included patients with schizophrenia or other non-affective psychosis (N = 32), schizotypal personality disorder (N = 15) or other mental illness (N = 16) and healthy controls (N = 18). The assessment encompassed EAFI, Examination of Anomalous Self-Experience (EASE), parts of Bonn Scale for the Assessment of Basic Symptoms (BSABS) and Positive and Negative Syndrome Scale (PANSS). For network analysis, the associations of EAFI with the other psychopathological variables were tested by Pearson's correlation coefficient and graphically represented using multidimensional clustering. Comparisons between correlations in the network were tested with Steiger's test.

RESULTS

Anomalies of imagination aggregated significantly in schizophrenia-spectrum disorders compared to other mental illness and healthy controls with no difference between schizophrenia and schizotypal disorder. In the network analysis, anomalies of imagination were closely inter-connected with self-disorders. Although, the anomalies of imagination correlated moderately with perceptual disturbance and positive, negative and general state symptomatology, these dimensions aggregated separately and relatively distant in the network.

CONCLUSIONS

The results support that anomalies of imagination are highly characteristic of schizophrenia-spectrum disorders and closely related to self-disorders.

Disrupted Sense of Agency as a State Marker of First-Episode Schizophrenia: A Large-Scale Follow-Up Study

Background: Schizophrenia is often characterized by a general disruption of self-processing and self-demarcation. Previous studies have shown that self-monitoring and sense of agency (SoA, i.e., the ability to recognize one's own actions correctly) are altered in schizophrenia patients. However, research findings are inconclusive in regards to how SoA alterations are linked to clinical symptoms and their severity, or cognitive factors. Methods: In a longitudinal study, we examined 161 first-episode schizophrenia patients and 154 controls with a continuous-report SoA task and a control task testing general cognitive/sensorimotor processes. Clinical symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Results: In comparison to controls, patients performed worse in terms of recognition of self-produced movements even when controlling for confounding factors. Patients' SoA score correlated with the severity of PANSS-derived "Disorganized" symptoms and with a priori defined symptoms related to self-disturbances. In the follow-up, the changes in the two subscales were significantly associated with the change in SoA performance. Conclusion: We corroborated previous findings of altered SoA already in the early stage of schizophrenia. Decreased ability to recognize self-produced actions was associated with the severity of symptoms in two complementary domains: self-disturbances and disorganization. While the involvement of the former might indicate impairment in self-monitoring, the latter suggests the role of higher cognitive processes such as information updating or cognitive flexibility. The SoA alterations in schizophrenia are associated, at least partially, with the intensity of respective symptoms in a state-dependent manner.

Consciousness and the rabbit holes of delirium

Delirium is a common disorder in hospitalized older adults and the defining characteristic is a disturbance of consciousness. Unfortunately, there are currently no testable measures of consciousness as pertains to its disruption in delirium. Not surprisingly rates of recognition of delirium suffer. Arguably, a greater understanding of the quantum of consciousness may improve delirium diagnosis through better diagnostic tools. Candidate dimensions of consciousness derived from fields of psychology, psychiatry, and philosophy are discussed and relevance to delirium explored. Based upon existing literature in the field of consciousness we identify the pre-reflective state, experiential awareness, and functional networks as candidate sites that may be affected in delirium. Opportunities for clinical instrument development and how these tools can be tested are discussed. We conclude that consciousness content may not hold to a unitary measurement, but facets of its integrity that are impacted in delirium are open to further exploration. Disorders in pre-reflective status, experiential awareness, and functional networks may represent the measurable "rabbit holes" of consciousness disturbance.

Effects of interactions between variation in dopaminergic genes, traumatic life events, and anomalous self-experiences on psychosis proneness: Results from a cross-sectional study in a nonclinical sample

Background

There is a growing number of studies showing interactions between genetic polymorphisms associated with dopaminergic neurotransmission and traumatic life events (TLEs) on a risk of psychotic-like experiences (PLEs). Anomalous self-experiences (ASEs) have been associated both with TLEs as well as with PLEs. However, it remains unknown what is the role of ASEs in the complexity of gene–environment interactions on the emergence of PLEs.

Patients and methods

We included 445 young adults—university students from three big cities in Poland. We used the Traumatic Events Checklist to assess TLEs, the Inventory of Psychotic-Like anomalous self-experiences in order to measure ASEs, and the Prodromal Questionnaire (PQ16) to record the level of PLEs. The following gene polymorphisms, related to dopaminergic neurotransmission, were determined: the catechol-O-methyltransferase (COMT) rs4680 polymorphism, the dopamine D2 receptor (DRD2) rs6277 polymorphism, and the dopamine transporter 1 (DAT1) rs28363170 polymorphism.

Results

There was a significant effect of the interaction between the DAT1 polymorphism, a severity of ASEs, and a history of TLEs on the level of PLEs. Among the DAT1 10R/10R homozygotes with low level of ASEs, a severity of PLEs was significantly higher in individuals with a history of any TLEs. Higher scores of the PQ16 were associated with a greater severity of ASEs both in the DAT1 9R allele carriers and the DAT1 10R/10R homozygotes.

Conclusion

Our findings imply that genetic liability related to aberrant dopamine transport might impact the association between TLEs and PLEs in subjects with high levels of ASEs.

The relation of basic self-disturbance to self-harm, eating disorder symptomatology and other clinical features: Exploration in an early psychosis sample

BACKGROUND AND AIMS

The notion of basic self-disturbance has been proposed as a core feature of schizophrenia-spectrum disorders and as an indicator of future transition to psychosis in high-risk populations. However, the relation of this notion to many clinical characteristics has not been explored. The aim of this study was: (a) to investigate the distribution of self-disturbance and other symptoms dimensions in ultra-high risk (UHR), first-episode psychosis (FEP) and healthy control groups; and (b) to explore the association of self-disturbance with a history of self-harm, suicidal attempt, eating disorder symptomatology, school bullying victimization and sexual or physical abuse.

METHODS

Patients with UHR status (n = 38) or FEP (n = 26) and healthy controls (n = 33) were assessed with the Examination of Anomalous Self-Experience (EASE) and the Comprehensive Assessment of at Risk Mental States (CAARMS). The clinical-historical variables were assessed through medical records.

RESULTS

The FEP group scored significantly higher on the EASE than the UHR group, which scored significantly higher than the healthy control group, which had a very low score. Multivariate logistic regression analyses revealed that higher EASE score was significantly associated with a history of self-harm, disordered eating and bullying victimization (but not with suicide attempts or sexual/physical abuse) after controlling for positive, negative and depressive symptoms.

CONCLUSION

These novel findings suggest that self-disturbance may be related to a history of school bullying victimization, self-harm and eating disorder symptomatology in patients with or at-risk of psychosis. If further confirmed, these findings are potentially relevant to clinical risk assessment and therapy.

Basic self-disorders in adolescence predict schizophrenia spectrum disorders in young adulthood: A 7-year follow-up study among non-psychotic help-seeking adolescents

BACKGROUND AND GOALS

Recent studies indicate that basic self-disorder (SD) is a core clinical phenotype of schizophrenia and its spectrum. The goal of the present study was to test the degree to which SD characterizes the pre-onset phase of schizophrenia-spectrum disorders (SSD). A secondary goal was to replicate previous findings regarding the long-term stability of SD.

METHOD

To accomplish these goals, the long-term association of SD in adolescence with SSD seven years later was examined in a sample of 39 non-psychotic, help-seeking adolescents. SD was assessed with the Examination of Anomalous Self-Experience (EASE), and presence of schizophrenia-spectrum and other co-morbid illnesses in young adulthood was assessed with the Operational Criteria+ (OPCRIT+) checklist for psychotic and affective disorders.

RESULTS

Nine (23.1%) of the 39 participants were diagnosed as suffering from SSD (three Schizophrenia, three non-organic and non-affective psychotic disorder, and three schizotypal disorder) in young adulthood. A diagnosis of SSD in young adulthood was significantly predicted by SD, but not by prodromal symptoms in adolescence. The correlation between the EASE total score at adolescence and young adulthood was moderate and significant (r = 0.64, p < .001).

CONCLUSIONS

These results provide first long-term prospective support, in a sample not enriched for risk for psychosis, for the possibility that SD is a clinical marker of risk for SSD. Also, they provide additional support for the longitudinal persistence of SD over time.

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.

Basic self-disturbances independently predict recovery in psychotic disorders: A seven year follow-up study

BACKGROUND

Recovery is the ultimate goal of psychosis treatment. Basic self-disturbances (BSDs) are non-psychotic phenomena associated with clinical outcome, present in prodromal, psychotic and residual phases of psychotic disorders.

AIM

To investigate the relationship between BSDs and recovery seven years after first treatment in patients with psychotic disorders.

METHOD

Prospective longitudinal study of 56 patients recruited during first adequate treatment for schizophrenia (n = 35) and other psychotic disorders (n = 21) (psychotic bipolar disorder, delusional disorder, psychotic disorder NOS). At baseline and follow-up BSDs were assessed using the Examination of Anomalous Self-Experience (EASE) manual, while standard clinical instruments were used to ascertained diagnosis, clinical symptom severity, and functioning. Recovery was defined as absence of psychotic symptoms and regaining of functioning that persisted the last two years before follow-up.

RESULTS

At follow up, 34% achieved recovery (5 (14%) with schizophrenia and 14 (67%) with other psychoses at baseline). Recovery was predicted by an absence of a schizophrenia diagnosis, low baseline level of BSDs and further reductions in BSDs from baseline to follow-up. Change in BSDs was the strongest predictor, also after adjusting for premorbid adjustment and duration of untreated psychosis, and was not confounded by diagnosis.

CONCLUSION

Low baseline levels of basic self-disturbances and further reductions over time independently predict recovery seven years later in first treated psychosis patients.

Self-disorders in Early Stages of the Schizophrenia Spectrum

The pathogenic nucleus of schizophrenia has varied according to the different eras and influences of distinguished clinical researchers. Self-disorders have also been recognised to be at the heart of this disorder, although they have seldom been studied due to their subjective nature. Recently, due to the growing interest in the study of the early stages of schizophrenia, the study of self-disorders has been resumed. The self-disorders in schizophrenia model, developed by Sass and Parnas, proposes that in this disorder the person suffers loss of the first-person perspective and experiences hyperreflexibility, diminished self-affection and disturbance of the field of awareness. Therefore, the person experiences feelings of strangeness about him/herself, difficulty in understanding the common sense of things and difficulty interacting with his/her environment. Based on this model, self-disorder evaluation instruments have been developed and empirical studies have been conducted to evaluate people at risk of developing a schizophrenia spectrum disorder. These studies show that self-disorders are found in prepsychotic stages and that their manifestation may predict the transition to schizophrenia spectrum disorders. These results have important clinical implications as they enable people in the early stages of the disorder to be identified and create the opportunity to apply early therapeutic interventions.

Anomalous self-experiences are strongly associated with negative symptoms in a clinical high-risk for psychosis sample

OBJECTIVE

Anomalous self-experiences (ASE) are considered as central features of the schizophrenia spectrum disorders and prodromal schizophrenia. We investigated total and single-item prevalence of these phenomena in a clinical high-risk (CHR) for psychosis sample, and associations with conventional psychosis-risk symptoms, present and childhood global/psychosocial functioning, and childhood trauma.

METHODS

The sample (n = 38) included 31 CHR, according to ultra-high risk or cognitive basic symptoms (COGDIS) criteria, and seven with non-progressive attenuated positive symptoms. Psychopathological evaluations included the Examination of Anomalous Self-Experience (EASE), Structured Clinical Interview for Prodromal Syndromes (SIPS), Schizophrenia Proneness Instrument - Adult (SPI-A) (only the COGDIS-criteria), a diagnostic interview (SCID-I), Global Assessment of Functioning - Split version (S-GAF), Premorbid Adjustment Scale (PAS) and Childhood Trauma Questionnaire (CTQ).

RESULTS

The mean total EASE score was in line with reports from other CHR samples, and was particularly enhanced in schizotypal personality disorder and in subjects fulfilling COGDIS-criteria. The four most frequent EASE-items were present in two-thirds or more of the participants. EASE total was significantly associated with negative and disorganization symptoms. A multiple regression analysis revealed that the level of negative symptoms explained most of the variance in EASE total.

CONCLUSIONS

These results corroborates other findings that anomalous self-experiences are frequent and important features in CHR conditions and in the schizophrenia spectrum. The strong associations with negative symptoms and cognitive disturbances (COGDIS) should be investigated in longitudinal studies to address causality, psychopathological pathways and schizophrenia spectrum specificity. The weaker correlation between EASE total and positive symptoms may partly be related to a restricted range of positive symptoms.

Schizotypal personality disorder in individuals with the Attenuated Psychosis Syndrome: Frequent co-occurrence without an increased risk for conversion to threshold psychosis

The Attenuated Psychosis Syndrome (APS), proposed as a condition warranting further study in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), is a controversial diagnostic construct originally developed to identify individuals at clinical high-risk for psychosis. The relationship of APS and Schizotypal Personality Disorder (SPD) remains unclear with respect to their potential co-occurrence and the effect of SPD on risk for conversion to threshold psychosis. We examined the prevalence and effect on conversion of SPD in a cohort of 218 individuals whose symptoms met APS criteria. Results indicated that SPD was highly prevalent (68%), and that SPD did not influence risk for conversion. Rather, total positive symptom burden measured by the Structured Interview for Psychosis-Risk Syndromes (SIPS; OR 1.12, p = 0.02) emerged as the strongest predictor of conversion. These data suggest that when encountering a patient whose presentation meets SPD criteria, the clinician should assess whether APS criteria are also met and, for 1-2 years, carefully monitor positive symptoms for possible conversion to threshold psychosis.

The construct validity of the Inventory of Psychotic-Like Anomalous Self-Experiences (IPASE) as a measure of minimal self-disturbance: Preliminary data

AIM

The Inventory of Psychotic-Like Anomalous Self-Experiences (IPASE) is a self-report measure of minimal self-disturbance. The aim of the current report was to assess the construct validity of the scale by examining its convergent validity with the gold-standard measure of minimal self-disturbance, the Examination of Anomalous Self-Experience (EASE), and its discriminant validity.

METHOD

The sample consisted of 46 participants (21 ultra-high risk for psychosis patients, 14 first episode psychosis patients, 11 healthy controls). Correlations between the clinical instruments were examined.

RESULTS

The IPASE correlated strongly with general psychopathology and positive psychotic symptoms, moderately with negative symptoms, and weakly with manic symptoms. The strongest correlation (r = 0.92) was apparent between IPASE and EASE total scores.

CONCLUSION

These preliminary data indicate construct validity of the IPASE, demonstrating both convergent and discriminant validity. The IPASE may be suitable as a screener measure for minimal self-disturbance, but should not be used as a replacement to measure the construct of minimal self-disturbance, which requires considerable psychopathological sophistication.

Basic self-disturbance, neurocognition and metacognition: A pilot study among help-seeking adolescents with and without attenuated psychosis syndrome

AIM

The goal of this pilot study was to assess the association between basic self-disturbance (SD) and deficits in neurocognitive and metacognitive functioning among help-seeking adolescents with and without attenuated psychosis syndrome (APS).

METHODS

Sixty-one non-psychotic, help-seeking adolescents (age 13-18) were assessed with the examination of anomalous self-experience, the structured interview for prodromal syndromes and a new metacognitive approach to neurocognitive assessment applied to two non-social (executive functions and verbal memory) and two social (theory of mind and emotion recognition) domains. After each answer, subjects were also requested to indicate their level of confidence in the answer and to decide whether they desired it to be "counted" toward their total score on the task. Each volunteered answer earned a 5-cent gain if correct, but an equal fine if wrong.

RESULTS

As hypothesized, metacognitive monitoring and control had a significant contribution to the prediction of SD over and above neurocognitive functioning and attenuated psychotic symptoms. However, the direction of this association was positive rather than negative. Also, inconsistent with or hypothesis, it was not moderated by the presence of APS.

CONCLUSIONS

These pilot results provide preliminary support a modest association between SD and metacognition, which is not reducible to neurocognition and APS. In addition, they raise an intriguing possibility regarding metacognitive monitoring and control being indicators of hyper-reflectivity that characterizes individuals with SD. However, further research with larger samples and high-stress assessment conditions are needed to assess this possibility.

Attenuated psychosis and basic self-disturbance as risk factors for depression and suicidal ideation/behaviour in community-dwelling adolescents

BACKGROUND AND AIMS

Adolescents at clinical high risk (CHR) for psychosis, as defined by the presence of attenuated psychosis symptoms (APS), exhibit increased levels of suicidal ideation and behaviour. However, no research thus far has examined the link between basic self-disturbances (SDs), an established marker for CHR, and suicidality/self-harm in this population. The goal of this pilot study was to assess the association between SD, depression and suicidal ideation and behaviour among non-help-seeking adolescents from the community.

METHOD

A total of 100 community-dwelling adolescents (age range: 13-16) were assessed using the Examination of Anomalous Self-experience, Prodromal Questionnaire, Structured Interview for Prodromal Syndromes, Mood and Anxiety Symptom Questionnaire and the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS). The K-SADS was used to derive a binary diagnosis of unipolar depression, as well as to measure suicidal ideation and behaviour and self-harm.

RESULTS

In a multiple regression analysis, SD accounted for variance in depressive symptoms and suicidality/self-harm over and above that accounted for by APS. Moreover, SD accounted for variance in suicidality/self-harm over and above that accounted for by depression symptoms.

CONCLUSIONS

These pilot results suggest that SD might be a unique dimension of vulnerability to depression and suicidality/self-harm in adolescence. Also, they encourage assessment of SD as part of a suicide risk assessment, particularly in the context of risk for subsequent psychosis.

Shared multisensory experience affects Others' boundary: The enfacement illusion in schizophrenia

Schizophrenia has been described as a psychiatric condition characterized by deficits in one's own and others' face recognition, as well as by a disturbed sense of body-ownership. To date, no study has integrated these two lines of research with the aim of investigating Enfacement Illusion (EI) proneness in schizophrenia. To accomplish this goal, the classic EI protocol was adapted to test the potential plasticity of both Self-Other and Other-Other boundaries. Results showed that EI induced the expected malleability of Self-Other boundary among both controls and patients. Interestingly, for the first time, the present study demonstrates that also the Other-Other boundary was influenced by EI. Furthermore, comparing the two groups, the malleability of the Other-Other boundary showed an opposite modulation. These results suggest that, instead of greater Self-Other boundary plasticity, a qualitative difference can be detected between schizophrenia patients and controls in the malleability of the Other-Other boundary. The present study points out a totally new aspect about body-illusions and schizophrenia disorder, demonstrating that EI is not only confined to self-sphere but it also affects the way we discriminate others, representing a potential crucial aspect in the social domain.

Mediating role of aberrant salience and self-disturbances for the relationship between childhood trauma and psychotic-like experiences in the general population

INTRODUCTION

The relationship between childhood trauma and the risk of psychosis is well established. However, the mechanisms of the relationship are still unknown. We investigated whether two factors involved in the risk of psychosis - self-disturbances and aberrant salience - mediate the relationship between childhood trauma and psychotic-like experiences in the general population.

METHODS

We tested parallel mediation models which assume that the relationship between childhood trauma (Childhood Trauma Questionnaire, the CTQ) and psychotic-like experiences (Prodromal questionnaire, PQ-16) is mediated by both self-disturbances and aberrant salience (Aberrant Salience Inventory, the ASI) in a general population sample (N = 649). Separate parallel mediation models were calculated for cumulative childhood trauma, exposure to abusive behaviors (emotional, physical and sexual abuse) and neglect (emotional and physical neglect) controlling for gender.

RESULTS

Childhood traumatic life events predicted psychotic-like experiences. Childhood trauma was also related to self-disturbances and aberrant salience. Self-disturbances and aberrant salience were related to psychotic-like experiences. Models of mediation for the relationship between cumulative childhood trauma and neglect and psychotic-like experiences revealed an indirect-only mediation by self-disturbances and aberrant salience. The model for childhood abuse suggested a complementary mediation and was affected by gender.

CONCLUSIONS

Our results provide tentative evidence that self-disturbances and aberrant salience are important factors in the translation of childhood trauma into the risk of psychosis in the general population. Causal relationships could not be inferred from this cross-sectional data. Hence, longitudinal studies on a clinical sample are warranted.

Toward a Phenomenological Psychotherapy for Schizophrenia

During the last decades, research in phenomenological psychopathology has provided a vast array of insights that are invaluable for understanding the experiential worlds of patients with schizophrenia. Precisely, knowledge of patients' experiences is a necessary basis for a sound and thoughtful psychotherapy. This is especially important in psychotherapy for schizophrenia, where patients' experiences may not always be easily accessible or understandable. In the available literature, we found only scattered suggestions for a translation of insights from phenomenological psychopathology into psychotherapeutic practice. The aim of this article is to offer a preliminary translation. First, we outline characteristics of the experiential worlds in schizophrenia, highlighting what we call "core experiences" and "experience-near concepts." Then we explore the psychotherapeutic methods and strategies that can be developed and elaborated on the basis of the accumulated research in phenomenological psychopathology, drawing also on experiences from a phenomenologically informed psychotherapy unit at the University Psychiatric Hospital of Ljubljana. Here, we propose principles of a phenomenological psychotherapy for schizophrenia, dividing them into the following subgroups: (1) overall goals, (2) general attitudes, (3) main domains, and (4) therapeutic strategies. The unique value of phenomenological psychotherapy seems to lie in its ability to capture the heart of the patients' experiences and their inherent vulnerabilities and then use these insights to inform psychotherapeutic interventions.

Basic Self-Disturbances Related to Reduced Anterior Cingulate Volume in Subjects at Ultra-High Risk for Psychosis

Introduction: Alterations of the "pre-reflective" sense of first-person perspective (e.g., of the "basic self") are characteristic features of schizophrenic spectrum disorders and are significantly present in the prodromal phase of psychosis and in subjects at ultra-high risk for psychosis (UHR). Studies in healthy controls suggest that neurobiological substrate of the basic self involves cortical midline structures, such as the anterior and posterior cingulate cortices. Neuroimaging studies have identified neuroanatomical cortical midline structure abnormalities in schizophrenic spectrum disorders. Objectives: i) To compare basic self-disturbances levels in UHR subjects and controls and ii) to assess the relationship between basic self-disturbances and alterations in cortical midline structures volume in UHR subjects. Methods: Thirty-one UHR subjects (27 antipsychotic-naïve) and 16 healthy controls were assessed using the 57-item semistructured Examination of Anomalous Self-Experiences (EASE) interview. All subjects were scanned using magnetic resonance imaging (MRI) at 3 T, and gray matter volume was measured in a priori defined regions of interest (ROIs) in the cortical midline structures. Results: EASE scores were much higher in UHR subjects than controls (p < 0.001). The UHR group had smaller anterior cingulate volume than controls (p = 0.037). There were no structural brain imaging alterations between UHR individuals with or without self-disturbances. Within the UHR sample, the subgroup with higher EASE scores had smaller anterior cingulate volumes than UHR subjects with lower EASE scores and controls (p = 0.018). In the total sample, anterior cingulate volume was inversely correlated with the EASE score (R = 0.52, p < 0.016). Conclusions: Basic self-disturbances in UHR subjects appear to be related to reductions in anterior cingulate volume.

Stability in basic self-disturbances and diagnosis in a first treated psychosis: A seven year follow-up study

BACKGROUND

Basic self-disturbances (BSDs) are considered core features of schizophrenia spectrum disorders, and are present in the prodromal, early psychotic and chronic phases. Considerable levels of BSDs are also present at first treatment in some patients with psychotic disorders outside the schizophrenia spectrum. There is limited knowledge about the stability of self-disturbances over time.

AIM

To explore the stability of BSDs in a seven-year follow-up of first treatment patients, and the association between baseline levels and changes in BSDs and diagnostic changes at follow-up.

METHOD

Longitudinal study of 56 patients (35 schizophrenia and 21 non-schizophrenia) recruited at their first treatment for a psychotic disorder. BSDs were assessed using the Examination of Anomalous Self-Experience (EASE), while diagnostic categories, clinical symptom severity, and functioning were assessed with standard clinical instruments.

RESULTS

The schizophrenia group had significantly lower levels of BSDs at follow-up compared to baseline. The EASE domain "Cognition and stream of consciousness" was the most stable. There were no diagnostic changes into or out of schizophrenia spectrum. Patients with schizophrenia had significantly higher levels of BSDs both at baseline and at follow up than patients with psychotic disorders outside the schizophrenia spectrum, who showed stable low levels.

CONCLUSION

We found a decrease and thus less stability in BSDs in schizophrenia than expected. This might indicate that BSDs tent to weaken over time, and that unknown individual characteristics may influence the development of BSDs. Diagnostic stability from baseline to follow-up may be due to long DUP before service entry.